AAOS Now

Published 12/1/2013
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S. Terry Canale, MD

From the ACA to YODA: Top Issues of 2013

This past year has been one of political turmoil. When it comes to orthopaedic issues in the news, 2013 has been a year of exciting controversies, generating several interesting news stories in AAOS Now. The top 10 news items of 2013, as selected by the AAOS Now Editorial Board, all received considerable coverage in the pages of AAOS Now.

The ACA (“Obamacare”)
The re-election of President Obama in 2012 ensured that the Patient Protection and Affordable Care Act (ACA) would be fully implemented. In 2013, the healthcare reforms commonly known as “Obamacare” were inadvertently reaffirmed by a dysfunctional Congress in the following ways:

  • Although the House of Representatives voted 46 times to repeal the law, the Senate refused to consider any of the proposed legislation.
  • Attempts to “dilute” the law by several states in the handling of health insurance exchanges and Medicaid expansion failed.
  • Not even the recent government shutdown could defund or delay implementation of the ACA.

None of these efforts succeeded in stopping Obamacare and we can only hope that the light at the end of the tunnel won’t be that of an oncoming train. The Republican strategy now seems to be to focus on how bad the process is and possibly gain political traction if the train runs out of steam and fails for any reason.

Including this issue, AAOS Now has published nearly 30 articles on various aspects of the ACA, making this subject the No. 1 story of the year.

No fiscal cliff or SGR fix
Debates on the federal budget and the debt ceiling continue, with Congress going to the brink of a deadline before acting. It’s the same tactic that’s used with physician payments under the sustainable growth rate (SGR) formula. As this issue goes to print, we physicians face the threat of a nearly 25 percent cut in Medicare payments beginning Jan. 1, 2014.

AAOS Now has published more than a dozen articles this year about the “movement” to replace the SGR. At the time of this writing, both the House and the Senate have proposed draft legislation to eliminate the SGR, but neither bill includes a “pay-for,” last estimated at $139 billion. Under both measures, the best we can hope for is that our payments will be frozen at current levels for 2014 (unless, of course, the Centers for Medicare & Medicaid Services [CMS] reduces the relative value units for specific procedures in the 2014 Medicare Physician Fee Schedule final rule, which had not yet been released as I write this).

The value of orthopaedics
I define value as quality divided by cost. But cost is more than just the hospital bill. Value should also consider the cost to society—the indirect savings that result when people receive appropriate orthopaedic care and can continue to work and contribute to society.

As orthopaedic surgeons, we know that our patients are getting quality results from procedures such as total joint replacement, anterior cruciate ligament reconstruction, and rotator cuff repair, and now we have objective analysis that shows these procedures deliver value to society as well.

The efforts of the AAOS Value Project Team have resulted in the development of an economic model and publication of four articles on the value of orthopaedic surgery. These articles reviewed the literature and objectively reviewed the three procedures with regard to quality to the patient and financial value to society and the government by measuring the impact on the productivity of the postoperative patient, enabling the patient to return-to-work rather than be on disability.

I have reviewed the articles, and it is hard to argue against the methodology, statistics, and results. AAOS Now has published six articles in 2013 on the value of orthopaedics and the procedures we perform, including this month’s cover story, “Rotator Cuff Treatments Pay Off.” The A Nation in Motion website has a special section on the value of orthopaedics (www.ANationInMotion.org/value). I hope that the results will be widely read so that people realize the value to society that orthopaedic surgeons deliver.

Operation Walk USA
This endeavor may not be as applicable to all orthopaedic surgeons as the first three issues, but it is related to the role orthopaedic surgeons have in society and the community. Operation Walk USA is in its third year, and each year the number of patients who benefit from these pro bono hip and knee replacement surgeries continues to grow. The surgeries are performed at no charge to the patient from the device maker, the anesthesiologist, the orthopaedic surgeon, or the hospital.

In December 2012, more than 200 patients benefitted from joint replacement surgeries performed under the auspices of Operation Walk USA. This year’s event takes place Dec. 2–7 and is projected to benefit up to 250 patients. Congratulations to Adolph V. Lombardi Jr, MD, and his volunteer board of directors for this outstanding humanitarian endeavor and thanks to all of the surgeons, anesthesiologists, ancillary personnel, hospitals, and companies that participate.

Steel girders give shape to the new AAOS headquarters and Orthopaedic Learning Center. Watch the construction’s progress at https://aaosbuilding.shutterfly.com

Metal-on-metal
Metal-on-metal (MoM) hip implants continue to generate news stories. In 2013, the emphasis was on the number of revisions in patients with both symptomatic and asymptomatic pseudocysts and the relationship of corrosion to pseudocysts. This year, hip resurfacing implants were also implicated as a cause of pseudocysts. Unfortunately, the only hip resurfacing procedure available presently is MoM.

The clinical management of patients with asymptomatic or symptomatic pseudocysts or, for that matter, all patients with MoM hip arthroplasty was a topic of much discussion in 2013. The legal liability is looming, and several class action lawsuits have already been filed.

Concussion and CTE
2013 seems to be the “year of the concussion.” Although it has long been known that those participating in contact sports, such as football, soccer, hockey, and even field hockey, could be subject to cerebral trauma and even repeated concussions, it was not widely known that concussions could result in chronic traumatic encephalopathy (CTE), leading to dementia, loss of memory and cognitive skills, and depression.

The National Football League (NFL) settled a lawsuit with 4,500 former players for $760 million in 2013, which sparked numerous news stories castigating the league for not admitting that concussions and recurrent concussions in football players might be related to CTE. Based on autopsies of 65 brains of deceased NFL players, 64 were determined to have CTE. Reports are now appearing that imply that concussions in middle school or high school athletes can cause CTE at this young age, but the real question is whether parents are going to let their children compete without more protection and changes in rules and equipment.

AAOS Now regularly reports on the concussion issue and its relationship to the future of contact sports and will continue to keep our readers informed.

Orthopaedic medications
In 2013, AAOS Now continued to follow three unrelated issues concerning medications used in orthopaedics:

  • Contamination of compounding medications—Compounding labs that mix combinations of medications were noted to have a break in sterile technique, resulting in contamination of steroids and analgesics used in epidural steroid injections. As a result, an outbreak of spinal infections, some lethal, occurred in 2012. Although some compounding pharmacies went out of business, the problem has recurred, and more strenuous rules and guidelines and oversight are being developed.
  • Venous thromboembolic (VTE) prophylaxis—As announced in last month’s AAOS Now (“SCIP VTE Measures Changing in 2014,” November 2013), the Academy’s development of clinical practice guidelines (CPGs) on the prevention of VTE disease and updates by the American College of Chest Surgeons to their guidelines on the prevention of VTE in patients undergoing orthopaedic surgery led to a consensus and revisions to the Surgical Care Improvement Project (SCIP) measures. These revisions go into effect on Jan. 1, 2014, and will allow aspirin, with and without mechanical compression, to be used as an acceptable form of prophylaxis for total joint replacement and hip fracture surgery.
  • Narcotic pain management—In 2013, the U.S. Food and Drug Administration issued warnings about the “epidemic-like” use of hydrocodone and recommended reclassifying it as a class II drug with more restrictions on its use. The move was prompted by an increase in drug diversion, which occurs when a drug is prescribed for one intended use only to be diverted for some other use, such as in addiction. The problem is that the prescribing physician can be held accountable for who ultimately takes the drug and its consequences. The legal liability for physicians for diversion became more clear in 2013.

YODA results
Results of the Yale Open Data Access (YODA) project were published in 2013. This study used independent researchers, overseen by the Yale Department of Research and funded by Medtronic, Inc., to review the results of clinical trials on the use of recombinant human bone morphogenetic protein (rh-BMP-2), marketed as Infuse® in spinal fusion surgery.

The review found that the product “provided little or no benefit compared with bone graft and may be associated with more harms, possibly including cancer.” In addition, although YODA found that the reporting of results was not biased, adverse events were incompletely, inadequately, and inconsistently described. Even with the YODA report, the controversy continued and more is sure to come in 2014. Stay tuned!

Boston Marathon bombings
Although not directly related to orthopaedics, the Boston Marathon bombings affected all Americans. Medical personnel, including orthopaedists, suddenly went from treating muscle strains, blisters, shin splints, and stress fractures in the medical tent on Copley Square to providing triage and trauma care for massive blood loss, amputations, and mutilated extremities such as those seen in war zones. AAOS Now saluted these courageous volunteers in the July issue and recognized their “one moment in time when they were more than they thought they could be.”

AAOS initiatives
Last, but maybe most important to the orthopaedic profession, were three AAOS endeavors.

  • Early revision of the CPGs on osteoarthritis (OA) of the knee and review of the available research on the controversial use of viscosupplementation (hyaluronic acid), putting to rest the nagging question of its efficacy by stating, “We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee.”
  • Participation in the “Choosing Wisely” campaign, endorsed by the AAOS and more than 50 other medical specialties. This campaign is designed to encourage consumers to question the use of certain treatments, such as the use of lateral sole (heel) wedges to treat OA knee, that are not supported by research. Both of these programs are suggestions for orthopaedists and are not “set in stone.”
  • The construction of a new home for orthopaedic societies and a state-of-the-art Orthopaedic Learning Center. Congratulations to the Arthroscopy Association of North America, the American Association of Hip and Knee Surgeons, the American Orthopaedic Society for Sports Medicine, and the Orthopaedic Learning Center for their partnership in this endeavor. The AAOS staff work hard to make our organization the finest medical association in all of medicine—they deserve a first-class home!

S. Terry Canale, MD, is the editor-in-chief of AAOS Now. He can be reached at aaoscomm@aaos.org

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