Keeping a Clinical Eye on Downstream Costs
Medical economics has progressed to the point where musculoskeletal physicians and surgeons cannot ignore the financial implications of their decisions. Unfortunately, in most practice locations it is difficult, if not impossible, to ascertain the downstream costs to patients and insurers of our postsurgical orders for imaging, laboratory testing, and physical therapy (PT). In the April 18, 2018 issue of The Journal, Egol et al. present results from a well-designed and adequately powered randomized trial of outcomes after patients with minimally or nondisplaced radial head or neck fractures were referred either to outpatient PT or to a home exercise program focused on elbow motion.
At all follow-up time points (from 6 weeks to an average of 16.6 months), the authors found that patients receiving formal PT had DASH scores and time to clinical healing that were no better than the outcomes of those following the home exercise program. In fact, the study showed that after 6 weeks, patients following the home exercise program had a quicker improvement in DASH scores than those in the PT group.
The minor limitations with this study design (such as the potential for clinicians measuring elbow motion becoming aware of the treatment arm to which the patient was assigned) should not prevent us from implementing these findings immediately into practice. Each patient going to physical therapy in this scenario would have cost the healthcare system an estimated $800 to $2,400.
I wonder how many other pre- and postsurgical decisions that we routinely make would change if we had similar investigations into the value of ordering postoperative hemoglobin levels, surgical treatment of minimally displaced distal fibular fractures, routine postoperative radiographs for uncomplicated hand and wrist fractures, and PT after routine carpal tunnel release. These are just some of the reflexive decisions we make on a daily basis that probably have little to no value when it comes to patient outcomes. Whenever possible, we need to think about the downstream costs of such decisions and support the appropriate scientific evaluation of these commonly accepted, but possibly misguided, practices.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
JBJS 100: Metal-on-Metal Hips and Shoulder Function
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Metal-on-Metal Bearings and Hypersensitivity in Patients with Artificial Hip Joints
H-G Willert, G H Buchhorn, A Fayyazi, R Flury, M Windler, G Köster, C H Lohmann: JBJS, 2005 January; 87 (1): 28
At the turn of the 21st century, many efforts were underway to discover why some patients who had received second-generation metal-on-metal hip replacements were having postoperative problems. This clinical and histomorphological study, illustrated with detailed tissue sections, showed that a lymphocyte-dominated immunological response could be involved.
Observations on the Function of the Shoulder Joint
V T Inman, J B deC M Saunders, L C Abbott: JBJS, 1944 January; 26 (1): 1
Back in the days when 30-page JBJS articles were not uncommon, these authors set out to examine the whole shoulder mechanism, with detailed anatomical drawings, radiographic analysis, and action potentials derived from living shoulder muscles. This comprehensive, “eclectic approach” was published at a time when polio was endemic, but it is still relevant today.
Fifth Anniversary of Boston Marathon Bombing
On the eve of the 2018 Boston Marathon, we wish all the participants a safe run tomorrow. And we remember all those who are still experiencing the aftermath of the 2013 Marathon Bombing.
Not a single person who reached a Boston hospital alive on April 15, 2013 died, a stunning result of years of preparation and teamwork. It Takes a Team provides a behind-the-scenes look at how the level 1 trauma centers involved that day ensured that their staffs had the emotional backing, resources, and systems in place so they could focus on their seriously injured patients. Click here to download the report for free.
We thank the many people whose dedication to disaster-preparedness helps ensure that the 2018 and future Boston Marathons will go on.
Overselling Stem Cells?
This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.
In orthopaedics, the term “biologics” is often applied to cell-based therapies. There are a number of centers using mesenchymal stem cells (MSCs) in musculoskeletal medicine, and a recent systematic review assessed the quality of literature and procedural specifics surrounding MSC therapy for osteoarthritis (OA)1.
The authors searched four large scientific databases for studies investigating MSCs for OA treatment. Among the 61 articles analyzed, 2,390 OA patients were treated, most with adipose-derived stem cells (ADSCs) (n = 29 studies) or bone marrow-derived stem cells (BMSCs) (n = 30 studies), though the preparation techniques varied within each group. In a subanalysis of 5 Level I and 9 Level II studies (288 patients), researchers found that 8 studies used BMSCs, 5 used ADSCs, and 1 used peripheral blood stem cells. A risk-of-bias analysis showed 5 Level I studies at low risk, 7 Level II studies at moderate risk, and 2 Level II studies at high risk. The authors concluded that although there is a “notion” that MSC therapy has a positive effect on OA patients, there is limited high-quality evidence and a dearth of long-term follow-up.
Despite the low-quality evidence and the many questions surrounding MSCs for treating OA, there are an estimated 570 clinics in the US marketing “stem cell” treatments for orthopaedic problems2. The American Academy of Orthopaedic Surgeons (AAOS) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases recently convened a symposium on this issue. According to Constance Chu, MD, professor of orthopaedic surgery at Stanford University and the symposium program chair, the objective was to establish a clear, collective impact agenda for the clinical evaluation, use, and optimization of biologics in orthopaedics, and to develop a guidance document on clinically meaningful endpoints and outcome metrics for the evaluation of biologics used in orthopaedics.
Symposium attendees examined the possible use of registries to generate clinical evidence on the use of biologics in orthopaedics. Registry models that could be employed to obtain data on practice patterns and early warning of potential issues include the American Joint Replacement Registry, the Kaiser Registry, and the International Cartilage Repair Registry. Another model could be a biorepository-linked registry similar to what has been established at the VA Hospital in Palo Alto, California, where samples from platelet-rich plasma are stored for later comparison with clinical outcomes.
References
- Jevotovsky DS, Alfonso AR, Einhorn TA, Chiu ES. Osteoarthritis and Stem Cell Therapy in Humans: A Systematic Review, Osteoarthritis and Cartilage (2018), doi: 10.1016/ j.joca.2018.02.906.
- Symposium by The American Academy of Orthopaedic Surgeons and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. “Optimizing Clinical Use of Biologics in Orthopaedic Surgery,” Feb. 15–17, 2018, at Stanford University.
Risk Reduction Compared with Access to Care: The Trade-Off of Enforcing a BMI Eligibility Criterion for Joint Replacement
Morbidly obese patients with severe osteoarthritis benefit from successful total joint arthroplasty. However, morbid obesity increases the risk of complications. https://bit.ly/2qpfj8w #JBJS
Long-Term Outcomes of Glenohumeral Arthrodesis
Glenohumeral arthrodesis is associated with a high rate of complications. Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. https://bit.ly/2HuHYBb #JBJS
Twitter: An “Essential Tool” for Surgeons?
While many surgeons may not think of Twitter as a boon to professional activities, this particular social-networking platform is “an essential tool” for the academic surgeon. So claim Logghe et al. in their recent article in the Journal of Surgical Research. The authors back up their claim with pertinent, real-life examples of how Twitter can be used to practice five core values promulgated by the Association for Academic Surgery: inclusion, leadership, innovation, scholarship, and mentorship.
Inclusion—Anyone with Internet access can sign up and easily use Twitter to interact with colleagues. The service is free and facilitates the creation of “virtual communities” through the use of hashtags, making it easy to follow posts of other surgeons and organizations.
Leadership—Twitter allows users to create and expand their own professional footprint while also helping the academic and/or clinical organizations with which they are affiliated increase their reach. As the authors astutely note, “Surgeons on Twitter become respected voices with large followings not only based solely on their academic pedigree, but also on the degree to which they share interesting content and participate in timely conversations.”
Innovation—Twitter facilitates sharing among like-minded individuals in similar fields by breaking the normal constraints of time and space. This enhances the potential for multidisciplinary collaboration that may not have occurred otherwise and helps surgeons find colleagues with whom to develop and promote new ideas.
Scholarship—Multiple studies have shown that using social media can increase the dissemination and viewership of academic material. Many journals (including JBJS) are embracing social media to amplify their message and generate further scholarly discussion of their content.
Mentorship—Twitter not only increases the opportunity for younger surgeons to find potential mentors, but also helps mentors increase their pool of prospective mentees. Users of Twitter are not constrained to one-on-one conversations. Instead, using hashtags and similar strategies, they can develop or nurture a mentor/mentee relationship with multiple professionals at the same time.
As a relatively new Twitter user myself, I am nowhere close to maximizing its potential to enhance my professional life. However, the more I use it, the more I understand its possibilities. I hope other orthopaedic surgeons realize these possibilities as well, because, like all social-media platforms, Twitter is only as powerful as its users. The more of us who participate, the better we will be as physicians—and the care of our patients is bound to improve.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Outcomes from Shoulder Fusion Are Durable, Not Spectacular
Glenohumeral arthrodesis is a salvage operation, so most patients and surgeons considering this option don’t have expectations of spectacular functional outcomes. Improving stability and relieving pain are usually the main goals. In the April 4, 2018 edition of The Journal of Bone & Joint Surgery, a retrospective study by Wagner et al. sheds light on long-term results of this procedure (mean follow-up of 12 years) and the patient and surgical factors that might improve or worsen outcomes.
The authors reviewed electronic and paper medical records of 29 cases of glenohumeral arthrodesis performed between 1992 and 2009. They also analyzed patient questionnaires, which included DASH, SSV, and SF-36 scoring instruments.
All patients reported improvement in pain at the time of their latest postoperative follow-up. However, 12 patients (41%) had postoperative complications, including nonunions, fractures, and deep infections. Eleven patients (38%) required additional post-arthrodesis surgical procedures. The mean postoperative shoulder position was 60° in flexion and 13° in external rotation.
The authors identified the following correlations between patient/surgical factors and outcomes:
- Patients with a history of brachial plexus injuries had worse clinical and functional outcomes.
- Patients with shoulders fused in abduction and flexion of >25° had better shoulder function but a slightly higher risk of peri-fixation fracture.
- There were no significant outcome differences between procedures that used plate-and-screw and screw-only fixation. However, incorporation of the acromion in fixation was strongly associated with a lower risk of nonunion.
The authors conclude that despite the limitations of this complex salvage procedure, “its ability to relieve pain and to maintain reasonable upper-extremity function in select patients should not be overlooked.”
Does Residency Prepare Surgeons for Early Orthopaedic Practice?
One goal of an orthopaedic surgery residency is to prepare residents for the procedures they will perform when they are attendings. Yet, until the retrospective cohort study by Kohring et al. in the April 4, 2018 issue of The Journal, it remained unclear how similar a resident’s surgical case mix was compared to the cases attendings saw in early practice. Kohring et al. used data from both the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Orthopaedic Surgery (ABOS) to compare the types of procedures residents performed between 2010 and 2012 to the cases junior attendings submitted for the ABOS Part II examination between 2013 and 2015. The authors then categorized the cases by CPT codes and split them into adult and pediatric categories to allow for further comparison.
Here are a few interesting findings from the study:
- More than half of all adult and pediatric procedures performed during residency and by early-career attendings fell within the top 10 CPT code categories.
- Knee and shoulder arthroscopy were the most commonly performed cases in adults during both residency and early practice.
- Residents take part in total knee and total hip arthroplasties much more frequently than do attendings in early practice.
- Attendings in early practice treat more than twice the number of proximal femur fractures than do residents during residency.
- Residents are exposed to a much higher rate of spinal fusion cases than are seen by early-practice attendings.
Although the authors conclude that the “similarity between residency and early practice experience is generally strong,” this study highlights some of the disparities between the two cohorts, and these findings may inform further research aimed at improving training for orthopaedic surgeons. By themselves, however, these results should not be used to change the experience residents have during their training. The authors mention the limitations inherent when comparing these two cohorts, and I can testify that my clinical practice has evolved tremendously in the 3 years since I started as an attending.
Furthermore, with more than 90% of orthopaedic residents going on to complete a subspecialty fellowship immediately after residency, it is safe to say that the degree of similarity between residency and attending case experience will vary from surgeon to surgeon.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
What’s New in Hand and Wrist Surgery 2018
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Sanjeev Kakar, MD, author of the March 21, 2018 Specialty Update on Hand and Wrist Surgery, selected the five most clinically compelling findings from among the nearly 40 studies summarized in the Specialty Update.
Distal Radius Fractures
—When can a patient safely drive after surgical treatment of a distal radial fracture? According to a prospective study by Jones et al.1, most patients can do so within 3 weeks following surgery. Twenty-three patients had their driving evaluated 2 and 4 weeks after volar plating. Sixteen of the 23 patients drove safely on a closed course with both hands on their first attempt, which averaged 18 days after surgery.
Scaphoid Fractures
—One factor contributing to scaphoid nonunion is impaired vascularity. So, if the proximal pole of the scaphoid is avascular, is the use of vascularized bone grafting mandatory? No, according to a prospective study by Rancy et al.2, which followed 35 scaphoid nonunion patients treated with curettage, nonvascularized bone grafting, and headless screw fixation. Nine of 23 proximal pole fractures demonstrated ischemia on MRI imaging; 28 of 33 were found to have impaired intraoperative punctate bleeding; and 18 patients had ≥50% tissue necrosis on pathological analysis. CT analysis revealed that 33 of the 35 scaphoids had healed by three months, leading the authors to conclude that nonvascularized bone grafting can suffice as long as the fracture is appropriately reduced and stabilized.
Kienbock Disease
—Lichtman et al.3 introduced a new algorithm for Kienbock disease management that incorporates previous classification systems plus 5 treatment-guiding questions:
- How old is the patient?
- What is the effect of the disease on the lunate?
- How does the disease affect the wrist?
- What treatments are available?
- What are the patient’s requirements?
Depending on the answers, the authors present treatment options ranging from lunate reconstruction to wrist salvage.
Ulnar Impaction
—Some surgeons view radiographic evidence of a reverse oblique inclination in the sigmoid notch as a contraindication for ulnar shortening in patients with ulnar impaction. However, using MRI, Ross et al.4 noted that reverse oblique inclinations of the distal radioulnar joint, as seen on plain radiographs, were not evident when coronal MRI scans were analyzed. They concluded that some patients previously thought to have contraindications to ulnar shortening may in fact be suitable candidates for that procedure.
Prescribing Opioids
—Dwyer et al.5 evaluated an opioid-reduction strategy for patients undergoing carpal tunnel release or volar locking-plate fixation of distal radius fractures. Patients received education and encouragement to use over-the-counter (OTC) medications along with opioids. Among the carpal tunnel cohort (n = 121), the average opioid prescription was for 10 pills compared with 22 in the previous year. Average actual consumption was 3 opioid pills and 11 OTC pills. In the distal radius fracture group (n = 24), the average opioid prescription was 25 pills compared with 39 the year before. These patients consumed on average 16 opioid pills with 20 OTC pills. Patient satisfaction was high in both groups. The authors recommend that physicians prescribe 5 to 10 opioid pills for carpal tunnel release and 20 to 30 pills after volar plating for distal radius fractures.
References
- Jones CM, Ramsey RW, Ilyas A, Abboudi J, Kirkpatrick W, Kalina T, Leinberry C. Safe return to driving after volar plating of distal radius fractures. J Hand Surg Am. 2017 Sep;42(9):700-704.e2.
- Rancy SK, Swanstrom MM, DiCarlo EF, Sneag DB, Lee SK, Wolfe SW, Scaphoid Nonunion Consortium. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol. 2017 Jan 1;1753193417732003.
- Lichtman DM, Pientka WF 2nd, Bain GI. Kienböck disease: a new algorithm for the 21st century. J Wrist Surg. 2017 Feb;6(1):2-10. Epub 2016 Oct 27.
- Ross M, Wiemann M, Peters SE, Benson R, Couzens GB. The influence of cartilage thickness at the sigmoid notch on inclination at the distal radioulnar joint. Bone Joint J. 2017 Mar;99-B(3):369-75.
- Dwyer CL, Soong MC, Hunter AA, Dashe J, Tolo ET, Kastayan NG. Prospective evaluation of an opioid reduction protocol in hand surgery. Read at the American Society for Surgery of the Hand Annual Meeting; 2017 Sep 7-9; San Francisco, CA. Paper no. 5.
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