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Silibinin: An old drug for hematological disorders

MSTS 2018 - Femur Mets and MM

Introduction: Silibinin (silybin), a non-toxic natural polyphenolic flavonoid, is the principal and the most biologically active component of silymarin. It is efficient in the treatment of acute and chronic liver disorders caused by toxins, drug, alcohol, hepatitis, and gall bladder disorders. Further, in our previous studies, we explored the anti-cancer efficacy in common cancers, such as lung, prostatic, colon, breast, bladder, as well as, hepatocellular carcinoma. Interestingly, silibinin is still not solely limited to the treatment of these diseases. Recent research endeavors suggest that silibinin may function diversely and serve as a novel therapy for hematological disorders. Areas covered: It discovered several interesting viewpoints in the widely studied mechanisms of silibinin in the hematological disorders. Expert commentary: In this report, we review the up-to-date findings of more potency roles of silibinin in β-thalassemia (β-TM), acute myeloid leukemia (AML), anaplastic large cell lymphoma (ALCL) and multiple myelomas (MM) therapy and attempt to clarify the mechanisms underlying its effects. There are two viewpoints: First, The functional mechanisms of silibinin in AML cells via regulating cell differentiation to exert anti-cancer effect; Second, combination treatment strategy may be a good choice.

Fracture of the greater trochanter after hip replacement

Management of Hip Fractures in the Elderly

Fracture of the femur is one of the common complications of hip replacement surgery. Five percent of femur fractures involve just the greater trochanter. This series consisted of 21 women and nine men with fractures of just the greater trochanter after total or partial hip replacement. The fracture was displaced 2.5 cm or less in 90% of patients. Only three (10%) patients had an increase in the amount of displacement more than 2 months after the fracture was recognized. The direction of displacement was always medially and superiorly toward the femoral head, rather than directly superiorly as in an ununited trochanteric osteotomy. For 18 (60%) patients, the fracture was asymptomatic. For 12 patients, the fracture was painful or there was a significant limp. In six of the 12 patients, the pain and limp improved over several months. There were no dislocations or subluxations in this series. Three patients continued to have pain or limp but thought it was not severe and declined surgical repair and experienced progressive improvement. In three patients, the pain, a limp, or both persisted at 1 year and the displacement was 2 cm or more. These three patients underwent operative repair of the trochanter. Two patients experienced improvement after repair of the trochanter. The conclusion was that fractures of the greater trochanter generally are stable and usually do not require additional treatment

Acromioclavicular joint reconstruction with the LARS ligament in professional versus non-professional athletes

DoD SSI (Surgical Site Infections)

PURPOSE: To compare outcomes of acromioclavicular (AC) joint reconstruction with ligament augmentation and reconstruction system (LARS) ligament in professional and non-professional athletes at 2-year minimum follow-up. METHODS: Forty-three patients (men; mean age 30, range 19-54 years) with Rockwood type III to V chronic AC joint dislocations underwent AC joint reconstruction with LARS ligament and standardized rehabilitation. Patients were divided into two groups: professionals (22) and non-professionals (21). Clinical and radiological evaluations were performed preoperatively, at 3- and 24-month follow-up. RESULTS: All clinical (Oxford and Constant) scores and patient satisfaction improved significantly from preoperative to follow-up intervals (p < 0.00001). However, professionals showed nonsignificant improvements from 3- to 24-month follow-up in Constant. Although groups differed preoperatively in Constant (p = 0.037), they were not different in preoperative-to-postoperative differences in clinical scores, postoperative final satisfaction and median time to return to unrestricted activity [4 (interquartiler range 3-5) months to return to full sport in professionals]. Follow-up radiographs revealed an AC joint ratio (clavicle inferior-to-superior translation as ratio of AC joint height) of 0.09 and 0.16 in 8/22 professionals, 0.19 and 0.31 in 9/21 non-professionals, 0.14 and 0.24 in 17/43 overall patients at 3- and 24-month follow-up, respectively. Slight loss of reduction (0.25 < AC joint ratio < 0.50): 21 %. There were no significant clinical-radiographic correlations. Complication: one coracoid fracture at follow-up and one wound infection. CONCLUSIONS: AC joint reconstruction with LARS ligament did not reveal differences in clinical outcomes between groups, with 2 % of failures (re-dislocations) at 2-year minimum follow-up. Superior radiological outcomes in professionals were not correlated to clinical results. LEVEL OF EVIDENCE: Therapeutic study-prospective comparative study, Level II.

En bloc Excision and Matched Metatarsal Transfer for Expansive Benign Osteolytic Lesions of the Metacarpal

DoD SSI (Surgical Site Infections)

Purpose Benign aggressive expansile osteolytic lesions such as giant cell tumors and aneurysmal bone cysts involving the metacarpal head pose problems in management. Unacceptably high rates of recurrence are reported after curettage and bone grafting. An en bloc excision of such tumors ideally requires osteoarticular replacement of the excised metacarpal heads to retain mobility and function. We used nonvascularized metatarsal head and shaft harvested from the foot to replace the metacarpal defect after en bloc resection to retain movement and function of metacarpophalangeal (MCP) joint. The purpose of this study was to evaluate results of patients who underwent this procedure. Method Nine patients treated with metatarsal transfer for osteoarticular reconstruction after en bloc excision of benign aggressive osteolytic metacarpal head tumors were reviewed retrospectively. The postoperative evaluation included examination of radiographs, joint mobility, and patient rated return of function using the Michigan Hand Questionnaire. Results Of 9 patients, 4 had aneurysmal bone cyst, 4 had giant cell tumor, and 1 an atypical cartilaginous lesion. Patients were aged between 14 and 45 years at the time of surgery. After an average of 44 months of follow-up (minimum follow-up of 24 months; range, 24–104 months), all patients had good postoperative function, satisfactory results, and no recurrence of tumor. The mean active range of motion at the reconstructed MCP joint was 75° (range, 0° to 90°). The Michigan Hand Questionnaire score averaged 80 (range, 69–92). No patient complained of donor site morbidity. One patient underwent MCP joint fusion after a pin tract infection. Conclusions Use of a matched metatarsal graft for osteoarticular reconstruction after en bloc excision of benign aggressive tumors involving the metacarpal head is a potential treatment option. In this limited series, consistent results with respect to functional range of motion at MCP joint, and without recurrence of tumor or notable donor site morbidity were obtained. Type of study/level of evidence Therapeutic IV.

Effect of preoperative application of buprenorphine transdermal patch on analgesic requirement in postoperative period in hip and knee replacement surgeries

OAK 3 - Non-arthroplasty tx of OAK

Background and Aims: Although no pain control following hip and knee replacement surgeries has attained gold standard, it is clear that patients should have optimum pain control after total knee arthroplasty and total hip arthroplasty for enhanced satisfaction and function. We conducted this study to evaluate the effect of preoperative application of buprenorphine transdermal patch on analgesic requirement in perioperative period after knee and hip replacement surgeries Material and Methods: Following institutional ethical committee approval and written informed consent, a prospective study was conducted in 50 patients of either gender belonging to ASA1 or ASA2 status, requiring either knee or hip replacement. The patients were assessed in preoperative period, and buprenorphine patch of 10 mg (sustained release of 10 μg/h) was applied either on the chest or on outer side of the arm 12 h before surgery. Total knee arthroplasty/total hip arthroplasty was done under combined spinal epidural blockade. Epidural infusion with 0.125% bupivacaine at a rate of 4-5 mL/h was continued in postoperative period. Intravenous opioid analgesics were avoided in postoperative period, and whenever required only iv paracetamol 1g was given. Outcome in terms of requirement of iv analgesic, visual analog pain score, any associated nausea vomiting, itching, and level of somnolence was noted in postoperative period at 1,2,3,4,8,12,16,20,24,48, and 72 h, respectively. Results: None of the patient required rescue analgesia in the first 2 h. During 72 h postoperative period of observation 32% of patients demanded rescue analgesics at 8th hour, followed by 20% at 4th hour and 16% at 12th hour. Conclusion: Preoperative application of transdermal patch significantly reduces the requirement of postoperative intravenous opioid and nonopioid analgesic drugs.

The clinical and radiographic course of early knee and hip osteoarthritis over 10 years in CHECK (Cohort Hip and Cohort Knee)

OAK 3 - Non-arthroplasty tx of OAK

Objective: To describe the radiographic and symptomatic course in subjects with hip or knee complaints suspected of early osteoarthritis (OA). Design: CHECK (Cohort Hip and Cohort Knee) is a multicenter, prospective observational cohort study of 1,002 subjects with first complaints in knee(s) and/or hip(s) (age 56 ± 5 years; 79% female; body mass index (BMI) 26 ± 4 kg/m2). Visits took place at baseline and at 2, 5, 8, and 10 year follow-up. At each visit, questionnaires were administered, physical examination performed, and X-ray images obtained. Clinical OA was defined according to the clinical American College of Rheumatism (ACR) criteria. Radiographic OA (ROA) was defined as Kellgren and Lawrence score (K&L) �2. Results: 83% of the subjects reported knee pain, 59% hip pain, and 42% reported both hip and knee pain at baseline. 85% of the subjects completed 10-year follow-up. Pain scores remained rather stable over time, although individual scores fluctuated. A total of 138 subjects never fulfilled the clinical American College of Rheumatology (ACR) criteria. 60% (n = 601) had ROA in one or both knees, and 51% (n = 513) had ROA in one or both hips at 10 years. Only 13.5% of the subjects did not develop ROA after 10 years. Most joint replacements (n = 52 (57%)) took place in subjects with multiple affected joints. Conclusions: The symptomatic course in subjects with hip or knee complaints suspected of OA remained fairly stable on population level, though individual scores fluctuated. The radiological course was progressive, with joint replacements particularly in subjects with both hip and knee OA.

Systematic review of the nutritional supplements dimethyl sulfoxide (DMSO) and methylsulfonylmethane (MSM) in the treatment of osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Objective: Conventional treatment of osteoarthritis (OA) with non�steroidal anti�inflammatory drugs is associated with serious gastrointestinal side effects and in view of the recent withdrawal of some cyclo�oxygenase�2 inhibitors, identifying safer alternative treatment options is needed. The objective of this systematic review is to evaluate the existing evidence from randomised controlled trials of two chemically related nutritional supplements, dimethyl sulfoxide (DMSO) and methylsulfonylmethane (MSM) in the treatment of OA to determine their efficacy and safety profile. Methods: The electronic databases [Cochrane Library, Medline, Embase, Amed, Cinahl and NeLH (1950 to November 2007)] were searched. The search strategy combined terms: osteoarthritis, degenerative joint disorder, dimethyl sulfoxide, DMSO, methylsulfonylmethane, MSM, clinical trial; double�blind, single blind, RCT, placebo, randomized, comparative study, evaluation study, control. Inclusion and exclusion criteria were applied. Data were extracted and quality was assessed using the JADAD scale. Results: Six studies were included [evaluating a total of 681 patients with OA of the knee for DMSO (N = 297 on active treatment); 168 patients for MSM (N = 52 on active treatment)]. Two of the four DMSO trials, and both MSM trials reported significant improvement in pain outcomes in the treatment group compared to comparator treatments, however, methodological issues and concerns over optimal dosage and treatment period, were highlighted. Conclusion: No definitive conclusion can currently be drawn for either supplement. The findings from all the DMSO studies need to be viewed with caution because of poor methodology including; possible unblinding, and questionable treatment duration and dose. The data from the more rigorous MSM trials provide positive but not definitive evidence that MSM is superior to placebo in the treatment of mild to moderate OA of the knee. Further studies are now required to identify both the optimum dosage and longer�term safety of MSM and DMSO, and definitive efficacy trials. © 2008 Osteoarthritis Research Society International.

Sports-related overuse injuries in children

Osteochondritis Dissecans 2020 Review

Increased intensity of sports activities combined with a decrease in daily physical activity is making overuse injuries in children more common. These injuries are located mainly in the epiphyseal cartilage. The broad term for these injuries is osteochondrosis, rather than osteochondritis, which more specifically refers to inflammatory conditions of bone and cartilage. The osteochondrosis may be epiphyseal, physeal, or apophyseal, depending on the affected site. The condition can either be in the primary deformans form or the dissecans form. While there is no consensus on the etiology of osteochondrosis, multiple factors seem to be involved: vascular, traumatic, or even microtraumatic factors. Most overuse injuries involve the lower limbs, especially the knees, ankle and feet. The most typical are Osgood-Schlatter disease and Sever's disease; in both conditions, the tendons remain relatively short during the pubescent grown spurt. The main treatment for these injuries is temporary suspension of athletic activities, combined with physical therapy in many cases. Surgery may be performed if conservative treatment fails. It is best, however, to try to prevent these injuries by analyzing and correcting problems with sports equipment, lifestyle habits, training intensity and the child's level of physical activity, and by avoiding premature specialization. Pain in children during sports should not be considered normal. It is a warning sign of overtraining, which may require the activity to be modified, reduced or even discontinued.

Supracondylar humerus fractures in children treated with closed reduction and percutaneous pinning

Pediatric Supracondylar Humerus Fracture 2020 Review

Supracondylar fractures of the humerus in children are important for frequency and type of associated serious complications. The management of this kind of fractures is still controversial (Skaggs et al. in J Bone Joint Surg Am 86:702-707, 2004; Kalllio et al. in J Pediatr Orthop 12:11-15, 1992). We are going to present our experience in the treatment of supracondylar humeral fracture in children. In the Orthopedic Department of Pisa, we treated 150 cases from 1989 to 2006. We are used to perform, emergency or within 12 h, reduction and two lateral-entry percutaneous pins fixation. The mean age was 7.5 years. We checked 125 cases, because we excluded all the cases with follow up less then 5 years. The mean follow up was 8.2 years. We used Gartland classification modified by Wilkins. We evaluated 125 cases by using the Flynn classification: 100 % of patients did not have impairment of the elbow joint mobility. We had seven valgus deviation, one of which was more then 10°. We also had 17 varus deviations, 11 of which were not over 8° and only 2 of them were 15°. The average value of the joint Baumann angle was calculated as great as 16°. The obtained results were classified as very good 80 %, good 11 %, sufficiently good 6 %, and bad 3 %. In our experience, all the fractures type II and III by Gartland have to be treated within 12 h, with closed reduction and stabilization with lateral-entry K-wire technique. The conservative treatment by cast is indicated only in type I fracture. The trans olecranic treatment is not realizable, for the stiffness which can occur, for the risk of iatrogenic ulnar nerve lesion, and for long-time hospitalization. The open reduction remains the first choice treatment for exposed or nonreducible fractures, and in cases of vascular injury.

RESEARCH: A prospective study of a modified pin-in-plaster technique for treatment of fractures of the distal radius

Distal Radius Fractures

Objectives: There are various pin-in-plaster methods for treating fractures of the distal radius. The purpose of this study is to introduce a modified technique of 'pin in plaster'. Methods: Fifty-four patients with fractures of the distal radius were followed for one year post-operatively. Patients were excluded if they had type B fractures according to AO classification, multiple injuries or pathological fractures, and were treated more than seven days after injury. Range of movement and functional results were evaluated at three and six months and one and two years post-operatively. Radiographic parameters including radial inclination, tilt, and height, were measured pre- and post-operatively. Results: The average radial tilt was 10.6° of volar flexion and radial height was 10.2 mm at the sixth month post-operatively. Three cases of pin tract infection were recorded, all of which were treated successfully with oral antibiotics. There were no cases of pin loosening. A total of 73 patients underwent surgery, and three cases of radial nerve irritation were recorded at the time of cast removal. All radial nerve palsies resolved at the six-month follow-up. There were no cases of median nerve compression or carpal tunnel syndrome, and no cases of tendon injury. Conclusion: Our modified technique is effective to restore anatomic congruity and maintain reduction in fractures of the distal radius.

Biomechanical study of upper-limb exoskeleton for resistance training with three-dimensional motion analysis system

Pediatric Supracondylar Humerus Fracture 2020 Review

The world's population is aging rapidly, particularly in developed countries. The trend toward prolonged life expectancy will increase the elderly population and thereby lead to an increase in occurrences of age-related health problems such as chronic disease. Healthcare services and home-based rehabilitation are in high demand, and the demand for professional physical therapy is imposing an increasing burden on the healthcare system. Rehabilitation training devices must keep pace with standards of care, be cost effective, and meet the home-based training requirements of today's rehabilitation trends. This article presents an experimental study of a novel spring-loaded upper-limb exoskeleton meant to enable a patient or nondisabled individual to move a limb at multiple joints in different planes for resistance training in a free and unconstrained environment. To assess the functionality of the design, we have measured its kinematic data while performing designated movements and adopted a motion-capture system to verify the function of our mechanism. The collected data and analysis of the kinematic and dynamic joint torques may not only verify our mechanism but also provide a profound understanding of the design requirements for an appropriate spring-loaded exoskeleton for upper-limb resistance training.

Shoulder prosthesis in the complex fractures or fractures with dislocation of humeral head: Comparison between endoprosthesis and reverse prosthesis

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Introduction Authors apply shoulder's prosthesis in split 4 fragments fractures of humeral proximal extreme, dislocation fractures of the humeral head, compression fractures involving more than 40 % of the articular surface. Materials and methods We analysed shoulder surgery cases of Dolo's Orthopaedic Unit from January 2009 to December 2011. 35 shoulder prosthetic implants were applied in patients with fractures of the proximal humeral epiphysis: reverse-geometry prostheses in 62 % of cases and in 38 % of cases endoprostheses. Average age was 73 years (57 min-93 max). On the left side of the prevalence (57 %) and females (80 %), rating by the score of Constant follow-up period of 17 months. Results 73 pts. mean Constant score for reverse-geometry prosthesis and 65 pts. for endoprosthesis. Pain (15 pts. max): 14 pts. for reversegeometry prosthesis and 13 pts. for endoprosthesis Activities of Daily Living (20 pts. max): 18 pts. for reverse-geometry prostheses and 16 pts. for endoprosthesis. Range of motion: internal rotation limitation in all patients. Best functional results were obtained in reversegeometry implants. Complications: 1 case of dislocation, 2 cases of stiffness, 2 cases of heterotopic calcifications in endoprostheses, 1 case of iatrogenic fracture of the diaphysis and 1 case of infection in reverse prostheses. Detection of torque strength of operated limb in abduction at 90(degrees) to the contralateral: all patients maintained at least 50 % and many of them>75 % of strength in comparison with nonoperated limb. Discussion In our experience fractures of the proximal humeral epiphysis in which there are signs for the application of a shoulder prosthesis: (1) it is not convenient procrastinate the application trying osteosynthesis, the subsequent intervention for removal the fixation then applying the prosthesis will be more complex and laborious with worse functional outcomes; (2) reverse prosthesis gives the functional results far better than the endoprosthesis; (3) several factors can affect the functional outcome of endoprosthesis like nonunion, migration and resorption of the tuberosities even if well performed in systems. Conclusions In our series: (1) the functional requirements of the patients had been met; (2) we applied much more reverse-geometry prostheses with better results; (3) we found more difficulty applying protesthesis in results of fracture; (4) we did not found problems of Scapular notch

Shoulder resurfacing in osteoarthritis: Surgical technique and mid-term results

Surgical Management of Osteoarthritis of the Knee CPG

Introduction Shoulder arthroplasty remains the treatment of choice for gleno-humeral osteoarthritis. The modularity of the modern prosthetic systems allow us to choose the implant best suited to the case to be treated. In this study we assessed the mid-term outcomes after shoulder resurfacing in osteoarthritis. Materials and methods From March 2005 to August 2011 we performed 984 shoulder arthroplasty, using the resurfacing in 60 cases (6 %) (mean age: 49 years; M/F: 36/24; dominant shoulder: 43 cases). Operations were performed under general anaesthesia with the patients in the beach chair position using a delto-pectoral approach and a lesser tubeorosity osteotomy. The mean follow-up was 44 months. Pre and postoperative radiographs included AP and axillary views. We implanted a humeral prosthesis in all cases and when we found a severe glenoid arthrosis, we performed: biologic resurfacing with omologue meniscus (n = 22), eccentric reaming and bloody microperforations (n = 10), biologic patch (Restore; DePuy Orthopaedics) (n = 4). All patients were assessed with the Constant- Murley (CS) score (mean + SD). Statistical significance was set at 5 % using the Student's t test for paired data. Results CS increased from 48.2 (SD:6.4) to 68.6 (SD:4.5) (p<0.05). X-rays showed a significant narrowing of joint space (5.92 mm postoperative vs. 1.65 mm at 37 months) in the cases treated with meniscus interposition while glenoid erosion was depicted in other 7 cases. Four unsatisfied patients with painful and stiff shoulder (follow- up: 31 months; CS: 52.6 + 1.4) underwent to meniscus removal and glenoid debridement (3 cases) and conversion in total arthroplasty (1 case). Discussion Resurfacing arthroplasty is an effective device in young patients with aadvanced gleno-humeral arthropathy but biologic resurfacing appear not adequate to treat glenoid arthritis where the prosthetic replacement remain the best available option. Conclusions Resurfacing arthroplasty is a good alternative to the total shoulder arthroplasty when the humeral bone stock is ensured but long-term FU studies are required to evaluate efficacy and survivorship

Acute Management of Traumatic Knee Dislocations for the Generalist

DOD - Acute Comp Syndrome CPG

Acute knee dislocations are an uncommon injury that can result in profound consequences if not recognized and managed appropriately on presentation. Patients presenting with knee pain in the setting of high- or low-energy trauma may have sustained a knee dislocation that spontaneously reduced. Prompt reduction of the dislocated knee and serial neurovascular examinations are paramount. Damage to the popliteal artery is a common associated injury that can be diagnosed on physical examination using ankle brachial indices (ABIs), CT angiography, or standard angiography. After reduction, patients with a normal pulse examination and an ABI >=0.9 may be observed, with serial examination performed to document vascular status and monitor for compartment syndrome. Patients with asymmetric pulses or an ABI <0.9 in the presence of pulses may be treated urgently depending on the results of additional vascular imaging, and patients with absent pulses and clear signs of vascular compromise should be treated emergently. Some knee dislocations are not reducible and should be taken emergently to the operating room for an open reduction. Persistent joint subluxation or severe soft-tissue injuries after reduction require temporary external fixation before definitive repair or reconstruction of ligaments is performed. Copyright 2015 by the American Academy of Orthopaedic Surgeons.

Arthritis increases the risk for fractures--results from the Women's Health Initiative

Management of Hip Fractures in the Elderly

OBJECTIVE: To examine the relationship between arthritis and fracture. METHODS: Women were classified into 3 self-reported groups at baseline: no arthritis (n = 83,295), osteoarthritis (OA; n = 63,402), and rheumatoid arthritis (RA; n = 960). Incident fractures were self-reported throughout followup. Age-adjusted fracture rates by arthritis category were generated, and the Cox proportional hazards model was used to test the association between arthritis and fracture. RESULTS: After an average of 7.80 years, 24,137 total fractures were reported including 2559 self-reported clinical spinal fractures and 1698 adjudicated hip fractures. For each fracture type, age-adjusted fracture rates were highest in the RA group and lowest in the nonarthritic group. After adjustment for several covariates, report of arthritis was associated with increased risk for spine, hip, and any clinical fractures. Compared to the nonarthritis group, the risk of sustaining any clinical fracture in the OA group was HR 1.09 (95% CI 1.05, 1.13; p < 0.001) and HR 1.49 (95% CI 1.26, 1.75; p < 0.001) in the RA group. The risk of sustaining a hip fracture was not statistically increased in the OA group (HR 1.11; 95% CI 0.98, 1.25; p = 0.122) compared to the nonarthritis group; however, the risk of hip fracture increased significantly (HR 3.03; 95% CI 2.03, 4.51; p < 0.001) in the RA group compared to the nonarthritis group. CONCLUSION: The increase in fracture risk confirms the importance of fracture prevention in patients with RA and OA

A small new idea for the training of plastic surgery residents

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Today, learning the craft of surgery is threatened by several factors, including the scarce availability of cadaver and animal models. METHODS: We propose the use of human limbs and tissues removed during commonly performed surgical procedures (e.g., lower limb amputations and abdominoplasties) as training models for plastic surgery residents. Lower limbs could be used for learning to design and harvest the majority of flap types in this region, while cutaneous lozenges from abdominoplasties could be used for training on most types of local skin flaps. RESULTS: The above-described models are routinely used by trainees in our residency program with enthusiasm and proficiency. Professors have found these models ideal for improving surgical education efficiency. CONCLUSIONS: In our opinion, the described models are valid adjuncts to currently adopted training tools in the field of surgery. They can help minimize costs as well as ethical and organizational problems, and offer training quite close to real operative situations.

Expression and predictive value of lymph-specific markers in urothelial carcinoma of the bladder

MSTS 2018 - Femur Mets and MM

OBJECTIVE: To evaluate the expression of multiple lymph-specific markers and to test its association with histopathological characteristics and clinical outcomes in patients with urothelial carcinoma of the bladder (UCB) treated by radical cystectomy (RC). PATIENTS AND METHODS: Vascular endothelial growth factor-C and -D (VEGF-C/-D), its receptor VEGF receptor-3 (VEGFR-3), and chemokine receptor type 7 (CCR7) expressions were assessed by immunohistochemistry in RC specimens of 119 patients. Semiquantitative analyses of marker expressions were correlated with clinical and pathological characteristics. Univariable and multivariable analyses were performed to identify predictors of disease-specific survival (DSS) and recurrence free survival (RFS). RESULTS: VEGF-C, VEGF-D, VEGFR-3, and CCR7 were overexpressed in 37.8%, 26.2%, 50.4%, and 23.5% of UCB samples, respectively. VEGF-D overexpression was significantly associated with a positive lymph node status (pN+). On univariable analysis, a higher pT stage, pN+, the presence of lymphovascular invasion (LVI) and vascular invasion (VI) (all P<0.001), and overexpressions of VEGF-D (P = 0.049) and VEGFR-3 (P = 0.032) were significantly associated with reduced DSS. On multivariable analysis, pT stage (P = 0.002) and pN+status (P = 0.009) were identified as independent predictors of reduced DSS. In a subgroup of patients without lymph node metastasis (pN0; n = 75), pT stage (P = 0.043) and VEGFR-3 overexpression (P = 0.008) were independent predictors of reduced DSS. CONCLUSION: Lymph-specific markers are frequently overexpressed in UCB. VEGF-D overexpression is associated with the presence of lymphatic metastasis. In patients without lymph node metastasis at the time of RC, an assessment of VEGFR-3 expression may improve the identification of high-risk patients. These findings require prospective validation to determine the potential benefit of more aggressive adjuvant treatment.

Outcome comparison in traumatic lower-extremity reconstruction by using various composite vascularized bone transplantation

DoD SSI (Surgical Site Infections)

Lower-extremity injury may present as a composite soft-tissue and bone defect, resulting directly from trauma or subsequent debridements. These composite defects often require vascularized osteocutaneous flaps for an effective, staged reconstruction. Among various donor sites, the vascularized fibular flap is generally considered the best option because of its inherent advantages. However, when the fibular flap is not available, iliac and rib flaps become the alternative choices. The purpose of this retrospective study was to compare the functional results of the alternatively chosen bone flaps (iliac and rib flaps) with those of the fibular flaps.

Hoffa's fat pad resection in total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

The authors have studied the consequences of resection of Hoffa's fat pad during total knee arthroplasty (TKA). Sixty eight patients undergoing primary TKA were randomised to have Hoffa's fat pad either resected or preserved. Biopsy specimens of Hoffa's fat pad were taken for pathological study in all patients. Radiological, functional and clinical evaluation was made after surgery, before discharge from hospital, after one month and after six months. Thirty six percent of the patients were found to present inflammatory infiltration of Hoffa's fat pad, and severe fibrosis was found in 33 %. A progressive decrease in postoperative anterior knee pain was found in 95% of the patients in both groups. Hoffa's fat pad resection did not appear to result in a change in patellar tendon length during the first six months after TKA. Preoperative fibrosis of Hoffa's fat pad may play a role in postoperative pain and range of motion

Perioperative contamination in primary total hip arthroplasty

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

All surgical procedures have the risk of microbial contamination. However, procedures in which prosthetic materials are involved have a high risk for future infectious problems because of the protection offered by the biofilm mode of growth. Studies of perioperative contamination have been done on involved surgical instruments, but whether these instruments transmit contamination to the prosthesis or future site of the prosthesis is not known. The aim of this study was to detect possible bacterial contamination in total hip arthroplasty through instruments that are used at the direct site of implantation during the primary procedure. Samples of the broaches used for preparing the acetabulum and femur, and samples of the reamed acetabular and femoral bone, were collected during 67 consecutive primary total hip arthroplasties in 67 patients. Broach samples were taken at the start and end of every reaming procedure. Four hundred two samples were taken, of which 26 were found to be positive for microorganisms. In 20 patients, at least one of these positive samples had been in direct contact with the actual prosthesis site, indicating that at least 30% of the involved patients had a possible bacterial contamination when leaving the operating theater. LEVEL OF EVIDENCE: Diagnostic study, Level I-1 (testing of previously developed diagnostic criteria in series of consecutive patients--with universally applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence

How to Choose Platelet-Rich Plasma or Hyaluronic Acid for the Treatment of Knee Osteoarthritis in Overweight or Obese Patients: A Meta-Analysis

OAK 3 - Non-arthroplasty tx of OAK

Objective. The purpose of this meta-analysis was to determine whether platelet-rich plasma (PRP) was better than hyaluronic acid (HA) for the treatment of knee osteoarthritis (OA) in overweight or obese patients. Design. Two reviewers independently used the keywords combined with free words to search English-based electronic databases according to Cochrane Collaboration guidelines, such as PubMed, Embase, ScienceDirect, and Cochrane library. The pooled data were analyzed using RevMan 5.3. Results. Ten randomized controlled trials (RCTs) with 1096 patients were included. During the first two months of follow-up, there was no significant difference between the two groups. At the 3rd, 6th, and 12th months of follow-up, the pooled analysis showed that PRP was better than HA for the treatment of knee OA in overweight or obese patients. There were significant differences between the two groups at Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score (3 months: MD = -1.35, [95% CI: -2.19 to -0.50], P=0.002, I2 = 0%; 6 months: MD = -7.62, [95% CI: -13.51 to -1.72], P=0.01, I2 = 88%; 12 months: MD = -12.11, [95% CI: -20.21 to -4.01], P=0.003, I2 = 94%). Conclusions. For overweight or obese patients with knee OA, intra-articular injection of PRP in a short time was not necessarily superior to HA, but long-term use was better than HA in pain and functional relief.

Oxford medial unicompartmental knee arthroplasty in patients younger and older than 60 years of age

Surgical Management of Osteoarthritis of the Knee CPG

We present a comparison of the results of the Oxford unicompartmental knee arthroplasty in patients younger and older than 60 years of age. The ten-year all-cause survival of the < 60 years of age group (52) was 91% (95% confidence interval (CI) 12), while in the > or = 60 years of age group (512), the figure was 96% (95% CI 3). For the younger group, the mean Hospital for Special Surgery score at ten-year follow-up (n = 21) was 94 of 100, compared with a mean of 86 of 100 for the older group (n = 135). The results show that the Oxford unicompartmental arthroplasty can achieve ten-year results that are comparable to total knee arthroplasty in patients < 60 years of age. We conclude that for patients aged over 50, age should not be considered a contraindication for this procedure

Microbiological and functional outcomes after open extremity fractures sustained overseas: The experience of a UK level I trauma centre

DoD SSI (Surgical Site Infections)

Background: Open extremity fractures carry a high risk of limb loss and poor functional outcomes. Transfer of extremity trauma patients from developing countries and areas of conflict adds further layers of complexity due to challenges in the delivery of adequate care. The combination of extensive injuries, transfer delays and complex microbiology presents unique challenges. Methods: A retrospective review was conducted to analyse the surgical and microbiological themes of patients with open extremity fractures transferred from overseas to our institution (Imperial College NHS Trust) between January 2011 and January 2016. Results: Twenty civilian patients with 21 open extremity fractures were referred to our unit from 11 different countries. All patients had poly-microbial wound contamination on initial surveillance cultures. Five patients (25%) underwent amputation depending on the extent of osseous injury; positive surveillance cultures did not preclude limb reconstruction, with seven patients undergoing complex reconstruction and eight undergoing simple reconstruction to achievewound coverage. Hundred percent of patients demonstrated infection-free fracture union on discharge. Conclusion: Patients with open extremity fractures transferred from overseas present the unique challenge of poly-microbial infection in addition to extensive traumatic wounds. Favourable outcomes can be achieved despite positive microbiological findings on tissue culture with adequate antimicrobial therapy. The decision to salvage the limb and the complexity of reconstruction used should be based on the chance of achieving meaningful functional recovery, mainly determined by the extent of bony injury. The complexity of reconstruction was based on the predicted long-term functionality of the salvaged limb.

Different competing risks models applied to data from the Australian Orthopaedic Association National Joint Replacement Registry

Management of Hip Fractures in the Elderly

PURPOSE: Here we describe some available statistical models and illustrate their use for analysis of arthroplasty registry data in the presence of the competing risk of death, when the influence of covariates on the revision rate may be different to the influence on the probability (that is, risk) of the occurrence of revision. PATIENTS AND METHODS: Records of 12,525 patients aged 75-84 years who had received hemiarthroplasty for fractured neck of femur were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. The covariates whose effects we investigated were: age, sex, type of prosthesis, and type of fixation (cementless or cemented). Extensions of competing risk regression models were implemented, allowing the effects of some covariates to vary with time. RESULTS: The revision rate was significantly higher for patients with unipolar than bipolar prostheses (HR = 1.38, 95% CI: 1.01-1.89) or with monoblock than bipolar prostheses (HR = 1.45, 95% CI: 1.08-1.94). It was significantly higher for the younger age group (75-79 years) than for the older one (80-84 years) (HR = 1.28, 95% CI: 1.05-1.56) and higher for males than for females (HR = 1.37, 95% CI: 1.09-1.71). The probability of revision, after correction for the competing risk of death, was only significantly higher for unipolar prostheses than for bipolar prostheses, and higher for the younger age group. The effect of fixation type varied with time; initially, there was a higher probability of revision for cementless prostheses than for cemented prostheses, which disappeared after approximately 1.5 years. INTERPRETATION: When accounting for the competing risk of death, the covariates type of prosthesis and sex influenced the rate of revision differently to the probability of revision. We advocate the use of appropriate analysis tools in the presence of competing risks and when covariates have time-dependent effects

Treatment of simple elbow dislocation using an immediate motion protocol

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

The results of treatment after closed reduction of elbow dislocation vary. Twenty consecutive patients with closed posterior elbow dislocations were treated prospectively on a rapid motion, nonimmobilized functional regimen. This treatment protocol emphasizes immediate active range of motion under close supervision. No slings or splints were employed. Final range of motion averaged -4 degrees to 139 degrees. All patients attained final extension within 5 degrees of the contralateral side. Each patient achieved his final range of motion within an average of 19 days after reduction of the dislocation. Arm circumference returned to normal at an average of 6.5 days. There was one redislocation. After treatment, all patients met qualification for graduation from the U.S. Naval Academy and were able to pursue unrestricted athletic and career options. Our findings suggest that an aggressive immediate motion rehabilitation allows nearly full final elbow motion and an excellent functional outcome

Update: Investigation of bioterrorism-related anthrax and adverse events from antimicrobial prophylaxis

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

CDC and state and local public health authorities continue to investigate cases of bioterrorism-related anthrax. As of November 7, a total of 22 cases of anthrax have been identified according to the CDC surveillance case definition; 10 were confirmed inhalational anthrax cases and 12 cases (seven confirmed and five suspected) were cutaneous anthrax (Table 1). The majority of cases have occurred in persons working at postal facilities in New Jersey (NJ) and the District of Columbia (DC) in which letters contaminated with anthrax were handled or processed using high-speed sorting machines, or at media companies in New York City (NYC) or Florida (FL) where letters, either confirmed or presumed to be contaminated with anthrax, were opened or handled. The probable exposures for a case of cutaneous anthrax in NJ and a case of inhalational anthrax in NYC remain unknown. Epidemiologic investigations of these cases and surveillance to detect new cases of bioterrorism-associated anthrax continue. This report updates the investigation of these cases and describes adverse events associated with antimicrobial prophylaxis

Pathogenetic considerations in ischemic necrosis of bone

DOD - Acute Comp Syndrome CPG

Many factors must be considered in the pathogenesis of ischemic necrosis of bone. Etiologic considerations deal with the heterogeneous disease categories that are associated with bone necrosis; these may affect bone circulation either directly or indirectly on either the arterial or the venous side. Moreover, the compartmental nature of bone makes it vulnerable to the direct effects of pathologic processes on the cellular elements of the intraosseous extravascular compartment. Once ischemia has been initiated, whether directly through influence on the circulatory tree or indirectly by the elevation of bone marrow pressure, the effects of ischemia are likely to be further potentiated because of the compartmental nature of bone blood flow. Once a critical level of ischemia is surpassed, it is possible that the condition becomes self perpetuating through increased bone marrow pressure leading to further ischemia. Interruption of this cycle by core decompression can be successful if extensive tissue death has not already occurred at the time of the intervention.

Comparison between intravenous and subcutaneous recombinant human erythropoietin (Epoetin alfa) administration in presurgical autologous blood donation in anemic rheumatoid arthritis patients undergoing major orthopedic surgery

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND AND OBJECTIVES: Intravenous (i.v.) Recombinant erythropoietin (Epoetin alfa) is effective in allowing autologous blood donation in patients unable to donate because of anemia. We undertook this open pilot study in order to asses whether a low subcutaneous (s.c.) dose of Epoetin alfa would prove as effective and well tolerated as the higher i.v. dose. Such a move would also decrease costs. MATERIALS AND METHODS: A total Epoetin alfa s.c. dose of 800 IU/kg was compared with a total i.v. dose of 1,800 IU/kg. Twenty-two rheumatoid arthritis patients, unable to donate because of hemoglobin (Hb) < 11 g/dl, received 300 IU/kg of IV Epoetin alfa twice weekly for 3 weeks (11 patients), or 100 IU/kg of s.c. Epoetin alfa twice weekly for 3 weeks plus an i.v. bolus of 200 IU/kg of Epoetin alfa at the first visit (11 patients). At each visit, all patients received 100 mg of i.v. iron saccharate and when the hematocrit (hct) > or = 34%, 350 ml of autologous blood (AB) were collected. RESULTS: No significant differences were observed between the 2 groups of treated patients in terms of units of AB collected (2.6 +/- 0.6 vs. 2.5 +/- 0.5 units for i.v. and s.c. groups, respectively), ml of RBC produced during the study period (291 +/- 99 vs. 337 +/- 65 ml for the i.v. and s.c. groups, respectively), or in the degree of reduced exposure to allogeneic blood in comparison with the control group. CONCLUSIONS: Lower dose of Epoetin alfa (reduced by 56%), supplemented by i.v. iron, is as effective and well tolerated as higher doses administered i.v., supplemented by i.v. iron

Predisposing factors in fixation failure of femoral prostheses following primary Charnley low friction arthroplasty. A 10- to 20-year followup study

Management of Hip Fractures in the Elderly

To identify factors affecting radiologically detected loosening of the Charnley femoral prosthesis, 326 femoral prostheses with 10- to 20-year followup were studied. After observation of postoperative radiological changes, the criteria for fixation failure detected radiologically, of femoral prostheses were defined as progression or accompanying occurrences of subsidence, demarcation, separation of the prosthesis from cement, cement fracture, or endosteal cavitation. Sixteen femoral prostheses (4.9%) developed radiologically detected fixation failure. Male gender, low canal flare index, low femoral score, large medullary canal width, low implant (cement and stem)/canal ratio, low stem/canal ratio, and varus orientation of the stem affected fixation failure. Inadequate cementing techniques such as low implant/canal and stem/canal ratios and varus stem orientation might be within the surgeon's control and should be avoided. An unfavorable canal geometry (stovepipe canal) and osteopenia of the femur, indicated by a low femoral score, are risk factors that might be out of the surgeon's control, and require future research

Posterior minimally invasive plate osteosynthesis for humeral shaft fractures

DoD SSI (Surgical Site Infections)

Fractures of the humeral shaft are common. Most of them can be successfully treated without surgery. In some cases, an operative intervention may offer faster and better functional results. One of the major problems with the open plating osteosynthesis is the extensive soft tissue stripping and disruption of periosteal circulation, caused by extensive surgical exposure, resulting in a relatively high rate of nonunion. Minimally invasive plate osteosynthesis (MIPO) techniques were developed to achieve a biologic fixation, although minimizing the complications of an open reduction. The incisions are small and remote from the fracture site to avoid direct fracture exposure. Thereby, MIPO technique obtains, theoretically, higher rates of union, lower infection risk, and decreases the need for bone graft. In the last years, MIPO has gained popularity with satisfactory clinical outcomes in the treatment of long bone fractures, especially in lower extremity. MIPO for humeral shaft fractures, however, could be a surgically dangerous procedure because of the risk of radial nerve injury. It was described by anterior and lateral approach. Humeral middle shaft fractures are possible to treat with a MIPO technique through an anterior, lateral, or a posterior approach. However, when the fracture is near the olecranon fossa, anterior approach is not possible as there is not enough space in the distal fragment to insert the amount of screws required to achieve stability. In this case, the posterior approach may be a good option for treatment. This article describes the MIPO technique through a posterior approach for the treatment of humeral shaft fractures.

Cultural competency and nursing care: an Australian perspective

Management of Hip Fractures in the Elderly

AIMS: To propose a process that will facilitate cultural competence in Australian nursing practice. BACKGROUND: Cultural diversity is a prominent feature of the Australian health system and is impacting significantly on nursing care quality. A fictitious, but typical clinical exemplar is profiled that identifies cultural insensitivity in care practices leading to poor quality outcomes for the health consumer and her family. Strategies are proposed that will reverse this practice and promote culturally competent nursing care and that locates overseas qualified nurses in this process. CONCLUSION: This paper contributes to nursing care quality internationally by articulating strategies to achieve cultural competence in practice. Nurses must pay attention to interpersonal relationships and develop respect for the health consumer's value systems and ways of being, in order to protect their rights and avoid the tendency to stereotype individuals from particular cultures. The expertise of qualified nurses from different cultures can greatly assist this process

Cohort differences and chronic disease profiles of differential disability trajectories

Management of Hip Fractures in the Elderly

OBJECTIVES: Research shows declining disability rates, but little is known about whether cohort differences are due to delayed onset, increased recovery, or reduced severity of impairment. Furthermore, disease is considered the proximate cause of disability yet chronic conditions rates are increasing, making it unclear whether the conditions predicting specific disability trajectories are changing. METHODS: We use a latent class analysis of disability trajectories and corresponding mortality with three birth cohorts of the National Long-Term Care Survey to determine how long-term experiences of disablement differ by cohort and chronic conditions. RESULTS: More recent cohorts were more likely to experience a decade free of disablement compared with all other disability trajectories. Sensory problems and hypertension correspond to trajectories of non-disablement, whereas hip fracture, stroke, arthritis, and diabetes predict more disabled experiences. DISCUSSION: Later life disability is measured nonparametrically to distinguish patterns among long-term trajectories. Findings suggest that more recent cohorts are more likely to forego or delay disability over a decade rather than experience prolonged periods of mild to severe disablement. Serious health events such as stroke, along with diabetes, characterize trajectories of high impairment, warranting future research

The treatment of the acute Essex-Lopresti injury

Distal Radius Fractures

The Essex-Lopresti injury (ELI) of the forearm is a rare and serious condition which is often overlooked, leading to a poor outcome. The purpose of this retrospective case study was to establish whether early surgery can give good medium-term results. From a group of 295 patients with a fracture of the radial head, 12 patients were diagnosed with ELI on MRI which confirmed injury to the interosseous membrane (IOM) and ligament (IOL). They were treated by reduction and temporary Kirschner (K)-wire stabilisation of the distal radioulnar joint (DRUJ). In addition, eight patients had a radial head replacement, and two a radial head reconstruction. All patients were examined clinically and radiologically 59 months (25 to 90) after surgery when the mean Mayo Modified Wrist Score (MMWS) was 88.4 (78 to 94), the mean Mayo Elbow Performance Scores (MEPS) 86.7 (77 to 95) and the mean disabilities of arm, shoulder and hand (DASH) score 20.5 (16 to 31): all of these indicate a good outcome. In case of a high index of suspicion for ELI in patients with a radial head fracture, we recommend the following: confirmation of IOM and IOL injury with an early MRI scan; early surgery with reduction and temporary K-wire stabilisation of the DRUJ; preservation of the radial head if at all possible or replacement if not, and functional bracing in supination. This will increase the prospect of a good result, and avoid the complications of a missed diagnosis and the difficulties of late treatment.

A randomized prospective study on the treatment of intra-articular distal radius fractures: open reduction and internal fixation with dorsal plating versus mini open reduction, percutaneous fixation, and external fixation

Distal Radius Fractures

PURPOSE: To compare 2 methods of surgical treatment for displaced intra-articular fractures of the distal radius: open reduction and internal fixation with dorsal plating (Pi Plate; Synthes, Paoli, PA) versus mini open reduction with percutaneous K-wire and external fixation. METHODS: Patients with AO type C intra-articular distal radius fractures were randomized into 2 groups: open reduction and internal fixation and dorsal plating or external fixation and K-wires and mini-open reduction. Patients over the age of 70 years with any associated soft-tissue or skeletal injury to the same limb and pre-existing wrist arthrosis or disability were excluded from the study. Objective, subjective, and radiographic outcomes were assessed at 2 weeks, 4 to 6 weeks, 10 to 12 weeks, 6 months, and 1- and 2-year intervals. The minimum follow-up period was 6 months; the average follow-up period was 18 months. The principal outcome analyzed was the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcomes included grip strength, range of motion, surgical procedure time, complications, and radiographic parameters. The groups were equal with respect to age, gender, fracture subtype, and number of workers' compensation cases. RESULTS: No significant difference was found in the Disabilities of the Arm, Shoulder, and Hand scores, our primary outcome. The dorsal plate group, however, showed a higher complication rate when compared with the external fixator group. The plate group had significantly longer tourniquet times when compared with the external fixator group. The plate group also had higher levels of pain at 1 year when compared with the external fixator group; however, this equalized after hardware removal. The external fixator group showed an average grip strength of 97% compared with the normal side and 86% in the dorsal plate group. CONCLUSIONS: At midterm analysis the dorsal plate group showed a significantly higher complication rate compared with the external fixator group; therefore enrollment in the study was terminated. The dorsal plate group also showed statistically significant higher levels of pain, weaker grip strength, and longer surgical and tourniquet times. Based on these results we cannot recommend the use of dorsal plates in treating complex intra-articular fractures of the distal radius.

Obesity and other modifiable factors for physical inactivity measured by accelerometer in adults with knee osteoarthritis

Surgical Management of Osteoarthritis of the Knee CPG

Objective To investigate the public health impact of obesity and other modifiable risk factors related to physical inactivity in adults with knee osteoarthritis (OA). Methods The frequency of inactivity as defined by the US Department of Health and Human Services was assessed from objective accelerometer monitoring of 1,089 participants (ages 49-84 years) with radiographic knee OA during the Osteoarthritis Initiative 48-month visit (2008-2010). The relationship between modifiable factors (weight status, dietary fat, fiber, smoking, depressive symptoms, knee function, knee pain, and knee confidence) with inactivity was assessed using odds ratios (ORs) and attributable fractions (AFs), controlling for descriptive factors (age, sex, race, education, lives alone, employment, frequent knee symptoms, and comorbidity). Results Almost half (48.9%) of participants with knee OA were inactive. Being overweight (OR 1.8, 95% confidence interval [95% CI] 1.2-2.5) or obese (OR 3.9, 95% CI 2.6-5.7), having inadequate dietary fiber intake (OR 1.6, 95% CI 1.2-2.2), severe knee dysfunction (OR 1.9, 95% CI 1.3-2.8), and severe pain (OR 1.7, 95% CI 1.1-2.5) were significantly related to inactivity, controlling for descriptive factors. Modifiable factors with significant average AFs were being overweight or obese (AF 23.8%, 95% CI 10.5-38.6%) and inadequate dietary fiber (AF 12.1%, 95% CI 0.1-24.5%), controlling for all factors. Conclusion Being obese or overweight, the quality of the diet, severe pain, and severe dysfunction are significantly associated with physical inactivity in adults with knee OA. All components should be considered in designing physical activity interventions that target arthritis populations with low activity levels. Copyright (copyright) 2013 by the American College of Rheumatology

Functional and phenotypical analysis of IL-6-secreting CD4⁺ T cells in human adipose tissue

OAK 3 - Non-arthroplasty tx of OAK

Emerging evidence indicates that a dynamic interplay between the immune system and adipocytes contributes to the disturbed homeostasis in adipose tissue of obese subjects. Recently, we observed IL-6-secretion by CD4⁺ T cells from the stromal vascular fraction (SVF) of the infrapatellar fat pad (IFP) of knee osteoarthritis patients directly ex vivo. Here we show that human IL-6⁺ CD4⁺ T cells from SVF display a more activated phenotype than the IL-6^- T cells, as evidenced by the expression of the activation marker CD69. Analysis of cytokines secretion, as well as expression of chemokine receptors and transcription factors associated with different Th subsets (Treg, Th1, Th2, Th17 and Tfh) revealed that IL-6-secreting CD4⁺ T cells cannot be assigned to a conventional Th subset. TCRbeta gene analysis revealed that IL-6⁺ and IL-6^- CD4⁺ T cells appear clonally unrelated to each other, suggesting a different specificity of these cells. In line with these observations, adipocytes are capable of enhancing IL-6 production by CD4⁺ T cells. Thus, IL-6⁺ CD4⁺ T cells are TCRalphabeta T cells expressing an activated phenotype potentially resulting from an interplay with adipocytes that could be involved in the inflammatory processes in the OA joint.

T1rho Magnetic Resonance Imaging at 3T Detects Knee Cartilage Changes After Viscosupplementation

OAK 3 - Non-arthroplasty tx of OAK

Viscosupplementation may affect cartilage. Changes in T1rho magnetic resonance imaging (MRI) relaxation times correlate with proteoglycan changes in cartilage. The authors hypothesized that T1rho MRI will show an improvement in proteoglycan content at 6 weeks and 3 months after viscosupplementation and that this improvement will correlate with functional outcome scores. Ten patients (mean age, 56 years; Kellgren-Lawrence grade 1 or 2) underwent T1rho MRI at baseline, 6 weeks, and 3 months after viscosupplementation. Volumetric T1rho means were calculated by depth and region. Visual analog scale (VAS), International Knee Documentation Committee (IKDC), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were obtained. Mean T1rho values decreased in the superficial patella at 6 weeks (10.3%, P=.002) and 3 months (7.9%, P=.018) and in the middle patella at 6 weeks (7.0%, P=.014) compared with baseline values. Deep patella T1rho values increased at 3 months compared with 6 weeks (9.9%, P=.033), returning to values similar to baseline. Mean T1rho values increased in the deep tibia at 6 weeks (4.7%, P=.048) and in the middle tibia (5.2%, P=.004) and deep tibia (11.2%, P=.002) at 3 months compared with baseline. At 6 weeks, improvement was seen in VAS (5.9 to 3.9, P<.01), IKDC-9 (55.3 to 63.7, P=.03), and WOMAC (43.9 to 32.8, P=.03) scores. Functional VAS (4.0, P=.02), IKDC-9 (67.8, P=.04), and WOMAC (30.0, P=.04) scores remained better at 3 months. T1rho MRI is a feasible noninvasive method of studying molecular changes in cartilage. Some segments improved after viscosupplementation, and others worsened, possibly reflecting natural history or symptom relief and subsequent increase in activity-related wear.

Relationship between serum 2 5-hydoroxyvitamin D levels and prevalent fracture risk in postmenopausalwomen

Management of Hip Fractures in the Elderly

Aim: Vitamin D insufficiency is frequently observed in general population, especially in elderly. The importance of vitamin D status in bone health has been noted. Vitamin D insufficiency is associated with an increase in PTH, which might be critical for an increase in bone fragility. However, the role of endogenous PTH in vitamin D insufficiency-induced fracture risk still remains unclear. The present study was performed to examine the relationships among vitamin D insufficiency, bone fragility and PTH in 202 postmenopausal women. Methods: BMD was measured using the DXA method at the lumbar vertebrae and femoral neck (FN). The presence of vertebral fractures was confirmed on x-ray and nonvertebral fractures were assessed by the clinical interview. Serum levels of Cr, CTX, intact PTH and 25- hydoroxyvitamin D [25(OH)D] were measured. Motor function tests included tandem walk test and measurements of grip strength. Results: The percentages of subjects with 25(OH)D levels below 20 ng/ml were 80.7%. Serum 25(OH)D levels were negatively related to age, Cr, CTX and PTH, although it was positively related to BMD. In multiple regression analysis, BMD was significantly related to 25(OH)D levels, when adjusted for age, BMI, Cr, CTX and PTH. Multiple logistic regression analysis showed that lower 25(OH)D levels were significantly related to prevalent fracture risk, when adjusted for age, BMI, tandem walk test, grip strength, Cr, CTX, PTH as well as FN BMD. The rate of the subjects with prevalent fractures was significantly higher in the group with lower PTH and lower 25(OH)D, compared to that of the groups with lower PTH and higher 25(OH)D or higher PTH and higher 25(OH)D. Conclusions: Vitamin D insufficiency was related to prevalent fracture risk independently of PTH. Functional hypoparathyroidism rather than functional hyperparathyroidism might be a risk factor for bone fragility in vitamin D insufficiency

Bacteriology swab in primary total hip arthroplasty-- does it have a role?

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Infection in joint replacement is a devastating complication, and in spite of the advances in surgery, it remains a challenge. The rate of deep infection following primary hip/knee arthroplasty is between 1% and 2%. The aim of this study was to determine whether obtaining bacteriology swabs at the time of surgery could help in further reducing the rate of infection following joint arthroplasty. A bacteriology swab of the synovial fluid was taken after opening the capsule of the hip joint and was sent for culture and sensitivity. Out of 142 swabs sent, four (2.1%) were found to be positive. Three of these patients were treated with antibiotics after obtaining sensitivities. None of the patients developed deep infection. Bacteriology swab in primary joint arthroplasty may have a role and may help in further reducing the incidence of deep infection in joint replacement surgery

Absolute monocytosis at diagnosis correlates with survival in diffuse large B-cell lymphoma-possible link with monocytic myeloid-derived suppressor cells

MSTS 2022 - Metastatic Disease of the Humerus

Some patients with lymphoma have monocytosis at diagnosis, but its significance is unclear. The recently recognized subpopulation, monocytic myeloid-derived suppressor cells (M-MDSCs), has immunoregulatory function, suppresses host anti-tumour immunity and plays a role in cancer tolerance. Data from 91 untreated patients with diffuse large B-cell lymphoma (DLBCL) were evaluated for monocytosis >1000/mm(3) at diagnosis and its significance compared with a number of well-established prognostic factors for DLBCL including age, stage, gender, B symptoms, extranodal sites, LDH and CRP levels, bone marrow involvement and International Prognostic Index (IPI) score. In 23 of these patients with DLBCL and 15 healthy controls, the proportion of M-MDSCs in the peripheral blood was determined by flow cytometry. Monocytosis was found in 17.6% of the patient cohort examined. In the multivariate analysis, bone marrow involvement, IPI score and monocytosis were the only independent prognostic factors seen to be associated with decreased progression free and overall survival. Patients with DLBCL had on average increased M-MDSCs counts at diagnosis compared with controls, which returned to normal after achieving remission. In conclusion, monocytosis was identified as an independent prognostic factor in DLBCL and correlated with worse overall survival. The significant increases in the M-MDSCs pool observed in some of the cases examined may possibly help to explain why monocytosis is associated with poor outcome in these patients.

Elbow arthroplasty for the treatment of bicolumn distal humeral fractures

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Distal humeral fractures are difficult to treat in elderly patients. Recent advances in precontoured and locked plates have made open reduction and internal fixation easier, but rigid and anatomic reconstruction is required for a successful result. In elderly patients with poor bone quality and an unreconstructable articular surface, total elbow arthroplasty can be a successful alternative to open reduction and internal fixation

Unusual complications of knee replacement surgery in a severe hemophilia B patient with high titer inhibitor

Surgical Management of Osteoarthritis of the Knee CPG

Background: Treatment of bleeding in hemophilia B patients with inhibitors is based on bypassing the intrinsic pathway or overwhelming the inhibitor with high-dose factor IX concentrates. For major surgery, these strategies may be unsuccessful or avoided to prevent venous thromboembolism (VTE). For patients who have failed tolerization or who have had anaphylaxis to plasma products, recombinant fVIIa is the remaining option for major surgery. Thromboelastography (TEG) may be used to guide rfVIIa dosing perioperatively. Case Report: A 34-year-old obese (BMI 33) male with severe hemophilia B and fIX inhibitor (peak 111.4 BU/mL) presented for left knee arthroplasty. He had previous anaphylaxis to plasma products during childhood and had failed immune tolerance at 16 years. He had severe flexion contracture with valgus deformity and complete obliteration of the tibial plateau. He was unable to work because of pain. He underwent left knee arthroplasty using rfVIIa (90 (mu)g/kg) every 2 hr and monitored with TEG. On Day 1, he developed posterior dislocation of the prosthesis and required closed reduction under anesthesia. On Day 5, he dislocated again and had surgical revision of the tibial component after receiving Botox 200 U IM to release the contracture. He continued on rfVIIa through Day 13 and then switched to a prothrombin complex concentrate (PCC). At Day 30, he continued to have serous drainage from the incision, and by Day 65, he developed wound dehiscence, requiring skin flap reconstruction. Incisional oozing was still present at Day 90, and formal physical therapy continues to be held pending complete wound healing, although joint motion has significantly improved (10(degrees)-90(degrees)) from baseline. PCC is being given for bloody drainage. Pharmacologic VTE prophylaxis was avoided. Conclusion: Although we encountered unusual complications, knee arthroplasty was successfully performed in this orthopedically complex inhibitor patient

Efficacy of continued alendronate for fractures in women with and without prevalent vertebral fracture: the FLEX trial

Management of Hip Fractures in the Elderly

In the Fracture Intervention Trial (FIT) Long Term Extension (FLEX) Trial, 10 years of alendronate (ALN) did not significantly reduce the risk of nonvertebral fractures (NVFs) compared with 5 years of ALN. Continuing ALN reduced the risk of clinical but not morphometric vertebral fractures regardless of baseline vertebral fracture status. In previous studies, ALN efficacy for NVF prevention in women without prevalent vertebral fracture was limited to those with femoral neck (FN) T-scores of -2.5 or less. To determine whether the effect of long-term ALN on fracture differs by vertebral fracture status and femoral neck (FN) T-score, we performed a post hoc analysis using FLEX data, a randomized, double-blind, placebo-controlled trial among 1099 postmenopausal women originally randomized to ALN in the FIT with mean ALN use of 5 years. In the FLEX Trial, women were randomized to placebo (40%) or ALN 5 mg/day (30%) or ALN 10 mg/day (30%) for an additional 5 years. Among women without vertebral fracture at FLEX baseline (n = 720), continuation of ALN reduced NVF in women with FLEX baseline FN T-scores of -2.5 or less [relative risk (RR) = 0.50, 95% confidence interval (CI) 0.26-0.96] but not with T-scores of greater than -2.5 and -2 or less (RR 0.79, 95% CI 0.37-1.66) or with T-scores of greater than -2 (RR 1.41, 95% CI 0.75-2.66; p for interaction = .019). Continuing ALN for 10 years instead of stopping after 5 years reduces NVF risk in women without prevalent vertebral fracture whose FN T-scores, achieved after 5 years of ALN, are -2.5 or less but does not reduce risk of NVF in women whose T-scores are greater than -2

Primary hemiarthroplasty in old patients with displaced femoral neck fracture: a 1-year follow-up of 103 patients aged 80 years or more

Management of Hip Fractures in the Elderly

103 patients with displaced femoral neck fractures (Garden 3-4) treated with primary hemiarthroplasty in the Department of Orthopedics, Malmo University Hospital, Sweden 1998-1999 were followed in a prospective, consecutive study for 1 year. Inclusion criteria were age of at least 80 years, signs of mental changes and/or residence in an institution. The control group consisted of 69 patients with internal fixation (Hansson hook pins). The arthroplasty group required more blood transfusions, a longer operation and had more superficial infections. No differences were detected as regards other complications, length of hospital stay, in-hospital mortality or ability to return home. The 1-year mortality rates were similar in the arthroplasty (29/103) and control groups (28/69). Within 1 year, we found a lower failure rate in the arthroplasty group (6/103) than in the control group (18/69). In the arthroplasty group, 2/103 had dislocations. Of the surviving arthroplasty patients at 12 months, 31/74 could walk as well as before the fracture and 55/74 had no pain. We recommend primary hemiarthroplasty for demented and/or institutionalized patients over 80 years with displaced femoral neck fractures

Musculo-skeletal manifestations of haemophilia

OAK 3 - Non-arthroplasty tx of OAK

Haemophilia left untreated or treated on demand destroys the joints at a very young age. Primary haematological prophylaxis, currently the gold standard for the treatment of haemophilia, is not completely effective. Moreover, it is only available for 25â??30% of patients worldwide. Advances in haematology, combined with the advances in orthopaedic surgery and other disciplines (physical medicine and rehabilitation, physiotherapy, specialised nursing, etc.), have made it possible to improve the musculo-skeletal manifestations of haemophilia in these patients through orthopaedic surgical interventions. These interventions are safe, even in the most complex cases, such as patients who develop inhibitors (antibodies to clotting factor) or are HIV + and HCV +. The risk of bleeding in surgical interventions is higher for people with haemophilia than for other patients and there is also a greater risk of infection. Both these factors increase the risk of a poor outcome. Whatever the surgical procedure, adequate surgical haemostasis must be achieved by infusion of concentrate of the deficient factor (factor VIII or factor IX), either in recombinant or plasma-derived form, at the correct doses (ideally for 10â??14 days). In patients with inhibitor there are also the aPCCs (activated prothrombin complex concentrates) and rFVIIa (recombinant activated FVII). Surgical orthopaedic interventions that are commonly required by haemophilia patients include synovectomy (open or arthroscopic), osteotomy, arthroscopic joint debridement, tendon lengthening, arthrodesis of the ankle, total joint replacement, resection or percutaneous treatment of pseudotumours, fasciotomy for compartment syndrome, neurolysis of the ulnar nerve, and other orthopaedic interventions.

2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

AAHKS (2) Corticosteroids

OBJECTIVE: This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence-based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA). METHODS: A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi-step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences. RESULTS: The guideline addresses the perioperative use of antirheumatic drug therapy including traditional disease-modifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low- or moderate-quality evidence. CONCLUSION: This guideline should help decision-making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high-quality direct randomized controlled trial data.

Selective augmentation of stem cell populations in structural fat grafts for maxillofacial surgery

Panniculectomy & Abdominoplasty CPG

Structural fat grafting utilizes the centrifugation of liposuction aspirates to create a graded density of adipose tissue. This study was performed to qualitatively investigate the effects of centrifugation on stem cells present in adipose tissue. Liposuction aspirates were obtained from healthy donors and either not centrifuged or centrifuged at 1,800 rpm for 3 minutes. The obtained fat volumes were divided into three layers and then analyzed. The results demonstrate that centrifugation induces a different distribution of stem cells in the three layers. The high-density layer displays the highest expression of mesenchymal stem cell and endothelial markers. The low-density layer exhibits an enrichment of multipotent stem cells. We conclude that appropriate centrifugation concentrates stem cells. This finding may influence the clinical practice of liposuction aspirate centrifugation and enhance graft uptake.

Bone mineral density in patients on maintenance hemodialysis and effect of chronic hepatitis C virus infection

Management of Hip Fractures in the Elderly

OBJECTIVE: To determine the prevalence of osteopenia and osteoporosis in HD patients at our center; to investigate whether HCV infection affects BMD in hemodialysis patients; to test for correlations between bone mineral density (BMD) and clinical and laboratory parameters in this population. SUBJECTS AND METHODS: The study involved 76 end-stage renal disease patients. Forty-three (56.6%) patients were tested negative for anti-HCV antibodies and HCV-RNA. Thirty-three (43.4%) of them had positivity of anti-HCV antibodies and permanent or intermittent HCV-RNA positivity at least for two years. Mean HD duration was 86.4 months. Patients completed a standard questionnaire that listed age, sex, occupation, education level; cause of renal failure, smoking history, dialysis duration, and sports activities engaged in during life, and pathologic bone fractures. The women answered additional items about age at menarche, number of pregnancies and menopausal status. Each subject underwent a baseline physical examination, including measurement of body weight and height for calculation of body mass index. The results of laboratory tests that had been done at monthly visits in the previous year were retrospectively evaluated, and mean levels for the year were used for correlation testing. Bone mineral density was measured in the spine, femoral neck and forearm. Relationships between BMD values and chronic HCV infection, laboratory results and clinical parameters were analyzed. RESULTS: In the 43 patients who were negative for anti-HCV antibodies and HCV-RNA, spine BMD testing showed osteopenia in 16 (37.2%) cases and osteoporosis in 7 (16.3%) cases. The corresponding values for the neck of the femur were 14 (32.6%) and 6 (14.0%), and for the forearm were 19 (44.2%) and 15 (34.9%). In the 33 anti-HCV antibodies and HCV-RNA positive patients; spine BMD testing showed osteopenia in 10 (30.3%) cases and osteoporosis in 7 (21.2%) cases. The corresponding values for the neck of the femur were 17 (51.5%) and 4 (12.1%), and for the forearm were 4 (12.1%) and 25 (75.8%). Bone mineral density decreased as dialysis duration increased (p<0.05). There was no statistical difference between BMD measurements of chronic HCV infection positive and negative group. CONCLUSION: However the mean BMD values for all three sites in the 76 HD patients were low HCV infection may not be a risk factor for low BMD in this population

Protelos: nonvertebral and hip antifracture efficacy in postmenopausal osteoporosis

Management of Hip Fractures in the Elderly

Strontium ranelate is a new treatment for postmenopausal osteoporosis, simultaneously increasing bone formation and decreasing bone resorption, thus rebalancing bone turnover in favor of bone formation. Strontium ranelate was demonstrated to significantly reduce the relative risk of vertebral fracture whatever the severity of the disease. In the TReatment Of Peripheral OSteoporosis (TROPOS) study, the incidence of nonvertebral and hip fractures, following treatment with strontium ranelate (Protelos, Servier) at a dosage of 2 g/day orally, was assessed over a 3-year period. In this double-blind, placebo-controlled trial, 5091 women with postmenopausal osteoporosis were assigned to either strontium ranelate (n = 2479) or placebo (n = 2453) treatment. Overall, the reduction in risk for nonvertebral fractures in patients treated with strontium ranelate was 16% (P = 0.04) and for major fractures (hip, wrist, pelvis and sacrum, ribs and sternum, clavicle and humerus), it was 19% (P = 0.031), compared with those treated with placebo. Women with osteoporosis and aged 74 years or more who were treated with strontium ranelate (n = 982) had a 36% reduction in risk of hip fracture (P = 0.046) over 3 years compared with those treated with placebo (n = 995). The difference in bone mineral density between groups was 8.2% for femoral neck and 9.8% for total hip at 3 years. The incidence of adverse events was comparable between groups. The study demonstrates that strontium ranelate treatment offers a safe and effective means of reducing the risk of nonvertebral and hip fractures in postmenopausal women with osteoporosis

Single Shot vs 24hr vs 48hr Continuous Adductor Canal Block After TKA

OAK 3 - Non-arthroplasty tx of OAK

If the patient is willing to participate and signs the consent, he/she will be randomized to one of the three treatment groups: 1. Single shot block 2. 24 hour catheter 3. 48 hour catheter The choice of anesthetic technique will be at the discretion of the anesthesiologist. In our institution we usually advocate for spinal anesthesia for total knee arthroplasty. All patients will receive their multimodal perioperative pain protocol (MP3) medication as per protocol in the patient receiving area (400 mg of gabapentin, 200 mg of Celecoxib, and 1gm of acetaminophen). Patients will be monitored during block performance with standard ASA monitors. All patients will be receiving 2 L of oxygen via a nasal cannula. Sedatives will be titrated to effect. Midazolam 1�2 mg, and fentanyl 50�100 mcg will be used for sedation. Block time out will be preformed according to standard operating procedure. All blocks will be done under ultrasound guidance. Sonosite S nerve machine will be used with a high frequency linear (HFL) US probe with 6�13 MHZ frequency. Both single shot and continuous adductor canal block will be performed according to the standard operating practices in our department 4. Ultrasound survey at the medial part of the thigh will take place, halfway between the superior anterior iliac spine and the patella. In a short axis view, the femoral artery will be identified underneath the sartorius muscle, with the vein just inferior and the saphenous nerve just lateral to the artery. The needle will be introduced in�plane and 2 to 3 mL of local anesthesia bolus will be used to verify correct placement of the needle in the vicinity of the saphenous nerve in the adductor canal. For single shot blocks: A bolus of total volume of 20 ml of ropivicaine 0.5% will be injected through the needle. For the continuous block: The catheter will be introduced and advanced 2�3 cm beyond the tip of the needle under ultrasound visualization. The needle was withdrawn over the catheter. Injection of a bolus of 5 ml of ropivacaine 0.5% will take place through the catheter while observing the spread of local anesthetic under ultrasound. The catheter hub will be affixed to the upper lateral thigh with sterile occlusive dressings and an anchoring device. Block success will be defined as a change in cutaneous sensation to touch with an alcohol pad in the saphenous nerve distribution over the medial leg within 30min after injection. Subjects with successful catheter placement per protocol and nerve block onset were retained in the study. Subjects with a failed catheter insertion or misplaced catheter indicated by a lack of sensory changes had their catheter replaced or were withdrawn from the study. At the conclusion of surgery, the catheters will be connected to a pump that will infuse local anesthetic. Ropivicaine 0.2% at 8 ml/hour. In the postoperative anesthesia care unit, intermittent boluses of hydromorphone will be used as needed. Postoperative analgesia will follow the MP3 protocol. Drugs that are used for the multimodal analgesia protocol include acetaminophen (1 gm every 8 hours for 72 hours), celecoxib (200 mg every 8 hours for 72 hours), Gabapentin (300 mg every 8 hours for one week if the patient is opioid naïve and for two weeks if patients are opioid tolerant), and oxycodone (5�10�15 mg oral as needed every 4 hours for pain based on patient reported pain score). All patients will receive prophylaxis for postoperative nausea and vomiting (PONV) during surgery. The protocol for prophylaxis against PONV include administration of 4 mg of dexamethasone after induction of anesthesia and 4 mg of ondansetron 20 minutes before recovery from anesthesia. Dexamethasone is withheld if the patient has poorly controlled diabetes mellitus (DM). Uncontrolled DM will be defined as random blood glucose above 250 mg/dl.

Establishment of a transplantable rat pulmonary carcinoma-derived cell line (IP-B12) as a new model of humoral hypercalcemia of malignancy and bone metastasis

MSTS 2018 - Femur Mets and MM

A cloned cell line (IP-B12) derived from a transplantable rat pulmonary carcinoma (IP), of which neoplastic cells produce parathyroid hormone-related protein (PTHrP), was established. Tumors induced in syngeneic F344 rats by intraperitoneal injection of IP-B12 cells had features of pulmonary adenocarcinomas, consisting of neoplastic cells immunopositive to PTHrP. The IP-B12 tumor-bearing rats developed severe emaciation and hypercalcemia, with a marked elevation of plasma PTHrP level; there was an increase in osteoclastic areas of the femur and calcium depositions in systemic organs, indicating progression to humoral hypercalcemia of malignancy (HHM) in the tumor-bearing rats. In addition, the injection of IP-B12 cells into the left cardiac ventricle of syngeneic rats resulted in osteolytic skeletal metastases in the long bones and vertebrae. In the metastatic lesions, histologically, neoplastic cells showed an immunopositive reaction to PTHrP, and a prominent osteoclastic activity was seen; bone lesions, including osteolysis, fracture, and nerve compression as well as replacement of bone marrow cells by proliferated tumor cells were similar to those reported in human cancer patients with bone metastases. IP-B12 is a new animal model for HHM and osteolytic bone metastases, and will become a useful tool for studies on the pathogenesis and therapeutic strategies for such conditions.

Upregulation of inflammatory genes and downregulation of sclerostin gene expression are key elements in the early phase of fragility fracture healing

Management of Hip Fractures in the Elderly

Fracture healing is orchestrated by a specific set of events that culminates in the repair of bone and reachievement of its biomechanical properties. The aim of our work was to study the sequence of gene expression events involved in inflammation and bone remodeling occurring in the early phases of callus formation in osteoporotic patients. Fifty-six patients submitted to hip replacement surgery after a low-energy hip fracture were enrolled in this study. The patients were grouped according to the time interval between fracture and surgery: bone collected within 3 days after fracture (n = 13); between the 4(th) and 7(th) day (n = 33); and after one week from the fracture (n = 10). Inflammation- and bone metabolism-related genes were assessed at the fracture site. The expression of pro-inflammatory cytokines was increased in the first days after fracture. The genes responsible for bone formation and resorption were upregulated one week after fracture. The increase in RANKL expression occurred just before that, between the 4(th)-7(th) days after fracture. Sclerostin expression diminished during the first days after fracture. The expression of inflammation-related genes, especially IL-6, is highest at the very first days after fracture but from day 4 onwards there is a shift towards bone remodeling genes, suggesting that the inflammatory phase triggers bone healing. We propose that an initial inflammatory stimulus and a decrease in sclerostin-related effects are the key components in fracture healing. In osteoporotic patients, cellular machinery seems to adequately react to the inflammatory stimulus, therefore local promotion of these events might constitute a promising medical intervention to accelerate fracture healing

Report on the Japanese Orthopaedic Association's 3-year project observing hip fractures at fixed-point hospitals

Management of Hip Fractures in the Elderly

BACKGROUND: The aim of this study was to assess the disability and mortality of hip fractures 1 year after initial visit (postoperatively) at fixed-point hospitals selected by the Japanese Orthopaedic Association Committee on Osteoporosis. METHOD: A total of 158 core orthopedic hospitals were selected for participation in this research. Subjects were all aged 65 years and older with hip fractures at the selected hospitals between January 1, 1999 and December 31, 2001. A prognostic survey of activities of daily living (ADL), assessed by the long-term care insurance criteria established by the Ministry of Health, Labour, and Welfare of Japan was performed 1 year after the initial visit. RESULTS: A total of 1992 hip fractures in patients aged 65 to 111 years were treated over the 3 years from 1999 to 2001. Among the 1992 patients, 4537 had femoral neck fractures and 6217 had trochanteric fractures. Surgical treatment was chosen for 85.6% of the femoral neck fractures and 88.2% of the trochanteric fractures. The mean duration from fracture to admission was 3.1 days, and the mean duration from admission to surgery was 11.2 days. The mean duration from surgery to discharge over the 3-year period was 49.8 days. Before hip fracture, the ratio of patients with J1 ("able to go out freely utilizing public transportation") or J2 ("able to visit immediate neighbors independently") on the long-term care insurance criteria was 50.9%. At 1 year after the initial visit, that result represented a decrease of 24.1 percentage points before hip fracture. A total of 70 patients died before undergoing surgery. In the present study, the 1-year mortality rate for the entire patient population over the 3-year period was 10.1%. CONCLUSIONS: Hip fracture patients show a decrease in the ADL score 1 year after the initial visit. Compared to other countries, the duration of hospitalization is longer in Japan, but the mortality rate is lower

The use of near-infrared spectrometry for the diagnosis of lowerextremity compartment syndrome

DOD - Acute Comp Syndrome CPG

While intracompartmental pressure monitoring is a widely used diagnostic tool to measure intracompartmental pressures in the setting of compartment syndrome, its invasive nature has prompted the development of noninvasive techniques, such as near-infrared spectrometry. We prospectively assessed the association between tissue oxygen saturation measured by near-infrared spectrometry and compartment pressure measured by intracompartmental pressure monitoring in a cohort of patients with compartment syndrome of the lower extremity. We hypothesized that tissue oxygen saturation measured by near-infrared spectrometry would negatively correlate with intracompartmental pressures. Tissue oxygen saturation was determined for all 4 compartments of the lower extremity in 7 patients using near-infrared spectrometry. All patients subsequently underwent lower-extremity fasciotomies. Mechanism of injury, compartment pressures, blood pressure, near-infrared spectrometry measurement of tissue oxygen saturation, and characteristics of the muscle at the time of fasciotomy were recorded. The strength of the correlations between tissue oxygen saturation and absolute and relative compartment pressures was estimated based on mixed linear (growth) models with repeated observations nested within patients. Our analyses demonstrated no significant relationship between tissue oxygen saturation measured by near-infrared spectrometry and the absolute or relative compartment pressures. This suggests that compartment tissue oxygen saturation measurements by near-infrared spectrometry do not correlate with the diagnosis of compartment syndrome, and that near-infrared spectrometry would not serve as a reliable diagnostic tool.

Long-term follow up of single-stage anterior cruciate ligament reconstruction and high tibial osteotomy and its relation with posterior tibial slope

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Open-wedge high tibial osteotomy is considered to be an effective treatment for medial compartmental osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. Young patients with anterior cruciate ligament (ACL) deficiency along with medial compartment osteoarthritis need a combined procedure of ACL reconstruction along with high tibial osteotomy to regain physiological knee kinematics and to avoid chondral damage. MATERIALS AND METHODS: We retrospectively analysed data from 30 patients who underwent arthroscopic ACL reconstruction along with medial opening-wedge osteotomy from Jan 2004 to June 2012 with a minimum follow up of 2 years. The pre-operative and post-operative posterior tibial slopes were measured. Functional outcome was analysed using clinico-radiological criteria, IKDC scoring and Lysholm score. RESULTS: Post-operative patients improved both clinically and functionally. The patients who had posterior tibial slope >5degree decrease, compared to patients who had less <5degree decrease, had better functional scores (IKDC and Lysholm score), which was statistically significant (p < 0.05). CONCLUSION: Our study has shown that decreasing the tibial slope >5degree compared to pre-operative value has functionally favourable effect on the reconstructed ACL graft and outcome. It is known that increasing slope causes an anterior shift in tibial resting position that is accentuated under axial loads. This suggests that decreasing tibial slope may be protective in an ACL deficient knee. Hence by placing the tricortical graft posterior to midline in the opening wedge reduces the posterior tibial slope and thereby reduces the stress on the graft leading to better functional outcome.

A protocol for staged arthroplasty to salvage infected nonunion of hip fractures

DoD SSI (Surgical Site Infections)

BACKGROUND: Nonunion of hip fractures is not uncommon. Total hip arthroplasty is used to salvage cases of non union or secondary arthritis in these fractures. However, this option may not be available or may be difficult to achieve when infection has superseded the site of nonunion. The objective of this prospective study was to assess if a staged protocol of treatment yields good results in these difficult cases. MATERIALS AND METHODS: Twenty-seven consecutive patients who had deep hip infection with failed treatment of hip fractures (intracapsular in 16 cases and extracapsular in 11) were treated between June 2007 and September 2011. Twenty-six completed the planned two-stage hip arthroplasty and one case was lost after the first stage. The average age of the patients was 48.9 years (range 26-74 years) with an average follow up period of 44 months (30-72 months). Analysis was done using the paired t test where P < 0.05 was considered significant. RESULTS: Infection was controlled in all cases that completed the treatment protocol with no recurrence in all cases at the latest follow up. The Harris hip score of the patients improved significantly from 29 preoperatively to 85 at the latest follow up (P < 0.0001). Two patients had hip dislocation with displacement of the trochanteric fragment while three other patients had fibrous union of the trochanter. CONCLUSIONS: Staged Arthroplasty procedure to salvage infected non-union of hip fractures is successful in eradicating infection and regaining hip function. Level of evidence IV.

Partial versus Intact Posterior Cruciate Ligament-retaining Total Knee Arthroplasty: a Comparative Study of Early Clinical Outcomes

DoD SSI (Surgical Site Infections)

OBJECTIVE: Whether the entire posterior cruciate ligament (PCL) should be retained during cruciate-retaining total knee arthroplasty (CR TKA) is controversial. The goal of this study was to compare the early clinical outcomes of partial versus intact PCL-retaining TKA. METHODS: Ninety-two patients who had undergone unilateral CR TKA from March 2012 to June 2013 were enrolled in this study. Forty-six of these patients were randomly selected to undergo intact PCL-retaining TKA (intact group), whereas the remaining 46 patients underwent tibial osteotomy together with anterolateral bundle and bone island resection (partial group). All operations were performed by a senior orthopedic surgeon and the PCL was released to some extent in both groups. After TKA, active and passive flexion and extension exercises of the knee and lower limb strength exercises were maintained until at least 3 months after surgery. Before surgery and 6, 12, and 24 months after surgery, range of motion, Knee Society Clinical Rating System scores (including clinical and functional scores of the knee) and maximum anteroposterior (AP) displacement of the knee at 30° and 90° of knee flexion were evaluated in both groups. RESULTS: Fourteen patients were rejected from the final analysis because of loss to follow-up or development of complications. Thus, 40 patients from the partial group and 38 from the intact group were followed up for 24-41 months (mean 32.8 months). Knee functional scores were significantly higher in the intact than in the partial group (88.1 vs. 84.8 points) 24 months after surgery There were no significant differences in range of motion or knee clinical scores between the two groups at any time point. However, 12 and 24 months after surgery, the mean maximum AP displacement of the knee in 90° knee flexion was significantly greater in the partial than in the intact group (12 months: 6.3 vs. 5.7 mm; 24 months: 7.0 vs. 6.2 mm). CONCLUSION: Double-bundle PCL plays an important role in maintaining knee stability; the entire PCL should therefore be retained during CR TKA.

Clinical Outcome Differences in the Treatment of Impending Versus Completed Pathological Long-Bone Fractures

MSTS 2022 - Metastatic Disease of the Humerus

BACKGROUND: The outcome differences following surgery for an impending versus a completed pathological fracture have not been clearly defined. The purpose of the present study was to assess differences in outcomes following the surgical treatment of impending versus completed pathological fractures in patients with long-bone metastases in terms of (1) 90-day and 1-year survival and (2) intraoperative blood loss, perioperative blood transfusion, anesthesia time, duration of hospitalization, 30-day postoperative systemic complications, and reoperations. METHODS: We retrospectively performed a matched cohort study utilizing a database of 1,064 patients who had undergone operative treatment for 462 impending and 602 completed metastatic long-bone fractures. After matching on 22 variables, including primary tumor, visceral metastases, and surgical treatment, 270 impending pathological fractures were matched to 270 completed pathological fractures. The primary outcome was assessed with the Cox proportional hazard model. The secondary outcomes were assessed with the McNemar test and the Wilcoxon signed-rank test. RESULTS: The 90-day survival rate did not differ between the groups (HR, 1.13 [95% CI, 0.81 to 1.56]; p = 0.48), but the 1-year survival rate was worse for completed pathological fractures (46% versus 38%) (HR, 1.28 [95% CI, 1.02 to 1.61]; p = 0.03). With regard to secondary outcomes, completed pathological fractures were associated with higher intraoperative estimated blood loss (p = 0.03), a higher rate of perioperative blood transfusions (p = 0.01), longer anesthesia time (p = 0.04), and more reoperations (OR, 2.50 [95% CI, 1.92 to 7.86]; p = 0.03); no differences were found in terms of the rate of 30-day postoperative complications or the duration of hospitalization. CONCLUSIONS: Patients undergoing surgery for impending pathological fractures had lower 1-year mortality rates and better secondary outcomes as compared with patients undergoing surgery for completed pathological fractures when accounting for 22 covariates through propensity matching. Patients with an impending pathological fracture appear to benefit from prophylactic stabilization as stabilizing a completed pathological fracture seems to be associated with increased mortality, blood loss, rate of blood transfusions, duration of surgery, and reoperation risk. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Double Tension Band Osteosynthesis in Inter-Condylar Humeral Fractures

Pediatric Supracondylar Humerus Fracture 2020 Review

INTRODUCTION: Intercondylar humerus fractures are uncommon in orthopaedic practice. The treatment for the same has been described in the literature and include paragonal and orthogonal fixation by using plates. Tension band wiring as a treatment for the same is sparsely described in the literature. AIM: To evaluate the effectiveness of "Double Tension Band wiring" method for the treatment of intercondylar fractures of humerus and compare the results with studies involving treatment with locked plates. MATERIALS AND METHODS: Twenty patients, all presenting with fresh fractures of the distal humerus, treated with double tension band wiring were retrospectively evaluated over a period of three years. Fractures were classified according to Jupiter classification of distal humeral fractures. There were 5 high T fractures, 13 low T fractures and 2 Y fractures. According to AO classification, all were C1 fractures. Average age of the patients was 56.20 years (32-70 years). There were 13 males and 07 females. RESULTS: Out of 20 cases treated with this method, rigid fixation and union was achieved in all of them. The average tourniquet time was 69 minutes with minimum of 50 minutes and maximum of 120 minutes. Radiological union was achieved at an average of 10.8 weeks (8-14weeks). Average range of motion was 104.5 degrees with maximum range of motion 120 degrees (10-130) and minimum of 70 degrees (30-100). Excellent or good results were obtained in 80% of the patients in our study. CONCLUSION: Double tension band is a reliable, less demanding and cost effective method of fixation of intercondylar fractures of humerus.

Immunohistochemical detection of nm23/NDP kinase and cathepsin D in medullary carcinomas of the thyroid gland

MSTS 2018 - Femur Mets and MM

Reduced expression of nm23/NDP kinase and increased expression of cathepsin D seem to be correlated with the high metastatic potential in a variety of malignancies. The expression of nm23/NDP kinase and that of cathepsin D have been evaluated by means of an immunohistochemical technique in paraffin-embedded tissues from 44 primary medullary carcinomas of the thyroid gland (MCT) and from the corresponding lymph node metastases in 32 of these cases. In addition, lymph node metastases from 4 cases were studied. We found that 36 of 44 (82%) primary and 26 of 36 (72%) lymph node metastatic MCT were nm23/NDP kinase positive, whereas 14 of the 44 (32%) primary and 17 of the 36 (47%) lymph node metastatic MCT were cathepsin D positive. We found no indication that the nm23/NDP kinase level has any prognostic significance in MCT. The cathepsin D level is close to being prognostically significant in this study, and we cannot exclude the possibility that it could be of prognostic value. However, it seems to be quite weak, and therefore of little use in a clinical situation.

Effects of squat lift training and free weight muscle training on maximum lifting load and isolinetic peak torque of young adults without impairments

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

BACKGROUND AND PURPOSE: Manual lifting is a frequent cause of back injury, and there is no evidence as to which training mode can provide the best training effect for lifting performance and muscle force. The purpose of this study was to examine the effects of a squat lift training and a free weight muscle training program on the maximum lifting load and isokinetic peak torque in subjects without known neuromuscular or musculoskeletal impairments. SUBJECTS: Thirty-six adults (20 male, 16 female) without known neuromuscular or musculoskeletal impairments participated. The subjects' mean age was 21.25 years (SD=1.16, range=20-24). METHODS: Subjects were divided into 3 groups. Subjects in group 1 (n=12) performed squat lift training. Subjects in group 2 (n=12) participated in free weight resistance training of their shoulder abductors, elbow flexors, knee extensors and trunk extensors. Subjects in group 3 (n=12) served as controls. The maximum lifting load and isokinetic peak torques of the trunk extensors, knee extensors, elbow flexors, and shoulder abductors of each subject were measured before and after the study. Training was conducted on alternate days for 4 weeks, with an initial load of 80% of each subject's maximum capacity and with the load increased by 5% weekly. RESULTS: All groups were comparable for all measured variables before the study. After 4 weeks, subjects in groups 1 and 2 demonstrated more improvement in maximum lifting load and isokinetic peak torque of the back extensors compared with the subjects in group 3, but the 2 training groups were not different. CONCLUSION AND DISCUSSION: The findings demonstrate that both squat lift and free weight resistance training are equally effective in improving the lifting load and isokinetic back extension performance of individuals without impairments

Improvement in aerobic fitness during rehabilitation after hip fracture

Management of Hip Fractures in the Elderly

OBJECTIVE: To evaluate the effect of an upper-body exercise program on cardiorespiratory fitness in older adults with hip fracture during inpatient rehabilitation. DESIGN: Randomized controlled trial using a convenience sample. SETTING: An inpatient rehabilitation unit. PARTICIPANTS: Twenty older patients (age, 81.3+/-7.2y; 14 women). INTERVENTION: Patients were randomly assigned to a control group (n=10) or a training group (n=10). Both groups attended physical and occupational therapy sessions 5 times a week during rehabilitation (mean length of stay, 32.9+/-5.3d). Patients in the training program used an arm crank ergometer 3 times a week for 4 weeks. MAIN OUTCOME MEASURE: Peak oxygen consumption (Vo(2)peak). RESULTS: Vo(2)peak increased significantly in the training group (8.9+/-1.4 to 10.8+/-1.7mL x kg(-1) x min(-1)) and did not change in the control group (8.9+/-1.2 to 8.8+/-1.6mL x kg(-1).min(-1)). At discharge, both groups were significantly improved in all functional outcome measures (Timed Up & Go [TUG] test, Berg Balance Scale [BBS], FIM instrument, two-minute walk test [2MWT], and ten-minute walk test [10MWT]). The training group performed significantly better in mobility (TUG, 2MWT, 10MWT) and balance (BBS) compared with the control group. There was a significant correlation between Vo(2)peak and the 2MWT (r=.81) and 10MWT (r=.85) in the training group at discharge. CONCLUSIONS: The upper-body exercise program had a significant effect on aerobic power. Our results suggest that aerobic endurance exercise should be integrated into standard rehabilitation to enhance patients' aerobic fitness and mobility after hip fracture surgery

Identification of streptococcus mitis group species by RFLP of the PCR-amplified 16S-23S rDNA intergenic spacer

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Mitis group streptococci are pioneer colonizers of tooth surfaces and are implicated in various pathologies. Thus, accurate identification of oral mitis group strains would be valuable for studies of plaque ecology and dental caries and for diagnostic use in endocarditis or sepsis patients. The aim of this study was to evaluate the usefulness of PCR-RFLP analysis of the 16S-23S intergenic spacer for differentiating and identifying streptococcus mitis group species. The 16S-23S rDNA spacer regions of 27 type and reference Streptococcus strains, representing 8 species, were studied by PCR-mediated amplification by using oligonucleotide primers FGPS 1490-72 and FGPL 132'-38. PCR products were digested, independently, with 14 restriction enzymes. Only AluI, MboI, CfoI, HinfI and MaeII distinguished some species, particularly AluI and CfoI, but not all the species. Eight clusters were clearly generated, corresponding to currently recognized species, but only with the addition of five ITS restriction patterns, generated by AluI + MboI + CfoI + HinfI + MaeII, then clustered by UPGMA, on a distance consensus matrix. The combination of these five ITS RFLP tests allowed a relatively conclusive genomic group differentiation of mitis group species. Despite this observation, more strains of each species will need to be analyzed, particularly clinical isolates, before arriving at general conclusions about the utility of ITS restrictions for identification of strains at the species level. An ITS PCR-RFLP-based identifying method for streptococcus mitis group species would provide significant advantages over other molecular taxonomic methods which require DNA extraction and DNA-DNA hybridization

External Fixator-assisted Ulnar Osteotomy: A Novel Technique to Treat Missed Monteggia Fracture in Children

DoD SSI (Surgical Site Infections)

OBJECTIVE: The treatment of missed Monteggia fracture remains a challenge, despite the various surgical methods described. The purpose of this study was to explore a new surgical technique utilizing external fixator-assisted ulnar osteotomy and to assess the surgical results in a case series. METHODS: Thirteen patients with missed Monteggia fractures were treated at our institution using this new surgical technique from August 2012 to January 2016. Our series included 11 boys and 2 girls. The left elbow was involved in 6 patients and the right elbow was involved in 7 patients. According to the Bado classification, 10 fractures were classified as Bado type I with anterior radial head dislocation and 3 were classified as Bado type III with anterolateral dislocation. The average age at the time of surgery was 5 years 8 months (range, 2 years 2 months-10 years). The mean trauma-to-surgery interval was 12 months (range, 2-36 months). All patients underwent ulnar osteotomy with angulation and lengthening using a temporary external fixator, plate fixation of the osteotomy, and open reduction of the radial head dislocation without annular ligament reconstruction. RESULTS: The average follow-up was 27 months (range, 16-44 months). The average operation time was 175 min (range, 140-215 min). The average length of distraction was 0.7 cm (range, 0.5-1.2 cm) and the average angulation was 28degree (range, 20degree-30degree) at the ulnar osteotomy site intraoperatively. The elbow performance score (Kim's) was excellent in 10 cases and good in 3 cases. No neurovascular complications, compartment syndrome or implant breakage occurred. No pain in the distal radioulnar joint or limited range of motion of the wrist occurred in any patient. The radial head remained reduced in all patients with no subluxation or redislocation. However, delayed ulnar union occurred in 3 cases, all of which were successfully treated with plaster cast immobilization within approximately 6 months postoperatively. One patient presented with cubitus valgus postoperatively with a carrying angle of 30degree, which was 10degree greater than the contralateral carrying angle. CONCLUSIONS: External fixator-assisted ulnar osteotomy offers substantial flexibility for achieving the optimal positioning of the transected ulna to reduce the radial head prior to the final ulnar osteotomy fixation with a plate, thereby facilitating an effective operative performance. Our procedure is a safe and effective method to treat missed pediatric Monteggia fractures.

Finite schematic eye models and their accuracy to in-vivo data

Upper Eyelid and Brow Surgery

Measurement of ocular wavefront aberration is becoming a popular clinical technique due to recent technical advances and an increasing awareness of its potential for practical application in the fields of surgical and optical refractive correction. In addition, information about the status of peripheral refraction determined from ocular wavefront aberrations is now being used to monitor the progression of myopia and other refractive errors in children, and as a basis for the study of the process of emmetropization. Several finite, anatomically accurate, wide-angled, model eyes have been proposed previously in an effort to produce a schematic eye that accurately reproduces vision under different practical circumstances. This paper compares these models in terms of their wavefront aberration, image quality metrics and peripheral refraction profiles and contrasts these with data from real eyes to assess their relative utility.

Fluoroscopy cannot recognize intraoperative fracture in patients receiving 2-incision total hip arthroplasty

Management of Hip Fractures in the Elderly

Intraoperative fluoroscopy is suggested as a standard procedure in 2-incision total hip arthroplasty. Between September 2003 and July 2004, 2-incision total hip arthroplasties were done in 18 hips with and another 18 hips without the use of fluoroscopy. In group 1, the anterior skin incision was initially limited to 5 cm. Fracture or instability was checked by fluoroscopy first and then the incision was enlarged to 8 cm for visualization. In group 2, incisions were made long enough to expose the surgical field. There were 2 femoral neck fractures in the fluoroscopy group. The fractures were linear in the anteromedial femoral neck and could not be detected by fluoroscopy. Such linear fractures if overlooked could result in serious complications such as fracture displacement or implant instability. Surgeons should not rely on intraoperative fluoroscopy to check implant stability, and visualization of the surgical field should not be compromised when doing minimally invasive approach for total hip arthroplasty

Are the Outcomes of Revision Knee Arthroplasty for Flexion Instability the Same as for Other Major Failure Mechanisms?

OAK 3 - Non-arthroplasty tx of OAK

Background Aseptic loosening, infection, and flexion instability have emerged as the leading etiologies for revision after total knee arthroplasty (TKA). Although studies have reported improved outcomes after revision TKA, the relative functional and clinical outcomes of patients revised for flexion instability and other failure etiologies have not been extensively reported. The aim of the study was to compare the functional and patient-reported outcomes of revision TKA for the common failure etiologies. Methods We retrospectively reviewed records of 228 consecutive cases of revision TKA from 2008 to 2014. Revisions performed for aseptic loosening (n = 53), septic revisions (n = 48), and isolated flexion instability (n = 45) with a minimum of 18 months follow-up were included for analysis. Revision for all other etiologies (n = 82) were excluded. The Modified Knee Society Score (KSS), KSS Function, and Western Ontario and McMaster Universities Osteoarthritis Index were recorded for all cases. A 7-point Likert scale was used to record patient's perception of outcomes after revision surgery and analyzed based on etiology. Results Although all groups showed improvement in outcome after revision TKA, the changes in Modified KSS and KSS-Function varied according to the etiology of failure of the primary procedure with the smallest improvement being reported by the flexion instability group. Conclusion Patients undergoing revision for isolated flexion instability have less improvement in functional outcome as compared with other etiologies. We hypothesize this is due to a higher baseline preoperative knee function in the flexion instability group.

Scintigraphy with 99mTc-phosphonate and 67gallium in patients suspected of primary bone tumors

MSTS 2018 - Femur Mets and MM

Whole-body scintigraphy with both 99mTc-phosphonate and 67Ga was performed on 92 patients suspected of primary bone tumors. In 46 patients with primary malignant bone tumors, scintigraphy with 99mTc-phosphonate disclosed the primary tumor in 44 cases and skeletal metastases in 11, and 67Ga scintigraphy detected the primary tumor in 43 cases, skeletal metastases in 6 cases and soft-tissue metastases in 8 cases. In 25 patients with secondary malignant bone tumors, bone scintigraphy visualized a single lesion in 10 cases and several lesions in 15 cases, and 67Ga scintigraphy detected the primary tumor in 17 cases, skeletal metastases in 17 cases and soft-tissue metastases in 9 cases. In 21 patients with benign bone disease positive uptake of 99mTc-phosphonate was recognized in 19 cases and uptake of 67Ga in 17 cases. It is concluded that bone scintigraphy should be used in patients suspected of primary bone tumors. If malignancy is suspected, 67Ga scintigraphy should be performed in addition.

Clinical impact of matrix metalloproteinase-7 mRNA expression in the invasive front and inner surface of tumor tissues in patients with colorectal cancer

MSTS 2018 - Femur Mets and MM

PURPOSE: Matrix metalloproteinase-7, reversion-inducing cysteine-rich protein with Kazal motifs, chemokine receptor 7, and vascular endothelial growth factor-C have been correlated with tumor invasion and lymph node metastasis in patients with gastrointestinal cancer. Our study of patients with colorectal cancer quantified the messenger ribonucleic acid (RNA) expressions at the deepest site of tumor invasion (the invasive front) and the tumor's inner surface. We investigated whether messenger RNA expressions can predict lymph node metastasis in colorectal cancer tumors and then evaluated the clinical implications of these results on the endoscopic treatment of early colorectal cancer. METHODS: Sixty patients with colorectal cancer participated in the study. Levels of matrix metalloproteinase-7, reversion-inducing cysteine-rich protein with Kazal motifs, chemokine receptor 7, and vascular endothelial growth factor-C messenger RNA in both the invasive front and inner surface of colorectal cancer tumors were measured by using real-time quantitative reverse transcriptase-polymerase chain reaction. RESULTS: The matrix metalloproteinase-7 values in the invasive front and inner surface were significantly higher in tumors with lymph node metastasis than in tumors without lymph node metastasis. The matrix metalloproteinase-7 expression levels in the invasive front correlated with inner surface expression levels. Both a univariate and multiple logistic regression analysis showed the matrix metalloproteinase-7 expression levels in both the invasive front and inner surface of tumors to be significantly associated with lymph node metastasis. CONCLUSIONS: Matrix metalloproteinase-7 messenger RNA in both the invasive front and inner surface of the tumor is a predictive factor associated with lymph node metastasis for patients with colorectal cancer. The results of this study might indicate further clinical applications of an endoscopic excision for cancer with submucosal invasion.

In Vitro Validation of a Closed Device Enabling the Purification of the Fluid Portion of Liposuction Aspirates

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Adipose tissue harvested through lipoaspiration is widely exploited in plastic and cosmetic surgery, because of its remarkable trophic properties, especially relying on the presence of adipose-derived stem cells. The common procedures for adipose-derived stem cell isolation are mainly based on tissue fractionation and enzymatic digestion, requiring multiple hours of uninterrupted work, unsuitable for direct surgical applications. Recent studies demonstrated the feasibility of isolating adipose stromal cells without the need for enzymatic digestion. These studies reported the processing of the fluid portion of liposuctioned adipose tissue (lipoaspirate fluid), which contains a significant amount of progenitor cells endowed with plastic and trophic features. In this article, the authors introduce a brand new closed device--the MyStem EVO kit--which allows nonenzymatic tissue separation and rapid isolation of lipoaspirate fluid from human liposuctioned adipose tissue. METHODS: Adipose tissue was liposuctioned from 14 donors, split into aliquots, and alternatively processed using either centrifugation or the MyStem EVO kit, to separate fatty and lipoaspirate fluid portions. The samples were analyzed comparatively by flow cytometry, histology, and differentiation assays. Osteoinductive and angioinductive features were analyzed through in vitro co-culture assays. RESULTS: The alternative procedures enabled comparable yields; the kit rapidly isolated lipoaspirate fluid comprising a homogenous cell population with adipose stem cell immunophenotype, bilineage potential, and efficient osteoinductive and angioinductive features. CONCLUSION: MyStem EVO allows the rapid isolation of lipoaspirate fluid with trophic properties within a closed system, and is potentially useful for regenerative medicine applications.

Improving Tibial Component Coronal Alignment During Total Knee Arthroplasty with the Use of a Double-Check Technique

OAK 3 - Non-arthroplasty tx of OAK

Objective: To compare the efficacy of the restoration of tibial component coronal alignment with a double-check technique and the conventional surgical technique during total knee arthroplasty (TKA) in knee osteoarthritis patients, and to investigate the distribution of the medial proximal tibial angle (MPTA) after TKA. Methods: A retrospective review was performed of 151 patients (179 knees) with knee osteoarthritis undergoing primary TKA in Beijing Chaoyang Hospital, Capital Medical University from February 2013 to January 2015 to evaluate the differences in MPTA in patients undergoing the conventional TKA and those undergoing a modified TKA with a double-check technique after the surgery. All patients were evaluated by MPTA, range of motion (ROM), Knee Society Clinical Rating System (KSS) clinical scores, and KSS functional scores. An MPTA deviation of 3° or greater was considered malalignment. Results: A total of 130 TKA procedures in 119 patients were included in the study: 64 knees treated with conventional TKA and 66 knees treated with the double-check technique TKA. The mean postoperative MPTA was 88.6° ± 2.2° in the conventional TKA group and 89.1° ± 1.5° in the double-check TKA group. The mean postoperative MPTA between the two groups was not significantly different. In the conventional TKA group, 79.7% (51 knees) had a postoperative MPTA deviation within 3° and 20.3% (13 knees) had a MPTA deviation greater than 3°. In the double-check TKA group, 93.9% (62 knees) had a postoperative MPTA deviation within 3°and 6.1% (4 knees) had a MPTA deviation greater than 3°. The postoperative MPTA deviation within 3° showed a statistically significant difference between the two groups. In the double-check TKA group, a 21.2% (14 knees) tibial malalignment was detected after the first check and a 9.1% (6 knees) tibial malalignment was detected after the second check. The mean postoperative ROM was 118.1° ± 9.2° in the conventional TKA group and 115.7° ± 10.1° in the double-check TKA group. The mean postoperative KSS clinical score was 89.3 ± 3.5 in the conventional TKA group and 89.0 ± 3.7 in the double-check TKA group. The mean postoperative KSS functional score was 84.8 ± 10.0 in the conventional TKA group and 84.9 ± 9.0 in the double-check TKA group. The mean postoperative ROM, KSS clinical scores, and KSS functional scores between the two groups were not statistically significantly different. Conclusion: Malalignment of the tibial component can occur after conventional TKA, and the double-check technique is an effective method to improve tibial component coronal alignment.

The association of AKNA gene polymorphisms with knee osteoarthritis suggests the relevance of this immune response regulator in the disease genetic susceptibility

OAK 3 - Non-arthroplasty tx of OAK

Recent studies have identified AKNA as a potential susceptibility gene for several inflammatory diseases. Here, we aimed to assess the potential association of AKNA polymorphisms with knee osteoarthritis (KOA) susceptibility in a Mexican population, following STREGA recommendations. From a DNA bank of 181 KOA patients and 140 healthy controls, two AKNA SNPs were genotyped using TaqMan probes. The association between KOA susceptibility and AKNA polymorphisms genotypes was evaluated by multivariated logistic regression analysis. Information regarding patients' inflammatory biomarkers levels was obtained and their association with AKNA polymorphisms genotypes was assessed by lineal regression. We found a positive association with the recessive inheritance model of both AKNA polymorphisms (A/A genotype for both) and KOA susceptibility adjusting by age, body mass index (BMI), gender and place of birth (OR = 2.48, 95% CI 1.09-5.65 for rs10817595 polymorphism; and OR = 4.96; 95% CI 2.421-10.2 for rs3748176 polymorphism). Additionally these associations were also seen after stratifying patients by KOA severity and age. Furthermore the total leukocyte count was positively associated with rs10817595 AKNA polymorphism (beta = 1.39; 95% CI 0.44-2.34) adjusting by age, BMI, gender, place of birth and disease severity. We suggest that regulatory and coding polymorphisms of the inflammatory modulator gene AKNA can influence the development of KOA. Further structural and functional studies might reveal the role of AKNA in OA and other rheumatic diseases.

Early effect of hyaluronic acid intra-articular injections on serum and urine biomarkers in patients with knee osteoarthritis: An open-label observational prospective study

OAK 3 - Non-arthroplasty tx of OAK

The aim of the study was to investigate the effect of hyaluronic acid (HA) intra articular injections (IA) on osteoarthritis (OA) biomarkers in patients with knee OA. Prospective open label study. Fifty-one patients with unilateral symptomatic K-OA received IA injections of 2mL of HA on days (D) 1, 7, 14 and were followed 3 months. At D-15 patients were examined and X-rays performed, to exclude patients with bilateral K-OA, or those with more than three symptomatic OA joints. From 15 days (D-15) before the first injection to D90 concomitant therapies were unchanged. Walking pain (WP) on VAS was obtained at each visit. Urine (U) and serum (S) samples were obtained at D-15, D1, D30, and D90. S-C2C, S-Cartilage oligomeric matrix protein, S-HA, S-CS 846 epitope, S-type II collagen propeptide, and U-type II collagen C telopeptide (U-CTX II/creatinin) were assayed. Predictive factors of response were analyzed using logistic regression. Correlations between variables were obtained using Spearman test. Forty-five patients were analyzed. Between D-15 and D1 there was no difference for any biomarkers At D1, WP (SD) was correlated with U-CTX II/creat (p = 0.006). Between D1 and D90: U-CTX II/creat decreased significantly. After adjustment for confounding variables there was a significant correlation between clinical response and U-CTX II/creat variation. U-CTX II and S-HA at baseline were independently predictive of clinical response. This study showed that 90 days after HA IA injections, U-CTX II levels significantly decrease compared to baseline, suggesting a slowdown of type II collagen degradation.

Oncologic emergencies

MSTS 2018 - Femur Mets and MM

Objectives: To provide an up-to-date review of current literature on the pathophysiology, diagnosis, and management of five key malignancy-related complications: superior vena cava syndrome, malignant pericardial effusion, malignant spinal cord compression, hypercalcemia, and acute tumor lysis syndrome. Data Sources: Database searches and review of relevant medical literature. Data Synthesis: Malignancy-related complications demand increased attention from intensivists due to their frequency and increasing cancer prevalence. Although such complications portend a poor prognosis, proper acute management can improve short-term outcomes by facilitating either definitive care of the underlying malignancy or the institution of appropriate palliative measures. Conclusions: Knowledge of malignancy-induced complications in critically ill patients expedites the ability of the intensivist to properly manage them. Five complications commonly requiring emergency management are addressed in this review. Specifically, superior vena cava syndrome may warrant radiation, chemotherapy, vascular stenting, or surgical resection. Malignant pericardial effusion may require emergency pericardiocentesis if cardiac tamponade develops. Malignant spinal cord compression demands immediate spinal imaging, glucocorticoids, and either surgery or radiation. Hypercalcemia requires aggressive intravenous hydration and a bisphosphonate. Acute tumor lysis syndrome necessitates intravenous hydration, rasburicase, and management of associated electrolyte abnormalities. © 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.

Fracture-pattern-related therapy concepts in distal humeral fractures

Distal Radius Fractures

Around one third of humeral fractures and 2-6% of all fractures occur to the distal part of the humerus. There is a bimodal distribution differentiating between young male patients with high-energy and elderly female patients with low-energy trauma related to osteoporosis. The AO classification and Dubberley subclassification are used in daily routine. Most fractures are diagnosed on radiographs. For further evaluation, three-dimensional computed tomography is recommended, especially for comminuted or complex fractures. Owing to the long immobilization and resultant poor functional outcome, conservative treatment is followed for inoperable patients. The operative approach and osteosynthesis depend on the fracture pattern. In A1 avulsion fractures, open reduction and screw fixation are recommended. In A2/A3 fractures, a triceps-sparing approach following a 90degree double-plate construction (radial dorsal/ulnar lateral) with locking plates is favored. Partial articular B1/B2 fractures are exposed via a medial or lateral approach using unilateral locking plates to stabilize the medial/lateral column. Coronal shear fractures (B3) are classified after Dubberley and are treated via an extended Kocher approach and headless compression screws in anteroposterior direction. If there is a further posterior comminution or a lateral column fragment, stabilization is needed for the lateral/medial column with a precontoured locking plate. In solely articular fracture patterns, a dorsal approach with either a 90degree or 180degree double-plate construction is advised. If a reconstruction is not possible owing to fracture complexity or bone quality, total elbow arthroplasty is a viable option. However, lifelong limitation in weight-bearing up to 5kg, limited longevity, and the potential for complicated revision surgery should be considered.

Medication safety: does intravenous acetaminophen promote perioperative hypothermia for total hip arthroplasty?

AAHKS (4) Acetaminophen

As an effective antipyretic with a yet-unknown mechanism-of-action, intravenous (IV) acetaminophen use for total hip arthroplasties (THA) may worsen perioperative hypothermia when combined with the known hypothermia-inducing effects of general anesthesia (GA), affecting wound healing, recovery times, and patient satisfaction. This retrospective chart review of primary THA cases compared perioperative heat loss for patients who received IV acetaminophen with GA (group A, n = 74) to those receiving GA alone (group B, n = 197). All patients received forced-air warming blankets. Neuraxial anesthesia cases were excluded. No significant temperature differences existed between group A (-0.33degreeC, SD = 0.36) and group B (-0.30degreeC, SD = 0.34, P > 0.05). IV acetaminophen use for THA does not appear to promote hypothermia under general anesthesia.

The thrust plate prosthesis in the treatment of osteoarthritis of the hip. Clinical and radiological outcome with minimum 5-year follow-up

Management of Hip Fractures in the Elderly

The thrust plate prosthesis (TPP) is a neck preserving femoral component in total hip arthroplasty (THA). We present our mid-term results from using the thrust plate prosthesis in young patients with hip arthritis. We conducted a retrospective review of a consecutive series of patients with a minimum of 5 years follow-up after total hip arthroplasty using the thrust plate prosthesis. Harris Hip Score (HHS) and Oxford Hip Score (OHS) were recorded preoperatively and at the last clinical review. Radiographic analysis was performed and patient satisfaction levels and complications were recorded. Between 1996 and 2000 we implanted 41 prostheses in 38 consecutive patients (3 bilateral). The mean age at time of surgery was 56 years (41-67) and the mean length of follow-up was 71 months. The HHS improved from a mean of 42 points preoperatively to 88 points at the last clinical review and the mean OHS also improved from 40 points to 18 points. Eighty-three percent of patients expressed that they were 'very satisfied' with the procedure. Implant survivorship was 95% at 5 years follow-up with revision surgery being the end point. Eight patients suffer discomfort when lying on the operated side. Many patients treated with the TPP show excellent improvement in clinical outcome scores and a high level of patient satisfaction but the complication rate gives some concern. We support the selective use of the TPP to treat young patients with hip osteoarthritis. (copyright) Wichtig Editore, 2008

Closure of patent foramen ovale for paradoxical emboli: intermediate-term risk of recurrent neurological events following transcatheter device placement

Management of Hip Fractures in the Elderly

OBJECTIVES: We report the largest and the longest follow-up to date of patients who underwent transcatheter patent foramen ovale (PFO) closure for paradoxical embolism. BACKGROUND: Closure of a PFO has been proposed as an alternative to anticoagulation in patients with presumed paradoxical emboli. METHODS: Data were collected for patients following PFO closure with the Clamshell, CardioSEAL or Buttoned Devices at two institutions. RESULTS: There were 63 patients (46 +/- 18 years) with a follow-up of 2.6 +/- 2.4 years. Fifty-four (86%) had effective closure of the foramen ovale (trivial or no residual shunt by echocardiography) while seven (11%) had mild and two (3%) had moderate residual shunting. There were four deaths (leukemia, pulmonary embolism, sepsis following a hip fracture and lung cancer). There were four recurrent embolic neurological events following device placement: one stroke and three transient events. The stroke occurred in a 56-year-old patient six months following device placement. A follow-up transesophageal echocardiogram showed a well seated device without residual shunting. Two of the four events were associated with suboptimal device performance (one patient had a significant residual shunt and a second patient had a "friction lesion" in the left atrial wall associated with a displaced fractured device arm). The risk of recurrent stroke or transient neurological event following device placement was 3.2% per year for all patients. CONCLUSION: Transcatheter closure of PFO is an alternative therapy for paradoxical emboli in selected patients. Improved device performance may reduce the risk of recurrent neurological events. Further studies are needed to identify patients most likely to benefit from this intervention

Surgical approaches to the humeral shaft

Distal Radius Fractures

Open fractures, transverse, short oblique and spiroid fractures of the humeral shaft, as well as comminuted fractures with radial palsy or vascular injury, mostly lead to bad end-results if treated conservatively. The same is valid in the case of bilateral humeral shaft fractures, multiple injuries, polytrauma, pathologic fractures and pseudarthrosis. Good end-results and a low rate of complications in the operative procedure require an adequate approach to the fractured limb as well as a meticulous care of the soft tissues. In plate osteosynthesis, the anterolateral approach for the proximal third of the shaft, the anterolateral approach with radial exposure for the middle third of the shaft and the posterior approach for the distal third of the shaft seem to offer the best pathway for reposition and fixation, respecting the biologic requirements for a successful osteosynthesis. The approaches for external fixation demand a thorough knowledge of the course of the axillary and radial nerves. Unreamed intramedullary nailing can be done in an anterograde and in a retrograde way. In anterograde nailing, damage of the rotator cuff must be avoided, in retrograde nailing, the elbow capsule should be left closed and untouched. [References: 25]

Monoclonal antibodies for medical oncology: A few critical perspectives

MSTS 2018 - Femur Mets and MM

Incorporation of antibodies as weapons for cancer therapy has meant a turning point in the survival, clinical and radiological response of many oncology patients. These drugs are effective, well designed missiles that either alone or in combination with chemotherapy are unavoidable weapons for breast, lung and colon cancer as well as for haematological tumours. In addition, incoming monoclonal antibodies (mAbs) and folder-like proteins will be incorporated into clinical practice in the near future. This review aims to discuss a few imminent indications of current mAbs that are used for solid tumours and to briefly introduce future mAbs to the reader.

Rheumatoid Arthritis of the Elbow

Pediatric Supracondylar Humerus Fracture 2020 Review

Rheumatoid arthritis (RA) is the most common form of inflammatory arthropathy. RA is considered a disease of synovial joints, although it can cause various extra-articular manifestations. The synovium appears to be the primary target; however, investigations are ongoing to determine the exact etiology and pathoanatomy. © 2011 Elsevier Inc.

Study of Cartilage Relaxometry and Physical Activity in Osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

This study is the radiological component of an earlier registered RCT under the title: Efficacy of Exercise on Physical Function and Cartilage Health in Patients With Knee Osteoarthritis. The main purpose in this component of the study is to evaluate the efficacy of aerobic exercise and strength training on the T2 and T1 rho relaxation times of the articular cartilage. It has been proven that exercise can improve function and reduce the need for analgesics in patients with osteoarthritis. With this study, we wish to investigate if different kinds of exercise can cause measurable improvements in T2 and T1 rho relaxation times of the articular cartilage, and also if this improvements are transient or permanent.

Adipose tissue derived stem cells: in vitro and in vivo analysis of a standard and three commercially available cell-assisted lipotransfer techniques

Panniculectomy & Abdominoplasty CPG

INTRODUCTION: Autologous fat grafting is commonly used to correct soft-tissue contour deformities. However, results are impaired by a variable and unpredictable resorption rate. Autologous adipose-derived stromal cells in combination with lipoinjection (cell-assisted lipotransfer) seem to favor a long-term persistence of fat grafts, thus fostering the development of devices to be used in the operating room at the point of care, to isolate the stromal vascular fraction (SVF) and produce SVF-enhanced fat grafts with safe and standardized protocols. Focusing on patients undergoing breast reconstruction by lipostructure, we analyzed a standard technique, a modification of the Coleman's procedure, and three different commercially available devices (Lipokit, Cytori, Fastem), in terms of 1) ability to enrich fat grafts in stem cells and 2) clinical outcome at 6 and 12 months. METHODS: To evaluate the ability to enrich stem cells, we compared, for each patient (n=20), the standard lipoaspirate with the respective stem cell-enriched one, analyzing yield, immunophenotype and colony-forming capacity of the SVF cells as well as immunophenotype, clonogenicity and multipotency of the obtained adipose stem cells (ASCs). Regarding the clinical outcome, we compared, by ultrasonography imaging, changes at 6 and 12 months in the subcutaneous thickness of patients treated with stem-cell enriched (n=14) and standard lipoaspirates (n=16). RESULTS: Both methods relying on the enzymatic isolation of primitive cells led to significant increase in the frequency, in the fat grafts, of SVF cells as well as of clonogenic and multipotent ASCs, while the enrichment was less prominent for the device based on the mechanical isolation of the SVF. From a clinical point of view, patients treated with SVF-enhanced fat grafts demonstrated, at six months, a significant superior gain of thickness of both the central and superior-medial quadrants with respect to patients treated with standard lipotransfer. In the median-median quadrant the effect was still persistent at 12 months, confirming an advantage of lipotransfer technique in enriching improving long-term fat grafts. CONCLUSIONS: This comparative study, based on reproducible biological and clinical parameters and endpoints, showed an advantage of lipotransfer technique in enriching fat grafts in stem cells and in favoring, clinically, long-term fat grafts.

Late dorsal tilt angulation of distal articular surface of radius in Colles' type of fracture at the end of the immobilization, can it be predicted?

Distal Radius Fractures

BACKGROUND: The objective was to predict the late dorsal tilt angulation of distal articular surface of radius in Colles' type of fracture with radioulna index difference, age, sex of the patient and dorsal cortex comminution. MATERIAL AND METHOD: Correlation between previously mentioned factors and the changing degree of dorsal tilt angulation of distal articular surface of radius were analyzed. Sixty three wrist radiographs of sixty two patients with Colles' type of fracture were evaluated for dorsal tilt angulation of distal articular surface, radioulna index before and after reduction and at the end of the immobilization, dorsal cortex comminution after reduction. The interobserver and intraobserver generalizability coefficients of the dorsal cortex comminution measurement method were analyzed. RESULTS: Dorsal cortex comminution, age and sex of the patient were the predictors of the dorsal tilt angulation of distal articular surface of Colles' type of fracture at the end of the immobilization. Partial correlation coefficient for dorsal cortex comminution, age and sex were 0.177, 0.201 and -8.206 respectively. The generalizability coefficients were rated as substantial to excellent. CONCLUSION: The late dorsal tilt angulation of distal articular surface of radius at the end of the immobilization can be predicted from size of dorsal cortex comminution, age and sex of the patients.

Concurrent fractures of the hip and wrist: a matched analysis of elderly patients

Distal Radius Fractures

INTRODUCTION: Osteoporotic fractures involving the hip and wrist are common in the elderly. The incidence of coincident hip and wrist fractures in the same patient is small but may represent a unique subpopulation of elderly with osteoporotic fragility fractures and little information has been published about these patients. MATERIALS AND METHODS: We performed a retrospective review studying a series of 33 elderly patients who were admitted with concurrent hip and wrist fractures and matched them with patients of similar age, race, gender and co-morbidities with isolated hip fractures analysing their pre-morbid functional status, degree of osteoporosis by the Singh's index, length of stay and re-admission rate. RESULTS: In our cohort of 33 matched pairs, location of fall in the study group consisted of 21 at home and 26 in the control group. The median duration of stay in hospital was 23 days versus 18 days in the control group. Bone density assessment of our study group revealed 18 patients with severe osteoporosis with Singh's index and 21 severe osteoporosis in the control group. The 1-year re-admission rate for the patients in the study group was 7 and 12 in the control group. Ambulatory status at discharge in the study group was 12 and in the control group 21. DISCUSSION AND CONCLUSION: Our study population demonstrated a higher proportion of community ambulators with fewer 1-year re-admission rates and a high cervical:trochanteric ratio of 2.7, all of which signify that they belong to a physiologically younger and more active cohort than our control group of isolated hip fractures. Patients with concurrent hip and wrist fractures were not significantly more osteoporotic, and showed a trend toward longer stay in hospital and incurred a higher cost of stay. The confluent upper limb injury was the likely reason for their post-discharge impaired ambulatory status. The most common location of injury in both groups of patients is at home.

Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation

DoD SSI (Surgical Site Infections)

Twenty-four patients had a severe open fracture of the tibia that was initially treated by external fixation and subsequently by reamed intramedullary nailing. The external fixation had been maintained for an average of fifty-two days (range, seven to 230 days). The mean interval between removal of the external fixator and intramedullary nailing was sixty-five days (range, three to 360 days). In five of the seven patients who had had an infection at one or more of the pin sites, an infection later developed around the intramedullary nail. In comparison, only one of the seventeen patients who had not had a pin-site infection had an infection later around the nail (p = 0.003). An analysis of other variables, including the duration of external fixation, wound coverage, other injuries, and the type of fracture, showed that none was a predictor of infection either at the pin sites or around the intramedullary nail. We concluded that a pin-site infection that develops during external fixation is a contraindication to the subsequent use of reamed intramedullary nailing in patients who have a fracture of the tibia.

Does the type of flooring affect the risk of hip fracture?

Management of Hip Fractures in the Elderly

BACKGROUND: The number of hip fractures occurring worldwide in 1990 was estimated at 1.7 million and is predicted to rise to 6.3 million by 2050. The vast majority occur as a result of simple falls and the impact of the femoral trochanter with the floor. Previous studies have addressed the problem from the patient's side of the impact. Little research has been carried out on the other surface involved in the impact, the floor. STUDY LOCATION: 34 residential care homes. METHODS: (1) The mechanical properties of the floor were measured with force transducers. (2) The number and location of falls and fractures on the various floors were recorded prospectively for 2 years. The threshold for reporting falls in different care homes was assessed using a standardised set of scenarios. RESULTS: A total of 6,641 falls and 222 fractures were recorded. Wooden carpeted floors were associated with the lowest number of fractures per 100 falls. The risk of fracture resulting from a fall was significantly lower compared to all other floor types (odds ratio 1.78, 95% CI 1.33-2.35). The mean impact force was significantly lower on wooden carpeted floors: 11.9 kN compared to the other floor types. DISCUSSION: The possible implications of our findings are considerable. Residents of homes are typically frail and many have a propensity to falls. In designing safer environments for older people, the type of floor should be chosen to minimise the risk of fracture. This may result in a major reduction in fractures in the elderly

Prediction of perimenopausal fractures by bone mineral density and other risk factors

Management of Hip Fractures in the Elderly

In a prospective population-based cohort study, we assessed whether bone mineral density (BMD) measurements of perimenopausal women and other risk factors for osteoporosis are predictive of subsequent fracture. Women aged 47-51 years chosen randomly from a population register who underwent a bone density measurement 2 years previously were followed up by questionnaire to assess the 2-year incidence of any self-reported fractures. We found that 44 women, out of 1857 who completed the questionnaire, sustained at least one fracture within a 2-year follow-up period. After adjustment for covariates, the odds ratio of sustaining a fracture was 1.6 (95% confidence interval [CI] 1.16-2.34) for every standard deviation reduction in BMD at the spine, for women with a prior history of fracture the odds ratio of a subsequent fracture was approximately 2 (95% CI 1.31-3.03), a family history of hip fracture (maternal grandmother) carried an odds ratio of 3.7 (95% CI 1.55-8.85), while being postmenopausal or having a hysterectomy resulted in an odds ratio of 1.98 (1.02-3.56). This study has shown that BMD measurements at the hip and spine and other risk factors predict any nonhip and nonspine perimenopausal fractures. Further follow-up is required to assess the predictive performance of BMD measurements and other risk factors for hip and spine fractures

Effect of therapist-based versus robot-assisted bilateral arm training on motor control, functional performance, and quality of life after chronic stroke: a clinical trial

Pediatric Supracondylar Humerus Fracture 2020 Review

BACKGROUND: Although bilateral arm training (BAT) has been widely studied, the comparative effects of therapist-based BAT (TBAT) versus robot-assisted BAT (RBAT) remains unknown. OBJECTIVE: This study compared the efficacy of TBAT, RBAT, and a control treatment (CT) on motor control, functional performance, and quality of life after chronic stroke. DESIGN: A randomized, pretest-posttest, control group design was used. METHODS: Forty-two patients (mean age=54.49 years, SD=9.69; mean length of time since stroke onset=17.62 months, SD=10.50) were randomly assigned to TBAT, RBAT, and CT groups. Each group received treatment for 90 to 105 minutes per session, 5 sessions on weekdays, for 4 weeks. Outcome measures included kinematic analyses, the Fugl-Meyer Assessment (FMA), the Motor Activity Log, and the Stroke Impact Scale (SIS). RESULTS: Large and significant effects were found in the kinematic variables, distal part of upper-limb motor impairment, and certain aspects of quality of life in favor of TBAT or RBAT. Specifically, the TBAT group demonstrated significantly better temporal efficiency and smoothness, straighter trunk motion, and less trunk compensation compared with the CT and RBAT groups. The RBAT group had increased shoulder flexion compared with the CT and TBAT groups. On the FMA, the TBAT group showed higher distal part scores than the CT group. On the SIS, the RBAT group had better strength subscale, physical function domain, and total scores than the CT group. Limitations This study recruited patients with mild spasticity and without cognitive impairment. CONCLUSIONS: Compared with CT, TBAT and RBAT exhibited differential effects on outcome measures. Therapist-based BAT may improve temporal efficiency, smoothness, trunk control, and motor impairment of the distal upper limb. Robot-assisted BAT may improve shoulder flexion and quality of life.

Registration of arthroplasties in Finland. A nationwide prospective project

Surgical Management of Osteoarthritis of the Knee CPG

Data on hip and knee arthroplasties have been compiled on a nationwide basis in Finland since 1980. Forty-five major departments contribute to the study providing data on the type of operation, the implant used, the diagnosis, and the 1-year clinical results. In the case of revision, new data are sent to the register, enabling survivorship analysis. Between 1980 and 1988, 25,966 operations were reported. Fifty-six percent had been made for primary osteoarthrosis, 22 percent for rheumatoid arthritis, 6.3 percent for secondary arthrosis, and 0.5 percent for CDH. In 1988, the total number of arthroplasties was 4,628: about two thirds hip and one third knee replacements. The annual incidence of primary total hip arthroplasties in 1988 was 58 per 100,000 inhabitants and that for the knees 25 per 100,000 inhabitants. More than 40 percent of the patients were under 65 years of age. In the whole series, primary thromboembolic complications occurred in 1.4 percent, luxations in 1.4 percent, infection in 0.9 percent, and evacuated hematoma in 0.6 percent. The annual frequency of re-arthroplasty increased between 1980 and 1988 from 9.8 to 13.6 percent, indicating an increasing orthopedic work load in the future

Bone disease from monoclonal gammopathy of undetermined significance to multiple myeloma: pathogenesis, interventions, and future opportunities

MSTS 2018 - Femur Mets and MM

Manifestations of bone disease-osteopenia, osteolytic lesions, and fractures-are the hallmark of multiple myeloma (MM) and occur clinically in the vast majority of patients. These abnormalities can have devastating clinical effects by increasing both the morbidity and mortality of patients. Bone disease is usually found when patients are diagnosed with active MM; however, recent data suggest that it is present in early myelomagenesis, including patients with myeloma precursor disease, monoclonal gammopathy of undetermined significance (MGUS). The primary mechanisms of abnormal bone remodeling are increased osteoclastic activity, which occurs in close proximity to active myeloma cells, and decreased activity of the surrounding osteoblasts. Better understanding of the pathogenesis of bone disease in MM will allow us to enhance our current therapeutic options in the treatment of bone disease. In patients with active MM and at least one lytic lesion, intravenous bisphosphonates have been shown to decrease skeletal-related events and pain, improve performance status, and maintain quality of life. Emerging evidence suggests that intervention at earlier stages of disease may prevent skeletal-related events at time of progression, but there is no evidence that bisphosphonates in this setting change the natural history of the disease.

Knee arthroscopy and arthrotomy under local anesthesia

Surgical Management of Osteoarthritis of the Knee CPG

We report our experience with knee arthroscopy in local anesthesia in 64 patients with subsequent arthrotomy in 14 of these. The effectiveness of the anesthetic method was evaluated by both the patient and the anesthetic personnel. There was no difference in pain assessment between arthroscopy alone and arthroscopy followed by arthrotomy. Half of the patients had no pain and only one regarded the procedure as very painful. Supplementary analgesia with 0.05 mg fentanyl was given to half of the patients not undergoing arthrotomy and to two thirds of those who had arthrotomy. It was not necessary to abandon any arthroscopic or surgical procedure because of pain. We conclude that local anesthesia is a safe and practical method for diagnostic arthroscopy, arthroscopic surgery, and minor arthrotomy

Activation of coagulation and deep vein thrombosis after bone marrow harvesting and insertion of a Hickman-catheter in ABMT patients with malignant lymphoma

MSTS 2022 - Metastatic Disease of the Humerus

Evidence of activation of coagulation was sought in serial plasma samples from 25 ABMT candidates with malignant lymphoma admitted for bone marrow harvesting: 10 females and 15 males, median age 41 years (range 27-58 years). Nineteen patients had non-Hodgkin's lymphoma (NHL) and six had Hodgkin's disease. Of those with NHL, 14 had high-grade and five low- grade disease. The plasma levels of markers of activation (prothrombin fragment 1 + 2, thrombin-antithrombin complexes, fibrinopeptide A and fibrinmonomers) increased significantly (P < 0.001) in association with harvesting. Except for fibrinopeptide A, the indicators of activation were still significantly elevated 24 h after marrow aspiration. Beta-thromboglobulin, a marker of the platelet release reaction, also increased significantly (P < 0.01). Four out of nine patients in whom a long-term central venous catheter was inserted just after marrow aspiration, developed catheter-related deep vein thrombosis, verified venographically, shortly after harvesting. These results suggest that patient with malignant lymphoma undergoing marrow harvesting develop a hypercoagulable state, and that insertion of a central intravenous catheter immediately after marrow harvesting should be avoided to prevent the development of symptomatic deep vein thrombosis.

Influence of hemianopic visual field loss on visual motor control

Upper Eyelid and Brow Surgery

BACKGROUND: Homonymous hemianopia (HH) is an anisotropic visual impairment characterized by the binocular inability to see one side of the visual field. Patients with HH often misperceive visual space. Here we investigated how HH affects visual motor control. METHODS AND FINDINGS: Seven patients with complete HH and no neglect or cognitive decline and seven gender- and age-matched controls viewed displays in which a target moved randomly along the horizontal or the vertical axis. They used a joystick to control the target movement to keep it at the center of the screen. We found that the mean deviation of the target position from the center of the screen along the horizontal axis was biased toward the blind side for five out of seven HH patients. More importantly, while the normal vision controls showed more precise control and larger response amplitudes when the target moved along the horizontal rather than the vertical axis, the control performance of the HH patients was not different between these two target motion experimental conditions. CONCLUSIONS: Compared with normal vision controls, HH affected patients' control performance when the target moved horizontally (i.e., along the axis of their visual impairment) rather than vertically. We conclude that hemianopia affects the use of visual information for online control of a moving target specific to the axis of visual impairment. The implications of the findings for driving in hemianopic patients are discussed.

Preventing the development of complex regional pain syndrome after surgery

AAHKS (2) Corticosteroids

The development of complex regional pain syndrome after orthopedic surgery is not uncommon. This article reviews the regional nerve blocks and pharmacologic therapies that may be beneficial in reducing the perioperative incidence of complex regional pain syndrome.

Risk factors for development of heterotopic ossification of the elbow after fracture fixation

Pediatric Supracondylar Humerus Fracture 2020 Review

BACKGROUND: Postoperative heterotopic ossification (HO) about the elbow may occur after surgical fixation of fractures and can contribute to dysfunction. Factors associated with HO formation after surgical fixation of elbow trauma are not well understood. METHODS: All patients who underwent surgery for elbow trauma at our institution from October 2001 through August 2010 were retrospectively reviewed. Patients with prior injury or deformity to the involved elbow were excluded. Demographic data; fracture type; surgical treatment; and presence, location, and size of HO were recorded. The Fisher exact test, Ï?(2) test, and multivariate logistic regression were used with an α value of .05 used for significance. RESULTS: A total of 159 patients were identified, with 89 (37 men and 52 women) meeting inclusion and exclusion criteria. The mean age was 54.4 years (range, 18-90 years), and the mean follow-up time was 180 days. Age, male gender, lateral collateral ligament repair, and dual-incision approach were not associated with increased ectopic bone formation. Distal humeral fractures were a significant predictor of heterotopic bone. In patients in whom HO ultimately developed, it was visible on radiographs obtained 2 weeks postoperatively in 86% of cases. CONCLUSION: This investigation found predictors for the development of HO after surgical fixation of intra-articular elbow fractures. Furthermore, HO went on to develop at the time of final follow-up in only 14% of patients without HO on radiographs obtained 2 weeks postoperatively. This may suggest that absence of HO on radiographs obtained 2 weeks postoperatively may predict a more favorable outcome.

Multiple Nonspecific Sites of Joint Pain Outside the Knees Develop in Persons With Knee Pain

OAK 3 - Non-arthroplasty tx of OAK

Objective: Many persons with knee pain have joint pain outside the knee, but despite the impact and high frequency of this pain, its distribution and causes have not been studied. We undertook this study to test the hypothesis of those studying gait abnormalities who have suggested that knee pain causes pain in adjacent joints but that pain adaptation strategies are highly individualized. Methods: We studied persons ages 50â??79 years with or at high risk of knee osteoarthritis who were recruited from 2 community-based cohorts, the Multicenter Osteoarthritis Study and the Osteoarthritis Initiative, and we followed them up for 5â??7 years. We excluded those with knee pain at baseline and compared those who had developed knee pain at the first follow-up examination (the index visit) with those who had not. We examined pain on most days at joint regions outside the knee in examinations after the index visit. Logistic regression analyses examined the risk of joint-specific pain adjusted for age, sex, body mass index, and symptoms of depression, and we performed sensitivity analyses excluding those with widespread pain. Results: In the combined cohorts, 693 persons had knee pain at the index visit and 2,793 did not. A total of 79.6% of those with bilateral knee pain and 63.8% of those with unilateral knee pain had pain during follow-up in a joint region outside the knee, compared with 49.9% of those without knee pain. There was an increased risk of pain at most extremity joint sites, without a predilection for specific sites. Results were unchanged when those with widespread pain were excluded. Conclusion: Persons with chronic knee pain are at increased risk of pain in multiple joints in no specific pattern.

Early serum IGF-I response to oral protein supplements in elderly women with a recent hip fracture

Management of Hip Fractures in the Elderly

BACKGROUND & AIMS: In patients with recent hip fracture, reduced serum IGF-I in relation to protein undernutrition is frequent. Elevation of circulating IGF-I in response to a daily oral supplement of 20 g of casein was observed after 6 months. This study determined if the response to casein as compared to whey protein can be observed as early as after one week. METHODS: 45 women were randomized after recent hip fracture in 3 groups receiving a preparation of 20 g of casein, an isocaloric supplement of 20 g of whey protein or an isocaloric supplement of 15 g of whey protein combined with 5 g of essential amino acids (a.a.). RESULTS: A similar significant elevation of serum IGF-I was already observed after 7 days for casein (+37.3 microg/L), whey (+29.4) and for whey+a.a. (+34.3). From day 7-28, no further significant rise in IGF-I was recorded. CONCLUSION: After one week of protein supplementation, the percent increase of IGF-I was of similar magnitude to that previously observed after 6 months of protein supplementation. It suggests that in hip fracture patients, long-term effects of various protein preparations on IGF-I could be predicted from changes observed as early as 7 days after the onset of supplementation

Does the combination of a simultaneous subcapital fracture of humerus and hip fracture in elderly patients carry a prognostic value?

Distal Radius Fractures

The most important factor to cause hip fractures in elderly is probably osteoporosis. Other factors are the increase in fall frequency and the protective response to trauma. Osteoporotic fractures occur most commonly, at the hip, vertebra, distal radius and proximal humerus. A combination of these is uncommon. Thirty-two women and six men treated between January 1990 and December 1999 for a combination of subcapital fracture of the humerus and hip fractures were evaluated retrospectively. The following parameters were reviewed: age, sex, pre-fall function, use of drugs, chronic and acute comorbidity, circumstances of the fall, length of hospitalization, treatment procedure, complications and post-hospitalization rehabilitation. Group I consisted of 15 patients aged 70-80 years and group II consisted of the remaining 23 patients, older than 80 years. In all 38 patients the simultaneous fractures were ipsilaterally. Hospital stay ranged from 7 to 17 days for the discharged 37 patients. Twenty-six of 28 patients, who were transferred to a rehabilitation center, returned to their previous activity of daily living (ADL). Among the nine remaining patients only five gained full recovery. A combination of fractures, occurs in the higher-age group, is quite traumatic to the patient and probably involves a greater impact force. In all patients it occurs in the ipsilateral side. In the elderly, even a minimal transmission to the osteoporotic hip can cause a fracture. The double trauma represents a better pre-morbid condition relative to patients in the same age group, thus it may serve as a prognostic indicator for success in rehabilitation.

CC chemokine receptor-like 1 functions as a tumour suppressor by impairing CCR7-related chemotaxis in hepatocellular carcinoma

MSTS 2018 - Femur Mets and MM

Atypical chemokine receptors (ACRs) have been discovered to participate in the regulation of tumour behaviour. Here we report a tumour-suppressive role of a novel ACR member, CC chemokine receptor like 1 (CCRL1), in human hepatocellular carcinoma (HCC). Both mRNA and protein expressions of CCRL1 correlated with the malignant phenotype of HCC cells and were significantly down-regulated in tumour tissue compared with paired normal liver tissue. In both the initial and validation cohorts (n = 240 and n = 384, respectively), CCRL1 deficiency was associated with advanced tumour stage and was an independent index for worse survival and increased recurrence. Furthermore, knock-down or forced expression of CCRL1 revealed that CCRL1 suppressed the proliferation and invasion of HCC cells in vitro and reduced tumour growth and lung metastasis in vivo, with depressed levels of CCL19 and CCL21. By sequestrating CCL19 and CCL21, CCRL1 reduced their binding to CCR7 and consequently mitigated the detrimental impact of CCR7, including Akt-GSK3beta pathway activation and nuclear accumulation of beta-catenin in tumour cells. Clinically, the prognostic value of the CCR7 expression in HCC depended on the expression level of CCRL1, suggesting that CCRL1 may serve as an upstream switch for the CCR7 signalling cascade. Together, our findings suggest that CCRL1 impairs chemotactic events associated with CCR7 in the progression and metastasis of HCC. Our results also show a potential interplay between typical and atypical chemokine receptors in human cancer. Copyright �� 2014 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.