Highlights from Journal of the American Academy of Orthopaedic Surgeons

March 2012 JAAOS News Highlights

Spine Patient Outcomes Research Trial (SPORT) Provides Lessons in Treatment and Care
The Spine Patient Outcomes Research Trial (SPORT) is the first comprehensive study to look at the effectiveness of different treatments for low back and leg pain. It was designed to provide data and outcomes to guide doctors and their patients in their treatment choices for three common spinal disorders: intervertebral disk herniation (IDH), degenerative spondylolisthesis (DS), and lumbar spinal stenosis (LSS). The results from the trial, which began in 2000, are already having a strong impact on orthopaedic practice, and the appropriate role of surgical intervention, according to a review on SPORT appearing in the March issue of the JAAOS. Treatment of spinal disorders, both surgical and nonsurgical, comes at a high cost to insurance providers, hospitals and society. However, the assessment of patient-generated outcomes has produced cost-effectiveness data supporting surgical treatment for these conditions, as they provide significant value to the patient over the long term. Most patients, according to the trial results, knew where their condition was headed. Those who noted improvement, or who felt that their symptoms were tolerable, recognized the value of waiting further, while those who felt no significant relief knew they needed surgical care. All primary outcomes "significantly favored surgical treatment "for IDH, DS and LSS. However, both surgical and non-surgical treatment for IDH resulted in significant relief of low back and leg pain. Surgery was much more effective over non-surgical treatments in treating DS and LSS symptoms.

New Study Urges Orthopaedic Surgeons to Proactively Diagnose, Treat Vitamin D Deficiency
Vitamin D critical to musculoskeletal health
A literature review in the March issue of the JAAOS looks at the role of vitamin D in bone and joint health development, maintenance and function, and at the importance of diagnosing and treating vitamin D deficiency (known as hypovitaminosis D or low vitamin D). Adequate levels of vitamin D are associated with higher bone mineral density, lower rates of osteoporosis-related fractures, and improved neuromuscular function. Vitamin D is obtained through diet and exposure to sunlight, however, a supplement often is necessary to maintain adequate levels. According to the National Health and Nutrition Examination Survey, approximately 30 percent of Americans have less than adequate vitamin D levels (less than 20 ng/mL); the number increases to more than 70 percent when using a more stringent cutoff (less than 30 ng/mL). There is a growing debate on just how much vitamin D children and adults need to prevent vitamin D deficiency, but the known effects of deficiency on bone health is of particular interest to orthopaedic surgeons and their patients. The study authors recommend that orthopaedic surgeons, in partnership with primary care physicians, play an active role in diagnosing and treating patients with potential vitamin D deficiency. Correcting low vitamin D levels may improve the results of treatment for a variety of orthopaedic conditions.

Study Outlines Treatments, Complications for Stress Fractures of the Tibia, Foot and Ankle
In competitive athletes, stress fractures most often occur in the tibia (shinbone), foot and ankle, leading to considerable delay in return to play. A literature review article, "Stress Fractures About the Tibia, Foot, and Ankle," appearing in the March issue of the JAAOS, outlines the many factors that can affect these types of injuries, including a person's general health, blood supply, training regimen and foot anatomy. The location of a stress fracture injury can impact the course of treatment and how quickly the injury heals. High-risk fractures, such as those to the anterior tibia, navicular (midfoot), proximal fifth metatarsal (foot), and medial malleolus (ankle), may require surgery. Surgery also may be recommended for individuals needing to return to play quickly following a stress fracture injury. Cast immobilization, weight-bearing restrictions and medication for pain control generally work well with low-risk fractures. However, more research is needed on other non-surgical treatment methods, such as pulsed ultrasound and extracorporeal shock wave therapy (ESWT), to confirm effectiveness.