Ancillary Advantage

05/05/2014

"The federal push for transparency regarding payments to physicians took another step forward when, on April 9, 2014, the Centers for Medicare & Medicaid Services (CMS) released data on Medicare payments for services provided in 2012 by approximately 880,000 physicians. These data include the number and type of services provided by each physician, average allowed payment, and the average Medicare payment paid to physicians."

The federal push for transparency regarding payments to physicians took another step forward when, on April 9, 2014, the Centers for Medicare & Medicaid Services (CMS) released data on Medicare payments for services provided in 2012 by approximately 880,000 physicians. These data include the number…

04/29/2014

Zimmer Agrees to Buy Biomet for $13.35 Billion
by Robin Young of Orthopedics This Week.

"In a stunning move, cross-town rivals Zimmer Holdings, Inc. and Biomet, Inc. have agreed to combine in a transaction which is valued at just over $13 billion and will affect the work lives of more than 14,000 employees and create a company with combined annual revenues of about $8 billion.

This transaction further consolidates the orthopedic industry as it puts together the #2 player (Zimmer) with the #4 player (Biomet) and reduces the number of major, diversified orthopedic implant and instrument companies from 5 to 4.

The last time Biomet was “acquired” occurred seven years ago in 2007 and the price tag was $11.4 billion.

The purchase will be paid in a combination of stock and cash. The deal is expected to close in the first quarter of 2015 and when the dust settles, Biomet shareholders will own about 16% of the combined companies.

The initial reaction from Wall Street’s analysts is positive.

Reasons for the Acquisition

In a conference call with Wall Street’s analysts this morning, Zimmer’s CEO David Dvorak said that there were four basic strategic growth reasons for the deal:

The combined companies will be more competitive with DePuy (JNJ), Stryker Corporation, Smith & Nephew and the other emerging suppliers of orthopedic implants. Indeed, on a combined basis the new company will have about 42% and 35% share of the worldwide knee and hip market, respectively.
It will improve the diversified portfolio of products for Zimmer. For example, the transaction doubles Zimmer’s spine and dental product revenues.
It expands the innovation platform. Combined, annual R&D spending jumps to $360 million.
And Zimmer points to emerging markets where, in certain instances, Biomet had a sales and distribution presence and Zimmer did not.

From Biomet’s perspective, the company had filed to “go public” and was, in effect, already marketing itself to prospective buyers. It turned out there was one big buyer sitting just down the road named Zimmer. And, frankly, these two Warsaw, Indiana-based firms are deeply rooted in a common culture, a common geography, a shared value set so that their combination may well feel to employees and other stakeholders as if it was somehow pre-ordained.

Early Surgeon Reaction

To a certain extent, this merger won’t change the day-to-day work of orthopedic physicians. But an increasingly consolidated industry does raise some concerns as well as opportunities as these top surgeons related to OTW this morning upon hearing the news.

From Javad Parvizi, M.D., FRCS, vice chairman and director of clinical research at the Rothman Institute at Thomas Jefferson University: “The Zimmer-Biomet merger is an interesting development that might provide new opportunities for some orthopedic surgeons that have been working with each of these companies. With such an infrastructure, there could be a real benefit in terms of education and research. The disadvantage—as with any merger—is that it could take away competition between the companies that is clearly useful for developments and progress. Lack of competition may lead to complacency and may deprive others from working with each company individually.”

From Tom Errico, M.D., chief division spine surgery, departments of orthopedic surgery and neurosurgery at New York University; “Zimmer was very interested in expanding its spine offerings and looked at a lot of companies. This is a huge leap for them and puts them squarely in the game in a positive way.”

What Now?

Over the next 8-10 months the lawyers, bankers and management teams at both companies will be combining the two companies. The whole mash up, Dvorak expects, will be done in the first quarter of 2015. In its first year, Zimmer’s accountant think that there will be about $150 million of savings from “synergies.”

04/22/2014

The latest "Look Inside" short film about how technology is helping amputees in South Sudan is inspiring.

The latest Look Inside short film shows how technology is changing lives in South Sudan.

04/21/2014

The Boston Athletic Association is going to need to update it's Top 10 rankings. Meb Keflezighi's time of 2:08:37 is made official...

A year after the Boston Marathon bombing, runners are preparing to take on the 26.2-mile challenge, proving there's no limit to their physical or mental mettle.

04/18/2014

http://www.beckersspine.com/spine/item/20405-10-factors-in-unplanned-30-day-readmissions-after-lumbar-spine-surgery

A study published in Spine examines the risk factors and causes of 30-day unplanned readmissions after lumbar spine surgery.

04/17/2014

MMA (Mixed Martial Arts) fighting is not for the faint of heart. A full contact combat sport that has quickly become one of America's most watched sports. But a recent study by the University of Toronto says to beware of the dangers involved with this sport. Story by Biloine W. Young of Orthopedics This Week.

"Beware of mixed martial arts (MMA) fighting! A study by researchers at the University of Toronto finds that MMA fighters are at a higher risk for brain injuries than are boxers or any other martial arts fighters. The study also found that concussion rates in MMA were greater than in both hockey and football.

The investigators looked at MMA fights from 2006 to 2012 and found that fighters were hit for an additional 3.5 seconds after having been knocked out. About one-third of all MMA fights end in a knockout or what is called a “technical knockout.” Losers in technical knockouts were hit on average, more than 19 times with 92% of the blows landing on the head.

The researchers concluded that, “Given that participation at amateur levels of the sport is growing rapidly, we expect to see high rates of traumatic brain injuries at more junior levels of amateur competition. These points strongly argue for banning the sport in youth and for preventive strategies to reduce the burden of traumatic brain injuries in professional MMA fighters who elect to fight.”

The largest organization in MMA fighting is the Ultimate Fighting Championship (UFC). The chief operating officer, Lawrence Epstein, told the Associated Press, “By partnering with the Cleveland Clinic, one of the world’s leading medical research institutions, on advanced studies aimed at not only preventing long-term brain injuries, but also identifying those predisposed to them, the UFC demonstrates true commitment to the safety of all professional athletes.”

Picture Source: Wikimedia Commons

04/15/2014

President of the NFL Physicians Society, Dr. Matthew Matava, says that ACL injuries are not on the rise, they are remaining consistent for the last four years. The article, published by Orthopedics This Week written by Elizabeth Hofheinz, M.P.H., M.Ed.

"In contrast to what many think, ACL injuries in the NFL are not increasing, says Matthew Matava, M.D., President of the NFL Physicians Society. Dr. Matava, an orthopedic surgeon with the Washington University School of Medicine and Team Physician for the St. Louis Rams, tells OTW, “While the general impression is that ACL injuries in the NFL are increasing, in fact they have remained consistent. In 2011 (preseason and regular season) we saw 55 such injuries; in 2012 it was 63, and in 2013 it was 57.”

“Players are being very up front, saying, ‘We can’t hit each other in the head, so we have to hit lower in order to make a tackle.’ So naturally, it would seem that we would see an increase in knee injuries. I think the ACL tears have remained relatively constant because the new concussion rules haven’t caused players to hit as low as perhaps they fear. However, any rule change has to be examined after being in affect several years in order to truly assess its effect on the game. Each and every player will tell a doctor, ‘I would rather be hit in the head than in the knees. I’ll take my chances with a concussion…that wouldn’t be career-ending.’ I tell them, ‘I can reconstruct your knee, but I can’t reconstruct your brain.’”

“And you would think that we would see more injuries in Thursday night games as compared to Sunday and Monday night games, but that has not been the case. While I do not have any theories as to why injuries remained the same, it could be that the three days between games is enough to recuperate from the prior week’s injuries. It is important to note that even if the numbers increase that all of this data represent a snapshot in time and should be analyzed after several years of data collection in order to truly assess any negative effects on injury rates.”

“Unfortunately, football is a collision sport and will always be associated with the risk for injury. The NFL and NFL Physician Society have committed significant resources and effort to reduce this risk. In addition, the collection of injury data is done in a scientifically rigorous fashion by an independent organization with significant experience and expertise in biomedical data collection.”

04/11/2014

Becker's Spine Review had some interesting statistics on Spine Surgeons.

Here are eight statistics on orthopedic and spine surgeon salaries based on a Healthcare Salaries report.

04/09/2014

Dr. Kevin Stone, TED speaker and known as one of the most knowledgeable in his field, gave his insights to Orthopedics This Week about the most recent AAOS conference in New Orleans. "His comments are interesting and insightful. And straight to the point. – Walter Eisner, Senior Writer

Biologics: Science Ahead of Performance

One thing that Dr. Stone noticed right away was the tremendous interest among the companies in biologic products and instruments that can put biologic treatments into the hands of physicians (scaffolds, PRP, bone marrow harvests for stem cells). But, he noticed, most major orthopedic suppliers have overlapping offerings. And, furthermore, the papers which these firms trotted out were, frankly, weak.

“Unfortunately while the intuitive understanding of biology says these should work, the papers presented demonstrated that the science is far ahead of the clinical performance. PRP (platelet-rich plasma) in particular seems to be a mixed bag of multiple growth factors with no consistency either between the products or even from the same patient at different times of the day. With this dramatic difference from what the regulatory bodies are used to seeing, one only wonders how the field will remain wide open and how the payers will deal with this variability in treatments and outcomes.”

He noted a genuine concern in a number of papers on the role of hyaluronic acid (HA), with some organizations now refusing to reimburse for it while others claim it has dramatically delayed the time for joint arthroplasty for many patients. “The role of joint lubrication in cartilage repair versus arthritis is yet to be defined although the science suggests that HA is very beneficial to healing cartilage.”

Shoulders: Cuff Repair Stuck in the Past Century

Stone noted that there appeared to be considerable overlap in topics at the Specialty Day meetings of AANA (Arthroscopy Association of North America) and AAOS. He said the hot topic is whether or not the extensive rotator cuff repair techniques using multiple anchors and sutures is any better than a more cost effective single anchor approach. “The success of cuff repair remains a disturbingly low number with possibly as many as 40% re-tears. The rehabilitation of rotator cuff repairs remains in the 20th Century with many top surgeons afraid to let their patients have active motion or strengthening for months after repair. This is reminiscent of the old days of ACL surgery.”

“SLAP [superior labrum, anterior to posterior] lesions of the shoulder are now being referred to as the plica of the shoulder with many papers demonstrating that very few (5%) of all SLAP tears need any surgical treatment. This is dramatically different from a few years ago when all the rage was new techniques in SLAP repair.”

The biceps tendon, added Stone, remains similar to the meniscus of the knee. “When diseased, the only treatment is destruction of the tendon by removal or anchoring non-anatomically. It is odd that there is almost no science around repairing this structure which so obviously plays a key role in the shoulder.”

The Knee and Meniscus Replacement: A House Divided

For knees, Stone said meniscus replacement remains quite divisive.

Knee Anatomy / Source: Wikimedia

Papers at the Meniscus Transplant Study Group focused on the importance of repairing the meniscus skirt ligaments in order to restore normal anatomy. He said there were multiple comments on expanding the indications for meniscus replacement, since it appears to provide long-term pain relief and improved function even in arthritic knees. He noted a paper by the Rush group demonstrated significant success in a series of 200 patients, though there was a high reoperation rate for scar tissue and other issues.

“A dramatic paper presented at the AAOS confirmed earlier data from Stone et al. that there was no difference in patients who received a meniscus transplant plus an osteotomy versus those who received the transplant alone. Alignment did not affect outcomes. This contrarian data disturbed many of the osteotomy surgeons particularly in Europe but is supported by other studies as well. The contrary argument was presented at the AANA meeting in a panel where the surgeons repeated the dogma that meniscus transplantation was only for the young and healthy knees without mal alignment. The techniques presented were old time open surgery despite the fact that all arthroscopic meniscus transplant techniques have been well published. It is unclear why the anti-meniscus transplantation bias still exists but the contrast is stark in the opinions and data.”

Stone said data on long-term successful outcomes of CMI [collagen meniscus implant] implantation from Europe continues to be reported, particularly by the Rizzoli group. “Zero complications in over 24 years of clinical use now should convince the FDA that revoking the approval for a device that helps so many people without a downside was a dumb idea. But don’t hold your breath. The CMI may come back as a PRP delivery device to augment meniscus repairs.”

Put a Nail in the Double Bundle Coffin

Finally, Stone said the double bundle era is coming to a close for many surgeons. “Hyped by the companies that sold many more fixation products and by one of the university groups, the data is simply not convincing enough surgeons that two holes are better than one for anatomic ACL surgery.” The best contribution from that era, said Stone, was to alert many surgeons of the importance of putting the ACL into the anatomic footprint.

The End of Hardware

The take away for general orthopedic surgeons and companies, said Stone, is that orthopedics is entering the anabolic era and leaving the age of cortisone and hardware as primary treatments.

“We have come to understand that it is better to stimulate repair by adding growth factors, cells, tissue, and scaffolds to injured areas rather than remove the tissue (meniscus, biceps tendon, damaged cartilage, hip labrum) even if the outcome is not perfect. ‘Better is better than artificially replaced,’ is the mantra of the biologic surgeon. Patients are becoming aware that cortisone represents inhibition of healing and that metal and plastic represent the last resort. The reports that up to 50% of patients with total knee replacements still have pain are circulating amongst the golfing crowd.

Safety First, Effectiveness Post-Market

He says that if the FDA approval process is to modernize and understand the gradations of improvement then shifting to safety approvals first with crowd sourced outcome data to follow new products is the way forward. Translated, he says this means, let new products on the market after safety studies and let the efficacy be determined by total post market release data. While not acceptable in the past, the Internet has provided the tools for far more clear data.

Big Data and Reimbursement

“Most patients have cell phones, email and are registered in some type of electronic record. The increased use of EMRs makes data collection even easier with integrated outcomes tools. For those not using EMRs, several companies have started to provide tools to organize and streamline the collection of outcome data. For surgeons, there is no longer any excuse to not follow all patients with at least subjective outcome measures filled out electronically. Look for these big data sets as a requirement for approval in the not too distant future.

So if it is better to stimulate repair first, which products to use? Is a partially repaired or restored joint with modest improvement better than a removed joint? Outcome data will decide the answer to these questions. For surgeons and companies alike, outcome data will rule the reimbursement world."

04/04/2014

Leaders in the foot and ankle industry spoke with Orthopedics This Week and gave them the surgeon who they would choose go to if they suffered from a alcaneous fracture or a needed an ankle replacement. Here are the tops 26 surgeons chosen and comments from the article:

"Ned Amendola, M.D.

Dr. Amendola is professor and director of the University of Iowa (UI) Sports Medicine Center. Dr. Amendola was named recipient of the Kim and John Callaghan Endowed Chair in Sports Medicine by the UI in June 2009. “He is an outstanding surgeon who treats many injured college athletes. Specifically, he is very good with malalignment problems of the foot and ankle. He is also a talented educator.”

John G. Anderson, M.D.

Dr. Anderson is the chairman of the Spectrum Health Department of Orthopaedic Surgery; he practices with Orthopaedic Associates of Michigan. “He has exceptional academic, programmatic, and organizational skills. His commitment to patient care and advancing the art of surgery puts him at the pinnacle of care providers.”

Robert B. Anderson, M.D.

Dr. Anderson is an orthopedic surgeon with OrthoCarolina, and is a past president of the American Orthopaedic Foot & Ankle Society (AOFAS). He is also a founding member of the Foot & Ankle Institute at OrthoCarolina. “His breadth of experience is enormous, and he is routinely called upon for complex cases. He is the one so many athletes seek out for treatment.”

Judith F. Baumhauer, M.D., M.P.H.

Dr. Baumhauer is a professor in the department of orthopaedics at the University of Rochester Medical Center. She is a past president of the AOFAS and is currently president of the American Board of Orthopaedic Surgery. “She is involved in clinical trials with the Carticept Medical and the U.S. aspects of rhPDGF. She has the ability to listen and then bring together people with totally disparate ideas…and leave them walking away thinking that XYZ solution was reasonable.”

Gregory C. Berlet, M.D.

Dr. Berlet is an orthopedic surgeon at the Orthopedic Foot and Ankle Center in Westerville, Ohio. “He is very widely known, well published, and is a much sought after speaker. He co-designed two different ankle replacement systems, and is extremely sought after for training expertise.”

Donald R. Bohay, M.D., F.A.C.S.

Dr. Bohay is an orthopedic surgeon with Orthopaedic Associates of Michigan. He is also clinical professor in the Department of Orthopaedic Surgery at Michigan State University and director of the Grand Rapids Orthopaedic Foot and Ankle Fellowship Program. “He has a great understanding of fusions and how they affect foot and ankle symptoms. He is an outstanding educator who has contributed to developing nationally recognized successful academic programs.”

James W. Brodsky, M.D.

Dr. Brodsky is an orthopedic surgeon with Orthopedic Associates of Dallas, and is clinical professor of orthopedic surgery at the University of Texas (UT) Southwestern Medical Center and Texas A&M Health Science College of Medicine. He is also director of the Foot and Ankle Surgery Fellowship Training Program at Baylor University Medical Center and UT Southwestern Medical Center. Dr. Brodsky is a past president of the AOFAS. “He is known for having published high quality articles on gait analysis. He has done great work on the effect of forefoot arthritis on gait and on various interventions and how they affect gait.”

Christopher P. Chiodo, M.D.

Dr. Chlodo is chief of the Foot and Ankle Surgery Service at Harvard, as well as an instructor at that institution. “He is doing important work on clinical outcomes in multiple arenas. This is insightful work that requires diligence because it takes so much time.”

Thomas O. Clanton, M.D.

Dr. Clanton is director for Foot and Ankle Sports Medicine at the Steadman Clinic in Vail, Colorado, and is a past president of the AOFAS. “He has extensive experience working with professional athletes in football, basketball, and skiing. “He is quite a good physician, a good surgeon and just a nice person.”

J. Chris Coetzee, M.D., Mb ChB

Dr. Coetzee is an orthopedic surgeon with Twin Cities Orthopedics in Minneapolis and clinical associate professor at the University of Minnesota Department of Orthopaedic Surgery. “He is uniquely talented and has a terrific grasp of issues happening in the field.”

Timothy R. Daniels, M.D.

Dr. Daniels is associate professor of surgery at the University of Toronto and head of orthopedic surgery at St. Michael’s Hospital. He is also Adjunct Scientist in the Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital. “He is involved in a cutting edge project on ankle arthritis and rhPDGF. He is a real thought leader and pushes the envelope regarding new surgical techniques and treatment options for foot and ankle fusions and hard-to-treat clinical problems.”

Richard D. Ferkel, M.D.

Dr. Ferkel is an orthopedic surgeon with the Southern California Orthopedic Institute, and is director of the Sports Medicine Fellowship Program at the same facility. Dr. Ferkel is also a clinical instructor of orthopedic surgery at the University of California Los Angeles. “He is a very good ankle arthroscopist…quite experienced and pioneering. He is the consummate educator to surgeons, fellows, and residents because he knows how to lead, is well spoken, and is exemplary with regard to patient care.”

Mark A. Glazebrook, M.S.C., Ph.D., M.D., FRCS(C)

Dr. Glazebrook is an assistant professor of surgery in the division of orthopedics at Dalhousie University in Nova Scotia. “He is a tremendous researcher who has great clarity of thought. He has great new ideas and is honest about his work.”

Steven L. Haddad, M.D.

Dr. Haddad is Senior Attending Physician at the Illinois Bone & Joint Institute in Chicago, as well as is section head of Foot and Ankle Surgery at NorthShore University Health Systems. Dr. Haddad is the current president of AOFAS. “He is a great inventor, and is very passionate about foot and ankle surgery. He is on the forefront as far as ankle replacement research and is a wonderful product developer.”

Kenneth Hunt, M.D.

Dr. Hunt is an assistant professor of orthopedic surgery at the Stanford University Medical Center in California. He practices at Stanford Hospital and Lucile Packard Children’s Hospital. “He combines clinical expertise with research acumen like few others. With a keen interest in sports injuries of the foot and ankle and a leadership role in the Orthopaedic Foot and Ankle Outcomes Research (OFAR) network, Ken will undoubtedly help shape the field of foot and ankle surgery as he progresses through his career.”

Jeffrey E. Johnson, M.D.

Dr. Johnson is a professor of orthopedic surgery at Washington University School of Medicine in St. Louis. “He has a great ability to manage very complex cases and deformities; his surgical approach involves multiple, well thought out steps. He is a very unassuming guy that everyone likes.”

Sheldon S. Lin, M.D.

Dr. Lin is associate professor at Rutgers New Jersey Medical School in Newark. “His work involves trying to determine whether biologics truly add to fusion rates. He is a true scientist, something that is really needed now that there are so many stem cell products out there.”

Thomas H. Lee, M.D.

Dr. Lee is an orthopedic surgeon at the Orthopedic Foot and Ankle Center in Westerville, Ohio. “Beyond his excellent clinical work, he has been a tremendous leader in the area of AOFAS membership; he possesses a strong understanding of electronic media. He has really ignited a spark amongst people with regard to international volunteerism.”

Jeremy J. McCormick, M.D.

Dr. McCormick is assistant professor of orthopedics at the Washington University School of Medicine in St. Louis. “He is a young guy with an inquisitive mind who is asking all the right questions regarding arthritis of foot and ankle and then designing research around that to improve on conventional wisdom.”

William C. McGarvey, M.D.

Dr. McGarvey is an associate professor in the department of orthopaedic surgery at The University of Texas Medical School at Houston. He is also program director of the UT Orthopaedic Surgery Residency Program. “He is an outstanding foot and ankle surgeon, and is an expert on trauma and small wire fixator frames.”

Murray J. Penner, M.D.

Dr. Penner is a clinical associate professor at the University of British Columbia in Vancouver. He is also a staff orthopedic surgeon at Cambie Surgery Centre and at St. Paul’s Hospital, both in Vancouver. “He is a rising star who is doing a lot of work in total ankle arthroplasty. He is a great researcher who is doing studies on total ankle arthroplasty and looking at the results of the STAR Ankle.”

Charles L. Saltzman, M.D.

Dr. Saltzman is professor and chair of orthopaedic surgery at the University of Utah in Salt Lake City. He also holds an adjunct Professorship in the Department of Bioengineering. Dr. Saltzman is a past president of the AOFAS. “He is probably the smartest foot and ankle surgeon in America. He is a great thinker and does groundbreaking research on the mechanics of forefoot surgery.”

Bruce J. Sangeorzan, M.D.

Dr. Sangeorzan is chief of the Orthopedics Service at Harborview Medical Center in Seattle. He also is professor and vice-chair of the University of Washington’s Department of Orthopaedics and Sports Medicine. Dr. Sangeorzan is president-elect of the AOFAS. “He is widely respected and sought after. He is a world expert on reconstructive treatment of patients after severe foot trauma.”

Lew C. Schon, M.D.

Dr. Schon is director of foot and ankle services at MedStar Union Memorial Hospital in Baltimore. He is also founder and director of the Orthobiologic Laboratory at that facility. He is a past president of the AOFAS. “He has a breadth of talents, i.e., anything from complex fusions to fine nerve work. He processes multiple components of complex deformity in various clinical situations.”

Keith L. Wapner, M.D.

Dr. Wapner is an orthopedic surgeon with Pennsylvania Orthopaedic Foot and Ankle Surgeons. He is also clinical professor of orthopedic surgery at the University of Pennsylvania. He is a past president of AOFAS. “He is an innovator and has made significant contributions to the technology in orthopedics. He is down-to-earth, humble guy who infuses sanity and calm into both the chaos of the OR and into society meetings.”

Alastair S. E. Younger, M.B., Ch.B., M.Sc., Ch.M., F.R.C.S.(C)

Dr. Younger is an associate professor at the University of British Columbia in Vancouver. “He is widely versed in clinical research on ankle arthritis and deformity and deformity. He is internationally recognized for his clinical expertise.”

04/01/2014

Hoping for a quick recovery!

Angels hitting coach Don Baylor was injured when trying to catch the ceremonial first pitch.

03/31/2014

A good read! What can you take from this and apply to your own life?

And the last one nearly broke my heart.