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Bundled payments are here to stay — 7 must-haves for a successful program


When former HHS Secretary Tom Price, MD, issued a proposed rule in August to cancel and scale back several Medicare bundled payment initiatives, it may have sounded like a death knell for bundles. However, it didn't deter Joseph Bosco, MD, professor and vice chair of The NYU Langone Department of Orthopedic Surgery. "Bundles are very much alive and well," Dr. Bosco said during an Oct. 27 presentation sponsored by Pacira Pharmaceuticals at the Becker's ASC Review 24th Annual Meeting: The Business and Operations of ASCs, held in Chicago. Read the full article. 

Dr. Shah to Present at Becker's 24th Annual Meeting: The Business and Operations of ASCs


The conference will take place October 26-28 in Swissotel, Chicago. Dr. Shah will be a speaker at the following panel: Total and Partial Outpatient Join Arthroplasties in ASC Setting Find more information about the conference. 

Rapid Recovery Reality in Oprah O Magazine and Elle Decor Magazine


American Academy of Orthopedic Surgeons 2018 Annual Meeting


Dr. Shah has had a study accepted as a poster presentation at the American Academy of Orthopedic Surgeons for 2018 in New Orleans, Louisiana. The study will be titled "Do We Need Hip Precautions? Dislocation Rates Following Mini-Posterolateral Approach THA With No Postoperative Hip Precautions". The poster will be displayed on March 6th from 8:00 AM to 6:00 PM and March 7th from 7:00 AM to 6:00 PM at the Morial Convention Center in New Orleans.

Alarmingly High Rate of Implant Fractures in One Modular Femoral Stem Design: A Comparison of Two Implants.


Shah RR, et al. J Arthroplasty. 2017.

Abstract

BACKGROUND: Reports of implant fracture at the modular junction have been seen in modular neck designs, stem-sleeve modular femoral stems, and diaphyseal engaging bi-body modular stems. To date, however, there has never been a direct comparison between 2 different implant designs from the same modular family. The purpose of this study is to compare the rate of implant failure of 2 such stem-sleeve modular femoral stem designs, the S-ROM and Emperion, to further identify factors which increase the risk of this mode of failure.

METHODS: A retrospective, single surgeon, review of our institutional database was performed to compare the 2 groups of patients.

RESULTS: A total of 1168 total hip arthroplasty procedures were included in our analysis, 547 (47%) with Emperion and 621 (53%) with S-ROM. Eight (1.5%) fractures in 7 patients occurred in the Emperion group compared to 1 (0.2%) fracture in the S-ROM group (P = .015).

CONCLUSION: The precise cause of the stem fractures in our study remains unknown and is likely multifactorial. Given the unexpectedly high rate of catastrophic implant failures in the form of stem fracture at the stem-sleeve junction, we recommend more judicious use of modularity in primary total hip arthroplasty.

Copyright © 2017 Elsevier Inc. All rights reserved. Read the Full Publication

Dr. Shah Featured in Chicago Health Article: Outpatient Surgery


When faced with an upcoming surgery, you might be presented with an unexpected option: Do you want to have your surgery in the hospital or in an ambulatory surgery center (ASC), a fully licensed facility that performs surgeries on an outpatient basis?

For some procedures, both the costs and the risks may be lower at an ambulatory care center.

In 1970, the nation’s first freestanding ambulatory care center opened, and today there are more than 5,400 Medicare-certified ASCs throughout the United States, according to the Ambulatory Surgery Center Association(ASCA). Illinois was a late adopter, but there are now 122 Medicare-certified ASCs in the state, performing more than 400,000 surgeries a year.

Read the Full Article Here

What if you could treat severe pain without narcotics?


The nation's opioid epidemic continues to make grim headlines as it devastates communities in Illinois and around the country. In Illinois, more people die each year of an opioid overdose, whether heroin or prescription painkillers, than of gun-related causes or car crashes, according to the Illinois Department of Public Health.

But there's reason for hope, courtesy of Chicago: a concentration of doctors and researchers who are the vanguard of a national push to treat pain without narcotics. Alternatives can't ​

come quickly enough, as drug overdoses in the state increased 7.6 percent from 2014 to 2015—making Illinois one of 19 states with a "statistically significant" uptick in overdose deaths, according to the Centers for Disease Control & Prevention.

"There's no doubt that alternative forms of pain management are essential to reducing opioid abuse," says Juliet Sorensen, a professor of law at Northwestern University who organized a recent symposium in Chicago on the epidemic. "But they take more time, more effort and more resources than popping a pill, which is how we got ourselves into this problem in the first place."

Concern about opioids has created a push for both the advancement of safer clinical alternatives and a better understanding of pain in general. As a result, Timothy Lubenow, an anesthesiologist and pain medicine specialist at Rush University Medical Center, tells his young medical fellows that there's never been a better time to work in the field. His Rush Pain Center has been a national leader in studying opioid alternatives including spinal cord stimulation.

For three decades Lubenow has specialized in the procedure, in which a device similar to a pacemaker is implanted under the skin. It uses mild bursts of electrical current to disrupt the pain signals that originate in the spine's nerve fibers, preventing them from reaching the brain. The replaceable devices, which last up to eight years, are a long-term treatment for chronic pain that can prevent people from remaining on prescription painkillers indefinitely. Lubenow says that while spinal cord stimulation has been FDA-approved since 1967, improvements in the devices over the past 18 months mean the electricity is better targeted and can be varied in intensity, which helps patients who have built up a tolerance.

"Stimulation is gaining greater traction because there have been a number of randomized controlled studies that show it reduces pain more than surgery," he says—especially in patients with chronic back pain. "It's an effective way to get by with a lower dose of opiates or no opiates at all."

There's a catch. Lubenow says it's a huge hassle to get insurers to approve the stimulators, which cost about $105,000. A month of opioids, by contrast, runs about $80.

One of his patients recently saw a 50 percent improvement in her nerve pain during a trial of a new stimulator. Despite the results, her insurance refused to pay for the device after the trial ended. Lubenow had to send a letter to the Illinois Department of Insurance, asking them to investigate, before the insurance money came through.

"Opioids are more economical in the short term but are an incredibly expensive drain on our economy in the long term," says Sorensen, the Northwestern professor. "That's why it's critical we move away from this short-term perspective."

UNDERSTANDING PAIN AND THE BRAIN

It's particularly critical when treating children and young adults. At Lurie Children's Hospital, doctors have reduced the use of opioids, especially in teens who undergo sports-related knee and shoulder operations. Instead, they insert catheters to deliver anesthetizing nerve blocks to the area for several days after surgery.

"We almost never use opioids exclusively and instead use a multimodal approach that is just as effective," says Dr. Santhanam Suresh, chairman of pediatric anesthesiology at Lurie and director of its pain management team. By "multimodal," he means an approach that includes nerve blocks to get patients over the hump of intense postoperative pain, combined with gabapentin, a non-narcotic seizure drug that also eases nerve pain. Plus, there's good old-fashioned ibuprofen.

Ritesh Shah, an orthopedic surgeon at the Illinois Bone & Joint Institute, has begun using a non-narcotic local anesthetic that he says allows his adult patients who get hip and knee replacements to recover more quickly and go home sooner than when treated with opioids. The painkiller, sold under the brand name Exparel and injected directly into the surgical site, offers pain relief for up to 72 hours. According to Shah, patients who receive it can get up and walk within 30 minutes of surgery, climb stairs within 60 minutes and go home after 90 minutes. Patients treated with opioids, meanwhile, stay in the hospital for several days and don't walk for 24 hours.

Shah says minimizing opioid use prevents feelings of light-headedness and fuzziness, which allows the patients to walk sooner. Walking lessens pain and prevents nausea because it helps move the bowels. "One of the best forms of pain control is early mobilization," he says. "When these patients get up and walk early on, they develop confidence and they actually have less pain."

Shah, who has no relationship with Exparel's manufacturer, Parsippany-Troy Hills, N.J.-based Pacira Pharmaceutical, says opioid painkillers are a big part of the reason traditional joint replacements require several days in the hospital. Those stays can cost between $10,000 and $20,000 and can put otherwise healthy patients at increased risk for hospital-acquired infections.

While doctors pursue opioid alternatives with patients, scientists at Chicago's research institutions, meanwhile, are trying to solve the problem on a different level, by better understanding how pain registers in the brain.

Northwestern scientists discovered that the mid-frontal gyrus—the yellow and red area—is responsible for placebo response in pain relief.
Northwestern scientists discovered that the mid-frontal gyrus—the yellow and red area—is responsible for placebo response in pain relief.

At Northwestern, scientists recently identified the region of the brain responsible for the so-called placebo effect, which explains why some people feel significant relief from fake treatments.

This is important because it will allow doctors to individualize pain therapy by choosing medication based on how a person's brain responds to a drug, says Vania Apkarian, a professor of physiology at Northwestern's Feinberg School of Medicine. This should reduce opioid use while still providing effective relief. "The placebo effect has been used as medicine for centuries without any scientific technology behind it," he says. "This study says there is a biologically based process behind it."

Ultimately, chronic pain management is an inexact science. Opioids are incredibly effective at reducing pain but should not be used for more than two or three months to avoid dependence, doctors say. Injections and spinal stimulation can work for longer-term pain, but they can lose efficacy over time.

"I think the problem is the unrealistic expectations created by the drug companies," says Khalid Malik, a professor of anesthesiology at the University of Illinois College of Medicine who runs UI Health's pain management center. "Everyone jumps on treatment bandwagons, but certain types of pain cannot be treated effectively."

In these cases, the psychological and holistic elements of pain management become critical. Hospitals are increasingly using multipronged, long-term approaches that eschew quick fixes in favor of cognitive therapy and biofeedback. The pain management groups at Rush, University of Illinois and Lurie all use psychologists to help patients develop coping skills, such as deep breathing and visualization.

Suresh, the Lurie anesthesiologist, says doctors also need to sit down with patients before surgery to minimize pain "catastrophizing." "We need to counsel patients, saying, 'You're going to be hurting, but here's what we're going to do,' " he says.

Dr. Shah Co-Authors Book For Orthopedic Surgeons In Training And Other Healthcare Providers


Dr. Shah says this is the book he wishes he’d had when he was an orthopedic resident himself. Titled “Pocket Orthopedic Surgery” the book is intended to provide highly relevant clinical information that residents can always carry in the hospital. Dr. Shah got the idea from another medical guidebook, Pocket Medicine, popular among Internal Medicine residents. The book has been published by Wolters Kluwer Health, a leading publisher in the health field. (More information here). Link To Amazon Page.

Fox News 32 Article: Chicago doc finds way to perform surgery with little or no narcotics


FOX 32 NEWS - An estimated 1 million Americans will undergo knee or hip replacement surgeries this year, and most will be given narcotics to deal with the pain. It’s just that sort of surgery-opiate cycle that is helping to fuel the opioid epidemic in this country. But one Chicago doctor has found a way to perform surgery with little or no narcotics. Read the article: http://www.fox32chicago.com/news/local/250050794-story#/

US News and World Report Article: Opioid Alternatives and Patient Communication Are Key for Combatting Epidemic


America's struggle with the growing opioid epidemic has swept national headlines, with some reports estimating that 91 people die every day in the United States from overuse of opioids. Even more astounding, is the fact that the U.S. makes up only 4.6 percent of the world's population, but consumes 80 percent of its opioids. And the Surgeon General's recent report highlighted that opioid analgesic pain relievers are now the most prescribed class of medications in the U.S., with more than 289 million prescriptions written each year. As a practicing orthopedic surgeon, these numbers are astonishing and concerning. As medical professionals, it is our job to take care of our patients and give them the best care and advice as possible. Prescribing opioids after surgery for many weeks or months has been the primary practice over the last several years, but recently there has been an outcry for change. Read the article: http://health.usnews.com/health-care/for-better/articles/2017-03-20/opioid-alternatives-and-patient-communication-are-key-for-combatting-epidemic