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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

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

Better News for TJA Patients with Depression

Mental Health Image for OBuzzOver the last 2 decades, research into how various “preexisting conditions” affect the outcomes of orthopaedic interventions has increasingly focused on the impact of mental health (a patient’s “state of mind” and coping abilities) and psychological diagnoses such as depression. The impact of mental health, depression, and personality characteristics on patient-reported outcomes following significant skeletal trauma has been well documented in the trauma literature. In addition, previous studies in knee arthroplasty have identified depression as a major factor in suboptimal patient outcomes.

In the October 17, 2018 issue of The Journal, Halawi et al. teased out the impact of depression and mental health—independently and in combination—on patient-reported outcomes following primary total joint arthroplasty (TJA) in 469 patients at a minimum follow-up of one year.

The authors used the validated SF-12 MCS instrument to assess patient baseline mental health at the time of surgery. They also used the widely accepted WOMAC score to assess joint-specific pain, stiffness, and physical function before and after surgery. Using these tools, the authors showed that, while depression alone may diminish some patient-reported gains obtained from arthroplasty, it does not seem to affect a patient’s overall outcome as much as poor mental health prior to surgery. In this study, patients with depression but good mental health achieved patient-reported outcomes comparable to those among normal controls. Still, patients without depression and in good mental health were found to have the most robust improvements after undergoing TJA.

Orthopaedic surgeons need to better understand the interplay between these complex psychological states and patient outcomes. These authors conclude that the effect of depression on patient-reported outcomes is “less pessimistic than previously thought,” but we welcome further studies examining the link between “the mind” and orthopaedic outcomes.  Finally, we should be ready to refer patients to our mental health colleagues when we detect a potential underlying nonphysical condition that might adversely affect the magnitude of benefit from the treatments we offer.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Activities that Patients—and their PTs—Should Avoid After THA

Hip Cup Friction for OBuzzThe adult joint-reconstruction community has made great strides in the last 2 decades in understanding what causes aseptic loosening of arthroplasty components. For example, revelations about polyethylene particulate debris has led to the production of  highly cross-linked polyethylene, which in turn has lowered wear rates, decreased revision rates, and increased the survivorship of total hip implants (see related OrthoBuzz post). Still, polyethylene debris is only one factor that can lead to aseptic loosening. Another important, yet often overlooked, factor is friction between the impacted acetabular shell and the host bone.

In the October 3, 2018 issue of The Journal, Bergmann et al. report data that help us better understand the “friction factor” in aseptic loosening. The authors implanted specially designed, instrumented acetabular components that measured in vivo friction moments among nine patients while they engaged in >1,400 different activities. The authors found that 124 of those activities led to friction moments >4 Nm—which appears to be the upper limit for facilitating a firm union between the acetabular component and the native socket.

Movements such as muscle stretching in the lunge position,  the breaststroke in swimming, 2-legged standing with muscles contracted,  and a single-legged stance while moving the contralateral leg were among those that created the highest friction between the implant and the host bone—and that could impede bone ingrowth into the acetabular component and thus contribute to aseptic loosening. The study also highlights the importance of periodic unloading of the prosthetic joint to allow proper synovial lubrication, which helps minimize the effects of high-friction moments. The good news is that the vast majority of activities studied do not appear to result in friction forces above the 4 Nm threshold.

Although these data should be confirmed with other in-vivo instrumented prostheses (assuming there are more patients willing to receive acetabular components capable of delivering telemetric data), they provide practical insight into the real-world forces placed on total hip prostheses after implantation. Such information can be used to counsel patients regarding high-friction and sustained-loading activities to be avoided, and it can help physical therapists and surgeons tailor postoperative regimens that optimize patient recovery while minimizing the risk to implanted prostheses.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Location, Location, Location: Geographic Disparities in Orthopaedic Care?

Geographic Distribution for OBuzzWhen it comes to access to many things people look for, big cities offer numerous advantages over small towns.  This seems to be true for consumer goods and services—and for access to health care, especially “high-tech” procedures. That is one issue that Suchman et al. touch on in their retrospective database study in the September 19, 2018 issue of The Journal.

The study evaluated almost 650,000 patients who underwent one of three meniscal procedures (meniscectomy, meniscal repair, or meniscal allograft transplantation) in New York State from 2003 to 2015. In determining which procedures were performed where, the authors found that meniscectomies and meniscal repairs—the vast majority of the procedures performed—were scattered throughout the state, but that meniscal transplants were performed almost exclusively at urban, academic hospitals. This finding is not surprising, considering the technical complexity of allograft transplantation. However, if a patient who would benefit from a meniscal allograft lived three hours from an urban, academic setting, they would either have to travel to the city to be evaluated, treated, and followed, or settle for a different procedure from a surgeon closer to home. Neither option would be optimal in terms of quality care.

At the same time, this article emphasizes that not every patient needs to go to a large hospital to receive excellent care. While a preponderance of recent data shows an association between hospital and surgeon procedure volume and patient outcomes, those data do not mean that smaller hospitals or “medium volume” surgeons should not perform certain procedures. In fact, medium volume surgeons performed the largest proportion of meniscal procedures evaluated in this study.

The fact is that the “delivery” of health care does not happen via FedEx or UPS. The burden falls on patients to transport themselves to the physician, not vice versa. And until that model drastically changes, access disparities based on geography will likely remain.

However, Suchman et al. also found that the majority of patients who underwent any meniscal procedure had private insurance—and that Medicaid patients had the lowest rates of meniscal surgery. Although disparities arising from socioeconomic/insurance status are also very difficult to address, they would seem to be more remediable than disparities related to geography.

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


Patient-Doctor Interaction Suffers with EMRs in Outpatient Clinics

EMR Times for OBuzzThe intended goals of requiring electronic medical record (EMR) systems in all hospitals and clinics were rational and, for the most part, patient-centered. EMRs have prevented large numbers of potentially serious medication errors, served as a secure means of making laboratory and imaging data readily available to surgeons, and have provided an efficient mode of communication among members of health care teams.

Unfortunately, the design of most, if not all, EMR systems is focused on coding and billing, not on the doctor-patient interaction during the all-important face-to-face clinic visit. This has had the unintended consequence of requiring dense, protracted documentation of care interactions that seems to de-emphasize the most important part of the EMR entry: the physician’s thought process and treatment plan.

In the September 19, 2018 edition of The Journal, Scott et al. provide us with a unique cost-and-productivity view into the impact that implementing an EMR had within an outpatient orthopaedic clinic.  During the first 6 months after a new EMR was launched, total labor costs increased, driven by attending surgeons and medical assistants spending increased time documenting visits. Although the total per-encounter cost returned to baseline levels after 6 months, more time was spent documenting encounters and less time was spent interacting with patients than before EMR implementation. So, even after a return to normal clinic “productivity” after the 6-month learning period, the price paid for increased time spent documenting on the new EMR was decreased provider-patient “face time.”

In my opinion, it is essential that we work to remedy this deficiency. Personally, I do not use EMR-provided templates for documenting physical exam findings, imaging study results, and treatment plans. Instead, I engage with the patient during the visit and make detailed notes in the EMR after the patient leaves. This probably results in “under-billing” for my services, but I am willing to pay that price to increase the value of the visit for the patient—and for my colleagues who may review my notes.

The study by Scott et al. is a necessary first step in understanding EMR ramifications in orthopaedics, but our community needs more broad-based research to further delve into the full impact of EMRs on patient care, patient satisfaction, and cost. Toward that end, the Orthopaedic Research and Education Foundation (OREF) recently extended until September 28, 2018 the deadline for grant proposals to investigate the impact of EMR regulations on the patient-physician relationship. We must continue to address this apparent problem to improve patient care, which was the goal of EMRs in the first place.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Helpful Hint for Managing Femoral Neck Stress Fractures

Hip Effusion for OBuzzThe incidence of patients presenting with proximal thigh and groin pain is increasing along with increased interest in recreational athletic activity. When it is associated with a history of increased physical activity, this pain profile often prompts the ordering of a hip MRI if presenting radiographs are unremarkable. However, surgeons often find it difficult to make accurate prognoses and treatment recommendations when the MRI findings suggest a femoral neck stress fracture.

In the September 5, 2018 issue of The Journal, Steele et al. provide us with helpful hints for determining when to proceed with surgical stabilization of the femoral neck in this clinical scenario. Of the femoral neck stress fracture patients in this study who progressed to a surgical procedure, >85% had an effusion on the initial MRI, compared with only 26% of those whose condition resolved with nonoperative treatment. In statistical terms, those who had a hip effusion had an 8-fold increased risk of progression to surgery compared to those without a hip effusion. Meanwhile, the overall fracture-line percentage on the initial MRI turned out to be a poor metric for predicting progression.

Stabilization of a femoral neck stress fracture with percutaneous implants usually improves pain and predictably prevents displacement of the fracture and the attendant risk of nonunion and osteonecrosis of the femoral head. Further clinical research should help validate the seemingly reliable MRI-based predictor identified by these authors.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

New Findings in Muscle Injury—An Under-Researched Subject

Periostin for OBuzzThe goal of orthopaedic surgery is to help the entire musculoskeletal system function in harmony, but the preponderance of orthopaedic research focuses on the skeletal system instead of muscles and tendons. Bone is the only organ that can heal by regenerating tissue that is usually just as effective as the original structure. Consequently, we have focused on developing systems to hold bone intact as it heals so that postinjury function is maximized. Decades have been spent understanding the critical biologic pathways of bone healing and developing implantable, pharmacologic, and cell-based therapies to optimize it.

However, we sometimes overlook the fact that the skeleton can’t move without muscles. Only a few researchers have devoted their careers to understanding skeletal muscle’s response to injury and approaches to enhance muscle recovery after disuse and injury. In the August 15, 2018 issue of The Journal, Hara et al. report on experiments with the protein periostin in mice. Periostin is involved with the process of muscle fibrosis, during which fibroblasts proliferate in the injured area of the muscle and create “scar tissue” that eventually inhibits muscle function.

In one experiment, the authors found that “knockout” mice without the gene that encodes for periostin had improved recovery in a lacerated gastrocnemius muscle, less fibrosis in the muscle, and a significantly reduced number of infiltrating fibroblasts than “wild” mice with the same induced injury. In a similar experiment, they found reduced muscle fibrosis in injured muscles of mice whose production of periostin was neutralized by an antibody injected into the injured muscle. Although a sharp injury to muscle (the laceration model used in these mouse experiments) is not a common clinical scenario in patients seen by orthopaedists, the Hara et al. study represents a step forward in understanding muscle response to injury.

While these findings need to be replicated and then translated into clinical applications for humans, they shed new light on the importance of preventing periostin-induced fibroblast migration after skeletal muscle injury. This research hints at a potential therapeutic strategy to enhance muscle’s functional recovery, which is the most sought-after outcome for patients.

The clinical sports and orthopaedic communities are in need of approaches to limit scarring and atrophy in the setting of muscle disuse and injury. Any of us who unavoidably injure muscle during surgical approaches to bones and joints or for graft harvests and other procedures should be heartened by these findings. It is my hope that more early-career researchers will focus on the first half of the term “musculoskeletal” to advance therapeutic approaches to problems that impact function to a much more permanent degree than do most bone injuries.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

More Evidence of Patient Benefits with Cross-Linked Polyethylene

XLPE Cup for OBuzzIn an OrthoBuzz post last year titled “Has Conventional Polyethylene Become Obsolete?,” we featured results from a small randomized trial that documented much-improved implant survival over 10 years with acetabular components made from cross-linked polyethylene (XLPE) compared with conventional polyethylene (CPE). In the August 1, 2018 issue of The Journal, we find further corroboration of the benefits realized by patients who receive XLPE acetabular components.

deSteiger et al. analyzed registry data involving more than 240,000 total hip arthroplasty (THA) patients and found markedly lower revision rates in those who received XPLE rather than CPE acetabular components. At a mean follow-up of 16 years, the cumulative percentage of revisions was 6.2% in the  XPLE group versus 11.7% in the CPE group.  Among patients <55 years of age at the time of THA, at 7 years there was a five-fold increase in revision rates for procedures done with CPE compared to those done with XLPE.

Because the authors observed that the between-group differences in revision rates became more pronounced over time, it is possible that this difference will continue to grow as more data is gathered. When we consider the vast number of THAs performed around the world each year, this XLPE-related decrease in revision rate could have a beneficial impact on millions of patients.

The documented success so far of XPLE is a clear case where understanding the nature of the original problem (polyethylene wear) and applying consistent and innovative research to find a solution have allowed patients worldwide to reap the benefits associated with THA, with some assurance that their hip replacement may, in fact, last for their rest of their life.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

The True “Bottom Line” for Advanced Technology: Patient Outcomes

distal radial malunion for OBuzzOrthopaedic surgery has been blessed with an explosion of diagnostic and therapeutic technology over the last several decades. Improvements in advanced imaging, minimally invasive surgical techniques, and biomaterials and implant design have resulted in both perceived and objectively measurable patient benefits. In many cases, these benefits have been documented with patient-reported functional outcome data as well as improved clinical outcomes such as range of motion, strength, return to work, and pain relief.

However, some of these technological advances serve as expensive substitutes for many of the basic procedures that are universally available at a fraction of the cost, such as taking a thorough history, performing a complete physical examination, and employing basic and time-tested surgical techniques when indicated. While new minimally invasive techniques and computer-assisted preoperative planning are impressive in many respects, it is important to remember the ultimate goal of any orthopaedic operation: improving the patient’s musculoskeletal function.

In the July 18. 2018 issue of The Journal, Buijze et al. examine results from a multicenter randomized trial that compared patient-reported outcomes after using either 2-dimensional (standard radiographs) or 3-dimensional (CT with computer assistance) planning for corrective osteotomy in patients with a distal radial malunion. Although post-hoc analysis revealed that this study was underpowered, the patient-reported outcomes (as measured by DASH and PRWE) were not significantly different between the two preoperative planning groups.

These findings do not mean that advanced technology does not have a place in preoperative planning, but for me the findings emphasize that the most important factors in any orthopaedic surgery are the surgeon’s judgment, skill, and experience. When a surgeon needs assistance maximizing one of those three variables, more advanced technologies may play a role in improving patient outcome. For example, among less experienced surgeons, I suspect that more detailed preoperative planning for a relatively uncommon procedure would improve patient outcome, but it would probably have little impact on the results of procedures performed by more experienced surgeons.

The authors of this study focus on the true bottom line for any surgical intervention: patient outcome. But the other bottom line must also be considered. With the per-procedure incremental cost of 3-D planning and patient-specific surgical guides for upper-extremity deformity corrections estimated to range between $2,000 and $4,000, we must continue to conduct this type of Level I research. For the days of laying one “advance” on top of another with no attention paid to the cost for individual patients and the overall system are long gone.

Marc Swiontkowski, MD
JBJS Editor-in-Chief