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Volume 5 - Issue 1, February 2012
Current Orthopaedic Practice E-News
Welcome Orthopaedics in Brief Clinical Pearls Article of the Month Practice Management
Editor: Nanci Kulig

Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, read about how statins may explain a patient's musculoskeletal pain. Learn the 6 factors that increase the risk of blindness after spinal fusion. Get hard data that can help determine how often to retest a patient's bone mineral density, and much more.

Even though we're 2 months into 2012, it's not too late to set some meaningful yearly goals for your practice. Check out this month's Practice Management for some ideas to get you jumpstarted.

In Article of the Month, please enjoy free access to an article from the February issue of the Journal of Orthopaedic Trauma.

Have a comment or suggestion? Contact me at editor@c-orthopaedicpractice.com.

Nanci Kulig
Editor, COP eNews

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Statins linked to musculoskeletal pain

Statins may increase the risk of musculoskeletal pain among people without arthritis, according to results from a recent study that also suggest the risk is not higher among users of statins who have arthritis.
     Researchers used the National Health and Nutritional Examination Survey 1999-2004 to evaluate the association between use of statins and prevalence of musculoskeletal pain. Among 5170 patients without arthritis, 23% of statin users reported musculoskeletal pain in any region, compared with 18% of those who did not use statins. In the lower extremities, pain was reported by 12% of statin users compared with 8% of nonusers. The association was not observed among patients with arthritis who also took statins.
     Statin use was associated with a significantly higher incidence of musculoskeletal pain in any part (33% higher), the lower back (47% higher), and the lower extremities (59% higher) among patients who did not have arthritis.

Source: Buettner C, Rippberger MJ, Smith JK, Leveille SG, Davis RB, et al. Statin use and musculoskeletal pain among adults with and without arthritis. Am J Med. 2012;125(2):176-182.

Six risk factors connect blindness to spinal fusion surgery

In the largest study of its kind to date, researchers have identified 6 risk factors that link ischemic optic neuropathy (ION) to spinal fusion surgery: 1) male sex; 2) obesity; 3) Wilson frame use; 4) longer duration of anesthesia; 5) greater amount of blood loss; and 6) decreased percentage of colloid administered. All 6 factors were significantly and independently associated with ION after spinal fusion surgery.
     Investigators gathered information from a national database created by the American Society of Anesthesiologists (ASA) to identify 80 patients who were blinded after spine surgery and compared the data with those of 315 patients who had undergone spinal fusion surgery but did not experience vision loss.
     Although ION is a rare complication (with the highest incidence reported as 1 in 1000 spine operations), it is devastating for patients and frustrating for clinicians because it can occur unexpectedly in healthy patients of all ages.
     "Our research represents the largest study performed on this complication to date with very detailed data available for comparison," the study's lead author, Lorri A. Lee, MD, of the University of Washington School of Medicine said in an American Society of Anesthesiologists news release. "Our identification of the six major risk factors for ION hopefully means that some of these risk factors can be modified in certain situations, with the potential to decrease the risk of blindness after major back surgery."

Source: Postoperative Visual Loss Study Group. Risk factors associated with ischemic optic neuropathy after spinal fusion surgery. Anesthesiology. 2012;116(1):15-24.

Timing of aquatic therapy depends on joint replaced

Starting aquatic therapy 6 days after total knee arthroplasty (TKA) is beneficial. However, waiting an additional week before beginning aquatic therapy is better after total hip arthroplasty (THA), new research suggests. Early aquatic therapy after TKA had an effect similar to that of nonsteroidal anti-inflammatory drugs in the treatment of osteoarthritis of the knee.
     Investigators randomly assigned 465 patients who underwent TKA or THA to participate in aquatic therapy either 6 or 14 days after surgery. Both groups had 30-minute therapy sessions 3 times for 4 weeks after surgery. Patients' physical function, pain, and stiffness were evaluated at 3, 6, 12, and 24 months after surgery.
     All of the outcome measures were more favorable among TKA patients who started aquatic therapy 6 days after their operation, compared with those who began therapy 14 days after surgery. The opposite was true among patients who underwent THA, the investigators reported.
     Total hip replacement "has a high rate of patient satisfaction, and patients report an improved quality of life after the procedure. Additional interventions, such as early aquatic therapy, may not lead to much improvement," said lead investigator Thoralf R. Liebs, MD, of the Department of Orthopaedic Surgery, University of Schleswig-Holstein Medical Center, Kiel, Germany, in a journal news release. But after total knee replacement, "patients are less satisfied, so the additional intervention has a greater effect."
     Dr. Liebs hypothesized that the force of the water during aquatic therapy reduces buildup of fluid in the knee joint. Because the knee capsule is closed after knee replacement, reduced fluid buildup leads to less pain. In hip replacement surgery, the joint capsule is not closed, so the effect of reduced fluid buildup is less.

Sources: Liebs TR, Herzberg W, Rüther W, Haasters J, Russlies M, et al. Multicenter randomized controlled trial comparing early versus late aquatic therapy after total hip or knee arthroplasty. Arch Phys Med Rehabil. 2011 Dec 16. [Epub ahead of print]. Archives of Physical Medicine and Rehabilitation [press release]. December 21, 2011.

Clavicular fractures by the numbers

In a recent study, investigators analyzed the prevalence of clavicular fractures among adults, estimated the number of fractures requiring surgery, evaluated the frequency of implant removal, and compared the functional outcomes of patients who had surgery with those who did not.
     Of 16,280 fractures treated at a set of British teaching hospitals during a 2-year period, 200 (1.23%) were clavicular fractures among adults. One hundred fifty nine patients (88%) were treated nonoperatively, and 21 patients (12%) required surgery-more than half of them for symptomatic nonunion. All clavicles united postoperatively.
     Patients with 81 conservatively managed undisplaced medial, middle, and lateral end fractures had excellent average UCLA shoulder scores after treatment. Investigators observed a statistical significance in UCLA scores between the operative and nonoperative patient groups with regard to mid-shaft fractures but not lateral-end fractures. In all, 43% of patients required removal of a metal implant because of soft tissue irritation.
     Based on their findings, investigators recommend surgical management of symptomatic nonunion and removal of metal implants for hardware-related irritation.

Source: Singh R, Rambani R, Kanakaris N, Giannoudis PV. A 2-year experience, management and outcome of 200 clavicle fractures. Injury. 2012;43(2):159-163.

Is Skype an effective assessment tool for research?

Investigators recently evaluated whether Skype is an effective tool to perform functional assessments of patients. Skype is a free program that allows videoconferencing between people who have a computer equipped with a camera and Internet access.
     Investigators conducted a prospective review of all patients with acromioclavicular joint hook plates for lateral-third clavicular fractures during a 5-year period. Functional assessments with Oxford and Constant shoulder scores were performed via Skype and compared with outpatient review using the Bland-Altman method. Of 36 patients (average age, 36 years), 33 had Skype capability, and 29 (83%) were willing to participate in the Skype assessment.
     Compared with outpatient review, use of Skype resulted in an average difference of -0.48 in Oxford score and -0.68 in Constant score. These differences were not clinically significant, which indicates that Skype may be an alternative to goniometry in this clinical setting. A survey showed that 93% of the 29 patients preferred Skype for follow-up, primarily because of its convenience and cost savings. The study demonstrates the potential for this assessment technique in offering patients more options for follow-up.

Source: Good DW, Lui DF, Leonard M, Morris S, McElwain JP. Skype: a tool for functional assessment in orthopaedic research. J Telemed Telecare. 2012 Jan 13 [Epub ahead of print].

How often to test bone mineral density?

Although bone mineral density (BMD) testing is recommended for women 65 years of age or older, there are few data to help determine the appropriate interval between BMD tests. Recent study findings indicate that osteoporosis develops in fewer than 10% of older, postmenopausal women during rescreening intervals of approximately 15 years, for those with normal bone density or mild osteopenia; 5 years, for those with moderate osteopenia; and 1 year, for those with advanced osteopenia.
     Investigators studied 4957 women, 67 years or older, with normal BMD or osteopenia and no history of either hip or clinical vertebral fracture or treatment for osteoporosis. Patients were followed-up prospectively for as long as 15 years. The BMD testing interval was defined as the estimated time for 10% of women to make the transition to osteoporosis before sustaining a hip or clinical vertebral fracture. Researchers accounted for estrogen use and clinical risk factors. Transitions from normal BMD and from three subgroups of osteopenia (mild, moderate, and advanced) were analyzed. Incident hip and clinical vertebral fractures and initiation of treatment with bisphosphonates, calcitonin, or raloxifene were evaluated as competing risks.

Source: Gourlay ML, Fine JP, Preisser JS, May RC, Li C, et al. Bone-density testing interval and transition to osteoporosis in older women. N Engl J Med. 2012;366(3):225-233.

Assessing the effects of long-term glucocorticoid treatment

Long-term, low-dose glucocorticoid (GC) treatment of polymyalgia rheumatica (PMR) is associated with serious adverse events, according to results of a retrospective study. After 2 years of treatment, a significant number of study patients developed osteoporosis, fractures, and arterial hypertension.
     At an average 60-month follow-up of 222 patients with an average duration of GC therapy of 46 months, researchers determined that 95 patients (43%) had experienced at least 1 adverse event after an average of 31 months of GC therapy and an average cumulative dose of 3.4 ± 2.4 g. Specifically, 55 patients developed osteoporosis; 31 had sustained fragility fractures; 27 developed arterial hypertension; 11 had developed diabetes mellitus; 9 had experienced acute myocardial infarction; 3 had had a stroke; and 2 had developed peripheral arterial disease.
     Duration of GC treatment was significantly associated with osteoporosis, fragility fractures, arterial hypertension, and acute myocardial infarction. Cumulative GC dose was significantly associated with osteoporosis, fragility fractures, and arterial hypertension. Adverse events occurred more frequently after 2 years of treatment.

Source: Mazzantini M, Torre C, Miccoli M, Baggiani A, Talarico R, et al. Adverse events during longterm low-dose glucocorticoid treatment of polymyalgia rheumatica: a retrospective study. J Rheumatol. 2012 Jan 15. [Epub ahead of print]

Calculating the risk of VTE after joint replacement

Even with appropriate prophylaxis for venous thromboembolism (VTE), approximately 1 in 100 patients undergoing total or partial knee arthroplasty (TPKA) and approximately 1 in 200 patients undergoing total or partial hip arthroplasty (TPHA) develops symptomatic VTE before hospital discharge. Rates of VTE after knee or hip replacement surgery are likely much higher than those reported in the study, because the risk period extends beyond the duration of hospitalization, which is quite short, noted Dr. John Heit, a cardiologist at the Mayo Clinic in Rochester, Minnesota, in an accompanying editorial.
     Investigators analyzed 47 studies comprising nearly 45,000 joint replacements. All patients received VTE prophylaxis with either low-molecular-weight heparin, subcutaneously administered factor Xa inhibitor, or orally administered direct inhibitor of factors Xa or IIa.
     The pooled rates of symptomatic deep vein thrombosis (DVT) were 0.63% for knee arthroplasty and 0.26% for hip arthroplasty. The pooled rates for pulmonary embolism were 0.27% for knee arthroplasty and 0.14% for hip arthroplasty. In TPKA studies, there was significant heterogeneity for the pooled incidence rates of symptomatic postoperative VTE, but there was less heterogeneity for DVT and pulmonary embolism. In TPHA studies, there was also less heterogeneity for VTE, DVT, and pulmonary embolism.

Sources: Januel JM, Chen G, Ruffieux C, Quan H, Douketis JD, et al. Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review. JAMA. 2012;307(3):294-303. Heit JA. Estimating the incidence of symptomatic postoperative venous thromboembolism: the importance of perspective. JAMA. 2012;307(3):306-307.

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Setting goals for 2012

It's a new year: time to take stock of your practice and set some goals. To build a successful practice, don't wait for good things to happen-make them happen. Here are some general categories to consider as you look for ways to grow your practice in 2012.

Financial goals

  • Start by looking at collected gross revenue for 2011 and set an ambitious but realistic goal for where you want to be at the end of 2012. A fairly young practice can grow dramatically--possibly 30%. A well-established practice would do very well to grow by 10% unless there's a major change, such as opening a branch office.
  • Write down some strategies ("big picture") for how you will increase gross revenue. Then create a tactical approach (how to do it) for each strategy. Some of the ideas below may be components of your strategy.
  • Develop a budget for the practice. A budget is determined by your expense categories projected ahead, so start with your key expense groups from 2011, such as payroll cost, occupancy cost, equipment, marketing, and general office overhead. Look at each of these expenses as a percentage of gross revenue and decide what percentage of revenue each category should be in 2012. Using your new gross revenue goal for 2012, convert the percentage in each expense category into dollars. That becomes your budget.
  • Remember that any expense that remains constant will decrease as a percentage of gross revenue if the gross figure is higher. A payroll cost of $200,000 per year is 25% of an $800,000 gross, but that same payroll is only 22% of a 900,000 gross. Raising your fees could cause many expense categories to immediately fall into the target range.


  • Try to invest in new instrumentation as often as possible.
  • Consider which devices or technology would help your practice the most.
  • Project the monthly cost of the new instrument and calculate whether it will increase revenue more than that amount. If so, it's a smart investment.


  • Get serious about marketing your practice and increasing the number of patients you see per day.
  • Evaluate your practice's web site. If it's not great, invest at least $2000 to make it spectacular.
  • Get your practice's Facebook page active and relevant.
  • Assign a side position, director of marketing, to one of your staff members and give him/her time to work on these projects.


  • Consider staffing levels. Many practices are understaffed and would grow if they hired an additional employee. The additional employee does not decrease profitability if increased production covers the cost.
  • Design a program for ongoing staff development. It starts with a staff meeting held every week for 1 hour. Block out the patient schedule for this and communicate with your staff.

Customer service

  • Become dedicated and passionate about customer service.
  • Review your office policies (written and unwritten) with your staff and ask whether each policy is designed for the patient's wants and needs, the physicians' wants and needs, or the staff's wants and needs. (Guess which one matters most if you want to increase revenue?)
  • Think of ways to improve word-of-mouth referrals, which remain the most powerful way to build a practice.
  • Survey patient satisfaction on a continuous basis. The best way is to use an online communication company, which sends an e-mailed evaluation form to patients after office visits.
  • Determine whether your office is convenient for patients. Do you have evening and Saturday hours? Do patients have a long wait in your office?

Monitor progress
Write down your goals, set deadlines, establish methods for measurement, and check your progress at least monthly. If you see that you are not on pace to achieve your goals, make changes that will put you back on track.

Adapted from Neil B. Gailmard, OD, MBA, FAAO, editor, Optometric Management Tip of the Week.

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Please submit any clinical questions you have or any solutions you've found to clinical problems at clinicalpearls@c-orthopaedicpractice.com. We'll do our best to answer your questions and share solutions.

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Enjoy free access to "Does Supplemental Epidural Anesthesia Improve Outcomes of Acetabular Fracture Surgery?" from the February issue of the Journal of Orthopaedic Trauma. Free access to this article lasts until your next issue of COP eNews> arrives, when you'll receive free access to a new article.

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