Heterotopic ossification (HO) is a known complication of hip arthroplasty. A double-blind, randomized, placebo-controlled trial by Beckmann et al. in the December 16, 2015 Journal of Bone & Joint Surgery showed that prophylaxis with naproxen dramatically reduced the prevalence of HO after hip arthroscopy, without serious medication-related side effects. These findings bolster findings from previous retrospective investigations that showed large reductions in HO prevalence among those taking nonsteroidal anti-inflammatory drugs (NSAIDs).
The patients in the study took naproxen (500 mg) or a placebo twice a day for three weeks following arthroscopic surgery for femoroacetabular impingement. After one year, the prevalence of radiographically determined HO in patients randomized to the naproxen group was 4% versus 46% in the patients randomized to the placebo group, an 11-fold difference. While the potential for serious GI and renal side effects with NSAIDs is well-documented, in this study only minor adverse reactions to study medication were reported in 42% of those taking naproxen and in 35% of those taking placebo.
Noting that the clinical consequences of HO following hip arthroscopy are “largely undetermined,” the authors still suggest a role for HO prophylaxis “because it could reduce the risk of developing symptomatic HO or requiring revision surgery for HO excision.”
In an accompanying commentary, Sverre Loken praises the authors for the well-designed study, but he cautions that “clinically relevant HO is uncommon, and this has to be weighed against the risk of serious side effects caused by NSAIDs.” He also emphasizes the observation Beckmann et al. make in the last paragraph of their study: that “the lowest dose and shortest duration of NSAID prophylaxis that still prevent HO remain to be determined.”
Every clinician treating musculoskeletal injury or disease knows that pain perception among patients is highly subjective and variable. Given the same objective magnitude of a pain stimulus, one person will grade it a 2 on the visual analog scale (VAS), while another will rate it an 8. I am sure that every dentist experiences similar patient variability! What is behind this, and what can we do with our decision making related to pain management to ensure compassionate and effective orthopaedic care?
We know that cultural and social factors play a role in pain perception, as do smoking and opiate-abuse history. Now, in a prognostic study in the August 5, 2015 edition of The Journal of Bone & Joint Surgery, Ernat et al. identify an association between pharmacologic treatment for anxiety and depression and poor outcomes, including higher postoperative pain scores, following primary surgery for femoroacetabular impingement (FAI) among members of the US military. The between-group difference in pain scores was significant only for antidepressant use, but 33 of the 37 patients in the study who took mental-health medications were on antidepressants.
I wonder whether the anxiety and depressive response to situational or relational stimuli that prompt an individual to seek mental-health treatment may be closely related to the same person’s response to painful musculoskeletal stimuli. Alternatively, incompletely treated anxiety or depression may influence a patient’s pain response to surgical treatment of FAI.
Either way, we need more research in this area so we can better manage our patients. An interesting study by Kane et al. that tested various approaches to standardizing patient pain reports showed how difficult normalizing pain scores is, but we still need to encourage further research into responses to painful stimuli, whether they be psychological or physical.
Marc Swiontkowski, MD
The April 1, 2015 JBJS features a level II prognostic study that analyzes registry data from 243 patients (mean age: 29) who underwent arthroscopic surgery to correct femoroacetabular impingement (FAI). Almost everyone experienced clinically important and statistically significant post-arthroscopy improvements in patient-reported outcomes. However, those with relative femoral retroversion (<5° anteversion) prior to surgery experienced smaller magnitudes of improvement than those with normal or increased femoral version.
Researchers found no association between the participants’ McKibbin index (calculated from both femoral and acetabular version) and patient-reported outcomes.
According to the authors and to commentator Keith Baumgarten, MD, these results indicate that surgeons should not consider femoral retroversion to be an absolute contraindication to arthroscopic correction of FAI. However, while the findings may help orthopaedists offer prognostic counseling to young and middle-aged adults who are considering arthroscopy for FAI, the authors say the findings “may not be externally valid in adolescents,” who represent a substantial percentage of patients diagnosed with this hip condition.
AAOS Now answers commonly asked coding questions for orthopaedic practices. This month’s column by Mary LeGrand, RN, senior consultant with KarenZupko & Associates, specifically addresses the following thorny coding issues in a Q&A format:
- Coflex interlaminar technology
- Modifier 51 or 59 in relation to intra-articular injections
- Open surgery for femoroacetabular impingement (FAI) syndrome
- Diskectomy and stenosis procedures
- ACL reconstruction