Published 11/1/2015
AAOS Now Staff

Second Look – Clinical News and Views

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)

FDA caution on tramadol for children
The U.S. Food and Drug Administration (FDA) is investigating the use of tramadol in children aged 17 years and younger, due to a rare but serious risk of slowed or difficult breathing. Tramadol is not FDA-approved for use in children but may be physician-directed in this population. Healthcare professionals should be aware of this side effect and consider prescribing alternatives that are FDA-approved for children.

Foot and Ankle
PNBs after tibia, ankle fracture surgery
Findings in the Journal of Orthopaedic Trauma (JOT) suggest that patients who receive peripheral nerve blocks (PNBs) as part of an analgesic protocol for surgical repair of tibia and ankle fractures may experience better postoperative pain management than those who do not. The prospective cohort study of 93 consecutive patients who underwent surgical repair of ankle and tibia fractures at a single center found that, compared to patients who did not receive regional anesthesia, patients who received PNBs had increased satisfaction with pain management, spent less time in severe pain during the first 24 hours postoperative, and had higher overall perception of pain relief.

Repair of high-energy pilon fracture
A study in JOT finds no significant difference in the use of locked or non-locked plates for the repair of high-energy pilon fracture. The randomized, prospective trial involved 33 patients with AO/OTA types A, B, and C tibial pilon fractures. No significant differences were found between cohorts in mechanism or injury pattern, average patient age, ratio of males to females, tourniquet time, operative time, interval to surgery, Ankle-Hindfoot Scale, or Short Musculoskeletal Function Assessment scores.

Risks for hip fracture surgery, elective THA
According to a French study in The Journal of the American Medical Association even when hip fracture patients and elective total hip arthroplasty patients (THA) are matched for age, sex, and preoperative comorbidities, hip fracture surgery patients have a higher risk of mortality and major complications. Based on data on 690,995 patients from the French National Hospital Discharge Database, patients who underwent elective THA were younger, more commonly male, and had less comorbidity compared to patients who had hip fracture surgery. Compared to THA patients, hip fracture patients had a 1.51 percent increase in absolute risk for mortality and a 3.54 percent increase in absolute risk for major postoperative complication.

Posterior-stabilized TKA inserts
Short-term data published in The Journal of Arthroplasty find no deleterious effects related to the use of cross-linked polyethylene (XLPE) inserts in total knee arthroplasty (TKA) compared to conventional polyethylene. The prospective cohort study involved 114 consecutive posterior-stabilized (PS) TKAs, 50 using conventional PE and 64 using a second-generation annealed XLPE. At mean 5-year follow-up, mean Knee Society Scores and SF-36 physical function subset scores were higher in the XLPE cohort. No radiographic osteolysis or mechanical failure related to tibial polyethylene was found in either group.

Comorbidities and complications after TKA
Research in Clinical Orthopaedics and Related Research finds that low serum albumin levels, more than morbid obesity, may be associated with increased mortality and major perioperative complications after TKA. Data were from from the National Surgical Quality Improvement Program (NSQIP) from 2006 to 2013. Morbidly obese patients (BMI < 40) had a higher rate of progressive renal insufficiency, superficial infection, and sepsis, but morbid obesity was not linked to the other 21 perioperative complications recorded in the NSQIP database, nor did the morbidly obese have a higher rate of mortality compared to those with lower BMI. Low serum albumin was associated with major perioperative complications, including (but not limited to) superficial surgical site infection, deep surgical site infection, organ space surgical site infection, and pneumonia.

Microfracture versus OAT for distal femur articular cartilage lesions
A study published in The American Journal of Sports Medicine (AJSM) finds both microfracture and osteochondral autograft transplantation (OAT) to be cost-effective first-line treatment options for isolated articular cartilage lesions of the distal femur. Although microfracture had a lower initial cost, the savings lessened over time. OAT was associated with a significantly lower cost for return to play in athletes at 1 year, 3 years, and 10 years, compared with microfracture.

Exercise, pain, and quality of life for patients with knee OA
A study in the British Journal of Sports Medicine suggests that land-based therapeutic exercise may offer short-term benefit to patients with knee osteoarthritis (OA). A pooled analysis of 44 studies found that land-based therapeutic exercise was significantly associated with moderately reduced pain and improved physical function immediately after treatment. In addition, evidence from 13 studies suggested that exercise significantly improved quality of life immediately after treatment with small effect. Finally, 12 studies provided 2-month to 6-month post-treatment sustainability data suggesting significantly reduced knee pain and 10 studies which demonstrated improved physical function.

Teens most at risk for primary anterior shoulder dislocations
A study of patients aged 10 to 16 years found that the rate of primary and recurrent anterior shoulder dislocations among 14- to 16-year-old patients was similar to that in a high-risk group of adults aged 17 to 20 years; the rate was considerable lower in patients aged 10 to 13 years. The study, published in AJSM, involved 1,937 patients aged 10 to 16 years (median age 15.0 years; 79.7 percent male) who underwent primary closed reduction (CR) for anterior shoulder dislocation.

Impact of HIV drug on newborns
According to a National Institutes of Health (NIH) study published in the journal Clinical Infectious Diseases, tenofovir disoproxil fumarate—a drug used to treat the human immunodeficiency virus (HIV) and reduce the transmission from mother to child—may lead to lower bone mineral content (BMC) in newborns who are exposed to the drug in the womb, compared to infants exposed to other anti-HIV drugs. A study of 74 infants exposed to tenofovir and 69 infants not exposed to the drug found BMC was 12 percent lower in the tenofovir-exposed group. Tenofovir use has been associated with bone loss and increased fracture risk in adults.

Shoulder and Elbow
Surgical treatment for lateral epicondylitis
A study in ASJM identifies factors associated with failure of nonsurgical treatment for lateral epicondylitis. The case control study of 580 patients treated for lateral epicondylitis at a single center found that 92 (16 percent) underwent surgical treatment at a mean of 6 months after initial visit. In a multivariate analysis, workers' compensation claim, prior injection, radial tunnel syndrome, previous orthopaedic surgery, and duration of symptoms longer than 12 months were significant independent predictors of surgical treatment.

Corticosteroids and PT for tennis elbow
Acute lateral epicondylitis of the elbow generally resolves within a year, whether or not patients received treatment, according to a Norwegian study in BMC Musculoskeletal Disorders. Of 157 patients assigned to one of three groups (physical therapy [PT] and corticosteroid injections; PT and placebo injections; no treatment other than pain relief) investigators found that the PT and corticosteroids showed no clear benefit or added effect over a year. Patients receiving corticosteroids had superior results at 6 weeks but symptoms then worsened. The placebo-injection and control groups both demonstrated a gradual increase in success.

BMI and risk of LSS
According a Swedish study in Spine, obese and overweight people may be at increased risk of lumbar spinal stenosis (LSS) compared to those with lower body mass index (BMI). The prospective, cohort study of 364,467 individuals participating in a nationwide occupational surveillance program for construction workers found that obese workers had an incidence rate ratio (IRR) of 2.18 for LSS, overweight workers had an IRR of 1.68, and underweight workers had an IRR of 0.52, compared with normal weight individuals.

Bone loss in SpA patients
Patients with early axial spondyloarthritis (SpA) may benefit from therapies employing anti-tumor necrosis factor (anti-TNF) and NSAIDs to protect against bone loss, according to findings from a French study published in Rheumatology. Of 265 patients (54 percent male, mean age 34.4 years) with early inflammatory back pain suggestive of axial SpA. In all, 39 patients (14.7 percent) had low BMD (Z score ≥ -2) at baseline, while 112 patients (42.3 percent) had a 2-year significant bone loss. Patients treated with anti-TNF had significant increases in BMD at the lumbar spine but BMD levels at the hip did not change. Hip BMD levels decreased in patients not treated with anti-TNF, and the difference between the two groups was significant.

Sports Medicine
Football and CTE
According to information released by the Concussion Legacy Foundation, brain tissue from 87 of 91 deceased former National Football League (NFL) players tested positive for chronic traumatic encephalopathy (CTE). CTE was found in the brain tissue in 131 of 165 individuals who, before their deaths, played football either professionally, semi-professionally, in college or in high school. The findings are consistent with previous research suggesting a link between football and long-term brain disease.

VTE risk factors after ACL reconstruction
A study in AJSM attempts to assess risk factors for the development of venous thromboembolism (VTE) after anterior cruciate ligament (ACL) reconstruction. The descriptive epidemiologic study involved 16,558 ACL reconstructions performed on 15,767 patients, with a total of 87 VTE events—55 deep venous thrombosis (DVT) and 35 pulmonary embolism (PE), with three patients documented with both DVT and PE. Patient age of 35 years or older was associated with increased likelihood of VTE, a history of nicotine was linked to an increased likelihood of DVT, and concomitant high tibial osteotomy increased the likelihood of PE. Concomitant posterior cruciate ligament reconstruction was linked to increased likelihood of VTE and DVT, while nonsteroidal drug use was associated with decreased odds of both VTE and DVT. Use of anticoagulants was associated with increased risk of VTE, DVT, and PE.

Anticoagulation protocols
Findings in The Journal of Bone & Joint Surgery suggest that current anticoagulation protocols may be inadequate for patients who undergo intramedullary (IM) nailing for skeletal metastatic disease. The retrospective review involved 287 patients with a total of 336 impending or pathologic long-bone fractures stabilized with IM nailing. The overall rate of venous thromboembolism (VTE) was 7.1 percent (24 of 336 fractures)—13 pulmonary embolism and 11 deep venous thrombosis. A significant positive correlation between lung-cancer histology and the development of VTE was found.