Much can be done to improve the rehab experience for knee and hip patients, says Douglas Dennis, M.D., an orthopedic surgeon with Colorado Joint Replacement in Denver. Dr. Dennis, past president of The Knee Society and the American Association of Hip and Knee Surgeons, tells OTW, “We have an NIH [National Institutes of Health] grant to conduct a prospective randomized study on accelerated rehab for TKR [total knee replacement]. With traditional TKR rehab the first 4-6 weeks are focused on motion and some strengthening. The results from our pilot study suggest that an accelerated rehab program including more aggressive motor strengthening at an earlier point in time will give the patient better functional results. There are a number of studies suggesting that patient satisfaction after TKR is about 80%. So while these are good operations that lessen pain and improve function, we are still not meeting the needs of knee replacement patients as well as we are meeting the needs of hip replacement patients.”
“Total hip surgery is overall a great thing. But when we take age matched patients with normal hips and compare them to those who haven’t undergone hip replacement, we find that the functional testing of those who underwent hip replacements was not as good. Hip replacement patients typically receive a list of exercise to do after discharge, so they just essentially go forward without a standardized postop therapy program. This is in contrast to knee replacement where the standard of care is that patients are seen by an outpatient physical therapist for several weeks postop. Do we need a more intensive rehab for total hip patients? If so, what exactly should that involve? For example, we have identified that total hip patients typically have deficits in the quadriceps muscle. When we look at these patient 3-6 months postop the hip musculature is recovering nicely, but quads are holding them back from doing things such as getting out of chairs and going up and down stairs. There is more we can do to help these people.”
Case Log Chaos Leading to Employment Problems?
When Dane Salazar, M.D., a former orthopedic surgery resident at the Loyola University Chicago Stritch School of Medicine, wished two graduating residents good luck several years ago, he got quite a surprise. Dr. Salazar tells OTW, “A review by the Residency Review Committee (RRC) revealed that while having identical rotation schedules and similar operative experiences these two graduating residents had widely disparate cases in their ACGME case logs. My colleagues and I were interested enough to conduct a survey of residents, and we found that the coding practices amongst orthopedic surgery residents in the United States were vastly different. The Accreditation Council for Graduate Medical Education (ACGME) case log system is supposed to [give] an accurate representation of the operative experience of the orthopedic surgical resident and a summary of their operative training. As we ventured into this study, we found substantial variability in how residents logged cases and what they considered to appropriate and inappropriate to log. Due to a paucity of guidance some residents believed that case logs should mirror the billing codes utilized by the attending surgeon while others felt that unbundling certain CPT codes more accurately reflected the operative experience.”
“We proposed seven common hypothetical orthopedic scenarios and asked residents if they would routinely log these cases into their ACGME case log and if so what code(s) they would commonly utilize. We saw substantial variability in both which procedures would have been recorded and what CPT codes would have been used.”
“Both under-coding and over-coding are issues that can follow a resident into his or her employment. More and more future employers are asking to review the ACGME case log; and presumably operative volume and accurate reporting are being taken into account during hiring decisions. Additionally from the residency program standpoint, a large variability amongst graduating residents can be a real red flag when residents who are supposed to have roughly the same training experience have vastly different coding logs.”
“We were surprised to learn that roughly 10% of respondents stated that training programs were inputting the cases into the log on their behalf. The case log system is based on manual entry and self-reporting by residents. These inaccuracies are likely multifactorial and are hypothesized to occur for several reasons: (1) residents do not keep written logs; (2) residents do not value the importance of logging every case, especially non-operating room procedures; (3) long periods of time often elapse between performing the case and entering the data, which can lead to inaccurate memory recall; (4) residents do not unbundle their cases appropriately or do not utilize appropriate CPT codes; (5) there is variability in interpretation of the ACGME’s definition of the term ‘procedure’ (i.e., does the term ‘procedure’ include joint injections, closed reductions, casting, or splinting?); and (6) there is no consensus on logging cases depending on a resident’s level of involvement in a procedure (i.e., resident surgeon, first assistant, or second assistant).”
“We plan to do a follow on project where we survey residency program directors and chairs; it will be interesting to see if there is variability between these individuals as far as what they expect. This will be a good litmus test on the guidance and direction that residents are receiving. The case logs really should accurately reflect the surgical experience of residents. The project highlighted some important issues in surgical education and I feel was at least in part the impetus for the recent improvements in guidance from the ACGME.”
New Virtual Surgical App for Orthopedists
How about reducing a fracture on your phone? A new app makes it possible to practice on virtual patients and get scored for your work from a mobile device. Nathan Skelley, M.D. is a third-year orthopedic surgery resident at Washington University in St. Louis School of Medicine, and is a reviewer for the web site iMedicalApps.com. Speaking on this new app by Otago Innovation Limited, Dr. Skelley tells OTW, “Bonedoc is a mobile app that simulates the treatment of hip fractures in a game environment. It gives doctors free reign over how to address patient positioning, fracture reduction, incision and implant placement. With Bonedoc, the user is graded on their ability to reduce the fracture and properly place implants. Your actions at one point of the operation will affect how you do at a later point during the operation. The app also makes it possible to share scores, which can create competition (and possibly enhance the learning process) among users.”
“The mobile app uses certain finger gestures to simulate surgical techniques. For example, the first task involves using fluoroscopy to position the hip fracture for surgery. During this time the user positions the foot with their finger while using fluoroscopy images. Once the fracture is reduced on AP and lateral views, the doctor then must make the incision. A single line incision is made with one finger swipe and spread apart to make four points to view the fracture. Retractors are not utilized in the app. The drill feature is uniquely simulated and provides for partially drilling and measuring screw depth by sliding the finger on the screen. There is, however, no function for depth gauging screw length, moving fluoroscopy to check screw alignment, or removing screws if unsatisfied with placement.”
“After fixation is complete, the app removes the surrounding soft tissues and allows the surgeon to view their fixation construct in isolation with the bone; the doctor can move around freely and zoom in and out to check their work. If they score high enough to pass, they can progress to the next surgery on the operating room list.”
“There are a few minor bugs, and limitations to the app. There is only one body region tested in the simulator and limited discussion of anatomy. It would be nice to operate on other simulated joints and fractures. Similarly, without haptic feedback on a mobile device, it is difficult to truly simulate the operating room environment. A major challenge with any surgical simulation program is that if you ask five orthopedic surgeons how to treat XYZ issue you are likely going to get five different responses. This makes designing and scoring a surgical simulation challenging. However, basic surgical simulation is becoming an increasingly important part of training physicians and this app is a great low-cost step in the right direction. It is a serious game that creates a first person surgeon instead of a first person shooter.
“Overall, this is a useful training tool. The ‘restart’ button is not a privilege that we have in the OR. Apps, like Bonedoc, have great potential to improve the education and training of future orthopedic surgeons.”
Capt. (Dr.) Nathaniel Nye Wins Sports Medicine Research Competition
Capt. (Dr.) Nathaniel Nye, a fellow in the National Capital Consortium Sports Medicine Fellowship at the Uniformed Services University, or USU, of the Health Sciences here, and Fort Belvoir Community Hospital, Virginia, won first place in the research competition at the American Medical Society for Sports Medicine, or AMSSM, annual meeting this month, earning the Best Overall Research Award.
Dr. Nye’s project, “Does abdominal circumference of body mass index better predict lower extremity injury risk?” was one of 32 semi-finalists selected for presentation at AMSSM’s annual meeting from more than 150 overall submissions. This marks the second consecutive year that the AMSSM’s Best Overall Research Award has been won by a USU Air Force physician.
