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Clinical Journal of Sport Medicine :... Jan 2021The use of local anesthetic painkilling injections to improve player availability is common practice in elite-level sport.
BACKGROUND
The use of local anesthetic painkilling injections to improve player availability is common practice in elite-level sport.
OBJECTIVE
To document the published use of local anesthetic injections in sport, according to number of injections, sites of injections, and complications reported.
DATA SOURCES
A systematic search of MEDLINE, Embase, CINAHL, AMED, Cochrane Database of Systematic reviews, SportDiscus, EBSCO Host, and Google Scholar.
RESULTS
One thousand nine hundred seventy local anesthetic injections reported on 540 athletes in 10 studies (from rugby league, American football, Australian football, and soccer) were reviewed. The most common areas of injection were as follows: the acromioclavicular (AC) joint; hand (including fingers); sternoclavicular joint (including sternum); rib injuries; and iliac crest contusions.
DISCUSSION
This review found some evidence of long-term safety for a limited number of injection sites (eg, AC joint) and some evidence of immediate complications and harmful long-term consequences for other sites. The quality of evidence is not high, with little long-term data and a lack of independent verification of the effects of the injections. Ideally, long-term follow-up should be conducted to determine whether these injections are safe, with follow-up undertaken independently of the treating physician and team.
CONCLUSIONS
Based on limited publications, there is some evidence of long-term safety; however, there is a lack of clear proof of either absolute safety or long-term harm for many of these procedures. Physicians and players in professional sport should proceed with caution in using local anesthetic injections.
Topics: Anesthetics, Local; Athletes; Humans; Injections; Pain Management
PubMed: 30789366
DOI: 10.1097/JSM.0000000000000716 -
Surgical Infections 2019Prophylactic antibiotic therapy is given routinely in the peri-operative period to prevent surgical site infection. However, in pediatric cardiac surgery, an optimal...
Prophylactic antibiotic therapy is given routinely in the peri-operative period to prevent surgical site infection. However, in pediatric cardiac surgery, an optimal schedule has not been defined. Pediatric recommendations follow the guidelines for adults, which might be improper because of the inherent challenges in pediatric research and the heterogeneity of the population. Implementation of an effective prophylaxis protocol is needed for children undergoing cardiac surgery, especially in view of worldwide antibiotic overuse and the development of drug resistance. In this review, we analyze the current knowledge supported by up-to-date publications about antibiotic prophylaxis in pediatric cardiac surgery. The PubMed database was searched for full-text journal articles describing peri-operative antibiotic prophylaxis in pediatric cardiac surgery published since 2000. Antibiotics used for standard prophylaxis with dosing schema, time of the first dose, additional dosage in extracorporeal circulation (ECC) priming, and prophylaxis duration were analyzed. Additionally, we looked for special clinical situations such as antibiotic prophylaxis in children with the sternum left open after surgery and patients with β-lactam allergy or pre-operative methicillin-resistant (MRSA) colonization or those requiring extracorporeal membrane oxygenation (ECMO). A total of 1,546 articles were evaluated, and we identified 20 for further analysis. On the basis of the current peri-operative antibiotic prophylaxis recommendations for cardiac surgery and the papers reviewed, we tried to propose a schedule for peri-operative antibiotic prophylaxis in pediatric cardiac surgery. There is a need for careful use and examination of the schedule proposed because the pharmacokinetics of antibiotics in pediatric patients with ECC is not fully understood. This should be evaluated further. Formulating uniform recommendations concerning peri-operative antibiotic prophylaxis is difficult.
Topics: Anti-Bacterial Agents; Antibiotic Prophylaxis; Hospitals, Pediatric; Humans; Perioperative Care; Surgical Wound Infection; Thoracic Surgery; Thoracic Surgical Procedures
PubMed: 30762492
DOI: 10.1089/sur.2018.272 -
New sternal closure methods versus the standard closure method: systematic review and meta-analysis.Interactive Cardiovascular and Thoracic... Mar 2019This study aimed to evaluate, by means of a systematic review, the efficiency of new methods for sternal closure in order to prevent sternal wound complications after... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
This study aimed to evaluate, by means of a systematic review, the efficiency of new methods for sternal closure in order to prevent sternal wound complications after sternotomy.
METHODS
The method of study was a systematic review of randomized clinical trials. We included studies that used rigid plates, thermoreactive clips, cables and flat wires, in comparison with the standard closure method. Patients included adults, regardless of gender and race.
RESULTS
Seven clinical trials were included involving 1810 patients. Five trials were carried out in the USA, 1 in Australia and 1 in Italy, and the trials include both male and female patients. The included studies compared conventional sternal closure with new closure methods (rigid plate, thermoreactive clips, cables and flat wires). The new sternal closure methods make little or no difference compared to the standard closure when we analyse deep sternal wound infection [risk ratio 0.38, 95% confidence interval (CI) 0.02-7.63; I2 = 74%; 5 studies], superficial wound infection (risk ratio 1.34, 95% CI 0.46-3.92; I2 = 11%, 3 studies) and death (risk ratio 1.16, 95% CI 0.42-3.21; I2 = 0%, 3 studies), but pain score was lower in new sternal closure methods (mean difference -0.57, 95% CI -0.98 to -0.16, I2 = 0%, 3 studies). There were no meta-analyses of sternal union, hospital stay, reoperation or mechanic ventilation time because of the high heterogeneity between the studies in terms of these outcomes.
CONCLUSIONS
New sternal closure methods probably make little or no difference regarding the prevention of sternal complications in the postoperative period when compared to the standard closure method.
Topics: Bone Plates; Bone Wires; Humans; Reoperation; Sternotomy; Sternum; Surgical Wound Dehiscence
PubMed: 30295795
DOI: 10.1093/icvts/ivy281 -
Infectious Diseases (London, England) Jan 2019Candida sternal wound infections (SWIs) following cardiac surgery are rare but are associated with a high mortality rate. Guidelines on this topic either propose no...
BACKGROUND
Candida sternal wound infections (SWIs) following cardiac surgery are rare but are associated with a high mortality rate. Guidelines on this topic either propose no suggestions for management or offer recommendations based on a small number of reports.
METHODS
This paper presents a case of a Candida SWI and its successful treatment with debridement using a burr, negative pressure vacuum therapy (NPVT) and dermal grafting. To investigate different methods of treating Candida SWIs following cardiac surgery, a review was completed using the MEDLINE database. Reports without English abstracts and without defined outcomes of therapy for individual patients were excluded.
RESULTS
Seventy-seven cases of Candida SWIs following cardiac surgery were identified in 20 articles published since 1999, including our case. Treatment strategies are identified: omentum flap; muscle flap; debridement and secondary wound healing with or without NPVT; debridement and primary closure; incision and drainage; only medical therapy. Patients documented in the articles were classified based on the following outcomes: cured (n = 41 patients [including the present case]), relapse infection (n = 25 patients) and death (n = 11 patients). The various methods used to treat patients were analysed.
CONCLUSIONS
Delayed closure reoperation with surgical debridement and NPVT have favourable outcomes. In the presence of widespread osteomyelitis, the use of omental flaps is advocated. Treatment with muscle flaps has a high rate of relapse. Debridement and secondary healing or conservative management with antifungals alone can be considered in the treatment of relapsing infection.
Topics: Aged; Aged, 80 and over; Candidiasis; Child, Preschool; Debridement; Female; Humans; Infant; Male; Middle Aged; Negative-Pressure Wound Therapy; Skin Transplantation; Sternum; Surgical Wound Infection; Thoracic Surgical Procedures; Treatment Outcome
PubMed: 30264627
DOI: 10.1080/23744235.2018.1518583 -
International Orthopaedics Jun 2019Traumatic sternal fractures are rare injuries. The most common mechanism of injury is direct blunt trauma to the anterior chest wall. Most (> 95%) sternal fractures...
PURPOSE
Traumatic sternal fractures are rare injuries. The most common mechanism of injury is direct blunt trauma to the anterior chest wall. Most (> 95%) sternal fractures are treated conservatively. Surgical fixation is indicated in case of fracture instability, displacement or non-union. However, limited research has been performed on treatment outcomes. This study aimed to provide an overview of the current treatment practices and outcomes of traumatic sternal fractures and dislocations.
METHODS
A systematic review of literature published from 1990 to June 2017 was conducted. Original studies on traumatic sternal fractures, reporting sternal healing or sternal stability were included. Studies on non-traumatic sternal fractures or not reporting sternal healing outcomes, as well as case reports (n = 1), were excluded.
RESULTS
Sixteen studies were included in this review, which reported treatment outcomes for 191 patients. Most included studies were case series of poor quality. All patients showed sternal healing and 98% reported pain relief. Treatment complications occurred in 2% of patients.
CONCLUSIONS
Treatment of traumatic sternal fractures and dislocations is an underexposed topic. Although all patients in this review displayed sternal healing, results should be interpreted with caution since most included studies were of poor quality.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Female; Fractures, Bone; Humans; Joint Dislocations; Male; Middle Aged; Sternum; Thoracic Injuries; Treatment Outcome; Wounds, Nonpenetrating; Young Adult
PubMed: 29700586
DOI: 10.1007/s00264-018-3945-4 -
The Annals of Thoracic Surgery Jul 2018Traditionally, wire cerclage has been used to reapproximate the sternum after sternotomy. Recent evidence suggests that rigid plate fixation for sternal closure may... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Traditionally, wire cerclage has been used to reapproximate the sternum after sternotomy. Recent evidence suggests that rigid plate fixation for sternal closure may reduce the risk of sternal complications.
METHODS
The Medline and Embase databases were searched from inception to February 2017 for studies that compared rigid plate fixation with wire cerclage for cardiac surgery patients undergoing sternotomy. Random effects meta-analysis compared rates of sternal complications (primary outcome, defined as deep or superficial sternal wound infection, or sternal instability), early mortality, and length of stay (secondary outcomes).
RESULTS
Three randomized controlled trials (n = 427) and five unadjusted observational studies (n = 1,025) met inclusion criteria. There was no significant difference in sternal complications with rigid plate fixation at a median of 6 months' follow-up (incidence rate ratio 0.51, 95% confidence interval [CI]: 0.20 to 1.29, p = 0.15) overall, but a decrease when including only patients at high risk for sternal complications (incidence rate ratio 0.23, 95% CI: 0.06 to 0.89, p = 0.03; two observational studies). Perioperative mortality was reduced favoring rigid plate fixation (relative risk 0.40, 95% CI: 0.28 to 0.97, p = 0.04; four observational studies and one randomized controlled trial). Length of stay was similar overall (mean difference -0.77 days, 95% CI: -1.65 to +0.12, p = 0.09), but significantly reduced with rigid plate fixation in the observational studies (mean difference -1.34 days, 95% CI: -2.05 to -0.63, p = 0.0002).
CONCLUSIONS
This meta-analysis, driven by the results of unmatched observational studies, suggests that rigid plate fixation may lead to reduced sternal complications in patients at high risk for such events, improved perioperative survival, and decreased hospital length of stay. More randomized controlled trials are required to confirm the potential benefits of rigid plate fixation for primary sternotomy closure.
Topics: Bone Plates; Bone Wires; Cardiac Surgical Procedures; Female; Humans; Male; Sternotomy; Surgical Wound Dehiscence; Surgical Wound Infection; Treatment Outcome; Wound Closure Techniques; Wound Healing
PubMed: 29577921
DOI: 10.1016/j.athoracsur.2018.02.043 -
The Journal of Thoracic and... Jul 2018
Meta-Analysis
Topics: Bone Wires; Humans; Prosthesis Design; Randomized Controlled Trials as Topic; Steel; Sternotomy; Sternum; Time Factors; Treatment Outcome; Wound Closure Techniques; Wound Healing
PubMed: 29572025
DOI: 10.1016/j.jtcvs.2018.02.033 -
The Cochrane Database of Systematic... Apr 2017Aortic valve disease is a common condition that is easily treatable with cardiac surgery. This is conventionally performed by opening the sternum longitudinally down the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Aortic valve disease is a common condition that is easily treatable with cardiac surgery. This is conventionally performed by opening the sternum longitudinally down the centre ("median sternotomy") and replacing the valve under cardiopulmonary bypass. Median sternotomy is generally well tolerated, but as less invasive options have become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access has raised safety concerns with regards to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity.
OBJECTIVES
To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement.
SEARCH METHODS
We performed searches of CENTRAL, MEDLINE, Embase, clinical trials registries, and manufacturers' websites from inception to July 2016, with no language limitations. We reviewed references of identified papers to identify any further studies of relevance.
SELECTION CRITERIA
Randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, trans-apical, trans-femoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. The quality of evidence was determined using the GRADE methodology and results of patient-relevant outcomes were summarised in a 'Summary of findings' table.
MAIN RESULTS
The review included seven trials with 511 participants. These included adults from centres in Austria, Spain, Italy, Germany, France, and Egypt. We performed 12 comparisons investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy.There was no evidence of any effect of upper hemi-sternotomy on mortality versus full median sternotomy (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.36 to 2.82; participants = 511; studies = 7; moderate quality). There was no evidence of an increase in cardiopulmonary bypass time with aortic valve replacement performed via an upper hemi-sternotomy (mean difference (MD) 3.02 minutes, 95% CI -4.10 to 10.14; participants = 311; studies = 5; low quality). There was no evidence of an increase in aortic cross-clamp time (MD 0.95 minutes, 95% CI -3.45 to 5.35; participants = 391; studies = 6; low quality). None of the included studies reported major adverse cardiac and cerebrovascular events as a composite end point.There was no evidence of an effect on length of hospital stay through limited hemi-sternotomy (MD -1.31 days, 95% CI -2.63 to 0.01; participants = 297; studies = 5; I = 89%; very low quality). Postoperative blood loss was lower in the upper hemi-sternotomy group (MD -158.00 mL, 95% CI -303.24 to -12.76; participants = 297; studies = 5; moderate quality). The evidence did not support a reduction in deep sternal wound infections (RR 0.71, 95% CI 0.22 to 2.30; participants = 511; studies = 7; moderate quality) or re-exploration (RR 1.01, 95% CI 0.48 to 2.13; participants = 511; studies = 7; moderate quality). There was no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.33, 95% CI -0.85 to 0.20; participants = 197; studies = 3; I = 70%; very low quality), but there was a small increase in postoperative pulmonary function tests with minimally invasive limited sternotomy (MD 1.98 % predicted FEV1, 95% CI 0.62 to 3.33; participants = 257; studies = 4; I = 28%; low quality). There was a small reduction in length of intensive care unit stays as a result of the minimally invasive upper hemi-sternotomy (MD -0.57 days, 95% CI -0.93 to -0.20; participants = 297; studies = 5; low quality). Postoperative atrial fibrillation was not reduced with minimally invasive aortic valve replacement through limited compared to full sternotomy (RR 0.60, 95% CI 0.07 to 4.89; participants = 240; studies = 3; moderate quality), neither were postoperative ventilation times (MD -1.12 hours, 95% CI -3.43 to 1.19; participants = 297; studies = 5; low quality). None of the included studies reported cost analyses.
AUTHORS' CONCLUSIONS
The evidence in this review was assessed as generally low to moderate quality. The study sample sizes were small and underpowered to demonstrate differences in outcomes with low event rates. Clinical heterogeneity both between and within studies is a relatively fixed feature of surgical trials, and this also contributed to the need for caution in interpreting results.Considering these limitations, there was uncertainty of the effect on mortality or extracorporeal support times with upper hemi-sternotomy for aortic valve replacement compared to full median sternotomy. The evidence to support a reduction in total hospital length of stay or intensive care stay was low in quality. There was also uncertainty of any difference in the rates of other, secondary outcome measures or adverse events with minimally invasive limited sternotomy approaches to aortic valve replacement.There appears to be uncertainty between minimally invasive aortic valve replacement via upper hemi-sternotomy and conventional aortic valve replacement via a full median sternotomy. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality-of-life analyses to be included as end points, as well as quantitative measures of physiological reserve.
Topics: Aged; Aortic Valve; Atrial Fibrillation; Blood Loss, Surgical; Cardiopulmonary Bypass; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Length of Stay; Middle Aged; Operative Time; Pain Measurement; Postoperative Complications; Randomized Controlled Trials as Topic; Reoperation; Sternotomy; Surgical Wound Infection
PubMed: 28394022
DOI: 10.1002/14651858.CD011793.pub2 -
Head & Neck Apr 2017Thyroid cancer is the fastest growing cancer in the United States. A small portion of differentiated thyroid cancers (DTCs; 2% to 13%) develop bone metastases, which can... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Thyroid cancer is the fastest growing cancer in the United States. A small portion of differentiated thyroid cancers (DTCs; 2% to 13%) develop bone metastases, which can decrease a patient's survival rate by more than 60%.
METHODS
A systematic literature search of studies, including patients with DTC with bone metastases, was conducted by following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A case series of patients with DTC diagnosed with bone metastases seen at our institution was also included.
RESULTS
A total of 616 bone metastases sites in 317 patients were identified in 14 case series. Ten patients were identified in our institutional case series. The most common sites of metastases are spine (34.6%), pelvis (25.5%), sternum and ribs (18.3%), extremities (10.2%), shoulder girdle (5.4%), and craniomaxillofacial (5.4%).
CONCLUSION
The axial skeleton is the primary target of bone metastases in DTC. The relative distribution of bone metastases and red marrow content follow a similar rank. © 2017 Wiley Periodicals, Inc. Head Neck 39: 812-818, 2017.
Topics: Adult; Aged; Bone Neoplasms; Carcinoma; Female; Humans; Incidence; Male; Middle Aged; Neoplasm Invasiveness; Neoplasm Staging; Prognosis; Risk Assessment; Skeleton; Survival Analysis; Thyroid Neoplasms
PubMed: 28079945
DOI: 10.1002/hed.24655 -
The Annals of Thoracic Surgery Dec 2016Early detection of patients at risk of sternal complications is essential to facilitate prevention and optimize timely intervention. A systematic review and... (Meta-Analysis)
Meta-Analysis Review
Early detection of patients at risk of sternal complications is essential to facilitate prevention and optimize timely intervention. A systematic review and meta-analysis was conducted to identify risk factors associated with sternal complications. The review included 17 full-text studies, of which 10 were entered into meta-analyses. Female gender, diabetes mellitus, obesity, bilateral internal mammary artery grafts, reoperation for postoperative complications, and blood product requirement were reported as significant predictors of sternal infection. The compilation of these risk factors may help to screen and stratify patients at risk of impaired sternal healing and warrants further investigation.
Topics: Cardiac Surgical Procedures; Female; Humans; Male; Postoperative Complications; Risk Factors; Sternum
PubMed: 27553500
DOI: 10.1016/j.athoracsur.2016.05.047