Botulinum toxin type A for treating chronic low back pain:A double blinded randomized control study

BACKGROUND Low back pain(LBP)is a prevalent issue that orthopedic surgeons frequently address in the outpatient setting.LBP can arise from various causes,with stiffness in the paraspinal muscles being a notable contributor.The administration of Botulinum toxin type A(BoNT-A)has been found to alleviate back pain by relaxing these stiff muscles.While BoNT-A is approved for use in numerous conditions,a limited number of randomized clinical trials(RCTs)validate its efficacy specifically for treating LBP.AIM To study the safety and the efficacy of BoNT-A in minimizing pain and improving functional outcomes in patients of chronic LBP(CLBP).METHODS In this RCT,adults aged 18-60 years with mechanical LBP persisting for at least six months were enrolled.Participants were allocated to either the Drug group,receiving 200 Ipsen Units(2 mL)of BoNT-A,or the Control group,which received a 2 mL placebo.Over a 2-month follow-up period,both groups were assessed using the Visual Analog Scale(VAS)for pain intensity and the Oswestry Disability Index(ODI)for disability at the start and conclusion of the study.A decrease in pain by 50%was deemed clinically significant.RESULTS The study followed 40 patients for two months,with 20 in each group.A clinically significant reduction in pain was observed in 36 participants.There was a statistically significant decrease in both VAS and ODI scores in the groups at the end of two months.Nonetheless,when comparing the mean score changes,only the reduction in ODI scores(15 in the placebo group vs 16.5 in the drug group,clinically insignificant)was statistically significant(P=0.012),whereas the change in mean VAS scores was not significant(P=0.45).CONCLUSION The study concludes that BoNT-A does not offer a short-term advantage over placebo in reducing pain or improving LBP scores in CLBP patients.

Limb length discrepancy after total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND Limb length discrepancy(LLD)after total knee arthroplasty(TKA)has been considered as one of the reasons for the unsatisfactory outcome.However,there is no consensus about the extent of LLD that can be considered as clinically relevant.AIM To evaluate the incidence of radiographic LLD and its impact on functional outcome following TKA.METHODS All randomized-controlled trial and observational studies on LLD in TKA,published till 22nd June 2020,were systematically searched and reviewed.The primary outcome was“limb lengthening or LLD after TKA”.The secondary outcomes included“assessment of LLD in varus/valgus deformity”and“impact of LLD on the functional outcome”.RESULTS Of 45 retrieved studies,qualitative and quantitative assessment of data was performed from eight studies and six studies,respectively.Five studies(n=1551)reported the average limb lengthening of 5.98 mm.The LLD after TKA was ranging from 0.4±10 mm to 15.3±2.88 mm.The incidence of postoperative radiographic LLD was reported in 44%to 83.3%of patients.There was no difference in the preoperative and postoperative LLD(MD-1.23;95%CI:-3.72,1.27;P=0.34).Pooled data of two studies(n=219)revealed significant limb lengthening in valgus deformity than varus(MD-2.69;95%CI:-5.11,0.27;P=0.03).The pooled data of three studies(n=611)showed significantly worse functional outcome in patients with LLD of≥10 mm compared to<10 mm(standard MD 0.58;95%CI:0.06,1.10;P=0.03).CONCLUSION Limb lengthening after TKA is common,and it is significantly more in valgus than varus deformity.Significant LLD(≥10 mm)is associated with suboptimal functional outcome.

Thirty-day mortality of patients with hip fracture during COVID-19 pandemic and pre-pandemic periods:A systematic review and metaanalysis

BACKGROUND Timely intervention in hip fracture is essential to decrease the risks of perioperative morbidity and mortality.However,limitations of the resources,risk of disease transmission and redirection of medical attention to a more severe infective health problem during coronavirus disease 2019(COVID-19)pandemic period have affected the quality of care even in a surgical emergency.AIM To compare the 30-d mortality rate and complications of hip fracture patients treated during COVID-19 pandemic and pre-pandemic times.METHODS The search of electronic databases on 1st August 2020 revealed 45 studies related to mortality of hip fracture during the COVID-19 pandemic and pre-pandemic times.After careful screening,eight studies were eligible for quantitative and qualitative analysis of data.RESULTS The pooled data of eight studies(n=1586)revealed no significant difference in 30-d mortality rate between the hip fracture patients treated during the pandemic and pre-pandemic periods[9.63%vs 6.33%;odds ratio(OR),0.62;95%CI,0.33,1.17;P=0.14].Even the 30-d mortality rate was not different between COVID-19 non-infected patients who were treated during the pandemic time,and all hip fracture patients treated during the pre-pandemic period(OR,1.03;95%CI,0.61,1.75;P=0.91).A significant difference in mortality rate was observed between COVID-19 positive and COVID-19 negative patients(OR,6.99;95%CI,3.45,14.16;P<0.00001).There was no difference in the duration of hospital stay(OR,-1.52,95%CI,-3.85,0.81;P=0.20),overall complications(OR,1.62;P=0.15)and incidence of pulmonary complications(OR,1.46;P=0.38)in these two-time frames.Nevertheless,the preoperative morbidity was more severe,and there was less use of general anesthesia during the pandemic time.CONCLUSION There was no difference in 30-d mortality rate between hip fracture patients treated during the pandemic and pre-pandemic periods.However,the mortality risk was higher in COVID-19 positive patients compared to COVID-19 negative patients.There was no difference in time to surgery,complications and hospitalization time between these two time periods.

Perioperative mortality and morbidity of hip fractures among COVID-19 infected and non-infected patients: A systematic review and meta-analysis

Purpose:Hip fractures among elderly patients are surgical emergencies.During COVID-19 pandemic time,many such patients could not be operated at early time because of the limitation of the medical resources,the risk of infection and redirection of medical attention to a severe infective health problem.Methods:A search of electronic databases(PubMed,Medline,CINAHL,EMBASE and the Cochrane Central Register of Controlled Trials)with the keywords"COVID","COVID-19","SARS-COV-2","Corona","pandemic","hip fracture","trochanteric fracture"and"neck femur fracture"revealed 64 studies evaluating treatment of hip fracture in elderly patients during COVID-19 pandemic time.The 30-day mortality rate,inpatient mortality rate,critical care/special care need,readmission rate and complications rate in both groups were evaluated.Data were analyzed using Review Manager(RevMan)V.5.3.Results:After screening,7 studies were identified that described the mortality and morbidity in hip fractures in both COVID-19 infected(COVID-19+)and non-infected(COVID-19-)patients.There were significantly increased risks of 30-day mortality(32.23%COVID-19+deathvs.8.85%COVID-19-death)and inpatient mortality(29.33%vs.2.62%)among COVID-19+patients with odds ratio(OR)of 4.84(95%CI:3.13-7.47,p<0.001)and 15.12(95%CI:6.12-37.37,p<0.001),respectively.The COVID-19+patients needed more critical care admission(OR=5.08,95%CI:1.49-17.30,p<0.009)and they remain admitted for a longer time in hospital(mean difference=3.6,95% CI:1.74-5.45,p<0.001);but there was no difference in readmission rate between these 2 groups.The risks of overall complications(OR=17.22),development of pneumonia(OR=22.25),and acute respiratory distress syndrome/acute respiratory failure(OR=32.96)were significantly high among COVID-19+patients compared to COVID-19-patients.Conclusions:There are increased risks of the 30-day mortality,inpatient mortality and critical care admission among hip fracture patients who are COVID-19+.The chances of developing pneumonia and acute respiratory failure are more in COVID-19+patients than in COVID-19-patients.