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Published 11/1/2009

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.

DMPA increases fracture risk in younger women
According to research presented at the 2009 annual meeting of the American Society for Bone and Mineral Research, use of the contraceptive depot medroxyprogesterone acetate (DMPA) is associated with an increased risk for fractures in young women. A review of 71,089 women with fracture diagnoses between 1995 and 2007, each of whom was matched with four controls (274,520 controls) according to age, sex, general practice, calendar time, and years of history in the database, found that DMPA users with current prescriptions refilled 3 to 9 times had adjusted odds ratios for fracture of 1.24 (95 percent confidence interval); the odds ratio rose to 1.54 when prescriptions were filled 10 or more times compared with those not using DMPA. When users were stratified by age, researchers found that odds ratios for current long-term use of DMPA were 1.69 for those younger than 50 years, and 0.82 for those older than 50 years.

Better clinical outcomes after carpal tunnel surgery
Patients with carpal tunnel syndrome without denervation may have a modestly better clinical outcome with surgery, according to a study in The Lancet (Sept. 26, 2009). In a parallel-group, randomized controlled trial of 116 patients from eight academic and private practice institutions, 57 patients were assigned to carpal tunnel surgery, and 59 were assigned a well-defined, nonsurgical treatment, including hand therapy and ultrasound. At 12 months follow-up, 101 patients (87 percent) were analyzed (49 of 57 in the surgery group and 52 of 59 in the nonsurgery group. Patients in the surgery group displayed a significant 12-month adjusted advantage for surgery in function and symptoms using the Carpal Tunnel Syndrome Assessment Questionnaire. No clinically important adverse events or surgical complications were reported.

Wrist fracture patients and osteoporosis
A Korean study in the Journal of Bone & Joint Surgery—American (JBJS-A) (Oct. 1, 2009) finds that patients with wrist fractures are less likely to be evaluated and managed for osteoporosis than those with hip or spine fractures. In reviewing a Korean database of 31,540 hip fractures, 58,291 spine fractures, and 61,234 wrist fractures in female patients older than age 50 during 2007, researchers found that 22.5 percent of patients with hip fractures, and 28.8 percent of patients with spine fractures underwent diagnostic bone density scans, compared to only 8.7 percent of patients with wrist fractures. Researchers also found that three to four times as many hip and spine fracture patients were managed with at least one medication approved for the treatment of osteoporosis compared to wrist fracture patients.

ACL injuries, readmissions on the rise
In a review of 70,547 anterior cruciate ligament (ACL) reconstructions performed between 1997 and 2006 in New York State, a research team found that the number of ACL reconstructions performed in a year increased from 6,178 in 1997 to 7,507 in 2006. Readmission within 90 days occurred at a 2.3 percent rate, and subsequent surgery on either knee within 1 year occurred at a 6.5 percent rate. Patients older than 40 years of age, with a pre-existing comorbidity, who were male, or who were operated on by a lower-volume surgeon were at increased risk for readmission within 90 days. Predictors of subsequent knee surgery included being female, having concomitant knee surgery, and being operated on by a lower-volume surgeon. Predictors of a subsequent ACL reconstruction included being younger than 40 years old, concomitant meniscectomy or other knee surgery, and surgery in a lower-volume hospital. The study appeared in JBJS-A (Oct. 1, 2009).

Using older blood cells increases DVT risk in trauma patients
A study published online in Critical Care finds that trauma patients transfused with 5 or more units of red blood cells (RBCs) may risk deep vein thrombosis (DVT) or multi-organ failure if any of the units have been stored for 28 or more days. In a retrospective cohort study of 202 trauma patients transfused with a minimum of 5 RBC units, 101 patients received fresh (stored for fewer than 28 days) RBC units and 101 received older RBC units (stored for 28 or more days). In general, no differences were found in admission vital signs, laboratory values, use of DVT prophylaxis, blood products, or Injury Severity Scores between study groups. DVT occurred in 16.7 percent of patients who received fresh RBC units and in 34.5 percent of patients who received older RBC units (p=0.006). Mortality rates for patients who received older RBC units were nearly twice as high as for those who received fresh RBC units (p=0.02).

Preventive RARα-agonist may reduce posttraumatic HO
A mouse study published online in the Journal of Orthopaedic Research finds that a pharmacologic strategy involving a selective nuclear retinoic acid receptor α (RARα)-agonist can counteract an ectopic skeletal-formation process and potentially represent a preventive treatment for heterotopic ossification (HO). Researchers found a synthetic retinoid can inhibit chondrogenesis in mouse limb micromass cultures. Control mice developed large HO-like masses that displayed abundant cartilage, endochondral bone, vessels, and marrow, while the formation of HO-like masses was markedly reduced in companion mice receiving daily oral doses of α-agonist.

Vitamin D helps prevent falls in elderly
A study published on the Web site of the British Medical Journal reports that elderly patients who take high levels of vitamin D can reduce their risk of falling. A meta-analysis of eight randomized controlled trials (n=2,426) of supplemental vitamin D found that high-dose daily supplements (1,000 international units [IU] or more) reduced the risk of falling by 19 percent among individuals aged 65 and older. Doses of supplemental vitamin D of less than 700 IU or serum 25-hydroxyvitamin D concentrations of less than 60 nmol/l may not reduce the risk of falling among older individuals.

Use ibuprofen for pediatric arm fracture pain relief
A study published in the Annals of Emergency Medicine (October 2009) finds that ibuprofen is as effective as acetaminophen with codeine in reducing pain and may lead to better functional outcomes for children with pediatric arm fractures. In a randomized, double-blind trial of 244 patients who received either 10 mg/kg doses of ibuprofen or 1 mg/kg doses (codeine component) of acetaminophen with codeine, the proportion of treatment failures for ibuprofen (20.3 percent) was lower than for acetaminophen with codeine (31.0 percent), though not statistically significant. In analyzing each day’s pain, researchers found that the proportion of children who had any function affected by pain was significantly lower for the ibuprofen group.

Hip fracture rates declining; comorbidities rising
A study in the New England Journal of Medicine (Oct. 14, 2009) finds that rates of hip fracture and subsequent mortality among persons 65 years and older are declining, while comorbidities among patients with hip fractures have increased. The observational study used data from a 20 percent sample of Medicare claims from 1985 to 2005, and medication data from 109,805 respondents to the Medicare Current Beneficiary Survey between 1992 and 2005. Between 1986 and 2005, the annual mean number of hip fractures was 957.3 per 100,000 (95 percent confidence interval) for women and 414.4 per 100,000 for men. Age-adjusted incidence of hip fracture increased from 1986 to 1995, and then steadily declined from 1995 to 2005. In women, incidence increased 9.0 percent from 1986 to 1995, then declined 24.5 percent by 2005. In men, the increase in incidence from 1986 to 1995 was 16.4 percent, and the subsequent decrease to 2005 was 19.2 percent. The incidence decrease is coincident with increased use of bisphosphonates. Over time, patients with hip fracture have had an increase in all comorbidities recorded except paralysis.