Last week, Thomson Reuters released the 2014 edition of the Journal Citation Reports (JCR). This annual report includes several journal performance metrics, the best known of which is certainly the Impact Factor. The Impact Factor measures the citation performance of journal articles over a two-year period.
Like all metrics, the Impact Factor has its strengths and weaknesses, its champions and detractors. At JBJS, we are focused on a range of metrics, including the quality of articles submitted to us for publication, author satisfaction, and direct reader feedback and engagement.
Having said that, we wish to acknowledge the painstaking work by our Editor-in-Chief, Editorial Board, reviewers, and authors who contributed to a second straight year of dramatic growth in our Impact Factor, which increased 22.5% to 5.280 (from 4.309). That’s the highest Impact Factor among the 72 orthopaedic journals included in the JCR.
We’re proud that JBJS is having a steadily increasing influence as a source of orthopaedic information. Our ultimate goal remains the same, however – to have a positive impact on surgical expertise, clinical outcomes, and patient care.
–Mady Tissenbaum, Publisher, JBJS
Attempts by orthopaedists to repair torn human ACLs have failed for the most part, so surgeons now rely almost exclusively on removing the torn ligament and replacing it with autograft or allograft tissue. But now research at Harvard by Martha Murray, MD—a co-author of several JBJS studies—suggests that a torn ACL can be prompted to repair itself.
As Dr. Murray explains in a video, “bridge-enhanced” ACL repair uses stitches and a spongy scaffold injected with the patient’s blood placed between the torn ends of the ACL. The bridge helps healing clots to form and helps surrounding cells grow to rejoin the ends of the ligament. Preclinical studies using this technique have resulted in successful ACL repairs and rates of subsequent knee arthritis that were lower than those seen with reconstruction techniques. Bridge-enhanced ACL repair would also eliminate the need for tissue harvesting in the many patients who choose the autograft reconstruction option.
After reviewing the data from the preclinical studies, the FDA approved the first safety study of this technique in humans, which is now underway.
The statistics about osteoporosis and associated fragility fractures are sobering:
- One-quarter of adults living in the US currently have osteoporosis or low bone density.
- Twenty-four percent of people aged 50 and older who sustain a hip fracture will die within a year after the fracture.
- Patients who have had one fragility fracture have an 86% increased risk for a second fracture.
Amid these troubling data stands hope from an effective, team-based clinical response—the fracture liaison service (FLS). In the April 15, 2015 edition of JBJS, Miller et al . explain how an FLS works and the results it achieves.
The authors define the fracture liaison service as “a coordinated care model of multiple providers who help guide the patient through osteoporosis management after a fragility fracture to help prevent future fractures.” The three key players on the FLS team are a coordinator (usually an advanced-practice provider), a physician champion (whom the authors say should be an orthopaedic surgeon), and a “nurse navigator.” Miller et al. describe the roles these FLS core team members play (including patient care and education and communication with other clinical services and administrators), suggest ways to organizationally justify an FLS, and lay out a stepwise implementation roadmap.
The authors conclude that an FLS “is adaptable to any type of health-care system, improves patient outcomes, and decreases complications and readmissions related to secondary fractures.” And there’s an important fringe benefit: “The FLS can help improve performance on quality measures…and help health-care organizations during this transition from volume payment to quality payment,” they say.
The fact that 12 of the 16 AAOS clinical practice guidelines for treating Achilles tendon ruptures are supported by “weak” or “inconclusive” evidence makes the recent JBJS Reviews article by Guss et al. on this subject all the more welcome.
The most emphatic point made by these authors is that functional rehabilitation protocols with early motion (and an associated shift away from long-term post-injury immobilization) have made a dent in the re-rupture rates historically seen with nonoperative treatment of Achilles tendon injuries, the incidence of which has increased in recent decades. The authors emphasize, however, that the delicate balance between loading and unloading of a healing Achilles tendon remains a rehabilitative challenge, and they encourage further research to identify which patients are more or less likely to experience success with nonoperative management.
The authors note also that the focus of outcomes research of different management methods has shifted from rates of re-rupture and infection to more specific functional measures—and, in some cases, to direct and indirect cost measures. For example, Guss et al. cite one meta-analysis that found that operatively treated patients returned to work almost three weeks earlier than those treated nonoperatively.
The authors also observe that the rate of deep vein thrombosis after Achilles rupture seems to be higher than that seen in other foot/ankle conditions, but they add that the majority of those thrombotic events are “unlikely to be clinically important.” Still, Guss et al. conclude that “prophylactic anticoagulation should be considered for older patients with an Achilles tendon rupture, including those treated nonsurgically.”
Two interesting investigations into lumbar spinal stenosis (LSS) appeared in the general medical literature recently.
—A registry-based observational study of nearly 900 patients in the BMJ found that microdecompression techniques were as effective as open laminectomy in improving disability scores 12 months after surgery. The two techniques yielded similar quality-of-life scores at the one-year point, but the microdecompression patients had shorter hospital stays.
—In Annals of Internal Medicine, a multisite randomized study of 170 patients 50 or older with lumbar spinal stenosis found that those receiving surgical decompression and those receiving physical therapy (2 PT visits per week for six weeks focused on lumbar flexion and general conditioning) had essentially the same functional outcomes at time points ranging from 10 weeks to two years after enrollment. However, 57% of patients assigned to PT crossed over to surgery—some due to high copays for physical therapy, said study co-author Anthony Delitto, PT. In an editorial accompanying the study, JBJS Deputy Editor for Methodology and Biostatistics Jeffrey Katz, MD, concluded, “Because long-term outcomes are similar for both treatments yet short-term risks differ, patient preferences should weigh heavily in the decision of whether to have surgery for LSS.”
Fluoroquinolone antibiotics do a great job fighting a broad spectrum of bacteria that cause many respiratory, urogenital, gastrointestinal, and bone and joint infections. However, in 2008, the FDA issued a “black-box warning” about the increased risk of tendinopathies in people taking these drugs, especially those older than 60.
Although rare, when fluoroquinolone-induced tendon ruptures occur, they involve the Achilles tendon 95% of the time. But in the April 8, 2015 edition of JBJS Case Connector, DeWolf et al. describe the case of an 81-year-old man whose sudden inability to extend the metacarpophalangeal joint of his ring finger occurred within one week after he started taking the fluoroquinolone ciprofloxacin for an ear infection.
In the OR, surgeons identified and debrided a ruptured extensor digitorum communis (EDC) tendon and attached it to the EDC of the adjacent middle finger. They found no bony protrusions or synovitis that could have caused tendon erosion, and cultures for bacterial and fungal infections came back negative. Those negative findings, combined with the patient’s medication history and lack of other risk factors such as gout or rheumatoid arthritis, led the authors to postulate with some certainty that ciprofloxacin was the etiological culprit.
DeWolf et al. remind orthopaedists that for general tendinopathy, “the mainstays of treatment include rest, physical therapy, and discontinuation of [any] offending medication.” Ruptured tendons are usually addressed surgically. Although the authors do not report having taken ultrasound images of this patient, they note that “ultrasound provides an inexpensive way to confirm that a tendon has been ruptured and also whether it is a partial or complete rupture.”
Many orthopaedists and primary care clinicians recommend acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) as a first-line approach for patients with osteoarthritis (OA) or back pain. However, two recent studies call into question how well these pharmacological approaches actually work.
A study employing a new-user design and data from the Osteoarthritis Initiative concluded that short-term use of prescription NSAIDs (such as naproxen, celecoxib, and meloxicam) had no clinical effect in more than 1,800 patients with radiographically confirmed knee osteoarthritis. Long-term use (defined as NSAID use reported at three consecutive annual assessments) was associated with clinically important but not statistically significant improvements in stiffness and function (per WOMAC scales), but not pain. Notably, the rate of NSAID use at all three annual assessments was very low, and the authors concluded that the common discontinuation of NSAID use suggested in this study “call[s] for further understanding of the extent to which potential side effects [of NSAIDs] can be mitigated with gastroprotective agents.”
A meta-analysis of acetaminophen’s effectiveness (13 randomized trials with a total of 5,366 patients) found that the medication did not improve pain, disability, or quality of life for back-pain sufferers, and that its pain-relieving effects in people with knee or hip OA were statistically but not clinically significant. These findings led an editorialist commenting on the meta-analysis to conclude that “the time has come to shift our attention away from tablets as the default option for managing chronic musculoskeletal pain.” As alternatives, he recommended topical NSAIDs, physical therapy, and better coaching on patient self-management. The editorialist also emphasized that these findings should not prompt clinicians to increase prescriptions for opioids.
The April 1, 2015 JBJS features a level II prognostic study that analyzes registry data from 243 patients (mean age: 29) who underwent arthroscopic surgery to correct femoroacetabular impingement (FAI). Almost everyone experienced clinically important and statistically significant post-arthroscopy improvements in patient-reported outcomes. However, those with relative femoral retroversion (<5° anteversion) prior to surgery experienced smaller magnitudes of improvement than those with normal or increased femoral version.
Researchers found no association between the participants’ McKibbin index (calculated from both femoral and acetabular version) and patient-reported outcomes.
According to the authors and to commentator Keith Baumgarten, MD, these results indicate that surgeons should not consider femoral retroversion to be an absolute contraindication to arthroscopic correction of FAI. However, while the findings may help orthopaedists offer prognostic counseling to young and middle-aged adults who are considering arthroscopy for FAI, the authors say the findings “may not be externally valid in adolescents,” who represent a substantial percentage of patients diagnosed with this hip condition.
Despite an overwhelming 392-to-37 vote in the House to scrap the SGR formula for physician Medicare payments, the Senate adjourned for a two-week recess without voting on the measure. Senators were distracted from taking action on the House SGR-repeal bill by a pre-recess “vote-o-rama” on other legislation, mostly budget amendments. Many in Washington expect that the Centers for Medicare and Medicaid Services will postpone Medicare payments during the first two weeks of April, essentially preventing the 21% slash in physician reimbursement set to kick in on April 1. That will buy time for the Senate to reconvene and vote on the SGR bill.
Jennifer Haberkorn of Politico Pro told Kaiser Health News that any amendments to the House-passed SGR measure that the Senate debates—such as a full “pay-for” or four years of expanded funding for the Children’s Health Insurance Program rather than two—“are unlikely to be approved, but [Senators] want to be able to make a point.” Conventional wisdom posits that the delay will not hurt the chances of an SGR repeal finally passing both chambers and being signed by President Obama.
Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
“Injuries Involving the Epiphyseal Plate” by Drs. Salter and Harris, published more than a half-century ago, has had a lasting impact on the field of orthopaedic surgery and on the practice of medicine in general. Every surgeon in our specialty—and almost every radiologist, pediatrician, and emergency physician—has at least a passing knowledge of the “Salter fractures.” This most enduring orthopaedic schema lives on in our practices because of its clarity of presentation, its guidance of our understanding, and its implications for treatment. It has outlasted many classifications developed before and since.
In addition to presenting the fracture classification in this classic and beautifully illustrated JBJS Instructional Course Lecture, the authors laid the groundwork with basic principles of mechanical failure and vascularity of the physis. The authors then use these principles to help explain how physeal damage may arise from misalignment, crushing, or vascular interruption. The authors elucidate these concepts further by presenting experimental studies of growth arrest, with resulting histology, and the effects of interpositional surgery. Salter and Harris then describe the famous five types of physeal injury and the clinical implications for treatment and prognosis.
Not content with generalities, the authors conclude with an extensive section describing the variations of physeal fractures in each long bone. The article is fun and inspiring to read because of the obvious fascination that the authors had in exploring the topic so completely. Rarely has experimental and clinical thought been so nicely interwoven. We don’t write that way now, and rarely if ever will we see a 36-page article in one of today’s orthopaedic journals; in many ways we are poorer for that.
Classification systems are highly cited and influential; they figure prominently in lists of top-cited orthopaedic articles. Those at the top earn this rank by their utility. This is just one of three monumental contributions by the late Dr. Salter of Toronto (along with introducing us to surgical reorientation of the acetabulum and to continuous passive motion). Please share your reactions to this classic article and its impact on you and your practice.
Paul Sponseller, MD
JBJS Deputy Editor for Pediatrics