OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew R. Schmitz, MD, a member of the JBJS Social Media Advisory Board.
The American Academy of Pediatrics (AAP) Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (POSNA) recently issued a list of tests and treatments that physicians and patients should avoid. The list appears on the Choosing Wisely® website, an initiative of the American Board of Internal Medicine (ABIM) Foundation.
The list highlights 5 commonly encountered pediatric orthopaedic scenarios/conditions that often consume excessive time and resources with little or no clinical value in return. The Evidence Based Committee and Advocacy Committee of POSNA developed the peer-reviewed list and vetted it through both the POSNA Board of Directors and the AAP Executive Committee.
Although geared toward family and primary care physicians, the list contains important take-home points for orthopaedic surgeons who might have pediatric patients walk through their doors. The recommendations include the following:
- Screening ultrasound for developmental hip dysplasia is not needed if the newborn has no risk factors and has a clinically stable hip exam. The substantial rate of false positives with screening ultrasounds likely causes many children to undergo unnecessary treatment.
- Simple in-toeing does not require a radiographic workup or brace or surgical treatment in children younger than 8 years old. Unless there is severe tripping, falling, or marked asymmetry, a watchful waiting approach is best for this condition, which typically resolves with growth.
- Custom orthotics or shoe inserts are not needed for children with asymptomatic or minimally symptomatic flat feet. If the flatfoot is minimally symptomatic and flexible (arch reconstitutes when the child stands on his/her toes), it can be managed with observation or over-the-counter orthotics.
- Advanced imaging such as MRI or CT should not be ordered for most musculoskeletal conditions in children until all appropriate clinical, laboratory, and plain film examinations have been done. Most pediatric conditions can be accurately diagnosed with a good history, physical exam, plain radiographs, and occasional labs. Use advanced imaging only if a specific question arises from the preceding workup. CT scans expose patients to high levels of radiation and should be used judiciously. If MRI is deemed necessary, it is best to have the consulting orthopaedist order the MRI with specific protocols and sequences.
- Buckle fractures do not need follow-up radiographs if pain and tenderness have resolved after immobilization. These common pediatric injuries are inherently stable.
Both POSNA and the AAP should be commended on their evidenced-based and common-sense approach for tackling these common pediatric orthopaedic conditions.
Matthew R. Schmitz, MD is vice chair of the Department of Orthopaedics and chief of Pediatric Orthopaedics and Adolescent Sports Medicine at San Antonio Military Medical Center in Ft. Sam Houston, Texas.
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:
- Rotator cuff repairs in asymptomatic/elderly patients
- Clavicle fracture plating in adolescents
- ACL repair in low-risk individuals
- 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?
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.
The Choosing Wisely campaign seeks to bring more awareness to tests and procedures that should be discussed between physicians and patients. The campaign was spearheaded by the ABIM Foundation, and the American Academy of Orthopaedic Surgeons (AAOS) partnered with the campaign to develop a list of the five things physicians and patients should question.
- Avoid performing routine post-operative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.
- Don’t use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief.
- Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.
- Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.
- Don’t use post-operative splinting of the wrist after carpal tunnel release for long-term relief.
The list was developed after review of approved clinical practice guidelines and included input from specialty society leaders.
Add findings from a recent study in Arthritis & Rheumatology to the growing body of evidence indicating that glucosamine and chondroitin supplements have no measurable impact on relieving knee osteoarthritis (OA). These findings add support to existing guidelines that recommend against the use of these supplements for OA treatment (see related OrthoBuzz article).
Utilizing a so-called “new user” design, researchers analyzed four-year follow-up data on more than 1,600 people who were not using glucosamine/chondroitin at baseline. In addition to measuring joint space width, researchers captured knee symptoms with WOMAC pain, stiffness, and function scales. They also employed marginal structural models to control for time-varying confounders. In the end, there were “no clinically significant differences” between supplement users and non-users, and the study authors claimed that, in addition to being consistent with meta-analyses of glucosamine/chondroitin, these findings extend the data set to include “a more general population with knee OA.