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Commentary and Perspective

Less Can Be More—A Skill We Are Losing?

Commentary on an article by Kenneth E. Egol, MD, et al.: “Minimally Displaced, Isolated Radial Head and Neck Fractures Do Not Require Formal Physical Therapy. Results of a Prospective Randomized Trial”

Dirschl, Douglas R. MDa

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The Journal of Bone and Joint Surgery: April 18, 2018 - Volume 100 - Issue 8 - p e54
doi: 10.2106/JBJS.17.01381
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Commentary

One of the (many) beautiful things about orthopaedics as a profession is that orthopaedists care for individuals who have a wide range of conditions, from the very complex and serious to the very simple and minor. My mentor repeatedly told me that orthopaedics is “primary care for the musculoskeletal system”; what he meant is that our profession will care for any patient with any musculoskeletal condition, however simple or complex.

In this ethos, orthopaedists care, at times, for patients whose injuries or conditions are known to be “self-limiting”—that is, the patients are highly likely to return to painless normal function whether they receive treatment or not. However, numerous forces press orthopaedists to provide care/treatment for these individuals beyond what is necessary. In our society, many patients are less than fully satisfied if they don’t receive “active” treatment, our health-care marketplace provides financial rewards for “doing more,” high patient-satisfaction ratings may be needed if we are to continue to garner referrals, and our practice setting may make it more time-efficient to recommend or prescribe treatment than to explain to a patient why that care may not be necessary.

One example of the result of these forces in action is the prescribing of physical therapy for simple, self-limiting conditions such as Mason-Hotchkiss type-I fractures of the radial head or neck. In my career, I have never recommended physical therapy for these patients and, I must admit, I had never even considered that physical therapy would be prescribed frequently for these injuries. My eyes were opened, however, when I read the article by Egol et al. in this issue of The Journal of Bone and Joint Surgery. The authors cite literature indicating that nearly 80% of attending orthopaedic surgeons surveyed prescribed physical therapy for patients who had a Mason type-I fracture of the radial head1. This and similar literature served as the basis for a simple, elegant, well-designed randomized controlled trial of patients who had a Mason-Hotchkiss type-I fracture to assess whether formal physical therapy resulted in improved patient outcomes compared with brief instruction and a home-exercise program. In both groups, clinical evidence of union was demonstrated at an average of 7 to 8 weeks, but at 6 weeks those in the home-exercise group had a significantly lower (better) mean DASH (Disabilities of the Arm, Shoulder and Hand) score than those who had undergone physical therapy. Compliance with attendance at physical therapy visits was ensured by direct measurement; compliance with home exercises was assessed on the basis of patient reporting. At all times beyond 6 weeks, there were no differences in outcomes between the 2 groups.

The message in this article is, like the study design, simple, clear, and elegant: prescribing physical therapy for isolated, minimally displaced, nonoperatively treated fractures of the radial head or neck is not cost-effective and does not add value. An equivalent outcome will be achieved, at no additional cost to the patient, by having the orthopaedist or office staff spend an additional few minutes with a patient to review home exercises. Additionally, while this is not the key message of the article, the study provides strong evidence against recommending serial radiographs and prolonged follow-up for these patients—interventions that also add to the cost of treatment. It appears that, for patients who have this injury, there are ample opportunities to reduce utilization of health-care resources by eliminating physical therapy, serial radiographs, and many office visits.

Value can be expressed as outcome divided by cost; this study provides a simple and clear example of practice patterns in our profession that add cost without adding value for patients. Although the results of the study cannot be generalized to all orthopaedic patients—or even to all those who have self-limiting conditions—they should be viewed as a call to action for all orthopaedists to evaluate and, where necessary, alter practice patterns, particularly for the treatment of very simple injuries and conditions, to ensure provision of optimal value for patients. As members of a profession that provides the full spectrum of primary and tertiary care for patients who have injuries and conditions of the musculoskeletal system, don’t we owe it to those in our care to provide highly effective care with the least utilization of resources?

Disclosure: The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/E712).

Reference

1. Mahmoud SS, Moideen AN, Kotwal R, Mohanty K. Management of Mason type 1 radial head fractures: a regional survey and a review of literature. Eur J Orthop Surg Traumatol. 2014 Oct;24(7):1133-7. Epub 2013 Dec 11.

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