Widespread Practice of Defensive Medicine Reported at Orthopedic Meeting

February 10, 2012

Defensive medicine-ordering tests, making referrals to specialists, and approving hospital admissions primarily to avoid liability and without providing significant benefit to patients-has been practiced by virtually all orthopedic surgeons, according to a study presented at the 2012 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Francisco.

Defensive medicine-ordering tests, making referrals to specialists, and approving hospital admissions primarily to avoid liability and without providing significant benefit to patients-has been practiced by virtually all orthopedic surgeons, according to a study presented at the 2012 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Francisco. In a first-ever national survey of orthopedic surgeons, 96% of respondents said they have engaged in these practices.

Researchers asked 2000 orthopedic surgeons to complete a Web-based survey. The results showed that 24% of tests were ordered for defensive reasons (x-ray films, 19%; CT scans, 26%; MRI scans, 31%; and ultrasonographic scans, 44%). Defensive medicine was the motivation behind 35% of specialist referrals, 23% of laboratory tests, and 18% of biopsies. Defensive hospital admissions averaged 7% each month.

The cost of defensive medicine per orthopedic surgeon respondent was about $8500 per month, or $100,000 per year, representing 24% of a physician's annual spending. The overall annual cost of defensive orthopedic care is $2 billion, the study estimated.

Physicians are concerned about malpractice issues and adjusting their practice procedures accordingly, suggested Manish K. Sethi, MD, lead study author and codirector of the Vanderbilt Orthopaedic Institute Center for Health Policy. Lower costs can be achieved easily by eliminating defensive medicine, he noted.

Other findings reported at the AAOS meeting include the following:

• Injection of platelet-rich plasma (PRP) enhances the rate of union in patients with ununited fractures of long bones, according to the results of a study conducted at the All India Institute of Medical Sciences in New Delhi. The finding was demonstrated by definitive radiographic evidence of healing.

The study patients had a variety of long-bone fractures, including those of the tibia, femur, humerus, and radius. The PRP injections were administered at the site of nonunion. Evidence of callus formation was seen in 55 patients by the end of 8 weeks. By 12 weeks, 40 of the 55 patients had bridging trabeculae; the remaining 15 patients had fracture union by 24 weeks. The authors noted that they cannot conclude that their method would be effective in the presence of bone defects.

Another study evaluated the effectiveness of PRP in patients with chronic plantar fasciitis whose symptoms were not responding to conservative treatment. At the 3-month follow-up, American Orthopaedic Foot & Ankle Society scores had improved for all patients. The mean scores for patients in the control and experimental groups were 81 and 95, respectively. At the 12-month follow-up, the average score for patients in the control group dropped to 58; the average score for patients in the experimental PRP group was 94. Although long-term success with PRP was seen in the study, the investigator suggested that the fundamental treatment paradigm of rest, ice, eccentric exercise, activity modification, and selective immobilization is still successful in most patients with mild to moderate disease.

• The benefits of total knee replacement (TKR) in older patients with osteoarthritis (OA), including a reduced risk of cardiovascular conditions and mortality, were highlighted in research presented at the meeting. Investigators reviewed Medicare records to identify patients who underwent TKR to relieve symptoms and those who did not. Outcomes of interest included average annual Medicare payments for related care; mortality; and new diagnoses of congestive heart failure (CHF), diabetes mellitus (DM), and depression.

In the OA TKR group, the risk of mortality was half that of the non-TKR group and the CHF rate was lower at 3, 5, and 7 years after surgery. There was no difference in DM rates among the groups. Depression rates were slightly higher in the TKR group during the first 3 years after surgery.

• Elite youth female soccer athletes face an increased risk of delayed or irregular menstruation, even though they report appropriate body perception and attitudes toward eating, according to a new research study. Also, female soccer players are more likely to experience a stress fracture or ligament injury.

The “female athlete triad”-menstrual dysfunction, eating attitudes, and stress fractures-place female athletes at risk for diminished performance and long-term health problems, it was noted. In the study of soccer players, the average age of menarche was 13 years. Irregular menstrual cycles, or absence of menstruation, were reported by 19% of 15- to 17-year-olds, 18% of college-age players, and 20% of professional athletes. A history of stress fractures was reported in 14% of the players; most occurred in the ankle or foot. The investigators suggested that more research is needed to identify the underlying causes and potential remedies and whether the findings translate to female athletes who participate in other team sports.

In another study, investigators evaluated the effects of a regular, progressive warm-up exercise program on knee injuries and health in female soccer players in Sweden. The intervention group completed a 15-minute muscular warm-up consisting of 6 progressively more difficult knee and core stability exercises twice a week throughout the season. There was a 64% decrease in anterior cruciate ligament (ACL) injuries in this group and an 83% reduction among “compliant,” fully participating players. In addition, there was a “significant” decrease in the rates of all severe knee injuries. The program is intended to replace the ordinary warm-up.

Another study, reported earlier in the Journal of Bone and Joint Surgery, compared MRI scans of male and female athletes with noncontact ACL injuries with those of athletes who participate in similar, at-risk sports but without a history of ligament injury. The study found that most of the women and only the ACL-injured men share a common geometry on the outside of their knee joint (their tibial plateau is much shorter and more rounded) that may help explain why women have an ACL injury rate 2 to 5 times higher than that of men.

• More than three-fourths of patients with orthopedic trauma have deficient or insufficient levels of vitamin D, a study found. Researchers have linked a lack of vitamin D with muscle weakness, bone fractures, and the inability of bones to fully heal. In this study, investigators evaluated patients with vitamin D levels categorized as “deficient,” “insufficient,” or “healthy”; 39% of patients were vitamin D–deficient and another 38.4% had insufficient levels of vitamin D. Patients aged 18 to 25 years had the lowest levels of vitamin D deficiency and insufficiency, but 29% were deficient and 54.7% were insufficient. The authors suggested that vitamin D deficiency is more prevalent than previously thought and that physicians consider treating patients who have fractures with a supplement to ensure optimal outcome.

• Discontinuing bisphosphonate use after an atypical femur fracture occurs can significantly lower the risk of a subsequent atypical fracture, according to a new research study. Investigators reviewed femur fracture data in patients older than 45 years enrolled in a large California HMO. The incidence of a subsequent atypical femur fracture occurring in the other thigh was 53.9% in patients who continued to use bisphosphonates for 3 or more years after their first fracture, compared with 19.3% in patients who discontinued bisphosphonate use. Overall, subsequent atypical femur fractures were decreased by 65.6% when the use of bisphosphonates was stopped within 1 year after the first fracture. The investigators recommended discontinuing bisphosphonate use as soon as possible after the initial atypical femur fracture has occurred and ongoing evaluation with radiography or MRI.

For more information, visit the AAOS Web site at http://www.aaos.org. Or, contact the organization at American Academy of Orthopaedic Surgeons, 6300 North River Road, Rosemont, IL 60018-4262; telephone: (847) 823-7186; fax: (847) 823-8125.