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Improve healing with intrawound use of vancomycin
Local application of vancomycin powder may offer a promising means to prevent postoperative infection after the open release of post-traumatic stiff elbows. Despite improvements in wound healing with intravenously administered prophylactic antibiotics and technical refinements, elbow infections still occur after some elective elbow operations.
Investigators conducted a retrospective review of 272 patients during a 4-year period. The control group (93 patients) received simple prophylaxis with standard, intravenously administered antibiotics. In the vancomycin group (179 patients), vancomycin powder was applied directly into the wound before closure along with standard, intravenously administered antibiotic prophylaxis.
After a follow-up period of at least 6 months, the control group had 6 infections (6.45%) compared with no infections in the vancomycin group, which was a statistically significant difference. No adverse effects were observed from open-wound use of vancomycin powder.
Source: Yan H, He J, Chen S, et al. Intrawound application of vancomycin reduces wound infection after open release of post-traumatic stiff elbows: a retrospective comparative study. J Shoulder Elbow Surg. 2014;23(5):686-692.
Is physical therapy effective for hip osteoarthritis?
Limited evidence supports the use of physical therapy for treatment of hip osteoarthritis. A new study suggests that physical therapy is not more effective than placebo for improving pain or function in adults with painful hip osteoarthritis. The findings raise questions about the value of physical therapy for these patients.
Investigators conducted a randomized, placebo-controlled, participant- and assessor-blinded trial in 102 adults. Inclusion criteria were hip pain levels of at least 40 mm on a 100-mm visual analog scale (range, 0-100 mm; 100 indicates worst pain possible) and hip osteoarthritis confirmed by radiograph. Forty-nine patients in the active group and 53 patients in the sham group underwent 12 weeks of intervention and 24 weeks of follow-up.
Participants attended 10 treatment sessions during a 12-week period. Active treatment included education and advice, manual therapy, home exercise, and gait aid if appropriate. Sham treatment included inactive ultrasonography and application of inert gel. For 24 weeks after treatment, the active group continued unsupervised home exercise, and the sham group self-applied inert gel 3 times weekly.
Primary outcomes were average pain and physical function at week 13, as assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). WOMAC function scores range from 0 (no difficulty) to 68 (extreme difficulty). Secondary outcomes were WOMAC pain and function scores at week 36 and impairments, physical performance, global change, psychological status, and quality of life at weeks 13 and 36.
Ninety-six patients (94%) completed week 13 measurements and 83 (81%) completed week 36 measurements. The between-group differences for improvements in pain were not significant. In the active group, the baseline average visual analog scale score was 58.8 mm (standard deviation [SD] 13.3) and the week-13 score was 40.1 mm (SD 24.6); in the sham group, the baseline score was 58.0 mm (SD 11.6) and the week-13 score was 35.2 mm (SD 21.4). The mean difference was 6.9 mm in favor of sham treatment.
The function scores were not significantly different between groups. The baseline average physical function score for the active group was 32.3 (SD 9.2), and the week-13 score was 27.5 units(SD 12.9). For the sham group, the baseline score was 32.4 units (SD 8.4), and the week-13 score was 26.4 units (SD 11.3). The mean difference was 1.4 units in favor of the sham group at week 13.
The only between-group difference in secondary outcomes was greater week-13 improvement in the balance step test in the active group. Nineteen of 46 patients (41%) in the active group reported 26 mild adverse effects, and 7 of 49 patients (14%) in the sham group reported 9 mild adverse events.
Source: Bennell KL, Egerton T, Martin J, et al. Effect of physical therapy on pain and function in patients with hip osteoarthritis: a randomized clinical trial. JAMA. 2014;311(19):1987-1997.
NSAIDs or corticosteroids for shoulder pain?
Nonsteroidal anti-inflammatory drugs (NSAIDs) are less effective than corticosteroid injections for patients with shoulder pain, suggest results from a recent meta-analysis. Investigators evaluated the drugs' effects over 4 to 6 weeks.
Six high-quality, randomized clinical trials (RCTs) that compared corticosteroid injection with NSAIDs for treatment of shoulder pain in 267 patients were included in the meta-analysis. The primary outcome was remission. Secondary outcomes were pain relief and improvement in range of active abduction.
For remission, NSAIDs were less effective than corticosteroids at 4 and 6 weeks. The 2 types of drugs did not significantly differ in pain relief or improvement in range of active abduction.
Given the limited number of studies and small size of each trial, the results should be interpreted with caution, investigators advise. More high-quality investigations are needed to evaluate the effectiveness of NSAIDs and corticosteroids for shoulder pain.
Source: Zheng XQ, Li K, Wei YD, et al. Non-steroidal anti-inflammatory drugs versus corticosteroid for treatment of shoulder pain: A systematic review and meta-analysis. Arch Phys Med Rehabil. 2014 May 16. pii: S0003-9993(14)00345-1. [Epub ahead of print]
How likely are fractures after alendronate therapy stops?
Clinicians are increasingly considering stopping bisphosphonate therapy after 3 to 5 years, but what are the risks of fracture during the subsequent 5 years? Among postmenopausal women who stop alendronate therapy after 4 to 5 years, age and hip bone mineral density at discontinuation are the greatest predictors of fractures during the next 5 years.
The prospective Fracture Intervention Trial Long-term Extension (FLEX) study randomized postmenopausal women, 61 to 86 years of age and previously treated with 4 to 5 years of alendronate therapy, to 5 more years of alendronate or placebo. The current analysis includes only the placebo group.
Investigators measured hip and spine bone mineral density (BMD) with dual-energy x-ray absorptiometry (DXA) when the women switched to placebo therapy (considered baseline) and after 1 to 3 years of follow-up. Two biochemical markers of bone turnover, urinary type 1 collagen cross-linked N-telopeptide (NTX) and serum bone-specific alkaline phosphatase (BAP), also were measured at baseline and after 1 and 3 years.
During 5 years of taking a placebo, 94 of 437 women (22%) experienced at least one symptomatic fracture; 82 had fractures after 1 year. One-year changes in hip DXA, NTX, and BAP results were not related to subsequent fracture risk, but higher age and lower hip BMD as measured by DXA at time of discontinuation were significantly related to increased fracture risk.
Follow-up measurements of DXA 1 year after discontinuation and of BAP or NTX 1 to 2 years after discontinuation are not associated with fracture risk.
Source: Bauer DC, Schwartz A, Palermo L, et al. Fracture prediction after discontinuation of 4 to 5 years of alendronate therapy: The FLEX study. JAMA Intern Med. 2014 May 5. [Epub ahead of print]
Linking postoperative delirium and mortality
In older adults who undergo hip fracture surgery, the duration of postoperative delirium is an important prognostic factor for 6-month mortality, a new report suggests. It is crucial to reduce the duration of delirium after surgery for these patients, investigators advise.
The findings are based on a prospective cohort study involving 199 patients (average age, 84 years). All patients underwent surgery for hip fracture and were followed-up for 6 months.
Postoperative delirium was assessed daily using the Confusion Assessment Method Algorithm and the Diagnostic and Statistical Manual of Mental Disorders criteria. Investigators accounted for several variables, including age, prefracture residence, Katz Activities of Daily Living Scale score, New Mobility Score, diagnosis of prefracture dementia, American Society of Anesthesiologists Score, albumin serum levels, Charlson Comorbidity Index score, and length of hospital stay.
Fifty-seven patients (28.6%) developed postoperative delirium. In the 6 months after surgery, 35 patients (17.6%) died. Of the 35 patients who died, 16 were among the 57 (28.1%) who had postoperative delirium, and 19 were among the 142 patients (13.4%) who did not experience postoperative delirium. The average duration of postoperative delirium was 2 days for participants from this group who died and 0.7 days for those who survived. After adjusting for covariates, each day of postoperative delirium increased the risk of dying during the next 6 months by 17%.
Source: Bellelli G, Mazzola P, Morandi A, et al. Duration of postoperative delirium is an independent predictor of 6-month mortality in older adults after hip fracture. J Am Geriatr Soc. 2014 Jun 2. [Epub ahead of print]
Albumin levels predict adverse effects after spine fusion
Preoperative hypoalbuminemia is an independent risk factor for postoperative adverse effects after elective spine surgery for degenerative and deformity causes, new study findings suggest. Physicians should use preoperative albumin levels to detect malnutrition and determine the risk of adverse surgical outcomes, investigators advise.
The prevalence of malnutrition in the hospitalized patient population recently has been recognized. Preoperative hypoalbuminemia, defined as serum albumin level less than 3.5 g/dL, has been associated with increased morbidity and mortality. To determine the effect of hypoalbuminemia on patients undergoing spinal fusion, investigators reviewed the medical records of 136 consecutive patients who had the procedure.
Preoperative serum albumin level was assessed for all patients and used to quantify nutritional status. Patients with serum albumin levels less than 3.5 g/dL were categorized as having hypoalbuminemia and being malnourished. Patient demographics, comorbidities, and rates of postoperative adverse effects were collected. Patients were also categorized into 2 groups based on their reasons for undergoing spinal fusion: elective degenerative/deformity or nonelective cases.
In all, 40 patients (29.4%) experienced at least 1 postoperative adverse effect. In patients undergoing elective surgery, preoperative albumin levels predicted a higher rate of adverse effects. The adverse effect rate among those who were malnourished was 35.7%, compared with 11.7% in those who were adequately nourished. In contrast, those undergoing nonelective surgery had similar adverse effect rates regardless of their albumin levels (malnourished, 46.5%; nourished, 42.1%). For patients undergoing elective spinal surgery, preoperative serum albumin level was a significant predictor of postoperative adverse effects.
Source: Adogwa O, Martin JR, Huang K, et al. Preoperative serum albumin level as a predictor of postoperative complication after spine fusion. Spine (Phila Pa 1976). 2014 May 28. [Epub ahead of print]
Determining factors for poor outcomes after ACL reconstruction
Both articular cartilage injury and meniscal tears or treatment at the time of anterior cruciate ligament reconstruction (ACLR) are significant predictors of long-term recovery, according to results from a new study. The level of recovery was determined by use of International Knee Documentation Committee (IKDC) score and Knee injury and Osteoarthritis Outcome Score (KOOS) 6 years after ACLR. Likewise, a grade 4 medial femoral condyle lesion significantly reduced a patient's Marx Activity Level score at 6 years.
For the study, 1512 patients who had ACLR were prospectively enrolled and followed longitudinally, with the IKDC, KOOS, and Marx activity rating score completed at the start of the study and at 2 and 6 years. A logistical regression model incorporated several variables, including patient demographics, surgical technique, articular cartilage injuries, and meniscal tears or treatment.
In all, 86% of participants completed the 6-year study. The cohort was 56% male and had a median age of 23 years at the time of enrollment, with 76% of participants reporting a noncontact injury mechanism. Concomitant injuries at surgery include articular cartilage lesions (medial femoral condyle, 25%; lateral femoral condyle, 20%; medial tibial plateau, 6%; lateral tibial plateau, 12%; patella, 20%; trochlea, 9%) and meniscus tears(medial, 38%; lateral, 46%).
Both articular cartilage lesions and meniscus tears were significant predictors of 6-year IKDC and KOOS outcomes. Grade 3 or 4 articular cartilage lesions, excluding patella, significantly reduced IKDC and KOOS results at 6 years. Grade 3 or 4 chondral lesions on the medial femoral condyle, medial tibial plateau, and lateral femoral condyle were associated with worse IKDC outcomes scores. Cartilage injury negatively affected KOOS results. The only significant predictor of reduced Marx activity rating score was the presence of a grade 4 lesion on the medial femoral condyle.
Lateral meniscal repairs were not associated with inferior results, but medial meniscal repairs predicted worse IKDC and KOOS results. Lateral meniscus tears that were left alone significantly improved prognosis. Patients undergoing small partial meniscectomy (?33%) on the medial meniscus fared worse than those who underwent larger excision (>50%) on either the medial or lateral meniscus, which improved prognosis.
Similar to previous studies, other significant predictors of lower outcome scores were lower baseline scores, higher body mass index, lower education level, smoking, and anterior cruciate ligament revisions.
Source: Cox CL, Huston LJ, Dunn WR, et al. Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and Marx activity level outcomes after anterior cruciate ligament reconstruction? A 6-year multicenter cohort study. Am J Sports Med. 2014;42(5):1058-1067.
Comparing two treatments for OA of the trapeziometacarpal joint
Both trapeziectomy with ligament reconstruction and tendon interposition and trapeziometacarpal arthrodesis are commonly performed procedures for the treatment of osteoarthritis (OA) of the thumb trapeziometacarpal joint. Which treatment is more effective?
Women who were at least 40 years of age were randomized either to trapeziectomy with ligament reconstruction and tendon interposition or to arthrodesis with plate and screws. Investigators assessed patients preoperatively and at 3 and 12 months after surgery with respect to pain, function (Patient-Rated Wrist/Hand Evaluation [PRWHE] and Disabilities of the Arm, Shoulder and Hand [DASH] questionnaires), joint motion, strength, adverse effect rate, and patient satisfaction.
The study enrolled 43 women before it was stopped early because of a significantly higher percentage of severe adverse effects after arthrodesis compared with trapeziectomy with ligament reconstruction and tendon interposition (71% versus 29%). The higher adverse effect rate for arthrodesis led to an increased rate of revision surgery (2 of 17 patients). In addition, significantly more patients (86%) in the group that underwent ligament reconstruction and tendon interposition reported that they would consider the same operation again, under the same circumstances, compared with the arthrodesis group (53%).
Investigators concluded that women who are at least 40 years of age with trapeziometacarpal osteoarthritis have fewer moderate and severe adverse effects after trapeziectomy with ligament reconstruction and tendon interposition and are more likely to consider the surgery again under the same circumstances than are those who undergo arthrodesis. However, 12 months after surgery, PRWHE and DASH scores were similar in both groups. Nonetheless, investigators do not recommend routine use of arthrodesis with plate and screws to treat women with stage II or III trapeziometacarpal osteoarthritis.
Source: Vermeulen GM, Brink SM, Slijper H, et al. Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary trapeziometacarpal osteoarthritis: a randomized controlled trial. J Bone Joint Surg Am. 2014 May 7;96(9):726-733.
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