Thoughts on research and more patients
Thomas Cutler
Description
Collection
Title:
Thoughts on research and more patients
Creator:
Thomas Cutler
Date:
5/8/2020
Text:
Hello Folks,
Yesterday, I received an email from the American Academy of Orthotists and Prosthetists about priorities in O&P research. Recently with this Covid situation, many offices have experienced a substantial reduction in patient volume. I believe it’s reasonable for the O&P community to have a legitimate interest in research that optimizes the number of viable prosthetic candidates. Question Everything” is a quote attributed to Euripides, Einstein, George Carlin, and Carl Sagan to name just a few. And for you headbangers, it’s also a song by Five Finger Death Punch. So… to all those in O&P observing from the edges like Junior Highers at their first co-ed dance, shall I ask it for all of us? Is there something wrong with how amputation surgery is designed, especially for transfemoral amputees, that reduces the likelihood of walking?
Since I intentionally and categorically did not say “how amputation surgery is performed” or “is executed”, this has nothing to do with surgeons and everything to do with accuracy of underlying assumptions when it comes to kinesiology and biomechanics. I found nothing to this effect in the AAOP research priorities.
While attending orthopedic surgery grand rounds a few months back, the chief of surgery expressed a sentiment of, “Look, if you’re over 60 and have a transfemoral amputation, you’re probably not going to walk. Now, we’ll give you a prosthesis, but we’re not expecting anything.” I was rather surprised to hear this and I, along with many of my colleagues, would disagree with his sentiment. Rather than shriek at him and call this “hate speech” in a room full of surgeons, I shared some research insights which explain why transfemoral amputees struggle, and why correcting some of these oversights could double the number of successful transfemoral prosthetic users for our offices.
I shared with them an article from Prosthetics & Orthotics International, December 2015, authored by Helito, page 463-469. First, the bad news. Only 25% of those getting amputation after an infected knee replacement (and an average of 6.8 surgeries) were successful ambulators. And the average age was 61. This makes that surgeon’s observation understandable, despite perhaps not being warranted. Now… The good news. The other half refused amputation. Despite an average age of 71, all of them were at least able to get around the house. Mind you, this is already the standard belief of clinicians in other medical professions, so there should be no worry to you folks about this kind of data getting out. Spoiler alert: it’s all about standing on the femur and having skeletal support. And we can do that for our TF patients.
Let’s connect the dots on some of these things such that they relate to O&P research priorities.
Medicare compensates surgeons about $750 for a transfemoral amputation. Does this explain why many surgeons are reluctant to engage with us? Utilization Review at the insurance company sees it as a “salvage” procedure, so they naturally pay a salvage rate. This helps me see the perspective of a surgeon. How about you? Despite being advised (Moore/Malone pg 142) to close off the periosteum (akin to a TF Ertl) allowing better weight bearing, the truth is that it’s not done.
An osseointegration article (Branemark, 2019) opens with “despite 30 years of socket improvement, there’s been no improvement in these issues”. Do you see the unintended conclusion? If improving the socket doesn’t improve the issues, there’s a significant possibility that the issues are caused before the socket is a part of the equation. Namely, that there’s room for improvement in the surgery. Again, not surgical technique. Design.
If we want better success and fewer falls with our patients, in addition to serving more amputees, shouldn’t we prioritize scrutinizing optimization of amputation surgery when it comes to research? And not only for the 10-15% who might be eligible for percutaneous osseointegration, but for every person facing amputation? People have been getting hip replacements since 1960. That’s 60 years of sticking an internal weight-bearing implant into the femur. And in case you didn’t know, surgeons make a respectable profit just from the implant itself.
Is everyone feeling better with this out in the open? See, boys? Dancing with a girl ain’t so bad after all, you know? Does anyone else step back to gain perspective, wondering why amputation choices resemble the extremes on the Covid debate? On the one side is regular amputation. Remove the IT band (seriously, why?), putting it on the medial femur to “balance” hip abduction, whistle past the graveyard of leaving the bone marrow exposed like “it’s probably fine”, and deflect discussions of the importance of skeletal support with a simple internal implant. If you don’t think it’s a discussion worth having, all I ask is that you back it up by putting it in writing with your name attached. The other side is “percutaneous osseointegration”. That’s like suggesting James Taylor and Willie Nelson ditch “shelter in place” and do a nationwide stadium tour together! How did we skip over any intermediate considerations and dash headlong into a world historically reserved for dental implants? Sure, there’s a small group of vocal proponents for perc-OI, but really? Can’t we pump the brakes a bit before resorting to this? ---All other orthopedic weight-bearing implants are internal. That’s a given. ---There’s a 55% surgical revision rate on perc-OI at 5 years. Can we lower the bar any further? With a simple internal implant, every vascular, general, and orthopedic surgeon could benefit from better outcomes without losing money on the surgery. At grand rounds, one surgeon expressed concern about infection and everyone nodded (as they should)… The FDA’s experts at the OOPD which approves these devices even expressed concern about infection both times I spoke with them, as well as grave concern that the complication rates shown in the research data was three times what was enumerated in the article.
I’m right there with the rest of you folks. This quarantine thing has taken quite the toll. And I’m grateful for the tremendous efforts that those folks put into this project. Being such a delicate topic, it’s understandable how it wasn’t included. Recently, the editorial staff of POI expressed their interest in having more qualitative research in their issues. The thing is… that’s you folks out in the regular world of O&P. …and me as well. There’s definitely a theory-practice gap. Coming from the “theory” side, they use Evidence Based Medicine. But we should be aware of our responsibility to contribute on the “practice” side. That’s where qualitative research comes in. One type of qualitative research is Grounded Theory. Regarding the theory-practice gap, this is where we come from the practice side and prove where the theory side falls short. So, we all have a part to play. For the record, I met with leaders of AOPA’s medical advisory board. Since they cancelled the full board meeting scheduled at 2019’s Annual meeting, I was unable to connect with all of them. After following up, I hit a dead end. Hopefully with more voices, we can eventually make more progress in time.
Stay safe out there as we navigate these strange waters far better together than we can alone,
Tom Cutler, CPO, FAAOP
Limbitless
Sent from Mail< <URL Redacted> > for Windows 10
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should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Yesterday, I received an email from the American Academy of Orthotists and Prosthetists about priorities in O&P research. Recently with this Covid situation, many offices have experienced a substantial reduction in patient volume. I believe it’s reasonable for the O&P community to have a legitimate interest in research that optimizes the number of viable prosthetic candidates. Question Everything” is a quote attributed to Euripides, Einstein, George Carlin, and Carl Sagan to name just a few. And for you headbangers, it’s also a song by Five Finger Death Punch. So… to all those in O&P observing from the edges like Junior Highers at their first co-ed dance, shall I ask it for all of us? Is there something wrong with how amputation surgery is designed, especially for transfemoral amputees, that reduces the likelihood of walking?
Since I intentionally and categorically did not say “how amputation surgery is performed” or “is executed”, this has nothing to do with surgeons and everything to do with accuracy of underlying assumptions when it comes to kinesiology and biomechanics. I found nothing to this effect in the AAOP research priorities.
While attending orthopedic surgery grand rounds a few months back, the chief of surgery expressed a sentiment of, “Look, if you’re over 60 and have a transfemoral amputation, you’re probably not going to walk. Now, we’ll give you a prosthesis, but we’re not expecting anything.” I was rather surprised to hear this and I, along with many of my colleagues, would disagree with his sentiment. Rather than shriek at him and call this “hate speech” in a room full of surgeons, I shared some research insights which explain why transfemoral amputees struggle, and why correcting some of these oversights could double the number of successful transfemoral prosthetic users for our offices.
I shared with them an article from Prosthetics & Orthotics International, December 2015, authored by Helito, page 463-469. First, the bad news. Only 25% of those getting amputation after an infected knee replacement (and an average of 6.8 surgeries) were successful ambulators. And the average age was 61. This makes that surgeon’s observation understandable, despite perhaps not being warranted. Now… The good news. The other half refused amputation. Despite an average age of 71, all of them were at least able to get around the house. Mind you, this is already the standard belief of clinicians in other medical professions, so there should be no worry to you folks about this kind of data getting out. Spoiler alert: it’s all about standing on the femur and having skeletal support. And we can do that for our TF patients.
Let’s connect the dots on some of these things such that they relate to O&P research priorities.
Medicare compensates surgeons about $750 for a transfemoral amputation. Does this explain why many surgeons are reluctant to engage with us? Utilization Review at the insurance company sees it as a “salvage” procedure, so they naturally pay a salvage rate. This helps me see the perspective of a surgeon. How about you? Despite being advised (Moore/Malone pg 142) to close off the periosteum (akin to a TF Ertl) allowing better weight bearing, the truth is that it’s not done.
An osseointegration article (Branemark, 2019) opens with “despite 30 years of socket improvement, there’s been no improvement in these issues”. Do you see the unintended conclusion? If improving the socket doesn’t improve the issues, there’s a significant possibility that the issues are caused before the socket is a part of the equation. Namely, that there’s room for improvement in the surgery. Again, not surgical technique. Design.
If we want better success and fewer falls with our patients, in addition to serving more amputees, shouldn’t we prioritize scrutinizing optimization of amputation surgery when it comes to research? And not only for the 10-15% who might be eligible for percutaneous osseointegration, but for every person facing amputation? People have been getting hip replacements since 1960. That’s 60 years of sticking an internal weight-bearing implant into the femur. And in case you didn’t know, surgeons make a respectable profit just from the implant itself.
Is everyone feeling better with this out in the open? See, boys? Dancing with a girl ain’t so bad after all, you know? Does anyone else step back to gain perspective, wondering why amputation choices resemble the extremes on the Covid debate? On the one side is regular amputation. Remove the IT band (seriously, why?), putting it on the medial femur to “balance” hip abduction, whistle past the graveyard of leaving the bone marrow exposed like “it’s probably fine”, and deflect discussions of the importance of skeletal support with a simple internal implant. If you don’t think it’s a discussion worth having, all I ask is that you back it up by putting it in writing with your name attached. The other side is “percutaneous osseointegration”. That’s like suggesting James Taylor and Willie Nelson ditch “shelter in place” and do a nationwide stadium tour together! How did we skip over any intermediate considerations and dash headlong into a world historically reserved for dental implants? Sure, there’s a small group of vocal proponents for perc-OI, but really? Can’t we pump the brakes a bit before resorting to this? ---All other orthopedic weight-bearing implants are internal. That’s a given. ---There’s a 55% surgical revision rate on perc-OI at 5 years. Can we lower the bar any further? With a simple internal implant, every vascular, general, and orthopedic surgeon could benefit from better outcomes without losing money on the surgery. At grand rounds, one surgeon expressed concern about infection and everyone nodded (as they should)… The FDA’s experts at the OOPD which approves these devices even expressed concern about infection both times I spoke with them, as well as grave concern that the complication rates shown in the research data was three times what was enumerated in the article.
I’m right there with the rest of you folks. This quarantine thing has taken quite the toll. And I’m grateful for the tremendous efforts that those folks put into this project. Being such a delicate topic, it’s understandable how it wasn’t included. Recently, the editorial staff of POI expressed their interest in having more qualitative research in their issues. The thing is… that’s you folks out in the regular world of O&P. …and me as well. There’s definitely a theory-practice gap. Coming from the “theory” side, they use Evidence Based Medicine. But we should be aware of our responsibility to contribute on the “practice” side. That’s where qualitative research comes in. One type of qualitative research is Grounded Theory. Regarding the theory-practice gap, this is where we come from the practice side and prove where the theory side falls short. So, we all have a part to play. For the record, I met with leaders of AOPA’s medical advisory board. Since they cancelled the full board meeting scheduled at 2019’s Annual meeting, I was unable to connect with all of them. After following up, I hit a dead end. Hopefully with more voices, we can eventually make more progress in time.
Stay safe out there as we navigate these strange waters far better together than we can alone,
Tom Cutler, CPO, FAAOP
Limbitless
Sent from Mail< <URL Redacted> > for Windows 10
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Citation
Thomas Cutler, “Thoughts on research and more patients,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 4, 2024, https://library.drfop.org/items/show/254985.
