Published 10/1/2009

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.

Effectiveness of ibuprofen
A study published in Annals of Emergency Medicine (Aug. 18, 2009) finds that ibuprofen may be at least as effective as acetaminophen with codeine for reducing pain in young outpatients with arm fractures. In a randomized, double-blind, clinical trial of 336 children, half (167) were given 10 mg/kg ibuprofen and half (169) were given 1 mg/kg/dose of acetaminophen with codeine during the first 3 days after discharge from the emergency department. Among patients who took ibuprofen, the proportion of treatment failures (insufficient pain relief requiring use of a secondary “rescue” medication) was 20.3 percent; among those treated with acetaminophen with codeine, it was 31.0 percent. When pain was analyzed by each day after injury, the proportion of children who had any function (play, sleep, eating, school) affected by pain was significantly lower for the ibuprofen group. Significantly more children receiving acetaminophen with codeine reported adverse effects and did not want to use it for future fractures.

Denosumab in prostate cancer patients
A study in the New England Journal of Medicine (NEJM) (Aug. 20, 2009) finds that denosumab, a biologic therapy being tested to treat osteoporosis, may be associated with an increased bone mineral density (BMD) and a reduction of new vertebral fractures among men who are receiving androgen-deprivation therapy for non-metastatic prostate cancer. A double-blind, multicenter study of 1,468 patients randomly assigned to receive either 60 mg of denosumab or placebo every 6 months found increased BMD of the lumbar spine at 24 months in the denosumab group, compared with a loss of BMD in the placebo group (p<0.001). significant differences between the groups were seen as early as 1 month and sustained through 36 months. denosumab therapy was also associated with significant increases in bmd at the total hip, femoral neck, and distal third of the radius at all time points. patients who received denosumab had a decreased incidence of new vertebral fractures at 36 months; rates of adverse events were similar between the two groups.>

Canadian hip fracture rates dropping
A Canadian study in the Journal of the American Medical Association (Aug. 26, 2009) finds that rates of hip fracture have steadily declined over a 21-year period. From 1985 through 2005, based on nationwide hospitalization data, age-adjusted hip fracture rates decreased by 31.8 percent in women and by 25.0 percent in men. A similar trend has been noted in the United States, despite growing numbers of elderly people.

Trauma care: Experience and timing
According to a study in Archives of Surgery (August 2009), surgeon experience does not affect overall mortality rates as much as the overall system of care. The retrospective cohort study at an academic Level 1 trauma center found that patients treated by novice surgeons vs experienced trauma surgeons demonstrated no difference in mortality. In related news, a review article in the Journal of the AAOS (September 2009) finds that a damage-control approach may be more advisable for a subset of patients with multiple injuries. According to an analysis of several trauma registries in Germany, patients with life-threatening injuries who were in surgery for 6 or more hours did not do as well as those who were in surgery for less than 3 hours. Stabilization procedures, such as using an external fixator, are recommended to delay more invasive and time-consuming surgeries for a few days.

A study in The Journal of Bone & Joint Surgery (September 2009) found that, of 203 patients with either a femoral or tibial shaft fracture who were treated with intramedullary nailing, those who had surgery performed between 4 p.m. and 6 a.m. experienced more unplanned re-operations than those who had surgery performed between 6 a.m. and 4 p.m. Healing times were similar for both groups.

A “snapshot of U.S. physicians”
According to the 2008 Health Tracking Physician Survey, about 75 percent of physicians accepted all or most new Medicare patients, but fewer than 60 percent provided charity care in 2008. The survey also found that physician demographics may be changing, with more women entering the field. Although three out of four physicians are men, women account for more than 40 percent of physicians younger than age 40. For more findings, see the online version of this article, available at www.aaosnow.org

Osteoporosis, cholesterol, and immune system linked
A study in Clinical Immunology (September 2009) elucidates the relationships among the development of osteoporosis, high cholesterol, and the immune system. According to scientists, exposing human T lymphocytes to minimally oxidized, low density lipoprotein (LDL) significantly enhances the production of RANKL, a chemical that stimulates cells whose sole purpose is to destroy bone. Using blood samples from healthy human volunteers, the authors cultured participants’ T cells. Half of the T cells were combined with normal LDL; the rest were combined with oxidized LDL. When stimulated to mimic an immune response, the T cells exposed to oxidized LDL began producing RANKL.

Radiation adds up
A study in NEJM (Aug. 27, 2009) finds that imaging procedures can result in high cumulative effective doses of radiation to patients. Utilization data was used to estimate cumulative effective doses of radiation for 952,420 adults (age 18–64 years) from Jan. 1, 2005, to Dec. 31, 2007. During the period, 655,613 enrollees (68.8 percent) had at least one imaging procedure associated with radiation exposure. In general, cumulative effective doses of radiation from imaging procedures increased with advancing age and were higher in women than in men. Computed tomography and nuclear imaging accounted for 75.4 percent of the cumulative effective dose, with 81.8 percent of the total administered in outpatient settings.

Knee extensor strength and knee OA
Thigh muscle strength does not appear to be a predictor of incident radiographic osteoarthritis (OA), but does seem to predict incident symptomatic knee OA, according to the results of a study published online in Arthritis Care & Research. Researchers followed 1,617 participants (2,519 knees) who did not have radiographic tibiofemoral OA and 2,078 participants (3,392 knees) who did not have symptomatic whole knee OA. Knee extensor strength and H:Q ratio at baseline significantly differed between men and women, but neither knee extensor strength nor H:Q ratio was predictive of incident radiographic tibiofemoral OA. However, compared with the lowest tertile (third), the highest tertile of knee extensor strength protected against development of incident symptomatic whole knee OA in both sexes. H:Q ratio was not predictive of incident symptomatic whole knee OA in either sex.