Published 12/1/2012
S. Terry Canale, MD

MoM, Healthcare Decision Are Top Issues of 2012

Quality issues also rank high on list

Orthopaedics made news in 2012—some good, some not-so-good. A recent survey of the AAOS Now editorial board found that two continuing controversies—metal-on-metal (MoM) total hip implants and the U.S. Supreme Court decision upholding President Obama’s healthcare reform legislation—were far-and-away the most interesting and impactful stories of 2012. And, like the polls leading up to the national presidential election, these two issues were neck-and-neck as the votes came in.

Right behind them were two quality-related topics that have the potential to change the practice of orthopaedics as we know it: the implementation of electronic health records (EHRs) and the expansion of the American Joint Replacement Registry (AJRR). The Centers for Medicare & Medicaid Services have finally defined Stage 2 “meaningful use” criteria for EHRs, and the AJRR has completed its pilot project and is reaching out to hospitals and healthcare systems across the United States to establish, for the first time, a meaningful, national joint registry.

Voting was just as close for the other topics on our “Top 10” list: the coming of the International Classification of Diseases–10 (ICD–10); new studies showing that pumping local anesthetics in the knee can lead to chondrolysis; the Academy’s efforts to reduce distracted driving and improve the image of orthopaedic surgery; new guidelines on the treatment of concussion; the impact of interventions such as epidural injections and bone morphogenetic protein (BMP) in the spine; the Academy’s new headquarters building; the growing epidemic of pain medication abuse and implications for prescribers; and the growing awareness of the role that orthopaedic surgeons can have in helping patients stop smoking.

I know, if you count them up, you’ll get more than 10, but that’s what happens with a tie. So, in capsule format, here’s the year 2012 in review…

The year kicked off with a special technology overview from the AAOS on MoM implants, addressing clinical outcomes, predictive factors related to those outcomes, and the prevalence of adverse events. The issue continued to attract attention throughout the year, as AAOS Now provided coverage of the following:

  • A symposium on bearing surfaces during the American Association of Hip and Knee Surgeons/Hip Society Specialty Day
  • An advisory from the British Hip Society in March against the use of stemmed, large-diameter MoM bearings of 36 mm or greater in primary total hip replacement
  • Two days of hearings by the U.S. Food and Drug Administration’s Orthopaedic and Rehabilitative Devices Panel on the risks and benefits of MoM hip replacement and resurfacing devices
  • Lessons learned from the MoM experience that can be applied to the “unknowns of new technology”

Healthcare reform
In late June, the Supreme Court of the United States upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA), which many—including myself—refer to as “Obamacare.” But that hasn’t put an end to the controversy over many of the provisions, and it has helped fuel the Presidential race. By the time you read this article, “Obamacare” will be in the news again, regardless of who wins the election.

EHRs and “meaningful use”
I like paper, always have. But we’re in a digital age, and the AAOS has taken multiple steps to help orthopaedists implement electronic records. Regardless of how meaningful you think the “meaningful use” criteria are, regulations and reimbursements are being designed to push all healthcare providers to adopt EHRs. If you’ve felt overwhelmed by the thought of it all, visit
www.aaos.org/emrtoolkit for help.

As a quality measure, the AJRR is better than anything the government has tried to do in my mind. More than 750,000 total hip and knee replacements are performed in the United States each year; if the data were collected in one place, they would be invaluable in improving outcomes. On page 38 you’ll find a roundtable discussion among orthopaedic surgeons who are working to turn the AJRR into a true national register. If they can achieve that goal, this might head our list of top stories next year!

I’m writing this on Halloween, and there’s nothing scarier than the prospect of 141,000 codes—approximately 70,000 of which are orthopaedic codes—under ICD–10. I can’t even remember the most common 10 codes we have now; I’m just hoping that the Academy’s coding database CodeX will be able to do it all for me—or I’ll be ready to retire—when ICD–10 finally goes into effect. Although the original implementation date was to be Oct. 1, 2013, CMS has moved it back to Oct. 1, 2014. The transition promises to be both complex and costly. AAOS Now will do its best to help guide you through it in the coming months.

Pain pumps in the knee
Two years ago, the link between the use of pain pumps and subsequent development of postarthroscopic glenohumeral chondrolysis made our Top 10 in 2010 list. Now pain pumps are back in the news, with a study published in The Journal of Bone and Joint Surgery–American showing that continuous intra-articular pain pump infusion of bupivacaine in the knee caused severe chondrolysis and onset of osteoarthrosis. Although a single injection may not be harmful, this is definitely a signal that orthopaedic surgeons should be judicious in the use of pain pumps for joint pain.

AAOS initiatives
Three AAOS initiatives made news this year—the “decide to drive” campaign, the “Nation in Motion” campaign, and the decision to construct a new headquarters building and Orthopaedic Learning Center (OLC). In cooperation with the Auto Alliance, the AAOS continued its public service campaign efforts to put an end to distracted driving with print and television ads, a toolkit, and a website. The “Nation in Motion” campaign, which launched at the 2012 Annual Meeting, is designed to deepen the understanding of the value that orthopaedic surgeons provide by improving health and enhancing quality of life for millions of Americans. A board game, website, and hundreds of stories from patients underscore the key message: orthopaedic surgeons provide the best value in American medicine.

The decision to construct a new orthopaedic headquarters building—large enough to house the AAOS, more than 20 orthopaedic organizations, and an expanded OLC—was announced in September. To maintain the Academy’s leadership in education, the new OLC will feature the latest in cutting-edge technology, with virtual reality and simulation tools, distance-learning opportunities, and educational programs that can’t be beat. The original OLC was the envy of all surgical specialties; the new one will surely set an even higher standard.

Spinal treatments
The impact of interventions such as epidural injections and bone morphogenetic protein (BMP) in the spine got a lot of attention this year. The Spine Patients Outcome Research Trial (SPORT) continues to generate data that can help guide treatment. Early in the year, we heard that epidural steroid injections do not improve outcomes for patients with lumbar spinal stenosis, which lead to a “Face-Off” on the topic in the November AAOS Now. The debate was overshadowed by reports of fungal meningitis in patients who had received injections of contaminated steroids prepared by a compounding pharmacy.

As for the use of BMP in spinal fusions, the controversy continues. Research presented at the 2012 AAOS Annual Meeting found no long-term benefits, and the results of industry-sponsored research are still under scrutiny. A recent Congressional investigation concluded that the funding company exerted some influence over the way results were reported, but an outside, unbiased investigation has yet to release its findings.

Speaking of treatment controversies, concussion injuries also made news—and legislative efforts to protect players who sustain concussions on the field are changing the rules of many games. See the interview by AAOS Now editorial board member Howard R. Epps, MD, and watch for continuing coverage on this topic.

Pain management
In September, David H. Sohn, JD, MD, editor of the AAOS Now Orthopaedic Risk Manager articles, published an insightful review of the medical-legal risks of pain management in orthopaedics. Dr. Sohn noted that the Drug Enforcement Agency, in its efforts to control diversion of pain medications to recreational or street users, is targeting providers—those who write the prescriptions—rather than the users who sell or abuse the medications. In the past, physicians have been accused of not treating pain aggressively enough; this article warns that we should not be deceived by patients who may have other motives for requesting prescription refills.

Smoking cessation
Every orthopaedic surgeon realizes the impact that smoking can have on outcomes—from longer times to union to higher rates of nonunions, infections, and wound complications. At the AAOS Now-sponsored Perioperative Smoking Cessation Forum, held prior to the 2012 AAOS Annual Meeting, we learned that surgery can be, as they say, “a teachable moment.”

The forum reviewed a number of intervention strategies that boil down to three simple steps: Ask, Advise, Refer. Ask patients about their use of tobacco every time you see them. Advise patients to stop smoking. Consider delaying elective surgeries to give patients an opportunity to stop. And refer them to programs that can help—either at your hospitals or through your state’s smoking Quitline (1-800-QUIT-NOW). It can’t hurt and it will help.

S. Terry Canale, MD, is editor-in-chief of AAOS Now.