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What’s Destroying Orthopedics?—The Three O’s (and one A).

by Dale D. Dalenberg MD

One of the reasons I became an orthopedic surgeon (as opposed to a physician with less of a procedure-based and more of an office-based practice, like a family practitioner or an internist) is because I felt that I had a better chance of helping people with a knife than with a pill.  During my training, my frustration with family practice was that 80% of the patients came in with the common cold or a non-specific backache, and those are two things that doctors cannot cure. I couldn’t see myself practicing a specialty where I couldn’t fix most of my patients—although I do respect the selfless dedication of those who toil in that field.  As for Internal Medicine, my frustration was that the main thing to do for patients was to prescribe medications, but you could never be sure if patients were going to be compliant with taking their pills.  At least with a patient etherized upon a table (to borrow a phrase from T.S. Eliot), the physician has the power to heal.  Of course it doesn’t always work out that way (a future blog is entitled “When Orthopedic Surgery Doesn’t Work”). But at least in theory, with reference to the surgeon’s scalpel, “nothing heals like cold steel.” 

Modern orthopedics has worked some real miracles.  Total hip replacement, for instance, is a godsend and one of the most successful interventions in all of medicine (only coronary artery bypass grafting comes close, and also maybe cataract extraction with intra-ocular lens implant.)  Before the 1960’s to 1980’s saw the advent of most of the orthopedic implant procedures we know today, there was a barbarism associated with this field featuring amputations, wards full of people in traction, body casts, and other horrors.  I spent my early years in practice doing endless total knee replacements on former Vietnam veterans who had blown out their knees in the jungles of Vietnam and, 20 years later, now had post-traumatic arthritis. Many of them had undergone old-fashioned open total meniscectomies or been casted for ACL tears, procedures that mercifully no longer exist. Orthopedics has expanded exponentially in its ability to help people, reduce pain, correct deformity, and improve quality of life.

But despite all the advances in orthopedic medicine & surgery, we are now faced with a quadruple threat to this profession that, taken together, may throw us back into the Dark Ages. We may come to see the blossoming of this field that occurred over the past 50 years as kind of a Golden Age, with a bleaker future to come.   I will hereby name those 4 threats and give a brief synopsis of each, but all of them will be the subject of future, more in-depth blog discussions. 

The Four Horsemen of the Apocalypse (“Three O’s and one A”) are: Obesity, Opioids, Organisms, and Anticoagulants.  (I could probably throw in a fifth one that has to do with government & insurance company over-reach—financial stakeholders practicing medicine without a license, threatening orthopedists’ autonomy and ability to treat their patients—but I’ll steer clear of that one for purposes of the present discussion.) Each of the “Three O’s and one A” are worthy of a series of blogs, and those will get written in due time, but let me briefly summarize the problems that these four threats present, and how they are threatening this noble profession.

Obesity.  We are all aware of the obesity epidemic.  I myself am actually obese, but I am within close reach of being merely overweight.  Therefore, I often use myself as an example, and I jest with patients who engage with me on the topic of their weight that my personal goal is to be overweight, and that they should try to be overweight too.  It is a cute way to talk about it, but it is a serious matter.  More often than ever before, I have had to talk to my patients about Body Mass Index (BMI: a calculated amalgamation of height and weight) and its implications on orthopedic health and surgical outcomes.  BMI is not a perfect measure, because a very muscular patient might be obese by BMI criteria and still not have a very high body fat percentage.  But for most of our pudgy middle-aged orthopedic patients (who make up an increasing percentage of patients in orthopedic practices), BMI is a useful data point.  The unfortunate fact is that when BMI goes over about 40 kg/m2 (the cutoff above which the patient is termed “morbidly obese”) the complication rates go way up for total joint replacements and spine procedures.  To be sure, slender people can have complications, but morbidly obese people have a lot of complications.  These include wound healing problems, infections, early failure of joint replacements, venous thromboembolism, and death.  Some data suggest that the failure rate of total knee replacement is 25% within 5 years for patients with BMI of 40 or above.  With 74% of Americans overweight or obese, this translates into a public health problem and a crisis for orthopedic surgeons.  We are being forced every day to suck it up and operate on patients with BMI over 40, even though we know the risks.  We have had to set limits, such as rarely doing joint replacements or major spinal fusions on people over BMI of 50, for fear that the risks would outweigh the benefits.  But no matter how we slice through the data, we are having to deal with complications every day that relate to obesity, and we are being increasingly challenged by patients who are morbidly obese and are therefore not good candidates for our otherwise successful interventions. 

Opioids.  We have also been hearing a lot lately about the so-called “opioid epidemic” and the excess incidence of related addictions, drug diversion, and death in the United States from prescription pain meds.  It seems that all of a sudden everybody is weighing in on the opioid issue—the news media, the Federal government, insurance companies, support groups for patients in pain who want doctors to be able to keep giving out drugs, advocacy groups for patients who think doctors are plying patients with too many drugs and want to restrict the practice.  You name it—everybody is weighing in with their own unique agenda on this topic, and physicians are being pulled every which way, from being told that they under-treat pain, to being told that they over-treat pain.  Unfortunately, whether we like it or not, opioids are here to stay, because more than 95% of the patients who seek orthopedic care are coming in for pain (with only a small minority coming for non-painful reasons, such as deformity.)  And yet, while we would ideally like to avoid opioids, we are constantly regaled with the risks of non-opioid pain meds, such as non-steroidal anti-inflammatory drugs (NSAIDs) and their GI, renal, hepatic, and cardiac risks.  Now the Federal government and Joint Commission on Accreditation of Hospitals are asking us to de-emphasize meds and concentrate on “non-pharmacological” treatments for pain.  But such non-medication therapies are hard to find and often poorly reimbursed by insurance.  Many such treatments, such as cognitive behavioral therapy, are written about far more than they are actually practiced, and are often only available to our most affluent patients who can afford to see private psychotherapists.  A few years ago, orthopedic surgeons rarely conducted predominantly “medical” orthopedic office visits where the discussion centered mostly on the meds. But nowadays, we are constantly conducting 45-minute office visits on patients who are not candidates for surgery, but who need extensive counselling or coordination of care about their musculoskeletal pain meds and non-operative therapies.  Any orthopedist who is not managing pain medically and trying to shuffle that aspect of care off to a so-called “pain clinic” or the primary care provider, is just burying his head in the sand and possibly condemning his patient to poor musculoskeletal pain management. And yet, that pain management is becoming ever more difficult, and it might even be over the heads of some orthopedists. Insurance companies have restrictive formularies, mostly for cost-containment purposes, which limit our options for many of these patients. More and more patients these days (before they ever show up in the orthopedic office) have accelerated their pain med usage to dangerously high doses of opioids, often mixing with benzodiazepines, often combining with psychotropic meds. It is easy to understand why many orthopedists would be overwhelmed unless they have made a special study of medical pain management. To make matters more complicated, there is a growing body of literature demonstrating that patients who are opioid tolerant pre-operatively have compromised results from otherwise usually successful orthopedic procedures, again making particular reference to spinal fusions and total joint replacements.  Another issue is that it is simply not safe to operate on patients who are already nearing our maximum comfort level with opioid dosages, because simply trying to control their pain post-op in the face of all their opioid tolerance could overdose and kill them.  Many of these opioid tolerant patients are very hyperalgesic (which basically means that opioids have caused their nervous system to lose its normal pattern of pain regulation and response, causing intense pain with even minor stimuli.)    These hyperalgesic patients are often still in lots of pain despite being “maxed out” on opioids, and they do very poorly when you add extra pain by operating on them. 

Organisms. The fact that almost all staphylococcal isolates are methicillin resistant (MRSA) these days is something that has arisen during my lifetime as a surgeon.  It is generally thought to be a consequence of the over-use and abuse of antibiotics.  And now we are hearing about the advent of superbugs hiding out in hospitals, such as on GI scopes.  This is a scary development for orthopedic implant surgery, because we are permanently implanting metallic and other devices into patients’ bodies that could act as nidus for bacteria to glom onto and proliferate.  Such bacteria are increasingly known to develop a slime layer on implants that cannot be permeated by antibiotics.  If the rise of bacterial resistance continues unabated, the day could come when it is too dangerous to use implants at all.  And that would spell the doom for orthopedics as we now know it.  The inability to safely implant devices into the human body would obliterate 50 years of progress in orthopedics.   

A is for Anticoagulants.  The use of anticoagulants (blood thinners) has   proliferated to the point where a large percentage of our older orthopedic patients are on them for everything from atrial fibrillation to heritable blood clotting disorders to recent cardiac stenting to venous thromboembolism.  Many of the newer anticoagulants are very effective at keeping stents from clotting off and preventing strokes caused by cardiac arrhythmias, and yet most of the newer anticoagulants cannot be effectively monitored or reversed. While there is no doubt that anticoagulants have important beneficial effects, every month I either witness or hear about an orthopedic complication caused by anticoagulants.  Post-op wound bleeds (hematomas) are at significant risk of becoming wound abscesses, as probably 20% of wound hematomas are colonized by bacteria.  Such blood collections are a rich culture medium for organisms. Sometimes necessary operations get delayed when patients show up with their blood too thinned for surgery—such delays can lead to further complications.  Another difficult scenario is bleeding into the spine, which can cause paralysis.  In short, coordinating the medical need for anticoagulants and the orthopedic needs of the patient, and managing the attendant risks and complications of anticoagulants, is a constant battle these days for orthopedic surgeons. 

We live in an era when government regulators and insurance companies are starting to blame hospitals and doctors for complications and are withholding payments for various occurrences, such as infections complications or readmissions to the hospital.   And yet, many infections and readmissions are not preventable—bacteria, for instance, are microscopic and ubiquitous—it is usually not a doctor or hospital’s fault when patients get infected.  Most of these efforts to punish or fine health care providers for complications are advertised as efforts to ensure “quality,” but there is always the lingering suspicion that the real goal is cost containment.  There is very little scientific evidence that the benchmarks hospitals and doctors are currently expected to meet equate to actual “quality.”  The frustration for surgeons is that “The three O’s and one A” are not easily squelched.  We can practice the best possible medicine and surgery and still get trampled by these Four Horsemen.  If I set out today to minimize my risks and tweak my numbers for the regulators by refusing to operate any patient with BMI over 40 where 20 years of excess weight trashed the knees, or any patient who is already opioid-tolerant but hoping for pain relief from an orthopedic procedure, I would end up with very few surgical patients.  Therefore, in the interest of helping people, we cannot be overly selective, despite the risks.  But on the other hand, we cannot be too cavalier about the risks posed by these Four Horsemen either, both in the interest of not injuring our patients, and in the interest of not letting the regulators punish us and fine us so much that we go out of business.  If we go out of business, we can’t help any patients.  It is a fine balancing act, and they don’t teach it in medical school.  There are so many factors these days that are outside our control.  For example, a patient comes in on irreversible anticoagulants requiring emergency surgery for a fracture; so we take on the risk, and the patient bleeds badly and ends up with an infected hematoma.  Or, a patient already on large doses of opioids for chronic pain comes in with an emergency need for an orthopedic operation, and the pain is not controllable because of the pre-existing opioid-induced hyperalgesia, and thus the patient persists in saying that the pain is 10 on a scale of 10 until you prescribe so much medicine that the patient becomes moribund and has to go on ventilator support.  Or, a patient weighing 330 pounds desperately needs a knee replacement and convinces you to do it because her other knee was replaced and did great; but she falls only 10 days postop and shatters her leg around her new prosthesis, necessitating an unplanned return to the OR (and a hospital readmission) through no fault of the surgeon or the hospital.  Orthopedic surgeons are mostly powerless to prevent these scenarios.   We navigate an endless minefield dealing with these Four Horsemen. 

Every one of these 4  problems has been around forever.  The reason they are worth discussing now is that times have changed.  When I started my training, orthopedists encountered each of these 4 problems only  occasionally.  Now—with an increasing tide of obesity, opioid use and abuse, bacterial antibiotic resistance, and anticoagulants being used for just about everything—we deal with these problems daily.  Left unchecked, these Four Horsemen of the Coming Apocalypse in Orthopedics are destroying our operations, destroying our reputations as surgeons, and causing great harm to our patients.  As a rule, orthopedic surgeons are smart and talented and up to the challenge.  But the public, insurance companies, and government entities need to know that we surgeons are fighting a different war now than we were fighting only 30 years ago when I started in this profession. 

In my future blogs I intend to discuss each of the above four topics in greater depth.  I also have a bucket list of topics to discuss on orthopedic pain management, orthopedic medico-legal issues, and some technical controversies, such as the raging debate about the use of aspirin (or not) for VTE prophylaxis after total joint replacement.  The theme is “Issues and Controversies.”  I welcome comments and criticisms.  Some of these Issues have no right or wrong answers—that is why they are controversies.  Stay tuned.