Summary Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0.83, 95% CI 0.63–1.09; p=0.18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1.91, 1.06–3.44; p=0.0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0.82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0.41) and sepsis (seven [1%] vs six [1%]; p=0.79). Interpretation In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws. Funding National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians’ Services Incorporated.
Health-related quality of life following decompression compared to decompression and fusion for degenerative lumbar spondylolisthesis: a Canadian multicentre study Background: Decompression alone (D) is a well-accepted treatment for patients with lumbar spinal stenosis (LSS) causing neurogenic claudication; however, D is controversial in patients with LSS who have degenerative spondylolisthesis (DLS). Our goal was to compare the outcome of anatomy-preserving D with decompression and fusion (DF) for patients with grade I DLS. We compared patients with DLS who had elective primary 1-2 level spinal D at 1 centre with a cohort who had 1-2 level spinal DF at 5 other centres. Methods:Patients followed for at least 2 years were included. Primary analysis included comparison of change in SF-36 physical component summary (PCS) scores and the proportion of patients achieving minimal clinically important difference (MCID) and substantial clinical benefit (SCB). Results:There was no significant difference in baseline SF-36 scores between the groups. The average change in PCS score was 10.4 versus 11.4 (p = 0.61) for the D and DF groups, respectively. Sixty-seven percent of the D group and 71% of the DF group attained MCID, while 64% of both D and DF groups attained SCB. There was no significant difference between D and DF for change in PCS score (p = 0.74) or likelihood of reaching MCID (p = 0.81) or SCB (p = 0.85) after adjusting for other variables. Conclusion:In select patients with DLS, the outcome of D is comparable to DF at a minimum of 2 years.Contexte : La décompression seule est un traitement bien accepté pour la sténose lombaire (SL) causant une claudication neurogène. Son utilisation ne fait cependant pas l'unanimité chez les patients atteints de SL qui souffrent d'un spondylolisthésis dégénératif (SLD). Notre objectif était de comparer l'issue d'une décompression avec préservation anatomique à celle d'une décompression-arthrodèse (DA) chez des patients atteints de SLD de grade 1. Nous avons comparé les patients atteints de SLD ayant subi une décompression élective primaire de niveau 1-2 dans un centre à une cohorte ayant subi une DA de niveau 1-2 effectuée dans 5 autres centres.Méthodes : Nous avons inclus les patients qui ont été suivis pendant au moins 2 ans. L'analyse primaire comportait une comparaison des changements aux scores sommaires pour la composante physique (CP) du questionnaire SF-36 et la proportion de patients ayant obtenu une différence minimale cliniquement importante (DMCI) et en ayant tiré un bienfait clinique substantiel (BCS). Résultats :Il n'y avait pas de différence significative entre les scores SF-36 des 2 groupes au départ. Le changement moyen du score pour la CP a été de 10,4 c. 11,4 (p = 0,61) dans les groupes soumis à la décompression et à la DA, respectivement. Soixante-sept pour cent des patients du groupe soumis à la décompression et 71 % du groupe soumis à la DA ont obtenu une DMCI, tandis que 64 % des 2 groupes ont obtenu un BCS. On n'a noté aucune différence significative entr...
V Ve en nt ti il la at to or ry y m mu us sc cl le e s st tr re en ng gt th h a an nd d e en nd du ur ra an nc ce e i in n m my ya as st th he en ni ia a g gr ra av vi is s We studied 17 patients with myasthenia gravis (four with ocular involvement alone and 13 with varying degrees of generalized myasthenia gravis). Spirometry, ventilatory muscle strength (maximum inspiratory and expiratory pressures (MIP and MEP)) and endurance (2 min incremental threshold loading test) were measured before and 20 min after i.m. neostigmine. We compared the results with those of 10 normal controls. We found no difference between patients with isolated ocular involvement and controls. Ocular myasthenia gravis patients did not improve after neostigmine. The patients with generalized myasthenia gravis had reduced baseline ventilatory muscle strength (MIP 67 cmH 2 O (70% of predicted), MEP 86 cmH 2 O (50% of pred) and endurance (mean maximal load achieved = 246 g, mean pressure at highest load (P) = 19.4 cmH 2 O) compared with controls. After neostigmine, there was a significant increase in MIP in patients with generalized myasthenia gravis and a trend towards an increased MEP. As a group, the patients with generalized myasthenia gravis did not demonstrate a change in their ventilatory muscle endurance after neostigmine; however, there was considerable interpatient variability in response.We conclude that patients with isolated ocular MG have normal ventilatory muscle strength when tested conventionally. The measurement of ventilatory muscle endurance by incremental threshold loading does not provide additional information to the measurement of ventilatory muscle strength in patients with generalized myasthenia gravis.
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