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Letters to the Editor to:

Current Concepts Review:
Angelo Salerno and Robert Hermann
Efficacy and Safety of Steroid Use for Postoperative Pain Relief. Update and Review of the Medical Literature
J Bone Joint Surg Am 2006; 88: 1361-1372 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Dr. Salerno responds to Dr. McKee
Angelo Salerno, Dip App Sc, Grad Dip, Mpod (Pod Surg)   (3 January 2007)
[Read Letter to the Editor] Dr. Salerno responds to Dr. Cary
Angelo Salerno, Dip App Sc, Grad Dip, Mpod   (3 January 2007)
[Read Letter to the Editor] Intra-operative Administration of Corticosteroids by Irrigation for Pain Relief
George R. Cary, Jr., M.D.   (20 December 2006)
[Read Letter to the Editor] Steroid use for post-operative pain
Michael David McKee, M.D., FRCS(C)   (25 July 2006)

Dr. Salerno responds to Dr. McKee 3 January 2007
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Angelo Salerno, Dip App Sc, Grad Dip, Mpod (Pod Surg)
Gilberton, SA 5081, Australia

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Re: Dr. Salerno responds to Dr. McKee

footmed{at}bigpond.net.au Angelo Salerno, Dip App Sc, Grad Dip, Mpod (Pod Surg)

There appear to be quite a number of case studies that presume a link between osteonecrosis and steroids. Unfortunately no high level prospective studies are available that make the link solid. I agree that osteonecrosis is such a devastating affliction that until certainty exists as to the true cause(s), then caution regarding the use of any dose of steroids should be considered. I feel that Asano(1) may offer an answer in respect to a specific genotype related to the metabolism of corticosteroids. It would certainly be interesting to determine whether the fifteen individuals that were afflicted with osteonecrosis in the 2001 report(2) had ‘at risk’ genotypes and therefore may have been at greater risk of steroid side effects. Not only is this an interesting topic, but a very important one.

1. Asano T, Takahashi KA, Chu HC, et al. ABCB1 C3435T and G2677T/A polymorphism decreased the risk for steroid induced osteonecrosis of the femoral head after kidney transplantation. Pharmacogenetics.2003; 13:675- 682.

2. McKee MD, Waddell JP, Kudo PA, Schemitsch EH, Richards RR. Osteonecrosis of the femoral head in men following short-course corticosteroid therapy: A report of 15 cases. Can Medical Association Journal, Jan 23, 2001;164(2), p 205-206.
Dr. Salerno responds to Dr. Cary 3 January 2007
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Angelo Salerno, Dip App Sc, Grad Dip, Mpod
Gilberton, SA 5081, Australia

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Re: Dr. Salerno responds to Dr. Cary

footmed{at}bigpond.net.au Angelo Salerno, Dip App Sc, Grad Dip, Mpod

I recognize that we did not elaborate on the efficacy of corticosteroids delivered by irrigation but we certainly documented its efficacy based on the limited controlled trails available to us from the literature. Foulkes and Robinson(1) reported that compared with a control group, patients undergoing lumbar diskectomy treated with intra-operative irrigation with Dexamethasone had a significant reduction in duration of hospitalization (p< 0.001) and a highly significant reduction in narcotic consumption (p<0.001). The medical literature otherwise failed to provide further high quality papers worthy of comment for this mode of administration and none could be found in the orthopaedic or podiatric surgery specialties. Irrigation does make good rational sense in the context you have explained. However, the preference by most surgeons was by the other modes of administration discussed.

Reference:

1. Foulkes GD, Robinson JS Jr. Intraoperative dexamethasone irrigation in lumbar microdiskectomy. Clin Orthop.1990; Dec 261: 224-8.
Intra-operative Administration of Corticosteroids by Irrigation for Pain Relief 20 December 2006
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George R. Cary, Jr., M.D.,
Orthopaedist
Orthopaedic Associates of New Orleans, New Orleans, LA 70115

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Re: Intra-operative Administration of Corticosteroids by Irrigation for Pain Relief

oano{at}oano.com George R. Cary, Jr., M.D.

To The Editor:

In a recent Current Concepts Review(1),Salerno and Hermann discussed the efficacy of injecting corticosteroids for postoperative pain reduction, but they did not discuss the efficacy of corticosteroids when delivered by irrigation. Delivery by irrigation reduces pain without the other systemic or local effects from the drug.

I have used the irrigation delivery method for years with excellent results. I spray one cc of long acting corticosteroid into small (hand or foot) surgical wounds and 2cc’s into larger wounds using a sterile 22 gauge needle syringe. Typically, I irrigate the operative wound when it is fully opened to its depth. I spray the drug onto all exposed tissues especially exposed periosteum and into open joints. I allow the excess to flow out of the incision. I close the incision leaving the remaining corticosteroid in the wound.

I believe that long acting (Betamethasone or Dexamethasone)perform better than shorter acting steroids and that they have better anti-inflammatory properties, a longer biologic half life (36-54 hours), and a smaller equivalent dose (.75mg vs. 20mg), with no sodium retaining potential. I note no major difference between using Betamethasone or Dexamethasone. I have found no evidence of delayed wound healing or increase in infection and believe that use of this technique can afford three days of pain relief in most patients.

The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

Reference:

1. Salerno A, Hermann R. Efficacy and safety of steroid use for postoperative pain relief. Update and review of the medical literature. J Bone Joint Surg Am 2006;88:1361-1372.
Steroid use for post-operative pain 25 July 2006
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Michael David McKee, M.D., FRCS(C),
Orthopaedic Surgeon
University of Toronto, Toronto, Ontario, CANDADA

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Re: Steroid use for post-operative pain

mckeem{at}smh.toronto.on.ca Michael David McKee, M.D., FRCS(C)

To The Editor:

I would like to congratulate Salerno et al. on their excellent review regarding steroid use to decrease post-operative pain (1). There is, however, one aspect of the use of these medications which I believe needs to be emphasized. Working in a centre with an interest in osteonecrosis of the femoral head, I have seen an alarming number of young individuals with this condition following the short-term use of steroid medication (2). Often these unfortunate patients are prescribed steroids for what could be considered to be nebulous indications at best (i.e. undiagnosed skin rash or poison ivy). While the cause/effect relationship remains controversial, it is my firm belief that even short-term use of steroid medication will, in a small but consistent percentage of patients, result in the subsequent development of (often bilateral) osteonecrosis of the femoral head - a devastating complication in a young individual. This is a fact which must be considered when deciding to use these medications.

The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

References:

1. Salerno A, Hermann R. Efficacy and safety of steroid use for postoperative pain releif. J Bone Joint Surg 88A no.6, 2006, 1361.

2. McKee MD, Waddell JP, Kudo PA, Schemitsch EH, Richards RR. Osteonecrosis of the femoral head in men following short-course corticosteroid therapy: A report of 15 cases. Can Medical Association Journal, Jan 23, 2001;164(2), p 205-206.