Whenever physicians implant a “foreign” device in the body, as orthopaedists often do, the implant is up against two crucial challenges: blood clots and bacteria. Solving both of those challenges took a big step forward with the recent publication in Nature Biotechnology of results with a new device-surface coating that thwarts blood clotting and keeps certain bacteria from sticking to it through glycocalyx formation. The repellant coating, called tethered-liquid perfluorocarbon, or TLP, is a modified version of the super-slippery stuff that the carnivorous pitcher plant uses to catch insects.
Harvard researchers tested the coating, the two constituents of which are already FDA-approved, in vitro on 20 different medical surfaces, including glass and metal, where it suppressed platelet adhesion and activation under simulated blood flow. They also tested it in vivo with catheters implanted into the large veins of pigs, where it prevented blood clotting for eight hours without the use of anticoagulants. In another in vitro experiment during which TLP-coated medical tubing was exposed to Pseudomonas aeruginosa for six weeks, only one in a billion of the bacteria were able to adhere.
It’s too early to say with certainty if and when TLP coatings might be ready for use on orthopaedic implants, but the approach raises hopes that a powerful new preventer of two major complications associated with orthopaedic device implantation is feasible in the near future.
It would be an understatement to suggest that the practice of medicine has changed during the past ten years. Indeed, every physician can think of a number of things that have impacted his or her practice. However, among the positive changes that have affected how we treat patients, evidence-based medicine ranks high on the list.
Evidence-based medicine has been defined as “the integration of best research evidence with clinical expertise and patient values.” Those who support evidence-based medicine note that it will prevent the bias that exists among health-care professionals who frequently base clinical decisions on custom and practice. Hence, the growth of evidence-based medicine along with the desire among clinicians to reduce variations in health-care delivery has had an important and positive impact on health-care practice and policy. Simply stated, the principles of evidence-based medicine serve as a means of decreasing variation in health-care delivery and improving patient outcomes.
The history of evidence-based medicine is interesting and is well covered in the article by David Jevsevar in the September 2014 issue of JBJS Reviews. Concepts and terms are defined, and the findings of research on health-care disparity are discussed. Clearly, the randomized controlled trial (RCT) has become the so-called gold standard in research methodology because of its ability to minimize confounding between patient groups. However, Dr. Jevsevar notes that there are concerns regarding the use of RCTs in the practice of medicine, including their expense as well as the time required for patient recruitment, data analysis, and study completion. As a result of these costs and challenges, most RCTs are now funded by industry, raising concerns about the potential external sources of bias.
This article also touches on other important concepts related to evidence-based medicine in clinical practice policy, such as the propagation and control of conflicts of interest, shared decision-making between physician and patient, and the development of best-practice applications to address the individual needs of and risks to each patient. Finally, it is apparent that the Patient Protection and Affordable Care Act (PPACA) that was signed into law on March 23, 2010 introduces important and vast changes in access to the U.S. health-care system. Designed to address the unsustainable growth in federal spending and the depletion of the Medicare trust fund that is predicted to occur by 2026, this legislation represents an attempt to “bend the cost curve” by showing the increase in annual health-care expenditures. It further makes the point that the absence of an essentially controlled U.S. health-care system creates a potentially large research laboratory promoting study opportunities to investigate the delivery of high-quality, evidence-based care. Thus, the opportunity for orthopaedic surgeons to become advocates for their patients, to take a leading role in shaping the future of evidence-based medicine, and to do so in a way that generates costs that our nation can afford presents a real opportunity to positively shape the future of orthopaedic practice.
Thomas A. Einhorn, MD, Editor, JBJS Reviews
Vernon Tolo, MD, JBJS Editor-in-Chief Emeritus, provided outstanding editorial stewardship for The Journal during the last four years. In this interview, he explains what the experience has meant to him.
JBJS: As you transition out of the role of Editor-in-Chief at JBJS, what will you miss the most?
Dr. Tolo: There are a few things I will miss. One is the opportunity to work with a great group of Deputy Editors, whose work is essential and so important to the Editor. I will miss the JBJS staff, who are all talented professionals and who provided great support to me during my time as Editor. And I will miss seeing the latest in research reports, often months before publication occurs. The time I spent as Editor were some of the most exciting and rewarding years of my orthopaedic career… a true privilege to be able to carry forward the tradition of JBJS. Nonetheless, I will not miss the relentless assignment of manuscripts which required nightly connection to my computer….but I still had a great time.
JBJS: When you first joined JBJS, what surprised you the most about The Journal or about journal publishing in general?
Dr. Tolo: I had known primarily about the editorial side of journal publishing from my years being a JBJS Deputy Editor. What surprised me the most when I became Editor was how little I knew about trends in medical publishing and the challenges facing journals such as JBJS in today’s publishing world. Being involved in meeting these challenges has stimulated me to think about problems and challenges that I otherwise would not have considered.
JBJS: As JBJS celebrates its 125th anniversary this year, how would you describe the impact of The Journal on orthopaedics?
Dr. Tolo: The Journal has had a tremendous impact on orthopaedics. For the first 100 years, JBJS was the primary written source of orthopaedic education for all orthopaedic surgeons in North America. Articles published in JBJS were the source of a large percentage of questions in the Board examinations for years. Even after the explosion of educational sources in the past 25 years, The Journal still holds a pre-eminent position for quality, trusted research reports that affect day-to-day patient care.
JBJS: How do you think JBJS can best support orthopaedics going forward?
Dr. Tolo: We need to continue to be the trusted source for new orthopaedic knowledge that improves patient care. The multiple journals that the JBJS family has developed over the past few years have really broadened the choices available to orthopaedists, as has the option for webinars throughout the year.
JBJS: What trends in orthopaedics are you most intrigued by?
Dr. Tolo: I am not sure “intrigued” is the right word, but I am concerned about the ongoing tendency for super-specialization within our profession. Despite having exposure to and training for the treatment of a wide variety of orthopaedic conditions during residency, orthopaedists are increasingly claiming they are inadequately trained to treat a wide variety of orthopaedic conditions, particularly once they have completed a fellowship in a subspecialty. For example, pediatric orthopaedists may feel uncomfortable treating hand or pelvic fractures. Sports medicine orthopaedists will often not get involved with treatments outside their fellowship training. And it goes on with many other examples. This situation only seems to be increasing. The ongoing challenge is how to adjust training programs to allow for appropriate broad-based training opportunities and still allow residents to focus on the subspecialty in which they will eventually practice.
The trend over the past several years of orthopaedics being a specialty selected by more medical students than there are residency openings will likely continue. We are still the most underrepresented surgical specialty for women in training programs and on faculties. While some progress has been made in this area, we need to increase the number of women in orthopaedics.
JBJS: Looking ahead to the next 20 years or so, what do you think might be three significant advances or changes in orthopaedics?
Dr. Tolo: The changes in orthopaedics have been so dramatic in the past 20 years that it is a challenge for me to predict how our profession will look in 2034. I think medical schools will finally include education in musculoskeletal disorders commensurate with the percentage of patients with these conditions who are seen by primary care physicians. Robotic surgery, currently so common in surgical specialties that deal with soft tissue disorders, may soon be ready for orthopaedic use, but that will be a decade or more from now. Biologics will be used more often, particularly in settings to decrease the onset of articular cartilage damage after ACL injury or intraarticular fractures, and this would be a major advance. It may be that a “bone glue” may supplant casts as a fracture treatment. Whatever advances occur, JBJS is where they should be published.
JBJS: What is your favorite thing about your profession?
Dr. Tolo: No question….it is helping patients get better. I am fortunate to have worked in pediatric orthopaedics my entire career. All children want to get better, and the ability to play a part in helping advance the health of children has been extremely rewarding for me. I still love going to work every day, and the grateful feedback that I receive almost daily from families is incredible. There are few other professions or vocations that provide this benefit.
JBJS: What are you looking forward to most as you make this transition?
Dr. Tolo: Once I have dealt with my withdrawal symptoms from my time at JBJS, I will increase my clinical outpatient and operative activity at the Children’s Hospital Los Angeles, mainly in spinal deformity, skeletal dysplasia, and cerebral palsy, though probably a bit less than 100% full time. I look forward to spending quality time with my wife Charlene, who has put up with a sometimes crazy schedule for 49 years of marriage, and to getting my golf handicap down to the low teens. It will be difficult for me to break away completely from orthopaedics, which has provided me with an incredibly satisfying career and multiple opportunities to contribute to our profession globally, through a number of societies/associations–and through JBJS.
Dr. Vinod Dasa, assistant professor of clinical orthopaedics at Louisiana State University Health Sciences Center in New Orleans, has scheduled a revision knee replacement for a 62-year-old female patient. But in the meantime, he’s relieved her chronic knee pain by freezing a peripheral sensory nerve with three needles through which very cold and highly pressurized liquid nitrous oxide is delivered. At the site of the target nerve, the N2O changes phase from liquid to gas, which is expelled out from the hand-held delivery device, leaving nothing behind but a frozen nerve. The degeneration of the nerve is temporary, and it eventually regenerates. The resulting pain relief can last up to three months, at which time pain signals flow once again.
This technique, trademarked as Focused Cold Therapy™, received FDA approval in 2013 for use as a reversible peripheral nerve block. According to Dr. Dasa, “Focused cold therapy offers reliable pain relief in areas such as the knee, which may allow for physical therapy to proceed and even reduce the need for systemic pain relievers.”
Baylor University basketball star Isaiah Austin was 20 years old when the NBA told him last month that he had Marfan syndrome and was ineligible to play professional basketball. Why was Austin not diagnosed with this potentially fatal connective-tissue disorder earlier in life? The answer may lie in a 2010 study by Sponseller et al. in JBJS. The authors point out that early diagnosis of Marfan syndrome is complicated by the fact that many of its recognizable skeletal features—including scoliosis and flat feet—appear with some frequency in the general population.
By studying people with confirmed Marfan syndrome and those without, the authors discovered that the most diagnostically relevant physical characteristics of the syndrome are craniofacial features such as narrow cranial shape and positive thumb and wrist signs. The combined presence of those characteristics yielded an area-under-the-curve diagnostic accuracy of 0.997. Doctors often recommend that people with suspected Marfan syndrome receive confirmatory genetic tests, which are readily available but expensive.
Even though it’s difficult to recognize Marfan syndrome on the basis of physical observation alone, Sponseller et al. suggest that orthopaedists “at least briefly visualize the entire patient” and consider a referral for genetic testing and/or echocardiogram when the aforementioned features are present.
For his part, Mr. Austin took the news in stride. He said he plans to return to Baylor to finish his degree and perhaps become a Marfan syndrome advocate-educator. His inspiring Instagram message: “Please do not take the privilege of playing sports or anything for granted.”
According to the orthopaedic surgeon edition of Kantar Media’s Website Usage & Qualitative Evaluation study, JBJS.org ranks hands down as the #1 orthopaedic site that surgeons visit most often and spend the most time on. The Kantar study evaluates the opinions of orthopaedic surgeons on 29 professional websites, including 8 orthopaedic sites. Not only does JBJS.org rank number 1 among the other 7 orthopaedic sites in frequency of visits (4.7 times/month), the website ranks first among all 28 sites evaluated in terms of time per session (20.31 minutes). Additionally, JBJS.org ranks #1 in delivering quality clinical content and keeping surgeons informed of the latest practices and procedures. JBJS ties for first place in the category of information on drugs, devices, or professional services. Also noteworthy is the fact that JBJS Reviews, a new online review journal from JBJS launched in November 2013, has already taken over third place in time spent and number of site visits.
JBJS Webinar Series
JBJS has held multiple live webinar events on a wide variety of topics, and we are pleased to announce the expansion of the JBJS Webinar Series in 2014. Each webinar has proven to be a successful tool in educating, informing and engaging orthopaedic surgeons around the world. In 2014, JBJS is continuing this educational program through a new series of interactive online events.
Our webinars bring together groups of authors to present recently published scientific research and data, and they include commentary from guest experts. Live Q&A sessions follow the author and commentator presentations to provide the audience with the opportunity to further explore the concepts and data presented. Webinars continue to be available on-demand for several months after the event.
AVAILABLE ON-DEMAND (Previously Recorded Events)
Total Knee Arthroplasty Critical Decision Making: Socioeconomic and Clinical Considerations (June 10, 2014) – Moderated by Charles R. Clark, MD
Panelists/Authors: Kevin J. Bozic, MD and Thomas S. Thornhill, MD
Commentators: Daniel J. Berry, MD and Kevin Garvey, MD
Preventing Arthroplasty-Associated Venous Thromboembolism (VTE) (May 12, 2014) – Moderated by Thomas A. Einhorn, MD
Panelists/Authors: Clifford W. Colwell Jr, MD and John T. Schousboe, MD
Commentators: Vincent Pellegrini Jr, MD and Jay Lieberman, MD
Anterior Cruciate Ligament (ACL) Reconstruction (March 5, 2014) – Moderated by Mark Miller, MD
Panelists/Authors: Freddie Fu, MD and Christopher Kaeding, MD
Commentators: Brett Owens, MD and Darren L. Johnson, MD
Adhesive Capsulitis/Frozen Shoulder (December 2013) – Moderated by Andrew Green, MD
Presented in conjunction with the Journal of Orthopaedic & Sports Physical Therapy.
Panelists/Authors: George Murrell, MD, Martin J. Kelley, DPT, Jo Hannafin, MD, PhD, and Philip W. McClure, PT, PhD
Periprosthetic Joint Infection (October 2013) – Moderated by Charles R. Clark, MD
Panelists/Authors: Kevin J. Bozic, MD and Craig J. Della Valle, MD
Commentators: Javad Parvizi, MD, FRCS, and Geoffrey Tsaras, MD, MPH
Measuring Value in Orthopaedic Surgery (September 2013) – Moderated by James Herndon, MD
Panelist/Author: Kevin J. Bozic, MD
Commentators: David Jevsevar, MD and Jon J.P. Warner, MD
Editor, JBJS Reviews: Thomas A. Einhorn, MD
Dr. William Oros, a University of Tennessee Medical Center (UTMC) orthopaedic trauma surgeon, recently performed surgery on a 37-year old Western lowland gorilla with a broken femur. The 385-pound gorilla, named Wanto, broke his leg while climbing bars in his indoor courtyard at the Knoxville Zoo. The zoo’s staff veterinarian Ed Ramsay evaluated Wanto and gave him pain medication to deal with the pain. Once radiographs confirmed the injury as a fracture, Ramsay contacted Dr. Oros for advice, and he volunteered to operate on Wanto himself. (Two years previously, Dr. Oros treated Dr. Ramsay’s broken leg.)
UTMC donated the use of a surgical table for the procedure, which took 3.5 hours to complete — about 2 times longer than the same surgery would take with a person.
The May 21, 2014 Orthopaedic Forum article, “Public perception regarding anterior cruciate ligament reconstruction” by Matava et al. is a timely reminder of how important physician-patient communication and patient education are.
In this study, 210 individuals (all but 7% of whom had a high school education and 50% of whom had a college degree) completed a predominantly multiple-choice questionnaire on their knowledge of anterior cruciate ligament (ACL) injury and its ramifications. Given the extensive media coverage of ACL injury in high-profile athletes, I think virtually everyone has heard the term “ACL.” But this study points out how superficial or incorrect patient knowledge is about ACL injury, even in this well-educated study cohort.
I urge you to read the article to see all the interesting findings, but here are a few of the most intriguing ones:
- 51% of factual questions were answered correctly.
- There was no correlation between education level and correct responses, but those with a higher activity level had a higher score on the survey.
- 16 participants with prior ACL injury had no more correct responses than those with no knee injury.
- 34% knew that the ACL was attached to bone at each end.
- 70% did not know that the risk for ACL injury is different between men and women.
- 48% thought that a complete ACL tear could heal without surgery.
- 33% thought ACL repair was needed to be able to walk.
- 32% thought ACL reconstruction surgery involved repairing the torn ligament.
While this article focused only on patient knowledge of ACL injury, the implications probably extend to essentially all orthopaedic surgical procedures. The push for us to use more shared decision making in deciding whether or not a surgical procedure is done requires that the patient has adequate information to make an informed decision. Unfortunately, the dearth of knowledge about a common knee injury among the general public highlighted in this article is so dramatic that it seems unlikely that the individuals surveyed could participate realistically in shared decision making about ACL surgery.
With orthopaedic procedures accounting for about 40% of CPT codes, it would be a huge challenge for orthopaedic practices to provide evidence-based education on all conditions prior to or during a discussion of possible surgical treatment. However, this article points out the need for much-improved patient education. Each orthopaedic practice will handle this differently, but perhaps when surgery is recommended, the physician extenders in an orthopaedic practice could suggest reliable websites through which patients can obtain information. The patients could then return with a list of questions that arose from their reading to be addressed during the final discussion related to surgical treatment.
However patient information is provided, this article points out the need for ongoing attention to filling the knowledge gap to realistically allow patients to be true participants in deciding which course of treatment is best.
Selected patients with osteomyelitis from diabetic foot infections can be treated medically or surgically with equal effectiveness, according to a small randomized study in Diabetes Care, purportedly the first study to prospectively compare the two treatments. Fifty-two patients with diabetic foot ulcers complicated by osteomyelitis received either a 90-day course of antibiotics or had the infected bone removed surgically, followed by a short course of antibiotics. Healing (complete epithelialization) occurred in 75% of the antibiotic group and 86% of the surgery group (p=0.33), and complications during treatment were also similar in the two groups. Clinical guidelines from the Infectious Diseases Society of America for dealing with diabetes-related foot osteomyelitis can be found here.