Published 1/1/2011

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.

Research supports osteoporosis drug “holiday”
Research conducted at the Loyola University Health System indicates that taking time off from bisphosphonate treatments for osteoporosis may be beneficial to bone health. An evaluation of 139 patients (123 females) diagnosed with osteoporosis or osteopenia who had taken bisphosphonates for an average of 6.8 years before taking a drug “holiday” from 2005 to 2010 found that over 3 years, five fractures occurred, but bone mineral density (BMD) did not change significantly. More work is needed to adequately assess the optimal duration of the drug holiday.

Knee OA pain associated with back pain
A study in Arthritis Care & Research (December 2010) finds that lower back pain (LBP), foot pain, and elbow pain are significantly associated with WOMAC Osteoarthritis Index knee pain scores. Of 1,389 patients aged 45 to 79 years from the Progression Cohort of the Osteoarthritis Initiative who had symptomatic tibiofemoral knee osteoarthritis (OA), 57.4 percent reported LBP. LBP patients had a WOMAC pain score of 6.5 (± 4.1), compared to scores of 5.2 (± 3.4) for patients without LBP (p < 0.0001). In models that looked at all pain locations simultaneously, only LBP, ipsilateral elbow pain, and ipsilateral foot pain were significantly associated with knee pain score.

Patients with minor ankle OA more satisfied after surgery
A study in Foot & Ankle International (November 2010) suggests that patients with no or minor arthritis who receive lateral ankle ligament reconstruction and cavovarus realignment osteotomy for idiopathic cavovarus deformity and lateral ankle ligament instability are more satisfied than those who have moderate or severe arthritis at time of treatment. The retrospective study of 22 patients examined results at mean 60.4 month follow-up. The 14 patients in Group 1 (“none to minimal arthritis”) had significantly improved mean AOFAS, Karlsson and Peterson, and VAS scores compared to the eight patients in Group 2 (“moderate to severe arthritis”). Only one patient in Group 1 had progression of arthritis, while five patients in Group 2 either had progression of arthritis or required an ankle fusion.

Treating Achilles tendon rupture
A study in the American Journal of Sports Medicine (AJSM) (November 2010) finds no statistically significant difference between surgical and nonsurgical treatment for acute Achilles tendon rupture. The randomized, controlled trial of 97 patients (79 men, 18 women; mean age, 41 years) with acute Achilles tendon rupture found that the surgically treated group had better results at 6-month follow-up than the nonsurgically treated group in some muscle function tests. At 12 months, the only difference between the two groups was in the heel-rise work test, which favored the surgical group. At 1-year follow-up, the nonsurgical group had six re-ruptures (12 percent) compared to two re-ruptures (4 percent) in the surgical group (p = 0.377).

For the AAOS Clinical Practice Guideline on the Diagnosis and Treatment of Acute Achilles Tendon Rupture, visit www.aaos.org/guidelines

Cost-effectiveness of double-bundle ACL repair
Data from a study in AJSM (December 2010) suggest that double-bundle anterior cruciate ligament (ACL) reconstruction may be cost-effective, despite higher upfront costs. The model assumed an otherwise healthy young person with a reconstructed ACL tear and a 12-year follow-up period. According to the study, 64 percent of double-bundle knees and 54 percent of single-bundle knees resulted in an International Knee Documentation Committee (IKDC) score of A. The incremental cost-effectiveness ratio of a double-bundle ACL reconstruction compared with a single-bundle ACL reconstruction was $6,416 per quality adjusted life year (QALY) in the baseline scenario; in an alternate scenario, it was $64,371 per QALY. More research is needed to confirm whether any difference in the distribution of IKDC outcomes exists between the two techniques, and the lack of any other demonstrated clinical benefit from the double-bundle technique may draw into question the clinical relevance of the difference in IKDC scores.

Bone-loss common in HIV-positive patients
Data presented in AIDS (Nov. 27, 2010) finds that human immunodeficiency virus (HIV)-infected patients are at increased risk for bone loss. Of 671 patients who had had at least one DEXA scan to determine BMD and establish related factors, 28 percent experienced progression to bone demineralization over a median of 2.5 years (12.5 percent progressed to osteopenia and 15.6 percent to osteoporosis). Factors associated with bone loss and progression were age, male sex, low body mass index, time on protease inhibitor, time on tenofovir, and current use of protease inhibitors.

Ultrasound guidance for intra-articular knee injections
According to data presented at the annual meeting of the American College of Rheumatology, sonographic needle guidance can be used to improve the outcomes and cost-effectiveness of intra-articular injections for knee OA. In the randomized study, patients who received injections with sonographic guidance had a 47.7 percent reduction in procedural pain (p < 0.001), a 41.7 percent reduction in pain scores at outcome (p < 0.03), and a 35.5 percent increase in therapeutic duration (p = 0.01) compared to those who received conventionally guided injections.