Keeping you up-to-date on recent headlines in orthopedic healthcar.

Investigators cite a lack of evidence supporting use of TENS for knee osteoarthritis ... Clinical researchers announced that despite 20 years of research on the use of electrostimulation techniques for treatment of osteoarthritis in the knee, they are still uncertain whether it reduces pain or physical disability, according to a Cochrane Systematic Review of electrostimulation trials in osteoarthritis. In transcutaneous electrical nerve stimulation (TENS), an electrical current is applied to the skin at the joint to stimulate the nerves in an effort to relieve osteoarthritis pain. The authors reviewed data from 18 small trials that together included 813 patients. According to the studies' findings for physical disability, 29 out of 100 people who received TENS treatment responded to treatment, compared to 26 out of 100 people who received fake TENS treatment or received their usual treatments. There was no difference in pain relief or in the number who dropped out due to adverse effects. "Although some people who have electrostimulation treatment for osteoarthritis of the knee show some improvement, our data suggest that this may not be greater than the improvement experienced by those who receive placebo treatment," lead researcher Anne Rutjes, PhD, of the Institute of Social and Preventive Medicine at the University of Bern (Bern, Switzerland), said. "After two decades of research on the use of these methods, there is still no clear evidence that they work." She acknowledged that data were only available for a few small trials, and many of these were of very poor quality. In particular, most did not provide enough information about the number of dropouts, and some failed to make any mention at all of adverse effects.

Orthopedic surgeons join provider-led electronic prescribing initiative ... The American Academy of Orthopaedic Surgeons (AAOS; Rosemont, Illinois) reported their participation in "Get Connected," a program designed to help more of the nation's physicians and other prescribers use electronic prescribing. Now backed by 17 of the nation's leading medical associations, Get Connected is intended to help physicians and other prescribers take advantage of current Medicare incentives aimed at increasing the adoption and use of e-prescribing. Beginning in 2011, incentives may also be available to physicians and other prescribers who use e-prescribing as part of an electronic health record. These additional incentives fall under the HITECH provisions within the American Recovery and Reinvestment Act. "There are many different activities driving the adoption of electronic prescribing by orthopedic surgeons," said Stephen Makk, MD, Chair of the AAOS Practice Management Committee. "Two key drivers are the CMS-sponsored E-Prescribing Incentive Program and the American Recovery and Reinvestment Act of 2009. Through participation in the Get Connected program, the AAOS goal is to provide members with an expanded resource where they can obtain comprehensive information and support on best practices for adoption of necessary technologies for secure, direct electronic connectivity to pharmacies and payer organizations." During the next four years, Medicare is providing incentive payments to eligible professionals who are successful electronic prescribers, as defined by the Medicare Improvement for Patients and Providers Act (MIPPA). Eligible professionals receive a 2% incentive payment in 2009 and 2010; a 1% incentive payment in 2011 and 2012; and a 0.5% incentive payment in 2013. Beginning Jan. 1, 2009, those physicians using a qualified system to send electronic prescriptions (at the rate defined by MIPPA) started to receive higher levels of reimbursement under Medicare. The focal point of the Get Connected program is an online portal – – where physicians and other prescribers can follow a step-by-step process designed to help them transition from paper-based prescribing to e-prescribing.

Study finds ACL reconstruction on the rise ... Patients who have their anterior cruciate ligament (ACL) reconstructed are more likely to have subsequent knee surgery if they are women or are treated by a surgeon who does a low volume of ACL reconstructions, according to a study in the October 2009 TK issue of The Journal of Bone and Joint Surgery. The study, conducted by investigators at Hospital for Special Surgery (HSS; New York), also found that overall, 6.5% of patients undergoing ACL surgery had to undergo another knee operation within one year. "It is a small minority of patients who need further surgery early on, but that is a lot of trips back to the operating room considering how much surgery is done," said Robert Marx, MD, an orthopedic surgeon in the Sports Medicine and Shoulder Service at HSS. "This is the largest study to look at factors that may affect subsequent surgeries after ACL reconstruction." ACL injuries are common in athletes. Some studies estimate that as many as 175,000 ACL reconstructions are done each year in the U.S. While investigators have studied technical aspects of the surgery and outcomes and safety in small groups of patients, few studies have examined the frequency of reconstruction and subsequent knee surgery in a large population of patients. To remedy this, researchers at HSS turned to the Statewide Planning and Research Cooperative System (SPARCS) database. This database run by the New York State Department of Health provides a census of all hospital admissions and ambulatory procedures within the state of New York. Investigators identified all ACL reconstructions performed between 1997 and 2006; the total was 70,547. They found that the frequency of ACL reconstruction increased from 6,178 in 1997 to 7,507 in 2006, a 21.5% increase. "The rate of ACL surgery went up dramatically during the study period," said Marx. The investigators then tracked how many of these patients had any subsequent operation within one year or subsequent ACL reconstruction on either knee, among other factors. "The SPARCS database lets us look at a very large number of patients with longitudinal follow-up, so we can see what happens to them as opposed to just what happened during hospital admission. We can follow them for a few years," said Marx. The researchers found that the frequency of subsequent surgery on either knee within one year was 6.5% (4,595 patients), and patients were more likely to have subsequent surgery if they were female or treated by a surgeon who performed a low volume of ACL surgeries. "We know that a risk of an ACL tear is much higher in females, between two- to ten-fold, but this is the first study to show that women are at a higher risk of subsequent surgery after ACL reconstruction," Marx said. Investigators also found that 1.9% (1,318 patients) of patients who underwent ACL reconstruction had a subsequent ACL reconstruction within one year. Patients were more likely to have a subsequent reconstruction if they were younger than age 40 and treated at a hospital that performed a low volume of ACL reconstructions.

Wrist fracture patients less likely to be evaluated for osteoporosis ... A study published in the October 2009 issue of the Journal of Bone and Joint Surgery suggests a disconnect between the way wrist-fracture patients and those with a spine or hip fracture are managed and evaluated. The study, conducted in 2007 among 97% of the women in Korea, reviewed the incidence of fractures around the hip, spine, and wrist in female patients age 50 and older and the prescription frequencies of bone density scans for osteoporosis, along with the use of medications for its treatment. "Our review of this national cohort indicates that patients with a wrist fracture are less likely to be evaluated and managed for osteoporosis than those with a hip or spine fracture," stated lead study author Hyunsik Gong, MD, in the Department of Orthopaedic surgery, Seoul National University, Bundang Hospital, Seoul National University College of Medicine (Seoul, South Korea). "Although the health system in the United States is different from that in Korea, physicians treating fractures are the initiators of osteoporosis care in both countries. Women over age 50, who are diagnosed with a wrist fracture should be evaluated for osteoporosis, since they have a higher risk of fracturing other bones." The study found that for women, over the age of 50: only 2.8% of those who had a distal radial fracture, underwent a bone mineral density scan; and only 22.9% were prescribed osteoporosis medication. "Our hypothesis was that physicians who treat fractures of the hip, spine, and wrist have different propensities or practice patterns regarding the evaluation and treatment of osteoporosis," said Gong. "Because patients with a wrist fracture are younger on the average than those with a hip or vertebral fracture, they offer physicians an important opportunity to initiate secondary prevention. We find it disappointing that many orthopedic and hand surgeons who treat wrist fractures choose not to provide osteoporosis evaluation and treatment when, in our opinion, they should do so." The study suggests that one reason that physicians fail to diagnose and treat osteoporosis is clinical inertia. However, the study identified several additional barriers to evaluation and treatment. For instance, the study pointed to the possibility that patients with wrist fractures may have a less serious perception of osteoporosis and thus may be more reluctant to undergo a bone mineral density examination or be treated for osteoporosis. "Women who break a wrist should know about their further fracture risks and the need to be treated accordingly," said Gong. "As a result of this research, I expect more patients with wrist fractures will get proper evaluation and management for osteoporosis."

– Compiled by Holland Johnson, MDD