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CBO Estimates 10-Year Cost of SGR Repeal at $174.5 Billion

According to the latest Congressional Budget Office (CBO) figures, replacing the SGR-based Medicare physician-reimbursement formula over the next 10 years, as proposed in legislation introduced last year, would cost $174.5 billion. But a closer look at the CBO numbers reveals that the accrued physician-payment costs over the same 10 years would be an estimated $137.4 billion if current reimbursement rates were frozen through 2025. That’s a difference of (only) $37.1 billion.

Under current law, fees that physicians receive for Medicare services will be cut by about 21% beginning on April 1, 2015. Two pending pieces of federal legislation—HR 4015 and S 2000—would repeal the SGR formula, but the bills do not include suggestions for covering the cost of an SGR replacement.

The American Hospital Association has gone on record against the “rob-hospitals-to-pay-doctors” approach that some people have advocated, saying in January that it “cannot support any proposal to fix the physician payment problem at the expense of funding for services provided by other caregivers.”

If a permanent repeal of the SGR formula isn’t politically feasible until after the 2016 presidential election, Congress will probably approve another short-term “patch” this year. That would be the 18th time in 12 years that legislators have kicked this expensive can down the road.

Three New Knee Studies Yield Interesting Results

We stumbled upon three recent studies of knee osteoarthritis (OA) that shed interesting new light on a condition that all orthopaedists deal with.

–A “network” meta-analysis in the Annals of Internal Medicine looked at 137 randomized trials of OA treatments comprising more than 33,000 participants. Treatments analyzed included acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, intra-articular (IA) steroids, IA hyaluronic acid, oral placebo, and IA placebo. For pain, all active treatments except acetaminophen yielded clinically significant improvement. IA hyaluronic acid came out on top for pain relief, although the authors postulated that an “integrated” placebo effect may explain that finding.

–A cost-modeling study in Arthritis Care & Research, co-authored by JBJS Deputy Editors for Methodology and Biostatistics Jeffrey Katz, MD and Elena Losina, PhD, revealed that the per-patient cost attributable to symptomatic knee OA over 28 years is $12,400. Any expanded indications for total knee arthroplasty (TKA) and a trend toward increased willingness among patients to undergo knee surgery will increase that cost. The researchers found that patients tried nonsurgical regimens for a mean of 13.3 years before opting for TKA, and they stress the need for more effective nonoperative therapies for knee OA.

–Wine drinkers, rejoice! A retrospective case-control study in Arthritis Research & Therapy found that people who drank four to six glasses of wine per week were less likely to develop knee OA than nondrinkers. Meanwhile, beer drinkers may want to switch to wine. The same study found that people who drank 8 to 19 half-pints of suds per week had an increased risk of developing knee OA. Researchers found no link between total alcohol consumption and risk of knee OA. The authors postulate that the resveratrol found in wine may be chondroprotective, and that the linkage between beer and increased blood levels of uric acid may explain the opposite finding. It’s wise to remember that studies investigating one or two dietary items can be less-than-definitive because they are usually retrospective, subject to recall bias, and do not account for complex interactions among many nutrients.

JBJS Classics: Cervical Discectomy and Interbody Fusion

JBJS-Classics-logoEach month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.

It is rare that an article published more than 50 years ago continues to have an impact on clinical practice today. But that is the case with “The Treatment of Certain Cervical-Spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion.” What make this article so unique are the details that Drs. George Smith and Robert Robinson put into describing the procedure and the careful follow-up of their early experience with this technique.

I have had a copy of this article in my files since I was a resident at Yale, training with Wayne Southwick, who had trained with Dr. Robinson at the time this approach to the cervical spine was developed. The two key contributors to anterior cervical spine surgery back in the 1950s were Dr. Robinson and the neurosurgeon Dr. Ralph Cloward.

Dr. Robinson’s technique has the support of biomechanical principles, which makes this particular approach and bone-graft fusion construct inherently stable; hence, its continued use to this very day. However, back in the ‘50s, and even when I trained in the 1970s, hardware to stabilize the spine following discectomy was not available in the US.

The approach that these authors described is very versatile and is utilized for all sorts of anterior procedures, including removal of intervertebral discs, arthrodesis, and vertebrectomy, and it allows for doing multiple-level procedures. The technique I use today is the same one that Dr. Southwick taught me and that he learned directly from Dr. Robinson.

Dr. Robinson has had a major impact on cervical spine surgery, and it was estimated that at one time 33% to 50% of members of the Cervical Spine Research Society were trained by him, by one of his residents or fellows, or by one of their residents or fellows—Dr. Robinson’s “offspring.”

I believe this technique will continue to stand the test of time, as it has during the past half century, and will have a major influence on spine surgery well into the future.

Charles Clark, MD

JBJS Deputy Editor for Adult Reconstruction and Spine

JBJS Reviews Editor’s Choice–Open Tibial Fractures

Orthopaedic surgeons have developed a heightened awareness of the scientific evidence that supports the decisions that they make in the care of patients. Levels of evidence and grades of recommendation have been used in scientific articles in order to frame information in an evidence-based manner. However, despite the substantial strides that have been made in promoting evidence-based practice throughout orthopaedic surgery, some historical dogma still exists and many surgeons do things based on what they were told or taught many years ago. One example is the so-called “six-hour rule,” in which it is considered the standard of care to urgently perform irrigation and debridement of an open tibial fracture within six hours after the time of injury.

Fractures of the tibial diaphysis are among the most common major long-bone fractures treated by orthopaedic surgeons. Up to 24% of these fractures present as open injuries, and a considerable portion are associated with severe soft-tissue compromise. Open tibial fractures receive different levels of treatment based on the severity of the injury according to the Gustilo and Anderson classification system. In the February 2015 edition of JBJS Reviews, Mundi et al. explore the practice patterns and clinical evidence to support four aspects of treatment that are essential to the management of open tibial fractures: irrigation and debridement, antibiotic prophylaxis, fracture stabilization, and wound management.

With regard to irrigation and debridement, although timely treatment within six hours after injury is considered the standard of care, there is insufficient evidence to support this practice. Moreover, the ideal irrigation solution and the optimum pressure of the irrigation are unknown.

Information on the use of antibiotics in the management of open tibial fractures is based on various well-designed studies, so the quality of the evidence to support some of these recommendations is better. Investigators agree that antibiotic prophylaxis should be started as soon as possible after presentation to an emergency department or hospital and that patients should receive antimicrobial coverage against gram-positive bacteria, typically with a first-generation cephalosporin. Gustilo and Anderson type-III injuries require additional antibiotic coverage, and the use of aminoglycosides is indicated, although the optimum regimen has not been established. Local antibiotic administration at the site of the injury (e.g., antibiotic-laden cement beads) is potentially beneficial but is primarily used for patients with type-III injuries.

The optimum time for closure of these wounds has yet to be determined, although primary closure is warranted under specific circumstances. For those injuries that require delayed closure, definitive coverage should not be delayed beyond seven days, even in the setting of negative-pressure wound therapy.

With regard to stabilization, techniques for the operative management of open tibial fractures have evolved and current evidence shows superior outcomes in association with intramedullary nailing as compared with plate fixation. However, there had been a debate regarding reamed versus unreamed intramedullary nailing. Interestingly, a randomized controlled trial was conducted to answer this question, and the results showed that both reamed and unreamed intramedullary nailing are reasonable options for the fixation of open tibial fractures, with the two techniques demonstrating comparable outcomes.

At this time, there remains a need for additional high-quality evidence to clarify the efficacy of specific techniques and treatments. In particular, guidelines detailing the optimal irrigation solution and pressure as well as the ideal duration of antibiotic prophylaxis are needed. Continued efforts to design and organize large-scale randomized clinical trials will be required in order to provide the kind of evidence that orthopaedic surgeons need so that they can provide the best care for their patients.

Thomas A. Einhorn, MD, Editor

Nonoperative Treatment of Type I Open Fractures in Kids Can Be Effective and Safe

When most laypeople—and perhaps some orthopaedists—see a child with a fractured arm or leg bone poking through a skin wound, they probably think surgery is inevitable. But a recent study in the Journal of Children’s Orthopaedics, co-authored by JBJS Deputy Editor for Pediatrics Paul Sponseller, MD, found that among 40 pediatric patients with nonoperatively treated type I open fractures (where the bone communicates with a clean wound less than 1 cm in length), there were no infections, and all patients eventually had complete bony union. The nonoperative treatment included irrigation and debridement followed by closed reduction and casting, and all patients were discharged home from the ED. The only complication was a small retained foreign body walled off by a non-infected granuloma that was removed uneventfully in the clinic four weeks after the initial procedure.

In a news release, Dr. Sponseller said, “Our findings indicate that when it comes to simple, clean open breaks, which are very common in kids, a minimalistic ‘clean, set the bone and watch’ approach could be just as effective as more aggressive surgical treatments.” The limited number of patients in the study did not power it sufficiently to draw ironclad conclusions, and the authors concluded that “additional prospective randomized clinical trials are needed to make a definitive level I recommendation regarding nonoperative management.”

What’s New in Adult Reconstructive Knee Surgery: 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 randomized studies cited in the January 21, 2015 Specialty Update on adult reconstructive knee surgery:

Minimizing Blood Loss

–A randomized study of 101 patients undergoing total knee arthroplasty (TKA) found that those receiving topical tranexamic acid (TXA) intra-articularly at the end of surgery had less blood loss and better postoperative hemoglobin levels than those who received a placebo.

–A randomized study of 50 TKA patients and 50 people undergoing total hip arthroplasty found that those receiving TXA had a significantly smaller decline in postoperative hemoglobin levels and needed 39% fewer units of transfused blood than a group that received normal saline solution.

Patellar Management

–A randomized study of 126 patients who underwent denervation or not after TKA with unresurfaced patellae found that the denervation group had better pain scores at three months and higher satisfaction and better range of motion at two years.

–Two randomized studies evaluated the impact of patellar eversion versus lateral retraction/subluxation for joint exposure. One study (n=117) found no between-group differences in quadriceps strength at one year, and the other (n=66) found no between-group differences in pain scores or flexion at three months and one year.

Implant Design

Most of the implant-design studies summarized in this Specialty Update can be summed up as “no difference.” Specifically,

–Three randomized studies attempting to evaluate high-flexion TKA designs (n=74, n=278, and n=122) caused the authors of the update to suggest that “the intention of providing greater clinical flexion through high-flex arthroplasty designs does not translate to a meaningful difference in patient outcomes.”

–A randomized study of 124 patients found no differences in maximal post-TKA flexion or functional scores between a group that received a bicruciate-substituting implant and one that received a standard posterior-stabilized design.

–A randomized trial of 34 patients who received prostheses with either highly cross-linked polyethylene or conventional polyethylene found no differences in wear-particle number, size, or morphology after one year.

–A 4- to 6.5-year follow-up study of 56 patients who received either mobile or fixed bearings during TKA found that the mobile-bearing group had greater mean range of motion, but there were no between-group differences in satisfaction or functional scores.

Instrumentation and Technique

–A randomized study of 47 patients whose surgeons used either customized cutting blocks or traditional instruments found no differences in clinical outcomes or mean component alignment. Moreover, surgeons abandoned customized blocks in 32% of the cases because of malalignment.

–A randomized study of 129 patients whose surgical approach was either medial parapatellar or subvastus, all of whom were managed with minimally invasive techniques, found no differences in pain, narcotic consumption, functional outcomes, and Knee Society Scores at postoperative times ranging from three days to three months.

Postoperative Care and Pain Management

–A trial among 249 post-TKA patients who received either one-to-one physical therapy (PT), group-based PT, or a monitored home program found no difference in outcomes at 10 weeks and one year.

–A randomized study of 160 post-TKA patients investigating the effect of continuous passive motion (CPM) machines led the study authors to conclude that CPM is neither beneficial nor cost-effective.

–A small randomized study of pain-management protocols found that a “multimodal” approach that included peri-articular injection led to less pain, less narcotic use, and higher satisfaction for up to six weeks after surgery than a patient-controlled analgesia approach.

–A three-way randomized pain-management study of 100 patients led study authors to recommend against posterior capsule injections and to conclude that “a sciatic nerve block [for TKA] has a minimal effect on pain control.”

–A three-way randomized study of 120 TKA patients found that those receiving preoperative dexamethasone and ondansetron had less nausea, shorter hospital stays, and used less narcotic medication than those who received ondansetron alone. “Dexamethasone should be part of a comprehensive total joint arthroplasty protocol,” the study authors concluded.

AMGA Survey: Orthopaedic Compensation Up 2.5% Over Last Year

Last year, we reported on orthopaedic surgeon compensation data from Medscape. This year, we take a look at orthopaedist compensation numbers (base salary, plus incentives and discretionary compensation) from the American Medical Group Association (AMGA).

According to the AMGA’s 2014 Medical Group Compensation and Financial Survey, median orthopaedic surgeon compensation in 2014 was $538,123, up 2.5% from 2013. Among the eight surgical specialties surveyed for compensation data (neurosurgery was not included), orthopaedists came in second to cardiac/thoracic surgeons (whose median was $569,073, up 8.2% from 2013).

Compensation data from orthopaedic subspecialists revealed the following medians, from lowest to highest:

Foot and Ankle                 $505,606

Hand                                 $513,864

Pediatrics                          $516,544

Trauma                              $540,197

Sports Medicine                 $549,048

Joint Replacement            $563,896

Oncology                            $569,353

Spine                                  $749,445

Readers should keep in mind that two-thirds of the more than 950 orthopaedists who responded to the compensation portion of the AGMA survey were from group practices comprised of more than 150 physicians. Data from those individuals may not represent the compensation realities for orthopaedic surgeons in independent or smaller group practices.

Report on Cost Variation Spotlights Knee, Hip Arthroplasty

The Health of America, a new report from the Blue Cross Blue Shield Association (BCBSA), found that the amounts charged by hospitals for hip- and knee-replacement surgeries in 64 US geographic markets vary wildly within and between markets.

The report focused on hip and knee replacements because those are among the fastest-growing medical interventions in the US. The report cited a June 4, 2014 JBJS study stating that between 1993 and 2009, primary knee replacements more than tripled, and primary hip replacements doubled.

The BCBSA report found that within-market cost variation for knee replacements exceeded $18,701 in 16 of the 64 markets analyzed. Twenty-two of the markets studied had a greater than $17,301 variation for hip replacements. The dubious distinction for highest variation within a market went to Boston, where there was a 313% gap between the lowest- and highest-priced hip replacement surgeries.

Overall, Montgomery, Alabama had the lowest average costs for knee and hip replacement surgeries (about $16,000 each), and New York City had the highest (about $60,000 each).

With ever-growing deductibles and other “cost-shifting” that increases out-of-pocket expenses for patients, it behooves individuals to talk to their doctor and their insurer, and to understand hospital charges as well as possible before agreeing to an elective procedure, orthopaedic or otherwise.

Hot Flashes Linked to Increased Risk of Hip Fracture in Women

Menopausal women who experience moderate to severe hot flashes are 1.78 times as likely to fracture a hip as women of similar age who don’t have hot flashes. Interestingly, the researchers, reporting in The Journal of Clinical Endocrinology & Metabolism, found no association between hot flashes and vertebral fractures. However, they did find that the more severe the hot flashes, the lower the women’s bone density at the femoral neck and lumbar spine.

None of the women studied were using hormone therapy to treat menopause at baseline, and very few started hormone therapy during the mean follow-up of 8.2 years. The findings include statistical adjustment for baseline age, BMI, smoking, and other variables.

Carolyn Crandall, MD, the lead author of the study, told the Washington Post that the reason for the hot flash-hip fracture connection is “entirely a mystery.” But the authors wrote that “our analysis does suggest that impaired physical functioning may partially explain the [hip-fracture] association.” They also surmised that lower estradiol levels in women with hot flashes may partly explain the association between hot flashes and decreased bone density.

Glucosamine Revisited, Again

Our OrthoBuzz report of the “near-death” of glucosamine/chondroitin may have been premature, according to a recent study published online in the Annals of the Rheumatic Diseases. The randomized, double-blind study assigned 606 patients with knee osteoarthritis and moderate-to-severe pain to receive either glucosamine (500 mg) and chondroitin (400 mg) three times a day, or one daily dose of the COX-2 inhibitor celecoxib (200 mg).

The study was designed to discern noninferiority between the supplements and celecoxib, and the results over six months showed equivalent benefits in both groups. WOMAC measures of pain decreased by 50.1% in the supplement group and 50.2% in the celecoxib group. Both groups also showed a >50% reduction in the presence of joint swelling, and adverse events were low in both groups.

One thing readers may want to consider when mulling over these results: The study was sponsored by the manufacturer of the glucosamine/chondroitin product used in the trial, and all authors disclosed financial relationships with that manufacturer.

An additional perspective on these and other glucosamine/chondroitin findings comes from JBJS Deputy Editor for Research Tom Bauer, MD, an ultra-marathon runner who’s free of arthritis symptoms and does take glucosamine/chondroitin supplements. Dr. Bauer emphasizes the distinction between preventing osteoarthritis and treating it. “Most published studies in humans, like this recent one, have tested glucosamine/chondroitin in patients with pre-existing osteoarthritis,” he said. “It’s a tall order to expect any oral medication to induce actual restoration of the articular surface, so I’m eager to see a decent chondroprotective study of these supplements in athletes who do not have osteoarthritis.”