In an ideal world, nothing would interfere with long-bone growth plates in kids and adolescents. But physes are the weakest areas of the growing skeleton and are thus vulnerable to any number of injuries and insults. The most frequent complication resulting from growth-plate disturbances is premature arrest of bone growth that can lead to alignment problems and limb-length discrepancies.
The October 28, 2015 “Case Connections” from JBJS Case Connector highlights four case reports focused on tibial and femoral growth-plate disturbances. In two of the case reports, including the springboard case by Tomatsuri et al. from the October 28, 2015 edition of JBJS Case Connector, the injuries were associated with reconstruction of a torn anterior cruciate ligament (ACL). The other two describe physeal injuries with infectious etiologies. The outcomes in all four case reports were positive because of careful and creative surgical interventions by highly skilled orthopaedists.
Infections of the spine are particularly challenging to orthopaedists because they often present emergently, can be difficult to diagnose precisely, and can have catastrophic or fatal outcomes if not treated effectively.The September 23, 2015 “Case Connections” from JBJS Case Connector discusses five cases of rare but serious spinal infections.
The “Case Connections” springboards from a September 9, 2015 JBJS Case Connector case report by Rosinsky et al. that describes a sixty-five-year-old man who presented with fever and intractable lumbar pain that radiated to his right leg. In this case, a methicillin-susceptible Staphylococcus aureus (MSSA) infection had formed a large lobulated epidural abscess at L4-S1, with paraspinal muscle and intradural extension. One year after an L3-S1 laminectomy and two follow-up surgeries to treat hematomas and repair dural perforations, the patient was neurologically intact and walking independently.
The Rosinsky et al. case and the three other relevant “connections” from the JBJS Case Connector archive emphasize that prompt, definitive diagnosis and treatment of spinal infections–and enlisting the expertise of infectious-disease specialists–can lead to positive outcomes, while delay and clinical confusion can end catastrophically or fatally.
The hip-arthroplasty community currently feels that the advantages gained from head-neck modularity outweigh the risks, but JBJS Case Connector raises that risk-benefit question in an August 26, 2015 “Watch” article. Modular head-neck failures of total-hip prostheses are indeed rare complications, but the potentially catastrophic consequences and a seemingly increased incidence are raising concern among orthopaedists.
Prompted by a case report by Swann et al. in the August 26, 2015 JBJS Case Connector and a report by Arvinte et al. in the April 22, 2015 JBJS Case Connector, the Watch describes three patients who experienced a complete head-neck dissociation seven to fourteen years after primary arthroplasty with modular components. The Watch also includes relevant findings from elsewhere in the orthopaedic literature to help surgeons better understand and minimize the risks.
The trunnion troubles described in this Watch represent a unique opportunity for orthopaedists and industry to work together to conduct multicenter retrieval studies to better understand, and prevent, these rare but serious outcomes. In the meantime, the Watch ends with the following message: “Absent ‘official’ protocols for monitoring THA patients with new-generation modular head-neck junctions, it would behoove hip surgeons to inform patients about these rare events and to encourage them to report any postoperative abnormalities, even if the signs or symptoms are not painful.”
Fluoroquinolone antibiotics do a great job fighting a broad spectrum of bacteria that cause many respiratory, urogenital, gastrointestinal, and bone and joint infections. However, in 2008, the FDA issued a “black-box warning” about the increased risk of tendinopathies in people taking these drugs, especially those older than 60.
Although rare, when fluoroquinolone-induced tendon ruptures occur, they involve the Achilles tendon 95% of the time. But in the April 8, 2015 edition of JBJS Case Connector, DeWolf et al. describe the case of an 81-year-old man whose sudden inability to extend the metacarpophalangeal joint of his ring finger occurred within one week after he started taking the fluoroquinolone ciprofloxacin for an ear infection.
In the OR, surgeons identified and debrided a ruptured extensor digitorum communis (EDC) tendon and attached it to the EDC of the adjacent middle finger. They found no bony protrusions or synovitis that could have caused tendon erosion, and cultures for bacterial and fungal infections came back negative. Those negative findings, combined with the patient’s medication history and lack of other risk factors such as gout or rheumatoid arthritis, led the authors to postulate with some certainty that ciprofloxacin was the etiological culprit.
DeWolf et al. remind orthopaedists that for general tendinopathy, “the mainstays of treatment include rest, physical therapy, and discontinuation of [any] offending medication.” Ruptured tendons are usually addressed surgically. Although the authors do not report having taken ultrasound images of this patient, they note that “ultrasound provides an inexpensive way to confirm that a tendon has been ruptured and also whether it is a partial or complete rupture.”
Pelvic binders can provide lifesaving compression in patients with hemodynamically unstable pelvic injuries. But a report in the March 11, 2015 JBJS Case Connector by Auston et al. emphasizes that such binders may do more harm than good in patients who have acetabular fractures without hemodynamic instability or other pelvic injuries. Because first responders or community physicians often apply pelvic binders, the authors cite the need for clearer guidelines for these devices and updated training of early clinical caregivers regarding their use. Potential complications of binder use cited previously in the literature include pressure sores, damage to internal organs, and sciatic nerve palsy, and Auston et al. suggest additional ones.
The authors describe three cases in which patients who were hemodynamically stable were placed in a pelvic binder, either during transport or ED evaluation, following blunt trauma sustained in motor-vehicle accidents. All three patients had acetabular fractures but no other abdominal or pelvic injuries. The authors suggest that pelvic binders may contribute to the displacement of acetabular fractures, and although they saw no visible evidence of chondral damage during open reduction and internal fixation of the fractures, they express concern about occult chondral abrasion and possible damage to chondrocytes at the cellular level if binders are used inappropriately.
The authors therefore conclude that while pelvic binders play an important role in patients with severe pelvic ring injuries and hemodynamic instability, “in the setting of a displaced acetabular fracture, we cannot recommend placement of a pelvic binder, even for pain relief or splinting during evaluation or transportation.”
The number of manuscripts submitted to The Journal of Bone & Joint Surgery (JBJS) from physicians and researchers in China has been steadily increasing, but the overall acceptance rate is relatively low. While the quality of the research performed in China is rapidly improving, orthopaedic researchers in China recognize the need for education related to experimental design, manuscript preparation and manuscript review. In June 2014, Dr. Thomas Bauer, JBJS deputy editor for research, participated in a two-day workshop in Shanghai that focused on helping Chinese researchers prepare and submit high-quality journal manuscripts.
During an afternoon workshop, Dr. Bauer and three other experienced Chinese editors/reviewers provided “face-to-face” reviewing with individual researchers who had provided and presented draft manuscripts. Dr. Bauer’s subsequent lectures included recommendations with respect to selecting the most appropriate journal for a specific paper, the contents of each section of a scientific manuscript, tables and figures, and how to respond to a manuscript review. He also described the general review process at JBJS and discussed “misbehaving authors,” including issues related to attempted duplicate publication, fraud, image manipulation, and plagiarism.
Based on review of 50 manuscripts from China that had been rejected, Dr. Bauer tabulated the reviewers’ comments to identify the most frequent reasons for manuscript rejection. The most frequent criticism reflected insufficient information about the number of patients or specimens and the lack of an explanation for sample size. Dr. Bauer also illustrated several recent manuscripts from China that have been published in JBJS and in JBJS Case Connector. Several other speakers also discussed issues related to experimental design and statistics.
The lively discussion from the audience of more than 100 researchers reflected intense desire to publish the best possible work in JBJS. We anticipate a striking increase in the number and quality of manuscripts from China in the near future.
Journals provide third-party validation for research reports. If you get published in a better journal, your work will likely be perceived as having been more successful. Editors and publishers feel the same way when it comes to how our audience rates our products. So we were very pleased when a recent independent third-party study found that our new review journal, JBJS Reviews, has rapidly become the #3 online journal in orthopaedics.
JBJS Reviews was launched just over six months ago, but it is already viewed as one of the top 3 professional resources for quality content, helping run an orthopaedic practice, and keeping surgeons informed. There are many other categories, but you get the idea – JBJS Reviews is already proving its worth.
Our Editor-in-Chief for JBJS Reviews, Tom Einhorn, MD, has done a fabulous job getting this new journal off the ground, and dozens of authors have contributed excellent reviews, and more are scheduled. We’re excited about the potential here.
That being said, the Journal of Bone & Joint Surgery still ranks #1 in nearly every category, so we have a lot to build upon there, as well. And that’s how we view it – being #1 is not a destination but an expectation, as is quickly joining the top 3. We need to keep working at a high level, improving what we do, and delivering great information in all formats.
Earlier this year, the Journal introduced the Peer-Review Statement, granting readers insight into how articles are peer-reviewed. A high percentage of readers find this valuable, we’ve learned. We are also introducing an integrated tablet app for iOS and Android devices. All our journals – the Journal, JBJS Reviews, JBJS Case Connector, and JBJS Essential Surgical Techniques – will appear in the single app. Best of all, if you already use the JBJS Reviews app, your next update will give you the integrated app seamlessly.
We value our readers and know how important your work is and how valuable your time is. I hope these improvements and high-quality resources serve you well.
The migration of traditional print businesses into online enterprises has created long-term demands on editorial functions, technology partnerships, and organizational cultures. From major technology firms like Google, Apple, and Facebook to enduring publishing brands like the New York Times, these demands have led to very public struggles over the past months.
This month, JBJS launches redesigned and upgraded Web sites, soon to be followed by a unified tablet app for iOS and Android that will include all JBJS journals (JBJS, JBJS Case Connector, JBJS Essential Surgical Techniques, and JBJS Reviews). Because of this and trends in user preferences, technology is front and center for us.
For scientific, medical, and scholarly publishers, online and digital products have been an increasing focus for more than two decades. But some change comes slowly, especially in the realm of organizational culture. During the print era, once an article was published, the cultural habit was to move on to the next set of articles. This approach allowed for batch work consistently oriented toward what was next.
No longer. With our Twitter feed now topping 10,000 followers, the moment an article is published, entirely new workflows begin– social media, archiving, editorial selections for new products and online marketing, and so forth. These activities change our culture, and require new technologies and new skills.
We also now have to rework our archives on a regular basis. This year, JBJS celebrates its 125th anniversary. While building our new sites, we had to migrate 125 years of articles into new formats, new designs, and new technology infrastructures – a major task that was far more difficult and intricate than moving a dozen shelves of bound volumes from one room to another.
We are busy transforming JBJS into a leading organization for the modern information economy – from our core journals to our online education offerings. While the challenges are real and the changes significant, we love the work, and our talents are sharpened every day.
I hope you enjoy our new Web sites, our new tablet app, and our efforts to bring you the best orthopaedic information in formats you can use.