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Volume 5 - Issue 3, June 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. Orthopaedics in Brief will keep your clinical knowledge current. This month, read about a novel suture technique for graft fixation. Find out whether neridronate improves bone marrow density. Learn the best way to manage patients after a failed arthroscopic rotator cuff repair, and more.

Want to know how to increase your practice's net income without treating even 1 extra patient? Check out this issue's Practice Management column.

In Article of the Month, please enjoy free access to an article from the June issue of the Journal of Spinal Disorders & Techniques.

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

Nanci Kulig
Editor, COP eNews

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Managing failed arthroscopic rotator cuff repair

More than 90% of patients with rotator cuff tears have successful outcomes after arthroscopic rotator cuff repair surgery, according to a recent review. With successful repair, patients have decreased pain, increased active range of motion, and improved shoulder strength function. Patients with failed rotator cuff syndrome, however, present a diagnostic and therapeutic challenge. These patients experience continued pain, weakness, and limited range of motion after arthroscopic rotator cuff repair.
     A review article outlines potential treatment and pain management options for these patients. The report recommends a thorough physical examination to exclude other causes of pain, weakness, and/or limited mobility such as cervical spine disease or a subsequent, secondary trauma to the shoulder. Standard radiographs of the shoulder should also be obtained. Findings from the examination or radiographs may warrant use of an advanced imaging modality such as MRI or ultrasonography.
     Depending on the situation, treatment options may include repair, partial repair (with or without biologic or synthetic substances), or a tendon transfer. Tendon transfers, in which the muscles and tendons of the shoulder are moved for rotator cuff deficiency, are a salvage option for younger patients and often produce good results. The typical candidate for successful revision surgery and repair is a patient younger than age 65 without signs of arthritis, pseudoparalysis, tendon retraction, or muscle atrophy.

Source: Strauss EJ, McCormack RA, Onyekwelu I, Rokito AS. Management of failed arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2012;20(5):301-309.

Comparing bearings used in THA

A new study compares the risks of complications and revision total hip arthroplasty (THA) in Medicare patients with different bearings. Using the 100% Medicare database, researchers calculated the adjusted risk of complications and revision THA for 148,827 patients who underwent THA. Of these patients, 93,929 had metal-on-polyethylene bearings, 49,646 had metal-on-metal bearings, and 5252 had ceramic-on-ceramic bearings. Investigators compared the adjusted risk of deep vein thrombosis, dislocation, periprosthetic joint infection (PJI), mechanical loosening, periprosthetic fracture, and revision THA up to 4 years postoperatively.
     After adjusting for patient and hospital factors, metal-on-metal bearings were associated with a higher risk of PJI, mechanical loosening, and deep vein thrombosis than metal-on-polyethylene bearings. Metal-on-metal bearings were associated with a higher risk of PJI than ceramic-on-ceramic bearings.
     Overall, short-term revision rates did not vary significantly by bearing type. Investigators concluded that the benefits of hard-on-hard bearings in Medicare patients are unproven, and further study is needed to compare long-term complication and revision rates with various bearing types.

Source: Bozic KJ, Lau EC, Ong KL, Vail TP, Rubash HE, Berry DJ. Comparative effectiveness of metal-on-metal and metal-on-polyethylene bearings in Medicare total hip arthroplasty patients. J Arthroplasty. 2012 May 17. [Epub ahead of print]

How vitamin D really affects bone

A new review analyzes direct versus indirect actions of vitamin D on bone and offers guidelines for use of vitamin D to prevent or treat bone loss and fractures.
     All cells comprising the skeleton-chondrocytes, osteoblasts, and osteoclasts-contain both the vitamin D receptor and the enzyme CYP27B1 required for producing the active metabolite of vitamin D, which is 1,25 dihydroxyvitamin D. Direct effects of 25 hydroxyvitamin D and 1,25 dihydroxyvitamin D on these bone cells have been demonstrated.
     However, major skeletal manifestations of vitamin D deficiency or mutations in the vitamin D receptor and CYP27B1, such as rickets and osteomalacia, can be corrected by increasing intestinal absorption of calcium and phosphate, which suggests the importance of indirect effects. Even so, these dietary manipulations do not reverse defects in osteoblast or osteoclast function that lead to osteopenic bone.

Source: Bikle DD. Vitamin D and bone. Curr Osteoporos Rep. 2012;10(2):151-159.

Percutaneous cerclage wiring for reduction of difficult femoral fractures

Periprosthetic femoral fractures (PPFs) positioned at or near well-fixed femoral prostheses (Vancouver type-B1) present a clinical challenge because of the quality of the bone stock and instability of the fracture. In a recent study, investigators evaluated the use of a new cerclage passer instrument (Synthes®, West Chester, PA) in patients with these difficult fractures.
     In the study, 10 consecutive patients with spiral, oblique, or wedge Vancouver type-B1 fractures were treated with closed percutaneous cerclage wiring through small, 2- to 3-cm incisions by use of the new cerclage passer instrument. Surgeons accomplished reduction and maintenance of reduction. Internal fixation with minimally invasive plate osteosynthesis (MIPO) was accomplished with a long locking compression plate to bridge the fracture.
     The average reduction time with percutaneous cerclage wiring was 24 minutes; average fixation time was 79 minutes; and average operative time was 103 minutes. Blood loss was minimal, and only 2 patients required transfusion. All fractures healed, with an average time to union of 18 weeks. One implant bent 10 degrees during the postoperative period, but it healed within 16 weeks. There was no evidence of loosening of any implants. Seven patients returned to their previous level of mobility. Two patients required walkers. (One patient died 2 months after surgery from a cardiovascular condition.) There were no implant failures, wound complications, or infections.
     Early results suggest that this reduction technique and fixation may be a useful treatment for these challenging fractures. Investigators caution that this technique requires care to avoid serious complications, including vascular injury.

Source: Apivatthakakul T, Phornphutkul C, Bunmaprasert T, Sananpanich K, Fernandez Dell'oca A. Percutaneous cerclage wiring and minimally invasive plate osteosynthesis (MIPO): a percutaneous reduction technique in the treatment of Vancouver type B1 periprosthetic femoral shaft fractures. Arch Orthop Trauma Surg. 2012;132(6):813-822.

Does neridronate improve bone mineral density and relieve back pain?

There is promising news for patients with beta thalassemia who have osteoporosis. Neridronate, a third-generation bisphosphonate with established efficacy in metabolic bone disease, seems to provide significant increases in bone mineral density at the lumbar spine and total hip. This was established with findings from the largest randomized trial in thalassemia-induced osteoporosis to date.
     In a randomized, open-label study, 118 adults with beta thalassemia and low bone mineral density were randomized to 1 of 2 treatment groups: 500 mg calcium with 400 IU of vitamin D daily, taken orally; or 500 mg calcium with 400 IU vitamin D daily, taken orally, plus intravenously administered neridronate 100 mg every 90 days.
     Patients who took neridronate demonstrated significant increases in bone mineral density at the lumbar spine and total hip 6 and 12 months after the start of treatment.
     Neridronate also significantly decreased serum bone alkaline phosphatase and C-telopeptide of collagen type 1 levels beginning as early as 3 months. These levels were significantly lower at 12 months compared with those in patients who did not take neridronate. Reductions in back pain and analgesic use also were noted after 3 months of treatment.
     Treatment was well tolerated by all patients. Neridronate was safe and effective in reducing bone resorption and increasing bone mineral density. Investigators forecast that reductions in back pain and improved quality of life will increase adherence to therapy.

Source: Forni GL, Perrotta S, Giusti A, et al. Neridronate improves bone mineral density and reduces back pain in Β-thalassaemia patients with osteoporosis: results from a phase 2, randomized, parallel-arm, open-label study. Br J Haematol. 2012 May 10. [Epub ahead of print]

Evaluating the modified finger-trap suture technique

The newly devised modified finger-trap (MFT) suture is a simple technique that is an attractive alternative to the Krackow and SpeedWhip suture techniques for tendon graft fixation in ligament reconstruction. Findings from an in vitro biomechanical evaluation show that the MFT suture provides a higher percentage elongation and equal load to failure compared with the Krackow and SpeedWhip suture techniques.
     To compare the tendon graft holding power of the MFT suture technique with that of other sutures, investigators used 40 fresh-frozen porcine flexor profundus tendons randomly divided into 4 groups: MFT suture, Krackow stitch, locking SpeedWhip stitch, and nonlocking SpeedWhip stitch. After the tendons were sutured, each tendon was pretensioned to 100 N for 3 cycles, and then cyclically loaded to 200 N for 200 cycles. Finally, each tendon was loaded to failure. Investigators measured percentage elongation, load to failure, and mode of failure for each suture-tendon construct.
     During the pretension phase, the MFT suture had the smallest percentage elongation of the suture-graft construct (13.5%) compared with the Krackow (16.9%), locking SpeedWhip (17.6%), and nonlocking SpeedWhip (33.3%) stitches. During cyclic loading, the MFT suture also showed a significantly smaller percentage elongation of the suture-graft construct (27.8%) than the Krackow (35.8%), locking SpeedWhip (33.7%), and nonlocking SpeedWhip (43.8%) stitches. The load to failure and cross-sectional area were not significantly different across the suture groups.

Source: Su WR, Chu CH, Lin CL, Lin CJ, Jou IM, Chang CW. The modified finger-trap suture technique: a biomechanical comparison of a novel suture technique for graft fixation. Arthroscopy. 2012;28(5):702-710.

Construct stiffness: supracondylar vs. condylar plate

Despite the limited bone contact area provided by the supracondylar plate, its construct stiffness is about the same as that of the condylar plate. Surgeons can use the supracondylar plate to treat extra-articular supracondylar fractures in carefully selected patients, new study findings suggest.
     Investigators compared the biomechanical properties of the supracondylar and condylar plates using 6 matched pairs of cadaveric femurs. A transverse osteotomy gap was created to simulate an OTA/AO type A3 supracondylar fracture. The left and right specimens were fitted with a supracondylar and a condylar plate, respectively.
     Investigators performed nondestructive axial compression, 3-point bending, and torsion tests, measuring the peak load of the bone-implant construction. They located the fracture site suitable for supracondylar plate application and calculated its correlation with femoral length. Sex influence also was discussed.
     The differences in stiffness between the supracondylar and condylar groups were not significant at 363.4 and 362.5 N/mm for compression, 229.5 and 237.6 N/mm in the sagittal plane and 195.5 and 188.4 N/mm in the coronal plane for 3-point bending, and 7.5 and 7.9 Nm/deg for axial torsion, respectively. The peak load was 4438N in the supracondylar group and 5215N in the condylar group. The average extent of the fracture site suitable for the application of the supracondylar plate was 70.86?mm. The femoral length and patient's gender did not seem to influence results.

Source: Liang B, Ding Z, Shen J, Zhai W, Kang L, et al. A distal femoral supra-condylar plate: biomechanical comparison with condylar plate and first clinical application for treatment of supracondylar fracture. Int Orthop. 2012 May 13. [Epub ahead of print]

More evidence about bisphosphonate risks

Evidence is mounting regarding the risks of bisphosphonate drugs. Another study has found an association between atypical femoral fractures and use of these drugs.
     The new study involved 477 patients, at least 50 years of age, with femoral fractures. Of those patients, 39 had atypical fractures, and 438 had classic fractures. In a retrospective investigation, researchers compared these groups with 200 people without femoral fractures.
     Investigators determined that 82% of the patients with atypical fractures were treated with bisphosphonates, including Actonel (Warner Chilcott Pharmaceuticals, Inc., Dublin, Ireland), or Fosamax (Merck, Whitehouse Station, NJ). Approximately 6% of patients with classic fractures were treated with bisphosphonates. Compared with patients who did not have fractures, use of bisphosphonates was associated with a 47% reduction in the risk of a classic fracture.
     Investigators also found that longer duration of bisphosphonate treatment increased the risk of atypical femoral fracture. The incidence of atypical fractures increased during a 12-year period. The researchers compared duration of bisphosphonate treatment with no treatment, and they determined that the odds ratio for an atypical fracture, compared with a classic fracture, was 35-to-1 for less than 2 years of treatment, 46-to-9 for 2 to 5 years of treatment, 117-to-1 for 5 to 9 years of treatment, and 175-to-7 for more than 9 years of treatment.
     Investigators concluded that an association between bisphosphonate use and atypical femoral fractures is highly likely, and that treatment duration directly correlates with risk. That being the case, the absolute number of atypical femoral fractures is small, meaning there is a positive benefit-to-risk ratio for bisphosphonate use.

Source: Meier RP, Perneger TV, Stern R, Rizzoli R, Peter RE. Increasing occurrence of atypical femoral fractures associated with bisphosphonate use. Arch Intern Med. 2012 May 21. [Epub ahead of print]

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Increase net income by reducing office errors

One sure-fire way to bolster your practice's net income is to reduce administrative errors. Administrative errors are a catch-all category for anything that doctors and staff do that costs the practice money. This category includes any type of office inefficiency, but let's focus on a few areas that could pay big dividends.

Fees that are not posted or collected
One would think that failure to charge or collect fees would be a rare occurrence in any business, but in some practices, it is common. Part of the problem stems from office management software programs that are slow and burdensome. In an effort to check out patients quickly, some employees do not post charges to a patient's account while the patient is in the office. Many staff members are just too busy to handle that task at the moment the patient arrives at the front desk after an appointment. The patient wants to leave, so the staff member writes up a paper receipt, accepts some form of payment from the patient, and places the record to the side to finish later.
     With the charges placed on hold and the patient gone, any number of problems may occur to prevent the charges from being entered into the management system. For example, another employee may tidy up the front desk and file the record.

Monthly procedures not followed
Some offices do not bill patients in a timely manner. Likewise, these offices may not review payments and claim rejections from insurance plans on a regular basis, and no one may be monitoring the accounts receivable aging report.
     It is crucial that a staff member is assigned to and given sufficient time to manage billings and collections for insurance plans and patients. Rejected claims should be corrected and refiled. Balances may be transferred from insurance plans to patients. Patients whose payments are past due should be called by telephone. All of these actions must be taken in a timely fashion, because if these issues are not handled quickly, the chance of successful collection drops dramatically.

Theft and embezzlement
Employee theft is an office error. If it happens on a large scale, theft is a management oversight. Employees have been known to steal cash or write fraudulent checks. Your practice may never be 100% protected from theft by employees, but strict accounting procedures and a close watch on inventory can reduce the problem effectively.
     Put a system in place that requires financial accuracy. The daily production report must always balance exactly with the cash drawer at the end of the day. Have 2 working cash trays, with a predetermined amount of cash to start the day, so the other cash drawer always stays with that day's production report until it is balanced. Any over or under cash amounts must be explained. Bank deposits should always match the day's receipts exactly in the form of cash, checks, and credit card payments. Bank deposit receipts are returned to the practice owner and monitored.

There are many ways that a practice can be inefficient and to some extent, these are management errors. Insufficient delegation is a common example. That said, no one is perfect, but if you review your office procedures and design them to reduce errors and omissions, your practice net income should increase.

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 "Oblique Lumbar Interbody Fixation: A Biomechanical Study in Human Spines," from the June issue of the Journal of Spinal Disorders & Techniques. 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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