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Dr. James Rickert’s Personal ‘Choosing Wisely’ List

The five-item AAOS contribution to the Choosing Wisely list of medical procedures that patients and physicians should question has been criticized from several quarters (see OrthoBuzz post “Do ‘Choosing Wisely’ Lists Protect Physician Income?”).

The latest scrutiny comes from Indiana orthopaedist James Rickert, MD, who founded the Society for Patient Centered Orthopaedic Surgery. Speaking at the recent Lown Institute Annual Conference (dubbed “The Road to RightCare”), Dr. Rickert said that among physicians who succumb to financial interests in recommending and performing procedures of dubious merit, orthopaedists are “one of the worst offenders.” He said it’s especially hard for those who own related businesses that benefit from high surgical volume (such as device distributorships or imaging centers) to set aside financial interests during clinical practice.

Here are five procedures Dr. Rickert thinks should be on the orthopaedic Choosing Wisely list:

  1. Vertebroplasty
  2. Rotator cuff repairs in asymptomatic/elderly patients
  3. Clavicle fracture plating in adolescents
  4. ACL repair in low-risk individuals
  5. Surgical removal of part of a torn meniscus

In citing the potential risks to patients who receive these procedures, Dr. Rickert admits to getting emails and other “grouchy comments” from fellow orthopaedists who don’t like his self-described “moral persuasion” campaign. What do you think of this list?

Bipartisan Doc-Fix Legislation Introduced

With 12 days to spare before a 21% reduction in physician Medicare payments takes effect, a bipartisan coalition of House and Senate lawmakers introduced identical bills that would scrap the SGR-based formula for physician reimbursement. Medscape.com reported that the SGR Repeal and Medicare Provider Payment Modernization Act of 2015 would boost physician pay by 0.5% during the second half of 2015 and in subsequent years from 2016 through 2019. The legislation redesigns the Medicare payment model from fee-for-service to pay-for-performance, and it also merges Medicare’s EHR and quality-reporting programs for easier administration by providers. Later this week or early next week, the House is expected to amend the legislation to extend the Children’s Health Insurance Program (CHIP) for two more years.

For the first time in recent memory, GOP leaders in both houses are indicating they won’t insist on specifying “pay-fors” for the entire cost of the bill. While Tea Party Republicans in the House are still calling for a complete cost offset, House Speaker John Boehner could get the bill passed amid Tea Party objections if he musters enough Democratic support.

In an online statement responding to the legislative filing, AAOS President Frederick Azar, MD, said, “The AAOS commends congressional leadership for introducing legislation to permanently repeal and replace the SGR formula.”

Stay tuned to OrthoBuzz…more will be revealed.

JBJS Editor’s Choice—Diabetes Boosts Infection Risk After ACL Surgery

swiontkowski marc colorIn the March 18 2015 edition of The Journal, Brophy et al. and investigators from the MOON Knee Group focus on that very rare complication of ACL reconstruction surgery: infection.  They prospectively followed a large cohort of more than 2,100 patients treated at multiple sites from 2000 to 2005.

The overall infection rate was less than 1%, which is in line with rates found in other studies. What was most notable is that the infection rate among patients with diabetes was 8.7% but only 0.7% in patients without diabetes. Statistically, having diabetes increased the odds of a post-ACL infection by nearly 19 times. Patients with diabetes should be counseled preoperatively so that they can be extra vigilant about detecting early signs of infection. Screening for diabetes prior to ACL surgery is not currently a standard of care, but it might be considered a reasonable approach in light of these findings. Surprisingly age and BMI were not associated with increased infection risk, and there was only a trend toward smokers being at higher risk.

Brophy et al. also found that patients receiving hamstring autografts were more than four times as likely to experience infection as those who received bone-tendon-bone (BTB) autografts. The authors’ hypothesis that the deep dissection required for hamstring harvest might increase infection risk seems plausible. It may also be that younger, healthier, more active patients (with presumably stronger immune systems) were more often offered BTB grafts.

What I like most about this study is that the MOON registry has very accurate clinical data because the investigators are clinicians who are highly invested in data quality. This is in distinction to studies that rely on administrative databases, where the coding of events is done by non-clinicians who may have less interest in entering highly accurate data.  Still, as clinically accurate as MOON data are, they are from more than a decade ago. Although the risk of post-ACL infection may be even lower in this decade, with these already-low rates, it would be difficult to statistically prove that progress.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

What’s New in Pediatric Orthopaedics: Level I and II Studies

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the February 18, 2015 Specialty Update on pediatric orthopaedics:

Spine

–The landmark BrAIST study found that bracing helps prevent adolescent idiopathic scoliosis curves from progressing to a surgical range (≥50°), with a number needed to treat of 3. (See related OrthoBuzz article.)

–A randomized trial comparing the SpineCor brace to rigid bracing for correction of scoliosis found that the rate of curve progression was significantly higher in the SpineCor group.

Neuromuscular Conditions

–A study on the role of steroids in patients with Duchenne muscular dystrophy found that glucocorticoid therapy decreased the need for spinal surgery to treat scoliosis.

Trauma

–A randomized trial among patients 4 to 12 years of age with a distal radial or distal both-bone fracture found that the use of a double-sugar-tong splint for immediate post-reduction immobilization was at least as effective as the use of a plaster long arm cast.

–A randomized controlled trial of 61 patients from 5 to 12 years old who had a supracondylar humeral fracture found no functional or elbow-motion benefits associated with hospital-based physical therapy after short-term casting.

Foot and Ankle

–A randomized trial of 27 children less than 9 months of age who had resistant metatarsus adductus found that a group receiving orthotic treatment had greater improvement in footprint heel bisector measurements than those receiving serial casting. The orthotic program required more active parental participation but was about half the cost of casting.

–A randomized study of children under 3 months of age with idiopathic clubfoot who were treated with the Ponseti method found that the failure rates and treatment times were significantly higher in a below-the-knee casting group than in an above-the-knee casting group.

Anesthesia for Hip Replacement: General vs Spinal

A large retrospective cohort study analyzing nearly 21,000 patients who underwent primary total hip arthroplasty (THA) found that the 61% who received general anesthesia were much more likely to experience an adverse event within 30 days than the 39% who received spinal anesthesia.

Among the adverse events analyzed, the increased risks associated with general anesthesia were more than five-fold for prolonged postoperative ventilator use and cardiac arrest, and more than two-fold for unplanned intubation and stroke. These findings are generally consistent with those of prior research into this question, but the authors say this is “the largest study to date” looking at the comparison.

The authors analyzed data from the National Surgical Quality Improvement Program (NSQIP), and they found that the increased adverse-event risk with general anesthesia held throughout all ranges of preoperative comorbidity. They therefore contend that while many previous studies have found advantages for spinal anesthesia in “medically complex” joint-replacement patients, “this study indicates that these benefits may also extend to patients with fewer medical comorbidities.”

Despite these findings, the authors stress that spinal anesthesia is not risk-free, with the potential (albeit low) for permanent injury to the spinal cord or spinal nerves. They also note that their 30-day postoperative analysis did not capture patient-centered metrics such as postsurgical pain or longer-term functional outcomes.

Rethinking the Use of Pelvic Binders with Acetabular Fractures

Pelvic binders can provide lifesaving compression in patients with hemodynamically unstable pelvic injuries. But a report in the March 11, 2015 JBJS Case Connector by Auston et al. emphasizes that such binders may do more harm than good in patients who have acetabular fractures without hemodynamic instability or other pelvic injuries. Because first responders or community physicians often apply pelvic binders, the authors cite the need for clearer guidelines for these devices and updated training of early clinical caregivers regarding their use. Potential complications of binder use cited previously in the literature include pressure sores, damage to internal organs, and sciatic nerve palsy, and Auston et al. suggest additional ones.

The authors describe three cases in which patients who were hemodynamically stable were placed in a pelvic binder, either during transport or ED evaluation, following blunt trauma sustained in motor-vehicle accidents. All three patients had acetabular fractures but no other abdominal or pelvic injuries. The authors suggest that pelvic binders may contribute to the displacement of acetabular fractures, and although they saw no visible evidence of chondral damage during open reduction and internal fixation of the fractures, they express concern about occult chondral abrasion and possible damage to chondrocytes at the cellular level if binders are used inappropriately.

The authors therefore conclude that while pelvic binders play an important role in patients with severe pelvic ring injuries and hemodynamic instability, “in the setting of a displaced acetabular fracture, we cannot recommend placement of a pelvic binder, even for pain relief or splinting during evaluation or transportation.”

Preventing Atypical Femoral Fractures Related to Bisphosphonates

Physicians worldwide frequently prescribe bisphosphonates such as alendronate (Fosamax) and ibandronate (Boniva) to treat osteoporosis and prevent fragility fractures. Unfortunately, long-term bisphosphonate use has been linked to an increased risk of atypical femoral fractures. In the March 3, 2015 edition of JBJS Reviews, Blood et al. offer some guidance on how to prevent such fractures.

The authors note that prodromal thigh pain and a radiolucent line on X-rays of patients with a history of chronic bisphosphonate use are strong indicators of an impending fracture. Among bisphosphonate users who have an incomplete fracture with little or no pain, the authors recommend a trial of discontinued bisphosphonates, protected weight-bearing, calcium and vitamin-D supplementation, and possible teriparatide (Forteo) therapy. They add that prophylactic fixation should be considered if there is no radiographic or symptomatic improvement after two to three months of that conservative approach. Blood et al. further recommend that patients at high risk for atypical femoral fracture, should consider discontinuing bisphosphonate therapy after five years of continuous use. They also encourage orthopaedists to assess the contralateral femur for signs of impending fracture in patients who have already had an atypical femoral fracture.

The recommendations by Blood et al. notwithstanding, we should stress that the absolute risk of atypical femoral fractures fractures is low (3.2 to 50 cases per 100,000 person-years among short-term bisphosphonate users and about 100 cases per 100,000 person-years among long-term users). Consequently, for most people with osteoporosis, the proven fragility-fracture risk-reduction benefits of bisphosphonates outweigh the risks of atypical femoral fracture.

Readers interested in this subject may want to read a related Case Connections article, which springboards from a January 14, 2015 Case Connector article.

Two New “Solutions” to Prickly Orthopaedic Problems

A study on rat knees in Osteoarthritis and Cartilage suggests that irrigating joints with hyperosmotic saline (600 mOsm) reduced surgically induced chondrocyte death, relative to irrigation with normal saline. Other measures of tissue repair and inflammation were also better in the joints that were irrigated with the hyperosmotic solution, although mild synovitis occurred in all joints regardless of the solution used. In a news release, study co-author Andrew Hall said, “Our study could have major implications for tens of thousands of people…It’s a cheap, simple solution that can protect the cartilage in the joint during arthroscopy and surgery.”

In a study on dog knees in Clinical Orthopaedics and Related Research, osteochondral allografts preserved in a special solution at room temperature yielded greater chondrocyte viability at 60 days than allografts stored within a medical-grade refrigeration unit. Viable grafts from each type of preservation delivered equivalent radiographic and biomechanical outcomes after six months. Commenting on this more than doubling of graft-storage life, study co-author James Stannard, MD, said, “The benefit to patients is that more graft material will be available, and it will be of better quality. This will allow us as surgeons to provide a more natural joint repair option for our patients.”

Readers should remember that these proof-of-concept studies were performed in animal models. Whether these simple “solutions” will work with human bone and cartilage tissue remains to be seen.

Stopping DMARDs Often Unnecessary for RA Patients Prior to Orthopaedic Surgery

Most patients with rheumatoid arthritis (RA) will undergo orthopaedic surgery during the course of their disease, and more than 80% of that cohort will be taking traditional or biologic disease-modifying antirheumatic drugs (DMARDs) at the time of their operations. That presents a dilemma, because stopping DMARDs can raise the risk of a rehab-hampering postoperative RA flare, while continuing the drugs is thought to increase the risk of postoperative infection.

A recent literature review in Seminars in Arthritis & Rheumatism suggests that surgeons should feel comfortable allowing patients to continue taking traditional DMARDs, such as sulfasalazine, as long as renal function is monitored. Emphasizing that more research is needed to pinpoint optimal start and stop dates for other DMARDs, review author Susan Goodman, MD, makes the following suggestions:

–Methotrexate: Continuing is recommended.

–Leflunomide: Discontinue for 1 week prior to surgery.

–Anti-TNF Alpha Drugs: Withhold therapy for 1.5 times the dosing interval.

–Tocilizumab: Exercise increased vigilance due to possible masking of signs of infection.

–Abatacept: Withhold for 2 to 3 weeks prior to surgery.

–Tofacitinib: Withhold for 2 days prior to surgery.

Dr. Goodman also observes that preoperative doses of corticosteroids, often used to cover RA flares in patients who’ve discontinued DMARDS, are often far higher than necessary, which could also increase infection risk.

 

Do Frustration and Inconvenience Equal Suffering?

A page-1 article in the February 18, 2015 New York Times caught our eye. It focused on patient “suffering” caused by the often frustrating, inconvenient, and noncommunicative way health care is delivered. Thomas H. Lee, MD, chief medical officer of the patient-satisfaction consultancy Press Ganey, was quoted as saying, “Every patient visit is a high-stakes interaction…And all you have to do is be the kind of physician your patient is hoping you will be.”

However, according to several online comments about the article from clinicians, alleviating this type of patient suffering may not be as simple as Dr. Lee suggests. Here’s a sampling:

MainerMD from Cleveland, OH:

To think that listening and communication will solve all of our problems cited here is horribly naive. Take 4 AM labs, for example. Doctors don’t order 4 AM labs to irritate patients. We do it because labs take time to run…What are we supposed to do? Let the patient sleep in, draw the labs at 8 AM, and then get called out of surgical cases or office visits to interpret the results and make a plan? …Wait until the end of the day to make plans, thereby delaying discharges and lengthening hospital stays? …The point is that these systems are complex, and things which irritate patients are not just the result of a lack of effort or personal shortcomings of doctors or nurses.

Rosy from Newtown, PA:

The bottom line is that we need to spend more time with patients, which is increasingly impossible.

Dr. DR from Texas:

Yes, feedback is great, and I think doctors can learn a lot from some of this data. But we also have to note that patients’ priorities (especially in a post-care survey) are not always in line with the best, evidence-based medical care.

Leo F. Flanagan from Stamford, CT:

It is time training in mindfulness, positive psychology, and hardiness is integrated into medical education. Caregivers who are trained to be resilient will not only be more attentive to patients, they will provide better clinical care.

Gary, an ER physician from Essexville, MI:

Inconvenience does not equate to the stroke or trauma patient’s suffering.

Dr. Abraham Solomon from Fort Myers, FL:

The patient is not his/her disease. The patient is a person with a medical problem. The whole person needs to be considered in solving the problem.

Rick, an ER physician from Pennsylvania:

Using patient surveys creates artificial and arbitrary measures that distract from the real questions of who gets better with the fewest complications, errors and inefficiencies. My highest ratings as an ER doc was when I gave everybody narcotics liberally, and ordered every fancy expensive test I could, “just to be sure” and to convince the patient I was “thorough” and I “cared.”

Regardless of one’s perspective, measuring patient satisfaction with the delivery of medical care is here for the midterm, at least. It would behoove us to consider the patient point of view as we balance how to interpret and respond to these measures.