Orthopedics

Surgeons perform an estimated 150,000 anterior cruciate ligament reconstructions (ACLRs) each year in the United States.¹ Most surgeons who perform ACLRs do so infrequently; American Board of Orthopaedic Surgery data suggest that about 90% of ACL surgical procedures are performed by surgeons who do fewer than 10 ACLRs annually.² Multiple studies have listed technical aspects as the most common reason for ACLR failure.^3-6 For this reason, it is important that surgeons focus on the technical aspects of the procedure to improve outcomes.

[Introductory paragraph provided in lieu of abstract.]

Surgeons perform an estimated 150,000 anterior cruciate ligament reconstructions (ACLRs) each year in the United States.¹ Most surgeons who perform ACLRs do so infrequently; American Board of Orthopaedic Surgery data suggest that about 90% of ACL surgical procedures are performed by surgeons who do fewer than 10 ACLRs annually.² Multiple studies have listed technical aspects as the most common reason for ACLR failure.^3-6 For this reason, it is important that surgeons focus on the technical aspects of the procedure to improve outcomes.

[Introductory paragraph provided in lieu of abstract.]

Surgeons perform an estimated 150,000 anterior cruciate ligament reconstructions (ACLRs) each year in the United States.¹ Most surgeons who perform ACLRs do so infrequently; American Board of Orthopaedic Surgery data suggest that about 90% of ACL surgical procedures are performed by surgeons who do fewer than 10 ACLRs annually.² Multiple studies have listed technical aspects as the most common reason for ACLR failure.^3-6 For this reason, it is important that surgeons focus on the technical aspects of the procedure to improve outcomes.

[Introductory paragraph provided in lieu of abstract.]

Drs. Stinner, Brooks, Fras, and Dennis of the Vanderbilt University Medical Center, Nashville, Tennessee, bring to light the important question of “communication” surrounding the efficient and appropriate care of the polytraumatized patient. Comparing their disparate experiences during residency with their common level one trauma center experience at Vanderbilt University Medical Center, it is commendable that they collectively worked to publish a commentary that argues the simple point that “we can do better.”¹

While leading with an arguably overarching condemnation of the current “system,” the article is not only provocative but is also largely accurate, sad to say. Communication is the cornerstone of quality medical care but unfortunately, for a myriad of reasons, the input and feedback loop between orthopedic trauma and critical care/trauma is often sporadic—the result of each service being siloed.

Measures have been taken to mitigate this potential deficiency—implementation of trauma care managers and nurse coordinators, and the inclusion of orthopedic trauma residents in trauma surgery rotations—but these are a poor substitute for interservice interactions at the fellow or attending level.

I am certain that these issues resonate with every orthopedic surgeon who has assisted in the care of the polytraumatized patient. We all know and can remember the “cleared” patient who was brought to preoperative holding for surgery only to be delayed because of elevated lactate, decreased hemoglobin, or inadequate resuscitation—stemming from a mismatch in communication between services on timing. And certainly we will recall in these circumstances the concomitant collective frustration of a delayed operating room, case-cart chaos, and unfair accusations of control-desk chicanery.

Although the Vanderbilt model may not be a clean fit for every trauma system, I commend the authors for exposing the proverbial “elephant in the room.” And while we may not agree that we live in a “constant state of chaos,” costly errors or miscommunication undoubtedly exist. Since the downside of performance improvement actions is exceedingly low, it behooves us to find ways to develop regular communication schemes in the interest of better care coordination for the polytraumatized patient.

Reference:

1. Stinner DJ, Brooks SE, Fras AR, Dennis BM. Caring for the polytrauma patient: is your system thriving or surviving? Am J Orthop. 2013;42(5):E33-E34.

Dr. Suk is Associate Editor of the journal; Chairman, Department of Orthopaedics, Geisinger Health System, Danville, Pennsylvania.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.

Am J Orthop. 2013;42(7):302. Copyright Frontline Medical Communications Inc. 2013. All rights reserved

Drs. Stinner, Brooks, Fras, and Dennis of the Vanderbilt University Medical Center, Nashville, Tennessee, bring to light the important question of “communication” surrounding the efficient and appropriate care of the polytraumatized patient. Comparing their disparate experiences during residency with their common level one trauma center experience at Vanderbilt University Medical Center, it is commendable that they collectively worked to publish a commentary that argues the simple point that “we can do better.”¹

While leading with an arguably overarching condemnation of the current “system,” the article is not only provocative but is also largely accurate, sad to say. Communication is the cornerstone of quality medical care but unfortunately, for a myriad of reasons, the input and feedback loop between orthopedic trauma and critical care/trauma is often sporadic—the result of each service being siloed.

Measures have been taken to mitigate this potential deficiency—implementation of trauma care managers and nurse coordinators, and the inclusion of orthopedic trauma residents in trauma surgery rotations—but these are a poor substitute for interservice interactions at the fellow or attending level.

I am certain that these issues resonate with every orthopedic surgeon who has assisted in the care of the polytraumatized patient. We all know and can remember the “cleared” patient who was brought to preoperative holding for surgery only to be delayed because of elevated lactate, decreased hemoglobin, or inadequate resuscitation—stemming from a mismatch in communication between services on timing. And certainly we will recall in these circumstances the concomitant collective frustration of a delayed operating room, case-cart chaos, and unfair accusations of control-desk chicanery.

Although the Vanderbilt model may not be a clean fit for every trauma system, I commend the authors for exposing the proverbial “elephant in the room.” And while we may not agree that we live in a “constant state of chaos,” costly errors or miscommunication undoubtedly exist. Since the downside of performance improvement actions is exceedingly low, it behooves us to find ways to develop regular communication schemes in the interest of better care coordination for the polytraumatized patient.

Reference:

1. Stinner DJ, Brooks SE, Fras AR, Dennis BM. Caring for the polytrauma patient: is your system thriving or surviving? Am J Orthop. 2013;42(5):E33-E34.

Dr. Suk is Associate Editor of the journal; Chairman, Department of Orthopaedics, Geisinger Health System, Danville, Pennsylvania.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.

Am J Orthop. 2013;42(7):302. Copyright Frontline Medical Communications Inc. 2013. All rights reserved

Drs. Stinner, Brooks, Fras, and Dennis of the Vanderbilt University Medical Center, Nashville, Tennessee, bring to light the important question of “communication” surrounding the efficient and appropriate care of the polytraumatized patient. Comparing their disparate experiences during residency with their common level one trauma center experience at Vanderbilt University Medical Center, it is commendable that they collectively worked to publish a commentary that argues the simple point that “we can do better.”¹

While leading with an arguably overarching condemnation of the current “system,” the article is not only provocative but is also largely accurate, sad to say. Communication is the cornerstone of quality medical care but unfortunately, for a myriad of reasons, the input and feedback loop between orthopedic trauma and critical care/trauma is often sporadic—the result of each service being siloed.

Measures have been taken to mitigate this potential deficiency—implementation of trauma care managers and nurse coordinators, and the inclusion of orthopedic trauma residents in trauma surgery rotations—but these are a poor substitute for interservice interactions at the fellow or attending level.

I am certain that these issues resonate with every orthopedic surgeon who has assisted in the care of the polytraumatized patient. We all know and can remember the “cleared” patient who was brought to preoperative holding for surgery only to be delayed because of elevated lactate, decreased hemoglobin, or inadequate resuscitation—stemming from a mismatch in communication between services on timing. And certainly we will recall in these circumstances the concomitant collective frustration of a delayed operating room, case-cart chaos, and unfair accusations of control-desk chicanery.

Although the Vanderbilt model may not be a clean fit for every trauma system, I commend the authors for exposing the proverbial “elephant in the room.” And while we may not agree that we live in a “constant state of chaos,” costly errors or miscommunication undoubtedly exist. Since the downside of performance improvement actions is exceedingly low, it behooves us to find ways to develop regular communication schemes in the interest of better care coordination for the polytraumatized patient.

Reference:

1. Stinner DJ, Brooks SE, Fras AR, Dennis BM. Caring for the polytrauma patient: is your system thriving or surviving? Am J Orthop. 2013;42(5):E33-E34.

Dr. Suk is Associate Editor of the journal; Chairman, Department of Orthopaedics, Geisinger Health System, Danville, Pennsylvania.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.

Am J Orthop. 2013;42(7):302. Copyright Frontline Medical Communications Inc. 2013. All rights reserved

Practicing sports medicine in a large Southern city has a number of pros and cons on an everyday basis. One of the many upsides is the trusting respect that patients have for their caregivers, doctors included. As an orthopedic resident in a large Northern city, I was often amazed at the distrust and skepticism that many patients showed toward the same professionals. I still believe—14 years later—that many of the surgeons I trained with are among the finest in the country, and they continue to lead the orthopedic world in many ways.

The trust that seems inherent in the population that I interact with on a daily basis can easily be taken for granted and/or misplaced. One manifestation of this misplaced trust occurs when a physician fails to educate a patient about their condition and treatment plan, and the patient is left wondering if the doctor is truly acting in their best interest, or if there are better options. On a daily basis, many patients who have come from every walk of life and every level of education simply want to better understand their condition and what their options are, in order to make an informed decision about what is best for them.

It is customary at this point in sports medicine practice to advise active people who suffer a torn anterior cruciate ligament (ACL) to undergo surgical reconstruction. Although the timing of surgery, surgical technique, postoperative rehabilitation, and return-to-activity criteria may differ from one surgeon to the next, the plan of care would generally be the same. The sports medicine literature would certainly support that there is more than one path to successful outcomes in ACL surgery, and it would also support there are some paths which are less likely to lead to success in some patient populations.

When encountering a patient whose surgeon did not explain the reasoning behind their specific treatment plan, what I find the most striking is that they had no idea that there was more than one way to achieve a successful outcome; they appreciate the education that we provide to help them decide which path to choose. In the case of ACL treatment, I believe that the treating physician should be well-versed in the available literature and offer considerable education to the patient about his or her options, and why the surgeon chose to recommend a specific treatment plan. I do not believe that simply saying that surgery is required, with no further discussion of the process and the inherent variables within it, is sufficient. With accessibility of information via any number of online sites, the dogmatic one-path-fits-them-all ACL surgeon may find that patients increasingly seek other opinions. The single-technique ACL surgeon may find happiness through years of successful outcomes—by his or her standards—but may ultimately find that savvy patients become aware of their other options.

I have sat through many national meetings and listened to respected surgeons talk about their techniques and innovation, along with their outcomes. Too many times I have heard that one technique, or one device, is better than another. I have also heard surgeons say with absolute certainty that a specific device or technique cannot lead to success. There is more than one way to drill a femoral tunnel for ACL reconstruction, and the ACL surgeon should be able to accomplish the goal of proper tunnel placement regardless of the technique he or she chooses. More than one graft option may lead to successful outcomes, and ACL surgeons should be skilled in the use of the various graft options. ACL surgeons should be versatile, not dogmatic and one-dimensional, allowing for a better understanding of the spectrum of injury. In saying this, I am certain that there is more than one path to successful outcomes in many of the injuries we treat as sports medicine physicians, and that thoughtful and considerate education of the patient regarding the reasoning behind our recommendations is of paramount importance.

Perhaps the patients I encountered in my training were not trusting right off the bat. I learned to watch and listen to my mentors as they communicated their knowledge to their patients. I fully recognize that clinicians who are reading this editorial likely are the ones most interested in education of both themselves and their patients. However, patients are increasingly aware that there is often more than one path to success, and I find it interesting that the medically uninformed patients seem to be more willing to accept this fact than many of the medically knowledgeable physicians.

Dr. Dugas is Editorial Board Member of this journal; and Fellowship Director, American Sports Medicine Institute, Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.

Am J Orthop. 2013;42(6):261. Copyright Frontline Medical Communications Inc. 2013. All rights reserved.

Practicing sports medicine in a large Southern city has a number of pros and cons on an everyday basis. One of the many upsides is the trusting respect that patients have for their caregivers, doctors included. As an orthopedic resident in a large Northern city, I was often amazed at the distrust and skepticism that many patients showed toward the same professionals. I still believe—14 years later—that many of the surgeons I trained with are among the finest in the country, and they continue to lead the orthopedic world in many ways.

The trust that seems inherent in the population that I interact with on a daily basis can easily be taken for granted and/or misplaced. One manifestation of this misplaced trust occurs when a physician fails to educate a patient about their condition and treatment plan, and the patient is left wondering if the doctor is truly acting in their best interest, or if there are better options. On a daily basis, many patients who have come from every walk of life and every level of education simply want to better understand their condition and what their options are, in order to make an informed decision about what is best for them.

It is customary at this point in sports medicine practice to advise active people who suffer a torn anterior cruciate ligament (ACL) to undergo surgical reconstruction. Although the timing of surgery, surgical technique, postoperative rehabilitation, and return-to-activity criteria may differ from one surgeon to the next, the plan of care would generally be the same. The sports medicine literature would certainly support that there is more than one path to successful outcomes in ACL surgery, and it would also support there are some paths which are less likely to lead to success in some patient populations.

When encountering a patient whose surgeon did not explain the reasoning behind their specific treatment plan, what I find the most striking is that they had no idea that there was more than one way to achieve a successful outcome; they appreciate the education that we provide to help them decide which path to choose. In the case of ACL treatment, I believe that the treating physician should be well-versed in the available literature and offer considerable education to the patient about his or her options, and why the surgeon chose to recommend a specific treatment plan. I do not believe that simply saying that surgery is required, with no further discussion of the process and the inherent variables within it, is sufficient. With accessibility of information via any number of online sites, the dogmatic one-path-fits-them-all ACL surgeon may find that patients increasingly seek other opinions. The single-technique ACL surgeon may find happiness through years of successful outcomes—by his or her standards—but may ultimately find that savvy patients become aware of their other options.

I have sat through many national meetings and listened to respected surgeons talk about their techniques and innovation, along with their outcomes. Too many times I have heard that one technique, or one device, is better than another. I have also heard surgeons say with absolute certainty that a specific device or technique cannot lead to success. There is more than one way to drill a femoral tunnel for ACL reconstruction, and the ACL surgeon should be able to accomplish the goal of proper tunnel placement regardless of the technique he or she chooses. More than one graft option may lead to successful outcomes, and ACL surgeons should be skilled in the use of the various graft options. ACL surgeons should be versatile, not dogmatic and one-dimensional, allowing for a better understanding of the spectrum of injury. In saying this, I am certain that there is more than one path to successful outcomes in many of the injuries we treat as sports medicine physicians, and that thoughtful and considerate education of the patient regarding the reasoning behind our recommendations is of paramount importance.

Perhaps the patients I encountered in my training were not trusting right off the bat. I learned to watch and listen to my mentors as they communicated their knowledge to their patients. I fully recognize that clinicians who are reading this editorial likely are the ones most interested in education of both themselves and their patients. However, patients are increasingly aware that there is often more than one path to success, and I find it interesting that the medically uninformed patients seem to be more willing to accept this fact than many of the medically knowledgeable physicians.

Dr. Dugas is Editorial Board Member of this journal; and Fellowship Director, American Sports Medicine Institute, Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.

Am J Orthop. 2013;42(6):261. Copyright Frontline Medical Communications Inc. 2013. All rights reserved.

Practicing sports medicine in a large Southern city has a number of pros and cons on an everyday basis. One of the many upsides is the trusting respect that patients have for their caregivers, doctors included. As an orthopedic resident in a large Northern city, I was often amazed at the distrust and skepticism that many patients showed toward the same professionals. I still believe—14 years later—that many of the surgeons I trained with are among the finest in the country, and they continue to lead the orthopedic world in many ways.

The trust that seems inherent in the population that I interact with on a daily basis can easily be taken for granted and/or misplaced. One manifestation of this misplaced trust occurs when a physician fails to educate a patient about their condition and treatment plan, and the patient is left wondering if the doctor is truly acting in their best interest, or if there are better options. On a daily basis, many patients who have come from every walk of life and every level of education simply want to better understand their condition and what their options are, in order to make an informed decision about what is best for them.

It is customary at this point in sports medicine practice to advise active people who suffer a torn anterior cruciate ligament (ACL) to undergo surgical reconstruction. Although the timing of surgery, surgical technique, postoperative rehabilitation, and return-to-activity criteria may differ from one surgeon to the next, the plan of care would generally be the same. The sports medicine literature would certainly support that there is more than one path to successful outcomes in ACL surgery, and it would also support there are some paths which are less likely to lead to success in some patient populations.

When encountering a patient whose surgeon did not explain the reasoning behind their specific treatment plan, what I find the most striking is that they had no idea that there was more than one way to achieve a successful outcome; they appreciate the education that we provide to help them decide which path to choose. In the case of ACL treatment, I believe that the treating physician should be well-versed in the available literature and offer considerable education to the patient about his or her options, and why the surgeon chose to recommend a specific treatment plan. I do not believe that simply saying that surgery is required, with no further discussion of the process and the inherent variables within it, is sufficient. With accessibility of information via any number of online sites, the dogmatic one-path-fits-them-all ACL surgeon may find that patients increasingly seek other opinions. The single-technique ACL surgeon may find happiness through years of successful outcomes—by his or her standards—but may ultimately find that savvy patients become aware of their other options.

I have sat through many national meetings and listened to respected surgeons talk about their techniques and innovation, along with their outcomes. Too many times I have heard that one technique, or one device, is better than another. I have also heard surgeons say with absolute certainty that a specific device or technique cannot lead to success. There is more than one way to drill a femoral tunnel for ACL reconstruction, and the ACL surgeon should be able to accomplish the goal of proper tunnel placement regardless of the technique he or she chooses. More than one graft option may lead to successful outcomes, and ACL surgeons should be skilled in the use of the various graft options. ACL surgeons should be versatile, not dogmatic and one-dimensional, allowing for a better understanding of the spectrum of injury. In saying this, I am certain that there is more than one path to successful outcomes in many of the injuries we treat as sports medicine physicians, and that thoughtful and considerate education of the patient regarding the reasoning behind our recommendations is of paramount importance.

Perhaps the patients I encountered in my training were not trusting right off the bat. I learned to watch and listen to my mentors as they communicated their knowledge to their patients. I fully recognize that clinicians who are reading this editorial likely are the ones most interested in education of both themselves and their patients. However, patients are increasingly aware that there is often more than one path to success, and I find it interesting that the medically uninformed patients seem to be more willing to accept this fact than many of the medically knowledgeable physicians.

Dr. Dugas is Editorial Board Member of this journal; and Fellowship Director, American Sports Medicine Institute, Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.

Am J Orthop. 2013;42(6):261. Copyright Frontline Medical Communications Inc. 2013. All rights reserved.