Tag Archive | Orthopaedics

Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations

The long-term effect of distal radial fracture malunion on activity limitations is unknown. https://bit.ly/2qYgOMh #JBJS

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Effect of Postoperative Mechanical Axis Alignment on Survival and Functional Outcomes of Modern Total Knee Arthroplasties with Cement

Abdel et al. report on the 20-year survivorship of total knee arthroplasty implants that were mechanically aligned (0° ± 3° relative to the mechanical axis) compared with those that were outside that range and considered outliers. https://bit.ly/2uqY77S #JBJS

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How “Conflicted” Are Medical Journal Editors?

Open Payments Logo for OBuzzMedical journal editors wield substantial power in deciding what gets published and potentially implemented in clinical practice. Theoretically, those decisions could be influenced by “commercial” relationships. To help ascertain the extent of such relationships, a recent retrospective observational study in the BMJ examined payments by US pharmaceutical and device manufacturers to 713 editors from 52 influential medical journals in 26 specialties, including orthopaedics.

Using data from the Open Payments database from 2014 and information gleaned from a survey of journal editors-in-chief, Liu et al. discovered the following:

  • Among 713 editors, 50.6% received some “general payments” (i.e, money deposited directly into personal bank accounts) from pharmaceutical or medical device manufacturers in 2014.
  • The median general payment to journal editors was $11, while the mean general payment was $28,136.
  • The highest median payments were found among journal editors in the specialties of endocrinology ($7,207), cardiology ($2,664), gastroenterology ($696), rheumatology ($515), and urology ($480). The median payment among orthopaedics editors was $121.
  • The two highest payments to individual editors were >$1 million, and those editors were in the specialties of cardiology and—you guessed it—orthopaedics.

Beyond the dollar-and-cents data, the authors discovered that only one-third of the 52 journal websites had readily accessible statements of conflict-of-interest (COI) polices. Among the journals with COI policies, 75% said they have formal recusal processes that exclude an editor from handling manuscripts where he/she has a conflict.

According to an accompanying appendix, among the 34 JBJS editors included in the analysis (i.e., the US-based editor-in-chief, deputy editors, and associate editors), six had received general payments >$50,000 in 2014. The JBJS COI statement asserts that if conflicts are disclosed that might affect an editor’s ability to adjudicate a manuscript fairly, “the paper will be reassigned to another editor.” It also states that “the Editor-in-Chief has no known conflicts of interests or competing interests and makes the final decision regarding acceptance or rejection of all manuscripts submitted.”

Clavicle Fractures: Incidence Up, Surgical Treatment Way Up

 

clavicle-fx-surgery-rateHow best to treat clavicle fractures remains a controversial question in orthopaedics. A study by Huttunen et al. in the November 2, 2016 JBJS does not resolve that controversy, but it sheds a little light on it.

The authors analyzed a validated Swedish hospital-discharge registry and determined that 44,609 clavicle fractures occurred in that country between 2001 and 2012. During that period, the incidence of clavicle fractures increased by 67%, from 35.6 to 59.3 per 100,000 person-years. During that same time, the rate of surgically treated clavicle fractures increased by 705%, from 2.5% of all clavicle fractures in 2001 to 12.1% in 2012. Surgical treatment was more common in men and in younger age groups. Nevertheless, nearly 90% of clavicle fractures were treated nonsurgically in 2012.

Huttunen et al. remain ambivalent in the discussion section of their study, saying that these and other recent findings “may support surgical treatment of young, active patients who need to return to their previous level of activity in the shortest possible time,” while noting that “high-quality evidence that surgery produces superior long-term results compared with nonoperative treatment remains lacking.”

JBJS Classics: Biomechanics of the Normal Elbow

jbjsclassics-2016OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

The classic 1981 JBJS article by B.F. Morrey et al. begs to be read carefully, in part because of the name of the lead author. More importantly, this study answers the question that arises with almost every patient with an elbow disorder: Is the achieved range of motion sufficient for activities of daily living? We can answer this question “yes” or “no” after reading this article, and in my own practice, I repeatedly refer to the information provided in it.

Dr. Morrey was an aerospace engineer who worked at NASA for two years before he attended medical school at the University of Texas Medical Branch. After his residency at the Mayo Clinic and after achieving a master’s degree in biomechanics from the University of Minnesota, he joined the staff at Mayo in 1978.

In this article, which integrates Dr. Morrey’s engineering and medical disciplines, he applied a high-tech device of that period (the triaxial electrogoniometer) to answer simple but eternal questions such as what degree of elbow flexion is needed to eat or perform personal hygiene.

It is the nature of human beings to notice particular joint impairments only when they disturb activities of daily living. Patient-reported outcome scores assessing subtle disturbances have recently been published, but we learned from Dr. Morrey’s article that patients with elbow flexion less than 130° will probably be reminded of their elbow problem whenever they try to use a telephone. (With today’s small cellular phones the problem might be even more accentuated.)

There is not much that a contemporary reviewer would criticise if this study were to be submitted today. Yes, the graphics would be nicer, and there would be more than 12 references. Modern computer-aided tools and methods for motion analysis might be more precise (and produce a mass of partially redundant data), but the results would remain essentially the same.

In fact, the question of functional elbow range of motion was revisited in JBJS by Sardelli et al. exactly 30 years after Dr. Morrey’s study appeared. Using modern three-dimensional optical tracking technology, Sardelli et al. found only minimal differences compared to findings in the Morrey et al. study. Only a few contemporary tasks like working on a computer (greater pronation) or using a cellular phone (greater flexion) appeared to require slightly more range of motion than previously reported.

Finally, it is the succinct and pointed results that amaze me whenever I recall the information from Dr. Morrey’s study. All we need to remember are four numbers: 100, 30, 130, and 50. Therein we are reminded that the patient needs to achieve a 100° arc of motion for flexion /extension (from 30° to 130°) and forearm rotation (50° of pronation and 50° of supination).

The authors were able to omit the conclusion sentence we see so often these days: “Further studies are needed…” The question about the minimal range of elbow motion needed to accomplish activities of daily living has been convincingly answered in this article. All residents should read this JBJS classic early, certainly before they examine their first patient with an elbow disorder.

Bernhard Jost, M.D.
JBJS Deputy Editor

JBJS Case Connections—Arthroscopy Solves Ornery Ortho Problems

Avulsed teres minor.gifThe indications for arthroscopic treatment of musculoskeletal injuries continue to expand as orthopaedists find new and creative ways to apply this flexible technology. The May 2016 “Case Connections” article springboards from a May 25, 2016 JBJS Case Connector report about an isolated avulsion of the teres minor tendon that was repaired arthroscopically. That unique case is linked to three others from the JBJS Case Connector archive:

  • Arthroscopic treatment of a knee flexion contracture
  • Arthroscopic reduction/fixation of an acetabular rim fracture
  • Arthroscopically assisted medial femoral condyle reduction

As impressive as these minimally invasive solutions are, orthopaedists should always keep in mind that arthroscopy, like any other surgical procedure, is not without its potential complications (see related “Case Connections” article).

JBJS Reviews Editor’s Choice–How Should New Orthopaedic Technology Be Introduced?

Over the past several decades, orthopaedic surgery has enjoyed an explosion in the development of new technologies. These technologies have largely improved the quality of orthopaedic care. The development of new technologies results in both disruptive and nondisruptive evolution and requires that orthopaedic surgeons gain specific knowledge of their appropriate use in clinical practice.

However, despite the advances developed from orthopaedic innovation, many discoveries have been associated with unanticipated adverse events. As an example, the original total hip replacement developed by Charnley featured a 1-piece femoral component with a 22.5-mm head. This was later changed to a larger-diameter head, resulting in increased volumetric wear of conventional polyethylene. In addition, new implants with sharp corners led to cement fractures and the development of so-called cement disease. More recently, metal-on-metal articulations have been associated with metallic particles and ion-induced bone and soft-tissue destruction. Ceramic-on-ceramic articulations may lead to implant breakage, striped wear, and squeaking. There is no question that total hip arthroplasty is an exceptionally successful technology, but there is concern regarding the way in which improvements and innovations gain regulatory approval and surgeon acceptance.

In the May 2016 issue of JBJS Reviews, Goodman et al. discuss the introduction of new technologies in orthopaedic surgery. They review the use of novel biologics and combination products and, in particular, single out platelet-rich plasma for the insufficient clinical evidence to support its use. Moreover, they describe the initial enthusiasm regarding the use of recombinant human BMP-2 for spine fusions but note that a review of clinical trials has revealed that there may be concerns regarding insufficient numbers of patients to assess safety, under-reporting of serious complications, conflict of interest among the investigators, and potential bias.

Goodman et al. address some very simple but nonetheless profound issues. For example, they ask, “How should new technologies be introduced into orthopaedics?” They further ask, “How should a surgeon learn to use new technology?” Perhaps most importantly, they raise the issue of ethical considerations related to the use of new technology.

The future of orthopaedic innovation looks bright. Some have commented that there are too many perceived barriers to gaining regulatory approval of new technologies. Recently, the structure and methodology by which approval of new medical technology is managed across the United States has come under increased scrutiny.

I do not think you can ever be too safe or too careful. This article by Goodman et al. is an excellent review of the issues and considerations. It’s a quick read but leaves plenty of room for thought!

Thomas Einhorn, Editor

JBJS Reviews

Atypical Femoral Fractures: An Update

F2.mediumWe posted our first “Case Connections” article about  bisphosphonate-related atypical femoral fractures (AFFs) one year ago. Since then, JBJS Case Connector has published three additional case reports on the same topic, suggesting that it’s time for a revisit. These three recent cases demonstrate that AFFs can occur despite prophylactic intramedullary (IM) nailing of an at-risk femur, that AFFs can present as periprosthetic fractures, and that men taking bisphosphonates—not just women—can experience AFFs.

JBJS Announces a New Benefit to its Authors: Kudos

JBJS values its authors tremendously, as they are essential to providing the high-quality orthopaedic content that The Journal continues to publish every other week for so many years. “The quality of The Journal of Bone & Joint Surgery depends on the quality of the musculoskeletal manuscripts we receive, and for that we rely on a dedicated community of researcher-authors. With increasing pressure on authors from governments, funders, and institutions to demonstrate the impact of their work, JBJS continues to seek ways to help our authors who help us,” said JBJS Editor-in-Chief, Marc Swiontkowski, MD in last week’s editorial “Helping the Authors Who Help Us”.

JBJS has partnered with Kudos, a service that provides tools for authors to maximize the visibility and reach of their published journal articles. JBJS is now offering Kudos to its authors as a free benefit, to ensure that the high quality work of its authors can reach the widest possible audience.

Launched in April 2014, Kudos is a service designed to help authors and their institutions and funders maximize and measure the visibility and impact of their published articles. Kudos is a web-based toolkit that helps authors increase the visibility and impact of the articles they publish with JBJS and other publishers. Using Kudos, authors can explain and share their work with wider audiences in order to boost article downloads, citations, and altmetrics. Kudos is already used by more than 37,000 researchers worldwide and is supported by more than 40 publishers, including JBJS. Learn more about Kudos as a benefit to JBJS authors here: http://jbjs.org/content/kudos-jbjs-authors.

Did you know that JBJS is an accredited CME provider?

For over 125 years, the Journal of Bone & Joint Surgery (JBJS) has been the premier journal for orthopaedic surgeons. Today, our publication portfolio has grown to 4 peer-reviewed, evidence-based journals. Two of these journals offer continuing medication education (CME) for orthopaedic generalists, specialists and allied health personnel. The development of the CME activities is overseen by a committee consisting of editors from The Journal and JBJS Reviews.

The JBJS CME program is designed to enhance the knowledge, competence and performance of orthopaedic surgeons worldwide, and to improve musculoskeletal health for their patients. Our CME program addresses a range of clinical topics including: adult hip and knee reconstruction, foot and ankle surgery, spine surgery, shoulder and elbow surgery, pain management, sports medicine, pediatrics, and trauma. After successful completion of the period of Provisional Accreditation, JBJS received full accreditation for our CME program in March of 2015.

The Journal of Bone and Joint Surgery, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Journal of Bone & Joint Surgery offers two CME activities: The Quarterly CME Activity and the Subspecialty CME Activity. Each of these CME activities is an interactive educational experience of examination questions based on articles published in the Journal of Bone & Joint Surgery. The Quarterly CME Activity contains 50 questions and is also designated for a maximum of 10 AMA PRA Category 1 Credits™. The Subspecialty CME activity contains 10 questions and is designated for a maximum of 5 AMA PRA Category 1 Credits™.

The Quarterly CME activity is approved by the American Board of Orthopaedic Surgery (ABOS) as a Self-Assessment Examination (SAE) that qualifies for SAE CME under the Board’s Maintenance of Certification (MOC) Program. Each Quarterly activity grants 5 SAE credits and must be submitted in pairs for maintenance of certification

JBJS Reviews, our newest journal, offers a journal-based CME activity with each article. Each article contains 5 CME assessment questions that can be completed and submitted after reading the article for 1 AMA PRA Category 1 Credit™.

JBJS is committed to providing timely, relevant CME to orthopaedic surgeons and allied health providers worldwide, promoting effective decision-making and clinical practice based on the gold-standard of peer-reviewed, scientific information contained within our publications.

You can access JBJS CME activities by visiting the JBJS Orthopaedic Education Center.