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All Posts in Category: Knee surgery

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New study of patients receiving physical therapy following total knee replacement raises new concerns over referral for profit

A new study concludes that patients who undergo total knee replacement (TKR) surgery and are referred to a physical therapist (PT) not affiliated with their surgeon’s practice have fewer visits and more individualized, one-on-one care. Conversely, the research showed that those who received physiotherapy services from a clinic owned by their physician had twice as many visits and were provided a less-intensive approach.

The study, e-published ahead of print in the scientific journal Health Services Research, examined whether the course of physical therapy treatments received by patients who undergo TKR surgery differs depending on whether the orthopedic surgeon (OS) has a financial stake in physical therapy services, often called physician self-referral. The authors reviewed 3,771 TKR episodes. Of those, 709 (18.8%) met criteria as self-referring. Of the remaining 3,062 episodes deemed non-self-referring (NSR), 2,215 (72.3%) were cases in which the OS who performed the TKR did not have an ownership interest in physical therapy services. For the remaining 847 NSR episodes, the OS had an ownership interest in physical therapy services, but the patient received services elsewhere.

Key findings included:

  • The duration of episodes of care provided by a physician-owned physical therapy practice were a week longer.
  • TKR patients who were treated in a clinic owned by their OS received an average of 8.3 more (or twice as many) PT visits than those who were treated in a clinic in which their OS had no financial stake.
  • When there is no financial incentive for the OS owner, the episodes of care were virtually identical to those received in a non-physician-owned clinic, making clear the link between financial profit and course of care.
  • Patients who received care in a non-physician-owned clinic tended to receive more one-on-one care than those who were self-referred to their physician’s own physical therapy services. Patients who were self-referred for treatment received less intensive interventions and more group care, an approach that requires more visits and potentially extends recovery time.

“When there is referral-for-profit, and from this data as related to group therapy and an extended number of visits, it stands to reason there is increased risk that the patient’s individual needs are of secondary importance to revenue. This has long been the concern here at the American Physical Therapy Association (APTA), and it is why we have fought so hard, alongside our partners in the Alliance for Integrity in Medicare Coalition, against physician-owned physical therapy services (POPTS),” said APTA President Sharon Dunn, PT, PhD, OCS. “This study provides further evidence that when the bottom line takes precedence in health care the patient loses. A patient’s welfare and recovery should always be the primary focus of treatment.”

Beyond the clinical implications, authors believe their study adds more weight to the argument against the in-office ancillary services (IOAS) exception to the Stark laws – federal legislation that prohibits most self-referral practices in Medicare. IOAS allows physicians to self-refer for several “common sense” or same-day treatments; unfortunately, it also creates loopholes for services that are rarely provided on the same day, including physical therapy, anatomic pathology, advanced imaging, and radiation therapy. Authors write that most research on these exceptions has reached the same conclusion as their own study: “that self-referral results in increased use of services and higher health care expenditures.”

The study was funded by the Foundation for Physical Therapy and was authored by Jean M. Mitchell, PhD, James D. Reschovsky, PhD, and Elizabeth Anne Reicherter, PT, DPT, PhD. Reicherter, who is currently employed by APTA, was with the Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, when the study was conducted.

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Study finds freezing nerves prior to knee replacement improves outcomes

The first study of its kind has found that freezing nerves before knee replacement surgery combined with traditional pain management approaches significantly improves patient outcomes. The results of the preliminary retrospective study led by Vinod Dasa, MD, Associate Professor of Clinical Orthopaedics at LSU Health New Orleans School of Medicine, were published online Feb. 10, 2016, in the journal, The Knee, as an Article in Press.

The study, a retrospective chart review, investigated the cases of 100 patients with advanced osteoarthritis requiring total knee replacement in Dr. Dasa’s LSU Health New Orleans orthopaedic practice. Half of them were treated with standard multiple pain management options, before cryoneurolysis (nerve freezing) was introduced to the practice. The first 50 patients to undergo cryneurolysis in addition to multimodal pain management comprised the treatment group, which was compared to the control group who had standard therapy alone. The treatment and control groups were similar in terms of gender, age and body mass index. The only difference is that the treatment group received cryoneurolysis via an FDA-approved handheld device five days prior to surgery. The KOOS (Knee Injury and Osteoarthritis Outcome Score), PROMS (Patient-reported Outcomes Measurement Information System), WOMAC (Western Ontario and McMaster Universities Arthritis Index) and Oxford Knee Score were used to measure outcomes.

“Patients in the treatment group had significantly shorter hospital stays, were prescribed significantly fewer opioids during the first 12 weeks post-operatively and had significantly fewer knee symptoms,” notes Dr. Vinod Dasa, Associate Professor of Clinical Orthopaedics at LSU Health New Orleans School of Medicine.

The ability to decrease hospital length of stay following total knee replacement should substantially reduce costs for hospitals and payers. In the present study, only 6% of patients treated with cryoneurolysis prior to surgery stayed in the hospital for two or more days compared to 67% of patients who did not receive this treatment. Similarly, almost half of patients treated with cryoneurolysis were discharged on the same day of surgery compared with only 14% in the control group. The shorter length of stay of the patients in the treatment group may be due to better local control of pain and a reduced need for nerve blocks that can impair motor function, as well as reduced use of opioids for pain control, which allows patients to walk and function well enough to go home sooner.

Approximately 600,000 knee replacements are performed each year, and this number is expected to increase in coming years. Although knee replacements usually are very successful in the long term, patients often experience a significant amount of pain during the immediate post-operative period, which can be a major hindrance to effective rehabilitation and restoration of function following surgery.

MNT 12 February 2016

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Muscle Strengthening Aids New Knees

A new study suggests that a carefully focused program of muscle strengthening can make an important difference in how well patients recover after knee replacement.  Patients who underwent six weeks of progressive muscle strengthening aimed at the quadriceps did much better than patients given conventional treatment. The study appears in the February issue of Arthritis Care & Research.  Almost 500,000 knee replacements are done in the United States each year, and patients often report that they still have problems doing things like walking and climbing.  For the study, more than 200 patients were divided into groups and given different treatments about four weeks after surgery.  One received conventional treatment. Another was also given quadriceps strengthening, while a third was given the strengthening and electrical stimulation to make the muscles contract.

While the electrical stimulation did not appear to make a difference, the muscle strengthening appeared to bring the patients back to a level of functioning almost normal for their age.  One of the authors, Lynn Snyder-Mackler of the University of Delaware, said in an e-mail message that knee replacement patients and their doctors should not underestimate the ability “to really improve their function.”

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Caring for Hips and Knees to Avoid Artificial Joints

PROTECT your joints now, or pay later.

That’s the message of today’s column, which could be headlined Joint Economics.

If you are one of the more than 400,000 people a year who have already had one or more hips or knees replaced — or someone who already has no choice but to consider joining their ranks — we offer our sympathies or encouragement or even congratulations, depending on how you are faring. But this column is for people who are not yet destined to necessarily become part of those statistics.

Although the human body has an amazing capacity to repair itself, our joints are surprisingly fragile.  When the cartilage that cushions bones wears away, it does not grow back. Thinning cartilage contributes to osteoarthritis, also known as degenerative arthritis, a painful and often debilitating condition.

Over time, arthritic joints can become so sore and inflamed that they need to be replaced with mechanical substitutes. A result: more pain, at least in the short term, and big medical bills.  Fortunately, you can act to protect your joints now, to reduce your chances of needing to replace them later.  And protect you should. The cost for a new hip or knee — the joints most commonly replaced — is $30,000 to $40,000. If you have insurance, your total out-of-pocket costs will be much less, but may still be $3,000 to $4,000. And don’t forget to factor in all those days of work you will miss before you get your new prosthetic.

Creaky joints are a growing national problem. The population is getting older, more people are overweight, and an increasing number of children and young adults are playing serious sports and getting seriously injured — all factors that contribute to osteoarthritis.

“Arthritis used to show up in people during their late 40s and 50s, now we’re seeing it earlier, like in the 30s and 40s,” said Dr. Patience White, a rheumatologist and the chief public health officer at the Arthritis Foundation.

The total national bill for hip replacements in 2007 was $19 billion, and $26 billion for knees, according to the federal Agency for Healthcare Research and Quality. Those figures are expected to rise significantly in the coming decade, Dr. White said. So protecting your joints will do more than save wear and tear on you and your budget. You could also be doing your part to curtail the national health care bill.  If your joints are still intact, or just beginning to creak, here are some ways to keep osteoarthritis at bay.

CONTROL YOUR WEIGHT The more you weigh, the more pressure on your joints, which can lead to joint damage. When you walk, each knee bears a force equivalent to three to six times the body’s weight. If you weigh a mere 120 pounds, your knees are taking a 360-pound, or more, beating with every step.

Studies have found a connection between being overweight and developing osteoarthritis of the knees, and to a lesser extent the hips. One recent review found that 27 percent of hip replacements and 69 percent of knee replacements might be attributed to obesity.  For reasons not well understood, weight is more of risk factor for women than men.

“A woman’s risk for developing O.A. is linearly related to her weight,” Dr. David Felson, a rheumatologist and arthritis prevention specialist at Boston University School of Medicine, said, referring to osteoarthritis.

“Men who are moderately overweight are not as at high a risk as a woman of the same weight,” Dr. Felson said.

But a woman can substantially lower her risk by shedding pounds. One study in which Dr. Felson was a co-author found that when a woman lost 10 pounds, her risk of arthritis of the knee dropped by half.

GO LOW-IMPACT Although no definitive link has been found between osteoarthritis of the knee and running (or any other sport), sports medicine doctors discourage their patients from running on hard pavement, playing tennis on concrete or activities like skiing over lots of moguls.

“Impact sports put too much stress on the joints, particularly the knees,” said Dr. Donald M. Kastenbaum vice chairman of orthopedic surgery at Beth Israel Medical Center in Manhattan. “These activities may lead to O.A. and they definitely can escalate the progression of the condition.”

If you run regularly, try to do so on a track or treadmill and consider swapping one run a week for something low-impact like swimming, biking, lifting weights or tai chi.

AVOID INJURY Easier said than done, of course. But major injuries, typically the type that require surgery, greatly increase your risk for osteoarthritis.  According to one big study, 10 to 20 years after a person injures the anterior cruciate ligament or menisci of the knee, that person has a 50% chance of having arthritis of the knee.

Those rates are even higher when the injury happens in your 30s or 40s, Dr. Felson said. “As you move into middle age, it’s crucial to avoid sports that predispose you to injury,” he said.  Weekend warriors, who sit at a desk Monday through Friday, and then run or play basketball for five hours straight on the weekend, are at a high risk for injury, and thus for osteoarthritis.

GET FIT It makes sense. The better toned your muscles are, the less likely you are to injure yourself (unless you are also playing football every Saturday morning).  And “building muscles up around joints acts like a shock absorber, spreading stress across the joint,” said Dr. Laith M. Jazrawi, chief of the sports medicine division at NYU Hospital for Joint Diseases. Pilates, moderate weight lifting, vinyasa yoga and swimming are all nonimpact forms of exercise that firm up your muscles without jeopardizing your cartilage.

No definitive link exists between increased flexibility and lower, or higher, rates of osteoarthritis. But some doctors interviewed said they believed that by regularly stretching your muscles you are less likely to injure your joints. It can’t hurt to judiciously stretch your muscles after a workout. And even if it won’t protect your joints from deterioration, it will certainly make your muscles feel better.

BE SKEPTICAL Don’t waste your money on specialized nutrients. Shark cartilage, glucosamine and chondroitin — popular supplements marketed for healthy joints — can be expensive and probably are of limited benefit, many specialists say.

“There’s some evidence to suggest glucosamine and chondroitin sulfate may be helpful in O.A. once it has started, but overall the results are inconclusive,” Dr. Jazrawi said. As for shark cartilage, there is no evidence to suggest that it has any benefit for treating the symptoms or the disease, he said. Joints are like car parts. With proper care and maintenance, they last longer.

New York Times

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Getting a New Knee or Hip? Do It Right the First Time

THERE is nothing like a new hip or knee to put the spring back in your step. Patients receiving joint implants often are able to resume many of the physical activities they love, even those as vigorous as tennis and hiking. No wonder, then, that joint replacement is growing in popularity.

In the United States in 2007, surgeons performed about 806,000 hip and knee implants (the joints most commonly replaced), double the number performed a decade earlier. Though these procedures have become routine, they are not fail-safe.  Implants must sometimes be replaced, said Dr. Henrik Malchau, an orthopedic surgeon at Massachusetts General Hospital in Boston. A study published in 2007 found that 7 percent of hips implanted in Medicare patients had to be replaced within seven and a half years.

The percentage may sound low, but the finding suggests that thousands of hip patients eventually require a second operation, said Dr. Malchau. Those patients must endure additional recoveries, often painful, and increased medical expenses.  The failure rate should be lower, many experts agree. Sweden, for instance, has a failure rate estimated to be a third of that in the United States.

Sweden also has a national joint replacement registry, a database of information from which surgeons can learn how and why certain procedures go awry. A registry also helps surgeons learn quickly whether a specific type of implant is particularly problematic. “Every country that has developed a registry has been able to reduce failure rates significantly,” said Dr. Daniel Berry, chief of orthopedic surgery at the Mayo Clinic in Rochester, Minn.

A newly formed American Joint Replacement Registry will begin gathering data from hospitals in the next 12 to 18 months.  Meanwhile, if you are considering replacing a deteriorating knee or hip, here are some ways to raise the chances of success and avoid a second operation.

EXPERIENCE COUNTS Choose — or request a referral to — an experienced surgeon at a busy hospital. “The most important variable is the technical job done by the surgeon,” said Dr. Donald C. Fithian, an orthopedic surgeon and the former director of Kaiser Permanente’s joint replacement registry.  Ask for recommendations from friends who have had successful implants and from doctors you know and trust. When you meet with the surgeon, ask how many replacements he or she does each year.

VOLUME MATTERS A study published in The Journal of Bone and Joint Surgery in 2004 found that patients receiving knee replacements from doctors who performed more than 50 of the procedures a year had fewer complications than patients whose surgeons did 12 procedures or fewer a year.  The researchers documented a similar trend when it came to hospital volume. Patients at hospitals that performed more than 200 knee replacements a year fared better than patients at hospitals that performed 25 or fewer.

ADJUST EXPECTATIONS Not everyone with joint pain will benefit from a joint replacement.  An implant can help reduce pain and improve mobility if the joint surface is damaged by arthritis, for instance. But a new joint will not help pain caused by inflammation of the surrounding soft tissue, said Dr. Berry, who is also vice president of the board of the American Academy of Orthopaedic Surgeons.  Some people with mildly arthritic joints, for instance, can manage well with the judicious use of medication. “Surgery comes with complications and risks, and should not be approached lightly,” Dr. Berry said.

Joint replacement is not a minor operation. If you have uncontrolled high blood pressure, chronic infection or another serious chronic condition, a joint replacement operation may be too risky a procedure for you. Seek advice from an experienced Orthopaedic Surgeon.

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New Models Of Implants Not Better, Study Finds

A new study suggests that the recent technology for artificial hips and knees did not perform any better than older, less expensive designs.

The study, which draws on data from Australia’s orthopedic registry, covered implants introduced from 2003 to 2007 and was published this week. The findings are significant for patients in the United States because many of the new designs, like so-called metal-on-metal hips, are widely used here. Those implants, which have both a ball and cup made of metal, are expected to fail prematurely in tens of thousands of patients rather than lasting 15 years or more as artificial joints are supposed to do.

The Australian study showed that not a single new artificial hip or knee introduced over a recent five-year period was any more durable than older ones. In fact, 30 percent of them fared worse. The Australian study concluded that both patients and taxpayer-financed health care programs were paying a high cost because surgeons were using newly designed implants, introduced with little test data, over existing designs that had track records.  ”Not only has the introduction of this technology been potentially detrimental to patient care, but the current approach may be an important driver of increased health care costs,” the review concluded.

Dr. Stephen E. Graves, the director of the Australian registry and a co-author of the study, said he believed that surgeons, hospitals and regulators should closely look at the review’s results. In the case of the all-metal hips, some experts say they believe that replacing them may cost companies, insurers and taxpayers billions of dollars.

”There needs to be a careful re-evaluation of current deficiencies in regulation,” Dr. Graves said in a recent e-mail.

The Australian review is part of a special issue of a medical journal, The Journal of Bone and Joint Surgery, devoted to studies that examine the benefits and the limitations of orthopedic registries. While America does not have a registry, the Food and Drug Administration is financing efforts to see whether data from sources like overseas databases and registries run by hospitals here can be used to better monitor device performance.  Many experts argue that such efforts are essential because 700,000 Americans undergo hip or knee replacement every year, and that number is expected to increase sharply as the population ages.  In a registry, information about a patient is entered into a database when he or she receives an implant. Then, when that patient undergoes surgery again to replace that device, more data is added. By looking at large numbers of patients followed in a registry, researchers can tell whether certain device models are failing prematurely at significantly higher rates.

But researchers in England, which has a registry, pointed out in another article in the same medical journal that a product-related disaster had likely already occurred before it was detected in a such a database. As a result, some experts say they believe that there must be greater scrutiny of implants either before or after they go on the market to detect problems earlier.  Another review in the same issue found that the results of published studies that accompany the introduction of new implants could bear little resemblance to registry findings about a device’s success once it went into broader use.  That problem occurs, the review by Australian researchers found, because surgeons involved in the original published reports are often involved in its development and may have a financial stake in them. In addition, such reviews tend to be short term.  Some surgeons say they believe that one type of all-metal implant known as a resurfacing device is permitting some patients to remain more active. However, data indicates that such benefits are limited to one group of patients, namely larger, middle-aged men.

This month, bipartisan legislation was introduced in the Senate that could force manufacturers to track the performance of implants like artificial hips after they have been approved for sale. Proponents of the bill acknowledge that the measure faces an uphill fight.  Both device producers and their allies in Congress have maintained that any additional F.D.A. regulations would slow the development and marketing of innovative products that benefit patients. For his part, Dr. Graves, the Australian official, said he believed that such arguments were misleading.

”The purpose of regulation is not to impede innovation but to ensure safety and effectiveness of medical devices,” he stated. ”This protects patients, but it also protects companies.”

New York Times December 23, 2011

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Chelsea's French defender Kurt Zouma

Chelsea defender Kurt Zouma suffers Anterior Cruciate Ligament injury

Chelsea defender Kurt Zouma is expected to be out of action for approximately six months after suffering a horrific knee injury in the Blues’ draw with Manchester United yesterday.  The France defender was in agony as he landed awkwardly from a challenge midway through the second half of the clash at Stamford Bridge.  The 21-year-old has found his feet again under Guus Hiddink but he’s now expected to miss Euro 2016 following injury to his anterior cruciate ligament.  The defender took to Twitter today to confirm that he requires surgery on his ACL and the recovery time from such injuries spans from between six to nine months.

Metro 16.2.2016

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Lindsey Vonn suffers fractured knee in Soldeu fall

Lindsey Vonn suffered a hairline fracture to her left knee after a fall in Andorra on Saturday but says she could even be fit to race on Sunday.  The American, who has a history of knee injuries, started well in poor visibility but failed to hold a corner in the latter stages of the course and crashed off the piste in Soldeu.  The race was interrupted for around 10 minutes as Vonn lay on the snow surrounded by medical staff and coaches before being transported off the hill on a ski-stretcher.  The 31-year-old was unable to stand and was taken to an Andorra hospital, but despite saying she would not get a scan on the injury until Monday, Vonn is not ruling out competing in Sunday’s super-combined race at the same venue.  “Got caught in the soft snow today and crashed pretty hard. X-rays showed I have a hairline fracture in my left knee and will get an MRI on Monday,” Vonn wrote on her Instagram account next to a picture of her knee with a large ice pack on it.

“I will wait and see how I feel tomorrow to decide if I can race. Will keep you updated.”

The race had been due to start in mid-morning, but was delayed for three hours because of the difficult conditions, with strong winds and snowfall also forcing organisers to lower the start.  Chasing her fifth title, Vonn is leading the overall World Cup standings and was 23 points clear of Lara Gut of Switzerland ahead of the Soldeu race.  She claimed her 76th World Cup victory last month, taking her closer to the overall record of 86 held by Sweden’s Ingemar Stenmark.  The race was won by Italy’s Federica Brignone who went out early before the snowfall increased in intensity.  She clocked 57.33secs on a shortened course, 0.13secs clear of American Laurenne Ross and 0.37secs better than Tamara Tippler of Austria.  “When I went down it was really good,” Brignone said. “It was not the best conditions for the best racers, but I took advantage of my luck.”  Gut could only finish in 16th place, meaning that she took 15 points to move to within eight points of the stricken Vonn in the standings.

Sky News 27/02/16

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