Episode Transcript
[00:00:03] Speaker A: Welcome to your Cases on Hold, a JBJS podcast hosted by Antonia Chen and Andrew Stonefield.
[00:00:10] Speaker B: Here we discuss the science of each issue of JBJS with an additional dose of entertainment and pop culture.
[00:00:17] Speaker A: Take us with you in the gym, on the commute, or most certainly whenever your case is on.
Welcome everyone, to your Cases on hold, the first episode of 2026 this is our 97th episode as we work our way toward 100.
The Milestone podcast is just on the Horizon.
It is January 6th for a January 7th release of the journal Bone and Joint Surgery.
As always, you are tuning in to hear the best that orthopedic research and education has to offer in 2026, the same as it was in 2022.
And as always, this is the opinions of myself and Dr. Chen and the other hosts of the podcast, not the opinions of the Board of Trustees, the Editor in Chief, the editor of the other constituent journals, or any members of the editorial board.
This episode is brought to you by the Miller Review Course. We are getting to that time of the year as our new or newly graduating trainees are getting ready for the written examination for Board certification. It's a great way to get all the knowledge and information you need so that you can be successful on that test, but it's also a great way to get some CME and to get caught up. It's very busy, busier than I think anyone has ever been in these times, and it's hard to stay up with what's important in orthopedics, what's game changing in orthopedics, and attending the Review course, even if you don't have to take the the Board exam is a great way to stay in touch and stay up to speed.
Let jbjs do the hard work of figuring what you need to know for you and then just reap the benefits of staying in Colorado, I think, and having that great experience with the Miller Review Course team.
As always, I am Andrew Schoenfeld, Associate Editor for Methods at the Journal of Bone Joint Surgery and as we all.
[00:02:40] Speaker B: Know, I have with me Antonia Chen, executive editor at JBJS.
[00:02:45] Speaker A: Appreciate everyone tuning in for this, our 97th episode and the 1st of January 2026.
I just want to say that we appreciate everything that our listening audience has done for us, lifting us up and elevating us on this platform.
It has been a great road to 97 episodes and we are on the doorstep of 100 and beyond.
One of our very first listeners was my father. He was a big fan of the podcast and he passed away at the end of 2025.
So I would like to dedicate at least my portion of this episode to my father, David Schoenfeld. May his memory be a blessing to all who knew him and those who did it.
So with that, let's go to top of the pile.
There we have a comparative in vitro analysis of wear particles generated by a viscoelastic disc versus two articulating Total Disc Replacements by Chin this comes with a comment so you don't have to take it from us. Humeral Head Reconstruction and Anatomic Shoulder Arthroplasty how to Assess it, how to Avoid Overstuffing and Whether it Matters by Shet Then we have the Hidden Cost of Robotics and Hip and Knee Arthroplasty by Adelani. This is a highlighted article for this issue.
Lost in Limbo the Unmatched Orthopedic Applicants Research Year Experience by Al Qaede.
Then we have Finding your why by Pizzulo.
Next, rethinking what Makes a Great Orthopedic Surgery Resident More Than a Manuscript by Harper When Half of Humanity Is Visible, Reflections on the Erasure of Female Surgeons by Uvinu and that one is Permanently Free.
With that, we will now be heading into the headlines. What's new and exciting in orthopedics this week?
As we've discussed, there have been changes in the format and construct of jbjs. Many of our avid readers and listeners will know this going back to the second half of November. As such, and as we change with the times, even here on your cases on hold, we will be covering some articles at times that we'll select that are not necessarily scientific articles, but one that we feel are interesting and informative and can still engender discussion, even if it's not science. You know, maybe some of it can still go on hold, as always. And so I'm leading us off with that kind of approach.
I selected for my headline Healthcare Leadership and Orthopedic Surgeons Exploring the Value of an Advanced Degree. This is an Orthopedic Forum article that came out of presentations at the American Orthopedic Association Conference by Salazar and colleagues.
I think this is very timely. It's part of the zeitgeist that we're dealing with. There's a lot of pressure on surgeons to bring new skills to the table, to acquire new skills. There are different ways, of course, to obtaining new skills. Both Dr. Chen and I have advanced degrees beyond the MD degree. I know you have an MBA. Did you get yours during your TR, like during medical school, like in conjunction with medical school.
[00:06:10] Speaker B: I did, I did one of those MD MBA programs where between my first and second year of medical school I did my mba. But it was one that you had to apply to during your first year of medical school. So it wasn't a. You applied into a joint degree program, you got into medical school and then you applied for the MBA between second and third year. First and second year.
[00:06:27] Speaker A: I mean, got it. Yeah. There are obviously lots of different ways to do it. For mine, I was a Robert Wood Johnson clinical scholar when that type of program existed at the University of Michigan. And I had already been in a like post fellowship attending for four years when I made the, the decision to take essentially time out of my career to attain a different set of skills that I honestly wouldn't be here doing this with you today, I don't believe if I didn't have that experience. So these experiences can be incredibly impactful on a career. They can really be life changing.
It's a relatively short piece. It only ends up being four pages in total.
And it's pretty superficial as a result. It isn't exhaustive either. They focus on MBAs, MPH, MHA, which is a Master of Healthcare Administration. Then they get a little bit outside the box through mj, Master of Jurisprudence, and then they do the AOA Apex Leadership Certificate, which I think was kind of done because this is an AOA forum.
I would say that while this article specifically touches on the AOA Apex Leadership program, what they're talking about, if you read the article, is any kind of organizational, proprietary leadership program. They're pretty, you can find them almost everywhere. Like national organizations, like ALS has one, ALA has one, healthcare organizations, like for a long time, the hospital where Dr. Chen and I used to work together and where I'm still working, Brigham Women's had like its own leadership program in common combination with Harvard Business School.
Those programs do not give you a degree. So they were talking about the value of an advanced degree. And then I thought it was strange that, you know, they devoted at least a quarter or so, maybe a little bit less than that, maybe an eighth of their paper to talking about a program that doesn't give you an advanced degree. At the end of the day, I think there are just some points that I would like to touch on. There isn't anything that they say, you know, they cover it in a very superficial way and it's kind of big picture, pros and cons. I guess you will.
But I think one thing I was a little bit taken Aback on is that they didn't include the type of degree that I have, which is a Master of Science. And they didn't include PhDs either, which seemed like kind of a huge sort of myopic oversight. Now granted, most people who get PhDs, they either do it before they went to medical school, they do it as part of an MD PhD program. And, and I think they were looking at these things as more what people may acquire post their training. And I would just like to make a couple of points. So the first thing is that, and I realize that this comes from a place of privilege, but nonetheless I'm a big believer in like you should pursue the things that interest you and you should pursue them in a way that you find fulfills you. So if you like the idea of getting additional education because the business of medicine excites you and really stimulates you, or getting a Master's of Science or an MPH to support your idea of what will be fulfilling from a research career standpoint excites and fulfills, then by all means you should pursue that. For the love of the game is the number one reason you should be doing these things or the love of acquiring additional skills in an area that you feel called to make a contribution.
I think it's a bad idea to say, well, if you want to go into healthcare administration at a hospital or in a university, you have to get an MBA or you have to do an MHA or you have to get an mph.
Sometimes that may be true, but those are pretty broad brushstrokes. And I think the other important thing that they really don't touch on and that would really want to emphasize is one, I think you do get what you pay for.
And not all these educational programs are created equal. A lot of them are executive MBA programs and they are associated with different, you know, universities and institutions.
Sometimes you are a little bit paying for the brand name, but sometimes that's an important thing and you're getting connections. You're, you're not just getting education, but you're creating connections and you're creating experiences that you then can leverage to achieve them. What you're setting up to achieve at the next level. And there may be certain career avenues where you do need the credential.
That may very well be true.
And you know, for example, if you are looking to compete successfully at like federal funded grants, right.
You're probably not going to be able to do that with just an MD and no other kind of specialized research training, be it from an MPH program or a Master of Science program or PhD program. That's just the reality. Like, it doesn't matter how much conventional experience you may have accrued through whatever it is you're doing. By and large, you're expected to sort of have that credential, to compete in that arena. But. And there may be other places where they want you to have an mba, but also they want you to have an MBA from a certain institution or a certain sector.
I never heard of anyone in, like, executive programs failing out of those programs. Right? So it's kind of like there are a lot of people these days who have MBAs and MPHs and, and even PhDs. There are lots of different ways to get PhDs and people have the credentials and, And I've been in meetings where known entities who have PhD after their name have said things, are talked about, research methodology, and it was just kind of like, wow, you're way off base in terms of what.
So, you know, it doesn't mean that just because you have the education or the credential behind you, you have this, you know, special insider wisdom. And I think that's really especially important. And probably the last thing I'll say on this is I think it also matters where you are in your career when you get these degrees, like somebody who's getting that, you know, you're obviously the chair of a department, it's worked out well for you. But we know other people, we have shared friends who got their MBAs, like, while they were in medical school.
And when, you know, they're eight years removed from that after residency and a research year in residency and they got another degree and then their fellowship, like, how much of their MBA are they really all. You haven't used those skills for almost a decade, right? Maybe you retain some things, but all of these things have an expiration stamp on the skills that you're learning and where you were when you were in medical school, getting an MBA is very different than the experience and knowledge and worldview, wisdom, capital W wisdom that you're bringing to the table. If you got the mba, as we have some shared colleagues who have, well, after your clinical training is done, like, you've already been an Attending, right? And the more proximate you are to the degree in that context, especially in this kind of, you're a clinician and you have the advanced degree, that it's probably worth more where you bring the wisdom, it helps you encapsulate and integrate the things that you're learning than you got the MBA when you were in medical School. It's not just, it just, it just doesn't worth it. It's not just worth it to say, oh yeah, I have an MBA, so I could be the CFO of a hospital because I got an MBA 20 years ago. Yeah, I'm good, you know, so I.
[00:14:28] Speaker B: Completely agree with that as someone who got my MBA in medical school.
And I will say the skills that I learned then are not the skills that I use now. And if I were to do it differently, I potentially want to do my MBA at a later point, you know, and you see some people who go into the chair roles or any roles honestly of leadership and then go get their mba, you're able to tailor your degree a lot more specifically. And you know, my example that I use is I went to Rutgers for medical school, so I went to Rutgers business school. Makes sense. It was all there in one combined program.
And what New Jersey is really known for is their pharmaceutical industry. And they do a great job in pharmaceuticals. They do a lot of supply chain. So I learned a lot about supply chain. I learned a lot about pharmaceuticals. But I'm not doing a lot of that in my current job right now. I understand them, which is great. But if I were to do it over again, potentially I would do one with a more healthcare leadership bent. And this is why they have these other programs, Harvard Business School being one of them. But all these business schools have this where they have, you know, a healthcare forward one or you know, certain parameters that I'm going to be able to look for that'd be more applicable to my current role, for example. So having a degree is not the end all be all right. So I completely agree with that. Timing does matter.
[00:15:36] Speaker A: So it can open certain doors. It can certainly in the right circumstance, the right degree at the right time for the right person can really make a life changing difference. I really am a testament to that with my own experience in my advanced degree after training. But it isn't for everybody and it's not a one size fits all.
[00:15:56] Speaker B: Yeah, totally agree.
[00:15:58] Speaker A: All right, let's get into your headline Trends and impact of pharmacological VTE prophylaxis timing for Traumatic Cervical Spinal Cord Injury across North American Trauma Centers by Issa and colleagues with an infographic 30 days free and a comment. It's the your case sampled Perfecta.
[00:16:18] Speaker B: So we're going back to the more traditional research study right now. What happens after complete traumatic cervical spinal cord injury? This is not a question that comes across my practice often, I have to admit, as a total joint surgeon. But that said, VTE is a commonplace complication in patients with spinal cord injury. Understandable they're not that mobile and does increase their VT EL risk. I didn't know how high it was. There's an 8 fold higher VT EL risk or risk of VT complications compared to other trauma patients who could also be non mobile.
6% for pulmonary embolism, which is pretty high for a complication. We don't see that often and up to 45% for DVTS.
So when should VT EL prophylaxis be initiated? There's always the balance between bleeding complications, especially if a patient undergoes surgery and VTE. So this group of mostly neurosurgeons came together and aim to evaluate two things. One, recent practice trends as they relate to the timing of VT EL prophylaxis at trauma centers across North America between 2013 and in 2020 and estimate number two estimate the risk of VT complications over this time interval as a function of VT prophylactis prophylaxis practice patterns. They use the American College of Surgeons Trauma Quality Improvement Program database and they did it from January 1st, 2013 to December 31st, 2020. They used strobe guidelines, had 900 ACS sites and they had level one to three trauma centers in North America.
Patients who are included with patients who had acute complete traumatic cervical spinal injury, defined as the Asia Grade A patients were excluded if they sustained non survivable injuries, were less than 16 years of age, had known bleeding or anticoagulation disorders, SCI patients who did not undergo spine surgery so they really wanted to focus on spine surgery patients because VT EL prophylaxis is a balance.
Patients who did not receive VT EL prophylaxis or are missing data regarding VT EL prophylaxis timing or those who had started prophylaxis prior to spine surgery were all excluded. What do they look for? They look for time to VT EL prophylaxis following surgery and the occurrence of VT EL complications. How did they define time to VT EL prophylaxis? It was the time in hours from spine surgery to the start of prophylaxis and VT complications were broken down to DVT and PE and they use mixed effects regression models to evaluate the adjusted estimate for each outcome according to the patient, the injury and hospital level covariates. There are 5,325 patients across 463 trauma centers. Understanding this is not a very, very common complication that happens, so being able to pull this data was really nice. The mean age in the cohort was 46.7 with a male predominance of 81%. Race was predominantly white at 62% black, 23%. The mean time to VTE prophylaxis initiation was 90 hours plus or minus 112 hours, which is a huge deviation. And the median time was 65 hours, an interquartile range of 39 to 105 hours. VT prophylaxis started at 114 hours in 2013 and by the time that they went got to 2020, it was down to 82 hours. So it was about a 20, 28% relative decrease. The annual trend of VTE prophylaxis initiation after surgery decreased by 5.2 hours per year over the eight year study interval. So they just kept reducing it over time. And it was associated with an annual reduction of 6.2% in the odds of VT EL complication occurrence. And the decrease in VT EL was from 13% in 2013 to 9% in 2020. Interestingly, those patients who were treated in university teaching hospitals and those with a higher Glasgow Coma Scale score were more likely to receive earlier VT EL prophylaxis. The multivariable mixed models, mixed effect regression models showed a significant reduction in time to VT prophylaxis and VT complications over the study period, especially even after adjustment. And they did a sensitivity analysis that showed the same thing. So it's interesting, we always say that the balance bleeding risk and we need to balance our VT EL risk, but in this case it really showed that as you reduce the time and note that the time really didn't go down to 24 hours after surgery, even 48 hours after surgery. Right. These are still talking about three to four days after surgery, which is not truly the case for our elective cases. But as you reduce the time to VT E prophylaxis, then you decrease your risk of VT complications. Now, what they didn't include here are things like bleeding complications or return to the OR for hematoma or epidural hemato, things like that. So there are things that we had they didn't add as the flip side, as the downside of starting VT prophylaxis earlier. But just looking at VT as a parameter, that's what they found in their study.
[00:20:59] Speaker A: Yeah, I was having a philosophical conversation with another editor in chief of a journal who was, you know, asking me like he wanted a general philosophy on when, you know, big data studies are worthwhile in these times. And this is probably where some type of multicenter big data study from an epidemiologic Standpoint really makes sense, you know, nothing, nothing more to say really. You know, some interesting findings and a good news story across the board, I think.
All right, we haven't put anything on hold yet.
[00:21:33] Speaker B: Not yet.
[00:21:34] Speaker A: We'll see if this will be the first case going on hold for 2026.
Betamethasone and triamcinolone acetonide have comparable efficacy as single intraarticular injections in knee osteoarthritis. A double blind randomized control trial by Watana Sirim Sambat and colleagues. 30 days free with an infographic and this is the lead article for this issue of jbjs.
This is a randomized controlled trial that involved 120 patients with symptomatic knee osteoarthritis randomized to receive either betamethasone or triamcinolone with an intraarticular injection and they were then filed for six months. Primary outcomes are the visual analog scale pain score at rest and during movement at the six month time point. The study was conducted in Thailand and involved one hundred and twenty individuals.
So the motivational premise behind this is that betamethasone and tramcinolone widely used with different pharmacokinetics.
This has to do particularly with duration of action.
They don't talk about it really until the end of the discussion. But I'll say up front that triamcinolone is cheaper or at least in the formulation that they're using.
So they're using for the betamethasone, this diprospan 1 which combines 2 milligrams of betamethasone, disodium phosphate, water soluble, rapid absorption, quick effect, and then there's 5 milligrams of betamethasone dipropionate. You were just talking about your MBA and the Pharmaco heavy. This is perfect for you.
[00:23:20] Speaker B: I feel like I'm at home now.
[00:23:23] Speaker A: So the beta methicone dipropionate is less water soluble, slow absorption, rapid onset and sustained anti inflammatory effects. So they're saying this may provide more effective pain reduction than the triamcinolone.
And they are also maintaining that research comparing at least this formulation, the diprospan type of betamethasone to triamcinolone, has not previously been performed. The actual approach follows all the best practices in the randomized trial. If you're interested in, you know, having a practical primer on all the points that you should touch on when writing up an rct, I think they do a nice job of doing this in an accessible way. The participants were randomized into two equal groups. One received the diaper span betamethasone formulation. The other got the triamcinolone at a 40 milligram.
And they say that since betamethasone is about five times more potent than the triamstinolone, they had to make the 7 milligrams of diaperspan and equivalent to the triamestinolone, which is why they injected 40 milligrams. They followed these patients through to the six month time point. Ultimately they found no significant differences observed between the betamethasone and tramcinolone preparations with respect to VAs pain functional score or performance based outcomes at 6 months. So it's a negative study. They did find equivalence and no significant differences really on any front.
They have like a little kind of trying to get a foot in the door for the betamethasone folks, which is that it improved active knee flexion by 4 degrees from baseline to six months. That was statistically significantly different.
And they said that this equals or exceeds the point estimates for the minimal clinically important change for knee flexion, but does not reach the minimally clinically important difference for knee flexion.
Those seem like distinctions without a difference to me. I will tell you, but this isn't my field of course and emphasizing it's not clinically important.
So all pretty clean up until that front. And then they say transinolone is economical, more available and with similar efficacy.
It seems like they think that trimecinolone is the better option. And then they say however more studies needed. It's just like what?
[00:25:52] Speaker B: Always more studies need to be done?
[00:25:54] Speaker A: No, no, no. Always not more studies needed. I mean I can't think of a more. They thought they checked all the boxes in terms of the approach. They did everything absolutely correct and they have the sample size powered for more studies are not needed. Now they might be talking specifically about cost effectiveness and they didn't talk about the cost here at all. But the sense that I get is that the diaper span is more expensive than the triamcinolone. So I don't even understand how a cost effectiveness analysis really features like yes, you didn't do a cost effectiveness analysis, but you probably don't need to either.
[00:26:27] Speaker B: No, I don't think that adds a lot to it. In all honesty.
I don't think people are choosing one fifth the other versus on like if you talk about hyaluronic acid versus a corticosteroid injection, there is some cost effectiveness or cost differences I think that play into that, but this is much less. So in that case I would say.
[00:26:44] Speaker A: Say yeah, So I mean everything was good until we got to the more I don't. More studies are not needed. It's. It's very clear like they both perform the same and probably overall across the globe and in any setting that I would surmise is trying to engage in cost consciousness in terms of the delivery of health care. The triumphantalone semester like the better option.
[00:27:11] Speaker B: Sounds like a plan and that's what I use in practice. So I feel pretty justified.
[00:27:15] Speaker A: Practice. We don't. We love nothing more than practice affirming research. Right.
[00:27:20] Speaker B: Perfect. I like it.
[00:27:22] Speaker A: You don't have to worry about whether it's going to illuminate the lamppost is illuminating or you're leaning on it because it's all one and the same.
[00:27:31] Speaker B: Perfect.
I like it when it's. What do they say about research? I like how a drunk uses a lamppost more for support than illumination so supports what I do.
[00:27:42] Speaker A: You brought that up in episode one.
[00:27:44] Speaker B: You are exactly right. And by the way, it's very cool that your dad listened from episode one. I guarantee you my mom has not listened to a single episode of this podcast.
[00:27:55] Speaker A: The next time I see your mom, I'm gonna be like, you need to. Why are you not listening to the podcast?
[00:28:01] Speaker B: You have to listen to one now.
[00:28:02] Speaker A: You have to look, the next ABJS meeting in Napa, your mom would be in Napa. There you go.
[00:28:08] Speaker B: Exactly.
[00:28:09] Speaker A: All right. Honorable mentions. Decreased robot related complications following development and adoption of a standardized safety protocol by Etigunta and colleagues. With a highlight on the COVID visual summary and 30 days free. So this study is talking about robot assisted surgery, which in the spine sense enables more precise instrumentation insertion.
And these authors felt that the introduction of standardized institutional guidelines would reduce complications associated with robotic screw placement. Seems like kind of a self fulfilling prophecy. And lo and behold, they looked at 264 patients in their historical group before and 290 patients after the implementation of the standardized protocol. And they went from a 2.3% robot related complication rate to a 0% complication rate. Now, as we discussed previously, nothing is always and nothing is never. So if you do enough, you're probably gonna run into some complications. But it certainly does seem like a meaningful reduction with comparable number of patients pre and post implementation of the protocol.
So they maintain that this can impact complications. If you can standardize robotic surgery guidelines, and that certainly makes sense to me. And then we have prevention of postoperative coronal imbalance in patients with adolescent idiopathic scoliosis with a major lumbar curve the intraoperative crossbar coronal balancing technique. This is by Kwan and colleagues with a comment this is a sneaky Spine special issue of jbjs. It kind of floated. I didn't even realize that as I was working through all these papers until this last one.
Like, you know what? This is a spine special issue.
[00:29:56] Speaker B: And that's what spine surgeons do. They're super sneaky in their way. It's impressive.
[00:30:01] Speaker A: Making all the dollars, raking in all the money the radar Post operative coronal imbalance is the main focus of this study, which aimed to evaluate the use of an intraoperative crossbar coronal balancing technique as a strategy to minimize the risk of postoperative coronal imbalance in patients with adolescent idiopathic scoliosis and what would be considered a major lumbar curve in the lengthy grade five or six category.
This involved 39 patients in one of those two categories. Kind of a small group wrote clinical retrospective of the author's experience.
Minimum two year follow up using this technique. Only two of the patients in the cohort developed the adverse outcome of postoperative coronal imbalance.
The authors maintain that this intraoperative crossbar coronal balancing technique is effective at minimizing the risk of PCI to the fullest extent possible in patients with adolescent idiopathic scoliosis and associated major lumbar curve we are about out of time for our first episode of 2026 major changes on the horizon. If you like what you heard, please like subscribe, share, get others to listen and enjoy all we have to offer here at your cases on hold. If you didn't like what you heard, we will not only have Dr. Chen hosting the next episode, but there will be another special guest host. So not going to tell you who, but you'll stay tuned and listen in next time for that and see what they have to say.
As always, it's a new year, but no matter what you do, your case is still on hold.
