Are orthopedists getting pushed out of bone health?

Radiologists are moving in as orthopedic surgeons provide less than 50% of bone treatment.

Issue: August 2005

Health care reforms, technological advances and the increasing role of neurosurgeons, radiologists and chiropractors are causing some to worry that orthopedists are being squeezed out of musculoskeletal treatment.

“We are ceding our ability to care … for the musculoskeletal health system to so many people who really don’t know the bone, don’t care about the bone,” Laura L. Tosi, MD, director, Pediatric Bone Health Program, Children’s National Medical Center, Washington, D.C., said at the 118th Annual Meeting of the American Orthopaedic Association. Tosi participated in a symposium on this topic, organized by Scott Boden, MD, at the meeting.

Laura L. Tosi, MD [photo]
Laura L. Tosi

“… We’re not seen as part of the solution. We’re seen as part of the problem.”

A recent report documenting preventive care after injury showed that only 18% of women older than 67 years who sustain an osteoporotic fracture receive care that meets evidence-based guidelines, said Tosi, a member of the Orthopedics Today editorial board. Similarly, a recent review of 37 studies focused on the diagnosis and treatment of osteoporosis after a fragility fracture found that, on average, only 11% of patients receive dual energy X-ray absorptiometry (DEXA) scans, and just 10% of fracture patients are prescribed bisphosphonates, she said. The bottom line: orthopedists and their primary care partners are providing inadequate fracture care. “Unfortunately, we are the frontline caregivers for fragility fractures, but we’re not seen as part of the solution,” Tosi said. “We’re seen as part of the problem,” she said.

Current data helps physicians better pinpoint at-risk patients, but it is largely ignored, Tosi said. “We know that in the senior population, once you have a single fracture, your risk of future fracture goes up from between 1.5- to 9.5-fold,” she said. “A history of fracture is more predictive than any other risk factor for future fracture,” she said. “It’s more predictive than bone density, family history or even patient sex.”

An 80-year-old woman with low bone density has a 20% risk for fracture in 10 years. If the same patient had a previous fracture and shows high bone turnover, her chances increase to 55%, Tosi said. “How could anyone deny this individual treatment?” she said.

Primary care

Orthopedists must regain “ownership of the bone,” because primary care physicians lack musculoskeletal training, she said. A study by Matthew DiCaprio, MD, discovered that only 41.8% of medical programs offer a pre-clinical module or block on musculoskeletal disorders, Tosi said. And only 20% require a clerkship in the field.

“Similarly, a study by Freedman and Bernstein (JBJS 2002) 78% of recent medical school graduates failed to demonstrate basic competency in basic musculoskeletal medicine when given a brief exam which included questions on osteoporosis,” she said. “How can we depend on primary care? We can’t,” Tosi said.

Boden feels that osteoporosis is just one example of where orthopedic surgeons have not accepted responsibility for care of the entire musculoskeletal system. There could be more opportunities in the future as more less invasive treatments are developed that take advantage of molecular biology discoveries, gene therapy and minimally invasive tissue regeneration. The operations of today may be replaced by earlier disease modifying therapies.

Non-orthopedic care

So who is taking care of bone injuries? Neurologists and interventional radiologists. “Neurosurgery does about 65% to 70% of the surgery in the Medicare population in the United States,” said James N. Weinstein, DO, the chair of orthopedics at Dartmouth-Hitchcock Medical Center. Preliminary data from 2003 also suggest that neurosurgeons performed nearly as many spinal fusions as orthopedists.

Current data shows that the number of interventional radiologists doing invasive procedures, such as vertebroplasty and kyphoplasty, are also increasing, while general surgeons treat almost 12,000 hip fractures a year, he said. The crowding of these specialties leaves orthopedists with a smaller piece of the pie. “We represent only about 3% of health care expenditures and we provide less than 50% of the musculoskeletal health care,” Weinstein said.

Current and future advances in bone treatment may make it easier for nonorthopedists to siphon patients. In recent years, researchers have explored the use of bone morphogenetic proteins and other growth factors. Thomas A. Einhorn, MD, a Boston University orthopedist, said that inexpensive agonists could come within the next decade. “A synthetic small molecule can probably be marketed for under $1000 and potentially be more potent than a current $5000 marketed recombinant growth factor,” he said.

“…Will advances in biotechnology and adjacent technologies enable non-orthopedists to compete for the surgical care of our patients?”

Thomas A. Einhorn, MD [photo]
Thomas A. Einhorn

Pfizer Inc. recently developed a synthetic molecule, which promotes trabecular bone growth, at 20% of the cost of recombinant growth factors, Einhorn said. Injecting the molecule into spines could decrease nonunions and help fusion procedures, he said. But Einhorn said that new technology will not diminish the need for orthopedic surgeons. “What I’m more worried about is how easy it would be for a radiologist to do those two operations …?” Einhorn said.

Emerging remote surgical procedures, such as Project Lindbergh, do not even require a surgeon’s presence. In Project Lindbergh, a woman in France had robots — controlled by surgeons in New York — remove her gall bladder, Einhorn said. “But, will advances in biotechnology and adjacent technologies, enable nonorthopedists to compete for the surgical care of our patients?” he said. “The answer to that is, I think it’s up to us,” Einhorn said.

The trend of other specialties successfully performing musculoskeletal procedures such as vertebroplasty makes it paramount that orthopedists take action, he said. “The primary care physicians are not going to refer the patients to us,” Einhorn said. “They’re referring them largely to neuroradiologists and interventional radiologists and other physicians who have mastered this [vertebroplasty] technique and are able to do this operation with reasonable results, as far as I can tell, and potentially disenfranchise orthopedic surgeons,” he said.

Not just technicians

But how can orthopedists ensure their place in bone care? The speakers and audience agreed that it is essential that orthopedists avoid being seen as technicians who only focus on surgical procedures. Rather, orthopedists must reclaim their role as keepers of the musculoskeletal system by taking a more active role in activities such as medical student education and the development of evidence-based care pathways.

“I think we have to accept some accountability in the management of the musculoskeletal system,” Weinstein said. “I say we need to work together across disciplines and collaborative learning and we must be willing to change our learning. And we must rely on good data to drive that change,” he said.

For more information:
Boden SD, Weinstein JN, Tosi LL, Einhorn TA. The orthopaedic surgeon of the future: proceduralist or keeper of the musculoskeletal system? Symposium #3. Presented at the 118th Annual Meeting of the American Orthopaedic Association. June 22-25, 2005. Huntington Beach, Calif.