Doctor Tarlow on Knees - The Lighter Side

Weight Gain Common with New Knees

2013-05-09T12:10:00.000-07:00

"Patients who undergo total knee replacement are at substantial risk for weight gain during the 5 years after the surgery, a large retrospective study showed.

The logical assumption may be that persons who are overweight or obese prior to surgery are more likely to lose weight following surgery. Because there is less pain and improved mobility, the impediments to increased activity and exercise are eased following surgery, and weight loss would logically follow," they observed.

However, that hasn't been the case.

Weight control efforts for patients having the surgery should therefore focus on long-term maintenance, they commented."

Observations of hundreds of Knee Replacement by Dr. Tarlow reinforce the conclusions in the study. Commonly heard in my office is "I can not lose weight because my knee is worn out". However, rarely will a patient lose significant weight or lead a more healthy, exercise focused life style despite successful knee surgery(less pain and improved mobility). In fact, most patients have gained noticeably more weight after knee surgery. Sometimes I wonder if I am just making it easier for people to walk to their refrigerator. I continue to counsel and encourage patients to address the serious medical condition of obesity with frustratingly little success. Without meaningful lifestyle change (dedication to exercise program and meal portion/choice control) people will not magically lose weight after joint replacement. When are American's going to be accountable for their own health and well being?. Your doctor or healthcare policy maker is not powerful enough to make you get healthy-you have to do it yourselves!

Only 1 in 5 Americans Getting Recommended Amounts of Exercise

2013-05-02T22:58:00.000-07:00

iStockphoto/Thinkstock(ATLANTA) -- Not enough of us are getting the right amount of exercise, according to a weekly report from the Centers for Disease Control and Prevention.

The CDC's Morbidity and Mortality Weekly Report says only about 20 percent, or one in five, U.S. adults are meeting the federal government's recommendations for physical activity, which includes aerobic and muscle strengthening components.

Government health officials recommend adults get at least 2.5 hours a week of moderate-intensity aerobic activity such as walking, or one hour and 15 minutes a week of vigorous-intensity aerobic activity, such as jogging or a combination of both. The recommendations also call for muscle strengthening activities such as push-ups, sit-ups or lifting weights.

The data, based on self-reported information from an annual phone survey by state health department, shows that 50 percent of U.S. adults are getting the recommended amounts of aerobic activity, and 30 percent are engaging in strength training.

“Although only 20 percent of adults are meeting the overall physical activity recommendations, it is encouraging that half the adults in the United States are meeting the aerobic guidelines and a third are meeting the muscle-strengthening recommendations,” said Carmen D. Harris, M.P.H, epidemiologist in CDC’s physical activity and health branch.

Harris added that this data provides a great foundation to build on, but stressed that there is still work to do. "Improving access to safe and convenient places where people can be physically active can help make the active choice the easy choice,” she said.

Other key findings in the CDC report:

The West and the Northeast regions had the highest proportion of adults who met the guidelines, with 24 percent and 21 percent respectively.

Women, Hispanics, older adults and obese adults were all less likely to meet the guidelines.

Young Athletes Playing One Sport At Risk for Serious Injury

2013-04-22T21:47:00.001-07:00

Intense, Specialized Training in Young Athletes Linked to Serious Overuse Injuries-These Injuries are preventable. Too much is not good.

From Loyola and Lurie Children’s Hospital

MAYWOOD, Ill. - Young athletes who specialize in one sport and train intensively have a significantly higher risk of stress fractures and other severe overuse injuries, even when compared with other injured athletes, according to the largest clinical study of its kind.

For example, young athletes who spent more hours per week than their age playing one sport – such as a 12-year-old who plays tennis 13 or more hours a week – were 70 percent more likely to experience serious overuse injuries than other injuries.

There were 859 total injuries, including 564 overuse injuries, in cases in which the clinical diagnosis was recorded. The overuse injuries included 139 serious injuries such as stress fractures in the back or limbs, elbow ligament injuries and osteochondral injuries (injuries to cartilage and underlying bone). Such serious injuries can force young athletes to the sidelines for one to six months or longer.

Among the study’s other findings:

Young athletes were more likely to be injured if they spent more than twice as much time playing organized sports as they spent in unorganized free play – for example, playing 11 hours of organized soccer each week, and only 5 hours of free play such as pickup games.
Athletes who suffered serious injuries spent an average of 21 hours per week in total physical activity (organized sports, gym and unorganized free play), including 13 hours in organized sports. By comparison, athletes who were not injured participated in less activity – 17.6 hours per week in total physical activity, including only 9.4 hours in organized sports.
Injured athletes scored 3.3 on researchers’ 6-point sports-specialization scale. Uninjured athletes scored 2.7 on the specialization scale. (On the sports specialization scale, an athlete is given a point for each of the following: Trains more than 75 percent of the time in one sport; trains to improve skill or misses time with friends; has quit other sports to focus on one sport; considers one sport more important than other sports; regularly travels out of state; trains more than eight months a year or competes more than six months per year.
Jayanthi offers the following tips to reduce the risk of injuries in young adults:
Do not spend more hours per week than your age playing sports. (Younger children are developmentally immature and may be less able to tolerate physical stress.)
Do not spend more than twice as much time playing organized sports as you spend in gym and unorganized play.
Do not specialize in one sport before late adolescence.
Do not play sports competitively year-round. Take a break from competition for one to three months each year (not necessarily consecutively).
Take at least one day off per week from training in sports.

Brisk Walking May Equal Running for Health

2013-04-05T12:38:00.004-07:00

Please see the below article. The take home message is that we can control our health and well being. People should consider how important their personal health and well being is, and make choices in line with their chosen ideals.

It's a matter of how far you walk or run, not how long, said Paul Williams, a staff scientist at the Lawrence Berkeley National Laboratory in Berkeley, Calif.

"Both of these activities reduce risk factors, and if you expend the same amount of energy you get the same benefit," Williams said. The key was the more people walked or ran each week, the more their health improved, he said.

The findings suggest "there is now some choice in the exercise you want to do," he said. Some people find running more convenient, others prefer walking, especially people just starting to exercise, he noted.

The advantage of running is you can cover twice as much ground in the same amount of time as you would walking, Williams pointed out. Other research using data from the walkers' and runners' studies found that for weight loss, running beats walking. That study appears in the April issue of Medicine & Science in Sports & Exercise.

Williams is referring to brisk walking, however. "Walking for exercise. It's not a mosey kind of thing, but actually walking for exercise,".

For the study, published online April 4 in Arteriosclerosis, Thrombosis and Vascular Biology, Williams and Dr. Paul Thompson, a cardiologist at Hartford Hospital in Connecticut, collected data from the National Runners' Health Study and the National Walkers' Health Study. More than 33,000 runners and nearly 16,000 walkers were involved.

The runners and walkers were 18 to 80 years old, but mostly in their 40s and 50s, the study authors noted.

4 Million Total Knees Walking Around the U.S.

2013-03-25T14:45:00.000-07:00

From March, 2013 Journal of Bone and Joint Surgery

In the last decade, the number of total knee replacements performed annually in the United States has doubled, with disproportionate increases among younger adults. While total knee replacement is a highly effective treatment for end-stage knee osteoarthritis, total knee replacement recipients can experience persistent pain and severe complications. We are aware of no current estimates of the prevalence of total knee replacement among adults in the U.S.

We estimated that 4.0 million adults in the U.S. currently live with a total knee replacement, representing 4.2% of the population fifty years of age or older. The prevalence was higher among females (4.8%) than among males (3.4%) and increased with age.

Among older adults in the U.S., total knee replacement is nearly as prevalent as congestive heart failure. Nearly 1.5 million of those with a primary total knee replacement are fifty to sixty-nine years old, indicating that a large population is at risk for costly revision surgery as well as possible long-term complications of total knee replacement.

These prevalence estimates will be useful in planning health services specific to the population living with total knee replacement.

Patients Not Too Worried About Some Financial Relationships Between Physicians and Industry

2013-03-19T21:35:00.000-07:00

A survey of 251 patients concluded FEW patients are worried about financial relationships between orthopedic surgeons and industry when the payment to physicians is for the purpose of patient benefit such as royalties for inventions or innovations and for consultancy.

Physicians and patients agree that it is not appropriate for physicians to receive gifts in situations in which there is no benefit to current or future patients.

Patients correctly concluded that their surgeon would hold patients' interest paramount, regardless of any appropriate financial relationship with a medical manufacturer.

Rehab After ACL Reconstruction Surgery

2013-03-14T18:23:00.000-07:00

ACL Tear from "clipping"

Rigorous rehabilitation is necessary for a successful outcome after ACL surgery. However, scientific rationale for rehabilitation is not advanced enough to lead to a standardized best practices routine.
What is known is that range of motion, strengthening and functional exercises are the keys to proper rehabilitation. Ideal safe period for return to sport is not known (range is 6-24 months). Accelerated rehab does not appear to be harmful. Home-based rehab can be successful. Use of neuromuscular stimulation and vibration training may or may not lead to better outcomes or faster return to sports. Benefits of knee bracing in the post operative or return to sport period may or may not be necessary or beneficial.
Hopefully one day scientific studies can lead to a standardized routine which optimizes outcomes for everyone.

13 Steps That Protect Our Patients From Surgical Site Infections

2013-03-04T21:42:00.000-07:00

New You Tube video entitled: 13 Steps That Protect Our Patients From Surgical Site Infections

http://www.youtube.com/watch?v=SbaGr5PN9MQ

Gram positive Cocci - Staph Aureus as seen through a microscope-the only place we want to see bacteria.

We take patient safety seriously at Advanced Knee Care.

Protecting patients' from Surgical Site Infections is job #1.

Total Knee Replacements Increasing-Over 600,000 Yearly in US

2013-03-03T18:12:00.000-07:00

Dr. Tarlow (right) Knee Surgery Photo

Compared to 1999, Total Knee Replacements have doubled (100% increase), to more than 600,000 per year. The population increased 11% in the same time period. The aggregate cost is 9 billion dollars.

The greatest increase was a tripling in the 45-64 year old group. The 65+ year old group doubled.
Factors to explain this increase include expanding indications for surgery and a shift to treat knee arthritis with this surgery.
A more active US population has led to an increase in sport-related knee injuries, resulting in more prematurely arthritic knees. Doctors are more likely to perform Knee Replacements in younger patients because of successful outcomes, implants last longer, and implants withstand greater activity levels. There is a greater demand from patients for this surgery (?direct to patient marketing of knee implants?) and this has also contributed to the increase.

ACL Surgery Does Not Shorten WNBA Career

2013-02-17T08:56:00.000-07:00

A study published online in the American Journal of Sports Medicine finds that a history of injury or surgery did not affect the round drafted or career length of players in the Women’s National Basketball Association (WNBA). The researchers conducted a descriptive epidemiology study of all 506 athletes entering the WNBA combine, an invitation-only precursor to the draft, during the period from 2000 to 2008. Overall, 73 athletes (14.4 percent) reported having ACL reconstruction and 50 athletes (9.9 percent) reported having meniscus surgery before entering the WNBA combine, but history of ACL or meniscus surgery did not affect career length in the WNBA.

A common knee surgery that can sideline athletes for months does not ultimately affect the career length of women invited to the Women's National Basketball Association (WNBA), according to a new study.

"With appropriate rehabilitation, ACL injuries do not mean an early end to an otherwise promising athletic career," said lead author Dr. Moira McCarthy, an orthopedic surgeon at the Hospital for Special Surgery in New York City.

McCarthy told Reuters Health she was surprised and impressed by just how many women enter the WNBA with a history of knee injury or surgery.

Fifteen percent of the athletes reported having torn an ACL, compared to less than a tenth of one percent in the general population. Almost all the injured athletes had reconstructive surgery.

With or without a history of surgery at these locations, the average WNBA career lasts between three and four years.

McCarthy's team also found that neither career length nor the round in which an athlete was drafted were affected by having had knee repairs.

While ACL injury is still a serious problem, things are looking up, according to Parker. "Our rehab techniques are better, prevention exercises are better, surgery is better," he said.

Antibiotics For Dental Procedures in Patients With Knee Replacements

2013-01-25T13:26:00.004-07:00

A clinical practice guideline released December, 2012 from an expert panel of orthopedic surgeons and dentists modifies the position statement released on this topic in 2009 by the American Academy of Orthopedic Surgeons. The 2009 recommendation suggested "forever" use of antibiotics for Knee Replacement patients having dental treatment, including cleaning in the setting of gum disease.

The new recommendation is:

The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.

This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable
to the individual patient rely on mutual communication between patient, physician, dentist and other healthcare practitioners.

Translation: In a healthy patient with no risk for infection with normal gums and teeth antibiotics are not needed. This is because the new finding is based on the fact that bacteria released into the blood from dental treatments do not result in artificial knee joints becoming infected. However, if a patient is immunocompromised from disease (diabetes, cancer treatment, immunosuppresive medications, etc) than these factors should be considered and may necessitate using antibiotics.

My new policy is to have all patients use antibiotics for Dental Treatment that produces bleeding or is associated with Dental infections in the first year after joint replacement. After one year only immunocompromised patients or patients being treated for dental infections require prophylactic antibiotics.

Smokers fare worse after knee surgery

2012-11-23T09:14:00.000-07:00

From Reuters

Smokers have worse outcomes after knee surgery than non-smokers, including less-complete healing and more surgical complications, according to a new analysis.

Smoking has a profound effect on circulation, so that means it even affects musculoskeletal healing.

Surgeons had a hunch smoking was related to worse outcomes after knee surgery.

They gathered the results of 14 studies, eight of which looked at surgical repair of knee ligaments, including the anterior cruciate ligament (ACL), and six of which examined repair of knee cartilage.

For instance, smokers were less likely to return to their pre-injury level of sport and experienced more pain. One study from the University of Pittsburgh School of Medicine found surgery patients who smoked were 64 percent less likely to report a successful outcome than non-smokers.

The one study that did not find any difference between smokers and non-smokers examined patients' risk of developing osteoarthritis in the knee.

Four studies on cartilage surgery found that smokers were less likely to have excellent results after surgery, had less improvement in the knee years later or had fewer beneficial proteins in the knee fluid than non-smokers.

Patient Choice an Increasingly Important Factor in the Age of the "Healthcare Consumer"

2012-11-16T09:04:00.000-07:00

From Harris Online

The decisions made by the public as "healthcare consumers" are becoming increasingly important, but relatively little is known about what guides their decision making process. This Harris Poll of 2,311 U.S. adults (ages 18 and over) surveyed online between July 16 and 23, 2012 by Harris Interactive represents an important first step in exploring this new category of market behavior.

Satisfaction with healthcare visits compared to other consumer services

Among the 84% of Americans who visited a doctor's office within the past year, nearly half (47%) reported being very satisfied with their last medical visit; an additional 36% described themselves as somewhat satisfied.

As might be expected, satisfaction falls short of levels observed for several other industries, particularly those with more of a focus on providing a pleasurable experience: very satisfied ratings are behind those reported for Americans' last restaurant visit (63%), their last online purchase (62%), and their last bank visit (59%). Very satisfied ratings are comparable to those recorded for U.S. adults' last hotel stay (49%), car purchase (47%) and department store visit (44%), and are ahead of those observed for their most recent health insurance company interaction (29%) and last mobile phone store visit (28%).

Dissatisfaction with most recent healthcare provider visits (17%) is comparable to levels observed for recent mobile phone store visits (also 17%) and health insurance company interactions (18%).

Many factors contribute to patients' experiences with their doctors and other healthcare providers. When asked to rate a series of factors on their importance in driving a positive experience, the clear top issue in patients' minds is their doctor's overall knowledge, training and expertise (with 83% rating it very important). Their doctor's ability to access their overall medical history (62%) and time spent with their doctor (59%) are the next most vital factors, while appearance and atmosphere of the doctor's office (26%) and minimizing paperwork (29%) are the least important issues.

Gap for Online Services: Results show a similar disparity for all of the tested services, including (among others) email access to doctors (12% have; 23% very important, 30% important), online appointment setting (11% have, 21% very important, 30% important) and online billing and payments (10% have, 21% very important, 29% important).

"Customer experience matters in healthcare and will continue to impact purchasing decisions and customer retention," notes Debra Richman, Senior Vice President, Healthcare Business Development & Strategy, Harris Interactive. "The healthcare consumer is increasingly evaluating brand equity, convenience and product or service value as they make choices. In an increasingly competitive healthcare marketplace, a positive customer experience will serve to differentiate health plans and providers."

Link to entire article ---http://www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/447/mid/1508/articleId/1074/ctl/ReadCustom%20Default/Default.aspx

Hospitals To Be Rated Like Hotels-Satisfaction Scores Affect Payments

2012-11-09T08:49:00.000-07:00

Patient-satisfaction score to help determine Medicare payments to hospitals.

As of Oct. 1, hospitals must now reckon with a provision that ties Medicare reimbursement to results of patient-satisfaction surveys, reports the Wall Street Journal. Nearly $1 billion is at stake. Many medical professionals say the requirement is unfair, especially to older urban hospitals that take in large numbers of emergency patients. Many also say that medical care delivery isn’t conducive to being rated like resorts or restaurants, and that proper care and a good outcome might not necessarily equate to a “great experience” for the patient. A hospital in South Carolina will reap $87,000 in extra Medicare pay over the next year after scoring well, while a facility in New Jersey will lose $240,000 because of low scores. The program is part of a broader pay-for-performance initiative in the federal healthcare overhaul.

It is presumed that Commercial insurers such as the Blue Crosses, United Healthcare, Aetna, Cigna will soon follow suit.

I agree that the system now going into place is unfair for the reason state above - Good outcomes and proper care does not always equate to a 5 Star hotel experience for a patient. One has to anticipate that this system will result in some negative unintended outcomes. What next ?!.

Obesity Doubles Failure Rates After Total Knee Replacement

2012-11-02T08:33:00.000-07:00

Complications after Total Knee Replacement (TKR) can require reoperation, implant removal, and months of intravenous antibiotics and months off work. Avoidance of complications include Patient Health Optimization to address and correct risk factors known to lead to adverse outcomes prior to surgery. It makes sense for the patient and it makes sense for society (cost and loss of productivity burden is high with TKR complications).

From J Bone Joint Surg Am, 2012 Oct .

Obesity (body mass index ≥30 kg/m²) is a well-documented risk factor for the development of osteoarthritis. An increased prevalence of total knee arthroplasty in obese individuals has been observed in the last decades.

Infection occurred more often in obese patients, with an odds ratio of 1.90. Deep infection occurred more often in obese patients, with an odds ratio of 2.38. Revision of the total knee arthroplasty, defined as exchange or removal of the components for any reason. Revision for any reason occurred more often in obese patients, with an odds ratio of 1.30.
Conclusions:

Obesity had a negative influence on outcome after total knee arthroplasty.

Dr. Tarlow is Arizona's Most Experienced Makoplasty Surgeon

2012-10-26T07:59:00.000-07:00

Dr. Tarlow of Scottsdale is a Board Certified Orthopedic Surgeon with 24 years of practice specializing in diagnosing and treating diseases and injuries of the knee. According to data provided by Mako Surgical Dr. Tarlow has performed more Robotic Partial Knee procedures than any other Arizona Orthopedic Surgeon.

To date Dr. Tarlow has done 118 medial compartment robotic partial resurfacing and 18 lateral compartment robotic partial resurfacings, for a total as of January, 2013 of 136 Makoplasty Knee procedure.

The most common clinical outcome has been outstanding with most patients having their expectation met or exceeded after the procedure.

Scottsdale Healthcare Thompson Peak acquired Arizona's second Makoplasty robot in January, 2011 (just several months after St. Luke's purchased the first). Dr. Tarlow performed the first Makoplasty procedure in Scottsdale in January 17, 2011.

The Makoplasty procedure is an excellent option for people with osteoarthritis predominately in one compartment of their knee. This procedure works EQUALLY well for the Lateral Compartment or the Medial Compartment of the knee. Dr. Tarlow is a strong proponent of unicompartmental knee replacement in the proper clinical setting.

There Is a Doctor Shorting Looming in America

2012-10-12T20:55:00.000-07:00

Across the US, President Obama’s health care law is expected to extend insurance coverage to more than 25 million people by 2014. But coverage will not necessarily translate into care: Local health experts doubt there will be enough doctors to meet the area’s needs. There are not enough now.

Monica Almeida/The New York Times

Temetry Lindsey, chief executive of Inland Health Services, seeks to hire more doctors.

The New York Times

The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. And that number will more than double by 2025, as the expansion of insurance coverage and the aging of baby boomers drive up demand for care. Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000.

Health experts, including many who support the law, say there is little that the government or the medical profession will be able to do to close the gap by 2014, when the law begins extending coverage to about 30 million Americans. It typically takes a decade to train a doctor.

“We have a shortage of every kind of doctor, except for plastic surgeons and dermatologists,” said Dr. G. Richard Olds, the dean of the new medical school at the University of California, Riverside, founded in part to address the region’s doctor shortage. “We’ll have a 5,000-physician shortage in 10 years, no matter what anybody does.”

Experts describe a doctor shortage as an “invisible problem.” Patients still get care, but the process is often slow and difficult. In Riverside, it has left residents driving long distances to doctors, languishing on waiting lists, overusing emergency rooms and even forgoing care.

Growth in the number of physicians has lagged in some areas, in no small part because sone areas have trouble attracting doctors, who might make more money and prefer living in other communities.

Moreover, across the country, fewer than half of primary care clinicians were accepting new Medicaid patients as of 2008. This is because doctor fees to care for patients in these entitlement programs are too low to cover the cost of providing the care, forcing some doctors out of business. This makes it hard for the poor to find care even when they are eligible for Medicaid. The expansion of Medicaid accounts for more than one-third of the overall growth in coverage in President Obama’s health care law. The question is - will there be doctors to provide this care? I think not - nurse practitioners and physicians assistants will take on these roles.

Providers say they are bracing for the surge of the newly insured into an already strained system.

Temetry Lindsey, the chief executive of Inland Behavioral & Health Services, which provides medical care to about 12,000 area residents, many of them low income, said she was speeding patient-processing systems, packing doctors’ schedules tighter and seeking to hire more physicians.

“We know we are going to be overrun at some point,” Ms. Lindsey said, estimating that the clinics would see new demand from 10,000 to 25,000 residents by 2014. She added that hiring new doctors had proved a struggle.

The pool of doctors has not kept pace, and will not, health experts said. Medical school enrollment is increasing, but not as fast as the population. The number of training positions for medical school graduates is lagging. Younger doctors are on average working fewer hours than their predecessors. And about a third of the country’s doctors are 55 or older, and nearing retirement.

Physician compensation is also an issue. The proportion of medical students choosing to enter primary care has declined in the past 15 years, as average earnings for primary care doctors and specialists, like orthopedic surgeons and radiologists, have diverged. A study by the Medical Group Management Association found that in 2010, primary care doctors made about $200,000 a year. Specialists often made twice as much.

Provisions within the Healthcare Law are expected to increase the number of primary care doctors by perhaps 3,000 in the coming decade - not nearly enough. Communities around the country need about 45,000.

Mr. Corcoran of the California Medical Association also said the state would need to stop cutting Medicaid payment rates; instead, it needed to increase them to make seeing those patients economically feasible for doctors. The private doctor model is disappearing because doctor fees are too low to cover the overhead and allow for a reasonable take home salary. Doctors are instead choosing to retire or become employed by large hospital corporations.

More doctors might be part of the answer as well. Most your doctors will opt for employment models with 40 hour work week. The current system can not train enough physicians.

With Medicine being a high stress occupation, with long work hours, decreasing pay and a broken malpractice system many students are choosing professions outside of health care.

Single vs. Double Bundle Anterior Cruciate Reconstruction (ACL)

2012-09-28T11:35:00.000-07:00

Dr. Tarlow comments: Dr. Fu is the one of the experts in double bundle ACL reconstruction. The fact that he is publishing a prospective study showing similar results with Double Bundle and modern day individualized Single bundle method-{all hamstring autografts}- tells us that both techniques can produce the excellent surgical outcomes that we strive to attain. As a patient you can expect the best outcomes when your surgeon recommends either of these techniques (Conventional single bundle technique is to be avoided-outcomes are inferior).

Double bundle ACL - 2 Tunnels with two strands hamstring graft each tunnel

Individualized Anterior Cruciate Ligament Surgery: A Prospective Study Comparing Anatomic Single- and Double-Bundle Reconstruction

Mohsen Hussein, MD (mhussein@artros.si),
Carola F. van Eck, MD, PhD,
Andrej Cretnik, MD, PhD,
Dejan Dinevski, PhD and
Freddie H. Fu, MD, DSc, DPs

+Author Affiliations

Artros Center for Orthopaedic Surgery and Sports Medicine, Ljubljana, Slovenia
Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
Faculty of Medicine, University of Maribor, Maribor, Slovenia
Faculty of Medicine, University of Maribor, Maribor, Slovenia
Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania

Abstract

Single bundle ACL - 4 strands of Hamstring Graft in a single tunnel

Background: Reconstruction of the anterior cruciate ligament (ACL) has become a commonly performed procedure. However, biomechanical studies have demonstrated that conventional single-bundle ACL reconstruction techniques are only successful in limiting anterior tibial translation but less effective for restoring rotatory laxity.

Purpose: This study aimed to compare the results of single- and double-bundle ACL reconstruction using an anatomic technique, individualized based on the patient’s native ACL size. The authors hypothesized that there would be no difference between the results of anatomic single-bundle (ASB) and anatomic double-bundle (ADB) reconstruction when the surgical technique is individualized.

Study Design: Cohort study; Level of evidence, 2.

Methods: Depending on intraoperative measurements of the ACL insertion site size, patients were selected for either ASB (n = 32) or ADB (n = 69) ACL reconstruction. In all groups, hamstring tendons autograft was used with suspensory fixation on the femoral side and bioabsorbable interference screw fixation on the tibial side. The outcomes were evaluated by an independent blinded observer using the Lysholm score, subjective International Knee Documentation Committee (IKDC) form, KT-1000 arthrometer for anteroposterior stability, and pivot-shift test for rotational stability. The average follow-up was 30 months (range, 26-34 months). There were no statistically significant differences in the baseline demographics of the 2 groups.

Results: There was no significant difference between the ADB and ASB groups for Lysholm score (93.9 vs 93.5), subjective IKDC score (93.3 vs 93.1), anterior tibial translation (1.5- vs 1.6-mm side-to-side difference), and pivot shift (92% vs 90% with negative pivot-shift examination).

Conclusion: Anatomic double-bundle reconstruction is not superior to anatomic single-bundle reconstruction when an individualized ACL reconstruction technique is used.

Rehospitalizations after surgical site infections add millions to health-care costs

2012-09-21T11:19:00.000-07:00

Dr. Tarlow comments: Patient Health Optimization prior to joint replacement surgery (lowering BMI, controlling diabetes, and cessation of smoking) are the cornerstones to the prevention of infections after Knee Replacement Surgery. PHO is a focus of Dr. T and Advanced Knee Care - if we are going to provide you surgical care we want to optimize the chances for success. It is about more than just the money - it is about your well being.

Infected knees are red, hurt, do not bend and sometimes drain liquid

San Antonio, Texas, June 4, 2012 – Preventing further complications in patients who develop infections after surgery to replace a knee or hip could save the U.S. healthcare system as much as $65 million annually, according to an analysis presented today at the 39th Annual Educational Conference and International Meeting of the Association for Professionals in Infection Control and Epidemiology (APIC).

The research team, led by Keith Kaye, MD, MPH, corporate director of Infection Prevention, Hospital Epidemiology and Antimicrobial Stewardship at Detroit Medical Center/Wayne State University, analyzed data from health insurance claims for approximately 40 million insured individuals covered by employer-based health plans. Their goal was to uncover the rate of readmission and the financial impact of surgical site infections (SSI) beyond the initial hospitalization for that diagnosis.

The team chose to follow patients who had received artificial knees and hips because treatment for an infected joint can be prolonged, involving lengthy courses of antibiotics and additional surgeries.

Of the 174,425 patients in the database who underwent hip or knee replacement in 2007, 2,134 (1.2 percent) were hospitalized for a surgical site infection (SSI) within one year following their procedure (in 2008). Of those, 267 (12.5 percent) were subsequently re-hospitalized in the year after the initial SSI hospitalization (in 2009) specifically due to SSI-related issues, for a total of 384 hospitalizations. The data also showed that 870 patients with SSI (40.8 percent) were hospitalized for other reasons labeled "all cause" during the year after their diagnosis, accounting for 1,770 readmissions.

Subsequent rehospitalizations for SSI were associated with an average hospital stay of 8.6 days, costing on average $26,812. Additional all-cause hospital readmissions were associated with an average hospital stay of 6.2 days and a cost of $31,046.

According to the Centers for Disease Control and Prevention, infections develop in about 1 to 3 out of every 100 patients who have surgery.

"The prosthetic joint population was important to study because these patients are particularly vulnerable to adverse events following surgical site infections, leading to unnecessary pain, suffering and medical costs," said Kaye. "This analysis shows the devastation of these infections and probably underestimates the true extent of the problem. Given the government's focus on reducing readmission rates, such complications could likely be a future target for decreased reimbursement."

A goal of the national Partnership for Patients is to reduce hospital readmissions by 20 percent by the end of 2013, as compared to 2010.

"What's important about the analysis by Dr. Kaye and colleagues is the report on the human suffering and financial impact of potentially preventable readmissions associated with SSI and all cause readmissions," said APIC 2012 President Michelle Farber, RN, CIC. "Infection preventionists need to be familiar with healthcare quality incentive programs to demonstrate the value of the infection prevention program to the financial health of their organizations and patient experience."

Lots to Lose: How America's Health and Obesity Crisis Threatens our Economic Future

2012-09-14T11:10:00.000-07:00

A report released by the nonprofit Bipartisan Policy Center offers recommendations for public and private sector promotion of healthy nutrition and exercise to reduce obesity. "Lots to Lose: How America's Health and Obesity Crisis Threatens our Economic Future" states that escalating healthcare costs are the primary driver of an increasing national debt, and obesity-related illness is an increasing portion of healthcare costs. Among other things, the report argues that nutrition and physical activity training should be incorporated in all phases of medical education, and that large, private-sector institutions should procure and serve healthier foods, using their significant market power to shift food supply chains and make healthier options more available and cost-competitive

America needs to address #1 one public health issue

June 5, 2012

Our nation is in the midst of a public health crisis so profound that is it undermining our well-being, our economic competitiveness and even our long-term national security.

Fully two-thirds of Americans are overweight or obese. One-third of American children are overweight or obese. And among children under the age of six, nearly one in five is overweight or obese. Obese people are far more likely to develop chronic diseases like diabetes, hypertension, asthma, heart disease and cancer. Obese children are more likely to have one or more risk factors for cardiovascular disease, to be prediabetic (i.e., at high risk for developing diabetes), and to suffer from bone and joint problems, sleep apnea, and social and psychological problems such as stigmatization and poor self-esteem. They are also very likely to become obese adults. In short, obesity is the most urgent public health problem in America today.

Link to full report: http://www.scribd.com/doc/95949310/Lots-to-Lose-How-America-s-Health-and-Obesity-Crisis-Threatens-our-Economic-Future

What Knee Surgeons Get Paid, and What Patients Think Knee Surgeons Get Paid

2012-09-07T11:04:00.000-07:00

Dr. T (center) and Team performing knee surgery

On average, patients thought that surgeons should receive $16,822 for total knee replacements. Patients estimated actual Medicare reimbursement to be $8,902 for total knee replacements. Seventy per cent of patients stated that Medicare reimbursement was “much lower” than what it should be, and only 1% felt that it was higher than it should be.

In reality, surgeons get paid on average $1,430 for a total knee. Thus patients were off by an order of magnitude in their estimates! The disconnect in public knowledge seems extreme.

In short, patients — the most important part of all of health care policy decisions — have absolutely no clue how much doctors get paid. They think we get paid (or, at least, deserve to) about 10 times more than we actually do!

Jared Foran, an orthopedic surgeon in Denver, is a co-author of a new study called “Patient Perception of Physician Reimbursement in Elective Total Hip and Knee Arthroplasty”. The authors surveyed 1,200 patients to see how much they thought orthopedic surgeons should make and what Medicare actually pays for a hip or knee replacement.

Medical Liability Reform Needed - We All Agree

2012-08-31T10:57:00.000-07:00

Legal System is Increasing Health Care Costs

NEW YORK, May 29, 2012 /PRNewswire/ -- A new nationwide poll finds that heavy majorities of voters across party lines believe that the legal system is increasing health care costs. The survey also found that 66 percent of voters favor taking medical claims out of the current legal system and putting them into new health courts with expert judges. The poll was conducted for Common Good by Clarus Research Group.

Among the poll's key findings are the following:

A strong majority of voters––75 percent––believe "lawsuits and legal fees are a major cause of high medical insurance rates." Eighty-nine percent of Republicans, 76 percent of independents and 62 percent of Democrats agree on this.
Sixty-eight percent agree that "plenty of good doctors are leaving the practice of medicine because of the number of lawsuits and the cost of liability insurance." Seventy-eight percent of Republicans, 64 percent of Democrats and 61 percent of independents agree.
Two-thirds (67 percent) of voters say they believe that "fear of being sued is causing doctors to order unnecessary medical tests and procedures just to protect themselves from possible lawsuits." Seventy-five percent of Republicans, 67 percent of independents and 59 percent of Democrats concur.
Nearly two-thirds (66 percent) of voters support the idea of creating special health courts to decide medical claims. Only 25 percent say those claims should be decided as they are now. There is virtually no difference between Democrats and Republicans on this issue: 68 percent of Republicans, 67 percent of Democrats and 61 percent of independents support health courts.

"Americans know they're paying unnecessary health care costs because our system of medical justice is unreliable," said Philip K. Howard, Chair of Common Good. "It's time to end the waste – tens of billions annually – and create reliable health courts."

The nationwide survey was conducted April 25-26, 2012 by Clarus Research Group, a nonpartisan polling firm based in Washington, D.C. The survey's sample of 1,000 self-identified registered voters has a margin of error of +/- 3.1 percent. Interviewing was conducted through live telephone calls, using both landline and cell calling.

Source: PR Newswire

Viscosupplementation for Knee Arthritis ?

2012-08-24T10:49:00.000-07:00

Dr. Tarlow's opinion - About half of my patients with mild to moderate osteoarthritis of the knee Visco injections report less pain and better function for 6-12 months following a series 3 weekly injections - brand of Visco does not matter in outcome. Patients with severe OA rarely benefit from type of injection.

If the first series of injections help then it is likely a repeat series will be successful. Not all insurers reimburse for this medication - so many patients pay out of pocket for the drug and come to the office for the doctor to inject the drug into their knee.

Another unknown is how and why this medication decreases pain - the mechanism is not clear at this time.

OA is the death of the articular cartilage cells that cover the bone.

Here is a summary of the recent literature review:

Hyaluronic acid has little effect on pain, none on function, new review states

Tuesday, June 12, 2012

It's not good news for baby boomers with arthritic knees: Injections of hyaluronic acid have little effect on pain and no effect on function, according to a new analysis.

Hyaluronic acid -- a lubricant in joint fluid that acts as a shock absorber -- declines with the wear-and-tear type of arthritis known as osteoarthritis. When nonsteroidal anti-inflammatory drugs don't provide relief, doctors sometimes prescribe injections of hyaluronic acid, also called viscosupplementation.

There is no evidence to suggest that viscosupplementation results in any relevant reduction in symptoms in patients with knee osteoarthritis, said study co-author Dr. Peter Juni, professor of clinical epidemiology at the University of Bern in Switzerland.

The U.S. Food and Drug Administration in 1997 approved the injections, which are commercially available from several companies and much more costly than pain relievers.

For the study, Juni's team reviewed 89 studies that compared injections with either a placebo treatment or no treatment. In all, the studies involved more than 12,000 adults aged 50 to 72.

The effect on pain was minimal, and the injections had no effect on functioning, the researchers found.

In some of the studies, the injections reached peak effectiveness at eight weeks, then declined.

"Viscosupplementation therapy for the knee appears to have some transient improvement in a relatively small number of patients for variable periods of time -- most often six to 12 months,"

Look at the pros and cons from a patient's perspective. Many turn to the injections to avoid surgery or medications, which can have their own harmful side effects, he said.

"Some patients, however -- particularly patients with earlier stage arthritis -- benefitted from viscosupplementation for periods of time sufficient to continue the use of this therapy," he said.

Infection Risk After Knee Replacement Skyrockets in Morbidly Obese

2012-08-21T10:19:00.000-07:00

The benefits of joint replacement should be carefully considered since there is a high risk of infection when joint replacement is performed in patients that are morbidly obese (defined as BMI > 30).

Study from July 2012 Journal of Bone and Joint Surgery.

Infection rate if normal weight is 4 in one thousand cases.

Infection rate if morbidly obese is 1 in ten cases.

A morbidly obese person is 25 times more likely to suffer an infection after joint replacement.
These risks are even higher if there is both Diabetes and Obesity.

The mental, physical and monetary cost to treat an infected total joint include minimum 2 more surgeries including removal of implant for a period of months, mobility with a walker, hard to drive and go to work for months, intravenous antibiotics for 4-8 weeks, and cost is at least $50,000 "extra" compared to no infection.

Current best practices recommend advising most patients to optimize body weight and exercise to improve leg function prior to Total Joint Replacement surgery. There are rare exceptions when the benefits of surgery warrant taking such a high risk.

Osteoporotic and Postmenopausal - Online Tool to Explore Options

2012-08-17T10:28:00.000-07:00

Bone mineral density (BMD) is reduced in Osteoporosis - making bones more fragile

“Healthy Bones: A Decision Aid for Women After Menopause,” is a new online tool from the Agency for Healthcare Research and Quality designed to help postmenopausal women explore the benefits and risks of various medications for low bone density. Based on an AHRQ-funded research review, “Treatment to Prevent Fractures in Men and Women with Low Bone Density or Osteoporosis—an Update to the 2007 Report (2011),” the decision aid walks women through a risk assessment, compares medications and other treatments for low bone density, and suggests questions for patients to ask their healthcare providers.

http://effectivehealthcare.ahrq.gov/ehc/decisionaids/osteoporosis/?PC=EHCIT5