Standard X-rays Misleading Surgeons?
When it comes to clavicle fractures, it looks like orthopedic surgeons are not in agreement on how to treat them…and X-rays may be the problem. Grant Jones, M.D. is a professor of orthopedic surgery and team physician at The Ohio State University. He tells OTW, “In the past, patients with clavicle fractures have been successfully treated in a non-operative fashion. However, a multicenter study from Canada found that there may be a higher rate of nonunion or other clinical problems in the long term if you do not perform open reduction and internal fixation of those fractures that are significantly displaced or shortened. It has been suggested that if there is greater than 2cm of shortening physicians should consider surgical intervention to decrease the rate of nonunion and improve clinical results.”
“Our team wanted to see how reliable surgeons are in determining the amount of shortening, the degree of displacement and the presence of communition on standard trauma radiographs with two main views: a straight AP [straight AP view of the clavicle] view of the clavicle and a 30 degree cephalad view. In particular, we were interested in shortening because, for many physicians, this is the main indication for surgery.”
“We selected radiographs of 30 patients with clavicle fractures who were treated operatively or non-operatively at The Ohio State University. Sixteen orthopedic surgeons from the Multi-Center Orthopaedic Outcome Network Shoulder Group (all fellowship trained in either shoulder surgery or sports medicine) viewed the radiographs with clinical vignettes. In their evaluations, they measured the degree of shortening in millimeters, determined the percentage of displacement, and determined whether there was communition. The surgeons were then asked to determine whether they would treat the clavicle fracture operatively or non-operatively.”
“It was a bit surprising to discover that there was not much agreement between surgeons as to whether a patient should be treated operatively or non-operatively. However, when we looked at the different variables, there was limited or poor agreement on the amount of shortening of the clavicle. In particular, in the critical range of 1-2cm shortening where one decides on surgery versus non-surgical management, there was poor agreement. And, when we surveyed the surgeons after they viewed the radiographs, they stated that their most important factor for determining the need for surgery was the amount of shortening.”
“The message to orthopedic surgeons is that we should not rely solely on standard plain radiographs (the standard trauma series) when deciding whether or not to operate. Doing so may make us over- or under- estimate the degree of shortening, which can lead to over or under treatment of these fractures. Based on our findings, it may be prudent to utilize the degree of communition and the degree of superior and inferior displacement, where there is better agreement, in addition to the amount of shortening when determining the need for surgery or utilize alternative views including contra-lateral clavicle radiographs to better assess the amount of shortening.”
“We are seeing many more clavicle fractures these days in this era of “extreme sports” (the X-Games phenomena), so this merits continuing study. Going forward, we may do a study to examine the reliability of other radiographic modalities in determining the degree of shortening.”
Hot New App Helps Parents Gauge Severity of Baseball Injuries
Does your average parent know if Johnny has a minor or a major baseball pitching injury? Absolutely not, says famed sports medicine surgeon Jimmy Andrews. Dr. Andrews told OTW, “When the people from Abracadabra Health approached me about developing an app I initially said, ‘What’s that?’ The outstanding physical therapist on our staff, Kevin Wilk was instrumental in making this happen, however, and we now have this program for your phone that will give parents specific advice on how to prevent baseball injuries. Interest in these pitching injuries is high, as is evidenced by the fact that the app—Throw Like a Pro—was retweeted over 50 million times in the first 24 hours.”
“The app helps parents keep track of how many pitches their child has thrown during a game, and when to pull them out if necessary. There are warm-up guidelines and a lot of information on overuse injuries, something that is a real problem given the now-popular trend of year round play.”
“Our ultimate goal is to have 100 different types of injuries and a variety of youth sports. We will have guidelines for prevention, first aid tips, and specific information on when an injury is serious enough to see a doctor. Parents have not been educated as to the risk factors associated with specific sports, so this should go a long way toward preventing injuries.”
“As for me, I would appreciate the support and feedback from my orthopedic colleagues. My goal is prevention, and frankly, the problem is the system. There are no regulations saying that kids must limit their play to the season. There is huge pressure by coaches to let them play year round. I am on the board of Little League International, an organization that has always taken the health and safety of its participants as the number one priority. Although we get a lot of criticism from other youth organizations because we tell parents to limit pitches and overall play, the pitch count rules from the American Sports Medicine Institute that we helped implement have already brought the injury rates down in the Little League Association. If we don’t change this ‘year round play’ mindset, I’m afraid that lawyers will get involved. I can see it now…’If you have been made to pitch more than 75 times in a year, please contact XYZ law firm.’ I don’t think anyone wants it to come to that.”
Silo Breaking in Healthcare: Surgeons, Business Leaders Collaborate on Value
What do experts from other industries know that doctors need to know? Some ahead-of-the-game orthopedic surgeons are finding out. Tony DiGioia, M.D. is a hip and knee specialist at the University of Pittsburgh Medical Center (UPMC) who is helping to chart a new course on value in healthcare. Dr. DiGioia tells OTW, “We are taking lessons learned from other industries and applying tools so that we can determine the true cost of delivering care. Until now we have used charges or insurance payments as a surrogate to estimate cost, but those numbers don’t represent the true cost of delivering care nor through a full cycle of care for instance from 30 days before surgery to 90 days after surgery. The charge system was developed in a completely different payment model where providers were paid a percentage of the charges so charges didn’t have to reflect the true cost of the care delivery—quite a disconnect.”
“What my colleagues and I are doing now is using the work of Robert Kaplan and Michael Porter from Harvard Business School on how to deliver value in healthcare. Value in healthcare means having health outcomes that are important to patients in the numerator then dividing by cost…but it must be the true cost in order to deliver those outcomes. While we have done a fairly good job with the getting the numerator right, we still lack reliable information on the true cost of delivering care. Dr. Kaplan has developed a true cost methodology used in other industries —known as Time-Driven Activity-Based Costing (TDABC). TDABC can give us the true cost of delivering care thru a full cycle of care and opens up the opportunity to answer the value equation and most importantly to drive change that delivers value for our patients and families. We have also found that by linking clinical performance with financial performance, we have been able to bring together all stakeholders in the conversation of delivering value. The most unique aspect of this work is that we will answer the value equation by putting the patient at the center and our focus which is also our mission i.e., taking care of patients. On the practical side, the patient is the only common denominator throughout the entire care experience. By focusing on patients, we can improve outcomes and experiences while reducing the cost to deliver that care.”
“In September we will be holding an new event called ‘The Business Case for Improving Value in Healthcare’ (www.DeliverValue.org) and Robert Kaplan will be the keynote speaker. This will be a superb opportunity to bring together the business community with clinical, financial and insurance industries and to learn about these new ideas on how to create a delivery care system that works for everyone. We must design a delivery system that meets the needs of the end users—this has been repeatedly shown in other industries. In healthcare, patients and family are the end users…and we have found that if you focus on the needs of patients and families that you can also meet the needs of all of the other constituents.”
Matthew R. Steensma, M.D. Wins Francis S. Collins Scholars Program
Dr. Matthew Steensma, an oncology orthopedic surgeon from Spectrum Health Medical Group and the Van Andel Institute in Grand Rapids, Michigan, has been named an inaugural winner of the Francis S. Collins Scholars Program in Neurofibromatosis Clinical and Translational Research, sponsored by the Neurofibromatosis Therapeutic Acceleration Program (NTAP) at The Johns Hopkins University.
Dr. Steensma’s work involves tumors of the musculoskeletal system, with a focus on individuals affected by neurofibromatosis type 1 (NF1), a condition that causes tumors to grow throughout the body.
The program is named for Francis S. Collins, the current director of the National Institutes of Health and former director of the National Human Genome Research Institute. It was Dr. Collins who led the team that discovered the NF1 gene.
