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Total joint replacement may improve cardiovascular health
Total joint replacement (TJR) may reduce the risk for cardiovascular events, including heart attack and stroke, and boost long-term survival among patients with osteoarthritis, according to new research presented at the 2014 Annual Meeting of the American Academy of Orthopaedic Surgeons in March.
In the study involving 2200 people older than 55 years with advanced osteoarthritis of the hip or knee, investigators determined that the odds of a serious cardiac event or death were 37% lower in patients who had undergone hip or knee total joint arthroplasty than in those who did not have such surgery.
According to investigators, the most likely explanation for the findings is that TJR improves patients' mobility. Physical activity of moderate intensity, such as a brisk walk, a few days a week has direct benefits to lower risk of hypertension, obesity, and diabetes. All of these conditions are highly prevalent in patients with osteoarthritis and are known to increase risk for cardiovascular disease. These findings provide further support for interventions designed to increase physical activity.
Source: Ravi B, Croxford R, Austin P, et al. TJA appears cardioprotective in patients with moderate-severe OA: A propensity-score matched landmark analysis. Presented at the 2014 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in New Orleans, Louisiana. March 14, 2014.
http://www.abstractsonline.com/Plan/ViewAbstract.aspx?mID=3358&sKey=2dc80a08-f6ef-474e-a7ec-bd3e9f560f3d&cKey=80058e4f-230b-4eef-b612-4f6f55ea670f&mKey=4393d428-d755-4a34-8a63-26b1b7a349a1
Popular supplement does not decrease knee pain
Taking oral glucosamine supplements does not decrease pain or improve knee bone marrow lesions, according to a study involving 201 participants with mild to moderate pain in one or both knees. Millions of Americans take glucosamine to treat osteoarthritis of the knee and other joints.
Participants were randomized and treated daily for 24 weeks with either 1500 mg of glucosamine hydrochloride in a 16-ounce bottle of diet lemonade or placebo. MRI was used to assess cartilage damage.
Trial results showed no difference in worsening of cartilage damage in participants in the glucosamine group compared with the placebo group. Researchers also reported that there was no advantage of glucosamine over placebo for improvement in bone marrow lesions. Glucosamine did not decrease urinary excretion of C-telopeptides of type II collagen - a predictor of cartilage destruction.
This Joints on Glucosamine (JOG) study was the first to investigate whether the supplement prevents worsening of cartilage damage or bone marrow lesions. The investigators concluded that drinking a glucosamine supplement does not reduce damage to knee cartilage, relieve pain, or improve function in persons with chronic knee pain.
Sources: Kwoh CK, Roemer FW, Hannon MJ, et al. Effect of oral glucosamine on joint structure in individuals with chronic knee pain: a randomized, placebo-controlled clinical trial. Arthritis Rheumatol. 2014;66(4):930-939. "Glucosamine Fails to Prevent Deterioration of Knee Cartilage, Decrease Pain," Arthritis & Rheumatology, news release, March 11, 2014.
How effective are opioids for chronic low back pain?
The use of opioid medications to treat chronic low back pain has increased dramatically. But how effective are opioids in reducing low back pain, and what are the risks?
Investigators conducted a review study to compare at least 4 weeks' use of noninjectable opioids for chronic lower back pain with placebo or other treatments. Comparisons with different opioids were excluded from the study. Outcomes included pain and function, using standardized mean difference or risk ratios with 95% confidence intervals, and absolute risk difference with 95% confidence intervals for adverse effects. The study quality was evaluated using Grading of Recommendations Assessment, Development, and Evaluation criteria.
Fifteen trials (5540 participants) met the inclusion criteria. Findings indicated that tramadol was better than placebo for relieving pain and improving function. Compared with placebo, transdermal buprenorphine decreased pain but did not improve function. Strong opioid medications (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol) were better than placebo for reducing pain and improving function.
One trial demonstrated little difference between tramadol and celecoxib for pain relief. Two trials (272 participants) demonstrated no difference between opioids and antidepressants for pain or function. Reviewed trials were characterized by low to moderate quality, high drop-out rates, short duration, and limited interpretability of functional improvement. No serious risks (addiction or overdose) or adverse effects (sleep apnea, opioid-induced hyperalgesia, hypogonadism) were reported.
The evidence suggests that opioids have short-term efficacy (moderate for pain and small for function) for treatment of chronic low back pain. The effectiveness and safety of long-term opioid therapy to treat this condition remain unproven.
Source: Chaparro LE, Furlan AD, Deshpande A, et al. Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review. Spine (Phila Pa 1976). 2014;39(7):556-563.
Assessing adherence to clinical guidelines for fragility fractures
Clinical guidelines advise that patients with fragility fractures should be evaluated for osteoporosis and treated for the disease if it is present. In a retrospective cohort study, these guidelines were met for less than one-third of women and less than one-sixth of men with a fragility fracture.
Investigators analyzed data gathered from 2001 through 2009 in a large, commercially insured community. Patients were at least 50 years of age and had a new, low-energy fracture of the hip, vertebra, wrist, or humerus, with no evidence of a fragility fracture, osteoporosis treatment, malignant disease, or Paget disease for 12 months preceding the fracture. Rates of diagnostic testing and pharmacotherapy for osteoporosis within 12 months of the fracture were evaluated.
Investigators analyzed whether 12-month adherence to treatment among patients who were treated with oral bisphosphonates differed between those who started therapy within 90 days or from 91 to 365 days after fracture.
Nineteen percent of women and 10% of men were prescribed osteoporosis pharmacotherapy after their fractures. Thirty percent of women and 15% of men underwent postfracture diagnostic testing, were prescribed pharmacotherapy, or both.
Treatment rates were highest after vertebral fracture and lowest after wrist or humeral fracture. Treatment rates significantly decreased over time (from 2001 through 2009). The average 12-month rate of adherence to treatment (medication possession ratio) was 56% among women and 61% among men. Adherence was similar between patients who had begun pharmacologic treatment soon after their fractures and those who started later.
Given their findings, investigators concluded that although primary fracture prevention is the ideal, secondary prevention is critical. The data reveal a need to reverse the downward trend in adherence to postfracture guidelines.
Source: Balasubramanian A, Tosi LL, Lane JM, et al. Declining rates of osteoporosis management following fragility fractures in the U.S., 2000 through 2009. J Bone Joint Surg Am. 2014;96(7):e52.
Pediatric sports injuries: male vs. female
Sports injuries in boys and girls differ by injury type, diagnosis, and body area, according to a retrospective chart review. Overall, girl athletes have a higher percentage of overuse injuries (62.5%) compared with traumatic injuries (37.5%). The opposite pattern is observed in boy athletes: 41.9% of injuries were attributable to overuse whereas 58.2% were traumatic.
Investigators used a random sampling of medical records of children 5 to 17 years of age assessed during a 10-year period at a sports medicine clinic within a large academic pediatric hospital. Information was collected and analyzed with regard to age, sex, height, weight, injury type (overuse vs. acute/traumatic), location of injury, and sports involvement.
Regarding specific areas of injury, female athletes sustained more injuries to the lower extremity (65.8%) and spine (11.3%) as compared with male athletes (53.7% and 8.2%, respectively). Male athletes had a greater percentage of injuries to the upper extremity (29.8%) compared with female athletes (15.1%). Types of hip/pelvis injury differed greatly by sex, with girls sustaining more overuse (90.9%) and soft-tissue injuries (75.3%). Injuries in boys tended to be traumatic (58.3%) and bony (55.6%) in nature. Boys were more likely than girls to participate in team and contact/collision sports.
Girls experienced patellofemoral knee pain at an approximately 3 times higher rate than boys (14.3% vs. 4.0%, respectively). Boys were twice as likely as girls to be diagnosed with osteochondritis dissecans (8.6% vs. 4.3%, respectively) and fractures (19.5% vs. 8.2%, respectively). Boys and girls sustained anterior cruciate ligament injuries at almost equal rate (10.0% and 8.9%, respectively).
Investigators reported that their results might be related to unique referral patterns, including a high number of female dancers.
Source: Stracciolini A, Casciano R, Levey Friedman H, et al. Pediatric sports injuries: a comparison of males versus females. Am J Sports Med. 2014;42(4):965-972.
Preoperative factors affecting rotator cuff repair
Although a goal of rotator cuff repair is to restore the torn tendon to its original insertion anatomically, it can be difficult to restore the entire footprint. Investigators evaluated variables that affect this repair coverage. They also analyzed differences in retear rate and clinical results between complete and incomplete footprint coverage in rotator cuff surgery.
From 2007 to 2009, a total of 85 consecutive repairs for medium-to-large rotator cuff tears were identified as having complete or incomplete coverage of their original footprints. The complete footprint coverage (CC) group included patients who had more than 50% of their footprint covered during repair, and patients in the incomplete coverage (IC) group had less than 50% of their footprint restored. Fifty-seven repairs were included in the CC group and 28 repairs in the IC group.
Tear size in the coronal plane was the only independent factor affecting the amount of footprint coverage. There was a statistically significant difference in the proportion of tendon integrity between groups. On postoperative MRI scans, 45.6% of the CC group had an intact tendon, 45.6% had a delaminated partial retear, and 8.8% had a full-thickness retear. In the IC group, 17.9% had an intact tendon, 60.7% had a delaminated partial retear, and 21.4% had a full-thickness retear. Clinical scores and range of motion at final follow-up visit showed no difference between the 2 groups.
Investigators concluded that repair quality based on retear classification was different between the groups. However, results indicated that neither complete nor incomplete footprint coverage in rotator cuff repair was associated with significant differences in clinical scores or range of motion at short-term follow-up.
Source: Koh KH, Lim TK, Park YE, et al. Preoperative factors affecting footprint coverage in rotator cuff repair. Am J Sports Med. 2014;42(4):869-876.
Tracking outcomes after total ankle replacement
For patients with posttraumatic osteoarthritis, early outcomes after total ankle replacement are comparable to those for patients with osteoarthritis and rheumatoid arthritis, new findings suggest.
In a recent study, investigators compared the differences in demographic data and clinical and patient-reported outcomes among patients with those 3 types of arthritis who underwent total ankle replacement with the MOBILITY Total Ankle System.
Patients were divided into 3 groups by type of arthritis. Investigators analyzed patient demographic data, American Orthopaedic Foot & Ankle Society (AOFAS) scores, and patient-reported outcomes. Patient-reported outcomes were measured with the Foot and Ankle Outcome Score (FAOS), the 36-item Short-Form (SF-36) Health Survey, and patient-satisfaction scores that were collected preoperatively and at 1 and 2 years after surgery.
The study included 106 consecutive patients who underwent total ankle replacement. The posttraumatic osteoarthritis group comprised 28 patients significantly younger (average age, 54.8 years) than the other groups. Patients in the rheumatoid arthritis group (n = 22) had a significantly lower mean body mass index (24.5 kg/m2) than those in the other groups. The osteoarthritis group included 56 patients and had a higher proportion of men (41 men).
The posttraumatic osteoarthritis group reported better scores for 2 of the 8 domains of the SF-36 preoperatively. At 1 year after surgery, the posttraumatic osteoarthritis group and the rheumatoid arthritis group had better FAOS results regarding pain than those in the osteoarthritis group. The posttraumatic osteoarthritis group also reported better scores for the general health domain of the SF-36.
At 2 years, the posttraumatic group continued to show significantly higher scores for the general health domain of the SF-36. There was no significant difference among the groups in AOFAS scores, other FAOS results, or patient-satisfaction scores.
Source: Ramaskandhan JR, Kakwani R, Kometa S, et al. Two-year outcomes of MOBILITY total ankle replacement. J Bone Joint Surg Am. 2014;96(7):e53.
Casting scaphoid waist fractures: to immobilize the thumb or not?
For confirmed nondisplaced or minimally displaced fractures of the waist of the scaphoid, it does not seem necessary to immobilize the thumb during casting. In a recent trial, there was a significant difference in the average extent of union, 10 weeks after injury, favoring treatment with a cast excluding the thumb: union rate of 85% with exclusion of the thumb compared with 70% when the thumb was included in casting. The overall union rate was 98%.
The study involved 62 patients with CT or MRI-confirmed nondisplaced or minimally displaced fracture of the scaphoid. The randomized trial compared treatment in a below-elbow cast that included or excluded the thumb. There were 55 waist and 7 distal fractures (owing to a miscommunication at 3 of the centers). Investigators adhered to intention-to-treat principles.
The primary outcome was the extent of union, as demonstrated on CT scans obtained after 10 weeks of cast treatment. Extent of union was expressed as a percentage of the fracture line that had bridging bone, which was determined by musculoskeletal radiologists blinded to treatment. Secondary study outcomes included wrist motion; grip strength; the Mayo Modified Wrist Score; the Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure; a visual analog scale for pain; and radiographic union at 6 months after injury.
There were no significant differences between groups for wrist motion; grip strength; Mayo Modified Wrist Score; DASH score; or pain intensity.
Source: Buijze GA, Goslings JC, Rhemrev SJ, et al. Cast immobilization with and without immobilization of the thumb for nondisplaced and minimally displaced scaphoid waist fractures: a multicenter, randomized, controlled trial. J Hand Surg Am. 2014;39(4):621-627.
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