Published 9/1/2015

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. Subscribe at www.aaos.org/news/news.asp (member login required)

Foot and ankle
Patients who have undergone Achilles tendon rupture repair have similar outcomes, regardless of whether they are treated postoperatively with either early weightbearing and early mobilization or early weightbearing with early immobilization in tension, according to findings from a study conducted in Finland and published online in the American Journal of Sports Medicine (AJSM). The randomized, controlled trial involved 50 patients with acute Achilles tendon rupture who received either early movement of the ankle between neutral and plantar flexion in a brace for 6 weeks or Achilles tendon immobilization in tension using a below-knee cast with the ankle in a neutral position for 6 weeks. Among the 37 patients with 11-year follow-up, no significant difference was found between cohorts in mean Leppilahti score, mean isokinetic plantar flexion peak torque deficit, or average work deficits in plantar flexion. However, calf muscle strength did not recover normally even at 11-year follow-up.

Hand and wrist
Non- and minimally displaced scaphoid waist fractures may best benefit from casting treatment, based on findings from a study in The Journal of Hand Surgery (July). The prospective, randomized trial involved 35 patients with acute non- or minimally displaced scaphoid waist fractures who underwent treatment with a below-elbow thumb spica cast (n = 21) or wrist arthroscopy and percutaneous antegrade screw fixation (n = 14). At 26-week follow-up, patients in the casted cohort had improved range of motion compared to those in the surgical cohort. At median 6-year follow-up, radiographic signs of arthritis in the radioscaphoid joint were more common in the surgically treated group than in the casted group. No significant differences were noted between cohorts in grip or pinch strengths at any time.

Hip and knee
A study published in the AJSM online examines long-term outcomes for patients who undergo anterior cruciate ligament (ACL) reconstruction using middle-third patellar tendon autografts. The longitudinal, prospective study involved 90 patients who were evaluated at 1, 2, 3, 4, 5, 7, 10, 15, and 20 years after surgery. At 20-year follow-up, 32 patients had sustained another ACL injury, primarily to the contralateral limb. Overall, 50 percent of patients participated in strenuous or very strenuous activities, and 63 percent had pain when kneeling. Female patients were less likely to injure the reconstructed ACL or to participate in strenuous activities and had poorer International Knee Documentation Committee (IKDC) subjective scores and more activity-related pain. Radiographic OA was found in 61 percent of patients, but OA symptoms were rarely reported.

According to findings published in Medical Care (August), a national, clinician-led, audit initiative was linked to substantial improvements in care and survival of older people with hip fracture in England. The researchers reviewed data on 471,590 patients aged 60 years or older who were admitted with a hip fracture to National Health Service hospitals in the United Kingdom. After the U.K. National Hip Fracture Database was launched in 2007, rates of early surgery increased from 54.5 percent to 71.3 percent, and 30-day mortality fell from 10.9 percent to 8.5 percent. In addition, the annual relative reduction in adjusted 30-day mortality was 1.8 percent per year from 2003 to 2007, compared with 7.6 percent per year from 2007 to 2011.

According to findings published in Clinical Orthopaedics and Related Research (CORR, online), use of a multidisciplinary team that includes orthopaedic surgeons, internal medicine physicians, social workers, and specialized physical therapists may decrease complication rates, improve time to surgery, and reduce hospital length of stay for patients with osteoporotic hip fractures. An economic analysis was used to determine whether implementation of a comanagement model of care for geriatric patients with osteoporotic hip fractures would be cost-effective at moderate-volume hospitals (at least 50 cases annually). For the base case, universal comanagement was more cost-effective than traditional care and risk-stratified comanagement. In addition, comanagement was more cost-effective than traditional management as long as the hip fracture case volume was more than 54 patients annually, and resulted in cost savings when more than 318 patients were treated annually.

Joint reconstruction
Findings published in The Journal of Bone & Joint Surgery (July 15) suggest that in-home "telerehabilitation" may be an effective alternative to in-person rehabilitation for patients who have undergone total knee arthroplasty (TKA). The prospective, randomized trial involved 205 TKA patients who underwent either telerehabilitation, using real-time, two-way video and audio interaction between a clinician at a rehabilitation center and a patient at home, or traditional rehabilitation through in-home visits. At 4-month follow-up of 182 patients, no significant differences were found between cohorts in adjusted gains to WOMAC score in pain, stiffness, function, and total score.

Data from a study published in the European Journal of Orthopaedic Surgery & Traumatology (online) suggest that the use of intravenous and topical tranexamic acid (TXA) may be associated with reduced blood loss and transfusion requirements for patients who undergo primary TKA. The prospective study involved 90 TKA patients who received either intravenous (IV) TXA, intra-articular TXA, or standard treatment. The mean drained blood loss was 192 mL (± 21 mL) among IV patients, 121 mL (± 17 mL) among intra-articular patients, and 415 mL (± 24 mL) among control patients. Further, about 43 percent of control patients required a transfusion, compared to 23 percent of IV patients and 17 percent of intra-articular patients.

Findings from a study published in Arthritis & Rheumatology (online) suggest that TKA may be effective for reducing knee pain in patients with rheumatoid arthritis (RA). Researchers reviewed data on 834 RA and 315 osteoarthritis (OA) patients who underwent index TKA between the ages of 65 and 68 years. Post-TKA, both groups had significant improvements for most domains of pain, function, and health-related quality of life. However, the impact was greater among OA patients. Overall, a diagnosis of RA, lower income, and pre-operative anxiety were independently associated with lower improvements in index knee pain following TKA.

Research published in CORR finds that preoperative patient-reported outcome measures may predict whether patients who undergo total hip arthroplasty (THA) will have clinically meaningful improvements in functional outcomes 1 year after surgery. The retrospective cohort study evaluated SF12 version 2 (SF12v2) and Hip Disability and Osteoarthritis Outcome Score (HOOS) scores of 537 primary unilateral THA patients. As preoperative mental and emotional health improved—indicated by a higher mental component score—HOOS and PCS threshold values also increased. Patients with a higher level of preoperative function were less likely to obtain meaningful improvement after THA.

Data from a small study published online in CORR suggest that preoperative antimicrobial prophylaxis may be safe before revision THA or revision TKA involving microbiologic sampling. The prospective study involved 40 patients (29 THA and 11 TKA) with suspected prosthetic joint infection of unknown cause. Three tissue samples were obtained from each patient before and after the administration of antimicrobial prophylaxis and no difference was found in likelihood of infection diagnosis between the samples obtained before and after administration of antimicrobial prophylaxis. The findings should be confirmed in larger, multicenter studies before applying data to a broader patient population.

Hospital-acquired conditions (HACs) were the strongest predictor of readmission after primary hip or knee arthroplasty, according to a study published in The Journal of Arthroplasty (August). The attempt to identify risk factors for readmission after hip and knee arthroplasty used national Veteran’s Administration data on 26,710 total and partial primary arthroplasty procedures (16,808 knees and 9,902 hips) across 96 hospitals between 2005 and 2009. The retrospective cohort study found the overall 30-day readmission rate to be 7.3 percent (n = 1940), with readmission rates of 8.4 percent for hip arthroplasty and 6.6 percent for knee arthroplasty. HACs accounted for 42 percent of all complications. Among HACs, urinary tract infections were the most common, followed by surgical site infections, venous thromboembolism, and pneumonia.

A study in Spine compared outcomes achieved by orthopaedic surgeons and neurosurgeons operating on the spine and found that the two specialty groups achieved equivalent outcomes in the metrics of mortality, 30-day readmission, and surgical site infection. The study involved 9,719 patients undergoing a spinal fusion between 2005 and 2011 as identified in the American College of Surgeons’ National Surgical Quality Improvement Program database; neurosurgeons performed 54 percent of the operations. Orthopaedic surgeons had a greater percentage of lumbar spine cases (76 percent vs. 65 percent; P < 0.001). There was no significant difference between specialties in the number of levels fused or operative technique used. Procedures done by neurosurgeons did have a lower incidence of blood transfusion (8.3 percent vs. 14.6 percent; P < 0.001).

According to a study in JAMA Pediatrics (online) athlete-to-athlete contact—not heading the ball—may be the most frequent mechanism of concussion in soccer. The retrospective analysis of longitudinal surveillance data collected from 2005 through 2014 across a nationally representative sample of U.S. high schools found the following:

  • Among girls, 627 concussions during 1,393,753 athlete exposures, with 51.3 percent of concussions linked to athlete-to-athlete contact, and 25.3 percent linked to heading.
  • Among boys, 442 concussions across 1,592,238 athlete exposures, with 68.8 percent linked to athlete-to-athlete contact, and 30.6 percent linked to heading.

Findings published in the Orthopaedic Journal of Sports Medicine (July) suggest that a comprehensive education program for coaches and practice contact restrictions may help reduce injuries in youth football. The authors reviewed injury data on three groups of players. The first group (741 players) participated in leagues that used both the Heads Up Football (HUF) coaching education program and the Pop Warner Football (PW) guidelines to restrict contact during practice. The second group (663 players) were in leagues that adopted only the HUF program, and the control group (704 players) were in leagues that didn’t participate in either program. Practice injury rates were highest in the control group; game injury rates were lowest in the HUF+PW group. The effects were stronger among 11- to 15-year-olds than among 5- to 10-year-old players.

A study in the Journal of Orthopaedic Trauma (JOT, July) suggests that the presence of a dedicated orthopaedic trauma advanced practice provider at a level I trauma center may help reduce length of stay (LOS) for orthopaedic patients. The retrospective chart review examined all patients discharged from the orthopaedic surgery service of a single, level I trauma center for 1 year prior to and 1 year after the addition of a single, full-time nurse practitioner (NP) to the orthopaedic trauma team. The hiring of the NP was associated with a statistically significant decrease in LOS across the following patient subgroups: patients transferred from the trauma service, patients 60 years and older, patients discharged to a rehabilitation facility, and patients discharged on antibiotics/wound vacuum-assisted closure therapy. In addition, length of time to surgery was also decreased after the staff addition.

Opioid use
The AAOS, the American Medical Association (AMA), and 25 other medical societies have convened a task force to collaboratively address the opioid public health epidemic by identifying and implementing best practices. The group has developed a roadmap with the goal of bringing healthcare professionals and patients together as partners on the path to eliminating this public health concern. Initially, the group plans to focus on the following priorities:

  • Use of state-based prescription drug monitoring programs (PDMPs)
  • Discussing pain management treatment options with patients
  • Robust education activities to meet the needs of specialty, practice, and patient populations

In addition, the group plans to work with states to ensure PDMPs protect patient privacy, contain relevant and reliable data, allow care teams to seamlessly integrate data into their work flows, and enable data sharing across state lines.

A report from the U.S. Centers for Disease Control and Prevention (CDC) finds that heroin use is on the rise in the United States, and that the strongest risk factor for heroin abuse or dependence is dependence on prescription opioids. A guide published by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) offers clinical guidance for providers whose patients may have an opioid use disorder.

According to data published in Medical Care (August), many patients who overdose on opioid medications use the painkillers only intermittently and at lower prescribed dosages. The research team reviewed records of patients who had at least one paid claim for an opioid prescription through the Washington Apple Health Medicaid system between April 2006 and December 2010, and who also had an emergency department (ED) or inpatient hospital claim for an opioid poisoning. They found that methadone poisonings occurred at 10 times the rate of other prescription opioid poisonings and increased during the study period. Rates of other prescription opioid poisonings appeared to level off after the 2007 implementation of a state opioid guideline. Among individuals with nonmethadone opioid poisonings, 44 percent were chronic users. Overall, in the week before the poisoning, 17 percent of patients had a prescribed dose that met the guidelines’ caution level (>120 mg/d morphine-equivalent dose [MED]), while 28 percent had doses <50 mg d med, and 48 percent had concurrent sedative prescriptions.>

A meta-analysis of placebo-controlled osteoarthritis (OA) treatment trials published in the Annals of Internal Medicine (online) suggests that method of placebo intervention may produce different clinical responses, thereby affecting interpretation of results. The researchers analyzed 149 randomized trials of adults with knee OA that compared widely used pharmaceuticals against oral, intra-articular, topical, and oral plus topical placebos. Intra-articular placebo and topical placebo were associated with significantly greater effect sizes than oral placebo. A differential model displayed marked differences in the relative efficacies and hierarchy of the active treatments compared with a network model that considered all placebos equivalent. In the model accounting for differential effects, intra-articular and topical therapies were superior to oral treatments in reducing pain, but when differential effects were ignored, oral nonsteroidal anti-inflammatory drugs were superior. Because few of the studies directly compared different placebos, the analysis could not decisively conclude whether disease severity and co-interventions systematically differed between trials evaluating different placebos.

Data from a study in Bone (October) suggest that implementation of an exercise program may be associated with an increase in bone mineral density (BMD) and bone turnover markers (BTM) in physically active men with osteopenia of the hip or spine. The authors examined the effects of resistance training or jump training among 38 physically active, middle-aged men who completed either a weight-lifting program (n = 19) or a jumping program (n = 19) for 1 year. Both programs required participants to complete 60 to 120 minutes of targeted exercises each week, and participants took calcium and vitamin D supplements for the duration of the program. At 6 months into the program, whole body and lumbar spine BMD had significantly increased among participants in both cohorts—increases that were maintained at 12 months. Total hip BMD increased only among those in the weightlifting program.