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.

Editorial Commentary: A Rigged Game-Surgeon Reimbursement Under the Resource-Based Relative Value Scale, Current Procedural Terminology, and the Affordable Care Act.

The value of surgeon procedural work is currently determined through a fee-setting process controlled by the Centers for Medicare & Medicaid Services. This process relies on the Resource-Based Relative Value Scale (RBRVS) to advise the Centers for Medicare & Medicaid Services concerning surgical work reimbursement. This system and several other government policy decisions over the past 25 years have placed orthopaedic surgeons at great disadvantage in establishing and maintaining the value of orthopaedic surgical work. Continued reliance on the RBRVS will result in further reductions in surgical reimbursements and may affect patient access to orthopaedic services. Orthopaedic surgeons must consider moving away from the RBRVS and Current Procedural Terminology as a way of determining value and instead establish price as the value signal in orthopaedic medicine. Bundled-payment methodologies offer one mechanism for establishing price in the marketplace.

A prospective study assessing the political advocacy of American Shoulder and Elbow Surgeons members.

BACKGROUND: This study assessed the current political standings and active political engagement of American Shoulder and Elbow Surgeons (ASES) members along with the political process as it relates to health care policy. METHODS: This survey study involved 552 ASES members. The survey was open for 2 weeks. Responses were received from 254 of the 552 members (46%), and their answers were analyzed. RESULTS: Six (2%) of the responding members were solo practitioners, 100 (39%) belonged to a private practice, 106 (42%) were providers at academic institutions or residency training programs, 25 (10%) were employed by a hospital, and 17 (7%) categorized themselves as other. Email was the preferred method of communication. Of all responding members, 110 (43%) stated they had contributed to the American Academy of Orthopaedic Surgery Political Advocacy Committee in the last 12 months. Four (10%) of the responding members have a relationship with an elected official, and 220 (87%) would be willing to become a key contact and reach out to a legislator. CONCLUSION: Moving forward, this survey can be used to better shape the political advocacy efforts of the ASES and potentially other subspecialty societies. The response that "a high percentage of members would like to be more involved" suggests the need for a program to help further educate and facilitate the membership on political advocacy.

Editorial Commentary: Where's the Respect? Physical Exam of the Shoulder.

On physical examination of the shoulder, and specifically the rotator cuff, the full and empty can tests associated with weakness are the tests of choice for supraspinatus tears. However, under the huge administrative burden and in the context of the primacy of imaging mandated by regulatory agencies and/or payor, medical insurance coverage for rotator cuff repairs requires other physical examination tests and many other criteria. Moreover, some propose to reduce or even eliminate regulatory requirements mandating documentation of a history and a physical examination. It could be prudent to leave the documentation of the history and examination to the discretion of providers. Respect must be shown for the physical exam!

Editorial Commentary: Patient Reported Outcomes Measurement Information System (PROMIS) May Be Our Promise for the Future.

Collection of patient-reported outcome data in orthopaedic surgery is more important than ever. A recent research article compares the Patient Reported Outcomes Measurement Information System to several general health and shoulder-specific scoring systems in patients with preoperative rotator cuff pathology. This study addresses important concepts such as validity, reliability, floor/ceiling effects, and "decreased question burden" or questionnaire brevity that orthopaedic surgeons should consider when they collect patient-reported outcome data. It is vitally important that orthopaedic surgeons become actively involved in data collection efforts.

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.

A Proficiency-Based Progression Training Curriculum Coupled With a Model Simulator Results in the Acquisition of a Superior Arthroscopic Bankart Skill Set.

PURPOSE: To determine the effectiveness of proficiency-based progression (PBP) training using simulation both compared with the same training without proficiency requirements and compared with a traditional resident course for learning to perform an arthroscopic Bankart repair (ABR). METHODS: In a prospective, randomized, blinded study, 44 postgraduate year 4 or 5 orthopaedic residents from 21 Accreditation Council for Graduate Medical Education-approved US orthopaedic residency programs were randomly assigned to 1 of 3 skills training protocols for learning to perform an ABR: group A, traditional (routine Arthroscopy Association of North America Resident Course) (control, n = 14); group B, simulator (modified curriculum adding a shoulder model simulator) (n = 14); or group C, PBP (PBP plus the simulator) (n = 16). At the completion of training, all subjects performed a 3 suture anchor ABR on a cadaveric shoulder, which was videotaped and scored in blinded fashion with the use of previously validated metrics. RESULTS: The PBP-trained group (group C) made 56% fewer objectively assessed errors than the traditionally trained group (group A) (P = .011) and 41% fewer than group B (P = .049) (both comparisons were statistically significant). The proficiency benchmark was achieved on the final repair by 68.7% of participants in group C compared with 36.7% in group B and 28.6% in group A. When compared with group A, group B participants were 1.4 times, group C participants were 5.5 times, and group C(PBP) participants (who met all intermediate proficiency benchmarks) were 7.5 times as likely to achieve the final proficiency benchmark. CONCLUSIONS: A PBP training curriculum and protocol coupled with the use of a shoulder model simulator and previously validated metrics produces a superior arthroscopic Bankart skill set when compared with traditional and simulator-enhanced training methods. CLINICAL RELEVANCE: Surgical training combining PBP and a simulator is efficient and effective. Patient safety could be improved if surgical trainees participated in PBP training using a simulator before treating surgical patients.

Evidence-based medicine, appropriate-use criteria, and sports medicine: how best to develop meaningful treatment guidelines.

We propose using appropriate-use criteria (AUC) as the methodology of choice for formulating and disseminating evidence-based medicine guidelines in sports medicine and arthroscopy. AUC provide a structured process for integrating findings from the scientific literature with clinical judgment to produce explicit criteria for determining the appropriateness of specific treatments. The use of AUC will enable surgeons to treat patients in a more consistent manner based on expert clinical consensus and evidence-based medicine. This methodology also will ensure that guidelines represent all stakeholders and available evidence.

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.

Vascular risk associated with bicortical tibial drilling during anteromedial tibial tubercle transfer.

For select patients with persistent patellofemoral pain, the anteromedial tibial tubercle transfer (Fulkerson osteotomy) provides excellent clinical results. This procedure, indicated for patients with patellar malalignment, has become one of the most popular distal realignment procedures. One potential concern with this technique is the proximity of the posterior vascular structures during bicortical tibial drilling for screw placement. To address this concern, we measured the proximity of these structures in 7 consecutive fresh-frozen cadaveric knees. For each knee, barium was injected into the femoral artery, and anteroposterior (AP) radiographs were taken to document the location of the popliteal vessels. Next, the initial steps of the Fulkerson osteotomy were performed. Then, a lateral release and the tibial osteotomy were performed, the tubercle was advanced into position, and two 9/64-inch extralong drill bits were placed through the tubercle and the posterior tibial cortex. Repeat AP radiographs were obtained, and digital calipers were used to measure the distance from the drill bits to the popliteal vessels. The vascular structure closest to the exit point of the superior drill bit was the bifurcation of the popliteal artery (mean distance, 8.3 mm; SD, 9.3 mm; range, 0.0-21.3 mm), and in 2 knees this structure directly overlay the bifurcation on the AP radiograph; the vascular structure closest to the exit point of the inferior drill bit was the posterior tibial artery (mean distance, 9.0 mm; SD, 8.0 mm; range, 0.0-20.0 mm), and again in 2 knees the drill bit lay directly over the artery on the AP radiograph. Bicortical drilling for screw placement during the anteromedial tibial tubercle transfer procedure may come precariously close to the posterior vascular structures of the knee, so orthopedic surgeons must take extreme caution not to drill past the posterior cortex during this part of the operation.

Safety and efficacy of US-approved viscosupplements for knee osteoarthritis: a systematic review and meta-analysis of randomized, saline-controlled trials.

BACKGROUND: Intra-articular injection of hyaluronic acid is a common, yet controversial, therapeutic option for patients with knee osteoarthritis (OA). The purpose of this research was to determine the safety and efficacy of US-approved viscosupplements for symptomatic knee OA. METHODS: We searched MedLine and EMBase for randomized, sham-controlled trials evaluating safety and/or clinical efficacy of US-approved viscosupplements in patients with symptomatic knee OA. Knee pain severity and knee joint function were assessed at 4 to 13 weeks and 14 to 26 weeks. Safety outcomes included serious adverse events, treatment-related serious adverse events, patient withdrawal, and adverse event-related patient withdrawal occurring at any time during follow-up. RESULTS: A total of 29 studies representing 4,866 unique patients (active: 2,673, control: 2,193) were included. All sham-controlled trials used saline injections as a control. Viscosupplementation resulted in very large treatment effects between 4 and 26 weeks for knee pain and function compared to preinjection values, with standardized mean difference values ranging from 1.07 to 1.37 (all P<0.001). Compared to controls, standardized mean difference with viscosupplementation ranged from 0.38 to 0.43 for knee pain and 0.32 to 0.34 for knee function (all P<0.001). There were no statistically significant differences between viscosupplementation and controls for any safety outcome, with absolute risk differences of 0.7% (95% confidence interval [CI]: -0.2 to 1.5%) for serious adverse events, 0% (95% CI: -0.4 to 0.4%) for treatment-related serious adverse events, 0% (95% CI: -1.6 to 1.6%) for patient withdrawal, and 0.2% (95% CI: -0.4 to 0.8%) for adverse event-related patient withdrawal. CONCLUSION: Intra-articular injection of US-approved viscosupplements is safe and efficacious through 26 weeks in patients with symptomatic knee OA.

A review of the special tests associated with shoulder examination. Part II: laxity, instability, and superior labral anterior and posterior (SLAP) lesions.

This is the second of a two-part article describing the various tests that have been used to examine the shoulder to find and treat problems in that area. Part I of this article (January/February 2003, pages 154-160) focused on tests used to examine rotator cuff abnormalities. This article attempts to clarify the tests of laxity, instability, and the superior labral anterior and posterior (SLAP) lesions by presenting them as described by the original authors, with the additional aim of providing a source for those wishing to refresh their knowledge without the need to refer to the original source material.

A review of the special tests associated with shoulder examination. Part I: the rotator cuff tests.

Careful examination of the shoulder is an essential component in forming a diagnosis of problems in this area. A number of tests have been described that are claimed to improve diagnostic accuracy by specifically examining one component of the shoulder complex. Many of these tests are eponymous, and there is confusion about not only how to perform them but also what conclusion to draw from the results. This article attempts to clarify the tests used to examine the rotator cuff by presenting them as described by the original authors with the additional aim of providing a source for those wishing to refresh their knowledge without the need to refer to the original source material.

An improved technique for arthroscopic resection of the acromioclavicular joint.

Resection is the accepted treatment for arthritis of the acromioclavicular joint. It may be performed either open or arthroscopically. During arthroscopic resection, visualizing the superior aspect of the joint and determining the limit of resection can be difficult. We describe a new technique to improve visualization during the procedure.

Use of a Caspari suture punch to repair a radial tear of the lateral meniscus.

SUMMARY: Radial meniscal injuries in young patients are challenging problems. A technique not previously described in the literature is presented for radial meniscal repair. A Caspari suture punch is used to repair the inner leaf of the radial tear followed by standard inside-out augmentation with zone-specific cannulas and No. 2.0 PDS suture. This technical note describes the technique and its result in a case report.

Pitfalls associated with FasT-Fix meniscal repair.

There are several devices currently available for all-inside meniscal repair. One of the newest of these devices, the FasT-Fix (Smith & Nephew, Endoscopic Division, Andover, MA), is attractive because it combines advantages of traditional inside-out meniscal repair with an all-inside technique. We chose to critically evaluate these devices in a cadaver model. FasT-Fix devices were inserted arthroscopically in 8 fresh-frozen cadaveric knees at 5 to 7 mm intervals. A total of 45 devices were placed (24 laterally, 21 medially), and the knees were subsequently dissected to determine the location of the inserted devices. Several potential pitfalls were identified during the evaluation. When using the depth penetration limiter that comes preset with the device (to a depth of 22 mm), superficial structures, including the iliotibial tract and even the skin, were at risk for penetration with the needle. The device could not effectively be inserted into the anterior meniscus or the extreme posterior horn. Other potential pitfalls seen during insertion of the FasT-Fix meniscal repair devices include suture tensioning issues (including failure of the suture during tightening), intra-articular deployment of the implants, premature deployment of both the first and second implants, difficulty in advancing the trigger for deployment of the second implant, and difficulty in placing vertical-mattress sutures. Although the FasT-Fix is already in clinical use, additional modifications would likely enhance meniscal repair using this device.

Fracture of Bilok interference screws on insertion during anterior cruciate ligament reconstruction.

New femoral and tibial interference screws for use during anterior cruciate ligament (ACL) reconstruction have been developed using a composite of poly-L-lactic acid (PLLA) and tricalcium phosphate (TCP). The combination is described as having better incorporation than standard bioabsorbable screws with no loss of mass during incorporation and without the brittle nature associated with conventional TCP implants. However, the screw can fracture during insertion, leaving the distal third inside the femoral or tibial tunnel, making extraction and revision difficult. This is a report of 2 cases of PLLA-TCP screw breakage, 1 occurring in the femoral tunnel and 1 occurring in the tibial tunnel.

Allograft anterior cruciate ligament reconstruction in patients over 40 years of age.

PURPOSE: The study goal was to determine the results of allograft anterior cruciate ligament (ACL) reconstruction in patients over 40 years old at a minimum of 24 months follow-up (mean, 59.7 months; range, 24 to 110 months). TYPE OF STUDY: Retrospective review. METHODS: The records of 57 consecutive patients (mean age at surgery, 45.0 years; range, 40.2 to 60.8 years) were reviewed retrospectively. Nine patients who had undergone either prior ACL reconstruction, extra-articular reinforcement of the intra-articular procedure, or subsequent upper tibial osteotomy were eliminated. One patient was lost to follow-up. Of the remaining 47 patients (48 knees), 29 (62%) were men, and 18 (38%) were women. Twenty-eight of the 47 study patients (60%) were available for clinical interview consisting of physical examination, radiographs, and functional testing. Twenty-seven of these patients also underwent KT-1000 measurement, and 26 underwent Biodex evaluation. The remaining 19 patients were interviewed by telephone. RESULTS: At follow-up, Lachman, anterior drawer, and pivot shift tests were 0 or 1 in 27 (96%) of 28 patients. Differences between the index and contralateral legs as measured by KT-1000 at 20 lb of force were 0 to 2 mm in 22 of 27 patients (81%) and 3 to 5.5 mm in 5 patients (19%). None had a side-to-side difference greater than 5.5 mm. Based on the International Knee Documentation Committee activity classification system, 26 (55%) of 47 patients achieved the same or higher grade of activity postoperatively as they had preinjury. CONCLUSIONS: Results of ACL reconstruction in patients over 40 compare favorably with those observed in younger patients. Age should not be a limiting factor in choosing surgical reconstruction to treat functional instability in the ACL-deficient patient.

Vascular risk associated with a posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique.

This study evaluated the risk to the popliteal artery associated with the tibial inlay technique in posterior cruciate ligament (PCL) reconstruction. Barium was injected into the femoral arteries of eight fresh-frozen cadaveric knees and anteroposterior (AP) radiographs were obtained. Dissection of the fascia overlying the gastrocnemius muscle, identification of the interval between the medial head of the gastrocnemius and the semimembranosus, and lateral retraction of the medial head of the gastrocnemius (the Burks and Schaffer approach) was performed. Subsequently, a bicortical screw was placed from posterior to anterior through the tibia as is performed in the tibial inlay technique. A second AP radiograph was obtained. The distance from the center of the screw to the edge of the popliteal artery was measured using digital calipers. The closest any screw came to the popliteal artery was 18.1 mm, and the average distance was 21.1 mm (21.1 +/- 4.6 mm, range: 18.1-31.7 mm). When this distance was calculated as a percentage of the tibial plateau width, the smallest value was 19.2% (24% +/- 4.9%, range: 19.2%-35.1%). A posterior approach for a tibial inlay PCL reconstruction procedure appears safe with respect to the popliteal artery.