Published 8/1/2015

Second Look—Clinical News and Views

ACLR revision factors
A study in The American Journal of Sports Medicine (AJSM) attempts to identify factors linked to increased risk of revision after allograft anterior cruciate ligament reconstruction (ACLR). The retrospective cohort study of 5,968 primary ACLR cases performed with allograft found that use of the BioCleanse processing method and irradiation greater than 1.8 Mrad were associated with a higher risk of revision when compared with all other processing methods, after adjustment for patient age, sex, and body mass index (BMI). In addition, bone–patellar tendon–bone allografts were at increased risk of revision compared with soft tissue allografts, and younger patient age and male sex were linked to increased risk of revision.

Treating FAI
Findings from a study in AJSM suggest that treating femoroacetabular impingement (FAI) with either hip arthroscopy or open surgical hip dislocation may offer excellent and equivalent hip survival rates at medium-term follow-up. The systematic review and meta-analysis of 16 studies covering 2,084 hips found that both treatments demonstrated good outcomes in their respective scoring systems. However, compared to open treatment, hip arthroscopy was associated with a higher general health-related quality of life score on the 12-Item Short-Form Survey physical component score.

Reducing 90-day mortality
According to findings in The Lancet, patients who are readmitted to the index hospital after a major surgical procedure have better survival rates compared to those admitted to a different institution. The review of Medicare claims data found that readmissions due to a surgical complication were more likely to be to the index hospital than to another hospital. Readmission to the index hospital was associated with a 26 percent lower risk of 90-day mortality than was readmission to another hospital, with inverse probability weighting used to control for selection bias. The effect was significant for all procedures in inverse probability-weighted models.

Bridging anticoagulation for elective procedures
A study in The New England Journal of Medicine (June 22) suggests that forgoing bridging anticoagulation may be noninferior to perioperative bridging with low-molecular-weight heparin for patients with atrial fibrillation who had warfarin treatment interrupted for an elective procedure. The randomized, double-blind, placebo-controlled trial of 1,884 patients who received either bridging anticoagulation therapy with low-molecular-weight heparin (n = 934) or placebo (n = 950), from 3 days till 24 hours preoperative and then for 5 to 10 days postoperative found that the incidence of arterial thromboembolism was 0.4 percent in the no-bridging group and 0.3 percent in the bridging group, while the incidence of major bleeding was 1.3 percent in the no-bridging group and 3.2 percent in the bridging group.

Volar locking plates for wrist fractures
A study published in The Journal of Hand Surgery (July) compared the use of volar locking plates (VLPs) to external fixation (EF) with adjuvant pins in the treatment of unstable distal radius fracture (DRF). The prospective, randomized study of 91 patients with unstable DRF who were treated with either VLP (n = 52) or EF (n = 49) found that the QuickDASH score was not statistically significantly different between cohorts at 5-year follow-up. Patients with VLP had statistically significant better supination, better radial deviation, and less radial shortening than EF patients. However, 11 VLP patients (21 percent) had their plates removed due to surgically related complications; 5 EF patients had proximal radial scar correction surgery owing to skin contracture.

Wear rates in cemented THA
A study in Clinical Orthopaedics and Related Research compared wear rates between oxidized zirconium femoral heads and stainless steel heads in cemented total hip arthroplasty (THA). The blinded, randomized trial included 100 THA patients who received one of the following bearing combinations: Highly crosslinked polyethylene (HXLPE) socket and oxidized zirconium head; HXLPE socket and stainless steel head; Ultrahigh-molecular-weight polyethylene (UHMWPE) socket and oxidized zirconium head; UHMWPE socket and stainless steel head. At minimum 4-year follow-up, based on results from 86 patients, all groups except for the UHUMWPE/stainless steel combination had a steady-state penetration rate well below the osteolysis threshold and a low difference between groups that may not be clinically important. Merle d’Aubigné outcome scores were statistically similar between all groups.

Complication risk in orthopaedic trauma patients
Data in the Journal of Orthopaedic Trauma (July) suggest that orthopaedic trauma patients may be twice as likely to sustain complications compared to general orthopaedic patients. The prospective, multicenter study of American College of Surgeons National Surgical Quality Improvement Program data found that the complication rate in the trauma group was 11.4 percent (n = 2,554 of 22,361) and 4.1 percent (n = 5,137 of 124,412) in the general orthopaedic cohort. After controlling for variables, trauma was a risk factor for developing complications. Hip and pelvis patients were four times more likely than upper extremity patients to develop any perioperative complication.

Reducing risk of knee OA
A study in Arthritis Care & Research suggests high annual rates of onset of knee osteoarthritis (OA) symptoms and calls for clinical and public health collaborations to reduce risk factors forand manage the impact of knee OA. Based on 1,518 patients aged 45 years or older with symptomatic OA at baseline, the average incidence rates at median 5.5-year follow-up were as follows: symptoms, 6 percent; radiographic OA, 3 percent; symptomatic OA, 2 percent; severe radiographic OA, 2 percent; and severe symptomatic OA, 0.8 percent. Incidence rates were highest among those with the following baseline characteristics: age 75 years or older, obese, a history of knee injury, or an annual household income of $15,000 or less.

Mortality for noncardiac surgery
Findings in Anesthesia & Analgesia (July) suggest that functional capacity may be an independent predictor of mortality within the American Society of Anesthesiologists (ASA) classification system. The retrospective, observational cohort study of 12,324 patients who underwent noncardiac surgery between 1998 and 2009 found that the odds ratio for mortality was 1.92 for ASA class II-B over ASA class III-A patients, 1.29 for ASA class III-B over ASA class IV-A patients, and 2.03 for ASA class IV-B over ASA class V patients, even though, by definitions, the higher class carries a greater disease burden.

Overuse injuries among high school athletes
Data in The Journal of Pediatrics suggest that overuse injury patterns among high school athletes may vary by sex and sport. According to the High School Reporting Information Online database (academic years 2006/2007 through 2011/2012), 2,834 overuse injuries were reported across 18,889,141 athletic exposures. Girls had higher rates of overuse injury compared to boys, with the greatest rates of overuse injury in girls’ track and field and girls’ field hockey. Overuse injuries represented 7.7 percent of all injuries and were evenly distributed across athletes in each year of high school, with distinct differences by sex.

Evaluating potential child-abuse patients
Data in Pediatrics suggest substantial variation in evaluation for occult fractures among young children with a diagnosis of abuse or injuries potentially linked to abuse. The retrospective study of 4,935 children aged younger than 2 years with a diagnosis of physical abuse and infants younger than 1 year with non–motor vehicle crash–related traumatic brain injury or femur fractures found that evaluations for occult fractures were performed in 48 percent of 2,502 children with an abuse diagnosis, in 51 percent of 1,574 infants with traumatic brain injury, and in 53 percent of 859 infants with femur fractures. Occult fracture evaluations were more likely to be performed at teaching hospitals than at nonteaching hospitals.

Arthroscopic rotator cuff repair in elderly athletes
Data presented at the annual meeting of the American Orthopaedic Society for Sports Medicine suggest that arthroscopic rotator cuff repair may reduce pain and improve function among active elderly patients. Based on prospective and retrospective (mean 3.6 year follow-up) data on recreational athletes aged 70 years or older who had undergone a primary or revision arthroscopic repair of full-thickness supraspinatus tears with or without infraspinatus and subscapularis tendon involvement, ASES scores improved from 56.0 preoperative to 90.3 postoperative, SANE scores improved from 63.1 to 85.1, QuickDASH from 34.1 to 11.3, and SF-12 PCS from 43.0 to 51.6. In addition, 24 of 31 patients were able to return to their sport at a similar level of intensity to preinjury levels.

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)