Video Summary: Prevalence and Outcomes of Unexpected Positive Intraoperative Cultures in Presumed Aseptic Revision Hip Arthroplasty

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

Mental Health Phenotypes and Patient-Reported Outcomes in Upper-Extremity Care   

Pain is a remarkable and, at times, poorly understood concept. There has been extensive research showing that patients with the same conditions can experience pain differently and that pain and activity intolerance simply can’t be explained by biomedical factors alone. We have all seen examples in our own clinics as surgeons, how 2 individuals with the same pathology and treatment can have different perceived outcomes.

In the current issue of JBJSMiner et al. explore this very topic in a prospective, cross-sectional study in which they used cluster analysis to identify mental health phenotypes (combinations of various types of misconceptions—unhelpful thoughts or cognitive biases—and symptoms of anxiety or depression) that could potentially help to direct care. A total of 137 adult patients seeking upper-extremity musculoskeletal care completed a survey that included demographics and mental health questionnaires (3 regarding unhealthy thoughts about pain and 2 addressing psychological distress) along with measures of upper-extremity-specific activity tolerance, pain intensity, and pain self-efficacy.

Through a clustering algorithm, 4 mental health phenotypes were identified in the study population:

  • Low misconceptions, low distress (77 patients)
  • Notable misconceptions (36 patients)
  • Notable depression and notable misconceptions (19 patients)
  • Notable anxiety, depression, and misconceptions (5 patients)

The authors observed significant differences in activity tolerance, pain intensity, and pain self-efficacy based on mental health phenotype. Specifically, patients with low misconceptions and low distress had significantly greater activity tolerance and pain self-efficacy than those with notable misconceptions, notable symptoms of depression, and notable psychological distress. Patients with low misconceptions and low distress also had significantly lower pain intensity than those with notable symptoms of depression and notable symptoms of anxiety.

The authors did not find an association between phenotypes and socioeconomic status, as measured by participants’ zip code (used to calculate the home area deprivation index). In addition, they found no difference between phenotypes in terms of discrete traumatic conditions (35% of patients), discrete nontraumatic conditions (47%), and nonspecific diagnoses (18%), although they caution that they may not have had enough balance to detect differences based on diagnostic category.

As surgeons, we must consider psychological factors when counseling our patients. As the authors note, “musculoskeletal specialty and pre-specialty care units can benefit from strategies that anticipate mental and social-health opportunities.” As we increase our understanding of the interplay between mental and physical health, our patients stand to gain.

Co-author David Ring, MD, PhD shares his perspective on this study in the related Author Insights video, found here.

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

Excellence in Peer Review 

As the backbone of the peer-review process, reviewers provide a vital service. JBJS is very grateful to all of our reviewers and thank them for their excellent work. One way we do that is through our Elite Reviewers Program, which recognizes those individuals who consistently provide stellar effort in service to the orthopaedic community, going above and beyond as reviewers. We recently welcomed in a new term of Elite Reviewers, which we do twice a year. More details about the program, and our current Elite Reviewers roster, can be found here. 

JBJS also strives to provide helpful resources for reviewers looking to improve their craft. In that vein, we would like to highlight a recent essay by Jasmine Wallace, the Peer Review Manager at the American Society for Microbiology. In her Scholarly Kitchen blog entry, Wallace offers a series of pointers on how to be a good peer reviewer and avoid the pitfalls of “bad” reviewer behavior. New and veteran reviewers alike might find the tips useful. 

Wallace’s recommendations include keeping track of deadlines and using each journal’s reviewer guidelines to ensure a review is in line with a journal’s goals. (JBJS’ Reviewer Resource Center provides guidelines and much more.) Perhaps most important is Wallace’s emphasis on keeping the “peer” in “peer review”. Wallace states that the “ultimate goal is to strengthen your community of researchers,” both when guiding work to acceptance and even when composing rejections in a way that will help authors to improve their research. 

We thank all of our reviewers for their dedication and hard work. 

Outpatient Orthopaedic Surgery: Recent Trends in the Medicare Population

The performance of orthopaedic procedures in ambulatory surgery centers (ASCs) continues to increase in the US. This practice is accelerating for multiple reasons: patients want to sleep in their own beds, hospitals can present a risky environment for nosocomial infection, inpatient surgical care is more costly, and some surgical teams find greater efficiency functioning in high-volume outpatient surgery centers—to name a few explanations for the shift we’re seeing. Over the last few years it has become clear that, in properly selected patients, certain arthroplasty procedures can be safely performed in the outpatient setting  with high patient satisfaction. Resources can be saved and directed to care that must be delivered in the hospital environment. 

New data on outpatient orthopaedic procedures in the Medicare population are presented in the latest issue of JBJS by Lopez et al., who examined trends in ASC procedure volume, utilization, and reimbursements between 2012 and 2017. They note that: 

  • A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare system during the study period, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case.  
  • Increasing procedure volume was driven significantly by increases in hand procedure volume. 
  • All states but Vermont were found to have ASCs, with most being located in the South (39.8%), followed by the West (26.5%), Midwest (20.1%), and Northeast (13.6%). ASC procedure utilization was strongly associated with metropolitan areas compared with rural areas.  
  • Orthopaedic procedure utilization, including for sports, hand, and spine procedures, was significantly higher in wealthier counties as well as in counties in the South. 

While an analysis of safety was outside the scope of this study, data have been reported elsewhere confirming that safety can be achieved in the outpatient setting. Our community must also address value, paying attention to implant and supply costs to trim waste and conserve resources wherever possible. It is my belief that somewhere around 80% to 85% of all orthopaedic procedures have the potential to be performed in outpatient environments if we expand the indications slowly and carefully along with the practices of regional anesthesia, home nursing care, and after-hours consultative resources to place patients and families at ease with these expanding programs over time.   

Marc Swiontkowski, MD
JBJS Editor-in-Chief 

Patient Perspectives in Orthopaedic Care: JBJS “What’s Important” Series 

Last year, JBJS expanded its popular “What’s Important” article series to include personal essays on what’s important to orthopaedic patients. Since its launch, the Patient Perspective series has included essays spanning a variety of topics—from what it’s like experiencing claustrophobia during an MRI for a shoulder injury, to confronting age-related bias in knee care, to learning to play the role of a “recovery partner” for a spouse following rotator cuff surgery. The importance of communication, compassion, and empathy have stood out among themes of these patient-focused essays. 

In the recently published “What’s Important: A Resilience Found in Running,” author Louise A. Atadja, BA shares her personal story as a longtime athlete who persevered despite the painful challenges of hip dysplasia and femoroacetabular impingement, and who went from orthopaedic patient to medical student inspired to become an orthopaedic surgeon.  

In her essay, she writes,

I would not have been able to get through this recovery without my family, coaches, and close friends, whose support kept me smiling through difficult days. I’m also grateful for the multidisciplinary team that was unwilling to give up on me. … In an age in which medicine is becoming more impersonal, I strongly encourage physicians to continue to find ways to truly connect with patients and not to overlook the whole person in their care.” 

Members of the orthopaedic community are invited to work with patients to submit an essay offering their insights, or to share their own experience “walking in the shoes” of a patient. Manuscripts can be submitted here, and additional guidance on submitting an article can be found at our Instructions for Authors. We remain inspired by the words of wisdom shared in the series to date. 

What’s New in Musculoskeletal Infection 2021

Every month, JBJS publishes a review of the most pertinent and impactful studies published 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 Thomas K. Fehring, MD summarizes the 5 most compelling findings from the >90 studies highlighted in the recently publishedWhat’s New in Musculoskeletal Infection.”

Albumin and Complication Risk

One recent study evaluated the effect of albumin levels on complications following primary and revision total joint arthroplasties (shoulder, elbow, wrist, hip, knee, ankle, or fingers). Patients with lower albumin levels preoperatively were at significantly increased risk for infection, pneumonia, sepsis, and other adverse outcomes compared with patients with normal albumin levels.

Antibiotic Prophylaxis and SSI Risk

–A retrospective cohort study using data from 436,724 total hip arthroplasty (THA) and 862,918 total knee arthroplasty (TKA) procedures examined antibiotic prophylaxis patterns and surgical site infection (SSI) risk1. Patients who received IV antibiotics other than cefazolin preoperatively had a higher risk of SSI.

Corticosteroid Injections and PJI

– A study using a large national database found that patients who underwent TKA and received a postoperative intra-articular corticosteroid injection (5,628 of 166,946 TKAs, 3.4%) had a significantly higher rate of periprosthetic joint infection (PJI) compared with a matched control cohort who did not receive an injection2.

Two-Stage Exchange

–A multicenter randomized controlled trial found that a 3-month course of microorganism-directed oral antibiotics significantly reduced the rate of failure from further infection after 2-stage revision of THA or TKA for chronic PJI3. Among 185 patients, treatment success was achieved for 87.5% of the patients who received 3 months of antibiotics vs 71.4% of those who did not.

Oral Antibiotics in Revision Arthroplasty

–Another multicenter randomized controlled trial evaluated the utility of adding rifampin to conventional antimicrobial therapy in cases of staphylococcal PJI treated with debridement and retention of the implant4. No significant advantage of adding rifampin to standard antibiotic therapy was found.


  1. Zastrow RK, Huang HH, Galatz LM, Saunders-Hao P, Poeran J, Moucha CS. Characteristics of antibiotic prophylaxis and risk of surgical site infections in primary total hip and knee arthroplasty. J Arthroplasty. 2020 Sep;35(9):2581-9. Epub 2020 Apr 18.
  2. Roecker Z, Quinlan ND, Browne JA, Werner BC. Risk of periprosthetic infection following intra-articular corticosteroid injections after total knee arthroplasty. J Arthroplasty. 2020 Apr;35(4):1090-4. Epub 2019 Nov 16.
  3. Yang J, Parvizi J, Hansen EN, Culvern CN, Segreti JC, Tan T, Hartman CW, Sporer SM, Della Valle CJ; Knee Society Research Group. 2020 Mark Coventry Award: microorganism-directed oral antibiotics reduce the rate of failure due to further infection after two-stage revision hip or knee arthroplasty for chronic infection: a multicentre randomized controlled trial at a minimum of two years. Bone Joint J. 2020 Jun;102-B(6_Supple_A):3-9.
  4. Karlsen ØE, Borgen P, Bragnes B, Figved W, Grøgaard B, Rydinge J, Sandberg L, Snorrason F, Wangen H, Witsøe E, Westberg M. Rifampin combination therapy in staphylococcal prosthetic joint infections: a randomized controlled trial. J Orthop Surg Res. 2020 Aug 28;15(1):365.

BMI Differentially Moderates Heritability of THA and TKA for Osteoarthritis

Genetic susceptibility to orthopaedic conditions is of interest to clinicians and patients alike. While the link between genetics and certain pediatric conditions is known, studies of sets of twins are providing new insights into adult issues, such as osteoarthritis, and the impact that genetics may have.

In the current issue of JBJS, Hailer et al. report on an investigation in Sweden in which they analyzed genetic susceptibility to hip and knee osteoarthritis necessitating total hip arthroplasty (THA) or total knee arthroplasty (TKA), and whether body mass index (BMI) moderates the heritability of these outcomes. They linked nearly 30,000 twin pairs with BMI information in the Swedish Twin Registry with the Swedish National Patient Register to identify twins who had undergone THA or TKA with a primary diagnosis of osteoarthritis. Structural equation modeling was then used to calculate the heritability of osteoarthritis treated with THA or TKA and how it related to BMI, age, and sex.

The authors note that, for radiographically defined knee osteoarthritis, previous twin studies have shown that the genetic susceptibility (“the proportion of the variation of a trait that can be attributed to the variation of genetic factors”) is between 0.4 to 0.8. In twin studies using total joint replacement as the outcome, heritability has been estimated to be 0.2 for TKA and 0.5 for THA.

Hailer et al. found that, on average in their cohort, approximately half of the susceptibility to undergo THA or TKA for osteoarthritis was explained by heritability, with similar estimates demonstrated for the 2 procedures: THA, 0.65 (95% CI, 0.59 to 0.70) and TKA, 0.57 (95% CI, 0.50 to 0.64). Of note, heritability decreased with higher BMI in both men and women for THA and in men for TKA. But in women, heritability for TKA increased with higher BMI (0.37 for a BMI of 20 kg/m2 and 0.87 for a BMI of 35 kg/m2).

Although the need for THA or TKA is not a perfect indicator of osteoarthritis (plenty of osteoarthritis does not become symptomatic enough to warrant total joint arthroplasty), this large study offers further data on the question of genetic susceptibility to the development of osteoarthritis. Understanding the influence of obesity (a modifiable risk factor) becomes increasingly important and warrants continued investigation in studies exploring heritability in relation to orthopaedic conditions. 

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

Ten-Year Results of the BIRMINGHAM HIP Resurfacing Implant System 

There have been 3 historic cycles of interest in surface replacement of the hip in the last 40 years. The second cycle occurred in the 1980s into the 1990s, when very high failure rates were reported. Biomaterial and design advancements fueled the most recent cycle of interest, which began 12 to 15 years ago. However, the enthusiasm that occurred at the advent of this most recent cycle ebbed as it became increasingly apparent that patient selection is critical and that the fairly difficult hip resurfacing procedure requires experience to reproducibly place the implants correctly. 

In the latest issue of JBJS,  Su et al. report the 10-year results of the post-market-approval study of the BIRMINGHAM HIP Resurfacing (BHR) implant system, a metal-on-metal system approved by the U.S. Food and Drug Administration in 2006. The study included a cohort of 280 hips (253 patients) undergoing primary BHR procedures across 5 sites. The mean patient age at the time of surgery was 51 years; 74% of the BHRs were implanted in male patients, and 95% of the hips had a diagnosis of osteoarthritis.  

Among the findings: 

  • 10-year survivorship free from all-cause component revision was 92.9%. Among male patients <65 years of age at the time of the procedure, the rate was 96%. 
  • Twenty hips underwent revision (at a mean of 5 years).  
  • Whole-blood cobalt and chromium levels were higher at 1 year after surgery compared with preop levels; they remained stable through 5 years, and then decreased somewhat at 10 years.  
  • Improvements in the EQ-5D visual analogue scale score and Harris hip score were noted at 1 year and were maintained through 10 years.  

These outcomes are encouraging, but as Su et al. point out, the cohort is not representative of typical total hip arthroplasty populations, who tend to be older and include a greater percentage of female patients. Moreover, the surgeons who performed the procedures were all experienced. Patient selection remains key, with younger male patients being the best candidates. Data such as these can help sharpen our focus as we refine arthroplasty concepts for further improvement in patient outcomes. 

For additional perspective on this study, see the commentary by Timothy S. Brown, MD 

Marc Swiontkowski, MD
JBJS Editor-in-Chief 

A Creative Approach to COVID-Era Journal Clubs

All recipients of the JBJS Robert Bucholz Journal Club Grant are asked to complete an end-of-year survey that includes a question about how they used the grant money. This interesting reply comes from Kyle Morgenstern, MD, an orthopaedic resident at the University of Minnesota.

Resident engagement in journal clubs has been a challenge over the last couple of years. In our hard-working residency it is tough for residents to take time out of their evening every month for journal club. Formerly, we used the JBJS grant funds to purchase food and drinks for attendees. But with the virtual nature of journal club this past year, we saw our attendance start to slide and had to find other ways to recruit residents and boost morale.

So at the beginning of the COVID era, we utilized the grant money to purchase items awarded to attendees for their participation. I figured that if we couldn’t offer food and drink in person, we could at least do it virtually, and we awarded DoorDash gift cards.

Later, we transitioned to awarding a textbook to one presenter at each Journal Club. The winner of the textbook for best presentation was selected via an anonymous Zoom-poll vote of the faculty in attendance. We do Journal Club “Specialty Nights,” so, for example, we awarded Operative Techniques in Shoulder and Elbow Surgery during our shoulder-and-elbow night.

Those who received a textbook were quite thankful, especially those entering their trauma rotations or going into a particular subspecialty. I think this is something we will continue to budget for in the future, as we return to in-person meetings coming out of the pandemic.”

Applications for the 2021-2022 Robert Bucholz Journal Club grant are now available. Please click here.