Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, discover if shock wave therapy is an effective treatment for chronic plantar fasciitis. Read how old bones can regain youthful healing. Find out whether oral steroids are any better than placebo for treating sciatica, how 3-dimensional printers are helping to create viable musculoskeletal tissue, and more.

In this month's Practice Management, learn how to reduce employee stress and improve office culture at your practice.

In Article of the Month, please enjoy free access to an article from the June issue of Techniques in Foot and Ankle Surgery.

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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Evaluating alignment in total knee arthroplasty

Successful results of total knee arthroplasty (TKA) depend, in part, on the precision of implant placement. Implant position and alignment influence stability, durability, and patellar tracking. Investigators set out to evaluate the accuracy of overall limb and component alignment in jig-assisted knee replacement and to evaluate functional outcomes with respect to alignment parameters.
     Investigators conducted a prospective study of 120 knees in 80 patients who underwent total knee replacement. The study included 54 women and 26 men. In all, 72 knees had osteoarthritis and 48 had rheumatoid arthritis. All patients were in moderate to severe pain before surgery. Preoperative and postoperative standing long-leg radiographs and postoperative CT scans were taken from all patients. The average follow-up period was 36 months.
     Before surgery, mechanical and tibiofemoral axes were outside acceptable ranges. Postoperatively, with respect to the mechanical axis, inliers (patients whose axes were within the acceptable range) had significantly better knee scores (P = 0.026) compared with the outliers (patients whose axes were outside of the acceptable range). However, the functional score did not show any significant difference between the two groups.
     Inliers with regard to tibiofemoral axis alignment parameters had extremely significant better knee scores (P = 0.0001) and functional scores (P = 0.0082) than patients in the outlier group. Sagittal and rotational femoral component angles in all 120 knees were within acceptable ranges. Similarly, the sagittal, the coronal, and the rotational component angles of the tibia in all 120 replaced knees were within acceptable ranges.
     Investigators concluded that aligning the mechanical axis, tibiofemoral angle within 0° ± 3° and placement of prostheses within 0° ± 3° to the normal alignment in all the three planes, significantly produces excellent functional outcomes.

Source: Manjunath KS, Gopalakrishna KG, Vineeth G. Evaluation of alignment in total knee arthroplasty: a prospective study. Eur J Orthop Surg Traumatol. 2015 May 31. [Epub ahead of print]

Shock wave therapy may help those with chronic plantar fasciitis

Extracorporeal shock wave therapy (ESWT) may relieve symptoms of chronic plantar fasciitis in as many as 65% of patients, according to new study results. Shock wave therapy is a non-invasive treatment that is given without anesthesia. Previous research about the treatment has offered inconsistent results.
     In the study, 246 patients with plantar fasciitis randomly received either a placebo or ESWT sessions consisting of 2,000 impulses at three, weekly intervals. Patients who had ESWT did not receive anesthesia or analgesia during the procedure. Pain levels were measured immediately after treatment and at 12 weeks after treatment ended. Pain was assessed when patients took their first steps in the morning and during daily activities.
     At 12 weeks after treatment, patients in the ESWT group had significant reductions in pain levels compared with the placebo group (a 69.2% reduction versus a 34.5% reduction). Diminished pain scores also were recorded in the ESWT group immediately after the procedure. Although there were no safety issues, many patients reported temporary pain and swelling during and after ESWT treatment.
     "Our study demonstrated that extracorporeal shock wave therapy is effective in the treatment of chronic, recalcitrant cases of plantar fasciitis," said lead study author Hans Gollwitzer, MD. "The advantage of this relatively new treatment is that it is non-invasive and that patients can continue with activity throughout the treatment."

Sources: Gollwitzer H, Saxena A, DiDomenico LA, et al. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study. J Bone Joint Surg Am. 2015;97(9):701-708. Up to 65 Percent of Patients With Chronic Plantar Fasciitis May Benefit From Shock Wave Therapy. American Academy of Orthopaedic Surgeons (AAOS), news release, May 6, 2015.

Restoring youthful healing to old bones

Fractures in geriatric patients often are slow to heal, but investigators at Duke Medicine, Durham, North Carolina, have identified a potential way to speed the healing process.
     In studies using mice, investigators determined the age-dependent contribution of native mesenchymal cells and circulating factors on bone repair. They also successfully manipulated the process by circulating blood and transplanting bone marrow from young mice into older mice, which helped the older bones to heal faster and stronger.
     Previous research identified an important role in fracture repair for a protein called beta-catenin. The protein requires precise modulation for successful bone fracture repair. In older people, beta-catenin levels are elevated during the early phases of bone repair, leading to the production of weaker tissue that is more like scar than bone.
     Investigators transplanted bone marrow cells from young mice to old mice, and demonstrated that young hematopoietic cells can recalibrate beta-catenin signaling during early fracture repair and restore healthy bone-healing in old mice.
     "The findings suggest that drug therapies might be able to modulate beta-catenin levels to improve the pace and quality of fracture repair, both in older adults and in people who have received bone implants," said senior author Benjamin A. Alman, M.D., chair of the Department of Orthopaedic Surgery at Duke University School of Medicine. "The next steps are to figure out what's making beta-catenin go up in older adults, so that we can target that cause," Dr. Alman said.

Sources: Baht GS, Silkstone D, Vi L, et al. Exposure to a youthful circulation rejuvenates bone repair through modulation of β-catenin. Nat Commun. 2015 May 19;6:7131. Old Bones Can Regain Youthful Healing Power. Duke Medicine, news release, May 19, 2015.

Oral steroids no better than placebo for sciatica

Despite widespread use, oral prednisone resulted in modestly improved function and no improvement in pain, compared with placebo, among patients with acute radiculopathy caused by a herniated lumbar disk, new research demonstrates.
     The study involved 269 adults who had radicular pain for 3 months or less, an Oswestry Disability Index (ODI) score of 30 or higher (range, 0-100; higher scores indicate greater dysfunction), and a herniated disk confirmed by MRI. Patients were randomly assigned in a 2 to 1 ratio to receive a tapering 15-day course of oral prednisone (5 days each of 60 mg, 40 mg, and 20 mg; total cumulative dose?=?600 mg) or matching placebo. In all, 181 patients took prednisone and 88 took a placebo.
     Patients reported functional ability and pain levels for 1 year. Patients who took prednisone were more likely to report a small improvement in function, defined as 50%, at 3 weeks and at 1 year. Patients who took prednisone had an adjusted average 6.4-point greater improvement in ODI scores at 3 weeks than the placebo group and an average 7.4-point greater improvement at 52 weeks.
     But pain was similar for both groups at those time points. Compared with the placebo group, the prednisone group showed a nonsignificant, adjusted average 0.3-point greater reduction in pain at 3 weeks and an average 0.6-point greater reduction at 52 weeks. There were no differences in surgery rates between the two treatment groups at 52 weeks.
     Having one or more adverse event at the 3-week follow-up was more common in the prednisone group than in the placebo group (49.2% vs 23.9%). Adverse effects, such as insomnia, increased appetite and nervousness, were twice as common at 3 weeks among patients who took prednisone. Nearly half of those who took prednisone reported at least one adverse effect, compared with about one-quarter of those who took a placebo. After 1 year, however, both groups had reported a similar number of adverse effects, according to investigators.
     Investigators say their findings do not close the book on steroids as a treatment for acute radiculopathy caused by a herniated lumbar disk, but rather serve as a discussion point for physicians and patients.

Sources: Goldberg H, Firtch W, Tyburski M, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015;313(19):1915-1923. Oral Steroids for Acute Sciatica Produce Limited Improvement in Function and Pain. Kaiser Permanente, news release, May 19, 2015.

Tracking complications after revision hip and knee arthroplasty

In a new study, investigators set out to determine the frequency of complications 30 days after aseptic revision hip arthroplasty (RHA) and aseptic revision knee arthroplasty (RKA). Investigators also aimed to identify patient-related risk factors that could predict major complications and prolong hospital stays beyond 7 days.
     Investigators used the National Surgical Quality Improvement Program (NSQIP) database to identify 2643 patients who had RHA and 2425 patients who had RKA between 2011 and 2012.
     The 30-day mortality rates for RHA and RKA were 1.0% and 0.1%, respectively. The overall complication rates were 7.4% for RHA and 4.7% for RKA. Multivariable analysis indicated that preoperative anemia is the most important modifiable independent predictor for both major complications and prolonged hospital stay after RHA and RKA.

Source: Liodakis E, Bergeron SG, Zukor DJ, et al. Perioperative Complications and Length of Stay after Revision Total Hip and Knee Arthroplasties: An Analysis of the NSQIP Database. J Arthroplasty. 2015 May 22. pii: S0883-5403(15)00422-2. [Epub ahead of print]

Creating more effective tissue with help from a 3-D printer

Use of 3-dimensional printing may allow for wider, more effective use of biocompatible materials in repairing human tissue in the musculoskeletal system. Despite intensive research hydrogels currently available for tissue repair cannot meet the mechanical or biological requirements for successful outcomes.
     Focusing on the challenging task of restoring cartilage, which requires both flexibility and mechanical strength, investigators researched a new combination of 3-D printed microfiber scaffolding and hydrogels. The new process reinforces soft hydrogels with highly organized, high-porosity microfiber networks that are 3D-printed with a technique called melt electrospinning writing.
     Testing of the new composites showed elasticity and stiffness comparable to knee-joint tissue, as well as the ability to support the growth and cross-linking of human cartilage cells. Compared with hydrogels or microfiber scaffolds alone, the new gel/scaffold composites had a stiffness that was up to 54-fold stronger.
     Modelling affirms that reinforcement with defined microscale structures will apply to numerous hydrogels. The stiffness and elasticity of the new composites approach that of articular cartilage tissue. Human chondrocytes embedded in the composites are viable, retain their round morphology, and are responsive to an in vitro physiological loading regime in terms of gene expression and matrix production.
     Investigators concluded that the new approach of reinforcing hydrogels with 3D-printed microfibers offers a fundament for producing tissue constructs with biological and mechanical compatibility. Investigators expect the new approach to impact other areas of soft-tissue engineering, including breast reconstruction and heart tissue.

Sources: Visser J, Melchels FP, Jeon JE, et al. Reinforcement of hydrogels using three-dimensionally printed microfibres. Nat Commun. 2015;6:6933. Advance in 3-D Printing Could Have Broad Applications. Technische Universität München, news release, May 15, 2015.

Common analgesia after shoulder surgery may have limited effectiveness

Interscalene block (ISB) can provide effective analgesia for as long as 6 hours with motion and 8 hours at rest after shoulder surgery, but a new study found no analgesic benefit after 8 hours. These findings contradict the prevailing wisdom that the ISB block, along with oral painkillers, keeps patients comfortable for the first 24 to 48 hours after surgery.
     Investigators analyzed results from 23 randomized controlled trials that involved 1090 patients. The duration of pain relief at rest and with motion after ISB were 8 and 6 hours, respectively. There were no additional pain relief benefits beyond 8 hours.
     Between eight and 16 hours after surgery, patients who had an ISB had almost similar pain to those who did not. Between 16 and 24 hours, those who had ISB were slightly worse off than those who did not, a phenomenon known as rebound pain. This phenomenon has been described in studies concerning knee and ankle surgery, but never for shoulder surgery.
     ISB reduced postoperative opioid consumption for up to 12 hours after surgery, providing an opioid-sparing effect and reducing opioid-related adverse effects. ISB also decreased postoperative nausea and vomiting at 24 hours, and expedited postanesthesia care and hospital discharge. The type, dose, and volume of local anesthetic used did not affect the results.
     Investigators write that their findings are useful for preoperative risk-benefit discussions before shoulder surgery.

Source: Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the real benefits of single-shot interscalene block please stand up? A systematic review and meta-analysis. Anesth Analg. 2015;120(5):1114-1129.

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Cut back on stress in the office

Many physicians and staff members feel stress on the job. It is an uncomfortable feeling that leads to bad attitudes, a negative office culture, and more frequent errors. If stress is common in your workplace, consider these tips for reducing it.

Talk it out
Stressful situations can stem from many causes, but communicating about them with your team will improve matters. Enhance communication by scheduling staff meetings at least once per week and allowing at least a half-hour per meeting. You can hold short, daily meetings as well, but you will need more time to flush out issues and set policies for the future. Pick a day and time of the week for a regular staff meeting and block it off from appointments.
     At a weekly staff meeting, review the problems of the past week and discuss how to prevent challenging situations. Do not blame anyone, and keep the meeting positive. Ask staff members to tell you about one thing that made a patient unhappy that week.

Review office policies
Review all your office policies with customer service in mind. Most policies should be patient-friendly. The goal is to identify and satisfy patients' wants and needs. Convert your office culture to one that is based on excellent service and letting the patient win. This type of culture will create a happier office.

Make lunch breaks required
Work toward requiring that all staff members take a lunch break. Try to change habits if some staff have decided to work through lunch in order to finish their work. Be careful in the process because some staff may work through lunch in order to increase their paid work hours, so forcing them to take lunch could mean reducing their pay. Nevertheless, taking a legitimate break and not thinking about work is a good way to decrease stress. Talking with co-workers about one's personal life or going out to lunch helps people relax. Consider giving staff members a 45-minute lunch break that they must take.

Reserve some openings in the schedule
If your office often runs behind schedule, everyone will feel the stress. Begin by looking for ways to save time, perhaps by delegating more tasks to staff or talking less. Also, consider inserting a couple of blocked appointment times every day to allow everyone to catch up or to create some space to add an emergency.

Have enough staff
Employing enough staff may be the best way to reduce stress. Having the right number of employees reduces stress for everyone. Yes, it is important to keep an eye on payroll costs, but often, an additional employee increases production and gross revenue more than the additional salary. Having enough staff means the phone can be answered and not go to voice mail. It means there will be someone at the front desk and patients will be served well. It means someone can check on insurance benefits before the day of the appointment. And, it means if someone calls in sick, the practice will still have enough staff to stay sane.

Hire a manager
Practice owners feel stress when they try to handle too much. A busy week of patients along with managing the staff and handling administrative duties is too much. Delegate some of the staff issues and administrative duties to a manager. A manager can be educated to handle most of the problems that arise with staff and also resolve patient complaints. But, do not expect a manager to know how to do it all. The practice owner still has to lead and coach the manager on how to do a good job. That takes time, but not as much time as doing it yourself.

Hire an associate physician
Most practice owners hire a manager to run the business side of the practice so they can continue to see patients. It might better serve the practice to hire an associate physician to see patients so the owner has time to run the business. An office manager is still needed, but the practice needs the leadership and vision of the owner. It needs a CEO mentality and no one can do that better than the owner. The transfer of patients can occur gradually, but as the practice grows larger, it needs more management time.

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, "Total Ankle Replacement through a Lateral Approach," from the June issue of Techniques in Foot and Ankle 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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