Editorial Commentary: Proficiency-Based Training: Are We Ready for a New Way to Train and Test Orthopaedic Surgeons?

Orthopaedic training has followed an apprentice/mentorship pathway of training throughout its history. This method of training is entrenched in Medicine and is the foundation for our current residency/fellowship method of attaining the appropriate training and credentialing of physicians and surgeons to safely care for our patients. Over the past 2 decades, the use of proficiency-based training has been shown to be effective in general surgery, cardiac surgery, vascular and plastic surgery, and now with the Copernicus project, in shoulder arthroscopy. Combining proficiency-based training with the rapid advances in virtual reality technology will allow surgeons to become competent with the surgical skills needed for surgery before ever touching a patient.     

Bone turnover markers: tools for prognosis and monitoring response to bisphosphonates?

Skeletal homeostasis is maintained by spatially coupled and balanced processes of osteolysis and osteogenesis. Several factors across the breast cancer continuum (e.g., adjuvant therapies, bone metastases in advanced disease) can disrupt this balance. Circulating levels of specific biochemical markers released during bone turnover provide relatively non-invasive means to assess ongoing rates of skeletal metabolism. Such markers may provide insight into the risk of bone loss and fractures in women with osteoporosis and during adjuvant therapy for breast cancer. In addition, bone marker levels and alterations might reflect tumor-bone interactions and response to bisphosphonate treatment in patients with bone metastases. Thus far, the largest body of evidence supports a potential role for urinary N-terminal cross-linked telopeptide of type I collagen (NTX) in predicting risks of skeletal morbidity and death, and monitoring response during zoledronic acid treatment, in patients with bone metastases. Other possible applications for bone markers include diagnosis of bone metastases and monitoring bone disease progression. Ongoing clinical trials evaluating the potential for bone marker changes to provide insights into the disease course and response to various classes of antiresorptive therapies are expected to expand the role of bone markers in the management of patients with breast cancer.     

Bone lengthening in children: how to predict the complications rate and complexity?

PURPOSE: Complications arising from limb-lengthening procedures are often severe leading to long-term residuals. The aim of this study was to determine whether the complication rate and complexity could be predicted using a distraction index for bone lengthening in children. STUDY DESIGN: This study retrospectively reviewed a series of 116 lower limbs lengthening in 88 consecutive patients (mean age 13.5). Mean follow-up 3.8 years. Lengthening percentage, lengthening index, distraction regenerate length, additional surgeries, and complications rate were used to evaluate the results of limb lengthening. The correlation between lengthening percentage and complication rate was particularly analyzed and its practicability illustrated. Scatter plots of complication rate (%) against lengthening percentage were constructed, and linear regression was used to investigate mathematical relationship between the variables. RESULTS: The lengthening index was 33 +/- 12.1 days/cm. The length of distraction regenerate was 6 +/- 3.2 cm. The lengthening percentage was 21 +/- 16.5. The scatter plots of neurological complication rate, residual deformities rate, broken pins rate, joint contractures rate, and hypertension rate against lengthening percentage showed a positive linear relationship with r = 0.8. CONCLUSIONS: The number of complications increased considerably with the increase in lengthening percentage. The lengthening percentage correlates very well with the complication rate and can be used to predict the complication rate. CLINICAL RELEVANCE: During planning a lengthening procedure, the lengthening percentage should be a useful tool to predict the complications rate and to discuss the risks and benefits with patients and their families. The knowledge about predictable complications should help prevent and early detect expected complications.     

Research Pearls: How Do We Establish the Level of Evidence?

Evidence-based medicine (EBM) guidelines were first introduced in 1986 and were defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Level of evidence (LOE) stratifies publications from Level I to Level V and provides the foundation for EBM. Three questions should be asked when an LOE is assigned to a scientific article: (1) What is the research question? (2) What is the study type? and (3) What is the hierarchy of evidence? In cases in which LOE is not appropriate or relevant (basic science and laboratory-based investigations), a clinical relevance statement should be used. Unfortunately, study quality is not assessed by the assigned hierarchy level. LOE and EBM have increased the number of investigations published with better levels of evidence. As authors, reviewers, editors, and publishers, we desire a system that is consistent, effective, and reliable. Fortunately, the system has proven to have all of those attributes with good interobserver and intra-observer values. The increase in investigations with higher LOEs allows for more frequent use of EBM.     

Bone graft substitutes for articular support and metaphyseal comminution: what are the options?

Subchondral and metaphyseal bone defects pose a great challenge for the Orthopaedic surgeon not only because the support for the articular surface has been lost but also because the mechanism for the nourishment of articular cartilage through the subchondral plate is distorted. A number of options are available to the surgeons, none of them perfect. Autografting has an appreciable high rate of harvest site morbidity, allograft is associated with infection transmission and host immunologic response. These realities have stimulated interest in supplying bone replacement materials (demineralised bone matrix, synthetic bone substitutes, bone morphogenic proteins). This paper presents the indications and applications of bone substitutes for metaphyseal defects and subchondral support in orthopaedic trauma.     

Bone stimulation for fracture healing: What's all the fuss?

Approximately 10% of the 7.9 million annual fracture patients in the United States experience nonunion and/or delayed unions, which have a substantial economic and quality of life impact. A variety of devices are being marketed under the name of “bone growth stimulators.” This article provides an overview of electrical and electromagnetic stimulation, ultrasound, and extracorporeal shock waves. More research is needed for knowledge of appropriate device configurations, advancement in the field, and encouragement in the initiation of new trials, particularly large multicenter trials and randomized control trials that have standardized device and protocol methods.     

Dialysis Adequacy and Response to Erythropoiesis-Stimulating Agents: What Is the Evidence Base?

Despite an increase in the use and average dose of erythropoiesis-stimulating agents (ESA) over the past 15 years, a substantial percentage of patients still do not achieve hemoglobin targets recommended by international guidelines. A clear relationship among hemoglobin or hematocrit levels, ESA dose, and increase in dialysis dose has been pointed out by a number of prospective or retrospective studies. This is particularly true in patients receiving inadequate dialysis. Increasing attention also has been paid to the relationship between dialysis, increased inflammatory stimulus, and ESA response because dialysate contamination and low-compatible treatments may increase cytokine production and consequently inhibit erythropoiesis. The biocompatibility of dialysis membranes and flux are other important factors. However, in highly selected, adequately dialyzed patients without iron or vitamin depletion, the effect of these treatment modalities on anemia seems to be smaller than expected. The role of on-line treatments still is controversial given that it is still difficult to discriminate between the effect of on-line hemodiafiltration per se from that of an increased dialysis dose. Very preliminary results obtained with short or long nocturnal daily hemodialysis on anemia correction are encouraging.     

Strengthening the enabling environment for women and girls: what is the evidence in social and structural approaches in the HIV response?

There is growing interest in expanding public health approaches that address social and structural drivers that affect the environment in which behaviour occurs. Half of those living with HIV infection are women. The sociocultural and political environment in which women live can enable or inhibit their ability to protect themselves from acquiring HIV. This paper examines the evidence related to six key social and structural drivers of HIV for women: transforming gender norms; addressing violence against women; transforming legal norms to empower women; promoting women’s employment, income and livelihood opportunities; advancing education for girls and reducing stigma and discrimination. The paper reviews the evidence for successful and promising social and structural interventions related to each driver. This analysis contains peer-reviewed published research and study reports with clear and transparent data on the effectiveness of interventions. Structural interventions to address these key social and structural drivers have led to increasing HIV-protective behaviours, creating more gender-equitable relationships and decreasing violence, improving services for women, increasing widows’ ability to cope with HIV and reducing behaviour that increases HIV risk, particularly among young people.