Literature

Evidence based literature that is truly important to your orthopaedic clinical practice.

The FDA this week approved dabigatran (Pradaxa) for prevention of DVT and pulmonary embolism following hip arthroplasty surgery. The approval follows FDA analysis of two randomized phase 3 trials (RE-NOVATE and RE-NOVATE II) in which patients who took dabigatran experienced lower rates of venous thromboembolism and all-cause death than those who took enoxaparin. Conversely, those taking the higher dose of dabigatran (220 mg) had higher rates of major bleeding than those taking enoxaparin. The FDA initially approved dabigatran to reduce the risk of stroke and embolism in patients with nonvalvular atrial fibrillation; the recent hip-replacement indication is the fourth in five years for this novel anticoagulant.

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The connection between patient pain and clinical orthopaedic outcomes has received much attention lately. Here are relevant findings from two recent studies: –An in-press study of 48 patients(average age of 72 years) who underwent TKA found that those with low pain thresholds prior to surgery (as measured with VAS scores while a blood-pressure cuff was inflated over the proximal forearm) were more likely to have lower Knee Society pain and function scores two years after surgery than those with moderate or high pain thresholds. The authors use this test in preoperative workups, and they advise patients who grade the cuff stimulus as severe that “their clinical outcomes are expected to be inferior to [those of] other patients,” encouraging such patients to take that into account before consenting to surgery.

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When treating shoulders with a Bankart lesion that includes an osseous fragment, many orthopaedic surgeons excise the fragment while repairing the capsulolabral complex, and then deploy one of various bone-augmentation procedures to address glenoid bone loss. But in the November 18, 2015 issue of JBJS, Kitayama et al. report on positive medium- to long-term results with a procedure that incorporates the osseous fragment into the Bankart repair and thus avoids invasive bone-grafting procedures. Thirty-eight patients with a chronic osseous Bankart lesion and >15% bone loss of the inferior glenoid who underwent the procedure described by Kitayama et al. were available for follow-up after a mean of 6.2 years.

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The rate of graft failure following anatomic ACL reconstruction has been reported to be as high as 13%, nearly double the reported failure rate of transtibial reconstructions. The majority of anatomic graft failures occur six to nine months after surgery, when patients commonly return to full sports activity. Findings from a cadaver study by Araujo et al. in the November 4, 2015 edition of The Journal of Bone & Joint Surgery may help explain these phenomena. The authors used a robotic system to measure in situ forces on 12 native cadaver ACLs and on three different reconstructions, one representing the anatomic approach and two reconstructions approximating traditional transtibial approaches.

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In an ideal world, nothing would interfere with long-bone growth plates in kids and adolescents. But physes are the weakest areas of the growing skeleton and are thus vulnerable to any number of injuries and insults. The most frequent complication resulting from growth-plate disturbances is premature arrest of bone growth that can lead to alignment problems and limb-length discrepancies. The October 28, 2015 “Case Connections” from JBJS Case Connector highlights four case reports focused on tibial and femoral growth-plate disturbances. In two of the case reports, including the springboard case by Tomatsuri et al. from the October 28, 2015 edition of JBJS Case Connector, the injuries were associated with reconstruction of a torn anterior cruciate ligament (ACL).

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Scoliosis is a three-dimensional deformity (coronal, axial, and sagittal), so it makes sense that a 3-D imaging method for evaluating the condition and measuring the impact of surgical correction would outperform traditional two-dimensional imaging techniques. That’s exactly what Newton et al. found in their Level II diagnostic study in the October 21, 2015 edition of The Journal of Bone & Joint Surgery. The authors analyzed 3-D and 2-D images from 120 patients with adolescent idiopathic scoliosis (AIS), before and after surgery with segmented thoracic pedicle-screw instrumentation. The mean preoperative Cobb angle on the standard 2-D view was 55° ± 10°, while on the 3-D view it was 52° ± 9° (p ≤ 0.001).

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Irrigation and debridement of open fractures have been standard practices since the late 1800s.  However, the finer details have not been agreed upon. For example, should we use higher pressures with pulsatile lavage devices?  And will adding soap to standard saline irrigation solution get better results? Answers to those two questions from lab and animal studies over the years have been limited and contradictory. The goal of the recently reported FLOW study (Fluid Lavage of Open Wounds) was to answer those questions definitively. Initially, a pilot study with just over 100 patients suggested that using soap might yield fewer adverse events requiring a return to the OR.

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It’s a generally accepted “fact” that total knee arthroplasty (TKA) ranks among the most significant modern medical advancements. But the October 22, 2015 NEJM published the first rigorously controlled randomized study that “proves” that “fact” by comparing TKA to nonsurgical management. One hundred patients with moderate-to-severe knee osteoarthritis were randomly assigned to undergo TKA followed by 12 weeks of rigorous nonsurgical treatment, or the nonsurgical treatment alone. Over a 12-month follow-up period, TKA was superior to nonsurgical treatment in terms of pain relief and functional improvement, but it was also associated with a higher number of serious adverse events, including deep-vein thrombosis and infection.

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Despite a higher rate of complications than in the general population, overall outcomes of lumbar spine surgery in patients with mild to moderate Parkinson disease are favorable, with significant improvements in spine-related pain and function. So concludes a study by Schroeder et al. in the October 21, 2015 Journal of Bone & Joint Surgery. Improvements were seen in surgeries with and without instrumentation over an average follow-up of more than two years. Among the 20 of 96 patients in the study who required revision surgery, risk factors for revision included a Parkinson disease severity of ≥3 on the modified Hoehn and Yahr scale, a history of diabetes mellitus, treatment for osteoporosis, and a combined anterior/posterior surgical approach (which was used in 22 of 63 patients who underwent instrumented fusions).

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As if on cue, a just-published study in JAMA backed up the recent AAOS statement on opioids by finding that neither the opiate oxycodone nor the muscle relaxant cyclobenzaprine (Flexeril) is a helpful adjunct to naproxen for acute, nontraumatic, nonradicular low back pain. The study randomized 323 emergency-department (ED) patients presenting with low back pain to receive a 10-day course of naproxen + placebo, naproxen + cyclobenzaprine, or naproxen + oxycodone/acetaminophen. The improvement in scores on the Roland-Morris Disability Questionnaire between the time of ED discharge and one week later was similar in all three groups. This finding led Journal Watch Emergency Medicine Associate Editor Daniel Pallin, MD to comment that “prescribing opioids for a condition that evidence-based consensus guidelines warn against can lead to abuse and addiction.

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