Archive for August, 2008

The Adverse Effect of COX-2 Selective Inhibitor on Ligament Healing

By: Rudy Dewantara MD

The widespread use of NSAIDs is a commonplace in acute sports injury in order to diminish pain and swelling particularly in acute phase. In general there are two groups of NSAIDs, non spesific (inhibit both COX-1 and COX-2 enzymes) and COX-2 selective inhibitor. Some studies have been performed on COX-2 selective inhibitor, celecoxib, to determine its effect on ligament injury.
In 2001, Christopher L. Elder et al used the surgically incised medial collateral ligament of male Sprague-Dawley rats as an experimental model for acute ligament injuries to investigate the effects of celecoxib on ligament healing. Fifty rats underwent surgical transection of the right medial collateral ligament. Postoperatively, half were given celecoxib for the first 6 days of recovery, the other half were not. The animals were sacrificed 14 days after the operation, and both the injured and uninjured medial collateral ligaments were mechanically tested to failure in tension. Celecoxib-treated/injured ligaments were found to have a 32% lower load to failure than untreated/injured ligaments. The results of this study is do not support use of cyclooxygenase-2 specific inhibitors in the treatment of ligament injuries.
Stuart J. Warden et al studied the use of celecoxib and low-intensity pulsed ultrasound, either used alone or combined. The result is low-intensity pulsed ultrasound accelerated but did not improve ligament healing, whereas celecoxib delayed but did not impair healing. When used in combination, the beneficial low-intensity pulsed ultrasound effect was cancelled by the detrimental celecoxib effect.
Some other similar studies on celecoxib showed the same results. Since acute soft injury involving ligament is one of the most frequent injury especially in atheletes, it is best to avoid the use of COX-2 selective inhibitor .

RUdy Dewantara MD


Drug Induced Liver Injury (DILI): A Warning for Orthopaedic Surgeon

By: Rudy Dewantara MD

As written by Robert Bruce Salter, in the Textbook of Disorders and Injuries of the Musculoskeletal System, pain by far is the most important presenting symptom for patient to seek consultation to orthopaedic surgeons in particular. Robert Bruce Salter also writes that relief of pain is of such immediate importance to the patient and can/should be provided by appropiate analgesics. This fact renders thoughtful consideration for orthopaedic surgeons, because consequently most of them will prescribe NSAIDs (non-steroidal anti inflammatory drugs) as the commonly-used analgesics. Inappropriate use of NSAIDs may have caused serious injury to liver, also known as Drug Induced Liver Injury (DILI).
In the United States, approximately 2000 cases of acute liver failure occur annually and drugs account for over 50% of them (39% are due to acetaminophen, 13% are idiosyncratic reactions due to other medications). Drugs account for 2-5% of cases of patients hospitalized with jaundice and approximately 10% of all cases of acute hepatitis. In the last few years, the US Food and Drug Administration (FDA) has withdrawn 2 drugs from the market for causing severe liver injury: bromfenac and troglitazone. Bromfenac (Duract), a nonsteroidal anti-inflammatory drug (NSAID), was introduced in 1997 as a short-term analgesic for orthopedic patients. Although approved for a dosing period of less than 10 days, patients used it for longer periods. This resulted in more than 50 cases of severe hepatic injury, and the drug had to be withdrawn in 1998 (Drug-Induced Hepatotoxicity, Nilesh Mehta, MD, Fellow, Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, State University of New York Upstate Medical Center, 2008).
DILI is now the leading cause of acute liver failure (ALF) in the United States, exceeding all other causes combined [see below: recent graphic data from WM Lee and colleagues from the Acute Liver Failure Study Group, updated to include data through 2007]

Although the exact mechanism of DILI remains largely unknown, it appears to involve 2 pathways — direct hepatotoxicity and adverse immune reactions.

The manifestations of drug-induced hepatotoxicity are highly variable, ranging from asymptomatic elevation of liver enzymes to fulminant hepatic failure. The injury may suggest a hepatocellular injury, with elevation of aminotransferase levels as the predominant symptom, or a cholestatic injury, with elevated alkaline phosphatase levels (with or without hyperbilirubinemia) being the main feature.

In order to prevent DILI while prescribing analgesics agent, an orthopaedic surgeons are expected to provide themselves with extensive knowledge on the pathology, diagnosis and treatment of DILI. Here are some of the journals and guidance to help us understanding more about DILI, just click the link below:

Rudy Dewantara MD

Article Review: The Effect of NSAIDs towards Ligament Healing

by: Rudy Dewantara MD

Ligament injury so far has been a common problem especially for atheletes. In United States alone the incidence is 850.000 per year, 70.833 per month, 16.346 per week, 2.328 per day, 97 per hour, 1 per minute, 0 per second. Ankle and knee are the most common sites for ligament injury in atheletes and render special consideration due to the high morbidity it brought. In general there are three grade of ligament injury, according to AAOS (American Academy of Orthopaedic Surgeon), grade 1 is of the lightest with only miscroscopic tearing of collagen fibers, grade II is partial tears of the ligament and grade III being the severe with complete or total rupture of the ligament. The principle of RICE (rest, ice, compression and elevation) remains the gold standard for acute phase and most of the times is accompanied with the administration of NSAIDs (non steroidal anti inflammatory drugs) to relieve pain and edema. However there are some controversy rise up related to the use of NSAIDs in ligament injury. Many studies were performed in order to determine the effect of NSAIDs to ligament healing. Some agents have been studied in clinical trial such as piroxicam, ibuprofen, indomethacin, celecoxib and others. Some studies suggest that NSAIDs do delay ligament healing, some others do not, and few of them advise us to be careful in selecting NSAIDs. This article review will explore some of those studies in order to determine the effect of NSAIDs towards ligament healing.

Ligament Healing
Ligament is a tough band of white fibrous connective tissue that links two bones together at a joint. Ligament is composed primarily of type I collagen, but they contain small amounts of types III and V. The type III collagen content has been reported to be 10% for ligament as opposed to 5% for tendon. Collagen types II, VI, XII, and XIV have also been reported to be in the ligament and capsule. However, these collagens appear to be associated with fibrocartilage that is found at the junction with bone, not in the midsubstance. The high content of type I collagen in these joint tissues not only leads to mechanical stability, but it also promotes elastic energy storage10.
The first phase of ligament healing is considered the inflammatory phase and occurs in the first week following injury. It starts with the migration of macrophages from tissues surrounding the injury. During this phase, the macrophages remove necrotic tissue and hematoma from the area of the injury thereby preparing the tissue bed for reconstruction. Collagenases and matrix metalloproteinases have a key role in removing not only collagen debris, but also matrix components from the site of injury. The last phase has been termed the remodeling phase. At approximately 8 week after injury, the recently laid down collagen fibers are brought into orientation along the axis of the ligament. The collagen fibers are originally oriented perpendicular to the long axis of the ligament. It is during this period that adhesions may become more numerous and tenacious. Older individuals have a lower metabolic activity within these structures that may be responsible for the diminished age-related tendon-healing capacity observed10.
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Free Full Text Journal Terbaru 2008 dari AAOS & JBJS

Berikut daftar full text terbaru dari AAOS & JBJS yang harusnya berbayar, namun bisa anda dapatkan FREE.. Silakan post email disini untuk yang berminat. Berikut daftar judulnya:

Dari AAOS:

1. Transient Osteoporosis
2. Orthopaedic Management of the Upper Extremity of Stroke Patients
3. Revision Total Knee Arthroplasty

Dari JBJS:

1. The effect of the platelet concentration in platelet-rich plasma gel on the regeneration
of bone
2. The pathogenesis and surgical treatment of tears of the rotator cuff
3. Ankle fractures in diabetic neuropathic arthropathy: Can Tibiotalar Arthrodesis Salvage the Limb?
4. Adeno-Associated Virus-2-Mediated bFGF Gene Transfer to Digital Flexor Tendons Significantly Increases Healing Strength.