Hemi vs THA Findings Helpful, But Not Practice-Changing
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The New England Journal of Medicine, the following commentary comes from Paul E. Matuszewski, MD.
A recent issue of The New England Journal of Medicine published the results from a large, multicenter randomized trial comparing the outcomes of hemiarthroplasty versus total hip arthroplasty (THA) to treat displaced femoral neck fractures in ambulatory adults.
The HEALTH investigators enrolled 1,495 patients in the study, and 85.1% of those patients had complete data for analysis after 2 years. The researchers found no significant differences between the groups with regard to the primary outcome—secondary hip procedures (7.9% in the THA group vs 8.3% in the hemi group). The risk of secondary hip procedures during the first year was higher in the THA group, but the hemiarthroplasty group had a higher risk of secondary procedures in the second year. Open/closed reductions of hip dislocations were the most common secondary procedures among the THA group, and revision to THA was the most common secondary procedure in the hemiarthroplasty group. The THA group had slightly better WOMAC scores, but the difference was not within a clinically significant range. There were no between-group differences noted in other patient-reported outcomes.
The HEALTH investigators followed these patients for only two years, which is notably the standard for many orthopaedic studies, but this short follow-up limits the practical application of these findings. The authors note that after the first year, primary THA was favorable with regard to secondary hip procedures. It is reasonable to think that this difference may become more compelling beyond 2 years, as more patients who received hemiarthroplasty are likely to be converted to THA.
The suggestion that there may not be an early benefit of THA over hemiarthroplasty in the ambulatory adult with a displaced femoral neck fracture contrasts with current recommendations from the American Academy of Orthopaedic Surgeons. However, the 2-year follow-up of this trial represents only a “snapshot” of the continuum of outcomes from these two hip-fracture treatments. The findings may add to our understanding of what our patients can expect during the first 2 years following these procedures, but I would caution surgeons against making any drastic changes to their current practice in response to this data.
Paul E. Matuszewski, MD is the Director of Orthopaedic Trauma Research and Assistant Professor of Orthopaedic Traumatology at the University of Kentucky.
Eschew the “Quick Fix” Approach to Early Knee OA
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in Arthritis Care & Research, the following commentary comes from Jeffrey B. Stambough, MD.
As orthopaedic surgeons, we share a collective objective to help patients improve function while minimizing pain. When patients come to our office for a new clinical visit for knee osteoarthritis (OA), we spend time getting to know them and gathering information about their activities, limitations, and functional goals. We balance this patient-reported information with discrete data points, such as weight, range-of-motion restrictions, and radiographic disease classification. Based on the symptom duration and other factors, most patients are not candidates for a knee replacement at this first visit. However, despite the publication of clinical practice guidelines for the nonoperative management of knee OA in 2008, with an update in 2013, significant variation exists in how orthopaedists treat these patients.
This guideline–practice disconnect is emphasized in findings from a recent study in Arthritis Care & Research that examined nonoperative knee OA management practices during clinic visits between 2007 and 2015. The authors found that the overall prescription of NSAID and opioid medications increased 2- and 3-fold, respectively, over that time, while recommendations for lifestyle interventions, self-directed activity, and physical therapy decreased by about 50%.
To me, the most troubling finding from this study is the sharp increase in narcotic prescriptions, because recent evidence demonstrates that narcotics do not effectively treat arthritis pain. Moreover, for patients who go on to arthroplasty, recent studies have found that preoperative opioid use portends worse postsurgical outcomes in terms of higher revision rates, worse function scores, and decreased knee motion.
The findings from this study also speak to a larger societal issue for doctors and patients alike: the desire for a “quick fix.” Despite the time pressure from increasing EHR documentation burdens, dwindling reimbursements, or lack of local resources, we owe it to our patients to counsel them on lifestyle modifications and self-management strategies to help them stay mobile, lose weight (if necessary), and take charge of their joint health. As orthopaedic surgeons, we must continue to strive to de-emphasize opioid pain medication when treating knee OA patients and support them in a holistic manner to ensure their overall health and the function and longevity of their native knee joint.
Jeffrey B. Stambough, MD is an orthopaedic hip and knee surgeon, an assistant professor of orthopaedic surgery at University of Arkansas for Medical Sciences, and a member of the JBJS Social Media Advisory Board.
Chicago Orthopaedic Surgery PGY1 Journal Club Commentary
I was pleasantly surprised and excited when I first heard about the citywide Chicago PGY1 journal club. This journal club was funded by the Robert Bucholz Resident Journal Club Grant through The Journal of Bone and Joint Surgery. The premise of this program was for all of the orthopedic surgery PGY1s from around the city to meet and discuss landmark articles specific to a certain orthopedic topic. The event that I attended was the first meeting of the program, and the focus of our discussion revolved around four orthopedic trauma articles. I recognized all of the articles as the guidelines established from these papers are still used in our trauma practice every day.
Although I knew the general principles derived from this literature, I found reading the full text beneficial as it helped provide a more thorough background into the reasoning behind the decisions we make in the management of various fracture patterns. What I found most educational however was the discussions we had with residents at various programs, specifically in regards to our institutions’ management of common orthopedic fractures. We each went around the table and discussed our ED management of injuries including humeral shaft fractures, femoral shaft fractures, open fractures, and our intraoperative technique for intramedullary nailing of tibial shaft fractures.
While there were small differences in our management of these injuries, we all seemed to abide by the general guidelines that were set into motion after the publication of these landmark articles. It brought into focus how influential this literature has been, and also gave me additional insight into possible alternative management algorithms that could produce similar outcomes. When working at one institution throughout your residency, that institutions protocols often become the “normal” for you. I now better recognize that it is important to keep an open mind and that there can be many methods to achieve a desired result.
Our meeting allowed for a low stress environment to both appreciate and constructively criticize how we think about orthopedic trauma. At our specific institution the discussion of articles occurs in a large group setting with attendings and senior residents, and usually focuses on more recent literature. I think it is essential to understand where we came from, and this citywide journal club provides that history while also encouraging open critical discussion. I think any junior resident would benefit from this type of educational open forum with their colleagues.
You can apply for your own Robert Bucholz Resident Journal Club Grant by clicking this link.
Jeremy Adler
Orthopaedic Surgery, PGY-2
University of Chicago
Jeremy.adler@uchospitals.edu
Not Your Grandparent’s Journal Club
OrthoBuzz occasionally receives posts from guest bloggers. The following commentary comes from Matthew R. Schmitz, MD, FAOA.
Medical education is a constant need, but how it’s delivered is always changing. When my grandfather was a surgeon, medical trainees brought their dusty textbooks and print journals to “fireside chats” at an attending’s home. Today, we have online journals, tablets and smartphones, podcasts, and “virtual” discussions on social media platforms. Although the technologies evolve, the need to discuss present and past literature remains constant.
These discussions often taken place nowadays through journal clubs. Medical residents across the continent routinely get together in formal or informal settings to discuss journal articles, not only to acquire the knowledge contained in the articles themselves, but also to learn how to properly read, critique, and digest the information.
JBJS provides medical education across multiple platforms, several of which I participate in. I strongly encourage residency programs to submit an application for the 2019-2020 JBJS Robert Bucholz Resident Journal Club Grant Program before the deadline of September 30, 2019. The grant allows medical educators to support their journal clubs in many ways:
- Investigating new and innovative alternatives to the traditional journal club.
- Bringing an author to your institution to discuss his or her articles.
- Hosting a virtual journal club with multiple authors via teleconference or social media.
- Purchasing food and refreshments within the “old school” method of a fireside chat at an attending’s home.
No matter the platform or methodology, journal clubs are a vital part of orthopaedic education, not only for interpreting literature, but also for incorporating knowledge into future clinical practice and for the joy and excitement of lifelong learning.
Matthew R. Schmitz, MD, FAOA is an orthopaedic surgeon specializing in adolescent sports and young adult hip preservation at the San Antonio Military Medical Center in San Antonio, TX. He is also a member of the JBJS Social Media Advisory Board.
Dual-Mobility Cups Lower Revision Risk in Some THAs
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The Journal of Bone & Joint Surgery, the following commentary comes from Matthew Deren, MD.
Early or late dislocation after total hip arthroplasty (THA) is a dreaded complication, and performing a THA to treat a hip fracture is known to increase the risk of postoperative prosthetic joint dislocation. Large-diameter femoral heads, like those used in metal-on-metal implants, offered the prospect of decreased risk of dislocation. Unfortunately, their promise of improved stability was subsequently offset by serious issues with wear. Orthopaedics is notable for technology that promised to solve one problem but led to another, and some wonder whether the increasing popularity of THA using dual-mobility cups to reduce dislocation risk might lead to another example of this paradoxical problem.
However, in the July 17, 2019 issue of The Journal, Jobory et al. published a population-based prospective cohort analysis based on data from the Nordic Arthroplasty Register Association. That study demonstrated a reduced revision risk with dual-mobility acetabular components when THA was performed to treat hip fracture in elderly patients. The authors propensity-score matched 4,520 hip fractures treated with dual-mobility THA to 4,520 hip fractures treated with conventional THA. The study included surgeries from 2001 to 2014, and the median follow-up was 2.4 years for all patients.
Dual-mobility constructs had a lower overall risk of any-component revision (hazard ratio of 0.75), which persisted after authors adjusted for surgical approach (hazard ratio of 0.73). Additionally, the dual-mobility construct had a lower risk of revision due to dislocation (hazard ratio of 0.45), but there was no difference in risk of deep infection between the cohorts. There was no significant difference in risk of any-component revision for aseptic loosening (hazard ratio of 0.544, p=0.052) until the authors adjusted for approach, which resulted in a decreased risk of any-component revision for aseptic loosening (hazard ratio of 0.500, p=0.030). When the authors compared revision of the acetabular component only, they found a reduced risk of revision for any cause as well as revision for dislocation in the dual-mobility cohort using both unadjusted data and data adjusted for surgical approach. Mortality was higher in the dual-mobility group compared with the conventional-component group (hazard ratio of 1.5).
Overall, this study gives us more information regarding the short-term revision risks of an implant design that is gaining popularity in the US. Although dual-mobility constructs seem to be associated with a decreased risk of revision for dislocation in a population of older adults with hip fracture, this data tells us little about this design and technology when used in younger, more active patients, who are at higher risk of polyethylene wear.
Matthew Deren, MD is an orthopaedic surgeon at UMass Memorial Medical Center, an assistant professor at University of Massachusetts Medical School, and a member of the JBJS Social Media Advisory Board.
Wide Variation in Orthopaedic Access Among Medicaid Patients
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Christopher Dy, MD, MPH, co-author of a recently published JBJS study.
It is no secret that patients with Medicaid (both adults and children) have difficulty making appointments for both elective and trauma-related orthopaedic care. They also travel further for care compared to privately insured patients. Conversely, Medicaid reimbursement rates for orthopaedic surgeries are substantially lower than those from Medicare and commercial insurers. Patients with Medicaid also tend to be more socially complex and have higher no-show rates for clinic appointments and surgery.
Consequently, as recently as 2011, only 40% of US orthopaedic surgeons were accepting new patients with Medicaid. This “bottleneck” effect may only get worse as reimbursement plans shift towards “pay-for-performance” and value-based payment, prompting surgeons and hospitals to become increasingly concerned about optimizing patient selection.
In a 2012 JBJS study, my colleague Ryan Calfee and co-authors demonstrated that patients with Medicaid were traveling to our institution (Washington University/Barnes Jewish Hospital in St. Louis) not only for complex cases, but also for simple and moderate-complexity hand surgery issues. These patients were bypassing hand surgeons closer to home partly because the local hand surgeons did not accept Medicaid.
With those findings in mind, we decided to more closely examine Medicaid care delivery in our region. Ideally, the insurance mix of the area surrounding a hospital should match the payer mix of the hospital. Most of us who currently work or have trained in large academic centers know that this is often not the case. Anecdotally, there are hospitals in every region that “cherry pick” the best-insured patients and transfer out the financially less desirable cases to a nearby teaching hospital. In our paper, published in the August 21, 2019 issue of JBJS, the concept of “Medicaid share ratio” is intended to reflect whether the hospital payer mix matches the insurance mix of the community. A value of 1 indicates a perfect balance.
We examined the Medicaid share ratios of the 22 hospitals in our region to see if the hospitals were “pulling their weight.” The Medicaid share ratios for elective orthopaedic care such as total joint arthroplasty ranged from 0.05 to 4.73, demonstrating massive imbalances on both ends of the spectrum. We also found very high variability in the delivery of elective orthopaedic care (coefficient of variation = 93, where values >60 are considered “very high”) and moderate variability in trauma care (coefficient of variation = 34).
Our findings were sobering, but not unexpected. The fact that some hospitals bear the brunt of care for the underinsured and uninsured is not new, and the federal government currently includes Disproportionate Share Hospital (DSH) payments to offset these losses. However, DSH payments are scheduled to decrease substantially in coming years as part of the original intent of the Affordable Care Act. If the continuing (and possibly worsening) burden of undercompensated care becomes financially suffocating to teaching and safety-net hospitals, they may seek to curb those losses in ways that could further limit access to underinsured patients and/or drive costs up for patients with other types of insurance.
At the surgeon level, we should address surgeon hesitation to accept Medicaid patients through engagement with specialty societies and policy reform. Our research team is currently working to learn more about what surgeons and patients think are potential solutions for these disparities in our region. As surgeons and researchers, we must work toward a more complete understanding of what drives these disparities in orthopaedic care. Otherwise, it will be impossible to figure out how to fix them.
Christopher Dy, MD, MPH is a hand and peripheral nerve surgeon, an assistant professor at Washington University Orthopaedics, and a member of the JBJS Social Media Advisory Board.
More Mortality Data on Hip Fractures in the Elderly
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD, in response to a recent study in the Journal of Orthopaedic Trauma.
Among the elderly, low-energy hip fractures are common injuries that almost all orthopaedic surgeons encounter. While operative management is typically the standard of care, there are some patients for whom nonoperative treatment is most aligned with their goals of care, usually because of chronic disease, fragility, and/or high risk of perioperative mortality.
When counseling elderly patients and family members about the risks and benefits of surgical management for a hip fracture, we have abundant data. We can estimate the length of rehabilitation, discuss the likelihood of regaining independence with ambulation, and quote the 30-day, 1-year, and 5-year mortality statistics. But what about the risks and benefits of nonoperative care? How long do these patients live? How many are alive 1 year after the fracture?
Chlebeck and colleagues attempt to answer those questions with a retrospective cohort study of 77 hip fracture patients who were treated nonoperatively and a matched cohort of 154 operatively treated hip fracture patients. Nonoperative management was chosen only after a palliative-care consult was obtained and after a thorough multidisciplinary discussion of treatment goals with the patient and family. Patients who elected nonoperative care were treated with early limited weight bearing and a focus on maximizing comfort. Researchers established a comparative operative cohort through 2:1 matched pairing, controlling for age, sex, fracture type, Charlson Comorbidity Index, preinjury living situation, preinjury ambulatory status, and presence of dementia and cardiac arrhythmia.
As one might expect, there was significantly lower mortality in the operative group. The in-hospital, 30-day, and 1-year mortality for nonoperatively treated patients was 28.6%, 63.6%, and 84.4% respectively. The mortality rates seen in the operative cohort were 3.9%, 11.0%, and 36.4% respectively. A Kaplan-Meier survival analysis revealed the median life expectancy in the nonoperative cohort to be 14 days, versus 839 days in the operative group (p <0.0001). Interestingly, the researchers found no difference in hospital length of stay between the two groups (5.4 vs. 7.7 days; p=0.10).
These results provide useful references for orthopedic surgeons to use when counseling hip fracture patients and their families. Surgical intervention remains the standard of care in most instances, and this study suggests that operative care offers a significant mortality benefit over nonoperative care even in relatively unhealthy patients, like those selected for the matched operative cohort.
This study also gives us data to help guide the expectations of patients who decide surgery is not in line with their wishes. Half of the patients who elected nonoperative care in this study died within 14 days of admission, and only 15.6% were still alive at 1 year. Additionally, choosing nonoperative care does not lengthen hospitalization, suggesting that these patients can be quickly transferred to a more comfortable setting.
Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.
VTE Prevention: Is Aspirin Really That Good?
OrthoBuzz occasionally receives posts from guest bloggers. In response to a three recent studies, the following commentary comes from Jeffrey B. Stambough, MD.
Throughout the last decade, we’ve experienced a boom in anticoagulation options to help prevent venous thromboembolism (VTE) associated with orthopaedic procedures. The use of aggressive anticoagulation, such as warfarin and various heparin formulations, is being questioned, largely due to concerns about bleeding risks and wound complications. Along with the newer direct oral anticoagulants such as rivaroxaban, over-the-counter aspirin (ASA) is gaining prominence as an anticoagulant due to its high efficacy, low cost, convenience for patients, favorable side-effect profile, and cardioprotective attributes. Current guidelines include the use of all these thromboprophylactic agents, but three recent studies lend credence to using aspirin as the primary VTE prophylactic agent when performing total joint arthroplasty (TJA).
In a March 20, 2019 JBJS study analyzing >31,000 TJAs performed at a single institution over 17 years, Rondon et al. found a 3-fold lower 30-day and 2-fold lower 1-year mortality rate in patients receiving ASA (81mg or 325 mg twice daily), compared to those who received non-aspirin thromboprophylaxis (mainly warfarin). No mortality differences were noted between the two ASA dosing regimens. While investigating specific causes of death, the authors discovered that the primary cause of death in the non-ASA cohort was cardiac related at all time points.
A second study, from the April 3, 2019 JBJS, looked into the effects of 3 antithrombotic agents on symptomatic VTE rates and periprosthetic infections in high-risk patients undergoing primary or revision TJA. When compared to the two more potent agents (warfarin and low-molecular-weight heparin), ASA proved more effective at reducing pulmonary embolism (PE) and VTE rates in high-risk patients, and it was also associated with lower rates of periprosthetic joint infection when compared with warfarin. Thus, it seems that even in patients deemed to be higher risk for developing VTE, ASA may be a safe, effective option.
Lastly, Runner et al. gleaned VTE prophylaxis data from >22,000 TJA cases submitted by surgeons sitting for Part 2 of ABOS between 2014 and 2016. The findings, reported in the April 2019 issue of the Journal of Arthroplasty, showed similar trends to those seen in the two previously mentioned studies: Mild (distal or superficial deep vein thrombosis [DVT]), moderate (nonfatal PE, proximal DVT) and severe (fatal PE) VTE events, as well as death, were significantly less frequent in those who received ASA compared to more aggressive agents (heparin or one of its analogs, direct oral agents, or warfarin). Also, patients who received ASA with or without mechanical prophylaxis had significantly lower complication rates (95.5% vs. 93.0%, p<0.001).
One firmly held dogma in medicine is that patients who are at higher risk for VTE should be treated with stronger anticoagulation medications. However, these 3 studies support the idea that less aggressive anticoagulation medication (specifically, low-dose aspirin) may be the more effective and safer option for most patients. In our ongoing quest to improve patient outcomes and mitigate risk around the TJA episode, we should consider using aspirin for thromboprophylaxis unless there is an explicit contraindication in a specific patient.
However, we should also keep in mind that these three studies have the common limitations of all retrospective analyses. Recent randomized trials have shown aspirin to be “noninferior” to other anticoagulants for VTE prevention, and in less than 2 years, we should have even more definitive answers to this question from the randomized, multicenter PEPPER trial, with its estimated 25,000 participants.
Jeffrey B. Stambough, MD is an orthopaedic hip and knee surgeon, an assistant professor of orthopaedic surgery at University of Arkansas for Medical Sciences, and a member of the JBJS Social Media Advisory Board.
Arthroscopy Beats PT for FAI at 8 Months
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent BMJ study, the following commentary comes from Matthew R. Schmitz, MD, FAOA.
Femoroacetabular impingement (FAI) syndrome continues to be a hot topic in the orthopaedic community. The first two decades of this century have seen huge increases in the number of hip arthroscopies performed in the US and UK,1,2 most of those to treat FAI. In the February 7, 2019 issue of BMJ, Palmer et al., reporting on behalf of the Femoroacetabular Impingement Trial (FAIT), published preliminary findings from a multicenter randomized controlled trial comparing arthroscopic hip surgery to activity modification and physiotherapy for symptomatic FAI.3
The trial randomized 222 patients with a clinical diagnosis of FAI into each cohort (110 in the physiotherapy group and 112 in the arthroscopy group). Follow-up assessments were performed by clinicians blinded to the treatment arm, and attempts were made to standardize both interventions. The participants will eventually be followed for 3 years, but this early report evaluated outcomes 8 months after randomization, with follow-up data available for >80% of patients in both groups.
Baseline characteristics with regard to demographics, radiographic findings, and clinical measurements were similar between the two groups. After adjusting for multiple potential confounders, the authors found that the mean Hip Outcomes Score Activities of Daily Living (HOS ADL) was 10 points higher in the arthroscopy group than in the physiotherapy group, exceeding the prespecified minimum clinically important difference (MCID) of 9 points. The MCID was reached in 51% of surgical patients compared to 32% in the therapy cohort. In addition, the patient acceptable symptomatic state (PASS)—defined as a HOS ADL ≥87 points—was achieved in 48% of surgical patients and only 19% of therapy patients. Relative to the physiotherapy group, the arthroscopic group also had better hip flexion and superior results in a variety of commonly used hip patient-reported outcomes scores.
The 8-month data from this study show that there is a real improvement in patient function and reported outcomes from arthroscopic management for FAI. It will be important, however, to follow these patients for the entire 3 years of the FAIT study to show whether these improvements persist. It should also be emphasized that only half of the patients treated with surgical management achieved MCID at the 8-month point. That finding supports what I tell patients in my young-adult hip-preservation clinics, which seems relevant as baseball season starts: There are rarely any home runs in arthroscopic hip surgery. There are mainly singles and doubles that we hope to stretch into doubles and triples. Still, it appears that even those base hits with arthroscopic surgery are better than the physiotherapy alternative—at least in the early innings of the game.
Matthew R. Schmitz, MD, FAOA is an orthopaedic surgeon specializing in adolescent sports and young adult hip preservation at the San Antonio Military Medical Center in San Antonio, TX. He is also a member of the JBJS Social Media Advisory Board.
References
- Maradit Kremers H, Schilz SR, Van Houten HK et al. Trends in Utilization and Outcomes of Hip Arthrocopy in the United States Between 2005 and 2013. J Arthroplasty 2017; 32:750-5.
- Palmer AJ, Malak TT, Broomfield J, et al. Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2018. BMJ Open Sport Exerc Med 2016;2:e000082
- Palmer AJ, Gupta VA, Fernquest S, et al. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicenter randomized controlled trial. BMJ 2019; 364:l185
Letting Go of the Script
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent New England Journal of Medicine Perspective, the following commentary comes from Adam Bitterman, DO.
The physician-patient relationship is highly regarded and has withstood the test of time. Unfortunately, today it appears to be under significant stress. While it is still possible to maintain a meaningful and professional doctor-patient connection, the balance between arriving at a correct diagnosis, moving down your patient list, and truly caring for each individual patient is difficult to find. The advent of electronic medical records (and their attendant task lists and button clicking) and satisfaction scores have not made maintaining meaningful patient relationships any easier.
In her February 7, 2019 Perspective piece for The New England Journal of Medicine, cardiologist Dr. Lisa Rosenbaum describes her encounters with the medical system as a patient after sustaining a Jones fracture. As she highlights her experience from the initial presentation in the emergency department to the follow-up examination with an orthopedic surgeon, she describes the repeated sensation of being a diagnosis treated by an algorithm rather than an individual with an ailment receiving care.
She also highlights an anecdote about another patient’s family pleading with a staff physician to “get off your script” and focus on treating the unique patient. Invoking the legacy of Sir Robert Jones, the orthopaedist after whom the foot fracture is named, Dr. Rosenbaum observes that “medicine teeters atop an edifice of workarounds,” as physicians try to play by the rules while taking good care of patients.
Standardization and treatment protocols have a useful role in many instances, but we physicians must remember that behind every complaint is a patient, an individual with personal connections to friends and family. It is easy to get caught up in the standardized protocols that reside within electronic medical records, but it takes only a moment to disconnect yourself from the screen and keyboard and provide the creative connection that patients desire. (A study in the upcoming February 20, 2019 JBJS addresses this topic.)
Although you may be encountering your seventh patient of the day with a Jones fracture, for each of those people, their foot is all that matters. It is our job—a decidedly difficult one—to provide the unique and sometimes creative treatment plan to all our patients, while somehow maintaining a top-tier standard of care that is reproducible for all.
Adam Bitterman, DO is a fellowship-trained foot and ankle surgeon practicing at Northwell Health in Huntington, NY. He is also a member of the JBJS Social Media Advisory Board.
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