Episode Transcript
[00:00:03] Speaker A: Welcome to the Ortho Joe Podcast, a joint production of the Journal of Bone and Joint Surgery and Ortho Evidence.
Join hosts Mohit Bhandari and Mark Swankowski as they discuss current topics and publications in the world of orthopedics and beyond.
[00:00:19] Speaker B: Well, hey, Mark, how are you? Good morning. Welcome to another great episode of Ortho Joe.
[00:00:26] Speaker C: Yeah, I'm good. It's amazing. We've been doing this for I think five years now.
[00:00:30] Speaker B: Gosh.
[00:00:31] Speaker C: Yeah, that's. And there are people still listening, which it just shocks me that we haven't turned everybody off that once tuned into this. But, you know, here we are again and we've both got a cup of Joe. So I'm still sticking with my Boston Journal roots, you know, and there's one.
[00:00:48] Speaker B: Day where I didn't do my Tim Hortons run.
So I have local in house, which is fine, but, you know, I wish I had my cup to, you know, just nice to have. It's against your Dunkin Donuts, you know, a little Canadian versus the U.S. yeah.
[00:01:04] Speaker C: It'S a little bit like the NHL battle cross border, you know, I mean.
[00:01:10] Speaker B: Today is an interesting day. We're going to take a look back at some studies that, you know, for each of us kind of struck, struck a chord with us for a host of reasons. And I believe also that we chose from a shorter list of papers that have generally been very well cited within the Journal of Bone and Joint Surgery. So we had a relative short list of many, many thousands of papers that we looked at. And from that, I'm actually quite curious, you know, what your top one or two papers were. And I suspect that there's many we could have chosen. So this is more just about things that probably resonate with things that are interesting to you, I'm sure, and a few things that are interesting to me. So I'm happy to go first or I'll let you go ahead, Mark. I don't know.
[00:01:56] Speaker C: Well, let me just give Christina Nelson all the credit because when we've done these in years past, she's kindly pulled the list of the most downloaded articles off the website, which is the fodder for this discussion. And thank you, Christina, for doing that. And I'll just kick it off that there was a highly viewed article on post operative weight bearing after ankle fracture fixation, which has been a topic that's been kicked around the last decade or so. There's a large trial out of the Metric Consortium led by Bill Abramski, recently published in many cohort studies that looked at it safe.
And what was, I think unique about this, it was a very well done trial. But they did not exclude any types of ankle injuries. So syndesmosis injuries were included, posterior mallellular fixation was included, et cetera, et cetera. And it turns out that the risk of losing, reduction and failure of fixation is almost nil with early weight bearing instructions to the patient. So I think this particular trial may be one that will finally, I think, answer along with the other previously done research that it is safe and efficacious to allow patients to bear weight with, with some perhaps obvious caveats about patients with Charcot disease that are diabetics, etc. So very, very important and well done trial. And I congratulate the authors. And you know, at the journal we always try to publish the things that are going to change practice. And I think this is one that's, that's done that. So it was fairly recently published.
[00:03:42] Speaker B: Yeah, and I think you're right too, Mark. Like, you know, it's always hard to think about, okay, what's going to actually move the needle. And you know, we've done a lot of work at Mac on the idea what does it mean to be creative and what's it mean to be creative in research and what's a creative idea? And it's got to be novel, but it also has to have a use, it has to have some use case at the end of it. To your point, how do you measure impact? You measure impact, I think on will people change their practice based on these findings? Your assertion is that people will change practice based on these. Or they, at least the evidence is there now to consider changing practice based on this paper. Yeah.
[00:04:14] Speaker C: Yes, absolutely.
[00:04:15] Speaker B: Yeah. So I think that that's really important. And because it's not just a single isolated trial, it's a trial that comes on the, you know, with a massive, you know, history of people exploring this question to various degrees. Whether it's observational studies, smaller trials, and ultimately doing a slightly larger trial that ultimately helps you and consolidates, I think is the way to go. So, yeah, for me it was. It's interesting that sometimes it's these, you know, questions we think about all day. You see them in the clinic, right. And you just, you make your decisions based on that individual. But overall it sounds like it's a, it's a really well designed paper. I, on the other hand, had a very slightly different choice and it had to do with the paper that. And I'll, I'll give you the storyline here. It says JBJS. It was in JBJS in October 15th of the 2025 and it was home call in sleep orthopedic surgeon. So you know, everyone has this perception that, well, you know, if you're at home, it's a little bit better and it's, you know, you can do more call if you're at home than if you're in house, because in house is going to be far more. I don't think, I don't think the argument was that in house is better than being at home. But the question is what's the impact on sleep of being at home? So they, they, they put, I guess there's a whoop straps on that. They kind of measure kind of your, your biorhythms and sleep. So they had 16 orthopedic attending surgeons and 14 surgery residents for a about 13 months where these, where this, where this diagnostic tools. Basically bottom line is they found that as you might expect, on average orthopedic surgeons sleep less than their residents.
Orthopedic surgeons on average, I think the number here was about six hours on average across the whole, on average across the year. And residents were 6.7. So not a huge difference, but you know, six versus seven hours or so basically.
Now when you're on phone call though, residents sleep decreased by 20%. So it was a pretty significant decrease over that period of time, you know, and it really wasn't like any sort of call to action. It was just like, hey, let's just be aware that sleep is really important and that, you know, we're not sleeping as much. I guess my broader question to you is six hours, does that, that's pretty accurate. Is that enough? Is that too much for some? The one thing I will start off with is Time magazine back in, oh gosh, 2023 said there are four things you need to be happy. They have these happiness experts and they said seven hours sleep is what you need. That's what they said. You got to have a hobby, you know, and we just had numerous podcasts. We're talking about people's hobbies. Got to get outside of the house and you got to meet people outside of the house. Those are the kind of four things that led to a general sense of happiness. But focusing on the sleep, is there some magic hours that you think is factual?
[00:07:19] Speaker C: No, I, I, I really don't think there's a mean that every individual needs to work towards. We've all known people that require more sleep and, and people that require less. And it has to do in large measure with many variables like age, physical activity, diet, the use of alcohol, et cetera, et cetera, et cetera. So I think it's a reasonable start with for a discussion, but I don't think it matters to the individual. And my question for the investigators would have been when comparing the attendings to the residents, it would be did they control for age? Because I think there is an argument to be made that as you age, you actually may require more sleep to function well than in your youth. And that certainly is our experience as trainees. Right. I mean on, on average what, what the work environment gives us when we're trainees is less.
And a lot of that has to do with anxiety that somebody's going to call us up with a clinical problem or a surgical problem that we are not sure we can deal with. And then of course, as we age, we get more confidence and experience and that that bit of anxiety dissipates significantly. So, a long answer, but I think it's, it's variable depending on age, stage of career and those other things I discussed.
Right.
[00:08:48] Speaker B: And I think the one thing that you can always add to this is, you know, what is the impact of not, you know, of not getting enough sleep? Because I'm sure if the average is going to be days that were there was much less than days, there's maybe a little bit more against the standard deviation and correlate that over those 13 months as to, well, you know, just mistakes. Right. However you want to quantify mistakes and you know, cognitive, cognitive decline as a result of lack of sleep in that next 24 hour period. So there's some of those things that I think really can get answered and need to be answered. But still it was a, it was a highly referenced paper in the journal for a whole bunch of reasons and I suspect it probably has some political ramifications, but I think people are generally curious. Right. What's happening and, and trying to understand that. So it was a topic of high interest, it seemed this past year.
Yeah.
[00:09:35] Speaker C: The other one I would bring our attention to is highly downloaded and reviewed was the issue of alignment guides in total knee arthroplasty that the gap based versus the overall alignment based of the femur and tibia and no essential difference. And it just comes to mind what the continued number of submissions in regards to the influence of robotics on total knee alignment that we've seen at the journal. Many, many, many articles that have shown that improved alignment with robotics and the whole nationwide push, I would say towards every, every Major hospital and most individual, particularly mid and early career surgeons being trained in robotics. And I just had a knee replaced a year ago by a highly skilled colleague of mine and he didn't use any robotics and man, am I happy I had it done. So I think we're going to continue to see these types of submissions regarding what's the real role of the advanced alignment techniques of robotics versus the other two, gap based and overall alignment based. And I don't know where it's going to come out. It seems to me as a non arthroplasty surgeon that the best argument for the use of robotics is the 5 to 7% of patients that really have bad alignment to start with to get the components in right to create the solution you want. Because you know, most of the evidence we have to date is that it doesn't really provide any short or long term advantage for the patients that are, you know, within that 90% of patients receiving knee arthroplasty. But boy, if you got a really deformed leg, really angulatory deformed leg, it will be really nice to be skilled with the technology. And to me that's the best article. I don't, I don't know what you are probably the best argument. I don't know what you think about that.
[00:11:40] Speaker B: Yeah, I mean I'm guessing I'm speaking clearly as, not as a clinical expert in arthroplasty, but I would say the idea of tools. So how would we look at right alignment tools and we're looking at robotics now but you know, it's going to evolve, it's going to continue to evolve. And I think there's a lot of, I mean every company has basically invested heavily in, in this perception that you know, robotics are going to become the future. And that's going to be really an interesting dynamic, you know, for the years to come.
And I think really what's going to help us a lot is research that really helps us understand the impact beyond the initial alignment, beyond the initial accuracy of putting an implant in what is the longer term impact? And you know, when people say, well, you know, this is, makes the X ray look better or you know, it's a, it's a tangible improvement in how, you know, the implant goes in. But you know, at the end of the day there's no difference between, you know, if it's human based versus a robotic focus.
The truth may be, you know, in other words, robotics may be in fact a great advantage in this area, but it may also be that surgeons are saying, well, you know, the knee is a little bit more forgiving or the hip is more forgiving, for example, and that, you know, the body like the same thing we used to always talk about in trauma, right? How much of a step is actually going to lead to a particular difference. And you would, multiple times we'd say, you know, you know, people can argue about a millimeter here and there for perfection, but the longer term outcomes don't, don't nest. The patient doesn't notice those differences, the extra time and energy. So that I think is going to be the debate, but we're not going to figure it out until we actually get those studies. I think, Mark, that actually revolves around those questions that are longer term outcomes following any of these technologies.
[00:13:22] Speaker C: So you're talking, you're Talking about the 20 year outcomes is what we, well.
[00:13:25] Speaker B: At least, or at least outcomes that give some idea of, you know, what is the impact on patient function, patient important outcomes, whatever that may be.
And you know, I guess you're right in the longer term, revision rates, etc.
That's going to be important. Now that still may not, you know, obvious the need for having other adjunctive technologies. It's just a matter of we got to be honest about the data we're collecting on that. You know, similarly, which was interesting to me some, you know, you wonder why certain papers get that, let's say that weren't published in the last year. But you know, there's a paper on cementless versus cemented total knee arthroplasty, and there was the midterm results of a prospective randomized trial, about 141 patients at 6 years. Basically, they found that there was no difference between cementless and cemented TKA of the same design in terms of survivorship, clinical and radiographic outcomes. Say, okay, fair enough, that's the smallest trial. You don't know if there really is a difference or not. It's midterm outcomes. This was published in June of 2023, but ranked very, very high in 2025 in terms of people being interested in that. I think that also gets to the point of when you have a trial or an important study design, people will continue to to it. And those cycles of interest, as things advance, become really, really important. And that led me to kind of think, well, you know, that's in 2023, what, like, what's the updated, you know, version of that? Is it still the same? Like, like, is that answer the answer? And with AI now it's pretty, pretty easy Mark to be able to go ahead and, you know, do these searches.
You know, this is the, you know, this is the ortho, Joe. So it's the journal and ortho in ortho evidence. And I thought, you know, what we, what I could do is just share with you a little output we got from a chat bot that, you know, that is a, it's, it's looking only at the ortho evidence database of about 14,000 randomized trials. So we're not looking anywhere else. And you know, we kind of look at the data set as the data set because it's randomized trial data. And you know, so I just, I typed it in and if I can just for one second just share with you the output. So for those of you who are listening, I'll be sure to explain what we're seeing here. But you just see here, Mark, hopefully you can see this. I'll just give you the one slide here. But if you look here, you know, you have, we just type it in, you know, should you perform a total knee arthroplasty with or without cement? So kind of a standard question.
Yeah. And it's, it's amazing now how quickly large language, like, you know, if you push out to a large language malls to say, make sense of the papers we give you. So, you know, an OE basically says, okay, we're going to go based on that topic. We're going to search and you see a number of papers on your, on the right hand side, but those are actual papers from numerous journals that come up in about 10 seconds or so.
And it was interesting that the nuance it gave and you know, so this will be for comments. This will be for those who are far more expert than you and I on total knee arthroplasty. But they said, yep, both cemented and cementless total knee arthroplasty provide broadly comparable clinical outcomes and implant survivorship and just make sense to the paper we just read about. But it did give a little caveat. Cementless fixation can be a valid alternative and may offer modest advantages in in pain, range of motion and radiographic findings in younger patients. But choice would then be individualized based on patient practice, implant design, surgical experience. Interesting how quickly you can get a narrative and then he goes into more detailed. But the reason I'm talking about this not so much as about what ortho evidence is doing, but just about just what we're likely to see, Mark, in terms of what's happening in AI and you know, it used to Be that, you know, you would search and then you would look through a bunch of papers as you did. You said you looked at this in Journal Club the other night. That's one of the papers.
Everything's changing. Like, you know, it's at your fingertips. So Journal Club will become much more dynamic in that someone might look at a paper and say, well, you know, let me just see what's going on. And you'll have multiple people doing immediate real time either validation of whatever someone is presenting because it's, because you're going to be able to get insight so quickly. The question is going to be what do you trust? And I think that's going to be the challenge we all face. But I found that particularly interesting for one reason, for a couple reasons. One, it was a randomized trial. So you know, they do have, they do hold the test of time. And number two, a paper published a couple of years ago actually was trending to be one of the top papers read and referenced in 2025, which tells you about, you know, when advances come, how papers within a journal can really being pushed up.
[00:18:08] Speaker C: Yeah, very interesting. Can I just ask, for the sake of our audience, a technical question? So in this summary which you put up after doing the search real time, it said that the uncertain technique may have an advantage in younger patients. Yes. Is that based, is that sentence based on data or could that be based on discussion portions of these randomized controlled published manuscripts?
[00:18:37] Speaker B: Yeah, that's a great point. Because, because, well, I can only speak to what we do at ortho evidence, at Ortho evidence because we don't, you know, we don't send the whole paper to the large language model. We have our own summary. So what we do is we have our own summary extracted which looks at really much the data and then we interpret the data. And so we don't have big discussion sections in our reports. They're meant to be 700 words or less. So that is coming likely, almost invariably from the results of a study.
But you can see that when it says may, it's almost invariably going to be a very modest impact. And you can see there was nothing about functional outcomes. It was all about it looks better, the radiographs look better and you know, it doesn't seem to be any complications early on, things like that, which is actually pretty consistent. Yeah. And that the challenge we face when we do chat GPT, for example, you know, you go, you get a, you know, hallucinated references that don't exist, etc. But here you can actually Click the reference and you can go to the actual report and then you can go from that to the original journal. And if you, if you have access to the journal, you can go ahead, download it. So, like, you've got to find it a way for people to be able to genuinely look at a summary with the references, click the reference and see where they got it from, rather than just hope that AI is telling me the truth. And I think that's going to be where we're going to have to evolve to, and I think the skeptics are going to need that type of information. So we hope to. We hope to launch this again early next year. But I thought it was interesting because, you know, we're just doing pilot testing. This just was a good example of that for me. So.
[00:20:05] Speaker C: Yeah, and it's a really important differentiation to assure a reader that it is based on data, not on an analysis of language from published manuscripts. Very, very important. And, well, oftentimes Christina will ask us, do we wish to predict what's going to be hot in the orthopedic world in the coming 2026? And we both agree that AI is going to be a topic of great interest and hopefully more education of our reading audience as to what to pay attention to, what sources, what, what engines, etc. Etc. Do you have specific plans to do?
You started doing focus issues with the journal this year, which I think everybody agrees is a great advance.
Do you have a plan to. To. To do regular updates on AI in our field?
[00:21:06] Speaker B: Mo.
It's almost like I planted the question mark, but we didn't, I assure you. No, no, no. Yeah, yeah.
[00:21:14] Speaker C: Our preparation for these, These podcasts are zero.
[00:21:17] Speaker B: So, yeah. You're giving away all our secret sauce.
Which is none. Which is none.
No. But I would say to you, it's exactly true. So we have a theme issue plan for AI in the new year, and I believe, you know, it's just, it's. It's almost in its final forms now, so, you know, as, you know. Good.
Now, the challenge we always face and something that's so rapidly evolving. Yeah. Is to stay as current as we possibly can. So we hope to bring this out earlier in the new. Earlier in the year than later, but, you know, who knows? There'll be multiple changes and edits over the year to, you know, concepts that are evolving, and we'll be sure to try to stay on top of that as much as you can. But, you know, like, you know, it used to be. Right. Used to be, Mark, you know, people would Ask, you know, what were you doing, you know, in March, early March of 2020, that was kind of, you know, the predecessor to March 11, where the whole world got shut down with COVID Now, the question I asked to audiences, and it's funny, they look at me funny, but it works because I then I show them, I show them the data, which is, what were you doing before November 2022? Let me ask you that. What were you doing? And, and people will say, well, November 2022. And then you say, well, actually, end of November 22nd was when the first chat GPT was released. And most of us thought, I don't know what the heck this is. And I thought it was some sort of joke. And then within four months, there were 1.9 billion users in four months.
It took over the world that quickly. And it's never, you know, it's just out. It's out. So now it's just now a race. It's a race to, you know, the world is racing to figure out, you know, how quickly to evolve to super intelligence. And, and so we'll see how 2026 goes, but I think we're going to see exponential changes from 2025 in AI.
[00:23:00] Speaker C: Well, I'm sure that's a, that's an accurate prediction, no doubt, Mo. And it'll be interesting to see where we end up, hopefully with some balance, because right now the enthusiasm seems to be far outweighing the caution.
[00:23:18] Speaker B: So 100% agree. There's a quote, actually, I could leave us with if you want. And I.
[00:23:23] Speaker C: Please.
[00:23:24] Speaker B: I reflect on it. There was a. No, but I'm going to look.
[00:23:26] Speaker C: Is it from Wayne's World?
[00:23:28] Speaker B: I wish, I wish that's a classic that, you know, that. That or dumb and dumb. I, you know, they're both, they're both classics, both Oscar winning for me. But anyways, it was a Nobel Prize in physics in 2012 and they said creativity belongs to humanity, not to machines. This is in 2012.
So, you know, there was some foreshadowing there. So I do think, you know, for us to remain human is to be as creative as possible and continue to push that forward.
[00:23:56] Speaker C: Way to end it, Mo.
[00:23:58] Speaker B: Alrighty, have yourself a lovely end of the year Mark, and then we'll be back, I'm sure, soon enough, with lots and lots of stuff for the new, for the new year.
[00:24:08] Speaker C: That'd be great. Looking forward to it. Cheers, Mo.
[00:24:10] Speaker B: All right, take care there.
