The Centers for Medicare and Medicaid Services (CMS) announced this week that it will not deny claims from providers during the first 12 months of ICD-10 implementation based on a lack of code specificity, “as long as the physician/practitioner use[s] a valid code from the right family.” Similarly, CMS will not penalize physicians whose coding lacks ICD-10 specificity when reporting to the Physician Quality Reporting System, Meaningful Use, or Value Based Modifier programs, as long as the submitted code comes from the “correct family.”
In making this joint announcement with the AMA, CMS also said it will establish a “communication and collaboration center,” which will house an ombudsman “to help receive and triage physician and provider issues.” As “ICD-Day” (October 1, 2015) looms, CMS is encouraging small-practice providers to avail themselves of the readiness tools at the “Road to 10” website, which includes a separate section for orthopaedists.
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 May 20, 2015 Specialty Update on foot and ankle surgery:
Talar and Calcaneal Fractures
- A prospective randomized study comparing the sinus tarsi approach with the minimally invasive approach to the calcaneus found significantly fewer wound healing complications and shorter operative times with the minimally invasive longitudinal approach, but better outcomes were noted with the sinus tarsi approach for Sanders type-IV fractures.
- An RCT comparing outcomes of operative and nonoperative treatment for displaced intra-articular calcaneal fractures found no between-group differences at one year, but a trend toward better pain scores and function was noted in the operative group at eight to twelve years.
- A prospective randomized study of treatments for severe lateral ankle sprains compared a walking boot with restricted joint mobilization for three weeks with immediate application of a functional brace. No between-group differences in pain scores or development of mechanical instability were found, but the immediate functional-brace group had better function scores and shorter recoveries.
- A randomized trial comparing neuromuscular training, bracing, and a combination of the two for managing lateral ankle sprains concluded that bracing is the dominant secondary preventive intervention.
Total Ankle Arthroplasty
- A Level II study comparing total ankle arthroplasty (TAA) with ankle arthrodesis found that both procedures improved gait postoperatively, but TAA came closer to restoring a normal gait.
- A Level II study comparing fixed and mobile-bearing TAA devices found nearly equivalent improvements in pain and function.
- A Level I study looking at TAA outcomes in relation to preoperative coronal-plane malalignment found that results were similar for ankles with a preoperative coronal-plane varus deformity of ≥10° and those with <10° of varus deformity.
Ankle and Hindfoot Arthrodesis
- A pilot RCT comparing B2A-coated ceramic granules with autograft in foot and ankle arthrodesis found that the B2A approach produced a 100% fusion rate, compared with a 92% rate in the autograft group.
- A Level II study found that weight-bearing cast immobilization provided outcomes that were similar to those of non-weight-bearing cast immobilization in non-operative management of acute Achilles tendon ruptures.
- In an RCT comparing standard-of-care orthoses with experimental pressure-based orthoses to prevent plantar foot ulcers, the experimental orthoses outperformed the standard ones.
- A Level I study investigating surgical-site infections after foot and/or ankle surgery found an increased risk of infection associated with concomitant peripheral neuropathy, even in patients without diabetes.
A randomized study of 80 postmenopausal women with mild knee osteoarthritis found that those assigned to a supervised progressive-impact exercise program (including jumping and change-of-movement exercises) thrice weekly for a year experienced more biochemical improvements in their patellar cartilage, as determined by MRI T2 relaxation time, than those in a non-intervention control group. The exercise group also saw greater improvement in muscle strength and aerobic capacity, while patient-reported KOOS-score changes were similar in both groups.
Although many clinicians deem high-impact activity to be contraindicated in this population, this study suggests that postmenopausal women with mild knee OA can, under the supervision of a physical therapist, be encouraged to include high-impact exercises in their fitness regimen.
In the February 18, 2015 issue of The Journal, Rohner et al. report their experience with knee arthrodesis using an intramedullary rod as the definitive treatment for failed total knee arthroplasties (TKAs) related to infection. They report the results for 26 patients treated between 1997 and 2013 who had undergone an average of 6 ±3 knee procedures prior to arthrodesis.
The outcomes for this cohort of patients are sobering. Persistent infection requiring additional surgery remained in 50% of the patients. The health-related quality-of-life measures and functional outcomes were abysmal, and 73% reported persistent pain at greater than 3 on the VAS. Obesity, high blood pressure, and diabetes were strong predictors of reinfection.
Many of us have taken comfort that knee fusion, by whatever surgical technique, is a reliable “bail out” for the problem of recurrent infection following revision of a loose or infected TKA. Nevertheless, any surgeon who has followed a patient with a knee fusion is fully aware of the functional disability associated with the stiff knee. Difficulties using public transportation and impaired sitting are just two inconveniences that these patients express unhappiness about.
Despite its retrospective design and relatively small number of cases, this report may cause the knee-reconstruction community to reconsider knee arthrodesis and instead attempt further staged revisions of the knee prosthesis. It may even prompt a slightly earlier move toward recommending trans-femoral amputation. It certainly will stimulate further research into infection prevention and into developing more predictable approaches for revising infected TKA prostheses.
Marc Swiontkowski, MD
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.
–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.
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.
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
Sports Medicine $549,048
Joint Replacement $563,896
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.
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.
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.”
Each 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.
In 1989, a group of sixty-seven asymptomatic individuals with no history of back pain or sciatica underwent magnetic resonance scans of the lumbar spine. In a landmark 1990 JBJS study, Boden et al. reported that three neuroradiologists who had no clinical knowledge of the patients interpreted the images as being substantially abnormal in 28% of the cohort (19 individuals). More specifically, a herniated nucleus pulposus was identified in 24 % of these asymptomatic subjects. These “magnetic-resonance positive” findings were more prevalent in older subjects; abnormal MRI findings were identified in 57% of those aged 60 to 80 years.
Boden et al. concluded that so many MRI findings of substantial abnormalities in asymptomatic people “emphasized the dangers of predicating a decision to operate on the basis of diagnostic tests—even when a state-of-the-art modality is used—without precise correlation with clinical signs and symptoms.”
However, despite the findings of Boden et al., during the last five years of the 1990s, Medicare claims showed a 40% increase in spine-surgery rates, a 70% increase in fusion-surgery rates, and a two-fold increase in use of spinal implants. Although spine-fusion surgery has a well-established role in treating certain spinal diseases, a 2007 systematic review of several randomized trials indicated that the benefits of fusion surgery were limited when treating degenerative lumbar discs with back pain alone. This review suggested the need for more thorough selection of surgical candidates, which was a caution also implied by Boden et al.
Although the three neuroradiologists in the Boden et al. study largely agreed on the absence or presence of abnormal findings on the MRIs, in 2014 Fu et al. reported on the interrater and intrarater agreements by four reviewers of MRI findings from the lumbar spine of 75 subjects. Even though this study used standardized evaluation criteria, there was significant variability in both interrater and intrarater agreement among the reviewers. As the Boden et al. study did 25 years ago, this study demonstrated the diagnostic limitations of MRI interpretation for lumbar spinal diseases.
In 2001, JBJS published a paper by Borenstein et al. that was a seven-year follow-up study among the same asymptomatic subjects studied by Boden et al. Borenstein et al. found that the original 1989 scans of the lumbar spine were not predictive of the future development or duration of low back pain. This led Borenstein et al. to conclude—as Boden et al. did—that “clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.”
Many important subsequent studies were inspired by the original findings of Boden et al. in JBJS. Most of them emphasize that for lumbar-spine diagnoses, an MRI is only one (albeit important) piece of data; that interpretation of MRIs is variable; and that all imaging information must be correlated to the specific patient’s clinical condition.
Several studies and national surveys indicate that approximately a quarter of US adults report having had back pain during the past 3 months, making this a common clinical complaint. But the findings of Boden, et al. and subsequent studies remind us that surgery is not always the appropriate treatment.
Daisuke Togawa, MD, PhD
JBJS Deputy Editor
A new report from Accenture estimates that by 2019, two-thirds of US health systems will offer patients the opportunity to digitally self-schedule physician appointments. By reducing the time spent scheduling and rescheduling (an average of 8 minutes per phone appointment versus less than a minute for online self-scheduling), this simple change could save the health care system an estimated $3.2 billion.
Accenture says that nationwide, 11% of health systems currently offer self-scheduling of appointments, but only 2.4% of patients who have the opportunity take advantage of it. That may be partly because retirees—a population that generally prefers conducting business by phone—make up nearly half of the US population. Still, a recent Accenture survey indicated that 77% of patients thought that the ability to book, change, or cancel medical appointments online was important.