On (and Off) the Record | Orthopedics This Week

On (and Off) the Record

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Dear OTW Reader: Surprising Infection Study Conclusion…Cervical Disc Replacement Cheaper Than Fusion?What Younger Patients CAN’T Know, But Ask Anyway says Dr. Elton Strauss…Your Reimbursement Hangs in the Balance says NYU’s Joseph Bosco as he discusses QA…and more….

Unexpected Study Outcome re: Infection and RA 

Dr. Craig Della Valle, a hip and knee surgeon at Midwest Orthopaedics at Rush, found that there is no difference in the cutoffs for diagnosing patients with RA (rheumatoid arthritis), which is unexpected and debunks the common myth that the tests surgeons normally use for diagnosis of infection are unreliable with RA patients. With the growing interest in infection diagnosis and control, this is important news. 

Dr. Della Valle, who helped to develop recent American Academy of Orthopaedic Surgeons (AAOS) guidelines on the diagnosis of infection, told OTW:

“At the recent AAOS meeting there were at least 300 people in the room for an instructional course lecture on infection. While there are new, much-needed guidelines on the diagnosis of infection, we are still faced with some unusual questions. For example, ‘Are the current testing parameters valid for patients with rheumatoid arthritis (RA)?’ We did a study looking at 811 revision total hips and knees, including 61 with RA. We found that there was no difference in the cutoffs for diagnosing people with RA, which is unexpected and debunks the common myth that the tests we normally use for the diagnosis of infection are unreliable in this population.

One of our current studies involving infection—which we hope will be finished in the next month or so—is a prospective randomized study where we are trying to determine if prophylactic antibiotics affect intra-operative culture results in patients undergoing revision hip or knee arthroplasty surgery. All patients studied have a known infection. In one group, antibiotics are given within one hour prior to incision, while the other group is having antibiotics held until intraoperative cultures have been obtained.

Thus far it does not appear that this one dose affects culture results. This builds on prior work done by Dr. Robert Barrack that suggests prophylactic antibiotics should not be withheld prior to most revision procedures as culture results do not seem to be affected. And given the value of intervention to prevent infection, they should be given in the vast majority of cases.”

Dr. Kevin Lutsky Joins Rothman Institute  

Kevin Lutsky, M.D., is now bringing his talents as a hand surgeon to the Rothman Institute in Philadelphia. After earning his M.D. from MCP Hahnemann School of Medicine, Dr. Lutsky did a residency at New York University Hospital for Joint Diseases, followed by a Hand, Upper Extremity and Microvascular Surgery Fellowship at Washington University in St. Louis/Barnes Jewish Hospital, St. Louis, Missouri. In the OR, Dr. Lutsky’s experience includes arthroscopy of the wrist and hand, management of trauma and complex fractures of the upper extremity, compressive neuropathies such as carpal and cubital tunnel syndromes, peripheral nerve injuries, arthritis of the wrist and hand and tendon injuries. Best wishes from OTW, Dr. Lutsky!

Young Knee Patients in the Dark About Prosthesis Longevity

Dr. Elton Strauss, Associate Professor of Orthopedic Surgery at the Mount Sinai School of Medicine, has been thinking a lot about the fact that nearly 5 million Americans are living with artificial knees…and that many of them are young. Dr. Strauss, who once chaired the AAOS Committee on Aging, tells OTW:

“The problem with patients asking for a knee replacement at a young age is that we’re not able to tell them how long their prosthesis is going to last. We can only tell them, ‘There is no clinical data for a prosthesis lasting 30 years.’ There are so many comorbidities that cloud the picture…like how much someone uses his or her leg. If you are 40 years old and sedentary and you don’t stress the joint, then the prosthesis will last longer. The day you take a car off the showroom floor—whether it’s a VW or a Rolls Royce—the car starts to gain mileage. Similarly, when I put in a prosthesis, the clock starts ticking.

Another constant concern is infection. If someone gets an infection somewhere else in her body—for example, a urinary tract infection—it’s possible that it could travel to the prosthesis. There is no blood supply there, and bacteria love to bond to cement and metal. I should also note that many of us have pretty ill patients—such as those with HIV and Hepatitis C—and we operate on them nonetheless. They are in so much pain that you can’t not operate on them. We used to tell women who were diabetic that they should not get pregnant…things have changed in that regard…as they are with joint replacement.”

Hospital Reimbursement Hangs in the Balance  

Joseph Bosco, M.D., is vice chair for clinical affairs in the Department of Orthopaedic Surgery at NYU Langone Medical Center. He is also director of the Center for Quality and Patient Safety at NYU Langone Hospital for Joint Diseases. Dr. Bosco told OTW:

“This is our fourth year of formally analyzing quality and patient satisfaction data for orthopedic procedures at NYU Langone. When we first embarked on this project many people didn’t understand its importance and/or how it would affect their practices as far as patient satisfaction and infection rates. Fundamentally, it’s all about alignment.

Every major institution has the resources available to implement a quality assessment initiative, but you must align those with the priorities of the institution…and the priorities have to be patient safety, patient satisfaction, and infection rates. The focus on quality assessment is going to increase significantly in the coming years; the state of New York is ahead of the game, and now publicly reports hospital quality data on its website. The reality is that it’s a competitive marketplace, and no one wants go to a hospital with a high infection rate. Our institution doesn’t want to hoard this information…the fact is that we are doctors for the greater good…and the NYU Langone Hospital for Joint Diseases is a recognized leader in the orthopedic community. This means that we have a responsibility, and need to speak at conferences and help other institutions that want to implement such a program.

The key element is to get buy in from doctors…and to do that you must explain that the hospital’s reimbursement may decrease if patients are not happy. The metric of ‘willingness to recommend XYZ hospital’ is critical; if a third of patients say that they wouldn’t recommend your hospital, then this is obviously not good for the individual doctors.”

Cervical Disc Replacement Cheaper than Fusion?

Dr. Sheeraz A. Qureshi, assistant professor at Mount Sinai Hospital in the Department of Orthopaedic Surgery specializing in spinal surgery, is doing some interesting work on cervical disc replacements these days. He tells OTW,

“I am involved in a study which is thus far showing that the rate of growth in the use of cervical disc replacement is increasing at a greater rate than anterior cervical disc and fusion. Although there are still more anterior cervical fusions performed, the rate of growth of cervical disc replacement is greater. Some of the main questions are, ‘Are we doing the smart thing in terms of cost effectiveness? Are we doing something that may be getting the same or somewhat better results, but is much more expensive?’

We have done a cost effectiveness study directly comparing cervical disc replacement and fusion, in which we used a decision tree model. We found that cervical disc replacement is actually less costly and more effective. In this study, which will be published soon, our primary assumption was that a patient who has neck problems has a health utility value (HUV) of some number. Then we assigned them a better HUV of some number after cervical disc replacement and after fusion. Because HUV in cervical spine surgery didn’t exist, we made assumptions as to these numbers based on data from joint replacements. Recently, we have received industry support in the form of patient specific data from IDE trials, and used their numbers to calculate these health utility factors. For example, patient A has a herniated disc and thus has health utility number of .5. Someone in an ideal health state of has a 1 and anyone less healthy has a smaller value. We are going to be publishing our findings and calculations so that this information is available to our colleagues. It should be a great help to anyone wishing to do cost effectiveness research.”

Magnus Persson, M.D., Ph.D. Joins Ascendx Board

Dr. Magnus Persson, a life sciences veteran with experience in the private and public sectors, has been elected to the board of directors of Ascendx Spine. Dr. Persson has been a partner in two life sciences-focused venture capital firms, one based in Sweden and one in California. His background also includes experience leading development teams of Phase II and III programs in the pharmaceutical industry; in addition, he has founded and led private as well as public biotech and medtech companies as chairman of the board and a director in Europe and the U.S. In addition, Dr. Persson has led several successful recruitment processes for senior management positions, including CEOs. All the best from OTW, Dr. Persson!


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