What We Owe our Patients—Continuous Improvement
It has been said that a surgeon’s skill and judgment account for between 80% and 90% of a patient’s outcome. (I believe this is true for both surgical and nonsurgical treatments.) Throw in a physician’s ability to listen and clearly communicate with patients, and I am sure we are approaching that 90% mark. That means that when we conduct randomized trials comparing two types of knee prostheses or fracture-fixation constructs, we are, in essence, scrutinizing only about 10% of the patient-outcome equation.
So how do we best evaluate the 90% of the outcome equation that is physician-dependent? With the advent of “bundled” episodes of care, the orthopaedic community has emphasized the need for risk-adjustment in evaluating surgeon performance. Clearly, there are certain patients who are at higher risk for worse outcomes than others, such as those with diabetes, nicotine abuse, advanced age, and less social support.
In the December 19. 2018 issue of The Journal, Thigpen et al. report on patient outcomes 6 months after arthroscopic rotator cuff repair in 995 patients treated by 34 surgeons. The authors evaluated patient-reported outcomes from all surgeons using both unadjusted and adjusted ASES change scores. The adjusted scores took into account about a dozen baseline patient characteristics, including symptom severity, functional and mental scores, medical comorbidities, and Workers’ Compensation status. Relative to performance rankings based on unadjusted data, risk adjustment significantly altered the rankings for 91% of the surgeons. According to the authors, these findings “underpin the importance of risk-adjustment approaches to accurately report surgeon performance.”
But what is of even greater interest to me is that risk adjustment led to positive increases in patient outcomes for some surgeons, while decreasing outcomes for other surgeons. Some of these outcome differences likely reflect each surgeon’s patient-selection biases, but in the words of the authors, the numbers strongly suggest “that there is a meaningful, distinguishable difference in patient outcomes between surgeons.”
What should we do with this data? In my opinion, surgeons in the lower 80% of the list, at least, ought to be engaging with the surgeons who demonstrated the highest adjusted performance scores to understand what is helping them obtain outcomes that are superior to everyone else’s. We owe it to our patients to understand what our personal outcomes are for at least the most common conditions we treat. I believe it borders on unethical behavior to quote patients outcome data of a procedure from the peer-reviewed literature when we have no idea how our personal results compare. Orthopaedic surgeons need to be more active in lobbying our groups and health systems to support best practices for clinical outcome data collection and reporting so we can, in turn, improve our care by adopting the best practices of the surgeons with the best outcomes.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
What’s New in Orthopaedic Rehabilitation 2018
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, Nitin Jain, MD, MSPH, a co-author of the November 21, 2018 Specialty Update on Orthopaedic Rehabilitation, summarized the most clinically compelling findings from among the more than 40 noteworthy studies summarized in the article.
Acute Pain Management
–A randomized double-blind study comparing 4 two-way combinations of analgesics (three of which contained an opioid medication)1 in emergency-department patients experiencing acute extremity pain found no significant between-group differences in mean pain scores at 1 and 2 hours after medication administration.
Total Hip Arthroplasty
–A randomized clinical trial of >100 patients who underwent unilateral total hip arthroplasty found no significant differences in functional outcomes between a group that participated after surgery in a self-directed home exercise program and a group that participated in a standardized physical therapy program.
Concussion
–An assessment of brain tissue from 202 American football players2 whose organs were donated for neuropathological evaluation found that 87% had evidence of chronic traumatic encephalopathy (CTE). Analysis of brain tissue from former NFL players in the cohort showed that nearly all had severe CTE.
Rotator Cuff Tears
–A study following the natural progression of full-thickness, asymptomatic, degenerative rotator cuff tears found that patients with fatty muscle degeneration were more likely to experience tear-size progression than those without fatty infiltration.
Low Back Pain
–A study consolidating data from 3 separate randomized trials attempted to evaluate the efficacy of radiofrequency (RF) neurotomy for treating a heterogeneous collection of diagnoses that commonly result in low back pain.3 No significant or clinically important differences were found when the RF procedure was compared with a standardized exercise program. The number needed to treat for all 3 arms of the study ranged from 4 to 8, with a median of 5. Some have called into question the methods of this study, particularly the diagnostic criteria used for patient inclusion and the potential inaccuracy of lumping together heterogeneous diagnoses.
References
- Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017 Nov 7;318(17):1661-7.
- Mez J, Daneshvar DH, Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, Alosco ML,Solomon TM, Nowinski CJ, McHale L, Cormier KA, Kubilus CA, Martin BM, Murphy L, Baugh CM, Montenigro PH, Chaisson CE, Tripodis Y, Kowall NW, Weuve J, McClean MD, Cantu RC,Goldstein LE, Katz DI, Stern RA, Stein TD, McKee AC. Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football. JAMA. 2017 Jul 25;318(4):360-70.
- Juch JNS, Maas ET, Ostelo RWJG, Groeneweg JG, Kallewaard JW, Koes BW, Verhagen AP, van Dongen JM, Huygen FJPM, van Tulder MW. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the Mint randomized clinical trials. JAMA. 2017;318(1):68-81.
What’s New in Shoulder and Elbow Surgery 2018
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, Robert Tashjian, MD, co-author of the October 17, 2018 Specialty Update on shoulder and elbow surgery, selected the most clinically compelling findings from among the 36 studies summarized in the Specialty Update.
Progression of Primary Osteoarthritis
–A study evaluating the relationship between glenoid erosion patterns and rotator cuff muscle fatty infiltration found that fatty infiltration was associated with B3 glenoids, increased pathologic glenoid retroversion, and increased joint-line medialization. The authors recommend close observation of patients with B-type glenoids, as the progression of glenoid erosion is more likely in B-type than A-type glenoids.
Perioperative Pain Management
–In a randomized controlled trial of perioperative pain management in patients undergoing primary shoulder arthroplasty, narcotic consumption during the first 24 postoperative hours was similar between a group that received interscalene brachial plexus blockade and a group that received intraoperative soft-tissue infiltration of liposomal bupivacaine. The interscalene group had lower VAS pain scores at 0 and 8 hours postoperatively; both groups had similar VAS pain scores at 16 hours; and the soft-tissue infiltration group had lower pain scores at 24 hours postoperatively.
Rotator Cuff
–In a reevaluation of patients with nonoperatively treated chronic, symptomatic full-thickness rotator cuff tears that had become asymptomatic at 3 months, researchers found that at a minimum of 5 years, 75% of the patients remained asymptomatic.1 The Constant scores in the group that remained asymptomatic were equivalent at 5 years to those who initially underwent surgical repair. While these findings suggest that nonoperative treatment can yield clinical success at 5 years, the authors caution that “individuals with substantial tear progression or the development of atrophy will likely have a worse clinical result.”
–A recent study of the progression of fatty muscle degeneration in asymptomatic shoulders with degenerative full-thickness rotator cuff tears found that larger tears at baseline had greater fatty degeneration, and that tears with fatty degeneration were more likely to enlarge over time. Median time from tear enlargement to fatty degeneration was 1 year. Because the rapid progression of muscle degeneration seems to occur with increasing tear size, such patients should be closely monitored if treated nonoperatively.
Shoulder Instability in Athletes
–An evaluation of outcomes among 73 athletes who had undergone Latarjet procedures found that, after a mean follow-up of 52 months, ASES scores averaged 93. However, only 49% of the athletes returned to their preoperative sport level; 14% decreased their activity level in the same sport; and 12% changed sports altogether. While the Latarjet can help stabilize shoulders in athletes, the likelihood is high that the athlete won’t return to the same level in the same sport after the procedure.
Reference
- Boorman RS, More KD, Hollinshead RM, Wiley JP, Mohtadi NG, Lo IKY, Brett KR. What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2018 Mar;27(3):444-8.
JBJS 100: Massive Rotator Cuff Tears, Continuous Passive Motion
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears
L M Galatz, C M Ball, S A Teefey, W D Middleton, K Yamaguchi: JBJS, 2004 February; 86 (2): 219
In one of the earliest studies to investigate the relationship between the anatomic integrity of arthroscopic rotator cuff repair and clinical outcome, these authors found that the rate of recurrent defects was high but that at 12 months after surgery, patients experienced excellent pain relief and functional improvement. However, at the 2-year follow-up, the clinical results had deteriorated substantially. Investigations into the relationship between cuff-repair integrity and clinical outcomes are ongoing.
The Biological Effect of Continuous Passive Motion on the Healing of Full-thickness Defects in Articular Cartilage: An Experimental Investigation in the Rabbit
R B Salter, D F Simmonds, B W Malcolm, E J Rumble, D Macmichael, N D Clements: JBJS, 1980 January; 62 (8): 1232
In this paper, Salter and colleagues hypothesized that “continuous passive motion [CPM] of a synovial joint in vivo would have a beneficial biological effect on the healing of full-thickness defects in articular cartilage.” They found that CPM stimulated more rapid and complete cartilage restoration than either immobilization or intermittent active motion, and since then CPM has been commonly used in humans after cartilage repair. However, CPM’s actual efficacy in people—after cartilage repair or total knee arthroplasty—remains controversial.
JBJS 100: Shoulder Impingement and Distraction Osteogenesis
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Anterior Acromioplasty for Chronic Impingement Syndrome in the Shoulder
C S Neer: JBJS, 1972 January; 54 (1): 41
For many years after its publication, this 1972 JBJS article changed the treatment approach for patients with shoulder disability. But more recently, arthroscopy and magnetic resonance imaging arthrography have identified other painful non-impingement shoulder conditions. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete rotator cuff tear, and performing aggressive rehabilitation prior to corrective surgery.
Use of the Ilizarov Technique for Treatment of Non-union of the Tibia Associated with Infection
G K Dendrinos, S Kontos, E Lyritsis: JBJS, 1995 June; 77 (6): 835
This case series described a technique of bone transport with bridging achieved by distraction osteogenesis. The defects averaged 6 cm, the mean duration of treatment was 10 months, and the mean time to union was 6 months. More recent research has focused on augmenting the osteogenic potential of tissues in the distraction gap with substances such as bone morphogenetic protein, platelet-rich plasma, and mesenchymal stem cells.
Which Pathology Comes First—Bone Loss or Fatty Infiltration of Rotator Cuff?
The relative roles of bones and muscles in joint pathologies are often difficult to tease apart. In the March 7, 2018 issue of The Journal, Donohue et al. report findings from their attempt to identify associations between preoperative fatty infiltration in rotator cuff muscles and glenoid morphology among 190 shoulders that underwent total shoulder arthroplasty (TSA) for glenohumeral osteoarthritis.
The painstaking analysis included orthogonal CT images to determine fatty infiltration, joint-line medialization assessments, direct measurements of glenoid version, and grading of glenoid morphology (from A1 through C2) using a modified Walch classification. Here’s what Donohue et al. found:
- High-grade posterior rotator cuff fatty infiltration was present in 55% of the 38 glenoids classified as B3, compared with only 8% fatty infiltration in the 39 A1-classified glenoids.
- Increasing joint-line medialization was associated with increasing fatty infiltration of all rotator cuff muscles.
- Higher fatty infiltration of the infraspinatus, teres minor, and combined posterior rotator cuff muscles was associated with increasing glenoid retroversion.
- After the authors controlled for joint-line medialization and retroversion, B3 glenoids were more likely than B2 glenoids to have fatty infiltration of the supraspinatus and infraspinatus.
The authors say these findings “support the idea that there is a causal association between rotator cuff muscle fatty infiltration and B3 glenoid morphology,” but they are quick to add that “from this study we cannot conclude [whether] these patterns of rotator cuff muscle fatty infiltration precede the progression of bone pathology, or vice versa.” Either way, these findings may inform patient-surgeon discussions about TSA, because both glenoid morphology and rotator cuff muscle quality are factors in glenoid-component longevity.
JBJS 100: Arthroscopic Supraspinatus Repair and OCD of the Talus
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Arthroscopic Repair of Full-Thickness Tears of the Supraspinatus
P Boileau, N Brassart, D J Watkinson, M. Carles, A M Hatzidakis, S G Krishnan: JBJS, 2005 June; 87 (6): 1229
This evaluation of the arthroscopic tension-band suture technique demonstrated that arthroscopic repair of an isolated supraspinatus detachment delivers good to excellent functional and tendon-healing results—and that the absence of tendon healing does not necessarily compromise pain relief and patient satisfaction.
Transchondral Fractures (Osteochondritis Dissecans) of the Talus
A L Berndt and M Harty: JBJS, 1959 Sept; 41 (6): 988
Berndt and Harty’s elegant clinical and anatomic study included a four-stage radiological classification scheme for traumatic talar lesions that still provides a valid foundation for decision-making with regard to operative or nonoperative treatment.
JBJS 100: Cuff Tear Arthropathy and Cervical Spine Disorders
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal constituted Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Cuff Tear Arthropathy
Neer CS 2nd, Craig EV, Fukuda: JBJS, 1983 Dec; 65 (9): 1232
These authors reported on what was then a relatively uncommon degenerative condition of the shoulder. Today, rotator cuff-deficient shoulders are much more common and can be better treated due to advances in our understanding of the pathophysiology and biomechanics of the condition.
The Treatment of Certain Cervical-spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion
Smith GW, Robinson RA: JBJS, 1958 June; 40 (3): 607
Dr. Robinson’s technique has the support of biomechanical principles, which makes this particular approach and bone-graft fusion construct inherently stable. The versatile approach is utilized for all sorts of anterior procedures, including removal of intervertebral discs, arthrodesis, and vertebrectomy.
What’s New in Orthopaedic Rehabilitation 2017
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, Nitin Jain, MD, MSPH, a co-author of the November 15, 2017 Specialty Update on Orthopaedic Rehabilitation, summarized the most clinically compelling findings from among the nearly 50 noteworthy studies summarized in the article.
Pain Management
–Results from a retrospective review1 of patients with noncancer pain highlighted that the risks of long-acting opioids extend beyond overdose, and include increased risks of cardiovascular death and all-cause mortality.
–A randomized prospective trial2 comparing celecoxib, ibuprofen, and naproxen for treating arthritis pain found no significant difference in the hazard ratios for those medications as related to risk of cardiovascular events.
Cost & Quality
–An assessment of a value-improvement initiative3 that examined hip and knee arthroplasty and hip fracture outcomes in a large regional health-care system found reduced costs and improvements in quality of care from 2012 to 2016.
Concussion
–A literature review4 of 7 studies determined that the long-term cognitive and neurogenerative effects of multiple concussions in patients ≤17 years of age remain inconclusive.
Spine
–A randomized trial5 found no difference between anesthetic-only and anesthetic-plus-steroid epidural injections in the treatment of lumbar spinal stenosis.
Shoulder
–A prospective cohort study6 by the MOON Shoulder Group found that the strongest predictor of failure of nonoperative treatment for symptomatic atraumatic rotator cuff tears was lower patient expectations that such treatment would be successful. Pain level, duration of symptoms, and tear anatomy did not predict treatment failure.
References
- Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016 Jun 14;315(22):2415-23.
- Nissen SE, Yeomans ND, Solomon DH, Lüscher TF, Libby P, Husni ME,Graham DY, Borer JS, Wisniewski LM, Wolski KE, Wang Q, Menon V,Ruschitzka F, Gaffney M, Beckerman B, Berger MF, Bao W, Lincoff AM; PRECISION Trial Investigators. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016 Dec 29;375(26):2519-29. Epub 2016 Nov 13.
- Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C, Johnson S,Gulbransen S, Pelt CE, Horton DJ, Graves KK, Greene TH, Anzai Y, Pendleton RC. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.
- Yumul JN, McKinlay A. Do multiple concussions lead to cumulative cognitive deficits? A literature review. PM&R. 2016 Nov;8(11):1097-103. Epub 2016 May 18.
- Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Sullivan SD,Bauer Z, Bresnahan BW, Avins AL, Nedeljkovic SS, Nerenz DR, Standaert C,Kessler L, Akuthota V, Annaswamy T, Chen A, Diehn F, Firtch W, Gerges FJ,Gilligan C, Goldberg H, Kennedy DJ, Mandel S, Tyburski M, Sanders W, Sibell D, Smuck M, Wasan A, Won L, Jarvik JG. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014 Jul 03;371(1):11-21.
- Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH,Carey JL, Harrell F, Holloway BG, Jones GL, Ma CB, Marx RG, McCarty EC,Poddar SK, Smith MV, Spencer EE, Vidal AF, Wolf BR, Wright RW; MOON Shoulder Group. 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2016 Aug;25(8):1303-11.
For Rotator Cuff Deficiency, RSA Delivers Good Long-term Results
In a recent OrthoBuzz post about minimal-incision total hip arthroplasty, we observed that “it is the long-term results [of orthopaedic procedures] that really matter.” Along those lines, in the November 15, 2017 issue of The Journal of Bone & Joint Surgery, Cuff et al. provide 10-year follow-up results of reverse shoulder arthroplasty (RSA) in patients with end-stage rotator cuff deficiency. The 5-year follow-up results were published in a 2012 JBJS article.
Forty-two of the original 96 shoulders were available for clinical follow-up at a minimum of 10 years. Here’s what the authors found:
- Patients retained their gains in total average preop-vs-postop ASES and SST scores.
- Survivorship (percentage of shoulders not requiring revision) was 90.7%.
- There was decreased range of shoulder motion in all planes between 5 and 10 years of follow-up, but there was no consistent trend of an increase in shoulder pain.
Cuff et al. attribute these positive and durable outcomes in part to the use of 5.0-mm peripheral locking screws for baseplate fixation, which they say “provided improved early fixation and allowed for osseous ingrowth into the baseplate.”
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