News in 10

The 10 items below are the most significant elements of recent editions of Headline News Now—the AAOS thrice-weekly, online update of news of interest to orthopaedic surgeons. Check this page regularly for updates.
Updated on January 26, 2015

1. Study: Mupirocin protocol may reduce MSSA and MRSA population in TJA patients.
Findings published online in The Journal of Arthroplasty suggest that a decolonization protocol using nasal mupirocin may effectively reduce positive cultures of methicillin-sensitive Staphylococcus aureus (MSSA), and methicillin-resistant Staphylococcus aureus (MRSA) in patients who undergo total joint arthroplasty (TJA). The research team instructed 289 consecutive primary or revision TJA patients at a single center to use 3-day preoperative chlorhexidine washes. Patients with positive cultures were treated with a 5-day course of intranasal mupirocin. Overall, 44 patients tested positive for preoperative MSSA colonization, while 12 tested positive for MRSA. On the day of surgery, the research team noted that only 15 patients had MSSA positive cultures, while one patient had a positive culture for MRSA.
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2. Study: Orthopaedic surgeons, neurosurgeons have similar complication rates for single-level ACDFs.
Findings published online in the journal Spine suggest that postoperative complication rates are similar for both orthopaedists and neurosurgeons performing single-level anterior cervical discectomy and fusions (ACDFs). The authors conducted a retrospective cohort study of 1,944 patients who underwent single-level ACDF between 2006 and 2012 and found that treating physician cohort (orthopaedic surgeons vs. neurosurgeons) was not associated with increased likelihood of overall complications, surgical site complications, or medical complications.
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3. Study: Men appear less likely to undergo evaluation and treatment for osteoporosis after DRF.
Data published in the Nov. 5 issue of The Journal of Bone & Joint Surgery suggest that men are less likely than women to be evaluated for osteoporosis after sustaining a distal radial fracture (DRF). The authors conducted a retrospective review of 95 men and 344 women older than 50 years who were treated for DRF at a single institution. They found that men overall had less severe fractures than women. However, 184 women (53 percent) were given a dual x-ray absorptiometry (DXA) scan after injury, compared to 17 men (18 percent). Among patients who underwent a DXA scan, nine men (9 percent of men overall) and 65 women (19 percent of women overall) had a diagnosis of osteoporosis. The authors found that male sex was an independent predictor of failure to undergo bone mineral density testing as well as to receive subsequent treatment with calcium and vitamin D or bisphosphonates.
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4. FDA announces approval of abuse-deterrent opioid analgesic.
The U.S. Food and Drug Administration (FDA) has announced the approval of hydrocodone bitartrate, an extended-release opioid analgesic designed to treat pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. The product has properties that are expected to reduce—but not totally prevent—abuse of the drug when chewed and then taken orally, or crushed and snorted or injected. Hydrocodone bitartrate is not approved for, and should not be used for, as-needed pain relief. FDA emphasizes that the product should only be prescribed to people for whom alternative treatment options are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient pain management. The agency is requiring postmarketing studies of hydrocodone bitartrate to assess the effects of the abuse-deterrent features.
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5. Study: Serum SNTF levels may offer diagnosis tool for concussion.
Data published online in the Journal of Neurotrauma suggest that elevated levels of brain-enriched protein calpain-cleaved alpha-spectrin N-terminal fragment (SNTF) in the blood shortly after sports-related concussion may predict the severity of post-concussion symptoms. The authors conducted a longitudinal analysis of serum SNTF in professional ice hockey players, 28 of whom had a concussion, along with 45 players evaluated during the preseason, 17 of whom were also tested after a concussion-free training game. They found that, compared to preseason levels, serum SNTF increased at 1 hour after concussion and remained significantly elevated from 12 hours to 6 days before declining to preseason baseline. In eight players, post-concussion symptoms resolved within a few days, and the authors noted that in those players serum SNTF levels had returned to baseline. Among 20 players withheld from play for 6 days or longer, serum SNTF levels rose from 1 hour to 6 days post-concussion, and at 12 to 36 hours differed significantly from less severe concussions. The authors suggest that serum SNTF may serve as a diagnostic and prognostic tool for sports-related concussion.
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6. Studies: 2011 ACGME resident duty hour reforms appear to have had little effect on patient safety.
A pair of studies published in the Dec. 10 issue of The Journal of the American Medical Association (JAMA) examine the effect on quality of resident duty hour limitations enacted in 2011 by the Accreditation Council for Graduate Medical Education (ACGME). The first study compared general surgery patient outcomes in both teaching and nonteaching hospitals for the 2 years before and the 2 years after the 2011 duty hour change, and found that reform was not associated with a significant change in death or serious morbidity in post-reform year 1, post-reform year 2, nor when both post-reform years were combined. The second study examined 30-day all-location mortality and 30-day all-cause readmission across 2,790,356 patients (6,384,273 admissions) in both teaching and nonteaching hospitals for the 2 years before and the 2 years after the 2011 duty hour change, and found "no significant post-reform differences in mortality accounting for teaching hospital intensity for combined medical conditions, combined surgical categories, or any of the individual medical conditions or surgical categories."
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7. Study: Anterior compartment intramuscular compartment pressure may help diagnose chronic exertional compartment syndrome.
Data from a study published online in The American Journal of Sports Medicine support the use of anterior compartment intramuscular compartment pressure (IMCP) as a diagnostic indicator of chronic exertional compartment syndrome (CECS). The researchers conducted a cohort study of 40 men aged 21 to 40 years, 20 of whom displayed symptoms of CECS of the anterior compartment and 20 asymptomatic controls. They continuously measured IMCP before, during, and after participants exercised on a treadmill, wearing identical footwear and carrying a 15-kg load. The researchers found that participants in the case cohort had higher IMCP immediately upon standing at rest compared with controls—a relationship that persisted throughout the exercise protocol, with the greatest difference corresponding to the period of maximal tolerable pain. The researchers write that sensitivity and specificity were consistently higher than existing criteria with improved diagnostic value.
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8. Study: Risk factors for cardiac complication after TKA and THA include older age, hypertension, and history of cardiac disease.
A study published in the Dec. 17 issue of JBJS looks at risk factors for cardiac complications within 30 days after primary unilateral total knee arthroplasty (TKA) and total hip arthroplasty (THA). The researchers reviewed data on 46,322 patients from the American College of Surgeons National Surgical Quality Improvement Program data set, and found that the overall cardiac complication rate per patient was 0.33 percent (n = 153) at 30-days postoperative. Across both TKA and THA cohorts, risk factors for cardiac complication included age of 80 years or older, hypertension requiring medication, and history of cardiac disease. Among patients who had a cardiac complication, 79 percent experienced it within 7 days of surgery.
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9. Study: Foot discomfort may discourage overweight children from exercise.
An Australian study found that overweight children who exercise may be at risk of pain and discomfort in the feet that may discourage such children from participating in physical activity. Although the researchers stated that changes to structure and function of developing feet in overweight/obese children could not be attributed to participating in the physical activity program followed by the study subjects, further research is warranted to gauge whether the increased plantar pressures and pressure-time integrals observed in the exercising children has an anatomical effect. They noted that the greater pressure and flatter arches in obese children can be an impediment to compliance with an exercise program. The study, appearing in the Journal of Science and Medicine in Sport, looked at a control group among a larger group of children participating in some type of a weight-control program, including diet modification alone. The feet in all the children—all of whom lost weight—showed growth in length and arch height, and while the researchers told Reuters they were surprised to detect no structural differences between those who exercised and those who didn’t, they noted that the measurement at 6 months may have taken place too long after the 10-week weight-loss trial ended to detect changes caused by exercise. One conclusion they made is that recommendation of non–weight-bearing exercise may be appropriate for overweight children.
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10. Study: Liposomal bupivacaine may reduce pain compared to femoral nerve block in knee arthroplasty.
Data presented at the annual meeting of the American Association of Hip and Knee Surgeons suggest that an injection of iposomal bupivacaine into the tissue surrounding the knee during surgery may reduce recovery time and increase patient satisfaction in the hours following knee arthroplasty. The research team evaluated 216 knee arthroplasty patients for pain control during the first 2 days after surgery. Half of the patients received continuous femoral nerve block and half received liposomal bupivacaine injection. They found that patients in the bupivacaine group had better pain relief for up to 2 days after surgery, and better knee function than those in the nerve block cohort.
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