Criticism of NEJM Partial Meniscectomy Mounting Rapidly
Let’s take a closer look at the recent New England Journal of Medicine article on arthroscopic partial meniscectomy, says Brian Cole, M.D. Dr. Cole, Professor in the Departments of Orthopaedic Surgery and Anatomy & Cell Biology at Rush University Medical Center, tells OTW, “There are a number of problems with this study. It took five years to enroll patients in the study, so there should have been a denominator amongst the five sites of several thousand potential meniscectomy patients in the practices of the investigators. In fact there were less than 200 enrolled; add to that the fact that almost 25% were dropped from the study. Then there is the issue that these were not acute, dramatic tears…they were degenerative menisci. This brings into question the generalizability of the population studied to the population at large with acute and chronic meniscal tears.”
“And their conclusion that ‘arthroscopic partial meniscectomy is of no value’ is not what the study showed. They looked at two surgical procedures, that had the common factor of irrigation and lavage with the only difference being one group underwent a concomitant debridement of the meniscus. If you want to know the impact of the different aspects of the treatment then a true ‘sham’ group would be needed where an incision is made without entering the joint. That said, both groups improved with surgery compared to their baseline clinical presentation.”
“Let’s say that the study had been appropriately powered. Then you can say that doing something to the meniscus may or may not make a difference. But arthroscopy did seem to make things better. It is a nuance because half of the patients had the meniscus treated and half did not…and these are degenerative, not traumatic, injuries.”
“I do congratulate the authors for the rigor in which the study was performed. I share concerns, however, with other orthopedic surgeons that this study could cause problems. If policy makers or insurers take the message away that surgery for meniscal tears isn’t effective when in fact this and several other studies have shown that it is effective when appropriately indicated, then I worry that coverage decisions may be erroneously made.”
AO Spine’s Global Classification Survey Results are in. Now Comes the Hard Part.
Alexander R. Vaccaro, M.D., Ph.D. is a spine surgeon with the Rothman Institute in Philadelphia. He is also vice chairman of the Department of Orthopaedics at Thomas Jefferson University. Dr. Vaccaro tells OTW, “In the trauma world spine surgeons are always searching for the most user friendly, universally accepted spinal classification system. The recently completed AO Spine Thoracolumbar Classification System, incorporating principles of the original AO and TLICS systems is now being validated, with the Rothman Institute being one of the study sites. The system, which was sent to 100 facilities in seven regions of the world, allows a validated assessment of the systems applicability in spinal trauma care as well as allows everyone to see how different regions of the world perceive the severity of injury through the development of a severity score. Does XYZ culture view a particular fracture pattern to be severe? Do they opt more for aggressive treatment or do they usually go the nonoperative route?”
“We are still working with the data, but thus far I’ve noticed that different regions of world look at spine injuries differently. Some societies regard specific injuries as being more unstable than others, therefore they opt for surgical intervention more often than other societies. That’s why we often notice that a surgery rate is higher in certain countries for specific spinal injuries. So we’re seeing that with these trauma cases people in some areas of the world are describing things as being more severe than people in other areas. It’s not like they think that it’s necessary to operate on everything, it’s that they perceive the injury as being more severe.”
“So are they right? To find out we must do well designed studies with evidence that rivals level I and level II data as RCTs [randomanized controlled trials] are difficult to do in the setting of trauma. I can say this, though. The European surgical community sees specific injuries as being more unstable than surgeons in North America. We don’t know why this is, but we have a meeting coming up that will hopefully shed light on this and other issues.”
“Traditionally, we would think that nonoperative care costs less, but that may not be the case if the person has to remain in a brace for an extended period of time and cannot work. There are others who say that surgery is less expensive because that person can return to work sooner. So the question is, ‘is acute care more expensive than nonoperative care, and if so, who pays? Is this an investment by insurers or does society pay for this?’ It will certainly take a while to come to these answers.”
Shake Up in Blood Clotting Numbers
What do you do when published data doesn’t match your clinical experience? You do your own study. Robert Z. Tashjian, M.D. is Associate Professor of orthopedic surgery at the University of Utah. Dr. Tashjian, a shoulder specialist, tells OTW, “My partners and I noticed that our clinical experience regarding blood clotting after total shoulder did not match the data in the literature. Most of the work in this area has been done by Mayo Clinic and Hospital for Special Surgery, which have reported great variability in DVTs [deep venous thrombosis] and pulmonary embolism (PE): the incidence ranges from .1% to 10-15%. We undertook a retrospective study of 10 years of shoulder replacement data, and examined 533 patients who underwent a shoulder arthroplasty evaluating for the incidence of venous thromboembolism (deep venous thrombosis and pulmonary embolism) as well as risk factors for the development of clotting. Examples of risk factors evaluated included comorbidities, smoking status, medications prior to surgery, hormone replacement, past cancer status, etc.”
“We found an overall clotting rate of 2.6%, which was more in line with our clinical experience, and PE was much more common than DVTs (2.3% versus 0.9%). Then we looked at factors affecting clotting and found that those with comorbidities and heavier patients were more likely to have a problem. Other factors we found associated with clotting included revision surgery and diabetes. One of the more interesting things was that surgeries in which patients had a higher preoperative hematocrit had a higher incidence of clotting. Here in Salt Lake City we are at a higher altitude and we have always wondered whether our clotting rate differ because of this. There is some data for other procedures indicating that a high pre-op hematocrit and hemoglobin can be a risk factor for clotting. Finally, we did find that patients with a history blood clotting prior to surgery had an increased risk for clotting after surgery similar to other authors.”
“So clotting—either PE or DVT—is not nominal…but it may not be significant enough to require therapeutic Lovanox or Coumadin on every shoulder replacement patient. Surgeons need to look for risk factors and not necessarily treat it preoperatively but be more aware of this postoperatively.”
Ojedapo Ojeyemi, M.D Has Joined the Team at American Spine.
Ojedapo Ojeyemi, M.D., a board certified orthopedic surgeon, has joined the team at American Spine. American Spine has 10 multi-disciplinary locations in the Maryland and Pennsylvania area.
Dr. Ojeyemi obtained his Bachelor’s Degree with Honors/Cum Laude from Stony Brook University. He completed his Medical Degree at SUNY Health Science Center in Brooklyn, New York. Dr. Ojeyemi then specialized in orthopedics and completed his residency at Howard University Hospital in Washington, DC. He went on to subspecialize in spine and did his fellowship at the world renowned Texas Medical Center in Houston. Dr. Ojeyemi held academic clinical appointments at Howard University Hospital prior to joining American Spine. At Howard University, Dr. Ojeyemi was actively involved in medical student and resident education and research, as well as patient care.
Dr. Ojeyemi practices general orthopedic surgery, but his subspecialty and main focus is leading minimally invasive spine surgery at American Spine. He is passionate about using the least invasive surgical approach while removing the pain source from a degenerated spine. He lectures worldwide about his success in using minimally invasive spinal techniques. Dr. Ojeyemi regularly performs complex open and minimally invasive spine procedures, minimally invasive and complex joint surgeries, sports medicine, hand and foot surgery, as well as orthopedic trauma surgery.
He is an active member of the American Academy of Orthopaedic Surgeons, J. Robert Gladden Orthopaedic Society, AO Spine, and North Atlantic Spine Society. Dr. Ojeyemi is dedicated to promoting minimally invasive spine surgery, motion preservation and percutaneous fusion, including endoscopic and laser thermodiskoplasty. In addition to his work at American Spine, Dr. Ojeyemi is involved in humanitarian medical missions work in Africa, particularly Nigeria. During these trips, his teams have performed advanced orthopedic care for trauma victims and children with deformities.
Thanks for the post. A lot of good information.