R. Carter Clement

A proposed set of metrics for standardized outcome reporting in the management of low back pain

Background and purpose — Outcome measurement has been shown to improve performance in several fields of healthcare. This understanding has driven a growing interest in value-based healthcare, where value is defined as outcomes achieved per money spent. While low back pain (LBP) constitutes an enormous burden of disease, no universal set of metrics has yet been accepted to measure and compare outcomes. Here, we aim to define such a set. Patients and methods — An international group of 22 specialists in several disciplines of spine care was assembled to review literature and select LBP outcome metrics through a 6-round modified Delphi process. The scope of the outcome set was degenerative lumbar conditions. Results — Patient-reported metrics include numerical pain scales, lumbar-related function using the Oswestry disability index, health-related quality of life using the EQ-5D-3L questionnaire, and questions assessing work status and analgesic use. Specific common and serious complications are included. Recommended follow-up intervals include 6, 12, and 24 months after initiating treatment, with optional follow-up at 3 months and 5 years. Metrics for risk stratification are selected based on pre-existing tools. Interpretation — The outcome measures recommended here are structured around specific etiologies of LBP, span a patient’s entire cycle of care, and allow for risk adjustment. Thus, when implemented, this set can be expected to facilitate meaningful comparisons and ultimately provide a continuous feedback loop, enabling ongoing improvements in quality of care. Much work lies ahead in implementation, revision, and validation of this set, but it is an essential first step toward establishing a community of LBP providers focused on maximizing the value of the care we deliver.

The Total Ankle Arthroplasty Learning Curve With Third- Generation Implants A Single Surgeon's Experience

Background. Renewed interest in total ankle arthroplasty (TAA) has developed globally as a result of recent literature supporting new-generation implants as a viable alternative to arthrodesis. The literature also demonstrates a learning curve among surgeons adopting TAA. The purpose of this study is to better define this learning curve for surgeons using third-generation implants. Methods. Charts and radiographs were reviewed for the initial 26 TAA procedures performed by the senior author. Three third-generation implants were used: SBi (Small Bone Innovations) STAR, Salto Talaris, and Wright Medical INBONE. We report perioperative and early postoperative complications. Results. Two perioperative fractures occurred in the first 9 cases, and the incidence subsequently dropped to 0 (P = .0431). Two cases of component malalignment occurred in the first 3 patients receiving the STAR implant, and the incidence then dropped to 0 (P = .0034). Five wound complications (4 minor and 1 major) occurred, all in the final 14 patients. No cases of nerve injury, tendon laceration, or deep vein thrombosis occurred. Two patients returned to the operating room as a result of complications, and the total perioperative and early postoperative complication rate was 27%. Conclusion. The observed rate of perioperative and early postoperative complications in this case series was low relative to other similar-sized studies, suggesting that third-generation implants can reduce adverse events. Our results demonstrate that some common complications could be avoided altogether (nerve/tendon injuries), some decreased quickly with experience (intraoperative fractures and component malpositioning), and some persisted unchanged throughout this study (wound complications). These findings should influence surgical training, surgeon willingness to adopt this procedure, and patient counseling. Levels of Evidence: Therapeutic, Level IV, Retrospective Case Series.

Are There Identifiable Risk Factors and Causes Associated with Unplanned Readmissions Following Total Knee Arthroplasty

We conducted a retrospective review of 3218 primary total knee arthroplasties (TKA) performed over two years at an urban academic hospital network using clinical and administrative data. Increased length of stay (LOS) was associated with readmission (P < 0.001). Readmission was not associated with age (P = 0.100), gender (P = 0.608), body mass index (P = 0.329), or staged bilateral procedures (P = 0.420). The most common readmitting diagnoses were post-operative infection (22.5%), hematoma (10.1%), pulmonary embolus (7.9%) and deep vein thrombosis (5.6%). Of readmissions, 53.9% were for surgical reasons and 46.1% were for medical reasons. Certain interventions described in previous literature may be more successful in minimizing unplanned readmissions by focusing on patients with extended LOS, elevated infection risk and low socioeconomic status.

Economic Viability of Geriatric Hip Fracture Centers

Management of geriatric hip fractures in a protocol-driven center can improve outcomes and reduce costs. Nonetheless, this approach has not spread as broadly as the effectiveness data would imply. One possible explanation is that operating such a center is not perceived as financially worthwhile. To assess the economic viability of dedicated hip fracture centers, the authors built a financial model to estimate profit as a function of costs, reimbursement, and patient volume in 3 settings: an average US hip fracture program, a highly efficient center, and an academic hospital without a specific hip fracture program. Results were tested with sensitivity analysis. A local market analysis was conducted to assess the feasibility of supporting profitable hip fracture centers. The results demonstrate that hip fracture treatment only becomes profitable when the annual caseload exceeds approximately 72, assuming costs characteristic of a typical US hip fracture program. The threshold of profitability is 49 cases per year for high-efficiency hip fracture centers and 151 for the urban academic hospital under review. The largest determinant of profit is reimbursement, followed by costs and volume. In the authors’ home market, 168 hospitals offer hip fracture care, yet 85% fall below the 72-case threshold. Hip fracture centers can be highly profitable through low costs and, especially, high revenues. However, most hospitals likely lose money by offering hip fracture care due to inadequate volume. Thus, both large and small facilities would benefit financially from the consolidation of hip fracture care at dedicated hip fracture centers. Typical US cities have adequate volume to support several such centers.

Saline-Coupled Bipolar Sealing in Simultaneous Bilateral Total Knee Arthroplasty

Background The efficacy of saline-coupled bipolar sealing devices in joint arthroplasty is uncertain, and the utility in simultaneous bilateral total knee arthroplasty (TKA) has not been reported. Methods This study compares the use of bipolar sealing and conventional electrocautery in 71 consecutive patients. The experimental and control groups were matched for age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, and preoperative hemoglobin. Variables of interest included blood loss, transfusion requirements, and operative characteristics. Results In comparison to patients treated with conventional electrocautery, those treated with the bipolar sealer were 35% less likely to require transfusion. The median number of transfusions per case was also significantly lower in the experimental group. Hemoglobin change, total blood loss, and length of stay were not significantly different between the groups. The experimental group had longer operative times. Conclusions Bipolar sealing shows promise as a blood loss reduction tool in simultaneous bilateral TKA. The marginal savings attributed to reduced transfusion rates with use of the bipolar sealer did not exceed the additional per-case expense of using the device. The decision to use the device with the goal of less blood loss must come with the additional expense associated with its use.

Patient Satisfaction Is Associated With Time With Provider But Not Clinic Wait Time Among Orthopedic Patients

Clinic wait time is considered an important predictor of patient satisfaction. The goal of this study was to determine whether patient satisfaction among orthopedic patients is associated with clinic wait time and time with the provider. The authors prospectively enrolled 182 patients at their outpatient orthopedic clinic. Clinic wait time was defined as the time between patient check-in and being seen by the surgeon. Time spent with the provider was defined as the total time the patient spent in the examination room with the surgeon. The Consumer Assessment of Healthcare Providers and Systems survey was used to measure patient satisfaction. Factors associated with increased patient satisfaction included patient age and increased time with the surgeon (P=.024 and P=.037, respectively), but not clinic wait time (P=.625). Perceived wait time was subject to a high level of error, and most patients did not accurately report whether they had been waiting longer than 15 minutes to see a provider until they had waited at least 60 minutes (P=.007). If the results of the current study are generalizable, time with the surgeon is associated with patient satisfaction in orthopedic clinics, but wait time is not. Further, the study findings showed that patients in this setting did not have an accurate perception of actual wait time, with many patients underestimating the time they waited to see a provider. Thus, a potential strategy for improving patient satisfaction is to spend more time with each patient, even at the expense of increased wait time. [Orthopedics. 2017; 40(1):43-48.].

Technical Tip and Cost Analysis for Lesser Toe Plantar Plate Repair With a Curved Suture Needle

The plantar plate is a thick ligamentous connection between the distal plantar metatarsal metaphyseal flare and the plantar base of the proximal phalanx. It has been recognized as the primary stabilizer of the metatarsophalangeal joint (MTP), and attenuation can lead to pain, instability, subluxation, and frank dislocation, including the eponymous “cross over toe” deformity. Insufficiency can result from acute traumatic tears but more commonly is the result of gradual degeneration, frequently associated with concomitant structural forefoot pathology including hammer or claw toe deformity or adjacent hallux valgus or rigidus. Tears tend to occur distally, and the second digit is most commonly affected. While most authors recommend conservative treatment before progressing to operative intervention, several operative techniques have been developed for recalcitrant cases. Initially, these involved tendon transfers and soft tissue releases, often used in conjunction. Synovectomy and osseous decompression were also described. Recurrence and continued pain were the most common complications seen after indirect repair techniques, and a cadaveric study suggested direct repair as a biomechanically viable alternative. These observations initially led to a technique utilizing a plantar approach for direct plantar plate repair or, in cases of more extensive damage, plantar plate transection with advancement and anchoring into the base of the proximal phalanx. Plantar repairs initially demonstrated good results when used in conjunction with tendon transfers and interphalangeal fusion. A dorsal approach for direct plantar plate repair subsequently gained attention as it has the potential to avoid painful plantar scars and allow access to adjacent MTPs through a single incision. Following a cadaveric study demonstrating its feasibility, multiple dorsal approach techniques were developed utilizing a metatarsal shortening osteotomy. At least 3 of these involve proprietary instruments to facilitate suture passage through the substance of the distal plantar plate. These facilitate efficient procedures and early data suggest good results, but the financial cost is substantial. The purpose of this article is to describe a technical modification to the dorsal approach to facilitate plantar plate repair without the relatively expensive proprietary instruments used for suture passage through the distal aspect of the plate and to analyze and discuss the potential associated cost reductions.

Fringe Benefits Among US Orthopedic Residency Programs Vary Considerably: a National Survey

BackgroundResidency programs compete to attract applicants based on numerous factors. Previous research has suggested that medical students consider quality of life among the most important factors in selecting a program. One aspect of workplace quality of life is the cadre of non-monetary benefits offered to employees. However, with federal funding for graduate medical education (GME) under consideration for spending cuts, the source and continuation of such benefits may be in question.Questions/PurposesThis study aimed to determine the level and variability of benefits beyond standard salary and insurance options available to trainees at US orthopedic residency programs and to assess the source of funding for those benefits.MethodsA 26-question survey investigating various benefits and funding sources was circulated by email to all ACGME-accredited orthopedic residency programs.ResultsThe survey was sent to 153 programs and 69 responded (45%). The majority offers their residents discretionary funds (77%) and conference funding (96%), most of which comes from the department, followed by the hospital or GME funding. Forty-one percent of respondents permit their residents to moonlight. The majority of respondents provide meal stipends (93%), free parking (71%), gym benefits (63%), surgical loupes (53%), and maternity/paternity leave beyond vacation time (55%). No statistically significant differences were found among top ranked residencies, top ranked orthopedic hospitals, or academic centers compared to their counterparts.ConclusionWhile some benefits are commonly offered, there is great variation in the availability and level of others. However, these differences were independent of program and hospital reputation as well as academic center status. Departments currently bear a substantial amount of the cost of these benefits internally.

Complications Following Operatively Treated Ankle Fractures in Insulin- and Non–Insulin-Dependent Diabetic Patients:

Background: Diabetics with ankle fractures experience more complications than the general population, but it is unclear whether complications differ between type 1 and 2 diabetics and between insulin- and non–insulin-dependent diabetics. This study aims to determine if there is a difference in postoperative complication rates between these groups. Methods: An administrative health care database from a large commercial insurer was queried to identify operatively treated ankle fractures in patients with type 1 (T1D), type 2 (T2D), type 2 insulin-dependent (T2ID), and type 2 non–insulin-dependent (T2NID) diabetes. Postoperative complications were identified to include postoperative stiffness, posttraumatic arthritis, amputation, implant removal, and infection. Subgroup analysis was performed to control for comorbidities. Results: A total of 20 703 closed and 2873 open operatively treated ankle fractures were identified. Patients with T1D experienced higher rates of amputation, postoperative infection, and total complications than patients with T2D (P < .05). Patients with T2ID experienced higher rates of amputation, infection, and total complications than those with T2NID (P < .0001). Subgroup analysis controlling for comorbidities showed a higher total complication rate for T1D compared with T2D in closed ankle fractures (P < .02) and for T2ID compared with T2NID in both open and closed ankle fractures (P < .0001). Conclusions: Patients with T1D and T2ID have higher complication rates than patients with T2D and T2NID, respectively. Foot and ankle surgeons should be cautioned not to classify diabetics as one cohort and should use these findings to stratify risk among this patient population. Levels of Evidence: Level III: Diagnostic

Blood Transfusion Rates as a Primary Outcome Measure: The Use of Predetermined Triggers and Display of Clinical Indications in Providing Accurate Comparative Transfusion Rates: In Reply

Atul F. Kamath, Daniel C. Austin, Peter B. Derman, R. Carter Clement, Jonathan P. Garino, Gwo-Chin Lee, Reply: We thank the readers for their letter to the editor, and for interest in our manuscript published in 2014. Issues surrounding blood management continue to be an important part of the global care of total joint arthroplasty patients as we move into 2017. In addition to our group’s multiple studies on the use of bipolar sealing devices in joint arthroplasty, we continue to examine our blood management and transfusion practices. We now routinely employ the use of tranexamic acid, which has further allowed a reduction in transfusion requirements. This may account for some of the differences between contemporary rates of transfusion, and historical rates presented before the routine use of tranexamic acid. We thank the readers for inquiring about the transfusion reduction rates as presented in our manuscript. The absolute reduction in transfusion rate was 83% to 55%, a difference of 28% points. The relative reduction as a percentage of the original transfusion rate of 83% would be approximately 35%. In a simpler comparison, for example, if the transfusion rate was reduced from 10% to 5%, we would have stated that there was an absolute reduction of 5% but a 50% reduction from the baseline rate (5%/10% = 0.5). In our manuscript, we acknowledge some of the limitations discussed by the readers’ letter to the editor. This study was not a prospective randomized controlled trial, and therefore issues of blinding and randomization do not apply. Rather, our study has important applications for real-world transfusion scenarios based on clinical scenario and patient comorbid conditions. We thank the readers for sharing their own data and algorithm for management, which, like our practice, involves careful evaluation of “comorbidity and cardiorespiratory risk, ongoing blood loss, and symptoms related to anaemia.” Likewise, confounders of age and dilutional anaemia are important considerations in any study of blood management, but are not controlled for in our clinical practice review. Again, we thank the readers for their letter to the editor, as well as their own institutional efforts to examine transfusion thresholds, understand adjunctive tools in blood management, and further the perioperative care of total joint patients.