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.
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.”
The latest market report from Transparency Market Research predicts that the global orthobiologics market will grow at a compound annual rate of nearly 6% over the next 5 years. In 2012, the orthobiologics market was worth $3.7 billion, and it is expected to hit $5.5 billion by the end of 2019. What will drive the growth? The 50+ population is expected to almost double by 2020, and increases in obesity and sports injuries will spur market growth. Technical improvements and a trend away from the use of autografts and allografts will also drive interest in orthobiologics.
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
In May, more than 300 orthopaedic surgeons attended the National Orthopaedic Leadership Conference in Washington, DC. During the conference, attendees took time to recognize the success of the AAOS Project Value initiative, which was started by former AAOS president John R. Tongue, MD. The initiative’s project team set out to quantify the social and economic benefits of musculoskeletal health care.
Four studies have been published as a result of this effort, three of which were published in JBJS:
- “The Direct and Indirect Costs to Society of Treatment for End-Stage Knee Arthritis,” JBJS, August 21, 2013. This article estimated that TKA has already generated lifetime societal savings to the U.S. economy of $12 billion.
- “Societal and Economic Impact of Anterior Cruciate Ligament Tears,” JBJS, October 2, 2013. Analysis found estimated annual savings from ACL reconstruction of $10 billion.
- “The Societal and Economic Value of Rotator Cuff Repair,” JBJS, November 20, 2013. Estimated lifetime savings to the U.S. economy were calculated to be $3.44 billion.
- “How Does Accounting for Worker Productivity Affect the Measured Cost-Effectiveness of Lumbar Discectomy?” Clinical Orthopaedics and Related Research, December 2013.
AAOS also hosts a website to highlight the notion of value in orthopaedics: www.ANationInMotion.org/value.
According to a recent JBJS readership study among 1,000+ orthopaedic surgeons and residents, sources used for obtaining clinical orthopaedic information vary depending on one’s resident or surgeon status. For example, 9 out of 10 residents rely heavily on online journals, compared to 8 out of 10 surgeons. The reliance gap between online and print journals is much more significant among residents (94% to 68%) compared to the gap among surgeons (80% to 77%). Mobile app usage is much more common among residents, with just more than half, 52%, using them heavily for clinical orthopaedic information, compared to 36% among surgeons. As the graph shows, two other significant differences between residents and surgeons are the use of textbooks and social media sites as sources of clinical information.
…And a Geography Gap:
Surgeons outside the US and Canada are more dependent on online journals for their clinical orthopaedic information than surgeons in North America (91% international to 77% US/Canada). Textbook usage also varies greatly by geography. Within the US and Canada, only 28% of surgeons rely heavily on textbooks, while close to 60% of international surgeons rate text books high in usage. Twice the percentage of international surgeons rely heavily on social media for clinical information, compared to those within the US/Canada (5% vs. 13%).
Orrin Franko, MD is a fifth-year orthopaedic surgery resident at University of California, San Diego. He has an interest in researching and promoting the orthopaedic uses of social media and mobile apps. In addition to multiple publications on these subjects, Dr. Franko is the founder and creator of TopOrthoApps.com, a website that reviews mobile apps for orthopaedic surgeons. We appreciate his willingness to answer a few questions for OrthoBuzz.
JBJS: Looking back on this year’s AAOS Annual Meeting in New Orleans, what were some of the highlights for you?
Dr. Franko: I was impressed by the combination of traditional posters, digital videos, and presentations. With regard to mobile technology, I was pleasantly surprised to see such a dramatic increase from just two years ago. This year I saw four posters that developed or validated a smartphone or tablet app for clinical use and patient care, something that I have never seen before. On the exhibit floor, iPads are now a ubiquitous platform for displaying education about products, and many new products integrate wireless capabilities and iPad functionality directly into their use.
JBJS: You presented several times in the Electronic Skills Pavilion at AAOS. Tell us a bit about the sessions and the audience response.
Dr. Franko: The Electronic Skills Pavilion provides a unique presentation opportunity for surgeons to give 45-minute talks on a variety of technology-related topics such as social media, practice websites, search engine optimization, and digital photography and videography. This year, I gave three talks on using mobile apps (iPad and iPhone) for education, patient information, and practice enhancement. The talks were very well attended, which suggests to me that surgeons are eager to learn how to use technology to improve their practice and efficiency.
JBJS: How have you seen the attitudes of orthopaedic surgeons toward mobile technology and apps change over the past 3 years?
Dr. Franko: The past 3 years have shown a clear up-trend in the prevalence and use of apps in hospitals and clinics among both residents and surgeons. This is reflected not only in my personal experience, but also in various studies that have assessed mobile-device usage among all physicians and specifically among orthopaedic surgeons. Using a phone in the hospital is no longer a distraction; it’s a critical educational device.
JBJS: What would you say to orthopaedists who are concerned about HIPAA compliance when using apps?
Dr. Franko: HIPAA will always be a “hot topic” with regard to mobile and wireless devices. This stems from a combination of fear about new technologies that are not well understood, and from the learning curve associated with the introduction of any new technology. First, I would remind everyone that historical medical documentation and care utilized paper charts, standard phone lines, fax machines, and text pagers—none of which are encrypted or HIPAA-compliant. In contrast, mobile devices, text messages, phone calls, and email are much more easily encrypted and protected from data breaches.
Admittedly, these systems are not perfect and never will be. However, if appropriate steps are taken to reduce risks, most hospitals permit the use of all these devices. Generally speaking, surgeons should be aware of patient information that is stored directly on their device versus “in the cloud” (on a remote server at another location). And, if information is stored in the cloud, this should be encrypted at a minimum. I equate the current status of mobile technology for patient care to the off-label use of FDA-approved medical devices: as long as surgeons are aware of how these new technologies work and take measures to protect their patients while working within the restrictions of their hospitals, they should be able to safely implement information technologies that benefit their patients.
JBJS: How do you think JBJS can best address the needs of orthopaedic residents?
Dr. Franko: I think JBJS is taking important steps to address residents’ needs to obtain reliable, peer-reviewed orthopaedic information. As a result of Google, the current generation of residents is accustomed to free, unlimited, and contextually searchable information without delay. This is in stark contrast to searching for archived journal articles on library shelves. By providing fully searchable article titles and full text with the ability to download PDFs for offline viewing, JBJS allows residents to find the information they need when it’s needed. Whether this is provided via a traditional website or via a mobile app is a decision of the journal, but mobile apps have proven to be efficient and reliable tools for journal reading.
(Editor’s note: The recent launch of JBJS Reviews included a free app for use with iOS and Android devices.)
JBJS: What trends in orthopaedics are you most intrigued by?
Dr. Franko: I am most intrigued by the ability to engage patients in the mobile sphere and help them to be participants in their own care. The increase in medical knowledge is true not only for residents and surgeons, but also for patients. Our patients have the ability to learn more about their diseases and potential treatment options than ever before, and they present to our clinics and hospitals with sophisticated questions and expectations about their care. I would like to see technology bridge the gaps between physicians and patients with regard to education and outcomes, while also potentially collecting useful data that can help guide further treatment.
JBJS: Looking ahead to the next 20 years, what three significant advances or changes in orthopaedics do you foresee?
Dr. Franko: While I cannot predict the future, I am hopeful that we will see technology enhance three specific areas of orthopaedic surgery. First, I expect to see drastic changes in resident education that utilize a combination of new technologies to disseminate orthopaedic information. That will include interactive digital journal club discussions, video and web-cast surgical techniques, online board-preparation courses, and curriculum changes that accommodate new work-hour restrictions. Second, I anticipate that medical record digitization will no longer be a burden and will rather demonstrate its potential benefits by improving clinical efficiency, patient safety, and enhancing outcomes research. Third, I am interested in watching the transition to universal healthcare and its impact on healthcare economics and ultimately patient outcomes. This will, in turn, greatly influence practice models and surgeon compensation for my generation of surgeons. That, in turn, will affect the way medical advances are developed and introduced into the field.
JBJS: What is your favorite thing about your profession?
Dr. Franko: The patients. Every day I have the opportunity to help people who are deeply motivated to improve and return to activity, which motivates me to help them in any way possible. My second favorite aspect of my profession is having such diverse and open-minded colleagues who are both exceptional clinicians as well as researchers. As a result, there has been great interest in studying the utility of new technology for the benefit of patient care.