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Österreichische Gesellschaft für Orthopädie und Orthopädische Chirurgie
Österreichische Gesellschaft für Rheumatologie Offizielles Organ der
Österreichischen Gesellschaft zur Erforschung des Knochens und Mineralstoffwechsels
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News-Screen Orthopädie Pieler-Bruha E
Journal für Mineralstoffwechsel &
Muskuloskelettale Erkrankungen
2013; 20 (4), 168-169
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168 J MINER STOFFWECHS 2013; 20 (4)
News-Screen Orthopädie
E. Pieler-Bruha
Postoperative Occipital Neuralgia With and Without C2 Nerve Root Transection During Atlantoaxial Screw Fixation: A Post-Hoc Comparative Outcome Study of Prospectively Collected Data
Yeom JS, et al. Spine J 2013; 13: 786–95.
Abstract
Background: Although routine transection of the C2 nerve root during atlantoaxial segmental screw fixation has been recommended by some surgeons, it remains controversial and to our knowledge no comparative studies have been performed to determine whether transection or preserva- tion of the C2 nerve root affects patient-derived sensory outcomes. Purpose: The purpose of this study is to specifi- cally analyze patient-derived sensory outcomes over time in patients with intentional C2 nerve root transection dur- ing atlantoaxial segmental screw fixation compared with those without transection. Study design: This is a post-hoc comparative analysis of prospectively collected patient-de- rived outcome data. Patient sample: The sample consists of 24 consecutive patients who underwent intentional bilateral transection of the C2 nerve root during posterior atlantoax- ial segmental screw fixation (transection group) and subse- quent 41 consecutive patients without transection (preser- vation group). Outcome measures: A visual analog scale (VAS) score was used for occipital neuralgia as the primary outcome measure and VAS score for neck pain, neck dis- ability index score and Japanese Orthopedic Association score for cervical myelopathy and recovery rate, with bone union rate as the secondary outcome measure. Methods:
Patient-derived outcomes including change in VAS score for occipital neuralgia over time were statistically compared between the two groups. This study was not supported by any financial sources and there is no topic-specific conflict of interest related to the authors of this study. Results: Seven (29 %) of the 24 patients in the transection group experi- enced increased neuralgic pain at 1 month after surgery either because of newly developed occipital neuralgia or aggravation of preexisting occipital neuralgia. Four of the seven patients required almost daily medication even at the final follow-up (44 and 80 months). On the other hand, only four (10 %) of 41 patients in the preservation group had increased neuralgic pain at 1 month after surgery, and at
≥ 1 year, no patients had increased neuralgic pain. The dif- ference in the prevalence of increased neuralgic pain be- tween the two groups was statistically significant at all time points (3, 6, 12, and 24 months postoperatively) except at 1 month postoperatively. The intensity of neuralgic pain, which preoperatively had not been significantly different between the two groups, was significantly higher in the transection group at the final follow-up. Conclusions: C2 nerve root transection is not a benign procedure and, in our experi- ence, more than a quarter of the patients experience in-
creased neuralgic pain following C2 nerve root transection.
Because the prevalence and intensity of postoperative neu- ralgia was significantly higher with C2 nerve root transec- tion than with its preservation, we recommend against rou- tine C2 nerve root transection when performing atlantoaxial segmental screw fixation.
Kommentar
In dieser Studie aus Seoul wurde die Entstehung einer Okzipital- neuralgie postoperativ nach einer atlantoaxialen Schrauben- osteosynthese mit und ohne C2-Nervendurchtrennung unter- sucht. Postoperativ wurden 24 Patienten in die „Durchtrennungs- gruppe“ und 41 in die „Erhaltungsgruppe“ eingeteilt. Es wurden postoperativ Neuralgieschmerz, Nackenschmerz, Beweglich- keit, Funktion, zervikale Myelopathie und Knochenfusion un- tersucht. Signifikant niedriger waren in der „Erhaltungsgruppe“
die Werte der Okzipitalneuralgieentstehung sowie die Intensi- tät von neuralgischen Okzipitalschmerzen.
Relevanz für die Praxis
Bei einer atlantoaxialen Schraubenfusion sollte eine Durch- trennung des C2-Nervs wenn möglich vermieden werden.
A Multicentre, Randomized, Placebo- and Active-Controlled Trial Comparing the Efficacy and Safety of Topical Ketoprofen in Transfersome Gel (IDEA-033) with Ketoprofen-Free Vehicle (TDT 064) and Oral Celecoxib for Knee Pain Associated with Osteoarthritis
Conaghan PG, et al. Rheumatology (Oxford) 2013; 52: 1303–12.
Abstract
Objective: To assess the efficacy and safety of 12-week treat- ment with ketoprofen in ultradeformable phospholipid ves- icles in patients with OA knee pain and to compare the effi- cacy with that of ketoprofen-free vehicle and celecoxib.
Methods: A multicentre, double-blind controlled study in which patients with knee OA and moderate pain were randomized to one of the six arms: topical ketoprofen 50 or 100 mg in ultradeformable vesicles (IDEA-033), 2.2 or 4.4 g ketopro- fen-free vehicle (TDT 064), oral celecoxib 100 mg or match- ing oral placebo, all bd. The primary outcome was change from baseline in the WOMAC pain subscale at week 12.
Results: A total of 1395 patients received treatment. Base- line mean WOMAC pain scores ranged from 4.7 to 4.8 across groups. The mean reduction in WOMAC pain score at week 12 was –1.9 (–40.8 %) for ketoprofen 50 mg, –1.9 (–40.9 %) for ketoprofen 100 mg, –1.9 (–39.8 %) for 2.2 g TDT 064, –1.8 (–37.8 %) for 4.4 g TDT 064, –1.9 (–40.4 %) for celecoxib
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J MINER STOFFWECHS 2013; 20 (4) 169 News-Screen Orthopädie
and –1.4 (–29.3 %) for oral placebo. IDEA-033 was not sta- tistically superior to TDT 064. All topical treatments were statistically superior to oral placebo and non-inferior to celecoxib. The most frequent types of treatment-related ad- verse events reported were gastrointestinal for oral (15.9 % for celecoxib) and dermal for topical applications (12.2 % for ketoprofen 100 mg). Conclusion: IDEA-033 was not superior to ketoprofen-free vehicle, but both formulations were superior to oral placebo and non-inferior to celecoxib in reducing OA knee pain.
Kommentar
In der Juliausgabe von Rheumatology fand sich diese Vergleichs- studie von dem neuen Transfersomegel (Flexiseq) gegen Trans- fersomegel mit Zusatz Ketoprofen gegen Ketoprofengel gegen Celecoxib per os. Nachdem das neue Transfersomegel sich als überlegen zu Celecoxib per os herausgestellt hatte, sollte un- tersucht werden, ob die Kombination der transformierbaren Phospholipide mit Ketoprofen noch wirksamer ist. Es wurden 1395 Probanden mit Ketoprofengel, Transfersomegel plus Ketoprofen, Trasfersomegel, Celecoxob 100 mg per os oder Placebo behandelt. Es zeigte sich eine Überlegenheit gegen- über Placebo von allen Therapeutika, es konnte jedoch keine Verbesserung der Wirksamkeit des Transfersomegels mit oder ohne Ketoprofen gefunden werden. Alle lokalen Therapeutika waren wirksamer als Celecoxib per os, jedoch nicht signifi- kant. Es wurden aber bei Celecoxib signifikant mehr Magen- Darm-Probleme angegeben.
Relevanz für die Praxis
Bei der konservativen Therapie der Osteoarthrose am Knie- gelenk bringt ein Ketoprofenzusatz zu dem lokal applizier- baren Transfersomegel keine verbesserte Wirksamkeit. Auf- grund von Magen-Darm-Problemen bei oralem Celecoxib ist das topische Transfersomegel zu bevorzugen.
A Systematic Review and Meta-Regres- sion of Mobile-Bearing Versus Fixed- Bearing Total Knee Replacement in 41 Studies
van der Voort P, et al. Bone Joint J 2013; 95-B: 1209–16.
Abstract
Mobile-bearing (MB) total knee replacement (TKR) was introduced to reduce the risk of aseptic loosening and wear
of polyethylene inserts. However, no consistent clinical ad- vantages of mobile- over fixed-bearing (FB) TKR have been found. In this study we evaluated whether mobile bearings have an advantage over fixed bearings with regard to revi- sion rates and clinical outcome scores. Furthermore, we determined which modifying variables affected the outcome.
A systematic search of the literature was conducted to col- lect clinical trials comparing MB and FB in primary TKR.
The primary outcomes were revision rates for any reason, aseptic loosening and wear. Secondary outcomes included range of movement, Knee Society score (KSS), Oxford knee score (OKS), Short-Form 12 (SF-12) score and radiologi- cal parameters. Meta-regression techniques were used to explore factors modifying the observed effect.
Our search yielded 1827 publications, of which 41 studies met our inclusion criteria, comprising over 6000 TKRs.
Meta-analyses showed no clinically relevant differences in terms of revision rates, clinical outcome scores or patient- reported outcome measures between MB and FB TKRs. It appears that theoretical assumptions of superiority of MB over FB TKR are not borne out in clinical practice.
Kommentar
In diesem niederländischen Review wurden die Ergebnisse nach Knietotalendoprothesen mit „Mobile-bearing“-Plateaus versus
„Fixed-bearing“-Plateaus verglichen. Die rotierenden Plateaus sollen ja das Risiko einer Lockerung herabsetzen. Es wurden Revisionsraten und klinisches Ergebnis in 41 aus 1827 Studien nachuntersucht. Insgesamt konnten > 6000 Knietotalendopro- thesen nachuntersucht werden. Es zeigte sich kein Unterschied zwischen den beiden Totalendoprothesentypen.
Relevanz für die Praxis
In dieser weiteren Reviewarbeit konnte erneut aufgezeigt werden, dass es keinen Unterschied im Ergebnis nach Knie- totalendoprothese mit dem teureren „Mobile-bearing“-Sys- tem und dem „Fixed-bearing“-Plateau gibt.
Korrespondenzadresse:
Dr. Elisabeth Pieler-Bruha
OA an der Abteilung für interdisziplinäre Schmerztherapie Hartmannspital
A-1050 Wien, Nikolsdorfer Gasse 32–36 E-Mail: [email protected]
