Journal Club Resident Spotlight: Jui-Yo Hsu

JBJS is pleased to highlight the orthopaedic residents who help implement the Robert Bucholz Resident Journal Club Grants at their institutions. The grant program promotes career-long skills in evaluating the orthopaedic literatureClick here for more information.

Name: Jui-Yo Hsu

Affiliation: National Taiwan University Hospital

What was the topic of the most “dynamic” journal club meeting you have had so far this year?

In March 2021, we hosted a spine journal club focusing on adolescent idiopathic scoliosis (AIS). It was our pleasure to have Prof. Andrew J. Schoenfeld, deputy editor of JBJS, join our discussion. His remarkable advice and unique insight inspired in-depth discussion. Our advisor and moderator, Prof. Shu-Hua Yang (楊曙華), chairperson of Taiwan Spine Society, who is also a pioneer in the field of AIS research, also provided great support to our journal club. The paper we presented was “Selecting the ‘Touched Vertebra’ as the Lowest Instrumented Vertebra in Patients with Lenke Type-1 and 2 Curves” (J Bone Joint Surg Am. 2020 Nov 18;102(22):1966-1973.) by Beauchamp, et al. All the faculty and residents were highly involved in the discussion. Due to the high relevance of this topic to clinical decision making in surgical correction of AIS, both Prof. Schoenfeld and Prof. Yang shared their viewpoints and precious clinical and surgical experiences with the audience.

What are the top 3 characteristics of an engaging, enlightening journal club presentation?

First, it’s important to keep the journal club intriguing to the participants. Therefore, choosing a good topic plays a key role. Residents will be more involved if the topic is clinically important, related to a familiar surgery, or connects to their own ongoing research. Second, because knowledge of the topic may vary between senior and junior residents, we assign one of our senior residents to provide background knowledge before the discussion. Reading the article and preparing in advance are required for every participant, and we also encourage everyone to come up with several questions before the journal club. Finally, support and participation from the faculty are crucial to the journal club. They can provide clinical experiences to residents and provoke further discussion. It is even more beneficial if the participants discuss their own cases with both colleagues and instructors.

How has the COVID-19 pandemic affected your journal-club activities?

In Taiwan, fortunately we were able to maintain normal lives and all residents and staff were able to participate in the journal club in person, despite the global pandemic. However, due to a local outbreak in Taiwan in early May 2021, restrictions were imposed on indoor gatherings. We therefore decided to host our journal club online. In fact, residents were more engaged in online journal club. Using the chatroom feature, residents were able to ask question at any time without interrupting the speaker, and supplementary materials could be shared by anyone at any time. I believe online meetings may become mainstream in the post COVID-19 era.

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

I have been reading Cribsheet: A Data-Driven Guide to Better, More Relaxed Parenting, from Birth to Preschool, by Emily Oster. It is a remarkable and useful book for first-time parents. I just welcomed my first child in April 2021, and this book provides practical advice in parenting with enormous medical references. Surprisingly, it was written by an economist. I feel more relieved and confident in parenting my son after reading this book.

How has free access to JBJS Clinical Classroom benefitted you and your journal club?

JBJS Clinical Classroom is very helpful in terms of learning orthopaedic knowledge for both junior and senior residents. Its innovative design makes it very easy and efficient to review previously learned concepts. The content is also very neat but with wide coverage across different specialties, which is also very helpful for orthopaedic board exam preparation.

What’s New in Spine Surgery 2021 

Every month, JBJS publishes a review of the most pertinent and impactful studies reported in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries. 

This month, co-author Jacob M. Buchowski, MD, MS summarizes the 5 most compelling findings from the studies highlighted in the recently published “What’s New in Spine Surgery.” 

Degenerative Cervical Myelopathy

–In a multicenter, double-blinded, placebo-controlled, randomized phase-3 trial, investigators found no additional benefit from riluzole use with regard to functional outcome scores among patients who underwent decompression and fusion for cervical myelopathy1. The primary outcome of interest was the change in the modified Japanese Orthopaedic Association (mJOA) score at 6 months. 

Dysphagia After Multilevel ACDF

–A Level-I double-blinded randomized controlled trial demonstrated a significant decrease in the severity of dysphagia after multilevel anterior cervical discectomy and fusion (ACDF) among patients who received local intraoperative corticosteroids (56 in the treatment group vs 53 in the control group)2. 

Preop. Epidural Steroid Injection and Postop. Infection 

–A retrospective study of patients who underwent lumbar spine surgical procedures for radiculopathy and/or spinal stenosis3 found that: 

  • In the decompression group, there was no significant difference in the postoperative infection rate between those who had a preoperative epidural steroid injection (2,957 of 9,903) and those who did not.  
  • Among those who underwent fusion, there was a significantly higher rate of infection (2.68%) for those who had preoperative epidural steroid injection (1,383 of 5,108) vs those who did not (1.69%).  
  • In the fusion group, there was a significantly higher rate of infection for those who had a steroid injection within 30 days or >90 days preoperatively, but patients with injection between 30 and 90 days preoperatively had no increased risk of postoperative infection. 

Adolescent Idiopathic Scoliosis (AIS)

–In a Level-IV study, investigators examined the relationship between thoracic morphology and pulmonary function in patients with AIS (mean age, 15.6 years)4. They found a strong positive correlation between the costophrenic angle distance and forced vital capacity, FEV1, vital capacity, and total lung capacity, suggesting that the costophrenic angle distance can be used to assess pulmonary function outcome. Their findings also suggest that an apical vertebral deviation ratio of >0.2 is associated with moderate to severe impairment of lung function. 

Early-Onset Scoliosis (EOS) 

–In a cross-sectional study of prospectively enrolled patients across multiple centers, investigators examined the influence of the classification of EOS etiology, radiographic parameters, and medical comorbidities on the Early Onset Scoliosis Questionnaire (EOSQ), a measure of health-related quality of life. Scores were lower in many EOSQ domains for patients with neuromuscular and syndromic etiologies. The total and subdomain scores were similar between patients with congenital and idiopathic EOS.  

References 

  1. Fehlings MG, Badhiwala JH, Ahn H, Farhadi HF, Shaffrey CI, Nassr A, Mummaneni P, Arnold PM, Jacobs WB, Riew KD, Kelly M, Brodke DS, Vaccaro AR, Hilibrand AS, Wilson J, Harrop JS, Yoon ST, Kim KD, Fourney DR, Santaguida C, Massicotte EM, Kopjar B. Safety and efficacy of riluzole in patients undergoing decompressive surgery for degenerative cervical myelopathy (CSM-Protect): a multicentre, double-blind, placebo-controlled, randomised, phase 3 trial. Lancet Neurol. 2021 Feb;20(2):98-106. Epub 2020 Dec 22. 
  2. Kim HJ, Alluri R, Stein D, Lebl D, Huang R, Lafage R, Bennett T, Lafage V, Albert T. Effect of topical steroid on swallowing following ACDF: results of a prospective double-blind randomized control trial. Spine (Phila Pa 1976). 2021 Apr 1;46(7):413-20.  
  3. Kreitz TM, Mangan J, Schroeder GD, Kepler CK, Kurd MF, Radcliff KE, Woods BI, Rihn JA, Anderson DG, Vaccaro AR, Hilibrand AS. Do preoperative epidural steroid injections increase the risk of infection after lumbar spine surgery? Spine (Phila Pa 1976). 2021 Feb 1;46(3):E197-202. 
  4. Deng Z, Luo M, Zhou Q, Yang X, Liu L, Song Y. Relationship between pulmonary function and thoracic morphology in adolescent idiopathic scoliosis: a new index, the “apical vertebra deviation ratio”, as a predictive factor for pulmonary function impairment. Spine (Phila Pa 1976). 2021 Jan 15;46(2):87-94. 

 

Cross-Cultural Mentorship in Orthopaedic Surgery

Source: Association of American Medical Colleges (AAMC).

In a new JBJS “What’s Important” article, Dr. David N. Bernstein and Dr. Addisu Mesfin discuss cross-cultural mentorship in orthopaedics, offering their personal reflections as a Black mentor and White mentee.

As the authors state, “Recent events in the United States have magnified our society’s continued struggle to effectively address structural racism. While many within the medical community have pledged to tackle race-related injustices, much of the measurable progress will take time to quantify accurately. However, one of the ways in which positive change may happen, and happen more expeditiously, is through active efforts to recruit Black learners into medical school and residency programs so that the country’s physician workforce is truly more representative of the populations it serves. Indeed, many in medicine, including leaders within orthopaedic surgery, have turned their attention toward this critical mission… It is no secret that mentorship is crucial to the professional and personal development of physicians and scientists, especially as a means to improve real diversity and inclusion, not just the appearance of it…” Read the full article here.

Use of Machine Learning to Predict Improvement After Hip Arthroscopy 

The management of expectations is crucial when counseling patients undergoing treatment for a musculoskeletal injury or condition. In hip arthroscopy, this is especially critical when discussing with patients—including athletes seeking to return to play—their anticipated outcomes following surgical treatment for femoroacetabular impingement syndrome (FAIS).

In the latest issue of JBJS, Kunze et al. report on their investigative efforts to develop and internally validate machine learning algorithms that can yield patient-specific predictions of which athletes will reach clinically relevant improvement in function after arthroscopy for FAIS.

A total of 1,118 athletes, identified through a retrospective review of clinical registry data, met the inclusion criteria. The primary outcome was attaining the minimal clinically important difference (MCID) in the Hip Outcome Score-Sports Subscale (HOS-SS) at a minimum of 2 years postoperatively. Six machine learning algorithm models were tested.

The authors found that 23.1% of the athletes did not achieve the MCID for the HOS-SS. Six variables optimized algorithm performance, with the following cutoffs found to decrease the likelihood of achieving the MCID:

  • Preoperative HOS-SS score of ≥58.3
  • Tönnis grade of 1 (early osteoarthritis)
  • Alpha angle of ≥67.1° on anteroposterior radiograph
  • Body mass index (BMI) of >26.6 kg/m2
  • Tönnis angle of >9.7° (indicating subtle instability or dysplasia)
  • Patient age of >40 years

The elastic-net penalized logistic regression (ENPLR) model was the most accurate model in this study.

The findings suggest that patient selection is paramount to the ability to achieve clinically relevant improvements in outcomes for patients treated with arthroscopy for FAIS. Multiple studies have demonstrated that increasing arthritis level and age, along with BMI, are associated with inferior patient-reported outcomes. In addition, hip instability and increased Tönnis angle have been shown to be associated with worse outcomes following hip arthroscopy. A greater alpha angle indicates a larger “deformity” and thus the potential for more damage at the time of surgery that cannot be completely addressed with today’s surgical techniques. “Higher” preoperative HOS-SS (although on a scale of 0 to 100, 58 is not that high) may make it more difficult for a patient to achieve enough of an improvement in their outcome score to be considered as having attained the MCID.

The ENPLR  model was converted into an open-source application, although as Kunze et al. point out, external validation is necessary before wider adoption of the application. Nonetheless, the model demonstrates the potential to help hip surgeons better educate our patients on expected outcomes and to assist with proper patient selection for the ever-evolving treatment of FAIS.

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

Co-author Kyle N. Kunze, MD discusses this study in an “Author Insights” video, found here.

JOPA Writing Award Spotlight: Christy Rose

The JBJS Journal of Orthopaedics for Physician Assistants (JOPA) continues the tradition of recognizing outstanding review articles and case studies submitted during the previous year by practicing PAs, NPs, and PA students. OrthoBuzz is pleased to spotlight the winners of the 2020 JBJS JOPA Writing Awards. 

Name: Christy W. Rose, MSM, PA-C

Affiliations: University Orthopedic Surgeons, Division of Ortho Tennessee; University of Tennessee Medical Center, Knoxville

JOPA Article: “The Great Mimicker: Atypical Gout Presentations from an Orthopaedic Oncology Perspective

Tell us about your paper.

This paper presents 5 patients who were referred to our orthopaedic oncology clinic for atypical osseous and soft-tissue lesions or masses. Some of the lesions even appeared malignant on initial imaging, but once biopsy results were obtained, the pathology was consistent with gout. Gout is known as the “great mimicker” because it does a fantastic job of disguising itself as other disease processes. This paper highlights some of those atypical presentations with the hope that other providers will keep gout on their list of potential diagnoses when these patients present. We also cover some suggestions when working up osseous and soft-tissue masses and discuss when it is appropriate to refer to an orthopaedic oncologist.

How did you decide to write on this topic? What was the most interesting “take-away,” in your opinion?

At our institution, we treat everything from sarcomas to lipomas and everything in-between. These cases were particularly interesting to me because they were all referred to us for concerns of more nefarious diagnosis. When the patients present to our clinic, sometimes they are terrified because they were told that they had cancer even before a tissue diagnosis was obtained. These cases highlight that “nothing is certain until it is certain.” I know that this is not a profound statement, but I feel like we need to be up front with our patients and educate them on potential diagnosis, but at the same time, don’t crush their hope that something less threatening may be going on.

What do you enjoy most about your career?

My supervising physician, Dr. Anna Wallace, and I are honored and deeply humbled to have the privilege to walk with patients as they the go through their various oncologic treatments and pre- and postoperative process. These patients are so inspiring and encouraging to me because they are warriors, and they keep fighting. The outcomes aren’t always joyful (cancer stinks), but they can leave an impression on you that changes you.

How do you stay informed about new developments in orthopaedics?

I attend conferences, read journal articles, and listen to CME lectures through various apps.

What are you currently reading/listening to/watching?

My husband and I have 3 children, ages 7, 5, and 2. At home, we watch a lot of PAW Patrol, Bluey, and various Lego movies. When we are not watching something animated, we enjoy the Marvel spin-off series. When I can find time for pleasure reading, I enjoy devotionals targeted at working moms and historical fiction.

More details about the JBJS JOPA Writing Awards can be found here.

E-Scooter Injury Data Can Help Inform Treatment Planning

Epidemiologic studies are often useful when it comes to detecting changes in treatment patterns, identifying disease trends, or understanding the acceptance of a new treatment. A recent study by Shichman et al. helps bridge the span between epidemiologic data and direct clinical care. In the June 16, 2021 issue of JBJS, the authors report on the fracture patterns and the mechanisms and management of injuries related to the use of electric scooters (e-scooters) as documented in their trauma center in Tel-Aviv, Israel. Among their findings:

  • A total of 716 fractures were diagnosed in 563 patients during the study period (2017 to 2020); 46.6% of the patients required hospitalization. Surgical treatment was recommended for 225 fractures.
  • Of the 492 upper-limb fractures, 89.2% occurred in a rider fall, and of the 210 lower-limb fractures, 15.7% occurred in rider-vehicle collisions. Head concussions and maxillofacial injuries were the most common associated injuries.
  • By AO/OTA classification, a radial-head fracture (2R1A, 2R1B, 2R1C) was the most common upper-limb fracture, followed by a distal radial fracture (2R3A, 2R3B, 2R3C). The most common upper-limb procedure was open reduction and internal fixation (ORIF) of the distal part of the radius.
  • The most common lower-limb fracture was a tibial plateau fracture (AO/OTA 41A, 41B, 41C). ORIF of the proximal part of the tibia was the most common lower-limb procedure.

The use of e-scooters is expanding in metropolitan areas worldwide, primarily in the form of street rentals. E-scooters can reach speeds in excess of 25 mph, and they require some practice in steering and braking. While an appealing alternative form of transportation for many, they present concerns and challenges related to safety.

The report by Shichman et al. can help trauma centers and orthopaedic surgeons understand the injury patterns they may encounter, and their potential incidence, should an e-scooter service become popular in their city. Such data can support the planning of resources to manage any increase in moderate-velocity vehicular injuries—and help inform conversations on e-scooter safety.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Co-author Ittai Shichman, MD discusses this study in an “Author Insights” video, found here.

Video Summary: Diagnostic Utility of a Point-of-Care Test of Calprotectin for PJI After TKA

A new JBJS video summary is available now. View the video below, and read the full article here.

Isoelastic Monoblock vs Modular Press-Fit Cup 

As the volume of total hip arthroplasty (THA) cases continues to rise, so too will the need for revision surgery. Revision THA can be complicated by insufficient bone stock on either the femoral or acetabular side, and researchers are gaining further insight into bone loss potentially related to implant design, such as loss that may occur through stress-shielding from press-fit implants.  

 In a randomized controlled trial recently reported in JBJS, Brodt et al. evaluated reduction in bone mineral density (BMD), primarily periacetabular BMD, as measured in 2 groups: patients who received a press-fit isoelastic monoblock cup (24 patients analyzed) and those who received a modular titanium press-fit cup (23 patients analyzed). At question was whether an isoelastic monoblock cup, with an elastic modulus similar to that of bone, would lead to less stress-shielding and thus less bone loss compared with a conventional modular titanium cup. 

Periprosthetic BMD was assessed at 1 week postoperatively (baseline) and at 4 years postoperatively using dual x-ray absorptiometry (DXA). The authors evaluated 4 regions of interest (ROIs) around the acetabular component and 7 ROIs around the femoral component based on regions previously described in the literature for assessing periprosthetic bone loss. 

Baseline patient characteristics, operative time, and improvement in clinical outcome scores did not differ between the groups.  A decrease in overall periacetabular BMD was found in both groups, but the difference between the groups was not significant. 

However, the researchers found a significant difference between the groups in BMD changes in certain periprosthetic regions. On the acetabular side, the group with the modular titanium cup had a 15.9% decrease in BMD in zone 2 (the superior pole of the acetabulum) compared with a decrease of 4.9% in the group with the isoelastic monoblock cup. And on the femoral side, the group with the modular titanium cup had a 15.4% decrease in BMD in zone 1 (along the greater trochanter) compared with a loss of 7% in the group with the isoelastic monoblock cup. None of the other regions differed significantly between the groups.   

Despite the relatively short follow-up and small (but adequately powered) numbers, these results are worthy of our consideration. I agree with the authors that longer follow-up is needed before conclusions can be drawn. As implant design can impact component longevity, it is critical that we evaluate differences to better understand the long-term implications. 

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

 

JBJS Webinar June 28–Femoral Neck Fractures: The THA vs Hemi Toss-Up

Consulting with their patients, orthopaedic surgeons make many decisions each day by weighing the best evidence available. One frequent—and controversial—decision is how best to treat displaced femoral neck fractures, a common injury among elderly patients.

Often this choice comes down to hemiarthroplasty (HA) or total hip arthroplasty (THA). The preponderance of evidence suggests that outcomes from both procedures are nearly equivalent. On Monday, June 28, 2021 at 8 pm EDT, JBJS will host a complimentary 1-hour webinar delving into the most recent findings about this dilemma. 

Mohit Bhandari, MD, PhD will present findings from a 2020 Level-I meta-analysis of 16 randomized controlled trials. Functional outcomes and 5-year rates of revision and dislocation were similar between groups. THA eked out a small advantage in health-related quality of life, and HA yielded minor reductions in operative time.

Bheeshma Ravi, MD, PhD will discuss data comparing the 2 procedures in terms of complications and costs. Based on findings from this propensity score-matched analysis, the nod goes to THA, with lower 1-year rates of revision surgery and lower health-care costs. 

Moderated by Bassam A. Masri, MD, FRCSC, the webinar will feature expert commentaries on these “neck-and-neck” findings. Pierre Guy, MD will comment on Dr. Bhandari’s paper, and Kelly Lefaivre, MD will weigh in on Dr. Ravi’s paper. 

The webinar will conclude with a 15-minute live Q&A session during which attendees can ask questions of all the panelists. 

Seats are limited–so Register Today!  

CME credit will be available for surgeons and PAs attending this event live for a minimum of 50 minutes. Directions to claim your CME credit will be sent out within 48 hours of the broadcast.