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Phosphoantigens and aminobisphosphonates: New leads targeting γδ T lymphocytes for cancer immunotherapy

MSTS 2018 - Femur Mets and MM

This paper briefly reviews what human γδ T lymphocytes are and what they can do in anticancer and anti-infectious immunity. Both phosphoantigens, a new class of immunostimulatory leads, and some anticancer aminobisphosphonates selectively activate these lymphocytes. So, new molecules under development and endowed with diverse additional bioactivities are promising new leads for the design of highly innovative anticancer immunotherapies. © 2006 Elsevier Ltd. All rights reserved.

Nail-medullary canal ratio affects mechanical axis deviation during femoral lengthening with an intramedullary distractor

OAK 3 - Non-arthroplasty tx of OAK

INTRODUCTION: Callus distraction of the femur using an intramedullary distractor has several advantages over the use of external fixators. However, difficulty in controlling the mechanical axis during lengthening may cause deformities and knee osteoarthritis. Purpose of the study is to answer the following questions: (1) is lengthening with an intramedullary device associated with a medial or lateral shift of the mechanical axis? (2) Which factors are associated with varisation/valgisation of the mechanical axis during lengthening? MATERIALS AND METHODS: We analysed pre-treatment and post-treatment radiographs from 20 patients who underwent unilateral femoral-lengthening procedures using intramedullary distractors. Patients with acute correction of pre-existing deformities or combined ipsilateral femoral and tibial lengthening were excluded. Mechanical axis deviations, osteotomy level, and nail-medullary canal ratio were recorded. RESULTS: Compared to the preoperative axis, the mechanical axis shifted medially in 7 patients (varisation group) and laterally in 13 patients (valgisation group). The groups did not significantly differ regarding preoperative leg length discrepancy (LLD), mechanical axis alignment, LLD-cause and implants used. The nail-medullary canal ratio significantly differed between groups (p<0.001), being <85% in the varisation group and >85% in the valgisation group. The distance between the lesser trochanter and the osteotomy site was significantly longer in the valgisation group (58.9+/-16.3mm, middle third of the femur) compared to the varisation group (40.6+/-11.4mm, proximal third of the femur; p=0.02). CONCLUSION: The nail-medullary canal ratio should be considered during preoperative planning. To avoid a varisation effect-for example, in cases with pre-existing varus alignment-it would be advisable to perform an osteotomy at the middle third of the femur with implantation of a nail that fully covers the medullary canal at the osteotomy site. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Recent aspects for disseminated carcinomatosis of the bone marrow associated with gastric cancer: What has been done for the past, and what will be needed in future?

MSTS 2018 - Femur Mets and MM

Disseminated carcinomatosis of the bone marrow is characterized by widespread bone metastasis (bone marrow infiltration) from solid tumors with hematological disorders coexisted. This disease is frequently complicated with gastric cancer among solid tumors although its incidence is very rare. In recent years, technological innovations in diagnosis and treatment for cancer have remarkably improved, which made survival rates of various cancers prolonged. Prognosis of disseminated carcinomatosis of the bone marrow associated with gastric cancer, however, is still poor (less than a year), possibly because this disease has not been given attention due to low incidence. In this review, I summarize the results obtained for the past, and propose ways to improve the prognosis of this disease.

The use of negative pressure wound therapy for random local flaps at the ankle region

DoD SSI (Surgical Site Infections)

Local random flaps are seldom used for reconstruction of complex ankle wounds because of concern for flap failure attributable to vascular compromise and tissue edema. Negative pressure wound therapy has been shown to improve perfusion and limit tissue edema. The objective of this study was to demonstrate the utility of negative pressure wound therapy in improving outcomes for local flaps of the ankle. Ten consecutive patients presenting with complex ankle wounds and reconstructed using local flaps were treated with negative pressure wound therapy postoperatively. Type of flap, immediate and long-term outcomes, and complications were assessed. Seventeen local flaps were performed on 10 patients to reconstruct their ankle wounds. Mean follow up was 88 days. All flaps healed without tissue compromise or necrosis. Only one partial dehiscence and no infections were observed. This study demonstrates that negative pressure therapy may contribute to the viability of random local flaps by decreasing venous congestion. Our experience using negative pressure wound therapy on local flaps suggests that it may serve as a useful adjunct to ensure successful closure of high-risk wounds.

Analysis of the bicipital groove as a landmark for humeral head replacement

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Many anthropometric studies of the normal glenohumeral relationship have been performed in an effort to identify reference points for the correct placement of the humeral head prosthesis in shoulder arthroplasty. The bicipital groove offers a useful landmark for placement of the lateral fin of the prosthesis. However, when fracture surgery is performed, only the distal portion of the bicipital groove may be available for reference. We evaluated the course of the bicipital groove as it moves distally along the humerus. Computer-assisted tomography axial images of 21 cadaveric humeri were obtained in order to follow the course of the bicipital groove from proximal to distal on the humerus. With use of the bisector of the transepicondylar axis as a reference point, the relative change in position of the bicipital groove from proximal to distal was measured. The mean change in rotation of the lateral lip from the proximal to the distal groove was 15.9 degrees, with an SD of 6.8 degrees (range, 4 degrees -32 degrees ). The 95% confidence interval range for the change was 12.8 degrees to 19 degrees. Thus, a significant amount of internal rotation occurs along the course of the bicipital groove. This has significant clinical implications when the bicipital groove is used as a landmark for humeral head replacement in fractures of the proximal humerus

Total hip arthroplasty for failed aseptic Austin Moore prosthesis

Management of Hip Fractures in the Elderly

BACKGROUND: Though Austin Moore (AM) replacement prosthesis has fairly good short term results for intracapsular femoral neck fractures in the elderly, it still is a compromised option and has a high failure rate in the long run. The objective of the present retrospective study is to analyze the functional outcome, assess survivorship of revision total hip arthroplasty (THA) at mid to long term followup, and evaluate intraoperative difficulties faced during conversion of failed aseptic AM prosthesis to cemented THA. MATERIALS AND METHODS: Eighty-nine cemented THA surgeries for failed AM prosthesis were performed between 1986 and 2005. AM failures were classified into seven groups on the basis of mode of failure. Infected failures were excluded from the study. There were 35 men and 54 women in the study group. The mean age was 68 years (range 57-91 years). Mean followup was 8 years (range 5-13 years). RESULTS: Average Harris Hip Score improved from 65 preoperatively (range 42-73) to 87 (range 76-90) at 1 year postoperatively and to 86 (range 75-89) at the last followup. The overall complication rate was 4.5%. CONCLUSION: Conversion THA is an excellent treatment strategy for symptomatic failed AM hemiarthroplasty in terms of pain relief and restoration of function and mobility as near as possible to the preinjury level. Also, hemiarthroplasty should not be used in physically active patients, even in elderly individuals. Careful patient selection for hemiarthroplasty versus THA is vital and may decrease the incidence of complications and ameliorate the outcomes in the treatment of intracapsular femoral neck fractures

The association of single nucleotide polymorphisms in the calcitonin gene with primary osteoarthritis of the knee in Mexican mestizo population

OAK 3 - Non-arthroplasty tx of OAK

Primary osteoarthritis (OA) is a multifactorial disorder with several genetics factors involved. Calcitonin (CT) has been suggested to possess chondroprotective effects and could play an important role in the pathogenesis of OA. The aim of this study was to investigate whether genetic variations in or adjacent to the CT gene may be associated with primary OA of the knee in Mexican mestizo population. We conducted a case-control study to investigate the association between six single nucleotide polymorphisms at the CT locus and OA of the knee in 107 cases and 106 controls. Cases were patients >40 years of age, with a body mass index (BMI) �27 and a radiologic score for OA of the knee �2. Controls were subjects >40 years of age with a radiologic score <2. Non-conditional logistic regression was developed to evaluate risk magnitude. The G allele and GT genotype frequencies of the G-706T polymorphism and the C allele and CC genotype of the C-778T polymorphism were significantly higher in patients with OA than in control subjects. The GG genotype of the G-706T was associated with lower risk of the development of OA of the knee. According to the results, the G-706T and the C-778T polymorphisms were related to the Cdx1 and Mzf1 transcription factor binding sites, respectively. Therefore, these could be related to regulation sequences in the CT gene promoter. In conclusion, G-706T and C-778T polymorphisms in the CT gene are significantly associated with the development of primary OA of the knee. © 2013 Springer-Verlag Berlin Heidelberg.

S-adenosyl methionine (SAMe) versus celecoxib for the treatment of osteoarthritis symptoms: a double-blind cross-over trial

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: S�adenosylmethionine (SAMe) is a dietary supplement used in the management of osteoarthritis (OA) symptoms. Studies evaluating SAMe in the management of OA have been limited to Non Steroidal Anti�inflammatory Drugs (NSAIDs) for comparison. The present study compares the effectiveness of SAMe to a cyclooxygenase�2 (COX�2) inhibitor (celecoxib) for pain control, functional improvement and to decrease side effects in people with osteoarthritis of the knee. METHODS: A randomized double�blind cross�over study, comparing SAMe (1200 mg) with celecoxib (Celebrex 200 mg) for 16 weeks to reduce pain associated with OA of the knee. Sixty�one adults diagnosed with OA of the knee were enrolled and 56 completed the study. Subjects were tested for pain, functional health, mood status, isometric joint function tests, and side effects. RESULTS: On the first month of Phase 1, celecoxib showed significantly more reduction in pain than SAMe (p = 0.024). By the second month of Phase 1, there was no significant difference between both groups (p < 0.01). The duration of treatment and the interaction of duration with type of treatment were statistically significant (ps < or = 0.029). On most functional health measures both groups showed a notable improvement from baseline, however no significant difference between SAMe and celecoxib was observed. Isometric joint function tests appeared to be steadily improving over the entire study period regardless of treatment. CONCLUSION: SAMe has a slower onset of action but is as effective as celecoxib in the management of symptoms of knee osteoarthritis. Longer studies are needed to evaluate the long�term effectiveness of SAMe and the optimal dose to be used.

Pattern of antibiotic prescription in the management of oral diseases among dentists in Kuwait

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

OBJECTIVES: The use and abuse of antibiotics have been of concern to the medical and the dental profession for sometime now, due mainly to the emergence of antibiotic-resistant bacteria. The objective of this project was to determine the rationale and the pattern of antibiotic prescription for dental management in Kuwait. METHODS: A questionnaire was distributed to 200 dental practitioners working in the Ministry of Health dental centers in Kuwait. The questionnaires sought answers to the clinical and non-clinical factors; signs, clinical conditions and dental treatment modalities for which the practitioners would prescribe antibiotics. RESULTS: Of the 200 questionnaires sent out, 168 (84%) respondents returned fully completed forms. A total of 107 (63.7%) of the respondents were males. Of respondents, 90% would prescribe antibiotics for patients with elevated body temperatures and evidence of systemic involvement, gross or diffuse facial swelling and closure of the eye due to inflammatory swelling. However, over 50% would prescribe antibiotics for cases with localized fluctuant swelling without any systemic involvement, while 59.6% would prescribe for patients with difficulty in swallowing as a result of an oral infection. Many respondents would consider antibiotic prescription for routine dental extraction, and for non-clinical reasons such as uncertainty of diagnosis, convenience, expectation of the patient and lack of time to treat immediately. Amoxicillin was the most frequently prescribed antibiotic. Higher knowledge regarding adequate indications for antibiotic use was associated with longer professional experience. CONCLUSIONS: The results of this analysis suggest that there is lack of uniformity in the rationale for antibiotic use among dental practitioners in Kuwait. There is an urgent need for the formulation of evidence-based guidelines, which should take into account the peculiar behavioral characteristics of the community

Cutting error of the distal femur in total knee arthroplasty by use of a navigation system

Surgical Management of Osteoarthritis of the Knee CPG

The aim of this study was to evaluate the alignment of the distal femoral cutting surface using a navigation system to determine the accuracy of bone cutting. We evaluated 20 knees in 20 patients. After cutting the distal femur, the cutting surface was validated using the navigated cutting block adapter, and the angular difference between the cutting surface and that preoperatively planned in the sagittal and coronal planes was recorded. The average error of all knees was 1.6 degrees +/- 2.2 degrees in extension, and 14 (70%) of 20 knees were cut in an extended position. Our tendency is to cut the distal femur in an extended position with the first femoral cut in the sagittal plane

Osteoarthritis guidelines:A progressive role for topical nonsteroidal anti-inflammatory drugs

OAK 3 - Non-arthroplasty tx of OAK

Current treatment guidelines for the treatment of chronic pain associated with osteoarthritis reflect the collective clinical knowledge of international experts in weighing the benefits of pharmacologic therapy options while striving to minimize the negative effects associated with them. Consideration of disease progression, pattern of flares, level of functional impairment or disability, response to treatment, coexisting conditions such as cardiovascular disease or gastrointestinal disorders, and concomitant prescription medication use should be considered when creating a therapeutic plan for a patient with osteoarthritis. Although topical nonsteroidal anti-inflammatory drugs historically have not been prevalent in many of the guidelines for osteoarthritis treatment, recent evidence-based medicine and new guidelines now support their use as a viable option for the clinician seeking alternatives to typical oral formulations. This article provides a qualitative review of these treatment guidelines and the emerging role of topical nonsteroidal anti-inflammatory drugs as a therapy option for patients with localized symptoms of osteoarthritis who may be at risk for oral nonsteroidal anti-inflammatory drugrelated serious adverse events. © 2013 Stanos, publisher and licensee Dove Medical Press Ltd.

Management of lower extremity arterial injuries

DOD - Acute Comp Syndrome CPG

Past and current military experience has contributed considerably to the advances made in the treatment of extremity vascular injuries. However, the management of arterial injuries of the lower extremity is still associated with significant rates of limb loss and functional deficits. The incidence of civilian arterial limb injuries, including those related to iatrogenic vessel catheterization, has increased over time, but remains fortunately uncommon. Several related issues, such as the initial order of intervention for associated bony injuries, use of temporary intravascular shunt, repair of concomitant venous injuries, and prophylactic fasciotomy, have been debated extensively and remain controversial The current treatment of extremity arterial injuries continues to evolve with the availability of superior imaging modalities and emerging endovascular technology. Additionally, the multi-disciplinary approach to the injured patients has produced improved limb-salvage and patient survival. In this review, we discuss the diagnostic evaluation, surgical and endovascular treatment of arterial injuries in the lower extremity.

Acetabular revision with a roof reinforcement ring and impacted allograft bone

Management of Hip Fractures in the Elderly

A series of 43 acetabular revisions treated with impacted allograft bone and a roof reinforcement ring were reviewed. The average follow-up was 5 years (2-15). The mean age was 70 years. The position of the hip center, and the orientation of the ring and cup were digitized and measured. The average inclination of the roof ring with respect to the horizontal was 44(degrees)(22(degrees)-60(degrees)) early post-operatively. The cup inclination was 33(degrees)(21(degrees)-49(degrees)). These figures did not change significantly at the latest follow-up. Definite loosening was defined as migration of the components or breakage of the screws. Four components were definitely loose. Two other patients had continuous radiolucent lines, but no migration of the components at the bone-implant interface. The radiographic success rate was 86%. Pre- and post-operative Harris Hip Score were 34.1 (18 - 65) and 71.6 (36 - 90) respectively. The study supports the use of impacted morsellized allograft bone and a roof reinforcement ring for cavitary acetabular defects

Incorrect diagnoses in patients with neutralizing anti-interferon-gamma-autoantibodies

MSTS 2022 - Metastatic Disease of the Humerus

Objectives: Early diagnosis of adult-onset immunodeficiency associated with neutralizing anti-interferon-gamma autoantibodies (anti-IFN? Abs) remains difficult given the lack of a distinctive phenotype and a routine test. This study aimed to investigate the determinants of incorrect tentative diagnoses and useful clues for early disease recognition. Methods: This study enrolled adult patients who had unexplained opportunistic infections diagnosed at six hospitals and identified those having neutralizing anti-IFN? Abs (cases). Demographics, medical history, initial presentations and laboratory data, causative pathogens, tentative diagnoses, and treatment were analysed and compared among individuals having neutralizing anti-IFN? Abs (cases) and those without (controls). Results: Among the 154 patients enrolled, neutralizing anti-IFN-? Abs were detected in 50 (71%) of 70 patients with disseminated non-tuberculous mycobacterial infection (dNTM) but not in 84 patients without dNTM. The median time from disease onset to the recognition of dNTM associated with neutralizing anti-IFN? Abs was 1.6 years (range, 0.25–19 years). Incorrect tentative diagnoses resulted in the administration of anti-tuberculosis regimens (60%, 30/50), immunosuppressants (48%, 24/50), and systemic chemotherapy (2%, 10/50) to the 50 cases. Multivariate analysis revealed that case patients were more likely than controls to present with multiple bone lesions (adjusted odds ratio (OR), 27.16; 95% confidence interval (CI), 1.21–609.59) and leukocytosis (adjusted OR, 1.48; 95% CI, 1.12–1.95); however, the controls had a higher rate of mycobacterial bloodstream infection (adjusted OR, 0.05; 95% CI 0.00–0.66). Conclusions: The high rate of incorrect tentative diagnoses led to frequent inappropriate management in patients with neutralizing anti-IFN? Abs, and highlighted the need for increased awareness among clinicians.

A comparison of sensory and motor loss after a femoral nerve block conducted with ultrasound versus ultrasound and nerve stimulation

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Controversy exists regarding the need for nerve stimulation when performing an ultrasound (US)-guided peripheral nerve block. We tested the hypothesis that the quality of a femoral nerve block (FNB) performed with US is equivalent to an FNB performed with US and nerve stimulation. METHODS: One hundred seven patients undergoing unilateral total knee arthroplasty were randomized to receive either a US-guided FNB (group US) or a US-guided FNB with nerve stimulation (group USNS). Thirty milliliters of bupivacaine 0.5% was injected in both groups. At 10, 20, 30, and 40 mins after block placement, blinded motor and sensory examinations were conducted. Secondary outcomes included time to perform the block, the number of needle redirections, and 24-hrs intravenously administered morphine equivalent consumption. RESULTS: There were no significant differences in the proportion of patients with either a partial or complete block. At 40 mins, 95.7% of the USNS subjects had a partial or complete sensory block of the femoral nerve (complete in 71.7% and partial in 24%) compared with 88.1% of US subjects (complete in 69% and partial in 19.1%; odds ratio, 2.97; P = 0.19). There were more needle redirections in group USNS (4.1 vs 1.1, P < 0.001), with a higher percentage of patients requiring 2 or more needle attempts (44.2% vs 18.9%, P < 0.01). The time to perform the block in group USNS was longer (188 vs 148 secs, P = 0.01). CONCLUSION: The addition of nerve stimulation to a US-guided FNB did not change preoperative block efficacy

Experience with etanercept in an academic medical center: are infection rates increased?

AAHKS (2) Corticosteroids

OBJECTIVES: There is little established information regarding the safety of antitumor necrosis factor therapies used outside the setting of clinical trials. This study evaluated the long-term safety and tolerability of open-label use of etanercept when used to treat patients with a variety of systemic rheumatic diseases. Reduction of concomitant corticosteroid and disease-modifying antirheumatic drug was also assessed. METHODS: Retrospective medical record review of 180 patients who were started on etanercept between December 1998 and April 2000 at an academic medical center. RESULTS: Most patients (81%) remained on therapy for longer than 6 months, and a significant number (43%) of patients for longer than 12 months. Etanercept was prescribed for rheumatoid arthritis (RA) in 144 patients and for diseases other than RA, including ankylosing spondylitis, psoriatic arthritis, and polymyositis, in 36 patients. Fifty-six percent of patients taking corticosteroids were able to reduce their dose and 51% of patients were able to taper their methotrexate dosages. Forty-three patients (26%) discontinued etanercept. Reasons for discontinuing therapy included serious adverse events (2.9%), of which infection was most common. These included a psoas abscess secondary to Mycobacterium avium-intracellulare, septic wrist, bacteremia, and septic total hip replacement. Two deaths associated with infection were seen. CONCLUSIONS: The majority of the studied patients tolerated etanercept for longer than 6 months. Many of these patients were able to subsequently taper or even discontinue corticosteroid and methotrexate therapy. Serious infections occurred in this patient population. Our results underscore the value of long-term observation under the conditions of clinical practice beyond controlled clinical trials.

Association of knee muscle strength with lower extremity dysfunction in patients with osteoarthritis: A comparison with rheumatoid arthritis patients and healthy controls

OAK 3 - Non-arthroplasty tx of OAK

Objectives: This study aims to evaluate the relationship between knee muscle strength and lower limb dysfunction in patients with osteoarthritis (OA) in the lower limbs. Patients and methods: A total of 126 subjects including 42 with OA in the lower limbs, 42 with rheumatoid arthritis (RA) and 42 healthy controls (mean age 52.65±7.17 years; range 40 to 71 years) were enrolled. The lower limb pain of the patients was evaluated using the visual analog scale (VAS). All participants underwent an isokinetic knee muscle strength test, a six-minute walking test (6MWT), and the Rheumatoid and Arthritis Outcome Scale (RAOS). The disease activity scores involving 28 joints (DAS 28) of RA patients and the Kellgren-Lawrence scores of OA patients were recorded. Results: The pain intensity was similar in the OA and RA patients. There was no statistically significant difference among the three groups in terms of the 6MWT times. All of the RAOS subscales were significantly lower in the OA and RA patients compared to the control group (p<0.001), however, there was no statistically significant difference between the two patient groups. No significant difference in the isokinetic peak-torque (PT) ratio was observed among the groups. In the OA and RA patients, the VAS score was not correlated with none of the PTs, while the 6MWD showed a significant association with all PTs. Correlation and regression analyses revealed relationship between the PT measurements and a few RAOS subscales. There was no significant relationship between the PTs and DAS 28 in RA patients. No significant effects the radiological grade with regard to the 6MWD, RAOS subscales, and PTs were found in OA patients. Conclusion: Our study results demonstrated that a higher number of OA and RA patients with lower limb involvement have lower-limb dysfunction, compared to those without any rheumatological disorder. We conclude that the burden of the disease may be similar in OA and RA patients with lower limb involvement, which may have an adverse effect on the functional capacity of the patients. © 2013 Turkish League Against Rheumatism. All rights reserved.

Surgical Correction of Cubitus Varus

Pediatric Supracondylar Humerus Fracture 2020 Review

Cubitus varus can arise from distal humerus fractures in childhood as a result of malunion, nonunion, or overgrowth. Several types of distal humerus osteotomies have been described to treat this deformity, each with its own benefits, drawbacks, and complications. This article details the surgical technique and expected outcomes for 4 of the most commonly used types of distal humerus osteotomies in the treatment of cubitus varus. Specifically, we will describe the techniques for the lateral closing-wedge osteotomy, the step-cut osteotomy and its variations, the dome osteotomy and its variations, and the multiplanar osteotomy.

Cartilage degeneration post-meniscectomy performed for degenerative disease versus trauma: data from the Osteoarthritis Initiative

OAK 3 - Non-arthroplasty tx of OAK

Objective: To compare the extent of cartilage deterioration in knees with prior meniscal resection related to trauma versus knees with resection related to degenerative disease, and to compare cartilage deterioration in knees with meniscal surgery to knees without meniscal surgery, controlling for prior knee trauma. Materials and methods: In this cross-sectional study, we assessed cartilage deterioration in right knees of Osteoarthritis Initiative participants: (i) with meniscal surgery due to injury (n = 79); (ii) matched control knees with a prior injury but without meniscal surgery (n = 79); (iii) with meniscal surgery but without preceding injury (n = 36); and (iv) matched control knees without meniscal surgery or prior knee injury (n = 36). Cartilage composition was measured using T2 measurements derived using semi-automatic cartilage segmentation of the right. Linear regression analysis was used to compare compartmental values of T2 between groups. Results: Comparing the mean T2 values in surgical cases with and without injury our results did not show significant differences (group i vs. iii, p > 0.05). However, knees with previous meniscal surgery showed significantly (p < 0.001) higher mean T2 values across all compartments (i.e., global T2) when compared to those without meniscal surgery for both knees with a history of trauma (group i vs. ii) and knees without prior trauma (group iii vs. iv). Similar results were obtained when analyzing the compartments separately. Conclusions: Cartilage deterioration, assessed by T2, is similar in knees undergoing meniscal surgery after trauma and for degenerative conditions. Both groups demonstrated greater cartilage deterioration than nonsurgical knees, controlling for prior knee injury.

Fractures and dislocations of the elbow

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

The function of the elbow is to position the hand in space. Elbow injuries must be carefully assessed and correctly managed to prevent long-term disability. The neurovascular structures around the elbow are vulnerable to traumatic and iatrogenic injury. The status of these structures must be carefully monitored and further injury due to the improper use of plaster or surgery must be avoided. The elbow is particularly prone to stiffness after injury and early movement should be the goal of most treatment strategies. Movement may be started soon as pain allows for injuries that are not complicated by bony or ligamentous instability. Unstable injuries should be treated surgically to allow early movement. (copyright) 2006 Elsevier Ltd. All rights reserved

[Evaluation of quality of life of female patients after bilateral total knee arthroplasty]

Surgical Management of Osteoarthritis of the Knee CPG

OBJECTIVES: We evaluated the quality of life of female patients following total knee arthroplasty. METHODS: The study included 50 women (mean age 67 years; range 52 to 84 years) who underwent bilateral total knee arthroplasty for primary osteoarthritis of the knee. All the patients were administered the Medical Outcomes Study Short Form-36 (SF-36) and the Knee Society Clinical Rating System (KSCRS) preoperatively and at six weeks, three and six months postoperatively. Particular attention was given to provide patients with sufficient information on surgery and postoperative rehabilitation program. RESULTS: Compared to preoperative scores, all the subscales of both instruments showed significant improvement at six weeks and six months (p<0.05). After six weeks, however, only SF-36 physical function scores continued to improve significantly till the final assessment (p<0.05), whereas the other subscales reflected only maintenance of improvement. Conversely, a consistent significant improvement after six weeks was seen in the pain score of the KSCRS, while the function score representing only maintenance of improvement. CONCLUSION: Significant improvement is achieved in the quality of life of female patients within six weeks after total knee arthroplasty. It appears that, beyond six weeks, this improvement continues to be significant only in the physical function score of the SF-36 and pain score of the KSCRS

Validity of frozen sections for analysis of periprosthetic loosening membranes

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Clinical findings and blood parameters often are inconclusive in patients with periprosthetic joint infections. Among the accepted criteria for diagnosis, histologic analysis of debrided tissue can detect infection in most cases but does not allow intraoperative decision making. We evaluated the validity of intraoperative frozen sections for detection of prosthetic infections. The results from frozen and permanent sections of periprosthetic membranes of 64 consecutive patients who underwent exchange procedures after hip arthroplasty were compared using the histopathologic consensus classification of Morawietz et al. Blood parameters (erythrocyte sedimentation rate, leukocyte count, C-reactive protein) and culture results of preoperatively aspirated joint fluid and intraoperative tissue samples were correlated with the histologic results. In 50 patients (78.1%), agreement was found between the frozen and permanent sections. Two patients (3.1%) revealed a discrepancy between the two histologic methods. In 12 patients (18.8%), a diagnosis was not possible based on the frozen sections because the tissue samples were not representative enough for definite classification. For the analyzable cases (n = 52), the sensitivity of frozen-section histologic analysis was 86.6%, specificity 100%, and accuracy 96.2%. Our data support a recommendation for use of intraoperative frozen sections for diagnosis of septic versus aseptic loosening in revision hip surgery. LEVEL OF EVIDENCE: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence

CECOG experts' recommendations on the use of denosumab in the prevention of skeletal-related events in bone metastases of lung cancer

MSTS 2018 - Femur Mets and MM

Purpose: Skeletal-related events represent a substantial burden for patients with advanced cancer. Randomized, controlled studies suggested superiority of denosumab over zoledronic acid in the prevention of skeletal-related events in metastatic cancer patients, with a favorable safety profile. Experts gathered at the 2012 Skeletal Care Academy in Istanbul to bring forward practical recommendations, based on current evidence, for the use of denosumab in patients with bone metastases of lung cancer. Recommendations: Based on current evidence, use of denosumab in lung cancer patients with confirmed bone metastases is recommended. It is important to note that clinical judgment should take into consideration the patient's general performance status, overall prognosis, and live expectancy. Currently, the adverse event profile reported for denosumab includes hypocalcemia and infrequent occurrence of osteonecrosis of the jaw. Therefore, routine calcium and vitamin D supplementation, along with dental examination prior to denosumab initiation are recommended. There is no evidence for renal function impairment due to denosumab administration. At present, there is no rationale to discourage concomitant use of denosumab and surgery or radiotherapy. © 2013 Springer-Verlag Wien.

Effects of cholinesterase inhibitors on postoperative outcomes of older adults with dementia undergoing hip fracture surgery

Management of Hip Fractures in the Elderly

OBJECTIVES: Cholinesterase inhibitors (ChEIs) may interact with muscle relaxants given during general anesthesia (GA), increasing the risk of postoperative complications. We evaluated the effects of ChEIs on the postoperative outcomes of older adults who underwent hip fracture surgery. DESIGN: Population-based cohort study using linked administrative databases. PARTICIPANTS: All individuals with dementia age 66 years or older, who underwent hip fracture surgery between April 1, 2003, and December 31, 2007, in Ontario, Canada. EXPOSURES: Use of any ChEI (donepezil, rivastigmine, or galantamine) before surgery. OUTCOMES: The primary composite outcome included any of the following: 30-day postoperative mortality; intensive care unit admissions; or in-hospital resuscitation. Secondary outcomes included postoperative respiratory failure and pneumonia. ANALYSIS: We stratified the study sample on the basis of residence (community or long-term care [LTC]) and type of anesthetic (general or regional) to create four residence/anesthesia groups. We used propensity scores to match users and nonusers of ChEIs within the residence/anesthesia strata. We then calculated the relative risks (RR) and 95% confidence intervals (CI) for outcomes associated with ChEIs in the matched groups. RESULTS: A total of 624 pairs of individuals from the community and 725 pairs from LTC were created among individuals who received GA. High rates of postoperative mortality and complications were observed in both ChEI users and nonusers. The RR of the primary outcome associated with ChEI use for individuals receiving GA was 0.88 (95% CI: 0.68-1.16; chi2 = 0.93; df = 1; p = 0.34) and 0.82 (95% CI: 0.63-1.04; chi2 = 2.59; df = 1; p = 0.11) in the community and LTC groups, respectively. In addition, ChEIs were not associated with any significant increased risk of postoperative respiratory complications. CONCLUSIONS: ChEI use was not associated with an increased risk of postoperative complications among older adults with dementia who underwent hip fracture surgery. However, the poor postoperative outcomes overall reinforced the need to prevent fractures and improve outcomes in this population

Local delivery of antimicrobial agents to the oral cavity

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Bacterial infections in the mouth are caused mainly by the normal endogenous flora and are rarely of exogenous origins. The bacteria may play a primary antiological role in disease or be secondary contaminators of disease caused by other pathogenic mechanisms. Antibacterial agents used topically are logical in the management of some of these infections and could be used for prevention or therapy. In both situations a variety of delivery methods has been proposed and can conveniently be classified according to duration of delivery as: short, medium and long-term. Most interest in antibacterial agents has been in the control of plaque-related diseases, particularly chronic gingivitis. Effective compounds show persistence of action for many hours, notably chlorhexidine. Chemical plaque control agents are of limited therapeutic value and are more valuable in the preventive mode. Such agents also are of no value in the treatment of chronic periodontitis unless delivered directly into pockets by irrigation or sustained delivery vehicles. In fact, even by irrigation, antibacterials appear to offer limited action above that of a washing-out effect. Sustained delivery vehicles are relatively numerous, but it is the antibacterial rather than the vehicle which appears important. Most data are available for chlorhexidine, metronidazole and tetracycline, with again chlorhexidine appearing of little value in a therapeutic mode. Despite encouraging results for metronidazole and tetracycline, more data are required demonstrating lasting adjunctive benefits of local antibacterials to conventional mechanical treatments. Despite the logic behind the use of topical antibacterials for oral infections, many prescribed uses are somewhat empirical and more controlled studies are required

Chondrosarcoma of bone: an assessment of outcome

MSTS 2022 - Metastatic Disease of the Humerus

BACKGROUND: The data on 227 patients who had been managed for a chondrosarcoma at one institution were reviewed to determine the nature of the lesions, the predictors of outcome, and whether there were any ways to change the treatment approaches to improve the results. METHODS: The patients were followed for a mean duration of six years (range, three to twenty-five years). The mean age of the patients was forty-seven years (range, nine to eighty-four years). The most prevalent sites of the tumors were the femur (seventy-eight), the pelvis (fifty-one), and the humerus (thirty-nine). The tumors were divided into two groups according to histological grade. Eighty-six tumors (sixteen atypical enchondromas and seventy grade-1 chondrosarcomas) that were locally destructive but were associated with a low likelihood of metastasis were considered to be low-grade. The remaining 141 lesions, which were locally destructive, potentially metastatic, and capable of causing death, were thought to be high-grade. One hundred and three of these 141 lesions were grade 2, and thirty-eight were grade 3 (eighteen of the thirty-eight were grade 3 only, and twenty were both grade 3 and dedifferentiated). Two hundred and twenty-four patients were managed with resection and a limb-sparing procedure; the remaining three patients had an amputation. Postoperative adjuvant radiation was used for fifty-six patients; chemotherapy, for thirty-five; and both radiation and chemotherapy, for nineteen. Flow cytometric patterns were analyzed for 105 patients. RESULTS: The patients who had a high-grade tumor were older than those who had a low-grade tumor (mean age [and standard deviation], 50+/-17.0 years compared with 40+/-15.9 years; p < 0.001). Pathological fracture, metastasis, local recurrence, and death were more prevalent in the group that had a high-grade lesion (p < 0.001). Predictors of metastasis and death in that group of patients included local recurrence, a pelvic location of the tumor, a tumor that was more than 100 cubic centimeters in size, a ploidic abnormality (aneuploidy coupled with a high mean DNA index), a histological grade of 3, and a dedifferentiated type of tumor (p < 0.001). CONCLUSIONS: Although the data are suggestive, with the numbers available for study we could not detect a significant difference in the rates of pulmonary metastasis and death between the patients who had a grade-3 lesion and those who had a grade-3 lesion that was also dedifferentiated. However, the interval between diagnosis and death was 32+/-22.8 months for the patients who had a grade-3 lesion compared with 5+/-3.7 months for those who had a grade-3 lesion that was also dedifferentiated (p < 0.001). Overall, patients who had had a resection with wide margins (margins extending outside the reactive zone) had a longer duration of survival than did those who had had a so-called marginal resection (margins extending outside the tumor but within the reactive zone) or an intralesional resection (margins within the lesion) (p < 0.04). Adjunctive chemotherapy or radiation, or both (which, it must be noted, was used, without a protocol, in a relatively small number of patients), after an intralesional resection, for recurrent disease, or for distant metastasis did not appear to alter the outcome.

The relationship between obesity and the age at which hip and knee replacement is undertaken

Surgical Management of Osteoarthritis of the Knee CPG

We audited the relationship between obesity and the age at which hip and knee replacement was undertaken at our centre. The database was analysed for age, the Oxford hip or knee score and the body mass index (BMI) at the time of surgery. In total, 1369 patients were studied, 1025 treated by hip replacement and 344 by knee replacement. The patients were divided into five groups based on their BMI (normal, overweight, moderately obese, severely obese and morbidly obese). The difference in the mean Oxford score at surgery was not statistically significant between the groups (p > 0.05). For those undergoing hip replacement, the mean age of the morbidly obese patients was ten years less than that of those with a normal BMI. For those treated by knee replacement, the difference was 13 years. The age at surgery fell significantly for those with a BMI > 35 kg/m(2) for both hip and knee replacement (p > 0.05). This association was stronger for patients treated by knee than by hip replacement

Osteoporosis: impact on health and economics

HipFx Supplemental Cost Analysis

Osteoporosis is a major public health problem through associated fragility fractures. The most common sites of fracture are the hip, spine and wrist, and these have an enormous health and economic impact. All fractures result in some degree of morbidity, but fractures at the hip are associated with the worst outcomes. The worldwide direct and indirect annual costs of hip fracture in 1990 were estimated at US$34.8 billion, and are expected to increase substantially over the next 50 years. Fracture incidence varies between populations, and is set to increase over coming decades as the global population becomes more elderly. This effect will be particularly marked in the developing world, which is additionally assuming more-westernized lifestyles that predispose to increased fracture risk. Strategies to target those at high risk of fracture have been developed, but preventative measures at the public health level are also urgently needed to reduce the burden of this devastating disease

Comparison of the pre-shaped anatomical locking plate of 3.5 mm versus 4.5 mm for the treatment of tibial plateau fractures

DOD - Acute Comp Syndrome CPG

Purpose: Treatment of tibial plateau fractures is discussed. A retrospective comparative study of fractures treated with an anatomical locking plate of 4.5 mm or 3.5 mm. Our hypothesis is that the 3.5 mm plates give an equivalent hold of fractures with comparable results and better clinical tolerance. Methods: From May 2010 to October 2011, 18 patients were operated on using a 4.5-mm LCP� anatomical plate (group A) and 20 patients received a3.5-mm LCP� anatomical plate (group B). Groups were comparable. One fracture was open. Results: For the Group A, 14 patients had a follow up of 35.3 months and for the Group B, 16 patients had a follow up of 27 months. Mobility was comparable in both groups. The Hospital for Special Surgery (HSS) score was 86.4 versus 80.6, the Lysholm score was 83.6 versus 77 for groups A and B respectively. Consolidation was 3.25 months versus 3.35 months and mean axis was 183.1° versus 181.6° for groups A and B. Mechanical axes during revision were statistically different to the controlateral axes. One secondary displacement was noted in group A and one secondary displacement in group B. Group A had eight patients reporting discomfort with the material versus three in group B (p < 0.05). Conclusion: The hypothesis is proven. In regards to the results, there is no significant difference between the two groups but the clinical tolerance was better in group B. More time is needed in the long term to better evaluate these severe fractures.

Bone density of the femoral neck following Birmingham hip resurfacing A 2-year prospective study in 27 hips

Management of Hip Fractures in the Elderly

Background Resurfacing is a popular alternative to a standard hip replacement in young arthritic patients. Despite bone preservation around the femoral component, there is little information regarding the bone quality. Patients and methods 32 patients underwent consecutive Birmingham hip resurfacing. The bone density of the femoral neck was measured preoperatively and then at 6 weeks, 3 months, 1 year, and 2 years. The femoral neck was divided into regions of interest. Results were available for 27 hips in 26 patients. Results The overall femoral neck bone density showed a trend towards a decrease at 6 weeks and 3 months but returned to the preoperative level at 1 year, and was maintained at 2 years. The combined superior regions of the neck showed a statistically significant decrease in bone density at 6 weeks and 3 months. This returned to preoperative levels at 1 year and was maintained at 2 years. Interpretation Bone density appears to decrease at 6 weeks and 3 months, suggesting that care is necessary until bone density begins to recover. (copyright) Nordic Orthopedic Federation

Treatment of distal radius fractures

Distal Radius Fractures

BACKGROUND: In light of the Norwegian Orthopaedic Association's wish to prepare guidelines for treatment of distal radius fractures, we have reviewed the knowledge base for the provision of such treatment. METHOD: The paper is based on systematic reviews of treatment of distal radius fractures from literature search in the following databases: the Cochrane Library, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE Cochrane), the Health Technology Assessment (HTA) database, PreMedline, Medline and Embase. RESULTS: There is evidence for recommending percutaneous pinning of unstable, dorsally displaced distal radius fractures rather than conservative treatment, but which pinning method is best remains uncertain. There is also documentation to support the use of external fixation rather than conservative treatment. There is insufficient documentation available to draw conclusions regarding the relative efficacy of the various methods of external fixation, but external fixation in combination with adjuvant pinning of the fracture fragment enhances the result compared to external fixation alone. The evidence indicates that plates may enhance functional short-term results for unstable distal radius fractures compared to external fixation. INTERPRETATION: There is evidence in support of differentiated treatment of distal radius fractures. However, many questions remain unanswered, and good prospective, randomised multi-centre trials are needed.

Does mud pack treatment have any chemical effect? A randomized controlled clinical study

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: The aim of this study was to reveal the efficacy of mud pack treatment in patients with knee osteoarthritis and to find the contribution of chemical factors to the build up of these effects. METHODS: Sixty patients were randomly assigned to directly applied mud pack (study) group or to nylon�covered mud pack (control) group. Thirty patients in the study group had mud application 15 times to both knees: heated mud, up to 43 degrees C, was applied to skin directly for 30 minutes. Thirty patients in the control group had the same treatment as the study group except heated mud was applied over an impermeable nylon pack. Primary outcome measures of the study were the Western Ontario and McMaster Universities (WOMAC) index, pain intensity on a visual analog scale (VAS), patient's assessment of disease severity index, physician's assessment of disease severity index, and analgesic consumption. The patients were evaluated before and after (end of 15th application) the intervention and followed up for 24 weeks at 4�week intervals. The results were assessed on an intent�to�treat basis. RESULTS: As compared to the baseline, significant decreases were observed in WOMAC, pain intensity, disease severity index scores, and analgesic consumption in both groups after the intervention. Observed improvements in the study group were found to be superior to the control during the whole postintervention follow�up, except for analgesic consumption in the third week. A significant number of patients in the study group showed minimal clinically important improvement as compared to the control group. CONCLUSION: Mud pack treatment significantly improved the pain and functional status of patients with knee osteoarthritis, whether applied directly or coated with nylon. Direct application was found to be superior, which implies chemical properties of the mud contribute to the build up of therapeutic effect.

The apoptosis of osteoblasts and osteocytes in femoral head osteonecrosis: its specificity and its distribution

AAHKS (2) Corticosteroids

The pathogenesis of nontraumatic osteonecrosis (ON) remains unclear. Some studies have suggested that nontraumatic ON is attributed to increased osteocytic apoptosis. To test this hypothesis, a controlled study must compare the apoptosis of osteocytes and osteoblasts in cases of ON and osteoarthritis (OA). To assess either the localized or diffuse patterns of this increased osteocytic and osteoblastic apoptosis, we evaluated both the proximal and distal regions of necrotic areas. Femoral heads resected for total hip prosthesis were included for this study. Of these, 10 were ON cases-three were induced by corticosteroids, three by alcohol abuse, one resulted from trauma, one resulted from hyperlipemia, and two were idiopathic-10 were osteoarthritis cases, and 1 from a patient suffering from a subcapital fracture. The TUNEL reaction was used to detect the apoptosis in osteoblasts and osteocytes. A semi-quantitative evaluation was conducted, at both distal and proximal areas relative to the lesions, specifically in the area surrounding the necrotic region in the osteonecrosis cases, in the eburnated bone in the osteoarthritis cases, and in the subchondral bone fracture. The apoptosis of osteoblasts and osteocytes was statistically more frequent in the regions close to the necrotic areas in the ON group. No difference was found in the unpaired areas. In the ON group, no difference was found in terms of the etiological factors. During ON, the apoptosis of osteocytes and osteoblasts is increased proximally to the necrotic regions in the patients presenting with osteoarthritis and subcapital fractures. This increase was found not only in the corticosteroid-induced ON cases but also in the idiopathic and alcohol abuse- and trauma-induced ON cases.

Percutaneous iliosacral screw fixation: early treatment for unstable posterior pelvic ring disruptions

DoD SSI (Surgical Site Infections)

OBJECTIVE: Open reduction and internal fixation of unstable posterior pelvic ring injury provides better bony stability and less long term morbidity than nonoperative treatment. However, open reduction and internal fixation of the posterior pelvis may involve substantial intraoperative blood loss, reported infection rates of 6 to 25%, and wound complications in 25%. Our hypothesis was that percutaneous cannulated iliosacral screws placed by fluoroscopic control would provide early, rapid, definitive stabilization with minimal blood loss, infection, and wound complications. DESIGN: A retrospective medical record and radiographic study. MATERIALS, METHODS, MEASUREMENTS AND MAIN RESULTS: Twenty consecutive patients with an unstable posterior pelvic ring injury treated by percutaneous fixation (41 screws) under fluoroscopic guidance were reviewed. Average patient age was 34 years, trauma score was 14.4 +/- 3.3, and Injury Severity Score was 22.9 +/- 10.6. Mechanisms were motor vehicle collisions (11), falls (3), crush injury (3), and pedestrian/auto (3). Pelvic injuries were classified as Tile B (5) or Tile C (15). Associated injuries were present in 80%. Seventy-five percent of patients underwent pelvic fixation less than 72 hours after injury with closed percutaneous screw placement achieved in 60%, assisted by open reduction in 25% or aided by anterior external fixation in 15%. Mean operative time was 52 minutes for patients requiring percutaneous screws only (7 of 20 patients, 35%), whereas average blood loss was 233 mL for all cases (including open anterior and posterior procedures). No loss of fixation or wound complications occurred during 9.6 months follow-up. CONCLUSIONS: Percutaneous iliosacral screw fixation for unstable posterior pelvic disruption provided early fixation with minimal operative time, minimal blood loss, and wound-related morbidity.

One-Stage Combined Postbariatric Surgery: A Series of 248 Procedures in 55 Cases

Panniculectomy & Abdominoplasty CPG

INTRODUCTION: Combined and/or multistage operations often are needed in postbariatric surgery. AIM: With this retrospective study of a series of 55 cases, we aim to determine the effectiveness and safety of one-stage combined postbariatric surgery. MATERIALS AND METHODS: A total of 248 postbariatric procedures were performed in one session (except one-staged gynecomastia case) in 55 patients. The procedures included face and neck lifting, upper and lower trunk lifting, gluteal fat injection, mammoplasty, gynecomastia correction, abdominoplasty, and thigh and arm lifting. Sagged tissues of the trunk and extremities were removed by avulsing after tumescent liposuction. Liposuction was performed also on the neighboring tissues. Multilayer repair from superficial fascia to the skin was carried out after meticulous hemostasis and suction drain insertion. RESULTS: At least two plastic surgeons and two assistants entered the operations; operation time never exceeded 4.5 h except in one, and blood transfusion was needed only in one case. All patients were discharged from the hospital after 1 or 2 nights. Postoperative problems included infection (3.64% of the patients), delayed wound healing after seroma formation (32.73%), abnormal scar formation (1.82%), and demanded scar revision and revisionary liposuction by 10 patients (18.18%). CONCLUSION: Combined postbariatric operations are very effective and the likelihood of serious complications could be decreased significantly when performed under certain conditions. The tumescent dermolipectomy method is a very useful method for these cases. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effects of Concomitant Methotrexate on Large Joint Replacement in Patients with Rheumatoid Arthritis Treated with Tumor Necrosis Factor Inhibitors: A Multicenter Retrospective Cohort Study in Japan

AAHKS (2) Corticosteroids

Objective To determine the effects of concomitant methotrexate (MTX) on the incidence of large joint replacement resulting from the progression of large joint destruction in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor (TNF) inhibitors. Methods A retrospective cohort study was performed using a multicenter registry. In total, 803 patients with RA who received etanercept or adalimumab were included. The first large joint replacement during treatment with etanercept or adalimumab was used as the outcome variable in predictive analyses. The cumulative incidence of large joint replacement was estimated using Kaplan-Meier curves, and the impact of concomitant MTX on the incidence of large joint replacement was assessed with Cox proportional hazards models. Propensity score matching was used to reduce selection bias. Results Of all patients, 601 (75%) received concomitant MTX at a median dosage of 8 mg/week (interquartile range 6-8). A total of 49 patients (62 joints) underwent large joint replacement during treatment with etanercept or adalimumab. The incidence of large joint replacement for patients with concomitant MTX was significantly lower than that for patients without MTX (P < 0.001). Multivariate analysis revealed that concomitant MTX independently predicted large joint replacement (hazard ratio 0.36, 95% confidence interval 0.20-0.65). Additionally, propensity score-matched analysis demonstrated that patients with concomitant MTX had a significantly lower incidence of large joint replacement than those without concomitant MTX (P = 0.032). Conclusion Concomitant MTX reduces the incidence of large joint replacement in patients with RA treated with TNF inhibitors.

Late presentation of fractures of the lateral condyle of the humerus in children

Pediatric Supracondylar Humerus Fracture 2020 Review

BACKGROUND: The current controversy regarding the management of fractures of the lateral condyle of the humerus presenting between 3 to 12 weeks prompted us to evaluate our results of open reduction and internal fixation of such fractures. PATIENTS AND METHODS: Twenty-one patients operated between March 1995 and February 2001 qualified for this study. Five patients presented between 3-4 weeks, nine between 5-8 weeks and seven between 9-12 weeks post injury. Ten fractures were classified as stage II and eleven as stage III (Jacob et al. criteria). The mean age was 8 years (range: 4-14 years). All patients underwent surgery (open reduction and internal fixation with K-wires/screw, with or without bone grafting). The results were assessed by the modified criteria of Agarwal et al. after an average follow-up of 2.3 years. RESULTS: Excellent to good results were observed in all the five patients presenting at 3-4 weeks post injury. In the patients presenting at 5-8 weeks, the results were excellent in one, good in four, fair in three, and poor in one patient. The fracture united in all cases; however, malunion was observed in four patients. The fractures that were operated at 9-12 weeks showed good results in one case, fair result in three cases, and poor result in three cases. Avascular necrosis of the lateral condyle in one patient, premature fusion in two patients, pin tract infection in three patients, and gross restriction of elbow movements in three patients were the major complications in this group. Accurate reduction was difficult as a result of new bone formation and remodeling at the fracture surfaces. Multiple incisions over the common extensor aponeurosis and bone graft supplementation were helpful for achieving acceptable reduction. CONCLUSION: Open reduction and internal fixation is recommended in all cases of displaced fractures of the lateral condyle of the humerus presenting at up to 12 weeks post injury. However, the results become poorer with increase in duration after injury and the grade of displacement. To avoid complications it is important to carry out careful dissection of the soft tissue attachments and to mobilize the fragment without the use of force.

Dietary protein intake and upper leg muscle strength in subjects with knee osteoarthritis: data from the osteoarthritis initiative

OAK 3 - Non-arthroplasty tx of OAK

The aims of this study were (1) to describe dietary protein intake, and (2) to evaluate the association between dietary protein intake and upper leg muscle strength in subjects with knee osteoarthritis (OA). Baseline data from the OA was used, in a cross-sectional study. All subjects were diagnosed with symptomatic and radiographic knee OA. Daily dietary protein intake was measured with the Block Brief 2000 food frequency questionnaire (g/kg body weight). The sum of knee flexion and extension strength of the index knee (N/kg bodyweight) was assessed with the Good Strength chair test. Linear regression analysis was used to test the association between dietary protein intake and muscle strength, adjusting for relevant confounders. Data from 1316 subjects (mean age 61.4 +/- SD 9.1 years, 57.0% female) were used. The mean daily protein intake was 0.72 +/- SD 0.30 g/kg bodyweight, and 65.1% of the subjects had a protein intake lower than the recommended daily allowance of 0.8 g/kg bodyweight. The mean muscle strength was 5.4 +/- SD 2.1 N/kg bodyweight. Lower protein intake was significantly associated with lower muscle strength (B = 0.583, 95% CI 0.230-0.936, p = 0.001). The majority of the subjects with knee OA had a dietary protein intake lower than the recommended daily allowance. Lower protein intake was associated with lower upper leg muscle strength. Longitudinal observational and interventional studies are needed to establish whether dietary protein intake has a causal effect on muscle strength in subjects with knee OA.

Intramedullary nail versus volar locking plate fixation for the treatment of extra-articular or simple intra-articular distal radius fractures: systematic review and meta-analysis

Distal Radius Fractures

AIMS: This study aims to compare the outcomes of intramedullary nail (IMN) and volar locking plate (VLP) fixation for treatment of extra-articular or simple intra-articular distal radius fractures. METHODS: PubMed, Embase, Medline and Cochrane Collaboration Central databases were searched for studies that compared the results of IMN and VLP fixation for the treatment of distal radius fractures up to March 2016. Stata 11.0 was used to perform the meta-analysis. RESULTS: Six randomized controlled trials (RCT) and two retrospective studies were included in this review, including 463 patients. No significant differences were found between two treatment methods in terms of any functional score, radiographic parameters and motion range in the late post-operative period (6, 12 and 24 months). However, IMN did better than VLP at the post-operative six weeks and three months, no matter which functional scoring system was used. The incidence of carpal tunnel syndrome (CTS) was 8.7% in the VLP group, significantly higher than that (0.8%) in the IMN group (OR, 0.183; 95%CI, 0.045-0.74). But for other complications, such as infection (OR, 0.449; 95%CI, 0.095-2.114), tendious damage (OR, 0.931; 95%CI, 0.238-3.648), tenosynovitis (OR, 0.806; 95%CI, 0.209-3.108), algodystrophy (pain) (OR, 0.795; 95%CI, 0.291-2.173) and radial nerve paraesthesia (OR, 1.8143; 95%CI, 0.834-3.942), no significant differences were found (P > 0.05). CONCLUSIONS: Compared to VLP, IMN could provide better early postoperative functional outcomes and reduce the incidence of carpal tunnel syndrome, which could be of particular help in restoring confidence for workers with specialized manual skills to return to their prior jobs. Additionally, the conclusion should be cautiously treated, because it was reached in the context of limited amount of studies and relatively small sample size. Therefore, future studies with good design and large samples are required to verify this conclusion.

American Society of Clinical Oncology 2007 clinical practice guideline update on the role of bisphosphonates in multiple myeloma

MSTS 2018 - Femur Mets and MM

PURPOSE: To update the recommendations for the use of bisphosphonates in the prevention and treatment of bone disease in multiple myeloma. The Update Committee expanded the guideline to include a discussion of osteonecrosis of the jaw (ONJ). METHODS: For the 2007 update, an Update Committee composed of members from the full panel completed a review and analysis of data published since 2002. Searches of Medline and the Cochrane Collaboration Library databases were performed. RECOMMENDATIONS: For multiple myeloma patients who have, on plain radiograph(s) or imaging studies, lytic destruction of bone or spine compression fracture from osteopenia, intravenous pamidronate 90 mg delivered over at least 2 hours or zoledronic acid 4 mg delivered over at least 15 minutes every 3 to 4 weeks is recommended. Clodronate is an alternative bisphosphonate approved worldwide, except in the United States, for oral or intravenous administration. New dosing guidelines for patients with pre-existing renal impairment were added to the zoledronic acid package insert. Although no similar dosing guidelines are available for pamidronate, the Update Committee recommends that clinicians consider reducing the initial pamidronate dose in patients with pre-existing renal impairment. Zoledronic acid has not been studied in patients with severe renal impairment and is not recommended in this setting. The Update Committee suggests that bisphosphonate treatment continue for a period of 2 years. At 2 years, physicians should seriously consider discontinuing bisphosphonates in patients with responsive or stable disease, but further use is at the discretion of the treating physician. The Update Committee also discusses measures regarding ONJ.

Surgical techniques and radiological findings of meniscus allograft transplantation

OAK 3 - Non-arthroplasty tx of OAK

Meniscus allograft transplantation has been performed over the past 25 years to relieve knee pain and improve knee function in patients with an irreparable meniscus injury. The efficacy and safety of meniscus allograft transplantation have been established in numerous experimental and clinical researches. However, there is a lack of reviews to aid radiologists who are routinely interpreting images and evaluating the outcome of the procedures, and also meniscus allograft transplantation is not widely performed in most hospitals. This review focuses on the indications of the procedure, the different surgical techniques used for meniscus allograft transplantation according to the involvement of the lateral and medial meniscus, and the associated procedures. The postoperative radiological findings and surgical complications of the meniscus allograft transplantation are also described in detail.

Bone Mineral Density Discordance and Exploration of One of its Causes

Management of Hip Fractures in the Elderly

Discordances between hip and spine areal density T-score values are common and incompletely understood. In a cohort of 1157 postmenopausal women, discordances of greater than 10% occurred in 91%, with spine bone mineral density (BMD) T-scores significantly less negative than femoral neck (FN) T-scores (p< 0.001). However, when T-scores based on bone mineral content (BMC) rather than BMD were used, the mean discordance was not significantly different from 0. This was largely because BMC at the FN had seemingly declined with age less rapidly than had BMD at that site. This can be explained by age-related areal expansion at the hip, which would be missed in the reported BMD output. One consequence is that if BMC-based T-scores are used to classify patients, substantially fewer individuals would have been judged osteoporotic in this cohort (two-thirds fewer for spine and three-fourths fewer for hip). (copyright) 2011 The International Society for Clinical Densitometry

Attitudes of adolescents about cosmetic surgery

Panniculectomy & Abdominoplasty CPG

Although the number of teenagers choosing to have cosmetic procedures is increasing at a rapid rate, few studies have been published describing their attitudes about aesthetic surgery. To understand better their beliefs about cosmetic surgery, voluntary, confidential surveys were sent to the entire junior class of a suburban high school. Although two thirds of the respondents knew someone who had undergone cosmetic surgery, only one third would choose it for themselves. Those who desired aesthetic surgery described people who have cosmetic procedures as "motivated," whereas those who would not choose this option believed individuals who do so are "vain." The most desired procedures were liposuction, rhinoplasty, and breast augmentation. The main reasons for not proceeding were health risks, cost, and fear of a bad result. The most common source of information about plastic surgery among the students was teen magazines and television.

Identification of factors associated with the development of knee osteoarthritis in a young to middle-aged cohort of patients with knee complaints

OAK 3 - Non-arthroplasty tx of OAK

The objective of this study was to identify risk factors for knee osteoarthritis (OA) development in a young to middle-aged population with sub-acute knee complaints. This, in order to define high risk patients who may benefit from early preventive or future disease modifying therapies. Knee OA development visible on radiographs and MR in 319 patients (mean age 41.5 years) 10 years after sub-acute knee complaints and subjective knee function (KOOS score) was studied. Associations between OA development and age, gender, activity level, BMI, meniscal or anterior cruciate ligament (ACL) lesions, OA in first-degree relatives and radiographic hand OA were determined using multivariable logistic regression analysis. OA on radiographs and MR in the TFC is associated with increased age (OR: 1.10, 95 % 1.04â??1.16 and OR: 1.07, 95 % 1.02â??1.13). TFC OA on radiographs only is associated with ACL and/or meniscal lesions (OR: 5.01, 95 % 2.14â??11.73), presence of hand OA (OR: 4.69, 95 % 1.35â??16.32) and higher Tegner activity scores at baseline before the complaints (OR: 1.20, 95 % 1.01â??1.43). The presence of OA in the TFC diagnosed only on MRI is associated with a family history of OA (OR: 2.44, 95 % 1.18â??5.06) and a higher BMI (OR: 1.13, 95 % 1.04â??1.23). OA in the PFC diagnosed on both radiographs and MR is associated with an increased age (OR: 1.06, 95 % 1.02â??1.12 and OR: 1.05, 95 % 1.00â??1.09). PFC OA diagnosed on radiographs only is associated with a higher BMI (OR: 1.12, 95 % 1.02â??1.22). The presence of OA in the PFC diagnosed on MR only is associated with the presence of hand OA (OR: 3.39, 95 % 1.10â??10.50). Compared to normal reference values, the study population had significantly lower KOOS scores in the different subscales. These results show that knee OA development in young to middle aged patients with a history of sub-acute knee complaints is associated with the presence of known risk factors for knee OA. OA is already visible on radiographs and MRI after 10 years. These high risk patients may benefit from adequate OA management early in life.

Therapeutic strategy of nephrotic syndrome in patients over eighty

Management of Hip Fractures in the Elderly

In the present paper, we report four very elderly patients (80 years of age or older) with primary nephrotic syndrome. In all patients, oral prednisolone (PSL) alternative day therapy was attempted and three patients responded very well (complete remission 2, partial remission 1). However, one patient exhibited no effect of PSL and died from acute oliguric renal failure in spite of aggressive measures including hemodialysis. Fracture of the femoral neck occurred in one patient during PSL therapy, although the relationship between the fracture and PSL therapy was uncertain. In addition to our reported cases, 5 cases of nephrotic syndrome in similar patients reported elsewhere are analyzed together with our cohort. PSL was commonly effective in inducing remission in very elderly patients (7 of 9 patients; 78%). Very elderly patients with nephrotic syndrome frequently suffer from oliguric renal failure, which has a potentially high mortality. Based on these data, we conclude that PSL therapy can ameliorate primary nephrotic syndrome in patients over the age of eighty years. However, the complications both of the disease and its treatment, (e.g., acute oliguric renal failure, hip fracture) must be carefully monitored

Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal, single-dose spinal or general anaesthesia

Management of Hip Fractures in the Elderly

Quantitative assessment of myocardial ischaemia during incremental spinal, single-dose spinal and general anaesthesia may provide guidelines for the choice of anaesthetic technique for osteosynthesis of hip fractures in the elderly atherosclerotic individual. Forty-three patients with coronary artery disease were allocated to receive either incremental spinal anaesthesia (bupivacaine 0.5% plain) (A), single-dose spinal anaesthesia (2.5 mL of bupivacaine 0.5% plain) (B) or general anaesthesia (fentanyl, thiopentone, atracurium, enflurane, N2O/O2) (C) for hip surgery. ST segment monitoring was performed from the induction of anaesthesia and for the following 48 h, and perioperative hypotension, blood loss and fluid therapy were recorded. ST depression developed in two out of 14 (A), seven out of 15 (B) and six out of 14 (C) patients (P = 0.14). In (A), a total of seven ST depressions occurred in the observation period as opposed to 125 in (B) and 16 in (C) (P < 0.05). Intra-operative ST depression only occurred in (B). Three (A), 33 (B) and 40 (C) hypotensive events were recorded (P < 0.002). Altogether, 56% of hypotensive patients developed ST depression compared with 10% of normotensive patients (P < 0.003). In (A), 1.6 mL of 0.5% bupivacaine were used as opposed to the fixed 2.5 mL dose in (B) (P < 0.001). In the first post-operative week, mortality was higher in (B) (P < 0.05) but, after 1 month, there was no significant difference in mortality between the three groups. The incidence of hypotension and myocardial ischaemia was lowest in the group receiving incremental spinal anaesthesia

Threading the femoral catheter through the stimulating needle tip: Comparison between bevel up and down positions

Surgical Management of Osteoarthritis of the Knee CPG

Background and Goal of Study: To determine whether threading a femoral catheter past a needle tip with the bevel down (facing the femoral nerve perineural space) ensures more solid and effective analgesia than with the bevel up (customary needle position) af ter total knee prosthesis in the first 48 hours. Materials and Methods: This was a prospective and randomized controlled trial. Forty patients undergoing total knee prosthesis were studied. Af ter ultrasound visualization of femoral nerve and local anaesthesia of the skin, a 5 cm stimulating needle was introduced 2 cm under the level of the inguinal crease at a 45(degrees) degree angle. Af ter patellar twitch was achieved at the lowest intensity stimulation (0.3 - 0.5 mA), the needle was immobilized. Five ml of ropivacaine 0.5% was injected through the needle, then the catheter was inserted with the bevel up (group I, n = 20) or down (group II, n = 20) to a length of 5 cm. Ipsilateral sciatic nerve block was placed with a single shot 20 ml of ropivacaine 0.5%. General anaesthesia was induced. Catheter position was confirmed by dye injection and x-ray in the recovery room before starting 0.2% ropivacaine 6 ml/h continuous infusion. Morphine consumption via patient controlled analgesia system and VAS scores were recorded at equal time intervals in the first 48 hours. Results and Discussion: No difference of ease between threading of the catheter to a length of 5 cm with the bevel up or down was noted. All catheters had a cephalic course. Catheter opacification showed that in group II, only 3 catheters were incorrectly situated versus 7 in group I. Analgesia was satisfactory (VAS (less-than or equal to) 3) with 17 patients in group II and 14 in group I. Morphine consumption in group II was 8 (plus or minus) 4 mg /24h versus 17 (plus or minus) 3 mg /24h in group I. Pain control during knee mobilization with continuous movement device was adequate in 18 patients in group II and 16 in group I. Some discrepancy occurred in 2 cases where the analgesia was adequate with the catheter in poor position. Conclusion(s): Femoral catheter placement through the stimulating needle with the bevel down ensures a better catheter position on the nerve progression plane among the perineural structures and is an effective method for providing satisfactory postoperative analgesia for patients af ter total knee replacement

Evaluation and quantification of geographical differences in wound complication rates following the extended lateral approach in displaced intra-articular calcaneal fractures - A systematic review of the literature

DoD SSI (Surgical Site Infections)

INTRODUCTION: Calcaneal fracture surgery is often performed via the extended lateral approach (ELA). Large differences are reported in literature on wound complication rates. Aim was to perform a systematic review on reported postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following the ELA and evaluate and quantify geographical differences. METHODS: A literature search was conducted in the MEDLINE and EMBASE databases and Cochrane Library. Studies before 2000, with <10 patients, biomechanical studies and reviews were excluded. No restrictions regarding language were applied. RESULTS: 3068 articles were identified of which 123 were included, with 8584 calcaneal fractures in 28 different countries. The average total number of POWC was 14.3%, with 3.8% of superficial and 2.2% of deep infections. The highest POWI rate was found in Europe (12.1%) and the lowest in North America (2.8%). A significant difference in incidence of deep POWI between continents was detected (median 0-3.8%). No differences were found in incidence of POWC and POWI between retro- and prospective studies (respectively p=0.970, p=0.748) or studies with <10 or >=10 operations per year (respectively p=0.326, p=0.378). However, lower rates of POWI were found in studies with a follow up of >3months (p=0.01). CONCLUSION: Large differences were detected in incidence of POWC and POWI following calcaneal fracture surgery with the ELA between countries and continents. We did not find a lower POWC or POWI rate in retrospective studies compared to prospective studies, larger studies or in studies in which more patients were treated annually. However, the rate of POWI was significantly lower in studies with a follow up of >3months. We advise the use of a reliable postoperative complication registration system and uniformity in the use of standardized definitions of wound complications for calcaneal fracture surgery.

Gene expression pattern of synovial cells from inflammatory and normal areas of osteoarthritis synovial membrane

Surgical Management of Osteoarthritis of the Knee CPG

Objective: The aim of this study was to compare the gene expression pattern of synovial cells from inflammatory (I) or normal/reactive (N/R) areas of a synovial membrane harvested from the same osteoarthritis (OA) patient. Methods: Synovial tissues were obtained from 12 knee OA patients at the time of total knee replacement. The inflammatory status of the synovial membrane was characterized according to macroscopic criteria and sorted as N/R and I. Biopsies were cultured separately for 7 days. Microarray gene expression profiling between N/R and I areas was performed. Western blot and immunohistochemistry confirmed the identified genes that were differentially expressed. Results: 896 differentially expressed genes between N/R and I zones were identified. The key pathways were related to inflammation, cartilage metabolism, Wnt signaling and angiogenesis. In the inflammatory network, TREM1 and S100A9 were strongly up-regulated. MMP-3 and -9, cathepsin H and S were significantly up-regulated in the cartilage catabolism pathway, whereas the most up-regulated anabolism enzyme was HAS1. Wnt-5A and LRP5 were up-regulated whereas FZD2 and DKK3 were down-regulated in the Wnt signaling. Finally, STC1, a protein involved in angiogenesis was identified as the most up-regulated gene in I zones compared to N/R zones. Conclusion: This study is the first to identify different expression pattern between two areas of the synovial membrane in the same patient. These differences concern several key pathways involved in OA pathogenesis. This analysis also provides information regarding new genes and proteins as potential targets for the future therapeutic. (c) 2013 American College of Rheumatology

Relative contributions of bone density, bone turnover, and clinical risk factors to long-term fracture prediction

Management of Hip Fractures in the Elderly

Long-term fracture prediction using bone mineral density remains controversial, as does the additional contribution from assessing bone turnover or clinical risk factors. We measured bone mineral density at various sites, along with biochemical markers of bone turnover, sex steroid levels, and over 100 clinical variables, at baseline on an age-stratified sample of 304 Rochester, MN women in 1980. The 225 postmenopausal women were subsequently followed for 3146 person-years (median, 16.2 years per subject), wherein they experienced 302 new fractures: 81% resulted from minimal or moderate trauma and 60% of these involved the proximal femur, thoracic or lumbar vertebrae, or distal forearm. Accounting for multiple fractures per subject, these osteoporotic fractures together were best predicted by baseline femoral neck bone mineral density (age-adjusted hazard ratio [HR] per SD decrease, 1.37; 95% CI, 1.10-1.70); 19 moderate trauma forearm fractures were best predicted by distal radius bone mineral content, whereas 28 hip fractures and 100 vertebral fractures were best predicted by femoral neck bone mineral density. Femoral neck bone mineral density performed comparably in predicting osteoporotic fracture risk within the first decade of follow-up (HR, 1.38; 95% CI, 1.10-1.74) as well as more than 10 years after baseline (HR, 1.39; 95% CI, 1.05-1.84). The older biochemical markers were not associated with fractures, but serum "free" estradiol index was independently predictive of short- and long-term fracture risk. Consistent clinical risk factors were not identified, but statistical power was limited. Identifying patients at increased long-term risk of fracture is challenging, but it is reassuring that femoral neck bone mineral density can predict osteoporotic fractures up to 20 years later

Visual concerns that interfere with daily activities in patients on rehabilitation units: a descriptive study

Upper Eyelid and Brow Surgery

The purpose of this study was to estimate the prevalence of patients with visual concerns that interfere with their activities of daily living (ADL) performance in physical rehabilitation units through occupational therapy assessment. Over the two-month study period, 215 adult inpatients from a physical rehabilitation hospital were evaluated using the Brief Vision Screen (BVS) through ADL. The BVS assessed four areas of visual concerns, namely left visual field, focusing, and near- and low-contrast acuity, while patients engaged in ADL. The occupational therapists identified 33% of patients who had at least one area of visual concern, with the largest proportion diagnosed with stroke (55%), followed by pulmonary disease (40%) and joint replacement (35%). When comparing the four areas of visual concerns in the BVS between the two major diagnostic groups (acquired brain injury, ABI and non-acquired brain injury, non-ABI), a significantly higher proportion of patients with ABI were identified as having left hemianopsia concerns compared to patients with non-ABI. No significant difference was observed in other areas of visual concern between the two groups. Findings indicated that visual concerns that interfere with ADL performance among older patients in rehabilitation units are common. The high proportion of patients with pulmonary disease identified as having visual concerns warranted further confirmation and investigation. Preliminary evidence to support the psychometric properties of the BVS for identifying visual concerns in patients on rehabilitation units was established.

Quality of hip and knee osteoarthritis management in primary health care in a Norwegian county: a cross-sectional survey

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Osteoarthritis (OA) is one of the most common causes of pain and disability in the adult population. Several studies have documented discordance between general practioners (GP) practice and management recommendations, but there is limited published information about patient reported experience of quality of care. The primary aim of this study was to assess the patient perceived quality of OA management in primary health care. Secondly, we wanted to explore the factors associated with the perceived quality of OA care. METHODS: A cross-sectional survey in six general practices in the county of Nord-Trondelag in Norway, patients with radiologically diagnosed OA, according to ICPC codes L89, L90 or L91 or clinical signs and symptoms corresponding to OA in the hip or knee and patient-reported quality of OA care on the 17-item OsteoArthritis Quality Indicator questionnaire (OA-QI). OA-QI summary pass rates were calculated, in which the numerator represents the number with indicators passed and the denominator represents the total number of eligible persons. Associations with summary pass rates were explored with demographic, disease related and health care related factors as independent variables. RESULTS: A total of 119 patients were included (response rate 42%). The median summary QI pass rate for all 17 QIs was 47% (Inter Quartile Range 33-65%), but there were large variation between the different items. The referral for weight reduction had the lowest pass rate (8%), whereas the highest pass rate was having received information about the importance of physical activity and exercise (84%). The median summary QI pass rates for both non-pharmacological- (QIs 1-11) and pharmacological (QIs 13-16) treatments were 50% (IQR 25-75). In bivariate regression analyses, only overall treatment satisfaction was significantly associated with QI pass rate (p = 0.001), with unstandardized beta = 6.1 (95% CI 2.7 to 9.5), i.e. a one-point increase on the five-point satisfaction scale was associated with a 6% increase in pass rate. CONCLUSION: Considering that the median summary QI pass rate was 47%, there might be room for improvement in OA care. Advice and the referral of OA patients in need of weight reduction seem to have the greatest potential for improvement.

Paediatric supracondylar fractures: An overview of current management and guide to open approaches

DOD - Acute Comp Syndrome CPG

Supracondylar fractures of the humerus are common fractures in children. Closed reduction and percutaneous pinning is the primary method of management, though 2-12% of these fractures require open reduction. There is no conclusive evidence to dictate the best surgical approach to the fracture. This paper aims to review supracondylar fractures of the humerus and discusses the early and late associated complications. The treatment options are then examined, with a focus on the preferred surgical approach to open reduction. If an orthopaedic surgeon is going to learn only one approach for reduction of these challenging fractures, then we recommend becoming familiar with the anterior approach. This is the approach one would need to use in most open fractures and in those where exploration of the brachial artery is indicated. It gives access to the neurovascular structures, to the fracture site and also to the soft tissues that are likely to block reduction. The cosmetic and functional outcomes are reported to be good. © 2013 Elsevier Ltd.

Changes in epidemiology of osteoporotic fractures

Management of Hip Fractures in the Elderly

Osteoporosis constitutes a major public health problem through its association with age related fractures. These fractures typically occur at the hip, spine and distal forearm. It has been estimated from incidence rates derived in North America that the lifetime risk of a hip fracture in Caucasian women is 17.5%, with a comparable risk in men of 6%. Age and sexadjusted hip fracture rates are generally higher in Caucasian than in Asian populations. Furthermore, the pronounced female preponderance in fracture incidence observed in white populations is not seen amongst blacks or Asians in whom ageadjusted female to male incidence ratios approximate unity. Life expectancy is increasing around the globe and the number of elderly individuals is rising in every geographic region. Assuming constant age-specific incidence rates for fracture, the number of hip fractures occurring worldwide among people aged 65 years and over will rise from 1.66 million in 1990 to 6.26 million in 2050. Studies performed in the United States, Scandinavia, and the United Kingdom, between 1930 and the late 1980s, consistently reported increases in the age-adjusted incidence of hip fractures among men and women. This increase appears to have levelled off, in the northern regions of the United States, as well as more recently in Europe. Rates in Asian populations continue to show substantial rises between the 1960s and the present time. In the most recent data available from the United States, the incidence of first ever hip fracture declined by 1.37% per year among women and 0.06% per year amongmen. The cumulative incidence of a second hip fracture after 10 years was 11% among women and 6% among men, when death was treated as a competing risk. The reduction in hip fracture occurrence was even greater than that expected from the declining incidence of hip fractures more generally. Age-period-cohort models have suggested influences of all three contributors to these secular trends. Among current risk factors for low bone density and trauma (low body mass index, cigarette smoking, alcohol consumption, physical inactivity and dietary calcium intake) the trends are best explained by physical inactivity. Developmental contributors to peak bone and muscle mass, for example maternal nutrition and lifestyle, also appear capable of contributing to cohort effects. Finally, debate continues on the role of more aggressive osteoporosis risk assessment and therapeutic strategies in contributing to the secular decline in hip fracture rates generally. Although pharmacologic intervention might be efficacious, only a minority of hip fracture patients remain so treated, and the scope for even greater reductions in incidence remains an enticing prospect

Tensioned reverse abdominoplasty

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Deformities of the upper portion of the abdominal wall can be difficult to solve, as in many cases abdominoplasties or mini-abdominoplasties lead to unsatisfactory results. Direct approaches to this region through inframammary incisions can be a good therapeutic option, once adequate patient selection has been performed and certain surgical principles are followed. METHODS: This technique should be primarily indicated for patients complaining of skin laxity predominantly in the upper abdomen and for patients who will have such excess after liposuction. In patients who require resection of a large amount of tissue, a single, broad, U-shaped dissection should be used, associated with midline fascia plication, when required (group 1). In patients with a smaller amount of tissue to be resected, two oblique tunnels can be made toward the navel, with no incision unification at the midline, to provide less evident scars (group 2). RESULTS: Eighteen procedures were performed: 12 in group 1 and six in group 2. Patients and surgeons were satisfied with the results. Only minor complications occurred, and they did not result in definitive sequelae. CONCLUSIONS: The principle of progressive tension suture, previously utilized in conventional abdominoplasties, is now originally employed in reverse abdominoplasties as a continuous suture, enabling proper flap positioning, keeping the inframammary sulcus at its original position, and preventing tension on the resulting scar. Tensioned reverse abdominoplasty is an easily applicable technique that provides good results and should be considered in cases of abdominal laxity predominantly in the upper abdomen.

Radiographic knee osteoarthritis impacts multiple dimensions of health-related quality of life: Data from the Osteoarthritis Initiative

OAK 3 - Non-arthroplasty tx of OAK

Objectives. To estimate the multi-dimensional health impact of radiographic knee OA and quantify the overall health-related quality of life (HRQoL) burden, using a preference-based health utilities measure. Methods. Data on self-reported HRQoL, measured using the SF-12 multi-dimensional health state instrument, were obtained for 2895 patients with radiographic knee OA (Kellgren-Lawrence grade of at least 2) from the Osteoarthritis Initiative and for a general population sample of 3202 from the National Health Measurement Study. The SF-12 was converted to the six-dimensional SF-6D classification to compute preference-based health utilities. Generalized ordinal regression and multinomial regression were used to estimate the health loss on each SF-6D dimension for Osteoarthritis Initiative participants with radiographic knee OA relative to the general population, adjusted for differences in age, BMI, sex, ethnicity and educational level. Predicted SF-6D profiles were then used to compute the average HRQoL loss attributable to radiographic knee OA. Results. Radiographic knee OA was associated with substantial health losses on all dimensions of the SF- 6D except for social functioning. Health losses increased with the radiographic severity of OA in dimensions related to physical health, while there was no relationship between worse radiographic disease and worse self-assessed health in mental and emotional dimensions of health. Overall, radiographic knee OA was associated with a HRQoL detriment of 0.040-0.044 at Kellgren-Lawrence grade 2, increasing to 0.045-0.050 at grade 3 and 0.073-0.081 at grade 4. Conclusion. Radiographic knee OA is significantly associated with worse HRQoL across most dimensions of health.

The effect of upper blepharoplasty on eyelid position when performed concomitantly with Muller muscle-conjunctival resection

Upper Eyelid and Brow Surgery

PURPOSE: To determine the effect on eyelid elevation of excising excess skin, orbicularis oculi muscle, and herniated orbital fat and reconstructing the upper eyelid crease (blepharoplasty) concomitant with a Muller muscle-conjunctival resection. METHODS: The charts of 202 patients who had undergone Muller muscle-conjunctival resection during an 8-year interval were reviewed. Three hundred forty-five eyelids were divided into two groups. Group 1 (n = 162) underwent a Muller muscle-conjunctival resection only, and group 2 (n = 183) had this procedure combined with excision of skin, orbicularis muscle, and herniated orbital fat with upper eyelid crease reconstruction. Each group was divided into three subgroups based on the amount of Muller muscle-conjunctival resection. Subgroup A had resection less than 7.75 mm; subgroup B, resection of 7.75 to 8.75 mm; and subgroup C, resection greater than 8.75 mm. The change in margin reflex distance-1 (MRD1) measurements of the upper eyelid levels (postoperative MRD1 minus preoperative MRD1) were calculated and compared between groups. RESULTS: The mean (+/- standard deviation) change in MRD1 was, respectively, 2.3 +/-1.0 mm and 1.9+/-1.0 mm for groups 1A and 2A; 3.1+/-1.3 mm and 2.1+/-1.2 mm for groups 1B and 2B; and 3.4+/-1.2 mm and 2.8+/-1.3 for groups 1C and 2C. CONCLUSIONS: Blepharoplasty performed concomitant with a Muller muscle-conjunctival resection reduced the anticipated postoperative eyelid elevation by as much as 1 mm. Surgeons who perform these procedures together should be aware that a larger Muller muscle-conjunctival resection may be required to obtain the desired increase in eyelid height postoperatively.

Bone histology at autopsy and matched bone scintigraphy findings in patients with hormone refractory prostate cancer: the effect of bisphosphonate therapy on bone scintigraphy results

MSTS 2018 - Femur Mets and MM

Bisphosphonates (BisP) are non-metabolized compounds with high bone affinity used in bone metastasis diagnosis and treatment. Currently, BisP are used to treat hypercalcemia of malignancy as well as to prevent, minimize, or delay skeletal morbidity. These compounds have a long half-life in bone. Thus long-term BisP treatment might saturate bone and interfere with a single-dose scanning agent used for bone scintigraphy when visualizing bone metastases. In an effort to answer this question, this study evaluated the concordance of histology and Technetium99 methylene diophosphonate (Tc99 MDP) bone scintigraphy in the diagnosis of bone metastases in prostate cancer patients. We assessed the concordance of findings between bone scintigraphy and histology using 188 bone biopsies from 11 autopsied patients who died with metastatic prostate cancer, 5 of whom were treated with pamidronate for 2 to 13 months before death. Overall agreement between histology and bone scintigraphy was 84%, 86% in non-pamidronate-treated patients and 82% in pamidronate-treated patients. Scintigraphic bone metastases without histological metastasis (false negatives = 12.7%) were observed in 24 anatomic locations; half of these were in one patient who had been treated with pamidronate and had no histological bone response to the carcinoma. There were only 4 sites where a positive bone scan was not associated with histologic metastasis (false positives = 2.21%). There was no statistical difference between the treated and non-treated group for concordance, specificity, sensitivity, positive and negative predictive values of bone scintigraphy and prevalence of histological abnormality. Long-term pamidronate treatment of prostate cancer bone metastases does not generally affect the ability to detect bone metastases with Tc99 MDP bone scintigraphy.

Ambulatory unicompartmental knee arthroplasty: Short outcome of 50 first cases

OAK 3 - Non-arthroplasty tx of OAK

Introduction: The reduction in length of stay (LOS) in orthopedic surgery has been steady for several years. For the past 3 or 4 years in France, the trend toward outpatient surgery has been growing upwards, as it is a goal for hospital administration. Materials and methods: This is a prospective, continuous, mono-centric, single operator study on 56 UKAs. Included were all UKAs carried out between January 2014 and December 2015, meeting the following criteria: voluntary patients, supportive family environment, absence of comorbidity (oral anticoagulants, diabetes, obesity), ASA score � 3. Preoperatively, patients received: Dexamethasone 2 mg/10 kg, Tranexamic acid 2 g, Cefazolin 2 g IV. All patients were operated on under general anesthesia with the same technique: Alpina® (Zimmer-Biomet) uni-prosthesis without tourniquet. The arthrotomy was closed after a capsular injection of a solution of 150 mg Ropivacaine + 30 mg Bi-Profenid®. Patient discharge on the same day evening was authorized by both surgeon and anesthesiologist. Three criteria were quantified: number of patients seen before the date of the first consultation for the removal of stitches (around day 12), Visual Pain Scale (10 points scale) on the first 12 days, and the level of satisfaction at the one-month postoperative visit. Results: Six patients (11%) were not included in the ambulatory program during the initial consultation. Three patients were not able to be discharged on the same day evening due to nausea and therefore remained hospitalized for one night. Eighteen patients (38%) were reviewed before D10: 13 patients were reviewed between D1 and D4 for bleeding through the dressing and 5 for pain not controlled by level 1 and 2 analgesics. The Visual Pain Scale (VPS) reached level 6 ± 2 by the 2nd day and then dropped to 1 ± 1 by the 12th day. At 1 month, 85% of the patients were satisfied or very satisfied with their care. There were no general or localized complications. Discussion: Ambulatory UKA surgery is possible for most patients. The inclusion rate for ambulatory UKA was 88% for Berger RA in 2010, therefore very close to this study rate of 89%. Ambulatory care is not only a change in surgical and anesthetic practice but a totally new management process involving all medical and non-medical actors. Ambulatory UKA surgery is feasible and safe for most patients. Level of evidence: IV, retrospective cohort study.

A comparison of Kneipp hydrotherapy with conventional physiotherapy in the treatment of osteoarthritis of the hip or knee: protocol of a prospective randomised controlled clinical trial

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: The increasing age of the population, especially in the western world, means that the prevalence of osteoarthritis is also increasing, with corresponding socioeconomic consequences. Although there is no curative intervention at present, in accordance with US and European guidelines, pharmacotherapeutic and non�pharmacological approaches aim at pain control and the reduction of functional restriction.It has been established that hydrotherapy for osteoarthritis of the hip or knee joint using serial cold and warm water stimulation not only improves the range of movement but also reduces pain significantly and increases quality of life over a period of up to three months. Weight reduction is important for patients with osteoarthritis of the hip or knee. In addition, conventional physiotherapy and exercise therapy have both been shown, at a high level of evidence, to be cost�effective and to have long�term benefits for pain relief, movement in the affected joint, and patient quality of life. METHODS/DESIGN: The study design consists of a prospective randomised controlled three�armed clinical trial, which will be carried out at a specialist clinic for integrative medicine, to investigate the clinical effects of hydrotherapy on osteoarthritis of the knee or hip joint, in comparison with conventional physiotherapy.One hundred and eighty patients diagnosed with osteoarthritis of hip or knee will be randomly assigned to one of three intervention groups: hydrotherapy, physiotherapy, and both physiotherapy and hydrotherapy of the affected joint. In the first group, patients will receive Kneipp hydrotherapy daily, with water applied in the form of alternate cold and warm thigh affusions (alternating cold and warm water stimulation is particularly relevant to the knee and hip regions).Patients in the second group will receive physiotherapy of the hip or knee joint three times a week. Patients in the physiotherapy�hydrotherapy combination group will receive both joint�specific physiotherapy three times a week and alternate cold and warm thigh affusions every day. Follow�up assessments will be on three levels: clinical assessment by the investigator; subjective patient assessment consisting of a patient diary, and questionnaires on admission and at the end of the treatment phase; and a final telephone assessment by the external evaluation centre. Assessments will be made at baseline, after two weeks of inpatient treatment, and finally after a further ten weeks of follow�up. The primary outcome measure will be pain intensity of the affected joint in the course of inpatient treatment, judged by the patient and the investigator. Secondary outcomes include health�related quality of life and joint�specific pain and mobility in the course of the study. Statistical analysis of the results will be on an intention�to�treat basis. CONCLUSION: This study methodology has been conceived according to the standards of the CONSORT recommendations. The results will contribute to establishing hydrotherapy as a non�invasive, non�interventional, reasonably priced, therapeutic option with few side effects, in the concomitant treatment of osteoarthritis of the hip or knee. TRIAL REGISTRATION: Trial registration number: NCT 00950326.

The relation between hip fracture and alzheimer's disease in the canadian national population health survey health institutions data, 1994-1995. A cross-sectional study

Management of Hip Fractures in the Elderly

PURPOSE: The purpose of this study is to examine the relation between hip fractures and Alzheimer's disease in institutionalized men and women who participated in the 1994-1995 Canadian National Population Health Survey (NPHS).METHODS: Participants in the institutional component of NPHS were randomly chosen from selected health care institutions from all provinces in Canada. A questionnaire, which assessed health, demographic and socio-economic status, risk factors, medication use, and falls, was administered by an interviewer. Proxy respondents were sought for residents who were ill or incapacitated. Logistic regression was used to examine the association between hip fractures and Alzheimer's disease in 408 men and 1105 women >/=65 years. Models were examined with either hip fracture or Alzheimer's disease as the dependent variable. Covariates that were assessed included osteoporosis, age group, sex, medications, reported falls and comorbid conditions.RESULTS: All hip fractures reported in this survey were the result of a fall, however only 3.7% of falls resulted in a hip fracture. Those who had sustained a hip fracture were more likely to have Alzheimer's disease (OR 2.0, 95% CI 1.1-3.5), osteoporosis (OR 4.3, 95% CI 2.5-7.4) and heart disease (OR 2.4, 95% CI 1.1-5.0). Respondents who had Alzheimer's disease were more likely to have sustained a hip fracture (OR 2.1 95% CI 1.2-3.6), to have osteoporosis (OR 1.9, 95% CI 1.5-2.5), and to have fallen (OR 1.4, 95% CI 1.1-1.8) and were less likely to be taking anti-psychotic medication (OR 0.4, 95% CI 0.3-0.6) than those with no diagnosis of Alzheimer's disease.CONCLUSIONS: There is an association between Alzheimer's disease and hip fractures that is independent of other covariates in this representative sample of institutionalized elderly Canadians

Total hip arthroplasty and perioperative oral carbohydrate treatment: A randomised, double-blind, controlled trial

AAHKS (4) Acetaminophen

Context Perioperative oral carbohydrate intake is beneficial to general surgery patients. Total hip arthroplasty is a common surgical procedure, and even a moderate improvement in patient outcome could have a significant effect on the resources needed for these patients. However, few studies have focused on the effects of carbohydrate intake on orthopaedic patients. Objective The purpose of this study was to investigate if perioperative oral carbohydrate intake alters the postoperative course for patients undergoing total hip arthroplasty. The primary hypothesis was that pain scores would be lower in patients treated with carbohydrate. Design A randomised, double-blind, controlled trial. Setting This study was carried out between September 2009 and April 2011 at a district Swedish hospital that specialises in orthopaedic surgery. Patients Sixty ASA physical status I-III patients scheduled for elective total hip arthroplasty were included. Exclusion criteria were obesity, diabetes, prior hip surgery to the same hip, ongoing infection, immunological deficiency or age less than 50 or more than 80 years. Interventions Patients were given 400 ml of either an oral 12.5% carbohydrate solution or a placebo beverage (flavoured water) 1.5 h before and 2 h after surgery. Main outcome measures Visual analogue scales were used to score six discomfort parameters. Results Immediately prior to surgery, the carbohydrate-treated patients were less hungry (median score 9.5 vs. 22 mm) and experienced less nausea (0 vs. 1.5 mm) (P<0.05). Postoperatively, patients in the carbohydrate group experienced less pain at 12, 16 and 20 h (median scores 20, 30 and 34 vs. 7, 5 and 0 mm; P<0.05). Conclusion This study shows that there is limited benefit from administering oral carbohydatre prior to total hip arthroplasty. © 2012 Copyright European Society of Anaesthesiology.

Uvulitis caused by anaerobic bacteria

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

OBJECTIVE: I present two children with bacteremic uvulitis due to anaerobic bacteria. RESULTS: Fusobacterium nucleatum was recovered from the blood, and Haemophilus influenzae type b was recovered from a surface uvular culture of one patient. beta-Lactamase-producing Prevotella intermedia was isolated for the blood of the other patient. Both patients responded to parenteral, followed by oral, antimicrobial therapy. CONCLUSIONS: These findings illustrate the need to send blood cultures for both aerobic and anaerobic bacteria in patients with uvulitis

Practical Review of Recognition and Management of Obesity and Lipohypertrophy in Human Immunodeficiency Virus Infection

Panniculectomy & Abdominoplasty CPG

Background. Obesity and lipohypertrophy are common in treated human immunodeficiency virus (HIV) infection and contribute to morbidity and mortality among HIV-infected adults on antiretroviral therapy (ART). Methods. We present a consensus opinion on the diagnosis, clinical consequences, and treatment of excess adiposity in adults with treated HIV infection. Results. Obesity and lipohypertrophy commonly occur among HIV-infected adults on ART and may have overlapping pathophysiologies and/or synergistic metabolic consequences. Traditional, HIV-specific, and ART-specific risk factors all contribute. The metabolic and inflammatory consequences of excess adiposity are critical drivers of non-AIDS events in this population. Although promising treatment strategies exist, further research is needed to better understand the pathophysiology and optimal treatment of obesity and lipohypertrophy in the modern ART era. Conclusions. Both generalized obesity and lipohypertrophy are prevalent among HIV-infected persons on ART. Aggressive diagnosis and management are key to the prevention and treatment of end-organ disease in this population and critical to the present and future health of HIV-infected persons.

Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: The recovery of quadriceps muscle force and function after total knee arthroplasty (TKA) is suboptimal, which predisposes patients to disability with increasing age. OBJECTIVE: The purpose of this investigation was to evaluate the efficacy of quadriceps muscle neuromuscular electrical stimulation (NMES), initiated 48 hours after TKA, as an adjunct to standard rehabilitation. DESIGN: This was a prospective, longitudinal randomized controlled trial. METHODS: Sixty-six patients, aged 50 to 85 years and planning a primary unilateral TKA, were randomly assigned to receive either standard rehabilitation (control) or standard rehabilitation plus NMES applied to the quadriceps muscle (initiated 48 hours after surgery). The NMES was applied twice per day at the maximum tolerable intensity for 15 contractions. Data for muscle strength, functional performance, and self-report measures were obtained before surgery and 3.5, 6.5, 13, 26, and 52 weeks after TKA. RESULTS: At 3.5 weeks after TKA, significant improvements with NMES were found for quadriceps and hamstring muscle strength, functional performance, and knee extension active range of motion. At 52 weeks, the differences between groups were attenuated, but improvements with NMES were still significant for quadriceps and hamstring muscle strength, functional performance, and some self-report measures. LIMITATIONS: Treatment volume was not matched for both study arms; NMES was added to the standard of care treatment. Furthermore, testers were not blinded during testing, but used standardized scripts to avoid bias. Finally, some patients reached the maximum stimulator output during at least one treatment session and may have tolerated more stimulation. CONCLUSIONS: The early addition of NMES effectively attenuated loss of quadriceps muscle strength and improved functional performance following TKA. The effects were most pronounced and clinically meaningful within the first month after surgery, but persisted through 1 year after surgery

Features of oral immunization

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

In this review, we focus on some key areas concerning the unique properties of the mucosal immune system. They are: (1) the fact that the common mucosal immune system consists of different compartments; (2) the advantages of oral vaccination, which can be exploited to antigen-specific sIgA-mediated local immune responses as well as systemic immunity; (3) efficacious oral immunization against respiratory infections; (4) oral tolerance with respect to activation of T cells which, after declining, can be repeatedly reinduced without changes in profile or magnitude, and (5) the use of transgenic plants as a new vaccine source for a new vaccination strategy, i.e. employing edible dietary vaccines

Management of Joint Contractures in the Spastic Upper Extremity

Pediatric Supracondylar Humerus Fracture 2020 Review

Upper extremity contractures in the spastic patient may result from muscle spasticity, secondary muscle contracture, or joint contracture. Knowledge of the underlying cause is critical in planning successful treatment. Initial management consists of physical therapy and splinting. Botulinum toxin can be helpful, as a therapeutic treatment in relieving spasticity and as a diagnostic tool in determining the underlying cause of the contracture. Surgical management options include release or lengthening of the causative muscle/tendon unit and joint capsular release, as required. Postoperative splinting is important to maintain the improved range of motion and protect any associated tendon lengthening or transfer.

Total hip arthroplasty after hip joint ankylosis

Surgical Management of Osteoarthritis of the Knee CPG

Background: Back pain and knee pain are typical secondary degeneration symptoms after hip ankylosis. Take down of hip ankylosis and implantation of a total hip arthroplasty (THA) is believed to be a promising treatment option. Methods: A total of 22 hip ankylosis patients [15 men, mean age 53.7 years (range 30-72 years); 7 women, mean age 50.8 years (range 42-61 years)] underwent THA during 1980-2000 after spontaneous (n = 10) or surgical (n = 12) fusion of the hip joint. The mean duration of ankylosis prior to THA was 32.5 years (range 2-61 years). Results: At the mean follow-up of 13.2 years (range 2-19 years), the Harris hip score averaged 84.9 points (range 70.1-99.0 points). All patients (100%) confirmed that they would undergo conversion surgery again. Aseptic loosening of two stems (one cemented, one cementless; 9.5%) and two deep infections (9.5%) required revision surgery. Conclusions: THA is a promising option for treatment of secondary long-term hip ankylosis sequelae. A conversion operation after spontaneous ankylosis provides better functional outcome than after surgical fusion. However, full function with complete pain relief and a negative Trendelenburg sign might be not attainable in all cases. (copyright) 2009 The Japanese Orthopaedic Association

Femoral neck and pelvic fatigue fractures in sportsmen and women

DoD SSI (Surgical Site Infections)

Fatigue fractures are the result of repeated mechanical stresses above the resistance threshold on a healthy bone. Repeated mechanical stress may cause fatigue fracture in the dendritic processes of osteocytes leading to an activation of bone remodeling where osteoclastic destruction is greater than osteoblastic formation. Fatigue fractures generally occur in young, healthy, active subjects and represent the most frequent pathology of sport and occur mainly in the lower limbs. The activities most at risk are: marathon, cross-country running, basketball, gymnastics, and ballet dancing and among army recruits. Femoral neck and pelvis are not the most common sites of fatigue fractures. The risk factors are: abrupt increment in the intensity of training, female sex, low body mass index, estrogen deficiency, predisposing anatomical factors and footwear errors. The diagnosis is suspected on mechanical pain of increasing intensity at the time of loading in a subject at risk and requires confirmation by radiological investigations. While plain radiographs must be performed as a first-line procedure, MRI has now become the gold-standard second-line imaging investigation, even providing for professional athletes prognostic factors to predict a return to sports activity. Except for fractures of the femoral neck in areas of tension, which are at high risk of complications and require surgical management, treatment is mainly based on sports rest and the normalization, where appropriate, of vitamin, calcium and energy intake.

Estimation of individual thigh muscle volumes from a single-slice muscle cross-sectional area and muscle thickness using magnetic resonance imaging in patients with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: This study aimed to identify the best single-slice anatomical muscle cross-sectional area (CSA) and muscle thickness (MT) on magnetic resonance imaging (MRI) to estimate the overall individual muscle volumes (MVs) of knee extensors and flexors in patients with knee osteoarthritis (KOA). METHODS: Twelve patients (24 legs; 4 men and 8 women) with KOA underwent a 1.5-Tesla axial MRI scan in the femoral region of interest (ROI), between the lesser trochanter and rectus femoris tendon. Individual MVs were calculated by numerical integration based on individual CSAs analyzed at the ROI. The best slice was determined as follows: coefficient of determination ( R²) between MVs measured and those estimated from the femoral length (FL) x CSAs or FL x MTs measured at each 10% interval level of the ROI. These estimation equations were applied for a cross-validation group (24 KOA patients: 12 men and 12 women). RESULTS: Estimated individual MVs of knee extensors and flexors, based on the CSAs at the distal 10% level, significantly correlated with each of the measured individual MVs ( R²: 0.79-0.96, p < 0.05 for all). Similarly, estimated individual knee extensor MVs, based on MTs at the mid-slice, significantly correlated with each of the measured individual MVs ( R²: 0.77-0.84, p < 0.05 for all). The application of the developed regression equation to the cross-validation group did not exhibit any systematic bias. CONCLUSION: These simple methods could be applied in prospective research with a larger number of patients with KOA.

Displaced supracondylar fractures of the humerus in children

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

We performed an audit of 71 children with consecutive displaced, extension-type supracondylar fractures of the humerus over a period of 30 months. The fractures were classified according to the Wilkins modification of the Gartland system. There were 29 type IIA, 22 type IIB and 20 type III. We assesed the effectiveness of guidelines proposed after a previous four-year review of 83 supracondylar fractures. These recommended that: 1) an experienced surgeon should be responsible for the initial management; 2) closed or open reduction of type-IIB and type-III fractures must be supplemented by stabilisation with Kirschner (K-) wires; and 3) K-wires of adequate thickness (1.6 mm) must be used in a crossed configuration. The guidelines were followed in 52 of the 71 cases. When they were observed there were no reoperations and no malunion. In 19 children in whom they had not been observed more than one-third required further operation and six had a varus deformity. Failure to institute treatment according to the guidelines led to an unsatisfactory result in 11 patients. When they were followed the result of treatment was much better. We have devised a protocol for the management of these difficult injuries

Bone metastases and quality of life

MSTS 2018 - Femur Mets and MM

Bone metastases are a common consequence of many malignancies. Few clinical trials have evaluated quality of life (QOL) as an endpoint in studies directed to medical or radiotherapy interventions for bone metastases. Given the lack of well-developed bone metastases specific QOL instruments, our group initiated the development of a bone metastases questionnaire in accordance with the European Organization for Research and Treatment of Cancer's (EORTC) module development guidelines. The module is currently in the final stage of development (international field testing) and is available for clinical use through the EORTC. This paper addresses previous clinical trials in patients with bone metastases receiving palliative RT, and describes the QOL assessments completed. The development of the EORTC bone metastases module and future research directions are also discussed. © 2011 Nova Science Publishers, Inc.

Outcomes of Patellofemoral Osteochondral Lesions Treated With Structural Grafts in Patients Older Than 40 Years

Osteochondritis Dissecans 2020 Review

Background Chondral lesions in the patellofemoral compartment represent a difficult entity to treat among active patients, with no clear consensus on the optimal treatment strategy. The purpose of this study was to review the functional outcomes of patients >40 years old with primary patellofemoral osteochondral lesions who underwent a cartilage restoration procedure with a structural graft. Methods Following institutional review board approval, 35 patients >40 years treated for patellofemoral chondral or osteochondral injuries were retrospectively identified. Seventeen (47%) had prior surgery (mean 1.4 procedures, range 1-4). Average follow-up was 3.6 ± 1.6 years. Average patient age was 51.5 years (range 40-72 years); 54% were male. Twenty-six (74%) had isolated trochlear lesions, 7 had isolated patellar lesions (20%), while 2 (6%) had bipolar lesions. Twenty patients (57%) were treated with synthetic biphasic scaffold plugs (SS), 9 (26%) with fresh osteochondral allograft (OCA) and 6 (17%) with osteochondral autograft transfer (OAT). Outcomes were measured with validated measures: Activity of Daily Living Score (ADL), International Knee Documentation Committee (IKDC) Subjective Evaluation form, and Marx Activity Scale (MAS). Results The average lesion size for the entire cohort was 3.1 ± 1.7 cm(2). Average defect size was 2.6 ± 1.7 cm(2) for the SS group, 4.3±1.5 cm(2) for the OCA group, and 2.9 ± 0.8 cm(2) for the OAT group ( P > 0.051). Outcome scores for the entire population demonstrated significant improvement in ADL ( P = 0.002) and IKDC scores ( P = 0.004) between baseline and final follow-up, while MAS scores were maintained ( P = 0.51). Conclusion Structural grafts are a viable treatment option for symptomatic focal osteochondral lesions of the patellofemoral joint in patients 40 years and older, with anticipated improvements in pain and function and maintenance of preoperative activity levels.

Long-term follow-up of MRC Myeloma IX trial: Survival outcomes with bisphosphonate and thalidomide treatment

MSTS 2018 - Femur Mets and MM

Purpose: Medical Research Council (MRC) Myeloma IX was a phase III trial evaluating bisphosphonate and thalidomide-based therapy for newly diagnosed multiple myeloma. Results were reported previously after a median follow-up of 3.7 years (current controlled trials number: ISRCTN68454111). Survival outcomes were reanalyzed after an extended follow-up (median, 5.9 years). Experimental Design: At first randomization, patients (N = 1,970) were assigned to bisphosphonate (clodronic acid or zoledronic acid) and induction therapies [cyclophosphamide-vincristine-doxorubicin- dexamethasone (CVAD) or cyclophosphamide-thalidomide-dexamethasone (CTD) followed by highdose therapy plus autologous stem cell transplantation for younger/fitter patients (intensive pathway), and melphalan-prednisone (MP) or attenuated CTD(CTDa) for older/less fit patients (nonintensive pathway)]. At second randomization, patients were assigned to thalidomide maintenance therapy or no maintenance. Interphase FISH (iFISH) was used to analyze cytogenics. Results: Zoledronic acid significantly improved progression-free survival (PFS; HR, 0.89; P = 0.02) and overall survival (OS; HR, 0.86; P = 0.01) compared with clodronic acid. In the intensive pathway, CTD showed noninferior PFS and OS compared with CVAD, with a trend toward improved OS in patients with favorable cytogenics (P=0.068). In the nonintensive pathway, CTDa significantly improved PFS (HR, 0.81; P = 0.007) compared with MP and there was an emergent survival benefit after 18 to 24 months. Thalidomide maintenance improved PFS (HR, 1.44; P < 0.0001) but not OS (HR, 0.96; P = 0.70), and was associated with shorter OS in patients with adverse cytogenics (P = 0.01). Conclusions: Long-term follow-up is essential to identify clinically meaningful treatment effects in myeloma subgroups based on cytogenetics. © 2013 American Association for Cancer Research.

Treatment of femoral neck fractures with a sliding compression screw and two Knowles pins

Management of Hip Fractures in the Elderly

Twenty-one patients with an average age of 65 years had displaced femoral neck fractures treated by a sliding compression screw and two Knowles pins. All patients had either Garden III or Garden IV fractures. One patient healed with a malunion and five developed symptomatic avascular necrosis; all of these patients required reconstructive surgery. There were no nonunions. The sliding compression screw with two Knowles pins gave a 100% rate of union, which was superior to most fixation methods. The incidence of avascular necrosis was 24%, the expected range for displaced femoral neck fractures

Falls in the elderly

Management of Hip Fractures in the Elderly

Falls are the leading cause of injury-related visits to emergency departments in the United States and the primary etiology of accidental deaths in persons over the age of 65 years. The mortality rate for falls increases dramatically with age in both sexes and in all racial and ethnic groups, with falls accounting for 70 percent of accidental deaths in persons 75 years of age and older. Falls can be markers of poor health and declining function, and they are often associated with significant morbidity. More than 90 percent of hip fractures occur as a result of falls, with most of these fractures occurring in persons over 70 years of age. One third of community-dwelling elderly persons and 60 percent of nursing home residents fall each year. Risk factors for falls in the elderly include increasing age, medication use, cognitive impairment and sensory deficits. Outpatient evaluation of a patient who has fallen includes a focused history with an emphasis on medications, a directed physical examination and simple tests of postural control and overall physical function. Treatment is directed at the underlying cause of the fall and can return the patient to baseline function

Arthroscopic surgery and a new classification system

Surgical Management of Osteoarthritis of the Knee CPG

Arthroscopic lavage and debridement is of significant value in the earlier stages of arthritis. This is probably through the removal or dilution of enzymes that are part of the degradative process of osteoarthritis. Mechanical problems such as meniscal tears and loose bodies also can be addressed at the same time. However, patients must be selected carefully for arthroscopic treatment. A severity scale is proposed based on clinical and radiological findings that should indicate in advance those patients who will have the greatest opportunity for improvement from an arthroscopic procedure. Critics have said that lavage and debridement does nothing to change the natural history of the disease and is no more than a placebo effect. While there is no strong evidence to suggest that it does modify the natural history of the disease, it definitely improves the quality of life for a significant period of time, with little in the way of complications or morbidity associated with the procedure. The placebo effect might explain some of the results, but the placebo effect is well-known in medicine, and if it does produce a positive result in terms of reduction of symptoms, it cannot be entirely discounted. The biological resurfacing of a joint under arthroscopic control is the challenge facing orthopedic surgeons today. Healing and restoration of articular tissues back to some functional biological state would seem to be a reasonable goal. If this can be achieved, the future will lie in the salvage of joints through arthroscopic procedures rather than the replacement of joints by arthroplasty

Increased mortality among patients sustaining hip fractures requiring surgery in a district general hospital

Management of Hip Fractures in the Elderly

Fractures of the femoral neck are a common condition the incidence of which continues to rise. Associated mortality remains very high and knowledge of factors contributing to this high mortality is crucial in understanding outcome for both patient and surgeon. A retrospective review of 1254 patients operated on for fracture neck of femur was conducted to identify mortality at 30 days, 90 days and one year. Age, type of fracture, sex and waiting time for surgery were evaluated along with mortality for 47 patients who sustained their fracture while already inpatients with other concurrent illnesses. Those patients who sustained an inpatient fracture were found to have significantly higher mortality at 30 days, 90 days and one year. We concluded that these patients represent a very high-risk group that needs special consideration in management of their fracture and concurrent medical condition to reduce their high mortality. (copyright) Wichtig Editore, 2007

Prevalence of Low Bone Mineral Density in Younger Versus Older Women With Distal Radius Fractures

Distal Radius Fractures

Although distal radius fractures (DRFs) are the most common fractures among younger women, few studies have examined bone health in this age group. We compared bone mineral density (BMD) of younger women (35-50 years) and older women (>50 years) treated for DRFs. Between January 2005 and August 2010, our orthopedic service obtained dual-energy x-ray absorptiometry scans from 128 women with DRFs (47 were 35-50 years old; 81 were older than 50 years). According to the World Health Organization classification system, 43% of the younger patients were osteopenic, and 6% were osteoporotic. Mean femoral neck BMD was 0.91 for the younger group and 0.80 for the older group (P < .05); t scores were -0.87 and -1.65, respectively (P < .05). The difference in femoral neck z scores between the younger and older patients was not statistically different: -0.69 and -0.67, respectively (P = .92). A notable proportion of younger patients with DRFs have osteopenia or osteoporosis. The similarity in z scores among younger and older women with DRFs and among patient groups differentiated by mechanism of injury suggests that any younger or older woman with a DRF should have her BMD evaluated and treated as appropriate.

Reducing delirium after hip fracture: a randomized trial

Management of Hip Fractures in the Elderly

OBJECTIVES: Delirium (or acute confusional state) affects 35% to 65% of patients after hip-fracture repair, and has been independently associated with poor functional recovery. We performed a randomized trial in an orthopedic surgery service at an academic hospital to determine whether proactive geriatrics consultation can reduce delirium after hip fracture. DESIGN: Prospective, randomized, blinded. SETTING: Inpatient academic tertiary medical center. PARTICIPANTS: 126 consenting patients 65 and older (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment through interviews with patients and designated proxies and review of medical records was performed at enrollment to ascertain prefracture status. Subjects were then randomized to proactive geriatrics consultation, which began preoperatively or within 24 hours of surgery, or "usual care." A geriatrician made daily visits for the duration of the hospitalization and made targeted recommendations based on a structured protocol. To ascertain study outcomes, all subjects underwent daily, blinded interviews for the duration of their hospitalization, including the Mini-Mental State Examination (MMSE), the Delirium Symptom Interview (DSI), and the Memorial Delirium Assessment Scale (MDAS). Delirium was diagnosed using the Confusion Assessment Method (CAM) algorithm. RESULTS: The 62 patients randomized to geriatrics consultation were not significantly different (P>.1) from the 64 usual-care patients in terms of age, gender, prefracture dementia, comorbidity, type of hip fracture, or type of surgical repair. Sixty-one percent of geriatrics consultation patients were seen preoperatively and all were seen within 24 hours postoperatively. A mean of 10 recommendations were made throughout the duration of the hospitalization, with 77% adherence by the orthopedics team. Delirium occurred in 20 /62 (32%) intervention patients, versus 32 / 64 (50%) usual-care patients (P =.04), representing a relative risk of 0.64 (95% confidence interval (CI) = 0.37-0.98) for the consultation group. One case of delirium was prevented for every 5.6 patients in the geriatrics consultation group. There was an even greater reduction in cases of severe delirium, occurring in 7/ 60 (12%) of intervention patients and 18 / 62 (29%) of usual-care patients, with a relative risk of 0.40 (95% CI = 0.18-0.89). Despite this reduction in delirium, length of stay did not significantly differ between intervention and usual-care groups (median +/- interquartile range = 5 +/- 2 days in both groups), likely because protocols and pathways predetermined length of stay. In subgroup analyses, geriatrics consultation was most effective in reducing delirium in patients without prefracture dementia or activities of daily living (ADL) functional impairment. CONCLUSIONS: Proactive geriatrics consultation was successfully implemented with good adherence after hip-fracture repair. Geriatrics consultation reduced delirium by over one-third, and reduced severe delirium by over one-half. Our trial provides strong preliminary evidence that proactive geriatrics consultation may play an important role in the acute hospital management of hip-fracture patients

Cost effectiveness of training rural providers to perform joint injections

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: Community-based outpatient clinics (CBOCs) have been established by the Department of Veterans Affairs (VA) to provide primary care services to veterans living in remote and rural regions. The objective of this study was to evaluate the cost effectiveness of training rural primary care providers to perform knee injections in CBOCs, thereby avoiding referring the patient to an urban medical center for an injection by rheumatology or orthopedic specialists. METHODS: We developed a decision-analysis model to compare costs and outcomes between rural providers who are trained to perform knee injections versus those who are not trained, therefore requiring a referral to a specialist to provide the injections. The model was run separately using costs from the perspective of the VA as well from the patient's perspective. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analyses were performed using 10,000 second-order Monte Carlo simulations. RESULTS: In our base-case analyses, the incremental cost-effectiveness ratio for trained rural providers was $21,190/QALY using costs from the perspective of the VA and $205/QALY using costs from the patient's perspective. Training rural providers was cost effective in 74.4% and 93.6% of 10,000 Monte Carlo simulations at a willingness-to-pay threshold of $50,000/QALY from the perspectives of the VA and the patient, respectively. CONCLUSION: Training rural providers to perform knee injections for patients with knee pain secondary to osteoarthritis appears cost effective using the commonly used threshold of $50,000/QALY if more than 20 such patients per year are seen at rural primary care clinics. These results provide support for our ongoing efforts to implement such a training program.

Wrist tendon forces with respect to forearm rotation

Distal Radius Fractures

PURPOSE: Early motion therapy protocols are desirable to reduce wrist stiffness after carpal injuries and distal radius fractures. Based on our assumption that a reduction in wrist tendon forces will be associated with a reduction in radioulnar carpal joint reaction force, the goal of this study was to determine the forearm position at which the wrist tendon forces required to initiate wrist motion were the least. METHODS: We tested 8 fresh-frozen cadaver forearms in a wrist and forearm motion simulator. In each specimen, we generated a wrist flexion-extension motion and a radioulnar deviation motion by pulling on the wrist flexor and extensor tendons with the forearm in supination, pronation, or neutral. We also performed a wrist flexion-extension motion during active forearm rotation. During each motion, we continuously recorded the forces in the 5 wrist tendons. We used repeated-measure analyses of variance to compare tendon forces. RESULTS: During the wrist flexion-extension motion, the summed peak wrist extensor forces were significantly less with the wrist in forearm supination than with the forearm in neutral or during active forearm rotation. For the summed peak wrist flexor forces, flexor tendon forces were significantly less with the forearm in supination compared with active forearm rotation. The extensor carpi radialis longus and flexor carpi ulnaris forces were significantly less in supination than during active forearm motion. During wrist radioulnar deviation motion, peak extensor carpi ulnaris force was significantly less with the forearm in supination than in neutral, and peak flexor carpi radialis force was significantly less with the forearm in supination than in pronation. CONCLUSIONS: Peak wrist tendon forces were least in the static forearm supinated position. CLINICAL RELEVANCE: To reduce deforming forces on a fresh carpal injury or distal radial fracture, active rehabilitation appears to be best initiated with the forearm held in supination.

Contribution of monoblock and bipolar radial head prostheses to valgus stability of the elbow

Distal Radius Fractures

BACKGROUND: The purpose of this study was to evaluate the stabilizing effect of radial head replacement in cadaver elbows with a deficient medial collateral ligament. METHODS: Passive elbow flexion with the forearm in neutral rotation and in 80 degrees of pronation and supination was performed under valgus and varus loads (1) in intact elbows, (2) after a surgical approach (lateral epicondylar osteotomy of the distal part of the humerus), (3) after release of the anterior bundle of the medial collateral ligament, (4) after release of the anterior bundle of the medial collateral ligament and resection of the radial head, and (5) after subsequent replacement of the radial head with each of three different types of radial head prostheses (a Wright monoblock titanium implant, a KPS bipolar Vitallium [cobalt-chromium]-polyethylene implant, and a Judet bipolar Vitallium-polyethylene-Vitallium implant) in the same cadaver elbow. Total valgus elbow laxity was quantified with use of an electromagnetic tracking device. RESULTS: The mean valgus laxity changed significantly (p < 0.001) as a factor of constraint alteration. The greatest laxity was observed after release of the medial collateral ligament together with resection of the radial head (11.1 degrees +/- 5.6 degrees). Less laxity was seen following release of the medial collateral ligament alone (6.8 degrees +/- 3.4 degrees), and the least laxity was seen in the intact state (3.4 degrees +/- 1.6 degrees). Forearm rotation had a significant effect (p = 0.003) on valgus laxity throughout the range of flexion. The laxity was always greater in pronation than it was in neutral rotation or in supination. The mean valgus laxity values for the elbows with a deficient medial collateral ligament and an implant were significantly greater than those for the medial collateral ligament-deficient elbows before radial head resection (p < 0.05). The implants all performed similarly except in neutral forearm rotation, in which the elbow laxity associated with the Judet implant was significantly greater than that associated with the other two implants. CONCLUSIONS AND CLINICAL RELEVANCE: This study showed that a bipolar radial head prosthesis can be as effective as a solid monoblock prosthesis in restoring valgus stability in a medial collateral ligament-deficient elbow. However, none of the prostheses functioned as well as the native radial head, suggesting that open reduction and internal fixation to restore radial head anatomy is preferable to replacement when possible.

Complications of pediatric supracondylar humeral fractures

Pediatric Supracondylar Humerus Fracture 2020 Review

Supracondylar humeral fractures are common in the pediatric population and can result in complications caused by both the injury itself and surgical or nonsurgical treatment. Neurologic complications are frequent, with the anterior interosseous nerve being the most common nerve affected. Vascular injuries, although less common, can result in long-term sequelae and should be recognized and treated promptly. Loss of reduction can occur with both surgical and nonsurgical treatment. Compartment syndrome and infection, although rare, require rapid recognition and treatment. It is important to be familiar with the potential complications surrounding the treatment of pediatric supracondylar humeral fractures to maximize outcomes and know when a referral may be warranted.

Regional intra-arterial mitomycin C infusion in previously treated patients with metastatic colorectal cancer and concomitant measurement of serum drug level

MSTS 2018 - Femur Mets and MM

Fifty-seven patients with unresectable metastatic colorectal cancer, after failing all conventional chemotherapy, were treated with mitomycin C (MMC) regional intra-arterial infusion. The regional artery (eg, hypogastric, hepatic, etc) was approached percutaneously via the femoral artery and MMC at a dose of 20 mg/m2 in 100 ml of 5% dextrose in water was infused for a 1-hour period; treatment was repeated every 6-8 weeks. Of 51 evaluable patients, five had objective response (three with pelvic tumor, one with liver and lung tumors, and one with liver tumors), 28 had stabilization of tumor, and 18 had no response. Median survival times for the responders, stabilized patients, and nonresponders were 46+, 39, and 22 weeks, respectively, with an overall survival of 32 weeks. The major side effect was necrotizing cellulitis occurring in the buttock following the pelvic infusion. Myelosuppression was manageable and other toxic effects were mild. Using the high-performance liquid chromatography method (total of 25 measurements), the average MMC levels in the peripheral circulation were 205, 62.4, and 16.0 ng/ml, respectively, immediately after injection and 1 and 2 hours following intra-arterial infusion. By 4 hours, no MMC could be detected in the peripheral circulation.

Phase 1 safety and tolerability study of BMP-7 in symptomatic knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: There are no proven therapies that modify the structural changes associated with osteoarthritis (OA). Preclinical data suggests that intra�articular recombinant human BMP�7 (bone morphogenetic protein�7) has reparative effects on cartilage, as well as on symptoms of joint pain. The objective of this study was to determine the safety and tolerability as well as dose�limiting toxicity and maximal tolerated dose of intra�articular BMP�7. The secondary objectives were to determine the effect on symptomatic responses through 24 weeks. METHODS: This was a Phase 1, double�blind, randomized, multi�center, placebo�controlled, single�dose escalation safety study consisting of 4 dosing cohorts in participants with knee OA. Each cohort was to consist of 8 treated participants, with treatment allocation in a 3:1 active (intra�articular BMP�7) to placebo ratio. Eligible participants were persons with symptomatic radiographic knee OA over the age of 40. The primary objective of this study was to determine the safety and tolerability of BMP�7 including laboratory assessments, immunogenicity data and radiographic assessments. Secondary objectives were to determine the proportion of participants with a 20%, 50%, and 70% improvement in the WOMAC pain and function subscales at 4, 8, 12, and 24 weeks. Other secondary outcomes included the change from baseline to 4, 8, 12, and 24 weeks for the OARSI responder criteria. RESULTS: The mean age of participants was 60 years and 73% were female. All 33 participants who were enrolled completed the study and most adverse events were mild or moderate and were similar in placebo and BMP�7 groups. The 1 mg BMP�7 group showed a higher frequency of injection site pain and there was no ectopic bone formation seen on plain x�rays. By week 12, most participants in both the BMP�7 and placebo groups experienced a 20% improvement in pain and overall the BMP�7 group was similar to placebo with regard to this measurement. In the participants who received 0.1 mg and 0.3 mg BMP�7, there was a trend toward greater symptomatic improvement than placebo. The other secondary endpoints showed similar trends including the OARSI responder criteria for which the BMP�7 groups had more responders than placebo. CONCLUSIONS: There was no dose limiting toxicity identified in this study. The suggestion of a symptom response, together with the lack of dose limiting toxicity provide further support for the continued development of this product for the treatment of osteoarthritis.

ICLH arthroplasty of the knee: 1968-1977

Surgical Management of Osteoarthritis of the Knee CPG

The essentially satisfactory results from the ICLH implant as used until 1975 were marred by examples of loosening and sinking of the tibial implant by patellar pain of varying severity, by wear of the tibial implant caused by fragments of cement and by failure consistently to control the alignment of the leg. This report describes the methods now being used to overcome these complications and gives an account of the success so far achieved with 200 arthroplasties

Mortality in outpatient surgery

Panniculectomy & Abdominoplasty CPG

BACKGROUND: The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) has reported statistics on morbidity and mortality for facilities that it accredits based on an analysis of unanticipated sequelae and surgical mortality. Data acquired through the first Internet-Based Quality Assurance and Peer Review reporting system (IBQAP) were reviewed and published in 2004. This article reports the accumulated data in the IBQAP through June of 2006, analyzing death associated with procedures performed in facilities approved by the AAAASF. With the exception of some statistics on the Medicare-aged population, there are few data reported in the literature related to deaths in outpatient surgery. METHODS: The IBQAP, designed in 1999 by the AAAASF, mandates biannual reporting of all unanticipated sequelae and random case reviews by all surgeons operating in AAAASF-accredited facilities. Surgical log numbers, whose entry is required, allow for tabulation of the number of cases and procedures performed by individual reporting surgeons. RESULTS: In this review of data collected using the IBQAP from January of 2001 through June of 2006, there were 23 deaths in 1,141,418 outpatient procedures performed. Pulmonary embolism caused 13 of the 23 deaths. Only one death occurred as the result of an intraoperative adverse event. CONCLUSIONS: A pulmonary embolism may occur after any operative procedure, whether it is performed in a hospital, an ambulatory surgery center, or a physician's office-based surgery facility. The procedure most commonly associated with death from pulmonary embolism in an office-based surgery facility is abdominoplasty. The frequency of pulmonary embolism associated with abdominoplasty warrants further study to determine predisposing factors, understand its cause, and introduce guidelines to prevent its occurrence.

Cloning and characterization of an alpha-enolase of the oral pathogen Streptococcus mutans that binds human plasminogen

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Streptococcus mutans is the etiologic agent of dental caries and is a causative agent of infective endocarditis. While the mechanisms by which S. mutans cells colonize heart tissue is not clear, it is thought that bacterial binding to extracellular matrix and blood components is crucial in the development of endocarditis. Previously, we have demonstrated that S. mutans cells have the capacity to bind and activate plasminogen to plasmin. Here we report the first cloning and characterization of an alpha-enolase of S. mutans that binds plasminogen. The functional identity of the purified recombinant alpha-enolase protein was confirmed by its ability to catalyze the conversion of 2-phosphoglycerate to phosphoenolpyruvate. The protein exhibited a Km of 9.5 mM and a Vmax of 31.0 mM/min/mg. The alpha-enolase protein was localized in the cytoplasmic, cell wall and extracellular fractions of S. mutans. Binding studies using an immunoblot analysis revealed that human plasminogen binds to the enolase enzyme of S. mutans. These findings identify S. mutans alpha-enolase as a binding molecule used by this oral pathogen to interact with the blood component, plasminogen. Further studies of this interaction may be critical to understand the pathogenesis of endocarditis caused by S. mutans

Early clinical and radiographic results of reverse shoulder arthroplasty with press-fit metaphyseal humeral fixation

Pediatric Supracondylar Humerus Fracture 2020 Review

Background: Reverse shoulder arthroplasty (RSA) has seen a recent transition from cemented to press-fit humeral stems. Several press-fit designs have focused on proximal fixation, yet there remains a paucity of data on their performance. The purpose of this study is to report early radiographic and clinical results of a third-generation RSA system, featuring metaphyseal porous metal fixation. Methods: A retrospective review was performed on primary RSA patients treated with a single third-generation standard-length implant system incorporating proximal osteointegration features with a minimum 2-year follow-up. Patient-reported outcome measures, including the Simple Shoulder Test, American Shoulder and Elbow Surgeons, Visual Analog Scale for pain, and Single Assessment Numeric Evaluation, as well as measured active motion (forward elevation, external, and internal rotation) were recorded at pre- and postoperative intervals. Immediate postoperative radiographs were used to measure filling ratios at the epiphyseal, metaphyseal, and diaphyseal levels. Most recent radiographs were also reviewed for bone adaptations, acromial fractures, scapular notching, and humeral loosening. Results: There were 90 patients included in the study, with an average age of 73 years (± 7.23) and clinical follow-up of 32 months (± 7.25). Indications included osteoarthritis with a rotator cuff tear (51%), osteoarthritis without a cuff tear (40%), fracture sequelae (2%), and locked anterior dislocation (2%). There were significant improvements in all measured motions and patient-reported outcome measures at the most recent follow-up, with good to excellent satisfaction in 91.1% of patients. High mean epiphyseal (0.90 ± 0.06) and metaphyseal (0.83 ± 0.07) filling ratios together with low mean diaphyseal filling ratio (0.48 ± 0.07) represented proximal fixation. There were 6 cases with scapular notching, 5 postoperative acromial fractures, and 2 with temporary postoperative neuropathy. Proximal bone resorption was seen in 18.9% of cases, and there were no cases of humeral loosening, baseplate failure, or need for revision. Conclusion: Primary RSA with a third-generation press-fit humeral component with metaphyseal fixation provides excellent early outcomes with no loosening and low rates of proximal stress-shielding. Results of this study support the use of an inlay humeral component with osteointegration features that facilitate proximal stem fixation. Level of Evidence: Treatment Study

Special feature: A comparison of occupational therapy intervention approaches for older patients after hip fracture

Management of Hip Fractures in the Elderly

This study addressed the current lack of research on the efficacy of occupational therapy intervention for older females after hip fracture. A quasi-experimental design was employed that compared two theoretical approaches to occupational therapy intervention. The research hypotheses of the study were that individuals who received occupational therapy intervention based on the Occupational Adaptation Frame of Reference would experience a greater sense of relative mastery, greater functional performance on a patient-chosen task, and greater functional independence on eight self-care tasks than individuals whose intervention was based on a biomechanical approach

Arthrodesis of the knee: Indications and treatment options

Surgical Management of Osteoarthritis of the Knee CPG

Arthrodesis as a salvage procedure remains a durable, time-proven technique for treatment of sepsis, tumor, failed arthroplasty, and the flail limb. It should be performed selectively, especially in light of modern arthroplasty and the increasingly favorable results of 2-stage reimplantation for the failed septic total knee arthroplasty. Arthrodesis of the knee can be performed through various techniques: (a) compression arthrodesis with external fixation, (b) compression arthrodesis with compression plating, (c) intramedullary rod fixation, and (d) a combination of intramedullary rod fixation and compression plating. Copyright (copyright) 2009 by Lippincott Williams & Wilkins

Italian guidelines for the diagnosis and infectious disease management of osteomyelitis and prosthetic joint infections in adults

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Bone and joint infections are recognized as difficult-to-treat infections that result in significant morbidity and mortality among patients and increased healthcare costs. This article presents the recommendations for the diagnosis and management of osteomyelitis and prosthetic joint infections in adults developed by Bone and Joint Infections Committee for the Italian Society of Infectious and Tropical Diseases. It contains data published through to November 2007. An evidence-based scoring system that is used by the Infectious Diseases Society of America was applied to treatment recommendations. (copyright) 2009 Springer

Agreement in Measurement of Optic Cup-to-Disc Ratio with Stereo Biomicroscope Funduscopy and Digital Image Analysis: Results from the Nigeria National Blindness and Visual Impairment Survey

Upper Eyelid and Brow Surgery

PURPOSE: To determine agreement in estimations of vertical cup-to-disc ratio (VCDR) between clinical stereo-biomicroscopic funduscopy and digital fundus image analysis. METHODS: Systematic sampling of 1-in-7 from a sample of 13,591 participants aged >/=40 years gave a subsample who were examined in detail. VCDR was estimated clinically by 60 diopter aspheric lens biomicroscopic funduscopy (c-VCDR) and by digital fundus images (i-VCDR) graded at the Moorfields Eye Hospital Reading Centre. Spearman's correlation coefficient, paired t-test and the Bland-Altman method to assess limits of agreement (LOA) between the two methods were applied. RESULTS: Of 1759 participants in the subsample, 848 participants (48%) with normal frequency doubling technology (FDT) visual fields and data for i-VCDR and c-VCDR in both eyes (n = 1696 eyes) were included in the analysis. By absolute difference of VCDR values for each eye between the two methods, 1585 eyes (94%) differed by </=0.2. Mean i-VCDR was 0.381 (standard deviation, SD 0.156), and mean c-VCDR 0.321 (SD 0.145). i-VCDRs were significantly larger by a mean difference of 0.061 (SD 0.121; 95% confidence interval, CI, 0.055-0.066; p < 0.001). The 95% LOA assessed by the Bland-Altman method were lower limit -0.182 (95% CI -0.192 to -0.172) and upper limit 0.303 (95% CI 0.293-0.313). The 95% LOA intervals narrowed with higher VCDR. CONCLUSION: Digital image analysis and clinical assessment are two distinct methods to measure VCDR; with larger i-VCDRs in this survey. Applying i-VCDR cut-off values to c-VCDR measurements in the Nigeria Blindness Survey might have underestimated glaucoma prevalence. It is recommended that all participants in glaucoma surveys have VCDR by digital image measurement.

How to improve the outcomes of surgically treated proximal humeral osteoporotic fractures? A narrative review

Pediatric Supracondylar Humerus Fracture 2020 Review

Proximal humeral fractures (PHF) are the third most common non-vertebral fragility fractures after hip and distal radius. It still controversial which treatment might be more appropriate, and surgically treated outcomes depends also on an appropriate technique. In order to clarify surgical indications, tips and pitfall a narrative review was conducted. Pinning, external fixation, plating and internal fixators has each one its advantages and disadvantages. During the procedure an appropriate use of the fixation device and handling of the soft tissue might be associated with better outcomes. Calcar comminution, varus angulation, medial dislocation of the shaft, fracture-dislocation are factors that could lead to choose a replacement. Hemiarthroplasty and reverse total shoulder arthroplasty are the most common prosthesis used in PHF. The restoration of humeral length and tuberosities might lead to an improvement in clinical outcomes and prosthesis survivorship.

Epidural abscess - An anesthetic nightmare

Surgical Management of Osteoarthritis of the Knee CPG

Epidural abscess is a rare but important infection which can expand and compress the central nervous system (CNS), causing severe symptoms, sequelae, or even death. This case is a description of a post-operative complication that aims to alert to a rare condition with devastating consequences in terms of patient morbidity and mortality. A 74 year old man with rheumatoid arthritis was admitted for total knee arthroplasty under a regional anaesthesia technique, having no complications during or immediately following the surgery. At the 5th post-operative day he presents with fever and lumbar pain, near the puncture site, with no other symptoms or neurological deficits associated. After a complete evaluation, the diagnosis of Spinal Epidural Abscess (SEA) was made. The patient was submitted to medical and surgical treatment, and was discharged six weeks after, fully recovered. Six months after the discharge he continues to have no sequelae. Although SEA is an uncommon disease, there is some evidence that the incidence may have increased over the last 30 years. Part of this increase may relate to the increase in sensitivity and accuracy of diagnosis by magnetic resonance imaging (MRI) for spinal evaluation and also to the aging of the population. Thinking of SEA is the key to diagnosis, which must always be considered, especially whenever the patient was submitted to surgery under regional anaesthesia technique. If the appropriate window of opportunity is missed, there can be compromise to the full recovery of the patients and the development of neurological deficits

Coronal Shear Fractures of the Distal Humerus: A Review of Diagnosis, Treatment, and Outcomes

Pediatric Supracondylar Humerus Fracture 2020 Review

Fractures of the capitellum and trochlea are uncommon fractures of the elbow and can be challenging to treat due to their size, location, and articular nature. Because of their intra-articular nature and predilection toward displacement, these fractures are typically treated operatively. Furthermore, capitellum fractures have high rates of associated injuries, including radial head fractures or lateral collateral ligament injury in ~30% to 60% of patients. In addition to open reduction internal fixation, operative options include fragment excision, arthroscopic assisted reduction and fixation, and elbow arthroplasty. In this article, we undertake a comprehensive literature review of capitellum fractures of the distal humerus, in an attempt to summarize the existing body of evidence and propose areas of future study.

Effect of ultrasound on mobility in osteoarthritis of the knee. A randomized clinical trial

OAK 3 - Non-arthroplasty tx of OAK

Ultrasound increases soft tissue extensibility and may be an effective adjunct in the treatment of knee contractures secondary to connective tissue shortening. A randomized clinical trial was conducted to determine the effectiveness of ultrasound in relieving stiffness and pain in patients (age mean = 67.5 years, SD = 13.0) who had osteoarthritis (OA) and a chronic knee contracture. Subjects received 12 treatments of exercise preceded by either ultrasound (n = 34) or sham ultrasound (n = 35) and a blinded evaluation at baseline, after treatment, and 2 months after treatment. MANCOVA controlling for baseline scores showed that there were no significant differences in knee active range of motion (ROM) (goniometry) or pain (visual analogue scale) between experimental and control groups. Possible explanations for the no difference finding involve dosage issues, muscle shortening, transiency of effects, and the effects of exercise. Paired t�tests revealed that both groups significantly improved (p less than 0.05) in active ROM, pain, and gait velocity, and maintained improvement for at least 2 months. Although ultrasound may not contribute to the management of patients with chronic knee stiffness and OA, benefits of the exercise program and increased activity secondary to program participation probably influenced the overall improvement.

Effects of proprioceptive circuit exercise on knee joint pain and muscle function in patients with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

[Purpose] This study applied proprioceptive circuit exercise to patients with degenerative knee osteoarthritis and examined its effects on knee joint muscle function and the level of pain. [Subjects] In this study, 14 patients with knee osteoarthritis in two groups, a proprioceptive circuit exercise group (n = 7) and control group (n = 7), were examined. [Methods] IsoMed 2000 (D&R Ferstl GmbH, Hemau, Germany) was used to assess knee joint muscle function, and a Visual Analog Scale was used to measure pain level. [Results] In the proprioceptive circuit exercise group, knee joint muscle function and pain levels improved significantly, whereas in the control group, no significant improvement was observed. [Conclusion] A proprioceptive circuit exercise may be an effective way to strengthen knee joint muscle function and reduce pain in patients with knee osteoarthritis.

Elevated serum cardiac troponin I in older patients with hip fracture: incidence and prognostic significance

Management of Hip Fractures in the Elderly

INTRODUCTION: Cardiovascular complications are the main causes of morbidity and mortality in patients with osteoporotic hip fracture (HF). The aim of this prospective study was to evaluate the incidence and prognostic significance of elevated cardiac troponin I (cTnI) in the early peri-operative period in older patients with HF. MATERIALS AND METHODS: A blind evaluation of myocardial injury as detected by cTnI elevation in 238 consecutive older patients with low-trauma HF (mean age 81.9 +/- 7.8 (SD) years; 72% females). Data on demographic and clinical characteristics, in-hospital mortality, hospital length of stay and discharge destination were collected prospectively. Serum cTnI level was analysed from blood collected routinely in the first 72 h of hospital admission. RESULTS: Sixty-nine (29%) patients had elevated cTnI (>0.06 microg/l) but myocardial injury was clinically recognised in only 23 (33%) and only 24 (34.8%) had a history of coronary artery disease (CAD). Patients with elevated cTnI were significantly older, more often had American Society of Anaesthesiologist status score >or=3, a history of CAD or stroke and more often were current smokers than the patients without cTnI elevation. In multivariate regression analysis only age was an independent predictor of cTnI elevation. Patients with cTnI release were twice as likely to have a length of stay >or=20 days (P = 0.047) and 2.7 times more likely to be discharged to a long-term residential care facility (RCF) (P = 0.013). cTnI level >or=1 microg/l was a strong independent predictor of all-cause mortality with 98.3% specificity and 89.1% negative predictive value. CONCLUSION: Peri-operative myocardial injury is common in older HF patients but is frequently unrecognised clinically. Elevated blood cTnI level is an independent predictor of prolonged length of hospital stay (>or=20 days), need for long-term RCF and mortality (if cTnI >or=1 microg/l)