Published 8/1/2011

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.

Wrong-site surgery rate increasing
Some researchers and patient safety experts say the problem of wrong-site surgery—surgery on the wrong patient or body part—has not improved in the 7 years since the introduction by The Joint Commission of the “universal protocol,” which requires verification of important details, marking of the surgical site, and a timeout just prior to surgery. Based on state data, The Joint Commission estimates that 40 wrong-site surgeries occur every week in U.S. hospitals and clinics. In addition, 93 cases of wrong-site surgery were reported in 2010, compared to 49 cases in 2004.

Vertebroplasty shows no advantage over placebo
According to a study published online in the British Medical Journal, vertebroplasty has no significant advantage over placebo (sham surgery) for patients with recent onset fracture or severe pain. The meta-analysis of two multicenter, blinded, placebo-controlled, randomized trials of vertebroplasty covering 209 total participants with at least one radiographically confirmed vertebral compression fracture found no advantage of vertebroplasty over placebo for participants with recent onset fracture or severe pain. In addition, vertebroplasty patients were more likely to be using opioids at one month than those who received the sham surgery.

E-prescribing error rates
A study published online in the Journal of the American Medical Informatics Association finds that electronic prescriptions are no less likely to contain errors than handwritten prescriptions. The retrospective cohort study of 3,850 computer-generated prescriptions received by a commercial outpatient pharmacy chain over a 4-week period during 2008 found that 452 (11.7 percent) of prescriptions contained a total of 466 errors, of which 163 (35.0 percent) were considered potential adverse drug events. Error rates by a computerized prescribing system ranged from 5.1 percent to 37.5 percent. Handwritten prescription error rates are estimated at around 12 percent.

July poses increased risk to patients
Patient mortality appears to increase during medical trainee academic year-end changeovers, according to information published online in Annals of Internal Medicine. The meta-analysis of 39 studies assessed the effect of the changeover on patient outcomes. The 13 higher-quality studies more often showed increased mortality and decreased efficiency at the changeover. Studies examining morbidity and medical error outcomes were of lower quality and produced inconsistent results. Thus, although evidence exists for increased mortality during changeover periods, heterogeneity in the literature does not permit firm conclusions about the degree of risk posed, safety risks, or problems with particular models.

Hip fracture types not linked to outcomes
An analysis of surgical treatments and outcomes in elderly hip fracture patients finds that the type of hip fracture does not appear to be independently related to patient outcomes, according to a study published in the Journal of Bone & Joint Surgery–American (JBJS-A) (June 15, 2011). The systematic review of 76 unique, randomized, controlled trials that involved both femoral neck fractures and intertrochanteric and subtrochanteric fractures also included 9 observational studies that addressed the link between patient characteristics and outcome variables by fracture type. According to the researchers, existing literature does not address broader questions about how patient factors, fracture type, and specific treatments affect mortality, functional status, and quality of life.

Surgical hip dislocation has few complications
Surgical hip dislocation—complete exposure of the hip joint so that various hip disorders can be treated—is a safe procedure with a low complication rate, according to a study in JBJS-A (June 15, 2011). The retrospective, multicenter analysis included 302 patients seen at eight different North American centers. Researchers found 18 Grade I complications (not clinically relevant and requiring no deviation from routine postoperative care); 6 Grade II complications (treated on an outpatient basis or with close observation and resolved); 9 Grade III complications (treatable and resolved with surgery or inpatient management); and 1 Grade IV complication (resulting in a long-term deficit). One or more complications were found in 30 of 334 hips; excluding heterotopic ossification, the complication rate was 4.8 percent.

Inhaled corticosteroids and fracture risk
A British study published online in the journal Thorax finds that long-term exposure to fluticasone and budesonide may be associated with an increased likelihood of fractures among patients with chronic obstructive pulmonary disease (COPD). The retrospective review of 16 randomized, controlled trials covering 17,513 participants and 7 observational studies covering 69,000 participants found that the use of inhaled corticosteroids was associated with a modest but statistically significant increase in fracture risk. Each 500 µg increase in beclomethasone dose equivalents was associated with a 9 percent increased risk of fractures.