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Volume 6 - Issue 2, April 2013
Current Orthopaedic Practice E-News
Welcome Orthopaedics in Brief 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 the sunshine vitamin is related to pain and lumbar spinal stenosis. Discover the common pitfalls in syndesmotic rupture management and whether meloxicam injections relieve lower back pain. Learn whether manipulation under anesthesia is safe and effective for relieving knee stiffness after primary total knee arthroplasty, and much more.

In this month's Practice Management, find out how to retain stellar employees without having their salaries climb much higher than normal compensation for their positions. (Hint: salary ranges and pay caps are not the answer.)

In Article of the Month, please enjoy free access to an article from the current 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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Hip arthroscopy complication rate higher than reported

Results of a new study involving more than 500 hip arthroscopic surgeries indicate that complication rates may be higher than suggested by previous reports. Researchers presented their findings in March at the American Orthopaedic Society for Sports Medicine's Specialty Day in Chicago, Illinois.
     In the new study, the overall complication rate after hip arthroscopy was 7.2%, which is higher than the 1.5% rate of adverse events previously reported in the literature, said lead author Christopher Larson, MD of the Minnesota Orthopaedic Sports Medicine Institute in Minneapolis. The multicenter trial is one of the first to evaluate complication rates for all arthroscopic hip procedures. In the trial, a grading scheme was used to analyze the possibility of complications based on demographic and surgical data. Earlier reports of complications either were published before the advent of new surgical techniques, such as labral repair and treatment of femoroacetabular impingement, or the reports were not comprehensive, Dr. Larson said.
     Between January 2011 and April 2012, researchers evaluated 573 patients (287 men and 286 women at an average age of 32 years) who underwent hip arthroscopy at 1 of 3 institutions. The diagnosis, demographic information, and procedures were recorded, and a validated complications grading classification tool was used for all patients on a prospective basis.
     The most common adverse event after surgery (22.7% of hips) was postoperative sensory disturbance in the leg, which persisted beyond 6 months in only 4 hips and was considered a sequela rather than a complication. No differences were noted in rate of complications between men and women, primary and revision surgery, labral repair and debridement, or higher and lower body mass index. "We hope that our research helps to provide new insights into surgery complications and how to prevent them," Dr. Larson said.

Source: Hip Surgery Complication Rate Higher Than Previously Reported. American Orthopaedic Society for Sports Medicine, news release, March 23, 2013. http://www.sportsmed.org/uploadedFiles/Content2/Media/Press_Room/Press_Releases/Specialty_Day_2013/Larson%20hip%20arthroscopy.pdf.

What's the relationship between vitamin D deficiency, pain, and lumbar spinal stenosis?

Patients with lumbar spinal stenosis (LSS) are at high risk for falls and fractures. In a new study, researchers demonstrated that vitamin D deficiency was highly prevalent in patients with LSS (74%). In addition, severe pain in these patients was associated with a higher rate of vitamin D deficiency and osteoporosis, which could be potential risk factors for falls and fractures.
     The study involved 350 consecutive patients who visited an orthopaedic outpatient clinic for chronic low back and leg pain and were diagnosed with LSS between May and October 2012. Pain was categorized into 1 of 4 groups based on location and severity: 1) mild to moderate back or leg pain; 2) severe back pain; 3) severe leg pain; or 4) severe back and leg pain. Covariates for vitamin D deficiency included age, sex, body mass index, level of education, medical history, season, location of residence, sunlight exposure score, and functional disability. Vitamin D deficiency (serum 25-hydroxyvitamin D [25-OHD] level <20 ng/mL) was measured with radioimmunoassay. Bone metabolic status, including bone mineral density and bone turnover markers, also was measured.
     The average serum 25-OHD level was 15.9 ± 7.1 ng/mL. Of the 350 patients, 260 (74%) were vitamin D deficient. A significantly higher prevalence of vitamin D deficiency was noted in patients who: 1) had medical comorbidity; 2) lived in an urban rather than a rural setting; 3) had lower scores for sunlight exposure; and 4) had severe leg pain or severe back and leg pain rather than mild to moderate pain.      
The pain category was significantly associated with lower sunlight exposure. However, the association between pain category and vitamin D deficiency remained significant even after adjusting for sunlight exposure. Severe back pain and severe back and leg pain were associated with a higher incidence of osteoporosis and a higher level of bone resorption marker (serum CTX).      
Based on their findings, the investigators recommended assessment of serum 25-OHD and bone mineral density in patients with LSS who have severe pain. Active treatment that combines vitamin D, calcium, or bisphosphonate should be considered according to the status of the bone metabolism.

Source: Kim TH, Lee BH, Lee HM, et al. Prevalence of vitamin D deficiency in patients with lumbar spinal stenosis and its relationship with pain. Pain Physicians. 2013;16(2):165-176.

What are common pitfalls in syndesmotic rupture management?

Syndesmotic injuries occur in up to 11% of all ankle injuries. Although optimal fixation in patients with syndesmotic injuries remains controversial, pitfalls that occur during their management can lead to poor outcomes.
     Researchers conducted a retrospective study of all ankle fractures operated during a 7-year period at a level 1 trauma center. They classified all cases with syndesmotic fixation and reviewed patients' records and x-rays. The timing of definitive syndesmotic fixation; the type of fixation (screw size and number, number of cortices); and the number of unplanned, syndesmotic-related reoperations were recorded.
     During the study, 70 syndesmotic ruptures were treated surgically, and there were 19 unplanned reoperations. The 3 reasons identified for reoperation were failure to diagnose the syndesmotic injury (47%), failure to achieve an anatomic reduction (31%), and loss of reduction due to fixation failure (21%). Type of fixation was not correlated with failure rate, nor was surgeon experience or patient sex or age.
     The reoperation rate for syndesmotic fixation may be higher than previously thought, researchers concluded. To reduce setbacks in treatment, they emphasized 3 critical points when managing these injuries: suspect the injury, document the stability of the syndesmosis, and reduce the fibula anatomically.

Source: Symeonidis PD, Iselin LD, Chehade M, Stavrou P. Common pitfalls in syndesmotic rupture management: a clinical audit. Foot Ankle Int. 2013;34(3):345-350.

How safe is manipulation under anesthesia for primary TKA?

Knee stiffness after primary total knee arthroplasty (TKA) is a well-recognized problem that leads to poor outcomes and may limit patients' activities of daily living. Manipulation under anesthesia is an option to treat knee stiffness, but how safe is it, and how efficacious is it over the long term?
     Investigators conducted a systematic review of the literature and located 14 studies (913 total patients) that reported range-of-motion results after manipulation under anesthesia at 10-year follow-up. The average premanipulation range of motion was 66 degrees, and the average final range of motion was 99 degrees. Compared with preoperative range of motion, the gain in the range-of-motion arc at 1-, 5-, and 10-year follow-up was 30 degrees, 33 degrees, and 33 degrees, respectively. Complications were rare, with 2 reported periprosthetic fractures resulting in a 0.2% incidence of adverse events.
     Investigators concluded that manipulation under anesthesia to treat stiffness after primary TKA is an effective procedure that restores range of motion. Early gains in motion seem to be maintained over the long term, and in some cases, patients may gradually improve further at mid-term follow-up. The risk of periprosthetic fracture is low, making manipulation under anesthesia a safe option for improving knee range of motion.

Source: Pivec R, Issa K, Kester M, Harwin SF, Mont MA. Long-Term Outcomes of MUA for Stiffness in Primary TKA. J Knee Surg. 2013 Mar 19. [Epub ahead of print]

Assessing 3 ways to treat lateral epicondylitis

Lateral epicondylitis is a common musculoskeletal disorder that lacks an effective treatment strategy. Investigators conducted a randomized controlled trial to analyze whether a single injection of platelet-rich plasma (PRP) is more effective than placebo (saline) or glucocorticoid to reduce pain in adults with lateral epicondylitis after 3 months.
     Sixty patients with chronic lateral epicondylitis were randomized (1:1:1) to receive a blinded injection of PRP, saline, or glucocorticoid. Investigators administered the Patient-Rated Tennis Elbow Evaluation questionnaire at 3 months to evaluate change in pain. Other outcomes were ultrasonographic changes in tendon thickness and color Doppler activity.
     The primary end point of pain reduction at 3 months was observed in all 3 groups, with no statistically significant difference among the groups. However, injection of glucocorticoid had a short-term pain-reducing effect at 1 month, in contrast to the other therapies. At 3 months, glucocorticoid was more effective than PRP and saline in reducing tendon thickness and color Doppler activity.

Source: Krogh TP, Fredberg U, Stengaard-Pedersen K, et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625-635.

Does less abdominal fat increase fracture risk?

Higher body weight is associated with greater bone mineral density and lower fracture risk. New study findings affirm this association. In a prospective study, investigators found that a lower level of abdominal fat was significantly associated with a higher fracture risk in women.
     The study involved a sample of 1126 participants (360 men and 766 women) older than 50 years who had been continuously followed up for an average of 5 years. The average age of participants was 71 years (range, 57-94 years). At baseline, bone mineral density at the femoral neck and lumbar spine and abdominal fat mass were measured with dual energy x-ray absorptiometry. The incidence of low-trauma and nonpathologic fractures was ascertained prospectively from x-ray reports.
     During the follow-up period, 19 men and 107 women sustained a fracture. In women, each 1 kg of lower abdominal fat mass was associated with a 50% higher risk of fracture after adjusting for age, femoral neck bone mineral density, falls, stature, physical activity, and previous fracture. Subgroup analysis by fracture type demonstrated that the association was mainly observed in clinical vertebral fracture. In men, although there was no statistically significant association between abdominal fat mass and fracture risk, the strength of this finding is negatively impacted by the low number of fractures.

Source: Yang S, Nguyen ND, Center JR, Eisman JA, Nguyen TV. Association between abdominal obesity and fracture risk: a prospective study. J Clin Endocrinol Metab. 2013 Apr 4. [Epub ahead of print]

Evaluating meloxicam injections for lower back pain

Periradicular injections of meloxicam (10 mg) seem to be an effective alternative to opioid and nonopioid analgesics for patients with intractable lower back pain from nerve root inflammation, according to recent study results.
     In the study, 72 patients (30 men, 42 women) with lower back pain or sciatica were followed up for 90 days to 6 years after injections of 10 mg meloxicam in 10 mL saline at each of the involved dermatomal levels. Patients verbally rated their lower back pain from 0 (no pain) to 10 (severe pain) before the injection of meloxicam; at 1, 5, 10, 30, and 60 minutes; and at 1-, 5-, 15-, 30-, and 90-day intervals after the injection. The meloxicam injection was repeated only if the pain score remained higher than 3. Rescue analgesic requirements and functional activity levels also were assessed from 30 to 90 days after the last injection of meloxicam.
     Before injection with meloxicam, the average lower back pain score was 8.60, despite the use of various analgesic regimens (nonsteroidal anti-inflammatory drugs [NSAIDs], glucocorticosteroids, paracetamol, oral opioids, gabapentinoid compounds, epidural or periradicular corticosteroids, and/or local anesthetics) as well as laser treatments and physical therapy. Most patients reported a decrease in pain intensity by approximately 50%, 1 to 2 minutes after the first meloxicam injection. Thirty-six patients (50%) required no further injections, 25 patients (35%) required a second injection after 7 days, and 11 patients (15%) required a total of 3 injections. After treatment with meloxicam, 10 patients (14%) required analgesia with oral NSAIDs. All patients were able to increase their level of functional activity after meloxicam treatment.

Source: Borghi B, Aurini L, White PF, et al. Long-lasting beneficial effects of periradicular injection of meloxicam for treating chronic low back pain and sciatica. Minerva Anestesiol. 2013;79(4):370-378.

Comparing endoscopic to mini-open carpal tunnel release

The decision to perform endoscopic or mini-open carpal tunnel release technique often is made by surgeons rather than patients with idiopathic carpal tunnel syndrome. But, which technique do patients with bilateral carpal tunnel syndrome prefer? To find out, investigators surveyed preferences of patients who had undergone an endoscopic release procedure on one hand and a mini-incision release on the other.
     In the study, 52 patients had one hand randomized to undergo endoscopic release and the other to undergo mini-incision release. Each patient was assessed with the Boston Carpal Tunnel Questionnaire (BCTQ) and the Disability of Arm, Shoulder and Hand (DASH) outcome measure preoperatively and at each follow-up visit. Three months after surgery, the patients selected the technique they preferred and explained why they preferred it to the other technique.
     Average BCTQ and DASH scores improved similarly in patients who preferred the endoscopic release and those who preferred the mini-incision release. Thirty-four patients preferred endoscopic release, and 13 preferred the mini-incision open technique. Scar or pillar pain was the most commonly cited factor for disliking either technique, followed by postoperative pain for the open technique and transient worsening of symptoms for the endoscopic technique.

Source: Kang HJ, Koh IH, Lee TJ, Choi YR. Endoscopic carpal tunnel release is preferred over mini-open despite similar outcome: a randomized trial. Clin Orthop Relat Res. 2013;471(5):1548-1554.

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How to handle salary creep

Your practice has an excellent employee whose stellar performance and long tenure with the practice have translated into regular raises or bonuses--and the employee now earns higher-than-normal compensation for his or her job position. How do you handle a raise request from an employee you do not want to lose? Should you implement a salary cap to establish upper pay limits for some jobs?

Evaluate the situation
First, evaluate the wages being paid to staff members when salary creep is the issue. Often, the situation is not that bad, and it is likely that the employee is not being paid an unreasonable wage. In most cases, salary creep is a worry about what might happen in the future rather than remorse about the current wage.
     Second, recognize the value of a staff member who has been with your practice a long time. If the employee does excellent work, has a great attitude, is liked by patients and co-workers, and knows every aspect of your practice procedures, he or she is worth fairly high compensation. It is difficult to find a person with all of those qualities. Such an employee generates a great deal of revenue for your practice.
     Reconsider announcing a range of wages or a pay cap for specific positions. It would hurt morale for employees to think they can go no further in their careers. Moreover, you will want to manage each employee individually, and circumstances change. Avoid boxing yourself in with policies that are too specific.

Compare wage amounts with those in other fields
If you wonder whether an employee is being paid too much or whether giving a raise makes sense, compare the compensation with similar positions in other fields. After all, wages are based on the job market, and that is based on what other employers are paying for a specific skill set. In this case, let's assume we are evaluating a smart, likeable, dependable employee with considerable skills. Determine your employee's total compensation, with wages and bonuses averaged, and express it as an annual salary prorated for a 40-hour work week. A quick rule of thumb is to take the hourly wage, double it, and add three zeros. For example, a $26 hourly rate is about equal to $52,000 in total annual compensation.
     When you consider a career for a bright person earning a living for his or her family, you may think $52,000 per year is reasonable compensation, but most people in the United States would not think of it as extremely high. It depends on the job, of course, but on the scale of all jobs, this salary may be middle to low. This analysis helps put things in perspective and may demonstrate that the salary in question is not out of line after all.

What can you do?
As you conduct reviews for higher-earning employees in your practice, do not feel forced to give raises. You may tell an employee that he or she is doing a great job, but that a raise is not in the budget at this time. Alternatively, you may award a small raise to show that the practice likes the employee's work. Although too small a raise may be perceived as an insult by some individuals, most reasonable people know that the economy is in trouble and that jobs are scarce right now. Even a raise of 50 cents per hour would convey to an employee that his or her work is valued. It is important to realize, however, that a 50-cent raise is really not a raise at all but a cost-of-living adjustment. Your practice must find a way to increase in profitability more than the cost of living each year.
     If you think your wage and payroll costs are getting too high, it may be because your practice is not profitable enough. If you could apply your current payroll expense to a higher gross revenue number, the payroll percentage would be lower. You effectively could afford to retain and pay the best staff. It is worth exploring ways to make your practice more profitable other than by limiting employee salaries or benefits.
     That said, you might also consider a bonus program for highly paid employees instead of a conventional raise. If an employee finds a way to achieve a high-level practice goal, you may be very happy to pay more.

Annual employment reviews
Although many human resource management books recommend annual staff performance reviews, consider migrating away from reviews that are forced by the calendar. Reviews that are based on the anniversary of employment always result in the employee expecting a raise. In that scenario, when you perform the review you must either give a raise you do not want to give or you must tell the employee why he or she is not getting a raise, which can have a demoralizing effect with a change in attitude.
     Many medical practices are small enough that it is possible to know at all times who is doing well and who is just adequate. Instead of annual reviews, consider giving more frequent feedback, such as daily or weekly comments. At the same time, be proactive in awarding raises or bonuses when you see good work. You must pay well to keep good people.

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

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Please enjoy free access to the article, "Management of First-Time Dislocations of the Shoulder in Patients Older than 40 Years: The Prevalence of Iatrogenic Fracture," from the April 2013 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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