In the July 6, 2016 issue of The Journal, Weinberg at al. carefully measure the rotational profile of 600 cadaveric human forearm bones. The precision of these measurements is outstanding and sets a new standard for this type of investigation. The authors put real numbers on the rotational relationships between the radius and ulna that Evans first proposed in JBJS in 1945—and that many surgeons have relied on for intraoperative assessments of forearm rotational alignment since then.
What this investigation documents is the wide range of rotational profiles in the human forearm, with broad standard deviations. It confirms what all clinicians experience every day—each patient’s anatomy is different. There is commonality in hard- and soft-tissue structure overall, but the range of size, shape, density, length, and rotation is patient-specific and highly variable.
Whether closed, percutaneous, or open methods are applied, the skill and experience of the surgeon trump radiographic rules/tips/guidelines. As is often said with fracture reduction, the surgeon is responsible for 80% of the outcome. Studies comparing different casting methods or fixation devices provide useful information that address the remaining 20%, but surgical technique and surgeon experience/judgment are the major determinants.
We must always remember that each patient is not only emotionally and socially unique, but also anatomically unique. Our job is to restore their individual anatomy to the best of our clinical ability. I am therefore not sure that repeating high-precision measurements of other osseous structures—only to re-confirm anatomic variability—will have much ultimate value for our community.
Marc Swiontkowski, MD
The study by Ramo et al. in the February 17, 2016 JBJS examines the evolution toward more aggressive operative treatment of children with isolated femoral fractures. This movement started 30 years ago, initially with the notion that adolescents should be treated as adults, with preferential intramedullary (IM) nail fixation. Concerns regarding damage to the femoral-head arterial supply led to the development of nails that could be started at the trochanteric region.
In the five- to twelve-year-old group, the options that have been documented as safe and effective include flexible nailing, plating, and external fixation, each with its own set of advantages and downsides. Fractures in kids ages four and five have generally been treated by spica cast management. However, parental concerns over cast care, more frequent radiographs, and the negative impact on family life have influenced many centers to move toward IM fixation even in this “preschool” age group.
The Ramo et al. study has all the limitations of a retrospective study, but it strongly suggests that in four- and five-year-olds, the radiographic outcomes of nailing and casting are equivalent after a mean follow-up of 32 weeks. These findings will provide some information for a shared decision-making discussion with parents, but as with many topics in pediatric fracture management, the clinical questions raised by this study beg for a prospective, controlled, multicenter trial. I agree with commentator Merv Letts, who points out that the Ramo et al. study raises important and complex clinical and family-environment issues that we need to grapple with as an orthopaedic community, but that more definitive answers will come only with prospective research and longer follow-up periods.
Marc Swiontkowski, MD
Marc Swiontkowski, MD, Editor-in-Chief of The Journal of Bone & Joint Surgery (JBJS) and Co-Editor of JBJS Case Connector, has announced that, effective January 1, 2016, Ronald W. Lindsey, MD, will join Tom Bauer, MD as Co-Editor of Case Connector. Dr. Swiontkowski will step down from his role as Case Connector Co-Editor but will remain as Editor-in Chief of JBJS. “I am confident that Ron and Tom will help move Case Connector into position as a foremost resource for clinicians seeking guidance and information on rare and unusual conditions from across the globe,” said Dr. Swiontkowski.
Dr. Lindsey is a Professor of Orthopaedic Surgery & Rehabilitation and Chair of the Department of Orthopaedic Surgery & Rehabilitation at the University of Texas Medical Branch, as well as a former Associate Editor for JBJS. After receiving his medical degree from Columbia University College of Physicians and Surgeons and completing an orthopaedic residency at Yale-New Haven Hospital, Dr. Lindsey pursued several fellowships at prestigious European orthopaedic institutions, including AO and spine fellowships at the University of Basel, and a spine fellowship at the University of Marseilles.
“I look forward to working with Dr. Bauer and the JBJS Case Connector editorial board to continue building a premier online database of peer-reviewed orthopaedic cases and the technology that enables orthopaedists to efficiently filter case information,” said Dr. Lindsey. “Our goal will always be to assist orthopaedic surgeons in the search for clinical precedents, connections, and trends in their efforts to improve patient care.”
In the November 18, 2015 edition of JBJS, Lawing et al. present a well-documented cohort study comparing the outcomes of open-fracture management with local administration of aminoglycoside antibiotics plus systemic antibiotics, versus systemic antibiotics alone. The impact of this intervention on the ultimate rate of deep infection is eye-catching. The deep-infection rate in the local-antibiotic group was 6%, compared to 14.2% in the control group (p = 0.011). Moreover, locally administered aminoglycosides did not have a negative impact on nonunion rates, as one might expect due to the osteocyte toxicity reportedly associated with some aminoglycosides.
There are, however, issues of administrator bias with this study, because the use of local antibiotics was based on attending-surgeon preference. In addition, surgeons make other individual judgments about open-fracture management, such as debridement technique, that were not controlled for in this study. We also went through a period of using local antibiotic drips and catheter pumps in the 1990s that did not seem to yield reproducible results.
Lawing et al. conclude with the hope that their study “will provide support for future prospective, blinded, and randomized trials” focused on this intervention. I believe the data here are compelling enough for one of our trauma clinical-trials networks to plan and conduct an adequately powered trial complete with prospective criteria and blinded outcome adjudication. One reason we publish cohort studies in The Journal is to stimulate just that sort of response in the orthopaedic-research community. It is my hope that within a few years, JBJS editors will be reviewing an RCT manuscript that completes the investigative cycle on this important clinical question.
Marc Swiontkowski, MD
The contributions to the field of shoulder surgery from Dr. Charles Neer are too numerous to document in any one commentary. A partial list would include shoulder arthroplasty (both hemi and total), the concept of impingement and acromial pathology, multidirectional instability, and the role of the AC joint in rotator cuff pathology.
Dr. Neer also made numerous contributions to the understanding of fracture care, including the distal femur and clavicle. But no area of fracture management was of greater interest to him and his colleagues at Columbia than the proximal humerus. This classic manuscript has been cited thousands of time and remains the seminal piece in the foundation of understanding fracture patterns in the proximal humerus—and the attendant treatment implications.
Dr. Neer introduced the concept of the four parts of the proximal humerus in this manuscript, and with it the implication of isolating the humeral-head blood supply in a four-part fracture. The impetus to understand the complication of avascular necrosis of the humeral head began with this manuscript, as did the critical debates regarding surgical versus nonsurgical intervention and replace-or-fix. An important area of ongoing debate is Neer’s definition of a “displaced” fracture in the proximal humerus as having > 1 cm of displacement. The orthopaedic community to this day is wrestling with this definition and its relevance to treatment and outcomes.
This classic manuscript also helped launch a decades-old conversation about the role of fracture or musculoskeletal-disease classification systems. Subsequent publications by Zuckerman and Gerber identified issues with inter- and intra-rater reliability when applying the Neer classification system to a set of radiographs. The reliability debate surrounding this classification system led us to understand the issue of forcing continuous variables (fracture lines are infinite in their trajectory and displacement) into dichotomous variables (a classification system). Because of Dr. Neer’s work and subsequent research, our community understands that when we make these classification designations, we will agree about 60% of the time (kappa statistic of 0.6). That level of agreement is not reflective of a “good” or “bad” classification system; rather, it’s a consequence of moving a continuous variable to a dichotomous variable.
So we remain indebted to Dr. Neer not only for laying the foundation for the treatment of patients with proximal humeral fractures, but also for vastly expanding our knowledge regarding the role, strengths, and weaknesses of disease and fracture-classification systems.
Marc Swiontkowski, MD
Orthopaedic surgical procedures to correct axial and appendicular skeletal deformities are usually dependent upon fixation devices, either external or internal or both. These devices are often developed through close collaboration with engineers who are generally employed by major manufacturing companies. After the devices successfully clear rigorous bench, in-vitro, and in-vivo testing, the standard initial presentation of clinical results is a case series.
All too often the initial report of results comes from a co-developer of the device, with inherent selection and detection bias that constitute what most readers would consider a conflict of interest. McCarthy and McCullough’s case series on five-year results with Shilla growth guidance in 33 children with early-onset scoliosis in the October 7, 2015 JBJS is an exception to that rule. The authors report every conceivable major and minor adverse event without holding back any negative information. They categorize complications as infection secondary to wound breakdown, spinal alignment issues, and implant issues. The overall complication rate was 73%, a rate that is not surprising given the fact that the device under study is designed to maintain correction of spinal deformity in growing children.
Thankfully, the authors reported no neurologic complications. Also on the positive side, they found that spinal curves averaging 69° preoperatively averaged 38.4° at the most recent follow-up or prior to definitive spinal instrumentation. McCarthy and McCullough also calculated a 73% reduction in the number of surgical procedures among their cohort, relative to what would be necessary to treat the same population with distraction methods every six months.
I applaud the authors for comprehensively reporting the results of correction of spinal deformity in this difficult clinical situation with high accuracy and strict definitions of major and minor events. This is how we will make advances in correcting deformity for skeletally mature and immature patients—with innovation, incremental improvement, and the widespread sharing of adverse events with the orthopaedic community. Armed with the information from this study, we must now see what the number and severity of complications look like when the broader community of orthopaedic surgeons applies these devices.
Marc Swiontkowski, MD
This week Mady Tissenbaum retires from her role as Publisher of The Journal of Bone & Joint Surgery. Mady walked through the doors of the JBJS office 42 years ago to assume the role of a copy editor. She has been with JBJS ever since and her career responsibilities developed as the organization grew and expanded. Mady has presided over multiple important changes at JBJS: the move to Needham with the purchase of our building when we outgrew the shared space with The New England Journal of Medicine, the transition from paper and typewriter manuscripts and paper review processes to electronic submission and review, the launch of The Journal online at jbjs.org, and the branching out of our offerings to include JBJS Case Connector, JBJS Essential Surgical Techniques and JBJS Reviews.
Mady has literally “done it all” at JBJS. She has trained and collaborated with 6 Editors and attended over 60 Trustee meetings. She has led countless staff meetings and presented at a similar number of Editorial Board meetings. She has run the HR services, done all the contracting for purchased services and knows every stage of development of our complex IT backbone.
In addition, she is the archivist for The Journal and has most of its history in her head. Throughout her career, she has committed herself to the legacy of quality content that JBJS is known for, as well as to the staff, authors, and readers. Her contributions have enhanced not only JBJS, but also the larger community of scholarly publishing.
We wish you Godspeed in retirement, Mady, and thank you from the bottom of our hearts for dedicating your career to JBJS and the physicians and patients it serves.
Fondly and with great respect,
Marc Swiontkowski, MD
In the February 18, 2015 issue of The Journal, Rohner et al. report their experience with knee arthrodesis using an intramedullary rod as the definitive treatment for failed total knee arthroplasties (TKAs) related to infection. They report the results for 26 patients treated between 1997 and 2013 who had undergone an average of 6 ±3 knee procedures prior to arthrodesis.
The outcomes for this cohort of patients are sobering. Persistent infection requiring additional surgery remained in 50% of the patients. The health-related quality-of-life measures and functional outcomes were abysmal, and 73% reported persistent pain at greater than 3 on the VAS. Obesity, high blood pressure, and diabetes were strong predictors of reinfection.
Many of us have taken comfort that knee fusion, by whatever surgical technique, is a reliable “bail out” for the problem of recurrent infection following revision of a loose or infected TKA. Nevertheless, any surgeon who has followed a patient with a knee fusion is fully aware of the functional disability associated with the stiff knee. Difficulties using public transportation and impaired sitting are just two inconveniences that these patients express unhappiness about.
Despite its retrospective design and relatively small number of cases, this report may cause the knee-reconstruction community to reconsider knee arthrodesis and instead attempt further staged revisions of the knee prosthesis. It may even prompt a slightly earlier move toward recommending trans-femoral amputation. It certainly will stimulate further research into infection prevention and into developing more predictable approaches for revising infected TKA prostheses.
Marc Swiontkowski, MD
Since 2003, JBJS has assigned level-of-evidence (LOE) ratings to all clinical articles, based on a system developed by the UK’s Centre for Evidence-Based Medicine (CEBM). The CEBM updated its rating system in 2011, and The Journal has revised its LOE guidance in ways that largely but not entirely reflect the CEBM update.
In an editorial in the January 7, 2015 JBJS, Editor-in-Chief Dr. Marc Swiontkowski and Associate Editor for Evidence-Based Orthopaedics Dr. Robert Marx note that the revised JBJS LOE table still divides studies by type and that “much of the ranking criteria remain the same.” However, the rows and columns have been transposed and a column focused on specific clinical questions has been added. The clinical-question column—which poses queries such as “Does this treatment help?”—can guide busy clinicians quickly and efficiently to the best available evidence about their immediate situation.
In addition, guidance in the new table’s footnotes permits flexibility to grade studies upward if there is a dramatic effect size or downward on the basis of small effect size or study-quality issues such as imprecision. Overall, the revised table clarifies and makes more transparent The Journal’s LOE-assignment process.
Notably, The Journal has decided to depart from the CEBM update in two important ways. We will not follow the CEBM’s policy of reserving Level-I designation for systematic reviews, believing that certain high-quality original research also merits Level-I status. In addition, because economic and population-health decisions play an increasingly important role in orthopaedic surgery today, we have retained economic studies in our table, while the CEBM eliminated such research from its update.
Finally, the editorial reminds readers that “a higher LOE does not necessarily reflect the clinical importance of a given study.” Ultimately, each reader is responsible for deciding what constitutes the best external evidence for his or her specific clinical question.
Please let us know what you think about the revised LOE table by clicking the “Leave a comment” button.