FDA White Paper Cites JBJS “Case Connections” Article
There are 15 references to JBJS studies in the recently published 149-page white paper on “Biological Responses to Metal Implants,” from the FDA’s Center for Devices and Radiological Health. Most of those references are made in Section 7.5.1 (pp. 54-57), which focuses on orthopaedic devices.
The plethora of JBJS references is not surprising, but we were happy also to see that a JBJS “Case Connections” article was cited twice in the white paper. While most of the section on orthopaedic devices discussed metal-on-metal (MoM) hip problems, the FDA noted that adverse biological responses to metals in orthopaedics sometimes occur in the upper extremity. It did so by citing “Adverse Local Tissue Reactions in the Upper Extremity,” which appeared in the May 24, 2017 issue of JBJS Case Connector. The FDA white paper cautioned that metal wear debris-related adverse reactions have occurred with shoulder suture anchors (five cases of which are described in the “Case Connections” article) and with intramedullary humeral nailing (one case of which is described in the “Case Connections” article).
Among the take-home points made by co-authors Thomas Bauer and Allan Harper in the cited “Case Connections” article is this: “Patients with shoulder suture anchors who develop delayed-onset pain and/or stiffness, osteolysis, chondrolysis, or early arthropathy should be evaluated and consideration should be given to the removal of loose or prominent anchors to lessen the risk of articular damage.”
Whole-Slide View of Rare Orthopaedic Tumor
JBJS Case Connector debuted digital whole-slide images back in 2016, and the February 27, 2019 case report by Lans et al. put that ability to link to and navigate an entire microscope slide to good use again.
The 27-year-old man described in this case report presented with a progressively painful right forearm. Conventional radiographs and MRI led clinicians to suspect a rare desmoplastic fibroma of the proximal aspect of the radius, but it was not until a CT-guided core biopsy was analyzed histologically that the diagnosis could be confirmed. The histologic findings, depicted in a digital whole-slide image, revealed a fibrous to fibro-osseous lesion composed of fibroblast-like cells with varying degrees of hypercellularity.
The patient subsequently underwent a wide-margin resection that preserved the radial head but created an 8.5-cm defect, which surgeons reconstructed with a vascularized fibular autograft. At the 2-year follow-up, the patient’s QuickDASH score was 2.7 and his PROMIS Upper Extremity and Physical Function Short Form score was 42.
For more information about JBJS Case Connector, watch this video featuring JBJS Editor-in-Chief Dr. Marc Swiontkowski.
JBJS Case Connector Now Discoverable on PubMed
The new year of 2018 brings with it the indexing of JBJS Case Connector on PubMed, going back to Volume 1, Issue 1.
Co-edited by Thomas W. Bauer, MD and Ronald W. Lindsey, MD, JBJS Case Connector currently compiles nearly 700 peer-reviewed orthopaedic case reports, empowering surgeons to identify emerging trends and find commonalities between cases to help them provide the best possible care for their patients.
In addition, monthly “Case Connections” essays explore the clinical relationships between recent and prior case reports, further helping surgeons to identify patterns. And JBJS Case Connector “Image Quizzes” provide interactive challenges based on recent Case Connector articles.
To learn more about JBJS Case Connector, click here.
JBJS Case Connector to Be Indexed in MEDLINE/PubMed
The National Library of Medicine has accepted JBJS Case Connector for indexing in MEDLINE/PubMed.
Launched in July 2011 and co-edited by Thomas W. Bauer, MD and Ronald W. Lindsey, MD, JBJS Case Connector compiles thousands of orthopaedic case reports, empowering surgeons to find cases similar to theirs, to identify emerging trends, and to distinguish between truly rare cases and repeated, related instances of a larger problem. Using this unique online journal, surgeons can find the commonalities between cases and filter case information by many important variables to provide the best possible care for orthopaedic patients.
In addition, monthly “Case Connections” essays explore the clinical relationships between recent articles and prior case reports in the wider orthopaedic literature, helping surgeons to identify potential patterns. And JBJS Case Connector “Image Quizzes” provide interactive challenges based on JBJS case-report images, featuring in-depth discussions of relevant ideas and concepts.
If you are not already a JBJS Case Connector subscriber, click here to learn more.
Jason Miller
Executive Publisher
JBJS Case Connections—Spinal Epidural Hematoma: Rare, But Potentially Devastating
Spinal epidural hematoma is a rare condition. Because the etiology is often unclear and the medical history is frequently innocuous, a high index of suspicion is required in order to maximize the chances of a successful outcome.
This month’s “Case Connections” spotlights 4 cases of spinal epidural hematoma involving 2 elderly women, a male Olympic-caliber swimmer, and a preadolescent boy.
In the springboard case, from the March 22, 2017, edition of JBJS Case Connector, Yamaguchi et al. report on a 90-year-old woman with a history of transient ischemic attacks (TIAs) and combined aspirin-dipyridamole therapy in whom a large spontaneous spinal epidural hematoma (SSEH) developed rapidly after she shifted her position in bed. The authors concluded that their case emphasized that “early diagnosis of an SSEH and prompt surgical intervention can avoid catastrophic and permanent neurological deterioration and compromise.”
Three additional JBJS Case Connector case reports summarized in the article focus on:
- An 82-year-old woman who developed an epidural hemorrhage and acute paraplegia following vertebroplasty
- A 22-year-old male collegiate swimmer who underwent an emergent operative spinal decompression procedure within 4 hours after presentation to the ED with searing back pain and decreased leg strength
- A 12-year-old boy who presented to the hospital with intense back pain along with numbness, tingling, and loss of motor function in the lower extremities 3 weeks after he had been pushed into a wall at school
Among the take-home points from this “Case Connections” article: MRI is the gold standard for the diagnosis of spinal epidural hematomas, and treatment typically involves operative decompression consisting of laminectomies and evacuation of the hematoma.
JBJS Case Connections—Preventing and Managing Post-THA Hip Dislocations
Hip dislocation is one of the most common perioperative complications of total hip arthroplasty (THA). The latest “Case Connections” article examines an often-overlooked spinal basis for THA dislocations, 2 cases of dual-mobility hip-bearing dissociations during attempted closed reduction for post-THA dislocations, and a unique application of Ilizarov distraction to treat a chronic post-THA dislocation.
The springboard case report, from the February 22, 2017, edition of JBJS Case Connector, describes the case of a 63-year-old woman who had experienced 4 anterior dislocations in less than 3 years after having her left hip replaced. Each dislocation was accompanied by lower back pain, and the patient also reported substantial pain in the contralateral hip. The authors emphasize the importance of recognizing pelvic retroversion and sagittal spinal imbalance before performing total hip arthroplasty.
Two additional JBJS Case Connector case reports summarized in the article focus on:
- The risks of performing closed reduction on patients with a dislocated dual-mobility hip design.
- A unique application of Ilizarov distraction to lengthen soft tissues for femoral-component reduction in a patient with a chronically dislocated hip replacement.
While closed reduction with the patient under sedation is a frequently employed first-line tactic that is often successful for dislocated THAs, these 3 cases show that creative surgical interventions may be necessary for optimal outcomes in patients with “complicated” hips and/or recurrent dislocations.
JBJS Case Connections—Osteochondritis Dissecans: Baseball and Genetics
The exact mechanism by which osteochondritis dissecans (OCD) lesions develop is poorly understood. This month’s “Case Connections” spotlights 3 case reports of OCD in young baseball players, 2 of whom developed the condition in the shoulder. A fourth case report details 3 presentations of bilateral OCD of the femoral head that occurred in the same family over 3 generations.
The springboard case report, from the December 28, 2016, edition of JBJS Case Connector, describes a 16-year-old Major League Baseball (MLB) pitching prospect in whom an OCD lesion of the shoulder healed radiographically and clinically after 8 months of non-throwing and physical therapy focused on improving range of motion and throwing mechanics. Three additional JBJS Case Connector case reports summarized in the article focus on:
- Shoulder OCD in a teenage baseball player that was treated arthroscopically
- Early elbow OCD in young throwers
- Three cases of bilateral femoral head OCD that occurred in multiple members of the same family
Among the take-home points emphasized in this Case Connections article:
- MRI arthrograms are the best imaging modality to determine the stability of most OCD lesions. Radiographs in such cases often appear normal.
- Early-stage OCD has the potential to heal spontaneously. Activity modification and physical therapy are effective treatments.
- There is not a “gold-standard” surgical intervention for treating unstable/late-stage OCD. Surgery frequently provides clinical benefits but often does not result in radiographic improvement.
JBJS Case Connections—Peculiar Sciatic Nerve Problems
Most insults to the sciatic nerve arise from intervertebral disc conditions or spinal stenosis. However, beyond these common etiologies for sciatic-nerve problems are a host of other, rarer causes. This month’s “Case Connections” explores 4 such peculiar examples.
The springboard case report, from the October 12, 2016 edition of JBJS Case Connector, describes 3 instances of sciatica caused by nerve compression from a perineural cyst arising from a paralabral cyst. All 3 patients were successfully treated with arthroscopic decompression. Three additional JBJS Case Connector case reports summarized in the article focus on:
- A 70-year-old woman with a history of thromboembolism who experienced sciatic nerve palsy from an anticoagulant-induced hematoma
- A 31-year-old woman with sciatic endometriosis who was successfully treated by a team of gynecologists, orthopaedists, and microsurgeons
- A 66-year-old woman in whom sciatic nerve injury occurred after repeated attempts at closed reduction of a dislocated hip prosthesis
Orthopaedists evaluating patients with symptoms characteristic of sciatic-nerve pathology should recognize that these symptoms may arise from a variety of etiological pathways. These patients require a complete history-taking, a thorough physical exam, and an attempt to rule out all possible lumbar causes.
JBJS Case Connector Debuts Whole-Slide Images
It is not often that readers of scholarly journals have a “Wow!” moment, a chance to be unexpectedly delighted by a new discovery.1 In the September 14, 2016 edition of JBJS Case Connector, Zhang et al. provide readers of the JBJS family of journals the first of what we hope will be many such moments: the ability to link to and navigate a digital, whole-slide image (WSI) of an entire microscope slide.
Figure 1
Illustrating the histology of tumors and the tissue-level details in basic science studies has long been a challenge. Until recently, readers were usually subjected to the few fields of view that the author chose to photograph. The more senior among you may remember with nostalgia attempting to make sense of fuzzy, black-and-white, circular, histology images viewed as if seen through an antique monocular microscope (Fig. 1). The advent of color printing (often at the author’s extra expense) and eventually digital photographs improved somewhat the quality of each image, but readers were still required to accept that the author had selected fields of view that were truly representative of the subject matter.
In their case report titled “Morphological Transformation of Giant-Cell Tumor of Bone After Treatment with Denosumab,” Zhang et al. include two links to whole-slide images. In the first, readers can link from a conventional digital photograph of a core needle biopsy to the whole-slide image of the giant cell tumor. The authors also include several conventional photographs of the tumor after resection, along with a link to the corresponding scanned microscope slide.
The use of a viewing algorithm similar to that used by Google Earth allows readers to navigate and zoom in on not just the few isolated fields of view selected by the authors, but the hundreds to thousands of additional fields contained in the original microscope slide of this complicated tumor. While it’s very helpful for illustrating tumor histology, we anticipate that WSI technology will be even more valuable when applied to basic science studies of fracture healing or cartilage, nerve, and tendon repair—as well as many other possible applications.
Thomas Bauer, MD
JBJS Case Connector Co-Editor
Reference
- Glassy EF, Rebooting the Pathology Journal. Learning in the Age of Digital Pathology. Archiv Pathol Lab Med 2014;138:728-729.
Case Connector “Watch”—Beware Wayward Wires in the Shoulder Girdle
A substantial number of patients, old and young, who sustain a proximal humeral fracture are managed with Kirschner wires (K-wires). Surgeons are especially likely to opt for wires over other forms of fixation when they need to protect the repair of a concomitant neurovascular injury, or in cases in which the patient cannot tolerate a more invasive surgery.
However, there is a somewhat frequent and potentially lethal drawback to using wires about the shoulder girdle. This latest JBJS Case Connector “Watch” looks at several cases in which wires were adequately placed in the shoulder but subsequently moved to other parts of the body. It also identifies apparent risk factors for wire migration and provides some guidance for minimizing that risk. Finally, it encourages orthopaedists to seriously consider alternate fixation options, whenever feasible, to eliminate the risk of wire migration altogether.
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