Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, read about the unexpected findings related to one-to-one physical therapy after total knee arthroplasty. Find out the results of a comparison of 2 treatments for facet joint syndrome. Learn how successful digit replantation really is, how body mass index and exercise relate to bone mineral density in women of all ages, and more.

In this month's Practice Management, discover why it is important to read your practice's profit and loss statement regularly.

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.

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

back to top

What's the best way to reduce blood loss after TKA?

What is the best way to reduce postoperative blood loss after total knee arthroplasty? Spanish investigators assessed whether fibrin glue or tranexamic acid reduces blood loss compared with routine hemostasis.
     Investigators conducted a randomized, single-center, parallel, open clinical trial involving 172 adult patients undergoing primary total knee arthroplasty. Patients were divided into 4 groups. Group 1 received one type of fibrin glue; group 2 received Tissucol (a second type of glue made with fibrinogen and thrombin); group 3 received intravenously administered tranexamic acid; and group 4 served as the control group and received routine hemostasis.
     Investigators recorded each patient's total blood loss, as collected in drains after surgery. They also calculated hidden blood loss and recorded patients' transfusion rates, preoperative and postoperative hemoglobin levels, number of blood units transfused, adverse events, and mortality.
     The average total blood loss collected in drains was 553.9 mL for group 1, 567.8 mL for group 2, 244.1 mL for group 3, and 563.5 mL for group 4. Compared with the control group, group 3 had significantly lower total blood loss. Blood loss was not significantly lower in groups 1 and 2.
     In all, 21% of patients received a blood transfusion. Two patients required transfusion in group 3 compared with 12 patients in group 4. In the 2 fibrin glue groups, similar numbers of patients required transfusion as in the control group. There was no difference among groups with regard to the percentage of adverse events.
     Based on their findings, investigators concluded that neither type of fibrin glue is more effective than routine hemostasis in reducing postoperative bleeding and transfusion requirements. However, results from this trial support findings from previous studies, which demonstrate that intravenously administered tranexamic acid can decrease postoperative blood loss.

Source: Aguilera X, Martinez-Zapata MJ, Bosch A, et al. Efficacy and safety of fibrin glue and tranexamic Acid to prevent postoperative blood loss in total knee arthroplasty: a randomized controlled clinical trial. J Bone Joint Surg Am. 2013;95(22):2001-2007.

How BMI and exercise relate to bone mineral density in women of all ages

When it comes to osteoporosis, a higher body mass index (BMI) appears to protect postmenopausal women, new data demonstrate. Moderate physical activity is also beneficial for bone health in postmenopausal women.
     During a 2-year study, investigators prospectively analyzed 283 Asian women to evaluate the effects of BMI and physical activity levels on bone mineral density (BMD) change in premenopausal and postmenopausal women. Bilateral femoral neck BMD was measured at the time of recruitment and at the 1- and 2-year points. Investigators used generalized linear modeling to evaluate the effects of BMI and physical activity levels (measured using the International Physical Activity Questionnaires scale) on BMD during the 2-year study period.
     Among premenopausal women, lower initial femoral neck BMD scores were linked to worsened BMD. In postmenopausal women, lower BMI was linked to worsened BMD. Postmenopausal patients with moderate activity levels had a lower likelihood of worsened BMD at 2 years. High physical activity levels also were associated with a lower risk of BMD worsening.
     Investigators recommended that, for secondary prevention of osteoporosis, postmenopausal women should be encouraged to participate regularly in moderate physical activity. An acceptable amount of activity would be walking 30 minutes a day at least 5 days per week.

Source: Wee J, Sng BY, Shen L, et al. The relationship between body mass index and physical activity levels in relation to bone mineral density in premenopausal and postmenopausal women. Arch Osteoporos. 2013 Dec;8(1-2):162.

Unexpected findings about one-on-one physical therapy

What type of physical therapy is most effective after total knee arthroplasty (TKA)? No therapy method, not even one-on-one rehabilitation, is superior to another in functional and physical outcomes, new research results suggest.
     Researchers investigated whether center-based, one-on-one physical therapy provides superior outcomes compared with group-based therapy or a simple monitored home-based program with regard to functional and physical recovery and health-related quality of life. The study involved 233 patients who were followed-up for 1 year after TKA. Two weeks after surgery, a computer-generated sequence assigned participants randomly to a 6-week treatment program consisting of 12 one-on-one therapy sessions, 12 group-based therapy sessions, or a monitored home program.
     For 12 months postoperatively, self-reported outcomes (Oxford Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index pain and function subscales, and Medical Outcomes Study 12-Item Short-Form Survey) and performance-based functional outcomes were measured by a blinded assessor. The primary outcome was knee pain and function, as measured with the Oxford Knee Score at 10 weeks postoperatively.
     Compared with all other types of therapy, participants who received one-on-one therapy did not have superior Oxford Knee Scores at week 10. The median score was 32 points for the one-on-one therapy group, 36 points for the group-based therapy group, and 34 points for the monitored home program group. In addition, one-on-one therapy was not superior to other therapies with regard to improving other outcomes during the first postoperative year. No adverse events were associated with any treatment type.
     As assessed in both short- and long-term follow-up after TKA, one-on-one therapy does not provide superior self-reported or performance-based outcomes compared with group-based therapy or a monitored home program.

Source: Ko V, Naylor J, Harris I, et al. One-to-one therapy is not superior to group or home-based therapy after total knee arthroplasty: a randomized, superiority trial. J Bone Joint Surg Am. 2013;95(21):1942-1949.

Comparing two treatments for facet joint syndrome

Treatment for back pain caused by facet joint syndrome is often conservative. Interventions, including intra-articular injections and medial branch nerve blocks, can help manage facet-mediated pain. Studies that have evaluated the effectiveness of these interventions, particularly facet joint injection, have produced conflicting results. A recent study compared the effectiveness of facet joint injection versus systemic corticosteroids in patients with a diagnosis of facet joint syndrome.
     In the study, 60 patients with a diagnosis of facet joint syndrome were randomized into experimental and control groups. The experimental group received intraarticular injection of 6 lumbar facet joints with triamcinolone hexacetonide. The control group received intramuscular injection of triamcinolone acetonide at 6 lumbar paravertebral points.
     Investigators evaluated patients at baseline and at 1, 4, 12, and 24 weeks after the interventions. They assessed patients using the visual analog scale, pain visual analog scale during extension of the spine, Likert scale, improvement percentage scale, Roland-Morris functional capacity questionnaire, 36-Item Short Form Health Survey, and record of medications taken. Homogeneity was tested using the Student t, Pearson chi-squared, and Mann-Whitney tests. Investigators also analyzed differences in the groups over time and differences between groups at each evaluation.
     Both groups were similar at baseline. Comparisons between the groups demonstrated an improvement in the experimental group regarding diclofenac intake and quality of life, in the "role physical" profile, assessed by 36-Item Short Form Health Survey. In the analysis at each time point, improvement in the experimental group also was documented by use of the Roland-Morris questionnaire, in the improvement percentage scale, and in response to treatment, as assessed by the Likert scale.
     Investigators concluded that both treatments are effective, although a slight superiority of intraarticular injection of corticosteroids over intramuscular injection was noted.

Source: Ribeiro LH, Furtado RN, Konai MS, et al. Effect of facet joint injection versus systemic steroids in low back pain: a randomized controlled trial. Spine (Phila Pa 1976). 2013;38(23):1995-2002.

Help with answering, "How soon can I return to work?"

If a patient who will undergo total hip arthroplasty (THA) or total knee arthroplasty (TKA) holds a job, he or she often will ask about return to work after surgery.
     Investigators conducted a systematic search of previous studies to determine which factors are associated with work status. All clinical studies concerning patients undergoing THA or TKA that offered quantitative information on work status before and after surgery were eligible for inclusion.
     Nineteen studies published between 1986 and 2013 were selected: 4 on THA, 14 on TKA, and a single study of THA and TKA. These studies included 3872 patients who underwent THA and 649 patients who had TKA. In 1 to 12 months after THA, the proportion of patients returning to work ranged from 25% to 95%. The average time before return to work varied from 1.1 to 13.9 weeks after THA.
     In 3 to 6 months after TKA, the proportion of patients returning to work ranged from 71% to 83%. The average time before return to work varied from 8.0 to 12.0 weeks after TKA. Factors related to work status after both procedures included sociodemographic, health, and job characteristics.
     Investigators concluded that the majority of patients who are employed before THA and TKA return to work postoperatively. However, determination of the rate and speed of return to work after either procedure is hampered by large variations in patient selection and measurement methods, which underscores the need for more standardization.

Source: Tilbury C, Schaasberg W, Plevier JW, et al. Return to work after total hip and knee arthroplasty: a systematic review. Rheumatology (Oxford). 2013 Nov 23. [Epub ahead of print]

How successful is digit replantation?

Despite advances in microsurgery, digit replantation is performed less frequently in the United States than it was 15 years ago. Do previously reported replantation success rates and results reflect the current experience in the US?
     To answer that question, investigators conducted a retrospective case study to analyze 121 digit replantations that were performed from 1997 through 2010 at 2 academic level I trauma hospitals. The thumb (40 cases) was the most commonly replanted digit, followed by the long finger (31 cases). The mechanism of injury was classified as sharp in 83 digits, crush in 19 digits, and avulsion in 18 digits. The majority of replantations were performed after level III (49 cases) or level IV (56 cases) amputation.
     Sixty-nine (57%) of the digit replantation procedures were successful, a rate that was lower than previously published success rates. Radial-digit involvement and no prior tobacco use were associated with replantation success.
     Investigators write that this modest success rate reflects a need for additional evaluation of current benchmarks and clinical settings in replantation surgery. These data help to inform patients, families, and physicians considering digit replantation.

Source: Fufa D, Calfee R, Wall L, et al. Digit replantation: experience of two U.S. Academic level-I trauma centers. J Bone Joint Surg Am. 2013;95(23):2127-2134.

Evaluating four surgical approaches for elbow arthrolysis

Four surgical approaches for open elbow release all appear effective, according to a study involving 100 patients treated for elbow contracture at a single facility between 1986 and 2008. In general, results of open elbow arthrolysis are durable, but there is some postoperative deterioration of extension gained during surgery, findings suggest. Surgeons can anticipate that at the final stage, patients will have obtained an average of 86% of intra-operative arc of motion (AOM). Patients with the most severe contractures experience the greatest gains.
     In the study, the indication for surgery was loss of mobility resulting from fractures, dislocation, simultaneous fracture/dislocation, or other nontraumatic causes. All patients underwent open elbow release through one of the following approaches: lateral (42 patients); medial (44 patients); combined medial-lateral (6 patients); or posterior (8 patients). Patients were clinically evaluated at a minimum of 24 months after arthrolysis.
     The average ranges of elbow extension, flexion, and AOM had increased significantly at follow-up by 20, 16, and 36 degrees, respectively. No significant difference was demonstrated with regard to surgical approach. However, investigators observed significant deterioration of intraoperative average extension and AOM during the follow-up period, by 13 and 14 degrees, respectively. The number of patients with AOM of at least 100 degrees increased from 3 patients preoperatively to 28 postoperatively.

Source: Breborowicz M, Lubiatowski P, Dlugosz J, et al. The outcome of open elbow arthrolysis: comparison of four different approaches based on one hundred cases. Int Orthop. 2013 Dec 3. [Epub ahead of print]

UKA: Evaluating a navigation system for implant alignment

A specifically designed navigation system for unicompartmental knee arthroplasty (UKA) results in better implant alignment, new research findings suggest. Two matched-paired groups of patients underwent medial UKA by either a conventional medial UKA or a non-image-guided navigation technique designed for unicompartmental prosthesis implantation. Thirty-one patients comprised each patient group.
     At a minimum of 6 months, all patients were clinically assessed using the Knee Society Score (KSS) and the Western Ontario and McMaster Osteoarthritis Index (WOMAC). Investigators evaluated radiographs of the frontal-femoral-component angle, the frontal-tibial-component angle, the hip-knee-ankle angle, and the sagittal orientation of components (slopes). Investigators also compared complications related to implantation technique, length of hospital stay, and surgical time.
     At the latest follow-up assessment, no statistically significant differences were observed in KSS function scores or WOMAC scores between the 2 groups. Patients who had undergone conventional UKA had a statistically significant shorter average surgical time.
     Investigators observed improved alignment in the group that had undergone navigated UKA. Tibial coronal and sagittal alignments were statistically better in the navigated group, with 5 outliers in the conventional alignment technique group. The postoperative mechanical axis was statistically better aligned in the navigated group, in which there were only 2 cases of overcorrection from varus to valgus.
     No differences in length of hospital stay or complications related to implantation technique were observed between groups. Investigators concluded that more research is needed to determine whether the improved alignment associated with the navigation technique results in better clinical results in the long term.

Source: Manzotti A, Cerveri P, Pullen C, Confalonieri N. Computer-assisted unicompartmental knee arthroplasty using dedicated software versus a conventional technique. Int Orthop. 2013 Dec 5. [Epub ahead of print]

back to top

Why your P&L statement is so important

Profit and loss (P&L) statements are useful as a way to measure the growth of your practice and to ensure that expenses are in line. Your practice's P&L statement holds valuable information that can help you identify something amiss, ask the right questions, avoid financial trouble, and improve practice management. Read on to learn about the nuts and bolts of a P&L statement as well as some nuances and tips about how to use the data in a practical way.

Nuts and bolts of P&Ls
A P&L, also called an income statement, is a summary of the income and expenses associated with your practice. The P&L statement can be generated by accountants and most financial software programs, such as QuickBooks. Consider using both of these methods, because it is smart to manage your own finances, but an accountant will include more advanced information in the P&L and will help you understand it.
     The P&L features a top line, the "middle stuff," and the bottom line. The top line is the total of all the income generated by the practice. It is shown in total dollars collected for a specified period of time, often 6 months or 1 year. This dollar amount is known as gross revenue.
     In the middle is a list of expenses. This list can be very long and detailed, or it can be quite short. Practice owners should design that aspect of the P&L by selecting the expense categories they want to see. When a payment is entered in your accounting software, it receives an account code. These codes are the expense categories in the P&L. Most QuickBooks P&L statements show many expense categories, but it may be more meaningful to group them into fewer categories.
     The bottom line is the profit or loss of the practice over the period of time that the P&L covers. Also referred to as net income, it is simply the gross income minus all of the expenses. There are often subtotals inserted at various places in the P&L statement.
     It is important to remember that the P&L is a summary over a period of time. The P&L is more accurate over a long period of time, such as 1 year, because some expenses are not incurred monthly, and they may be higher in some months than others. Income and expenses are always shown in dollars, but it is also helpful to express the dollars as a percentage. Some expenses increase along with sales, so it is helpful to look at those as a percentage of income.

Special notes on P&L statements
Look over your last P&L and consider whether you want to reallocate some items that are currently not in the correct category for practice use. Once your P&L is categorized as you want to see it, show it to your accountant or business manager for future formatting.

• Gross revenue. This should be the amount you collect and deposit into the bank after insurance adjustments. This area details not only how much money came in, but where it came from: insurance reimbursements, patient fees, research funds, even miscellaneous sources such as rental income from sublet office space. If income is more or less than expected, find out why. The issue may be short-term: staff vacations (perhaps some payments weren't posted or the practice saw fewer patients than usual), a payment was late, or an insurance company switched to a new computer system. The problems may also be chronic: an insurer changed its reimbursement policy or a procedural glitch has stalled billing.
• Direct costs of professional services. This is where you tally physician salaries and other related expenditures, such as medical supplies.
• Indirect costs of professional services. These costs include payroll taxes for professional staff, malpractice insurance, general liability and workmen's compensation insurance, professional development and accreditation, and medical waste removal.
• Costs of support staff. This should include all costs of employees, including benefits, uniforms if the practice pays for these, taxes related to staff members, and so forth.
• Occupancy cost. Think of this as rent, but it also includes taxes, insurance, maintenance, utilities, and any expense related to the facility. If you own the building, you should assign a true market rent value to analyze your P&L properly. The rent is not really free even if there is no payment being made. Some doctors may charge themselves excessive rent to increase cash flow. Adjust it to be normal for your area.
• Marketing. This category includes all of the expenses related to publicizing the practice: running newspaper advertisements, updating a website, or having brochures printed. Three percent of income is a typical expense level for marketing.
• Equipment. This should include lease payments and interest on equipment loans.
• General office overhead. This category covers everything that is not covered in the expense categories already described.
• Practice net income. This bottom line is, in theory, everything that is left over after deducting the expense categories from gross revenue. Consider whether any quasi-personal expenses, such as car expense, personal travel, or items that you use personally have been included in practice expense categories. Technically, that is part of your net. If there is any retained profit in your company, that amount is also part of the net income.

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

back to top

Please enjoy free access to the article, "Arthroscopic Release of the Stiff Arthroplasty" from the December issue of 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.

back to top

If you prefer not to receive e-mail from us, please use the following link
to remove your e-mail address from our list: Removal Request
View our Privacy Policy | Copyright © 2012 | Terms of Use

You are receiving this e-mail because you have agreed to receive e-mail communications
from Lippincott, Williams and Wilkins, Inc.

Lippincott, Williams and Wilkins, Inc. | Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103 | (215) 521-8300

Please take a moment to make sure your newsletters don't get marked as spam.
Add info@mylwwjournals.com to your 'approved senders' list or address book.