Foot, Ankle Patients Avoiding Clots by “Sheer Luck” // JUST Fixing Rotator Cuff Not Enough // and More!

Blood Clots: A Roll of the Dice for Foot & Ankle Patients

Are foot and ankle surgeons being made to guess when it comes to blood clots and pulmonary emboli?

“Yes, ” says Christopher DiGiovanni, M.D., chief of the Division of Foot & Ankle Surgery at Massachusetts General Hospital and Newton Wellesley Hospital.

Dr. DiGiovanni told OTW, “As opposed to hip and knee replacement, foot and ankle surgery is sorely lacking when it comes to preventing blood clots in the legs or pelvis. These are potentially fatal events, and we foot and ankle surgeons are seriously lacking in data to help us guide patients and create a shared decision making model. All existing studies are not appropriately powered to render valid scientific conclusions; it has been this way for decades. In order to answer pertinent questions, we need a lot of patients and different study arms. Anyone will tell you that it’s a great idea…but no one wants to pay for it. The sad bottom line is that we have been making decisions on these patients using only level 4/5 evidence. There are patients being undertreated and overtreated…and by sheer luck some are being treated correctly.”

“There are guidelines from the American Academy of Orthopaedic Surgeons (AAOS) and the National Institute for Health and Care Excellence, and others. None of them have ever addressed anything below the knee. Foot and ankle is a nascent specialty, so we are lagging behind our ‘cousins.’”

“When I was a resident there was no foot and ankle specialty, so no one was forced to think about these patients. All of a sudden there are a growing number of actual fellowship trained foot and ankle surgeons. For many years hip surgery was the big focus, and thus there was a lot of attention on blood clots and death from pulmonary embolism. People panicked and said, ‘We have to study this!’ There are now scientific guidelines related to hip surgery, and surgeons can rely on these algorithms to steer patients in the right direction. We foot and ankle surgeons are shooting from the hip. As a result, patients and doctors suffer.”

Asked what made him so passionate about this subject, Dr. DiGiovanni commented, “I had a patient who was doing fine about four weeks after surgery. I left for the AAOS meeting and then got an emergency call saying that this person had developed an immune reaction to his medication. This man, who had six children, died. I have never forgotten him. I knew that we needed to do better. I wrote letters to the drug companies, the insurance companies, the National Institutes of Health, etc. All agreed that this was an important issue…but no one wanted to pay for a study.”

So Dr. DiGiovanni approached the only entity able to handle such a large issue: the Patient-Centered Outcomes Research Institute. “Partly funded by industry, insurers, and the government, PCORI is an independent organization that distributes $200-$400 million/year. Our application involves 26, 500 patients and 50 sites in the U.S. Although the study will cost $15 million, it would save the government even more. If we can create the proper algorithms then we will avoid unnecessary complications and morbidity.”

“A critical message to my physician colleagues is that this work is important not just for orthopedic surgeons, but for primary care doctors as well. Foot and ankle problems are one of the most common musculoskeletal reasons that patients seek out a primary care doctor. Even if the patient doesn’t end up in surgery, nonoperative approaches such as casting set them up for a potential clot.”

“At the end of our proposed study we will have a huge dataset and will be able to look at the data and say, ‘Those who do not have clots…what do they have in common?’ We will be able to stratify the risks and create a checklist for primary care doctors. Maybe a score of 0-3 means the patient needs nothing; 4-6 means they need a low dose aspirin; greater than 6 means they need a full anticoagulant for x number of weeks. All of this will only enhance our efforts to give patients more information and empowerment when it comes to their healthcare.”

Penn Medicine: De-mystifying the Scapula

When it comes to scapular dyskinesis, treat the cause, not the symptoms, says one of the world’s foremost orthopedic researchers.

Louis J. Soslowsky, Ph.D. is director of the Penn Center for Musculoskeletal Disorders at the University of Pennsylvania. Dr. Soslowsky, who is also an associate dean at the Perelman School of Medicine at Penn, set out to determine the role of scapular motion in shoulder functioning.

He told OTW, “Scapular dyskinesis, a condition where the position and the movement of the scapula is abnormal, is present in a large majority of shoulder injuries. As a field, however, we haven’t been accustomed to looking for it during patient exams. While for 20 years we have used a rat shoulder model to ask questions related to the rotator cuff, we only recently began doing so with scapular dyskinesis. We need to ask questions such as, ‘How important is scapular motion in the functioning of the shoulder? What came first, the injury or the scapular dyskinesis?’”

“We were indeed able to create scapular dyskinesis in a rat model that does a good job of mimicking the human condition. We knew that if we found that scapular dyskinesis was the causative factor, and not the result, then we could treat the earlier event.”

“It was fascinating to find that when there is scapular dyskinesis and overuse combined that there is a greater adverse effect on tendon properties. Someone with an active job or active sport and scapular dyskinesis will be at a much higher risk for future tendon and joint damage than someone who does not have a high activity job.”

“This study suggests that we need to pay better attention to the scapula. When someone comes in with a rotator cuff tear, take a look at the scapula to see if it is winging. If scapular dyskinesis is present, then that tendon will heal poorly…just fixing the rotator cuff tear alone will still leave the patient with altered functioning and a poorly healed tendon. It is possible that in some cases the scapula is out of balance, and that it would suffice to fix the scapula with physical therapy (separately from physical therapy for the rotator cuff).”

Asked why this issue has not been addressed more often, Dr. Soslowsky notes, “Most times, people don’t actually point to the scapula when reporting shoulder pain. If the orthopedic surgeon knows to look for it, however, then scapular dyskinesis is not hard to diagnose. We now know that it can be the primary causative factor in a shoulder injury. We must stop treating the symptoms and treat the problems.”

“The next questions are: ‘Now that we know the scapula is a big issue, how can we get it to function well into the future? How can we correct scapular abnormality?’ We just don’t know that much about how the scapula is controlled. I look forward to presenting these results at the upcoming Penn Throwing Symposium on January 23, 2016.”

CHOP: Redesigned Fellows Program Attracting Best, Brightest

What does one of the top hospitals in the country do to “land” star orthopedic fellows? Focus on their development!

John M. Flynn, M.D., is chief of orthopedics at the Children’s Hospital of Philadelphia (CHOP).

He tells OTW, “We have redesigned our selection process to find the right young surgeons for our program. Several years ago we had may 20-30 dates, interviewing 1 or 2 applicants on the fly during a normal workday. We would just slip out of the OR clinic for a few minutes to talk with someone and then go back to what we were doing. We recently decided to make the fellowship a strategic priority, and we began to close down the practice in the afternoon and have 3 group interview dates. We have turned the whole experience into a thoughtful, focused matchmaking process.”

“By the time we meet with the applicants we have reviewed their letters of recommendation, and they have completed a one page bio summarizing where they ‘came from, ’, where they are, and where they want to go in their career. Everyone we interview has the academic qualifications to be our fellow. What we want to determine on interview day is how they would fit into the CHOP Orthopaedic Surgery environment.”

“Our overarching goal is to create the next generation of leaders in our field. We have the highest surgical caseload of any pediatrics orthopedic fellowship in the US; we need to make sure that a future fellow likes to be busy. Some programs have a slower pace with lots of time in clinic; we have 5-7 ORs going most every day. We want to be sure that they can thrive in this fast-paced, clinically rich environment.”

 

“We are really looking for people who are going to take maximum advantage of all that we have to offer. Our program has 16 surgeons in all of the subspecialties in pediatric orthopedics. We publish over 100 papers per year, edit the major texts in our filed, and have 26 residents and many medical students pass through over the course of the year. We want people who are willing and able to fully participate in all of these aspects of the program—clinical, research and teaching.”

“We think that the fellows can feel our dedication to their training and our passion to mentor them after graduation. One applicant recently told us, ‘I’ve interviewed at a number of programs and they have never been this organized.’ We are looking forward to a new group of excited, curious fellows this year.”