HSS at Rio Olympics; Ortho Hospitals Shorten Arthroplasty LOS?; New Tool for Avoiding Avascular Necrosis

HSS Gave Its Best for Olympic Athletes in Rio

When an Olympic athlete in Rio suffered an orthopedic injury this summer, the best were on hand to offer their expertise. Hospital for Special Surgery (HSS) has a tradition of working with the U.S. Olympic Committee. In 2013, HSS was named the first National Medical Center of the USOC’s National Medical Network.

In addition to providing onsite care, Hospital for Special Surgery developed a Sports Emergency Curriculum for volunteer health personnel at the Olympic Games in Rio de Janeiro (CME credits are still available). Five online video courses address a number of topics, including acute medical illness; on-site orthopedic emergencies; athletic injuries occurring on the field; the doping control process; and how to create an emergency action plan.

Scott Rodeo, M.D., co-chief emeritus of the Sports Medicine and Shoulder Service at HSS and chairman of the Sports Medicine Committee for the United States Olympic Swim Team, came up with the idea for the courses during discussions with Dr. João Grangeiro, the Brazilian physician who is chief medical officer for the 2016 Rio Games.

Some topics included: Common Medical Issues: Management during Competition Time; Management of On-Site Orthopedic Emergencies: Lacerations/Open Wounds, Fractures and Joint Dislocations.

Dr. Rodeo told OTW, “I put together the list of topics based on the knowledge base that is required for a physician who will be taking care of athletes. The overall goal was to provide a broad overview of fundamental sports medicine information.”

Asked what sort of injuries he treated, Dr. Rodeo noted, “We typically take care of a mix of both ‘medical’ issues and musculoskeletal injuries. The medical issues include upper respiratory tract infections, sinusitis, sore throats, earaches, gastroenteritis (travelers’ diarrhea), and rashes.

“The musculoskeletal injuries that are seen depend very much on the specific sport and the type of athlete. For example, in swimmers we may see exacerbations of pre-existing conditions such as overuse shoulder pain, low back pain, muscle soreness, etc. There is also a surprisingly high incidence of jammed fingers and even finger fractures from striking the hand vigorously on the wall at the finish of a race. In other sports where there is the potential for contact or collision (such as judo, karate, cycling, etc.) we may see acute fractures, soft tissue contusions, joint subluxations, and even concussions.

“As a team physician you have to be able to take care of a wide variety of injuries and illnesses. As a physician gains experience with a specific sport, they become well-versed in the types and patterns of injury germane to that sport, and that aids their ability to make an accurate diagnosis and provide effective and timely treatment.”

Orthopedic Specialty Hospitals Reduce Shoulder Arthroplasty LOS

New research performed at the Rothman Institute of Orthopaedics and Methodist Hospital–Thomas Jefferson University Hospitals in Philadelphia has found that length of stay (LOS) following shoulder arthroplasty was significantly shorter than at a tertiary referral center.

Surena Namdari M.D., M.Sc., associate professor of Orthopaedic Surgery at the Rothman Institute told OTW, “As a large private practice orthopaedic group that is affiliated with an urban, academic general hospital, we are able to investigate care provided in different practice settings. Given that surgeons within our shoulder and elbow division operate at both an orthopaedic specialty hospital as well as a general hospital, we are in a unique position to determine the advantages and disadvantages of performing shoulder arthroplasty in each of these care environments.

“As there has been recent controversy regarding the need for specialty hospitals, we sought to examine how utilization of an orthopaedic specialty hospital affects length of stay after primary shoulder arthroplasty when matching patients for demographic factors, procedural variables, and comorbid conditions.

“The results of this study suggest that selective utilization of an orthopaedic specialty hospital may be an effective method of reducing length of stay after shoulder arthroplasty. A cohort of patients from the orthopaedic specialty hospital, matched with a nearly identical cohort of patients from the general hospital in age, gender, body mass index, medical comorbidities, insurance type, and discharge destination, had an hospital length of stay that was more than half a day shorter (0.54 day) during the same time period.

“It is important for the reader to know that, during the study period, the Rothman Institute had majority ownership stake in the orthopedic specialty hospital discussed in this manuscript and a co-management arrangement for management of the musculoskeletal product line at the tertiary referral center (Methodist Hospital–Thomas Jefferson University Hospitals) discussed in this manuscript. The tertiary referral center also owned a minority ownership stake in the orthopedic specialty hospital.

“We believe that our retrospective study is hypothesis-generating.

“Based on the findings, we speculate that utilization of an orthopaedic specialty hospital for carefully selected patients may have potential clinical and financial benefits through significantly decreased hospital length of stay.

“The role for orthopaedic specialty hospitals in the changing healthcare economy is currently not clearly defined, but the current legislative climate limits further expansion of physician-owned specialty hospitals. It is our hope that the results of this study open the door for further investigation into the role that specialty hospitals may play in safely meeting increasing healthcare demands, while containing costs.

“The reason for this decreased length of stay is likely multifactorial and may result from fast-track rehabilitation, strict disposition protocols, and more effective establishment of patient expectations for discharge at a specialty hospital. The additional utilization of a nurse navigator to help guide discharge planning and disposition in the preoperative period may further improve the efficiency of both an orthopaedic specialty hospital and a high-volume tertiary care center for timely discharge. We believe that utilization of both a tertiary care hospital and a specialty hospital within a single healthcare system allows for optimal demand-matching of patients to the most clinically appropriate and cost-effective setting.”

New Tool for Avoiding Avascular Necrosis

After fixation of femoral neck fractures there is always the chance that patients will develop avascular necrosis of the femoral head.

Michael J. Weaver, M.D. an assistant professor at Harvard Medical School and program director of the Harvard Orthopaedic Fellowship, along with his colleagues, undertook a retrospective study of 120 patients treated for a femoral neck fracture.

He told OTW, “I was in clinic seeing patients with one of our residents, Beverly Ting, and we saw a young patient with a displaced femoral neck fracture in follow-up. I noticed the head was radiolucent, and commented that this may represent a finding similar to Hawkin’s sign. The blood supply to the femoral head must be intact for the patient to develop disuse osteopenia during a period of non-weight bearing. While it made sense clinically, we found little previous research into the area and so designed a study to evaluate the phenomenon better.

“We found that patients who have had femoral neck fracture fixation tend to develop disuse osteopenia if they go on to heal, while those that have problems with nonunion or osteonecrosis tend to have relative sclerosis of the femoral head—indicating that at the time of injury or surgery the blood supply was damaged.

“Using this tool allows surgeons to provide useful prognostic information to their patients. If there is disuse osteopenia at their 6-week visit, the patient will almost always go on to heal uneventfully and without osteonecrosis. Conversely, I council patients with relative sclerosis, that there may be problems with healing and I follow them more closely.

“This study provides another tool to help prognosticate patients with femoral neck fractures. Previous studies into this rely on intra-operative assessment such as drilling small holes in the femoral head to look for bleeding. It is easy to apply and involves only looking critically at routinely obtained X-rays.

“One of the most rewarding facets of academic practice is the chance to work with residents. I have found that, as in this case, the stimulation and daily interaction makes work more fun, and can inspire studies such as this one.”