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 30, 2013

1. Study: 4.2 percent of U.S. population aged 50 and older has undergone TKA.
A study published in the March 6 issue of JBJS estimates the prevalence of primary and revision total knee arthroplasty (TKA) among adults 50 years or older in the United States. The research team combined data from the Osteoarthritis Policy Model, data on annual TKA utilization, and U.S. Census data to estimate the number of living adults who have undergone TKA. They estimate that approximately 4 million adults in the United States currently live with a total knee replacement, representing 4.2 percent of the population aged 50 years or older. The prevalence was higher among females than among males and increased with age. Overall, the lifetime risk of primary TKA from the age of 25 years was 7.0 percent for males and 9.5 percent for females.
Read the abstract…

2. Study: Bilateral TKA may increase risk of VTE compared to unilateral TKA when mobile compression device is the only prophylaxis.
According to a study published in the March issue of the Journal of Arthroplasty, the risk of venous thromboembolic events (VTE) may be significantly higher for patients who undergo simultaneous bilateral total knee arthroplasty (TKA) compared with patients who undergo unilateral TKA. The authors clinically evaluated 55 patients who underwent simultaneous bilateral TKA (110 knees) against 287 patients who underwent unilateral TKA (287 knees). All patients used a mobile compression device as monotherapy prophylaxis. The authors found that patients in the bilateral group had 6 VTEs (10.9 percent) and 2 pulmonary embolisms (PEs, 3.6 percent), compared to 9 VTEs (3.1 percent) and 0 PEs in the unilateral group.
Read the abstract…

3. JBJS article reviews issues surrounding pediatric ACL reconstruction.
An article published in the March 6 issue of the Journal of Bone & Joint Surgery (JBJS) reviews current concepts in the reconstruction of the anterior cruciate ligament (ACL) in pediatric athletes. The writers note that current literature supports a trend toward early surgical treatment of pediatric ACL tears, but the optimal approach to reconstruction in that age group is controversial. Among other things, the article examines:

• The unique anatomic considerations pertaining to ACL reconstruction in the skeletally immature athlete
• Preoperative clinical and radiographic assessment of the pediatric patient with a suspected ACL injury
• Transphyseal and physeal-sparing reconstruction techniques
• Clinical outcomes according to patient and technique-specific factors
• Age-specific injury prevention treatment strategies

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4. Link between obesity and OA goes beyond intuitive connection.
A review article published in the March issue of the Journal of the AAOS examines the association between obesity and osteoarthritis (OA). The authors argue that, although a biomechanical relationship between obesity and OA is intuitive, systemic links between obesity and OA have been widely reported in general medical literature, but only rarely in orthopaedic journals. Orthopaedic surgeons, the authors say, should be aware of obesity’s systemic implications with respect to OA and take that systemic factor into account when counseling patients.
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Read the abstract…
An interview with the authors appears in the March issue of AAOS Now…

5. Study: Obesity associated with loss of reduction after operative treatment of ankle syndesmosis.
Data from a study published in the April issue of the Journal of Orthopaedic Trauma suggest a strong association between obesity and loss of reduction after operative treatment of ankle syndesmosis. The authors conducted a retrospective cohort study of 213 patients with operative syndesmotic injuries. They found that 15 percent of patients considered to be obese sustained a failure of fixation, compared with 1.8 percent of patients in the nonobese cohort. Factors such as diabetes mellitus, smoking status, and type of construct used were not predictive of loss of reduction. The authors state that, after adjustment for injury severity, obese patients were 12 times more likely to suffer a loss of reduction compared with nonobese patients.
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6. Study: Use of PAs in EDs linked to benefits for hospital, physicians, and patients.
A study published in the April issue of the Journal of Orthopaedic Trauma finds that the use of physician assistants (PAs) can increase emergency department (ED) pull-through and decrease patients’ times to operating room, operative times, lengths of stay, and complications. The retrospective case series study of 1,104 trauma patients with orthopaedic injuries at a single Level II trauma center found that, with PA involvement, trauma patients with orthopaedic injuries were seen on average 205 minutes faster, total ED time decreased 175 minutes, and time to surgery improved by 360 minutes. Overall operating room parameters with PA involvement improved minimally, but postoperative deep vein thrombosis prophylaxis increased by a mean of 6.73 percent, postoperative antibiotic administration increased by 2.88 percent, postoperative complications decreased by 4.67 percent in, and average length of stay decreased by 0.61 days.
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7. Trial suggests little benefit to vertebral body stenting over balloon kyphoplasty for patients with osteoporotic vertebral fractures.
A study published in the April 3 issue of the Journal of Bone & Joint Surgery finds no beneficial effect of vertebral body stenting over balloon kyphoplasty with regard to amount of kyphosis correction, radiation exposure time, or cement leakage among patients with painful osteoporotic vertebral fractures. The authors conducted a two-armed, randomized, controlled trial of 65 patients (100 involved vertebral levels) with fresh osteoporotic vertebral compression fractures and who were treated with either balloon kyphoplasty or vertebral body stenting. They found that median reduction of kyphosis was 4.1 degrees after balloon kyphoplasty and 3.7 degrees after vertebral body stenting. In addition, the authors observed cement leakage at 20 percent of the vertebral levels treated with balloon kyphoplasty and 30 percent of those treated with vertebral body stenting, and non-significant differences in radiation exposure time between the two intervention arms.
Read the abstract…

It should be noted that existing AAOS Clinical Practice Guidelines (CPGs) recommend against vertebroplasty for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact.
Read the AAOS CPG (PDF)…

8. Study: Distal and proximal procedures offer similar outcomes for correction of severe hallux valgus deformity.
Findings from a study conducted in the United Kingdom and published in the April issue of the Bone & Joint Journal suggest that distal chevron osteotomy with an associated distal soft-tissue procedure may have efficacy for correcting severe hallux valgus deformity. The authors conducted a prospective, randomized, controlled trial of 110 consecutive female patients (110 feet). Patients underwent either a proximal (n = 56) or a distal (n = 54) procedure. At follow-up (mean 39 months, proximal group; mean 38 months, distal group), the authors found that the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal score, patient satisfaction level, and complications were similar in each group, and both methods showed significant postoperative improvement and high levels of patient satisfaction.
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9. Study finds little efficacy for HA in treatment of GH-OA.
Findings from a study published in the May issue of the Journal of Shoulder and Elbow Surgery suggest little efficacy for treating glenohumeral osteoarthritis (GH-OA) with sodium hyaluronate (HA). The authors conducted a double-blind, randomized, controlled, multicenter trial of 300 patients with GH-OA. Overall, 150 received HA and 150 received phosphate-buffered saline (PBS) in 3 weekly injections. At 26-week follow-up, both cohorts displayed mean improvement from baseline in visual analog scale (VAS), and the HA group had a slightly higher percentage of high responders on the Outcome Measures in Rheumatoid Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI). However, differences between groups did not reach statistical significance. The authors noted that, in a subset of patients with GH-OA and no concomitant shoulder pathologies, differences between in VAS and OMERACT-OARSI high-responder rates between groups were 4.0 mm and 8.37 percent, respectively, which reached statistical significance in favor of HA.
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10. Healthcare community responds to Boston Marathon tragedy.
An article in MedPage Today looks at the Boston Marathon bombings from the aspect of emergency preparedness. The author states that coordination and integration among hospital staff are keys to handling a large scale trauma event. A spokesperson for Tufts Medical Center notes that existing relationships between emergency department staff and first responders helped the network of various emergency systems work smoothly and efficiently.
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"Our hearts go out to everyone affected by this tragedy," said AAOS President Joshua J. Jacobs, MD, in a separate statement. "Fellows of the AAOS demonstrated their caring, compassion, and expertise by providing both first aid and definitive orthopaedic care. The AAOS stands with the citizens of Boston during this difficult time."

In the wake of the Boston Marathon bombings, the Journal of the AAOS is offering free online access to all of its recently published clinical and surgical techniques articles on the treatment of severe trauma. The articles are largely drawn from the trauma care experiences of military and domestic orthopaedic surgeons who have treated personnel severely wounded while serving in Iraq and Afghanistan. Three complete supplemental Extremity War Injury publications and more than a dozen articles are available free of charge until May 31, 2013.
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