Published 7/1/2017

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)

Patient safety
Biologics in young athletes—
A study in Current Sports Medicine Reports (May/June) suggests that physicians, parents, and coaches should exercise caution when considering the use of platelet-rich plasma (PRP) or stem cells to treat injuries in young athletes. According to the study’s authors, little is known about the safety or effectiveness of regenerative treatments for musculoskeletal injuries in children and adolescents. The collaborative study, which involved sport medicine clinicians, researchers, and a bioethicist, included the following seven-point call to action:

  1. Exercise caution in treating youth with cell-based therapies as research continues.
  2. Improve regulatory oversight of these emerging therapies.
  3. Expand governmental and private research funding.
  4. Create a system of patient registries to gather treatment and outcomes data.
  5. Develop a multiyear policy and outreach agenda to increase public awareness.
  6. Build a multidisciplinary consortium to gather data and promote systematic regulation.
  7. Develop and pursue a clear collective impact agenda to address the "hype" surrounding regenerative medicine.

Pain management—Data on the effect of opioid prescribing by quantity on the pain management scores for patients following discharge from surgery suggest no significant difference between scores in patients stratified in the first quintile for opioid prescribing and those in the fifth quintile. The study, reported in The Journal of the American Medical Association (JAMA; May 16), tabulated the mean quantity of opioids (by oral morphine equivalents) prescribed for 31,481 patients in 47 Michigan hospitals who underwent orthopaedic, general, gynecologic, cancer, cardiac, and vascular surgery. The authors concluded that the results show that in these patients, postoperative opioid prescribing was not correlated with pain measures within the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a scoring survey used to determine hospital payments. The authors note that concern has been raised that HCAHPS could incentivize overprescribing of opioids and that the U.S. Centers for Medicare & Medicaid Services plans to remove pain management from payment criteria, "even though little is known regarding the possible correlation between HCAHPS scores and postdischarge prescribing."

SSI risk—A study published in Infection Control & Hospital Epidemiology (online) finds that the risk of surgical site infection (SSI) developing in patients increases in warmer weather, The New York Times reports. The retrospective cohort analysis involved more than 55 million hospitalizations with a primary diagnosis of SSI between 1998 and 2011. Data from the National Climatic Data Center was used to estimate the monthly average temperatures for all of the more than 2,500 hospital locations. The researchers found that the highest incidence of SSI was in August, with the lowest in January. After controlling for demographic and hospital-level characteristics, they also found that for every 5-degree Fahrenheit increase in average monthly temperature, the risk of hospital admission for an SSI increased by 2.1 percent.

SSI prevention guideline—The U.S. Centers for Disease Control and Prevention has released a guideline for the prevention of SSI. Among other things, the guideline notes that infection is the most common indication for revision in total knee arthroplasty and the third most common indication in total hip arthroplasty. The guideline includes a section on prosthetic joint arthroplasty, covering topics such as blood transfusions, systemic immunosuppressive therapy, intra-articular corticosteroid injections, anticoagulation, orthopaedic surgical space suits, postoperative antimicrobial prophylaxis, and biofilms.

Osteoporosis guideline—The American College of Physicians (ACP) has issued a new guideline regarding treatment of osteoporosis to prevent fracture. Among other things, the guideline offers a strong recommendation that clinicians offer pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis, and a strong recommendation against the use of menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for treatment of osteoporosis in women.

H2-blockers and PPIs—
According to findings presented at the annual meeting of the Pediatric Academic Societies, infants who are prescribed H2-blockers or proton pump inhibitors (PPIs) may be at increased risk of bone fracture later in childhood. The researchers reviewed data on 874,447 healthy children born within the Military Health System and who received care within the system for at least 2 years. They noted that about 10 percent of the children were prescribed antacids in the first year of life, including H2-blockers and PPIs, with a small percentage prescribed both. The researchers found that infant PPI prescriptions were associated with a 22 percent increased likelihood of fracture, while children prescribed both PPIs and H2-blockers had a 31 percent increased likelihood of fracture. The researchers state that use of H2-blockers alone was not associated with an immediate increase in fractures, but was linked to an increased likelihood of fracture with time.

Tibial plateau fracture—Data published in the Journal of the AAOS (May) suggest that nonsurgical treatment may be appropriate for selected patients with minimally displaced tibial plateau fractures. The researchers conducted a retrospective, comparative study of 37 patients who were treated nonsurgically for tibial plateau fracture at a single institution. Indications for nonsurgical treatment were minimal fracture displacement or preclusion of surgery because of comorbidities. At mean 21-month follow-up, they found that 59 percent of patients (n = 22) attained good to excellent functional outcomes. However, surgery that was precluded by a factor other than minimal fracture displacement was a predictor of poor outcome.

POCUS—Findings published in Academic Emergency Medicine (online) suggest that point-of-care-ultrasound (POCUS) may offer accurate, timely, and low-pain assessment of distal forearm injuries in pediatric patients. The research team conducted a cross-sectional study of 169 children aged 4 to 17 years with a suspected nonangulated distal forearm fracture, who underwent both radiographic and POCUS assessment. Overall, 76 patients were diagnosed with fracture. The research team found that sensitivity of POCUS for distal forearm fractures was 94.7 percent and specificity was 93.5 percent. In addition, POCUS was associated with a significantly lower median pain score compared to radiography, and no significant difference in median caregiver satisfaction score. Investigators also found that, compared to radiographs, POCUS was associated with significantly lower median procedure duration.

CNFC—According to a study published in the Journal of Orthopaedic Trauma (June), use of continuous femoral nerve catheter (CNFC) for postoperative pain control may be associated with reduced opioid consumption for older patients with proximal femur fracture. The researchers conducted a retrospective, comparative study of 265 consecutive geriatric hip fracture patients who underwent surgical treatment, 149 of whom were treated with standard analgesia without nerve catheter and 116 of whom received an indwelling CFNC. They found that patients in the CFNC cohort reported lower average pain scores preoperatively, on postoperative day 1, and on postoperative day 2. In addition, the CFNC group consumed 39 percent less morphine equivalents on postoperative day 1 and 50 percent less morphine equivalents on postoperative day 2. Compared with patients undergoing standard analgesia, patients with CFNC had a lower rate of opioid-related side effects and were more likely to be discharged to home.

Concussion in sport—
The British Journal of Sports Medicine (online) has published a consensus statement from the 5th International Consensus Conference on Concussion in Sport. The statement is based on screening of approximately 60,000 published studies, and among other things, offers recommendations for sideline evaluation, noting that a key concept in sideline assessment is the rapid screening for a suspected sport-related concussion (SRC), rather than the definitive diagnosis of head injury. "It is important to note that SRC is an evolving injury in the acute phase," the authors write, "with rapidly changing clinical signs and symptoms, which may reflect the underlying physiological injury in the brain. SRC is considered to be among the most complex injuries in sports medicine to diagnose, assess, and manage. The majority of SRCs occur without loss of consciousness or frank neurological signs. At present, there is no perfect diagnostic test or marker that clinicians can rely on for an immediate diagnosis of SRC in the sporting environment."

Weight loss—
According to a study published in Radiology (online), patients with high body mass index (BMI) who lose weight may slow the progression of knee cartilage degeneration. The research team reviewed data from the Osteoarthritis Initiative on 640 overweight (BMI ≥ 25 kg/m2) and obese (BMI ≥ 30 kg/m2) participants, with risk factors for osteoarthritis (OA) or mild to moderate radiographic findings of OA. Patients were assessed via Whole-Organ Magnetic Resonance Imaging Score (WORMS) at baseline and 48 months, and categorized into three groups based on weight loss. Compared with patients in the stable weight cohort (n = 320), the research team found that the adjusted mean increase of cartilage WORMS was smaller in the 5 percent to 10 percent weight loss cohort (n = 238) and smallest in the > 10 percent weight loss cohort (n = 82).

Degenerative knee disease—An international panel has released a guideline on arthroscopic surgery for degenerative knee arthritis and meniscal tears. Among other things, the guideline, published as a "BMJ Rapid Recommendation," offers a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease.

Intra-articular triamcinolone—Findings published in JAMA (May 16) suggest that triamcinolone injection may be less effective than placebo for treatment of symptomatic knee osteoarthritis (OA). The authors conducted a randomized, placebo-controlled, double-blind trial of 119 patients with symptomatic knee OA with ultrasonic features of synovitis, who were treated with intra-articular triamcinolone or saline every 12 weeks for 2 years. At 2-year follow-up, they found no significant difference across cohorts in the Western Ontario and McMaster Universities Osteoarthritis index Likert pain subscale. However, the authors noted that intra-articular triamcinolone was associated with significantly greater cartilage volume loss compared to saline.

Preoperative opioids—A study in The Journal of Bone & Joint Surgery (JBJS; May 17) suggests that preoperative opioid use may be linked to a reduction in pain relief following total knee arthroplasty. The authors reviewed data from a prospective, cohort study of 156 patients with a mean age of 65.7 years and mean body mass index (BMI) of 31.1 kg/m2, 36 of whom (23 percent) had had at least one opioid prescription. They found that the mean baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score was 43.0 points for patients with no prior opioid use and 46.9 points for those who had used opioids. At 6-month follow-up, they found that the nonopioid cohort saw a reduction in WOMAC pain score of 33.6 points, compared to a reduction of 27.0 points in the opioid cohort.

Two-tunnel transtibial repair—Data from a study in The American Journal of Sports Medicine (AJSM; online) suggest that two-tunnel transtibial repair of radial meniscus tears may offer comparable results to inside-out repair of vertical meniscus tears. The research team conducted a cohort study of 27 patients who underwent two-tunnel transtibial pullout repair for radial meniscus tears and 33 patients who underwent inside-out repair for vertical meniscus tears. At 2-year follow-up, they found no significant differences across cohorts for any postoperative outcome scores (Lysholm score, Western Ontario and McMaster Universities Osteoarthritis Index, Short Form–12 physical component summary, Tegner activity scale, and patient satisfaction).

ACL reconstruction—A study published online in AJSM (online) examines return to play issues among National Football League (NFL) players who undergo anterior cruciate ligament (ACL) reconstruction. The authors compared information on 38 defensive players who underwent ACL reconstruction—28 of whom returned to play at least one NFL game—against a group of matched controls. They found that 23 players successfully returned to play at least half a season (eight games). However, returning athletes in the ACL reconstruction cohort retired significantly sooner and more often after surgery than their matched controls. In addition, in seasons leading up to their injury, athletes who successfully returned to play started a greater percentage of their games and made more solo tackles per game compared with athletes in the ACL reconstruction group who did not return to play and compared with healthy control players. After the season of surgery, athletes in the ACL reconstruction group who returned to play decreased their number of games started and number of solo tackles per game, while their matched controls experienced no significant decreases.

Osteonecrosis of the femoral head—
According to a study conducted in China and published in the journal Clinical Orthopaedics and Related Research (online), vascularized fibular grafting may be effective for management of osteonecrosis of the femoral head. The authors conducted a randomized, controlled trial of 21 patients (54 hips) who presented with Association Research Circulation Osseous (ARCO) stages I to IIIB bilateral osteonecrosis. All patients were treated bilaterally, with one side treated with core decompression and the contralateral side concurrently treated with fibular grafting. At 6-month and 36-month follow-up, the authors found that decompression-treated hips had lower vascularity than fibular-grafted hips based on single-photon emission computed tomography. In addition, they note that progression of ARCO staging was more severe in the decompression group than the fibular grafting group at 36 months. Further, mean Harris Hip Score was lower in the decompression group than in the fibular grafting group throughout the follow-up period, although the differences were at or below the minimal clinically important difference of 10 points early on. At 18-, 24-, 30-, and 36-month follow-up, the scores favored fibular grafting. The authors found no difference between decompression-treated hips and fibular-grafted hips regarding progression to total hip arthroplasty at 36 months.

Shoulder and elbow
Fatty muscle degeneration—
Findings published in JBJS (May 17) suggest that progression of fatty muscle degeneration may be more likely in rotator cuff tears that are larger at baseline, enlarge over time, and undergo a larger magnitude of enlargement. The research team conducted a prospective study of 156 shoulders with full-thickness rotator cuff tear, 70 of which had measurable fatty muscle degeneration of at least one rotator cuff muscle at some time point. They found that overall, patients with fatty muscle degeneration in the shoulder were older than those without degeneration, and the median size of the tears at baseline was larger in shoulders with degeneration than in shoulders that did not develop degeneration. In addition, tears with fatty muscle degeneration were more likely to have enlarged during follow-up compared to tears that never developed muscle degeneration. The median time from tear enlargement to progression of fatty muscle degeneration was 1 year for the supraspinatus and 1.1 years for the infraspinatus muscle.

AC joint dislocation—A study conducted in Canada and published in the Journal of Orthopaedic Trauma (online) suggests that hook plate fixation may not be superior to nonoperative treatment for acute, complete acromioclavicular (AC) joint dislocation. The authors conducted a randomized, controlled trial of 83 patients with acute, complete dislocation of the AC joint. Overall, 43 patients were treated nonoperatively and 40 were treated operatively. At 3-month follow-up, they found that patients in the nonoperative cohort had better physical health scores than the operative cohort based on the Short Form-36 (SF-36) version 2 survey. There were no significant differences between the physical health scores of the two groups at any other time point (6 weeks, 6 months, 1 year, and 2 years). Further, SF-36 mental health scores were similar between the nonoperative and operative groups at all follow-up intervals.

Hand and wrist
Dupuytren contracture—According to a study in The Journal of Hand Surgery (online) recurrent Dupuytren contracture in joints previously successfully treated with collagenase clostridium histolyticum (CCH) may be effectively retreated with up to three injections of CCH. The researchers analyzed prospectively collected data on 51 patients (51 joints) with contracture recurrence (increased ≥ 20° with a palpable cord) following successful treatment. Overall, 35 joints (69 percent) received one injection, 12 (24 percent) received two injections, and four (8 percent) received three injections. At 1-year follow-up, they found that 57 percent of joints achieved contracture of 5° or less and 86 percent of patients had a 20° or greater increase in range of motion. One ligament injury was reported.

Adult spinal deformity—
A study The Spine Journal (May) examines trends in spinal deformity surgery among older patients. The researchers reviewed information from the Nationwide Inpatient Sample database on an estimated 29,237 patients who underwent adult spinal deformity surgery between 2004 and 2011. They found that surgical incidence among patients aged 60 years and older increased during that period from 1.9 to 6.5 cases per 100,000 people, while utilization in patients younger than 60 increased from 0.59 to 0.93. Data suggest that the largest increase in surgical utilization was for patients aged 65–69 years, with an increase of 0.68 patients per 100,000 people per year, followed by patients aged 70–74 years, with a rate of 0.56 patients per 100,000 people per year. The researchers write that, although complication risk increased with age, within-age group rates remained stable over time. They note that inflation-adjusted mean hospital charges increased from $171,517 in 2004 to $303,479 in 2011.

Intraoperative methadone—According to a study published in Anesthesiology (May), administration of intraoperative methadone may help reduce postoperative opioid requirements, decrease pain scores, and improve patient satisfaction with pain management following spinal fusion surgery. The research team conducted a randomized, double-blind, controlled trial of 115 patients who received either methadone 0.2 mg/kg at the start of surgery or hydromorphone 2 mg at surgical closure. They found that median hydromorphone use was reduced in the methadone group on postoperative days 1, 2, and 3. In addition, pain scores at rest, with movement, and with coughing were lower in the methadone group at 21 of 27 assessments, and overall satisfaction with pain management was higher in the methadone group than in the hydromorphone group until the morning of postoperative day 3.