Published 6/1/2014

Second Look—Clinical News and Views

Recurrent lumbar disk herniation
Data from a Swedish study published in Clinical Orthopaedics and Related Research (CORR) suggest that repeat surgery for recurrent lumbar disk herniation (LDH) may be efficacious, although with less improvement, compared to primary LDH surgery. Data on 8,497 patients from the Swedish National Spine Register were reviewed; 8,350 patients underwent primary surgery for LDH and 147 underwent reoperation for recurrent LDH within the first year. At 1- to 2-year follow-up, 79 percent of patients in the primary LDH group and 58 percent of patients in the recurrent LDH group were satisfied with their outcomes. In addition, 74 percent of patients in the primary LDH group reported no or better leg pain, compared to 65 percent of patients in the recurrent group. However, reoperation for recurrent LDH represented the largest independent risk for dissatisfaction, while reoperation and smoking represented similar risks for less improvement in leg pain.

Predicting rotator cuff retear
A study published online in The American Journal of Sports Medicine examines factors that may predict rotator cuff retear. The retrospective study of 1,000 consecutive patients who had undergone a primary rotator cuff repair by a single surgeon, using an arthroscopic inverted-mattress knotless technique found an overall retear rate of 17 percent at 6-month follow-up. Retears occurred in 27 percent of full-thickness tears and 5 percent of partial-thickness tears. The best independent predictors of retear were anteroposterior tear length, tear size area, mediolateral tear length, tear thickness, age at surgery, and surgical time.

Fixation of the distal tibiofibular syndesmosis
Findings from a study in The Bone & Joint Journal (April) suggest that both polylevolactic acid and titanium screws provide adequate fixation and functional recovery when used for fixation of the distal tibiofibular syndesmosis, but polylevolactic acid screws may be associated with a higher incidence of foreign body reactions. The researchers randomly allocated 168 patients to receive either polylevolactic acid (n = 86) or metallic (n = 82) screws. At mean 55.8-month follow-up, Baird scoring system scores were similar in the two groups. However, 18 patients in the polylevolactic acid group had a mild foreign body reaction and 8 had a moderate foreign body reaction. In the metallic groups, only 8 patients had foreign body reactions—all mild. In addition, heterotopic ossification developed in 3 patients who received polylevolactic acid screws.

FAI and complex hip deformities in adolescents
A study in the Journal of Pediatric Orthopaedics (JPO) (April/May) suggests that open femoroacetabular impingement (FAI) surgery through surgical dislocation of the hip (SDH) should be considered for management of adolescents with FAI and complex hip deformities associated with pediatric disorders. The retrospective review of 29 young athletes (mean age 17 years) treated for symptomatic FAI found significant improvement in WOMAC-Pain subscale, and marginally significant improvement in median UCLA physical activity level. The research team found no statistically significant correlation between change in UCLA score and the addition of a second procedure other than femoral head-neck osteochondroplasty, and no statistically significant correlation between severity of cartilage injury and change in UCLA or WOMAC scores.

RCT on pain after TKA
A continuous intra-articular infusion of ropivacaine can serve as a safe, effective alternative to epidural analgesia plus single-injection femoral nerve block (FNB) after total knee arthroplasty (TKA), concludes a study published in CORR. The randomized double-blind trial compared the side-effect profile, analgesic efficacy, and functional recovery among 94 patients assigned to one of the two treatments. During the first 12 and 24 postoperative hours, the mean maximum visual analog scale pain scores were higher in the ropivacaine group than in the epidural group, but after 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. No differences in complication frequency were seen.

Trampoline injuries in children
A study published online in JPO finds that 289,876 people—mostly children—received care at emergency departments (EDs) between 2002 and 2011 for fractures sustained during trampoline use, with associated healthcare costs of more than $400 million. All injuries (including fractures) from trampoline use led to more than 1 million ED visits during the decade, resulting in more than $1 billion in healthcare costs. Approximately 60 percent of fractures occurred in the upper extremities, while lower extremity fractures accounted for nearly 36 percent of fractures. Data on trampoline injuries came from the National Electronic Injury Surveillance System.

Are MRSA infections decreasing?
A study in The Journal of the American Medical Association (April 9) estimates that 30,800 fewer invasive methicillin-resistant Staphylococcus aureus (MRSA) infections occurred in the United States in 2011 compared with 2005. Based on data on MRSA cultures across nine U.S. metropolitan areas from 2005 through 2011, 80,461 invasive MRSA infections were reported nationally in 2011. Of those, 48,353 were healthcare–associated community-onset (HACO) infections, 14,156 were hospital-onset infections, and 16,560 were community-associated infections. Since 2005, adjusted national estimated incidence rates for HACO infections decreased by 27.7 percent, hospital-onset infections decreased by 54.2 percent, and community-associated infections decreased by 5.0 percent.

Group exercise program for frozen shoulder
Findings from a study in the Journal of Shoulder and Elbow Surgery (April) suggest that a hospital-based exercise class may be more effective than either individual physiotherapy or a home exercise program for the treatment of frozen shoulder. The randomized, single-blind trial involved 75 patients with frozen shoulder who were treated with either a group exercise class, individual physiotherapy, or home exercises alone. At 12-month follow-up, participants in the exercise group showed greater improvement in Constant Score and Oxford Shoulder Score than did participants in the other two groups; participants in both physiotherapy groups had better range of motion and scores on the Hospital Anxiety and Disability Scale compared to patients in the home exercise group.

Imageless navigation for cementless THA
A study in The Journal of Arthroplasty (April) finds that imageless computer-assisted navigation may more accurately position the acetabular component in cementless total hip arthroplasty (THA) compared to conventional technique. The prospective, randomized study of 130 patients assigned half to undergo THA using an imageless navigation system and half to a freehand conventional technique. Based on postoperative CT scans of the pelvis, no significant differences were found for postoperative mean inclination between cohorts. Significant differences for mean postoperative acetabular component anteversion, for mean deviation of the postoperative anteversion from the target position of 15°, and for outliers regarding inclination and anteversion between the computer-assisted and the freehand-placement groups were found.

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)