Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, read about current trends in repairing rotator cuffs. Learn how to manage anticoagulation in geriatric patients with hip fractures. Find out the pluses and minuses of a new drug for postmenopausal osteoporosis, discover the value of 3-dimensional color-volume images, and more.

In this month's Practice Management, discover how to make the most of computers in patient examination rooms.

In Article of the Month, please enjoy free access to an article from the current issue of Spine.

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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Tracking current trends in rotator cuff repair

In a recent study, investigators evaluated national surgical trends and hospital costs with regard to shoulder arthroscopy and rotator cuff repair (RCR). Study findings confirm a shift from open toward arthroscopic RCR and associated procedures in the outpatient setting.
     Investigators used the Florida State surgical database to analyze population-adjusted shifts in RCR technique (arthroscopic vs open) from 2000 to 2007. Investigators used the Nationwide Inpatient Sample database from 2001 from 2009 to tabulate the total number of inpatient RCRs, the inpatient hospital type (rural, urban non-teaching, or urban teaching), and the cost.
     A 163% increase in outpatient procedures in Florida was noted, with a 353% increase in arthroscopic RCRs. Although there was a decrease in open RCRs, a 2-fold increase in total RCRs was noted. Associated procedures, such as subacromial decompression, distal clavicular resection, and extensive glenohumeral debridement, increased by 440%, 589%, and 1253%, respectively.
     Nationwide data demonstrated a 59% decrease in inpatient RCRs that was similar in all hospital settings. Hospital charges associated with RCR increased by 145%, but hospital costs increased by only 85%.
     This study indicates how orthopaedic surgery practice is evolving with the implementation of arthroscopic RCR during the past decade. The increased cost partly explains the shift, but investigators call for future studies to examine and explain national trends further.

Source: Iyengar JJ, Samagh SP, Schairer W, et al. Current trends in rotator cuff repair: surgical technique, setting, and cost. Arthroscopy. 2014 Jan 24. pii: S0749-8063(13)01244-1249. [Epub ahead of print]

Managing anticoagulation in geriatric patients with hip fracture

Active management to reverse anticoagulation in geriatric patients with hip fracture may allow for earlier surgery without increasing complications, according to new research. In a retrospective chart review, investigators compared surgical outcomes in warfarin-treated geriatric patients with hip fractures with those of patients not taking warfarin.
     The study involved 1080 patients ages 60 and older admitted to a geriatric fracture center between 2006 and 2012 for surgical repair of a nonpathological, nonperiprosthetic hip fracture. Of all patients, 84 (8%) were taking warfarin at the time of admission. Patients using warfarin had a higher average Charlson Comorbidity Index score (3.8 vs 3.1). Atrial fibrillation was the most common indication for anticoagulation (83%). The average international normalized ratio (INR) before surgery was 1.7. Vitamin K, fresh-frozen plasma, or both were given to all patients taking warfarin with an admission INR of at least 2.0.
     In general, it took longer for patients taking warfarin to get to surgery than for those not taking warfarin (28.9 vs 21.7 hours). Length of hospital stay was longer for those taking warfarin than those not taking warfarin (4.8 vs 4.2 days). Neither time to surgery nor length of stay was significantly different after adjustment for baseline comorbidity.
     Investigators did not observe any significant differences between the 2 groups with regard to thromboembolic event rates, bleeding complication rates, mortality, or 30-day readmission after surgery.

Source: Gleason LJ, Mendelson DA, Kates SL, Friedman SM. Anticoagulation management in individuals with hip fracture. J Am Geriatr Soc. 2014 Jan 2.[Epub ahead of print]

Mortality after total joint replacement drops substantially

Mortality rates after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) have decreased substantially since the early 1990s, despite patients having greater presurgical comorbidity, according to a new study. Experts hypothesize that advances in postsurgical care explain the findings.
     In a Danish retrospective nationwide cohort study, investigators identified 71,812 patients who underwent THA and 40,642 patients who underwent TKA between January 1989 and December 2007. All-cause mortality and disease-specific mortality were assessed and stratified by calendar periods. Using Cox proportional hazards models, relative risk (RR) of mortality was calculated among different calendar periods and adjusted for age, sex, and comorbid diseases.
     Starting in the early 1990s, short-term survival after elective THA and TKA has greatly improved. Compared with the period between 1989 and 1991, 60-day mortality rates between 2004 and 2007 were substantially lower for patients undergoing THA (RR, 0.40) and for patients undergoing TKA (RR, 0.37). Overall, the rate of death in the 2 months after surgery decreased over time, from about 3.4% each year between 1989 and 1991 to 1.4% each year between 2003 and 2007.
     The decrease in mortality was greatest for deaths from myocardial infarction, venous thromboembolism, pneumonia, and stroke. Although patients tended to have more presurgical comorbidities over time, the duration of hospital stay was reduced by about half.

Source: Lalmohamed A, Vestergaard P, de Boer A, et al. Changes in mortality patterns following total hip or knee arthroplasty over the past two decades: a nationwide cohort study. Arthritis Rheumatol. 2014;66(2):311-318.

Evaluating long-term outcomes after cervical disc arthroplasty

Cervical disc arthroplasty (CDA) may result in better mid- to long-term functional recovery and a lower rate of subsequent surgical procedures than anterior cervical discectomy and fusion (ACDF), investigators concluded in a recent study.
     Investigators conducted a systematic review and a meta-analysis that included randomized controlled trials reporting mid- to long-term outcomes (48 months or longer) after CDA and ACDF and compared the outcomes. Five US Food and Drug Administration randomized controlled trials that reported 4 to 6 years of follow-up data were retrieved.
     Compared with patients who underwent ACDF, those who had CDA had a lower mid- to long-term rate of reoperation and greater mid- to long-term improvements in the Neck Disability Index, neck and arm pain scores, and Short Form 36 Health Survey physical component score. In addition, segmental motion was maintained in patients who underwent CDA. Mid- to long-term rates of adjacent segment disease and neurological success did not differ significantly between the 2 groups.
     Investigators determined that there were too few studies in patients with adjacent segment disease, so they recommend that future research focus on this condition.

Source: Ren C, Song Y, Xue Y, Yang X. Mid- to long-term outcomes after cervical disc arthroplasty compared with anterior discectomy and fusion: a systematic review and meta-analysis of randomized controlled trials. Eur Spine J. 2014 Feb 11. [Epub ahead of print]

How useful are 3-D color-volume images?

Three-dimensional (3-D) color volume-rendered (VR) images are said to be more time-efficient than cross-sectional computed tomographic (CT) images for diagnosis of peroneal tendon dislocation. However, how good is the diagnostic performance of this technique?
     Investigators assessed the diagnostic accuracy of 3-D color VR CT images of the ankle for peroneal tendon dislocation in 105 patients with acute calcaneal fractures (a total of 121 ankle CT studies). Peroneal tendon dislocation was diagnosed on multiplanar CT images by consensus of 2 musculoskeletal radiologists, which served as the reference standard. In each case, the radiologists classified the existence of peroneal tendon dislocation using 3 degrees of certainty (definite, probable, and possible). Diagnostic performance of 3-D images for peroneal tendon dislocation was evaluated by calculating the sensitivity, specificity, and area under the receiver-operating characteristic (ROC) curves.
     Forty-eight (40%) of 121 studies showed peroneal tendon dislocation based on readings using multiplanar reformatted images. Based on findings related to the sensitivity and specificity of images, investigators concluded that the diagnostic accuracy of 3-D images is comparable to, but not as good as, that of multiplanar rendering images for diagnosis of peroneal tendon dislocation in patients with acute calcaneal fractures.

Source: Ohashi K, Sanghvi T, El-Khoury GY, et al. Diagnostic accuracy of 3D color volume-rendered CT images for peroneal tendon dislocation in patients with acute calcaneal fractures. Acta Radiol. 2014 Feb 3. [Epub ahead of print]

Treating postmenopausal osteoporosis with odanacatib

Publicity highlighting the adverse effects of bisphosphonates may explain, in part, the decline in the market for antiosteoporosis drugs in recent years. Also, the proportion of patients who have clinical fractures and receive adequate treatment remains low. So, there are unmet needs in this field. Will the new drug odanacatib be a viable treatment for women with postmenopausal osteoporosis?
     Odanacatib is a cathepsin K inhibitor that is being developed for the treatment of postmenopausal osteoporosis. Odanacatib is a bone resorption inhibitor, but it preserves some degree of bone formation. This differentiates this new family of drugs from existing therapies. Odanacatib increases bone mineral density at the spine and hip. In finite element studies, it improves estimated bone strength at the spine and hip as well as at the distal tibia and radius.
     The drug's safety profile has been satisfactory so far. A robust antifracture efficacy was announced when the phase III pivotal trial was terminated after interim analysis, but complete results are not yet available. In short, odanacatib may have an important role in future guidelines if it provides a substantial advantage, compared with the effective and inexpensive current generic drugs, in antifracture efficacy and safety.

Source: Chapurlat RD. Treatment of postmenopausal osteoporosis with odanacatib. Expert Opin Pharmacother. 2014 Mar;15(4):559-564. Epub 2014 Jan 24.

Meniscal tear: How do symptoms compare with arthroscopic findings?

No direct correlation exists between the location of pain and the location of pathology in the knee in patients with a suspected meniscal tear, new study findings suggest.
     From a possible 856 patients referred for arthroscopy, 213 patients agreed to take part in the study, and 193 (90%) completed the study. Patients in the study indicated the area of their symptoms on a diagram showing the 4 aspects of the knee joint. Investigators grouped patients by location of symptoms: medial, lateral, posterior, or a combination of these areas.
     Pathologic findings identified at arthroscopy were recorded on the International Knee Documentation Committee (IKDC) surgical form. The location of knee pathology was categorized as medial compartment, lateral compartment, or a combination. Finally, investigators sought an association between patient-identified locations of knee pain and the location of pathologic findings during arthroscopy.
     Of the 193 patients who completed the study, 69 (36%) presented with a single location of pain, and the remaining 124 (64%) had multiple areas. Investigators did not find a significant correlation between reported locations of pain and pathologic findings.

Source: Campbell J, Harte A, Kerr DP, Murray P. The location of knee pain and pathology in patients with a presumed meniscus tear: preoperative symptoms compared to arthroscopic findings. Ir J Med Sci. 2014 Mar;183(1):23-31.

Finding best treatments for unstable thoracolumbar/lumbar burst fractures

Posterior short-segment pedicle screw fixation is a popular treatment for unstable thoracolumbar/lumbar burst fractures. However, progressive kyphosis and a high rate of hardware failure due to lack of the anterior column support remain a concern. Investigators set out to determine the value of treating patients with thoracolumbar/lumbar burst fractures by use of posterior short-segment pedicle screw fixation, along with transforaminal thoracolumbar/lumbar interbody fusion (TLIF) during the same procedure.
     A consecutive series of 20 patients with isolated thoracolumbar/lumbar burst fractures received posterior short-segment pedicle screw fixation and TLIF. All patients were followed-up for a minimum of 2 years. Investigators evaluated demographic data, neurologic status, anterior vertebral body height, segmental Cobb angle, and treatment-related complications.
     The average operative time was 167 minutes. Blood loss averaged 820 mL. All patients recovered with solid fusion of the intervertebral bone graft and without main complications, such as misplacement of the pedicle screw, nerve or vessel lesion, or hardware failure. Postoperative radiographs demonstrated a good fracture reduction that was well maintained until bone graft fusion. Neurological recovery of 1 to 3 Frankel grades was observed in 14 patients with partial neurological deficit; 3 grades of improvement was observed in 1 patient; 2 grades of improvement was observed in 6 patients; and 1 grade of improvement was documented in 6 patients. All of the 6 patients with no paraplegia at the time of admission remained intact neurologically. In one patient with Frankel D grade at admission, no improvement was observed.
     Based on their findings, investigators concluded that posterior short-segment pedicle fixation, used with TLIF, seems to be a feasible option to manage selected patients with thoracolumbar/lumbar burst fractures. This technique allows the surgeon to treat all 3 columns via a single approach with less surgical trauma and good results.

Source: Wang L, Li J, Wang H, et al. Posterior short segment pedicle screw fixation and TLIF for the treatment of unstable thoracolumbar/lumbar fracture. BMC Musculoskelet Disord. 2014 Feb 11;15(1):40. [Epub ahead of print]

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Making the most out of examination-room computers

These days, most health care practices have networked computer terminals in examination rooms. A computer monitor situated on the counter or desk near the patient chair can have a positive effect on the patient experience. There are several ways to maximize the use of this valuable tool.

View images from diagnostic testing
As imaging is a large part of orthopaedic care, sharing images with patients on a convenient monitor can go a long way in helping them better understand their condition and have a positive overall care experience at your practice. Typically, the testing that produces the image is performed by a technician at a different location. The image is saved on the office network and can be retrieved by the physician in the examination room. The doctor reviews the image with the patient and describes what the image shows and what it means.
     A large, flat-screen monitor greatly enhances the viewer experience of seeing images of his or her bones or joints. Consider a 22- or 25-inch monitor, which is now fairly inexpensive for the patient care enhancement it delivers. The monitor can be desk- or wall-mounted, as long as the patient has a good view.
     Images obtained during studies such as arthrography, bone scans, discography, computed tomography, magnetic resonance imaging, ultrasonography, and other modalities are both informative and impressive when viewed on a large scale. Many instruments and cameras produce high-resolution images that look great when enlarged. Showing the patient a video clip taken during a procedure or diagnostic test also can be valuable.
     Computer-generated videos or still diagrams for patient education also look great on a large screen. Use these tools to explain conditions to patients, but remember that a little goes a long way.

Connect to the internet
A high-speed internet connection that a provider can access in each examination room is valuable for many purposes. For one, a practice can have its own website running in the background on all monitors. A doctor can bring up the practice's website or Facebook page to show patients some interactive aspects or to use his or her own image library for education.
     Doctors also can bring up other websites of interest, such as educational demonstrations or information about products from the manufacturer. To save time, be sure to bookmark useful web sites for easy connection.

Share electronic health records
Patient records are now an impressive part of the patient experience. You may want to control how much of the record the patient sees by manipulating the format of information or swiveling the screen. That said, all patients have access to their own records, so the record should be an open book.

Advertise your practice
Because patients often sit in the examination chair and look toward the large-screen monitor, your practice can prepare an automatic slide show that displays various aspects of the practice: physician biographies, the existence of branch offices, any awards or honors the practice or care providers at the practice have received, and more. This is also a good place to advertise upcoming events such as health fairs or bone mineral density screenings.
     One warning as you enhance your examination room computer systems: be sure to remain compliant with HIPAA regulations. It's a good idea to password-protect your computers and to ensure that patient names and personal health information cannot be seen by others. An automatic screen saver with a short activation time and a password needed to refresh the screen works well.

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, "Impact of Diabetes on the Outcomes of Cervical Laminoplasty: A Prospective Cohort Study of More Than 500 Patients with Cervical Spondylotic Myelopathy" from the February issue of Spine. 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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