Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations.

BACKGROUND: Gastrocnemius recession is a surgical technique commonly performed on individuals who suffer from symptoms related to the restricted ankle dorsiflexion that results when tight superficial posterior compartment musculature causes an equinus contracture. Numerous variations for muscle-tendon unit release along the length of the calf have been described for this procedure over the past century, although all techniques share at least partial or complete release of the gastrocnemius muscle given its role as the primary plantarflexor of the ankle. There exists strong evidence to support the use of this procedure in pediatric patients suffering from cerebral palsy, and increasingly enthusiastic support-but less science-behind its application in treating adult foot and ankle pathologies perceived to be associated with gastrocnemius tightness. The purpose of this study, therefore, was to evaluate currently available evidence for using gastrocnemius recession in three adult populations for whom it is now commonly employed: Achilles tendinopathy, midfoot-forefoot overload syndrome, and diabetic foot ulcers. METHODS: A systematic review of the literature was performed on December 21, 2013 using the PubMed, Scopus, and Cochrane databases along with the search term "(gastrocnemius OR gastrocsoleus) AND (recession OR release OR lengthening)." This search generated 1141 results; 12 articles found in the references of these papers were also screened for inclusion. In total, 18 articles met our inclusion criteria. These articles were reviewed and assigned a classification (I-V) of Level of Evidence, according to the criteria recommended by the Journal of Bone & Joint Surgery. Based on these classifications, a Grade of Recommendation was assigned for each of the indications of interest. RESULTS: Grade B evidence-based literature ("fair") exists to support the use of gastrocnemius recession for the treatment of isolated foot pain due to midfoot/forefoot overload syndrome in adults. There are some data in support of utilizing gastrocnemius recession to treat midfoot or forefoot ulcers and non-insertional Achilles tendinopathy in adults, but to date this evidence remains Grade Cf. Insufficient evidence (Grade I) is currently available to make any recommendation either for or against this procedure for the treatment of insertional Achilles tendinopathy. CONCLUSION: Scientific literature continues to grow in support of using isolated gastrocnemius recession as an effective treatment strategy for a variety of lower limb pathologies, although it remains clear that higher evidence levels and more carefully controlled investigations will be necessary to more convincingly define the true efficacy and ideal applications of gastrocnemius recession in the adult population. LEVEL OF EVIDENCE: Level IV systematic review.

Medicare data transparency may confuse consumers comparing hospitals for total joint arthroplasty.

The release of new hospital-specific Medicare data was heralded as a major development in transparency that would empower consumers. Using this data, we sought to investigate differences in payments and outcomes for total joint arthroplasty (TJA). We compared the fifty hospitals top-ranked by U.S. News & World Report for orthopedics to non-ranked hospitals. Available surgical outcome metrics were similar for all hospital groups. Top-ranked hospitals discharged a significantly higher volume of TJAs compared to other hospitals. Top-ranked hospitals submitted higher average charges to Medicare, and received higher payments in return. This premium was the direct result of Medicare's own reimbursement policies, and reveals little about consumer pricing. While comprehensive, Medicare's new databases provide little help to consumers wishing to compare hospitals for TJA.

Availability of consumer prices for bunion surgery.

BACKGROUND: Today, insurance insulates most patients from the true costs of the health care services they consume. Economists believe that the absence of price signals incentivizes patients to pursue more extensive care than they would otherwise. Reformers propose restoring price consciousness to patients as a way to tame the soaring costs of American health care. To test this idea, we decided to gauge the availability and variability of price quotes for a common elective surgery-bunion repair. METHODS: Orthopedic clinics were sorted by state and randomly selected from an online directory maintained by the American Orthopaedic Foot and Ankle Society. Each selected clinic was contacted up to 3 times in an attempt to get a full, bundled price quote using a standardized patient script. If this was unavailable, an isolated quote for the physician fee alone was solicited. RESULTS: Of the 141 clinics contacted, 56 (39.7%) could provide a physician price estimate and 12 (8.5%) could give a complete bundled estimate, including hospital fees. The overall mean bundled price quoted was $18 332, while the overall mean physician fee quoted was $2487. There was no statistically significant difference in the mean price quoted by academic and private clinics, nor was regional variation observed. CONCLUSION: We found low price availability for elective bunion procedures. CLINICAL RELEVANCE: However, the wide variation observed in the prices that were quoted suggests that a very determined patient may be able to spend substantially less on an elective surgery if they were willing to select a provider carefully.

Comorbidities in patients undergoing total knee arthroplasty: do they influence hospital costs and length of stay?

BACKGROUND: Increasing national expenditures and use associated with TKA have resulted in pressure to reduce costs through various reimbursement cuts. However, within the arthroplasty literature, few studies have examined the association of medical comorbidities on resource use and length of stay after joint arthroplasty. QUESTIONS/PURPOSES: The purpose of this study was to examine the association between individual patient characteristics (including demographic factors and medical comorbidities) on resource allocation and length of stay (LOS) after TKA. METHODS: We queried the 2009 Nationwide Inpatient Sample dataset for International Classification of Diseases, 9(th) Revision code, 81.54, for TKAs. An initial 621,029-patient cohort was narrowed to 516,745 after inclusion of elective TKAs on patients aged between 40 and 95 years. Using generalized linear models, we estimated the effect of comorbidities on resource use (using cost-to-charge conversions to estimate hospital costs) and the LOS controlling for patient and hospital characteristics. Across the 2009 national cohort with TKAs, 12.7% had no comorbidities, whereas 32.6% had three or more. The most common conditions included hypertension (67.8%), diabetes (20.0%), and obesity (19.8%). Mean hospital costs were USD 14,491 (95% confidence interval [CI], 14,455-14,525) and mean hospital LOS was 3.3 days (95% CI, 3.29-3.31) in this data set. RESULTS: Patients with multiple comorbidities were associated with increased resource use and LOS. Higher marginal costs and LOS were associated with patients who had an inpatient death (USD +8017 [95% CI, 8006-8028], +2.3 [CI, 2.15-2.44] days over baseline), patients with recent weight loss (USD +4587 [95% CI, 4581-4593], +1.5 [CI, 1.45-1.61) days], minority race (USD +1037 [95% CI, 1035-1038], +0.3 [CI, 0.28-0.33] days), pulmonary-circulatory disorders (USD +3218 [95% CI, 3214-3221], +1.3 [CI, 1.25-1.34] days), and electrolyte disturbances (USD +1313 [95% CI, 1312-1314], +0.6 [CI, 0.57-0.60] days). All p values were < 0.001. CONCLUSION: Multiple patient comorbidities were associated with additive resource use and LOS after TKA. Current reimbursement may not adequately account for these patient characteristics. To avoid potential loss of access to care for sicker patients, payment needs to be adjusted to reflect actual resource use. LEVEL OF EVIDENCE: Level IV, economic and decision analysis. See the Instructions for Authors for a complete description of levels of evidence.

Total joint arthroplasty: trends in medicare reimbursement and implant prices.

Total joint arthroplasty (TJA) continues to be a popular target of cost control efforts. In order to provide a unique overview of financial trends facing TJA, we analyzed Medicare databases including 100% of beneficiaries, as well as industry surveys of implant list prices. Although there was a substantial increase in TJA utilization over the period 2000-2011 (+26.9%), growth has been stagnant since 2005. New coding schemes have made complicated cases more lucrative for hospitals (+2.5% to 6.5% per year), while reimbursements for uncomplicated cases have fallen (-0.7% to -0.6%). Physician reimbursements have declined on all case types (-2.5% to -2.1% per year), while list prices of orthopedic implants have risen (+4.8% to 5.5%). These trends should be kept in mind while contemplating future changes to TJA payment.

Economic burden of foot and ankle surgery in the US Medicare population.

BACKGROUND: Musculoskeletal diseases affecting the foot and ankle are common and can result in debilitating pain and chronic disability. The purpose of this study was to estimate the economic burden associated with operative interventions targeting these afflictions in the Medicare population. METHODS: Procedure incidence was determined using data from Medicare Part B National Summary Data Files (for 2000-2011). Health care and productivity costs were estimated for each year using an incidence-based cost model, using demographic information from 10 633 patient encounters at the University of Iowa Hospitals and Clinics over the period January 1, 2000, to December 31, 2010. RESULTS: The estimated economic burden of foot and ankle surgery in the Medicare population was $11 billion in 2011, up 38.2% since 2000. Direct health care costs were responsible for only 11% of this total, while indirect productivity costs contributed the remainder. Procedures targeting the foot accounted for over two-thirds of total economic burden, or $7.6 billion. Treatments for fracture and dislocation contributed the most to overall economic burden (31.0% of total), followed by reconstructive procedures (30.7%) and amputations (13.3%). CONCLUSION: Even in an older population, considerable productivity losses are associated with foot and ankle surgery. An increasing share of the population older than 65 expects to be fit to work, making disability in older Americans more monetarily important. At the same time, trends in chronic disease mean that the incidence of foot and ankle problems is likely to increase in the Medicare population. LEVEL OF EVIDENCE: Level III, economic analysis.

Trends in orthopedics: an analysis of Medicare claims, 2000-2010.

The complete Medicare Part B claims databases for the years 2000 through 2010 were queried. Musculoskeletal procedures were grouped into 12 anatomical or functional groups for multiyear analysis. Utilization rates per 1000 Medicare beneficiaries and spending per Medicare beneficiary were calculated. Compound annual growth rates were used to compare spending trends with national health care spending data. Medicare payments for orthopedic procedures increased 63.7% in 10 years, from $1.6 billion in 2000 to $2.6 billion in 2010. The number of procedures increased by a similar proportion, from 8.2 to 13.6 million (66.9%); the average reimbursement per procedure decreased slightly. The overall utilization rate increased by 41.4% over the past decade, from 206.73 to 292.41 per 1000 beneficiaries. Considerable variation was found when these procedures were analyzed, with utilization rates per 1000 beneficiaries ranging from large increases (spine, +214.5%; endoscopy, +128%) to modest decreases (hand and fingers, -9.9%). Payment trends, corrected for inflation and growth in the number of Medicare enrollees, showed similar heterogeneity. Payment per beneficiary increased at only 0.65% above inflation for orthopedic procedures, well below the 4.67% compound annual growth rate seen for overall Medicare spending.These data demonstrate that, despite significant increases in its utilization, orthopedics does not appear to be a driver for increases in Medicare spending over the past decade. Only spinal and endoscopic procedures stand out as having experienced exceptional growth; demonstration of clinical success and cost effectiveness in these areas would be helpful to strengthen support for these evolving trends in orthopedic practice.

Declines in lower extremity amputation in the US Medicare population, 2000-2010.

BACKGROUND: Despite evidence that improved outcomes are associated with more distal lower extremity amputations (LEA), the impact of recent advances in the orthopedic approach to diabetic foot ulcer (DFU) on the use and anatomic level of LEAs is unknown. METHODS: We queried the complete Medicare Part B claims database (2000-2010) for volume and reimbursement of all codes designating LEAs (hip and below) as well as a selection representing orthopedic treatments for DFU. Procedures were grouped for analysis; utilization rates per 100,000 Medicare enrollees and compound annual growth rates (CAGRs) of payments were calculated. Data are presented in the context of national health care spending trends. RESULTS: LEA utilization rates declined from 282.5 to 201.0 per 10(5) enrollees (-28.8%) over the decade. In general, declines were greatest for the most proximal levels and smallest for the most distal sites. Use of orthopedic treatments for DFUs, including Achilles tendon release and total contact casting, rose from 26.0 to 63.3 per 10(5) enrollees (+143.3%). Payment trends mirrored utilization data. During this period, total health care spending in the United States increased at a CAGR of 6.5%, whereas total Medicare payments rose at a CAGR of 8.9%. CONCLUSION: The last decade saw a marked decline in the use of LEA in the Medicare population, despite unfavorable demographic changes. Furthermore, it became more likely for LEAs to occur at distal, limb-conserving locations. Over the same period, use of orthopedic treatments for DFU increased sharply. LEVEL OF EVIDENCE: Level III, retrospective comparative database analysis.

Central angiotensin (1-7) enhances baroreflex gain in conscious rabbits with heart failure.

In chronic heart failure (CHF), arterial baroreflex function is impaired, in part, by activation of the central renin-angiotensin system. A metabolite of angiotensin (Ang) II, Ang-(1-7), has been shown to exhibit cardiovascular effects that are in opposition to that of Ang II. However, the action of Ang-(1-7) on sympathetic outflow and baroreflex function is not well understood, especially in CHF. The aim of this study was to determine the effect of intracerebroventricular infusion of Ang-(1-7) on baroreflex control of heart rate and renal sympathetic nerve activity in conscious rabbits with CHF. We hypothesized that central Ang-(1-7) would improve baroreflex function in CHF. Ang-(1-7) (2 nmol/1 µL per hour) or artificial cerebrospinal fluid (1 µL per hour) was infused by an osmotic minipump for 4 days in sham and pacing-induced CHF rabbits (n=3 to 6 per group). Ang-(1-7) treatment had no effects in sham rabbits but reduced heart rate and increased baroreflex gain (7.4±1.5 versus 2.5±0.4 bpm/mm Hg; P<0.05) in CHF rabbits. The Ang-(1-7) antagonist A779 (8 nmol/1 µL per hour) blocked the improvement in baroreflex gain in CHF. Baroreflex gain increased in CHF+Ang-(1-7) animals when only the vagus was allowed to modulate baroreflex control by acute treatment with the ß-1 antagonist metoprolol, indicating increased vagal tone. Baseline renal sympathetic nerve activity was significantly lower, and baroreflex control of renal sympathetic nerve activity was enhanced in CHF rabbits receiving Ang-(1-7). These data suggest that augmentation of central Ang-(1-7) inhibits sympathetic outflow and increases vagal outflow in CHF, thus contributing to enhanced baroreflex gain in this disease state.