Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, check out the new guidelines from the American Academy of Orthopaedic Surgeons regarding the treatment of hip fractures, anterior cruciate ligament injuries, and hip dysplasia in infants. Learn how engineered cartilage can repair articular cartilage defects. Track the changing trends in treatment of femoral neck fractures. Find out if it's possible to quantify instability before revision of a total knee replacement, whether immune activity can predict the speed of recovery after surgery, and more.

This month's Practice Management explores the benefits of adding a physician extender to your practice.

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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New AAOS practice guidelines are released

The American Academy of Orthopaedic Surgeons (AAOS) released 3 new clinical practice guidelines (CPG) with evidence-based recommendations for diagnosing and treating hip fractures in patients ages 65 and older, anterior cruciate ligament (ACL) injuries, and hip dysplasia in infants up to 6 months old.

Repairing hip fracture in geriatric patients
Many of the recommendations in the new CPG aim to reduce postoperative delirium in patients with hip fractures, according to W. Timothy Brox, MD, chair of the AAOS CPG on the Management of Hip Fractures in the Elderly Work Group. Results from multiple studies indicate that patients who experience postoperative delirium are less likely to return to preinjury levels of function, are more frequently placed in nursing homes, and have increased rates of mortality.
     The CPG include a "strong" recommendation for preoperative regional analgesia to reduce pain in patients with hip fractures, a practice that is not standard care in all settings. The hip fracture CPG also recommend:

• Surgical repair within 48 hours of hospital admission;
• Intensive physical therapy after hospital discharge;
• An osteoporosis evaluation; and
• Vitamin D and calcium supplementation.

Managing ACL injuries
With regard to ACL repair, the new CPG recommend, with "moderate" supporting evidence, that reconstructive surgery in appropriate candidates be performed within 5 months of an ACL injury to protect the knee joint. Nonsurgical treatment is appropriate for some patients, including those with less active lifestyles who do not place significant demands on the knee.
     The CPG also state that there is moderate evidence to support surgical reconstruction in active, young adult patients (age 18-35 years) with an ACL tear. The CPG support the use of autograft or allograft tissue for repairing a sprained or torn ACL. However, younger or highly active patients may not do as well with allograft tissue. Recent research indicates a higher failure rate with allograft tissue among patients younger than 25 years.
     In addition, the CPG:

• Support the use of either patellar tendon or hamstring tendons for autograft surgery, with moderate strength evidence, and
• State that good outcomes are possible with either a single- or double-bundle surgical technique.

Treating hip dysplasia in infants
Although screening for developmental dysplasia of the hip (DDH) often includes ultrasonography before the patient is 6 months old, the new CPG recommend selective ultrasonographic screening if an infant has any the following DDH risk factors: breech presentation at birth, a family history of DDH, or signs or history of hip instability. DDH can be detected by listening and feeling for "clunks" as the hip is placed in various positions. The CPG do not recommend routine ultrasonographic screening in infants younger than 6 weeks old, even for children with DDH risk factors.

Source: "American Academy of Orthopaedic Surgeons releases new guidelines on hip fractures in older adults, ACL injuries, and infant dysplasia of the hip."" American Academy of Orthopaedic Surgeons. September 9, 2014.

From nose to knee: using engineered cartilage to repair knees

Nasal septum cells can adapt to the environment of the knee joint and repair articular cartilage defects, report researchers at the University Hospital of Basel, Switzerland. The nasal cartilage cells' ability to self-renew and adapt to the joint environment is associated with the expression of Hox genes.
     In contrast to articular chondrocytes, serially cloned nasal chondrocytes could be reverted continuously from differentiated to dedifferentiated states, conserving the ability to form cartilage tissue in vitro and in vivo. Nasal chondrocytes could also be reprogrammed to perform stable expression of Hox genes typical of articular chondrocytes upon implantation into goat articular cartilage defects, directly contributing to cartilage repair.
     Researchers reported that their findings identify previously unrecognized regenerative properties of Hox-negative differentiated neuroectoderm cells in adults, which implies a role for the nasal cells in articular cartilage repair. Preliminary evidence from an ongoing phase 1 clinical trial supports the safety and feasibility of autologous nasal chondrocyte-based engineered tissues for treatment of traumatic articular cartilage lesions.

Source: Pelttari K, Pippenger B, Mumme M, et al. Adult human neural crest-derived cells for articular cartilage repair. Sci Transl Med. 2014;6(251):251ra119.

Tracking trends in the treatment of femoral neck fractures

The most substantial changes in the treatment of femoral neck fractures were observed in younger patients, according to new study results. Currently, a smaller percentage of board-certification candidates treat femoral neck fractures than in the past, which may reflect a trend toward specialty care.
     In the study, investigators used the American Board of Orthopaedic Surgery database to identify all femoral neck fractures that had been treated and reported by candidates taking part II of the licensing examination from 1999 to 2011. The data were used to document rates of internal fixation, hemiarthroplasty, and total hip arthroplasty. The longitudinal trends were then stratified by patient age (younger than 65, 65 to 79, 80 years and older) and the declared subspecialty of the candidate.
     A total of 19,541 femoral neck fractures had been treated by 4450 board-certification candidates. The use of total hip arthroplasty increased from 0.7% of fractures in 1999 to 7.7% in 2011. Use of hemiarthroplasty decreased from 67.1% in 1999 to 63.1% in 2011 (P = 0.020). Use of internal fixation declined from 32.2% in 1999 to 29.2% in 2011. An increase in total hip arthroplasty occurred in all geographic regions, with substantial variation among locations.
     During the same period, the proportion of patients younger than age 65 who were managed with total hip arthroplasty increased from 1.4% to 13.1%. Certification candidates with a declared subspecialty of "adult reconstruction" showed a strong trend toward the use of total hip arthroplasty (4.3% from 1999 to 2002, 21.1% from 2009 to 2011), whereas "trauma" subspecialty candidates demonstrated decreasing use of internal fixation (40.9% from 1999 to 2002, 32.9% from 2009 to 2011). The percentage of candidates who treated at least one femoral neck fracture decreased from 54.8% between 1999 and 2002 to 46.3% between 2009 and 2011.

Source: Miller BJ, Callaghan JJ, Cram P, et al. Changing trends in the treatment of femoral neck fractures: a review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am. 2014;96(17):e149.

Quantifying instability before revision of a total knee replacement

Instability is the reason for revision of a primary total knee replacement (TKR) in 20% of patients. The diagnosis of instability hinges on the patient's symptoms and a subjective clinical assessment. Investigators assessed whether a standardized forced leg extension measure could quantify instability.
     A total of 25 patients (11 men/14 women, average age 70 years) who were scheduled to undergo revision TKR for instability of a primary implant were assessed with a Nottingham rig preoperatively and at 6 and 26 weeks postoperatively. Output was quantified in revolutions per minute (rpm) by accelerating a stationary flywheel. A control group of 183 patients (71 men/112 women, average age 69 years) who had undergone primary TKR were evaluated for comparison.
     Before revision surgery, all 25 patients with instability exhibited a distinctive pattern of reduction in "mid-push" speed. The average reduction was 55 rpm. Postoperatively, no patient exhibited this pattern, and there was no reduction in mid-push speed. The change between preoperative and postoperative assessments was significant. No patients in the control group exhibited this pattern at any of the intervals assessed. The between-group difference was also significant. On the basis of their finding, investigators concluded that a quantitative diagnostic test to assess an unstable primary TKR could be developed.

Source: Hamilton DF, Burnett R, Patton JT, et al. The identification and quantification of instability in a primary total knee replacement prior to revision. Bone Joint J. 2014;96-B(10):1339-1343.

New criteria and a mobile app for treating pediatric elbow fractures

The American Academy of Orthopaedic Surgeons (AAOS) released new Appropriate Use Criteria (AUC) and an accompanying mobile app to aid trauma and emergency department physicians and orthopaedic residents in the treatment of pediatric supracondylar humeral fractures.
     "These are very serious injuries requiring appropriate evaluation and treatment," said James Sanders, MD, chair of the AAOS AUC for the Management of Pediatric Supracondylar Humerus Fractures Work Group. "These criteria will be helpful for clinicians who treat these injuries on an occasional basis."
     The AAOS AUC provides algorithms to assist in treatment decisions, including hypothetical scenarios and possible treatments, which are ranked for appropriateness based on the latest research and clinical expertise and experience.
     The app has 3 sections and can be accessed from any computer Web browser, tablet, or mobile device. The first section provides a list of considerations to help care providers decide whether the hospital and staff have the knowledge and capability to treat a pediatric supracondylar humeral fracture successfully. The second section lists nearly 3200 possible patient-injury scenarios. The user identifies the relevant scenario, and the third section of the app shows the related treatments, ranked according to appropriateness.

Source: American Academy of Orthopaedic Surgeons releases criteria and a mobile app for optimally treating broken elbows in children. September 9, 2014.

http://newsroom.aaos.org/media-resources/Press-releases/american-academy-of-orthopaedic-surgeons-releases-criteria-and-a-mobile-app-for-optimally-treating-broken-elbows-in-children.htm

Grip-strength ratio correlates with DASH scores

Grip strength reflects fairly well the degree to which people can use their hands. The Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure 3 is a 30-item questionnaire that reflects patients' opinions of their disability due to upper-limb disorders. It is time-consuming to complete and process. Investigators assessed whether grip strength and grip-strength ratio correlate with DASH scores and might provide an assessment short cut.
     Investigators recorded grip strength in both hands and DASH scores for 3 groups of subjects: 20 healthy volunteers, 17 patients after distal radial fractures, and 12 patients with different hand or wrist conditions. Grip-strength ratio was calculated as grip strength in the injured or nondominant hand divided by grip strength in the healthy or dominant hand.
     Grip-strength ratio was 0.97 in healthy volunteers, 0.52 in patients after distal radial fracture, and 0.74 in patients with various other hand or wrist disorders. In all groups, there were significant correlations between grip-strength ratio and DASH score as well as DASH subsections (considering only questions 1 to 21 or only questions 22 to 30). The correlations between grip-strength ratio and DASH were much stronger than the correlation between grip strength alone and DASH, which emphasizes the value of using the ratio.
     Investigators concluded that grip-strength ratio correlates well with DASH score in patients with various hand and wrist conditions. They stated that the ratio is an especially valuable tool to assess patients who speak a different language and have problems with the nondominant hand. Investigators also noted that grip-strength ratios are probably easier to monitor over time than DASH scores.

Source: Beumer A, Lindau TR. Grip strength ratio: a grip strength measurement that correlates well with DASH score in different hand/wrist conditions. BMC Musculoskelet Disord. 2014 Oct 6;15(1):336. [Epub ahead of print]

Forecasting the ease of recovery after surgery

How quickly will a patient recover after surgery? Will he or she be plagued with lingering fatigue and pain or be back to normal in no time? New research suggests that specific immune activity immediately after surgery can predict the speed of a patient's recovery.
     Investigators at the Stanford University School of Medicine (Stanford, California) have discovered that the activity level of a small set of immune cells during the first 24 hours after surgery provides strong clues as to how quickly patients will recover from surgery-induced fatigue and pain.
     To characterize the phenotypic and functional immune response to surgical trauma, single-cell mass cytometry was applied to serial whole-blood samples from 32 patients undergoing hip replacement. Simultaneous analysis of 14,000 phosphorylation events in precisely phenotyped immune cell subsets revealed uniform signaling responses among patients, demarcating a surgical immune signature. When regression analysis was performed against clinical parameters of surgical recovery, including functional impairment and pain, there were strong correlations with a specialized set of immune cells.
     These results demonstrated the capacity of mass cytometry to survey the human immune system in a relevant clinical context. The mechanistically derived immune correlates indicate diagnostic signatures and potential therapeutic targets that could be used to improve recovery after surgery.

Source: Gaudillière B, Fragiadakis GK, Bruggner RV, et al. Clinical recovery from surgery correlates with single-cell immune signatures. Sci Transl Med. 2014;6(255):255ra131.

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Consider the benefits of nonphysician clinicians

If seeing patients and managing a practice make for a tight schedule, but you do not want to hire another physician, consider adding a physician extender to your practice. In orthopaedic practices, these midlevel clinicians include physician assistants (PAs), nurse practitioners (NPs), and athletic trainers (ATs).
     Midlevel providers bring many benefits to an orthopaedic practice. Even if the salary and benefits of a midlevel provider equal the revenue he or she generates, having this staff member allows the physician to take on and perform more highly compensated work, thus increasing practice revenue. Midlevel providers can also increase patient satisfaction and quality of care.
     Practice owners should look for ways to delegate patient care so that surgeons in the practice can focus on more complex issues and conditions requiring surgical management. That said, be sure that each care provider's assigned duties adhere to his or her scope of practice, federal and state laws, and payer guidelines.

Physician assistants
Most people who apply to PA programs already have a bachelor's degree and some professional experience in health care. Their work experience, combined with a PA education, allows most PAs to integrate easily into primary care settings, where they can order tests and prescribe treatments. PAs can work in a variety of capacities within an orthopaedic practice. For instance, they can provide acute care, primary musculoskeletal care, or serve as operating room assistants.
     It is important to note that PAs are not the same as orthopaedic physician assistants or orthopaedic assistants. There are differences in scope of practice, licensure and certification, and reimbursement.

Nurse practitioners
NPs have advanced education and clinical training beyond their registered nurse preparation. NPs can specialize in orthopaedic care and opt for national certification through the Orthopaedic Nurses Certification Board to obtain the ONP-C (Orthopaedic Nurse Practitioner-Certified) designation. Orthopaedic NPs can care for patients with musculoskeletal system conditions across acute and primary care settings, including osteoporosis and arthritis.

Athletic trainers
Not to be confused with personal trainers or fitness trainers, ATs are health care professionals who collaborate with physicians to provide preventive services, emergency care, clinical diagnoses, and therapeutic intervention and rehabilitation in patients with injuries and other medical conditions. ATs can triage, obtain patient histories, perform evaluations, provide instruction on exercise prescriptions, and offer rehabilitation and general patient education.
     To become a certified AT (ATC), a student must graduate with a bachelor's or master's degree from an accredited program and pass a test administered by the Board of Certification. More than 70% of ATCs hold at least a master's degree. AT jobs have usually been related to sports. Given the increasing emphasis on prevention and an aging population, however, the demand for ATs in hospitals, health care practices, and other settings has increased.

Sources: Enhancing Your Practice's Revenue: Pearls and Pitfalls. American Academy of Orthopaedic Surgeons. 2011. American Society of Orthopaedic Assistants at http://asoa-ortho.org/sections/about-opa.php. Orthopaedic Nurses Certification Board at http://oncb.org/apn-certification/ National Athletic Trainers' Association at http://www.nata.org/athletic-training

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Please enjoy free access to the article, "Long-term Outcomes after Revision Neural Decompression and Fusion for Same-level Recurrent Lumbar Stenosis: Defining the Effectiveness of Surgery" from the October 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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