Too Much Randomness in Posterior Shoulder Instability Literature
The eminent James Bradley, M.D. is helping to bring order out of chaos with his practical, rigorous research. Dr. Bradley, a sports medicine specialist with Burke & Bradley Orthopedics at the University of Pittsburgh Medical Center, is also head orthopedic surgeon for the Pittsburgh Steelers. He tells OTW, “My colleagues and I have just completed a systematic review and meta-analysis on unidirectional posterior instability of the shoulder. Of the 1, 035 publications that we reviewed, 27 arthroscopic articles and 26 open articles met the inclusion criteria. We found that there is no standard as far as shoulder outcome measures to assess posterior shoulder instability; the ASES (American Shoulder and Elbow Society) was the scoring system most commonly used in the publications we reviewed. A total of 21 different functional outcome scales for posterior instability were used in these studies…because of this it is difficult to compare groups against one another. Our group uses the Kerlan Jobe Upper Extremity Score because it is very stringent. Many systems are too lenient…it’s fine to have normal range of motion, but can a throwing athlete return to his previous level of play? Can he throw a baseball 90mph?”
“Our study also showed that arthroscopy was effective and reliable as far as satisfaction and outcome scores. And, despite similar outcome measures to the overall athlete population, throwing athletes were less likely to return to their pre-injury levels of sport as compared to the contact athletes or the general athlete population. Additionally, we found that suture anchors resulted in less recurrence and fewer revisions than anchorless repairs.”
“Personally, the most interesting thing we found was that the literature suggests that patients treated with arthroscopy have superior outcomes as compared to those undergoing open repair. They fare better as far as stability, recurrence, patient satisfaction, return to sport, and return to sport at their previous level of play.”
“In the next few days we will be sending our write-up to the American Journal of Sports Medicine. The message to my colleagues is, ‘Talk to your throwing athletes and tell them that it is not as likely that they will get back to the same level of play as the general population of throwing athletes.’ And in these cases you should consider using a suture anchor and you should stay away from an open procedure.”
AOSSM Award Winner: “Assessment of graft fixation angles and how they stumbled upon co-dominance”
Nicholas Kennedy is only in his second year of medical school, but he is already working with luminaries of the orthopedic world. And he has just garnered major national recognition. Kennedy, a student at Oregon Health and Science University School of Medicine, was awarded the Excellence in Research Award from the American Orthopaedic Society for Sports Medicine (AOSSM). He explains, “I was fortunate enough to undertake a project with Robert LaPrade, M.D., Ph.D. at the Steadman Clinic. We tested a biomechanical evaluation of a reconstruction of the posterior cruciate ligament (PCL) examining different graft fixation angles. We used the KUKA robotic system, which can move in six degrees freedom, and we had Mary Goldsmith, MSc, a robotic engineer, program the robot to apply specific clinical examinations. We examined the knees from 0-120 degrees of flexion looking at posterior translation, internal and external rotation, and varus and valgus. We examined the native state, resected state, and the reconstructed single and double bundle PCL reconstructed states.”
“We were able to assess both translational and force differences, measured on the grafts, between the different graft fixation angles. For the single-bundle reconstruction we focused on reconstructing the functional dominant anterolateral bundle. We utilized an Achilles allograft for the reconstruction and fixed the graft at 75°, 90° and 105° of flexion. Those fixations were chosen based on a previous study which had shown that 75°-105° was the range of flexion the anterolateral bundle was found to be most effective. Amongst the single-bundle fixation options we found all three to be comparable in regards to translations and graft forces.
For double-bundle reconstructions we found that both grafts were important in restraining posterior translation and internal rotation throughout a range of flexion. Also we found the two grafts were interdependent upon each other, or in other words graft forces observed were dependent upon fixation angle of that graft as well as the fixation angle of the other graft. With this information we were able to validate co-dominance of the two bundles. We evaluated six different combinations again fixing the anterolateral bundle at 75°, 90° and 105° and fixing the posteromedial bundle at 0° and 15°. We again found minimal differences amongst the 6 fixation combinations. However, we did find that fixation of the posteromedial bundle at 15° led to significantly increased posteromedial bundle forces. With that in mind we recommend fixation combinations with the posteromedial bundle at 0° of knee flexion.”
“Our study was able to build on other recent studies to assess these different fixation angles in response to the most clinically applicable motions for the posterior cruciate ligament. Our study not only gave us several different clinically viable options for single and double bundle posterior cruciate ligament reconstructions, but it also provided us with valuable information regarding co-dominance of the two grafts. This study also will help pave the way for future studies more fully assessing the PCL in its role with other major ligamentous structures of the knee.”
FORCE Total Joint Registry Certified as PQRS
Now it is even easier for physicians who accurately report quality measures to be rewarded. Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR)—a national database that collects implant and patient outcomes data on total joint knee and hip replacements—has been certified as a CMS Physician Quality Reporting System Qualified Registry (PQRS). At the helm of this effort is David Ayers, M.D., chair of the Department of Orthopedics and Physical Rehabilitation and director of the Musculoskeletal Center of Excellence at the University of Massachusetts Medical School. Dr. Ayers tells OTW, “Through PQRS, physicians can earn a PQRS incentive by reporting quality measures. On surgeon request, FORCE-TJR will be submitting outcome measures and thus helping surgeons meet PQRS reporting requirements. We applied to participate because there were criteria from CMS that we were already collecting…a subset of measures that they validated, including patient reported outcomes. This latter measure is critical because they have a number of quality measures about pain and function; our members who collected pre and postoperative patient reported outcomes are already in good shape as far as that is concerned.”
“One of the advantages of being part of a registry is that it makes reporting quality information like PQRS pretty easy for surgeons. CMS has a user friendly webpage that talks about how to get started and how to select a registry to work with. For orthopedic surgeons, one choice is FORCE-TJR. PQRS metrics are doctor or practice metrics not hospital metrics. Registry information can help patients can make data driven decisions.”
“There is some confusion on the part of doctors regarding the ‘group measure, ’ an indicator that surgeon members of FORCE are likely to submit. It is a measure proposed by the American Association of Hip and Knee Surgeons to capture four clinical care measures at the time of surgery. FORCE-TJR has a user friendly system to capture these measures as well.”
Patricia Franklin, M.D., MBA, MPH is director of clinical research at University of Massachusetts Medical School’s department of Orthopedics and Physical Rehabilitation, and a principal investigator in the FORCE project. She tells OTW, “We look forward to working with registry participants to help ensure that their data is reported correctly. Doing this right will mean that we have the information we need on best total joint practices so that patients will benefit and surgeons can avoid penalties. This year—2014—is the last year that providers can receive the CMS bonus as an incentive for sending in data. After that, participants must report data to avoid a penalty, i.e., a lower Medicare reimbursement.”
“We are also using the information in this registry for other regional incentives. For example, in the Commonwealth of Massachusetts Blue Cross Blue Shield has a pay-for-performance opportunity for orthopedic surgeons to submit patient reported outcomes and receive a sizeable bonus (on the hospital level). For our Massachusetts hospitals that are participating in FORCE-TJR we are providing that information so that hospitals are eligible for that bonus. That is an advantage being part of a registry.”
