Published 12/1/2009

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.

Shortage of sleep an issue
A study in the Journal of the American Medical Association (Oct. 14, 2009) finds that surgical procedures performed by physicians who had less than 6 hours of sleep were associated with an increased rate of complications. The matched retrospective cohort study found that complications occurred in 82 of 1,317 post-nighttime procedures performed by surgeons with sleep opportunities of 6 hours or less (6.2 percent) compared to 19 of 559 post-nighttime procedures performed by surgeons with sleep opportunities of more than 6 hours (3.4 percent).

Warfarin use in trauma patients
A study in the Journal of the American College of Surgeons (September 2009) finds that warfarin use may be associated with a 30 percent increased risk of death among all trauma patients and a 20 percent increased risk in patients 65 and older. However, the study did not find a definitive connection between warfarin use and post-trauma death.

Single sport players more prone to injuries
A study presented at the International Society for Tennis Medicine and Science World Congress finds that playing one sport year round increases the risk of injury, particularly in young players. Junior tennis players who played only tennis were more likely to withdraw from tournaments for medical reasons, typically injuries. Typical injuries included muscle strains, ankle sprains, hip injuries, patellar instability, spinal stress fractures, tendinitis of the wrist, and rotator cuff injuries.

Good intentions compromise clinical trials
A study in the September/October issue of the journal IRB: Ethics & Human Research finds that the scientific validity of clinical trials may be compromised by the desire of investigators to act in the best medical interests of patients. An online survey of clinical researchers, physicians, and other research staff found that almost 64 percent of respondents thought that researchers should deviate from the protocol to improve care to patients. Among respondents who had worked on a trial that prohibited using a medication that they believed to be in a subject’s best medical interest, more than 28 percent reported giving the restricted medication at least once. Of the respondents whose patients met termination criteria but seemed to benefit medically from the trial, 9 percent reported keeping the patient in the trial.

Teriparatide better for steroid-induced osteoporosis
A study published in Arthritis & Rheumatism (November 2009) finds that teriparatide may be more effective than alendronate for treatment of glucocorticoid-induced osteoporosis. The 36-month, randomized, double-blind, controlled trial involved 428 patients with osteoporosis (aged 22–89 years) who had received 5 mg/day of prednisone equivalent for 3 months preceding screening. At 36 months, patients who received teriparatide had increases in bone mineral density that were nearly double those experienced by patients on alendronate. Fewer patients had vertebral fractures in the teriparatide group than in the alendronate group; most fractures occurred during the first 18 months of treatment. No significant difference was found between groups in the incidence of non- vertebral fractures.

Physicians spending more time with patients
An analysis of a representative sample of office-based adult visits to primary care physicians in the United States finds that the mean visit duration increased from 18.0 to 20.8 minutes from 1997 to 2005, even as the number of total annual visits increased from 273 million to 338 million. For general medical examinations, visit duration increased by 3.4 minutes over the same time-frame. Additionally, quality of care improved for one of three counseling or screening indicators and for four of six medication indicators. The study appeared in the Archives of Internal Medicine (Nov. 9, 2009).

First steps to understanding FOP
Research published in the Journal of Clinical Investigation (Nov. 2, 2009) provides some understanding of how fibrodysplasia ossificans progressiva (FOP) might develop at a cellular level in the human body. A series of in vitro assays using several mammalian cell lines and chick limb bud micromass cultures determined that a mutant R206H ACVR1 gene activates bone morphogenetic protein (BMP) signaling even in the absence of BMP. The cell-signaling cascade that results culminates in changes in gene expression and the formation of new bone. The data support the conclusion that the mutant R206H ACVR1 receptor in FOP patients is an activating mutation that induces BMP signaling in a BMP-independent and BMP-responsive manner to promote chondrogenesis, consistent with the ectopic endochondral bone formation in these patients.