James D. Heckman

Introducing Levels of Evidence to The Journal

Orthopaedic surgeons have always based their clinical care on evidence. Surgeons use evidence to make decisions tailored to an individual patients needs and circumstances. The primary sources of evidence for clinicians are studies published in the medical and surgical literature, such as The Journal of Bone and Joint Surgery. In June 2000, The Journal introduced the quarterly Evidence-Based Orthopaedics section 1. This section introduces orthopaedic surgeons to recent randomized trials relevant to the practice of orthopaedic surgery published in forty-two journals other than The Journal of Bone and Joint Surgery. Structured abstracts of these studies are …

Acceleration of tibia and distal radius fracture healing in patients who smoke

A low intensity ultrasound device was investigated as an accelerator of cortical and cancellous bone fracture healing in smokers and non-smokers. Statistically significant reductions in healing time for smokers and nonsmokers were observed for tibial and distal radius fractures treated with an active ultrasound device compared with a placebo control device. The healing time for a tibial fracture was reduced 41% in smokers and 26% in nonsmokers with the active ultrasound device. Similarly, distal radius fracture healing time was reduced by 51% in smokers and 34% in nonsmokers with the active device. Treatment with the active ultrasound device also substantially reduced the incidence of tibial delayed unions in smokers and nonsmokers. The use of the active ultrasound device accelerates cortical and cancellous bone fracture healing, substantially mitigates the delayed healing effects of smoking, speeds the return to normal activity, and reduces the long-term complication of delayed union.

Publication Bias in Orthopaedic Research: An Analysis of Scientific Factors Associated with Publication in The Journal of Bone and Joint Surgery (American Volume)

BACKGROUND Positive outcomes are common in the orthopaedic literature, and there are many who believe it may be due to the preferential publication of studies with positive findings-a phenomenon known as publication bias. The purpose of this investigation was to determine whether positive findings rendered a manuscript submitted to The Journal of Bone and Joint Surgery (American Volume) more likely to be accepted for publication. METHODS A total of 1181 manuscripts submitted to The Journal of Bone and Joint Surgery between January 1, 2004, and June 30, 2005, for publication as scientific articles were analyzed, with 855 meeting the inclusion criteria. The direction of the study findings (positive, neutral, or negative) was independently graded by three blinded reviewers. The final disposition (acceptance or rejection) was recorded, as was information on the scientific characteristics plausibly related to acceptance or rejection. Logistic regression was used to identify factors associated with acceptance for publication. RESULTS The overall acceptance rate was 21.8% (186 of 855 studies). The study outcome was positive for 72.5% (620) of the manuscripts. The acceptance rate for the 235 manuscripts with nonpositive findings was 23.0% (fifty-four studies) compared with 21.3% (132) of the 620 studies with positive findings (crude odds ratio, 1.10 [95% confidence interval, 0.77 to 1.58]; p = 0.593). After controlling for all covariates, the adjusted odds ratio was 0.92 (95% confidence interval, 0.62 to 1.35; p = 0.652). In the multivariate analysis, the only factor significantly associated with acceptance for publication was level of evidence (p = 0.001). CONCLUSIONS We found no evidence of publication bias in the review of manuscripts for publication by The Journal of Bone and Joint Surgery, as positive and nonpositive studies were accepted at similar rates. The dearth of nonpositive studies in the orthopaedic literature is of concern, and may be due largely to investigator-based factors. Orthopaedic researchers should submit negative and neutral studies for publication, confident that the likelihood of acceptance will not be influenced by the direction of study findings.

An AOA critical issue: aging of the North American population: new challenges for orthopaedics.

In the next twenty years, the number of North Americans who are more than fifty-five years old will increase by at least thirty-five million 1-4, a change that will create great challenges for the specialty of orthopaedics in both Canada and the United States. The ability of this population to remain physically active will depend upon a better understanding of the aging process and the development of methods to prevent and treat age-related injuries and diseases of the musculoskeletal system. Aging, the normal decline in cell, tissue, and organ system function that progresses with time following skeletal maturity, is not a disease 2,3,5, but it increases the risk of injuries and degenerative diseases that impair musculoskeletal function. As a result, impairments of the musculoskeletal system are among the most prevalent and symptomatic disorders associated with middle and old age 4,6-8. Common age-related musculoskeletal disorders include acute fractures of the hip, spine, and distal aspect of the radius; insufficiency fracture of the pelvis; muscle pain and weakness; muscle-tendon junction injury; osteoarthritis of the hip, knee, foot, and hand; intervertebral disc degeneration; spinal stenosis; and rupture of the rotator cuff tendon 2-4. By decreasing strength, restricting movement, and causing pain, these impairments prevent middle-aged and older people from making full use of their abilities and opportunities for leisure and work and from participating in the regular physical activity necessary to maintain physical and mental health. Age-related deterioration of musculoskeletal tissues and function do not necessarily progress inexorably, and appropriate interventions can restore musculoskeletal function in middle-aged and older patients 2,3,9. To ensure that the North American population receives appropriate musculoskeletal care, orthopaedic surgeons need to understand how the rapid increase in …

Fractures and dislocations of the forefoot: operative and nonoperative treatment

Abstract Effective treatment of common bone injuries of the forefoot is dependent on a clear understanding of both the osseous anatomy of the foot and the biomechanics of gait. Obtaining a thorough history and performing a careful physical examination are especially important because the complex anatomy of the region often makes radiographic diagnosis difficult. The keys to making the correct diagnosis in the injured forefoot are detailed, with emphasis on obtaining the appropriate radiographic studies. Included in the discussion are injuries to Lisfranc’s joint and the metatarsophalangeal and sesamoid joints, as well as metatarsal and phalangeal fractures. Guidelines for operative and nonoperative management of these injuries are presented.

Supramalleolar osteotomy for the treatment of symptomatic tibial malunion.

Summary: Supramalleolar osteotomy was performed on eight patients who were symptomatic from a malunion of the distal two-thirds of the tibia. The patients subjective reports of pain, limp, appearance, instability, and limitation of activity were evaluated pre- and postoperatively. Objective measurements of range of motion, angular deformity, and radiographic signs of ankle arthritis were also evaluated. All of the patients had varus malunion with a mean angulation of 15°. Three of these patients also had sagittal malalignment. Supramalleolar dome or wedge osteotomies were performed to correct the coronal and sagittal plane deformities. Either internal (three patients) or external (five patients) fixation devices were applied to maintain correction. All osteotomies healed. The final mean angulation was 0° in the coronal plane and 8° of recurvatum. Complications included pin tract infections, wound breakdown, failure to completely correct the deformities, and loss of reduction. Seven of the patients reported symptomatic improvement after the procedure. The one patient who had a loss of reduction became more symptomatic.

Nonscientific Factors Associated with Acceptance for Publication in The Journal of Bone and Joint Surgery (American Volume)

BACKGROUND While it is widely accepted that scientific factors may render a study more likely to be accepted for publication, it is less clear whether nonscientific factors may also be associated with publication. The purpose of this study was to identify the nonscientific factors associated with acceptance for publication by The Journal of Bone and Joint Surgery (American Volume). METHODS A total of 1173 manuscripts submitted to The Journal of Bone and Joint Surgery between January 1, 2004, and June 30, 2005, for publication as scientific articles were analyzed as part of a study on publication bias in the editorial decision-making process. Information was collected on nonscientific factors plausibly associated with acceptance for publication, including study location, conflict-of-interest disclosure, sex of the author, primary language, and the number of prior publications by the corresponding author in frequently cited orthopaedic journals. The final disposition term (acceptance or rejection) was recorded, and logistic regression was used to identify factors associated with acceptance for publication. RESULTS Manuscripts from countries other than the United States or Canada were significantly less likely to be accepted (odds ratio, 0.51; 95% confidence interval, 0.28 to 0.92; p = 0.026). Factors positively associated with acceptance for publication were conflict-of-interest disclosure involving a nonprofit entity (odds ratio, 1.92; 95% confidence interval, 1.35 to 2.73; p < 0.001) and ten or more prior publications in frequently cited orthopaedic journals by the corresponding author (odds ratio, 2.01; 95% confidence interval, 1.33 to 3.05; p = 0.001). We did not find a significant association between acceptance and conflict-of-interest disclosure involving a for-profit company, sex of the corresponding author, or primary language. CONCLUSIONS Manuscripts submitted to The Journal of Bone and Joint Surgery were more likely to be accepted if they were from the United States or Canada, reported a conflict of interest related to a nonprofit entity, or were authored by an individual with ten or more prior publications in frequently cited orthopaedic journals.

Excellence Through Peer Review

Over the last few months, many changes have occurred in your Journal, with the addition of such new features as The Orthopaedic Forum, Ethics in Practice, and Evidence-Based Orthopaedics as well as electronic enhancements through our collaborative efforts with the Video Journal of Orthopaedics . All of these changes have been made to increase The Journals usefulness to all orthopaedic surgeons, regardless of their specialty interest. This first issue of 2001 has a new style of presentation that we hope will enhance your ability to read, use, and enjoy the material presented in The Journal . While many changes have occurred and are occurring in The Journal, the long-standing tradition of delivering high-quality peer-reviewed information, established by my predecessors and professionally conducted by our outstanding corps of Deputy and Associate Editors and reviewers, continues unchanged. Adherence to those high standards is well encapsulated in …

Non-union of the clavicle in a child. A case report.

A case of symptomatic non-union of the clavicle occurred in a 12-year-old boy. Differential diagnosis roentgenographic and histologic observations, including the results of resection of the non-union site and stablization of the proximal clavicle using the coraco-acromial ligament demonstrated that this rare condition can be restored to full asymptomatic function without any internal metallic fixation devices.

The Fate of Manuscripts Rejected by The Journal of Bone and Joint Surgery (American Volume)

BACKGROUND Of the many manuscripts that are submitted to The Journal of Bone and Joint Surgery (American Volume) (JBJS-A) for publication, the majority are not accepted. However, little is known about the outcome of these rejected submissions. To determine the fate of studies rejected by JBJS-A, we conducted a follow-up investigation of all clinical and basic science manuscripts that were submitted to The Journal between January 2004 and June 2005 but were not accepted. METHODS For each rejected manuscript, data were extracted on a wide variety of scientific and nonscientific characteristics, which were plausibly related to subsequent publication. PubMed searches were conducted to determine which manuscripts achieved full publication within five years, and logistic regression was used to identify the factors associated with publication. To further elucidate the factors associated with publication, a survey was administered to the corresponding author of each rejected manuscript. RESULTS At five years following rejection by JBJS-A, 75.8% (696 of 918) of manuscripts had reached full publication. In the multivariate analysis, factors associated with a higher likelihood of subsequent publication included grade of initial review by JBJS-A (p = 0.029), disclosure of a for-profit or nonprofit conflict of interest (p = 0.028 and 0.027, respectively), and a greater number of prior publications in frequently cited orthopaedic journals by the corresponding author (p < 0.0001). Manuscripts were less likely to reach full publication if the corresponding author was from Asia or the Middle East (p = 0.004) or was a woman (p = 0.003). Among survey respondents who indicated that their study had not yet reached full publication, the most commonly cited reason was lack of time (reported by 51.4% of respondents [thirty-eight of seventy-four]). CONCLUSIONS Most manuscripts (75.8%) not accepted by JBJS-A were published elsewhere within five years of rejection. The factors predictive of subsequent publication were primarily investigator-related as opposed to study-related. Given this low threshold for eventual publication, readers are encouraged to use criteria other than inclusion in the PubMed database to identify high-quality papers.