X-Ray Often Better and Cheaper than MRI in Knee Diagnostics

A weight-bearing X-ray is a better diagnostic tool and much less expensive than the MRI typically prescribed for patients with knees affected by osteoarthritis, according to a recent study. A patient’s medical history and a routine physical should be the starting point for a primary-care physician, followed by basic diagnostics.

"MRIs are being used in excess. Many doctors no longer talk to or examine their patients. Instead, they are going right for the technology," said Wayne Goldstein, MD. Dr. Goldstein, lead author on the study, is a clinical professor of orthopedics at the University of Illinois at Chicago College of Medicine and chairman of the Illinois Bone and Joint Institute.

"This is another example of over-utilization of the health-care system. It has become easier to go for the high-cost imaging. On average, an X-ray can cost less than $150, while an MRI can cost around $2,500". Medical imaging now accounts for 10%-15% of Medicare payments to physicians, compares with less than 5% only 10 years ago.

In 2008, Medicare will reimburse doctors more than $400 per MRI. By contrast, a 4-view X-ray which effectively reveals osteoarthritis and is routinely used by most orthopaedic surgeons, reimburses doctors just over $43. It is estimated that these MRI costs will continue to row at an annual rate of 20% or more in 2008. In the United States more than 533,000 total knee replacements were performed in 2005, primarily because of severe pain, swelling of stiffness of the knee caused by osteoarthritis.

A random sample of 50 knee arthroplasty patients found that 32 of the 50 had had a knee MRI within 2 years before surgery, ordered by their primary-care or orthopedic physician. The MRI did not produce any diagnostic information which could not have been provided by an X-ray, and more than 50% did not have any X-rays before surgical consultation.

"There are some indications for MRI, such as suspicion of avascular necrosis [in which blood loss to the area causes bones to break down, something which may not be seen on early X-rays], but that is not a common condition," Dr. Goldstein said. Dr. Goldstein and his co-authors believe that the main reason for this over-utilization of the MRI is a lack of education on this diagnostic technique, especially with family and primary-care physicians.

Dr. Goldstein added, "We fix this problem through educating physicians on the appropriate use of MRIs. We also need to educate our patients. Virtually every adult experiencing a knee problem should first have an appropriate set of X-rays before considering an MRI, which has been marketed as the premier diagnostic tool, so patients often come into the office expecting, even demanding, an MRI. Physicians need to look at why they are ordering an MRI and consider whether it is truly necessary."

The study was presented at the 75th Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in March, 2008.

Knee Surgery Recovery and Range of Motion Limited By Obesity

After total knee replacement surgery, obesity limits a patient’s range of motion, makes the recovery period longer and calls for extended physical therapy, according to a recent study. A patient’s body mass index (BMI)—a correlation between height and weight—has a direct relationship on the knee’s range of motion and need for manipulation under anesthesia.

Close to 20% of patients with a BMI of 25 to 30 needed manipulation for improved flexibility and to break up scar tissue, while patients with a BMI of less than 25 needed the manipulation. Said Geoffrey Westrich, MD, lead author of the study and an associate professor of orthopaedic surgery at Hospital for Special Surgery in New York City, "For anyone considering knee replacement surgery, recovery time is always an important consideration". Heavy patients, he continued, need to be advised that their weight will probably slow their recovery.

Data from 309 patients (400 knee replacements) who underwent the procedure at Hospital for Special Surgery was evaluated for the effect of BMI on range of motion and the need for manipulation under anesthesia. Patients with BMI from less than 25 to more than 29.9 were divided into groups: major findings from the study were as follows:

  • The greater a patient’s BMI, the less range of motion they can expect after knee surgery
  • Age was not a predictor for range of motion
  • Gender was a predictor for range of motion and the need for manipulation
  • Regardless of BMI: – Men had a 4.6-degree higher range of motion than women – Less than 10 percent of men needed manipulation six weeks after surgery compared to 18.5 percent for women

"Our study reinforces the drain that obesity is having on the health-care system," Dr. Westrich said. "The obesity epidemic is causing health-care expenditures to grow at a rapid rate. Insurance companies, Medicare, hospital administrators, and patients need to understand that obesity will likely cause different patient outcomes, including more complications that may require further surgical interventions."
Dr. Westrich concludes that "setting realistic expectations prior to surgery is paramount to patient care.". Surgeons performed more than 533,000 knee replacements in 2005.

The study was presented at the 75th Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in March, 2008.

Will There Be Enough Orthopedic Surgeons to Meet Joint Replacement Demand?

According to a new study by Dr. Iorio and his colleagues to be presented at the 75th Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), the numbers of hip and knee replacement surgeries have increased dramatically in the last 10 years.

Dr. Iorio, senior attending orthopedic surgeon at the Lahey Clinic in Massachusetts said, "We are preparing for an epidemic of serious proportions."

In 2005, 285,000 total hip replacements and 523,000 total knee replacements were performed in the United States. By 2030, these two procedures are expected to jump to 572,000 and 3.4 million, respectively. Said Dr. Iorio: "The demand for these procedures will grow rapidly, and the orthopedic workforce will not be able to keep up. The supply of orthopedic surgeons will only increase 2 percent during 2000 and 2020. What we have on our hands is an access problem."

A 2005 survey of more than 23,000 AAOS members revealed:

  • 30 percent identified themselves as general orthopedic surgeons
  • 13 percent of orthopedic surgeons identified themselves as specialists in sports medicine
  • 10 percent identified themselves as hand surgeons
  • Only 7 percent identified themselves as primary surgical specialists for the adult hip and knee

"Simply put," Iorio added, "there will be a need for services that overwhelms the supply of physicians who will be able to fill that demand. Patient care is of utmost concern to us. Getting arthritic patients back to the quality of life they once had is always first and foremost. If these projections come to life, the access for a joint replacement will negatively impact patient care."

Older Adults Can Recover Well from Anterior Cruciate Ligament Surgery (ACL)

Today, older adults are staying active much longer, making them susceptible to injuries—especially vulnerable to tearing their anterior cruciate ligament (ACL).

A new study presented today at the 75th Annual Meeting of the American Academy of Orthopaedic Surgeons, found that these active baby boomers who undergo ACL surgery are about as likely to return to pre-injury levels of activity as much younger people. These findings have led researchers to conclude that age itself should not be a factor when determining candidates for the increasingly common knee-ligament surgery.

"Twenty years ago we did not see older patients being so active later in life. ACL surgery was rarely considered for people in their 40s and 50s," said Diane Dahm, MD, assistant professor of orthopaedic surgery at the Mayo Clinic in Minnesota."Older patients today want to continue to run, play basketball and be active late into life, so they need a level of knee stability that will support an active lifestyle."

The study followed the recovery of 34 patients aged 50 to 66 for an average of 48 months between 1990 and 2002 following ACL surgery at the Mayo Clinic. Patients with injuries to multiple knee ligaments were excluded.

The study found that after ACL surgery:

  • 83 percent were rated as normal or near-normal
  • 83 percent returned to playing sports
  • patients went from 4.3 before surgery to 8.3 postoperatively on the UCLA ( University of California at Los Angeles), activity score
  • five of the 34 patients required additional knee surgery

"Today’s active baby boomers are pushing the envelope for when people are considered to be too old for ACL surgery," concluded Dr. Dahm."When considering candidates for ACL surgery, people’s fitness levels and their desire to return to an active lifestyle should be taken into account rather than looking at age."

The ACL is one of the most commonly injured ligaments of the knee. The incidence of ACL injuries is currently estimated at approximately 200,000 annually, with 100,000 ACL reconstructions performed each year. In general, the incidence of ACL injury is higher in people who participate in high-risk sports, such as basketball, football, skiing and soccer.

Fractured Shoulder May Lead to Higher Incidence of Broken Hip in Older Women

Older women who suffer a broken shoulder (proximal humerus fracture) have a high risk for also breaking a hip within a year after the shoulder injury.

A new study presented today at the 75th Annual Meeting of the American Academy of Orthpaedic Surgeons (AAOS), found that after a shoulder fracture a woman’s risk of fracturing a hip within the following year was five times greater. The risk decreased after the first year but still remained elevated.

Understanding the connection between these injuries is important to preventing hip fractures. Hip fractures account for more than 350,000 hospital admissions in the United States and more than 60,000 nursing home admissions each year. Women have greater risk because of their higher susceptibility to osteoporosis.

Statistics show:

  • about 70 percent of hip fracture patients are women
  • more than 4 percent of hip fracture patients die during their initial hospitalization
  • 24 percent die within a year of the injury
  • about half of women who sustain hip fractures lose the ability to walk independently

Preventing hip fracture poses s a significant quality-of-life issue. "Earlier studies have shown that there is an increased risk of hip fracture after a proximal humerus fracture, but our study found that there is a defined window of time in which the risk is much greater than previously thought. Additionally, other research has shown that interventions within the first three months can reduce the risk of subsequent fractures," said Jeremiah Clinton, MD, co-author of the study and acting clinical instructor at the University of Washington, Department of Orthopaedics. "If we maximize our hip-fracture prevention efforts up front, we may have a much better chance of helping the patient avoid a life-changing and potentially life-ending injury."

The study followed a group of older, Caucasian women for nearly 10 years and found that, while 8 percent of women who did not break a shoulder suffered hip fractures, approximately 14 percent of those who suffered a shoulder fracture later sustained a hip fracture.

The strongest risk factors for hip fracture were age and hip bone mineral density. Other factors included:

  • self-reported health status
  • height at 25 years of age
  • history of recent falls
  • impaired depth perception
  • history of prior fractures

Even when controlling these factors, the researchers still found the increased risk for hip fracture in the first year after a proximal humerus fracture. The reasons for the connection between humerus fracture and hip fracture are still unclear. "It may be associated medical problems, limited use of the injured shoulder, or there could be something about the treatment for the first fracture, such as narcotic pain medications, which could have caused the patient to fall and break a hip," Dr. Clinton said. "Now that we are aware of the relationship between these types of fractures, we can take precautions, intervene early and hopefully help to prevent some hip fractures from occurring."