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AAOS 2013: Clinical News Highlights – March 19

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Military Personnel Return to Duty Following Severe Injury to the Lower Extremity

Return to Duty of Special Operations Personnel after Limb Salvage for High Energy Lower Extremity Trauma
Return to Run (RTR) orthotic rehab initiative successfully returns 13 of 14 special operations personnel to duty

High-energy lower-extremity trauma (HELET) is common in modern warfare, often resulting in severe tissue damage, chronic pain, neurovascular injury and significant muscle loss. The Return to Run (RTR) program is an integrated orthotic and rehabilitation initiative designed to return high-level function to wounded warriors.  It includes use of the new Intrepid Dynamic Exoskeletal Orthosis (IDEO), a custom-fit device made from carbon and fiberglass that supports the foot and ankle allowing for greater mobility and vigorous rehabilitation. In the study, researchers reviewed RTR records of 14 Special Operations Command (SOCOM) personnel – 10 Army Special Forces, three Navy Sea Air Land (SEALs), and one Air Force Pararescue Jumper (PJ) – who sustained HELET injuries and completed the RTR program. Records were reviewed for functional capabilities – the ability to walk, run and jump without assistive devices; and occupational capabilities – standing continuously for more than one hour, moving with a load of 20 pounds or more, and the ability to return to duty and combat. Recreational capabilities include running and agility sport participation. Following RTR, 13 of the 14 service members (including three who had initially considered amputation) were deemed fit to return to duty, and at least seven returned to combat.

Gauging the Effects of a Sunny Climate on Vitamin D Levels in Hip Fracture Patients

Vitamin D Insufficiency in Patients with Acute Hip Fractures of All Ages and Both Sexes in a Sunny Climate
Living in a sunny climate does not improve vitamin D levels in hip fracture patients

While it is well known that a majority of hip fracture patients of all ages and both sexes have insufficient or deficient levels of vitamin D, a new study looks at whether or not living in a warm, sunny climate improves patient vitamin D levels. Researchers retrospectively reviewed the vitamin D levels of 1,539 patients, including 448 acute hip fracture patients and 1,091 total hip(THR) or total knee replacement(TKR) patients, from December 2010 to December 2011 at a major medical center in southern California. Patients were categorized based on their vitamin D levels – deficient, insufficient or sufficient – and according to age and sex. The mean vitamin D levels for the hip fracture and the THR and TKR patients were 26.38 ng/mL and 29.92 ng/mL, respectively. More patients in the hip fracture group were deficient or insufficient (65.8 percent versus 54 percent), and patients age 71 years and older were more deficient or insufficient in the hip fracture group than the joint replacement group (66.7 percent versus 47.13 percent). Overall, the majority of patients age 18 and older of both sexes with hip fractures had insufficient levels of vitamin D, and those age 71 or older had significantly lower levels than the control group of THA and TKA patients.

Measuring the Effects of Smoking on Orthopedic Healing, Pain

Smoking Cessation and the Aging Spine Patient
Spine patients who quit smoking report diminished pain

Smoking is a known risk factor for back pain and disc disease. In this study, researchers reviewed smoking cessation rates and related pain in 6,779 patients undergoing treatment for spinal disorders with severe axial (spine) or radicular (leg) pain. Information on each patient’s age, gender, weight, smoking history, assessment of pain, treatment type and co-morbid depression also were assessed. Overall, 8.9 percent of patients over the age of 55 smoked compared with 23.9 percent of those aged 55 and younger. Twenty-five percent of the patients older than age 55 had quit smoking, as did 26.1 percent of those younger than age 55. Current smokers in both age groups reported greater pain than those who had never smoked. Mean improvement in reported pain over the course of treatment was significantly different in non-smokers and current smokers in both age groups. Those who quit smoking during the course of care reported greater pain improvement than those who continued to smoke. As a group, those who continued smoking during treatment had no clinically significant improvement in reported pain, regardless of age.

Presenting New Research on Metal-on-metal Implants

MRI is Predictive of Adverse Tissue Reaction in Failed Metal-on-metal Hip Arthroplasty
An MRI can predict adverse tissue reaction in MoM patients, expediting treatment

Magnetic Resonance Imaging (MRI)can detect a failing, or potentially failing, metal-on-metal hip implant(MoM) early on, according to a new study, resulting in timely revision surgery and decreasing the risk for further tissue damage and pain. Researchers reviewed the MRI images of 70 patients who ultimately underwent revision surgery for a failed MoMimplant. The images were assessed for the presence of tissue damage, swelling and other characteristics.  The study found that an MRI is highly sensitive and specific to identifying tissue damage in MoM total hip replacement(THR) patients. Early identification of at-risk patients can result in timely revision surgery, when necessary, decreasing pain and future damage to surrounding hip tissue. Lead author disclosure.

On Friday, March 22, the educational session “Optimizing Management of Patients with Metal-on-metal Hips,” will feature seven orthopaedic experts discussing the identification and treatment of MoM hip failure.

In December 2012, the American Academy of Orthopaedic Surgeons(AAOS) issued an Information Statement on Metal-on-metal Hip Arthroplasty(replacement)  recommending a “low threshold” for commencing the evaluation of a patient with an MoM hip replacement, as “early recognition and diagnosis will facilitate the initiation of appropriate treatment prior to significant adverse biological reactions.” The statement also provides a detailed overview of various diagnostic and treatment methods to limit patient discomfort, and outlines when to quickly initiate treatment, and if necessary revision.

Source: AAOS.

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