Published 6/1/2017

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
Codeine and tramadol warning—
The U.S. Food and Drug Administration (FDA) has issued a safety communication restricting the use of codeine and tramadol in children. The agency states that such drugs carry serious risks, including slowed or difficult breathing and death, and appear to be a greater risk in children younger than 12 years. FDA states that tramadol and codeine should not be used in children younger than 12 years, and should be limited in some older children. The agency is adding a contraindication (its strongest warning) to the drug labels of codeine and tramadol, saying that codeine should not be used to treat pain or cough and tramadol should not be used to treat pain in children younger than 12 years.  FDA also is adding the following:

  • A new contraindication to the tramadol label warning against its use in children younger than 18 years to treat pain after surgery to remove the tonsils and/or adenoids.
  • A new warning to the drug labels of codeine and tramadol to recommend against their use in adolescents between 12 and 18 years who are obese or have other conditions that may increase the risk of serious breathing problems.
  • A strengthened warning to mothers that breastfeeding is not recommended when taking codeine or tramadol medicines, due to the risk of serious adverse reactions in breastfed infants.

Advanced imaging—Findings published in Health Affairs (April) suggest an overall reduction in the use of advanced imaging since 2008̶–2009. The research team drew data from Medicare Part B databases, and calculated utilization rates per 1,000 enrollees for all advanced imaging modalities, as well as professional component relative value unit (RVU) rates per 1,000 beneficiaries for all imaging modalities. They found that utilization rates and RVU rates grew substantially until 2008 and 2009, respectively, and then began to decrease, followed by a downward trend through 2014.

Opioid use disorder—A study in the Journal of Addiction Medicine (online) suggests that patients with opioid use disorder (OUD) may be at increased risk of morbidity and mortality. The researchers reviewed mortality data on 2,576 OUD patients treated at a single system. They found 465 confirmed deaths (18.1 percent), corresponding to a crude mortality rate of 48.6 per 1000 person-years and standardized mortality ratio of 10.3. Leading causes of mortality included drug overdose and disorder (19.8 percent), cardiovascular diseases (17.4 percent), cancer (16.8 percent), and infectious diseases (13.5 percent).

Persistent opioid use—Findings presented in JAMA Surgery (online) suggest that new persistent opioid use following surgery is more likely to be associated with behavioral and pain disorders than with type of surgical procedure. The researchers reviewed information on 36,177 adult patients from a nationwide insurance claims database and found that 29,068 (80.3 percent) underwent minor surgical procedures and 7,109 (19.7 percent) underwent major procedures. They noted that rates of new persistent opioid use were similar across cohorts, and ranged from 5.9 percent to 6.5 percent. Incidence of new persistent opioid use in a nonoperative control cohort was 0.4 percent. The researchers found that an increased likelihood of new persistent opioid use was associated with preoperative tobacco use, alcohol and substance abuse disorders, mood disorders, anxiety, and preoperative pain disorders.

Vancomycin prophylaxis—Data from a study in Clinical Orthopaedics and Related Research (CORR; online) suggest that many patients may not be adequately dosed with vancomycin prophylaxis prior to total joint arthroplasty (TJA). The research team notes that patients are often given a fixed 1-gram dose instead of the recommended dosing of 15 mg/kg. The authors conducted a retrospective study of 7,638 primary TJA patients at a single center, 1,828 of whom received vancomycin prophylaxis and 5,810 of whom received cefazolin monotherapy. They found that 2 percent (n = 32) of patients receiving vancomycin experienced periprosthetic joint infection (PJI), compared to 1 percent (n = 62) of cefazolin patients. Overall, 94 percent (1,726 of 1,828) of patients received a fixed 1-gram dose of vancomycin, of whom 64 percent (1,105 of 1,726) were considered underdosed. No patients with adequate dosing or overdosing of vancomycin developed PJI with methicillin-resistant Staphylococcus aureus.

Pulmonary complication—Findings from a study in the Journal of the American College of Surgeons (online) suggest that high obesity may be linked to increased risk of pulmonary complication following outpatient surgery. The researchers analyzed 444,532 outpatient surgery cases from the 2012–2013 National Surgical Quality Improvement Program database. They found 996 all-cause pulmonary complications (defined as pneumonia, pulmonary embolism, unplanned intubation, or ventilator-assisted respiration for greater than 48 hours within 30 days of surgery). Binary logistic regression identified body mass index (BMI) as an independent predictor of a pulmonary complication, with increasing risks associated with higher BMI. However, the researchers note that obesity-associated risk "was low compared with the risk associated with advanced age, prolonged surgical duration as well as the risk of comorbidities including congestive heart failure, chronic obstructive pulmonary disease, and renal failure."

OCD—According to a study in The American Journal of Sports Medicine (AJSM; online), patients with osteochondritis dissecans (OCD) who are treated with fragment excision may be at greater risk of osteoarthritis (OA) and arthroplasty than those treated with fragment preservation or chondral defect grafting. The researchers conducted a cohort study of 221 OCD patients with mean 16.3-year follow-up. Overall, 134 patients were treated with fragment excision, 78 with fragment preservation, and nine with chondral defect grafting. The researchers found that the cumulative incidence of OA in the fragment excision group was 12 percent at 5 years, 17 percent at 10 years, 26 percent at 15 years, 39 percent at 20 years, and 70 percent at 30 years. In comparison, the cumulative incidence of OA in the fragment preservation group was 3 percent at 5 years, 7 percent at 10 years, 16 percent at 15 years, 25 percent at 20 years, and 51 percent at 30 years. In addition, patients in the fragment excision cohort were significantly more likely to undergo arthroplasty compared to those in the fragment preservation cohort. No patients in the chondral defect grafting group had developed OA or undergone arthroplasty at most recent follow-up.

Posttraumatic OA—A study in Nature Medicine (online) suggests that local clearance of senescent cells may reduce the development of posttraumatic OA. The authors conducted a mouse study and found that senescent cells accumulated in the articular cartilage and synovium after anterior cruciate ligament transection, and selective elimination of senescent cells attenuated the development of posttraumatic OA, reduced pain, and increased cartilage development. Further, intra-articular injection of a senolytic molecule that selectively killed senescent cells validated the results in transgenic, nontransgenic, and aged mice.

Postmenopausal women—Findings in The Journal of Clinical Endocrinology and Metabolism (online) examines the use of menopausal hormone therapy (HT) and genetic links to fracture risk in postmenopausal women. The research team reviewed data on 9,922 genotyped white postmenopausal women, aged 50 to 79 years, who participated in the Women's Health Initiative HT randomized trials. The investigators developed two weighted genetic risk scores (GRSs): one based on 16 fracture-associated variants and another based on 50 bone mineral density (BMD) variants. The researchers note that both GRSs were associated with increased fracture risk. They also observed a significant additive interaction, in which the highest quartile of both GRSs and randomization to placebo were associated with excess fracture risk. "These results suggest that HT reduces fracture risk in postmenopausal women," they write, "especially in those at highest genetic risk of fracture and low BMD."

Hip and knee
Mortality after arthroplasty—A study conducted in the United Kingdom and published in The Journal of Bone & Joint Surgery (JBJS; April 5) examines factors linked to mortality after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) for OA. The researchers reviewed registry data on 332,734 THA patients and 384,291 TKA patients. Overall, they found that the main causes of death were malignant neoplasms, followed by circulatory system disorders, respiratory system disorders, and digestive system diseases. During the first 90 days after surgery, they found that the primary cause of death was ischemic heart disease. They also noted an elevated risk of death from circulatory, respiratory, and digestive system-related causes within 90 days postoperatively, compared with 91 days to 1 year postoperatively.

Two-stage THA revision—Data from a study published in CORR (online) suggest that single-stage acetabular revision may be an effective technique for selected patients who undergo two-stage THA revision for infection. The researchers conducted a therapeutic study of 35 patients who underwent surgical treatment for an infected THA using a single-stage acetabular revision as part of a two-stage THA exchange if the acetabular defect classification was Paprosky Types 2B, 2C, 3A, 3B, or pelvic discontinuity and a two-stage procedure was preferred for the femur. At minimum 2-year follow-up (mean 42 months), they found that 34 of 35 patients appeared to be free of infection. The researchers state that the mean Harris Hip Score was 61 ± 13 points after the first operation and 82 ± 16 points 2 years after the second operation.

MOM hip resurfacing—According to a study in JBJS (April 19), female patients may experience more pain and metal sensitization than male patients after primary metal-on-metal (MOM) hip resurfacing arthroplasty. The research team reviewed data on 1,038 male and 1,575 female patients with idiopathic joint pain following total joint arthroplasty who were referred for in vitro metal-sensitivity testing. They found that the median lymphocyte stimulation index (SI) among males was 2.8 (mean 5.4) compared with median 3.5 (mean 8.2) among females. In addition, 49 percent of females had an SI of ≥ 4 (reactive) compared with 38 percent of males, and the implant-related level of pain was also significantly higher among females compared with males.

ACL reconstruction—Findings from a study in CORR (online) suggest that bone shape features in the tibia and femur may be associated with abnormal knee kinematics after anterior cruciate ligament (ACL) injury and reconstruction. The research team conducted a prospective study of 38 patients who were followed after acute ACL injury and prior to ligamentous reconstruction. Based on magnetic resonance imaging, they found that 2 of 20 specific femur bone shape features and 2 of 20 specific tibial bone shape features were associated with an increasingly anterior side-to-side difference (SSD) in the tibial position for the patients with ACL injury before surgical treatment. At 1 year after surgical treatment, the research team found that 2 of 20 femoral shape features were associated with SSD in the tibial position in extension, 1 of 20 femoral shape features was associated with SSD in the tibial position in flexion, and 3 of 20 tibial shape features were associated with SSD in the tibial position in flexion.

Meniscal lesions—According to a study in AJSM (online), there may be little longer-term benefit for knee arthroscopy performed in middle-aged patients with knee pain and meniscal lesions. The researchers conducted a randomized, controlled trial of 150 patients aged 45 to 64 years who were treated with either a 3-month exercise program or a 3-month exercise program plus one knee arthroscopic surgery within 4 weeks. At 3-year follow-up, both intention-to-treat and as-treated analyses revealed no significant difference across cohorts in change from baseline for the Knee Injury and Osteoarthritis Outcome Score pain subscore. Overall, a "factorial analysis of the effect of the intervention and age, onset of pain, and mechanical symptoms indicated that older patients improved more, regardless of treatment, and surgery may be more beneficial for patients without mechanical symptoms (as-treated analysis)," the researchers write. They note that a previously published study of the same patient cohorts found a reduction in pain for knee arthroscopic surgery patients at 1 year.

Knee cartilage injury—Data from a study published in AJSM (online) suggest that osteochondral allograft (OCA) transplantation may be a successful treatment option for active patients who sustain a cartilage injury to their knee. The researchers reviewed information on 142 highly active patients (149 knees) who participated in sport or recreational activity prior to a cartilage injury and underwent OCA transplantation. At mean 6-year follow-up, they found that 75.2 percent of knees had returned to sport or recreational activity. Based on a survey of patients who did not return to sport, knee-related issues and lifestyle changes were cited as reasons. Overall, patients who did not return to sport were more likely to be female, have injured their knee in an activity other than sport, and have a larger graft size. The researchers note that after OCA transplantation, 25.5 percent of knees underwent further surgery, with 14 knees (9.4 percent of entire cohort) considered allograft failures. Among the patients (135 knees) in which the graft had remained in situ, 91 percent were satisfied with the results of the surgery.

Shoulder and elbow
Shoulder arthroplasty—
A study published in JBJS (April 5) compares the use of interscalene block and injectable liposomal bupivacaine in shoulder arthroplasty procedures. The authors conducted a randomized, controlled trial of 78 patients who received interscalene brachial plexus blockade treatment and 78 patients who received bupivacaine liposome injectable suspension treatment. During the first 24 hours after surgery, they found that the mean total postoperative opioid consumption was 14.8 ± 11.3 morphine equivalent units in the blockade group and 14.4 ± 16.8 morphine equivalent units in the suspension group. In addition, they found that the mean visual analog scale (VAS) pain score was significantly lower in the blockade group than in the suspension group at 0 hours and 8 hours postoperatively, but not at 16 hours postoperatively. At 24 hours, VAS pain scores were significantly higher in the blockade group than in the suspension group.

Ambulatory TSA—Data from a study in JBJS (April 19) suggest that ambulatory total shoulder arthroplasty (TSA) may be a viable and safe practice model for appropriate patients. The authors reviewed information from a national insurance database on 706 patients who underwent ambulatory TSA and 4,459 patients who underwent inpatient TSA. They found no significant difference across cohorts in complication rate or readmission rate. In addition, the authors found that patients in the ambulatory group had significantly lower costs compared with those in matched controls.

Rotator cuff repair—Findings published in Arthroscopy (online) suggest that concomitant biceps tenodesis may be associated with increased risk of reoperation for patients who undergo isolated rotator cuff repair (RCR). The authors reviewed data on 33,481 arthroscopic RCR patients from a national insurance database. They subdivided patients into three groups—group 1: RCR without biceps tenodesis (n = 27,178); group 2: RCR with concomitant arthroscopic biceps tenodesis (n = 4,810); and group 3: RCR with concomitant open biceps tenodesis (n = 1,493). Overall, 2,509 patients underwent reoperation for RCR or biceps tenodesis within 1 year following RCR. The authors found no significant difference in 30-day or 90-day reoperation rates across cohorts. However, compared with patients who did not have a tenodesis, they found significantly more patients who had a tenodesis required a reoperation by 6-month and 1-year follow-ups. They note that overall, urinary tract infections were more common in patients who did not have a tenodesis, while dislocation, nerve injury, and surgical site infection were more common in tenodesis patients.

Lumbar spinal surgery—
Data published in The Spine Journal (online) suggest that elderly patients who undergo lumbar spinal surgery may be at increased risk of complication and readmission. The researchers conducted a retrospective cohort study of 2,320 patients older than 80 years who underwent lumbar spine surgery. They found that 379 (16.34 percent) patients experienced at least one complication or death. Overall, 75 (3.23 percent) experienced a major complication, 338 (14.57 percent) experienced a minor complication, 86 (6.39 percent) patients were readmitted to the hospital within 30 days, and 10 (0.43 percent) deaths were recorded in the initial 30 days postoperatively. The researchers noted that increased surgical times, and instrumentation and/or fusion procedures were associated with increased risk of complication. In addition, they found that patients considered underweight (body mass index < 18.5) or who were functionally debilitated at time of admission were at increased risk of readmission.