Archive | March 2015

Senate Recesses Before Voting on SGR Repeal

Despite an overwhelming 392-to-37 vote in the House to scrap the SGR formula for physician Medicare payments, the Senate adjourned for a two-week recess without voting on the measure. Senators were distracted from taking action on the House SGR-repeal bill by a pre-recess “vote-o-rama” on other legislation, mostly budget amendments. Many in Washington expect that the Centers for Medicare and Medicaid Services will postpone Medicare payments during the first two weeks of April, essentially preventing the 21% slash in physician reimbursement set to kick in on April 1. That will buy time for the Senate to reconvene and vote on the SGR bill.

Jennifer Haberkorn of Politico Pro told Kaiser Health News that any amendments to the House-passed SGR measure that the Senate debates—such as a full “pay-for” or  four years of expanded funding for the Children’s Health Insurance Program rather than two—“are unlikely to be approved, but [Senators] want to be able to make a point.” Conventional wisdom posits that the delay will not hurt the chances of an SGR repeal finally passing both chambers and being signed by President Obama.

JBJS Classics: Epiphyseal Plate Injuries

JBJS-Classics-logoEach month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.

Injuries Involving the Epiphyseal Plate” by Drs. Salter and Harris, published more than a half-century ago, has had a lasting impact on the field of orthopaedic surgery and on the practice of medicine in general.  Every surgeon in our specialty—and almost every radiologist, pediatrician, and emergency physician—has at least a passing knowledge of the “Salter fractures.”   This most enduring orthopaedic schema lives on in our practices because of its clarity of presentation, its guidance of our understanding, and its implications for treatment. It has outlasted many classifications developed before and since.

In addition to presenting the fracture classification in this classic and beautifully illustrated JBJS Instructional Course Lecture, the authors laid the groundwork with basic principles of mechanical failure and vascularity of the physis.  The authors then use these principles to help explain how physeal damage may arise from misalignment, crushing, or vascular interruption.  The authors elucidate these concepts further by presenting experimental studies of growth arrest, with resulting histology, and the effects of interpositional surgery.   Salter and Harris then describe the famous five types of physeal injury and the clinical implications for treatment and prognosis.

Not content with generalities, the authors conclude with an extensive section describing the variations of physeal fractures in each long bone. The article is fun and inspiring to read because of the obvious fascination that the authors had in exploring the topic so completely.  Rarely has experimental and clinical thought been so nicely interwoven. We don’t write that way now, and rarely if ever will we see a 36-page article in one of today’s orthopaedic journals; in many ways we are poorer for that.

Classification systems are highly cited and influential; they figure prominently in lists of top-cited orthopaedic articles.  Those at the top earn this rank by their utility.  This is just one of three monumental contributions by the late Dr. Salter of Toronto (along with introducing us to surgical reorientation of the acetabulum and to continuous passive motion). Please share your reactions to this classic article and its impact on you and your practice.

Paul Sponseller, MD

JBJS Deputy Editor for Pediatrics

Dr. James Rickert’s Personal ‘Choosing Wisely’ List

The five-item AAOS contribution to the Choosing Wisely list of medical procedures that patients and physicians should question has been criticized from several quarters (see OrthoBuzz post “Do ‘Choosing Wisely’ Lists Protect Physician Income?”).

The latest scrutiny comes from Indiana orthopaedist James Rickert, MD, who founded the Society for Patient Centered Orthopaedic Surgery. Speaking at the recent Lown Institute Annual Conference (dubbed “The Road to RightCare”), Dr. Rickert said that among physicians who succumb to financial interests in recommending and performing procedures of dubious merit, orthopaedists are “one of the worst offenders.” He said it’s especially hard for those who own related businesses that benefit from high surgical volume (such as device distributorships or imaging centers) to set aside financial interests during clinical practice.

Here are five procedures Dr. Rickert thinks should be on the orthopaedic Choosing Wisely list:

  1. Vertebroplasty
  2. Rotator cuff repairs in asymptomatic/elderly patients
  3. Clavicle fracture plating in adolescents
  4. ACL repair in low-risk individuals
  5. Surgical removal of part of a torn meniscus

In citing the potential risks to patients who receive these procedures, Dr. Rickert admits to getting emails and other “grouchy comments” from fellow orthopaedists who don’t like his self-described “moral persuasion” campaign. What do you think of this list?

Bipartisan Doc-Fix Legislation Introduced

With 12 days to spare before a 21% reduction in physician Medicare payments takes effect, a bipartisan coalition of House and Senate lawmakers introduced identical bills that would scrap the SGR-based formula for physician reimbursement. Medscape.com reported that the SGR Repeal and Medicare Provider Payment Modernization Act of 2015 would boost physician pay by 0.5% during the second half of 2015 and in subsequent years from 2016 through 2019. The legislation redesigns the Medicare payment model from fee-for-service to pay-for-performance, and it also merges Medicare’s EHR and quality-reporting programs for easier administration by providers. Later this week or early next week, the House is expected to amend the legislation to extend the Children’s Health Insurance Program (CHIP) for two more years.

For the first time in recent memory, GOP leaders in both houses are indicating they won’t insist on specifying “pay-fors” for the entire cost of the bill. While Tea Party Republicans in the House are still calling for a complete cost offset, House Speaker John Boehner could get the bill passed amid Tea Party objections if he musters enough Democratic support.

In an online statement responding to the legislative filing, AAOS President Frederick Azar, MD, said, “The AAOS commends congressional leadership for introducing legislation to permanently repeal and replace the SGR formula.”

Stay tuned to OrthoBuzz…more will be revealed.

JBJS Editor’s Choice—Diabetes Boosts Infection Risk After ACL Surgery

swiontkowski marc colorIn the March 18 2015 edition of The Journal, Brophy et al. and investigators from the MOON Knee Group focus on that very rare complication of ACL reconstruction surgery: infection.  They prospectively followed a large cohort of more than 2,100 patients treated at multiple sites from 2000 to 2005.

The overall infection rate was less than 1%, which is in line with rates found in other studies. What was most notable is that the infection rate among patients with diabetes was 8.7% but only 0.7% in patients without diabetes. Statistically, having diabetes increased the odds of a post-ACL infection by nearly 19 times. Patients with diabetes should be counseled preoperatively so that they can be extra vigilant about detecting early signs of infection. Screening for diabetes prior to ACL surgery is not currently a standard of care, but it might be considered a reasonable approach in light of these findings. Surprisingly age and BMI were not associated with increased infection risk, and there was only a trend toward smokers being at higher risk.

Brophy et al. also found that patients receiving hamstring autografts were more than four times as likely to experience infection as those who received bone-tendon-bone (BTB) autografts. The authors’ hypothesis that the deep dissection required for hamstring harvest might increase infection risk seems plausible. It may also be that younger, healthier, more active patients (with presumably stronger immune systems) were more often offered BTB grafts.

What I like most about this study is that the MOON registry has very accurate clinical data because the investigators are clinicians who are highly invested in data quality. This is in distinction to studies that rely on administrative databases, where the coding of events is done by non-clinicians who may have less interest in entering highly accurate data.  Still, as clinically accurate as MOON data are, they are from more than a decade ago. Although the risk of post-ACL infection may be even lower in this decade, with these already-low rates, it would be difficult to statistically prove that progress.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

What’s New in Pediatric Orthopaedics: Level I and II Studies

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. Here is a summary of selected findings from Level I and II studies cited in the February 18, 2015 Specialty Update on pediatric orthopaedics:

Spine

–The landmark BrAIST study found that bracing helps prevent adolescent idiopathic scoliosis curves from progressing to a surgical range (≥50°), with a number needed to treat of 3. (See related OrthoBuzz article.)

–A randomized trial comparing the SpineCor brace to rigid bracing for correction of scoliosis found that the rate of curve progression was significantly higher in the SpineCor group.

Neuromuscular Conditions

–A study on the role of steroids in patients with Duchenne muscular dystrophy found that glucocorticoid therapy decreased the need for spinal surgery to treat scoliosis.

Trauma

–A randomized trial among patients 4 to 12 years of age with a distal radial or distal both-bone fracture found that the use of a double-sugar-tong splint for immediate post-reduction immobilization was at least as effective as the use of a plaster long arm cast.

–A randomized controlled trial of 61 patients from 5 to 12 years old who had a supracondylar humeral fracture found no functional or elbow-motion benefits associated with hospital-based physical therapy after short-term casting.

Foot and Ankle

–A randomized trial of 27 children less than 9 months of age who had resistant metatarsus adductus found that a group receiving orthotic treatment had greater improvement in footprint heel bisector measurements than those receiving serial casting. The orthotic program required more active parental participation but was about half the cost of casting.

–A randomized study of children under 3 months of age with idiopathic clubfoot who were treated with the Ponseti method found that the failure rates and treatment times were significantly higher in a below-the-knee casting group than in an above-the-knee casting group.

Anesthesia for Hip Replacement: General vs Spinal

A large retrospective cohort study analyzing nearly 21,000 patients who underwent primary total hip arthroplasty (THA) found that the 61% who received general anesthesia were much more likely to experience an adverse event within 30 days than the 39% who received spinal anesthesia.

Among the adverse events analyzed, the increased risks associated with general anesthesia were more than five-fold for prolonged postoperative ventilator use and cardiac arrest, and more than two-fold for unplanned intubation and stroke. These findings are generally consistent with those of prior research into this question, but the authors say this is “the largest study to date” looking at the comparison.

The authors analyzed data from the National Surgical Quality Improvement Program (NSQIP), and they found that the increased adverse-event risk with general anesthesia held throughout all ranges of preoperative comorbidity. They therefore contend that while many previous studies have found advantages for spinal anesthesia in “medically complex” joint-replacement patients, “this study indicates that these benefits may also extend to patients with fewer medical comorbidities.”

Despite these findings, the authors stress that spinal anesthesia is not risk-free, with the potential (albeit low) for permanent injury to the spinal cord or spinal nerves. They also note that their 30-day postoperative analysis did not capture patient-centered metrics such as postsurgical pain or longer-term functional outcomes.

Stuart Weinstein Wins OREF Award for Practice-Changing Scoliosis Research

WeinsteinThe Orthopaedic Research and Education Foundation (OREF) has bestowed its 2015 Clinical Research Award on Stuart Weinstein, MD, professor of orthopaedic surgery at the University of Iowa Hospitals & Clinics and former chair of the JBJS Inc. Board of Trustees.

Dr. Weinstein and his co-investigator Lori Dolan, PhD were recognized for a lifetime of clinical research into adolescent idiopathic scoliosis (AIS). Decades of their work culminated in the landmark BrAIST trial, a randomized/preference-cohort study that compared bracing to watchful waiting in 242 patients with AIS. That study found a treatment success rate of 72% in the bracing group, compared with a rate of 48% in the watchful-waiting group. BrAIST delivered Level I evidence that bracing can substantially reduce the risk of curvature progression to the surgical threshold of 50° or greater, and it has already started to change the way pediatric orthopaedists practice.

“Our research….has given patients and parents a solid evidence base upon which to make informed, patient-centered choices,” Dr. Weinstein told AAOS Now recently.

New NEJM Article Cites Old Clinical Guidelines for Knee OA Treatment

A “Clinical Therapeutics” article in the March 12, 2015 New England Journal of Medicine focuses on viscosupplementation for knee osteoarthritis (OA). In presenting a case vignette and making a therapeutic recommendation, Australian author David Hunter, MB, PhD, invokes the old, 2008 AAOS clinical practice guideline (CPG), which, according to Dr. Hunter, “determined that the evidence was inconclusive and a recommendation could not be made for or against the use of intraarticular hyaluronate.” However, the AAOS updated CPGs for knee OA in 2013, and the guideline for viscosupplementation changed substantially. It now reads: “We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee,” and that recommendation receives a “Strong” rating, based on evidence from more recent research studies.

In the end, the patient in the case vignette—a 67-year-old woman with knee pain, radiographic signs of knee OA, and a BMI of 32—was advised not to use hyaluronate injections and instead was encouraged to lose weight and undertake a muscle-strengthening exercise program.

Surgery and Sling Deliver Equal Outcomes for Proximal Humerus Fractures

A multisite, randomized trial of 250 patients (mean age of 66) with a displaced fracture of the surgical neck of the humerus found that mean Oxford Shoulder Score (OSS) outcomes were essentially the same among those who had surgery (plate fixation or humeral head replacement) and those who were treated with a sling and physical therapy. The OSS measures were made at 6, 12, and 24 months after randomization.

Proximal humerus fracture account for an estimated 5% to 6% of adult fractures, with most of them occurring in people older than 65. The authors of this study concluded that, amid what appears to be an uptick in surgical management of such fractures, “these results do not support the trend of increased surgery for patients with displaced fractures of the proximal humerus.”