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Tekçe G, Arıcan M, Karaduman ZO, Turhan Y, Sağlam S, Yücel MO, Coşkun SK, Tuncer C, Uludağ V. Radiologic and histopathologic effects of favipiravir and hydroxychloroquine on fracture healing in rats. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03147-y. [PMID: 38743116 DOI: 10.1007/s00210-024-03147-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/05/2024] [Indexed: 05/16/2024]
Abstract
Fracture healing is a process in which many factors interact. In addition to many treatments, physical and biological therapy methods that affect different steps of this process, there are many biological and chemical agents that cause fracture union delay. Although the number of studies on fracture healing is increasing day by day, the mechanism of fracture healing, which is not fully understood, still attracts the attention of all researchers. In this study, we aimed to investigate the effects of favipiravir and hydroxychloroquine used in the treatment of COVID-19. In this study, 48 male Wistar rats weighing 300 ± 50 g were used. Each group was divided into eight subgroups of six rats each to be sacrificed at the 2nd and 4th weeks and evaluated radiologically and histologically. Favipiravir (group 1), hydroxychloroquine (group 2), favipiravir + hydroxychloroquine (group 3), and random control (group 4) were used. A statistically significant difference was observed between the 15th day histological scoring averages of the groups (p < 0.05). Although there was no statistically significant difference between the 15th day radiological score distributions of the groups (p > 0.05), we obtained different results in terms of complete bone union distributions and radiological images of the fracture line. Although favipiravir has a negative effect on fracture union in the early period, favipiravir may have a positive effect on fracture union in the late period. We did not find any effect of hydroxychloroquine on fracture union.
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Affiliation(s)
- Giray Tekçe
- Department of Orthopedics and Traumatology, Faculty of Medicine, Duzce University, 81000, Duzce, Turkey
| | - Mehmet Arıcan
- Department of Orthopedics and Traumatology, Faculty of Medicine, Duzce University, 81000, Duzce, Turkey.
| | - Zekeriya Okan Karaduman
- Department of Orthopedics and Traumatology, Faculty of Medicine, Duzce University, 81000, Duzce, Turkey
| | - Yalcın Turhan
- Department of Orthopedics and Traumatology, Faculty of Medicine, Duzce University, 81000, Duzce, Turkey
| | - Sönmez Sağlam
- Department of Orthopedics and Traumatology, Faculty of Medicine, Duzce University, 81000, Duzce, Turkey
| | - Mücahid Osman Yücel
- Department of Orthopedics and Traumatology, Faculty of Medicine, Duzce University, 81000, Duzce, Turkey
| | | | - Cengiz Tuncer
- Department of Neurosurgery, Faculty of Medicine, Duzce University, Duzce, Turkey
| | - Veysel Uludağ
- Department of Orthopedics and Traumatology, Faculty of Medicine, Duzce University, 81000, Duzce, Turkey
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Ryan PM, Scherry H, Pierson R, Wilson CD, Probe RA. NSAID use in orthopedic surgery: A review of current evidence and clinical practice guidelines. J Orthop Res 2024. [PMID: 38273720 DOI: 10.1002/jor.25791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/01/2024] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a valuable class of medications for orthopedic surgeons and often play a pivotal role in pain control. However, there are many common stipulations resulting in avoidance of its use in the treatment of musculoskeletal disease. This review summarizes the mechanism of action of NSAIDs as well as provides an overview of commonly used NSAIDs and the differences between them. It provides a concise summary on the osseous effects of NSAIDs with regard to bone healing and heterotopic ossification. Most of all, it serves as a guide or reference for orthopedic providers when counseling patients on the risks and benefits of NSAID use, as it addresses the common stipulations encountered: "It irritates my stomach," "I have a history of bariatric surgery," "I'm already on a blood thinner," "I've had a heart attack," and "I've got kidney problems" and synthesizes both current research and society recommendations regarding safe use and avoidance of NSAIDs.
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Affiliation(s)
| | | | - Ryan Pierson
- Washington University Orthopaedics, Saint Louis, Missouri, USA
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Stiller CO, Hjemdahl P. Lessons from 20 years with COX-2 inhibitors: Importance of dose-response considerations and fair play in comparative trials. J Intern Med 2022; 292:557-574. [PMID: 35585779 DOI: 10.1111/joim.13505] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit the enzyme cyclooxygenase (COX), which forms prostaglandins involved in pain and inflammation. COX inhibitors have analgesic and anti-inflammatory effects, but also increase risks for gastrointestinal ulcers, bleeding, and renal and cardiovascular adverse events. Identification of two isoforms of COX, COX-1 and COX-2, led to the development of selective COX-2 inhibitors, which were launched as having fewer gastrointestinal side effects since gastroprotective prostaglandins produced via COX-1 are spared. The balance between COX-1 mediated prothrombotic thromboxane and COX-2 mediated antithrombotic prostacyclin is important for thrombotic risk. An increased risk of suffering myocardial infarction and death with COX-2 inhibitor treatment is well established from clinical trials and observational research. Rofecoxib (Vioxx) was withdrawn from the market for this reason, but the equally COX-2 selective etoricoxib has replaced it in Europe but not in the United States. The "traditional" NSAID diclofenac is as COX-2 selective as celecoxib and increases cardiovascular risk dose dependently. COX inhibitor dosages should be lower in osteoarthritis than in rheumatoid arthritis. Randomized trials comparing COX-2 inhibitors with NSAIDs have exaggerated their gastrointestinal benefits by using maximal NSAID doses regardless of indication, and/or hidden the cardiovascular risk by comparing with COX-2 selective diclofenac instead of low-dose ibuprofen or naproxen. Observational studies show increased cardiovascular risks within weeks of treatment with COX-2 inhibitors and high doses of NSAIDs other than naproxen, which is the safest alternative. COX inhibitors are symptomatic drugs that should be used intermittently at the lowest effective dosage, especially among individuals with an increased cardiovascular risk.
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Affiliation(s)
- Carl-Olav Stiller
- Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet and Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet and Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
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Goodnough LH, Ambrosi TH, Steininger HM, Butler MGK, Hoover MY, Choo H, Van Rysselberghe NL, Bellino MJ, Bishop JA, Gardner MJ, Chan CKF. Cross-species comparisons reveal resistance of human skeletal stem cells to inhibition by non-steroidal anti-inflammatory drugs. Front Endocrinol (Lausanne) 2022; 13:924927. [PMID: 36093067 PMCID: PMC9454294 DOI: 10.3389/fendo.2022.924927] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
Fracture healing is highly dependent on an early inflammatory response in which prostaglandin production by cyclo-oxygenases (COX) plays a crucial role. Current patient analgesia regimens favor opioids over Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) since the latter have been implicated in delayed fracture healing. While animal studies broadly support a deleterious role of NSAID treatment to bone-regenerative processes, data for human fracture healing remains contradictory. In this study, we prospectively isolated mouse and human skeletal stem cells (SSCs) from fractures and compared the effect of various NSAIDs on their function. We found that osteochondrogenic differentiation of COX2-expressing mouse SSCs was impaired by NSAID treatment. In contrast, human SSCs (hSSC) downregulated COX2 expression during differentiation and showed impaired osteogenic capacity if COX2 was lentivirally overexpressed. Accordingly, short- and long-term treatment of hSSCs with non-selective and selective COX2 inhibitors did not affect colony forming ability, chondrogenic, and osteogenic differentiation potential in vitro. When hSSCs were transplanted ectopically into NSG mice treated with Indomethacin, graft mineralization was unaltered compared to vehicle injected mice. Thus, our results might contribute to understanding species-specific differences in NSAID sensitivity during fracture healing and support emerging clinical data which conflicts with other earlier observations that NSAID administration for post-operative analgesia for treatment of bone fractures are unsafe for patients.
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Affiliation(s)
- L. Henry Goodnough
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, United States
| | - Thomas H. Ambrosi
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Holly M. Steininger
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - M. Gohazrua K. Butler
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Malachia Y. Hoover
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - HyeRan Choo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | | | - Michael J. Bellino
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, United States
| | - Julius A. Bishop
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, United States
| | - Michael J. Gardner
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, United States
| | - Charles K. F. Chan
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
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Kim H, Kim DH, Kim DM, Kholinne E, Lee ES, Alzahrani WM, Kim JW, Jeon IH, Koh KH. Do Nonsteroidal Anti-Inflammatory or COX-2 Inhibitor Drugs Increase the Nonunion or Delayed Union Rates After Fracture Surgery?: A Propensity-Score-Matched Study. J Bone Joint Surg Am 2021; 103:1402-1410. [PMID: 34101675 DOI: 10.2106/jbjs.20.01663] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The effects of nonsteroidal anti-inflammatory drugs (NSAIDs)/cyclooxygenase (COX)-2 inhibitors on postoperative fracture-healing are controversial. Thus, we investigated the association between NSAID/COX-2 inhibitor administration and postoperative nonunion or delayed union of fractures. We aimed to determine the effects of NSAID/COX-2 inhibitor administration on postoperative fracture-healing with use of a common data model. METHODS Patients who underwent operative treatment of a fracture between 1998 and 2018 were included. To determine the effects of NSAID/COX-2 inhibitor administration on fracture-healing, postoperative NSAID/COX-2 inhibitor users were compared and 1:1 matched to nonusers, with 3,264 patients matched. The effect of each agent on bone-healing was determined on the basis of the primary outcome (nonunion/delayed union), defined as having a diagnosis code for nonunion or delayed union ≥6 months after surgery. The secondary outcome was reoperation for nonunion/delayed union. To examine the effect of NSAIDs/COX-2 inhibitors on bone union according to medication duration, a Kaplan-Meier survival analysis was performed. RESULTS Of the 8,693 patients who were included in the analysis, 208 had nonunion (178 patients; 2.05%) or delayed union (30 patients; 0.35%). Sixty-four (30.8%) of those 208 patients had a reoperation for nonunion or delayed union. NSAID users showed a significantly lower hazard of nonunion compared with the matched cohort of nonusers (hazard ratio, 0.69 [95% confidence interval, 0.48 to 0.98]; p = 0.040) but did not show a significant difference in the other matched comparison for any other outcomes. Kaplan-Meier survival analysis revealed significantly lower and higher nonunion/delayed union rates when the medication durations were ≤3 and >3 weeks, respectively (p = 0.001). For COX-2 inhibitors, the survival curve according to the medication duration showed no significant difference among the groups (p = 0.9). CONCLUSIONS Our study demonstrated no short-term impact of NSAIDs/COX-2 inhibitors on long-bone fracture-healing. However, continued use of these medications for a period of >3 weeks may be associated with higher rates of nonunion or delayed union. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hyojune Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Department of Orthopaedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Do-Hoon Kim
- Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Min Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Erica Kholinne
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Faculty of Medicine, Universitas Trisakti, Department of Orthopedic Surgery, St. Carolus Hospital, Jakarta, Indonesia
| | - Eui-Sup Lee
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Wael Mohammed Alzahrani
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Wan Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Ho Jeon
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyoung Hwan Koh
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Multimodal Nonopioid Pain Protocol Provides Equivalent Pain Versus Opioid Control Following Meniscus Surgery: A Prospective Randomized Controlled Trial. Arthroscopy 2021; 37:2237-2245. [PMID: 33713756 DOI: 10.1016/j.arthro.2021.02.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 02/18/2021] [Accepted: 02/25/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the effectiveness of a nonopioid pain regimen in controlling postoperative pain as compared with a traditional opioid pain control following primary meniscectomy or meniscal repair. METHODS Ninety-nine patients undergoing primary meniscectomy or meniscal repair were assessed for participation. A prospective randomized control trial was performed in accordance with the Consolidated Standards of Reporting Trials 2010 statement. The 2 arms of the study included a multimodal nonopioid analgesic protocol and a standard opioid regimen with a primary outcome of postoperative pain level (visual analog scale) for the first 10 days postoperatively. Secondary outcomes included patient-reported outcomes, complications, and patient satisfaction. Randomization was achieved using a random-number generator. Patients were not blinded. Data collection was done by a blinded observer. RESULTS Eleven patients did not meet the inclusion criteria, and 27 declined participation. A total of 61 patients were analyzed with 30 randomized to the opioid regimen and 31 randomized to the nonopioid regimen. Patients receiving the nonopioid regimen demonstrated noninferior visual analog scale scores compared with patients who received opioid pain medication (P > .05). No significant differences were found in preoperative (opioid: 58.9 ± 7.0; nonopioid: 58.2 ± 5.5, P = .724) or postoperative (opioid: 59.8 ± 6.5; nonopioid: 54.9 ± 7.1, P = .064) Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form scores. No difference was found in recorded side effects between both groups at any given time point: constipation, nausea, diarrhea, upset stomach, and drowsiness (P > .05). CONCLUSIONS This study found that a multimodal nonopioid pain protocol provided equivalent pain control and patient outcomes following primary meniscus surgery while having an equivalent side effect profile. All patients reported satisfaction with their pain management without requiring emergency opioid analgesia. LEVEL OF EVIDENCE Level I, prospective randomized controlled trial.
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Pountos I, Panteli M, Walters G, Giannoudis PV. NSAIDs inhibit bone healing through the downregulation of TGF-β3 expression during endochondral ossification. Injury 2021; 52:1294-1299. [PMID: 33472741 DOI: 10.1016/j.injury.2021.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/21/2020] [Accepted: 01/04/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION & AIMS Non Steroidal Anti-Inflammatory drugs (NSAIDs) are potent inhibitors of post-traumatic pain. Several studies have highlighted that NSAIDs could exert a negative effect on bone healing process possibly by down-regulating chondrogenesis and endochondral ossification. The aim of the study is to explore the potential mechanism though which NSAIDs can affect chondrogenesis. M&M: Trabecular bone from the fracture site was isolated from 10 patients suffering from long bone fractures. Mesenchymal Stem Cells (MSCs) were isolated following collagenase digestion and functional assays to assess the effect of diclofenac sodium on chondrogenesis were performed. Gene expression analysis of 84 key molecules was performed. RESULTS Diclofenac sodium inhibits chondrogenic differentiation and induces a strong inhibition of prostaglandin E-2 (PGE-2) production during chondrogenic differentiation. Replenishment of PGE-2 did not reverse this negative effect. Chondrogenic inhibition is similar in cells treated only for the first week of chondrogenic differentiation or continuously for 3 weeks. Gene analysis shows a strong downregulation of TGF-β3 and FGF-1 while TNF was upregulated. CONCLUSION NSAIDs seem to affect the transition phase of mesenchymal stem cells towards functional chondrocytes. This effect is unrelated to the endogenous production of PGE-2. The downregulation of the expression of key molecules like TGF-β3 seem to be the underlying mechanism.
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Affiliation(s)
- Ippokratis Pountos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, United Kingdom.
| | - Michalis Panteli
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Gavin Walters
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, United Kingdom
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Schug SA. Do NSAIDs Really Interfere with Healing after Surgery? J Clin Med 2021; 10:jcm10112359. [PMID: 34072128 PMCID: PMC8198282 DOI: 10.3390/jcm10112359] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/18/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023] Open
Abstract
Perioperative analgesia should be multimodal to improve pain relief, reduce opioid use and thereby adverse effects impairing recovery. Non-steroidal anti-inflammatory drugs (NSAIDs) are an important non-opioid component of this approach. However, besides potential other adverse effects, there has been a longstanding discussion on the potentially harmful effects of NSAIDs on healing after surgery and trauma. This review describes current knowledge of the effects of NSAIDs on healing of bones, cartilage, soft tissue, wounds, flaps and enteral anastomoses. Overall, animal data suggest some potentially harmful effects, but are contradictory in most areas studied. Human data are limited and of poor quality; in particular, there are only very few good randomized controlled trials (RCTs), but many cohort studies with potential for significant confounding factors influencing the results. The limited human data available are not precluding the use of NSAIDs postoperatively, in particular, short-term for less than 2 weeks. However, well-designed and large RCTs are required to permit definitive answers.
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Affiliation(s)
- Stephan A Schug
- Anaesthesiology and Pain Medicine, Medical School, University of Western Australia, 6000 Perth, Australia
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Zangrilli J, Szukics P, Austin L, Horneff JG. Perioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery. JBJS Rev 2021; 9:e20.00191. [PMID: 33999881 DOI: 10.2106/jbjs.rvw.20.00191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
» Acetaminophen is an effective addition to a multimodal pain regimen; however, evidence to support intravenous versus oral administration requires further evaluation. » While nonsteroidal anti-inflammatory drugs are a valuable addition to a multimodal pain strategy, concerns regarding their effect on healing after certain procedures (i.e., rotator cuff repair) in select patients may preclude their use. » The use of perioperative gabapentinoids have varied results for pain control, and additional research is warranted to support their use after certain shoulder procedures. » Opioid-prescribing should be limited and reserved for severe postoperative pain. When prescribed, opioids should be taken at the lowest possible dose and for the shortest period. » Centrally acting analgesics such as tramadol have been shown to be as effective as opioids and have a lower risk of complications. » Nerve blocks are an excellent addition to multimodal pain management strategies. Longer-lasting formulations of perioperative single-shot injections and indwelling catheters may reduce rebound pain.
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Affiliation(s)
- Julian Zangrilli
- Department of Orthopaedic Surgery, Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | - Patrick Szukics
- Department of Orthopaedic Surgery, Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | - Luke Austin
- Rothman Institute of Orthopaedics at Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - John G Horneff
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Faki Y, Er A. Different Chemical Structures and Physiological/Pathological Roles of Cyclooxygenases. Rambam Maimonides Med J 2021; 12:RMMJ.10426. [PMID: 33245277 PMCID: PMC7835113 DOI: 10.5041/rmmj.10426] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This review describes cyclooxygenase (COX), which synthesizes prostanoids that play an important role in living things. The authors conducted a national and international literature review on the subject. The COX enzyme uses arachidonic acid to form prostanoids, which play a role in several physiological and pathological conditions. This enzyme has different isoforms, mainly COX-1 and COX-2. The constitutive isoform is COX-1, while COX-2 is the inducible isoform. Both are expressed in different tissues and at different levels, but they may also coexist within the same tissue. Both isoforms show essentially the same mode of action, but their substrates and inhibitors may differ. The COX-1 isoform, which plays a role in the continuation of physiological events, has an increased expression level in various carcinomas, and the COX-2 isoform, which is increased in inflammatory conditions, is typically expressed at low physiological levels in some tissues such as the brain, kidney, and uterus. In addition to investigating the efficacies of the COX-1 and COX-2 isoforms, the discovery of potential new COX enzymes and their effect continues. This review also looks at the roles of the COX enzyme in certain physiological and pathological conditions.
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Affiliation(s)
| | - Ayse Er
- To whom correspondence should be addressed. E-mail:
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11
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Yang Y, Zhang T, Jiang M, Yin X, Luo X, Sun H. Effect of the immune responses induced by implants in a integrated three-dimensional micro-nano topography on osseointegration. J Biomed Mater Res A 2020; 109:1429-1440. [PMID: 33253467 DOI: 10.1002/jbm.a.37134] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 12/12/2022]
Abstract
In order to explore the abilities of an integrated three-dimensional micro-nano topography in immunomodulation and promoting bone formation, present study focuses on the titanium sheets used in the micro-nano topography by treating them with the sandblasted, large-grit and acid-etched (SLA)and alkaline thermal reaction. Further, we characterized and obtained the surface morphology, roughness, and hydrophilicity of the titanium sheets. Moreover, we detected their in vitro cytocompatibility and cell proliferation as well. In addition, investigation was carried out for the immunomodulatory ability of the titanium sheets in a micro-nano topography by observing the expression of M1 (classical activated macrophage) and M2 (alternatively activated macrophage) type marker factors, inflammatory factors, and morphological changes of RAW264.7 cells cultured on the titanium sheets in different topographies. Through cell migration experiments and coculture, we observed the effects of different titanium sheet immune environments on osteoblast migration, extracellular matrix mineralization, and osteoblast gene expression. These results showed that the micro-nano topography constructed through SLA and alkaline thermal treatment improved the hydrophilicity and promoted the cell proliferation. Moreover, it promoted RAW264.7 cells to polarize as M2 phenotype, thereby leading to the anti-inflammatory effect of local microenvironments. This facilitated osteoblasts to secrete bone morphogenetic protein-2 (BMP2) and vascular endothelial growth factor. Nonetheless, these findings provided a theoretical basis for the molecular biological mechanism related to implants in a micro-nano topography which promoted the osteointegration while offering a meaningful theoretical basis for the clinical treatment of such implants.
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Affiliation(s)
- Yun Yang
- Department of Prosthodontics, School of Stomatology, Shandong University, Jinan, China.,Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Ting Zhang
- Department of Prosthodontics, School of Stomatology, Shandong University, Jinan, China.,Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
| | - Mengyang Jiang
- Department of Prosthodontics, School of Stomatology, Shandong University, Jinan, China
| | - Xiaojie Yin
- Department of Prosthodontics, School of Stomatology, Shandong University, Jinan, China
| | - Xiayan Luo
- Department of Prosthodontics, School of Stomatology, Shandong University, Jinan, China
| | - Huiqiang Sun
- Department of Prosthodontics, School of Stomatology, Shandong University, Jinan, China.,Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Jinan, China
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Marmor MT, Dailey H, Marcucio R, Hunt AC. Biomedical research models in the science of fracture healing - Pitfalls & promises. Injury 2020; 51:2118-2128. [PMID: 32591215 DOI: 10.1016/j.injury.2020.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/14/2020] [Indexed: 02/02/2023]
Abstract
Development of intervention strategies to stimulate fracture healing has long been a focus of musculoskeletal research. Considerable investment in empirical research has led to the discovery of several genes and signaling pathways that are involved in skeletal development and regeneration. However, there are currently very few biologic interventions that can efficiently be used to enhance fracture healing in clinical practice. This translational barrier is due in part to experimental barriers to mechanism discovery. Animal models, biomechanical models, finite element models, and mathematical models are a few examples of models that aid in the discovery of mechanisms. Understanding the advantages, limitations, and specialized uses of each model type is critical to our ability to interpret mechanistic insights from such research and to help bridge the translation gap between pre-clinical research and clinical practice. In this review, we look at specific modeling methods used in the study of the fracture healing mechanism. We also discuss the strength and limitations to translation of each method, hopefully leading to a better understanding of how we can use models to advance the study of fracture healing.
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Affiliation(s)
- Meir T Marmor
- Department of Orthopaedic Surgery, Zuckerberg San Francisco General Hospital, Orthopaedic Trauma Institute, University of California, San Francisco, CA, United States.
| | - Hannah Dailey
- Department of Mechanical Engineering and Mechanics, Lehigh University, Bethlehem, PA, United States
| | - Ralph Marcucio
- Department of Orthopaedic Surgery, Zuckerberg San Francisco General Hospital, Orthopaedic Trauma Institute, University of California, San Francisco, CA, United States
| | - Anthony C Hunt
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, CA, United States
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McVeigh LG, Perugini AJ, Fehrenbacher JC, White FA, Kacena MA. Assessment, Quantification, and Management of Fracture Pain: from Animals to the Clinic. Curr Osteoporos Rep 2020; 18:460-470. [PMID: 32827293 PMCID: PMC7541703 DOI: 10.1007/s11914-020-00617-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Fractures are painful and disabling injuries that can occur due to trauma, especially when compounded with pathologic conditions, such as osteoporosis in older adults. It is well documented that acute pain management plays an integral role in the treatment of orthopedic patients. There is no current therapy available to completely control post-fracture pain that does not interfere with bone healing or have major adverse effects. In this review, we focus on recent advances in the understanding of pain behaviors post-fracture. RECENT FINDINGS We review animal models of bone fracture and the assays that have been developed to assess and quantify spontaneous and evoked pain behaviors, including the two most commonly used assays: dynamic weight bearing and von Frey testing to assess withdrawal from a cutaneous (hindpaw) stimulus. Additionally, we discuss the assessment and quantification of fracture pain in the clinical setting, including the use of numeric pain rating scales, satisfaction with pain relief, and other biopsychosocial factor measurements. We review how pain behaviors in animal models and clinical cases can change with the use of current pain management therapies. We conclude by discussing the use of pain behavioral analyses in assessing potential therapeutic treatment options for addressing acute and chronic fracture pain without compromising fracture healing. There currently is a lack of effective treatment options for fracture pain that reliably relieve pain without potentially interfering with bone healing. Continued development and verification of reliable measurements of fracture pain in both pre-clinical and clinical settings is an essential aspect of continued research into novel analgesic treatments for fracture pain.
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Affiliation(s)
- Luke G McVeigh
- Department of Orthopaedic Surgery, Indiana University School of Medicine, 1130 W. Michigan St, FH 115, Indianapolis, IN, 46202, USA
| | - Anthony J Perugini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, 1130 W. Michigan St, FH 115, Indianapolis, IN, 46202, USA
| | - Jill C Fehrenbacher
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Fletcher A White
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Melissa A Kacena
- Department of Orthopaedic Surgery, Indiana University School of Medicine, 1130 W. Michigan St, FH 115, Indianapolis, IN, 46202, USA.
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
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Abstract
PURPOSE OF REVIEW The failure of bony union following a fracture, termed a fracture nonunion, has severe patient morbidity and economic consequences. This review describes current consensuses and future directions of investigation for determining why, detecting when, and effective treatment if this complication occurs. RECENT FINDINGS Current nonunion investigation is emphasizing an expanded understanding of the biology of healing. This has led to assessments of the immune environment, multiple cytokines and morphogenetic factors, and the role of skeletogenic stem cells in the development of nonunion. Detecting biological markers and other objective diagnostic criteria is also a current objective of nonunion research. Treatment approaches in the near future will likely be dominated by the development of specific adjunct therapies to the nonunion surgical management, which will be informed by an expanded mechanistic understanding of nonunion biology. Current consensus among orthopedists is that improved diagnosis and treatment of nonunion hinges first on discoveries at the bench side with later translation to the clinic.
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Affiliation(s)
- G Bradley Reahl
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, 02118, USA.
| | - Louis Gerstenfeld
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Michael Kain
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, 02118, USA.
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Cross-Cultural Comparison of Nonopioid and Multimodal Analgesic Prescribing in Orthopaedic Trauma. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e2000051. [PMID: 33970576 PMCID: PMC7434039 DOI: 10.5435/jaaosglobal-d-20-00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: After musculoskeletal injury, US providers prescribe opioids more frequently and at higher dosages than prescribers in the Netherlands and Haiti; however, the extent of variation in nonopioid analgesic prescribing is unknown. The aim of our study was to evaluate how nonopioid prescribing by orthopaedic residents varies by geographic context. Methods: Orthopaedic residents in three countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the United States) responded to surveys using vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for postdischarge analgesia. We quantified the likelihood and dose of acetaminophen or a nonsteroidal anti-inflammatory drug prescription. We constructed multivariable regressions with generalized estimating equations to describe differences in nonopiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. Results: Compared with residents from the United States, residents from Haiti were more likely to prescribe nonopioids (odds ratio, 3.22 [confidence interval, 1.94 to 5.34], P < 0.0001) and residents from the Netherlands nearly always prescribed nonopioids. Of those cases where one or more opioid was prescribed, providers also prescribed a nonopioid (acetaminophen or nonsteroidal anti-inflammatory drug) in 345/603 (57.2%) of US, 152/152 (100%) of Dutch, and 69/97 (71.1%) of Haitian cases (Fisher exact test P value <0.0001). Finally, providers prescribed only nonopioids for pain control in 3/348 (0.86%) of US, 32/184 (17.4%) of Dutch, and 107/176 (60.8%) of Haitian cases (Fisher exact test P < 0.0001). Conclusions: When comparing multimodal analgesic patterns, US prescribers prescribed nonopioid analgesics less frequently than prescribers in two other countries, one low income and one high income, either in isolation or in conjunction with opioids.
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Noble J, Zarling B, Geesey T, Smith E, Farooqi A, Yassir W, Sethuraman U. Analgesia Use in Children with Acute Long Bone Fractures in the Pediatric Emergency Department. J Emerg Med 2020; 58:500-505. [DOI: 10.1016/j.jemermed.2019.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 01/30/2023]
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Main RP, Shefelbine SJ, Meakin LB, Silva MJ, van der Meulen MC, Willie BM. Murine Axial Compression Tibial Loading Model to Study Bone Mechanobiology: Implementing the Model and Reporting Results. J Orthop Res 2020; 38:233-252. [PMID: 31508836 PMCID: PMC9344861 DOI: 10.1002/jor.24466] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/23/2019] [Indexed: 02/04/2023]
Abstract
In vivo, tibial loading in mice is increasingly used to study bone adaptation and mechanotransduction. To achieve standardized and defined experimental conditions, loading parameters and animal-related factors must be considered when performing in vivo loading studies. In this review, we discuss these loading and animal-related experimental conditions, present methods to assess bone adaptation, and suggest reporting guidelines. This review originated from presentations by each of the authors at the workshop "Developing Best Practices for Mouse Models of In Vivo Loading" during the Preclinical Models Section at the Orthopaedic Research Society Annual Meeting, San Diego, CA, March 2017. Following the meeting, the authors engaged in detailed discussions with consideration of relevant literature. The guidelines and recommendations in this review are provided to help researchers perform in vivo loading experiments in mice, and thus further our knowledge of bone adaptation and the mechanisms involved in mechanotransduction. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:233-252, 2020.
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Affiliation(s)
- Russell P. Main
- Department of Basic Medical Sciences and Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA,Corresponding author: Russell Main ()
| | - Sandra J. Shefelbine
- Department of Bioengineering, Department of Mechanical and Industrial Engineering, Northeastern University, Boston, MA, USA
| | - Lee B. Meakin
- Bristol Veterinary School, University of Bristol, Langford, Bristol BS40 5DU, UK
| | - Matthew J. Silva
- Departments of Orthopaedic Surgery and Biomedical Engineering, Musculoskeletal Research Center, Washington University, Saint Louis, MO, USA
| | - Marjolein C.H van der Meulen
- Meinig School of Biomedical Engineering and Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY, USA
| | - Bettina M. Willie
- Research Centre, Shriners Hospital for Children-Canada, Department of Pediatric Surgery, McGill University, Montreal, Canada
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Zhang S, Huo S, Li H, Tang H, Nie B, Qu X, Yue B. Flufenamic acid inhibits osteoclast formation and bone resorption and act against estrogen-dependent bone loss in mice. Int Immunopharmacol 2020; 78:106014. [DOI: 10.1016/j.intimp.2019.106014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/14/2019] [Accepted: 10/28/2019] [Indexed: 12/26/2022]
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Abstract
Prostaglandins (PGs) are highly bioactive fatty acids. PGs, especially prostaglandin E2 (PGE2), are abundantly produced by cells of both the bone-forming (osteoblast) lineage and the bone-resorbing (osteoclast) lineage. The inducible cyclooxygenase, COX-2, is largely responsible for most PGE2 production in bone, and once released, PGE2 is rapidly degraded in vivo. COX-2 is induced by multiple agonists - hormones, growth factors, and proinflammatory factors - and the resulting PGE2 may mediate, amplify, or, as we have recently shown for parathyroid hormone (PTH), inhibit responses to these agonists. In vitro, PGE2 can directly stimulate osteoblast differentiation and, indirectly via stimulation of RANKL in osteoblastic cells, stimulate the differentiation of osteoclasts. The net balance of these two effects of PGE2 in vivo on bone formation and bone resorption has been hard to predict and, as expected for such a widespread local factor, hard to study. Some of the complexity of PGE2 actions on bone can be explained by the fact that there are four receptors for PGE2 (EP1-4). Some of the major actions of PGE2 in vitro occur via EP2 and EP4, both of which can stimulate cAMP signaling, but there are other distinct signaling pathways, important in other tissues, which have not yet been fully elucidated in bone cells. Giving PGE2 or agonists of EP2 and EP4 to accelerate bone repair has been examined with positive results. Further studies to clarify the pathways of PGE2 action in bone may allow us to identify new and more effective ways to deliver the therapeutic benefits of PGE2 in skeletal disorders.
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Affiliation(s)
- Carol Pilbeam
- Department of Medicine and Musculoskeletal Institute, UConn Health, Farmington, CT, USA.
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Hjorthaug GA, Søreide E, Nordsletten L, Madsen JE, Reinholt FP, Niratisairak S, Dimmen S. Short-term perioperative parecoxib is not detrimental to shaft fracture healing in a rat model. Bone Joint Res 2019; 8:472-480. [PMID: 31728186 PMCID: PMC6825043 DOI: 10.1302/2046-3758.810.bjr-2018-0341.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objectives Experimental studies indicate that non-steroidal anti-inflammatory drugs (NSAIDs) may have negative effects on fracture healing. This study aimed to assess the effect of immediate and delayed short-term administration of clinically relevant parecoxib doses and timing on fracture healing using an established animal fracture model. Methods A standardized closed tibia shaft fracture was induced and stabilized by reamed intramedullary nailing in 66 Wistar rats. A ‘parecoxib immediate’ (Pi) group received parecoxib (3.2 mg/kg bodyweight twice per day) on days 0, 1, and 2. A ‘parecoxib delayed’ (Pd) group received the same dose of parecoxib on days 3, 4, and 5. A control group received saline only. Fracture healing was evaluated by biomechanical tests, histomorphometry, and dual-energy x-ray absorptiometry (DXA) at four weeks. Results For ultimate bending moment, the median ratio between fractured and non-fractured tibia was 0.61 (interquartile range (IQR) 0.45 to 0.82) in the Pi group, 0.44 (IQR 0.42 to 0.52) in the Pd group, and 0.50 (IQR 0.41 to 0.75) in the control group (n = 44; p = 0.068). There were no differences between the groups for stiffness, energy, deflection, callus diameter, DXA measurements (n = 64), histomorphometrically osteoid/bone ratio, or callus area (n = 20). Conclusion This study demonstrates no negative effect of immediate or delayed short-term administration of parecoxib on diaphyseal fracture healing in rats. Cite this article: G. A. Hjorthaug, E. Søreide, L. Nordsletten, J. E. Madsen, F. P. Reinholt, S. Niratisairak, S. Dimmen. Short-term perioperative parecoxib is not detrimental to shaft fracture healing in a rat model. Bone Joint Res 2019;8:472–480. DOI: 10.1302/2046-3758.810.BJR-2018-0341.R1.
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Affiliation(s)
- G A Hjorthaug
- Department of Orthopedic Surgery, Martina Hansens Hospital, Sandvika, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo (UIO), Oslo, Norway; Experimental Orthopedic Research, Institute for Surgical Research, Oslo University Hospital (OUS), Oslo, Norway
| | - E Søreide
- Division of Orthopedic Surgery, OUS, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, UIO, Oslo, Norway; Experimental Orthopedic Research, Institute for Surgical Research, OUS, Oslo, Norway
| | - L Nordsletten
- Division of Orthopedic Surgery, OUS, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, UIO, Oslo, Norway; Experimental Orthopedic Research, Institute for Surgical Research, OUS, Oslo, Norway
| | - J E Madsen
- Division of Orthopedic Surgery, OUS, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, UIO, Oslo, Norway; Experimental Orthopedic Research, Institute for Surgical Research, OUS, Oslo, Norway
| | | | - S Niratisairak
- Institute of Clinical Medicine, Faculty of Medicine, UIO, Oslo, Norway; Biomechanics Lab, Division of Orthopedic Surgery, OUS, Oslo, Norway
| | - S Dimmen
- Department of Orthopedic Surgery, Lovisenberg Diaconal Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, UIO, Oslo, Norway; Experimental Orthopedic Research, Institute for Surgical Research, OUS, Oslo, Norway
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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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Gallaher HM, Butler JR, Wills RW, Priddy LB, Elder SH, Heller SM, Brinkman E, Baumgartner W. Effects of short- and long-term administration of nonsteroidal anti-inflammatory drugs on osteotomy healing in dogs. Vet Surg 2019; 48:1318-1329. [PMID: 31291009 DOI: 10.1111/vsu.13282] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/17/2019] [Accepted: 06/18/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the influence of short-term administration of carprofen on bone healing in dogs. STUDY DESIGN Randomized controlled experimental study. ANIMALS Eighteen purpose-bred sexually mature hound dogs. METHODS Tibial osteotomies were performed, and dogs were divided into three groups: no carprofen (n = 6), 2-week administration of carprofen at 2.2 mg/kg twice daily (n = 6), and 8-week administration of carprofen at 2.2 mg/kg twice daily (n = 5). Bone healing was evaluated radiographically at 4 and 8 weeks postoperatively. Postmortem, fracture healing was assessed via biomechanical testing (three-point bending), histological cartilage:callus ratio, and bone mineral density (BMD) with quantitative computed tomography. RESULTS No biomechanical difference was detected between dogs that received no carprofen and those that received 2 weeks of carprofen or between those that received 2 weeks vs 8 weeks of carprofen. Stiffness (P = .035) and maximum stress (P = .042) were higher in dogs that received no carprofen than in those that received 8 weeks of carprofen. Radiographic healing did not differ between dogs without carprofen and those with 2-week administration of carprofen (P = .9923). However, tibias of dogs without carprofen and those with 2-week administration of carprofen were more healed compared with those in the 8-week-carprofen group at 4 and 8 weeks after surgery (P = .0011). No treatment effect was detected by cartilage:callus ratio or BMD. CONCLUSION Long-term administration of carprofen had a negative effect on bone healing compared with short-term or no administration of carprofen. CLINICAL SIGNIFICANCE Nonsteroidal anti-inflammatory drugs should be used cautiously in dogs at risk for delayed bone healing, and administration should be discontinued beyond the perioperative period in dogs with fractures or osteotomies.
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Affiliation(s)
- Hayley M Gallaher
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - James R Butler
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Robert W Wills
- Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Lauren B Priddy
- Department of Agricultural and Biological Engineering, Bagley College of Engineering, Mississippi State University, Mississippi State, Mississippi
| | - Steven H Elder
- Department of Agricultural and Biological Engineering, Bagley College of Engineering, Mississippi State University, Mississippi State, Mississippi
| | - Sarah M Heller
- Department of Agricultural and Biological Engineering, Bagley College of Engineering, Mississippi State University, Mississippi State, Mississippi
| | - Erin Brinkman
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Wes Baumgartner
- Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
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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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Dougherty CD, Hung YY, Weintraub MLR, Patel S, King CM. Osseous and Soft Tissue Complications Associated With Foot and Ankle Surgery in Patients With Rheumatoid Arthritis Taking a Variety of Antirheumatic Medications. J Foot Ankle Surg 2019; 58:508-513. [PMID: 30885450 DOI: 10.1053/j.jfas.2018.09.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Indexed: 02/03/2023]
Abstract
There are multiple antirheumatic drug modalities available to patients with symptomatic rheumatoid arthritis (RA) that function to suppress the overactive immune system, but the inflammatory and immune suppression may contribute to postoperative complications. The purpose of this study was to determine if antirheumatic medications increased the risk of both soft tissue and osseous postoperative complications in patients with RA who underwent foot and ankle surgery. We reviewed patients with RA, aged 18years and older, who underwent either an elective or a nonelective foot or ankle surgery involving an osseous procedure between 2009 and 2014. Chart review was conducted to document procedure type, active medications, and postoperative complications. Of the final 110 subjects meeting inclusion criteria, 31 (28%) patients had a postoperative complication (13 soft tissue, 9 osseous, and 9 both soft tissue and osseous). There was no statistically significant association between taking antirheumatic medications in the perioperative period and postoperative complications. Increased surgery duration and peripheral neuropathy were associated with a statistically significant increase in postoperative complications. Every 15 minutes of increased surgery time led to a 1.2-fold increase in complication risk. Nonelective procedures had a higher risk of soft tissue complications than did elective procedures (odds ratio 4.2, 95% confidence interval 1.1 to 16.0). Although there was no statistically significant association between the specific medication and complications, some medications trended toward statistical significance. When working with patients with RA, our findings suggest the importance of considering the risk of surgery duration and the potential risk of antirheumatic medications in the perioperative period.
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Affiliation(s)
- Colten D Dougherty
- Third-Year Resident, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser San Francisco Bay Area Foot and Ankle Residency, San Francisco, CA
| | - Yun-Yi Hung
- Third-Year Resident, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser San Francisco Bay Area Foot and Ankle Residency, San Francisco, CA
| | - Miranda L Ritterman Weintraub
- Senior Research Project Manager, Graduate Medical Education, Kaiser Permanente Oakland Medical Hospital, Oakland, CA
| | - Sandeep Patel
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics, Kaiser Foundation Hospital, Walnut Creek, CA
| | - Christy M King
- Residency Director, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Foundation Hospital, Oakland, CA.
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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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Bicket MC, White E, Pronovost PJ, Wu CL, Yaster M, Alexander GC. Opioid Oversupply After Joint and Spine Surgery. Anesth Analg 2019; 128:358-364. [DOI: 10.1213/ane.0000000000003364] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Fader L, Whitaker J, Lopez M, Vivace B, Parra M, Carlson J, Zamora R. Tibia fractures and NSAIDs. Does it make a difference? A multicenter retrospective study. Injury 2018; 49:2290-2294. [PMID: 30270011 DOI: 10.1016/j.injury.2018.09.024] [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: 07/11/2018] [Revised: 09/08/2018] [Accepted: 09/09/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare healing time for diaphyseal tibia fractures (OTA/AO 42 A, B, C) treated with intramedullary nailing (IMN) in one geographic cohort using nonsteroidal anti-inflammatory drugs (NSAIDs) for post-operative pain control to that of another geographic cohort using opioid medications. The groups represent differing cultural approaches to post-operative pain control. We hypothesized there would be no difference in healing time. METHODS Tibia fractures presenting at two level I trauma centers located in different countries between January 1, 2010 and December 31, 2017 were retrospectively screened for enrollment. Fractures classified as OTA/AO 42 A, B, or C that were treated with IMN and had radiographic follow up to union were included. At hospital discharge, one cohort (n = 190) was prescribed NSAIDs and the other (n = 182) was prescribed opioids for pain control. Each analgesic method represented the standard of care for that location. Fracture union was defined as cortical bridging in at least 3 out of 4 cortices on AP and lateral radiographs. The primary outcome was healing time on radiographic evaluation. RESULTS There was no statistically significant difference in healing time between the opioid and NSAID groups: 185 vs 180.5 days respectively (p = 0.64). Both groups had similar mean age. Student t-tests were run to compare rates of tobacco use, diabetes mellitus (DM), open fractures, and polytrauma between the two groups. The opioid cohort had statistically significant higher rates of tobacco use, DM, and polytrauma. The NSAID cohort, however, had a larger number of open fractures. CONCLUSION The difference in healing time between the NSAID and opioid groups was not statistically significant. The deleterious effect of NSAID use on fracture healing has been debated for decades. Numerous animal studies have supported this theory; however, high quality clinical studies in humans have not provided convincing evidence to substantiate this negative effect. Our study suggests that NSAIDs may be used safely and effectively in the acute phase of fracture healing without significantly increasing the risk of delayed union or nonunion. Prospective randomized studies are necessary to rule out the negative effect of NSAIDS on bone healing.
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Affiliation(s)
- Lauren Fader
- University of Louisville, Department of Orthopedic Surgery, Louisville, Kentucky, United States.
| | - John Whitaker
- University of Louisville, Department of Orthopedic Surgery, Louisville, Kentucky, United States
| | - Miguel Lopez
- University of Louisville, Department of Orthopedic Surgery, Louisville, Kentucky, United States
| | - Bradley Vivace
- University of Louisville, Department of Orthopedic Surgery, Louisville, Kentucky, United States
| | | | - Jon Carlson
- University of Louisville, Department of Orthopedic Surgery, Louisville, Kentucky, United States
| | - Rodolfo Zamora
- University of Louisville, Department of Orthopedic Surgery, Louisville, Kentucky, United States
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Understanding the Opioid Epidemic: Factors Predictive of Inpatient and Postdischarge Prescription Opioid Use After Orthopaedic Trauma. J Orthop Trauma 2018; 32:e408-e414. [PMID: 30247285 DOI: 10.1097/bot.0000000000001256] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The purpose of this study was to determine which factors influence inpatient and postdischarge opioid use after orthopaedic trauma. DESIGN Retrospective cohort study. SETTING Single Level 1 trauma center. PARTICIPANTS The study included 235 adult trauma patients treated operatively for fracture with minimum 1 overnight hospital stay. INTERVENTION Operative fracture management. MAIN OUTCOME MEASUREMENT Total opioid pain medication use, in oral morphine equivalents, in inpatient and postdischarge settings. RESULTS Controlling for length of stay, inpatient opioid use was negatively correlated with age and positively correlated with Injury Severity Score, intensive care unit (ICU) admission, and baseline tobacco use (P < 0.0001, adjusted R = 0.274). Discharge opioid prescription amount was negatively correlated with age, the presence of a complication, and ICU admission and positively correlated with inpatient opioid use (P < 0.0001, adjusted R = 0.201). Postdischarge opioid use was associated with larger amounts of opioids prescribed at discharge, a patient history of alcohol use at baseline, and ICU admission (P < 0.0001, R = 0.123). CONCLUSION Nonmodifiable factors accounted for the level of inpatient opioid use in a trauma population. Higher inpatient use predicts larger opioid prescriptions at discharge, whereas larger discharge prescription predicts greater postdischarge opioid use. Strategies to reduce postdischarge opioid use should begin with reductions in inpatient opioid use. Multimodal pain strategies may be needed to achieve this goal. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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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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Merrill HM, Dean DM, Mottla JL, Neufeld SK, Cuttica DJ, Buchanan MM. Opioid Consumption Following Foot and Ankle Surgery. Foot Ankle Int 2018; 39:649-656. [PMID: 29506395 DOI: 10.1177/1071100718757527] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
UNLABELLED Background Orthopedic surgeons frequently prescribe pain medications during the postoperative period. The efficacy of these medications at alleviating pain after foot/ankle surgery and the quantity of medication required (and conversely, leftover) are unknown. METHODS Patients undergoing foot/ankle surgery during a 3-month period who met inclusion criteria were surveyed at their first postoperative visit. Information collected included gender, number of prescribed pills remaining, satisfaction with pain control, and willingness to surrender leftover opioids to a Drug Enforcement Administration (DEA) disposal center. Additional data, including utilization of a perioperative nerve block and type (bony versus nonbony) and anatomic region of procedure, were collected through review of the medical record. All data were analyzed in a retrospective fashion. A total of 171 patients with a mean age of 53.1 ± 15.5 years (range, 18-81 years) were included in the study. RESULTS The mean number of opioids taken was 27.2 ± 17.5 pills (range, 0-70). The mean number of short-acting opioids and long-acting opioids taken was 21.4 ± 14.8 and 9.2 ± 5.0 pills, respectively. Most (73.5%) patients were satisfied with their pain control. Patients who underwent ankle/hindfoot surgery took more long-acting opioids on average than others ( P = .047). There was not a significant difference in opioid usage between bony and nonbony procedures. Of those with leftover opioids, 63% were willing to surrender them to a DEA disposal center. Patients willing to surrender leftover medications had both more short-acting ( P < .001) and long-acting ( P = .015) opioids leftover than those not willing to surrender them. CONCLUSION Most patients undergoing foot/ankle surgery had opioids leftover at the first postoperative visit, and most were willing to surrender them. We can adequately treat patients' pain and decrease the number of opioid pills available in the community by decreasing the number of pills prescribed and encouraging disposal of leftovers. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Haley M Merrill
- 1 The Orthopaedic Foot & Ankle Center, a Division of the Center for Advanced Orthopaedics, Falls Church, VA, USA
| | - Daniel M Dean
- 2 Medstar Georgetown University Hospital, Department of Orthopaedic Surgery, Washington, DC, USA
| | - Jay L Mottla
- 2 Medstar Georgetown University Hospital, Department of Orthopaedic Surgery, Washington, DC, USA
| | - Steven K Neufeld
- 1 The Orthopaedic Foot & Ankle Center, a Division of the Center for Advanced Orthopaedics, Falls Church, VA, USA
| | - Daniel J Cuttica
- 1 The Orthopaedic Foot & Ankle Center, a Division of the Center for Advanced Orthopaedics, Falls Church, VA, USA
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Osteoimmunology: Effects of Standard Orthopaedic Interventions on Inflammatory Response and Early Fracture Healing. J Am Acad Orthop Surg 2018; 26:343-352. [PMID: 29659378 DOI: 10.5435/jaaos-d-16-00646] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Achieving fracture union is highly dependent on the initial inflammatory phase of fracture healing, which is influenced by both the local and systemic inflammatory environments. The rapidly emerging field of osteoimmunology involves the study of the interactions between the immune system and the skeletal system. Recent research has advanced the current state of knowledge regarding the effects of the surrounding soft-tissue injury, fracture hematoma, and the method of fracture fixation on the inflammatory phase of fracture healing. Acute systemic inflammation, as seen in patients with polytrauma, and chronic systemic inflammation, as seen in patients with diabetes or rheumatoid arthritis, affects the inflammatory phase of fracture healing. The use of NSAIDs can influence early fracture healing. Understanding the effects of standard orthopaedic interventions on the local and systemic inflammatory responses and early fracture healing is important for optimizing fracture union.
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Houben IB, Raaben M, Van Basten Batenburg M, Blokhuis TJ. Delay in weight bearing in surgically treated tibial shaft fractures is associated with impaired healing: a cohort analysis of 166 tibial fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1429-1436. [PMID: 29633016 PMCID: PMC6132919 DOI: 10.1007/s00590-018-2190-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/21/2018] [Indexed: 02/07/2023]
Abstract
Background The relation between timing of weight bearing after a fracture and the healing outcome is yet to be established, thereby limiting the implementation of a possibly beneficial effect for our patients. The current study was undertaken to determine the effect of timing of weight bearing after a surgically treated tibial shaft fracture. Materials and methods Surgically treated diaphyseal tibial fractures were retrospectively studied between 2007 and 2015. The timing of initial weight bearing (IWB) was analysed as a predictor for impaired healing in a multivariate regression. Results Totally, 166 diaphyseal tibial fractures were included, 86 cases with impaired healing and 80 with normal healing. The mean age was 38.7 years (range 16–89). The mean time until IWB was significantly shorter in the normal fracture healing group (2.6 vs 7.4 weeks, p < 0.001). Correlation analysis yielded four possible confounders: infection requiring surgical intervention, fracture type, fasciotomy and open fractures. Logistic regression identified IWB as an independent predictor for impaired healing with an odds ratio of 1.13 per week delay (95% CI 1.03–1.25). Conclusions Delay in initial weight bearing is independently associated with impaired fracture healing in surgically treated tibial shaft fractures. Unlike other factors such as fracture type or soft tissue condition, early resumption of weight bearing can be influenced by the treating physician and this factor therefore has a direct clinical relevance. This study indicates that early resumption of weight bearing should be the treatment goal in fracture fixation. Level of evidence 3b.
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Affiliation(s)
- I B Houben
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - M Raaben
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M Van Basten Batenburg
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - T J Blokhuis
- Department of Surgery, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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Wei F, Zhou Y, Wang J, Liu C, Xiao Y. The Immunomodulatory Role of BMP-2 on Macrophages to Accelerate Osteogenesis. Tissue Eng Part A 2018; 24:584-594. [DOI: 10.1089/ten.tea.2017.0232] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Fei Wei
- The Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
- The Australia-China Center for Tissue Engineering and Regenerative Medicine (ACCTERM), Queensland University of Technology, Brisbane, Australia
| | - Yinghong Zhou
- The Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
- The Australia-China Center for Tissue Engineering and Regenerative Medicine (ACCTERM), Queensland University of Technology, Brisbane, Australia
| | - Jing Wang
- The Australia-China Center for Tissue Engineering and Regenerative Medicine (ACCTERM), Queensland University of Technology, Brisbane, Australia
- State Key Laboratory of Bioreactor Engineering, East China University of Science and Technology, Shanghai, People's Republic of China
| | - Changsheng Liu
- The Australia-China Center for Tissue Engineering and Regenerative Medicine (ACCTERM), Queensland University of Technology, Brisbane, Australia
- State Key Laboratory of Bioreactor Engineering, East China University of Science and Technology, Shanghai, People's Republic of China
| | - Yin Xiao
- The Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
- The Australia-China Center for Tissue Engineering and Regenerative Medicine (ACCTERM), Queensland University of Technology, Brisbane, Australia
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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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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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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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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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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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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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Thybo KH, Hägi-Pedersen D, Wetterslev J, Dahl JB, Schrøder HM, Bülow HH, Bjørck JG, Mathiesen O. PANSAID - PAracetamol and NSAID in combination: study protocol for a randomised trial. Trials 2017; 18:11. [PMID: 28069072 PMCID: PMC5223299 DOI: 10.1186/s13063-016-1749-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 12/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Effective postoperative pain management is essential for the rehabilitation of the surgical patient. No 'gold standard' exists after total hip arthroplasty (THA) and combinations of different nonopioid medications are used with virtually no evidence for additional analgesic efficacy compared to monotherapy. The objective of this trial is to investigate the analgesic effects and safety of paracetamol and ibuprofen alone and in combination in different dosages after THA. METHODS PANSAID is a placebo-controlled, parallel four-group, multicentre trial with centralised computer-generated allocation sequence and allocation concealment and with varying block size and stratification by site. Blinding of assessor, investigator, caregivers, patients and statisticians. Patients are randomised to four groups: (A) paracetamol 1 g × 4 and ibuprofen 400 mg × 4, (B) paracetamol 1 g × 4 and placebo, (C) placebo and ibuprofen 400 mg × 4 and (D) paracetamol 0.5 g × 4 and ibuprofen 200 mg. The two co-primary outcomes are 24-h consumption of morphine and number of patients with one or more serious adverse events within 90 days after surgery. Secondary outcomes are pain scores during mobilisation and at rest at 6 and 24 h postoperatively, and number of patients with one or more adverse events within 24 h postoperatively. Inclusion criteria are patients scheduled for unilateral, primary THA; age above 18 years; ASA status 1-3; BMI >18 and <40 kg/m2; women must not be pregnant; and provision of informed consent. Exclusion criteria are patients who cannot cooperate with the trial; participation in another trial; patients who cannot understand/speak Danish; daily use of strong opioids; allergy against trial medication; contraindications against ibuprofen; alcohol and/or drug abuse. A total of 556 eligible patients are needed to detect a difference of 10 mg morphine i.v. the first 24 h postoperatively with a standard deviation of 20 mg and a family wise type 1 error rate of 0.025 (two-sided) and a type 2 error rate of 0.10 for the six possible comparisons of the four intervention groups. DISCUSSION We started recruiting patients in December 2015 and expect to finish in September 2017. Data analysis will be from September 2017 to October 2017 and manuscript submission ultimo 2017. TRIAL REGISTRATION EudraCT: 2015-002239-16 (12/8-15); ClinicalTrials.gov: NCT02571361 . Registered on 7 October 2015.
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Affiliation(s)
- Kasper Højgaard Thybo
- Department of Anaesthesiology, Næstved Hospital, Ringstedgade 61, 4700, Næstved, Denmark.
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Næstved Hospital, Ringstedgade 61, 4700, Næstved, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Rigshospitalet, Department 7812, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Jørgen Berg Dahl
- Department of Anaesthesiology, Bispebjerg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
| | | | - Hans Henrik Bülow
- Department of Anaesthesiology, Holbæk Hospital, Smedelundsgade 60, 4300, Holbæk, Denmark
| | - Jan Gottfrid Bjørck
- Department of Orthopedic Surgery, Nykøbing Falster Hospital, Fjordvej 15, 4800, Nykøbing Falster, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital Køge, Lykkebækvej 1, 4600, Køge, Denmark
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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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Ketorolac Administered in the Recovery Room for Acute Pain Management Does Not Affect Healing Rates of Femoral and Tibial Fractures. J Orthop Trauma 2016; 30:479-82. [PMID: 27124828 DOI: 10.1097/bot.0000000000000620] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether ketorolac administered in the immediate perioperative period affects the rate of nonunion in femoral and tibial shaft fractures. DESIGN Retrospective comparative study. SETTING Single Institution, Academic Level 1 Trauma Center. PATIENTS Three hundred and thirteen skeletally mature patients with 137 femoral shaft (OTA 32) and 191 tibial shaft (OTA 42) fractures treated with intramedullary rod fixation. INTERVENTION Eighty patients with 33 femoral shaft and 52 tibial shaft fractures were administered ketorolac within the first 24 hours after surgery (group 1-study group). Two-hundred thirty-three patients with 104 femoral shaft and 139 tibial shaft fractures were not (group 2-control group). MAIN OUTCOME MEASUREMENTS Rate of reoperation for repair of a nonunion and time to union. RESULTS Average time to union of the femur was 147 days for group 1 and 159 days for group 2 (P = 0.57). Average time to union of the tibia was 175 days for group 1 and 175 days for group 2 (P = 0.57). There were 3 femoral nonunions (9%) in group 1 and eleven femoral nonunions (11.6%) in group 2 (P = 1.00). There were 3 tibial nonunions (5.8%) in group 1 and 17 tibial nonunions (12.2%) in group 2 (P = 0.29). The average dose of ketorolac for patients who healed their fracture was 85 mg, whereas it was 50 mg for those who did not (P = 0.27). All patients with a nonunion in the study group were current smokers. CONCLUSIONS Ketorolac administered in the first 24 hours after fracture repair for acute pain management does not seem to have a negative impact on time to healing or incidence of nonunion for femoral or tibial shaft fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Konijnenbelt-Peters J, van der Heijden C, Ekhart C, Bos J, Bruhn J, Kramers C. Metamizole (Dipyrone) as an Alternative Agent in Postoperative Analgesia in Patients with Contraindications for Nonsteroidal Anti-Inflammatory Drugs. Pain Pract 2016; 17:402-408. [DOI: 10.1111/papr.12467] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 04/13/2016] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Corine Ekhart
- Netherlands Pharmacovigilance Centre Lareb; ‘sHertogenbosch the Netherlands
| | - Jacqueline Bos
- Department of Clinical Pharmacy; Canisius Wilhelmina Ziekenhuis; Nijmegen the Netherlands
| | - Jörgen Bruhn
- Department of Anaesthesiology; Radboud UMC; Nijmegen the Netherlands
| | - Cornelis Kramers
- Department of Clinical Pharmacy; Canisius Wilhelmina Ziekenhuis; Nijmegen the Netherlands
- Department of Internal Medicine; Radboud UMC; Nijmegen the Netherlands
- Department of Pharmacology-Toxicology; Radboud UMC; Nijmegen the Netherlands
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Abstract
Delayed union and nonunion of tibial and femoral shaft fractures are common orthopedic problems. Numerous publications address lower extremity long bone nonunions. This review presents current trends and recent literature on the evaluation and treatment of nonunions of the tibia and femur. New studies focused on tibial nonunion and femoral nonunion are reviewed. A section summarizing recent treatment of atypical femoral fractures associated with bisphosphonate therapy is also included.
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Affiliation(s)
- Anthony Bell
- Department of Orthopaedics and Rehabilitation, Ambulatory Care Center, University of Florida College of Medicine-Jacksonville, 2nd Floor, 655 West 8th Street, C126, Jacksonville, FL 32209, USA
| | - David Templeman
- Department of Orthopaedics, Hennepin County Medical Center, University of Minnesota, 701 Park Avenue S, Minneapolis, MN 55404, USA.
| | - John C Weinlein
- Regional One Health, University of Tennessee-Campbell Clinic, Memphis, TN, USA
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Bottlang M, Tsai S, Bliven EK, von Rechenberg B, Klein K, Augat P, Henschel J, Fitzpatrick DC, Madey SM. Dynamic Stabilization with Active Locking Plates Delivers Faster, Stronger, and More Symmetric Fracture-Healing. J Bone Joint Surg Am 2016; 98:466-74. [PMID: 26984914 PMCID: PMC4788849 DOI: 10.2106/jbjs.o.00705] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Axial dynamization of fractures can promote healing, and overly stiff fixation can suppress healing. A novel technology, termed active plating, provides controlled axial dynamization by the elastic suspension of locking holes within the plate. This prospective, controlled animal study evaluated the effect of active plates on fracture-healing in an established ovine osteotomy model. We hypothesized that symmetric axial dynamization with active plates stimulates circumferential callus and delivers faster and stronger healing relative to standard locking plates. METHODS Twelve sheep were randomly assigned to receive a standard locking plate or an active locking plate for stabilization of a 3-mm tibial osteotomy gap. The only difference between plates was that locking holes of active plates were elastically suspended, allowing up to 1.5 mm of axial motion at the fracture. Fracture-healing was analyzed weekly on radiographs. After sacrifice at nine weeks postoperatively, callus volume and distribution were assessed by computed tomography. Finally, to determine their strength, healed tibiae and contralateral tibiae were tested in torsion until failure. RESULTS At each follow-up, the active locking plate group had more callus (p < 0.001) than the standard locking plate group. At postoperative week 6, all active locking plate group specimens had bridging callus at the three visible cortices. In standard locking plate group specimens, only 50% of these cortices had bridged. Computed tomography demonstrated that all active locking plate group specimens and one of the six standard locking plate group specimens had developed circumferential callus. Torsion tests after plate removal demonstrated that active locking plate group specimens recovered 81% of their native strength and were 399% stronger than standard locking plate group specimens (p < 0.001), which had recovered only 17% of their native strength. All active locking plate group specimens failed by spiral fracture outside the callus zone, but standard locking plate group specimens fractured through the osteotomy gap. CONCLUSIONS Symmetric axial dynamization with active locking plates stimulates circumferential callus and yields faster and stronger healing than standard locking plates. CLINICAL RELEVANCE The stimulatory effect of controlled motion on fracture-healing by active locking plates has the potential to reduce healing complications and to shorten the time to return to function.
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Affiliation(s)
- Michael Bottlang
- Portland Biomechanics Laboratory, Legacy Research Institute, Portland, Oregon,E-mail address for M. Bottlang:
| | - Stanley Tsai
- Portland Biomechanics Laboratory, Legacy Research Institute, Portland, Oregon
| | - Emily K. Bliven
- Portland Biomechanics Laboratory, Legacy Research Institute, Portland, Oregon
| | | | - Karina Klein
- Musculoskeletal Research Unit, Vetsuisse Faculty, University of Zürich, Zürich, Switzerland
| | - Peter Augat
- Institute of Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Julia Henschel
- Institute of Biomechanics, Trauma Center Murnau, Murnau, Germany
| | | | - Steven M. Madey
- Portland Biomechanics Laboratory, Legacy Research Institute, Portland, Oregon
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Palmer GM. Pain management in the acute care setting: Update and debates. J Paediatr Child Health 2016; 52:213-20. [PMID: 27062626 DOI: 10.1111/jpc.13134] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 11/26/2015] [Accepted: 11/26/2015] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Greta M Palmer
- Department of Anaesthesia and Pain Management, Royal Children's Hospital.,Murdoch Children's Research Institute.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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