Commentary The thought-provoking and well-performed study by Lähdeoja et al. represents a retrospective review of 209 patients who sustained a proximal humeral fracture as adolescents and had an impressive follow-up ranging from 7 to 19 years and a thorough and rigorous methodology to assess outcomes. The authors did an outstanding job matching cohorts to make valid comparisons with a similar group without a fracture. The study found that patients who sustained a proximal humeral fracture as adolescents healed well and had good outcomes in long-term follow-up. The study also found no significant differences between patients treated operatively and those treated nonoperatively. It is well known that proximal humeral fractures heal well in young children; however, less is known in adolescents. A recent systematic review found that, since the 1946 inception date in the National Library of Medicine’s computer-based retrospective search service, there have only been 4 prospective cohort studies and 8 retrospective cohort studies examining proximal humeral fractures in children1. None has explicitly focused on fractures occurring during adolescence. The current study by Lähdeoja et al. will add to the growing mountain of evidence that shows that even adolescents do well after this kind of injury. Lähdeoja et al. believe that their findings will influence the practice of orthopaedics as they can help to guide the treatment of proximal humeral fractures in adolescence by using the idea that less is more and noting that most patients can be treated nonoperatively with minimally burdensome methods for the patients and that parents can be assured that the outcomes are good. However, one should note that the idea of less is more can have different interpretations. Dolly Parton once famously said, “People say that less is more, but I think more is more.” She was, of course, referring to the absurdity of noting that a qualifier (less) is opposite to its meaning. The architect Frank Lloyd Wright is correct in stating that “Less is more only when more is too much.” Based on the results of this study, a surgical procedure for proximal humeral fractures in adolescence seems “too much.” However, the incentive to operate in many health-care environments may create a substantial surgeon preference toward treating fractures operatively. There have been a decrease in some reimbursement schedules for orthopaedic procedures2 and a concern for surgeons being incentivized to perform more cases to maintain productivity goals3; decreased reimbursement is a known stressor contributing to surgeon burnout. From a purely orthopaedic viewpoint, this article confirms that nonoperative treatment yields similar or superior results to those of operative treatment of proximal humeral fractures in adolescents. This study comes from an economically highly developed Scandinavian country, Finland, where more than three-quarters of the population received health care through the public system, in 20194, higher than the mean of 71.7% for Organization for Economic Cooperation and Development (OECD) countries5. Finland is one of the most efficient public-sector health service producers, and its model should be applauded and analyzed for generalizability. To quote one final author, Yvon Chouinard, the founder of the apparel and equipment company Patagonia, in his book6, Let My People Go Surfing: The Education of a Reluctant Businessman, “The more you know, the less you need.” In the case of proximal humeral fractures in adolescence, the more we know and understand the long-term consequences of these injuries, the less we need to worry about treating them operatively.
BACKGROUND:Women are underrepresented in the orthopaedic surgery workforce in the U.S. The purpose of this study was to elucidate the representation of women among fellowship program directors (PDs) in orthopaedic surgery. METHODS:This was a retrospective cohort study of fellowship PDs in orthopaedic surgery during the 2022 to 2023 academic year. Academic, training, and demographic characteristics were collected from internet-based resources. Participation-to-prevalence ratios (PPRs) were calculated for both men and women. A PPR of <0.8 indicated underrepresentation and a PPR of >1.2 indicated overrepresentation. Bivariate analyses were utilized to assess the correlation between sex diversity and geographic region and between sex diversity and Accreditation Council for Graduate Medical Education (ACGME)-accreditation status. The relationship between the median annual salary and the sex diversity of each orthopaedic subspecialty was analyzed with use of the Pearson correlation coefficient. RESULTS:This study included 600 fellowship PDs, 40 (6.7%) of whom were women. In total, 24.5% of the fellowship PDs were assistant professors (8.8% women versus 91.2% men, p < 0.001); 26.2% were associate professors (9.6% women versus 90.4% men, p < 0.001); 36.8% were full professors (4.5% women versus 95.5% men, p < 0.001); and 12.5% were unranked (2.7% women versus 97.3% men, p < 0.001). The representation of women increased with academic rank, as reflected in their prevalence at the assistant (PPR = 0.67), associate (PPR = 0.77), and full professor (PPR = 0.80) levels. Among the orthopaedic subspecialties, musculoskeletal oncology (19.0%), pediatric orthopaedics (14.6%), and hand surgery (12.6%) had the highest proportions of women fellowship PDs. PPRs were lowest for orthopaedic sports medicine (PPR = 0.35), shoulder and elbow (PPR = 0.45), and adult reconstruction (PPR = 0.52). Women PDs had equitable representation in musculoskeletal oncology (PPR = 1.17), hand surgery (PPR = 1.02), foot and ankle (PPR = 0.84), and orthopaedic trauma (PPR = 0.80). Median subspecialty compensation was negatively correlated with the prevalence of women among fellowship PDs (r = -0.70, p = 0.036). Geographic region was not associated with sex diversity (p = 0.434), but programs with ACGME accreditation had significantly more women fellowship PDs than those without (11.0% versus 3.9%, p < 0.001). CONCLUSIONS:Women are underrepresented among orthopaedic fellowship PDs, especially in certain subspecialties (orthopaedic sports medicine, shoulder and elbow, and adult reconstruction). More research is needed to understand the barriers that impact the representation of women among leadership positions in orthopaedic surgery. CLINICAL RELEVANCE:Greater sex diversity among fellowship PDs may help to increase the recruitment of women into orthopaedic subspecialties. The equitable consideration of orthopaedic surgeons from all backgrounds for leadership positions can increase workforce diversity, which may improve the vitality of the orthopaedic community.
Commentary Nearly 400 types of skeletal malformations, including those that involve the spine, have been characterized by molecular and cellular analyses1. Identification of genetic components that control the integrity of intervertebral discs—and that predispose to spinal degeneration in aging patients when mutated—represents a challenging goal. Spinal conditions that occur later in life may emerge from faulty musculoskeletal tissue repair after accidental injury and the influences of comorbidities. The collective stochastic and often undocumented events in the life of a patient can easily complicate attempts at defining genetic predispositions. To manage the statistical noise that comes from random mutations within the human population (“nature”) and the randomness of life’s events (“nurture”), it is necessary to examine massive genetic data sets with many thousands of patients. Technological advances that allow cost-effective DNA sequencing have made it feasible to compare large patient populations matched on the basis of specific codes for medical conditions. Consequently, several studies have made impressive attempts at defining genetic variations linked to a range of surgically relevant musculoskeletal complications, including degenerative rotator cuff disease2, arthroplasty3, adhesive capsulitis of the shoulder4, and end-stage knee osteoarthritis5. The current paper by Bovonratwet et al. at the Hospital for Special Surgery in New York provides the latest installment in a growing set of orthopaedic studies in this journal that investigate the relationship between genetic variations and the risk of surgery for spinal conditions. Similar to prior published efforts by Yanik et al.2, Brüggemann et al.3, and Kulm et al.4,5, the study by Bovonratwet et al. leverages the power of the UK Biobank, which has genetic data for about 400,000 patients, of whom a total of about 20,000 (∼5%) had 1 of 4 spinal conditions (i.e., lumbar spondylolisthesis, spinal stenosis, degenerative disc disease, and pseudarthrosis after spinal fusion). Results from this large data set (“training population”) were then tested using the FinnGen database (“test population”) for validation. The analysis yielded multiple different genetic variants across 7 chromosomes. On average, the authors discovered 2 distinct loci per spinal condition. These findings are consistent with the genetic complexities of spinal conditions and suggest that the diseases are polygenic, as expected. Several nucleotide variants associated with 4 common spinal conditions were located in loci encoding anonymous genes that have not been experimentally explored. Degenerative disc disease was associated with a locus containing 2 genes that affect chondrogenesis: CHST3 (for carbohydrate sulfotransferase 3) promotes sulfation of chondroitin, and SMAD3 is the inducible target of chondrogenic transforming growth factor (TGF)-β signaling. Remarkably, 1 chromosomal region significantly associated with both lumbar spondylolisthesis and spinal stenosis contained overlapping sets of genes (i.e., GFPT1 and NFU1) that encode proteins involved in cell metabolism. These genes represent attractive targets for studies on genetic causality for these 2 spinal conditions. While it is tempting to speculate about potential mechanistic implications, the genetic biomarkers for spinal conditions mapped to large regions containing several genes. Whether these genes are even expressed in cell types and tissues relevant to homeostasis and repair of spinal tissues remains to be determined. Lack of similarity among studies indicates that endogenous tissue-specific repair processes may be predominant in the genetic landscape. One major strength of this study is the control for demographics and comorbidities. Yet, even with access to nearly 400,000 people who form a fairly homogeneous study cohort (i.e., White elderly people in Britain), this population size is not nearly large enough to identify the many genes that undoubtedly contribute to spinal conditions. The observation that only a few genetic variants were replicated in the Finnish cohort may further reflect the polygenicity of disease factors and genetic differences of Finnish patients. In closing, just as our emotions can run up or down our spine depending on whether we are in a positive or negative mood, genetic variation appears to affect spinal diseases. Some DNA mutations may literally be running down our spine, by destroying either disc integrity or our capacity for repair after injury. The positive news is that recognition of genetic predispositions may enhance consideration of behavioral modifications or guide surgical decisions. The paper by Bovonratwet et al. will inspire future studies, while bringing us 1 step closer to that goal.
Commentary Accurate identification of offending pathogens is the end goal for the current arms race occurring in the field of periprosthetic joint infection (PJI). Investigators have inundated the orthopaedic literature with a plethora of diagnostic tests that either improve culture methods or pivot into genetic analysis1. Although quite a few of these tests have been shown to identify organisms more often than traditional culture, concerns regarding poor performance and false-positive results linger2. The presence of viable but not culturable (VBNC) bacteria, which can reside on well-performing implants, compounds this concern3. Furthermore, despite the negative attitude regarding culture-negative infections, numerous examples in which culture status has had no impact on treatment success rates exist within the contemporary literature4,5. Therefore, the direct clinical benefit of expensive genetic-based tests remains incompletely understood. A less complicated method of improving the yield of microorganisms from intraoperative samples is sonication, in which high-intensity sound waves are used to disrupt pathogen-related biofilm. Although commonly thought to reside only on implant surfaces, pathogens can actually aggregate on tissue surfaces and even within the synovial fluid itself, leading investigators to try their hand at sonicating everything that comes out of the patient. Until recently, interest in sonication has been inconsistent because of concerns regarding contamination when transferring samples from the operating room to the laboratory, and because of the bulky equipment needed to properly sonicate large arthroplasty components. Ji et al. have attempted to overcome these concerns by bringing sonication tools directly into the operating room. They prospectively analyzed 64 revision arthroplasty cases (36 with PJI, 28 aseptic failures) in which the culture results for conventional synovial fluid (synovial fluid directly and a saline solution lavage of tissue) were compared with implant fluid (a retrieved implant was immersed in fluid, the implant was sonicated, and the fluid was retrieved) and soft-tissue fluid (retrieved tissue was immersed in fluid, then sonicated, and the fluid was retrieved). They found that sonicated samples were significantly more likely to generate positive culture results, exhibiting better sensitivity and better overall diagnostic performance as indicated by the Youden index. However, the very high number of false positives in the aseptic failure group (18%!) is a cause for concern. Furthermore, our understanding of how technique-dependent intraoperative sonication may be is still too limited for such sonication to be diagnostically useful. Are the findings from this study going to bring sonication into an operating room near you? Not yet. Nevertheless, efforts such as these demonstrate that surgeons continue to be interested in becoming more hands-on in the PJI diagnostic process (as also evidenced by leukocyte esterase strips and lateral-flow alpha defensin tests). This involvement is likely to be beneficial, since surgeons can most reliably identify tissue and fluid samples that appear to be the most concerning. However, issues with contamination and false positivity remain omnipresent simply because the collected samples must leave the sanctity of the sterile field to be analyzed. For now, it is quite clear that these studies must continue to be performed and that a consistent methodology for how diagnostic results are reported is essential.
Commentary The human microbiome—the ecosystem of bacteria living and interacting on (and in) human tissues—is enormously complex. Our understanding of its impact is evolving. Next-generation sequencing (NGS) techniques allow for the identification of microbial species and can be used to elaborately interrogate the composition of the bacterial community in specific anatomic sites. This has been extensively described in relation to the gut microbiome, the largest concentration of bacteria in the human body, where complex ecological interactions alter immunology1, pathogenesis2 and metabolic functions3. Far less is known about the microbiomes of anatomic sites previously considered sterile, such as the placenta, the central nervous system, and now the synovium. No one disputes that bacteria and bacterial DNA may transiently penetrate these protected spaces, but whether bacteria truly live there remains to be demonstrated. This preliminary study by Goswami et al. represents a relevant attempt to identify the microbiome of the human osteoarthritic hip and knee. The investigators obtained synovial fluid, tissue, and swabs from patients undergoing primary total hip or knee arthroplasty for osteoarthritis—patients with no overt signs of infection. Concordance in bacterial community composition among samples from the same patient was observed. Variations in diversity were seen depending on the hospital of enrollment and on whether patients had received a corticosteroid injection; these differences may be proxies for broader differences in patient-specific microbial composition. Surprisingly, comorbidities and demographic variables had no significant impact on the microbes found within a joint in this study. The detected microbes ranged from common to obscure—including some that are traditionally considered pathogenic and many others that are not. Some of the common sequences obtained included those of Staphylococcus, Streptococcus, and Pseudomonas. However, even though these are recognized orthopaedic pathogens, it would be surprising to confirm that they persist in clinically uninfected joints. Other bacteria found with frequency included some that are typically found in the environment but only occasionally cause opportunistic infections, such as Paenarthrobacter and Brevundimonas. The limitations of NGS techniques are important to consider. The presence of nucleic acids does not mean the presence of living microbes: remnants of dead bacteria, contamination introduced during sample collection and processing, and even miscategorized mammalian DNA in the vast NGS sequence libraries can all lead to positive findings even when no living bacteria are present. NGS findings are also difficult to confirm by alternate means (such as microscopy or culture), as the microbial burden is so low. A healthy degree of skepticism is warranted, given recent studies of low-biomass microbiomes in other tissues not known to harbor bacteria, such as the human fetus4,5. To their credit, the authors acknowledge these important limitations of their study. So, what can we learn from this study? First, the study serves as a reminder that the presence of microbial DNA in joints, in the absence of other findings of infection, is not diagnostic of infection. This is an important point particularly as it pertains to the molecular diagnosis of periprosthetic joint infection, which is gaining faster in popularity than in evidence. Optimizing molecular tests to diagnose infections is complicated by the implication that all joints may have subclinical quantities of bacterial DNA. Second, it is plausible that microbial nucleic acids are present in osteoarthritic joints. If the findings of this study are confirmed, further work should be done to establish whether these products are being produced intra-articularly by living bacteria, whether they are unique to diseased joints, and whether they represent a disease state that might benefit from treatment. The burden of proof should be high. Further confirmation of these findings with optimal controls, using alternate methodologies, and with replication across other populations (for instance, comparing osteoarthritic and healthy joints) will be needed to convince us that a stable microbiome exists within the joint capsule. Lastly, the techniques used in this study are less broadly available and much more complex than other existing diagnostic tools. The expertise to critically evaluate this type of methodology is beyond the scope of many clinicians. Further education and elaboration on clinically relevant findings are critical to realize the full clinical benefit of NGS in orthopaedics. In summary, this provocative paper offers evidence that microbial DNA is present in the osteoarthritic joint. The next steps that are needed will be to confirm these findings with appropriate controls at every juncture, and to evaluate whether these nucleic acids derive from living intra-articular bacterial communities or from transient circulation of dead microbes.
Commentary Total joint replacement (TJR) is the ultimate procedure in patients with end-stage osteoarthritis. Knee and hip arthroplasty represent reliable treatments with favorable patient outcomes. However, revision TJR (rTJR) or other surgeon interventions such as manipulation under anesthesia (MUA) are not uncommon even if periprosthetic joint infection (PJI) is avoided. For example, joint implants may loosen aseptically due to insufficient osseointegration or joints may stiffen due to excessive deposition of collagenous scar tissue1,2. Translational studies using animal models that replicate these conditions allow development of prophylactic strategies that prevent aseptic loosening or arthrofibrosis after TJR. Identification of patients who are at risk for revision surgery would permit a range of informed decisions regarding clinical care, including prophylaxis, vigilant monitoring, and/or early intervention. Revision surgery is linked to a range of comorbidities, as well as modifiable and nonmodifiable risk factors. Genetic variation drives many biological processes. Therefore, Dr. Brüggemann and colleagues examined whether rTJR has a genetic component. Unlike in classic congenital disorders, familial analysis to determine inheritance of traits that predispose to rTJR is not realistic. Arthroplasty often occurs later in life, while surgical procedures and devices for joint replacement continue to evolve during each generation. Instead, Brüggemann and colleagues performed a genomewide association study (GWAS) using a database obtained from >60,000 DNA samples (blood or saliva) in the Swedish Twin Registry. The authors retrieved a subcohort of ∼1,100 twins who underwent TJR. A subset of these patients was subsequently recommended for revision surgery within ∼10 years for aseptic loosening or other reasons. Twin studies involving monozygotic and dizygotic twins provide duplicate measurements of genotype-phenotype correlations, permitting calculation of genetic versus environmental determinants (Falconer’s formula). However, because it is rare for both siblings in a twin pair to require rTJR (that is, twins were not concordant for this phenotype), this study was unable to leverage such twin information; instead, it leveraged the power of a well-annotated genetic database. Brüggemann and colleagues characterized a number of single-nucleotide polymorphisms (SNPs) that exhibited significant correlations with rTJR. Fascinatingly, SNPs linked to aseptic loosening include an apoptosis and autophagy-related gene (ELAPOR2, also known as EIG121L) that is implicated in bone morphogenetic protein (BMP) signaling in frogs3, and a transmembrane protein (SLC6A6) that transports the osteocyte-derived metabolite taurine4. The risk of revision for any reason was also increased by genetic variation in the SLC6A6 gene and the gene encoding calmodulin-binding transcription activator 1 (CAMTA1), which is an ancient protein involved in intracellular calcium signaling5. Collectively, SNPs in genes involved in bone formation or calcium signaling represent specific genetic biomarkers for revision risk. One key question is whether the identified rTJR-related nucleotide variations also mechanistically affect osseointegration of implants. The answer depends on whether the SNP can affect the function or regulation of the gene and its expression in a relevant cell type. For example, if an SNP in the SLC6A6 gene resides in an intron, an optimistic interpretation is that it could affect expression of the gene by altering mRNA splicing, but it is more likely that such a position rules out a mechanistic role. Oddly enough, 1 SNP is located in the coding region of the gene that provides the molecular genetic basis for the common blood types A, B, AB, or O in the ABO blood group system. The observed variation defines blood type B, because it alters the activity of the encoded glycosyl-transferase responsible for generating A and/or B antigens on erythrocytes. Although this specific genetic variation reflects increased revision risk, it is unlikely to be causative. Rather, the statistical association observed in this study informs surgeons that patients with blood type B have more than a threefold higher chance of revision surgery. The study by Brüggemann et al. provides solid progress in the field because it was expertly designed and executed with a high level of statistical rigor to define novel genetic associations rather than mechanistic causality. Nevertheless, studies on genetic factors in surgical outcomes are limited by variations in the surgical procedures (e.g., device, anatomy, surgeon), patient conditions (e.g., obesity, diabetes, smoking), and database parameters (e.g., population size, medical coding). Expanding the genetic frontiers in TJR surgery will require massive data acquisition via multi-institutional international efforts that aid in the identification of not only genetic and environmental factors associated with disease conditions, but also the interactions between these factors as they alter heritability patterns. Irrespective of these limitations, this study defines novel genetic biomarkers for increased risk of rTJR, a clinically important end point, that permit informed decisions regarding patient care.
Commentary Early failures of unicompartmental knee arthroplasty (UKA) were observed after introduction of the technique in the 1970s, leading Kozinn and Scott1 to consolidate their recommendations for successful UKA in 1989. These have emerged as our most routinely accepted traditional indications for patient selection and include an age of <60 years, a weight of <180 lb (81.6 kg), avoidance of strenuous labor, minimal baseline pain, a preoperative arc of motion of ≥90° with <5° of flexion contracture, and angular deformity of <15°; contraindications include patellofemoral or contralateral condylar degeneration, inflammatory arthropathy, chondrocalcinosis, and anterior cruciate ligament (ACL) insufficiency1,2. Current evidence on contemporary UKA designs has challenged and expanded on traditional criteria for patient selection such that today UKA is estimated to be performed in 8% to 12% of all knee arthroplasties, with 90% of these being performed in the medial compartment3. Ekhtiari et al. add to our growing body of evidence in support of the use of UKA and are to be commended on their recent large and unfunded report “Unicompartmental Knee Arthroplasty: Survivorship and Risk Factors for Revision. A Population-Based Cohort Study with Minimum 10-Year Follow-up.” The authors demonstrate outcomes rivaling survivorship seen with total knee arthroplasty (TKA) and identify risk factors that should be considered when selecting a patient for UKA today. By using administrative records of a single-payer health-care system (Ontario, Canada), they explored patient factors including age, sex, diabetes, income quintile, and rurality. They also explored available surgical data—i.e., whether or not the UKA was performed with cement. A notable strength of this study is that it is very well powered, with a conservative estimate that 1,537 patients were needed to detect a 50% prevalence of revision with a 2% margin of error and 95% confidence interval. Between 2002 and 2006, the authors followed 4,385 patients with a minimum 10-year follow-up—remarkably with <0.1% of data missing. Although not quite as well powered as large national registry studies, this study has a similar impact with such robust data collection and so large a sample size. The vast majority of patients evaluated (98%) had primary osteoarthritis (OA) of the knee, with only 16 UKAs performed for osteonecrosis and none for inflammatory arthritis. Seven hundred and seventy-nine patients underwent all-cause revision, with the cumulative risk of all-cause revision being 16.5% at 10 years accounting for patients censored at the time of final follow-up. The predominant reason for UKA revision was “mechanical loosening,” accounting for 650 (83.4%) of the 779 failures. The second most common cause of revision was periprosthetic joint infection (PJI), accounting for 129 of the 779 failures. Perhaps the greatest study weakness, which the authors readily acknowledge, is that “mechanical loosening” was likely an all-encompassing designation as they were unable to distinguish between the use of mobile and fixed-bearing implants or to know whether OA developed in other compartments. It has been established that UKA may commonly fail due to progression of OA or mobile-bearing dislocation as well as to implant loosening and infection2. In the current study, these possible (or even more likely) known causes for implant revision were not captured, a limitation inherent to the databases analyzed. The risk of revision within 10 years following UKA was higher in male patients (hazard ratio [HR]: 1.38, p < 0.001) and diabetic patients (HR: 1.49, p < 0.001). Surprisingly, stratifying by whether or not the patient had diabetes revealed no difference in the risk of revision due to PJI. However, an age older than 50 years (HR: 0.70, p = 0.008 for patients 50 to 59 years old and HR: 0.36, p < 0.001 for patients 70 to 79 years old), the use of cemented implants (HR: 0.69, p = 0.001), and more recent surgery (HR: 0.91, p < 0.001) were all protective against revision surgery following primary UKA. The median time to revision was 4.05 years, with Kaplan-Meier survivorship estimates of 97.2% at 1 year, 90.5% at 5 years, 83.5% at 10 years, and 81.9% at 15 years. The authors freely recognize limitations inherent to their administrative database study including informative censoring, which may limit any survival analysis. Additional potentially important patient factors (such as body mass index [BMI], smoking status, presurgical motion, limb alignment, or which compartment was replaced) and surgeon factors (such as surgical volume) were not captured in their data set. The authors’ findings regarding age are perhaps the most exciting challenge to traditional thinking for patients being considered for UKA. They clearly demonstrate a progressively lower HR for revision following UKA with progressively increasing age at the time of the index procedure. This finding is consistent with contemporary reports including a recent systematic review of 20 studies evaluating patients who underwent UKA when they were older than 70 that showed favorable clinical outcomes and 10-year survivorship of 87.5% to 98%4. By reinforcing recent evidence and adding new evidence for our appraisal, the large cohort study by Ekhtiari et al. should convincingly change surgeons’ criteria for selecting UKA for older patients who may otherwise be suitable candidates but, using more traditionally accepted criteria, would instead undergo TKA. Evidence regarding other factors—such as male sex, having diabetes, and using cementless fixation—is more mixed in the literature, and these factors should be evaluated further. As we continue to expand on traditional indications for UKA, this procedure will undoubtedly remain an important alternative in the orthopaedic armamentarium for predominantly unicompartmental OA of the knee. We should be grateful to Ekhtiari et al. for sharing their findings and enabling us to better characterize the role of UKA for the management of painful knee unicompartmental degeneration.
In my 25 years of orthopaedic practice, my patient’s explanation was a first. Because of fire season, she wished to delay an essential ankle surgery that would leave her non-weight-bearing for 8 weeks. “Doc, I can’t have surgery right now. I can’t evacuate if there’s a wildfire,” she explained. The patient lived in a semi-rural area of the Sierra Nevada foothills, an area of high fire danger. That same year, another patient arrived for an 8 a.m. appointment and told me I had probably saved his life, but not because of his recent surgery. He had left his foothill community at dawn for the long drive to my Bay Area office. After he departed, a firestorm erupted in his area, burning his home and small town to the ground. I have always had a strong affinity for the outdoors. For decades, our family vacations with our 3 children centered on visiting national parks: marveling at herds of bison in Yellowstone, the breathtaking beauty of the Grand Tetons, and the uniqueness of Bryce and Arches. I felt that I was doing my part to preserve the environment by enjoying the outdoors, driving a Prius, avoiding red meat, and donating money to charitable causes. But in 2019, I read The Uninhabitable Earth by David Wallace-Wells1. This book details what our planet will look like with increasing degrees of climate warming. The miraculous ecosystems in our national parks and the world over are at risk of devastation. Worse, vast regions of our planet may become uninhabitable to humans, creating hundreds of millions of climate refugees. Reading this shocked me. I could not “unsee” these consequences of climate change. I knew I had to do more to protect the environment for my children and grandchildren. Two years ago, an emergency alert warned me to evacuate my own home because of an approaching wildfire. Luckily, the fire was quickly extinguished with little damage to my neighborhood. Sheltering at our friends’ house for the night was a minor inconvenience compared with the experiences of countless people across the U.S. who have lost their homes in recent fires, floods, and superstorms. They are climate refugees. It is clear that the climate crisis has become a part of our everyday lives much sooner than I expected. Furthermore, scientific research has demonstrated that the changing climate is having a profound impact on our health2. Extreme heat killed 19,000 Americans in 2018, considerably more than gun homicides3. Air pollution, worsened by a warming climate, is estimated to be responsible for 18% of worldwide deaths, or 10 million people annually4. Climate change is a human health emergency. Realizing that I could do more to protect patient health from the climate crisis, I joined a health-care professionals group called Climate Health Now. The group’s mission is to address the human health emergency—to improve the health of all people by advocating for climate-related solutions. Using our health expertise, we educate our elected officials and other decision-makers about the health impacts of the climate crisis. Our goal is to achieve legislative and policy outcomes that will benefit our patients’ health and protect the environment. We also educate other health-care providers about the many health impacts of our changing climate, such as from extreme heat, severe weather events, and worsening air pollution. There is precedent for the physician voice as a leader for environmental change. In 1990, the World Health Organization concluded that “the health sector must play an active role nationally in formulating and implementing strategies to prevent climatic change and combat its effects.”5 An American Medical Association policy “encourages physicians to be spokespersons for environmental stewardship.”6 So, what does this have to do with orthopaedics? We are physicians, trained to respect science and facts. We evaluate complex situations, diagnose problems, and prescribe treatments to remedy the condition. If we ignore the science, we neglect our obligation to health. It’s time to apply our skills, empathy, and leadership to the climate crisis. Furthermore, we need to take some responsibility for the 8% to 10% of our country’s total greenhouse gas emissions produced by the U.S. health-care sector7. The United Nations Intergovernmental Panel on Climate Change just released a report alerting us to Code Red for humanity8. Sixty percent of Americans view global warming as a major threat, and 65% want the government to do more to reduce the effects of climate change9. Individual actions, such as buying an electric car, installing rooftop solar panels on your house, or taking fewer airplane trips, are important but inadequate to address the scale of this emergency. Time is short. We must act collectively by implementing sweeping policy changes that prioritize climate in every aspect of government and society. As orthopaedists, we must step outside our area of expertise and step up for our patients. This is a health emergency that is already impacting us all. The treatment is active civic engagement. The health-care community has encouraged our government leaders to make major climate and health policies in the past. The Clean Air Act of 1970 substantially decreased 6 toxic air pollutants and is estimated to have saved millions of lives10. We need to enact such a program now that will eliminate greenhouse gas emissions and transition our economy away from dependence on fossil fuels. Such a program developed by the Goldman School at the University of California, Berkeley will reportedly avoid 85,000 premature deaths and save $1.2 trillion in health and environmental costs through 2050 by decreasing air pollution11. Similarly, Princeton University’s Carbon Mitigation Initiative provides 5 pathways to net zero greenhouse gas emissions by 2050 in its Net-Zero America Project12. The physician voice can help change policy. I urge you to join one of many physician-led groups, such as Climate Health Now, Physicians for Social Responsibility, and the Medical Society Consortium on Climate and Health, or to become involved in a local environmental group, such as a 350.org chapter. These organizations welcome and encourage new members and teach us how to make an impact. Or embrace an issue of particular interest to you, like Blough and Karsh, who wrote a previous JBJS “What’s Important” article about operating room waste13. Or if you want more information on how to become involved, please email me. An hour or two a week can make a difference. Climate change is directly affecting our patients’ health and our ability to provide care for them. Editors of 220 medical journals from around the world have recently called for “emergency action” on climate change, to limit global temperature increases to 1.5°C14. I look forward to the American Academy of Orthopaedic Surgeons and the American Orthopaedic Association initiating discussions and providing leadership to address this public health emergency.
Commentary The attempt to identify real advantages of surgical treatment over conservative treatment for lumbar herniation has spurred a continuing series of studies over the last 40 years. Despite varying in population, size, study design, treatment techniques, and patient condition, most studies have had very similar findings: that surgery provides faster pain relief, with improved scores, at earlier time points. However, in almost all studies, those differences decrease with time and vanish after 1 or 2 years. The article by Bailey et al. contains valuable information for surgeons considering prompt surgical intervention for chronic lumbar disc herniation rather than a more common nonoperative treatment regimen prior to possible surgery. In undertaking this randomized controlled trial (RCT) using intention-to-treat analysis, the authors took advantage of a feature of the Canadian health-care system with its inherent waiting periods of >6 months, which limited the ability of patients in the nonoperative group to cross over to surgery in the early periods of the study. Nevertheless, this study recorded 24 crossover events: 2 early events, 12 events between 6 and 12 months, and 10 events by 2 years. In addition, 8 patients in the surgery cohort did not have surgery. In the first 6 months, crossover events were indeed low. However, with the increasing number of crossover events after 6 months and then more after 12 months, the unique advantage in study design between this RCT, undertaken in Canada, and previously published RCTs appears to vanish. In contrast to several other prior studies mentioned by the authors, this study showed evidence of advantages of prompt discectomy rather than additional nonoperative treatment over the longer term of 2 years as well as at 1 year after treatment group assignment. Under close scrutiny, the differences at 1 year and earlier do appear to be meaningful, but the differences at 2 years are not substantial and do not refute the findings of most other related studies: that the difference between groups decreases over time, becoming clinically unimportant by 2 years. The interpretation of many published studies is made difficult by statistical methodology and metrics that are not readily familiar to most surgeons, but it is important to look deeper before accepting an author’s conclusions at face value. In their paper, the authors use and recognize a minimal clinically important difference (MCID) in the patient-reported outcome measures. Based on a study by Lauridsen et al., Bailey et al. chose 2 as the MCID for their leg pain score, meaning that any difference of <2 is recognized as not clinically meaningful1. However, the authors report the mean difference between treatment groups in their primary outcome measure, leg pain, to be 1.3, well below their acknowledged MCID, indicating that the difference is not clinically important even though it might be significantly different. The MCID can be determined in many ways with use of different methods, so perhaps the value of 2 is off-base2. Copay et al. compared several different ways of determining the MCID with use of similar data on similar outcome measures3. They found the best estimates to be 4.9 for the SF-36 physical component summary (PCS) score, 1.6 for leg pain, and 1.2 for back pain. Although the SF-36 PCS score reported by Bailey et al. is just above Copay’s proposed MCID (5.3 vs. 4.9) indicating clinical importance, the mean differences found by Bailey et al. for leg pain and back pain were both lower than Copay’s proposed MCIDs, indicating differences that are clinically unimportant. So what can we conclude? Although the results of the study by Bailey et al. offer strong evidence for a difference in outcome measures at 6 and 12 months as previously reported4, there was a very marginal or clinically unimportant difference between Bailey’s groups at 2 years. Additionally, readers should always be wary of the very real placebo effect in studies such as this, in which no blinding of patients or surgeons has been accomplished. Based on these considerations, the authors’ conclusion that “microdiscectomy is superior” at 2 years may be just a little bold. The choice to undertake surgery or nonoperative treatment prior to potential surgery should not be taken lightly, even for patients with chronic conditions, because surgery entails risks. The overall surgical complication rate at 2 years reported by Bailey et al. was 15% (with at least one surgery-related adverse event occurring in 12 of 80 patients who underwent surgery). The rate in a previously reported meta-analysis was similar, at 12.5% for open microdiscectomy5. An RCT design, as used by Bailey et al., selects patients blindly for assignment to one treatment or another and reports the results as means for each cohort. Physicians, however, should never blindly choose treatment based solely on what appears to be best for the average patient but should rely instead on a range of available information about individual patients, including pain level, function, mental state, length of symptoms, and above all, patient preference. It may be informative that, even in a socialized medical environment, 40 of the 64 patients initially assigned to the nonoperative treatment group did not go on to have surgery within the time frame of the study even though they could have easily done so at 6 months without cost. The guidance suggested by Legrand et al.6, that the best approach is to “let the patient choose between treatments,” remains valid. Those authors recommended that patients be informed that surgery does not modify the long-term outcome but can speed up recovery, at the expense of potential complications, most of which are reversible6.
Diastematomyelia is a rare congenital abnormality of the spinal cord. This paper summarises more than 30 years' experience of treating this condition. Data were collected retrospectively on 138 patients with diastematomyelia (34 males, 104 females) who were treated at our hospital from May 1978 to April 2010. A total of 106 patients had double dural tubes (type 1 diastematomyelia), and 32 patients had single dural tubes (type 2 diastematomyelia). Radiographs, CT myelography, and MRI showed characteristic kyphoscoliosis, widening of the interpedicle distance, and bony, cartilaginous, and fibrous septum. The incidences of symptoms including characteristic changes of the dorsal skin, neurological disorders, and congenital spinal or foot deformity were significantly higher in type 1 than in type 2. Surgery is more effective for patients with type 1 diastematomyelia; patients without surgery showed no improvement.
The World Health Organization ( WHO) launched the first Global Patient Safety Challenge in 2005 and introduced the '5 moments of hand hygiene' in 2009 in an attempt to reduce the burden of health care associated infections. Many NHS trusts in England adopted this model of hand hygiene, which prompts health care workers to clean their hands at five distinct stages of caring for the patient. Our review analyses the scientific foundation for the five moments of hand hygiene and explores the evidence, as referenced by WHO, to support these recommendations. We found no strong scientific support for this regime of hand hygiene as a means of reducing health care associated infections. Consensus-based guidelines based on weak scientific foundations should be assessed carefully to prevent shifting the clinical focus from more important issues and to direct limited resources more effectively.We recommend caution in the universal adoption of the WHO '5 moments of hand hygiene' by orthopaedic surgeons and other health care workers and emphasise the need for evidence-based principles when adopting hospital guidelines aimed at promoting excellence in clinical practice.
An eight-week-old boy developed severe thoracic spondylodiscitis following pneumonia and septicaemia. A delay in diagnosis resulted in complete destruction of the T4 and T5 vertebral bodies and adjacent discs, with a paraspinal abscess extending into the mediastinum and epidural space. Antibiotic treatment controlled the infection and the abscess was aspirated. At the age of six months, he underwent posterior spinal fusion in situ to stabilise the spine and prevent progressive kyphosis. At the age of 13 months, repeat imaging showed lack of anterior vertebral body re-growth and he underwent anterior spinal fusion from T3 to T6 and augmentation of the posterior fusion. At the age of five years, he had no symptoms and radiographs showed bony fusion across the affected levels. Spondylodiscitis should be included in the differential diagnosis of infants who present with severe illness and atypical symptoms. Delayed diagnosis can result in major spinal complications with a potentially fatal outcome.
Diastematomyelia is a rare congenital abnormality of the spinal cord. This paper summarises more than 30 years' experience of treating this condition. Data were collected retrospectively on 138 patients with diastematomyelia (34 males, 104 females) who were treated at our hospital from May 1978 to April 2010. A total of 106 patients had double dural tubes (type 1 diastematomyelia), and 32 patients had single dural tubes (type 2 diastematomyelia). Radiographs, CT myelography, and MRI showed characteristic kyphoscoliosis, widening of the interpedicle distance, and bony, cartilaginous, and fibrous septum. The incidences of symptoms including characteristic changes of the dorsal skin, neurological disorders, and congenital spinal or foot deformity were significantly higher in type 1 than in type 2. Surgery is more effective for patients with type 1 diastematomyelia; patients without surgery showed no improvement.
This review is aimed at clinicians appraising preclinical trauma studies and researchers investigating compromised bone healing or novel treatments for fractures. It categorises the clinical scenarios of poor healing of fractures and attempts to match them with the appropriate animal models in the literature. We performed an extensive literature search of animal models of long bone fracture repair/nonunion and grouped the resulting studies according to the clinical scenario they were attempting to reflect; we then scrutinised them for their reliability and accuracy in reproducing that clinical scenario. Models for normal fracture repair (primary and secondary), delayed union, nonunion (atrophic and hypertrophic), segmental defects and fractures at risk of impaired healing were identified. Their accuracy in reflecting the clinical scenario ranged greatly and the reliability of reproducing the scenario ranged from 100% to 40%. It is vital to know the limitations and success of each model when considering its application.
Despite excellent results, the use of cemented total hip replacement (THR) is declining. This retrospective cohort study records survival time to revision following primary cemented THR using the most common combination of components that accounted for almost a quarter of all cemented THRs, exploring risk factors independently associated with failure. All patients with osteoarthritis who had an Exeter V40/Contemporary THR (Stryker) implanted before 31 December 2010 and recorded in the National Joint Registry for England and Wales were included in the analysis. Cox's proportional hazard models were used to analyse the extent to which risk of revision was related to patient, surgeon and implant covariates, with a significance threshold of p < 0.01. A total of 34 721 THRs were included in the study. The overall seven-year rate of revision for any reason was 1.70% (99% confidence interval (CI) 1.28 to 2.12). In the final adjusted model the risk of revision was significantly higher in THRs with the Contemporary hooded component (hazard ratio (HR) 1.88, p < 0.001) than with the flanged version, and in smaller head sizes (< 28 mm) compared with 28 mm diameter heads (HR 1.50, p = 0.005). The seven-year revision rate was 1.16% (99% CI 0.69 to 1.63) with a 28 mm diameter head and flanged component. The overall risk of revision was independent of age, gender, American Society of Anesthesiologists grade, body mass index, surgeon volume, surgical approach, brand of cement/presence of antibiotic, femoral head material (stainless steel/alumina) and stem taper size/offset. However, the risk of revision for dislocation was significantly higher with a 'plus' offset head (HR 2.05, p = 0.003) and a hooded acetabular component (HR 2.34, p < 0.001). In summary, we found that there were significant differences in failure between different designs of acetabular component and sizes of femoral head after adjustment for a range of covariates.
Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.
A delay in the diagnosis of paediatric acute and subacute haematogenous osteomyelitis can lead to potentially devastating morbidity. There are no definitive guidelines for diagnosis, and recommendations in the literature are generally based on expert opinions, case series and cohort studies.All articles in the English literature on paediatric osteomyelitis were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the Cochrane Library and reference lists. A total of 1854 papers were identified, 132 of which were examined in detail. All aspects of osteomyelitis were investigated in order to formulate recommendations.On admission 40% of children are afebrile. The tibia and femur are the most commonly affected long bones. Clinical examination, blood and radiological tests are only reliable for diagnosis in combination. Staphylococcus aureus is the most common organism detected, but isolation of Kingella kingae is increasing. Antibiotic treatment is usually sufficient to eradicate the infection, with a short course intravenously and early conversion to oral treatment. Surgery is indicated only in specific situations.Most studies were retrospective and there is a need for large, multicentre, randomised, controlled trials to define protocols for diagnosis and treatment. Meanwhile, evidence-based algorithms are suggested for accurate and early diagnosis and effective treatment.
The Journal of Bone and Joint Surgery. British volumeVol. 87-B, No. 1 EditorialsFree AccessWider horizonsJ. ScottJ. ScottEditorSearch for more papers by this authorPublished Online:1 Jan 2005https://doi.org/10.1302/0301-620X.87B1.16059AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail At its most simple the function of this Journal is to invite submissions covering as wide an area of orthopaedic surgery as possible, submit them to a rigorous system of peer review, choose those that represent the best clinical and basic science, edit them so that their message is clearly and unambiguously stated and then publish them. It is clearly incumbent upon us, when considering both authors and readers, to ensure that this process is carried out as quickly as possible so that contributions retain their originality. We receive about 1100 papers each year and publish about 15%, and these figures remain constant. Some, particularly those which require extensive modification both by the authors and the editorial staff, may not be published for more than a year after acceptance. By increasing to 12 issues per year, we hope to include about 60 more clinical papers annually and, hopefully, to increase the acceptance rate slightly and shorten the time to publication. Our aim is to offer a reviewing process which gives a final opinion within six weeks of submission and an editorial process which ensures publication within three months of acceptance.The increase in the number of issues will also allow us to publish more material both of broad general interest such as review articles and of more specialist interest such as annotations and aspects of current management. We have during recent years increased the number of our reviewers and now have (as listed at the back of this issue) about 250 available to us from 23 countries and this will hopefully encourage more international contributions. We continue to work closely with EFORT and this year is the 75th anniversary of the founding of SICOT which we will be marking with an editorial next month.Original material increasingly includes references to classification systems, statistical packages and an extended bibliography. These, for reason of space, cannot be accommodated within the pages of the Journal. This material will now be available on our website ( www.jbjs.org.uk) which, as from this month, has a new host (HighWire).The correspondence section of the Journal is particularly vulnerable to the passage of time and loss of topicality. We plan therefore to put the majority of letters and responses from authors on the website. Currently archive material back to 1996 is available on the website and this will be extended later this year to all archive material from our foundation in 1948. Other new features will include an occasional commissioned expert opinion on specific papers and enhanced alerting options.I hope that authors will appreciate a faster reviewing and editorial process as well as a slightly increased acceptance rate, that readers will appreciate the increased number of issues and that both will enjoy the new facilities available on the website.FiguresReferencesRelatedDetails Vol. 87-B, No. 1 Metrics Downloaded 254 times History Published online 1 January 2005 Published in print 1 January 2005 InformationCopyright © 2005, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download
Since 1996 more than one million metal-on-metal articulations have been implanted worldwide. Adverse reactions to metal debris are escalating. Here we present an algorithmic approach to patient management. The general approach to all arthroplasty patients returning for follow-up begins with a detailed history, querying for pain, discomfort or compromise of function. Symptomatic patients should be evaluated for intra-articular and extra-articular causes of pain. In large head MoM arthroplasty, aseptic loosening may be the source of pain and is frequently difficult to diagnose. Sepsis should be ruled out as a source of pain. Plain radiographs are evaluated to rule out loosening and osteolysis, and assess component position. Laboratory evaluation commences with erythrocyte sedimentation rate and C-reactive protein, which may be elevated. Serum metal ions should be assessed by an approved facility. Aspiration, with manual cell count and culture/sensitivity should be performed, with cloudy to creamy fluid with predominance of monocytes often indicative of failure. Imaging should include ultrasound or metal artifact reduction sequence MRI, specifically evaluating for fluid collections and/or masses about the hip. If adverse reaction to metal debris is suspected then revision to metal or ceramic-on-polyethylene is indicated and can be successful. Delay may be associated with extensive soft-tissue damage and hence poor clinical outcome.
