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AAOS Now

Published 10/1/2014

Second Look—Clinical News and Views

Radiographs for children
Findings from a study published online in Annals of Emergency Medicine suggest that plain anteroposterior (AP) pelvic radiographs may have limited sensitivity for identifying children with pelvic fractures or dislocations after blunt trauma. The prospective, multicenter, observational study of children younger than 18 years with blunt torso trauma involved 12,044 patients in the Pediatric Emergency Care Applied Research Network. Of the 451 (3.7 percent) patients with pelvic fractures or dislocations, 65 (14 percent) underwent surgical intervention and 21 (4.7 percent) had age-adjusted hypotension when initially seen. In the emergency department, 382 of the 451 patients had plain AP pelvic radiographs, with a sensitivity of 78 percent for patients with pelvic fractures or dislocations, 92 percent for patients undergoing surgical intervention, and 82 percent for patients with hypotension.

Estimating inpatient morbidity
According to a study published in Clinical Orthopaedics and Related Research (CORR, September), the Elixhauser comorbidity method may be more accurate than the Charlson Index for predicting inpatient death after orthopaedic surgery. The data analysis of 14,007,813 patients who underwent orthopaedic surgery between 1990 and 2007, as identified in the National Hospital Discharge Survey, found that the Elixhauser comorbidity adjustment better predicted in-hospital case mortality, compared to the Charlson model. It also performed 60 percent better than Charlson in predicting mortality and better discriminated inpatient morbidity. However, the difference in absolute improvement in predictive power between the two models was of “dubious clinical importance.”

Delaying surgery for proximal humeral fracture
Data from a study published in the Journal of Shoulder and Elbow Surgery (September) suggest that delaying surgery for proximal humeral fracture may increase the likelihood of adverse events, length of stay, and nonroutine discharge. Based on data for more than 70,000 patients from the Nationwide Inpatient Sample, patients who underwent surgery 3 days or more after admission for proximal humerus fracture had increased inpatient adverse events, prolonged postoperative stay, and increased nonroutine discharge; however, delay of surgery was not linked to increased risk of in-hospital death.

Smoking cessation after discharge
Data from a study funded by the National Institutes of Health and published in The Journal of the American Medical Association (Aug. 20) suggest that use of a postdischarge intervention could help adult smokers quit smoking. The randomized trial of 397 hospitalized daily smokers who wanted to quit smoking after discharge found that patients assigned to a sustained care program that included automated interactive voice response telephone calls and their choice of free U.S. Food and Drug Administration (FDA)-approved smoking cessation medication were more likely to sustain a biochemically validated 7-day tobacco abstinence at 6 months, compared to patients who received standard care.

Wear and pseudotumors
Data from a study published online in CORR suggest that metal wear alone may not explain the histologic reactions and pseudotumors around metal-on-metal (MoM) hip implants. The review of data on 119 MoM total hip arthroplasties and hip resurfacings found no association between wear magnitude and aseptic lymphocytic vasculitis-associated lesions score. Median wear depth (ball and cup) was greater in hips with metallosis compared to those without.

Arthroscopic rotator cuff repair
According to findings published online in The American Journal of Sports Medicine, early passive range of motion (ROM) exercise may accelerate recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but is also associated with improper tendon healing in shoulders with large-sized tears. The systematic review and meta-analysis of six randomized, controlled trials covering 482 patients found that patients treated with early ROM demonstrated more improvement overall in shoulder forward flexion than the delayed rehabilitation group. Early ROM was linked to a higher rate of recurrent tendon tears.

Treatment of ACL injuries
A study published in The Journal of Bone & Joint Surgery (JBJS Aug. 6) examines differences in clinical courses following nonsurgical or surgical treatment of ACL injuries. The prospective cohort study of 143 patients who sustained an ACL injury found that surgically treated patients (n = 100) were significantly younger, more likely to participate in level-I sports (handball, basketball, soccer), and less likely to participate in level-II sports (volleyball, gymnastics, skiing) prior to injury, compared to nonsurgically treated patients (n = 43).

The AAOS has recently issued a clinical practice guideline on managing ACL injuries; see “Strong Recommendations Support ACL Treatment.”

Outcomes for heel fractures
Data from a study published online in The BMJ suggest that open reduction and internal fixation of displaced, intra-articular calcaneal fractures may offer little benefit over nonsurgical treatment (elevation, ice, and splinting). The pragmatic, multicenter, assessor-blinded, randomized trial of 143 patients across 22 institutions in the United Kingdom found no significant difference between treatment cohorts at 2-year follow-up in mean Kerr-Atkins scores, nor in any secondary outcomes; complications and reoperations were more common in those who were surgically treated.

Impact location and concussion severity
According to a study published online in Pediatrics, concussion outcomes may generally be independent of impact location. Data from the National High School Sports-Related Injury Surveillance Study indicate that most concussions resulting from player-to-player collisions occurred from front-of-the-head (44.7 percent) and side-of-the-head (22.3 percent) impacts. Yet number of symptoms reported, prevalence of reported symptoms, symptom resolution time, and length of time to return to play were not associated with impact location. A larger proportion of football players sustaining concussions from top-of-the-head impacts experienced loss of consciousness than those who sustained concussions from impacts to other areas of the head.

Bisphosphonate treatment and breast cancer risk
According to a study published online in the journal JAMA Internal Medicine, bisphosphonate treatment may not decrease the risk of invasive postmenopausal breast cancer. Based on data from two randomized, double-blind, placebo-controlled trials covering 14,224 patients, no significant difference in the rate of breast cancer between patients who received treatment with bisphosphonates and those who did not at mean follow-ups of 3.8 years and 2.8 years. Outcomes were similar for both trials.

THA outcomes in HIV patients
Data from a study published online in CORR suggest that patients with human immunodeficiency virus (HIV) infection may be at modestly increased risk of longer and more complicated hospital stays after total hip arthroplasty (THA). Based on data on 2,656,696 patients without HIV and 9,275 patients with HIV from the Nationwide Inpatient Sample database, patients with HIV were more likely to have major and minor complications than those without HIV. Patients undergoing THA who had HIV also had an increased length of hospital stay.

Concussion awareness in female soccer teams
A study published online in JAMA examines concussion rates and associations for female soccer players of middle-school age. The prospective cohort study of 351 female athletes aged 11 to 14 years, who played soccer between March 2008 and May 2012, found that 59 concussions occurred across 43,742 athletic exposure hours. Symptoms lasted a median of 4.0 days (mean, 9.4 days), and “heading” the ball accounted for 30.5 percent of all concussions. Overall, 58.6 percent of players continued to play with symptoms, and 44.1 percent sought medical attention for concussion.

Infection after open fracture
Data from a Canadian study published online in the Journal of Orthopaedic Trauma suggest that time to surgery or antibiotics may not be a factor in the likelihood of infection after open fracture. The prospective cohort study of 686 patients (737 fractures) who were seen at one of three level 1 trauma centers found that infection developed in 46 (6 percent) of fractures. Median time to surgery was 9 hours 4 minutes for patients without infection and 7 hours 39 minutes for patients with infection. Gustilo Grade 3B/3C fractures accounted for 37 percent of infections.

Anticoagulant vs aspirin
A study published in the Journal of Hospital Medicine compares VTE and bleeding rates for anticoagulants and aspirin after major lower extremity orthopaedic surgery. The meta-analysis of eight randomized trials covering 1,408 patients found no significant difference between anticoagulants and aspirin for deep vein thrombosis, a nonsignificant trend favoring anticoagulation for hip fracture repair, and a nonsignificant trend favoring aspirin for TKA and THA.

Nonsurgical management for spondylolisthesis
Findings in the Journal of Pediatric Orthopaedics (July/August) suggest that nonsurgical management of minimally symptomatic or asymptomatic children with a high-grade spondylolisthesis may be safe. The database review of 49 patients with a high-grade (Meyerding grade III to V) spondylolisthesis found 24 patients treated surgically and 25 initially treated nonsurgically (10 of the nonsurgically treated patients eventually required surgical intervention). No significant difference in outcome was found between cohorts.

Nighttime bracing for scoliosis
Data from a study published in the Journal of Pediatric Orthopaedics (Sept.) suggest little difference in progression to surgery among patients with mild idiopathic scoliosis who are treated with either nighttime bracing or observation. The prospective, comparative study involved 37 premenarchal, Risser 0 female patients with Cobb angle measurements between 15 degrees and 25 degrees (16 patients were treated with observation and 21 with bracing). At 2-year follow-up, all patients in the observation group progressed to the fulltime bracing threshold of 25 degrees, while 29 percent of patients in the nighttime bracing group did not progress to the threshold.

MSK injuries in veterans
A study in JBJS (July 2) suggests that orthopaedic injuries are among the primary drivers for U.S. soldiers who served in Iraq to leave the military. The longitudinal, observational study of 4,087 surviving soldiers from a single Army brigade deployed to Iraq from 2006 to 2007 found that 163 soldiers sustained combat-related musculoskeletal (MSK) trauma and 587 soldiers had MSK injuries not related to battle. Overall, 374 soldiers were declared unfit by the Physical Evaluation Board and 236 were referred for at least one MSK condition.

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)