Published 12/1/2012

Second Look-Clinical News and Views

Study: Impact of smoking on spine outcomes
A study in the Oct. 1 Spine analyzes the treatment effect (TE) among patients treated surgically and nonsurgically for spinal stenosis (SpS). The review of data on 654 patients (419 treated surgically) participating in the Spine Patient Outcomes Research Trial used 53 baseline variables to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index (ODI) over 4 years. All analyzed subgroups that included at least 50 patients improved significantly more with surgery than with nonsurgical treatment—except for smokers.

Study: Bracing and ACL reconstruction outcomes
Findings from a meta-analysis in the Oct. 3 Journal of Bone & Joint Surgery—American (JBJS-A) suggest that new approaches to rehabilitation after anterior cruciate ligament (ACL) reconstruction may be helpful, but range-of-motion, strengthening, and functional exercises remain key factors for successful surgical outcomes. The evaluation of 29 Level I and Level II studies found that bracing following ACL reconstruction is neither necessary nor beneficial and adds to the cost of the procedure.

Study: Obesity and TKA outcomes
Results of a meta-analysis and systematic literature review in JBJS-A (Oct. 17) show that obesity had a negative influence on outcomes after total knee arthroplasty (TKA), with more short-term complications and poorer long-term outcomes compared to non-obese patients. The evaluation of 20 studies comparing the outcomes of TKA in different weight groups found that complications, including infection, deep infection requiring surgical débridement, and revision for any reason, occurred more often in obese patients than in non-obese patients.

Study: Weight-bearing after pediatric closed tibial shaft fractures
Children who are allowed to bear weight immediately after application of a cast for tibial shaft fracture had similar time to healing as those who were non–weight-bearing, and showed no difference in angulation or shortening, researchers report in JBJS-A (Oct. 17). Researchers compared children with low-energy fractures who were fitted either with a cast with the knee in 10° of flexion and allowed immediate weight-bearing or with a cast in 60° of flexion and counseled against weight bearing. Both groups had the same results for healing time (10.8 weeks), mean coronal and sagittal alignment, and mean shortening. At 6 weeks, the weight-bearing group had better overall scores and better standing skills.

Study: Reducing risk of SSI after arthroplasty, spinal fusion
Use of nasal mupirocin with topical chlorhexidine gluconate (CHG) prior to surgery may reduce risk of surgical site infection (SSI) with Staphylococcus aureus, according to data presented at the Infectious Diseases Week 2012 conference. The open label, randomized trial compared SSI after arthroplasty or spine fusion surgery in patients receiving two applications of topical CHG with either one application nasal povidone-iodine (PI) or 5 days of nasal mupirocin ointment prior to surgery. The PI group (887 cases) had one case of deep S aureus SSI and one case of superficial S aureus SSI; the mupirocin group

(879 surgeries) had five cases of deep S aureus SSI and no superficial cases.

Meningitis outbreak
A review article in the New England Journal of Medicine (NEJM) (Oct. 19) looks at the fungus associated with recent reports of contaminated methylprednisolone injections and an outbreak of more than 200 cases of meningitis. The authors recommend alerting patients to tell physicians about any new onset of headache, neck stiffness, photophobia, fever, or stroke-like symptoms. They suggest a very low threshold for performing lumbar puncture if any symptoms suggest possible central nervous system infection. Patients who have no symptoms should not undergo lumbar puncture or joint aspiration, but should be told to call their physicians immediately if symptoms occur.

Study: ESI linked to increased risk of fractures
Data presented at the annual meeting of the North American Spine Society (NASS) suggest that patients treated with an epidural steroid injection (ESI) for back pain may have a greater likelihood of bone fractures in the spine. The retrospective study involved 6,000 patients (3,840 women and 2,160 men; average age 66 years old) treated for back pain between 2007 and 2010. Half of the patients received at least one steroid injection; the other half did not. The risk of fracture increased 29 percent with each steroid injection.

Study: BMP use in pediatric spinal fusions
According to data in the Journal of the American Medical Association (Oct. 10), 9.2 percent of pediatric spinal arthrodesis procedures may include the use of bone morphogenic protein (BMP), even though BMP has not received approval from the U.S. Food and Drug Administration for use in pediatric spinal procedures. Based on data from the Kids’ Inpatient Database, Healthcare Cost and Utilization Project researchers found that BMP was used in 771 of 8,289 pediatric spinal arthrodesis cases. The estimated prevalence of in-hospital complications among patients who received BMP was 3 percent, compared to 3.6 percent for those who did not receive BMP. An adjusted analysis showed that procedures that used BMP were on average 19 percent more costly than those that did not involve BMP.

Study: Improving osteoporosis testing, treatment compliance
A study in the American Journal of Medicine (September) finds that a simple intervention with supplied educational material improved patient follow-up with osteoporosis treatment. Based on data from 240 patients (123 controls; 117 interventions) older than 60 years who were discharged home from emergency departments and who had vertebral fractures reported but were not treated for osteoporosis, physician intervention significantly increased osteoporosis treatment, bone mineral density (BMD) testing, and BMD testing or treatment at 3 months. In addition, 3 months after controls were re-allocated to physician plus patient interventions, 22 percent had started treatment and 65 percent had BMD testing or treatment. Physician plus patient interventions increased BMD testing or treatment an additional 16 percent compared with physician only interventions.

These items originally appeared in AAOS Headline News Now, a thrice-weekly enewsletter that keeps AAOS members up to date on clinical, socioeconomic, and political issues, with links to more detailed information. Subscribe at www.aaos.org/news/news.asp (member login required)