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Extremities Feature

Source: Wikimedia Commons and Harrygouvas

Dramatic Rise in Shoulder Arthroplasty…and More…

Elizabeth Hofheinz, M.P.H., M.Ed. • Sun, November 25th, 2012

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Dramatic Rise in Shoulder Arthroplasty…Dissecting Causes of Surgical Errors…No Pay for Reverse Shoulders? and More…

Shoulder Arthroplasty Exploding

John Sperling, M.D., M.B.A. is professor of Orthopedic Surgery at Mayo Clinic. We recently caught up with him at a shoulder arthroplasty course he was teaching in Chicago. He tells OTW, “We continue to see a significant growth in interest in shoulder arthroplasty; we are seeing this at the residency level, fellowship level, as well as among practicing orthopedic surgeons. One of the primary drivers of this trend is that the technology is better than ever, and the recognition of the extraordinary benefits shoulder arthroplasty can have on the quality of life for our patients. Orthopedic surgeons, as well as primary care physicians, are recognizing that shoulder arthroplasty can consistently deliver pain relief and restoration of function.”

“The main driver in shoulder arthroplasty over the past decade has been the introduction of the reverse arthroplasty—it has truly revolutionized our practice. The results of the reverse arthroplasty have been very encouraging. The reverse provides an important option in treating patients with rotator cuff insufficiency, four part proximal humerus fractures, as well as cases with significant glenoid bone deficiency. The percentage growth in shoulder arthroplasty has been much higher than in hip or knee arthroplasty because of the widening spectrum of shoulder pathologies that can potentially benefit from this procedure. With this benefit, shoulder arthroplasty is now being performed in younger patients. Therefore, one area that holds promise in the future is the development of bearing surfaces with better wear properties. Our goal now is to have these advancements translate into longer life for shoulder implants.”

 Dissecting the Causes of Surgical Errors

James Herndon, M.D is a former president of the American Academy of Orthopaedic Surgeons (AAOS). A tireless advocate for patient safety in residency, Dr. Herndon has chaired the department of orthopedics at Harvard, Brown, and “Pitt.” He tells OTW, “The number of errors and adverse events occurring in residency as well as in practice continues to be a problem. Unfortunately, doctors haven’t taken a leadership role in trying to understand and analyze these errors. Frankly, I just don’t know why. Many doctors feel that they are already doing their very best for each individual patient, and they don’t think about or recognize that they are making mistakes, often accepting them as complications. While there is a resumed effort by the Academy leadership to look at safety-related systems issues, we must also look at an individual’s surgery-related responsibilities. There was an AAOS survey a few years ago that determined that 60% of the mistakes made were related to the individual surgeon in the OR, in treatment, or in diagnosis.”

“My colleagues and I have done studies showing that fatigue is a problem amongst residents, but all the work on fatigue and limiting work hours in the U.S. has only been directed at residents. In England and the rest of Europe they limit the hours of residents and consultant doctors. I think we need to find a way to assess fatigue before the surgeon enters the OR. If a surgeon has been up all night after working all day and faces elective cases the next morning then that is a huge problem. We need some form of computerized exam to determine their response time and whether they are too fatigued to operate on their elective cases. My colleagues and I have also done studies looking at the personality types of doctors and readmissions. We’ve known for years that certain macho/high risk takers amongst pilots do in fact make more mistakes. Our own study found that about 20% of the readmissions were related to surgeons that had a macho type personality. To what extent that can be ‘trained out’ of someone is unclear, but some attempt at remediation by coaching or other means is necessary in my opinion.”

Rare Bug on the Rise

Michael T. Archdeacon, M.D., M.S.E. is director of the Division of Musculoskeletal Traumatology at the University of Cincinnati Medical Center. He is also professor and vice chairman of orthopaedic surgery at the University of Cincinnati College of Medicine and the former chief of staff at University Hospital of Cincinnati. He is keeping a watchful eye on the rise of a certain, heretofore rare, bacteria. He tells OTW, “We are unfortunately seeing an increase in what was once a rare bug—acinetobacter. It’s a very tough bacteria to fight because it has developed resistance to many antibiotics. A decade few ago physicians had hardly ever encountered acinetobacter, but now it’s not uncommon to see it in open fractures with significant soft tissue damage or immunocompromised hosts. This increasing occurrence and multiple drug resistance is likely related to our increased use of antibiotics. We do our best to go after it with a combination of antibiotics, aggressive surgical debridement, and hardware removal, but in the end, some patients ultimately end up with an amputation. It was first recognized in the early 2000s when soldiers were returning from Iraq; now it has spread to the civilian population. It’s unclear how we are going to fight this bug…and it will most likely get worse before it gets better. Research for alternative treatment modalities is critical as current strategies are not effective in many cases.”

No Pay for Reverse Shoulders?

Jon J.P. Warner, M.D. is chief of the Harvard Shoulder Service at Massachusetts General Hospital and co-director of the Harvard Combined Shoulder Fellowship. He has just completed his tenure as president of the American Shoulder and Elbow Society (ASES). He tells OTW, “The focus of my year as president was the creation of a value based care approach to shoulder care. If five or ten different surgeons are treating a rotator cuff tear, there are usually great variations in the cost of that care. The way that things are being paid for affects what we do. In Massachusetts, for example, a major insurance carrier has decided that it will no longer pay for reverse prosthesis, the fastest growing shoulder joint replacement surgery. They determined that the complications were too high that overall care was too expensive. While the failure rate is high in the hands of nonexperts, it is reliable surgery in the hands of experts and it can change a patient’s life by relieving pain and improving function. It is odd, because we know that volume and experience correlate to overall outcomes, yet we let any surgeon do any kind of procedure.”

“We were able to work with this insurer and they put their decision on hold with the understanding that we would provide them with guidelines for criteria to approve this type of surgery. Of course, many surgeons will say that what we are trying to do is going to threaten their livelihood. But outcomes for the patient are more important than livelihood. This is unheard of but this ‘accountability through outcomes’ may be the easiest way through this. My colleagues and I are working with Harvard Business School as well as insurance companies on value based initiatives…and you don’t often see such a collaboration.”

“One of the things I did was to modify the ASES mission statement and add a vision statement to encompass value based care. We are, to my knowledge, one of the only specialty societies which have done so. I also created a value based committee in our organization in order to partner with other societies so that we can look for opportunities to create value for patients, insurers, and the government. Our effort includes evidence based medicine, which to date has been poorly applied. We are also working on rewriting shoulder care policies for the industrial accident board for the commonwealth of Massachusetts. Also exciting is that we are working with a very large insurer to create value based centers of excellence for shoulder care. We want to avoid the assertion/accusation that we are trying to redirect care to suit own people and exclude others. We have no intention of limiting access. I don’t care who does this as long as we have accountability, transparency, and discoverable outcomes.”

Richard Fisher, M.D. New Chair at HVO

Health Volunteers Overseas (HVO) has announced that Dr. Richard Fisher is the new chair of the HVO Board of Directors. Dr. Fisher is an orthopedic surgeon who has served as an HVO Board member since 2009 and, until this past February, served as chair of Orthopaedics Overseas, the founding division of HVO. Dr. Fisher has been an active HVO member for many years, and has served as a volunteer in Bangladesh, Peru, Bhutan, Ghana, and Vietnam. He served as Country Director for HVO’s USAID-funded rehabilitation project in Mozambique and was a member of the Technical Advisory Group for HVO’s Vietnam Rehabilitation Project. Dr. Fisher is a member of the WHO (World Health Organization) Expert Panel for Clinical Technology, a participant in the WHO Global Initiative for Emergency Essential Surgical Care, and co-editor of the WHO publication Surgical Care at the District Hospital. He was a Fulbright Fellow in Sri Lanka in 2007.

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One Response to “Dramatic Rise in Shoulder Arthroplasty…and More…”

  1. Justin says:

    There are patients like myself who scour the Internet looking for innovations in shoulder replacement for younger patients. We are a minority, but we need your help.

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