Published 12/1/2013

Second Look—Clinical

Sentinel Event Alert on retained foreign objects
The Joint Commission (TJC) has issued a Sentinel Event Alert on the unintended retention of foreign objects (URFOs). TJC recommends the adoption of guidelines, processes, and tools designed to help team members develop risk reduction strategies, including the following:

  • use of a highly reliable and standardized counting system
  • development and implementation of evidence-based, organization-wide policy and procedures for the prevention of URFOs
  • team briefings and debriefings to allow team members to express patient safety concerns
  • verbal verification by the surgeon of the results of the counting procedure
  • documentation of the results of counts of surgical items, instruments, or items intentionally left inside a patient (such as a needle or device fragments deemed safer to remain than remove)
  • use of assistive technologies to supplement manual counting procedures and methodical wound exploration, such as bar-coding, radio-opaque material or radiofrequency tags to detect technology-enabled soft goods, and radio frequency identification systems

BMI and postoperative inflammation
A study in Clinical Orthopaedics and Related Research (CORR) (October) finds that obesity may be associated with a proinflammatory state after total hip arthroplasty (THA). The prospective, cross-sectional study of 60 patients (20 normal weight, 20 overweight, 20 obese) who underwent elective primary unilateral THA found no correlation between body mass index (BMI) and postoperative spontaneous circulating cytokine levels. However, an association was found between BMI and enhanced cytokine reactivity, suggesting priming of the innate immune system in obesity and a potential for excessive postoperative inflammatory response.

Fewer social ties, more pain?
Results of a study presented at the annual meeting of the American College of Rheumatology/Association of Rheumatology Health Professionals suggest that socially isolated individuals are more likely to experience serious, ongoing pain following THA surgery than those with good social ties. A survey of 932 patients conducted 2 years after primary or revision THA for either osteoarthritis or rheumatoid arthritis found that patients who lacked social ties—eg, unmarried, with few friends or relatives, and unaffiliated with community or religious organizations—had almost three times increased risk of having pain that was as severe as it had been before surgery.

Outcomes for cementless or cemented TKAs
(November) reports on a randomized trial of 145 patients who received either a porous tantalum cementless tibial component or a cemented conventional tibial component in posterior cruciate retaining total knee arthroplasty (TKA). At 5-year follow-up, the mean Knee Society Score was 90.4 in the cementless group and 86.5 in the cemented group, while the WOMAC Osteoarthritis Index was 15.1 in the cementless group and 19.1 in the cemented group, with no differences in the frequency of complications or in aseptic loosening between the two groups.

Obesity may correlate with rising TKA rates
Rising obesity rates among those younger than age 65 correlate with increasing rates of TKA in these younger patients, reports UMassMedNow, based on data compiled by more than 125 orthopaedic surgeons in 22 states across the country in FORCE-TJR, a nationwide comprehensive database of total joint arthroplasty (TJA) surgical and patient-reported outcomes. Of the first 9,000 patients tracked, 55 percent of patients younger than age 65 were categorized as technically obese, compared with 43 percent of patients 65 years and older. Twice as many patients younger than age 65 were morbidly obese—with BMI greater than 40—compared with those older than age 65. Lower mental health scores and higher rates of smoking were also linked to younger patients.

Concussion updates
A new report from the Institute of Medicine (IOM) and the National Research Council notes that, although progress has been made in amassing information about the causes and extent of concussion in youths, much remains unknown in regard to diagnosis, management, and prevention, along with the short- and long-term consequences of concussions and of repetitive head impacts that do not result in concussion symptoms. The report finds little evidence that current sports helmet designs reduce the risk of concussions, but stresses the importance using properly fitting helmets and mouth guards to reduce the risk of other injury, including skull fracture.

Concussion rates are higher among high school athletes than college athletes and the reported number of individuals aged 19 and younger treated in U.S. emergency departments for concussions and other non-fatal, sports- and recreation-related traumatic brain injuries increased from 150,000 in 2001 to 250,000 in 2009. The IOM called on the U.S. Centers for Disease Control and Prevention to establish a national surveillance system for concussions.

Data from a survey of 119 high school football players presented at the annual meeting of the Pediatric Academic Societies indicate that young athletes can identify concussion symptoms and know they risk serious injury if they returned to the field too quickly after concussion. Yet just 54 percent said that they would report such symptoms to the coach, and 53 percent said that they would continue to play even if they had a headache from such an injury.

Allograft, autograft ACL reconstruction outcomes
A meta-analysis in The American Journal of Sports Medicine (October) compared outcomes for patients who underwent anterior cruciate ligament (ACL) reconstruction with autograft bone–patellar tendon–bone (BPTB) with those for patients who underwent reconstruction with allograft BPTB. Outcomes on subjective International Knee Documentation Committee (IKDC), Lysholm, Tegner activity, single-legged hop, and KT-1000 arthrometer were statistically significantly in favor of autografts, while return to preinjury activity level, overall IKDC, pivot shift, and anterior knee pain were significantly in favor of allografts. Allograft patients had a threefold increase in rerupture rates compared with autograft patients.

Binge drinking and fracture healing
Study results presented at the American Society for Bone and Mineral Research annual meeting show three ways that alcohol impairs bone healing after a fracture. The mouse study found that the callus was less mineralized, the bone that formed was weaker, levels of malondialdehyde (a molecule that serves as a marker for oxidative stress, which impairs cell function) were higher, and levels of the protein OPN, which recruits stem cells to the injury site, were lower in alcohol-exposed mice compared to controls.

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)