Friday,  February 22, 2013

Topic: Straight Forward Carpal Tunnel Release Is as Good as It Gets

Epineurotomy is not necessary when doing median nerve decompression for the first time.

By Luc Jasmin,MD, PhD, FRCS (C), FACS, FAANS
Associate
Cedars Sinai Hospital (Neurosurgery)
UCSF (Anatomy)
San Francisco, CA
Background: Long-lasting median nerve compression can lead to perineural fibrosis and constriction of the nerve. During an open decompression, doing an epineurotomy prolongs surgery and increases the risk of nerve damage, yet it is seen as the right thing to do by some. Adding an epineurotomy to standard decompression is not supported by the literature. {Yet, this literature is based on epineurotomies done in patients with and without perineural fibrosis and nerve constriction.}

Objective: To determine whether an epineurotomy is useful in patients with obvious narrowing of the nerve at the time of the first surgery.
Design: Single-center, prospective, randomized, double-blind controlled trial.

Participants/Methods: Adults unresponsive to conservative therapy were included in the study after electrodiagnostic confirmation (distal sensory latency >3.5 ms and/or distal motor latency >4.5 ms) and MRI identification of an hourglass constriction of the median nerve. Patients who had previous carpal tunnel surgery were excluded. The nerve diameter was measured preoperatively (days 1 to 3) and on days 90 and 180 postoperative with high-definition MRI. Standard open carpal tunnel decompression with (treatment group, n=25) or without (sham group, n=25) longitudinal epineurotomy was done. The primary outcome measure was median nerve volume on MRI. For statistical analysis, a difference of at least 25% was necessary to assert a difference between groups (n=25 per group).
Results: The median nerve increased in volume at 90 and 180 days postoperative equally in both groups. Electrodiagnostic values and grip tests were improved to the same degree in both groups. At 180 days, the motor and sensory conduction improved markedly in both groups by >80% and >60%, respectively. The pain score was slightly higher in the epineurotomy group at 180 days. Only in the sham group was greater nerve volume associated with less pain.

Conclusions: Epineurotomy of the median nerve does not improve outcomes, even when a clear constriction of the nerve is documented.

Reviewer's Comments: In contrast to the first surgery, when re-exploring because of a failed first surgery, doing a longitudinal epineurotomy in addition to completing the section of the transverse carpal ligament is often necessary. I would recommend that you watch the online video by Dr Susan Mackinnon showing how a revision should be done. Note that even well-done carpal tunnel surgery is not always successful simply because the nerve might have been compressed for too long. On this topic, take a look at the article of Chandra and colleagues (World Neurosurgery 2012) advocating doing early surgery to improve outcomes.

Article Reviewed: The Effect of Epineurotomy on the Median Nerve Volume After the Carpal Tunnel Release: A Prospective Randomised Double-Blind Controlled Trial; Crnković T, Bilić R, et al: Int Orthop; 2012; 36; September.

Take-Home Pearl
Epineurotomy is not necessary when doing median nerve decompression for the first time.

Friday, February 22, 2013

Topic: Zoledronic Acid Reduces Risk of Vertebral Fractures in Men With Osteoporosis  

Zoledronic acid reduces the risk of vertebral fractures by 67% in men with osteoporosis, a benefit that is similar to that observed in postmenopausal women.

By Elaine Sachter, MD, FACP
Internist
Virginia Mason Medical Center
Seattle, WA
Background: 40% of osteoporotic fractures occur in men; however, there are a lack of data on fracture outcomes in men treated for osteoporosis. Most studies in men have looked at surrogate markers such as bone turnover and bone mineral density.

Objective: To study the effect of zoledronic acid on the risk of vertebral fracture in men with osteoporosis.

Design: Multicenter, double-blind placebo-controlled trial.

Participants/Methods: 1199 men, aged 50 to 85 years, with either primary or hypogonadism-associated osteoporosis, were randomized to receive zoledronic acid 5 mg IV at study initiation and at 12 months, or placebo. Eligibility criteria were either osteoporosis (T score of ≤-2.5 at the total hip, femoral neck, or lumbar spine) or osteopenia (T score of ≤-1.5 at the total hip or femoral neck) and 1 to 3 prevalent mild-to-moderate vertebral fractures. Exclusion criteria included: 25-hydroxy vitamin D level <15 ng/mL; renal insufficiency (creatinine clearance <30 mL/min); hypocalcemia; and hypercalcemia. All participants received vitamin D and calcium supplementation. The primary outcome was the occurrence of ≥1 new radiographic vertebral compression fractures (defined as a loss of vertebral height of ≥20% and ≥4 mm) over 24 months.

Results: {The rate of new radiographic vertebral fractures was 1.6% in the zoledronic acid group and 4.9% in the placebo group (relative risk, 0.33; 95% CI, 0.16 to 0.70; P =0.002).} Treatment with zoledronic acid, versus placebo, was associated with fewer moderate to severe compression fractures (P =0.02) and less loss of height (P =0.003). There was a small difference in the incidence of symptomatic vertebral or non-vertebral fractures (1.0% vs 1.8%) but this did not reach statistical significance. Participants treated with zoledronic acid, versus placebo, had higher bone mineral density scores and lower measures of bone turnover (P <0.05 for both). The total testosterone level did not affect the anti-fracture efficacy of zoledronic acid. There was not a significant difference in the death rates between the treatment and placebo groups (2.6% vs 2.9%) or in the incidence of adverse events.

Conclusions: Zoledronic acid treatment was associated with a significantly reduced risk of vertebral fracture among men with osteoporosis.

Reviewer's Comments: For men with osteoporosis, treatment with 2 annual doses of zoledronic acid was associated with a 67% reduction in radiographic, but not clinical, vertebral compression fractures over 2 years. This finding was similar to that reported in studies of postmenopausal women. Zoledronic acid reduced the risk of height loss and moderate-to-severe vertebral fractures, both of which are associated with an increased risk of subsequent vertebral and non-vertebral fractures. The study was not powered to detect reductions in non-vertebral fractures, but these rates were consistently lower in men who received zoledronic acid. These results provide evidence of effective anti-fracture therapy for men with osteoporosis and should encourage additional trials. The study was funded by Novartis Pharma.

Article Reviewed: Fracture Risk and Zoledronic Acid Therapy in Men With Osteoporosis; Boonen S, Reginster J-Y, et al: N Engl J Med; 2012; 367; November.

Take-Home Pearl
Zoledronic acid reduces the risk of vertebral fractures by 67% in men with osteoporosis, a benefit that is similar to that observed in postmenopausal women.

Friday, February 22, 2013

Topic:  How Common Is Periodontal Disease in Adults?

The prevalence of periodontitis in adults in the United States is 47%.

By Vincent G. Kokich, Sr, DDS, MSD
Professor, Department of Orthodontics
University of Washington
Seattle, WA

Background: Today, more adults are receiving orthodontic treatment. Some of those adults have significant malocclusions, and some of the treatment will occur over several years. If these individuals have periodontitis, it could compromise the outcome of treatment.

Objective: To determine the prevalence of periodontal disease in adults in the United States.  

Design:  This was an extensive survey of >3700 adults. This was part of the National Health and Nutrition Examination Survey (NHANES). This survey was completed during 2009 and 2010.  

Methods:  The authors calculate that this survey represents information on >64 million adults. The periodontal health was assessed using a periodontal probe and probing 6 sites on every tooth. Disease was classified as either mild, moderate, or severe depending on whether 3, 4, or 6 mm of attachment loss had occurred, respectively.

Results: 47% of U.S. adults have periodontitis. When classified in the various categories, 8.7% have mild periodontitis, 30% have moderate periodontitis, and 8.5% have severe periodontitis. {Total periodontitis in adults from 30 to 34 years of age was 24.4% versus 70.1% in adults aged ≥65 years. The incidence/prevalence of periodontitis was significantly higher in males than in females.

Conclusions:  Periodontitis in the adult U.S. population is much higher than has been previously reported based on past studies.}

Reviewer's Comments: This was an excellent study and should be an alert to any orthodontist treating adults. Based on these results, nearly half of the patients coming in for orthodontic treatment have underlying attachment loss. If they have active disease, this can be a serious problem for the orthodontist during treatment. It is recommended that all adult patients receive a thorough periodontal evaluation to prevent problems from occurring due to underlying periodontitis.

Article Reviewed: Prevalence of Periodontitis in Adults in the United States: 2009 and 2010; Eke PI, Dye BA, et al: J Dent Res; 2012; 91; October.
 

Take-Home Pearl
The prevalence of periodontitis in adults in the United States is 47%.