Published 7/1/2008

Second Look – Clinical News and Views

If you missed these Headline News Now items the first time around, AAOS Now gives you a second chance to review them. Headline News Now—the AAOS thrice-weekly, online update of news of interest to orthopaedic surgeons—brings you the latest on clinical, socioeconomic, and political issues, as well as important announcements from AAOS. Links to additional information are available online at www.aaosnow.org

Hospitals attempt to ease ED overcrowding
According to a study conducted by the nonprofit Center for Studying Health System Change (HSC), safety-net hospitals are looking for ways to reduce the stress placed on emergency departments (EDs) by increasing numbers of patients seeking care for nonemergencies. The following are among the approaches being used:

  • Employing a “fast-track” approach for nonurgent care in a separate setting
  • Helping patients establish “medical homes” for preventive and primary care
  • Identifying other providers and scheduling appointments for those with nonurgent conditions
  • Designating staff to work with patients prior to arrival to direct them to primary care settings

The study suggests that a combination of approaches could help stem ED use for non-urgent care.

Adverse events higher among obese revision THA patients
Swiss researchers have evaluated the effect of obesity on the incidence of adverse events, functional outcome, residual pain, and patient satisfaction after revision total hip arthroplasty (THA), in a study published in the journal Arthritis Care and Research. The incidence rate for one complication increased with rising body mass index (BMI) (from 1.8 cases/100 person-years if BMI <25 to 17.9 cases 100 person-years if bmi="35)." among the 80 patients who had a follow-up visit at 5 years, obese patients had moderately lower functional results and higher levels of residual pain, but similar patient satisfaction levels.>

Possible link between prostate cancer and bone fracture risk
A link may exist between prostate cancer and a higher risk of bone fracture, according to a study in the journal Bone. Australian researchers analyzed data from the Osteoporosis Epidemiology Study and found that prostate cancer developed in 43 of 822 men who have been followed for nearly 20 years. Compared to the men without prostate cancer, those with the disease showed a 50 percent increase in the risk of fracture. For the 22 patients who were treated with androgen deprivation therapy, the risk approximately doubled.

Oral estrogen may increase VTE risk
A study in the British Medical Journal finds that oral estrogen may increase the risk of venous thromboembolism (VTE) in women, especially during the first year of treatment. Researchers conducted a systematic review and meta-analysis of eight observational studies and nine randomized controlled trials. Compared to controls, the odds ratio of first time VTE in current users of oral estrogen was 2.5, and the odds ratio for patients taking transdermal estrogen was 1.2. The authors suggest that transdermal estrogen may be safer with respect to VTE risk, but say that more data are required to assess differences in risk across the wide variety of hormone regimens.

Sciatica study: Surgery has short-term benefits only
Two-year outcomes for patients with sciatica are similar whether surgery or a conservative care approach was chosen, according to a study in the British Medical Journal. Dutch researchers conducted a randomized controlled trial of 283 patients who had radiologically confirmed disk herniation and lumbosacral radicular syndrome that lasted for 6 to 12 weeks. Overall, 141 patients were assigned to undergo early surgery, and 142 were assigned to conservative treatment. Of patients in the control group, 62 (44 percent) eventually required surgery. The authors found no significant difference between groups in disability scores during the first two years. Improvement in leg pain was faster for patients in the early surgery group, but the short-term benefit of early surgery was no longer significant by 6 months and continued to narrow between 6 and 24 months.

Study: Minimally invasive THA has higher complication rate
To assess early complications, clinical success, and alignment, a small study in Surgical Technology International XVII compares a minimally invasive dual-incision muscle-sparing surgical technique with a standard posterolateral approach in THA. Five complications were reported in the dual-incision group; the posterolateral group had one complication. Postoperative radiographic alignment of the prosthesis was closer to optimal in the posterolateral group.

Cumulative exposure to emergency scans may increase cancer risk
Long-term buildup of radiation resulting from repeated ED radio­graphs and scans may be placing some patients at an increased risk for cancer, according to a study presented at the annual meeting of the Society for Academic Emergency Medicine. Researchers reviewed a 5-year period of diagnostic testing exposure among a randomly selected group of ED patients at two hospitals. Patients averaged a cumulative radiation dose calculated as 40 milliseiverts (mSV) during the 5-year study period, and 10 percent of the study patients averaged 100 mSV during that time. Most patient radiation exposure stemmed from computed tomography scans and nuclear medicine testing.

RSA advances correlate to improved outcomes
A study in the June issue of the Journal of Bone and Joint Surgery (JBJS-Am) finds that recent advances in reverse shoulder arthroplasty (RSA) have improved outcomes and decreased complication rates. Researchers examined 96 shoulders (94 patients) treated with RSAs from February 2004 to March 2005 and found that average total American Shoulder and Elbow Surgeons (ASES) scores improved from 30 preoperatively to 77.6 at 2 years follow-up; average ASES pain scores improved from 15 to 41.6; and average Simple Shoulder Test scores improved from 1.8 to 6.8. A blind range-of-motion analysis showed that average abduction improved from 61 degrees preoperatively to 109.5 degrees postoperatively; average flexion, from 63.5 degrees to 118 degrees; and average external rotation, from 13.4 degrees to 28.2 degrees (p < 0.0001).

Study: Stainless steel better than titanium for pediatric femoral fixation
Less expensive stainless steel elastic nails may be clinically superior to titanium nails for pediatric femoral fixation, according to a study in the June issue of JBJS-Am. Researchers compared the outcomes of 104 children with femoral fractures, 56 of whom were treated with titanium elastic nails and 48 of whom were treated with stainless steel elastic nails. Both nail types were of similar design, and a similar retrograde insertion technique was used in both groups. In the titanium group, the malunion rate was 23.2 percent (13 patients), compared to 6.3 percent (3 patients) in the stainless steel group. The rate of major complications was 35.7 percent (20 patients) for titanium nails and 16.7 percent (8 patients) for stainless steel nails. The rates of minor complications, insertion times, and extraction times were similar for the two groups.

Study: Blood substitutes associated with increased risk of MI and death
Researchers conducting a meta-analysis of randomized controlled trials report that—based on the available data—the use of cell-free hemoglobin-based blood substitutes (HBBS) may be associated with a significantly increased risk of myocardial infarction (MI) and death. Authors of the study, which appeared in the Journal of the American Medical Association, reviewed 16 trials involving five different products and 3,711 patients in varied patient populations. They found an overall statistically significant increase in the risk of death (164 deaths in the HBBS-treated groups and 123 deaths in the control groups). The increased risk of MI with HBBS was also statistically significant (59 MIs in the HBBS-treated groups and 16 MIs in the control groups.