Author Interviews, Columbia, NEJM, Orthopedics, Osteoporosis / 21.09.2016 Interview with: Felicia Cosman, M.D. Medical Director of the Clinical Research Center Helen Hayes Hospital Professor of Medicine Columbia University College of Physician and Surgeons New York Editor-in-Chief, Osteoporosis International What is the background for this study? What are the main findings? Response: Amgen and UCB presented detailed data from the Phase 3 FRAME study in an oral session at ASBMR 2016, and the data were also published in the New England Journal of Medicine. Additionally, the FRAME abstract has been awarded the 2016 ASBMR Most Outstanding Clinical Abstract Award. The FRAME data show significant reductions in both new vertebral and clinical fractures in postmenopausal women with osteoporosis. Patients receiving a monthly subcutaneous 210 mg dose of romosozumab experienced a statistically significant 73 percent reduction in the relative risk of a vertebral (spine) fracture through 12 months, the co-primary endpoint, compared to those receiving placebo (fracture incidence 0.5 percent vs. 1.8 percent, respectively [p<0.001]). By six months, new vertebral fractures occurred in 14 romosozumab and 26 placebo patients; between six to 12 months, fractures occurred in two versus 33 additional patients in each group, respectively. Patients receiving romosozumab experienced a statistically significant 36 percent reduction in the relative risk of a clinical fracture, a secondary endpoint, through 12 months compared to those receiving placebo (fracture incidence 1.6 percent vs. 2.5 percent, respectively [p=0.008]). In patients who received romosozumab in year one, fracture risk reduction continued through month 24 after both groups transitioned to denosumab treatment through the second year of the study: there was a statistically significant 75 percent reduction in the risk of vertebral fracture at month 24 (the other co-primary endpoint) in patients who received romosozumab followed by denosumab vs. placebo followed by denosumab (fracture incidence 0.6 percent vs. 2.5 percent, respectively [p<0.001]). Clinical fractures encompass all symptomatic fractures (both non-vertebral and painful vertebral fractures; all clinical fractures assessed in the FRAME study were symptomatic fragility fractures. A 33 percent reduction in relative risk of clinical fracture was observed through 24 months after patients transitioned from romosozumab to denosumab compared to patients transitioning from placebo to denosumab (nominal p=0.002, adjusted p=0.096). (more…)
Author Interviews, MRI, Orthopedics, Radiology / 15.09.2016 Interview with: Muyibat Adelani, MD Assistant Professor of Orthopaedic Surgery Washington University St. Louis What is the background for this study? What are the main findings? Response: In our practice, we noticed that more patients are coming in already having had MRIs. We wanted to know how many people actually had weight-bearing knee x-rays before the MRI. We found that only a quarter of patients had weight-bearing x-rays before the MRI. We found that half of the MRIs obtained prior to referral to an orthopaedic surgeon did not contribute to the patient's treatment. (more…)
Author Interviews, JAMA, Orthopedics / 12.09.2016 Interview with: R. Grant Steen, PhD Medical Affairs, Bioventus LLC Durham, North Carolina What is the background for this study? What are the main findings? Response: When we started this research, it was really only guesswork as to how big a problem fracture nonunion really is. What we've done is to work with an enormous database of patient health claims, with two goals. First, we wanted to characterize how common fracture nonunion is among patients across a wide age range. Second, we wanted to identify risk factors that make a patient more likely to have problems healing. We've now succeeded in both aims. We know that roughly 5% of fracture patients will go to nonunion, and we know a whole host of risk factors that predispose them to do so. Most of the risk factors that we've identified—with a few exceptions—would not be a surprise to physicians who treat fracture patients. However, what we've done is to put all of these risk factors in a broader context, so that we know which risk factors are most important and which are less so. For example, it has been known for a long time that smoking is a risk factor for nonunion. What we've shown is that, in the scheme of things, it's not all that important. Let me be more precise here, because this is an important point. If all you know about a patient is that they smoke, we've shown that smoking is associated with a 62% increase in risk of nonunion. That's a lot. But, as you learn more about that patient and can factor that new knowledge into a risk prediction, it turns out that smoking, all by itself, increases the risk of nonunion by only about 20%. However, smoking is a surrogate marker for a range of other risk factors that also increase risk, including male gender, cardiovascular disease, obesity, vitamin D deficiency, alcoholism, and so on. Once you factor these separate risk factors into your new nonunion prediction, you have a much more nuanced—and probably much more accurate—prediction of nonunion risk. (more…)
Author Interviews, Orthopedics / 26.08.2016 Interview with: Brandon J. Erickson, MD Midwest Orthopaedics Rush, Rush University Medical Center Chicago, IL What is the background for this study? What are the main findings? Response: Ulnar collateral ligament reconstruction (UCLR), also known as Tommy John surgery has become a common procedure amongst major league baseball (MLB) pitchers. It is unclear if a limit on innings pitched following Tommy John surgery should be instituted to prevent revision Tommy John surgery. The purpose of this study was to determine if innings pitched following Tommy John surgery is associated with an increased risk of revision Tommy John surgery amongst MLB pitchers. To answer this question we located all MLB pitchers between 1974-2015 who pitched at least one full season following their Tommy John surgery and included them in our analysis. Pitch counts and innings pitched for the first full season following Tommy John surgery as well as total pitch count and total innings pitched over the course of the player’s career were recorded. Pitch counts and innings pitched were compared amongst players who required revision Tommy John surgery and those who did not. We were able to include 154 pitchers. Of these, 135 pitchers did not require revision Tommy John surgery while 19 underwent revision Tommy John surgery.  No significant difference existed between pitchers who underwent revision Tommy John surgery and those who did not when comparing number of innings pitched in the season following Tommy John surgery,  number of pitches thrown in the season following Tommy John surgery,  number of innings pitched in the pitcher’s career following Tommy John surgery and number of pitches thrown in the pitcher’s career following Tommy John surgery.  Furthermore, no difference existed in revision rate between pitchers who pitched more or less than 180 innings in the first full season following Tommy John surgery. (more…)
Author Interviews, Orthopedics, Science, Technology / 21.07.2016 Interview with: Emilia Morosan PhD,  Professor Rice University Physics and Astronomy Houston TX 77005 What is the background for this study? What are the main findings?  Dr. Morosan: My group works mainly on searching for compounds with magnetic properties. The first step in the characterization of such compounds is powder X-ray diffraction, which requires grinding the samples to fine powder. When we discovered such a compound based on (titanium) Ti and (gold) Au, we were unable to grind it because of its apparent hardness. This prompted the hardness measurement on the magnetic compound (with equal amounts of Ti and Au) and also on other mixtures of the two metals. The main result of this study was that the particular compound beta-Ti3Au was the hardest among all Ti-Au mixture in our study and compared to previous hardness measurements on these binary alloys. Most remarkable was the four-fold increase in hardens in beta-Ti3Au over Ti, or most other biocompatible engineering alloys. Furthermore, beta-Ti3Au also has higher wear resistance, meaning its durability extends beyond that of other alloys. (more…)
Author Interviews, Exercise - Fitness, Orthopedics / 13.07.2016 Interview with: Dr. Marcos Muñoz Jimenez University of Jaén What is the background for this study? What are the main findings? Response: Barefoot running has become very popular in recent years and remains a hotly debated topic among runners. The debate about the pros and cons of barefoot running is current. Many coaches consider barefoot training to have an effect on muscle strength and to be important for performance and for preventing injuries. The main objective of this study is to determine what changes in foot strike, inversion-eversion and foot rotation are produced after a 12-week programme of barefoot running with progressive volume at the end of the athletes daily training session. Our data support that a 12-week programme of barefoot running training, applied by progressively increasing the volume of barefoot running, causes significant changes to foot strike patterns with a tendency towards midfoot strike, regardless of running speed. (more…)
Author Interviews, Orthopedics / 11.07.2016 Interview with: Dr. Duong Nguyen, Medicine Professional Corporation MD,MSc(c),FRCSC,DipABOS,DipSportsMed(ABOS),FAAOS,CIME Diplomate of the American Board of Orthopaedic Surgery Subspecialty Board Certification in Sports Medicine Fellow of the American Academy of Orthopaedic Surgeons Certified Independent Medical Examiner (ABIME) Diplomate Sport & Exercise Medicine (CASEM) Arthroscopic & Reconstructive Shoulder,Elbow & Knee Surgery Medical Director / Urgent Sports Injury & Fracture Clinic MSc Candidate/ Clinical Epidemiology & Health Research Methodology Adjunct Clinical Professor - McMaster University Toronto, ON. What is the background for this study? What are the main findings? Response: ACL re-tear after surgery is a serious complication in the sports medicine world with many implications for the athlete such as lost game time, the morbidity of a second surgery and extended rehabilitation, lost scholarship, decreased self esteem and social isolation,as well as decreased academic performance. We found in our study that athletes who are less than 25, are female, and have a graft size less than 8 mm are at increased risk for ACL re-tear after surgery. (more…)
Author Interviews, Exercise - Fitness, Orthopedics / 19.05.2016 Interview with: Robert Keller, M.D., Chief resident Department of Orthopedic Surgery Henry Ford Hospital Detroit What is the background for this study? What are the main findings? Dr. Keller:  Injuries to the medial ulnar collateral ligament (the ligament torn in pitchers requiring tommy john surgery) are common in overhead-throwing athletes. Recent data supports that the number of MLB pitchers requiring tommy john surgery continues to increase, with estimates near 25% of all MLB pitchers undergoing tommy john surgery.   Recent investigations have attempted to analyze factors that contribute to UCL injuries with the aim to decrease the rate of injury. Studies have suggested that possible risk factors include pitching mechanics, pitch type (curve ball, fastball, etc), g, pitching fatigue, chronic overuse, and pitch velocity, among other factors. Specifically, increased pitch velocity has been implicated as a risk factor for UCL injury.  However, no study has exclusively attempted to assess whether MLB pitchers who required Tommy John surgery pitch at a higher velocity than those that do not. Pitch type (fastball, curveball, slider, etc) is another significant factor that has been investigated as a contributor to UCL injuries. Various biomechanical studies have attempted to correlate pitch types with torque across the throwing elbow, with contrasting results: some suggest fastballs create more torque, whereas others found off-speed pitches produce increased stresses. Beyond not evaluating MLB pitchers, these previous studies also failed to evaluate the volume or amount of a specific pitch type thrown by these pitchers that may contribute to UCL injuries. (more…)
Author Interviews, Medical Imaging, NYU, Orthopedics, Radiology / 18.03.2016 Interview with: Sanjit Konda, MD Assistant professor of Orthopaedic surgery NYU Langone Medical Center What is the background for this study? What are the main findings? Dr. Konda: We serendipitously found that we could identify periarticular fractures associated with deep knee wounds with the use of a CT-scan. We published a study in the Journal of Orthopaedic Trauma showing that a CT scan could identify a traumatic arthrotomy of a joint better than a saline load test, which at the time was considered the diagnostic gold standard. When we presented that work, we received criticism that we were subjecting patients to a high dose of radiation for a diagnostic test; however, our rationale at the time was that the saline load test was a painful, invasive procedure using a needle, and that we would trade a bit of radiation for lack of invasive procedure. This got us thinking of ways we could decrease the amount of radiation in the CT yet maintain the same diagnostic accuracy of identifying penetrating joint injuries. Collaborating with Dr. Soterios Gyftopoulos, an assistant professor in the Department of Radiology at NYU Langone, we were able to successfully reduce the amount of radiation in these CT scans and still get good bony images. We then thought, if we can get a CT scan that shows us good bony detail and is safer, then why shouldn’t we be doing it on every joint fracture, not just these arthrotomy cases? We then applied this to our current research protocol, REDUCTION(Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury) in which we reduced the average amount of radiation from 0.43 msV to 0.03 msV, or down to the average dose given in a routine chest X-ray. After running a comparison study with our ultra-low dose radiation protocol compared to conventional CT scans, we found we were able to obtain nearly the exact same types of images for various joint fractures and locations without sacrificing any diagnostic accuracy in most cases. We gave sets of these CT scans to orthopaedic surgeons to analyze, and found we achieved 98 percent sensitivity and 89 percent specificity with the ultra-low dose CT scans when occult fractures, or those that could not be seen on an X-ray, were removed from our analysis. (more…)
Author Interviews, BMJ, Exercise - Fitness, Orthopedics / 10.03.2016 Interview with: David Morrissey MB PhD FRCS (Tr&Orth) Orthopaedic Specialist Registrar What is the background for this study? What are the main findings? Dr. Morrissey: Injury rates in rugby union have increased substantially over the past twenty years, both in the professional and amateur game. The pattern of injury has also changed, reflecting higher grades of trauma. Our institution is a tertiary referral centre for pelvic and acetabular trauma serving a population of 4.5 million. The majority of our cases occur as a result of high velocity trauma such as road traffic accidents. We have not previously seen hip dislocations/acetabular fractures occurring secondary to sporting participation. In the past number of years, however, we have identified four such injuries in three juvenile patients, that occurred during rugby union participation. These injury patterns may have sub-optimal outcomes in up to 30% of patients and can severely affect a young person’s life. The demographic change may be due to changes in the physical development of players as well as an increased emphasis on the tackle/ruck area. In the juvenile game, differing rates of maturation magnify size differences between players, potentially increasing the risk of injury. (more…)
Author Interviews, Cost of Health Care, Medicare, NYU, Orthopedics / 04.03.2016 Interview with: Richard Iorio, MD Dr. William and Susan Jaffe Professor of Orthopaedic Surgery Chief of the Division of Adult Reconstructive Surgery NYU Langone Medical Center What is the background for this study? What are the main findings? Dr. Iorio: NYU Langone Medical Center’s Department of Orthopaedic Surgery realized early that alternate payment strategies based on value rather than volume were going to be increasing in prevalence and represent the future of compensation strategies  As leaders in orthopaedics, we knew that we must embrace this change and develop strategies and effective protocols to successfully navigate this alternative payment universe. In 2011, NYU Langone’s Hospital for Joint Diseases was chosen as a pilot site for CMS’s Bundled Payment Care Initiative, focusing on Medicare patients undergoing a total joint replacement. Beginning in 2013, we implemented protocols developed at our hospital focusing on preoperatiive patient selection criteria in an effort to ensure better outcomes for Medicare patients who underwent total joint replacements. Under a bundled payment program, hospitals assume financial responsibility for any complications over the entire episode of care 90 days after surgery, including postsurgical infections and hospital readmissions. We compared year over year outcomes from year 1 to year 3 of this program, and found:
  • Average hospital length of stay decreased from 3.58 days to 2.96 days;
  • Discharges to inpatient rehabilitation or care facilities decreased from 44 percent to 28 percent;
  • Average number of readmissions at 30 days decreased from 7 percent to 5 percent; from 11 percent to 6.1 percent at 60 days; and from 13 percent to 7.7 percent at 90 days;
  • The average cost to CMS of the episode of care decreased from $34,249 to $27,541 from year one to year three of the program.
Annals Internal Medicine, Author Interviews, Orthopedics / 11.02.2016 Interview with: Teppo L N Järvinen MD PhD Sports Medicine, Orthopedic Surgery, Clinical Trials University of Helsinki, Helsinki MedicalResearch: What is the background for this study? What are the main findings? Dr. Järvinen: When the primary analysis of the FIDELITY trial was published in the New England Journal of Medicine (, showing that arthroscopic partial meniscectomy (APM) is no better than sham/placebo surgery in relieving knee pain and improving knee function in patients with a degenerative meniscus tear and no knee OA, the study was met with unprecedented criticism, even hostility. The advocates of APM (which was at the time and probably still is the most common orthopedic procedure in the US and most other “western” countries) argued – despite the fact that our study only confirmed what several other high-quality RCTs had suggested – that  arthroscopic partial meniscectomy is a highly beneficial procedure in the “right” patients. Among the subgroups of patients allegedly having a favourable response to APM, those experiencing “mechanical symptoms” — sensations of knee catching or locking — represented the most obvious group who would benefit from  arthroscopic partial meniscectomy surgery. This assertion is plausible because knee catching or locking is believed to result from a mechanical blocking mechanism in the knee - a piece of the joint structure lodging between the articular surfaces. Because degenerative meniscal tears are very common pathologic alterations found by arthroscopy in the knee joints of patients with degenerative knee disease, trimming the torn meniscus should, in theory at least, improve the apparent mechanical derangement. Against this background, it is somewhat unusual that no study has yet specifically tested whether  arthroscopic partial meniscectomy is effective in alleviating these symptoms. Mechanical symptoms are usually thought to be a solid indication for arthroscopic knee surgery. This is what we set out to examine in our secondary analysis of our sham-surgery controlled FIDELITY trial.

Our key finding: arthroscopic partial meniscectomy (partial resection of a torn meniscus) does not reduce or alleviate mechanical symptoms any better than a sham surgical procedure.

Author Interviews, Exercise - Fitness, Orthopedics / 01.12.2015 Interview with: Uwe Schütz, M.D. Radiologist and specialist in orthopedics and trauma surgery Department of Diagnostic and Interventional Radiology University Hospital of Ulm Germany Medical Research: What is the background for this study? What are the main findings? Dr. Schütz: In this study, which is a small part of the Trans Europe Foot Race (TEFR) TEFR-project, we investigated the question, what happens to the joints, in detail to the joint cartilage of the lower extremities, when running 4500 km without any day rest for nearly 10 weeks. Is there really a risk for developing an arthrosis when doing this, like some researches and many physicians postulate? Well, what we find when accompanying 44 ultra-athletes with a modern 1.5Tesla MRI mounted on a custom made 38tonnes truck trailer day by day over 64 days on their way throughout whole Europe is, that the joint cartilage is initially altered by this running burden: It shows signals of cartilage matrix degradation beneath the first 1000 to 1500 km of running. But then the situation changes. When further running occurs, then the cartilage shows the ability to partially regenerate under ongoing running burden. This is a pretty new and astonishing finding, first time measured and observed in human joint in vivo. But knowledge of Scandinavian animal studies show the same behavior in dog cartilage. (more…)
Author Interviews, Blood Clots, Orthopedics, PLoS / 16.11.2015 Interview with: Banne Nemeth, MD and  Suzanne C. Cannegieter MD PhD Leiden University Medical Center The Einthoven Laboratory for Experimental Vascular Medicine Clinical Department of Epidemiology and Orthopedic Surgery Medical Research: What is the background for this study? What are the main findings? Dr. Nemeth: Clinicians cannot currently accurately predict who will develop venous thrombosis, but it would be very helpful to be able to identify individuals at high risk for venous thrombosis because the condition can be prevented by giving anticoagulants before a clot forms (thromboprophylaxis). The ability to predict venous thrombosis would be particularly useful in patients who have had a lower limb immobilized in a cast after, for example, breaking a bone. These patients have an increased risk of venous thrombosis compared to patients without cast immobilization. We developed and validated a prediction model to identify patients with plaster cast of the lower extremity who are at high risk to develop venous thrombosis. A clinical risk score named, L-TRIP(cast) score (Leiden Thrombosis Risk Prediction for patients with cast immobilization score), was developed containing 14 clinical risk factors such as age, sex, BMI, use of oral contraceptives and location of plaster cast. Patients that score 9 points or higher are classified as being at high risk for venous thrombosis. Clinicians may decide to prescribe thromboprophylaxis therapy for these patients. (more…)
Author Interviews, BMJ, Bone Density, Calcium, Mineral Metabolism, Orthopedics / 03.10.2015 Interview with: Dr. Mark J Bolland Associate professor of medicine Department of Medicine University of Auckland Auckland New Zealand Medical Research: What is the background for this study? Dr. Bolland: Many guidelines advise older people to take at least 1000-1200 mg/day of calcium to improve bone density and prevent fractures. The average calcium intake in most countries is a lot less than these recommendations, and so many people take calcium supplements to increase their calcium intake. However, recent concerns about the safety of calcium supplements have led experts to recommend increasing calcium intake through food rather than by taking supplements, even though the effect of increasing dietary calcium intake on bone health had not been clearly established. Our study was designed to fill this evidence gap. Medical Research: What are the main findings? Dr. Bolland: Firstly, we found that increasing calcium intake either from the diet or by taking calcium supplements led to similar, small, one-off increases in bone density of 1-2%. These increases do not build up over time and are too small to produce significant reductions in the chance of having a fracture. Secondly, the level of dietary calcium intake is not associated with the risk of having a fracture. Thirdly, in clinical trials, calcium supplements have only small, inconsistent benefits on preventing fractures, with no effect on fractures seen in the highest quality trials (more…)
Author Interviews, Orthopedics, Surgical Research / 08.08.2015

Frank R. Noyes, M.D. President and Medical Director, Noyes Knee Institute and the Cincinnati Sports medicine Research and Education Foundation Cincinnati, Interview with: Frank R. Noyes, M.D. President and Medical Director, Noyes Knee Institute and the Cincinnati Sports medicine Research and Education Foundation Cincinnati, Ohio MedicalResearch: What is the background for this study? Dr. Noyes: Meniscectomy, or removal of the meniscus in the knee, frequently leads to early arthritis – especially in younger active individuals. The meniscus provides a cushion between the femur (thigh bone) and tibia (shin bone) and aids in keeping the knee stable. There are two menisci in the human knee; one on the inner portion (medial) and one on the outer portion (lateral). The problem is that once a meniscus is removed, there are no options for patients who experience knee pain other than a transplant. The operation uses human cadaver menisci from young donors that are implanted intact into the recipient’s knee. This operation has been performed at our Center for 25 years in patients who are typically under the age of 50 and who have some arthritis in their knee and experience pain with activity. There are few long-term clinical studies on meniscus transplantation that provide results in patients who are at least 10 years postoperative. MedicalResearch: What are the main findings? Dr. Noyes: This study reports the long-term results and survival analysis of 40 consecutive meniscus transplants, with a 100% follow-up obtained an average of 11 years postoperatively. The survivor analysis, which included magnetic resonance imaging (MRI) and x-ray criteria in addition to symptoms and clinical examination, revealed transplant survival rates of 68% at 7 years and 48% at 10 years postoperatively. The results of the symptom and activity level analyses in patients without failure of the transplant showed that only 11% experienced pain with daily activities and 72% were able to participate in low-impact athletics many years after surgery. (more…)
Author Interviews, Opiods, Orthopedics, Pain Research, Pharmacology / 08.05.2015

Hassan R. Mir, MD, MBA Associate professor of Orthopaedics and Rehabilitation Vanderbilt Orthopaedic Interview with: Hassan R. Mir, MD, MBA Associate professor of Orthopaedics and Rehabilitation Vanderbilt Orthopaedic Institute and and Brent J. Morris, M.D. Shoulder and Elbow Surgery Fellowship Texas Orthopaedic Hospital in affiliation with the University of Texas Houston Health Science Center, Houston, TexasDr. Brent J. Morris, M.D. Shoulder and Elbow Surgery Fellowship Texas Orthopaedic Hospital University of Texas Houston Health Science Center, Houston, Texas Medical Research: What is the background for this study? What are the main findings? Dr. Mir: The past few decades have seen an alarming rise in opioid use in the United States, and the negative consequences are dramatically increasing. The US represents less than 5% of the world's population, yet consumes 80% of the global opioid supply. Management of pain is an important part of patient care, however, the increased usage of opioids for the treatment of pain has led to several unanticipated aftereffects for individual patients and for society at large. Orthopaedic surgeons are the third highest prescribers of opioid prescriptions among physicians in the United States. Orthopaedic patients can experience a tremendous amount of pain with acute injuries and chronic conditions, and the treatment plan may involve opioid prescriptions for relief of discomfort. A significant number of orthopaedic patients and their families are at risk for repercussions from opioid use. We must work together to decrease the use of opioids for musculoskeletal pain. Clinicians should aim to control pain and improve patient satisfaction while avoiding overprescribing opioids. A comprehensive strategy of risk assessment is needed to identify patients who may be at risk for opioid abuse. Objective measures including patient history, recognition of aberrant behavior, urine drug testing, state prescription drug–monitoring programs, and opioid risk-assessment screening tools may be necessary in select cases. (more…)
Author Interviews, Orthopedics / 05.11.2013

Dr. Geoffrey S. Marecek, MD Department of Orthopaedic Surgery University of Southern California Keck School of Medicine Los Angeles, Interview with: Dr. Geoffrey S. Marecek, MD Department of Orthopaedic Surgery University of Southern California Keck School of Medicine Los Angeles, CA What are the main findings of the study? Dr. Marecek: There were several main findings: 1. It is not safe to drive while wearing a sling or splint on the upper extremities 2. It is not safe to drive while wearing a brace, cast, or boot on the lower extremities 3. Braking function does not return to normal for at least 4 weeks after knee arthroscopy, total knee arthroplasty (TKA) and total hip arthroplasty (THA), for 9 weeks after ankle fracture repair, and for 6 weeks after weight bearing begins for a fracture (up to 18 weeks for articular fractures). (more…)