Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, discover if switching from low molecular weight heparin to dabigatran can help prevent venous thromboembolism in patients undergoing total hip or knee replacement. Read about the impact dietary magnesium has on bone health. Find out the best way to treat Achilles tendon rupture, if a nonopioid injection improves knee replacement recovery, what to keep in mind when treating the spines of aging patients, and more.

In this month's Practice Management, learn how you may be overlooking qualified job candidates.

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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Switching to dabigatran prevents venous thromboembolism

In a new study, investigators evaluated the safety and efficacy of switching therapy from low molecular weight heparin (LMWH; enoxaparin) to dabigatran for prevention of venous thromboembolic events (VTE) in patients undergoing elective total hip or knee replacement surgery (THR/TKR).
     Investigators conducted a prospective, multicenter, observational study involving patients undergoing THR or TKR who were to receive 40 mg of enoxaparin for thromboprophylaxis. Enoxaparin was initiated before or after surgery according to facility practice and was switched to 220 mg of dabigatran once daily at a time chosen by investigators. Endpoints were major bleeding events, and the composite of symptomatic VTE and all-cause mortality, from last use of enoxaparin to 24 hours after the last intake of dabigatran.
     For radiculopathy, epidural corticosteroids were associated with an immediate, short-term reduction in pain (weighted mean difference on a scale of 0 to 100, -7.55). Patients also demonstrated short-term improvement in function (standardized mean difference after exclusion of an outlier trial, -0.33) and a reduced short-term surgery risk (relative risk, 0.62). However, these effects were below predefined minimum clinically important difference thresholds, and there were no long-term benefits.
     The study involved 168 (81 THR, 87 TKR) patients, of whom 161 received both enoxaparin and dabigatran, two received dabigatran only, and five received enoxaparin only. The median time of the first dabigatran tablet was 24 hours after the last enoxaparin dosage. The median number of days that patients took dabigatran was 36. No symptomatic VTE or death occurred during the study. One major bleeding event occurred at the surgical site and required treatment cessation. Three minor bleeding events occurred.
     In the normal clinical setting, switching from LMWH to dabigatran in patients who had THR and TKR was safe and effective in preventing VTE. All adverse events were consistent with the known safety profile for dabigatran. Also, switching from a subcutaneous to an oral anticoagulant may offer greater convenience in the outpatient setting after discharge.

Source: Wurnig C, Clemens A, Rauscher H, et al. Safety and efficacy of switching from low molecular weight heparin to dabigatran in patients undergoing elective total hip or knee replacement surgery. Thromb J. 2015 Nov 26;13:37.

How much impact does dietary magnesium have on bone health?

Previous research regarding dietary magnesium intake and its impact on osteoporosis and the risk of fractures has had conflicting results. A new meta-analysis suggests that high magnesium intake was not associated with increased risk of fracture; however, a positive, marginally significant correlation did occur between magnesium intake and bone mineral density (BMD) in the total hip and femoral neck, investigators report.
     Although there is some evidence regarding the association between magnesium intake, BMD and fractures, no earlier research summarized findings in this regard. In the current study, investigators systematically reviewed the current evidence on this association and performed a meta-analysis involving 12 observational studies.
     Data suggest that high intakes of magnesium were not significantly associated with risk of total hip fracture (summary effect size 1.92; 95 % CI 0.81, 4.55) or total fractures (1.01; 0.94-1.07). Combining four effect sizes, a positive marginally significant correlation was observed between magnesium intake and total BMD (pooled r 0.16; 95 % CI 0.001, 032). Based on nine effect sizes, a marginally significant association existed between magnesium intake and femoral neck BMD (0.14; 0.001, 0.28). However, no significant correlation was found between magnesium intake and BMD in the lumbar spine (0.09; -0.01, 0.19).

Source: Farsinejad-Marj M, Saneei P, Esmaillzadeh A. Dietary magnesium intake, bone mineral density and risk of fracture: a systematic review and meta-analysis. Osteoporos Int. 2015 Nov 10. [Epub ahead of print]

Comparing total knee replacement with nonsurgical treatment

For patients with knee osteoarthritis who were eligible for unilateral total knee replacement, undergoing total knee replacement followed by nonsurgical treatment resulted in greater pain relief and functional improvement after 12 months than nonsurgical treatment alone, according to new study results. However, total knee replacement was associated with more serious adverse events than nonsurgical treatment. Also, most patients who received just nonsurgical treatment did not undergo total knee replacement by the end of a 12-month follow-up.
     The randomized, controlled trial involved 100 patients with moderate-to-severe knee osteoarthritis who were eligible for unilateral total knee replacement. Patients were randomly assigned to total knee replacement followed by 12 weeks of nonsurgical treatment (total-knee-replacement group) or to receive only 12 weeks of nonsurgical treatment (nonsurgical-treatment group). The nonsurgical treatment was delivered by physiotherapists and dietitians and involved exercise, education, dietary advice, use of insoles, and pain medication.
     The primary outcome was the change from baseline to 12 months in the average score on four Knee Injury and Osteoarthritis Outcome Score subscales that covered pain, symptoms, activities of daily living, and quality of life (KOOS4). Scores range from 0 (worst) to 100 (best).
     In all, 95 patients completed the 12-month follow-up assessment. In the nonsurgical-treatment group, 13 patients (26%) required total knee replacement before the 12-month follow-up. In the intention-to-treat analysis, the total-knee-replacement group had greater improvement in the KOOS4 score than did the nonsurgical-treatment group (32.5 vs. 16.0; adjusted average difference, 15.8). However, the total-knee-replacement group had 24 serious adverse events, compared with six in the nonsurgical-treatment group.

Source: Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606.

Evaluating cemented and uncemented arthroplasty in patients with a displaced fracture of the femoral neck

Using an uncemented hydroxyapatite-coated stem to treat displaced fractures of the femoral neck in elderly people is not as effective as using a cemented stem, according to new research.
     In a randomized, controlled study, investigators compared functional and radiographic outcomes between modern cemented and uncemented hydroxyapatite-coated stems after 1 year in patients who had surgical treatment for a fracture of the femoral neck. A total of 141 patients older than 65 years were included. Patients were randomly selected to be treated with a cemented stem or an uncemented stem. Investigators evaluated patients at 4 and 12 months.
     The cemented group performed better than the uncemented group on the Harris hip score (78 vs. 70.7) at 4 months and for the Short Musculoskeletal Function Assessment Questionnaire dysfunction score at 4 (29.8 vs. 39.2) and 12 months (22.3 vs. 34.9). The average EuroQul Group-5D index score was better in the cemented group at four (0.68 vs. 0.53) and 12 months (0.75 vs. 0.58) follow-up. There were nine intraoperative fractures in the uncemented group and none in the cemented group.

Source: Inngul C, Blomfeldt R, Ponzer S, Enocson A. Cemented versus uncemented arthroplasty in patients with a displaced fracture of the femoral neck: a randomised controlled trial. Bone Joint J. 2015;97-B(11):1475-1480.

First ever ibuprofen skin patch offers transdermal analgesia

The first ibuprofen patch, which offers transdermal drug delivery at a consistent dose rate, has been patented.
     Significant amounts of the drug (up to 30% weight) can be incorporated into the polymer matrix that adheres the patch to a patient's skin, with the drug being delivered at a steady rate for as long as 12 hours. This new adhesive technology will allow for the development of several long-acting over-the-counter analgesics that can be used to treat many conditions, such as chronic back pain, neuralgia, and arthritis without the potential risks of oral doses.
     Researchers reportedly also have had had great results using it with methyl salicylate and are now exploring other uses of the patch. The ibuprofen patch is expected in markets in about two years.

Source: University of Warwick, England. Researchers create world's first ibuprofen patch - delivering pain relief directly through skin. News release. Dec. 8, 2015.
http://www2.warwick.ac.uk/newsandevents/pressreleases/researchers_create_world146s

Finding the best way to treat Achilles tendon rupture

The percutaneous method is the best surgical treatment for Achilles tendon rupture, according to investigators who compared the efficiency of nonoperative and operative procedures in the treatment of ruptured Achilles tendon in professional and amateur athletes.
     The study included 90 professional or amateur athletes with rupture of the Achilles tendon who were between 25 and 40 years of age (average 35 years). A total of 30 athletes underwent an open procedure, 30 athletes were treated with a percutaneous method, and 30 were treated nonoperatively. All patients who had surgery were tested 1 year after their procedure.
     Investigators used an isokinetic dynamometer to compare the open and percutaneous methods. Results for patients who had the percutaneous method were 15% better than for those who had the open procedure. Results for the group treated nonoperatively were 20% better than those for the group treated percutaneously.
     The percutaneous method was easier technically than the open method. Time spent in hospital was 14.5 times shorter with the percutaneous procedure compared with the open procedure. Hospital stays for patients who had the percutaneous procedure ranged from 0.5 to 2 days, compared with a range of 10 to 24 days for the open procedure. Return to sport activities was twice as fast with the percutaneous procedure compared with the open procedure.
     There were no postoperative infections or reruptured Achilles tendons in the group treated with the percutaneous procedure. One patient in the group treated with the open procedure had postoperative infection (4.2%). In the nonoperative group, there were three reruptures of the Achilles tendon within 1 year, and one patient developed adhesions that resulted in loss of function and resulted in operative treatment.

Source: Cukelj F, Bandalovic A, Knezevic J, et al. Treatment of ruptured Achilles tendon: Operative or non-operative procedure? Injury. 2015 Nov 10. pii: S0020-1383(15)00687-7. [Epub ahead of print]

Nonopioid joint injection improves knee replacement recovery

A nonopioid treatment other than a nerve block works better for patients recovering from knee replacement surgery, according to a study by Andrew Shinar, M.D., associate professor of orthopaedic surgery and rehabilitation at Vanderbilt University, Nashville, Tenn. The study results were so encouraging that the Vanderbilt Joint Replacement Center stopped administering nerve blocks during knee replacements.
     The study compared 40 patients who received combined femoral and sciatic nerve blocks to 40 patients who received intraarticular injections of a numbing drug. The patients who got the nonopioid, numbing medicine reported less pain and were able to walk farther 24 hours after their surgeries than the other patients.
     Dr. Shinar said that although he and his colleagues have not evaluated the long-term effects of the intraarticular injections in regard to range of motion or recovery time, a positive effect was noted in the short-term.
     In addition, the injections eliminated the need for Foley catheters, bypassing the potential complication of a urinary tract infection.
     Dr. Shinar's study was different from others comparing the effectiveness of the two pain control treatments in that it looked at the combined use of femoral and sciatic nerve blocks.
     Composite pain scores among patients who received the intraarticular injections were a full point lower than those who received nerve blocks. Patients who received the injections also walked about four times the distance a day after their surgeries than patients who received nerve blocks. In addition, they were less likely to be discharged to a rehabilitation facility.
     The results of this study were presented at the 2015 annual meetings of the Southern Orthopaedic Association and Tennessee Orthopaedic Society.

Source: Vanderbilt University. Joint injections speed knee replacement recovery:?study. News release. Oct. 15, 2015. http://news.vanderbilt.edu/2015/10/joint-injections-speed-knee-replacement-recovery-study/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+vanderbilt-research+%28Vanderbilt+Research+News%29

Treating the aging spine

With the great numbers of aging baby boomers, it becomes of even greater importance for orthopaedic spine surgeons to recognize the special challenges involved in caring for older patients with spine pathology, according to a new report. Spine pathologies unique to aging, such as osteoporosis and degenerative deformities, need recognition and resolutions.
     Recent treatment options and recommendations for optimizing bone health include vitamin D and calcium supplementation, diphosphonates, and teriparatide. Optimizing spinal fixation in elderly patients with osteoporosis is critical. Cement augmentation of pedicle screws is promising.
     With geriatric odontoid fractures, nonsurgical support with a collar may be appropriate for the low-demand patient, whereas surgical fixation is favored for high-demand patients. Management of degenerative deformity must correct sagittal plane balance, including consideration of pelvic incidence. Lastly, various osteotomies may prove helpful in this setting.

Source: Choma TJ, Rechtine GR, McGuire RA Jr, Brodke DS. Treating the aging spine. J Am Acad Orthop Surg. 2015;23(12):e91-e100.

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Making the good hire

Most practice owners try very hard to prevent hiring a job candidate who will not work out. They go to great lengths to screen out the wrong type of employees during the interview process. This is understandable, but are they missing out on a good hire? Most employers do not think about that aspect when recruiting job candidates. It is problematic to reject a person who would have been a good employee based on assumptions that are inaccurate. In spite of best efforts, both of these situations occasionally occur: hiring the wrong person and rejecting a good person. Being aware of both possibilities will help improve your chances of finding good employees.

How the wrong candidate gets hired
Most strategies in the recruiting and hiring process aim to prevent an employer from making a bad hire. It is valuable to consider a candidate's education, job history, professional experience, and other factors on the resume. Pre-employment testing for job skills and personality also is a useful tool. Despite these factors, it is impossible to really know a new employee until he or she has worked the job for a few weeks. Because eventually, true work ethic, job skills, and personality traits surface.
     The interview is the best chance before hiring to get to know the person. But, job applicants can become masters at not revealing their true selves during an interview. It is only natural for candidates to put their best foot forward and suppress their negative traits in order to get a job offer. It is all too easy to hire an employee who:

• seemed extremely happy and pleasant in the interview, only to have him or her never smile at patients and actually be quite rude
• claimed to be a great team player, only to have him or her create hard feelings among coworkers that hurt office morale
• had great clinical experience in previous jobs, only to find out that he or she really was not that bright
• received positive reports during a reference check, only to have the employee be chronically late for work and frequently call in sick.(The reference source might have been afraid to tell the truth for fear of legal action.)

     When the new employee is not quite what you hoped, it is best to have a talk about the issues right away. Let him or her know what your expectations are. Give the new employee the knowledge and a chance to improve. But if performance does not quickly improve, it is best to part ways early and resume your search.

How a good candidate gets overlooked
Sometimes practice owners know they are understaffed and have been searching for "the right person" for months. Except for very unusual circumstances, it should not take that long.
     The goal in hiring is not to seek perfection, but rather to hire the best person available in the job market at the wage range the practice can afford. Perform a reasonable search for suitable applicants and make an offer to the best candidate, even if that person is far from perfect. If the new hire is lacking in some skills, offer him or her the knowledge and education to perform the tasks.
     Some of the applicants who are rejected by a practice owner or office manager would probably have become excellent employees or at least average ones. Below are some ways that good candidates get passed over.

• The person who did not seem friendly was actually just very nervous in the interview. When the employee is no longer nervous, this person may have a great smile and use it often.
• When you called another physician in town for a reference, he said the applicant caused a lot of problems in his practice. The truth, however, may be that the applicant was a good employee but the physician views your practice as a threat and does not want to help you.
• A credit check on the applicant revealed a history of financial problems and a low credit score. There could be many reasons why a person has financial problems but could still be an excellent employee. The person may need another chance and certainly needs a job.
• There were spelling errors on an applicant's resume. You passed on interviewing this applicant and instead hired someone with a perfect resume, which someone else created, much of it was not true, and that hire cannot spell well either.
• You got a bad vibe about a candidate during a phone interview; the applicant seemed timid. However, without seeing the person's body language, excellent appearance, and eye contact, you misjudged, and this person now works for another practice in town.

It is challenging to sort through applicants. It might be worthwhile to invite a promising candidate to observe the practice while you conduct a working interview for a day or two at an agreed upon pay rate. In the end, trust your instincts, make a job offer, and hope for the best. But, do not be shocked if it does not work out.

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, "Routine Upright Imaging for Evaluating Degenerative Lumbar Stenosis: Incidence of Degenerative Spondylolisthesis Missed on Supine MRI," from the December 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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