Friday, March 15, 2013

Immediate postoperative x-rays - value?

Immediate Postoperative Radiographs After Shoulder Arthroplasty Are Often Poor Quality and Do Not Alter Care

It is always wonderful when folks question the value of a practice: does the benefit justify the cost?

The issue with this paper is whether the authors are answering the question for all of us, or just for themselves. 

What this paper really says is that the authors found it difficult to obtain high-quality, postoperative shoulder radiographs immediately after surgery. Furthermore their postoperative underpenetrated single-view radiographs taken in internal rotation did not change their postoperative management and were not considered adequate to serve as a baseline for followup studies. Appropriately, they questioned the value of their routine postoperative radiographs after shoulder arthroplasty.

Their retrospective study showed that when postoperative films were taken later on in their office, they were able to obtain multiview radiographs, and most were deemed adequate to serve as baseline radiographs. 

Our experience is a bit different. For example, here are the recovery room films on a man who came from another state for a total shoulder on his second side.

These films enabled us to reassure ourselves and him that his alignment and prosthetic fixation were as expected. They will serve as the baseline films for our prospective followup study of shoulder outcomes. He left the medical center with a printed copy of these films for his personal file for comparison should he need additional films near home before our routine followup.

To be fair, the radiology techs that work in our recovery room are well trained in taking shoulder radiographs and each of our post operative films is personally supervised by a member of the surgical team (resident, fellow or attending surgeon).

So the point is that postoperative films can be of good quality and and be helpful in clinical management, but one needs to exert quality control to make sure the value is there.

No sooner do I get this post up, and one of my best friends (the kind who always shoots straight with me) fires back: "I continue to question whether taking good [recovery room films] adds value. I can't answer this for the shoulder. I'm pretty sure that my practice of taking PACU films does not add value.  I've never diagnosed a knee fracture on one of these films (knock wood), and as far as I can tell, have never changed management based on one of these films.

Of all the points made in your commentary, the value argument even for good-quality films is the least compelling for me, but, again, I'm not a shoulder guy. For example, the concept of using them for a prospective study is particularly iffy – I assume the cost is not covered by a research grant – and I think the value of using them as a take-home for patients probably needs to be substantiated.

My general sense is that it should be incumbent on those of us who order a test (such as me ordering PACU films on knees) to prove their value, otherwise we should desist."

In a country where health care costs are rising without bound, we need to ask these tough questions.

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