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March 14, 2014

American Academy of Orthopaedic Surgeons (AAOS) 2014 Annual Meeting Clinical News Highlights

March 11, 2014
 
Postoperative “Doctor Shopping” Linked to Higher Narcotic Use among Orthopaedic Patients
  • An estimated 20 percent of patients seek out additional providers for narcotic prescriptions
     

“Doctor shopping,” the growing practice of obtaining narcotic prescriptions from multiple providers, has led to measurable increases in drug use among postoperative orthopaedic trauma patients. In the new study, “Narcotic Use and Postoperative Doctor Shopping in the Orthopaedic Trauma Population,” researchers reviewed prescription records for 151 adult patients admitted to an orthopaedic unit at a level one trauma center between January and December 2011. Using the Tennessee  Controlled Substance Monitoring Database (CSMD), researchers reviewed data on narcotic prescriptions obtained three months before, and within six months after, each patient’s orthopaedic procedure. The study found that overall, 20 percent of patients were “doctor shopping.” The group that sought multiple providers for postoperative narcotics (“doctor shoppers”) used narcotics four times longer than single provider patients (112 days versus 28 days); had a median of seven narcotic prescriptions compared to two prescriptions; and had a higher morphine equivalent dose (MED) each day (43 milligrams versus 26 milligrams) than the single-provider group. The study also found that patients were 4.5 times more likely to seek out an additional provider if they had a history of preoperative narcotic use. The study authors recommend close monitoring of narcotic prescriptions and related requests following orthopaedic surgery. Lead author disclosure.
 
Patients with Metabolic Disorder May Face Higher Complication Risk Following Total Joint Replacement Surgery
 

  • Patients who are overweight, with hypertension, most at risk
 
Metabolic syndrome is a combination of disorders, such as obesity with a body mass index (BMI)≥30kg/m², dyslipidemia (an abnormal amount of lipids in the blood), hypertension and diabetes. An estimated 47 million adults, ages 20 and older, and one million adolescents in the U.S. have this syndrome which increases the risk of cardiovascular disease.  In the new study, “Impact of Metabolic Syndrome on Peri-operative Complication Rates after Total Joint Replacement Surgery,” researchers found that total joint replacement patients with three or more risk factors were almost three times as likely to have complications within the first year after joint replacement. The study included 168 patients with characteristics of metabolic syndrome who underwent  total hip and total knee replacements. Of the 39 patients with three or more risk factors, only 21 (16.3 percent) had complications within the first year. Obesity, measured by BMI, had the biggest impact on postoperative complications, with complications occurring in 16.2 percent of the patients with a BMI greater than 30 kg/m2.  For patients with BMI below 30 kg/m2, risk for complications was only 1.6 percent. The impact of BMI becomes even greater when combined with hypertension: 30.8 percent of patients with a BMI≥30kg/m2 and hypertension experienced complications. Identifying, counseling and addressing these issues in patients with metabolic syndrome risk factors could reduce complication rates, according to the study authors. Lead author disclosure.
 
Study Finds No Greater Injury Risk on Artificial Playing Surfaces
  • No statistically significant difference in professional soccer player injury rates on artificial, natural turf

The use of artificial playing surfaces at sport venues has increased significantly in recent years, primarily due to the advantages of artificial turf over natural grass: longer playing hours, lower maintenance costs and greater resilience to harsh weather conditions. Despite these advantages, many elite professional soccer teams are reluctant to install artificial turf because of a perception that injuries occur more often on these types of surfaces. In the new study, "Safety of Third Generation Artificial Turf in Male Elite Professional Soccer Players,” Italian researchers reviewed injuries involving players in the top Italian football (soccer) league during the 2011-2012 season. A total of 2,580 hours of play were recorded (1,270 hours on artificial turf and 1,310 on grass). For every 1,000 hours of play there were 23 injuries recorded on artificial surfaces and 20 on grass, with muscle strains being the most common injury (13 on artificial turf, 14 on grass). The authors of the study do not consider the injury rates between the two surfaces to be statistically significant, as only three injuries per 1,000 hours of play were attributable to artificial surfaces. The study authors conclude that there are no major differences between the nature and causes of injuries sustained on artificial turf and those that occur on natural grass surfaces. Lead author disclosure.
 
Major League Baseball Players Win More Games, Allow Fewer Walks Following Tommy John Surgery
  • Since 1986, 83 percent of patients returned to successful pitching in the major leagues following treatment for common elbow injury

Ulnar collateral ligament (UCLR) reconstruction, otherwise known as “Tommy John Surgery,” is a procedure frequently performed on Major League Baseball (MLB) pitchers with a damaged or torn ulnar collateral ligament, a common elbow injury, typically from overuse.  In the new study, “Rate of Return to Pitching and Performance after Tommy John Surgery in Major League Baseball Pitchers,” * researchers looked at the rate of return to MLB pitching following UCLR, the level of performance in pitchers returning to MLB, and the difference in overall performance between pitchers who underwent UCLR and demographic-matched controls who did not. Researchers evaluated UCLR pitchers between 1986 and 2012 using a number of performance-based statistics and compared them with matched controls: age, body mass index (BMI), position, handedness and MLB experience. In the year prior to surgery, the UCLR pitchers were outperformed by controls in terms of the number of innings pitched, games played and winning percentage. However, after undergoing UCLR, pitchers allowed significantly fewer walks and hits per inning pitched (WHIP), won a higher percentage of games, and recorded lower earned run averages (ERA) than prior to their surgeries. The UCLR pitchers also recorded higher winning percentages and lower WHIP and ERA in their post-surgical career than the control group. Overall, 83 percent of UCLR patients were able to return to MLB, and their careers on average lasted an additional 3.9 years. The authors of the study concluded that there is a high rate of pitchers returning to MLB following UCLR, with a significant improvement in pitching performance. Lead author disclosure.
* ”Rate of Return to Pitching after Tommy John Surgery in Major League Baseball Pitchers,” appeared in the December 2013 American Journal of Sports Medicine.
Total Hip Replacement Surgery Safe for Nonagenarian Patients
  • Despite advanced age and preoperative morbidity rates, surgical complication rates comparable to those of younger patients

As more Americans are living well into their 90s, the number of nonagenarian total hip replacement(THR) candidates continues to increase. In the study, ”Total Hip Arthroplasty Proves Safe for Nonagenarian Patients,”researchers reviewed patient characteristics and rates of postoperative morbidity, mortality and readmission among patients who underwent elective THR surgery between April 2001 and December 2011. Of the 43,543 THRs performed during this period, only 183 were performed on nonagenarians (0.4 percent). Before surgery, nonagenarians had the highest prevalence of peripheral vascular disease, hypertension and valvular heart disease, increasing their risk of surgical complications. Nonagenarian patients had the highest incidence of death within 90 days (2.7 percent compared to the overall average of 0.4 percent), and the highest rate of readmission within 90 days (15 percent compared to 10.3 percent for patients aged 80 to 89, and 6.3 percent for those younger than 80). Length of hospital stay was comparable for nonagenarians (3.4 days) to octogenarians (3.3 days), and the patients in their 90s showed no significant differences in the incidence of surgical site infection or pulmonary embolisms. The authors of the study concluded that nonagenarian patients can safely undergo a THR, despite advanced age and a higher prevalence of comorbidities. Overall, the nonagenarian patients experienced a complication rate comparable to those of younger THR patients, and the higher mortality rate is well within expectations for individuals age 90 and older. Lead author disclosure.
 
Genetics, Cartilage Type May Explain High-functioning Senior Athletes with Hip Abnormalities
  • Most hips with signs of femoracetabular impingement (FAI) will not develop osteoarthritis

Genetics may explain why some senior athletes are high functioning despite having  one or both hip abnormalities typically associated with early onset osteoarthritis(OA):  developmental dislocation of the hip (dysplasia), a loose hip joint; or femoroacetabular impingement (FAI), a condition in which the hip bones are abnormally shaped. In the study, ”Prevalence of Radiographic Abnormalities in Senior Athletes with Well-functioning Hips,”researchers evaluated the hips of 546 senior athletes (1,087 hips) with an average age of 67 (57 percent were male) for radiographic signs of FAI and dysplasia. Eighty-two percent of hips had radiographic evidence of FAI; 67 percent had at least one sign of cam FAI, in which the alpha angle of the bone was ≥50° on either hip; and 8 percent had isolated pincer impingement FAI, in which an extra bone extends out over the normal rim of the hip socket. Twenty-four percent of the senior athletes had signs of both cam and pincer FAI. Osteoarthritis was present in 17 percent of the hips. Ninety-three percent of the hips with OA had evidence of FAI, and 10 percent, dysplasia. While hips with FAI were more likely to have OA, 72 percent of the hips with FAI showed little to no evidence of OA. According to the study authors, the findings may indicate that other factors, possibly genetics or the patient’s type of cartilage, may play a role in preserving the hip joints in these high functioning senior athletes. Lead author disclosure.
 
March 12
 
Infection is the Leading Cause of Failed Prosthetic Knee Joints
  • Optimizing patient health before surgery may reduce need for revisions
 
The number of total knee replacement(TKR) procedures continues to climb, as does the number of revision total knee replacement (RTKR) surgeries. In the study, ”The Epidemiology of Revision Total Knee Arthroplasty in the United States,” researchers used the Nationwide Inpatient Sample (NIS) to evaluate the cause of knee failure for 301,718 revision RTKR surgeries performed between 2005 and 2010. Revision surgeries were more common in women (58 percent) and most often performed in patients, ages 65 to 74. A moderate severity of illness score (related to patient comorbid illness) was identified in more than 60 percent of patients. Infection in the prosthetic knee joint (periprosthetic joint infection) was the most common reason for revision (25 percent of patients), and mechanical loosening was the cause in 18.5 percent of patients. Revision TKR procedures were more commonly performed in large, urban non-teaching hospitals in the Southern and Midwestern regions of the United States. Revisions due to periprosthetic fractures were associated with the longest length of hospital stay (up to seven days), with an average hospitalization cost of $35,000. Elderly and female patients with a moderate number of comorbidities represented the largest proportion of the revision population. The authors suggest that optimizing patient health before surgery and paying meticulous attention to efforts by the surgical team to minimize the risk of periprosthetic joint infection may decrease the number of knee replacement revisions.  Lead author disclosure.

In a related study, “The Incidence of and Risk Factors for 30-Day Surgical Site Infections following Total Joint Arthroplasty”(Embargo: March 11), researchers found that patient characteristics and comorbidities, especially morbid obesity, were associated with a dramatic increase in infection risk.
 
March 13
 
Patients Should Wait at Least Six Weeks, Optimally 12 Weeks, before Driving after Total Shoulder Replacement Surgery
  • Significant reduction in simulator collisions at 12 weeks, compared to pre-surgery and two weeks post-surgery rates
 
More than 53,000 Americans have total shoulder joint replacement(SJR) surgery each year, and yet the effects of this surgery on a patient’s ability to safely drive a vehicle, and the appropriate recovery time before patients should return to driving, have yet to be determined.  In a new study,“Driving Performance after Total Shoulder Arthroplasty,”  the driving skills of 28 shoulder replacement patients, with a mean age of 65 ±10 years, were tested at four distinct time points before, during and after surgery using a driving simulator. The first test was conducted before surgery; a second test, 14 days following surgery; and third and fourth tests at six and 12 weeks post-surgery, respectively. The number of total simulator collisions, off-road collisions, on-road collisions, center-line crosses and off-road excursions were recorded at each trial. Pain Visual Analog Scale (VAS) and Shoulder Pain and Disability Index (SPADI) scores also were documented, in addition to annual driving mileage and hours slept the previous night.  In 28 patients, the mean number of collisions decreased from 6.2 during the first test (pre-surgery) to 5.9 at the second test (two weeks after surgery); and from 5.2 during the third test to 4.2 by the fourth and final test. There was a statistically significant difference in the mean number of collisions between the first and fourth test.  Also, patients who drove less than 1,800 miles per year incurred a greater number of collisions at the first and fourth tests, compared to patients who drove more than 8,700 miles per year.  “At risk driving behavior,” quantified as the number of center-line crosses, decreased from 20.6 during the first test to 14.8 by the fourth test.  According to the study authors, patients showed improved driving performance at 12 weeks, with a significant decrease in the number of collisions in the simulated driving course compared to the tests conducted preoperatively and two weeks after surgery. The study authors recommend that patients wait at least six weeks, and optimally 12 weeks, to resume driving following shoulder replacement surgery. Lead author disclosure.
 
Study Identifies Genetic Differences in Female Athletes with ACL Injuries
  • Findings may be “tip of the iceberg” in determining the role of genetics in ACL structure

Female athletes are two-to-eight times more likely to suffer an anterior cruciate ligament(ACL) injury than males. And while there have been reports about  possible anatomic, hormonal and neuromuscular factors that may place females at greater risk for these injuries, little research has looked specifically at the role of genetics. For the first time, a new study identified varied female-to-male expression of several genes leading to proteins maintaining ligament structure. In the study, “Gene Expression Differences in Young Male and Female Ruptured Anterior Cruciate Ligaments,” a biopsy of normally discarded ruptured ACL tissue was obtained during surgery from seven male and seven female young athlete patients. Biopsies were then divided into groups for microscopic (histological) and gene microarray analysis. Thirty-two significantly differentially expressed genes were isolated from male and female tissue, of which 14 were not linked to either X or Y chromosome. The 14 genes were then grouped according to skeletal muscular development, function and cellular growth. In females, compared to males, the microarray analysis showed altered responses in signaling pathways that regulate cartilage and tissue growth. The study authors believe the findings represent “the tip of the iceberg” in terms of determining the role of genetics in ACL structure and tendency toward increased ligament injury in female compared to male athletes. Lead author disclosure.
 
March 14


Most Charnley Total Hip Replacements Viable after 35 Years
  • Age and health status affect function more than inplant wear
 
In the new study, “Assessment of Durability and Function at Minimum 35-Year Follow up of THR Patients 50 and Under,”  researchers sought to evaluate the clinical, radiographic and functional outcomes of a Charnley  total hip replacement(THR), a traditional hip prosthesis consisting of a polyethylene acetabular (plastic) cup and a metal femoral head, in patients under age 50 at a minimum of 35 years after the initial surgery.  Out of 69 THR patients (93 hip replacements) who participated in a 25-year follow up assessment, 32 were still alive (44 percent) and 30 were available for an evaluation.  Out of the original 93 hip replacements, 28 required revision surgery.  The 30 patients with viable hip components were assessed through quality of life and hip scores, and activity measurements, including six-minute walk and pedometer monitoring.   Although 63.5 percent of the original hip replacements were functioning at the latest follow-up examination or at the time of patient death, a significant decrease in activity level, as measured by functional scores, was seen over time.  Age and health related factors, as opposed to implant failure, limited activity in this cohort at long-term follow up. According to the study authors, the results reflect the durability of cemented hip replacements, and provide a benchmark comparison for THR performed in younger patients with other designs, materials and techniques. Lead author disclosure.
 
Children Diagnosed as Obese More Likely to Have Wrist Fractures, Complications Related to Healing
  • Surgical pinning at the onset of fracture may ensure faster healing
 
Children considered obese are more likely to suffer a distal radius fracture, a bone break near the wrist, and more likely to experience complications related to the healing of the fracture. In the study, “Childhood Obesity Increases the Risk of Failure in the Treatment of Distal Forearm Fracture,”
the records and outcomes of 157 patients with distal radius fractures who received emergency department and/or surgical treatment were collected from a large urban pediatric practice between January 2011 and June 2012. All patients were initially treated with fiberglass casting, and monitored until their bone break healed (radiographic union). Each patient’s age, weight, height and number of office visits, subsequent surgeries and the type/angle of the fracture were recorded and analyzed. Sixty-six (42 percent) of the children were diagnosed as overweight, with a Body Mass Index (BMI) greater than the 85thpercentile; and 46 (29 percent) as obese, with a BMI greater than the 95thpercentile.  A total of 27 children required repeat reduction (the surgical repositioning of the fractured bone). Of the 91 children without obesity, 14 (12 percent) required the second procedure. However, of the children with obesity, 13 (28 percent) required repeat reduction. Obese children had significantly more follow-up visits requiring X-rays or other images, and were significantly less likely to have an initial, successful bone repositioning in the emergency room. Children diagnosed as obese should be followed early and closely, and possibly have their fractures surgically pinned from the onset, to expedite and ensure appropriate healing. Lead author disclosure.
 
Obesity Linked to Higher Hospital Charges, Longer Hospital Stays and Higher Rates of Surgical Intervention in Orthopaedic Trauma Patients
  • Obese patients had lower injury severity scores

Approximately one-third of the American population is obese and the number is rising, as is the number of obese individuals involved in high-energy accidents with multiple injuries. In the new study, ”The Relationship of Obesity to Increasing Health Care Burden in the Setting of Orthopedic Polytrauma,”  
researchers identified 301 patients with multiple traumatic injuries (polytrauma) who had orthopaedic injuries requiring intensive care unit (ICU) admission at a major trauma hospital between 2006 and 2011. Patients with a truncal body mass index (TBMI) <30 were considered nonobese (78.41 percent, 236 individuals), and patients with a TBMI of 30 or greater were considered obese (21.6 percent, 65 individuals). Higher TBMI was associated with longer hospital stays, more days spent in the intensive care unit (ICU), more frequent discharge to a long-term care facility, higher rate of orthopaedic surgical intervention, and increased total hospital costs. Despite the higher cost of care, and greater frequency of complications, the obese patients in the study, overall, had lower injury severity scores. Lead author disclosure.
 
Gastric Bypass Surgery May Diminish Knee Pain in Obese Patients
  • Bariatric surgery in patients with no or little osteoarthritis offers comparable pain reduction and improvement in mobility compared to that typically achieved with knee replacement surgery
 
There is a known link between elevated body mass index (BMI) and symptomatic knee osteoarthritis(OA). While patients who have undergone gastric bypass surgery (GBS)—a procedure that closes off much of the stomach and causes food to bypass a portion of the small intestine?typically lose weight, the comparative impact of this weight loss on knee pain and function has not been measured. The study, The Impact of Gastric Bypass Surgery Compared to Total Knee Arthroplasty on Knee Symptoms,”  included two groups of patients: 20 GBS patients (16 women and four men) with a mean age of 52 years and a mean pre-operative BMI of 45.6 kg/m², and 40 patients who underwent total knee replacement (TKR) for symptomatic OA. The groups were matched two-to-one by age, gender and BMI. In both groups, knee symptoms were assessed preoperatively, as well as at six months and one year following surgery. Bariatric surgery patients reported significant improvement in mean knee pain (6.95 versus 2.30 points) and physical function (21.5 versus 7.05) at one-year follow up. When compared to patients who underwent TKR, the percentage improvement in mean pain scores was similar between the two groups at six months (49.9 percent versus 58.3 percent) and one year (62.7 percent versus 68.2 percent). The GBS group experienced a significantly greater percentage improvement in physical function at six months (66.3 percent versus 46.7 percent), and a similar, though marginally non-significant difference at one year (68.4 percent versus 51.5 percent).  Comparatively, GBS patients with self-reported OA had greater knee pain and worse function preoperatively when compared to those without OA, as well as a smaller percentage improvement in pain (63.5 versus 74 percent) and function (66.4 versus 72.9 percent) at final follow up. The study authors recommend that surgeons consider bariatric consultation for obese patients who have knee symptoms but lack advanced osteoarthritis or other conditions amendable to orthopaedic management. Lead author disclosure.
 
Platelet-rich Plasma (PRP) Treatment More Effective than Cortisone for Severe Hip Bursitis
  • PRP provided short- and long-term pain relief

Chronic hip bursitisis a common yet difficult condition to treat successfully. A recent study compared the results of PRPand cortisone injections in patients with severe chronic hip (greater trochanteric) bursitis. In the study, “Platelet-Rich Plasma (PRP) More Effective than Cortisone for Severe Chronic Hip Bursitis,”40 patients were selected for the study and randomly divided into two groups: one group was treated with a single injection of 40 milligrams (mg) of methylprednisolone, and the second group, a single injection of PRP. Results were recorded using the Harris Hip Score (HHS), which assesses a patient’s functionality before and after hip treatment; and the Western Ontario and McMaster Universities Arthritis Index (WOMAC), which measures pain, stiffness and functional limitation. Befo
Contact(s):
Lauren Pearson Riley
phone: 847-384-4031
Kristina Goel
phone: 847-384-4034
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TEKGROUP International, Inc.

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