Government Forcing Orthopods Into Primary Care? // 500th O-Arm Installed // and More…

500th O-Arm Installed

An “O-Arm” by the way is the orange Popsicle-colored portable imaging machine sold by Medtronic Spine for intraoperative imaging. It lets spine surgeons know—before they leave the OR—that everything was well-positioned. How important is that? According to Eric Epperson, senior director of Public relations & communications for Medtronic Spine, who is paid to make sure we know such things, “The challenge with minimally invasive surgery is that it is more difficult to visualize the anatomy; in addition, there is a strong need to keep radiation exposure to a minimum. Medtronic has installed over 500 O-arm imaging systems globally. This is a technology that works in conjunction with our StealthStation Navigation system. The O-arm provides real-time 3D and 2D images…and there is much less radiation for the surgical staff compared to the alternate fluoroscopy approaches. The solution is similar to the concept of a ‘global positioning system’ in that the surgeon’s instruments are tracked in space and are localized to a ‘map’ of the specific patient anatomy. So, critically, the surgeon is able to confirm the precision of his or her work before the patient leaves the OR. There is no more, ‘Maybe I should have repositioned that screw before patient X left.’ Surgeons have a larger-than-usual field of view; because of this, and the fact that we use flat panel technology, the chance of error is minimized. When the King of Spain needed spine surgery recently, I’m proud to say that he sought out a hospital that had a Medtronic O-arm.”

Government Forcing Orthopods Into Primary Care?

There is some concern and even skepticism out there these days about the disconnect between the number of medical school graduates and residency slots. You might say that Richard Iorio, M.D. is one of the conspiracy theorists. Dr. Iorio is the Dr. William and Susan Jaffe Professor of Orthopaedic Surgery and the chief of adult reconstructive surgery at NYU Langone Medical Center. He tells OTW, “The number of medical school graduates continues to rise, while the number of residency slots has remained frozen for roughly 10 years. This clearly creates competition—not necessarily a bad thing—but it also means that there may come a time when these graduates are struggling to put a career together. And frankly, it’s unclear if the government is interested in rectifying this situation. The fact is that if they can limit the number of residency slots then that could force these graduates into primary care. And with primary care as the key to controlling costs and referrals to specialists in the age of heath care reform, by limiting the number of specialists, the lack of access will ultimately decrease health care expenditures to these specialists. We already don’t produce enough orthopedic surgeons as it is. So, the government may see decreasing access to care for older orthopedic patients as a viable way to save a substantial amount of money. But I’m a cynic…or maybe a realist.”

Genetics of Hip Dysplasia Decoded

Javad Parvizi, M.D., director of research for The Rothman Institute in Philadelphia, tells OTW, “My team and I are working on the genetics of developmental dysplasia of the hip…and we have located the gene. We would have never guessed that this gene could influence joint development. It controls a very specific transcription factor that is critical for the development of the joint; those with dysplasia either lack the gene or the ability to have it expressed. It’s a great story, really. Our work is based on our experience with a large family (70 members) in Utah. We went to their family reunion, rented an X-ray machine, and lined everyone up for DNA samples and X-rays. This has allowed us to sequence this gene (which is for the Caucasians). This means that developmental dysplasia of the hip is a genetic disorder, something never before proven. It also means that this particular gene can be used as a screening when children are growing, thus replacing our currently crude screenings. And if we can detect this condition early then we can intervene to prevent osteoarthritis at a young age.”

Compensating for the ACGME

An orthopedic surgeon who directs a major residency program tells OTW, “The biggest change I’m seeing in graduate medical education is that it is becoming increasingly formalized. Fifteen years ago there was little structure and it was more experience-based where you were exposed to whatever you were supposed to be learning. The ACGME (Accreditation Council for Graduate Medical Education) has altered its focus; it used to concentrate on whether or not the facility had the necessary components for education. Then it switched to looking at whether the educational components were being used well, and now they are moving away from that and towards looking at the finished product, i.e., ‘Are residents adequately educated?’ Along with this they are moving away from worrying about how it’s done. Twenty years ago there was a requirement that you hold resident conferences and then 10 years ago they required that you take attendance. Now they are more interested in if the residents actually learned anything at those conferences.”

“This is all very stressful for residency programs, partly if not totally because for years academic medical centers have run on the efforts of residents. Now with the duty hour restrictions and more rigorous requirements for educating residents it means they are not available to do as much work. The programs have basically handled this by hiring huge numbers of physician assistants. And frankly, there are a fair number of residents who are violating duty hour restrictions and not attending all the conferences. This is a patient care issue because these are often residents who would ideally have more supervision. And as many of us know, there is no evidence that duty hour restrictions improve patient safety. If the ACGME could develop a better means of improving patient safety then the duty hour restriction might be lifted. This restriction is a blunt tool for what they want—patient safety—but related to that is resident fatigue. So ideally you would just focus on fatigue and make programs figure out how they can be assured that residents are not overly tired. Even though the idea was that they would go home and sleep more we know they are not doing that…they’re just doing something else.”

Freddie Fu, M.D. et al. Win Prestigious Hughston Award

The team at Pittsburgh—along with colleagues from Slovenia—has done it…they have walked off with the 2013 Hughston Award, an honor bestowed on the most outstanding paper that appeared in American Journal of Sports Medicine in the year 2012.

The article, “Prospective Randomized Clinical Evaluation of Conventional Single-Bundle, Anatomic Single-Bundle, and Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: 281 Cases With 3- to 5-Year Follow-up, ” is by Mohsen Hussein, Carola F. van Eck, Andrej Cretnik, Dejan Dinevski and Freddie H. Fu. This collaboration between Pittsburgh and Slovenia began almost 10 years ago, at which time Dr. Hussein was a fellow at the University of Pittsburgh in the Department of Orthopaedic Surgery. The team indicates that great lengths were taken to design this level I trial to the highest standards possible. They cite Slovenia as being an ideal country to perform a randomized controlled trial, as it is a socialized medicine system with only three trained ACL (anterior cruciate ligament) surgeons in the entire country. Thus, they found recruitment and follow-up of patients to be excellent.