Literature

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

Over the last 10 years, the AAOS has invested a great deal of effort and resources into developing Clinical Practice Guidelines (CPGs) and Appropriate Use Criteria. One rationale for these efforts was to follow the lead of our cardiovascular brethren, who have disseminated the highest level of evidence available to their community to help ensure that clinical decision making, in collaboration with the patient and family, is supported by the most solid science. The paper published in the October 21, 2015 edition of JBJS by Oetgen et al. provides us with an evaluation of the impact of CPGs in managing femoral shaft fractures in children.

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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. Here is a summary of selected findings from Level I and II studies cited in the September 16, 2015 Specialty Update on hip replacement: Transfusion and Blood Management –Studies continue to demonstrate that tranexamic acid decreases the need for transfusion when used either intravenously or topically. –The routine use of a drain following total hip replacement, even when used for reinfusion of shed blood, provides little to no benefit and does not decrease the risk of transfusion.1 Preoperative Patient Teaching

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The goals of orthopaedic surgery for children with cerebral palsy (CP) include pain and spasticity reduction and improvements in hygiene and functional mobility. A multicenter study by Mulcahey et al. in the September 16, 2015 JBJS found that when assessing changes in lower-extremity mobility derived from orthopaedic surgery among 255 CP patients, computerized adaptive testing (CAT) was more sensitive than other commonly used instruments.  Specifically, improvements in function detected by the CAT at 12 and 24 months following surgery were greater than the changes detected by the relevant domains of the oft-administered Pediatric Outcomes Data Collection Instrument (PODCI). Interestingly, neither of those two instruments, nor the timed “up & go” test, performed well with patients at level II of the Gross Motor Function Classification System.

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In less than a week from this posting, on October 1, 2015, ICD-10 diagnosis codes will debut. OrthoBuzz already reported on the 12-month leniency policy announced by the Centers for Medicare and Medicaid Services (CMS).  In addition, during the home-stretch to the ICD-10 launch, CMS has published an online series of “cheat sheets” to help providers select at least the first few correct digits for the new codes. The guidance is primarily for family practitioners, but there are sections for back and neck pain and joint and limb pain that orthopaedists might find useful. Keep in mind that private insurers are not obliged to follow CMS’s leniency lead in this area, although according to a Medscape.com article, Aetna, Humana, and Anthem have announced that they will.

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The September 16, 2015 JBJS study by Robinson et al. offers clear proof that many of our patients are sensitive to price when it comes to choosing where to go for arthroscopic surgery of the knee or shoulder. This phenomenon began at least a decade ago when employers began shifting the cost burden of health care coverage onto their employees. The findings from Robinson et al. confirm the increasing strength of this effect. The authors analyzed administrative data from the California Public Employees’ Retirement System (CalPERS) to evaluate the impact of so-called “reference-based benefits” on patient choice for the setting of arthroscopy—hospital-based outpatient departments or freestanding ambulatory surgery centers (ASCs).

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Perioperative anticoagulation for patients undergoing orthopaedic surgery remains a challenge. Currently, there is insufficient evidence to provide definitive recommendations for care. Recent estimates suggest that, in the U.S. alone, there are over two million patients with atrial fibrillation who receive warfarin each year. Moreover, >100,000 heart valve replacements are performed annually. In the September 2015 issue of JBJS Reviews,Dundon et al. review current recommendations for perioperative management of patients on existing anticoagulation therapy. They note that cessation of warfarin is based on risk stratification for thromboembolic events and bleeding risk, with cessation and bridging therapy being recommended if patients are at high risk for thromboembolic events or bleeding.

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A late-August headline on MedPage Today ominously read, “MI Risk Soars After Joint Replacement.” The article cited a recent Arthritis & Rheumatology study that found a more than 8-fold increase in risk of myocardial infarction (MI) for one month after knee replacement and a more than 4-fold increased risk during the month after hip replacement, all compared with equal numbers of matched controls who did not have joint replacement surgery. A look at the absolute risk instead of the relative risk, however, reveals a different and less scary story. For example, among the 13,849 patients who underwent knee replacement, 306 (2.2%) had a heart attack within the first month after surgery.

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We know that more than 1 million total hip and total knee replacements are performed each year in the US. But how many people are actually walking around right now with such prostheses? That’s the question Kremers et al. answer in the September 2, 2015 edition of The Journal of Bone & Joint Surgery. Using the so-called “counting method” to combine historical incidence data, these Mayo Clinic authors concluded that about 7 million US residents (slightly more than 2% ) were living with a hip or knee replacement in 2010. Prevalence of hip replacement was 0.83%, while that of knee replacement was 1.52%.

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JBJS values its authors tremendously, as they are essential to providing the high-quality orthopaedic content that The Journal continues to publish every other week for so many years. “The quality of The Journal of Bone & Joint Surgery depends on the quality of the musculoskeletal manuscripts we receive, and for that we rely on a dedicated community of researcher-authors. With increasing pressure on authors from governments, funders, and institutions to demonstrate the impact of their work, JBJS continues to seek ways to help our authors who help us,” said JBJS Editor-in-Chief, Marc Swiontkowski, MD in last week’s editorial “Helping the Authors Who Help Us”.

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Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left. George Phalen’s article, “The Carpal-Tunnel Syndrome,” was published in The Journal of Bone and Joint Surgery in 1966.

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