News in 10

The 10 items below are the most significant elements of recent editions of Headline News Now—the AAOS thrice-weekly, online update of news of interest to orthopaedic surgeons. Check this page regularly for updates.
Updated on June 10, 2014

1. Study: Randomized trial finds intraarticular analgesia an effective alternative to epidural plus nerve block in TKA.
A continuous intraarticular infusion of ropivacaine can serve as a safe, effective alternative to epidural analgesia plus single-injection femoral nerve block (FNB) after total knee arthroplasty (TKA), concludes a study published in Clinical Orthopaedics and Related Research. The randomized double-blind trial compared the side-effect profile, analgesic efficacy, and functional recovery among 94 patients assigned to one of the two treatments. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group, but after 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. No differences in complication frequency were seen. The authors note that any improved analgesia seen in patients who receive epidural analgesia plus single-injection FNB "must be weighed against the disadvantage of a higher likelihood of knee buckling and delayed ambulation with that treatment approach." Possible side effects of epidural analgesia include nausea, hypotension, pruritis, somnolence, dizziness, and respiratory depression.
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2. Study: Trampoline use leads to high number of fractures and other injuries in children.
As reported by Medical News Today, a study published online in the Journal of Pediatric Orthopaedics finds that approximately 288,876 people—mostly children—received care at emergency departments (EDs) between 2002 and 2011 for fractures sustained during trampoline use, with associated healthcare costs of more than $400 million. In addition, all injuries (including fractures) from trampoline use led to more than 1 million ED visits during the decade, resulting in more than $1 billion in healthcare costs. The researchers analyzed data on trampoline injuries from the National Electronic Injury Surveillance System, which contains data from a sample of 100 hospitals nationwide, and found that the average age of patients with trampoline-related fractures was 9.5 years. Approximately 60 percent of fractures occurred in the upper extremities, such as fingers, hands, forearms, and elbows, while lower extremity fractures, which accounted for nearly 36 percent of fractures, were most often fractures of the tibia/fibula and ankles. In addition, 4.4 percent of fractures occurred in the axial skeleton, defined as the spine, skull/face, or rib/sternum.
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Read the abstract…

Read the AAOS Position Statement on Trampolines and Trampoline Safety…

3. Study: ASCs may offer "efficient" path to quality and cost savings.
Findings published in the May issue of the journal Health Affairs suggest that ambulatory surgery centers (ASCs) offer an efficient approach to meeting predicted growth in demand for outpatient surgeries, and may reduce costs while improving the quality of healthcare delivery. The research team reviewed data from the U.S. Centers for Disease Control and Prevention on 52,000 surgical visits across 437 facilities over 4 years. They found that procedures performed in ASCs took 31.8 fewer minutes than those performed in hospitals—a 25 percent decrease—and estimated that patient costs were $363 to $1,000 lower per procedure in ASCs, while outcomes were similar in both ASCs and hospitals.
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Read the abstract…

4. Physician registration for CMS Open Payments (Sunshine Act) program to begin June 1.
On June 1, 2014, physicians and teaching hospital representatives will be able to register on the U.S. Centers for Medicare & Medicaid Services (CMS) Enterprise Portal. Registration is a voluntary process, but only registered users will be able to dispute information reported by industry that they believe to be inaccurate or incomplete. Registration will be conducted in two phases for the first Open Payments reporting year:

  • Phase 1 (begins June 1) includes user registration in CMS' Enterprise Portal.
  • Phase 2 (begins in July) includes physician and teaching hospital registration in the Open Payments system, and allows them to review and dispute data submitted by applicable manufacturers and applicable group purchasing organizations prior to public posting of the data.

CMS states that disputed data, if not corrected by industry, will still be made public, but will be marked as disputed.

AAOS strongly encourages members to register.
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Learn more about the review and dispute process…

5. Study: Concussion diagnosis rates on the rise in high school sports.
According to findings published online in The American Journal of Sports Medicine, national concussion diagnosis rates for high school sports increased significantly between 2005 and 2012. The authors used the High School Reporting Information Online sports injury surveillance system to calculate concussion rates over a 7-year period. They found that, during the study period, there were 4,024 concussions, with overall concussion diagnosis rates increasing significantly from 0.23 per 1,000 athlete-exposures in academic year 2005-2006 to 0.51 per 1,000 exposures during 2011-2012.
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6. Study: Higher BMI linked to longer stays and increased costs after TKA.
A study published in the May 7 issue of The Journal of Bone & Joint Surgery suggests that obesity may be associated with longer hospital stays and higher costs in total knee arthroplasty (TKA), and the effect of obesity on costs may be independent of obesity-related comorbid conditions and complications. The research team reviewed data on 8,129 patients who had undergone 6,475 primary TKAs and 1,654 revision TKAs at a single center. They found that length of stay and direct medical costs were lowest for patients with body mass index (BMI) values in the normal to overweight range, while increasing BMI was associated with significantly longer hospital stays and costs. After adjustment, the research team found that every 5-unit increase in BMI beyond 30 kg/m2 was associated with approximately $250 to $300 higher hospitalization costs in primary TKA and $600 to $650 higher hospitalization costs in revision TKA.
Read the abstract…

7. Should handshaking between physicians and patients be banned?
Physicians should stop shaking hands with their patients to limit the transmission of pathogens and disease, suggests an editorial in The Journal of the American Medical Association. Instead, the authors recommend adopting a suitable alternative—such as hand waving, placing the hand over the heart, bowing, or the Namaste gesture (a slight bow and hands pressed together, palms touching and fingers pointing upwards, thumbs close to the chest)—and promoting it with extensive educational programs and appropriate signage to ensure acceptance. “Given the tremendous social and economic burden of hospital-acquired infections and antimicrobial resistance, and the variable success of current approaches to hand hygiene in the health-care environment, it would be a mistake to dismiss, out of hand, such a promising, intuitive, and affordable ban,” the authors write.
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8. MGMA survey notes practice challenges dealing with ACA patients.
A Medical Group Management Association (MGMA) survey of 728 medical groups covering more than 40,000 physicians assesses the impact of Affordable Care Act (ACA) exchanges on those practices during the first 120 days of 2014. The researchers found that more than 80 percent of respondents said their practices are participating with products sold on the ACA exchanges, and that more than 90 percent of those practices have already seen patients covered under the new law. However, 62 percent of respondents reported moderate to extreme difficulty identifying patients with ACA exchange coverage (compared to traditional commercial coverage), and 60 percent stated that factors such as eligibility, cost-sharing, and network coverage were somewhat or much more difficult to determine. Overall, MGMA notes three primary themes, based on the survey responses:

  • Practices have experienced difficulty in identifying patients with ACA coverage and obtaining essential information related to that coverage.
  • Practices are facing a number of challenges related to patient cost-sharing for ACA insurance exchange coverage.
  • Practices have concerns about the impact of the network design of many ACA exchange products.

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Read the complete report (PDF)…

9. GAO report finds that orthopaedists buck the trend in self-referral for PT services.
A report from the U.S. Government Accountability Office (GAO) examines physician self-referral and Medicare spending for physical therapy (PT) services, and finds that self-referring orthopaedic surgeons, on average, referred fewer PT services than non–self-referring orthopaedic surgeons. In contrast, self-referring family practice and internal medicine providers in urban areas generally referred more PT services than their counterparts who did not self-refer. From 2004 to 2010, the report finds that non–self-referred PT services increased at a faster rate than self-referred PT services, and over that time, the number of self-referred PT services per 1,000 Medicare fee-for-service beneficiaries held generally flat, while non–self-referred PT services grew by about 41 percent.

In response to the report, Frederick M. Azar, MD, president of AAOS stated, "Physical therapy outcomes are best when a patient’s surgeon and therapist can work closely together. This study confirms the responsible use of in-office ancillary services by orthopaedic surgeons and the importance of maintaining the integration of those services in an orthopaedic surgeon’s office to allow for the continuation of care and to provide the best treatment option for patients."
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Read the GAO summary…

Read the complete report (PDF)…

Read the AAOS statement…

10. Study: BMI most important factor driving increase in TKA.
Data published in the June 4 issue of The Journal of Bone & Joint Surgery suggest that body mass index (BMI) has played the most important role in increasing demand for total knee arthroplasty (TKA) above that of total hip arthroplasty (THA). The authors compiled a minimum of 10 years of data from sources such as the Nationwide Inpatient Sample, the Federal Register, the U.S. Centers for Medicare & Medicaid Services (CMS), the Behavioral Risk Factor Surveillance System, and AAOS. They found that the number of TKAs performed in the United States more than tripled from 1993 to 2009, while the number of THAs approximately doubled. Of all factors examined, the authors noted that BMI played the most substantial role in increasing demand for TKA above that of THA, with younger individuals affected to a greater degree. In addition, growth in TKA volume far outpaced that of THA among the patient population with a body mass index of ≥25 kg/m2, but not among those with a body mass index of <25 kg/m2.
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Read the abstract…