Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, find out if unilateral kyphoplasty is safer and more effective than the bilateral procedure for relieving back pain caused by osteoporotic vertebral compression fractures. Discover whether a decade's worth of guidelines for treatment of metastatic bone disease has had any effect on survivorship and quality of life. Learn about a new treatment for psoriatic arthritis, how to assess when conditions are right to use bicompartmental or unicompartmental knee arthroplasty, and more.

In this month's Practice Management, learn how to extend an employment offer that pleases your candidate and suits your practice's financial health.

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

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

Sincerely,
Nanci Kulig
Editor, COP eNews
editor@c-orthopaedicpractice.com

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Unilateral vs. bilateral kyphoplasty for vertebral compression fractures

Both unilateral and bilateral kyphoplasty are effective in alleviating the back pain caused by osteoporotic vertebral compression fracture, according to results of new research. Both treatment methods are equally safe. Although kyphoplasty is typically performed via a bilateral approach, surgeons increasingly favor a unilateral approach due to concerns about long-term adverse effects. However, little evidence has been available regarding the safety of the unilateral approach.
     Investigators conducted a systematic review and meta-analysis to compare the short- and long-term safety and efficacy of unilateral and bilateral kyphoplasty. They analyzed 4 randomized controlled trials involving 158 cases.
     Investigators did not find any significant difference between unilateral and bilateral kyphoplasty in pain relief at short- or long-term follow-up. The rate of adjacent vertebral fracture was not statistically different between the 2 treatments. The rate of cement leakage was comparable, and loss of vertebral height in long-term follow-up did not differ. However, operation time and cement dosage were considerably less for unilateral than for bilateral kyphoplasty.
     Investigators recommend more research to analyze the efficacy of and adverse reactions associated with the 2 approaches.

Source: Yang LY, Wang XL, Zhou L, Fu Q. A systematic review and meta-analysis of randomized controlled trials of unilateral versus bilateral kyphoplasty for osteoporotic vertebral compression fractures. Pain Physician. 2013;16(4):277-290.

How effective are guidelines for metastatic bone disease?

Guidelines for managing patients with metastatic bone disease have been available for more than a decade, yet basic errors in care continue, according to new study findings. These errors affect patient survival and quality of life.
     In the study, investigators reviewed a series of cases that highlight common errors in managing patients with metastatic bone disease despite the availability of guidelines.
     Improvements in adjuvant and neoadjuvant treatment have increased both the number of patients living with metastatic bone disease and their length of survival. As a consequence, the incidence of adverse effects associated with metastatic bone disease that surgeons see has increased and will likely increase further.
     The British Orthopaedic Oncology Society is set to publish revised, detailed guidelines on best practices in managing patients with metastatic bone disease.

Source: Harvie P, Whitwell D. Metastatic bone disease: Have we improved after a decade of guidelines? Bone Joint Res. 2013 Jun 1;2(6):96-101.

Antibody may become new treatment for psoriatic arthritis

The fully human monoclonal antibody ustekinumab significantly improves active psoriatic arthritis compared with placebo, according to results of a randomized, placebo-controlled, phase 3 trial. Ustekinumab may offer an alternative treatment to approved biologic treatments, investigators conclude.
     Many patients with psoriasis develop psoriatic arthritis, a chronic inflammatory disease that afflicts peripheral synovial, axial, and entheseal structures. Ustekinumab is an effective treatment for moderate-to-severe plaque psoriasis.
     Between 2009 and 2011, 615 adults with active psoriatic arthritis from 104 sites in Europe, North America, and Asia-Pacific were randomly assigned to 1 of 3 treatments: placebo, 45 mg ustekinumab, or 90 mg ustekinumab. Patients took their assigned agent at week 0, week 4, and every 12 weeks thereafter. At week 16, patients with less than 5% improvement in both tender and swollen joint counts entered a masked early-escape arm. These patients were administered either ustekinumab 45 mg (patients entering from the placebo group) or 90 mg (patients entering from the 45-mg ustekinumab group).
     At week 24, all remaining patients in the placebo group were administered ustekinumab 45 mg, which they continued at week 28 and every 12 weeks thereafter. The primary endpoint was achieving American College of Rheumatology 20% improvement criteria (ACR20) or better at week 24.
     Investigators demonstrated that more patients treated with ustekinumab (42% in the 45-mg group and 50% in the 90-mg group) than those treated with placebo (23%) achieved ACR20 at week 24. Responses were maintained at week 52. By week 16, approximately 42% of patients in the ustekinumab and placebo groups had experienced adverse events.

Source: McInnes IB, Kavanaugh A, Gottlieb AB, et al. Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial. Lancet. 2013 Jun 12. [Epub ahead of print]

When are conditions right to use bi- or unicompartmental knee arthroplasty?

Bicompartmental knee arthroplasty (BKA) and unicompartmental knee arthroplasty (UKA) are possible and desirable alternatives to conventional total knee arthroplasty (TKA). BKA and UKA preserve bone stock and ligaments in patients with limited osteoarthritis (OA) and an intact anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). Findings from a new study indicate that many patients with medial or lateral compartmental osteoarthritis, with or without patellar compartment defects, have undergone TKA. The study results suggest that indications for partial arthroplasty may increase when cartilage in each compartment is evaluated along with ligaments and the status of subchondral bone.
     Investigators retrospectively analyzed preoperative magnetic resonance imaging (MRI) scans of the knee in patients who underwent knee arthroplasty. They assessed the potential for UKA or BKA as an alternative treatment. Data were analyzed from the Osteoarthritis Initiative public use data set, which included 4796 subjects between the ages of 45 and 79 years. Every year from 2004 to 2010, patients underwent MRI of their knees. Extensive quantitative measurements of the knee MRI scans were performed during follow-up visits for 87 patients who had undergone knee arthroplasty.
     Investigators assessed the cartilage thickness and defect size in the medial femorotibial joint, lateral femorotibial joint, and patellofemoral joint, as well as ligamentous injury, bone marrow edema, and subchondral cyst size.
     Eighty-five of the 87 patients (98%) underwent TKA, whereas 2 patients (2%) had UKA. On the basis of the preoperative MRI analysis, 51 of 87 patients (59%) met the criteria for TKA, including the 2 patients who underwent UKA. This rate is significantly lower than 98%, which is the proportion of patients who had TKA. Among the 85 patients who underwent TKA, 31 (37%) met the criteria for BKA, and 5 patients (6%) met the criteria for UKA.

Source: Yamabe E, Ueno T, Miyagi R, Watanabe A, Guenzi C, Yoshioka H. Study of surgical indication for knee arthroplasty by cartilage analysis in three compartments using data from Osteoarthritis Initiative (OAI). BMC Musculoskelet Disord. 2013;14:194.

Another reason not to smoke

Smoking negatively affects bone healing via delayed union, nonunion, and other adverse effects, according to a systematic review that focused on nonspinal orthopaedic studies. Investigators reviewed 9 tibial studies and 8 other orthopaedic studies that involved measures of bone healing and cigarette smoking. Of these 17 studies, results of 13 supported the conclusion that smoking negatively influences bone healing.

Source: Patel RA, Wilson RF, Patel PA, Palmer RM. The effect of smoking on bone healing: A systematic review. Bone Joint Res. 2013;2(6):102-111.

Is early use of below-elbow casting safe for children with forearm fractures?

Which is better for children with nonreduced diaphyseal both-bone forearm fractures: 6 weeks of above-elbow casting (AEC), or 3 weeks of AEC and then 3 weeks of below-elbow casting (BEC)?
     Investigators randomly assigned 47 children with forearm fractures to 1 of these 2 groups. The primary outcome was limitation of pronation and supination after 6 months. The secondary outcomes were redisplacement of the fracture, rate of adverse effects, limitation of flexion and extension of wrist and elbow, cast comfort, cosmetics, limitations in activities of daily living, and radiographic assessment.
     The average limitation of pronation and supination was 23.3 for children treated with AEC and 18.0 for children treated with AEC and BEC. All other outcomes were similar in both groups. On the basis of their findings, the investigators concluded that early conversion to BEC is safe in the treatment of nonreduced diaphyseal both-bone forearm fractures in children.

Source: Colaris JW, Reijman M, Allema JH, et al. Early conversion to below-elbow cast for non-reduced diaphyseal both-bone forearm fractures in children is safe: preliminary results of a multicentre randomised controlled trial. Arch Orthop Trauma Surg. 2013 Jul 17. [Epub ahead of print]

How does comorbidity affect recovery after hip fracture?

Investigators considered the effect of 6 chronic conditions on recovery after surgical repair for hip fracture. These conditions were stroke, congestive heart failure, diabetes, chronic obstructive pulmonary disease, arthritis, and cancer. Researchers conducted a longitudinal study involving 238 community-dwelling adults, 65 years of age or older, with unilateral hip fractures who had undergone surgical repair and inpatient rehabilitation.
     Patients were followed-up for 1 year after discharge from an inpatient rehabilitation facility. To assess functional improvement, investigators used the Functional Independence Measure (FIM) at inpatient rehabilitation facility admission and discharge and at 2, 6, and 12 months after discharge. A mixed-effect model was applied to quantify FIM functional improvement patterns among groups with and without selected preexisting chronic conditions while adjusting for potential confounding variables.
     Maximal functional improvement occurred during rehabilitation and the first 6 months after rehabilitation across all 6 chronic conditions. Compared with patients without the selected preexisting chronic conditions, those who had sustained a stroke had significantly worse self-care, transfer, and locomotion ratings. They also had less functional improvement at 1 year (adjusted average FIM score, 5.74) compared with those who had not had a stroke (adjusted average FIM score, 6.56). Significant interactions in stroke with time were seen in self-care, which suggests that patients who sustain a stroke before hip fracture have poorer functional improvement over time than those who do not.
     Patients with congestive heart failure had significantly worse transfer and locomotion ratings than patients without any of the 6 preexisting chronic conditions. The patients with congestive heart failure demonstrated a faster rate of recovery over time in locomotion than those without.
     On the basis of their findings, researchers advise that care plans should include monitoring patients for the first 6 months after discharge from inpatient rehabilitation, when a great amount of functional improvement is expected. Because patients who have had a stroke may require supervision for 12 months after rehabilitation, the discharge plan should include methods to monitor long-term care needs.

Source: Mathew RO, Hsu WH, Young Y. Effect of comorbidity on functional recovery after hip fracture in the elderly. Am J Phys Med Rehabil. 2013;92(8):686-696.

Assessing median neuropathy in malunited fractures of the distal radius

What is the prevalence of median neuropathy in patients with malunited fractures of the distal radius? What is the relationship between radiographic findings and the condition? Is corrective osteotomy without carpal tunnel release sufficient treatment?
     A new study suggests a high rate of subclinical median neuropathy in patients with malunited distal radial fractures that cannot be predicted by conventional radiographic parameters. Results also support corrective osteotomy without carpal tunnel release as sufficient treatment for median neuropathy.
     The study involved 30 patients who were referred for treatment of symptomatic distal radial malunion. The patients underwent nerve conduction studies of both wrists by a board-certified neurologist under standardized conditions. Test results were correlated with conventional radiographic parameters (radial tilt, radial inclination, palmar shift, ulnar variance, and radiolunate and capitolunate angle) and computerized tomography-based measurements of the cross-sectional area of the carpal tunnel. After corrective osteotomy without carpal tunnel release, 10 of 13 patients with unilateral preoperative median neuropathy agreed to electrodiagnostic reexamination by the same neurologist.
     Of the 30 patients, 19 (63%) had abnormal test results, but only 7 patients reported paresthesia of median-innervated fingers. There was no correlation between median neuropathy and conventional radiographic parameters.
     Unexpectedly, the cross-sectional area of the carpal canal was significantly larger in patients with median neuropathy. Symptoms resolved in all patients after corrective osteotomy. Postoperatively, 6 of 10 patients demonstrated improvement on nerve conduction studies, although only 4 patients had normal test results.

Source: Megerle K, Baumgarten A, Schmitt R, van Schoonhoven J, Prommersberger KJ. Median neuropathy in malunited fractures of the distal radius. Arch Orthop Trauma Surg. 2013 Jul 18. [Epub ahead of print]

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Extending a job offer

After advertising an available position, reviewing resumes, and interviewing applicants, you have found a suitable candidate. Now, it is time to extend a job offer. How do you decide how much money to offer? What about health care and other benefits? Here are some pointers that will help land your candidate-without giving away too much.

The starting wage
     Candidates often consider several factors before accepting a job offer, but the big one is pay. If you get the wage right, the candidate usually will accept. Deciding on the starting wage is more art than science, and experience in hiring certainly helps. To help you decide on pay, start by having all candidates complete a 2- page job application while seated in your reception room. This allows you better control over the information than a prepared resume, which could have been written by someone other than the applicant.
     Two of the questions on the application should be: "Date you can start" and "Wage desired (per hour)." The wage-desired question is key to the hiring process. Have your office manager conduct the initial interviews, and pay attention to that wage figure. If the question is left blank, have your manager ask each candidate to please name an amount, pushing for the information if necessary in a respectful way, indicating that it will be very helpful. You will almost always get a number without revealing the wage you are willing to pay.
     One reason for having the candidate state his or her desired wage is that most people will name the lowest number they can accept because they want the job offer. They know that if they aim too high, it may mean no job. The wage requested is often lower than you would have been willing to pay.

So how much?
There are several factors to consider when you decide how much money to offer initially:

• What are the applicant's job experience and skills, including aptitude with computer technology?
• Will the candidate need the normal amount of training, or much more than that?
• What was the candidate's wage history at previous jobs, and is he or she asking for much more than was earned at the most recent job?
• What are the wages currently being paid to your other employees with similar job experience and skills? Although you may have a policy that wage information should be kept confidential, realize that coworkers often share this information with each other. You should not have to defend what you pay any employee, but parity is a good question to ask yourself.
• Is the wage requested realistic for a good employee in this career? A quick way to convert hourly wages into a full-time salary is to double the hourly wage and add three zeros. For example, $16 per hour is $32,000 per year. Is $32,000 per year considered a high salary in general terms? Consider that the U.S. Government placed the 2012 poverty threshold for a family of four at $23,000.
• Overall, how much do you like the candidate? This question considers personality, appearance, communication skills, and other traits.
• Does the candidate need health insurance? You may be able to offer a much higher hourly wage if no health insurance is needed. It's also wise to consider provisions of the Affordable Care Act and know what your practice is required by law to offer in the way of health insurance.

     The points above are important to consider, but always go back to the desired wage as stated on the application, and if possible, try to offer that amount. If you offer a lower amount, you run the risk of the candidate accepting the job but continuing to look for employment elsewhere. You may see little point in paying more than the amount requested, because you are trying to keep payroll costs as low as possible. That said, you may decide occasionally to offer more when the amount requested is very low. If the desired wage is higher than you can manage comfortably, consider passing on this applicant or having a frank conversation about wages and take it from there.

Do you offer benefits?
For many candidates, employment benefits can be more important than wages. This is especially true with regard to health insurance for people with lower-wage jobs. To attract the best employees, you need excellent benefits, so look closely at what you offer in health insurance.
     Although it is expensive, try to provide an excellent program, such as 80% of premiums covered in a major PPO plan with a drug benefit. A high deductible is usually accepted well. Other benefits matter also, like a retirement plan, vacations, paid holidays, paid training programs, and more. If you put a nice package together and if your office gives a favorable impression, you will hire most of the people you want.

What are the deal breakers?
Some aspects of compensation are negotiable, and you can give more if you have a great candidate, but decide in advance on items that are deal breakers. If your office has evening and weekend hours, one of your nonnegotiable items may be that every employee must work 2 evenings per week until 7 pm and Saturdays from 9 am to 1 pm.
     Even if you find a stellar candidate, do not give away the farm. Keep in mind that most employees have faults, and you typically will find them within the first few weeks on the job.

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, "Use of Autogenous Bone Graft Compared with RhBMP in High-risk Patients: A Comparison of Fusion Rates and Time to Fusion," from the July issue of the Journal of Spinal Disorders and 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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