Hospital for Special Surgery Perspectives

Hot Topics for 2017 in Orthopedics

Anya Romanowski, MS, RD

Disclosures

March 13, 2017

Editorial Collaboration

Medscape &

Background

Medscape had the privilege of interviewing Todd J. Albert, MD, surgeon-in-chief and medical director at Hospital for Special Surgery (HSS) in New York City. He is also chairman of the Department of Orthopaedic Surgery and a professor of orthopaedic surgery at Weill Cornell Medical College. We talked about some of the hot topics to be presented at the upcoming American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting and some of the recent advances in orthopedic surgery.

Hot Topics at AAOS 2017

Medscape: I want to begin with a little bit about last year's AAOS conference. Many of the discussions centered on patient-reported outcomes. What are the hot topics to be presented this year?

Todd J. Albert, MD

Dr Albert: Again, the hot topics this year will be focused on patient-reported outcomes, because it does continue to be a hot topic. However, it is gaining a little increase in sophistication, such as in what kind of specific outcome measures are best for understanding specific diseases. I think there will be a little more focus on cost and outcomes—real quality measures.

Because of the changing nature of the healthcare environment and a focus on value, outcome measures and measurements of value will continue to be a hot topic. What you might see are some more sophisticated ways to measure outcomes—not just patient-reported health quality-of-life measures such as PROMIS (Patient-Reported Outcomes Measurement Information System) or disease-specific or generic outcomes, but for functional things like orthopedics and wearable devices.

We are working on things like that at HSS. If somebody needs a total hip replacement and can't walk, and has a wearable device that measures their activity patterns before and after the procedure, that's really valuable information—their ability to walk and get around. Determining how a hand patient is able to use their hands, using devices that can measure that, and then comparing that information to their health-related quality of life measures—that's a really sophisticated way to look at outcomes and value, and then to tie in cost to that as well.

Medscape: So, these wearable devices record information and provide the patient outcome data to the surgeon for follow-up.

Dr Albert: Correct, and there are no problems with recall. There are no problems with the patient having to tell you in person, because you can get it directly and download it.

HSS Orthopedic Topics of Interest

Medscape: What topics will you be presenting at AAOS?

Dr Albert: I'm presenting two large lectures. One is an orthopedic review course for people preparing for board certification and recertification. It's an anxious time for surgeons, and they obviously want to be certified. There are different parts of the course, and I'm participating in the review course for the spine. The course also covers trauma and pediatric spine deformities. Then there is a cervical and lumbar degenerative lecture; I'm presenting the section on degenerative. That will be a 30-minute lecture covering the "waterfront" of what they need to know for their board exam.

On specialty day, I am giving a lecture on predictors of adjacent segment disease—wearing out a level above or below after a fusion or a spinal procedure—which is an important topic.

Then our group is giving some talks about using bone morphogenic protein, which makes bone. It's been relatively controversial when used off-label, but its use is being considered for deformity procedures in the neck. We have some other approaches for the spine.

Medscape: I'd be interested in seeing the outcomes of using the bone morphogenic protein. Are there any presentations by other HSS faculty that you're particularly excited about?

 
It's important to tell people to not just brag and pound your chest about how great your results are, but to also note what doesn't work.
 

Dr Albert: Well, I'm excited about all of them. Not including the Orthopedic Research Society meeting and only what is being presented at AAOS, we have 160 presentations from HSS, and they're in the form of symposia, case presentations, posters, and podium presentations.

They're all important to different degrees. What I'm probably most excited about are the papers looking at population health or large datasets, as well as our experience in a couple of broad topics. What works? What doesn't work? It's important to tell people to not just brag and pound your chest about how great your results are, but to also note what doesn't work. I'm always interested in that. I'm proud that our researchers are looking at that. What are the failure mechanisms? What are the predictors of people getting a stiff knee after a total knee arthroplasty, or failure in spine surgery or sport surgery?

What Makes a Surgeon Competent?

Dr Albert: One of our focuses in our Healthcare Research Institute has been trying to figure out the minimum number of procedures someone has to do to make them competent. Alternatively, should they even be doing it? It's a big thing in surgery. You can imagine what it might be like as the chief medical officer to have to tell somebody, "You can't do this procedure because you don't do enough of them."

Medscape: In order to be competent.

Dr Albert: Yes, or is there a cut point? We have done this with Stephen Lyman, PhD, who is in our Healthcare Research Institute. We look at the Sparks database, which is a huge database of millions of patients from New York State. It can tell us, if a hospital does X number of procedures, what is their complication rate? If they do less than X number—say, total joints—is their infection rate significantly higher than another 'hospital's? Is their revision rate significantly higher?

For individual surgeons, if they do less than X, then we have to apply it to our staff because we want to be the best. We don't want anybody doing something if we think their risk is going to be higher, if the patient is going to have a complication.

Preventing Surgeon Burnout

Medscape: In the press recently, there's been a lot of focus on fatigue and burnout of surgeons in terms of patient volume, overlapping surgeries, and others aspects of performing procedures. How do you manage that at HSS, to keep your surgeons healthy and focused?

Dr Albert: It's a wonderful question. I'm very proud to say (and I'm not responsible for this) that we dug into the topics that you just alluded to when they came out. In our bylaws—basically, our rules—you cannot do simultaneous surgery at HSS. It's in our bylaws and it's been that way long before I came here 3 years ago.

Specialties that perhaps do shorter surgeries, or predictable shorter surgeries, are allowed to do what is called "flip rooms": They finish one surgery and then go to another room and start another surgery. Two patients should not be operated on at the same time in different rooms, which is not followed at all hospitals. I wouldn't say that this prevents burnout, but it prevents error, complications, and misadventures.

To prevent burnout, we try to keep our surgeons as happy as possible, to focus everything around what it takes to practice medicine to be the best. That's not always successful; sometimes you can't prevent what's happening in somebody's life that may be another stressor. But as much as possible, we try to make the environment here as pleasant and as happy as possible.

Medscape: That then carries down to the patient in terms of outcomes and minimizing complications.

Dr Albert: Yes, I think that's very true. One of the things that has really been noted at HSS—and I've been doing this at almost all grand rounds talks, talking about value and a new healthcare paradigm—is that the culture here is such that it's not just the surgeons who strive. Every single person who works here, whether the nursing staff, physical therapy staff, PAs, security, has such a vested interest in the patient outcomes being so good. They are so proud of it that you really just feel it. It makes a difference. It's intangible, almost difficult to measure, until you look at our results. And the patients feel it.

Surgical Innovations

Medscape: Are there any other recent surgical advances at HSS, or at other hospitals, that particularly excite you?

Dr Albert: I'm not embarrassed to tell you—but I'm slightly embarrassed to tell you—that I learned about some exciting technological innovations very recently. One is robotic surgery around the knee. It's outside my subspecialty, which is cervical spine specialty, so I wasn't familiar with it. What some of our surgeons are doing with robotic surgery in the knee, and how they're studying it to decide whether it's better rather than just a fad, is very exciting.

I was impressed with the thought process around how they are testing this. The idea is that potentially it's a good surgery, but maybe you can make it so precise that it becomes error-free—not, perhaps, for the expert who does a zillion of them, but for the person who's done less or wants to guarantee a perfect result. I'm interested in that.

The other one is some of the biomechanical sensors inside implants, like a wearable device, to show how the patient is doing, how they're loading their joint. That I find interesting as well.

Medscape: We will all be walking around with sensor chips in order to get the outcomes that we truly we want to achieve. Once the data are presented, it will obviously lead to more research focused on minimizing complications, shortening surgical procedural time, and so on.

Dr Albert: The other thing everybody here is doing, and which is a buzzword also, is personalized medicine. There's a lot of research being done across the street in our basic labs about looking for predictors. Are there patient factors that may be predictive of a patient having a less good outcome after a total joint? Stiffness is an important factor over scarring, so the type of blood markers may be determinants of that.

New Cervical Spine Research

Medscape: You specialize in cervical spine research and procedures. Are you working on any research at the moment that you would like to share with us today?

Dr Albert: Yes. We have a couple of things that are going on that I'm very excited about. We are almost three-quarters done with the enrollment for a randomized, prospective, double-blind study looking at the effect of local steroids in the neck. One of the problems, when we do neck surgery in the front, is swallowing. I say that to every patient and they say, "What problems?" It's a really great surgery in that there are very few complications, and patients usually go home that day or the next day and do spectacularly well.

Almost 100% of neck surgery patients have some swallowing issue. One of the things we do to try to minimize that is put steroid in a goop in the neck, because it decreases inflammation. But no one's ever studied it really carefully to determine whether it negatively affects fusion or, looking at it in a metric-based way, does it positively affect swallowing" We are using very fancy swallowing scores and all kinds of things.

It's double-blinded: I don't know if the patient gets a steroid; only my research person knows who tells the scrub nurse. We use Gelfoam®, which keeps the bleeding to a minimum; we put the steroid in the Gelfoam. I get the Gelfoam either alone or in steroids; I don't know and the patient doesn't know. Then it's unblinded, I believe, a year after surgery. We look at whether the steroid affects fusion rate and whether there are any complications.

That's one of my studies. I'm also working on a multicenter study. I don't know if you've heard of the PCORI (Patient-Centered Outcomes Research Institute) grants. It is a granting agency, like the National Institutes of Health. When the Affordable Care Act was enacted, PCORI provided about $3 billion for clinical studies and for unanswered questions in medicine and science. I'm the site principal investigator here at HSS for the study, but it was started at Lahey Clinic. I think it's being conducted at 12 sites across the country. We are looking at people who have spinal cord compression and signs and symptoms of it, but at whether anterior surgery or posterior surgery works better. I think this study is really going to make a difference in what we're doing. We are nearly finishing patient enrollment for it. There will be a series of papers coming up. It will be a good dataset.

Medscape: How long is the study going to run?

Dr Albert: We're going to have our initial enrollment done by year's end and then there will probably be follow-up at 1, 3, and 5 years.

Medscape: Any final comments for our orthopedist audience regarding research?

Dr Albert: Yes. I think that the focus going forward in orthopedic research is really going to be about how to continue to do less invasive techniques without compromising quality, and using whatever ancillary tools we can use for those effects, studying the value, cost, and quality to really get fair comparators.

Todd J. Albert, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Facet Link; Gentis; Invivo Therapeutics; Spinicity; Vital 5: United Healthcare
Holds an investment interest in: Biomerix; Crosstrees Medical; International Orthopedic Alliance (Bonovo); Invuity; Paradigm Spine, LLC; Pulse Equity; Gentis; Spinicity
Received income in an amount equal to or greater than $250 from: DePuy Synthes, Inc.; Zimmer Biomet

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