Literature

Evidence based literature that is truly important to your orthopaedic clinical practice.

Meaningful use (MU) Stage 2 and 3 requirements have been a bane of existence for many physician practices, so a collective sigh of relief was heard when acting CMS administrator Andy Slavitt hinted recently that a more streamlined approach to regulating health care IT is coming. Suggesting that MU as we know it may end altogether sometime in 2016, Slavitt offered few specifics in a speech at the recent JP Morgan Healthcare Conference, saying only that details of the new plan will come out “over the next few months.” Beth Israel Deaconess Medical Center CIO John Halamka, MD, a frequent blogger on the subject of meaningful use, has said more than once that Stages 2 and 3 tried to do too much too fast, while lauding the functional foundation established by Stage 1.

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We posted our first “Case Connections” article about  bisphosphonate-related atypical femoral fractures (AFFs) one year ago. Since then, JBJS Case Connector has published three additional case reports on the same topic, suggesting that it’s time for a revisit. These three recent cases demonstrate that AFFs can occur despite prophylactic intramedullary (IM) nailing of an at-risk femur, that AFFs can present as periprosthetic fractures, and that men taking bisphosphonates—not just women—can experience AFFs. Share this story: TwitterFacebookLinkedIn Like this: LikeLoading... Related

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The two numbers that you’ll want to remember from the computer model-based cost-effectiveness study by McLawhorn et al. in the January 20, 2016 Journal of Bone & Joint Surgery are $13,910 and $100,000. The first number is an incremental cost-effectiveness ratio (ICER). Here, it’s the estimated added cost per quality-adjusted life year (QALY) for morbidly obese patients (BMI ≥35 kg/m2) with end-stage knee osteoarthritis who undergo bariatric surgery two years prior to total knee arthroplasty (TKA), compared with similar patients who undergo immediate TKA. The $100,000 is the threshold “willingness to pay” (WTP) that the authors used in their evaluation. Willingness to pay reflects the amount society and healthcare payers such as Medicare and private insurers are willing to pay for a patient to accrue one year lived in perfect health.

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Whenever the impact of surgeon volume on patient outcomes for technically complex interventions has been assessed, the following correlation has held: the higher the surgeon volume, the better the patient outcomes. Working with us at the University of Washington in 1997, Dr. Hans Kreder was one of the first to observe this relationship in joint replacement surgery.1 Patients whose hip replacement was performed by a “high-volume” surgeon (>10 hip replacements per year) were significantly less likely to die or have an infection or revision than those whose procedure was performed by a “low-volume” surgeon (<2 hip replacements per year).

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All you stats geeks out there will love the January 6, 2016 study in The Journal of Bone & Joint Surgery by Schilling and Bozic. We at OrthoBuzz are going to skip the gory statistical details for the most part and focus on the essential findings. First the premise and purpose of the study: Because measuring and improving health care outcomes are nowadays top priorities, risk adjustment—methods to account for differences in patient characteristics across providers—has become a contentious issue. General risk-assessment models tend not to be well-tailored to orthopaedic procedures. So Schilling and Bozic developed a series of risk-adjustment models specific to 30-day morbidity and mortality following hip fracture repair (HFR), total hip arthroplasty (THA), and total knee arthroplasty (TKA).

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Marc Swiontkowski, MD, Editor-in-Chief of The Journal of Bone & Joint Surgery (JBJS) and Co-Editor of JBJS Case Connector, has announced that, effective January 1, 2016, Ronald W. Lindsey, MD, will join Tom Bauer, MD as Co-Editor of Case Connector. Dr. Swiontkowski will step down from his role as Case Connector Co-Editor but will remain as Editor-in Chief of JBJS. “I am confident that Ron and Tom will help move Case Connector into position as a foremost resource for clinicians seeking guidance and information on rare and unusual conditions from across the globe,” said Dr. Swiontkowski. Dr. Lindsey is a Professor of Orthopaedic Surgery & Rehabilitation and Chair of the Department of Orthopaedic Surgery & Rehabilitation at the University of Texas Medical Branch, as well as a former Associate Editor for JBJS.

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It seems that anytime a lower extremity undergoes operative treatment, the question is raised regarding the need for and type of thromboprophylaxis. However, controversy exists regarding the use of prophylaxis against venous thromboembolic disease (VTED) after foot and ankle surgery, largely because there are insufficient data from large-scale randomized trials to help guide foot and ankle surgeons in their decision-making processes. Currently, foot and ankle surgeons are forced to make decisions on the basis of incomplete information and contradictory guidelines. Moreover, there is inaccuracy in extrapolating findings from hip and knee arthroplasty studies to the foot and ankle population. In the December 2015 issue of JBJS Reviews,Guss and DiGiovanni review VTED in the setting of foot and ankle surgery and recognize that certain patient populations may be at higher risk, including patients over the age of forty years with acute Achilles tendon ruptures, patients over the age of fifty years with ankle fractures, patients with diabetes mellitus, patients with connective-tissue inflammatory diseases, and patients with a history of VTED.

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JBJS Case Connector has issued a “Watch” regarding the rare but potentially catastrophic fracture of ceramic femoral heads used in hip replacements. Ceramic hip components are often chosen for younger patients to minimize long-term wear. Ceramic femoral head fractures arise mainly from trauma; non-compatible, damaged, or contaminated femoral head/stem taper connections; or material or manufacturing defects. Because ceramic head fractures are more likely to occur from insults during or after implantation than from manufacturing defects, the Watch includes four “golden rules” surgeons can follow to reduce the risk of these events, including making sure that the tapers on both the head and stem are compatible in all dimensions.

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A case-control study by Boraiah et al. in the December 2, 2015 JBJS describes a risk-stratification tool that helps predict which patients undergoing total joint arthroplasty (TJA) are likely to be readmitted to the hospital after discharge. The authors used the tool—dubbed the Readmission Risk Assessment Tool, or RRAT—preoperatively among 207 patients who were subsequently readmitted after primary TJA and two cohorts of 234 patients each (one random and one age-matched) who were not. The total RRAT score for each individual is the cumulative sum of all scores for modifiable risk factors such as infection, smoking, obesity, diabetes, and VTE. Non-modifiable risk factors such as age, sex, race, and socioeconomic status are not included in the scoring system.

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The November 25, 2015 “Case Connections” looks at four JBJS Case Connector cases involving injuries to the cervical spine in which the outcomes were about as good as anyone could have wished, considering the potential for disaster. Two of the cases required surgical intervention to achieve the positive outcomes, but the outcomes in the other two cases were remarkably positive without surgery. While these four cases of cervical spine injury had relatively “happy endings,” orthopaedic surgeons and other health-care professionals treating patients with any suspected spine injury are trained to proceed with the utmost care and caution out of concern for devastating neurological sequelae.

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