Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.
This month, co-author Timothy R. Daniels, MD, FRCSC summarizes the 5 most compelling findings from the >80 studies highlighted in the recently published “What’s New in Foot and Ankle Surgery.”
–With virtual foot and ankle examinations become more widespread during the COVID-19 pandemic, a recent paper on telehealth consultations offers guidance on preparing patients for the appointment as well as examination instructions that can be read by clinicians to patients and a checklist for medical record documentation1.
–Evaluating trends in foot and ankle surgery in Germany over the past decade, 1 study found that the volume of foot and ankle operations increased 39.5%, while the population increased 0.9%2. The volume of first metatarsophalangeal joint (MTPJ) arthrodesis and ankle arthrodesis rose 77% and 31%, respectively, whereas first MTPJ arthroplasty and total ankle replacement declined 48% and 39%.
Total Ankle Replacement
– In a prospective series of total ankle replacement procedures in which a standard anterior approach or an extensile anteromedial surgical approach was used in patients at higher risk for wound complications, 17 (2.6%) of 660 patients had major and 39 (5.9%) had minor wound-healing issues3. All major wound complications occurred in the anterior-approach group.
–A recent study assessed the utility of preoperative imaging and intraoperative histopathology in Morton neuroma4. Among 313 suspected neuromas operatively resected during the 10-year study period, Morton neuroma was confirmed in 309 (98.7%) on histopathologic examination. The postoperative treatment course was not altered for any patient on the basis of the pathology report, challenging the cost and utility of histopathologic evaluation of resected neuromas.
–Another recent study investigated the question of whether sociodemographic factors impact PROMIS scores meeting the Patient-Acceptable Symptom State (PASS) among foot and ankle patients. The authors found that patients ≥65 years of age accepted more functional limitation than younger patients, patients in the lowest income brackets reported more severe functional limitations as satisfactory compared with patients in the highest income brackets, and patients in the lowest income bracket sought surgical care later than those in the highest income bracket5.
- Eble SK, Hansen OB, Ellis SJ, Drakos MC. The virtual foot and ankle physical examination. Foot Ankle Int. 2020 Aug;41(8):1017-26. Epub 2020 Jul 8.
- Milstrey A, Domnick C, Garcia P, Raschke MJ, Evers J, Ochman S. Trends in arthrodeses and total joint replacements in foot and ankle surgery in Germany during the past decade-back to the fusion? Foot Ankle Surg. 2020 May 26 [Epub ahead of print].
- Halai MM, Pinsker E, Daniels TR. Effect of novel anteromedial approach on wound complications following ankle arthroplasty. Foot Ankle Int. 2020 Oct;41(10):1198-205. Epub 2020 Jul 18.
- Raouf T, Rogero R, McDonald E, Fuchs D, Shakked RJ, Winters BS, Daniel JN, Pedowitz DI, Raikin SM. Value of preoperative imaging and intraoperative histopathology in Morton’s neuroma. Foot Ankle Int. 2019 Sep;40(9):1032-6. Epub 2019 May 29.
- Bernstein DN, Mayo K, Baumhauer JF, Dasilva C, Fear K, Houck JR. Do patient sociodemographic factors impact the PROMIS scores meeting the patient-acceptable symptom state at the initial point of care in orthopaedic foot and ankle patients? Clin Orthop Relat Res. 2019 Nov;477(11):2555-65.
Personal communication goes a long way in establishing and cementing surgeon-patient relationships. I learned years ago that something as simple as giving patients my email address diminished their fear and anxiety because it gave them direct access to me. Now, due largely to the recent pandemic, more numerous and sophisticated forms of “telemedicine” have come to the forefront of health-care delivery.
In the February 3, 2020 issue of The Journal, Kingery et al. report results from a randomized controlled trial investigating whether brief day-of-surgery communications between surgeons and patients who underwent an outpatient sports-medicine procedure affected patient satisfaction scores. To find out, the researchers randomized 3 surgeons into 1 of 3 patient-communication modalities:
- No contact (standard of care)
- Phone call the evening after surgery
- Video call the evening after surgery
Satisfaction among the 250 participating patients was assessed at the first face-to-face postoperative visit using the standardized S-CAHPS questionnaire, which evaluates patient experiences before, during, and after an outpatient surgery. Patients also completed a 9-item questionnaire specifically designed for this study. The authors focused on the rate of “top-box” responses (the highest rating possible) in each of the 3 groups group.
Kingery et al. found that day-of-surgery postoperative communication between patients and surgeons, either by video or phone, significantly improved S-CAHPS top-box response rates relative to the no-contact group. Specifically, phone calls were associated with a 16.1 percentage point increase in the top-box response rate, while video calls were associated with a 17.8 percentage point increase. The authors also found that patients contacted by video or phone were more likely to recommend their surgeon and felt more informed than those who were not contacted.
Although the authors did not record the content or duration of the conversations in the 2 contact groups, these data strongly suggest that patients welcome day-of-surgery communication—and that such encounters improve patient satisfaction. I therefore think we all should consider leveraging technology, especially that which has arisen from the COVID pandemic, to help give our patients a better overall health-care experience. A few non-reimbursable minutes at the end of the day could have lasting, positive effects on both patients and us.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Under the best of circumstances, coding and documenting medical visits and procedures for Medicare and private payers can be a headache. Now, with the pandemic-related increased use of electronic communication between physicians and patients—including video, telephone, and portal-based email—things have gotten even more challenging. Thankfully, in a recent fast-tracked JBJS article, Hinckley et al. offer some valuable assistance with how to code and document telemedicine and other electronic interactions with patients.
The authors summarize the electronic-communication guidelines from the Centers for Medicare and Medicaid Services (CMS) for documenting these visits and for selecting the appropriate CPT codes and modifiers as of April 20, 2020. They emphasize that private payers may not follow CMS guidelines, so “continued attention to CMS, CPT, and private payer websites is necessary.”
Hinckley et al. also emphasize that CPT codes now distinguish between telemedicine (video) visits, email visits, and telephone services. One of the most useful tools the authors offer appears in an Appendix, where 4 sample grids for musculoskeletal documentation and coding are provided.
It might be wise to familiarize yourself and/or your office staff with these new policies, procedures, and codes, because, as the authors conclude, whatever “new normal” eventually emerges, electronic communication with patients “will likely become a more prominent aspect of our clinical presence and platforms.”
For obvious reasons, the use of telemedicine has surged during the COVID-19 pandemic. If you are wondering what a “virtual” orthopaedic physical exam looks like, Tanaka et al. explain the process in words and images in a recent fast-tracked JBJS article.
At the time they schedule their virtual visit, patients are asked to confirm their audiovisual capabilities, and they receive specific instructions about camera positioning, body positioning, setting, and attire to improve the efficiency of the visit.
Tanaka et al. give step-by-step instructions for virtually evaluating the knee, hip, shoulder, and elbow. They describe how they measure range of motion using a web-based goniometer (see Figure), and they explain how to conduct virtual strength tests for each joint. To enable post-exam follow-up discussions with patients, the authors recommend using “the screen-sharing function that is presumably available on all interactive telehealth platforms.”
The authors acknowledge the limitations inherent in a virtual orthopaedic exam, such as the inability to directly palpate the joint or perform provocative tests. They also admit that the patient population that would potentially benefit the most from televisits—older patients with limited mobility and who are at higher risk for infection during the pandemic—are also those who may have the most difficulty implementing the technology.
The rapid rise of telemedicine in orthopaedics has occurred due to unexpected necessity, but many expect that its widespread use will continue post-pandemic. Tanaka et al. cite future directions for the technology, including the development of validated, modified examination techniques and advancements that will improve interactivity during the physical examination. For now, though, these experience-based guidelines should help orthopaedists optimize the quality and efficiency of their upcoming virtual visits for common musculoskeletal conditions.
Under the best of circumstances, an orthopaedic residency requires trainees and trainers to balance clinical work, surgical skills, didactics, and academic investigations. The global COVID-19 crisis is certainly not the best of circumstances. A fast-track article just published in JBJS explains how the urban, high-volume orthopaedic department at Emory University School of Medicine in Atlanta created a two-team system that helps residents keep learning, helps maintain a healthy workforce, and addresses the needs of orthopedic patients amid this unprecedented situation.
Emory is now dividing its orthopaedic residents into “active duty” and “working remotely” teams. In observation of the presumed incubation period of COVID-19 symptoms, transitions between active and remote activities occur every two weeks. A similar “platooning” system is in place for both faculty and administrators to safeguard a healthy network of leaders and command-and-control decision makers.
Active duty residents participate in in-person surgical encounters and virtual ambulatory encounters. Orthopaedic surgical cases deemed essential present an ideal opportunity for active-duty education, the authors observe, and there is also a role for supplementation of surgical education in the form of virtual reality or simulation training. Faculty members cover their in-person clinics without resident assistance when possible, but most musculoskeletal subspecialty visits can be performed with video-enabled telemedicine, and active-duty residents are part of these virtual clinic visits in real time.
Remotely working residents participate by videoconference in daily faculty-led, case-based didactics. The authors recommend virtually conducted one-and-a-half-hour collaborative, interactive learning sessions on predetermined schedules and topics. Each session includes question-based learning, facilitated with the use of an audience-response system. Remotely working residents also study for their boards and work on clinical research projects, grant writing, and quality improvement projects.
Finally, this team system, championed by strong departmental leadership, allows for isolation of any resident who acquires COVID-19, allowing them time to recover, while diminishing the risk of rapid, residency-wide disease transmission.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad Krueger, MD, in response to a recent study in the Annals of Internal Medicine.
Few disease processes are as prevalent within the United States as hip and knee osteoarthritis (OA). While OA is commonly thought to be a disease of older age, the reality is that over half of all individuals with knee arthritis are younger than 65. While some of those individuals will eventually go on to have a knee arthroplasty, before that, most OA patients try various other treatments in an effort to decrease pain and increase function. Medications such as NSAIDs and others are certainly a part of these treatment efforts, but nonpharmacologic treatments are also widely recommended.
However, as Bennell et al. clearly state in their Annals article, patients face multiple barriers to the implementation of these nonoperative, nonpharmacologic modalities, including cost and transportation to relevant clinical specialists. The authors used these barriers as the rationale for a randomized trial in which an intervention group of knee OA patients received Internet-based educational material, online pain-coping skills training, and videoconferencing with a physiotherapist who provided individualized exercises for each patient. A control group received only the educational material.
At 3 and 9 months, both groups showed improvements in pain and function, but the intervention group had significantly greater improvements than the control group. More importantly, the people in the intervention group largely adhered to all online programs on their own and were very satisfied with the prescribed treatments, especially the video-based physiotherapy component.
Internet-based health interventions are certainly not new. However, my suspicion is that 20 years from now we will look back and wonder why we did not use them more often. They are self-directed, cost-effective, reproducible, and available to any of the 87% of Americans over the age of 50 who, according to the Pew Research Center, use the Internet. These online interventions require no driving to an office, and patients can easily track their own progress by seeing how many modules they have completed.
While there are certainly limitations to the findings from Benell et al., as an accompanying editorial by Lisa Mandl, MD points out, the study serves as a very strong proof of concept that should be expanded upon. Dr. Mandl herself proclaims that “these results are encouraging and show that ‘telemedicine’ is clearly ready for prime time.”
With the number of ways we “stay connected” always increasing, it seems important for orthopaedists to learn how to use these technologies to benefit our patients. Doing so may require some adjustments, but the ultimate goal of improving the quality of life for our patients warrants whatever creativity and open-mindedness might be necessary.
Chad Krueger, MD is a military orthopaedic surgeon at Womack Army Medical Center in Fort Bragg, North Carolina.
In the May 4, 2016 issue of The Journal, Gruca et al. describe the very effective outreach efforts among Iowan orthopaedic surgeons to rural patients throughout their state. Iowa’s orthopaedic surgeons have demonstrated a high degree of commitment to staffing so-called visiting consultant clinics (VCCs) in rural communities. Forty-five percent of all Iowa-based orthopaedists traveled a cumulative total of 32,496 miles per month during 2014 to staff VCCs.
No matter where they live, patients typically do not like to travel far for medical care. For conditions like cancer or severe cardiac disease, the prospect of travel may be more acceptable, because patients and families feel that the potential for significant illness or death warrants “whatever it takes” to gain access to the highest level of expertise available. But for routine musculoskeletal diagnoses such as osteoarthritis of the knee or rotator cuff tendinosis, the option of gaining access to a high degree of expertise closer to home is very appealing.
I wonder, however, whether the loss of time and expertise entailed with surgeons driving long distances makes sense. My hunch is that in the next few years, web-based telemedicine—which Gruca et al. say was lagging in Iowa at the time of their study—will become the norm for delivering specialty care to rural communities. Also, while it probably doesn’t make sense to outfit and staff small rural critical-access hospitals to do complex orthopaedic surgical procedures, it might be sensible in those settings to use local “physician extenders” for outpatient consultation and pre- and postoperative care. I predict that we will soon see manuscripts submitted to The Journal documenting the quality and cost-effectiveness of care delivered to “geographically disadvantaged” patients in those alternative ways as well.
Marc Swiontkowski, MD
Since our last post about interstate physician licensing in August 2014, 15 states have introduced legislation to approve the plan, which would establish a voluntary process to streamline licensing for physicians in multiple states. Legislative chambers in three of those 15 states—South Dakota, Utah, and Wyoming—have already voted to endorse the compact. According to the Federation of State Medical Boards, the House chambers in Wyoming and Utah passed compact legislation unanimously.
It’s not surprising that largely rural states are leading the bandwagon of support for the compact, because one of its main objectives is to increase physician services in underserved areas via face-to-face visits with patients across nearby state borders or via telemedicine.