I Chose the Right Field

As I rotate on non-orthopaedic rotations, I am constantly confirming my decision to choose orthopaedics.  I know that I'm rotating through these services for a reason, and each patient that I take care of provides an important learning opportunity.  That said, at the end of a rough month on a general surgery or non-surgical rotation, I'll take ten tough orthopaedics days over these other rotations any day.

There are many people that I have taken care of over the last six months whom I will remember for the rest of my career.  Not to mention, many lessons that I will keep with me.  In addition to the patients, off service rotations are important because they give you an insight into how other services operate.  You get an opportunity to meet the residents and attendings on other services and develop an understanding of what is and what is not an appropriate reason to request consultation.  I also enjoy getting  into the operating room with other surgeons.  There, I have been able to pick up a variety of important surgical techniques that will make me a better surgeon.

Own the Bone: Osteoporosis and the Orthopaedic Surgeron

As orthopaedic surgeons, we see a lot of patients who have fragility or osteoporosis related fractures.  These fractures are defined as those that occur from a standing height and are pathologic fractures.  Common fragility fractures include vertebral body compression fractures, femoral neck fractures, and distal radius fractures.  It has been estimated that 1.5million osteoporosis related fractures occur annually, to the tune of approximately $10 billion.  Hip fractures in osteoporotic individuals increases the risk of death in the next year by 10-30%.  Individuals who present with one fragility fracture are at increased risk of suffering from another fracture in the future.  In fact, this and age are the two most important non-modifiable risk factors for osteoporosis related fracture.

Osteoporosis is the result of an imbalance in bone metabolism.  In the physiologic system, bone is constantly being broken down and repaired by a very tightly controlled interplay between osteoblasts (bone forming cells) and osteoclasts (bone resorbing cells).  This interplay is modulated by a variety of hormones including parathyroid hormone, calcitonin, Vitamin D, estrogen and testosterone, just to name the most important.

There are two types of osteoporosis:  primary and secondary osteoporosis.  Primary osteoporosis is the most common and is related to menopause (or loss of estrogen) or extremes of age (also known as senile osteoporosis).  Secondary osteoporosis  is the result of a disease process such as multiple myeloma or endocrine imbalance.  Secondary osteoporosis can also be caused by exogenous corticosteroid use, even at doses as low as 10mg daily, although some may not argue this is not a necessarily low dose of prednisone.

Because of the morbidity and mortality of osteoporosis related fractures, not to mention the cost of care, appropriate individuals should be screened for the diagnosis of osteoporosis.  This includes all women over 60 years of age, men over seventy, and individuals over 50 at increased risk for osteoporosis:  those with previous fragility fracture, family history of fractures, frailty, low BMI, and treatment with medications such as corticosteroids, anticonvulsants, long-term heparin use, chemotherapeutic/transplant drugs, hormone/endocrine therapies, lithium and aromatase inhibitors.  Of course, all individuals presenting with suspected fragility fractures should also be screened for osteoporosis, either in the acute setting or as an outpatient soon after their discharge from the hospital.

Screening is achieved through a variety of modalities, most common being dual energy x-ray absorptiometry (DXA).  This radiographic test is used to asses bone density in the hip and spine.  This density is then assigned a t-score and a z-score.  The t-score is a comparison to the bone density of healthy young adults.  The z-score is a comparison to age and sex matched individuals.   Most commonly, the t-score is used to make a diagnosis of osteoporosis.  A t-score greater than -2.5 standard deviations (SD) from the mean is considered to be significant enough to make the diagnosis of osteoporosis.  T-scores from -2.5 to -1.5 SD are considered to be diagnostic for osteopenia.

Individuals who present with fragility fractures should have a laboratory work-up to rule out secondary causes of osteoporosis.  These studies include CBC with differential, complete metabolic profile including alkaline phosphatase, TSH, and Vitamin D levels.  Other studies to consider include serum protein electrophoresis (SPEP), 24-hour urinary calcium, parathyroid hormone, testosterone (in males), and many others.

In addition to treatment of the fracture, individuals found to have osteoporosis should be undergo treatment to prevent further bone loss and, in the ideal world, promote a more physiologic bone remodeling to occur.  Those who smoke or drink alcohol excessively should be counseled to stop.  Post-menopausal women should receive between 1200-1500mg of calcium daily.  Adults greater than 50 years of age should receive 800-1000 IU of vitamin D3 daily.  Individuals with osteoporosis should be encouraged to exercise and should undergo evaluation for fall risk.  This often includes a visit to the home and scrutiny of medication lists for medications which may increase risk of fall.  Lastly, medications intended to alter the course of the disease process such as bisphosphanates and estrogen therapy, among other, should be prescribed.  This will often entail consultation with a primary care physician or endocrinologist.

As i mentioned in the title of this post, the American Orthopaedic Association has started a campaign that they call Own the Bone.  This initiative was designed to increase awareness and encourage orthopaedic surgeons to take a more active role in the prevention, diagnosis and treatment of osteoporosis.  Of course, the management of osteoporosis requires a multi-disciplinary approach, but the catalyst, unfortunately, for treatment is often the first diagnosis of a fragility fracture.   One observational study published in The Journal of Bone and Joint Surgery (JBJS)  by Dell et al. outlined a process by which a group in the Kaiser system was able to decrease their incidence of hip fractures by 38% (970 fractures) using a multi-disciplinary screening approach.  If the cost of treating one fracture is estimated at $30,000, that amounts to a total savings of over $29million.

Next time you see a patient with a hip fracture, think beyond three screws versus intrameduallary nail.  Start the process to rule out osteoporosis.  Consult medicine colleagues to assist in the diagnosis and management of the disease.  When seeing patients in the office for non-fracture care, identify and encourage screening in appropriate individuals.  This is a way we can have a significant impact on the life expectancy and quality of life of our patients.

Sources


Dell et al.  "Osteoporosis Disease Management:  What Every Orthopaedic Surgeon Should Know."  JBJS.    
     2009;91  Suppl 6:79-86.
Jacobs-Kosman et al.  "Osteoporosis."  Emedicine:  Rheumatology.  
     http://emedicine.medscape.com/article/330598-overview 
Lucas and Einhorn.  "Osteoporosis:  The Role of the Orthopaedist."  JAAOS.  1993;1:48-56.

The End of Intern Year

The end of intern year  is in sight.  Three months left, and then a new set of interns will be here to take over the painful task of being the ward secretary.  Second year, however, may be more painful than the first.  This is the time that you are supposed to become an orthopaedic surgeon.  The amount to learn is incredible.  I don't mind some pain, however.  After all, no pain, no gain!

With that, congrats to all who matched.  I'm looking forward to your arrival.

The Value of Communication

I work at a large academic medical center.  To officially consult a service, you have to place an order into our EMR.  A lot of times, teams will put the consult order into the computer, but they won't call to discuss their consult.  For example, when I was doing ortho, I would get a call from a ward secretary to inform me of a consult that was placed 30 minutes ago:  'rule out nec fasc' or 'rule out compartment syndrome.' 

Nec fasc is shorthand for necrotizing fasciitis, more commonly known as flesh eating bacteria.  This is not a diagnosis that should be taken lightly, nor should it wait 30 minutes to be seen!  If the patient really has necrotizing fasciitis, and you leave them for another 30 minutes, they could lose a limb, or worse, their life.  Compartment syndrome is the same sort of situation.  These are examples of orthopaedic emergencies, situations when a consultant should drop what they are doing and go see the patient immediately.  Granted, the yield for these consults is somewhat low, but if you're concerned enough to worry about something that is considered an emergency, you should call and talk to the person who will be doing the consult directly.  Imagine if I placed a computer consult to the cardiologist that said 'rule out ST elevation MI,' and then allowed the patient to lay in their bed for the next 20-30 minutes waiting for the ward secretary to notice the order on the printer and call the consult!

It's not just emergent consults, however.  If another service wants me to come and see a patient, I'm always happy to.  I'll never refuse a consult.  I do, however, appreciate a phone call to hear the story first hand.  Not only do I like to hear the story, it's always easier to understand the question when you can ask questions back.  If imaging needs to be ordered, I can make sure I have everything I need to take appropriate care of the patient.

Communication, however, is a two way street.  Common sense would say that when you are finished with a consult, you should call the consulting service and discuss your recommendations.  Sure, the recommendations are scribbled on the chart or dictated and won't be available to read for another 6-8 hours.  Calling gives the consultant the ability to explain their plan and the thought process behind that plan.  It provides an opportunity for the person who placed the consult to ask questions.  Most importantly, it makes sure everyone is on the same page.

Too many times, especially in a large medical center, the plan gets confused.  One hand doesn't know what the other is doing.  Each individual team is making recommendations that contradict the other.  In the end, the patient and their family becomes confused and frustrated, and that is a recipe for disaster.

Ring Enhancing Lesions

 

Although I'm supposed to be talking about orthopaedic surgery stuff on this blog, it's kind of hard to gather good material when you aren't actually seeing patients with musculoskeletal problems.  

This is a case that I saw during an off service rotation that I think almost everyone would find interesting.  It's the true House sort of mystery.  

I've been unfortunate enough to see two cases like this during my short medical career.  Each time, the patient presented the same way.  They were brought to the ED by a family member because of strange behavior.  They were both having trouble with memory and were acting strangely.  Neither was able to really communicate.  They would answer questions with short phrases.  One was getting confused and had become incontinent of both stool and urine.  One had a CT scan (without contrast) that was read as negative.  The other got a head CT with and without IV contrast which showed some ring enhancement.  Both ended up getting MRI scans that looked similar to the above picture, which I stole from the interweb.

One patient was found to have metastatic breast cancer.  The other, at least to the point I stopped taking care of them, remains a medical mystery.  Although, trust me, the neurologists, ID docs, and probably many other specialties by this point are on the case.

For those wondering, the differential diagnosis for ring enhancing brain lesions is not terribly long.  I found this case at Medscape as a good example of the presentation.  They provide the pnemonic MAGIC DR to help remember the DDx:  metastatic disease, abscess, glioma, infarction, contusion, demyelination, and resolving hematoma/radionecrosis.  

One of the most interesting categories is probably abscess.  Their are three classic infections tested on the boards:  toxoplasmosis and CMV in immunocompromised individuals and neurocysticercois. I think that cysticercosis is probably the most interesting, but that's just me.

Cysticercosis is an infection in which an individual (usually from Mexico in the test question) eats undercooked pork and then begins acting strangely.  The patients experiences these symptoms when the pork that they ingested is infected with tapeworm (Taenia solium) eggs.  The eggs hatch and the larvae burrow their way through the lining of the intestines.  They then find their way into the circulation and are then free to migrate throughout the body.  Their most common stomping grounds include the musculature, brain parenchyma and the eyes.  In the eye, if the larvae are alive, you may actually be able to see them moving around in the eye.  Treatment is with either antihelmenthic drugs like albendazole or surgical removal.

What lessons can we learn from this case?  1)  Always cook your pork.  2)  If a patient presents acting strangely, you should think about ordering your head CT with and without IV contrast.

Syndrome Unrealistic Expectations (SUE)

I did an exhaustive (Google) search, and didn't find this, so I'd like to proclaim myself the first to describe the Syndrome of Unrealistic Expectations or SUE for short.

This is an incredibly prevalent disease.  Not only is it seen among patients in both the inpatient and outpatient setting, but also in their family and friends.  Some common symptoms include improper utilization of medical resources, delusions that health care is free and labile mood.  There are associations with chronic pain syndromes, tobacco abuse and a never ending request for the drug 'dilauda.'  The disease is seen in both men and women and in people of all races.  No diagnostic tests are usually necessary or available.  It is strictly a clinical diagnosis.

There is no known cure for this disease.  It seems to be communicable and maybe even heritable.  Groups are working on developing a vaccine and are enrolling interested individuals in studies.

Strength in Numbers

As I am sure many of you have heard, the Center for Medicare and Medicaid Services (CMS) is once again set to cut reimbursement to physicians.  In fact, that cut is supposed to take effect today.  This is not the first time physicians have faced this cut, but Congress in the past has passed legislation to delay cuts.  This may still occur.  In fact, CMS will not process claims for physician reimbursement during the first two weeks of March, as a temporary patch is once again expected.

Whitecoat makes an interesting suggestion on his blog:  that physicians should just allow the cuts to take effect, but then stop taking care of Medicare patients.  His argument is simply that instead of allowing our healthcare system to continue to teeter on brink of death, why not just allow the natural history of the disease to progress and force the collapse of our healthcare system that will in turn, push us more towards the overhaul that we so desperatly need.

One group of physicians at the Mayo Clinic in Arizona has done just that.  That have stopped seeing Medicare patients.  There are, of course, two sides to this argument.  First, and foremost, how would such an approach in large numbers affect care for those who qualify for Medicare?  Second, is it fair for physicians to accept a 21% pay cut in return for taking care of often very complex medical problems?  Let's not forget that the current level of reimbursement is hardly adequate.

I have another suggestion, and it's a crazy one.  What would happen if all of the physicians in a certain specialty in a certain area decided to form what would in essence be one large practice?  What if all of the orthopaedic surgeons in one state decided that they were going to join together and refuse to take care of Medicare patients? 

We're going to get to a point where crazy things have to happen.  We've seen what Congress has been able to do with health care reform.  For the send time in 20 years, they have attempted to make a change, and their attempt failed.  The jury is still out on what can be done, as President Obama is pushing hard for meaningful reform to occur.  I've said it before, and I'll say it again, we're asking the wrong people to enact the change. 

It's time for physicians to take charge of their own destiny.  While many of us would rather not get in the mix and just stick to the business of taking care of our patients, this approach is nearly as ineffective as my crazy idea above.  We're not doing our patients any favors by allowing this current strategy of using temporary patches to stave off the inevitable.