Published 12/1/2016

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)

Osteoporosis—According to a report by the International Osteoporosis Foundation (IOF), millions of people with osteoporosis are going undiagnosed and untreated, leaving them at risk for fracture. The IOF asserts that, although safe and cost-effective therapies for treating osteoporosis are widely available, approximately 80 percent of patients who have already sustained a broken bone due to osteoporosis remain unprotected against future fractures. The IOF lists 10 major care gaps clustered into four major themes: case finding and management, public awareness, government and health system issues, and lack of data. Citing the "impending catastrophic burden that will be placed on the world's population and economy by fragility fractures," the organization encourages national health authorities worldwide to implement possible solutions outlined in the report.

Fracture-associated drugs—A study published in JAMA Internal Medicine (October) looks at prescription drug use patterns before and after fragility fracture. The research team conducted a retrospective cohort study of 168,133 community-dwelling Medicare beneficiaries who were enrolled in fee-for-service Medicare with drug coverage and who sustained a fracture of the hip, shoulder, or wrist. Overall, 77.1 percent of hip, 74.1 percent of wrist, and 75.9 percent of shoulder fracture patients were exposed to at least one nonopiate drug associated with increased fracture risk in the 4 months before fracture. The research team found that about 7 percent of those patients discontinued the drug exposure following fracture, but this was offset by new users after fracture, leaving no significant change in the proportion of the cohort exposed following fracture and no change in the average number of fracture-associated drugs used.

Patient safety
Antibiotics—A new Cochrane review published in JAMA Dermatology (online) finds little evidence that the use of antibiotics or antiseptics helps heal open surgical wounds by slowing the growth of dangerous micro-organisms. The researchers reviewed data from 11 randomized trials that evaluated the effects of topical or systemic antibiotic or antiseptic use on secondary intention surgical wound healing. The studies were conducted in the United States, Europe, Africa, and Asia between 1998 and 2013 and involved more than 800 patients. Among the 11 trials, 4 compared antiseptic treatment to other treatment with no antimicrobials, 4 studied alternative antimicrobial options, and 3 compared management with and without antimicrobial agents. The reviewers found low-quality evidence that antibiotic or antiseptic wound management of open surgical wounds would decrease time to healing, increase the number of wounds healed, or decrease adverse events or infection. The reviewers note, however, that because the studies were small and often poorly reported, the interventions they examined may not accurately reflect current clinical practice.

Transmission vectors—A study presented at the IDWeek conference examines hospital rooms and healthcare personnel as vectors for pathogen transmission. The research team collected 2,185 cultures from the clothing of 40 intensive care nurses, 455 cultures from 167 patients, and 2,919 cultures from patients' rooms over 120 12-hour shifts. They confirmed 12 instances of at least one of five pathogens being transmitted from the patient or the room to the scrubs, with six incidents each of transmission from patient to nurse or room to nurse. The research team found an additional 10 transmissions from the patient to the room. They did not document any nurse-to-patient or nurse-to-room transmission. They note that pockets and sleeves of scrubs were most likely to be contaminated, as were the bed rails in the rooms.

Hand and wrist
Opioids—A study published in The Journal of Hand Surgery (online) suggests that many opioid-naïve patients may continue to fill opioid prescriptions for 90 days or more following hand surgery. The research team reviewed insurance claim information on 77,573 opioid-naïve adult patients who underwent an elective or trauma-related hand surgery procedure between 2010 and 2012. Overall, 59,725 patients (77 percent) filled a perioperative opioid prescription. Of those, 13 percent of patients continued to fill prescriptions between 90 and 180 days after surgery. The researchers note that elective surgery patients were more likely than trauma patients to continue to fill opioid prescriptions after 90 days. Overall, younger age, female gender, lower income, comprehensive insurance, higher Elixhauser comorbidity index, mental health disorders, and tobacco dependence or abuse were associated with prolonged opioid use.

Foot and ankle
Surgeon volume—A study published in Foot & Ankle International (October) suggests that increased surgeon volume may be associated with decreased complication rates and hospital length of stay following total ankle arthroplasty (TAA). The authors conducted a retrospective cohort study of 4,800 TAA patients and found that the 90th percentile of surgeon volume was 21 cases per year. Based on multivariate analysis, they found that procedures performed by high-volume surgeons were associated with decreased overall complications and rate of medial malleolus fracture, shorter length of stay, and lower hospital charges.

Hip and knee
Cam deformity and acetabular dysplasia—Data from a study conducted in The Netherlands and published in Arthritis & Rheumatology (online) suggest that patients with cam deformity and acetabular dysplasia may be predisposed to hip osteoarthritis (OA), independent from other known risk factors. The research team reviewed information on 4,438 participants aged 55 years or older without OA at baseline. At mean 9.2-year follow-up, they found that individuals with cam deformity and acetabular dysplasia each had a two-fold increased risk for developing OA, compared to those without deformity. The research team notes that pincer deformity was not associated with increased risk of OA.

Periprosthetic hip infection—A study published in The Journal of Bone & Joint Surgery (Oct. 5) examines the efficacy of various imaging techniques for diagnosis of periprosthetic hip infection. The researchers conducted a systematic review and meta-analysis of 31 studies, representing 1,753 hip prostheses. They found that the pooled sensitivity and specificity were 88 percent and 92 percent, respectively, for leukocyte scintigraphy; 86 percent and 93 percent for fluorodeoxyglucose positron emission tomography; 69 percent and 96 percent for combined leukocyte and bone marrow scintigraphy; 84 percent and 75 percent for antigranulocyte scintigraphy; and 80 percent and 69 percent for bone scintigraphy. The researchers write that there was not enough clinical data to perform meta-analyses for radiography, ultrasonography, computed tomography, and magnetic resonance imaging. They conclude that, of currently used imaging techniques, leukocyte scintigraphy has satisfactory accuracy in confirming or excluding periprosthetic hip infection, while combined leukocyte and bone marrow scintigraphy was the most specific imaging technique. They note that fluorodeoxyglucose positron emission tomography offered appropriate accuracy in confirming or excluding periprosthetic hip infection, but "may not yet be the preferred imaging modality because of limited availability and relatively higher cost."