Under the best of circumstances, an orthopaedic residency requires trainees and trainers to balance clinical work, surgical skills, didactics, and academic investigations. The global COVID-19 crisis is certainly not the best of circumstances. A fast-track article just published in JBJS explains how the urban, high-volume orthopaedic department at Emory University School of Medicine in Atlanta created a two-team system that helps residents keep learning, helps maintain a healthy workforce, and addresses the needs of orthopedic patients amid this unprecedented situation.
Emory is now dividing its orthopaedic residents into “active duty” and “working remotely” teams. In observation of the presumed incubation period of COVID-19 symptoms, transitions between active and remote activities occur every two weeks. A similar “platooning” system is in place for both faculty and administrators to safeguard a healthy network of leaders and command-and-control decision makers.
Active duty residents participate in in-person surgical encounters and virtual ambulatory encounters. Orthopaedic surgical cases deemed essential present an ideal opportunity for active-duty education, the authors observe, and there is also a role for supplementation of surgical education in the form of virtual reality or simulation training. Faculty members cover their in-person clinics without resident assistance when possible, but most musculoskeletal subspecialty visits can be performed with video-enabled telemedicine, and active-duty residents are part of these virtual clinic visits in real time.
Remotely working residents participate by videoconference in daily faculty-led, case-based didactics. The authors recommend virtually conducted one-and-a-half-hour collaborative, interactive learning sessions on predetermined schedules and topics. Each session includes question-based learning, facilitated with the use of an audience-response system. Remotely working residents also study for their boards and work on clinical research projects, grant writing, and quality improvement projects.
Finally, this team system, championed by strong departmental leadership, allows for isolation of any resident who acquires COVID-19, allowing them time to recover, while diminishing the risk of rapid, residency-wide disease transmission.
Every month, JBJS publishes 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 OrthoBuzz summaries of these “What’s New” articles. This month, author Christopher J. Dy, MD, MPH selected the 5 most clinically compelling findings from the more than 50 studies summarized in the March 18, 2020 “What’s New in Hand and Wrist Surgery.”
—A retrospective case series investigating 3 treatments for scaphoid nonunion among >100 patients1 found the following:
- Those receiving iliac crest bone graft (n=31), most of whom had carpal collapse with preserved proximal pole vascularity, had a union rate of 71%, a time-to-union of 19 weeks, and a reoperation rate of 23%.
- Those receiving an intercompartmental supraretinacular artery flap (n=33), most of whom had osteonecrosis of the proximal pole and half of whom had carpal collapse, had a union rate of 79%, a time-to-union of 26 weeks, and a reoperation rate of 12%.
- Those receiving a free vascularized medial femoral condyle flap (n=45), most of whom had carpal collapse, osteonecrosis, and prior surgery, had a union rate of 89%, a time-to-union of 16 weeks, and a reoperation rate of 16%.
—Among 13 patients with scaphoid nonunion and osteonecrosis who were treated with cancellous autograft packing and volar-plate fixation,2 there was 100% fracture union, with most achieving union within 18 weeks. However, preoperative carpal-collapse rates were not reported, making it difficult to assess the role of this procedure.
Finger Replantation: Financial Issues
—The frequency and success rates of finger replantation have been decreasing in the US. A review of physician reimbursement for these procedures3 found that replantation has lower reimbursement per work relative value unit (RVU) than many other common hand surgeries, including revision amputation, carpal tunnel release, and trigger finger surgery. This “relative devaluation” may help explain the decline in frequency and success of finger replantation.
Socioeconomics of Carpal Tunnel Syndrome
—Among patients seeking treatment for carpal tunnel syndrome, those from areas of “increased social deprivation” had worse physical function, pain interference, anxiety, and depression than patients from more affluent areas.4
Cubital Tunnel Syndrome
—A study of preoperative dynamic ultrasound in patients with cubital syndrome5 found that ultrasound was far more reliable than preoperative clinical examinations in predicting ulnar nerve stability within the cubital tunnel (88% match with intraoperative findings vs 12% match, respectively). Preoperative ultrasound may therefore help surgeons counsel patients about the possible need for nerve transposition.
- Aibinder WR, Wagner ER, Bishop AT, Shin AY. Bone grafting for scaphoid nonunions: is free vascularized bone grafting superior for scaphoid nonunion?Hand (N Y). 2019 Mar;14(2):217-22. Epub 2017 Oct 27.
- Putnam JG, DiGiovanni RM, Mitchell SM, Castañeda P, Edwards SG. Plate fixation with cancellous graft for scaphoid nonunion with avascular necrosis. J Hand Surg Am.2019 Apr;44(4):339.e1-7. Epub 2018 Aug 10.
- Hooper RC, Sterbenz JM, Zhong L, Chung KC. An in-depth review of physician reimbursement for digit and thumb replantation. J Hand Surg Am.2019 Jun;44(6):443-53. Epub 2019 Apr 17.
- Wright MA, Beleckas CM, Calfee RP. Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation. J Hand Surg Am.2019 Apr;44(4):335.e1-9. Epub 2018 Jun 23.
- Rutter M, Grandizio LC, Malone WJ, Klena JC. The use of preoperative dynamic ultrasound to predict ulnar nerve stability following in situ decompression for cubital tunnel syndrome. J Hand Surg Am.2019 Jan;44(1):35-8. Epub 2018 Nov 27.
Among >100,000 total hip arthroplasty (THA) patients ≥55 years of age whose data resides in a Canadian arthroplasty database, the 15-year cumulative incidence of periprosthetic joint infection (PJI) was 1.44%, according to a study by the McMaster Arthroplasty Collaborative in the March 18, 2020 issue of JBJS.
In addition to finding that the overall risk of developing PJI after THA has not changed over the last 15 years in this cohort, the authors found the following factors associated with increased risk of developing a PJI:
- Male sex (absolute increased risk of 0.48% at 10 years)
- Type 2 diabetes (absolute increased risk of 0.64% at 10 years)
- Discharge to a convalescent-care facility (absolute increased risk of 0.46% at 10 years)
The authors view the third bulleted item above as “a surrogate marker of frailty and poorer general health.”
Patient age, surgical approach, surgical setting (academic versus rural), use of cement, and patient income were not associated with an increased risk of PJI. Nearly two-thirds of PJI cases occurred within 2 years after surgery, and 98% occurred within 10 years postoperatively.
The authors conclude that these and other substantiated findings about PJI risk factors “should be reviewed with the patient during preoperative risk counseling.”
Nonoperative management of proximal humerus fractures in the elderly used to be fairly common, but multiple studies have shown poor outcomes. Open reduction and internal fixation (ORIF) with locked-plate constructs has shown some promise, but it has been fraught with complications. Most recently, reverse total shoulder arthroplasty (rTSA) has emerged as a possible surgical solution, but this is a complicated procedure, and questions have arisen about long-term outcomes. Compounding this conundrum are the varying degrees of severity of proximal humeral fractures.
In the March 18, 2020 issue of The Journal, Fraser et al. share 2-year results from a multicenter, single-blinded randomized trial that compared rTSA to ORIF for severely displaced proximal humeral fractures in patients 65 to 85 years of age. Included patients (n=124) had OTA/AO 11-B2 or 11-C2 fractures with >45° valgus or >30° varus in the anteroposterior view, or >50% displacement of the humeral head. Using the Constant shoulder score as the primary outcome measure, the authors demonstrated both a statistically significant and clinically meaningful difference favoring rTSA in this cohort.
The mean Constant score was 68.0 points for the rTSA group compared to 54.6 points for the ORIF group. The mean between-group difference, 13.4 points, was significant (p<0.001) and exceeded the minimal clinically important difference of 10 points. The Constant-score difference between ORIF and rTSA was most pronounced (18.7 points) in patients with C2 fractures, but there was no significant score difference in those with B2 fractures. Secondary outcomes (Oxford Shoulder Scores) showed a consistent trend of the rTSA group scoring higher than the ORIF group at 2 years.
Although this study indicates an advantage for rTSA, one must consider that only severely displaced fractures were investigated and that 2-year follow-up for joint arthroplasty is considered short term. In a Commentary about this article, Peter A. Cole, MD points out that “if there was a 25% revision rate for reverse TSA at 5 to 10 years, then the superior results would be reversed, and we would be reinventing another wheel in orthopaedics.”
Clearly, longer-term studies in this population are a necessity, and Fraser et al. say they plan to follow these patients in 5-year intervals.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Disclosure: The co-authors of this post are lifelong, die-hard, pathological fans of the Boston Red Sox.
At this time of a global public-health emergency, we probably should not be distracted by things like this, but… Yesterday the Boston Red Sox announced that left-handed pitcher Chris Sale, one of the best hurlers in baseball, would undergo Tommy John surgery, otherwise known as ulnar collateral ligament reconstruction (see related Clinical Summary). This, by itself, is not surprising, because by some estimates, one-third of all Major League Baseball pitchers have that operation.
What puts the hitch in our windup is this: In August of 2019, Sale, who was experiencing his worst season ever stat-wise, received an injection of platelet-rich plasma (PRP) in his left elbow and was shut down for the rest of the season. Here we are, 8 months later, and he is facing a surgery that was veritably inevitable and could have happened then rather than now.
PRP has shown promise in treating some musculoskeletal conditions, but its effectiveness in elbow injuries is unproven at best. In response to a surge of research interest in PRP, JBJS recently published an article calling for standardization of PRP preparation protocols and more responsible reporting of methods and findings in the literature so that any positive findings can be replicated in future investigations.
No surgery date for Sale has been announced (most elective orthopaedic surgeries are being postponed to redirect resources to the COVID-19 pandemic), and we don’t know who will perform the surgery. What we do know is that this year is the first of a 5-year, $145 million contract for Sale. While it’s silly to use the words “schedule” or “timeline” for anything now, a best-case scenario would have Sale back on the mound in games in June or July of 2021. We are not privy to the terms of Sale’s contract, but we assume the clock on it is ticking, and several months of an elite pitcher’s career was wasted waiting for a treatment to work that is not backed by any solid science.
Click here for a compendium of JBJS content related to PRP.
JBJS Developmental Editor
JBJS Chief Operating Officer
The mind and heart of almost everyone on the planet are now focused to some extent on COVID-19. In the first of what will be a series of fast-tracked JBJS articles about how orthopaedic surgeons are helping mitigate the pandemic, Liang et al. describe orthopaedists’ early experiences in Singapore, where the first case of COVID-19 was confirmed in a tourist from Wuhan, China on January 23, 2020.
Singapore has had a nationwide outbreak-response system (called DORSCON, for Disease Outbreak Response System Condition) since the SARS crisis of 2003 (see Figure). Immediately after the first evidence of community spread of the virus on the island, on February 7, 2020, the Ministry of Health raised the DORSCON status to Orange, which triggered the following outbreak-control measures:
- Ramping up of contact tracing
- Mandatory 14-day quarantining of those in close contact with people who had confirmed infections
- A 2-week mandatory leave of absence for healthcare workers with recent travel histories to China
- Compulsory, twice-daily temperature screenings of all healthcare workers
The COVID-19-driven changes in orthopaedic practice revolved around 2 strategies:
- Clinical Urgency
- Musculoskeletal trauma and tumor patients were operated on as scheduled, but elective surgical cases were postponed to free up beds for confirmed or suspected COVID-19 patients.
- Orthopaedists were encouraged to consider temporary pain-relieving measures (such as corticosteroid injections or nerve-root blocks) for patients with severe pain whose surgeries were postponed.
- Patient and Healthcare-Worker Protection
- Clinicians have been advised to prolong the duration between nonurgent follow-up appointments. All patients attending outpatient clinics are screened for risk factors and have their temperatures checked. Febrile patients are moved to the emergency department for further evaluation.
- Orthopaedic teams wear surgical masks for all patient encounters and practice strict hand-hygiene practices.
- When evaluating orthopaedic patients suspected of or diagnosed with COVID-19, all staff wear full personal protective equipment. Whenever possible, such evaluations take place in pressure-negative isolation units, and these patients are co-managed with infectious-disease colleagues.
- If surgery on a suspected or confirmed COVID-19 patient is needed, it is performed by a dedicated orthopaedic contamination team; these teams are segregated from the rest of the staff to minimize the risk of cross-contamination.
Technology Tools for Training
Telemedicine and telerehabilitation have helped ensure the quality of patient care in Singapore, and technology is also being used to keep orthopaedic training going. Because all interhospital rotations and in-person combined teaching programs have been suspended, residency training programs are relying on videoconferencing platforms for scheduled teaching sessions. For trainees who engage with instructional videos or webinars, faculty members follow up with online discussions.
As residents take shifts in the emergency department to assist with COVID-19 screening, they learn important lessons in management of limited resources and “softer” skills such as empathy and teamwork.
Liang et al. conclude with this admonition to orthopaedic surgeons everywhere: “Stay vigilant even when reviewing low-risk elective patients; be champions of good hygiene practices, and be open-minded in the adoption of novel workplace technologies.”
Orthopaedic surgeons work hard to find good alternatives to total hip arthroplasty (THA) in patients <50 years old. That’s because the high functional demands and longer remaining lifespan in these patients can result in excessive wear of the bearing surfaces and loosening of the components—both of which have been documented in multiple publications. But what happens when THA is the most viable solution for a posttraumatic or congenital hip problem in a very young patient because arthrodesis or other osteotomies are not feasible?
In the March 18, 2020 issue of The Journal, Pallante et al. report medium-term outcomes of THA in 78 patients who were ≤20 years of age at the time of surgery, with follow-ups ranging from 2 to 18 years. The findings included the following:
- 10-year survivorship for reoperation of 95.0%
- 10-year survivorship for revision of 97.2%
- 10-year survivorship for complications of 89.5%
Overall, the linear articular wear averaged 0.019 mm/yr in the ceramic-on-ceramic, ceramic-on-highly cross-linked polyethylene, and metal-on-highly cross-linked polyethylene bearings studied, and the average modified Harris hip score in the cohort was 92.
However, despite these impressive clinical and survivorship outcomes, I advise orthopaedists not to lower their resistance to performing THA on these very young patients, many of whom present with hip problems caused by deforming conditions such as Legg-Calve-Perthes disease. We really need 30 to 40 years of outcome data to truly understand what happens with function, revision rates, and wear characteristics in this population. Having said that, I am confident that this group from Mayo will continue reporting on this patient cohort at 5- to 10-year intervals, so that the worldwide orthopaedic community can keep learning from this experience.
Marc Swiontkowski, MD
JBJS is pleased to highlight the orthopaedic residents who help implement the Robert Bucholz Resident Journal Club Grants at their institutions. The purpose of this program is to promote career-long skills in evaluating the orthopaedic literature as it relates to practice decision making among orthopaedic residents. Click here for more information about the grant program.
Name: Carl Herndon, MD
Affiliation: Columbia University Medical Center, New York, NY
What was the topic of the most “dynamic” journal club meeting you have had so far this year?
We recently had a journal club focusing on adult joint reconstruction, and discussed different fixation strategies of implants (broadly cement vs cementless fixation). We evaluated the following 3 studies:
Stea S, Comfort T, Sedrakyan A, Havelin L, Marinelli M, Barber T, Paxton E, Banerjee S, Isaacs AJ, Graves S. Multinational comprehensive evaluation of the fixation method used in hip replacement: interaction with age in context. The Journal of bone and joint surgery. American volume. 2014 Dec;96(Suppl 1):42-51.
Khanuja HS, Vakil JJ, Goddard MS, Mont MA. Cementless femoral fixation in total hip arthroplasty. JBJS. 2011 Mar 2;93(5):500-9.
Nam D, Lawrie CM, Salih R, Nahhas CR, Barrack RL, Nunley RM. Cemented versus cementless total knee arthroplasty of the same modern design: a prospective, randomized trial. The Journal of bone and joint surgery. American volume. 2019 Jul 3;101(13):1185.
Based on your journal club experiences, what are the top 3 characteristics of an engaging, enlightening journal club presentation?
1. Hand-on activities: We always lead off our journal club with a sawbones exercise where senior residents, fellows, and attendings lead junior residents through a topical saw bones. Great to get everyone thinking and a chance for everyone to learn.
2. Multilevel involvement: Having everyone there from interns all the way to senior attendings is critical as we evaluate the literature with different biases and can all learn together.
3. Atmosphere: Reading these articles and discussing them doesn’t have to be boring! Having food or snacks and scheduling it at the end of the day allows for a more laid-back vibe to learning that is conducive to discussion.
What advice about running a top-notch journal club program do you have for residents who will manage a Robert Bucholz Resident Journal Club Grant next year?
Plan it out in advance, and put dates on the calendar for everyone to know when it’s happening. Nothing worse than trying to do all this work and having no one show up!
Aside from orthopaedic content (journals and otherwise), what have you been reading lately?
Once a Runner by John L. Parker Jr. One of my favorite books.
In an OrthoBuzz post from early 2016, JBJS Editor-in-Chief Marc Swiontkowski, MD observed the following about volume-outcome relationships in total hip and total knee arthroplasty: “the higher the surgeon volume, the better the patient outcomes.”
Now, in a national database analysis of >38,200 patients who underwent a reverse total shoulder arthroplasty (RSA), Farley et al. find a similar inverse relationship between hospital volumes of this increasingly popular surgery and clinical outcomes. Reporting in the March 4, 2020 issue of JBJS, they found a similarly inverse relationship between hospital volume and resource utilization.
This study distinguishes itself with its large dataset and by crunching the data into specific hospital-volume strata for each category of clinical outcome (90-day complications, 90-day revisions, and 90-day readmissions) and resource-utilization outcome (cost of care, length of stay, and discharge disposition).
Specifically, on the clinical side, Farley et al. found the following:
- A 1.42 times increased odds of any medical complication in the lowest-volume category (1 to 9 RSAs/yr) compared with the highest-volume category (≥69 RSAs/yr)
- A 1.38 times increased odds of any readmission in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥70 RSAs/yr)
- A 1.88 times increased odds of any 90-day revision in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥54 RSAs/yr)
Here are the findings from the resource-utilization side:
- A 4.03 times increased odds of increased cost of care in the lowest-volume category (1 to 5 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
- A 2.26 times increased odds of >2-day length of stay in the lowest-volume category (1 to 10 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
- A 1.68 times increased odds of non-home discharge in the lowest-volume category (1 to 31 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
Farley et al. say hospital volume should be interpreted as a “composite marker” that is probably related to surgical experience, ancillary staff familiarity, and protocolized pathways. They “recommend a target volume of >9 RSAs/yr to avoid the highest risk of detrimental 90-day outcomes,” and they suggest that the outcome disparities could be addressed by “consolidation of care for RSA patients at high-performing institutions.”
JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.
Peter A Cole, MD, FAOA
Division Medical Director, HealthPartners Orthopaedics & Sports Medicine
Program Medical Director, HealthPartners Trauma Network
Orthopaedic Trauma Director, Regions Hospital
Professor, University of Minnesota
Regions Hospital – HealthPartners, St. Paul, MN
University of Minnesota, Minneapolis, MN
Years in practice: Since 1998 – 21 years
How did you begin reviewing for other journals and for JBJS in particular?
I think the reviewer invitations began to arrive after I began thematic publishing back in the early 2000’s. Thematic publishing means consecutive publications on the same topic. My own publishing themes included minimally invasive fracture care, complex scapular trauma, and fracture pattern mapping for example. Perhaps, editors use this threshold of success in the peer review process as the qualification for a successful reviewer. I believe achievement in thematic publishing has more to do with being invited, than networking, committee or political positions, or being a nice person, though these things help.
What is your top piece of advice for those reviewers who aspire to reach Elite status?
Thoughtful, structured, scientific, timely reviews—period. No one quality alone is good enough, not even 3 out of 4. I review for three journals consistently, and others on a selective case by case basis. I have rejected many offers to be a journal reviewer in order to protect the integrity of the main three I have chosen. It is hard to turn down experts and friends in order to keep the main thing the main thing.
Aside from orthopaedic manuscripts, what have you been reading lately?
I read and study The Bible consistently, if not daily—as the primary source of wisdom and personal growth. I enjoy books on entrepreneurialism, leadership, spiritual growth and an occasional biography.
Learn more about the JBJS Elite Reviewers program.