The Journal of Bone and Joint Surgery. British volumeVol. 87-B, No. 2 AnnotationsFree AccessThe use of outcome scores in surgery of the shoulderP. Harvie, T. C. B. Pollard, R. J. Chennagiri, A. J. CarrP. HarvieSpecialist Registrar in Trauma and OrthopaedicsThe John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK.Search for more papers by this author, T. C. B. PollardClinical Research FellowDepartment of Orthopaedics, Frenchay Hospital, Park Road, Frenchay, Bristol BS16 1LE, UK.Search for more papers by this author, R. J. ChennagiriSpecialist Registrar in Trauma and OrthopaedicsThe John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK.Search for more papers by this author, A. J. CarrNuffield Professor of Orthopaedic SurgeryNuffield Department of Orthopaedic Surgery, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK.Search for more papers by this authorPublished Online:1 Feb 2005https://doi.org/10.1302/0301-620X.87B2.15305AboutSectionsView articleSupplemental MaterialPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail View articleThe pursuit of ‘best practice’, health economic planning, the increasing awareness and expectations of patients, pressure from politicians and the media, and the emergence of league tables for surgeons are some of the reasons why orthopaedic surgeons are encouraged to adopt evidence-based strategies for managing their patients. Levels of evidence have been devised which allow publications to be ranked or given a grade of recommendation.1,2 The highest levels are assigned to well-designed, randomised, controlled trials and systematic reviews of such trials.Lower levels are offered by cohort studies in which patients are compared with a control group treated at the same time and in the same institution. Such studies are ranked higher than randomised trials of poor quality, retrospective cohort studies or case-control studies. Individual case series and poorly designed cohort studies are lower still while the final level is expert opinions without critical appraisal and descriptive studies or reports from expert committees (Table I). Proper studies require good design and the use of validated outcome measures. We have carried out a systematic review of the use of outcome scores and research methods in surgery of the shoulder to establish whether the literature provides suitable evidence on which to establish best practice.Review of the literatureA systematic review was undertaken of all articles relating to the shoulder published in the Journal of Shoulder and Elbow Surgery, the Journal of Bone and Joint Surgery [Br] and the Journal of Bone and Joint Surgery [Am] between January 1992 and December 2002. After manual searching, all papers which documented any form of clinical outcome were included for more detailed review.3–53 Those relating to anatomy, pathology, biomechanics, engineering design or technical aspects which did not involve a clinical outcome were excluded. Each paper chosen was placed into one of 16 broad categories according to its subspecialty. The exact number of patients studied as well as the minimum, maximum and mean periods of follow-up were recorded. A ‘grade of recommendation’ and ‘level of evidence’ were assigned to each paper in accordance with the standards shown in Table I. All criteria used to describe a clinical outcome were recorded, whether in the form of observations such as power or range of movement, or by the use of a recognised scoring system. Each paper was reviewed to ascertain whether a description of the outcome method used and the reasons for its selection were included in the text. In particular, we looked for details of the original group of patients on which any outcome score was based. An outcome score was regarded as appropriate if it was used unmodified for a validated group of patients.ResultsWe reviewed 1106 articles relating to surgery on the shoulder. Of these, 496 were excluded on the basis of non-clinical content. The remaining 610 underwent more detailed review. There were 198 case reports and 379 cohort studies, the latter including 19 RCTs, but no systematic reviews (Table I). The mean sample size was 42 (1 to 1063). The overall mean follow-up was 27 months (1 to 540) with a minimum of 12 (1 to 540) and a maximum of 68 months (1 to 540). A formal outcome was described in 569 (93.3%) articles. Of these, 271 (47.6%) used clinical assessment, 217 (38.1%) an outcome score and 81 (14.2%) both. A total of 44 different outcome scores were encountered, 22 clinician-based (50.0%), 21 patient-based (47.7%) and one clinician- and patient-based (2.3%). Of 439 applications of an outcome score, 266 (60.6%) were clinician-based, 105 (23.9%) patient-based and 68 (15.5%) clinician- and patient-based. Trends in the use of the different types of score are shown in Figure 1. Of 298 articles using outcome scores, 126 (42.3%) described the details of the score within the text, but only eight (2.7%) made clear the reasons for the choice of the particular score.Closer scrutiny of the use of clinical assessment in 352 articles showed a mean of 2.3 observations (1 to 6) per article. Those used were range of movement (208), pain (202), function/activities of daily living (129), power (88), radiological appearance (83), patient satisfaction (67) and stability (47). In the 298 articles using a formal outcome score a mean of 1.5 outcomes (1 to 6) was used per article. Overall, of the 439 applications of an outcome score 282 (64.2%) were regarded as being appropriate (Fig. 2). All formal outcome measures identified during the course of this review are listed.DiscussionThe proposal that clinical outcome in orthopaedic surgery could be analysed systematically so that patients would receive increased benefits from their treatment was first introduced by Codman et al3 in the second decade of the 20th century, and is the basis of his concept of the “End Result”. Unfortunately, his peers did not share his enthusiasm. Codman’s frustration culminated at a meeting on January 6, 1915 in which he ridiculed his colleagues and members of the hospital board, portraying them in a large cartoon as an ostrich burying its head in the sand and choosing to ignore what was happening around it. Codman’s career declined thereafter and he died in relative anonymity. Systematic reviews of randomised, controlled trials offer the maximum levels of evidence upon which clinical decisions can be based. No such reviews were found in the course of this investigation. Although 19 randomised, controlled trials (3.1%) were identified, 538 papers (88.2%) described case series offering low levels of evidence. The undertaking of a randomised, controlled trial for a surgical procedure is costly and time-consuming. Nevertheless, increased use of cohort or case-control studies would considerably improve the level of evidence available.The use of validated outcome scores allows comparisons to be made between studies. If scores are modified or used on inappropriate groups of patients, such comparisons are flawed. The European Society for Surgery of the Shoulder and Elbow and the Japanese Orthopaedic Association have each given guidance on the preferred use of outcome scores. However, such recommendations are not uniformly accepted. Our review has shown that study cohorts are generally small, periods of follow-up short and levels of evidence low. The overall pattern of the application of an outcome score is highly variable and at times inappropriate. We have identified changes made to outcome scores, often without proper testing of the modification and without justification. For example, the Neer rating4 was initially used to assess the outcome of displaced fractures of the proximal humerus, but was modified to assess total shoulder arthroplasty5 and, more recently, repair of the rotator cuff,6 although its formal statistical validation for use with these differing groups has not been undertaken.The score of Constant and Murley7 is widely used, but large variations occur in how it is formulated. Pain is often assessed using separate visual analogue scales, the methods of measuring power vary and, most importantly, the fact that scores should be normalised for age and gender is selectively ignored.8 The application of objective clinical assessment of pain, range of movement, power and stability are acceptable means of measuring outcome. However, the means by which such assessments are measured and documented and the number of such criteria used in studies is variable. Scores may be patient-based such as the Oxford shoulder score,9 clinician-based as the Constant-Murley score or a combination of both as in the modified American Shoulder and Elbow Surgeons form.10 There are condition-specific scores such as the Oxford shoulder instability score11 and non-condition-specific scores such as the simple shoulder test.12 In recent years there has been a proliferation of patient-based outcome scores recognising the benefits of such scores compared with clinician-based assessments. The latter are susceptible to bias and error, and may not represent the view of the patient.13 Patient-based scores are designed for use in clinical trials and are valid for comparing and aggregating cohort studies.14–16 Their use will directly improve levels of evidence. Despite the trend to move away from the application of clinician-based outcome scores, our review has shown that in practice the magnitude of this shift is highly variable. Over the last decade the use of clinician-based scores has remained high. An overall understanding of the initial population upon which scores were first based is lacking. Newer scores such as the shoulder pain and disability index (SPADI)17 were initially based on a cohort of 37 male patients with shoulder pain which was either musculoskeletal, neurogenic or of unknown aetiology. The patient self-reporting section of the modified American Shoulder and Elbow Surgeons assessment form (M-ASES) has undergone validation. However, this was based on only 63 patients, 25 of whom had impingement, but only one had undergone hemiarthroplasty and two had tears of the rotator cuff.18 The use of outcome scores on cohorts for which they have not been validated casts doubt on the validity of the results.ConclusionForty-four different outcome scores were encountered in the course of this review, many being applied inappropriately. There is a trend towards the increased use of validated patient-based scores, but many have not been properly tested for validity, repeatability and sensitivity to change. Scores are not valid when used in a modified form and their use should be discouraged. Levels of evidence were generally low, with 88.2% of level 4, and with only a small number of RCTs. Improvement in the design of the studies and the use of appropriately validated outcome scores would substantially increase the levels of evidence on which to base best practice in surgery of the shoulder.Supplementary materialA table showing the list of outcome scores identified in the course of this review is available with the electronic version of this article, on our website at www.jbjs.org.uk.Table I. Hierarchy of evidence of reviewed papers with sample sizes and minimum, maximum and mean follow-up (range)Follow-up (mths)Grade of recommendationLevel of evidenceStudy designNumberSample sizeMinimumMaximumMeanA1aSystematic review (with homogeneity) of randomised, controlled trials0NANANANA1bIndividual randomised, controlled trials with independent blinding1285 (29 to 245)24 (3 to 120)32 (3 to 120)24 (3 to 120)1c‘All-or-none’ case series162124925B2aSystematic review (with homogeneity) of cohort studies0NANANANA2bIndividual cohort studies and low-quality randomised, controlled trials2573 (6 to 300)24 (1 to 180)66 (1 to 120)36 (1 to 194)2cOutcomes research29184 (8 to 1063)NANANA3aSystematic review of case-control studies0NANANANA3bIndividual case-control studies5154 (29 to 538)30 (5 to 120)32 (12 to 120)37 (9 to 120)C4Case series and poor-quality cohort and case-control studies538131 (1 to 667)22 (1 to 540)68 (1 to 540)27 (1 to 540)D5Expert opinion without explicit critical appraisal0NANANANAFig. 1 Proportion of combined and clinician- and patient-based scores used to assess outcome over the period of study.Fig. 2 Manner of application of frequently encountered outcome scores (CMS, Constant-Murley shoulder score; ASES, American Shoulder and Elbow Surgeons standardised shoulder assessment form; UCLA, University of California Los Angeles shoulder rating scale; Neer, Neer shoulder rating; Rowe, Rowe instability score; SST, simple shoulder test; SF-36, 36-item short-form health survey; HSS, Hospital for Special Surgery shoulder assessment; MSTS, Musculo-skeletal tumour score; DASH, Disabilities of the arm shoulder and hand questionnaire; SPADI, shoulder pain and disability index).We wish to thank Mrs Pat Deeley, Academic Secretary to Professor A. 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No AccessJournal of UrologyAdult Urology1 Oct 2009Guideline for Management of the Clinical T1 Renal Massis accompanied byIncreased Tissue Factor Expression and Poor Nephroblastoma PrognosisPercutaneous Microwave Ablation or Nephrectomy for VX-2 Carcinoma in Rabbit KidneyTemporary Segmental Renal Artery Occlusion Using Reverse Phase Polymer for Bloodless Robotic Partial Nephrectomy Steven C. Campbell, Andrew C. Novick, Arie Belldegrun, Michael L. Blute, George K. Chow, Ithaar H. Derweesh, Martha M. Faraday, Jihad H. Kaouk, Raymond J. Leveillee, Surena F. Matin, Paul Russo, and Robert G. Uzzo Steven C. CampbellSteven C. Campbell Financial interest and/or other relationship with Pfizer, Sanofi Aventis, Novartis, Aventis Pharmaceuticals. More articles by this author , Andrew C. NovickAndrew C. Novick The Panel dedicates this work to Dr. Andrew Novick, who served as Chair of the Panel until his untimely death in 2008. Dr. Novick was well recognized for his contributions to renal surgery, and kidney cancer in particular. More articles by this author , Arie BelldegrunArie Belldegrun Financial interest and/or other relationship with Galil Medical, Wilex, Bayer, Pfizer, ROEI Medical, Amgen, Agensys, Hana Biosciences, Cougar Biotechnology. More articles by this author , Michael L. BluteMichael L. Blute More articles by this author , George K. ChowGeorge K. Chow More articles by this author , Ithaar H. DerweeshIthaar H. Derweesh More articles by this author , Martha M. FaradayMartha M. Faraday More articles by this author , Jihad H. KaoukJihad H. Kaouk Financial interest and/or other relationship with Endocare, Intuitive Surgical. More articles by this author , Raymond J. LeveilleeRaymond J. Leveillee Financial interest and/or other relationship with Pluromed, LMA Urology-Suisee, Boston Scientific, ACMI, Applied Medial, ValleyLab, Ethicon, Intuitive Surgical. More articles by this author , Surena F. MatinSurena F. Matin Financial interest and/or other relationship with Johnson & Johnson Wound Management. More articles by this author , Paul RussoPaul Russo Financial interest and/or other relationship with Wilex AG. More articles by this author , and Robert G. UzzoRobert G. Uzzo Financial interest and/or other relationship with Pfizer, Bayer. More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2009.07.004AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Kidney. In: AJCC Cancer Staging Manual. Edited by . New York: Springer Verlag2002: 323. Google Scholar 2 : Cancer statistics, 2008. CA Cancer J Clin2008; 58: 71. Google Scholar 3 : Global increases in kidney cancer incidence, 1973–1992. Eur J Cancer Prev2002; 11: 171. Google Scholar 4 : Increased incidence of serendipitously discovered renal cell carcinoma. Urology1998; 51: 203. 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F, Kapp M, Arnold S, Gellert L, Hameed O, Clark P, Wile G, Coogan A and Giannico G (2017) Core Needle Biopsy and Fine Needle Aspiration Alone or in Combination: Diagnostic Accuracy and Impact on Management of Renal MassesJournal of Urology, VOL. 197, NO. 6, (1396-1402), Online publication date: 1-Jun-2017.Lenis A, Tan H, Halpern J, Laviana A, Shuch B and Hu J (2016) Ablative Therapies for Early Stage Kidney Cancer and the Evolving Role of the UrologistUrology Practice, VOL. 4, NO. 2, (162-168), Online publication date: 1-Mar-2017.Ito T, Derweesh I, Ginzburg S, Abbosh P, Raheem O, Mirheydar H, Hamilton Z, Chen D, Smaldone M, Greenberg R, Viterbo R, Kutikov A and Uzzo R (2016) Perioperative Outcomes Following Partial Nephrectomy Performed on Patients Remaining on Antiplatelet TherapyJournal of Urology, VOL. 197, NO. 1, (31-36), Online publication date: 1-Jan-2017.Lallas C, Scotland K, Zhang M, Schaeffer D, Calvaresi A, Gomella L, Brown D, Shaw C and Trabulsi E (2016) Clinical Influences 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date: 1-Nov-2016.Larcher A, Capitanio U, Terrone C, Volpe A, De Angelis P, Dehó F, Fossati N, Dell’Oglio P, Antonelli A, Furlan M, Simeone C, Serni S, Carini M, Minervini A, Fiori C, Porpiglia F, Briganti A, Montorsi F and Bertini R (2016) Elective Nephron Sparing Surgery Decreases Other Cause Mortality Relative to Radical Nephrectomy Only in Specific Subgroups of Patients with Renal Cell CarcinomaJournal of Urology, VOL. 196, NO. 4, (1008-1013), Online publication date: 1-Oct-2016.Pierorazio P, Johnson M, Patel H, Sozio S, Sharma R, Iyoha E, Bass E and Allaf M (2016) Management of Renal Masses and Localized Renal Cancer: Systematic Review and Meta-AnalysisJournal of Urology, VOL. 196, NO. 4, (989-999), Online publication date: 1-Oct-2016.Moskowitz D, Chang J, Ziogas A, Anton-Culver H and Clayman R (2016) Treatment for T1a Renal Cancer Substratified by Size: “Less is More”Journal of Urology, VOL. 196, NO. 4, (1000-1007), Online publication date: 1-Oct-2016.Borgmann H, Reiss A, Kurosch M, Filmann N, Frees S, Mager R, Tsaur I and Haferkamp A (2016) R.E.N.A.L. 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Failures for Renal Cell CarcinomaJournal of Urology, VOL. 195, NO. 3, (594-600), Online publication date: 1-Mar-2016.Laguna M (2015) Re: Trifecta and Optimal Perioperative Outcomes of Robotic and Laparoscopic Partial Nephrectomy in Surgical Treatment of Small Renal Masses: A Multi-Institutional StudyJournal of Urology, VOL. 195, NO. 2, (298-298), Online publication date: 1-Feb-2016.Laguna M (2015) Re: Five-Year Analysis of a Multi-Institutional Prospective Clinical Trial of Delayed Intervention and Surveillance for Small Renal Masses: The DISSRM RegistryJournal of Urology, VOL. 195, NO. 2, (297-298), Online publication date: 1-Feb-2016.Tabayoyong W, Abouassaly R, Kiechle J, Cherullo E, Meropol N, Shah N, Dong S, Thompson R, Smaldone M, Zhu H, Ialacci S and Kim S (2015) Variation in Surgical Margin Status by Surgical Approach among Patients Undergoing Partial Nephrectomy for Small Renal MassesJournal of Urology, VOL. 194, NO. 6, (1548-1553), Online publication date: 1-Dec-2015.Chang X, Liu T, Zhang F, Qian C, Ji C, Zhao X, Liu G and Guo H (2015) The Comparison of R.E.N.A.L., PADUA and Centrality Index Score in Predicting Perioperative Outcomes and Complications after Laparoscopic Radio Frequency Ablation of Renal TumorsJournal of Urology, VOL. 194, NO. 4, (897-902), Online publication date: 1-Oct-2015.Danzig M, Ghandour R, Chang P, Wagner A, Pierorazio P, Allaf M and McKiernan J (2015) Active Surveillance is Superior to Radical Nephrectomy and Equivalent to Partial Nephrectomy for Preserving Renal in Patients with Small Renal Masses: Results from the DISSRM RegistryJournal of Urology, VOL. 194, NO. 4, Online publication date: A, S, E, M, G, C, Leveillee R, Cadeddu J and Gahan J (2015) Oncologic of Radio Frequency Ablation for Small Renal Masses: Clear Cell vs of Urology, VOL. 194, NO. 3, Online publication date: A, Woldu S, A, G, Pierorazio P, J, M, G and McKiernan J (2015) Predicting Renal after Nephron Sparing SurgeryJournal of Urology, VOL. 194, NO. 3, Online 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The Journal of Bone and Joint Surgery. British volumeVol. 88-B, No. 2 AnnotationFree AccessThe international rank order of publications in major clinical orthopaedic journals from 2000 to 2004B. H. Bosker, C. C. P. M. VerheyenB. H. BoskerResearch FellowDepartment of Orthopaedic Surgery and Traumatology, Isala Clinics, Weezenlanden Hospital, P. O. Box 10500, 8000 GM Zwolle, The Netherlands.Search for more papers by this author, C. C. P. M. VerheyenConsultant Orthopaedic SurgeonDepartment of Orthopaedic Surgery and Traumatology, Isala Clinics, Weezenlanden Hospital, P. O. Box 10500, 8000 GM Zwolle, The Netherlands.Search for more papers by this authorPublished Online:1 Feb 2006https://doi.org/10.1302/0301-620X.88B2.17018AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail Publications in peer-reviewed journals are the most important determinant by which research is rated and funding awarded. In this study, the publication rate in orthopaedic surgery of individual countries was scored in selected clinical journals in order to identify those which are making the principal contributions to the development of the orthopaedic discipline.A total of 15 major clinical orthopaedic journals was selected. All articles with abstracts were scored for the country of the corresponding author through a bibliometric search in Medline/PubMed over a period of five years (2000 to 2004). The total number of publications, the number adjusted for size of population and the impact factor of the journal were assessed for each country.A total of 13 311 articles were scored, of which 92% were generated by 15 countries with 47.4% by the United States, followed by Japan (8.0%) and the United Kingdom (7.3%). Corrected for population size, eight smaller European countries led this ranking with Sweden, Switzerland and Finland at the top, with the United States in their midst in sixth place. Japan and Finland scored the highest mean impact factor.This observational study demonstrates that the United States is the most productive country in absolute number of publications in the selected clinical orthopaedic journals, and when normalised for population size, the smaller European countries with a high proficiency in English were most successful.Our objective was to identify the countries which generate knowledge and progress in orthopaedic surgery and consider the factors that enabled them to be major contributors.MethodsThe major clinical orthopaedic journals were selected and ranked by the senior author (CCPMV) from the ‘orthopedics’ category of journals established by the Institute for Scientific Information as searched in April 2005.1 He chose to add the American Journal of Sports Medicine to that list. The 15 journals with the highest impact factor were chosen. The Medline/PubMed Journals Database2 was searched for these journals, and all articles with an abstract, as indicated in the ‘limits’ function in PubMed, were selected. The country of the corresponding author was used as the source nation for the article. Countries with fewer than 50 publications during the period tested were excluded. The mean impact factor for the period of review was calculated, as were the totals for each journal and country. For the calculation of publications per million inhabitants, the 2005 national population data were derived from the UN Population Information Network.3 The domestic expenditure on research as a percentage of the gross domestic product was taken as an indicator for the amount of national research funding.ResultsThere was a total of 13 311 articles with abstracts in the 15 chosen journals during the period of the review. All the selected journals were in English, 11 from the United States and four from Europe. The figures for the top 15 journals and countries are shown in Table I, in which the ranking order is determined by impact factor for the journals and by the total number of publications for the countries. The 15 countries listed account for 92% of the total number of articles, the first five countries for 71.9% and the United States by itself for 47.4%. The contribution from the United States was the highest in Orthopedic Clinics of North America (89.5%) and the American volume of the Journal of Bone and Joint Surgery (69.1%). The United Kingdom was responsible for 7.3% of the total scored articles. Its share in the British volume of the Journal of Bone and Joint Surgery was 37.7% of the 974 publications. Of these 367 articles, England had the highest share with 324 (88.2%), followed by Scotland with 38 (10.4%), Northern Ireland with four and Wales with one. Sweden scored 23.6% of the papers in the Acta Orthopedica Scandinavica, now Acta Orthopaedica. Table II ranks the publications per million inhabitants and establishes the position of each country. The data for domestic expenditure on research are listed as a percentage of the gross domestic product and are from 2002 or the last available year.4–6DiscussionThe United States has traditionally led the rankings in the output of publications in each of the 20 fields of science defined by the Institute for Scientific Information, and consequently also in clinical medicine overall.1 It is therefore not surprising that the same country also tops the ranking for total publications in major clinical orthopaedic journals. In similar recent studies of high-ranked journals in other medical specialties, their mean percentage was 37 (24 to 48).7–14When corrected for the size of population, the smaller western European countries (ranks 1 to 5, 7, 8) outrank the others, with the United States in their midst. The sixth place of the United States with clinical orthopaedic papers is substantially higher than their rank of 13 in the comparable list of publications in clinical medicine (1992 to 2002).15Some major western European countries perform rather poorly. France, Italy, Spain and Germany are low in lists normalised for population size in both clinical medicine and orthopaedics, as is Japan. Germany has some fine orthopaedic journals published in the native language such as Zeitschrift für Orthopädie und ihre Grenzgebiete, Der Unfallchirurg and Der Orthopäde with impact factors of approximately 0.50, but not sufficient to qualify for selection in the present study.We chose 15 major clinical orthopaedic journals since a broader selection would include a larger number of articles which will never be cited and therefore lack scientific impact. Narrowing the selection enhances the scientific quality of the selected papers but this disqualifies mainstream contributions. Many important contributions to orthopaedics are in publications which are not specific to orthopaedics and may be ranked higher than any journal in our list.The number of citations in top journals might be a more sensitive marker of scientific impact than the impact factor and the number of publications. However, it is hard to assess, and there is also a potential selection bias. We, therefore, decided to use the mean impact factor as an autonomous indicator of the prestige of a journal. Its limitations are acknowledged when used to compare large series but it has become an influential tool within the scientific world to evaluate research and award funding.16We originally planned to relate the total of clinical orthopaedic publications to the number of orthopaedic surgeons practising in a country, but it was not possible to construct such a list. It could also be argued that the number of scientists working in musculoskeletal research should also be included.The editorial process differs in the selected journals. Peer-reviewed journals such as both the American and British volumes of the Journal of Bone and Joint Surgery and Acta Orthopaedica are treated identically to those such as Clinical Orthopaedics and Related Research and Orthopedic Clinics of North America which have a relatively large number of invited manuscripts.It may be suggested that our findings are merely a reflection of the preference of editorial boards to select manuscripts written in proper English. Apart from the evident factor of size of population, national funding capacity and proficiency in English may also be important factors in the ranking.17The gross domestic expenditure on research as a percentage of gross domestic product was used as a determinant for the national funding capacity. Norway, Denmark, The Netherlands and Austria do well in clinical orthopaedic publications corrected for population size with relatively modest research funding, particularly when contrasted with Israel, Japan, Germany, Taiwan, South Korea and France. This finding contradicts the study from Man et al,17 who stated that publication output in major medical journals is linked to research funding at a national level. Their paper also suggested that proficiency in English may be an important determinant for publication in English-language medical journals. It is remarkable that five European countries where English is not the native language outrank all five where it is. The poor proficiency in English of the Mediterranean countries, as well as Japan, may partly explain their lower scores in publications corrected for population size.We are aware of only one other article that focuses on the ranking of countries with respect to publications in orthopaedic literature (1991 to 2001) which, in particular analysed the share of Japan.18 The selection of journals and articles was different from ours in that the top seven orthopaedic journals from the Institute for Scientific Information list were picked and it was not limited to articles with an abstract on Medline/PubMed. It therefore included editorials, letters to the editor and case reports. It focused on total production only, not taking population size into account.The conclusions from our study cannot be strict or definitive. However, it is obvious that, as in all other fields of science, the United States is the most productive country in terms of absolute number of publications (47.4%) in the selected clinical orthopaedic journals. When corrected for population size, the smaller European countries with a high proficiency in the English language were most successful.Table I. Top 15 countries ranked according to total of publications in clinical orthopedic journals (2000 to 2004)15 countries*IF†meanPublications totalUSJPUKGECASENLCHTRKOAUFRITFIAT* US, United States; JP, Japan; UK, United Kingdom; GE, Germany; CA, Canada; SE, Sweden; NL, Netherlands; CH, Switzerland; TR, Turkey; KO, South Korea; AU, Australia; FR, France; IT, Italy; FI, Finland; AT, Austria† mean impact factor between 2000 and 2004Spine2.20240910493371249714458812357485852255515Am J Sports Med2.1871344342173614241320-42348223J Bone Joint Surg [Am]2.061040719423224551015213199189810Arthroscopy1.5110124721094064211314133164101640520J Bone Joint Surg [Br]1.479747311936755293130351030342913627Eur Spine J1.30537572146803247514223492613127Clin Orthop1.262188140816451818028314514391934271333Knee Surg Sp Tr Arthrosc1.114074221316543413176251283064Orthop Clin North Am1.01257230-1281----7----Acta Orthop Scand1.0048321382247411434111277682410J Arthroplasty0.971019523681272164302020215231114613J Shoulder Elbow Surg0.93435206432925147618212117564J Orthop Trauma0.93541306242331326921141113322J Pediatric Orthop0.756453811933634-4323231916773Foot Ankle Int0.6665138523313413411182810271175Total publications (Ranking)133116315 (1)1070 (2)974 (3)668 (4)548 (5)407 (6)332 (7)307 (8)281 (9)280 (10)279 (11)241 (12)213 (13)179 (14)156 (15)Publ/10E6 inhabitants (Ranking)21.2 (6)8.4 (16)16.2 (11)8.1 (17)17.0 (9)45.0 (1)20.4 (7)41.3 (2)3.8 (21)5.9 (19)13.8 (13)4.0 (20)3.7 (22)34.1 (3)19.0 (8)Table II. Country ranking according to publications, impact factor and research spendingCountryPublications/10E6 (Ranking)Total publications (Ranking)Mean impact factor (Ranking)Research spending (% GDP*) (Ranking)* GDP, gross domestic productSweden45.0 (1)407 (6)1.36 (17)4.27 (2)Switzerland41.3 (2)307 (8)1.35 (18)2.63 (7)Finland34.1 (3)179 (14)1.58 (1)3.40 (3)Norway23.6 (4)109 (20)1.54 (3)1.62 (16)Denmark21.7 (5)118 (18)1.33 (19)2.19 (11)United States21.2 (6)6315 (1)1.44 (9)2.82 (6)Netherlands20.4 (7)332 (7)1.49 (5)1.94 (13)Austria19.0 (8)156 (15)1.39 (13)1.34 (18)Canada17.0 (9)548 (5)1.50 (4)1.85 (15)Israel16.8 (10)113 (19)1.25 (22)4.90 (1)United Kingdom16.2 (11)974 (3)1.41 (11)1.90 (14)Ireland14.5 (12)60 (23)1.24 (23)1.17 (19)Australia13.8 (13)279 (11)1.42 (10)1.53 (17)Greece9.2 (14)102 (21)1.38 (14)0.67 (22)Belgium9.0 (15)94 (22)1.33 (20)1.96 (12)Japan8.4 (16)1070 (2)1.58 (1)3.09 (4)Germany8.1 (17)668 (4)1.40 (12)2.50 (8)Taiwan6.2 (18)142 (16)1.46 (7)2.45 (9)South Korea5.9 (19)280 (10)1.45 (8)2.96 (5)France4.0 (20)241 (12)1.48 (6)2.20 (10)Turkey3.8 (21)281 (9)1.31 (21)0.64 (23)Italy3.7 (22)213 (13)1.38 (15)1.07 (20)Spain2.9 (23)125 (17)1.36 (16)0.96 (21)References1 Institute for Scientific Information. http://www.isinet.com (accessed 17/03/05). 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18 major orthopaedic journals compared for Impact Factor and SCImago4 January 2010 | BMC Musculoskeletal Disorders, Vol. 11, No. 1The 100 classic papers of orthopaedic surgery A BIBLIOMETRIC ANALYSISJ. C. Kelly, R. W. Glynn, D. E. O’Briain, P. Felle, J. P. McCabe1 October 2010 | The Journal of Bone and Joint Surgery. British volume, Vol. 92-B, No. 10Chirurgische Forschung im internationalen Vergleich4 March 2010 | Der Chirurg, Vol. 81, No. 4Letters to the editorThe Bulletin of the Royal College of Surgeons of England, Vol. 89, No. 4Geographic origin of publications in surgical journals31 October 2006 | British Journal of Surgery, Vol. 94, No. 2Trends in modern shoulder surgery: personal observationsJournal of Orthopaedic Science, Vol. 12, No. 1 Vol. 88-B, No. 2 Metrics History Published online 1 February 2006 Published in print 1 February 2006 InformationCopyright © 2006, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download
Background Periprosthetic joint infection (PJI), with all its disastrous consequences, continues to pose a challenge to the orthopaedic community. Practicing orthopaedic surgeons have invested great efforts to implement strategies that may minimize surgical site infection (SSI). While new discoveries in orthopaedic research allow us to answer more questions each year on the basis of high-level evidence, there remain numerous topics—including many important ones—for which the evidence is limited, contradictory, or absent. For these clinical issues, it sometimes is helpful to know whether general consensus on diagnosis or treatment exists among individuals who specialize in these areas. Toward that end, we convened a meeting of an international panel of experts during 2 days (July 31 and August 1, 2013) in Philadelphia, PA, USA. The meeting was the penultimate step of a 10-month-long process to generate a set of best practices for management of PJI through engagement of experts in the field. More than 300 experts from various disciplines including orthopaedic surgery, infectious disease, musculoskeletal pathology, microbiology, anesthesiology, dermatology, nuclear medicine, rheumatology, musculoskeletal radiology, veterinary surgery, and pharmacy, as well as numerous scientists with interest in orthopaedic infections attended. Delegates from 52 countries covering all major regions of the globe participated, representing 160 medical institutions and research centers, having memberships in more than 100 medical societies and boards, and sharing a collective experience of many thousands of cases. The panel undertook this consensus effort to help the global medical community improve the efficacy, lower the complication rates, and move toward adoption of standardized measures and techniques for management of PJI. As mentioned, the lack of evidence for many aspects of clinical practice compels the medical community to seek alternatives for development of best practices. A consensus panel is one such alternative, and the process sought to produce a set of procedures and methods using group judgment on a subject matter for which objective information is lacking [2, 3, 6, 11, 15, 17, 20]. When judgments differ, it is important to understand why, and to develop a process to create, if possible, a common view. The word consensus has origins in the Latin word consentire, which means to give assent or approval or to feel together. A dictionary definition of consensus is “a general agreement” and also, very importantly, “group solidarity or concord of opinion or sentiment” [13]. Consensus, therefore, means general agreement about an idea or opinion among most individuals in a group. Majority support for an idea spans from unanimous support (100% agreement) to a simple majority (greater than 50%). Unanimity has been reported as being difficult to achieve, especially in large groups even when, or possibly because, the consensus process is well run. Unanimity is not always a panacea, as sometimes it may occur as a result of “coercion, fear, undue persuasive power or eloquence, inability to comprehend alternatives, or plain impatience with the process of debate” [8, 14, 18]. Even so, the closer to 50/50 a group is vis-à-vis an issue or opinion, the greater the polarization and conflict around that issue. Usually, consensus is understood as the shared opinion of an overwhelming, or super-, majority of the individuals in a group. A supermajority is a majority substantially greater than a simple majority [8, 9, 14, 18]. Although a specific and widely accepted definition of consensus in exact percentage terms does not exist, one rule of thumb is to define consensus as views shared by more than 75% of a group. A more detailed breakdown may establish three levels of consensus as follows [9, 10]: (1) weak consensus = between 3/5 and 2/3 (60%-66%) of a group agree with a given opinion; (2) consensus = between 2/3 and 3/4 (67%-75%) of the individuals of the group agree; and (3) strong consensus = three or more members of a group agree for each dissenting one (≥ 75% individuals in a group agree on an opinion). Unanimous support, when everyone in a group agrees, is the strongest consensus. A consensus process seeks to generate the consent or agreement of all participants around a specific issue, opinion, or recommendation The consensus process involves a series of steps designed to help individuals in a group deliberate ideas or issues and lead them to agree on a resolution that can be supported by as many individuals in the group as possible, even if the specific resolution is not the preferred one of every individual. As noted, many consensus processes attempt to reach a threshold of 75% agreement or greater, that is, a supermajority of 3:1 or better [8-10]. It is important when one refers to a supermajority to take into consideration abstentions and to differentiate between a simple supermajority (based on individuals of a group who are present and have voted) and an absolute supermajority (based on the total number of voters who are qualified or allowed to vote). For example, if a recommendation wins 80% of the vote but only 30% of the eligible voters actually voted, the recommendation is supported by a relative supermajority, but it does not have the support of an absolute supermajority (actually, far from it; that recommendation garnered only 24% of total possible votes). For purposes of our process, we evaluated consensus using both relative and absolute supermajority rules, and more detail on this will follow below, in the Methods section. A robust consensus process has the following characteristics [5, 8-10, 12, 18], which we sought to incorporate in the process used here: Inclusive: The consensus process involved all relevant stakeholders and included as many different views and perspectives as possible. Comprehensive: An effort was made to present all available relevant data (eg, sharing of literature references and studies) for all participants in the process to be thoroughly informed. Participatory: The consensus process actively and repeatedly solicited the input and engagement of all participants. Egalitarian: Individuals were given equal opportunity to voice their views and those views were given equal weight and efforts were made to mitigate the potential effect of differential status of participants (eg, comments were depersonalized). Credible: Broad and representative participation is key to ensure widespread acceptance of recommendations. Invitation to participants in the process was extended without bias other than selecting individuals with relevant expertise. Collaborative: Participants were encouraged to contribute to a common set of recommendations by adding their thoughts to what other members of the group had suggested. The process offered the means (eg, resources, time, technology) to facilitate a sense of working together and in collaboration. Cooperative: Participants were reminded multiple times that the goal was to reach a set of recommendations that had the support of most of the members of the group rather than the views of specific constituencies or their own. Voting through a consensus process is an alternative to other commonly used decision-making processes such as Robert’s Rules of Order, which are designed to pass resolutions based on a majority vote [16]. This type of decision-making process typically is faster than a consensus process, but its adversarial dynamics often undermine the ability of a group to successfully implement a contentious decision. One major criticism of consensus processes that seeks the input and collaboration of a large number of participants is that it is time-consuming and that the time commitment required of every participant to engage in the process is so substantial that it actually may decrease participation. However, the time invested in creating consensus pays off as implementation of the group’s recommendations tends to be much smoother. The arguments in favor of well-designed and managed consensus processes are that these processes lead to the following benefits [5, 8-10, 12, 18, 19]: (1) better decisions (by including the input of a large number of varied participants, the resulting recommendations will represent more varied and richer views); (2) better implementation (by including views from as many relevant participants as possible and by encouraging as much agreement as possible, the process makes participants more engaged and responsible in implementing the resulting recommendations); and (3) better group relationships (by creating a cooperative, collaborative, inclusive group atmosphere, the process fosters greater group cohesion and interpersonal connections). Methods: The International Consensus Meeting on PJI The consensus process at the International Consensus on Periprosthetic Joint Infection was designed specifically to address as many issues surrounding the management of PJI as possible. The process engaged a large number of individuals from many countries and from various specialties to agree on what is known about PJI (based on available literature) and lead to identification of areas in need of further evidence. The process had three phases: (1) a phase when participants in the process worked remotely and exchanged ideas through a modified Delphi process [1, 7, 12]; (2) a phase when participants worked face-to-face to address and resolve final issues and details and voted on resolutions; and (3) a dissemination and publication phase. The first phase of the process lasted more than 9 months and consisted of identifying the issues and writing position papers or recommendations. This phase was done by conducting a comprehensive review of the available relevant literature. The evidence for current practices, whenever available, then was summarized and presented to the participants. An opportunity was provided to the members to voice their opinion collectively and anonymously. The second phase of the consensus was done in a face-to-face meeting during 2 days in Philadelphia. On the first day of the meeting, delegates of each workgroup convened in individual rooms to discuss their recommendations and disagreements. Once their recommendations were finalized, members of all workgroups convened in a general assembly and shared their recommendations with all the delegates. Importantly, all delegates were likely to have seen the recommendations of other workgroups during the previous months as the recommendations of all workgroups were posted on the social media website that the consensus used for communications, and numerous opinions were exchanged. In the general assembly, further discussions occurred and suggestions were made. The final set of recommendations was loaded onto the electronic audience response system at the end of the first day to be presented the next day for voting by the delegates. The electronic audience response system displays the recommendations on a giant screen one recommendation at a time, pauses for a set amount of time to give the audience a chance to read the recommendation, think about it, and vote by pressing a a “yes”, “no”, or “abstain” button on hand-held units. The following day, all voting delegates were given the opportunity to read the posed questions and recommendations on a large screen and cast their vote. During the day-long meeting, all 207 questions and recommendations were presented and voted on. After the second day of the face-to-face meeting, the final document was assembled and sent to all delegates for their final review during a 2-week period. Numerous communications were exchanged during that period leading to generation of the final document. The third phase will involve dissemination of the produced document to orthopaedic and musculoskeletal infectious disease specialists, and other disciplines. The consensus document and its supplemental material, including this document, are being made available through open access. The consensus document will be posted on the websites of numerous societies, will be published as PubMed cited material, and will be published as an electronic book and a paper book. We also intend to have the document translated into numerous languages. The process by which the PJI consensus was generated is described below (Fig. 1).Fig. 1: A flowchart shows the 14-step consensus processStep 1: Establishing a Steering Committee In September 2012, the idea of conducting an international consensus on the topic of PJI was conceived by two authors of this article (JP, TG). Soon after these discussions, a steering committee consisting of those authors, 17 liaisons, a biostatistician, and a medical editor were assembled. The time line for the entire process was determined and the main objectives were set. At that point, it was intended that the face-to-face meeting of delegates would take place during the annual meeting of the Musculoskeletal Infection Society in August 2013. Step 2: Identification of Issues and the Themes The steering committee then met in person or conducted conference calls on numerous occasions to identify the issues that surround the medical community regarding management of PJI. The issues were organized under the chronologic stages of patient care. Fifteen major areas were identified: (1) mitigation and education on comorbidities, (2) patient preparation, (3) perioperative antibiotics, diagnosis of and treatment and of management of or and of PJI. It was that position papers of the and experience would be one on each as the basis for consensus. Step and of At this point, a of potential experts was The of experts was based on two (1) publication (2) clinical interest in management of PJI. A of such experts was generated and an electronic was to these The consensus group included orthopaedic infectious disease specialists, musculoskeletal and and experts in many other disciplines. The was to this process as open and inclusive as possible a of A total of individuals be of individuals accepted the to in this The experts were given the of the workgroup with issues of interest to For those not a the experts were to a workgroup that with issues to their expertise. The steering committee the participants to as the interest of the participants but also views and countries of to ensure and of ideas and to of consensus process dissenting views to so that can be and as as possible [5, Step of and and The steering committee for each workgroup a and two It was that each workgroup had a from the and also from a different of the for help with writing the position papers and support the an individual was to each The of the was to each by and ability to with writing the position The were responsible for conducting a comprehensive literature review and writing the first of the consensus based on the available literature. We to ideas and comments on a social media website specifically for this and the were responsible for this website for comments from experts and them into the document whenever possible. In worked with conference (JP, who provided and that there were between made in each position Step the After the comprehensive literature the first of the consensus document on of the was the literature review by the position authors and those with the consensus process, an also a literature The generated position papers were intended to the consensus process by as the to in each of the The of the position papers consisted of an of the an of the available a and a of recommendations for In in the available evidence were during this Step the The generated document consisting of position papers was sent to and members of each workgroup for review and In the entire document, consisting of the position was posted on the social media website for review by all Although members used and the for as an of for was that new participants in and all discussions their workgroup members used the for Step of the At this members of workgroups were encouraged to read the posted document and their comments by means a Delphi process [1, 7, to each participant was to on the following (1) there published or that are important and that have not been included in the literature (2) agree with the main of the position (3) agree with the main recommendations of the position to one or more agree with the suggestions for new one or more or there one or more specific around the by this paper that would to or The numerous comments and suggestions that were generated during these months were evaluated and into the document. The consensus position papers many during this period. We sought to engage as many workgroup members as possible, as much as possible, to participant in the position paper recommendations. We also that participants their opinions by detailed when possible, references to the literature. of the workgroup also was encouraged to actively their agreement with the to and as a Step of the Step was of the position we were at toward consensus each of the The experts were given 2 the face-to-face meeting to comments or suggestions had regarding the position Step of the the comments and suggestions generated as a result of further input from the members were into the document 2 the meeting in Philadelphia. The document was loaded onto in for The of the document that would be in the meeting of was to all members in the days of the face-to-face An electronic of the entire document was also on and to the members on their to the members were encouraged to to the Step in the participants had been to the consensus meeting in in if possible. The of this conference were (1) to the consensus on each topic through of issues in a face-to-face meeting and (2) to vote on every recommendation in a using an audience response system that allowed delegates to vote and anonymously. On the the the workgroups were given the opportunity to together in a face-to-face meeting for the first a modified group process the workgroups the document as it and After the meeting, all members together in a general assembly and presented their recommendations as would be voted on the following for by all members was provided at this two the day the voting were designed to disagreements. Step The voting place on the second day of the In line with the of the and electronic voting system was The voting system allowed all participants to allowed every participant one and allowed the vote to be given anonymously. The voting in this was used to the of agreement with each of the recommendations and not to given that there were 207 resolutions and to delegates voting on them at given time, voting was to be a more and of the to which the assembly of delegates or not with each of the recommendations. The voting was in a large the to minimize the and of an voting minimize and on the at the working day was into voting of 2 The voting was by one of us is in the development and implementation of consensus The given to the delegates the vote were the We will vote on what best practices are we on what we not and on what we need to to know more will be voting there will be of of will be allowed a vote not agree with the consensus or recommendation, vote We will the following definition of to weak to to strong 75% or We will have time at the end of the day to on the issues that not consensus. that not reach consensus will be and if voting will be if of a was made. strong consensus is the of the consensus recommendations on which vote was will be The presented below the voting on each consensus The and their and the evidence and literature used to them are provided supplemental are available with the of Step The of the After the meeting in and of the that were the next of the document was sent to all including those who not the meeting in person but had been involved in every step of the The document was to all by one of us and members were encouraged to their comments to so that the The was to ensure that the questions and recommendations that were voted on not that may have the of what had been voted on by the delegates. Step to 2 after the meeting in Philadelphia, the final document was sent to all delegates who were to their agreement and of the document. The majority of the delegates provided their of the final document. A comments were provided and into the document. The final document was at this Step of the Consensus The generated consensus document has been to orthopaedic for publication and The involved know that the will be published in more than one and are being in this publication The document has also been posted on numerous websites of various The document is also being translated to various and will also be published as an and a paper book. It is our to this document to all of and in Participants engaged in the the of the participants exchanged more than participants into the social media website that was made available for this process and of them used the website more than were more than views on the website and 31 were The process was comprehensive as different were and cited all consensus was for a large majority of the recommendations all a relative supermajority strong consensus (≥ was for of the 207 recommendations the only two recommendations below an agreement of the more absolute supermajority strong consensus was for of the 207 recommendations and consensus in of the recommendations. The voting on all 207 consensus were by of agreement” supplemental are available with the of that is, the consensus were by the percentage of agreement of the delegates that actually this consensus there were of 207 consensus with consensus of more than that had an agreement between and two that between and and only two that had of than The voting on all 207 consensus by supplemental are available with the of that is, the consensus were by the number delegates that with the consensus by the total number of delegates that were this more consensus there were of 207 consensus with absolute supermajority of more than that had an agreement of between and that between and and that had of than and The present consensus the best practice for PJI consisting of 207 recommendations organized under More than individuals in a consensus process designed to and participation. delegates from 52 countries representing 160 different medical institutions voted on those 207 recommendations. This and global effort in support for a large number of with of all recommendations a supermajority of The of this consensus process represent a step toward a better of the of techniques and adoption of best practices, a more and to the management of and identifying further clinical research to improve patient care.
In the current age of information overload, how does a physician determine the best source of information for his or her specialty? Given a finite amount of time but an increasing amount of information, what should be the selection criteria for educational input? With thousands of journals available, how is the value or importance of a scientific journal determined? All of these questions lie at the center of a centuries-old issue: Where does one obtain the most original, most significant, and most clinically relevant scientific results? In the mid-1930s, S. C. Bradford realized that the core literature for any given scientific discipline was composed of fewer than 1000 journals.1,2 Of these 1000 journals, only a few have a strong relevance to the given topic, while there are many with a weaker relevance to it. Those with a weak relevance to the given topic, however, usually have a strong relevance to another discipline. Thus, the core scientific literature forms itself around various topics, with individual journals becoming more or less relevant depending on the topic. Bradford found that a small core of essential journals forms the literature basis for all disciplines; furthermore, most of the important papers are published in relatively few journals. More to the point, recent citation analyses have shown that as few as 150 journals account for half of what is cited and one quarter of what is published. A core of 2000 journals now accounts for 85 percent of published articles and 95 percent of cited articles.1 The question remains: how does one determine the value or importance of a scientific journal? One of the primary means is the journal's "impact factor," which is determined by the Institute for Scientific Information. DEFINITIONS Institute for Scientific Information (ISI) A database publishing company that publishes Current Contents and Science Citation Index. The institute's database covers more than 16,000 international journals, books, and proceedings in the sciences, social sciences, and humanities. Its mission is to provide comprehensive coverage of the world's most influential and important research. Science Citation Index (SCI, also called "Journal Citation Report") One of the databases created by the Institute for Scientific Information that focuses exclusively on scientific publications. It provides current and retrospective bibliographic information, abstracts, and cited references from 3700 of the world's leading scholarly science and technical journals, covering more than 100 disciplines. It utilizes rigorous, ongoing selection criteria to maintain a dynamic listing of journals in its database, including editorial content, quality of peer review of journals, timeliness of publication, English language accessibility, international diversity, and sophisticated citation analysis. Impact Factor A measure of the frequency with which the "average article" in a journal has been cited in a particular year. This factor is a ratio between the citations and recent citable published articles, calculated by dividing the number of all current citations of articles published in a journal during the preceding 2 years by the total number of articles published in those 2 years. In short, it is a ratio of citations and recent citable articles published.3 The higher the number, the greater the impact factor; the greater the impact factor, the more "scientifically prestigious" a journal is; the more prestigious a journal, the greater the desire on the authors' part to submit papers to that journal for publication. PRACTICAL IMPLICATIONS OF THE SCIENCE CITATION INDEX As implied above, journals with a higher impact factor are considered to be more prestigious than those with lower impact factors. The average article in such journals is cited more frequently than those in "lesser" journals. Because researchers want their results disseminated as often and as broadly as possible, they will want to send their papers to those journals that have the higher impact factors. Publication in journals with higher impact factors is important not just for individual researchers. Tenure and promotion committees, research grant selection committees, committees that document intellectual property, and faculty committees that document academic productivity all take seriously the impact factor. Publishing articles in journals with high impact factors is a hallmark of academic achievement; it correlates highly with the opinion of peers as to a scientist's contribution to his or her field, and is used for promotional and grant reviews.4 Having articles cited completes the chain of publication, which itself underpins the evolution of scientific knowledge. In addition, a researcher can use the impact factor to help select what literature to search for any given subject. A high impact factor for a journal can serve as a selection criterion to help researchers weed out lower-quality journals.5 PLASTIC AND RECONSTRUCTIVE SURGERY'S IMPACT FACTOR The most recent Journal Citation Report was issued on June 22, 2005, and provided the Journal's impact factor for 2004 (the impact factor score always lags behind by 1 year). The 2004 impact factor for this Journal was 1.872, compared with 1.629 for 2003. In 2004, this Journal ranked thirty-third out of 139 surgical journals, compared with fortieth out of 141 surgical journals in 2003. Journal articles were cited 14,107 times in 2004, compared with 12,050 citations in 2003. For comparison, the top surgical journal in 2003 was the Annals of Surgery, with an impact factor of 5.937. Table 1 lists a selection of subspecialty specific journals especially pertinent to plastic and reconstructive surgery.Table 1: Journals Pertinent to Plastic and Reconstructive SurgeryAll of these journals, and others, form the core literature for plastic and reconstructive surgery. Some plastic surgery journals, which are good sources of plastic surgery information, unfortunately are not indexed by the Institute for Scientific Information. Thus, they do not qualify for an impact factor and are not listed in the Citation Index. LIMITATIONS ON THE VALUE OF THE IMPACT FACTOR SCORE Lumping the specialty-specific journals that pertain only to plastic and reconstructive surgery in with all surgical titles, and then assigning them a number (either an impact factor or a ranking within the overall surgical field), is somewhat misleading. Elite journals that cover a broad general field can be highly selective in the articles they publish, because they are not restricted to a specific area within medicine but cover the field as a whole. Hence, it is not surprising that they carry articles of generally high quality and citability.3 Specialty journals, on the other hand, deal with a specific field and are committed to covering a wide range of topics within that particular field. In addition, they are committed to publishing articles of a confirmatory nature that back up original research. This sort of article does not result in press releases and is not featured in national news stories. (Interestingly, an article in the New England Journal of Medicine found that coverage of medical research in the popular media amplified the effects of that research on the scientific community. Articles in New England Journal of Medicine that were covered by The New York Times received a disproportionate number of scientific citations in each of the 10 years after the New England Journal of Medicine articles appeared.6) Another area of potential skewing of the impact factor comes into play with foreign language publications. Much high-quality scientific literature published in foreign languages is not included in the English-language databases. Studies conducted regarding articles published in French,7 Spanish,8 and German9 all found the impact factor to underestimate the value and importance of such foreign language research. For a number of reasons, articles in specialty journals can vary in quality and immediacy more than those in general journals. For this reason, it is inappropriate to compare such specialty journals with the general and review journals. The overall quality and strength of a scientific journal can, and should, be calculated based on a number of metrics, not just the journal's impact factor. Other objective metrics include the journal's circulation, both to relevant society members (if the journal is a society journal) and to nonsociety or nonspecialty members. The online presence and availability of a journal's content, especially on globally disseminated databases such as Ovid, serve as an important index of a journal's position in the literature. Advertisement sales are often an important measurement of a journal's importance and strength. The number of pages published in a year can serve as an indication of a journal's strength and importance in the field, as can the international diversity of the authors who submit and publish in a journal. All of these components, in addition to the impact factor, help form an overall picture of a publication's strength. Fortunately, in all of these categories, Plastic and Reconstructive Surgery remains the leader in the field of plastic and reconstructive surgery. THE PHILOSOPHICAL ISSUE AND PLASTIC AND RECONSTRUCTIVE SURGERY We return then to the real issue that underlies the impact factor: what are the best sources of clinically and scientifically important plastic and reconstructive surgical literature? The importance of reading journal articles for clinical care is evident. The increasing number of journals from which important and relevant articles are found, combined with the decreasing number of personal subscriptions, makes it more important than ever for physicians to choose carefully which journals to subscribe to and read.2 This decision should not be based on intuition alone. Plastic and Reconstructive Surgery is dedicated to being the best single source of relevant clinical and scientific information for plastic surgeons worldwide. We are committed to providing the plastic surgery community in particular and the broader medical community in general with better articles based on more stringent and demanding review criteria. Interestingly, since I became Editor-in-Chief and since the entire process of submitting and reviewing manuscripts for publication in the Journal went online via Enkwell, there has been a dramatic increase in manuscript submissions, upward of 50 percent more submissions than the previous year. We are not able to increase either the number of issues published or the number of pages published per year. On the contrary, we are committed to decreasing our number of issues from 14 per year in 2006 to 13 per year in 2007 and 12 per year in 2008. Because the number of issues and pages we publish per year will decrease, we naturally have to dramatically increase our rejection rate to accept only the best of the best articles. This is also what you, the reader, want from the Journal, as indicated in our reader surveys. Readers have indicated that they want more quality and less quantity, more articles with online videos, and evidence-based studies that scientifically document how the practice of plastic surgery can improve and not merely articles that express one expert's opinion. You have also indicated that you want more review articles on special topics related to your clinical practice, as well as basic research that would improve patient care and safety. The Journal will deliver these kinds of studies. We are increasing our article rejection rate and are accepting only the best, most significant and important articles that feature novel information. We are working on improving the timeliness of publication of articles we accept; we are going to dramatically reduce the time from acceptance of an article to the time of publication. This improvement will give Plastic and Reconstructive Surgery articles greater immediacy. Also, we will intensify our cooperative efforts with the American Society of Plastic Surgeons to have more lay-press exposure for articles published in the Journal. Along with this, we will continue our efforts to appeal to a broader subscriber and readership base in related specialties (such as dermatology, oculoplasty, and otolaryngology). Lastly, we are dedicated to make improvements to the delivery of articles via both the online and print modalities. Plastic and Reconstructive Surgery is committed to improving its impact factor score. We believe that the score will increase through our commitment to providing all manuscripts with rigorous, stringent peer review, meeting high standards of excellence, and shortening the time from acceptance to publication. We believe that Plastic and Reconstructive Surgery offers the best articles in the field, and we think that the best guarantee of quality of articles lies not in the Journal's impact factor score but rather in the peer review process we give to all manuscripts. That is why we salute our Editorial Board, Section Editors, and the more than 500 reviewers annually who continue to help make and keep Plastic and Reconstructive Surgery strong and the most consistent and optimal source of information for all of plastic surgery. For the benefit and improvement of plastic surgery worldwide, we continue to encourage authors to send their quality and potentially landmark papers to the Journal.
No AccessJournal of UrologyAdult Urology: Urolithiasis/Endourology1 Jun 2005CHAPTER 1: AUA GUIDELINE ON MANAGEMENT OF STAGHORN CALCULI: DIAGNOSIS AND TREATMENT RECOMMENDATIONS GLENN M. PREMINGER, DEAN G. ASSIMOS, JAMES E. LINGEMAN, STEPHEN Y. NAKADA, MARGARET S. PEARLE, and J. STUART WOLF GLENN M. PREMINGERGLENN M. PREMINGER , DEAN G. ASSIMOSDEAN G. ASSIMOS , JAMES E. LINGEMANJAMES E. LINGEMAN , STEPHEN Y. NAKADASTEPHEN Y. NAKADA , MARGARET S. PEARLEMARGARET S. PEARLE , and J. STUART WOLFJ. STUART WOLF View All Author Informationhttps://doi.org/10.1097/01.ju.0000161171.67806.2aAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Retrospective follow-up of patients with struvite calculi. In: Urolithiasis Clinical and Basic Research. Edited by . New York: Plenum Press1981: 191. Google Scholar 2 : Surgical, bacteriological, and biochemical management of infection stones. JAMA1971; 215: 1470. 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StudyJournal of Urology, VOL. 188, NO. 4, (1195-1200), Online publication date: 1-Oct-2012.Knoll T, Schubert A, Fahlenkamp D, Leusmann D, Wendt-Nordahl G and Schubert G (2018) Urolithiasis Through the Ages: Data on More Than 200,000 Urinary Stone AnalysesJournal of Urology, VOL. 185, NO. 4, (1304-1311), Online publication date: 1-Apr-2011.Duty B, Okhunov Z, Smith A and Okeke Z (2018) The Debate Over Percutaneous Nephrolithotomy Positioning: A Comprehensive ReviewJournal of Urology, VOL. 186, NO. 1, (20-25), Online publication date: 1-Jul-2011.Scales C, Krupski T, Curtis L, Matlaga B, Lotan Y, Pearle M, Saigal C and Preminger G (2018) Practice Variation in the Surgical Management of Urinary LithiasisJournal of Urology, VOL. 186, NO. 1, (146-150), Online publication date: 1-Jul-2011.Korets R, Graversen J, Kates M, Mues A and Gupta M (2018) Post-Percutaneous Nephrolithotomy Systemic Inflammatory Response: A Prospective Analysis of Preoperative Urine, Renal Pelvic Urine and Stone CulturesJournal of Urology, VOL. 186, NO. 5, (1899-1903), Online publication date: 1-Nov-2011.Viprakasit D, Sawyer M, Herrell S and Miller N (2018) Changing Composition of Staghorn CalculiJournal of Urology, VOL. 186, NO. 6, (2285-2290), Online publication date: 1-Dec-2011.Yuruk E, Binbay M, Sari E, Akman T, Altinyay E, Baykal M, Muslumanoglu A and Tefekli A (2018) A Prospective, Randomized Trial of Management for Asymptomatic Lower Pole CalculiJournal of Urology, VOL. 183, NO. 4, (1424-1428), Online publication date: 1-Apr-2010.Krambeck A, Khan N, Jackson M, Lingeman J, McAteer J and Williams J (2018) Inaccurate Reporting of Mineral Composition by Commercial Stone Analysis Laboratories: Implications for Infection and Metabolic StonesJournal of Urology, VOL. 184, NO. 4, (1543-1549), Online publication date: 1-Oct-2010.Kefer J, Turna B, Stein R and Desai M (2018) Safety and Efficacy of Percutaneous Nephrostolithotomy in Patients on Anticoagulant TherapyJournal of Urology, VOL. 181, NO. 1, (144-148), Online publication date: 1-Jan-2009.Yuruk E, Tefekli A, Sari E, Karadag M, Tepeler A, Binbay M and Muslumanoglu A (2018) Does Previous Extracorporeal Shock Wave Lithotripsy Affect the Performance and Outcome of Percutaneous Nephrolithotomy?Journal of Urology, VOL. 181, NO. 2, (663-667), Online publication date: 1-Feb-2009.Hyams E and Shah O (2018) Percutaneous Nephrostolithotomy Versus Flexible Ureteroscopy/Holmium Laser Lithotripsy: Cost and Outcome AnalysisJournal of Urology, VOL. 182, NO. 3, (1012-1017), Online publication date: 1-Sep-2009.Breda A, Ogunyemi O, Leppert J, Lam J and Schulam P (2018) Flexible Ureteroscopy and Laser Lithotripsy for Single Intrarenal Stones 2 cm or Greater—Is This the New Frontier?Journal of Urology, VOL. 179, NO. 3, (981-984), Online publication date: 1-Mar-2008.Krambeck A, LeRoy A, Patterson D and Gettman M (2018) Long-Term Outcomes of Percutaneous Nephrolithotomy Compared to Shock Wave Lithotripsy and Conservative ManagementJournal of Urology, VOL. 179, NO. 6, (2233-2237), Online publication date: 1-Jun-2008.Mariani A (2018) Combined Electrohydraulic and Holmium:YAG Laser Ureteroscopic Nephrolithotripsy of Large (Greater Than 4 cm) Renal CalculiJournal of Urology, VOL. 177, NO. 1, (168-173), Online publication date: 1-Jan-2007.El-Nahas A, Shokeir A, El-Assmy A, Mohsen T, Shoma A, Eraky I, El-Kenawy M and El-Kappany H (2018) Post-Percutaneous Nephrolithotomy Extensive Hemorrhage: A Study of Risk FactorsJournal of Urology, VOL. 177, NO. 2, (576-579), Online publication date: 1-Feb-2007.Lee R, Passerotti C, Cendron M, Estrada C, Borer J and Peters C (2018) Early Results of Robot Assisted Laparoscopic Lithotomy in AdolescentsJournal of Urology, VOL. 177, NO. 6, (2306-2310), Online publication date: 1-Jun-2007.Neto E, Mitre A, Gomes C, Arap M and Srougi M (2018) Percutaneous Nephrolithotripsy With the Patient in a Modified Supine PositionJournal of Urology, VOL. 178, NO. 1, (165-168), Online publication date: 1-Jul-2007.El-Assmy A, Shokeir A, Mohsen T, El-Tabey N, El-Nahas A, Shoma A, Eraky I, EL-Kenawy M and EL-Kappany H (2018) Renal Access by Urologist or Radiologist for Percutaneous Nephrolithotomy—Is it Still an Issue?Journal of Urology, VOL. 178, NO. 3, (916-920), Online publication date: 1-Sep-2007.Morris D, Wei J, Taub D, Dunn R, Wolf J and Hollenbeck B (2018) Temporal Trends in the Use of Percutaneous NephrolithotomyJournal of Urology, VOL. 175, NO. 5, (1731-1736), Online publication date: 1-May-2006.Morris D, Taub D, Wei J, Dunn R, Wolf J and Hollenbeck B (2018) Regionalization of Percutaneous Nephrolithotomy: Evidence for the Increasing Burden of Care on Tertiary CentersJournal of Urology, VOL. 176, NO. 1, (242-246), Online publication date: 1-Jul-2006. Volume 173Issue 6June 2005Page: 1991-2000 Advertisement Copyright & Permissions© 2005 by American Urological Association, Inc.MetricsAuthor Information GLENN M. PREMINGER Financial interest and/or other relationship with Boston Scientific-Urology, Olympus American, Inc., Mission Pharmacal and Applied Urology. More articles by this author DEAN G. ASSIMOS Financial interest and/or other relationship with Medical Reviews in Urology, Ixion and Boston Scientific. More articles by this author JAMES E. LINGEMAN Financial interest and/or other relationship with Olympus, Lumenis, Thermatrix, Midstate Mobile Lithotripsy, LP, Progressive Thermotherapy, LP, Storz Medical and Boston Scientific. More articles by this author STEPHEN Y. NAKADA Financial interest and/or other relationship with Cook Urology, Applied Medical and Boston Scientific. More articles by this author MARGARET S. PEARLE Financial interest and/or other relationship with Applied Medical, Percutaneous Systems, Inc., Cook Urology and Boston Scientific. More articles by this author J. STUART WOLF More articles by this author Expand All Advertisement PDF downloadLoading ...
The year 2020 began quietly, except for the news of a novel virus outbreak, felt to be a local problem in Wuhan, China. In the United States, economy was booming and the world had great expectations of a wonderful 2020. What followed has stunned the world with a “never seen before,” calamity; the COVID-19 pandemic with over two and a half million individuals infected and nearly 200 000 lives lost so far. The havoc created by this global tragedy has impacted upon many lives in many ways. We need to quickly think and to plan, as to how our professional and personal lives will be conducted in the days, weeks, months, and years ahead. At the moment there is total chaos, in every part of the world, particularly in New York city. The day-to-day life is disrupted; regular patient care of diseases and cancers is in disarray, with the focus of medical care shifted to the management of patients with COVID-19. Surgery is limited to emergencies and cancer cases that cannot be postponed without a negative impact on their outcome. The great majority of hospital beds is occupied by COVID-19 patients, and sudden makeshift hospitals are created to accommodate the surge. Temporary morgues in refrigerated trucks are to be seen at every local hospital in New York city to “house” the over 14 000 patients who have died in the last 4 weeks. What comes next, and when this will end is unknown; our future and the future of the world are frightening in its uncertainty. With a fragile future, how do we conduct our day-to-day activities, and plan to retain our robust education and training programs, to educate and train the next generation of head and neck surgeons? The major onslaught of the first wave of cases and mortality from those exposed to the disease may slow down in the weeks to come, as observed in China, but life is unlikely to return to normal in the foreseeable future. “Business as usual” will not work, since we do not know the impact of the aftermath of this pandemic, the risk of a rebound second cycle of splurge in the number of cases worldwide in the fall and winter, and the potential risk of annual outbreaks from COVID-19. We have great expectations from our scientists that we will find a therapeutic solution for the treatment of COVID-19, and great hopes that a vaccine would be developed in the future to prevent infection. We have to develop strategies to modify, devise, and reshape our current methods of education and training to sustain a robust training program and continue to support our current work force geared to educate and train succeeding generations of students and trainees.1 The drastic changes that have affected our work and life during the past 2 months have taught us that remote communications, education, teaching, learning and training are possible and have to be incorporated in our current systems. Human communication forever has been practiced on a one-to-one basis with the production of sounds/verbal speech and the ability to hear and interpret spoken words. Science and technology permitted the transmission of spoken words to be heard at a distance with the introduction of the megaphone. Advancing technology gave us the radio to hear people from remote distances, and television gave us the capability to see and hear people “live” from remote distances. The internet and development of social media made human communications a “norm” in the current generation. We can now communicate with not one but multiple individuals through multiple platforms and applications. The development of these technologies in remote communication can easily be applied to remote learning. The usual academic activities occupying good part of our working week involves lectures, grand rounds and tumor boards, case conferences, journal clubs, and other similar activities. All of these activities had required physical presence and an assembly of individuals, but we have come to realize that nearly all of these activities can be conducted remotely through the internet. Live video lectures and grand rounds can be easily and effectively delivered through Webex or Zoom conferencing where hundreds of people are able to see/hear the speaker live with the ability to interact with two-way conversations. Case conferences and tumor boards can be conducted quite effectively on these platforms with screen sharing. The need to be “physically present” is not essential for conducting most academic activities. Even after the passing of the current pandemic, such activities may continue to be conducted on such platforms. This would be convenient and effective and can offer such activities to an even larger audience. We can imagine a future where every institution and academic center will have an open “online book,” where every learning activity is available to the world. With easy access to the internet in every part of the world, remote learning has become a way of life in many domains of education and learning. This is vividly demonstrated by a plethora of online courses available from many universities around the world. In the specialty of otolaryngology, general surgery, and head and neck surgery, even operative surgery is possible to be learnt by watching expertly demonstrated surgical procedures performed by leading surgeons and surgical educators on the websites of the American College of Surgeons, the American Academy of Otolaryngology Head and Neck Surgery, the International Federation of Head and Neck Oncologic Societies (IFHNOS), and other similar organizations. Remote learning in all domains of surgical education is feasible and available. Testing and examinations have traditionally required the candidates to report to a designated location, where the examination in paper form is handed to the candidates to be completed in the designated time frame, while a proctor is supervising the candidates. That is no longer necessary. Multiple-choice written examinations can be taken securely online, with defined time limits. Many universities and colleges offer these examinations coordinated and conducted by commercial examination companies such as Exam Soft. Offering such examinations online is less labor intensive, more cost effective, more practical, and may attract a larger number of students from remote locations to participate. Traditionally, oral examinations are conducted “in person,” where the candidate and the examiners meet in private and conduct face-to-face conversation with questions and answers. The purpose of this exercise is to assess the candidates' immediate assessment, judgment, and knowledge. However, with modern technology and two-way private video platforms, such an encounter can be effectively conducted remotely. The IFHNOS has taken a lead on developing the first remote learning online fellowship program in head and neck surgery and oncology, which has been in existence for the past 6 years.2 The Global Online Fellowship (GOLF) program was introduced in 2014. It is a 2-year curriculum with seven written multiple-choice online examinations, a 1 month of observership, and an oral examination (www.ifhnos.net/global). Nearly 400 candidates have registered from 48 countries during the past 6 years, and 244 have graduated. The goal of this program is to improve the knowledge base and judgment of surgeons in their own home environment, without displacing them, within their resources, in their institution or place of practice, and on their own patients. This program has been very successful and is received enthusiastically in all parts of the world. In the past, the oral examinations were conducted on-site in various locations in Australasia, Central Asia, Europe, and Latin America. Beginning this year, IFHNOS plans to conduct the oral examinations online, either using Webex, Zoom, or a similar technological platform. Medical consultations, conversations, and office visits in the private office or in clinics are the mainstay of practice in head and neck surgery, where follow-up visits form a large percentage of our office or clinic volume. With the risk of locoregional failure of up to 40% and the risk of developing multiple primaries approaching 35%, posttreatment follow-up or surveillance has been emphasized through decades. This takes a significant amount of investment of time, effort, and personnel on the part of the clinician, and an expense, in travel and investment of time away from work and home on the part of the patient. In the past, when surgery was the only treatment of mucosal cancers of the head and neck, the follow-up schedule recommended was very laborious. The common practice was once a month the first year, every other month the second year, every 3 months the third year, every 4 months the fourth year, and every 6 months thereafter. After discovery of a second primary or a recurrence patients were put back on the same schedule. In head and neck surgery, the stringent follow-up schedule was designed on the basis that nearly 80% of the patients who were to recur, would have recurred in the first 24 months, with a median time to recurrence of 9 months. However, with the combination of surgery and radiotherapy, the locoregional recurrence rates declined significantly, and the median time to recurrence was also prolonged. Thus, the need to see the patients every month in the first year, or every 2 months in the second year, became less compelling. Many have argued against such intensive physician/patient personal interactions and suggested less stringent follow-up schedules. Multiple trials of close follow-up vs less stringent follow-up for similar-staged patients have been proposed, but rarely accepted or came to fruition (J. Shah and L. Harrison, personal communication, 1996). The absolute benefit of detecting an asymptomatic recurrence or a new primary during routine follow-up examination is questioned, compared to the patient who reports for examination when the earliest symptoms develop suggesting a recurrence. Although, there are no randomized trials to compare this, the probability of a major difference in outcome is unlikely. In addition, only a very small number of patients are found to have recurrence or a new primary which is totally asymptomatic during a routine follow-up examination. Some institutions and practices have transitioned the follow-up care of low-risk patients to “survivorship clinics” run by physician assistants/advanced practice providers or nurse practitioners. This second level of care for low-risk patients will reduce the follow-up volume for the clinician, but will still not do away with the inconvenience of travel, and investment of time and cost of the service, on the part of the patient. It is in this arena that telemedicine will play an important role. Many patients who are at low risk of recurrence can be followed by telemedicine on a video call. During that call, if the caregiver finds the need for a close physical examination, the patient may be asked to see his/her primary care physician, closer to home, and a clinical picture, intraoral photograph or a picture of larynx/pharynx done with a fiberoptic laryngoscope can be sent to the head and neck surgeon. Imaging studies can be read and reviewed online and avoid the need for “physical presence” of patient and surgeon. This practice will require a culture change among head and neck surgeons and their trainees. We will have to train our residents/fellows in developing a work ethic of practicing telemedicine. The current methodology of payment is “procedure” based (current procedural terminology [CPT]). To adequately compensate the specialist for his time, talent, expertise, and opinion, a new methodology or codes will need to be developed from CPT to current expertise terminology. An entirely new payment schedule will be required dependent on the extent and length of consultation; mail review, telephone, video consultation, tumor board involving multiple physicians will all require redefinition. For many institutions, including our own, this already exists for the international patient and has been highlighted by the current COVID outbreak. The events experienced in the past few weeks have put a significant strain on the practice of medicine in general, and head and neck surgery in particular. They have forced us to think and develop strategies for transition of our current practices in patient care, education, and training to innovative solutions and prioritize the levels of patient care. Only recently, numerous guidelines have appeared in all media and means of communications to strategize the optimal use of operating room space and staff. Conduct of safe surgery avoiding exposure to aerosolized viral transmission and prioritizing patients at high risk of an adverse outcome if surgery is not performed have been put into practice. Routine and elective cancer surgery is being postponed. If the pandemic continues for several months, the current fellows in training will not have the volume of the required surgical cases to gain the experience necessary for completing the fellowship. One solution to address this problem is to extend their fellowship by 3 to 6 months. However, this may prove to be impractical due to a variety of reasons. These include commitments made to incoming fellows who will start their training on July 1, additional salary support, housing, and the fellows themselves may have made personal or professional commitments for their respective postfellowship careers. We will need to develop ongoing teleeducation much as is being done with the IFHNOS GOLF program with similarly defined goals and expectations to be met before certification. Another potential solution is to implement regular operative techniques, group discussions with faculty members with video demonstration of surgical techniques highlighting the finer details of operative procedures and the “dos” and “don'ts” in the operative procedure. Experiencing the huge impact of the COVID pandemic on the society and economy of the globe and the severe strain it has put on the health care systems have been a humbling experience. It has brought the realization that all medical and surgical training programs have a component of disaster management. We need a complete reassessment of man power needs. How many surgeons were lost during this pandemic? How many more senior surgeons have elected to take early retirement or were some lost to COVID? What are the manpower needs for increasing remote evaluation? What new technology is needed? Current platforms like Zoom cannot handle the chaos. What are the privacy issues of remote consultation? We have many challenges to face, but with challenge comes opportunity. The challenge created by the COVID-19 pandemic has brought reality to life and humility in our minds and has given us the appreciation of the “luxuries and comforts” in which we practiced, taught, and trained head and neck surgery. I have shared my thoughts for dealing with these difficult times and any such future calamity that may come to keep our education and training programs sustainable by embracing technology and alternative means to teach and train our younger generation. The author appreciates the input from Dr Murray Brennan, Director of the International Center of Memorial Sloan Kettering Cancer Center, in the preparation of this manuscript.
The safety of wide-awake (WA) anesthesia has been documented in multiple studies. An advantage of WA is the ability to do Lean and Green hand surgery. Lean and Green surgery can be performed safely with considerable cost savings, reduced waste, and high patient satisfaction. This study reviews one surgeon's experience combining both WA and Lean and Green surgery principles in an office-based procedure room. This study evaluates patient satisfaction, complications, and cost savings in a group of patients treated with WA anesthesia and a Lean and Green technique. A retrospective chart review of a single surgeon's office-based cases was performed. In total, 437 surgical cases performed over a 12-month period were reviewed. Institutional review board approval was not needed for the chart review. Study items included infections, secondary procedures, patient satisfaction, and cost and trash savings seen with custom (Lean and Green) surgical packs. The overall infection rate was 5% (all superficial infections). All infections were treated with oral antibiotics. There were no deep infections and no secondary procedures. The cost and waste savings using the Lean and Green surgical packs were significant. Using the custom surgical packs, there was a cost savings of $4,650 for the year. The waste savings were significant: 2,211 pounds (lbs) or 1.1 tons. Patient satisfaction was high. In total, 99% rated their surgical experience the same or better than a dental visit. In addition, 99% would recommend to a friend or family member, and 99% would do the office-based surgery again. Office-based WA hand surgery using Lean and Green principles is safe and cost-effective with high patient satisfaction. Office-based hand surgery combined with WA surgical principles and custom Lean and Green surgical packs was safe, cost-effective, and environmentally sound with high patient satisfaction.
Depression, a leading cause of disability, is a known predictor of poorer outcomes in upper-extremity procedures. Associated mood and somatic symptoms may interfere with the assessment of postoperative recovery, making it difficult to distinguish between postoperative-related symptoms and those linked to depression. This study examines the impact of depression on patient-reported outcomes following carpometacarpal (CMC) arthroplasty (trapeziectomy with ligament reconstruction and tendon interposition) for basilar thumb arthritis. We hypothesized that patients with a diagnosis of major depressive disorder or active antidepressant treatment before surgery will have poorer upper-extremity outcomes at 1 year compared with patients without depression. Patients who underwent isolated thumb CMC arthroplasty at a single academic center were screened for inclusion. Baseline demographic data, psychiatric history, and antidepressant use at the time of surgery were collected retrospectively. Patients with concomitant psychiatric diagnoses other than depression, those undergoing multiple procedures at the time of thumb CMC arthroplasty, or individuals with additional chronic upper-extremity pathology were excluded. The Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire was administered before surgery to establish baseline scores and at 3, 6, and 12 months after surgery. Quick Disability of the Arm, Shoulder, and Hand scores were analyzed using an independent samples t test and a linear mixed effects model to adjust for the time from surgery, sex, race, and body mass index at the time of surgery. Seventy-three (22.3%) of 328 patients had a diagnosis of depression or were receiving antidepressant treatment at the time of surgery. Before surgery, the average QuickDASH score was 41.4 for the patients with depression and 40.3 for patients without. At 1 year after surgery, these averages were 28.8 and 24.0, respectively. No significant difference in QuickDASH scores was observed between patients with depression or receiving antidepressant treatment and those without at any time point. This study demonstrates no significant difference in postoperative QuickDASH scores between patients with a diagnosis of depression or antidepressant treatment and those without following thumb CMC arthroplasty. These findings suggest that a history of depression may not adversely affect patient-reported outcomes after thumb CMC arthroplasty. Prognostic IV.
Our purpose was to determine whether the quantity of initial opioid prescriptions combined with routinely collected clinical factors and patient-reported data (PRD) can be used to predict prolonged opioid use after hand surgery and to generate a presurgical prediction model that can be tested for use every day. We performed a retrospective analysis of 12,117 adults who underwent hand surgery at a single, large academic hand center from 2018 to 2022. Opioid prescription data were obtained from electronic medical records, and patients were categorized into high/low initial opioid prescription groups based on quantile regression-adjusted total morphine milligram equivalents (MMEs). Multivariable logistic regression was performed to predict postoperative opioid use at 3 months, incorporating demographic, clinical, and PRD variables, including high versus low initial prescription status from the quantile model. Stepwise logistic regression across 15 imputed data sets generated pooled odds ratios and 95% confidence intervals. Model performance was assessed using receiver operating characteristic and precision-recall curves. Patients receiving adjusted high initial opioid doses had significantly greater odds of continued opioid use 3 months after surgery. Additional predictors included higher Charlson Comorbidity Index, greater preoperative pain, lower preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health scores, opioid/marijuana/medication history, postoperative antibiotic use, minority racial background, and Medicare/Medicaid insurance. Predictive model performance was moderate, with a 3-month precision-recall curve area under the curve of 0.135 in the training set and 0.157 in the test set. Combining adjusted postoperative prescription amount and PRD with routinely captured electronic health record variables yields a predictive algorithm that accurately flags hand surgery patients at risk for prolonged postoperative use. If prospectively validated, embedding this tool into clinical workflows may enable targeted counseling, opioid prescribing guidance, proactive multimodal analgesia, and overall safer, data-driven opioid stewardship. Prognostic IIb.
This study aims to evaluate indicators of continued research involvement and activity among hand fellowship faculty. Specifically, we assess the impact of research publication counts during different stages of medical training and geographic factors on the academic productivity of hand surgeons. A retrospective cross-sectional analysis was conducted using data from all fellowships listed on the American Society for Surgery of the Hand Fellowship Directory from June 2024 to July 2024. Faculty names were collected, and an algorithm was used to automate searches for research publication output across preresidency, residency, fellowship, and postfellowship periods. PubMed and Scopus databases were used to compile publication counts and H-indices. Data were categorized by geographic regions (Northeast, Midwest, South, West) and analyzed using descriptive statistics, Kruskal-Wallis tests, and negative binomial regression to determine the relationship between publication counts during training and total career publications. The analysis included 94 hand fellowship programs and 645 physicians. Major regional differences were observed in publication counts during fellowship, postfellowship, and overall medical careers, with the Midwest showing the highest averages. A negative binomial regression revealed that publication counts during residency and fellowship, as well as the length of the medical career, independently predicted total career publications. Finally, Southern programs had the highest area deprivation index values, whereas Western programs had the highest Hirsch index to area deprivation index ratios, indicating increased productivity regardless of the area's socioeconomic status. Research publication counts during hand surgeon training, particularly during fellowship, serve as key indicators of continued research leadership. Geographic variations suggest regional differences in research productivity and resource availability. These findings underscore the importance of early and sustained research involvement for academic success in hand surgery. Prognostic III.
Social media is the ultimate equalizer. It gives a voice and a platform to anyone willing to engage. —Amy Jo Martin, American author I never thought that social media would have changed my life at all. Certainly, if you had asked me 10 years ago when Facebook and Twitter were still a toddler and infant, respectively, whether social media would change the practice of plastic surgery, I would have “unfriended” you! But, alas, social media have impacted the doctor-patient relationship, the marketing of practices and academic journal articles, and the perception of physicians by society. Much has changed in the social media sphere over the past 13 years. The landscape of social media has changed and evolved dramatically in the past 13 years. In 2003, MySpace dominated the social media market but now is virtually nonexistent. Mark Zuckerberg launched Facebook in 2004 as a closed network connecting students and then alumni from a small group of colleges. This became the disruptive technology that changed the game. It spanned generations, attracting high-schoolers, college students, parents, and even grandparents to social media, proving to be an innovative juggernaut. Then, in 2006, Twitter launched and revolutionized social media with its brevity and ability to disseminate information quickly to the masses. On a personal note, I launched my Twitter account in 2009, but did not become an active, daily user until several years afterward. At first, Twitter appeared superfluous; I thought it was nothing more than a modality for the famous (and some infamous) people to share their opinions 140 characters at a time. Although the social network may include a lot of celebrities, there are a lot of “real” people sharing information and passions on Twitter which, in my book, have truly made Twitter a success. Next came LinkedIn, which served as a platform to display your digital resume and develop an interactive, online Rolodex to open up career paths. Google Plus surfaced in 2011 and endeavored to capitalize on the search engine’s popularity, but never burgeoned into everyday use like other Google products. Finally, newer media such as Pinterest, Snapchat, and Instagram are extremely popular among millennials like my children. Not all new social media survive. For example, Vine, the microvideo social network, was shuttered by the company that bought it: Twitter. Many more social media sites have gone the way of Vine because not all of them have staying power. For each social media platform that makes it, I would guess there are 10 that do not. Most are low-profile; others gather momentum and national attention but are forced out of the sphere anyway. However, the past decade has proven one thing: social media itself are not going away; they have become part of our lives, with good and bad side effects. SOCIAL MEDIA FABRIC Today, social media have become an integral part of the fabric of our lives, our society, and, of course, medicine, including plastic surgery—academically, personally, and professionally. Academic Over the years, through a learning curve, Facebook and Twitter in particular have become a way for us at Plastic and Reconstructive Surgery and PRS Global Open (@PRSJournal on Twitter; @PRSJournal and @PRSGlobalOpen on Facebook) to communicate and reach more readers. We are able to reach expanded networks of plastic surgeons and affiliated specialists, and the public, with the latest science in the field; we have been able to embark on public education campaigns to inform about board-certified plastic surgeons and true, safe, efficacious plastic surgery. Through our social media accounts, in conjunction with the accounts of the American Society of Plastic Surgeons (@ASPSNews and @ASPS_Members), we have launched award-winning communities (#PRSJournalClub) and showcased the great innovations at Plastic and Reconstructive Surgery and PRS Global Open rapidly when articles are published; we can broadcast advances in all of plastic surgery, RealSelf answers, YouTube videos that show and explain procedures and news in lay terms and show that plastic surgeons are “real people” in a good way. I share my own published articles by means of social media, and share other important works I have read—independent of the source—so that those in my networks can all be apprised of the latest science. Personal I use the networks for personal and professional purposes. For example, when I am not with my children, I routinely communicate with them by means of Facebook, Twitter, Instagram and, most recently, Snapchat (my millennial daughter’s personal favorite). I consider contact with patients a personal matter too, but I do keep some boundaries: Just as I give all my patients my personal cell number and e-mail address so they can text me directly with any questions or problems and check in after their procedures, I give my patients the link to my public/professional Facebook page. They can communicate and interact with me on that platform but not in the postoperative time period; I still prefer patients to either call or text me with postoperative questions. In addition, I maintain a personal Facebook page enabling me to connect with family and friends that remains private from my patients—I never share or interact with patients from my private account! The slippery slope begins when patients become friends or friends become patients and then deciding who should gain access to which Facebook account. Many patients also find me on Twitter and interact with me there as well, asking surgical questions or providing reviews. Professional I professionally also use social media as a tool to share my life as a real plastic surgeon and my practice, the Dallas Plastic Surgery Institute, with patients and consumers. I don’t think I’m alone in this: social media may soon supersede plastic surgeons’ professional Web sites as the primary marketing tool for private practices. In my view, professional Facebook pages and public-facing Twitter accounts are the most common ways to market a plastic surgery practice by means of social media. However, more and more, Snapchat and Instagram have become very interesting venues to continue that social media interaction as well. A surgeon can post a photograph, video gallery, or even live, interactive surgery. However, as with most good things, there can be a darker side as well. So, let’s take a closer look at the good, the bad, and the ugly sides of social media as a tool for plastic surgeons to teach the public what we do each and every day. THE UGLY One ugly side effect of social media is that they can pull you into their gravity, and make you feel you need to be connected 24/7. This can actually have a negative effect on your personal life and your practice. You can feel like you are living in a fishbowl with the world watching you and your every move. There is a healthy way to incorporate social media into your life and reap the benefits without compromising your time: it’s all about setting clear boundaries, and achieving balance.1 The major ugliness on social media comes from anonymity-bolstered negativity and occasional abuse. Social media can draw a peculiar set of people who now have a voice to reach you, and affect you—and you cannot control. These trolls or cyberbullies can produce disparaging and false statements about you tantamount to vicious character assassination, mob mentality, and even emotional abuse. One can see the evidence in the recent U.S. presidential campaign, where social media have borne witness to malicious statements from both camps, and even more malevolence from the social media world at large—so much so that The New Yorker called 2016 “The Year of the Political Troll”2; the summer Olympics of 2016 showed ugly—and dangerous—to one of our American gymnasts3; the release of a female-led Hollywood reboot led to truly foul treatment of an actress.4 Often, the best way to handle these situations is to ignore the comments; in short, “don’t feed the trolls.” However, sometimes a response may be necessary—in cases like these, the best path forward is to be measured, evidence-based, and to not take it personally. In plastic surgery, particularly aesthetic surgery, patients who may be dissatisfied can turn to social media to unleash a tirade on their surgeon, challenging operations where millimeters produce profound changes. The challenge is to manage social media—which are essentially an open microphone for anyone to state anything, even utterly false claims—into a productive educational and marketing tool to promote patient safety and good outcomes. Knowledge is power, and having the right knowledge is the key to success in educating the patient. THE BAD Social media have no peer to peer filter. I have seen Snapchat and Instagram posts—and posts on the other social networks as well—advocating techniques and technology as if they were the gold standard, when what is being discussed has not even been written up in a peer-reviewed journal! All that is said goes unchecked and is often presumed to be true; and it is frequently not true. That is a major issue for both consumer awareness and patient safety issues. Some in medicine are mitigating the educational component and resorting to sensationalism to attract viewers. This type of social media can be extremely raw, giving viewers instant, unfiltered access to a vast array of medical information and opinions from various medical professionals (some of whom possess no credibility). This plethora of information truly puts the onus on the consumer to do more homework, more research, and more filtering to find out what information is true and useful versus what is false and potentially harmful. That is why Plastic and Reconstructive Surgery and PRS Global Open strive to promote evidence-based medicine and justify our social media comments with links to scientific studies as frequently as possible. We need to arm the public with the same information we have. That is why board-certified plastic surgeons and the Journal are in this social media arena—to promote scientifically proven methods and techniques by means of peer-reviewed articles after intense peer-review scrutiny. I encourage all plastic surgeons to ask their patients what they have read or heard about the procedure in question on social media, so you can help to set realistic expectations and weed out any misinformation. Furthermore, social media sharing of any patient image on these platforms must adhere to the same stringent patient consent process that we use to publish patient images in Plastic and Reconstructive Surgery and PRS Global Open. I have seen surgeons’ live Snapchat videos of procedures such as rhinoplasty or even vaginoplasty, which can call into question ethical issues and Health Insurance Portability and Accountability Act of 1996 compliance. Any image or video including a patient, whether he or she is identifiable or not, should be approved—in writing—by the patient. If that is not possible, then at the bare minimum, any image that includes identifying imagery must have the patient’s consent to post on social media. Remember: identifying imagery is not just the face or portions thereof. Tattoos, birthmarks, and even specific injuries can be used to identify a patient. It is imperative that any social media sharing that involves patients be done in a tasteful, safe, and ethical manner without compromising patient care and safety; and with consent. THE GOOD Facebook By means of your Facebook page, you can help educate the consumer about all aspects of plastic surgery and medicine. However, it takes time and some sustained effort to get enough followers to get noticed and to truly make a difference. We have found that spending even $5 on Facebook to “boost” a post can truly expand the reach of a given post; however, we are still looking through the data to learn whether that translates to lasting traffic or true conduits back to a practice site or journal article. Facebook Live is a novel tool that can be used to broadcast real-time advice and results. We at Plastic and Reconstructive Surgery are beginning to teach plastic surgery by means of Facebook Live and including, through our new “PRS Journal Grand Rounds,” experts from all over the world discussing controversial topics and providing technical pearls. Twitter Twitter is a good platform for engaging a potentially large and diverse audience. Using hashtags is a good way to automatically consolidate topics and themes, especially if a certain hashtag is trending at the time. Some of the most frequent ones I use are #PlasticSurgery, #BreastReconstruction, #Rhinoplasty, #PRSJournalClub, and #ILookLikeASurgeon; of course, each of these has its own special uses. These hashtags are highly interactive and educational tools because they allow everyone talking about the same subject matter to find each other’s information. Recently, I conducted a Twitter poll for 48 hours with almost 500 responses, asking which social media site gave them the most useful medical information. The public’s social media response was Twitter. Obviously, it is clearly biased, because only Twitter users were surveyed, but is an interesting exercise nevertheless demonstrating the interactive component (Fig. 1).Fig. 1.: Final results of the author’s Twitter poll: “Where do you currently get your best medical information using social media?”Snapchat and Instagram Snapchat and Instagram have rapidly evolved in plastic surgery into vast marketing tools. These applications have totally leveled the playing field for mass marketing of plastic surgery and medicine. An individual can make a huge splash with a single Snapchat or Instagram post, gaining social media traction quickly. There is an innate public affection for witnessing surgery, particularly live and interactive, that now some plastic surgeons are using to their advantage by sharing streaming videos from the operating room. If done well, these streaming live feeds can convert followers into patients, epitomizing social media’s outreach as the ultimate marketer. However, there is an inherent challenge for all of us to prevent sensational marketing gimmicks that may lead patient or the consumer to believe or think we can solve all problems with a short video clip on Instagram or Snapchat. Some plastic surgeons have gained thousands (even millions!) of followers and become online stars by means of Snapchat and Instagram with campaigns such as live surgery broadcasts; however, this has been problematic at times by drawing attention to incorrect techniques and non–board-certified practitioners. However, in the hands of ethical, board-certified plastic surgeons, this extended educational and practice-marketing technique can be a positive experience if done in a fair and ethical manner to preserve the dignity and safety of the patient. Campaigns Consumers need to be aware of the differences between board-certified plastic surgeons and noncertified individuals. This is a huge opportunity for members of the largest plastic surgery societies to engage a large number of potential consumers and the public about who and what real board-certified plastic surgeons are, and what they do each day. The challenge is to present great and useful information that patients can use to find a real plastic surgeon, committed to safety and success with long-lasting, effective outcomes. The American Society of Plastic Surgeons has a recurring theme and “Do your Homework” campaign (#DoYourHomework) on social media encouraging patients to educate themselves on procedures and surgeons (Fig. 2). A recent article5 documented the early results of the “#PlasticSurgery” (Fig. 3) hashtag campaign on Twitter as a public education tool for true, board-certified plastic surgery and evidence-based results and research. Campaigns such as this can be used to combat online bullies and misinformation alike; and the upswell of communities following high-profile negative attacks of a few often reaffirm my faith in humanity, and social media.Fig. 2.: Twitter post from the American Society of Plastic Surgeons demonstrating the use of the “#DoYourHomework” hashtag as a public education tool.Fig. 3.: Twitter post from Plastic and Reconstructive Surgery demonstrating the use of #PlasticSurgery as a promotional tool for evidence-based medicine and peer-reviewed science.CONCLUSIONS Of course, social media have become an integral part of our lives. We use them to connect with family and friends; to market to patients; and to learn about novel operations, cutting-edge science, and what is happening in the world. Nevertheless, we must remain in control of how social media affect us, and how we use them. Otherwise, the consequences can be disastrous. Some days, I find myself checking my Twitter and Facebook accounts multiple times, often as much as my e-mails, as they provide a social release and an educational resource. Other days, I don’t even look at social media at all. Although online platforms can initiate introduction to new people, they cannot and will never supplant face-to-face interaction, which I believe is crucial to creating and maintaining long-term friendships and meaningful doctor-patient interaction and education. It is essential to not let social media control your life and engross you, consuming your already limited time. Social media can be a powerful tool; it is up to you—the operator—to remain in control of this tool to maximize the presentation of your practice, your papers, and your profession. What is interesting is the power and the impact of social media … So we must try to use social media in a good way. —Malala Yousafzai, activist for female education; youngest-ever Nobel Prize laureate ACKNOWLEDGMENTS The author would like to thank Anup Patel, M.D., and Aaron Weinstein for assistance editing this Editorial.
Injuries to the triangular fibrocartilage complex (TFCC) are a common cause of ulnar-sided wrist pain in children and adolescents. Although outcomes of surgical treatment have been reported in this population, the indications for surgical treatment and the role of conservative therapy have not been elucidated. This study aimed to determine the results of nonsurgical treatment of suspected TFCC tears in children and adolescents and identify factors associated with conversion to surgical treatment. A retrospective review of pediatric patients treated initially nonoperatively for suspected TFCC tears was performed. Demographic data, injury mechanism, radiographic measurements, hand therapy notes, need for surgery, and patient-reported outcome measures were collected. Based on whether or not surgery was required, patients were divided into 2 groups: conservative only (CO) and conservative to surgery (CS). These groups were compared with respect to patient, injury, and treatment characteristics. Thirty-six total patients were included, of whom 13 were treated successfully with nonsurgical treatment (CO group), and 23 required conversion to surgical treatment (CS group), for an overall success rate of conservative treatment of 36%. Duration of symptoms prior to treatment was significantly shorter for the CO group (median 13 days) than for the CS group (median 73 days). All patients with successful nonsurgical management were treated with an above-elbow cast. Patient-reported outcomes did not differ between the groups at the conclusion of treatment. This study found conservative treatment to be successful in only a third of children and adolescents with a suspected TFCC tear, and only when above-elbow immobilization was used after a relatively short duration of symptoms. For patients with a longer duration of symptoms or persistent symptoms following above-elbow immobilization, surgery can be offered without a trial of further conservative treatment. Therapeutic III.
Localized tenosynovial giant cell tumors (GCTTS), also known as giant cell tumors of tendon sheath, are benign lesions that represent the second most common tumor of the hand. The standard treatment for GCTTS is marginal excision; however, recurrence is common, with rates of 4% to 56% reported in the literature. This study aimed to identify clinical, imaging, and surgical factors associated with recurrence following surgical excision of localized GCTTS. In this retrospective cohort study, following institutional review board approval, we analyzed 74 patients with histologically confirmed localized GCTTS treated at a single academic medical center between 2001 and 2024. The mean follow-up was 7.4 years. All surgeries were performed by fellowship-trained hand surgeons using marginal excision with surgical adjuncts including extensile incisions, loupe magnification, tourniquet control, and secondary survey of the surgical bed. Patients were divided into nonrecurrent (n = 63) and recurrent (n = 11) cohorts. Fifty-five clinical parameters were collected from medical records and patient interviews. Statistical analyses were performed using Fisher exact tests to compare clinical parameters between the nonrecurrent and recurrent cohorts. The overall recurrence rate was 15% with a mean follow-up of 7.4 years. Three statistically significant predictors of recurrence were identified: (1) Bone involvement was present in 100% of recurrent cases versus 47.6% of nonrecurrent cases, representing the strongest predictor. Although bone involvement demonstrated high sensitivity (100%), it had low specificity (52.4%). (2) Neurovascular bundle involvement (63.6% vs 25.4%) and (3) presence of satellite lesions (18.2% vs. 0%) were also identified; however, this last finding is based on only two cases and should be interpreted with caution as a preliminary observation rather than a confirmed predictor. Joint involvement (81.8% vs 58.7%) and flexor tendon involvement (45.5% vs 23.8%) demonstrated trends toward recurrence without reaching statistical significance. Tumor size, duration of symptoms, pseudocapsule integrity, surgeon's experience, and osteoarthritis were not associated with recurrence. The wide confidence intervals reflect the limited precision inherent in the small sample size. Bone involvement and neurovascular bundle involvement are significant predictors of recurrence in localized GCTTS. The exclusive occurrence of satellite lesions in the recurrent group suggests greater vigilance for satellite lesions during surgery; however, the sample is insufficient to establish a definitive predictive relationship. The relatively low recurrence rate (15%) achieved in this series likely reflects the standardized surgical approach with meticulous technique. Notably, the high nonrecurrence rate (73.2%) among patients with bone involvement suggests that aggressive curettage as part of a standardized protocol can substantially mitigate recurrence risk even in these technically challenging cases. Preoperative magnetic resonance imaging is valuable for identifying these high-risk features and guiding surgical planning. Until additional prognostic markers become available, meticulous surgical technique with attention to identified risk factors remains the cornerstone of preventing recurrence in localized tenosynovial giant cell tumors. Patients with these high-risk factors of recurrence should also be counseled about recurrence and followed at least 5 years. Prognostic III.
Spontaneous midsubstance ruptures of the flexor digitorum profundus (FDP) tendon are rare and often overlooked because of their subtle presentation and lack of preceding trauma. These injuries most often involve the little finger. We report two cases of spontaneous midsubstance FDP rupture in otherwise healthy males who presented with loss of active distal interphalangeal and proximal interphalangeal joint flexion and benign examination findings. Magnetic resonance imaging in both cases demonstrated complete midsubstance rupture of the FDP tendon in the palm with an atrophic flexor digitorum superficialis. Each patient underwent primary four-strand core repair with an epitendinous running suture. One required carpal tunnel and Guyon canal release after a five-week delay to surgery. Both patients achieved excellent functional recovery with no pain and near-full range of motion at 5 months after surgery. As demonstrated by these cases, finger flexion deficits without edema or pain should prompt consideration of midsubstance FDP rupture, for which timely direct repair can yield excellent outcomes.
Food insecurity (FI) is recognized as an important social determinant of health (SDH) that may disproportionately affect orthopedic patients. However, there are limited publications evaluating FI within the orthopedic hand population. The objective of this study is to evaluate the incidence of FI among hand clinic patients to identify key SDHs that may inform targeted interventions and improve clinical care for patients with hand pathologies. This prospective cross-sectional study was conducted using patient surveys at outpatient orthopedic hand clinics at an academic institution. Adults ≥18 years with hand or distal upper-extremity pathology were included; excluded were pediatric patients and patients with injuries proximal to the elbow, concomitant nonupper extremity injuries, malignancy, or chronic neuropathy/pain. Surveys included Household Food Security Survey-6 for FI, the Hospital Anxiety and Depression Scale for anxiety and depression, Disabilities of the Arm, Shoulder, and Hand (QuickDASH) for upper-extremity function, and the Risk Analysis Index for frailty. Data collected included demographics, employment, housing status, insurance, zip code, injury characteristics, and secondary outcomes such as infection, reoperation, amputation, and nonunion. Statistical analysis was performed with P < .05 as significant. Of the screened patients, 21% were FI. Those with low or very low food security had higher average scores on the Hospital Anxiety and Depression Scale, QuickDASH score, and Risk Analysis Index compared to those with marginal or high food security. These findings indicate that lower food security status is associated with worse mental health, frailty, and a higher level of disability. This study shows an association between patients experiencing FI and factors known to affect outcomes such as frailty, depression, and anxiety. This is revealed further by a statistically significant difference in QuickDASH scores between food-insecure and food-secure patients. FI is an untapped SDH thar may prove modifiable for an at-risk population. Symptom Prevalence Study IV.
To the Editor, Anatomical Sciences Education: As both an anatomy student and anatomy demonstrator, Anatomical Sciences Education has become my go-to journal to further my knowledge of the latest developments in anatomy education, innovations in pedagogical practice, and indeed perspectives on current affairs in the field. The world is experiencing an ongoing and serious pandemic, and I felt it necessary to comment, from the perspective of a student, on the impact this pandemic has had and is having on students’ anatomical education, and my concerns about the implications it might have on the future of current anatomy students. In the remainder of this letter, I wish to present some of my reflections on this matter. Readers will be aware that the outbreak of the novel coronavirus began in Wuhan, China, in late December 2019 (Zhu et al., 2020), and spread exponentially in our age where increasing urbanization and frequent international travel allow for the uninterrupted transmission of infectious diseases (Alirol et al., 2011). The first reported case in the United States was on 20th January 2020 (Holshue et al., 2020), and the first cases in the United Kingdom was detected on 31st January (Moss et al., 2020). The World Health Organization named the disease caused by this severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as Covid-19 on 11th February (WHO, 2020a), and subsequently labeled it a pandemic on 11th March (WHO, 2020b). On 2nd April, the number of cases reported worldwide crossed 1 million, with 205 countries and territories affected (Worldometer, 2020). As governments struggle to contain the vicious spread of Covid-19, and with over a third of the world’s population currently under some form of lockdown (Kaplan et al., 2020), the effects the virus has had on people’s daily lives is clearly like nothing most people have experienced before. One of the many affected sectors is education (UNESCO, 2020). In the United Kingdom, the majority of universities and medical schools had suspended face-to-face teaching by 17th March 2020 (Staton and Jack, 2020), forcing students to move to online distance learning for the indefinite future. Pandemics are not a new occurrence. Indeed, Galen of Pergamon documented a 20-year smallpox pandemic starting in 166 AD (Mattern, 2011), and more recently the world experienced the 2003 severe acute respiratory syndrome (LeDuc and Barry, 2004) and 2009 H1N1 swine flu pandemics (Collignon, 2011). Although the Covid-19 pandemic is likely to be the first which current anatomy students are affected by, lessons and experiences can be drawn from the previous crises to help us adapt and continue education. For example, web-based learning was already successfully used in the 2003 pandemic to minimize the reduction in education that students received (Patil et al., 2003; Lim et al., 2009), and is once again being used to great effect (Lim, 2020). It is of course entirely possible for students to learn anatomy without a cadaver and solely from textbooks and online resources (McMenamin et al., 2018), and indeed a number of medical schools no longer use cadaver dissection (Patel et al., 2015). However, the disappeared practical teaching at the hands of Covid-19, regardless of whether students normally receive cadaveric teaching or not, will most likely have many lasting impacts on students. In light of the learning environment now being far less than optimal, the loss of face-to-face contact and direct interactions with both peers and teachers may potentially stunt students’ development as anatomists. Despite the advances in technology that allow for online distance learning, acquiring anatomical knowledge in the laboratory, ideally through cadaver dissection, is often still regarded as not only a rite of passage but also the most effective method (Ghosh, 2017). When students lost access to dissection rooms, they lost access not only to cadavers, but also to a range of other optimal learning modalities: prosections, models, pathology specimens, skeletons, and others (Sugand et al., 2010). Previous authors have highlighted that the modern medical curriculum already restricts students’ exposure to anatomy (Warner and Rizzolo, 2006), and indeed this pandemic has further shortened the contact time current students have received. As a result, current anatomy students are being taught anatomy without access to practical-based learning materials, be that cadavers, prosections, or models. Anatomy learning without cadavers is a practice which is generally seen as less favorable, but one which has arguable merits and has been used as standard in many institutions (McLachlan et al., 2004), but when prosections, models, and other learning materials are also removed, learning becomes difficult. Adaptation to online distance learning is no easy task for students or teachers, and simply providing an online atlas is unlikely to provide students with an “appreciation for the fabric of the human body” (Gregory and Cole, 2002). Despite there being a large number of online anatomy software programs available for students to use, they can often be costly. Institutions that can afford to do so should endeavor to give their students access to these during the current situation. However, to account for equality of opportunity between institutions with varying financial freedom, I would implore software companies to consider providing all anatomy students with temporary free access to their programs during the pandemic. Having said this, previous studies have demonstrated that, despite being useful, online programs provide significantly lower rates of self-perceived learning and satisfaction compared to dissection (Mathiowetz et al., 2016). There is also a steep learning curve associated with using these programs for both teachers and students (Doubleday et al., 2011), with many students finding it difficult to manipulate models and focus on structures of interest (Attardi et al., 2016), thus further bringing into question their usefulness in times as challenging as a pandemic. However, studies investigating the efficacy of purposely designed, solely online programs have not yet been done. Indeed, the Covid-19 crisis may serve to inform us on whether such approaches are able to deliver appropriate learning gain. Further, if these online programs were suitably integrated into curriculum design and used to carefully guide students through a learning journey, rather than simply made available as another resource, then perhaps these tools could prove very beneficial. Mixed methods of teaching and learning anatomy in the current crisis are clearly needed. The addition of instructional dissection videos goes part of the way toward normality, where students can essentially watch a prerecorded dissection taking place (Langfield et al., 2018). Indeed, even direction toward appropriate YouTube videos can help students to understand anatomical concepts (Jaffar, 2012). In conjunction with online digital photographs of cadavers, interactive anatomy images, and the provision of self-testing tools (O’Byrne et al., 2008), students may start to feel supported in their online distance learning. The importance of personal online interactions cannot be overlooked however, and attempting to reduce the distance between learners through provision of chat rooms or real-time tutorials is a key element to successful online learning (Stone and Barry, 2019). It would seem that a purposely designed online course which integrates a number of elements into a learning journey would potentially provide a solution to the current pause in face-to-face teaching. Further, a modern ideal for home learning of anatomy would be in the form of virtual reality (VR) resources (Erolin et al., 2019), and although we are not quite yet in the age where this technology is a household staple, there are elements of it which could be adapted to a remote learning environment. Indeed, most smartphones are compatible with Google Cardboard allowing students to experience VR from their own phones, if provided with suitable software (Izard et al., 2017). The implication the pandemic has on summative assessment is a further worry for students. Among the plethora of modalities used to assess anatomy are the written spotter examination (Smith and McManus, 2015) and oral viva (Evans et al., 2014). However, these methods can obviously not be used in the current situation. With a move to online examinations seemingly inevitable for this year’s global cohort of anatomy students, I question their preparedness for this form of assessment and wonder whether students will perform to the standard that they might have if their examinations were in the modality they were planned to be. This being said, studies have demonstrated that students tend to score similarly regardless of whether the examination is practical or online (Inuwa et al., 2012). Although many students already use anatomy flash cards and digitized spotter-like tests in their learning, I would call on institutions to provide students with clear guidance on the adjusted format of their examinations and to provide ample opportunity for no-stakes practice of these new modalities. Indeed, it has been raised by previous authors that traditional spotter examinations are arguably not an effective assessment technique, as they focus almost entirely on testing a students’ ability to recall information (Choudhury et al., 2016). Therefore, perhaps the Covid-19 pandemic presents institutions with an opportunity for innovation in assessment approaches that allow for accurate representation of both a student’s knowledge and understanding of anatomical sciences. Aside from the challenges relating to continuing students’ anatomical education online, the Covid-19 pandemic also raises issues relating to current anatomy students’ futures. Students consider working with cadaveric material a crucial part of their development toward becoming a professional in the field (Smith et al., 2014), be that as a doctor, dentist, or biomedical scientist. Clinically meaningful learning of anatomy is crucial to students’ understanding of the relevance of their knowledge to future practice (Collins, 2008). As such, students’ clinical understanding and appreciation for the relevance of anatomy might well suffer due to the current lack in practical teaching, at the detriment to their future, and so adaptive institutions must ensure that online learning resources do not lose this important clinical relevance (Turney, 2007). As an aspiring surgeon, I am particularly concerned about the reduction in dissection experience that current anatomy students received (Drake et al., 2014). Cadaver dissection is an invaluable opportunity for the development of fine motor skills in a stress-free environment (Krähenbühl et al., 2017), and so I wonder what implications this might have on the future of students in similar positions to myself. Indeed, this worry extends further to the future of surgery in a much wider sense. Poor anatomy teaching at medical school is often cited by students as a reason for not considering a surgical career (Cooper and Gray, 2014), and although the current situation of anatomy teaching is not intentional, it is possible that the quality of teaching that students are now able to receive may be of lower than prior to the pandemic. Whether the pandemic causes a drop in applications to surgical training posts for this year’s students will not be known for many years, but abandoning dissection has proven detrimental to the competency of future surgeons (Memon, 2018). A further compounding factor on this issue is the fact that many students discover their love or natural talent for surgery as an anatomy student—“Gross anatomy […] may also be an unrecognized fork in the road in [students’] pursuit of choosing a medical specialty” (Archibald and Carlson, 2009). Perhaps through this disappeared practical teaching, we are losing the opportunity to discover the next top surgeons of our time, or creating students that had a distinct gap in their anatomical understanding. For those students who wish to become future anatomy teachers, the lack of complete and ongoing exposure to a variety of teaching and learning techniques may well impact on the styles and methods they will later employ as teachers. Without giving them the opportunity to consider best teaching practices from their perspectives as students (Estai and Bunt, 2016), I question whether they will feel suitably prepared to enter the employment market with the confidence that they possess not only the anatomical understanding but also the pedagogical experience to become effective educators of the future. On the other hand, students in this situation might wish to seize the opportunity to expose themselves to a broader range of teaching techniques than they might have otherwise encountered. Many institutions worldwide have now made prerecorded lectures freely available to the general public, and so students could experience other teachers’ styles from around the world. Alternatively, students could experiment with online peer teaching groups, and take turns delivering a short anatomy tutorial to their peers through a video conference with the opportunity to receive feedback on the effectiveness of their teaching style. For those more inclined toward practical work, students could experiment with more artistic techniques, such as body painting, anatomical drawing, clay work, or the use of pipe cleaners in order to see what techniques work for them and which they therefore may wish to trial when teaching (McMenamin, 2008; Lefroy et al., 2011; Kooloos et al., 2014). There are also a number of practical issues to consider as a result of the pandemic. With students no longer allowed to attend face-to-face teaching, the cadavers they were working on may now not be fully utilized, depending on individual institutional set-up. Aside from the many implications this has on students’ learning, as outlined above, it is also a sad situation as it is not what the donors wanted. However, perhaps dissection laboratory staff could utilize these cadavers for making prosection materials, creating image libraries, or using them for specialist short courses, in order to ensure that the donors are used for the highest education benefit which the circumstances allow. An argument could of course be made for allowing students to complete their dissection in the new academic year, and indeed most embalming techniques would allow for the cadavers to still be usable by that time (Brenner, 2014), however this is clearly logistically difficult from both storage space and time commitment perspectives, and so would vary in viability between institutions. Indeed, even if this provision were possible, graduating students would still miss out. It is important to note that missed practical experiences are a disappointment to both students and their teachers, not just the students. What is clear from the contributions regularly published in Anatomical Sciences Education is that the anatomical community is a very creative and adaptive one. Anatomy educators will undoubtedly do their upmost to accommodate students who wish to regain at least part of the cadaveric experience which Covid-19 has caused them to lose, and this is something which students can take comfort in. The immediate future of dissection is called into question also, with the indefinite suspension of the vast majority of body donation schemes to universities and hospitals (HTA, 2020). It is obvious that this will result in a severe shortage of donor bodies for the incoming academic cohorts, which in turn will have significant influence on the modality and quality of teaching which they will receive. With the potential risks associated from coming into contact with people who died from Covid-19 (Finegan et al., 2020), it is unclear when and how body donation schemes will restart. Nevertheless, even when the Human Tissue Authority was introduced in the United Kingdom in 2004 following a national scandal of organ retention without consent (Sheach Leith, 2007), the drop in number of body donors still recovered, so we can only assume that they will do so again after this crisis. This issue does however lead me to question whether this pandemic may leave us with lasting change on how anatomy education and indeed wider university education is carried out (Jones, 2020), just as it is likely to leave us with a realization that many of our social norms are obsolete, like traveling to work at an office (Hern, 2020). Potential educational disruption and uncertainty about students’ futures are no doubt two of the unavoidable by-products of the pandemic we currently live through, but there is also a more fundamental emotional experience which many anatomy students may now be facing. It is not just anatomy which students learn from the body donors. Indeed, students develop personal and professional competencies through interactions with their donor (Weeks et al., 1995), and build a certain special emotional relationship with them over the course of their program. The fact that students learn a whole range of nontraditional discipline-independent skills (NTDIS) through their study of and interaction with anatomy should not be disregarded (Evans and Pawlina, 2015). For students who learn on cadavers, the donor is their first patient, and for those who learn anatomy through modalities, the use of human representations symbolizes the future patient (Evans et al., 2018). Students’ internal and external development of emotional intelligence, situational awareness, and professional behaviors, as well as personal feelings of love and empathy are all catalyzed in the anatomy laboratory through interactions with peers, teachers, technicians, academics, and the donors. It is clear that anatomy curricula teach students much more than just anatomy, and NTDIS are a crucial element of this (Evans and Pawlina, 2015). In these challenging times, it is therefore especially important for students to be aware of their NTDIS sets, and to be adaptable and resilient to their circumstance (Evans et al., 2018). As a result of prematurely leaving the laboratory, I fear many students will be left feeling guilty that they have not yet had the opportunity to say thank you and goodbye to their donor bodies—“a necessary ritual for students” (Boeckers and Boeckers, 2016). Although there will be opportunities for students to pay their respects, these will undoubtedly not occur in the usual manner and so may not serve their full purpose for some students. I therefore wish to end this letter by asking students to spend some time reflecting on their experiences in the anatomy laboratory prior to the Covid-19 pandemic, and to look forward to the time when they will be allowed to return to it.
Trimmed proximal and distal nerve stumps should be morphometrically matching and show evidence of healthy fascicular tissue to potentiate nerve regeneration. We hypothesized that differences exist between nerve trimming instruments, providing guidance for optimal nerve-trimming techniques. Three common surgical instruments were used to trim nerves in three human upper-extremity specimens: a slotted neurotome, a no. 11 surgical blade with a tongue depressor, and super-cut serrated microscissors. Peripheral nerves in flexor tendon zones II and V of the hand were trimmed by surgeons experienced in microsurgery. Microcomputed tomography was used to evaluate the length of damage of the retained nerve stump of trimmed nerves. This damage was measured as the distance from the end of the trimmed nerve to the cross-sectional level with circumferentially intact epineurium and recovered fascicular morphology, which was compared between instruments. The transverse cut end of the nerve was also qualitatively examined using cryoscanning electron microscopy for fascicular distortion and surface roughness. The length of intraneural damage of the proximal and distal nerve stumps was similar between cutting instruments in zone II and in pooled samples (zone II and zone V). In zone V nerve samples, length of intraneural damage was significantly more variable in the scalpel-trimmed samples compared to the neurotome-trimmed and scissor-trimmed samples. Additionally, the cryoscanning electron microscopy images showed that the cut end of nerves trimmed with a scalpel or neurotome had less apparent fascicular distortion and roughness than nerves trimmed with super-cut serrated microscissors. Neurotome-trimmed nerves were the only group that exhibited transverse nerve end surface consistency, smoothness, and less fascicular distortion. We found that use of a surgical blade improves the quality of nerve preparation for repair or reconstruction over the use of super-cut serrated microscissors. Basic Science V.
Preoperative mental health challenges are associated with lower patient-reported outcomes following traumatic hand surgery. However, the association between mental health and recovery following regenerative peripheral nerve interface (RPNI), a surgical treatment option for upper-extremity (UE) neuromas, is not well characterized. This study investigated the outcomes of RPNI for UE neuromas in amputees and nonamputees, and evaluated for associations between preoperative mental health and patient-reported outcomes. We hypothesized that RPNI would improve pain and function, irrespective of baseline mental health or amputation status. A retrospective analysis of point-of-care data was conducted on patients undergoing RPNI for UE neuromas. Patient-reported outcome measures (PROMs) included the numerical 11-point visual analog scale (VAS) for pain, Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Global Mental Health (GMH), and Global Physical Health (GPH). Patients were stratified into tertiles based on preoperative GMH scores, with the bottom third defined as "poor" preoperative mental health. Subgroup evaluations compared outcomes between amputees and nonamputees. Paired t tests analyzed changes in PROMs from before to after surgery. Overall, VAS scores improved from 6.2 to 3.5, PROMIS UE improved from 29.5 to 31.0, and GPH improved from 40.3 to 41.8. Patients with lowest preoperative mental health scores showed greater VAS improvement (-3.3) than upper tertiles (-2.5). The lowest GMH tertile improved in PROMIS UE and GPH, as did the upper two tertiles. Amputees and nonamputees had comparable VAS improvements (-2.6 vs -2.8). Regenerative peripheral nerve interface resulted in clinically and statistically significant improvements in pain reduction (P < .05) with mild improvements in UE function. Patients with lower preoperative mental health scores reported similar or greater pain improvements and similar functional improvements. This suggests that RPNI benefits patients regardless of mental health status. Comparable pain outcomes in amputees and nonamputees support RPNI as a treatment for neuromas. Therapeutic IV.
There is a paucity of information regarding the prevalence of focal chondromalacia with chronic dynamic scapholunate instability (CDSI), and current treatment algorithms do not account for its presence. We aimed to determine the prevalence and distribution of chondromalacia in CDSI. We conducted a retrospective, longitudinal, cohort study of all wrist arthroscopies performed from January 2008 to December 2020. We included wrists with an arthroscopically confirmed primary diagnosis of CDSI. Patients were grouped based on the presence (CDSI+C) or absence (CDSI-C) of focal carpal chondromalacia. All ligament tears were debrided, and focal chondral lesions were treated with chondral shaving to partial carpectomy. We followed the Debride-First-Then-Wait protocol, which incorporates a waiting period for patients to assess if arthroscopic intervention alone is sufficient to return to normal daily activities. The surgeon considers the patient's perceived wellness when determining the need for a subsequent Dynadesis (tendon-to-tendon transfer through the distal scaphoid) or partial fusion. Of 255 wrist arthroscopies, 164 wrists (155 patients) met the inclusion criteria. Focal chondromalacia was arthroscopically identified in 48% of wrists, with a notably higher occurrence in older patients and those with lunotriquetral ligament or triangular fibrocartilage tears. The most frequent sites of chondromalacia were the radial styloid (27%) and the scaphoid body (15%). Dynadeis was performed in 29% of wrists in the CDSI+C cohort and 47% in the CDSI-C cohort. Four percent of CDSI+C wrists necessitated partial wrist fusion. Focal chondromalacia is common in patients with CDSI. The presence of focal lesions alone did not notably decrease the efficacy of arthroscopic treatment as <50% of patients needed a secondary procedure (7.4-year follow-up). The distribution of focal chondromalacia suggests injuries to other wrist ligaments. We recommend using the Debride-First-Then-Wait protocol to aid in selecting a personalized and lower-risk treatment for CDSI. Therapeutic IIb.