Published 6/1/2012

Second Look- Clinical

Obesity and medical costs
Research in the Journal of Health Economics (January) suggests that obesity may account for as much as 21 percent of all U.S. medical costs. The authors drew data from the Medical Expenditure Panel Survey for 2000–2005, and focused on genetic variation in weight to eliminate the impact of other factors—such as back injury—that could affect both weight gain and medical costs. They found that obesity increases one’s annual medical costs by $2,741 (in 2005 dollars) compared to a non-obese person.

Nonsurgical treatment of Legg-Calvé-Perthes disease
A study in the Journal of Bone and Joint Surgery–American (JBJS-A) (Apr. 4) attempts to establish a modern benchmark for long-term outcomes following nonsurgical, weight-bearing treatment of Legg-Calvé-Perthes disease. The prospective study involved 56 patients (58 hips) with the condition who were enrolled in a multicenter trial between 1984 and 1991 and treated with hip range-of-motion exercises or bracing. At mean 20.4-year follow-up, three patients had undergone hip arthroplasty and one had undergone pelvic osteotomy. Of the remaining hips, 14 had no hip osteoarthritis (OA), 16 had Tönnis grade 1 OA, and 24 had grade 2 or 3 moderate or severe OA. Patients had a mean Iowa Hip Score of 74 (range, 43 to 100).

Magnetic growing rods in scoliosis patients
Early data published online in The Lancet suggest that use of a magnetically controlled growing rod (MCGR) procedure can be more cost-effective and offer improved quality of life for scoliosis patients, compared to a traditional growing rod procedure. Of five patients who received the MDGR, two have reached 24 months’ follow-up. The mean degree of scoliosis as measured by Cobb angle was 67 degrees before implantation, and 29 degrees at 24 months. Length of the instrumented segment of the spine increased by a mean of 1.9 mm with each distraction. Throughout follow-up, both patients had no pain, had good functional outcome, and were satisfied with the procedure. No MCGR-related complications occurred.

Nonunions in midshaft clavicle fracture
A study in JBJS-A (Apr. 18) finds that, compared to nonsurgical treatment, surgical treatment of patients with substantially displaced midshaft fractures of the clavicle is associated with a lower rate of nonunion and symptomatic malunion. The review of six studies (412 patients) found 29 nonunions among 200 patients treated nonsurgically, compared with 3 nonunions in 212 patients treated surgically. The nonsurgical group also had a higher rate of symptomatic malunion than the surgical group.

Outpatient surgery and VTE risk
A study published online in Annals of Surgery examines risk factors for venous thromboembolism (VTE) events after outpatient surgery. The prospective, observational cohort study of 259,231 patients in the American College of Surgeons National Surgical Quality Improvement Program database found an overall 30-day incidence of VTE of 0.15 percent. Independent risk factors for VTE included, but were not limited to, current pregnancy, active cancer, older age (age groups 41 to 59 years and 60 years or more), body mass index of 40 kg/m2 or higher, surgical time of 120 minutes or more, and arthroscopic surgery.

Hip function in THA and resurfacing patients
A United Kingdom study published online in BMJ finds no difference in hip function at 1 year between patients who received total hip arthroplasty (THA) and those who underwent resurfacing arthroplasty. The assessor-blinded, randomized, controlled trial involved 126 patients older than age 18 years with severe arthritis of the hip joint (60 resurfacing patients and 66 THA patients). At 12 months, the mean Oxford hip score was 40.4 in the resurfacing group and 38.2 in the THA group; the mean Harris hip score was 88.4 in the resurfacing group and 82.3 in the THA group. Overall complication rates did not differ but the THA group had more wound complications and the resurfacing group had more thromboembolic events.

Blood loss during posterior spinal fusion
According to a study published online in Spine, the relative risk of blood loss during pediatric corrective spine surgery may be linked to the underlying condition causing the spinal deformity. The retrospective review of 617 patients (aged 10 to 18 years) who underwent spinal fusion surgery (at least 5 levels) by a single surgeon from 2001 through 2011 found that, after adjustment, blood loss differed significantly by diagnostic group. Patients with cerebral palsy had a significantly higher normalized blood loss than patients with idiopathic scoliosis, Scheuermann’s kyphosis, other neuromuscular disorders, or genetic and syndromic disorders.

Activity after TKA
A study published online in the Journal of Arthroplasty finds statistically and clinically significant differences between patients’ expected and actual activity after total knee arthroplasty (TKA). Data on actual and expected participation in 36 leisure activities from 83 patients (aged 45 to 88 years) with knee OA were collected preoperatively and at 12-month follow-up. Despite average patient expectations of exercising 23 hours per week, patient activity had only increased to about 11 hours per week at 12 months.

PRFM and rotator cuff repair
Findings from a study published online in the American Journal of Sports Medicine suggest that platelet-rich fibrin matrix (PRFM) applied to the tendon-bone interface during rotator cuff repair may have little effect on tendon healing or muscle strength. The randomized, controlled trial involved 67 patients undergoing arthroscopic rotator cuff tendon repair who either received PRFM at the tendon-bone interface (n = 36) or standard repair with no PRFM (n = 31). At 6 and 12 weeks post-surgery, ultrasound found no significant differences in healing, and at minimum 1-year follow-up, no differences in tendon-to-bone healing, strength, or vascularity were found.

Adding fusion to laminectomy
For patients with degenerative grade I spondylolisthesis with lumbar spinal stenosis, laminectomy with lumbar spinal fusion may offer improved quality of life compared to laminectomy alone, according to data presented at the American Association of Neurological Surgeons annual meeting. The prospective, five-center randomized controlled trial of 66 patients aged 50 to 80 years (mean, 66.7 years) found that surgery was associated with significant improvement in SF-36 physical component summary (PCS) and Oswestry Disability Index scores at each time point up to 5 years, and laminectomy with fusion was linked with significantly better SF-36 PCS scores than laminectomy alone at 6 months, 2 years, and 4 years.

Static or dynamic splinting for posttraumatic elbow stiffness
According to data published in JBJS-A (April 18), both dynamic and static splinting can be effective in reducing posttraumatic elbow stiffness. The prospective, randomized trial involved 66 patients with posttraumatic elbow stiffness—35 treated with static progressive (turnbuckle) splints and 31 treated with dynamic splints. At 3-, 6-, and 12-month follow-up, no significant differences were found between the groups in the following areas: flexion arc, improvement in the arc of flexion, or average score on the Disabilities of the Arm, Shoulder and Hand evaluation.

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)