David F. Martin, M.D.: New ABOS Executive Medical Director
David F. Martin, M.D., a professor of orthopedic surgery at the Wake Forest School of Medicine, is the new executive medical director of The Board of Directors of the American Board of Orthopaedic Surgery (ABOS). Dr. Martin is already familiar with the role, as he has served as the interim executive director of the ABOS since the retirement of Shepard R. Hurwitz, M.D. earlier this year. He served on the ABOS Board of Directors from 2005-2015 and was president of the Board in 2011-2012.
Dr. Martin is the former director of sports medicine at Wake Forest University and he was the Wake Forest Demon Deacon’s team physician for 18 years. Dr. Martin will remain on the faculty of Wake Forest School of Medicine and continue to see patients and perform surgery there. Martin also has research interests which focus on running injuries, knee injuries, throwing injuries, and orthopedic education.
A graduate of Dartmouth College, David Martin received his medical degree from The Johns Hopkins University School of Medicine, then completed his residency at Johns Hopkins Hospital. He did Orthopaedic Sports Medicine Fellowships at the Hughston Orthopaedic Clinic and the Union Memorial Hospital. Dr. Martin was also a major in the U.S. Army Reserve.
Dr. Martin told OTW, “I begin by evaluating each ABOS program and look for ways to streamline and improve Board Certification and Maintenance of Certification processes. Our Diplomates are faced with increasing burdens of documentation and regulation and the ABOS needs to continue to ensure that maintaining Board Certification is meaningful and valuable. This will enable the ABOS to stay true to its mission of benefitting the public and its vision to improve the quality of care and outcomes for our patients.
“I am most enthusiastic about the opportunity to collaborate with an incredibly talented and dedicated Board of Directors and work with the dedicated, hardworking staff that our COO Aaron White has assembled at the ABOS offices in Chapel Hill. It is exciting to work with such an outstanding team of individuals—I am passionate about the ABOS and its processes. We have the right people in place to make a difference for our patients and our profession.”
Total Elbow Replacement: New Infection Prevention Protocol
New work is shedding light on an under-researched area in orthopedics…the elbow. Researchers from the University of Nebraska Medical Center (UNMC), Hospital Alemán in Argentina, and Mayo Clinic have explored the use irrigation and debridement (I&D) with retention of the implant for the treatment of periprosthetic infection of a total elbow arthroplasty (TEA). The team was able to study 20 patients who underwent such treatment from 1990 to 2010; the mean follow-up was seven years.
A co-author on the study was Philipp N. Streubel, M.D., assistant professor in the Department of Orthopaedic Surgery and Rehabilitation at UNMC. Dr. Streubel told OTW, “Infected arthroplasties represent one of the most difficult problems to manage in orthopedics. In many instances temporary implant removal is required to fully clear the infection. In the presence of well-fixed implants, significant bone loss can occur during implant removal. This poses a special challenge in the elbow, where bone stock is fairly limited. As a result, the senior author of our paper has been treating infected elbow arthroplasties with well-fixed implants with serial debridements, placement of antibiotic-laden cement beads and intravenous antibiotics, while retaining the implants. The purpose of this study was to determine the success rate and outcomes of this specific protocol.”
“Staged reimplantation requires removal of infected implants with placement of an antibiotic laden cement spacer and intravenous antibiotics to clear the infection. This carries the advantage of removing all possible bacteria that may be attached to the original implant, especially in biofilm forming organisms. However, especially in the setting of well-fixed implants, significant bone loss and periprosthetic fractures can occur during the process of implant removal. In the elbow this may lead to requiring more complex reconstructions or even the inability to reimplant a prosthesis altogether.”
Asked about the challenges/milestones involved in the study, Dr. Streubel commented to OTW, “The main difficulty for this type of study is obtaining adequate follow-up. Despite our best efforts to obtain follow up data on all included patients, we had a loss of follow up in 13% of cases. Even though this is an acceptable rate for such a cohort study, our results should be interpreted keeping this proportion of unknown outcomes in mind.”
“We were pleasantly surprised to see the success rate of this protocol to allow implant retention in 80% of patients with a high level of patient satisfaction. However, multiple procedures are frequently required prior to achieving the final result. Furthermore, patients in most instances require lifelong antibiotic suppression.”
“Very limited data exists on the treatment of periprosthetic infections of the elbow. Our study makes a significant contribution to this topic. We believe that as a consequence of this study, orthopedic surgeons managing this difficult scenario will be more inclined to follow the protocol presented for implant retention.”
“There is no other complication that generates more anxiety to patients and surgeons than an infected arthroplasty. Due to the smaller size and limited soft tissue coverage of the elbow, periprosthetic infections of this joint are easily one of the most complex orthopedic problems to manage.”
TKA: Patient-Reported Pain & Function
Scientists from the University of Massachusetts Medical School (UMMS) teamed up to obtain a clearer picture on the severity of symptoms in pre-TKA (total knee arthroplasty) patients. Using data from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR), the researchers were able to assess pain and function for 6, 936 patients.
A co-author on the study was Patricia D. Franklin, M.D., M.B.A., M.P.H., executive director for research at the Musculoskeletal Center of Excellence at UMMS.
Dr. Franklin, registry director for FORCE-TJR, told OTW, “Some research published in the past few years suggested that the growing number of U.S. TJR procedures each year may represent ‘over-utilization’ of TJR in patients who do not have advanced symptoms. These studies often based the need assessment on x-ray images, and were limited to a small number of surgical practices.”
“In contrast, FORCE-TJR collects standardized patient-reported symptom severity (e.g., pain with movement) from all patients before TJR. We wanted to evaluate the severity of pain and functional limitation among the national FORCE cohort at the time of surgery to understand the symptom severity of patients undergoing TJR today. FORCE includes a national sample of patients from more than 150 surgeons in 28 states, so the findings are relevant for both Medicare and private pay patients across the U.S.”
“Of importance, the FORCE data found that over 90% of patients reported significant pain, functional limitations, or both at the time of TJR. Symptom profiles support that the vast majority of today’s TJR patients have advanced knee/hip disease and can benefit from TJR. This conclusion was true for both the older and younger patients. In addition, the 8-10% of patients with less severe pain/disability described daily symptoms and quality of life limitations—or rational reasons for seeking TJR.”
As for how their results might affect the orthopedic field, Dr. Franklin noted, “First, patient-reported outcome measures support patients and surgeons when discussing knee or hip symptom severity to determine the need and timing for TJR. Second, PROs [patient reported outcomes] can quantify the benefit of TJR surgery (e.g., reduced post-op pain and improved function). Of note, CMS [Centers for Medicare and Medicaid Services] began a mandatory bundled payment pilot program in April 2016 in 67 communities that will offer incentives to collect pre-op and post-TJR PROs. The CMS pilot uses the same PROs that are reported in this paper and collected on all FORCE-TJR patients.”
“Second, FORCE-TJR now has national risk-adjusted norms for pre-op and post-TJR PROs. FORCE members can compare the profile of their patients selected for TJR to national norms, as well as compare outcomes. The FORCE program is now open to all interested sites.
“Hospitals and surgeons who are participating in bundled payment programs for TJR can benefit from collecting PROs to guide quality monitoring and improvement, and cost management. Patients feel engaged in their care when their PRO responses are reviewed at the office visit and used to support shared decision making.”
