Archive | April 2014

JBJS Special Report: “It Takes a Team” Audio Interview with Kent Anderson, CEO/Publisher of JBJS

Kent Anderson, CEO/Publisher of the JBJS Special Report: “It Takes a Team”, sits down and talks about the 2013 Boston Marathon Bombings. Some of the topics that Kent discusses in the interview are the emphasis on teamwork in healthcare, the importance of the first responders and orthopaedic surgeons who treated the survivors and lessons learned from this horrific tragedy. Listen now: http://bit.jbjs.org/1ph87Hu

Neuromuscular Training Reduces ACL Injury Risk in Adolescent Athletes

Research reported at the 2014 AAOS Annual Meeting concluded that universal neuromuscular training for young athletes can be an effective and inexpensive way to avoid ACL sprains and tears. The research also found that screening tools, such as isokinetic tests to identify neuromuscular deficits, may reduce ACL injuries among high-risk athletes.

The modeling study evaluated a hypothetical cohort of 10,000 student athletes ages 14 to 22. Universal training reduced the incidence of ACL injury by 63%, while the screening program for at-risk athletes reduced the incidence rate by 40%. The study concluded that universal training would save an average of $275 per player per season when compared to estimated ACL reconstruction costs.

“Use of both preventative measures and screening tools sounds appealing, but often there are significant financial, administrative and social hurdles that have to be overcome before they can be implemented on a widespread level,” cautioned lead study author Eric F. Swart, MD, an orthopaedic resident at Columbia University Medical Center in New York.

For more information, read here: http://m.prnewswire.com/news-releases/universal-neuromuscular-training-reduces-acl-injury-risk-in-young-athletes-250280401.html

Low-Oxygen Treatment Helps People with Incomplete Spinal-Cord Injuries Walk Better

A recent study conducted at Emory University’s Center for Rehabilitation Medicine showed that short periods of breathing low oxygen levels can help patients with incomplete spinal-cord injuries walk better. The research included people with no joint shortening; some controlled ankle, knee and hip movements; and the ability to walk at least one step without human assistance.

Each of the participants was exposed to short periods of low-oxygen breathing (hypoxia). They breathed through a mask for about 40 minutes a day for 5 days, receiving 90-second periods of low oxygen levels followed by 60 seconds of normal oxygen levels. The participants were tested several times during the treatment and at one and two weeks post-treatment. Each participant improved their walking speed and endurance.

An editorial accompanying the study, published in Neurology, speculates that the low-oxygen treatment triggers spinal serotonin to induce protein changes that help restore spinal-cord connections.

For more information, read here: http://news.emory.edu/stories/2013/12/new_treatment_for_spine_injuries/

Keep It Single: Supervised Exercise with One Focus Helps with Knee OA

In a systematic review of 48 randomized controlled trials, European researchers found that a single type of exercise—either aerobic, resistance, or performance—was more effective for treating knee osteoarthritis than a mix of different exercise types. For pain reduction, quadriceps-specific resistance exercises were the most efficacious. The study, in the March 2014 Arthritis & Rheumatology, also concluded that the best results were achieved when the exercise program was supervised and engaged in thrice weekly for at least four weeks.

AAOS Annual Meeting Roundup

With 840 scientific presentations, 560 posters, and 200 instructional course lectures, even OrthoBuzz couldn’t comprehensively summarize the 2014 AAOS Annual Meeting in New Orleans. But here’s a small random sampling of findings reported at the meeting that you might find interesting. Please remember that these data have not appeared in peer-reviewed journals and should be considered preliminary.

TENS for Low Back Pain Could Save Medicare Nearly a Half-Billion Dollars

If all of its estimated 1.5 million beneficiaries with chronic low back pain were treated with TENS—transcutaneous electrical nerve stimulation—Medicare could save about $417 million in annual treatment costs, said Michael Minshall, MPH (paper #474). The figures are based partly on published research showing that TENS patients use significantly fewer health care resources (hospital and office visits, imaging, physical therapy, and surgery) than those receiving other treatments.

Allografts Fail Three Times More Frequently than Autografts in Primary ACL Reconstruction

A prospective randomized trial of 99 ACL reconstruction patients in their twenties revealed a 10-year 26.5% failure rate when tibialis posterior tendon allografts were used, compared with an 8.5% failure rate for hamstring autografts. Presenter Craig Bottoni, MD (paper # 462) said both groups received the same fixation technique and the same postoperative rehab program by physical therapists who were blinded to the treatment allocation.

Tranexamic Acid Cuts Transfusion Rates during TJA without Boosting VTEs

Scott Wingerter, MD (paper #1) presented data from Washington University School of Medicine (WUSM) showing that transfusion rates declined substantially during primary and revision hip and knee replacement procedures after tranexamic acid began being used routinely at WUSM. The incidence of venous thromboembolism was also lower in the group that received tranexamic acid, although that difference was not statistically significant.

Repeat Skin Antisepsis May Reduce Surgical Site Infections

A randomized, prospective study of nearly 600 patients undergoing total joint replacement found that those who received additional skin antisepsis with an iodine povacrylex/alcohol combination after surgical draping but before incise draping were far less likely to experience a superficial surgical site infection than those who received standard skin preparation with chlorhexidine, alcohol, and betadine. Presenter Tiffany Morrison, MS (paper # 49) also noted a non-significant difference in rates of skin blistering between the two groups.

Publisher’s Note: The Unseen Costs of Providing Online Information

Providing information online is neither free nor easy, despite the general perception that online information can or should be free.

The perceptual problem is one we business types describe in terms of “variable costs.” The variable costs of online are small, usually a fraction of what they are to deliver a printed issue. Because the user discerns no significant variable costs when downloading information, the perception is that online can be free or much cheaper than print, where the variable costs are more readily apparent (printed materials and postal costs that vary in proportion to the quantity of output).

However, where online information differs significantly from our print legacy is in fixed costs – those costs we have to incur to make the first instance of something—to design a site, to make content accessible, to program interfaces and data systems, and so forth. These fixed costs of online information publishing are significant, and they are not decreasing.

Fixed costs for online information delivery include 24/7 worldwide availability; long-term contracts with providers of  publishing software, media players, analytics packages, email packages, and so forth; and management staff to develop new systems, migrate systems through software upgrades, and migrate content from earlier generations of Web markup languages to newer ones. The list is long and growing longer.

Boiling it down a little, here are the main reasons why the fixed costs of providing information online are not decreasing:

  • Users want more convenience, options, and capabilities. From tablet versions to inline video to online customer service, publishers and others are continually building new services and incurring new fixed costs.
  • Expertise in software and content development is expensive. It takes really talented people to make online a reality. These people command good wages, and the market for their talent is very competitive.
  • Content is more like software. Content used to be a one-time event – you’d finish editing an article, put it into a nice page layout, and print it. Now, content goes through versions just like software. The markup languages that render it online evolve, and publishers have to revise their entire archives with each major evolution. Multimedia introduces new layers of similar work–and additional costs.
  • Print business models are under stress, so online has to carry more of the costs. A decade ago, online was an accessory for a robust print publisher. Now, print is losing its ability to carry the full load, shifting the fixed costs for print to online. This means a higher proportion of the cost for content creation, editorial work, art work, and management has to be carried by the online business.

As we’ve been doing for hundreds of years, publishers are trying to find a balance for users between cost and value. It’s especially tricky right now because so many factors are changing all at once.

Users want more and better information through their tablets, smartphones, and laptop and desktop computers. We’re continually adapting to meet these expectations. In the coming months, we will have many exciting announcements about our developing online capabilities. Already, we are publishing inline videos and accepting video content from authors at a high rate. Our new JBJS Reviews journal has a well-reviewed iOS and Android app you can use now. More tablet capabilities are coming later this year, as are revamped Web sites.

We’re excited about the future, and we love the capabilities online publishing provides –making information more immediately available worldwide, showing and telling, and providing users with ways to find content quickly and easily. But while it’s amazing and useful, online represents a new kind of information economy for us content providers – one that has more in common with software companies than with printers.

App review: MediBabble Helps Bridge Language Barriers

According to TopOrthoApps.com, a medical-app review site, MediBabble does a very good job helping doctors communicate with non-English speaking patients. The app received very high scores in “coolness,” functionality, and overall features. MediBabble contains a very robust database of medical phrases and does not require an Internet connection. The app enables providers to ask patients closed-ended questions in their native language during all-important history-taking. Currently the app supports Chinese, French, German, Haitian Creole, and Russian.

How Many Healthcare Resources Do Orthopaedic Surgeons Use?

With medical costs under constant scrutiny, the Vanderbilt Orthopaedic Institute Center for Health Policy conducted a study titled “Patterns of Costs and Spending Among Orthopaedic Surgeons Across the US.” The authors sought to determine orthopaedic surgeon contributions to total health care expenditures, and the results were recently published online in the American Journal of Orthopaedics. With 1,214 people responding to the survey (a 61% response rate), results showed that the average monthly expenditure per US orthopaedic surgeon is $33,436, or a little more than $400,000 a year. That means that the 20,400 orthopaedic surgeons spend about $8.2 billion a year. The results showed some differences in spending by type of practice and geographic location, with private practices in the Northeast tending to spend the most. The findings may help orthopaedic surgeons analyze their spending to lower costs without sacrificing quality.

An ICD-10 Win and SGR Loss for Orthopaedists in Latest Congressional Action

By a vote of 64 to 35, the US Senate approved a one-year “patch” of the current SGR-based Medicare payment formula, rather than entirely replacing the flawed system. President Obama signed the bill, which provides a 0.5% increase in physician Medicare reimbursements for the rest of 2014.

It’s the 17th such temporary stopgap Congress has passed over the last 11 years, and it came despite staunch opposition to another short-term “doc fix” by many physician groups, including the AMA and the AAOS. When the House passed the same measure a week earlier, AAOS president Frederick Azar, MD, said he was “profoundly disappointed.”

There was a last-ditch but unsuccessful effort by Senate Finance Committee chairman Ron Wyden (D-Oregon) to get his colleagues to vote on a permanent repeal of the SGR formula. Had Congress not acted at all, a 24% cut in Medicare reimbursements would have taken effect April 1, 2014. Previous patch votes have been accompanied by congressional promises to use the reprieve to hammer out a bipartisan deal to pay for a permanent SGR repeal. That has never happened, and few are optimistic that it will happen this year.

As physicians are swallowing the bitter pill of another SGR patch, some are relieved with another stipulation in the bill: a one-year delay in the implementation of the ICD-10 code set until at least Oct. 1, 2015. The AMA recently estimated that implementing the new, more complex code set could cost small practices up to $225,000, and last July the AAOS supported a bill to stop the transition to ICD-10 so physicians could develop an appropriate alternative. Another provision in the new bill gives the secretary of Health and Human Services permission to address “misvalued codes” used in the Medicare physician fee schedule.

According to Thomas Barber, MD, chair of the AAOS Council on Advocacy, “The delay in ICD-10 implementation may provide temporary relief for some, but the importance of a permanent SGR policy together with the harmful misvalued codes provision in this patch greatly outweigh any benefits.”

Read a summary of the bill’s provisions here: http://www.massmed.org/Advocacy/Key-Issues/Medicare/Summary–Protecting-Medicare-Access-Act-of-2014/#.UzrNkqJ0lyI

Portrait of an Orthopaedic Trauma Surgeon and Compassionate Caregiver

Dr. David Lhowe, orthopaedic trauma surgeon at Massachusetts General Hospital, spent time in a makeshift field hospital next to what was the World Trade Center after the 9/11 attacks and a month on a US Navy hospital ship help­ing survivors of the Indonesia earthquake—the deadliest natural disaster in recorded history. Lhowe calls these opportunities to help “an unbelievable gift” in It Takes a TeamThe 2013 Boston Marathon: Preparing for and Recovering From a Mass-Casualty Event, a special report co-published by JBJS and JOSPT.

It Takes a Team describes how Dr. Lhowe performed surgery on Kaitlynn Cates after she sustained deep-tissue shrapnel wounds in her right calf from the Boston Marathon bombings. Cates appreciated his clear and calm explanations of the surgical plan and what would happen after. “In emergencies, it’s often hard for patients to concentrate, so I try to simplify to the best of my ability, lay out the main points of consideration or concern, and continue the conversation later,” he said.

Cates still occasionally visits Lhowe, even though she’s been discharged as a surgical patient. “I find talking to him very com­forting,” Cates said. In addition to helping her navigate clinical intricacies of her ongoing care, Lhowe simply lends a sympathetic ear. “If I have the time to talk and if talking helps her, that’s great,” he said.

It Takes a Team-The 2013 Boston Marathon: Preparing for and Recovering From a Mass-Casualty Event is divided into three parts:

  • Part 1: Readiness—Fortune Favors Prepared Teams
  • Part 2: Response and Recovery—April 15 Through December 31
  • Part 3: The Road Ahead—A Long Haul for Each and All

Download a PDF of the full report