Fiscal Responsibility in Orthopedics

October not only introduces the expected autumnal change in climate resulting in cooler temperatures, shorter periods of daylight, and vibrant color changes to foliage, it also signals the start of the 2012 budgeting season for the orthopedic department.

As part of our "formalized" orthopedic service line at St. Joseph's Hospital, we are fortunate that this process for us has evolved to be a true partnership with the hospital, and a genuine multidisciplinary team effort which involves the physicians, nurses, physical therapy, and many other clinical support personnel. 

Gone are the days where the hospital holds sole decision-making authority when it comes to projecting operational costs (those recurring on a regular basis), and capital costs (purchase of equipment).  The difference between these two types of expenditures can easily be correlated to running or managing the finances of a household.  Operating costs associated with household management include the groceries purchased on a regular basis, as well as the payment of monthly utility bills.  In orthopedics, operational costs include the supplies and implants used during surgical procedures.  Capital costs associated with a household include the replacement of appliances that are at the end of their life (refrigerators, washers/dryers, snowblowers) or items that are new purchases (an entertainment center or furniture). In orthopedics, capital items include equipment that needs to be replaced such as drills, instruments, surgical tables, or specially designed hospital beds or chairs, as well as new technology-type items that keep our program up-to-date and able to deliver the highest quality patient care.

As physician leaders of this service, we take this responsibility very seriously. Escalating health care costs, specifically the rising cost of medical supplies and devices, are the responsibility of everyone to keep controlled. We work exhaustively with the Orthopedic Service Line Administrator to accomplish these very lofty goals.  

To accomplish this challenging task, we, along with the service line administrator, have hardwired specific processes into our service line management:

**Monthly product standardization meetings to explore new and alternative products that have the potential to improve quality while reducing costs

**Supply and implant control--no vendors, surgeons, or staff bring new items into the OR without prior committee review and approval

**Periodic implant re-bidding process for hip and knee components to ensure that costs remain controlled

**Scheduled replacement of equipment only when warranted and at end of life

**Review of all newly available orthopedic technology and planned addition if it makes sense from a quality and patient care standpoint as opposed to a passing fad

We have had significant positive results in controlling costs with this approach.  Our successful management of the orthopedic service line supplies and implants garnered recent national attention.  Our process was recently presented at the Managing Today's OR Suite Conference in Chicago.  A follow up article relative to this topic will be published in their national journal later this year.

Rest assured that we manage the hospital's precious resources for orthopedics in a fiscally responsible manner to ensure that the highest quality care is provided at the lowest cost. The effort in this regard is never considered finished and continues on an ongoing basis.  Our goal is to strengthen the orthopedics program at the hospital both today as well as into the future.

Game Time

We’re always a little hyped up. It’s a little early, 7am, but we’ve been up for 2 hours.  Everyone prepares in a different way. For some it’s a physical movement or mental traits- brisk calculated activity, silent concentration, talkative, etc. There is usually some music in the background the genre varying. The importance of the event doesn’t need to be discussed, we all get it. The team is not random but carefully selected- they are the best of the best. They all chose to be a part of this elite team, some at considerable personal expense. There is a hierarchy, there has to be for this type of operation. Even though there is a hierarchy it does not belay the importance the essentialness of each person that’s a part of our team.

The team leader asks the members “Are we ready to begin?” – a resounding “Yes” with a sense of purpose is elicited.  A member of the team leaves the room to begin the encounter.

For security purposes, the target will be identified as “Bill”.

A team member approaches Bill, gathers the appropriate information, asks if he has any concerns and begins pushing the gurney into the OR.

We’ve already slipped Bill some specially prepared “medication”. He’s “happy”.

The mood as he enters the room is of quiet confidence. Everyone on this assignment has been here many times before, and the sense of winning is in the air.

Positioning, preparation and draping occur as a matter of routine.

There is a “time out” where the entire team stops, we review our goals our tools our mission and before beginning we all confirm that we are on the same page.

“Time to rock and roll” says the leader. There is some “white noise” in the background, better known as music. There is very little talking, everyone knows their roles so well there doesn’t have to be words- there are motions, there is anticipation, an occasional request. We move quickly, without the sense of rushing, but with deliberateness that radiates confidence.

The operation is going smoothly and there is a relaxed joviality in the air. Suddenly in a calm but firm manner- “bleeder” is verbalized. Sudden change in the atmosphere, flight or fight response instantly. No jokes all business. Suction, clamps, ties- control quickly achieved. Second and third checks – OK everything good. No high fives or celebration, just the professionalism that comes with experience. The mood shifts and we relax again.  The components of the joint replacement are placed and the results are up to the standards of the team.

Now there is a moment where everyone feels it- that sense of “Yeah Baby”, perfect. We don’t necessarily say it but we feel it- everyone in the room does. We relish that feeling for a bit (we live for it), and then get ready for our next mission.

Operation Walk Syracuse Extends Its Gratitude to Franciscan Companies

Operation Walk Syracuse would like to extend our heartfelt appreciation to Franciscan Companies for their tremendous support to Operation Walk Syracuse.  Thanks to their donation our Nepalese patients will have the use of reacher/grabbers, sock aides, commodes, raisted toilet seats, wheelchairs, oximeters, and glucose monitors during our November visit.  It is through the generosity of groups like Franciscan that we are able to provide this life-altering procedure for people around the world with limited access to care.

Franciscan Companies is an affiliate of St. Joseph’s Hospital Health Center. Through a variety of companies and partnerships, Franciscan Companies extends the reach of the St. Joseph’s network throughout the Central New York community. From home health care services to durable medical equipment, from infusion services to medication dispensing machines, Franciscan ensures that patients discharged from St. Joseph’s Hospital—as well as other hospitals in the area—receive the continued care, services and products they need for improved health and comfort.

Follow Up to Channel 10 Story

A recent YNN story which aired on Saturday, July 16^th focused on two elements related to joint replacement surgery:

·         Implant materials (surgeon interview)

·         Outcomes after joint replacement surgery (physical therapist interview)

Unfortunately, the two twains of the interviews never intersected and there was no opportunity for the surgeon, board-certified and fellowship trained in adult reconstructive surgery, to weigh in with his expertise on the topic of functionality after total joint replacement surgery.

The  physical therapist interview cited a study (studies) which report findings that significant impairments and functional limitations continue at one year post total knee replacement.¹  This study, published more than ten years ago, also clearly had a major design flaw.  Patients in the study group were significantly heavier and had a higher percentage of body fat than the control group members.  This makes the reported findings suspect because clearly the two groups had major differences.

Two more recent publications in the physical therapy literature cite dramatically different findings than the 1998 study.  A recent meta-analysis of the literature published just this year reports that in the areas of perceived physical functioning, functional capacity, and actual daily activity, patients experienced significant improvement postsurgery compared to presurgery.²

Another study (published in 2008) evaluated physical activity after total hip replacement and found that despite having experienced a major surgical procedure, patients having undergone total hip replacement had achieved a level of physical activity consistent with the normative population, and even exceeded the intensity of physical activity for the same group at both light and moderate intensity levels.³

Restoration of mobility and function are obvious reasons to pursue joint replacement surgery, however, the number one reason patients choose to undergo a hip or knee replacement is to obtain relief from debilitating arthritis pain.  Joint replacement surgery is a last resort intervention after more conservative interventions such as physical therapy, medications, and injections have failed.  After the risks, benefits, and alternative options have been thoroughly discussed with the patient, he or she is the sole decision-maker to move forward with joint replacement surgery.  The surgical procedure itself relieves the arthritis pain, but the surgery itself only serves as the conduit for improved motion and function postoperatively.  Patient participation in the postoperative rehabilitation plan is the most important determinant in achieving physical activity goals.

¹Walsh, M., Woodhouse, L., Thomas, S., & Finch, E.  Physical Impairments and Functional limitations: a Comparison of Individuals 1 Year after Total Knee Arthroplasty with Control Subjects.  Physical Therapy.  1998; 78(3):  248-254.

²Vissers, M.M., Bussman, J., Jan, V., et al.  Recovery of Physical Functioning after Total Hip Arthroplasty:  Systemic Review and Meta-Analysis of the Literature.  Physical Therapy.  2011; 91(5):  615-629.

³Wagenmakers, R., Stevens, M., Zijlstra, W., Jacobs, M., et al. Habitual Physical Activity Behavior of Patients after Primary Total Hip Arthroplasty.  Physical Therapy.  2008; 88(9):  1039-1048.

Our thanks to Megan Hickey, Manager of PM&R, for her assistance in this review of the physical therapy literature.

Joint Replacement Materials: What's in an Implant?

More than a million people in the U.S. each year experience relief from pain and improved function as a result of total joint replacement surgery.  This life-altering procedure is regarded as one of the most valued developments in the history of surgery.  Currently Hip Replacement is the single most reliable operative procedure developed by modern medicine followed closely by second place winner, Knee Replacement surgery.  Although the procedure has been made routine in major centers, ongoing clinical research, design improvements, and improved wear resistance of the man-made materials used in the implants remain an evolving science.

WHY ARE MATERIALS IMPORTANT?

A “bearing surface” is a mechanical engineering term that describes the area of contact between two objects. Nature’s joint bearing surface is articular cartilage. When healthy articular cartilage rubs against itself in a healthy joint, very little friction is produced and virtually no wear particles are made.  Articular cartilage has no nerve endings so the natural rubbing of a joint is painless.  Articular cartilage gets all its nutrients from the fluid in a joint and has no blood supply.  This makes articular cartilage vulnerable to damage over one’s lifetime.  Some of this damage cannot be repaired and in arthritis, loss of the articular cartilage covering in a joint ensues. When arthritis develops in a joint, the articular cartilage is initially worn and eventually lost.  The result is bone rubbing on bone. Bone is a particularly poor bearing surface.  Not only is bone on bone a high friction bearing surface, it is also a very painful one.

Joint replacement components bearing surfaces are made of a variety of materials. These materials include highly cross-linked polyethylene (plastic), cobalt-chromium alloy (metal), and ceramic. Rubbing between these material couplings naturally produces some wear particles.  Man made materials still produce more friction than natural joint surfaces, and therefore experience a greater wear rate. This can impact the longevity of the implants. In addition, the wear particles produced can cause tissue inflammation surrounding the joint. We as joint designers and surgeons want to minimize both the production of wear particles and any inflammation they may stimulate around the replaced joint.  Optimal joint replacement implants are made from materials which produce very low friction and produce very little wear particles. This combination will help to maximize the longevity of an implant. The average age of joint replacement patients is getting younger.  The reasons are many.  A more active patient population is one, longer life-spans is another, and unfortunately, increasing obesity is a third.

IMPLANT MATERIAL OPTIONS AND COMBINATIONS

All materials used in joint replacement implants are very safe and only rarely cause localized or systemic reactions in the body.  Friction in an artificial joint results in the release of miniscule particles, hundreds of times smaller than a grain of sand, into the area surrounding the joint cavity.  This may occasionally result in an inflammatory response that can trick the body into reacting in an inflammatory manner and resorbing bone around the implant.  This is called osteolysis and, when extensive, can cause discomfort, loosening of the implant, and the need for revision surgery.  The best way to combat the development of this problem and increase the joint replacement implant life is by improving the wear resistance of the bearing materials in the man-made implants.

As new materials are developed and introduced, projecting long term effectiveness is a challenge.  Prior to use in joint replacement surgery, implant “wear” is tested in laboratory simulators that to the best of their ability, mimic the activity of the joint being tested. Testing in a lab outside of the body is an inexact science.  Although we can measure the size and volume of the wear particles produced, the biological reaction to them is absent.  Once safety is established with a simulator, the best way to determine the effectiveness of the implant surfaces is to implant them in patients and follow the performance carefully over years.  Prospective, randomized clinical studies tell us the performance in people!  Nothing is as reliable to tell us what works better and what does not as data from these studies.  The downside is it takes years to get the information.  National databanks called “Joint Replacement Registries” can both increase the reliability of this data and give us answers sooner because of the large volumes involved.

WHAT IMPLANT MATERIAL IS BEST?

Your surgeon will carefully evaluate your individual situation and goals to determine the material or combination of materials that is best for your joint replacement surgery.  Age, level of activity, gender, weight, deformity, and many other variables, are all factors when choosing the implant that is best for you.

MATERIALS

·         Metal-on-Metal Bearings

These materials were the first to be used in total hip replacements in the 1960’s, but less than optimal design and the development of newer materials over time resulted in these falling out of favor until recent times.  Improved manufacturing processes, recognition of the importance of a smooth surface finish, the recognized strength of cobalt-chromium alloys, and an improved understanding of the physical and chemical behaviors of metals have led to resurgence in the use of metal-on-metal materials for hip replacement.

Concerns remain about the wear particles that are generated by metal-on-metal implants and the hypersensitivity to the wear particles that may result.  Metal-on-metal implants are not used in patients with poorly functioning kidneys (the means for excretion of the particles) or in women of child-bearing age.  These implants are mostly reserved for young, active, and healthy male patients.

·         Metal-on-Polyethylene Bearings

These are the most commonly used combinations with the longest term clinical data available.  Polyethylene is a type of high durability plastic.  Although these are subject to the principles of wear as well, the results are locally less profound than metal-on-metal bearings and there is a long and successful track record for hip and knee replacements using these materials.  Ongoing research and development with these materials continue to result in implant wear improvements.  Various methods of sterilization of the polyethylene have resulted in altering the molecules in a way that strengthens them and decreases wear (a process called cross linking).  This combination of materials is commonly used in both hip and knee implants.  Dramatic improvement of polyethylene wear resistance in the last ten years is generally accepted as the biggest advance in joint replacement technology of the last 30 years.

·         Ceramic Bearings

Ceramic surfaces have been shown to be more wear resistant due to their ability to be polished to a very smooth finish and remain resistant to scratching.  Because of their brittleness, however, they are more susceptible to fracture than other materials.  Patients with highly active lifestyles who are subject to high impact activities are not the best candidates for ceramic implants.

Ceramic materials can be combined with polyethylene or ceramic itself and are most commonly found in hip implants.  A small number of patients with ceramic-on-ceramic hip implants experience an annoying “squeaking” sound during normal movement and activity.

The future evolution of joint replacement materials promises to bring newer materials with hopes of longer implant life and less wear characteristics.  One example of new technology advancement is a hybrid metal-ceramic material.  Through special manufacturing conditions, the surface of the metal material can be converted to ceramic which results in an implant with the favorable characteristics of both metal and ceramic.  More discoveries of this nature are undoubtedly on the horizon.  Long term clinical studies are essential to prove that any improvements in materials actually lead to longer lasting implant life with improved outcomes.

CONCLUSION

Joint replacement surgery is currently a highly successful procedure resulting in exceptional outcomes.  There is no combination of materials that works best in all joints for all patients.  Your surgeon will determine the implant materials that are are optimal for your individual situation. 

For more information about this topic, watch YNN, Ch. 10 news on Saturday, July 16^th to hear Dr. Brett Greenky discuss implant materials used in hip and knee replacement surgery.

Knee Pain in the Elderly: Common symptoms, varied causes

Knee pain in the elderly is a very common occurrence. The knee is the largest and most complex joint in the body. Injuries and diseases of the knee are frequent sources of disability, pain, and lost days from work.  Discomfort may be associated with many different diseases. The pain can affect the ability to ambulate, participate in daily activities and sleep comfortably.    The causes of pain usually originate in the knee joint.  Occasionally, a problem elsewhere can trigger pain that is referred to the vicinity of the knee.  Problems that originate in the knee joint itself are generally easy to diagnose and can be treated by your primary care physician, rheumatologist, or orthopedic surgeon.  Referred pain to the knee usually comes from either the hip or the spine and can be more difficult to diagnose.

Statistically, Americans are nearly 100% likely to have an episode of knee pain at least once in their lifetime. The incidence of knee pain is higher with increasing age and therefore is very common in the elderly. Initial attacks of knee pain, may respond to home remedies such as the use of rest, ice or heat, anti-inflammatory medications, weight loss, and a low impact exercise program.  Knee pain that lasts more than 10 days and is associated with swelling in the joint or inability to weight bear generally requires a visit to your physician.  Physical exam x-rays and occasionally blood testing are included in the diagnostic evaluation. 

Common causes of knee pain

            Inside the knee joint

a.       Osteoarthritis

b.      A torn meniscus

c.       Rheumatoid or Inflammatory Arthritis

d.      Gout

e.       Knee joint infection

f.        Tendonitis or Bursitis

Outside of the knee joint

a.       Hip arthritis

b.      Sciatica

                       

Osteoarthritis (OA) is the most common cause of knee pain in the elderly.  OA is the wear and tear type of arthritis that we are all subject to.  The incidence is slightly higher in women than men.  Increasing rates of obesity and decreased rates of exercise have resulted in an epidemic of OA in our society.  Most patients experience a slow gradual increase in pain and swelling.  Physically, there is often a bow legged appearance especially with weight bearing.  Inside the knee, a patch like loss of covering cartilage on the end of the bones allows the bones to rub together. Commonly the arthritis is also associated with a longstanding meniscus tear.   Initial treatment consists of rest, ice, anti-inflammatory medicines, weight loss and a low impact exercise program.  Injectable lubricates are available for arthritic knees and can temporarily diminish symptoms in moderate cases.  Dietary supplements are commonly advocated (glucosamine and chondroitin) but have never been shown effective in scientific studies. For severe arthritis, knee replacement surgery has extremely high success and patient satisfaction rates.

The meniscus is a structure in the knee shaped much like a washer. It is rubbery in nature and acts to help increase the contact area between the thigh and shinbone as they meet in the joint. Twisting and squatting activities are known to facilitate tears of the meniscus and can be the inciting event to bring on pain. A torn meniscus or cartilage can occur at any age.  Although this condition is common in young athletes, it can occur in the elderly as well.  In the elderly, the tear usually occurs incrementally and gradually over a period of months or years.  As a result, the appearance of a problem can be sudden or insidious.  Most torn menisci are on the medial or inside joint line of the knee and are associated with swelling, intermittent locking, difficulty with squatting or rising from a chair. When the tear catches, the patient will have a snapping or a grinding sensation. This problem can turn on and off like a light switch. With large tears the ability to ambulate is limited. A physical exam can establish the diagnosis.  Initial treatment includes rest, ice, and anti-inflammatory medications.  A steroid injection into the joint may help dramatically. Occasionally arthroscopic surgery is necessary to resolve the symptoms.

Rheumatoid arthritis is less common overall than osteoarthritis and presents more in women by a ratio of 8 to 1. Rheumatoid arthritis is an autoimmune disease in which the immune system of the patient begins attacking the synovial lining and covering cartilage within the joint.  Hallmarks of the disease include: at least an hour of morning stiffness, rashes, symmetrical involvement, and joint deformity especially in the hands. The disease process eventually destroys the joint surface. Laboratory data frequently can confirm the presence of rheumatoid arthritis. Over the last decade the use of disease-modifying medications have become prevalent and for the first time in modern history, the disease can actually be slowed dramatically by the appropriate use of these medications. Generally after the diagnosis of rheumatoid arthritis is made the patient should come under the care of a family doctor or rheumatologist who can administer and monitor the use of these medications appropriately. If and when rheumatoid arthritis causes significant destruction of the cartilage covering the end of the bone, knee replacement surgery is an appropriate next step.

Gout is more common in elderly men.  It occurs in genetically sensitive patients when uric acid levels in their blood exceed the saturation point and they crystallize in synovial joints.  The crystals cause sudden intense pain, swelling and redness. The big toe knuckle is most commonly involved, followed by the ankle and the knee joint.  Attacks can be triggered by diet (foods high in urates), alcohol and aggravation.  Some diuretics are known to trigger an attack.  The diagnosis requires a reasonable suspicion and can be confirmed by the finding the presence of gout crystals in fluid from the knee joint.  An attack will subside rapidly after the administration of the right medications.  Prevention of further attacks is accomplished by diet, and prophylactic medicine.  Although infection of the knee joint is unusual, it closely mimics gout with the main difference being the presence of fever and malaise. Infection can occur after a penetrating injury, or in immuno-compromised patients. 

Tendonitis and bursitis of the knee are common in patients of all ages. They can occur as a result of injury, repetitive activities, arthritic conditions or even gout. Generally the location of the pain is specific to the presence of a tendon or a bursal sack and treatment is supportive with anti-inflammatory medications and rest. The conditions usually resolve promptly.

Osteoarthritis(OA) of the hip joint can cause pain radiating to the knee. Patients sometimes arrive convinced that the knee is the source of the problem, only to find out that x-rays of the knee are normal and x-rays of the hip on the same side show severe arthritis. Generally the type of limp caused by a bad hip has a characteristic John Wayne waddle while the knee limp is more stiff-legged.

Sciatic pain emanating from the low back commonly results in pain radiating across the knee. Nerves exit the spine and coalesce into the sciatic nerve. Pressure on these nerves from arthritis or disk problems can produce pain down the back of the leg and the posterior aspect of the knee.  Cramping, spasms, and numbness often accompany pain from sciatica. 

Summary

There are many causes of knee pain in the elderly; most conditions are not serious and can be treated using anti-inflammatory medications, rest, ice, and activity modification. If the symptoms don’t resolve over 10 days to 2 weeks a visit to your doctor is advised.  A diagnosis will likely be made quickly and appropriate treatment begun.  Longstanding and increasing knee pain in the elderly is most likely arthritis related.  Arthritis is the loss of the cartilage covering on the end of the bones that meet in the knee joint.  If this becomes severe, and medication, physical therapy, exercise and weight loss do not resolve the problem, knee replacement surgery results in extremely high success and satisfaction rates in appropriately selected patients.

Musings on Nepal



Namaste.  (nah-mah-stay).  This simple Hindu greeting is expressed by pressing the palms of the hands together in front of the heart.  The head is bowed slightly as the word is spoken.  It literally means “the spirit or light within me recognizes and honors the spirit or light within you.”

We very recently returned from a journey to Kathmandu, Nepal, a valley burrowed deep in the recess of the Himalayas, the highest mountains on earth.  Our primary purpose—to assess the medical facilities and prepare for Operation Walk Syracuse’s November trip to Nepal to perform desperately needed hip and knee replacement surgery.

The stark contrasts of reality that we witnessed are staggering and pervasive in both city and village life.  The region and the people are primordial, yet caught in the throes of modernization.  It is a place of breath-taking beauty and unspeakable poverty.  Sanitation is more than a pervasive issue.

Kathmandu lies deeply isolated in a valley surrounded by mountains.  City roads are dangerously crowded, unguided due to the lack of traffic signs and signals.  Travel by car, bus, or motorbike is a treacherous, grueling affair.  Most mountain villages are reachable only by dirt roads and footpaths.

The pollution is pervasive.  Noxious fumes hang low over the city and we observed many people struggling to protect their airways through the use of masks or scarves placed over their mouths and noses.

The hospital environment will be challenging.  The medical facility falls far short of those we comfortably use in the U.S.  The challenges in providing effective medical and surgical care are very apparent.  Paucity of resources, a hospital physical plant that is lacking hot water, adequate toileting facilities, and up-to-date equipment and supplies add to the already challenging care environment.

By contrast, the physicians and orthopedic clinical staff areknowledgeable, enthusiastic, motivated, and committed to meet the needs of their patients.  We were warmly greeted and welcomed to the Medical College.  Our hosts were extraordinarily gracious.  We collaboratively planned for our November surgical joint replacement marathon which will include our team of nearly 40 health care providers who will travel with us to Nepal.  In addition to the cordial welcome from the medical staff, hospital administration, and the Minister of Health, we were warmly greeted by twenty of the prospective patients.  We left the hospital bearing the x-rays for fifty (50) patients who are hoping to receive ninety-three (93) joint replacement procedures during our abbreviated visit in November.  A daunting and overwhelming task is at hand.

We saw so very little during our short visit but more than enough to make us appreciate what we have here, and how much we take that for granted each and every day.

It was all about the people.  We were struck by the extremes of everything they experience, yet are sincerely welcoming and positive.  Ox-drawn carts and cows share the roads with taxis and other motorized vehicles.  T-shirt clad teenagers sell roadside wares next to sari-clad women washing clothes at a public well.  As we wandered through the narrow brick streets of Bhaktapur, an ancient city with Hindu and Buddhist temples that seem unchanged for centuries, or gazed across the terraced-fields that lie at the gateway to Everest after hiking to the highest point of Nagarkot, we remained most in awe of the remarkable inhabitants of this country. 

As we departed Kathmandu dreading the long, jet-lag filled return to Syracuse, we were energized by what we had seen and what promises to lie ahead.  We eagerly look forward to the next time that we will be met with the greeting we received from everyone in Nepal, rich or poor:  Namaste.  This humbling gesture is meant to recognize that we essentially are all on equal standings.  We are one with these people as we prepare to travel more than 7,500 miles to the other side of the world on this life-altering trip.  Until then, we will hold on to the people of Nepal and so many of the lessons learned.

 

Himalayas



In the Streets of Bhaktapur