Elite Reviewer Spotlight: Peter Murray

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.

Name: Peter M. Murray, MD

Affiliation: Mayo Clinic, Jacksonville, FL

Years in practice: 27 years

How did you begin reviewing for other journals and for JBJS in particular?

Personal invitations

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Concentrate on the methodology of the manuscript you are reviewing – most manuscript problems can be traced back to faulty methodology.

Aside from orthopaedic manuscripts, what have you been reading lately?

The Biography of Ulysses S. Grant.

Learn more about the JBJS Elite Reviewers program.

Orthopaedic Interns Across Chicago Learn and Bond in Journal Club

OrthoBuzz occasionally receives posts from guest bloggers. The following contribution comes from Rob Christian, MD and Maddy Lyons, MD.

Editor’s Note: The application deadline for the 2019-2020 JBJS Robert Bucholz Resident Journal Club Grant Program has been extended to November 1, 2019.

Junior residents often hear attendings, fellows, and senior residents quote landmark studies, but few find the time to track down and read these important papers on their own. So, when the Northwestern University Orthopaedic Residency Program was awarded one of the JBJS Robert Bucholz Resident Journal Club Grants, Haley Smith, MD (PGY-2) and I used the funding to pilot an Intern Journal Club, inviting all the interns in orthopaedic surgery residency programs across Chicago to read and discuss landmark studies.

Over the last decade, several hospitals in Chicago, such as John H. Stroger, Jr. Hospital of Cook County and Ann & Robert H. Lurie Children’s Hospital of Chicago, have trained teams of orthopaedic residents from multiple programs. Working in the hospital with residents from different programs is a great educational experience, and we thought these resident teams could be even more effective if they interacted with one another prior to working together in the hospital.

Our Intern Journal Club met quarterly, and had impressive attendance, especially considering the busy intern work schedule. Each journal club session featured 4 to 5 landmark studies (suitable for PGY-1s), and discussions were led by senior residents selected across the programs.  Articles discussed came from all orthopaedic subspecialties. In addition to literature-based discussions, the get-togethers fostered collegial relationships among the different programs.

For me, the most rewarding part of the Intern Journal Club has been meeting the interns as they begin their residencies and guiding discussion to help them think critically about orthopaedic literature. With the continued support of the JBJS Robert Bucholz Resident Journal Club Grant, we look forward to continuing to host the Intern Journal Club for this year’s intern class.

Rob Christian, MD (PGY-5)
McGaw Medical Center of Northwestern University

*          *          *          *

Initially, the JBJS Chicago Intern Journal Club felt like it was adding articles to an endless intern reading list. However, it turned out to be one of the more valuable and fun educational experiences of my intern year.

The meetings provided the unique opportunity to meet residents from the other Chicago programs. Exchanging stories of intern-year trials and tribulations quickly bonded our group. It was interesting to discover the differences and similarities in our programs, our rotations, and even in the ways in which we manage injuries. In addition to building relationships with peers across programs, the journal clubs allowed me to connect with senior residents who have similar career interests and build several new mentorships.

The articles that we read and discussed were landmark studies that shape the practice of orthopaedics on a daily basis. Through morning conferences, OITE practice questions, and clinical care, interns are exposed repeatedly to fundamentals of orthopaedics, such as open fracture management and functional bracing of humeral shaft fractures. However, without our Intern Journal Club, I may not have explored the studies on which these practice-shaping principles are built. An open, discussion-based format with senior residents helped me understand the “whys” of what we are taught.

We are fortunate to have so many great orthopaedic residency programs in Chicago, each with unique strengths. I hope that our Intern Journal Club continues in the years to come to inspire future collaboration in educational, social, and networking events among the local residency programs.

Maddy Lyons, MD (PGY-2)
Loyola University Medical Center

What’s New in Shoulder and Elbow Surgery 2019

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 all such OrthoBuzz summaries. This month, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from the 50 studies summarized in the October 16, 2019 “What’s New in Shoulder and Elbow Surgery.

Rotator Cuff Repair
–A randomized controlled trial compared immediate and delayed surgical repair of partial-thickness rotator cuff tears.1 No differences in retear rates were found, suggesting that a trial of nonoperative management remains appropriate for partial-thickness tears.

–The search continues for biologic augmentations to improve healing after rotator cuff repair. A study that randomized patients to weekly human growth hormone injections for 3 months or no injections after repair of a large tear found no difference in healing rates.2 Another randomized study of the effect on cuff-repair healing of platelet-rich plasma in a fibrin matrix found no improvement.3 A similar randomized trial of platelet-rich plasma plus thrombin in patients with a single-row repair of the supraspinatus found no differences in clinical outcomes or healing rates.4

–Psychosocial factors have been associated with pain relief and functional improvement after rotator cuff repairs. A longitudinal cohort study found that higher fear-avoidance behavior and alcohol use of ≥1 to 2 times per week compared with alcohol use ≤2 to 3 times per month negatively impacted shoulder pain and function at 18 months postoperatively.5

Osteochondritis Dissecans of the Capitellum
–A study evaluated predictors of success of nonoperatively treating patients with osteochondritis dissecans of the capitellum who did not have fluid underneath the fragment.6 Researchers found that lesion healing was associated with the following:

  • Smaller overall lesion size
  • No clear margins of the fragment on MRI
  • Absence of cyst-like lesions

The authors include a nomogram that clinicians can use to predict healing.

UCL Insufficiency
–A study investigated baseball position-specific factors affecting return to play after ulnar collateral ligament (UCL) reconstruction.7 Investigators found the following:

  • Position players returned to play sooner than pitchers, but they had lower rates of return to play.
  • Catchers had the lowest likelihood of return to play (58.6%) and pitchers had the highest (83.7%).

These findings could help clinicians set expectations for players undergoing UCL reconstruction.

References

  1. Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair after 6-month period of nonsurgical treatment. Am J Sports Med.2018 Apr;46(5):1091-6. Epub 2018 Mar 5.
  2. Oh JH, Chung SW, Oh KS, Yoo JC, Jee W, Choi JA, Kim YS, Park JY. Effect of recombinant human growth hormone on rotator cuff healing after arthroscopic repair: preliminary result of a multicenter, prospective, randomized, open-label blinded end point clinical exploratory trial. J Shoulder Elbow Surg.2018 May;27(5):777-85. Epub 2018 Jan 11.
  3. Walsh MR, Nelson BJ, Braman JP, Yonke B, Obermeier M, Raja A, Reams M. Platelet-rich plasma in fibrin matrix to augment rotator cuff repair: a prospective, single-blinded, randomized study with 2-year follow-up. J Shoulder Elbow Surg.2018 Sep;27(9):1553-63. Epub 2018 Jul 9.
  4. Malavolta EA, Gracitelli MEC, Assunção JH, Ferreira Neto AA, Bordalo-Rodrigues M, de Camargo OP. Clinical and structural evaluations of rotator cuff repair with and without added platelet-rich plasma at 5-year follow-up: a prospective randomized study. Am J Sports Med.2018 Nov;46(13):3134-41. Epub 2018 Sep 20.
  5. Jain NB, Ayers GD, Fan R, Kuhn JE, Baumgarten KM, Matzkin E, Higgins LD. Predictors of pain and functional outcomes after operative treatment for rotator cuff tears. J Shoulder Elbow Surg.2018 Aug;27(8):1393-400.
  6. Niu EL, Tepolt FABae DSLebrun DGKocher MSNonoperative management of stable pediatric osteochondritis dissecans of the capitellum: predictors of treatment successJ Shoulder Elbow Surg.2018 Nov;27(11):2030-7.
  7. Camp CL, Conte SD’Angelo JFealy SAFollowing ulnar collateral ligament reconstruction, professional baseball position players return to play faster than pitchers, but catchers return less frequentlyJ Shoulder Elbow Surg.2018 Jun;27(6):1078-85. Epub 2018 Mar 23.

Elite Reviewer Spotlight: Sophia Sangiorgio

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.

Name: Sophia N. Sangiorgio, PhD

Affiliation: Orthopaedic Institute for Children / UCLA Departments of Orthopaedic Surgery and Bioengineering, Los Angeles, CA

Years in practice: I am a biomechanical engineer, specializing in orthopaedic implant performance. I have been working in orthopaedic research for nearly 20 years and on the UCLA faculty for 12 years.

How did you begin reviewing for other journals and for JBJS in particular?

I have been reviewing manuscripts for JBJS for 5 years, and reviewing for other orthopaedic journals, both clinical and biomechanical, for 10 years.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Take time to provide constructive feedback that provides the authors with a chance to respond and the means to improve their manuscript.

Aside from orthopaedic manuscripts, what have you been reading lately?

Current concepts in preventative health, with a focus on increasing health span (prolonging physical and mental performance) and not simply lifespan. I also enjoy reading fiction to relax and unwind.

Learn more about the JBJS Elite Reviewers program.

MRI for Detecting Rapidly Progressive Knee OA: No Crystal Ball

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Knee osteoarthritis (KOA) typically develops over a decade or more. However, 1 in 5 people with KOA have more pain and disability at onset, have accelerated radiographic knee osteoarthritis (AKOA), and experience end-stage disease within 4 years. The use of demographics and clinical findings has resulted in only a 40% rate of correctly classifying patients who will develop AKOA instead of longer-term KOA.

Investigators recently conducted a case–control study using data from the OsteoArthritis Initiative (OAI), including demographic, clinical, and biochemical data, along with radiographic and magnetic resonance (MR) imaging data.1 The researchers hypothesized that the addition of an MR imaging-based scoring system would more accurately identify patients at risk for AKOA. They used classification and regression tree (CART) models to assess the ability of baseline MR features to classify participants who will develop AKOA and whether adding baseline MR features to an existing model improved classification of adults who will develop AKOA.

The existing model consisted of clinical data that included pain, function, physical exam findings, and quality-of-life measures. Demographic data included age, sex, and BMI collected at baseline. Biochemical data included high-sensitivity C-reactive protein and serum blood sugar. Data obtained from MR imaging scores included bone marrow lesion volume, effusion-synovitis volume, cartilage damage index, meniscal extrusion and degeneration, cruciate ligament degeneration, and patellar fat pad changes.

Contrary to the hypothesis, the CART models with and without MR features each explained approximately 40% of the variability. Adding MR-based features to the model improved specificity (0.90 vs. 0.82), but lowered sensitivity (0.62 vs. 0.70). Interestingly, the authors found that serum glucose, effusion-synovitis volume, and cruciate ligament degeneration were statistically important variables in classifying individuals who are likely to develop AKOA.

The clinical take home is that early MR data may be useful in sorting out mechanical complaints, but not in determining who will develop AKOA. In contrast, in later stages of KOA, MR images may reveal far greater damage than can be detected on radiographs.

Reference

  1. Price LL, Harkey MS, Ward RJ, MacKay JW, Zhang M, Pang J, Davis JE, McAlindon TE, Lo GH, Amin M, Eaton CB, Lu B, Duryea J, Barbe MF, Driban JB. Role of Magnetic Resonance Imaging in Classifying Individuals Who Will Develop Accelerated Radiographic Knee Osteoarthritis. J Orthop Res. 2019 Nov;37(11):2420-2428. doi: 10.1002/jor.24413. Epub 2019 Jul 29. PMID: 31297900

“Appropriate” Management of Distal Radial Fractures Improves Outcomes, Lowers Cost

Many surgeons realize that to improve value, we must improve the quality of care while decreasing its cost. Clinical Practice Guidelines (CPGs) developed by the AAOS and other medical societies are designed to help improve the quality of care and safety for patients, while also reducing inappropriate care and decreasing cost. Unfortunately, the evidence used for the development of CPGs is often of mixed quality. It is therefore crucial that studies evaluate patient outcomes when clinicians do and do not adhere to CPGs, so we can ensure that the guidelines are achieving their objective of improving care.

In the October 16, 2019 issue of The Journal of Bone and Joint Surgery, Giladi et al. hypothesize that adhering to Recommendation 3 of the AAOS CPG regarding radiographic indications for operative management of distal radial fractures would yield improved patient outcomes and cost benefits. Recommendation 3 of the CPG suggests that fractures with post-reduction radial shortening of >3 mm, dorsal tilt of >10°, or intra-articular displacement or step-off of >2 mm should be operatively treated. The authors retrospectively reviewed 266 patients, 145 of whom were treated operatively and 121 of whom were treated nonoperatively. Based on the guideline recommendation, only 6 patients were determined to have undergone inappropriate operative fixation, but 68 patients in the nonoperative cohort received inappropriate treatment; many of those had higher-grade fractures that, per the guideline, should have been surgically treated.

Using QuickDASH outcome scores at 4 time points up to 1 year and 1-year direct cost data, the authors compared the appropriately treated operative cohort to both the appropriate and inappropriate nonoperative groups. They also compared the appropriate and inappropriate nonoperative groups to each other. QuickDASH outcomes for appropriate nonoperative treatment were better than those for inappropriate nonoperative treatment at 1 year. In addition, inappropriate nonoperative treatment cost 60% more than appropriate nonoperative treatment. Although this cost comparison did not reach statistical significance, (p=0.23), it does  suggest a cost savings with adherence to the CPGs. Appropriately treated operative patients reported less disability than the inappropriately nonoperative group.

As we continue to work at increasing health-care value, it is critical that we review CPGs in action, as Giladi et al. have done in this study.  A potential next step would be to investigate whether the modest improvements in QuickDASH scores noted between appropriate operative treatment and inappropriate nonoperative treatment justify the 6-fold higher cost of operative treatment.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Association ≠ Causation: Are Steroid Injections for OA Risky?

A recent report in Radiology citing possible complications from injecting steroids into painful joints with osteoarthritis (OA) has received lots of attention in the mainstream media. Radiologists from Boston, Germany, and France reviewed the existing literature and found an association between intra-articular steroid injections and a small increased risk of four adverse joint findings: accelerated OA progression, subchondral insufficiency fracture, complications from osteonecrosis, and bone loss. However, the study did not include a control group that did not receive injections, and therefore it cannot be used to assess whether injections are associated causally with the adverse joint findings.

In an interview with Boston radio station WBUR, lead author Ali Guermazi, MD stressed the point that readers should not conclude from this report that steroid injections cause these complications, adding that additional research in this area is “urgently needed.” In the same radio coverage, Jeffrey Katz, MD, a professor of orthopaedic surgery at Boston’s Brigham & Women’s Hospital and a Deputy Editor at JBJS, said patients who have received such injections or plan to should not be overly worried. However, he added that “for clinicians and patients who’ve been doing injections for several years, it’s worth it to pause and say, ‘Do we want to discuss [again] what we think are the benefits and risks of this.’”

Elite Reviewer Spotlight: Kodali Siva Prasad

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.

Name: Kodali Siva Rama Krishna Prasad

Affiliation: Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, Mid-Glamorgan, Wales, United Kingdom.

Years in practice: More than 20 years.

How did you begin reviewing for other journals and for JBJS in particular?

James Heckman was instrumental in establishing me as JBJS reviewer. We developed an intellectual bond, which continued in recent years with admiration for the dynamic leadership of Marc Swiontkowski for successful expansion and diversification of JBJS portfolio of journals. I am also fortunate to share excellent rapport with Editors of JBJS group of journals. I was highlighted by JBJS as a Top Reviewer for two successive years before achieving the current Elite Reviewer status.

I owe it to Greer Richardson for encouraging me as an International reviewer for Foot and Ankle International (FAI). Unusually he sent me two supportive complimentary e-mails regarding excellence of my first review for FAI, which boosted my indifferent initial confidence and laid the foundation for reviewer role for major international journals. Later I enjoyed an eventful close association with David Thordarson, who created the first and only International Assistant Editor post for me in FAI and then facilitated further listing as Editorial Board Member for active participation in Trans-Atlantic tele-conferences of the FAI Editorial Board.

I started as a reviewer for Clinical Orthopaedics and Related Research (CORR), when Richard Brand was Editor in Chief. I developed during Seth Leopold’s tenure as I was selected as a Top Reviewer for CORR and subsequently designated as an International Associate Editor with inspirational glimpses of editorial dynamics in implementation of a different philosophy of direction and publication of contemporary orthopaedic research with emphasis on quality of evidence and insights. In addition, a chance meeting in London with James Scott, the then-Editor-in-Chief, heralded reviewer role on this side of the Atlantic for JBJS Br (later designated Bone and Joint Journal) with subsequent addition of Bone and Joint Research.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

A perfect study does not exist and it follows that a perfect review is unattainable. Consistent efforts for excellence toward perfection as a hallmark of a review remain the ultimate aim. Conscious time limit, however, is not the main objective. It helps to expedite a review if the manuscript is read on the first day of acceptance with preliminary notations and certain undercurrents of thinking and analysis. At times, I follow it up with recent relevant literature review to clarify any doubtful issues and read the manuscript again after one or two days to draft the review in earnest. Knowing the particular journal well helps immensely. In my experience, the first draft of a review is not always the final draft. I would not submit a review until I am happy that it is comprehensive and certainly final. Recommendation also entails an element of balanced judgment. In the context of consistent efforts for uncompromising pursuit of excellence of reviews, the aim for Elite Reviewer status amounts to an incidental goal in the service of science and humanity as a team.

Aside from orthopaedic manuscripts, what have you been reading lately?

I regularly read classics and have a collection of several century-old Editions. It is a great pleasure to leaf through the great works of previous centuries. Recently I read a comparative work between Kalidasa and Shakespeare, arguably the greatest poets and dramatists in Sanskrit and English literature. Of late, I have become an admirer of John Greenleaf Whittier. I am also an avid reader of Victor Hugo, an illustrious French poet and novelist, whose prose even in translation sounds poetic. We had an occasion to visit the Residence of Victor Hugo in exile in Guernsey.

Finally, Keats remains a favourite poet. Pertinent to review of manuscripts, Keats’ famous first line of the first draft of Endymion was “A thing of beauty is forever a joy”, which he later modified to “A thing of beauty is a joy for ever”. This illustrates that even a greatest poet has to work on the first inspiration with an admittedly rare revision even after publication – highly relevant to a reviewer, particularly an Elite reviewer.

Learn more about the JBJS Elite Reviewers program.

ACL Grafts: Diameter Does Matter, Sort Of

Clinical failure of anterior cruciate ligament (ACL) reconstructions continues to be a too-common scenario. The increasing incidence of ACL revision is due to a variety of factors, including greater intensity of postsurgical physical activity, technical issues, and anatomical influences of the proximal tibia and distal femur. Registries are important sources of data for ACL-related investigations, but I think they are most useful in clarifying experimental designs for more sophisticated clinical research.

In a cohort study in the October 16, 2019 issue of The Journal, Snaebjornsson et al. examined the influence of ACL graft diameter on the risk of revision surgery over 2 years in >18,000 subjects whose data resided in the national knee ligament registries of Sweden and Norway. The vast majority of those patients (92.8%) received a hamstring autograft, with 7.2% receiving a patellar tendon autograft. Overall, the 2-year rate of ACL revision was 2.63% for patellar tendon autografts and 2.08% for hamstring autografts, a statistically nonsignificant difference in relative risk.

However, the authors found an important correlation between graft diameter in the hamstring tendon cohort, with autografts <8 mm in diameter being associated with a higher risk of revision, compared with larger-diameter hamstring autografts. Additionally, patients treated with hamstring graft diameters of ≥9 mm or ≥10 mm had a lower risk of ACL revision surgery than those treated with patellar tendon grafts of any size.

One key limitation that should influence our interpretation of this study is a lack of detail regarding how compliant surgeons were intraoperatively with the use of the measurement device that is depicted in the manuscript and shown above. In addition, the limitations of registry data did not permit the authors to adjust for postsurgical exposures, such as return to sport, the increasing intensity of which makes rerupture more likely. Additional relevant information that would have aided interpretation of the findings includes the relative size of the tibia and femur, lateral condyle size and shape, and proximal tibial slope.

Despite these limitations, this study should prompt further research that uses robust clinical designs to more fully investigate the impact of graft diameter on ACL rerupture rates.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Elite Reviewer Spotlight: Robert Arciero

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.

Name: Robert A. Arciero, MD

Affiliation: University of Connecticut Health

Years in practice: 32 years

How did you begin reviewing for other journals and for JBJS in particular?

I was asked by editors and/or associate editors because of my interests in shoulder and knee injuries in sports medicine.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

It may sound trite, but the reviewer must read the manuscript thoroughly and reflect on each aspect of the purpose, hypothesis, methods, results, and conclusion. Each section should be approached with a serious number of “why”s.

I think it is important that the reviewer have some command of the published literature on the particular topic and be willing to review that literature to review or comment on the manuscript.

Reviewing is a tedious process and takes time. It takes me routinely 1 to 2 hours to review properly.

Aside from orthopaedic manuscripts, what have you been reading lately?

I have been reading a lot about the Greatest Generation lately and biographies on some of my sports heroes — Ted Williams, Mickey Mantle etc. I also practice a lot of guitar.

Learn more about the JBJS Elite Reviewers program.