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Alcohol Improves Bone Density?; Early Motion = Less Rotator Cuff Pain; Muscle Mass Predicts Mortality in Fracture Patients

Elizabeth Hofheinz, M.P.H., M.Ed. • Thu, June 22nd, 2017

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Alcohol Helps Functioning After Fracture Fixation?

Although at first glance you might toast these results, the authors advise a bit of caution. Researchers from New York University Hospital for Joint Diseases (NYU HJD) have found that when it comes to functioning after fracture fixation, social and moderate drinking had a protective effect as far as functional outcomes.

Their work, “Social to Moderate Alcohol Consumption Provides a Protective Effect for Functional Outcomes After Fixation of Orthopaedic Fractures,” was published in the June 2017 edition of the Journal of Orthopaedic Trauma.

Kenneth Egol, M.D., a co-author on the study, vice chair for education in the department of orthopaedic surgery at NYU HJD, told OTW, “The association between modest alcohol consumption and good bone health has been cited in the literature. For example, moderate alcohol intake increases bone density, particularly in elderly women. In operative orthopaedic patents, low-level alcohol drinkers have a decreased risk of 30-day post-operative complications. With these associations in mind, we sought to identify the association between modest alcohol consumption and functional outcomes following surgical management of acute and chronic orthopaedic fractures.”

At baseline, there was no significant difference in baseline SMFA scores among abstinent, social, and moderate drinkers. However, at 3-, 6-, and 12-month follow-up intervals, the mean SMFA [Short Musculoskeletal Function Assessment] scores of social and moderate drinkers were significantly lower than those of abstinent patients, indicative of better functional outcomes. Although these results initially seem surprising, they are in fact consistent with the available literature; there is a ‘J-shape’ relationship between alcohol and health. Moderate alcohol has been shown to have multiple benefits compared to abstinence, is like when you compare those people who doesn't get supplements as kratom online and the people that consume it, and find better results on the ones that does.

“Perhaps the most difficult aspect of this study was to systematically stratify the drinking behaviors of our patients as there are many facets of drinking, such as frequency, chronicity, and binge habits. Nonetheless, we characterized our patients into groups according to their self-reported alcohol consumption frequency by utilizing the classification system established by the National Institute of Alcohol Abuse and Alcoholism (NIAAA).”

“The mechanism by which social and moderate alcohol consumption provides a protective association with functional outcomes of orthopaedic patients remains elusive. Perhaps the personality of these moderate drinkers enables them to adapt to stresses in their environment, such as an orthopaedic injury. Further studies should be performed to fully understand the association we observed.”

“As orthopaedic surgeons, it is our responsibility to strive to understand how particular lifestyle factors and use of various substances affect the outcomes of our patients. Although we are not condoning alcohol usage for our operative patients, the phenomenon we observed is very intriguing and should be further studied to fully appreciate the clinical effects of modest alcohol consumption following operative treatment of orthopaedic fractures.”

Rotator Cuff Repair: Early Movement=Less Pain

After learning that their colleagues were divided on whether to get patients moving right after arthroscopic rotator cuff repair or make patients wait for weeks, researchers dove in to determine any differences in outcomes. Their study, “The Effect of Early Range of Motion on Quality of Life, Clinical Outcome, and Repair Integrity after Arthroscopic Rotator Cuff Repair,” was published in the June 2017 edition of Arthroscopy.

Two co-authors on the study were Mark P. Cote, P.T., D.P.T., M.S. C.T.R., director of outcomes, research, and quality for the UConn Musculoskeletal Institute at UConn Health, and Augustus D. Mazzocca, M.S., M.D., the Harry and Helen Gray/Harry R. Gossling, M.D. Chair in Orthopaedic Surgery.

Drs. Cote and Mazzocca told OTW, “When this study was conceived there was little known about how the postoperative period impacted patient outcomes following rotator cuff repair. Rehabilitation is believed to be an important factor however postoperative protocols tend to vary from surgeon to surgeon. We wanted to optimize the postoperative recovery period and felt rehabilitation was the best place to start.”

“We had reviewed the literature and conducted a survey at an orthopaedic society meeting and found that surgeons generally fall into to one of two categories, those who allowed their patients to move early, sometimes almost immediately, and those who preferred to wait about four weeks before initiating range of motion exercises. This dichotomy sparked our interest and led to the design of a randomized clinical trial to examine whether or not a difference in patient-reported outcomes and structural failure rates existed between these two different approaches.”

The authors wrote, “…Seventy-three patients from a single surgeon's practice who underwent arthroscopic repair of a single-tendon rotator cuff tear were randomized to either an early motion protocol (starting 2 to 3 days after surgery) or a delayed motion protocol (starting 28 days after surgery)…”

Drs. Cote and Mazzocca commented to OTW, “Rotator cuff repair impacts patient health on several levels. We wanted to ensure we were capturing meaningful data at each of these levels. We made it a point to include patient-reported outcome measures, in particular a disease specific quality of life measure as we were interested in the impact of the two rehabilitation protocols from the perspective of the patient. We also included MRI [magnetic resonance imaging] evaluation of the repair at six months to examine the status of the repair. These outcome measures allowed us to capture what effect each of these two protocols had on healing and allowed us to quantify the experience of the patient throughout the postoperative period.”

“Patients in both groups did very well. At six months post repair, there was no difference between the two groups in terms of healing on MRI and patient reported outcome measures. This is important because six months after the repair is when most patients return to work and sport activity. At the beginning of the recovery process, the patients in the early group were doing better in terms of physical symptoms, i.e., less pain, more comfortable. However at six months both groups had very good and near equivalent outcome scores.”

“Patients who had a recurrent tear on MRI at six months felt great and in some cases better than those with an intact repair. This interesting finding was discovered due to our study design. An MRI at six months post repair is not the standard of care, especially in patients who felt great. To our surprise, some of these patients had a recurrent tear. We are planning to follow these patients long term to determine whether the recurrent tear becomes symptomatic.”

“The patients who moved early had less physical symptoms however compliance with postoperative instructions is important. Patients who were not compliant with the sling or home program tended to have a recurrent tear on MRI.”

CT: Muscle Size Predicts Mortality in Hip Fracture Patients

In what is the first study to use the imaging technology to link survival with hip fractures, researchers from the University of California (UC) Davis School of Medicine and the Wake Forest School of Medicine have determined that using computed tomography (CT) to evaluate muscle health may help doctors identify the best treatments for elderly patients who fall and break their hips.

Their research, “CT of Patients with Hip Fracture: Muscle Size and Attenuation Help Predict Mortality,” was published in the June issue of the American Journal of Roentgenology.

The authors wrote, “A retrospective 10-year study of patients with hip fracture was conducted with the following inclusion criteria: age 65 years or older, first-time hip fracture treated with surgery, and CT of the chest, abdomen, or pelvis. This yielded 274 patients…”

Robert Boutin, M.D. is a radiologist with UC Davis Health and a co-author on the study. His journey through this research was a very personal one. Dr. Boutin told OTW, “A few months after my father—an orthopedic surgeon—died at age 93, my mother fell and broke her hip. One month after my mother’s hip fracture, my mother died at the age of 91. She had been in great health all her life, but she had become frail—with what we now know as ‘sarcopenia.’”

“At work, I see hip fractures every day—every single day. But I hadn’t really processed how severe the carnage was: over age 65, 1 in 4 patients will be dead within one year. And if you’re over age 90, then there’s a 94% likelihood that you will not be alive and walking one year after a hip fracture. I wanted to understand whether life could be better for these older people—like my mother. Over 300,000 elderly people are hospitalized for hip fractures every year in the United States.”

“Sarcopenia (broadly defined as significant loss of muscle mass and function) is a prevalent but under-recognized problem. Muscle is the biggest protein reservoir in the human body, and patients need that reservoir during times of metabolic stress, like with a cancer or a hip fracture.”

“The association between sarcopenia and decreased survival has been studied most extensively in patients with various forms of cancer, using special software that makes evaluation impractical for most doctors. In our study, however, we were interested in orthopedic patients and making the evaluation straightforward; we used the routine PACS [picture archiving and communication system] viewing software available to all the healthcare providers at our hospital.”

“Although subjective assessments of patient health status are often very good among experienced clinicians, risk stratification has become a major priority in medicine because of the growing emphasis on health care safety, quality, and cost effectiveness (e.g., pay-for-performance models of reimbursement). Mortality rates associated with hip fractures are now widely tracked as an important indicator of inpatient quality of care.”

“First, we examined our hospital electronic medical record to identify patients who survived versus those who had not. Since we wanted to make certain our mortality statistics were correct in all our patients, we also checked for deaths with the National Center for Health Statistics at the U.S. Centers for Disease Control and Prevention.”

“In cross checking National Death Index data with our hospital electronic medical records, we were surprised to find that National Death Index data provided a much more comprehensive accounting of mortality events. The lesson here was that patients may get discharged and then die in the community, but these deaths are often not recorded in hospital medical records.”

“Second, while we were not surprised by a 1-year mortality rate of 28%, I was surprised by how many patients had died at 5 years: ~80%! I take this information as a challenge—what can we do to improve outcomes in our aging population?”

“We found that in older adults with hip fractures, CT findings of decreased paravertebral muscle size and density are independently associated with decreased overall survival—even after adjusting for risk factors like age, sex, and numerous comorbidities. This was true in both men and women.”

“These previously unused CT measurements therefore may have implications when planning surgery (e.g., deciding on pinning versus arthroplasty) and when determining expectations about outcomes with patients.”

“I now believe that diagnosing and treating sarcopenia will become as commonplace as diagnosing and treating osteoporosis. Sarcopenia has been recognized recently with a new ICD-10 diagnostic code, and clinical trials are evaluating prescriptions of exercise regimens, nutritional support, and investigational pharmaceuticals.”

“With more than 82 million CT scans performed annually in the United States, we’re usually looking for something specific, like a fracture or a tumor. The fundamental paradigm shift here is there’s lots of information on these CT scans that is not being used—but is just waiting there for us to analyze. The beautiful thing is that, without any additional testing, we can ‘harvest’ that unused information to identify potentially treatable conditions, like frailty and osteoporosis. These conditions help predict patient prognosis. Patient prognosis influences medical and surgical decision making. This is ‘personalized medicine’ in action. The biological age of patients is more important than their chronological age.”

“Although core muscles are not routinely analyzed in patients with hip fractures, CT examinations include them on every scan. Using routine CT, we found that muscle atrophy and fatty infiltration in older patients with hip fractures are significantly associated with mortality.”

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