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Source: Wikimedia Commons and Photography Harris A Ewing

U.S. Neurosurgeons Overly Defensive?; 1st Annual Anterior Hip Foundation Meeting; Sagittal Deformity and THA Dislocation Linked!

Elizabeth Hofheinz, M.P.H., M.Ed. • Fri, March 31st, 2017

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U.S. Neurosurgeons Overly Defensive?

A new observational cross-sectional study from the Department of Neurosurgery at Brigham and Women’s Hospital and Harvard Medical School in Boston has found that spine neurosurgeons are significantly more likely to practice defensive medicine than non-spine neurosurgeons. The study, entitled, Defensive Medicine in U.S. Spine Neurosurgery, was published in the February 2017 edition of Spine. The researchers, including Timothy R. Smith, M.D., Ph.D., M.P.H., emailed 3,344 members of the American Board of Neurological Surgeons.

The authors wrote, “Multivariate analysis revealed that spine neurosurgeons were roughly three times more likely to practice defensively compared with non-spine neurosurgeons when controlling for high-risk procedures, annual malpractice premium, percentage of patients publicly insured, malpractice claims in the last three years, and state medical-legal environment.”

Dr. Smith told OTW, “Our group has been interested in defensive practices in high risk specialties for some time. Specifically, we have investigated neurosurgery and spine surgery. We have examined these practices in the U.S., Canada, South Africa and now Holland. We are especially interested in defining the scope off the problem, and potentially any potential opportunities for reduction via comparisons and contrasts with other types of health care delivery systems.”

“The largest challenge with this type of research is attempting to quantify an inherently subjective topic. We have elected to use a survey-based paradigm, and have had decent success.”

“We were surprised to learn the ubiquity of defensive medicine among spine neurosurgeons in the U.S. In fact, on average, spine neurosurgeons had a significantly higher rate of ordering labs, medications, referrals, procedures, and imaging solely for liability concerns compared with non-spine neurosurgeons. They were/are immune to their medical-legal environment.”

“We are currently looking at spine surgery in Europe to assess the nature of defensive practice there. We are also looking at estimating the cost of defensive medicine in the U.S. We hope to clearly define and reduce this type of practice.”

1st Annual Anterior Hip Foundation Meeting

The Anterior Hip Foundation, Inc. (AHF), a non-profit organization based in Santa Monica, California, will be holding its first annual Anterior Approach Innovation Symposium June 23-24, 2017 in Las Vegas, Nevada.

The organization’s mission statement reads, “The Anterior Hip Foundation (AHF) is devoted to the continuous advancement of the anterior approach hip surgical technique, the development and refinement of associated medical device technologies, and the furtherance of educational programs and training courses for physicians to continue improving patient care.”

The inaugural AHF Innovation Symposium will welcome prominent thought leaders on anterior approach hip replacement. Included in the two-day program are debates on the nuances of surgical technique, and a chance for attendees to share their clinical experience.

AHF President Joel Matta, M.D. commented to OTW, “Anterior approach hip replacement today represents nearly a third of all hip arthroplasty procedures performed in the USA, and the pool of positive clinical data continues to deepen every year. We founded the AHF to be a catalyst for sharing knowledge, fostering technological innovation, and optimizing patient outcomes. Our success will be defined by how well we educate and empower physicians and surgical staff to achieve excellent results with the anterior approach procedure.”

AHF Vice-President Charles DeCook, M.D. stated, “The AHF aspires to deliver top notch, independent education and learning events, and our Innovation Symposium reflects this. We are hosting the program at the magnificent Bellagio Resort in Las Vegas, and we have announced a Call for Papers & Presentations to invite all meeting attendees to submit papers, posters, and surgical experiences. The AHF is an open forum to advance the science and knowledge of anterior approach, and we have spared no expense to make it a terrific and memorable experience for all attendees! Interested physicians and healthcare professionals can register at or email presentations to”

Sagittal Deformity and THA Dislocation Linked

New research presented at the recent American Academy of Orthopaedic Surgeons annual meeting in San Diego focused on patients with a sagittal deformity who had undergone total hip arthroplasty (THA), who, despite having what is thought of as good acetabular cup positioning, still experienced instability.

Aaron J. Buckland, M.D. is assistant professor of orthopedic surgery and director of Spine Research at NYU Langone Medical Center. He commented to OTW, “When I was a resident, I noticed several cases of dislocations in patients who had perfectly good-looking X-rays, and good acetabular positions of their hip replacements.”

“These patients had spinal deformity or lumbar fusions, and despite these cups being positioned in the safe zones, dislocations still occurred. We didn’t understand why that would happen, so that’s when we started looking at lumbar mechanics and how sitting and standing alignment changed in patients with spinal pathologies.”

“Then, we moved onto more collaborative work with our adult reconstructive surgeon colleagues at NYU Langone to look at this problem on a wider scale among patients with spinal deformity.”

He and his co-authors wrote, “Using standard stereoradiography, we evaluated the spinopelvic parameters, acetabular cup anteversion, and inclination of 139 THAs in 107 patients with sagittal spinal deformity. Standing images were compared with supine pelvic radiographs to evaluate dynamic changes in acetabular cup position. Dislocation and revision rates were procured through retrospective chart review. The spinal parameters and acetabular cup positions among dislocators were compared with those who did not dislocate.”

Asked for details on what the findings mean for the safe zone, he said “The safe zone was a concept developed in the 1970s where a low dislocation rate was noted if the cup was put within certain alignment parameters, and now it seems the safe zone is not appropriate for all patients.”

“The safe zone still has relevance in patients with normal spines, without a deformity or lumbar fusion, but we’re now finding that’s not the case for all pathologies. Standard X-rays for judging hip prosthesis positioning are taken lying down, which is different than functional positions of sitting and standing, so surgeons are also learning more about preoperative planning and taking these additional images.”

“There have been some controversies as to which order you should do these surgeries, but if someone has a complex spinal problem, they should make a shared care decision between adult reconstructive and spine colleagues on which order to do a hip replacement or fusion surgery. We are also focusing more on the subset of patients with a degeneration and fusion in sitting and standing alignment to develop an algorithm to make patient specific implant positioning.”

Regarding challenges to collaboration between hip and spine surgeons, Dr. Buckland commented, “At our institution adult reconstructive surgeons and spine surgeons are very likeminded and collegial. More and more, surgeons are realizing the interaction between the spine and pelvis is an important relationship we don’t understand that well, but now this relationship is being talked about increasingly.”

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