Published 8/1/2009

Second Look

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.

Ropivacaine infusion after cuff surgery?
study in the Journal of Bone & Joint Surgery—American (JBJS-A) (July 1, 2009) finds minimal evidence supporting the use of ropivacaine infusion following rotator cuff surgery if preemptive ropivacaine and intraoperative parecoxib are used. In a randomized, double-blind, placebo-controlled trial of 158 patients who were given either arthroscopic decompression (n=88, 43 in the placebo arm and 45 in the ropivacaine arm) or rotator cuff repair (n=70, 35 in each treatment arm), researchers found that ropivacaine infusion resulted in a significant but clinically unimportant improvement in average pain in the first 12 hours after surgery compared to placebo. No difference was detected between groups with regard to the maximum pain in the first 12 hours or the average or maximum pain in the second 12 hours, with or without adjustment for opioid use, and no difference was found between groups with regard to the amount of oral analgesia used. No difference was detected between groups with regard to the prevalence of nausea and vomiting, catheter leakage, delayed discharge, or stiff painful shoulder, and no participant in either group developed a postoperative infection.

Proprioceptive training for ankle sprain patients
online study in the British Medical Journal finds that a proprioceptive training program may help prevent self-reported recurrences of ankle sprain. The randomized, controlled trial of 522 athletes (aged 12-70 yrs.) who sustained lateral ankle sprains found that 56 of the 256 athletes assigned to the intervention group reported a recurrent ankle sprain, compared to 89 of the 266 athletes in the control group. Researchers found no significant differences among athletes in either group who received medical treatment for their injury, although athletes in the intervention group who were not medically treated had a significantly lower risk of recurrence than controls who were not medically treated.

Tubular diskectomy or microdiskectomy?
Compared to conventional microdiskectomy, tubular diskectomy may not result in a significant improvement in disability for sciatica patients,
according to data in the Journal of the American Medical Association (JAMA) (July 8, 2009). The randomized controlled trial involved 328 patients (18 to 70 years old) who had persistent leg pain ( longer than 8 weeks) due to lumbar disk herniations and were treated at 7 general hospitals in the Netherlands from January 2005 to October 2006. Overall, 167 patients underwent tubular diskectomy, and 161 patients underwent conventional microdiskectomy. Based on intention-to-treat analysis, patients with conventional microdiskectomy had lower pain scores than those with tubular diskectomy at 8 weeks postsurgery and at 1 year followup. A year after surgery, 69 percent of patients assigned to tubular diskectomy reported a good recovery compared to 79 percent of those assigned to conventional microdiskectomy.

TKA improves function in older patients
study in the journal Medical Care (July 2009) finds that total knee arthroplasty (TKA) may be effective in improving function in older people. Among 2,272 Medicare patients diagnosed with osteoarthritis from 1994 to 2006, 516 patients received TKA and 1,756 did not. Researchers matched the TKA patients with 515 controls with similar baseline functioning, health status, socioeconomic characteristics, and time before TKA or diagnosis of osteoarthritis of the lower leg and followed the patients for 4 years. TKA patients had a 17.5 percent increase in mobility, a 39.3 percent increase in gross motor fuctioning, and a 46.8 percent decrease in limitations on activities of daily living compared to patients in the control group.

Use of BMP in spinal fusions increasing
study in JAMA (July 1, 2009) finds that the use of bone-morphogenetic protein (BMP) in spinal fusion is increasing. Nationwide usage of BMP has increased from 0.69 percent of all fusions in 2002 to 24.89 percent of all fusions in 2006. Researchers also foundthat use of BMP in anterior cervical fusion procedures was associated with a higher rate of complications. BMP use was also associated with greater inpatient hospital charges across all categories of fusion.

Patients often not told of abnormal results
According to a
study in the Archives of Internal Medicine (June 22, 2009), healthcare providers often fail to inform patients or to document informing patients of abnormal outpatient test results. In a retrospective review of the medical records of 5,434 randomly selected patients aged 50 to 69 years in 19 community-based and 4 academic medical center primary care practices, researchers found 135apparent failures to inform or to document informing the patient. Use of a “partial electronic medical record” (EMR) was associated with higher failure rates compared to having no EMR or having an EMR that included both progress notes and test results.

Vena cava filters better for VTE prophylaxis in risky trauma patients
Although venous thromboembolism (VTE) is common among patients with severe injuries, pulmonary embolism (PE) is not a major cause of death among such patients, according to the results of a Canadian
study published online in PLoS Medicine. The research team assessed various VTE prophylaxis strategies using cost and clinical data from patients admitted to a single trauma center with severe head/neck and/or abdomen/pelvis injuries. The estimated incidence of deep vein thrombosis at 12 weeks was 15 percent for the pneumatic compression device and Doppler ultrasound strategies, and 25 percent for the vena cava filter strategy. In contrast, the estimated incidence of PE was 2.9 percent with the pneumatic compression device, 1.5 percent with Doppler ultrasound, and only 0.3 percent with the vena cava filter. Estimated healthcare costs per patient at 12 weeks were comparable for the Doppler ultrasound and pneumatic compression device strategies, but higher for the vena cava filter strategy. The expected mortality among all three strategies was similar.

Screen infants for hip dysplasia
According to a
study in JBJS-A (July 1, 2009) screening newborn children for hip dysplasia reduces the likelihood that they will have a non-arthritic hip at the age of 60 years. The authors analyzed data from more than 70 research studies and clinical trials dating back to 1939 to compare long-term outcomes in the following screening strategies: no screening, universal screening of newborns with both physical examination and ultrasonography, or universal screening with physical examination but only selective use of ultrasonography for high risk babies. An analytic model found that the optimum strategy for reducing the probability of having a non-arthritic hip at age 60 was to screen all infants for hip dysplasia with a physical examination, and use ultrasonography for high-risk infants.

Diabetes increases risk in joint replacement procedures
study in JBJS-A (July 1, 2009) finds that patients with uncontrolled diabetes mellitus exhibited significantly increased odds of surgical and systemic complications, higher mortality, and increased length of stay during the index hospitalization following lower extremity total joint arthroplasty. In a retrospective study of 1,030,013 joint replacement patients (1988 to 2005), 3,973 had uncontrolled diabetes mellitus, and 105,485 had controlled diabetes mellitus. Compared with patients with controlled diabetes mellitus, patients with uncontrolled diabetes mellitus had significantly increased Odds of stroke, urinary tract infection, ileus, postoperative hemorrhage, transfusion, wound infection, and death were significantly higher among patients with uncontrolled diabetes mellitus. These patients also had a significantly increased length of stay (almost a full day) compared with patients with controlled diabetes. All patients with diabetes had significantly higher inflation-adjusted postoperative charges when compared with non-diabetic patients.

Sports injuries and ED visits
According to
data released by the U.S. Agency for Healthcare Research and Quality, sports-related injuries such as broken bones, bruises, and scrapes accounted for 22 percent of hospital emergency department (ED) visits for children ages 5 to 17 in 2006. Other findings include:

  • 81 percent of all ED visits were for bruises, sprains and strains, arm fractures, or cuts and scrapes to the head, neck, or chest
  • 1.3 percent of visits resulted in hospital admissions, mostly for leg and arm fractures
  • Teens were 5 times more likely than children to be treated for sports injuries in EDs
  • The data were drawn from the agency’s Sports Injuries in Children Requiring Hospital Emergency Care, 2006 report.