June 2018

President's Message - Update on Falls

Update on Falls

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Marc Hochberg, MD, MPH, MACP, President, USBJI

Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States. Approximately one-quarter of older adults (aged 65 and above) report having one or more falls each year resulting in approximately 3 million visits to emergency rooms per year. Burns and Kakara from the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, recently published an analysis of deaths from falls among older adults in the U.S. from 2007 to 2016 ⁽¹⁾. They noted an annual increase in both the number of falls as well as age-adjusted death rates from falls; the rate of deaths from falls increased by an average of 3.0 percent per year reaching a rate of over 60 per 100,000 persons aged 65 and above in 2016 (see Figure). When examined by age group, persons aged 85 and above (often classified as the “oldest old”), had the highest death rate: over 250 per 100,000 or more than 1 in 400 persons. Interestingly, death rates from falls were higher in men than women and in whites compared to non-whites.

Falls are the major modifiable risk factor for fractures; indeed, over 90 percent of osteoporotic fractures result from a fall from standing height. There are many factors that have been identified to increase the risk of falls; the most important are advanced age, having a history of prior falls and any medical condition associated with an impairment in gait, balance, physical function, vision or mobility.

The U.S. Preventive Services Task Force recently published evidence-based recommendations on the prevention of falls in community-dwelling older adults aged 65 and above who are not known to have osteoporosis or vitamin D deficiency. The Task Force recommends exercise interventions to prevent falls; the types of exercise considered include supervised individual and group exercise classes, physical therapy, gait and balance training, resistance training, flexibility and endurance training as well as tai chi. In addition, a “multifactorial intervention” that includes an assessment of modifiable risk factors for falls with customized interventions for each patient also was recommended. The initial “multifactorial” assessment could include a comprehensive geriatric assessment or an assessment using a combination of various components, such as balance, gait, vision, postural blood pressure, medication usage, home environment, cognition, and psychological health. This type of multi-disciplinary assessment is consistent with recommendations from the American Geriatric Society (AGS) and should be combined with a comprehensive management strategy directed at all identified modifiable risk factors. The AGS also recommends adaptation of the home environment, minimization or withdrawal of psychoactive medications, management of postural hypotension, and use of appropriate footwear.

The USBJI has revised the curriculum in its public education program “Fit to a T” to place greater emphasis on fall prevention in an effort to align with the Center for Medical Technology Policy’s “Strategic Roadmap to Prevent Secondary Fractures” that has been endorsed by the American Society for Bone and Mineral Research and the USBJI. In addition, persons should download health information on preventing falls from the websites of the Centers for Disease Control and Prevention and the National Institute on Aging.

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(1) Burns E, Kakara R: Deaths from fall among persons aged > 65 years - United States, 2007-2016. MMWR Morb Mortal Wkly Rep 2018;67:509-14.

Related articles in this Newsletter ASBMR Pushes for Progress with the Secondary Fracture Prevention Initiative; Why Bone Health Management Matters.

Arthritis and Low Back and Neck Pain: Prevalence, Healthcare Utilization and Cost Data Updates

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Updated and expanded, the Arthritis and Low Back and Neck Pain chapters of The Burden of Musculoskeletal Diseases in the United States (BMUS) have been released (www.boneandjointburden.org).

The Arthritis chapter places new emphasis on the most prevalent forms of Arthritis, including Osteoarthritis, various forms of Inflammatory Arthritis, Gout, Joint Infection, Fibromyalgia, Juvenile Arthritis, and Joint Pain/Joint Replacement. Both chapters include more disparities data. The chapters are undergoing review, but can be viewed as advance publication for the forthcoming 4^th Edition.

More than 100,000 unique Users have accessed BMUS, 25% of which are repeat Users.

The Hidden Impact of Musculoskeletal Disorders on Americans

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The Hidden Impact of Musculoskeletal Disorders on Americans presents data highlights from BMUS and the storyline of people with these disorders and how that storyline does not have to be.

The booklet was distributed to Congressional leaders and their staff on Capitol Hill in Washington, DC, during the National Orthopaedic Leaders Conference in June, and is available to every USBJI Member society for their members to use and distribute.

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The booklet contains a series of new graphics describing the limitations of diseases on activities of daily living of Americans, overall and by age group. Musculoskeletal conditions are either the most or second most reported.

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The booklet is available at www.boneandjointburden.org. Print copies of the booklet, and graphics, are available on request, email usbji@affinity-strategies.com.

BMUS is produced as a collaborative effort to be used to raise awareness about musculoskeletal disorders, and for researchers of musculoskeletal health questions, by USBJI Member society members and other individuals and with support from the American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, American Society for Bone and Mineral Research, Genentech, Medtronic, National University of Health Sciences, Orthopaedic Trauma Association, Radius Health, Sanofi-Genzyme – Regeneron, Scoliosis Research Society, and Zimmer Biomet.

USBJI Board/Annual Meeting and Elections

June 7 the USBJI Board and guests met to develop strategies to increase the number of Americans the USBJI reaches with its programs and communications. Offering their experience and perspectives representatives from Acumed, DJO Global, Flexion Therapeutics, Pfizer, Radius Health, Regeneron, Sanofi Genzyme, and Zimmer Biomet added to the deliberations of Board members who represent MSK health professional specialties and patient advocates, in a session led by Dr. John Ventura. The meeting also addressed gaps in the data the USBJI is presenting on Osteoarthritis, how the USBJI can best contribute to the ASBMR’s Roadmap to address the crisis in the treatment of Osteoporosis, and plans for a multidisciplinary knowledge exchange meeting later in the year.

June 8 the Board met and elected Dr. Matthew Dobbs as President-Elect. Dr. Paul Ullucci was re-elected to serve as Treasurer. Dr. Dobbs will become President next June 2019, and serve a two-year term.

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Matthew Dobbs, MD - President-Elect

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Paul Ullucci, Jr., PT, PhD, DPT, ATC, SCS, CSCS, EMR

Chronic Low Back Pain Task Force

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The Global Alliance for Musculoskeletal Health (G-MUSC) recently cited data from the 2016 Global Burden of Disease (GBD) for noncommunicable diseases noting that low back pain remains the leading cause of global disability. This is true as well in the United States as demonstrated in a recent article published in the Journal of the American Medical Association.

On June 8 the USBJI Board created a Task Force to be chaired by Dr. Dobbs, to include a primary care provider, chiropractor, osteopath, physiatrist, rheumatologist, physical therapist, occupational health nurse and other persons as deemed appropriate and necessary to study the feasibility of developing a multidisciplinary educational program and care model to improve pain and function without the need for chronic opioid analgesics, improve patient’s ability to continue or return to work and, possibly, avoid expensive surgical procedures and hospitalizations with their attendant risk of complications.

The Task Force will review the data in BMUS, the goals in Healthy People 2020 and 2030 as well as other publications, and provide a recommendation.

USBJI Strategic Plan 2018-2021

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The USBJI Board approved the organization’s Strategic Plan for the period June 2018-2021 on June 8. The new plan crystalizes vision and mission statements from earlier years into shorter sharper statements. The USBJI’s Vision is that every American knows how to maximize musculoskeletal health throughout his or her lifetime, and its Mission to raise the priority of musculoskeletal health through the collective action of all stakeholders.

The plan’s Goals build on those laid out in previous plans since the beginning of the Bone and Joint Decade, focusing on awareness, public and professional education, and research. An important addition is specific inclusion in research of the understanding of the impacts of sex, gender, race/ethnicity and socioeconomic status on musculoskeletal health.

View USBJI Strategic Plan.

A Young Investigator's Optimistic Outlook

Carrie Peterson, PhD, Assistant Professor, Department of Biomedical Engineering, Virginia Commonwealth University

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Currently, our lab focuses on non-invasive brain and nerve stimulation to both treat and evaluate neuromuscular function in individuals with cervical spinal cord injury. Individuals with cervical spinal cord injury want to improve their upper limb function more than any other lost function, and we aim to help in that regard. In the treatment realm, we are evaluating the efficacy of a repetitive form of non-invasive brain stimulation to increase the excitability of muscle affected by partial paralysis. Paired with physical rehabilitation, we believe targeted stimulation of the nervous system will further promote recovery of neuromuscular function after spinal cord injury, and other neurologic injuries. We are also working to develop a new, non-invasive technique to better clinically evaluate the extent of muscle paralysis after neurologic injury. Our current projects are supported by a National Center of Neuromodulation for Rehabilitation Pilot Award, and a VCU Center for Clinical and Translational Research Pilot Award.

More than one basket for eggs
With a formal educational background in mechanical engineering, my graduate work focused on musculoskeletal modeling and dynamics simulation to better understand muscle function and deficits during walking in individuals post-stroke. I transitioned to a focus on neurorehabilitation during my postdoctoral training. Specifically, we found deficits in neural activation of surgically transferred muscle in individuals with SCI after upper limb reconstruction, which provided the impetus for our current work focused on neurorehabilitation. With expertise in two distinct areas (i.e., two baskets for eggs), I am able to focus experimental work in our laboratory on neurorehabilitation, and also participate in collaborative work involving dynamics simulation analyses.

Prepared to determine my biggest challenges
Engineering and science lead to more questions, and we certainly have questions. The next step for our research lab is to leverage our preliminary findings into a projects with a larger scope. I am confident that my participation in the USBJI/YII program will help us to achieve our next step. From my past experiences as a graduate student and postdoctoral researcher, having excellent mentors is a key to success. Through mentorship and guidance on grant/fellowship writing techniques, I was able to obtain research support from the National Science Foundation and the Craig H. Neilsen Foundation. With the support of the USBJI/YII program and mentors, and my local mentors and support system at VCU, I am happy to have no shortage of experts willing and able to help me prepare high caliber grant applications. While I would classify the biggest challenges in my career “to be determined,” I feel prepared and supported to face these challenges whenever and however they become determined.

Dr. Peterson is a USBJI Young Investigator Initiative (YII) participant and is an assistant professor in the Department of Biomedical Engineering at Virginia Commonwealth University (VCU). Dr. Peterson directs the Neuromuscular Rehabilitation Engineering Laboratory, which designs and evaluates rehabilitation to improve neuromuscular function in individuals who have suffered a neurologic injury.

For more information, please e-mail me at: clpeterson@vcu.edu

Nutrition in the Management of Osteoporosis and Knee Osteoarthritis

Leslie Shen, BS, MS, PhD, Department of Pathology, Texas Tech University Health Sciences Center

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Osteoporosis, a degenerative bone disease, is characterized by low bone mass and microstructural deterioration of bone tissue that results in bone fragility and an increased susceptibility to fractures. Osteoporosis is a major health problem in the elderly, particularly women. Knee osteoarthritis a progressive joint disease characterized by cartilage degradation reparative bone response and joint inflammation, is a major age-related public health problem and a leading cause of long-term pain, disability, reduced quality of life, and contributing to mortality. Knee osteoarthritis is one of the five leading causes of disability that affects more than one-third of persons >65 years of age.

Nutrition plays an important role in the management of both osteoporosis and knee osteoarthritis in an aging population, where nutritional deficits are common. Proper nutrition either from diet or supplements may mitigate the progress of osteoporosis and knee osteoarthritis and their associated clinical/functional outcomes.

Dr. Leslie Shen was recently invited to give talks, on Nutrition for Joint Health: Current Knowledge and Future Directions, at the International Conference on Frailty & Sarcopenia Research, Miami Beach, FL, March 3, 2018, and on Nutrition for Bone and Joint Health: Aspects of Clinical Practice, at Nutrition 2018 (the Annual Meeting of the American Society of Nutrition), Boston, MA. In July, she will present similar topics in both English and Chinese at the 7^th Asian Congress of Dietetics at Hong Kong.

Her osteoporosis seminar covers (i) etiology of osteoporosis and how to evaluate bone status, (ii) identifying factors affecting calcium and vitamin D metabolism, sources of dietary calcium and vitamin D, (iii) beneficial effects of other nutrients on bone health, and (iv) possible mechanisms for bioactive components on bone health.

Her osteoarthritis seminar covers (i) overall prevalence and etiology of knee OA, (ii) potential beneficial effects of nutrition or dietary supplements on joint health, (iii) harmful effects of dietary factors on joint health, (iv) possible mechanisms for knee OA-protective effects of nutrition, and (v) and future directions for research.

Dr. Leslie Shen is a USBJI Young Investigator Initiative alumni (2006/2007) and a tenured professor since 2014 in the Department of Pathology at Texas Tech University Health Sciences Center, Lubbock, TX. Dr. Shen maintains a research program in the area of natural products/dietary bioactive components and exercise related to musculoskeletal health and obesity-related disorders covering both animal studies and clinical trials. Her research and presentations are well received by funding agencies (federal and industry), international/national scientific societies, and public media. She received the Texas Tech System Chancellor’s Council Distinguished Research Award in 2011. Dr. Shen is a Fellow of the NIH Clinical Research Management (2017) and a Fellow of the Hedwig van Ameringen Executive Leadership in Academic Medicine (ELAM) program (2018). Shen is also the founding director for the Center of Excellence for Integrative Health in 2018, Texas Tech University Health Sciences Center, TX.

Call for Applications -July 15 Deadline - Young Investigator Initiative Grant Mentoring and Career Development Program

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Deadline approaching for young investigators to apply for the Young Investigator Initiative Grant Mentoring and Career Development Program - July 15, 2018.

The United States Bone and Joint Initiative (USBJI) and Bone and Joint Canada are dedicated to increasing research of musculoskeletal diseases. To keep pace with the high and increasing burden of these diseases, a higher level of research performed by young investigators in the musculoskeletal diseases is required, and future levels of research assured. This is particularly important given the current environment for research funding, and academic careers. In response, the Young Investigator Initiative is a grant mentoring and career development program providing early-career investigators an opportunity to work with experienced researchers in our field to assist them in securing funding and other survival skills required for pursuing an academic career.

To date 222 participants (57%) have successfully obtained $354 million in grants for 1,359 new musculoskeletal research studies. Participants consider this program instrumental to their success. They rate highly the one-on-one mentoring with experienced researchers, the opportunity for inter-disciplinary and peer-to-peer exchange, and collaborations established during workshops.

This grant mentoring and career development program is open to promising junior faculty, senior fellows or post-doctoral researchers nominated by their department or division chairs seeking to pursue a career in clinical or basic research. It is also open to senior fellows or residents that are doing research and have a faculty appointment in place or confirmed. Basic and clinical investigators, without or with training awards, are invited to apply. Investigators selected to take part in the program attend two workshops, 12-18 months apart, and work with faculty between workshops to develop their grant applications. The Fall 2018 workshop is scheduled to take place November 9-11, 2018, in Toronto, Ontario. The unique aspect of this program is the opportunity for attendees to maintain a relationship with a mentor until their application is funded.

For more about the program and detailed application instructions, please refer to www.usbji.org/programs/yii.

AAOS Board of Directors approves new systematic literature review on the “Management of Surgical Site Infections"

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The American Academy of Orthopaedic Surgeons (AAOS) has developed a systematic literature review to provide the most up to date recommendations for the management of surgical site infections following orthopaedic surgery. The systematic review includes recommendations regarding diagnostic criteria and associated risk factors as well as antibiotic protocols and rifampin use. This systematic review is intended for use by orthopaedic surgeons, infectious disease specialists and other care providers that manage orthopaedic surgical site infections and was developed by a 12-member multidisciplinary work group with representatives from 7 societies. For further information on the AAOS Systematic Literature Review on the Management of Surgical Site Infections, please visit orthoguidelines.org.

Collaborative Effort Produces Perioperative Medication Guidelines in Patients with Rheumatic Diseases Requiring Arthroplasty

Benjamin M. Stronach, MD, MS, Vice-Chair, AAHKS Patient and Public Relations Committee

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There has been significant progress made over the past decade in the medical management for patients with rheumatic diseases such as systemic lupus erythematosus, rheumatoid arthritis, spondyloarthritis, and juvenile rheumatoid arthritis. This includes the advent of biologic agents, such as monoclonal antibodies, along with the expansion of use and development of improved disease modifying anti-rheumatic drugs (DMARDs). This rapid advancement in medical management has been beneficial for patients to include decreased symptoms and delayed joint damage from their autoimmune disease. Despite these benefits, many patients with rheumatic diseases still require hip and/or knee arthroplasty and this patient population is at higher risk for infection, dislocation and readmission after surgery in comparison to patients with osteoarthritis. These novel treatment agents have increased the complexity of care and raised concern for infection in the perioperative period due to their immunosuppressive effects. The appropriate management of these medications at the time of elective surgery is likely to mitigate the risk for infection but there has previously been little direct evidence available to guide the treatment team.

A collaborative effort was undertaken between the American Academy of Hip and Knee Surgeons (AAHKS) and the American College of Rheumatology (ACR) to provide clinical guidelines for the use of these medications during the perioperative period of joint replacement. The panel was led by Bryan D. Springer MD, an orthopedic surgeon at the OrthoCarolina Hip and Knee Center in Charlotte, North Carolina and Susan M. Goodman MD, a rheumatologist at the Hospital for Special Surgery in New York. The ACR guideline development process was utilized which employs the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. A panel of experts was assembled to review, evaluate and determine the level of evidence in the available literature followed by the development of seven recommendations based on their findings.

Several of the key recommendations are as follows: continue nonbiologic DMARDs in the perioperative period; withhold biologic medications for one treatment cycle prior to surgery and restart after surgery once the patient has appropriate wound healing; withhold tofacitinib for at least seven days prior to surgery; withhold rituximab and belimumab prior to surgery in all systemic lupus erythematosus patients.

This effort is an excellent example of interdisciplinary collaboration to provide better and safer care for our patients. The guidelines will undergo scheduled updates as new information, and new agents, become available for the treatment of these debilitating diseases. Please review the guidelines for all provided recommendations and more information regarding their development. There is also further information regarding specific medications to include a detailed table providing recommendations for use. These guidelines have been published in the Arthritis Care & Research Journal and the Journal of Arthroplasty.

ASBMR Pushes for Progress with the Secondary Fracture Prevention Initiative

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The ASBMR Secondary Fracture Prevention Initiative brings together a coalition of 40 professional medical and health care organizations and patient-advocacy groups from around the globe to find common ground on a pathway for focused attention to reduce the number of avoidable second fractures in individuals with osteoporosis.

In the past decade, the 30-year downward trend in hip fractures in the U.S. has plateaued, indicating that the field as a whole must take action to aggressively reduce fracture risk in our aging population. Experts are now acknowledging that there is a crisis caused by the declining rate of testing, diagnosis and treatment of high-risk patients. Allowing these patients to go untested and untreated frequently leads to debilitating fractures that cause disability, loss of independence and even death.

This initiative builds on the ASBMR Call to Action to Address the Crisis in the Treatment of Osteoporosis in 2016. As a direct outcome of the Call to Action, a Stakeholder Summit was held in 2017 to begin the development of a Strategic Roadmap to Prevent Secondary Fractures and a report summarizing the recommendations was released in December 2017. A second phase is now underway to work with a Coalition to translate the Strategic Roadmap into a specific and detailed Action Plan to be implemented in order to achieve the goal of substantially reducing secondary fractures. ASBMR has engaged the Center for Medical Technology Policy (“CMTP”), an independent non-profit committed to improving clinical evidence for decision making, to assist the Coalition in crafting the Action Plan to be released in late 2018.

The initial efforts will focus on the target population of men and women 65 years of age and older who have suffered a hip or vertebral fracture and who seek clinical attention. This focus is not intended to imply that other patient populations should not be treated, but it represents a well-defined at-risk subpopulation for which consensus on a public health initiative is achievable.

The Coalition will identify lessons learned from prior programs and prioritize approaches for moving forward, select quantitative goals, develop proposals for strategies with U.S. government agencies to improve reimbursement options, develop consensus recommendations for clinical care, and develop educational materials to align stakeholder messaging. Most importantly, the Action Plan will include specific tasks and identify responsible parties and timelines.

Click here to see the organizations that have joined the Coalition with the ASBMR Secondary Fracture Prevention Initiative to intensify their current efforts and collaborate on new opportunities to increase the screening, diagnosis and treatment of high-risk individuals to prevent fractures and to partner with patients to make informed choices about osteoporosis treatment options.

Why Bone Health Management Matters

Paul A. Anderson, MD, FAOA, Own the Bone Steering Committee Chair

Why Bone Health Management Matters: AAOS/AOA Co-Branded Symposium at AAOS 2018

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Fragility fractures account for an estimated 800,000 hospital admissions per year, and this number is rising as the population ages. Patients who have had a fragility fracture are two to six times more likely to have another fracture, making secondary fracture prevention an imperative for the delivery of quality orthopaedic care to a growing population of older adults. In a symposium, “Secondary Fracture Prevention,” presented at AAOS 2018, we discussed strategies to develop and implement fragility fracture service line improvements, and to initiate bone health care coordination for fragility fracture patients at increased risk of future osteoporotic fractures. The expert speakers included Douglas Dirschl, MD, FAOA, Sanford E. Emery, MD, MBA, FAOA, Joseph Lane, MD, FAOA, Debra Sietsema, RN, PhD, and Eeric Truumees, MD, FAOA.

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Douglas Dirschl, MD, FAOA at the podium in New Orleans

The AOA developed Own the Bone (OTB), a quality improvement program, to encourage orthopaedic surgeons to become involved in the bone health management and initiation of care coordination for fragility fractures. During the symposium, the speakers tackled how to start a fragility fracture program and get administration on board, why secondary fracture prevention is needed, the Own the Bone secondary fracture prevention program, and diagnosis and assessment of osteoporosis. Some of the takeaways from these talks are incontrovertible reasons for action. Dr. Lane presented on the basics of medical management for orthopaedists, 70% of whose patients are deficient in vitamin D at the time of fracture. In addition, as I presented, an examination of the estimated cost per quality-adjusted life year (QALY) of $10-$25,000 per patient supports secondary fracture prevention bone health treatment, while the number needed to treat (NNT) is estimated at 28-32, far below other conditions widely treated.

The stakes for our specialty’s reputation and future go beyond fragility fractures and secondary fracture prevention, as the consequences of unaddressed metabolic bone disease can result in surgical complications. Increasingly, the linkages between poor bone health and negative outcomes after orthopaedic surgery provide a rationale for bone health optimization, particularly for spine fusion and arthroplasty patients.

As Dr. Sanford Emery presented, “Pre-operative Bone Health Optimization,” two questions are salient for our specialty:

Does osteoporosis negatively affect our elective surgical outcomes?
Is pre-operative optimization doable and effective?

Dr. Emery walked the audience through a literature review, suggesting that both questions can be answered in the affirmative and that it is incumbent upon orthopaedic surgeons to act. In spine fusion patients, a retrospective study using CT to look at pedicle screw loosening showed a statistical increase rate of loosening with Hounsfield Unit (HU) of less than 116,[1] which reflected poor bone mass. In addition, lower pre-operative HU measurements are associated with adjacent segment fracture after spinal fusion.[2] Pre-operative treatment of 30-90 days of recombinant human parathyroid hormone (PTH) showed higher insertional torque in treated groups of osteoporotic women with thoracic and lumbar fusions.[3] A prospective case series shows PTH given postoperatively for 18 months showed less proximal junctional kyphosis above long lumbar/thoracolumbar fusion.[4]

Further, there is an epidemic of patients having periprosthetic fractures almost always related to osteoporosis. Femoral bone loss after total knee arthroplasty is supported by a meta-analysis of 11 studies in Europe and Asia which conducted serial DXA after TKA, and which showed rapid 18-20% supracondylar and intracondylar bone loss that does not normalize within 24 months. A meta-analysis of bisphosphonate use showed significant reduction revision of surgeries - up to 55% - in TKA patients and up to 54% in THA patients.[5]

Surveys of orthopaedic surgeons in Europe and New Zealand reveal that more than 65% said they would reconsider their operative strategy for THA patients if BMD were low, and 29% indicated they would change their surgical plan if the patient’s T-score was found to be less than - 2.5. The same study, Dr. Emery pointed out, shows that only 4% seek pre-operative BMD measurements.[6]

Each year in the US, there are approximately 1 million patients who undergo elective hip and knee replacement surgeries at our hands. It is estimated that 50% of these patients have low bone mass, placing them at risk of complications. Diagnosis and treatment of poor bone health pre-operatively is feasible, and appears to reduce such complications. Orthopaedic surgeons who treat new fragility fractures, spine and total joint patients play a critical role in owning our patients’ bone health, and in diagnosing and beginning medical management of patients with underlying bone fragility to improve their care and outcomes. Fracture liaison services established for secondary fracture prevention can be used to provide this care.

[1] Arch Orthop Trauma Surgery (2016) 136: 1063-1067.

[2] Spine (2013): 35 (5): 415-418.

[3] J Neurosurg Spine (2014): 21: 425-431.

[4] Osteoporos Int (2016) 27: 3495-3502.

[5] PLoS One (2015) 10 (10): e01239927.

[6] Adv Orthop (2016): Article ID 8079354.

EHR Incentives - Are We There Yet?

Eric Stiefel, M.D.

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In April of 2018, CMS issued a proposed rule that could mean a major overall to its EHR Incentive program. The program retitles the Meaningful Use (MU) program to “Promoting Interoperability”, and shifts focus to align with other value-based models by concentrating on data exchange between hospitals, providers, and patients (Table 1). According to CMS the program also aims to reduce the time and cost required to participate and make is easier for patients to access their medical records electronically by supporting app-based technologies. The Promoting Interoperability program introduces several new measures, while suns etting some familiar MU measures such as: providing summary of care, medical reconciliation, secure messaging and patient-specific education materials (Table 2). Other new additions include query of prescript drug monitoring programs and documentation of opioid treatment agreements. Further, the updated rules will require participants upgrade to 2015 edition CERT.

While CMS cites decreased physician burden as a primary objective, historically, physicians have struggled to keep pace with the changing requirements associated with CMS’s EHR incentive program. In a survey of examining providers experience with EHR systems, respondents reported loss of productivity and cost as major concerns when changing to a new system, and only 43 percent of respondents were satisfied with the change after implementation (1). In a study examining the direct and indirect EHR cost, providers in a small group practice could expect to spend $162,000 for implementation and an additional $85,000 in maintenance expenses during the first year (2). In a 2016 case report by Becker’s hospital review, three hospitals reported spending between 50 and 72 million dollars to upgrade their EHR systems. The cost for Hospitals can be even more staggering with isolated reports of Hospitals spending more than one billion dollars on EHR software upgrades.

As physicians, we can only hope that this new program will not only bring a change in name, but also result in value added to the patient experience, and that once the target is set for providers to hit, CMS will not move our mark in the foreseeable future. However, it is important that we participate in the process and advocate for our patients and profession. The Question remains, will this new program add value to the patent experience, or serve yet another distraction for providers?

AANA is actively involved in submitting comments on this proposed rule, and other societies might wish to do so. The more societies potentially affected by the ruling and submitting comment, the more likely it is that our views and positions will be considered.

National Association of Orthopaedic Nurses

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The National Association of Orthopaedic Nurses (NAON) has had an exciting start to 2018! Since the last association update in November, we released new products, held a successful 38^th Annual Congress, and provided tremendous networking opportunities for Nurse Navigators.

New Products

NAON has published two new editions of publications which are excellent resources for all healthcare providers treating patients with musculoskeletal disorders. In early 2018, NAON released the 5^th edition of An Introduction to Orthopaedic Nursing. The target audience for this manual is the bedside nurse providing direct patient care in a clinical setting. It is a solid reference for others in the continuum of care - clinical nurse specialists, bedside care providers, nurse practitioners, educators, and students. NAON also released the 3^rd edition of its Orthopaedic Surgery Manual. This comprehensive textbook is an excellent resource for members of the healthcare team along the entire treatment continuum.

Networking with Nurse Navigators

Every month, NAON’s Director of Education, Tandy Gabbert, MSN, RN, ONC, leads an informational networking call for a network of nurse navigators in multiple roles and settings. During this call, various topics ranging from developing a mentor program to implementing best practices for outpatient joint replacement patients are discussed. Since its inception, the group has grown to include over 100 individuals who are interested in learning more about the navigator role and how it functions in various roles and settings.

NAON has had a very busy – and very successful – year thus far. We look forward to continuously supporting orthopaedic nurses in their diverse roles as we continue 2018.

Preventing Anterior Cruciate Ligament Injuries in Middle and High School Athletes will Reduce Societal Costs!

Paul Ullucci, Jr., PT, PhD, DPT, ATC, SCS, CSCS, EMR

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Anterior cruciate ligament (ACL) injuries often occur while participating in sports activities. ACL injuries may prevent the athlete from returning to their chosen sport or reduce their physical activity level for the rest of their life. Additionally, the trauma associated with ACL injuries can lead to damaging musculoskeletal problems, which will affect the individual later in life. Prevention of ACL injuries must have the highest priority for all those involved in sports.

The National Athletic Trainers’ Association’s (NATA) Position statement “Prevention of Anterior Cruciate Ligament Injury” was designed specifically to highlight the need for a multidimensional approach to reducing anterior cruciate ligament (ACL) injuries¹ and the prevention of consequential health issues. ACL injuries as the result of contact (direct blow to the knee/leg) or noncontact (those caused by aberrant movement/forces about the knee joint) are acutely debilitating in nature and have lasting effects that can last a lifetime.¹ The direct impact ACL injuries have on the injured athlete is readily apparent in the form of lost time from participation in sport/work as well as the financial costs associated with physician visits, imaging and rehabilitation in lieu of or following surgical intervention^1,2 Indirect costs are somewhat harder to quantify but include lost wages for the injured athlete and those who care for the them as well as transportation costs to and from appointments.

Recently researchers have begun to look at the long-term sequelae of ACL injuries to better understand the long-term effects these injuries may have on the athlete’s risk of developing osteoarthritis (OA) within the injured knee. Mather et al ² have attempted to determine the exact cost of suffering an ACL injury on society by taking the number of new ACL injuries in the United States and combining it with the odds of individual actually developing OA. They estimate the potential cost of these injuries to be 4.24 Billion dollars for those who choose not to undergo surgical repair and 2.78 Billion dollars for those who elect to have surgery. ² While these numbers are certainly staggering, they become even more disconcerting when one that the number of ACL injuries has actually been increasing since.^1,2

The position statement clearly identifies the need for the early, middle school age, implementation of a prevention program for athletes which is developmentally appropriate and stimulating enough to ensure compliance.¹ The statement specifically recommends that girls and those in high risk sports such as soccer and football should be given age appropriate training including exercises designed to improve strength, flexibility and balance.¹ Agility training and plyometric training should be sport, age and ability specific.¹ The authors specifically recommend that these exercises be performed 2 to 3 times per week for a minimum of 15-20 minutes with the emphasis of ensuring that the athletes are actively engaged in order to ensure long term compliance with the program.¹

School administrators, coaches, parents and athletes should use the information in the position statement to leverage their current resources to reduce the risk of ACL injuries. Specifically, local strength and conditioning experts, athletic trainers, physical therapists and local medical professionals should work together to develop a comprehensive program to reduce the risk of ACL tears in their athletes.¹ Screening should be incorporated into the program to identify those with specific movement or structural impairments which place them at additional risk so that more athlete specific training can be performed on their own or as part of the team’s ACL prevention program. As the leading inter-professional association in musculoskeletal health the United States Bone and Joint Initiative (USBJI) applauds the NATA, the NATA Foundation and the authors of the position statement in articulating the best way to reduce the number of ACL injuries in today’s athletes. We hope that this will have the added benefit of reducing the number of individuals suffering from traumatic OA in the future.

The position statement itself is available, free of charge by clicking on the link below.
https://www.nata.org/sites/default/files/prevention_of_anterior_cruciate_ligament_acl_injury_position_statement.pdf

Padua DA, DiStefano LJ, Hewett TE, et al. National Athletic Trainers' Association Position Statement: Prevention of Anterior Cruciate Ligament Injury. Journal of athletic training. 2018;53(1):5-19.
Mather RC, 3rd, Koenig L, Kocher MS, et al. Societal and economic impact of anterior cruciate ligament tears. The Journal of bone and joint surgery American volume. 2013;95(19):1751-1759.

OREF Clinical Research Award and 2019 Grant Funding Opportunities Now Available

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OREF Clinical Research Award

OREF and the American Academy of Orthopaedic Surgeons (AAOS) are soliciting manuscripts for this annual award, which recognizes outstanding clinical research related directly to musculoskeletal disease or injury. Manuscripts should represent a large body of cohesive scientific work generally reflecting years of investigation. If the submission reflects a single project, it should be of high significance and impact. Manuscripts must be submitted by members (or candidate members) of the AAOS, Orthopaedic Research Society (ORS), Canadian Orthopaedic Association (COA), or Canadian Orthopaedic Research Society (CORS).

The award is presented to the recipient by an OREF representative at the Academy's annual meeting during the Kappa Delta Award presentations.

The deadline to apply for this award is July 1, 2018. Complete details, including submission guidelines and instructions, are available at http://www.oref.org/grants-and-awards/award-programs and on the AAOS website. When applying, be sure to check the OREF Clinical Research Award box to be considered for this award.

Applications for Nearly $500,000 in 2019 First-Round Funding Now Being Accepted
Requests for Applications (RFAs) for the first round of OREF grants to be funded in 2019 are now available. Please visit the OREF website for more information, including available funding by grant, eligibility requirements, application requirements and deadlines.

Please note, many of the grants require investigators to first submit a letter of intent (LOI). Selected applicants will be invited to submit a full proposal. The LOI deadline is July 2, 2018.

The Orthopaedic Research and Education Foundation Prevention of Musculoskeletal Youth Sports Injuries Research Grant in Honor of James R. Andrews, MD (LOI required)
The Orthopaedic Research and Education Foundation Impact of Regulatory Policies on the Patient-Physician Relationship Research Grant in Honor of Sigvard Hansen, MD (LOI required)
The Orthopaedic Research and Education Foundation Wright Medical Total Ankle Replacement Research Grant (LOI required)
The Orthopaedic Research and Education Foundation Stryker Robotic-Assisted Total Hip Replacement Clinical Research Grant (LOI required)
The Orthopaedic Research and Education Foundation, in Honor of the Knee Society, Funding made possible by Dr. Peter Walker, PhD, Treatment of Knee Osteoarthritis Research Grant (LOI required)
OREF/ASES/Rockwood Clinical Research Grant in Shoulder Care

Information about future grant opportunities, including tentative RFA dates, can be found on the OREF website at http://www.oref.org/grants-and-awards/grant-programs.

Patients Lead Way in TMD Advances

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The TMJ Association (TMJA) was founded in 1986 in Milwaukee, WI with the mission to improve the quality of health care and lives of everyone affected by Temporomandibular Disorders (TMD). The founders themselves were patients who suffered harm from TMJ treatments.

At that time, patients were referred to dentists and told the cause of their problem originated from their teeth and jaw position. There were no clinical trials to demonstrate safety and efficacy of the treatments prescribed (practices which persist today). No clinical trials directed surgeons on how to repair temporomandibular joints. The TMJA became the 911 for patients to detail harms resulting from these treatments. From the number and types of patient experiences, it became apparent there were a multitude of problems, no consistently reliable solutions available, and a need for scientific studies to improve patient care. TMJA’s goals were to: advocate for science directed toward TMD, support patients who contacted the TMJA for help and guidance, and serve as a resource for information on research and treatments.

Several key advocacy efforts resulted in:

The 1992 Congressional Hearing on TMJ implants. The hearing and subsequent media coverage was pivotal in establishing the TMJA as the voice of TMD patients and the advocate for interdisciplinary/multidisciplinary research.
25 years of congressional report language for advancing TMD research.
Eight biennial scientific meetings co-sponsored with the NIH.

TMD are a complex and poorly understood set of conditions characterized by pain in the jaw joint area and jaw problems. Approximately 12% of the population or 36 million people in the U.S. are affected by TMD; the majority women in their childbearing years.

A result of TMJA’s advocacy was the National Institute of Dental and Craniofacial Research funding of the Orofacial Pain Prospective Evaluation and Risk Assessment study. The findings have fundamentally changed the paradigm, unequivocally transforming the concept of TMD as a dental problem to a medical problem. Today scientists recognize TMD as a multisystem disorder with overlapping conditions influenced by multiple biological and environmental factors rather than solely an orofacial pain condition. However, diagnosis and care of patients have not changed to reflect this major paradigm shift, with many patients continuing to receive treatments solely focused on teeth and jaws. Moreover, the medical community lacks education regarding the complexity and systemic aspects of TMD as well as its many comorbid medical conditions. Patients are treated by a multitude of practitioners across numerous disciplines with treatments that have the potential to cause harm.

The TMJA is working hard to change this! Our current project, the TMJ Patient-led RoundTable is the first patient-led initiative sponsored by the Medical Device Epidemiology Network. The project brings together all stakeholders in TMD with the overall objectives to: 1) understand the factors leading to success or failure of TMD treatments, 2) develop a roadmap for establishing precision medicine guidelines that predict individual outcomes for treatments, and 3) incorporate patient preferences and experiences into premarket research and post market surveillance of all TMD therapies.

Raise Awareness About Bone and Joint Health in Your Community

Bone and Joint Action Week is held annually October 12-20 with activities focused on disorders including arthritis, back pain, trauma, pediatric conditions, fracture prevention and osteoporosis. The themes and their related activities are designed to raise awareness worldwide about prevention, disease management and treatment. Plan now to host or present programs in your community to educate patients and their family, friends and support networks on how to manage and take control of their bone and joint health. The USBJI works with community groups and organizations to raise awareness and understanding of the advances that have and continue to be made to lessen pain, improve mobility, and restore function for those who live with bone and joint conditions and pain through the Experts in Arthritis and Fit to a T programs.

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Experts in Arthritis is a free patient education program for people with arthritis and people who care about them. Arthritis and other rheumatic conditions are the second most common musculoskeletal disease among adults in America. The program offers people with arthritis the opportunity to be better informed about current scientific evidence and management strategies in the treatment and care of osteoarthritis, rheumatoid arthritis, and juvenile arthritis. Other forms of arthritis can be incorporated, based on need. The Arthritis Tips booklet has been translated into Spanish and is available on our website. To present or host this ready-to-use program package in your community visit: www.ControlArthritis.org.

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Fit to a T is a free patient education program to educate both men and women about fracture prevention, assessing risk for fracture and osteoporosis, and how to prevent bone loss and a fragility fracture, particularly secondary fractures. This education program is called “Fit to a T” because the T-score is the measure of a person’s bone density and susceptibility to fracture.

Vitamin D and Your Bone Health

We have recently updated the Vitamin D handout information. This update is a joint effort of the USBJI with the American Medical Women’s Association and Healthy Women magazine. It is available to download from the Fit to a T program website: www.Fit2T.org. All live session program participants will receive a copy along with other program materials.

Each program features a ready-to-use package which features a PowerPoint presentation, speaker notes, handout materials and a question and answer period. All materials are supplied free of charge and USBJI will work with you to promote program sessions and provide planning support, r egister online .

Visit www.ControlArthritis.org and www.Fit2T.org to learn more and view the entertaining whiteboard videos, available in English and Spanish, that encapsulate the messages for each program. Share these videos by adding the links to wellness pages, newsletters and communications or download to share in your community to encourage healthy lifestyle changes and raise awareness about bone and joint health.

Contact USBJI at usbji@affinity-strategies.com or call 847-430-5052 for more information.

You are here

June 2018

In This Issue

Calendar of Events

Update on Falls

Why Bone Health Management Matters: AAOS/AOA Co-Branded Symposium at AAOS 2018

OREF Clinical Research Award

Vitamin D and Your Bone Health