Orthopedics

High school students are injuring themselves more severely even as overall injury rates have declined, according to a new study presented at the annual meeting of the American Academy of Orthopaedic Surgeons.

The study compared injuries from a 4-year period ending in 2019 to data from 2005 and 2006. The overall rate of injuries dropped 9%, from 2.51 injuries per 1,000 athletic games or practices to 2.29 per 1,000; injuries requiring less than 1 week of recovery time fell by 13%. But, the number of head and neck injuries increased by 10%, injuries requiring surgery increased by 1%, and injuries leading to medical disqualification jumped by 11%. 

“It’s wonderful that the injury rate is declining,” said Jordan Neoma Pizzarro, a medical student at George Washington University, Washington, who led the study. “But the data does suggest that the injuries that are happening are worse.”

The increases may also reflect increased education and awareness of how to detect concussions and other injuries that need medical attention, said Micah Lissy, MD, MS, an orthopedic surgeon specializing in sports medicine at Michigan State University, East Lansing. Dr. Lissy cautioned against physicians and others taking the data at face value. 

“We need to be implementing preventive measures wherever possible, but I think we can also consider that there may be some confounding factors in the data,” Dr. Lissy told this news organization. 

Ms. Pizzarro and her team analyzed data collected from athletic trainers at 100 high schools across the country for the ongoing National Health School Sports-Related Injury Surveillance Study.

Athletes participating in sports such as football, soccer, basketball, volleyball, and softball were included in the analysis. Trainers report the number of injuries for every competition and practice, also known as “athletic exposures.”

Boys’ football carried the highest injury rate, with 3.96 injuries per 1,000 AEs, amounting to 44% of all injuries reported. Girls’ soccer and boys’ wrestling followed, with injury rates of 2.65 and 1.56, respectively. 

Sprains and strains accounted for 37% of injuries, followed by concussions (21.6%). The head and/or face was the most injured body site, followed by the ankles and/or knees. Most injuries took place during competitions rather than in practices (relative risk, 3.39; 95% confidence interval, 3.28-3.49; P < .05).

Ms. Pizzarro said that an overall increase in intensity, physical contact, and collisions may account for the spike in more severe injuries.

“Kids are encouraged to specialize in one sport early on and stick with it year-round,” she said. “They’re probably becoming more agile and better athletes, but they’re probably also getting more competitive.” 

Dr. Lissy, who has worked with high school athletes as a surgeon, physical therapist, athletic trainer, and coach, said that some of the increases in severity of injuries may reflect trends in sports over the past two decades: Student athletes have become stronger and faster and have put on more muscle mass. 

“When you have something that’s much larger, moving much faster and with more force, you’re going to have more force when you bump into things,” he said. “This can lead to more significant injuries.”

The study was independently supported. Study authors report no relevant financial relationships. 

A version of this article originally appeared on Medscape.com.

High school students are injuring themselves more severely even as overall injury rates have declined, according to a new study presented at the annual meeting of the American Academy of Orthopaedic Surgeons.

The study compared injuries from a 4-year period ending in 2019 to data from 2005 and 2006. The overall rate of injuries dropped 9%, from 2.51 injuries per 1,000 athletic games or practices to 2.29 per 1,000; injuries requiring less than 1 week of recovery time fell by 13%. But, the number of head and neck injuries increased by 10%, injuries requiring surgery increased by 1%, and injuries leading to medical disqualification jumped by 11%. 

“It’s wonderful that the injury rate is declining,” said Jordan Neoma Pizzarro, a medical student at George Washington University, Washington, who led the study. “But the data does suggest that the injuries that are happening are worse.”

The increases may also reflect increased education and awareness of how to detect concussions and other injuries that need medical attention, said Micah Lissy, MD, MS, an orthopedic surgeon specializing in sports medicine at Michigan State University, East Lansing. Dr. Lissy cautioned against physicians and others taking the data at face value. 

“We need to be implementing preventive measures wherever possible, but I think we can also consider that there may be some confounding factors in the data,” Dr. Lissy told this news organization. 

Ms. Pizzarro and her team analyzed data collected from athletic trainers at 100 high schools across the country for the ongoing National Health School Sports-Related Injury Surveillance Study.

Athletes participating in sports such as football, soccer, basketball, volleyball, and softball were included in the analysis. Trainers report the number of injuries for every competition and practice, also known as “athletic exposures.”

Boys’ football carried the highest injury rate, with 3.96 injuries per 1,000 AEs, amounting to 44% of all injuries reported. Girls’ soccer and boys’ wrestling followed, with injury rates of 2.65 and 1.56, respectively. 

Sprains and strains accounted for 37% of injuries, followed by concussions (21.6%). The head and/or face was the most injured body site, followed by the ankles and/or knees. Most injuries took place during competitions rather than in practices (relative risk, 3.39; 95% confidence interval, 3.28-3.49; P < .05).

Ms. Pizzarro said that an overall increase in intensity, physical contact, and collisions may account for the spike in more severe injuries.

“Kids are encouraged to specialize in one sport early on and stick with it year-round,” she said. “They’re probably becoming more agile and better athletes, but they’re probably also getting more competitive.” 

Dr. Lissy, who has worked with high school athletes as a surgeon, physical therapist, athletic trainer, and coach, said that some of the increases in severity of injuries may reflect trends in sports over the past two decades: Student athletes have become stronger and faster and have put on more muscle mass. 

“When you have something that’s much larger, moving much faster and with more force, you’re going to have more force when you bump into things,” he said. “This can lead to more significant injuries.”

The study was independently supported. Study authors report no relevant financial relationships. 

A version of this article originally appeared on Medscape.com.

High school students are injuring themselves more severely even as overall injury rates have declined, according to a new study presented at the annual meeting of the American Academy of Orthopaedic Surgeons.

The study compared injuries from a 4-year period ending in 2019 to data from 2005 and 2006. The overall rate of injuries dropped 9%, from 2.51 injuries per 1,000 athletic games or practices to 2.29 per 1,000; injuries requiring less than 1 week of recovery time fell by 13%. But, the number of head and neck injuries increased by 10%, injuries requiring surgery increased by 1%, and injuries leading to medical disqualification jumped by 11%. 

“It’s wonderful that the injury rate is declining,” said Jordan Neoma Pizzarro, a medical student at George Washington University, Washington, who led the study. “But the data does suggest that the injuries that are happening are worse.”

The increases may also reflect increased education and awareness of how to detect concussions and other injuries that need medical attention, said Micah Lissy, MD, MS, an orthopedic surgeon specializing in sports medicine at Michigan State University, East Lansing. Dr. Lissy cautioned against physicians and others taking the data at face value. 

“We need to be implementing preventive measures wherever possible, but I think we can also consider that there may be some confounding factors in the data,” Dr. Lissy told this news organization. 

Ms. Pizzarro and her team analyzed data collected from athletic trainers at 100 high schools across the country for the ongoing National Health School Sports-Related Injury Surveillance Study.

Athletes participating in sports such as football, soccer, basketball, volleyball, and softball were included in the analysis. Trainers report the number of injuries for every competition and practice, also known as “athletic exposures.”

Boys’ football carried the highest injury rate, with 3.96 injuries per 1,000 AEs, amounting to 44% of all injuries reported. Girls’ soccer and boys’ wrestling followed, with injury rates of 2.65 and 1.56, respectively. 

Sprains and strains accounted for 37% of injuries, followed by concussions (21.6%). The head and/or face was the most injured body site, followed by the ankles and/or knees. Most injuries took place during competitions rather than in practices (relative risk, 3.39; 95% confidence interval, 3.28-3.49; P < .05).

Ms. Pizzarro said that an overall increase in intensity, physical contact, and collisions may account for the spike in more severe injuries.

“Kids are encouraged to specialize in one sport early on and stick with it year-round,” she said. “They’re probably becoming more agile and better athletes, but they’re probably also getting more competitive.” 

Dr. Lissy, who has worked with high school athletes as a surgeon, physical therapist, athletic trainer, and coach, said that some of the increases in severity of injuries may reflect trends in sports over the past two decades: Student athletes have become stronger and faster and have put on more muscle mass. 

“When you have something that’s much larger, moving much faster and with more force, you’re going to have more force when you bump into things,” he said. “This can lead to more significant injuries.”

The study was independently supported. Study authors report no relevant financial relationships. 

A version of this article originally appeared on Medscape.com.

The latest guideline for perioperative management of antirheumatic medication in patients undergoing total hip (THA) and total knee arthroplasty (TKA) offers recommendations based on the latest evidence, but many of those recommendations are based on a low level of evidence, according to a speaker at the 2023 Rheumatology Winter Clinical Symposium.

Martin Bergman, MD, clinical professor of medicine at Drexel University, Philadelphia, said the development of the American College of Rheumatology/American Association of Hip and Knee Surgeons guideline was necessary because there was a lack of consensus on when to stop treatments prior to patients with rheumatologic disease undergoing THA and TKA, and when it was appropriate to restart those treatments.

“We all were having the same problem, and I think everybody recognized that just stopping medicines forever didn’t make sense, but maybe continuing medicines also didn’t make sense,” Dr. Bergman said.

While the 2017 ACR/AAHKS perioperative management guideline contained good recommendations, the “explosion” of new medications in rheumatology made it necessary to update the guideline with the latest data on new medications such as immunosuppressants.
 

2022 guideline recommendations

In the 2022 guideline, which covers disease-modifying treatments taken by patients with rheumatoid arthritis, spondyloarthritis, and psoriatic arthritis, the authors reaffirmed their recommendations to continue methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, and apremilast through total joint arthroplasty.

Where the 2022 guideline differs from the 2017 guideline is in which biologics are covered and under what circumstances they should be withheld and restarted around surgery. The 2022 guideline includes recommendations for abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, guselkumab, infliximab, ixekizumab, rituximab, secukinumab, tocilizumab, and ustekinumab. Each biologic has its own recommended stop and restart times based around the dosing interval and respective method of administration. Dr. Bergman said a general rule with biologics under the new guideline is that the timing of surgery should occur approximately 1 week after the first missed dose of the medication. The only biologic that does not follow this pattern is rituximab, where surgery should be planned for 1 month after the last missed dose.

Dr. Bergman noted that how the guidelines handle interval dosing with infliximab may present a problem. The guideline provides recommendations for patients receiving infliximab every 4 weeks, every 6 weeks, and every 8 weeks. However, Dr. Bergman said this can create a scenario where a patient receiving infliximab at a dose of 3 mg/kg every 8 weeks has surgery at 9 weeks, a patient receiving 5 mg/kg every 6 weeks has surgery at 7 weeks, and a patient receiving 10 mg/kg every 4 weeks has surgery at 5 weeks. “There is some intellectual problem with it,” he said.

Another change from the 2017 guideline is how long to wait for surgery after stopping Janus kinase inhibitors. While the 2017 guideline recommended withholding JAK inhibitors 7 days before surgery, the 2022 guideline lowered that waiting period to 3 days, Dr. Bergman explained.

Concerning use of steroids around THA and TKA surgery, “the days of stress steroid dosing are done,” Dr. Bergman said. “You don’t have to stress dose them. You just follow them, and you keep them on their steroid dose.”

The new guideline recommends restarting therapy once the wound is healed and there is no physical evidence of infection at approximately 2 weeks. “There’s no data to support this,” he said, and his concern is that patients who have stopped a tumor necrosis factor inhibitor may flare if they don’t restart their medication.

While the guideline also covered recommendations for systemic lupus erythematosus, they are “very similar” to the recommendations for inflammatory arthritis, Dr. Bergman noted. “If you have somebody who is not very sick, you stop the medications,” he said, “but try to stop anything else about a week before the surgery. If they’re sick, you basically have to keep them on their medications.”
 

Caveats in guideline

The recommendations in the 2022 guideline come with a number of caveats, Dr. Bergman noted. For instance, the authors acknowledged limitations in the guideline regarding providing recommendations for only THA and TKA, the “paucity of evidence” around direct infection risk resulting from medications in the perioperative period for THA and TKA, the nonseparation of biologics when assessing infection risk, and the use of dosing interval as a metric for stopping the drug without considering the drug’s half-life.

A “crucial caveat,” Dr. Bergman said, was that the guideline focused on infection risk based on a statement from a panel of patients prior to the development of the 2017 guideline, which “stated very clearly any risk of infection, while rare, was more significant to them than the possibility of postoperative flares, despite flares being reported in over 60% of patients after surgery.

“For the patients, the paramount question was infection, infection, infection, infection. That’s all they cared about, and that is the basis behind a lot of the decision-making here,” Dr. Bergman said.

Another caveat came from a communication Dr. Bergman received from one of the panel members. The panel member noted there were no conclusions or recommendations provided in the guideline for how to manage perioperative flares, such as restarting a corticosteroid or biologic agent. “There was a lot of discussion about what to do with steroids if patients flare, or what to do with [other] medications if they flare, and they just couldn’t come to a consensus,” Dr. Bergman said. “It’s just not discussed.”

Dr. Bergman said he is “somewhat critical” of the ACR/AAHKS guideline, but noted it is an “ambitious project” given the lack of evidence for the recommendations. “The alternative was stop the medications forever and having people really flare, or at least try to get some semblance of rationality behind what we’re going to do,” he said.
 

Response from attendees

Jack Cush, MD, a rheumatologist based in Dallas and executive editor of RheumNow.com, took issue with the new recommendations surrounding stopping infliximab. When giving a patient infliximab every 8 weeks at 3 mg/kg, “you’re giving [it] at the nadir of the drug,” he said.

Rather than drug half-life, “it’s about inflammation,” he emphasized. “Inflammation is dominant in causing infection. It drives risk more than anything. The worst thing you can do is wash someone out.

“If you’re going beyond 8 weeks on infliximab, you’re getting closer to washing them out,” he pointed out. “I think it’s a really bad idea.”

Allan Gibofsky, MD, JD, professor of medicine at Weill Cornell Medicine and codirector of the Clinic for Inflammatory Arthritis and Biologic Therapy at Hospital for Special Surgery, both in New York, explained that the guideline is not standard of care, which would be subject to malpractice if not implemented properly.

“When you have guidelines, you follow them unless there are clinical situations which would necessitate another approach to the patient,” he said. “Professional institutions and associations will never put forth rules, they will put forth guidelines so you have the opportunity to deviate from them when the appropriate clinical situation dictates.”

Dr. Bergman reported being a speaker and consultant for AbbVie, Amgen, Bristol-Myers Squibb, GlaxoSmithKline, Novartis, Pfizer, and Regeneron; he holds stock in Johnson & Johnson and Merck.

The latest guideline for perioperative management of antirheumatic medication in patients undergoing total hip (THA) and total knee arthroplasty (TKA) offers recommendations based on the latest evidence, but many of those recommendations are based on a low level of evidence, according to a speaker at the 2023 Rheumatology Winter Clinical Symposium.

Martin Bergman, MD, clinical professor of medicine at Drexel University, Philadelphia, said the development of the American College of Rheumatology/American Association of Hip and Knee Surgeons guideline was necessary because there was a lack of consensus on when to stop treatments prior to patients with rheumatologic disease undergoing THA and TKA, and when it was appropriate to restart those treatments.

“We all were having the same problem, and I think everybody recognized that just stopping medicines forever didn’t make sense, but maybe continuing medicines also didn’t make sense,” Dr. Bergman said.

While the 2017 ACR/AAHKS perioperative management guideline contained good recommendations, the “explosion” of new medications in rheumatology made it necessary to update the guideline with the latest data on new medications such as immunosuppressants.
 

2022 guideline recommendations

In the 2022 guideline, which covers disease-modifying treatments taken by patients with rheumatoid arthritis, spondyloarthritis, and psoriatic arthritis, the authors reaffirmed their recommendations to continue methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, and apremilast through total joint arthroplasty.

Where the 2022 guideline differs from the 2017 guideline is in which biologics are covered and under what circumstances they should be withheld and restarted around surgery. The 2022 guideline includes recommendations for abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, guselkumab, infliximab, ixekizumab, rituximab, secukinumab, tocilizumab, and ustekinumab. Each biologic has its own recommended stop and restart times based around the dosing interval and respective method of administration. Dr. Bergman said a general rule with biologics under the new guideline is that the timing of surgery should occur approximately 1 week after the first missed dose of the medication. The only biologic that does not follow this pattern is rituximab, where surgery should be planned for 1 month after the last missed dose.

Dr. Bergman noted that how the guidelines handle interval dosing with infliximab may present a problem. The guideline provides recommendations for patients receiving infliximab every 4 weeks, every 6 weeks, and every 8 weeks. However, Dr. Bergman said this can create a scenario where a patient receiving infliximab at a dose of 3 mg/kg every 8 weeks has surgery at 9 weeks, a patient receiving 5 mg/kg every 6 weeks has surgery at 7 weeks, and a patient receiving 10 mg/kg every 4 weeks has surgery at 5 weeks. “There is some intellectual problem with it,” he said.

Another change from the 2017 guideline is how long to wait for surgery after stopping Janus kinase inhibitors. While the 2017 guideline recommended withholding JAK inhibitors 7 days before surgery, the 2022 guideline lowered that waiting period to 3 days, Dr. Bergman explained.

Concerning use of steroids around THA and TKA surgery, “the days of stress steroid dosing are done,” Dr. Bergman said. “You don’t have to stress dose them. You just follow them, and you keep them on their steroid dose.”

The new guideline recommends restarting therapy once the wound is healed and there is no physical evidence of infection at approximately 2 weeks. “There’s no data to support this,” he said, and his concern is that patients who have stopped a tumor necrosis factor inhibitor may flare if they don’t restart their medication.

While the guideline also covered recommendations for systemic lupus erythematosus, they are “very similar” to the recommendations for inflammatory arthritis, Dr. Bergman noted. “If you have somebody who is not very sick, you stop the medications,” he said, “but try to stop anything else about a week before the surgery. If they’re sick, you basically have to keep them on their medications.”
 

Caveats in guideline

The recommendations in the 2022 guideline come with a number of caveats, Dr. Bergman noted. For instance, the authors acknowledged limitations in the guideline regarding providing recommendations for only THA and TKA, the “paucity of evidence” around direct infection risk resulting from medications in the perioperative period for THA and TKA, the nonseparation of biologics when assessing infection risk, and the use of dosing interval as a metric for stopping the drug without considering the drug’s half-life.

A “crucial caveat,” Dr. Bergman said, was that the guideline focused on infection risk based on a statement from a panel of patients prior to the development of the 2017 guideline, which “stated very clearly any risk of infection, while rare, was more significant to them than the possibility of postoperative flares, despite flares being reported in over 60% of patients after surgery.

“For the patients, the paramount question was infection, infection, infection, infection. That’s all they cared about, and that is the basis behind a lot of the decision-making here,” Dr. Bergman said.

Another caveat came from a communication Dr. Bergman received from one of the panel members. The panel member noted there were no conclusions or recommendations provided in the guideline for how to manage perioperative flares, such as restarting a corticosteroid or biologic agent. “There was a lot of discussion about what to do with steroids if patients flare, or what to do with [other] medications if they flare, and they just couldn’t come to a consensus,” Dr. Bergman said. “It’s just not discussed.”

Dr. Bergman said he is “somewhat critical” of the ACR/AAHKS guideline, but noted it is an “ambitious project” given the lack of evidence for the recommendations. “The alternative was stop the medications forever and having people really flare, or at least try to get some semblance of rationality behind what we’re going to do,” he said.
 

Response from attendees

Jack Cush, MD, a rheumatologist based in Dallas and executive editor of RheumNow.com, took issue with the new recommendations surrounding stopping infliximab. When giving a patient infliximab every 8 weeks at 3 mg/kg, “you’re giving [it] at the nadir of the drug,” he said.

Rather than drug half-life, “it’s about inflammation,” he emphasized. “Inflammation is dominant in causing infection. It drives risk more than anything. The worst thing you can do is wash someone out.

“If you’re going beyond 8 weeks on infliximab, you’re getting closer to washing them out,” he pointed out. “I think it’s a really bad idea.”

Allan Gibofsky, MD, JD, professor of medicine at Weill Cornell Medicine and codirector of the Clinic for Inflammatory Arthritis and Biologic Therapy at Hospital for Special Surgery, both in New York, explained that the guideline is not standard of care, which would be subject to malpractice if not implemented properly.

“When you have guidelines, you follow them unless there are clinical situations which would necessitate another approach to the patient,” he said. “Professional institutions and associations will never put forth rules, they will put forth guidelines so you have the opportunity to deviate from them when the appropriate clinical situation dictates.”

Dr. Bergman reported being a speaker and consultant for AbbVie, Amgen, Bristol-Myers Squibb, GlaxoSmithKline, Novartis, Pfizer, and Regeneron; he holds stock in Johnson & Johnson and Merck.

The latest guideline for perioperative management of antirheumatic medication in patients undergoing total hip (THA) and total knee arthroplasty (TKA) offers recommendations based on the latest evidence, but many of those recommendations are based on a low level of evidence, according to a speaker at the 2023 Rheumatology Winter Clinical Symposium.

Martin Bergman, MD, clinical professor of medicine at Drexel University, Philadelphia, said the development of the American College of Rheumatology/American Association of Hip and Knee Surgeons guideline was necessary because there was a lack of consensus on when to stop treatments prior to patients with rheumatologic disease undergoing THA and TKA, and when it was appropriate to restart those treatments.

“We all were having the same problem, and I think everybody recognized that just stopping medicines forever didn’t make sense, but maybe continuing medicines also didn’t make sense,” Dr. Bergman said.

While the 2017 ACR/AAHKS perioperative management guideline contained good recommendations, the “explosion” of new medications in rheumatology made it necessary to update the guideline with the latest data on new medications such as immunosuppressants.
 

2022 guideline recommendations

In the 2022 guideline, which covers disease-modifying treatments taken by patients with rheumatoid arthritis, spondyloarthritis, and psoriatic arthritis, the authors reaffirmed their recommendations to continue methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, and apremilast through total joint arthroplasty.

Where the 2022 guideline differs from the 2017 guideline is in which biologics are covered and under what circumstances they should be withheld and restarted around surgery. The 2022 guideline includes recommendations for abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, guselkumab, infliximab, ixekizumab, rituximab, secukinumab, tocilizumab, and ustekinumab. Each biologic has its own recommended stop and restart times based around the dosing interval and respective method of administration. Dr. Bergman said a general rule with biologics under the new guideline is that the timing of surgery should occur approximately 1 week after the first missed dose of the medication. The only biologic that does not follow this pattern is rituximab, where surgery should be planned for 1 month after the last missed dose.

Dr. Bergman noted that how the guidelines handle interval dosing with infliximab may present a problem. The guideline provides recommendations for patients receiving infliximab every 4 weeks, every 6 weeks, and every 8 weeks. However, Dr. Bergman said this can create a scenario where a patient receiving infliximab at a dose of 3 mg/kg every 8 weeks has surgery at 9 weeks, a patient receiving 5 mg/kg every 6 weeks has surgery at 7 weeks, and a patient receiving 10 mg/kg every 4 weeks has surgery at 5 weeks. “There is some intellectual problem with it,” he said.

Another change from the 2017 guideline is how long to wait for surgery after stopping Janus kinase inhibitors. While the 2017 guideline recommended withholding JAK inhibitors 7 days before surgery, the 2022 guideline lowered that waiting period to 3 days, Dr. Bergman explained.

Concerning use of steroids around THA and TKA surgery, “the days of stress steroid dosing are done,” Dr. Bergman said. “You don’t have to stress dose them. You just follow them, and you keep them on their steroid dose.”

The new guideline recommends restarting therapy once the wound is healed and there is no physical evidence of infection at approximately 2 weeks. “There’s no data to support this,” he said, and his concern is that patients who have stopped a tumor necrosis factor inhibitor may flare if they don’t restart their medication.

While the guideline also covered recommendations for systemic lupus erythematosus, they are “very similar” to the recommendations for inflammatory arthritis, Dr. Bergman noted. “If you have somebody who is not very sick, you stop the medications,” he said, “but try to stop anything else about a week before the surgery. If they’re sick, you basically have to keep them on their medications.”
 

Caveats in guideline

The recommendations in the 2022 guideline come with a number of caveats, Dr. Bergman noted. For instance, the authors acknowledged limitations in the guideline regarding providing recommendations for only THA and TKA, the “paucity of evidence” around direct infection risk resulting from medications in the perioperative period for THA and TKA, the nonseparation of biologics when assessing infection risk, and the use of dosing interval as a metric for stopping the drug without considering the drug’s half-life.

A “crucial caveat,” Dr. Bergman said, was that the guideline focused on infection risk based on a statement from a panel of patients prior to the development of the 2017 guideline, which “stated very clearly any risk of infection, while rare, was more significant to them than the possibility of postoperative flares, despite flares being reported in over 60% of patients after surgery.

“For the patients, the paramount question was infection, infection, infection, infection. That’s all they cared about, and that is the basis behind a lot of the decision-making here,” Dr. Bergman said.

Another caveat came from a communication Dr. Bergman received from one of the panel members. The panel member noted there were no conclusions or recommendations provided in the guideline for how to manage perioperative flares, such as restarting a corticosteroid or biologic agent. “There was a lot of discussion about what to do with steroids if patients flare, or what to do with [other] medications if they flare, and they just couldn’t come to a consensus,” Dr. Bergman said. “It’s just not discussed.”

Dr. Bergman said he is “somewhat critical” of the ACR/AAHKS guideline, but noted it is an “ambitious project” given the lack of evidence for the recommendations. “The alternative was stop the medications forever and having people really flare, or at least try to get some semblance of rationality behind what we’re going to do,” he said.
 

Response from attendees

Jack Cush, MD, a rheumatologist based in Dallas and executive editor of RheumNow.com, took issue with the new recommendations surrounding stopping infliximab. When giving a patient infliximab every 8 weeks at 3 mg/kg, “you’re giving [it] at the nadir of the drug,” he said.

Rather than drug half-life, “it’s about inflammation,” he emphasized. “Inflammation is dominant in causing infection. It drives risk more than anything. The worst thing you can do is wash someone out.

“If you’re going beyond 8 weeks on infliximab, you’re getting closer to washing them out,” he pointed out. “I think it’s a really bad idea.”

Allan Gibofsky, MD, JD, professor of medicine at Weill Cornell Medicine and codirector of the Clinic for Inflammatory Arthritis and Biologic Therapy at Hospital for Special Surgery, both in New York, explained that the guideline is not standard of care, which would be subject to malpractice if not implemented properly.

“When you have guidelines, you follow them unless there are clinical situations which would necessitate another approach to the patient,” he said. “Professional institutions and associations will never put forth rules, they will put forth guidelines so you have the opportunity to deviate from them when the appropriate clinical situation dictates.”

Dr. Bergman reported being a speaker and consultant for AbbVie, Amgen, Bristol-Myers Squibb, GlaxoSmithKline, Novartis, Pfizer, and Regeneron; he holds stock in Johnson & Johnson and Merck.

High levels of high-density lipoprotein cholesterol (HDL-C) in older adults are associated with a higher risk of sustaining a fracture than lower HDL-C levels, a new study suggests.

Raycat/Getty Images

“Two animal studies showing that HDL-C reduces bone mineral density by reducing osteoblast number and function provide a plausible explanation for why high HDL-C may increase the risk of fractures,” Monira Hussain, MBBS, MPH, PhD, of Monash University in Melbourne, told this news organization. “So, it was not surprising when our analyses provided evidence that amongst those in the highest quintile of HDL-C (> 74 mg/dL), there was a [33%] increased risk of fractures.”

After adjustment, one standard deviation increment in HDL-C level was associated with a 14% higher risk of fracture during a 4-year follow-up.

Based on this and other studies, Dr. Hussain said, “I believe that the finding of a very high HDL-C [should] alert clinicians to a higher risk of mortality, fractures, and possibly other threats to their patient’s health.”

The study was published online in JAMA Cardiology.
 

Independent risk factor

For this report, the researchers conducted a post hoc analysis of data from the Aspirin in Reducing Events in the Elderly (ASPREE) clinical trial and the ASPREE-Fracture substudy.

ASPREE was a double-blind, randomized, placebo-controlled primary prevention trial of aspirin. Participants were 16,703 community-dwelling Australians and 2,411 individuals from the United States with a mean age of 75 and without evident cardiovascular disease, dementia, physical disability, or life-limiting chronic illness.

The ASPREE-Fracture substudy collected data on fractures reported post randomization from the Australian participants. Fractures were confirmed by imaging and adjudicated by an expert panel and included both traumatic and minimal trauma fractures.

Of the 16,262 participants who had a plasma HDL-C measurement at baseline (55% women), 1,659 (10.2%) experienced at least one fracture over a median of 4 years. This included 711 minimal trauma fractures (for example, falls from standing height) and 948 other trauma fractures, mainly falls on stairs, ladders, or stools.

Higher rates of fractures occurred in the highest quintile of HDL-C level where the mean level was 89 mg/dL. At baseline, participants in that quintile had a lower BMI, a high prevalence of current/former smoking and current alcohol use, 12 years or longer of school, more physical activity, and higher use of antiosteoporosis medication. They also had less chronic kidney disease, diabetes, prefrailty/frailty, or treatment with lipid-lowering drugs.

In a fully adjusted model, each standard deviation increment in HDL-C level was associated with a 14% higher risk of fractures (hazard ratio, 1.14). When analyzed in quintiles, compared with participants in Q1, those in Q5 had a 33% higher risk for fracture (HR, 1.33).

Prevalence rates were similar between the sexes. The increase in fracture risk appeared to be independent of traditional risk factors for fractures, including age, sex, physical activity, alcohol use, frailty, BMI, smoking status, diabetes, chronic kidney disease, use of lipid-lowering or antiosteoporosis drugs, and education, the authors note.

The results persisted in sensitivity analyses in restricted subgroups of interest and in stratified analyses – including, for example, only minimal fractures; participants not taking antiosteoporosis drugs or statins; never smokers; nondrinkers; and those engaging in minimal physical activity (walking less than 30 minutes per day).

No association was observed between non–HDL-C levels and fractures.

The authors conclude that the study “provides robust evidence that higher levels of HDL-C are associated with incident fractures in both male and female individuals, independent of conventional risk factors.”
 

Clinically useful?

Commenting on the study for this news organization, Marilyn Tan, MD, clinic chief of the Endocrine Clinic and clinical associate professor of medicine at Stanford (Calif.) University, said, “I certainly would not recommend anyone do anything to actively lower their HDL levels. HDL levels are largely determined by genetics, diet, and lifestyle, with some effects from certain medications/supplements. Studies have demonstrated that moderately higher HDL levels may be protective for atherosclerosis.”

In the current study, she said, “Causation has not been proven, and importantly there is no evidence that reducing HDL levels reduces fracture risk. Also, this association between raised HDL levels and fracture risk has not been demonstrated consistently in other studies.”

Furthermore, she noted, the preclinical trials on which the authors based their hypothesis – that is, an association between HDL and a reduction in the number and function of osteoblasts – “has not been demonstrated widely in human subjects.”

“We have a large armamentarium of FDA-approved treatments for osteoporosis that have been clinically proven to reduce fracture risk very significantly, and these are the tools [in addition to lifestyle changes] we should use to reduce fracture risk,” Dr. Tan concluded.

John Wilkins, MD, of Northwestern University, Chicago, and Anand Rohatgi, MD, MSCS, of UT Southwestern Medical Center, Dallas, also point out some limitations of the study in a related editorial.

They note the inclusion of predominantly healthy adults with a mean age of 75, a population that could yield different findings from middle-aged cohorts with chronic illnesses, as well as a lack of clarity regarding the possible role of alcohol intake among the study participants.

Furthermore, the editorialists write, although significant associations were shown in this study, “models were not adjusted for detailed measures of exercise/activity, triglycerides, or any other lipids, including other HDL compositional measures such as HDL-P or ApoA-I levels. There was no assessment of whether HDL-C improved discrimination, reclassification, or any other validated measures of risk prediction performance.

“Taken together,” they conclude, “this study alone leaves several unanswered questions as to whether high HDL-C could be a useful biomarker to detect fracture risk.”

No commercial funding was disclosed. The authors report no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

High levels of high-density lipoprotein cholesterol (HDL-C) in older adults are associated with a higher risk of sustaining a fracture than lower HDL-C levels, a new study suggests.

Raycat/Getty Images

“Two animal studies showing that HDL-C reduces bone mineral density by reducing osteoblast number and function provide a plausible explanation for why high HDL-C may increase the risk of fractures,” Monira Hussain, MBBS, MPH, PhD, of Monash University in Melbourne, told this news organization. “So, it was not surprising when our analyses provided evidence that amongst those in the highest quintile of HDL-C (> 74 mg/dL), there was a [33%] increased risk of fractures.”

After adjustment, one standard deviation increment in HDL-C level was associated with a 14% higher risk of fracture during a 4-year follow-up.

Based on this and other studies, Dr. Hussain said, “I believe that the finding of a very high HDL-C [should] alert clinicians to a higher risk of mortality, fractures, and possibly other threats to their patient’s health.”

The study was published online in JAMA Cardiology.
 

Independent risk factor

For this report, the researchers conducted a post hoc analysis of data from the Aspirin in Reducing Events in the Elderly (ASPREE) clinical trial and the ASPREE-Fracture substudy.

ASPREE was a double-blind, randomized, placebo-controlled primary prevention trial of aspirin. Participants were 16,703 community-dwelling Australians and 2,411 individuals from the United States with a mean age of 75 and without evident cardiovascular disease, dementia, physical disability, or life-limiting chronic illness.

The ASPREE-Fracture substudy collected data on fractures reported post randomization from the Australian participants. Fractures were confirmed by imaging and adjudicated by an expert panel and included both traumatic and minimal trauma fractures.

Of the 16,262 participants who had a plasma HDL-C measurement at baseline (55% women), 1,659 (10.2%) experienced at least one fracture over a median of 4 years. This included 711 minimal trauma fractures (for example, falls from standing height) and 948 other trauma fractures, mainly falls on stairs, ladders, or stools.

Higher rates of fractures occurred in the highest quintile of HDL-C level where the mean level was 89 mg/dL. At baseline, participants in that quintile had a lower BMI, a high prevalence of current/former smoking and current alcohol use, 12 years or longer of school, more physical activity, and higher use of antiosteoporosis medication. They also had less chronic kidney disease, diabetes, prefrailty/frailty, or treatment with lipid-lowering drugs.

In a fully adjusted model, each standard deviation increment in HDL-C level was associated with a 14% higher risk of fractures (hazard ratio, 1.14). When analyzed in quintiles, compared with participants in Q1, those in Q5 had a 33% higher risk for fracture (HR, 1.33).

Prevalence rates were similar between the sexes. The increase in fracture risk appeared to be independent of traditional risk factors for fractures, including age, sex, physical activity, alcohol use, frailty, BMI, smoking status, diabetes, chronic kidney disease, use of lipid-lowering or antiosteoporosis drugs, and education, the authors note.

The results persisted in sensitivity analyses in restricted subgroups of interest and in stratified analyses – including, for example, only minimal fractures; participants not taking antiosteoporosis drugs or statins; never smokers; nondrinkers; and those engaging in minimal physical activity (walking less than 30 minutes per day).

No association was observed between non–HDL-C levels and fractures.

The authors conclude that the study “provides robust evidence that higher levels of HDL-C are associated with incident fractures in both male and female individuals, independent of conventional risk factors.”
 

Clinically useful?

Commenting on the study for this news organization, Marilyn Tan, MD, clinic chief of the Endocrine Clinic and clinical associate professor of medicine at Stanford (Calif.) University, said, “I certainly would not recommend anyone do anything to actively lower their HDL levels. HDL levels are largely determined by genetics, diet, and lifestyle, with some effects from certain medications/supplements. Studies have demonstrated that moderately higher HDL levels may be protective for atherosclerosis.”

In the current study, she said, “Causation has not been proven, and importantly there is no evidence that reducing HDL levels reduces fracture risk. Also, this association between raised HDL levels and fracture risk has not been demonstrated consistently in other studies.”

Furthermore, she noted, the preclinical trials on which the authors based their hypothesis – that is, an association between HDL and a reduction in the number and function of osteoblasts – “has not been demonstrated widely in human subjects.”

“We have a large armamentarium of FDA-approved treatments for osteoporosis that have been clinically proven to reduce fracture risk very significantly, and these are the tools [in addition to lifestyle changes] we should use to reduce fracture risk,” Dr. Tan concluded.

John Wilkins, MD, of Northwestern University, Chicago, and Anand Rohatgi, MD, MSCS, of UT Southwestern Medical Center, Dallas, also point out some limitations of the study in a related editorial.

They note the inclusion of predominantly healthy adults with a mean age of 75, a population that could yield different findings from middle-aged cohorts with chronic illnesses, as well as a lack of clarity regarding the possible role of alcohol intake among the study participants.

Furthermore, the editorialists write, although significant associations were shown in this study, “models were not adjusted for detailed measures of exercise/activity, triglycerides, or any other lipids, including other HDL compositional measures such as HDL-P or ApoA-I levels. There was no assessment of whether HDL-C improved discrimination, reclassification, or any other validated measures of risk prediction performance.

“Taken together,” they conclude, “this study alone leaves several unanswered questions as to whether high HDL-C could be a useful biomarker to detect fracture risk.”

No commercial funding was disclosed. The authors report no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

High levels of high-density lipoprotein cholesterol (HDL-C) in older adults are associated with a higher risk of sustaining a fracture than lower HDL-C levels, a new study suggests.

Raycat/Getty Images

“Two animal studies showing that HDL-C reduces bone mineral density by reducing osteoblast number and function provide a plausible explanation for why high HDL-C may increase the risk of fractures,” Monira Hussain, MBBS, MPH, PhD, of Monash University in Melbourne, told this news organization. “So, it was not surprising when our analyses provided evidence that amongst those in the highest quintile of HDL-C (> 74 mg/dL), there was a [33%] increased risk of fractures.”

After adjustment, one standard deviation increment in HDL-C level was associated with a 14% higher risk of fracture during a 4-year follow-up.

Based on this and other studies, Dr. Hussain said, “I believe that the finding of a very high HDL-C [should] alert clinicians to a higher risk of mortality, fractures, and possibly other threats to their patient’s health.”

The study was published online in JAMA Cardiology.
 

Independent risk factor

For this report, the researchers conducted a post hoc analysis of data from the Aspirin in Reducing Events in the Elderly (ASPREE) clinical trial and the ASPREE-Fracture substudy.

ASPREE was a double-blind, randomized, placebo-controlled primary prevention trial of aspirin. Participants were 16,703 community-dwelling Australians and 2,411 individuals from the United States with a mean age of 75 and without evident cardiovascular disease, dementia, physical disability, or life-limiting chronic illness.

The ASPREE-Fracture substudy collected data on fractures reported post randomization from the Australian participants. Fractures were confirmed by imaging and adjudicated by an expert panel and included both traumatic and minimal trauma fractures.

Of the 16,262 participants who had a plasma HDL-C measurement at baseline (55% women), 1,659 (10.2%) experienced at least one fracture over a median of 4 years. This included 711 minimal trauma fractures (for example, falls from standing height) and 948 other trauma fractures, mainly falls on stairs, ladders, or stools.

Higher rates of fractures occurred in the highest quintile of HDL-C level where the mean level was 89 mg/dL. At baseline, participants in that quintile had a lower BMI, a high prevalence of current/former smoking and current alcohol use, 12 years or longer of school, more physical activity, and higher use of antiosteoporosis medication. They also had less chronic kidney disease, diabetes, prefrailty/frailty, or treatment with lipid-lowering drugs.

In a fully adjusted model, each standard deviation increment in HDL-C level was associated with a 14% higher risk of fractures (hazard ratio, 1.14). When analyzed in quintiles, compared with participants in Q1, those in Q5 had a 33% higher risk for fracture (HR, 1.33).

Prevalence rates were similar between the sexes. The increase in fracture risk appeared to be independent of traditional risk factors for fractures, including age, sex, physical activity, alcohol use, frailty, BMI, smoking status, diabetes, chronic kidney disease, use of lipid-lowering or antiosteoporosis drugs, and education, the authors note.

The results persisted in sensitivity analyses in restricted subgroups of interest and in stratified analyses – including, for example, only minimal fractures; participants not taking antiosteoporosis drugs or statins; never smokers; nondrinkers; and those engaging in minimal physical activity (walking less than 30 minutes per day).

No association was observed between non–HDL-C levels and fractures.

The authors conclude that the study “provides robust evidence that higher levels of HDL-C are associated with incident fractures in both male and female individuals, independent of conventional risk factors.”
 

Clinically useful?

Commenting on the study for this news organization, Marilyn Tan, MD, clinic chief of the Endocrine Clinic and clinical associate professor of medicine at Stanford (Calif.) University, said, “I certainly would not recommend anyone do anything to actively lower their HDL levels. HDL levels are largely determined by genetics, diet, and lifestyle, with some effects from certain medications/supplements. Studies have demonstrated that moderately higher HDL levels may be protective for atherosclerosis.”

In the current study, she said, “Causation has not been proven, and importantly there is no evidence that reducing HDL levels reduces fracture risk. Also, this association between raised HDL levels and fracture risk has not been demonstrated consistently in other studies.”

Furthermore, she noted, the preclinical trials on which the authors based their hypothesis – that is, an association between HDL and a reduction in the number and function of osteoblasts – “has not been demonstrated widely in human subjects.”

“We have a large armamentarium of FDA-approved treatments for osteoporosis that have been clinically proven to reduce fracture risk very significantly, and these are the tools [in addition to lifestyle changes] we should use to reduce fracture risk,” Dr. Tan concluded.

John Wilkins, MD, of Northwestern University, Chicago, and Anand Rohatgi, MD, MSCS, of UT Southwestern Medical Center, Dallas, also point out some limitations of the study in a related editorial.

They note the inclusion of predominantly healthy adults with a mean age of 75, a population that could yield different findings from middle-aged cohorts with chronic illnesses, as well as a lack of clarity regarding the possible role of alcohol intake among the study participants.

Furthermore, the editorialists write, although significant associations were shown in this study, “models were not adjusted for detailed measures of exercise/activity, triglycerides, or any other lipids, including other HDL compositional measures such as HDL-P or ApoA-I levels. There was no assessment of whether HDL-C improved discrimination, reclassification, or any other validated measures of risk prediction performance.

“Taken together,” they conclude, “this study alone leaves several unanswered questions as to whether high HDL-C could be a useful biomarker to detect fracture risk.”

No commercial funding was disclosed. The authors report no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Corticosteroid (CS) injections may worsen progression of knee osteoarthritis as seen on radiography and whole-knee MRI. Injecting hyaluronic acid (HA) instead, or managing the condition without injections, may better preserve knee structure and cartilage, according to results of two related studies presented at the annual meeting of the Radiological Society of North America.

The findings come nonrandomized, observational cohort studies, leading knee OA experts to call for further study in randomized trial settings. In the meantime, shared decision-making between patients and clinicians is advised on the use of these injections.

For knee OA, most patients seek a noninvasive treatment for symptomatic relief. “At least 10% of these patients undergo local treatment with injectable corticosteroids or hyaluronic acid,” the lead author of one of the studies, Upasana Upadhyay Bharadwaj, MD, research fellow in musculoskeletal radiology at the University of California, San Francisco, said in a video press release.

Researchers in both studies used data and images from the Osteoarthritis Initiative (OAI), a multicenter, longitudinal, observational study of 4,796 U.S. patients aged 45-79 years with knee OA. Participants were enrolled from February 2004 to May 2006.

The OAI maintains a natural history database of information regarding participants’ clinical evaluation data, x-rays, MRI scans, and a biospecimen repository. Data are available to researchers worldwide.
 

Two studies draw similar conclusions

In one study, Dr. Bharadwaj and colleagues found that HA injections appeared to show decreased knee OA progression in bone marrow lesions.

They investigated 8 patients who received one CS injection, 12 who received one HA injection, and 40 control persons who received neither treatment. Participants were propensity-score matched by age, sex, body mass index (BMI), Kellgren-Lawrence (KL) grade, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Physical Activity Scale for the Elderly (PASE).

The researchers semiquantitatively graded three Tesla MRI scans that had been obtained at baseline, 2 years before the injection, and 2 years after the injection, using whole-organ MRI score (WORMS) for the meniscus, bone marrow lesions, cartilage, joint effusion, and ligaments.

They quantified OA progression using the difference in WORMS between baseline and 2-year follow-up, and they used linear regression models, adjusted for age, sex, BMI, KL grade, WOMAC, and PASE, to identify the link between type of injection and progression of WORMS.

At 2 years, the authors found a significant association between CS injection and postinjection progression of WORMS over 2 years for the knee overall, the lateral meniscus, lateral cartilage, and medial cartilage. There was no significant link between HA injection and postinjection progression of WORMS or between either injection type and progression of pain, as quantified by WOMAC. There was also no significant difference in progression of WORMS over the 2 years prior to injection for CS and HA injections.

“Corticosteroid injections must be administered with caution with respect to long-term effects on osteoarthritis,” Dr. Bharadwaj advised. “Hyaluronic acid injections, on the other hand, may slow down progression of knee osteoarthritis and alleviate long-term effects while offering similar symptomatic relief to corticosteroid injections. Overall, they are perhaps a safer alternative when looking at medium- and long-term disease course of knee osteoarthritis.”

In the second study, lead author Azad Darbandi, MS, a fourth-year medical student at Chicago Medical School, North Chicago, and colleagues found that patients who received CS injections experienced significantly more medial joint space narrowing.

They identified 210 knees with imaging at baseline and at 48 months that received CS injections, and 59 that received HA injections; 6,827 knees served as controls. The investigators matched 50 patients per group on the basis of confounding factors, which included age, sex, BMI, comorbidities, surgery, and semiquantitative imaging outcomes at baseline. They performed ANCOVA testing using 48-month semiquantitative imaging outcomes as dependent variables and confounding variables as covariates.

The researchers analyzed joint space narrowing, KL grade, and tibia/femur medial/lateral compartment osteophyte formation and sclerosis.

At 4 years, the average KL grade in the CS group was 2.79, it was 2.11 in the HA group,;and it was 2.37 in the control group. Intergroup comparisons showed significant differences in KL grade between CS and HA groups and between CS and control groups. Medial compartment joint space narrowing was 1.56 in the CS group, 1.11 in the HA group, and 1.18 in controls. There was a significant difference between the CS and control groups. Other dependent variables were not significant.

“These preliminary results suggest that corticosteroid injections accelerated the radiographic progression of osteoarthritis, specifically medial joint space narrowing and Kellgren-Lawrence grading, whereas hyaluronic acid injections did not,” Mr. Darbandi said in an interview.

“OA radiographic progression does not always correlate with clinical progression, and further research is needed,” he added.

Proper matching of patients at baseline for confounding factors is a strength of the study, Mr. Darbandi said, while the retrospective study design is a weakness.
 

Experts share their perspectives on the preliminary results

Michael M. Kheir, MD, assistant professor of orthopedic surgery at the University of Michigan Health System, who was not involved in the studies, said he would like to see further related research.

“Perhaps steroid injections are not as benign as they once seemed,” he added. “They should be reserved for patients who already have significant arthritis and are seeking temporary relief prior to surgical reconstruction with a joint replacement, or for patients with recalcitrant pain after having already tried HA injections.”

William A. Jiranek, MD, professor and orthopedic surgeon at Duke Health in Morrisville, N.C., who also was not involved in the studies, was not surprised by the findings.

“It is important to do these studies to learn that steroid injections do not come with zero cost,” he said.

“I am pretty sure that a percentage of these patients had no cartilage loss at all,” he added. “We need to understand which OA phenotypes are not at risk of progressive cartilage loss from steroid injections.”

Annunziato (Ned) Amendola, MD, professor and sports medicine orthopedic surgeon at Duke Health in Durham, N.C., who was also not involved in the studies, said he would like to know how injection effectiveness and activity level are related.

“If the injections were effective at relieving pain, and the patients were more active, that may have predisposed to more joint wear,” he said. “It’s like tires that last longer if you don’t abuse them.”
 

Shared decision-making and further research recommended

Amanda E. Nelson, MD, associate professor of medicine in the division of rheumatology, allergy, and immunology at the University of North Carolina at Chapel Hill, said: “The lack of randomization introduces potential biases around why certain therapies (CS injection, HA injection, or neither) were selected over others (such as disease severity, preference, comorbid conditions, other contraindications, etc), thus making interpretation of the findings challenging.

“The causal relationship remains in question, and questions around the efficacy of intra-articular HA in particular, and the ideal settings for intra-articular therapy in general, persist,” noted Dr. Nelson, who was also not involved in the studies. “Thus, shared decision-making between patients and their providers is essential when considering these options.”

C. Kent Kwoh, MD, professor of medicine and medical imaging at the University of Arizona and director of the University of Arizona Arthritis Center, both in Tucson, said in an interview that these types of studies are important because CS injections are common treatments for knee OA, they are recommended in treatment guidelines, and other good options are lacking.

But he pointed out that the results of these two studies need to be interpreted with caution and should not be used to decide the course of treatment.

“These data are hypothesis generating. They suggest association, but they do not show causation,” said Dr. Kwoh, who was also not involved in the studies. “Both studies are secondary analyses of data collected from the OAI, which was not specifically designed to answer the questions these studies are posing.

“The OAI was not a treatment study, and participants were seen only once a year or so. They may have had joint injections anytime from only days to around 1 year before their visit, and their levels of activity or pain just prior to or just after their joint injections were not reported,” Dr. Kwoh explained.

The reasons why patients did or did not receive a specific joint injection – including their socioeconomic status, race, access to insurance, and other confounding factors – were not assessed and may have affected the results, he added.

The fact that both studies used the same data and came to the same conclusions gives the conclusions some strength, he said, but “the gold standard to understanding causation would be a randomized, controlled trial.”

Mr. Darbandi’s research received grant support from Boeing, His c-authors, as well as all experts not involved in the studies, reported no relevant financial relationshiips. Dr. Bharadwaj did not provide conflict-of-interest and funding details. Dr. Kwoh reported membership on panels that have developed guidelines for the management of knee OA.

A version of this article first appeared on Medscape.com.

Corticosteroid (CS) injections may worsen progression of knee osteoarthritis as seen on radiography and whole-knee MRI. Injecting hyaluronic acid (HA) instead, or managing the condition without injections, may better preserve knee structure and cartilage, according to results of two related studies presented at the annual meeting of the Radiological Society of North America.

The findings come nonrandomized, observational cohort studies, leading knee OA experts to call for further study in randomized trial settings. In the meantime, shared decision-making between patients and clinicians is advised on the use of these injections.

For knee OA, most patients seek a noninvasive treatment for symptomatic relief. “At least 10% of these patients undergo local treatment with injectable corticosteroids or hyaluronic acid,” the lead author of one of the studies, Upasana Upadhyay Bharadwaj, MD, research fellow in musculoskeletal radiology at the University of California, San Francisco, said in a video press release.

Researchers in both studies used data and images from the Osteoarthritis Initiative (OAI), a multicenter, longitudinal, observational study of 4,796 U.S. patients aged 45-79 years with knee OA. Participants were enrolled from February 2004 to May 2006.

The OAI maintains a natural history database of information regarding participants’ clinical evaluation data, x-rays, MRI scans, and a biospecimen repository. Data are available to researchers worldwide.
 

Two studies draw similar conclusions

In one study, Dr. Bharadwaj and colleagues found that HA injections appeared to show decreased knee OA progression in bone marrow lesions.

They investigated 8 patients who received one CS injection, 12 who received one HA injection, and 40 control persons who received neither treatment. Participants were propensity-score matched by age, sex, body mass index (BMI), Kellgren-Lawrence (KL) grade, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Physical Activity Scale for the Elderly (PASE).

The researchers semiquantitatively graded three Tesla MRI scans that had been obtained at baseline, 2 years before the injection, and 2 years after the injection, using whole-organ MRI score (WORMS) for the meniscus, bone marrow lesions, cartilage, joint effusion, and ligaments.

They quantified OA progression using the difference in WORMS between baseline and 2-year follow-up, and they used linear regression models, adjusted for age, sex, BMI, KL grade, WOMAC, and PASE, to identify the link between type of injection and progression of WORMS.

At 2 years, the authors found a significant association between CS injection and postinjection progression of WORMS over 2 years for the knee overall, the lateral meniscus, lateral cartilage, and medial cartilage. There was no significant link between HA injection and postinjection progression of WORMS or between either injection type and progression of pain, as quantified by WOMAC. There was also no significant difference in progression of WORMS over the 2 years prior to injection for CS and HA injections.

“Corticosteroid injections must be administered with caution with respect to long-term effects on osteoarthritis,” Dr. Bharadwaj advised. “Hyaluronic acid injections, on the other hand, may slow down progression of knee osteoarthritis and alleviate long-term effects while offering similar symptomatic relief to corticosteroid injections. Overall, they are perhaps a safer alternative when looking at medium- and long-term disease course of knee osteoarthritis.”

In the second study, lead author Azad Darbandi, MS, a fourth-year medical student at Chicago Medical School, North Chicago, and colleagues found that patients who received CS injections experienced significantly more medial joint space narrowing.

They identified 210 knees with imaging at baseline and at 48 months that received CS injections, and 59 that received HA injections; 6,827 knees served as controls. The investigators matched 50 patients per group on the basis of confounding factors, which included age, sex, BMI, comorbidities, surgery, and semiquantitative imaging outcomes at baseline. They performed ANCOVA testing using 48-month semiquantitative imaging outcomes as dependent variables and confounding variables as covariates.

The researchers analyzed joint space narrowing, KL grade, and tibia/femur medial/lateral compartment osteophyte formation and sclerosis.

At 4 years, the average KL grade in the CS group was 2.79, it was 2.11 in the HA group,;and it was 2.37 in the control group. Intergroup comparisons showed significant differences in KL grade between CS and HA groups and between CS and control groups. Medial compartment joint space narrowing was 1.56 in the CS group, 1.11 in the HA group, and 1.18 in controls. There was a significant difference between the CS and control groups. Other dependent variables were not significant.

“These preliminary results suggest that corticosteroid injections accelerated the radiographic progression of osteoarthritis, specifically medial joint space narrowing and Kellgren-Lawrence grading, whereas hyaluronic acid injections did not,” Mr. Darbandi said in an interview.

“OA radiographic progression does not always correlate with clinical progression, and further research is needed,” he added.

Proper matching of patients at baseline for confounding factors is a strength of the study, Mr. Darbandi said, while the retrospective study design is a weakness.
 

Experts share their perspectives on the preliminary results

Michael M. Kheir, MD, assistant professor of orthopedic surgery at the University of Michigan Health System, who was not involved in the studies, said he would like to see further related research.

“Perhaps steroid injections are not as benign as they once seemed,” he added. “They should be reserved for patients who already have significant arthritis and are seeking temporary relief prior to surgical reconstruction with a joint replacement, or for patients with recalcitrant pain after having already tried HA injections.”

William A. Jiranek, MD, professor and orthopedic surgeon at Duke Health in Morrisville, N.C., who also was not involved in the studies, was not surprised by the findings.

“It is important to do these studies to learn that steroid injections do not come with zero cost,” he said.

“I am pretty sure that a percentage of these patients had no cartilage loss at all,” he added. “We need to understand which OA phenotypes are not at risk of progressive cartilage loss from steroid injections.”

Annunziato (Ned) Amendola, MD, professor and sports medicine orthopedic surgeon at Duke Health in Durham, N.C., who was also not involved in the studies, said he would like to know how injection effectiveness and activity level are related.

“If the injections were effective at relieving pain, and the patients were more active, that may have predisposed to more joint wear,” he said. “It’s like tires that last longer if you don’t abuse them.”
 

Shared decision-making and further research recommended

Amanda E. Nelson, MD, associate professor of medicine in the division of rheumatology, allergy, and immunology at the University of North Carolina at Chapel Hill, said: “The lack of randomization introduces potential biases around why certain therapies (CS injection, HA injection, or neither) were selected over others (such as disease severity, preference, comorbid conditions, other contraindications, etc), thus making interpretation of the findings challenging.

“The causal relationship remains in question, and questions around the efficacy of intra-articular HA in particular, and the ideal settings for intra-articular therapy in general, persist,” noted Dr. Nelson, who was also not involved in the studies. “Thus, shared decision-making between patients and their providers is essential when considering these options.”

C. Kent Kwoh, MD, professor of medicine and medical imaging at the University of Arizona and director of the University of Arizona Arthritis Center, both in Tucson, said in an interview that these types of studies are important because CS injections are common treatments for knee OA, they are recommended in treatment guidelines, and other good options are lacking.

But he pointed out that the results of these two studies need to be interpreted with caution and should not be used to decide the course of treatment.

“These data are hypothesis generating. They suggest association, but they do not show causation,” said Dr. Kwoh, who was also not involved in the studies. “Both studies are secondary analyses of data collected from the OAI, which was not specifically designed to answer the questions these studies are posing.

“The OAI was not a treatment study, and participants were seen only once a year or so. They may have had joint injections anytime from only days to around 1 year before their visit, and their levels of activity or pain just prior to or just after their joint injections were not reported,” Dr. Kwoh explained.

The reasons why patients did or did not receive a specific joint injection – including their socioeconomic status, race, access to insurance, and other confounding factors – were not assessed and may have affected the results, he added.

The fact that both studies used the same data and came to the same conclusions gives the conclusions some strength, he said, but “the gold standard to understanding causation would be a randomized, controlled trial.”

Mr. Darbandi’s research received grant support from Boeing, His c-authors, as well as all experts not involved in the studies, reported no relevant financial relationshiips. Dr. Bharadwaj did not provide conflict-of-interest and funding details. Dr. Kwoh reported membership on panels that have developed guidelines for the management of knee OA.

A version of this article first appeared on Medscape.com.

Corticosteroid (CS) injections may worsen progression of knee osteoarthritis as seen on radiography and whole-knee MRI. Injecting hyaluronic acid (HA) instead, or managing the condition without injections, may better preserve knee structure and cartilage, according to results of two related studies presented at the annual meeting of the Radiological Society of North America.

The findings come nonrandomized, observational cohort studies, leading knee OA experts to call for further study in randomized trial settings. In the meantime, shared decision-making between patients and clinicians is advised on the use of these injections.

For knee OA, most patients seek a noninvasive treatment for symptomatic relief. “At least 10% of these patients undergo local treatment with injectable corticosteroids or hyaluronic acid,” the lead author of one of the studies, Upasana Upadhyay Bharadwaj, MD, research fellow in musculoskeletal radiology at the University of California, San Francisco, said in a video press release.

Researchers in both studies used data and images from the Osteoarthritis Initiative (OAI), a multicenter, longitudinal, observational study of 4,796 U.S. patients aged 45-79 years with knee OA. Participants were enrolled from February 2004 to May 2006.

The OAI maintains a natural history database of information regarding participants’ clinical evaluation data, x-rays, MRI scans, and a biospecimen repository. Data are available to researchers worldwide.
 

Two studies draw similar conclusions

In one study, Dr. Bharadwaj and colleagues found that HA injections appeared to show decreased knee OA progression in bone marrow lesions.

They investigated 8 patients who received one CS injection, 12 who received one HA injection, and 40 control persons who received neither treatment. Participants were propensity-score matched by age, sex, body mass index (BMI), Kellgren-Lawrence (KL) grade, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Physical Activity Scale for the Elderly (PASE).

The researchers semiquantitatively graded three Tesla MRI scans that had been obtained at baseline, 2 years before the injection, and 2 years after the injection, using whole-organ MRI score (WORMS) for the meniscus, bone marrow lesions, cartilage, joint effusion, and ligaments.

They quantified OA progression using the difference in WORMS between baseline and 2-year follow-up, and they used linear regression models, adjusted for age, sex, BMI, KL grade, WOMAC, and PASE, to identify the link between type of injection and progression of WORMS.

At 2 years, the authors found a significant association between CS injection and postinjection progression of WORMS over 2 years for the knee overall, the lateral meniscus, lateral cartilage, and medial cartilage. There was no significant link between HA injection and postinjection progression of WORMS or between either injection type and progression of pain, as quantified by WOMAC. There was also no significant difference in progression of WORMS over the 2 years prior to injection for CS and HA injections.

“Corticosteroid injections must be administered with caution with respect to long-term effects on osteoarthritis,” Dr. Bharadwaj advised. “Hyaluronic acid injections, on the other hand, may slow down progression of knee osteoarthritis and alleviate long-term effects while offering similar symptomatic relief to corticosteroid injections. Overall, they are perhaps a safer alternative when looking at medium- and long-term disease course of knee osteoarthritis.”

In the second study, lead author Azad Darbandi, MS, a fourth-year medical student at Chicago Medical School, North Chicago, and colleagues found that patients who received CS injections experienced significantly more medial joint space narrowing.

They identified 210 knees with imaging at baseline and at 48 months that received CS injections, and 59 that received HA injections; 6,827 knees served as controls. The investigators matched 50 patients per group on the basis of confounding factors, which included age, sex, BMI, comorbidities, surgery, and semiquantitative imaging outcomes at baseline. They performed ANCOVA testing using 48-month semiquantitative imaging outcomes as dependent variables and confounding variables as covariates.

The researchers analyzed joint space narrowing, KL grade, and tibia/femur medial/lateral compartment osteophyte formation and sclerosis.

At 4 years, the average KL grade in the CS group was 2.79, it was 2.11 in the HA group,;and it was 2.37 in the control group. Intergroup comparisons showed significant differences in KL grade between CS and HA groups and between CS and control groups. Medial compartment joint space narrowing was 1.56 in the CS group, 1.11 in the HA group, and 1.18 in controls. There was a significant difference between the CS and control groups. Other dependent variables were not significant.

“These preliminary results suggest that corticosteroid injections accelerated the radiographic progression of osteoarthritis, specifically medial joint space narrowing and Kellgren-Lawrence grading, whereas hyaluronic acid injections did not,” Mr. Darbandi said in an interview.

“OA radiographic progression does not always correlate with clinical progression, and further research is needed,” he added.

Proper matching of patients at baseline for confounding factors is a strength of the study, Mr. Darbandi said, while the retrospective study design is a weakness.
 

Experts share their perspectives on the preliminary results

Michael M. Kheir, MD, assistant professor of orthopedic surgery at the University of Michigan Health System, who was not involved in the studies, said he would like to see further related research.

“Perhaps steroid injections are not as benign as they once seemed,” he added. “They should be reserved for patients who already have significant arthritis and are seeking temporary relief prior to surgical reconstruction with a joint replacement, or for patients with recalcitrant pain after having already tried HA injections.”

William A. Jiranek, MD, professor and orthopedic surgeon at Duke Health in Morrisville, N.C., who also was not involved in the studies, was not surprised by the findings.

“It is important to do these studies to learn that steroid injections do not come with zero cost,” he said.

“I am pretty sure that a percentage of these patients had no cartilage loss at all,” he added. “We need to understand which OA phenotypes are not at risk of progressive cartilage loss from steroid injections.”

Annunziato (Ned) Amendola, MD, professor and sports medicine orthopedic surgeon at Duke Health in Durham, N.C., who was also not involved in the studies, said he would like to know how injection effectiveness and activity level are related.

“If the injections were effective at relieving pain, and the patients were more active, that may have predisposed to more joint wear,” he said. “It’s like tires that last longer if you don’t abuse them.”
 

Shared decision-making and further research recommended

Amanda E. Nelson, MD, associate professor of medicine in the division of rheumatology, allergy, and immunology at the University of North Carolina at Chapel Hill, said: “The lack of randomization introduces potential biases around why certain therapies (CS injection, HA injection, or neither) were selected over others (such as disease severity, preference, comorbid conditions, other contraindications, etc), thus making interpretation of the findings challenging.

“The causal relationship remains in question, and questions around the efficacy of intra-articular HA in particular, and the ideal settings for intra-articular therapy in general, persist,” noted Dr. Nelson, who was also not involved in the studies. “Thus, shared decision-making between patients and their providers is essential when considering these options.”

C. Kent Kwoh, MD, professor of medicine and medical imaging at the University of Arizona and director of the University of Arizona Arthritis Center, both in Tucson, said in an interview that these types of studies are important because CS injections are common treatments for knee OA, they are recommended in treatment guidelines, and other good options are lacking.

But he pointed out that the results of these two studies need to be interpreted with caution and should not be used to decide the course of treatment.

“These data are hypothesis generating. They suggest association, but they do not show causation,” said Dr. Kwoh, who was also not involved in the studies. “Both studies are secondary analyses of data collected from the OAI, which was not specifically designed to answer the questions these studies are posing.

“The OAI was not a treatment study, and participants were seen only once a year or so. They may have had joint injections anytime from only days to around 1 year before their visit, and their levels of activity or pain just prior to or just after their joint injections were not reported,” Dr. Kwoh explained.

The reasons why patients did or did not receive a specific joint injection – including their socioeconomic status, race, access to insurance, and other confounding factors – were not assessed and may have affected the results, he added.

The fact that both studies used the same data and came to the same conclusions gives the conclusions some strength, he said, but “the gold standard to understanding causation would be a randomized, controlled trial.”

Mr. Darbandi’s research received grant support from Boeing, His c-authors, as well as all experts not involved in the studies, reported no relevant financial relationshiips. Dr. Bharadwaj did not provide conflict-of-interest and funding details. Dr. Kwoh reported membership on panels that have developed guidelines for the management of knee OA.

A version of this article first appeared on Medscape.com.

Patients who seek fracture care at a facility that treats a higher proportion of patients from racial or ethnic minorities or a higher number of uninsured patients are more likely to face a longer-than-recommended delay in treatment, according to new data.

Regardless of individual patient-level characteristics such as race, ethnicity, or insurance status, these patients were more likely to miss the recommended 24-hour benchmark for surgery.

“Institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix,” write study author Ida Leah Gitajn, MD, an orthopedic trauma surgeon at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and colleagues.

“While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias,” the authors wrote.

The study was published online  in JAMA Network Open.
 

Site performance varied

Racial inequalities in health care utilization and outcomes have been documented in many medical specialties, including orthopedic trauma, the study authors write. However, previous studies evaluating racial disparities in fracture care have been limited to patient-level associations rather than hospital-level factors.

The investigators conducted a secondary analysis of prospectively collected multicenter data for 2,565 patients with hip and femur fractures enrolled in two randomized trials at 23 sites in the United States and Canada. The researchers assessed whether disparities in meeting 24-hour time-to-surgery benchmarks exist at the patient level or at the institutional level, evaluating the association of race, ethnicity, and insurance status.

The cohort study used data from the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT), which enrolled patients from 2018-2021 and followed them for 1 year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in the analysis, which was conducted from April to September of this year.

The cohort included 2,565 patients with an average age of about 65 years. About 82% of patients were White, 13.4% were Black, 3.2% were Asian, and 1.1% were classified as another race or ethnicity. Among the study population, 32.5% of participants were employed, and 92.2% had health insurance. Nearly 40% had a femur fracture with an average injury severity score of 10.4.

Overall, 596 patients (23.2%) didn’t meet the 24-hour time-to-operating-room benchmark. Patients who didn’t meet the 24-hour surgical window were more likely to be older, women, and have a femur fracture. They were less likely to be employed.

The 23 sites had variability in meeting the 24-hour benchmark, race and ethnicity distribution, and population-based health insurance. Institutions met benchmarks at frequencies ranging from 45.2% (for 196 of 433 procedures) to 97.4% (37 of 38 procedures). Minority race and ethnicity distribution ranged from 0% (in 99 procedures) to 58.2% (in 53 of 91 procedures). The proportion of uninsured patients ranged from 0% (in 64 procedures) to 34.2% (in 13 of 38 procedures).

At the patient level, there was no association between missing the 24-hour benchmark and race or ethnicity, and there was no independent association between hospital population racial composition and surgical delay. In an analysis that controlled for patient-level characteristics, there was no association between missing the 24-hour benchmark and patient-level insurance status.

There was an independent association, however, between the hospital population insurance coverage and hospital population racial composition as an interaction term, suggesting a moderating effect (P = .03), the study authors write.

At low rates of uninsured patients, the probability of missing the 24-hour benchmark was 12.5%-14.6% when racial composition varied from 0%-50% minority patients. In contrast, at higher rates of uninsured patients, the risk of missing the 24-hour window was higher among more diverse populations. For instance, at 30% uninsured, the risk of missing the benchmark was 0.5% when the racial composition was low and 17.6% at 50% minority patients.

Additional studies are needed to understand the findings and how health system programs or structures play a role, the authors write. For instance, well-funded health systems that care for a higher proportion of insured patients likely have quality improvement programs and other support structures, such as operating room access, that ensure appropriate time-to-surgery benchmarks for time-sensitive fractures, they say.
 

Addressing inequalities

Troy Amen, MD, MBA, an orthopedic surgery resident at the Hospital for Special Surgery, New York, said, “Despite these disparities being reported and well documented in recent years, unfortunately, not enough has been done to address them or understand their fundamental root causes.”

Dr. Amen, who wasn’t involved with this study, has researched racial and ethnic disparities in hip fracture surgery care across the United States. He and his colleagues found disparities in delayed time-to-surgery, particularly for Black patients.

“We live in a country and society where we want and strive for equality of care for patients regardless of race, ethnicity, gender, sexual orientation, or background,” he said. “We have a moral imperative to address these disparities as health care providers, not only among ourselves, but also in conjunction with lawmakers, hospital administrators, and health policy specialists.”

Uma Srikumaran, MD, an associate professor of orthopedic surgery at Johns Hopkins University, Baltimore, wasn’t involved with this study but has researched racial disparities in the timing of radiographic assessment and surgical treatment of hip fractures.

“Though we understand that racial disparities are pervasive in health care, we have a great deal left to understand about the extent of those disparities and all the various factors that contribute to them,” Dr. Srikumaran told this news organization.

Dr. Srikumaran and colleagues have found that Black patients had longer wait times for evaluation and surgery than White patients.

“We all want to get to the solutions, but those can be difficult to execute without an intricate understanding of the problem,” he said. “We should encourage this type of research all throughout health care in general but also very locally, as solutions are not likely to be one-size-fits-all.”

Dr. Srikumaran pointed to the need to measure the problem in specific pathologies, populations, geographies, hospital types, and other factors.

“Studying the trends of this issue will help us determine whether our national or local initiatives are making a difference and which interventions are most effective for a particular hospital, geographic location, or particular pathology,” he said. “Accordingly, if a particular hospital or health system isn’t looking at differences in the delivery of care by race, they are missing an opportunity to ensure equity and raise overall quality.”

The study was supported by funding from the Patient Centered Outcomes Research Institute. Dr. Gitajn reported receiving personal fees for consulting and teaching work from Stryker outside the submitted work. Dr. Amen and Dr. Srikumaran reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Patients who seek fracture care at a facility that treats a higher proportion of patients from racial or ethnic minorities or a higher number of uninsured patients are more likely to face a longer-than-recommended delay in treatment, according to new data.

Regardless of individual patient-level characteristics such as race, ethnicity, or insurance status, these patients were more likely to miss the recommended 24-hour benchmark for surgery.

“Institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix,” write study author Ida Leah Gitajn, MD, an orthopedic trauma surgeon at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and colleagues.

“While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias,” the authors wrote.

The study was published online  in JAMA Network Open.
 

Site performance varied

Racial inequalities in health care utilization and outcomes have been documented in many medical specialties, including orthopedic trauma, the study authors write. However, previous studies evaluating racial disparities in fracture care have been limited to patient-level associations rather than hospital-level factors.

The investigators conducted a secondary analysis of prospectively collected multicenter data for 2,565 patients with hip and femur fractures enrolled in two randomized trials at 23 sites in the United States and Canada. The researchers assessed whether disparities in meeting 24-hour time-to-surgery benchmarks exist at the patient level or at the institutional level, evaluating the association of race, ethnicity, and insurance status.

The cohort study used data from the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT), which enrolled patients from 2018-2021 and followed them for 1 year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in the analysis, which was conducted from April to September of this year.

The cohort included 2,565 patients with an average age of about 65 years. About 82% of patients were White, 13.4% were Black, 3.2% were Asian, and 1.1% were classified as another race or ethnicity. Among the study population, 32.5% of participants were employed, and 92.2% had health insurance. Nearly 40% had a femur fracture with an average injury severity score of 10.4.

Overall, 596 patients (23.2%) didn’t meet the 24-hour time-to-operating-room benchmark. Patients who didn’t meet the 24-hour surgical window were more likely to be older, women, and have a femur fracture. They were less likely to be employed.

The 23 sites had variability in meeting the 24-hour benchmark, race and ethnicity distribution, and population-based health insurance. Institutions met benchmarks at frequencies ranging from 45.2% (for 196 of 433 procedures) to 97.4% (37 of 38 procedures). Minority race and ethnicity distribution ranged from 0% (in 99 procedures) to 58.2% (in 53 of 91 procedures). The proportion of uninsured patients ranged from 0% (in 64 procedures) to 34.2% (in 13 of 38 procedures).

At the patient level, there was no association between missing the 24-hour benchmark and race or ethnicity, and there was no independent association between hospital population racial composition and surgical delay. In an analysis that controlled for patient-level characteristics, there was no association between missing the 24-hour benchmark and patient-level insurance status.

There was an independent association, however, between the hospital population insurance coverage and hospital population racial composition as an interaction term, suggesting a moderating effect (P = .03), the study authors write.

At low rates of uninsured patients, the probability of missing the 24-hour benchmark was 12.5%-14.6% when racial composition varied from 0%-50% minority patients. In contrast, at higher rates of uninsured patients, the risk of missing the 24-hour window was higher among more diverse populations. For instance, at 30% uninsured, the risk of missing the benchmark was 0.5% when the racial composition was low and 17.6% at 50% minority patients.

Additional studies are needed to understand the findings and how health system programs or structures play a role, the authors write. For instance, well-funded health systems that care for a higher proportion of insured patients likely have quality improvement programs and other support structures, such as operating room access, that ensure appropriate time-to-surgery benchmarks for time-sensitive fractures, they say.
 

Addressing inequalities

Troy Amen, MD, MBA, an orthopedic surgery resident at the Hospital for Special Surgery, New York, said, “Despite these disparities being reported and well documented in recent years, unfortunately, not enough has been done to address them or understand their fundamental root causes.”

Dr. Amen, who wasn’t involved with this study, has researched racial and ethnic disparities in hip fracture surgery care across the United States. He and his colleagues found disparities in delayed time-to-surgery, particularly for Black patients.

“We live in a country and society where we want and strive for equality of care for patients regardless of race, ethnicity, gender, sexual orientation, or background,” he said. “We have a moral imperative to address these disparities as health care providers, not only among ourselves, but also in conjunction with lawmakers, hospital administrators, and health policy specialists.”

Uma Srikumaran, MD, an associate professor of orthopedic surgery at Johns Hopkins University, Baltimore, wasn’t involved with this study but has researched racial disparities in the timing of radiographic assessment and surgical treatment of hip fractures.

“Though we understand that racial disparities are pervasive in health care, we have a great deal left to understand about the extent of those disparities and all the various factors that contribute to them,” Dr. Srikumaran told this news organization.

Dr. Srikumaran and colleagues have found that Black patients had longer wait times for evaluation and surgery than White patients.

“We all want to get to the solutions, but those can be difficult to execute without an intricate understanding of the problem,” he said. “We should encourage this type of research all throughout health care in general but also very locally, as solutions are not likely to be one-size-fits-all.”

Dr. Srikumaran pointed to the need to measure the problem in specific pathologies, populations, geographies, hospital types, and other factors.

“Studying the trends of this issue will help us determine whether our national or local initiatives are making a difference and which interventions are most effective for a particular hospital, geographic location, or particular pathology,” he said. “Accordingly, if a particular hospital or health system isn’t looking at differences in the delivery of care by race, they are missing an opportunity to ensure equity and raise overall quality.”

The study was supported by funding from the Patient Centered Outcomes Research Institute. Dr. Gitajn reported receiving personal fees for consulting and teaching work from Stryker outside the submitted work. Dr. Amen and Dr. Srikumaran reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Patients who seek fracture care at a facility that treats a higher proportion of patients from racial or ethnic minorities or a higher number of uninsured patients are more likely to face a longer-than-recommended delay in treatment, according to new data.

Regardless of individual patient-level characteristics such as race, ethnicity, or insurance status, these patients were more likely to miss the recommended 24-hour benchmark for surgery.

“Institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix,” write study author Ida Leah Gitajn, MD, an orthopedic trauma surgeon at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and colleagues.

“While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias,” the authors wrote.

The study was published online  in JAMA Network Open.
 

Site performance varied

Racial inequalities in health care utilization and outcomes have been documented in many medical specialties, including orthopedic trauma, the study authors write. However, previous studies evaluating racial disparities in fracture care have been limited to patient-level associations rather than hospital-level factors.

The investigators conducted a secondary analysis of prospectively collected multicenter data for 2,565 patients with hip and femur fractures enrolled in two randomized trials at 23 sites in the United States and Canada. The researchers assessed whether disparities in meeting 24-hour time-to-surgery benchmarks exist at the patient level or at the institutional level, evaluating the association of race, ethnicity, and insurance status.

The cohort study used data from the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT), which enrolled patients from 2018-2021 and followed them for 1 year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in the analysis, which was conducted from April to September of this year.

The cohort included 2,565 patients with an average age of about 65 years. About 82% of patients were White, 13.4% were Black, 3.2% were Asian, and 1.1% were classified as another race or ethnicity. Among the study population, 32.5% of participants were employed, and 92.2% had health insurance. Nearly 40% had a femur fracture with an average injury severity score of 10.4.

Overall, 596 patients (23.2%) didn’t meet the 24-hour time-to-operating-room benchmark. Patients who didn’t meet the 24-hour surgical window were more likely to be older, women, and have a femur fracture. They were less likely to be employed.

The 23 sites had variability in meeting the 24-hour benchmark, race and ethnicity distribution, and population-based health insurance. Institutions met benchmarks at frequencies ranging from 45.2% (for 196 of 433 procedures) to 97.4% (37 of 38 procedures). Minority race and ethnicity distribution ranged from 0% (in 99 procedures) to 58.2% (in 53 of 91 procedures). The proportion of uninsured patients ranged from 0% (in 64 procedures) to 34.2% (in 13 of 38 procedures).

At the patient level, there was no association between missing the 24-hour benchmark and race or ethnicity, and there was no independent association between hospital population racial composition and surgical delay. In an analysis that controlled for patient-level characteristics, there was no association between missing the 24-hour benchmark and patient-level insurance status.

There was an independent association, however, between the hospital population insurance coverage and hospital population racial composition as an interaction term, suggesting a moderating effect (P = .03), the study authors write.

At low rates of uninsured patients, the probability of missing the 24-hour benchmark was 12.5%-14.6% when racial composition varied from 0%-50% minority patients. In contrast, at higher rates of uninsured patients, the risk of missing the 24-hour window was higher among more diverse populations. For instance, at 30% uninsured, the risk of missing the benchmark was 0.5% when the racial composition was low and 17.6% at 50% minority patients.

Additional studies are needed to understand the findings and how health system programs or structures play a role, the authors write. For instance, well-funded health systems that care for a higher proportion of insured patients likely have quality improvement programs and other support structures, such as operating room access, that ensure appropriate time-to-surgery benchmarks for time-sensitive fractures, they say.
 

Addressing inequalities

Troy Amen, MD, MBA, an orthopedic surgery resident at the Hospital for Special Surgery, New York, said, “Despite these disparities being reported and well documented in recent years, unfortunately, not enough has been done to address them or understand their fundamental root causes.”

Dr. Amen, who wasn’t involved with this study, has researched racial and ethnic disparities in hip fracture surgery care across the United States. He and his colleagues found disparities in delayed time-to-surgery, particularly for Black patients.

“We live in a country and society where we want and strive for equality of care for patients regardless of race, ethnicity, gender, sexual orientation, or background,” he said. “We have a moral imperative to address these disparities as health care providers, not only among ourselves, but also in conjunction with lawmakers, hospital administrators, and health policy specialists.”

Uma Srikumaran, MD, an associate professor of orthopedic surgery at Johns Hopkins University, Baltimore, wasn’t involved with this study but has researched racial disparities in the timing of radiographic assessment and surgical treatment of hip fractures.

“Though we understand that racial disparities are pervasive in health care, we have a great deal left to understand about the extent of those disparities and all the various factors that contribute to them,” Dr. Srikumaran told this news organization.

Dr. Srikumaran and colleagues have found that Black patients had longer wait times for evaluation and surgery than White patients.

“We all want to get to the solutions, but those can be difficult to execute without an intricate understanding of the problem,” he said. “We should encourage this type of research all throughout health care in general but also very locally, as solutions are not likely to be one-size-fits-all.”

Dr. Srikumaran pointed to the need to measure the problem in specific pathologies, populations, geographies, hospital types, and other factors.

“Studying the trends of this issue will help us determine whether our national or local initiatives are making a difference and which interventions are most effective for a particular hospital, geographic location, or particular pathology,” he said. “Accordingly, if a particular hospital or health system isn’t looking at differences in the delivery of care by race, they are missing an opportunity to ensure equity and raise overall quality.”

The study was supported by funding from the Patient Centered Outcomes Research Institute. Dr. Gitajn reported receiving personal fees for consulting and teaching work from Stryker outside the submitted work. Dr. Amen and Dr. Srikumaran reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Roy Altman, MD, was a father, a husband, a teacher, a physician, an editor, and a mentor. He died November 30 as a result of complications related to Parkinson’s disease.

Altman was an editorial advisory board member for MDedge Rheumatology/Rheumatology News since the publications’ start in 2002. He also treated patients and taught students at the University of Miami and the University of California, Los Angeles. A father of four adult children and a grandfather to nine grandchildren, Altman was also a husband to Linda, “his lifelong partner.”

“[He] had this tremendous editorial expertise to be able to manage different journals at the same time without conflict,” said Marc Hochberg, MD, MPH, a professor of medicine, epidemiology, and public health and head of the division of rheumatology and clinical immunology at the University of Maryland School of Medicine, Baltimore. “This was done in the days before electronic publishing, in the days before everything was being done on the computer.”

Publications where Altman served as editor include Osteoarthritis and Cartilage and Seminars in Arthritis and Rheumatism.

In addition to editing articles, Altman also had an active patient panel, while lecturing and traveling internationally, Hochberg said. Altman accomplished this “while maintaining a very active family life,” remembers Hochberg, who learned from Altman about ways to achieve work-life balance.

“That’s important when you’re a junior faculty member – and you’re trying to develop your academic career – that you prioritize what you need to do to be successful in the world of academic medicine, especially rheumatology,” said Hochberg, who described Altman as a “very close friend.”

Teacher, physician, and mentor

John FitzGerald, MD, PhD, MBA, chief of clinical rheumatology at the University of California, Los Angeles, looks back on the more than 15 years that Altman drove 1 hour each way to teach fellows about topics including osteoarthritis. “He really valued teaching. ... that was a lot of his focus,” said FitzGerald, who adds that Altman also enjoyed his relationships with patients.

Altman joined the University of California, Los Angeles, faculty as a professor of medicine in the division of rheumatology and immunology in 2003. Before arriving at UCLA, he was chief of rheumatology and immunology at the University of Miami for many years.

“His patients loved him because he was providing treatments and services that they really had trouble finding elsewhere,” FitzGerald said. Altman entrusted FitzGerald with giving him injections between patients or during lunch for the arthritis that increasingly bothered him.

“He was very appreciative of having the care provided to him. ... he was also sort of playful and teasing,” FitzGerald said.

Altman also took on the role of teacher at home, according to his daughter, Evie. “My dad loved to diagnose; he enjoyed piecing together the disparate physical and radiologic clues to determine the cause of disease or pain. When I was much younger, he taught me how to spot someone with Paget’s Disease from the other end of the room.”

“He loved teaching, imparting his knowledge to others,” she added, remembering the slide sessions Altman presented to his students at their family home. “We loved [the slide sessions] because we could get pizza for dinner, and we got really good at spotting the biological markers of rheumatoid arthritis.”

Aaron Altman said his father was “impassioned by bringing people alleviation of their pain and suffering. It drove him to his very core.”

Researcher and family man

Evie Altman said in an interview that many people don’t know her father was one of the first practitioners of arthroscopy. “He would bring the then-rigid scopes into our elementary school class for ‘show and tell.’ Also, he traveled to the Bolivian jungles in the late 1970s to gather specific red ants whose venom locals had reported as an arthritic treatment,” she said.

Ultimately, Altman isolated the venom’s active ingredient, said Evie, who remembers that her father studied the effect of the treatment for many years. “This eventually led to his research with capsaicin peppers, which was developed into a cream used widely today.”

“Growing up, our garage freezer always had serum and patient urine in one section, away from the ice cream,” Evie added.

In 2011, Sally Koch Kubetin reported for Rheumatology News on Altman’s habit of donning his wife’s handpainted ties. His motivation? It was “born of the sensible desire to be recognizable in a busy world,” she wrote.

Evie said that her mother started painting ties for her father early in his career. Two of his favorite ties, she said, are the “Lady and the Tramp” tie featuring the two dogs eating spaghetti from the same bowl and the Winnie the Pooh tie. “Mostly, he loved the ties because my mom made them,” she said.

Student and military doctor

Altman received his medical degree from the University of Miami School of Medicine after earning an undergraduate degree from Michigan State University, East Lansing, Kubetin reported. The University of Miami School of Medicine was also where he did his internship, residency, and fellowship in rheumatology.

Kubetin reported that Altman’s military service interrupted his training. During his service as a lieutenant in the U.S. Navy active duty reserve, he was a general medical officer and cared for sailors and officers at Naval Air Station Point Mugu in Oxnard, Calif.

Altman had a second academic appointment as a professor of orthopedics when he was in Miami, according to the Rheumatology News profile. In addition, he was the clinical director of the geriatric research, education, and clinical center, and chief of the arthritis section in the division of medicine at the Miami Veterans Affairs Medical Center.

“Persistence, stubbornness, and all around stick-to-it-iveness defined him in our eyes,” said his daughter, Sarah. His daughter, Ruth, credits her father’s kindness and patience with informing how she practices veterinary medicine. “When I went to rounds with dad on Saturdays, he went to a nearby flower place downtown to get mom flowers almost every week if he could,” she said.

Altman announced at the family’s annual summer reunion in 2021 that he would stop seeing patients, said his daughter, Evie. He continued to present slide sessions and grand rounds to medical students at UCLA until early this year. Altman continued to edit journals and review articles until he died from complications of Parkinson’s disease.

He published articles in medical journals that number in the thousands, according to a website established by Altman’s family that honors his life. Altman was born in Astoria, N.Y., on May 16, 1937, and moved to Miami Beach with his parents when he was young.

Roy Altman, MD, was a father, a husband, a teacher, a physician, an editor, and a mentor. He died November 30 as a result of complications related to Parkinson’s disease.

Altman was an editorial advisory board member for MDedge Rheumatology/Rheumatology News since the publications’ start in 2002. He also treated patients and taught students at the University of Miami and the University of California, Los Angeles. A father of four adult children and a grandfather to nine grandchildren, Altman was also a husband to Linda, “his lifelong partner.”

“[He] had this tremendous editorial expertise to be able to manage different journals at the same time without conflict,” said Marc Hochberg, MD, MPH, a professor of medicine, epidemiology, and public health and head of the division of rheumatology and clinical immunology at the University of Maryland School of Medicine, Baltimore. “This was done in the days before electronic publishing, in the days before everything was being done on the computer.”

Publications where Altman served as editor include Osteoarthritis and Cartilage and Seminars in Arthritis and Rheumatism.

In addition to editing articles, Altman also had an active patient panel, while lecturing and traveling internationally, Hochberg said. Altman accomplished this “while maintaining a very active family life,” remembers Hochberg, who learned from Altman about ways to achieve work-life balance.

“That’s important when you’re a junior faculty member – and you’re trying to develop your academic career – that you prioritize what you need to do to be successful in the world of academic medicine, especially rheumatology,” said Hochberg, who described Altman as a “very close friend.”

Teacher, physician, and mentor

John FitzGerald, MD, PhD, MBA, chief of clinical rheumatology at the University of California, Los Angeles, looks back on the more than 15 years that Altman drove 1 hour each way to teach fellows about topics including osteoarthritis. “He really valued teaching. ... that was a lot of his focus,” said FitzGerald, who adds that Altman also enjoyed his relationships with patients.

Altman joined the University of California, Los Angeles, faculty as a professor of medicine in the division of rheumatology and immunology in 2003. Before arriving at UCLA, he was chief of rheumatology and immunology at the University of Miami for many years.

“His patients loved him because he was providing treatments and services that they really had trouble finding elsewhere,” FitzGerald said. Altman entrusted FitzGerald with giving him injections between patients or during lunch for the arthritis that increasingly bothered him.

“He was very appreciative of having the care provided to him. ... he was also sort of playful and teasing,” FitzGerald said.

Altman also took on the role of teacher at home, according to his daughter, Evie. “My dad loved to diagnose; he enjoyed piecing together the disparate physical and radiologic clues to determine the cause of disease or pain. When I was much younger, he taught me how to spot someone with Paget’s Disease from the other end of the room.”

“He loved teaching, imparting his knowledge to others,” she added, remembering the slide sessions Altman presented to his students at their family home. “We loved [the slide sessions] because we could get pizza for dinner, and we got really good at spotting the biological markers of rheumatoid arthritis.”

Aaron Altman said his father was “impassioned by bringing people alleviation of their pain and suffering. It drove him to his very core.”

Researcher and family man

Evie Altman said in an interview that many people don’t know her father was one of the first practitioners of arthroscopy. “He would bring the then-rigid scopes into our elementary school class for ‘show and tell.’ Also, he traveled to the Bolivian jungles in the late 1970s to gather specific red ants whose venom locals had reported as an arthritic treatment,” she said.

Ultimately, Altman isolated the venom’s active ingredient, said Evie, who remembers that her father studied the effect of the treatment for many years. “This eventually led to his research with capsaicin peppers, which was developed into a cream used widely today.”

“Growing up, our garage freezer always had serum and patient urine in one section, away from the ice cream,” Evie added.

In 2011, Sally Koch Kubetin reported for Rheumatology News on Altman’s habit of donning his wife’s handpainted ties. His motivation? It was “born of the sensible desire to be recognizable in a busy world,” she wrote.

Evie said that her mother started painting ties for her father early in his career. Two of his favorite ties, she said, are the “Lady and the Tramp” tie featuring the two dogs eating spaghetti from the same bowl and the Winnie the Pooh tie. “Mostly, he loved the ties because my mom made them,” she said.

Student and military doctor

Altman received his medical degree from the University of Miami School of Medicine after earning an undergraduate degree from Michigan State University, East Lansing, Kubetin reported. The University of Miami School of Medicine was also where he did his internship, residency, and fellowship in rheumatology.

Kubetin reported that Altman’s military service interrupted his training. During his service as a lieutenant in the U.S. Navy active duty reserve, he was a general medical officer and cared for sailors and officers at Naval Air Station Point Mugu in Oxnard, Calif.

Altman had a second academic appointment as a professor of orthopedics when he was in Miami, according to the Rheumatology News profile. In addition, he was the clinical director of the geriatric research, education, and clinical center, and chief of the arthritis section in the division of medicine at the Miami Veterans Affairs Medical Center.

“Persistence, stubbornness, and all around stick-to-it-iveness defined him in our eyes,” said his daughter, Sarah. His daughter, Ruth, credits her father’s kindness and patience with informing how she practices veterinary medicine. “When I went to rounds with dad on Saturdays, he went to a nearby flower place downtown to get mom flowers almost every week if he could,” she said.

Altman announced at the family’s annual summer reunion in 2021 that he would stop seeing patients, said his daughter, Evie. He continued to present slide sessions and grand rounds to medical students at UCLA until early this year. Altman continued to edit journals and review articles until he died from complications of Parkinson’s disease.

He published articles in medical journals that number in the thousands, according to a website established by Altman’s family that honors his life. Altman was born in Astoria, N.Y., on May 16, 1937, and moved to Miami Beach with his parents when he was young.

Roy Altman, MD, was a father, a husband, a teacher, a physician, an editor, and a mentor. He died November 30 as a result of complications related to Parkinson’s disease.

Altman was an editorial advisory board member for MDedge Rheumatology/Rheumatology News since the publications’ start in 2002. He also treated patients and taught students at the University of Miami and the University of California, Los Angeles. A father of four adult children and a grandfather to nine grandchildren, Altman was also a husband to Linda, “his lifelong partner.”

“[He] had this tremendous editorial expertise to be able to manage different journals at the same time without conflict,” said Marc Hochberg, MD, MPH, a professor of medicine, epidemiology, and public health and head of the division of rheumatology and clinical immunology at the University of Maryland School of Medicine, Baltimore. “This was done in the days before electronic publishing, in the days before everything was being done on the computer.”

Publications where Altman served as editor include Osteoarthritis and Cartilage and Seminars in Arthritis and Rheumatism.

In addition to editing articles, Altman also had an active patient panel, while lecturing and traveling internationally, Hochberg said. Altman accomplished this “while maintaining a very active family life,” remembers Hochberg, who learned from Altman about ways to achieve work-life balance.

“That’s important when you’re a junior faculty member – and you’re trying to develop your academic career – that you prioritize what you need to do to be successful in the world of academic medicine, especially rheumatology,” said Hochberg, who described Altman as a “very close friend.”

Teacher, physician, and mentor

John FitzGerald, MD, PhD, MBA, chief of clinical rheumatology at the University of California, Los Angeles, looks back on the more than 15 years that Altman drove 1 hour each way to teach fellows about topics including osteoarthritis. “He really valued teaching. ... that was a lot of his focus,” said FitzGerald, who adds that Altman also enjoyed his relationships with patients.

Altman joined the University of California, Los Angeles, faculty as a professor of medicine in the division of rheumatology and immunology in 2003. Before arriving at UCLA, he was chief of rheumatology and immunology at the University of Miami for many years.

“His patients loved him because he was providing treatments and services that they really had trouble finding elsewhere,” FitzGerald said. Altman entrusted FitzGerald with giving him injections between patients or during lunch for the arthritis that increasingly bothered him.

“He was very appreciative of having the care provided to him. ... he was also sort of playful and teasing,” FitzGerald said.

Altman also took on the role of teacher at home, according to his daughter, Evie. “My dad loved to diagnose; he enjoyed piecing together the disparate physical and radiologic clues to determine the cause of disease or pain. When I was much younger, he taught me how to spot someone with Paget’s Disease from the other end of the room.”

“He loved teaching, imparting his knowledge to others,” she added, remembering the slide sessions Altman presented to his students at their family home. “We loved [the slide sessions] because we could get pizza for dinner, and we got really good at spotting the biological markers of rheumatoid arthritis.”

Aaron Altman said his father was “impassioned by bringing people alleviation of their pain and suffering. It drove him to his very core.”

Researcher and family man

Evie Altman said in an interview that many people don’t know her father was one of the first practitioners of arthroscopy. “He would bring the then-rigid scopes into our elementary school class for ‘show and tell.’ Also, he traveled to the Bolivian jungles in the late 1970s to gather specific red ants whose venom locals had reported as an arthritic treatment,” she said.

Ultimately, Altman isolated the venom’s active ingredient, said Evie, who remembers that her father studied the effect of the treatment for many years. “This eventually led to his research with capsaicin peppers, which was developed into a cream used widely today.”

“Growing up, our garage freezer always had serum and patient urine in one section, away from the ice cream,” Evie added.

In 2011, Sally Koch Kubetin reported for Rheumatology News on Altman’s habit of donning his wife’s handpainted ties. His motivation? It was “born of the sensible desire to be recognizable in a busy world,” she wrote.

Evie said that her mother started painting ties for her father early in his career. Two of his favorite ties, she said, are the “Lady and the Tramp” tie featuring the two dogs eating spaghetti from the same bowl and the Winnie the Pooh tie. “Mostly, he loved the ties because my mom made them,” she said.

Student and military doctor

Altman received his medical degree from the University of Miami School of Medicine after earning an undergraduate degree from Michigan State University, East Lansing, Kubetin reported. The University of Miami School of Medicine was also where he did his internship, residency, and fellowship in rheumatology.

Kubetin reported that Altman’s military service interrupted his training. During his service as a lieutenant in the U.S. Navy active duty reserve, he was a general medical officer and cared for sailors and officers at Naval Air Station Point Mugu in Oxnard, Calif.

Altman had a second academic appointment as a professor of orthopedics when he was in Miami, according to the Rheumatology News profile. In addition, he was the clinical director of the geriatric research, education, and clinical center, and chief of the arthritis section in the division of medicine at the Miami Veterans Affairs Medical Center.

“Persistence, stubbornness, and all around stick-to-it-iveness defined him in our eyes,” said his daughter, Sarah. His daughter, Ruth, credits her father’s kindness and patience with informing how she practices veterinary medicine. “When I went to rounds with dad on Saturdays, he went to a nearby flower place downtown to get mom flowers almost every week if he could,” she said.

Altman announced at the family’s annual summer reunion in 2021 that he would stop seeing patients, said his daughter, Evie. He continued to present slide sessions and grand rounds to medical students at UCLA until early this year. Altman continued to edit journals and review articles until he died from complications of Parkinson’s disease.

He published articles in medical journals that number in the thousands, according to a website established by Altman’s family that honors his life. Altman was born in Astoria, N.Y., on May 16, 1937, and moved to Miami Beach with his parents when he was young.

A new study reports that slowly lowering weights builds and strengthens muscles almost as well as lifting and lowering them, as you would do with a typical rep.

That means, for example, that you could use two hands to lift a dumbbell, then one hand to slowly lower it, while sacrificing little in the way of results. Focusing on the lowering – or the “eccentric” contraction – can lead to a more efficient gym session, Japanese researchers say.

In the study, published in the European Journal of Applied Physiology, researchers divided people into three groups of 14 for a 5-week, twice-weekly comparison.

One group performed dumbbell curls from full extension to about one-quarter of the way up, for 2 seconds up and 2 seconds down, in three sets of 10 reps. Another 14 people performed only the lift portion of the movement (a researcher helped them reset the weight after each rep), and another 14 did only the lowering part of the move.

The group that both lifted and lowered the weights increased the maximum force they could produce on a lift by 18% and increased the thickness of the biceps muscle by 11%.

The people who only lowered the weights nearly matched that, increasing their maximum force by 14% and muscle size by 10%. The lifting-only group increased their max force by 11%, while muscle size increase was insignificant. 

Your muscle fibers work two ways. When you lift a dumbbell from a straight arm up to your shoulder, your biceps muscle is using a “concentric” contraction. As you lower that dumbbell back down, the biceps muscle is working to put the brakes on the descent – that’s called an “eccentric” contraction. 

The lifting-plus-lowering group saw the biggest gains because they were pretty much doing twice the number of reps. The lowering-only group made similar improvements in strength and muscle with only half the work. 

Study author Masatoshi Nakamura, PhD, a professor at Nishikyushu University, Japan, believes that eccentric muscle contractions produce greater neurological adaptations in the spine and brain than concentric contractions. In other words, your nerves learn to send more of the “pull harder” signal to your muscles. 

At the same time, the spring action of a large protein called “titin” in the muscle fibers produces greater force during eccentric contractions while using less energy, and more titin could account for the increase in muscle size, which is called hypertrophy. 

“Titin in the muscle fibers could be the best explanation for muscle hypertrophy,” Dr. Nakamura says. “However, we believe that other factors, such as neurological adaptations, also play a large role in increasing muscle strength.”

The short range of motion used in the dumbbell curls was an important factor. A study, published in the Journal of Strength and Conditioning Research, found that a partial range-of-motion triceps exercise produced greater muscle growth than full range-of-motion movements. 

Although the people in this newest study only performed dumbbell curls, “we think the effect is similar in other muscles,” Dr. Nakamura says.

Your muscles are much stronger when lowering than they are lifting, so Dr. Nakamura suggests choosing a heavy weight to perform single-arm dumbbell curls. Use both arms to raise the dumbbell into the 50-degree position, then lower it over a 2-second count. For two-handed bent- or straight-bar curls, you can ask a spotter to help you lift the weights into position between slow lowering moves. 

You can also try the same trick with leg curl or leg extension exercise machines, using two legs to lift the weight and allowing one leg to lower it.

In the near future, your gym might contain more equipment that was designed specifically around lowering movements.

“Other machines that can emphasize eccentric contraction are gradually being developed,” Dr. Nakamura says.

A version of this article first appeared on WebMD.com.

A new study reports that slowly lowering weights builds and strengthens muscles almost as well as lifting and lowering them, as you would do with a typical rep.

That means, for example, that you could use two hands to lift a dumbbell, then one hand to slowly lower it, while sacrificing little in the way of results. Focusing on the lowering – or the “eccentric” contraction – can lead to a more efficient gym session, Japanese researchers say.

In the study, published in the European Journal of Applied Physiology, researchers divided people into three groups of 14 for a 5-week, twice-weekly comparison.

One group performed dumbbell curls from full extension to about one-quarter of the way up, for 2 seconds up and 2 seconds down, in three sets of 10 reps. Another 14 people performed only the lift portion of the movement (a researcher helped them reset the weight after each rep), and another 14 did only the lowering part of the move.

The group that both lifted and lowered the weights increased the maximum force they could produce on a lift by 18% and increased the thickness of the biceps muscle by 11%.

The people who only lowered the weights nearly matched that, increasing their maximum force by 14% and muscle size by 10%. The lifting-only group increased their max force by 11%, while muscle size increase was insignificant. 

Your muscle fibers work two ways. When you lift a dumbbell from a straight arm up to your shoulder, your biceps muscle is using a “concentric” contraction. As you lower that dumbbell back down, the biceps muscle is working to put the brakes on the descent – that’s called an “eccentric” contraction. 

The lifting-plus-lowering group saw the biggest gains because they were pretty much doing twice the number of reps. The lowering-only group made similar improvements in strength and muscle with only half the work. 

Study author Masatoshi Nakamura, PhD, a professor at Nishikyushu University, Japan, believes that eccentric muscle contractions produce greater neurological adaptations in the spine and brain than concentric contractions. In other words, your nerves learn to send more of the “pull harder” signal to your muscles. 

At the same time, the spring action of a large protein called “titin” in the muscle fibers produces greater force during eccentric contractions while using less energy, and more titin could account for the increase in muscle size, which is called hypertrophy. 

“Titin in the muscle fibers could be the best explanation for muscle hypertrophy,” Dr. Nakamura says. “However, we believe that other factors, such as neurological adaptations, also play a large role in increasing muscle strength.”

The short range of motion used in the dumbbell curls was an important factor. A study, published in the Journal of Strength and Conditioning Research, found that a partial range-of-motion triceps exercise produced greater muscle growth than full range-of-motion movements. 

Although the people in this newest study only performed dumbbell curls, “we think the effect is similar in other muscles,” Dr. Nakamura says.

Your muscles are much stronger when lowering than they are lifting, so Dr. Nakamura suggests choosing a heavy weight to perform single-arm dumbbell curls. Use both arms to raise the dumbbell into the 50-degree position, then lower it over a 2-second count. For two-handed bent- or straight-bar curls, you can ask a spotter to help you lift the weights into position between slow lowering moves. 

You can also try the same trick with leg curl or leg extension exercise machines, using two legs to lift the weight and allowing one leg to lower it.

In the near future, your gym might contain more equipment that was designed specifically around lowering movements.

“Other machines that can emphasize eccentric contraction are gradually being developed,” Dr. Nakamura says.

A version of this article first appeared on WebMD.com.

A new study reports that slowly lowering weights builds and strengthens muscles almost as well as lifting and lowering them, as you would do with a typical rep.

That means, for example, that you could use two hands to lift a dumbbell, then one hand to slowly lower it, while sacrificing little in the way of results. Focusing on the lowering – or the “eccentric” contraction – can lead to a more efficient gym session, Japanese researchers say.

In the study, published in the European Journal of Applied Physiology, researchers divided people into three groups of 14 for a 5-week, twice-weekly comparison.

One group performed dumbbell curls from full extension to about one-quarter of the way up, for 2 seconds up and 2 seconds down, in three sets of 10 reps. Another 14 people performed only the lift portion of the movement (a researcher helped them reset the weight after each rep), and another 14 did only the lowering part of the move.

The group that both lifted and lowered the weights increased the maximum force they could produce on a lift by 18% and increased the thickness of the biceps muscle by 11%.

The people who only lowered the weights nearly matched that, increasing their maximum force by 14% and muscle size by 10%. The lifting-only group increased their max force by 11%, while muscle size increase was insignificant. 

Your muscle fibers work two ways. When you lift a dumbbell from a straight arm up to your shoulder, your biceps muscle is using a “concentric” contraction. As you lower that dumbbell back down, the biceps muscle is working to put the brakes on the descent – that’s called an “eccentric” contraction. 

The lifting-plus-lowering group saw the biggest gains because they were pretty much doing twice the number of reps. The lowering-only group made similar improvements in strength and muscle with only half the work. 

Study author Masatoshi Nakamura, PhD, a professor at Nishikyushu University, Japan, believes that eccentric muscle contractions produce greater neurological adaptations in the spine and brain than concentric contractions. In other words, your nerves learn to send more of the “pull harder” signal to your muscles. 

At the same time, the spring action of a large protein called “titin” in the muscle fibers produces greater force during eccentric contractions while using less energy, and more titin could account for the increase in muscle size, which is called hypertrophy. 

“Titin in the muscle fibers could be the best explanation for muscle hypertrophy,” Dr. Nakamura says. “However, we believe that other factors, such as neurological adaptations, also play a large role in increasing muscle strength.”

The short range of motion used in the dumbbell curls was an important factor. A study, published in the Journal of Strength and Conditioning Research, found that a partial range-of-motion triceps exercise produced greater muscle growth than full range-of-motion movements. 

Although the people in this newest study only performed dumbbell curls, “we think the effect is similar in other muscles,” Dr. Nakamura says.

Your muscles are much stronger when lowering than they are lifting, so Dr. Nakamura suggests choosing a heavy weight to perform single-arm dumbbell curls. Use both arms to raise the dumbbell into the 50-degree position, then lower it over a 2-second count. For two-handed bent- or straight-bar curls, you can ask a spotter to help you lift the weights into position between slow lowering moves. 

You can also try the same trick with leg curl or leg extension exercise machines, using two legs to lift the weight and allowing one leg to lower it.

In the near future, your gym might contain more equipment that was designed specifically around lowering movements.

“Other machines that can emphasize eccentric contraction are gradually being developed,” Dr. Nakamura says.

A version of this article first appeared on WebMD.com.

For patients with severe arthritis, joint replacement is considered when more conservative treatments have failed. Because patients with obesity have a higher risk of complications during and after surgery, some surgeons, hospitals, and insurance companies have adopted body mass index cutoffs as a basis for deciding whether to offer patients these elective surgeries. But some experts argue that these cutoffs are arbitrary, exclude patients who can still benefit from the surgery, and can increase disparities in care.

“By enforcing cutoffs in general, you’re losing the ability for each surgeon to determine who they want to operate on,” said Daniel Wiznia, MD, assistant professor of orthopedic surgery at Yale University, New Haven, Conn. He is on the leadership committee of the Movement Is Life Caucus, a nonprofit group focused on eliminating disparities in musculoskeletal health. “For every surgeon, it’s up to them to decide if they feel comfortable doing the surgery,” he noted in an interview. “My guidance for that would be, don’t just say no because of the number – look at the patient’s entire medical profile.”

According to the Centers for Disease Control and Prevention, nearly 42% of adults in the United States have a BMI over 30, and 9.2% of adults have a BMI over 40. This excess weight puts additional stress on joints: When a person is walking, experts estimate that the force on the knees can be two to three times someone’s body weight. Over time, this pressure can wear down the cartilage on joints.

As a result, people who are overweight or obese are more likely to develop osteoarthritis and to need joint replacements. According to a Canadian study, patients with a BMI of 30-35 are 3.4 times as likely to require a hip replacement and are 8.5 times as likely to require a knee replacement compared to individuals with a BMI in the “healthy weight” range. With a BMI above 40, individuals were 8.5 times more likely to need a hip replacement and were 32.7 times as likely to need a knee replacement.
 

More complications, greater expense

While there are no universally recommended BMI cutoffs for joint replacement surgery, it is not uncommon for institutions to require that patients have a BMI below a certain value (usually 35-40) to proceed with surgery. A 2013 survey of physicians from the American Association of Hip and Knee Surgeons found that 52% of surgeons required a BMI below 40 to qualify for surgery.

One of the main reasons for these cutoffs is the elevated risk of complications during and after surgery. Research suggests that obesity is associated with higher rates of wound dehiscence, prosthetic joint infection (PJI), and revision total joint arthroplasty. One 2016 study suggests that patients with a BMI of 35-39.9 are twice as likely to experience PJI compared to patients with a BMI below 35. For patients with a BMI of 40 or higher, PJI is four times as likely.

Another study found that patients whose BMI is 35-40 and who undergo total joint arthroplasty have a 6.4-fold greater risk of deep incision infection. For those with a BMI over 40, that rises to a 12.9-fold increased risk compared to patients with a BMI of 18.5-25. Patients with obesity tend to have other comorbidities that can increase the risk of complications during surgery, such as type 2 diabetes, coronary artery disease, and chronic kidney disease.

Because of the increased risk of complications, health care costs tend to be higher for patients with obesity. The growing popularity of bundled health payments can discourage operating on patients who are more likely to experience complications, such as patients with high BMIs, noted Dr. Wiznia.

Research suggests that minorities and people with lower socioeconomic status are disproportionately affected by these cutoffs. According to the CDC, among non-Hispanic Black Americans and Hispanic Americans, rates of obesity are higher than among their White counterparts, and these patients are less likely to undergo joint replacement. Strictly enforcing this eligibility criterion can worsen those disparities. A study involving 21,294 adults over age 50 from the National Health and Nutrition Examination Survey (NHANES) found that requiring a BMI of under 35 for total joint arthroplasty resulted in Black patients being 39% less likely to be eligible for surgery than White patients. And individuals with an annual household income under $45,000 were 19% less likely to qualify for surgery than those with a household income above $45,000.
 

BMI no better than other risk factors

Although high BMI is independently associated with a higher risk of complications, the increased risk of complications conferred by a BMI at or above 40 is similar to or lower than those of other comorbidities that surgeons generally accept, said Nicholas Giori, MD, PhD, professor of orthopedic surgery at Stanford (Calif.) University, and chief of orthopedic surgery at the VA Palo Alto Health Care System. These other comorbidities include age older than 75, hypertension that requires medication, and insulin-controlled diabetes. “The independent risk of just having the diagnosis of insulin-dependent diabetes is actually comparable to the independent risk of having obesity by itself,” he told this news organization, “and all of us operate on [patients with] diabetes.”

Also, there is no BMI at which the risk of complications suddenly increases, according to the American Academy of Orthopaedic Surgeons. “It’s a rising complication rate as you go into higher BMIs,” Dr. Giori said. “If you operate on someone with a BMI of 39 vs. 41, you’re not going to find that much of a difference [in risk].” But if a medical system enforced a hard BMI cutoff of 40, one patient would qualify for surgery while the other would be barred.
 

Weight not as “modifiable” as previously thought

Weight is often considered a “modifiable factor” for a person considering undergoing total joint arthroplasty, but research suggests that the issue is more complicated. “Obesity is tricky, because some people are successful [in weight loss],” said Dr. Giori. Those tend to be the more memorable stories. “But a large majority have a really hard time losing substantial weight – enough to make a difference in risk,” he continued.

A study conducted in North Carolina found that restricting patients with a BMI over 40 from having elective total joint arthroplasty procedures until their weight was optimized did not result in successful weight loss. Only 20% of patients who originally presented with a BMI above this limit eventually underwent surgery after 2 years, and fewer than half of these patients had achieved a BMI of less than 40 at the time of their surgery. A third of all patients in the study did not return to the orthopedic office after their first visit.

“To hold a hard cutoff when it’s very, very hard to modify ... is essentially telling people that they are not going to ever have surgery,” Dr. Giori said; “I think that can be unfair to some patients.”

Bariatric surgery is often suggested for patients with obesity who have not experienced successful weight loss with diet and lifestyle changes alone, but bariatric surgery comes with its own complications. Research on outcomes from total joint arthroplasty among patients with who have lost weight with bariatric surgery has yielded mixed results. “I rarely push anyone hard to go that route but present it as an option for certain patients,” said Benjamin M. Stronach, MD, an orthopedic surgeon at the University of Arkansas for Medical Sciences, in Little Rock. He usually brings up bariatric surgery with patients with a BMI in the high 40s or higher to gauge their interest. If patients are already considering weight loss surgery, his office provides referrals.

But even bariatric surgery does not result in successful long-term weight loss for every patient, Dr. Stronach said. He’s seeing more and more patients who come for consultations after having undergone bariatric surgery 10 to 15 years ago. These patients lost a significant amount of weight, but then gained the weight back. He noted that bariatric surgery can be very successful for some patients who adhere to their postbariatric regimen. “We typically see fairly impressive results in the short term,” he said.
 

Patients with obesity benefit from joint replacement

Although patients with obesity are at higher risk for complications from joint replacement surgery, research suggests that these patients can still benefit greatly from these surgeries and that these surgeries remain cost-effective. Some studies have found that patients with obesity tend to have worse outcomes after surgery than patients who are not obese, but often, patients with high BMIs are starting from a lower point, with greater joint pain and limited mobility, Dr. Giori said. But the improvements – that is, net change in measured outcomes – can be greater for obese patients.

“Several studies have shown equal or greater improvements in validated outcome scores, function, and satisfaction compared with nonobese patients after surgery,” authors wrote in a recent review article in which they discuss how to optimize joint replacement surgery for patients with obesity. The article, published in the November 2022 issue of the Journal of the American Academy of Orthopaedic Surgeon (JAAOS), is part of a collection of review articles by the Movement Is Life Caucus.

Encourage weight loss, but look beyond the number

Rather than adhering to strict BMI cutoffs, some experts urge surgeons to consider the patient as a whole and to evaluate each individual’s overall health and potential risk. Dr. Giori generally considers high BMI as just another comorbidity when assessing a patient’s overall risk. “For a person who only has a high BMI but is otherwise healthy, I see no reason not to go ahead and schedule that person for surgery, because reducing the patient’s BMI will not substantially reduce the patient’s complication risk, and a delay in surgery may adversely affect the patient’s quality of life and ability to earn a living,” he said.

“If someone is between a BMI of 40 and 45, we are definitely going to have a discussion about weight,” Dr. Stronach said. He generally counsels against surgery for any patient with a BMI at 45 or above. He wants patients to have a BMI below 40 before surgery but considers individual cases for exceptions. “We will still move forward at times with someone with a BMI of 41, as an example, who is otherwise healthy,” he said. Similarly, if a patient has lost a significant amount of weight (e.g., the patient’s BMI was reduced from 50 to 41), the patient is actively engaged in improving their health, and surgeons believe the patient has significantly reduced their risk, “a lot of time, we’re not going to draw a line in the sand right at [a BMI of] 40,” he said.

While using a BMI of under 35 or 40 as a guideline when starting to work with patients is reasonable, working toward a weight loss of 5%-10% of total body weight is another goal to consider, authors advise in the JAAOS obesity review article. Research suggests that even a 5% reduction in overall body weight can reduce surgical complications and can improve a patient’s glucose and lipid levels and cardiac profile. Referrals to dietitians and weight loss programs, as well as behavioral counseling, can also be useful in initiating weight loss and keeping patients engaged in the process, the authors wrote.
 

Consider a patient’s comorbidities

Many patients with obesity have comorbidities, such as type 2 diabetes and hypertension, that can also be optimized for surgery so as to lower a patient’s overall risk profile. For patients with diabetes, achieving an A1c of 8% or lower can be a reasonable goal and can reduce risk. “We’ve found that an HbA1c level of 8% or less is something that virtually all diabetics (though not everybody) can reach, and it’s something that can be reached in a reasonable amount of time,” Dr. Giori said. Preoperative use of beta-blockers, continued use of ACE inhibitors or angiotensin receptor blockers, and behavioral modifications can improve a patient’s cardiac health before surgery.

Malnutrition can be a correctable problem for patients, regardless of BMI. In the Movement Is Life collection of optimization articles, experts recommend that orthopedists screen for malnutrition with blood tests for albumin, vitamin D, transferrin, and total lymphocyte count. Patients with malnutrition should be screened for food insecurity, experts advise, and surgical candidates with deficiencies can be given supplements of omega-3 fatty acids, arginine, and protein shakes.

Surgeon comfort and shared decision-making

Dr. Wiznia emphasized that the patient and surgeon need to discuss the risks of surgery, concerns about potential complications, and how a complication could affect the patient’s life moving forward. “Ultimately, the surgeon needs to make the decision [of whether or not to proceed [with surgery] with the patient,” he said, “but not every surgeon is going to feel comfortable operating on these patients, and not every medical institution is going to have the equipment and the investments to support surgeons doing it.”

Dr. Giori agreed that surgeons should proceed only with surgical cases they feel comfortable with. Certain surgeons may decide not to operate on individuals with higher BMIs because of the potential complications and can refer these patients to more specialized care centers. Operating on larger patients is more difficult and requires surgical skills and expertise that the surgeon may not have, he noted. “What I do object to is a system-wide BMI cutoff – for example, if an insurance company won’t pay for you to have a joint replacement, regardless of where you go or who your surgeon is,” Dr. Giori added. “I think that’s wrong, because it’s not patient centered and it’s basically excluding people from having a life-altering operation.”

Dr. Giori and Dr. Wiznia report no relevant financial relationships. Dr. Stronach is a consultant for DJ Orthopaedics, Johnson & Johnson, and MiCare Path.

A version of this article first appeared on Medscape.com.

For patients with severe arthritis, joint replacement is considered when more conservative treatments have failed. Because patients with obesity have a higher risk of complications during and after surgery, some surgeons, hospitals, and insurance companies have adopted body mass index cutoffs as a basis for deciding whether to offer patients these elective surgeries. But some experts argue that these cutoffs are arbitrary, exclude patients who can still benefit from the surgery, and can increase disparities in care.

“By enforcing cutoffs in general, you’re losing the ability for each surgeon to determine who they want to operate on,” said Daniel Wiznia, MD, assistant professor of orthopedic surgery at Yale University, New Haven, Conn. He is on the leadership committee of the Movement Is Life Caucus, a nonprofit group focused on eliminating disparities in musculoskeletal health. “For every surgeon, it’s up to them to decide if they feel comfortable doing the surgery,” he noted in an interview. “My guidance for that would be, don’t just say no because of the number – look at the patient’s entire medical profile.”

According to the Centers for Disease Control and Prevention, nearly 42% of adults in the United States have a BMI over 30, and 9.2% of adults have a BMI over 40. This excess weight puts additional stress on joints: When a person is walking, experts estimate that the force on the knees can be two to three times someone’s body weight. Over time, this pressure can wear down the cartilage on joints.

As a result, people who are overweight or obese are more likely to develop osteoarthritis and to need joint replacements. According to a Canadian study, patients with a BMI of 30-35 are 3.4 times as likely to require a hip replacement and are 8.5 times as likely to require a knee replacement compared to individuals with a BMI in the “healthy weight” range. With a BMI above 40, individuals were 8.5 times more likely to need a hip replacement and were 32.7 times as likely to need a knee replacement.
 

More complications, greater expense

While there are no universally recommended BMI cutoffs for joint replacement surgery, it is not uncommon for institutions to require that patients have a BMI below a certain value (usually 35-40) to proceed with surgery. A 2013 survey of physicians from the American Association of Hip and Knee Surgeons found that 52% of surgeons required a BMI below 40 to qualify for surgery.

One of the main reasons for these cutoffs is the elevated risk of complications during and after surgery. Research suggests that obesity is associated with higher rates of wound dehiscence, prosthetic joint infection (PJI), and revision total joint arthroplasty. One 2016 study suggests that patients with a BMI of 35-39.9 are twice as likely to experience PJI compared to patients with a BMI below 35. For patients with a BMI of 40 or higher, PJI is four times as likely.

Another study found that patients whose BMI is 35-40 and who undergo total joint arthroplasty have a 6.4-fold greater risk of deep incision infection. For those with a BMI over 40, that rises to a 12.9-fold increased risk compared to patients with a BMI of 18.5-25. Patients with obesity tend to have other comorbidities that can increase the risk of complications during surgery, such as type 2 diabetes, coronary artery disease, and chronic kidney disease.

Because of the increased risk of complications, health care costs tend to be higher for patients with obesity. The growing popularity of bundled health payments can discourage operating on patients who are more likely to experience complications, such as patients with high BMIs, noted Dr. Wiznia.

Research suggests that minorities and people with lower socioeconomic status are disproportionately affected by these cutoffs. According to the CDC, among non-Hispanic Black Americans and Hispanic Americans, rates of obesity are higher than among their White counterparts, and these patients are less likely to undergo joint replacement. Strictly enforcing this eligibility criterion can worsen those disparities. A study involving 21,294 adults over age 50 from the National Health and Nutrition Examination Survey (NHANES) found that requiring a BMI of under 35 for total joint arthroplasty resulted in Black patients being 39% less likely to be eligible for surgery than White patients. And individuals with an annual household income under $45,000 were 19% less likely to qualify for surgery than those with a household income above $45,000.
 

BMI no better than other risk factors

Although high BMI is independently associated with a higher risk of complications, the increased risk of complications conferred by a BMI at or above 40 is similar to or lower than those of other comorbidities that surgeons generally accept, said Nicholas Giori, MD, PhD, professor of orthopedic surgery at Stanford (Calif.) University, and chief of orthopedic surgery at the VA Palo Alto Health Care System. These other comorbidities include age older than 75, hypertension that requires medication, and insulin-controlled diabetes. “The independent risk of just having the diagnosis of insulin-dependent diabetes is actually comparable to the independent risk of having obesity by itself,” he told this news organization, “and all of us operate on [patients with] diabetes.”

Also, there is no BMI at which the risk of complications suddenly increases, according to the American Academy of Orthopaedic Surgeons. “It’s a rising complication rate as you go into higher BMIs,” Dr. Giori said. “If you operate on someone with a BMI of 39 vs. 41, you’re not going to find that much of a difference [in risk].” But if a medical system enforced a hard BMI cutoff of 40, one patient would qualify for surgery while the other would be barred.
 

Weight not as “modifiable” as previously thought

Weight is often considered a “modifiable factor” for a person considering undergoing total joint arthroplasty, but research suggests that the issue is more complicated. “Obesity is tricky, because some people are successful [in weight loss],” said Dr. Giori. Those tend to be the more memorable stories. “But a large majority have a really hard time losing substantial weight – enough to make a difference in risk,” he continued.

A study conducted in North Carolina found that restricting patients with a BMI over 40 from having elective total joint arthroplasty procedures until their weight was optimized did not result in successful weight loss. Only 20% of patients who originally presented with a BMI above this limit eventually underwent surgery after 2 years, and fewer than half of these patients had achieved a BMI of less than 40 at the time of their surgery. A third of all patients in the study did not return to the orthopedic office after their first visit.

“To hold a hard cutoff when it’s very, very hard to modify ... is essentially telling people that they are not going to ever have surgery,” Dr. Giori said; “I think that can be unfair to some patients.”

Bariatric surgery is often suggested for patients with obesity who have not experienced successful weight loss with diet and lifestyle changes alone, but bariatric surgery comes with its own complications. Research on outcomes from total joint arthroplasty among patients with who have lost weight with bariatric surgery has yielded mixed results. “I rarely push anyone hard to go that route but present it as an option for certain patients,” said Benjamin M. Stronach, MD, an orthopedic surgeon at the University of Arkansas for Medical Sciences, in Little Rock. He usually brings up bariatric surgery with patients with a BMI in the high 40s or higher to gauge their interest. If patients are already considering weight loss surgery, his office provides referrals.

But even bariatric surgery does not result in successful long-term weight loss for every patient, Dr. Stronach said. He’s seeing more and more patients who come for consultations after having undergone bariatric surgery 10 to 15 years ago. These patients lost a significant amount of weight, but then gained the weight back. He noted that bariatric surgery can be very successful for some patients who adhere to their postbariatric regimen. “We typically see fairly impressive results in the short term,” he said.
 

Patients with obesity benefit from joint replacement

Although patients with obesity are at higher risk for complications from joint replacement surgery, research suggests that these patients can still benefit greatly from these surgeries and that these surgeries remain cost-effective. Some studies have found that patients with obesity tend to have worse outcomes after surgery than patients who are not obese, but often, patients with high BMIs are starting from a lower point, with greater joint pain and limited mobility, Dr. Giori said. But the improvements – that is, net change in measured outcomes – can be greater for obese patients.

“Several studies have shown equal or greater improvements in validated outcome scores, function, and satisfaction compared with nonobese patients after surgery,” authors wrote in a recent review article in which they discuss how to optimize joint replacement surgery for patients with obesity. The article, published in the November 2022 issue of the Journal of the American Academy of Orthopaedic Surgeon (JAAOS), is part of a collection of review articles by the Movement Is Life Caucus.

Encourage weight loss, but look beyond the number

Rather than adhering to strict BMI cutoffs, some experts urge surgeons to consider the patient as a whole and to evaluate each individual’s overall health and potential risk. Dr. Giori generally considers high BMI as just another comorbidity when assessing a patient’s overall risk. “For a person who only has a high BMI but is otherwise healthy, I see no reason not to go ahead and schedule that person for surgery, because reducing the patient’s BMI will not substantially reduce the patient’s complication risk, and a delay in surgery may adversely affect the patient’s quality of life and ability to earn a living,” he said.

“If someone is between a BMI of 40 and 45, we are definitely going to have a discussion about weight,” Dr. Stronach said. He generally counsels against surgery for any patient with a BMI at 45 or above. He wants patients to have a BMI below 40 before surgery but considers individual cases for exceptions. “We will still move forward at times with someone with a BMI of 41, as an example, who is otherwise healthy,” he said. Similarly, if a patient has lost a significant amount of weight (e.g., the patient’s BMI was reduced from 50 to 41), the patient is actively engaged in improving their health, and surgeons believe the patient has significantly reduced their risk, “a lot of time, we’re not going to draw a line in the sand right at [a BMI of] 40,” he said.

While using a BMI of under 35 or 40 as a guideline when starting to work with patients is reasonable, working toward a weight loss of 5%-10% of total body weight is another goal to consider, authors advise in the JAAOS obesity review article. Research suggests that even a 5% reduction in overall body weight can reduce surgical complications and can improve a patient’s glucose and lipid levels and cardiac profile. Referrals to dietitians and weight loss programs, as well as behavioral counseling, can also be useful in initiating weight loss and keeping patients engaged in the process, the authors wrote.
 

Consider a patient’s comorbidities

Many patients with obesity have comorbidities, such as type 2 diabetes and hypertension, that can also be optimized for surgery so as to lower a patient’s overall risk profile. For patients with diabetes, achieving an A1c of 8% or lower can be a reasonable goal and can reduce risk. “We’ve found that an HbA1c level of 8% or less is something that virtually all diabetics (though not everybody) can reach, and it’s something that can be reached in a reasonable amount of time,” Dr. Giori said. Preoperative use of beta-blockers, continued use of ACE inhibitors or angiotensin receptor blockers, and behavioral modifications can improve a patient’s cardiac health before surgery.

Malnutrition can be a correctable problem for patients, regardless of BMI. In the Movement Is Life collection of optimization articles, experts recommend that orthopedists screen for malnutrition with blood tests for albumin, vitamin D, transferrin, and total lymphocyte count. Patients with malnutrition should be screened for food insecurity, experts advise, and surgical candidates with deficiencies can be given supplements of omega-3 fatty acids, arginine, and protein shakes.

Surgeon comfort and shared decision-making

Dr. Wiznia emphasized that the patient and surgeon need to discuss the risks of surgery, concerns about potential complications, and how a complication could affect the patient’s life moving forward. “Ultimately, the surgeon needs to make the decision [of whether or not to proceed [with surgery] with the patient,” he said, “but not every surgeon is going to feel comfortable operating on these patients, and not every medical institution is going to have the equipment and the investments to support surgeons doing it.”

Dr. Giori agreed that surgeons should proceed only with surgical cases they feel comfortable with. Certain surgeons may decide not to operate on individuals with higher BMIs because of the potential complications and can refer these patients to more specialized care centers. Operating on larger patients is more difficult and requires surgical skills and expertise that the surgeon may not have, he noted. “What I do object to is a system-wide BMI cutoff – for example, if an insurance company won’t pay for you to have a joint replacement, regardless of where you go or who your surgeon is,” Dr. Giori added. “I think that’s wrong, because it’s not patient centered and it’s basically excluding people from having a life-altering operation.”

Dr. Giori and Dr. Wiznia report no relevant financial relationships. Dr. Stronach is a consultant for DJ Orthopaedics, Johnson & Johnson, and MiCare Path.

A version of this article first appeared on Medscape.com.

For patients with severe arthritis, joint replacement is considered when more conservative treatments have failed. Because patients with obesity have a higher risk of complications during and after surgery, some surgeons, hospitals, and insurance companies have adopted body mass index cutoffs as a basis for deciding whether to offer patients these elective surgeries. But some experts argue that these cutoffs are arbitrary, exclude patients who can still benefit from the surgery, and can increase disparities in care.

“By enforcing cutoffs in general, you’re losing the ability for each surgeon to determine who they want to operate on,” said Daniel Wiznia, MD, assistant professor of orthopedic surgery at Yale University, New Haven, Conn. He is on the leadership committee of the Movement Is Life Caucus, a nonprofit group focused on eliminating disparities in musculoskeletal health. “For every surgeon, it’s up to them to decide if they feel comfortable doing the surgery,” he noted in an interview. “My guidance for that would be, don’t just say no because of the number – look at the patient’s entire medical profile.”

According to the Centers for Disease Control and Prevention, nearly 42% of adults in the United States have a BMI over 30, and 9.2% of adults have a BMI over 40. This excess weight puts additional stress on joints: When a person is walking, experts estimate that the force on the knees can be two to three times someone’s body weight. Over time, this pressure can wear down the cartilage on joints.

As a result, people who are overweight or obese are more likely to develop osteoarthritis and to need joint replacements. According to a Canadian study, patients with a BMI of 30-35 are 3.4 times as likely to require a hip replacement and are 8.5 times as likely to require a knee replacement compared to individuals with a BMI in the “healthy weight” range. With a BMI above 40, individuals were 8.5 times more likely to need a hip replacement and were 32.7 times as likely to need a knee replacement.
 

More complications, greater expense

While there are no universally recommended BMI cutoffs for joint replacement surgery, it is not uncommon for institutions to require that patients have a BMI below a certain value (usually 35-40) to proceed with surgery. A 2013 survey of physicians from the American Association of Hip and Knee Surgeons found that 52% of surgeons required a BMI below 40 to qualify for surgery.

One of the main reasons for these cutoffs is the elevated risk of complications during and after surgery. Research suggests that obesity is associated with higher rates of wound dehiscence, prosthetic joint infection (PJI), and revision total joint arthroplasty. One 2016 study suggests that patients with a BMI of 35-39.9 are twice as likely to experience PJI compared to patients with a BMI below 35. For patients with a BMI of 40 or higher, PJI is four times as likely.

Another study found that patients whose BMI is 35-40 and who undergo total joint arthroplasty have a 6.4-fold greater risk of deep incision infection. For those with a BMI over 40, that rises to a 12.9-fold increased risk compared to patients with a BMI of 18.5-25. Patients with obesity tend to have other comorbidities that can increase the risk of complications during surgery, such as type 2 diabetes, coronary artery disease, and chronic kidney disease.

Because of the increased risk of complications, health care costs tend to be higher for patients with obesity. The growing popularity of bundled health payments can discourage operating on patients who are more likely to experience complications, such as patients with high BMIs, noted Dr. Wiznia.

Research suggests that minorities and people with lower socioeconomic status are disproportionately affected by these cutoffs. According to the CDC, among non-Hispanic Black Americans and Hispanic Americans, rates of obesity are higher than among their White counterparts, and these patients are less likely to undergo joint replacement. Strictly enforcing this eligibility criterion can worsen those disparities. A study involving 21,294 adults over age 50 from the National Health and Nutrition Examination Survey (NHANES) found that requiring a BMI of under 35 for total joint arthroplasty resulted in Black patients being 39% less likely to be eligible for surgery than White patients. And individuals with an annual household income under $45,000 were 19% less likely to qualify for surgery than those with a household income above $45,000.
 

BMI no better than other risk factors

Although high BMI is independently associated with a higher risk of complications, the increased risk of complications conferred by a BMI at or above 40 is similar to or lower than those of other comorbidities that surgeons generally accept, said Nicholas Giori, MD, PhD, professor of orthopedic surgery at Stanford (Calif.) University, and chief of orthopedic surgery at the VA Palo Alto Health Care System. These other comorbidities include age older than 75, hypertension that requires medication, and insulin-controlled diabetes. “The independent risk of just having the diagnosis of insulin-dependent diabetes is actually comparable to the independent risk of having obesity by itself,” he told this news organization, “and all of us operate on [patients with] diabetes.”

Also, there is no BMI at which the risk of complications suddenly increases, according to the American Academy of Orthopaedic Surgeons. “It’s a rising complication rate as you go into higher BMIs,” Dr. Giori said. “If you operate on someone with a BMI of 39 vs. 41, you’re not going to find that much of a difference [in risk].” But if a medical system enforced a hard BMI cutoff of 40, one patient would qualify for surgery while the other would be barred.
 

Weight not as “modifiable” as previously thought

Weight is often considered a “modifiable factor” for a person considering undergoing total joint arthroplasty, but research suggests that the issue is more complicated. “Obesity is tricky, because some people are successful [in weight loss],” said Dr. Giori. Those tend to be the more memorable stories. “But a large majority have a really hard time losing substantial weight – enough to make a difference in risk,” he continued.

A study conducted in North Carolina found that restricting patients with a BMI over 40 from having elective total joint arthroplasty procedures until their weight was optimized did not result in successful weight loss. Only 20% of patients who originally presented with a BMI above this limit eventually underwent surgery after 2 years, and fewer than half of these patients had achieved a BMI of less than 40 at the time of their surgery. A third of all patients in the study did not return to the orthopedic office after their first visit.

“To hold a hard cutoff when it’s very, very hard to modify ... is essentially telling people that they are not going to ever have surgery,” Dr. Giori said; “I think that can be unfair to some patients.”

Bariatric surgery is often suggested for patients with obesity who have not experienced successful weight loss with diet and lifestyle changes alone, but bariatric surgery comes with its own complications. Research on outcomes from total joint arthroplasty among patients with who have lost weight with bariatric surgery has yielded mixed results. “I rarely push anyone hard to go that route but present it as an option for certain patients,” said Benjamin M. Stronach, MD, an orthopedic surgeon at the University of Arkansas for Medical Sciences, in Little Rock. He usually brings up bariatric surgery with patients with a BMI in the high 40s or higher to gauge their interest. If patients are already considering weight loss surgery, his office provides referrals.

But even bariatric surgery does not result in successful long-term weight loss for every patient, Dr. Stronach said. He’s seeing more and more patients who come for consultations after having undergone bariatric surgery 10 to 15 years ago. These patients lost a significant amount of weight, but then gained the weight back. He noted that bariatric surgery can be very successful for some patients who adhere to their postbariatric regimen. “We typically see fairly impressive results in the short term,” he said.
 

Patients with obesity benefit from joint replacement

Although patients with obesity are at higher risk for complications from joint replacement surgery, research suggests that these patients can still benefit greatly from these surgeries and that these surgeries remain cost-effective. Some studies have found that patients with obesity tend to have worse outcomes after surgery than patients who are not obese, but often, patients with high BMIs are starting from a lower point, with greater joint pain and limited mobility, Dr. Giori said. But the improvements – that is, net change in measured outcomes – can be greater for obese patients.

“Several studies have shown equal or greater improvements in validated outcome scores, function, and satisfaction compared with nonobese patients after surgery,” authors wrote in a recent review article in which they discuss how to optimize joint replacement surgery for patients with obesity. The article, published in the November 2022 issue of the Journal of the American Academy of Orthopaedic Surgeon (JAAOS), is part of a collection of review articles by the Movement Is Life Caucus.

Encourage weight loss, but look beyond the number

Rather than adhering to strict BMI cutoffs, some experts urge surgeons to consider the patient as a whole and to evaluate each individual’s overall health and potential risk. Dr. Giori generally considers high BMI as just another comorbidity when assessing a patient’s overall risk. “For a person who only has a high BMI but is otherwise healthy, I see no reason not to go ahead and schedule that person for surgery, because reducing the patient’s BMI will not substantially reduce the patient’s complication risk, and a delay in surgery may adversely affect the patient’s quality of life and ability to earn a living,” he said.

“If someone is between a BMI of 40 and 45, we are definitely going to have a discussion about weight,” Dr. Stronach said. He generally counsels against surgery for any patient with a BMI at 45 or above. He wants patients to have a BMI below 40 before surgery but considers individual cases for exceptions. “We will still move forward at times with someone with a BMI of 41, as an example, who is otherwise healthy,” he said. Similarly, if a patient has lost a significant amount of weight (e.g., the patient’s BMI was reduced from 50 to 41), the patient is actively engaged in improving their health, and surgeons believe the patient has significantly reduced their risk, “a lot of time, we’re not going to draw a line in the sand right at [a BMI of] 40,” he said.

While using a BMI of under 35 or 40 as a guideline when starting to work with patients is reasonable, working toward a weight loss of 5%-10% of total body weight is another goal to consider, authors advise in the JAAOS obesity review article. Research suggests that even a 5% reduction in overall body weight can reduce surgical complications and can improve a patient’s glucose and lipid levels and cardiac profile. Referrals to dietitians and weight loss programs, as well as behavioral counseling, can also be useful in initiating weight loss and keeping patients engaged in the process, the authors wrote.
 

Consider a patient’s comorbidities

Many patients with obesity have comorbidities, such as type 2 diabetes and hypertension, that can also be optimized for surgery so as to lower a patient’s overall risk profile. For patients with diabetes, achieving an A1c of 8% or lower can be a reasonable goal and can reduce risk. “We’ve found that an HbA1c level of 8% or less is something that virtually all diabetics (though not everybody) can reach, and it’s something that can be reached in a reasonable amount of time,” Dr. Giori said. Preoperative use of beta-blockers, continued use of ACE inhibitors or angiotensin receptor blockers, and behavioral modifications can improve a patient’s cardiac health before surgery.

Malnutrition can be a correctable problem for patients, regardless of BMI. In the Movement Is Life collection of optimization articles, experts recommend that orthopedists screen for malnutrition with blood tests for albumin, vitamin D, transferrin, and total lymphocyte count. Patients with malnutrition should be screened for food insecurity, experts advise, and surgical candidates with deficiencies can be given supplements of omega-3 fatty acids, arginine, and protein shakes.

Surgeon comfort and shared decision-making

Dr. Wiznia emphasized that the patient and surgeon need to discuss the risks of surgery, concerns about potential complications, and how a complication could affect the patient’s life moving forward. “Ultimately, the surgeon needs to make the decision [of whether or not to proceed [with surgery] with the patient,” he said, “but not every surgeon is going to feel comfortable operating on these patients, and not every medical institution is going to have the equipment and the investments to support surgeons doing it.”

Dr. Giori agreed that surgeons should proceed only with surgical cases they feel comfortable with. Certain surgeons may decide not to operate on individuals with higher BMIs because of the potential complications and can refer these patients to more specialized care centers. Operating on larger patients is more difficult and requires surgical skills and expertise that the surgeon may not have, he noted. “What I do object to is a system-wide BMI cutoff – for example, if an insurance company won’t pay for you to have a joint replacement, regardless of where you go or who your surgeon is,” Dr. Giori added. “I think that’s wrong, because it’s not patient centered and it’s basically excluding people from having a life-altering operation.”

Dr. Giori and Dr. Wiznia report no relevant financial relationships. Dr. Stronach is a consultant for DJ Orthopaedics, Johnson & Johnson, and MiCare Path.

A version of this article first appeared on Medscape.com.

Adults who underwent either total ankle replacement or ankle fusion for end-stage ankle osteoarthritis showed similar clinical scores and adverse event numbers, in a randomized controlled trial of approximately 300 patients.

Ankle osteoarthritis remains a cause of severe pain and disability. Patients are treated nonoperatively if possible, but surgery is often needed for individuals with end-stage disease, wrote Andrew Goldberg, MBBS, of University College London and colleagues in the Annals of Internal Medicine.

“Most patients with ankle arthritis respond to nonoperative treatments, such as weight loss, activity modification, support braces, and analgesia, [but] once the disease has progressed to end-stage osteoarthritis, the main surgical treatments are total ankle re-placement or ankle arthrodesis,” Dr. Goldberg said, in an interview.

In the new study, patients were randomized to receive either a total ankle replacement (TAR) or ankle fusion (AF).

“We showed that, in both treatment groups the clinical scores improved hugely, by more than three times the minimal clinically important difference,” Dr. Goldberg said in an interview.

“Although the ankle replacement arm improved, on average, by more than an extra 4 points over ankle fusion, this was not considered clinically or statistically significant,” he said.

The study is the first randomized trial to show high-quality and robust results, he noted, and findings support data from previous studies.

“Although both TAR and ankle fusion have been shown to be effective, they are very different treatments, with one fusing the bones so that there is no ankle joint movement, and the other replacing the joint with the aim of retaining ankle joint movement. It is difficult for a patient to know which treatment is more suitable for them, with most seeking guidance from their surgeon,” he said.

Generating high-quality evidence

The study, a randomized, multicenter, open-label trial known as TARVA (Total Ankle Replacement Versus Ankle Arthrodesis), aimed to compare the clinical effectiveness of the two existing publicly funded U.K. treatment options, the authors wrote.

Patients were recruited at 17 U.K. centers between March 6, 2015, and Jan. 10, 2019. The study enrolled 303 adults aged 50-85 years with end-stage ankle osteoarthritis. The mean age of the participants was 68 years; 71% were men. A total of 137 TAR patients and 144 ankle fusion patients completed their surgeries with clinical scores available for analysis. Baseline characteristics were mainly similar between the groups.

Blinding was not possible because of the nature of the procedures, but the surgeons who screened the patients were not aware of the randomization allocations, the researchers noted. A total of 33 surgeons participated in the trial, with a median number of seven patients per surgeon during the study period.

For TAR, U.K. surgeons use both two-component, fixed-bearing and three-component, mobile-bearing implants, the authors write. Ankle fusion was done using the surgeon’s usual technique of either arthroscopic-assisted or open ankle fusion.

The primary outcome was the change in the Manchester–Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores from baseline to 52 weeks after surgery. The MOXFQ-W/S uses a scale of 0-100, with lower scores representing better outcomes. Secondary outcomes included change in the MOXFQ-W/S scores at 26 weeks after surgery, as well as measures of patient quality of life.

No statistically significant difference

Overall, the mean MOXFQ-W/S scores improved significantly from baseline to 52 weeks for both groups, with average improvements of 49.9 in the TAR group and 44.4 points in the AF group. The average scores at 52 weeks were 31.4 in the TAR group and 36.8 in the AF group.

The adjusted difference in score change from baseline was –5.56, showing a slightly greater degree of improvement with TAR, but this difference was not clinically or statistically significant, the researchers noted.

Adverse event numbers were similar for both procedures, with 54% of TAR patients and 53% of AF patients experiencing at least 1 adverse event during the study period. Of those, 18% of TAR patients and 24% of AF patients experienced at least 1 serious adverse event.

However, the TAR patients experienced a higher rate of wound healing complications and nerve injuries, while thromboembolism was higher in the AF patients, the researchers noted.

A prespecified subgroup analysis of patients with osteoarthritis in adjacent joints suggested a greater improvement in TAR, compared with AF, a difference that increased when fixed-bearing TAR was compared with AF, the authors wrote.

“This reinforces previous reports that suggest that the presence of adjacent joint arthritis may be an indication for ankle replacement over AF,” the authors wrote in their discussion.

“Many of these patients did not have any symptoms in the adjacent joints,” they noted.

“The presence of adjacent joint arthritis, meaning the wear and tear of the joints around the ankle joint, seemed to favor ankle replacement,” Dr. Goldberg said. Approximately 30 joints in the foot continue to move after the ankle is fused, and if these adjacent joints are not healthy before surgery [as was the case in 42% of the study patients], the results of fusion were less successful, he explained.

A post hoc analysis between TAR subtypes showed that patients who had fixed-bearing TAR had significantly greater improvements, compared with AF patients, but this difference was not observed in patients who had mobile-bearing TAR, the researchers noted.

Dr. Goldberg said it was surprising “that, in a separate analysis, we found that the fixed-bearing ankle replacement patients [who accounted for half of the implants used] improved by a much greater difference when compared to ankle fusion.”

The study findings were limited by several factors including the short follow-up and study design that allowed surgeons to choose any implant and technique, the researchers noted.

Other limitations include a lack of data on cost-effectiveness and the impact of comorbidities on outcomes, they wrote. However, the study is the first completed multicenter randomized controlled trial to compare TAR and AF procedures for end-stage ankle osteoarthritis and shows that both yield similar clinical improvements, they concluded.

Data can inform treatment discussion

The take-home messages for clinicians are that both ankle replacement and ankle fusion are effective treatments that improve patients’ quality of life, and it is important to establish the health of adjacent joints before making treatment recommendations, Dr. Goldberg said.

“Careful counseling on the relative risks of each procedure should be part of the informed consent process,” he added. Ideally, all patients seeking surgical care for ankle arthritis should have a choice between ankle replacement and ankle fusion, but sometimes there is inequity of provision of the two treatments, he noted.

“We now encourage all surgeons to work in ankle arthritis networks so that every patient, no matter where they live, can have choice about the best treatment for them,” he said.

Researchers met the challenge of surgical RCT

Randomized trials of surgical interventions are challenging to conduct, and therefore limited, wrote Bruce Sangeorzan, MD, of the University of Washington, Seattle, and colleagues in an accompanying editorial. However, the new study was strengthened by the inclusion of 17 centers for heterogeneity of implant type and surgeon experience level, the editorialists said in the Annals of Internal Medicine.

The study is especially important, because ankle arthritis treatment is very understudied, compared with hip and knee arthritis, but it has a similar impact on activity, editorial coauthor Dr. Sangeorzan said in an interview.

“Randomized controlled trials are the gold standard for comparing medical therapies,” he said, “but they are very difficult to do in surgical treatments, particularly when the two treatments can be differentiated, in this case by movement of the ankle.”

In addition, there is a strong placebo effect attached to interventions, Dr. Sangeorzan noted. “Determining best-case treatment relies on prospective research, preferably randomized. Since both ankle fusion and ankle replacement are effective therapies, a prospective randomized trial is the best way to help make treatment decisions,” he said.

The current study findings are not surprising, but they are preliminary, and 1 year of follow-up is not enough to determine effectiveness, Dr. Sangeorzan emphasized. However, “the authors have done the hard work of randomizing the patients and collecting the data, and the patients can now be followed for a longer time,” he said.

“In addition, the trial was designed with multiple secondary outcome measures, so the data can be matched up with larger trials that were not randomized to identify key elements of success for each procedure,” he noted.

The key message for clinicians is that ankle arthritis has a significant impact on patients’ lives, but there are two effective treatments that can reduce the impact of the disease, said Dr. Sangeorzan. “The data suggest that there are differences in implant design and differences in comorbidities that should influence decision-making,” he added.

Additional research is needed in the form of a longer study duration with larger cohorts, said Dr. Sangeorzan. In particular, researchers need to determine what comorbidities might drive patients to one type of care vs. another, he said. “The suggestion that [patients receiving implants with two motion segments have better outcomes than those receiving implants with a one-motion segment] also deserves further study,” he added.

The research was supported by the UK National Institute for Health and Care Research Health Technology Assessment Programme. The trial was sponsored by University College London. Dr. Goldberg disclosed grant support from NIHR HTA, as well as financial relationships with companies including Stryker, Paragon 28, and stock options with Standing CT Company, Elstree Waterfront Outpatients, and X Bolt Orthopedics.

The editorialists had no financial conflicts to disclose.

Adults who underwent either total ankle replacement or ankle fusion for end-stage ankle osteoarthritis showed similar clinical scores and adverse event numbers, in a randomized controlled trial of approximately 300 patients.

Ankle osteoarthritis remains a cause of severe pain and disability. Patients are treated nonoperatively if possible, but surgery is often needed for individuals with end-stage disease, wrote Andrew Goldberg, MBBS, of University College London and colleagues in the Annals of Internal Medicine.

“Most patients with ankle arthritis respond to nonoperative treatments, such as weight loss, activity modification, support braces, and analgesia, [but] once the disease has progressed to end-stage osteoarthritis, the main surgical treatments are total ankle re-placement or ankle arthrodesis,” Dr. Goldberg said, in an interview.

In the new study, patients were randomized to receive either a total ankle replacement (TAR) or ankle fusion (AF).

“We showed that, in both treatment groups the clinical scores improved hugely, by more than three times the minimal clinically important difference,” Dr. Goldberg said in an interview.

“Although the ankle replacement arm improved, on average, by more than an extra 4 points over ankle fusion, this was not considered clinically or statistically significant,” he said.

The study is the first randomized trial to show high-quality and robust results, he noted, and findings support data from previous studies.

“Although both TAR and ankle fusion have been shown to be effective, they are very different treatments, with one fusing the bones so that there is no ankle joint movement, and the other replacing the joint with the aim of retaining ankle joint movement. It is difficult for a patient to know which treatment is more suitable for them, with most seeking guidance from their surgeon,” he said.

Generating high-quality evidence

The study, a randomized, multicenter, open-label trial known as TARVA (Total Ankle Replacement Versus Ankle Arthrodesis), aimed to compare the clinical effectiveness of the two existing publicly funded U.K. treatment options, the authors wrote.

Patients were recruited at 17 U.K. centers between March 6, 2015, and Jan. 10, 2019. The study enrolled 303 adults aged 50-85 years with end-stage ankle osteoarthritis. The mean age of the participants was 68 years; 71% were men. A total of 137 TAR patients and 144 ankle fusion patients completed their surgeries with clinical scores available for analysis. Baseline characteristics were mainly similar between the groups.

Blinding was not possible because of the nature of the procedures, but the surgeons who screened the patients were not aware of the randomization allocations, the researchers noted. A total of 33 surgeons participated in the trial, with a median number of seven patients per surgeon during the study period.

For TAR, U.K. surgeons use both two-component, fixed-bearing and three-component, mobile-bearing implants, the authors write. Ankle fusion was done using the surgeon’s usual technique of either arthroscopic-assisted or open ankle fusion.

The primary outcome was the change in the Manchester–Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores from baseline to 52 weeks after surgery. The MOXFQ-W/S uses a scale of 0-100, with lower scores representing better outcomes. Secondary outcomes included change in the MOXFQ-W/S scores at 26 weeks after surgery, as well as measures of patient quality of life.

No statistically significant difference

Overall, the mean MOXFQ-W/S scores improved significantly from baseline to 52 weeks for both groups, with average improvements of 49.9 in the TAR group and 44.4 points in the AF group. The average scores at 52 weeks were 31.4 in the TAR group and 36.8 in the AF group.

The adjusted difference in score change from baseline was –5.56, showing a slightly greater degree of improvement with TAR, but this difference was not clinically or statistically significant, the researchers noted.

Adverse event numbers were similar for both procedures, with 54% of TAR patients and 53% of AF patients experiencing at least 1 adverse event during the study period. Of those, 18% of TAR patients and 24% of AF patients experienced at least 1 serious adverse event.

However, the TAR patients experienced a higher rate of wound healing complications and nerve injuries, while thromboembolism was higher in the AF patients, the researchers noted.

A prespecified subgroup analysis of patients with osteoarthritis in adjacent joints suggested a greater improvement in TAR, compared with AF, a difference that increased when fixed-bearing TAR was compared with AF, the authors wrote.

“This reinforces previous reports that suggest that the presence of adjacent joint arthritis may be an indication for ankle replacement over AF,” the authors wrote in their discussion.

“Many of these patients did not have any symptoms in the adjacent joints,” they noted.

“The presence of adjacent joint arthritis, meaning the wear and tear of the joints around the ankle joint, seemed to favor ankle replacement,” Dr. Goldberg said. Approximately 30 joints in the foot continue to move after the ankle is fused, and if these adjacent joints are not healthy before surgery [as was the case in 42% of the study patients], the results of fusion were less successful, he explained.

A post hoc analysis between TAR subtypes showed that patients who had fixed-bearing TAR had significantly greater improvements, compared with AF patients, but this difference was not observed in patients who had mobile-bearing TAR, the researchers noted.

Dr. Goldberg said it was surprising “that, in a separate analysis, we found that the fixed-bearing ankle replacement patients [who accounted for half of the implants used] improved by a much greater difference when compared to ankle fusion.”

The study findings were limited by several factors including the short follow-up and study design that allowed surgeons to choose any implant and technique, the researchers noted.

Other limitations include a lack of data on cost-effectiveness and the impact of comorbidities on outcomes, they wrote. However, the study is the first completed multicenter randomized controlled trial to compare TAR and AF procedures for end-stage ankle osteoarthritis and shows that both yield similar clinical improvements, they concluded.

Data can inform treatment discussion

The take-home messages for clinicians are that both ankle replacement and ankle fusion are effective treatments that improve patients’ quality of life, and it is important to establish the health of adjacent joints before making treatment recommendations, Dr. Goldberg said.

“Careful counseling on the relative risks of each procedure should be part of the informed consent process,” he added. Ideally, all patients seeking surgical care for ankle arthritis should have a choice between ankle replacement and ankle fusion, but sometimes there is inequity of provision of the two treatments, he noted.

“We now encourage all surgeons to work in ankle arthritis networks so that every patient, no matter where they live, can have choice about the best treatment for them,” he said.

Researchers met the challenge of surgical RCT

Randomized trials of surgical interventions are challenging to conduct, and therefore limited, wrote Bruce Sangeorzan, MD, of the University of Washington, Seattle, and colleagues in an accompanying editorial. However, the new study was strengthened by the inclusion of 17 centers for heterogeneity of implant type and surgeon experience level, the editorialists said in the Annals of Internal Medicine.

The study is especially important, because ankle arthritis treatment is very understudied, compared with hip and knee arthritis, but it has a similar impact on activity, editorial coauthor Dr. Sangeorzan said in an interview.

“Randomized controlled trials are the gold standard for comparing medical therapies,” he said, “but they are very difficult to do in surgical treatments, particularly when the two treatments can be differentiated, in this case by movement of the ankle.”

In addition, there is a strong placebo effect attached to interventions, Dr. Sangeorzan noted. “Determining best-case treatment relies on prospective research, preferably randomized. Since both ankle fusion and ankle replacement are effective therapies, a prospective randomized trial is the best way to help make treatment decisions,” he said.

The current study findings are not surprising, but they are preliminary, and 1 year of follow-up is not enough to determine effectiveness, Dr. Sangeorzan emphasized. However, “the authors have done the hard work of randomizing the patients and collecting the data, and the patients can now be followed for a longer time,” he said.

“In addition, the trial was designed with multiple secondary outcome measures, so the data can be matched up with larger trials that were not randomized to identify key elements of success for each procedure,” he noted.

The key message for clinicians is that ankle arthritis has a significant impact on patients’ lives, but there are two effective treatments that can reduce the impact of the disease, said Dr. Sangeorzan. “The data suggest that there are differences in implant design and differences in comorbidities that should influence decision-making,” he added.

Additional research is needed in the form of a longer study duration with larger cohorts, said Dr. Sangeorzan. In particular, researchers need to determine what comorbidities might drive patients to one type of care vs. another, he said. “The suggestion that [patients receiving implants with two motion segments have better outcomes than those receiving implants with a one-motion segment] also deserves further study,” he added.

The research was supported by the UK National Institute for Health and Care Research Health Technology Assessment Programme. The trial was sponsored by University College London. Dr. Goldberg disclosed grant support from NIHR HTA, as well as financial relationships with companies including Stryker, Paragon 28, and stock options with Standing CT Company, Elstree Waterfront Outpatients, and X Bolt Orthopedics.

The editorialists had no financial conflicts to disclose.

Adults who underwent either total ankle replacement or ankle fusion for end-stage ankle osteoarthritis showed similar clinical scores and adverse event numbers, in a randomized controlled trial of approximately 300 patients.

Ankle osteoarthritis remains a cause of severe pain and disability. Patients are treated nonoperatively if possible, but surgery is often needed for individuals with end-stage disease, wrote Andrew Goldberg, MBBS, of University College London and colleagues in the Annals of Internal Medicine.

“Most patients with ankle arthritis respond to nonoperative treatments, such as weight loss, activity modification, support braces, and analgesia, [but] once the disease has progressed to end-stage osteoarthritis, the main surgical treatments are total ankle re-placement or ankle arthrodesis,” Dr. Goldberg said, in an interview.

In the new study, patients were randomized to receive either a total ankle replacement (TAR) or ankle fusion (AF).

“We showed that, in both treatment groups the clinical scores improved hugely, by more than three times the minimal clinically important difference,” Dr. Goldberg said in an interview.

“Although the ankle replacement arm improved, on average, by more than an extra 4 points over ankle fusion, this was not considered clinically or statistically significant,” he said.

The study is the first randomized trial to show high-quality and robust results, he noted, and findings support data from previous studies.

“Although both TAR and ankle fusion have been shown to be effective, they are very different treatments, with one fusing the bones so that there is no ankle joint movement, and the other replacing the joint with the aim of retaining ankle joint movement. It is difficult for a patient to know which treatment is more suitable for them, with most seeking guidance from their surgeon,” he said.

Generating high-quality evidence

The study, a randomized, multicenter, open-label trial known as TARVA (Total Ankle Replacement Versus Ankle Arthrodesis), aimed to compare the clinical effectiveness of the two existing publicly funded U.K. treatment options, the authors wrote.

Patients were recruited at 17 U.K. centers between March 6, 2015, and Jan. 10, 2019. The study enrolled 303 adults aged 50-85 years with end-stage ankle osteoarthritis. The mean age of the participants was 68 years; 71% were men. A total of 137 TAR patients and 144 ankle fusion patients completed their surgeries with clinical scores available for analysis. Baseline characteristics were mainly similar between the groups.

Blinding was not possible because of the nature of the procedures, but the surgeons who screened the patients were not aware of the randomization allocations, the researchers noted. A total of 33 surgeons participated in the trial, with a median number of seven patients per surgeon during the study period.

For TAR, U.K. surgeons use both two-component, fixed-bearing and three-component, mobile-bearing implants, the authors write. Ankle fusion was done using the surgeon’s usual technique of either arthroscopic-assisted or open ankle fusion.

The primary outcome was the change in the Manchester–Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores from baseline to 52 weeks after surgery. The MOXFQ-W/S uses a scale of 0-100, with lower scores representing better outcomes. Secondary outcomes included change in the MOXFQ-W/S scores at 26 weeks after surgery, as well as measures of patient quality of life.

No statistically significant difference

Overall, the mean MOXFQ-W/S scores improved significantly from baseline to 52 weeks for both groups, with average improvements of 49.9 in the TAR group and 44.4 points in the AF group. The average scores at 52 weeks were 31.4 in the TAR group and 36.8 in the AF group.

The adjusted difference in score change from baseline was –5.56, showing a slightly greater degree of improvement with TAR, but this difference was not clinically or statistically significant, the researchers noted.

Adverse event numbers were similar for both procedures, with 54% of TAR patients and 53% of AF patients experiencing at least 1 adverse event during the study period. Of those, 18% of TAR patients and 24% of AF patients experienced at least 1 serious adverse event.

However, the TAR patients experienced a higher rate of wound healing complications and nerve injuries, while thromboembolism was higher in the AF patients, the researchers noted.

A prespecified subgroup analysis of patients with osteoarthritis in adjacent joints suggested a greater improvement in TAR, compared with AF, a difference that increased when fixed-bearing TAR was compared with AF, the authors wrote.

“This reinforces previous reports that suggest that the presence of adjacent joint arthritis may be an indication for ankle replacement over AF,” the authors wrote in their discussion.

“Many of these patients did not have any symptoms in the adjacent joints,” they noted.

“The presence of adjacent joint arthritis, meaning the wear and tear of the joints around the ankle joint, seemed to favor ankle replacement,” Dr. Goldberg said. Approximately 30 joints in the foot continue to move after the ankle is fused, and if these adjacent joints are not healthy before surgery [as was the case in 42% of the study patients], the results of fusion were less successful, he explained.

A post hoc analysis between TAR subtypes showed that patients who had fixed-bearing TAR had significantly greater improvements, compared with AF patients, but this difference was not observed in patients who had mobile-bearing TAR, the researchers noted.

Dr. Goldberg said it was surprising “that, in a separate analysis, we found that the fixed-bearing ankle replacement patients [who accounted for half of the implants used] improved by a much greater difference when compared to ankle fusion.”

The study findings were limited by several factors including the short follow-up and study design that allowed surgeons to choose any implant and technique, the researchers noted.

Other limitations include a lack of data on cost-effectiveness and the impact of comorbidities on outcomes, they wrote. However, the study is the first completed multicenter randomized controlled trial to compare TAR and AF procedures for end-stage ankle osteoarthritis and shows that both yield similar clinical improvements, they concluded.

Data can inform treatment discussion

The take-home messages for clinicians are that both ankle replacement and ankle fusion are effective treatments that improve patients’ quality of life, and it is important to establish the health of adjacent joints before making treatment recommendations, Dr. Goldberg said.

“Careful counseling on the relative risks of each procedure should be part of the informed consent process,” he added. Ideally, all patients seeking surgical care for ankle arthritis should have a choice between ankle replacement and ankle fusion, but sometimes there is inequity of provision of the two treatments, he noted.

“We now encourage all surgeons to work in ankle arthritis networks so that every patient, no matter where they live, can have choice about the best treatment for them,” he said.

Researchers met the challenge of surgical RCT

Randomized trials of surgical interventions are challenging to conduct, and therefore limited, wrote Bruce Sangeorzan, MD, of the University of Washington, Seattle, and colleagues in an accompanying editorial. However, the new study was strengthened by the inclusion of 17 centers for heterogeneity of implant type and surgeon experience level, the editorialists said in the Annals of Internal Medicine.

The study is especially important, because ankle arthritis treatment is very understudied, compared with hip and knee arthritis, but it has a similar impact on activity, editorial coauthor Dr. Sangeorzan said in an interview.

“Randomized controlled trials are the gold standard for comparing medical therapies,” he said, “but they are very difficult to do in surgical treatments, particularly when the two treatments can be differentiated, in this case by movement of the ankle.”

In addition, there is a strong placebo effect attached to interventions, Dr. Sangeorzan noted. “Determining best-case treatment relies on prospective research, preferably randomized. Since both ankle fusion and ankle replacement are effective therapies, a prospective randomized trial is the best way to help make treatment decisions,” he said.

The current study findings are not surprising, but they are preliminary, and 1 year of follow-up is not enough to determine effectiveness, Dr. Sangeorzan emphasized. However, “the authors have done the hard work of randomizing the patients and collecting the data, and the patients can now be followed for a longer time,” he said.

“In addition, the trial was designed with multiple secondary outcome measures, so the data can be matched up with larger trials that were not randomized to identify key elements of success for each procedure,” he noted.

The key message for clinicians is that ankle arthritis has a significant impact on patients’ lives, but there are two effective treatments that can reduce the impact of the disease, said Dr. Sangeorzan. “The data suggest that there are differences in implant design and differences in comorbidities that should influence decision-making,” he added.

Additional research is needed in the form of a longer study duration with larger cohorts, said Dr. Sangeorzan. In particular, researchers need to determine what comorbidities might drive patients to one type of care vs. another, he said. “The suggestion that [patients receiving implants with two motion segments have better outcomes than those receiving implants with a one-motion segment] also deserves further study,” he added.

The research was supported by the UK National Institute for Health and Care Research Health Technology Assessment Programme. The trial was sponsored by University College London. Dr. Goldberg disclosed grant support from NIHR HTA, as well as financial relationships with companies including Stryker, Paragon 28, and stock options with Standing CT Company, Elstree Waterfront Outpatients, and X Bolt Orthopedics.

The editorialists had no financial conflicts to disclose.

Low-dose aspirin taken daily fails to reduce the risk of fractures and increases the risk of serious falls in older adults, a new study finds.

Previous research suggests that aspirin may reduce the risk of fragility fractures by delaying bone loss, but the direct effects of aspirin on bone microarchitecture and the association between aspirin use and fracture risk in humans has not been explored, corresponding author Anna L. Barker, PhD, and colleagues wrote in their paper published in JAMA Internal Medicine.

Dr. Barker, who is executive director of research and innovation for Silverchain (a senior care program), said, in an interview, that she and her coauthors hypothesized “that aspirin could reduce both falls and fractures by reducing cardiovascular-associated physical and cognitive impairments and the anti-inflammatory properties mediating bone remodeling.”
 

Study methods and results

In the ASPREE-FRACTURE substudy, the authors examined the impact of daily low-dose aspirin (100 mg) on incidence of any fracture in more than 16,000 community-dwelling adults aged 70 years and older. A secondary endpoint was the incidence of serious falls, defined as falls requiring a hospital visit. Individuals with chronic illness and cardiovascular or cerebrovascular disease were excluded, as were those with dementia or other cognitive impairment, or a physical disability.

The study population included 16,703 participants enrolled in the larger Aspirin in Reducing Events in the Elderly (ASPREE) clinical trial between 2010 and 2014. Of these, 8,322 were randomized to aspirin and 8,381 to a placebo. The median age was 74 years, and 55% of the participants were women.

Over a median follow-up of 4.6 years (76,219 total person-years), the risk of first fracture was similar between the aspirin and placebo groups (hazard ratio, 0.97), but the risk of serious falls was significantly higher in the aspirin group (884 falls vs. 804 falls, P = .01).

The incidence of first fracture was similar between the aspirin and placebo groups (813 vs. 718), as was the incidence of all fractures (1,394 and 1,471, respectively).

The results for both fractures and falls were essentially unchanged in a multivariate analysis controlling for variables known to affect fracture and fall risk and remained similar for different types of fractures (hip, trauma-related, nonpathological) as well, the researchers noted.

In their discussion, the researchers wrote that the clinical significance of the study is the inability of aspirin to reduce the risk of fractures in otherwise healthy older adults. They expressed surprise at the increase in serious falls, citing their hypothesis that the antiplatelet effects of aspirin may reduce cardiovascular and cerebrovascular events, thereby slowing physical decline and decreasing fall risk.

The increased risk of serious falls was not accompanied by an increase in fractures, and the increased fall risk was similar across subgroups of aspirin users, the researchers said.

Low-dose aspirin’s failure to reduce the risk of fractures but increasing the risk of serious falls adds to evidence that this agent provides little favorable benefit in a healthy, White older adult population.

The study findings were limited by several factors including the relatively homogeneous older and healthy population, and possible insufficient study duration to allow for changes in fracture and fall risk, the researchers noted. Other potential limitations include that the dose of aspirin used in the study was too low to affect bone remodeling and the lack of data on bone density, rheumatoid arthritis, and osteoporosis, they said.

However, the results were strengthened by the large sample size and high participant retention rate, and represent the first known examination of data from a randomized, controlled trial of the effect of aspirin on fractures, they added.
 

Setting the stage for more research

Overall, “This study adds to the growing body of evidence from other studies that the use of aspirin in people who do not have a risk of cardiovascular disease or stroke provides little benefit,” said Dr. Barker, who is also a professor at Monash University, Melbourne, Australia. However, “Older adults with a medical reason to take aspirin should continue to do so,” she emphasized.

“The most important thing the study showed is the primary endpoint, which was that aspirin use does not have an effect on fracture risk,” said Neil Skolnik, MD, of Sidney Kimmel Medical College, Philadelphia, in an interview.

“The increase in serious falls, as defined by a fall resulting in a visit to a hospital, is likely due to an increased risk of bleeding after a fall on aspirin,” said Dr. Skolnik, who was not involved in the study. Dr. Skolnik added that the current study findings support the current recommendations of the United States Preventive Services Task Force, which he quoted as follows, “The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older.”

The study was supported by the National Institute on Aging and the National Cancer Institute at the National Institutes of Health; the National Health and Medical Research Council (Australia); Monash University; and the Victorian Cancer Agency. Lead author Dr. Barker was supported in part by the NHMRC and also disclosed grants from the NHMRC outside the current study. The ASPREE substudy also was supported by the University of Pittsburgh Claude D. Pepper Older American Independence Center and the Wake Forest University Claude D. Pepper Older Americans Independence Center. Bayer AG provided the aspirin used in the study but had no other role. Dr. Skolnik had no financial conflicts to disclose, but he serves on the editorial advisory board of Family Practice News.

Low-dose aspirin taken daily fails to reduce the risk of fractures and increases the risk of serious falls in older adults, a new study finds.

Previous research suggests that aspirin may reduce the risk of fragility fractures by delaying bone loss, but the direct effects of aspirin on bone microarchitecture and the association between aspirin use and fracture risk in humans has not been explored, corresponding author Anna L. Barker, PhD, and colleagues wrote in their paper published in JAMA Internal Medicine.

Dr. Barker, who is executive director of research and innovation for Silverchain (a senior care program), said, in an interview, that she and her coauthors hypothesized “that aspirin could reduce both falls and fractures by reducing cardiovascular-associated physical and cognitive impairments and the anti-inflammatory properties mediating bone remodeling.”
 

Study methods and results

In the ASPREE-FRACTURE substudy, the authors examined the impact of daily low-dose aspirin (100 mg) on incidence of any fracture in more than 16,000 community-dwelling adults aged 70 years and older. A secondary endpoint was the incidence of serious falls, defined as falls requiring a hospital visit. Individuals with chronic illness and cardiovascular or cerebrovascular disease were excluded, as were those with dementia or other cognitive impairment, or a physical disability.

The study population included 16,703 participants enrolled in the larger Aspirin in Reducing Events in the Elderly (ASPREE) clinical trial between 2010 and 2014. Of these, 8,322 were randomized to aspirin and 8,381 to a placebo. The median age was 74 years, and 55% of the participants were women.

Over a median follow-up of 4.6 years (76,219 total person-years), the risk of first fracture was similar between the aspirin and placebo groups (hazard ratio, 0.97), but the risk of serious falls was significantly higher in the aspirin group (884 falls vs. 804 falls, P = .01).

The incidence of first fracture was similar between the aspirin and placebo groups (813 vs. 718), as was the incidence of all fractures (1,394 and 1,471, respectively).

The results for both fractures and falls were essentially unchanged in a multivariate analysis controlling for variables known to affect fracture and fall risk and remained similar for different types of fractures (hip, trauma-related, nonpathological) as well, the researchers noted.

In their discussion, the researchers wrote that the clinical significance of the study is the inability of aspirin to reduce the risk of fractures in otherwise healthy older adults. They expressed surprise at the increase in serious falls, citing their hypothesis that the antiplatelet effects of aspirin may reduce cardiovascular and cerebrovascular events, thereby slowing physical decline and decreasing fall risk.

The increased risk of serious falls was not accompanied by an increase in fractures, and the increased fall risk was similar across subgroups of aspirin users, the researchers said.

Low-dose aspirin’s failure to reduce the risk of fractures but increasing the risk of serious falls adds to evidence that this agent provides little favorable benefit in a healthy, White older adult population.

The study findings were limited by several factors including the relatively homogeneous older and healthy population, and possible insufficient study duration to allow for changes in fracture and fall risk, the researchers noted. Other potential limitations include that the dose of aspirin used in the study was too low to affect bone remodeling and the lack of data on bone density, rheumatoid arthritis, and osteoporosis, they said.

However, the results were strengthened by the large sample size and high participant retention rate, and represent the first known examination of data from a randomized, controlled trial of the effect of aspirin on fractures, they added.
 

Setting the stage for more research

Overall, “This study adds to the growing body of evidence from other studies that the use of aspirin in people who do not have a risk of cardiovascular disease or stroke provides little benefit,” said Dr. Barker, who is also a professor at Monash University, Melbourne, Australia. However, “Older adults with a medical reason to take aspirin should continue to do so,” she emphasized.

“The most important thing the study showed is the primary endpoint, which was that aspirin use does not have an effect on fracture risk,” said Neil Skolnik, MD, of Sidney Kimmel Medical College, Philadelphia, in an interview.

“The increase in serious falls, as defined by a fall resulting in a visit to a hospital, is likely due to an increased risk of bleeding after a fall on aspirin,” said Dr. Skolnik, who was not involved in the study. Dr. Skolnik added that the current study findings support the current recommendations of the United States Preventive Services Task Force, which he quoted as follows, “The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older.”

The study was supported by the National Institute on Aging and the National Cancer Institute at the National Institutes of Health; the National Health and Medical Research Council (Australia); Monash University; and the Victorian Cancer Agency. Lead author Dr. Barker was supported in part by the NHMRC and also disclosed grants from the NHMRC outside the current study. The ASPREE substudy also was supported by the University of Pittsburgh Claude D. Pepper Older American Independence Center and the Wake Forest University Claude D. Pepper Older Americans Independence Center. Bayer AG provided the aspirin used in the study but had no other role. Dr. Skolnik had no financial conflicts to disclose, but he serves on the editorial advisory board of Family Practice News.

Low-dose aspirin taken daily fails to reduce the risk of fractures and increases the risk of serious falls in older adults, a new study finds.

Previous research suggests that aspirin may reduce the risk of fragility fractures by delaying bone loss, but the direct effects of aspirin on bone microarchitecture and the association between aspirin use and fracture risk in humans has not been explored, corresponding author Anna L. Barker, PhD, and colleagues wrote in their paper published in JAMA Internal Medicine.

Dr. Barker, who is executive director of research and innovation for Silverchain (a senior care program), said, in an interview, that she and her coauthors hypothesized “that aspirin could reduce both falls and fractures by reducing cardiovascular-associated physical and cognitive impairments and the anti-inflammatory properties mediating bone remodeling.”
 

Study methods and results

In the ASPREE-FRACTURE substudy, the authors examined the impact of daily low-dose aspirin (100 mg) on incidence of any fracture in more than 16,000 community-dwelling adults aged 70 years and older. A secondary endpoint was the incidence of serious falls, defined as falls requiring a hospital visit. Individuals with chronic illness and cardiovascular or cerebrovascular disease were excluded, as were those with dementia or other cognitive impairment, or a physical disability.

The study population included 16,703 participants enrolled in the larger Aspirin in Reducing Events in the Elderly (ASPREE) clinical trial between 2010 and 2014. Of these, 8,322 were randomized to aspirin and 8,381 to a placebo. The median age was 74 years, and 55% of the participants were women.

Over a median follow-up of 4.6 years (76,219 total person-years), the risk of first fracture was similar between the aspirin and placebo groups (hazard ratio, 0.97), but the risk of serious falls was significantly higher in the aspirin group (884 falls vs. 804 falls, P = .01).

The incidence of first fracture was similar between the aspirin and placebo groups (813 vs. 718), as was the incidence of all fractures (1,394 and 1,471, respectively).

The results for both fractures and falls were essentially unchanged in a multivariate analysis controlling for variables known to affect fracture and fall risk and remained similar for different types of fractures (hip, trauma-related, nonpathological) as well, the researchers noted.

In their discussion, the researchers wrote that the clinical significance of the study is the inability of aspirin to reduce the risk of fractures in otherwise healthy older adults. They expressed surprise at the increase in serious falls, citing their hypothesis that the antiplatelet effects of aspirin may reduce cardiovascular and cerebrovascular events, thereby slowing physical decline and decreasing fall risk.

The increased risk of serious falls was not accompanied by an increase in fractures, and the increased fall risk was similar across subgroups of aspirin users, the researchers said.

Low-dose aspirin’s failure to reduce the risk of fractures but increasing the risk of serious falls adds to evidence that this agent provides little favorable benefit in a healthy, White older adult population.

The study findings were limited by several factors including the relatively homogeneous older and healthy population, and possible insufficient study duration to allow for changes in fracture and fall risk, the researchers noted. Other potential limitations include that the dose of aspirin used in the study was too low to affect bone remodeling and the lack of data on bone density, rheumatoid arthritis, and osteoporosis, they said.

However, the results were strengthened by the large sample size and high participant retention rate, and represent the first known examination of data from a randomized, controlled trial of the effect of aspirin on fractures, they added.
 

Setting the stage for more research

Overall, “This study adds to the growing body of evidence from other studies that the use of aspirin in people who do not have a risk of cardiovascular disease or stroke provides little benefit,” said Dr. Barker, who is also a professor at Monash University, Melbourne, Australia. However, “Older adults with a medical reason to take aspirin should continue to do so,” she emphasized.

“The most important thing the study showed is the primary endpoint, which was that aspirin use does not have an effect on fracture risk,” said Neil Skolnik, MD, of Sidney Kimmel Medical College, Philadelphia, in an interview.

“The increase in serious falls, as defined by a fall resulting in a visit to a hospital, is likely due to an increased risk of bleeding after a fall on aspirin,” said Dr. Skolnik, who was not involved in the study. Dr. Skolnik added that the current study findings support the current recommendations of the United States Preventive Services Task Force, which he quoted as follows, “The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older.”

The study was supported by the National Institute on Aging and the National Cancer Institute at the National Institutes of Health; the National Health and Medical Research Council (Australia); Monash University; and the Victorian Cancer Agency. Lead author Dr. Barker was supported in part by the NHMRC and also disclosed grants from the NHMRC outside the current study. The ASPREE substudy also was supported by the University of Pittsburgh Claude D. Pepper Older American Independence Center and the Wake Forest University Claude D. Pepper Older Americans Independence Center. Bayer AG provided the aspirin used in the study but had no other role. Dr. Skolnik had no financial conflicts to disclose, but he serves on the editorial advisory board of Family Practice News.