Interventional orthopedics

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Nivens

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I've been coming across this phrase in my internet meanderings with increasing frequency. Seems to describe much of what interventional pain docs do, plus things like PrP injections and other theoretical regenetive compounds. Any thoughts on whether existing pain docs will get to play in this space or will this be primarily the orthopods' and physiatrists' territory (if it is ever realized at all)?

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Well, it's good marketing. It also is used as a "dog whistle" to signify to patients and referring providers that: 1) You're not a "chronic pain doctor;" 2) You cater to a younger, healthier, more physically active oriented patient population, 3) You are musculoskeletally oriented.

For example, patients you WON'T see sitting in an interventional orthopedist's waiting room: Opioid tolerant fibromyalgia patients; treatment refractory facial pain with medication overuse headache; "failed back" worker's compensation patients seeking disability; chronic hemiplegic stroke patients with persistent neuropathic pain; SCI patient with painful spasticity; female pelvic pain patient with history of endometriosis status post TAH-BSO and multiple laparoscopies; "groinalgia" status-postherniaraphy; IBS/chronic abdominal pain; "wound-care"/non-healing ulcer patients; chronic fatigue syndrome or Chronic Lyme disease patients...

None of those patients get referred to Interventional Orthopedists/Physiatrists...they *DO* get referred and try to line up around the block to be seen in Pain Clinics...so, if you don't mind giving up those patients (and their payers) call yourself an "Interventional Orthopedist" instead...
 
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Sort of blows my mind that I could theoretically call myself that after an anesthesia residency... (And pain fellowship, of course)
 
I've heard "interventional spine specialist" or "interventional spine/sports specialist" but never interventional orthopedist. Seems like you'd have to be an orthopedic surgeon to call yourself that. I mean aren't all orthopedists interventional?
 
Yes, I agree. Or "conservative orthopedics" or something. With any of these, you do risk stepping on toes but it's not really deceptive IMO.
 
Sort of blows my mind that I could theoretically call myself that after an anesthesia residency... (And pain fellowship, of course)

The term was coined by PRP/Stem Cell companies (well, one company) to describe Interventional Pain doctors, or non-surgeon Sports Med doctors, who do PRP/Stem Cell injections.

If you want to have mutually beneficial relationships with the Orthopods in your area, I would avoid using this term.
 
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Well, it's good marketing. It also is used as a "dog whistle" to signify to patients and referring providers that: 1) You're not a "chronic pain doctor;" 2) You cater to a younger, healthier, more physically active oriented patient population, 3) You are musculoskeletally oriented.

:laugh: That's great.

You should submit that as a proposal for a lecture at the AAPMR meeting--Practice Management Section.

"Marketing your Spine Practice, Creating the Perfect Dog Whistle---See the patients you want, and none of the ones you don't"
 
interventional cardiologists took over cardiothoracic surgeons market
 
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Better term than Orthology which just showed up in my inbox
 
interventional cardiologists took over cardiothoracic surgeons market

true. I know one very prominent researcher/clinician in stem cells/prp who believes we could take over 50% of the work away from orthopedic surgeons, once stem cell/prp protocols are optimized and every pain fellowship includes adequate training in peripheral nerve RF ablation for the shoulder/knee/hip, etc.

Its all about branding, treating every joint in the body, and convincing the local PCPs to just send every musculoskeletal case to you first, and not to ortho. This is how cardiology took the market away from cardiac surgery, because #1 they always see the patient first and #2 they developed lower risk interventional procedures compared to cardiac surgery.

We all know there are too many spine surgeries, particularly fusions, but multiple studies have also demonstrated that a significant percentage of shoulder, hip, and knee arthroscopies are unnecessary and often counterproductive for the patient. Even arthroplasty, while great for old patients with end stage DJD, shouldn't be the first choice for younger patients (under 55) with moderate-severe OA, as surgically revising their implant 2-3 times over their lifetime carries plenty of additional risks both to relative pain control of the joint and general medical risks of infection, PE, anesthesia, etc.
I have personally seen many patients under 30, 40, or 50yrs with significant persistent joint pain s/p arthroplasty/arthroscopy. Unfortunately, many of these surgeries often took place after the patient only failed PT. Sometimes the patients are offered one steroid injection before the orthopod goes right to surgery. Viscosupplemention is often not offered, the quality of PT is generally not properly evaluated, bracing is often not considered, prolo/stem cells/PRP are never mentioned, nor is peripheral joint RF ablation. This why we need to see patients first, and if it angers some orthopedists I don't care.
 
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true. I know one very prominent researcher/clinician in stem cells/prp who believes we could take over 50% of the work away from orthopedic surgeons, once stem cell/prp protocols are optimized and every pain fellowship includes adequate training in peripheral nerve RF ablation for the shoulder/knee/hip, etc.

Its all about branding, treating every joint in the body, and convincing the local PCPs to just send every musculoskeletal case to you first, and not to ortho. This is how cardiology took the market away from cardiac surgery, because #1 they always see the patient first and #2 they developed lower risk interventional procedures compared to cardiac surgery.

We all know there are too many spine surgeries, particularly fusions, but multiple studies have also demonstrated that a significant percentage of shoulder, hip, and knee arthroscopies are unnecessary and often counterproductive for the patient. Even arthroplasty, while great for old patients with end stage DJD, shouldn't be the first choice for younger patients (under 55) with moderate-severe OA, as surgically revising their implant 2-3 times over their lifetime carries plenty of additional risks both to relative pain control of the joint and general medical risks of infection, PE, anesthesia, etc.
I have personally seen many patients under 30, 40, or 50yrs with significant persistent joint pain s/p arthroplasty/arthroscopy. Unfortunately, many of these surgeries often took place after the patient only failed PT. Sometimes the patients are offered one steroid injection before the orthopod goes right to surgery. Viscosupplemention is often not offered, the quality of PT is generally not properly evaluated, bracing is often not considered, prolo/stem cells/PRP are never mentioned, nor is peripheral joint RF ablation. This why we need to see patients first, and if it angers some orthopedists I don't care.

visco is only covered in the knee, and it is only sometimes where i practice. neither is PSP, prolo, stem cells, and possibly peripheral joint ablation. until this entities are covered, i dont see how the treatment model will change.

also, as it currently stands, most of that crap doesnt work anyway. you want to put a brace on an arthritic hip or shoulder? knees dont work, either. PT for joints is useless.

i dont think we should jump to a total joint replacement, but lets be reasonable.
 
visco is only covered in the knee, and it is only sometimes where i practice. neither is PSP, prolo, stem cells, and possibly peripheral joint ablation. until this entities are covered, i dont see how the treatment model will change.

also, as it currently stands, most of that crap doesnt work anyway. you want to put a brace on an arthritic hip or shoulder? knees dont work, either. PT for joints is useless.

i dont think we should jump to a total joint replacement, but lets be reasonable.

I agree that PT doesn't work for severe OA, but good PT for optimal biomechanics, strength and flexibility certainly help mild OA of the shoulder/knee and many other shoulder issues. Bracing does work in the right situations such as mild patellar/medial knee compartment OA, etc. However I agree there many patients that can't be helped by bracing or PT.

Prolo is covered using the general joint injection codes by most insurance companies. You don't make lots from it, but it is technically covered, as is fluoro guidance if also used concurrently.
Similarly, peripheral nerve ablation is covered by every insurance company I've ever used except medicaid. You have no argument on that one. Again it doesn't pay a mint, but it is technically covered.

PRP/Stem cells, visco for joints other than knee, is cash pay, but with the average deductible reaching $5000 for most private plans, these options easily cost less than surgery.

The main thing is to provide your patients with the full range of available non-surgical treatments, and review the relative risks and benefits of peripheral nerve RF/visco/PRP/stem cell injections vs arthroscopy/arthroplasty.

I know I would want to have all the options if it was my body. Sometimes surgery is the right thing to do, but too often it just becomes the default step because it's the only tool of orthopedic surgeons other than a cortisone injection.
 
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I agree that PT doesn't work for severe OA, but good PT for optimal biomechanics, strength and flexibility certainly help mild OA of the shoulder/knee and many other shoulder issues. Bracing does work in the right situations such as mild patellar/medial knee compartment OA, etc. However I agree there many patients that can't be helped by bracing or PT.

Prolo is covered using the general joint injection codes by most insurance companies. You don't make lots from it, but it is technically covered, as is fluoro guidance if also used concurrently.
Similarly, peripheral nerve ablation is covered by every insurance company I've ever used except medicaid. You have no argument on that one. Again it doesn't pay a mint, but it is technically covered.

PRP/Stem cells, visco for joints other than knee, is cash pay, but with the average deductible reaching $5000 for most private plans, these options easily cost less than surgery.

The main thing with all these options is to provide your patients with the full range of available non-surgical treatments, and review the relative risks and benefits of peripheral nerve RF/visco/PRP/stem cell injections vs arthroscopy/arthroplasty.
I know I would want to have all the options if it was my body.

if we can come up with good neuroablative procedures for the major joints, im all for it. sometimes you just have to cut. if im 45 with severe hip or knee OA, i want a new joint. none of this beating around the bush. if m 80 and sick, thats a different story.
 
if we can come up with good neuroablative procedures for the major joints, im all for it. sometimes you just have to cut. if im 45 with severe hip or knee OA, i want a new joint. none of this beating around the bush. if m 80 and sick, thats a different story.

Glad to hear you support RF for joints. I don't agree on the 45 yr old but do on the sick 80 year old.

If you get your knee replaced at 45 years old, you'll need that TKA revised at least twice in a normal lifetime, or three times if you are particularly long-lived. Any orthopedic surgeon will tell you that one revision is doable and similarly successful for most (but not all) patients, however success rates are much worse with a second revision for any joint in the body. Also initial knee replacements don't have the 99% success rates of that hip replacements do as the TKA success rate is only 80%. And in my own admittedly ancedotal experience, at least 25% of young THA under 50 yrs don't do well either.

I do agree that for severe hip or knee OA, if the patient is at least 55 years old, then arthroplasty becomes much more attractive. However, even at that age it depends on their sports/activity level/BMI/medical health etc and whether its hip vs knee arthroplasty. At 65 and over, I would recommend arthroplasty for most joints unless they have a major medical contraindication.
 
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