American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting Clinical News Highlights





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. Lead author disclosure.
Gauging the Effects of a Sunny Climate on 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. Lead author disclosure.
Measuring the Effects of Smoking on Orthopaedic Healing, 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. Lead author disclosure.
Smoking has been linked to prolonged healing time and greater risk for complications in orthopaedic and other surgeries. In this new study, researchers reviewed records of all total hip replacement (THR, or total hip arthroplasty) patients between 2007 and 2009 to identify patients who used tobacco products at the time of surgery, or who smoked regularly prior to surgery. There were 110 patients who regularly smoked, with a mean age of 55 and a mean follow up of 46 months following THR. A control group was matched 2:1 with the smoking group based on gender, date of surgery within six months, age within five years, related medical conditions (co-morbidities) and immunosuppressive conditions. The smoking group was categorized as current or former smokers, and according to the number of packs of cigarettes smoked per year.  At the most recent follow up, the patients who smoked had a 92 percent survival rate compared to 99 percent for non smokers. Of the nine THR revisions in smokers, four were done to alleviate pain and/or to repair a loose acetabular component (the hip socket), and five resulted from infection. Of the current smokers, six of 65 had revisions (9.2 percent); of the former smokers, 2 out of 45 patients (4.4 percent). Overall, the patients who smoked had a higher overall revision rate and a higher incidence of other complications. The study authors recommend smoking cessation programs for all patients considering THR. Lead author disclosure.