Published 6/1/2019

Second Look – Clinical

Hip and knee

After-hours calls in a joint replacement practice—A study published in The Journal of Arthroplasty (online) evaluated the effectiveness of an after-hours phone number for total joint replacement patients to contact a surgical team member after discharge. Researchers collected data on phone calls from July 3, 2017, through Oct. 3, 2017, that took place after 4 p.m., during weekends, and on holidays. They documented the duration, chief complaint, and resolution of all phone calls. The phone number provided access to a surgeon or midlevel provider on the Hip and Knee Reconstruction Service. During the study period, 325 cases were performed, and a total of 68 phone calls were placed by 55 patients; 26 went to surgeons, and 42 went to midlevel providers. Calls lasted an average of 3.9 minutes and were made an average of 17.5 days after surgery. Poor health literacy was correlated with increased calls during the first postoperative week; there was an association between pain as the chief complaint and primary versus revision surgery. The researchers concluded that an after-hours call option may provide reassurance for some patients.

Objective and subjective recovery from hip fracture—According to a prospective, observational secondary analysis published in Osteoporosis International (online), functional recovery after hip fracture may take longer than subjective recovery. A total of 173 hip fracture patients aged ≥ 65 years (mean age, 84 years; 79.2 percent female) were included in the study; most (77.4 percent) were community-dwelling. Lower extremity function (Timed Up and Go [TUG] test, knee extensor and flexor strength) and grip strength were assessed at baseline and again at six and 12 months. The 36-Item Short Form Health Survey was administered at three- and nine-month follow-up. TUG, knee extensor, and knee flexor strength all significantly improved within six months, but there was no further significant improvement between six and 12 months. From baseline to six months and six to 12 months, grip strength decreased. From three to nine months, subjective physical functioning showed improvement but not after that timeframe.

Pre- and postoperative activity in THA patients—A study published in The Bone & Joint Journal (online) analyzed 24-hour activity profiles in total hip arthroplasty (THA) patients to determine whether they were associated with postoperative outcomes. The study included 51 THA patients (mean age, 64 years) from a single hospital who underwent the same surgical approach with the same prosthesis type. Patients wore wrist accelerometers that captured activity profiles 24 hours preoperatively and at two, six, 12, and 26 weeks postoperatively. Patients spent a mean 19.5 hours a day sedentary or asleep preoperatively; 24-hour activity patterns did not change largely postoperatively. During awake hours, sedentary activities comprised a mean 620 minutes a day preoperatively and 641 minutes a day six months postoperatively. Light-, moderate-, and vigorous-intensity activities did not significantly improve. Sleep efficiency remained poor throughout the study period.

Hand and shoulder

Predictors in rotator cuff tears—In a study published in BMC Musculoskeletal Disorders (online), researchers identified preoperative factors associated with the repairability of large-sized and massive rotator cuff tears. The study included 66 patients (11 large-sized tears and 55 massive tears), of whom 54 underwent complete repair and 12 underwent partial repair. The following factors were associated with repairability: age, mediolateral and anteroposterior tear size, rotator cuff arthropathy, superior migration of humeral head, fatty infiltration and atrophy of the supraspinatus muscle, and fatty infiltration of infraspinatus muscle. The receiver operating characteristic (ROC) curve determined the following cutoff levels for each predictor: age ≥ 65 years, mediolateral tear size ≥ 36 mm, anteroposterior tear size ≥ 22 mm, Hamada’s rotator cuff arthropathy ≥ grade 2, acromiohumeral interval ≥ 6 mm, supraspinatus fatty infiltration ≥ stage 3, the presence of supraspinatus muscle atrophy, and infraspinatus fatty infiltration ≥ stage 1.

Foot and ankle

Outcomes for synthetic cartilage implant hemiarthroplasty—A study published in Foot & Ankle International (April) found positive midterm outcomes for synthetic cartilage implant hemiarthroplasty. The study followed an original randomized, controlled trial. Of 135 eligible original trial patients, 112 were evaluated in the present study. Two years following surgery, 9.2 percent of patients underwent implant removal and conversion to arthrodesis. Between two and five years, the rate of patients undergoing implant removal and conversion to arthrodesis was 7.6 percent. In patients who did not require revision, patient-reported outcomes after two years were maintained at a mean 5.8 years. Most patients (93.4 percent) said they would undergo the procedure again.

Practice management

Medicare Hospital Readmissions Reduction Program—In a cross-sectional study published in JAMA Internal Medicine (online), researchers associated hospital stratification under Medicare’s Hospital Readmissions Reduction Program with a significant change in excess readmissions penalties. A total of 3,049 hospitals were included in the study. Teaching hospitals and large hospitals were more likely to have reduced penalties. Compared to for-profit hospitals, not-for-profit hospitals had lower odds of reduced penalties. Northeast hospitals were more likely than those in the Midwest and South to have a penalty reduction. Hospitals with patients from the most disadvantaged neighborhoods, with a high incidence of disabilities, and with the highest Medicaid eligibility cutoffs were significantly more likely to have reduced penalties.


Fracture risk in diabetes patients—In a cross-sectional study published in Bone (May), researchers developed a tool that could estimate vertebral fracture risk in patients with type 2 diabetes. A total of 808 patients were included in the study. Researchers used logistic regression analysis to identify variables associated with vertebral fracture; the variables were stratified by cutoff values calculated with ROC curves. Each factor was given a relative weight and assigned a tentative score; the score’s cutoff point was used to predict vertebral fracture. After logistic regression analysis, the following factors were associated with vertebral fracture risk: age, diabetes duration, body mass index, serum albumin, and T score at femoral neck.

Treatment considerations

NSAIDs and bone healing—Nonsteroidal anti-inflammatory drugs (NSAIDs) may have a negative impact on bone healing, according to a meta-analysis published in JAAOS (April 1). Researchers conducted a literature review of studies reporting the effect of NSAIDs on bone healing in pediatric and adult patients. Primary outcomes included delayed union, nonunion, or pseudarthrosis with at least six months of follow-up. NSAID exposure significantly increased the risk for delayed union or nonunion in adult patients but did not impact pediatric patients. Low dose and short duration of exposure also did not affect nonunion or delayed union risk.

Outcomes for anesthesia methods—In a study published in BMC Anesthesiology (online), varying anesthesia methods used in orthopaedic surgeries were associated with different outcomes. PubMed, Embase, and the Cochrane Library were queried for relevant studies through March 10, 2018. Final analysis included 23 studies involving a total 2,393 patients. Nerve block analgesia was associated with reduced postoperative nausea or vomiting and urine retention compared to epidural anesthesia. Both interscalene block and local infiltration anesthesia significantly reduced back pain compared to epidural anesthesia.


Obesity in pediatric limb fracture patients—In a study published in The Bone & Joint Journal (April), obese pediatric limb fracture patients were more likely to undergo open reduction and internal fixation (ORIF) and have inpatient complications. Researchers queried the Kids’ Inpatient Database on children up to 17 years old who underwent open and closed treatment of humeral, radial and ulna, femoral, tibial, and ankle fractures. ORIF rates were significantly higher among obese patients with distal humeral, distal radius and ulna, distal femoral, tibial and fibula shaft, and ankle fractures. ORIF for upper and lower limb fractures among obese patients was correlated with significantly increased lengths of stay, hospital charges, and complications.


Quality of life in pelvic ring fracture patients—Five- and 10-year health-related quality of life outcomes were positive for pelvic ring fracture patients in a study published in Injury (online). Pelvic ring fracture patients admitted to two centers in the Netherlands between 2006 and 2011 were asked to complete the Majeed Pelvic Score (MPS), EuroQol-5D (EQ-5D), and Short Musculoskeletal Function Assessment (SMFA) questionnaires. A total of 136 patients returned the questionnaires, and median follow-up was 8.7 years. The mean MPS score was 85.1; mean EQ-5D VAS score was 74; mean EQ-5D index scores were 0.87, 0.81, and 0.82 in tile B, A, and C patients, respectively; and mean SMFA index was 24.