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AAOS Now

Published 3/1/2003

Second look

Exercise benefits TKA, OA patients
Exercise can help patients recover after total knee arthroplasty (TKA), according to a study published in the Feb. 15, 2009 issue of Arthritis Care & Research. In a randomized controlled trial of 200 patients undergoing primary, unilateral TKA for knee osteoarthritis (OA) and 41 patients eligible for enrollment who served as controls, patients who received 6 weeks of outpatient physical therapy (volitional strength training or volitional strength training with neuromuscular electrical stimulation [NMES]) had better strength, activation, and function than patients in the control group.

Another study in the same publication found that patients with a high mechanical strain score and a low muscle strength score were at greater risk for knee OA. The authors used longitudinal data from 1,678 men and women, age 55–85 years, evaluated over a 12-year period. Risk was calculated after adjustment for age, sex, region of living, education, lifetime physical work demands, lifetime general physical activity, body mass index, current total physical activity level, and depression.

Outpatient surgery becoming more common
A report released by the U.S. National Center for Health Statistics shows that the rate of visits to free-standing surgical centers tripled between 1996 and 2006 to 15 million surgeries and other procedures per year. Surgeries at free-standing centers now account for 42 percent of all outpatient operations.

COX-2 improves bone healing in older mice
A mouse study published in the Jan. 15, 2009 issue of Journal of Bone and Mineral Research suggests that cyclooxygenase 2 (COX-2)/EP4 agonists may compensate for deficient molecular signals that result in aging-associated reduction in fracture healing. Using a femoral fracture repair model in two groups of mice (age 7–9 weeks or 52–56 weeks), the authors evaluated healing and found that aging was associated with a decreased rate of chondrogenesis, decreased bone formation, reduced callus vascularization, delayed remodeling, and altered expression of genes involved in repair and remodeling. Local administration of an EP4 agonist to the fracture repair site in the older mice enhanced the rate of chondrogenesis and bone formation to levels observed in the younger mice, suggesting that the expression of COX-2 during the early inflammatory phase of repair regulates critical subsequent events including chondrogenesis, bone formation, and remodeling.

“Partnership building” needed on TKA
A study published in the Jan. 15, 2009, issue of Arthritis Care & Research finds that differences of opinion between patients and healthcare providers regarding the risks and benefits of TKA can affect patient satisfaction and commitment to treatment. Surveys of 101 study participants and observers’ examination of audio recordings found modest-to-poor agreement between patients and providers regarding the severity of patients’ OA and the expected benefits and risks of TKA. Providers and patients were in greater agreement regarding OA severity when providers spent more time building partnerships with patients. Differences between providers’ and patients’ concerns about surgery were greater when patients were less participatory, African American, or expressed lower trust in their physicians.

Arthroscopic treatment of FAI
Accompanied by suitable rehabilitation, hip arthroscopy can provide good short-term outcomes and high patient satisfaction among patients with femoroacetabular impingement (FAI), according to a study in the January 2009 issue of the Journal of Bone and Joint Surgery—British Volume. In a prospective study of 112 patients (62 women, 50 men; mean age 40.6 years) who had arthroscopic surgery for FAI during an 8-month period, the authors found that mean modified Harris hip score (HHS) improved from 58 to 84 and median patient satisfaction was 9 (range: 1 to 10) at a mean follow-up of 2.3 years. Ten patients underwent total hip replacement at a mean of 16 months (range: 8 to 26 months) after arthroscopy. The predictors of a better outcome were the preoperative modified HHS, joint space narrowing less than or equal to 2 mm, and repair of labral pathology instead of débridement.

Osteoporosis risk in assisted-living residents
A study published in the January 2009 issue of the Journal of the American Geriatrics Society suggests assisted-living (AL) residents may be at increased risk for osteoporotic fracture. In a cross-sectional study of 107 individuals (mean age 82.7±5.7 years) living in community and AL facilities in Connecticut, researchers found no group differences in reported fracture, diagnosis of osteoporosis, or previous bone mineral density (BMD) assessment, but AL residents had lower quantitative heel ultrasound T-scores and lower levels of vitamin D and parathyroid hormone than community residents. Age, sex, and site of residence were significant predictors of heel T-score, explaining 53.7 percent of the variance.

Shoulder injuries in high school athletes
A study published in the January-February 2009 issue of the Journal of Athletic Training finds that shoulder injuries among high school students are relatively common in predominately male sports such as baseball (18 percent of all injuries), wrestling (18 percent), and football (12 percent). In a prospective injury surveillance study of 100 nationally representative U.S. high schools during the 2005-2006 and 2006-2007 school years, researchers found 805 shoulder injuries across 3,550,141 athlete-exposures (1 athlete participating in 1 practice or competition). Although 44.8 percent of athletes sustaining a shoulder injury returned to play in less than 1 week, 22.9 percent were out of play for more than 3 weeks, and 6.2 percent required surgery. Common mechanisms of shoulder injury included player-to-player contact (57.6 percent) and contact with the playing surface (22.8 percent).

Surgeon performance improves with “warm-ups”
A 15- to 20-minute preoperative warm-up of simple surgical exercises can lead to a substantial increase in surgical skills proficiency during follow-up tasks, according to a study in the February 2009 issue of the Journal of the American College of Surgeons. In a study of 46 surgeons across varying specialties and experience levels, surgeons who performed standardized exercises as a preoperative warm-up displayed significant improvements in outcomes measures after warm-up exercises, with similar results seen across surgeons with differing experience levels.

MRSA on the rise in young patients
The number of pediatric methicillin-resistant Staphylococcus aureus (MRSA) head and neck infections is on the rise, finds a study published in the January 2009 issue of the Archives of Otolaryngology—Head and Neck Surgery. In a retrospective review of 21,009 pediatric head and neck S. aureus infections that occurred between January 2001 and Dec. 31, 2006, at more than 300 hospitals in the United States (mean patient age=6.7 years), the authors found that MRSA was seen in 21.6 percent (n = 4,534) of all patient isolates. The rates increased from 11.8 percent in 2001 to 28.1 percent in 2006—a 16.3 percent increase over the 6 years for all pediatric head and neck S. aureus infections.

Presurgical pain may anticipate postsurgical pain
A study in the November 2008 issue of Foot & Ankle International finds that the intensity of a patient’s preoperative pain may be predictive of anticipated postoperative pain. In a prospective study of 98 patients undergoing orthopaedic foot and ankle operations, patients who experienced pain before the operation anticipated feeling higher pain intensity immediately postoperatively. The severity of preoperative pain was highly predictive of anticipated postoperative pain and 6-week postoperative pain, and both preoperative pain and anticipated pain predicted higher immediate postoperative pain. Age, gender, and preoperative diagnosis (acute versus chronic) did not have a significant effect on the severity of pain that patients experienced.

CDC updates field triage guidelines
The U.S. Centers for Disease Control and Prevention (CDC) has revised its field triage guidelines. The revised recommendations offer guidance on new technologies such as vehicle crash notification systems, which alert emergency services that a crash has occurred and automatically summon assistance; the right place and right time to best use crucial emergency care resources; and vehicle crash damage criteria that can help determine which patients may require care at a trauma center.

Incentive programs encourage e-prescribing
The Jan. 21, 2009 Wall Street Journal reports that incentives from the U.S. government and health insurers have more than doubled the number of physicians using electronic prescribing (eRX) over the past year, to about 12 percent of all office-based physicians. The Medicare Improvements for Patients and Providers Act of 2008 authorized eRX—an incentive program for eligible professionals who are successful e-prescribers. Some private health plans have also begun offering extra payments along with free equipment such as digital handheld devices, and a coalition of technology companies is giving physicians free e-prescribing software to encourage the changeover.

Improving diversity and professionalism in medical schools
A multi-discipline panel of medical and institutional leaders stated that medical schools should focus on expanding diversity and increasing professionalism, including the following:

  • Giving students more opportunities to learn the principles of quality improvement, patient safety, and patient-centered care
  • Preparing students to work effectively and collaboratively as members of healthcare teams and as part of a system of care
  • Using more community-based settings (and fewer hospital-based settings) as classrooms
  • Ensuring that physicians have more background in public health education and the role that social factors play in affecting patient health
  • Emphasizing the importance of problem solving and self-directed learning