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Volume 5 - Issue 6, December 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, find out how administering 3 doses of hydrocortisone after a knee replacement prevents 2 types of complications. Learn how patients with osteoarthritis and rheumatoid arthritis differ after hip and knee arthroplasty. Read new evidence about managing irreparable rotator cuff tears, and more.

In this month's Practice Management, find out why doctors who attend practice management conferences have more-profitable practices. Also, discover how to find a great practice management conference or Webinar, and which topics can help you reach your goals for your practice.

In Article of the Month, please enjoy free access to an article from the current issue of Techniques in Shoulder & Elbow Surgery.

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

Nanci Kulig
Editor, COP eNews

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The (expanding) benefits of hydrocortisone after knee replacement

Administration of 3, 100-mg doses of hydrocortisone 8 hours apart after bilateral knee replacement decreased and maintained a lower degree of inflammation, a new study showed. The hydrocortisone also helped to prevent respiratory distress.
     In all, 34 patients (17 patients and 17 control subjects) were enrolled in a double-blind, randomized, placebo-controlled study. Three doses of intravenous hydrocortisone (100 mg) or placebo were administered 8 hours apart. Levels of urinary desmosine, a marker of lung injury, were obtained at baseline and at 1 and 3 days postoperatively. Investigators also measured levels of interleukin-6 (IL-6) to gauge inflammatory response at baseline and at 6, 10, 24, and 48 hours postoperatively. Pain scores, presence of fever, and functional outcomes also were recorded.
     Levels of IL-6 increased in both groups but were significantly higher in the control group and peaked at 24 hours. Urinary desmosine levels increased significantly by 24 hours in the control group but were unchanged in the study group. Pain scores at 24 hours were significantly lower in the study group than in the control group (1.4 vs. 2.4), as was the presence of fever (11.8% vs. 47.1%). Range of motion at the knee was significantly greater in the study group (81.6 vs. 70.6 in the right knee and 81.4 vs. 73.4 in the left knee).
     Administration of corticosteroids after bilateral knee replacement decreased the prevalence of fever, lowered visual analog scale pain scores, and improved knee motion. The significantly lower values of desmosine in the study group suggest that hydrocortisone also may protect against lung injury and respiratory distress.

Source: Jules-Elysee KM, Wilfred SE, Memtsoudis SG, et al. Steroid modulation of cytokine release and desmosine levels in bilateral total knee replacement: a prospective, double-blind, randomized controlled trial. J Bone Joint Surg Am. 2012 Oct 24. [Epub ahead of print]

How patients with OA and RA differ after hip and knee replacement

Compared with patients with osteoarthritis (OA), patients with rheumatoid arthritis (RA) are at higher risk of dislocation after total hip arthroplasty (THA) and at higher risk of infection after total knee arthroplasty (TKA), according to findings from a recent study.
     Investigators analyzed the results of 40 studies published between January 1990 and December 2011. The studies included patients with arthritis who were at least 18 years of age and had undergone THA or TKA.
     The findings indicate that patients with RA are at increased risk of dislocation after THA (adjusted odds ratio, 2.16). "Fair" evidence also supports increased risks of infection and early revision after TKA among patients with RA, compared with patients with OA.
     There was no evidence of differences in rate of revision at later time points, in 90-day mortality, or in rate of venous thromboembolic events after THA or TKA in patients with RA compared with patients with OA. Only 3 studies (7.5%) explicitly defined RA, and only 11 studies (27.5%) adjusted for covariates such as age, sex, and comorbidity.

Source: Ravi B, Escott B, Shah PS, et al. A systematic review and meta-analysis comparing complications following total joint arthroplasty for rheumatoid arthritis versus for osteoarthritis. Arthritis Rheum. 2012;64(12):3839-3849.

Tracking the fate of bone graft-derived cells after transplantation

Grafting bone between the tendon graft and the bone tunnel in anterior cruciate ligament reconstruction strengthens the tendon graft. However, the biological role of the bone graft has been unclear. New research shows that within 4 weeks of transplantation, bone graft cells migrate to the tendon graft, where they differentiate into cells involved in collagen production and macrophages. Bone graft cells may help with early-stage remodeling of tendon grafts.
     The Achilles tendons of Sprague-Dawley (SD) wild-type rats and bone of green fluorescent protein (GFP) transgenic rats were harvested and transplanted into bone tunnels drilled in the femurs at the knees of SD rats. The femurs were harvested 1, 2, or 4 weeks after transplantation, and their histologic characteristics were analyzed. Biomechanical tests were performed on the tendon graft 2 and 4 weeks after transplantation to evaluate the ultimate force to failure.
     A small number of GFP-positive cells were in the tendon graft 2 weeks after transplantation. The cell count in the tendon graft increased at 4 weeks after transplantation. The ultimate failure load in the bone graft group was higher than that in a control group at both 2 and 4 weeks after transplantation.

Source: Komiyama H, Arai Y, Kajikawa Y, et al. The fate and role of bone graft-derived cells after autologous tendon and bone transplantation into the bone tunnel. J Orthop Sci. 2012 Nov 14. [Epub ahead of print]

Taking stock of talar neck fractures

Optimal management of talar neck fractures has yet to be determined, according to investigators who conducted a review that included 21 reports involving 943 talar neck fractures. The findings highlight the challenges of treating patients with talar neck fractures.
     Investigators analyzed data concerning open fractures; the interval to surgery and its relationship to the incidence of avascular necrosis; the rates of malunion and nonunion, posttraumatic arthrosis, and secondary salvage procedures; and functional outcomes.
     The rate of avascular necrosis was 33%, with no demonstrated relationship between the interval to surgery and the rate of avascular necrosis. Malunion occurred approximately 17% of the time, with nonunion occurring approximately 5% of the time. Posttraumatic arthrosis occurred in 68% of patients, although secondary salvage procedures were only performed in 19% of patients. Functional outcomes were difficult to assess because of the variability of reported outcomes and unvalidated measures.
     Although this review has improved understanding of talar neck fractures, investigators call for additional studies that use validated outcome measures to determine the effect of delayed surgery on outcomes and treatment methods.

Source: Halvorson JJ, Winter SB, Teasdall RD, Scott AT. Talar neck fractures: a systematic review of the literature. J Foot Ankle Surg. 2012 Nov 13. [Epub ahead of print]

Assessing clinical consequences of disc prosthesis surgery

Are patients who have disc prosthesis surgery more or less likely than patients who undergo rehabilitation to develop adjacent level degeneration (ALD) and index-level facet arthropathy (FA)? In a new report that compared the courses of degeneration after treatment with disc prosthesis surgery or rehabilitation, the rate of ALD was similar at 2 years of follow-up. However, the surgery group exhibited increased FA at the implant level.
     The study included 116 patients with at least a 1-year history of low back pain, Oswestry Disability Index score of 30 points or more, and degenerative changes in 1 or 2 lower lumbar spine levels. MRI scans were obtained before treatment and at 2-year follow-up visits. ALD and index-level FA were determined based on the majority assessment of 3 independent, experienced radiologists. ALD was assessed by evaluating Modic changes, posterior high-intensity zone in the disc, nucleus pulposus signal, disc height, disc contour, and FA.
     ALD developed at similar rates in both patient groups. In patients treated with surgery, index-level FA developed or increased in 20 patients (34%) and decreased in 1 patient. In patients treated with rehabilitation, 2 patients (4%) had new or increased FA at the index or degenerated disc level, and 1 patient had decreased FA. Development of ALD and FA was not related to clinical outcome.

Source: Hellum C, Berg L, Gjertsen O, et al. Adjacent level degeneration and facet arthropathy after disc prosthesis surgery or rehabilitation in patients with chronic low back pain and degenerative disc: second report of a randomized study. Spine (Phila Pa 1976). 2012;37(25):2063-2073.

Does varus alignment increase after medial meniscectomy?

Arthroscopic meniscectomy in patients with medial meniscal tears aggravates varus alignment in the lower extremity, as observed during a final follow-up examination, according to results of a new study. The increase in varus deformity was significantly higher among patients who underwent total meniscectomy than in those who had partial meniscectomy.
     The study involved 56 patients between the ages of 20 and 60 years who underwent arthroscopic medial meniscectomy for medial meniscal tears and were followed-up for a minimum of 5 years. Alignment in the lower extremity was measured preoperatively and again at the last follow-up visit. Change in varus alignment, defined as the difference between preoperative alignment and alignment at the last follow-up visit, was analyzed with regard to sex, age, body mass index (BMI), resection amount (partial or total), preoperative alignment, and follow-up duration. Multiple linear regression analysis was used.
     Varus deformity increased by 1.7 degrees, from a preoperative average of 2.4 degrees, to an average of 4.1 degrees at the last follow-up visit, which was statistically significant. Only the resection amount (partial meniscectomy or total meniscectomy) was significantly related to the change in varus alignment. Other factors, including sex, age, BMI, preoperative alignment, presence of cartilage injury, and follow-up duration were not significantly related to the change in varus alignment after the procedure.

Source: Yoon KH, Lee SH, Bae DK, Park SY, Oh H. Does varus alignment increase after medial meniscectomy? Knee Surg Sports Traumatol Arthrosc. 2012 Nov 11. [Epub ahead of print]

Managing irreparable rotator cuff tears

How effective for patient status and quality of life is surgical management of an irreparable rotator cuff tear? To find out, investigators conducted a prospective case-control study involving 68 patients who received either arthroscopic debridement associated with acromioplasty and bursectomy (AP group) or arthroscopic partial repair of the rotator cuff tear (PR group).
     Follow-up periods ranged from 5 to 9 years. During the study, investigators assessed preoperative and postoperative range of motion (ROM), modified-UCLA shoulder scores, and measurements of strength. The rotator cuff quality of life (RC-QOL) score was used at the time of the last follow-up visit to assess patients' perception of their quality of life.
     During the follow-up period, ROM measures increased significantly from preoperative to postoperative evaluations, with significant intergroup differences. The overall modified-UCLA shoulder score average preoperative value was 7.6 for the AP group and 8.6 for the PR group. The postoperative values at the most recent follow-up visit showed a statistically significant improvement in both groups. The RC-QOL demonstrated a statistically significant difference between the groups: the AP group had an average score of 61.8, and the PR group had an average score of 71.2.
     Investigators concluded that both treatment modalities are effective in reducing patients' symptoms. However, the partial repair technique resulted in better functional outcomes. The choice of technique should take into account the patient's acromiohumeral interval and level of daily activity.

Source: Franceschi F, Papalia R, Vasta S, et al. Surgical management of irreparable rotator cuff tears. Knee Surg Sports Traumatol Arthrosc. 2012 Dec 2. [Epub ahead of print]

Use of pedicle screws to correct spinal deformity from cerebral palsy

Pedicle screw instrumentation can achieve excellent correction of spinal deformity in children with quadriplegic cerebral palsy. Use of pedicle screw instrumentation also offers low complication and reoperation rates and high parent satisfaction, according to results of a new study.
     Investigators reviewed charts of 212 consecutive patients with adolescent idiopathic scoliosis who underwent posterior spinal arthrodesis, with all-pedicle-screw instrumentation, for clinical, radiographic, and Scoliosis Research Society (SRS)-22 outcomes. In a group consisting of 51 patients, a bilateral screw corrective technique was used, which involved 2 rods and bilateral segmental pedicle screws. In a second group of 161 patients, a unilateral pedicle screw technique was used that consisted of a rod with unilateral segmental pedicle screws and another rod to provide stability of the construct through 2-level screw fixation at the proximal and distal ends.
     There were no significant differences between the 2 groups with regard to age, Risser grade at surgery, preoperative and postoperative scoliosis angle, coronal Cobb correction, length of hospital stay, and SRS scores. Correction of upper thoracic curves was significantly better among patients who underwent the bilateral screw technique compared with those that had the unilateral technique. Increased surgical time and intraoperative blood loss were recorded in the bilateral-technique group. The implant cost was reduced by an average 35% in the unilateral-technique group because fewer pedicle screws were required.
     Both unilateral and bilateral pedicle screw techniques achieved excellent deformity correction that was maintained at 2-year follow-up. Both techniques also have been associated with high levels of patient satisfaction and low complication rates.

Source: Tsirikos AI, Subramanian AS. Posterior spinal arthrodesis for adolescent idiopathic scoliosis using pedicle screw instrumentation: Does a bilateral or unilateral screw technique affect surgical outcome? J Bone Joint Surg Br. 2012;94(12):1670-1677.

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Why you should seek out practice management information

Doctors who attend practice management courses do so for the pure educational value, not for continuing education (CE) credit. States often confer little or no CE credit for practice management courses. That said, consider seeking more practice management education at live meetings and at webinars, because there is a high return on your investment of time and money.
     Physicians who attend practice management meetings have the largest and most successful practices. Of course, not everyone wants a large, high-income practice, and to each his or her own. For those who want more practice profitability, attending several practice management courses every year can help greatly.

Choosing meetings
There are many sources for great meetings. You have an e-mail address and likely see many opportunities to gain practice management information. Evaluate these offerings and choose some of them; move outside of your usual circles. Consider the following resources for practice management education:

  • National conferences;
  • Regional conferences;
  • Smaller specialty meetings;
  • Consulting firms;
  • Magazine publishers;
  • Physician alliance groups;,
  • Buying groups; and
  • Vendors and laboratories.

     Live meetings located outside your home state offer many benefits. Although you will incur some travel costs and have to take time away from the office, you will gain new insights into many topics that result in higher revenue. There is a level of enthusiasm that can inspire you to implement new ideas. Attending a meeting also offers an organized time to reflect on what your practice is doing well and where you can improve. Plus, some of the best learning comes from talking with like-minded colleagues at breaks and at meals.
     Webinars also offer excellent opportunities to gain practice management skills. Many of these are free and may have a sponsor. Some practice management webinars are generic, and some are product related, but both can bring high value. Many of the best opportunities to grow your practice involve a product or instrument. The leading companies in these fields are ideally positioned with experts to provide education on their products.

What are the topics?
Practice management courses cover a wide range of new topics. Examples include:

  • Marketing with social media, e-mail, and websites;
  • How to recruit and hire better staff members;
  • How to motivate and train staff members;
  • Office design;
  • Using scribes;
  • Buying or selling a practice;
  • Coding and billing;
  • Clinical efficiency; and
  • Electronic medical records.

Staff members need education also
Meetings featuring practice management education are valuable for staff members. Practices that think big and send key staff to these meetings are rewarded with higher productivity and better attitudes at work.

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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Please enjoy free access to the article, "Economical and Efficacious Beach Chair Traction Positioning for Shoulder Arthroscopy" from Techniques in Shoulder & Elbow 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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