Recent research from Vanderbilt University could change the future of orthopaedic treatment and training nationwide.

Andrew Shinar, MD, associate professor of Orthopaedics and Rehabilitation and chief for the Division of Arthritis and Joint Replacement, presented two studies at July’s Southern Orthopaedic Association meeting in Asheville, N.C.

Pain Control & Knee Replacement

In one study, Shinar and his peers looked at the effectiveness of using local injections over (traditionally used) nerve blocks for knee replacements. The study, which included 82 patients, revealed those who received injections experienced less pain and faster recovery than those who received nerve blocks.

“Nerve blocks work well but come with risks,” Shinar said. “Patients can’t use their leg for a while after surgery, which increases the risk of falling, as well.”

Patients who received injections experienced less pain following surgery, were able to walk longer distances, and left the hospital sooner. “The injections are good for 8 to 12 hours which is the most intense point following surgery, but patients can then get out of bed and walk five times further in the following 24 hours,” he said.

Narcotic Use among Ortho Patients

A second study presented by Shinar examined the number of patients taking narcotics prior to knee or hip replacement surgeries. The study was spurred by a survey that ranked Tennessee high among states with illegal narcotic use and the resulting Tennessee Prescription Safety Act of 2012.

“The whole problem of opiates is amazing,” said Shinar. “Restrictions came about because Tennessee is outpacing the U.S. in opiate-related deaths from overdose.”

Shinar said the habit of treating common back and other pains with narcotics had become so widespread that opiate-related deaths increased fourfold between 2000 and 2012. Of the people who misuse opioids, over half get them from friends or relatives for free, Shinar said.

The Prescription Safety Act established a database for prescribing providers to monitor drug use. Shinar looked at patients coming in for total joints to see what medications they listed. Comparing narcotic use among patients from the last two months of years 2011-2014, Shinar saw a 38 percent drop in patients taking narcotics in the years after regulations were implemented. “That means primary care providers aren’t prescribing narcotics as often, which means regulations are having a desired effect,” Shinar said.

Better Diagnosis, Treatment for Sarcoma

More than 9,000 soft tissue sarcomas are diagnosed in the U.S. each year, and another 2,500 patients are diagnosed with primary bone sarcomas. Unfortunately, many of those patients are initially misdiagnosed, said Ginger Holt, MD, orthopaedic oncologist and professor of Orthopaedic Surgery and Rehabilitation at Vanderbilt Orthopaedic Institute. As the third largest sarcoma facility in the nation, The Vanderbilt Sarcoma Center often sees patients who require much larger surgeries and longer treatments due to misdiagnosis by primary care physicians or general surgeons.

Holt, whose team sees more than 300 sarcoma patients annually, found that one-third had to undergo a much larger surgery often due to incomplete excision of the mass. “Doctors often think it’s a benign fatty tumor and leave part of it behind,” Holt explained. “Without imaging, they usually only see the tip of the iceberg that’s pushed through.”

She then set out to find commonalities among misdiagnosed patients. Surprisingly, distance from a treatment center wasn’t a factor. “We have patients come to us from four hours away with a proper workup, while patients in our own backyard were being misdiagnosed,” she said. There also was no connection between misdiagnosis and a patient’s financial status, leaving Holt to conclude that perhaps the problem was tied to physician recognition and training. She then sent surveys to medical schools nationwide and soon discovered a gaping educational lapse.

“We looked at resident education and found that among general surgery programs, the educational process lacked training in the area of bumps, lumps and masses,” she concluded.

While training was included in 85 percent of orthopaedic surgery programs, only 35 percent of general surgery students were properly prepared. “Patients are poorly educated because this is a rare condition, but physicians also are poorly educated,” she said. “That’s where we want to make the biggest difference.”

To that end, Holt has partnered with American College of Surgeons to implement physician-training programs. She is also working to supplement general surgery curriculum at Vanderbilt and is urging insurance companies to provide educational training for physicians. That’s because a 2014 medical malpractice study showed the majority of lawsuits for primary care providers stemmed from misdiagnosis, with the dollar amount for sarcoma-related lawsuits greater than most others.

“Many doctors see this so infrequently that they don’t know the proper mechanism for imaging and referral, but the problem can become serious because patients often end up with amputation or a nasty surgery,” Holt explained.

Her advice to physicians: If a lump is bigger than a golf ball, painful or growing, it needs an MRI scan or 3D imaging. “The biggest burden of misdiagnosis is to patients, who endure extra surgery and radiation,” said Holt. “However, it also becomes a burden to the entire healthcare system.”