The Softer Side of Better Patient Outcomes
It goes almost without saying that a patient’s return to work after an orthopaedic injury or musculoskeletal disorder would correlate with the severity of the condition. But what about the connection between return to work and a more “touchy-feely” parameter, such as the patient-surgeon relationship?
Dubert et al. conducted a longitudinal observational study of 219 patient who were 18 to 65 years of age and had undergone operations for upper-limb injuries or musculoskeletal disorders. In the August 7, 2019 issue of JBJS, they report that a positive relationship between patient and surgeon hastened return to work and reduced total time off from work.
At the time of enrollment (a mean of 149 days after surgery), the authors assessed the patient-surgeon relationship with a validated, 11-item questionnaire called Q-PASREL, and they collected patients’ functional and quality-of-life scores at the same time. The authors then tracked which patients had returned to work 6 months later, and they calculated how many workdays those who did return had missed.
The Q-PASREL questionnaire explores surgeon support provided to the patient, the patience of the surgeon, the surgeon’s appraisal of when the patient can return to work, the cooperation of the surgeon regarding administrative issues, the empathy perceived by the patient, and the surgeon’s use of appropriate vocabulary.
Here is a summary of the findings:
- At 6 months after enrollment, 74% of patients who had returned to work had given their surgeon a high or medium-high Q-PASREL score. By contrast, 64% of the patients who had not returned to work had given their surgeon a low or medium-low Q-PASREL score.
- The odds of returning to work were 56% higher among patients who gave surgeons the highest Q-PASREL scores compared with those who gave surgeons the lowest scores.
- The “body structure” subscore on one of the functional measurements and the Q-PASREL quartile were the only two independent predictors of total time off from work among patients who had returned to work.
After asserting that their study “confirms that surgeons’ relationships with their patients can influence the patients’ satisfaction and outcomes,” Dubert et al. go on to suggest that the findings should prompt surgeons to “work on empathy, time spent with their patients, and communication.” While they rightly claim that such improvements would entail “little financial investment and no side effects,” perhaps the authors, who practice in France, underestimate the effort that goes into changing behavior—and into addressing the time constraints imposed by the US health care system?
Why Are Some Patients Unhappy after “Successful” Repair of Shoulder Instability?
It has been estimated that 13% to 16% of patients who undergo arthroscopic stabilization procedures for recurrent shoulder instability are dissatisfied with their outcome, despite a technically “successful” operation. Similarly high rates of patient dissatisfaction in the face of an objectively “well-done” surgery are pervasive in most orthopaedic subspecialties and often leave both surgeon and patient frustrated and perplexed. Prior research has suggested that patient expectations, psychological characteristics, and socioeconomic factors play a major role in these cases of patient dissatisfaction. But identifying precise patient or injury factors that can alert surgeons as to which patients may be unsatisfied after their procedure has remained elusive for many common injuries.
In the June 19, 2019 issue of The Journal, Park et al. examine the bases for patient dissatisfaction after arthroscopic Bankart repair (with or without remplissage) for recurrent shoulder instability. Not surprisingly, patient age, size of the glenoid bone defect, and the number of patient postoperative instability events correlated with an objective failure of the operation (i.e., instability requiring a repeat operation). However, the study found that the number of instability events and the preoperative width of the Hill-Sachs lesion correlated with the subjective failure of the operation (i.e., the patient was dissatisfied based on response to a single question about “overall function” 2 years after surgery). For the 14 out of 180 patients who were dissatisfied despite not experiencing a revision, intermittent pain plus psychological characteristics such as apprehension and anxiety about recurrent instability were common reasons for dissatisfaction.
It is becoming clearer with each passing year that simply correcting anatomic pathologies does not always result in happy patients. Orthopaedic surgeons need to employ patient interviewing techniques to identify issues such as anxiety, depression, pain-perception concerns, and substance abuse—all of which can negatively influence the degree of patient satisfaction with the result and are somewhat modifiable preoperatively.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Subacromial Balloon May Benefit Irreparable Cuff Tears
The surgical options for treating irreparable tears of the supraspinatus—cuff reconstruction, tendon transfers, and shoulder replacement—are limited and complicated. But biomechanical results from a cadaveric study of 14 shoulders by Lobao et al., published in the June 5, 2019 issue of JBJS, suggest that a biodegradable balloon spacer inserted subacromially could effectively treat such insufficiencies, possibly postponing the need for more aggressive procedures.
Using an irreparable supraspinatus tear model and sophisticated instruments, the authors determined that, at postoperative time 0, the saline-inflated balloon:
- Restored intact-state glenohumeral contact pressures at most abduction angles
- Moved the humeral head inferiorly by a mean of 6.2 mm at 0° of abduction and 3.0 mm at 60°
- Increased deltoid load by 8.2% at 0° and by 11.1% at 60°.
The balloon, however, did not restore glenohumeral contact area to that of an intact shoulder.
Although the authors cite a previous clinical case series using this approach,1 they are quick to point out that “it is not possible to correlate our findings with clinical scenarios.” Nevertheless, they say that the biomechanical data obtained from this cadaveric study “suggest that the balloon may be of benefit clinically, at least in the immediate postoperative setting.”
Reference
- Deranlot J, Herisson O, Nourissat G, Zbili D, Werthel JD, Vigan M, Bruchou F. Arthroscopic subacromial spacer implantation in patients with massive irreparable rotator cuff tears: clinical and radiographic results of 39 retrospectives cases. Arthroscopy. 2017 Sep;33(9):1639-44. Epub 2017 Jun 8
Assessing Fatty Infiltration in Rotator Cuff Tears: MRI vs Ultrasound
In the setting of rotator cuff injuries, higher degrees of fatty infiltration into cuff muscles are positively correlated with higher repair failure rates and worse clinical outcomes. MRI continues to be the gold standard imaging modality for evaluating fatty infiltration of the rotator cuff, but ultrasound represents another viable modality for that assessment—at considerably lower cost. Such is the conclusion of Tenbrunsel et al. in a recent issue of JBJS Reviews.
The authors reviewed 32 studies that investigated imaging modalities used to assess fatty infiltration and fatty atrophy. They found that grading fatty infiltration using ultrasound correlated well with grading using MRI. However, the authors identified difficulties distinguishing severe from moderate fatty infiltration on ultrasound, but they added that discerning mild from moderate fatty infiltration is more important clinically. Tenbrunsel et al. also mention sonoelastography, which measures tissue elasticity and can also be used to help determine the severity of fatty atrophy of the rotator cuff.
Overall, the trade-off between MRI and ultrasound comes down to higher precision with the former and lower cost with the latter.
For more information about JBJS Reviews, watch this video featuring JBJS Editor-in-Chief Dr. Marc Swiontkowski.
What’s New in Sports Medicine 2019
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Albert Gee, MD, a co-author of the April 17, 2019 “What’s New in Sports Medicine,” selected the five most clinically compelling findings from among the 30 noteworthy studies summarized in the article.
Anterior Cruciate Ligament (ACL) Reconstruction
–Norwegian researchers randomized 120 patients to undergo either single-bundle or double-bundle ACL reconstruction and followed them for 2 years.1 They found no difference between the 2 techniques in any patient-reported outcome, knee laxity measurements, or activity levels. These results, along with the preponderance of evidence from other comparative trials over the last 5 years, strongly suggest that routine use of 2 bundles to primarily reconstruct a torn ACL adds no clinical benefit over a well-positioned single-bundle reconstruction.
Knee Cartilage Repair
–A randomized study compared long-term patient outcomes after knee cartilage repair using microfracture versus mosaicplasty.2 Included patients had 1 or 2 focal femoral lesions measuring between 2 and 6 cm2. Better outcomes after a minimum of 15 years of follow-up were found in the mosaicplasty group. Although there were only 20 patients in each arm, the Lysholm-score differences between the groups were both clinically important and statistically significant. More patients in the mosaicplasty group than in the microfracture group said they would have the surgery again, knowing their 15-year outcome.
Rotator Cuff
–UK researchers randomized 313 patients with ≥3 months of subacromial pain and an intact rotator cuff who had completed a nonoperative program of physical therapy and injection to 1 of 3 groups: arthroscopic subacromial decompression, diagnostic arthroscopy (“sham” surgery), or no intervention.3 At 6 months and 1 year, all groups demonstrated statistically significant and clinically important improvement, but patient-reported outcome scores were significantly better in both surgical groups compared with the no-treatment group. The data suggest that patients such as these improve over time, regardless of management, but that surgical decompression may offer a slight benefit over nonoperative management because of the placebo effect.
–A randomized controlled trial investigated the effect of a formal preoperative education program (2-minute video plus handout)4 about postoperative narcotic use, side effects, dependence risk, and addiction potential among >130 patients undergoing arthroscopic rotator cuff repair surgery. The education group consumed 33% less narcotic medication at 6 weeks and 42% less at 12 weeks compared with the control group. Among the more than one-quarter of the patients who had used opioids prior to surgery, those randomized to the education group were 6.8 times more likely than controls to discontinue narcotic use during the study period.
Hip Arthroscopy
–A randomized controlled trial of >300 patients compared hip arthroscopy and “best conservative care” for treating femoroacetabular impingement (FAI).5 Only 8% of patients crossed over from conservative care to the surgical group. The mean adjusted difference in iHOT-33 scores at 1 year was 6.8, in favor of hip arthroscopy. However, adverse events were more frequent in the arthroscopy cohort, and a within-trial economic evaluation suggested that hip arthroscopy was not cost-effective compared with conservative care during the 1-year trial period.
References
- Aga C, Risberg MA, Fagerland MW, Johansen S, Trøan I, Heir S, Engebretsen L. No difference in the KOOS Quality of Life Subscore between anatomic double-bundle and anatomic single-bundle anterior cruciate ligament reconstruction of the knee: a prospective randomized controlled trial with 2 years’ follow-up. Am J Sports Med.2018 Aug;46(10):2341-54. Epub 2018 Jul 18.
- Solheim E, Hegna J, Strand T, Harlem T, Inderhaug E. Randomized study of long-term (15-17 years) outcome after microfracture versus mosaicplasty in knee articular cartilage defects. Am J Sports Med.2018 Mar;46(4):826-31. Epub 2017 Dec 18.
- Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, Shirkey BA, Donovan JL, Gwilym S, Savulescu J,Moser J, Gray A, Jepson M, Tracey I, Judge A, Wartolowska K, Carr AJ; CSAW Study Group. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018 Jan 27;391(10118):329-38. Epub 2017 Nov 20.
- Syed UAM, Aleem AW, Wowkanech C, Weekes D, Freedman M, Tjoumakaris F, Abboud JA, Austin LS. Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial. J Shoulder Elbow Surg.2018 Jun;27(6):962-7. Epub 2018 Mar 26.
- Griffin DR, Dickenson EJ, Wall PDH, Achana F, Donovan JL, Griffin J, Hobson R, Hutchinson CE, Jepson M,Parsons NR, Petrou S, Realpe A, Smith J, Foster NE; FASHIoN Study Group. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet. 2018 Jun 2;391(10136):2225-35. Epub 2018 Jun 1.
Clavicle Fracture Research: Enough Already?
Orthopaedic surgeons and their staffs are aware of the paradigm shift that has taken place in the last 10 to 15 years regarding the treatment of clavicle fractures. Interest in the outcome differences between surgical and nonsurgical treatment has grown substantially since the 2007 Canadian Orthopaedic Trauma Society publication in JBJS showed that, relative to nonoperative treatment, plate fixation of displaced midshaft clavicle fractures resulted in improved functional outcomes and fewer malunions in active adult patients. Since that time, The Journal alone has published 14 articles related to management of clavicle fractures. In addition, the orthopaedic literature contains a number of well-conducted meta-analyses on the topic, comparing both nonoperative and surgical treatment as well as different methods of surgical fixation.
So, with all this evidence, why have we published the randomized controlled trial on this topic by King et al. in the April 3, 2019 issue of The Journal? Partly because the authors build upon our knowledge by comparing a relatively new fixation device (a flexible intramedullary locked nail) to a more standard treatment (an anatomically contoured plate). These plate and nail devices are very different from one another in terms of mechanics and surgical technique, and the flexible nail used in this study is much different than the rigid, straight nails or pins that have been used in the past.
A union rate of 100% was observed in both groups, but the authors found that the flexible nail was significantly faster in terms of operative time. (A single surgeon experienced with both devices performed all 72 surgeries.) They also found that the DASH scores between the groups were similar until the 12 month follow-up, at which point the flexible intramedullary nail group had statistically better scores. The authors concede, however, that the 12-month DASH-score difference “might not be clinically relevant.”
There is one other reason why we deemed this article important: The flexible intramedullary device used in this study is substantially more expensive than prior fixation devices that have been shown to effectively treat clavicular fractures. King et al. did not compare device costs, but whenever we study a device that adds to the total cost of care we should attempt to prove that it adds enough patient benefit to warrant the added expense. As the authors conclude, both devices evaluated in this study appear to be effective at treating displaced/shortened clavicular fractures, and there are a number of other factors that both the surgeon and patient should consider (such as surgeon skill and experience and cosmetic results) when deciding which treatment to use.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
March 2019 Article Exchange with JOSPT
In 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 March 2019, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “The Impact of Decreased Scapulothoracic Upward Rotation on Subacromial Proximities.”
In this shoulder kinematics study of 40 people classified as having high or low scapulothoracic upward rotation, contact between the coracoacromial arch and rotator cuff tendon occurred in 45% of participants. The relatively low prevalence of contact suggests that subacromial rotator cuff compression may be less common than traditionally presumed.
Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in Elderly Patients
Background: Elderly patients with a displaced femoral neck fracture treated with hip arthroplasty may have better function than those treated with internal fixation. We hypothesized that hemiarthroplasty would be superior to screw fixation with regard to hip function, mobility, pain, quality of life, and the risk of a reoperation in elderly patients with a nondisplaced femoral neck fracture.
What We Owe our Patients—Continuous Improvement
It has been said that a surgeon’s skill and judgment account for between 80% and 90% of a patient’s outcome. (I believe this is true for both surgical and nonsurgical treatments.) Throw in a physician’s ability to listen and clearly communicate with patients, and I am sure we are approaching that 90% mark. That means that when we conduct randomized trials comparing two types of knee prostheses or fracture-fixation constructs, we are, in essence, scrutinizing only about 10% of the patient-outcome equation.
So how do we best evaluate the 90% of the outcome equation that is physician-dependent? With the advent of “bundled” episodes of care, the orthopaedic community has emphasized the need for risk-adjustment in evaluating surgeon performance. Clearly, there are certain patients who are at higher risk for worse outcomes than others, such as those with diabetes, nicotine abuse, advanced age, and less social support.
In the December 19. 2018 issue of The Journal, Thigpen et al. report on patient outcomes 6 months after arthroscopic rotator cuff repair in 995 patients treated by 34 surgeons. The authors evaluated patient-reported outcomes from all surgeons using both unadjusted and adjusted ASES change scores. The adjusted scores took into account about a dozen baseline patient characteristics, including symptom severity, functional and mental scores, medical comorbidities, and Workers’ Compensation status. Relative to performance rankings based on unadjusted data, risk adjustment significantly altered the rankings for 91% of the surgeons. According to the authors, these findings “underpin the importance of risk-adjustment approaches to accurately report surgeon performance.”
But what is of even greater interest to me is that risk adjustment led to positive increases in patient outcomes for some surgeons, while decreasing outcomes for other surgeons. Some of these outcome differences likely reflect each surgeon’s patient-selection biases, but in the words of the authors, the numbers strongly suggest “that there is a meaningful, distinguishable difference in patient outcomes between surgeons.”
What should we do with this data? In my opinion, surgeons in the lower 80% of the list, at least, ought to be engaging with the surgeons who demonstrated the highest adjusted performance scores to understand what is helping them obtain outcomes that are superior to everyone else’s. We owe it to our patients to understand what our personal outcomes are for at least the most common conditions we treat. I believe it borders on unethical behavior to quote patients outcome data of a procedure from the peer-reviewed literature when we have no idea how our personal results compare. Orthopaedic surgeons need to be more active in lobbying our groups and health systems to support best practices for clinical outcome data collection and reporting so we can, in turn, improve our care by adopting the best practices of the surgeons with the best outcomes.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Treating Displaced AC Joint Dislocations: Patient Expectations Matter
Often in life, when there are many potential solutions for a single problem, none of them is found to be universally better than the others. That certainly seems to be the case when it comes to treating type III- and -IV acromioclavicular (AC) joint dislocations. Multiple studies have tried to clarify whether nonoperative or operative management is superior in this relatively common injury, but it is becoming increasingly clear that there is no single “right” answer. Many patients do fine with nonoperative treatment; others report being highly satisfied with an operation.
In the November 21, 2018 issue of The Journal, Murray et al. try to provide further guidance for treating these injuries. They performed a prospective, randomized controlled trial that compared nonoperative treatment with open reduction and tunneled suspensory device fixation among 60 patients with a type-III or type-IV AC joint dislocation. The authors used DASH, OSS, and SF-12 scores to quantify functional differences between the groups at 6 weeks, 3 months, 6 months, and 1 year post-injury. They found that, while the operative group showed improved radiographic alignment of the AC joint compared to the nonoperative group, there were no differences in functional outcomes between the two groups at any time beyond the 6-week mark (at which point the nonoperative group had better outcomes).
Notably, 5 of the 31 patients allocated to nonoperative treatment ended up requesting surgical treatment for the injury because of persistent discomfort (4 patients) or cosmesis (1 patient). Also, not surprisingly, the mean economic expenditure in the fixation group was significantly greater than that in the nonoperative group.
Whether to provide operative or nonoperative treatment for type-III and -IV acromioclavicular joint dislocations is not an easy decision, and it entails multiple factors. While this study evaluates only one modern surgical technique for treating this injury, the data is valuable nonetheless for informing a shared decision-making process to help patients choose the most appropriate treatment for them. The good news is that, whether managed operatively or not, patients tend to improve significantly after these injuries, and after 1 year end up with a shoulder that functions well. The authors conclude that “the routine use of [this surgical procedure] for displaced AC joint injuries is not justified,” and that “treatment should be individualized on the basis of [patient] age, activity level, and expectations.”
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
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