Joint, Cartilage Damage Caused by Rotator Cuff Surgery?
A new study indicates that patients showing up in your office for joint replacement or other surgery may have had earlier damage done to their joint structures due to a previous rotator cuff tear. Louis J. Soslowsky, Ph.D. is the Director of McKay Orthopaedic Research Laboratory at the University of Pennsylvania. Dr. Soslowsky, who is also the Director of the Penn Center for Musculoskeletal Disorders, told OTW, “We received a grant from the NIH/NIAMS [National Institutes of Health/ National Institute of Arthritis and Musculoskeletal and Skin Diseases] to study when one should operate on a rotator cuff tear and the effects of that tear or surgery on the whole joint. There are patients who—even if the joint function is intact—had cartilage and other joint damage. A particularly interesting aspect of this was that we looked at the role of the biceps.”
“One group of surgeons typically cuts the biceps in the presence of a rotator cuff tear, believing that the biceps is a key source of pain and functionality wasn’t adversely affected without the biceps; the other group doesn’t cut. One of the things we did in our rat model was to hypothesize that detachment of the biceps in the presence of a supraspinatus or infraspinatus tear would affect the functioning and mechanical properties of other tissues like the glenoid articular cartilage. To our surprise, we found that detachment of the biceps actually improved shoulder function and created less damage when we already had an infraspinatus of supraspinatus tear. In the presence of either of these tears there was a disruption of force balance at the joint, both superiorly and posteriorly. The biceps is anterior but when the force is disrupted you are actually altering the anterior force, which seems to create better balance.”
“This work is especially important because this associated joint damage can go unrecognized for years until someone shows up for a joint replacement or other surgery.”
Boston Marathon: Motivated Doctor Takes Up the Challenge
When the bombs went off at the Boston Marathon in 2013, a young physician from Wisconsin was one of those who ran to the aid of those in need. A year later, Jeremy Metzler, M.D., a family medicine and sports medicine physician at Prevea Health in Green Bay, ran the marathon himself. Dr. Metzler tells OTW, “I was in the medical tent, shadowing a physician and learning about sports medicine. We were half a block away from the first explosion, and one block away from the second explosion. The sides of the tent shook, but at first I thought it might be a canon fired in honor of Patriot Day. The whole tent fell silent, however, and people started coming in looking panicked. I grabbed some gloves and ran toward the finish line.”
“I ran past the gentleman whose photo everyone saw…the one in the wheelchair wearing a cowboy hat. I reached the finish line where there were a lot of wounded people; my job was basically keeping pressure on people’s wounds. Frankly, I blocked out a lot of what happened. I don’t even know how long I was there. The police cleared us out due to concerns about the possibility of more explosions. I helped transfer patients back to medical tent, helped get people in ambulances, and attended to others while they waited for ambulances. The police came in with bomb sniffing dogs…it was like nothing I had ever experienced.”
“I had always taken care of runners and had considered doing a marathon. So many lives being changed in such a radical way made up my mind, however, and I decided to run the Boston Marathon this year. On the day of the race the atmosphere was unbelievable…very emotional there were signs everywhere supporting those who had been killed and injured. There were groups running in honor of the 8-year-old boy who was killed and his charity. We had 36, 000 runners from all over the world…all feeling the same powerful emotions. It was a real honor to be a part of this event.”
OrthoCarolina, BCBSNC Team Up to Coordinate Knee Replacement
For North Carolina residents in need of knee replacement, things might be getting easier…and cheaper. Steve Hendrick is the Chief Operating Officer of OrthoCarolina. He tells OTW, working with Blue Cross Blue Shield of North Carolina (BCBSNC), “we have developed a coordinated care approach where patients pay a single price for the entire episode of a knee replacement that will save 10 to 30% on the cost of surgery. This came about because we were hearing from BCBSNC that the total cost of care within our market was out of line regionally and nationally. We also began seeing employers in our area getting aggressive about exploring lower cost options. Lowe’s Home Improvement—which has its corporate headquarters nearby—struck a deal with Cleveland Clinic that encouraged employees and their dependents to travel to Ohio for elective cardiology procedures. PepsiCo did a similar deal with John Hopkins for patients to travel to Maryland for joint replacements. OrthoCarolina saw the writing on the wall, and we started looking into how we could evolve our practice from the traditional fee-for-service model into a value based model where reimbursement is tied to quality outcomes.”
“Several hospitals declined to work with us on this but after BCBS approached us we were able to find some willing to take this on together. Our doctors realized that we had to do something or all the elective orthopedic procedures would be referred out of state!”
“This program has received high satisfaction and praise from the initial patients that have participated. Not only is it lowering the cost of care, but it is a much better experience for them and their family members. Within the coordinated care program, each patient is assigned two navigators, one for clinical issues and one for administrative issues. The administrative navigator takes care of coordinating all registration, billing, and other administrative details for the patient with all parties involved. This allows the patient to know up front what everything is going to cost and ensures they will receive only one simple bill for the entire surgical episode from OrthoCarolina. The clinical navigator explains everything that is going to happen upfront and is with the patient thru the entire process to address any questions or concerns. This single coordinated approach, focused centrally on the patient, really helps the care team be efficient while providing the best experience possible for the patients.”
“On the cost side, if you look at the national data on the total cost of elective joint replacements you will see that the surgeon’s portion of it is only 6-8% of the total episode cost. However, the doctor controls a large portion of the remaining cost but does it unknowingly. We got all of our joint replacement surgeons in a room and they developed a standard protocol on how to care for these patients. We looked at all of the fixed and variable costs for each of the surgeons across various hospitals they performed surgeries in. We focused in on things they all did the same as well as things done differently. When then focused on the differences and associated supply cost to get the doctors to weigh in on things such as, ‘Why do you use this? Is it more effective? Is there any research data to justify using it? Is the more expensive option better? How much better?’, etc.”
“The doctors were stunned when they saw the cost information, i.e., what some of their patients and/or insurance companies were being billed. Doctors typically have no idea how much a total episode of care costs their patient as they only have information on their charge for the surgery and post-op follow up care. What really got their attention was when the BCBSNC people said, ‘No offense, but if you did the surgeries for free it would not move the needle on the cost problem we have in the market.’ OrthoCarolina is actively working with BCBSNC to expand the program to include hip replacements and other common surgical procedures.”
“In addition to the BCBSNC deal, OrthoCarolina also just reached a state-wide exclusive agreement with one of the region’s largest employers to provide care thru the coordinated care program to its 28, 000 employees and their dependents. The program is for 20 different orthopedic conditions relating to total joint replacement, back and spine care. This deal is very unique in that it is a ‘hard-steerage’ program in which the company decided that its employees will only have benefit coverage for those conditions if they see OrthoCarolina physicians and have the surgery performed at specific Center of Excellence hospitals.”
“The bottom line is that doctors must step up take a leadership position. The national migration to a value based reimbursement system (which needs to occur) is underway. They are better positioned than anyone else to do this.”
Mohit Bhandari, M.D., M.Sc., Ph.D., FRCSC Receives Distinguished Alumni Award
MacMaster University has announced that Dr. Mohit Bhandari has been selected to receive the 2014 Distinguished Alumni Award for the Sciences. Dr. Bhandari has dedicated many years of outstanding service to the medical profession and has been instrumental in raising the standards of orthopedic care. Dr. Bhandari currently serves as Professor and Academic Head of the Division of Orthopaedic Surgery as well as the Department of Surgery Associate Research Chair at McMaster University. He also holds a Canada Research Chair in Musculoskeletal Trauma and Surgical Outcomes.
The Distinguished Alumni Award recognizes McMaster University graduates who have attained a high level of distinction and achievement through scholarship, research, teaching, creative contributions to the arts or sciences and/or service to society. This award is intended to honor alumni whose accomplishments and contributions are of national and/or international significance, and/or have had a seminal or transformative impact on their field of endeavor.
