The Near-Term Ramifications of Long-Term Trends in Orthopedic Surgical Reimbursement.

BACKGROUND: There has been 25-year trend of decreasing value for orthopedic surgical work based on the Resource-Based Relative Value Scale (RBRVS) for Medicare reimbursement. This study was undertaken to estimate the time that Medicare payment rates for time spent in the office doing cognitive work will equal time dedicated in the operating room to performing procedural work based on long-term negative payment trends. METHODS: The RBRVS Update Committee database was accessed to extract the time elements for 2 procedures, total knee arthroplasty and total hip arthroplasty (27447 and 27130), on the day of surgery. The evaluation and management code mix for 2 mid-sized orthopedic practice was averaged to create an amalgamated rate for the reimbursement of office work on an hourly rate. A graph of the 25-year trend line in Medicare reimbursement for arthroplasty procedures was used to create a trend line. The trend line was then extrapolated to estimate the time in the future that the hourly rate for office work would equal the hourly rate for surgery. RESULTS: Time inputs and the Medicare conversion factor for 2021 were used in this analysis. Total procedural time for both 27447 and 27130 was 204 minutes (3.4 hours) on the day of surgery. An amalgamated hourly office rate of 7.9 relative value unit was calculated from the average of the 2 mid-sized private practices for an overall in office Medicare reimbursement of $318.89/h, with $1083.04 for the 3.4 hours allowed in the RBRVS Update Committee database for a joint replacement. When the trend line for reimbursement was extrapolated to the $1083.04 price point, the year corresponding to the point where hourly office reimbursement would equal hourly surgical work was 2024. CONCLUSION: Policymakers in Washington and practicing orthopedic surgeons need to consider the looming economic parity of surgical and cognitive work for Medicare. Continued negative reimbursement rates are likely to decrease patient access to necessary surgical care and result in de facto rationing of arthroplasty services for Medicare patients. The deployment of the orthopedic workforce is likely to change to accommodate the decreases in the value of surgical work. This trend will have significant impact on the practice of musculoskeletal medicine and patient access to orthopedic services.

Kettle test efficacy in predicting cognitive and functional outcomes in geriatric rehabilitation.

BACKGROUND/AIM: Limited research has been available to support the use of the Kettle Test in a subacute rehabilitation setting with patients diagnosed with a variety of medical conditions. The Kettle Test is an occupation based performance measure designed to detect cognitive processes and function. The aim of this research was to measure the correlation between three cognitive tests, the Mini-Mental State Examination (MMSE), Cognitive Functional Independence Measure (Cognitive FIM) and the Kettle Test. Secondly, to assess the efficacy of these tests in predicting functional outcomes via the motor subscale of the Functional Independence Measure (mFIM). METHODS: A prospective single-centre cohort study in a subacute rehabilitation setting of 97 patients. RESULTS: Correlation coefficients between the tests were statistically significant and moderately strong, with values ranging from 0.593 to -0.589. Significant positive correlations were seen between admission MMSE, Cognitive FIM and the mFIM and significant negative correlations between Kettle Test scores and the mFIM. The Kettle Test score had a stronger relationship with mFIM (r = -0.40; P < 0.01) compared to the Cognitive FIM (r = 0.33; P < 0.01) and MMSE (r = 0.26; P < 0.05). The Kettle Test variance is significantly associated with the MMSE and Cognitive FIM at admission and discharge measures. Modelling identified that age and gender significantly contribute to this relationship. When adjusted for age and gender the MMSE and Cognitive FIM both explained the 47% of the variance at discharge. CONCLUSION: There were statistically significant inter-test correlations between the MMSE, Cognitive FIM and Kettle Test. The Kettle Test had the strongest relationship to patient functional outcomes.

Strong Correlation Between Femoral Condyle Radius of Curvature and Anterior-Posterior Length: Implications for Osteochondral Allograft Matching.

BACKGROUND: The radius of curvature (ROC) of the femoral condyle is a factor in potential cartilage incongruities following osteochondral allograft (OCA) transplantation. Accurate restoration of the chondral surface may be achievable by using "best-fit" donor-recipient matching based on linear femorotibial dimensions, such as the femoral condyle anterior-posterior length (APL), femoral condyle width (lateral-medial length, LML), femoral hemicondyle width (HCW), and tibial plateau width (TPW), particularly if they correlate well with the ROC. This study aimed to investigate the correlative relationship between femorotibial dimensions and the ROC. METHODS: Computed tomography (CT) scans from 49 patients (31 men 28 ± 10 years old and 18 women 27 ± 6 years old) were analyzed. Axial images were used for APL and LML measurements, while coronal images were used for HCW and TPW. True sagittal images of the medial femoral condyle (MFC) and lateral femoral condyle (LFC) were used to calculate their individual ROCs by determining the best-fit circles along the condylar surface. Linear regression models were used to determine the relationship between the femorotibial dimensions and ROC. Measurements were repeated for a randomly selected subset of the data, and intraclass correlation coefficients (ICCs) were calculated to investigate intra- and interobserver reliability. RESULTS: All femorotibial dimensions showed significant correlations with the MFC and LFC ROCs (p < 0.01). The ROC correlations with femorotibial dimensions were found to be in the following descending order: APL (R2 ≥ 0.83), LML (R2 ≥ 0.52), TPW (R2 ≥ 0.36), and HCW (R2 ≥ 0.27). The intra- and interobserver reliabilities for the APL (ICC > 0.98) and ROC (ICC > 0.94) were excellent. CONCLUSIONS: The ROC was strongly correlated with the APL of the MFC and LFC. Donor-recipient APL matching in OCA transplantation may provide a level of matching similar to that achievable by direct ROC measurements. CLINICAL RELEVANCE: Determining the most predictive femorotibial dimension for ROC restoration in the OCA matching process may improve clinical outcomes, particularly for patients with large osteochondral lesions.

The "BioHumi" Humeral Head Osteochondral Allograft Transplantation for Reverse Hill-Sachs Lesion of the Shoulder.

Osteochondral defects of the shoulder due to posterior instability are less frequent than those caused by anterior instability. Although uncommon, locked posterior dislocations can create sizable osteochondral lesions of the anterior humeral head known as reverse Hill-Sachs lesions. Treatment of these defects to restore the congruent contour of the glenohumeral joint is essential to reduce recurrence of instability and prevent long-term sequelae of arthritis. Historically, nonanatomic options, such as transposition of the subscapularis tendon or lesser tuberosity into the defect and humeral rotational osteotomy, have been endorsed to treat reverse Hill-Sachs lesions. More contemporary techniques have focused on restoring not only the bony architecture but also the chondral surface using fresh osteochondral allografts. The evolution of this approach has been challenging because of the large impacted wedge-shaped defect typically encountered with a locked posterior dislocation. Many surgeons employ techniques using multiple circular grafts or customizing a nonanatomic graft to fill these defects. Given the unstable nature of these grafts, metallic screws are often placed through the chondral surface for fixation. The evolution of the "BioHumi" technique has made treatment of large reverse Hill-Sachs lesions technically simpler and more reproducible using innovative instrumentation to transplant an elliptical osteochondral allograft.

Arthroscopic-Assisted Intraosseous Bioplasty of the Humeral Head for Osteonecrosis.

Osteonecrosis of the humeral head is an uncommon condition, and treatment options are controversial. The shoulder is the second most common location for osteonecrosis, typically presenting between the second and fifth decades of life. Early diagnosis and treatment are essential because osteonecrosis may progress and lead to significant pain and loss of function. Nonoperative options are limited and are based on addressing the cause of the osteonecrosis. Multiple surgical treatments have been described, and these techniques continue to evolve. Open core decompression of the humeral head has been found to be an effective surgical option to restore blood supply and stimulate new bone formation. The evolution of arthroscopic techniques combined with biological adjuncts allows a minimally invasive approach with potential to accelerate revascularization and bone growth. We describe our technique for arthroscopic-assisted intraosseous bioplasty of the humeral head for the treatment of osteonecrosis.

Failure and Complication Rates in Common Sports and Arthroscopic Procedures: Reality Check.

Expectations following sports medicine and arthroscopic procedures have been elevated because of captivating modern-day media coverage of high-profile athletic injuries, surgery, and rapid return to sports. Unfortunately, this general perception may be misleading, and orthopedic sports medicine physicians must be aware of the harsh reality of the trials and tribulations associated with the subspecialty. The purpose of this review article is to provide an updated brief overview of the complications and failure rates associated with common arthroscopic procedures including rotator cuff repair, biceps tenodesis, Bankart procedure, Latarjet procedure, anterior cruciate ligament reconstruction, anterior cruciate ligament repair, meniscal repair, tibial tubercle osteotomy, and medial patellofemoral ligament reconstruction. Highlighting the complications is the first step toward early recognition, enhancing preventative measures, and successful management.

Efficacy of standard- vs reduced-dose insulin for treatment of hyperkalemia: A quasi-experiment.

PURPOSE: Hyperkalemia more commonly affects patients with a glomerular filtration rate of less than 60 mL/min. Using intravenous (IV) insulin to shift potassium intracellularly may cause hypoglycemia, requiring additional treatment or longer hospitalization. Literature on insulin dosing in this context is limited, with one previous study indicating that 5 units of IV insulin might be as effective and result in less hypoglycemia than the standard dose of 10 units of IV insulin. The hyperkalemia treatment pathway at our institution was revised in May 2018 to include a reduced-dose option (5 units of insulin) for patients with end-stage renal disease. This study aimed to compare the prevalence of hypoglycemia between patients who received standard-dose vs reduced-dose IV insulin. METHODS: This single-center, retrospective, quasi-experimental study evaluated the impact of revision of the hyperkalemia treatment pathway by assessing rates of hypoglycemia during the 6 months before and after implementation of the revised pathway. The primary endpoint was prevalence of hypoglycemia, defined as a blood glucose level of less than or equal to 70 mg/dL. RESULTS: There was no statistically significant difference in the occurrence of hypoglycemia when comparing the pre- and postimplementation groups (36 [17.7%] patients vs 34 [18.7%] patients; P = 0.7924). The postimplementation group had a statistically significant lower reduction in potassium levels after treatment than the preimplementation group (mean [interquartile range], -0.9 [-1.3, -0.5] mEq/L vs -0.6 [-1.2, -0.2] mEq/L; P = 0.0095). Baseline potassium levels were similar between the groups. CONCLUSION: Administration of reduced-dose IV insulin for treatment of hyperkalemia was significantly less effective in lowering serum potassium levels and did not decrease prevalence of hypoglycemia. When accounting for potential confounders, the only variable that was associated with hypoglycemia was pretreatment glucose level.

The "BioHumi" Humeral Head Elliptical Osteochondral Allograft Transplantation.

Cartilage defects of the humeral head in young, active patients provide a challenge to treating surgeons. The causes of humeral head osteochondral lesions are variable, but these lesions most commonly result from trauma and recurrent glenohumeral instability. Palliative and reparative techniques such as arthroscopic debridement and microfracture have traditionally been used as surgical treatment but have high failure rates. Similarly to surgical trends in the knee, cartilage restoration in the shoulder is becoming more prevalent in younger patients. Osteochondral allograft transplantation (OAT) has been used as a joint-preserving surgical option to restore hyaline cartilage in multiple joints for decades. Although OAT is more commonly used to re-establish the subchondral bony architecture in the treatment of recurrent shoulder instability, the procedure may also be indicated in young, active patients with focal humeral head chondral defects. OAT has been shown in early studies to provide improvement in functional outcome scores and good long-term graft survival with relatively low rates of complications. This report describes our straightforward, reproducible technique for the treatment of large, oblong chondral defects of the humeral head using OAT.

Lateral Meniscal Allograft Transplant: Dovetail Bone Bridge Preparation.

Meniscal tears are among the most common knee injuries encountered by an orthopaedic surgeon. Once treated with total meniscectomy, meniscal preservation is now the standard of care. Not all meniscal tears are repairable, and meniscal allograft transplantation has become an integral part of the preservation algorithm. This procedure is often recommended in a young active patient with healthy articular cartilage who has undergone a previous subtotal or total meniscectomy. There are many surgical methods for meniscal allograft transplantation, and the bone bridge technique has shown good improvement in outcome scores and good long-term survival. We describe our preferred technique for preparation of the dovetail bone bridge meniscal allograft for lateral meniscal allograft transplantation.

Distal Patellar Tendon SpeedBridge Repair.

Patellar tendon ruptures are rare injuries in young athletes, resulting in disruption of the extensor mechanism, and require surgery for functional recovery. Several techniques have been reported, including end-to-end repair and single-row suture anchor constructs. The strength of these repairs has been questioned, and they are commonly augmented. We endorse a double-row repair technique that provides an anatomic restoration of the footprint, has high fixation strength, eliminates the need for graft augmentation, and allows early motion.

Arthroscopic Low-Profile Knotless Repair of SLAP Tears With Suture Tape.

SLAP tears have been a controversial topic in shoulder surgery for decades. The indications for repair of SLAP tears, as well as the methods of repair, have undergone a recent evolution. The use of intra-articular knots for SLAP repair has fallen out of favor because of potential abrasive damage to the rotator cuff and glenohumeral articular cartilage due to knot migration and prominence. In response to this potential iatrogenic injury, arthroscopic techniques have undergone an evolution using advanced techniques with low-profile knotless repairs. We describe our preferred low-profile knotless technique for SLAP repair using LabralTape (Arthrex) in a horizontal mattress configuration.

Arthroscopic-Assisted Bone Graft Harvest From the Proximal Humerus for Distal Third Clavicle Fracture Nonunion.

Clavicle fracture nonunion can lead to persistent pain and loss of shoulder function. Distal clavicle fractures have the greatest risk of nonunion and are often treated surgically. Bone grafting plays a vital role in the treatment of distal clavicle nonunion. Although multiple options for bone graft exist, the iliac crest has long been considered the gold standard for harvest. Despite its extensive use, multiple complications have been associated with iliac crest bone graft harvest. We advocate a surgical technique for arthroscopic bone graft harvest from the proximal humerus with open reduction and internal fixation of an ipsilateral distal clavicle nonunion.

Physeal-Sparing Transosseous-Equivalent Arthroscopic Rotator Cuff Repair.

Rotator cuff injuries in the skeletally immature population are uncommon, with most tears resulting from trauma or overuse in throwing athletes. Although the literature has referenced multiple repair methods in the pediatric population, an arthroscopic physeal-sparing technique has yet to be described. Given the proximity of the proximal humerus growth plate to the typical anchor placement during rotator cuff repair, we advocate a technique that avoids violation of the proximal humeral physis. Our technique shows an arthroscopic physeal-sparing repair using standard arthroscopic equipment and fluoroscopy.

Interference screw versus suture anchor fixation for subpectoral tenodesis of the proximal biceps tendon: a cadaveric study.

PURPOSE: The purpose of this study was to compare the biomechanical properties of 2 fixation methods for subpectoral proximal biceps tenodesis. METHODS: In 9 matched pairs of cadaveric shoulders, an open subpectoral tenodesis was performed 1 cm proximal to the inferior border of the pectoralis major tendon by use of either an 8 x 12-mm Bio-Tenodesis screw (Arthrex, Naples, FL) with No. 2 FiberWire sutures (Arthrex) or a 5.5-mm Bio-Corkscrew double-loaded suture anchor (Arthrex) with No. 2 FiberWire sutures. The specimens were dissected and mounted in a material testing machine. Cyclic loading (20 to 60 N, 100 cycles, 0.5 mm/s, 5-N preload) was performed, followed by an unloaded 30-minute rest, a 5-N preload, and a load-to-failure protocol (1.25 mm/s) with a 100-lb load cell. Ultimate load (in Newtons), stiffness (in Newtons per millimeter), and modes of failure were recorded. Data were analyzed by use of paired t tests and Wilcoxon signed rank tests. RESULTS: Proximal biceps tenodeses with Bio-Tenodesis screws had a significantly higher mean load to failure (169.6 +/- 50.5 N; range, 99.6 to 244.7 N) than those with Bio-Corkscrew suture anchors (68.5 +/- 33.0 N; range, 24.2 to 119.4 N) (P = .002). Bio-Tenodesis screws also had a significantly higher stiffness (34.1 +/- 9.0 N/mm; range, 20.6 to 48.9 N/mm) than Bio-Corkscrews (19.3 +/- 10.5; range, 5.9 to 32.9 N/mm) (P = .038). CONCLUSIONS: In this cadaveric study the Bio-Tenodesis screw showed a statistically significantly higher load to failure and significantly higher stiffness than the Bio-Corkscrew anchor when used for tenodesis of the proximal biceps tendon in a subpectoral location. CLINICAL RELEVANCE: Biomechanical comparison of these 2 fixation techniques provides information on stiffness and load to failure of alternate fixation methods.

Are fishbowl activities effective for teaching pharmacotherapy and developing postformal thought in pharmacy students? A pilot study.

BACKGROUND AND PURPOSE: Case based learning is a commonly used pedagogy to facilitate active learning and development of problem-solving skills, however its utility may be limited in a large lecture environment. Fishbowl activities have been utilized in higher education to encourage discussion and postformal thinking and may be useful in engaging large class sizes in collective problem-solving activities. EDUCATIONAL ACTIVITY AND SETTING: The fishbowl activity took place in a second-year six-credit hour infectious disease course delivered in the spring of 2017, consisting 95 students. A pre-post survey was administered via Google® forms and consisted of demographic items (age, race, gender), students' self-reported level of preparation, perceived benefits of the activity, strengths and weakness of the fishbowl activity, and postformal thought using the Complex Postformal Thought (PFT) questionnaire. FINDINGS: Aggregate mean postformal thinking score was 51.98 in the pre-survey and 56.26 in the post-survey (p < 0.05). A majority of respondents agreed or strongly agreed that the activity helped them learn, was better than traditional lecture, and helped them prepare for material that would be on the exam. DISCUSSION: Overall, this activity was generally well received by the students and may have positively impacted their postformal thinking. It appears that the fishbowl activity concept may transfer easily to pharmacy education and be an additional active learning tool for pharmacy educators based on these limited pilot results. SUMMARY: Fishbowl activities may be a valuable educational tool for the development of postformal thinking skills in pharmacy students. Further studies are needed to evaluate the effectiveness and applicability of using this active learning approach in pharmacy education.

Distal Triceps Speed Bridge Repair.

Distal triceps ruptures are uncommon injuries resulting in loss of elbow extension strength and necessitating surgical repair to ensure optimal functional outcome. Traditional fixation techniques using running, locking sutures through the tendon secured through bone tunnels have been shown to poorly restore the anatomic footprint and are mechanically inferior to anatomic repairs. We endorse restoring the anatomic footprint of the distal triceps, similar to the well-researched rotator cuff repair model.

Reverse rotator interval closure.

We describe a technique for reducing capsular volume arthroscopically by shifting the anterior inferior glenohumeral ligament (AIGHL) and capsule up to the top of the subscapularis. This procedure is performed when laxity exists in the absence of a Bankart lesion. The AIGHL is first released from the capsule. This allows sutures to be placed through the capsule inferiorly so that it can be shifted up superiorly during the repair. The AIGHL and capsule are then released from the underlying subscapularis. Sutures are then passed through the capsule and out of the accessory anterior portal, progressing laterally. A BirdBeak suture passer (Arthrex, Naples, FL) is inserted through the superior edge of the subscapularis and is used to grasp each undersurface strand of suture and pull it through and out of the anterior portal. The sutures are then tied sequentially, effectively shifting the capsule and ligament up in a superior direction.

Medial femoral condyle strength after tunnel placement for single- and double-bundle posterior cruciate ligament reconstruction.

Single-bundle posterior cruciate ligament (PCL) reconstruction can restore normal posterior laxity; double-bundle reconstruction is needed to more closely mimic normal knee kinematics. Drilling two tunnels removes additional bone from the medial femoral condyle and may interfere with its vascular supply, increasing the risk of fracture or subchondral collapse. Three groups of seven synthetic femurs were tested: no tunnels, single anterolateral 10-mm tunnel, and double tunnel (anterolateral 10-mm tunnel and posteromedial 8-mm tunnel). The distal femur was potted to rigidly hold each specimen during testing. Compressive loading was performed at 2 mm/minute using an Instron (Instron Corp, Canton, Mass). Load and displacement at failure were recorded; stiffness was calculated from those measurements. Mean failure load of the double-tunnel group (7705 N) was significantly lower than the intact group (10962 N, P < .008). No other significant differences were detected. In this model, the double-bundle technique significantly reduced failure force, increasing the potential risk of medial femoral condyle fracture compared to the intact femur. The double-bundle technique also trended toward reduced stiffness. Therefore, a period of postoperative protected weight bearing is recommended.

Arthroscopic Treatment of Capitellum Osteochondritis Dissecans With Micronized Allogeneic Cartilage Scaffold.

Osteochondritis dissecans (OCD) of the capitellum is a common disorder that causes pain and functional limitation in the adolescent elbow. Although conservative management is the first line of treatment, surgical intervention is usually recommended for patients with persistent mechanical symptoms, loose bodies, or unstable lesions. Elbow arthroscopy has become the gold standard to evaluate and treat symptomatic OCD lesions. Arthroscopic debridement and bone marrow stimulation have been shown to yield good short-term results. Unfortunately, long-term follow-up has shown less favorable outcomes, with degenerative changes frequently documented. Current marrow stimulation techniques promote the formation of fibrocartilage, which is known to be less durable than hyaline cartilage. We describe an arthroscopic technique of debridement and drilling supplemented with a micronized allogeneic cartilage scaffold to address OCD lesions of the capitellum in an effort to promote hyaline cartilage formation.

Factors associated with decreased muscle strength after anterior cruciate ligament reconstruction with hamstring tendon grafts.

PURPOSE: To identify factors associated with decreased muscle strength and activity after anterior cruciate ligament (ACL) reconstruction with semitendinosus-gracilis tendon (ST-G) grafts. TYPE OF STUDY: Retrospective review. METHODS: Eighty-five patients who underwent ACL reconstruction with ST-G grafts were evaluated at a mean of 44.4 months after surgery. Patients underwent isokinetic testing, physical examination, radiographs, instrumented laxity testing, and Lysholm, Cincinnati, and International Knee Documentation Committee (IKDC) ratings. Cartilage and meniscal pathology at surgery was reviewed. Strength group 1 (n = 30) showed greater than 20% deficits in strength; strength group 2 (n = 55) had less than 20% strength deficits. Activity group 1 (n = 60) maintained their IKDC activity level at final follow-up relative to preinjury level; activity group 2 (n = 25) decreased activity by 1 or more levels. RESULTS: With all patients combined, there was less than a 4% difference in mean hamstring and quadriceps strength between the reconstructed and contralateral legs at follow-up. Knee flexion deficits were associated with decreased hamstring strength. Subjective giving way and squatting/kneeling discomfort were associated with decreased quadriceps strength. Patients in strength group 1 were more likely to have squatting/kneeling discomfort and lower Cincinnati Function scores. Activity group 2 had a longer interval from injury to surgery and more chondromalacia at surgery. At follow-up, activity group 2 had lower subjective scores and was more likely to have pain, swelling, giving way, and flexion deficits. Activity group 2 also had greater deficits in quadriceps strength. CONCLUSIONS: Articular cartilage injury and meniscal pathology were not associated with decreased muscle strength. ACL reconstruction with ST-G grafts has a 38% incidence of squatting/kneeling pain that occurs secondary to patellofemoral crepitus, harvest site symptoms, and tibial hardware sensitivity. LEVEL OF EVIDENCE: Level IV, therapeutic, case series, no control group.