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Volume 6 - Issue 1, February 2013
Current Orthopaedic Practice E-News
Welcome Orthopaedics in Brief Article of the Month Practice Management
Editor: Nanci Kulig

Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, find out whether dexamethasone is effective for local infiltration analgesia. Learn why it is important to assess for deep vein thrombosis in athletes. Read what research suggests is the best treatment for acute patellar dislocation, and more.

In this month's Practice Management, discover an interesting topic to raise during a staff meeting. Plus, get an idea for a staff education exercise that could help improve patient service.

In Article of the Month, please enjoy free access to an article from the current issue of Spine.

Have a comment or suggestion? Contact me at editor@c-orthopaedicpractice.com.

Nanci Kulig
Editor, COP eNews

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All-arthroscopic vs. mini-open rotator cuff repair in small tears

Among patients with full-thickness small to medium-sized tears, do clinical outcomes differ in the first year between those who had all-arthroscopic (AA) and those who underwent mini-open (MO) rotator cuff repair? To find out, researchers randomly assigned 100 patients to 1 of the 2 repairs.
     Researchers evaluated patients' clinical status before surgery and at 6, 12, 26, and 52 weeks after surgery. Ultrasonography was used to assess the repair's structural integrity 1 year postoperatively.
     Forty-seven patients in the AA group and 48 in the MO group completed the study. Five patients did not complete follow-up. Primary and secondary outcome measures significantly improved in both groups. Differences between the treatment groups with regard to overall average primary and secondary postoperative outcome scores did not reach statistical significance. However, at 6 weeks of follow-up, Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale score for pain and impairment, and active forward flexion were significantly more improved in the AA group compared with the MO group. A re-tear occurred in 8 patients (17%) in the AA group and 6 patients (13%) in the MO group. Five patients (11%) in the AA group and 6 patients (13%) in the MO group developed adhesive capsulitis.
     Researchers concluded that functional outcome, pain, range of motion, and complications do not differ significantly between patients treated with AA repair and those treated with MO repair in the first year after surgery. Patients seem to realize the benefits of treatment sooner with the arthroscopic procedure.

Source: van der Zwaal P, Thomassen BJ, Nieuwenhuijse MJ, et al. Clinical outcome in all-arthroscopic versus mini-open rotator cuff repair in small to medium-sized tears: a randomized controlled trial in 100 patients with 1-year follow-up. Arthroscopy. 2013;29(2):266-273.

How effective is dexamethasone on local infiltration analgesia?

Intraoperative local infiltration analgesia is used with increasing frequency in joint replacement surgery. There is considerable variation among drug combinations, and the analgesic effects of each drug are not well understood. In a recent study, adding a corticosteroid to local anesthetics in local infiltration analgesia reduced inflammation locally and systemically. Also, adding the corticosteroid resulted in significant early pain relief and rapid recovery in patients who underwent total knee arthroplasty.
     In the study, 40 patients were randomly assigned to a corticosteroid or control group. Patients in the corticosteroid group received a peri-articular injection of ropivacaine, dexamethasone, and isepamicin. Dexamethasone was omitted from the analgesic mixture in the control group. The primary outcome was pain severity at rest, which was measured with a 100-mm visual analog scale.
     Pain severity in the corticosteroid group was lower than that in the control group, and there were significant differences between the groups at 1 and 3 days after surgery. Reduction in postoperative pain was associated with a decrease in levels of serum C-reactive protein and interleukin 6 in drainage fluid. Fifteen of 20 patients in the corticosteroid group could perform a straight leg raise 2 days after surgery, compared with a significantly lower 5 of 20 patients in the control group who could perform the leg raise at the same point postoperatively.

Source: Ikeuchi M, Kamimoto Y, Izumi M, et al. Effects of dexamethasone on local infiltration analgesia in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2013 Jan 11. [Epub ahead of print]

Assessing for deep vein thrombosis in athletes

Typically, athletes have a low risk of venous thrombosis; however, this population has many acquired risk factors that make it important to keep the possibility in mind. Because deep vein thrombosis (DVT) can occur after orthopaedic procedures, knowing a patient's hereditary and acquired risk factors for DVT is essential.
     Hereditary forms of thrombophilia include factor V Leiden and prothrombin G20210A mutations and deficiencies of antithrombin III, protein C, and protein S. Acquired risk factors include trauma, immobilization, and surgical procedures. Typical acquired risk factors for athletes include hemoconcentration, trauma, immobilization, long-distance travel, and use of oral contraceptives. During preparticipation physical examinations and preoperative assessments, orthopaedic surgeons should consider screening athletes for thrombogenic risk factors, including history of venous thrombosis, hypercoagulable disorders, or high-altitude exercise.
     If a patient is at high risk for DVT, preventive measures should be undertaken, including physical antithrombotic measures and/or low-molecular-weight heparin. If an athlete develops DVT, a risk factor assessment should be conducted and anticoagulation treatment administered in accordance with American College of Chest Physicians guidelines.

Source: Grabowski G, Whiteside WK, Kanwisher M. Venous thrombosis in athletes. J Am Acad Orthop Surg. 2013;21(2):108-117.

Acute patellar dislocation: best treatment

Common among adolescents, acute patellar dislocation frequently is associated with sporting and physical activities. Patellar re-dislocation after a first episode seems to depend mostly on the medial patellofemoral ligament injury that represents the primary ligamentous restraint, providing 50% to 60% of the restraining force against lateral patellar displacement. After a first patellar dislocation, 94% to 100% of patients experience medial patellofemoral ligament rupture.
     Controversy continues as to how to manage patients with a first patellar dislocation. Although most authors report good results with conservative treatment after a first-time dislocation, several circumstances may warrant surgical intervention. For instance, a surgical approach would be necessary in the presence of severe cartilage damage or a relevant disruption of the medial stabilizers with subluxation of the patella. In such patients, reconstruction of medial stabilizers should follow treatment of the chondral injury.
     Medial patellofemoral ligament reconstruction may be a more reliable method of stabilizing the patella than repairing it, which has limitations related to the location of the medial patellofemoral ligament injury. Currently, there is no evidence to indicate that osseous abnormalities should be treated in addition to restoration of the medial patellofemoral ligament.

Source: Panni AS, Vasso M, Cerciello S. Acute patellar dislocation. What to do? Knee Surg Sports Traumatol Arthrosc. 2013;21(2):275-278.

Pulsed healing for delayed union of long-bone fractures

Patients with delayed union of long-bone fractures who received an early application of pulsed electromagnetic field (PEMF) achieve a significantly increased rate of union and overall reduced time to union compared with patients who receive PEMF after 6 months or more of delayed union, according to new study results.
     Previous studies indicate that PEMF is an effective adjunct treatment for nonunion long-bone fractures. In most studies, PEMF treatment is not implemented until at least 6 months of delayed union or nonunion after fracture treatment. In this prospective study involving 58 patients with delayed union of long-bone fractures, researchers compared the outcomes of patients receiving early application of PEMF with those of a sham-treated control group. Healing status was evaluated clinically and radiographically. Treatment efficacy was assessed at 3-month intervals.
     Patients in the PEMF group had a higher rate of union than those in the control group after the first 3 months of treatment, but these results were not statistically significant. PEMF treatment conducted for an average of 4.8 months resulted in a 77.4% success rate, which was significantly higher than the 48.1% success rate documented in the control group, which had an average duration of 4.4 months of sham treatment. The average total time from operation to the end of the study was 9.6 months for patients in the PEMF treatment group.

Source: Shi HF, Xiong J, Chen YX, et al. Early application of pulsed electromagnetic field in the treatment of postoperative delayed union of long-bone fractures: a prospective randomized controlled study. BMC Musculoskelet Disord. 2013 Jan 19;14:35.

Comparing long-term outcomes of 2 treatments for rotator cuff intact osteoarthritis

How do patients fare 10 years after having hemiarthroplasty (HA) or total shoulder replacement (TSR) as treatment of osteoarthritis? In a new study involving 33 patients, researchers intraoperatively randomized patients to either HA or TSR (13 HA and 20 TSR) after glenoid exposure and tracked their progress for a minimum of 10 years postoperatively. With the exception of patients who died, no patients were lost to follow-up.
     At 6 months and at 1 year, patients who underwent TSR had less pain than those who had HA, and this finding became more pronounced at 2 years postoperatively. However, by 10 years postoperatively, there were no statistically significant differences between the groups with respect to pain, function, or activities of daily living. No patients in the HA group rated their shoulders as pain-free at 10 years; however, 42% of surviving TSR patients rated their shoulders as pain-free at 10 years. During the follow-up period, 4 patients who underwent HA required revision to TSR for severe pain secondary to glenoid erosion. Two shoulders in the TSR group required revision. Nine of the 13 patients who underwent HA (69%) and 18 of the 20 patients who underwent TSR (90%) remained in situ at death or at the 10-year review.
     Based on their findings, researchers concluded that TSR has advantages over HA with respect to pain and function at 2 years. The long-term review does not support the contention that HA avoids TSR-related adverse events later. Instead, HA was associated with an unacceptable rate of glenoid component failure.

Source: Sandow MJ, David H, Bentall SJ. Hemiarthroplasty vs total shoulder replacement for rotator cuff intact osteoarthritis: how do they fare after a decade? J Shoulder Elbow Surg. 2013 Jan 16. pii: S1058-2746(12)00445-4. [Epub ahead of print]

A new way to ID the biopsy track in musculoskeletal tumor surgery

Patients with malignant musculoskeletal tumors can experience recurrence along the biopsy track after a percutaneous needle biopsy. To excise the track with the tumor completely, identification is essential. However, identifying this track becomes increasingly difficult over time.
     During a 3-month period in an initial prospective study, 22 of 45 patients (48.8%) who underwent resection of a musculoskeletal tumor had an unidentifiable biopsy site at operation. Identification of the biopsy site is statistically more difficult after 50 days.
     To prevent this issue, investigators began the practice of marking the biopsy site with India ink. In all 55 patients who underwent this procedure, the biopsy track was identified preoperatively--a statistically significant difference. Therefore, investigators recommended this technique as a safe, easy, and accurate way to ensure adequate excision of the biopsy track.

Source: Jalgaonkar A, Dawson-Bowling SJ, et al. Identification of the biopsy track in musculoskeletal tumour surgery: A novel technique using India ink. Bone Joint J. 2013;95-B(2):250-253.

Spinal imaging: merits of 2-D thick-slice magnetic resonance myelography

Two-dimensional (2-D), single, thick-slice magnetic resonance myelography (MRM) could improve spinal imaging as an add-on to routine magnetic resonance imaging (MRI) sequences, according to results of a new study. In the study, 220 patients underwent 2-D single thick-slice MRM that was performed using a T2-weighted, half-Fourier acquisition, single-shot turbo spin-echo (HASTE) sequence in addition to routine MRI of the spine.
     The images were evaluated for additional diagnostic information in spinal and extra-spinal regions. Investigators used a 3-point grading system to evaluate the utility of MRM in detecting spinal or extraspinal issues. Grade 1 represented no benefit from MRM. Grade 2 indicated that MRM offered some benefit. Grade 3 indicated that MRM was essential to detecting findings.
     The utility of MRM in the spine was categorized as grade 3 in 10.9% of cases (24/220), grade 2 in 21.8% of cases (48/220), and grade 1 in 67.3% of cases (148/220). Overall, additional merit of MRM in the spine was documented in 32.7% of cases (72/220). In 14.1% of cases, extraspinal pathologic entities were identified.

Source: Aggarwal A, Azad R, Ahmad A, Arora P, Gupta P. Additional merits of two-dimensional single thick-slice magnetic resonance myelography in spinal imaging. J Clin Imaging Sci. 2012 Dec 31;2:84. [Epub ahead of print]

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Patient communication: a potential staff meeting topic

If you're looking for a compelling topic for an upcoming staff meeting, consider covering the importance of good, caring patient communication. Staff members need continual reminders about how important it is to make the entire patient experience pleasant. It is essential that the appointment schedule, the insurance paperwork, the medical record system, and any job frustrations not get in the way of a caring relationship with patients. If effective patient communication can be achieved on a regular basis, your practice will be successful.
     An example of a patient communication misstep that occurred during a visit to an orthopaedic specialist follows.
     A technician, who was around age 25, escorted a patient who was about 70 years of age to an examination room. They were walking down a narrow hallway that did not allow them to walk side by side, so the technician led the way. While walking, she decided to start taking the case history, presumably to save time. The first problem was that she faced straight ahead, as she walked, so it was difficult for the patient to hear her clearly. It may not have helped that he was older. It also did not help that the patient could not walk as fast as the technician (it was an orthopaedic office, after all).
     While walking, the technician asked what sounded like, "So did you have a totalnee?" The patient said "I beg your pardon?" The technician responded without turning her head or making an effort to speak more clearly: "Did you have a total knee or just a partial?" The patient said, "I'm sorry, I don't understand..."
     The patient history eventually was recorded, but the patient probably felt frustrated. Should the technician have expected the patient to know the meaning of "totalnee?" Medical terms, especially jargon, may not be in a patient's normal vocabulary. A caring staff member must take the time to ask questions in a quiet and private environment, looking directly at the patient and using a clear tone of voice.

A potential staff education exercise
This exercise involved tellers at a bank, but it could be useful in any office that deals with the public. Bank tellers were asked to take part in role-play sessions, in which they were to act as bank customers. The intent was to make the tellers more sensitive to elderly customers who often come into the bank in person rather than using electronic or drive-up services. Each teller had to wear eyeglasses with petroleum jelly smeared on the lenses to simulate a customer with vision problems. The tellers also had to place cotton balls in their ears. They waited in line until it was their turn, and then they had to carry out a transaction, such as write a check and accept cash back. The bank president related that the role-playing exercise was a great learning experience that stayed with the employees.

Adapted from Neil B. Gailmard, OD, MBA, FAAO, editor, Optometric Management Tip of the Week.

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Please enjoy free access to the article, "Outpatient Surgery Reduces Short-Term Complications in Lumbar Discectomy: An Analysis of 4310 Patients from the ACS-NSQIP Database" from the February 2013 issue of Spine. Free access to this article lasts until your next issue of COP eNews arrives, when you'll receive free access to a new article.

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