Archive | August 2016

Could Bundled Payments Work with Cervical Fusion?

ACDF_Reimbursement_VariationThe answer to that question depends largely on how much the 90-day episode of care actually costs. Virk et al., in the August 17, 2016 edition of JBJS, provide benchmark data that could help policymakers design bundled payments for cervical fusions that are economically viable for providers.

The authors analyzed the Medicare 5% National Sample Administrative Database and found that 4,506 patients in that cohort underwent a one to two-level anterior cervical discectomy and fusion (ACDF) for cervical radiculopathy from 2005 to 2012. The mean cost per patient of the procedure plus the 90-day postoperative period was $15,417. The physician reimbursement represented 20.4% of that total, with the surgeon receiving 18% of the total. Reimbursements for hospitals for inpatient care represented nearly 73% of the total reimbursement. The study did not account for reimbursements from “Medigap” plans or private payers.

The authors also analyzed data from the same database for 90-day episodes of care related to total knee arthroplasty (TKA). The mean per-patient reimbursement for TKA patients was $17,451. The authors noted significant regional variation in reimbursement for ACDF, with the lowest rates in the Northeast and Midwest and the highest rates in the West.

Among the conclusions made by Virk et al. is the following: “Although payments to physicians have been implicated in the rise of health-care costs, the data suggest that the greater opportunity for reducing expenses involves hospital-related reimbursement.”

Click here for more OrthoBuzz coverage of bundled payments in orthopaedics.

2016 JOPA Video Awards

VideoAward_TwitterIn addition to the recently announced JBJS Journal of Orthopaedics for Physician Assistants (JOPA) writing awards, JBJS is offering two additional $1,000 awards for the following:

  • Best Physical Exam Video by a certified, practicing PA or NP (suggested length of 10 to 15 minutes)
  • Best Injection Technique Video by a certified, practicing PA or NP (e.g., subacromial, knee, or trigger finger injection)

Please submit videos without accompanying text, except for the title and author(s).

Submit your video via the JOPA Editorial Manager submission site, and please include a signed Video License Agreement.

For complete information on submitting video to JOPA, including sample videos, click here.

Please address questions regarding the video or writing contests to

What’s New in Orthopaedic Trauma

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, David Teague, MD, co-author of the July 7, 2016 Specialty Update on orthopaedic trauma, selected the eight most clinically compelling findings from among the 35 studies summarized in the Specialty Update.


–The randomized PROFHER trial found that surgical treatment of acute displaced proximal humeral fractures (with either ORIF or hemiarthroplasty) yielded no difference in patient outcomes compared with nonsurgical sling treatment at time points up to 2 years. Surgery was also significantly more expensive.1


–A randomized trial of 461 patients with an acute dorsally displaced distal radial fracture found no difference at one year in primary or secondary outcomes between a group that received ORIF and a group that received Kirschner-wire fixation. K-wire fixation was also more cost-effective.2


–A retrospective study of 137 type-III open tibial fractures concluded that both antibiotic prophylaxis and definitive wound coverage should occur as soon as possible for severe open tibial fractures. Prehospital antibiotic administration should be considered when transport is expected to take longer than one hour. 3


–A randomized trial of 214 patients who received either supervised physical therapy or engaged in self-directed home exercise after six weeks of immobilization treatment for an ankle fracture found no difference in activity and quality-of-life outcomes at 1, 3, and 6 months.4

Managing Thromboembolism

–A registry study examining the incidence of deep venous thrombosis (DVT)/pulmonary embolism (PE) after surgery for a fracture distal to the knee identified the following risk factors for a thromboembolic event: previous DVT or PE, oral contraceptive use, and obesity.

Wound Care

–A randomized controlled trial of 2,447 patients compared irrigation with normal saline solution at various pressures to castile soap irrigation. Saline was superior in terms of reoperation rates after 12 months but irrigation pressure did not influence the reoperation rate.5

–A retrospective cohort study involving 104 patients who required a fasciotomy found that hospital stays were shorter among patients who underwent delayed primary closure (DPC) or a split-thickness skin graft on the first post-fasciotomy surgery. The authors noted limited utility of repeat surgeries to achieve DPT if fasciotomy wounds were not closed primarily on the first return trip.6


–A prospective observational study of 376 trauma patients requiring orthopaedic surgery found that those with a BMI of >30 kg/m2 had an overall complication rate of 38% and had longer hospital stays, longer delays to definitive fixation, and higher infection rates than nonobese patients.7


  1. Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C,Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47.
  2. Costa ML, Achten J, Plant C, Parsons NR, Rangan A, Tubeuf S, Yu G, Lamb SEUK. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess.2015 Feb;19(17):1-124: v-vi
  3. Lack WD, Karunakar MA, Angerame MR, Seymour RB, Sims S, Kellam JF, Bosse MJ. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015 Jan;29(1):1-6.
  4. Moseley AM, Beckenkamp PR, Haas M, Herbert RD, Lin CW; EXACT Team. Rehabilitation after immobilization for ankle fracture: the EXACT randomized clinical trial. JAMA. 2015 Oct 6;314(13):1376-85.
  5. Bhandari M, Jeray KJ, Petrisor BA, Devereaux PJ, Heels-Ansdell D, Schemitsch EH, Anglen J, Della RoccaGJ, Jones C, Kreder H, Liew S, McKay P, Papp S, Sancheti P, Sprague S, Stone TB, Sun X, Tanner SL,Tornetta P 3rd., Tufescu T, Walter S, Guyatt GH; FLOW Investigators. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015 Dec 31;373(27):2629-41. Epub 2015 Oct 8.
  6. Weaver MJ, Owen TM, Morgan JH, Harris MB. Delayed primary closure of fasciotomy incisions in the lower leg: do we need to change our strategy? J Orthop Trauma. 2015 Jul;29(7):308-11.
  7. Childs BR, Nahm NJ, Dolenc AJ, Vallier HA. Obesity is associated with more complications and longer hospital stays after orthopaedic trauma. J Orthop Trauma. 2015 Nov;29(11):504-9.

JBJS Case Connections—Induced Membrane Technique Fills Many Bone Voids

Induced Membrane TechniqueSince its introduction in the late 20th century, the 2-stage induced membrane technique has been lauded for its bone-reconstruction advantages over alternatives such as distraction osteogenesis and vascularized bone. The cases presented in this month’s “Case Connections demonstrate that the technique can work with a variety of bone-defect shapes, sizes, and locations.

The springboard case, from the August 10, 2016 edition of JBJS Case Connector, describes 3 cases of chronic post-infection osteomyelitis in children in whom large diaphyseal defects were successfully treated with the induced membrane technique. Three additional JBJS Case Connector case reports summarized in the article focus on:

It is imperative to resolve all active infection before or during stage 1 of this procedure, and careful spacer removal prior to stage 2 is of paramount importance to prevent damage to the induced membrane.

JBJS JOPA Image Quiz: A Teenager with Thumb Pain After Hand-First Slide

JOPA IQ ThumbThis month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) describes the case of a 14-year-old boy with a history of a bifid first metacarpal who injured his thumb while sliding hand-first into a base during a baseball game. Anteroposterior and lateral radiographs of the thumb are shown, and findings from the physical exam are detailed in words and photos.

The Image Quiz reviews the function of and injuries to the ulnar collateral ligament (UCL), including the injury classically described as “skier’s thumb.” Pick the best among four possible next steps in diagnosing and treating this injury.

​Revision TKA: Similar Outcomes with Cemented or Hybrid Stem Fixation

One key question for orthopaedic surgeons regarding revision total knee arthroplasty (TKA) is how best to affix femoral and tibial stems. The August 17, 2016 edition of the Journal of Bone & Joint Surgery contains findings from a Level I randomized trial by  Heesterbeek et al . that addresses this clinical conundrum.

Thirty-two patients with Type-I or II bone defects who needed a revision TKA received the same basic implant, with the femoral components and tibial baseplates being cemented in all cases. However, in half the patients the femoral and tibial stems were cemented, and in the other half the stems were press-fit (so-called hybrid fixation).

Measuring micromotion with radiostereometric analysis (RSA) at baseline, 6 weeks, and 3, 6, 12, and 24 months, the authors found no significant between-group differences in component migration. Similarly, at the 2-year follow-up, there were no significant between-group differences in clinical scores, including KOOS and visual analog ratings of pain and satisfaction.

The authors expressed concern about what they deemed the “relatively high” number of components in both groups that migrated > 1 mm (translation) or > 1° (rotation), and they are continuing to follow all these patients to determine whether clinically relevant component loosening eventually ensues.

JBJS Editor’s Choice: Cosmesis Matters

Orthopaedic surgery is generally a discipline where functional restoration and pain relief take precedence over esthetics. However, all practicing surgeons know that how incisions appear is important to many patients and their families. This is especially true in pediatric orthopaedics, where parents feel a responsibility to limit any adverse experiences their child may have.Scar_8_17_16

In the August 17, 2016 edition of The Journal, Davids et al. provide our community with an important contribution regarding some basic principles of scar management in children—in this case, kids with cerebral palsy who had a second surgery to remove an implant. The take-home message is that scars that are acceptably thin with minimal discoloration are safe to treat and do well cosmetically with a repeat incision through the original scar. Scars that are broad and/or discolored basically end up with the same appearance when the implant is removed through excision (a second incision about the margins of the first incision) and layer closure.

This field is ripe for further investigation, and careful attention to methodology will be very important. Interventions that deserve additional study include topical and intralesional treatments for healing incisions, the impact of immobilization on the quality of scars below the knee, and the effects on scars of limited weight bearing, to name a few. Similar investigations in select groups of adults with scars about the shoulder, knee, and ankle will also be welcome additions to this objective evaluation of surgical-incision outcomes by Davids et al.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

“Adequate” Amount of Graft Boosts Success in Foot/Ankle Fusion

Graft_Material_8_3_16A therapeutic Level II study by DiGiovanni et al.  in the August 3, 2016 edition of The Journal of Bone & Joint Surgery examined the relationship between successful foot/ankle fusions and the amount of graft material used. The authors found that among 573 procedures in which graft material (either autograft or AUGMENT bone graft) occupied ≥50% of the cross-sectional fusion space at nine weeks, 81% were successfully fused at 24 weeks. However, among 101 procedures with <50% of the graft space filled, only 21% were successfully fused at 24 weeks.

The authors determined both graft-fill percentages at nine weeks and fusion success at 24 weeks using CT scans. The percentage of graft fill was estimated by mental summation of graft fill present in each individual CT slice of the joint, and joint fusion was determined by measuring the percentage of osseous bridging in the same semiquantitative manner.

The significant fusion rate differences between joints with and without ≥50% graft fill were consistent regardless of whether autograft or allograft was used and regardless of which joint was fused. The authors conclude that these findings “demonstrated that when a surgeon can eliminate bone-to-bone gaps in any joint intended for fusion,…such a joint has a significantly better chance of ultimately achieving fusion,” although they caution against “overpacking a joint with excessive graft material.” DiGiovanni et al. cite the need for further research “to determine the ideal amount of graft material required for a clinically relevant and impactful effect on fusion” and to help develop “graft materials that are easier to introduce and can be more precisely inserted into the intended fusion space.”

JBJS Classics: The Moseley Straight-Line Graph for Leg-Length Discrepancies

jbjsclassics-2016OrthoBuzz regularly brings 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 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.

One of the hallmarks of a great journal article is whether it changes practice. In 1977, Colin Moseley presented a new method of predicting future leg growth that automatically takes into consideration the child’s growth percentile and the amount of growth inhibition in the short leg. Dr. Moseley’s method has been widely accepted because it is user-friendly and only requires three data points at each visit to the clinic – skeletal age and length of the long and the short legs. The accuracy of the prediction relies on serial measurements at different time points during the child’s growth. The more data points,  the more accurate the prediction. Unlike other methods, no mathematical calculations are necessary.

Then as now, the beauty of the method is that the growth of both the long and short legs can be represented by straight lines on a graph. Dr. Moseley accomplished this by mathematically converting Green and Anderson’s growth-remaining data into a logarithmic form. The straight-line graph improved upon the Green and Anderson data, as it was able to address the influence of the child’s growth in height by providing a nomogram to plot longitudinal skeletal age data to determine the end of growth. Moseley’s graph also provided reference slopes to aid in decision-making about when epiphysiodesis should be performed.

Dr. Moseley compared the accuracy of his method to that of the Green and Anderson growth-remaining method by doing a retrospective study based on data from 30 children treated with epiphysiodesis who had adequate scanograms and skeletal-age radiographs. The patients came from the Shriner’s Hospitals for Crippled Children in Montreal, Canada and the Alfred duPont Institute in Wilmington, Delaware.

Dr. Moseley found that the straight-line graph proved to be as accurate as the growth-remaining method—and more accurate in cases of high growth inhibition. It is interesting to note that Dr. Moseley was the only person doing this study and there was no test for interobserver error, which would certainly be one of the concerns raised by today’s reviewers for JBJS. The study could also have been strengthened if Dr. Moseley had validated his method with a series of prospective cases.

Dr. Moseley made certain assumptions in developing this method for predicting leg-length discrepancy at maturity. He used skeletal age and not chronological age as the norm. He assumed that growth of both the long and short legs was linear and that each individual child would remain in the same growth percentile with respect to skeletal age.

In 1982, Frederic Shapiro from Boston Children’s Hospital reported five developmental patterns in leg-length discrepancies in JBJS. Interestingly, type 1, which comprised a large proportion of the 803 cases reviewed, had a linear growth pattern where the discrepancy increased at the same proportionate rate. This finding supported the assumptions that Dr. Moseley made for the majority of his cases, but it also confirmed that not all discrepancies progress at the same rate, the notable exceptions being in children with Perthes disease and leg-length discrepancies arising from femoral fractures.

Eng Hin Lee, MD, FRCS(C)
JBJS Deputy Editor

Positive Culture at Reimplantation in 2-Stage Exchange Arthroplasty Warrants Aggressive Treatment

Many orthopaedists order cultures of tissue and synovial fluid samples during the reimplantation phase of two-stage exchange arthroplasties. Now, thanks to a retrospective study by Tan et al. in the August 3, 2016 JBJS, surgeons have some guidance on how to interpret the results from such cultures.OB P.pngThe authors reviewed 267 cases of periprosthetic joint infections (186 knees and 81 hips) that were treated with two-stage exchange arthroplasty. Intraoperative tissue samples were obtained at the time of reimplantation, and 33 joints (12.4%) were found to have one or more positive cultures. Of those 33 cases, 15 (45.5%) had a subsequent arthroplasty failure, compared with 49 (20.9%) of the cases that were culture-negative at reimplantation. Failure rates did not differ between cases with 1 positive culture and those with ≥ 2 positive cultures.

After controlling for other variables, the authors determined that a positive intraoperative culture at the time of reimplantation was independently associated with >2.5 times the risk of subsequent treatment failure. These findings prompted Tan et al. to conclude that “even single positive cultures…should be treated aggressively.” They report that at their institution (the Rothman Institute in Philadelphia), “any positive culture at the time of reimplantation is now considered important…and is treated with systemic antibiotics.”

Among the limitations of this study is its inability to accurately assess the impact of antibiotic treatment in patients with positive cultures. The authors also stress the need for further evaluation of rapid intraoperative diagnostic tools that have shown promise in determining infection eradication more quickly than cultures can.