True innovation—improvement way beyond the incremental—is rare in orthopaedics, whether it’s pre- and postoperative management, surgical technique, or prosthetic design. Innovation is even rarer, understandably, in addressing conditions that themselves are rare. Rarer still are innovations in treating pediatric conditions because of the many different congenital etiologies that don’t present in sufficient numbers to meaningfully study interventions.
Congenital pseudarthrosis of the tibia is one such rare pediatric condition, and it is one of the most challenging problems facing pediatric orthopaedic surgeons. In its pre-fracture state, this condition is called congenital tibial dysplasia or anterolateral bowing of the tibia. The goal of treatment at this stage is preventing fracture in the dysplastic, bowed area, because post-fracture union is difficult to achieve and maintain—and because chronic nonunion puts patients at risk for long-term pain, deformity, and disability.
In the December 2, 2020 issue of The Journal, Laine et al. present results of a simple outpatient surgical solution to this problem in 10 pediatric patients who were followed for an average of 5 years. Using a limited-exposure, plate-and-screw approach to control physeal growth, these authors produced correction in tibial alignment in all 10 patients. Most importantly, no patient developed a tibial fracture or pseudarthrosis after the guided-growth procedure, which also improved radiographic appearance of dysplastic bone and preserved leg length. Although 6 of the 10 patients required a plate exchange, the authors’ institution now offers this procedure as first-line treatment to all patients presenting with pre-fracture congenital tibial dysplasia.
Congenital bowing of the tibia is a condition that will probably never be subject to a controlled clinical trial due to the (fortunately) low number of patients affected. However, carefully conducted small cohort studies such as this can reveal true innovation that advances care for small but very vulnerable populations.
Marc Swiontkowski, MD
The cost of medical care in the United States has been shown to rise with advancing patient age, and total joint arthroplasty (TJA) is a prime example of this unsurprising phenomenon. In attempts to curtail costs and reduce variability, Medicare and other payers have introduced alternative payment models (APMs), such as the Bundled Payments for Care Improvement (BPCI) initiative. In this model’s application to TJA, when participating institutions keep the cost of the “episode” below a risk-adjusted target price, they accrue the savings as a profit, but they sustain a financial penalty if the episode costs more than the target price.
Multiple studies have suggested that APMs can negatively affect the fiscal health of institutions that care for many high-risk patients. Although increasing age has been associated with higher-cost episodes of care, age is not one of the factors that the BPCI model accounts for. Consequently, concerns have been raised that providers may practice “cost discrimination” against very old patients.
In the October 7, 2020 issue of The Journal, Petersen et al. examine how an aging population has affected a New York City orthopaedic center in terms of the BPCI model applied to TJA. The authors analyzed the relationship between patient age and cost of care among 1,662 patients who underwent primary total hip and knee arthroplasty over a 3-year period under BPCI. They then used a modeling tool to predict shifting age demographics for their local area out to the year 2040.
Petersen et al. found that under BPCI, their institution sustained a nearly $2,000-per-case loss for TJA care episodes among patients 85 to 99 years of age. Currently this loss is offset by profits realized by performing TJAs in younger patients. However, predictive modeling identified an inflection point of 2030, after which a relative increase in older patients and a decrease in younger patients will yield an overall net decrease in profits for primary TJA.
Because no one, including orthopaedic surgeons, can turn back the clock on aging, health care stakeholders must find ways either to adjust downward the cost of care for the elderly (seemingly difficult without adversely affecting outcomes) or adjust reimbursement models to account for the increased costs associated with aging. I agree with the conclusion of Petersen et al.: “The BPCI initiative and [other] novel APMs should consider age as a modifier for reimbursement to incentivize care for the more vulnerable and costly age groups in the future.”
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Most health researchers attribute the well-defined racial disparities seen in outcomes for both acute and chronic illnesses to unequal access to health care, particularly preventive care. There are currently between 30 million and 40 million uninsured patients in the US who do not have access to routine preventive care and receive the majority of their health care through hospital emergency rooms. This seems to be related to the prevailing opinion in our country that access to primary care physicians and routine preventive measures is not a basic right.
Emergency care, however, is more or less available to everyone, and that would theoretically reduce or eliminate the racial disparities in outcomes for emergent conditions such as hip fractures. Yet, in 2016, JBJS published research indicating that disparities in care and outcome occur in the management of hip fracture, with black patients found to be at greater risk for delayed surgery, reoperation, readmission, and 1-year mortality than white patients. That begs the question whether there are inherent racial differences beyond the health-care delivery system that might partly account for these disparate outcomes.
In the July 5, 2018 issue of The Journal, Okike et al. try to answer that question. The authors used data from Kaiser Permanente, a large health system with a modestly diverse population that has equal access to care that is known for its adherence to standardized protocols. Okike et al. analyzed the outcomes of nearly 18,000 hip fracture patients according to race (black, white, Hispanic, and Asian). In this uniformly insured population with few or no barriers to access, Okike et al. found that the outcomes for patients, regardless of race, were similar. These findings strongly suggest that when patients are given equal access to health care that is delivered according to standardized protocols, the racial disparities found in previous studies of outcomes of emergent conditions may disappear.
Okike et al. are quick to emphasize that their findings are not an indication that “efforts to combat disparities are no longer required.” I would argue that this study further supports the need to address the issue of access to care on a policy level if we are going to make progress toward achieving racial equality in medical and orthopaedic outcomes. Much of the access-to-care progress we made between 2008 and 2016 is evaporating; I look forward to the day when we can redirect the national focus on this issue at the highest policy-making levels.
Marc Swiontkowski, MD
JBJS Essential Surgical Techniques (EST) is pleased to congratulate the winners of its two Editor’s Choice Awards for 2017:
The award for best surgical-technique article went to Morteza Kalhor, MD; Diego Collado, MD; Michael Leunig, MD; Paulo Rego, MD; and Reinhold Ganz, MD for Recommendations to Reduce Risk of Nerve Injury During Bernese Periacetabular Osteotomy (PAO).
The recipients of the best Key Procedures video award were Jorge Chahla, MD; Gilbert Moatshe, MD; Lars Engebretsen, MD, PhD; and Robert F. LaPrade, MD, PhD for Anatomic Double-Bundle Posterior Cruciate Ligament Reconstruction.
In the November 15, 2017 issue of The Journal, Courtney et al. carefully evaluate CMS data to compare TKA and THA costs, complications, and patient satisfaction between physician-owned and non-physician-owned hospitals. The authors used risk-adjusted data when comparing complication scores between the two hospital types, in an attempt to address the oft-rendered claim that surgeons at physician-owned facilities “cherry pick” the healthiest patients and operate on the highest-risk patients in non-physician-owned facilities.
In general, the findings suggest that, for TKA and THA, physician-owned hospitals are associated with lower costs to Medicare, fewer complications and readmissions, and superior patient-satisfaction scores compared with non-physician-owned hospitals. These findings should come as no surprise to readers of The Journal. One fundamental principle of health care finance is that physicians control 70% to 80% of the total cost of care with their direct decisions. When physician incentives are aligned with those related to the facility, the result is better care at lower cost.
Nevertheless, many policymakers remain convinced that physician-owners are completely mercenary and base every decision on maximizing profit margins—even if that includes ordering unnecessary tests, performing unnecessary procedures, or using inferior implants. We need more transparency among physician-owners at local and national levels to address these usually-erroneous assumptions, which are frequently repeated by local non-physician-owned health systems. For example, we should be transparent with the percentage of the margin that ends up in the physician-owner’s pocket. Whatever the “right” percentage is, I believe it should not be the dominant factor in a physician’s total income..
The findings from Courtney et al. should spur further debate on this issue. I am confident that the best outcomes for individual patients and the public result when physicians (and their patients) stay in direct control of decision making regarding care, when surgeons are appropriately motivated to be cost- and outcome-effective, and when we all do our part to care for the under- and uninsured.
Marc Swiontkowski, MD
In the March 15, 2017 issue of The Journal, Johns et al. report results from a Level III cohort study comparing arthroscopic vs open irrigation for control of acute native-knee sepsis. The authors collected information on more than 160 patients with knee sepsis over a 15-year period, which is a large cohort of patients with this relatively unusual clinical problem.
The data show a cumulative success rate of 97% with arthroscopic treatment after 3 irrigations and debridements vs 83% success in the arthrotomy group after the same number of procedures—a clinically important difference. Significantly fewer arthroscopic procedures were required for successful treatment, relative to open procedures, and post-procedure median knee range of motion was significantly greater in the arthroscopic group (90°) than in the open treatment group (70°).
The fact is that arthroscopic instruments allow a greater volume of irrigation fluid to be instilled with better access to the posterior recesses of the knee. With an open arthrotomy, it is more difficult to irrigate with high volumes, and the posterior recesses of the knee are not well accessed. It seems clear that arthroscopic management of acute knee sepsis should be the standard of care for these reasons, as well as because the technique is minimally invasive in terms of soft tissue stripping and incision size.
Treating infections of major-weight bearing joints is following a trend seen in surgical management of many orthopaedic conditions—smaller exposures with use of adjunctive visualization techniques.
Marc Swiontkowski, MD
In the December 7, 2016 issue of JBJS, Krause et al. analyze data from a 2013 industry-sponsored RCT to investigate correlations between nonunions of hindfoot/ankle fusions indicated by early postoperative computed tomography (CT) and subsequent functional outcomes. Whether nonunion was assessed by independent readings of those CT scans at 24 weeks or by surgeon composite assessments at 52 weeks, patients with failed healing had lower AOFAS, SF-12, and Foot Function Index scores than those who showed osseous union.
This study suggests that a CT should be obtained from patients who are at least 6 months out from a surgical fusion and are not progressing in terms of activity-related pain and function. Depending on the specific CT findings, a repeat attempt at bone grafting, with the possible addition of bone-graft substitute and/or possible modification of internal fixation, may be warranted to forestall later clinical problems.
Krause et al. imply that trusting plain radiographs that show no indication of fusion failure is not acceptable when patient pain and function do not improve in a timely fashion. Conversely, they conclude that their findings do not support “the concept of an asymptomatic nonunion (i.e., imaging indicating nonunion but the patient doing well),” because nonunions identified early by CT eventually resulted in worse clinical outcomes. The authors also noted that obesity, smoking, and not working increased the risk of nonunion, corroborating findings from earlier studies.
While advanced imaging such as CT is not necessary in foot/ankle fusion patients who are improving in terms of function, pain, and swelling , this study stresses the importance of achieving union following these fusion procedures.
Marc Swiontkowski, MD
One of the observations that I have made during my years in academic medicine is that the more popular a topic appears to be in the literature, the less likely we are to really understand it. After all, if we need to write about it so much, it must mean that there is still much to learn. This certainly seems to be the case with regard to injuries of the anterior cruciate ligament (ACL). ACL injuries are among the most common injuries sustained in the United States. Over 100,000 ACL reconstructions were performed in the United States in 2006, and the annual rate has continued to increase over time. Although some patients have achieved good results after nonoperative treatment, a survey of the American Orthopaedic Society for Sports Medicine showed that the majority of respondents used nonoperative treatment for fewer than 25% of their patients with ACL injuries.
Noyes et al.1 described the so-called “rule of thirds.” According to this rule, one-third of patients with an ACL injury will compensate well with nonoperative treatment (copers), one-third will avoid symptoms of instability by modifying activities (adapters), and one-third will require operative reconstruction (noncopers). Unfortunately, there does not seem to be any way to predict which group an individual patient will fall into. Thus, there is still substantial ambiguity in determining which patients are most likely to benefit from early intervention with ACL reconstruction following injury.
In this month’s issue of JBJS Reviews, Secrist et al. used the literature to perform a comparison of operative and nonoperative treatment of ACL injuries. They noted that only 3 randomized controlled trials have compared operative and nonoperative treatment of ACL injuries and that 2 of those studies involved the use of ACL suturing as opposed to more modern forms of reconstruction. The third study involved only 32 patients. All studies had substantial methodological limitations. The authors concluded that there have been no Level-I studies comparing ACL reconstruction with nonoperative treatment.
In their review article, Secrist et al. attempted to define and evaluate the available data on the natural history of nonoperatively treated ACL injuries and to determine how the functional outcomes and injury risks associated with nonoperative treatment compared with those associated with reconstruction. Moreover, they sought to define prognostic factors and rehabilitation protocols associated with successful operative outcomes. Finally, they compared the outcomes following early versus delayed ACL reconstruction.
However, by the end of the article, one gets the feeling that the authors have “come full circle.” The authors summarize their findings by saying that some patients can cope with a torn ACL and return to preinjury activity levels, including participation in pivoting sports. On the other hand, patients who have an ACL injury along with a concomitant meniscal injury are at increased risk for osteoarthritis, and it is unclear what effect reconstruction of an isolated ACL has on future osteoarthritis risk in ACL-deficient patients who are identified as “copers.”
I suspect that we will continue to see articles on this topic for many years to come. In light of the “rule of thirds” and the additional impact of meniscal injury, the allocation of a particular patient to operative or nonoperative treatment remains unclear.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
- Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptomatic anterior cruciate-deficient knee. Part II: the results of rehabilitation, activity modification, and counseling on functional disability. J Bone Joint Surg Am. 1983 Feb;65(2):163-74 Medline.
Injuries to the musculoskeletal system are among the most common wounds of war. Compared with extremity injuries in the civilian population, injuries sustained in combat tend to be due to high-energy explosions and are associated with a greater degree of contamination and a longer timeline for recovery and healing. Importantly, the sequelae of musculoskeletal injuries sustained during combat tend to lead to more long-term disability than those affecting other organ systems.
In this month’s Editor’s Choice article, Rivera et al. review the current literature on combat injuries of the lower extremity and suggest that explosions are the most common mechanism of injury encountered by deployed service members. While exposure to an explosion does not necessarily result in a specific limb injury, the explosion mechanism does contribute to more severe injuries. Moreover, among service members who sustain open fractures of the tibia, foot, and ankle, infection is a common complication and is associated with more severe soft-tissue injury. As a result, surgeons who are deployed in combat settings are now performing more fasciotomies for limbs that are at risk. However, the outcomes and complication rates associated with these procedures are not well established, and the causes of late amputations are not always clear.
As part of a comprehensive review of this topic, Rivera et al. pose 3 important clinical questions that are ideal for translational research investigation. First, they ask, “What is the best way to manage and transport patients who have severe open fractures in order to minimize infection?” Indeed, while negative-pressure wound therapy (NPWT) appears to be a promising wound-care technique, additional study is needed in order to know how to best augment the standard of care for battlefield medicine. Second, “What is the best way to treat fasciotomy wounds and the late sequelae of the compartment syndrome?” In order to answer this question, a broader understanding of compartment syndrome detection and the indications for surgical treatment are needed. Finally, “What is the best way to select limbs for salvage and to optimize the reconstruction of injured tissues?” This question must explore not only the patient’s perspective but also the multitude of causes that lead to late amputation.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
In the February 18, 2015 issue of The Journal, Rohner et al. report their experience with knee arthrodesis using an intramedullary rod as the definitive treatment for failed total knee arthroplasties (TKAs) related to infection. They report the results for 26 patients treated between 1997 and 2013 who had undergone an average of 6 ±3 knee procedures prior to arthrodesis.
The outcomes for this cohort of patients are sobering. Persistent infection requiring additional surgery remained in 50% of the patients. The health-related quality-of-life measures and functional outcomes were abysmal, and 73% reported persistent pain at greater than 3 on the VAS. Obesity, high blood pressure, and diabetes were strong predictors of reinfection.
Many of us have taken comfort that knee fusion, by whatever surgical technique, is a reliable “bail out” for the problem of recurrent infection following revision of a loose or infected TKA. Nevertheless, any surgeon who has followed a patient with a knee fusion is fully aware of the functional disability associated with the stiff knee. Difficulties using public transportation and impaired sitting are just two inconveniences that these patients express unhappiness about.
Despite its retrospective design and relatively small number of cases, this report may cause the knee-reconstruction community to reconsider knee arthrodesis and instead attempt further staged revisions of the knee prosthesis. It may even prompt a slightly earlier move toward recommending trans-femoral amputation. It certainly will stimulate further research into infection prevention and into developing more predictable approaches for revising infected TKA prostheses.
Marc Swiontkowski, MD