AAOS Now

Published 1/1/2018

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).

Fracture
Hip fracture surgery—According to a study in The Journal of the American Medical Association (JAMA; Nov. 28), increased wait time prior to hip fracture surgery may be associated with increased risk of mortality and complication for older patients. The researchers reviewed data on 42,230 hip fracture patients with a mean age of 80.1 years and found that overall risk of complication increased when wait times were longer than 24 hours. Comparing a subset of 13,731 patients who received surgery within 24 hours against a matched cohort of 13,731 patients who received surgery after 24 hours, they found that patients who waited longer were at significantly increased risk of 30-day mortality and complication risk.

Nail and locking plate fixation—A study published in JAMA (Nov. 14) suggests similar outcomes for nail fixation or locking plate fixation of acute, displaced, extra-articular fracture of the distal tibia in adult patients. The authors conducted a multicenter, randomized trial of 258 patients aged 16 years or older who underwent fixation with either intramedullary nail or locking plate. They found a statistically significant difference in favor of nail fixation based on Disability Rating Index at 3-month follow-up, but no such difference at 6 or 12 months. The authors also found no statistically significant differences in complications across cohorts, including number of postoperative infections. However, they note that further surgery was more common in the plate group at 12-month follow-up.

Fracture fixation delay—Data in the Journal of Orthopaedic Trauma (JOT; December) suggest that definitive fracture fixation may safely be performed in the presence of an open abdomen. Members of the research team conducted a retrospective, observational, cohort study of 81 adult polytrauma patients with an open abdomen after “damage control” laparotomy and associated major fractures that required surgical repair. Overall, 32 patients received fracture fixation concurrent with an open abdomen, while 49 underwent abdominal wall closure prior to fracture fixation. The researchers found that incidence of surgical site infection was 3.1 percent among concurrent fixation patients and 30.6 percent among later fixation patients.

Negative pressure wound therapy—Findings published in JOT (December) suggest that antibiotic delivery to a wound via chitosan sponge may be more effective than polymethylmethacrylate (PMMA) beads for patients treated with negative pressure wound therapy (NPWT). The authors conducted a prospective study of contaminated musculoskeletal wounds in goats that were treated with either PMMA bead pouch, PMMA bead pouch with NPWT, chitosan sponge, or chitosan sponge with NPWT. After treatment, they found significantly fewer bacteria in wounds treated with antibiotic chitosan sponge compared to antibiotic PMMA bead depot, and that NPWT was not associated with a reduction in effectiveness of the chitosan sponge.

Patient Safety
Cardiac complication—Findings in the Journal of the American Heart Association (online) suggest that use of a geriatric-sensitive risk index tool may help identify surgical patients aged 65 years or older who are at increased risk of cardiac complications from noncardiac surgery. The researchers developed a model using the National Surgical Quality Improvement Program (NSQIP) 2013 geriatric cohort, and validated it with the NSQIP 2012 geriatric cohort. They found that the newly developed Geriatric-Sensitive Cardiac Risk Index offered significant improvement in assessing cardiac risk in geriatric patients undergoing noncardiac surgery compared to the Revised Cardiac Risk Index and the Gupta Myocardial Infarction or Cardiac Arrest calculator.

Air pollution—Data published in The Lancet—Planetary Health (November) suggest that poor air quality may increase risk of bone fractures and osteoporosis. Members of the research team reviewed information on osteoporosis-related fracture hospital admissions among 9.2 million Medicare enrollees aged 65 years or older. They found that risk of bone fracture admissions at osteoporosis-related sites was greater in areas with higher concentrations of particulate matter in the atmosphere, particularly in low-income communities. In addition, the researchers found that black carbon concentration was associated with higher bone mineral density loss over time at multiple anatomical sites, including femoral neck and ultradistal radius.

Concussion—According to a study in the Journal of the AAOS (December), female athletes may be more likely than male athletes to experience concussion. The authors conducted a retrospective cohort study of 1,200 university varsity athletes (822 male, 378 female) who were at risk of sports-related concussion. Overall, 228 athletes experienced at least one concussion. The authors found that risk factors for collegiate concussion included female sex and precollegiate concussion, while prolonged recovery was predicted by the presence of eight or more post-concussion symptoms for all athletes and for female athletes only; this finding was not statistically significant for male athletes.

Hip and knee
I&D with component retention—Findings in The Journal of Arthroplasty (online) suggest high failure rates for patients with periprosthetic joint infection who undergo irrigation and débridement (I&D) with component retention after total knee arthroplasty (TKA). The researchers conducted a multicenter, observational study of 216 cases of I&D with retention of components performed on 206 patients. They found that the estimated failure rate was 57.4 percent at 4 years, with a median survival time of 14.32 months, and a 5-year mortality rate of 19.9 percent. The researchers write that the data suggest that I&D may have a limited ability to control infection in TKA and recommend that it be used selectively under optimum conditions.

Arthrodesis or amputation—A study published in Clinical Orthopaedics and Related Research (December) looks at trends associated with TKA failure. The researchers reviewed information on 44,466 patients aged 65 years or older from the Medicare 100% National Inpatient Claims Database, all of whom were diagnosed with infected TKA and underwent revision. The researchers identified 1,182 knee arthrodeses and 1,864 above-knee amputations (AKAs) among the study population. They note that clinical factors associated with arthrodesis included acute renal failure, obesity, and having additional infection-related revisions; while higher Charlson comorbidity score, obesity, deep vein thrombosis, and additional revisions were factors associated with increased likelihood of AKA. The researchers found that increased risk of mortality was linked with amputation but not arthrodesis.

FAI—A study in The American Journal of Sports Medicine (online) examines factors linked to acceptable outcomes following hip arthroscopy for femoroacetabular impingement (FAI). The authors conducted a case-control study of 386 patients who underwent primary hip arthroscopic surgery with routine capsular closure for FAI and who had failed nonsurgical management. At minimum 2-year follow-up, they found that younger age, Tönnis grade 0, and lower preoperative Hip Outcome Score (HOS)–Activities of Daily Living (ADL) score were linked with achieving minimal clinically important difference (MCID) for HOS-ADL, while younger age, larger medial joint space width, and higher preoperative HOS-ADL score were linked with achieving the patient acceptable symptom state (PASS) for the HOS-ADL. Younger age, lower body mass index, non–workers’ compensation status, and lower preoperative HOS—Sport-Specific Subscale (SSS) score were associated with MCID for the HOS-SSS, and younger age, Tönnis grade 0, running, and higher preoperative HOS-SSS score were associated with PASS for the HOS-SSS.

Shoulder
Arthroscopic subacromial decompression—Findings from a study conducted in the United Kingdom and published in The Lancet (online) suggest little difference in outcomes for patients with subacromial shoulder pain treated with various options. The authors conducted a multicenter, randomized, pragmatic, parallel group, placebo-controlled trial of 274 patients treated with arthroscopic subacromial decompression (n = 90), investigational arthroscopy only (n = 94), or no intervention (n = 90). At 6-month follow-up, they found no significant difference in mean Oxford Shoulder Score across cohorts. The authors note that both surgical groups displayed a small benefit over no treatment, but write that the differences were not clinically important. Two patients in each cohort experienced frozen shoulders.

Spine
TTIF—A study conducted in China and published in Spine (online) suggests that administration of tranexamic acid (TXA) may help reduce blood loss without affecting prethrombosis-state molecular markers for patients undergoing transforaminal thoracic interbody fusion (TTIF) surgery. Members of the research team conducted a randomized, double-blind, placebo-controlled trial of 80 patients with thoracolumbar fracture-dislocation who underwent TTIF, and who received pre- and intraoperative TXA (n = 39) or placebo (n = 41). They found that, compared to placebo, TXA administration was linked to reduced visible and hidden blood loss and true total blood loss during surgery. In addition, the researchers found no significant difference across cohorts in prevalence of deep venous thrombosis or pulmonary embolus.