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Enhancing Follow-up Care after Orthopaedic Surgery

Assessing the Effects of Vitamin D Deficiency

Preventing Pulmonary Embolism Following Joint Replacement Surgery

Minimizing the Effects of Osteoarthritis

Improving Post-Surgical Outcomes

Preventing Falls and Hip Fractures

Eliminating Research Bias

Assessing Orthopaedic Care Trends

Treating Handgun Injuries

Preserving Hip Resurfacing

Improving Pediatric Orthopaedic Care

Assessing the Effects of Shorter Hospital Stays on Surgical Outcomes, Costs

 



For Immediate Release:

For more information, contact:

Lauren Pearson Riley  847-384-4031  708-227-1773  pearson@aaos.org
Kristina Goel 847-384-4034 312-388-5241 goel@aaos.org

 

American Academy of Orthopaedic Surgeons (AAOS) 2012 Annual Meeting Clinical News Highlights

Enhancing Follow-up Care after Orthopaedic Surgery
Post Surgical Phone Support Improves Outcomes Following Knee Replaceme
(Embargo: February 7)
* Telephone support recommended for at-risk patients

Poor emotional health and morbid obesity are associated with less functional gain following total knee replacement (TKR) surgery. Approximately 180 patients were categorized by gender, body mass index (BMI) and emotional health. Each patient randomly received either emotional telephone support by a trained behavioral specialist, or standard patient care. Telephone support included three phone calls before surgery, one in-person hospital visit, and eight weekly post-operative calls. Telephone emotional support was well received by all patients. Among high-risk TKR patients, those who received telephone support reported significantly higher post-surgery physical activity and function at six months than those who received standard of care. A tailored, telephone-delivered emotional support program can be helpful in improving activity and function for patients, and especially those at risk for sub-optimal outcome.

Online Support Following Joint Replacement Surgery is Cost and Time Effective for Patients
(Embargo: February 8)
* Fewer routine follow-up visits may improve physician access for critical care

Patients who have had a total joint replacement (TJR) are expected to return to their physician’s office or clinic regularly for routine follow-up care. One year following TJR, 210 patients (with no known complications) either were asked to complete a Web-based follow-up, which included an online survey and an X-ray taken at the nearest Internet-enabled facility; or to return to the clinic/office for their regular appointment. The patients who chose the Web-based follow-up reported less travel-related costs ($4.00 versus $21.41), distance traveled (29.1 km versus 110.2 km), and time spent (44.6 minutes versus 55.6 minutes) on their routine follow-up care. In addition, patients in the usual care group missed 5.7 hours of work on average, and their caregivers, 6.4 hours. Web-based follow-up can provide significant time and cost savings to TKR patients without complications, and make the physician’s office more accessible to new patients, patients awaiting surgery, and/or patients with post-surgical complications.

Assessing the Effects of Vitamin D Deficiency
44 Percent of Postmenopausal Women with Distal Radius Fracture Have Low Levels of Vitamin D  
(Embargo: February 7)
* Preventative efforts may reduce the number of hip fractures

Wrist fractures, also called distal radius fractures (DRF), are among the most common osteoporosis-related fractures occurring on average 15 years earlier than hip fractures. As researchers recently linked vitamin D deficiency with muscle weakness, increased fall risks, and bone fractures, investigators sought to determine the prevalence of vitamin D deficiency among post menopausal women with DRF. Medical records of 104 post menopausal women treated for a DRF, and 107 age-matched control patients with soft tissue disease, were reviewed. Mean vitamin D levels were “significantly” lower in the DRF group of patients. Specifically, 26 percent of the DRF patients were vitamin D insufficient (having vitamin D serum levels between 20 and 32 ng/ml), and 18 percent, deficient (serum levels below 20 ng/ml), compared to 11 percent and 2 percent of patients being vitamin D insufficient and deficient, respectively, in the control group. Further research may determine whether vitamin D supplementation (or, maintaining adequate vitamin D levels) can help prevent distal radius fractures, or prevent future fractures in patients that experience their first distal radius fracture.

Preventing Pulmonary Embolism Following Joint Replacement Surgery
Risk of Pulmonary Embolism (PE) Greatest During First Week Following Total Joint Replacement
(Embargo: February 7)
* Prolonged use of therapies to minimize blood clot risk may be unnecessary

The elevated risk of pulmonary embolism (PE) – a blood clot that travels from the leg to the lungs – has been well established, yet little is known about the natural course and timing of this potentially fatal condition. The records of 25,660 patients who received total joint replacement (TJR) between 2000 and 2010 were reviewed. All patients received the anticoagulation (blood thinning) drug Coumadin immediately following surgery and each was monitored, but not screened, for PE. Pulmonary embolism occurring within 90 days of the joint replacement was documented. The median occurrence of PE was two days following surgery, with 254 out of 286 cases of PE (88.8 percent) occurring within the first seven days after surgery.  Based on the findings of this study, anticoagulation treatment beyond seven days may not be necessary.

Aspirin Prevents Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) in Joint Replacement Patients
(Embargo: February 7)
* Anticoagulation therapies may be necessary to prevent blood clots in high-risk patients

Following a total joint replacement, anticoagulation (blood thinning) drugs can prevent Deep Vein Thrombosis (DVT), a blood clot deep within the extremities, or a pulmonary embolism (PE), a complication that causes a blood clot to move to the lungs. However, prolonged use of these therapies may increase the risk of hemorrhage and infection. Investigators performed a venography, a test for DVT, before and after knee or hip surgery on 1,500 patients. All patients used a foot pump, and wore an elastic stocking, immediately after surgery.  In addition, each patient took a regular dose of aspirin beginning two days post-surgery. The incidence of DVT was 19.2 percent (32.7 percent in total knee replacement and 5.6 percent in total hip replacement patients) which is below normal. None of the PE cases were fatal or severe, and there were no complications caused by the aspirin. Age and a high patient body mass index (BMI) were among the factors associated with a higher risk for DVT. Aspirin along with the use of stockings and a foot pump are safe and effective therapies in preventing DVT and PE in most joint replacement patients. Patients at high risk for DVT made require the use of anticoagulation therapies.

Minimizing the Effects of Osteoarthritis
Video-Based Home Exercise Can Minimize Osteoarthritis Pain, Improve Mobility
(Embargo: February 8)
* Exercise did not stop osteoarthritis progression

The benefits of exercise in minimizing pain and improving mobility for individuals living with osteoarthritis has been well documented. Over a one-year period, 107 individuals with diagnosed osteoarthritis in the knee were randomized to either a DVD-based exercise group, or a control group. The “DVD” group received a DVD-based exercise program, as well as verbal and hands-on exercise instructions, for the first four to eight weeks. The individuals in both groups were evaluated at three, six and 12 months. Participants in the exercise group reportedly exercised 5.3, 5.0 and 3.8 times per week at three, six and 12 month intervals.  The improvements in pain and physical function were significantly greater in the DVD group than the control group at all intervals. However, there were no significant differences between the two groups in osteoarthritis progression. Video-based home exercise programs can enhance adherence to a prescribed exercise program, can reduce pain, improve physical function, and improve life quality in patients living with knee osteoarthritis.

Improving Post-Surgical Outcomes
Anxiety Trait Linked to Postoperative Pain in Men Following Total Knee Replacement
(Embargo: February 8)
* Women less satisfied with pain control after surgery

Increased pain following surgery has long been linked to anxiety and “catastrophizing,” an extreme response to stress. Ninety-seven patients – men and women – who were about to undergo minimally invasive total knee replacement (TKR) surgery, completed a brief survey to quantify their level of anxiety, as well as their typical level of anxiety and potential for catastrophizing. Pain data was then collected for seven days following surgery. Catastrophizing did not correlate with postoperative pain or pain medication use in either men or women, nor did a patient’s level of acute anxiety. However, men with anxiety traits – a high level of anxiety unrelated to a stressful event – had higher post-operative pain ratings resulting in longer hospital stays. Women generally reported higher post-operative pain levels than men, and women were consistently less satisfied with pain control. Further research is needed to identify patients most likely to have difficulty with TKR pain management.

Antidepressant Use Linked with Less Patient Satisfaction after Hip Replacement
(Embargo: February 8)
* Understanding a patient’s mental health status before hip replacement surgery may improve education and care

Patients taking antidepressants up to three years prior to undergoing a total hip replacement (THR) were more likely to report greater pain  before and after surgery and less satisfaction with their procedure. In this investigation, 1,657 patients (13 percent of the study population) used antidepressants up to three years before surgery. The patients were surveyed before and one year after the THR. The investigators found that a patient’s mental health status, assessed by the use of antidepressants before surgery, was a significant factor in predicting outcomes, as well as gender (men are more likely to report lower outcomes), advanced age and co-morbidity (other joint diseases or conditions which affect walking). According to the investigators, a patient’s mental health status should be assessed prior to surgery and taken into consideration during post-operative care.

Preventing Falls and Hip Fractures
Undiagnosed Neurological Disorders May Cause Falls and Hip Fractures in the Elderly
(Embargo: February 9)
* Hip fracture patients should be screened for cervical myelopathy

Hip fractures are a common cause of morbidity and mortality in elderly patients. Cervical myelopathy is a common neurological condition that can diminish balance and coordination. Investigators screened 28 hip fracture patients and 35 hip replacement patients (all cognitively healthy) for cervical myelopathy. Eighteen percent (five) of the hip fracture patients did indeed have cervical myelopathy. None of the hip replacement patients tested positive for the condition. Undiagnosed neurological disorders may predispose patients to falls and fractures. Screening for cervical myelopathy should be standard care for all hip fracture patients, to reduce the risk for additional falls and fractures.

Eliminating Research Bias
Study Finds that Authors with Financial Conflicts are Reporting Negative Outcome in Major Orthopaedic Journals  
(Embargo: February 10)
* Results confirm integrity of scientific reporting and publication peer review process

As a conflict of interest can increase the potential for research bias and study outcomes, the American Academy of Orthopaedic Surgeons (AAOS) and major orthopaedic journals require all presenters and authors to disclose potential professional conflicts. A systematic review of three major orthopaedic journals – the Journal of Bone and Joint Surgery(American and British editions) and the Journal of Arthroplasty (JOA) – was conducted for all articles related to metal-on-metal total hip replacement between October 1999 and May 2011. Of the 411 metal-on-metal total hip studies, 64 reported data pertaining to survivorship, failure, and revision rates and were included in the analysis. Over time, the articles became increasingly negative. This negative trend persisted when analyzing the subgroup of studies written by authors with financial disclosures. Fifty-nine percent (38) of the studies reported a conflict of interest. Papers published by authors with a conflict of interest were equally likely to report negative results compared to authors without conflicts. While these results are encouraging and speak to the integrity of scientific reporting, efforts to ensure data transparency and more robust disclosure programs should continue.

Assessing Orthopaedic Care Trends
Economic Factors Impact Orthopaedic Trauma Volume
(Embargo: February 7)
* Orthopaedic trauma cases decline in weak economy

Previous studies have found that human behavior during a recession is remarkably different than that during a bullish economy. For example, people tend to spend more time focused on working and less time engaging in leisure and recreation activities, resulting in fewer motor vehicle and other accidents. According to a 10-year study at a Level 1 regional trauma center, economic trends do impact orthopaedic trauma volume.  Between 1999 and 2009, a local county’s population steadily grew at an annual rate between .9 and 2.9 percent. Unemployment rates peaked in 2002 at 5.4 percent, declined to 3.3 percent in 2006, and rose again in 2009 to 10.7 percent. While general trauma volume increased during the later years, there was a significant negative association between orthopaedic trauma volume and county unemployment rates of the previous year.  

Treating Handgun Injuries
Modern, Low-Energy Ammunition Can Cause Deep Tissue Damage
(Embargo: February 7)
* Orthopaedic surgeons should pay close attention to handgun injuries, provide aggressive care when needed

Gunshot injuries are typically categorized as low- or high-energy based on the weapon’s missile velocity and mass. Typically, low energy injuries are treated with simple wound care, with or without antibiotics, regardless of the presence of a fracture. In contrast, high energy injuries are treated more aggressively.  However, modern low-energy handgun ammunition is designed to inflict significant soft tissue damage, which can cause infection and compartment syndrome (a painful condition that occurs when pressure within the muscles builds to dangerous levels). A review of ballistics data from forensic scientists and law enforcement officers in a major U.S. city police department, as well as gunshot-induced fractures from a single level 1 trauma center, found that low-energy handgun injuries have become more prevalent, and with hollow point ammunition (designed to expand when entering the body), can cause severe underlying tissue injury that may be overlooked by clinicians.  Orthopaedic surgeons need to be aware of this powerful new ammunition, and the likelihood that even “low energy” handguns can cause substantial bone and soft tissue injury.

Preserving Hip Resurfacing
Excessive Sporting Activity May Impair Long-Term Success of Hip Resurfacing (Embargo: February 8)
* P atients should limit activities to maintain hip prosthesis

In hip resurfacing the femoral ball in the hip joint is not removed, but instead is trimmed and capped with a smooth metal covering.  Young and active patients with arthritis often choose hip resurfacing over total hip replacement to minimize the risk of hip dislocation and preserve bone for a revision surgery, should the primary resurfacing fail.  However, the long-term effects of sports on a resurfaced hip were unknown.  Investigators surveyed 445 patients between one and five years after hip resurfacing. Type of activity, frequency and duration of the sessions, and intensity of participation were documented. Over the next 10 years, each patient’s hip status was monitored. The mean age of the patients was 48.7 years, and 74 percent were male. There was a correlation between higher activity scores and risk for surgical revision. Other independent risk factors for revision included small component size, low body mass index, and 1st generation surgical technique. Patients with an Impact Score (IS) lower than 50 had a revision risk rate 3.8 times lower than the patients with an IS of 50 or greater. Survivorship for patients with a lower IS score at eight years was 96.4 percent versus 88.8 percent. Large amounts of high impact sporting activities – such as daily running or tennis– can be detrimental to the long-term success of hip resurfacing arthroplasty. Surgeons should advise patients to limit their physical activity to levels that the device can sustain.

Improving Pediatric Orthopaedic Care
Ultrasound Can Reliably Diagnose Hip Dysplasia at Age 6 Months
(Embargo: February 9)
* Radiation no longer required to detect common congenital birth defect

Developmental dislocation (dysplasia) of the hip (DDH) is a common congenital condition in which a child's upper thighbone is dislocated from the hip socket. The condition can be present at birth or develop during a child's first year of life. Plain radiography (X-rays) has long been the gold standard screening modality for this condition in 6-month-old children, despite concerns over exposing very young children to ionizing radiation. Thirty-five, 5 to 7 month-old children at high risk for DDH were screened with the standard pelvis X-ray, as well as a bilateral non-stress hip ultrasounds. Blinded orthopaedic surgeons then evaluated the X-rays and ultrasounds for standard measure of hip dysplasia. Of the 35 children involved in the study, only one was diagnosed with dysplasia, and the diagnosis was made on both the ultrasound and X-ray.  Ultrasound provided good quality images with 100 percent diagnostic correlation to the X-rays in all patients. Ultrasound is a reliable alternative imaging method to X-rays for DDH screening in 5-to-7 month old children.

Obese Children More Likely to Suffer Growth Plate Fractures
(Embargo: February 8)
* Injuries in overweight and obese children more often from “low-energy” impact, and involve the growth plate

Obese children are 74 percent more likely to sustain a fracture of the growth plate, the softer end of the bone where growth occurs. The study involved 224 children visiting a Maryland hospital with a fracture. Information was collected on each patient regarding their sex, age, height, weight, fracture location and pattern. Patients ages 2 to 16 were divided into two groups for comparison: a “normal weight” group and an “obese/overweight” group for children with a body mass index (BMI) greater than the 85 percentile.  The overweight/obese group represented 41.3 percent of the fracture population, and had a statistically significantly higher rate of growth plate injuries (40 percent versus 23 percent). The study, which is ongoing, also looked at the type of incidents causing the fractures, and found that the obese/overweight children had a greater number of injuries resulting from “low-energy” contact or impact, such as falling from a standing position. The findings could provide greater insight into the inherent risks for overweight and obese children pertaining to exercise and physical activity.

Assessing the Effects of Shorter Hospital Stays on Surgical Outcomes, Costs
Shorter Hospital Stay for Total Knee Replacement Linked with Greater Revision and Mortality Risks
(Embargo: February 9)
* Any TKR short-stay hospital protocol should be implemented gradually to ensure capacity, avoid complications

No previous research has quantified and compared the costs and outcomes between total knee replacement (TKR) patients who have differing lengths of hospital stay following surgery. Investigators identified Medicare patients who had undergone TKR between 1997 and 2009.  The patients were separated into the following groups: outpatient, 1-day inpatient, 2-day inpatient, 3- or 4-day inpatient (standard of care), and 5 plus day inpatient. Investigators reviewed outcomes for the patient groups including annual payments, mortality, readmission, revision and common complications. After adjusting for various factors, the results were compared at 90 days, one year, and two years after surgery.  Compared to patients who had the standard of care 3-4 day hospital stay, the incremental payments for osteoarthritis costs at 2 years were - $6,964 (lower) for the outpatient group, - $3,327 for patients hospitalized for one day, -$1,681 for two days, and +$1,159 for five plus days. At 90 days, the outpatient group had less pain and stiffness compared to the standard care (3-4 day) group, but had a higher risk for mortality, readmission and dislocation. Investigators recommend that hospitals that choose to implement shorter stay protocols for TKR patients, should do so gradually and only with appropriate and sufficient capabilities.

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