Many orthopaedic surgeons still believe that physical therapy (PT) services simply add to the total cost of care without improving patient outcomes. During my orthopaedic education, several knowledgeable attending surgeons said patients can be shown exercises in the orthopaedic clinic and do them on their own to avoid the increased expense of PT services. This belief extended to preoperative PT (“prehab”) to prepare patients for joint-replacement procedures. Until now, the impact of prehab on the total cost of care had not been rigorously evaluated.
In a well-designed study in the October 1, 2014 edition of The Journal, Snow et al. investigated whether preoperative PT affected total episode-of-care cost for hip- and knee-replacement procedures. They used CMS (Centers for Medicare & Medicaid Services) data from 169 urban and rural hospitals in Ohio and gleaned 4733 complete records to answer the question. The outcome measures of interest were utilization of post-acute care in the first 90 days after the procedure and total episode-of-care costs. The study defined post-acute care as admission to a skilled nursing facility, use of inpatient rehabilitation services, or use of home health services.
Nearly 80% of patients who did not receive preoperative PT services utilized post-acute care services, compared with 54% of patients who did receive prehab services. This resulted in a mean cost reduction of $871 per episode (after adjusting for age and comorbidities), with much of the savings accruing from decreased use of skilled nursing facilities. In their discussion, the authors note that prehab in this study generally consisted of only one or two sessions, and they therefore suggest that “the value of preoperative physical therapy was primarily due to patient training on postoperative assistive walking devices, planning for recovery, and managing patient expectations, and not from multiple, intensive training sessions to develop strength and range of motion.”
So it seems that prehab can reduce the overall cost of care in the setting of joint replacement. Further investigations using commercial insurance datasets to supplement this CMS data will be useful in developing treatment protocols and policies in this age of global payments for episodes of care.
Marc Swiontkowski. MD, Editor-in-Chief, JBJS
One measure of success for leaders is whether the organization they’ve led is stronger upon their departure. That’s a responsibility I’ve taken seriously for nearly 5 years as CEO/Publisher of STRIATUS/JBJS, Inc.
In the near future, I will be leaving STRIATUS/JBJS, Inc. to become Publisher at the American Association for the Advancement of Science (AAAS), which publishes the journal Science, along with Science: Translational Medicine, Science: Signaling, and Science: Advances.
While I’m sad to leave my colleagues and this audience, I’m happy to report that over the last 5 years, STRIATUS/JBJS, Inc. has improved and grown in a number of ways:
- This year, The Journal’s impact factor increased nearly 33% to its highest level ever, while The Journal remains the most-read journal in the specialty.
- Our new review journal, JBJS Reviews, is already one of the top online journal destinations in the field.
- The new JBJS Recertification Course has proven popular and effective with surgeons preparing for their maintenance-of-certification exams.
- JBJS Case Connector is improving clinical awareness and acumen on a monthly basis, with “Case Connections” synthesizing old and new information and “Watches & Warnings” alerting the field to emerging trends.
- With a growing video library, JBJS Essential Surgical Techniques continues to provide in-depth, step-by-step guidance on new surgical techniques, and plans to take practical surgical video to a new level in 2015.
With an excellent editorial team led by our new Editor-in-Chief, Marc Swiontkowski, MD, these journal and educational products are poised for long-term success.
In addition to improving and extending its core products, STRIATUS/JBJS, Inc., has diversified into new areas, adding important tools to the scientific literature, products emphasizing quality evidence and peer review. SocialCite, which allows feedback on the quality and appropriateness of journal citations, has major publishers participating in its pilot phase. PRE-val, which brings increased transparency and accountability to peer review, is also generating significant interest across the sciences.
It has been an honor working with the superb staff and editors at STRIATUS/JBJS, Inc., as well as serving the orthopaedic community – orthopaedic surgeons, physical therapists, physician assistants, and others – over the last 5 years. Thank you.
Many orthopaedic surgeons come from an active background, often including competitive sports and other “high energy” activities. Injury is no stranger to many of us. In fact, it is often a youthful injury that put us in contact with an orthopaedic surgeon and spurred us to consider a career as a physician. Once we gain exposure to the various specialties in medical school rotations, we often find that orthopaedic surgeons are the most contented lot and have abundant enthusiasm for their patient-care activities… and we join the tribe.
Knee injury is common to many sporting activities, and of the various types of knee injuries, ACL rupture is among the most common. Many orthopaedists have experienced it firsthand. During my surgical education, ACL repair was in its infancy and we were navigating the transition between extra-articular and intra-articular reconstruction. Early in my academic career, I could identify many colleagues who had an ACL tear (diagnosed by physical exam with perhaps an arthrogram to check for meniscal tears, in those days prior to MRI) who had not undergone surgical reconstruction. This was my own personal situation. Now that the diagnosis is highly reliable and highly reproducible outpatient arthroscopic reconstruction is available, I suspect this is no longer the case. However, for patients who have lower functional expectations and demands in their future, nonoperative treatment should still be an option.
In the August 6, 2014 JBJS, Grindem et al. do the orthopaedic community a huge service by providing data from a prospectively enrolled and carefully followed cohort of 143 patients with ACL rupture who were treated both operatively and non-operatively. This study design carries all the limitations associated with any cohort study, with selection bias being a big factor. The findings that the 100 patients who selected reconstruction were younger and had expectations of higher-level sport activity are not surprising. This same surgically treated cohort was more likely to experience knee re-injury, probably due to increased exposure from level-I sports. The 43 nonsurgical patients returned to level-II sports in the first year much more quickly and in the second year were more likely to return to level-III sports than their surgically treated counterparts. In essence, there were no major differences between the two populations at two years in terms of knee extensor and flexor weakness. Those findings are no doubt highly correlated to patient factors such as rehabilitation compliance.
I conclude that there is still a role for non-operative management of ACL rupture in patients who select this route during a shared decision making process. We know that there seems to be a higher risk of subsequent meniscal injury in people without an ACL, but many patients are willing to accept this risk.
Donald Fithian tells us what he thinks of this study in an accompanying JBJS commentary. What do you think?
This is my first Editor’s Choice for OrthoBuzz as new Editor-in-Chief of JBJS. I am following the example of my esteemed predecessor, Vern Tolo, who recently issued an Editor’s Choice warning about our failure to improve the management of patients with fragility fractures in terms of appropriate diagnosis and treatment of underlying osteoporosis. That is a failure of under-treatment. I want to focus on a potential issue of overtreatment.
In the July 2, 2014 JBJS, Leroux et al. describe the risk factors for repeat surgery after ORIF of midshaft clavicle fractures. The study analyzed 1,350 patients treated with surgery between 2002 and 2010 in Ontario. It is important to note that this analysis includes years after 2007, when JBJS published the seminal multicenter RCT on this topic by the Canadian Orthopaedic Trauma Society (COTS). The essence of that study was that ORIF with plate fixation results in a lower rate of nonunion and better functional outcomes predominantly in patients who have completely displaced fractures with about 2 cm of shortening or displacement.
Since that publication, we have seen an explosion in the operative treatment of midshaft clavicle fractures in North America. However, all too often the inclusion criteria derived from the seminal RCT are not referenced in individual patient decision making, and the presence of a clavicle fracture–regardless of degree of displacement–becomes an indication for surgical management.
The findings of the Leroux study should help put a hard stop to this! These researchers found a 24.6% incidence of repeat surgery in this cohort of patients. The most common reoperation was isolated implant removal (18.8%), and the incidence of major complications included nonunion (2.6%), deep infection (2.6%), pneumothoraces (1.2%), and malunion (1.1%). Risk of reoperation was increased in female patients and in those with major medical comorbidities. Limited surgeon experience increased the risk of reoperation for infection.
The orthopaedic surgery community must heed these data and act upon them. We should not misinterpret the COTS study to “encourage” a patient to opt for surgery if he or she has a midshaft clavicle fracture with less than 2 cm of shortening or displacement. The technical aspects of surgery for midshaft clavicle nonunion is not that different than that for a fresh fracture, so avoidance of nonunion must be thoughtfully discussed with the patient before recommending surgical fixation.
The bottom line that Leroux et al. provide is that surgery for a midshaft clavicle fracture is not a guaranteed success and that surgeon experience matters. And beyond clavicle fractures, let’s be sure we use our literature during shared decision making in an accurate and appropriate manner. That is a basic tenet of professionalism that we all should subscribe to.
JBJS welcomes Dr. Marc Swiontkowski as our new Editor-in-Chief. Dr. Swiontkowski is a trauma specialist and professor in the Department of Orthopaedic Surgery at the University of Minnesota Medical School. He is also the former CEO of TRIA Orthopaedics and past president of the American Orthopaedic Association and the Orthopaedic Trauma Association.
We are excited to work with Dr. Swiontkowski to continue strengthening JBJS as it supports the practice of orthopaedics and musculoskeletal health for everyone.
As Dr. Swiontkowski works with our departing Editor-in-Chief, Dr. Vern Tolo, during this transition, he was gracious enough to answer a few questions for OrthoBuzz.
JBJS: As you transition into the role of Editor-in-Chief at JBJS, what are you most excited about?
Dr. Swiontkowski: The opportunity to work with a highly talented group of editors and authors to influence the course of musculoskeletal medicine and surgery is what excites me the most.
JBJS: What are your goals for JBJS?
Dr. Swiontkowski: I hope to maintain our excellence in peer review while innovating in new ways to deliver information to surgeons in ways that are most useful for clinical decision making.
JBJS: As JBJS celebrates its 125th anniversary this year, how would you describe the impact the Journal has had on orthopaedics?
Dr. Swiontkowski: JBJS has been at the forefront of all the important developments in the field, and those developments have directly impacted patients with musculoskeletal disorders.
JBJS: How do you think JBJS can best support orthopaedics going forward?
Dr. Swiontkowski: In the future, JBJS will continue to support and recognize our highly skilled panel of reviewers, while developing new mechanisms for educating and delivering highly refined information to surgeons.
JBJS: You helped found and have served as the CEO of TRIA Orthopaedics, a full-service outpatient orthopaedic center in Bloomington, MN. What have you learned about community orthopaedics as a result of starting and growing that practice?
Dr. Swiontkowski: Community surgeons are interested in access to the highest quality scientific information to support their clinical decision making. They are also willing to contribute to new-knowledge development if the process is well refined with appropriate support.
JBJS: What trends in orthopaedics are you most intrigued by?
Dr. Swiontkowski: Four trends come to mind:
- The move away from general hospital-based care.
- The move toward patient-oriented functional outcomes to evaluate the results of care
- The openness to consider better ways to identify patients most likely to benefit from a particular treatment….and
- The move away from incremental implant design improvements toward understanding surgeon factors that have the greatest impact on patient results.
JBJS: Looking ahead to the next 20 years or so, what three significant advances or changes in orthopaedics do you foresee?
Dr. Swiontkowski: I think we’ll see the following changes:
- The full transition to milestone-based surgeon education
- The ability to identify patient and surgeon characteristics that have the biggest impact on outcomes for use in shared decision making processes
- The move away from general hospital-based care toward musculoskeletal treatment centers.
JBJS: What is your favorite thing about your profession?
Dr. Swiontkowski: It’s incredibly fulfilling to be completely trusted by patients to act in their best interest with the use of very powerful orthopaedic interventions.