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
In a November 16, 2016 JBJS study whose findings have implications for both research and practice, Katz et al. analyzed data from the MeTeOR trial to answer two questions:
- What prompts patients with meniscal tears and knee osteoarthritis who are randomized to physical therapy (PT) in trials comparing PT to arthroscopic partial meniscectomy (APM) to cross over from nonoperative therapy to APM?
- Do those who cross over to APM receive symptom relief that’s comparable to those originally randomized to APM?
After careful multivariate analysis of 48 patients who crossed over in the MeTeOR trial (representing 27% of those originally randomized to PT), the authors identified two factors associated with a higher likelihood of crossover: a baseline WOMAC Pain Score of ≥40 and symptom duration of <1 year. The authors also found that patients who crossed over to APM were just as likely to experience improvement in pain scores as those originally randomized to APM.
From a research standpoint, the authors suggest that future investigators may wish to make “special efforts” to keep patients who present with severe pain and relatively short symptom duration in nonoperative therapy. Clinically, Katz et al. say the findings “underscore the emerging treatment recommendation…to try a PT regimen before opting for APM.”
Whether and when to surgically treat injuries to the anterior cruciate ligament (ACL) remain difficult questions for patients, doctors, and physical therapists to answer.
On Wednesday, March 30, 2016 at 12:30 pm EDT, a complimentary webinar, hosted jointly by JBJS and the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), will arm orthopaedists and physical therapists with up-to-date information to help ensure the best possible clinical decisions for patients with ACL injuries.
Hege Grindem, PT PhD, will present the JBJS paper, “Nonsurgical or Surgical Treatment of ACL Injuries,” and Vincent Eggerding, MD, will present the JOSPT systematic review, “Factors Related to the Need for Surgical Reconstruction After ACL Rupture.”
Moderated by JBJS Deputy Editor Robert Marx, MD, the webinar will include additional perspectives on these clinical questions from three ACL
experts, Daniel Whelan, MD, Lynn Snyder-Mackler, PT, ScD, and Lars Engebretsen, MD.