Number of Medical Complaints Before Concussion May Help Predict Recovery Time


“Good information for you to have when dealing with someone who hit their head and has lots of varied complaints afterwards. Being sensitive to the sensations of your body is unhealthy and associated with my conditions. Recent research using electric shocks to produce pain show changes in nerve behavior. Other evidence implication hyper-somatization with fibromyalgia.” Bill Chesnut, MD

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Number of Medical Complaints Before Concussion May Help Predict Recovery Time       Released: 20-Apr-2016 7:05 PM EDT
American Academy of Neurology (AAN)


Number of Medical Complaints Before Concussion May Help Predict Recovery Time               Newswise — MINNEAPOLIS – Athletes who have medical complaints, like aches and pains, that have no known physical cause may take longer to recover after a concussion, according to a study published in the April 20, 2016, online issue of Neurology®, the medical journal of the American Academy of Neurology.

Called psychosomatic symptoms, such complaints are often described as psychological distress expressed as physical illness.

“The goal of this study was to determine how physical complaints before and after concussion play a role in recovery,” said study author Lindsay D. Nelson, PhD, assistant professor of Neurosurgery and Neurology at the Medical College of Wisconsin in Milwaukee. “We found the greatest predictor of recovery after a concussion was the severity of early post-concussion symptoms. But somatic complaints before injury also play an important role, either by possibly enhancing how a person experiences the injury or affecting their reporting of post-concussive symptoms.”

For the study, 2,055 high school and college athletes were evaluated before the start of the season for balance, thinking and memory skills and psychological problems such as depression, anxiety and psychosomatic problems such as feeling faint or dizzy, nausea or upset stomach or pains in chest or heart. For the psychosomatic problems, the athletes rated how often they had been bothered by these symptoms during the last week. About 50 percent of the participants had at least one of 6 symptoms, and the other 50 percent had no symptoms.

During the season, 127 athletes suffered a concussion. Those athletes were then reassessed within the first 24 hours of injury and then again at 8, 15 and 45 days after the injury.

Of the concussed athletes, 61 percent played football, 24 percent played soccer, 6 percent played lacrosse, 3 percent were wrestlers, 3 percent played hockey, 2 percent played rugby and 1 percent played field hockey. Of the group, 80 percent was male.

On average, concussion symptoms lasted five days, with 64 percent of concussed athletes saying their symptoms were gone after one week and the vast majority, 95 percent, saying they no longer had symptoms after one month.

After concussion, those athletes who had reported pre-injury psychosomatic symptoms had longer recovery times, recovering at a slower rate than those who had no psychosomatic symptoms. For people with symptoms, about 80 percent had recovered within about 20 days of the concussion. For those with no symptoms, about 80 percent had recovered within about 10 days.

Those who had more severe physical symptoms after their concussions, like headache and balance issues, recovered at a slower rate than those with less severe symptoms.

“That these athletes were relatively healthy physically and psychologically highlights the relevance of psychosomatic symptoms and the role they play in recovery even in healthy people,” said Nelson. “Our hope is our study will lead to further research, because identifying those at risk for prolonged recovery is critical to developing early interventions that improve outcomes for people who suffer concussions.”

The study was funded by the U.S. Army Medical Research and Materiel Command, the Clinical and Translational Science Institute, and the National Institutes of Health National Center for Advancing Translational Sciences.

Learn more about concussion at, where you can access the AAN’s Sports Concussion Guideline, QuickCheck app, and other resources.
The American Academy of Neurology, an association of 30,000 neurologists and neuroscience professionals, is dedicated to promoting the highest quality patient-centered neurologic care. A neurologist is a doctor with specialized training in diagnosing, treating and managing disorders of the brain and nervous system such as Alzheimer’s disease, stroke, migraine, multiple sclerosis, brain injury, Parkinson’s disease and epilepsy.

For more information about the American Academy of Neurology, visit or find us on Facebook, Twitter, Google+ and YouTube.




Psychother Psychosom Med Psychol. 2011 Feb;61(2):82-6. doi: 10.1055/s-0030-1270518. Epub 2011 Feb 18.

[The usefulness of the Brief Symptom Inventory 18 (BSI-18) in psychotherapeutic patients].

[Article in German]

Franke GH1Ankerhold AHaase MJäger STögel CUlrich CFrommer J.

Author information


The BSI-18, an abridged version of the Brief Symptom Inventory of Derogatis, contains the 3 six items scales Somatization, Depression, Anxiety, and the Global Score (GSI). In a sample of N=638 psychotherapeutic patients, reliability and validity were proven. Reliability of the 3 scales was good: Somatization α=0.79, Depression α=0.84, Anxiety α=0.84, and GSI α=0.91. The postulated three-factor structure was proven sufficiently using confirmatory and explorative factor analyses. The questionnaire separated different patients groups. Judgments of the therapists corresponded well with the self-rating behavior of the patients. In conclusion, the psychometric evaluation of the BSI-18 resulted in persuasive evidence for its reliability and validity. The loss of information, as a result of item reduction, is acceptable analyzing large samples; in cases of individual analyses, the SCL-90-R is advised.


The Accidental Deadly Drug Prescription

“There are many publications the medical world about opioid medications. Managing chronic pain without risking accidental death is hard. This article looks at anther much less known risk of opioid medications. The grave risk for some is combining an opioid with a benzodiazepine drug such as Xanax. This is a commentary in the Wall Street Journal. Dr. Wen shows you the difficulty in practicing the best medicine, being effective and keeps risks as low as possible. If you friends who take pain pills, tell them about the benzodiazepine class of drugs, all of their brand names. ” Bill Chesnut, MD

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The Accidental Deadly Drug Prescription.   Many doctors are unaware that a drug like Valium or Xanax, taken with an opioid, could be fatal. By LEANA S. WEN,MD_______March 30, 2016

My patient was a college student brought into the emergency room after a minor car accident. Although CT scans showed no spinal fractures, he had severe neck pain and spasms. Instinctively, I prescribed Percocet for pain and Valium for muscle spasms. But I didn’t know then what I know now: These two drugs, when taken together, could interact and cost him his life.

Opioids—including prescriptions such as Percocet and OxyContin, as well as the illicit form, heroin—are under increased scrutiny. The number of Americans dying from an opioid overdose has quadrupled over the past decade, according to the Centers for Disease Control and Prevention. This week President Obama joined health officials and advocates to raise awareness of this growing epidemic. Clinicians and the public, however, are often unaware of the threat posed by opioid interaction with another frequently prescribed drug.

Benzodiazepines, known to most Americans as Xanax or Valium, typically treat anxiety or insomnia. But when combined with opioids, as they often are, they can suppress the instinct to breathe, increase sleepiness and cause death. In 2010, one in three unintentional overdose deaths in the U.S. from prescription opioids also involved benzodiazepines, according to the National Vital Statistics System. Maryland Department of Health data show more than 70% of deaths in the state associated with benzodiazepines also involved prescription opioids.

Despite this danger, doctors prescribe both drugs at increasing rates. The CDC reported that in 2012 there were over 259 million prescriptions of opioids in the U.S.—more than one for every adult. That year there were nearly 40 benzodiazepine prescriptions for every 100 Americans. Hospital admissions for patients with combined addiction to opioids and benzodiazepines have increased by 569% over 10 years, according to anotherfederal study.

Why do doctors continue to prescribe this deadly combination? In part, because that is what they are taught. When I was in medical school in the early 2000s, I learned to treat muscle pain and spasms with both opioids and benzodiazepines, so I routinely prescribed them together. A 2015 study published in the journal Pain Medicine found that one in three patients with chronic pain on opioids was also on benzodiazepines. Just as I acted on instinct with my ER patient, doctors prescribe medications based on habit.

Most overdose-education campaigns focus exclusively on the opioid epidemic, in part because there is an easy-to-use antidote available, naloxone. In Baltimore, we have increased its availability by allowing all 620,000 residents to obtain a naloxone prescription—no questions asked. Last year, we conducted over 8,000 targeted trainings, going to high-risk areas like jails, bus shelters and public markets to demonstrate use of this lifesaving medication.

Likewise, education for physicians has focused on increasing monitoring of opioid prescriptions, rather than on decreasing their use with benzodiazepines. But with mounting scientific and epidemiological evidence about this deadly combination, doctors must adjust their patterns. Shouldn’t they already know that combining these drugs is dangerous? Unfortunately, the figures suggest they don’t.

Last month, I co-led a coalition of over 40 city health-commissioners and state health-directors who sent a petition urging the Food and Drug Administration to require a “black-box warning”—the FDA’s strongest risk communication—any time that opioids and benzodiazepines are prescribed together. Such a warning would sound the alarm about the danger of taking these drugs at the same time. Thousands of health officials, academics, researchers, physicians and citizens signed our petition.

Studies show that black-box warnings change how physicians prescribe potentially dangerous medications. In the mid-2000s, a black-box warning was issued for an antidepressant associated with suicide in youth. This resulted in a 22% drop in prescriptions, according to a study in the American Journal of Psychiatry. Physicians listened to the warning and changed their practices.

The FDA recently proposed a black-box warning on opioids. It is a welcome move: 44 Americans die every day from prescription opioid overdose. Yet, while one-third of those deaths were associated with an unintentional combination with benzodiazepines, the FDA’s new warning doesn’t mention the dangers of combining the drugs.

When I look back at my practice, I wonder how many deaths my colleagues and I might have caused inadvertently—and how many we could have prevented if we had known the potential dangers sooner. It’s a harrowing thought that should spur physicians to change their prescribing practices and patients to look inside their medicine cabinets.

Dr. Wen is an emergency physician and the health commissioner for the city of Baltimore.


Immediate release opioids for pain control are a poorer choice than extended release

“I want to share my understanding of better ways to control pain with opioids. My comment here is not putting the post below in perspective, but a chance to share what I learned controlling acute and chronic pain by prescribing opioid medications. My comments are not research, just experience.

Immediate release (IR) opioids for pain control are the poorer choice when extended release (ER) forms of the same medication exist. The extended release drugs have a lower and slower rise in maximum blood level, do not have a trough of inadequate dose level and do not have frequency and severity of personality impairments seen with immediate-release medications. The lack of personality changes is with ER medications prescribed at drug levels controlling the pain adequately. The same degree of pain control with an IR drug can have personality changes. The personality side effects are especially concerning in co-morbidities such as depression. Ten percent of Americans studied have depression, often don’t get treatment, and are at risk for depressive exacerbations on pain control medication.

 Examples of ER medications that have been approved and used extensively are tramadol, both IR and ER, hydrocodone, both IR and ER, oxycodone IR and ER. The costs of the ER form is higher than IR of the same drug. Buprenorphine, Butrans, is available in an extended release patch that lasts a week.

 There are two factors that have delayed the more common use of ER opioids. First is the first formulations of ER drugs could be altered and injected by drug abusers. The new ER formulations are much harder to inject. They cannot be crushed by common methods using. They don’t dissolve to inject the drug intravenously and similar. The second factor is that the prescriber must create and submit a “prior authorization” form before you can get the ER medication. There are free software that makes obtaining the “prior auth” a matter of only a few keyboard clicks, if your provider uses them. I find using the software for prior authorizations and the software to look up your insurance drug formulary is efficient. It’s more work and time to get the ER form of an opioid than prescribing the IR form of the same drug.“ Bill Chesnut, MD.

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 Leading the News  AMA Morning Rounds 3.23.2016.    FDA to update warning for immediate-release opioids

The Washington Post (3/22, Bernstein) reports in “To Your Health” that the Food and Drug Administration announced that “it will require new warnings about the risk of addiction, abuse, overdose and death for short-acting opioid pain medications.” The boxed warning for immediate-release opioids “also will warn of the danger that chronic use of the drugs by pregnant women can result in…Neonatal Opioid Withdrawal Syndrome” in newborns. The new warnings “will emphasize that immediate-release opioids should be a last resort for severe pain.”

The New York Times (3/22, A13, Tavernise, Subscription Publication) reports that “the new labels also include ‘clearer instructions’ for directions like initial drug dose and dose changes during therapy.”



What’s New in Adult Reconstructive Knee Surgery

“This is a review article from JBJS, a specialty update. These updates are yearly, cover the new developments and often mention consensus opinions. The comments about tibial osteotomy surgery for knee arthritis are important. In the national consensus, an osteotomy is one surgical choice that is not a knee replacement. The surgical technique for tibial osteotomy is significantly improved by the instruments developed by Arthrex, Naples Florida, in my opinion, based on personally performing many tibial osteotomies. If you need arthritis knee surgery, find a surgeon who offers tibial osteotomy as a choice.” Bill Chesnut, MD.

To return to New Health News for more news:

What’s New in Adult Reconstructive Knee Surgery: Level I and II Studies.                                               OrthoBuzz Feb 26, 2016.

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in January 20, 2016 Specialty Update on adult reconstructive knee surgery:

Nonsurgical Management and Osteotomy

  • A Cochrane database review found that land-based therapeutic exercise programs were modestly beneficial to patients with knee arthritis. Individualized programs were more effective than exercise classes or home-exercise programs.1
  • A study comparing intravenous administration of tanezumab versus naproxen and placebo in patients with hip and knee osteoarthritis found that tanezumab effectively relieved pain and improved function at week 16.2
  • A comparison of platelet-rich plasma (PRP) injections and hyaluronic acid (HA) injections found both treatments to be equally effective in improving knee function and reducing symptoms as measured by the IKDC subjective score.3
  • A study comparing opening-wedge and closing-wedge high tibial osteotomy found that among patients who did not go on to conversion to TKA, there were no between-group differences in clinical or radiographic outcomes at six years of follow-up.

Implants, Instrumentation, and Technique

  • A comparison of highly cross-linked and conventional polyethylene in posterior cruciate-substituting TKA found no differences in pain, function, and radiographic outcomes at a mean of 5.9 years.
  • A randomized study of 140 patients that compared the use of patient-specific instrumentation (PSI) and conventional instrumentation found no differences in clinical, operative, and radiographic results.4
  • In a randomized trial of 200 patients, the use of electromagnetic computer navigation resulted ininsignificantly fewer outliers from the target alignment, compared with the use of conventional instrumentation. There were no between-group differences in clinical outcomes.5
  • In a prospective randomized trial, the use of computer-assisted navigation during TKA resulted in lower systemic embolic loads, compared with TKA performed using conventional intramedullary instrumentation.
  • A randomized controlled trial comparing kinematically and mechanically aligned TKA found that kinematic alignment with patient-specific guides provided better pain relief and restored better function and range of motion than mechanical alignment using conventional instruments.6
  • A randomized study of selective patellar resurfacing in 327 knees followed for a mean of 7.8 years found higher satisfaction among patients with a resurfaced patella.7

Pain and Blood Management:    A randomized controlled trial comparing femoral and adductor canal blocks found that adductor canal blocks decreased time to discharge readiness without an increase in narcotic consumption.8

  • A trial comparing periarticular injections (PAIs) of liposomal bupivacaine with conventional bupivacaine PAI found no between-group differences in VAS pain scores 72 hours postoperatively orin patient narcotic consumption.9
  • A double-blinded randomized trial comparing topical versus intravenous administration of tranexamic acid found no significant differences in estimated blood loss or complications.

Rehabilitation and Complications

  • A randomized trial of 205 post-TKA patients found no differences in WOMAC scores for pain, function, and stiffness in groups thatreceivedtelerehabilitation or face-to-face home therapy.
  • A randomized trial found that Kinesio Taping helped reduce postoperative pain and swelling and improved knee extension during early postoperative rehabilitation.10
  • A trial comparing oral edoxaban and subcutaneous enoxaparin for post-TKA thromboprophylaxis found that edoxaban wasthe more effective agent. The incidence of bleeding events was similar in both groups.11

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Surgeons Get Graded: Report Card Is Online

“Transparency of complications is increasing. You can go to the Surgeon Scorecard to see the complication rates of your surgeon and your hospital compared to other surgeons and hospitals. Refreshing.” Bill Chesnut, MD

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 Surgeons Get Graded: Report Card Is Online

The ProPublica “Surgeon Scorecard” has been available online since July 15. If any AAOS members haven’t yet checked out this tool, it might be a good idea to look yourself up. The scorecard details complication rates for individual surgeons who perform any of eight different procedures, five of which are orthopaedic (hip and knee replacement, cervical spine fusion, and anterior and posterior column lumbar fusion).

ProPublica, founded in 2007, describes itself as “an independent, nonprofit newsroom that produces investigative journalism in the public interest.” Although it accepts advertising, major funding comes from philanthropic organizations.

To create the Surgeon Scorecard, ProPublica analyzed Medicare billing records for nearly 17,000 surgeons and identified 66,569 complications over 5 years (2009–2013). Complications were reported if the patient was readmitted to the hospital within 30 days of the index procedure. The cost of these readmissions was estimated at $645.3 million.  AAOS 2015.

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Periarticular injection may be preferable to epidural analgesia for pain relief after simultaneous bilateral total knee arthroplasty.

Pain control after simultaneous bilateral total knee arthroplasty: a randomized controlled trial comparing periarticular injection and epidural analgesia.

To return to New Health News:

BACKGROUND: Periarticular injection is becoming more commonly utilized for pain relief following total knee arthroplasty. However, we are aware of no randomized controlled trial that has investigated the efficacy of periarticular injection for pain relief after simultaneous bilateral total knee arthroplasty.

METHODS: We performed a randomized controlled trial of patients scheduled for simultaneous bilateral total knee arthroplasty. Seventy-one patients with 142 involved knees were randomly assigned to receive periarticular injection or epidural analgesia. Other perioperative interventions, including spinal anesthesia, surgical techniques, and postoperative medication protocols, were identical for all patients. The primary outcome was postoperative pain at rest, measured with the use of a 100-mm visual analog scale (VAS) during the initial twenty-four-hour postoperative period. The cumulative VAS score was calculated with use of the area under the curve and compared between the groups.

RESULTS: Postoperative pain at rest, quantified as the area under the curve of serial assessments during the initial twenty-four-hour postoperative period, was significantly less in the periarticular injection group than in the epidural analgesia group (174.9 ± 181.5 mm × day compared with 360.4 ± 360.6 mm × day; p = 0.0073). The prevalences of nausea on the night of surgery and postoperative day 1 and of pruritus were significantly lower in the periarticular injection group than in the epidural analgesia group (14% and 45%, p = 0.0031; 14% and 55%, p = 0.0003; and 0% and 15%, p = 0.014, respectively).

CONCLUSIONS: Periarticular injection was associated with better pain relief during the first twenty-four hours following simultaneous bilateral total knee arthroplasty and decreased opioid-related side effects compared with epidural analgesia. Periarticular injection may be preferable to epidural analgesia for pain relief after simultaneous bilateral total knee arthroplasty.

LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.      Authors: Sachiyuki Tsukada;Motohiro Wakui;Akiho Hoshino

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TXA , Tranexamic Acid, Reduces Postoperative Morbidity in Foot and Ankle Surgery Patients

“TXA, tranexamic acid, is a drug that decreases bleeding. It is another breakthrough in surgery. It can be given orally, injected into the wound during surgery and used intravenously before, during and after surgery. It’s first highly successful orthopedic use is decreasing bleeding in total knee replacement. Less wound bleeding during and after surgery means a lower incidence of almost all complications in the operated leg. If you are having invasive extremity surgery, ask about it. Ask about it as about TEA, the acronym more commonly used.” Bill Chesnut, MD

Study: TXA Reduces Postoperative Morbidity in Foot and Ankle Surgery Patients

The results of a prospective randomized controlled trial—presented in Poster P206 on display in Academy Hall C—indicate that preoperative administration of 1 gram of tranexamic acid (TXA) significantly reduced blood loss, pain, and swelling in patients undergoing foot and ankle surgery. The abstract of the study, conducted by Nicholas A. Abidi, MD; Ashish Govan, BS; Clay Christensen, BS; and Jess Gifford, BS, reads as follows:

Previously published papers have demonstrated that administration of TXA prior to skin incision during hip and knee arthroplasty has resulted in significant reduction of blood loss, pain, and swelling. This prospective randomized trial sought to determine whether there were demonstrable reductions in postoperative ecchymosis, erythema, edema, pain, and incisional bleeding in patients who received TXA prior to incision for foot and ankle surgical procedures.

In this trial, 100 consecutive patients undergoing foot and ankle surgery by one surgeon were randomized into two groups: Group I and Group II. In Group I, 50 patients were administered 1 gram of TXA intravenously 20 minutes prior to skin incision. In Group II, 50 patients did not receive TXA. Demographics were obtained along with preexisting medical conditions and medications for each group. The reviewer was blinded as to the treatment groups. The reviewer was asked to rate patients’ pre- and postoperative foot and ankle images for ecchymosis, edema, erythema, and degree of fresh blood on the postoperative incision and first postoperative dressings using a scale of 0 to 3. These results were ranked and compared. Patients were also administered a Foot Function Index survey preoperatively and postoperatively at each visit.

A combination of patients undergoing forefoot, midfoot, hindfoot, and ankle surgeries qualified for the study. Data analysis showed statistically significant reductions in postoperative ecchymosis, edema, erythema, and bleeding at 2 and 6 weeks in patients who received 1 gram of TXA 20 minutes prior to skin incision, with P values of < 0.05 and F values greater than 1.0. There was one complication in the non-TXA group; one patient with excessive swelling underwent amputation of the tips of toes 2+3 after forefoot reconstruction. There were no medical complications in the TXA group. Foot function index pain scores were lower between weeks 2 and 6 postoperatively in patients who received TXA preoperatively than in patients who had not received TXA.

Preoperative administration of 1 gram of TXA significantly reduced blood loss, pain, and swelling in patients undergoing foot and ankle surgery. Patients experienced no deleterious detectible medical side effects from administration of TXA. Further studies with more patients are warranted to elaborate on these preliminary results.


Liposomal Bupivacaine as Effective as Femoral Nerve Block

“Femoral Nerve Block (FNB) is a standard part of multimodal pain control for total knee replacement. This study is of ACL surgery which is an outpatient procedure with the patient leaving the surgery facility the same day. There can be complications of FNB including weakness of the quadriceps muscle which extends the knee. This study shows that injecting liposomal Bupivacaine, an extended release local anesthetic, at surgery works as well as FNB except in the first 8 hours. If not using FNB, supplemental pain control in addition to injecting liposomal bupivacaine is suggested in the first 8 hours after surgery.” Bill Chesnut,MD

 Liposomal Bupivacaine as Effective as Femoral Nerve Block in Managing Pain After ACL Surgery

DG News online _March 2, 2016 by Jill Stein

ORLANDO, Fla — March 2, 2016 — Liposomal bupivacaine (LB) is at least as effective as femoral nerve block (FNB) for managing pain after anterior cruciate ligament (ACL) reconstruction, researchers said here on March 1 at the 2016 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS).

Femoral nerve block is the mainstay for pain management after knee surgery, but it may cause nerve injury, delayed quadriceps activation, and residual quadriceps weakness.

Kelechi R. Okoroha, MD, Henry Ford Health System, Detroit, Michigan, and colleagues randomised 100 patients undergoing primary ACL reconstruction to receive either intraoperative local infiltration of LB (20 cc bupivacaine/10cc saline) using a standardised injection protocol or preoperative FNB.

Following surgery, patients were asked to record their pain levels (Visual Analog Scale [VAS]) and opioid consumption for 4 days. The primary endpoint of the study was postoperative pain levels

The data demonstrated a significant increase in pain in the LB group between post-operative hours 0 to 8 (mean 6.3 vs 4.8; P = .01). However, there was no significant difference between average daily pain levels in the 2 groups on each postoperative day (POD) 0 (mean 6.1 vs 5.4; P = .10), POD 1 (mean 5.5 vs 5.4; P = .97), and POD 2 (mean 4.5 vs 4.5; P = .52).

There was also no significant difference in average IV morphine equivalents consumed between the LB and FNB groups on POD 0, 1, and 2.

Patients receiving a FNB had a greater number of sleep disturbances on POD 0 (4.4 vs 3.1) and were more likely to call their doctor the following day due to pain (29% vs 8%).

There was no significant difference in satisfaction with pain management between the groups.

“The findings suggest that local infiltration anaesthesia with LB may be employed to provide similar overall pain control as FNB after ACL reconstruction without the risk of nerve irritation,” reported Dr. Okoroha.

He added that because of the significant increase in pain in the LB group between 0 to 8 hours postoperatively, patients receiving LB might benefit from a supplemental anaesthetic to cover the acute postoperative period.

[Presentation title: Liposomal Bupivacaine Versus Femoral Nerve Block in Managing Pain After Anterior Cruciate Ligament Reconstruction. Abstract P426]


Warnings about concurrent use of opioids, benzodiazepines.

“This is an important health fact that is not broadly known. This is not research. It is a petition asking for warning labels. A combination of benzodiazepines and opioid pain medications is common. Benzodiazepines are a class of psychoactive drugs used to treat anxiety, insomnia, and a range of other conditions. They are one of the most widely prescribed medications in the U.S., particularly among elderly patients. Benzodiazepines possess sedative, hypnotic, anti-anxiety, anticonvulsant, and muscle relaxant properties.” Bill Chesnut, MD.

Public health officials petition FDA to add boxed warnings about concurrent use of opioids, benzodiazepines.

The Washington Post (2/22, Dennis) reports in “To Your Health” that “dozens of public health officials and academics across the country are pushing the Food and Drug Administration to warn people about the potential dangers of taking” opioid pain medications along with benzodiazepines. In a petition, officials from 41 state and municipal health departments, as well as some universities, “urged the agency” to add boxed warnings to both medications, “given evidence that using them together increases the chance of deadly overdoses.”


Why Exercise Can Help Make You Happier

“The value of exercise as a treatment has been increasing documented in the last three decades. This information is timely because of the increasing rate of injury by using prescription opioid pain medications. Controlling depression decreases pain.” Bill Chesnut, MD

Why Exercise Can Help Make You Happier   by Mladen Golubic, M.D., Ph. D. Cleveland Clinic Wellness newsletter 2.24.16

Lifestyle factors — like food choices, physical activity and stress — have a profound effect on your mood and strongly influence whether or not you may develop anxiety and depression. Here’s a fact you may not know: Depression is projected to be a leading social and economic burden worldwide by 2020, second only to coronary artery disease! In fact, about 10 percent of the U.S. population suffers from depression at any point in time. Why so much depression? It is suspected that continuously increasing levels of stress are contributing to the rapid rise in depression. Increased stress hormones not only damage nerve cells, but also prevent growth of new ones in parts of the brain responsible for positive mood states. While there are effective treatments for depression, for example psychotherapy and antidepressant medications, only about a third of depression sufferers actually receive these treatments. What can be done for the remaining two-thirds? A lot.

Physical activity has been identified as an effective alternative treatment, either alone or in combination with standard therapies. In fact, the American Psychiatric Association now includes exercise in their treatment recommendations. It’s easy to understand why: Data from randomized clinical trials provide solid evidence about the benefits of both aerobic (walking, running, biking) and resistance (strength) training for those afflicted with depression. The recommended amount? Three to five exercise sessions per week, of 45 to 60 minutes each. Here’s more great news: People with depressive symptoms may experience improvements within four weeks of starting an exercise routine. And if that’s not enough to convince you of the mental health benefits of exercise, consider this: While stress decreases the growth of new nerve cells that can boost your mood, exercise does the opposite. Exercise grows the brain!

While there is no doubt about the effectiveness of exercise in reducing symptoms of depression, it does take real effort to begin and maintain an exercise routine. To be successful, find an exercise that you love to do. Many people enjoy walking, which has several health benefits if you reach 10,000 steps a day. If you begin to lose interest in your routine, change it up. Take a new fitness class, start dancing, begin a yoga practice or take bike rides with friends or family. And if you’re pressed for time, you may want to look into short, high-intensity workouts that do not require any equipment but use only body weight. They can be performed anywhere and can be done in as little as seven minutes a day. But high-intensity workouts are not for everyone, so please discuss this idea with your doctor before attempting it on your own. Even if your exercise frequency, intensity and duration are below the current recommendation, do not despair. Engaging in at least some physical activity may still be beneficial for patients with depression, according to the authors of the report.

If you’re not suffering from depression, you should know that exercise has numerous other health benefits, too. Regular physical activity can lower your blood pressure, improve your cholesterol profile, help control blood sugar, and reduce your risk of heart disease, diabetes and common cancers. And of course, it will help you achieve or maintain a healthy weight. What medication can do all that? Yes, you’re right. None. Such a pill does not exist and probably will not for generations to come. If it is ever created, it won’t be cheap. Exercise is free and readily available. So just do it.



Mindfulness training focused on stress reduction may benefit people with chronic low back pain

“Low back pain is increasingly seen as a chronic condition that requires multimodal approach. Combining exercise, massage, topical modalities like heat or an electrical stimulator, anti-inflammatories, acetaminophen helps most people. There is a condition of hypersensitivity to pain that is now being documented by testing. This makes the pain worse. Exercises make the pain better if properly done and daily. This is another tool to add, mindfulness training, which helped lower low back pain levels. The first two paragraphs are from Medscape. The second article below is from the Journal of American Medical Association Internal Medicine for the details and more comment” Bill Chesnut, MD

Mindfulness training focused on stress reduction may benefit people with chronic low back pain

Reuters (2/23, Doyle) reports that in a 282-patient study, an eight-week program of mindfulness training focused on reducing stress may benefit people with chronic low back pain. The findings were published online Feb. 22 in JAMA Internal Medicine.

According to Medscape (2/23, Garcia), an accompanying editorial observed, “Attention to underlying mechanisms of behavioral change (i.e., how or why the treatment leads to change) will be key, as will efforts directed at identifying what treatment components and/or specific combinations might be particularly influential in treatment outcomes.”


The Editorial referenced   above  by Medscape: Why We Need Nonpharmacologic Approaches to Manage Chronic Low Back Pain in Older Adults

M. Carrington Reid, MD, PhD1; Anthony D. Ong, PhD2; Charles R. Henderson Jr, MS2 JAMA Intern Med. Published online February 22, 2016. doi:10.1001/jamainternmed.2015.8348

Chronic pain is one of the most common conditions encountered by health care professionals, particularly among patients 65 years and older, and is associated with substantial disability and costs.1,2 Management of chronic pain in older adults is complicated by age-related physiologic changes, competing comorbidities that limit treatment choices, and numerous patient (eg, fear of deleterious effects of medications) and physician (eg, lack of training) barriers. One of the most significant barriers to effective management, however, is a limited evidence base to guide treatment decisions. Recent reviews have documented the paucity of high-quality randomized clinical trials in the field.1,2 Shortcomings include study durations of 12 weeks or less, a lack of study population diversity, and enrollment of young-old study populations without major comorbidities. Studies focused on nonpharmacologic interventions are particularly needed, given that many barriers exist regarding the use of pharmacologic treatments in this target population. Studies further document that older adults with chronic pain are receptive to nonpharmacologic therapies3,4; many already use nondrug treatments and cite concerns about adverse drug effects and the use of too many medications as reasons.4 In this issue of JAMA Internal Medicine, Morone and colleagues5 begin to address this important knowledge gap by presenting data from a well-conducted randomized clinical trial that evaluated the effects of a mindfulness meditation intervention among older adults with chronic low back pain.


FDA postpones decision on opioid addiction implant_ Probuphine

“This is a policy report in the media referring to research that developed an implant to decrease opioid crave for six months. The medical issues are complicated. I don’t have the original report. Deciding on approval of this implant has more considerations than a short-lived oral medication. Let’s hope there is found to be a safe way to use this breakthrough.” Bill Chesnut, MD

 FDA postpones decision on opioid addiction implant_ Probuphine

 The Boston Herald (2/20, Kalter) reported that the Food and Drug Administration “postponed its decision on a matchstick-sized implant that would reduce cravings for people battling opioid addiction.” An advisory committee had recommended the approval of Probuphine in January. The device releases a steady dose of buprenorphine over a six-month period.

In a related story, according to STAT (2/19, Scott), a report issued by Senator Ed Markey (D-MA) accused the Food and Drug Administration of “failing to properly consult with its advisory committees to vet the approval of certain opioid drugs.” In the report, Markey said he “would continue to oppose the nomination of Dr. Robert Califf” until “the FDA changed its procedures.”

AMA News February 21, 2016.__WASHINGTON — The Food and Drug Administration is failing to properly consult with its advisory committees to vet the approval of certain opioid drugs, Massachusetts Senator Ed Markey alleges in a new report and letter obtained by STAT.

Markey, in a Feb. 19 letter to Health and Human Services Secretary Sylvia Mathews Burwell, said that until the FDA changed its procedures, he would continue to oppose the nomination of Dr. Robert Califf, President Obama’s choice to be the agency’s next commissioner. The first Senate floor vote, a procedural vote, on Califf’s nomination will be held Monday evening.

The report produced by Markey’s office laid out three problems from his point of view: First was that so-called “abuse-deterrent” opioids can still be abused. Second, since 2010, the FDA has not always consulted advisory committees when approving abuse-deterrent opioids.

“[The] FDA needs outside expert advice on all opioid approval decisions,” Markey wrote. “Whether an opioid is abuse deterrent or not hasn’t prevented tens of thousands of people who have had their wisdom teeth removed or experienced lower back pain from getting addicted to these painkillers.”

Markey and other lawmakers, including Senator Joe Manchin of West Virginia, have used Califf’s nomination to urge changes at the FDA that would address the opioid crisis, which is killing nearly 30,000 Americans a year.

The report underlines problems with the FDA’s approval process, said Andrew Kolodny, chief medical officer at Phoenix House, which runs dozens of addiction centers in the United States.

Kolodny emphasized that the abuse-deterrent drugs the FDA is approving can still be abused. Abuse-deterrent drugs are usually intended to only stop the pill from being crushed or injected, Kolodny said. Many people end up addicted to opioids by simply swallowing the pills.

“I have had very serious concerns about the FDA’s opioid decision-making for a long time,” he said. “I’m actually pleased that [Markey is] taking a stand on this.”

The agency has recently endured significant controversy for not consulting with advisory committees. The approval of Oxycontin for children saw backlash, including from Democratic presidential candidate Hillary Clinton. An advisory committee was not consulted on the approval, and those critical of the decision, including Kolodny, said they didn’t believe a committee would have favored it.

The episode was one of those highlighted by Markey’s report, which charged that the FDA “ignored its own guidance calling for an advisory committee when a question of ‘pediatric dosing’ is involved.”

Third, and the point that Markey focused on in his letter, the opioid action plan that the agency released earlier this month in response to the addiction crisis still allows some abuse-deterrent opioids to be approved without an advisory committee being consulted.


Clinical Practice Guideline for Post-Surgical Pain Management

“Significant gains in surgery pain control are available now. They are the use of long established modalities now used safely together. The importance of the original research is to have the dosage chart for each of the modalities. The term multimodal therapy is used for the general area of surgery pain control. Multimodal therapy improves the quality of recovery, shortens complication rates and readmission rates. It also increases costs. Being aware and having a source may become helpful for someone who is having surgery. They should discuss these facts with their anesthesiologist and their surgeon.” Bill Chesnut, MD

 American Pain Society Publishes Clinical Practice Guideline for Post-Surgical Pain Management                                          February 17, 2016

CHICAGO — February 17, 2016 — The American Pain Society (APS) has released a new evidence-based clinical practice guideline with 32 recommendations to help clinicians achieve optimal pain management following surgery.

According to numerous studies, the majority of surgical patients receive inadequate pain relief, which can heighten the risk for prolonged post-surgical pain, mood disorders, and physical impairment.

“The intent of the guideline is to provide evidence-based recommendations for better management of postoperative pain, and the target audience is all clinicians who manage pain resulting from surgery,” said lead author Roger Chou, MD, Oregon Evidence-based Practice Center.

Dr. Chou said the key recommendation in the guideline, based on high-quality evidence, is wider use of a variety of analgesic medications and techniques.

“The guideline strongly advises use of multimodal anesthesia that target different mechanisms of actions in the peripheral and central nervous systems,” he said. “Randomized trials have shown that multimodal anesthesia involving simultaneous use of combinations of several medications — acting on different pain receptors or administered through different techniques — are associated with superior pain relief and decreased opioid consumption compared with use of a single medication administered by one technique.”

Dr. Chou added that evidence also indicates that non-pharmacological therapies, such as cognitive behavioral therapies and transcutaneous elective nerve stimulation, can be effective adjuncts to pharmacological therapies.

Written by a 23-member expert panel representing anesthesia, pain management, surgery, nursing, and other medical specialties, the APS guideline — published in the Journal of Pain — is based on the panel’s review of more than 6,500 scientific abstracts and primary studies.

The guideline’s 32 recommendations are rated as strong, moderate or weak based on scientific evidence cited as high, moderate or low quality. The recommendations are based on the premise that optimal pain management begins in the preoperative period and should be based on assessment of the patient and development of individual care plans for the surgical procedure involved.

Three other recommendations in the APS guideline are graded strong with high-quality evidence. They are:
• Adults and children can be given acetaminophen and/or non-steroidal anti-inflammatory drugs as part of multimodal analgesia for management of postoperative pain.
• Clinicians should consider surgical site-specific peripheral regional anesthetic techniques with proven efficacy in adults and children for certain procedures.
• Spinal analgesia is appropriate for major thoracic and abdominal procedures, particularly in patients at risk for cardiac and pulmonary complications or prolonged intestinal distress.

The APS Guideline offers 11 other strong recommendations, based on moderate or weak evidence. They include:
• Clinicians should provide patient and family-centered, individually tailored education to patients and caregivers about treatment options for postoperative pain.
• Oral administration of opioids is preferred to intravenous administration for post-operative analgesia.
• Intravenous patient-controlled analgesia (PCA) can be used when parenteral administration of analgesics is required.
• Clinicians should consider giving preoperative doses of celecoxib in appropriate adult patients.
• Gabapentin and pregabalin can be considered for multimodal postoperative analgesia. The medications are associated with lower opioid requirements after surgery.
• Surgical facilities should provide clinicians with access to a pain specialist for patients with inadequately controlled postoperative pain.

The APS postoperative pain management guideline was endorsed by the American Society for Regional Anesthesia.

SOURCE: American Pain Society


Is BMI an Independent Risk Factor for Unfavorable Outcomes Following Total Hip Arthroplasty

“These two commentaries are editorial balance to an article ‘ Effect of Body Mass Index on Complications and Reoperations After Total Hip Arthroplasty’. I did not post the original article as the commentaries explain the research and the healthcare problem that is developing. This problem is that CMS has changed payment for surgery in total hip replacement to a bundle, a single payment to the hospital, who then pays the surgeon. This starts in April, 2016. The amount of payment is affected by the complication and readmission rate. Both hospitals and surgeons will be pressured, probably forced into selecting healthy patients who will have lower complications and faster recovery. Both of those factors change what the hospital is paid and the profile of the surgeon. There is not an answer I can see inside this new payment construct, which begins April 1 for most hospitals and the surgeons who operate there. This is my best understanding of the real conflict that will effect healthcare decisions. I am not a part of the discussions occurring as I retired July, 2015.” Bill Chesnut, MD


Is BMI an Independent Risk Factor for Unfavorable Outcomes Following Total Hip Arthroplasty?

Commentary on an article by Eric R. Wagner, MD, et al.: “Effect of Body Mass Index on Complications and Reoperations After Total Hip Arthroplasty”

Nader Toossi, MD; Norman A. Johanson, MD

J Bone Joint Surg Am, 2016 Feb 03; 98 (3): e11 .


High body mass index (BMI) has been shown to have a strong association with unfavorable outcomes following total hip arthroplasty1. An increasing proportion of patients undergoing total hip arthroplasty have a high BMI value2. The article by Wagner et al. is a single institution’s retrospective review of prospectively collected data regarding 21,361 primary total hip arthroplasties performed between 1985 and 2012. The relationship between BMI, as an independent variable, and outcomes were reported as hazard ratios, and survival estimates were made by the Kaplan-Meier method. The findings are largely consistent with those of the current literature; however, the treatment of BMI as a continuous variable is unique and represents an advance in understanding obesity in more of a “dose-response” relationship to surgical complications and points to a more refined risk-adjustment strategy. This is the greatest strength of the study.

A limitation of the study is its failure to address the combined effect of diabetes and high BMI on the surgical outcomes. Diabetes mellitus is strongly associated with both high BMI values and certain surgical complications, such as periprosthetic joint infection and wound dehiscence3. Although the authors offered a credible explanation for the increased risk of infection, they did not present statistical evidence of controlling for the confounding effect of diabetes in their analysis. There are different ways to control for the confounding effect of diabetes on the outcome, such as case-matching, stratification, or adjusting for diabetic status in a multivariable analysis. The investigators could have stratified the patients on the basis of their diabetic status, or they could have adjusted for diabetes in the Cox model in addition to the other variables, such as age, sex, and preoperative diagnosis.

Although the large number of cases in this study is an advantage, and the focus on long-term follow-up (an average of ten years for the total cohort) is usually considered to be a point of strength in studies of arthroplasty outcomes, the long follow-up duration in this specific study is fraught with a limitation. Independent variables, such as sex and race, are constant throughout the lifetime of a patient. Some independent variables, such as age, follow a predictable trend over time. However, BMI neither remains constant nor follows a predictable trend over time4,5. This variability may confound the interpretation of outcomes, especially those that have a significant dose-response relationship. Additionally, the normal-BMI cohort may change its weight and, accordingly, BMI over the long term. The BMI value at the time of a complication or revision years later might vary substantially from the value at the time of total hip arthroplasty. Thus, one of the weaknesses of the present study is due to the inability to follow trends of BMI for individual patients during a long duration of follow-up postoperatively. The longer the follow-up duration, the higher the chances that the BMI value would change over the period of study.

Despite these limitations, the article paves the way for future and more comprehensive studies. This study points toward the importance of examining larger and more contemporary databases to elucidate the impact of higher levels of BMI, such as morbid obesity (a BMI of ≥40 kg/m2) and super obesity (a BMI of ≥50 kg/m2), on the array of commonly encountered complications.


What Will We Do Now with the Super-Obese Patient Undergoing Total Hip Arthroplasty?

Commentary on an article by Kimona Issa, MD, et al.: “Bariatric Orthopaedics: Total Hip Arthroplasty in Super-Obese Patients (Those with a BMI of ≥50 kg/m2)”

Raymond Paul Robinson, MD

J Bone Joint Surg Am, 2016 Feb 03; 98 (3): e12 .


The increasing body weights of our patients and the growing responsibility to avoid postoperative adverse events have put a new urgency into expanding our knowledge of the impact of comorbidities such obesity on our patients and health-care system. Thirty years ago in my own practice, performing a total hip replacement on a patient with a body mass index (BMI) of >40 kg/m2 was unusual. Higher complication rates were expected and were addressed as necessary. Now even heavier patients are appearing in our clinics, putting more pressure on surgeons and hospitals. The implementation of bundled payment requiring that hospitals cover any postoperative complication or need for readmission within ninety days will further increase these pressures. Not surprisingly, there is concern that patients with comorbidities such as extreme obesity may not be able to obtain care.

Issa et al. present new data about outcomes and complications of super-obese patients undergoing total hip arthroplasty. These data will be helpful in understanding the cost of care and expectations of the patient and health-care professionals. The authors present an excellent retrospective review of forty-five patients (forty-eight hips) with a minimum BMI of 50 kg/m2 who underwent total hip arthroplasty at one of four high-volume joint centers. They compare implant survival, complication rates, Harris hip scores, Short Form-36 (SF-36) scores, and University of California Los Angeles (UCLA) activity scores with a matched control group of patients with a BMI of <30 kg/m2. Patients were followed for four to twelve years, which further contributes to the previous study by Issa et al. on super-obese patients undergoing total hip arthroplasty followed for three years1.

In the current study, Issa et al. report an 8.2% lower implant survival rate in the super-obese patient at a mean time of six years and a 4.5% rate of septic revision. Compared with the non-obese patients, super-obese patients had inferior clinical results, as demonstrated by significantly lower postoperative scores. It is important to note that these results were submitted from experienced surgeons practicing in high-volume joint centers.

Equally important is the documentation that, even from 2001 to 2010, super-obese patients had difficulty finding surgeons who would perform the surgical procedure on them. Although the authors do not tell us why other surgeons would not operate on these patients, bundled payment will likely make access to care even harder for these patients. This article provides needed data that will help us to understand the increased burden of the super-obese patient on our health-care system.

Issa et al. point out that the study was retrospective, although many of the data were accumulated prospectively. The authors also do not discuss the option of delaying the surgical procedure on these patients until and unless they lose weight or undergo a bariatric surgical procedure, which are relevant alternative approaches.


Mental Health Has a Stronger Association with Patient-Reported Shoulder Pain

“This article is an example of a type of research weakness in orthopedic surgery, in my view. Note that this Journal of Bone and Joint Surgery, America, balanced the report with a commentary the journal editors requested from an expert. The expert rightly emphasizes this correlation between mental health and how a rotator cuff tear feels is not be used to deny care particularly surgically repairing the rotator cuff. There are many other factors to consider and many unknowns that predict predicting the course of shoulder pain from a torn rotator cuff.” Bill Chesnut, MD

 Mental Health Has a Stronger Association with Patient-Reported Shoulder Pain and Function Than Tear Size in Patients with Full-Thickness Rotator Cuff Tears

James D. Wylie, MD, MHS; Thomas Suter, MD; Michael Q. Potter, MD; Erin K. Granger, MPH; Robert Z. Tashjian, MD    J Bone Joint Surg Am, 2016 Feb 17; 98 (4): 251 -256 .

Background: Patient-reported outcome measures have increasingly accompanied objective examination findings in the evaluation of orthopaedic interventions. Our objective was to determine whether a validated measure of mental health (Short Form-36 Mental Component Summary [SF-36 MCS]) or measures of tear severity on magnetic resonance imaging were more strongly associated with self-assessed shoulder pain and function in patients with symptomatic full-thickness rotator cuff tears.

Methods: One hundred and sixty-nine patients with full-thickness rotator cuff tears were prospectively enrolled. Patients completed the Short Form-36, visual analog scales for shoulder pain and function, the Simple Shoulder Test (SST), and the American Shoulder and Elbow Surgeons (ASES) instrument at the time of diagnosis. Shoulder magnetic resonance imaging examinations were reviewed to document the number of tendons involved, tear size, tendon retraction, and tear surface area. Age, sex, body mass index, number of medical comorbidities, smoking status, and Workers’ Compensation status were recorded. Bivariate correlations and multivariate regression models were calculated to identify associations with baseline shoulder scores.

Results: The SF-36 MCS had the strongest correlation with the visual analog scale for shoulder pain (Pearson correlation coefficient, −0.48; p < 0.001), the visual analog scale for shoulder function (Pearson correlation coefficient, −0.33; p < 0.001), the SST (Pearson correlation coefficient, 0.37; p < 0.001), and the ASES score (Pearson correlation coefficient, 0.51; p < 0.001). Tear severity only correlated with the visual analog scale for shoulder function; the Pearson correlation coefficient was 0.19 for tear size (p = 0.018), 0.18 for tendon retraction (p = 0.025), 0.18 for tear area (p = 0.022), and 0.20 for the number of tendons involved (p = 0.011). Tear severity did not correlate with other scores in bivariate correlations (all p > 0.05). In all multivariate models, the SF-36 MCS had the strongest association with the visual analog scale for shoulder pain, the visual analog scale for shoulder function, the SST, and the ASES score (all p < 0.001).

Conclusions: Patient mental health may play an influential role in patient-reported pain and function in patients with full-thickness rotator cuff tears. Further studies are needed to determine its effect on the outcome of the treatment of rotator cuff disease.

Once Again, the Status of the Rotator Cuff Does Not Correlate with Patient Symptoms

Commentary on an article by James D. Wylie, MD, MHS, et al.: “Mental Health Has a Stronger Association with Patient-Reported Shoulder Pain and Function Than Tear Size in Patients with Full-Thickness Rotator Cuff Tears”

Michael Khazzam, MD

J Bone Joint Surg Am, 2016 Feb 17; 98 (4): e14 .


Decision-making strategies for the appropriate treatment of patients with symptomatic, atraumatic, full-thickness rotator cuff tears are becoming increasingly difficult. It is becoming clear that symptoms of rotator cuff tears do not correlate with disease severity. There have been several recent studies attempting to define a relationship of rotator cuff tears with symptoms such as pain and patient-reported outcome measures13.

In this Level-II prospective cohort study, Wylie et al. evaluated 169 patients and examined the relationship between rotator cuff tear severity on magnetic resonance imaging (MRI) (number of tendons torn, tear size, tear retraction, and tear area) and patient-reported outcomes, pain, and mental health as measured by the Short Form-36 Mental Component Summary (SF-36 MCS) score. The authors pose two important questions regarding the association of rotator cuff tear morphology and patient-reported outcome measures: How does mental health as assessed by the SF-36 MCS correlate with shoulder function and rotator cuff tear severity; and is tear morphology more likely associated with patient-reported shoulder function than pain, American Shoulder and Elbow Surgeons (ASES) scores, or Simple Shoulder Test (SST) scores? Interestingly, the SF-36 MCS correlated with the visual analog scale (VAS) for pain, SST score, and ASES score (all p < 0.001) but morphologic measures of tear severity generally did not (p > 0.05 except for the association of tear retraction with the SST).

The Multicenter Orthopaedic Outcome Network (MOON) Shoulder Group1 performed a Level-III cross-sectional cohort study of pretreatment data and found that no anatomic measure of rotator cuff tear severity—including number of tendons (p = 0.5), amount of retraction (p = 0.9), humeral head migration (p = 0.3), or amount of fatty infiltration (p = 0.4)—was associated with pain. The group did find that an increasing number of medical comorbidities (p = 0.002), race (p = 0.041), and lower education level (p = 0.004) correlate with increased VAS for pain. Harris et al.2 also performed a prospective Level-III cohort study analyzing pretreatment data of the MOON Shoulder Group to determine which factors were associated with worse patient-reported outcomes, including ASES and Western Ontario Rotator Cuff (WORC) index scores. That study found that tear size, tear retraction, and superior humeral head migration did not correlate with patients’ pain and were not associated with worse ASES or WORC index scores. The presence of atrophy of the supraspinatus (p = 0.04) and infraspinatus (p = 0.003) was associated with lower patient-reported outcomes.

The results of these studies are all in agreement that morphologic tear characteristics are not correlated with pain or patient-reported outcome measures, but may be more directly correlated with shoulder physical function. Interestingly, in the current study, Wylie et al. found, using multivariate regression models, that improving SF-36 MCS scores by 15 to 20 points would lead to a clinically important change in pain, ASES score, and SST score. These data identify a patient-related adjustable factor that can be addressed by improving mental health to aid in the treatment of rotator cuff disease. The primary limitation of the current study includes selection bias, as only 39% of eligible subjects were actually enrolled in the study.

The authors provide further evidence that the status of the rotator cuff is not the primary variable that results in patient symptom severity or decline in shoulder-specific health-related quality of life. Future well-designed, prospective cohort studies are needed to identify what is the primary cause of symptoms in patients with rotator cuff tears and why some tears remain asymptomatic.


Evidence for spinal cord hypersensitivity in chronic pain

“This publication from PAIN is an example of increasing findings showing that some people have increased awareness of their musculoskeletal system sensations. This is also described, as here, as “hypersensitivity”, a term I don’t use because it may be prejudicial in tone. There is more data in the fibromyalgia literature that you can access by Internet search. I added emphasis to the last two sentences about conclusions of this research.” Bill Chesnut, MD

 Pain    Volume 107, Issues 1–2, January 2004, Pages 7–15

Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia


Patients with chronic pain after whiplash injury and fibromyalgia patients display exaggerated pain after sensory stimulation. Because evident tissue damage is usually lacking, this exaggerated pain perception could be explained by hyperexcitability of the central nervous system. The nociceptive withdrawal reflex (a spinal reflex) may be used to study the excitability state of spinal cord neurons. We tested the hypothesis that patients with chronic whiplash pain and fibromyalgia display facilitated withdrawal reflex and therefore spinal cord hypersensitivity. Three groups were studied: whiplash (n=27), fibromyalgia (n=22) and healthy controls (n=29). Two types of transcutaneous electrical stimulation of the sural nerve were applied: single stimulus and five repeated stimuli at 2 Hz. Electromyography was recorded from the biceps femoris muscle. The main outcome measurement was the minimum current intensity eliciting a spinal reflex (reflex threshold). Reflex thresholds were significantly lower in the whiplash compared with the control group, after both single (P=0.024) and repeated (P=0.035) stimulation. The same was observed for the fibromyalgia group, after both stimulation modalities (P=0.001 and 0.046, respectively). We provide evidence for spinal cord hyperexcitability in patients with chronic pain after whiplash injury and in fibromyalgia patients. This can cause exaggerated pain following low intensity nociceptive or innocuous peripheral stimulation. Spinal hypersensitivity may explain, at least in part, pain in the absence of detectable tissue damage.


Solving America’s opioid crisis: Remember the patient

“Caring for patients with chronic pain is complicated. It requires close attention and frequent monitoring of the treatment response. “ Bill Chesnut, MD

 Solving America’s opioid crisis: Remember the patient  AMA News_1/25/2016, 3:43 PM

Physicians, medical organizations and public health experts around the nation all have shared reasons why the opioid overdose epidemic must be top of mind in the medical world, and it comes down to one focus—the patient. A panel of experts recently gave recommendations that lead the way to making patient-focused pain management possible.

Reducing the stigma of chronic pain

One important aspect of the efforts to combat the opioid epidemic is reducing stigma so that patients with chronic pain do not lose access to the care that they need.

“What is our role as physicians in this current problem?” asked John A. Renner, MD, president of the American Academy of Addiction Psychiatry and professor of psychiatry at Boston University School of Medicine, speaking to physician leaders at the AMA State Legislative Strategy Conference earlier this month during a session on the opioid crisis.

“This epidemic is not going to be contained until we change practice within medicine,” Dr. Renner said. “Medicine does not shrink from treating these chronic conditions.”

There are many things that physicians can do now to begin those changes, he added. “Before prescribing opiates for either acute or chronic pain, the clinician must screen every patient for a history of substance use disorders and for co-occurring psychiatric disorders. A review of the PDMP should be part of every routine assessment.”

“Recognize that patients with any history of alcoholism or substance use disorder are at higher risk for abuse, and they should be managed very carefully,” Dr. Renner said. “This means avoiding prescribing opiates if there are other medications that may be more effective, careful[ly] prescribing … opiates if that is necessary, [and] it means monitoring the patient carefully, to look at how the treatment is progressing.”

However, this does not mean withholding opiates from patients with acute pain, he said.

Dr. Renner cited a case where a patient with a history of addiction needed surgery. The surgeon gave the patient a four-day supply of opioids but also carefully monitored the patient during those four days and the time following to make sure the patient’s pain was managed sufficiently.

“Sometimes prescribing [opioid-based] medication is the best way to prevent relapse,” Dr. Renner said. In other cases, “we need to work with primary care physicians as well as pain management specialists to develop alternatives for handling chronic pain without relying on opiates.”

“There is a moral imperative to treat pain,” said Myra Christopher, the Kathleen M. Foley chair for pain and palliative care at the Center for Practical Bioethics. “Those who are in the healing professions have ethical and moral obligations to do so.”

“That does not mean that there is a moral imperative, an ethical duty or obligation to prescribe opioids,” she added. “It means there is a moral imperative to address this issue [of chronic pain].” One solution, Christopher suggested, is to increase training in pain management.

“If you ask any medical school applicant” why they want to go to medical school, “they will say ‘I want to alleviate, or I want to treat pain and suffering,’” Christopher said. “That notion is really the foundation of what it means to be a healing profession.” However, although comprehensive management for chronic pain is necessary for many patients, most physicians have inadequate training on this approach.

Actions physicians can take to end the overdose crisis

In conjunction with patient-focused chronic pain management, physicians also need to be vigilant in taking steps to prevent overdose and treat patients who are living with substance use disorder.

“Where do we start when there are 44 people dying from opioid-related overdoses every day?” said Patrice A. Harris, MD, chair-elect of the AMA Board of Trustees, who also chairs the AMA Task Force to Reduce Prescription Opioid Abuse, during her opening remarks.

“This public health crisis related to opioid misuse and heroin addiction results in nearly 30,000 deaths annually and challenges us as physicians to amplify our current efforts and actions,” Dr. Harris said. “We use the word ‘actions’ deliberately [because] we must take concrete actions that will help end this crisis.”

The task force focuses on five recommendations for all physicians from “inside the profession,” Dr. Harris said. “These recommendations come from physicians who treat acute pain, chronic pain and patients who have substance use disorder. We must also look inwardly …. As physicians, we run toward the health crisis, not away from it.”

Action No. 1: Physicians should “voluntarily register for and use [their] state prescription drug monitoring programs (PDMP),” Dr. Harris said.

One example of a successful PDMP comes from the Ohio State Medical Association (OSMA). Also speaking on the panel with Christopher and Dr. Harris, Michael Bourn, DO, medical director of pain and palliative services at Doctor’s Hospital in Columbus, Ohio, described the success of his state’s PDMP for physician leaders.

The Ohio Automated Rx Reporting System (OARRS) is a tool to track the dispensing and personal furnishing of controlled prescription drugs to patients. OARRS is designed to monitor this information for suspected abuse or diversion and can give a prescriber or pharmacist critical information regarding a patient’s controlled substance prescription history to identify high-risk patients who could benefit from early intervention.

In 2010 there were about 5,000 Ohio prescribers with a voluntary OARRS account, but that number has increased to over 36,000 presently and counting. Between 2007 and 2014 the number of OARRS reports requested increased 5,900 percent, signifying its expanded use throughout the state in just seven years. In that same seven year period, Ohio experienced an approximately 50 percent decrease in “doctor shoppers” throughout the state and saw a significant drop in the number of patients seeking multiple prescriptions.

Action No. 2: “Focus on education,” Dr. Harris said. “Encourage yourselves and encourage your colleagues to ask themselves: When was the last time you took CME that was focused on opioid prescribing, to learn how to effectively use your state’s PDMP and to learn how to recognize the signs of abuse?”

Actions Nos. 3 and 4: “The third and fourth recommendations have to do with the stigma of pain,” Dr. Harris said. It’s important to reduce the stigma that surrounds pain patients in order for those with chronic pain to receive the care and the prescriptions they need to live happier, healthier lives, Dr. Harris said. It is also important to reduce the stigma of substance use disorder and increase access to treatment so patients feel comfortable in seeking that treatment.

Action No. 5: “Consider co-prescribing naloxone and support broad Good Samaritan protections,” Dr. Harris said. Last year access to naloxone—the life-saving medication that can reverse the effects of an opioid overdose by restoring breathing and preventing death—was increased substantially through new products and availability. “At the end of the day, remember what is most important—our patients.”

From JAMA Newsletter 1.26.16.                                 By AMA staff writer Troy Parks


Study examines impact of early physical therapy for lower-back pain

“This is an example of the media not saying what the study demonstrated. Fortunately, they linked to the original publication in JAMA, October 13, 2015. There you find that PT was not so good, but a little good.” Bill Chesnut, MD

Study examines impact of early physical therapy for lower-back pain

The NPR (10/14, Shallcross) “Shots” blog reports that a study published Oct. 13 in the Journal of the American Medical Association examines “the impact of early physical therapy” for lower-back pain. Researchers “looked at more than 200 patients with lower-back pain to see whether physical therapy sessions would make a difference if they started the sessions soon after they began having pain” instead of waiting a few weeks to see if people could recover on their own.

HealthDay (10/14, Reinberg) points out that “early physical therapy produced a modest improvement in the study participants’ ability to function after three months, compared with no physical therapy” at all. At the one-year mark, however, “no significant difference in function was found between the two groups.”


If you read the entire abstract, the conclusions are different than the media reported.

Conclusions and Relevance. Among adults with recent-onset LBP, early physical therapy resulted in statistically significant improvement in disability, but the improvement was modest and did not achieve the minimum clinically important difference compared with usual care.

Trial Registration Identifier: NCT01726803



After Hip-Replacement Surgery, Medication Use Decreases

“The patient database of Norway is analyzed from 2005 to 2011. It shows that total joint replacement decreases the prescribing of pain medications and sleep aids.” Bill Chesnut, MD

After Hip-Replacement Surgery, Medication Use Decreases

Newswise — December 1, 2015 – A new study, published November 15, in the journal PAIN® provides information on the trajectories of prescription drug use before and after hip-replacement surgery—total hip arthroplasty (THA), one of the most common types of joint replacement surgery. Hip-replacement surgery is commonly followed by long-term reductions in the use of prescription drugs for pain and insomnia. But use of these medications increases during the year before hip replacement—and jumps even higher in the period immediately after surgery, according to Dr. Tone Blågestad of the University of Bergen, Norway, and colleagues.

PAIN® is the official publication of the International Association for the Study of Pain (IASP). The journal is published by Wolters Kluwer.

Drug Use Rises, Then Falls after Hip Replacement
The researchers merged Norwegian national joint replacement and prescription databases to analyze medication use by nearly 40,000 patients undergoing THA from 2005 to 2011. The patients’ average age was 68.5 years; about three-fourths underwent THA because of primary osteoarthritis.

The scientists analyzed trends in prescription drug use over two years: four quarters before and four quarters after hip-replacement surgery. The study focused on various classes of drugs used to treat pain (analgesics) and insomnia (hypnotics), as well as drugs to treat anxiety and depression.

Overall, about half of patients filled a prescription for some type of analgesic in the year before surgery. Analgesic use included nonsteroidal anti-inflammatory drugs (NSAIDs, such as naproxen) in 38 percent of patients, opioids (morphine and related drugs) in 16 percent, and other non-opioid analgesics in 12 percent.

Use of pain medications continued to increase during the last quarter before THA—and then increased dramatically in the first quarter after surgery. The sharpest increases were for opioids, which increased to 28 percent in the last quarter before THA, then to 65 percent in the first quarter afterward; non-opioid analgesics increased to 21 percent and then to 60.5 percent.

The percentage of patients who filled prescriptions for hypnotic drugs also increased from the quarter before to the quarter after surgery—from 14 percent to 25 percent. Analysis of the drug volume (dosage) showed a similar pattern.

With continued follow-up after THA, medication use decreased. By one year after THA, opioid use had decreased to 14 percent, NSAID use to 18 percent, and non-opioid analgesic use to 13 percent. Use of hypnotic drugs also decreased, along with medications to treat anxiety. There was little or no change in the use of antidepressants, however.

“Patients with chronic pain are frequent users of analgesic and psychotropic drugs and thereby risk adverse drug events,” Dr. Blågestad and coauthors write. There is special concern about the potential for serious adverse effects of opioids, including drug overdose.

The results suggest that use of pain medications increases in the year before hip-replacement surgery, with a further increase immediately afterward, followed by a long-term decrease. That pattern is consistent with previous studies on pain scores in the period before and after THA.

Hypnotic drug use shows a similar trend, suggesting that sleep problems get worse, then improve with long-term pain relief after THA. The lack of change in antidepressant use suggests that depression in patients undergoing hip replacement isn’t necessarily related to hip pain.

“Overall, the present results extend the positive effects of THA to include reduced reliance on medication to alleviate symptoms,” Dr. Blågestad and colleagues report. The finding that hypnotics follow the same prescription trajectory as analgesics highlights the link between pain and sleep. The researchers add, “Our results warrant attention to the increased risk of adverse medication effects occurring with the increased use of both opioids and hypnotics in the recovery phase.”

Click here to read “Prescription trajectories and effect of total hip arthroplasty on the use of analgesics, hypnotics, antidepressants and anxiolytics: Results from a population of total hip arthroplasty patients.”

Article: “Prescription trajectories and effect of total hip arthroplasty on the use of analgesics, hypnotics, antidepressants and anxiolytics: Results from a population of total hip arthroplasty patients” (doi: 10.1097/j.pain.0000000000000414)


MRI Reveals Weight Loss Protects Knees

“This important article includes beautiful MRI images of knee arthritis. I cannot reproduce them here. You can see some of these in HealthImaging,

This text is relevant without the pictures. This type of research will stand the test of time. The point is for obese patients to lose weight knowing that it can help their knee arthritis. Don’t jump to the conclusion that you should go directly to total knee replacement.

This report adds to the importance of medicine developing an effective treatment for those who are obese; more many our current methods don’t work.” Bill Chesnut, MD

MRI Reveals Weight Loss Protects Knees

CHICAGO — Obese people who lose a substantial amount of weight can significantly slow the degeneration of their knee cartilage, according to a new MRI study presented today at the annual meeting of the Radiological Society of North America (RSNA).

Alexandra Gersing, M.D.

Obesity is a major risk factor for osteoarthritis, a degenerative joint disease that affects more than a third of adults over the age of 60, according to the Centers for Disease Control and Prevention. The knee joint is a common site of osteoarthritis, and in many people the condition progresses until total knee replacement becomes necessary. Aging baby boomers and a rise in obesity have contributed to an increased prevalence of knee osteoarthritis.

“Degenerative joint disease is a major cause of pain and disability in our population, and obesity is a significant risk factor,” said the study’s lead author, Alexandra Gersing, M.D., from the Department of Radiology and Biomedical Imaging at the University of California, San Francisco. “Once cartilage is lost in osteoarthritis, the disease cannot be reversed.”

Dr. Gersing and colleagues recently investigated the association between different degrees of weight loss and the progression of knee cartilage degeneration in 506 overweight and obese patients from the Osteoarthritis Initiative, a nationwide research study focused on the prevention and treatment of knee osteoarthritis. The patients either had mild to moderate osteoarthritis or risk factors for the disease. They were divided into three groups: a control group who did not lose weight, a second group who lost a little weight, and a third group who lost more than 10 percent of their body weight. The researchers then used MRI to quantify knee osteoarthritis.

“Through T2 relaxation time measurements from MRI, we can see changes in cartilage quality at a very early stage, even before it breaks down,” Dr. Gersing said.

When the researchers analyzed differences in the quality of cartilage among the three groups over a four-year time span, they found evidence that weight loss has a protective effect against cartilage degeneration and that a larger amount of weight loss is more beneficial.

“Cartilage degenerated a lot slower in the group that lost more than 10 percent of their body weight, especially in the weight-bearing regions of the knee,” Dr. Gersing said. “However, those with 5 to 10 percent weight loss had almost no difference in cartilage degeneration compared to those who didn’t lose weight.”

Substantial weight loss not only slows knee joint degeneration—it also reduces the risk of developing osteoarthritis, Dr. Gersing said. Along with moderate exercise, weight loss is one of the primary interventions against the disease.

“It’s most helpful if these lifestyle interventions take place as early as possible,” Dr. Gersing said.



Figure 1. Cartilage T2 maps indicating worsening cartilage quality (red) after 48 months in an obese patient without weight loss (top row) compared to a patient with >10% weight loss (bottom row) in which only little cartilage degeneration is found.

Figure 2. Knee joint of patient without weight loss (A) showing severe cartilage defects after 48 months, whereas in the knee joint of a patient with a substantial amount of weight loss (B), cartilage remains intact.

Knee replacement surgery may relieve pain more effectively than nonsurgical therapy alone??

“These articles based on a publication in the New England Journal of Medicine have unintended consequences. Readers are led to conclude that a total knee replacement is the only effective treatment for knee arthritis. That is not right. I am posting elsewhere on this site a publication in the Journal of the American Academy of Orthopedic Surgery this month outlining the many other therapies that effectively control pain and maintain function in an arthritic knee. “Bill Chesnut, MD

Knee replacement surgery may relieve pain more effectively than nonsurgical therapy alone.

The New York Times (10/22, Saint Louis, Subscription Publication) reports that research published in The New England Journal of Medicine suggests that “knee replacement surgery relieves pain and improves function in patients with severe osteoarthritis much more effectively than nonsurgical therapy alone.” For the “study, 50 adults with moderate to severe osteoarthritis completed exhaustive nonsurgical treatment, including exercise and supervised weight loss.” Meanwhile, “a similar group of patients received knee replacements, followed by the nonsurgical therapy.”

The AP (10/22, Marchione) reports that “after one year, the surgery group improved twice as much as the others did on scores for pain, activities of daily living and quality of life.” But, “two-thirds of those not given surgery still had a meaningful improvement, and only one-fourth of them ended up having surgery within the year.”

AMA News, October 2015.


Hospitals turning to new ways to control pain

“This is happy news. Help spread the word.” Bill Chesnut, MD

 Hospitals turning to new ways to control pain

 On the front of its Personal Journal section, the Wall Street Journal (9/29, D1, Landro, Subscription Publication) reports that hospitals are increasingly turning to new devices to minimize pain, such as needleless blood drawing devices, hand-held vein finders, topical numbing agents, and fast-acting pain control nasal sprays. Pain control has become a bigger priority than in the past due to its high ranking on patient satisfaction surveys.

AMA Wire newsletter, October 2015.


Four in ten Americans know someone addicted to opioids, survey finds

“Four in ten Americans know someone addicted to opioids, this survey finds. It is more prevalent than it is apparent. If someone’s behavior is off, and it wasn’t, suspect, they have a health problem that is being treated with opioids.” Bill Chesnut, MD

Four in ten Americans know someone addicted to opioids, survey finds

The Washington Post (11/24, Bernstein) reports that nearly four in 10 Americans “know someone who has been addicted to prescription” pain medications, “including 25 percent who say it was a close friend or family member and 2 percent who acknowledge their own addiction, according to a new poll” released today by the Kaiser Family Foundation. The survey also found that 16 percent of people say they know someone who has died from an opioid overdose. The Post adds that by “a margin of 77 percent to 58 percent, those polled say it is easy to get non-prescribed” pain medications “than say it is easy for people who medically need the drugs to get them.”

Bloomberg News (11/24, Tozzi) reports that the demographics of those “touched by the crisis skew white, higher-income, college-educated, younger, and male.” According to the article, drug overdoses “are eclipsing car crashes as a leading cause of accidental death for American adults.”

Drew Altman, president and CEO of the Kaiser Family Foundation, writes on the Wall Street Journal (11/24) “Washington Wire” blog that the broad impact of opioid addiction means the issue will likely gain more political traction.

Sen. Shaheen proposes $600 million in additional funding to fight opioid abuse TheAP (11/24, Ramer) reports that Sen. Jeanne Shaheen (D-NH) “is proposing $600 million in emergency funding to address” an opioid abuse “crisis that she says is spiraling out of control.” Shaheen, who announced her funding bill yesterday, said, “This should be an all-hands-on-deck moment, not just for New Hampshire but for our country.” According to the AP, most of the money in Shaheen’s proposal would go to HHS, including $250 million distributed to states as block grants for prevention and treatment programs. The CDC “would get $50 million to support work on prescription monitoring and other programs, and the National Institute on Drug Abuse would get $35 million for targeted research on drug addiction.”

AMA newsletter, November, 2015.


Study suggests exercise prevents lower back pain

“This study and another elsewhere posted are finding that exercise is essential for the common variety of low back pain, lumbago. This summary in the AMA Wire does not point out that this may not be true in patients with actual nerve impingement causing back pain and sciatica pain.” Bill Chesnut, MD

Study suggests exercise prevents lower back pain

The NPR (1/12, Bichell) “Shots” blog reports that a study published in JAMA Internal Medicine analyzed 21 studies of treatment methods for lower back pain, “involving over 30,000 people in total.” The findings show that “back belts and show insoles didn’t seem to offer a benefit,” and that any kind of exercise “reduced the risk of repeated lower-back pain in the year following an episode between 25 and 40 percent.” In a corresponding editorial, Dr. Tim Carey at the University of North Carolina at Chapel Hill writes that healthcare providers don’t prescribe exercise enough, pointing out that “fewer than half of patients participate in an exercise program, even if they have long-term back pain.” Carey discovered that passive treatments, like ultrasound or orthotic insoles, were far more common. The discrepancy may be because of the health industry’s focus on “sellable products, and exercise isn’t one.”

TIME (1/12, Sifferlin) adds that about 80 percent of people will experience lower back pain at some point in their life. While exercise was found to be effective, “the researchers say it’s unclear whether these effects would last beyond a year.” The study authors write, “This finding raises the important issue that, for exercise to remain protective against future [lower back pain], it is likely that ongoing exercise is required.”



7 Million People in US Walking on Artificial Knees or Hips

“This is an editorial comment in the Journal of Bone and Joint Surgery, Sept 11, 2015. The full scientific article is in that issue and too technical to post here. It is a significant contribution to human productivity and secondarily quality of life if the patient takes advantage of the regained function.” Bill Chesnut, MD

7 Million People in US Walking on Artificial Knees or Hips

We know that more than 1 million total hip and total knee replacements are performed each year in the US. But how many people are actually walking around right now with such prostheses?

That’s the question Kremers et al. answer in the September 2, 2015 edition of The Journal of Bone & Joint Surgery. Using the so-called “counting method” to combine historical incidence data, these Mayo Clinic authors concluded that about 7 million US residents (slightly more than 2% ) were living with a hip or knee replacement in 2010.

Prevalence of hip replacement was 0.83%, while that of knee replacement was 1.52%. Not surprisingly, prevalence increased with age (5.26% for total hip and 10.38% for total knee at 80 years of age), but the authors also found a shift toward younger people having the procedure.

These prevalence stats for hip and knee replacement are similar to those for stroke (6.8 million) and myocardial infarction (7.6 million), underscoring just how common these orthopaedic procedures are. Even in the unlikely event that the annual incidence of these joint replacements remains steady rather than rises, the authors estimate that 11 million people will be living with artificial hips or knees in 2030.

According to Kremers et al., among the many implications of these findings is “a need for the medical profession and the policy makers to recognize and address the lifelong needs of this population,” including the development of evidence-based protocols for follow-up care and radiographic assessments.

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