Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, discover how injected corticosteroids are linked to joint deterioration. Read about a new surgical technique that makes Achilles tendon repair stronger and safer. Find out whether meniscal surgery increases the risk of osteoarthritis and cartilage loss, if a specific type of rehabilitation improves functional ability after lumbar surgery, how surgical treatment for acetabular fracture impacts mortality among elderly patients, and more.

In this month's Practice Management, discover how to create Disney customer service magic at your practice.

In Article of the Month, please enjoy free access to an article from the April 1st 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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Joint deterioration linked to corticosteroid injections

Corticosteroids may be cytotoxic to mesenchymal stem cells (MSCs), the direct progenitors of chondrocytes and other musculoskeletal tissue, according to new research. The result is that, in exchange for temporary analgesia, injected corticosteroids may hinder MSCs' regenerative capacity.
     In the study, human MSCs were isolated and cultured from periarticular adipose tissue obtained from 20 patients undergoing primary total hip arthroplasty (THA). For 60 minutes, MSCs were exposed to one of four commonly used corticosteroid preparations: betamethasone sodium phosphate-betamethasone acetate (6 mg/mL), dexamethasone sodium phosphate (4 mg/mL), methylprednisolone (40 mg/mL), or triamcinolone acetonide (40 mg/mL). Among the four preparations (treatment groups), cells were exposed to increasing concentrations then were allowed to recover in standard culture media for 24 hours. After the recovery period, cell viability was measured using MTS assay quantified in units of optical density.
     The researchers found that exposure to corticosteroids significantly decreased MSC viability in a dose-response pattern; average optical density measured by MTS assay decreased in all groups with increasing steroid concentration. However, there were large differences among preparations, and these differences remained at every concentration level. In general, dexamethasone was found to be most gentle on MSCs. The investigators concluded that choosing dexamethasone may produce less harmful effects than other injectable steroids.

Source: Wyles CC, Houdek MT, Wyles SP, et al. Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clin Orthop Relat Res. 2015 Mar;473(3):1155-1164.

Meniscal surgery increases risk of OA and cartilage loss

Surgery to repair meniscal tears may increase the risk of osteoarthritis and cartilage loss in some patients, according to research presented at the annual meeting of the Radiological Society of North America (RSNA) in Chicago, Illinois. The findings indicate that the decision for surgery requires careful consideration to avoid accelerated disease onset, researchers said.
     In the study, investigators examined data from the Osteoarthritis Initiative, a large, ongoing observational study of knee osteoarthritis incidence and progression. Patients in the study were on average 60.2 years old and predominantly overweight, with an average body mass index (BMI) of 28.3. About two-thirds of the patients were women.
     Investigators studied MRI scans of 355 knees that developed osteoarthritis during a 5-year period, and a control group that was matched for age, sex, arthritic severity in both knees and BMI. Knees with no meniscal damage were also part of the analysis. Of all knees, 31 had meniscal surgery during the year before the arthritis diagnosis, and 280 knees had signs of meniscal damage on MRI but did not have surgery. Investigators assessed the risk of developing arthritis and cartilage loss during the subsequent year for all groups.
     Patients without knee osteoarthritis who had meniscal surgery had a greatly increased risk of developing osteoarthritis and cartilage loss in the year after surgery compared with patients who did not have surgery, regardless of the presence or absence of a meniscal tear in the year before, investigators report.
     All 31 knees that had meniscal surgery during the prior year developed osteoarthritis, compared with 165 (59%) of the knees with meniscal damage that didn't have surgery. In addition, cartilage loss was much more common in knees that had surgery: 81% of knees with surgery showed cartilage loss compared with 40% of knees with meniscal damage and no surgery.
     "Indications for meniscal surgery might need to be discussed more carefully in order to avoid accelerated knee joint degeneration," said investigator Frank W. Roemer, MD, from Boston University School of Medicine the University of Erlangen-Nuremberg in Germany. Alternatives to surgery, such as physical therapy, use of ice, and nonsteroidal antiinflammatory medications, might be acceptable.

Source: Common Knee Surgery May Lead to Arthritis and Cartilage Loss. Radiological Society of North America (RSNA), news release, December 3, 2014.

A new technique to repair Achilles tendons is stronger, safer

A new surgical technique for Achilles tendon repair could potentially become the new gold standard, according to its creator, Timothy Miller, MD, assistant professor of clinical orthopaedic surgery and sports medicine at The Ohio State University Wexner Medical Center, Columbus, Ohio.
     Traditional Achilles tendon repair of knotting sutures together at the tear site can interfere with healing. Miller's new method is a "suture loop technique" that uses a modified giftbox suture configuration. It strengthens the repair by moving the knots away from the injury site, hence decreasing the risk of retearing the tendon when activity resumes. "We found that this suture technique is stronger than having just two, simple sutures going across the tear site, with knots near the tear site," Miller said. "Now, we have a total of six strands of suture across the tendon, with no knots that could potentially interfere with healing. So it's stronger and decreases the risk of re-tear."
     This technique also allows for quicker recovery. With the traditional technique, a return to full activity could take as long as 9 months. The new technique reduces that time to 6 months.

Sources: Miller TL, Harwood JL. Harrison RK, Nerone VS. Achilles tendon repair using nonabsorbable suture loop for modified giftbox technique. Tech Orthop. 2015;30(1):33-38. New Surgical Technique Helps Make Achilles Tendon Repairs Stronger, Safer. The Ohio State University Wexner Medical Center, news release, March 2, 2015.

Identifying which patients will have continued pain after surgery

In determining which patients will have long-lasting pain after shoulder surgery, cognitive coping style and genetic predisposition to pain sensitivity may be greater factors than the scope or intensity of the procedure, according to new findings from a University of Florida Health study. The findings could help develop better methods to manage patients' pain.
     Among a group of patients who had shoulder surgery, those who had both a high pain sensitivity variant in a specific gene as well as worrying thoughts about pain on a questionnaire were twice as likely to have pain 1 year after surgery, investigators report.
     The article by the University of Florida team, which also included a psychologist, statistician, geneticist, exercise scientist, and surgeons, describes two studies. The first study was designed to help investigators understand the genetic and psychological factors that may best predict pain intensity and duration. Nearly 200 healthy participants developed a minor shoulder injury through targeted exercises and had their pain levels measured daily until pain resolved.
     In the second study, researchers tested 150 patients undergoing shoulder surgery. Participants responded to two questionnaires that assessed their attitudes and beliefs about pain. One measured fear of various painful situations, ranging from a paper cut to slamming a hand in a car door. A second questionnaire assessed pain catastrophizing, which is characterized by beliefs that pain will worsen or nothing can be done to stop it.
     Participants also were tested for genes linked to pain sensitivity and inflammation. One week prior to surgery and 3, 6, and 12 months after surgery, researchers assessed participants' pain using a measure of pain intensity that asks respondents to rate their pain on a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable.
     Researchers found that patients who had both a high pain sensitivity variant of the COMT gene and high levels of pain catastrophizing had a greater than 40% risk of continued pain 1 year after surgery, compared with less than 20% among patients without those factors.
     The ability to tailor analgesia treatments is a long-term goal of the research and is the topic of a study investigators are planning to launch in late 2015. In it, investigators will evaluate whether a medication that targets genes linked to pain sensitivity and inflammation, in combination with behavioral strategies to address pain beliefs, results in better pain management for high-risk participants with a minor shoulder injury.

Sources: George SZ, Wallace MR, Wu SS, et al. Biopsychosocial influence on shoulder pain: risk subgroups translated across preclinical and clinical prospective cohorts. Pain. 2015;156(1):148-156. UF Researchers Identify Which Patients Are At Risk for Continued Pain after Orthopedic Surgery. University of Florida Health, new release, March 16, 2015.

ACL surgery improves health and function for 6 years

Most patients who had surgery to repair and rebuild an anterior cruciate ligament (ACL) tear demonstrated significant improvement in physical function at 2 years, which continued for at least 6 years after surgery, new research suggests. Patients who were most likely to have a lasting, positive outcome were younger, had a lower body mass index (BMI), and had the remnants of the torn ACL completely excised during surgery.
     In the study, investigators analyzed the outcomes of 1,411 patients (44% female; average patient age at enrollment, 23 years) who had ACL surgery at one of four major medical centers. Questionnaires to assess health, well-being, and function were completed by each patient before surgery and at 2 and 6 years after surgery.
     The average physical health score was 41.9 and the average mental health score was 51.7 at baseline. At 2 years after surgery, the physical and mental health scores were stable at 53.6 and 52 points, respectively, and 54 and 52.4 at year 6. There were several other findings from the study.

• ACL reconstruction resulted in large improvements in physical function scores, with an average improvement of 12 points (out of 100) at 2 years and 6 years after surgery.
• At 6 years after ACL surgery, patients gained an average of 5.3 quality-adjusted life years (QALYs). One QALY represents 1 year of perfect health; .5 QALY, 6 months.
• Baseline activity level was a significant predictor of mental health scores but not physical function scores.
• Predictors of worse postoperative outcomes were a shorter follow-up time after surgery, revision ACL reconstruction, smoking at baseline, fewer years of education, and damage to the cartilage under the patella.
• Physical function continued to improve over the long term after reconstruction. Patients who required a revision reconstruction did not fare as well as patients who had a single reconstruction.
• Mental health scores over the 6-year period did not significantly change, but scores consistently remained above the population norm of 50 points.

Sources: Dunn WR, Wolf BR, Harrell FE Jr, et al. Baseline predictors of health-related quality of life after anterior cruciate ligament reconstruction: a longitudinal analysis of a multicenter cohort at two and six years. J Bone Joint Surg Am. 2015;97(7):551-557. ACL surgery May Significantly Improve Physical Health and Function for At Least Six Years In Younger Patients. American Academy of Orthopaedic Surgeons, news release, April 7, 2015.

Evaluating "a to p" screw for posterior malleolar fixation in trimalleolar ankle fractures

Patients with trimalleolar ankle fractures in whom the posterior malleolus was treated with posterolateral buttress plating had superior clinical outcomes compared with those treated with anterior to posterior (AP) lag screws.
     In a recent study, 16 patients had posterior buttress plating, and 11 underwent AP screw fixation, with average follow-up times of 54.9 months and 32 months, respectively. Demographic data were similar in both treatment groups. Short Musculoskeletal Function Assessment (SMFA) scores were the main outcome measurements. Investigators also evaluated immediate postoperative radiographs for residual gap/step-off and long-term, follow-up radiographs for the degree of arthritis.
     The posterolateral plating group demonstrated superior postoperative SMFA scores compared with the AP screw group with statistically significant differences in the SMFA bother index (26.7 vs. 9.2, P = 0.03) and trends toward improvement in the mobility (28.3 vs. 12.9, P = 0.08) and functional indices (20.2 vs. 9.4, P = 0.08). There were no significant differences in range of motion or the development of ankle arthritis over time.

Source: O'Connor TJ, Mueller B, Ly TV, et al. "A to p" screw versus posterolateral plate for posterior malleolus fixation in trimalleolar ankle fractures. J Orthop Trauma. 2015;29(4):e151-156.

Does surgical treatment for acetabular fracture reduce mortality among elderly patients?

Controversy exists regarding the effect of operative treatment on mortality after acetabular fracture in elderly patients. Findings from a new study that evaluated the effect on mortality of four possible treatments for acetabular fracture demonstrate that operative treatment does not increase or decrease mortality when comorbidities are taken into account.
     The study involved 454 patients (average age 74 years; 67% male) with acetabular fracture. The patients received one of 4 treatments: nonoperative management with early mobilization, percutaneous reduction and fixation, open reduction and internal fixation, or acute total hip arthroplasty. Investigators created Kaplan-Meier survival curves and used Cox proportional hazards models to calculate unadjusted and adjusted hazard ratios (HRs) for covariates of interest.
     In contrast to findings from previous, smaller studies, overall mortality was relatively low at 16% at 1 year. Unadjusted survivorship curves suggested higher 1-year mortality rates for nonoperatively treated patients (21% vs. 13%, P < 0.001); however, nonoperative treatment was associated with other risk factors for higher mortality. When accounting for these patient risk factors, the final multivariate model of survival demonstrated no significant difference in hazard of death for nonoperative treatment (0.92, P = 0.6) nor for any of the three operative treatment subgroups (P range, 0.4-0.8).
     Investigators discovered a significantly increased hazard for factors such as the Charlson comorbidity index [HR, 1.25 per point (95% CI, 1.16-1.34)] and age [HR, 1.08 per year of age more than 70 years (95% CI, 1.05-1.11)]. Also, associated fracture patterns (compared with elementary patterns) significantly increased the hazard of death with a ratio of 1.51 (95% CI, 1.10-2.06).
     The reasons for these findings are unknown. Investigators conclude that regardless of the causes the decision for operative versus nonoperative treatment of geriatric acetabular fractures should not be based on the concern for increased or decreased mortality alone.

Source: Gary JL, Paryavi E, Gibbons SD, et al. Effect of surgical treatment on mortality after acetabular fracture in the elderly: a multicenter study of 454 patients. J Orthop Trauma. 2015;29(4):202-208.

Improving functional ability after lumbar disc surgery

Lumbar open laser microdiscectomy is regarded as an effective and safe intervention for lumbar disc prolapse. However, early postoperative disability that affects daily activity is a risk for patients. A pilot study indicates that a type of individualized, manipulative rehabilitation begun soon after surgery may be a valuable treatment option after spinal surgery.
     The pilot study involved 21 patients, between the ages of 25 to 69 years, who had lumbar microdiscectomy at a major metropolitan spine surgery hospital. Investigators randomly assigned patients to receive either manipulative rehabilitation or standard care. Rehabilitation started 2 to 3 weeks after surgery. Patients had a 30-minute rehabilitation session twice a week for 4 weeks.
     Primary outcomes were the Roland-Morris disability questionnaire and the visual analogue pain scale. Investigators assessed outcome measures at baseline and after intervention.
     In the group who received early individualized manipulative rehabilitation, early post-operative physical disability was reduced by 55%, compared with a 5% decrease for those who received standard care. Likewise, early postoperative residual leg pain decreased with rehabilitation (55%) and standard care (9%).

Source: Kim BJ, Ahn J, Cho H, et al. Early individualised manipulative rehabilitation following lumbar open laser microdiscectomy improves early post-operative functional disability: A randomized, controlled pilot study. J Back Musculoskelet Rehabil. 2015 Mar 19. [Epub ahead of print]

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Bring some Disney magic to your practice

"Have a magical day!" Most people who have visited Disney World in Orlando, Florida have heard this from a Disney staff member-or even during an automated wake-up call. And, most people who have visited Disney World have experienced the magic of Disney customer service. Disney staff occasionally offer visiting conference attendees a "Business behind the Magic" tour, produced by the Disney Institute. One pearl of wisdom dispensed during this tour is that Disney leaders do not micromanage, they "over manage." This concept correlates well with achieving a great patient experience in an orthopaedic practice.

What is Disney over management?
"Over managing," as described by the staff at Disney, differs from micromanaging because it is intentional and the intent is positive. Here is what Disney means by the over manage concept:

• Think about your challenge or goal differently and to a greater degree.
• Pay extraordinary attention to the details.
• View what is "typical" or "corporate best practices" as a baseline as opposed to an acceptable standard.

How to "over manage" your practice
Done correctly, over management creates consistently pleasant experiences for patients, which results in greater patient satisfaction and word-of-mouth referrals.
     Begin by listing each interaction that occurs between your office and the patient during a typical visit and then discuss each of those points with your staff. Disney calls these interactions "moments of truth." Brainstorm ways to make each event more pleasant for the patient.
     Here is a quick list of moments of truth to consider and improve upon:

• the patient's initial phone call to ask about services and fees or to schedule an appointment;
• planning for insurance benefits to be used;
• confirming the appointment;
• greeting the patient upon arrival;
• the waiting experience;
• calling the patient to the examination room;
• taking a case history;
• introducing the patient to the doctor;
• recording data in the electronic health record system;
• performing the examination;
• explaining the patient education and treatment plan;
• arranging for additional medical testing or care; and,
• continuing communication with patients, including asking them to complete a satisfaction survey.

If you refine these points and invest in them with money and through staff education, your practice will become more successful. Aim to exceed the patient's expectations the way Disney does with their guests.

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, "Reducing Surgical Site Infection in Spinal Surgery with Betadine Irrigation and Intrawound Vancomycin Powder," from the April 1st 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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