AAOS: Bloggers discuss air travel for patients after total joint reconstruction, infection

CHICAGO — Some of the most anticipated research in the field of orthopedics is being presented at this year's American Academy of Orthopaedic Surgeons Annual Meeting. To expand our coverage, Orthopedics Today caught up with residents to get their opinions and impressions on this year’s conference.

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Study suggests patients can safely fly soon after arthroplasty

By Roshan P. Shah, MD, JD

There are no good guidelines on whether fresh arthroplasty patients can travel by airline in the immediate postoperative period. But the presentation yesterday by Herbert J. Cooper, MD may help us understand the risks. They found venous thromboembolism in 3 of 220 patients who flew (1.4%) and 13 of 1,245 patients (1%) who did not. Notably, the study group was largely chemoprophylaxed with aspirin and the average flight duration was about 3 hours. Although a definitive conclusion cannot be made on the risks, the rates are low and similar. The authors suggest that early flight may be safe and describe their recommendations of wearing compression stockings, performing ankle pumps, and getting up to walk during the flight.

There are no good guidelines on whether fresh arthroplasty patients can travel by airline in the immediate postoperative period. But the presentation yesterday by may help us understand the risks. They found venous thromboembolism in 3 of 220 patients who flew (1.4%) and 13 of 1,245 patients (1%) who did not. Notably, the study group was largely chemoprophylaxed with aspirin and the average flight duration was about 3 hours. Although a definitive conclusion cannot be made on the risks, the rates are low and similar. The authors suggest that early flight may be safe and describe their recommendations of wearing compression stockings, performing ankle pumps, and getting up to walk during the flight.

Roshan P. Shah

Expectations for symptom relief after knee arthroplasty in young patients may be better set following the presentation by Ryan Nunley, MD. In a multicenter survey of patients youunger than 60 years, more than 90% were satisfied with their pain relief. However, there were some residual symptoms in about a third of patients.

Glenn J. Kerr, MD reported results of an investigation into the effect of malnutrition on elective arthroplasty patients. In a prospective study of more than 2,000 patients, the authors found the prevalence of malnutrition to be 8.5%. The complication rate of malnourished patients was 12% compared to 2.9% of patients with normal transferring and albumin values. Notably, more than 40% of the malnourished patients were obese. Malnourished patients were more likely to be revision cases and more likely to have a hospital stay of more than 3 days. These results will be relevant as risk stratification begins to determine patient eligibility for elective procedures. It will be interesting to learn how the outcomes change when the malnutrition is corrected, and further, how the costs of these tests balance against savings associated with an intervention.

References:

Berend KR. Paper #698. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.

Cooper HJ. Paper #694. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.

Kerr GJ. Paper #771. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.

Disclosure: Shah has no relevant financial disclosures.

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Propionibacterium acnes infections in shoulder surgery continue to be a vexing problem

By Jason E. Hsu, MD

Friday’s morning shoulder and elbow session on shoulder arthritis and anatomic shoulder arthroplasty was devoted to Propionibacterium acnes infections, which continue to be a widely discussed topic in shoulder surgery during the past few years.

Diagnosing the infection is difficult due to the low virulence of the organism, vague clinical presentation and difficulty in growing the organism. Recent literature support the practice of holding cultures for at least 10 days to 14 days if such an infection is suspected. Data presented yesterday suggest that a substantial percentage of infections are missed unless the cultures are held past 14 days. Frederick A. Matsen, MD and the group from the University of Washington showed a high rate of positive cultures in revision arthroplasty setting, with upwards of 70% of the infections positive for P. acnes. Intra-operative frozen sections have not been reliable in determining whether a P. acnes infection is present, as demonstrated by Joseph P. Iannotti, MD, and his group from Cleveland Clinic. Thomas Duquin, MD and the group from University of Buffalo presented interesting data that suggested that hemolytic strains of P. acnes are more pathogenic and may have a more aggressive clinical presentation than non-hemolytic strains.

Jason E. Hsu

Other presentations from the morning session included two studies that implicate local anesthetics in the induction of cell death in chondrocytes and synoviocytes. In particular, 0.5% bupivacaine caused direct release of matrix metalloproteases and chondrocyte injury. Also, studies on anatomic total shoulder arthroplasties continued to show that glenoid loosening is a common problem seen with long term follow-up. Discussion questioned the clinical significance of this finding given the low rates of revision for symptomatic loosening in comparison to the rate of radiographic glenoid loosening.

The afternoon session was highlighted by a prospective multicenter, randomized control trial from the United Kingdom that compared primary plate fixation to nonoperative treatment of displaced midshaft clavicle factors. Their data show that non-union was significantly reduced with plate fixation, and the plate fixation group had statistically better functional outcomes. However, this difference was not significant when patients when non-unions were removed excluded.

The balance of presentations focused on shoulder instability and provided additional perspectives to Tuesday’s sports medicine sessions on instability. Seung-Hyun Cho, MD and colleagues from Korea show that bony Bankart lesions under 25% of the glenoid can be successfully be managed arthroscopically with various repair techniques. Gilles Walch, MD and his group from France presented long-term results of the Latarjet procedure and demonstrated that the prevalence of postoperative development of arthritis is low at 20 years. As pointed out by moderators G. Russell Huffman, MD and Robert Z. Tashjian, MD, the challenge of long-term patient follow-up may explain discrepancies in rates of osteoarthritis development between this study and the long term studies recently reported by Lennart Hovelius, MD, which demonstrated a high rate of arthropathy after dislocation.

References:

Papers #571, #578, #579, #580, #581, #582, #583, #585, #707, #715 and #716. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.

www.ncbi.nlm.nih.gov/pubmed/19254851

Disclosure: Hsu has no relevant financial disclosures.