The 2007 ABJS Marshall Urist Award: The impact of direct-to-consumer advertising in orthopaedics

Direct anterior versus mini-anterolateral approach for primary total hip arthroplasty: early postoperative outcomes and complications

Background

Anterior-based approaches to primary total hip arthroplasty (THA) are being used more frequently, and several variations have been described. The supine direct anterior (DA) approach has been widely studied, but few studies have compared it with the mini-anterolateral (mini-AL) approach (abductor-sparing, Watson-Jones approach) in the lateral decubitus position. This study aims to compare early perioperative complications and outcomes between these 2 approaches.

Methods

This study retrospectively reviewed 340 consecutive THAs (n = 170 DA, n = 170 mini-AL) performed by 3 arthroplasty surgeons at a single institution between January 2017 and May 2018. The primary outcome was reoperation for any reason within 1 year. Secondary outcomes included wound-healing complications and several perioperative factors. A Student's t-test was used for continuous variables, and a chi-squared test was used for categorical variables.

Results

In this cohort, 6 patients (4%) from the mini-AL group required reoperation within 1 year, compared with 2 patients (1%) from the DA group (P = .024). However, the DA group had 13 patients (8%) with wound-healing complications compared with 6 patients (4%) in the mini-AL group 4% (P = .036). Perioperative outcomes were similar for operative time, distance walked with physical therapy, morphine milligram equivalent consumed, length of stay, and discharge disposition. Pain scores during index hospitalization were also similar.

Conclusions

Patients who underwent THA using the supine DA approach had fewer reoperations within 1 year, but more wound-healing complications compared with the mini-AL approach in the lateral decubitus position. For surgeons performing primary THA using an anterior-based approach, relative risks and benefits of these approaches must be understood.

Level of Evidence

Level III.

Patient willingness to contribute to the cost of novel implants in total joint arthroplasty: the Canadian experience

Background

In Canada, health care is covered by provincial health insurance programs; patients do not directly participate in paying for their acute care expenses. The aim of this study is to assess the willingness of Canadian patients to contribute to the costs of novel total joint arthroplasty implants.

Methods

We administered a questionnaire to patients attending an outpatient arthroplasty clinic in Ontario. In the questionnaire, the longevity and risk of complications of a “standard” implant were described. We asked if participants would be willing to contribute to the cost of 3 novel implants that had differing longevities and risks of complications compared with the standard implant.

Results

One hundred and fifteen patients completed our questionnaire. Up to 62% of patients were willing to contribute a copayment to get an implant with greater longevity. Willingness to pay decreased to 40% for an implant with greater longevity but an increased risk of complications. Forty percent of participants were willing to pay for an implant with the same longevity as the standard implant but a decreased risk of complications. Participants with a higher income were more willing than other participants to contribute to the cost of a novel implant with greater longevity or lower complication rates.

Conclusion

This study demonstrated that up to 62% of our sample of patients in Ontario were willing to share the costs of a novel total joint replacement implant. Willingness to pay was associated with the proposed benefits of the implant and certain patient characteristics. Our study shows that a high proportion of Canadian patients may be willing to copay to have access to new technologies.

Direct to consumer advertising of robotic heart bypass surgery: effectiveness, patient satisfaction and clinical outcomes

Purpose

Robotic coronary artery bypass (rCABG) is a relatively novel and less invasive form of surgery. A yearlong direct-to-consumer advertising (DTCA) campaign was initiated to provide the community with information regarding rCABG, increase awareness and recruit patients. To optimize information content and ensure appropriate messaging for future campaigns, this study aims to analyze the campaign effectiveness and compared service quality perceptions and clinical outcomes, following surgery across DTCA-responder and control groups.

Design/methodology/approach

The institution initiated an rCABG program and one-year DTCA campaign. The authors prospectively documented all rCABG referrals prompted by these ads (DTCA-responder group) and concurrent referrals from medical providers (controls). Groups were compared according to baseline characteristics, perioperative outcomes, patient satisfaction (HCAHPS survey) and functional capacity at three weeks (Duke Activity Status Index). At six months, both groups were surveyed for patient satisfaction and unmet expectations.

Findings

There were 103 DTCA responders and 77 controls. The subset of responders that underwent rCABG (n = 54) had similar characteristics to controls, except they were younger, less likely to have lung disease or to be scheduled as an urgent case. Both groups had similar 30-day clinical outcomes, functional capacity recovery and overall satisfaction at three weeks. Follow-up interviews at six months and four years revealed that the DTCA group reported more unmet expectations regarding the “size of the skin incisions” and “recovery time” but no concern about “expertise of their surgeon”.

Practical implications

The DTCA campaign was effective at recruiting patients. The specific focus of the ads and narrow timeframe for decision-making about CABG lends confidence that the incremental cases seen during the campaign were prompted primarily by DTCA. However, differences in unmet expectations underscore the need to better understand the impact of message content on patients recruited via DTCA campaigns.

Originality/value

This is one of the first studies to provide real-world direct empirical evidence of patients’ clinical and attitudinal outcomes for DTCA campaigns. Furthermore, the findings contradict prevailing beliefs that DTCA is ineffective for prompting surgical referrals.

A Qualitative and Quantitative Comparative Analysis of Commercial and Independent Online Information for Hip Surgery: A Bias in Online Information Targeting Patients?

BACKGROUND

Direct to consumer (DTC) advertising, targeting the public over the physician, is an increasingly pervasive presence in medical clinics. It is trending toward a format of online interaction rather than that of traditional print and television advertising.

METHODS

We analyze patient-focused Web pages from the top 5 companies supplying prostheses for total hip arthroplasties, comparing them to the top 10 independent medical websites. Quantitative comparison is performed using the Journal of American Medical Association benchmark and DISCERN criteria, and for comparative readability, we use the Flesch-Kincaid grade level, the Flesch reading ease, and the Gunning fog index. Content is analyzed for information on type of surgery and surgical approach.

RESULTS

There is a statistically significant difference between the independent and DTC websites in both the mean DISCERN score (independent 74.6, standard deviation [SD] = 4.77; DTC 32.2, SD = 10.28; P = .0022) and the mean Journal of American Medical Association score (Independent 3.45, SD = 0.49; DTC 1.9, SD = 0.74; P = .004). The difference between the readability scores is not statistically significantly. The commercial content is found to be heavily biased in favor of the direct anterior approach and minimally invasive surgical techniques.

CONCLUSION

We demonstrate that the quality of information on commercial websites is inferior to that of the independent sites. The advocacy of surgical approaches by industry to the patient group is a concern. This study underlines the importance of future regulation of commercial patient education Web pages.

Greater inadvertent muscle damage in direct anterior approach when compared with the direct superior approach for total hip arthroplasty

Aims

We wished to quantify the extent of soft-tissue damage sustained during minimally invasive total hip arthroplasty through the direct anterior (DA) and direct superior (DS) approaches.

Materials and Methods

In eight cadavers, the DA approach was performed on one side, and the DS approach on the other, a single brand of uncemented hip prosthesis was implanted by two surgeons, considered expert in their surgical approaches. Subsequent reflection of the gluteus maximus allowed the extent of muscle and tendon damage to be measured and the percentage damage to each anatomical structure to be calculated.

Results

The DA approach caused substantially greater damage to the gluteus minimus muscle and tendon when compared with the DS approach (t-test, p = 0.049 and 0.003, respectively). The tensor fascia lata and rectus femoris muscles were damaged only in the DA approach. There was no difference in the amount of damage to the gluteus medius muscle and tendon, piriformis tendon, obturator internus tendon, obturator externus tendon or quadratus femoris muscle between approaches. The posterior soft-tissue releases of the DA approach damaged the gluteus minimus muscle and tendon, piriformis tendon and obturator internus tendon.

Conclusion

The DS approach caused less soft-tissue damage than the DA approach. However the clinical relevance is unknown. Further clinical outcome studies, radiographic evaluation of component position, gait analyses and serum biomarker levels are necessary to evaluate and corroborate the safety and efficacy of the DS approach. Cite this article: Bone Joint J 2016;98-B1036–42.

Robotic and navigation systems in orthopaedic surgery: how much do our patients understand?

BACKGROUND

Technology in orthopaedic surgery has become more widespread in the past 20 years, with emerging evidence of its benefits in arthroplasty. Although patients are aware of benefits of conventional joint replacement, little is known on patients' knowledge of the prevalence, benefits or drawbacks of surgery involving navigation or robotic systems.

METHODS

In an outpatient arthroplasty clinic, 100 consecutive patients were approached and given questionnaires to assess their knowledge of navigation and robotics in orthopaedic surgery. Participation in the survey was voluntary.

RESULTS

Ninety-eight patients volunteered to participate in the survey, mean age 56.2 years (range, 19 to 88 years; 52 female, 46 male). Forty percent of patients thought more than 30% of National Health Service (NHS) orthopaedic operations involved navigation or robotics; 80% believed this was the same level or less than the private sector. One-third believed most of an operation could be performed independently by a robotic/navigation system. Amongst perceived benefits of navigation/robotic surgery was more accurate surgery (47%), quicker surgery (50%), and making the surgeon's job easier (52%). Sixty-nine percent believed navigation/robotics was more expensive and 20% believed it held no benefit against conventional surgery, with only 9% believing it led to longer surgery. Almost 50% would not mind at least some of their operation being performed with use of robotics/navigation.

CONCLUSIONS

Although few patients were familiar with this new technology, there appeared to be a strong consensus it was quicker and more accurate than conventional surgery. Many patients appear to believe navigation and robotics in orthopaedic surgery is largely the preserve of the private sector. This study demonstrates public knowledge of such new technologies is limited and a need to inform patients of the relative merits and drawbacks of such surgery prior to their more widespread implementation.

Patients' willingness to contribute to cost of novel implants in total joint arthroplasty

As health care organizations adapt to more accountable financial models, it is increasingly important to assess how patients value new technologies, and their willingness to contribute to their cost. A questionnaire described features of a 'standard' implant including its longevity and risk of complications. We asked if participants would be willing to contribute to the cost of 3 novel implants with differing longevity and risk of complications. Our cohort included 195 patients, 45% were willing to add a co-pay to increase the longevity. Willingness to pay decreased to 26% with increased risk of complications, and 29% were willing to pay for a decreased risk of complications. Patients with higher education level, private insurance and males were more willing to contribute for a novel prosthesis. This study demonstrated that 26%-45% of patients are willing to share costs of a novel prosthesis. Willingness to pay was associated with the proposed implant benefits and with patient characteristics.

[Early results of gender-specific posterior stabilized total knee arthroplasty without patella resurfacing]

INTRODUCTION

To address anatomical gender differences in total knee arthroplasty (TKA) specific total knee prostheses have been developed for women. Potential benefits of these modified prostheses are currently under debate. The present study investigated whether the modified design features bring benefits compared to uni-sex TKA.

METHODS

A total of 80 prospectively blinded and randomized patients underwent implantation of unilateral TKAs with NexGen LPS Gender Solutions (Zimmer, Warsaw, USA, group gender-specific GS prosthesis, n = 40) or NexGen LPS Flex (Zimmer, Warsaw, USA, control group standard prosthesis ST, n = 40) The follow-up was carried out 10 days and 6 weeks postoperatively. Clinical data and the subjective assessment of quality of life were evaluated using the Knee Society Clinical Rating System (KSS), the short form 36-item health survey (SF-36) and the Western Ontario and McMaster Universities OA Index (WOMAC).

RESULTS

The two groups showed equal values in KSS, SF-36 and WOMAC preoperatively and ten days postoperatively the GS group reached an average KSS knee score of 62.6 ± 16.1 points (ST group 56.9 ± 14.7, p = 0.184) and a functional score of 28.5 ± 12.1 (ST group 24.3 ± 15.3, p = 0.082). In the overall score the GS group reached 91.1 ± 24.1 points (ST group 81.0 ± 27.1, p = 0.104). The GS group reached a knee score of 85.5 ± 14.4 points (ST group 77.8 ± 16.8, p = 0.03) and a functional score of 68.1 ± 20.7 points (ST group 62.3 ± 18.5, p = 0.185) 6 weeks postoperatively. In the overall score the GS group reached 153.7 ± 30.7 points (ST group 139.6 ± 32.4, p = 0.048). The analysis of SF-36 and WOMAC showed no significant differences at all time points. No evidence of loosening or migration was observed in both groups.

CONCLUSIONS

Based on the data presented, gender-specific TKA type NexGen LPS Gender Solutions has advantages in terms of early functional outcome. This result is not reflected in the patient satisfaction and is not considered to be clinically relevant.

Current concepts in knee replacement: features and imaging assessment

OBJECTIVE

This article reviews current concepts of knee replacement. Features of traditional and new prosthetic designs, materials, and surgical techniques are discussed. Normal and abnormal postoperative imaging findings are illustrated. Complications are reviewed and related to the current understanding about how and why these failures occur.

CONCLUSION

It is well known that after knee replacement, patients with complications may be asymptomatic, and, for this reason, assessment of postoperative imaging is important. The foundation of radiologic interpretation of knee replacement is knowledge of the physiologic purpose, orthopedic trends, imaging findings, and complications.

Feasibility and safety of performing outpatient unicompartmental knee arthroplasty

PURPOSE

Unicompartmental knee arthroplasty (UKA) has a faster short-term recovery than total knee arthroplasty (TKA). The purpose of this study was to determine the feasibility and safety of performing outpatient UKAs in a consecutive group of patients presenting with unicompartmental knee osteoarthritis.

METHODS

A total of 105 consecutive patients underwent unicompartmental arthroplasty before noon with the intention of being discharged as an outpatient. All patients followed an established rapid recovery pathway to facilitate a same-day discharge. Post-operative complications and hospital readmissions were retrospectively recorded for all patients at one week and at three months after surgery.

RESULTS

All of the 105 patients (100 %) indicated for outpatient UKA could be discharged home on the same day of surgery. No patients required readmission within the first week post-operatively, while one patient required readmission between week one and week 12. The single patient who required readmission developed a post-operative infection requiring irrigation/debridement with polyethylene liner exchange and intravenous antibiotics.

CONCLUSION

Using an established, multidisciplinary, rapid recovery protocol, outpatient UKA is safe and feasible in the vast majority of patients.

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.

Sources of information influencing decision-making in orthopaedic surgery - an international online survey of 1147 orthopaedic surgeons

Background

Manufacturers of implants and materials in the field of orthopaedics use significant amounts of funding to produce informational material to influence the decision-making process of orthopaedic surgeons with regards to choice between novel implants and techniques. It remains unclear how far orthopaedic surgeons are really influenced by the materials supplied by companies or whether other, evidence-based publications have a higher impact on their decision-making. The objective was to evaluate the subjective usefulness and usage of different sources of information upon which orthopaedic surgeons base their decisions when acquiring new implants or techniques.

Methods

We undertook an online survey of 1174 orthopaedic surgeons worldwide (of whom n = 305 were head of their department). The questionnaire included 34 items. Sequences were randomized to reduce possible bias. Questions were closed or semi-open with single or multiple answers. The usage and relevance of different sources of information when learning about and selecting orthopaedic treatments were evaluated. Orthopaedic surgeons and trainees were targeted, and were only allowed to respond once over a period of two weeks. Baseline information included country of workplace, level of experience and orthopaedic subspecialisation. The results were statistically evaluated.

Results

Independent scientific proof had the highest influence on decisions for treatment while OEM (Original Equipment Manufacturer) driven activities like newsletters, white papers or workshops had the least impact. Comparison of answers from the three best-represented countries in this study (Germany, UK and USA) showed some significant differences: Scientific literature and congresses are significantly more important in the US than in the UK or Germany, although they are very important in all countries.

Conclusions

Independent and peer-reviewed sources of information are preferred by surgeons when choosing between methods and implants. Manufacturers of medical devices in orthopaedics employ a considerable workforce to inform or influence hospital managers and leading doctors with marketing activities. Our results indicate that it might be far more effective to channel at least some of these funds into peer-reviewed research projects, thereby assuring significantly higher acceptance of the related products.

Patient preferences and willingness to pay for arthroplasty surgery in patients with osteoarthritis of the hip

Little is known about the economic value patients place on effective treatment of osteoarthritis (OA) of the hip. The purpose of this study was to evaluate the value of total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) to patients with advanced hip OA by measuring their preferences and willingness to pay (WTP) for either procedure. Seventy-three patients younger than 65 years with advanced hip OA reviewed information about the risks and benefits of THA and HRA and were asked which procedure they would choose and how much they would be willing to pay for it. Sixty-nine percent of patients chose THA (average WTP, $69 419) and 31% chose HRA (average WTP, $83 195). There was no correlation between WTP and annual income or total assets. However, patients with modest income and assets could have reported that they were willing and able to pay more than they could actually afford, and WTP dropped and correlation with income rose if we excluded high responses from the poorest respondents. These results may have important policy implications as patients are asked to share a greater burden of the cost of their care for chronic conditions such as OA.

Determinants of return to work after carpal tunnel release

PURPOSE

The determinants of time to return to work-a common measure of treatment effectiveness-are incompletely defined. Our primary hypothesis was that employment circumstances are the strongest determinant of earlier return to work. Our secondary hypothesis was that return to work in patients with desk-based jobs is predicted by patient expectations and other psychosocial factors.

METHODS

We enrolled 65 employed patients with limited incision open carpal tunnel release in a prospective cohort study. Patients completed validated measures of depression, coping strategies, pain anxiety, and job burnout. Heavy lifting was not allowed for 1 month after surgery. Return to modified and full work duty was recorded in days. Although not specifically an exclusion criterion, none of the patients had a workers' compensation claim or other source of secondary gain.

RESULTS

Patients returned to modified duty an average of 11.8 days and full duty at an average of 18.9 days after surgery. Predictors of earlier return to modified duty in multivariate analyses included desk-based work and both the number of days patients expected to take off and the numbers of days they wanted to take off for the entire cohort, with an additional influence from catastrophic thinking in desk-based workers. Predictors of earlier return to full duty in multivariate analyses included desk-based work and number of days patients expected to take off before for the entire cohort, fewer days off desired in non-desk-based workers, fewer days off desired and change in work role in desk-based workers, and lower pain anxiety in part-time workers.

CONCLUSIONS

The most important determinant of return to full duty work after limited incision open carpal tunnel release is job type, but psychological factors such as patient expectations, catastrophic thinking, and anxiety in response to pain also have a role.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Factors associated with rapid progression to knee arthroplasty: complete analysis of three-year data from the osteoarthritis initiative

OBJECTIVES

Only a few studies have identified prognostic factors indicating risk of future knee arthroplasty in patients with osteoarthritis (OA) of the knee. The Osteoarthritis Initiative (OAI) is a National Institutes of Health and privately funded cohort study of 4796 persons with or at high risk of knee OA. The OAI is ideally suited to a more extensive study of knee arthroplasty prognostic factors than has been undertaken. The purpose of our study was to identify patient factors which predict rapid progression to knee arthroplasty, defined as arthroplasty within three years of baseline data collection.

METHODS

We used alternating logistic regression models to analyze complete three year follow-up data from the OAI on 4670 persons with, or at risk for knee OA, aged 45 to 79 years during the years 2004 to 2008.

RESULTS

A total of 128 knees (116 persons) underwent knee arthroplasty during the study period. After adjusting for known prognostic factors, several previously unidentified predictors of future knee arthroplasty were found including past history of knee surgery (RR=2.04, 95% CI=1.33, 3.13), knee flexion contracture in degrees (RR=1.06, 95% CI=1.02, 1.11) and pain, on a 0 to 10 scale, with active knee flexion (RR=1.58, 95% CI=1.04, 2.39).

DISCUSSION/CONCLUSIONS

This study identifies new and easily measured clinical variables that are associated with more rapid progression to arthroplasty. The data may help to inform both physicians and patients of medical history and clinical examination findings most highly associated with short-term arthroplasty.

Emerging ideas: Shared decision making in patients with osteoarthritis of the hip and knee

BACKGROUND

Despite the widely reported success of total joint arthroplasty (TJA) in reducing pain and improving quality of life and function for patients with hip or knee osteoarthritis, rates of TJA use vary widely throughout the United States, with broad disparities based on geographic, racial, and socioeconomic factors. Shared decision-making approaches, which require an exchange of information between patients and their physicians, can be helpful in improving patient satisfaction with their treatment decision and appropriate use of TJA.

QUESTIONS/HYPOTHESES

Expected-value decision analysis models incorporating evidence-based outcome data with individual patient preferences regarding health states and willingness to pay, when used in shared decision-making models, will improve satisfaction among patients with hip or knee osteoarthritis and lead to more appropriate use of TJA.

PROPOSED PROGRAM

Patients with hip or knee osteoarthritis will be randomized to usual care or participation in a shared decision-making intervention. Patients in the shared decision-making intervention arm will have their preferences for individual health states related to osteoarthritis and TJA measured using the time trade-off technique, and these values will be incorporated in an expected-value decision analysis model, which also will incorporate the patient's willingness to pay for a particular treatment intervention and evidence-based outcome probabilities. The patient's decision for operative versus nonoperative care and their level of satisfaction with their decision will be compared using chi square and Mann-Whitney rank-sum tests.

SIGNIFICANCE

Information regarding patient preferences for particular health states and willingness to pay can be combined with evidence-based outcome data in expected-value decision analysis models, which will help inform shared clinical decision making between surgeons and their patients with hip or knee osteoarthritis.

Total hip arthroplasty: what information do we offer patients on websites of hospitals?

Background

Physicians face a new challenge; the self-educated patient. The internet is an important source that patients use to become self-educated. However, the individual choice for best treatment is difficult. The aim of this study was to investigate what kind of information is offered to total hip arthroplasty patients by internet and what information is appreciated by them.

Methods

Websites of orthopedic departments of all hospitals in the Netherlands were evaluated. In addition, a cohort of 102 patients, diagnosed with arthritic joint disorders, filled in an online survey and gave their opinion concerning the importance of this information.

Results

Eighty different orthopedic websites of hospitals were identified. Websites presented information regarding the orthopedic staff surgeon (76%) and the postoperative rehabilitation process (66%). They also offered referral to other orthopedic websites (61%), the opportunity to make an outpatient appointment (21%), and the opportunity to submit an online question (15%). Patients rated the presence of information regarding prosthesis survival as very important (> 70%). However, the information on the type of prosthesis used by the hospital, and survival data of the prosthesis, were only present in ~ 9% and 5% respectively, of the websites.

Conclusions

The content of health information on websites of hospitals is highly variable for total hip arthroplasty. Information regarding the hip implant and prosthesis survival is highly appreciated by patients, however, mostly absent on orthopedic websites in the Netherlands. The internet provides an enormous potential for orthopedic surgeons to inform the self-educated patient.

Randomized clinical trials in orthopaedic surgery: strategies to improve quantity and quality

Randomized clinical trials (RCTs) generally provide the highest quality and least biased evidence for treatment effectiveness. Relatively few high-quality RCTs have been published in the orthopaedic literature. Barriers to increasing the quantity of trials include the orthopaedic culture, patient preferences, and the availability of treatment outside trials. Challenges to conducting better quality trials include sample size, random allocation, and blinding. Undertaking more high-quality trials can improve the evidence available for determining treatment effectiveness, resulting in better patient care.

"On the other hand ...": the evidence does not support the use of hand-carried ultrasound by hospitalists

In the right hands, ultrasound is a safe and helpful diagnostic imaging tool. However, evidence supporting the use of hand-carried ultrasound (HCU) by hospitalist physicians has not kept pace with expanding application of these devices. In spite of its strategic point-of-care benefit, use of this technology by hospitalists may not ultimately translate into improved efficiency and better clinical outcomes. Optimal levels of training in image acquisition and interpretation remain to be established. Novelty, availability, and the results of a few small studies lacking patient-centered outcomes remain insufficient grounds to justify the expanded clinical utilization of these medical imaging devices by nonspecialists.

The Canadian Joint Replacement Registry-what have we learned?

The Canadian Joint Replacement Registry (CJRR) was launched in 2000 through the collaborative efforts of the Canadian Orthopedic Association and the Canadian Institutes for Health Information. Participation is voluntary, and data collected by participating surgeons in the operating room is linked to hospital stay information from administrative databases to compile yearly reports. In the fiscal year 2006-2007, there were 62,196 hospitalizations for hip and knee replacements in Canada, excluding Quebec. This represents a 10-year increase of 101% and a 1-year increase of 6%. Compared to men, Canadian women have higher age-adjusted rates per 105 for both TKA (148 vs. 110) and THA (86 vs. 76). There also exist substantial inter-provincial variations in both age-adjusted rates of arthroplasty and implant utilization that cannot be explained entirely on the basis of differing patient demographics. The reasons for these variations are unclear, but probably represent such factors as differences in provincial health expenditure, efforts to reduce waiting lists, and surgeon preference. The main challenge currently facing the CJRR is to increase procedure capture to > 90%. This is being pursued through a combination of efforts including simplification of the consent process, streamlining of the data collection form, and the production of customized reports with information that has direct clinical relevance for surgeons and administrators. As the CJRR continues to mature, we are optimistic that it will provide clinically important information on the wide range of factors that affect arthroplasty outcome.

The impact of disruptive innovations in orthopaedics

The US healthcare system is currently facing daunting demographic and economic challenges. Because musculoskeletal disorders and disease represent a substantial and growing portion of this healthcare burden, novel approaches will be needed to continue to provide high-quality, affordable, and accessible orthopaedic care to our population. The concept of "disruptive innovations," which has been studied and popularized by Harvard Business School Professor Clayton Christensen, may offer a potential framework for developing strategies to improve quality and control costs associated with musculoskeletal care. The introduction of mobile fluoroscopic imaging systems, the development of the Surgical Implant Generation Network intramedullary nail for treatment of long bone fractures in the developing world, the expanding role and contributions of physician assistants and nurse practitioners to the orthopaedic team, and the rise of ambulatory surgery centers are all examples of disruptive innovations in the field of orthopaedics. Although numerous cultural and regulatory barriers have limited the widespread adoption of these "disruptive innovations," we believe they represent an opportunity for clinicians to regain leadership in health care while at the same time improving quality and access to care for patients with musculoskeletal disease.

Executive summary: value-based purchasing and technology assessment in orthopaedics

As US healthcare expenditures continue to rise, reform has shifted from spending controls to value-based purchasing. This paradigm shift is a drastic change on how health care is delivered and reimbursed. For the shift to work, policymakers and physicians must restructure the present system by using initiatives such as process reengineering, insurance and payment reforms, physician reeducation, data and quality measurements, and technology assessments. Value, as defined in economic terms, will be a critical concept in modern healthcare reform. We summarize the conclusions of this ABJS Carl T. Brighton Workshop on healthcare reform.

Internet access produces misinformed patients: managing the confusion

The Internet has produced a truly phenomenal increase in access to information. This is really only helpful to patients if the information is filtered and appropriate to their specific needs. Too often patients access information about conditions they have self-diagnosed and bring it to the consultation with their physician, who then has to spend time disabusing the patients of the misinformation they have accumulated. Patients also return home from their initial consultation, access the Internet, and come up with all manner of promotional information from companies and even orthopedic practices that they want explained to them by their physician. It is the overwhelming conclusion of orthopedic specialists that this kind of Internet use is actually a burden for them in caring for patients and is not contributing to patient enlightenment. It does not have to be this way, if physicians will do just 2 things: first, create white papers for patients that address common current questions, such as surgical approach or bearing surfaces for implants and why we do what we do. This is a huge time saver and will preempt many questions. Second, develop their own website or select excellent nonprejudicial sites to which they can refer patients. To do less will invite a neverending parade of questions irrelevant to patient welfare.

Economic considerations in minimally invasive total joint arthroplasty

Minimally invasive techniques for hip and knee arthroplasty have been gaining popularity in recent years. Despite the apparent widespread enthusiasm for these procedures, there is little published evidence demonstrating superior quality of life outcomes directly attributable to the surgical technique. The current debate regarding the value of minimally invasive surgery extends beyond the demonstrated or potential clinical benefits of these procedures. Economic considerations of patients, surgeons, hospitals, and payers are prominent factors in this debate and will continue to influence the adoption of minimally invasive surgical procedures. Developing an understanding of the barriers posed by our healthcare delivery system to minimally invasive surgical procedures and how these barriers impact each of the stakeholders in the healthcare system will foster a rational deployment of these promising new approaches to hip and knee arthroplasty in the future.