The impact of disruptive innovations in orthopaedics

Disparities Among Industry's Highly Compensated Orthopaedic Surgeons

The prosperous financial relationship between physicians and industry remains a highly scrutinized topic. Recently, a publicly available website was developed in conjunction with the U.S. Affordable Care Act to shed light on payments from industry to physicians with the goal of increasing transparency. The purpose of this study was to assess possible relationships between industry payments and orthopaedic surgeon gender, subspecialty training, and practice settings.

Impact of North American Institutions on Orthopedic Research in Low- and Middle-Income Countries

There exists an unmet need for locally relevant and sustainable orthopedic research in low- and middle-income countries. Partnerships between high-income countries and low- and middle-income countries can bridge gaps in resources, knowledge, infrastructure, and skill. This article presents a select list of models for high-income countries/low- and middle-income countries research partnerships including academic partnerships, international research consortia, professional society-associated working groups, and nongovernmental organization partnerships. Models that produce research with lasting legacy are those that promote mutually beneficial partnerships over individual gains.

Knowledge of orthopaedic implant costs and healthcare schemes among orthopaedic residents

There is a paucity of available research on knowledge of orthopaedic implant costs and healthcare schemes among orthopaedic residents. With the rising healthcare costs in Singapore, it is imperative for residents, who are the future surgeons, to understand these issues in order to provide proper counselling and cost-effective management. This study aimed to quantify how accurately they understood these issues and determine if senior residents had better knowledge given their increased experience. An online survey was administered to all orthopaedic residents within a residency programme. There was poor knowledge of implant costs and healthcare schemes among residents. Junior residents fared better at healthcare schemes, while senior residents fared better at estimation of implant costs. Education on these issues should be incorporated into the residency programme to bring about more holistic and cost-conscious clinicians.

Effect of Facility Ownership on Utilization of Arthroscopic Shoulder Surgery

INTRODUCTION

We examined practice patterns and surgical indications in the management of common shoulder procedures by surgeons practicing at physician-owned facilities.

METHODS

This study was a retrospective analysis of 501 patients who underwent arthroscopic shoulder procedures performed by five surgeons in our practice at one of five facilities during an 18-month period. Two of the facilities were physician-owned, and three of the five surgeons were shareholders. Demographics, insurance status, symptom duration, time from injury/symptom onset to the decision to perform surgery (at which time surgical consent is obtained), and time to schedule surgery were studied to determine the influence of facility type and physician shareholder status.

RESULTS

Median duration of symptoms before surgery was significantly shorter in workers' compensation patients than in non-workers' compensation patients (47% less; P < 0.0001) and in men than in women (31% less; P < 0.001), but was not influenced by shareholder status or facility ownership (P > 0.05). Time between presentation and surgical consent was not influenced by facility ownership (P = 0.39) or shareholder status (P = 0.50). Time from consent to procedure was 13% faster in physician-owned facilities than in non-physician-owned facilities (P = 0.03) and 35% slower with shareholder physicians than with nonshareholder physicians (P < 0.0001).

DISCUSSION

The role of physician investment in private healthcare facilities has caused considerable debate in the orthopaedic surgery field. To our knowledge, this study is the first to examine the effects of shareholder status and facility ownership on surgeons' practice patterns, surgical timing, and measures of nonsurgical treatment before shoulder surgery.

CONCLUSIONS

Neither shareholder status nor facility ownership characteristics influenced the speed with which surgeons determined that shoulder surgery was indicated or surgeons' use of preoperative nonsurgical treatment. After the need for surgery was determined, patients underwent surgery sooner at physician-owned facilities than at non-physician-owned facilities and with nonshareholder physicians than with shareholder physicians.

LEVEL OF EVIDENCE

Level III.

Current state of the art in total knee arthroplasty computer navigation

PURPOSE

Computer-assisted surgery in orthopaedics is passing through the initial adapter phase of technology adoption. It started more than 20 years ago, but the uptake of technology is still not widespread. The purpose of this article is to introduce the reader to the basic technology and familiarize with the terminology used in the computer navigation.

METHODS

During this time, the technology has matured and we have the evidence to prove its benefits for patients. Not only does it help placing the prosthetic components in correct orientation, it also helps with other parameters like blood loss and fat embolism reduction. In addition to being a teaching and training tool, it has also opened new areas of research which now question the traditional practices. Since it is not in commonly used, the basic aspects of computer navigation are not very well known.

RESULTS

This paper outlines some important definitions and restates the classification of navigation within the spectrum of computer-assisted technologies; it then elaborates on the key principles behind navigation in knee arthroplasty and goes through some of the differences between navigation systems. Finally, it describes in some detail the surgical steps with an image-free knee navigation system.

CONCLUSIONS

Computer-assisted navigation is not mainstream yet, but this article should help readers unfamiliar with the technology to understand the basic terms and how it actually works.

LEVEL OF EVIDENCE

III.

EVALUATION OF THE KNOWLEDGE ON COST OF ORTHOPEDIC IMPLANTS AMONG ORTHOPEDIC SURGEONS

Objective:

To determine the knowledge of Brazilian Orthopedic Surgeons on the costs of orthopedic surgical devices used in surgical implants.

Methods:

A questionnaire was applied to Brazilian Orthopedic Surgeons during the 46^th Brazilian Congress on Orthopedics and Traumatology.

Results:

Two hundred and one Orthopedic Surgeons completely filled out the questionnaire. The difference between the average prices estimated by the surgeons and the average prices provided by the supplier companies was 47.1%. No differences were found between the orthopedic specialists and other subspecialties on the prices indicated for specific orthopedic implants. However, differences were found among orthopedic surgeons who received visits from representatives of implant companies and those who did not receive those visits on prices indicated for shaver and radiofrequency device. Correlation was found between length of orthopedic experience and prices indicated for shaver and interference screw, and higher the experience time the lower the price indicated by Surgeons for these materials.

Conclusion:

The knowledge of Brazilian Orthopedic Surgeons on the costs of orthopedic implants is precarious. Reduction of cost of orthopedics materials depends on a more effective communication and interaction between doctors, hospitals and supplier companies with solid orientation programs and awareness for physicians about their importance in this scenario.Level of Evidence III, Cross-Sectional Study.

Treatment With the SIGN Nail in Closed Diaphyseal Femur Fractures Results in Acceptable Radiographic Alignment

BACKGROUND

The burden of orthopaedic trauma in the developing world is substantial and disproportionate. SIGN Fracture Care International is a nonprofit organization that has developed and made available to surgeons in resource-limited settings an intramedullary interlocking nail for use in the treatment of femoral and tibial fractures. Instrumentation also is donated with the nail. A prospectively populated database collects information on all procedures performed using this nail. Given the challenging settings and numerous surgeons with varied experience, it is important to document adequate alignment and union using the device.

QUESTIONS/PURPOSES

The primary aim of this research was to assess the adequacy of operative reduction of closed diaphyseal femur fractures using the SIGN interlocking intramedullary nail based on radiographic images available in the SIGN database. The secondary aims were to assess correlations between postoperative alignment and several associated variables, including fracture location in the diaphysis, degree of fracture site comminution, and time to surgery. The tertiary aim was to assess the functionality of the SIGN database for radiographic analyses.

METHODS

A review of the prospectively populated SIGN database was performed for patients with a diaphyseal femur fracture treated with the SIGN nail, which at the time of the study totaled 32,362 patients. After study size calculations, a random number generator was used to select 500 femur fractures for analysis. Exclusion criteria included open fractures and those without radiographs during the early postoperative period. The following information was recorded: location of the fracture in the diaphysis; fracture classification (AO/Orthopaedic Trauma Association [OTA] classification); degree of comminution (Winquist and Hansen classification); time from injury to surgery; and patient demographics. Measurements of alignment were obtained from the AP and lateral radiographs with malalignment defined as deformity in either the sagittal or coronal plane greater than 5°. Measurements were made manually by the four study authors using on-screen protractor software and interobserver reliability was assessed.

RESULTS

The frequency of malalignment greater than 5° observed on postoperative radiographs was 51 of 501 (10%; 95% CI, 6.5-11.5), and malalignment greater than 10° occurred in eight of 501 (1.6%) of the femurs treated with this nail. Fracture location in the proximal or distal diaphysis was strongly correlated with risk of malalignment, with an odds ratio (OR) of 3.7 (95% CI, 1.5-9.3) for distal versus middle diaphyseal fractures and an OR of 4.7 (95% CI, 1.9-11.5) for proximal versus middle fractures (p < 0.001). Time from injury to surgery greater than 4 weeks also was strongly correlated with risk of malalignment (p < 0.001). Inherent fracture stability, based on fracture site comminution as per the Winquist and Hansen classification (Class 0-1 stable versus 2-4 unstable) showed an OR of 2.3 (95% CI, 1.2-4.3) for malalignment in unstable fractures. Interobserver reliability showed agreement of 88% (95% CI, 83-93) and mean kappa of 0.81 (95% CI, 0.65-0.87). The SIGN database of radiographic images was found to be an excellent source for research purposes with 92% of reviewed radiographs of acceptable quality.

CONCLUSIONS

The frequency of malalignment in closed diaphyseal femoral fractures treated with the SIGN nail closely approximated the incidence reported in the literature for North American trauma centers. Increased time from injury to surgery was correlated with increased frequency of malalignment; as humanitarian distribution of the SIGN nail increases, local barriers to timely care should be assessed and improved as possible. Prospective clinical study with followup, despite its inherent challenges in the developing world, would be of great benefit in the future.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The effect of a non-surgical orthopaedic physician on wait times to see a paediatric orthopaedic surgeon

AIMS

High referral volumes to paediatric orthopaedic surgeons create long clinic waiting lists. The use of extended scope roles for doctors and health professionals is one strategy to address these wait times. We completed a 6-month trial of a non-surgical paediatric orthopaedic physician role (NSP) to help manage non-urgent referrals to our service from local general practitioners (GPs).

METHODS

For a 6-month period, the majority of non-urgent GP referrals were assessed by a US-trained NSP. Wait times were compared between this period and the same time period in the previous year. Family and referrer satisfaction was determined through postal surveys.

RESULTS

Over the trial period, the NSP saw a total of 155 new patient referrals, which represented 49% of all non-urgent GP referrals for the period. Before the trial, only 75% of non-urgent referrals were seen within 131 days (19 weeks) with 10% waiting more than 215 days (31 weeks). By the end of the trial, 75% of referrals were seen within 55 days (8 weeks) and 90% within 61 days (9 weeks). The most common outcome was discharge with management advice. 12% of patients were referred on to an orthopaedic surgeon but only 1% went on to a surgical wait list. Families and referrers reported high levels of satisfaction and only three patients discharged by the NSP were referred back for orthopaedic surgeon review.

CONCLUSION

The NSP role was effective at reducing clinic wait times for patients with non-urgent paediatric orthopaedic conditions, while maintaining family and referrer satisfaction.

Entrepreneurship in the academic radiology environment

RATIONALE AND OBJECTIVES

Innovation and entrepreneurship in health care can help solve the current health care crisis by creating products and services that improve quality and convenience while reducing costs.

MATERIALS AND METHODS

To effectively drive innovation and entrepreneurship within the current health care delivery environment, academic institutions will need to provide education, promote networking across disciplines, align incentives, and adapt institutional cultures. This article provides a general review of entrepreneurship and commercialization from the perspective of academic radiology departments, drawing on information sources in several disciplines including radiology, medicine, law, and business.

CONCLUSIONS

Our review will discuss the role of universities in supporting academic entrepreneurship, identify drivers of entrepreneurship, detail opportunities for academic radiologists, and outline key strategies that foster greater involvement of radiologists in entrepreneurial efforts and encourage leadership to embrace and support entrepreneurship.

The implementation of a pilot femur fracture registry at Komfo Anokye Teaching Hospital: an analysis of data quality and barriers to collaborative capacity-building

BACKGROUND

Trauma registries are essential for injury surveillance and recognition of the burden of musculoskeletal injury in low- and middle-income countries (LMICs). The purpose of this study was to pilot a femur fracture registry at Komfo Anokye Teaching Hospital (KATH) to assess data quality and determine the barriers to research partnering in LMICs.

METHODS

All patients admitted to KATH with a fracture of the femur, or Arbeitsgemeinschaft für Osteosynthesefragen (AO) class 31, 32, 33, were entered into a locally designed, electronic femur fracture database. Patients' characteristics and data quality were assessed by using descriptive statistics. Orthopedic trauma research barriers and opportunities were identified from key informants at the research site and supporting site.

RESULTS

Ninety-six femur fracture patients were enrolled into the registry over a 5-week period. The majority of patients resided in the Ashanti region surrounding the hospital (78 %). Most participants were involved in a road traffic crash (58 %) and physiologically stable with a Cape Triage Score of yellow upon admission (84 %). AO class 32 femur fractures represented the majority of femur fractures (78 %). Median times from injury to admission, admission to surgery, and surgery to discharge were 0, 5, and 10 days, respectively. Data quality analysis showed that data collected at admission had higher rates of completion in the database relative to data collected at various follow-up time points.

CONCLUSIONS

Data and data quality analyses highlighted characteristics of femur fracture patients presenting to KATH as well as the technological, administrative support, and hospital systems-based challenges of longitudinal data collection in LMICs.

Patient-specific instruments: industry's innovation with a surgeon's interest

PURPOSE

The aim of this study was (1) to survey the orthopaedic companies about the volume of patient-specific instruments (PSI) used in Europe and worldwide; (2) to survey a group of knee arthroplasty surgeons on their acceptance of PSI and finally; (3) to survey a medico-legal expert on PSI-related issues.

METHODS

Seven orthopaedic implant manufacturers were contacted to obtain their sales figures (in volume) of PSI in Europe and worldwide for the 2011 and 2012 period. During the Open Meeting of the Belgian Knee Society, a survey by a direct voting system was submitted to a selection of knee surgeons. Finally, a number of medico-legal 'PSI-related' questions were submitted to an adult reconstruction surgeon/legal expert.

RESULTS

The total volume, for all contacted companies, of PSI in Europe for 2012 was 17,515 total knee arthroplasty (TKA) and 82,556 TKA worldwide. Biomet (Warsaw, USA) was the number one in volume, both in Europe as worldwide with their Signature system. Biomet represented 27 % of the market share in PSI worldwide. Stryker preferred not to reply to the survey because of the FDA class 1 recall on ShapeMatch cutting guides. Eighty per cent of the Belgian knee surgeons expressed a great interest in PSI and especially, for 58 % of them, if it would increase their surgical accuracy. They valued it even more in unicompartmental arthroplasty, and 55 % was ready to use single-use instruments. Surprisingly, 47 % of surgeons thought it was the company's responsibility if something goes wrong with a PSI-assisted case. The medico-legal expert concluded that PSI is a complex process that exposes surgeons to new risks in case of failure and stated that companies should not produce surgical guides without validation of the planning by the surgeon.

CONCLUSION

Patient-specific instruments is of great interest if it can proof to increase the surgical accuracy in knee arthroplasty to the level surgeons are expecting and if in the same time it would make the surgical process more efficient.

LEVEL OF EVIDENCE

V.

Orthopaedic surgeons frequently underestimate the cost of orthopaedic implants

BACKGROUND

A poor understanding of cost among healthcare providers may contribute to high healthcare expenditures. Currently, it is unclear whether and how much surgeons know about the costs of implantable medical devices (IMDs).

QUESTIONS/PURPOSES

We (1) determined the level of comfort with orthopaedic IMD costs among orthopaedic residents and attending surgeons, (2) quantified how accurately surgeons understand the costs of orthopaedic IMDs, and (3) identified which constructs yield the most accurate cost estimations among residents and attending surgeons.

METHODS

A questionnaire was presented to 60 residents and 37 attending orthopaedic surgeons from two large academic medical centers. Respondents estimated the cost of 13 commonly used orthopaedic devices. Fifty-one surgeons participated (36 residents, 15 attending surgeons), for an overall response rate of 53%. Cost estimates were compared against the actual material costs, and we recorded the percentage error for each estimate.

RESULTS

More than ½ of the respondents rated their knowledge of IMD cost as poor. The mean percentage error in estimation for all respondents was 69% (range, 29%-289%). Overall, 67% of responses were underestimations and 33% were overestimations. Residents demonstrated a mean percentage error of 73% (range, 29%-289%) while attending surgeons had a mean percentage error of 59% (range, 49%-79%). Residents and attending surgeons demonstrated differences in accuracy within groups and between groups based on the IMD being estimated.

CONCLUSIONS

We found the knowledge of orthopaedic IMD costs among the orthopaedic residents and attending surgeons surveyed was poor. Further investigation of how physicians conceptualize material costs will be important to healthcare cost control.

Orthopedic specialty hospitals: centers of excellence or greed machines?

Orthopedic specialty hospitals have recently been the subject of debate. They are patient-centered, physician-friendly health care alternatives that take advantage of the economic efficiencies of specialization. Medically, they provide a higher quality of care and increase patient and physician satisfaction. Economically, they are more efficient and profitable than general hospitals. They also positively affect society through the taxes they pay and the beneficial aspects of the competition they provide to general hospitals. Their ability to provide a disruptive innovation to the existing hospital industry will lead to lower costs and greater access to health care. However, critics say that physician ownership presents potential conflicts of interest and leads to overuse of medical care. Some general hospitals are suffering as a result of unfair specialty hospital practices, and a few drastic medical complications have occurred at specialty hospitals. Specialty hospitals have been scrutinized for increasing the inequality of health care and continue to be a target of government regulations. In this article, the pros and cons are examined, and the Emory Orthopaedics and Spine Hospital is analyzed as an example. Orthopedic specialty hospitals provide excellent care and are great assets to society. Competition between specialty and general hospitals has provided added value to patients and taxpayers. However, physicians must take more responsibility in their appropriate and ethical leadership. It is critical to recognize financial conflicts of interest, disclose ownership, and act ethically. Patient care cannot be compromised. With thoughtful and efficient leadership, specialty hospitals can be an integral part of improving health care in the long term.

Effect of facility on the operative costs of distal radius fractures

PURPOSE

The purpose of this study was to investigate whether ambulatory surgery centers can deliver lower-cost care and to identify sources of those cost savings.

METHODS

We performed a cost identification analysis of outpatient volar plating for closed distal radius fractures at a single academic medical center. Multiple costs and time measures were taken from an internal database of 130 consecutive patients and were compared by venue of treatment, either an inpatient facility or an ambulatory, stand-alone surgery facility. The relationships between total cost and operative time and multiple variables, including fracture severity, patient age, gender, comorbidities, use of bone graft, concurrent carpal tunnel release, and surgeon experience, were examined, using multivariate analysis and regression modeling to identify other cost drivers or explanatory variables.

RESULTS

The mean operative cost was considerably greater at the inpatient facility ($7,640) than at the outpatient facility ($5,220). Cost drivers of this difference were anesthesia services, post-anesthesia care unit, and operating room costs. Total surgical time, nursing time, set-up, and operative times were 33%, 109%, 105%, and 35% longer, respectively, at the inpatient facility. There was no significant difference between facilities for the additional variables, and none of those variables independently affected cost or operative time.

CONCLUSIONS

The only predictor of cost and time was facility type. This study supports the use of ambulatory stand-alone surgical facilities to achieve efficient resource utilization in the operative treatment of distal radius fractures. We also identified several specific costs and time measurements that differed between facilities, which can serve as potential targets for tertiary facilities to improve utilization.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decisional Analysis III.

The role of SIGN in the development of a global orthopaedic trauma database

BACKGROUND

The global burden of injury is receiving recognition as a major public health problem but inadequate information delays many proposed solutions. Many attempts to collect reliable data on orthopaedic trauma have been unsuccessful. The Surgical Implant Generation Network (SIGN) database is one of the largest collections of fracture cases from lower and middle income countries.

QUESTIONS/PURPOSES

We describe the information in the SIGN database then address two questions: In the context of the design and implementation of a global trauma database, what lessons does the SIGN database teach? Does the SIGN program have a role in the evolution of a wider global system?

METHODS

The SIGN database is Internet based. After treating a patient with a SIGN nail surgeons enter radiographs and details of the case.

RESULTS

Over 26000 cases are in the SIGN database. The database has been used as a source of cases for followup studies. Analysis shows the data are of sufficient quality to allow studies of fracture patterns but not for outcome studies or bone measurement. WHERE DO WE NEED TO GO?: A global database with more comprehensive coverage of injuries, causes, treatment modalities and outcomes is needed. HOW DO WE GET THERE?: The SIGN database itself will not become a global trauma database (GTD) but the personnel of the SIGN program have much to offer in the design and adoption of a GTD. Studies of suitable methods of data collection and the incentive to use them are required.