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The Economics of Revision THA for Fractures: Sustainable?

At the risk of  economic oversimplification, it is difficult to sustainably provide a service when payment for it is less than the cost to perform it. But that is one reality exposed by Hevesi et al. in the May 15, 2019 issue of The Journal. Using National Inpatient Sample and ACS-NSQIP data, the authors compared the average costs and 30-day complication rates for revision total hip arthroplasties (THAs) performed for 3 different indications—fractures, wear/loosening, and instability—at both a local and national level. They found that the average hospitalization costs associated with a revision THA related to a fracture were 33% to 48% higher (p < 0.001) than the cost of revision THAs related to wear or instability.

However, the authors emphasize that all 3 of these indications for revision THA are reimbursed at the same rate based on Medicare Diagnosis-Related Group (DRG) codes. DRGs take into account patient comorbidities to determine reimbursement levels—but they do not adjust payments for THA revision according to indication. Hevesi et al. note that the only DRG reimbursement level that would cover the average cost of a revision THA for a fracture would be one performed on a patient with severe medical comorbidities or a major complication. Not surprisingly, patients who underwent a revision THA to treat a fracture were found to have a higher age and more medical comorbidities than those undergoing a revision for wear or instability.

The authors use this data to make a very compelling case that DRGs for revision THA should be changed so they are indication-specific, taking into account the underlying reason for the revision. They observe that “a DRG scheme that does not distinguish between indications for revision THA sets the stage for disincentivizing the care of fracture patients and incentivizing referrals to other facilities.” Those “other facilities” usually end up being large tertiary-care centers, which the authors claim “perform a higher percentage of the costlier revision THA indications.”

This problem of reimbursement inequality is not unique to revision THAs and requires further investigation in many fields. Unless “the system” addresses these subtle but important differences, tertiary referral centers may be inundated with patients who need procedures that cost more to perform than the institutions receive in reimbursement—an unsustainable scenario.

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

Trauma in the Developing World: A Call to Action

Over the past decade and a half, the problem of musculoskeletal trauma has been identified as impacting more individuals in developing countries than HIV, drug-resistant tuberculosis, and other infectious diseases that are commonly recognized as public health crises. The need for access to surgical treatment for patients who sustain traumatic injuries has recently garnered more attention. Yet funding from nongovernmental organizations and other national/international foundations has not reached the levels necessary to appropriately address this important public health issue.

In the May 15, 2019 issue of The Journal, Agarwal-Harding et al. document the issue of patients experiencing delayed access to musculoskeletal trauma care in the sub-Saharan country of Malawi. Thanks to the development of a trauma-care registry serving both rural and urban health centers in Malawi, the authors were able to clarify the factors associated with delayed presentation for care.

Not surprisingly, those factors included distance from treatment centers and sustaining an injury during a weekend. These issues are likely widespread throughout Africa and in many other developing countries, where EMS services are sparse at best and treatment facilities are generally under-resourced. Although an increasing number of people in developing countries are being injured in road/vehicle-related accidents, many of the patients evaluated in this study did not experience high-energy trauma, but were instead injured from falls and during sporting activities. In short, they experienced the types of injuries that are likely to occur to everyday people doing everyday activities anywhere in the world.

The issue of delayed access to care is addressable if we continue to acknowledge the incredible public health burden that musculoskeletal trauma places on individuals and society within the developing world. These injuries not only affect patient quality of life, but they also have large impacts on families and communities due to a loss of income or disability-imposed restrictions on community engagement. Addressing this issue is of great interest to the readers of JBJS, who are volunteering to serve the orthopaedic needs of the developing world in ever-increasing numbers.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

A Rash of Broken Femoral Nails—What’s Up?

I’ll be honest: I have never worried much about breakage of the cephalomedullary nails I implant for proximal femur fractures. Instead, I’m focused on the fracture reduction, soft-tissue handling, and proper implant positioning. These nails are very strong. Sure, failures of these implants may occur and have been reported. But I have never had a lengthy discussion with a patient about the potential risk of the implant breaking during normal activity—and I doubt many other surgeons have either.

That is why the article by Lambers et al. in the May 1, 2019 issue of The Journal grabbed my attention. The authors carefully analyzed 16 cases in which a specific cephalomedullary nail (the TFNA, made from a titanium-molybdenum alloy) broke in 13 patients after an average of 5 months. Of note, 3 patients who underwent a revision with the same type of nail had a repeat fracture of the implant. The majority of these patients had been treated for a reverse oblique intertrochanteric fracture —a type that we all commonly see and treat—and all the fractures had been well reduced at the time of nail insertion.

The implant fractures all occurred at the proximal aperture of the nail and were consistent with fatigue fracture of the alloy. But they all showed a unique “stepped propagation” pattern, whereby, according to the authors, “a planar crack arrested, changed planes by 90°, progressed, arrested, and then changed planes again by 90° until final failure.”

These types of implant failures are not common for this nail, but they apparently happen more often than I thought. I am certain that the manufacturer will be responding to this data, and I look forward to future design changes—especially because the authors hypothesize that prior changes to this nail’s design and/or alloy may have contributed to these breakages. Then again, there may have been errors in technique that made these types of failures more common, or maybe a different implant would have been a better choice for some of these patients. To me, matching fracture type and implant choice is very important.

I look forward to learning more about this issue and will keep these types of implant failures in the back of my mind during hip-fracture cases. In the meantime, Lambers et al. advise “vigilant clinical and radiographic surveillance of patients with unstable hip fracture patterns who undergo osteosynthesis with use of a TFNA implant.”

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

Shared Decision Making among Guatemalan Orthopaedists

The concept of asking and accounting for patient preferences in non-emergent treatment decisions has been discussed in the medical literature for nearly two decades. Michael J. Barry, MD and others have quite fully developed this notion of “shared decision making” (SDM). In the context of patient desires, SDM includes a presentation of the treatment options and the data regarding those treatment options, and a discussion of potential complications involved in each option.

The earliest work on SDM centered around patient choices for managing prostate disease, degenerative disc disease of the lumbar spine, and urinary incontinence. Only recently have orthopaedic surgeons embraced this concept, as more of us get training in and practice the necessary communication skills and cultural competency needed to engage our patients in SDM. But we still have a long way to go when it comes to facility with SDM, and this seems to be especially true in the orthopaedic communities of some non-US countries.

In the May 1, 2019 issue of The Journal, Martinez-Siekavizza et al. report results of a survey on the use of SDM among orthopaedic surgeons in Guatemala. Survey recipients were questioned about their SDM techniques in the clinical scenario of intertrochanteric hip fracture, although hip fracture may not have been the ideal condition to focus on, given the worldwide acceptance that this condition is almost always best managed surgically. Nevertheless, the survey showed that 25% of the surgeon respondents ”never” or “hardly ever” allowed their patients to participate in the treatment decision-making process. While the authors cite many systemic reasons for such lack of patient participation (such as surgical consent not being required in Guatemala and the limited resources in many rural areas of the country that often leave no choices available), 75% non-engagement with patients/families strikes me as very high.

The key facet of shared decision making is discussing all the potential treatment options with the patient. This aspect of SDM seems especially important for nontrauma elective cases in which the “best” treatment option may be less clear than in trauma cases.  Even so, Martinez-Siekavizza et al. found that surgeons who discussed the different treatment options with patients had an almost 3-fold greater likelihood of allowing patients to participate in decision making than those who did not. This makes intuitive sense, as it would be difficult for patients to take part in treatment decisions if they are not informed about the options that exist.

As surgeons, we need to do our best to ensure that patients understand all their treatment options, and we should sharpen our focus on shared decision making during our patient interactions. JBJS looks forward to receiving more manuscripts from all over the world that explore the techniques and value of SDM in orthopaedic patient management.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Diagnosing PJI: When The “Urine Dipstick” Outperforms Conventional Labs

Despite what seems like a new, high-quality study being published on the topic every week or so, orthopaedic surgeons still have an extremely hard time determining whether a prosthetic hip or knee is infected or not. We have an array of available tests and the relatively easy-to-follow criteria for a periprosthetic joint infection (PJI) from the Musculoskeletal Infection Society (MSIS), but a large number of these patients still fall into the gray zone of “possibly infected.” This predicament is especially thorny in patients who received antibiotics just prior to the diagnostic workup, which interferes with the accuracy of many tests for PJI.

In the April 17, 2019 issue of The Journal, Shahi et al. remind orthopaedic surgeons about a valuable tool that can be used in this scenario. Their retrospective study looked at 121 patients who had undergone revision hip or knee arthroplasty due to an MSIS criteria-confirmed periprosthetic infection. Shahi et al. sought to determine which diagnostic tests were least affected by prior antibiotic administration. The authors found that erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, synovial white blood cell (WBC) count, and polymorphonuclear neutrophil (PMN) percentage were all significantly lower in the 32% of patients who had received antibiotics within 2 weeks of those tests, compared with the 68% who did not receive antibiotics. The only test that was found not to be significantly affected by the prior admission of antibiotics was the urine-based leukocyte esterase strip test.

Considering the ease and rapidity with which a leukocyte esterase test can be performed and evaluated (at a patient’s bedside, with immediate results), its low cost, and the fact that it is included in the MSIS criteria, these findings are very important and useful. While we would prefer that patients with a possibly infected total hip or knee not receive antibiotics prior to their diagnostic workup, previous antibiotic exposure remains a relatively common scenario. The findings from this study can assist us in those difficult cases, and they add further evidence to support the value and reliability of the easy-to-perform leukocyte esterase test.

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

Coordinated Geriatric Hip Fracture Programs: They Work

The practice of using a geriatrician- or a hospitalist-based co-management team to care for elderly patients who are admitted to the hospital for treatment of fragility fractures or other orthopaedic procedures is now more than a decade old. These services have grown in popularity because patients are living longer with comorbidities and becoming more complex to manage medically, and because shift-based hospitalist practices have become more common. These coordinated partnerships help the hospitalist- or geriatrician-led medical team optimize the patient’s care medically, while allowing the orthopaedic surgeon to focus on the patient’s musculoskeletal condition. The consensus I have heard is that patients are better off with these co-management systems, but hard evidence has been sparse.

In the April 17, 2019 issue of The Journal, Blood et al. report on the use of the Institute for Healthcare Improvement (IHI) Global Trigger Tool to assess the adverse-event impact of a Geriatric Hip Fracture Program (GHFP). In a bivariate analysis of pre- and post-GHFP data, the authors document a decrease in the rate of adverse events and shorter lengths of stay among elderly hip-fracture patients after GHFP implementation. However, multivariable analysis confirmed only a trend toward decreasing adverse-event rates after the implementation of the program. This study also seems to confirm what many of us already know empirically—that hip-fracture patients with severe medical comorbidities (i.e., a high Charlson Comorbidity Index) are at increased risk of adverse events no matter what system of care they receive.

Still, what most orthopaedic surgeons have felt was a “no-brainer,” coordinated approach to optimizing patient care and decreasing adverse events now has more evidence of effectiveness. Because such programs decrease both adverse events and length of stay among elderly patients hospitalized for a hip fracture, orthopaedic surgeons everywhere should advocate for increased geriatrician training to support this movement. Furthermore, these findings should encourage further research into additional patient-centric medical care strategies that could improve outcomes for these patients.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Patient-Specific Instruments’ Effects on TKA Revision

Whenever we introduce new technology or techniques in hopes of improving orthopaedic surgery, at least one of two criteria should be met: The new technology should improve the outcome at a maintained cost, or it should decrease cost while maintaining at least an equivalent outcome. If neither of these conditions is met, we need to think twice about adopting it. To help us answer these “value” questions, we need relevant data. This is why studies such as the one by McAuliffe et al. in the April 3, 2019 issue of The Journal are so important.

The authors use the Australian Orthopaedic Association National Joint Replacement Registry to compare the rate of revision between 3 types of primary total knee arthroplasty (TKA):

  1. Those performed with image-derived instrumentation (IDI, i.e., patient-specific cutting jigs)
  2. Those performed using computer navigation
  3. Those using neither technology

McAuliffe et al. found no significant differences between groups in terms of cumulative percent revision at 5 years. Subgroup analysis revealed a higher rate of revision (hazard ratio [HR] 1.52, p = 0.01) for the IDI group relative to the computer-navigated group when patients were ≤65 years old. In addition, the IDI group had a much higher rate of patellar revision when patients received posterior-stabilized knees (HR of 5.33 when compared with the computer-navigated group, and HR of 4.16 when compared with the neither-technology group).

This study seems to suggest that whatever the benefits of IDI may be in terms of attaining a “proper” mechanical axis during TKA, IDI does not translate into a lower revision rate. And when these revision data are viewed in the face of the added costs associated with IDI, it makes little sense to advocate for the widespread use of this technology for TKA at this time.

While this study focused on TKAs, the take-home message can be extended. Orthopaedic surgery is by nature complex, requiring that multiple steps be performed in harmony to produce an optimal outcome. It is easy for us to focus on (and measure) a couple of key outcome variables and base our opinions of a technique’s or technology’s success on such findings. But when it comes to “novel” techniques and technological “breakthroughs,“ we need a lot of data on many different variables before we can make meaningful conclusions, change our practice, and advise our patients.

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

Clavicle Fracture Research: Enough Already?

Orthopaedic surgeons and their staffs are aware of the paradigm shift that has taken place in the last 10 to 15 years regarding the treatment of clavicle fractures. Interest in the outcome differences between surgical and nonsurgical treatment has grown substantially since the 2007 Canadian Orthopaedic Trauma Society publication in JBJS showed that, relative to nonoperative treatment, plate fixation of displaced midshaft clavicle fractures resulted in improved functional outcomes and fewer malunions in active adult patients. Since that time, The Journal alone has published 14 articles related to management of clavicle fractures. In addition, the orthopaedic literature contains a number of well-conducted meta-analyses on the topic, comparing both nonoperative and surgical treatment as well as different methods of surgical fixation.

So, with all this evidence, why have we published the randomized controlled trial on this topic by King et al. in the April 3, 2019 issue of The Journal? Partly because the authors build upon our knowledge by comparing a relatively new fixation device (a flexible intramedullary locked nail) to a more standard treatment (an anatomically contoured plate). These plate and nail devices are very different from one another in terms of mechanics and surgical technique, and the flexible nail used in this study is much different than the rigid, straight nails or pins that have been used in the past.

A union rate of 100% was observed in both groups, but the authors found that the flexible nail was significantly faster in terms of operative time. (A single surgeon experienced with both devices performed all 72 surgeries.) They also found that the DASH scores between the groups were similar until the 12 month follow-up, at which point the flexible intramedullary nail group had statistically better scores. The authors concede, however, that the 12-month DASH-score difference “might not be clinically relevant.”

There is one other reason why we deemed this article important: The flexible intramedullary device used in this study is substantially more expensive than prior fixation devices that have been shown to effectively treat clavicular fractures. King et al. did not compare device costs, but whenever we study a device that adds to the total cost of care we should attempt to prove that it adds enough patient benefit to warrant the added expense. As the authors conclude, both devices evaluated in this study appear to be effective at treating displaced/shortened clavicular fractures, and there are a number of other factors that both the surgeon and patient should consider (such as surgeon skill and experience and cosmetic results) when deciding which treatment to use.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Revisiting INR Targets Prior to TKA

An elevated International Normalized Ratio (INR)—a standardized gauge for how long it takes blood to clot—is rarely a good sign when someone is about to undergo an elective orthopaedic procedure. This is especially true for larger surgeries such as total hip or knee arthroplasty, in which there are already concerns about perioperative bleeding. Excessive surgery-related blood loss can lead to wound complications, increased length of hospital stay, and higher mortality rates. But what precisely constitutes an “elevated” INR? While some recommendations suggest that elective procedures be performed only when a patient’s INR is ≤1.5, the evidence supporting this recommendation, especially in the setting of total knee arthroplasty (TKA), is sparse at best.

In the March 20, 2019 issue of The Journal, Rudasill et al. use the National Surgical Quality Improvement Program (NSQIP) database to help define what “elevated” should mean in the context of TKA. They evaluated data from >21,000 patients who underwent a TKA between 2010 and 2016 and who also had an INR level reported within one day before their joint replacement. They stratified these patients based on their INR levels (≤1, >1 to 1.25, >1.25 to 1.5, and >1.5). Using multivariate regression analysis to adjust for patient demographics and comorbidities, the authors found a progressively increasing risk of bleeding requiring transfusion for each group with an INR >1 (odds ratios of 1.19, 1.29 and 2.02, respectively).  Relative to patients with an INR of ≤1, Rudasill et al. also found a significantly increased risk of infection in TKA patients with an INR >1.5 (odds ratio 5.34), and an increased risk of mortality within 30 days of surgery among patients with an INR >1.25 to 1.5 (odds ratio 3.37). Lastly, rates of readmission and the length of stay were significantly increased in patients with an INR >1.25.

While there are certainly weaknesses inherent in using the NSQIP dataset, this study is the first to carefully evaluate the impact of slight INR elevations on post-TKA morbidity and mortality. While I was not surprised that increasing INR levels were associated with increased bleeding events, I was impressed by the profound differences in length of stay, infection, and mortality between patients with an INR ≤1 and those with an INR >1.25. I agree with the authors’ conclusion that “current guidelines for a target INR of <1.5 should be reconsidered for patients undergoing TKA.”  Further, based on the risks highlighted in this study, prospective or propensity matched cohort studies should be performed to help determine whether anyone with an INR >1 should undergo a TKA.

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

Changing Workplace Culture to Avoid Physician Burnout

In the February 6, 2019 issue of JBJS, David A. Rothenberger, MD contributed a thoughtful and practical “What’s Important” article about how to foster well-being among physicians and thus reduce the risk of physician burnout.

Since the article’s publication, Dr. Rothenberger has received many comments from readers. Here are several, de-identified to protect privacy, along with some responses from Dr. Rothenberger:

In my opinion, the internal culture of medicine, and specifically surgery, is to blame for poor mental health, burnout, and depression… [Surgeons are] trying to make up declining reimbursement by working harder. .. I too lived in that culture and relished being the busiest surgeon in the system, knocking out 10 to 12 operations a day,… but after the age of 50, I began noticing age catching up and increasing negativity within the profession. That is about when I decided to bail out. I have never looked back, although I miss my patients. Our profession… rewards self-punishment. Like you, I am hopeful that this will change for future physicians… My hope is that the welcome influx of women physicians will teach us misguided men a thing or two about taking care of oneself, one’s family, and understanding the limits of what we can do.

 

I believe burnout, in my case, was caused by, among other things, the destruction of our fee schedules… My brightest child wanted to follow in my footsteps, and I talked him out of it… I feel society has forsaken us.  I plan to quit this November, and it’s not soon enough.

To which Dr. Rothenberger replied as follows:
“I understand your decision to leave medicine,… but my advice is ‘do not go it alone.’ Get some support from someone you trust who understands this predicament… Plan for your future after medicine.  Re-imagine your life.”

 

I know a lot of physicians here who have problems in their practice, including a lot of my partners. I think the concept of a Chief Wellness Officer [CWO] is a great idea. I plan on forwarding [your “What’s Important” article] to our administration.

To which Dr. Rothenberger replied as follows:
“A CWO will help only if the other leaders of your system are committed to changing the culture of the workplace.  It is not an easy undertaking, but I think the return on investment justifies the multiyear approach we are taking here [at the University of Minnesota].”

 

It is really meaningful that you have emphasized that this is a bigger issue than the individual. I believe you are absolutely correct in highlighting a culture shift that prioritizes giving…factors [such as autonomy] back to physicians. [That] is probably the single most effective way to turn this around.

I am finishing my orthopedic residency… Our hospital system occasionally holds “wellness activities” that typically include massage and similar events, but these often don’t work with a busy surgeon’s schedule.  I’m interested in making burnout prevention a more recognized issue within our department and want to help bring in resources to help our residents and staff, but I am struggling with how best to practically bring this about. Do you have any advice for integrating wellness resources and burnout prevention into a busy orthopaedic department?

To which Dr. Rothenberger replied as follows:
“Wellness activities” like massage, yoga, and exercise classes are often put together by Human Resources for the workforce at large.  They are useful to individuals but do little to change the workplace culture… Our effort here at the University of Minnesota is to build a Well-Being Alliance of health care professionals who are working together as a coalition of the willing to restore well-being and joy to the practice of medicine.  We will do this by changing our workplace culture—a multiyear effort.  Features of our Alliance are that it is

  1. Interprofessional (i.e., it involves MDs, nurses, pharmacists, etc.)
  2. Longitudinal (i.e., it includes students; residents and fellows; early, mid and late-career physicians; and retired members of our community)
  3. Evidence-based as much as possible, and
  4. Financially and operationally sustainable.”

These issues of physician wellness and burnout prevention need to be highlighted locally, and local resources need to be brought to bear to address the challenge. I’m grateful to be at the University of Minnesota, where Dr. Rothenberger and the Well-Being Alliance are tackling the problem in meaningful ways.

Marc Swiontkowski, MD
JBJS Editor-in-Chief