Published 7/1/2018

Second Look - Clinical News and Views

Patient safety

Denosumab—A study in The Lancet—Diabetes & Endocrinology (online) suggests that denosumab may help reduce risk of fracture for certain patients who have been prescribed glucocorticoids. Members of the research team conducted an international, double-blind, active-controlled, double-dummy, noninferiority study of 795 adult patients, 505 of whom were glucocorticoid continuing and 290 of whom were glucocorticoid initiating; participants were randomly assigned to receive either denosumab (n = 398) or risedronate (n = 397). At 12 months, the researchers found that denosumab was both noninferior and superior to risedronate for effect on bone mineral density (BMD) at the lumbar spine in both the glucocorticoid-continuing and glucocorticoid-initiating cohorts. Overall incidence of adverse events (AEs), serious AEs, and fractures was similar between treatment groups.

Revised “hour-1 bundle”—The Surviving Sepsis Campaign has released a revised “hour-1 bundle,” highlighting the following five steps that healthcare professionals should take as soon as sepsis is recognized:

  1. Measure lactate level. Remeasure if initial lactate is
    > 2 mmol/L.
  2. Obtain blood cultures prior to administration of antibiotics.
  3. Administer broad-spectrum antibiotics.
  4. Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L.
  5. Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain (mean arterial pressure) ≥ 65 mmHg.

VTE—The addition of unfractionated heparin (UH) to aspirin did not decrease the incidence of venous thromboembolism (VTE) following total joint arthroplasty compared to aspirin alone, according to a study published in Orthopedics (online). Researchers retrospectively reviewed data from a single hospital system and identified 5,350 patients: 1,024 received aspirin only, 1,695 received aspirin plus one UH dose, and 2,631 received aspirin plus multiple UH doses. Rates of deep vein thrombosis and pulmonary embolism did not significantly vary; however, transfusion rates were significantly greater with one and multiple UH doses compared to aspirin alone.

Alendronate—The osteoporosis drug alendronate may reduce the risk of cardiovascular death, heart attack, and stroke, according to a study published in the Journal of Bone and Mineral Research (online). For this retrospective, cohort study, researchers used a population-wide database managed by the Hong Kong Hospital Authority to identify 4,594 patients with newly diagnosed hip fracture who received an anti-osteoporosis medication between 2005 and 2013, along with a matched control cohort of 13,568 patients. They found that patients who received alendronate had significantly lower risk of one-year cardiovascular mortality and incident myocardial infarction. The drug was also associated with a marginally significant reduction in the risk of stroke at five and 10 years. The strength of the association declined over time but remained significant, the researchers noted.

Surgical navigation—Data published in the Journal of Bone & Joint Surgery (JBJS; May 16) suggest that use of a cone-beam computed tomography (CT)–guided navigation system designed for osteotomies with joint-sparing bone cuts may be associated with better cut accuracy, regardless of surgeon experience. The authors compared 126 navigated cuts and 126 non-navigated cuts performed by 18 orthopaedic oncologists of varying experience levels. They found that, even in expert hands, navigated cuts were significantly more accurate than non-navigated cuts.

Bone health diet—Protein-rich diets—even those with protein levels above the current recommended dietary allowance—may help reduce bone loss and hip fracture risk, provided there is also adequate calcium intake, according to an expert consensus published in Osteoporosis International (online). Among other things, the researchers found that:

  • BMD may be positively associated with dietary intake.
  • Protein and calcium combined in dairy products have beneficial effects on calciotropic hormones, bone turnover markers, and BMD.
  • There appears to be no direct evidence of osteoporosis progression, fragility fractures, or altered bone strength with the acid load originating from a balanced diet.

The European Society for Clinical and Economical Aspects of Osteoporosis, Osteoarthritis, and Musculoskeletal Diseases and the International Osteoporosis Foundation both endorse this expert consensus.

Hip and knee

Knee osteoarthritis conservative treatment—According to a study in the Journal of the AAOS (JAAOS; May 1), naproxen coupled with intra-articular (IA) corticosteroids may be an effective treatment for patients treated conservatively for knee osteoarthritis (OA). The authors conducted a network meta-analysis of 53 randomized, controlled trials that included a minimum of 30 patients in each study group. For pain, they found that all active treatments were more effective than oral placebo, with IA corticosteroids having the largest magnitude of effect and significant difference over IA placebo. For function, the authors noted that no IA treatments showed significant effects compared to either placebo, and naproxen was the only treatment that displayed clinical significance compared to oral placebo. They wrote that cumulative probabilities showed naproxen to be the most effective individual treatment, and when combined with IA corticosteroids, it was the most likely to improve pain and function.

Cementless femoral stem fixation—Data from a study conducted in Australia and published in Clinical Orthopaedics and Related Research (online) suggest that cementless femoral stem fixation may be associated with a higher early rate of revision compared to cemented fixation in patients aged 75 years or older. The authors reviewed data from the Australian Orthopaedic Association National Joint Replacement Registry to identify the three cemented and cementless femoral stems with the lowest 10-year revision rates. They found that early revision was 9.14 times more common among the three cementless stems compared to the three cemented stems. Three months postoperatively, they found no significant difference in revision rates between cohorts.


Cephalomedullary fixation—According to findings published in the Journal of Orthopaedic Trauma (online), use of a helical blade may be linked to increased risk of failure compared to screw fixation for the treatment of hip fracture with cephalomedullary nail fixation. The researchers retrospectively reviewed data on 126 patients treated with cephalomedullary fixation for low-energy hip fracture at a single center. They found that seven failures of fixation (5.6 percent) occurred, all after use of a helical blade. Overall, five failures resulted from medial migration of the helical blade through the femoral head, whereas two resulted from typical superolateral cutout and varus collapse.

Acetabular fracture—A study conducted in the Netherlands and published in the Bone & Joint Journal (online) looked at outcome trends following surgical repair of acetabular fracture.

The researchers reviewed data on 220 patients who underwent surgery for an acetabular fracture at a single center. At mean six-year follow-up, they found that 55 (25 percent) had developed post-traumatic OA and 33 (15 percent) had undergone THA at a mean 2.75 years. Based on 164 patients who completed both the 36-Item Short Form Health Survey and the modified Harris Hip Score questionnaires, the researchers stated that patients who underwent THA had worse functional outcomes compared to those who retained their native hip joint.