Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Tibia Vara: Osteochondrosis Deformans Tibia
WP Blount: JBJS, 1937 January; 19 (1): 1
In this classic article, Blount detailed clinical and radiologic features of the affected lower extremities of 13 children with bowlegs. Nearly 80 years have passed since Blount’s original description, and not much more is known about this enigmatic developmental disorder. Given the potential for less postoperative morbidity, there has been a resurgence of “guided growth” strategies to treat this and other pediatric limb deformities.
Lumbar Disc Disorders and Low-back Pain: Socioeconomic Factors and Consequences
JN Katz: JBJS, 2006 April; 88 (Suppl 2): 21
The 21st century has brought with it a sharper focus on both the socioeconomic factors contributing to medical conditions and the socioeconomic consequences of those conditions. Back in 2006, Dr. Katz found that the total annual costs of low back pain in the US exceeded $100 billion, two-thirds of that in the form of indirect costs (e.g., lost wages and reduced productivity). He also found that fewer than 5% of patients who have a low back pain episode account for 75% of the total costs, prompting Dr. Katz to emphasize the ongoing “critical importance of identifying strategies to prevent these disorders and their consequences.”
Every month, JBJS publishes a Specialty Update—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 OrthoBuzz Specialty Update summaries.
This month, Nitin Jain, MD, MSPH, a co-author of the November 21, 2018 Specialty Update on Orthopaedic Rehabilitation, summarized the most clinically compelling findings from among the more than 40 noteworthy studies summarized in the article.
Acute Pain Management
–A randomized double-blind study comparing 4 two-way combinations of analgesics (three of which contained an opioid medication)1 in emergency-department patients experiencing acute extremity pain found no significant between-group differences in mean pain scores at 1 and 2 hours after medication administration.
Total Hip Arthroplasty
–A randomized clinical trial of >100 patients who underwent unilateral total hip arthroplasty found no significant differences in functional outcomes between a group that participated after surgery in a self-directed home exercise program and a group that participated in a standardized physical therapy program.
–An assessment of brain tissue from 202 American football players2 whose organs were donated for neuropathological evaluation found that 87% had evidence of chronic traumatic encephalopathy (CTE). Analysis of brain tissue from former NFL players in the cohort showed that nearly all had severe CTE.
Rotator Cuff Tears
–A study following the natural progression of full-thickness, asymptomatic, degenerative rotator cuff tears found that patients with fatty muscle degeneration were more likely to experience tear-size progression than those without fatty infiltration.
Low Back Pain
–A study consolidating data from 3 separate randomized trials attempted to evaluate the efficacy of radiofrequency (RF) neurotomy for treating a heterogeneous collection of diagnoses that commonly result in low back pain.3 No significant or clinically important differences were found when the RF procedure was compared with a standardized exercise program. The number needed to treat for all 3 arms of the study ranged from 4 to 8, with a median of 5. Some have called into question the methods of this study, particularly the diagnostic criteria used for patient inclusion and the potential inaccuracy of lumping together heterogeneous diagnoses.
- Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017 Nov 7;318(17):1661-7.
- Mez J, Daneshvar DH, Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, Alosco ML,Solomon TM, Nowinski CJ, McHale L, Cormier KA, Kubilus CA, Martin BM, Murphy L, Baugh CM, Montenigro PH, Chaisson CE, Tripodis Y, Kowall NW, Weuve J, McClean MD, Cantu RC,Goldstein LE, Katz DI, Stern RA, Stein TD, McKee AC. Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football. JAMA. 2017 Jul 25;318(4):360-70.
- Juch JNS, Maas ET, Ostelo RWJG, Groeneweg JG, Kallewaard JW, Koes BW, Verhagen AP, van Dongen JM, Huygen FJPM, van Tulder MW. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the Mint randomized clinical trials. JAMA. 2017;318(1):68-81.
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of August 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Impact of Risk Adjustment on Provider Ranking for Patients With Low Back Pain Receiving Physical Therapy.”
The authors’ findings confirmed their hypothesis that robust risk adjustment is essential for objective comparison of patient-reported outcomes and for accurately reflecting quality of care among patients treated for low back pain.
Previously, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected what he deemed to be the most clinically compelling findings from among the more than 25 studies cited in the June 20, 2018 Specialty Update on Spine Surgery. In this OrthoBuzz post, Theodore J. Choma, MD, author of the Specialty Update on Spine Surgery, selected his “top five.”
–A registry study of 765 patients with adult isthmic spondylolisthesis and at least 2 years of post-treatment outcome data found that at 1 year, global-assessment improvements were reported in 54% of patients who underwent uninstrumented posterolateral fusion, 68% of patients who underwent instrumented posterolateral fusion, and 70% of patients who underwent interbody fusion. Although similar patterns were seen in VAS back pain scores and in 2-year data, fusion with instrumentation was associated with a higher risk of reoperation.
Acute Low Back Pain
–In a cost analysis using data from a previously published Level-II study that randomized 220 patients with acute low back pain to early physical therapy or usual (delayed-referral) care, authors concluded that the incremental cost of early PT was $32,058 per quality-adjusted life year and that early PT is therefore cost-effective.1
Metabolic Bone Disease
–A randomized trial of 66 women ≥50 years of age who had osteoporosis and had undergone lumbar interbody arthrodesis found that those who received once-weekly teriparatide for 6 months following surgery demonstrated higher fusion rates than those in the control cohort (69% versus 35%). Once weekly teriparatide may be worth considering to improve fusion rates in this challenging patient population.
Adult Deformity Correction
–To test the hypothesis that performing 3-column osteotomies more caudally in the lumbar spine might improve sagittal malalignment correction, authors analyzed 468 patients from a spine deformity database who underwent 3-column osteotomies.2 The mean resection angle was 25.1° and did not vary by osteotomy level. No variations were found in the amount of sagittal vertical axis or pelvic tilt correction, but lower-level osteotomies were associated with more frequent pseudarthroses and postoperative motor deficits.
Spinal Cord Injury
–Authors directly measured the mean arterial pressure and cerebrospinal fluid pressure in 92 consecutive patients with traumatic spinal cord injury. Using that data to indirectly monitor the patients’ spinal cord perfusion pressure,3 the authors found that patients who experienced more episodes of spinal cord perfusion pressures <50 mm Hg were less likely to manifest objective improvements in spinal cord function.
- Fritz JM, Kim M, Magel JS, Asche CV. Cost-effectiveness of primary care management with or without early physical therapy for acute low back pain: economic evaluation of a randomized clinical trial. Spine (Phila Pa 1976).2017 Mar;42(5):285-90.
- Ferrero E, Liabaud B, Henry JK, Ames CP, Kebaish K, Mundis GM, Hostin R, Gupta MC, Boachie-Adjei O,Smith JS, Hart RA, Obeid I, Diebo BG, Schwab FJ, Lafage V. Sagittal alignment and complications following lumbar 3-column osteotomy: does the level of resection matter?J Neurosurg Spine. 2017 Nov;27(5):560-9. Epub 2017 Sep 8.
- Squair JW, Bélanger LM, Tsang A, Ritchie L, Mac-Thiong JM, Parent S, Christie S, Bailey C, Dhall S, Street J,Ailon T, Paquette S, Dea N, Fisher CG, Dvorak MF, West CR, Kwon BK. Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury. 2017 Oct 17;89(16):1660-7. Epub 2017 Sep 15.
Every month, JBJS publishes a Specialty Update—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 OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Chad Krueger, MD, JBJS Deputy Editor for Social Media, to select the five most clinically compelling findings from among the more than 25 studies cited in the June 20, 2018 Specialty Update on Spine Surgery.
—A Level-III retrospective analysis found that patients who received a preoperative cervical epidural steroid injection prior to an anterior cervical discectomy and fusion or a posterior cervical fusion had a significantly greater risk of postoperative infection than those who did not receive a preoperative steroid injection.1 Prospective studies are needed to further clarify the perioperative infection risk associated with cervical epidural steroid injections.
—A Level-II randomized pilot trial comparing titanium-coated PEEK interbody spacers with non-coated PEEK spacers among 40 patients who underwent transforaminal lumbar interbody fusion found that patients in both groups had 92% fusion at 3 months, with no significant between-group differences in pain and disability outcomes.2
—A Level-II randomized study of 108 patients who underwent lumbar discectomy compared outcomes among those who experienced 2 weeks versus 6 weeks of postoperative activity restriction. At the 1-year follow-up there was a nonsignificant difference in recurrent herniation (11% in the 2-week group versus 7% in the 6-week group) and no significant between-group differences in pain or disability scores.3
RF Ablation for Chronic Low Back Pain
—A Level-II meta-analysis involving 454 patients with chronic low back pain found that those who underwent radiofrequency (RF) lumbar-facet denervation had significantly reduced VAS back pain compared to a group that underwent a sham procedure or epidural block. Those in the denervation group who benefited most were those who had responded favorably to an initial diagnostic facet block.4
Adolescent Idiopathic Scoliosis
—A Level-II study assessing the ability of surface topography to evaluate spinal deformity in children with adolescent idiopathic scoliosis followed 45 patients for 1 year. This method plus radiography allowed researchers to determine mild curves with strong negative predictive value and sensitivity. The authors estimated that surface topographic analyses could reduce patient exposure to ionizing radiation by eliminating 31% of surveillance radiographs in these patients.5
- Cancienne JM, Werner BC, Puvanesarajah V, Hassanzadeh H, Singla A, Shen FH, Shimer AL. Does the timing of preoperative epidural steroid injection affect infection risk after ACDF or posterior cervical fusion?Spine (Phila Pa 1976). 2017 Jan 15;42(2):71-7.
- Rickert M, Fleege C, Tarhan T, Schreiner S, Makowski MR, Rauschmann M, Arabmotlagh M. Transforaminal lumbar interbody fusion using polyetheretherketone oblique cages with and without a titanium coating: a randomised clinical pilot study. Bone Joint J.2017 Oct;99-B(10):1366-72.
- Bono CM, Leonard DA, Cha TD, Schwab JH, Wood KB, Harris MB, Schoenfeld AJ. The effect of short (2-weeks) versus long (6-weeks) post-operative restrictions following lumbar discectomy: a prospective randomized control trial. Eur Spine J.2017 Mar;26(3):905-12. Epub 2016 Nov 2.
- Lee CH, Chung CK, Kim CH. The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trials. Spine J.2017 Nov;17(11):1770-80. Epub 2017 May 30.
- Hong A, Jaswal N, Westover L, Parent EC, Moreau M, Hedden D, Adeeb S. Surface topography classification trees for assessing severity and monitoring progression in adolescent idiopathic scoliosis. Spine (Phila Pa 1976).2017 Jul 1;42(13):E781-7.
An estimated 85% of all adults will experience low back pain at some point in their lives. So-called “red flag” questions were developed to help primary care providers determine whether a patient’s back pain warranted an escalation of care, either through advanced imaging or referral to a spine specialist. However, in the March 7, 2018 issue of JBJS, Premkumar et al. found that, despite the widespread use of red flag questions, it appears that they have limited clinical usefulness when applied in isolation in a referral spine practice setting.
The authors analyzed the responses to commonly asked red flag questions from more than 9,000 patients presenting to a spine center with low back pain. They found that >90% of the patients had a positive response to at least one of the questions, but only 8% actually had a red flag diagnosis. Furthermore, the authors found that a negative response to one or two of the questions did not preclude a red flag diagnosis. No single red flag question had a sensitivity >75% or a clinically useful negative likelihood ratio—a measure of a screening tool’s ability to rule out a diagnosis.
Importantly, however, certain combinations of positive answers were predictive of specific disease processes. For example, a history of trauma in patients over the age of 50 years was predictive for a diagnosis of spinal compression fracture, and back pain in a patient with a history of a primary oncologic diagnosis should alert physicians to the possibility of metastatic disease. Conversely, the authors say that low back pain that awakens a patient from sleep was not found to be a useful parameter for making any diagnosis.
This is the first large-scale study to evaluate the clinical utility of these questions in the setting of low back pain, and the authors question their usefulness as screening tools. While the concept behind red flag questions remains valid, the rigid application of such questions in decision making regarding advanced imaging or additional testing is not appropriate. The utility of red flag screening questions for low back pain needs additional testing, especially in the primary care setting.
Marc Swiontkowski, MD
In 2015, JBJS launched an“article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of May 2017, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Risk of Recurrence of Low Back Pain (LBP): A Systematic Review.”
In that systematic review, the authors found low quality and heterogeneity among studies of this topic. They concluded that “the available research does not provide robust estimates of the risk of LBP recurrence and provides little information about factors that predict recurrence in people recently recovered from an episode of LBP.”
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Brett A. Freedman, MD, in response to a recent JAMA study on treatment for chronic low back pain.
Chronic low back pain (CLBP) is truly a bio-psycho-social disease. Cherkin et al. in the March 22/29, 2016 issue of JAMA published a randomized clinical trial comparing the performance of two psychologically focused interventions for CLBP with usual care.
The authors randomly assigned 342 subjects solicited from an integrated health plan in the state of Washington who had at least 3 months (average 7.3 years) of nonspecific CLBP to one of three cohorts: mindfulness-based stress reduction (MBSR), cognitive behavioral therapy (CBT), or usual care. MBSR is a pain self-management program that incorporates yoga and focuses on “increasing awareness and acceptance of moment-to-moment experiences.” The two therapy arms included eight 2-hour sessions.
The primary and secondary outcomes were computed values on patient-reported outcome (PRO) instruments compared from baseline out to one year. According to intention-to-treat analysis, MBSR and CBT resulted in a significantly higher chance of patients obtaining a clinically meaningful response, which equated to a >30% improvement in scores on the modified Roland Disability Questionnaire at 26 weeks after enrollment (61% for MBSR vs. 58% for CBT vs. 44% for usual care).
While these findings are interesting and support the notion of more research into non-pharmacological and non-interventional CLBP treatment, the impact of this study is limited by inherent flaws. The investigators’ intent was to have the usual care group represent a control group. However, the usual care cohort was far from controlled. At the time of enrollment, those randomized to the usual care cohort were each given $50 and were set free to “seek whatever treatment [for their CLBP], if any, they desired.” The resultant placebo effect of receiving active treatment (i.e. MBSR, CBT) versus no prescribed treatment (i.e. usual care cohort) is substantial.
Also, aside from reporting their collected PRO data, the authors say little about what happened to the usual care group during this trial, further making this cohort too nebulous to serve as a meaningful comparator. If this cohort is excluded from the analysis, this becomes a negative-findings study, since there were no significant differences in any measured outcome between the MBSR and CBT cohorts, aside from mental health measures, which were significantly improved following CBT.
Another major flaw is the very high rates of patient noncompliance with treatment. Only 51% of the subjects in the 2 therapy arms attended at least 6 of the sessions, and 13 subjects (11%) in each of the active-therapy groups attended no sessions. A substantial minority of patients failed to meaningfully participate in their prescribed intervention, yet their improved outcomes are attributed to the impact of these programs. If the same lack of adherence to protocol occurred in a pharmacological or surgical study, the results would be ignored and the article would likely go unpublished, or at least not published in a high-impact journal such as JAMA.
In conclusion, the greatest merit of this study is the research question it poses. We certainly need more work on this subject, but unfortunately this particular study does little to further advance our understanding of the best practices for approaching the bio-psycho-social disease we call CLBP.
Brett A. Freedman, MD is an orthopaedic surgeon specializing in spine trauma and degenerative spinal diseases at the Mayo Clinic in Rochester, MN.
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of key findings from Level I and II studies cited in the November 18, 2015 Specialty Update on orthopaedic rehabilitation:
- A prospective comparison of patients who received either skilled physical therapy (PT) or a standardized home exercise program after total knee arthroplasty (TKA) found that range of motion and functional outcome were similar in the two groups after two years, but the home program was nearly half the cost of PT.1
- A randomized trial of 198 patients who underwent TKA compared telerehabilitation with face-to-face rehab. After two months, WOMAC and KOOS scores and functional and range-of-motion tests were all noninferior for telerehabilitation.
- A randomized trial of community-dwelling elderly patients who had undergone hip fracture surgery found that an individualized home-based rehab program produced superior functional outcomes, balance, and mobility recovery when compared with a standard, non-structured home exercise program.2
- A claims-data study of 4733 people who underwent hip or knee replacement found a 29% decrease in postoperative acute service utilization among those who had preoperative PT.
- A randomized trial comparing active transcutaneous nerve stimulation (TENS), placebo TENS, and standard care during rehab for TKA found that adding either active or placebo TENS to standard care significantly reduced movement pain in the immediate postoperative period.3
- A randomized study found that in-hospital sling-based range-of-motion therapy had a clinically beneficial effect up to three months after TKA surgery in terms of passive knee flexion range of motion, compared with an in-hospital continuous passive motion protocol.4
- A randomized trial comparing weight-bearing and non-weight-bearing for nonoperative treatment of Achilles tendon ruptures found no significant between-group differences in the Total Rupture Score or heel-rise strength.
- A systematic review and meta-analysis comprising 402 patients who had undergone surgical Achilles tendon repair found that postoperative early weight-bearing and early ankle motion exercises were associated with a lower minor complication rate and greater functional recovery when compared with conventional immobilization.5
- A randomized trial comparing 12 weeks of individualized resistance training to physiotherapy without resistance training in adolescents and young adults with bilateral spastic cerebral palsy found that neither group demonstrated improvements in performance of daily physical activity.6
- A randomized trial of three methods of weight-bearing training (verbal instruction, bathroom scale training, and haptic biofeedback) found that haptic feedback was superior to the other methods at helping patients maintain weight-bearing status.7
Amputation and Prosthetics
- A systematic review of studies comparing rigid versus soft dressings after amputation determined that rigid dressings resulted in significantly shorter time from amputation to fitting of a prosthesis.8
- A randomized trial of phantom pain found that a protocol of progressive muscle relaxation, mental imagery, and phantom exercises yielded more significant reductions in the rate and intensity of phantom pain than a program of standard physical therapy.9
Low Back Pain
- Among patients with low back pain, a three-way randomized trial (standard care, standard care + extensible lumbosacral orthoses, and standard care + inextensible lumbosacral orthoses) found that inextensible lumbar orthoses led to a greater improvement in Oswestry Disability Index scores than the other two approaches.10
- Büker N,,Akkaya S, Akkaya N, Gökalp O, Kavlak E, Ok N, Kıter AE, Kitiş A.Comparison of effects of supervised physiotherapy and a standardized home program on functional status in patients with total knee arthroplasty: a prospective study. J Phys Ther Sci. 2014 Oct;26(10):1531-6. Epub 2014 Oct 28.
- Salpakoski A, Törmäkangas T, Edgren J, Kallinen M, Sihvonen SE, Pesola M,Vanhatalo J, Arkela M, Rantanen T, Sipilä S. Effects of a multicomponent home-based physical rehabilitation program on mobility recovery after hip fracture: a randomized controlled trial. J Am Med Dir Assoc. 2014 May;15(5):361-8. Epub 2014 Feb 20.
- Rakel BA, Zimmerman MB, Geasland K, Embree J, Clark CR, Noiseux NO,Callaghan JJ, Herr K, Walsh D, Sluka KA. Transcutaneous electrical nerve stimulation for the control of pain during rehabilitation after total knee arthroplasty: A randomized, blinded, placebo-controlled trial. Pain. 2014 Dec;155(12):2599-611.Epub 2014 Sep 28.
- Mau-Moeller A, Behrens M, Finze S, Bruhn S, Bader R, Mittelmeier W. The effect of continuous passive motion and sling exercise training on clinical and functional outcomes following total knee arthroplasty: a randomized active-controlled clinical study. Health Qual Life Outcomes. 2014 May 9;12:68.
- Huang J, Wang C, Ma X, Wang X, Zhang C, Chen L. Rehabilitation regimen after surgical treatment of acute Achilles tendon ruptures: a systematic review with meta-analysis. Am J Sports Med. 2015 Apr;43(4):1008-16. Epub 2014 May 2.
- Bania TA, Dodd KJ, Baker RJ, Graham HK, Taylor NF. The effects of progressive resistance training on daily physical activity in young people with cerebral palsy: a randomised controlled trial. Disabil Rehabil. 2015 Jun 9:1-7. [Epub ahead of print].
- Fu MC, DeLuke L, Buerba RA, Fan RE, Zheng YJ, Leslie MP, Baumgaertner MR, Grauer JN. Haptic biofeedback for improving compliance with lower-extremity partial weight bearing. Orthopedics. 2014 Nov;37(11):e993-8.
- Churilov I, Churilov L, Murphy D. Do rigid dressings reduce the time from amputation to prosthetic fitting? A systematic review and meta-analysis. Ann Vasc Surg. 2014 Oct;28(7):1801-8. Epub 2014 Jun 6.
- Brunelli S, Morone G, Iosa M, Ciotti C, De Giorgi R, Foti C, Traballesi M. Efficacy of progressive muscle relaxation, mental imagery, and phantom exercise training on phantom limb: a randomized controlled trial. Arch Phys Med Rehabil. 2015Feb;96(2):181-7. Epub 2014 Oct 23.
- Morrisette DC, Cholewicki J, Logan S, Seif G, McGowan S. A randomized clinical trial comparing extensible and inextensible lumbosacral orthoses and standard care alone in the management of lower back pain. Spine (Phila Pa 1976). 2014 Oct 1;39(21):1733-42.
As if on cue, a just-published study in JAMA backed up the recent AAOS statement on opioids by finding that neither the opiate oxycodone nor the muscle relaxant cyclobenzaprine (Flexeril) is a helpful adjunct to naproxen for acute, nontraumatic, nonradicular low back pain.
The study randomized 323 emergency-department (ED) patients presenting with low back pain to receive a 10-day course of naproxen + placebo, naproxen + cyclobenzaprine, or naproxen + oxycodone/acetaminophen. The improvement in scores on the Roland-Morris Disability Questionnaire between the time of ED discharge and one week later was similar in all three groups. This finding led Journal Watch Emergency Medicine Associate Editor Daniel Pallin, MD to comment that “prescribing opioids for a condition that evidence-based consensus guidelines warn against can lead to abuse and addiction.”