Literature

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

The prescribing of selective serotonin reuptake inhibitors (SSRIs) for nonpsychiatric disorders has climbed steadily in recent years, and the June 2013 FDA approval of paroxetine to treat hot flashes associated with menopause is likely to expose more women to this popular class of antidepressants. A new observational, claims-based analysis found that 137,000 women between the ages of 40 and 64 without mental illness who started an SSRI between 1998 and 2010 were 67% to 76% more likely to break a bone during the subsequent one to five years than 236,000 women of the same age who took indigestion drugs during the same time period.

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The Centers for Medicare and Medicaid Services (CMS) announced this week that it will not deny claims from providers during the first 12 months of ICD-10 implementation based on a lack of code specificity, “as long as the physician/practitioner use[s] a valid code from the right family.” Similarly, CMS will not penalize physicians whose coding lacks ICD-10 specificity when reporting to the Physician Quality Reporting System, Meaningful Use, or Value Based Modifier programs, as long as the submitted code comes from the “correct family.” In making this joint announcement with the AMA, CMS also said it will establish a “communication and collaboration center,” which will house an ombudsman “to help receive and triage physician and provider issues.

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The July 1, 2015 JBJS contains a database-driven analysis by Duchman et al. of more than 78,000 patients who underwent primary total hip or knee arthroplasty between 2006 and 2012. The authors found that the 10% who were current smokers had a higher rate of wound complications (1.8%), compared with rates in former smokers (1.3%) and nonsmokers (1.1%). Current smokers had approximately twice the rate of deep wound infections compared with former smokers or nonsmokers. The authors note, however, that periprosthetic infections—a specific complication of great interest to orthopaedists and patients—are not captured by the National Surgical Quality Improvement Program (NSQIP) database from which the analyzed data was extracted.

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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. The most lasting legacy from William Harris’s classic evaluation of post-traumatic mold arthroplasty published in 1969 is embodied in the paper’s subtitle, which refers to “a new method of result evaluation.

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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 May 20, 2015 Specialty Update on foot and ankle surgery: Talar and Calcaneal FracturesA prospective randomized study comparing the sinus tarsi approach with the minimally invasive approach to the calcaneus found significantly fewer wound healing complications and shorter operative times with the minimally invasive longitudinal approach, but better outcomes were noted with the sinus tarsi approach for Sanders type-IV fractures.An RCT comparing outcomes of operative and nonoperative treatment for displaced intra-articular calcaneal fractures found no between-group differences at one year, but a trend toward better pain scores and function was noted in the operative group at eight to twelve years.

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The overall rate of symptomatic lower-extremity deep vein thrombosis (DVT) following arthroscopic ACL procedures is reported to be <0.3%, and guidelines from the American College of Chest Physicians recommend against DVT prophylaxis prior to arthroscopic knee surgery, unless a patient has risk factors for blood clots. But some patients are unknowingly at high risk for clots, as a case report byAckerman et al. in the June 10, 2105 JBJS Case Connector shows. A 45-year-old woman presented for arthroscopic ACL reconstruction in her left knee. Unbeknownst to her or her surgeons, the patient had asymptomatic May-Thurner syndrome—an anatomic variant of the iliac blood vessels in which the right common iliac artery crosses over the left common iliac vein, compressing the vein against the lumbar spine.

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One benefit of our digital age is that it allows virtually real-time “conversations” to be published between authors of orthopaedic studies and their colleagues, without the lag time imposed by print. Case in point is the engaging back-and-forth between James Sanders, MD (co-author of theApril 16, 2014 JBJS study titled “Bracing for Idiopathic Scoliosis: How Many Patients Require Treatment to Prevent One Surgery?”) and Hans-Rudolf Weiss, an orthopaedic surgeon from Germany. The original study found that bracing for idiopathic adolescent scoliosis substantially decreased the risk of curve progression to a surgical range—but only when patients wore the brace at least 10 hours a day.

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Surgical site infections (SSIs) can cancel out the benefits of surgery, and they’re the number-one cause of hospital readmissions following surgery. The most prevalent pathogenic culprit is Staphylococcus aureus. A study of patients undergoing cardiac or hip or knee arthroplasty surgery at 20 hospitals in nine states found that the following protocol reduced the rate of complex (deep incisional or organ-space) S. aureus SSIs by about 40% overall—and by about 50% among patients undergoing hip or knee arthroplasty (an absolute difference of 17 infections per 10,000 joint replacements):Preoperative screening of nasal samplesIntranasal mupirocin and chlorhexidine baths for up to five days prior to surgery for patients testing positive for methicillin-resistant S.

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The relationships between body weight and joint replacement are debated often in the orthopaedic community. Some surgeons are so concerned about perioperative complications related to obesity that they recommend delaying arthroplasty in obese patients until weight loss is achieved. But what are the likelihood and implications of weight changes after joint replacement? For those answers, in the June 3, 2015 edition of JBJS,Ast et al. tracked differences in body mass index (BMI) among nearly 7,000 patients for two years after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Establishing a 5% BMI change as “clinically meaningful,” the researchers found that:Most patients (73% of those undergoing THA and 69% of those undergoing TKA) experienced no weight change.

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With the clock ticking toward an October 1, 2015 compliance deadline for ICD-10, Tennessee Rep. Diane Black recently introduced a bill, HR 2247, that would require a transition period for the changeover from ICD-9 codes. Rep. Black’s bill would not stall the October 1 compliance date, but it would require the U.S. Department of Health and Human Services (HHS) to provide transparent end-to-end testing of the new system to certify that it’s fully functional. According to the legislation, during the testing period and for 18 months following HHS certification, the Centers for Medicare and Medicaid Services (CMS) would be prohibited from denying claims “due solely to the use of an unspecified or inaccurate code.

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