Mortality rates at 10 years after metal-on-metal hip resurfacing compared with total hip replacement in England: retrospective cohort analysis of hospital episode statistics

Objectives To compare 10 year mortality rates among patients undergoing metal-on-metal hip resurfacing and total hip replacement in England.

Design Retrospective cohort study.

Setting English hospital episode statistics database linked to mortality records from the Office for National Statistics.

Population All adults who underwent primary elective hip replacement for osteoarthritis from April 1999 to March 2012. The exposure of interest was prosthesis type: cemented total hip replacement, uncemented total hip replacement, and metal-on-metal hip resurfacing. Confounding variables included age, sex, Charlson comorbidity index, rurality, area deprivation, surgical volume, and year of operation.

Main outcome measures All cause mortality. Propensity score matching was used to minimise confounding by indication. Kaplan-Meier plots estimated the probability of survival up to 10 years after surgery. Multilevel Cox regression modelling, stratified on matched sets, described the association between prosthesis type and time to death, accounting for variation across hospital trusts.

Results 7437 patients undergoing metal-on-metal hip resurfacing were matched to 22 311 undergoing cemented total hip replacement; 8101 patients undergoing metal-on-metal hip resurfacing were matched to 24 303 undergoing uncemented total hip replacement. 10 year rates of cumulative mortality were 271 (3.6%) for metal-on-metal hip resurfacing versus 1363 (6.1%) for cemented total hip replacement, and 239 (3.0%) for metal-on-metal hip resurfacing versus 999 (4.1%) for uncemented total hip replacement. Patients undergoing metal-on-metal hip resurfacing had an increased survival probability (hazard ratio 0.51 (95% confidence interval 0.45 to 0.59) for cemented hip replacement; 0.55 (0.47 to 0.65) for uncemented hip replacement). There was no evidence for an interaction with age or sex.

Conclusions Patients with hip osteoarthritis undergoing metal-on-metal hip resurfacing have reduced mortality in the long term compared with those undergoing cemented or uncemented total hip replacement. This difference persisted after extensive adjustment for confounding factors available in our data. The study results can be applied to matched populations, which exclude patients who are very old and have had complex total hip replacements. Although residual confounding is possible, the observed effect size is large. These findings require validation in external cohorts and randomised clinical trials.

 BMJ 2013;347:f6549

 http://www.bmj.com/content/347/bmj.f6549

Post-traumatic ulna plus variance associated with poor outcomes for distal radius fractures

Post-traumatic ulna plus variance associated with poor outcomes for distal radius fractures

Researchers in this study found that post-traumatic ulna plus variance greater than 2 mm was the only factor significantly associated with poor outcome when analyzing a cohort of young patients with unilateral distal radius fractures who were not yet at risk for osteoporosis.

“The present study showed that post-traumatic ulna [plus variance] is the most important factor in predicting bad outcome in non-osteoporotic patients, but that especially intra-articular fractures and to a lesser extent dorsal tilt may be of importance too,” the researchers wrote in the study abstract.

The researchers evaluated pre-reduction anteroposterior and lateral wrist radiographs from 66 patients with a median age of 42 years, according to the abstract. They measured fracture pattern, radial length, inclination, joint surface tilt, ulnar variance and measured outcomes using the Gartland and Werley score.

Although not statistically significant, the researchers noted that intra-articular fracture pattern may also be a strong marker for a poor outcome.

Beumer A. BMC Musculoskelet Disord. 2013. doi:10.1186/1471-2474-14-170.

Distal Radius Fractures: Is the use of locking plates justified?

Surgical Treatment of Distal Radial Fractures with a Volar Locking Plate Versus Conventional Percutaneous Methods: A Randomized Controlled Trial

Background:  The aim of this study was to compare the outcomes of displaced distal radial fractures treated with a volar locking plate with the results of such fractures treated with a conventional method of closed reduction and percutaneous wire fixation with supplemental bridging external fixation when required. Our aim was to ascertain whether the use of a volar locking plate improves functional outcomes.

Methods:  A single-center, pragmatic, randomized controlled trial was conducted in a tertiary care institution. One hundred and thirty patients (eighteen to seventy-three years of age) who had a displaced distal radial fracture were randomized to treatment with either a volar locking plate (n = 66) or a conventional percutaneous fixation method (n = 64). Outcome assessments were conducted at six weeks, twelve weeks, and one year. Outcomes were measured on the basis of scores on the Patient Evaluation Measure (PEM) and QuickDASH questionnaire (a shortened version of the Disabilities of the Arm, Shoulder and Hand, or DASH, Outcome Measure), EuroQol-5D (EQ-5D) scores, wrist range of motion, grip strength, and radiographic parameters.

Results:  The rate of follow-up at one year was 95%. Patients in the volar locking-plate group had significantly better PEM and QuickDASH scores and range of motion at six weeks compared with patients in the conventional-treatment group, but there were no significant differences between the two groups at twelve weeks or one year. Grip strength was better in the plate group at all time points. The volar locking plate was better at restoring palmar tilt and radial height. Significantly more patients in the plate group were driving at the end of six weeks, but this did not translate to a significant difference between groups in terms of those returning to work by that time.

Conclusions:  Use of a volar locking plate resulted in a faster early recovery of function compared with use of conventional methods. However, no functional advantage was demonstrated at or beyond twelve weeks. Use of the volar locking plate resulted in better anatomical reduction and grip strength, but there was no significant difference in function between the groups at twelve weeks or one year. The earlier recovery of function may be of advantage to some patients.


Karantana A et al. Surgical Treatment of Distal Radial Fractures with a Volar Locking Plate Versus Conventional Percutaneous Methods. J Bone Joint Surg Am 2013; 95: 1737–44; doi: 10.2106/JBJS.L.00232

More myths busted: Copper and magnet therapy are useless in rheumatoid arthritis

Folklore remedies for pain and inflammation in rheumatoid arthritis include the application of magnets and copper to the skin. Despite the popular use of devices containing magnets or copper for this purpose, little research has been conducted to evaluate the efficacy of such treatments.

Objective

To investigate whether the practice of wearing magnetic wrists straps, or copper bracelets, offers any specific therapeutic benefit for patients with rheumatoid arthritis.

Design

Randomised double-blind placebo-controlled crossover trial.

Methods

70 patients, aged 33 to 79 years and predominantly female (n = 52), with painful rheumatoid arthritis were recruited from general practices within Yorkshire. Participants were randomly allocated to wear four devices in a different order. Devices tested were: a standard (1502 to 2365 gauss) magnetic wrist strap, a demagnetised (<20 gauss) wrist strap, an attenuated (250 to 350 gauss) magnetic wrist strap, and a copper bracelet. Devices were each worn for five weeks, with treatment phases being separated by one week wash-out periods. The primary outcome measured was pain using a 100 mm visual analogue scale. Secondary pain measures were the McGill Pain Questionnaire and tender joint count. Inflammation was assessed using C-reactive protein and plasma viscosity blood tests and by swollen joint count. Physical function was assessed using the Health Assessment Questionnaire (Disability Index). Disease activity and medication use was also measured.

Results

65 participants provided complete self-report outcome data for all devices, four participants provided partial data. Analysis of treatment outcomes did not reveal any statistically significant differences (P>0.05) between the four devices in terms of their effects on pain, inflammation, physical function, disease activity, or medication use.

Principal findings

The results of this trial indicate that participants with rheumatoid arthritis obtained little if any specific therapeutic benefit from magnet therapy, involving the use of a 2200 gauss magnetic wrist strap for just over one month. The experimental wrist strap, which was typical of other commonly available devices as regards its magnetic properties and method of application, did not appear to outperform: (a) a very weak (300 gauss) magnetic wrist strap; (b) a non-magnetic wrist strap; or (c) a copper bracelet. Whilst estimated 95% confidence intervals for the individual comparison of experimental and control devices indicate that use of the standard magnetic wrist strap may have resulted in a modest reduction in pain, equivalent to 12 mm on a 100 mm pain VAS, they also indicate the possibility that use of this device may have resulted in a slight increase in pain. Despite such uncertainty, these differences may be viewed as small in terms of potential clinical relevance, and further results obtained for secondary pain measures failed to indicate any analgesic benefit whatsoever resulting from magnet therapy. No overall statistically significant differences were found between experimental and control devices for the primary pain outcome measure (i.e. pain VAS), the McGill Pain Questionnaire, self-assessed measures of tender and swollen joints, disease activity status, physical function, feelings of helplessness, or for two different blood tests used for monitoring levels of acute phase reactants as indicators of bodily inflammation, even when controlling for medication use, local rather than systemic inflammation, and non-compliance. Similarly, we did not observe any evidence, of statistical significance or likely clinical importance, to suggest superiority of the copper bracelet over other control devices.

Conclusions

Wearing a magnetic wrist strap or a copper bracelet did not appear to have any meaningful therapeutic effect, beyond that of a placebo, for alleviating symptoms and combating disease activity in rheumatoid arthritis.

 Richmond JS et al. Copper Bracelets and Magnetic Wrist Straps for Rheumatoid Arthritis – Analgesic and Anti-Inflammatory Effects: A Randomised Double-Blind Placebo Controlled Crossover Trial. PLoS ONE 20138(9): e71529

Decompression for cervical spondylotic myelopathy has potential to reverse neurological damage

At the 1-year follow-up, researchers who performed surgical decompression in patients with cervical spondylotic myelopathy found significantly improved disability-related, functional and quality-of-life outcomes, according to a study recently published in Journal of Bone & Joint Surgery.

“The results of this trial support the use of decompression surgery as a viable treatment for cervical spondylotic myelopathy and could lead to a change in practice to treat this condition,” neurosurgeon Michael G. Fehlings, who is medical director of the Krembil Neuroscience Centre at Toronto Western Hospital, stated in a press release. “With few existing interventions available for these patients, it is encouraging to have data showing improvements in quality of life as a result of surgery, in some cases, even reversing serious neurological damage that could have resulted in paralysis.”

 

Fehlings and colleagues analyzed results from a trial with 278 patients who had mild, moderate or severe cervical spondylotic myelopathy (CSM) conducted between 2005 and 2007 at 12 centers in the United States and Canada. Of the patients enrolled, 222 patients had 1-year follow-up data available.

The researchers found improved modified Japanese Orthopaedic Association, Neck Disability Index, SF-36 version 2 and Nurick grade scores in all patients between baseline and 1-year postoperative, according to the abstract. The rate of improvement did not depend upon preoperative CSM severity, and after a multivariate analysis, the results were unchanged when they adjusted for confounders.

“Although all patients experienced improvement in their condition after surgery, the challenge now is to ensure patients suffering from CSM receive surgical intervention in the earlier stages of the disease,” Fehlings said. “This approach ensures patients avoid permanent neurological impairment, and will reduce costs to the healthcare system over the long term.”

Reference:
Fehlings MG. J Bone Joint Surg Am. 2013;doi:10.2106/JBJS.L.00589.

5 Myth busters in Orthopaedivcs

Five Things Physicians and Patients Should Question

According to the AAOS, there are 5 myths that do not bring a substantial EBM based benefit for the orthopaedc patient. 

1

Avoid performing routine post-operative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.

Since ultrasound is not effective at diagnosing unsuspected deep vein thrombosis (DVT) and appropriate alternative screening tests do not exist, if there is no change in the patient’s clinical status, routine post-operative screening for DVT after hip or knee arthroplasty does not change outcomes or clinical management.

2

Don’t use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief.

The use of needle lavage in patients with symptomatic osteoarthritis of the knee does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness or swelling.

3

Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.

Both glucosamine and chondroitin sulfate do not provide relief for patients with symptomatic osteoarthritis of the knee.

4

Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.

In patients with symptomatic osteoarthritis of the knee, the use of lateral wedge or neutral insoles does not improve pain or functional outcomes. Comparisons between lateral and neutral heel wedges were investigated, as were comparisons between lateral wedged insoles and lateral wedged insoles with subtalar strapping. The systematic review concludes that there is only limited evidence for the effectiveness of lateral heel wedges and related orthoses. In addition, the possibility exists that those who do not use them may experience fewer symptoms from osteoarthritis of the knee.

5

Don’t use post-operative splinting of the wrist after carpal tunnel release for long-term relief.

Routine post-operative splinting of the wrist after the carpal tunnel release procedure showed no benefit in grip or lateral pinch strength or bowstringing. In addition, the research showed no effect in complication rates, subjective outcomes or patient satisfaction. Clinicians may wish to provide protection for the wrist in a working environment or for temporary protection. However, objective criteria for their appropriate use do not exist. Clinicians should be aware of the detrimental affects including adhesion formation, stiffness and prevention of nerve and tendon movement.

American Academy of Orthopedic Surgeons. Choosing Wisely®. Five Things Physicians and Patients Should Question. Online 11. September 2013

Incidence of displacement after nondisplaced distal radial fractures in adults.

BACKGROUND:

It is standard practice to closely monitor distal radial fractures treated nonoperatively to ensure that there is no fracture displacement. Patients are often asked to initially return weekly for radiographs. To our knowledge, nondisplaced distal radial fractures in adults have not been specifically evaluated to determine if this level of vigilance is required. If this subset of fractures is unlikely to displace, the cost, radiation exposure, and inconvenience of weekly office visits could be spared.

METHODS:

Using our billing database, we identified 642 closed distal radial fractures among the patients who presented to our institution during the four-year period from the beginning of 2006 to the end of 2009. Radiographs of the injuries were reviewed to identify fractures for which radiographic measurements were within predefined radiographic norms. Only those fractures that were believed to be nondisplaced by all reviewers were classified as nondisplaced for the purposes of this study. Radiographic measurements were made at the time of injury and at the time of fracture union to evaluate for displacement over time. The total number of clinic visits and radiographs that were received were calculated from the longitudinal medical record for each patient.

RESULTS:

Eighty-two fractures were identified as nondisplaced. None displaced or required operative intervention. The largest measured difference from injury to fracture union for radial inclination was 3.6° (average 0.8°); for radial height, 2.1 mm (average 0.5 mm); and for palmar tilt, 3.1° (average 1.0°). These numbers are all within the error of measurement.

CONCLUSIONS:

Nondisplaced distal radial fractures in adults appear to be inherently stable, and it may be appropriate to treat this subset of distal radial fractures with cast immobilization (when swelling allows) and a single follow-up visit with radiographs to document union at the time of cast removal.

LEVEL OF EVIDENCE:

Prognostic Level III.

Roth KM, Blazar PE, Earp BE, Han R, Leung A: Incidence of displacement after nondisplaced distal radial fractures in adults.J Bone Joint Surg Am. 2013 Aug 7;95(15):1398-402. doi: 10.2106/JBJS.L.00460.

CT scans increase the risk of cancer in children

Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians

 

Objective To assess the cancer risk in children and adolescents following exposure to low dose ionising radiation from diagnostic computed tomography (CT) scans.

Design Population based, cohort, data linkage study in Australia.

Cohort members 10.9 million people identified from Australian Medicare records, aged 0-19 years on 1 January 1985 or born between 1 January 1985 and 31 December 2005; all exposures to CT scans funded by Medicare during 1985-2005 were identified for this cohort. Cancers diagnosed in cohort members up to 31 December 2007 were obtained through linkage to national cancer records.

Main outcome Cancer incidence rates in individuals exposed to a CT scan more than one year before any cancer diagnosis, compared with cancer incidence rates in unexposed individuals.

Results 60 674 cancers were recorded, including 3150 in 680 211 people exposed to a CT scan at least one year before any cancer diagnosis. The mean duration of follow-up after exposure was 9.5 years. Overall cancer incidence was 24% greater for exposed than for unexposed people, after accounting for age, sex, and year of birth (incidence rate ratio (IRR) 1.24 (95% confidence interval 1.20 to 1.29); P<0.001). We saw a dose-response relation, and the IRR increased by 0.16 (0.13 to 0.19) for each additional CT scan. The IRR was greater after exposure at younger ages (P<0.001 for trend). At 1-4, 5-9, 10-14, and 15 or more years since first exposure, IRRs were 1.35 (1.25 to 1.45), 1.25 (1.17 to 1.34), 1.14 (1.06 to 1.22), and 1.24 (1.14 to 1.34), respectively. The IRR increased significantly for many types of solid cancer (digestive organs, melanoma, soft tissue, female genital, urinary tract, brain, and thyroid); leukaemia, myelodysplasia, and some other lymphoid cancers. There was an excess of 608 cancers in people exposed to CT scans (147 brain, 356 other solid, 48 leukaemia or myelodysplasia, and 57 other lymphoid). The absolute excess incidence rate for all cancers combined was 9.38 per 100 000 person years at risk, as of 31 December 2007. The average effective radiation dose per scan was estimated as 4.5 mSv.

Conclusions The increased incidence of cancer after CT scan exposure in this cohort was mostly due to irradiation. Because the cancer excess was still continuing at the end of follow-up, the eventual lifetime risk from CT scans cannot yet be determined. Radiation doses from contemporary CT scans are likely to be lower than those in 1985-2005, but some increase in cancer risk is still likely from current scans. Future CT scans should be limited to situations where there is a definite clinical indication, with every scan optimised to provide a diagnostic CT image at the lowest possible radiation dose.

 Mathews. J. D. et al. Cancer risk in 680.000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013 online 22. Mai; doi: 10.1136/bmj.f2360

Opinions regarding the managment of hand and wrist injuries in athletes

Abstract

Injuries to the hand and wrist are commonly encountered in athletes. Decisions regarding the most appropriate treatment, the timing of treatment, and return to play are made while balancing desires to resume athletic activities and sound orthopedic principles. Little recognition in the literature exists regarding the need for a different approach when treating these injuries in elite athletes and the timing to return to play.

This study explored the complexities of treating hand and wrist injuries in the elite athlete. Thirty-seven consultant hand surgeons for teams in the National Football League, National Basketball Association, and Major League Baseball completed a brief electronic survey about the management of 10 common hand injuries. Notable variability existed in responses for initial management, return to protected play, and return to unprotected play for all injuries, aside from near consensus agreement (94%) that elite athletes with stable proximal interphalangeal dislocations could immediately return to protected play. Basketball surgeons were less likely to recommend early return to protected play than non-basketball surgeons. Baseball surgeons were more likely to recommend early unprotected play after scaphoid fixation. Football surgeons were more likely to recommend earlier return to protected play after thumb ulnar collateral ligament injuries, whereas basketball surgeons were less likely to recommend earlier return to protected play.

This study demonstrated wide variability in how consultant hand surgeons approach the treatment of hand and wrist injuries. The findings emphasize the need to individually tailor treatment decisions to the patient’s desires and demands, particularly in high-performance athletes.

The authors are from the Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York.
The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Michelle Gerwin Carlson, MD, Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, 523 E 72nd St, 4th Floor, New York, NY 10021 (carlsonm@hss.edu).

Injuries to the hand and wrist are commonly encountered in athletes.^1–3  After arriving at a diagnosis, the treating physician must address the many considerations that make treating an athlete different than caring for other patients. Decisions regarding the most appropriate treatment, the timing of treatment, and circumstances surrounding return to play are made while balancing desires to resume athletic activities and sound orthopedic principles.⁴  The same complexities that differentiate the treatment of athletes from nonathletes are what distinguish the management of injuries in elite athletes.⁵  High-performance athletes are likely to have a different perspective than casual athletes, placing greater importance on return to play given the implications on their livelihood. Given these differences, expectations for treatment outcomes in elite athletes are likely to be higher than those of casual athletes. Although the literature is replete with case series and expert opinions regarding the management of hand and wrist injuries in athletes, little recognition exists regarding the need for a different approach when treating injuries in elite athletes and timing to return to play.

To further explore the complexities of treating hand and wrist injuries in elite athletes, the authors conducted a survey of consultant hand surgeons for professional football, basketball, and baseball teams in the United States. Physicians were asked about their practice of timing of surgery and return to play (both protected and unprotected) for 10 common hand injuries. The authors hypothesized opinions would vary widely regarding the treatment of hand and wrist injuries in elite athletes, with notable differences based on experience with athletes from different sports.

Materials and Methods

To generate the study cohort, team physicians for every team in the National Football League, National Basketball Association, and Major League Baseball were contacted and asked for the contact information for their consultant hand surgeon. Those 78 hand surgeons were requested to complete a brief electronic survey with questions about the management of metacarpal shaft fractures, scaphoid fractures, pisiform fractures, hamate hook fractures, thumb ulnar collateral ligament injuries, and dislocations of the proximal interphalangeal joint. This survey included questions about indications for surgery, return to protected play, and return for unprotected play (Table  ). The survey items were derived from the senior author’s (M.G.C.) experience in treating professional athletes, including primary coverage of a National Basketball Association team. Invitations to complete the anonymous survey were distributed via e-mail using third-party software (SurveyMonkey, Palo Alto, California). One reminder to complete the survey was sent after the initial invitation. The research protocol was approved by the authors’ institutional review board prior to survey administration.
 

Table: Return to Play and Treatment Recommendations According to Hand and Wrist Injury

Crosstab calculations and chi-square analysis were performed using SPSS version 19.0 software (IBM, Armonk, New York). Responses were compared by sport treated by the surgeon (baseball vs no baseball; football vs no football; basketball vs no basketball), by the number of sports treated (1 sport or more than 1 sport), and number of professional athletes treated (more or less than 12 per year). An a priori sample size calculation was not performed because a convenience sample of a limited cohort was planned.

Results

Thirty-seven consultant hand surgeons completed the survey, all of whom were affiliated with at least 1 professional sports team. Respondents were asked which sport they were currently affiliated with and were allowed to list more than 1 sport. Fifteen respondents reported that they treated elite athletes in only 1 sport and 22 reported that they treated elite athletes from more than 1 sport. The most commonly treated sports were baseball (n=22) and football (n=22), followed by basketball (n=19) and hockey (n=12). Eighteen of the respondents treated more than 12 elite athletes in 1 year, whereas 19 treated less than 12 elite athletes in 1 year.

Metacarpal Fractures

Protected Play. Slightly more than half (n=21; 56.8%) of the 37 respondents allow elite athletes with nondisplaced metacarpal fractures to return to protected play at 3 to 4 weeks after injury, whereas 14 (37.8%) allow immediate return to protected play. Surgeons who treated basketball players were less likely to recommend early return to protected play than non-basketball surgeons (P=.047).
Unprotected Play. Most respondents (n=27; 73%) waited until 4 to 8 weeks after injury for unprotected play to resume.

Scaphoid Fractures

Protected Play. Slightly more than half of the 37 respondents (n=19; 51.4%) allow elite athletes to return to protected play 4 to 6 weeks after treatment of a nondisplaced a scaphoid fracture. Twelve surgeons (32.4%) allow elite athletes to return to protected play immediately.
Unprotected Play. Opinions regarding return to unprotected play were more variable: 9 (24.3%) allow return to unprotected play after 4 to 6 weeks, 18 (48.6%) after 6 to 12 weeks, and 10 (27%) wait more than 12 weeks. Surgeons who treated baseball players were more likely than non-baseball surgeons to recommend their patients to unprotected play earlier after treatment of a nondisplaced a scaphoid fracture (P=.005). Surgeons who treated athletes from more than 1 sport were also more aggressive in recommending earlier unprotected play after treatment of a non-displaced a scaphoid fracture (P=.042).

Pisiform Fractures

Treatment Decision. For elite athletes with pisiform fractures, 11 (29.7%) surgeons allow immediate return to play, 7 (18.9%) recommend immediate excision, 8 (21.6%) recommend splinting for 4 weeks followed by return to sport, 3 (8.1%) recommend excision after 4 weeks if not healed, and 8 (21.6%) recommend excision after 8 weeks if not healed.
Surgeons who treat more than 12 elite athletes in 1 year are more likely to recommend immediate treatment (either immediate return to play or immediate excision), whereas surgeons who treat less than 12 elite athletes in 1 year are more likely to explore delayed treatment options (P=.043).

Hamate Hook Fractures

Protected Play. Following excision of hamate hook fractures, 11 (30.6%) of 36 surgeons allow immediate return to protected play, 19 (52.8%) allow return to protected play after 2 weeks, and 6 (16.7%) of surgeons allow return to protected play in 6 weeks.
Unprotected Play. More than half of the 37 surgeons (n=20; 54.1%) allow return to unprotected play at 6 weeks, 15 (40.5%) allow return to unprotected play at 2 weeks, and 1 (2.7%) allows immediate return to unprotected play.

Thumb Ulnar Collateral Ligament Tears

Treatment Decision. For an elite athlete with a complete thumb ulnar collateral ligament tear, 14 (37.8%) of the 37 surgeons recommended immediate repair, 12 (32.4%) recommended repair at the end of the season (if within 6 weeks), 3 (8.1%) recommended repair at the end of the season (if within 3 months), 7 (18.9%) recommended repair at the end of the season (even if beyond 6 months from injury), and 1 (2.7%) surgeon recommended nonoperative treatment.
Protected Play. For return to protected play after thumb ulnar collateral ligament injury, 5 (13.9%) of 36 surgeons recommended immediate return, 20 (55.6%)recommended waiting 2 weeks, 10 (27.8%) recommended waiting 6 weeks, and 1 (2.8%) recommended waiting 3 months. Surgeons who treat football players are more likely to recommend earlier return to protected play than non-football surgeons (P=.023), whereas surgeons who treat basketball players are less likely to recommend earlier return to protected play than non-basketball surgeons (P=.021).
Unprotected Play. For return to unprotected play, most of the 36 surgeons (n=23; 63.9%) recommended waiting 3 months.

Stable Proximal Interphalangeal Joint Dislocation

Protected Play. Almost all 36 (n=34; 94.4%) surgeons recommended immediate return to protected play for elite athletes with stable proximal interphalangeal dislocations, whereas 2 (5.6%) surgeons recommended waiting 4 weeks.
Unprotected Play. More than one-quarter (n=11; 29.7%) of the 37 surgeons recommended returning to unprotected play after 4 weeks, 14 (37.8%) recommended waiting 4 to 8 weeks, and 3 (8.1%) surgeons recommended a period of more than 3 months before return to unprotected play.

Discussion

Increasing awareness of the influence of patient expectations on treatment outcomes⁶  indicates that surgeons need to be more cognizant of what patients desire and expect from treatment. This is particularly true when treating athletes who not only participate in sports for recreational or fitness pursuits but also rely on their athletic abilities for their livelihood. Recognition of elite athletes as a distinct patient population is important in allowing surgeons and patients to participate in shared decision making that balances the desires of immediate return to play with long-term sequelae.⁴  In the current study, the authors demonstrated wide variability in how consultant hand surgeons approach the treatment of hand and wrist injuries. The individual experiences of the respondents have shaped their approaches to management, as the current results indicate that those who care for athletes of different sports occasionally have significantly different thresholds for return to protected and unprotected play. Treatment is tailored to the demands of the individual athletes and their sports, as evidenced by instances of more conservative management among surgeons who treat basketball players, whose sport requires distinct dexterity with a short interval between games.
Although this survey provides a glimpse into the decision making of consultant hand surgeons, it is beyond the scope of this investigation to indicate whether these treatment recommendations predict outcomes, and this research needs to be done. Surgeons must carefully counsel patients about the risks and benefits of each nuanced aspect of treatment and, in situations where athletic performance has deep-seated career or financial implications, informed and shared decision making is critical to ensure satisfactory outcomes.
As the authors demonstrated, a major challenge in treating elite athletes is determining the appropriate time frame for return to play. The benefits of early return must be weighed against the consequences of potential complications. Although all patients with fractures who return to play too early may experience delayed healing or nonunion, the difficulty in treating these sequelae vary depending on the type of fracture. Metacarpal shaft nonunions or malunions can be readily treated with internal fixation and bone grafting (if needed), whereas pisiform nonunions can be treated with excision. However, premature return to play after scaphoid fracture can create unnecessarily challenging treatment scenarios because an acute fracture that is easily treatable may develop into a difficult-to-treat nonunion. Because the latter may have substantial negative short- and long-term effects, return to play after scaphoid fractures should be approached with more caution. For example, the authors prefer to confirm at least 50% healing with computed tomography before allowing return to play. Conversely, for proximal interphalangeal dislocations, the risk of a redislocation is small, especially with buddy taping, and the likelihood of being able to reduce a redislocated joint is high. Surgeons have a low threshold to allow immediate return to play for this injury.
The main limitations of the current study are centered on the survey tool. The injuries included in the survey are those that were felt to be commonly encountered, but with at least mild to moderate controversy regarding treatment. The survey was not designed to assess actual treatment decisions, but rather to demonstrate variability in decision making among consultant hand surgeons. A formalized validation process was not undertaken, but the survey was internally piloted among the hand surgery faculty of the authors’ academic institution. The response rate of the study cohort was 47% (37 of 78 consultant hand surgeons), which is less than desired but acceptable when compared with other surveys of professional surgeon groups.^7–11  It is possible that the results may have been different if a larger proportion of the study cohort had completed the survey. Despite these limitations, the authors believe that the study has demonstrated the amount of variability in the decision making of consultant hand surgeons.

Conclusion

The findings emphasize the need to individually tailor treatment decisions to patients’ desires and demands, particularly in high-performance athletes. This survey has spurred the formation of a group of consultant hand surgeons who are now collaborating for multicenter prospective studies of hand and wrist injuries in elite athletes.

CJ Dy; E Khmelnitskaya; KA Hearns; MG Carlson: Opinions Regarding the Management of Hand and Wrist Injuries in Elite Athletes.Orthopedics; June 2013 - Volume 36 · Issue 6: 815-819

Major Medical Outcomes With Spinal Augmentation vs Conservative Therapy

Importance  The symptomatic benefits of spinal augmentation (vertebroplasty or kyphoplasty) for the treatment of osteoporotic vertebral compression fractures are controversial. Recent population-based studies using medical billing claims have reported significant reductions in mortality with spinal augmentation compared with conservative therapy, but in nonrandomized settings such as these, there is the potential for selection bias to influence results.
Objective  To compare major medical outcomes following treatment of osteoporotic vertebral fractures with spinal augmentation or conservative therapy. Additionally, we evaluate the role of selection bias using preprocedure outcomes and propensity score analysis.
Design, Setting, and Participants  Retrospective cohort analysis of Medicare claims for the 2002-2006 period. We compared 30-day and 1-year outcomes in patients with newly diagnosed vertebral fractures treated with spinal augmentation (n = 10 541) or conservative therapy (control group, n = 115 851). Outcomes were compared using traditional multivariate analyses adjusted for patient demographics and comorbid conditions. We also used propensity score matching to select 9017 pairs from the initial groups to compare the same outcomes.
Exposures  Spinal augmentation (vertebroplasty or kyphoplasty) or conservative therapy.
Main Outcomes and Measures  Mortality, major complications, and health care utilization.
Results  Using traditional covariate adjustments, mortality was significantly lower in the augmented group than among controls (5.2% vs 6.7% at 1 year; hazard ratio, 0.83; 95% CI, 0.75-0.92). However, patients in the augmented group who had not yet undergone augmentation (preprocedure subgroup) had lower rates of medical complications 30 days post fracture than did controls (6.5% vs 9.5%; odds ratio, 0.66; 95% CI, 0.57-0.78), suggesting that the augmented group was less medically ill. After propensity score matching to better account for selection bias, 1-year mortality was not significantly different between the groups. Furthermore, 1-year major medical complications were also similar between the groups, and the augmented group had higher rates of health care utilization, including hospital and intensive care unit admissions and discharges to skilled nursing facilities.
Conclusions and Relevance  After accounting for selection bias, spinal augmentation did not improve mortality or major medical outcomes and was associated with greater health care utilization than conservative therapy. Our results also highlight how analyses of claims-based data that do not adequately account for unrecognized confounding can arrive at misleading conclusions.

Brendan J. McCullough, Bryan A. Comstock, Richard A. Deyo, William Kreuter, Jeffrey G. Jarvi^: Medical Outcomes With Spinal Augmentation vs Conservative Therapy, JAMA, ONLINE FIRST

Claimant solicitors attack insurer’s ‘biased’ whiplash proposals

Wednesday 17 July 2013 by John Hyde

Claimant solicitors have dismissed a report into whiplash by insurer Axa as ‘highly biased’ and based on inaccurate or outdated statistics.

The insurance giant yesterday put pressure on the government to impose new medical and time limits for making low-value RTA claims.

The report pointed to countries such as Sweden and France as proof that the number of exaggerated or fraudulent claims will fall if the threshold is set higher.

But the Motor Accident Solicitors Society today rejected Axa’s report and said it ‘promised enlightenment but delivers only a blinkered view’.

In a statement, MASS said: ‘There are real dangers in trying to draw direct comparisons across different legal systems which have alternative structures, classifications of injuries and systems of award. 

‘Other countries may have a smaller proportion of whiplash claims, but this is likely to mean that genuine accident victims are not compensated and cannot access the support and rehabilitation services that they need.’

Axa had claimed that whiplash accounts for just 3% of all bodily injury claims in France, but MASS argued this figure was back-dated to 2004. The claimant organisation said the insurance industry’s own research, published this year, found there had been a 1,000% increase in whiplash claims, which now account for 30% of all PI claims.

Axa had lobbied for whiplash claims to be rejected without an x-ray or MRI scan, but MASS said it was ‘disingenuous’ to impose such rules for a soft-tissue injury.

The group added that by excluding injured people from receiving damages, more pressure would be placed on the NHS and the benefits system because it would have to support claimants unable to work.

The Law Society, which is running an advertising campaign urging accident victims to go to a solicitor, also dismissed the Axa recommendations. 

A Society spokesman said: ‘Whiplash can cause real, painful and debilitating injuries, not always revealed by x-rays or MRI scans. There is evidence that some insurers have offered paltry, insulting sums in compensation for nasty injuries. 

‘We are not interested in defending the small minority of accident claims which are fraudulent, but anyone who has suffered a genuine injury should get advice from a solicitor.’

 http://www.lawgazette.co.uk/news/claimant-solicitors-attack-insurer-s-biased-whiplash-proposals

Is It Time to Refine? An Exploration and Simulation of Optimal Antibiotic Timing in General Surgery

Postoperative infections increase morbidity, resource use, and costs. Our objective was to examine whether within guideline recommendations an optimal time exists for an initial dose of antibiotic to reduce postoperative infections in general surgery, and to simulate the magnitude of a reduction in infections should an optimal time be implemented.

Study Design

The population consisted of 6,731 patients who underwent 7,095 general surgery procedures between January 5, 2006 and June 25, 2012. Patients with pre-existing infections, such as pneumonia and sepsis, and patients with no recorded use of antibiotics were excluded, as were patients on vancomycin and surgical procedures longer than 4 hours in duration. The final analysis dataset included 4,453 patients. The National Surgical Quality Improvement Program was used for perioperative variables and outcomes. The end point was a composite of wound disruption; superficial, deep, organ space, surgical site infections; and sepsis. Semi-parametric logistic regression was used to study the association between antibiotic timing and infection.

Results

There were 444 (10%) patients with a primary end point of infectious complication. A nonlinear “bowl-shaped” relationship between duration of interval from antibiotic administration and surgical incision and infection was observed; lowest risk corresponding to administration time close to incision was 4 minutes before incision (95% one-sided CI, 0–18 minutes). The model suggested optimal timing would result in an 11.3% reduction in the primary infection end point.

Conclusions

Risk of infectious complications decreased as antibiotic administration moved closer to incision time. These data suggest an opportunity to reduce infections by 11.3% by targeting initial antibiotic administration closer to incision.


 Koch CG et al. Is It Time to Refine? An Exploration and Simulation of Optimal Antibiotic Timing in General Surgery. J Am Coll Surg 2013; online 10. Juli

Shoulders with bony Bankart lesions show bone fragment absorption

Shoulders with bony Bankart lesions show bone fragment absorption

Bone fragment absorption in shoulders with bony Bankart lesions after traumatic anterior shoulder instability correlated with the time after trauma, according to results of this study by Japanese researchers.

“Bone fragment absorption was seen in all of the shoulders with bony Bankart lesions. Most bone fragments showed severe absorption within 1 year after the primary traumatic episode,” Shigeto Nakagawa, MD, PhD, and colleagues from Osaka, Japan, wrote in the study abstract. “Before arthroscopic Bankart repair, not only glenoid defects but also bone fragment absorption should be assessed.”

Nakagawa and colleagues prospectively analyzed 163 shoulders using CT scans. They found that 55 shoulders had no glenoid defects, 16 shoulders had erosions, and 92 shoulders had glenoid defects, according to the abstract. The average glenoid defect size was 7.9% at less than 1 year, 10.7% between 1 year and 2 years and 11.3% after 2 years. 

The results showed some bone fragment absorption in all shoulders with glenoid defects: <50% absorption was seen in 32 shoulders, >50% absorption in 45 shoulders and 100% absorption in 15 shoulders. In shoulders scanned at less than 1 year, the extent of absorption was 51.9%. Between 1 year and 2 years, the extent of absorption was 65.3%, while in shoulders scanned after 2 years the extentof absorption was 70%, according to the abstract. 

Nakagawa S. Am J Sports Med. 2013. doi:10.1177/0363546513483087

Review: Researchers unclear whether ACL reconstruction prevents long-term OA development

Review: Researchers unclear whether ACL reconstruction prevents long-term OA development

Researchers from the United States and France used results from a 23-year follow-up of a case series by researchers in Lyon, France and a systematic review of the literature to find the long-term effects of ACL reconstruction, meniscal repair and degenerative change of osteoarthritis on patients with an ACL injury.

“Data from the Lyon series indicate that patients with no evidence of degenerative change on plain films 11 years after surgery are at very low risk to develop osteoarthritis over the next 15 years,” Philippe Neyret, MD, and colleagues wrote in the study. “Similarly, if early evidence of degenerative change is visible on radiographs 11 years following surgery, the risk of significant progression of osteoarthritis over the next 15 years is quite high.”

 

Neyret and colleagues found in their literature review that patients with ACL-deficient knees showed osteoarthritis (OA) in 40% of cases after 15 years, with some studies showing 90% of patients developing OA in long-term follow-up at 25 years and 35 years. However, their literature review provided mixed results for whether ACL reconstruction reduced the long-term incidence of OA.

The researchers noted the meniscus plays an important role at the time of ACL reconstruction: OA risk increased anywhere from twofold to tenfold for patients with a total meniscectomy compared to patients with an intact meniscus, according to the abstract.

Magnussen R. Cartilage. 2013. doi:10.1177/1947603513486559

Axa calls for three-day limit on whiplash claims

Link to Law Gazette.co.uk

Tuesday 16 July 2013 by John Hyde

Whiplash claims should be made within three days of the alleged accident and include evidence of physical injury if they are to succeed, insurance giant Axa said today.
The recommendations are part of a wishlist for the government to adopt on whiplash, copying models already in place in France and Sweden.
In its whiplash report published today at a roundtable co-hosted by former justice secretary Jack Straw, Axa said research suggests its reforms would significantly reduce the number of exaggerated or fraudulent claims.
The report recommends that whiplash injuries should not be recognised until doctors can see evidence of the injury, such as an MRI scan or x-ray. Axa says this system is already in place in France, where the average cost of an insurance premium is roughly two-thirds of that in the UK and whiplash injuries account for 3% of all bodily injury claims.
In Sweden, where Axa said insurance costs 46% less on average than in the UK, insurers generally reject cases where symptoms appear more than 72 hours after the accident.
A whiplash commission set up in 2002 created this rule of thumb to counteract the increasing number of claims and insurance costs came down as a result.
The Axa recommendations go further in asking for medical evidence than the Ministry of Justice has previously indicated. The government is expected to introduce a national accredited panel of experts to assess contested whiplash claims in the autumn.
Axa also calls on the government to extend the small-claims track limit to £10,000 – double the threshold currently proposed.
The insurer also wants existing reforms, particularly the ban on referral fees, to be more vigilantly policed, with further legislation if necessary. The report stated: ‘It seems clear that the Legal Aid, Sentencing and Punishment of Offenders Act 2012 (LASPO) is being circumvented by those who are finding creative ways around the ban.’
Chris Voller (pictured), Axa claims director, said: ‘Certain measures adopted in France and Sweden in particular offer very valuable insight into what works in practice and demonstrate several elements which could be adopted by the UK and that we believe would make a significant difference to the cost of premiums.
‘We would urge the government to look at what has worked in France and Sweden – specifically in relation to the requirement for medical evidence and the implementation of a minimum time threshold – as it considers how best to manage whiplash claims moving forward.’

ACL re-injuries are six times more likely for athletes after ACL reconstruction and return-to-sport

According to a presenter at the American Orthopaedic Society for Sports Medicine Annual Meeting, Chicago, athletes who sustained an ACL injury are at greater risk for subsequent ACL injuries during the first 2 years after reconstruction and return-to-sport compared to athletes who have not had an ACL injury. 

 “Our second injury rate in the first 24 months is relatively high. We see more contralateral injuries in female athletes than ipsilateral re-tears in the ACL reconstruction cohort, and the second ACL injury seems to occur early on after the return-to-sport,” said Mark V. Paterno, PT, PhD, MBA, SCS, ATC, from the Cincinnati Children’s Hospital, said at the American Orthopaedic Society for Sports Medicine Annual Meeting.

Paterno and colleagues studied the incidence rate of a second ACL injury in the 2 years following ACL reconstruction and return-to-sport in a young, active population. They hypothesized the incidence rate of a subsequent ACL injury would be less than the incidence rate reported within the first 12 months after return-to-sport, but greater than the ACL injury incidence rate in an uninjured cohort of young athletes.

In their prospective study, the investigators enrolled 78 patients (59 women, 19 men) aged 10 years to 25 years who underwent ACL reconstruction and returned to a pivoting/cutting sport and compared them to 47 healthy, control athletes (34 women, 13 men) without a history of ACL or lower extremity injury. All athletes were playing a pivot/cut sport for more than 50 hours per year. Each athlete was followed for injury and athletic exposure data.

Paterno and colleagues found 23 patients in the ACL reconstruction group and four athletes in the uninjured group had an ACL injury during the 24-month period. The overall incidence rate of a second ACL injury within 24 months after ACL reconstruction and return-to-sport was nearly six times greater than uninjured group.

Female athletes who had an ACL reconstruction showed a four times greater rate of injury within 24 months of return-to-sport than the female control athletes. Within the ACL reconstruction group, the female athletes were two times more likely to have a contralateral injury, he said.

Overall, 29.5% of athletes had a second ACL injury within 24 months of return-to-sport with 20.5% having a contralateral injury and 9% having an ipsilateral graft re-tear injury. More women (23.7%) had a contralateral injury than men (10.5%).

Reference:

Paterno MV. Paper #2. Presented at the American Orthopaedic Society for Sports Medicine Annual Meeting; July 11-14, 2013; Chicago.

Expectations predict the outcome after injuries

Background

Individuals' expectations on returning to work after an injury have been shown to predict the duration of time that a person with work-related low back pain will remain on benefits; individuals with lower recovery expectations received benefits for a longer time than those with higher expectations. The role of expectations in recovery from traumatic neck pain, in particular whiplash-associated disorders (WAD), has not been assessed to date to our knowledge. The aim of this study was to investigate if expectations for recovery are a prognostic factor after experiencing a WAD.

Methods and Findings

Holm et al used a prospective cohort study composed of insurance claimants in Sweden. The participants were car occupants who filed a neck injury claim (i.e., for WAD) to one of two insurance companies between 15 January 2004 and 12 January 2005 (n = 1,032). Postal questionnaires were completed shortly (average 23 d) after the collision and then again 6 mo later. Expectations for recovery were measured with a numerical rating scale (NRS) at baseline, where 0 corresponds to “unlikely to make a full recovery” and 10 to “very likely to make a full recovery.” The scale was reverse coded and trichotomised into NRS 0, 1–4, and 5–10. The main outcome measure was self-perceived disability at 6 mo postinjury, measured with the Pain Disability Index, and categorised into no/low, moderate, and high disability. Multivariable polytomous logistic regression was used for the analysis. There was a dose response relationship between recovery expectations and disability. After controlling for severity of physical and mental symptoms, individuals who stated that they were less likely to make a full recovery (NRS 5–10), were more likely to have a high disability compared to individuals who stated that they were very likely to make a full recovery (odds ratio [OR] 4.2 [95% confidence interval (CI) 2.1 to 8.5]. For the intermediate category (NRS 1–4), the OR was 2.1 (95% CI 1.2 to 3.2). Associations between expectations and disability were also found among individuals with moderate disability.

Conclusions

Individuals' expectations for recovery are important in prognosis, even after controlling for symptom severity. Interventions designed to increase patients' expectations may be beneficial and should be examined further in controlled studies.

 Holm LW, Carroll LJ, Cassidy JD, Skillgate E, Ahlbom A (2008) Expectations for Recovery Important in the Prognosis of Whiplash Injuries. PLoS Med 5(5): e105. doi:10.1371/journal.pmed.0050105

Pseudotumors in metal-on-metal hips

Study: High rate of hip resurfacing wear associated with pseudotumors

In this study, researchers from the United Kingdom concluded the majority of pseudotumors seen in patients with failed metal-on-metal hip resurfacing implants are due to implant wear.

“This increased wear is associated with soft tissue necrosis and a heavy nonspecific foreign-body macrophage response coupled with a variable adaptive or specific immune response,” David W. Murray, FRCS(Orth), and colleagues wrote in the study abstract. “A minority of pseudotumors are associated with low wear and a prominent immune response.”

Murray and colleagues examined 56 metal-on-metal hip resurfacing implants – 45 cases had a symptomatic tumor as the reason for failure, according to the abstract. They found that 80% of tumors were from a “highly worn” implant and substantial necrosis and a heavy macrophage infiltrate was present in most periprosthetic soft tissue. They also noted aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) infiltrate in many patients. However, even low wear was correlated with a strong ALVAL infiltrate response, according to the abstract.

“These findings confirm that minimizing wear from metal-on-metal hip resurfacing arthroplasty prostheses would lead to a reduction in the incidence of pseudotumor,” the authors wrote. “However, a small number of pseudotumors are still likely to occur, which may be due to an exacerbated adaptive immune response.”

Grammatopoulos G. J Bone Joint Surg Am. 2013. doi:10.2106/JBJS.L.00775.

Removal of horizontal meniscus tears: Does your patient benefit from surgery?

Clinical issue:

It was thought that the clinical outcomes of arthroscopic meniscectomy will be better than those of nonoperative treatment for a degenerative horizontal tear of the medial meniscus. 

The study:

In a randomized controlled trial (level 1 evidence), a total of 102 patients with knee pain and a degenerative horizontal tear of the posterior horn of the medial meniscus on magnetic resonance imaging werefollowed up between January 2007 and July 2009. The study included 81 female and 21 male patients with an average age of 53.8 years (range, 43-62 years). Fifty patients underwent arthroscopic meniscectomy (meniscectomy group), and 52 patients underwent nonoperative treatment with strengthening exercises (nonoperative group). Functional outcomes were compared using a visual analog scale (VAS) for pain, Lysholm knee score, Tegner activity scale, and patient subjective knee pain and satisfaction. Radiological evaluations were performed using the Kellgren-Lawrence classification to evaluate osteoarthritic changes. 

Results: 

In terms of clinical outcomes, meniscectomy did not provide better functional improvement than nonoperative treatment. At the final follow-up, the average VAS scores were 1.8 (range, 1-5) in the meniscectomy group and 1.7 (range, 1-4) in the nonoperative group (P = .675). The average Lysholm knee scores at 2-year follow-up were 83.2 (range, 52-100) and 84.3 (range, 58-100) in the meniscectomy and nonoperative groups, respectively (P = .237). In addition, the average Tegner activity scale and subjective satisfaction scores were not significantly different between the 2 groups. Although most patients initially had intense knee pain with mechanical symptoms, both groups reported a relief in knee pain, improved knee function, and a high level of satisfaction with treatment (P < .05 for all values). Two patients in the meniscectomy group and 3 in the nonoperative group with Kellgren-Lawrence grade 1 progressed to grade 2 at the 2-year follow-up. 

Conclusion: 

There were no significant differences between arthroscopic meniscectomy and nonoperative management with strengthening exercises in terms of relief in knee pain, improved knee function, or increased satisfaction in patients after 2 years of follow-up. 

Source: 

Ji-Hyeon Yim, Jong-Keun Seon, Eun-Kyoo Song,  Jun-Ik Choi, Min-Cheol Kim,  Keun-Bae Lee,  Hyoung-Yeon Seo: A Comparative Study of Meniscectomy and Nonoperative Treatment for Degenerative Horizontal Tears of the Medial Meniscus. Presented at the 38th annual meeting of the AOSSM, Baltimore, Maryland, July 2012.