Musculoskeletal diseases

Objective: To investigate the impact, quality and acceptability of a musculoskeletal screening clinic provided by physiotherapists for patients referred to the outpatient orthopaedic department at a major metropolitan hospital.Design, setting and participants: Prospective observational trial undertaken between 29 November 2005 and 6 June 2006 at the Northern Hospital (a tertiary teaching hospital in outer Melbourne) of 52 patients with non-urgent musculoskeletal conditions who were assessed by one of two physiotherapists with postgraduate qualifications and subsequently by an orthopaedic surgeon.Main outcome measures: Proportion of new patients referred who could have been managed without needing to see a surgeon; level of agreement between physiotherapists and orthopaedic surgeon on diagnoses and management decisions; and levels of satisfaction of patients, referring general practitioners and the orthopaedic surgeon with the physiotherapist-led screening initiative.Results: 45 of 52 selected patients (31 women and 21 men; mean age, 53.3 years) attended their appointment with the physiotherapist; of these, 38 also attended a later appointment with the orthopaedic surgeon. Seven of the 38 patients were listed for surgery, and seven others needed management by the surgeon (injection for three, imaging for four). Almost two-thirds (63%) were appropriate for non-surgical management. The physiotherapists identified the same patient management plans as the surgeon for 74% of the group. Patients and doctors reported high levels of satisfaction with the physiotherapist-led service.Conclusions: Nearly two-thirds of patients with non-urgent musculoskeletal conditions referred by their GPs to one public outpatient orthopaedic department did not need to see a surgeon at the time of referral, and were appropriately assessed and managed by experienced, qualified physiotherapists.

Leonie B Oldmeadow DPhysio · Harvinda S Bedi MB BS, FRACS, MPH · Hugh T Burch BApplSc(HumanMovt), BApplSc(Physio), MManipPhysio · Jenni S Smith BApplSc(Physio), GradDipPhysio(Research) · Edmund S Leahy BApplSc(Physio), MManipPhysio · Miron Goldwasser MB BS, FRACS

Medicare funding could jeopardise the research needed to establish the benefits and risks of this procedure Recent publications and regulatory decisions about the therapeutic use of vertebroplasty, or injection of bone cement into diseased vertebrae such as osteoporotic fractures, call for a closer look at the evidence. New drug treatments are not considered to have proven efficacy until, at the very least, they have been evaluated in randomised controlled trials. Even then, their safety is not guaranteed, particularly for uncommon adverse effects, or those for which there is a long delay between exposure and clinical manifestation. Adverse effects that have a high prevalence may also be difficult to detect, as exemplified by the much-delayed recognition of the association between myocardial infarction and strokes and rofecoxib.1 In Australia, drugs must also be shown to be cost-effective compared with existing subsidised treatments before they are accepted into the Pharmaceutical Benefits Scheme. The Medical Services Advisory Committee (MSAC) recently recommended vertebroplasty for interim public funding for restricted indications, including painful osteoporotic vertebral compression fractures confirmed by diagnostic imaging and not controlled by conservative medical therapy.2 While technology appraisals of vertebroplasty by health policymakers in a variety of settings, including Australia, have recognised that there is inadequate high-quality evidence on which to base a reimbursement decision, many have subsequently recommended public funding.3 Making these reimbursement decisions in the face of limited evidence raises some concerns. Firstly, while uncontrolled studies have suggested that vertebroplasty may be an efficacious treatment for painful osteoporotic spinal fractures not responsive to conservative management, uncontrolled studies tend to overestimate treatment benefit for a variety of reasons.4 They fail to take into account the natural history of the condition, which is that it improves over time; they make no allowance for the statistical artefact of “regression to the mean”; and they do not adjust for the placebo response, which is likely to be accentuated with an invasive procedure.5 At present, the best available evidence for efficacy of vertebroplasty are data from two controlled before–after studies that compared volunteers who were offered the treatment with those who refused it.6,7 This constitutes level III-2 evidence in the National Health and Medical Research Council (NHMRC) hierarchy of levels of evidence, which ranges from I for the highest level to IV for the lowest level.8 While these studies showed an early benefit of vertebroplasty over conservative treatment, it is likely that they too have overestimated the treatment effect,9 particularly as volunteers who agree to have a new therapy are known to have a better outcome than those who refuse it. Patient self-selection bias in one study meant that, in comparison to those who refused treatment, those who agreed were considerably more disabled at baseline and so had more potential to improve.6 Participants in the other study were treated relatively early after presentation with an acute vertebral fracture, and most of them were admitted as inpatients, so the results may not be relevant to patients who have had pain for longer than a few weeks.7 Of more concern than questionable efficacy is the potential for harm. The risk of subsequent vertebral fracture once a spinal fracture has occurred in patients not exposed to vertebroplasty is very high — the risk within a year of a single vertebral fracture has been estimated to be about 20% in those with untreated osteoporosis and about 10% in those treated with bisphosphonates.10 Several uncontrolled studies have now suggested an increased incidence of vertebral fractures after vertebroplasty, particularly in vertebrae adjacent to treated levels or if cement has leaked into the adjacent disc,11,12 while the two controlled before–after studies have yielded conflicting results in this regard.6,7 Yet, like heart attacks and strokes with rofecoxib, in the absence of rigorous controlled trials that are powered to detect an increased incidence of an already prevalent condition, this may take time to become evident. Furthermore, while the risk of immediate complications (such as cement leakage into the spinal canal, adjacent disc and venous circulation) from the procedure when it is performed by experienced operators, is estimated from published case series to be low, it is likely that the incidence of immediate complications will be higher in routine use, where there is likely to be a learning curve, and there are no restrictions on who can perform the procedure.13 Now that proponents of vertebroplasty have the imprimatur of MSAC approval, promotion of this procedure to the medical community and the public has intensified. For example, a recent “advertorial” in Australian Family Physician claimed that vertebroplasty is a safe, effective, and cost-effective procedure when performed in an appropriate technical environment by adequately trained interventional radiologists.14 Yet, as outlined above, the available evidence is weak and does not justify these strong claims. The way forward is to gather the necessary evidence. To this end, a multicentre, randomised, double-blind, placebo-controlled trial of vertebroplasty for painful osteoporotic spinal fractures has been funded by the NHMRC and is currently underway in Australia. In addition to gathering evidence on short-term efficacy, all trial participants are being followed up for 2 years so that the question of long-term safety and, in particular, risk of future fractures can be assessed. However, public funding of vertebroplasty through Medicare has the potential to seriously undermine the success of this and other trials by not only providing easy access to an unproven treatment, but also by lending implicit support to its use. This may result in a situation where the true effects of this treatment may never be established. At present, the trial has recruited almost a quarter of the required sample and, at the current rate of recruitment, is expected to be complete within 4 years. A second randomised, double-blind, placebo-controlled trial of vertebroplasty for osteoporotic spinal fractures is in progress in the United States. These trials will provide pivotal evidence on the value of vertebroplasty. At present, vertebroplasty, while promising, is of unproven safety, effectiveness and cost-effectiveness. Thus, the promotion and routine use of this procedure outside of the research setting remains unjustified and premature, and the onus remains on the proponents of vertebroplasty to prove their claims. Primum non nocere, or first, do no harm.

Rachelle Buchbinder MB BS(Hons), MSc, FRACP · Richard H Osborne PhD

Objective: To review our experience with percutaneous radiofrequency ablation (RFA) for osteoid osteoma.Participants, design and setting: Retrospective review of 24 patients with osteoid osteoma treated with percutaneous RFA at St Vincent’s Hospital, Melbourne, from August 2000 to February 2005.Main outcome measures: Initial response to treatment, return of symptoms, time to recurrence, complications and histopathological correlation.Results: In 23 of 24 patients, there was immediate relief of symptoms. One-third of patients had a return of symptoms. The 24 patients underwent a total of 32 RFA procedures. Of the eight patients who had a recurrence, five had an initial lesion ≥ 10 mm in maximum diameter. Twenty-three of the 24 patients were pain-free at the end of the study period. Patients were followed up for a median of 26 months. There were no long-term complications.Conclusions: Percutaneous RFA is a safe and efficacious treatment for osteoid osteoma with a low morbidity rate. Despite recurrence after treatment, re-treatment is simple and effective.

Richard A Kjar MB BS · Gerard J Powell MB BS, FRACS · Stephen M Schilcht MB BS, FRANZCR · Peter J Smith MB BS, FRANZCR · John Slavin MB BS, FRACPA · Peter F M Choong MD, FRACS

To the Editor: I note with interest the findings of Diamond et al.1 However, I would like to make some comments about the validity of the results presented. The authors state that an intention-to-treat analysis was used. However, this was unusual as the intention was to treat everybody, with the control group being made up of patients who were offered the intervention but refused it because of the lack of published data on the safety of the procedure. There was a marked decrease in the pain scores at 24 hours in the intervention group. The methods state that all patients were offered similar analgesia titrated to individual need. However, there was no mention of how many of the intervention group (if any), compared with the control group, received parenteral analgesia. The intervention group may have tended to receive more parenteral analgesia than the control group, but this was not mentioned. Indeed, Predey et al2 specifically mention this possibility in their review. Diamond et al state that lower pain scores persisted in the vertebroplasty-treated group at 6 weeks. However, from the results given in Box 3, it seems that there was no clinically significant difference between the intervention and control groups at 6 weeks. I would have liked the report to have included pain scores at 1 week. The decision to use means ± 1 SD instead of 95% CIs in the results is interesting. One SD will only include 66% of a normal population whereas a 95% CI would refer to the mean ± 2 SDs. More importantly, the size of the SD introduces the possibility of an enormous spread in the pain scores for both groups, which was not commented on in the Results or the Discussion. Finally, it was unclear whether the patients were treated in the private or public hospital system. Regardless of my comments above, I applaud any attempt to treat back pain in elderly people (especially that caused by osteoporotic crush fractures) in a time-expedient fashion. I look forward to the day when this therapy is first-line treatment for this disease and not something to consider 2 weeks down the track. The cost savings in reduced length of stay and the decreased morbidity associated with this treatment, as well as the reduced geriatric workload with the more rapid improvement in function, must outweigh the initial up-front costs.

James L Mallows

In reply: We thank Mallows for his constructive comments, and would like to reply as follows. 1. Intention-to-treat analysis is normally associated with randomised controlled trials (RCTs). Our study was not an RCT, as patients who refused vertebroplasty formed the comparison group.1 We used intention-to-treat analysis to indicate that all patients who were assessed as eligible for our study at the outset were enrolled and were all included in the results presented, irrespective of subsequent events (ie, whether they were completely compliant, had died or were lost to follow-up). We thought it was important to make clear that the study was prospective, that all patients entered into the study were represented in the outcomes, and that patients had not been selected on the basis of later events or results. 2. A description of the analgesic requirements of a subgroup of the patients in our study has been published.2 More than 90% of the vertebroplasty-treated cohort were either able to cease or reduce their analgesia dose by at least 50% within 24 hours after the procedure. Before the procedure, an intravenous injection of pethidine (50–100 mg) was the only parenteral analgesia given routinely and would not have affected the pain scores at 24 hours. 3. Pain scores at 6 weeks were statistically lower in the vertebroplasty-treated group compared with the control group. The clinical significance was not apparent, as measured by the changes in the Barthel indices. This indicator is only a crude assessment of patients’ wellbeing, and a more detailed questionnaire of activities of daily living may have shown a difference. Pain scores recorded at 24, 48, 72 and 96 hours after the procedure would have been more sensitive, so that the additional pain, without vertebroplasty, could have been calculated from the area under the pain curve; the more data points, the more accurate the curve. 4. We elected to report the results as means ± 1 SD instead of 95% CIs. We used SDs to be consistent with our previous publications and other reports in this field. We agree that we could have used 95% CIs. 5. Patients were referred to Sydney Imaging Group from the inpatients and outpatients departments of St George public and private hospitals. All patients were treated without any out-of-pocket patient expenses. Private hospital inpatients were billed according to standard Medicare fees and outpatients were bulk-billed, which was revenue neutral for the radiology practice.

Terrence H Diamond · Carl Bryant · Lois Browne · William A Clark

Objective: To examine the conditions leading to sideswipe injury of the upper limb in motor vehicle accidents and to highlight the severity of these injuries.Design and setting: Prospective study of upper-limb sideswipe injuries in patients admitted to Royal Perth Hospital, Western Australia, between August 2003 and January 2005.Participants: Eleven patients sustaining sideswipe injuries to the upper limb.Main outcome measures: Accident pattern, type of injury, surgical management, complications, and functional and employment implications.Results: Ten patients required open reduction and internal fixation for open fractures of the humerus, ulna and radius, and nine underwent additional surgical procedures including nerve, artery and tendon repair, and free flaps and split-skin grafting. The injury severity scores ranged from 9 to 25. The severity of injuries led to extensive functional deficits in eight patients, affecting employment prospects in seven.Conclusion: Appropriate educational programs, legislation and improvements in traffic conditions, especially in rural areas, as well as changes in current car design, could contribute to preventing these devastating and complex injuries.

Vera Kinzel PhD, MD, AFRCS · Allan P Skirving MB BS, FRCS · Michael N Wren MB BS, FRACS · Rene Zellweger MD, PhD

Magnetic resonance imaging and arthroscopy of the hip have shown that labral injuries, chondral injuries, rim lesions, synovitis and tears of the ligament teres are common causes of hip, groin and low-back pain. Hip arthroscopy is used both as a diagnostic and therapeutic tool; it has been shown to be of benefit in recent traumatic labral injury, but disappointing in the management of chronic hip pain (which may be associated with degenerative change, and chondral lesions of the acetabulum). The McConnell multimodal physiotherapy regimen is effective in treating patellofemoral pain. Anterior cruciate ligament rupture is three to five times more common in women, but neuromuscular training appears to decrease its incidence. Patellar tendon and hamstring grafts appear to be equally effective in anterior cruciate ligament reconstruction. Articular cartilage defects remain a significant problem, and the efficacy of treatments such as autologous chondrocyte implantation is still unclear.

Peter D Brukner MB BS, FACSP · Kay M Crossley BAppSci(Physio), PhD · Hayden Morris MB BS, FRACS · Simon J Bartold BSc, FASMF, FAAPSM · Bruce Elliott PhD, FAAKPE, FISBS

Richard F O’Reilly,* Ian A Burgess,† Bernard Zicat‡ * Physician, † Radiologist, ‡ Orthopaedic Surgeon, Mater Misericordiae Hospital, Rocklands Road, North Sydney, NSW 2060. roreillyATbigpond.net.au To the Editor: In a recent editorial, Gallus estimates the cost of doing ultrasonography in all patients after unilateral hip or knee replacement, with further testing in the 9% or 26% of patients, respectively, found to have deep vein thrombosis (DVT), to be about $200 000 per 1000 patients.1 We agree. He then states, “Many would argue that extended prophylaxis is likely to be the simplest, cheapest and perhaps safest solution”. However, prophylaxis is also expensive. Subcutaneous enoxaparin 40 mg administered daily for 30 days costs $170, or $170 000 per 1000 patients.2 In our study, we found DVTs in 1086 of 5999 patients (18.1%) before discharge,3 so that extended prophylaxis would involve 81.9% of patients receiving prophylactic doses of anticoagulants, with the risk of unwanted bleeding, despite the absence of DVT on ultrasound at Day 7 postoperatively. In addition, if an ultrasound scan was not done before discharge, the 18.1% of patients with a DVT would receive only prophylactic (not therapeutic) doses of anticoagulant for their DVT. We plan a further study to check the prevalence of post-discharge DVT by repeating ultrasonography at 90 days postoperatively in patients without DVT on ultrasound at Day 7. We suspect the prevalence is lower than suggested in the literature, as the data on late presentation of DVTs have been obtained by retrospective study of the number of patients re-admitted to hospital with DVT. Finally, on the question of whether performing ultrasonography on all patients has clinical benefit, we concur with Gallus when he writes that “Logic suggests it should . . .”.

Richard F O’Reilly · Ian A Burgess · Bernard Zicat

In reply: O’Reilly and colleagues belatedly address the need to consider bleeding risk and costs when choosing between management routines designed to prevent venous thrombosis and pulmonary embolism. Their otherwise valuable article1 failed to record bleeding rates when patients (almost 17%) with subclinical calf-vein thrombosis were exposed to therapeutic (not prophylactic) anticoagulant dosages. Nor did they evaluate the dollar and manpower costs of their complex management routines. Present evidence-based international guidelines from the Seventh ACCP (American College of Chest Physicians) Conference on Antithrombotic and Thrombolytic Therapy recommend effective prophylaxis for at least 10 days in all patients having hip or knee replacement, extending to 28–35 days after hip replacement.2 The ACCP guidelines also recommend against routine use of ultrasound screening because it is “neither clinically effective nor cost effective”.2 This is a Grade 1A recommendation from the ACCP (“Grade 1” implies certainty “that the benefits do, or do not, outweigh the risks, burdens, and costs”; “Grade A” refers to recommendations based on “randomized clinical trials with consistent results [that] provide evidence with a low likelihood of bias”).3 To reverse this recommendation would require randomised comparisons between routine prophylaxis alone or routine prophylaxis supplemented by screening ultrasonography — powered to permit meaningful measures, in both groups, of thromboembolism rates, bleeding rates and costs. Routinely screening for subclinical thrombosis after major joint surgery should not be done outside suitably designed clinical trials until such evidence is available. The role of logic in medicine is to generate hypotheses, which must then be tested by clinical trial. Unfortunately, evidence derived from uncontrolled cohort studies remains limited to Grade C (based on “observational studies or [on] generalization from one group of patients included in randomized trials to a different, but somewhat similar, group of patients”).3

Alexander S Gallus

To the Editor: Osteonecrosis of the jaw, recently reported in patients treated with bisphosphonates, may be analogous to the historic occupational disease “phossy jaw”.1,2 Phossy jaw was osteonecrosis of the jaw caused by exposure to white phosphorus during the manufacture of matches. “Lucifer” strike-anywhere matches were first produced in 1833. They were made by dipping the match ends into a mixture containing white phosphorus.3 Workers were exposed to fumes from the white phosphorus during mixing and spreading of the dip material, and dipping, drying and boxing of the matches.3,4 The first case series, comprising 22 cases, was reported in Vienna in 1845.5 About 11% of those exposed developed the disease.5 The average period from first exposure to diagnosis was 5 years.4,5 Occasionally, this period was as short as a few months.5 The mandible and maxilla could be affected, the mandible in 60% of cases (Box).3 Dental decay was considered a prerequisite, and preventive measures included dental surveillance and treatment within the factories.4 In that pre-antibiotic era, phossy jaw was fatal in about 20% of cases, usually because of septicaemia or meningitis.5 Donald Hunter, British doyen of occupational medicine, commented: “It was the most distressing of all the occupational diseases because it was very painful and was accompanied by a foul fetid discharge that made its victims almost unendurable to others. It was obstinate and chronic, the treatment was agonising and the final result was a distressing disfigurement. It was this disfiguring effect plain to every observer that made phosphorus poisoning so notorious and led to determined efforts for its abolition in every civilised land.”5 In 1906, several European countries banned the manufacture and importation of white phosphorus matches at the Berne Convention.4,5 A safe substitute, sesquisulfide, had been discovered by a French chemist and successfully used for manufacture of strike-anywhere matches in 1898.4,6 In the United States, John Andrews published a report in 1910 of 150 cases of phossy jaw from 15 of 16 match factories then in operation.4,6 The Diamond Match Company, which held the American patent rights for sesquisulfide, waived their rights, thereby allowing the entire US match industry to use this alternative.6 Congress then passed the Esch law, which imposed a prohibitive tax on white phosphorus matches and banned their import and export.4,6 Eventually safety matches were developed that used amorphous red phosphorus, which did not have the toxic properties of white phosphorus.5 Phosphorus necrosis of the jaw A Deformity resulting from excision of entire lower jaw in a case of phosphorus necrosis. (Case of Dr John P. Andrews, The Occupational Diseases, W Gilman Thompson, D Appleton & Co, New York, 1914). B Phosphorus necrosis of entire lower jaw excised by Mr McCarthy in 1884 (London Hospital Medical College Museum).

A Michael Donoghue

Objective: To review acute spinal cord injuries (ASCIs) in all Australian codes of football (rugby union [RU], rugby league [RL], Australian Rules football [ARF] and soccer) for 1997–2002 and to compare data with those of a 1986–1996 survey.Design: Retrospective review of hospital records, and structured interviews with injured players.Participants and setting: Patients admitted to any of the six Australian spinal cord injury units with a documented football-related ASCI over the period 1997–2002.Outcome measures: Average annual incidence of ASCIs per 100 000 players in the different codes, final Frankel grading of injuries, and wheelchair status.Results: Fifty-two footballers (45 adult men and seven schoolboys) suffered ASCIs between 1997 and 2002. The average annual incidence of ASCIs per 100 000 players was 3.2 for RU, 1.5 for RL, 0.5 for ARF and 0.2 for soccer. While there has been little change in incidence since the 1986–1996 survey, there has been a trend towards less severe injuries in RU and RL, but not in ARF. There have been no scrum injuries in RL since 1996, when the scrum stopped being contested. Seven injuries occurred in RU scrums, six at the moment of engagement of the opposing teams. The incidence of 2-on-1 and “gang” tackles (involving multiple tacklers) in RL is disturbing. Overall, 39% of injured players became permanently wheelchair-dependent.Conclusions: There continues to be good reason to revise the laws of scrum engagement in RU. The laws relating to multiple tacklers in RL should be examined. The insurance cover for injured players is grossly inadequate. The longstanding need for a registry of spinal cord injuries for all football codes regrettably remains unmet.

David J Carmody MB BS · Thomas K F Taylor DPhil(Oxon), FRACS · David A Parker FRACS · Myles R J Coolican FRACS · Robert G Cumming MB BS, MPH, PhD

What is the evidence? Venous thrombosis and pulmonary embolism continue to be significant complications of hip or knee replacement surgery. Seven to 10 days of anticoagulant prophylaxis starting before or soon after surgery fail to prevent 20%–30% of venous thromboembolic events. It is this residual thrombosis rate that provides a spur for adding pre-discharge screening to routine prophylaxis, with the aim of detecting and treating silent thrombosis before it progresses to clinical disease. In this issue of the Journal, O’Reilly and colleagues (page 154) report on routine venous ultrasound examination performed on almost 6000 patients before discharge from hospital 6–7 days after major joint surgery. Within this large cohort, subclinical deep vein thrombosis (DVT) was detected in 9%, 26% and 37% of patients after hip, knee or bilateral knee replacement, respectively. This was despite intensive in-hospital prophylaxis using an anticoagulant (mostly low-molecular-weight heparin) plus intermittent calf compression and the use of elastic stockings. Thrombosis was proximal (affecting the popliteal, femoral or iliac veins) in 1.5%, 1.3% and 1.1% of patients after hip, knee or bilateral knee replacement, respectively. When considering how best to use this information, we should ask several questions. First, is ultrasonography reliable for detecting subclinical DVT? Although it is preferred for investigating clinically suspected disease, opinions are divided about its value in screening for subclinical thrombi, which are often no more than a few centimetres long. Ultrasonography is observer-dependent, and screening by this method has not been validated through large, blinded comparisons with the “gold standard” of bilateral venography. However, an excellent systematic overview of ultrasonography2 has reported a positive predictive value for subclinical proximal DVT of over 80% if disease prevalence is low and the false positive rate is no more than 5% (results with calf DVT were less impressive). So the 1%–1.5% proximal DVT rate reported by O’Reilly et al is probably valid. Second, are the DVT rates seen by O’Reilly et al consistent with previously reported results of routine venography? The answer is yes. Overall DVT rates 5–10 days after hip replacement in people given warfarin, low-molecular-weight heparin, fondaparinux (a specific inhibitor of activated factor X) or ximelagatran (an oral thrombin inhibitor) have been shown to be about 20%, 10%, 4%, and 8%, respectively, while proximal DVT rates are about 5%, 2%, 1.5%, and 3%, respectively.3, Reported rates of DVT after knee replacement are also consistent.3, If anything, the rate of proximal DVT found by O’Reilly et al is on the low side, perhaps because they combined chemical with physical prophylaxis and/or because ultrasound examination is less sensitive for detecting proximal DVT than is venography. Third, does ultrasonographic screening at discharge bring any clinical benefit? We just do not know. Logic suggests it should, but attempts to validate the value of pre-discharge screening by randomised trials have failed. Perhaps the trials were underpowered to detect real but small reductions in rates of venous thromboembolism. Or perhaps it is a wrong assumption that new thrombus formation is not a problem once patients leave hospital. We now know that thrombosis risk after major joint (especially hip) surgery persists for at least 4–6 weeks and that duration of prophylaxis is a major determinant of success. The rates of venous thromboembolism (subclinical, symptomatic and confirmed) in randomised comparisons are substantially reduced by persisting with preventive therapy until 4–5 weeks after a hip fracture or hip replacement rather than stopping (as in the study by O’Reilly et al) when patients are discharged from hospital.3,5,6 Hence, the recent recommendation by the American College of Chest Physicians (ACCP) for at least 10 days’ prophylaxis after major joint surgery, extending to 28–35 days after hip arthroplasty or hip fracture.3 The obvious explanation for reduced rates of venous thromboembolism is suppression of late thrombus formation. More intriguing is the apparent resolution of small venous thrombi formed soon after surgery — an effect best seen in one of the fondaparinux trials (the “PENTHIFRA-Plus” trial),5 in which the venographically detected thrombosis rate with ongoing prophylaxis was negligible (1.4%) 4 weeks after hip fracture surgery and well below the 8.3% rate previously found after 7 days of preventive therapy.6 (The latter rate is similar to the 9% DVT rate observed by O’Reilly et al after 1 week of intense prophylaxis.) By contrast, the thrombosis rate after 4 weeks among PENTHIFRA-Plus trial patients given a placebo following 1 week of fondaparinux therapy was 35%,5 a figure much higher than the 8.3% observed after 7 days in the earlier trial.6 The high DVT rates observed by O’Reilly et al confirm that in-hospital prophylaxis alone is not enough. Many would argue that extended prophylaxis is likely to be the simplest, cheapest and perhaps safest solution. Even if pre-discharge screening for subclinical disease might pre-empt the need for continued prophylaxis, there remain significant questions of resource availability, cost and possible harm. Ultrasound examination alone, if done in all patients and followed by further testing in the 9% or 26% of patients with thrombosis after unilateral hip or knee surgery, would cost (at current Medicare Benefits Schedule rates) about $200 000 per 1000 patients. The approach of O’Reilly et al was to treat all clots, regardless of their extent or position, with full doses of an anticoagulant for at least 2 weeks. This includes silent clots in the soleus or gastrocnemius muscle veins whose natural history is uncertain and perhaps mostly benign.7 But any decision to use anticoagulant therapy must balance potential benefit with likely bleeding risk. In this case, both remain unknowns, as the authors do not report on treatment complications. Evidence-based recommendations by expert groups are not prescriptions, and require judgement when applied to clinical practice. Even so, we should note the recent, firm (Grade 1A) recommendation by the 7th ACCP Conference on Antithrombotic and Thrombolytic Therapy3 against routine screening for DVT after major joint surgery, based on the lack of any demonstrable clinical effectiveness or cost-effectiveness of such screening.

Alexander S Gallus MB BS, FRCPA FRACP

Objective: To determine the prevalence of venous thromboembolism (VTE) after total hip replacement (THR), total knee replacement (TKR) or bilateral TKR in a large sample of patients in a major hospital orthopaedic unit.Design, setting and patients: The Mater Misericordiae Hospital, North Sydney, NSW, a 195-bed private hospital. All patients who had THR, TKR or bilateral TKR at the hospital between 1 April 1995 and 31 December 2001 had physical prophylaxis (graduated compression elastic stockings or intermittent pneumatic compression, or both) and chemical prophylaxis (anticoagulant) against VTE. All underwent ultrasonography of both legs before discharge, with a small, symptomatic group also undergoing a ventilation/perfusion lung scan (V/Q scan) and computed tomographic pulmonary angiography.Main outcome measures: Prevalence of deep-vein thrombosis (DVT) and symptomatic pulmonary embolism (PE) before discharge.Results: Among a total of 5999 patients, the pre-discharge prevalence of DVT after THR, TKR or bilateral TKR was 8.9%, 25.6% and 36.9%, respectively. The prevalence of symptomatic non-fatal in-hospital PE was 1.9%, while the prevalence of fatal in-hospital PE was 0.05%.Conclusions: Despite short-term chemical and physical thromboprophylaxis, the prevalence of DVT after lower-limb joint replacement, measured by pre-discharge ultrasonography, was high. The rate of symptomatic non-fatal in-hospital PE was moderate, but fatal in-hospital PE was rare.

Richard F O’Reilly MB BS, FRACP · Ian A Burgess MB BS, FRANZCR · Bernard Zicat MD, FRCSC, FRACS

An elderly man attending a dermatology outpatient clinic for an unrelated skin complaint proudly insisted on demonstrating his simple do-it-yourself (DIY) solution to a deformity of his great toenails (pincer nail) that he had endured for many years. As he slipped off his socks, a number of medical students observing the consultation turned ashen (see Figures). Pincer nails are a transverse overcurvature of the nail, commonly caused either by degenerative osteoarthritis of the distal interphalangeal joints or by ill-fitting shoes. Less commonly, they may be associated with subungual tumours or ingestion of β-blockers. Treatment options for pincer nail usually include bracing (with steel or plastic devices that exert countertension on the nail), surgery to ablate the lateral horns of the nail matrix, or permanent removal of the nail either chemically or surgically.1 Our patient found that, by inserting a stainless steel screw through the free edge of each of his overgrown and overcurved great toenails and into a small broad nut, he was able to satisfactorily correct his deformity by making a series of tightening adjustments over a period of months. Our patient’s novel approach, which is quite unlike that of usual bracing devices, exerted countertension on the ventral aspect of the free edge of the nail. Korean authors have recently described a similar technique using custom-fitted aluminium splints. These are bound with cyanoacrylate adhesive to the ventral nail plate after separating the affected great toenail longitudinally using CO2 laser vaporisation.2 Our patient’s device might begin to create some discomfort as the nail grows longer, requiring repositioning (proximally) to maintain the effect on moulding nail growth, although these considerations were not discussed in the brief consultation with our patient!

Alex Chamberlain MB BS · Annika Smith · Adrian Mar FACD

Adrian B Wenban Associate Governor, Australian Spinal Research Foundation, PO Box 1047, Springwood, QLD 4127. adrianwenbanATwanadoo.es To the Editor: Bogduk, in his recent clinical update on management of chronic low back pain, stated that “zygapophysial joint pain can be relieved by radiofrequency neurotomy (E2, E3), and techniques are emerging for treating sacroiliac joint pain and internal disc disruption (E2, E3, E4)”.1 (E2, E3 and E4 refer to the levels of evidence: E2 evidence is obtained from at least one properly designed randomised controlled trial; E3 from pseudorandomised controlled trials or comparative studies; and E4 from case series, either post-test or pre-test and post-test.) I have two concerns about this statement. Both involve the fact that at least three systematic reviews (E1 level of evidence) have now been published on treatment of lumbar zygapophysial joint-mediated low back pain with radiofrequency procedures.2-4 Together, these three reviews cast considerable doubt on Bogduk’s claim about the role of radiofrequency neurotomy. My first concern is that the earliest of those systematic reviews,2 which came to a very different conclusion from that of Bogduk, was published in 2001, well before he submitted his clinical update to the Journal on 16 July 2003. Yet, he does not mention that review, even though he was obviously aware of it, as evidenced by his letter to the journal Regional Anesthesia and Pain Medicine expressing concern with the methods underpinning the review.5 Even if Bogduk disagrees with the conclusions of that review, justification for excluding it from the evidence base of his recent clinical update seems warranted. Secondly, two more recent systematic reviews3,4 have come to conclusions very different from those of Bogduk on the role of radiofrequency neurotomy in treatment of lumbar zygapophysial joint pain. The first of those two reviews, from the Cochrane Collaboration Back Review Group, concludes: “There is . . . conflicting evidence for its [radiofrequency denervation] effectiveness for lumbar zygapophysial joint pain. There is limited evidence suggesting that intradiscal radiofrequency may not be effective in relieving discogenic low back pain. Further high-quality randomized controlled trials are needed, with larger patient samples and data on long-term effects, for which current evidence is inconclusive.”3 The second review concludes: “Current studies fail to give more than sparse evidence to support the use of interventional techniques [zygapophysial injections and radiofrequency denervation] in the treatment of lumbar zygapophysial joint-mediated low back pain. This review emphasizes the need for larger, prospective, randomized controlled trials with uniform inclusion and exclusion criteria, standardized treatment, uniform outcome measures and an adequate duration of follow-up period so that definitive recommendations for the treatment of lumbar zygapophysial joint-mediated pain can be made.”4 In summary, authors who knowingly exclude important relevant evidence from clinical updates should at a minimum justify the exclusion of that evidence. Given the collective weight of recent relevant systematic reviews, considerable doubt now exists about the role of radiofrequency procedures in the treatment of lumbar zygapophysial joint pain.

Adrian B Wenban

Nikolai Bogduk Director, Department of Clinical Research, Royal Newcastle Hospital, David Maddison Building, Newcastle, NSW 2300. mgillamATmail.newcastle.edu.au In reply: Although systematic reviews have identified three studies of lumbar radiofrequency neurotomy, they do not take into account technical errors in the procedure. Neither the study of Gallagher et al1 nor that of Leclaire et al2 used techniques that could coagulate the target nerves accurately, consistently, and thoroughly.3 Therefore, these studies are not a measure of the efficacy of the procedure when performed correctly and have no place in a systematic review. Nor are systematic reviews permitted to include complementary, observational studies like that of Dreyfuss et al.4 Yet, this study sets the benchmark for what outcomes can be achieved, if and when correct techniques are used. The “conflicting” evidence reported by systematic reviews arises because inaccurate surgical techniques are used. When studies using inaccurate techniques are eliminated, there is no conflict. The literature reduces to one controlled study5 and one complementary study.4 These were the studies that I cited in the clinical update on chronic low back pain.6 In the face of that literature, the conclusion that I proffered, and which Wenban has quoted, is valid. Zygapophysial joint pain can be relieved by radiofrequency neurotomy. Perhaps the extra words that are required are provided that correct techniques are used.

Nikolai Bogduk

David S Elder Occupational Physician, 517 St Kilda Road, Melbourne, VIC 3004. delderATbigpond.net.au To the Editor: In Bogduk’s review of the management of low back pain,1 he cited several international guidelines but did not address the effect of returning the patient to work. Disappointingly, return to work was mentioned only as an outcome of multidisciplinary therapy, with no mention at all of a planned and purposeful return to work in the suggested approach. This is surprising, given the literature available2,3 and the significant adverse effects of being out of work.4 Further, the algorithm in Box 3 (general practice management of chronic low back pain) appears to have a never-ending loop: I am cautious of the adverse effects that the reductionist model can have,5 and it appears possible in this algorithm to be forever stuck in the investigative loop. An additional pathway from this loop to intensive therapy would allow progression in some cases. The inclusion of a return to work in management of low back pain has been extensively analysed in the Australian setting and shown to significantly reduce disability.6 This advice should be included in any clinical update on management of low back pain.

David S Elder

John Salmon,* Anna Hilyard† * Pain Management Specialist, Bethesda Hospital, 25 Queen Mary Drive, Claremont, WA 6010; † Director, Achieve Pain Control Group, Perth, WA. salmon8ATbigpond.com To the Editor: Bogduk’s article on management of chronic low back pain1 was disappointingly retrogressive as a guide for general practitioners. Compartmentalising back pain management as monotherapy, multidisciplinary therapy or “reductionism”, and favouring the last, reinforces the medical model which has singularly failed to stem the epidemic of low back pain disability affecting the developed world. The biopsychosocial model of chronic spinal pain is now widely accepted and rationally emphasises the multi- or interdisciplinary model of management.2,3 Bogduk’s preference for the reductionist approach may be reasonable in a specialised centre and as a basis for research, but must justify its practical relevance in the face of the following: Available data on the reductionism approach are meagre, conflicting and mainly derived from pain-clinic populations likely to differ from patients presenting to GPs. Diagnostic joint and disc injection procedures and radiofrequency treatment performed to the required standard are available in only a very few centres. Radiofrequency lesioning of the nerve supply to symptomatic joints has been shown to provide pain relief limited to 9–18 months.4 Repeat lesioning may be less effective and is impracticable in the long term. At best, these treatments could be considered palliative. Of course, patients can only benefit from accurate diagnosis and reduction of pain from identified peripheral generators. Unfortunately, for most people with chronic back pain, it is not that simple. Usually there are multiple pathologies and pain generators, multisegmental dysfunction, disrupted motor control and interacting peripheral and central neural sensitisation mechanisms. And that is just the “bio” of the biopsychosocial model. There is then the interplay with the individual’s psychological and social environment. It is often a challenge to communicate the diagnosis effectively in the face of conflicting input from other health providers, the media and patient preconceptions. Just “plonking” “the diagnosis” before a patient and dangling a seductive “techno fix” that does not deliver in the long term is precisely what renders patients with chronic pain increasingly bewildered, dysfunctional and desperate to try one passive treatment after another. The biopsychosocial model provides a basis for management in both general and specialist practice. Appropriate interventions to reduce pain-generator input are embedded in a cognitive behavioural management matrix that imbues patients with accurate, relevant knowledge of their conditions and commonsense self-management techniques to maintain appropriate activity levels, goal setting and psychological positivity. For a time-challenged GP, collaboration with an activation- and exercise-oriented physiotherapist can be effective. The GP’s role is to provide the “white coat authority” so vital in recruiting patient confidence.

John Salmon · Anna Hilyard

Nikolai Bogduk Director, Department of Clinical Research, Royal Newcastle Hospital, Newcastle, NSW 2300. mgillamATmail.newcastle.edu.au In reply: There is a difference between wishful thinking and evidence. Elder advocates a focus on return to work. Elsewhere, I have described how this should be pursued.1 However, the evidence supports success only in the context of acute and subacute pain. I was commissioned to write on low back pain. In that context, evidence is lacking. Even Waddell, whom Elder cites,2 conspicuously avoided the issue of chronic low back pain; his evidence pertains only to acute low back pain. Salmon and Hilyard promote the biopsychosocial model. Indeed, this model is now widely accepted. Even our own studies have shown how successful it can be to recognise and treat patients’ fears and mistaken beliefs.3 However, the evidence of success is limited to acute and subacute low back pain. The predictions of the biopsychosocial model have not been fulfilled in the context of chronic low back pain. Although better than no therapy, behavioural therapy is not more effective than other therapies, and does not “reduce pain generator input”, as Salmon and Hilyard contend. Insurers, who pay for this treatment, do not share their enthusiasm for it.4 Salmon and Hilyard also repeat the commonly held view that patients have multiple pain generators. There is no actual evidence for this assertion, while the available evidence indicates the opposite. When investigated comprehensively, fewer than 10% of patients have more than one simultaneous pain generator.5 Further, Salmon and Hilyard consider that complete relief of pain for 9–18 months amounts to palliative therapy. Yet the opposite is true. Not relieving pain by behavioural therapy is palliative. They also deprecate radiofrequency neurotomy with the accusation that it “may be less effective” when repeated, but fail to cite the literature showing that this is not the case. They are correct in stating that reductionist procedures performed to the required standard are available in only a few centres. However, this does not invalidate these procedures; it reflects only a political and ideological problem in healthcare delivery. They also fail to reveal that in many places where these procedures are available, they are not performed according to best-practice standards. It is not the procedures, but misguided and unscrupulous practitioners, who render patients bewildered and dysfunctional.

Nikolai Bogduk

Re: “Medical management of osteoarthritis of the knee and hip joints”, a Clinical Update article by Grainger R and Cicuttini FM in the 1 March 2004 issue of the Journal (Med J Aust 2004: 180; 232-236). The authors have requested a correction because their statement “both diclofenac and celecoxib are more COX-2 selective than meloxicam” is incorrect, and should read “both meloxicam and celecoxib are more COX-2 selective than diclofenac.” The html and pdf versions of the article on the eMJA website were corrected on 28 April 2004. The COX-2 selectivity of meloxicam over diclofenac has been demonstrated in vitro using Human Whole Blood Assay and William Harvey Modified Human Whole Blood Assay (WHMA). In an in-vitro analysis assessing the degree of inhibition of COX-2 relative to COX-1 for over 40 non-steroidal anti-inflammatory drugs using the WHMA, both meloxicam and celecoxib demonstrated fivefold to 50-fold selectivity for COX-2 over COX-1, while less than fivefold selectivity for COX-2 over COX-1 was observed with diclofenac. Analysis of the percent inhibition of COX-1 seen when COX-2 is inhibited by 80% showed that the concentration of meloxicam sufficient to inhibit COX-2 isoenzymes by 80% produces only 25% inhibition of COX-1 isoenzymes. By contrast, the concentration of diclofenac necessary to produce 80% inhibition of COX-2 produced almost 70% inhibition of COX-1.1

Rebecca Grainger MB ChB (Distinction) · Flavia M Cicuttini FRACP, PhD

The first decade of the 21st century has been designated by the United Nations and the World Health Organization as the Decade of Bone and Joint Disease. The Decade was initiated to focus attention on the growing burden of musculoskeletal diseases occurring worldwide as the population of the global village ages.1 Australia — along with some 60 other countries — has signed up to the Decade,2 ...

Peter M Brooks MD, FRACP, FAFRM · Michael J Hooper MB BS, FRACP · Richard A Smallwood AO, MD, FRACP, FRCP

Osteoarthritis is a common, chronic condition which requires an individualised management plan involving multiple kinds of treatment. Exercise programs and the Arthritis Self-Management Program reduce pain and disability associated with osteoarthritis. Paracetamol is the most appropriate first-line analgesic. Non-steroidal anti-inflammatory drugs may be used as second-line analgesia on an as-needed basis (including continuous use), but must be used with caution. Cyclo-oxygenase-2-specific inhibitors are used if there are risk factors for upper-gastrointestinal complications, but only after considering cardiovascular risk. Glucosamine sulfate is a safe and effective over-the-counter treatment. Intra-articular therapies are used when others have failed.

Rebecca Grainger MB ChB (Distinction) · Flavia M Cicuttini FRACP, PhD

Timothy J McCulloch Anaesthetist, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050. tmccullATusyd.edu.au To the Editor: Chilov and colleagues have presented an updated set of guidelines for management of hip fracture, which included the statement “regional anaesthesia is recommended for most patients”.1 The evidence for this recommendation was graded as Level I (National Health and Medical Research Council) and was supported by a single reference, namely a systematic review from the Cochrane Database by Parker et al.2 Parker et al performed a meta-analysis of the published trials examining the effect of regional versus general anaesthesia on a variety of outcomes after surgery for hip fracture. A possible difference in 1-month mortality was found in favour of regional anaesthesia, but this difference was borderline using one statistical model (relative risk, 0.7; 95% CI, 0.5–1.0) and non-significant using another model. There was no significant difference in mortality at 3 months or 1 year, and no significant difference in a variety of other outcomes. Appropriately, the authors concluded that “both regional and general anaesthesia produce comparable results and therefore anaesthetists should choose which technique is most appropriate for each individual patient”.2 One of the many difficulties in interpreting meta-analyses of regional anaesthesia is that most of the published trials were performed some decades ago. For example, one study that contributed a large proportion of the data within the Cochrane meta-analysis was conducted between 1980 and 1982, and patients were explicitly excluded if they were receiving low-dose anticoagulation therapy.3 The relevance of such trials to patients receiving general anaesthesia today is highly questionable, given the improvements in general anaesthetic drugs and techniques and the importance now placed on routine thromboprophylaxis. There is a wide range of opinion within the specialty of anaesthesia regarding the place of major regional blockade, with little outcome-based evidence to support any particular advantage of these techniques. Although medical practitioners can benefit greatly from the efforts of reviewers to develop guidelines based on the best available evidence, care must be taken to ensure that recommendations do not go beyond what is supported by available data. Particular care needs to be taken when recommendations are made for areas of practice outside the reviewers’ expertise. The authors of these guidelines might consider withdrawing their recommendation regarding choice of anaesthesia.

Timothy J McCulloch

Michael N Chilov,* Ian D Cameron,† Lynette M March‡ * Intern, Concord Hospital [corresponding author], 50 Mi Mi Street, Oatley, NSW 2223; † Chair, Rehabilitation Medicine, University of Sydney; and Director, Aged Care and Rehabilitation Services, Northern Sydney Area Health Services, Rehabilitation Studies Unit, Ryde, NSW; ‡ Senior Staff Specialist in Rheumatology and Clinical Epidemiology, Department of Rheumatology, Royal North Shore Hospital, St Leonards, NSW. mchilovATgmp.usyd.edu.au In reply: We thank McCulloch for his comments regarding the use of regional anaesthesia in the surgical management of hip fracture. He makes the point that surgical and anaesthetic techniques have improved and implies that the advantage seen for regional anaesthesia in published studies may no longer be present. Given that controversy still exists, we would recommend that further randomised controlled trials be conducted. However, for the following reasons, we stand by our recommendation that the available evidence supports the use of regional anaesthesia for most patients with this condition. Our current recommendation is unchanged from the earlier version of the guideline (published in the Journal in 1999),1 and is also consistent with at least one other published guideline.2 A number of the concerns raised by McCulloch were addressed in the response to a letter by another correspondent after the publication of the original guidelines.3 While we acknowledge that the review by Parker et al4 only found the reduction in mortality at 1 month to be of borderline significance, when our review team reassessed the original articles using the Cochrane Collaboration protocol we reached a summary odds ratio for mortality of 0.68 (95% CI, 0.49–0.96). With time and further studies we expect that this estimate of effect will become more precise as the power of the meta-analysis is increased. This view is supported by a systematic review of all randomised studies comparing regional anaesthesia with general anaesthesia across surgical specialties. The study of Rodgers et al found a statistically significant reduction in mortality (odds ratio, 0.70; 95% CI, 0.54–0.90) when regional anaesthesia was compared with general anaesthesia.5 This overall point estimate is very similar to that of Parker et al in their meta-analysis of patients with hip fracture. Although lack of power meant that statistical significance did not exist within individual surgical specialties, there was, in fact, little difference in the effect across surgical groups, with no significant heterogeneity between studies. Serious complications of regional anaesthesia (eg, spinal haematoma) are extremely rare, as shown in the recent PEP study in Australia and New Zealand that reported no cases in 4603 patients undergoing regional blockade.6 This should be compared with the number needed to treat with regional anaesthesia to prevent one death of 38, according to the data of Parker et al.4 There is no doubt that our recommendation needs to be considered in the context of individual patient characteristics and, while the recommendation may not apply to all patients with hip fracture, we feel that the available evidence supports the use of regional anaesthesia.

Michael N Chilov · Ian D Cameron · Lynette M March

Osteoporosis is:

Tuan V Nguyen PhD · Jacqueline R Center PhD · John A Eisman MB BS, PhD