Nonsurgical Management of Osteoarthritis of the Knee: What You Should Be Injecting Now and in the Future.

Osteoarthritis of the knee affects many Americans. With the aging of the population and increasing comorbidities (eg, obesity, diabetes, hypertension, heart disease), the use of oral or topical NSAIDs is often contraindicated. Injectable treatment options are advantageous because of the ability to decrease or avoid the unwanted systematic adverse effects of NSAIDs. Injectable treatment options for osteoarthritis of the knee go back to the 1950s, beginning with corticosteroids, which remain widely used despite concerns that they may have adverse effects on articular chondrocytes and short duration of efficacy. The recent (FDA approval in 2017) introduction of a sustained-release corticosteroid (triamcinolone acetonide extended-release) offers significantly longer benefit than standard cortisone products and with substantially lower concentration levels of chondrocyte exposure to the steroid. Hyaluronic acid was added to the options for intra-articular injection in osteoarthritis of the knee in the late 1990s and remains widely used despite some controversy over its efficacy. Although guidelines for the use of hyaluronic acid for management of osteoarthritis of the knee have varied widely, careful analysis of the data and patient's perceived efficacy indicate its continued and important role in managing osteoarthritis of the knee. Finally, the past 15 years have seen an explosion in the use of biologics including platelet-rich plasma and pluripotential (often termed stem) cells. The science behind their use and efficacy is evolving and continued study is warranted.

The Conservative Treatment of Osteoarthritis of the Knee.

Osteoarthritis has one of the highest associations for all-cause mortality in the United States. Comorbidities are common in patients with end-stage disease. In most cases, it is critical to exhaust conservative modalities of care before resorting to surgical intervention. This article discusses common conservative approaches focusing on injectable treatments that can be employed prior to total knee replacement. [Orthopedics. 2018; 41(5):256-260.].

Editorial Commentary: Knee Meniscus and Hip Labrum: The Dilemma of Degenerative Tears.

The dilemma for orthopaedic surgeons attempting to solve the problem of treating a knee meniscal tear in an older patient has always been whether or not a conservative approach is of value and if a surgical approach will provide benefit to the patient. Today, the same might be said of hip labral tears. Physical therapy is a wonderful tool to strengthen muscles, but it does not correct underlying pathology, which is often the source of joint pain. In an older patient with a symptomatic internal derangement, it is important for surgeons and payers to recognize that a simple outpatient surgical procedure often can improve that patient's symptoms.

Employment Contracts: The Good, the Bad, and the Ugly.

Recent trends indicate that a greater number of orthopaedic surgeons who complete their residency and/or fellowship training are accepting employment positions at hospitals. Moreover, established orthopaedic surgeons with successful private practices have begun to consider whether aligning with hospitals and larger health systems can be effectively accomplished. A comprehensive evaluation of institution-based employment opportunities is essential for orthopaedic surgeons considering hospital-based employment. Surgeons should be aware of the healthcare, clinical, and administrative opportunities of private practice employment versus hospital-based employment before accepting a clinical position.

Outpatient Total Joint Arthroplasty.

PURPOSE OF REVIEW: Outpatient total joint arthroplasty (OTJA) allows for a safe, cost effective pathway for appropriately selected patients. With current pressures on arthroplasty surgeons and their associated institutions to reduce costs per episode of care, it is important to define the steps and challenges associated with establishing an outpatient arthroplasty program. RECENT FINDINGS: Several studies have outlined techniques of selecting patients suitable for this type of postoperative pathway. With emerging concerns about patients who undergo outpatient arthroplasty being at increased risk of medical complications, which may lessen projected cost savings, it is important to identify value-based strategies to optimize patient recovery after OTJA. This article reviews digital techniques for patient selection and data collection, operating room efficiency systems, and provides a summary of methods to build and maintain value in outpatient total joint replacement within the framework of bundled payment reimbursement.

First, Do No Harm: Protect the Articular Cartilage When Performing Arthroscopic Knee Surgery!

It is not uncommon to damage the articular surface when performing routine arthroscopic surgical procedures of the knee. The article reviews the background, literature, and technique of performing a partial medial collateral ligament release in a tight knee when attempting to access the posterior medial compartment.

Getting Ready for ICD-10 and Meaningful Use Stage 2.

For the past 24 years, most developed countries have used the International Classification of Diseases, Tenth Revision (ICD-10) to report physician services. In the United States, physicians have continued to use the American Medical Association Current Procedural Terminology, Fourth Edition and the Healthcare Common Procedure Coding System. The ICD-10-Clinical Modification (CM) has approximately 4.9 times more codes than the International Classification of Diseases, Ninth Revision. ICD-10-CM allows for more specific descriptors of a procedure and is broken down by category, etiology, anatomic site, severity, and extension. ICD-10-CM is scheduled to be implemented by Medicare and commercial payers on October 1, 2015. In addition to ICD-10 implementation, physicians have to meet the requirements of the Meaningful Use Electronic Health Record Incentive Program. The Meaningful Use program is designed to promote the use of certified electronic health technology by providing eligible professionals with incentive payments if they meet the defined core and menu objectives of each stage of the program. All core measures must be met; however, providers can choose to meet a preset number of menu measures. Meaningful Use Stage 1 required eligible professionals to meet core and menu objectives that focused on data capture and sharing. Meaningful Use Stage 2 requires eligible professionals to meet core and menu objects that focus on advanced clinical processes for a full year in 2015. Stage 3 has been delayed until 2017, and core and menu measures that will focus on improving outcomes have not yet been defined. It is important for orthopaedic surgeons to understand the history of and techniques for the use of ICD-10-CM in clinical practice. Orthopaedic surgeons also should understand the requirements for Meaningful Use Stages 1 and 2, including the core objectives that must be met to achieve satisfactory attestation.

Abandoning microfracture of the knee: has the time come?

Marrow stimulation has been performed for more than 45 years beginning with the simple drilling of bony surfaces, burring or "abrading" the sclerotic lesion, and more recently using awls to penetrate eburnated bone to promote blood flow to the bony surface. Multiple authors have promoted these procedures as "helpful," but others have confirmed only short-term relief with destruction of the subchondral surface. Unfortunately, proponents do not compare their marrow stimulation results to a control group that had debridement alone. A recent study confirmed that microfracture (MF) is equivalent to debridement and does not affect the subchondral bone, which therefore does not reduce the success rates of future surgery subsequent to MF. This brief review summarizes some of the factual data showing that marrow stimulation may not offer any improvement over debridement alone and that, in fact, MF results in significant destruction to the subchondral bone.

Nonoperative treatment of unicompartmental arthritis: from bracing to injection.

The published recommendations for the nonoperative treatment of osteoarthritis (OA) of the knee include weight loss, physical therapy to strengthen lower-extremity musculature, nonsteroidal antiinflammatories, nutritional supplements, topical treatments, and steroid injections. Evidenced-based results have been mixed using these treatment modalities. The results using unloader braces and viscosupplementation have also been variable. This article reviews the use of conservative treatment of OA of the knee.

The pros and cons of hospital employment.

The pros and cons of hospital employment vary significantly in today's economic environment. This chapter summarizes the advantages and disadvantages of hospital employment with an emphasis on the critical aspect of formalizing an agreement with the hospital employer to prevent future salary reductions and/or termination.

Management of infections after arthroscopy.

Management and evaluations of infections after arthroscopy of the knee and shoulder can be difficult and fraught with complications, both medical and legal. This article reviews the literature regarding arthroscopic infections from a historical perspective and discusses the treatment of knee and shoulder infections as well as the complications associated with delayed treatment. It is critical to make the diagnosis as soon as possible subsequent to the initial procedure to avoid postoperative sequelae consisting of stiffness and a decrease in function.

Treatment of OA of the knee in the middle-aged athlete: the role of arthroscopy.

Knee arthroscopy for patients with osteoarthritis remains controversial. The outcome of arthroscopic debridement in a patient with symptomatic arthritis, and in the absence of mechanical symptoms, is inconsistent and short lived. However, in carefully selected patients with mild or moderate arthritis on standing radiographs, with the acute onset of symptoms, well-localized joint line pain, and painful mechanical symptoms, improved knee function can be expected. Regardless, the natural history of the disease process is unaltered. Patients, especially higher demand middle-aged athletes, must be counseled about the prognosis of degenerative arthritis, the limited positive effects of the arthroscopic procedure, the potential for complications, and the probable need for reconstructive surgery in the future.

Interscalene block for shoulder surgery in physician-owned community ambulatory surgery centers.

PURPOSE: To retrospectively report on a series of patients who had interscalene block regional anesthesia performed for outpatient open and arthroscopic shoulder surgical procedures in a community-based ambulatory surgery center setting. METHODS: We reviewed the cases of 1,945 patients who had interscalene block regional anesthesia performed during an 8-year period. RESULTS: The complication rate was 0.63%, with all complications occurring in the immediate postoperative period, none of which were permanent. CONCLUSIONS: With an expert, experienced anesthesia team, the interscalene block can be a safe method (temporary complication rate, 0.63%) of intraoperative anesthesia and perioperative analgesia for outpatient open and arthroscopic shoulder surgery in physician-owned ambulatory surgery centers. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Current strategies for nonsurgical, arthroscopic, and minimally invasive surgical treatment of knee cartilage pathology.

The current approaches to treating articular cartilage defects in the knee comprise a spectrum from pharmacologic therapies to total knee arthroplasty. Nonsurgical treatment can include anti-inflammatory medications, bracing, and physical therapy. Surgical treatments include reconstructive repair of a small or large defect using microfracture, osteochondral autograft transplantation, autologous chrondrocyte transplantation, or osteochondral allograft transplantation; realignment procedures including osteotomies; and unicompartmental arthroplasty. A comprehensive algorithm can be used to determine the appropriate treatment for knee defects.

The use of hyaluronan after arthroscopic surgery of the knee.

Viscosupplementation is defined as the use of intra-articular hyaluronan therapy for symptomatic osteoarthritis (OA). Originally used for the treatment of ophthalmic disorders, viscosupplementation has been available for over a decade in the United States for the treatment of pain secondary to OA of the knee in patients who have not responded adequately to conservative oral pharmaceuticals including nonsteroidal anti-inflammatories and simple analgesics. The majority of patients with symptomatic knee OA will have evidence of meniscal and/or articular surface pathology, and most orthopaedic surgeons include arthroscopic surgery as a possible treatment modality for the symptomatic patient. Although arthroscopic meniscectomy is the most commonly performed orthopaedic procedure in the United States, in patients with concomitant OA, disease-related pain can persist after arthroscopic surgery. This article reviews some of the more recent evidence recommending the use of viscosupplementation for the management of symptomatic knee OA and pain relief after arthroscopy.