The Need for Preop Psych Evals in Orthopaedic Surgery

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Impact Science, in response to a recent ”What’s Important” article in JBJS.

In orthopaedic surgery, pre-existing psychiatric conditions in patients can have a detrimental effect on outcomes. Previous studies have shown poor improvement in postoperative self-reported pain scores among patients with psychosomatic conditions or mood disorders. Robust published evidence also suggests that psychiatric conditions can lead to complications in the treatment course, including an increased length of hospital stay and higher total systemwide costs. However, despite compelling evidence in the literature, orthopaedic surgeons—especially those early in their career—lack protocols to evaluate a patient’s current and past psychiatric history and symptom severity.

A recent “What’s Important” article in The Journal of Bone & Joint Surgery emphasizes the need for such an assessment tool. In the article, Albert T. Anastasio, MD, a resident in orthopaedic surgery at Duke University Medical Center, cites the example of bariatric surgery, where protocols have long existed for preoperative patient assessments for a history of alcohol and drug abuse. He argues convincingly that the development and use of such tools should be extended to orthopaedic procedures. For example, Dr. Anastasio questions the wisdom of a hypothetical elective spine surgery in a patient with an unaddressed psychosomatic disorder and borderline pathology on advanced imaging.

At the same time, Dr. Anastasio is quick to highlight the challenges of developing such a tool, mainly because of the subjective nature of psychiatric symptoms. But he cites existing tools that attempt to objectively evaluate psychiatric symptoms, such as the Patient Health Questionnaire-9, which is used to quantify the severity of major depressive disorder. Dr. Anastasio also cautions that any such metric should not serve as a “definitive cutoff” for surgery.

Underlying Dr. Anastasio’s call for psychiatric risk-assessment protocols is the importance of developing and enhancing collaboration between orthopaedics and psychiatry, two disciplines that he says are often “considered very far removed from each other.”

Impact Science is a team of specialized subject-area experts (Life Sciences, Physical Sciences, Medicine & Humanities) who collaborate with authors, societies, libraries, universities, and various other stakeholders for services to enhance research impact. Impact Science aims to democratize science by making research-backed content accessible to the world.

JBJS Extends Deadline for International Journal Club Grants

For the first time, JBJS is expanding its Robert Bucholz Resident Journal Club Grant Program to orthopaedic residency programs beyond North America.

The deadline for international applicants has been extended until 31 October 2020.

Grants of US$1,500 will be awarded to support selected Journal Club programs for the coming academic year. Funds can be used for subscriptions to orthopaedic journals and resources, travel grants for guest speakers, and costs associated with the monthly journal club meetings.

To apply, click here, download and fill out the form, and return it to journalclub@jbjs.org by 31 October 2020.

Elite Reviewer Spotlight: Leon Benson

JBJS is pleased once again to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name:

Leon S. Benson, MD

Affiliation:

Illinois Bone and Joint Institute, Glenview, Illinois

Years in practice: Thirty

How did you begin reviewing for other journals and for JBJS in particular?

I started reviewing for journals 15 years ago and began reviewing for the JBJS 13 years ago.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

I think it is important to read the article, if possible, as soon as you receive the invitation (same day).  I often find that my opinions solidify after thinking about the manuscript for a few days.  If I read the article right away, I am afforded some time to be thoughtful without delaying the review for more than a week. 

Aside from orthopaedic manuscripts, what have you been reading lately?

Dead Wake by Erik Larsen

All the Light We Cannot See by Anthony Doerr

American Prometheus by Kai Bird and Martin J. Sherwin

Hell’s Cartel by Diarmuid Jeffreys

Learn more about the JBJS Elite Reviewers program.

Reducing Local Recurrence of Adamantinomas

The international multicenter study by Schutgens et al. in the October 7, 2020 issue of JBJS reports findings from an analysis of >300 cases of patients diagnosed with either classic adamantinomas (ADs) or osteofibrous dysplasia-like adamantinomas (OFD-ADs) who were followed for 7 to >10 years. The mean age at diagnosis was 17 years. The authors conclude that OFD-AD and AD are “parts of a disease spectrum but should be regarded as different entities.” Their findings, they say, also “support reclassification of OFD-AD into the intermediate locally aggressive [but non-metastatic] category” of bone tumors.

Perhaps the most clinically interesting findings in this study are related to local recurrence, which the authors describe as a “multifactorial” phenomenon in both tumor types. They found local recurrence in 22% of the OFD-AD cases and 24% of the AD cases. None of the recurrences in the OFD-AD group progressed to AD, which is a malignant disease with metastatic potential.

The authors found that the unadjusted cumulative incidence of local recurrence was higher if a pathological fracture was reported and if resection margins were contaminated. So, to reduce the risk of local recurrence in both tumor types, Schutgens et al. suggest “preventing pathological fracture after diagnosis and achieving uncontaminated margins with resection.”  The uncontaminated resection should include the periosteum of the involved bone at the time of surgery.

Elite Reviewer Spotlight: Donald Anderson

JBJS is pleased once again to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name:

Donald D. Anderson, PhD [most people call me by my nickname, “Don.”

Affiliation:

Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, IA

Years in practice:

I am a full-time academic researcher, having completed my PhD in December 1989, which I guess means that I have “been in practice” for just over 30 years now.

How did you begin reviewing for other journals and for JBJS in particular?

I began accepting requests to review manuscripts immediately after finishing up my PhD. Over the years, the number of journals that rely on my reviewing talents has increased. Somewhere along the way, JBJS started reaching out, and saying “yes” to that invitation was a pretty easy decision.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Be generous with your time, especially when the manuscript you’re referred is from your area of expertise and the study sounds interesting. Okay to say “no” on occasion, but try to make that the exception. Then set a reminder for when the review is due and find a few hours to give it your full attention. Don’t sweat grammatical issues. Just tackle the big picture and technical points that occur to you.

Aside from orthopaedic manuscripts, what have you been reading lately?

I hate to admit it, but I read so much at work lately, that I don’t do much personal reading. However, I just picked up Isaac Asimov’s Foundation to re-read.

Learn more about the JBJS Elite Reviewers program.

What I Learned at the ASSH 2020 Virtual Annual Meeting

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes Christopher Dy, MD, MPH in response to his recent participation in the virtual Annual Meeting of the American Society for Surgery of the Hand.

The year 2020 has brought with it many “firsts.” For example, due to the COVID-19 pandemic, the Annual Meeting for the American Society for Surgery of the Hand (ASSH) was moved from San Antonio to a virtual platform. Kudos to the Annual Meeting chairs (Dawn Laport, MD and Ryan Calfee, MD), ASSH president Martin Boyer, MD, and the ASSH staff for constructing an amazing experience. Here are some general take-homes from my first-ever virtual conference experience:

  • A virtual conference provides attendees with a ton of flexibility and customization. While there are often “conflicting,” concurrent sessions during an in-person meeting where I have to decide between 2 sessions, the virtual ASSH meeting format offered the ability to go back and watch prior courses and lectures. When we (hopefully) go back to in-person meetings, it would help if more sessions were recorded and made available to attendees on demand.
  • The virtual conference requires a lot more pre-meeting preparation for all parties involved, especially presenters. Because the sessions that would normally occur in the large, main halls were hosted on a professionally run platform with A/V engineers, presenters were required to attend more than a few “tech” rehearsals, as well as submit their presentation slides 4 to 6 weeks in advance. I admit that it was harder for me to present from slides that didn’t feel as fresh, since I couldn’t revise them the night before!
  • While it was convenient to view most of the meeting from my couch (or exercise bike), I really miss the in-person interactions with colleagues and friends that you get while moving between sessions. It’s also harder to pull yourself away from your family and your practice when you are “participating” in a meeting from home or office.

Here are 4 technical things I learned from the sessions I attended, largely biased toward my personal interests. I encourage readers to leave comments by clicking on the “Leave a Comment” button in the box next to the title.

  • Innovation continues for distal nerve transfers to treat peripheral nerve palsy. Professor Jayme Bertelli from Brazil gave talks demonstrating both technical aspects and his own results following transfers such as ECRL [extensor carpi radialis longus]-to-AIN [anterior interosseous nerve], distal AIN to distal PIN [posterior interosseous nerve], and opponens pollicis to adductor pollicis. I am eager to read more about these transfers and get into the cadaver lab to refine my surgical technique. (Precourse 03 and Symposium 18)
  • The debate about “supercharging” (reverse end-to-side) nerve transfers continues. There is laboratory evidence supporting the role of a supercharged nerve transfer in preserving the distal muscle unit and the distal nerve stump. However, there is controversy regarding whether it is benign and/or beneficial to have 2 “competing” sources of muscle innervation, in cases where the “native” nerve reaches the distal target after the axons coming from the supercharged transfer have been placed. While many surgeons have adopted supercharged nerve transfer into their practice, there is far more laboratory and clinical research needed to substantiate this practice and refine the indications for use. (Precourse 03 and Symposium 11)
  • Utilization of wide-awake, local-anesthesia, no-tourniquet (WALANT) hand surgery continues to grow. Surgeons are performing a growing number of different surgeries (including fracture cases and complex tendon transfers) with WALANT, and some are doing these cases in procedure rooms or offices rather than in a formal operating room. These changes are driven by both surgeon and patient preference, as well as potential cost advantages for both parties. For surgeons, there is a potential for increased revenue with WALANT, but this can come with logistical challenges such as stocking sterile trays and making sure that medications are available. The trend toward increasing utilization of WALANT in procedure rooms and in surgeons’ offices is likely to continue. (Instructional courses 24 and 56 and related OrthoBuzz post)
  • Teaching in the operating room has shifted. Many current trainees prefer to use videos for case preparation rather than focusing on book chapters, technique articles, or primary literature. Consequently, there is a growing embrace of video among hand-surgeon educators. Videos that are short, discuss indications, and provide rationale for technique-related decisions are favored. Today’s trainees are also less likely to respond well to the classic Socratic method of teaching and may need more overtly delivered feedback. (Instructional courses 10 and 36)

Christopher Dy, MD, MPH is a hand and wrist surgeon, an assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis, and a member of the JBJS Social Media Advisory Board.

Time Waits For No One—Aging Increases Costs

The cost of medical care in the United States has been shown to rise with advancing patient age, and total joint arthroplasty (TJA) is a prime example of this unsurprising phenomenon. In attempts to curtail costs and reduce variability, Medicare and other payers have introduced alternative payment models (APMs), such as the Bundled Payments for Care Improvement (BPCI) initiative. In this model’s application to TJA, when participating institutions keep the cost of the “episode” below a risk-adjusted target price, they accrue the savings as a profit, but they sustain a financial penalty if the episode costs more than the target price.

Multiple studies have suggested that APMs can negatively affect the fiscal health of institutions that care for many high-risk patients. Although increasing age has been associated with higher-cost episodes of care, age is not one of the factors that the BPCI model accounts for. Consequently, concerns have been raised that providers may practice “cost discrimination” against very old patients.

In the October 7, 2020 issue of The Journal, Petersen et al. examine how an aging population has affected a New York City orthopaedic center in terms of the BPCI model applied to TJA. The authors analyzed the relationship between patient age and cost of care among 1,662 patients who underwent primary total hip and knee arthroplasty over a 3-year period under BPCI. They then used a modeling tool to predict shifting age demographics for their local area out to the year 2040.

Petersen et al. found that under BPCI, their institution sustained a nearly $2,000-per-case loss for TJA care episodes among patients 85 to 99 years of age. Currently this loss is offset by profits realized by performing TJAs in younger patients. However, predictive modeling identified an inflection point of 2030, after which a relative increase in older patients and a decrease in younger patients will yield an overall net decrease in profits for primary TJA.

Because no one, including orthopaedic surgeons, can turn back the clock on aging, health care stakeholders must find ways either to adjust downward the cost of care for the elderly (seemingly difficult without adversely affecting outcomes) or adjust reimbursement models to account for the increased costs associated with aging. I agree with the conclusion of Petersen et al.: “The BPCI initiative and [other] novel APMs should consider age as a modifier for reimbursement to incentivize care for the more vulnerable and costly age groups in the future.”

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Elite Reviewer Spotlight: Jonathan Levy

JBJS is pleased once again to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name:

Jonathan Levy, MD

Affiliation:

Holy Cross Orthopaedic Institute

Fort Lauderdale, FL 33308

Years in practice: 14

How did you begin reviewing for other journals and for JBJS in particular?

Immediately after fellowship, I became interested in assisting in journal reviews.  There is no question, reviewing manuscripts and research makes me a better critical thinker, researcher, and author!

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Review each article with the perspective as if it was your own manuscript.  Even if the manuscript represents research that you do not feel is fit for JBJS, there is value in your review.  Spend time to critique the manuscript in an effort to make it better!

Aside from orthopaedic manuscripts, what have you been reading lately?

Like most, I have been on top of the daily news more so now than ever before.  Editorials on COVID and the politics of this year have become entertaining!

Learn more about the JBJS Elite Reviewers program.

Complex Technology Demands Conflict-Free Reporting

In the October 7, 2020 issue of The Journal, Du et al. report on a multicenter database-derived cohort of 167 patients with early-onset scoliosis treated with traditional growing rods and followed for ≥2 years after “final” fusion. These researchers report that 19% of those patients required a repeat surgery following fusion, most commonly for surgical-site infection and anchor-site failure. Multivariate analysis of risk factors for reoperation following final fusion revealed the following:

  • Curve progression requiring revision surgery during the spine-lengthening process
  • The number of levels spanned with the growing rods
  • The duration of treatment

Du et al. report these results without spin in a way that is most useful for surgeons who are considering using these implants in their armamentarium. This is the way all new technology, especially complex advances in surgical care, should be reported.

Orthopaedic implants and instruments continue to evolve, almost always toward more sophisticated digital technology, complex engineering, and more numerous moving parts. The advent of magnetic growing rods for treating early-onset scoliosis is just one example. Often such advances are reported on by surgeons who are conflicted by personal and financial interests in the technology. This leads to all manner of potential bias–indication bias, reporting bias, selection bias, and detection bias to name just a few. Readers should evaluate this type of data with a high degree of suspicion.

What we need throughout orthopaedics are more multicenter, multisurgeon, “deconflicted” cohort studies and clinical trials. When such rigorous studies are conducted to investigate “high-tech” growing rods in patients with early-onset scoliosis, I will not be surprised if researchers find the same risk factors for reoperation after fusion that Du et al. found.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Cannabis Users Should Disclose Prior to Surgery

Although many patients believe marijuana is an effective agent to treat chronic and nerve pain, the effect of cannabis on acute musculoskeletal pain has been questioned. In an OrthoBuzz post from 2019, we reported findings published in JBJS indicating that, compared with “never users,” patients who reported using marijuana during recovery from a traumatic musculoskeletal injury experienced increases in both total prescribed opioids and duration of opioid use.

At the 2020 annual meeting of the American Society of Anesthesiologists, researchers reported parallel findings. Among 118 patients who underwent open reduction and internal fixation to repair a tibial fracture, 25% reported using cannabis prior to surgery. When researchers compared the patients who had used cannabis with those who had not, they found the following perioperative and postoperative results among the users:

  • A higher intraoperative requirement for inhalation anesthetic
  • Higher reported pain scores while in the postacute care unit after surgery
  • Higher in-hospital postoperative opioid consumption

In a press release about this study, lead author Ian Holmen, MD is quoted as saying, “…it is important for patients to tell their physician anesthesiologist if they have used cannabis products prior to surgery to ensure they receive the best anesthesia and pain control possible.”