Published 2/1/2017

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
Ankle arthroplasty and arthrodesis—Data from a study published in Foot & Ankle International (December) suggest that the conventional definition of a satisfactory outcome following ankle arthroplasty and arthrodesis may be inadequate. The researchers conducted a cross-sectional survey of 85 ankle arthroplasty and 15 ankle arthrodesis patients. Based on survey responses, the researchers categorized patients as "Recovered-Resolved" (better with no symptoms or residual effects), "Recovered, not Resolved" (better with residual effects), or "Not Recovered." They found that only 15 percent of patients were considered Recovered-Resolved, while 69 percent were Recovered, not Resolved and 14 percent were Not Recovered. However, Recovered-Resolved and Recovered, not Resolved patients had similarly high satisfaction summary scores. The researchers argue that, as patients' perceptions of satisfactory outcomes were not predicated on the resolution of all limitations, the conventional definition of satisfactory outcomes should be expanded accordingly.

Plantar fasciitis—According to a study in Foot & Ankle International (January), treatment with incobotulinumtoxinA (IBTA) may help improve foot function and pain for patients with plantar fasciitis. The researchers conducted a randomized, double-blinded, placebo-controlled trial of 50 patients with plantar fasciitis who received an injection of either IBTA (n = 25) or saline (n = 25) in the affected foot. At 6-month follow-up, they found that mean Foot and Ankle Ability Measures increased from 36.3 to 73.8 in the IBTA cohort and from 35.9 to 40.9 in the placebo cohort. In addition, mean pain score decreased from 7.2 to 3.6 in the IBTA group and from 8.4 to 7.9 in the placebo group. At 12-month follow-up, the IBTA group maintained significantly better function and pain scores than the placebo group, and no patients in the IBTA group and 3 patients in the placebo group had undergone surgery for recalcitrant plantar fasciitis

Shoulder and elbow
TSA—Findings published in the Journal of Shoulder and Elbow Surgery (December) suggest that implementation of an immediate range of motion (ROM) protocol may be associated with more rapid return of function following total shoulder arthroplasty (TSA) compared to a delayed ROM protocol, although immediate ROM may reduce the healing rate of a lesser tuberosity osteotomy. The authors conducted a randomized, controlled trial of 60 TSA patients who participated in an immediate motion (IM) or delayed motion (DM) protocol. At 1-year follow-up, they found no significant difference between cohorts in final ROM or functional healing scores. The authors noted that patients in the IM group displayed higher functional outcome scores initially, but noted no difference across groups at 3 months. Further, the rate of osteotomy healing was 81 percent in the IM group and 96 percent in the DM group.

Hip and knee
Meniscectomy—Data from a study in The American Journal of Sports Medicine (online) suggest that use of postoperative viscosupplementation may not offer significant clinical benefits following arthroscopic meniscectomy. The researchers conducted a double-blind, randomized, controlled trial of 90 patients aged 18 to 55 years with chronic, symptomatic meniscal tears requiring partial resection; a healthy contralateral knee; no previous surgery on the index knee; and no other concurrent articular lesions requiring surgical treatment. Patients received either meniscectomy alone or meniscectomy with an injection of 3 mL hyaluronic acid at the end of the procedure. At 15-, 30-, 60-, and 180-day follow-up, the researchers noted improvement in both cohorts in International Knee Documentation Committee Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score, visual analog scale (VAS) for pain, VAS for general health status, and Tegner scores, but no significant difference across cohorts in outcome scores at any time point. In addition, the mean time to return to full sports activity and satisfaction rate were comparable between groups.

TKA—Data from a study conducted in the United Kingdom and published in The Bone & Joint Journal (online) suggest that patients younger than 55 years who undergo total knee arthroplasty (TKA) should be informed regarding an increased risk of dissatisfaction. The research team conducted a prospective study of 157 patients (177 TKAs) aged 17 to 54 years. They found that 44 patients (24.9 percent [44 TKAs]) were unsure or dissatisfied with their knee. Based on univariate analysis, significant predictors of dissatisfaction included Kellgren-Lawrence osteoarthritis grades 1 and/or 2, poor preoperative Oxford Knee Score (OKS), complications, poor improvements in Short Form-12 physical component score and OKS, and indication. Based on multivariate analysis, poor preoperative OKS, poor improvement in OKS, and postoperative stiffness independently predicted dissatisfaction.

Anterior cervical discectomy and fusion—A study published in Spine (Dec. 1) argues for the importance of careful patient selection, aggressive preoperative medical optimization, and appropriate postoperative management for patients undergoing elective anterior cervical diskectomy and fusion. The researchers reviewed information on 17,088 patients from the National Surgical Quality Improvement Program database. Of 545 patients (3.2 percent) readmitted within 30 days, they noted that 53.8 percent (n = 293) were readmitted for nonsurgical site-related reasons, with neuropsychiatric (n = 44), cardiovascular (n = 39), and pneumonia (n = 37) being the most common reasons. Overall, 33.8 percent (n = 184) were readmitted for surgical site-related reasons, with surgical site infection (n = 42), hemorrhage/hematoma (n = 42), and dysphagia (n = 32) being the most common reasons. The researchers state that 15.6 percent (n = 84) had undocumented reasons for readmission. In multivariate analysis, only older age and higher American Society of Anesthesiologists class were independently associated with readmissions.

Nonaccidental trauma evaluation—Findings published in the Journal of Pediatric Orthopaedics (online) suggest that many healthcare providers may not conduct recommended nonaccidental trauma (NAT) evaluations for young femur fracture patients. The authors conducted a retrospective review of 281 pediatric patients younger than 36 months. They found that overall, 41 percent were evaluated for NAT. Overall, younger age, transfer from an outside facility, and identification of another fracture were significantly associated with receipt of a NAT evaluation, but fracture pattern and patient sex were not. Prior to publication of an AAOS clinical practice guideline (CPG) on treatment of pediatric diaphyseal femur fractures, 43 percent of nonwhite patients and 19 percent of white patients underwent NAT evaluation, compared to 43 percent and 47 percent respectively after publication.

Atypical femoral fracture—A study published in The Journal of Bone & Joint Surgery (Dec. 7) examines surgically controllable factors related to healing time following operative treatment of complete femoral fractures associated with long-term use of bisphosphonates. The authors reviewed data on 99 patients (109 fractures) surgically treated for a complete atypical femoral fracture and with a documented history of bisphosphonate therapy. They observed that 76 fractures (69.7 percent) displayed osseous union within 6 months after index surgery and 33 fractures (30.3 percent), showed delayed union or nonunion. Overall, supra-isthmic fracture location, femoral bowing of ≥ 10° in the coronal plane, and a lateral/medial cortical thickness ratio of ≥ 1.4 were predictive of problematic healing but were uncontrollable factors. Iatrogenic cortical breakage around the fracture site and a ratio of ≥ 0.2 between the remaining gap and the cortical thickness on the anterior and lateral sides of the fracture site were controllable predictive factors linked with problematic healing.

Patient safety
Postmenopausal osteoporosis—The American Association of Clinical Endocrinologists and the American College of Endocrinology have issued a set of CPGs for the diagnosis and treatment of postmenopausal osteoporosis. Recommendations given the highest evidence rating include:

  • Provide counseling on reducing the risk of falls, particularly among the elderly.
  • Strongly recommend medications for patients with osteopenia or low bone mass and a history of a fragility fracture of the hip or spine.
  • Medications that reduce the risk of fractures include alendronate, risedronate, zoledronic acid, and denosumab.
  • Treatment with teriparatide should be limited to 2 years.
  • Successful treatment of osteoporosis is defined as stable or increasing bone mineral density with no evidence of new fractures or fracture progression.

In addition, the guidelines recommend a "drug holiday" for patients with moderate fracture risk after taking an oral bisphosphonate for 5 years or an intravenous (IV) bisphosphonate for 3 years. Patients at higher fracture risk should continue oral therapy for up to 10 years and IV therapy for up to 6 years.

Overlapping surgery—Findings from a study published in the Annals of Surgery (online) suggest that overlapping surgery may be safe, at least in concept. The researchers reviewed data on 10,765 overlapping surgical cases, of which 10,614 (98.6 percent) were matched to 16,111 non-overlapping procedures at a single center. They found that 30-day mortality, morbidity, and length of stay were not statistically different across cohorts, and that adjusted risk for inpatient mortality was greater for non-overlapping surgery compared to overlapping surgery. However, the researchers write that the findings "support the safety of overlapping surgical procedures at this center but may not extrapolate to other centers."

In related news, the U.S. Senate Finance Committee has issued a report on the practice of concurrent and overlapping surgeries. The committee contacted 20 teaching hospitals regarding the practice and examined guidance from the U.S. Centers for Medicare & Medicaid Services and the American College of Surgeons. Among the recommendations in the report, the committee suggests that surgical records or notes document the following:

  • That the primary surgeon was immediately available for the entirety of the case
  • The portion of the procedure performed by the backup surgeon, if applicable
  • The names of all staff who participated in the surgery or were present in the operating room
  • Surgical times—including the start and end of the procedure and the times staff entered and exited the operating room

Opioids—A poll conducted by The Washington Post and the Kaiser Family Foundation suggests that as many as one-third of Americans who have taken prescription opioids for at least 2 months may have become addicted to or physically dependent on the drugs. Most long-term users said that they were introduced to opioids via physician prescription, but more than six in ten said physicians offered no advice on how or when to stop taking the drugs, and one in five said physicians provided insufficient information about the risk of side effects, including addiction.