A comparison of the outcomes following intra-articular steroid injection alone or arthrocentesis alone in the management of internal derangement of the temporomandibular joint

CONTEXT

One of the main causes of chronic facial pain is temporomandibular disorders (TMDs) which may turn out to be a major cause for disability. The two types of treatment strategies may be undertaken to counter temporomandibular joint (TMJ) disorders, namely conservative management and surgical intervention. Surgical management can be classified into invasive open methods and minimally invasive procedures such as arthrocentesis, intra-articular steroid injection, and arthroscopy.

AIMS

The aim of this study is to compare the efficacy of Kenacort (Triamcinolone) as an intra-articular corticosteroid injection and arthrocentesis for lysis and lavage, for the treatment of the temporomandibular joint disorders.

SUBJECTS AND METHODS

Twenty patients with internal derangement of temporomandibular joint (IDTMJ) not responding to conservative management and meeting the inclusion criteria randomly underwent either intra-articular steroid injection or arthrocentesis and the results of the two procedures were evaluated and compared.

STATISTICAL ANALYSIS USED

Unpaired t-test, repeated-measures ANOVA. A value of P < 0.05 is considered to be statistically significant.

RESULTS AND CONCLUSION

Both procedures turned out to be successful in reducing pain and improving mouth opening, both in a short-term and a long-term use. Upon comparison in our series of patients, arthrocentesis was noted to be a better treatment modality in the long term for the management of IDTMJ.

Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

BACKGROUND

Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications.

METHODS

HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896).

FINDINGS

Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71).

INTERPRETATION

Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care.

FUNDING

Canadian Institutes of Health Research.

Surgical complications in neuromuscular scoliosis operated with posterior- only approach using pedicle screw fixation

Background

There are no reports describing complications with posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) using pedicle screw fixation in patients with neuromuscular scoliosis.

Methods

Fifty neuromuscular patients (18 cerebral palsy, 18 Duchenne muscular dystrophy, 8 spinal muscular atrophy and 6 others) were divided in two groups according to severity of curves; group I (< 90°) and group II (> 90°). All underwent PSF and SSI with pedicle screw fixation. There were no anterior procedures. Perioperative (within three months of surgery) and postoperative (after three months of surgery) complications were retrospectively reviewed.

Results

There were fifty (37 perioperative, 13 postoperative) complications. Hemo/pneumothorax, pleural effusion, pulmonary edema requiring ICU care, complete spinal cord injury, deep wound infection and death were major complications; while atelectesis, pneumonia, mild pleural effusion, UTI, ileus, vomiting, gastritis, tingling sensation or radiating pain in lower limb, superficial infection and wound dehiscence were minor complications. Regarding perioperative complications, 34(68%) patients had at least one major or one minor complication. There were 16 patients with pulmonary, 14 with abdominal, 3 with wound related, 2 with neurological and 1 cardiovascular complications, respectively. There were two deaths, one due to cardiac arrest and other due to hypovolemic shock. Regarding postoperative complications 7 patients had coccygodynia, 3 had screw head prominence, 2 had bed sore and 1 had implant loosening, respectively. There was a significant relationship between age and increased intraoperative blood loss (p = 0.024). However it did not increased complications or need for ICU care. Similarly intraoperative blood loss > 3500 ml, severity of curve or need of pelvic fixation did not increase the complication rate or need for ICU. DMD patients had higher chances of coccygodynia postoperatively.

Conclusion

Although posterior-only approach using pedicle screw fixation had good correction rate, complications were similar to previous reports. There were few unusual complications like coccygodynia.

Leg lengthening by distraction osteogenesis using the Ilizarov apparatus: a novel concept of tibia callus subsidence and its influencing factors

This article studies the incidence and magnitude of delayed callus subsidence, which will also help in study the hypothesis of three cortex corticalisation to determine the time of fixator removal during distraction osteogenesis (DO). Eighty-one tibia segments with mean lengthening of 7.7 +/- 2.9 cm were studied with age, gender, skeletal maturity, amount and percentage of lengthening, callus pattern, callus shape, number of cortices seen at the time of fixator removal, bone mineral density (BMD) ratio, and callus diameter ratio analysed for their effect on callus subsidence. All segments had tibia callus subsidence ranging from 4 mm to 3.2 cm with 54% having significant subsidence of more than 1 cm. Multivariate regression analysis revealed only the amount of lengthening and callus patterns to be significant. In conclusion, we can say that tibia callus subsidence is a significant delayed complication and factors affecting it can be used to determine the time of fixator removal.

Inhibition of dioxin effects on bone formation in vitro by a newly described aryl hydrocarbon receptor antagonist, resveratrol

Aryl hydrocarbon receptor (AhR) ligands are environmental contaminants found in cigarette smoke and other sources of air pollution. The prototypical compound is TCDD (2,3,7, 8-tetrachlorodibenzo-p-dioxin), also known as dioxin. There is an increasing body of knowledge linking cigarette smoking to osteoporosis and periodontal disease, but the direct effects of smoke-associated aryl hydrocarbons on bone are not well understood. Through the use of resveratrol (3,5,4'-trihydroxystilbene), a plant antifungal compound that we have recently demonstrated to be a pure AhR antagonist, we have investigated the effects of TCDD on osteogenesis. It was postulated that TCDD would inhibit osteogenesis in bone-forming cultures and that this inhibition would be antagonized by resveratrol. We employed the chicken periosteal osteogenesis (CPO) model, which has been shown to form bone in vitro in a pattern morphologically and biochemically similar to that seen in vivo, as well as a rat stromal cell bone nodule formation model. In the CPO model, alkaline phosphatase (AP) activity was reduced by up to 50% (P<0.01 vs control) in the presence of 10(-9) M TCDD and these effects were reversed by 10(-6) M resveratrol (P<0.05 vs TCDD alone). TCDD-mediated inhibition of osteogenesis was restricted primarily to the osteoblastic differentiation phase (days 0-2) as later addition did not appear to have any effects. Message levels for important bone-associated proteins (in the CPO model) such as collagen type I, osteopontin, bone sialoprotein and AP were inhibited by TCDD, an effect that was antagonized by resveratrol. Similar findings were obtained using the rat stromal bone cell line. TCDD (at concentrations as low as 10(-10)M) caused an approximately 33% reduction in AP activity, which was abrogated by 3. 5x10(-7) M resveratrol. TCDD also induced a marked reduction in mineralization ( approximately 75%) which was completely antagonized by resveratrol. These data suggest that AhR ligands inhibit osteogenesis probably through inhibition of osteodifferentiation and that this effect can be antagonized by resveratrol. Since high levels of AhR ligands are found in cigarette smoke, and further since smoking is an important risk factor in both osteoporosis and periodontal disease, it may be postulated that AhR ligands are the component of cigarette smoke linking smoking to osteoporosis and periodontal disease. If so, resveratrol could prove to be a promising preventive or therapeutic agent for smoking-related bone loss.