One of the fastest-growing medical specialties is orthopedics, with growing public awareness since the war in Southwest Asia began at the start of the century. That war’s signature improvised explosive devices (IEDs), combined with advanced body armor protecting the warfighter’s torso – but not arms and legs – has led to both tremendous advances in the saving of severely damaged limbs and a stunning revolution in prosthetics for those whose limbs could not be saved.
But advances also have been seen in non-prosthetic-related orthopedic surgeries and treatments, within military medicine but even more substantially within the Veterans Health Administration (VHA) and the nation’s growing population of veterans. While bolstered by some 3.5 million mostly young veterans from nearly two decades of combat in Iraq and Afghanistan, it is the aging Vietnam-era cohort of more than 2 million veterans that is increasing the demand on VHA orthopedic care.
“In FY 17, we performed 815,000 surgical clinic visits and 56,116 non-surgical orthopedic cases; 21,000 of those – 38 percent – were in-patient. Probably 25 percent of what we do is joint replacements – hip replacements totaled 4,639 last year, along with 9,628 knee replacements. The other 75 percent are largely arthroscopy of the knee and shoulder,” noted Dr. William Gunnar, the VHA’s national director of surgery.
The older age of VHA orthopedic patients means there are more complications due to other medical conditions and a longer recovery time, both of which increase the demand on VHA medical centers and clinical personnel.
“It’s really a remarkable amount of surgery. The median wait time from scheduling to completion was 26 days for hips; 49 percent of knees were performed within 30 days of scheduling, which is when the patient and doctor are ready to move forward. We’re not trauma centers. We have an older patient population compared to the DOD [Department of Defense] and tend not to have traumatic injuries; we deal primarily with degenerative joint disease.”
Gunnar said the Department of Veterans Affairs (VA) is well resourced to provide timely and high-quality orthopedic surgery, whether at one of approximately 100 facilities or authorized in the community at non-VA centers.
“People forget how large we are; the statistics are stunning. The VHA surgery program is located at 137 facilities; 110 are in patient and the rest ambulatory. We see 6.5 million clinic visits, perform 3.2 million consults, and, in our 870 ORs [operating rooms], perform 420,000 surgical procedures a year,” he said.
U.S. Army Reserve Col. Paul Phillips III (left), a member of the
orthopedic surgery team at Hill Country Memorial Medical Group in
Fredericksburg, Texas, explains X-ray results to patient Don Huston
and his wife, Alice, during a clinic visit March 14, 2018. DOD photo by Derrick Crawford
In 1996, the VA performed a total of 5,423 hip and knee replacements at 97 facilities. In 2017, that number had ballooned to 14,267 carried out at 98 facilities.
“So, there has been a tripling of the case volume in the last two decades, treated by the same number of facilities,” he remarked. “In FY 17, we outsourced 5,000 cases for community care services in orthopedic surgery for in-patient procedures, presumably joint replacements. From a surgical perspective, we outsourced about 20 percent of our caseload in 2014, bumped up to 26 percent, then returned to 20 percent within a couple of years. Of the 56,000 cases we did in FY 17, 21,298 were in patient.”
The number of women in combat situations, fighting wars with no defined front lines, also increased significantly since 9/11, leading to a corresponding increase in female veterans. However, Gunnar reported the number of women the VA sees for joint replacement surgery is still small, with 93 percent of all hip and knee replacement patients being male, with an average age of 65.
The older age of VHA orthopedic patients means there are more complications due to other medical conditions and a longer recovery time, both of which increase the demand on VHA medical centers and clinical personnel.
“Older patients may need a considerable workup that requires various medical specialists, typically including cardiologists, to prepare them for the OR to ensure the risk can be optimized and known. That time is variable. The Choice Act requires whenever we can’t provide services within 30 days, it is referred to community care,” he explained.
Although DOD is responsible for the health care of active-duty military personnel and the VA for veterans, the two massive care systems cooperate and share physicians and facilities in a number of locations around the country.
“That said, we hold ourselves to once the individual is ready to be scheduled, the clock starts for us. Often the veteran will not want to be scheduled, especially for an elective, within 30 days but perhaps three months from now. We still track and include those in our median time.”
The Veterans’ Access to Care through Choice, Accountability, and Transparency Act of 2014 provided primary care, in-patient and out-patient specialty and mental health care for eligible veterans when the local VA health care facility could not provide the services due to a lack of available VA specialists, long wait times, or extraordinary distance from the veteran’s home. Due to run out of funds, it was replaced in June 2018 when President Donald Trump signed the VA Mission Act, which also expanded caregiver assistance to the families of disabled veterans, extended coverage to all veterans (not just those with post-9/11 medical needs), and eliminated the Choice Act’s 30-day/40-mile restrictions.
Although DOD is responsible for the health care of active-duty military personnel and the VA for veterans, the two massive care systems cooperate and share physicians and facilities in a number of locations around the country.
“Once someone transitions to veteran status and is enrolled in the VA and signed up at one of our facilities, depending on the environment, there may be some cross-collaboration. Those are managed locally between the VA and DOD facilities,” Gunnar said. “For instance, [the] Sacramento VA [Medical Center] has a relationship with David Grant Medical Center at Travis AFB [Air Force Base], where clinicians from both DOD and the VA operate together. Orthopedic care at our Anchorage VA [Healthcare System] is done by a collaboration of DOD and VA orthopedists at Elmendorf AFB. That also is true in Honolulu.”
An X-ray of a knee. Knee replacements are among the most common procedures in an aging cohort. PTrump16 image via Wikimedia Commons
DOD’s top medical care center is the Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland, which both treats military patients and conducts research into new approaches to care and rehabilitation. Walter Reed’s Orthopedics and Rehabilitation Center offers a wide range of services, including:
- physical medicine and rehabilitation
- occupational therapy
- physical therapy
- amputee care
- orthotics and prosthetics
- orthopaedic surgery
- traumatic brain injury
- chiropractic
“Board-certified, trained specialists address the full spectrum of orthopedic musculoskeletal concerns, from pain management and sports medicine to total joint replacement. … State-of-the-art equipment, facilities, and techniques are used in arthroscopic and open musculoskeletal repair, reconstruction, and joint replacement,” the facility’s website states. “WRNMMC also participates in research in the advancement of orthopedic care, evaluating cartilage growth and transplantation to arthritic knees.
The nationwide doctor shortage is most severe among specialists, including orthopedic surgeons, and has added to the pressures on VA facilities to meet patient needs in a timely manner.
“Specialists in hand, upper extremity, and microvascular surgery treat common and complex conditions, including traumatic, degenerative, congenital, and overuse/repetitive motion injuries. Foot, ankle, and adult-reconstructive surgeons perform joint reconstruction, replacement, and revision. Physical therapists and technicians provide expert knowledge, resources, and guidance in the treatment and prevention of recurrent injuries.
The nationwide doctor shortage is most severe among specialists, including orthopedic surgeons, and has added to the pressures on VA facilities to meet patient needs in a timely manner.
“Obviously, any given environment or any of our 137 programs may struggle with hiring. There are processes to work through that, whether hiring full-time employees with benefits or through a contractual relationship. There is a host of options for hiring surgeons,” Gunnar said. “That doesn’t mean there may not be challenges at any given facility.
“But, as a whole, I see a rising number of cases at the facilities we have and our timeliness standards are reasonable, so if I lose an orthopedic surgeon at one facility, I have the option to outsource that care to the community and the patient can either wait or be referred to the community. Often they stay with the VA, because they like their doctors.”