ON Call is a forum for opinions, questions, controversies, and instructive discussions across the field of orthopaedics and its relevant subspecialties.
Sunday, June 24, 2012
So, as I sit here on a Sunday morning, I am watching ESPN and they are discussing head injuries / concussions in football players. There is technology available to measure the amount of impact in the helmet and some have correlated this impact to determine what critical levels are in student athlete. Several orthopaedic surgeons are intimately involved with teams - college and professional. I am surprised that this is the first I have heard of this ... should this be something we should be advocating for as a society across all levels of play.
Little League Baseball has become a greater part of my life. Did you know that 6-year-olds are pitching? Did you know that there are some coaches out there teaching 6 and 7 year olds to throw curve balls and sliders? Why? So that they can strike out the side on kids who are barely out of diapers? Or so they can win their local-yokel town-ball championship? It makes no sense. The amount of stress on the elbow of a young person that a slider or curve ball place is tremendous and likely unhealthy. Why is it that we risk our youth for this? And, while the sports community has recommendations for pitching for younger athletes, the age needs to be younger and the penalties more aggressive.
Finally, there's the older person fragility fracture. More and more patients are coming to our center who are older sustaining injuries that are, frankly, related to their age. However, the number of patients who are not being treated in a preventive fashion is staggering.
The orthopaedic community has a responsibility for preventive care to those around us and I think we need to figure out mechanisms to improve our ability to do this. This role will be more and more important as we move forward.
Monday, May 07, 2012
The political process has always fascinated me. I don't fully understand it but it impacts our daily lives more than we (and by we I mean the medical community) really give it credit for.
I was recently at the National Orthopaedic Leadership Conference in Washington, DC. I had an opportunity to go to Capitol Hill and meet with my Congressman and / or their representatives. In some cases, our group actually spent a considerable amount of time with the member of Congress themselves and in other meetings, we were with a staffer, who, in one case, had been on the job for less than a week.
The variability with which the issues are being addressed or even discussed was shocking. The staffer who was new to healthcare knew little of IPAB or the issues that would affect access to care. On the other hand, some staffers were directly involved with policy writing which, dare I say, made them more knowledgeable than the Member of Congress they represented.
Ultimately, the decision comes down to the nine Supreme Court Justices. Up for grabs is the "individual mandate" which is the glue that holds the entire Health Care bill ) together. The mandate, according the Obama administration, is necessary to rein in the cost-shifting to the insured caused by uninsured individuals who receive free or “uncompensated” care when they visit emergency rooms and fail to pay. If the mandate is struck down by the Court, the whole bill is at risk. By all discussion on the Hill (that sounds very "politco" I know), four of the Justices are in favor of the mandate (and therefore the health care law), three are against it, leaving two left to decide the fate of health care in our country.
It truly is an awe inspring, amazing process ... and for those of us in the medical profession, one that could change the face of health care moving forward.
Monday, April 02, 2012
What do you do with your patients who smoke?
Does it really impact fusions, bone healing, or implant incorporation?
Do soft tissue not heal as well in those that smoke?
If all of that is true, then how long do you wait? How much smoking is "bad for you" and for "how long"?
I am, in no ways, promoting smoking or anything of that nature. I am trying to gain an understanding of the factors that impact our decision making in choosing to operate on patients and also what we consider factors that will affect outcomes.
I can tell you that I operate on several patients who actively smoke at the time of their traumatic event. There is little time for counseling or smoking cessation. Some of these patients go on to heal - bone and soft tissue - despite continued smoking.
So, when does it really make a difference? Or is it a matter of convenience on our part? There is data ... I think.
What are you doing for your patients / your surgeries / your outcomes in those that smoke?
Saturday, March 10, 2012
So, admittedly, I am a Philadelphia Eagles fan. Born and raised around the Philadelphia area, it’s hard for me not to root for the Eagles, Flyers, Sixers, and, of course, the Phillies. I readily admit that I have a soft spot for the Cubs having lived in Chicago and I do like the Red Sox (only because I dislike the Yankees so much).
On the Philadelphia radio waves, there is A LOT of talk about the Philadelphia Eagles trying to obtain Peyton Manning now that he has been released by the Indianapolis Colts. There is a lot of controversy about what to do with Michael Vick given the chance the Eagles took with him.
I am trying to look at this objectively. Peyton Manning has had no less than three surgeries to his cervical spine. Football is a high-energy contact sport. You can see where I am headed with this. You have to wonder – what it’s worth? If something were to happen on the field – tough hit, awkward fall, a bounty strike by one of the Saints linebackers – it could result in Peyton not just missing a few games, but being on a ventilator the remainder of his life. I have patients who return to high impact activity after surgery, but professional football vs going for a run on the weekend are two different events. So, from my perspective, what is the role of the medical community hear?
I hear stories of medical professionals who are involved with professional sports teams who have their recommendations altered because of the circumstances – playoffs, ticket sales, division rival, etc.
But, what is our role? Look at the Ryan Howard situation. Wound complication after an Achilles Tendon rupture well publicized in the media. Where does the responsibility of the team physician lie – to the team or to the patient? This is difficult. In some scenarios, as a team physician, you are EMPLOYED by the team and therefore, to some degree, you decision making process may be affected by that. But, shouldn’t the obligation be towards the patient / player?
I know I have said to patients in the past, “If you were an elite level athlete we would do “x” but since you are a weekend warrior, the surgical plan is “y”?” Is that reasonable? Shouldn’t all patients be treated the same?
Wednesday, January 25, 2012
I had clinic yesterday and one of the recurring themes was the request for pain medication - narcotic pain medication. I heard a variety of reasons - my PCP told me to ask you, I was referred to you for my pain, I ran out of my medication, pain management won't see me, I didn't have time to get to my other appointment, etc etc.
I am constantly perplexed as to what our role (as orthopaedic surgeons) is in terms of pain management. Part of my confusion stems from where our roles begin and end. As the overseers of the musculoskeletal system, are we responsible for anything pain related when it comes to back, bone, muscles, or tendons? Are anti-inflammatories enough? Are they problematic? Is there a role for opiods? Should we be using more alternative therapies? Where do pain modulation agents like gabapentin fit in?
I saw a recent statistic that 99% of the hydrocodone medication and 80% of the prescription opiods are consumed by the United States. What are we doing so differently compared to other countries? Is it a matter of managing expectation?
Also, where does our obligation begin and end if we operate on a patient?
There are several articles this month within Orthopaedic Network that examine pain and pain management. I think it behooves us as a specialty to understand and modulate pain in our patients better without creating a culture of addiction.
Friday, December 09, 2011
Who? When? How?
I feel like a news reporter. More and more patients are coming in seeking this as a remedy to their "ankle" arthritis and "foot" pain. "Can't we just replace it, doc?" is something that I am hearing more often.
From our patients' perspective, hip and knee arthroplasty have been wildly (and widely) successful. The quality of life improvement seen after THA or TKA mirrors that of having a CABG.
So, of course, if we can replace the hip and the knee and even the shoulder, then the remedy for my foot pain must be a replacement too?
I've read the review articles on TAA. I've seen the technique on video and in person. I've spoken with surgeons who perform TAA's. I've witnessed conversions of fusions to arthroplasty.
But, at the end of the day, I am left scratching my head. Part of my confusion is my own practice. As my trauma practice is maturing, I am starting to see more post-traumatic arthritis after injury (and most times, surgery). Confusion is replaced by frustration because I am at a loss on how to council these patients:
1) Do nothing
2) NSAIDs, PT, Activity Modification
5) Viscosupplementation (off label)
7) Distraction chondrogenesis
Is TAA a viable option for someone who is 32 yo, works construction, and has post-traumatic arthritis after a pilon fractures? If not, then is TAA ready for prime time? Do we really understand ankle kinematics the way we have come to understand (and continue to discover) knee kinematics?
I am left with more questions than answers.
Monday, November 14, 2011
I would really like to hear from the hip gurus out there. I need to better understand the hip. I need to understand the pathology, the etiology of said pathology, the treatment options (and algorithms), the outcomes, and, ultimately, the science of it all.
I readily admit that some of what we do in orthopedics is based on experience and Level V or VI evidence (does Level VI even exist)? I am trying to understand the revolution that has surrounded the hip over the past 20 years - from the work of Ganz and open procedures around the hip to some of the novel arthroscopic work being done.
I recently saw a presentation by a hip specialist at a meeting I was at ... the presentation was excellent and focused entirely on diagnosing the problem.
I feel like we are with the hip where we were the elbow several years ago - just starting to understand it, making assumptions, doing research, and having experts really come to the front and open our eyes.
In some ways, I am a little more hesitant when it comes to the hip. In part, this may be due to my own hubris thinking I know the hip. Then I think, why should the hip be any different than the knee or the shoulder?
I need some direction. I think there are a lot of orthopaedic surgeons out there who feel that way.
Tuesday, October 25, 2011
It sounds like a bad movie title - the theme of this blog. If it were a movie though, my guess is that it would sell out the first weekend, and then ticket sales would fall through the floor.
What do I mean? There is A LOT of interest in with navigation, and now robotic surgery - with the predominant focus on total joint arthroplasty.
Navigation has been available for at least a decade and involves placing fiducials (markers) on the patient, referencing those markers, and then making cuts and placement of implants based on those reference points. The surgeon uses a computer screen which guides him or her. It is much like playing one of those wireless gaming systems like Wii or Kinectiv.
Robotic surgery in orthopaedics is relatively new. Advanced imaging is loaded into a system and then the robot is on the field with the surgeon making bone cuts and actually helping with the procedure. Robotics have been used in other fields in a exponential fashion, predominantly urology.
But, these systems come at a price. The costs are significant and often require a capital expense from the health system or hospital.
The real question, though, involves clinical outcomes. There are lots and lots and lots of manuscripts on navigation, but I have yet to see on where clinical outcomes are BETTER than traditional surgery.
I am not a total joint surgeon. I do know the literature that says the more you do, the better you are. That just makes sense. So, if you do 1000 joint replacements per year, do you need the robot? Why would you use navigation? Is it faster? Is there less blood loss?
Or, is this about marketing? The orthopaedic world is about volume and drawing patients to your practice ... so is having a robot for the purpose being able to have a radio ad or a billboard? Or maybe you are really interested in the question and there will be answer about whether it's really better or not.
I need to buy another ticket.
Wednesday, September 07, 2011
What is the role of the orthopaedic surgeon? Are we simply technicians who fix fractures in this unique patient population? If that is the case, are we properly equipped (literally and figuratively) to do this?
I readily admit that it is not easy to be the person primarily managing this patient population. At our institution, we've tried to work with our hospitalists, our geriatricians, our endocrinologists, our rheumatologists, the AOA Own the Bone, our hospital administrators, our research groups, etc etc to develop some sort of system to help facilitate the care of geriatric orthopaedic patients and those that sustain fragility fractures.
How have we done? Not well I don't think ...
Having said that, I will say that I have learned a lot from my attempts to put this together ... In my humble opinion, this requires a substantial effort or champion on the orthopaedic side to help facilitate the medical and surgical aspect of the care of these patients.
In addition, assuming we can address the collaborative effort along with the streamlining their care, I fully believe that we (as a group) need to have a better understanding of fracture fixation in this patient population. Recognizing that we have advanced technology liked locking plates, is that really enough? Is the issue existing technology or the need for a better method of fracture fixation from a physician / surgeon perspective.
I would like to hear how others have done it ... or have not done it ... there has to be a way that can be applied across health systems and hospitals. I've included some articles recently published in Current Orthopaedic Practice and the Journal of Orthopaedic Trauma. In addition, the Journal of Bone Joint Surgery recently published some compelling research as well (abstract at: http://jbjs.org/article.aspx?articleid=35837).
Tuesday, August 09, 2011
All right - so I'm not sure where to go with this one ... I read with interest the Canadian study - prospective, multi-center, randomized - looking at fixation of clavicle fractures from a few years ago. Their results were favorable in terms of fixation of clavicle fractures for certain patterns.
However, it appears that fixation of clavicles has become the norm now - and that data is being quoted when patients are having their clavicles fixed.
In fact, we have no moved from relatively inexpensive reconstruction plates and screws to fancier clavicle nails which cost several fold more. There is no data to support an increased rate of union or significant clinical improvement with the use of non-traditional fixation techniques.
But then there were the two publications attached to this blog in recent issues of the Journal of Pediatric Orthopaedics showing a trend towards fixation of clavicle fractures in the adolescent patient population.
I have always considered myself very data driven so it is hard for me to wrap my head around this - fixing clavicles in kids ... really?
Friday, July 22, 2011
It's Boards week here in the States. This is the week that nervous, over dressed, and anxious young orthopaedic surgeons fly into Chicago, navigate their way to the their hotel and then the next day are peppered with questions about their cases, their mistakes, and their practice patterns. And, when it's all said and done, some 90 or so minutes later, it's rather un-fulfilling - all the build-up and then "done".
Months later you receive your notification of passing or not. And then that's it ... until the re-certification process. :)
I have to say that in my humble opinion, I think the American Board of Orthopaedic Surgery does an excellent job of reviewing applicants for board certification and examining them. The process, despite having a subjective component, is extremely well organized and has gone through rigorous psychometric testing.
Ultimately, there is a value to being board certified - because of their efforts, it actually means something.
Having said that, I wonder about the re-certification process ... I wonder about what should go into this. Should it simply review what you do in practice or should there be some assessment of modernization in your practice patterns? Should it be obvious that you are reading and keeping up on the literature? Should it be an examination or an in-person interview? One person recently suggested to me that maybe the examiners should come see them in their practice to assess their "certifiability". My response is that we are all "certifiable" to some degree.
I know we have some international members as part of this site and it would be interesting to hear what their certification process entails ...
Saturday, July 16, 2011
Is it bad when the New York Times and the Wall Street Journal are running stories on what seems like a regular basis regarding certain orthopaedic devices and implants?
Many of you probably have read or heard of recent editorial pieces and comments on those pieces regarding BMP-2.
The real question, which I don't think I've seen addressed yet to some degree, is what is the role of Industry Sponsored Research? Does it have a place in Orthopaedic Surgery? And if so, in what way?
Maybe the plea should be made to the federal funding agencies like the NIH - if the pay line weren't in the single percentage points maybe we wouldn't have to turn to industry to fund our research.
Or maybe we should turn to the federal government and look for them to restore reimbursement to reasonable levels so that physicians don't feel compelled to become consultants or seek to enhance their income.
Or maybe we should turn to industry and say that sponsorship come in DIRECT costs only and paying surgeons to do research is not appropriate.
But, let's also not forget that without industry sponsored research, we would not have made the advances we have in medicine, whether it's pharmaceuticals or implants.
Is Industry Sponsored Research tainted regardless of the quality of the research being performed?
Monday, June 27, 2011
No, I am not referring to Orthopaedic Surgeons, often referred to as "Pods" in short, but rather the concept of Physician Owned Distributorships (PODs). The concept is that the physician, in this case the orthopaedic surgeon, is the distributor of implants to the hospital. This, essentially, limits the need for additional resources or personnel to be in the operating room and also limits 3rd party individuals in the positioning of implants within the hospital or surgery center setting.
The Wall Street Journal recently published an article on PODs with emphasis on Congress looking into the legality of such organizations, particularly from a STARK perspective (anti-trust).
I would like to hear from those who have experience on either end of the POD concept and also from our international readers who might provide a unique perspective on the financial relationships between vendors, hospitals, and physicians.
Thursday, March 31, 2011
Okay, so what are you all using? Or anything at all for that matter?
I was recently at a trauma meeting where the term "Holy Water" was thrown around.
At the end of the day, I keep waffling. There's A LOT of data out there that I am sure our community is aware. What does it all mean? It's like alphabet soup.
Recently, the FDA did not approve a product containing recombinant human BMP for fear that it may lead to cancer ... really?
Then there was another article published in the literature about the off label use of a certain biologic approaching 90% ...
And there's the non-invasive biologics - like ultrasound and electrical stimulation.
So I ask you - what's the answer?
Wednesday, March 09, 2011
The AAOS meeting is always an interesting experience. I am not sure what I should take away from it ... So I pose to you, what did you feel was the most important aspect of the meeting ...
Additionally, I'd like to hear what you think this Blog should focus on. My interests (aside from orthopaedics - which Malcom Gladwell might disagree given his position on Expertise) include education and health policy. I also have an interest in the "machine" that makes health systems and hospitals work. There is a lot going on with looking at different financial models and different strategies going on with revenue enhancement.
We can also focus on the science of orthopaedics ... although I'm not sure what that really means. Our department recently hosted Dr. Bhandari from McMaster University as a Grand Rounds speaker. His talk was, simply, fantastic. It provided a perspective on what we do and how we do it ... and how we NEED to do it with respect to the use of Evidenced Based Medicine ... or as the term of the year is - compartive effectiveness research.
Look forward to hearing your thoughts.
Tuesday, February 15, 2011
It's that time of year again ... I look forward to the annual meeting. I know it's controlled chaos - a well oiled machine with multiple pistons running simultaneously. It truly is an amazing coordinated effort.
From what I have heard, and I have NO REFERENCE for this statement, it is the second largest meeting (by size) of it's kind within the medical world with the radiology conference being bigger (because of the floor space required for the various imaging machines).
Regardless, the Annual Meeting attracts participants for a variety of reasons - the talks, the exhibitis, the friends, the location, the advocacy, etc.
I've always wondered how different people approach the AAOS meeting. I don't think I've quite figured it out ... I will say that when I go, I feel like kid in a candy story - sensory overload in the best possible way. Maybe that's because I really enjoy what I do.
Friday, February 11, 2011
All I needed was to see the title “Sleep Deprivation, Elective Surgical Procedures, and Informed Consent” and my heart sank. This was right before the beginning of the New Year. I didn’t see this in a medical journal or through one of my RSS Feeds but rather on the local news. “Where is this going” is all I could think of.
Of course, I immediately grabbed my smartphone and found the article in the NEJM and with my eyes straining to read the 2pt font on my miniature phone screen scanned the text trying not to form any opinion or bias or react like I typically do when I see things written like this.
I e-mailed myself the article so that I would remember to read it when I was at my laptop. And I did – every word. In fact, I even looked at the references.
It’s hard for me to really figure out where I stand on the issue. As an orthopaedic surgeon, particularly a trauma surgeon, I am involved with surgery at all hours of the day and night – as are some of the residents that I work with. In addition, I have faculty from other subspecialties who take call who have elective schedules the next day.
I would think and hope that we know our limitations. I think patients should know as much as is reasonably possible before entering the operating room. Communication is critical. However, mandating that I disclose if I am tired or if I am adequately rested is not the solution. Better methods of understanding and managing fatigue along with work-life balance are critical to maintain longevity and prevent burnout.
Wednesday, January 05, 2011
Welcome to the ON Call Blog on LWW’s new Orthopaedics Network! This new site offers subscribers a unique opportunity to access the entire collection of LWW published Orthopaedics journals in a single website. Journal articles in Orthopaedics Network are organized in a series of topical-based ‘channels.’ These channels serve as a simplified way for Orthopaedic surgeons to discover the latest research and techniques in their area of focus without having to spend a lot of time combing through a series of journals. The advantages to this are multi-fold, bringing together a vast amount of information quickly and efficiently. Now, for example, if you are interested in peri-prosthetic fractures, articles can be culled from Current Orthopaedic Practice, the Journal of Orthopaedic Trauma, Techniques in Arthroplasty, and a number of other resources with a few clicks of your mouse. In addition to the standard topical channels, subscribers can create their own personal channel based on existing channels and add custom criteria like journal filters and keywords to narrow down to custom topics. (View complete list of journals and channels here.)
Full-text journal articles are available in Orthopaedics Network dating back to the beginning of 2008. Subscribers have access to full text HTML and PDFs (when available) of all articles, plus any supplemental materials. Abstract access is available for all articles prior to 2008.
As Orthopaedics Network’s Web Editor, I will guide subscribers to “must-read” Featured Articles and, with this ON Call Blog, provide insight into the latest developments in orthopaedics worldwide. Watch this space for much more over the coming months and years. For more information on subscription options, including how to start your 15-day free trial, please visit this page.)
I look forward to seeing you and having you be a part of our growing network.
Samir Mehta, MD, Web Editor
University of Pennsylvania