NSAID exposure and risk of nonunion: a meta-analysis of case-control and cohort studies

Demineralized Bone Matrix Add-On for Acceleration of Bone Healing in Atypical Subtrochanteric Femoral Fracture: A Consecutive Case-Control Study

Background. Delayed union and nonunion are common complications in atypical femoral fractures (AFFs) despite having good fracture fixation. Demineralized bone matrix (DBM) is a successfully proven method for enhancing fracture healing of the long bone fracture and nonunion and should be used in AFFs. This study aimed to compare the outcome after subtrochanteric AFFs (ST-AFFs) fixation with and without DBM. Materials and Methods. A prospective study was conducted on 9 ST-AFFs patients using DBM (DBM group) during 2013-2014 and compared with a retrospective consecutive case series of ST-AFFs patients treated without DBM (2010–2012) (NDBM group, 9 patients). All patients were treated with the same standard guideline and followed up until fractures completely united. Postoperative outcomes were then compared. Results. DBM group showed a significant shorter healing time than NDBM group (28.1 ± 14.4 versus 57.9 ± 36.8 weeks, p = 0.04). Delayed union was found in 4 patients (44%) in DBM group compared with 7 patients (78%) in NDBM group (p > 0.05). No statistical difference of nonunion was demonstrated between both groups (DBM = 1 and NDBM = 2, p > 0.05). Neither postoperative infection nor severe local tissue reaction was found. Conclusions. DBM is safe and effective for accelerating the fracture healing in ST-AFFx and possibly reduces nonunion after fracture fixation. Trial registration number is TCTR20151021001.

Pain management in the acute care setting: Update and debates

Pain management in the paediatric acute care setting is underutilised and can be improved. An awareness of the analgesic options available and their limitations is an important starting point. This article describes the evolving understanding of relevant pharmacogenomics and safety data of the various analgesic agents with a focus on agents available in Australia and New Zealand. It highlights the concerns with the use of codeine in children and discusses alternative oral opioids. Key features of oral, parenteral, inhaled and intranasal analgesic agents are discussed, as well as evidence supported use of sweet tasting solutions and non-pharmacological interventions. One of the biggest changes in acute care pain management has been the advent of intranasal fentanyl providing reliable potent analgesia without the need for intravenous access. The article will also address the issue of multimodal analgesia where a single agent is insufficient.

New modalities of pain treatment after outpatient orthopaedic surgery

Postoperative pain relief is one of the cornerstones of success of orthopaedic surgery. Development of new minimally-invasive surgical procedures, as well as improvements in pharmacological and local and regional techniques should result in optimal postoperative pain control for all patients. The analgesic strategy has to be efficient, with minimal side effects, and be easy to manage at home. Multimodal analgesia allows for a reduction of opiate use and thereby its side effects. Local and regional analgesia is a major component of this multimodal strategy, associated with optimal pain relief, even upon mobilization, and it has beneficial effects on postoperative recovery. Ultrasound guidance improves the success rate of distal nerve blocks and makes distal selective blockade possible, helping to preserve the limb's motility. Besides peripheral nerve blocks, local infiltration (incisional and/or intra-articular) is also important to consider. Duration of the nerve blockade is limited after a single injection. This must be taken into consideration to avoid the recurrence of pain when the patient returns home. Continuous perineural blocks using catheters are an option that can be easily managed at home with monitoring by home-care nurses. Extended-release liposomal bupivacaine and adjuvants such as dexamethasone could significantly enhance the duration of the sensory block, thereby reducing the indications for pain pumps. Non-pharmacological approaches, such as cryotherapy, hypnosis and acupuncture should not be ignored.

Ibuprofen - a Safe Analgesic During Cardiac Surgery Recovery? A Randomized Controlled Trial

Introduction: Postoperative pain-management with non-steroid anti-inflammatory drugs has been controversial, due to related side-effects. We investigated whether there was a significant difference between an oxycodone-based pain-management regimen versus a slow-release ibuprofen based regimen, in a short term post-cardiac surgery setting. Particular attention was given to the rate of myocardial infarction, sternal healing, gastro-intestinal complications, renal failure and all-cause mortality.

Methods: This was a single-centre, open label parallel design randomised controlled study. Patients, who were undergoing cardiac surgery for the first time, were randomly allocated either to a regimen of slow-release oxycodone (10 mg twice daily) or slow-release ibuprofen (800 mg twice daily) combined with lansoprazole. Data relating to blood-tests, angiographies, surgical details and administered medicine were obtained from patient records. The follow-up period was 1 to 37 months (median 25 months).

Results: One hundred eighty-two patients were included in the trial and available for intention to treat analysis. There were no significant difference between the groups (P>0.05) in the rates of sternal healing, postoperative myocardial infarction or gastrointestinal bleeding. The preoperative levels of creatinine were found to increase by 100% in nine patients (9.6%) in the ibuprofen group, resulting in an acute renal injury (in accordance with the RIFLE-criteria). Eight of these patients returned to normal renal function within 14 days. The levels of creatinine in patients in the oxycodone group were not found to increase to the same magnitude.

Conclusion: The results of this study suggest that patients treated postoperatively, following cardiac surgery, are at no greater risk of harm if short term slow release ibuprofen combined with lansoprazole treatment is used when compared to an oxycodone based regimen. Renal function should, however, be closely monitored and in the event of any decrease in renal function ibuprofen must be discontinued.

Trends of non-union and prescriptions for non-steroidal anti-inflammatory drugs in the United States, 1993-2012

BACKGROUND AND PURPOSE

Surgical care and pain management for patients with fractures have evolved over the years. We wanted to ascertain if there were any changes in the incidence of non-unions and, if so, whether the use of non-steroidal anti-inflammatory drugs (NSAIDs), including COX-2 selective inhibitors, might have an effect.

PATIENTS AND METHODS

We used the National Inpatient Sample (NIS) to estimate the annual number of patients hospitalized for surgical treatment of a non-union between 1993 and 2012, and calculated age-adjusted rates of non-union. We estimated the prevalence of prescriptions for NSAIDs from 1996 through 2012 using the Medical Expenditure Panel Survey (MEPS). The interrupted time-series analysis was used to relate quarterly rates of non-union to changes in prescriptions for NSAIDs between 1996 and 2009.

RESULTS

The annual estimate of non-unions in the USA declined 30% from 25,634 in 1993 to 17,815 in 2012 (p < 0.001). Specifically, the age-adjusted rate of non-unions decreased by 44% from 8.6 per 10(5) persons in 1996 to 4.8 per 10(5) persons in 2012 (p < 0.001). However, there was an 8% increase in the incidence rate of non-unions (p = 0.003) between 2000 and 2004, when certain COX-2 selective inhibitors were on the market and their prescriptions were prevalent at around 6% among those with fractures. A drop in non-union estimates from 22,321 in 2010 to 18,789 in 2011 (p = 0.04) also coincided with a marked decrease in prescriptions for NSAIDs in patients with fractures, from 22% to 14% (p = 0.02).

INTERPRETATION

Non-unions in the USA declined substantially between 1993 and 2012, but this was interrupted by changes in prescriptions for NSAIDs, with sustained increases between 2000 and 2004 followed by transient decreases in 2005 and 2011.

Different effects of indomethacin on healing of shaft and metaphyseal fractures

BACKGROUND AND PURPOSE

NSAIDs are commonly used in the clinic, and there is a general perception that this does not influence healing in common types of human fractures. Still, NSAIDs impair fracture healing dramatically in animal models. These models mainly pertain to fractures of cortical bone in shafts, whereas patients more often have corticocancellous fractures in metaphyses. We therefore tested the hypothesis that the effect of an NSAID is different in shaft healing and metaphyseal healing.

METHODS

26 mice were given an osteotomy of their left femur with an intramedullary nail. 13 received injections of indomethacin, 1 mg/kg twice daily. After 17 days of healing, the femurs were analyzed with 3-point bending and microCT. 24 other mice had holes drilled in both proximal tibias, to mimic a stable metaphyseal injury. A screw was inserted in the right tibial hole only. After 7 days of indomethacin injections or control injections, screw fixation was measured with mechanical pull-out testing and the side without a screw was analyzed with microCT.

RESULTS

In the shaft model, indomethacin led to a 35% decrease in force at failure (95% CI: 14-54). Callus size was reduced to a similar degree, as seen by microCT. Metaphyseal healing was less affected by indomethacin, as no effect on pull-out force could be seen (95% CI: -27 to 17) and there was only a small drop in new bone volume inside the drill hole. The difference in the relative effect of indomethacin between the 2 models was statistically significant (p = 0.006).

INTERPRETATION

Indomethacin had a minimal effect on stable metaphyseal fractures, but greatly impaired healing of unstable shaft fractures. This could explain some of the differences found between animal models and clinical experience.

Fracture healing: an appraisal of the effects of frequently prescribed medications

BACKGROUND

Recognizing the existence of adverse drug effects of frequently prescribed drugs can empower a clinician with knowledge to avoid dangerous adverse effects that may result in hazardous, negative patient outcomes on either fracture healing or bone health. Pharmacovigilance reports have described the influence of medications, allowing for bone health to be quite unpredictable.

METHODS

First, mechanisms found in the medical literature of potential drug adverse effects regarding fracture healing are presented. Second, the 100 most frequently prescribed medications in 2010 are reviewed regarding adverse effects on fracture healing. These reported adverse effects are evaluated for medical causation. Last, a data table describing the 100 reviewed medications and their reported effects on fracture healing is provided.

RESULTS

The actual number of different medications in the review was 72. Reported drug adverse effects on bone and fracture healing occurred with 59 of the 72 drugs (81.9%). These adverse effects are either described as a definitive statement or represented by postmarketing case reports. Thirteen of the 72 review drugs (18.1%) did not have any description of the possible effects on bone health. A total of 301 cases reports describing delayed union, malunion, and nonunion of fractures represent 31 of the 72 medications reviewed (43.1%).

CONCLUSIONS

This review offers the health-care provider information regarding potential adverse drug effects on bone health. Empowered with this information, clinicians may assist their patients in maximizing pharmacologic outcomes by avoiding these reported harmful adverse effects.

Acute pediatric musculoskeletal pain management in North America: a practice variation survey

Children's musculoskeletal (MSK) injury pain remains poorly managed. This survey of pediatric emergency physicians and orthopedic surgeons assessed analgesia administration practices and discharge advice for children with acute MSK pain; 683 responses were received. Ibuprofen was the most commonly reported analgesic used in the emergency department (52%) and at discharge (68%). Most (85%) reported using oral opioids in the previous 6 months. Codeine use was the most commonly reported opioid used in the emergency department (38%) and at home (51%). For equal levels of pain, younger children received less opioids than older children. Younger physicians and recent graduates chose acetaminophen and codeine more than older and more experienced colleagues, who preferred ibuprofen and non-codeine containing opioid compounds (P < .001 and .006, respectively). Orthopedic surgeons reported less ibuprofen use than pediatric emergency physicians (P < .001). Choice of analgesic agents is heterogeneous among physicians and is influenced by pain severity, child's age, and physician characteristics.

Nonsteroidal anti-inflammatory drugs' impact on nonunion and infection rates in long-bone fractures

BACKGROUND

There is a dearth of clinical data regarding the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on long-bone fracture (LBF) healing in the acute trauma setting. The orthopedic community believes that the use of NSAIDs in the postoperative period will result in poor healing and increased infectious complications. We hypothesized that, first, NSAID use would not increase nonunion/malunion and infection rates after LBF. Second, we hypothesized that tobacco use would cause higher rates of these complications.

METHODS

A retrospective study of all patients with femur, tibia, and/or humerus fractures between October 2009 and September 2011 at a Level 1 academic trauma center was performed . In addition to nonunion/malunion and infection rates, patient records were reviewed for demographic data, mechanism of fracture, type of fracture, tobacco use, Injury Severity Score (ISS), comorbidities, and medications given.

RESULTS

During the 24-month period, 1,901 patients experienced LBF; 231 (12.1%) received NSAIDs; and 351 (18.4%) were smokers. The overall complication rate including nonunion/malunion and infection was 3.2% (60 patients). Logistic regression analysis with adjusted odds ratios were calculated on the risk of complications given NSAID use and/or smoking, and we found that a patient is significantly more likely to have a complication if he or she received an NSAID (odds ratio, 2.17; 95% confidence interval, 1.15-4.10; p < 0.016) in the inpatient postoperative setting. Likewise, smokers are significantly more likely to have complications (odds ratio, 3.19; 95% confidence interval, 1.84-5.53; p < 0.001).

CONCLUSION

LBF patients who received NSAIDs in the postoperative period were twice as likely and smokers more than three times likely to suffer complications such as nonunion/malunion or infection. We recommend avoiding NSAID in traumatic LBF.

LEVEL OF EVIDENCE

Epidemiologic & therapeutic study; level II.

[NSAIDs and risk of anastomotic leakage after gastrointestinal surgery]

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most popular analgesics administered after open or laparoscopic gastrointestinal surgery. By blocking the cyclooxygenase, they are likely to inhibit fibroblastic response to tissue injury and therefore to impair the healing process. Recent publications, based on large cohorts of patients, have highlighted the significant association between AINS administration and the occurrence of postoperative anastomotic complications. Even if not yet supported by high level methodological proofs, cautions should be placed on the use of this pharmaceutical class in this setting. Many questions remain unresolved, especially concerning the influence of NSAIDs cox-2 selectivity, or administration duration.

NSAIDs and fracture healing

PURPOSE OF REVIEW

Published data raise concerns about the use of nonselective NSAIDs and selective cyclo-oxygenase (COX)-2 inhibitors as anti-inflammatory or analgesic drugs in patients after a recent fracture or who are undergoing (uncemented) arthroplasty or osteotomy. However, clinical reports on the effect of COX-2 inhibition on fracture healing in humans have been variable and inconclusive. This review gives an overview of the published data and an advice when to avoid NSAIDs.

RECENT FINDINGS

Prostaglandins play an important role as mediators of inflammation and COX are required for their production. Inflammation is an essential step in the fracture healing process in which prostaglandin production by COX-2 is involved. Data from animal studies suggest that NSAIDs, which inhibit COX-2, can impair fracture healing due to the inhibition of the endochondral ossification pathway. Animal data suggest that the effects of COX-2 inhibitors are dependent on the timing, duration, and dose, and that these effects are reversible.

SUMMARY

These animal data, together with the view of limited scientifically robust clinical evidence in humans, indicate that physicians consider only short-term administration of COX-2 inhibitors or other drugs in the pain management of patients who are in the phase of fracture or other bone defect healing. COX-2-inhibitors should be considered a potential risk factor for fracture healing, and therefore to be avoided in patients at risk for delayed fracture healing.

Special Considerations for Multiple Limb Amputation

It has been estimated that more than 1.6 million individuals in the United States have undergone at least one amputation. The literature abounds with research of the classifications of such injuries, their etiologies, epidemiologies, treatment regimens, average age of onset (average age of amputation), and much more. The subpopulation that is often overlooked in these evaluations, however, is comprised of individuals who have suffered multiple limb loss. The challenges faced by those with single-limb loss are amplified for those with multiple limb loss. Pain, lifestyle adjustment, and quality of life return are just a few key areas of concern in this population. Along with amputations resulting from trauma, many individuals with multiple amputations have endured them as a result of dysvascular disease. Over recent years, amputations as a result of dysvascular disease have risen to comprise more than 80 % of new amputations occurring in the United States every year. This compares to just 54 % of total current prevalence. Those with diabetes comorbid with dysvascular disease make up 74 % of those with dysvascular amputations, and these individuals with diabetes comorbid with dysvascular disease have a 55 % chance of enduring an amputation of their contralateral limb within 2-3 years of their initial amputation. With the well-documented aging of the nation's population and the similarly skyrocketing prevalence of dysvascular disease and diabetes, it can be expected that the number of individuals with multiple limb loss will continue to increase in the United States. This article outlines the recommended measures of care for this particular subpopulation, including pain management, behavioral health considerations, strategies for rehabilitation for various levels and variations of multiple limb loss, and the assistive technology and adaptive equipment that might be available for these individuals to best enable them to continue healthy, fulfilling lives following amputation.

Use of ketorolac is associated with decreased pneumonia following rib fractures

BACKGROUND

The effectiveness of the nonsteroidal anti-inflammatory drug ketorolac in reducing pulmonary morbidity after rib fractures remains largely unknown.

METHODS

A retrospective cohort study was conducted spanning January 2003 to June 2011 assessing pneumonia within 30 days and potential adverse effects of ketorolac among all patients with rib fractures who received ketorolac <4 days after injury compared with a random sample of those who did not.

RESULTS

Among 202 patients who received ketorolac and 417 who did not, ketorolac use was associated with decreased pneumonia (odds ratio, .14; 95% confidence interval, .04 to .46) and increased ventilator-free days (difference, 1.8 days; 95% confidence interval, 1.1 to 2.5) and intensive care unit-free days (difference, 2.1 days; 95% confidence interval, 1.3 to 3.0) within 30 days. The rates of acute kidney injury, gastrointestinal hemorrhage, and fracture nonunion were not different.

CONCLUSIONS

Early administration of ketorolac to patients with rib fractures is associated with a decreased likelihood of pneumonia, without apparent risks.

Pharmacophysiology of bone and spinal fusion

BACKGROUND CONTEXT

In recent years, the number of complex spinal surgeries has increased significantly in the elderly population, where the prevalence of low bone density is highest. Consequently, spine surgeons often treat osteoporotic patients who are associated with higher rates of instrumentation failure. Therefore, establishing a successful fusion requires an appropriate substrate for bone formation and local bone remodeling. The fusion process can be supported by therapies that seek to shift the balance of bone homeostasis to increased formation and reduced resorption.

PURPOSE

Thorough understanding of the physiology of bone formation and adjunctive therapies can help improve fusion rates. Therefore, we present a thorough review of the latest pharmacologic agents used to enhance bone strength and surgical spinal fusion.

METHODS

Systematic review of literature.

RESULTS

Current knowledge on bone physiology has led to the development of several pharmacologic agents that enhance bone formation and strengthen the human skeleton. At present, natural supplements of vitamin D and calcium or synthetic medications like bisphosphonates are widely used before and after spine surgeries to enhance bone fusion. Additional physiologic agents, including testosterone, parathyroid hormone, calcitonin, and growth hormone, have been shown to improve bone mass density or spinal fusion in both animal and human studies. As in other medical fields, gene therapy has shown viability and promise with the use of both viral and nonviral vectors.

CONCLUSIONS

Through the understanding of bone physiology, numerous natural and synthetic pharmacologic agents have been developed to enhance the body's skeleton and to improve outcomes of spinal fusion surgery.

Medical management of acute pain in patients with chronic pain

The number of patients with chronic pain has increased over the years, as well as the number of patients who manage chronic pain with opioids. As prescribed opioid use has increased, so has its abuse and misuse. It has also been estimated that the number of people using opioids illicitly has doubled worldwide over the last 20 years. Management of chronic pain with opioids is associated with pathophysiological phenomena such as tolerance, dependence and hyperalgesia. They can become a problem when chronic pain patients present for a surgical procedure. Furthermore, patients who are on opioids on a regular basis require higher amounts during the perioperative period. The perioperative management of the chronic pain patient is difficult and complex. Developing an appropriate plan that can fulfill patients' and surgical team's needs requires skills and experience. The aim of this review is to describe the options available for the optimal perioperative management of acute pain in patients with a history of chronic pain.

Vertebral compression fractures: a review of current management and multimodal therapy

Vertebral compression fractures are a prevalent disease affecting osteoporotic patients. When symptomatic, they cause significant pain and loss of function and have a high public health impact. In this paper we outline the diagnosis and management of these patients, with evidence-based review of treatment outcomes for the various therapeutic options. Diagnosis involves a clinical history focusing on the nature of the patient’s pain as well as various imaging studies. Management is multimodal in nature and starts with conservative therapy consisting of analgesic medication, medication for osteoporosis, physical therapy, and bracing. Patients who are refractory to conservative management may be candidates for vertebral augmentation through either vertebroplasty or kyphoplasty.

A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery

PURPOSE

Major spine surgery with multilevel instrumentation is followed by large amount of opioid consumption, significant pain and difficult mobilization in a population of predominantly chronic pain patients. This case-control study investigated if a standardized comprehensive pain and postoperative nausea and vomiting (PONV) treatment protocol would improve pain treatment in this population.

METHODS

A new regimen with acetaminophen, NSAIDs, gabapentin, S-ketamine, dexamethasone, ondansetron and epidural local anesthetic infusion or patient controlled analgesia with morphine, was introduced in a post-intervention group of 41 consecutive patients undergoing multilevel (median 10) instrumented spinal fusions and compared with 44 patients in a pre-intervention group.

RESULTS

Compared to patients in the pre-intervention group, patients treated according to the new protocol consumed less opioid on postoperative day (POD) 1 (P = 0.024) and 2 (P = 0.048), they were mobilized earlier from bed (P = 0.003) and ambulation was earlier both with and without a walking frame (P = 0.027 and P = 0.027, respectively). Finally, patients following the new protocol experienced low intensities of nausea, sedation and dizziness on POD 1-6.

CONCLUSIONS

In this study of patients scheduled for multilevel spine surgery, it was demonstrated that compared to a historic group of patients receiving usual care, a comprehensive and standardized multimodal pain and PONV protocol significantly reduced opioid consumption, improved postoperative mobilization and presented concomitant low levels of nausea, sedation and dizziness.

Stress fractures of the pelvis and legs in athletes: a review

CONTEXT

Stress fractures are common injuries in athletes, often difficult to diagnose. A stress fracture is a fatigue-induced fracture of bone caused by repeated applications of stress over time.

EVIDENCE ACQUISITION

PubMed articles published from 1974 to January 2012.

RESULTS

Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis.

CONCLUSIONS

These injuries can lead to substantial lost time from participation. Treatment will vary by fracture location, but most stress fractures will heal with rest and modified weightbearing. Some may require more aggressive intervention, such as prolonged nonweightbearing movement or surgery. Contributing factors should also be addressed prior to return to sports.

Multimodal pain management after spinal surgery for adolescent idiopathic scoliosis

Corrective surgery for scoliosis is an extensive procedure with well-known problems of postoperative pain control. Additional problems with nausea, vomiting, ileus, and sedation can result in delayed mobilization and a prolonged inpatient hospital stay. At our institution, a multimodal approach to pain management has been used to successfully address these issues. The use of intravenous acetaminophen has been a helpful adjunct to our armamentarium of pain medication in this patient population. We present an illustrative case of our use of multimodal analgesia beginning intraoperatively and continuing during the acute inpatient postoperative period.

Effects of a selective cyclooxygenase-2 inhibitor (celecoxib) on fracture healing in rats

BACKGROUND

Several studies suggested that celecoxib interferes with bone healing while others contradict these findings. This study was conducted to investigate the effects of celecoxib on bone healing in rats femur mold with a dose based on body surface area conversion.

MATERIALS AND METHODS

72 adult female Sprague Dawley rats were randomly divided into three groups after the internal fixation operation of nondisplaced transverse mid diaphyseal fractures of the right femurs. Each group was treated with 1% methylcellulose, celecoxib (21 mg/kg/d) for 1 week, or celecoxib (21 mg/kg/d) for 4 weeks after surgeries respectively. Bone healing scores and callus formation were evaluated by radiographs at 3, 4, 6 weeks after surgeries. Half of these rats were sacrificed for histological analysis at 4 weeks after surgery. The remaining fractured femurs were evaluated by biomechanical tests at 6 weeks after surgery.

RESULTS

The mean radiographic scores for fracture healing of both short and long term groups were lower than that of the control group and the differences among the three groups were statistically significant (P < 0.05) at 3, 4, 6 weeks after surgery. The mean bone trabecula density of both groups was smaller than that of the control group and the differences were also statistically significant (P < 0.05) at 4 week. The maximum load, total energy and stiffness in both the short term and long term groups were significantly decreased compared with those in the control group (P < 0.05) at 6 week.

CONCLUSION

Both short term and long term sustained use of celecoxib in rat models has significantly inhibitory effects on rat fracture healing.

Osteoporotic vertebral fractures: current concepts of conservative care

INTRODUCTION

Osteoporotic vertebral compression fractures (VCFs) are a growing public health problem with important socio-economic effects in western countries. In the USA, 10 million people over 50 suffer from osteoporosis. In these patients, 1.5 million annual fractures have been registered, and 50% of these are vertebral compression.

SOURCES OF DATA

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the keywords 'osteoporosis', 'vertebral compression fractures', 'brace', 'bracing', 'orthosis', 'conservative management' and 'rehabilitation' over the years 1966-2011. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context of conservative management of osteoporotic vertebral fractures.

AREAS OF AGREEMENT

Conservative management for patients with osteoporotic vertebral fractures includes bed rest, pain medication, physiotherapy and bracing.

AREAS OF CONTROVERSY

A conservative management for patients with osteoporotic VCFs s has not been standardized. The utility of vertebral augmentation techniques has been questioned by recent randomized controlled trials.

GROWING POINTS

Randomized controlled trials are being performed worldwide on vertebral augmentation techniques.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although spinal orthoses are commonly used for the management of patients with osteoporotic vertebral fractures, in the literature there is only one randomized controlled trial on bracing for this condition. While the best conservative management for subjects with osteoporotic VCFs s is not defined and standardized, no conclusions on the superiority of vertebral augmentation techniques over conservative management can be drawn.

Clinical pharmacology of nonsteroidal anti-inflammatory drugs in dogs

OBJECTIVES

To discuss the clinical pharmacology of currently licensed veterinary NSAIDs and to review gastrointestinal and renal adverse effects as well as drug-drug interactions that have been reported with these drugs. To review the use of NSAIDs in the peri-operative setting and their use in patients with osteoarthritis. To further review the reported effects of NSAIDs on canine articular cartilage and liver as well as the clinical relevance of a washout period.

DATABASES USED

PubMed, CAB abstracts and Google Scholar using dog, dogs, nonsteroidal anti-inflammatory drugs and NSAID(s) as keywords.

CONCLUSIONS

A good understanding of the mechanisms by which NSAIDs elicit their analgesic effect is essential in order to minimize adverse effects and drug-drug interactions. Cyclooxygenase (COX) is present in at least two active isoforms in the body and is the primary pharmacologic target of NSAIDs. Inhibition of COX is associated with the analgesic effects of NSAIDs. COX is present in the gastrointestinal tract and kidneys, along with other areas of the body, and is also the likely reason for many adverse effects including gastrointestinal and renal adverse effects. The newer veterinary approved NSAIDs have a lower frequency of gastrointestinal adverse effects in dogs compared to drugs such as aspirin, ketoprofen and flunixin, which may be due to differential effects on the COX isoforms. There are currently no published reports demonstrating that the newer NSAIDs are associated with fewer renal or hepatic adverse effects in dogs. NSAIDs remain the cornerstone of oral therapy for osteoarthritis unless contraindicated by intolerance, concurrent therapies or underlying medical conditions. NSAIDs are also effective and frequently used for the management of post-operative pain.

The relation between zoledronic acid infusion and interbody fusion in patients undergoing transforaminal lumbar interbody fusion surgery

BACKGROUND

Zoledronic acid (ZOL) has been shown to significantly increase bone mineral density and to decrease the incidence of osteoporotic fractures. However, its safety when used after lumbar interbody fusion surgery remains unclear. We sought to determine whether ZOL infusion 3 days after transforaminal lumbar interbody fusion (TLIF) affects the risk of nonunion.

METHODS

This was a randomized, double-blind, placebo-controlled trial involving subjects who underwent TLIF surgery. Eighty-two subjects (≥50 years of age) were randomly assigned to receive either 5 mg intravenous ZOL (N=41) or placebo (N=41) 3 days after surgery. Each patient received a lumbar computed tomography scan 6 months and 12 months postoperatively. We evaluated interbody fusion using the multiplanar reconstruction technique. Clinical outcome was evaluated with the Oswestry Disability Index. Bone turnover markers (amino terminal propeptides of type I collagen and C-telopeptide of type I collagen) were measured to investigate the biological effects of ZOL on spinal fusion.

RESULTS

In the ZOL group, 7 levels (11.5%) exhibited non-union; in the placebo group, 9 levels (14.5%) exhibited nonunion at 12 months postoperatively. This difference was not statistically significant (P=0.82). The difference in ODI scores between two groups was not statistically significant at any of the follow-up times. However, ZOL decreased bone turnover markers significantly.

CONCLUSIONS

There was no association between ZOL treatment and nonunion of the lumbar spinal bone. Thus, undergoing lumbar interbody fusion surgery is not a valid reason to suspend or avoid treatment with ZOL.

Conservative management of patients with an osteoporotic vertebral fracture

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing.

In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.

Perioperative ketorolac use in children undergoing lower extremity osteotomies

BACKGROUND

Ketorolac has previously been shown to afford good pain relief in children undergoing surgery. Due to concerns about potential complications, particularly nonunion, delayed union, and excessive blood loss, ketorolac use has been limited in pediatric orthopaedics. The goal of this study is to examine complications associated with the perioperative use of ketorolac in children undergoing lower extremity osteotomies.

METHODS

A retrospective review was conducted of 327 consecutive children undergoing osteotomy surgery who had a minimum of 6 months follow-up. Of the 327 patients, 299 patients (625 osteotomies) had received ketorolac perioperatively and 28 (57 osteotomies) had not.

RESULTS

There was no significant difference in the rate of either osseous or soft tissue complications between the 2 groups. There were no nonunions in either of the groups. Delayed union occurred in 5 of 682 osteotomies (0.7%), including 0.6% in the ketorolac group (4/625 osteotomies), and 1.8% (1/57 osteotomies) in the nonketorolac group (P=0.893). Wound complications occurred in 16/327 patients overall (4.9%), including 13/299 (4.3%) in the ketorolac group and 3/28 (10.7%) in the nonketorolac group (P=0.301). There was no significant difference in estimated blood loss (EBL) (P=0.584) or the need for blood transfusion (P=0.777) between the 2 groups. Of the 19 occasions when blood was transfused perioperatively in the ketorolac group, 15 patients had undergone unilateral (3 patients) or bilateral (12 patients) varus derotational osteotomy as part of their surgery. Overall, 15 of 113 patients (13.3%) in the ketorolac group who underwent unilateral or bilateral varus derotational osteotomy required blood transfusion, with rates of 31.8% (7/22) in those who had undergone concomitant pelvic osteotomy(ies) and 8.7% (8/91) in those who had not.

CONCLUSIONS

The results of this study support the safety of perioperative ketorolac use in children undergoing lower extremity osteotomies.

LEVEL OF EVIDENCE

Level III.

Risk of anastomotic leakage with use of NSAIDs after gastrointestinal surgery

PURPOSE

Analgesic regimes to avoid opioid-related adverse effects have been recommended in gastrointestinal surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) are an important component of opioid sparing regimes in that these drugs indirectly reduce pain by inhibiting inflammation. Although beneficial for most surgical patients, animal studies and recent clinical studies suggest a harmful effect on new intestinal anastomoses by increasing the rate of leakage. NSAIDs may indirectly disturb anastomotic healing by inhibiting inflammation as an integrated part of the wound healing process in an early, critical phase after surgery.

METHODS

A literature review based on a structured search in PubMed of clinical and experimental studies investigating the effects of NSAIDs on anastomotic healing and leakage rates after intestinal surgery, as well as proposed mechanisms and effects studied in animal models.

RESULTS

Three recent observational cohort studies (accumulated n = 882) indicate an increased rate of anastomotic leakages (15-21%) associated with cyclooxygenase-2 (COX-2) selective NSAIDs after intestinal surgery compared to the leakage rates in controls or historical cohorts (1-4%). Three prospective studies on related topics contain relevant data on NSAIDs and are compared to these studies. Several experimental animal studies support an increased risk for anastomotic leakage with the use of NSAIDs.

CONCLUSION

The reported effects of NSAIDs on anastomotic healing suggest an increased risk for leakage. A better understanding of the complex interactions of NSAID-induced inhibition on anastomotic healing is a prerequisite for the safe use of NSAIDs. Until more data are available, a careful use of NSAIDs may be warranted in gastrointestinal anastomotic surgery.

Osteoimmunology and osteoporosis

The concept of osteoimmunology is based on growing insight into the links between the immune system and bone at the anatomical, vascular, cellular, and molecular levels. In both rheumatoid arthritis (RA) and ankylosing spondylitis (AS), bone is a target of inflammation. Activated immune cells at sites of inflammation produce a wide spectrum of cytokines in favor of increased bone resorption in RA and AS, resulting in bone erosions, osteitis, and peri-inflammatory and systemic bone loss. Peri-inflammatory bone formation is impaired in RA, resulting in non-healing of erosions, and this allows a local vicious circle of inflammation between synovitis, osteitis, and local bone loss. In contrast, peri-inflammatory bone formation is increased in AS, resulting in healing of erosions, ossifying enthesitis, and potential ankylosis of sacroiliac joints and intervertebral connections, and this changes the biomechanical competence of the spine. These changes in bone remodeling and structure contribute to the increased risk of vertebral fractures (in RA and AS) and non-vertebral fractures (in RA), and this risk is related to severity of disease and is independent of and superimposed on background fracture risk. Identifying patients who have RA and AS and are at high fracture risk and considering fracture prevention are, therefore, advocated in guidelines. Local peri-inflammatory bone loss and osteitis occur early and precede and predict erosive bone destruction in RA and AS and syndesmophytes in AS, which can occur despite clinically detectable inflammation (the so-called 'disconnection'). With the availability of new techniques to evaluate peri-inflammatory bone loss, osteitis, and erosions, peri-inflammatory bone changes are an exciting field for further research in the context of osteoimmunology.

Pulmonary embolism prophylaxis with inferior vena cava filters in trauma patients: a systematic review using the meta-analysis of observational studies in epidemiology (MOOSE) guidelines

Prophylactic inferior vena cava filters (pIVCFs) for the prevention of pulmonary embolism (PE) are controversial. Current practice guidelines (EAST and ACCP) are based on the critical appraisal of observational studies. As a result, their recommendations are conflicting and may account for practice pattern variation. The purpose of this study is to critically review the available literature and ascertain the level of evidence both for and against the use of pIVCFs for PE prophylaxis in trauma patients. We searched PubMed and Web of Science for publications from 1950 until July 2010 that assessed the efficacy of PE prevention with pIVCFs in the trauma population. We followed the MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines for design, implementation, and reporting. The Newcastle-Ottawa Score was used for quality and comparability assessment. Seven observational studies met inclusion criteria for this meta-analysis, representing 1,900 patients. Only one study was published in this decade. The rate of PE was statistically lower in the IVCF group compared to a matched control group without IVCFs (OR 0.21, 95% CI 0.09-0.49). There was no significant difference in DVT. Using the MOOSE criteria these results show a decreased likelihood of PE among trauma patients who receive pIVCFs. Although these results could favor the placement of pIVCFs, the lack of contemporary use of pharmacologic prophylaxis across studies does not allow us to make firm conclusions either for or against the routine use of pIVCFs. Prospective randomized trials are needed to determine the role of pIVCFs in high-risk trauma patients.