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Volume 5 - Issue 2, April 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 a new tool to reduce the risk of performing wrong-site surgeries and whether corticosteroids can be used to treat carpal tunnel syndrome. Plus, find out whether hyaluronic acid is effective for treating osteoarthritis in joints other than the knee, and more.

Can you guess your best source of information about practice management (besides COP eNews Practice Management)? Your colleagues! Learn how to find or create a practice management study group that will help grow your practice.

In Article of the Month, please enjoy free access to an article from the March issue of Techniques in Foot & Ankle Surgery.

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

Nanci Kulig
Editor, COP eNews

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New tool aims to reduce wrong-site surgeries

A new tool intended to reduce the incidence of wrong-site surgery recently became available. The Targeted Solutions Tool (TST), developed by the Joint Commission Center for Transforming Healthcare, offers a systematic process to identify, measure, and reduce risks in key processes that can contribute to a wrong-site surgery.
     Because wrong-site surgery incidents are rare but devastating, the TST helps monitor surgical cases for weaknesses that might result in a wrong-site surgery. The TST helps organizations evaluate risks across their surgical system, including scheduling, the preoperative period, and operating room areas. All Joint Commission-accredited health care organizations have access to the TST via their secure Joint Commission Connect extranet.
     The wrong-site surgery project began in July 2009 with 8 U.S. hospitals and ambulatory surgical centers joining the Center to develop solutions. During the course of the project, the 8 participating organizations reduced the number of surgical cases with risks by 46% in the scheduling area, by 63% in the preoperative setting, and by 51% in the operating room. The hospitals and ambulatory surgical centers that pilot tested the TST experienced the same gains as the original participants.
     Although reporting is not mandatory in most states, according to some estimates, the national incidence--which includes wrong patient, wrong procedure, wrong site, and wrong side surgeries--is as high as 40 per week. For more information about the TST, visit the Joint Commission's Web site at http://www.jointcommission.org/targeted_solutions_tool_for_wrong_site_surgery_debuts/.

What leads to ACL injury?

Findings from a study presented at the 2012 annual meeting of the Orthopaedic Research Society suggest that combined multiplanar loading is the most critical loading mechanism in injury of the anterior cruciate ligament (ACL).
     Timothy E. Hewett, PhD, FACSM, director of research, Ohio State University Sports Health and Performance Institute and Cincinnati Children's Sports Medicine Biodynamics Center, and colleagues conducted impact tests on 19 cadaver legs to simulate jump landing under combinations of abduction, internal rotation, and anterior shear.
     Axial impact alone produced an average ACL strain of 5.8%. Addition of an abduction moment increased average ACL strain to 9.8%, and adding internal rotation to axial impact loading produced an average ACL strain of 8.2%. The combination of abduction, internal rotation, and anterior shear under axial impact increased the average peak ACL strain significantly, to 17.9%.
     Read the presentation abstract.

Predicting mortality in patients with pelvic fractures

Patients with pelvic fractures who do not survive their injuries are often men with severe multiple trauma and major hemorrhage, according to a new German study.
     Investigators prospectively collected data for 5340 patients listed in the German Pelvic Trauma Registry between April 30, 2004, and July 29, 2011. At a median of 2 days after trauma, 238 patients (4%) had died. The main cause of death was massive bleeding (34%), predominantly from the pelvic region (in 62% of all patients who died due to massive bleeding).
     Overall, 56% of nonsurvivors were male. Nonsurvivors were characterized by a higher incidence of complex pelvic injuries, a lower incidence of isolated pelvic ring fractures, lower initial blood hemoglobin concentration and systolic arterial blood pressure, and higher injury severity scores.

Source: Holstein JH, Culemann U, Pohlemann T, Working Group Mortality in Pelvic Fracture Patients. What are predictors of mortality in patients with pelvic fractures? Clin Orthop Relat Res. 2012 Feb 22. [Epub ahead of print]

Treating carpal tunnel syndrome with corticosteroids

Corticosteroid injection is an appropriate treatment in carefully selected patients with carpal tunnel syndrome, according to new study results. Patients with the highest risk of relapse are female and diabetic and have neurophysiologic confirmation of diagnosis.
     Study participants were managed with open carpal tunnel decompression or corticosteroid injection. During the study period, 1564 consecutive patients were diagnosed with carpal tunnel syndrome, of whom 824 (53%) received a corticosteroid injection as their primary treatment. Investigators used Kaplan-Meier survivorship methodology to determine the 5-year rate of reintervention. Risk factors for reintervention were also determined.
     The overall 5-year Kaplan-Meier rate of secondary carpal tunnel decompression was 15% at 1 year and 33% at 5 years. The need for secondary carpal tunnel decompression was independently associated with female sex, diabetes mellitus, and positive nerve conduction studies at diagnosis.
     Investigators suggest that clinicians use their results to guide initial treatment and counsel patients about the risk of relapse. Access the article.

Evaluating a tool to treat tibial fractures

Investigators recently evaluated the clinical experience and outcomes of intramedullary nailing of proximal, midshaft, and distal tibial fractures with the Expert Tibia Nail (ETN; Synthes GmbH, Switzerland). The ETN is an implant that offers a range of proximal and distal locking options in multiple planes and is indicated to increase the stability of the implant and bone construct.
     The study involved 180 patients with 185 tibial fractures treated at 10 trauma units (levels I, II and III) by use of intramedullary reamed and unreamed nailing with the ETN. Patients were examined at 12 weeks and at 1 year.
     The 1-year follow-up rate was 81%. At 1 year, the overall prevalence of delayed union was 12.2%. The prevalence of delayed union was higher for open fractures (18.2%) than for closed fractures (9.7%). The rate of delayed union, by fracture location, was 5.9%, 16.7%, and 10.5% in proximal third, midshaft, and distal third cases, respectively.
     Patients with a plated fibular fracture had an 8-fold higher risk of delayed union. The rate of malalignment (>5 degrees) in any plane 1 year after surgery was 5.5%. Proximal third fractures were associated with a higher risk of postoperative malalignment (17.6%) than other fracture locations. The rate of secondary malalignment was 1.4%. There was a 9.2% risk of unplanned reoperation.
     On the basis of their findings, investigators concluded that intramedullary ETN fixation of tibial fractures results in low rates of delayed union, primary and secondary malalignment, implant-related complications, and secondary surgery. In addition, fibular plating has a negative effect on healing of the tibia.

Source: Attal R, Hansen M, Kirjavainen M, et al. A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN). Arch Orthop Trauma Surg. 2012 Mar 20. [Epub ahead of print]

Is hyaluronic acid effective for treating OA in joints other than the knee?

Intra-articular injection of hyaluronic acid (HA) is a well-known treatment in patients with knee osteoarthritis (OA). However, less is known about the efficacy of intra-articular HA as used in the hallux metatarsophalangeal joint, the ankle, the hip, the sacroiliac joint, the facet joints, the first carpometacarpal joint, the shoulder, and the temporomandibular joint. Investigators conducted a systematic review of all prospective studies about the effects of intra-articular HA in these joints.
     Evidence suggests that, compared with baseline, intra-articular HA has a positive effect on joint condition. There is also limited evidence that HA is superior to placebo. However, no strong evidence supports the idea that HA is superior to treatments of OA such as corticosteroids, physiotherapy, or other conservative measures. Investigators recommend that future research compare HA treatment with other types of intra-articular or conservative treatment.

Source: Colen S, Haverkamp D, Mulier M, van den Bekerom MP. Hyaluronic acid for the treatment of osteoarthritis in all joints except the knee: What is the current evidence? BioDrugs. 2012;26(2):101-112.

Is the new medical food Theramine safe and effective?

A new amino acid medical food (Theramine) seems to be effective to relieve low back pain without causing any significant adverse effects, and it may offer a viable alternative to current therapies, according to new study findings.
     Investigators performed a 28-day double-blind randomized controlled trial involving 129 patients with moderate to severe back pain of at least 6 weeks' duration. Patients were randomly assigned to receive medical food alone, naproxen alone (250 mg per day), or both medical food and naproxen. All patients were assessed with the Roland-Morris Disability Questionnaire, Oswestry Low Back Pain Scale, and visual analog scale. Laboratory analysis, including complete blood count, C-reactive protein (CRP), and liver function, was performed at baseline and at 28 days to assess the safety and the impact on inflammatory markers.
     At baseline, there were no statistically significant differences among the groups with regard to low back pain. At day 28, patients in both the medical food group and the combined therapy group (medical food with naproxen) had significantly superior reductions in pain compared with the naproxen-alone group. Patients who received both medical food and naproxen demonstrated more functional improvement than those in the group that received naproxen alone.
     Compared with the other treatment groups, patients who received naproxen alone had significant elevations in CRP, and tests of liver function revealed elevated alanine transaminase and aspartate transaminase. Medical food alone or with naproxen was not associated with significant change in liver function or CRP, perhaps because the medical food mitigated the effects observed with naproxen alone.

Source: Shell WE, Charuvastra EH, Dewood MA, May LA, Bullias DH, Silver DS. A double-blind controlled trial of a single dose naproxen and an amino acid medical food theramine for the treatment of low back pain. Am J Ther. 2012;19(2):108-114.

Does arthroscopic surgery benefit degenerative medial meniscal tears?

Findings from a recent study indicate that arthroscopic surgery followed by exercise therapy is not superior to the same exercise therapy alone for patients with nontraumatic, degenerative medial meniscal tears.
     Investigators conducted a prospective randomized intervention study involving 96 middle-aged patients with MRI-verified degenerative medial meniscal tears and radiographically documented grade 1 or lower osteoarthritis. Patients underwent radiographic examination before randomization and 5 years later. The patients were randomly assigned to either arthroscopic treatment followed by exercise therapy for 2 months or to exercise therapy alone.
     At the start of the study and at 24 and 60 months of follow-up, the patients completed 3 questionnaires (Knee Injury and Osteoarthritis Outcome Score [KOOS], Lysholm Knee Scoring Scale, and Tegner Activity Scale) and rated their pain using the visual analog scale (VAS).
     Both groups demonstrated highly significant clinical improvements by 24 and 60 months on all subscales of KOOS, Lysholm Knee Scoring Scale, and VAS. One third of the patients assigned to exercise therapy alone did not feel better after the treatment but improved after arthroscopic surgery. Radiographic evidence showed that 2 patients from each group had slight progression of their osteoarthritis after 5 years.
     Because of its success in two thirds of patients, the authors recommend exercise therapy alone as initial treatment for degenerative medial meniscal tears, although one third of patients eventually may require arthroscopic surgery for symptom relief.

Source: Herrlin SV, Wange PO, Lapidus G, Hållander M, Werner S,Weidenhielm L. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surg Sports Traumatol Arthrosc. 2012 Mar 23. [Epub ahead of print]

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Join a study group and grow your practice

One of the most powerful practice management resources you may ever encounter is a small study group of orthopaedists. Study groups, also called peer groups or roundtable networks, comprise 8 to 12 like-minded physicians who meet in a neutral setting, such as a hotel conference room, with the goal of helping and learning from each other. Office manager groups can also be very beneficial.
     Study groups can exist for decades, with participants often learning more from fellow group members than by any other means. A study group is not only an excellent learning experience, it is also great fun. A 5-hour meeting can fly by when you're meeting long-time colleagues and swapping stories. Management strategies and clinical pearls are easy to implement because you learned them from peers who are using the techniques. You become motivated to try new things because you can feel the passion in someone who has seen it work well.

Finding a group
It might be tough to find a group to join, but you can always start your own group. Ask some friends and former classmates to join, and have each of them ask a few more people. You could also seek a consulting firm or physicians' alliance that organizes and facilitates study groups. Keep the following tips in mind when forming a study group.

  • It's best to be in a group where none of the participants is from the same geographical location.
  • Study groups depend on complete and open sharing of data and strategies, and that won't happen if competitors are in the room. This is why regional meetings don't work as well as national ones.
  • There is some advantage to being in a group of physicians who have similar practices, but there is also much to be learned from doctors who do things differently.
  • Mixing modes of practice, age groups, sexes, revenue levels, and other variables can be very eye opening and productive.
  • Organizing the hotel, meeting space, food and beverage service, and many other details can be a chore. The job can be rotated among the members.
  • It is best to meet every 6 months.
  • Members of the group may share financial data and bring a packet of printed materials to pass out to the others.
  • It may be possible to get some industry support for study group meetings.
  • You may find that you're not perfectly compatible with every member of your group, but you may gain valuable information from the group as a whole.

The agenda
Time can pass quickly in a study group. One good way to begin the meeting is ask each member at the table to describe what is new in his or her practice. If this is a new group, an introduction to the practice and the owner is shared. If each physician speaks for only 15 minutes and there are questions for 5 minutes, it will take 4 hours to cover 12 members. And you haven't started on the agenda yet!
     Most groups operate in a flexible and casual manner, and the discussion goes wherever the interest of the group takes it. One member serves as the moderator or facilitator to keep the flow moving. Members often take notes.
     Typically, the group or an organizer will submit agenda topics in advance. The topics can be practice management-related or clinical, and in many cases, they span both. The group members should look at each agenda item as a topic that one could either present or learn more about. Each member can suggest a topic about which to offer expertise or ask questions of the others.

Location and cost
Most groups move the location of the meetings to various destinations. Consider these aspects when choosing a location:

  • Convenience of large airports for easy travel;
  • Warm weather during winter months;
  • Fun destinations;
  • Rotating through the home cities of members so a tour of that practice can be on the agenda; and
  • Scheduling in conjunction with an orthopaedic conference.

There is typically some travel cost involved in these semi-annual meetings, but it is tax-deductible, and study group veterans say the costs are a sound investment for building a better practice.

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 the "Role of Platelet-rich Plasma in Foot and Ankle Surgery: Current Concepts," from the March issue of the Techniques in Foot & Ankle Surgery. 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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