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Electronic Portal Usage among Orthopaedic Patients

Physician groups and hospitals have come to rely on electronic patient portals (EPPs) for many things, including appointment scheduling and reminders, delivery of test results, and pre- and post-visit information gathering from patients. Most of the research into the clinical efficacy and cost-effectiveness of EPPs has taken place in primary care and internal medicine settings. But in the August 5, 2020 issue of The Journal of Bone & Joint Surgery, Varady et al. examine the benefits of EPP use among patients undergoing orthopaedic procedures of various types. In the process, they also uncover racial and socioeconomic disparities in the use of EPPs.

The retrospective review of >18,000 patients (average age of 56.9 years) undergoing an orthopaedic procedure at 2 Boston-area academic hospitals found a veritable 50-50 split between those who used the EPP and those who did not. Relative to white patients, African-American and Hispanic patients were significantly less likely to use the EPP. Other demographic factors associated with portal nonuse were non-English speaking, male sex, low income, and having less than a college education.

Multivariable regression analysis demonstrated that, relative to EPP nonuse, EPP use was associated with significantly lower no-show rates, increased odds of completing one or more patient-reported outcome measures (PROMs), and improved overall patient satisfaction. The degree of after-surgery functional improvements measured with PROMs was the same among EPP users and nonusers.

The authors home in on the benefits of the 27% reduction in missed appointments this study divulged. First and foremost, missed appointments have been shown to negatively affect patient outcomes. On the provider side, no-shows increase staff frustration and cost time and money. (The 2 hospitals realized a combined estimated $200,000 in savings over 1 year from the reduction in no-shows.) Consequently, Varady et al. say that “the benefit of reducing missed appointments alone may be sufficiently strong to warrant efforts to increase EPP enrollment.”

Increased efforts among orthopaedic office staff and clinicians to enroll patients in portal usage during their hospital stay or during pre- or postoperative visits could also help address the disparity issue. “These results have important implications for the orthopaedic surgery community in…achieving more equitable care,” the authors conclude.

Owning the Bone in Spine Surgery

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Approximately 20% of patients who undergo spine surgery have osteoporosis, which has a significant impact on spine-surgery complications such as failure of fixation devices and collapse fractures following fusion procedures. In a recent critical analysis review, authors focus on improving outcomes by identifying and optimizing patients with osteoporosis prior to spine surgery. The multidisciplinary team involved in that process should include primary care providers, endocrinologists, physical therapists, and orthopaedic surgeons.

The predominant tool for assessing bone mineral density (BMD) is dual x-ray absorptiometry. The diagnosis is based on a T score, which represents the number of standard deviations between the patient’s BMD and that of a healthy 30-year-old woman. Standard deviations  ≤─2.5 define osteoporosis. The Z score is similar to the T score but compares the patient to an age- and sex-matched individual.

A history of low-energy fracture, such as a wrist fracture following a fall from a standing height, is considered a sentinel event for suspicion of fragility fractures. The combination of a fragility fracture and low BMD is considered to be severe osteoporosis. The most common form of osteoporosis is associated with a postmenopausal decrease in mineralization, but there are other causes. These include advanced kidney disease, hypogonadism, Cushing disease, vitamin D deficiency, anorexia and/or bulimia, rheumatoid arthritis, hyperthyroidism, primary hyperparathyroidism, and some medications (e.g., anticonvulsants, corticosteroids, heparin, and proton pump inhibitors).

Forty-seven percent of patients undergoing spine deformity surgery and 64% of cervical spine surgery patients have low vitamin D levels. Postoperative bone health can be enhanced in women ≥51 years old with daily intake of 800 to 1,000 units of vitamin D and 1,200 mg of daily calcium. There is no solid evidence that pre- or postoperative bisphosphonates have a positive impact on bone healing. Conversely, some series have shown that teriparatide, an anabolic parathyroid hormone, may improve time-to-fusion and help reduce screw pull-out after lumbar fusion in postmenopausal women.

Calcitonin has been shown to reduce the incidence of vertebral compression fracture, but there is no concrete evidence that it supports spine-fusion healing. Similarly, there is no strong evidence for the use of estrogen or selective estrogen receptor modulators in this surgical scenario. There is evidence that when the human monoclonal antibody denosumab is combined with teriparatide, spine-fusion healing may be improved relative to the use of teriparatide alone. Finally, the review article identifies screw size, screw position, and other surgical considerations that can improve fixation strength.

Using the “Own the Bone” practices promulgated by the American Orthopaedic Association and the technical considerations described in this review, we should be able to mitigate osteoporosis-related postoperative complications in spine-surgery patients.

JOPA 2019 Writing Awards

Since 2016, The Journal of Bone & Joint Surgery and JBJS Journal of Orthopaedics for Physician Assistants (JOPA) have awarded two $500 prizes to outstanding JOPA review articles or case studies written by authors who were PA students at the time of article submission.

The 2019 award winners for best articles by PA students produced high-quality literature reviews that address current and impactful topics. We recognized author Matthew Morrow, BA, PA-S out of Northwestern University for “The Effects of Cannabinoid Use on Acute Orthopaedic Pain: A Review of the Current Literature,” which showed that cannabis use provided little to no pain relief for acute musculoskeletal pain. The review also concluded that cannabis use while recovering from musculoskeletal trauma may be associated with an increased use of narcotics. The article suggests that cannabis use has a larger role for chronic rather than acute musculoskeletal pain.

Brittany Szabo, PA-S and Justin Gambini, MSPAS, PA-C, from Campbell University College of Pharmacy and Health Sciences, were recognized for “Ewing Sarcoma: A Review on Primary Bone Malignancy in Pediatrics and the Diagnosis, Treatment, and Challenges of Managing Ewing Sarcoma.” This article provided a comprehensive review of a “can’t miss” orthopaedic diagnosis, including clinical and diagnostic signs for orthopaedic providers to look for.

Congratulations to our 2019 PA student writing-award winners! We are offering two $500 awards again this year, so please encourage all of your PA students to submit an article for consideration! Deadline for submission is December 31, 2020.

And be on the lookout for an announcement about 2 additional 2019 JOPA Writing Award winners.

Dagan Cloutier, PA-C
Editor, JBJS Journal of Orthopaedics for Physician Assistants

Questions About Survival of Ultraporous Cups in THA

Acetabular components for primary total hip arthroplasty (THA) made with ultraporous surfaces were developed to enhance osseointegration and biological fixation. In the July 1, 2020 issue of The Journal of Bone & Joint Surgery, Palomaki et al. report on a registry study that suggests that implant survival with these components over an average follow-up of 3.6 years is not so “ultra.”

The authors evaluated >6,000 primary THAs that used a Tritanium ultraporous cup and >25,000 THAs that used a conventional cup, all performed between 2009 and 2017. When they compared the two groups for revision for any reason, the 5-year Kaplan-Meier survivorship of the Tritanium group (94.7%) was inferior to that of the conventional-cup group (96.0%). When revision for aseptic loosening was examined, the 5-year survivorship was also inferior for the Tritanium group (99.0%) compared with the conventional group (99.9%). Regression analysis revealed that the Tritanium group had a much higher risk of revision for aseptic loosening 2 to 4 years after surgery (hazard ratio, 11.2; p <0.001). Interestingly, these survivorship and risk-of-revision differences disappeared when the authors analyzed data for the period from May 15, 2014 to December 31, 2017–when the registry was updated to include patient BMI and ASA-class data.

The authors cite several caveats that readers should apply to these findings. The registry did not capture radiographic findings for these patients, so potentially relevant imaging data could not be analyzed. And, despite the database upgrade in 2014, there was a dearth of available data on patient comorbidities. Finally, wide confidence intervals for some of the hazard-ratio calculations suggest the need to confirm revision-risk findings with further research.

Limitations notwithstanding, the study by Palomaki et al. suggests that the performance of ultraporous cups may not meet the hopes and expectations of hip surgeons and their patients.

July 2020 Article Exchange with JOSPT

For the last 6 years, JBJS has participated in 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 2020, JBJS and OrthoBuzz readers will have open access to the JOSPT systematic review and meta-analysis titled “Effectiveness of Weight-Loss Interventions for Reducing Pain and Disability in People with Common Musculoskeletal Disorders.”

The authors found low-credibility evidence that behavioral weight-loss interventions produced small to moderate improvements in pain intensity and disability in people with hip or knee osteoarthritis. They also found moderate-credibility evidence that combined diet and exercise weight-loss strategies improved pain intensity and disability compared to diet-only interventions for knee osteoarthritis.

Rethinking How We Spend Healthcare Dollars During—and After—the Pandemic

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Frederick A. Matsen, MD and Jeremy S. Somerson, MD.

The coronavirus pandemic is having a profound effect on healthcare economics. A recent article in Health Affairs1 estimates that the median direct medical cost of a single symptomatic COVID-19 case can exceed $3,000 during the course of the infection alone. As of this writing, there have been almost 2.5 million confirmed cases in the US,2 with the number of known cases doubling every 2 months.3 These numbers suggest that the direct medical costs of the pandemic could easily exceed $8 billion. In addition, federal legislation enacted to help mitigate the effects of the pandemic is estimated to cost more than $480 billion over the next 10 years.4

Independently, the application of new technologies has also been pushing healthcare costs upward for decades. Long before the pandemic, a 2008 report from the  Congressional Budget Office concluded that “the bottom line from all these analyses is that the single most important factor driving the long-term increase in health care costs involves medical technology” and that “technological advances on average have brought major health improvements, but they often then get applied in settings where their benefits seem much less obvious.”5

In orthopaedics, we are strongly attracted to technology. In some cases – such as arthroscopy – technological advances enable less invasive, more effective, and safer treatments. In other cases, the patient benefits “seem much less obvious.” A recent review article makes the following observations about technology use in arthroplasty:

  • Computer-assisted technologies that are used in arthroplasty include navigation, image-derived instrumentation, and robotics.
  • Computer-assisted navigation improves accuracy and allows for real-time assessment of component positioning and soft-tissue tension.
  • It is not clear whether the implementation of these technologies improves the clinical outcome of surgery.
  • High cost and time demands have prevented the global implementation of computer-assisted technologies.

If we take shoulder arthroplasty as a general example, we see that prior to the introduction of routine preoperative CT scans, 3D planning, patient-specific instrumentation, metal-backed and augmented glenoid components, and short-stemmed and stemless humeral components, the results of anatomic total shoulder replacement for osteoarthritis were excellent, with 10-year revision rates under 5%.6,7 Such outcomes do not leave much room for improvement from newer technologies, each of which carries incremental costs of research, development, clearance by the FDA, marketing, learning curves, and potential product recalls and unanticipated long-term adverse effects.8 As Rosenthal et al. recently pointed out, “Since 3D planning and intraoperative navigation is more costly than 2D planning, and augmented glenoid components are more costly than standard glenoid components, the cost-benefit of these changes with respect to mid-term and long-term clinical outcomes and implant survival has not been ascertained.”9

Robust clinical data are needed to establish the incremental benefit to patients of each new technology in order to justify its associated incremental costs in comparison to legacy approaches that have been in place for years.

As a more specific example, the average cost of a preoperative shoulder CT scan ranges from $625 to $8,400,10 yet it remains to be demonstrated whether application of this technology leads to better shoulder arthroplasty outcomes in comparison to results obtained with conventional preoperative radiographic imaging.11 Agyeman et al. recently concluded that  “although CT scans are associated with greater financial cost and exposure to radiation than radiographs, the literature has yet to describe the additional clinical value and/or potential cost-value benefit as a result of improved outcomes provided by the use of CT scans in patients undergoing total shoulder arthroplasty, even when integrated with virtual planning software and generation of patient specific instrumentation.” If a preoperative shoulder CT scan costs $1,000, the very low end of the aforementioned range, avoiding routine preoperative CTs in 3 shoulder-arthroplasty patients would save an amount of money equal to the average direct medical cost of a patient with COVID-19—$3,000.

We conclude that this is a good time to seriously reconsider how we apply new technologies in orthopaedics by asking a simple question: Are we spending our more-precious-than-ever healthcare dollars in ways that best serve the population as a whole?

Frederick A. Matsen III, MD is a professor in the Department of Orthopaedics and Sports Medicine at the University of Washington Medical Center in Seattle. Jeremy S. Somerson, MD is a fellowship-trained shoulder and elbow surgeon at the University of Texas Medical Branch in Galveston.

References

  1. Bartsch SM, Ferguson MC, McKinnell JA, O’Shea KJ, Wedlock PT, Siegmund SS, et al. The potential health care costs and resource use associated with COVID-19 in the United States. Health Aff (Millwood). 2020;39(6):927-35.
  2. John Hopkins University CSSE. COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at John Hopkins University (JHU). 2020 Accessed June 28, 2020. Available from: https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6.
  3. Hernandez S, O’Key S, Watts A, Manley B, Pettersson H, CNN. Tracking Covid-19 cases in the US. CNN, 2020 Accessed June 28, 2020. Available from: https://www.cnn.com/interactive/2020/health/coronavirus-us-maps-and-cases/.
  4. Congressional Budget Office. The budgetary effects of laws enacted in response to the 2020 Coronavirus pandemic, March and April 2020. 2020 Accessed June 28, 2020. Available from: https://www.cbo.gov/system/files/2020-06/56403-CBO-covid-legislation.pdf.
  5. Congressional Budget Office. Technological change and the growth of health care spending. 2008 Accessed June 28, 2020. Available from: https://www.cbo.gov/publication/24748.
  6. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Annual report 2019: Hip, Knee & Shoulder Arthroplasty. Total Shoulder outcomes over two decades. Figure ST22, Page 16. 2019 Accessed June 28, 2020. Available from: https://aoanjrr.sahmri.com/documents/10180/668596/Hip%2C+Knee+%26+Shoulder+Arthroplasty/c287d2a3-22df-a3bb-37a2-91e6c00bfcf0.
  7. Neer CS, 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64(3):319-37.
  8. Somerson JS, Neradilek MB, Hsu JE, Service BC, Gee AO, Matsen FA, 3rd. Is there evidence that the outcomes of primary anatomic and reverse shoulder arthroplasty are getting better? Int Orthop. 2017;41(6):1235-44.
  9. Rosenthal Y, Rettig SA, Virk M, Zuckerman JD. The impact of preoperative three-dimensional planning and intraoperative navigation of shoulder arthroplasty on implant selection and operative time: a single surgeon’s experience. J Shoulder Elbow Surg. 2020;Epub ahead of print.
  10. Poslusny C. How much does a CT scan cost? New Choice Health, Inc., Pensacola, FL, Accessed June 28, 2020. Available from: https://www.newchoicehealth.com/ct-scan/cost.
  11. Matsen FA, 3rd, Whitson A, Hsu JE, Stankovic NK, Neradilek MB, Somerson JS. Prearthroplasty glenohumeral pathoanatomy and its relationship to patient’s sex, age, diagnosis, and self-assessed shoulder comfort and function. J Shoulder Elbow Surg. 2019;28(12):2290-300.

How Much Ulnar Lengthening in Kids with HME-Related Radial Head Dislocation?

Lengthening the ulna is a common method of treating radial head dislocations due to hereditary multiple exostoses (HME) in pediatric patients, but the optimal amount of ulnar lengthening remains unclear. In the June 17, 2020 issue of JBJS, Huang et al. demonstrate that using the proportional ulnar length of 1.1 as a guide to ulnar lengthening can promote spontaneous correction of the radial shaft deformity. The authors arrived at the 1.1 proportion by measuring the normal lengths of the ulna and radius in 20 pediatric patients of different age groups.

Huang et al. then treated 30 forearms (average patient age of 7.4 years) that had a radial head dislocation associated with HME. They excised the osteochondroma around the physis of the distal part of the ulna prior to lengthening. They then pulled the radial head down to the plane of the ulnar coronoid process with a Kirschner wire and lengthened the ulna to predicted proportional length using a modified Ilizarov frame. The technique also facilitated lengthening of the soft tissues of the elbow.

At the time of frame removal, reduction of the dislocated radial head was achieved in 28 forearms (93%). Forearm function also improved markedly, as did radial bowing and the radioarticular angle. The actual ulnar lengthening distance in these patients was greater than the predicted lengthening using the proportional method, but that contributed to the spontaneous remodeling of the radial shaft deformity, and there were no instances of wrist impingement.

The authors conclude that this study demonstrates that, in this clinical scenario, the “proportional ulnar length is a safe and effective parameter to use as the ulnar lengthening reference value.” But they also note that the small number of patients and the average follow-up of 63 months in this study should be expanded in future research.

Pledge from JBJS Regarding Race-Based Inequalities

The JBJS Board of Trustees published a statement today that addresses the global COVID pandemic and the worldwide demonstrations against systematic racism. As an organization, JBJS has pledged to take the following actions to promote racial equality in health care and in other aspects of human affairs that we influence:

  • In addition to the >100 articles already published in JBJS that explore health care disparities, The Journal will now prioritize manuscripts that delineate solutions to these widespread inequities.
  • JBJS will continue to support initiatives that increase minority representation in orthopaedic surgery programs throughout the US—including minority members of academic faculties. We will also publish data on the results of those efforts.
  • JBJS will look inward to promote greater diversity within our own organization.

We hope the readers of JBJS and OrthoBuzz are also taking action in their homes, workplaces, and communities to ensure that all people are treated fairly and equally.

Revision Shoulder Arthroplasty: IV or Oral Antibiotics?

Surgeons performing revision shoulder arthroplasty typically order postoperative antibiotics to be administered while they wait for results from intraoperative cultures. Based on their index of suspicion from preoperative exams and intraoperative observations, they order either intravenous (high suspicion of infection) or oral (low suspicion) antibiotics during the waiting period. In the June 3, 2020 issue of JBJS, Yao et al. report on a retrospective review of 175 patients who underwent revision shoulder arthroplasty, finding that surgeons’ presumptive choice of antibiotic type matched the culture results in 75% of the cases.

Among the 175 patients in the study, IV antibiotics were initiated in 62, while 113 patients received oral antibiotics. Cultures from 49 of the 62 patients started on IV antibiotics came back positive, and cultures from 83 of the 113 patients started on oral antibiotics came back negative. Treatment of patients whose initial antibiotic regimen did not match culture results was modified accordingly.

After multivariate analysis Yao et al. found that male sex, prior ipsilateral infection, and intraoperative presence of a humeral membrane were 3 independent predictors of surgeons initiating IV antibiotics. Antibiotic-related adverse events (including GI, dermatologic, and allergic reactions) occurred in 19% of the patients. Not surprisingly, the rate of these complications was highest among those receiving IV antibiotics.

Although the surgeons’ empirical initiation of antibiotic administration route was “correct” 75% of the time, that still left 25% of the patients needing modification of therapy based on culture results. While the authors observe that their study was  not designed “to report the relative effectiveness of the 2 antibiotic protocols in minimizing the risk of recurrent infection,” their findings confirm that preoperative and intraoperative observations can help surgeons select the “right” type of antibiotic without culture results—and that is heartening.

Screening Orthopaedic Patients for Asymptomatic COVID-19

During the initial surge of COVID-19, symptomatic patients were thought to be mainly responsible for spreading the virus, and guidelines therefore focused on identifying and isolating patients with fever, cough, or shortness of breath. However, as the asymptomatic spread became better understood, the need for more widespread, consistent molecular testing protocols became evident—and this is especially important now that elective orthopaedic surgery has resumed. Performing a surgical procedure on an asymptomatic patient with COVID-19 could lead to contamination of the operating room and other hospital zones, possibly infecting staff and other patients.

In the latest JBJS fast-track article related to COVID-19, Gruskay et al. describe a protocol for universal PCR swab testing of all orthopaedic surgery admissions at their New York City hospital during the 3 weeks between April 5, 2020 and April 24, 2020. At that time, only urgent orthopaedic procedures were being performed. Swab testing of 99 patients revealed a high rate of COVID-19 infections—the majority of which were in patients with no symptoms. With these published findings, the authors “hope to… make a case for nasopharyngeal testing of all preoperative patients.”

During those 3 weeks in April, 7 (58.3%) of the 12 patients who tested positive for COVID-19 had no symptoms consistent with the infection on presentation, and only 1 of those patients had pneumonia that appeared on a preoperative chest radiograph. Three asymptomatic patients who tested positive developed postoperative hypoxia, with 2 requiring intubation.

In recommending routine preoperative PCR testing for orthopaedic patients, the authors acknowledge the high specificity but only moderate sensitivity of the swab test, “but few other practical options exist,” they say. Evidence suggests that CT evaluation is the most accurate diagnostic test for COVID-19 pneumonia, but its use for screening is impractical. Chest radiography is more widely available, faster, and cheaper and emits less radiation than CT, but the sensitivity for diagnosing COVID-19 pneumonia with radiographs is reported as only 70%.