Tuesday, January 24, 2012

Dr. Henry Finn: Top 3 Clinical Concerns for Orthopedic Surgeons in 2012

Written by Laura Miller | January 23, 2012  From Beckers 

1. Developing treatment algorithms for problematic orthopedic implants. Research and development is slow in orthopedic surgery, and even when new devices are approved for use, they may have an unforeseen negative impact on patients. Through international joint replacement registries, orthopedic surgeons are able to detect trends in implant failure faster than before, and researchers are now studying these failures to determine which patients are at high risk and how patients can be treated better in the future.

One recent example is metal-on-metal hip replacements; almost all major orthopedic device companies have a metal-on-metal hip implant on the market despite the recall of DePuy's MoM implant in mid-2010.

"The metal-on-metal hip bearing replacements were done in younger patients as a first hip replacement with the hopes they would last longer," says Dr. Finn. "While that has been the case for certain implants, we are also seeing a rash of unexpected complications, most frequently in menopausal women. If the implants are slightly mal-positioned, they could cause a catastrophic reaction with damage to the soft tissue and bone. The damage makes revision surgery exceedingly difficult."

Dr. Finn focuses on revision surgeries and often sees patients from around the country who are seeking his help for problems following their index joint replacement. However, if he can't identify a clear reason for a revision, Dr. Finn is more cautious about moving forward with surgery.

"The algorithms for patient care in this instance are still being developed," he says. "A patient might come to me who doesn't have criteria for a revision surgery, but their hip doesn't feel right or they have elevated serum ion levels. I am hesitant to do a revision surgery without the appropriate criteria, which we are still in the midst of developing."

2. Continued struggle to prevent thromboembolic disease.
For several years, orthopedic surgeons have been keenly aware of the risks associated with deep vein thrombosis and more than willing to follow the guidelines for preventing such a complication. However, there are new — and potentially conflicting — guidelines available for surgeons heading into 2012. In Sept. 2011, American Academy of Orthopaedic Surgeons released updated guidelines for preventing thromboembolic disease. Among the points discussed in the guidelines was the use of pharmacologic agents and mechanical compressive devices, which can work well or poorly depending on the situation.

"We are always walking a tightrope with the medications we use to prevent thromboembolic disease," says Dr. Finn. "The more we anticoagulate the blood to prevent clots, the higher risk there is for bleeding complications. There have been guidelines by other areas of medicine that put orthopedic surgeons in a compromised position because they felt like if they didn't use blood thinners at a high level, they were putting their patients at risk. The new AAOS guidelines take evidence-based medicine into consideration."

The AAOS guidelines make recommendations based on cited studies and give the grade of the recommendation (inconclusive, weak, moderate or strong) based on the quality of the studies cited for the recommendation. This way, orthopedic surgeons can discuss the guidelines as they pertain to each individual patient's situation and follow them according to their expertise.

"We all want to prevent thromboembolic disease, but we don't want to cause additional problems by trying to prevent it," Dr. Finn says. "The AAOS guidelines give us more leeway to customize our thrombomembolic prophylaxis without fear that we aren't following the strict guidelines. It has given us the opportunity to practice the art of medicine instead of following a strict cookbook developed in another field of medicine."

3. Fewer incentives exist for even beneficial simultaneous joint replacements. Some suggest the logical trend for elective orthopedic surgery during tough economic times would be simultaneous joint replacements — patients only have one period in the OR for surgery on both joints and while the recovery period might be longer than patients undergoing single joint replacements, they won't have to undergo the same process again for the second joint. However, Dr. Finn has seen the number of simultaneous joint replacements decreasing, partially because reimbursement incentivizes providers to deliver two episodes of care instead of one.

"From a purely financial standpoint, hospitals and physicians are motivated not to do simultaneous replacements," says Dr. Finn. "Some literature shows there is a significant increased risk to performing the simultaneous procedures, but if the patient is selected appropriately and they have the right pre-operative work-up, they can have good outcomes."

In his experience, Dr. Finn has found patients with deformity and contractures can have better outcomes with simultaneous replacements because the untreated joint could have a negative impact on the corrected side. "For patients with flexion contractures, if you correct it on one side and not the other, they are less likely to keep it corrected because of their biomechanics," says Dr. Finn.

Henry Finn, MD, FACS, medical director of the Chicago Center for Orthopedics at Weiss Memorial Hospital and professor of surgery at the University of Chicago

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