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Virtual Reality Coming to Grand Rounds // Same-Day Bilateral Knee Replacements Safe // and More!

Elizabeth Hofheinz, M.P.H., M.Ed. • Sun, March 30th, 2014

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Virtual Reality Coming to Grand Rounds?

Let’s say you are a fellow in hand surgery at, say, University of the Hand. Wouldn’t it be informative to know how an established thought leader from, say, Duke Orthopaedics would treat a specific case? Now that is possible through the Orthopaedic Education Initiative (OEI) on forMD.com. Greg Chang, MHA, was formerly associate director at Duke Orthopaedics and is currently cofounder and CEO of forMD. He tells OTW, “The idea for the Orthopaedic Education Initiative began when I was at Duke, and grew from discussions with and leadership from several orthopedic surgeons, including Jay Parvizi from the Rothman Institute and Scott Levin at the University of Pennsylvania. The objective is to allow individuals to connect to one another by subspecialty to share knowledge and learn from experts and colleagues. Our program, forMD.com, allows residents, fellows, faculty, and alumnae of residency programs to collaborate and learn from one another so as to accelerate the evolution of knowledge in the field.”

“At present we have 17 academic orthopedic groups that have volunteered to lead these discussions on a rotating basis and four programs have already done so: Duke, Rothman Institute, Hospital for Special Surgery, and Tulane University. More than 40 organizations have signed up thus far; the best news is that a full 20% of all U.S. orthopedic surgeons are already participating.”

“There are other orthopedic learning/connection sites on the internet, but our differentiating factor is that we allow orthopedic surgeons to connect through natural affinity groups they already belong to. The process is as follows: Each time an institution leads a discussion they select a topic that is considered, i.e., something that hasn’t been completely settled in the field and share it with the appropriate subspecialty, society, and/or residency alumni group. A deidentified case is reviewed, along with the appropriate imaging, etc. In the initial phase of the discussion, each surgeon provides treatment options, followed by feedback from the community. Then after a week or two of discussion the faculty member who is leading the discussion follows up with his or her input as to how they would treat them.”

For those concerned about site privacy issues, Chang notes, “This is an invitation-only site and the information held at the same level of security that you would find in any web-based EMR or HIPAA compliant platform. Additionally, we sign a contract with each institution verifying that we will not share their information with third parties to ensure the purity of the community and the privacy of all discussions.”

“This is a terrific opportunity to provide and access thought leadership on a larger scale, something that usually only happens at large medical conferences or visiting professorships. On a macro scale the goal is to connect the international orthopedic community to share best practices.”

Same-Day Bilateral Knee Replacements Safe for Select Patients

A recent study has found that patients with inflammatory arthritis who underwent same-day bilateral knee replacements had the same outcomes as patients with osteoarthritis (OA). Mark Figgie, M.D. is a hip and knee surgeon at Hospital for Special Surgery in New York. He told OTW, “Since inflammatory arthritis is a systemic disease, patients have historically had poorer outcomes, including higher complication rates. We wanted to see if our results with bilaterals in carefully selected patients were comparable to patients with OA; I was pleasantly surprised at results showing that the outcomes were no different in patients with OA. I expected those with inflammatory arthritis to have higher complication rates, more prolonged hospital stays, and more transfers to a rehab facility.”

“The inflammatory patients are in many ways in better shape when they come to us. What we see with OA is patients who are sicker and more obese; in inflammatory arthritis, because the disease is treated more aggressively, then they are often in better condition. However, those with inflammatory arthritis tend to have more severe contractures and joint deformity. If both knees have bad contractures, you should do both knees the same day because if one knee is straight and the other is contracted then the patient won’t rehab properly. This study shows that orthopedic surgeons can take on these patients with difficult deformities and get good results.”

“In a separate study we looked at how patients fare if you do both knees during the same hospital stay, but not on the same day. Patients whose surgeries were five days apart didn’t do as well because you do the first knee and by the time you do the second knee their coagulation factors out of whack because they are responding to the stress of first surgery. In these cases there was a higher rate of phlebitis, wound problems and ileus. Our recommendation is that if they are not healthy enough to undergo both surgeries the same day then you should stage the operations a couple of months apart.”

“It’s primarily the higher volume joint replacement centers that are doing bilaterals for inflammatory arthritis because you need a coordinated team of cardiologists, rheumatologists, anesthesiologists, etc. Such teamwork is critical to ensuring that the patients are well screened and optimized for surgery.”

Massive Study: Off-Label THA, TKA on the Rise

Most total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients are becoming off-label, says a 10-year study from the Cleveland Clinic. Wael Barsoum, M.D. is vice chair of the Department of Orthopaedic Surgery and Chairman of Surgical Operations at that facility. He told OTW, “We are seeing a massive new national epidemiological trend towards off-label THA and TKA. Our cross-sectional study, which involved a weighted sample of 7, 769, 863 patients, found that the national prevalence of off-label THA and TKA was at least 30.4% and 37.0%, respectively. Based on this study, we can predict that by 2040, most total joint reconstruction of the hip and knee will be off-label (THA, 86.1%; TKA, 91.5%).”

“We also wanted to find out if the labeling makes sense and if patients are doing well. Amazingly, the joint replacement devices that were approved in the 1970s by the FDA still serve as today’s predicate device. So if you want to use the 510(k) process for approval of new implants you are stuck with the same labeling. We wondered if this labeling is really based on science. We know that indications for joint surgery have expanded and that patients are living longer and are heavier, so it makes sense that more and more will be off-label. We wanted to know if these patients used more resources and if we are doing them a disservice.”

“The study did show that it is minimally more expensive to care for most types of off-label patients (part of this is the prolonged hospital stay). Also, we found that off-label patients had a slightly greater likelihood for a perioperative complication. Patients with neurological or mental disorders had the worst outcomes of the off-label subgroups that we analyzed. This work makes us cognizant that as more and more joint replacements are off-label, we must expect that some of these patients will stay in the hospital longer and that their care may be more complicated. As we move toward more accountable care medicine we need to think more of how doctors, systems, and insurers can stratify patients from a risk perspective…this data helps us do that. It doesn’t make sense to pay the same amount for someone who is healthy versus someone who is very sick.”

Michael J. Greller, M.D. Awarded Most Compassionate Doctor Award

Michael J. Greller, M.D. has been awarded with Vitals 2013 Most Compassionate Doctor Award.

Dr. Greller practices at Advanced Orthopedics and Sports Medicine Institute (AOSMI) in Freehold, New Jersey.

The distinction of Most Compassionate Doctor recognizes physician excellence and is given only to those receiving exceptional reviews by their patients. Only three percent of practicing physicians are selected, making this achievement a testament to Dr. Greller’s style, manner, and successful patient care. Moreover, Dr. Greller received this same honor in 2012, making him a winner in two consecutive years.

Dr. Greller is a board-certified, fellowship-trained sports medicine orthopedic surgeon. He earned his medical degree from Albert Einstein College of Medicine, New York and completed his residency in orthopedic surgery at the Hospital for Joint Diseases Orthopedic Institute—New York University Medical Center. Dr. Greller also completed a fellowship in sports medicine at Temple University, and spent an extra year specializing in minimally invasive arthroscopic procedures of the shoulder, hip, knee, and ankle. Dr. Greller was one of the first New Jersey surgeons to use minimally invasive computer-assisted hip and knee replacements. He is managing partner and president of AOSMI, and secretary/treasurer of the medical staff at CentraState Medical Center. He is on staff at CentraState Medical Center, Robert Wood Johnson University Hospital, and Raritan Bay Medical Center.

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