ORLANDO, Fla.—Children and adolescents who take medication for attention-deficit hyperactivity disorder (ADHD) show decreased bone density, according to a large cross-sectional study presented today at the 2016 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS).

“This is an important step in understanding a medication class, that is used with increasing frequency, and its effect on children who are at a critical time for building their bones,” said senior study author Jessica Rivera, MD, an orthopaedic surgeon with the U.S. Army Institute of Surgical Research.

ADHD is a common neurobehavioral condition often diagnosed in childhood. The U.S. Centers for Disease Control and Prevention (CDC) estimate 6.4 million children were diagnosed with ADHD through 2011. In addition, the CDC says that parents reported 3.5 million children and teenagers taking medications to treat ADHD, a 28 percent increase from 2007—2011.

In this study, researchers identified 5,315 pediatric patients in the CDC’s National Health and Nutrition Examination Survey (NHANES) and compared children who reported taking ADHD medications with survey participants not on these medications. The results indicate that children on ADHD medication had lower bone mineral density in the femur, femoral neck and lumbar spine. Approximately 25 percent of survey participants on ADHD medication met criteria for osteopenia, a condition characterized by lower than normal peak bone density, and this was significantly higher compared to participants not on medication.

Dr. Rivera added that a definite link has not been established between osteopenia in childhood and osteoporosis later in life, which increases the risk of brittle and porous bones, and ultimately, fracture risk. However, low-bone density in children theoretically could have long-term implications and lead to poor bone health in adulthood because childhood and adolescence is when growing bones accrue mass and strength.

Medications used by patients in the study were: methylphenidate (Ritalin), dexmethylphenidate (Focalin), dextroamphetamine (Dexedrine), atomoxetine (Strattera) and lisdexamfetamine (Vyvanse). These medications can cause gastrointestinal problems such as decreased appetite and stomach upset, which may result in poor nutrition and reduced calcium intake. The drugs also may diminish bone density because they alter the sympathetic nervous system, which plays an important role in bone remodeling, or regeneration.

Dr. Rivera said that because most skeletal growth occurs by ages 18-20, physicians should realize the potential threat that ADHD medications pose to maturing bones and consider nutritional counseling and other preventative measures.
In addition, “Parents of patients taking ADHD medications should be informed of potential bone loss, especially if the findings of this study are validated in prospective studies.” said Dr. Rivera.

The study’s statistical model ruled out other potential causes of low bone density including age, sex, race/ethnicity and poverty levels. The study did not take into account information on medication dose, duration of use, or changes in therapy because of the limitations of the NHANES survey data.

This study recently appeared in the online edition of the Journal of Pediatric Orthopaedics.

Quoted from aaos.org

ROSEMONT, Ill. (Feb. 1, 2016)—According to a new literature review in the February issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), a team-based care approach (consisting of the patient, family members, the orthopaedic surgeon and other medical practitioners) on total knee replacement (TKR) procedures, in conjunction with newer pain management strategies, is key to maximizing patient outcomes.

Arthritis of the knee impacts approximately 50 percent of Americans over the age of 60. “TKR is a highly successful procedure used to treat symptomatic knee arthritis that’s not responsive to nonsurgical treatments like injections, weight loss, physical therapy and non-narcotic medications,” says lead study author and orthopaedic surgeon Calin S. Moucha, MD, chief of adult reconstruction and joint replacement surgery at The Mount Sinai Hospital in New York City.

“Managing post-surgical pain is key to promoting early postoperative mobility, reducing medication side effects, and increasing patient satisfaction,” says Dr. Moucha.

Traditional pain management for TKRs include a computerized pump called the patient-controlled analgesia (PCA) with or without an epidural which can lead to nausea, vomiting, urinary retention, low blood pressure, constipation and itching. Newer pain-control strategies—referred to as multimodal protocols—more effectively manage pain and limit side effects. These include:

• a combination of pain management medications (e.g., oral medications and nerve blocks) taken before and after surgery;
• regional anesthesia with pre-operative nerve blocks performed by an anesthesiologist; and,
• intra-operative pain injections performed by the orthopaedic surgeon within the knee.

Multimodal protocols are found to:

• lower patient pain severity ratings in the first few days following surgery;
• minimize unwanted side effects more commonly associated with traditional pain control protocols;
• reduce the overall amount of narcotic pain medication needed for postoperative pain control; and,
• help patients be better able to participate in early postoperative physical therapy and be more satisfied with their postoperative pain control.

The study authors also note that:

• patients should avoid long-term chronic narcotic use for knee arthritis pain control prior to surgery because it can lower the patient’s pain threshold and result in increased postoperative pain;
• patients should not abruptly stop oral medications as there is a risk of rebound pain and the development of chronic pain. Many patients will use their prescribed medicines for least the first two weeks after surgery, then taper off as tolerated;
• pain medication may be necessary beyond the first two weeks for certain activities such as physical therapy sessions, but first speak to your orthopaedic surgeon about this; and,
• a strong support system (family, friends, or a combination of both) can be very helpful to the patient in achieving the quickest recovery and return home.

Quoted from aaos.org

ROSEMONT, Ill. – The American Academy of Orthopaedic Surgeons (AAOS) today introduced a new clinical practice guideline (CPG) for adults undergoing surgery to improve motion and relieve pain caused by osteoarthritis of the knee. The guidelines focus on the surgical procedure most commonly performed for this condition, total knee replacement (TKR).

“Total knee replacement is a safe and effective technique that benefits patients immensely. Many of the guidelines in the CPG are strongly recommended because the literature and other evidence of good outcomes was very compelling,” said David Jevsevar, MD, MBA, chair of the AAOS Committee on Evidence-Based Quality and Value.

Better known as “wear-and-tear” arthritis, osteoarthritis of the knee happens when cartilage in the knee joint breaks down from repeated use, hereditary factors, or related diseases. Bone-on-bone contact creates symptoms that can include pain, swelling, and stiffness in the knee, and decreased ability to walk or rise from a sitting position.

In cases where surgery is warranted, the CPG is the first evidence-based guideline for diagnosis, treatment, rehabilitation and safety for patients. The guidelines are timely because TKR is the No. 1 procedure, in terms of costs, reimbursed by the Centers for Medicare and Medicaid Services (CMS). Effective April 2016, CMS will issue bundled payment for TKR in designated geographic markets—one fixed cost reimbursement for everything from initial consult through recovery. Health care institutions can use the new guideline to assist in planning the highest quality care to comply with the new rules, according to Dr. Jevsevar.

The CPG, “Surgical Management of Osteoarthritis of the Knee,” provides guidelines for physicians and patients to consider when making decisions about knee replacement. The AAOS recognizes that a patient’s lifestyle and expectations, along with physician experience, also heavily influence treatment decisions. Among the key CPG recommendations in the report that received a “strong” rating are:

• Reduction of risk factors such as weight and smoking
• Administration of multi-modal anesthesia, including local anesthetic and nerve blockade around the knee joint to decrease pain and opioid use following TKR
• Treatment with tranexamic acid to decrease postoperative blood loss and transfusions following TKR
• Starting rehabilitation the same day TKR is performed to reduce length of hospital stay.

Quoted from aaos.org

New guidelines also aim to prevent repeat fractures

ROSEMONT, Ill. – The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors recently approvedAppropriate Use Criteria (AUC) for treatment and rehabilitation of elderly patients with hip fractures, in addition to postoperative direction to help prevent fractures from recurring.

A common fracture in older adults, hip fractures often occur due to falls or slips because bones are fragile.

“Hip fractures are one of the most feared injuries in older adults because this trauma creates pain and can force a change in lifestyle or limited mobility. We are providing evidence-based assistance for physicians and patients to determine the best course of action for surgery and follow-up care,” said Robert Quinn, MD, AUC Section Leader for the AAOS Committee on Evidence-Based Quality and Value.

Pinning bones back together using surgical screws versus reconstructing the hip joint through total hip replacement (THR) surgery has long been debated. The AUC criteria rely on peer-reviewed studies and practices to recommend different procedures depending on a patient’s individual indications such as activity levels, bone and joint health, location(s) of the fracture, and whether the break is stable or displaced. The AUC addresses patients age 60 and above with fractures caused by low-impact events.

The AUC panel included physicians and physical therapists from leading academic medical centers, in addition to orthopaedic and other professional medical societies, who reviewed 30 potential patient scenarios to create the“Appropriate Use Criteria for the Treatment of Hip Fractures in the Elderly.” Each treatment in each patient scenario is rated “appropriate,” “may be appropriate,” and “rarely appropriate.”

For example, THR is rated “appropriate” for a highly active patient with a non-displaced fracture in the neck of the femur bone. However, the same procedure is “rarely appropriate” for a non-ambulatory patient.

Another example rates reattaching bone with a specific type of screw (sliding hip anti-rotation screws) as “appropriate” for highly active patients with and without arthritis who have a stable fracture of the intertrochanteric crest, located near the top of the femur.

Dr. Quinn added that in some cases, the AUC review panel did not reach consensus on a single best course of action due to surgeons’ preferences and multiple correct treatments for surgery.

Accompanying the AUC, the AAOS created a “Preoperative Checklist” to assist surgeons and allied medical providers in delivering quality care to patients by completing 12 important initiatives. They include limiting preoperative traction; managing Warfarin, a blood-thinning medication; and discussing the patient’s home environment prior to discharge.

Hip fracture recovery guidelines
The second AUC, “Appropriate Use Criteria for Postoperative Rehabilitation for Low Energy Hip Fractures in the Elderly,” provides universal recommendations for recovery across elderly patient populations including:

• Interdisciplinary care to prevent deep vein thrombosis
• Prevention or management of postoperative delirium
• Multi-modal perioperative pain management
• Interdisciplinary management of recovery at rehabilitation and skilled-nursing facilities
• Home care therapy following discharge
• Osteoporosis assessment and management.

Supplementing the AUC, a “Perioperative Prevention of Future Fractures Checklist,” emphasizes important follow-up measures to reduce patients’ risk for future injuries. Participation in a fall prevention program, and supplements and medications to improve bone density are among the recommendations.

“It is very important to think ahead to make the right care choices after a fracture is repaired. Not only can this help patients recover, but this also helps prevent fractures from happening again, which is a big problem,” Dr. Quinn said.

Quoted from aaos.org