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Attention PAs and NPs: JBJS JOPA CME Membership

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Access the most relevant peer-reviewed orthopaedic content, including unlimited CME, by purchasing a 1-year JBJS JOPA CME membership—for the limited-time special rate of $99.

Your JBJS JOPA CME membership includes the following essential ingredients for your professional development and education:

  • New JBJS Reviews CME every week
  • Full access to JBJS Reviews and JBJS Journal of Orthopaedics for Physician Assistants (JOPA)
  • Monthly Image Quizzes
  • Annual PA Salary Survey
  • Physical Exam and Injection Video Library

With more than 50 AMA PRA Category 1 CreditsTM available annually* with your membership, you can complete all your CME for under $100.

To obtain the special $99 rate, click here and enter code WHQ834AA at checkout.

*The Journal of Bone and Joint Surgery Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. JBJS designates each JBJS Reviews journal-based activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

For TKA Pain Relief, Motor-Sparing Blocks Last Longer than Periarticular Infiltration

Adductor Canal Block for OBuzz
Analgesia after total knee arthroplasty (TKA) is a multimodal affair these days. Main goals include maintaining adequate patient comfort while limiting opiate use and permitting early mobilization.

In the August 2, 2017 issue of JBJS, Sogbein et al. report on a blinded randomized study comparing the performance of two types of analgesia often used in multimodal TKA pain-management protocols: preoperative motor-sparing knee blocks and intraoperative periarticular infiltrations.

Prior to surgery, the 35 patients in the motor-sparing block group received a midthigh adductor canal block under ultrasound guidance, combined with posterior pericapsular and lateral femoral cutaneous injections. The 35 patients in the periarticular infiltration group received study-labeled local anesthetics intraoperatively, just prior to component implantation.

Defining the “end of analgesia” as the point at which patient-reported pain at rest or activity rated ≥6 on the numerical rating scale and rescue analgesia was administered, the authors found that the duration of analgesia was significantly longer for the motor-sparing-block group compared with the periarticular-infiltration group. The infiltration group had significantly higher scores for pain at rest for the first 2 postoperative hours and for pain with knee movement at 2 and 4 hours. There were no between-group differences in time to mobilization, length of hospital stay, opiate consumption, or functional recovery.

By Itself, Spine Surgery Not a Risk Factor for Prolonged Opioid Use

OpioidsThe use of prescription painkillers in the US increased four-fold between 1997 and 2010, and postoperative overdoses doubled over a similar time period. In the August 2, 2017 edition of The Journal of Bone & Joint Surgery, Schoenfeld et al. estimated the proportion of nearly 10,000 initially opioid-naïve TRICARE patients who used opioids up to 1 year after discharge for one of four common spinal surgical procedures (discectomy, decompression, lumbar posterolateral arthrodesis, or lumbar interbody arthrodesis).

Eighty-four percent of the patients filled at least 1 opioid prescription upon hospital discharge. At 30 days following discharge, 8% continued opioid use; at 3 months, 1% continued use; and at 6 months, 0.1%. Only 2 patients (0.02%) in this cohort continued prescription opioid use at 1 year following surgery.

In an adjusted analysis, the authors found that an age of 25 to 34 years, lower socioeconomic status, and a diagnosis of depression were significantly associated with an increased likelihood of continuing opioid use. Those patient-related factors notwithstanding, the authors claim that the outcomes in their study “directly contravene the narrative that patients who undergo spine surgery, once started on prescription opioids following surgery, are at high risk of sustained opioid use.”

However, in his commentary on this study, Robert J. Barth, PhD, cautions that the exclusion criteria restricted even this large sample to about 19% of representative spine surgery candidates, making the findings not widely generalizable. Having said that, the commentator adds that the study supports findings of prior research that persistent postoperative opioid use is more related to “addressable patient-level predictors” than postsurgical pain. He also notes that the findings are “supportive of guidelines that call for surgical-discharge prescriptions of opioids to be limited to ≤2 weeks.”

August 2017 Article Exchange with JOSPT

JOSPT_Article_Exchange_LogoIn 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of August 2017, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Clinical Prediction Models for Patients With Nontraumatic Knee Pain in Primary Care: A Systematic Review and Internal Validation Study.”

This systematic review yielded two new prognostic models for function and recovery in patients with nontraumatic knee pain. A longer duration of complaints predicted poorer function.

After Bunion Surgery, Immediate X-rays Predict Recurrence Risk

Bunion_for_OBuzz.pngRecurrence rates after surgical treatment for hallux valgus (bunion) range from 4% to 25%. Findings from a study by Park and Lee in the July 19, 2017 edition of The Journal of Bone & Joint Surgery suggest that non-weight-bearing radiographs taken immediately after surgery can provide a good estimate of the risk of recurrence.

The study analyzed proximal chevron osteotomies performed on 117 feet. At an average follow-up of two years, the hallux valgus recurrence rate was 17%. (Recurrence was defined as a hallux valgus angle [HVA] of ≥20°.)

Bunions were 28 times more likely to recur when the postoperative HVA was ≥8° than when the HVA was <8°. The HVA continued to widen over time in patients with recurrent bunions, but stabilized at six months in those without recurrence. An immediate postoperative sesamoid position of grade 4 or greater was also significantly associated with recurrence.

If future studies confirm their results, the authors believe that such data could be used “to suggest intraoperative guidelines for satisfactory correction of radiographic parameters,” and thus help surgeons minimize the risk of hallux valgus recurrence. Commentator Jakup Midjord, MD concurs, noting that non-weight-bearing radiographs can be “closely related to intraoperative radiographs, so we can modify correction as needed in the operating room.”

Why EHR Data & Analytics Matter to Orthopaedic Practices

Weisstein Headshot for O'Buzz.jpg

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.

Selecting and/or changing your electronic health record (EHR) system is an investment of time, money, and training. There should be a thorough vetting process in place so you can select the right technology for your practice. One of the many questions you should ask when evaluating an EHR for your practice is the system’s ability to capture and display data. Data capture and analysis are critical for many reasons, one of which is reporting for the Merit-Based Incentive Payment System (MIPS).

The Value of Structured/Discrete Data
You want an EHR system that can capture structured, actionable data and automate patient and regulatory compliance documentation in near real-time. It is crucial to focus specifically on what is known as “discrete” or “structured” data. The opposite of narrative data, discrete/structured data captures specifics from each patient encounter.

Structured data matters so much because it is mineable—that is, it can be uniquely identified retrospectively. Structured data is crucial for group analytics, research, and the imminent obligations, such as MIPS, that the government and payers are placing on orthopaedic groups.

To maximize financial success, your EHR system should automatically capture all the data you need at the point of care to build and report your composite MIPS score. Once you have this data, you need tools that can help you visualize and analyze it.

The Importance of Visible Analytics
Analytics tools in your EHR system should:

1) Comparatively benchmark your near real-time quality and cost data to those of your peers

2) Visibly illustrate financial information to improve your bottom line and operations.

It is essential for everyone at a practice to have access to this real-time comparative benchmarking of both quality and cost data to succeed under MIPS. The analytics tools should not only show individual clinician performance and practice performance, but also where you stand when compared to other orthopedic surgeons and practices.

Making your financials visible can aid in improving your bottom line and operations far beyond a MIPS score. Having peer-to-peer comparisons in real-time will give you the chance to make operational changes, if necessary, to improve your practice.

From patient check-in to discharge, your analytics tool should enable you to identify and track key clinical, financial and operational processes to uncover insights to help optimize your practice. For example, orthopaedists would undoubtedly benefit from analytics on the prescribing of high-risk medications such as narcotics, blood thinners, and NSAIDs. Ultimately, robust analytics capabilities can help you measure and enhance your performance by making high-quality medical decisions for your patients and keeping costs down.

Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.

Let Unstable Chondral Lesions Be During Partial Meniscectomy

Chondral Debridement Graph for OBuzzMore than 900,000 patients every year undergo knee arthroscopy in the US. Many of those procedures involve a partial meniscectomy to address symptomatic meniscal tears. Surgeons “scoping” knees under these circumstances often encounter a chondral lesion—and most proceed to debride it.

However, in the July 5, 2017 issue of JBJS, Bisson et al. report on a randomized controlled trial that suggests there is no benefit to arthroscopic debridement of most unstable chondral lesions when they are encountered during partial meniscectomy. With about 100 patients ≥30 years old in each group, the authors found no significant differences in function and pain outcomes between the debridement and observation groups at the 1-year follow-up. In fact, relative to the debridement group, the observation group had more improvement in WOMAC and KOOS pain scores at 6 weeks, better SF-36 physical function scores at 3 months, and increased quadriceps circumference at 6 months.

The authors conclude that these findings “challenge the current standards” of typically debriding chondral lesions in the setting of arthroscopic partial meniscectomy. They also surmise that, in conjunction with declining Medicare reimbursements for meniscectomies with chondral debridement, these results “may lead to a reduction in the rate of arthroscopic debridement.”

Centenarians Fare Pretty Well After Hip Fracture Treatment

Centenarian.jpgPeople 100 years old and older—centenarians—make up only 0.02% of the current US population. Nevertheless, the number of centenarians is expected to increase five-fold by 2060. That is in part what prompted Manoli III et al. to analyze a large New York State database to determine whether patients ≥100 years old who sustained a hip fracture fared worse in the hospital than younger hip-fracture patients. The study appears in the July 5, 2017 issue of The Journal of Bone & Joint Surgery.

Only 0.7% of the more than 168,000 patients ≥65 years old included in the analysis sustained a hip fracture when they were ≥100 years old. Somewhat surprisingly, centenarians incurred costs and had lengths of stay that were similar to those of the younger patients. However, despite those similarities, centenarians had a significantly higher in-hospital mortality rate than the younger patients. Male sex and an increasing number of comorbidities were found to predict in-hospital mortality for centenarians with hip fractures.

Manoli III et al. also found that, relative to other age groups, centenarians were managed nonoperatively at a slightly higher frequency when treated for extracapsular hip fractures. For intracapsular fractures, an increasing proportion of patients >80 years were managed with hemiarthroplasty and nonoperative treatment. Finally, among centenarians, time to surgery did not affect short-term mortality rates, suggesting a potential benefit to preoperative optimization.

July 2017 Article Exchange with JOSPT

JOSPT_Article_Exchange_LogoIn 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of July 2017, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “An Integrated Model of Chronic Whiplash-Associated Disorder.”

This clinical commentary explains how psychological and neurobiological factors interact with, and are influenced by, existing personal and environmental factors to contribute to the development of chronic whiplash-associated disorder.

The Acetabulum’s Role in SCFE: Cause or Consequence?

Acetabular Version for O'Buzz.jpegThe multifactorial pathogenesis of slipped capital femoral epiphysis (SCFE) almost certainly involves the acetabulum, but previous studies about that relationship have been inconclusive. In the June 21, 2017 issue of JBJS, Hesper et al. report on a matched-cohort study that used precise measurements gleaned from CT to determine that acetabular retroversion—not acetabular depth or overcoverage of the femoral head—is associated with SCFE.

The authors carefully measured acetabular depth, head coverage, and retroversion in three groups of hips: the affected hips of 36 patients with unilateral SCFE, the unaffected contralateral hips of those same patients, and healthy hips of 36 age- and sex-matched controls. They observed no deep acetabula or acetabular overcoverage in the SCFE-affected hips, but they did find a lower mean value for acetabular version (i.e., retroversion) at the level of the femoral-head center in the SCFE-affected hips, relative to contralateral and control hips.  The acetabulum was retroverted cranially in cases of severe SCFE compared with mild and moderate cases.

These findings support the hypothesis that SCFE-affected hips have reduced acetabular version, but the authors note that “additional studies will be necessary to determine whether acetabular retroversion is a primary morphological abnormality associated with the mechanical etiology of SCFE, or if it is an adaptive response to the acetabulum after the slip.” Either way, Hesper et al. conclude that their data “may help with planning treatment for patients with residual pain and limited motion related to femoroacetabular impingement after SCFE.