Marius M. Scarlat

Complications with reverse total shoulder arthroplasty and recent evolutions.

Since its description by Paul Grammont from Dijon, France, several tens of thousands of reverse total shoulder arthroplasties (RTSA) have been performed for diverse conditions. The purpose of this analysis is to identify the complications of this procedure in the literature and in clinical practice. A total of 240 papers concerning RTSA published between 1996 and 2012 have been identified. Over 80 papers describe complications associated with this type of implant. A list of prostheses satisfying European and US standards, CE and FDA approved, has been produced on the basis of information provided by the manufacturers. Data from the literature do not support a meta-analysis. The inventory of best practices shows excellent results in the short and medium term in specific indications, while the number of complications varies between 10 and 65 % in long-term series. Complications can be classified into (A) non-specific including infections (superficial and deep), phlebitis, haematoma, neurological complications of the suprascapular, radial and axillary nerves and (B) specific complications associated with RTSA including (1) on the glenoid side: intraoperative fracture of the glenoid and acromion, late fracture of the scapula, impingement at the scapular neck (notching), glenoid loosening, dissociation of the glenoid component (snatching of the glenosphere) and fractures of the glenoid baseplate; (2) on the humeral side: metaphyseal deterioration, humeral loosening, instability of the shoulder, stiffness with limitation of external and/or internal rotation; and (3) muscular complications with fatty degeneration of the deltoid. Additionally we have identified specific situations related to the type of implant such as the disassembly of the humeral or the glenoid component, dissociation of the polyethylene humeral plate, dissociation of the metaphysis and osteolysis of the tuberosities. The integration of results from different clinical series is difficult because of the lack of a database and the multitude of implants used.

The Telegraph nail for proximal humeral fractures: A prospective four-year study

Proximal humeral fractures in 67 patients older than 50 years treated with the Telegraph nail (FH Orthopedics, Heimsbrunn, France) were monitored for 4 years to assess the fracture pattern (weighted Constant score), ranges of motion, and patient satisfaction. The outcome was best in patients with extraarticular surgical neck fractures (mean weighted Constant score, 93.5%); scores were 85% and 77.5%, respectively, for valgus impacted fractures and intraarticular displaced or dislocated fractures. Some or all of the hardware was removed in 21 patients (31%). Two required implant removed for mechanical problems related to screw positioning or migration; 8 were revised because proximal migration of the implant resulted in subacromial impingement. Avascular necrosis occurred in 18% of valgus impacted fractures and in 37.5% of displaced articular or dislocated fractures. Secondary migration of the tuberosities occurred in 6 (all 4-part fractures). The Telegraph nail provides a reproducible and satisfactory outcome for surgical neck and valgus impacted fractures in older patients. The outcome was less satisfactory for unstable articular or dislocated fractures.

Impact and alternative metrics for medical publishing: our experience with International Orthopaedics.

PurposeThis paper compares the traditional tools of calculation for a journal’s efficacy and visibility with the new tools that have arrived from the Internet, social media and search engines. The examples concern publications of orthopaedic surgery and in particular International Orthopaedics.Methods and resultsUntil recently, the prestige of publications, authors or journals was evaluated by the number of citations using the traditional citation metrics, most commonly the impact factor. Over the last few years, scientific medical literature has developed exponentially. The Internet has dramatically changed the way of sharing and the speed of flow of medical information. New tools have allowed readers from all over the world to access information and record their experience. Web platforms such as Facebook® and Twitter® have allowed for inputs from the general public. Professional sites such as LinkedIn® and more specialised sites such as ResearchGate®, BioMed Central® and OrthoEvidence® have provided specific information on defined fields of science. Scientific and professional blogs provide free access quality information. Therefore, in this new era of advanced wireless technology and online medical communication, the prestige of a paper should also be evaluated by alternative metrics (altmetrics) that measure the visibility of the scientific information by collecting Internet citations, number of downloads, number of hits on the Internet, number of tweets and likes of scholarly articles by newspapers, blogs, social media and other sources of data.Conclusions and discussionThis article provides insights into altmetrics and informs the reader about current tools for optimal visibility and citation of their work. It also includes useful information about the performance of International Orthopaedics and the bias between traditional publication metrics and the new alternatives.

The lateral impaction of the shoulder

Abstract 17 patients had radiographic demonstration of injury to the clavicle, scapula and ribs from an impact delivered to the lateral shoulder. The study included 13 males and 4 females whose ages ranged from 18 to 83 years (average 45 years). Most injuries were sustained in falls or motor vehicle accidents. Analysis of these cases suggests a biomechanical hypothesis concerning the transmission of the impact forces within the shoulder girdle. According to this hypothesis, the impaction force applied to the lateral shoulder is transmitted from outside inward following two paths. The anterior and superior path passes through the acromio-clavicular joint, the clavicle, the costo-clavicular joint and the sterno-clavicular joint. The posterior and inferior path is transmitted within the gleno-humeral joint, the scapula and the scapulo-thoracic joint. Major impacting force is required to disrupt the anterior and posterior arches of the shoulder girdle. When both of these supporting structures are damaged, the patient is at risk for more serious injuries, including disruption of the thorax, shoulder joint, brachial plexus and neck.Résumé  Les auteurs communiquent l’observation des caractéristiques communes pour 17 cas de traumatismes complexes de l’épaule, associant comme lésions des fractures de la clavicule de l’omoplate et des côtes. L’analyse des cas suggère une hypothèse biomécanique concernant la transmission des forces d’impaction traumatique au niveau de la ceinture scapulaire. Conformément a cette hypothèse, la force traumatique appliqué sur la face externe de l’épaule est transmise de l’extérieur vers l’intérieur sur deux voies vectorielles. La voie antéro-supérieure passe par l’articulation acromio-claviculaire, la clavicule, l’articulation costo-claviculaire et l’articulation sterno-claviculaire. La voie postéro-inférieure passe par l’articulation gléno-humérale, l’omoplate et le complexe scapulo-thoracique. Théoriquement, les lésions peuvent se produire sur tout point du trajet vectoriel. En particulier, les lésions peuvent se manifester au niveau de l’arche antérieure ou postérieure du cintre omo- cle-thoracique, en extérieur et a l’intérieur du cintre.

Best one hundred papers of International Orthopaedics: a bibliometric analysis

IntroductionInternational Orthopaedics was founded in 1977. Within the 40 volumes and 247 issues since its launch, 5462 scientific articles have been published. This article identifies, analyses and categorises the best cited articles published by the journal to date.MethodsWe searched Elsevier Scopus database for citations of all papers published in International Orthopaedics since its foundation. Source title was selected, and the journal’s title was introduced in the search engine. The identified articles were sorted based on their total number of received citations, forming a descending list from 1 to 100. Total citations and self-citations of all co-authors were recorded. Year of publication, number of co-authors, number of pages, country and institution of origin and study type were identified.ResultsThe best 100 papers and their citations correspond approximately to 2% of all the journal’s publications. Total citations ranged from 62 to 272; 26 papers had >100 citations, of which self-citations accounted for <4%. Mean authorship number per paper was four and mean page number 6.5. United States, Japan and Germany ranked the top three countries of origin. The most common study type was case series, and most common topics were adult reconstruction, sports medicine and trauma.ConclusionsThis article identifies topics, authors and institutions that contributed with their high-quality work in the journal’s development over time. International Orthopaedics remains faithful to its authors and readers by publishing topical, well-written articles in excellent English.

Setting standards for medical writing in orthopaedics

Once the privilege of few clinical scholars in the field of orthopaedics, medical writing has become a must for career advancement. The number of papers submitted and published yearly has increased steadily, and with the development of the Internet, manuscript and journals have become easily accessible. Medical writing has risen to become a discipline in itself, with rules and standards. However, heterogeneity in the quality of papers submitted still prevails, with large variations in both form and content. With countries such as China and India submitting an exponential number of manuscripts, it is important and helpful that standards of medical writing be emphasised to help writers who do not always have the required support to produce an outstanding manuscript. In this paper, we summarise what may become standards for medical writing in the field of orthopaedics.

Attractive papers and accurate English

Medical writing has a long and distinguished history. It shows the latest considerations about the diagnosis, treatment, prevention, prognosis, practice management, surgical approaches or techniques and much more. Once the privilege of few clinical scholars in the field of orthopaedics, medical writing has recently become a must for career advancement. Writing a scientific paper that will get published is one of the most rewarding achievements in a medical career [1]. However, medical writing should include both medical knowledge and expertise in writing. Moreover, writing medical literature has its own special considerations, with rules and standards; it should be easy to understand, precise and should not confuse the readers. A physician who wants to share his research with colleagues communicates that responsible experience. Yet, some write, while others do not. Those who write gain intellectual stimulation, generate discussion, advance their discipline, enhance their reputation, and/or earn income. Those who do not write claim not having enough time. They blame the assistant or secretarial support, having no mentor or enough knowledge to express. Lack of time for research and writing is an important reason, especially for physicians in private practice. In contrast, lack of secretarial help, collegial support, and research access are not as valid now because of the computers and Internet [2–4]. Preparation of a manuscript crowns the mountain of hard work that preceded it, starting from defining a rationale (research question), writing a protocol, submitting it to the Institutional Review Board (IRB) for approval, recruitment of patients and data analysis. Yet, publication is not guaranteed; reporting a large series does not merit publication unless important and/or novel information is provided. Moreover, publication depends not only on the methodology used and quality of data analysis, but also on how the paper is written [1]. An article submitted to our Journal is first seen by the Publishing Assistant who will check if the submission fits the Journal standards, if the references are formatted according to the Instructions for the authors and if the word count is within reasonable limits. The papers that qualify are sent to the Editor and therefore a cover letter is recommended; this may be the first item that the Editor reads about the study. It should be personal and explain why the study was performed. It should be addressed with the manuscript and include the date of submission and the title. The Editor rapidly reviews the article to see if it falls within the Journal’s scope and if it is prepared according to the Instructions for Authors; articles that are outside the Journal’s scope, report an unimportant topic, include outdated information, provide conclusions that are inconsistent with the data, and those that are carelessly prepared are immediately rejected and returned to the authors. If the paper matches the Editor’s criteria, it is sent to Reviewers for peer review. The Reviewers agree or decline to review and are encouraged to write a thoughtful review that is honest and free of bias, confident, and polite, suggesting a decision to the Editor. The assigned Reviewers are generally chosen for personal experience, many are senior academicians and researchers, yet all are volunteers. In our Journal policy we try to involve new and young reviewers matching them with the more experienced ones. Their role is to advise the Editor and eventually to help the authors to improve their production [3–5]. * Marius M. Scarlat mscarlat@gmail.com

Imperfection leads to progress

A recent editorial published jointly by JBJS, CORR and BJJ has established a new set of guidelines for the publication of randomized clinical trials [1]. The purpose of these guidelines is clearly and explicitly set out in the editorial and one cannot argue with the intent. As pointed out in the editorial biased acceptance by journals of positive outcome trials versus neutral or negative outcome trials may lead to an incorrect interpretation of data. By requiring registration of all randomized clinical trials in a public repository of clinical trials all results must be available thus avoiding unnecessary duplication and providing a more balanced picture when performing literature searches or meta-analyses. Randomized clinical trials remain the supposed gold standard of clinical research but the value of other research in orthopaedics should not be under-estimated. There are a variety of other examples of valuable research activity that clearly advance the art and science of surgery. It should be recognized that a randomized clinical trial requires extensive infrastructure if it is to be done properly. A large number of patients from which to recruit study subjects is required. Experienced investigators to explain the trial to possible participants and recruit those patients to the trial have to be hired. Clearly defined primary and secondary outcomes agreed to by all of those individuals enrolling patients in the trial and surgeons capable of performing the intervention skillfully, repetitively and without variation will have to be trained. Statisticians are required for appropriate sample size calculation and loss to follow-up provisions to ensure that sufficient patients are enrolled to provide evidence of clear differences between both the primary and secondary outcomes. Diagnostic imaging capability is often sophisticated in order to provide accurate information around prosthetic migration, fracture union, curve correction or other calculations that have to be extremely precise. Finally the statistical analysis at the end of the trial will evaluate the results and determine whether or not the intervention being studied was effective. Most hospitals, clinics or universities where orthopaedic surgery is practiced do not have these resources or if they do have them they are rationed and orthopaedic surgeons must compete for resources with other investigators from other specialties. The cost of running such trials, especially if a number of centers are enrolled, may be prohibitive. Finding funding for these trials is a challenge and industry sponsored trials are often viewed with suspicion. It is imperative that all types of orthopaedic research be encouraged and supported. Small schools or clinics with limited resources may still provide meaningful information to guide orthopaedic practice. A hospital-based registry, for example, can clearly track the outcomes for specific surgical procedures using a validated outcome tool provided without cost. A number of these tools are available and have been used by small hospital or clinic-based registries. Some of these registries have been in existence for decades and provide valuable information over years of review. Cohort studies using a retrospective analysis of prospectively gathered data may be done with relative ease with these hospital-based registries. The effect of introducing a change in patient care, either surgical or non-surgical, can easily be tracked by retrospective analysis of quality prospectively gathered data. These studies are very common, usually valuable in providing information and often form the basis for a more formal randomized clinical trial. * Marius M. Scarlat mscarlat@gmail.com

Scientific Misconduct (Fraud) in Medical Writing

Scientific misconduct (fraud) in medical writing is an important and not infrequent problem for the scientific community. Although noteworthy examples of fraud surface occasionally in the media, detection of fraud in medical publishing is generally not as straightforward as one might think. National bodies on ethics in science, strict selection criteria, a robust peer-review process, careful statistical validation, and anti-plagiarism and image-fraud detection software contribute to the production of high-quality manuscripts. This article reviews the various types of fraud in medical writing, discusses the related literature, and describes tools journals implement to unmask fraud. [Orthopedics. 2018; 41(2):e176-e183].

Bone and joint infection, from prevention to complications

Editor’s Pick: While preparing the next issue we look for evidence and for trends. We would like so much to have great news to share with our readers and provide reliable science. This is why sometimes we create the “Editor’s Pick” that stands for a specific direction or orientation that we observe during the last months and that is of interest for our colleagues, readers. As the turnover of science publications is becoming frenetic we could eventually find often specific trends and novelties to communicate. Some of that information is contradictory and we have to be really careful with choices in outlining evidence and sustainable care. This month’s pick is “Infection” a vast subject that brings papers and research in almost every issue. Infection and Microbiology are science branches and specialties with dedicated Journals and specific units in patient care. However, there are very few specific services of “Bone and Joint Infection” created in big institutions in order to copewith high volume care. Our infectiologists are the same experts that care for necrotizing fasciitis, burns, intensive care units subjects or meningitis. Obviously the Orthopedic Surgeon is facing the infected patient with a painful and inflammatory joint, at the same title as the Neurologist who cares for meningitis or the Pneumologist who manages severe lung or pleura infection. We face facts but our field of expertise is somewhere else, at the border. For us, infection is a complication. Complications with infections are more frequent than we imagine as many loosen implants or unexplained disturbances have somewhere micro-organisms that are compromising function and finally are responsible for failures as it results from a thoughtful systematic review published by the University of Washington in Seattle [1]. A great research published by the French office of “Medcins sans Frontières” jointly with a Hospital in Amman (Jordan) showed that hidden infections in a reconstructive surgery program are frequently underestimated. This retrospective study was undertaken of 1891 civilian war-wounded patients from Iraq, Syria, Yemen and Gaza treated in Amman from August 2006 to January 2016. One thousand three hundred and fiftythree people underwent surgical interventions for previous bone injury and had systematic bone cultures. Many patients (46%) without any clinical, biological or radiological signs of infection demonstrated infection based on bone cultures. The authors conclude that bone culture should become a prerequisite for any reconstruction in such contexts [2]. Newmethods for diagnosing periprosthetic infection include multiplex-PCR and biomarkers such as alpha-defensin. A study published in this issue [3] compared these new methods with clinical assessment, conventional microbiological methods and histopathology. The authors from the University of Mannheim (Germany) compared results of conventional microbiology and histopathology of punction fluid and tissue specimens with the results of the alphadefensin test and multiplex-PCR from the synovial membrane specimen harvested from hip and knee surgeries in thirty joints from twenty-eight patients. The authors conclude after a solid statistical analysis that neither alphadefensin test nor multiplex-PCR could detect periprosthetic infection immediately and reliably. Multiplex-PCR was suitable for detecting the non-infected but not the truly infected. Alphadefensin test was helpful but showed no satisfactory results. Conventional microbiological methods remain themost reliable for periprosthetic infection diagnosis [3]. A study wrote by Daniel Péréz-Prieto and colleagues from Spain focuses on chronic and low-grade infections that are so * Marius M. Scarlat mscarlat@gmail.com