BMI Irrelevant to Meniscus Repair; Sarcopenia Raises Mortality Rate; Rothman’s New Post-Op Data System Cuts Readmissions
Elizabeth Hofheinz, M.P.H., M.Ed. • Thu, March 23rd, 2017
Meniscus Repair: BMI Does Not Affect Failure
New research from The Ohio State University Wexner Medical Center is making us rethink the effect of body mass index (BMI) on meniscal repair. It turns out, say researchers, led by David Flanigan, M.D., that BMI has no effect on whether or not meniscus repair surgery will fail.
The study, entitled, “The Relationship between Body Mass Index and Risk of Failure following Meniscus Repair,” was published in The Journal of Knee Surgery. Researchers investigated 410 patients who underwent meniscal repair surgery from 2006 to 2012, and found no significant difference in the rate of failures in those with a normal BMI (less than 25) and those with an elevated BMI (25 or higher).
David Flanigan, M.D., an orthopedic surgeon at Ohio State Wexner Medical Center, was lead author of the study. He told OTW, “We started a database of our patients who had a meniscus repair to ask some unanswered questions in our literature. Obesity has been shown to adversely affect many surgeries of the lower extremity and spine. We did not know how it affected this specific injury.”
“In regards to the study, the findings were contrary to our hypothesis. We thought higher BMI would have higher failure rates. This finding is supportive of an approach to repair any meniscus that is reparable regardless of weight. Of course any study leads to more questions.”
“With a population that is becoming more overweight, is there a limit to these findings? Our study did not have enough morbidly obese patients to comment.”
Sarcopenia, Acetabular Fractures, Mechanisms of Injury, and Complications
Research performed at the Warren Alpert Medical School of Brown University has delved into the question of whether sarcopenia is common in elderly patients with acetabular fractures, and if it correlates with lower-energy mechanisms of injury, higher rates of complications, and higher mortality than in patients with normal muscle mass. The study, published in the February 1, 2017 edition of The Journal of Bone and Joint Surgery, was entitled, “Increased Mortality in Elderly Patients with Sarcopenia and Acetabular Fractures.”
Lead author Matthew Deren, M.D. is an orthopedic surgeon at the Warren Alpert Medical School. He told OTW, "We care for many elderly patients with acetabular fractures, but we didn't have any great data on how they fare after these injuries. Some appeared frailer than others, which is why we were interested in seeing if these sarcopenic patients have different mechanisms of injury and recovery following these injuries.”
“The most important results were the mortality data, which reveals that patients with sarcopenia have a much higher mortality at 1 year than those without sarcopenia. This is an expected result, but important for counseling families regarding the injuries of these patients."
“We noticed that there was great variation in our elderly patients presenting with acetabular fractures, including the eventual outcome of these fractures. We felt that sarcopenia might be a more scientific method of quantifying the ‘look test,’ that first impression that many clinicians speak of when first examining a patient. We wondered if there was any difference in those patients that appeared frail, or sarcopenic, compared to the healthier older adults that sustained acetabular fractures. Additionally, with our aging population, we have noticed more elderly patients with acetabular fractures, and there is not a great consensus on the best method of treating these patients. Furthermore, it encourages us to view sarcopenia as a recognizable entity that may be studied in other patient groups and by other means of diagnosis. We think that this study demonstrates that sarcopenia may be an important factor that was previously unrecognized in our orthopedic trauma population.”
“Of particular interest is that finding that sarcopenia seemed to be more predictive than the well-established American Society of Anesthesiologists (ASA) Score for predicting risk of 1-year mortality. We suspect that some patients, who may be malnourished or frail but lack other comorbidities, may be identified as sarcopenic even though their ASA score may not reflect their risks. This was a surprise to us.”
“There are many ways to measure sarcopenia, and this is only one. We think that by using one of the many methods of identifying sarcopenic patients, we can further define the risk that this condition may present. Then we can do a better job as physicians in identifying those patients at higher risk, which allows for better counseling of patients and their families of the relative risk of both their fracture treatment and their overall health.”
Roman Hayda, M.D., director of the Division of Orthopaedic Trauma at Warren Alpert, was a co-author on the study. He commented to OTW, “We were seeing an increasing number of elderly patients with acetabular fractures; the literature is unclear regarding the optimal treatment. Meanwhile, comorbidities likely have a major impact on outcome.”
"We found that sarcopenia is a better indicator for mortality than the Charlson Comorbidity Index. Sarcopenia patients had a 29% 1-year mortality rate compared to 12% in non-sarcopenic patients. Sarcopenia was also associated with anterior column fracture and low energy mechanisms. In the elderly patient, sarcopenia may be a better indicator of musculoskeletal health and mortality than other measures.”
“Maintaining musculoskeletal health is more than just maintaining bone mass. In addition to looking at medical conditions and age, an assessment of muscle mass may offer another predictor of outcome and be useful in counseling patients and their families."
Rothman Institute, Force Therapeutics Optimize Rehab for Over 15,000 Patients
The Philadelphia-based Rothman Institute and the New York-based Force Therapeutics have teamed up to aid patients prepare for and recover from surgery. The result? Over 15,000 Rothman patients have had access to the Force Therapeutics platform that allows interactive, video-based exercise and educational materials prescribed by the surgeon. The home recovery tool engages patients in a daily, personalized physical therapy [PT] care plan and enables their successful recovery in the home.
Alexander R. Vaccaro, M.D., Ph.D., M.B.A. is president of Rothman Institute and chairman of Orthopaedics at Thomas Jefferson University. When asked about examples of the functional outcomes that are improving as a result of partnering with Force, he told OTW, “Force measures multiple outcomes through their platform, traditional PRO's [patient reported outcomes] as well as patient generated data (daily pain level, temperature) and also passive activity tracking (how far patients are walking after surgery). This gives us a comprehensive and up-to-date picture of the patient and how that patient is actually managing in the home after surgery. Their patients reach better functional outcomes, often earlier in their recovery.”
“Force-enabled patients have reduced readmissions—they have the right information at their fingertips prescribed by their surgeon care teams. They kick off an evidence based rehab plan as soon as they return home from the hospital (before they might have started traditional PT). This speeds up the patient’s recovery process and their feedback allows the care teams at the hospital to understand their needs and respond immediately.”
“Force collects multiple data points on each patient including daily pain, temperature, ROM [range of motion], wound pictures, videos and activity via step tracking and GPS [global positioning system]. In order to capture outcomes data, they use multiple modules from Force. The platform sends patients reminders via text or SMS [short message service] when outcomes are due and the patients can fill out their digital forms anywhere. Patients log in to the Force app regularly to receive new exercises and education based upon the stage of their rehab (days post-surgery) they answer simple questions from the care team each time they log in. Force will capture information on how their incision is healing, the mobility of their operated extremity—and track progress against benchmarks which will create alerts if the patient is off track.”
As for an example of how the transparency translates into evidenced-based care, Dr. Vaccaro commented, “By tracking patient’s data and activity in real-time, surgeon care teams are able to know which patients need our attention and triage appropriately. This results in reduced emergency department visits, calls into the practice and ultimately better patient care. Additionally, an enhanced understanding the patients' functional progress, the rate of that progress and what is necessary to achieve that progress, helps Force optimize care. Force uses research and data from the platform to help with these decisions. Force wants the best experience for post-op patients. What they have found is that that the best experience for the patient (and Force) is post-op recovery in the home with Force providing transparent, real time patient data to us, and education/communication to them.”