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 http://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 may eventually be applied to other tendon to bone surgeries, such as bicep tears or patellar tendon tears in the knee. Future studies will look to determine the optimum delivery time of teriparatide injections after surgery.
Analyzing Expectations After Joint Replacement
The Particulars: The goal of total hip and knee replacement surgeries is to provide durable pain relief and improvement of function so that patients can resume enjoyable, productive lives. Patient expectations after total joint replacement surgery are an important factor in perceived outcomes. Unrealistic patient expectations that are not properly addressed preoperatively or achieved after surgery can lead to patient dissatisfaction. Low patient expectations for function after surgery may lead to poorer adoption of postoperative recovery strategies, such as physical therapy.
Data Breakdown: Researchers compared expectations of 42 patients undergoing one of two joint replacement surgeries (total hip replacement and total knee replacement) with those of their doctors through surveys. Significant variability was observed between surgeons and their patients. A clinically meaningful disagreement was observed in 68% of patients; 53% of the patients’ expectations exceeded expectations of their surgeons.
Take Home Pearl: Doctor and patient expectations are sometimes not aligned when knee and hip joint replacement surgery is utilized. Steps need to be taken to bridge the expectation gap. Results indicate that inexpensive, educational interventions (eg, preoperative classes) could be offered, and steps should be taken to use these interventions to improve patient and physician dialogue.
Spinal Procedures Using BMP
The Particulars: Research has shown that bone morphogenetic protein (BMP) is widely used as a substitute for iliac crest bone grafts, and its use has been increasing at a rapid pace in recent years. From 2003 to 2007, the use of BMP more than quadrupled, being used in 23,900 procedures in 2003 to 103,194 procedures in 2007. Currently, the FDA has approved BMP only for anterior lumbar interbody fusion.
Data Breakdown: To examine the prevalence of the on- and off-label use of BMP in the United States, researchers examined data from the Nationwide Inpatient Sample from October 2002 through December 2007. During this timeframe, there were 340,251 primary inpatient procedures involving BMP, 92.8% of which were for spine fusions. Only 16.6% of the procedures in the study involved theFDA-approved use of BMP. Most spine procedures involved off-label uses of BMP, including 30% for posterior lumbar interbody fusion/transforaminal lumbar interbody fusion; 20.4% for posterolateral spine fusion; 13.6% for cervical fusions; and 3.9% for thoracolumbar fusions.
Take Home Pearls: The vast majority of spinal procedures involving BMP appear to be off-label uses. Although it is believed that BMP is safe and effective for some of these off-label uses, concerns about the protein’s use include its cost and medical issues (eg, potential heterotopic bone formation, transient bone resorption, soft tissue swelling, seroma formation, and radiculitis). When using BMP off-label, physicians must be cautious and have good reason to believe it will be used safely and effectively.
A Look at Complications in Pediatric Hip Arthroscopy
The Particulars: Hip arthroscopy has become an effective procedure in adults and is beginning to be utilized in children and adolescents. Currently, complication rates associated with the procedure have not been as well characterized for children and adolescents as they have been for adults.
Data Breakdown: A retrospective analysis of 198 primary hip arthroscopies was carried out in 175 patients aged 18 and younger in order to identify complications and general adverse outcomes. The majority of indications for surgery in the analysis were for isolated labral tears and labral tears with femoral acetabular displacement. The complication rate in the study population was 3.5%. Complications after arthroscopy included: transient pudendal nerve palsy, apophysitis, arthrofibrosis, instrument breakage, suture abscess, and synovitis.
Take Home Pearl: Hip arthroscopy in children and adolescents appears to be a safe procedure with few complications.
Total Shoulder Arthroplasty Safe for Octogenarians
The Particulars: Little data exist about the safety or efficacy of shoulder replacement in patients aged 80 and older. Because of the paucity of data, some physicians may be hesitant to recommend surgery to patients in this age range.
Data Breakdown: A study was performed to review the safety and outcomes of primary shoulder arthroplasty for octogenarian patients with osteoarthritis. Between 1980 and 2000, 51 total shoulder replacements in 45 patients between the ages of 80 and 89 were performed. Medical comorbidities were common in this patient group, length of hospital stay was prolonged, and blood transfusions were common. However, there were no perioperative deaths, and pain was significantly reduced. Patients also experienced improved motion in active elevation, external rotation, and internal rotation.
Take Home Pearls: Total shoulder arthroplasty appears to be safe and effective for the treatment of osteoarthritis among patients aged 80 and older. The treatment appears to be definitive for most patients for the remainder of their lives, but medical or surgical complications are common. More intense patient care in the perioperative period may be required.