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What We Owe our Patients—Continuous Improvement

It has been said that a surgeon’s skill and judgment account for between 80% and 90% of a patient’s outcome. (I believe this is true for both surgical and nonsurgical treatments.) Throw in a physician’s ability to listen and clearly communicate with patients, and I am sure we are approaching that 90% mark. That means that when we conduct randomized trials comparing two types of knee prostheses or fracture-fixation constructs, we are, in essence, scrutinizing only about 10% of the patient-outcome equation. 

So how do we best evaluate the 90% of the outcome equation that is physician-dependent? With the advent of “bundled” episodes of care, the orthopaedic community has emphasized the need for risk-adjustment in evaluating surgeon performance. Clearly, there are certain patients who are at higher risk for worse outcomes than others, such as those with diabetes, nicotine abuse, advanced age, and less social support.

In the December 19. 2018 issue of The Journal, Thigpen et al. report on patient outcomes 6 months after arthroscopic rotator cuff repair in 995 patients treated by 34 surgeons. The authors evaluated patient-reported outcomes from all surgeons using both unadjusted and adjusted ASES change scores. The adjusted scores took into account about a dozen baseline patient characteristics, including symptom severity, functional and mental scores, medical comorbidities, and Workers’ Compensation status. Relative to performance rankings based on unadjusted data, risk adjustment significantly altered the rankings for 91% of the surgeons.  According to the authors, these findings “underpin the importance of risk-adjustment approaches to accurately report surgeon performance.”

But what is of even greater interest to me is that risk adjustment led to positive increases in patient outcomes for some surgeons, while decreasing outcomes for other surgeons. Some of these outcome differences likely reflect each surgeon’s patient-selection biases, but in the words of the authors, the numbers strongly suggest “that there is a meaningful, distinguishable difference in patient outcomes between surgeons.”

What should we do with this data? In my opinion, surgeons in the lower 80%  of the list, at least, ought to be engaging with the surgeons who demonstrated the highest adjusted performance scores to understand what is helping them obtain outcomes that are superior to everyone else’s. We owe it to our patients to understand what our personal outcomes are for at least the most common conditions we treat. I believe it borders on unethical behavior to quote patients outcome data of a procedure from the peer-reviewed literature when we have no idea how our personal results compare. Orthopaedic surgeons need to be more active in lobbying our groups and health systems to support best practices for clinical outcome data collection and reporting so we can, in turn, improve our care by adopting the best practices of the surgeons with the best outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Treating Displaced AC Joint Dislocations: Patient Expectations Matter

Often in life, when there are many potential solutions for a single problem, none of them is found to be universally better than the others. That certainly seems to be the case when it comes to treating type III- and -IV acromioclavicular (AC) joint dislocations. Multiple studies have tried to clarify whether nonoperative or operative management is superior in this relatively common injury, but it is becoming increasingly clear that there is no single “right” answer. Many patients do fine with nonoperative treatment; others report being highly satisfied with an operation.

In the November 21, 2018 issue of The Journal, Murray et al. try to provide further guidance for treating these injuries. They performed a prospective, randomized controlled trial that compared nonoperative treatment with open reduction and tunneled suspensory device fixation among 60 patients with a type-III or type-IV AC joint dislocation. The authors used DASH, OSS, and SF-12 scores to quantify functional differences between the groups at 6 weeks, 3 months, 6 months, and 1 year post-injury. They found that, while the operative group showed improved radiographic alignment of the AC joint compared to the nonoperative group, there were no differences in functional outcomes between the two groups at any time beyond the 6-week mark (at which point the nonoperative group had better outcomes).

Notably, 5 of the 31 patients allocated to nonoperative treatment ended up requesting surgical treatment for the injury because of persistent discomfort (4 patients) or cosmesis (1 patient). Also, not surprisingly, the mean economic expenditure in the fixation group was significantly greater than that in the nonoperative group.

Whether to provide operative or nonoperative treatment for type-III and -IV acromioclavicular joint dislocations is not an easy decision, and it entails multiple factors. While this study evaluates only one modern surgical technique for treating this injury, the data is valuable nonetheless for informing a shared decision-making process to help patients choose the most appropriate treatment for them. The good news is that, whether managed operatively or not, patients tend to improve significantly after these injuries, and after 1 year end up with a shoulder that functions well. The authors conclude that “the routine use of [this surgical procedure] for displaced AC joint injuries is not justified,” and that “treatment should be individualized on the basis of [patient] age, activity level, and expectations.”

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

JBJS 100: Femoral Fractures, Shoulder Dislocations

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Closed Intramedullary Nailing of Femoral Fractures
RA Winquist, ST Hansen Jr, DK Clawson: JBJS, 1984 January; 66 (4): 529
This paper, which carefully explains how IM nailing procedures were refined as the authors’ experience grew from 1968 to 1979, ushered in the standard of care that exists today and spelled the end of traction treatment and plate fixation. It remains one of the most-cited articles in the history of musculoskeletal trauma literature.

Nonoperative Treatment of Primary Anterior Shoulder Dislocation in Patients 40 Years of Age and Younger
L Hovelius et al: JBJS, 2008 May; 90 (5): 945
After 25 years of follow-up, half of >200 primary shoulder dislocations in Swedish patients aged 12 to 25 that had been treated nonoperatively had not recurred or had become stable over time. Based on these findings, the authors opine that “routine, immediate surgery for the treatment of all first-time dislocations in patients 25 years of age or younger will result in a rate of unnecessary operations of at least 30%.”

What’s New in Shoulder and Elbow Surgery 2018

Shoulder & elbowEvery month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, Robert Tashjian, MD, co-author of the October 17, 2018 Specialty Update on shoulder and elbow surgery, selected the most clinically compelling findings from among the 36 studies summarized in the Specialty Update.

Progression of Primary Osteoarthritis
–A study evaluating the relationship between glenoid erosion patterns and rotator cuff muscle fatty infiltration found that fatty infiltration was associated with B3 glenoids, increased pathologic glenoid retroversion, and increased joint-line medialization. The authors recommend close observation of patients with B-type glenoids, as the progression of glenoid erosion is more likely in B-type than A-type glenoids.

Perioperative Pain Management
–In a randomized controlled trial of perioperative pain management in patients undergoing primary shoulder arthroplasty, narcotic consumption during the first 24 postoperative hours was similar between a group that received interscalene brachial plexus blockade and a group that received intraoperative soft-tissue infiltration of liposomal bupivacaine. The interscalene group had lower VAS pain scores at 0 and 8 hours postoperatively; both groups had similar VAS pain scores at 16 hours; and the soft-tissue infiltration group had lower pain scores at 24 hours postoperatively.

Rotator Cuff
–In a reevaluation of patients with nonoperatively treated chronic, symptomatic full-thickness rotator cuff tears that had become asymptomatic at 3 months, researchers found that at a minimum of 5 years, 75% of the patients remained asymptomatic.1 The Constant scores in the group that remained asymptomatic were equivalent at 5 years to those who initially underwent surgical repair. While these findings suggest that nonoperative treatment can yield clinical success at 5 years, the authors caution that “individuals with substantial tear progression or the development of atrophy will likely have a worse clinical result.”

–A recent study of the progression of fatty muscle degeneration in asymptomatic shoulders with degenerative full-thickness rotator cuff tears found that larger tears at baseline had greater fatty degeneration, and that tears with fatty degeneration were more likely to enlarge over time. Median time from tear enlargement to fatty degeneration was 1 year. Because the rapid progression of muscle degeneration seems to occur with increasing tear size, such patients should be closely monitored if treated nonoperatively.

Shoulder Instability in Athletes
–An evaluation of outcomes among 73 athletes who had undergone Latarjet procedures found that, after a mean follow-up of 52 months, ASES scores averaged 93. However, only 49% of the athletes returned to their preoperative sport level; 14% decreased their activity level in the same sport; and 12% changed sports altogether. While the Latarjet can help stabilize shoulders in athletes, the likelihood is high that the athlete won’t return to the same level in the same sport after the procedure.

Reference

  1. Boorman RS, More KD, Hollinshead RM, Wiley JP, Mohtadi NG, Lo IKY, Brett KR. What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2018 Mar;27(3):444-8.

JBJS 100: Harris Hip Score, Clavicle Fractures

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Traumatic Arthritis of the Hip after Dislocation and Acetabular Fractures—Treatment by Mold Arthroplasty: An End-Result Study Using a New Method of Result Evaluation
W H Harris: JBJS, 1969 June; 51 (4): 737
The most lasting legacy from this classic 1969 article from William Harris is the author’s proposed hip score. A “single, reliable figure” designed to be equally applicable to different hip problems and different treatments, the Harris Hip Score is still used worldwide today in routine evaluations before and after hip arthroplasty. Not surprisingly, this article remains the most frequently cited paper in the hip arthroplasty literature.

Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures
Canadian Orthopaedic Trauma Society: JBJS, 2007 January; 89 (1): 1
Amid the ongoing debate about whether to operate on which type of clavicle fractures, this multicenter, randomized clinical trial stands out for its rigorous design and focus on patient-oriented outcomes. Local irritation and unsightly prominence from hardware notwithstanding, these findings support primary plate fixation of completely displaced midshaft clavicle fractures in active adult patients.

Risk Factors for Failure of Arthroscopic Revision Anterior Shoulder Stabilization

Recurrent anterior instability following a failed Bankart repair in the shoulder represents a challenging clinical scenario.

Full article: https://bit.ly/2M4Xxp0

JBJS.IG.17.01028.ig

JBJS 100: Bankart Repair, Carpal Tunnel Assessment

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

The Bankart Procedure: A Long-Term End-Result Study
C R Rowe, D Patel, W W Southmayd: JBJS, 1978 January; 60 (1): 1
This was the first large clinical series with long follow-up to report the findings and results of the open Bankart repair. The results were almost uniformly excellent or good, and this study contributed to the demise of nonanatomic shoulder repairs.

A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome
D W Levine, B P Simmons, M J Koris, L H Daltroy, G G Hohl, A H Fossel, J N Katz: JBJS, 1993 January; 75 (11): 1585
Distinguishing interventions that work from those that don’t requires rigorous outcomes research, which, in turn, relies on standardized, patient-centered measures that have proven reliability and validity. Meeting these criteria are the Symptom Severity and Functional Status Scales for carpal tunnel syndrome described in this oft-cited JBJS study from 25 years ago.

JBJS 100: Proximal Humeral Fractures, Stem Cells

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Displaced Proximal Humeral Fractures: Classification and Evaluation
C Neer: JBJS, 1970 September; 52 (6): 1077
Complex distal humeral fractures have long challenged orthopaedic surgeons and their patients. Often the first step in fracture-management decision-making is classification, and in this 1970 study, Dr. Neer proposed a 6-group classification based on the presence or absence of displacement of one or more of the four major proximal segments. Since then, this classification has been variably adapted by multiple authors, but its usefulness remains intact.

The Effect of Implants Loaded with Autologous Mesenchymal Stem Cells on the Healing of Canine Segmental Bone Defects
S F Bruder, K H Kraus, V M Goldberg, S Kadiyala: JBJS, 1998 July; 80 (7): 985
Research into mesenchymal stem cells (MSCs) to augment healing of tendons, chondral and bone defects, and other connective tissues has taken off since these authors used autologous MSCs to help heal 21-mm segmental femoral defects. Radiographic union occurred rapidly at the interface between host bone and porous ceramic cylinders loaded with MSCs, and a large collar of bone had formed around the cell-loaded implants after 16 weeks.

Shoulder Arthroplasty: Doxy + Cefazolin No Better than Cefazolin Alone Against P. Acnes

Doxycycline for OBuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Andrew D. Duckworth, MSc, FRCSEd(Tr&Orth), PhD, in response to a recent study in JBJS.

Propionibacterium acnes (now called Cutibacterium acnes, according to an updated classification) is a ubiquitous microbe in the setting of shoulder surgery and is a well-established cause of indolent infection and prosthetic loosening1,2.  In 2016, JBJS published a study by Hsu et al. investigating single-stage revision shoulder replacement in patients with subclinical infection, and the authors reported that almost half of the patients had >2 positive cultures for P. acnes3.  However, the exact consequence of positive cultures at the time of primary surgery is unknown, and the efficacy of specific antibiotic prophylaxis against this microbe remains unclear.

In the June 6, 2018 issue of JBJS, Rao et al. randomised 56 patients scheduled to undergo a primary anatomic or reverse total shoulder replacement to receive either preoperative cefazolin alone (n=27) or a combination of cefazolin and doxycycline (n=29) 4.  All patients had standard skin preparation at the time of surgery with both alcohol and chlorhexidine.

The primary outcome measure was ≥1positive culture after 14 days of incubation from either superficial and/or deep-tissue samples taken intraoperatively. The authors deemed that a decrease of 50% in the positive culture rate would be clinically significant. However, they found no significant difference between the groups in terms of the primary outcome measure (p=0.99).  The authors carried out a secondary analysis to determine which other factors might be associated with ≥1 positive P. acnes culture and found that younger age, male sex, and a lower Charlson Comorbidity Index were predictive.  Although this study was potentially underpowered, it demonstrated that in patients undergoing primary shoulder arthroplasty, preoperative doxycycline does not significantly reduce the prevalence of positive culture rates for P. acnes.

These findings are similar to those found in previous research and should lead us to question whether preoperative antibiotics aimed specifically at preventing P. acnes infection associated with shoulder arthroplasty are truly useful. P. acnes infections are difficult to detect both clinically and via culture—which makes any intervention difficult to measure, especially in a potentially underpowered study. Consequently, larger studies in this area would help to more definitively determine whether preoperative antibiotics aimed specifically at P. acnes decrease infection rates or, instead, may be adding to the growing problem of bacterial resistance. In particular, such trials seem most useful when they focus on patients who are at higher risk of these specific infections—in this case, younger, healthy males.

Finally, as Rao et al. wisely observed, doxycycline is a bacteriostatic agent, which slows the growth and production of bacteria, rather than a bactericidal agent, which kills bacteria.  Given that antimicrobial limitation, doxycycline might not be the most appropriate prophylactic drug to be investigating for these cases.

Andrew D. Duckworth, MScFRCSEd(Tr&Orth), PhD is a consultant orthopaedic trauma surgeon at Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, and he is a member of the JBJS Social Media Advisory Board.

References

  1. Gausden EB, Villa J, Warner SJ, Redko M, Pearle A, Miller A, Henry M, Lorich DG, Helfet DL, Wellman DS. Nonunion After Clavicle Osteosynthesis: High Incidence of Propionibacterium acnes.  J Orthop Trauma. 2017 Apr;31(4):229-235.
  2. Chuang MJ, Jancosko JJ, Mendoza V, Nottage WM. The Incidence of Propionibacterium acnes in Shoulder Arthroscopy.  2015 Sep;31(9):1702-7.
  3. Hsu JE, Gorbaty JD, Whitney IJ, Matsen FA III. Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium. J Bone Joint Surg 2016;98:2047-2051.
  4. Rao AJ, Chalmers PN, Cvetanovich GL, O’Brien MC, Newgren JM, Cole BJ, Verma NN, Nicholson GP, Romeo AA. Preoperative Doxycycline Does Not Reduce Propionibacterium acnes in Shoulder Arthroplasty.  J Bone Joint Surg Am. 2018 Jun 6;100(11):958-964.

JBJS 100: Massive Rotator Cuff Tears, Continuous Passive Motion

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears
L M Galatz, C M Ball, S A Teefey, W D Middleton, K Yamaguchi: JBJS, 2004 February; 86 (2): 219
In one of the earliest studies to investigate the relationship between the anatomic integrity of arthroscopic rotator cuff repair and clinical outcome, these authors found that the rate of recurrent defects was high but that at 12 months after surgery, patients experienced excellent pain relief and functional improvement. However, at the 2-year follow-up, the clinical results had deteriorated substantially. Investigations into the relationship between cuff-repair integrity and clinical outcomes are ongoing.

The Biological Effect of Continuous Passive Motion on the Healing of Full-thickness Defects in Articular Cartilage: An Experimental Investigation in the Rabbit
R B Salter, D F Simmonds, B W Malcolm, E J Rumble, D Macmichael, N D Clements: JBJS, 1980 January; 62 (8): 1232
In this paper, Salter and colleagues hypothesized that “continuous passive motion [CPM] of a synovial joint in vivo would have a beneficial biological effect on the healing of full-thickness defects in articular cartilage.” They found that CPM stimulated more rapid and complete cartilage restoration than either immobilization or intermittent active motion, and since then CPM has been commonly used in humans after cartilage repair. However, CPM’s actual efficacy in people—after cartilage repair or total knee arthroplasty—remains controversial.