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Published 10/1/2015

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.

Foot and Ankle
Adjunct therapy with PRP and HA for arthroscopic talar OCL treatment

Data from a Turkish
study in Foot & Ankle International (August) suggest that treatment with platelet-rich plasma (PRP) or intra-articular hyaluronic acid (HA) may improve clinical outcomes for patients who undergo arthroscopic surgery for talar osteochondral lesions (OCLs). The prospective, randomized, blinded study involved 40 patients with talar OCLs in their ankle joints who were treated with arthroscopic débridement and microfracture. Patients also received PRP (n = 13) or HA (n = 14); the control group received a saline injection (n = 13). At mean 15.3-month follow-up, the two treatment cohorts had significant improvement in average AOFAS score and visual analog pain scale (VAS) score compared to the control group. Patients in the PRP group saw additional significant improvement in AOFAS and VAS scores compared to those in the HA group.

Hip and Knee
Study examines early data on recalled hip system

An online
study in Clinical Orthopaedics and Related Research (CORR) attempts to evaluate early data from a follow-up study of the recalled Articular Surface Replacement (ASR) hip system. The prospective study involved 288 patients (333 hips) who received DePuy Orthopaedics ASR and ASR XL hip systems and who had a metal artifact reduction sequence magnetic resonance imaging (MIR) scan of the hip performed at a mean time of 6 years after surgery. Moderate or severe adverse local tissue reactions (ALTRs) were identified in 79 hips. The direct lateral approach was used in 41 hips and the posterior approach in 38 hips. In patients in whom the lateral approach was used, 83 percent had an anterior ALTR, while 71 percent of patients in the posterior approach group had posterior ALTRs. The researchers noted no differences in patient-reported outcome measures between patients with moderate-to-severe ALTRs and those with no ALTR findings on MRI. In addition, use of ASR XL was an independent risk factor for moderate-to-severe ALTRs, and patients with ASR XL also had a thicker synovium and larger maximal ALTR diameter compared to patients treated with ASR.

Risk of MI after THA, TKA
Data from a
study published online in Arthritis & Rheumatology suggest that arthritis patients who undergo total hip or total knee arthroplasty (THA or TKA) may be at increased risk of myocardial infarction (MI). The authors conducted a time-stratified, propensity score-matched, cohort study of 6,063 THA patients and 6,063 non-THA controls, as well as 13,849 TKA patients and 13,849 non-TKA controls. During the first postoperative month, there was a significantly increased risk of MI among THA and TKA patients compared to controls who did not undergo joint arthroplasty. Using venous thromboembolism as a positive control outcome, both the first month and overall hazard ratios of MI were substantially increased for THA and TKA.

Congenital femoral deficiency

study of outcomes for two methods of limb-lengthening in pediatric patients with congenital femoral deficiency found that use of a motorized intramedullary nail resulted in fewer complications than did use of circular external fixation. The level III study, published in The Journal of Bone & Joint Surgery (Sept. 2), involved 14 skeletally mature patients who underwent 14 lengthening sessions using circular fixation and 13 patients who underwent 15 sessions using the motorized nail. The amount lengthened in the two groups was similar (mean of 4.8 cm in the circular fixation group and 4.4 cm in the motorized nail group). Complications occurred in all lengthening sessions of the patients managed with circular external fixation and in 73 percent of the 15 sessions of those managed with the motorized nail.

Pediatric lateral condyle fractures
data indicate that closed reduction and percutaneous pinning (CRPP) is associated with decreased surgical times and does not significantly increase the incidence of complications when used as an alternative to ORIF for pediatric lateral condyle fractures (LCFs) of the humerus. The cohort study, published in the Journal of Pediatric Orthopaedics, followed 191 pediatric LCF patients who had been treated with either ORIF (n = 163) or CRPP (n= 28) for 12 weeks. CRPP was associated with significantly shorter surgical times (mean: 25.4 min) compared to ORIF (mean: 52.6 min.). A nearly anatomic reduction was obtained in all fractures, no intraoperative or immediate postoperative complications were observed, and patients in both groups recovered similar range of motion at latest follow-up. The overall complication rate was 6.3 percent for ORIF and 3.6 percent for CCRP.

Shoulder and Elbow
Assessing traumatic anterior shoulder instability–related lesions on MRAs

Data from a
study in the Journal of Shoulder and Elbow Surgery (JSES, September) suggest that experienced orthopaedic surgeons may be more accurate than radiologists in assessing traumatic anterior shoulder instability–related lesions on magnetic resonance arthrograms (MRAs). A total of 45 surgically confirmed MRAs were assessed by four radiologists, four orthopaedic surgeons, two radiologic teams, and two orthopaedic teams across two medical centers. No significant difference in diagnostic accuracy between cohorts of radiologists and orthopaedists was found. However, at each center, the most experienced orthopaedic surgeon was more accurate than others in diagnosing lesion type, and in three of four cases, the difference was significant.

PJI in shoulder
Data from a
study published in JSES (September) suggest that leukocyte esterase (LE) may be an unreliable marker for the diagnosis of shoulder periprosthetic joint infection (PJI). The prospective study involved 45 primary and 40 revision shoulder arthroplasties. Of 5 primary arthroplasties with positive tissue cultures, only 1 was positive for LE. Similarly, of 16 revisions with positive cultures, 4 were positive for LE. Among revision surgeries overall, LE had sensitivity of 25 percent and specificity of 75 percent to predict positive cultures.

Smoking and SSI
Data from a
study published in CORR (online) suggest that cigarette smoking is linked to increased risk of surgical site infection (SSI) after open reduction and internal fixation (ORIF) of a closed elbow fracture. A review of data on 1,320 adult patients who underwent surgery for elbow fracture found 1,113 patients had a closed fracture. Use of plate and screw fixation and use of external fixation prior to surgery were associated with higher infection rates. However, when a subset analysis was performed for closed fractures, only smoking was associated with higher infection rates. Because plate fixation and temporary external fixation are likely surrogates for more complex injuries, no recommendations should be inferred from the association.

Reducing infection rates for scoliosis surgery

Findings from a
study published in the Journal of Pediatric Orthopaedics (online) suggest that use of a plastic multilayered closure technique may reduce the likelihood of postoperative wound complication for patients who undergo posterior spinal fusion for nonidiopathic scoliosis. The retrospective review involved 76 patients with a primary diagnosis of scoliosis associated with a syndrome or neuromuscular disease, who underwent posterior spinal fusion using either nonstandardized wound closure performed by an orthopaedic surgical team (n = 42) or a plastic multilayered closure technique and rotational flap coverage when needed performed by a plastic surgeon (n = 34). The wound complication rate in the nonstandardized closure group was 19 percent compared with 0 percent in the plastic multilayered closure group. In addition, the unanticipated return to the operating room rate was 11.9 percent for nonstandardized closure patients and 0 percent for plastic multilayered closure patients.

Outcomes for primary posterior spinal fusion with instrumentation
published in Spine (Sept. 1) suggest that type of bone graft or substitute may not influence outcomes for patients who undergo primary posterior spinal fusion with instrumentation. The retrospective cohort analysis involved 461 patients—152 patients treated with autogenous iliac crest (AIC) bone graft, 199 with allograft, and 110 with bone substitute (BS). The patients in the BS group had significantly smaller preoperative curves and shorter operative times. However, the BS cohort had significantly longer hospital stays, used higher quantities of patient-controlled intravenous analgesia, and used epidurals longer. Patients in the AIC group used patient-controlled intravenous analgesia significantly longer. Overall, there were no differences between cohorts regarding curve type, number of levels fused, postoperative infections, pseudarthrosis, reoperations for any indication, and SRS-30 scores at most recent follow-up.

Sports Medicine
Mid-term outcomes after ACLR

study published in The American Journal of Sports Medicine (August) finds similar mid-term clinical outcomes among patients who undergo anterior cruciate ligament reconstruction (ACLR) using either titanium or bioabsorbable poly-L-lactic acid with hydroxyapatite (PLLA-HA) screws. The randomized, controlled trial involved 40 ACLR patients who received either PLLA-HA or titanium screws. At both 2- and 5-year follow-up, no significant difference between cohorts were found in IKDC (International Knee Documentation Committee) and Lysholm knee score, KT-1000 arthrometer, and single-legged hop test. At 2 years, MRI revealed a smaller femoral tunnel in the PLLA-HA group compared to the titanium group; at 5 years, that distinction had disappeared.

OA risk after ACL tear
According to a study published in the British Journal of Sports Medicine (August) medial meniscal injury and meniscectomy after anterior cruciate ligament (ACL) rupture may increase risk of later development of osteoarthritis (OA). The research team conducted a meta-analysis of 64 studies and found that, at minimum 2-year follow-up, medial meniscal injury/meniscectomy displayed moderate evidence for influencing OA development, while lateral meniscal injury/meniscectomy and time between injury and reconstruction both showed moderate evidence for no relationship.

Vision test for concussion
Findings from a
study published in Concussion (online) suggest that use of a rapid number naming test, in which athletes read numbers on a series of cards as quickly as possible, may have efficacy in sports-related concussion testing. The meta-analysis of 15 studies covering 1,419 participants found that all studies used preseason baseline scores of the King-Devick (K-D) test to identify concussed versus non-concussed athletes. The test had 86 percent sensitivity (96 of 112 concussed athletes had K-D worsening) while specificity was 90 percent (181 of 202 controls had no K-D worsening).

Débriding muscle

An online
study in the Journal of Orthopaedic Trauma (JOT) examines the possibility that surgeons may occasionally débride viable muscle. The blinded, prospective study involved 36 biopsies collected from 20 patients who underwent débridement for open fracture, compartment syndrome, infection, or crush injury. Based on surgeon impressions using the “four Cs” system (muscle color, consistency, contractility, and capacity to bleed), 25 specimens were considered to be dead muscle, 10 borderline, and one healthy. However, a pathologic analysis of the 35 specimens considered by the surgeon to be dead or borderline muscle demonstrated normal muscle or mild interstitial inflammation in 21 specimens.

Postoperative pain management for tibia, ankle fractures
Findings from a
study published in JOT (September) suggest that use of peripheral nerve blocks (PNBs) as part of an analgesic protocol for surgical repair of tibia and ankle fractures may improve postoperative pain management. The prospective cohort study involved 93 consecutive patients undergoing surgical repair of fractures of the ankle and tibia. During the first 24 hours after surgery, average pain scores were similar across cohorts. However, patients who received PNBs reported greater satisfaction with pain management, spent less time in severe pain, and had a higher overall perception of pain relief compared to those who did not. In addition, patients receiving PNBs demonstrated better quality of recovery (as measured by the Quality of Recovery Questionnaire) at 24-hour, but not 48-hour, follow-up.

Preadmission shower regimen

According to a
study in JAMA Surgery, use of a standardized preadmission shower regimen may inhibit or kill gram-positive or gram-negative surgical wound pathogens prior to elective surgery. The prospective analysis involved 120 healthy volunteers who were randomized to take either two or three showers with 4 percent chlorhexidine gluconate. Cohorts were further divided into three subgroups: no pause, 1-minute pause, or 2-minute pause before rinsing. The the mean composite chlorhexidine gluconate concentrations were significantly higher in the 1- and 2-minute pause groups compared against the no-pause groups. Overall, no significant difference in concentrations was found between 2 and 3 showers, or between 1- and 2-minute pauses.

Delirium linked to adverse outcomes
Data from a
study published in JAMA Surgery suggest that delirium may be a significant contributor to adverse outcomes among older surgical patients. The prospective cohort study involved 566 patients aged 70 years or older without recognized dementia or history of delirium, who underwent elective major orthopaedic, vascular, or abdominal surgical procedures with a minimum 3-day hospitalization. Major complications developed in 47 patients (8.3 percent) and delirium was found in 135 patients (23.9 percent). Delirium significantly increased all adverse outcomes, including prolonged length of stay, institutional discharge, and 30-day readmission. Patients with both complications and delirium displayed the highest rates of all adverse outcomes. Overall, delirium exerted the highest attributable risk at the population level compared with all other adverse events.