Published 12/1/2015

Second Look—Clinical

Bone health
According to findings presented at the annual meeting of the American Society for Bone and Mineral Research and reported on in Medscape, patients treated with denosumab may see a persistent reduction in bone turnover, continued increases in bone density, and low incidences of fracture over a 10-year period. The data were derived from the 3-year Fracture Reduction Evaluation of Denosumab in Osteoporosis Every Six Months (FREEDOM) study and its 7-year extension phase, covering more than 2,000 women. The researchers noted 13 cases of osteonecrosis of the jaw and two cases of atypical femoral fracture in the group taking denosumab.

Falls in older men—According to a Canadian study published online in The BMJ, men who start treatment with prostate-specific α antagonists may be at increased risk of falls and fractures. The data review involved 147,084 men aged 66 years or older who filled their first outpatient prescription for prostate-specific α antagonists tamsulosin, alfuzosin, or silodosin and a 1:1 matched cohort of men who did not initiate α antagonist therapy. Exposure to a prostate-specific α antagonist was associated with a significantly increased risk of falling and sustaining a fracture.

Lateral condylar fractures—
Two studies in the Journal of Pediatric Orthopaedics examine the use of screw fixation of lateral condylar fractures. The first, a retrospective analysis of 96 patients aged 12 years or younger treated at a single institution during a 7-year period, found an overall complication rate of 19 percent (5 percent when lateral overgrowth was excluded) and a union rate of 99 percent. The second study used a synthetic bone model of pediatric lateral condyle fractures (Milch type II) to calculate stiffness and maximum force through both tension and compression testing. In tension testing, stiffness and maximum force were significantly greater with screw fixation compared with K-wire fixation; compression testing showed statistically significant increased maximum force and a trend towards increased stiffness with screw fixation as compared with K-wires.

Treating moderate knee OA—
Data from a study in The New England Journal of Medicine (Oct. 22) suggest that treatment with total knee arthroplasty (TKA) followed by nonsurgical treatment may offer greater pain relief and functional improvement for patients with moderate-to-severe knee osteoarthritis (OA) than nonsurgical treatment alone. The randomized, controlled trial involved 95 patients who underwent either unilateral TKA followed by 12 weeks of nonsurgical treatment or 12 weeks of nonsurgical treatment alone. At 12-month follow-up, 26 percent of patients in the nonsurgical group had undergone TKA, while 2 percent of patients in the TKA group received only nonsurgical treatment. Overall, patients in the TKA group saw greater improvement in KOOS4 score compared to those in the nonsurgical-treatment group. However, the TKA cohort had 24 serious adverse events, compared to 6 in the nonsurgical cohort.

Hip fracture admissions—
Findings from a study in the Journal of Orthopaedic Trauma (JOT) suggest that geriatric hip fracture patients admitted to a hospital's orthopaedic service may have shorter lengths of stay (LOS) and reduced readmissions than those admitted to the medicine service. The single-center retrospective study involved 614 geriatric hip fracture patients over a 10-year period. About half (49.2 percent) were admitted to the orthopaedic service and half (50.8 percent) to medicine. Patients admitted to orthopaedics had a median 4.5 day LOS, compared to a 7-day LOS for patients admitted to medicine. Readmissions were significantly higher for patients admitted to medicine (n = 92, 29.8 percent) compared to orthopaedics (n = 70, 23.1 percent).

Rotator Cuff Tears—
A study comparing the effectiveness of physiotherapy, acromioplasty, and rotator cuff repair for the treatment of symptomatic nontraumatic rotator cuff tears (RCTs) found no significant difference in clinical outcomes among the interventions at 2-year follow-up. The randomized controlled trial, published in The Journal of Bone & Joint Surgery (JBJS), was conducted at three hospitals in Finland between October 2007 and December 2013. Shoulders with symptomatic, nontraumatic, supraspinatus tears (n = 180) were randomized to receive physiotherapy, acromioplasty with physiotherapy, and rotator cuff repair, acromioplasty, and physiotherapy. Analysis was by intention to treat; of the six crossover patients, five were from the physiotherapy group and one was from the acromioplasty group. At 2-year follow-up no significant differences were found in the mean change of Constant scores, visual analog scale for pain scores, or patient satisfaction among the groups.

Platelet-rich plasma—According to a study in The American Journal of Sports Medicine, arthroscopic acromioplasty may improve outcomes for patients with chronic rotator cuff tendinopathy, but coapplication of platelet-rich plasma may have no significant effect on those outcomes. The randomized, controlled trial of 60 patients between 35 and 75 years old who were diagnosed with rotator cuff tendinopathy found no significant difference in patient-reported outcomes between cohorts in Oxford Shoulder Score at 2-year follow-up. An analysis of tendon biopsy specimens taken 12 weeks after treatment found no significant difference in Bonar score between groups.

AC joint dislocation—Data published in the JOT indicate that patients who undergo nonsurgical treatment for acute acromioclavicular (AC) joint dislocation may experience fewer complications and return to work sooner than those who undergo surgical treatment. The prospective, randomized, multicenter trial of 83 patients with acute (<28 days from the time of injury), grade iii, iv, or v dislocations of the ac joint. at 6-week and 3-month follow-up, disabilities of the arm, shoulder and hand (dash) scores were significantly better in the nonsurgical cohort, with no significant difference in dash score between cohorts at 6 months, 1 year, or 2 years. overall, constant scores were statistically similar across cohorts at all time points.>

Patients with Parkinson disease—
According to a study in JBJS, patients with Parkinson disease may see a reduction in spine-related pain after lumbar spine surgery. The retrospective study of 96 patients found improvements in the following scores at mean 30.1-month follow-up: visual analog scale (VAS) for back pain, VAS for lower-limb pain, Oswestry Disability Index score, and Short Form-12 Physical Component Summary. Overall, 19 patients had early complications, and 20 required revision surgery.

Treating back pain—A study in The Journal of the American Medical Association finds that adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone may not improve short-term functional outcomes or pain for patients with acute, nontraumatic, nonradicular low back pain (LBP). The randomized, double-blind study involved 323 emergency department patients in 3 cohorts (naproxen + cyclobenzaprine, naproxen + oxycodone/acetaminophen, naproxen + placebo). Measures of pain, functional impairment, and use of health care resources were not different between the study groups at 7-day or at 3-month follow-up.

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.