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Rotator Cuff Repair: Analyzing Trends

Arthroscopic and open repair of rotator cuff tears have been established in published research to have comparable clinical results, with each having distinct advantages and disadvantages. Some studies have looked at geographic variation in the number of rotator cuff surgical procedures performed. Others have explored variations in what surgeons deemed to be indications for rotator cuff surgery. Despite many investigations having addressed repair techniques, indications for surgery, and outcomes in selected patients, little has been reported on recent trends of rotator cuff repair use nationwide. In a study published in the February 2012 Journal of Bone and Joint Surgery, Alexis C. Colvin, MD, and colleagues examined the rates of medical visits for rotator cuff pathology and for open and arthroscopic rotator cuff repair between 1996 and 2006 throughout the United States. The setting where the surgery was performed and the characteristics of patients—including age, sex, and comorbidities—were also analyzed in the study. “We wanted to determine if surgeons are now performing more arthroscopic rotator cuff repairs than in years past and where these repairs are being performed,” explains Dr. Colvin. “We also wanted to learn more about the characteristics of patients who had surgery in inpatient versus outpatient settings, surgical times associated with these procedures, and trends in anesthesia use.” Rotator Cuff Repairs on the Rise According to findings, the volume of all rotator cuff repairs increased by 141% from 1996 to 2006 (Table). While the number of arthroscopic procedures increased by 600%, the number of open repairs increased by only 34% during the time period assessed. “The number of open repairs increased for patients who were younger than...

The Changing Tide of Knee Arthroscopy in the U.S.

CDC data show that knee arthroscopy is one of the most frequently performed ambulatory orthopedic procedures in the United States. The surgery is now primarily used for the removal of loose bodies, debridement of meniscal tears, debridement and recontouring of cartilage flaps, arthroscopically assisted ligament reconstruction and meniscal transplantation, and synovectomy. In the early 1980s, there was a shift toward performing some surgical procedures on an outpatient basis for a variety of reasons. “Advances in anesthesia and surgical techniques, financial incentives to providers and patients, and enhancements in postoperative pain management were all factors that led to this shift,” explains Richard A. Marder, MD. “It’s well understood that the number of ambulatory surgical procedures is increasing, but there has been little study exploring the frequency and magnitude of these procedures occurring in outpatient settings in the U.S.” Significant 10-Year Trends In the June 1, 2011 Journal of Bone and Joint Surgery, Sunny H. Kim, PhD, Jose Bosque, MD, John P. Meehan, MD, Amir Jamali, MD, and Dr. Marder had a study published that described the changes in demographics and utilization of knee arthroscopy in ambulatory settings between 1996 and 2006 in the U.S. The investigation, which analyzed CDC data from the National Survey of Ambulatory Surgery, also sought out to determine the most common reasons for knee arthroscopy over the past decade. “Our analysis revealed several interesting trends,” says Dr. Marder. “First, between 1996 and 2006, the number of knee arthroscopies increased by 49% (Table 1). The increase in knee arthroscopy procedures was much steeper than the growth of the U.S. population during the same period.” “Clinicians should continue to...

Strategies to Manage Traction-Table Complications

Traction tables are used in different types of procedures for the hip and femur, including fracture fixation, hip arthroscopy, and less-invasive arthroplasty. Although there is a relatively low incidence of traction table-related complications, usage is not without risks. Complications range from the relatively benign, such as transient post­operative groin numbness, to the catastrophic and life-threatening, such as injuries to the perineal integument and soft tissues, neurologic impairment, and iatrogenic compartment syndrome of the well leg. Although severe events are rare, they have serious implications to patient safety. Reviewing the Current Literature In the November 2010 Journal of the American Academy of Orthopaedic Surgeons, my colleagues and I published a review that assessed the medical literature relating to traction-table complications after surgery. In our analysis, several key themes emerged. First, greater awareness by surgeons of these events—especially for potentially catastrophic events—is critical to improving patient safety and quality. Second, certain positions on traction tables should be avoided—especially the hemilithotomy position—to avoid complications. Third, efforts should be made to ensure that positioning and draping permit ongoing evaluation of the uninjured extremities and the overall condition of patients. For example, reduce the use of shower curtains or drapes since these make it difficult for surgeons to see the well leg or check the abdomen in trauma patients. “Although there is a relatively low incidence of traction-table related complications, usage is not without risks.” Specific types of patients and situations can increase the likelihood of traction-table complications. Patients with complex fracture patterns and older individuals appear to be at greater risk for these complications. Complex fractures often require longer surgery durations. This can put...

Guidelines for Managing Patients With Shoulder Arthritis

According to data from the CDC, more than 51 million Americans have been diagnosed with some form of arthritis, and the estimated annual cost for medical care of arthritis and joint pain was $281.5 billion in 2004. Arthritis of the glenohumeral joint can be the result of primary osteoarthritis, posttraumatic deformity, inflammatory arthritis, sepsis, or avascular necrosis. Epidemiological data suggest that the incidence of glenohumeral joint osteoarthritis is more common in women and appears to increase with age. The risk of shoulder arthritis is increased by a history of injury or surgery to the shoulder. “Patients diagnosed with osteoarthritis of the shoulder experience pain, progressive loss of function, and diminished quality of life,” says Rolando Izquierdo, MD. “Shoulder replacement surgery has become the third most common joint surgery, following hip and knee replacements, due to the increasing burden of glenohumeral joint osteoarthritis. Most treatments for glenohumeral joint osteoarthritis are associated with some known risks, especially invasive and operative treatments. Contraindications can also vary widely based on the treatment administered. As such, discussion of available treatments and procedures that may be applicable to patients should rely on mutual communication with physicians. This dialogue should weigh the potential risks and benefits for each patient, based on their individual medical characteristics.” Evidence-Based Guidelines The American Academy of Orthopaedic Surgeons (AAOS) recently released an evidence-based clinical practice guideline on the treatment of glenohumeral joint osteoarthritis in adults aged 19 and older. The guideline provides information on patient management after the diagnosis of osteoarthritis of the glenohumeral joint. The final treatment guidelines contain 16 recommendations and include both operative and non-operative treatment options (Table)....

Conference Highlights: American Academy of Orthopaedic Surgeons 2010

The American Academy of Orthopaedic Surgeons, or AAOS, held its 2010 annual meeting from March 9 to 12 in New Orleans. The features below highlight some of the news emerging from the meeting. For more information on these items and other research that was presented, go to www.aaos.org. Improving Healing After Rotator Cuff Surgery The Particulars: Rotator cuff tears are common sports injuries that lead to pain and restricted motion. Surgery to repair the damage can help reduce pain, but poor healing can still occur, leading to an incomplete recovery of function. Studies have indicated that less than 70% of rotator cuff repairs are completely healed when evaluated 2 years after surgery. Teriparatide (Forteo, Eli Lilly), an FDA-approved therapy for osteoporosis that has been shown to stimulate bone growth and slow the rate of bone loss, might enhance the healing process after rotator cuff surgery. Data Breakdown: Using a rat model, researchers performed rotator cuff surgery and then administered teriparatide injections in amounts comparable to human doses. At 2 weeks after surgery, the repair was not as strong in the rats who received teriparatide injections. However, at weeks 4 through 8, the tendon to bone interface appeared much more like normal tissue. Closer examination showed that the rats receiving teriparatide injections produced more bone and cartilage cells. The organization of the tissue was also better, more closely resembling normal tissue. The tendon was also significantly stiffer, a sign of proper healing, at 8 weeks. Take Home Pearls: Teriparatide injections appear to be a promising strategy to promote improved healing and function in patients undergoing rotator cuff surgery. The agent...
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