In my 20-plus years serving as a deputy editor and editor of JBJS, I have never seen the kind of media interest in research published in The Journal that the Harper et al. study on distal radius fractures in older men has received.
This well-done retrospective evaluation of 95 males and 344 females who were treated for a distal radius fracture at a single institution has been discussed in multiple forums and media outlets, including the national newswire services, scientific and clinical blog sites, and health reports on local and national TV newscasts.
One conclusion from the Harper et al. analysis was that males older than 50 who had a distal radius fracture are receiving far worse follow-up care compared to females with the same characteristics in terms of bone-mineral density testing and subsequent pharmacologic treatment to prevent future fractures. For example, an older male with a fragility-caused distal radius fracture is nearly 10 times less likely to undergo bone-density testing than a woman with the same fracture. What is so newsworthy about this finding as to prompt headlines such as “Gender Bias in Osteoporosis Screening”?
My hypothesis is that orthopaedic research has focused too much on procedural-based interventions. When research such as the Harper et al. study extends beyond developing new therapies to matters of population health and application of evidence-based therapies, the public pays especially close attention. Previous OrthoBuzz posts by my JBJS predecessor Vern Tolo, MD and JBJS Reviews Editor-in-Chief Tom Einhorn, MD have called on clinicians to take a more aggressive approach toward primary and secondary prevention of fragility fractures. JBJS commentator Douglas Dirschl, MD says that the gender disparity revealed by Harper et al. “should shock the medical community into improved performance.”
Orthopaedic surgeons are increasingly working in teams consisting of family physicians with additional musculoskeletal training, radiologists, anesthesiologists, nurses, PTs, OTs, and athletic trainers. As our field expands its scope to “musculoskeletal health, prevention, and treatment” and away from exclusively invasive interventions, let’s continue to invite the public along. Based on the media coverage of the Harper et al. study, the public appears to be a willing partner in our attempts to reduce the risk of fragility fractures.
Do you think including preventive and population-health perspectives is the right direction for our field? Send us a comment of support or a dissenting view by clicking on the “Leave a Comment” button in the box to the left.
Marc Swiontkowski, MD
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.
The Impact Factor uses a simple calculation – number of citations to scholarly articles published in a two-year period divided by the number of those articles. The resulting number allows various constituencies to compare the purported intellectual impact of a particular journal against other comparable journals and to trend impact over time.
For years, The Journal of Bone & Joint Surgery has focused on giving surgeons at the interface of clinical practice and academic research the best information possible, making the Impact Factor a number we didn’t focus on much. Our measurements of reader feedback and engagement have been much more important, and will continue to be.
Still, imagine our pleasant surprise when this year our Impact Factor rose dramatically, increasing 33% from 3.234 to 4.309. In addition, measurements such as what Thomson Reuters calls the “Article Influence Score” roughly doubled for JBJS.
There are many reasons for increases like this, but excellent editorial content is clearly the leading candidate for praise. As you know, Vern Tolo, MD, recently transitioned out of the role of Editor-in-Chief for The Journal. He clearly deserves much of the credit for these numbers, which occurred under his careful editorial stewardship. The Journal’s superb Deputy Editors, methodology and statistical consultants, and editorial staff also deserve praise for consistently pushing the standards of The Journal higher.
Best of all, our Impact Factor rose while our engagement with readers also increased. Recent readership surveys show that our readers are reading us in print as much as ever, online more than ever, and engaging with our social media outlets more and more every day..
We’re proud that JBJS has increasing impact as an orthoapedic journal. Our goal remains the same, however – to have a positive impact on surgical expertise, patient care, and outcomes.
This is my first Editor’s Choice for OrthoBuzz as new Editor-in-Chief of JBJS. I am following the example of my esteemed predecessor, Vern Tolo, who recently issued an Editor’s Choice warning about our failure to improve the management of patients with fragility fractures in terms of appropriate diagnosis and treatment of underlying osteoporosis. That is a failure of under-treatment. I want to focus on a potential issue of overtreatment.
In the July 2, 2014 JBJS, Leroux et al. describe the risk factors for repeat surgery after ORIF of midshaft clavicle fractures. The study analyzed 1,350 patients treated with surgery between 2002 and 2010 in Ontario. It is important to note that this analysis includes years after 2007, when JBJS published the seminal multicenter RCT on this topic by the Canadian Orthopaedic Trauma Society (COTS). The essence of that study was that ORIF with plate fixation results in a lower rate of nonunion and better functional outcomes predominantly in patients who have completely displaced fractures with about 2 cm of shortening or displacement.
Since that publication, we have seen an explosion in the operative treatment of midshaft clavicle fractures in North America. However, all too often the inclusion criteria derived from the seminal RCT are not referenced in individual patient decision making, and the presence of a clavicle fracture–regardless of degree of displacement–becomes an indication for surgical management.
The findings of the Leroux study should help put a hard stop to this! These researchers found a 24.6% incidence of repeat surgery in this cohort of patients. The most common reoperation was isolated implant removal (18.8%), and the incidence of major complications included nonunion (2.6%), deep infection (2.6%), pneumothoraces (1.2%), and malunion (1.1%). Risk of reoperation was increased in female patients and in those with major medical comorbidities. Limited surgeon experience increased the risk of reoperation for infection.
The orthopaedic surgery community must heed these data and act upon them. We should not misinterpret the COTS study to “encourage” a patient to opt for surgery if he or she has a midshaft clavicle fracture with less than 2 cm of shortening or displacement. The technical aspects of surgery for midshaft clavicle nonunion is not that different than that for a fresh fracture, so avoidance of nonunion must be thoughtfully discussed with the patient before recommending surgical fixation.
The bottom line that Leroux et al. provide is that surgery for a midshaft clavicle fracture is not a guaranteed success and that surgeon experience matters. And beyond clavicle fractures, let’s be sure we use our literature during shared decision making in an accurate and appropriate manner. That is a basic tenet of professionalism that we all should subscribe to.
JBJS welcomes Dr. Marc Swiontkowski as our new Editor-in-Chief. Dr. Swiontkowski is a trauma specialist and professor in the Department of Orthopaedic Surgery at the University of Minnesota Medical School. He is also the former CEO of TRIA Orthopaedics and past president of the American Orthopaedic Association and the Orthopaedic Trauma Association.
We are excited to work with Dr. Swiontkowski to continue strengthening JBJS as it supports the practice of orthopaedics and musculoskeletal health for everyone.
As Dr. Swiontkowski works with our departing Editor-in-Chief, Dr. Vern Tolo, during this transition, he was gracious enough to answer a few questions for OrthoBuzz.
JBJS: As you transition into the role of Editor-in-Chief at JBJS, what are you most excited about?
Dr. Swiontkowski: The opportunity to work with a highly talented group of editors and authors to influence the course of musculoskeletal medicine and surgery is what excites me the most.
JBJS: What are your goals for JBJS?
Dr. Swiontkowski: I hope to maintain our excellence in peer review while innovating in new ways to deliver information to surgeons in ways that are most useful for clinical decision making.
JBJS: As JBJS celebrates its 125th anniversary this year, how would you describe the impact the Journal has had on orthopaedics?
Dr. Swiontkowski: JBJS has been at the forefront of all the important developments in the field, and those developments have directly impacted patients with musculoskeletal disorders.
JBJS: How do you think JBJS can best support orthopaedics going forward?
Dr. Swiontkowski: In the future, JBJS will continue to support and recognize our highly skilled panel of reviewers, while developing new mechanisms for educating and delivering highly refined information to surgeons.
JBJS: You helped found and have served as the CEO of TRIA Orthopaedics, a full-service outpatient orthopaedic center in Bloomington, MN. What have you learned about community orthopaedics as a result of starting and growing that practice?
Dr. Swiontkowski: Community surgeons are interested in access to the highest quality scientific information to support their clinical decision making. They are also willing to contribute to new-knowledge development if the process is well refined with appropriate support.
JBJS: What trends in orthopaedics are you most intrigued by?
Dr. Swiontkowski: Four trends come to mind:
- The move away from general hospital-based care.
- The move toward patient-oriented functional outcomes to evaluate the results of care
- The openness to consider better ways to identify patients most likely to benefit from a particular treatment….and
- The move away from incremental implant design improvements toward understanding surgeon factors that have the greatest impact on patient results.
JBJS: Looking ahead to the next 20 years or so, what three significant advances or changes in orthopaedics do you foresee?
Dr. Swiontkowski: I think we’ll see the following changes:
- The full transition to milestone-based surgeon education
- The ability to identify patient and surgeon characteristics that have the biggest impact on outcomes for use in shared decision making processes
- The move away from general hospital-based care toward musculoskeletal treatment centers.
JBJS: What is your favorite thing about your profession?
Dr. Swiontkowski: It’s incredibly fulfilling to be completely trusted by patients to act in their best interest with the use of very powerful orthopaedic interventions.
In last month’s Editor’s Choice, JBJS Editor in Chief Vern Tolo. MD, called for more concerted efforts among orthopaedists to link care of fragility fractures to evaluation and treatment of osteoporosis. Now, JBJS Reviews Editor in Chief Thomas Einhorn, MD, echoes Dr. Tolo’s message in reference to the May 2 JBJS Reviews article on managing patients with osteoporotic distal radial fractures:
According to Dr. Einhorn, “This must-read article provides a concise summary of how to advance the diagnosis and treatment of osteoporosis and fragility fractures. The authors explain the latest evidence about the ‘three main pillars’ of treatment of distal radial fractures in people with osteoporosis: primary prevention, acute management, and reduction of risk of future fractures. The strides made among US orthopaedists to recognize and manage osteoporosis with programs such as the American Orthopaedic Association’s ‘Own the Bone’ initiative have been commendable. However, on a global scale, our specialty is woefully behind in taking an aggressive approach toward prevention and treatment of osteoporosis.”
The article “Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial menisectomy” is an interesting report of a randomized, double-blind, controlled study carried out over a 2-year period following subtotal medial menisectomy.
While the positive impact of mesenchymal stem cells (MSCs) on both the meniscus and articular cartilage has been demonstrated in animal models, this study looks at the potentially beneficial effects in humans after partial menisectomy. MSC injection in this setting resulted in no apparent complication secondary to these injections. Pain in patients with osteoarthritis was also improved over 2 years compared to those patients treated only with hyaluronate injection. Most intriguing, though, was that in 24% of patients with lower dose MSC and in 6% with higher dose MSC, there was an increase in meniscal volume on MRI by > 15%. None in the control group showed any volume change.
With the large number of meniscal injuries treated surgically in all age groups, MSC injection following partial menisectomy may prove to be a safe method to decrease osteoarthritic pain and potentially increase the volume of the remaining meniscus.