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 April 23, 2012

1. NCLS letter voices opposition to liability reform proposal.
The Hill reports that the National Conference of State Legislatures (NCLS) has sent a letter to leaders in the U.S. House of Representatives to state their "strong, bipartisan opposition" to a bill that, among other things, would cap noneconomic damages in medical liability cases at $250,000. The bill would also repeal the Medicare Independent Payment Advisory Board (IPAB); the tort reform component is seen as a way to balance the cost of repealing IPAB. NCLS argues that adoption of a federal liability cap would undermine state rights and disregards factors unique to each particular state.
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2. Study: No significant differences in 5-year outcomes among three trapeziectomy variations.
A study published in the March issue of the Journal of Hand Surgery finds that outcomes of three variations of trapeziectomy were similar after a minimum follow-up of 5 years. The authors conducted a randomized trial of 153 thumbs with trapeziometacarpal osteoarthritis. Patients underwent either simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50 percent of the flexor carpi radialis tendon. At minimum 5-year follow-up (range 5 to 18 years), grip strength and key and tip pinch strengths did not differ among the 3 groups, and range of movement of the thumb was similar across groups. At 5 years, no significant difference in the number of complications between groups was found, and good pain relief achieved was maintained in the longer term, irrespective of surgery type. The authors note that improvements in grip strength achieved at 1 year after surgery were preserved, while key and tip pinch strengths deteriorated with time, but type of surgery did not influence those outcomes.
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3. Study: Functional outcomes similar for certain fibula fractures whether treated surgically or nonsurgically.
According to a study published in the March issue of the Journal of Orthopaedic Trauma, patients treated for undisplaced, unstable, isolated fibula fractures had equivalent functional outcomes whether treated surgically or nonsurgically, but patients managed with surgery were at lower risk of displacement and problems with union. The authors conducted a randomized, multicenter clinical trial of 81 patients at six Level 1 trauma centers. Overall, 41 patients were treated surgically by open reduction and internal fixation of the fibula, while 40 patients underwent nonsurgical treatment, which included the use of a short leg cast or brace and protected weight bearing for 6 weeks. No statistically significant differences were found in functional outcome scores or pace of recovery between the groups at any time interval up to 12 months. However, at 12-month follow-up, 5 patients in the surgical group had had a surgical site infection and 5 patients required hardware removal, while in the nonsurgical group, 8 patients had a medial clear space greater than or equal to 5 mm, and 8 patients had delayed union or nonunion.
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4. Study: Thromboprophylaxis may have little effect on thromboembolic events after surgical treatment of ankle fractures.
A study published in the March 21 issue of the Journal of Bone and Joint Surgery—American (JBJS-A) finds that clinically detectable thromboembolic events after the surgical treatment of ankle fractures are uncommon and may not be influenced by thromboprophylaxis. The authors conducted a retrospective chart review of 1,540 patients who underwent open reduction and internal fixation of ankle fracture at three institutions between Jan. 1, 1997, and April 30, 2005. At minimum 6-month follow-up, they found that the incidence of thromboembolic events was 2.99 percent (n = 46), with 2.66 percent (n = 41) involving a deep venous thrombosis and 0.32 percent (n = 5) involving a nonfatal pulmonary embolism. Overall, 16.43 percent of patients received thromboprophylaxis during their hospital stay and after discharge. Use of thromboprophylaxis had no apparent impact on the occurrence of thromboembolic events. Patients with one or more risk factors displayed a greater risk of a thromboembolic event than patients with no risk factors. Additionally, no significant correlation could be identified between the occurrence of thromboembolic events and fracture types, age, or sex.
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5. Study: Independent exercise could reduce need for physical therapy after arthroscopic meniscectomy.
According to a study published in the March 21 issue of JBJS-A, a structured, independent exercise protocol may reduce the need for physical therapy after arthroscopic meniscectomy. The research team reviewed records of 155 injured workers who had undergone 164 primary arthroscopic meniscectomies. Patients either underwent traditional physical therapy or were given a written referral specifying the exact number of physical therapy visits that were approved, a kit containing exercise equipment with a booklet illustrating twenty-five exercises, and a prescribed rehabilitation protocol outlining the philosophy, expected subjective and functional outcomes, and specific objective weekly goals. The researchers found that the median number of physical therapy visits per patient was 40 percent lower in the study group than in the control group, yet there was no significant difference between groups with regard to permanent partial disability rate, time to release to light duty, time to release to full duty, time to claim closure, or rate of impairment.
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6. How common is MRSA in elective spine surgery?
A study published online in the journal Clinical Orthopaedics and Related Research looks at the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) among patients undergoing elective spine surgery. The authors retrospectively reviewed prospectively collected data from 990 patients who underwent elective spine surgery during 2010. Of 503 patients who were screened for MRSA, 14 (2.8 percent) were colonized with MRSA. The rates of early wound complications (defined as wound drainage or the presence of an abscess) were similar for patients who were screened and pretreated for MRSA (17 of 503) and for with those who were not (17 of 487).
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7. Study: More patients undergo knee arthroplasty for less severe OA.
According to a study published online in the journal Clinical Orthopaedics and Related Research, variation in the extent of tibiofemoral osteoarthritis (OA) in patients preparing for joint arthroplasty may be greater than previously described. The authors drew data on 97 patients taking part in the Osteoarthritis Initiative who underwent knee arthroplasty and who had relevant radiographs taken during the 12 months prior to surgery. They found that the proportion of patients with a modified Kellgren-Lawrence (KL) grade of 3 or higher was 0.81, which was less than the 0.95 estimated population proportion. Of patients who underwent knee arthroplasty, 85 percent (n = 82) had at least one tibiofemoral joint compartment that had no joint space narrowing, and one in six patients with OA who underwent knee arthroplasty had a KL grade of 2 or lower.
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8. Study: No short-term increase in cancer risk after MoM THA.
A United Kingdom study published online in the journal BMJ finds no short-term increased risk of cancer diagnosis after total hip arthroplasty (THA) using metal-on-metal (MoM) bearing surfaces. The authors reviewed data on 40,576 THA patients given MoM bearing surfaces and 248,995 THA patients given alternative bearings. They found that new diagnoses of cancer among THA patients overall was lower than predicted, as compared to general population matched by age and sex. In addition, at mean 3-year follow-up, the authors found no significant difference in cancer diagnosis rates between the experimental and control groups. However, the authors point out that some forms of cancer have a long latency period and argue for continued investigation regarding longer term effects of exposure to orthopaedic metals.
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Read the complete study…

9. Specialty societies encourage physicians to consider all factors before testing.
The ABIM Foundation (a not-for-profit foundation established by the American Board of Internal Medicine [ABIM]), in concert with nine medical specialty associations, has made available a website resource designed to encourage physicians and patients to reduce the use of potentially unnecessary medical testing. The following are among the recommendations submitted by various societies:

• Don’t do imaging for low back pain within the first 6 weeks, unless red flags are present (American Academy of Family Physicians)
• Don’t use dual-energy x-ray absorptiometry (DXA) screening for osteoporosis in women younger than age 65 or men younger than age 70 with no risk factors (American Academy of Family Physicians)
• Don’t image for suspected pulmonary embolism without moderate or high pre-test probability (American College of Radiology)
• Avoid nonsteroidal anti-inflammatory drugs in individuals with hypertension or heart failure or chronic kidney disease of all causes, including diabetes (American Society of Nephrology)

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Visit the website…

10. Study: NA a viable treatment for Dupuytren contracture.
A study published in the April issue of the Journal of Hand Surgery examines the efficacy of needle aponeurotomy (NA) for the treatment of Dupuytren contracture. The research team conducted a retrospective study of 474 patients (1,013 fingers) treated with NA for metacarpophalangeal (MP) or proximal interphalangeal (PIP) joint contracture of 20 degrees or greater from March 2005 to May 2008. The researchers noted that immediately post-procedure, MP joint contractures were corrected an average of 99 percent and PIP contractures an average of 89 percent. At minimum 3-year follow-up, 72 percent of the correction was maintained for MP joints and 31 percent was maintained for PIP joints. Complications were rare except for skin tears, which occurred in 3.4 percent (n = 34) of digits.
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