Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, read about what one group of researchers learned is the best way to treat neck pain. Discover a novel way to decrease bone destruction from cancer. Track advances in orthopaedic tissue engineering. Find out why most splinting for children is done incorrectly, whether treatment for spinal compression fractures without a brace is as effective as treatment with a brace, and more.

In this month's Practice Management learn how to see more patients per day - without working harder or putting in longer hours.

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

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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Exposed vs. buried intramedullary implants for pediatric forearm fractures

Results from a new study showed no significant differences in rates of infection, refracture, or overall adverse events based on whether intramedullary implants after operative fixation of pediatric forearm fractures were left exposed or buried beneath the skin.
     In a retrospective comparative cohort study, implants were left exposed in 128 patients (38%) and buried beneath the skin in 208 patients (61%); 3 patients had buried and exposed hardware (1%). Investigators analyzed data on demographics, injury, surgical technique, and adverse events.
     Patients in the buried-implant group were older (average, 10.3 vs. 8.5 years); heavier (average, 38.6 vs. 31.9 kg); and had fewer open injuries (23% vs. 41%) than those in the exposed-implant group. The group with buried implants had their devices removed later than those in the exposed-implant group (median, 3.5 vs. 1.2 months). There was no difference in time to removal for patients with refracture and those without (median, 1.3 vs. 2.0 months). In all, 36% of exposed implants were successfully removed in the office. Adverse events were documented in 56 patients (17%). There were 16 patients (5%) with refracture and 12 patients (4%) with infection.
     There was no significant difference between the groups with respect to rates of refracture (3% vs. 7%), infection (4% vs. 2%), or overall adverse events (15% vs. 17%). Nor was there a difference between groups with respect to loss of reduction, nondelayed or delayed union, loss of motion, hypertrophic granuloma, or tendon rupture. Buried implants were associated with penetration through the skin (4%). Injury to the dominant arm and need for open reduction were significant predictors of adverse events.

Source: Kelly BA, Miller P, Shore BJ, et al. Exposed versus buried intramedullary implants for pediatric forearm fractures: a comparison of complications. J Pediatr Orthop. 2014;34(8):749-755.

Finding the best way to treat neck pain

A multicenter study of 169 men and women with cervical radicular pain suggests that both epidural corticosteroid injections and conservative treatment with physical therapy and analgesic medication work equally well to relieve pain in the short term. Over time, however, a combination of the 2 treatments seems to offer the most relief, according to research led by pain specialists at the Johns Hopkins University School of Medicine, Baltimore, Maryland.
     For the study, investigators recruited 169 individuals older than 18 years from 8 academic, military, and Veterans Administration medical centers. All participants were diagnosed with neck pain from a herniated disc or narrowing of the spinal canal (stenosis) that inflamed or pinched nerves in the neck and caused pain that radiated to the arms. Participants were placed into 1 of 3 treatment groups: corticosteroid injections; conservative therapy consisting of physical therapy plus treatment with gabapentin and/or nortriptyline; or a combination of both.
     After 1 month, investigators documented no significant differences in outcomes between epidural corticosteroid injection and conservative treatments. Combination therapy provided better improvement than stand-alone treatment on some measures of pain.
     Three months after treatment, 57% of patients treated with combination therapy experienced meaningful relief in their arm pain and were satisfied with treatment, compared with 27% of patients in the conservative-therapy group and 37% in the group that received injections alone.
     "All of this suggests that epidural steroid injections should not be a first-line, stand-alone treatment, but they may improve outcomes when used in conjunction with a multidisciplinary treatment approach that includes physical therapy and exercise," says Steven P. Cohen, MD, professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine and the director of the Johns Hopkins Blaustein Pain Treatment Center.

Sources: Cohen SP, Hayek S, Semenov Y, et al. Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study. Anesthesiology. 2014;121(5):1045-1055. "Study Identifies Best Way to Treat Neck Pain." Johns Hopkins University news release, October 23, 2014.

Men are more likely to die after hip fracture

Investigators from the University of Adelaide, Australia, expressed concern about their new findings confirming that older men have a greater mortality risk in the first 12 months after a hip fracture. "There has been evidence that being male is an independent risk factor for early death after a hip fracture. But until we had the results of this study, we didn't realize the extent of the problem, which is particularly significant given recent improvements in hip fracture care and outcomes," said research leader Mellick Chehade, associate professor at the University's Centre for Orthopaedic and Trauma Research and an orthopaedic trauma consultant with the Royal Adelaide Hospital.
     Investigators analyzed data from 728 South Australian patients with hip fractures during a 10-year period. Findings included the following:

• Most hip fractures occurred among women (71%);
• More fractures occurred in people living independently at home (58%) rather than in those in residential care;
• Men living at home were twice as likely as women to die within the first 12 months after a hip fracture (29% vs. 14%); and
• Men living in residential care were 1.3 times more likely to die within the first 12 months after a hip fracture than women (57% vs. 43%).

"These figures serve to highlight the major impact a hip fracture can have on elderly people's overall health and quality of life," associate professor Chehade said.

Source: "Men Have Twice the Death Rate from Hip Fractures," University of Adelaide, Australia, press release, November 26, 2014.

Decreasing bone destruction from cancer

Studies in animals and humans show that a blockade of nerve growth factor (NGF) attenuates both malignant and nonmalignant skeletal pain. Investigators set out to discover other benefits that NGF blockade might confer in patients with bone cancer.
     Using a mouse graft model of bone sarcoma, investigators demonstrated that early treatment with an NGF antibody reduced tumor-induced bone destruction, delayed time to bone fracture, and increased use of the tumor-bearing limb. Early blockade of NGF also reduced weight loss in mice with bone sarcoma, a finding that is consistent with animal studies of osteoarthritis and head and neck cancer.
     In extent and duration of pain relief, NGF blockade reduced pain by 40% to 70%, depending on the metric assessed. This analgesic effect occurred even in animals with late-stage disease. Based on their findings, investigators also concluded that NGF blockade administered immediately upon detection of tumor metastasis to bone may help preserve the integrity and use of limbs, delay time to tumor-induced bone fracture, and maintain body weight.

Source: McCaffrey G, Thompson ML, Majuta L, et al. NGF blockade at early times during bone cancer development attenuates bone destruction and increases limb use. Cancer Res. 2014;74(23):7014-7023.

Most children receive improper splinting at EDs and trauma centers

More than 90% of potential pediatric fractures are splinted improperly in emergency departments and urgent care centers, according to a study by researchers at the University of Maryland School of Medicine and presented at the American Academy of Pediatrics National Conference & Exhibition in San Diego.
     "Unfortunately, many practitioners in emergency departments and urgent care settings incorrectly applied splints, potentially causing injury," said the presenting and senior author, Joshua M. Abzug, MD, assistant professor of orthopaedics at the University of Maryland School of Medicine.
     The study included 275 children up to age 18 who were treated initially in community hospital emergency departments and urgent care facilities, then later evaluated by University of Maryland pediatric orthopaedic specialists. The patients in the study had a range of fractures affecting all extremities, including fingers, arms, ankles, and knees.
     The researchers used a questionnaire to obtain information that included patient demographics, type of splint, type of initial treatment facility, practitioner type, and time from splint application to orthopaedic evaluation. Investigators evaluated each splint, took photos before removing it, and documented any soft-tissue complications that were evident. Two members of the pediatric orthopaedic team evaluated each splint for functional position, appropriate length, and presence of an elastic bandage on the skin.
     The most common reason for improper splint placement was application of an elastic bandage directly on the skin, which occurred in 77% of children. In 59% of patients, joints were immobilized incorrectly, and in 52%, the splint was not the appropriate length. As a result of improper treatment with splints, skin and soft-tissue complications were observed in 40% of patients.
     As part of a follow-up study, Abzug and colleagues are creating educational signs for placement in EDs at community hospitals and in urgent care facilities. The signs will include photos of a correctly placed splint and instructions for splint application using current guidelines.

Source: "Study: Splints Placed Improperly In 93% of Suspected Pediatric Fractures Treated In Emergency Rooms/Urgent Care Centers." Press release from the University of Maryland Medical Center, October 10, 2014.

Tracking advances in orthopaedic tissue engineering

Data to support the use of multilayer scaffolds in musculoskeletal tissue engineering are promising but limited, according to a review of current research. In the near future, the use of next-generation scaffolds in orthopaedic tissue engineering will help to decrease the invasiveness of grafting techniques used for reconstruction of bone, osteochondral defects, and tendon-to-bone interfaces.
     Investigators evaluated studies that highlight current knowledge and potential future applications of multilayer scaffolds in orthopaedic tissue engineering. They divided the studies into 3 main categories based on tissue types and interfaces that multilayer scaffolds were used to regenerate: bone, osteochondral junction, and tendon-to-bone interfaces.
     In vitro and in vivo studies suggest that it is possible to use stratified scaffolds comprising multiple layers with distinct compositions for regeneration of specific tissue types that are in the same scaffold and anatomic location. This emerging tissue-engineering approach has potential applications in regeneration of bone defects, osteochondral lesions, and tendon-to-bone interfaces. The data demonstrated successful basic research findings that encourage clinical applications.

Source: Atesok K Doral MN, Karlsson J, et al. Multilayer scaffolds in orthopaedic tissue engineering. Knee Surg Sports Traumatol Arthrosc. 2014 Dec 3. [Epub ahead of print]

Spinal compression fracture treatment: brace or no brace?

Patients who wear a brace as treatment for a spinal compression fracture have comparable outcomes in pain, function, and healing as patients who do not wear a brace, new study findings indicate.
     In their study, investigators randomly assigned 60 patients with acute single-level osteoporotic compression fractures to 1 of 3 treatment groups within 3 days of injury. The treatment groups were no brace, soft brace, or rigid brace. The primary outcome was baseline adjusted Oswestry Disability Index score at 12 weeks after compression fracture. The noninferior margin of the Oswestry Disability Index was set at an average of 10 points.
     At 12 weeks after compression fracture, the baseline adjusted Oswestry Disability Index score in the no-brace group was similar scores in the soft-brace and rigid-brace groups. The average adjusted Oswestry Disability Index score was 35.95 points in the no-brace group and 37.83 points in the soft-brace group, a difference of -1.88 points between the groups. Similarly, the average adjusted Oswestry Disability Index score was 35.95 points in the no-brace group and 33.54 points in the rigid-brace group, a difference of 2.41 points between the groups.
     During the follow-up period, no significant differences were documented among the groups in overall Oswestry Disability Index scores, visual analog scale scores for back pain, or anterior body compression ratios. Improvement in back pain and progression of anterior body compression were similar among the 3 groups.

Source: Source: Kim HJ, Yi JM, Cho HG, et al. Comparative study of the treatment outcomes of osteoporotic compression fractures without neurologic injury using a rigid brace, a soft brace, and no brace: a prospective randomized controlled non-inferiority trial. J Bone Joint Surg Am. 2014;96(23):1959-1966.

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Increasing patient flow through greater efficiency

Contrary to conventional wisdom, seeing more patients per day need not be stressful for physicians or staff members, reduce quality of care, or detract from the patient experience. Nor does increasing patient flow mean that anyone must work harder. It does mean increased profitability for the practice.
     Seeing more patients usually means more than redesigning your appointment schedule, although there are many good ways to achieve that goal. The strategy depends on your philosophy about care and how much time is required to perform an examination that meets your standards. For the most part, seeing more patients in the same amount of time involves finding ways to be more efficient.
     Before setting out to increase patient flow and improve efficiency, determine whether the practice has patients who want appointments but are not able to schedule them. If demand from patients is high, there is a clear need for a change in your routine, and making that change will be rewarding. If you do not have great demand from patients seeking an appointment, increase flow and efficiency anyway. Then, use the new free time to market the practice. Here are some key strategies to help increase flow and improve efficiency.

Go ahead and delegate
Think about what you could delegate if you had the staff and the setup to make it work. Pick some things and make it happen. To achieve higher delegation in your clinical setting, you may need more instrumentation, more specialized staff members, or a change in room layout. These sorts of changes are a smart investment.

Consider the practice's staffing needs
Often, the toughest part of implementing change is figuring out what to do first. One of the best first steps may be to hire another employee. Do not worry about increasing payroll costs; it is almost a certainty that productivity will increase and you'll bring in more new revenue than the employee costs.

Ensure multiple examination rooms per doctor
The baseline for efficiency, unless the practice is a new start-up or very small, is 2 examination rooms per working physician. More than 2 examination rooms per physician is even better. If you cannot find the space to convert, you might have to look for larger office space, but be creative. Meet with a contractor and ask whether it is possible to move a wall, add a doorway, take out a closet, or repurpose a space that does not get much use.

Use scribes
This is really another form of delegation, but having a technician record examination findings is a huge time saver. How much time could be saved if physicians did not have to record any data in the electronic record system?

Cut down on chit-chat
Is it possible that you talk too much? Many patients enjoy talking with the physician, and it is important that they understand their conditions. Yet idle chatter might not be as interesting as the physician thinks. Slightly less talk could be a good thing. Most people want to get on with their day.
     Conversely, perhaps some patients talk too much and hold up the physician unnecessarily. In that case, consider having a staff meeting on how to disengage tactfully from chatty patients.

Watch for wasted time
Be on the lookout for ways time is wasted at your practice. For instance, valuable time is being wasted when a physician must walk patients to and from the reception area. Those minutes add up.

Update the appointment schedule
As office efficiency improves, design a new appointment template that will keep the physicians and staff busy but not running behind schedule. Decide on a number of patients each physician should see per hour or day. Consider having some technicians start their work day 15 to 30 minutes before the physicians officially start their schedule. The same could happen with lunch breaks. Have staff get started so that the patient is ready when the physician starts work. Of course, then the physician cannot be late!

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, "Radial Neck Fractures in Children: Results When Open Reduction Is Indicated" from the December issue of the Journal of Pediatric Orthopaedics. 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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