Faculty Bibliography

Reimbursement continues to decrease for orthopaedic surgeons specializing in total joint arthroplasty (TJA). Practice information from the Medical Group Management Association (MGMA) Cost Survey and Private practice Compensation Survey and CMS locality reimbursement data was used to develop a practice model for a TJA specialist performing 300 TJA per year (66% knees, 33% hips, 15% revision surgery), evaluating 3000 outpatient visits per year based on, current Medicare reimbursement rates. Our model shows that the anticipated physician compensation is well below the mean compensation reported for a TJA specialist irrespective of geographic location. When MGMA practice expense data are applied to the Medicare-only model, the salary level is unsustainable. Further decreases in Medicare Part B reimbursement will only worsen the disparity.

The aging baby boomer generation will soon start using tremendous orthopedic surgical resources. This group has also been identified as a group at high risk for having undiagnosed hepatitis C virus (HCV) infection. We conducted a study to assess the prevalence of HCV among orthopedic surgery patients at our institution-using their demographic data to determine whether they represent a unique cohort at high risk for having undiagnosed HCV. We estimated that we operated on as many as 233 patients with undiagnosed HCV in 2011. A cost-effective, universal preoperative HCV screening program may reduce the risk for occupational exposure in orthopedic surgery and significantly benefit public health by bringing undiagnosed patients to treatment. A robust screening program requires several ethical considerations. By offering routine screening to patients, orthopedic surgeons have an opportunity to maintain intraoperative safety and improve the health of the public.

BACKGROUND: Health care payers, including the federal government, increasingly base reimbursement on quality. Payers consider readmission rates after total joint arthroplasty an indicator of quality. The Patient Protection and Affordable Care Act contains provisions that preclude payment of hospital cost associated with joint arthroplasty readmissions occurring within 30 days of discharge. This study evaluates the readmission rates and the incidence of "never events" after inpatient shoulder arthroplasty procedures. METHODS: A retrospective view of all shoulder arthroplasty was performed from 2005 to 2011, with specific emphasis on the readmission rate 30, 60, and 90 days after the procedure. The incidence of never events as defined by the Centers for Medicare and Medicaid Services was also analyzed. RESULTS: During the study period, 680 shoulder arthroplasty procedures were performed. Overall readmission rate was 5.9%. For hemiarthroplasty (HA), total shoulder arthroplasty (TSA), and reverse total shoulder arthroplasty (RTSA), 90-day readmission rates were 8.8%, 4.5%, and 6.6%, respectively. Readmission rates within 30 days of admission were significantly more common for HA and RTSA compared with readmission rates after 30 days. There was a 1.0% incidence of never events, and the incidence associated with each of the 3 arthroplastic procedures did not differ significantly. CONCLUSION: Readmission within the first 90 days after shoulder arthroplasty occurred in 5.9% of patients. There was a 1% incidence of never events. In addition, most readmissions after HA and RTSA occurred within 30 days of discharge. As health care expenditures become more closely scrutinized, readmission rates after shoulder arthroplasty will become increasingly important.

Recent evidence suggests a substantial rise in the number of revision total joint arthroplasty (TJA) procedures performed. The New York State SPARCS inpatient database was utilized to identify revision total shoulder, knee, and hip arthroplasty procedures between 1993 and 2010. Yearly incidence and related epidemiology were analyzed. A total of 1,806 revision TSA, 26,080 revision TKA, and 35,254 revision THA cases were identified. The population-based incidence of these procedures increased 288%, 246%, and 44% respectively (P<0.001). Revision burden for hip arthroplasty decreased from 16.1% in 2001 to 11.5% in 2010 (P<0.001). The rates of revision TSAs and TKAs increased at a substantially faster rate than that of revision THAs. Revision burden for hip arthroplasty steadily has decreased since 2001.

When performing revision shoulder surgery, it is important that the surgeon understands why the index procedure failed and has a clear plan to address problems in the revision procedure. The most common cause of failure after anterior instability shoulder surgery is a failure to treat the underlying glenoid bone loss. For most defects, a Latarjet transfer can effectively restore anterior glenoid bone stock and restore shoulder stability. Persistent anterior shoulder pain after rotator cuff surgery may be the result of missed biceps pathology. This can be effectively treated via a biceps tenodesis. The most difficult failures to treat after acromioclavicular joint reconstruction surgery are those involving fractures of either the coracoid or the clavicle. Clavicle hook plates can be used as supplemental fixation during the treatment of these fractures to help offload the fracture site and allow healing while restoring stability to the acromioclavicular articulation. A failed hemiarthroplasty for a proximal humeral fracture frequently results when the tuberosities fail to heal correctly. This complication can be avoided by paying close attention to the implant position and the tuberosity fixation. If hemiarthroplasty is unsuccessful, the patient is best treated with conversion to a reverse shoulder arthroplasty.

The unsustainable rising cost of medical care is creating financial pressures that will critically alter the way that health care is paid for and delivered. Limited resources dictate that physicians must become more efficient at providing high quality care. In an effort to provide financial incentive for delivering quality care, the federal government instituted value-based purchasing to transform Medicare from a passive payer of claims to an active purchaser of medical care. Healthcare providers must follow the basic tenants of certain quality principles to maximize reimbursement under the value-based purchasing system.

The relationship between pharmaceutical and biomedical technology companies (industry) and medical practitioners has been a topic of discussion and concern for several de- cades. The large monetary payments and extravagant gifts to physicians from these companies have been regulated and largely stopped; however, there still exists an active rapport between physicians and industry. Little formal instruction is given to medical students and residents on what constitutes a conflict of interest when entering these business partnerships. In this study, we presented a set of scenarios depicting industry-physician interactions to medical students, orthopaedic surgery residents, and attending physicians and asked them to decide whether a conflict of interest is depicted. Our goal was to determine whether a disparity exists in the ability to identify conflicts of interest across the levels of training. Of 200 potential participants, 70 provided responses to the survey (35%). Thirty-five (50%) were attending physicians, 18 (25.7%) residents, 12 (17.1%) medical students, and 8 (11.4%) de- clined to provide level of training. There was no significant difference in the ability to identify a conflict of interest across seniority level for the 13 questions. Our results suggest that both medical students and resident physicians are able to identify which interactions with industry pose a possible conflict of interest as accurately as attending physicians can.

BACKGROUND: The purpose of this study was to examine functional outcomes following ORIF of displaced proxi- mal humerus fractures in patients who received brachial plexus blocks compared to those who underwent general anesthesia. METHODS: We retrospectively reviewed prospectively col- lected data on 92 patients. Patients were grouped according to anesthesia type: regional interscalene brachial plexus block, with or without general anesthesia, or general anes- thesia alone. Patients were asked to complete the Disabili- ties of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion assessments at a minimum of 6-month follow-up. Plain radiographic films were obtained to assess fracture healing. RESULTS: Forty-five (48.9%) patients with 45 proximal humerus fractures received a regional anesthetic, while 47 (51.1%) patients with 48 proximal humerus fractures had general anesthesia. No significant differences existed in demographic information or fracture type. DASH scores at the most recent follow-up were significantly better in the regional block group (38.6) compared to the general anes- thesia group (53.1) (p = 0.003). The regional block group had significantly better passive and active forward elevation and external rotation range and equivalent internal rotation (p = 0.002, 0.005, 0.002, and 0.507, respectively). CONCLUSION: Patients who received regional anesthetic via a brachial plexus interscalene blocks had better functional outcomes and range of motion at the most recent clinical follow-up. Regional anesthesia provides patients with pro- longed postoperative pain relief, which may allow for early mobilization, increasing the likelihood that the patient's function and range of motion will return to baseline.