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Managing Rotator Cuff Tears

Managing Rotator Cuff Tears

For many older surgical procedures that are associated with good provider and patient experiences—including rotator cuff tear repair—the strength of the literature supporting their use is weak because it was often deemed unethical to compare treatments that work with placebo. With their high prevalence and potentially large cost burden, rotator cuff repairs are an ideal topic for a clinical practice guideline. However, when the American Academy of Orthopaedic Surgeons (AAOS) Board of Directors recently sought to develop a guideline, they found that the strength of the literature was poor. Therefore, appropriate use criteria (AUC) were developed based on available evidence from the literature and sound clinical judgment of expert clinicians. Examining Best Evidence In developing the AUC, an AAOS writing panel first identified 432 clinical scenarios that clinicians would likely face among patients with rotator cuff tears. “These were based on factors such as symptom severity and the patient’s overall health,” explains James O. Sanders, MD, AUC Section Leader. “They were also based on whether alcoholism or drug abuse was present, if workman’s compensation could affect the outcome, the size of the tear and whether it was old or new, and the patient’s response to prior treatment.” Potential treatments to consider for each scenario included non-surgical modalities, partial repair and/or debridement, repair, reconstruction, and arthroplasty. After the 2,160 total voting items in the AAOS document were modified, a voting panel reviewed the strength of evidence for each scenario and discussed how they would approach it in practice before voting on the appropriateness of the treatments for these scenarios. Panel members assigned each of the voting items a level of...
Gender Differences in Total Hip Arthroplasty

Gender Differences in Total Hip Arthroplasty

Research has shown that total hip arthroplasty (THA) can significantly improve function and quality of life and reduce pain. THA has yielded excellent results when assessed at 5 to 7 years after the procedure. Despite these successes, there is still ongoing debate about how certain factors relating to patients, implants, surgeons, procedures, and volume affect THA outcomes. The contribution of each of these types of factors is difficult to evaluate independently. The FDA recently provided guidance for the enrollment of women and for conducting sex-specific analyses in device studies, with an emphasis on transparency. “This is an important issue in orthopedics,” explains Monti Khatod, MD. Sex differences in THA are substantial, and industry has already started developing sex-specific devices. Furthermore, THA is more often performed in women than men. Sex-specific risk factors and outcomes have been investigated for most other major surgical procedures, but Dr. Khatod says it is even more important to understand these differences in THA, especially with the location of the femoral head center, size and shape of the femoral canal, and trabecular patterns. “It’s still unclear how anatomical sex differences can influence functional outcomes and implant survivorship,” he says. “While some studies suggest that men have higher perioperative complication and failure rates, others have observed similar failure rates and functional outcomes among men and women.” Taking a Closer Look At Joint Replacement In a study published in JAMA Internal Medicine, Dr. Khatod and colleagues used a large total joint replacement registry cohort of elective primary THA in 46 hospitals within the United States. The purpose of the analysis was to determine whether sex was associated...
Shoulder Arthroplasty for Proximal Humeral Nonunions

Shoulder Arthroplasty for Proximal Humeral Nonunions

Shoulder fractures are common injuries among the elderly, but the management of these fractures can be challenging for physicians. Treatment options include nonoperative modalities, osteosynthesis, and arthroplasty, but patients can still suffer from substantial pain and functional impairment even after receiving these interventions. Nonunions have been frequently linked to bone loss, poor bone quality, and soft-tissue contractures. “In previous studies, surgeons have had difficulty achieving fracture union with internal fixation and bone-grafting treatments in patients with proximal humeral fracture nonunions,” explains Thomas R. Duquin, MD. “As an alternative, unconstrained shoulder arthroplasty has been advocated for treating these nonunions. Unfortunately, research has documented high rates of unsatisfactory results with arthroplasty, especially with regard to functional outcomes.” Study Results on Proximal Humeral Nonunions In the Journal of Bone and Joint Surgery, Dr. Duquin and colleagues recently had a study published that reviewed the results and complications of conventional anatomic shoulder arthroplasty for proximal humeral nonunions. The study also identified factors associated with success or failure. From 1976 to 2007, 67 patients who underwent unconstrained shoulder arthroplasty for proximal humeral nonunions were followed for more than 2 years. The study included 49 women and 18 men with an average age of 64 and a mean duration of 9 years follow-up. Fracture type was assessed according to the Neer rating classification. There were two-part fractures in 36 patients, three-part fractures in 16 patients, and four-part fractures in 15 patients. Hemiarthroplasty was performed in 54 individuals, and total shoulder arthroplasty was done in 13. According to findings, there were 33 excellent or satisfactory results based on a modified Neer rating classification (Figure 1). “For...

A Look at Complications After Total Joint Arthroplasty

Results of a meta-analysis suggest that patients with rheumatoid arthritis (RA) appear to be at higher risk for dislocation following total hip arthroplasty than those with osteoarthritis who have these procedures (odds ratio, 2.16). Patients with RA also had a greater risk for infection following total knee arthroplasty. Abstract: Arthritis & Rheumatism, December 2012....

Total Knee Arthroplasty Among Medicare Beneficiaries

Approximately 600,000 total knee arthroplasties (TKA) are performed each year in the United States, costing about $15,000 per procedure. “TKA has been shown to markedly improve health-related quality of life and functional status and is highly cost-effective,” says Peter Cram, MD, MBA. “The number of TKA procedures in the U.S. has been increasing in recent years due to the surgery’s effectiveness for reducing pain and improving function for our aging population.” This trend, however, may further strain the government, insurers, and patients struggling with the ever-increasing healthcare spending. Despite the important role of TKA in healthcare utilization and costs, few analyses have evaluated recent trends in using these surgeries as well as outcomes associated with them. In an issue of JAMA, Dr. Cram and colleagues had a study published that evaluated longitudinal trends in primary and revision TKA among Medicare enrollees. The analysis involved more than 3 million Medicare patients who underwent primary TKA and over 300,000 who underwent revision TKA. A secondary objective was to examine patient and hospital factors that increased risk for hospital readmission. Significant Increases in TKA The number of Americans undergoing primary and revision TKA jumped substantially from 1991 to 2010, according to findings from Dr. Cram’s study. The volume of initial knee replacements and revisions more than doubled during the study period. Among Medicare beneficiaries, annual primary TKA volume increased by 161.5%, rising from 93,230 to 243,802. Per capita utilization increased by 99.2%, increasing from 31.2 procedures per 10,000 Medicare enrollees in 1991 to 62.1 procedures per 10,000 in 2010. Revision TKA volume increased by 105.9%, rising from 9,650 to 19,871. Per capita...
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