The Journal of the American Academy of Orthopaedic Surgeons
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J Am Acad Orthop Surg · Nov 2016
Understanding Value-based Reimbursement Models and Trends in Orthopaedic Health Policy: An Introduction to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
In 2015, the US Congress passed legislation entitled the Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act (MACRA), which led to the formation of two reimbursement paradigms: the merit-based incentive payment system (MIPS) and alternative payment models (APMs). The MACRA effectively repealed the Centers for Medicare and Medicaid Services (CMS) sustainable growth rate (SGR) formula while combining several CMS quality-reporting programs. As such, MACRA represents an unparalleled acceleration toward reimbursement models that recognize value rather than volume. ⋯ The APM pathway includes the following programs: Medicare accountable care organizations as part of the Medicare Shared Savings Program, Bundled Payments for Care Improvement, and Comprehensive Primary Care initiative. Existing APMs have yet to be determined as eligible. We provide a contextual framework of the healthcare legislation that has led to the formation of current health policy and offer recommendations regarding SGR how orthopaedic surgeons may best steer through such reimbursement models.
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Stress modulation is the concept of manipulating bridge plate variables to provide a flexible fixation construct that allows callus formation through uneventful secondary bone healing. Obtaining absolute stability through the anatomic reduction of all fracture fragments comes at the expense of fracture biology, whereas intramedullary nailing, which is more advantageous for diaphyseal fractures of the lower extremity, is technically demanding and often may not be possible when stabilizing many metaphyseal fractures. ⋯ Numerous surgeon-controlled variables can be manipulated to increase flexibility without sacrificing strength, including using longer plates with well-spaced screws, choosing titanium or stainless steel implants, and using locking or nonlocking screws. Axially dynamic emerging concepts, such as far cortical locking and near cortical overdrilling, provide further treatment options when bridge plating techniques are used.
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J Am Acad Orthop Surg · Jul 2016
ReviewIntramedullary Fixation of Clavicle Fractures: Anatomy, Indications, Advantages, and Disadvantages.
Historically, management of displaced midshaft clavicle fractures has consisted of nonsurgical treatment. However, recent literature has supported surgical repair of displaced and shortened clavicle fractures. Several options exist for surgical fixation, including plate and intramedullary (IM) fixation. ⋯ However, concerns persist regarding the complications associated with the use of these implants, including implant failure, migration, skin complications, and construct stability. Second-generation IM implants have been developed to reduce the limitations of earlier IM devices. Although anatomic and clinical studies have supported IM fixation of midshaft clavicle fractures, further research is necessary to determine the optimal fixation method.
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J Am Acad Orthop Surg · Jul 2016
Comparative StudyComplications After Surgical Management of Proximal Femoral Metastasis: A Retrospective Study of 417 Patients.
Proximal femoral fractures resulting from metastatic disease often require surgical management. Few studies have compared surgical techniques, and physicians' preferred strategies vary. This study compared revision and complication rates among surgical strategies. ⋯ Therapeutic Level III.
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Proximal junctional kyphosis (PJK) is a common complication following adult spinal deformity surgery. It is defined by two criteria: a proximal junctional sagittal Cobb angle (1) ≥ 10° and (2) at least 10° greater than the preoperative measurement. PJK is multifactorial in origin and likely stems from surgical, radiographic, and patient-related risk factors. ⋯ In keeping with the broad spectrum of the disease, classification schemes are needed to better describe and stratify the severity of PJK. The most severe form is proximal junctional failure. A consensus on a uniform definition of proximal junctional failure is needed to allow for more systematic study of this phenomenon.