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Current Evidence for Acute Pain Management of Musculoskeletal Injuries and Postoperative Pain in Pediatric and Adolescent Athletes. Clin J Sport Med 2019; 29:430-438. [PMID: 31460958 DOI: 10.1097/jsm.0000000000000690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Sports-related injuries in young athletes are increasingly prevalent with an estimated 2.6 million children and adolescents sustaining a sports-related injury annually. Acute sports-related injuries and surgical correction of sports-related injuries cause physical pain and psychological burdens on pediatric athletes and their families. This article aims to evaluate current acute pain management options in pediatric athletes and acute pain management strategies for postoperative pain after sports-related injuries. This article will also elucidate which areas of pain management for pediatric athletes are lacking evidence and help direct future clinical trials. DATA SOURCES We conducted a literature search through PubMed and the Cochrane Central Register of Controlled Trials to provide an extensive review of initial and postoperative pain management strategies for pediatric sports-related musculoskeletal injuries. MAIN RESULTS The current knowledge of acute pain management for initial sports-related injuries, postoperative pain management for orthopedic surgeries, as well as complementary and alternative medical therapies in pediatric sports-related injuries is presented. Studies evaluating conservative management, enteral and nonenteral medications, regional anesthesia, and complementary medical therapies are included. CONCLUSIONS Adequate pain management is important for sports injuries in children and adolescents for emotional as well as physical healing, but a balance must be achieved to provide acceptable pain relief while minimizing opioid use and side effects from analgesic medications. More studies are needed to evaluate the efficacy of nonopioid analgesic medications and complementary therapies in pediatric patients with acute sports-related injuries.
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van den Bosch CM, Cronjé L, de Vasconcellos K, Skinner D. Paediatric postoperative analgesia prescribing report card: “could do better”. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2019. [DOI: 10.36303/sajaa.2019.25.4.2257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: A key element of paediatric pain management is prescribing and dispensing analgesia. This process differs in children, putting them at greater risk of drug error.
Methods: This study was a retrospective postoperative analgesia prescription chart review of children who had orthopaedic surgery in a tertiary hospital in Durban, South Africa. Patient records of 202 children, aged 6 months to 12 years, with 232 theatre visits were reviewed. Prescription charts were inspected for patient characteristics, evidence of good prescribing practice and data regarding the prescribing and administration of analgesia.
Results: Of the 257 analysed charts 254 (99%) had paracetamol, 208 (81%) had an opioid and 49 (19%) had a nonsteroidal antiinflammatory drug (NSAID) prescribed. Underdosing was evident in all groups of analgesics prescribed. Opioids were more often prescribed with a pro-re-nata caveat and were the least correctly dispensed. There were no prescription charts in which all the requirements for good prescribing practice were complete.
Conclusions: This study demonstrates a high rate of paediatric drug error in both the prescribing and dispensing of analgesia. Potential under-utilisation of NSAIDs in this orthopaedic population is also noted. Lack of knowledge or confidence needed by clinicians to adhere to principles of paediatric dosing and multimodal analgesia may be contributing factors. Issues pertaining to paediatric analgesia prescribing and dispensing are highlighted and should be targeted by institution and population specific interventions.
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Sherwin A, Pollard V, Bolger C, Moore M. Adjuvant analgesics in spinal surgery. Br J Hosp Med (Lond) 2019; 78:712-715. [PMID: 29240497 DOI: 10.12968/hmed.2017.78.12.712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Peri- and postoperative pain control can present a challenge to any doctor, particularly in the setting of spinal surgery. The use of adjuvant pain agents and multimodal analgesia is changing the face of modern anaesthesia and offering clinicians more avenues to control perioperative pain. This article discusses the use of adjuvant medications and some of the evidence surrounding their use in spinal surgery.
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Affiliation(s)
- Aislinn Sherwin
- Specialist Registrar, Department of Anaesthesia, Critical Care and Pain Medicine, Beaumont Hospital, Dublin 9, Ireland
| | - Valerie Pollard
- Consultant Anaesthetist, Department of Anaesthesia, Critical Care and Pain Medicine, Beaumont Hospital, Dublin 9, Ireland
| | - Ciaran Bolger
- Consultant Neurosurgeon, Department of Neurosurgery, Beaumont Hospital, Dublin 9, Ireland
| | - Michael Moore
- Consultant Anaesthetist, Department of Anaesthesia, Critical Care and Pain Medicine, Beaumont Hospital, Dublin 9, Ireland
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Wright JA. An update of systemic analgesics in children. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2019. [DOI: 10.1016/j.mpaic.2019.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Multiple factors impact fracture healing; thus, endocrine optimization and nutritional optimization warrant investigation in the acute fracture and nonunion patient. This article presents current evidence regarding the role of the endocrinologists and the dietician in the fracture patient as well as the most recent data assessing the vitamin D axis in these populations. Similarly, the most recent information regarding the use and risks of NSAIDs in fracture healing are presented. The fracture surgeon must consider each individual patient and weigh the benefits versus the costs of host optimization.
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery. Anesth Analg 2019; 128:1107-1117. [PMID: 31094775 DOI: 10.1213/ane.0000000000003925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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Affiliation(s)
- Ellen M Soffin
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Samantha S Ko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher L Wu
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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Predictors of mechanical complications after intramedullary nailing of tibial fractures. Orthop Traumatol Surg Res 2019; 105:523-527. [PMID: 30954391 DOI: 10.1016/j.otsr.2019.01.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 10/27/2018] [Accepted: 01/14/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary (IM) nailing is the gold standard treatment for tibial shaft fractures, but can be associated with various mechanical complications, including delayed union. HYPOTHESIS We believe that complications do not occur randomly, but in certain conditions that contribute to their development. Risk factors likely to predict delayed union can be identified to support prevention. MATERIALS AND METHODS A cohort of 171 fractures treated by IM nailing between 2005 and 2015 was reviewed retrospectively. Independent variables included intrinsic, patient-related factors and extrinsic factors such as those related to the fracture or surgery. A multiple logistic regression model was used to determine which factors can predict each type of complication. RESULTS Delayed union occurred in 22.8% of patients. Smoking and high-energy trauma were risk factors. Hardware breakage was significantly reduced (p<0.05) when the nail diameter was greater than 10mm. A nail diameter/reamer diameter ratio outside the recommended limits (0.80-0.99) was more likely to be associated with screw failure. Diabetes is a risk factor for hardware migration, which itself is associated with other complications. DISCUSSION Nonunion is the most common complication after IM nailing of tibial shaft fractures. Smoking cessation after a fracture is necessary in our opinion, even if the literature is ambivalent on this aspect and stopping to smoke once the fracture occurs may not be sufficient to prevent a poor outcome. Use of a nail diameter/reamer diameter between 0.80 and 0.99 favors union and prevents hardware breakage. Hardware migration in a diabetic patient may be a warning sign of other types of complications. LEVEL OF EVIDENCE Retrospective cohort study. Level IV.
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Abstract
PURPOSE We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. METHODS A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018. RESULTS We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy. CONCLUSIONS Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.
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Abstract
INTRODUCTION NSAIDs inhibit osteogenesis and may result in delayed union or nonunion. The purpose of this meta-analysis was to determine whether their use leads to delayed union or nonunion. METHODS We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included studies of pediatric and adult patients NSAID exposure and healing bone. The outcomes of interest were delayed union, nonunion, or pseudarthrosis with at least six months of follow-up. A maximum likelihood random-effects model was used to conduct meta-analysis and meta-regression. RESULTS NSAID exposure increased delayed union or nonunion (odds ratio [OR], 2.07; confidence interval [CI], 1.19 to 3.61). No effect was noted in pediatrics (OR, 0.58; CI, 0.27 to 1.21) or low dose/short duration of exposure (OR, 1.68; CI, 0.63 to 4.46). CONCLUSION Analysis of the literature indicates a negative effect of NSAIDs on bone healing. In pediatric patients, NSAIDs did not have a significant effect. The effect may be dose or time dependent because low-dose/short-duration exposure did not affect union rates.
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Perioperative Protocol for Elective Spine Surgery Is Associated With Reduced Length of Stay and Complications. J Am Acad Orthop Surg 2019; 27:183-189. [PMID: 30192251 DOI: 10.5435/jaaos-d-17-00274] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Healthcare reform places emphasis on maximizing the value of care. METHODS A prospective registry was used to analyze outcomes before (1,596 patients) and after (151 patients) implementation of standardized, evidence-based order sets for six high-impact dimensions of perioperative care for all patients who underwent elective surgery for degenerative spine disease after July 1, 2015. RESULTS Apart from symptom duration, chronic obstructive pulmonary disease prevalence, estimated blood loss, and baseline Oswestry Disability Index, no significant differences existed between pre- and post-protocol cohorts. No differences in readmissions, discharge status, or 3-month patient-reported outcomes were seen. Multivariate regression analyses demonstrated reduced length of stay (P = 0.013) and odds of 90-day complications (P = 0.009) for postprotocol patients. CONCLUSION Length of stay and 90-day complications for elective spine surgery improved after implementation of an evidence-based perioperative protocol. Standardization efforts can improve quality and reduce costs, thereby improving the value of spine care. LEVEL OF EVIDENCE Level III (retrospective review of prospectively collected data).
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Zhou Y, Wu S, Zhou H, Huang H, Zhao J, Deng Y, Wang H, Yang Y, Yang J, Luo L. Chiral pharmaceuticals: Environment sources, potential human health impacts, remediation technologies and future perspective. ENVIRONMENT INTERNATIONAL 2018; 121:523-537. [PMID: 30292145 DOI: 10.1016/j.envint.2018.09.041] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 09/20/2018] [Accepted: 09/23/2018] [Indexed: 05/06/2023]
Abstract
Chiral pharmaceuticals (CPs), including non-steroid anti-inflammatory drugs (NSAIDs), β-blockers and some herbicide and pesticides, are widely used in aquaculture, clinical treatment and many other fields. However, people are increasingly concerned about such ubiquitous pollutants, which can frequently be detected in contaminated soil and water. In large part, the significant sources of chiral pharmaceuticals stem from industrial processes, such as the direct discharge of untreated or incompletely treated wastewaters containing chiral pharmaceuticals, incorrect storage and use, animal wastes and biosolids. The main ways for human exposure to chiral pharmaceuticals are the disease treatment process and chiral pharmaceuticals contaminants. According to the results of a series of toxic studies, some diseases, even cancers, may be associated with exposure to certain chiral pharmaceuticals. Therefore, the treatment of chiral pharmaceuticals has become an important issue. The current advanced remediation techniques for chiral pharmaceuticals include the conventional method (sorption and sonolysis), biotransformation (an aerobic granular sludge-sequencing batch reactor and constructed wetland system) and advanced oxidation processes (ozonation and photocatalysis). Herein, in this review, we summarize the current status and sources of chiral pharmaceuticals, potential effects on human health, as well as the superiority, disadvantages and prospects of current advanced remediation technologies. Moreover, we also anticipate the prospect of the future research needed for chiral pharmaceuticals pollutant remediation.
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Affiliation(s)
- Yaoyu Zhou
- College of Resources and Environment, Hunan Agricultural University, Changsha 410128, China; Hunan International Scientific and Technological Cooperation Base of Agricultural Typical Pollution Remediation and Wetland Protection, Hunan Agricultural University, Changsha 410028, China.
| | - Shikang Wu
- College of Resources and Environment, Hunan Agricultural University, Changsha 410128, China; Hunan International Scientific and Technological Cooperation Base of Agricultural Typical Pollution Remediation and Wetland Protection, Hunan Agricultural University, Changsha 410028, China
| | - Hao Zhou
- State Key Laboratory of Organic Geochemistry, Guangzhou Institute of Geochemistry, Chinese Academy of Sciences, Guangzhou 510640, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Hongli Huang
- College of Resources and Environment, Hunan Agricultural University, Changsha 410128, China
| | - Jia Zhao
- College of Resources and Environment, Hunan Agricultural University, Changsha 410128, China
| | - Yaocheng Deng
- College of Resources and Environment, Hunan Agricultural University, Changsha 410128, China.
| | - Hua Wang
- College of Bioscience and Biotechnology, Hunan Agricultural University, Changsha 410128, China
| | - Yuan Yang
- College of Resources and Environment, Hunan Agricultural University, Changsha 410128, China
| | - Jian Yang
- College of Resources and Environment, Hunan Agricultural University, Changsha 410128, China
| | - Lin Luo
- College of Resources and Environment, Hunan Agricultural University, Changsha 410128, China
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Prediction of tibial nonunion at the 6-week time point. Injury 2018; 49:2075-2082. [PMID: 30172349 DOI: 10.1016/j.injury.2018.07.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 07/03/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary (IM) nail fixation is a common operative treatment, yet concerns regarding the frequency of complications, such as nonunion, remain. Treatment of tibial shaft fractures remains a challenge, and little evidence of prognostic factors that increase risk of nonunion is available. The aim of this study was to develop a predictive model of tibial shaft fracture nonunion 6 weeks after reamed intramedullary (IM) nail fixation based on commonly collected clinical variables and the radiographic union score for tibial fractures (RUST). METHODS A retrospective case-control study was conducted. All tibial shaft fractures treated at our level I trauma center from 2007 to 2014 were retrospectively reviewed. Only patients with follow-up until fracture healing or secondary operation for nonunion were included. Fracture gaps ≥3 mm were excluded. A total of 323 patients were included for study. RESULTS Infection within 6 weeks of operation, standard RUST, and the Nonunion Risk Determination (NURD) score had statistically significant associations with nonunion (odds ratio > or < 1.0; p < 0.01). The NURD score was increasingly predictive of nonunion with decreasing RUST. All patients in the high RUST group (RUST ≥ 10), achieved union regardless of NURD score. In the medium RUST group (RUST 6-9), 25% of patients with a NURD score ≥7 experienced nonunion. In the low RUST group (RUST <6 or infection within 6 weeks), 69% of patients with a NURD score ≥7 experienced nonunion. CONCLUSION Three variables predicted nonunion. Based on these variables, we created a clinical prediction tool of nonunion that could aid in clinical decision making and discussing prognosis with patients.
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Chu JY, Yeh KT, Lee RP, Yu TC, Chen IH, Peng CH, Liu KL, Wang JH, Wu WT. Open reduction and internal fixation with plating is beneficial in the early recovery stage for displaced midshaft clavicular fractures in patients aged 30-65 years old. Tzu Chi Med J 2018; 30:242-246. [PMID: 30305789 PMCID: PMC6172902 DOI: 10.4103/tcmj.tcmj_25_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objectives: Midshaft clavicular fractures are increasingly treated operatively rather than nonoperatively. Studies have shown mixed results for both types of treatment. The aim of this study was to compare the early-stage functional status associated with open reduction and internal fixation (ORIF) with plating and that associated with conservative treatment for displaced midshaft clavicular fractures. Materials and Methods: A single-center retrospective review of the results of 120 cases of displaced midshaft clavicular fractures in patients aged 30–65 years old was conducted. The primary outcome was fracture union status at 6 months. Other outcomes were subjective shoulder value (SSV) scores, visual analog scale (VAS) scores, and radiographic shortening at 6 weeks, 3 months, and 6 months. The complication rates in the operative and nonoperative groups were recorded. Results: The delayed union rate at 6-month postoperatively and VAS scores at 6 weeks, 3 months, and 6 months postinjury were significantly higher in the conservative treatment group than in the ORIF group. SSV scores were significantly improved at 6-month postinjury in the ORIF group. Conclusions: This is the first study to discuss the importance of early-stage functional restoration after ORIF with plating for displaced midshaft clavicular fractures. This surgery leads to lower pain complications in the earlier stages of bone healing and lower delayed union rates compared with conservative treatment, in patients aged 30–65 years old.
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Affiliation(s)
- Jian-Yuan Chu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Kuang-Ting Yeh
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ru-Ping Lee
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| | - Tzai-Chiu Yu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ing-Ho Chen
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Cheng-Huan Peng
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Kuan-Lin Liu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jen-Hung Wang
- Department of Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Wen-Tien Wu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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Ramirez‐Garcia‐Luna JL, Wong TH, Chan D, Al‐Saran Y, Awlia A, Abou‐Rjeili M, Ouellet S, Akoury E, Lemarié CA, Henderson JE, Martineau PA. Defective bone repair in diclofenac treated C57Bl6 mice with and without lipopolysaccharide induced systemic inflammation. J Cell Physiol 2018; 234:3078-3087. [DOI: 10.1002/jcp.27128] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/09/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Jose L. Ramirez‐Garcia‐Luna
- Bone Engineering LabsInjury, Repair & Recovery Program, Research Institute‐McGill University Health CentreMontreal Québec Canada
- Experimental SurgeryFaculty of Medicine, McGill UniversityMontreal Québec Canada
| | - Timothy H. Wong
- Bone Engineering LabsInjury, Repair & Recovery Program, Research Institute‐McGill University Health CentreMontreal Québec Canada
- Biotechnology Program, University of British ColumbiaVancouver British Columbia Canada
| | - Daniel Chan
- Bone Engineering LabsInjury, Repair & Recovery Program, Research Institute‐McGill University Health CentreMontreal Québec Canada
- Biotechnology Program, University of British ColumbiaVancouver British Columbia Canada
| | - Yazeed Al‐Saran
- Bone Engineering LabsInjury, Repair & Recovery Program, Research Institute‐McGill University Health CentreMontreal Québec Canada
- Experimental SurgeryFaculty of Medicine, McGill UniversityMontreal Québec Canada
| | - Ayman Awlia
- Bone Engineering LabsInjury, Repair & Recovery Program, Research Institute‐McGill University Health CentreMontreal Québec Canada
- Experimental SurgeryFaculty of Medicine, McGill UniversityMontreal Québec Canada
| | - Mira Abou‐Rjeili
- Bone Engineering LabsInjury, Repair & Recovery Program, Research Institute‐McGill University Health CentreMontreal Québec Canada
- Experimental MedicineFaculty of MedicineMcGill UniversityMontreal Québec Canada
| | - Suzie Ouellet
- Bone Engineering LabsInjury, Repair & Recovery Program, Research Institute‐McGill University Health CentreMontreal Québec Canada
| | - Elie Akoury
- Experimental SurgeryFaculty of Medicine, McGill UniversityMontreal Québec Canada
| | - Catherine A. Lemarié
- Experimental MedicineFaculty of MedicineMcGill UniversityMontreal Québec Canada
- The Lady Davis Institute for Medical Research, McGill UniversityMontreal Québec Canada
| | - Janet E. Henderson
- Bone Engineering LabsInjury, Repair & Recovery Program, Research Institute‐McGill University Health CentreMontreal Québec Canada
- Experimental SurgeryFaculty of Medicine, McGill UniversityMontreal Québec Canada
| | - Paul A. Martineau
- Bone Engineering LabsInjury, Repair & Recovery Program, Research Institute‐McGill University Health CentreMontreal Québec Canada
- Experimental SurgeryFaculty of Medicine, McGill UniversityMontreal Québec Canada
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Nolte MT, Elboghdady IM, Iyer S. Anesthesia and postoperative pain control following spine surgery. ACTA ACUST UNITED AC 2018. [DOI: 10.1053/j.semss.2018.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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66
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How Will the Foot and Ankle Orthopedic Community Respond to the Growing Opioid Epidemic? FOOT & ANKLE ORTHOPAEDICS 2018. [DOI: 10.1177/2473011418764463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In the midst of the current opioid crisis, it has become critically important to properly manage opioid-prescribing patterns for the treatment of postoperative pain. There is currently a scarcity of literature specifying prescription and consumption patterns following orthopedic surgery and specifically foot and ankle surgery. Clinical guidelines for postoperative pain management are deficient.
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Guo C, Lei M, Wang Y, Hua L, Xue S, Yu D, Zhang C, Wang D. Oral Administration of Probiotic Lactobacillus Casei Shirota Decreases Pneumonia and Increases Pulmonary Functions after Single Rib Fracture: A Randomized Double-Blind, Placebo-Controlled Clinical Trial. J Food Sci 2018; 83:2222-2226. [PMID: 30020533 DOI: 10.1111/1750-3841.14220] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/04/2018] [Accepted: 05/18/2018] [Indexed: 12/13/2022]
Abstract
Considerate proportion of elderly patients with a rib fracture is susceptible to pulmonary complications, especially pneumonia. We aimed to assess the effect of oral administration of the probiotic Lactobacillus casei Shirota (LcS) on pneumonia and pulmonary functions among elderly patients with single rib fracture. The current study including 204 eligible elderly patients with a single rib fracture was conducted. Patients were randomly assigned to receive oral administration of skimmed milk containing either a commercial probiotic LcS or placebo daily for 1 mo after the fracture, followed by pneumonia assessments, pulmonary function testing including forced expiratory volume (FEV), negative inspiratory pressure (NIP), and forced vital capacity (FVC), as well as evaluation of potential adverse effects including myocardial infarction, acute kidney injury, nonunion of fractured bone, or stroke. After 1 mo consumption, patients in the LcS group exhibited decreased pneumonia and increased recovery of pulmonary functions, in terms of FEV, FVC, and NIP, compared to the placebo group. No difference was observed in incidence of adverse events between the 2 groups. In patients with a single rib fracture, oral administration of the probiotic LcS was associated with a lower incidence of pneumonia and increased pulmonary functions without causing severe adverse effects. PRACTICAL APPLICATION To conclude, after 1-mo LcS consumption, in patients with a single rib fracture, oral administration of the probiotic LcS was associated with a lower incidence of pneumonia and increased pulmonary functions without causing severe adverse effects.
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Affiliation(s)
- Chunhua Guo
- Dept. of Orthopedics, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Min Lei
- Dept. of Nutrition and Diet, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Yong Wang
- Dept. of Orthopedics, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Limei Hua
- Dept. of Nutrition, Bethune Int. Heping Hospital, No. 398, Zhong Shan West Road, Shijiazhuang, 050082, Hebei Province, China
| | - Sujuan Xue
- Dept. of Nutrition and Diet, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Dan Yu
- Dept. of Nutrition and Diet, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Chunhua Zhang
- Dept. of Emergency Medicine, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Dawei Wang
- Dept. of Oral and Maxillofacial Surgery, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
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Should Nonsteroidal Anti-inflammatory Drugs be Contraindicated in the Perioperative Period After Spinal Fusion Surgery? Clin Spine Surg 2018; 31:223-224. [PMID: 29757754 DOI: 10.1097/bsd.0000000000000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Buchheit T, Zura R, Wang Z, Mehta S, Della Rocca GJ, Steen RG. Opioid exposure is associated with nonunion risk in a traumatically injured population: An inception cohort study. Injury 2018; 49:1266-1271. [PMID: 29801700 DOI: 10.1016/j.injury.2018.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 03/21/2018] [Accepted: 05/02/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Certain common medications are associated with an elevated risk of fracture and recent data suggests that medications can also increase nonunion risk. Medication use is a modifiable nonunion risk factor, but it is unknown whether risk accrues solely to chronic medication use or whether there is also risk inherent to acute use. METHODS Multivariate logistic regression was used in an inception cohort to calculate odds ratios (OR) for fracture nonunion associated with medication use, in context with other risk factors demonstrated to influence nonunion. Patient-level health claims for medical and drug expenses were compiled from a payer database. Patients were included if they had a fracture coded in 2011, with continuous enrollment for 1 month prior to and 12 months after fracture. The database contained demographic descriptors, treatment procedures per CPT codes, co-morbidities per ICD-9 codes, and prescriptions per National Drug Codes. Chronic medication use was defined as ≥30 days of prescription prior to fracture with ≥1 day afterward; acute use was any other prescription. RESULTS Most non-analgesic medications were safe in acute or chronic use, but risk of nonunion was elevated for a wide range of analgesics. Overall, 45,085 fractures (14.6% of fractures) affected patients using chronic opioids. Nonunion OR was elevated for acute and chronic use of Schedule 2 opioids including acetaminophen/oxycodone, hydromorphone, oxycodone, and acetaminophen/hydrocodone bitartrate, as well as Schedule 3-5 opioids including tramadol (all, p < 0.0001). The highest ORs were associated with chronic administration of Schedule 2 opioids. DISCUSSION Most medications do not increase nonunion risk, but acute and chronic use of NSAIDs or opioids was associated with impaired fracture healing. There is particular risk in prescribing opioid analgesics for fracture, though literature suggests that roughly half of opioid-naïve patients receive such a prescription. CONCLUSIONS Patients evaluated in this study were not a random sample of Americans; they may approximate a random sample of the Emergency Department population in the United States. Thus, trauma patients may represent a population enriched for nonunion risk factors. Opioids impair recovery from injury; if they also predispose to injury, the ongoing opioid epidemic could presage an increase in nonunion prevalence.
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Affiliation(s)
- Thomas Buchheit
- Dept. of Anesthesiology, Duke University Medical Center, Durham, NC, United States.
| | - Robert Zura
- Dept. of Orthopaedic Surgery, Louisiana State University Medical Center, New Orleans, LA, United States.
| | - Zhe Wang
- Dept. of Statistics, North Carolina State University, Raleigh, NC, United States.
| | - Samir Mehta
- Dept. of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States.
| | - Gregory J Della Rocca
- Dept. of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, United States.
| | - R Grant Steen
- Dept. of Orthopaedic Surgery, Louisiana State University Medical Center, New Orleans, LA, United States.
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NAT2 ultra-slow acetylator and risk of anti-tuberculosis drug-induced liver injury. Pharmacogenet Genomics 2018; 28:167-176. [DOI: 10.1097/fpc.0000000000000339] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Borgeat A, Ofner C, Saporito A, Farshad M, Aguirre J. The effect of nonsteroidal anti-inflammatory drugs on bone healing in humans: A qualitative, systematic review. J Clin Anesth 2018; 49:92-100. [PMID: 29913395 DOI: 10.1016/j.jclinane.2018.06.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/29/2018] [Accepted: 06/08/2018] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in postoperative pain management. While an increasing number of in vitro and animal studies point toward an inhibitory effect of NSAIDs on bone healing process, the few existing retro- and prospective clinical studies present conflicting data. DESIGN The aim of this qualitative, systematic review was to investigate the impact of perioperative use of NSAIDs in humans on postoperative fracture/spinal fusion healing compared to other used analgesics measured as fracture nonunion with radiological control. PATIENTS/INTERVENTIONS We performed a systematic literature search of the last 38 years using PubMed Embase and the Cochrane Controlled Trials Register including retro- and prospective clinical, human trials assessing the effect of NSAIDs on postoperative fracture/spinal fusion healing when used for perioperative pain management with a radiological follow up to assess eventual nonunion. Due to different study designs, drugs, dosages/exposition times and different methods to assess fracture nonunion, these studies were not pooled for a meta-analysis. A descriptive summary of all studies, level of evidence, study quality and study bias assessment using different scores were used. MAIN RESULTS Three prospective randomized controlled studies and thirteen retrospective cohort human studies were identified for a total of 12'895 patients. The overall study quality was low according to Jadad and Oxford Levels of Evidence scores. CONCLUSIONS Published results of human trials did not show strong evidence that NDAIDs for pain therapy after fracture osteosynthesis or spinal fusion lead to an increased nonunion rate. Reviewed studies present such conflicting data, that no clinical recommendation can be made regarding the appropriate use of NSAIDs in this context. Considering laboratory data of animal, human tissue research and recommendation of clinical reviews, a short perioperative exposition to NSAIDs is most likely not deleterious. However, randomized, controlled studies are warranted to support or refute this hypothesis.
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Affiliation(s)
- Alain Borgeat
- Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland.
| | - Christian Ofner
- Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Andrea Saporito
- Service of Anaesthesiology, Bellinzona Regional Hospital, Bellinzona, Switzerland
| | - Mazda Farshad
- Spine Surgery, Balgrist University Hospital Zurich, Switzerland
| | - José Aguirre
- Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
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Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE The purpose of this study was to evaluate the effect of postoperative ketorolac administration (ie, dosage and duration of use) on pseudarthrosis following thoracolumbar posterolateral spinal fusions. SUMMARY OF BACKGROUND DATA Ketorolac is a nonsteroidal anti-inflammatory drug often administered for pain control after spine surgery. The main concern with ketorolac is the risk of pseudarthrosis following fusion. MATERIALS AND METHODS A systematic search of multiple medical reference databases was conducted for studies detailing postoperative ketorolac use in lumbar fusion and scoliosis surgery in adult and pediatric patients, respectively. Meta-analysis was performed using the random-effects model for heterogeneity as this study analyzes heterogenous patient populations undergoing variable approaches to fusion and variable numbers of levels with variable means of detection of pseudarthrosis. Outcome measure was pseudarthrosis. RESULTS Overall, 6 studies totaling 1558 patients were reviewed. Pseudarthrosis was observed in 119 (7.6%) patients. Pseudarthrosis were observed in adults with ketorolac administered for >2 days [odds ratio (OR), 3.44, 95% confidence interval (95% CI), 1.87-6.36; P<0.001], adults with doses of ≥120 mg/d (OR, 2.93, 95% CI, 1.06-8.12; P=0.039), and adults with ketorolac administered for >2 days and at doses ≥120 mg/d (OR, 4.75, 95% CI, 2.34-9.62; P<0.001). Ketorolac use in smokers was associated with pseudarthrosis (OR, 8.71, 95% CI, 2.23-34.0; P=0.002). CONCLUSION Ketorolac, when administered for >2 days and/or at a dose of ≥120 mg/d, is associated with pseudarthrosis in adults after posterolateral lumbar fusion. Ketorolac use in smokers is also associated with pseudarthrosis.
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Marquez-Lara A, Hutchinson ID, Nuñez F, Smith TL, Miller AN. Nonsteroidal Anti-Inflammatory Drugs and Bone-Healing: A Systematic Review of Research Quality. JBJS Rev 2018; 4:01874474-201603000-00004. [PMID: 27500434 DOI: 10.2106/jbjs.rvw.o.00055] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are often avoided by orthopaedic surgeons because of their possible influence on bone-healing. This belief stems from multiple studies, in particular animal studies, that show delayed bone-healing or nonunions associated with NSAID exposure. The purpose of this review was to critically analyze the quality of published literature that evaluates the impact of NSAIDs on clinical bone-healing. METHODS A MEDLINE and Embase search was conducted to identify all articles relating to bone and fracture-healing and the utilization of NSAIDs. All human studies, including review articles, were identified for further analysis. Non-English-language manuscripts and in vitro and animal studies were excluded. A total of twelve clinical articles and twenty-four literature reviews were selected for analysis. The quality of the clinical studies was assessed with a modified Coleman Methodology Score with emphasis on the NSAID utilization. Review articles were analyzed with regard to variability in the cited literature and final conclusions. RESULTS The mean modified Coleman Methodology Score (and standard deviation) was significantly lower (p = 0.032) in clinical studies that demonstrated a negative effect of NSAIDs on bone-healing (40.0 ± 14.3 points) compared with those that concluded that NSAIDs were safe (58.8 ± 10.3 points). Review articles also demonstrated substantial variability in the number of cited clinical studies and overall conclusions. There were only two meta-analyses and twenty-two narrative reviews. The mean number (and standard deviation) of clinical studies cited was significantly greater (p = 0.008) for reviews that concluded that NSAIDs were safe (8.0 ± 4.8) compared with those that recommended avoiding them (2.1 ± 2.1). Unanimously, all reviews admitted to the need for prospective randomized controlled trials to help clarify the effects of NSAIDs on bone-healing. CONCLUSIONS This systematic literature review highlights the great variability in the interpretation of the literature addressing the impact of NSAIDs on bone-healing. Unfortunately, there is no consensus regarding the safety of NSAIDs following orthopaedic procedures, and future studies should aim for appropriate methodological designs to help to clarify existing discrepancies to improve the quality of care for orthopaedic patients. CLINICAL RELEVANCE This systematic review highlights the limitations in the current understanding of the effects of NSAIDs on bone healing. Thus, withholding these medications does not have any proven scientific benefit to patients and may even cause harm by increasing narcotic requirements in cases in which they could be beneficial for pain management. This review should encourage further basic-science and clinical studies to clarify the risks and benefits of anti-inflammatory medications in the postoperative period, with the aim of improving patient outcomes.
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Affiliation(s)
- Alejandro Marquez-Lara
- 1Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Sauerschnig M, Stolberg-Stolberg J, Schmidt C, Wienerroither V, Plecko M, Schlichting K, Perka C, Dynybil C. Effect of COX-2 inhibition on tendon-to-bone healing and PGE2 concentration after anterior cruciate ligament reconstruction. Eur J Med Res 2018; 23:1. [PMID: 29304843 PMCID: PMC5756348 DOI: 10.1186/s40001-017-0297-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 12/12/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs are commonly used to reduce pain and inflammation in orthopaedic patients. Selective cyclooxygenase-2 (COX-2) inhibitors have been developed to minimize drug-specific side effects. However, they are suspected to impair both bone and tendon healing. The objective of this study is to evaluate the effect of COX-2 inhibitor administration on tendon-to-bone healing and prostaglandin E (PGE2) concentration. METHODS Thirty-two New Zealand white rabbits underwent reconstructions of the anterior cruciate ligaments and were randomized into four groups: Two groups postoperatively received a selective COX-2 inhibitor (Celecoxib) on a daily basis for 3 weeks, the two other groups received no postoperative COX-2 inhibitors at all and were examined after three or 6 weeks. The PGE2 concentration of the synovial fluid, the osseous integration of the tendon graft at tunnel aperture and midtunnel section, as well as the stability of the tendon graft were examined via biomechanic testing. RESULTS After 3 weeks, the PGE2 content of the synovial fluid in the COX-2 inhibitor recipients was significantly lower than that of the control group (p = 0.018). At the same time, the COX-2 inhibitor recipients had a significantly lower bone density and lower amount of new bone formation than the control group (p = 0.020; p = 0.028) in the tunnel aperture. At the 6-week examination, there was a significant increase in the PGE2 content within synovial fluid of the COX-2 inhibitor recipients (p = 0.022), whose treatment with COX-2 inhibitors had ended 3 weeks earlier; in contrast, the transplant stability decreased and was reduced by 37% compared to the controls. CONCLUSIONS Selective COX-2 inhibitors cause impaired tendon-to-bone healing, weaken mechanical stability and decrease PGE2 content of the synovial fluid. The present study suggests a reluctant use of COX-2 inhibitors when tendon-to-bone healing is intended.
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Affiliation(s)
- Martin Sauerschnig
- Center for Musculoskeletal Surgery, University Hospital Charité, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Experimental Trauma Surgery, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany. .,Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany. .,Trauma Hospital Graz, Unfallkrankenhaus der Allgemeinen Unfallversicherungsanstalt (AUVA), Göstinger Straße 24, 8020, Graz, Austria.
| | - Josef Stolberg-Stolberg
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Carmen Schmidt
- Center for Musculoskeletal Surgery, University Hospital Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Valerie Wienerroither
- Department of Experimental Trauma Surgery, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Michael Plecko
- Trauma Hospital Graz, Unfallkrankenhaus der Allgemeinen Unfallversicherungsanstalt (AUVA), Göstinger Straße 24, 8020, Graz, Austria
| | - Karin Schlichting
- Center for Musculoskeletal Surgery, University Hospital Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, University Hospital Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Christian Dynybil
- Center for Musculoskeletal Surgery, University Hospital Charité, Charitéplatz 1, 10117, Berlin, Germany
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Seymour RB, Ring D, Higgins T, Hsu JR. Leading the Way to Solutions to the Opioid Epidemic: AOA Critical Issues. J Bone Joint Surg Am 2017; 99:e113. [PMID: 29088045 DOI: 10.2106/jbjs.17.00066] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the past 2 decades, overdoses and deaths from prescription opioids have reached epidemic proportions in the United States. The widespread use of opioids complicates management of the orthopaedic surgery patient in the acute and chronic settings. Orthopaedic surgeons are some of the top prescribers of opioids in the complex setting of chronic use, abuse, and diversion. METHODS The literature regarding the basic science of pharmacologic options for pain management (e.g., opioids and nonsteroidal anti-inflammatory drugs), the impact of strategies on bone and soft-tissue healing, and pain relief are summarized as they relate to the management of orthopaedic injuries and conditions. Additionally, a section on designing solutions to address the current opioid crisis is presented. RESULTS The mechanism of action of different classes of analgesic medications is discussed, as well as the basic scientific evidence regarding the impact of narcotic and nonnarcotic analgesic medications on bone-healing and on other organ systems. Differences between pain and nociception, various treatment strategies, and clinical comparisons of the effectiveness of various analgesics compared with opioids are summarized. Finally, options for addressing the opioid crisis, including the description of a large system-wide intervention to impact prescriber behavior at the point of care using health-information solutions, are presented. CONCLUSIONS Orthopaedic leaders, armed with information and strategies, can help lead the way to solutions to the opioid epidemic in their respective communities, institutions, and subspecialty societies. Through leadership and education, orthopaedic surgeons can help shape the solution for this critical public health issue.
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Affiliation(s)
- Rachel B Seymour
- 1Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina 2Department of Orthopaedic Surgery, University of Texas at Austin, Austin, Texas 3Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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Risk Factors for Failure of Bone Grafting of Tibia Nonunions and Segmental Bone Defects: A New Preoperative Risk Assessment Score. J Orthop Trauma 2017; 31 Suppl 5:S55-S59. [PMID: 28938394 DOI: 10.1097/bot.0000000000000982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop a clinically useful prediction model of success at the time of surgery to promote bone healing for established tibial nonunion or traumatic bone defects. DESIGN Retrospective case controlled. SETTING Level 1 trauma center. PATIENTS Adult patients treated with surgery for established tibia fracture nonunion or traumatic bone defects from 2007 to 2016. Two hundred three patients met the inclusion criteria and were available for final analysis. INTERVENTION Surgery to promote bone healing of established tibia fracture nonunion or segmental defect with plate and screw construct, intramedullary nail fixation, or multiplanar external fixation. MAIN OUTCOME MEASURES Failure of the surgery to promote bone healing that was defined as unplanned revision surgery for lack of bone healing or deep infection. No patients were excluded who had a primary outcome event. RESULTS Multivariate logistic modeling identified 5 significant (P < 0.05) risk factors for failure of the surgery to promote bone healing: (1) mechanism of injury, (2) Increasing body mass index, (3) cortical defect size (mm), (4) flap size (cm), and (5) insurance status. A prediction model was created based on these factors and awarded 0 points for fall, 17 points for high energy blunt trauma (OR = 17; 95% CI, 1-286, P = 0.05), 22 points for industrial/other (OR = 22; 95% CI, 1-4, P = 0.04), and 28 points for ballistic injuries (OR = 28; 95% CI, 1-605, P = 0.04). One point is given for every 10 cm of flap size (OR = 1; 95% CI, 1-1.1, P < 0.001), 10 mm of mean cortical gap distance (OR = 1; 95% CI, 1-2, P = 0.004), and 10 units BMI, respectively (OR = 1.5; 95% CI, 1-3, P = 0.16). Two points are awarded for Medicaid or no insurance (OR = 2; 95% CI, 1-5, P = 0.035) and 3 points for Medicare (3; 95% CI, 1-9, P = 0.033). Each 1-point increase in risk score was associated with a 6% increased chance of requiring at least 1 revision surgery (P < 0.001). CONCLUSIONS This study presents a clinical score that predicts the likelihood of success after surgery for tibia fracture nonunions or traumatic bone defects and may help clinicians better determine which patients are likely to fail these procedures and require further surgery.
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Ekegren CL, Hart MJ, Cameron PA, Edwards ER, Oppy A, de Steiger R, Page R, Liew S, Hau R, Bucknill A, Gabbe BJ. Do non-steroidal anti-inflammatory drugs impair fracture healing? A survey of Australian orthopaedic surgeons. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2017. [DOI: 10.1002/jppr.1309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Christina L. Ekegren
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
| | - Melissa J. Hart
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Orthopaedics; Royal Melbourne Hospital; Melbourne Australia
| | - Peter A. Cameron
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Australia
| | - Elton R. Edwards
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Department of Orthopaedic Surgery; The Alfred Hospital; Melbourne Australia
| | - Andrew Oppy
- Department of Orthopaedic Surgery; Royal Melbourne Hospital; Melbourne; Australia
| | - Richard de Steiger
- Epworth Health; Melbourne Australia
- Department of Surgery; University of Melbourne; Melbourne Australia
| | - Richard Page
- Department of Orthopaedics; University Hospital Geelong; Geelong Australia
- School of Medicine; Deakin University; Geelong Australia
| | - Susan Liew
- Department of Orthopaedic Surgery; The Alfred Hospital; Melbourne Australia
- Department of Surgery; Monash University; Melbourne Australia
| | - Raphael Hau
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Department of Orthopaedic Surgery; Northern Hospital; Epping Australia
| | - Andrew Bucknill
- Department of Orthopaedic Surgery; Royal Melbourne Hospital; Melbourne; Australia
| | - Belinda J. Gabbe
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
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Richards CJ, Graf KW, Mashru RP. The Effect of Opioids, Alcohol, and Nonsteroidal Anti-inflammatory Drugs on Fracture Union. Orthop Clin North Am 2017; 48:433-443. [PMID: 28870304 DOI: 10.1016/j.ocl.2017.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The estimated rate of fracture nonunion is between 5% and 10%, adding significant cost to the health care system. The cause of fracture nonunion is multifactorial, including the severity of the injury, patient factors resulting in aberrancies in the biology of fracture, and the side effects of pain control modalities. Minimizing surgeon-controlled factors causing nonunion is important to reduce the cost of health care and improve patient outcomes. Opioids, alcohol, and nonsteroidal anti-inflammatory drugs have been implicated as risk factors for fracture nonunion. Current literature was reviewed to examine the effects of opioids, alcohol, and nonsteroidal anti-inflammatory drugs on fracture union.
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Affiliation(s)
- Christopher J Richards
- Department of Orthopaedic Surgery, Cooper University Hospital, 3 Cooper Plaza, Camden, NJ 08103, USA.
| | - Kenneth W Graf
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ 08103, USA
| | - Rakesh P Mashru
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ 08103, USA
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Sullivan D, Lyons M, Montgomery R, Quinlan-Colwell A. Exploring Opioid-Sparing Multimodal Analgesia Options in Trauma: A Nursing Perspective. J Trauma Nurs 2017; 23:361-375. [PMID: 27828892 PMCID: PMC5123624 DOI: 10.1097/jtn.0000000000000250] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Challenges with opioids (e.g., adverse events, misuse and abuse with long-term administration) have led to a renewed emphasis on opioid-sparing multimodal management of trauma pain. To assess the extent to which currently available evidence supports the efficacy and safety of various nonopioid analgesics and techniques to manage trauma pain, a literature search of recently published references was performed. Additional citations were included on the basis of authors' knowledge of the literature. Effective options for opioid-sparing analgesics include oral and intravenous (IV) acetaminophen; nonsteroidal anti-inflammatory drugs available via multiple routes; and anticonvulsants, which are especially effective for neuropathic pain associated with trauma. Intravenous routes (e.g., IV acetaminophen, IV ketorolac) may be associated with a faster onset of action than oral routes. Additional adjuvants for the treatment of trauma pain are muscle relaxants and alpha-2 adrenergic agonists. Ketamine and regional techniques play an important role in multimodal therapy but require medical and nursing support. Nonpharmacologic treatments (e.g., cryotherapy, distraction techniques, breathing and relaxation, acupuncture) supplement pharmacologic analgesics and can be safe and easy to implement. In conclusion, opioid-sparing multimodal analgesia addresses concerns associated with high doses of opioids, and many pharmacologic and nonpharmacologic options are available to implement this strategy. Nurses play key roles in comprehensive patient assessment; administration of patient-focused, opioid-sparing, multimodal analgesia in trauma; and monitoring for safety concerns.
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Affiliation(s)
- Denise Sullivan
- Anesthesiology/Pain Management Service, Jacobi Medical Center, Bronx, New York (Ms Sullivan); Inpatient Pain Management, Northwestern Medicine-Central DuPage Hospital, Winfield, Illinois (Ms Lyons); Anesthesiology, University of Colorado Hospital, Aurora, Colorado (Dr Montgomery); and Clinical Outcomes, New Hanover Regional Medical Center, Wilmington, North Carolina (Dr Quinlan-Colwell)
| | - Mary Lyons
- Anesthesiology/Pain Management Service, Jacobi Medical Center, Bronx, New York (Ms Sullivan); Inpatient Pain Management, Northwestern Medicine-Central DuPage Hospital, Winfield, Illinois (Ms Lyons); Anesthesiology, University of Colorado Hospital, Aurora, Colorado (Dr Montgomery); and Clinical Outcomes, New Hanover Regional Medical Center, Wilmington, North Carolina (Dr Quinlan-Colwell)
| | - Robert Montgomery
- Anesthesiology/Pain Management Service, Jacobi Medical Center, Bronx, New York (Ms Sullivan); Inpatient Pain Management, Northwestern Medicine-Central DuPage Hospital, Winfield, Illinois (Ms Lyons); Anesthesiology, University of Colorado Hospital, Aurora, Colorado (Dr Montgomery); and Clinical Outcomes, New Hanover Regional Medical Center, Wilmington, North Carolina (Dr Quinlan-Colwell)
| | - Ann Quinlan-Colwell
- Anesthesiology/Pain Management Service, Jacobi Medical Center, Bronx, New York (Ms Sullivan); Inpatient Pain Management, Northwestern Medicine-Central DuPage Hospital, Winfield, Illinois (Ms Lyons); Anesthesiology, University of Colorado Hospital, Aurora, Colorado (Dr Montgomery); and Clinical Outcomes, New Hanover Regional Medical Center, Wilmington, North Carolina (Dr Quinlan-Colwell)
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Zura R, Watson JT, Einhorn T, Mehta S, Della Rocca GJ, Xiong Z, Wang Z, Jones J, Steen RG. An inception cohort analysis to predict nonunion in tibia and 17 other fracture locations. Injury 2017; 48:1194-1203. [PMID: 28377261 DOI: 10.1016/j.injury.2017.03.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 03/25/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The epidemiology of fracture nonunion has been characterized so it is potentially possible to predict nonunion using patient-related risk factors. However, prediction models are currently too cumbersome to be useful. We test a hypothesis that nonunion can be predicted with ≤10 variables, retaining the predictive accuracy of a full model with 42 variables. METHODS We sought to predict nonunion with prospectively-acquired inception cohort data for 18 different bones, using the smallest possible number of variables that did not substantially decrease prediction accuracy. An American nationwide claims database of ∼90.1 million participants was used, which included medical and drug expenses for 2011-2012. Continuous enrollment was required for 12 months after fracture, to allow sufficient time to capture a nonunion diagnosis. Health claims were evaluated for 309,330 fractures. A training dataset used a random subset of 2/3 of these fractures, while the remaining fractures formed a validation dataset. Multivariate logistic regression and stepwise logistic regression were used to identify variables predictive of nonunion. P value and the Akaike Information Criterion (AIC) were used to select variables for reduced models. Area-under-the-curve (AUC) was calculated to characterize the success of prediction. RESULTS Nonunion rate in 18 fracture locations averaged 4.93%. Algorithms to predict nonunion in 18 locations in the full-model validation set had average AUC=0.680 (±0.034). In the reduced models, average validation set AUC=0.680 (±0.033) and the average number of risk factors required for prediction was 7.6. There was agreement across training set, validation set, and reduced set; in tibia, reduced model validation AUC=0.703, while the full-model validation AUC=0.709. Certain risk factors were important for predicting nonunion in ≥10 bones, including open fracture, multiple fracture, osteoarthritis, surgical treatment, and use of certain medications, including anticoagulants, anticonvulsants, or analgesics. DISCUSSION Nonunion can be predicted in 18 fracture locations using parsimonious models with <10 patient demography-related risk factors. The model reduction approach used results in simplified models that have nearly the same AUC as the full model. Reduced algorithms can predict nonunion because risk factors important in the full models remain important in the reduced models. This prognostic inception cohort study provides Level I evidence.
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Affiliation(s)
- Robert Zura
- Dept. of Orthopaedic Surgery, Louisiana State University Medical Center, New Orleans, LA, United States.
| | - J Tracy Watson
- Dept. of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO, United States.
| | - Thomas Einhorn
- Dept. of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY, United States.
| | - Samir Mehta
- Dept. of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States.
| | | | - Ze Xiong
- Dept. of Statistics, North Carolina State University, Raleigh, NC, United States.
| | - Zhe Wang
- Dept. of Statistics, North Carolina State University, Raleigh, NC, United States.
| | - John Jones
- Clinical Affairs, Bioventus LLC, Durham, NC, United States.
| | - R Grant Steen
- Dept. of Orthopaedic Surgery, Louisiana State University Medical Center, New Orleans, LA, United States.
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Lawton B, Goldstein H, Davis T, Tagg A. Making a difference: Pragmatic paediatric pain management. Emerg Med Australas 2017; 29:262-264. [DOI: 10.1111/1742-6723.12791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ben Lawton
- Emergency Department; Lady Cilento Children's Hospital; Brisbane Queensland Australia
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
- Emergency Department; Logan Hospital; Brisbane Queensland Australia
| | - Henry Goldstein
- Emergency Department; Lady Cilento Children's Hospital; Brisbane Queensland Australia
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
| | - Tessa Davis
- Accident and Emergency, Chelsea and Westminster Hospital; London UK
| | - Andrew Tagg
- Emergency Department; Footscray Hospital; Melbourne Victoria Australia
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Abstract
OBJECTIVES To determine opioid-prescribing practices to the orthopaedic trauma (OT) population at one Level I trauma center. DESIGN A retrospective study of discharge prescriptions for adult patients with OT. Prescription details, injury burden, and patient demographics were abstracted for patients from initial injury through a 2-month follow-up. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Adult patients with OT admitted over a 30-day period (n = 110). INTERVENTION All discharge and follow-up opioid prescriptions were recorded. MAIN OUTCOME MEASUREMENTS Morphine milligram equivalents (MMEs) per day, number of opioid prescriptions, type/dose of medication prescribed. RESULTS One hundred thirty-five discharge prescriptions were written for 110 patients with orthopaedic injuries during the review period. All patients received opioids at the time of discharge. The MMEs prescribed at the time of discharge was 114 mg (54-300 mg) for a mean of 7.21 days (2-36.7 days). Although patients with preinjury risk factors were prescribed discharge opioids for a similar duration (7.00 days vs. 7.30 days, P = 0.81) than those without risk factors, they were prescribed significantly more MMEs than those without (130 vs. 108, P < 0.05) and were more likely to receive extended-release and long-acting opioids than those without (42.11% vs. 21.98%). CONCLUSIONS Pain management after OT continues to be opioid-centric despite involving a population at risk. Further focus on prescriber and patient education, risk evaluation with mitigation, guideline development, and comprehensive pain management strategies are warranted in the OT population. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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84
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The Association Between Adjuvant Pain Medication Use and Outcomes Following Pediatric Spinal Fusion. Spine (Phila Pa 1976) 2017; 42:E602-E608. [PMID: 27584679 DOI: 10.1097/brs.0000000000001892] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A comparative effectiveness database study. OBJECTIVE The aim of this study was to describe variation in use of adjuvant therapies for managing postoperative pain in in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and determine association between use of these therapies and patient outcomes. SUMMARY OF BACKGROUND DATA Variation in postoperative pain management for children undergoing PSF for AIS likely impacts outcomes. Minimal evidence exists to support strategies that most effectively minimize prolonged intravenous (IV) opioids and hospitalizations. METHODS We included patients aged 10 to 18 years discharged from one of 38 freestanding children's hospitals participating in a national database from December 1, 2012, to January 5, 2015, with ICD9 codes indicating scoliosis and PSF procedure. Use of ketorolac, gamma aminobutyric acid (GABA) analogues (GABAa), and benzodiazepines was compared across hospitals. Hierarchical logistic regression adjusting for confounders and accounting for clustering of patients within hospitals was used to estimate association between these therapies and odds of prolonged duration of IV opioids, prolonged length of stay (LOS), and early readmissions. RESULTS Across hospitals, use of ketorolac and GABAa was highly variable and increased over time among 7349 subjects. Use of ketorolac was independently associated with significantly lower odds of prolonged LOS [odds ratio (OR) 0.75, 95% confidence interval (95% CI) 0.64-0.89] and prolonged duration of IV opioid (OR 0.84, 95% CI 0.73-0.98). GABAa use was significantly associated with decreased odds of prolonged IV opioid use (OR 0.63, 95% CI 0.53-0.75). Readmission rate at 30 days was 1.6% and most strongly associated with prolonged LOS. CONCLUSION In this national cohort of children with AIS undergoing PSF, patients who received postoperative ketorolac or GABAa were less likely to have prolonged IV opioid exposure. Given the rapid increase in use of adjuvant therapies without strong evidence, resources should be devoted to multicenter trials in order to optimize effectiveness and outcomes. LEVEL OF EVIDENCE 3.
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85
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Nwachukwu BU, Runyon RS, Kahlenberg CA, Gausden EB, Schairer WW, Allen AA. How are we measuring clinically important outcome for operative treatments in sports medicine? PHYSICIAN SPORTSMED 2017; 45:159-164. [PMID: 28276990 DOI: 10.1080/00913847.2017.1292108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Minimal clinically important difference (MCID) and other measures of minimum clinical importance are increasingly recognized as important clinical considerations for evaluating the efficacy of an intervention. As our interpretation of clinical outcome evolves beyond statistical significance, psychometric properties such as MCID will be increasingly important to various stakeholders in the orthopaedic community. The purpose of this study was to: 1) describe the state of clinically important outcome reporting and 2) describe the methods used to derive these psychometric values for sports medicine patients undergoing operative treatments. METHODS A review of the MEDLINE database was performed. Studies primarily deriving and reporting clinically important outcome measures for operative interventions in sports medicine were included. Demographic, methodological and psychometric properties of included studies were extracted. Level of Evidence and the Newcastle Ottawa Scale (NOS) were used to assess study quality. Statistical analysis was primarily descriptive. RESULTS Fifteen studies met inclusion criteria; 10 of the 15 studies were Level II evidence and mean NOS score was 5.3/9. Minimal detectable change (MDC) was the most commonly derived measure of clinical importance, calculated in 53.3% of studies, followed by MCID, calculated in 40.0% of studies. A combination of distribution and anchor-based methods was the most commonly used method to determine clinical importance (N = 7, 46.7%) followed by distribution only (N = 5, 33.3%). Predictors of clinically important change were reported in four studies and were most commonly related to pre-operative functional score. CONCLUSIONS MDC and the MCID are the most commonly reported measures of clinically important outcome after operative treatment in sports medicine. A combination of both distribution and anchor-based methods is commonly used to derive these values. More attention should be paid to reporting outcomes that are clinically important and developing guidelines for reporting clinical meaningful outcome.
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Affiliation(s)
- Benedict U Nwachukwu
- a Department of Orthopaedic Surgery , Hospital for Special Surgery , New York , NY , USA
| | - R Scott Runyon
- a Department of Orthopaedic Surgery , Hospital for Special Surgery , New York , NY , USA
| | - Cynthia A Kahlenberg
- a Department of Orthopaedic Surgery , Hospital for Special Surgery , New York , NY , USA
| | - Elizabeth B Gausden
- a Department of Orthopaedic Surgery , Hospital for Special Surgery , New York , NY , USA
| | - William W Schairer
- a Department of Orthopaedic Surgery , Hospital for Special Surgery , New York , NY , USA
| | - Answorth A Allen
- a Department of Orthopaedic Surgery , Hospital for Special Surgery , New York , NY , USA
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86
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DePeter KC, Blumberg SM, Dienstag Becker S, Meltzer JA. Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications? J Emerg Med 2017; 52:426-432. [DOI: 10.1016/j.jemermed.2016.09.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/13/2016] [Accepted: 09/15/2016] [Indexed: 12/19/2022]
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Fragomen AT, Rozbruch SR. Lengthening and deformity correction about the knee using a magnetic internal lengthening nail. SICOT J 2017; 3:25. [PMID: 28322717 PMCID: PMC5360097 DOI: 10.1051/sicotj/2017014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 02/13/2017] [Indexed: 12/01/2022] Open
Abstract
Introduction: The introduction of the internal lengthening nail (ILN) has changed the treatment of complex malalignment and shortening about the knee. Acute correction of the deformity and gradual lengthening through this osteotomy site has greatly simplified postoperative recovery. This manuscript is a review of the techniques that are currently being used in surgery. Methods: The article is broken into two sections: distal femur osteotomy and tibia osteotomy. Each is addressed separately since they have different personalities. Also included are topics of particular interest that surface in ongoing conferences regarding the ILN. This work is a mix of expert opinion and best practice supported by peer reviewed publications on the topic. Results: Most published series demonstrate excellent results with the ILN. Certain precautions are reiterated including avoiding mechanical failure, need for a percutaneous osteotomy, need for over-reaming, and the need for blocking screws. Discussion: Current controversies will be brought to light and discussed. The reader should find this aspect particularly helpful in navigating this rapidly evolving field.
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Affiliation(s)
- Austin T Fragomen
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY 10021, USA
| | - S Robert Rozbruch
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY 10021, USA
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88
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Stocki D. Review of Recent Advances in Pain Management for Pediatric Spinal Fusion. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0209-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sivaganesan A, Chotai S, White-Dzuro G, McGirt MJ, Devin CJ. The effect of NSAIDs on spinal fusion: a cross-disciplinary review of biochemical, animal, and human studies. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2719-2728. [PMID: 28283838 DOI: 10.1007/s00586-017-5021-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 02/19/2017] [Accepted: 02/25/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE Non-steroidal anti-inflammatory drugs (NSAIDs) play an important role in postoperative pain management. However, their use in the setting of spine fusion surgery setting has long been a topic of controversy. In this review we examined relevant research, including in vivo, animal, and clinical human studies, with the aim of understanding the effect of NSAIDs on spinal fusion. STUDY DESIGN/SETTING Systematic review of study designs of all types from randomized controlled trials and meta-analyses to single-institution retrospective reviews. METHODS A search of PubMed and Embase was conducted using the keywords: "spine," "spinal fracture," NSAIDs, anti-inflammatory non-steroidal agents, bone, bone healing, fracture, fracture healing, yielding a total of 110 studies. Other 28 studies were identified by cross-referencing, resulting in total 138 studies. RESULTS There is no level I evidence from human studies regarding the use of NSAIDs on spinal fusion rates. The overall tone of the spine literature in the early 2000s was that NSAIDs increased the rate of non-union; however, nearly all human studies published after 2005 suggest that short-term (<2 weeks) postoperative use have no such effect. The dose dependency that is seen with a 2-week postoperative course is not present when NSAIDs are only used for 48 h after surgery. CONCLUSIONS NSAID appear to have dose-dependent and duration-dependent effects on fusion rates. The short-term use of low-dose NSAIDs around the time of spinal fusion surgery is reasonable. Spine surgeons can consider the incorporation of NSAIDs into pain control regimens for spinal fusion patients with the goal of improving pain control and reducing the costs and complications associated with opioids.
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Affiliation(s)
- Ahilan Sivaganesan
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Ave. So., T4224 Medical Center North, Nashville, TN, 37232-2380, USA.
| | - Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Ave. So., T4224 Medical Center North, Nashville, TN, 37232-2380, USA.,Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, NC, USA
| | - Clinton J Devin
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Ave. So., T4224 Medical Center North, Nashville, TN, 37232-2380, USA.,Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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90
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Diaper R, Wong E, Metcalfe SA. The implications of biologic therapy for elective foot and ankle surgery in patients with rheumatoid arthritis. Foot (Edinb) 2017; 30:53-58. [PMID: 28262590 DOI: 10.1016/j.foot.2017.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 12/30/2016] [Accepted: 01/25/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is one of a number of inflammatory arthropathies resulting in foot pain and deformity. Patients with this disease may require surgical intervention as part of their management. Many of these patients are now taking biologic agents which pose several risks to patients in the perioperative phase. The surgical team therefore need to be aware of these associated complications and how to manage these cases. AIM This paper aims to review the current literature about perioperative needs (foot and ankle surgery) associated with patients with rheumatoid arthritis receiving biologic therapy. MAIN FINDINGS The majority of the literature discusses the perioperative complications associated with patients on anti-TNFα therapy with few studies investigating the other biologics in common use. There is conflicting evidence as to the safety of continuing or stopping biologic drug therapy prior to orthopaedic procedures. The British Society for Rheumatology (BSR) have produced guidelines for the management of patients on anti-TNFα therapy or the biologic agent Tocilizumab. These recommendations suggest the risks of post-operative infection need to be balanced against the risk of a post-operative disease flare. In essence, it is suggested anti-TNFα therapy is stopped 3-5 times the half-life of the drug whilst Tocilizumab is stopped 4 weeks prior to surgery. CONCLUSION Good communication is needed between the surgical team and the local Rheumatology department managing the patient's disease in order to optimise perioperative care. Local pathways may vary from the BSR recommendations to determine the most suitable course of action with regards to continuing or stopping biologic therapy prior to foot and ankle surgery.
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Affiliation(s)
- Ross Diaper
- Podiatry Department, Turner Centre, St. James Hospital, Locksway Road, Portsmouth PO4 8LD, UK.
| | - Ernest Wong
- Department of Rheumatology, Portsmouth Hospitals Trust, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
| | - Stuart A Metcalfe
- Podiatry Department, Turner Centre, St. James Hospital, Locksway Road, Portsmouth PO4 8LD, UK
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Cowan R, Lim JH, Ong T, Kumar A, Sahota O. The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care. Drugs Aging 2017; 34:1-11. [PMID: 27913981 DOI: 10.1007/s40266-016-0427-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The care of the older person with hip fracture is complicated by their comorbid condition, limited physiological reserve, cognitive impairment and frailty. Two aspects of hip fracture management that have received considerable attention are how best to manage the pain associated with it and the ideal mode of anaesthesia. Existing literature has reported on the suboptimal treatment of pain in this orthogeriatric cohort. With recent advancements in medical care, a number of options have emerged as alternatives to conservative systemic analgesia. Systemic analgesia, such as opioids, can lead to untoward side effects, especially in this particular group of patients. Hence, peripheral nerve blocks, epidural analgesia and regional anaesthesia have emerged as options in the delivery of adequate pain relief in hip fractures. Besides that, there is ongoing debate regarding the appropriate anaesthesia technique for surgical repair of the fractured hip. The benefits and risks related to either spinal anaesthesia or general anaesthesia have been subject to studies determining which method is associated with better short- and long-term outcomes. In this review, we aim to examine the evidence behind the different analgesia options available, compare spinal and general anaesthesia, and discuss the importance of the multidisciplinary orthogeriatric model of care in hip fracture and its potential role in other fragility fractures.
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MESH Headings
- Aged
- Aged, 80 and over
- Analgesia, Epidural/methods
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anesthesia, Conduction/methods
- Anesthesia, General/methods
- Anesthesia, Spinal/methods
- Female
- Hip Fractures/drug therapy
- Hip Fractures/surgery
- Humans
- Male
- Nerve Block/methods
- Pain/prevention & control
- Pain Management/methods
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Affiliation(s)
- Rachel Cowan
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Jun Hao Lim
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Terence Ong
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK.
- School of Medicine, University of Nottingham, Medical School, Nottingham, UK.
| | - Ashok Kumar
- School of Medicine, University of Nottingham, Medical School, Nottingham, UK
| | - Opinder Sahota
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
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Thevendran G, Shah K, Pinney SJ, Younger AS. Perceived risk factors for nonunion following foot and ankle arthrodesis. J Orthop Surg (Hong Kong) 2017; 25:2309499017692703. [PMID: 28219308 DOI: 10.1177/2309499017692703] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND A major complication of foot and ankle arthrodesis is nonunion, which occurs in approximately 12% of cases. Various factors influence a patient's risk for nonunion following foot and ankle arthrodesis. We surveyed international foot and ankle surgeons to determine (1) risk factors perceived most important for nonunion, (2) factors considered absolute contraindications for arthrodesis, and (3) differences among expert groups regarding perceived risk factors and their stratification. METHODS A questionnaire was e-mailed to members of a major foot and ankle journal editorial board and four foot and ankle society executive committees. The relative risk of 18 potential nonunion risk factors was rated from 1 to 10, using smoking 1 pack/day as a benchmark score of 5.00. RESULTS The response rate was 72% (100/139); 81% declared foot and ankle surgery encompasses >90% of their practice. The highest perceived risk factors ( p < 0.001) were smoking 2 packs/day (mean score 8.69), lack of fusion site stability (8.66), and poor local vascularity (7.66). The least important risk factors ( p < 0.001) were perceived to be age >60 years (mean score 2.54), rheumatoid arthritis (3.05), and osteoporosis (3.56). The most frequently cited absolute contraindications to arthrodesis surgery were local infection (46%), poor local vascularity (41%), and smoking (32%). CONCLUSION To improve arthrodesis outcomes, resource allocation and patient and surgeon education should focus on smoking, construct stability, and local vascularity. Development of an objective nonunion risk assessment tool to identify patients at risk for nonunion using these results could help maximize the efficiency of available resources.
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Affiliation(s)
| | - Kalpesh Shah
- 2 Golden Jubilee National Hospital, Clydebank, Scotland, United Kingdom
| | - Stephen J Pinney
- 3 San Francisco Orthopaedic Surgeons Medical Group, San Francisco, CA, USA
| | - Alastair Se Younger
- 4 Department of Orthopaedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Effects of Indomethacin and Meloxicam, Nonsteroidal Anti-inflammatory Drugs, on Tibia Fracture Union in Rats. JOURNAL OF ORTHOPEDIC AND SPINE TRAUMA 2016. [DOI: 10.5812/jost.10701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. THE JOURNAL OF PAIN 2016; 17:131-57. [PMID: 26827847 DOI: 10.1016/j.jpain.2015.12.008] [Citation(s) in RCA: 1572] [Impact Index Per Article: 196.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 12/11/2022]
Abstract
UNLABELLED Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence. PERSPECTIVE This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.
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Liu HX, Jiang N, Liang HY, Zhou YY, Feng XH, Feng XY, Zhang HQ, Wu ZK, Jiang Q, Fu J, Ma XJ, Chen P. Bushen Qiangji Granule () medicated serum inhibits osteogenic differentiation of fibroblasts in ankylosing spondylitis by inhibiting the BMP/Smads signal pathway in vitro. Chin J Integr Med 2016; 22:817-822. [PMID: 27783321 DOI: 10.1007/s11655-016-2268-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To explore the mechanism of Bushen Qiangji Granule (, BSQJ) in restraining the osteogenic differentiation of ankylosing spondylitis (AS) fifibroblasts. METHODS Hip joint capsules were obtained from AS patients (n=10) receiving total hip replacement and healthy hip joint capsules from patients with hip fracture (n=10) receiving surgery as a control. Finite fifibroblast lines were established from these tissue samples to observe the effect of BSQJ on suppressing osteogenic differentiation of fifibroblasts. The expression of osteogenic marker gene corebinding factor a1 (Cbfa1) and Smad family proteins were examined by Western blot and real-time quantitative polymerase chain reaction (qPCR). RESULTS The mRNA expression level of Cbfa1 was significantly higher in AS fibroblasts than that in normal fibroblasts and the expression of pSmad1, pSmad5, Smad4 and Cbfa1 in AS fibroblasts was also higher, demonstrating the activation of the BMP/Smads signal pathway in AS fifibroblasts. BSQJ-medicated serum not only restrained the mRNA and protein expression levels of Cbfa1 and inhibited protein expression level of Smad4 but also decreased the expression quantities of pSmad1 and pSmad5. CONCLUSIONS BSQJ can inhibit osteogenic differentiation of AS fifibroblasts in vitro by suppressing the activation of the BMP/Smads signal pathway. This may be the important molecular mechanism of BSQJ in regulating AS ossifification.
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Affiliation(s)
- Hong-Xiao Liu
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Nan Jiang
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Hui-Ying Liang
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Ying-Yan Zhou
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Xing-Hua Feng
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Xiao-Yan Feng
- Department of Vaccine Engineering, Beijing Institute of Basic Medical Sciences, Beijing, 100850, China
| | - He-Qiu Zhang
- Department of Vaccine Engineering, Beijing Institute of Basic Medical Sciences, Beijing, 100850, China
| | - Zhi-Kui Wu
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Quan Jiang
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Jiao Fu
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Xiao-Juan Ma
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Peng Chen
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
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96
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Hansen MS, Petersen EE, Dahl JB, Wetterslev J. Post-operative serious adverse events in a mixed surgical population - a retrospective register study. Acta Anaesthesiol Scand 2016; 60:1209-21. [PMID: 27417678 DOI: 10.1111/aas.12762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/11/2016] [Accepted: 06/15/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The number of surgical procedures is increasing, and knowledge of surgical risk factors, post-operative mortality and serious adverse events (SAE) is essential. The aim with our study was to determine the risk of a composite outcome of post-operative: death; myocardial infarction; pulmonary embolism; stroke; gastrointestinal bleeding; dialysis or reoperation. METHODS Data of surgical procedures in the period from January 1, 2012 to June 30, 2012 were retrieved from the Danish Anaesthesia Database (DAD). Follow-up of all patients undergoing hip or knee replacement, abdominal or gynaecological surgery was conducted retrieving data from The Danish Civil Registration System and the National Patient Register. Total observation time was from January 1, 2012 to June 6, 2013. RESULTS A total7449 adult patients were included in the final analysis. The risk of the composite outcome during a follow-up until 342 days after inclusion of the last patient was estimated to 8.3%, 95% Confidence Intervals (CI) (7.8-9.0), with a median observation time of 437 days (IQR 387-485, range 0-522). The risk of the composite outcome within 90- and 180-day follow-up of each patient was 4.8% (4.4-5.3) and 5.9% (5.4-6.5), respectively. Mortality within longest follow-up as well as 90 and 180 days post-operatively was 3.6% (3.1-4.0), 1.7% (1.4-2.0), and 2.2% (1.9-2.6), respectively. CONCLUSION We found a risk of one or more events in the composite outcome within 342 days after inclusion of the last patients of 8.3% (7.8-9.0). The results are applicable in estimations of adequate sample sizes in future clinical trials investigating effects of interventions on SAEs.
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Affiliation(s)
- M. S. Hansen
- Department of Anaesthesiology; Dep. 4231; Centre of Head and Orthopaedics; Rigshospitalet; Copenhagen Denmark
| | - E. E. Petersen
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Dep. 7812; Copenhagen Denmark
| | - J. B. Dahl
- Department of Anaesthesiology; Dep. Z; Bispebjerg Hospital; København Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Dep. 7812; Copenhagen Denmark
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97
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Kahlenberg CA, Nwachukwu BU, Schairer WW, McCormick F, Ranawat AS. Patient Satisfaction Reporting for the Treatment of Femoroacetabular Impingement. Arthroscopy 2016; 32:1693-9. [PMID: 27157663 DOI: 10.1016/j.arthro.2016.02.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate how patient satisfaction after surgical femoroacetabular impingement (FAI) treatment is measured and reported in the current evidence base. METHODS A review of the MEDLINE database was performed. Clinical outcome studies of FAI that reported a measure of patient satisfaction were included. Patient demographics, clinical outcome scores, and patient satisfaction measures were extracted. The NewCastle Ottawa Scale (NOS) was used to grade quality. Statistical analysis was primarily descriptive. RESULTS Twenty-six studies met inclusion criteria; the mean NOS score among included studies was 5.7. Most studies were level 3 or 4 (n = 25, 96.1%). A 0 to 10 numeric scale, described by some studies as a visual analog scale, was the most commonly used method to assess satisfaction (n = 21; 80.8%), and mean reported scores ranged from 6.8 to 9.2 out of 10. Four studies (15.4%) used an ordinal scale, and 1 study (3.8%) used willingness to undergo surgery again as the measure of satisfaction. None of the included studies assessed preoperative satisfaction or patient expectation. Pooled cohort analysis was limited by significant overlapping study populations. Predictors of patients' satisfaction identified in included studies were presence of arthritis and postoperative outcome scores. CONCLUSIONS Patient satisfaction was not uniformly assessed in the literature. Most studies used a 0- to 10-point satisfaction scale, but none distinguished between the process of care and the outcome of care. Although satisfaction scores were generally high, the quality of the methodologies in the studies that reported satisfaction was low, and the studies likely included overlapping patient populations. More work needs to be done to develop standardized ways for assessing patient satisfaction after arthroscopic hip surgery and other procedures in orthopaedic sports medicine. LEVEL OF EVIDENCE Level III, systematic review of Level III studies.
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Affiliation(s)
- Cynthia A Kahlenberg
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A..
| | - Benedict U Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - William W Schairer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Frank McCormick
- Sports Medicine Department, LESS Institute, Fort Lauderdale, Florida, U.S.A
| | - Anil S Ranawat
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
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98
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Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables. Clin Orthop Relat Res 2016; 474:1385-95. [PMID: 27125823 PMCID: PMC4868164 DOI: 10.1007/s11999-016-4821-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Accurate prediction of tibial nonunions has eluded researchers. Reliably predicting tibial nonunions at the time of fixation could change management strategies and stimulate further research. QUESTIONS/PURPOSES We asked (1) whether data from medical records, fracture characteristics, and radiographs obtained at the time of fixation would identify features predictive of tibial fracture nonunion; and (2) whether this information could be used to create a model to assess the chance of nonunion at the time of intramedullary (IM) nail fixation of the tibia. METHODS We retrospectively reviewed all tibial shaft fractures treated at our center from 2007 to 2014. We conducted a literature review and collected data on 35 factors theorized to contribute to delayed bone healing. Patients were followed to fracture healing or surgery for nonunion. Patients with planned prophylactic nonunion surgery were excluded because their nonunions were anticipated and our focus was on unanticipated nonunions. Our cohort consisted of 382 patients treated with IM nails for tibial shaft fractures (nonunion, 56; healed, 326). Bivariate and multivariate regression techniques and stepwise modeling approaches examined the relationship between variables available at definitive fixation. Factors were included in our model if they were identified as having a modest to large effect size (odds ratio > 2) at the p < 0.05 level. RESULTS A multiple variable logistic regression model was developed, including seven factors (p < 0.05; odds ratio > 2.0). With these factors, we created the Nonunion Risk Determination (NURD) score. The NURD score assigns 5 points for flaps, 4 points for compartment syndrome, 3 points for chronic condition(s), 2 points for open fractures, 1 point for male gender, and 1 point per grade of American Society of Anesthesiologists Physical Status and percent cortical contact. One point each is subtracted for spiral fractures and for low-energy injuries, which were found to be predictive of union. A NURD score of 0 to 5 had a 2% chance of nonunion; 6 to 8, 22%; 9 to 11, 42%; and > 12, 61%. CONCLUSIONS The proposed nonunion prediction model (NURDS) seems to have potential to allow clinicians to better determine which patients have a higher risk of nonunion. Future work should be directed at prospectively validating and enhancing this model. LEVEL OF EVIDENCE Level III, diagnostic study.
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99
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Wright JA. An update of systemic analgesics in children. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2016. [DOI: 10.1016/j.mpaic.2016.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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100
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Dunn LK, Durieux ME, Nemergut EC. Non-opioid analgesics: Novel approaches to perioperative analgesia for major spine surgery. Best Pract Res Clin Anaesthesiol 2016; 30:79-89. [DOI: 10.1016/j.bpa.2015.11.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 10/27/2015] [Accepted: 11/16/2015] [Indexed: 01/07/2023]
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