5, 000 Patient Anterior Hip Study Results Announced

Over 5, 000 patients and three high volume orthopedic centers may just convince some surgeons to take a chance on anterior approach hip replacement. Steven Barnett, M.D. of the Hoag Orthopedic Institute in Irvine, California, tells OTW, “Despite adoption of anterior hip surgery, there has not been a great deal of clinical research in this area as compared to other approaches. We set out to look at patients from the day of surgery until 90 days postop and examine the safety of this approach. Our retrospective chart review included 5, 000 patients from three centers: The Hoag Orthopedic Institute (along with Dr. Robert Gorab and Dr. Jay Patel), St. John’s Health Center (where we worked with Joel Matta, M.D.), and The Anderson Orthopaedic Clinic (where we worked with William Hamilton, M.D.).”

“We found an overall complication rate of 3.28%, which is equal to if not lower than that of other approaches. If you break that number down, the rate of medical complications was 1.36%; and surgical complication rate was 1.9% (hematomas, infection, deep vein thrombosis/pulmonary embolism, intraoperative fractures, dislocations). The dislocation rate for the entire cohort was 0.23%. These are short term results, so we can’t comment on functional comparisons of patients down the road. We can say, however, that using an anterior approach to hip replacement is safe and has a reasonable complication rate.”

“Our goal now is to continue to track these patients out to five to ten years in order to determine how they are faring functionally. I’m pleased to be able to say to my naturally cautious colleagues, that if they are considering this approach, they can move forward. My own patients who are five years postop are doing as well if not better than those on whom I used a posterior approach. At this point in my career, I do 100% of my total hip patients with an anterior approach.”

Knee Dislocations: How to Have Fewer Failed Ligament Reconstructions

In what is purported to be the first prospective randomized study on knee dislocation in the literature, James Stannard, M.D. has determined that hinged external fixation used along with reconstruction following knee dislocation was associated with fewer failed ligament reconstructions than external bracing. Dr. Stannard, chairman of the Department of Orthopaedic Surgery at the University of Missouri and medical director of the Missouri Orthopaedic Institute, tells OTW, “Knee dislocations were previously thought to be uncommon, but in fact as we look at trauma patients it is evident that they are more common than we thought. When someone tears a ligament such as the ACL [anterior cruciate ligament] you can reconstruct it and use early aggressive motion to allow the knee to function. This works because the knee has four groups of ligaments; when you have three intact and one torn you don’t need anything other than a brace. But if you dislocate the knee and three of the four ligaments are torn, if you use aggressive motion then you risk loosening and the failure rate is higher.”

“This was a Level I study involving my results with the hinge and without; we found a remarkable improvement amongst those who had the Compass Hinge. Also, there was a statistically significant lower revision rate amongst those treated with this hinge. You could say this device is like the world’s best knee brace. It has pins that go into the bone and hold it where it belongs; there is no motion in the saggital plane, no rotation or side to side motion, and no ligament loosening.”

“The most important issue is to determine precisely when to use it. It could be useful in situations where all four of the ligament groups are torn and there is a lot of capsule damage and instability. It could also be helpful if there are associated secondary injuries such as a tibial plateau fracture. This device, which is a powerful tool to obtain motion while maintaining stability, should be used in the most severe cases. It is expensive, with a price tag of roughly $8, 000 – $10, 000. But if it saves a revision surgery, then that would be worth the cost.”

“Our study confirms that hinged external fixation used along with reconstruction following knee dislocation has a place in our array of treatment options. We do need more studies to figure out exactly when to use it; ideally we can do additional prospective randomized comparisons to determine the indications. While I don’t have anything planned at the moment, we are building up our database of knee dislocations and could potentially partner with other institutions in order to achieve the necessary numbers for such a study.”

Dr. Stannard notes that the funding for this study came from an unrestricted grant from Smith & Nephew, and that they had no editorial influence.

New Study Nails Reop Rates for Shoulder Arthroplasty

A group from Mayo Clinic has decided to fill in some blanks in the shoulder arthroplasty literature. Philipp Streubel, M.D., an orthopedic surgeon with Mayo Clinic, Minnesota, tells OTW, “Some of my colleagues and I felt there was a dearth of information in the literature regarding reoperation rates in shoulder arthroplasty, which has a potential of being a major cost driver for this procedure. While there a half a million hip and knee arthroplasties done each year compared to 50, 000 shoulder arthoplasties, the latter surgeries are increasing at a higher rate than the former. This is an indication of broader indications and of the fact that patients are staying healthy and active into their later years.”

“We conducted a retrospective cohort study of 30- and 90-day reoperation rates after shoulder arthroplasty. We reviewed charts from the Mayo Clinic joint registry from January 2000 to December 2010 identifying 2, 823 shoulder replacements. Of those, 45 patients (1.6%) had a reoperation during the first 90 days and 22 (0.8%) during the first 30 days after surgery. We found that patients after revision arthroplasties had a significantly higher risk of being readmitted. We found that the two most important causes of reoperation were infection and instability of the shoulder. One-fifth of patients required at least two reoperations. Reoperation led to either prolongation of the initial hospital stay or a readmission in the vast majority of cases.”

“This is the first study to examine reoperation rates after shoulder arthroplasty. It does thereby establish an important benchmark for this metric which may prove useful as new policies for reimbursement are developed. For example, The Affordable Care Act plans on penalizing institutions that have patients with a readmission rate that is higher than expected. The information provided by this study will help in setting such expectations and provide policymakers with a usable metric.”

“It should however be kept in mind that this information comes from a high volume joint replacement institution. Several studies have shown that higher volume surgeons at higher volume institutions have fewer complications and lower costs. Our findings may therefore not be generalizable to the general orthopaedic community. This should be recognized at the moment of establishing definitive reference benchmarks.”

David Kim, M.D. Joining OrthoNeuro

OrthoNeuro announced today that David Kim, M.D. will join their multi-specialty physician group on July 14th, 2014. Dr. Kim is a fellowship-trained orthopedic spine surgeon who specializes in minimally invasive approaches to the neck and low back. Dr. Kim worked in private practice specializing in spine surgery for over 14 years. He was most recently employed by OhioHealth Orthopedic Surgeons. Dr. Kim has privileges at Dublin Methodist Hospital and is the director of spine surgery at Doctors Hospital.

Dr. Kim graduated from Yale University cum laude with a Bachelor Degree in Biology. He attended Medical School at the University of Rochester School of Medicine in Rochester, New York. Dr. Kim was awarded a research grant at the National Institutes of Health in Bethesda, Maryland for MRI and metabolism. He completed his orthopedic residency at Hahnemann University in Philadelphia, and then a spine surgery fellowship at Southern Illinois University in Springfield, Illinois.

5, 000 Patient Anterior Hip Study Results Announced

Over 5, 000 patients and three high volume orthopedic centers may just convince some surgeons to take a chance on anterior approach hip replacement. Steven Barnett, M.D. of the Hoag Orthopedic Institute in Irvine, California, tells OTW, “Despite adoption of anterior hip surgery, there has not been a great deal of clinical research in this area as compared to other approaches. We set out to look at patients from the day of surgery until 90 days postop and examine the safety of this approach. Our retrospective chart review included 5, 000 patients from three centers: The Hoag Orthopedic Institute (along with Dr. Robert Gorab and Dr. Jay Patel), St. John’s Health Center (where we worked with Joel Matta, M.D.), and The Anderson Orthopaedic Clinic (where we worked with William Hamilton, M.D.).”

“We found an overall complication rate of 3.28%, which is equal to if not lower than that of other approaches. If you break that number down, the rate of medical complications was 1.36%; and surgical complication rate was 1.9% (hematomas, infection, deep vein thrombosis/pulmonary embolism, intraoperative fractures, dislocations). The dislocation rate for the entire cohort was 0.23%. These are short term results, so we can’t comment on functional comparisons of patients down the road. We can say, however, that using an anterior approach to hip replacement is safe and has a reasonable complication rate.”

“Our goal now is to continue to track these patients out to five to ten years in order to determine how they are faring functionally. I’m pleased to be able to say to my naturally cautious colleagues, that if they are considering this approach, they can move forward. My own patients who are five years postop are doing as well if not better than those on whom I used a posterior approach. At this point in my career, I do 100% of my total hip patients with an anterior approach.”

Knee Dislocations: How to Have Fewer Failed Ligament Reconstructions

In what is purported to be the first prospective randomized study on knee dislocation in the literature, James Stannard, M.D. has determined that hinged external fixation used along with reconstruction following knee dislocation was associated with fewer failed ligament reconstructions than external bracing. Dr. Stannard, chairman of the Department of Orthopaedic Surgery at the University of Missouri and medical director of the Missouri Orthopaedic Institute, tells OTW, “Knee dislocations were previously thought to be uncommon, but in fact as we look at trauma patients it is evident that they are more common than we thought. When someone tears a ligament such as the ACL [anterior cruciate ligament] you can reconstruct it and use early aggressive motion to allow the knee to function. This works because the knee has four groups of ligaments; when you have three intact and one torn you don’t need anything other than a brace. But if you dislocate the knee and three of the four ligaments are torn, if you use aggressive motion then you risk loosening and the failure rate is higher.”

“This was a Level I study involving my results with the hinge and without; we found a remarkable improvement amongst those who had the Compass Hinge. Also, there was a statistically significant lower revision rate amongst those treated with this hinge. You could say this device is like the world’s best knee brace. It has pins that go into the bone and hold it where it belongs; there is no motion in the saggital plane, no rotation or side to side motion, and no ligament loosening.”

“The most important issue is to determine precisely when to use it. It could be useful in situations where all four of the ligament groups are torn and there is a lot of capsule damage and instability. It could also be helpful if there are associated secondary injuries such as a tibial plateau fracture. This device, which is a powerful tool to obtain motion while maintaining stability, should be used in the most severe cases. It is expensive, with a price tag of roughly $8, 000 – $10, 000. But if it saves a revision surgery, then that would be worth the cost.”

“Our study confirms that hinged external fixation used along with reconstruction following knee dislocation has a place in our array of treatment options. We do need more studies to figure out exactly when to use it; ideally we can do additional prospective randomized comparisons to determine the indications. While I don’t have anything planned at the moment, we are building up our database of knee dislocations and could potentially partner with other institutions in order to achieve the necessary numbers for such a study.”

Dr. Stannard notes that the funding for this study came from an unrestricted grant from Smith & Nephew, and that they had no editorial influence.

New Study Nails Reop Rates for Shoulder Arthroplasty

A group from Mayo Clinic has decided to fill in some blanks in the shoulder arthroplasty literature. Philipp Streubel, M.D., an orthopedic surgeon with Mayo Clinic, Minnesota, tells OTW, “Some of my colleagues and I felt there was a dearth of information in the literature regarding reoperation rates in shoulder arthroplasty, which has a potential of being a major cost driver for this procedure. While there a half a million hip and knee arthroplasties done each year compared to 50, 000 shoulder arthoplasties, the latter surgeries are increasing at a higher rate than the former. This is an indication of broader indications and of the fact that patients are staying healthy and active into their later years.”

“We conducted a retrospective cohort study of 30- and 90-day reoperation rates after shoulder arthroplasty. We reviewed charts from the Mayo Clinic joint registry from January 2000 to December 2010 identifying 2, 823 shoulder replacements. Of those, 45 patients (1.6%) had a reoperation during the first 90 days and 22 (0.8%) during the first 30 days after surgery. We found that patients after revision arthroplasties had a significantly higher risk of being readmitted. We found that the two most important causes of reoperation were infection and instability of the shoulder. One-fifth of patients required at least two reoperations. Reoperation led to either prolongation of the initial hospital stay or a readmission in the vast majority of cases.”

“This is the first study to examine reoperation rates after shoulder arthroplasty. It does thereby establish an important benchmark for this metric which may prove useful as new policies for reimbursement are developed. For example, The Affordable Care Act plans on penalizing institutions that have patients with a readmission rate that is higher than expected. The information provided by this study will help in setting such expectations and provide policymakers with a usable metric.”

“It should however be kept in mind that this information comes from a high volume joint replacement institution. Several studies have shown that higher volume surgeons at higher volume institutions have fewer complications and lower costs. Our findings may therefore not be generalizable to the general orthopaedic community. This should be recognized at the moment of establishing definitive reference benchmarks.”

David Kim, M.D. Joining OrthoNeuro

OrthoNeuro announced today that David Kim, M.D. will join their multi-specialty physician group on July 14th, 2014. Dr. Kim is a fellowship-trained orthopedic spine surgeon who specializes in minimally invasive approaches to the neck and low back. Dr. Kim worked in private practice specializing in spine surgery for over 14 years. He was most recently employed by OhioHealth Orthopedic Surgeons. Dr. Kim has privileges at Dublin Methodist Hospital and is the director of spine surgery at Doctors Hospital.

Dr. Kim graduated from Yale University cum laude with a Bachelor Degree in Biology. He attended Medical School at the University of Rochester School of Medicine in Rochester, New York. Dr. Kim was awarded a research grant at the National Institutes of Health in Bethesda, Maryland for MRI and metabolism. He completed his orthopedic residency at Hahnemann University in Philadelphia, and then a spine surgery fellowship at Southern Illinois University in Springfield, Illinois.