TEA Proves Durable in Elderly Patients with Distal Humeral Fractures
Several studies have demonstrated good short- and intermediate-term outcomes with total elbow arthroplasty (TEA) to treat acute distal humeral fractures. Now, in the September 20, 2017 issue of The Journal of Bone & Joint Surgery, Barco et al. provide data confirming that TEA provides durable pain relief and motion improvements over a minimum of 10 years, albeit with a number of major complications.
Among 44 TEAs performed in elderly patients with and without inflammatory arthritis whom the authors followed for ≥10 years, the mean Mayo Elbow Performance Score was 90.5 points. Five elbows (11%) developed deep infection that required surgical treatment. The revision-free survival rates for elbows with rheumatoid arthritis were 85% at 5 years and 76% at 10 years, while survival rates for elbows without rheumatoid arthritis were 92% at both time points. That difference was not statistically significant, although men in the study were much more likely to experience a revision than women. Twenty-five of the 44 patients died during the long-term follow-up, but the majority of those had their implant in place.
While reporting on these promising long-term revision-free survival rates, Barco et al. emphasize that complications were “frequent and diverse in nature…and have required a reoperation, including implant revision, in 12 of 44 patients.” So, while the good news is that a majority of patients in this situation will die with a useful joint and sound implant, the authors conclude that “surgeons treating this kind of injury should follow their patients over time and should be prepared to manage a wide array of complications using complex techniques.”
The Future of Private Practice Under Value-based Care
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.
An increasingly frequent concern is that the Merit-based Incentive Payment System (MIPS) and value-based care in general could lead to the demise of private physician practices. With the prevalence of that concern comes pressure for private practices to join Accountable Care Organizations (ACOs), where groups of doctors and/or hospitals synergize to deliver coordinated care to Medicare patients. ACOs certainly have their benefits, but the risks of joining one need to be evaluated as well. An ACO may work for one orthopaedic practice but not for another. From my perspective, private practices, both small and large, will be able to thrive under MIPS. Here’s why:
- First, the final ruling from MACRA has given physicians the ability to report with the ‘pick your pace’ model. The slow, phased introduction for MIPS gives practices a window of time to get on track. 2017 is the transitional year, giving practices time to identify processes and an EHR system that best fit their needs.
- Second, CMS established flexible MIPS measurements based on practice size. (Small practices are typically considered to be those with ≤15 providers, and large practices have >15 providers.)
- Third, if you have the right support from your vendors—especially your EHR system vendor—you will have a built-in MIPS intelligence platform, composite scoring, and support and advisory services to help you along the way.
- Finally, the government has earmarked an extra $500 million for “exceptional performance” for each year of the first five years of MIPS. The right EHR system can direct and support you to achieve this exceptional-performance rating.
Ultimately, the decision to join an ACO or remain a private practice is a multifactorial one. You should consider the options available and how they will impact you, both in the short term and long term. Either way, value-based care is here to stay, and finding an EHR vendor with the best resources for your practice is a crucial component for success.
Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.
After Achilles Repair, Musculotendinous Strength Remains a Big Challenge
Amid ongoing uncertainty regarding the optimum management of Achilles tendon ruptures, recent controlled trials seem to have moved the pendulum back toward nonsurgical treatment. Still, there are many people walking around on surgically repaired Achilles tendons, and in the September 20, 2017 issue of The Journal, Heikkinen et al. report on the 13+-year outcomes of operative repair followed by early functional postoperative management in 52 patients.
All orthopaedic surgeons who have treated patients with this tendon injury have noted the postoperative calf atrophy. Using carefully analyzed MRI studies, these authors found that the mean volumes of the soleus, medial gastrocnemius, and lateral gastrocnemius muscles were 13%, 13%, and 11% lower, respectively, in the affected legs than in the uninjured legs. The mean 6% elongation of the repaired tendon that Heikkinen et al. also found at this long-term follow-up makes sense, because we are repairing tendinous tissue whose inherent collagen bundle structure has been “overstretched” prior to total failure. It also makes sense that surgeons are often hesitant to shorten the ends of the tendon aggressively for fear of placing too great a tensile strain on the suture repair.
What is most impressive to me is the degree of calf-muscle atrophy revealed in these results. Whether the findings from future trials tilt us further toward nonoperative or back toward operative care, we need to solve the muscle atrophy issue. The solution will most likely come from even more aggressive rehabilitation. To date, many of us have erred on the side of not pushing these patients too far during rehab, out of concern for failure of repair or reinjury.
With solid surgical and nonsurgical treatments for fractures, we have solved many issues to achieve optimum bone healing with good anatomic and strength outcomes. However, we have not really begun to make gains on limiting muscle, ligament, and tendon atrophy in lower extremity injuries. This should be high on the agenda for the trauma research community during the next 2 to 3 decades.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Fewer In-Hospital Complications with TAA vs Ankle Fusion
Among the many variables discussed when patients and surgeons make a decision between ankle arthrodesis (fusion) and total ankle replacement (TAA) for end-stage ankle arthritis, in-hospital complication rate is an often-overlooked point of comparison, partly due to a dearth of good data.
In the September 6, 2017 edition of The Journal of Bone & Joint Surgery, Odum et al. report findings from a matched cohort study that compared these two ankle procedures in terms of minor and major perioperative complications. To make more of an apples-to-apples comparison, the authors statistically matched 1,574 patients who underwent a TAA with an equal number of those who underwent fusion.
A major in-hospital complication (such as a pulmonary embolism or mechanical hardware problem) occurred in 8.5% of fusion patients and in 5.3% of TAA patients. After adjusting for case mix, Odum et al. found that ankle arthrodesis was 1.8 times more likely than TAA to be followed by a major complication. Regarding minor in-hospital complications (such as venous thrombosis or hematoma/seroma), the authors found a 29% lower risk of complications among arthrodesis patients compared to TAA patients, although that difference was not statistically significant (p = 0.14). Regardless of surgical procedure, patient age ≤67 years and the presence of multiple comorbidities were independently associated with a higher risk of a major complication.
A possible explanation for the lower in-hospital major-complication rate in TAA patients, say the authors, is that “TAA is more likely to be performed in younger, healthier patients with better bone quality and smaller deformities.”
D-Dimer Levels May Help with PJI Diagnoses
The percentage of periprosthetic joint infections (PJIs) among patients requiring revision arthroplasty of the hip and knee is increasing. PJIs have important clinical implications both for revision surgical procedures as well as pre- and postoperative management. Any extra help we can get making a PJI diagnosis outside of the obvious (where the patient presents with a draining wound) would be most welcome.
In the September 6, 2017 issue of The Journal, Shahi et al. present compelling data from a prospective study suggesting that serum D-dimer levels may help diagnose PJI—and thereby help determine the optimal timing of component reimplantation. The authors determined that 850 ng/mL was the optimal threshold value for D-dimer in diagnosing PJI. Moreover, with sensitivity of 89% and specificity of 93%, this test outperformed the widely used ESR and CRP tests, which until now have proven to be the “best” tools we have at our disposal.
Ideally, after these results are confirmed in larger populations of patients undergoing revision arthroplasty, the serum D-dimer test—inexpensive and almost universally available—will be used in all high-volume joint replacement centers. The continued pursuit of diagnostic and treatment methodologies for patients with suspected PJI is definitely warranted, given the increasing number of patients requiring arthroplasty and combined lifetime knee- and hip-replacement revision rates hovering around 10% to 12%. The identification of D-Dimer elevation as a potentially more accurate diagnostic tool than our currently available tests is a welcome contribution.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
September 2017 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 September 2017, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Assessment of Psychometric Properties of Various Balance Assessment Tools in Persons With Cervical Spondylotic Myelopathy.”
This cross-sectional study concluded that a brief version of the Balance Evaluation Systems Test (BESTest) is the most-preferred tool for assessing balance among patients with cervical spondylotic myelopathy.
Thank you, JBJS Reviewers
JBJS would like to thank and acknowledge all of the reviewer feedback received for Peer Review Week 2017. Below are the 2017 JBJS top reviewers who responded to the survey:
Robert J. Barth, PhD
Keith M. Baumgarten, MD
Timothy Bhattacharyya, MD
Eric M. Black, MD
Desmond Brown, MD
Pablo Castañeda, MD
Michael W. Chapman, MD
Antonia Chen, MD
Quanjun Cui, MD
Thomas DeCoster, MD
John R. Denton, MD
Sarah DeWitt, MD
Shivi Duggal, MD, MBA
Steve Elder, MD
Christopher Evans, MD
Mary Forte, PhD, DC
Joshua Gary, MD
Michelle Ghert, MD
Jessica Goetz, MD
James H. Herndon, MD
Carlos Higuera, MD
Nitin Jain, MD
Kelly Johnston, MD
Richard Kang, MD
Michael Kelly, MD
David H. Kim, MD
H. Mike Kim, MD
Michael Klassen, MD
William Lack, MD
Simon Lambert, MD
Loren Latta, MD
Gwo-Chin Lee, MD
Mengnai Li, MD
Guoan Li, MD
Luke McDonald, MD
Terence McIff, MD
Harry A. McKellop, PhD
Dana Mears, MD
James Michelson, MD
Peter M. Murray, MD
Dr. Jonathan Negus, MD
William Obremskey, MD
Javad Parvizi, MD
Benjamin Kyle Potter, MD
Hollis Potter, MD
William M. Ricci, MD
David Ring, MD
Raymond Robinson, MD
Joseph Schwab, MD
Brian J. Sennett, MD
James A. Shaw MD
Franklin H. Sim, MD
Marvin E. Steinberg, MD
James B Stiehl, MD, MBA
Kimberly Templeton, MD
Richard Terek, MD, FACS
Karen Troy, MD
Dionysios-Alexandros Verettas, MD
Scott Weiner, MD
Brian C. Werner, MD
John Wixted, MD
James Wright, MD
Alan Hargen, MD
We would like to thank these individuals as well as our entire pool of reviewers, whose ongoing contributions to JBJS enable us to continually work towards our mission of improving patient care around the world.
Peer Review Week Day 5-PM
JBJS is helping celebrate Peer Review Week 2017 by formally recognizing some of its top reviewers for their contributions. Each day during Peer Review Week 2017, JBJS will profile six different top reviewers on OrthoBuzz each morning and afternoon. This afternoon, let’s meet Brian J.Sennett, Antonia Chen, and Terrence McIff.
Brian J. Sennett, MD
University of Pennsylvania
What do you like best about reviewing for JBJS?
Improving the level of publications by analytically evaluating articles for submission. JBJS is such a significant publication that I feel that it is very important that the readership has access to the best articles.
How do you find time to review for JBJS?
I find time because I believe it is important. There is never enough time for everything. Reviewing for JBJS is one of my priorities.
What do you see as JBJS‘ role in shaping the future of orthopaedics?
I see JBJS as the leader in shaping orthopaedic knowledge and care. While the annual meeting of the AAOS is a phenomenal meeting, it occurs just once a year. JBJS allows the readership to stay up-to-date all year long.
Antonia Chen, MD
Rothman Institute
What do you like best about reviewing for JBJS?
I am honored at the opportunity to be one of the first to see the latest research that will ultimately shape the future of orthopaedics. It is humbling to play some small part in working with JBJS to provide authors with a critical review of research studies, and ultimately help shape meaningful and impactful manuscripts.
How do you find time to review for JBJS?
I make time for activities that are important to me, and I view reviewing for JBJS as a privilege.
What do you see as JBJS‘ role in shaping the future of orthopaedics?
JBJS provides orthopaedic surgeons with the ultimate voice for our field. It’s a unique balance of cutting edge research and evidence based studies that facilitate sound clinical decisions in the setting of quality, cost-conscious care for our patients.
Terence McIff, MD
University of Kansas Medical Center
What do you like best about reviewing for JBJS?
Very efficient process. Fast feedback. I feel like I am contributing to maintain the quality of JBJS and the quality of information that our residents depend on for their education.
How do you find time to review for JBJS?
I do have to put it as one of my priorities. Sometimes I feel that I just don’t have time for another review but have learned that setting aside specific time to study and complete the review makes it doable.
What do you see as JBJS‘ role in shaping the future of orthopaedics?
JBJS is the standard studied by our orthopedic residents and staff. As long as it continues to be a trusted source for up-to-date practices and innovations it will serve the community well.
Thank You, JBJS Elite Reviewers
The JBJS Elite Reviewers Program publicly recognizes our best reviewers for their outstanding efforts. Reviewers who review 4 or more manuscripts per year, rarely decline an invitation to review a manuscript (responding within 48 hours), and complete highly graded reviews within 1 week are eligible for the program. Elite Reviewers receive the following benefits in recognition of their exemplary performance:
- No submission fees for papers of which the reviewer is the first author (for 12 months)
- Free CME credits for all reviews
- Free online access to all JBJS publications
- A letter to the reviewer’s department head from JBJS Editor-in-Chief, Marc Swiontkowski, MD, recognizing and commending his/her good work
- Name recognition on the JBJS Elite Reviewers Program Web page and on the masthead of The Journal
For JBJS Consultant Reviewer Guidelines, visit http://bit.ly/2cWvYvc.
To learn how you can be a better reviewer visit http://bit.ly/2cRt1hY.
Here is an updated list of JBJS Elite Reviewers:
Peer Review Week Day 5-AM
JBJS is helping celebrate Peer Review Week 2017 by formally recognizing some of its top reviewers for their contributions. Each day during Peer Review Week 2017, JBJS will profile six different top reviewers on OrthoBuzz each morning and afternoon. This morning, let’s meet Desmond Brown, Christopher Evans, and Keith Baumgarten.
Desmond Brown, MD
Boston University School of Medicine
What do you like best about reviewing for JBJS?
I like doing my part to find a small island of truth in the middle of the great sea of uncertainty.
How do you find time to review for JBJS?
I do reviews mostly at night or on weekends, whenever I have a block of quiet time sufficient to read an article carefully and think about. I take notes and then return to it later to re-read it and write my review.
What do you see as JBJS‘ role in shaping the future of orthopaedics?
I think that sound and ethical research is essential for medicine to progress. I think that JBJS will continue to push for the highest standards in research, help to identify interesting and promising developments, and bring them to the attention of the orthopaedic world.
Christopher Evans, MD
Mayo Clinic
What do you like best about reviewing for JBJS?
I think it helps the orthopaedic community to have laboratory PhDs like myself review manuscripts that lie in the realm of science and translation. It also helps people like me understand, integrate and appreciate clinically relevant components of the orthopedic research enterprise.
How do you find time to review for JBJS?
In-flight entertainment!
What do you see as JBJS‘ role in shaping the future of orthopaedics?
As the leading, most established and most cited orthopaedic journal it will continue to serve as an opinion leader and arbiter in the field of orthopedics.
Keith M. Baumgarten, MD
Orthopedic Institute
What do you like best about reviewing for JBJS?
Reviewing for JBJS allows me to see cutting edge research prior to publication. It allows me to assist other authors in optimizing their manuscripts. In addition, reviewing manuscripts makes me a better author and researcher.
How do you find time to review for JBJS?
I find time to review for JBJS in between surgical cases, when I am travelling to outreach clinics, and during dedicated research time.
What do you see as JBJS‘ role in shaping the future of orthopaedics?
JBJS publishes cutting edge, peer-reviewed research that increases world-wide orthopaedic knowledge through evidence-based medicine.
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