Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, find out if implant design influences outcomes following total knee arthroplasty. Learn how the seasons affect hip fracture recovery. Get the lowdown on a common drug for back pain. Discover how a brace might help patients with patellofemoral osteoarthritis. Find out whether surgery for acute spinal conditions is viable for patients over 80 years, whether silver-coated endoprostheses offer greater protection against infection, and more.

In this month's Practice Management, learn how to minimize the effects of any negative online reviews your practice may receive.

In Article of the Month, please enjoy free access to an article from the current issue of the Techniques in Shoulder & Elbow Surgery.

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

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

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Does implant design influence outcomes after TKA?

The type of prosthesis used during total knee arthroplasty (TKA) can affect patient outcomes, according to a new study in which patients received either Kinemax (Howmedica Corp.) or a Triathlon (Stryker Corp.) TKA.
     The double-blind study involved 212 patients (average age of 69 years, 62% females). Patients were randomly selected to receive either a Kinemax or a Triathlon TKA. Investigators assessed patients preoperatively, at 6 weeks, 6 months, 1 year, and 3 years after surgery. Outcome assessments included the Oxford Knee Score; range of motion; pain numerical rating scales; lower limb power output; timed functional assessment battery, and a satisfaction survey.
     Compared with patients who received a Kinemax TKA, those who had a Triathlon TKA had a significantly greater range of motion (P=0.009), greater lower limb power output (P=0.026) and reduced reports of 'worst daily pain' (P=0.003) during the 3 years of follow-up. Patients who received Triathlon TKA also reported significantly better satisfaction with the outcome (P=0.001) than patients who received the Kinemax.
     No significant differences between the two groups were found with regard to the Oxford Knee Score, report of 'average daily pain,'' or timed functional performance tasks.

Source: Hamilton DF, Burnett R, Patton JT, et al. Implant design influences patient outcome after total knee arthroplasty: a prospective double-blind randomised controlled trial. Bone Joint J. 2015;97-B(1):64-70.

Surgery in winter associated with impaired hip fracture healing

Patients who undergo primary osteosynthesis of a femoral neck fracture during the winter have a greater risk of conversion to hip arthroplasty later on compared with patients who have the surgery during other seasons. These new study results also suggest an association between seasonal changes in vitamin D levels and impaired healing of femoral neck fracture.
     The study involved 2779 patients, all older than 60 years, who underwent internal screw fixation for primary femoral neck fracture and were discharged in 2000. Investigators tabulated cases requiring conversion to arthroplasty during an 8-year follow-up period. Risk factors assessed included sex, age, fracture type, season of primary surgery, and surgical delay.
     During the follow-up period, investigators identified 190 conversions to hip arthroplasty (6.8%), yielding an overall incidence of 19.5 per 1000 person-years. The crude incidence rates of conversions after osteosynthesis in winter, spring, summer, and fall were 28.6, 17.8, 16.9, and 14.7 per 1000 person-years, respectively. Apart from younger age, female sex and intracapsular fracture displacement, wintertime surgery significantly increased the risk of conversion (fall vs. winter, hazard ratio (HR): 0.50; spring vs. winter, HR: 0.63; summer vs. winter, HR: 0.62).

Source: Sebestyén A, Mester S, Vokó Z, et al. Wintertime surgery increases the risk of conversion to hip arthroplasty after internal fixation of femoral neck fracture. Osteoporos Int. 2014 Dec 4. [Epub ahead of print]

Evaluating the effectiveness of a common drug for back pain

Pregabalin (Lyrica) was not more effective than an active placebo in reducing painful symptoms or functional limitations in patients with neurogenic claudication associated with lumbar spinal stenosis, according to a new study.
     In the randomized, double-blind, 2-period, crossover trial, 29 people were randomized to receive pregabalin followed by active placebo (i.e., diphenhydramine) or active placebo followed by pregabalin. Each treatment period lasted 10 days, including a 2-step titration. Periods were separated by a 10-day washout period, including a 3-day taper phase after the first period.
     Investigators used a novel approach to evaluate the effectiveness of pain treatments. Because the pain associated with the lumbar spinal stenosis is present when a person is upright or walking, investigators asked participants to report their pain levels while walking for 15 minutes on a treadmill.
     The primary outcome measure was the time to the first report of moderate pain during the treadmill test. Secondary outcome measures included pain intensity at rest, pain intensity at the end of the treadmill test, distance walked, and validated self-report measures of pain and functional limitation including the Roland-Morris Disability Questionnaire, modified Brief Pain Inventory-Short Form, Oswestry Disability Index, and Swiss Spinal Stenosis Questionnaire.
     Investigators did not find any significant difference in the levels of pain experienced by those taking the drug and those who received a placebo. Also, none of the secondary outcome measures of pain or functional limitation were significantly improved by pregabalin compared with active placebo.

Source: Markman JD, Frazer ME, Rast SA, et al. Double-blind, randomized, controlled, crossover trial of pregabalin for neurogenic claudication. Neurology. 2015;84(3):265-272.

Tracking the benefits of a brace for patellofemoral osteoarthritis

Braces used to treat patellofemoral (PF) osteoarthritis (OA) reduce the volume of bone marrow lesions in the targeted compartment of the knee and relieve knee pain, new study findings suggest.
     In a recent study, investigators assessed whether a brace relieved pain and improved structural outcomes in people with painful PF OA. In all, 126 participants (ages 40 to 70 years) were randomly allocated to wear a brace or not for 6 weeks. Participants underwent MRI of the knee at baseline and 6 weeks. Investigators measured bone marrow lesions on post-contrast fat suppressed sagittal and proton density weighted axial images.
     The primary symptom outcome was change in pain at 6 weeks during a preselected painful activity. The primary structural outcome was the change in bone marrow lesion volume.
     At the start of the study, the average visual analogue scale (0-10 cm) pain score at baseline was 6.5 cm. In all, 94 knees (75%) had PF bone marrow lesions at baseline. Participants who were assigned to wear a brace did so for an average 7.4 hours per day.
     After accounting for baseline values, participants who wore a brace had less knee pain than participants who did not wear a brace at 6 weeks (difference between groups was -1.3 cm). The participants who wore a brace also had reduced PF bone marrow lesion volume (a difference of -490.6 mm3) but not tibiofemoral volume.

Source: Callaghan MJ, Parkes MJ, Hutchinson CE, et al. A randomised trial of a brace for patellofemoral osteoarthritis targeting knee pain and bone marrow lesions. Ann Rheum Dis. 2015 Jan 16. pii: annrheumdis-2014-206376.[Epub ahead of print]

Advantages of an outside-in drilling technique in ACL reconstruction

Arthroscopic-assisted reconstruction of the anterior cruciate ligament (ACL) using the outside-in femoral tunnel drilling technique offered good functional outcome results in the short-term and satisfactory results at mid-term follow-up, according to new research.
     Anatomic positioning of the femoral and tibial tunnels in the native ACL femoral and tibial footprints requires an independent drilling either via an accessory medial portal (trans-portal drilling) or an outside-in drilling technique. Conventional trans-tibial drilling (dependent drilling) does not accurately position the femoral tunnel in the native ACL footprint. The current study evaluated functional outcomes of anatomic single-bundle ACL reconstruction using the outside-in femoral tunnel drilling technique.
     The study design was a single-surgeon, single-center prospective case series study involving 64 patients with complete ACL tears. The average follow-up period was 15.8 months. Follow-up evaluations consisted of objective and subjective International Knee Documentation Committee (IKDC) scores, Lysholm knee score, Short Form (SF)-36 score, visual analog scale (VAS)score for patient satisfaction and pain, and Kellgren and Lawrence (K/L) classification of osteoarthritis.
     Objective IKDC scores revealed that 60 patients had grade "A" and 4 had grade "B", while no single patient had grade "C" or "D". The average Lysholm Score was 92.4, average subjective IKDC was 91.5. Average SF-36 score was 96.7. The average VAS for operation satisfaction was 9.7. Average VAS for pain was 0.3. Forty-nine patients had a normal K/L classification, 7 were grade "1", 8 were grade "2". A comparison of preoperative and follow-up Objective IKDC, Subjective IKDC, Lysholm, SF-36, and VAS for pain scores revealed statistically significant differences.

Source: Abdelkafy A. Anatomic single-bundle anterior cruciate ligament reconstruction using the outside-in femoral tunnel drilling technique: a prospective study and short- to mid-term results. Arch Orthop Trauma Surg. 2015 Jan 29. [Epub ahead of print]

New "box-loop" technique helps stabilize elbows

Elbow instability remains a challenging surgical problem. One researcher has developed a method to reconstruct both the medial and lateral collateral ligaments using one graft. The technique uses a "box-loop" design, in which the donor tendon is passed through the humerus and ulna and tied back to itself, creating a loop.
     An evaluation of the technique included 14 patients with an average follow-up of 64 months. Nine patients were evaluated both clinically and radiographically. An additional 5 patients participated by phone questionnaire.
     According to the Summary Outcome Determination provided by the patients, 7 elbows were normal or nearly normal, 4 were greatly improved, 2 were improved, and 1 was worse compared with before surgery. The Summary Outcome Determination score average was 7 (range, -2 to 10). The American Shoulder and Elbow Surgeons scores (including both clinic patients and phone questionnaire patients) ranged from 36 to 100, with an average of 81. Of the 14 patients, 8 had an American Shoulder and Elbow Surgeons self-satisfaction score of 10. The average Quick Disabilities of the Arm, Shoulder, and Hand score was 13 (range, 0-64). The average Mayo Elbow Performance Index score was 88 (range, 60-100), with 4 excellent (90-100), 3 good (75-89), and 3 fair (60-74) results, and no poor results.
     Results of this study suggest that the "box-loop" technique has excellent midterm results. Compared with separate medial- and lateral-sided reconstruction, bone tunnel formation as well as graft fixation are simplified.

Source: Finkbone PR, O'Driscoll SW. Box-loop ligament reconstruction of the elbow for medial and lateral instability. J Shoulder Elbow Surg. 2015 Feb 5. pii: S1058-2746(14)00675-2. [Epub ahead of print]

Is surgery a viable option for older patients with acute spinal conditions?

As the number of geriatric Americans continues to rise, so does the percentage of patients with acute spinal conditions. New study results demonstrate significant benefits from surgical treatment for lumbar spinal stenosis with and without degenerative spondylolisthesis. Plus, surgical treatment does not carry a higher overall complication or mortality rate for patients older than 80 years when compared to patients younger than age 80.
     In the study, investigators reviewed Spine Patient Outcomes Research Trial (SPORT) data for 105 patients, ages 80 and older, and for 1130 patients younger than 80 years with lumbar stenosis alone or combined with degenerative spondylolisthesis. Patient clinical characteristics, including age, sex, ethnicity, college and work status, body mass index (BMI), smoking, comorbidities, level of back and leg pain, self-assessment of general health and treatment preference, were reviewed at baseline. Levels of pain, assessment of general health, complications, the need for revision surgery, and mortality were measured postoperatively for up to 4 years.
     Fifty-eight (55%) of the patients who were at least 80 years old had either a spinal fusion (arthrodesis) or laminectomy, as did 749 (66%) of the patients under the age of 80. At baseline, patients older than 80 years had a higher prevalence of hypertension, heart disease, osteoporosis and joint problems, but a lower BMI, and a lower prevalence of depression and smoking. Below are some other findings.

• Averaged over a 4-year follow-up period, operatively treated patients who were at least 80 years old had significantly greater improvement in all primary and secondary outcome measures compared with patients of a similar age who had nonsurgical treatment.
• Comparable rates of complications during and after surgery, reoperations, and postoperative mortality were noted in both groups.
• Patients older than 80 years had a significantly greater proportion of multi-level lumbar laminectomies compared with younger patients (60% versus 32%).
• The benefits of surgery in patients at least 80 years of age were similar to those in younger patients, except in terms of pain and physical function, which were higher in younger patients.

"This study demonstrates that surgery for the treatment of lumbar stenosis and degenerative spondylolisthesis provides significant benefits compared with nonoperative treatment in patients over the age of 80," said lead study author Jeffrey A. Rihn, MD, an orthopaedic surgeon at the Rothman Institute and Associate Professor at Thomas Jefferson University Hospital in Philadelphia, Pa. Significant improvement in function was noted after surgery, and the complication rates were comparable to those in younger patients.

Sources: Rihn JA, Hilibrand AS, Zhao W, et al. Effectiveness of surgery for lumbar stenosis and degenerative spondylolisthesis in the octogenarian population: analysis of the Spine Patient Outcomes Research Trial (SPORT) data. J Bone Joint Surg Am. 2015;97(3):177-185. "Is Surgery a Viable Treatment Option for Patients Age 80+ with Acute Spinal Conditions?" American Academy of Orthopaedic Surgeons (AAOS) news release, February 4, 2015.

Evaluating the incidence of early periprosthetic infection with silver-treated endoprostheses

Silver-coated endoprostheses were associated with a lower rate of early periprosthetic infection, investigators report. In a recent study, the Agluna®-treated (Accentus Medical, Ltd; United Kingdom) implants were particularly useful in 2-stage revisions for infection and in patients who had incidental positive cultures at the time of implantation of the prosthesis. Also, results indicated that debridement with antibiotic treatment and retention of the implant are more successful with silver-coated implants.
     Investigators reviewed 85 patients with Agluna®-treated tumor implants treated between 2006 and 2011 and matched them with 85 control patients treated between 2001 and 2011 with identical, but uncoated, tumor prostheses. In all, 106 men and 64 women with an average age of 42.2 years were included in the study.
     There were 50 primary reconstructions (29.4%); 79 one-stage revisions (46.5%) and 41 two-stage revisions for infection (24.1%). The overall post-operative infection rate of the silver-coated group was 11.8% compared with 22.4% for the control group (P = 0.033, chi-square test).
     Seven of the 10 infected prostheses in the silver-coated group were treated successfully with debridement, antibiotics, and implant retention compared with only 6 of the 19 patients (31.6%) in the control group (P = 0.048, chi-square test). Three patients in the silver-coated group (3.5%) and 13 patients in the control group (15.3%) had chronic periprosthetic infection. The overall success rates in controlling infection by two-stage revision in the silver-coated group was 85% (17/20) compared with 57.1% (12/21) in the control group.

Source: Wafa H, Grimer RJ, Reddy K, et al. Retrospective evaluation of the incidence of early periprosthetic infection with silver-treated endoprostheses in high-risk patients: case-control study. Bone Joint J. 2015;97-B(2):252-7.

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How to handle negative on-line reviews

Reviews that are published on the Internet--both positive and negative--can greatly impact the reputation of a practice. Not too long ago, if a patient had a complaint, he called the practice about it. In most cases, the issue could be resolved to everyone's satisfaction. Of course, the patients who contacted the office often had a serious complaint or were particularly outspoken. Now with the advent of the Internet and Google, Yelp, Angie's List, Yahoo, Facebook and other social media, many people write comments about all aspects of the service they receive. Those comments are posted for all to see-whether the facts presented are correct or not.
     Negative reviews often seem a bit unfair to practice owners, but there are ways to minimize their effects. Here is a short list for what to do if your practice gets a bad survey or review.

• Make sure your practice gets a lot of reviews. A bad review is only a problem when it is one of only three reviews. In this case, the bad review gets too much attention and never goes away. But if you have 50 reviews, no one notices if there are a few negative ones and even if someone notices, it makes your practice look credible. Also, because new reviews are usually posted at the top, getting a lot of reviews will push the bad one out of sight fairly quickly and make it irrelevant.
• To get a lot of reviews, consider working with an electronic communication company, such as Solutionreach, WebSystem3, Demandforce, or 4PatientCare. Use this service to email every patient after each exam, thank them for selecting your practice, and ask them to complete a survey or to write a review. Also, instruct your staff to encourage happy patients to write a review.
• If your practice gets a lot of negative reviews, solve that problem first. Carefully consider the content of the negative reviews, and make whatever changes are necessary.
• When the practice gets a bad survey or review, investigate what happened by talking to the staff involved based on the comments. You want the truth, so be understanding with employees about the situation. Show staff members the comments and get their side of the story.
• Resist feelings of anger or hurt when reading a bad review. You may feel the person is not being fair, but that reaction is not best for your practice. Accept that your office made a mistake, even if it is only in the perception that the patient had. Force yourself to see the issue from the patient's point of view.
• If you can discover who wrote the review, call the person right away. During the conversation, do not give excuses or try to change the patient's mind. Instead, thank the patient for bringing the problem to your attention. Assure the person that you take the issue seriously and that you will take steps to prevent the issue from occurring again. If it is appropriate, give the patient a refund or offer a gift card to Starbucks or another popular retailer. Finally, apologize for the problem. Apologizing may be hard to do, but it is what the patient wants and needs. Plus, it works wonders in promoting good will toward your practice.
• Consider posting a comment under a negative online review. Word your comment carefully because many people will judge your response. Write about the same topics you would mention during a phone call (see above): thank the person for the review, talk about improving the practice, and apologize. If the review was anonymous, ask the person to contact your office so you can correct the problem.

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, "Double-row Rotator Cuff Repair: The New Gold Standard," from the March issue of the 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.

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