Antibiotic prophylaxis after total joint replacements (Authors' reply to Letters to the Editor)

Reply to Comment in Hong Kong Med J. 2010 Aug;16(4):320published_or_final_versio

Antibiotic prophylaxis after total joint replacements

Objectives: To review the latest evidence on antibiotic prophylaxis for patients with total joint replacements to prevent prosthesis infections. Data sources: Literature search of Medline and PubMed until June 2009. Study selection: Studies of patients with total joint replacements from around the world, studies concerning antibiotic prophylaxis, as well as chemoprophylaxis guidelines from orthopaedic associations were searched. Data extraction: Literature review, original articles, case reports, best practice guidelines. Data synthesis: With the rising incidence of patients with total joint replacements, subsequent deep infection of the implants is a rare but dreaded complication which has immense physiological, psychological, financial, and social implications. Guidelines from urologists, gastroenterologists, and dental surgeons attempt to identify high-risk patients who may be more susceptible to prosthetic joint infections. These patients are provided with prophylactic antibiotics before any invasive procedure that may cause bacterial seeding to prosthetic joints. Most orthopaedic associations around the world adopt a similar policy to provide prophylaxis to cover any anticipated chance of bacteraemia. The American Association of Orthopaedic Surgeons adopts the most cautious approach in which all patients with total joint replacements who undergo any procedure that breaches a mucosal surface receive prophylactic antibiotics. Conclusion: The guidelines from the American Association of Orthopaedic Surgeons seem to have an all-encompassing policy when it comes to providing prophylactic antibiotics. Nonetheless, physicians must still exercise their judgement and customise the treatment to each patient. The benefits of prophylactic antibiotics must be balanced against the risks of drug side-effects and the emergence of antibiotic resistance.published_or_final_versio

Authors' reply

link_to_subscribed_fulltex

Superelastic rods: the future of scoliosis curve correction

Despite the myriad new spinal instrumentation systems, scoliosis can rarely be fully corrected, especially when the curves are stiff. A novel superelastic nickel-titanium (nitinol) rod that maximises the ability to slowly correct spinal deformities by utilising the viscoelastic properties of the spine has been developed. This parallel, double-blinded, randomised controlled trial compared the safety and efficacy of these new rods to conventional titanium rods in 23 patients with adolescent idiopathic scoliosis. The superelastic nitinol rods were found to be safe, could gradually correct scoliosis curves, and ultimately resulted in better coronal and sagittal alignments compared to traditional rods. Despite the myriad new spinal instrumentation systems, scoliosis can rarely be fully corrected, especially when the curves are stiff. A novel superelastic nickel-titanium (nitinol) rod that maximises the ability to slowly correct spinal deformities by utilising the viscoelastic properties of the spine has been developed. This parallel, double-blinded, randomised controlled trial compared the safety and efficacy of these new rods to conventional titanium rods in 23 patients with adolescent idiopathic scoliosis. The superelastic nitinol rods were found to be safe, could gradually correct scoliosis curves, and ultimately resulted in better coronal and sagittal alignments compared to traditional rods.British Orthopaedic Association/Irish Orthopaedic Association Annual Congress (BOA/IOA), Dublin, Ireland, 13–16 September 2011. In Journal of Bone and Joint Surgery British Volume Orthopaedic Proceedings, 2012, v. 94 n. SUPP XXXIX, p. 10

A randomized controlled trial assessing the safety and efficacy of a novel superelastic rod in comparison to conventional titanium rod for scoliosis curve correction

Concurrent Session 4B: Innovative Methods - Paper no. 74SUMMARY: By use of a novel superelastic nitinol rod, we were able to demonstrate in a randomized controlled trial that it has the same safety profile as standard titanium rods, but can result in a superior degree of correction in both the sagittal and coronal plane in patients with Adolescent Idiopathic Scoliosis. INTRODUCTION: Current implant technologies correct scoliosis at the time of surgery and thus are unable to overcome viscoelastic properties of the spine. If this can be achieved, in a similar manner to the Ilizarov technique, superior correction may be possible. A novel superelastic nitinol rod that can maximize curve correction by gradually correcting scoliosis after surgery has been developed by the authors. This is a parallel, double-blinded, randomized controlled trial comparing the safety and efficacy of these nitinol rods (Group 1) to conventional titanium rods (Group 2). METHODS: Twenty-three adolescent idiopathic scoliosis (AIS) subjects, with mean age of 15 years, were recruited. All subjects had single thoracic curves and were randomized at the time of surgery to receive either the nitinol rods or conventional rods. Assessments were carried out based on preoperative anteroposterior and lateral standing and fulcrum bending radiographs, postoperative standing radiographs, and serum nickel levels. All assessments were made by two blinded observers. RESULTS: Eleven subjects were in Group 1 and 12 in Group 2. All subjects were followed for a minimum of 12 months and a mean of 24 months. Mean preoperative Cobb angles in Group 1 and Group 2 were 58.18° and 53.51° respectively, while mean post-operative Cobb angles at 6 months were 17.79° and 16.70° respectively. The fulcrum bending correction index of group 1 subjects improved a mean of 6% from post-operative week 1 to week 24 while that of group 2 subjects improved a mean of 3% within the same time. Of those subjects who had abnormal pre-operative sagittal alignments, 80% from group 1 improved by post-operative week 4, while 67% from group 2 subjects improved. Balance parameters, nickel levels, and complication rates did not differ significantly. CONCLUSION: This is the first study to demonstrate that the novel superelastic rods are safe, can gradually correct curves after surgery, ultimately resulting in better coronal and sagittal alignments compared to traditional rods. Larger multi-center trials are needed to further substantiate these findings.The 18th International Meeting on Advanced Spine Techniques (IMAST 2011), Copenhagen, Denmark, 13-16 july 2011

A randomized controlled trial assessing the safety and efficacy of a novel superelastic rod in comparison to conventional titanium rod for scoliosis curve correction

Best Spine Paper Award Presentation: no. AP07Conference Theme: Occupational Orthopaedic

A ramdomized controlled trial assessing the safety and efficacy of a novel superelastic rod in comparison to conventional titanium rod for scoliosis curve correction

Concurrent Session 4B: Innovatiove Methods - Paper no. 74SUMMARY: By use of a novel superelastic nitinol rod, we were able to demonstrate in a randomized controlled trial that it has the same safety profile as standard titanium rods, but can result in a superior degree of correction in both the sagittal and coronal plane in patients with Adolescent Idiopathic Scoliosis. INTRODUCTION: Current implant technologies correct scoliosis at the time of surgery and thus are unable to overcome viscoelastic properties of the spine. If this can be achieved, in a similar manner to the Ilizarov technique, superior correction may be possible. A novel superelastic nitinol rod that can maximize curve correction by gradually correcting scoliosis after surgery has been developed by the authors. This is a parallel, double-blinded, randomized controlled trial comparing the safety and efficacy of these nitinol rods (Group 1) to conventional titanium rods (Group 2). METHODS: Twenty-three adolescent idiopathic scoliosis (AIS) subjects, with mean age of 15 years, were recruited. All subjects had single thoracic curves and were randomized at the time of surgery to receive either the nitinol rods or conventional rods. Assessments were carried out based on preoperative anteroposterior and lateral standing and fulcrum bending radiographs, postoperative standing radiographs, and serum nickel levels. All assessments were made by two blinded observers. RESULTS: Eleven subjects were in Group 1 and 12 in Group 2. All subjects were followed for a minimum of 12 months and a mean of 24 months. Mean preoperative Cobb angles in Group 1 and Group 2 were 58.18° and 53.51° respectively, while mean post-operative Cobb angles at 6 months were 17.79° and 16.70° respectively. The fulcrum bending correction index of group 1 subjects improved a mean of 6% from post-operative week 1 to week 24 while that of group 2 subjects improved a mean of 3% within the same time. Of those subjects who had abnormal pre-operative sagittal alignments, 80% from group 1 improved by post-operative week 4, while 67% from group 2 subjects improved. Balance parameters, nickel levels, and complication rates did not differ significantly. CONCLUSION: This is the first study to demonstrate that the novel superelastic rods are safe, can gradually correct curves after surgery, ultimately resulting in better coronal and sagittal alignments compared to traditional rods. Larger multi-center trials are needed to further substantiate these findings.link_to_OA_fulltextThe 18th International Meeting on Advanced Spine Techniques (IMAST), Copenhagen, Denmark, 13-16 July 2011. In Final Program of 18th IMAST, 2011, p. 93, Paper no. 7

A randomized controlled trial assessing the safety and efficacy of a novel superelastic rod in comparison to conventional titanium rod for scoliosis curve correction

Oral Presentation - Spine Section: [SS-1] Symposium 1 - Scoliosis: [SS-1-3]The 8th Combined Congress of the Spine and Paediatric Sections of the Asia Pacific Orthopaedic Association (APOA 2011), Gifu, Japan, 1-4 June 2011

Is there a better alternative to a randomized control design for assessing the efficacy and effectiveness of bracing in AiS?

Session VII – Adolescent / Outcomes / Congenital Scoliosis - Podium Presentation Abstracts: paper no. 87SUMMARY: With the support of the Scoliosis Research Society, we examined the feasibility of conducting a single-blind comprehensive cohort study that assesses both efficacy and effectiveness of bracing in AIS. The study incorporates a RCT and an option allowing patients to choose their desirable treatment. Besides, it also has a treatment exit plan for those with significant progression. Our study showed that it outperforms a conventional RCT in terms of recruitment ability. INTRODUCTION: Current randomized controlled trials (RCTs) for assessing the efficacy of bracing in patients with adolescent idiopathic scoliosis (AIS) suffer from poor recruitment. Besides, patients who consent for randomization may be a highly selected group of individuals who really have no preference on treatment; thus may limit the assessment of effectiveness. Therefore, we aimed to determine the feasibility of an alternative study design, “the comprehensive cohort study” that can overcome the concerns of conventional RCTs. METHODS: AIS patients aged ≥10 years, had Risser sign between 0-II, and had a Cobb angle of 25° to <30° or 20° to <25° with 5° deterioration over the past 4 months were invited to join a RCT. Those declined were given an option to stay in the study, but choose whether they wish to be braced or observed. A randomization schedule was generated for all patients whether or not they joined the RCT; thus additional patients who made their own choice may also fit with the randomized choices. Blinded out-of-brace radiographic and psychosocial assessments were made. Compliance was assessed. For those without brace but had ≥6° curve progression or reached 30° were considered failures, and braces were offered. Patients were followed every 4 months. RESULTS: Over 1 year, there were 87 eligible patients, 68 (78%) patients (5 boys and 63 girls) with mean age of 12.5 years (range: 10 to 15 years) consented to participate with a median follow-up of 57 weeks. Of which, 19 (28%) patients accepted randomization with respectively 13 and 6 patients allotted to brace and observation. For others who declined randomization, 18 (37%) chose brace and 28 (57%) patients had their choice of treatment the same as that on the randomization schedule. Braced patients had a daily average of over 17 hours within the first year. 10 patients had ≥6° curve progression during follow-up. CONCLUSION: This Comprehensive Cohort Study design has the potential to improve the rate of recruitment such that both efficacy and effectiveness of bracing in AIS can be assessed. Our preliminary study showed that it can be feasibly conducted with less recruitment burden. A larger scale study with longer follow-up is needed to address the question of efficacy and effectiveness of braces.link_to_OA_fulltex