Archive | November 2018

Preventing Acetabular Component Migration in Revision THA

Revision total hip arthroplasty (THA) is a challenging procedure for many reasons, not the least of which is the risk of aseptic loosening leading to re-revision, especially in patients with severe acetabular defects. Acetabular components made of porous tantalum have a developed a good reputation for lower rates of re-revision, relative to components made of other materials. In the November 21, 2018 issue of The Journal of Bone & Joint Surgery, Solomon et al. bolster the evidence base regarding the success of porous tantalum acetabular components in revision THA.

The authors conducted a single-center prospective cohort study that used radiostereometric analysis (RSA) to accurately measure acetabular component migration in 55 revision THAs that involved a porous tantalum acetabular component. Over a mean follow-up of 4 years, 48 of the 55 components migrated <1 mm, the threshold that, based on previous findings in the literature, the authors defined as predicting later loosening. Five of the 7 components that exceeded the threshold were re-revised for loosening related to patient symptoms.

The RSA data for the 5 components that required re-revision revealed large proximal translations and sagittal rotations that increased over time until re-revision, although the RSA  readings revealed that the majority of the migration occurred in the first 6 weeks. Among the components that did not exceed the 1 mm threshold for migration at 2 years, none have been subsequently re-revised for loosening.

The authors also analyzed fixation methods in this cohort. They found that, at 2 years, the median proximal translation of components that used inferior screw fixation was significantly lower than that of components without inferior screw fixation. The take-home messages from this study seem to be as follows:

  • Porous tantalum acetabular components really do perform well in revision THA.
  • When indicated, inferior screw fixation lowers the risk of component migration.
  • Early component migration is a good predictor of long-term component survivorship.

Guest Posts: Two Views on Gawande’s New Yorker Article about EMRs

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent New Yorker article by Atul Gawande, the following two commentaries come from Matthew Christian, MD, and Paul Matuszewski, MD, respectively.

In his November 12, 2018 article in The New Yorker, Dr. Atul Gawande notes that more than 90% of American hospitals have been computerized in the past decade. In theory, that should make documentation easier, but Gawande cites a 2016 study revealing that most physicians now spend 2 hours documenting for every 1 hour of face-to-face patient interaction. That hit home to me when I joined a group practice that uses an electronic medical record (EMR) system for clinical documentation. One of my senior partners informed me that he spends 2 hours per day at home finishing clinic notes and dictations.

The downside of digitization seems clear. Dr. Gawande cites a study noting that primary care physicians screen positive for depression at a rate double that of the general population. A Mayo clinic study discovered that the amount of computer documentation was a strong predictor of physician burnout.

Gawande further describes medicine as a “complex adaptive system” that is “meant to evolve with time and changing conditions.” EMRs, conversely, seek to universalize and mandate best practices—often to a fault—with little or no flexibility. In Gawande’s adaptive model, computerization is “all selection and no mutation.”

What makes medicine so engaging and satisfying for me is treating each patient in a unique and personalized manner. It seems that the last bastion of the happy physician is the proceduralist, of which the orthopaedic surgeon is an example. We spend 2 or 3 fewer days a week documenting clinical visits and instead solve unique and intellectually challenging musculoskeletal problems. This break from a computer screen frees us to do the thing we have spent our whole adult lives training for—practicing medicine. That is, until the procedure is complete and we must log in to complete the operative notes, postop orders, attending attestation, and other seemingly endless tasks.

Matthew Christian, MD is an orthopaedic surgeon at OSS Health in York, Pennsylvania and a member of the JBJS Social Media Advisory Board.

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The electronic medical record—a marvelous marriage of modern technology and medicine to improve care for patients. At least, that was the promise.  How it has played out over the past decade, however, leaves much to be desired from the perspective of physicians. Patient care has not been streamlined, and mounting evidence suggests that EMRs have increased the workload for physicians, adversely altered the physician-patient relationship, and increased the degree of physician burnout.1  Atul Gawande’s New Yorker article outlines his and other physician experiences with EMRs, concluding that many physicians—especially nonsurgeons bound to an office or clinic—now hate their computers.

But why? Gawande describes the evolution of EMRs from simple “cool” programs into complex, “very uncool” systems, eventually culminating in what former IBM software engineer Frederick Brooks described as the “Tar Pit.” That’s when a system becomes so complex and universalized for so many different people and functions (clinical and administrative in the case of EMRs) that it becomes the electronic equivalent of miles of bureaucratic red tape. For physicians, the “Tar Pit” means more clicks, more steps, more checks, more alerts and notifications—with little or no improvement for patients and less work/life balance for doctors.

Gawande relates the experience of a primary-care physician who once effectively maintained her own problem list for each of her patients. But the list has become in her words “utterly useless,” because now anyone across the organization can modify it, often inserting duplication and inaccuracies.  Computerized complexity that adds more work but little to no value discourages physicians from engaging with the system, compounding the problem.

Gawande’s article doesn’t go into detail about how we can solve this problem, but it presents several ways that physicians and hospital systems have coped. Some have resorted to medical scribes (often aspiring med students) or more highly trained overseas physicians who transcribe physician encounters. Some tech-savvy physicians expend effort to bend the software to their will – customizing components of the EMR despite pushback from vendors. This has led to various home-grown apps designed to help improve workflow and reduce hassles.

Time will tell whether these or other workarounds will actually help. One thing is certain, however. Unless physicians take charge and guide the design (and redesign) of EMR technology, the system will fail to serve the physician, and the current reality of the physician serving the system will persist.

Paul E. Matuszewski, MD is an assistant professor of orthopaedic traumatology and Director of Orthopaedic Trauma Research at the University of Kentucky School of Medicine and a member of the JBJS Social Media Advisory Board.

Reference

  1. Arndt et al. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Fam Med. 2017 (15) 5, 419-426
    Editor’s Note:
    The US Department of Health and Human Services has unveiled a draft plan to ease the burden of using EMR software. The draft strategy is open for public comments through January 28, 2019. Also, see this related OrthoBuzz Editor’s Choice post from JBJS Editor-in-Chief Dr. Marc Swiontkowski.

 

What’s New in Orthopaedic Rehabilitation 2018

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, Nitin Jain, MD, MSPH, a co-author of the November 21, 2018 Specialty Update on Orthopaedic Rehabilitation, summarized the most clinically compelling findings from among the more than 40 noteworthy studies summarized in the article.

Acute Pain Management

–A randomized double-blind study comparing 4 two-way combinations of analgesics (three of which contained an opioid medication)1 in emergency-department patients experiencing acute extremity pain found no significant between-group differences in mean pain scores at 1 and 2 hours after medication administration.

Total Hip Arthroplasty

–A randomized clinical trial of >100 patients who underwent unilateral total hip arthroplasty found no significant differences in functional outcomes between a group that participated after surgery in a self-directed home exercise program and a group that participated in a standardized physical therapy program.

Concussion

–An assessment of brain tissue from 202 American football players2 whose organs were donated for neuropathological evaluation found that 87% had evidence of chronic traumatic encephalopathy (CTE). Analysis of brain tissue from former NFL players in the cohort showed that nearly all had severe CTE.

Rotator Cuff Tears

–A study following the natural progression of full-thickness, asymptomatic, degenerative rotator cuff tears found that patients with fatty muscle degeneration were more likely to experience tear-size progression than those without fatty infiltration.

Low Back Pain

–A study consolidating data from 3 separate randomized trials attempted to evaluate the efficacy of radiofrequency (RF) neurotomy for treating a heterogeneous collection of diagnoses that commonly result in low back pain.3 No significant or clinically important differences were found when the RF procedure was compared with a standardized exercise program. The number needed to treat for all 3 arms of the study ranged from 4 to 8, with a median of 5. Some have called into question the methods of this study, particularly the diagnostic criteria used for patient inclusion and the potential inaccuracy of lumping together heterogeneous diagnoses.

References

  1. Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017 Nov 7;318(17):1661-7.
  2. Mez J, Daneshvar DH, Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, Alosco ML,Solomon TM, Nowinski CJ, McHale L, Cormier KA, Kubilus CA, Martin BM, Murphy L, Baugh CM, Montenigro PH, Chaisson CE, Tripodis Y, Kowall NW, Weuve J, McClean MD, Cantu RC,Goldstein LE, Katz DI, Stern RA, Stein TD, McKee AC. Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football. JAMA. 2017 Jul 25;318(4):360-70.
  3. Juch JNS, Maas ET, Ostelo RWJG, Groeneweg JG, Kallewaard JW, Koes BW, Verhagen AP, van Dongen JM, Huygen FJPM, van Tulder MW. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the Mint randomized clinical trials. JAMA. 2017;318(1):68-81.

Treating Displaced AC Joint Dislocations: Patient Expectations Matter

Often in life, when there are many potential solutions for a single problem, none of them is found to be universally better than the others. That certainly seems to be the case when it comes to treating type III- and -IV acromioclavicular (AC) joint dislocations. Multiple studies have tried to clarify whether nonoperative or operative management is superior in this relatively common injury, but it is becoming increasingly clear that there is no single “right” answer. Many patients do fine with nonoperative treatment; others report being highly satisfied with an operation.

In the November 21, 2018 issue of The Journal, Murray et al. try to provide further guidance for treating these injuries. They performed a prospective, randomized controlled trial that compared nonoperative treatment with open reduction and tunneled suspensory device fixation among 60 patients with a type-III or type-IV AC joint dislocation. The authors used DASH, OSS, and SF-12 scores to quantify functional differences between the groups at 6 weeks, 3 months, 6 months, and 1 year post-injury. They found that, while the operative group showed improved radiographic alignment of the AC joint compared to the nonoperative group, there were no differences in functional outcomes between the two groups at any time beyond the 6-week mark (at which point the nonoperative group had better outcomes).

Notably, 5 of the 31 patients allocated to nonoperative treatment ended up requesting surgical treatment for the injury because of persistent discomfort (4 patients) or cosmesis (1 patient). Also, not surprisingly, the mean economic expenditure in the fixation group was significantly greater than that in the nonoperative group.

Whether to provide operative or nonoperative treatment for type-III and -IV acromioclavicular joint dislocations is not an easy decision, and it entails multiple factors. While this study evaluates only one modern surgical technique for treating this injury, the data is valuable nonetheless for informing a shared decision-making process to help patients choose the most appropriate treatment for them. The good news is that, whether managed operatively or not, patients tend to improve significantly after these injuries, and after 1 year end up with a shoulder that functions well. The authors conclude that “the routine use of [this surgical procedure] for displaced AC joint injuries is not justified,” and that “treatment should be individualized on the basis of [patient] age, activity level, and expectations.”

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Comparing the Potential of Cartilage-Cell Therapies

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs.Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson. 

Other than by using shell allografts, it is not possible to replant whole cartilage or cells that even come close to a biological construct matching original cartilage. The old adage that cartilage, unlike bone, cannot repair itself holds true, as the natural damage repair of cartilage leads to the formation of “scar” cartilage (fibrocartilage).

However, there are connective tissue progenitor cells that can be found in multiple different tissues, and chondrogenic connective-tissue progenitors (CTP-Cs) are found within articular cartilage, even if it is osteoarthritic. Investigators recently designed a study to quantitatively define the CTP-Cs resident in cartilage and to compare overall cartilage-cell concentration, CTP-C prevalence, and biological potential of cells in tissues taken from patients with different grades of osteoarthritis.

Investigators procured samples of osteoarthritic articular cartilage from 23 patients undergoing elective total knee arthroplasty. All patients had grade 3-4 osteoarthritis on the medial side and grade 1-2 on the lateral side. Each patient sample was assessed for mean cell concentration and CTP prevalence by subjecting cells from a unit measure of cartilage to specific conditions to promote colony formation. The biological potential of the CTPs was measured using sophisticated imaging analysis.

Cell concentration was significantly greater (p < 0.001) in grade 3-4 cartilage than in grade 1-2 cartilage. This matches findings from previous histologic reports. Although the prevalence of CTP-Cs varied widely, it trended lower in grade 3-4 than grade 1-2 cartilage samples (p = 0.078). The biological performance of CTP-Cs from grade 1-2 and grade 3-4 cartilage was comparable. Increased cell concentration was a significant predictor of decreased CTP-C prevalence (p = 0.002). Sex was not a predictor of cell concentration, but age correlated negatively with prevalence of CTP-Cs. The number of cells per colony varied widely across the 23 patients, implying a highly individualized capacity.

This research contributes to our understanding of what might constitute appropriate cell selection for combination with biochemical interventions that could lead to robust cartilage repair that has greater longevity.

Residents in the OR—What’s the Risk?

Orthopaedic educators have long confronted the subtle implication that resident participation in surgical care can contribute to patient harm or even death. While there have been numerous changes in residency education to improve the  supervision and training of residents, the reality is that surgical trainees have to learn how to operate. This fact can leave surgical patients understandably nervous, and many of them heave heard rumors of a “July effect”—a hypothetical increase in surgery-related complications attributed to resident education at the beginning of an academic year. To provide further clarity on this quandary, in the November 21, 2018 issue of The Journal, Casp et alexamine the relationship between complication rates after lower-extremity trauma surgery (for hip fractures, predominantly), the participation and seniority of residents, and when during the academic year the surgery occurred.

The authors used the NSQIP surgical database to examine >1,800 patient outcomes after lower-extremity surgery according to academic-year quarter and the postgraduate year of the most senior resident involved in the case. The analysis revealed two major findings:

  1. Overall, there was no “July effect” at the beginning of the academic year in terms of composite complication rates.
  2. Cases involving more senior residents were associated with an increased risk of superficial surgical site infection during the first academic quarter.

While the authors were unable to provide a precise reason for the second finding, they hypothesized that it could have been related to more stringent data collection early in the academic year, senior-resident inexperience with newly increased responsibilities, or the warm-temperature time of year in which the infections occurred. Casp et al. emphasize that the database used in the study was not robust in terms of documenting case details such as complexity and the degree of resident autonomy, which makes cause-and-effect conclusions impossible to pinpoint.

Although this large database study does not answer granular questions regarding the appropriate role of residents in orthopaedic surgery, it should stimulate further research in this area. Gradually increasing responsibility is necessary within residency programs so that residents develop the skills and decision-making prowess necessary for them to succeed as attending surgeons. Studies like this help guide future research into the important topic of graduate medical education, and they provide patients with some reassurance that the surgical care they receive is not affected by the time during the academic-calendar year in which they receive it.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

More Evidence: Coordinated Care Reduces Risk of Second Fragility Fracture

Fracture liaison services and similar coordinated, multidisciplinary fragility-fracture reduction programs for patients with osteoporosis work (see related OrthoBuzz posts), but until now, the data corroborating that have come from either academic medical centers or large integrated health care systems. The November 7, 2018 issue of The Journal of Bone and Joint Surgery presents solid evidence from a retrospective cohort study that a private orthopaedic practice-based osteoporosis management service (OP MS) also successfully reduces the risk of subsequent fragility fractures in older patients who have already sustained one.

Sietsema et al. collected fee-for-service Medicare data for Michigan residents who had any fracture from April 1, 2010 to September 30, 2014 (mean age of 75 years). From that data, they compared outcomes for patients who received nurse-practitioner-led OP MS care from a single-specialty private orthopaedic practice within 90 days of the first fracture to outcomes among a propensity-score-matched cohort of similar patients who did not receive OP MS care. There were >1,300 patients in each cohort, and both groups were followed for an average of 2 years. The private practice’s OP MS services incorporated the multidisciplinary protocols promulgated by the American Orthopaedic Association’s “Own the Bone” program.

The cohort exposed to OP MS had a longer median time to subsequent fracture (998 versus 743 days), a lower incidence rate of any subsequent fracture (300 versus 381 fractures per 1,000 person-years), and higher incidence rates of osteoporosis medication prescriptions filled (159 versus 90 per 1,000 person-years). Over the first 12 months of the follow-up period, total medical costs did not differ significantly between the 2 cohorts.

These findings are consistent with those reported from academic or integrated health-system settings. According to the authors, this preponderance of evidence “emphasize[s] the importance of coordinated care in reducing subsequent fractures, lengthening the time to their occurrence, and improving patient outcomes.” Sietsema et al. conclude further that “the U.S. Medicare population would benefit from widespread implementation of such models in collaboration with orthopaedic providers and payers.”

Physical Parameters Beyond BMI Affect TKA Outcomes

It is well established that obese patients who undergo total joint arthroplasty have increased risks of complications and infections. But what about folks who are not obese, but are just generally large? Do they also have increased post-arthroplasty complications, compared to their smaller counterparts? That is the question Christensen et al. explored in a registry-based study in the November 7, 2018 edition of JBJS.

In addition to BMI, the authors examined 3 other physical parameters—body surface area, body mass, and height—to determine whether these less-studied characteristics (all contributing to “bigness”) were associated with an increased rate of various adverse outcomes, including mechanical failure and infection, after primary total knee arthroplasty (TKA).  They evaluated data from more than 22,000 TKAs performed at a single institution and found that the risk of any revision procedure or revision for a mechanical failure was directly associated with every 1 standard deviation increase in BMI (Hazard Ratio [HR], 1.19 and 1.15, respectively), body surface area (HR, 1.37 and 1.35, respectively), body mass (HR, 1.30 and 1.27, respectively), and height (HR, 1.22 and 1.23, respectively). In this study, 1 standard deviation was equivalent to 6.3 kg/m2 for BMI, 0.3 m2 for body surface area, 20 kg for body mass, and 10.5 cm for height.

These findings, while not all that surprising, are enlightening nonetheless. The study shows that increasing height has a greater negative impact on TKA outcomes than previously thought. While I spend a lot of time counseling patients with high BMIs about the increased risks of undergoing a TKA (and while such patients can take certain actions to lower their BMI prior to surgery), I do not spend nearly as much time counseling patients who are much taller than normal about their increased risks (and height is not a modifiable risk factor). Nor do I spend much time thinking about a patient’s overall body mass or body surface area in addition to their BMI. This study will remind me not to overlook these less commonly examined  physical parameters when discussing TKA with patients in the future.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

November 2018 Article Exchange with JOSPT

In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of November 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Does Health Care Utilization Before Hip Arthroscopy Predict Health Care Utilization After Surgery in the US Military Health System? An Investigation Into Health-Seeking Behavior.

This observational cohort study found that patients who used more health care prior to hip arthroscopy also used more health care after surgery. The findings lead the authors to conclude that clinicians “should consider prior patterns of health care utilization…when determining care plans and prognosis.”

Pre-Visit Pain and Anxiety Influence Patient Satisfaction

Biopsychosocial for O'BuzzExperienced orthopaedic clinicians understand that anxious patients with high levels of pain are  some of the most challenging to evaluate and treat. Both anxiety and pain siphon away the patient’s focus and concentration, complicating the surgeon’s job of relaying key diagnostic and treatment information—often leaving patients confused and dissatisfied. Moreover, such patients usually want a quick solution to their physical pain and mental angst, whether that be a prescription for medication or surgery.  At the same time, despite controversy, variously defined levels of “patient satisfaction” are being used as a metric to evaluate quality and value throughout the US health-care system. This reinforces the need for orthopaedists to understand the complex interplay between biological and psychological elements of patient encounters.

In the November 7, 2018 issue of The Journal, Tyser et al. use validated instruments to clarify the relationship between a patient’s pre-existing function, pain, and anxiety and the satisfaction the patient received from a new or returning outpatient visit to a hand/upper extremity clinic. Not surprisingly, the authors found that higher levels of physical function prior to the clinic visit correlated with increased satisfaction after the visit, as measured by the widely used Press Ganey online satisfaction survey.  They also noted that higher antecedent levels of anxiety and pain, as determined by two PROMIS instruments, correlated with decreased levels of patient satisfaction with the visit. The authors assessed patient satisfaction only with the clinic visit and the care provider, not with any subsequent treatment.

Most patients are likely to experience some level of pain or anxiety when they meet with an orthopaedic surgeon. To leave patients more content with these visits, we need to set appropriate expectations for the visit in advance of the interaction and develop real-time, in-clinic strategies that help patients cope with anxiety. Such “biopsychosocial” strategies may not by themselves dictate the ultimate treatment, but they may go a long way toward helping patients understand their options and feel satisfied with the care provided. Secondarily, such strategies may help improve the satisfaction scores that administrators, rightly or wrongly, are increasingly using to evaluate musculoskeletal practitioners.

Marc Swiontkowski, MD
JBJS Editor-in-Chief