Archive | May 2014

A Conversation with Dr. Brian Parsley, President of AAHKS

Dr. Brian S. Parsley is President of the American Association of Hip and Knee Surgeons (AAHKS). He was kind enough to answer a few questions for OrthoBuzz.

JBJS: What have been your key goals for AAHKS during your presidency?

Dr. Parsley: AAHKS is a growing organization that has established itself as the premier organization for hip and knee arthroplasty education, advocacy, and support in the United States. Our membership has experienced continued record growth, as has our Annual Meeting. This year will focus on continuing our growth nationally, but we will also focus more on developing international membership and partnerships through educational opportunities. We are blessed with outstanding experts in arthroplasty techniques and innovation, in patient advocacy and legislative and regulatory affairs, and with expertise on how to navigate through this ever-changing healthcare arena to ensure that the patients we serve are well cared for. This requires a constant review and upgrade of our internal organizational systems to manage these priorities effectively and efficiently.

JBJS: How do you think JBJS can best address the needs of the members of AAHKS and other subspecialty organizations?

Dr. Parsley: JBJS continues to be one of the premier resources for quality educational content and serves as a foundation for identifying “Best Practices” recommendations. The expansion of JBJS into alternative methods to communicate with the orthopaedic community through forums such as this and educational webinars indicates an interest in remaining a respected resource.

JBJS: As a specialist in diagnosing and treating arthritis, are there new or emerging approaches to treatment that you see as particularly promising?

Dr. Parsley: The success of total joint arthroplasty today is outstanding, and the quality-of-life improvement this procedure provides is life changing for the vast majority of patients. We continue to focus on new techniques for joint preservation through cartilage research and exploring when early intervention to treat hip or knee abnormalities is indicated to improve function and extend joint preservation. I also see the continued emergence of bicruciate-retaining TKA to potentially provide knee replacements that have a more anatomic stabilization and function and hopefully improved outcomes. Continued refinement of the mechanical functions of the joint implants for both the hip and knee are ongoing; this includes further improvements of the polyethylene articulation, improvements in trunion design for modular hip designs, and improvements in implant geometry that will hopefully extend the life of implants even further.

JBJS: What trends in orthopaedics generally are you most intrigued by?

Dr. Parsley: The delivery of orthopaedic care is undergoing major changes as the fee-for-service model is being challenged and value propositions introduced. This is the most disruptive change in orthopaedics today. The associated changes in the physician practice from the private-sector model to a significant rise in physician employment will potentially have an impact on the patient-physician relationship and our role as patient advocate, and this is a cause for concern. Physicians need to get engaged and lead the way during this time of change.

JBJS: Looking ahead to the next 20 years or so, what do you think might be three significant advances or changes in orthopaedics?

Dr. Parsley: As I mentioned above, the changes in healthcare delivery will be the most significant, but at the same time they will provide opportunities for improvement in the value of the services we provide. Extensive work is being done in the field of orthobiologics and the potential benefits of stem cell research. This field may help us prevent or delay the devastating effects of arthritis. Lastly, the emphasis today on evidence-based medicine will help us refine the care that we provide and decrease the variability of outcomes going forward. This is in the best interest of our patients.

JBJS: What changes do you expect to come as a result of the Affordable Care Act (ACA)?

Dr. Parsley: Continuing on the current path is unsustainable. The passage of the Affordable Care Act has changed the face of medicine and will pose many challenges in the years ahead. The fact is that this is the new law of the land, and the sooner we accept that fact and move forward the better. Still, there is no question the ACA can be modified and improved upon. There are tremendous opportunities for orthopaedics to refocus and take the lead on the management of musculoskeletal care for our patients, and not just as a surgical event within an episode of care. We have not only the surgical skill sets, but we also have the ability to manage the entire episode of care–and we should. There is no one who knows and understands the needs of the patient with an orthopaedic problem better than we do and what care the patient needs. I am very concerned that patients will suffer if the orthopaedic surgeon does not step up and take the lead in this changing healthcare delivery system. We need to maintain the patient–physician relationship and continue to be the patient’s advocate. The most successful early programs since passage of the ACA have all been physician-driven.

In the field of arthroplasty, the evolution of bundled payments is coming and in my opinion, bundled payments will soon be the rule rather than the exception. There is great potential to provide excellent care to patients more effectively and efficiently at a lower cost, resulting in higher value to the patient and the healthcare system. But that requires the physician to be actively engaged in the process.

JBJS: You have participated in several service-oriented activities, including the Houston Haitian Recovery Initiative. How has participating in these activities enriched your medical practice?

Dr. Parsley: I have always felt that the Good Lord gives us all gifts; it is what you do with those gifts that makes a difference. I am blessed to be an orthopaedic surgeon, and I feel that I am doing what was meant to be. Sharing these gifts with others by serving those in need through medical mission work in Guatemala, Haiti, Ecuador, or even in Houston–whether it be with surgical skills, with leadership and volunteer recruitment, or with philanthropy–is life-changing for all involved. I have made more than 45 medical mission trips in the past 18 years, the majority to Guatemala with Faith In Practice. The first of 4 trips I made to Haiti was 6 days following the devastating earthquake several years ago. I am humbled by the patients we treat and the faith that they show in a total stranger such as me. These missions reinvigorate my soul and reinforce the reasons that I went into medicine in the first place. The sanctity of the patient-physician relationship is communicated through the touch of the hand, the smile on their faces, the hugs of gratitude, and the incredible faith they share with you. Everyone should give back in some way as part of this wonderful profession.

JBJS: What is your favorite thing about your profession?

Dr. Parsley: I am truly blessed to be an orthopaedic surgeon and am surrounded by highly motivated and talented people with a can-do attitude and a focus on quality care. The camaraderie, respect, and friendships that develop in the orthopaedic family as we continue to strive to be the best we can be on behalf of the patients we serve is always a motivation and a pleasure.

Hormone Therapy May improve Joint-Implant Outcomes in Women

According to a recent study in the Annals of the Rheumatic Diseases, women who take hormone replacement therapy (HRT) for at least 6 months after a total hip or knee replacement may cut the risk of revision surgery by almost 40%. This potential reduction in revision rate becomes even more impressive when one considers estimates that put the number of knee replacements in the US at close to 3.5 million annually by the year 2030.

The study, which compared joint-replacement outcomes in 2,700 female HRT users with outcomes in 8,100 matched nonusers, found no difference in revision rates relative to HRT use before surgery.

Elena Losina, PhD., JBJS deputy editor for methodology and biostatistics, called this study “well designed and executed” in an article in Arthritis Today. But she was quick to add that “to consider these results more definitively in clinical practice, they need to be confirmed and reproduced in a multicenter randomized controlled trial.”

3-D-Printed Cast Builds in Ultrasound Bone Stimulation

Among several standout characteristics of the Osteoid cast invented by industrial designer Deniz Karasahin is that it’s made by a 3-D printer using ABS plastic. Loading 3-D CAD data from a scan of a patient’s limb into the printer enables Karasahin to custom fit a medical cast that minimizes itching and odor and is lighter-weight than currently available plaster and plastic designs.

Perhaps more importantly, the Osteoid cast can accommodate a low-intensity pulsed ultrasound bone stimulator (LIPUS) by allowing direct skin contact through the cast’s unique ventilator holes. Using this stimulator for 20 minutes daily can purportedly reduce healing times and increase healing rates in non-union fractures. To find out more see, http://www.pocket-lint.com/news/128658-3d-printed-osteoid-cast-could-heal-broken-bones-40-per-cent-faster.

Do “Choosing Wisely” Lists Protect Physician Income?

Kaiser Health News and the Chicago Tribune recently collaborated on a story that led with the following observation: “When America’s joint surgeons were challenged to come up with a list of unnecessary procedures in their field, their selections shared one thing: none significantly impacted their incomes.”

The comment refers to the five items on the AAOS-approved Choosing Wisely list of orthopaedic-related procedures that physicians and patients should discuss and question (see the related OrthoBuzz item from Feb. 26, 2014).

Orthopaedists are not alone in this allegedly income-protecting tactic: “Some of the largest medical associations selected rare services or ones that are done by practitioners in other fields and will not affect their earnings,” the article stated.

For example, the Choosing Wisely list developed by the North American Spine Society (NASS) does not include spinal fusion, a controversial but lucrative procedure. “What we did when we made up the list was to start with more straightforward situations and hopefully expand that later,” said NASS board member F. Todd Wetzel in the article. That explanation makes some sense, considering that the evidence base for many tests and procedures—orthopaedic and otherwise—is equivocal.

Ultimately, the best decisions are made on a patient-by-patient basis, and the patient’s role in the Choosing Wisely campaign can’t be overemphasized. It’s about having a rational and respectful two-way conversation when a patient insists on having a certain test because his or her friend with the same symptoms had that test—or when a physician strongly recommends a certain procedure, the risks and benefits of which the patient doesn’t understand.

While it’s hard not to agree with Morden et al. in their NEJM Perspective piece (Feb. 13, 2014) that “more numerous and more courageous lists should be developed,” patient-education efforts must be ramped up because culling out low-value tests and procedures from the health care system should not and cannot solely be the responsibility of physicians.

Epidural Steroid Injections to Get New Warning Label

In late April, the FDA issued a safety announcement cautioning that corticosteroids delivered by epidural injection to treat back and neck pain may cause “rare but serious adverse events”–including vision loss, stroke, paralysis, and death. The agency is requiring an additional label warning to increase awareness of the risks, which were confirmed after the FDA reviewed cases from its Adverse Event Reporting System. Although anesthesiologists, physiatrists, and specialists other than orthopaedic surgeons often administer such injections, orthopaedists should note that as far as the FDA is concerned, the safety and efficacy of epidural steroid injections for neck and back pain have not been established. The FDA said it plans to convene an advisory committee later this year to “discuss the benefits and risks of epidural corticosteroid injections and to determine if further FDA actions are needed.”

Too Much Ado about Online Doctor Ratings?

Many physicians rail about the unfairness and inaccuracy of online ratings by patients, but in a recent piece in theatlantic.com, Richard Gunderman, MD, vice chair of the Radiology Department at Indiana University, takes a logical and dispassionate look at the problem—and how misleading information can actually harm patients. He begins with the observation that the cohort of raters is usually very small. As with underpowered medical studies, he notes that meager participation in online ratings “lowers the probability that the online rating truly reflects the aggregate views of the physician’s patients…and exaggerates the influence of even a single disgruntled or highly laudatory reviewer.”

While conceding that satisfaction is an important factor in a patient’s encounter with the health care system, and that satisfied patients are “generally more likely to follow a doctor’s recommendations,” he observes that there’s a tendency for patients to overrate convenience factors such as ease of getting an appointment and parking. More important aspects of quality care—a doctor’s knowledge, skill, and judgment—“may be difficult or impossible for most patients to evaluate thoroughly,” he claims.

Finally, he argues that some highly rated doctors are just plain bad, as attested to by last year’s case of a New Jersey cardiologist rated “very good” by patients who defrauded insurers of $20 million and employed unlicensed health care personnel. The worst-case scenario, Gunderman says, occurs when a preoccupation with online ratings impels doctors to act against their own professional judgment to boost their scores.

Antibiotics as Effective as Conservative Surgery for Diabetic Foot Osteomyelitis

Selected patients with osteomyelitis from diabetic foot infections can be treated medically or surgically with equal effectiveness, according to a small randomized study in Diabetes Care, purportedly the first study to prospectively compare the two treatments. Fifty-two patients with diabetic foot ulcers complicated by osteomyelitis received either a 90-day course of antibiotics or had the infected bone removed surgically, followed by a short course of antibiotics. Healing (complete epithelialization) occurred in 75% of the antibiotic group and 86% of the surgery group (p=0.33), and complications during treatment were also similar in the two groups. Clinical guidelines from the Infectious Diseases Society of America for dealing with diabetes-related foot osteomyelitis can be found here.

Medical Applications of Google Glass Growing

Augmedix, one of several start-ups devising applications for Goggle Glass in health care, is developing a seamless way for Glass-wearing doctors to push information to and from electronic health records (EHRs). A recent study in the International Journal of Medical Informatics found that doctors who use EHRs in the exam room spend much of their time looking at the computer screen rather than at the patient. The Augmedix product would record information from the doctor-patient interaction automatically and potentially boost “face time.” Meanwhile, Austin, TX-based Pristine has developed an app that lets Glass-wearing physicians transmit HIPAA-compliant video and audio of patients to authorized computers. The idea is to enable real-time consults with specialists located remotely from the patient. (See related OrthoBuzz item from Jan. 30, 2014.)

Publisher’s Note: The 2014 Boston Marathon – An Amazing Day for Positive Outcomes

The 2013 Boston Marathon was stolen from the athletes and the city by two terrorist bombs, which led to four deaths, hundreds of injuries, a city shuttered for long stretches, and a tense manhunt that concluded with one suspect dead and the other injured. But the 2013 Marathon wasn’t finished until the end of the day on April 21, 2014. Marathon Monday 2014 in Boston was a glorious day for more than 32,000 runners and more than a million spectators. It was a day throughout which the outcomes of orthopaedic, disaster preparedness, physical therapy, and emergency medicine teamwork were again on display.

From prosthetic limbs to fundraising groups paying it forward, the 2014 Boston Marathon was inspiring end-to-end. As thousands of runners observed a moment of silence in the chill morning at the Hopkinton start, the profound shared experience of the past year or years settled upon them. Urged to “Take back that finish line!” the runners ran through sun-filled streets to the finish line 26.2 miles away. Children, families, and strangers clapped, shouted, and urged them on every step of the way.

In March, in conjunction with our friends at the Journal of Orthopaedic and Sports Physical Therapy (JOSPT), we published a special report on the emergency preparedness, long-term care, and outcomes for many of those caught up in last year’s Marathon bombings. This report is available online for free at http://sites.jbjs.org/ittakesateam/2014/. I urge you to take a look.

If there was ever an event that showed how the skill, knowledge, and diligence of medical professionals benefited people with the resolve and strength to make the most of it, the 2014 Boston Marathon was that event. As families embraced at the finish line, as friends, heroes, and survivors shared in the accomplishment of completing not just one marathon but so much more, one theme stood out: the amazing strides made possible through teamwork in orthopaedic care, physical therapy, emergency medicine, trauma surgery, and system-wide planning.

Must-Have Knee-Replacement App for Patients

TopOrthoApps.com, a medical-app review site, gives My Knee Guide a top rating for patients who are thinking about having a knee replacement. The app, available for iPhones and iPads, received the highest ratings for functionality, coolness, and overall features. This app includes a calendar of specific surgery details, email alerts to remind patients of things to do, and a guide that tells patients what to expect on the days prior to and after surgery. From the physician perspective, My Knee Guide helps orthopaedic surgeons set expectations for patients and educates them throughout the process. The app also includes commentaries from patients about their actual experiences with knee replacement.