***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: It has been suggested that reamed intramedullary nailing of the femur should be avoided in some patients with multiple injuries . We have studied prospect ively the effect of femoral reaming on the inflammatory process as implicated in the pathogenesis of acute respiratory distress syndrome ( ARDS ) and multiple-organ failure ( MOF ) . We studied changes in the levels of serum interleukin-6 ( IL-6 ) ( proinflammatory cytokine ) , neutrophil CD11b ( C3 ) receptor expression ( activated neutrophil adhesion molecule ) , serum soluble intracellular adhesion molecule ( s-ICAM-1 ) , serum soluble E-selectin ( the soluble products of endothelial adhesion molecules ) and plasma elastase ( neutrophil protease ) in a series of patients with femoral fractures treated by nailing .  We have also compared reamed nailing with unreamed nailing . We found that the levels of serum IL-6 and elastase rose significantly during the nailing procedure indicating a measurable ' second hit ' . There was no clear response in leukocyte activation and no difference in the release of endothelial adhesion molecule markers . There was no significant difference between groups treated by reamed and unreamed nailing . Although clinical ly unremarkable , the one patient who died from ARDS was shown to be hyperstimulated after injury and again after nailing , suggesting the importance of an excessive inflammatory reaction in the pathogenesis of these serious problems . Our findings have shown that there is a second hit associated with femoral nailing and suggest that the degree of the inflammatory reaction may be important in the pathogenesis of ARDS and MOF Background and purpose After joint replacement , a repair process starts at the interface between bone and cement . If this process is disturbed , the prosthesis may never become rigidly fixed to the bone , leading to migration— and with time , loosening . Cox-2 inhibitors are widely used as postoperative analgesics , and have adverse effects on bone healing . This could tamper prosthesis fixation . We investigated whether celecoxib , a selective Cox-2 inhibitor , increases prosthesis migration in total knee replacement ( TKR ) . Methods 50 patients were r and omized to either placebo or celecoxib treatment , 200 mg twice daily , for 3 weeks after TKR  ( NexGen ; Zimmer ) . Maximum total point motion ( MTPM ) of the tibial component was measured after 2 years using radiostereometric analysis ( RSA ) . In addition , range of motion , pain , and , subjective outcome were evaluated . Results No differences in prosthesis migration , pain scores , range of motion , and subjective outcome were found after 2 years . Confidence intervals were narrow . Interpretation It is unlikely that Celecoxib increases the risk of loosening , and it may be used safely in conjunction with TKR Introduction Potential adverse effects of nonsteroidal anti-inflammatory drugs ( NSAIDs ) on bone metabolism and fracture healing are contradictive to their wide application in post-traumatic treatment . Our objective was to investigate changes to periosteal callus formation with respect to NSAID and central analgesic drug application . Our hypothesis was that callus formation is delayed in animals treated with the non-specific NSAID diclofenac . Material s and methods The left tibia of forty male Wistar rats were osteotomized , stabilized with a Kirschner wire , and r and omized into four groups of ten animals . Group 1 received a placebo , group 2 received the central analgesic tramadol ( 20 mg/kg per day ) throughout the study , and groups 3 and 4 were treated with sodium diclofenac ( 5 mg/kg per day ) . Group 3 received diclofenac for seven days , followed by placebo until sacrifice ( short-term ) , while group 4 animals received diclofenac for the full period ( long-term ) . Animals were sacrificed 21 days after osteotomy . Results Under light microscopy , all osteotomies healed successfully and independently of the drug treatment . Histomorphometry revealed delayed callus maturation in long-term diclofenac treated animals , with significantly higher amounts of cartilage and less bone , particularly in the outermost region of periosteal callus . Short-term NSAID and tramadol application did not significantly alter callus differentiation . Conclusion Callus maturation in vivo was impaired after long-term application of diclofenac which corresponds to the in vitro findings of a dose-dependent effect of NSAIDs on osteoblast proliferation STUDY OBJECTIVE We compare the treatment of pain in children with arm fractures by ibuprofen 10 mg/kg versus acetaminophen with codeine 1 mg/kg/dose ( codeine component ) . METHODS This was a r and omized , double-blind , clinical trial of children during the first 3 days after discharge from the emergency department ( ED ) . The primary outcome was failure of the oral study medication , defined as use of the rescue medication . Pain medication use , pain scores , functional outcomes , adverse effects , and satisfaction were also assessed . RESULTS Three hundred thirty-six children were r and omized to treatment , 169 to ibuprofen and 167 to acetaminophen with codeine ; 244 patients were analyzed . Both groups used a median of 4 doses ( interquartile range 2 , 6.5 ) . The proportion of treatment failures for ibuprofen ( 20.3 % ) was lower than for acetaminophen with codeine ( 31.0 % ) , though not statistically significant ( difference=10.7 % ; 95 % confidence interval -0.2 to 21.6 ) . The proportion of children who had any function ( play , sleep , eating , school ) affected by pain when pain was analyzed by day after injury was significantly lower for the ibuprofen group . Significantly more children receiving acetaminophen with codeine reported adverse effects and did not want to use it for future fractures . CONCLUSION Ibuprofen was at least as effective as acetaminophen with codeine for outpatient analgesia for children with arm fractures . There was no significant difference in analgesic failure or pain scores , but children receiving ibuprofen had better functional outcomes . Children receiving ibuprofen had significantly fewer adverse effects , and both children and parents were more satisfied with ibuprofen . Ibuprofen is preferable to acetaminophen with codeine for outpatient treatment of children with uncomplicated arm fractures BACKGROUND The Oxford Levels of Evidence are now routinely assigned at many orthopaedic journals . One disadvantage of this approach is that study design s with a higher level of evidence may be given greater weight than the overall quality of the study merits . In other words , there is no guarantee that research is scientifically valid simply because a more sophisticated study design was employed . The aim of this study was to review Level-I and II therapeutic studies on lateral epicondylitis to measure variation in quality among the highest-level study design s. METHODS Fifty-four prospect i ve r and omized therapeutic trials involving patients with lateral epicondylitis were evaluated by two independent  review ers according to the Oxford Levels of Evidence , a modification of the Coleman Methodology Score ( a 0 to 100-point scale ) , and the revised CONSORT ( Consoli  date d St and ards of Reporting Trials ) score . RESULTS The two review ers were consistent in their use of the Oxford Levels of Evidence ( kappa = 0.73 , p < 0.01 ) , the modified Coleman Methodology Score ( kappa = 0.73 ; p < 0.01 ) , and the CONSORT score ( kappa = 0.53 ; p < 0.01 ) . Both review ers rated the majority of studies as Level II ( 91 % and 94 % ) and as unsatisfactory according to the Coleman Methodology Score ( 87 % and 89 % ) and the CONSORT score ( 62 % and 63 % ) . Areas of deficiency included poor descriptions of recruitment ( > 90 % of the trials ) , power-level calculations ( 73 % ) , r and omization ( 58 % ) , blinding ( 90 % ) , and participant flow ( 50 % ) as well as inadequate follow-up , sample size , and blinding . CONCLUSIONS The use of the gold-st and ard trial design , the prospect i ve r and omized therapeutic study ( Level-I or II evidence ) , does not ensure quality research or reporting . Critical analysis of scientific work is important regardless of the study design . Clinical scientists should be familiar with the CONSORT criteria and adhere to them when reporting clinical trials Background : There is controversy surrounding the relative effectiveness of local irradiation and oral indomethacin for prophylaxis against heterotopic ossification following surgical treatment of acetabular fractures . The purpose of this study was to compare the efficacy of these two commonly used methods in a prospect i ve , r and omized trial . Methods : From July 1992 to June 1999 , 166 patients in whom a fracture of the acetabulum was treated surgically through a posterior , extensile , or combination approach were r and omized to receive either indomethacin or radiation therapy postoperatively . Seventy-eight patients received 800 cGy of local radiation therapy within seventy-two hours after surgery , and seventy-two patients received a six-week course of indomethacin ( 25 mg three times a day ) beginning within twenty-four hours after surgery . Sixteen additional patients were r and omized but did not receive treatment with either prophylactic regimen . At an average of fourteen months , the extent of heterotopic ossification was assessed on plain radiographs with use of the classification of Brooker et al. The grade of ossification was correlated with hip motion . Results : There was no significant difference between treatment groups with regard to patient age , gender , Glasgow Coma Scale , operative time , estimated operative blood loss , duration of follow-up , or presence of closed head injury . The Injury Severity Score appeared to be the only covariate that was significantly different between the groups ( p = 0.019 ) . Grade -III or IV ossification developed in eight ( 11 % ) of the patients in the indomethacin group and three ( 4 % ) in the radiation therapy group . The difference was not significant ( p = 0.22 ; 95 % confidence interval , -1.1 % , + 15.7 % ) . No complications related to the prophylaxis were noted in either group . Heterotopic ossification developed in all sixteen patients who did not receive prophylaxis , with six demonstrating grade -III or IV changes . The overall prevalence of grade -III or IV heterotopic ossification was 7 % ( eleven of 150 ) in the treated groups and 38 % ( six of sixteen ) in the untreated group . We did not find any association between the prevalence of heterotopic ossification and fracture type ( p = 0.296 ) or posterior hip dislocation ( p = 0.306 ) . Grade -I , II , and III heterotopic ossification did not decrease the range of motion of the hip except in flexion . Conclusions : Both local radiation therapy and indomethacin were found to provide effective prophylaxis against heterotopic ossification following surgical treatment of acetabular fractures through a posterior or extensile approach . We detected no significant difference in efficacy between the two prophylactic regimens Indomethacin is commonly administered for the prophylaxis of heterotopic ossification ( HO ) after the surgical treatment of acetabular fractures . Non-steroidal anti-inflammatory drugs such as indomethacin , have been associated with delayed healing of fractures and mechanically weaker callus . Our aim was to determine if patients with an acetabular fracture , who received indomethacin for prophylaxis against HO , were at risk of delayed healing or nonunion of any associated fractures of long bones . We review ed 282 patients who had had open reduction and internal fixation of an acetabular fracture . Patients at risk of HO were r and omised to receive either radiation therapy ( XRT ) or indomethacin . Of these patients , 112 had sustained at least one concomitant fracture of a long bone ; 36 needed no prophylaxis , 38 received focal radiation and 38 received indomethacin . Fifteen patients developed 16 nonunions . When comparing patients who received indomethacin with those who did not , a significant difference was noted in the rate of nonunion ( 26 % v 7 % ; p = 0.004 ) . Patients with concurrent fractures of the acetabulum and long bones who receive indomethacin have a significantly greater risk of nonunion of the fractures of the long bones when compared with those who receive XRT or no prophylaxis A double-blind , placebo-controlled study of a selective cyclooxygenase (COX)-2 inhibitor administered in 107 patients for 6 weeks after total knee arthroplasty was done to determine any benefits . All patients received celecoxib preoperatively and during hospitalization . At hospital discharge , patients were r and omized to receive celecoxib or placebo for 6 weeks . Narcotic use , knee flexion , Knee Society Score , Oxford Knee Score , and Short-Form 12 scores were determined preoperatively and at postoperative intervals to 1 year . Visual analog scale scores documented pain at rest , at night , and with activities . The celecoxib group used fewer narcotics and had significantly better visual analog scale scores , knee flexion , Knee Society Score scores , Oxford Knee Score scores , and Short-Form 12 physical composite scores than the placebo group . Knee flexion remained significantly improved through 1 year . These results demonstrate that patients who took celecoxib for 6 weeks after total knee arthroplasty had a less painful and 
    Output:
    
Thus , withholding these medications does not have any proven scientific benefit to patients and may even cause harm by increasing narcotic requirements in cases in which they could be beneficial for pain management .