Published 1/1/2017

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)

Spinal cord concussion—Findings from a study published in The Spine Journal (online) suggest limited evidence regarding current practice standards for return to play following spinal cord concussion (SCC). The researchers conducted a systematic review of 16 studies and found that, although some patients played after surgery without problems, several patients experienced recurrent SCC due to herniation at levels adjacent to the surgical sites. With respect to important predictors, the researchers noted that more patients who experienced recurrence of symptoms or spinal cord injury following return to play had a "long" duration of symptoms (> 24 hours) compared to those who were problem-free. However, the researchers state that most of the data reviewed were drawn from small sample sizes, and argue that future prospective multicenter studies should be conducted to determine predictive factors of poor outcomes following return to play following SCC.

Ankylosing spondylitis—According to findings presented at the American College of Rheumatology/Association of Rheumatology Health Professionals (ACR/ARHP) annual meeting, use of NSAIDs and tumor necrosis factor inhibitors (TNFi) in patients may help slow radiographic progression of ankylosing spondylitis. The researchers reviewed data from a prospective cohort of 527 patients with at least 2 years of radiologic and clinical follow-up. Overall, NSAIDs and TNFi were used in 78.0 percent and 58.4 percent of patients, respectively. At mean 4.29-year follow-up, the researchers found that multivariate results displayed significant interaction between NSAIDs and TNFi, indicating lower progression only for patients treated with TNFi and high-dose NSAIDs.

Hip and knee
Hip fracture—A study published in Medical Care (online) suggests that nursing home factors may significantly affect clinical outcomes for hip fracture patients. The authors conducted a retrospective cohort study of 42,781 hip fracture patients who were discharged to a nursing home between 2005 and 2009. They found that, compared with hospital factors, nursing home factors explained three times more variation in odds of 30-day mortality, seven times more variation in the odds of 180-day mortality, and eight times more variation in the odds of 180-day death or new dependence in locomotion. Nursing home characteristics that predicted 30- and 180-day outcomes included bed count, chain membership, and performance on selected quality measures. The authors state that hospital characteristics did not consistently correlate with outcomes.

Metal-on-XLPE—A study published in The Journal of Bone & Joint Surgery (Nov. 2) examines wear rates for larger highly cross-linked polyethylene (XLPE) articulations in primary total hip arthroplasty (THA). The research team conducted a randomized, controlled trial of 56 THA patients aged 65 to 74 years who received either 36-mm or 28-mm metal-on-XLPE articulation. They found that the mean annual proximal wear rates between 1 and 3 years were 0.00 mm/year for the 36-mm cohort and 0.01 mm/year for the 28-mm cohort. The authors write that no patient had a proximal wear rate of > 0.1 mm/year, with mean wear very low in all directions. The wear rate of 36-mm articulations was not significantly greater than that of 28-mm articulations on the basis of proximal, medial two-dimensional, and three-dimensional wear. However, the research team argues that "before a 36-mm metal-on-XLPE articulation is widely recommended, particularly in young active patients, long-term wear rates and association between wear and periprosthetic osteolysis should be determined."

Shoulder and elbow
Rotator cuff repair—Findings from a study published in The American Journal of Sports Medicine (online) suggest that fatty degeneration (FD) of the infraspinatus may be associated with a failure to heal after rotator cuff repair. The authors conducted a cohort study of 132 patients who underwent arthroscopic repair of full-thickness rotator cuff tears. At mean 12.7-month follow-up, they observed inadequate healing in 18.2 percent of patients, with an inverse relationship between repair tension and healing at the repair site. However, after adjustment for sex, age, tear size, amount of retraction, tendon quality, and FD of rotator cuff muscles, only FD of the infraspinatus displayed an association with the anatomic outcome of the repair.

Hepatitis C—According to a study published in Clinical Orthopaedics and Related Research (December), patients with hepatitis C may be at increased risk of complication following total shoulder arthroplasty (TSA). The researchers retrospectively reviewed data on 1,466 TSA patients with hepatitis C and 21,502 matched control TSA patients. Compared with patients in the control cohort, patients with hepatitis C had greater likelihood of infection within 3 months and 1 year, revision TSA within 1 year and 2 years, dislocation within 1 year, postoperative fracture within 1 year, systemic or medical complications within 3 months, and blood transfusion within 3 months.

Patient safety
Pulmonary complications—Results of a multicenter study reveal that even mild postoperative pulmonary complications (PPCs) are associated with increased early postoperative mortality, intensive care unit (ICU) admission, and hospital length of stay. Published in JAMA Surgery (online), the study involved 1,202 patients (American Society of Anesthesiologists Classification 3) who underwent noncardiothoracic surgery requiring 2 hours or more of general anesthesia with mechanical ventilation. All surgeries were performed between May and November 2014. At least one PPC occurred in 401 patients (33.4 percent). The most common complications were the need for prolonged oxygen therapy and atelectasis; severe complications were rare. The researchers found that even relatively mild complications were associated with significantly increased hospital stay, admission to the ICU, and mortality within the first week after surgery.

Frailty screening—Findings from a study published in JAMA Surgery (online) suggest that use of preoperative frailty screening may be associated with reduced mortality following surgery. The authors conducted a prospective cohort study of 9,153 patients from a single center who were seen for major, elective, noncardiac surgery. They found that implementation of a frailty screening initiative (FSI) was associated with a reduction in 30-day mortality from 1.6 percent (84 of 5,275) to 0.7 percent (26 of 3,878). The authors note that FSI was associated with a significant reduction in mortality among frail patients, from 12.2 percent (24 of 197) to 3.8 percent (16 of 424). In addition, the magnitude of improvement among frail patients increased at 180 and 365 days, and multivariable models revealed improved survival after FSI implementation, after controlling for age, frailty, and predicted mortality.
Sepsis—Findings presented by the U.S. Centers for Disease Control and Prevention at the IDWeek conference suggest that use of antibiotics may be associated with increased risk of sepsis, compared with no antibiotic therapy. The researchers conducted a retrospective cohort study of 12.7 million hospital stays across 516 centers, including 18,307 that were associated with a sepsis admission within 90 days of discharge following previous admission. Compared with no antibiotics, the odds ratio for sepsis was:

  • 1.78 following treatment with high-risk antibiotics
  • 1.10 following treatment with low-risk antibiotics
  • 1.22 following treatment with no-risk antibiotics

In addition, the researchers found that patients treated for more than 14 days had more than twice the risk of later sepsis as those given shorter therapy, regardless of antibiotic type.

Opioids—A study published in Pain (online) suggests that opioids prescribed at discharge from the emergency department (ED) may offer no advantage compared to NSAIDs for risk of moderate to severe musculoskeletal pain among patients who have been involved in a motor vehicle collision (MVC). The research team analyzed existing study data on 948 patients who were seen in an ED following an MVC. At 6-week follow-up, no difference in risk for moderate to severe musculoskeletal pain was found between patients who were discharged with opioid analgesics and those discharged with NSAIDS. However, the research team notes that at 6 weeks, patients who were prescribed opioids were more likely than those prescribed NSAIDS to report continued use of prescription opioid medications.

Septic shock—A study conducted in Germany and published in The Journal of the American Medical Association (Nov. 1) suggests that treatment with hydrocortisone may not reduce the risk of septic shock compared to placebo for adults with severe sepsis. The authors conducted a double-blind, randomized trial of patients with severe sepsis who were treated with either 200 mg of hydrocortisone for 5 days followed by dose tapering until day 11, or placebo. They found that septic shock occurred in 21.2 percent of patients (36 of 170) in the hydrocortisone group and 22.9 percent of patients (39 of 170) in the placebo group. The authors noted no significant differences between hydrocortisone and placebo groups for time until septic shock, mortality in the ICU or hospital, or mortality at 28, 90, or 180 days. In addition, patients in the hydrocortisone cohort were at increased risk of secondary infection, muscle weakness, and hyperglycemia compared to those in the placebo cohort.

SSI guidelines—The World Health Organization (WHO) has released a set of guidelines on the prevention of surgical site infection (SSI). The guidelines include 29 recommendations based on 26 reviews of recent evidence. Among other things, the guidelines recommend the following:

  • Surgical antibiotic prophylaxis should be applied before and during surgery only.
  • Orthopaedic surgery patients with known nasal colonization of Staphylococcus aureus should receive perioperative intranasal applications of mupirocin 2 percent ointment with or without a combination of chlorhexidine gluconate body wash.
  • Surgical patients should not be shaved (with hair removal, if necessary, performed by clipper only).
  • Patients should bathe or shower prior to surgery with either plain or antimicrobial soap.

WHO states that the recommendations are designed to complement the organization's existing Surgical Safety Checklist.

Hospital infections—Experience at two hospitals indicates that the use of copper in surface materials subject to touch as well as in linens and garments may provide natural protection against infectious microbes, the American Journal of Infection Control (Dec. 1) reports. Copper, long viewed as having sterilizing properties, has been shown in studies to destroy or deactivate pathogens such as MRSA and norovirus. At Grinnell Regional Medical Center in Iowa, after "high touch" surfaces such as bed rails, toilet levers, light switches, and IV poles were fitted in copper alloy in half of 18 patient rooms, 88 percent of rooms with copper fixtures had bacterial samples below recommended concentration levels, while 55 percent of the non-copperized rooms exceeded the threshold. Sentara Leigh Hospital in Virginia saw a 78 percent reduction in Clostridium difficile–related infections in a new wing in which copper-impregnated composite was used for hard surfaces and patients received copper-laced linens and gowns. At Grinnell, the average cost of outfitting a room in copper was $5,500.

Osteoarthritis—Preliminary study data presented at the ACR/ARHP annual meeting suggest a potential positive treatment effect for the novel Wnt inhibitor SM04690 for osteoarthritis (OA) patients. The research team conducted a first-in-human, multicenter, single-dose-escalation, randomized controlled trial of SM04690 in patients with moderate to severe OA. Escalation cohorts were dosed at 0.03 mg, 0.07 mg, and 0.23 mg SM04690 per 2 mL injection, in cohorts of 20 patients, with 4 patients in each cohort randomized to placebo. Compared to placebo, the research team found statistically more Outcome Measures in Rheumatology-Osteoarthritis Research Society International strict responders in the 0.07 mg cohort at week 12, and numerically more in the 0.03 mg cohort at week 24. In addition, at weeks 12 and 24, more patients in the 0.07 mg cohort met both pain and function criteria than those receiving placebo.

Hormone therapy—According to a study conducted in Switzerland and published in The Journal of Clinical Endocrinology & Metabolism (online), menopausal hormone therapy (MHT) may be associated with preservation of bone microarchitecture in older women. The authors conducted a cross-sectional study of 1,279 women aged 50 to 80 years who were categorized according to MHT status (current, past, and never users). They found that patients in the current user cohort displayed higher trabecular bone score (TBS) values and bone mineral density (BMD) values compared to those in the past user or never user cohorts. In addition, compared with never users, past MHT users exhibited higher lumbar spine and total hip BMD and a trend for higher TBS. The authors state that the 10-year loss of TBS and BMD at lumbar spine and total hip was significantly lower for both current and past users compared to never users. They note that MHT duration had no effect on bone parameters.