Published 1/1/2014

Second Look—Clinical News and Views

Pediatric sports- and recreation-related injuries
Data in the Journal of Pediatric Orthopaedics (December) suggest that, contrary to current perception, the incidence of pediatric sports- and recreation-related (SRR) injuries may not have increased in the United States during the last 10 years. Based on data from 2000, 2005, and 2010 on patients 8 to 14 years of age from the National Electronic Injury Surveillance System, musculoskeletal injuries decreased by 10.8 percent in 2005 and by 12.4 percent in 2010 for the top eight SRR activities in children. During the same time span, sports-specific injuries decreased in six of the SRR activities, with maximal decreases in bicycling (38.1 percent), roller sports (20.8 percent), and trampolines (17.5 percent). Football and soccer injuries increased by 22.8 percent and 10.8 percent, respectively.

BMI and cLBP
Findings published in Spine (Dec. 1) suggest no significant relationship between body mass index (BMI) and self-reported pain and disability among patients treated with exercise for chronic low back pain (cLBP). The retrospective, multicenter study of 128 patients with cLBP, who underwent 8 weeks of exercise-based treatment found no baseline relationships between BMI and self-reported pain or disability and no relationship between baseline BMI or changes in BMI with exercise-related changes in pain and disability, respectively. Overall, BMI was not a predictor of exercise-based pain and disability changes.

Tired physicians and risk of complications
A Canadian study in the Journal of the American Medical Association (JAMA) (Nov. 6) finds no significant increase in complications among physicians who operated the night before elective surgery and those who did not. The population-based, matched, retrospective cohort study of 94,183 laparoscopic cholecystectomy procedures between 2004 and 2011 found no significant association in conversion rates to open operations between surgeons when they operated the night before, compared with when they did not. No association was found between the risk of iatrogenic injuries or death and whether the surgeon operated the night before.

BMI and functional improvement after TSA
Findings from a study in the Journal of Bone & Joint Surgery (JBJS) (Nov. 6) suggest that, although primary total shoulder arthroplasty (TSA) may improve shoulder function (American Shoulder and Elbow Surgeons [ASES] scores) in patients regardless of their weight, obese and overweight patients may not experience a significant improvement in overall physical function (SF-36 Physical Component Scores). The data comparison of 76 patients who underwent primary TSA found that, at 2-year follow-up, patients classified as normal weight (BMI < 25 kg/m2) improved average SF-36 scores by 15.4 points, compared to an improvement of 6.3 points in overweight patients (BMI, 25–29.9 kg/m2), and an improvement of 4.4 points in obese patients (BMI > 30 kg/m2).

Nonsurgical patients and opioids
According to a study in the Journal of Hospital Medicine, many nonsurgical patients are treated with opioids. A review of 1.14 million adult nonsurgical admissions from 286 U.S. hospitals found that opioids were prescribed in 51 percent of cases. Among patients exposed to opioids, 0.60 percent experienced severe opioid-related adverse events.

In related news, a study in the Annals of Internal Medicine (Nov. 12) evaluated the quality and content of guidelines on the use of opioids for chronic pain and found that a variety of recent guidelines agree on several opioid risk mitigation strategies, including the following: upper dosing thresholds, cautions with certain medications, attention to drug–drug and drug–disease interactions, and use of risk assessment tools, treatment agreements, and urine drug testing.

ACS after pediatric tibial shaft fractures
Data from a study in the Journal of Orthopaedic Trauma (November) suggest that acute compartment syndrome (ACS) associated with tibial shaft fractures in pediatric patients may be more common than previously reported. The retrospective case control study of 216 tibial shaft fractures in 212 patients (median age 13 years) seen at a single center during a 5-year period found a diagnosis of ACS in 11.6 percent of cases; the incidence of ACS among patients 14 years or older who were involved in a motor vehicle accident was 48 percent.

Improving outcomes for hip fracture patients
Findings in the Canadian Medical Association Journal suggest that time to surgery after hip fracture may affect patient outcomes. The pilot study involved 60 patients aged 45 years or older at three centers who were randomly assigned to undergo either accelerated (median time to surgery 6.0 hours) or standard care (median time to surgery 24.2 hours). Major perioperative complications occurred in 30 percent of patients in the accelerated care group and in 47 percent of those in the standard care group.

MoM THA vs. hybrid HR
A study in The Bone & Joint Journal (November) comparing midterm survival rates for 192 patients (219 hips) treated with either total hip arthroplasty (THA) using 28-mm metal-on-metal (MoM) uncemented devices or hybrid hip resurfacing (HR) found no significant differences between the groups in rates of revision or reoperation without revision at mean 8-year follow-up. Mean UCLA activity scores were significantly higher in the HR cohort, but WOMAC Osteoarthritis Index scores were similar for both groups at last follow-up. Overall, osteolysis—mostly in the proximal femur—was found in 30 of 81 THA patients (37.4 percent) compared with 2 of 83 HR patients (2.4 percent). At 5 years, mean metal ion levels for cobalt and chromium were similar in both groups; titanium ion levels were significantly higher in the HR group.

RA, OA TJA patients and complications
Data published in Arthritis & Rheumatism suggest that patients with rheumatoid arthritis (RA) who are treated with total joint arthroplasty (TJA) are at increased risk for complications compared to patients with osteoarthritis (OA). The review of 43,997 THA and 71,793 total knee arthroplasty (TKA) recipients found that TJA recipients with RA had higher age and sex-standardized rates of dislocation following THA and greater rates of infection following TKA. After adjustment, patients with RA remained at increased risk for dislocation within 2 years of THA, and for infection within 2 years of TKA, compared to recipients with OA.

Tranexamic acid and blood loss in TKA patients
A study in JBJS (Nov. 20) suggests that the use of intravenous tranexamic acid may decrease postoperative blood loss after TKA. The randomized, controlled trial of 172 patients undergoing primary TKA found that patients treated with intravenous tranexamic acid had significantly less total blood loss than patients treated with fibrin glue, fibrinogen and thrombin, or control patients treated only with routine hemostasis. There was no significant difference with regard to the need for transfusion between patients in the two fibrin groups and controls.

RSA and hemiarthroplasty
According to a meta-analysis in the Journal of Shoulder and Elbow Surgery (December), reverse shoulder arthroplasty (RSA) may be associated with improved forward flexion and functional outcome scores compared with hemiarthroplasty for older adults with proximal humeral fractures. Based on data from 15 studies covering 377 patients treated with RSA and 504 patients treated with hemiarthroplasty, patients in the RSA group had improved forward flexion and functional outcome scores, compared to patients in the hemiarthroplasty group, but RSA was associated with decreased external rotation. Both groups had similar rates of postoperative complication.

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)