The Economics of Revision THA for Fractures: Sustainable?
At the risk of economic oversimplification, it is difficult to sustainably provide a service when payment for it is less than the cost to perform it. But that is one reality exposed by Hevesi et al. in the May 15, 2019 issue of The Journal. Using National Inpatient Sample and ACS-NSQIP data, the authors compared the average costs and 30-day complication rates for revision total hip arthroplasties (THAs) performed for 3 different indications—fractures, wear/loosening, and instability—at both a local and national level. They found that the average hospitalization costs associated with a revision THA related to a fracture were 33% to 48% higher (p < 0.001) than the cost of revision THAs related to wear or instability.
However, the authors emphasize that all 3 of these indications for revision THA are reimbursed at the same rate based on Medicare Diagnosis-Related Group (DRG) codes. DRGs take into account patient comorbidities to determine reimbursement levels—but they do not adjust payments for THA revision according to indication. Hevesi et al. note that the only DRG reimbursement level that would cover the average cost of a revision THA for a fracture would be one performed on a patient with severe medical comorbidities or a major complication. Not surprisingly, patients who underwent a revision THA to treat a fracture were found to have a higher age and more medical comorbidities than those undergoing a revision for wear or instability.
The authors use this data to make a very compelling case that DRGs for revision THA should be changed so they are indication-specific, taking into account the underlying reason for the revision. They observe that “a DRG scheme that does not distinguish between indications for revision THA sets the stage for disincentivizing the care of fracture patients and incentivizing referrals to other facilities.” Those “other facilities” usually end up being large tertiary-care centers, which the authors claim “perform a higher percentage of the costlier revision THA indications.”
This problem of reimbursement inequality is not unique to revision THAs and requires further investigation in many fields. Unless “the system” addresses these subtle but important differences, tertiary referral centers may be inundated with patients who need procedures that cost more to perform than the institutions receive in reimbursement—an unsustainable scenario.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
In My Hands, There’s a Dog Leash
As a journalist covering symposia at the 2019 AAOS Annual Meeting last week, I repeatedly heard the phrase “in my hands…,” referring to a surgeon’s individual experience with this or that technique. That got me to thinking about a research letter published in the March 6, 2019 issue of JAMA Surgery. This retrospective cross-sectional analysis of emergency department data revealed that the annual number of patients ≥65 years old presenting to US emergency departments with fractures associated with walking leashed dogs more than doubled during 2004 to 2017. Women sustained more than three-quarters of those fractures, and while the hip was the most frequently fractured body part, collectively, the upper extremity was the most frequently fractured region. Slightly more than one-quarter of those patients were admitted to the hospital.
The authors rightly pinpoint the “gravity of this burden”; the hip-fracture data alone are worrisome. And in a related online article by hand and wrist surgeons from Rush University Medical Center (titled “Doggy Danger”), the focus is on the many injuries that the human leash-holding apparatus can sustain. The authors of the JAMA Surgery research letter and the Rush authors offer common-sense advice for all us older dog walkers out there, including:
- Dog obedience training that teaches Bowser not to pull or lunge while on leash
- Selection of smaller dogs for older people contemplating acquiring a canine companion
- Holding the leash in your palm, not wrapping it around your hand
- Paying attention to where you walk, and being situationally aware (That means not texting while your dog is momentarily sniffing to see who peed on that post.)
- Selecting footwear that is appropriate for the terrain and environmental conditions during your walk
To these tidbits I would add finding a safe area where your dog can “be a dog” off-leash, preferably with other dogs and people. Socializing is good for both species, and most dog trainers and owners agree that “a tired dog is a good dog.”
The research letter states that a “risk-benefit analysis with respect to dog walking as an exercise alternative is essential,” and the authors do a concise job of quantifying fracture risk and suggesting risk-reduction strategies. The list of benefits from dog walking is too long to itemize here; suffice to say that the advantages run the gamut from physical to mental to spiritual. But let’s be safe and sensible out there. We owe it to our families (dogs included, of course) and to all those overworked orthopaedic trauma surgeons to stay on the sidewalks and in the forests and fields–and out of the ER.
Lloyd Resnick
JBJS Developmental Editor
Keeping a Clinical Eye on Downstream Costs
Medical economics has progressed to the point where musculoskeletal physicians and surgeons cannot ignore the financial implications of their decisions. Unfortunately, in most practice locations it is difficult, if not impossible, to ascertain the downstream costs to patients and insurers of our postsurgical orders for imaging, laboratory testing, and physical therapy (PT). In the April 18, 2018 issue of The Journal, Egol et al. present results from a well-designed and adequately powered randomized trial of outcomes after patients with minimally or nondisplaced radial head or neck fractures were referred either to outpatient PT or to a home exercise program focused on elbow motion.
At all follow-up time points (from 6 weeks to an average of 16.6 months), the authors found that patients receiving formal PT had DASH scores and time to clinical healing that were no better than the outcomes of those following the home exercise program. In fact, the study showed that after 6 weeks, patients following the home exercise program had a quicker improvement in DASH scores than those in the PT group.
The minor limitations with this study design (such as the potential for clinicians measuring elbow motion becoming aware of the treatment arm to which the patient was assigned) should not prevent us from implementing these findings immediately into practice. Each patient going to physical therapy in this scenario would have cost the healthcare system an estimated $800 to $2,400.
I wonder how many other pre- and postsurgical decisions that we routinely make would change if we had similar investigations into the value of ordering postoperative hemoglobin levels, surgical treatment of minimally displaced distal fibular fractures, routine postoperative radiographs for uncomplicated hand and wrist fractures, and PT after routine carpal tunnel release. These are just some of the reflexive decisions we make on a daily basis that probably have little to no value when it comes to patient outcomes. Whenever possible, we need to think about the downstream costs of such decisions and support the appropriate scientific evaluation of these commonly accepted, but possibly misguided, practices.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
What’s New in Orthopaedic Trauma
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. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, David Teague, MD, co-author of the July 5, 2017 Specialty Update on orthopaedic trauma, selected the five most clinically compelling findings from among the 34 studies summarized in the Specialty Update.
Tibial Fractures
A randomized, sham-controlled clinical trial1 failed to demonstrate improved functional recovery or accelerated radiographic healing with the addition of low-intensity pulsed ultrasound (LIPUS) to the postoperative regimen of fresh tibial fractures.
Postsurgical Weight-Bearing
Two studies support early weight-bearing (WB) after certain operatively managed lower extremity injuries, an allowance that may substantially improve a patient’s early independence. One randomized study2demonstrated that immediate WB after locked intramedullary fixation of tibial fractures is not inferior in union time, complication rates, or early function score when compared with a 6-week period of non-WB. The second randomized trial3 found early WB after select ankle fracture fixation (no syndesmosis or posterior malleolar fixation included) resulted in no increase in complications, fewer elective implant removals, and improved 6-week function, relative to late weight-bearing.
Pelvic Injuries
The addition of posterior fixation to anterior fixation for patients with anteroposterior compression type-2 injuries (symphysis disruption, unilateral anterior sacroiliac joint widening) improved radiographic results and led to fewer anterior plate failures.
Hip Fractures
Less femoral neck shortening occurred with cephalomedullary nail fixation devices (2 mm) than with a side plate and lag screw construct (1 cm) when treating OTA/AO 31-A2 intertrochanteric fractures (unstable, 3 or more parts) in patients ≥55 years of age, although functional outcomes were similar for the two groups.
References
- Busse JW, Bhandari M, Einhorn TA, Schemitsch E, Heckman JD, Tornetta P 3rd, Leung KS, Heels-Ansdell D, Makosso-Kallyth S, Della Rocca GJ, Jones CB, Guyatt GH; TRUST Investigators writing group. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ. 2016 ;355:i5351.
- Gross SC, Galos DK, Taormina DP, Crespo A, Egol KA, Tejwani NC. Can tibial shaft fractures bear weight after intramedullary nailing? A randomized controlled trial. J Orthop Trauma. 2016 ;30(7):370–5.
- Dehghan N, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall JA, Stephen DJ, Kreder HJ. Early weightbearing and range of motion versus non-weightbearing and immobilization after open reduction and internal fixation of unstable ankle fractures: a randomized controlled trial. J Orthop Trauma. 2016 ;30(7):345–52.
What’s New in Foot and Ankle Surgery
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. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Sheldon Lin, MD and Michael Yeranosian, MD, co-authors of the May 18, 2016 Specialty Update on foot and ankle surgery, to select the five most clinically compelling findings from among the more than 50 studies they cited.
Ankle Fractures and Syndesmotic Injuries
–A randomized study compared syndesmotic fixation versus no fixation in patients with supination-external rotation (SER) IV-type ankle fractures and positive intraoperative stress tests (persistent widening of the medial clear space). At four years of follow-up researchers found no clinical or radiological differences between the two groups.1
–A randomized single-blinded trial to help determine optimal methods for soft-tissue management after ankle trauma compared standard treatment using ice and elevation with the use of multilayer compression bandages. Researchers found that multilayer compression therapy resulted in faster resolution of edema than cryotherapy.
Total Ankle Arthroplasty
–A prospective cohort study found that patients undergoing total ankle arthroplasty (TAA) had higher preoperative expectation scores than did those undergoing ankle arthrodesis. TAA patients were also more likely than arthrodesis patients to report improved postoperative satisfaction scores. Postoperative expectation and satisfaction scores in both groups were closely linked to postoperative Ankle Osteoarthritis Scale (AOS) scores. The study emphasizes the importance of preoperative patient education.2
Orthobiologics
–A randomized controlled trial looking at union rates in ankle and hindfoot arthrodesis compared the use of recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) plus an injectable osteoconductive beta-tricalcium phosphate (β-TCP) collagen matrix to standard autograft. Complete fusion of all involved joints at 24 weeks occurred in 84% of those treated with the growth factor-matrix combination and in 65% of those treated with autograft (p <0.001).3
Patient-Reported Outcomes Assessment
–The 10-center Orthopaedic Foot & Ankle Outcomes Research (OFAR) Network conducted a three-month trial of collecting preoperative and six-month postoperative patient outcome information using the Patient Reported Outcomes Measurement Information System (PROMIS). Of the 328 patients enrolled, 76% completed the preoperative instruments and 43% completed the six-month postoperative instruments. Despite substantial loss to follow-up, the OFAR Network process enabled easy data aggregation and analysis, suggesting its utility in facilitating multicenter trials.4
References
- Kortekangas THJ, Pakarinen HJ, Savola O, Niinimäki J, Lepojärvi S, Ohtonen P, Flinkkilä T, Ristiniemi J. Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study. Foot Ankle Int. 2014 Oct;35(10):988-95. Epub 2014 Jun 24.
- Younger ASE, Wing KJ, Glazebrook M, Daniels TR, Dryden PJ, Lalonde KA, Wong H, Qian H, Penner M. Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot Ankle Int. 2015 Feb;36(2):123-34.
- Daniels TR, Younger ASE, Penner MJ, Wing KJ, Le ILD, Russell IS, Lalonde KA, Evangelista PT, Quiton JD, Glazebrook M, DiGiovanni CW. Prospective randomized controlled trial of hindfoot and ankle fusions treated with rhPDGF-BB in combination with a β-TCP-collagen matrix. Foot Ankle Int. 2015 Jul;36(7):739-48.Epub 2015 Apr 6.
- Hunt KJ, Alexander I, Baumhauer J, Brodsky J, Chiodo C, Daniels T, Davis WH, Deland J, Ellis S, Hung M, Ishikawa SN, Latt LD, Phisitkul P, SooHoo NF, Yang A, Saltzman CL; OFAR (Orthopaedic Foot and Ankle Outcomes Research Network). The Orthopaedic Foot and Ankle Outcomes Research (OFAR) network: feasibility of a multicenter network for patient outcomes assessment in foot and ankle. Foot Ankle Int. 2014Sep;35(9):847-54.
JBJS Classics: The Küntscher Method of IM Fixation
OrthoBuzz regularly brings 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 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.
In 1957 Gerhard Küntscher presented his work on intramedullary (IM) nailing to the American Academy of Orthopaedic Surgeons. His classic JBJS paper on the subject, published in January 1958, summarized his views on this comparatively new technique and encouraged other surgeons to use it for the treatment of long bone fractures and nonunions.
Küntscher pointed out that callus was very sensitive to mechanical stresses, and therefore any treatment method should aim at complete immobilization of the fracture fragments throughout the healing process. External splints, such as plaster casts, did not achieve that, and “inner splints” fixed to the outside of the bone damaged the periosteum.
In advocating for intramedullary fixation, Küntscher was careful to distinguish nails from pins. He was very complimentary about J. and L. Rush, who developed intramedullary pinning, but he pointed out that, unlike pins, nails allowed both longitudinal elasticity and cross-sectional compressibility if they were designed with a V-profile or clover-leaf cross section. This cross-sectional elasticity allowed the nail to fit the canal and expand during bone resorption.
Not only did Küntscher appreciate the biomechanics of the intramedullary nail, but he also pointed out the physical and psychological advantages of early mobilization, particularly in the elderly. He also emphasized that massage was unnecessary—and potentially harmful—during the recovery phase, claiming that any measures that make patients more conscious of their injuries are psychologically disadvantageous.
Küntscher used intramedullary nailing to treat fractures, nonunions, and osteotomies of the femur, tibia, humerus, and forearm. He accepted that it was “a most daring” approach that would destroy the nutrient artery, but he pointed out that proper nailing almost always prevented pseudarthoses and that antibiotics had checked the threat of infection. He said further that perioperative x-rays entailed short exposures and that the “electronic fluoroscope” had, even back then, practically eliminated the risk of x-ray injury to assistants.
The paper clearly illustrates Küntscher’s widespread knowledge and innovative skills. However, it was the subsequent development of locked nails that resulted in intramedullary nailing becoming the treatment of choice for femoral and tibial fractures. Time will tell if modern orthopaedic surgeons will catch up with Küntscher and use nailing for humeral and forearm diaphyseal fractures.
Charles M Court-Brown, MD, FRCSCEd
JBJS Deputy Editor
JBJS Editor’s Choice—A More Aggressive Approach to Dens Nonunion
In the February 3, 2016 JBJS study by Joestl et al., the authors report persistent radiographic nonunions in nearly 100% of 28 geriatric patients five years after being treated nonoperatively for a dens fracture nonunion. Traditionally these older patients were placed in halo vests or hard cervical collars, based on the rationale that frail, elderly patients might not survive upper-cervical fusion. That strategy, however, often results in skin problems, pin-site infections, and chronic upper-cervical and posterior-cranium pain.
With an increasingly elderly population looming during the next two decades, we will be seeing dens injuries and nonunions in higher numbers. The increased numbers of patients presenting with this injury may allow for a carefully planned multicenter randomized controlled trial, but I think the current status of information regarding this fracture is robust enough to suggest the following treatment approach: Much like the way we currently manage elderly patients with hip fractures, we should be prepared to more seriously consider operative treatment for patients over the age of 65 with a dens fracture—especially when there is concern about persistent nonunion and instability or development of neurological impairments. Although that may formerly have been considered an aggressive approach (and may still be ill-advised in high-surgical-risk patients), this study–plus systematic reviews of other smaller cohort studies–provides ample justification to consider proceeding operatively.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Nauth/McKee VideoWins JBJS EST Editor’s Choice Award
To celebrate the launch of “Key Procedures” in October, JBJS Essential Surgical Techniques (EST) invited authors to enter their videos in a contest for the Editor’s Choice Video Award. We are pleased to announce that Aaron Nauth and Mic
hael D. McKee have won the inaugural Editor’s Choice Video Award for their video article “Open Reduction and Internal Fixation of Both-Bones Forearm Fractures.” This video is now live on JBJS Essential Surgical Techniques, with complimentary access.
“Key Procedures” videos offer orthopaedic surgeons succinct 15- to 20-minute, peer-reviewed videos from experts in a variety of subspecialty areas. These videos focus on performing core orthopaedic procedures such as meniscal root repairs, direct anterior hip exposure for total hip arthroplasty, and proximal tibial valgus osteotomy .
JBJS Essential Surgical Techniques is offering free access to “Key Procedures” videos for a limited time. Starting in March 2016, the videos will be viewable only by JBJS EST subscribers.
JBJS Case Connections: Happy Endings to Unusual Cervical Spine Injuries
The November 25, 2015 “Case Connections” looks at four JBJS Case Connector cases involving injuries to the cervical spine in which the outcomes were about as good as anyone could have wished, considering the potential for disaster. Two of the cases required surgical intervention to achieve the positive outcomes, but the outcomes in the other two cases were remarkably positive without surgery.
While these four cases of cervical spine injury had relatively “happy endings,” orthopaedic surgeons and other health-care professionals treating patients with any suspected spine injury are trained to proceed with the utmost care and caution out of concern for devastating neurological sequelae. Watchful waiting under close medical scrutiny is sometimes warranted, but many cases of cervical fracture, dislocation, or instability call for operative stabilization to reduce the risk of life-changing or life-threatening consequences. The potential seriousness of surgical complications when operating on the spine must also be recognized.
JBJS Classics: Understanding Proximal Humeral Fractures
The contributions to the field of shoulder surgery from Dr. Charles Neer are too numerous to document in any one commentary. A partial list would include shoulder arthroplasty (both hemi and total), the concept of impingement and acromial pathology, multidirectional instability, and the role of the AC joint in rotator cuff pathology.
Dr. Neer also made numerous contributions to the understanding of fracture care, including the distal femur and clavicle. But no area of fracture management was of greater interest to him and his colleagues at Columbia than the proximal humerus. This classic manuscript has been cited thousands of time and remains the seminal piece in the foundation of understanding fracture patterns in the proximal humerus—and the attendant treatment implications.
Dr. Neer introduced the concept of the four parts of the proximal humerus in this manuscript, and with it the implication of isolating the humeral-head blood supply in a four-part fracture. The impetus to understand the complication of avascular necrosis of the humeral head began with this manuscript, as did the critical debates regarding surgical versus nonsurgical intervention and replace-or-fix. An important area of ongoing debate is Neer’s definition of a “displaced” fracture in the proximal humerus as having > 1 cm of displacement. The orthopaedic community to this day is wrestling with this definition and its relevance to treatment and outcomes.
This classic manuscript also helped launch a decades-old conversation about the role of fracture or musculoskeletal-disease classification systems. Subsequent publications by Zuckerman and Gerber identified issues with inter- and intra-rater reliability when applying the Neer classification system to a set of radiographs. The reliability debate surrounding this classification system led us to understand the issue of forcing continuous variables (fracture lines are infinite in their trajectory and displacement) into dichotomous variables (a classification system). Because of Dr. Neer’s work and subsequent research, our community understands that when we make these classification designations, we will agree about 60% of the time (kappa statistic of 0.6). That level of agreement is not reflective of a “good” or “bad” classification system; rather, it’s a consequence of moving a continuous variable to a dichotomous variable.
So we remain indebted to Dr. Neer not only for laying the foundation for the treatment of patients with proximal humeral fractures, but also for vastly expanding our knowledge regarding the role, strengths, and weaknesses of disease and fracture-classification systems.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
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