Archive | May 2015

Two New Legislative Approaches to ICD-10

With the clock ticking toward an October 1, 2015 compliance deadline for ICD-10, Tennessee Rep. Diane Black recently introduced a bill, HR 2247, that would require a transition period for the changeover from ICD-9 codes. Rep. Black’s bill would not stall the October 1 compliance date, but it would require the U.S. Department of Health and Human Services (HHS) to provide transparent end-to-end testing of the new system to certify that it’s fully functional. According to the legislation, during the testing period and for 18 months following HHS certification, the Centers for Medicare and Medicaid Services (CMS) would be prohibited from denying claims “due solely to the use of an unspecified or inaccurate code.” Essentially, that means CMS would have to accept, process, and pay claims that are submitted with either ICD-9 or ICD-10 codes.

Two weeks prior to the filing of Rep. Black’s legislation, Texas Rep. Ted Poe introduced HR 2126, which would simply prohibit HHS from replacing ICD-9 until the Comptroller General completes a study “to identify steps that can be taken to mitigate the disruption on health care providers resulting from a replacement of ICD-9.” Both pieces of legislation have been referred to the House Committee on Energy and Commerce and the House Committee on Ways and Means.

JBJS Reviews Editor’s Choice–Spine Surgery in an Ambulatory Setting

Improvements in surgical procedures continue to evolve at a brisk pace. It seems that, every year, incisions become smaller and operations, more streamlined. Certain operations that in the past would only have been performed as inpatient procedures are now being considered for outpatient surgery with same-day discharge.

In the May 2015 issue of JBJS Reviews, Kurd et al. review the ability to perform spine surgery in an ambulatory setting. The authors note that anterior surgical discectomy and fusion is now commonly performed in an ambulatory surgery center and, if patients are carefully selected, lumbar microdiscectomies and laminectomies can be performed in an ambulatory surgery center as well. The authors stress the importance of an established transfer plan to a hospital when needed and the ability to treat neurologic complications if they occur. Most importantly, the ability to treat potentially serious complications in a timely manner is critical.

The rationale for performing spine surgery in an ambulatory surgery center is primarily for the convenience of the patient. The authors note that friendly staff, minimal wait times, efficiency, and perhaps ease of parking allow for ambulatory surgery centers to have overall patient satisfaction rates of up to 92%. In addition, by moving procedures out of a hospital and into ambulatory surgery centers, the cost savings to Medicare alone have been substantial.

Practice guidelines for some of the important decisions regarding patients undergoing anesthesia have been established by the Society for Ambulatory Anesthesia (SAMBA), whose goal is to provide guidance on the use of anesthesia in an ambulatory setting. Recommendations such as avoiding general anesthesia when possible, using propofol for induction and maintenance, avoiding nitrous oxide and other volatile anesthetics, minimizing the use of opioids, and maintaining adequate hydration are among the most important. In addition, SAMBA recommends that all diabetic patients undergoing surgery at an ambulatory surgery center should have a hemoglobin A1C of <7%.

While several reports have established the safety of performing cervical surgical spine surgery in an ambulatory surgery center, concerns still exist regarding the treatment of life-threatening events such as an epidural hematoma. Other rare complications such as vertebral artery injury or esophageal injury require intraoperative consultation with another surgery subspecialty such as vascular surgery or otolaryngology, and such consultations may not be available in an ambulatory surgery center.

The spinal procedure that is most commonly performed on an outpatient basis is a single-level lumbar decompression. Microdiscectomy is also frequently performed. This article reviews the largest prospective series of outpatient lumbar discectomies to date and indicates that the role of proper patient selection is paramount and that comorbidities such as obesity, chronic obstructive pulmonary disease, and a history of stroke increase the risk of needing hospitalization. As the use of the ambulatory setting for spinal surgery continues to evolve, further delineation of the ideal conditions and requirements will become evident. In the meantime, elderly patients and patients with multiple comorbidities may be better managed at a hospital as they are at an increased risk of requiring hospitalization.

Thomas A. Einhorn, MD

Editor, JBJS Reviews

Is the Burgeoning Medical Scribe Industry a Good Thing?

ImaginScribee conducting an in-depth physical exam and history-taking with a patient in your office, while someone stands silently and expressionlessly in the background taking notes on a laptop about the interaction. That’s essentially what medical scribes do, and their services are in increasingly high demand as doctors and hospitals try to meet meaningful use guidelines with often-unwieldy EHR systems.

Physicians remain responsible for the content of every patient’s medical record, which requires a review of the scribe’s notes, but the scribe industry promises to save physicians hours of work each day. Most scribes are medical students or pre-med undergrads hoping to embellish their medical school applications with in-the-trenches experience—and make a few extra bucks ($8 to $16 an hour). The American College of Medical Scribe Specialists estimates that the number of medical scribes in the U.S. will jump five-fold in the next five years, from 20,000 currently to 100,000 by 2020.

OrthoBuzz recently spoke with one middle-aged orthopaedist whose practice experimented with medical scribes but who felt uncomfortable having a stranger listening in on the patient-physician interaction. In a recent “viewpoint” piece in JAMA, George Gellert, MD, posed another reason why medical scribes might not be a good idea: they could impede the needed innovations in EHRs that will be driven primarily by direct physician engagement with the technology and feedback on it.

OrthoBuzz would like to know about your experiences with medical scribes. Please tell us what’s working and what’s not by clicking on the “leave a comment” button in the box to the left.

Increasing Orthopaedic Subspecialization: Cause for Celebration or Alarm?

In thswiontkowski marc colore May 20, 2015 edition of The Journal of Bone & Joint Surgery, Horst et al. document the increasing subspecialization of orthopaedic residency graduates taking the American Board of Orthopaedic Surgery (ABOS) Part II oral exams. The authors found that in 2013, 90% of applicants for the Part II exam were fellowship-trained. Among those fellowship-trained applicants, 81% of the procedures they performed in 2013 were in their field of fellowship training.

One possible interpretation of these findings is that the increasing complexity of interventional care in our field calls for additional subspecialized expertise in order to serve patients well. Another is that deficiencies during the five-year orthopaedic training scheme leave young surgeons feeling incompletely prepared for independent practice. This narrowing of scope certainly can occur with the highly super-specialized faculty practices in some training programs, where residents are often not exposed to the management of routine orthopaedic conditions.

To address what Horst et al. see as potential “gaps in coverage across the field of orthopaedic surgery,” the ABOS is embarking on a program to evaluate the orthopaedic curriculum nationwide to usher in a new era of competency-based education. In the meantime, it is worth considering that smaller U.S. communities of 5,000 to 10,000 citizens really need orthopaedic surgeons with a broad set of diagnostic and therapeutic skills. Younger surgeons who start practicing in larger urban settings also need the same broad skill set to fulfill their community responsibilities for urgent/emergent care—and to successfully care for patients with a broad range of musculoskeletal problems while they build a referral base in their area of subspecialization.

Both of those scenarios require that orthopaedic surgeons in training and those who train them rededicate themselves to producing clinicians with broad skills who can serve their communities while exercising their professional responsibilities and fulfilling their personal goals.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

Psychological Distress Lowers Patient Satisfaction Scores

The main goal of orthopaedic surgeons is to help patients feel and function as well as possible. In that context, the notion of “patient satisfaction” is as old as Hippocrates himself. But in an era when patient satisfaction is eagerly measured and used to evaluate physician performance and determine compensation, the phrase takes on broader significance.

The May 20, 2015 JBJS features a retrospective study by Abtahi et al. that determined that psychologically distressed patients give significantly lower satisfaction scores following spine surgery than patients categorized as “normal.” These findings bolster an increasing body of evidence suggesting that patient-specific characteristics have a greater bearing on patient satisfaction measures than the actual quality of care delivered.

The study looked at 103 patients at a single academic spine surgery center who completed both a patient satisfaction survey (Press Ganey Medical Practice Survey, scored from 0 to 100) and a Distress and Risk Assessment Method (DRAM) questionnaire for the same clinical encounter. Using the DRAM data, researchers classified the patients into four groups: normal, at-risk, distressed-depressive, and distressed-somatic.

The mean overall patient satisfaction scores were as follows:

  • 90.2 in the normal group
  • 94.7 in the at-risk group
  • 87.5 in the distressed-depressive group
  • 75.7 in the distressed-somatic group

Mean scores for patient satisfaction with the provider, in the same group order as above, were 94.2, 94.2, 90.6, and 74.9, respectively.

The authors offer two possible explanations for the findings: “Patients with greater levels of distress and less effective coping strategies may be more likely to  perceive their entire medical care experience in a more negative light, or…psychological distress negatively impacts provider empathy and the communication quality between doctor and patient.”

In a commentary on the study (free content), Robert Barth, PhD observes that implementing scientifically credible health care guidelines often conflicts with patient expectations and decreases patient satisfaction. He argues that “monitoring the scientific credibility of health care is a much more direct and valid approach than judging the quality of health care on the basis of patient satisfaction.” At the same time, Barth cites prior research connecting psychological distress to poorer surgical outcomes and says the findings from Abtahi et al. “emphasize the need for clinicians to thoroughly consider the psychological makeup of the patient when providing surgical and other general medical services.”

JBJS Classics: The Role of Continuous Passive Motion in Orthopaedics

EachJBJS-Classics-logo 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.

Based in part on clinical observations of persistent stiffness, pain, and cartilage damage after prolonged immobilization, in a 1960 JBJS paper, Robert B. Salter described degenerative changes in cartilage of rabbit knee joints that had been immobilized. He suggested that this “obliterative degeneration” might be related to adherence of synovium to the articular surface, and he wondered elsewhere in the orthopaedic literature, “If intermittent motion is good for articular cartilage, would continuous motion be even better?”

This background led to the classic December 1980 JBJS publication in which Salter and his colleagues hypothesized that “continuous passive motion of a synovial joint in vivo would have a beneficial biological effect on the healing of full-thickness defects in articular cartilage.”

To test the hypothesis, Salter et al. made full-thickness cartilage defects at four sites in the knees of 147 rabbits. The rabbits were subjected postoperatively to either immobilization, intermittent active motion (normal cage activity), or continuous passive motion (CPM) created by a custom-made apparatus. Outcome measures included clinical observation of the animals, joint stiffness, and histology.

The extent of ultimate postoperative stiffness, adhesions, and cartilage healing all varied with the degree of immobilization, leading the authors to conclude that CPM

  • Was well tolerated by the animals without causing harm detectable by gross or histologic evaluation
  • Was associated with fewer adhesions than immobilization, and
  • Stimulated more rapid and complete cartilage restoration than either immobilization or intermittent active motion.

Subsequent work by Salter and co-workers evaluated the effect of CPM on other animal models of full-thickness cartilage defects, intra-articular fractures, acute septic arthritis, patellar tendon injury, ligament repair, autogenous and allogenic periosteal and osteoperiosteal grafts, and other conditions. Based in part on the favorable results of these pre-clinical studies as well as preliminary clinical trials, Salter suggested in CORR in1989 that CPM might be indicated after a host of other orthopaedic procedures, including open reduction and internal fixation of intra-articular or selected diaphyseal and metaphyseal fractures, capsulotomy and arthrolysis for post-traumatic arthritis, synovectomy for rheumatoid arthritis or hemophilic arthropathy, arthrotomy and drainage of septic arthritis, release of contractures or adhesions, metaphyseal osteotomy with internal fixation, and reconstruction of a medial collateral ligament.

A Google Scholar search in October 2014 indicated that the 1980 Salter at al. JBJS publication has been cited approximately 1,096 times. Many of the articles that cite the 1980 JBJS study appropriately focus on the effect of CPM on either the histology of cartilage repair, or the effect of CPM on adhesions and joint stiffness.

However, Salter’s observation of decreased stiffness in animals treated with CPM has been extrapolated to clinical applications that were not included in his original work, most notably total knee arthroplasty (TKA).Today the clinical use of CPM after arthroplasty is controversial. A 2010 Cochrane review, for example, identified 20 randomized controlled trials of 1,335 patients in which CPM had been evaluated after TKA. The review concluded that there is evidence that CPM increases knee flexion range of motion, but “the effects are too small to be clinically worthwhile.” A more recent 2014 Cochrane review of 11 randomized clinical trials involving 808 patients concluded that there is not enough evidence to conclude that CPM reduces venous thromboembolism after total knee arthroplasty.

With respect to CPM after cartilage-repair procedures, many other investigators have confirmed the findings Salter reported in 1980 in animal models. Indeed, the basic-science support is strong enough that CPM has been commonly used in humans after cartilage repair, yet its actual efficacy in people remains controversial. For example, in a 2010 systematic review, Fazalare and co-workers reviewed 1,087 human clinical studies in which CPM had been used after cartilage repair procedures. In spite of that large number of studies, Fazalare was unable to find any randomized, controlled studies related to CPM, and heterogeneity among procedures and outcome measures in those articles precluded performing a meta-analysis.

Authors of today may be envious of the more than 6,900 words and 52 photographs, photomicrographs, and graphs (totaling 20 printed pages) that JBJS devoted to Salter et al. in 1980, and one can’t help but wonder what this classic JBJS paper would look like if modified to fit today’s standards. But the main message is this: in spite of high-quality basic science studies using animal models, there remains a need for well-controlled studies in humans to test the efficacy of CPM after cartilage repair and other procedures.

Thomas W. Bauer, MD, PhD

JBJS Deputy Editor for Research

What’s New in Sports Medicine: 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 April 15, 2015 Specialty Update on sports medicine:


–A systematic review of Level-I and II studies suggests that the structural integrity of rotator cuff repairs (or lack thereof) does not correlate with validated patient subjective outcome measures.

–Authors of a randomized clinical trial comparing open and arthroscopic stabilization for recurrent anterior shoulder instability concluded that young male patients with visible Hill-Sachs lesions on radiographs may fare better with open repairs.

–A quantitative literature synthesis of 31 studies (2,813 shoulders) supported primary surgery for highly active young adults who sustain an anterior shoulder dislocation.

–Following rotator cuff surgery, patients randomized to receive a combined axillary and suprascapular nerve block experienced less pain and a lower frequency of rebound pain in the first 36 hours than those receiving only a suprascapular nerve block.

–A Level-II meta-analysis of early passive motion versus strict sling immobilization after arthroscopic rotator cuff repair found that early passive motion resulted in improved forward flexion at 6 and 12 months, with no apparent increased retear rate.


–A randomized trial comparing single- and double-bundle ACL reconstruction with the use of hamstring autograft found no differences in pivot shift or clinical scores at two years.

–Twenty patients with subacute ACL injuries were randomized to “prehabilitation” or control groups. At 12 weeks after surgery, the prehab group showed sustained improvements in single-leg hop and Cincinnati scores, but peak torque and muscle-mass gains had regressed to levels similar to those in the control group.

–A randomized study comparing contralateral versus ipsilateral hamstring tendon harvest for ACL repair identified neither drawbacks nor advantages with the contralateral approach.

–Sixty patients who’d received an isolated meniscal repair were randomized to get either a traditional rehab protocol (brace and toe-touch weigh bearing) or “free rehabilitation.” Based on MRI, partial healing or lack of healing occurred in 28% of the free rehabilitation group and in 36% of the traditional group.

–Authors of a systematic review concluded that nonirradiated allogenic tissue may be superior to radiated allografts for primary ACL reconstruction.

Cartilage Regeneration

–A randomized controlled trail comparing microfracture alone to microfracture plus application of a novel chitosan-based device demonstrated greater lesion filling and superior repair tissue with the novel device, although there were no differences in clinical benefit and safety at 12 months.

–A randomized controlled trial comparing accelerated with conventional rehabilitation following cartilage repair found that the accelerated group reached full weight-bearing two weeks earlier than the conventional group and reported higher quality-of-life scores.


–In a Level-II study of a population with acute hamstring injuries, those who received a single autologous platelet-rich plasma injection plus rehab had significantly reduced return-to-play time than a group that received rehab without the injection.


–A randomized study of 230 patients with chronic lateral epicondylitis found that those receiving leukocyte-enriched platelet-rich plasma had “clinically meaningful improvement” in pain at 24 weeks, compared to those in an “active control” group.

Foot & Ankle

–A randomized study of 84 patients with nonsurgically treated Achilles tendon tears showed no significant differences in rerupture rates or return-to-work times between a group given a weight-bearing cast and a group given a non-weight-bearing cast.

–A randomized trial of 200 patients with Achilles ruptures compared stable surgical repair and accelerated rehabilitation to nonoperative management. Surgical repair was not found to be superior to nonoperative treatment in terms of functional results, physical activity, or quality of life.

Protecting Surgeons’ Hands from Radiation during Fluoroscopy

The InF1.mediumternational Commission on Radiological Protection (ICRP) currently recommends a maximum of 50 rem (500 millisieverts, or mSv) of occupational hand-radiation exposure annually. A fascinating study using a surgeon manikin, mini and standard fluoroscopic c-arms, and a Sawbones model of distal radial fracture fixation showed that hand-radiation exposure averaged 31 µSv per minute. That finding suggests that hand surgeons would not approach the ICRP-recommended hand-exposure limit unless they performed close to 2,000 hand procedures involving fluoroscopy each year. However, authors Hoffler et al. are quick to add that “the effect of consistent exposure that does not exceed the annual limit, but continues for a multiple-decade career, is unknown.”

It comes as little surprise that treating a distal radial fracture can be a high-exposure event. To quantify the situation more precisely, Hoffler et al. fit a surgeon manikin with radiation-attenuating glasses, thyroid shield/apron, and gloves, and measured radiation exposure with dosimeters placed on the manikin in both exposed and shielded positions. They exposed the Sawbones model and the manikin, which was in a standard seated position for hand surgery, to radiation from three mini and three standard fluoroscopes for fifteen minutes continuously. The authors explained their rationale for fifteen minutes of continuous exposure as follows: “The mean fluoroscopy time for volar radial plating at our institution is sixty seconds…It is common for hand surgeons to use a fluoroscope fifteen times a month…If exposures average sixty seconds each, the hand surgeon could be routinely exposed to fifteen minutes of fluoroscopy monthly.”

The authors found that hand exposure was 13 times higher than exposures at the thyroid, groin, or chest. The eyes, the second-most exposed site, received an average of 4 µSv per minute. Radiation-attenuating gloves reduced hand exposure by a mean of 69%, and radiation-attenuating glasses decreased eye exposure by a mean of 65%. There were no significant differences in hand exposure between the mini and standard fluoroscopes.

OrthoBuzz encourages orthopaedic surgeons to consider these findings in light of the current proliferation of fluoroscopes outside the OR, especially in office settings. For their part, the authors encourage surgeons to minimize their own and their patients’ radiation exposure “by understanding the basic physics of x-ray radiation and maximizing all of the safety technologies that their specific fluoroscopy units offer,” including the use of personal protective equipment.

Short-Term Benefit from Electrical Stimulation after Rotator Cuff Repair

Ask anyone who has had rotator cuff surgery, and they’ll tell you how painful the first three postop months can be. Electrical stimulation might make that time period easier for patients.

A recent randomized controlled trial in Orthopedics found that 32 patients who received pulsed electromagnetic stimulation (applied at home through a battery-operated device) six to eight hours daily for six weeks after arthroscopic rotator cuff surgery had lower VAS pain scores and better Constant-Murley scores three months after surgery, when compared to a placebo group of 34 patients who used identical devices with the batteries removed. Additionally, patients in the active-treatment group returned to work and daily activities after an average of 3.4 months after surgery, compared to an average of 5.3 months for those in the control group.

All participants had similar small-to-medium rotator cuff tears, received the same surgical single-row repair, and underwent virtually identical rehab protocols. Clinical and functional outcomes had continued to improve for all patients at the two-year follow-up, but by then the between-group differences seen at three months had disappeared. The authors did not conduct an economic analysis of the use of the electromagnetic treatment.

Although this study shows that benefits from electromagnetic stimulation are short-lived, they occur at a postsurgical point in time that is clinically difficult for many rotator cuff patients.

3D Printing Moves from Metal to “Real” Bone

OrthoBuzz has reported previously on the 3D printing of implantable skeletal structures (click here for an example), but the materials used were metallic. Now, two new accomplishments with 3D printing have produced material that mimics the physiochemical properties and porous structure of real bone.

First, students from California State University in Long Beach created the LuxNova OsBot 3D printer. The students say that the OsBot can replicate the unique and complex structure of human bone tissue down to the micro and nano levels.

Meanwhip21le, in China, the Xi’an Particle Cloud Advanced Materials Technology Co. has wrapped up animal testing on a similar bioprinting device and is poised to enter human trials. The device uses both UV light and heat to “laminate” binder material until a bonelike structure is fabricated. In rabbits, the 3D-printed bone exhibited new bone-cell activity on its surface almost immediately after implantation.

Theoretically, surgeons could use 3D-printed bone grafts to replace cancerous or severely traumatized bone tissue, obviating the need for amputation or cadaver grafts.