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Volume 6 - Issue 3, June 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 if knee or hip arthroplasty outcomes are affected by anesthesia technique. Discover whether operative or nonoperative treatment is better for clavicular fractures. Learn about a simple test to distinguish neck from shoulder pain, a new way to manage persistent hemorrhage in patients with unstable pelvic fractures, and more.

In this month's Practice Management, pick up pointers to help difficult talks with employees go as smoothly as possible.

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

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

Nanci Kulig
Editor, COP eNews

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Epidural trumps general anesthesia

Epidural anesthesia is associated with significantly fewer postoperative complications and lower mortality than general anesthesia in patients undergoing primary hip or knee arthroplasty, according to findings from a recent study.
     To determine whether epidural or neuraxial anesthesia produces better outcomes than general anesthesia, researchers from Weil Medical College of Cornell University, New York, evaluated data collected from about 400 hospitals between 2006 and 2010. The study included 382,236 cases. Patients who underwent primary hip or knee arthroplasty were subgrouped by the type of anesthesia they received: general (74.8%), neuraxial (11%), or combined neuraxial-general (14.2%).
     Compared with general anesthesia, neuraxial anesthesia resulted in an 80% lower 30-day mortality rate and a 30% to 50% lower risk of major adverse events, including stroke, pneumonia, kidney failure, and the need for mechanical ventilation. Neuraxial anesthesia also resulted in a 30% lower risk of prolonged length of hospital stay and lower patient costs than general anesthesia.

Source: Memtsoudis SG, Sun X, Chiu YL, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology. 2013;118(5):1046-1058.

Willow bark effective for musculoskeletal pain

A long-term clinical trial has shown the efficacy and safety of willow bark extract for analgesia in patients with musculoskeletal disorders (MSD). The study data suggest that the aqueous willow bark extract STW 33-I can be a basic treatment in long-term therapy of painful musculoskeletal disorders, and that it can be combined with nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, if necessary.
     The study involved 436 patients with pain caused primarily by osteoarthritis (56%) and with back pain (60%). The patients were treated with STW 33-I. Comedication with other NSAIDs and opioids was allowed. Researchers evaluated outcomes using extensive patient reports, including pain questionnaires and patient diaries.
     Pain intensity was measured with a visual analog scale (0-100 mm). During the study period, average reductions in pain intensity, from a baseline value of 58 mm (±23 mm) to 32 mm (±22 mm) after 24 weeks were significant, even after 3 weeks. The total reduction was 45.6% from baseline. The relative reductions in weekly averages of daily patient self-rated pain scores (6-point Likert scale) were between 33% and 44% of the baseline values during the course of the study. No relevant drug interactions were reported.

Source: Uehleke B, Müller J, Stange R, et al. Willow bark extract STW 33-I in the long-term treatment of outpatients with rheumatic pain mainly osteoarthritis or back pain. Phytomedicine. 2013 Jun 1. pii: S0944-7113(13)00132-133. [Epub ahead of print]

Clavicular fractures: is operative or nonoperative treatment better?

When it comes to clavicular fractures, operative treatment generally is better than nonoperative treatment. That said, decisions should be made in accordance with specific conditions for clinical application, according to a meta-analysis of 5 previous studies involving 633 clavicular fractures.
     The differences in nonunion (risk ratio [RR], 0.12); malunion (RR, 0.11); and neurologic complications (RR, 0.45) between operative and nonoperative treatment were statistically significant. There was no statistically significant difference between operative and nonoperative treatment in delayed union.

Source: Liu GD, Tong SL, Ou S, et al. Operative versus non-operative treatment for clavicle fracture: a meta-analysis. Int Orthop. 2013 May 5. [Epub ahead of print]

Distinguishing neck from shoulder pain

The Arm Squeeze Test may help distinguish cervical nerve root compression from shoulder disease when the diagnosis is in doubt, new study results show. The Arm Squeeze Test involves squeezing the middle third of the upper arm. A positive result to this test may indicate a cervical cause of shoulder pain.
     In the study, images obtained before the arm squeeze test confirmed diagnosis of cervical nerve root compression or shoulder disease in 1567 patients. Patient conditions were as follows: 903 with rotator cuff tear, 155 with shoulder adhesive capsulitis, 101 with acromioclavicular (AC) joint arthropathy, 55 with calcifying tendinitis, and 48 with glenohumeral arthritis. Also included in the study group were 305 patients with cervical nerve root compression from C5 to T1 and shoulder radicular pain, plus 350 healthy volunteers who served as control subjects. The Arm Squeeze Test result was positive when the score on a visual analog scale (VAS) was 3 points or higher upon squeezing the middle third of the upper arm compared with the AC joint and anterolateral-subacromial area.
     The test was positive in 96.7% of patients with cervical nerve root compression, compared with 3.87% with rotator cuff tear, 1.93% with adhesive capsulitis, no patients with AC arthropathy, 1.81% with calcifying tendinitis, and 8.33% with glenohumeral arthritis. A positive result was obtained in 4% of asymptomatic patients.
     When patients with cervical nerve root compression were compared with controls and patients with shoulder diseases, the Arm Squeeze Test had sensitivity of 0.96 and specificity ranging from 0.91 to 1.

Source: Gumina S, Carbone S, Albino P, et al. Arm Squeeze Test: a new clinical test to distinguish neck from shoulder pain. Eur Spine J. 2013 Apr 21. [Epub ahead of print]

Carpal tunnel release in diabetic and nondiabetic patients

Establishing the minimal clinically important difference on patient-reported outcome questionnaires is important to evaluate a patient's perspective of treatment effectiveness. The authors of a new study determined the minimal clinically important difference after carpal tunnel release in diabetic and nondiabetic patients using the Boston Carpal Tunnel Questionnaire. They found that compared with nondiabetic patients, diabetic patients needed a greater score improvement on functional and symptom severity scales to be considered satisfied.
     In the study, researchers prospectively evaluated 114 patients (87 nondiabetic and 27 diabetic patients) undergoing carpal tunnel release. For each patient, researchers obtained a standard history, physical examination, and preoperative electrodiagnostic studies to confirm carpal tunnel syndrome. Patients completed the Boston Carpal Tunnel Questionnaire before and at 3 and 6 months after surgery. Patients also remarked on their level of satisfaction at the final follow-up visit.
     The authors applied the receiver operating characteristic curve approach to determine the minimal clinically important difference in symptom and function severity scales on the questionnaire. The authors used patient satisfaction as the reference standard to compare against the standardized change in scores after surgery for the 2 groups.
     For both diabetic and nondiabetic patients, symptom and function severity scales showed large effect sizes (>0.8) at 3 and 6 months after surgery. At 6 months after surgery, to be satisfied, diabetic patients required a minimal clinically important difference of 1.55 for symptom and 2.05 for function scales. In comparison, nondiabetic patients required minimal clinically important differences of 1.45 and 1.6 for symptom and function scales, respectively. Overall, diabetic patients had less improvement in Boston Carpal Tunnel Questionnaire final scores compared with nondiabetic patients.

Source: Ozer K, Malay S, Toker S, Chung KC. Minimal clinically important difference of carpal tunnel release in diabetic and nondiabetic patients. Plast Reconstr Surg. 2013;131(6):1279-1285.

Evaluating preparations of glucosamine for osteoarthritis

How effective are various preparations of glucosamine to treat osteoarthritis? Researchers documented that glucosamine hydrochloride is ineffective for pain related to knee osteoarthritis. When taken for more than 6 months, glucosamine sulphate may have function-modifying effects, but it demonstrated no pain-reduction benefits.
     Results from 19 trials (3159 patients) were used in the meta-analysis. The trials demonstrated great inconsistency in pain reduction. Consistency was evaluated using the I2 index. Effect size was estimated using Cohen's standardized mean difference.
     The combined effect size in glucosamine sulphate trials was -0.22, and the I2 was 82.3%. The combined effect size in glucosamine hydrochloride trials was -0.03, with an absence of heterogeneity.
     No treatment effect size was observed favoring glucosamine sulphate in trials of less than 24 weeks' duration, and the I2 remained high (88.5%). No significant treatment effect size was observed in trials of more than 24 weeks' duration compared with placebo, with heterogeneity of zero. In function-modifying outcomes, glucosamine sulphate showed no significant effect on Lequesne index reduction compared with placebo in trials of less than 24 weeks' duration. Pooling data from studies with durations of more than 24 weeks presented a significant combined effect size of -0.36 with an absence of heterogeneity.

Source: Wu D, Huang Y, Gu Y, Fan W. Efficacies of different preparations of glucosamine for the treatment of osteoarthritis: a meta-analysis of randomised, double-blind, placebo-controlled trials. Int J Clin Pract. 2013;67(6):585-594.

A new way to treat glenohumeral joint dislocation?

The glenohumeral joint is the most frequently dislocated joint in the body. Numerous techniques for reducing acute anterior dislocation of the glenohumeral joint have been described. A new study demonstrated that Janecki's forward elevation maneuver is a simple, safe, painless, and effective reduction method.
     In the study, the forward elevation maneuver was applied to 27 patients with traumatic anterior glenohumeral joint dislocation. For each patient, the forward elevation maneuver was used to reduce the anterior glenohumeral joint dislocation. Investigators noted the type of dislocation, the effectiveness of the procedure in achieving reduction, the need for premedication, the ease of performing the reduction, and any adverse events.
     Janecki's forward elevation maneuver was successful in 25 of the 27 patients (93%) on the first attempt. Premedication was not used for 22 patients, and reduction was successful in 20 of them. The method was unsuccessful in 2 patients. Twenty-three of the patients (85%) experienced no pain or mild pain. No adverse events related to the reduction technique were observed.

Source: Guner S, Guner SI, Gormeli G, et al. A Simple, Safe and Painless Method for Acute Anterior Glenohumeral Joint Dislocations: "The Forward Elevation Maneuver." Arch Orthop Trauma Surg. 2013 May 14. [Epub ahead of print]

Managing hemodynamically unstable patients with severe pelvic fractures

Transcatheter angiographic embolization (TAE) is a safe and efficient way to treat persistent hemorrhage in patients with unstable pelvic fractures who are first managed with surgical fracture stabilization procedures, investigators report.
     In a 9-year study, 803 patients were identified with pelvic fractures; 295 of the fractures (37%) were unstable. Fifteen patients, all with unstable fractures (2%), remained hypotensive despite adequate fluid resuscitation and emergent surgical fracture stabilization. These 15 patients underwent TAE.
     The median age in the TAE group was 58 years (range, 22-82 years), and the median injury severity score was 35.8. Thirteen of the 15 patients (87%) underwent initial external fixation, and 2 patients (13%) were treated with a C-clamp before TAE.
     Radiographic success, defined as an absence of contrast extravasation as revealed by completion angiography, was observed in all 15 patients. In all, 3 patients (20%) died during hospitalization, but mortality did not relate to persistent or recurrent pelvic hemorrhage. In the remaining 12 patients, there were no early or late complications of TAE. Preperitoneal pelvic packing was performed in 2 patients, both of whom had open pelvic fractures.
     Investigators concluded that TAE is a safe and effective procedure to treat persistent hemorrhage in patients with unstable pelvic fractures who first undergo surgical fracture stabilization. No early or late bleeding recurrence was observed, and the procedure had an 80% survival rate. Preperitoneal pelvic packing can be reserved for patients with open fractures and active bleeding.

Source: Metsemakers WJ, Vanderschot P, Jennes E, et al. Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: outcomes of a single centre experience. Injury. 2013;44(7):964-968.

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How to have a "talk" with a staff member

Do you ever get an uncomfortable feeling when you need to have a talk with an employee about a problem, and you dread the entire process? Confrontation can be stressful, and sometimes it can make the situation worse. Many physicians prefer to avoid confrontation and live with the problem. Here are some tips that will make these difficult talks with employees easier.
     How you approach a meeting with a staff member depends greatly on the nature of the problem or the new concept you are proposing. The advice here is general in nature; you should always consider the individual, his or her personality, and the history surrounding the event that led to this conference. In addition, think about who should be present at the meeting. Some issues are best discussed at a full staff meeting, other matters are suitable to address in a small group, and sensitive matters require one-on-one private meetings. Be respectful of employees' dignity and do not embarrass them in front of coworkers.

Don't try to fix everything
Realize that the practice owner, physician, or office manager should not try to solve all minor complaints or employee disagreements. Sometimes, getting embroiled in a battle over who did what to whom escalates a situation into a bigger mess than it was to begin with. What often works is to let people cool off; frequently they can resolve their differences themselves. For this reason, physicians and managers should not become close personal friends with staff. Be friendly and caring, but not best pals.
     An office manager should allow employees to vent about an issue and offer some sympathy and understanding without necessarily taking action. Knowing whether to act requires judgment. Some staff grievances are justifiable and could lead to a change in office policy or additional staff training to preserve fairness to all. That said, pick your battles carefully and be willing to let some complaints go.

Start Softly
If a staff member's behavior is hurting the practice, you must address it. It could be frequent tardiness, repeated errors, lack of team work, or a poor attitude.
     Start off without making it a big deal. Find the staff member when he or she is not too busy and say you would like to talk for a minute. Go into a private office and sit down. Depending on the circumstances, try to lighten the mood. Realize that this employee is most likely worried about this private meeting and could be defensive. Smile. Begin by saying something positive about this employee's work, if possible. Employees can be extremely sensitive to criticism, so speak calmly and slowly. Don't become angry. If you display any emotion, disappointment may be more appropriate. If the staff member becomes angry, be understanding about his or her feelings but ask for calm. Reassure the employee that you want to hear his or her side.

Ask questions first
Address the reason for the meeting by describing what you have observed or the nature of the problem, and ask the employee to tell you what he or she knows about the issue. Try to remain quiet in the beginning, but ask for the employee's input. Ask how the employee feels and if there are any problems. You may want to offer an observation such as, "You don't seem to be happy on the job."
     Listening to the employee's response will help you decide where to take the discussion next. If you have relied on others for a description of a problem, be prepared for a different set of facts that might even change your mind. This is why it is best to start the discussion by asking questions; your initial impression may change.
     If you want to change or add to this employee's job duties, ask if he or she would like to accept the new task, and let the employee know how it would help the practice.

Present the issue clearly
After gathering the facts, follow your instincts about what is best for the practice. Try to be fair to all parties. Propose a compromise, ask the staff member to make a better effort, or ask him or her to be the first to make peace with a coworker.
     Be prepared to be clear in presenting the main issue you want to see changed or improved. It is best if you have facts or data to draw upon, not hearsay and conjecture, which are easily challenged. After explaining the problem, see whether the employee acknowledges his or her role in it and projects a desire to fix it. If the staff member denies the issue completely and seems not to know what you are talking about, the response does not bode well for resolution. In those cases, make your point and watch the situation closely. It is likely that another meeting will be needed.

Protect confidentiality
Be considerate of your other employees when you share a problem that they will perceive as having been communicated by a coworker. If possible, try to observe the issue yourself so you can present it as something you saw or heard.

The domino effect
Be aware that changes you implement in office procedure often have a domino effect. One change aimed at solving a problem can cause many other problems you may not have anticipated. Aim for prevention by thinking about all aspects of the practice and patients. Consider staff input.
     Lastly, think of managing your practice as similar to steering a ship. You can't turn it on a dime. Most changes must be made in small increments and adjustments.

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, "Soft Tissue Reconstruction: Free Tissue Transfer in Dysvascular and Diabetic Patients," from the June 2013 issue of Techniques in Foot and 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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