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The magnitude and duration of the effects of some mouthrinse products on salivary bacterial counts

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The persistence of action or substantivity of an antimicrobial agent in the mouth relates to the plaque inhibitory action of that compound. Substantivity can be assessed by measuring the magnitude and duration of the fall in salivary bacteria following single rinses with antimicrobials. This was a randomised single-blind, cross-over study measuring the effects of single 60-s rinses of 5 mouthwash products on salivary bacterial counts in 14 healthy human volunteers. Effects over a 7-h period were compared with a chlorhexidine rinse product (positive control) and saline (negative control). All but one rinse, containing cetylpyridinium chloride (CPC), significantly reduced bacterial counts compared to saline up to 5-7 h. No rinse produced the magnitude or duration of effect noted for chlorhexidine and decrements from baseline, with one exception, were highly significantly lower than with the chlorhexidine product. Comparing the 2 CPC rinses, the findings suggest that the activity of one product was vitiated by some other ingredient. The triclosan/copolymer, the essential oil/phenolic and one CPC products exhibited similar persistence. In those cases where information is available, these data are consistent with comparative plaque inhibitory findings for the products or their active ingredients. Again, it is concluded that the method is a useful screening and comparison test for the potential plaque inhibitory activity of antimicrobial oral hygiene products

The inter-teres approach to glenoid neck fractures: an alternative approach to glenoid fixation

Pediatric Supracondylar Humerus Fracture 2020 Review

Background: Scapula fractures are rare injuries that are generally treated nonoperatively. When surgery is performed, it is commonly undertaken through the posterior approach, which can be invasive and unforgiving on the soft tissues. We describe an alternative safe approach between teres major and minor that remains deep to a fascial sling formed by the combined infraspinatus and teres minor fasciae and deep to the primary nerve to teres minor, which is a terminal branch of the axillary nerve. Methods: Between January 2008 and June 2014, there were 22 patients who underwent scapula fixation with this approach who were retrospectively identified and prospectively invited for clinical review by the American Shoulder and Elbow Surgeons (ASES) evaluation form and Constant score. Postoperative external rotation (ER) power in both abduction and adduction was also assessed. Results: Five patients were lost to follow-up. All of the remaining patients were male with a mean age of 44.5 years (28-66 years). Mean follow-up time was 34.7 months (3-72 months). The mean ASES score for the 17 patients was 86.6 (41.6-100); the mean Constant score was 89.3 (22-100). The only significant factor affecting the ASES score was an ipsilateral neurologic upper limb injury. ER power was improved or equivalent to the contralateral side in 8 of the 10 patients assessed for ER; it was weaker in 2 patients, both of whom had surgical fixation of the vertebral border of the scapula. Conclusion: The inter-teres approach may be a safe alternative approach in glenoid fixation, although the loss of ER strength needs further evaluation.

Results after cementless medial oxford unicompartmental knee replacement-incidence of radiolucent lines

OAK 3 - Non-arthroplasty tx of OAK

Purpose: Tibial radiolucent lines (RL) are commonly seen in cemented unicompartmental knee replacement (UKR). In the postoperative course, they can be misinterpreted as signs of loosening, thus leading to unnecessary revision. Since 2004, a cementless OUKR is available. First studies and registry data have shown equally good clinical results of cementless OUKR compared to the cemented version and a significantly reduced incidence of RL in cementless implants. Methods: This single-centre retrospective cohort study includes the first 30 UKR (27 patients) implanted between 2007 and 2009 with a mean follow-up of 5 years. Clinical outcome was evaluated using the OKS, AKS, range of movement (ROM) and level of pain (VAS). Standard radiologic evaluation was performed at three months, one and five years after surgery. The results five years after implantation were compared to a group of 27 cemented Oxford UKR (OUKR) in a matched-pair-analysis. Results: Tibial RL were seen in 10 implants three months after operation, which significantly decreased to five after one year and to three after five years (p = 0.02). RL did not have a significant influence on revision (p = 1.0) or clinical outcome after five years. RL were always partial, never progressive and strictly limited to the tibia. There was no significant difference in the incidence of tibial RL five years after implantation between cemented and cementless implants (cemented: 4, cementless: 3, p = 1.0). Conclusions: After cementless implantation RL were limited to the tibia, partial and never progressive. During short term follow-up the incidence of RL decreased significantly. RL seem to have no influence on clinical outcome and revision.

Intramedullary, antibiotic-loaded cemented, massive allografts for skeletal reconstruction. 26 cases compared with 19 uncemented allografts

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

We compared the outcomes of 26 intramedullary cemented massive allografts with 19 allografts without cementation; all allografts were used for reconstruction after excision of bone sarcomas. In the cementation group, 12 allografts were used as osteochondral grafts (proximal humerus 4, proximal tibia 4, and distal femur 4), 7 as intercalary diaphyseal allografts of the femur, and 7 for a knee arthrodesis. In the uncemented allografts, 3 allografts were used as osteochondral grafts (proximal humerus 2, proximal tibia 1), 2 as intercalary diaphyseal allograft of the femur, and 14 for a knee arthrodesis. The average length of follow-up was 40 (25-60) months. 14 of 26 cemented allografts had an excellent (osteotomy line: not visible) or good (fusion > or = 75% of the cortical thickness) healing of the junction site. Infection developed in 1 allograft. Fracture occurred in 4 of 12 cemented osteochondral allografts due to a subchondral collapse (all in the proximal tibia). Fractures at the junction site in the lower extremity developed in 4 of 22 cemented allografts. In 19 allografts without cementation, 11 had excellent or good healing of the junction. Late infection developed in 4 allografts, fracture of the allograft in 3 cases, and junction fracture in 3 of 17 patients with reconstruction of the lower extremity. Intramedullary graft cementation seems to reduce the fracture and infection rates

The aggregation of human platelets by Lactobacillus species

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The ability to aggregate human platelets was examined for five Lactobacillus rhamnosus strains and five Lactobacillus paracasei subsp. paracasei strains isolated from patients with infective endocarditis (IE), 25 laboratory isolates from the same two species, and 14 strains from five other oral species, namely Lactobacillus acidophilus, Lactobacillus fermentum, Lactobacillus oris, Lactobacillus plantarum and Lactobacillus salivarius. Amongst the L. rhamnosus strains, platelets were aggregated by all five IE strains and 8/16 laboratory strains. For the L. paracasei subsp. paracasei strains, the respective numbers were 2/5 and 2/9. Aggregation also occurred with 11/14 strains of the other five species; each species was represented. The optimal ratio of bacteria to platelets for aggregation was approximately 1:1, and there was considerable variation in the lag phase that preceded aggregation, depending on the source of the platelets. Overall, the lag phase varied between 0.25 +/- 0.1 and 20.4 +/- 3.2 min and the percentage aggregation ranged between 70 +/- 2.6 and 104 +/- 13.5%. Confirmation that aggregation was being observed came from studies with five strains on the inhibitory effects of EDTA, dipyridamole, apyrase, imipramine, acetylsalicylic acid and quinacrine. Inhibition of aggregation by L. rhamnosus strains by the peptide arginine-glycine-aspartic acid-serine (RGDS) further indicated a role for fibronectin and/or fibrinogen. Pronase treatment of cells for 1 h and extraction of bacterial surface components with 0.1 M-Tris/HCl (pH 8.5) at 37 degrees C for 1 h stopped aggregation in 8/9 IE strains. Extracted surface proteins (200 micrograms) completely inhibited platelet aggregation by 8/9 of the homologous strains.(ABSTRACT TRUNCATED AT 250 WORDS)

Sciatic nerve block causing heel ulcer after total knee replacement in 36 patients

Surgical Management of Osteoarthritis of the Knee CPG

Femoral and sciatic nerve blocks are often used for postoperative analgesia following total knee replacement surgery. In this report, we focus on cases of heel ulcers which occurred following the implementation of peripheral nerve block in concert with knee replacement surgery. In some instances, heel ulcers have resulted in delayed rehabilitation and prolonged hospital stays in this group of patients, which makes this phenomenon a potential burden on the healthcare system. Pressure points in the foot should be protected after the implementation of nerve blocks to prevent pressure sores. An awareness of this unusual complication related to knee replacement surgery is necessary to prevent its occurrence and avoid delays in patient rehabilitation and recovery

One-year follow-up of efficacy and cost of repeated doses versus single larger dose of intra-articular hyaluronic acid for knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Purpose: A recent 3-month randomized, open-label controlled trial found that the intra-articular hyaluronic acid injection (GO-ON®) given as a single dose of 5 mL is as effective and safe as three repeated doses of 2.5 mL in patients with knee osteoarthritis. However, the information on the long-term efficacy and economic implications of the single-dose regimen is still limited. Hence, this follow-up study was designed to compare the effectiveness and costs of the two regimens 12 months following the treatment. Methods: All the 127 patients, who received either three repeated doses (n = 64) or a single dose (n = 63) of GO-ON in the previous trial, were followed up in month 12 following the treatment. The effectiveness of both the regimens was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the mean WOMAC scores were compared with those recorded at the baseline and in month 3. Additionally, the total treatment costs of the two regimens, taking account of both direct and indirect costs, were computed and compared. Results: A total of 125 patients (98.4%) completed the assessment. Despite the reduction of the overall mean WOMAC score from 39.24 to 19.93 (p < 0.001) in the first 3 months following the treatment with GO-ON, no further changes were observed up to month 12 (p > 0.95). In the meantime, the two regimens did not differ in the mean WOMAC scores (p = 0.749) and in the subscale scores for pain (p = 0.970), stiffness (p = 0.526), and physical functioning (p = 0.667) in month 12. The cost for single-dose injection was found to be approximately 30% lower compared to the repeated doses. Conclusion: These findings indicate that the single larger dose of GO-ON is as effective as the repeated doses over 12 months, and yet the total treatment cost is lowered.

Incidence proportions and prognosis of breast cancer patients with bone metastases at initial diagnosis

MSTS 2022 - Metastatic Disease of the Humerus

Introduction: Population-based data on the incidence and prognosis of bone metastases at diagnosis of breast cancer are currently limited. Hence, we conducted this study to analyze the incidence proportions and prognostic factors of patients with breast cancer and bone metastases at the time of cancer diagnosis. Materials and methods: Patients with primary invasive breast cancer and bone metastases at initial diagnosis between 2010 and 2014 were identified using the Surveillance, Epidemiology, and End Results (SEER) dataset and Fudan University Shanghai Cancer Center (FUSCC) cohort. Multivariable logistic regression was performed to identify predictors of the presence of bone metastases at diagnosis. Univariate and multivariate analyses were performed to determine the effects of each variable on survival. Results: Of 229, 195 patients from SEER database included in the analysis, 8295 patients had bone metastases at initial diagnosis, reflecting 3.6% of the entire study population, and 65.1% of the subset with metastatic disease to any distant site. Patients with hormone receptor (HR)-positive human epidermal growth factor receptor 2 (HER2)-negative represented the highest incidence proportions among patients with metastatic disease (73.9%). Among entire cohort, multivariable logistic regression identified eight factors as predictors of the presence of bone metastases at diagnosis. Median OS for the patients with bone metastases in SEER and FUSCC cohorts was 30.0 and 68.2 months, respectively. Patients with HR-positive HER2-positive subtype had the longest median OS, and patients with triple-negative subtype showed the shortest median OS. Multivariable Cox model in SEER cohort confirmed age, histology, grade, tumor subtype, extraosseous metastatic sites, history of primary surgery, insurance status, marital status, and income as independent prognostic factors for both OS and BCSS. Conclusions: The findings of this study provide population-based estimates of the incidence and prognosis for patients with bone metastases at initial diagnosis of breast cancer.

Experience with sunitinib treatment for metastatic renal cell carcinoma in a large cohort of Israeli patients: Outcome and associated factors

MSTS 2022 - Metastatic Disease of the Humerus

Background: The VEGFR/PDGFR inhibitor sunitinib was approved in Israel in 2008 for the treatment of metastatic renal cell carcinoma (mRCC), based on an international trial. However, the efficacy of sunitinib treatment in Israeli mRCC patients has not been previously reported. Objectives: To report the outcome and associated factors of sunitinib treatment in a large cohort of Israeli mRCC patients. Methods: We conducted a retrospective study of an unselected cohort of mRCC patients who were treated with sunitinib during the period 2006-2013 in six Israeli hospitals. Univariate and multivariate analyses were performed to determine the association between treatment outcome and clinicopathologic factors. Results: We identified 145 patients; the median age was 65 years, 63% were male, 80% had a nephrectomy, and 28% had prior systemic treatment. Seventy-nine percent (n=115) had clinical benefit (complete response 5%, n=7; partial response 33%, n= 48; stable disease 41%, n=60); 21% (n=30) were refractory to treatment. Median progression-free survival (PFS) was 12 months and median overall survival 21 months. Factors associated with clinical benefit were sunitinib-induced hypertension: [odds ratio (OR) 3.6, P = 0.042] and sunitinib dose reduction or treatment interruption (OR 2.4, P = 0.049). Factors associated with PFS were female gender [hazard ratio (HR) 2, P = 0.004], pre-sunitinib treatment neutrophil-to-lymphocyte ratio = 3 (HR 2.19, P = 0.002), and active smoking (HR 0.19, P < 0.0001). Factors associated with overall survival were active smoking (HR 0.25, P < 0.0001) and sunitinib-induced hypertension (HR 0.48, P = 0.005). To minimize toxicity, the dose was reduced or the treatment interrupted in 39% (n=57). Conclusions: The efficacy of sunitinib treatment for mRCC among Israeli patients is similar to that in international data.

Posterior dislocation of a cruciate-retaining total knee arthroplasty following an acute bacterial infection

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Background: We report a rare complication of posterior dislocation of a cruciate-retaining total knee arthroplasty following an acute bacterial infection. The mechanism of dislocation proved to be septic loosening of the femoral component and a tear of the posterior cruciate ligament near to the femoral insertion site. The tear arose during the treatment of acute septic arthritis following total knee arthroplasty when the patient attempted full weight-bearing with the affected limb in a semiflexion position and twisted the knee. Methods and results: Successful treatment was provided with subsequent surgical debridement, removal of the loosened prosthesis, the application of systemic antibiotics, and a revision total knee arthroplasty utilizing a posteriorly stabilized prosthesis after adequate control of the infection. Conclusion: Soft-tissue protection from full weight-bearing of the knee during the treatment of an acute infection following total knee arthroplasty and timely removal of the loosened total knee prosthesis are recommended in order to prevent such a complication

Subconjunctival herniated orbital fat: A benign adipocytic lesion that may mimic pleomorphic lipoma and atypical lipomatous tumor

Upper Eyelid and Brow Surgery

Prolapse of subconjunctival intraconal orbital fat is a rare cause of an intraorbital mass lesion. Over the past several years, we have seen a number of cases in which this prolapsed fat was confused pathologically with a neoplasm of adipocytic lineage, specifically pleomorphic lipoma and atypical lipomatous neoplasm (well-differentiated liposarcoma). We report the clinical, histopathologic, and immunohistochemical findings in 21 specimens from 17 patients, all of whom presented with prolapsed intraconal orbital fat. All specimens were routinely examined and processed for light microscopy. Immunohistochemistry for CD34, CD68, S100 protein, vimentin, alpha-smooth muscle actin, and Ki-67, and Giemsa, Masson trichrome, and alcian blue histochemical stains were performed. Clinical and follow-up information was extracted from a chart review. The mean age (+/-SD) of the patients was 65.6+/-11.9 years (range: 41 to 85 y); 2 were women and 15 were men. Subconjunctival prolapsed orbital fat was localized in the superotemporal quadrant or lateral canthus around the rectus muscle below the lacrimal gland. The lesions were unilateral in 10 and bilateral in 7 patients. No recurrence was clinically evident over a mean (+/-SD) follow-up time of 2.5+/-3.2 years (range: 1 mo to 13.5 y). Histopathologically, all specimens showed an admixture of mature fat, fibrous septae lacking hyperchromatic cells, adipocytes with intranuclear vacuoles (Lochkern cells), multinucleated giant cells with a wreathlike configuration of normochromatic nuclei (floret cells), and varying numbers of histiocytes, lymphocytes, plasma cells, and mast cells. "Control" sections of normal orbital fat showed occasional Lochkern cells but lacked floret cells. By immunohistochemistry, the floret cells expressed only CD34 and vimentin, whereas the Lochkern cells expressed CD34, S100 protein, and vimentin. We conclude that subconjunctival herniated orbital fat commonly contains multinucleated floretlike giant cells, fibrous septae, and Lochkern cells, features that may result in diagnostic confusion with pleomorphic lipoma and atypical lipomatous neoplasms. Importantly, specific diagnostic features, such as aggregates of bland spindled cells associated with wiry collagen, as seen in pleomorphic lipoma, and enlarged hyperchromatic cells within fibrous septae, as in atypical lipomatous neoplasms, are entirely absent in herniated orbital fat. Multinucleated floret cells present in prolapsed orbital fat likely represent a reactive phenomenon, as they are not present in normal orbital fat.

Delayed celiotomy for the treatment of bile leak, compartment syndrome, and other hazards of nonoperative management of blunt liver injury

DOD - Acute Comp Syndrome CPG

BACKGROUND: Management of blunt liver injury is predominantly nonoperative. However, complications occur in 10% to 25% of patients, with half taking place more than 24 hours after injury. Few reports have addressed the management of the new pattern of these delayed complications, which is the objective of this study. METHODS: Adult patients admitted to our level one trauma center from 1995 to 2000 with blunt liver injury were identified. Demographic, physiologic and laboratory data, computed tomography (CT) and operative findings, and complications were reviewed. RESULTS: Blunt liver injury was identified in 192 patients. Thirty-nine patients (20%) underwent immediate celiotomy. The remaining 153 patients were initially managed nonoperatively. Liver-related complications developed in 19 (12%) patients. Fifteen patients underwent delayed celiotomy to treat secondary inflammatory processes, from bile leak (6), hemorrhage (5), and hepatic abscess (1), and to treat abdominal compartment syndrome (2), and decompress hepatic compartment syndrome (1). Although no deaths or complications were directly caused by delayed celiotomy, 2 deaths (11%), occurring early in this series, were attributed to liver-related complications. CONCLUSIONS: These complications, occurring in 12% of patients with liver injuries, may be a consequence of initial nonoperative management. Although these findings do not negate nonoperative management of blunt liver injury, this approach can be hazardous and requires diligence to recognize and treat delayed and potentially fatal complications.

Multiple myeloma

MSTS 2018 - Femur Mets and MM

Multiple myeloma (MM) is a malignant haematological disease characterised by a clonal population of plasma cells in the bone marrow. The disease occurs predominantly in the elderly and results in lytic bone lesions, blood cytopenias and the production of monoclonal immunoglobulin heavy and light chains. MM is an incurable condition and therefore treatment is reserved for symptomatic patients or those with documented bone lesions. The international staging system (ISS) offers a prediction of prognosis at diagnosis based on albumin and B2 microglobulin levels. Treatment involves a spectrum of health care professionals. Oral and intravenous chemotherapy, radiotherapy, stem cell transplantation and other novel therapies are all useful modes of treatment.

Introduction of intracapsular hip fractures: anatomy and pathologic features

Management of Hip Fractures in the Elderly

The morbidity, mortality, and financial burden related to intracapsular hip fractures in elderly patients in the United States will continue to increase as the population ages. An appreciation of the anatomy and pathologic features of intracapsular hip fractures is necessary for successful treatment

Prosthetic replacement of the knee joint for osteoarthritis of the knee and retropatellar osteoarthritis. When is which endoprosthesis indicated?

Surgical Management of Osteoarthritis of the Knee CPG

Having exhausted conservative and operative joint retentive treatment, alloplastic substitution of the knee joint is indicated if, apart from a strong sensation of pain, a major destruction of all joint surfaces with or without loss of motion and/or clear axial deviations with or without instabilities are roentgenologically verified. Most frequent indications for total alloplastic replacement of the knee joint are gonarthrosis, rheumatoid arthritis and posttraumatic arthrosis. Age, size, activity and habits of the patient must be taken into account during joint replacement preparation. The optimal patient for a total knee alloarthroplastic is normal weight, over than 70 years of age, healthy, and works in a sitting position. The present age limit for knee joint substitution lies between 55 and 65 years. Most important absolute contraindications are acute infections of the knee joint, lacking stretch apparatus functions, and extended soft tissue defects. Low biological age, adiposity, and frequent physical activity of the patient are relative contraindications. Indication of surface replacement prosthesis (non- and semi-constrained) resp. connected hinge prosthesis (with and without axial rotation) and choice of the most suitable prosthesis are dependent on the quality of passive and active stabilizers, i.e. from the type of deformity, basic illness, patient type and, above all, on empirically established clinical results. Since the introduction of surface replacement prosthesis, indication for form-conclusive models has been limited to extreme joint deformities in connection with ligamentary instability, and to revisions. In any other case, non-constrained and semiconstrained surface replacement prosthesis are indicated depending on the condition of the involved tissue. It is both recommended to replace the patella as a matter of routine, and not to replace it at all, or to provide only some knee joints with a patella back surface replacement. Indications for the substitution of the patella back surface are rheumatic arthritis, eburnated bones in the patello-femoral joint, cystic changes in the patella, lack of congruence between patella and patella slide channel of the femural component as well as a bad patella guidance. Absolute contraindication for patella back surface replacement is an insufficient patella bone basis on which an adequate component bracing cannot be achieved. With most patients with rheumatic arthritis, the patella back surface ought to be replaced. Indication of unicompartimental knee joint substitution is retrograde in recent years. The unicompartimental arthroplastic is only indicated with older, normal weight patients of 60 years and more with an illness of the medial or lateral knee joint half without any strong deformity or instability due to osteoarthrosis, osteonecrosis, or traumatic arthrosis. Essential prerequisites for the implantation of an unicondylar sleigh prosthesis are intact cruciate and collateral ligaments, malpositions under 20(degrees), and a flexion contracture under 10(degrees)

The relationship between the OSTEODENT index and hip fracture risk assessment using FRAX

Management of Hip Fractures in the Elderly

OBJECTIVES: The OSTEODENT index is a predicted probability of osteoporosis derived from a combination of an automated analysis of a dental panoramic radiograph and clinical information. This index has been proposed as a suitable case-finding tool for identification of subjects with osteoporosis in primary dental care; however, no data exist on the relationship between OSTEODENT index and fracture risk. The aims of this study were to assess the relationship between the OSTEODENT index and hip fracture risk as determined by FRAX and to compare the performance of the OSTEODENT index and FRAX (without femoral BMD data), in determining the need for intervention as recommended in UK national treatment guidance. STUDY DESIGN: The study was a retrospective analysis of data from 339 female subjects (mean age 55.3 years), from 2 centers: Manchester (UK) and Leuven (Belgium). Clinical information and femoral neck BMD were available for FRAX, and dental panoramic radiographic data and clinical information were available to calculate the OSTEODENT index. Subjects were classified into "treat" or "lifestyle advice and reassurance" categories using the National Osteoporosis Guideline Group (NOGG) threshold. RESULTS: The OSTEODENT index result was significantly related to the 10-year probability of hip fracture derived from the reference standard FRAX tool (Rs = 0.67, P < .0001); 84 patients (24.8%) were allocated to the "treat" category on the basis of FRAX and the UK national guidance. Using this "treatment/no treatment" classification as the reference standard, ROC analysis showed no significant difference between areas under the curves for the OSTEODENT index (0.815) and the 10-year probability of hip fracture derived from the FRAX index without BMD (0.825) when used as tests for determining therapeutic intervention. CONCLUSION: The results suggest that the OSTEODENT index has value in prediction of hip fracture risk. Prospective trials are needed to confirm this finding and to examine the feasibility for its use in primary dental care

Perioperative mortality after hemiarthroplasty related to fixation method

Management of Hip Fractures in the Elderly

Background and purpose: The appropriate fixation method for hemiarthroplasty of the hip as it relates to implant survivorship and patient mortality is a matter of ongoing debate. We examined the influence of fixation method on revision rate and mortality. Methods We analyzed approximately 25,000 hemiarthroplasty cases from the AOA National Joint Replacement Registry. Deaths at 1 day, 1 week, 1 month, and 1 year were compared for all patients and among subgroups based on implant type. Results Patients treated with cemented monoblock hemiarthroplasty had a 1.7-times higher day-1 mortality compared to uncemented monoblock components (p < 0.001). This finding was reversed by 1 week, 1 month, and 1 year after surgery (p < 0.001). Modular hemiarthroplasties did not reveal a difference in mortality between fixation methods at any time point. Interpretation This study shows lower (or similar) overall mortality with cemented hemiarthroplasty of the hip. (copyright) 2011 Nordic Orthopaedic Federation

Femoral condyle geometry in the normal and varus knee

Surgical Management of Osteoarthritis of the Knee CPG

Femoral condyle geometry was evaluated in 30 normal and 30 varus knees using magnetic resonance imaging. In the sagittal view, the distal part of the medial condyle was deformed in the varus knees, but there was no significant difference in the posterior part of the medial condyle between the normal and varus knees. In the transverse view, the transepicondylar axis (a reliable rotational landmark) showed approximately 6 degrees external rotation relative to the posterior condylar axis in the varus knees and the normal knees. The results of this study suggest that no hypoplasia exists at the posterior part of the medial condyle in varus knees. In addition, the posterior condylar axis may be a reliable rotational landmark but is in relative internal rotation in varus knees when total knee arthroplasty is performed

A cost-minimisation study of alternative discharge policies after hip fracture repair

HipFx Supplemental Cost Analysis

It is widely assumed that health care costs can be reduced considerably by providing care in appropriate health care institutions without unnecessary technological overhead. This assumption has been tested in a prospective study. Conventional discharge after hip fracture surgery was compared with an early discharge policy in which patients were discharged to a nursing home with specialised facilities for rehabilitation. We compared costs for both strategies from a societal perspective, using comprehensive and detailed data on type of residence and all kinds of medical consumption during a 4-month follow-up period. As expected, early discharge reduced the hospital stay (with 13 days, p=0.001). More patients were discharged to a nursing home (76% versus 53%). Total medical costs during follow-up were reduced from an average of euro;15338 to euro;14281, representing relatively small and not significant savings (p=0.3). There are two explanations for this unexpected result. First, costs incurred by hip fracture patients were relatively less while in hospital. Hence, nursing home costs almost equalled hospital costs per admission day. Second, compared with the conventionally discharged group early discharged patients were subjected to more medical procedures during the first post-operative days. We conclude that: (1). early discharge shifted rather than reduced costs; (2). the details of costing have a major influence on the cost-effectiveness of alternative discharge policies

Primary viscocanalostomy for juvenile open-angle glaucoma

Upper Eyelid and Brow Surgery

PURPOSE: To evaluate the efficacy and safety of primary viscocanalostomy for medically uncontrolled juvenile open-angle glaucoma (JOAG). DESIGN: Prospective, noncomparative, interventional case-series study. METHODS: The study included 20 eyes of 20 consecutive patients with medically uncontrolled JOAG who were treated by viscocanalostomy at one institution. No surgical or laser procedure preceded viscocanalostomy. Surgical outcome was defined as an overall success by the following criteria: no visual field deterioration, no optic-neuropathy progression, postoperative intraocular pressure IOP < or =20 mm Hg, and IOP reduction > or =30% compared with baseline values with or without medication. When medications were not required, success was defined as complete. Cases that did not fulfill the aforementioned criteria and cases in which a surgical revision or further goniopuncture was performed were defined as a failure. RESULTS: Gender distribution was similar. Fourteen eyes belonged to the white race; five eyes belonged to the black race, and one eye belonged to Arab ethnicity. Mean age (+/-SD) at operation was 33.77 +/- 6.16 years, with the mean preoperative IOP (+/-SD) at 22.9 +/- 4.77 mm Hg. Thirty-six months after operation, 16 cases (80%) were considered an overall success. In 11 cases (55%), success was complete. Four cases (20%) were considered failures. No serious complications were documented either during or after operation. In two cases (10%), we documented a spontaneously reabsorbed microhyphema. Trabeculo-Descemet-membrane microperforation occurred in two cases (10%). In two other cases (10%), Trabeculo-Descemet-membrane perforation occurred and was accompanied by iris prolapse that needed peripheral iridectomy. CONCLUSION: Primary viscocanalostomy can efficiently and safely reduce intraocular pressure in cases of medically uncontrolled JOAG and provide a rational alternative to conventional surgical modalities.

A randomized, double-blind, double-dummy comparison of the efficacy and tolerability of low-dose transdermal buprenorphine (BuTrans seven-day patches) with buprenorphine sublingual tablets (Temgesic) in patients with osteoarthritis pain

OAK 3 - Non-arthroplasty tx of OAK

CONTEXT: Osteoarthritis (OA) is a common cause of chronic pain, particularly in the older population. Modern approaches to the management of OA pain recommend tailoring treatment to the individual. This study examines treatment options for OA pain in the form of low�dose transdermal and sublingual opioid analgesia. OBJECTIVES: The aims of this trial were to compare the efficacy and tolerability of seven�day, low�dose transdermal buprenorphine patches (BuTrans, Napp Pharmaceuticals Limited UK) with sublingual buprenorphine (Temgesic, Schering�Plough Limited UK) in patients with moderate to severe pain caused by OA of the hip(s) and/or knee(s), and to establish analgesic equivalence of the two products. METHODS: Two hundred forty�six patients with OA pain in the hip(s) and/or knee(s) were enrolled in this randomized, double�blind, parallel�group study; 110 completed the study. Patients were randomized to receive transdermal buprenorphine patches (5, 10, and 20 microg/hour) or sublingual buprenorphine (200 and 400 microg tablets). Their medication was titrated to pain control and they were treated for up to seven weeks. The main outcome measures were pain intensity (primary outcome), sleep disturbance, quality of life, and safety assessments. RESULTS: Patients' Box Scale�11 pain scores decreased between entry and assessment in both treatment groups. During the 28�day assessment period, the estimated mean treatment differences (95% confidence intervals) were 0.00 (�0.68,0.69), �0.11 (�0.85,0.63), and �0.13 (�0.95,0.68), for the morning, midday, and evening scores, respectively. All the confidence intervals were within the prespecified limits for equivalence (�1.5, 1.5). Use of escape medication was low. In both treatment groups, sleep disturbance caused by pain decreased between entry and assessment. Patients' quality of life improved during the study. Significantly fewer patients receiving the transdermal buprenorphine patches reported nausea (P=0.035), dizziness (P=0.026), and vomiting (P=0.039). CONCLUSION: In conclusion, seven�day, low�dose transdermal buprenorphine patches are as effective as sublingual buprenorphine, with a better tolerability profile.

Superior medial geniculate artery pseudoaneurysm after primary total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Vascular complications after total knee arthroplasty are rare. To date, there are 7 reported cases of pseudoaneurysms affecting the popliteal artery and 6 cases affecting one of the geniculate arteries. We present a case of a geniculate artery pseudoaneurysm that shared symptoms of a deep venous thrombosis on physical examination of a patient who underwent primary total knee arthroplasty. To date, there are no reports in American literature of pseudoaneurysms affecting the superior medial geniculate artery after primary total knee arthroplasty. After a vascular workup including computed tomographic angiography, surgical management included evacuation of the pseudoaneurysm and ligation of the feeding artery. The patient went on to successful recovery

Magnetic resonance imaging characterization of orbital changes with age and associated contributions to lower eyelid prominence

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Multiple orbital aging models have been suggested to explain the progressive development of lower eyelid prominence. Objective data to support these theories are limited, however. METHODS: Orbital anatomy was measured with high-resolution orbital magnetic resonance imaging in the quasi-sagittal plane parallel to the long axis of the orbit passing through the globe center. The association between measurements and age was analyzed by stratifying subjects into predetermined age groups and as a continuous variable. RESULTS: Forty subjects (17 men and 23 women) were imaged and are reported by age group: 12 to 29 years, 30 to 54 years, and 55 to 80 years. Inferior periocular soft-tissue area anterior to the anteroposterior globe axis increased with age: 99, 103, and 131 mm (p = 0.008), respectively. The largest contributor to this size increase was fat expansion: 28, 31, and 43 mm (p = 0.009), respectively. Total orbital fat also increased with age: 335, 377, and 398 mm, respectively (p = 0.035). The globe position relative to the inferior orbit in both the anteroposterior and the superoinferior planes remained unchanged. CONCLUSIONS: The authors' measurements suggest that with aging there is a significant increase in anterior inferior periocular soft-tissue volume, and that fat expansion is the main contributor to this volume increase. These observations provide supporting evidence that orbital fat expansion occurs with age and is the primary age-associated contributor to lower eyelid prominence, rather than globe descent or fat repositioning caused by weakening of the orbital septum. We believe these data suggest that fat excision should be a component of treatment for lower eyelid prominence. Copyright © 2008 by the American Society of Plastic Surgeons.

Clinical and radiological results of high flex total knee arthroplasty: a 5 year follow-up

Surgical Management of Osteoarthritis of the Knee CPG

INTRODUCTION: In a prospective randomized study, we compared the results after implantation of the mobile bearing high flex TKA with a fixed bearing posterior stabilized TKA in 60 patients (30 patients each group). METHOD: We evaluated the hospital for special surgery-score (HSS) and different radiological parameters preoperatively, as well as 3 months, 3 and 5 years postoperatively. RESULT: Three months postoperatively, the high flex group showed better results in scores for pain, ROM (122.5 degrees vs. 107.33 degrees), as well as in the overall HSS (87.21 vs. 82.68 points). Three and 5 years postoperatively, there were no differences between both the groups in all scores, but the HSS is still increasing. CONCLUSION: The theoretical advantages of the mobile bearing knee prostheses were reflected in the clinical results, only partly and temporarily

Comparison of 18F-DOPA, 18F-FDG and 68Ga-somatostatin analogue PET/CT in patients with recurrent medullary thyroid carcinoma

MSTS 2018 - Femur Mets and MM

PURPOSE: To retrospectively evaluate and compare (18)F-FDG, (18)F-DOPA and (68)Ga-somatostatin analogues for PET/CT in patients with residual/recurrent medullary thyroid carcinoma (MTC) suspected on the basis of elevated serum calcitonin levels. METHODS: Included in the study were 18 patients with recurrent MTC in whom functional imaging with the three tracers was performed. The PET/CT results were compared on a per-patient basis and on a per-lesion-basis. RESULTS: At least one focus of abnormal uptake was observed on PET/CT in 13 patients with (18)F-DOPA (72.2% sensitivity), in 6 patients with (68)Ga-somatostatin analogues (33.3%) and in 3 patients with (18)F-FDG (16.7%) (p < 0.01). There was a statistically significant difference in sensitivity between (18)F-DOPA and (18)F-FDG PET/CT (p < 0.01) and between (18)F-DOPA and (68)Ga-somatostatin analogue PET/CT (p = 0.04). Overall, 72 lesions were identified on PET/CT with the three tracers. (18)F-DOPA PET/CT detected 85% of lesions (61 of 72), (68)Ga-somatostatin analogue PET/CT 20% (14 of 72) and (18)F-FDG PET/CT 28% (20 of 72). There was a statistically significant difference in the number of lymph node, liver and bone lesions detected with the three tracers (p < 0.01). In particular, post-hoc tests showed a significant difference in the number of lymph node, liver and bone lesions detected by (18)F-DOPA PET/CT and (18)F-FDG PET/CT (p < 0.01 for all the analyses) and by (18)F-DOPA PET/CT and (68)Ga-somatostatin analogue PET/CT (p < 0.01 for all the analyses). The PET/CT results led to a change in management of eight patients (44%). CONCLUSION: (18)F-DOPA PET/CT seems to be the most useful imaging method for detecting recurrent MTC lesions in patients with elevated serum calcitonin levels, performing better than (18)F-FDG and (68)Ga-somatostatin analogue PET/CT. (18)F-FDG may complement (18)F-DOPA in patients with an aggressive tumour.

Fixation, survival and osteolysis with a modern posterior-stabilized total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Early failure of the NexGen prosthesis with a 3(degrees) fluted, 4 hole tibial component has been reported. We evaluated fixation, survival and osteolysis with the NexGen LPS prosthesis with a 7(degrees) fluted, solid tibial component at a mean of 10. years. Knees were evaluated using Knee Society and LEAS scores, survival analysis, and univariable modeling. No knee had tibial loosening or debonding. With the endpoint mechanical failure (132 knees), the 12. year survival was 88.8% (CI 61.5-97.1).With failure defined as any reoperation (132 knees), the 12. year survival was 88.1% (CI 62.3-96.7). Osteolysis occurred in 16 knees, associated with male gender and LEAS score. >. 10. Loosening was not seen with this tibial component. (copyright) 2014 Elsevier Inc

Plication of Neck Strap Muscles and Platysma for Double Chin Correction - A Retrospective Study

Panniculectomy & Abdominoplasty CPG

INTRODUCTION: There is an increased need for recontouring chin and submental areas for esthetic reasons. Reports of such surgeries across the world are present in the literature. India too has its share of chin and neck reconstruction needs. This study was carried out to document a single-center experience of authors' approach in isolated submentoplasty. MATERIALS AND METHODS: A retrospective analysis of case records of submentoplasty during 2012-2017 was collated. Cases fulfilling inclusion and exclusion criteria were selected for this study. A qualitative assessment of the outcomes was performed. RESULTS: Sixteen cases who had undergone isolated submental lipectomy with platysma plication formed the study group. The mean age was 44.38 ± 5.49, with a range of 37-54 years. There were 9 females and 7 males. The mean age of females was 42.89 ± 4.01, while for males, it was 46.29 ± 6.79 years. The mean follow-up ranged for 16.2 ± 3.4 months (14-20 months). None of the patients had major complications. DISCUSSION AND CONCLUSION: The modified mini-neck lift approach for an isolated submental lipectomy and strap muscles of suprahyoid group with platysma plication is presented. Careful manipulation of the fat removal, plication of platysma, strap muscle and positioning of incision would help to a greater extent. The anatomical challenges for this variation are discussed.

Bacteremia following intraoral suture removal

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Following dental extractions, prophylactic antibiotic protection of patients at high risk of cardiovalvular infection is usually discontinued before suture removal. To determine whether bacteremia is created upon removal of intraoral sutures, twenty healthy patients who required extractions of at least five erupted teeth and placement of several sutures were selected without regard to sex, age, or race. Blood samples were drawn preoperatively, immediately after the extractions, before suture removal, and immediately following removal of the intraoral silk sutures. The samples were cultured in prereduced and aerobic media suitable for quantitative colony counts. Fourteen of 16 patients yielded positive blood cultures following tooth extractions. One of 20 patients yielded a positive blood culture following suture removal. Even though the incidence of bacteremia following intraoral suture removal is relatively low (5%), this study suggests that intraoral suture removal is not a benign procedure for those persons who are considered high-risk cardiac patients

Retrospective study of outcomes in hyalgan(R)-treated patients with osteoarthritis of the knee

Surgical Management of Osteoarthritis of the Knee CPG

Objective: To evaluate therapeutic success [defined as lack of total knee replacement surgery (TKR) or other significant clinical intervention during a 6-month follow-up] and to identify baseline patient and disease characteristics associated with improved pain relief and quality of life (QOL) in patients in a clinical practice who were treated with a single course of Hyalgan(R) (intra-articular hyaluronan) for pain associated with osteoarthritis (OA) of the knee. Design and setting: This was an uncontrolled, retrospective study conducted at a single US clinical orthopaedic practice. Patients: 248 patients with moderate to severe OA of the knee. Intervention: All patients received a single course of intra-articular Hyalgan(R) therapy during an 18-month period, and had a radiogram of the treated knee within the 6 months before treatment. Results: A total of 218 of 363 (60.1%) knees (248 patients) with moderate to severe OA were judged successfully treated over a 6-month follow-up period; only 20.3% of cases required TKR. On the basis of a multivariate analysis that correlated improvements in pain and QOL assessed by a retrospective questionnaire with baseline patient and disease characteristics, taller patients (>165cm), patients with less severe OA, and patients with patellofemoral compartment involvement had the greatest improvement in pain relief and quality of life following treatment with Hyalgan(R). Conclusions: Hyalgan(R) was effective in patients with moderate to severe OA, and may have delayed TKR in 80% of patients. Taller patients, patients with less severe OA, and patients with patellofemoral compartment involvement showed the greatest pain relief and improvements in QOL

Effects of information framing on the intentions of family physicians to prescribe long-term hormone replacement therapy

Management of Hip Fractures in the Elderly

OBJECTIVE: To determine whether the way in which information on benefits and harms of long-term hormone replacement therapy (HRT) is presented influences family physicians' intentions to prescribe this treatment.DESIGN: Family physicians were randomized to receive information on treatment outcomes expressed in relative terms, or as the number needing to be treated (NNT) with HRT to prevent or cause an event. A control group received no information.SETTING: Primary care.PARTICIPANTS: Family physicians practicing in the Hunter Valley, New South Wales, Australia.INTERVENTION: Estimates of the impact of long-term HRT on risk of coronary events, hip fractures, and breast cancer were summarized as relative (proportional) decreases or increases in risk, or as NNT.MEASUREMENTS AND MAIN RESULTS: Intention to prescribe HRT for seven hypothetical patients was measured on Likert scales. Of 389 family physicians working in the Hunter Valley, 243 completed the baseline survey and 215 participated in the randomized trial. Baseline intention to prescribe varied across patients-it was highest in the presence of risk factors for hip fracture, but coexisting risk factors for breast cancer had a strong negative influence. Overall, a larger proportion of subjects receiving information expressed as NNT had reduced intentions, and a smaller proportion had increased intentions to prescribe HRT than those receiving the information expressed in relative terms, or the control group. However, the differences were small and only reached statistical significance for three hypothetical patients. Framing effects were minimal when the hypothetical patient had coexisting risk factors for breast cancer.CONCLUSIONS: Information framing had some effect on family physicians' intentions to prescribe HRT, but the effects were smaller than those previously reported, and they were modified by the presence of serious potential adverse treatment effects

Single-Staged Total Body Lift after Massive Weight Loss

Panniculectomy & Abdominoplasty CPG

This is a retrospective clinical report of a single-staged total body lift in 8 massive weight loss patients. While the combination of circumferential abdominoplasty, a modified lower body lift, and medial thighplasty adequately treats the lower torso and thighs, the residual skin laxity in the upper torso and breasts leaves an incomplete result. Hence, a 2-stage total body lift was designed. The second stage, called the upper body lift, removes epigastric and midback rolls of skin, adjusts the inframammary fold, and reshapes the breast or corrects gynecomastia, leaving behind a near circumferential transverse scar partially hidden by the breasts. In selected patients, a complete torso correction, the total body lift, was done in a single stage. Four to 31 months later, 7 of the 8 patients were satisfied. One male with ultrasonic-assisted lipoplasty and a lateral skin excision found the chest skin too loose. Blood transfusions ranged from none to 4 units. The operations range from 7 to 12 hours of general anesthesia. Hospital stays were from 3 to 4 days. The complications included 3 resolved seromas, 2 minor wound infections due to fat and skin necrosis, and 1 minor skin dehiscence. One patient was readmitted to the hospital due to hypoalbuminemia and generalized edema. Scar revisions and liposuction are scheduled for 2 patients. Single stage total body lift is effective and safe in selected patients after massive weight loss when performed by a plastic surgeon and team experienced in body contouring surgery.

The femoral supracondylar nail: preliminary experience

Management of Hip Fractures in the Elderly

The treatment of supracondylar fractures of the femur with an intramedullary nail presents some theoretical advantages. Compared to plate osteosynthesis, intramedullary fixation requires less extensive dissection and is biomechanically more favorable. In the elderly patient, these characteristics seem important since bone quality, extensive procedures and bone grafting remain problematic. Since August 1994 we have treated 16 consecutive closed fractures of the distal femur (A.O. type: 7 A.1, 2 A.3, 4 C.1, and 3 C.2) with the Green-Seligson-Henry intramedullary retrograde supracondylar nail. Twelve elderly and osteoporotic patients had suffered low-energy trauma, three young patients had been involved in a traffic accident and one other young patient had attempted suicide. The operative technique, complications and results are described. All fractures healed within a few months (2 to 7) without bone grafting. No failure of the fixation material and no deep infection were encountered. With most elderly patients the functional result was judged satisfactory, considering the population studied. Intraoperative determination of alignment and avoiding shortening were the major difficulties, especially with long oblique or comminuted fractures. Two major complications were encountered in the young population. In one instance nail protrusion in the intercondylar notch caused a deep patellar cartilage erosion and sympathetic distrophy leading to a 15 degrees flexion deformity. Another young patient needed a quadriceps release at the fracture site and subsequently a femoral valgus osteotomy in order to achieve an acceptable final result. In elderly osteoporotic patients presenting an isolated supracondylar fracture, antegrade nailing remains the "safest" technique by avoiding an unnecessary arthrotomy. When previous hip or knee surgery precludes the use of antegrade nailing techniques or when the fracture extends into the intercondylar region, retrograde supracondylar nailing offers some advantages compared to conservative treatment or plate osteosynthesis. On the other hand in young patients, anatomic reduction and alignment should be the goal, and open reduction with plate osteosynthesis, supplemented by bone grafting if needed, should remain the gold standard. When this seems technically impossible, the antegrade or retrograde insertion of an intramedullary nail with intraoperative assessment of length and fracture alignment is an interesting alternative

Pain relief in day care arthroscopic knee surgery: A comparison between intra-articular ropivacaine and levobupivacaine: A prospective, double-blinded, randomized controlled study

Surgical Management of Osteoarthritis of the Knee CPG

Background: Post-operative pain frequently hampers implementation of day care arthroscopic knee surgery in spite of so many analgesic, local anesthetic drugs and routes of administration. Aims: The aim of the present study was carried out to compare the efficacy of ropivacaine and levobupivacaine when administered through intra-articular route in controlling pain after day care arthroscopic knee surgery. Setting and Design: It was a prospective, double-blinded and randomized controlled study. Materials and Methods: April 2008-December 2008, 60 patients of both sex, of American Society of Anesthesiologists physical status I and II, undergoing day care arthroscopic knee surgery were randomly assigned into two groups (R, L). Group R received 10 ml of 0.75% ropivacaine, whereas group L received 10 ml of 0.50% levobupivacaine through intra-articular route at the end of the procedure. Pain assessed using visual analog scale (VAS) and diclofenac sodium given as rescue analgesia when VAS >3. Time of first analgesic request and total rescue analgesic were calculated. Statistical Analysis and Results: based on comparable demographic profiles; time for the requirement of first post-operative rescue analgesia (242.16 (plus or minus) 23.86 vs. 366.62 (plus or minus) 24.42) min and total mean rescue analgesic requirement was (104.35 (plus or minus) 18.96 vs. 76.82 (plus or minus) 14.28) mg in group R and L respectively. Group R had higher mean VAS score throughout the study period. No side effects found among the groups. These two results were clinically and statistically significant (P < 0.05). Conclusion: Hence, it was evident that intra-articular levobupivacaine give better post-operative pain relief, with an increase in time of first analgesic request and decreased need of total post-operative analgesia compared with ropivacaine

Perioperative changes in cerebral ischemic markers in the cerebrospinal fluid after preoperative nimodipine treatment

Management of Hip Fractures in the Elderly

BACKGROUND: Elderly patients with previous organ damage are at risk for minor neurologic deficits after major surgery. Spinal catheter analgesia is used whenever possible in this group and enables regular cerebrospinal fluid (CSF) sampling. Nimodipine, a calcium blocker, may have neuroprotective effects. We examined whether preoperative treatment with nimodipine affects ischemic markers in the CSF during extracranial surgery.METHODS: We performed a prospective, randomized, placebo-controlled, double-blind study in patients (ASA III or IV, 65-85 years) that underwent elective implantation surgery of the hip joint with intrathecal catheter anesthesia. Starting 15 h before surgery, patients received either 30 microg x kg(-1) h(-1) of nimodipine (n = 20) or 0.9% saline solution (placebo, n = 23) as a central venous infusion. The concentrations of neuron-specific enolase, hypoxanthine, creatine-kinase, lactate and pH in the CSF were determined before and immediately after surgery as well as 6 and 24 h after surgery.RESULTS: Before surgery, the baseline CSF pH was normal in all patients. Immediately after surgery it fell significantly to 7.08 +/- 0.29 in the placebo group and non-significantly to 7.27 +/- 0.38 in the treatment group; all values were normalized at 6 and 24 h after surgery in both groups. In the placebo group, lactate levels rose significantly from 1.48 +/- 0.28 mmol l(-1) before surgery to 1.77 +/- 0.27 mmol l(-1) immediately after surgery, and to 2.03 +/- 0.32 mmol l(-1) 24 h after surgery. In the treatment group, lactate concentrations remained stable up to 6 h after surgery (1.55-1.62 mmol l-1), while an increase to 2.10 +/- 0.48 mmol l(-1) was observed 24 h after the operation. Neuron-specific enolase, hypo-xanthine and creatine-kinase showed no change in either group.CONCLUSION: In conclusion, preoperative nimodipine treatment reduced intraoperative CSF acidosis and delayed surgery-related increases in lactate concentration in the CSF by several hours in elderly, comorbid patients at risk for minor postoperative neurologic deficits

Dental occlusion and posture: An overview

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Objectives: In recent decades, it has been suggested that disorders of the masticatory system such as malocclusions, can influence whole body posture. A growing number of patients are seeking concomitant treatment for dental malocclusions and postural disorders. The aim of this overview is to critically analyze the relationship between dental occlusion and posture. Materials and methods: A literature overview was carried out to analyze the association between " malocclusion" versus " head posture", " spine curvature", and " body sway" Results: The studies showed that even if some associations have been found between occlusal factors and postural alterations, there is not enough scientific evidence to support a cause-effect relations. Most studies suffer from major flaws such as lack of control groups, failure to take into account for the possible confounders, inappropriate study design, and lack of sufficient reliability and validity of used diagnostic tests. Conclusions: On the basis of this overview, it is not advisable to perform occlusal and/or orthodontic treatment, especially if irreversible and expensive, to treat or prevent postural imbalances or alteration of spine curvatures. (copyright) 2011 Societa Italiana di Ortodonzia SIDO

Primary Hinged External Fixation of Terrible Triad Injuries and Olecranon Fracture-Dislocations of the Elbow

Distal Radius Fractures

This study aimed to introduce a new treatment that apples primary hinged external fixation for complex fracture-dislocations of the elbow in 12 cases. We retrospectively assessed the functional outcomes of eight patients with terrible triad injuries and three patients with an olecranon fracture-dislocation of the elbow, who were treated at our hospital using a primary hinged external fixator between June 2012 and December 2014. Ten patients underwent repair or replacement of the radial head, while three underwent repair of the olecranon. In principle, they were treated without reconstruction of the coronoid fracture and collateral ligament injury. The patients were evaluated for a mean follow-up period of 16 months after the initial surgery. Early mobilization was encouraged while the hinged external fixator was in place. At the follow-up, the mean Mayo Elbow Performance Score was 93 points; the results were "excellent" in six cases and "good" in five. No patients had recurrent elbow instability. Only one patient needed an additional procedure after the initial operation. These results suggested that primary hinged external fixation without repair of the ligament and soft tissue is an effective minimally invasive surgery for the management of terrible triad injuries and olecranon fracture-dislocations of the elbow.

Local effects of malignancy on bone

MSTS 2018 - Femur Mets and MM

PURPOSE OF REVIEW: Skeletal-related complications occur commonly in many solid tumors including breast, prostate and lung cancer as well as multiple myeloma. In addition, malignancies and their associated treatment may result in bone loss or osteoporosis. This review will focus solely on recent data associated with metastatic bone disease with a focus on breast cancer, prostate cancer and multiple myeloma. Bone loss or osteoporosis associated with cancer will be covered in a separate article in this issue. RECENT FINDINGS: Recent progress in understanding the pathophysiology of bone metastases has pointed to several novel pathways: transforming growth factor beta; receptor activator of nuclear factor beta ligand and osteoprotegerin; and Wnt signaling pathways and associated factors such as dickkopf-1 and endothelin-1. SUMMARY: The identification of new pathways is important in metastatic bone disease from cancer and has allowed for the development of novel therapeutics aimed at preventing the devastating complications of bone metastases. Bisphosphonates remain the predominant therapy in use for the treatment and prevention of skeletal-related adverse effects from cancer. [References: 41]

Amoxycillin-resistant streptococci in dental plaque

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

This investigation was undertaken to study the prevalence of amoxycillin-resistant oral streptococci in normal healthy patients and patients with a cardiac condition, susceptible to infective endocarditis. Samples of supragingival dental plaque were collected from two test groups, children with congenital heart disease and adults with a history of rheumatic fever, and two control groups comprising normal healthy children and normal healthy adults. Bacteria from these samples were grown on a medium selective for oral streptococci, as well as on the same medium containing known concentrations of amoxycillin. The results indicate that a high percentage of rheumatic heart patients and children with congenital heart disease harboured amoxycillin-resistant oral streptococci. The level of amoxycillin resistance in the plaque of adults with rheumatic heart disease was significantly greater than in that of normal adults. In view of the high percentage of patients at risk harbouring amoxycillin-resistant streptococci, it is important that the individual clinical situation be monitored. Perhaps antibiotic sensitivity tests should be performed to select an appropriate antibiotic for prophylaxis of infective endocarditis

Impact of exercise on bone health and contraindication of oral contraceptive use in young women

Management of Hip Fractures in the Elderly

PURPOSE: The effect of quantified resistance and high impact exercise training on bone mass as modified by age and oral contraceptive (OCont) use in young women was studied.METHODS: Women were categorized by age (18-23 vs 24-31 yr) and OCont use, and were then randomized into either three sessions of resistance exercise plus 60 min.wk-1 of jumping rope or a control group for 24 months. Total body, spine, femoral neck, greater trochanter, Ward's area, and radial bone mineral density (BMD) and/or content (BMC), biochemical markers of bone turnover, dietary intake of calcium, lean body mass, maximal oxygen uptake, and strength were determined at baseline and every 6 months.RESULTS: Total body (TB) BMC percent change from baseline was higher in exercisers compared with nonexercisers at 6 and 24 months. OCont users had lower bone turnover at baseline and a decrease in TBBMC from baseline compared with non-OCont users at 24 months. Spine BMC and BMD decreased in the exercise and OCont group at 6 months and remained significantly below nonexercisers who used oral contraceptives at 2 yr. Femoral neck BMD also decreased in the exercise and oral contraceptive group at 6 months.CONCLUSIONS: Exercise prevented a decline in TBBMC seen in the nonexercisers. On the other hand, exercise in oral contraceptive users prevented the increase observed in the spine of the nonexercise plus OCont group

Relationship of femoral head and acetabular size to the prevalence of dislocation

Management of Hip Fractures in the Elderly

Two clinical studies, one prospective randomized and one retrospective, were performed to evaluate the relationship of femoral head size and acetabular component outer diameter to the prevalence of dislocation of the modular total hip replacement. Between October 1995 and April 1996, 31 primary total hip arthroplasties in 30 patients were randomized to a femoral head diameter of 22 mm or 28 mm, for two groups of acetabular components of outer diameters of 56 mm or larger and 54 mm or smaller. Head size (22 mm) and acetabular component outer diameter ((greater-than or equal to) 56 mm) were found to increase the risk of dislocation. From December 1984 to January 1994, 308 primary total hip arthroplasties were performed through a posterior approach by one surgeon using a modular 28 mm femoral head and one type of uncemented acetabular component. The rate of dislocation for acetabular components with an outer diameter of 62 mm or larger was increased significantly (five of 36 hips, 14 %) compared with those with an outer diameter of 60 mm or smaller (11 of 272 hips, 4%)

Hospital characteristics and quality of care

Management of Hip Fractures in the Elderly

OBJECTIVE: To compare quality of care measured by explicit criteria, implicit review, and sickness-adjusted outcomes at different types of hospitals. DESIGN: Further analysis of data retrospectively abstracted from medical records to evaluate the effects of prospective payment on quality of care for hospitalized Medicare patients. SETTING: Hospitals in five states were sampled to represent the national Medicare admissions along many dimensions. PATIENTS: A total of 14,008 elderly patients with one of the following five diseases: congestive heart failure, acute myocardial infarction, pneumonia, stroke, or hip fracture. These patients were randomly sampled from those with these diseases in 297 hospitals in two time periods, 1981 to 1982 and 1985 to 1986. OUTCOME MEASURES: Explicit criteria, implicit review, and mortality within 30 days of admission adjusted for sickness at admission. RESULTS: Quality of care ratings for hospital types are similar using explicit criteria, implicit review, and outcomes adjusted for sickness at admission. Quality differences between types of hospitals were large, with the lowest group estimated to have four percentage points higher mortality than major teaching hospitals in a cohort of patients with average mortality of 16%. Quality varies from state to state, but teaching, larger, and more urban hospitals have better quality in general than nonteaching, small, and rural hospitals. Hospital quality persists over time, but small nonteaching hospitals narrowed the gap with better quality hospitals between 1981 and 1986. CONCLUSIONS: The different measures led to consistent and plausible relationships between quality and hospital characteristics. Thus, valid information about hospital quality can be obtained. We need to develop ways to use such information to improve care

Advantages of exercise in rehabilitation, treatment and prevention of altered morphological features in knee osteoarthritis. A narrative review

OAK 3 - Non-arthroplasty tx of OAK

Knee osteoarthritis (OA) represents one of the most common causes of disability in the world. It leads to social, psychological and economic costs with financial consequences, also because a further increase is expected. Different knee OA treatments are usually considered in relation to the stage of the disease, such as surgical management and pharmacologic and non-pharmacologic treatments. Treatment should begin with the safest and least invasive one, before proceeding to more invasive, expensive ones. Non-pharmacologic, behavioral treatments of knee OA are recommended not only in rehabilitation but also in prevention because many risk factors, such as excess weight, obesity and joint tissue inflammation, can be monitored and thus prevented. In the present review, we analyze data from the most recent literature in relation to the effects of physical exercise on prevention, therapy and rehabilitation in knee OA. All data suggest that physical exercise is an effective, economical and accessible tool to everyone, in the treatment and prevention of knee OA. The literature search was conducted on PubMed, Scopus and Google Scholar using appropriate keywords in relation to knee osteoarthritis.

Management of Osteochondritis Dissecans Lesions of the Knee, Elbow and Ankle

Osteochondritis Dissecans 2020 Review

Although osteochondritis dissecans (OCD) has been a recognized condition for more than 100 years, our understanding of the etiology, natural history, and treatment remains poorly characterized. OCD most commonly affects the knee, followed by the elbow and ankle. Adolescents and young adults are most commonly affected. Patients present with vague, often intermittent symptoms and generally have no history of acute injury. Although diagnosis can be made with plain radiographs, treatment decisions are generally based on MRI. Skeletal maturity and stability of the OCD lesion determine treatment. Treatments range from immobilization and activity restriction to operative therapies. Clinical indications are discussed.

Connexin 32 down-regulates the fibrinolytic factors in metastatic renal cell carcinoma cells

MSTS 2018 - Femur Mets and MM

Fibrinolytic factors have an important role in tumor progression through the degradation of extracellular matrix. The increased levels of urokinase-type plasminogen activator (uPA), uPA-receptor (uPAR) and type-1 PA inhibitor (PAI-1) are reported in human renal cell carcinoma (RCC). Connexin (Cx) gene, a member of gap junction, is known to act as a tumor suppressor gene. We have reported that Cx32 improves malignant phenotypes of metastatic RCC cells via the inhibition of Src-dependent signaling. In this study, we examined the effect of expression of Cx32 gene on the production of uPA, uPAR and PAI-1, and on the induction of PAI-1 stimulated by hypoxia in a human metastatic RCC cell line, Caki-1 cells. Cx32 expression decreased both mRNA level and production of PAI-1, uPA and uPAR in Caki-1 cells. Cx32 also decreased hypoxia-inducible factor (HIF)-1alpha and HIF-2alpha mRNA level. PP1, a Src inhibitor, significantly decreased PAI-1, uPA, uPAR and HIF-alpha mRNA levels in Caki-1 cells. Furthermore, Cx32 suppressed the induction of HIF-2alpha protein in Caki-1 cells under hypoxia. PAI-1 mRNA level in Cx32-transfected Caki-1 cells was lower than that of mock transfectant under hypoxic conditions. These results suggest that Cx32 might reduce PAI-1, uPA and uPAR production in metastatic RCC cells via the inhibition of Src-dependent induction of HIF-1alpha and HIF-2alpha gene expression and that Cx32 might suppress hypoxia-inducible gene expression under hypoxic conditions.

Osteoporosis in men

Management of Hip Fractures in the Elderly

Male osteoporosis is an increasingly important public health problem: from age 50 onward, one in three osteoporotic fractures occurs in men and fracture-related morbidity and mortality are even higher than in women. In 50% of osteoporotic men, an underlying cause can be identified (secondary osteoporosis). In the absence of an identifiable etiology, male osteoporosis is referred to as 'idiopathic osteoporosis' in men aged 30-70 years and as 'age-related osteoporosis' in older men. As in women, estrogen, not testosterone, appears the most important sex steroid regulating male skeletal status. Diagnosis and treatment recommendations are still largely based on bone mineral density (BMD), with osteoporosis defined as a T-score of 2.5 standard deviations below young adult values. However, there is ongoing discussion as to whether male or female reference ranges should be used and, like in women, treatment decisions are increasingly based on absolute fracture risk estimations rather than on BMD alone. In men, evidence-based data on the efficacy of pharmacologic interventions in reducing fracture risk are convincing but not conclusive. In particular, bisphosphonates and teriparatide seem to be as effective in men as in women

257 ankle arthroplasties performed in Norway between 1994 and 2005

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND AND PURPOSE: There have been few reports on the long-term outcome of ankle replacements. The Norwegian Arthroplasty Register has been registering ankle replacements since 1994, but no analysis of these data has been published to date. Here we report data on the use of total ankle replacements and the revision rate in the Norwegian population over a 12-year period. METHODS: We used the Norwegian Arthroplasty Register to find ankle arthroplasties performed between 1994 and 2005. Patient demographics, diagnoses, brands of prosthesis, revisions, and time trends were investigated. RESULTS: There were 257 primary ankle replacements, 32 of which were cemented TPR prostheses and 212 of which were cementless STAR prostheses. The overall 5- year and 10-year survival was 89% and 76%, respectively. Prosthesis survival was the same for the cementless STAR prosthesis and the cemented TPR prosthesis. There was no significant influence of age, sex, type of prosthesis, diagnosis, or year of operation on the risk of revision. The incidence of ankle replacements due to osteoarthritis, but not due to inflammatory arthritis, increased over the years. INTERPRETATION: The revision rate was acceptable compared to other studies of ankle arthroplasties, but high compared to total knee and hip arthroplasties. The overall incidence of ankle replacements increased during the study period

Displaced fracture of the neck of the radius with complete 180 degrees rotation of the radial head during closed reduction

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

We report a case of fracture of the radial neck in a teenage girl in which 180 degrees rotation of the radial head occurred at close reduction. Although this was corrected, avascular necrosis of the radial head occurred. To our knowledge only four cases of such iatrogenic malpositioning have been described in the literature

Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

DoD SSI (Surgical Site Infections)

PURPOSE: The perioperative consequences of direct oral anticoagulants (DOACs) in hip fracture patients are not sufficiently investigated. The primary aim of this study was to determine whether DOAC-users have delayed surgery compared to non-users. Secondarily, we studied whether length of hospital stay, mortality, reoperations and bleeding complications were influenced by the use of DOAC. METHODS: The medical records of 314 patients operated for a hip fracture between 2016 and 2017 in a single trauma center were assessed. Patients aged < 60 and patients using other forms of anticoagulation than DOACs were excluded. Patients were followed from admission to 6 months postoperatively. Surgical delay was defined as time from admission to surgery. Secondary outcomes included length of hospital stay, transfusion rates, perioperative bleeding loss, postoperative wound ooze, mortality and risk of reoperation. The use of general versus neuraxial anaesthesia was registered. Continuous outcomes were analysed using Students t test, while categorical outcomes were expressed by Odds ratios. RESULTS: 47 hip fracture patients (15%) were using DOACs. No difference in surgical delay (29 vs 26 h, p = 0.26) or length of hospital stay (6.6 vs 6.1 days, p = 0.34) were found between DOAC-users and non-users. DOAC-users operated with neuraxial anaesthesia had longer surgical delay compared to DOAC-users operated with general anaesthesia (35 h vs 22 h, p < 0.001). Perioperative blood loss, transfusion rate, risk of bleeding complications and mortality were similar between groups. CONCLUSION: Hip fracture patients using DOAC did not have increased surgical delay, length of stay or risk of reported bleeding complications than patients without anticoagulation prior to surgery. The increased surgical delay found for DOAC-users operated with neuraxial anaesthesia should be interpreted with caution.

Surgeon error in performing intraoperative estimation of stem anteversion in cementless total hip arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

To examine the accuracy of intraoperative estimation of stem anteversion in total hip arthroplasty (THA), we compared the intraoperatively estimated stem anteversion (estimated prosthetic anteversion) to stem anteversion measured by postoperative computed tomography (true anteversion) in 73 hips in 73 patients. Estimated prosthetic anteversion was significantly greater than true anteversion by 5.8°, and the mean absolute value of surgeon error was 7.3° ranging from 11° underestimation to 25° overestimation. Surgeons tended to overestimate when the true anteversion was smaller. A multivariate analysis showed that advanced knee osteoarthritis significantly increased surgeon error. These results indicated that estimated prosthetic anteversion was generally larger than true anteversion and that the grade of knee osteoarthritis affected the degree of surgeon error. © 2013 Elsevier Inc.

Comparison of Direct Perioperative Costs in Treatment of Unstable Distal Radial Fractures: Open Reduction and Internal Fixation Versus Closed Reduction and Percutaneous Pinning

Distal Radius Fractures

BACKGROUND: As the United States transitions to value-based insurance, bundled payments, and capitated models, it is paramount to understand health-care costs and resource utilization. The financial implications of open reduction and internal fixation (ORIF) with a volar locking plate for management of unstable distal radial fractures have not been established. We aimed to elucidate cost differences between ORIF and closed reduction and percutaneous pinning (CRPP). Our hypothesis was that ORIF has greater direct perioperative costs than CRPP but that the costs equilibrate over time. METHODS: We reviewed financial data for 40 patients prospectively enrolled and randomized to undergo CRPP or ORIF for treatment of a closed, displaced, unstable distal radial fracture. Clinical and functional outcomes, hospital-associated direct perioperative costs, postoperative care and therapy costs, and costs for additional procedures were compared. Cost data were stratified into perioperative, 90-day, and 1-year periods, and were reported utilizing cost ratios (CRs) relative to the CRPP cohort. Statistical analysis was performed with chi-square and independent-samples t tests with an alpha level of <0.05. RESULTS: Seventeen patients underwent CRPP and 23 underwent ORIF with a volar plate. Patients who underwent ORIF incurred greater 90-day (CR = 2.03/1.0, p < 0.001) and 1-year (CR = 1.60/1.0, p < 0.001) direct costs than those who underwent CRPP. The differential was greatest in the immediate perioperative period and gradually decreased over time. Operating room fees (CR = 1.7/1.0, p < 0.001), operating room implants, anesthesia (CR = 1.8/1.0, p < 0.001), and total perioperative costs (CR = 2.7/1.0, p < 0.001) were significantly greater in the ORIF cohort. Rehabilitation and cast technician costs were comparable (CR = 0.9/1.0 [ORIF/CRPP], p = 0.69). At 1 year, the CR for all costs of decreased to 1.6/1.0 (ORIF/CRPP, p < 0.001). Compared with the CRPP cohort, the ORIF cohort demonstrated significantly better functional outcomes at 6, 9, and 12 weeks and similar outcomes at 1 year. CONCLUSIONS: ORIF for a displaced, unstable distal radial fracture incurred greater direct costs than CRPP. Although implant costs for ORIF provided the greatest cost differential, additional procedures and higher clinic costs in the CRPP cohort narrowed the 90-day and 1-year cost gaps. LEVEL OF EVIDENCE: Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Potential use of bisphosphonates in invasive extramammary Paget's disease: an immunohistochemical Investigation

MSTS 2018 - Femur Mets and MM

Invasive extramammary Paget's disease (EMPD) is relatively rare and is reported to be highly metastatic to lymph nodes or even other organs, including bone. Histologically, EMPD shows significant numbers of lymphocytes around the tumor mass, suggesting the possible development of novel immunomodulatory therapy for EMPD by targeting these infiltrating lymphocytes. Previously, bisphosphonates (BPs) were administered for the treatment of malignancy, especially osteolytic bone disease. Recent reports also suggested that BPs might have a direct antitumor effect through several pathways beyond their beneficial effect on bone metastasis. Among them, the abrogation of immunosuppressive cells, myeloid derived suppressor cells (MDSC), by BPs might be one of the optimal methods to induce an antitumor immune response both locally and at sites remote from the tumor. In this study, we employed immunohistochemical staining for immunosuppressive macrophages and cytotoxic T cells in the lesional skin of patients with noninvasive EMPD and those with invasive EMPD.

Preoperative use of recombinant human erythropoietin before total joint arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Background: Previous reports have suggested that the use of recombinant human erythropoietin is effective for decreasing the need for perioperative allogeneic blood transfusion. The purpose of this study was to evaluate the efficacy of erythropoietin in combination with, and compared with, preoperative autologous donation for reducing allogeneic blood requirements for total joint arthroplasty. Methods: Two hundred and forty patients undergoing primary and revision total hip or knee arthroplasty were enrolled into three groups with different treatment regimens: (1) erythropoietin and preoperative autologous donation (Group 1), (2) erythropoietin alone (Group 2), and (3) preoperative autologous donation alone (Group 3). Patients were evaluated with regard to requirements for allogeneic transfusion, change from the baseline to the lowest postoperative hemoglobin value, postoperative complications, and adverse reactions. Results: The rate of allogeneic transfusion was 11% in Group I (erythropoietin and preoperative autologous donation) compared with 28% in Group 2 (erythropoietin alone) and 33% in Group 3 (preoperative autologous donation alone). Within Group 1, patients who had a unilateral primary arthroplasty had an allogeneic transfusion rate of 4% and those who had a bilateral or revision arthroplasty had an allogeneic transfusion rate of 17%. In Groups 2 and 3, the allogeneic transfusion rates were 14% and 15%, respectively, for the patients who had a unilateral primary arthroplasty and 35% and 47%, respectively, for those who had a bilateral or revision arthroplasty. Conclusions: Preoperative use of erythropoietin in conjunction with preoperative autologous donation reduces the need for allogeneic blood transfusion associated with total joint arthroplasty more effectively than does either erythropoietin or preoperative autologous donation alone. Level of Evidence: Therapeutic study, Level II-1 (prospective cohort study). See Instructions to Authors for a complete description of levels of evidence

Test re-test reliability of centre of pressure measures during standing balance in individuals with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Assessment of changes in standing balance following an intervention requires accurate measurement of balance parameters. The reliability of centre of pressure measures of balance during single-leg standing has not been reported in individuals with knee osteoarthritis. The purpose of this study was to assess the test re-test reliability of force platform centre of pressure measures during single-leg standing in older adults with knee osteoarthritis. Twenty-five adults with radiographic evidence of knee osteoarthritis performed single-leg standing balance trials on a laboratory-grade force platform on two occasions, no more than 14 days apart.

Update on the use of antibiotics in cutaneous surgery

Reconstruction After Skin Cancer

BACKGROUND: Antibiotics are often prescribed in perioperative settings, including dermatologic surgery. Given the continued evolution in the breadth and complexity of cutaneous procedures performed and inevitable localized or distant infections that occasionally occur, it seems prudent to periodically evaluate findings and recommendations from the literature regarding the use of antibiotics in cutaneous surgery. MATERIALS AND METHODS: Literature review from English-language sources from the past 30 years, especially focusing on sources from the past 5 to 10 years. Data were examined for a variety of cutaneous surgical procedures, routes of antibiotic administration, and consideration of both cutaneous and distant infections. RESULTS: The literature suggests that, for most routine skin procedures, antibiotic use is probably not warranted for the prevention of surgical wound infection, endocarditis, and late prosthetic joint infections. During prolonged Mohs procedures, delayed repairs, grafts, takedowns of interpolation flaps, or any procedure that breaches a mucosal surface, the evidence is less clear, and decisions should be made on a case-by-case basis. Topical antibiotics are probably overused, although silver sulfadiazine may have an undeserved negative reputation among dermatologists. Systemic prophylactic antibiotics for laser resurfacing and liposuction appear not to be routinely necessary, although patients with known prior herpes infection likely should receive antiviral prophylaxis. The overall reported infection rates and infectious complications remain low in dermatologic surgery, and antibiotic therapy may be prescribed excessively or inappropriately as a result. CONCLUSION.: Antibiotics continue to be widely used, and through varying routes of administration, in the setting of dermatologic surgery. Prudent use of these agents is indicated in high-risk patients, certain anatomic locations, and the presence of overt infection. Additional studies may help clarify the most appropriate indications, and in which patient populations, in the future.

Women with hip fracture experience greater loss of geometric strength in the contralateral hip during the year following fracture than age-matched controls

Management of Hip Fractures in the Elderly

This study examined femur geometry underlying previously observed decline in BMD of the contralateral hip in older women the year following hip fracture compared to non-fractured controls. Compared to controls, these women experienced a greater decline in indices of bone structural strength, potentially increasing the risk of a second fracture. INTRODUCTION: This study examined the femur geometry underlying previously observed decline in BMD of the contralateral hip in the year following hip fracture compared to non-fractured controls. METHODS: Geometry was derived from dual-energy X-ray absorptiometry scan images using hip structural analysis from women in the third cohort of the Baltimore Hip Studies and from women in the Study of Osteoporotic Fractures. Change in BMD, section modulus (SM), cross-sectional area (CSA), outer diameter, and buckling ratio (BR) at the narrow neck (NN), intertrochanteric (IT), and shaft (S) regions of the hip were compared. RESULTS: Wider bones and reduced CSA underlie the significantly lower BMD observed in women who fractured their hip resulting in more fragile bones expressed by a lower SM and higher BR. Compared to controls, these women experienced a significantly greater decline in CSA (-2.3% vs. -0.2%NN, -3.2% vs. -0.5%IT), SM (-2.1% vs. -0.2%NN, -3.9% vs. -0.6%IT), and BMD (-3.0% vs. -0.8%NN, -3.3% vs. -0.6%IT, -2.3% vs. -0.2%S) and a greater increase in BR (5.0% vs. 2.1%NN, 6.0% vs. 1.3%IT, 4.4% vs. 1.0%S) and shaft outer diameter (0.9% vs. 0.1%). CONCLUSION: The contralateral femur continued to weaken during the year following fracture, potentially increasing the risk of a second fracture

Recreational and athletic activity after total elbow arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Background Artificial joint replacement surgery is one of the most reliable procedures for the joint that has already seen an irreversible joint destruction as the means for pain relief and functional reconstruction even in the era of biologic agents. Total elbow arthroplasty (TEA) are also increasingly being performed to improve function and quality of life. Some patients who underwent TEA may wish to return to recreational and athletic activity, although there are few evidences about proper strength, duration, and little have been reported about complication rate in recreational and athletic activity after total elbow arthroplasty in contrast with total hip, knee, and shoulder arthroplasty 1,2. Therefore, we reviewed our patients after TEA about their function, activity of daily living, and athletic activity. Objectives We aimed to investigate the relation between function and activity of daily living and both recreational and athletic activity in patients after TEA. Methods 83 elbows of 69 patients after TEA were available for this study. There were 68 patients with rheumatoid arthritis and one patient with osteoarthritis. Average age (year-old) was 60.8 +/- 8.6, and follow-up period (month) was 80.3 +/- 43.4. They were examined about whether they had ever participated in recreational and athletic activities after TEA or not. Patients who had participated in recreational and athletic activities (group A) were asked the kind of sports they had. On the other hand, patients who had not participated in recreational and athletic activities (group B) were asked the reason why they had not. Their clinical condition of elbows after operation was assessed according to the scoring system of Japanese Orthopaedic Association (JOA) elbow score. They also examined about health assessment questionnaire - disability index (HAQ-DI), disability of arm, shoulder, and hand (DASH) score, Hand 20 score. Statistical analysis was performed between group A and group B on HAQ-DI, DASH, Hand20, and JOA score by Mann-Whitney U test. Results 13 of 69 patients participated in recreational and athletic activities on various levels. The kind of sports they participated in were swimming (4 patients), playing catch (4 patients), badminton (3 patients), table tennis (2 patients), and others (2 patients). HAQ-DI, DASH, Hand20, and JOA score were 1.41+/- 0.80 (p=0.274), 35.8 +/- 23.2 (p=0.281), 30.4 +/- 23.8 (p=0.046), and 91.3 +/- 3.2 in group A (p=0.175), and 1.13 +/- 0.78, 43.5 +/- 24.6, 47.3 +/- 28.9, 89.3 +/- 7.6 in group B, respectively. Conclusions Hand20 score were only related in participation in recreational and athletic activity, although their clinical condition of elbows were similarly excellent in both group A and B. The current study indicate that athletic activity might not deteriorate clinical condition of elbows after TEA, and that remaining function on upper extremity largely might influence patients' decision to participate in recreational and athletic activity because most TEAs were performed for patients with rheumatoid arthritis

Polysaccharide hemostatic system reduces blood loss in high-body-mass-index patients undergoing simultaneous bilateral total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Background To investigate the efficacy of a topically applied hemostatic agent used to reduce blood loss in patients undergoing simultaneous bilateral total knee arthroplasty (TKA). Methods Thirty-two patients (5 male, 27 female) mean age 65 (plus or minus) 9.3 (46-80) undergoing single-stage bilateral TKA were enrolled in the study and divided in two groups. Groups 1 and 2 consisted of patients with body mass index (BMI) <30 and >30, respectively. Polysaccharide hemostatic agent (PHA; 3 g) was applied topically to the right knees of each patient intraoperatively. The left knees were used as controls. A negative suction drain was used and the effect of PHA and BMI on postoperative bleeding was evaluated. Results Blood loss was significantly higher (p = 0.027, r = 0.397) for patients with higher BMI. Treatment by local application of PHA to potential bleeding sites significantly reduced blood loss-314 (plus or minus) 151 ml (50-600) for the right knees versus 468 (plus or minus) 140 ml (150-700) for the left knees (p = 0.007) in group 1; 420 (plus or minus) 251 ml (100-900) for the right knees versus 620 (plus or minus) 229 ml (350-1125) for the left knees (p = 0.036) in group 2. Blood loss reduction between the right and left knees was no different between the two groups (p = 0.173). Conclusions By reducing blood loss and the need for postoperative blood transfusion in patients with high BMI, PHA can be of value as adjuvant therapy in new bloodmanagement procedures in major joint-replacement surgery. (copyright) The Japanese Orthopaedic Association 2012

The Divine Proportion "Ace of Spades" Umbilicoplasty: A New Method of Navel Positioning and Plasty in Abdominoplasty

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Achievement of a well-balanced positioned navel along the longitudinal axis with a pleasing shape and hidden scarring will have a tremendous impact on the overall cosmetic outcome of an abdominoplasty. In this era of navel display, piercing, and tattooing, an increasing attention is paid by people toward navel shape and position. However, in plastic surgery, there is no standardization regarding navel repositioning and plasty during abdominoplasty. The aim of this article is to describe the clinical translation of our observational study on navel surface anatomy by reporting our experience with a new umbilicoplasty technique. MATERIALS AND METHODS: Between July 2013 and March 2014, 23 consecutive patients underwent elective deep inferior epigastric perforator free flap breast reconstruction. Patients' mean age was 45.5 years (range, 36-68 years). Ten patients were normal weight, 11 were overweight, and 2 were class-1 obese. All 23 patients underwent the divine proportion ace of spade umbilicoplasty. RESULTS: Pleasant looking, depressed, and oval navels with superior hooding were successfully achieved. No infection or necrosis of the navel skin or abdominal skin flaps was experienced. Additionally, no scar constriction, navel distortion, or stenosis occurred. Postoperative results were graded as excellent in 8 cases (36%), very good in 12 (55%), and good in the 2 cases (9%) with mildly hypertrophic scars. Patient satisfaction was high to very high. CONCLUSIONS: A Fibonacci caliper might aid in the proper positioning of the umbilicus on the abdominal wall avoiding an undesirable high- or low-riding navel. The "ace of spades" umbilicoplasty restores a natural-looking depressed navel with an oval shape and superior hooding.

Use of glucosamine and chondroitin in persons with osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Glucosamine and chondroitin are members of a group of dietary supplements often termed "complementary agents," "disease-modifying agents," or "disease-modifying osteoarthritis drugs" (DMOADs). They are among the best-selling dietary supplements in the United States. DMOADs are thought to act by affecting cytokine-mediated pathways regulating inflammation, cartilage degradation, and immune responses. Given the results of recent studies, investigators have begun to question whether the popular combination of glucosamine and chondroitin alleviates disease progression or pain in people with mild to moderate knee osteoarthritis. Reasons proposed for the lack of benefit include incorrect dosing, suboptimal compound manufacture, and a lack of complete understanding of when and how to apply the compounds. In addition, adjuvant medications also could augment the therapeutic potential of these agents. Although these agents are considered safe, some uncommon and minor adverse effects have been reported, including epigastric pain or tenderness (3.5%), heartburn (2.7%), diarrhea (2.5%), and nausea (1%). In conclusion, although some questions have arisen about whether DMOADs are as effective as has been claimed, a trial should be considered in in selected patients with sustained refractory cases of osteoarthritis.

Nephrogenic fibrosing dermopathy: A comprehensive review for the dermatologist

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Nephrogenic fibrosing dermopathy (NFD) is an acquired, idiopathic, chronic, progressive eruption of the skin sometimes accompanied by systemic fibrosis that occurs in the context of renal failure. The age of patients with NFD ranges from 8 to 87 years at the time of onset, with a mean age of 46.4 years. Most cases have been reported in the US and Europe, but recently cases have also been reported in India. About 175 cases have been noted in a registry established for NFD patients. Even in the setting of renal disease, NFD still occurs rarely and its cause is unknown. Patients present with hard, indurated, sometimes peau d'orange plaques. They often show a distinctive physical appearance, with elbows and knees angled inward, and most patients complain of a loss of range of motion. Histology demonstrates thickened collagen bundles with surrounding clefts, mucin, and a proliferation of fibroblasts and elastic fibers, sometimes with reticular, dermal, large epithelioid or stellate spindle cells. Fibrosis of NFD can affect the internal organs and thus the term nephrogenic systemic fibrosis has been used by some analysts to describe this fibrosing process. The fibrosis of NFD appears to be due to the effects of a cell referred to as the circulating fibrocyte. Rare cases of partial-to-complete spontaneous resolution have been reported in the absence of specific therapy. Treatments yield inconsistent results and include restoration of renal function, extracorporeal photopheresis, photodynamic therapy, high-dose intravenous immunoglobulin, and other immunosuppressive therapies. (copyright) 2006 Adis Data Information BV. All rights reserved

Radiological outcomes in a randomized trial comparing opening wedge and closing wedge techniques of high tibial osteotomy

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: The aim of the present study was to examine changes in radiological variables in a prospective randomized study comparing opening wedge (OW) and closing wedge (CW) techniques of high tibial osteotomy (HTO). Our hypothesis was that there would be no differences in joint line angles or correction accuracy between the two groups, that patellar height would increase after CW HTO and decrease after OW HTO, and that leg length and posterior tibial slope would decrease after CW HTO and increase after OW HTO. METHODS: Radiological data were collected from 70 patients participating in an ongoing prospective randomized clinical trial comparing OW and CW HTOs. Digital standing hip-knee-ankle (HKA) radiographs as well as lateral radiographs in 30degree of flexion were obtained preoperatively and at 6 months for each patient. Joint line angles, HKA angle, leg length, Insall-Salvati index, Miura-Kawamura index and posterior tibial slope were measured using medical planning software. The complete preoperative radiological examinations of the first 50 patients were used in a study of intra- and inter-rater reliability of the measurements. RESULTS: The mean posterior slope was reduced by 2.5degree in CW HTO, whereas it remained unchanged in OW HTO (p < 0.001). Mean leg length decreased 5.7 mm in CW HTO and increased 3.1 mm in OW HTO (p < 0.001). Changes in joint line angles, patellar height indexes and the correction accuracy showed no significant differences comparing the two techniques. Frontal plane reliability measurement intra- and inter-rater intraclass correlation coefficient (ICC) varied from 0.81 to 0.99. Sagittal plane intra- and inter-rater ICC varied from 0.60 to 0.87. Posterior tibial slope intra- and inter-rater ICC showed the lowest values (0.70 and 0.60, respectively) corresponding to a smallest real difference of 4.5degree and 5.5degree, respectively. CONCLUSIONS: Posterior tibial slope and leg length changes were significantly different in CW compared to OW HTOs. We recommend that possible alterations in tibial slope and leg length are considered when the technique of HTO is to be chosen. Landmark-based medical planning software shows good reliability and can be used in preoperative planning and postoperative evaluations of HTOs. Level of evidence: I.

Proliferative injection therapy for osteoarthritis: a systematic review

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: To systematically analyse randomised controlled trials (RCTs) about efficacy and safety of proliferative injection therapy (prolotherapy) for treatment of osteoarthritis (OA). METHODS: CENTRAL, Embase and MEDLINE were searched. Two reviewers independently conducted screening and data extraction. RCTs were assessed with the Cochrane risk of bias tool. Type of treatment, study design, dosing, efficacy outcomes and safety outcomes were analysed. The protocol was registered in PROSPERO (CRD42016035258). RESULTS: Seven RCTs were included, with 393 participants aged 40-75 years and mean OA pain duration from three months to eight years. Follow-up was 12 weeks to 12 months. Studies analysed OA of the knee joint (n = 5), first carpometacarpal joint (n = 1) and finger joints (n = 1). Various types of prolotherapy were used; dextrose was the most commonly used irritant agent. All studies concluded that prolotherapy was effective treatment for OA. No serious adverse events were reported. The studies had considerable methodological limitations. DISCUSSION: Limited evidence from low-quality studies indicates a beneficial effect of prolotherapy for OA management. The number of participants in these studies was too small to provide reliable evidence. CONCLUSIONS: Current data from trials about prolotherapy for OA should be considered preliminary, and future high-quality trials on this topic are warranted.

Objective analysis of lateral elbow exposure with the extensor digitorum communis split compared with the kocher interval

Distal Radius Fractures

Background: The most widely used surgical approach to treat radial head fractures is through the Kocher interval. However, the extensor digitorum communis (EDC) splitting approach is thought to allow easier access to the anterior half of the radial head, which is more commonly fractured. The aim of this cadaveric study was to compare the osseous and articular surface areas visible through the EDC split and the Kocher interval. Methods: Four approaches were used in fresh frozen cadaveric upper extremities: EDC splitting (n = 6), modified Kocher (n = 6), extended EDC splitting (n = 6), and extended modified Kocher (n = 4). For each approach, the osseous and articular surface areas visualized were outlined with use of a burr. Each elbow was then stripped of soft tissue and a digitized threedimensional model was created with use of a surface scanning system. The visible surface area obtained with each approach was mapped and quantified with use of the markings created with the burr. Results: The EDCsplitting approach provided greater exposure of the anterior half of the radial head (median, 100%) compared with the modified Kocher approach (68%, p < 0.05). The extended modified Kocher and extended EDC splitting approaches provided comparable visualization of the distal aspect of the humerus, capitellum, radial head, and coronoid process. Conclusions: The results suggest that the EDC splitting approach provides more reliable visualization of the anterior half of the radial head whileminimizing soft-tissue dissection and reducing the risk of iatrogenic injury to the lateral ulnar collateral ligament. Copyright © 2014 By The Journal of Bone and Joint Surgery, Incorporated.

Characterization of knee osteoarthritis in Latin America. A comparative analysis of clinical and health care utilization in Argentina, Brazil, and Mexico

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: The burden of knee osteoarthritis (OA) in Latin America is unknown. OBJECTIVE: To determine the demographic, clinical, and therapeutic characteristics of patients with OA in Argentina, Brazil, and Mexico. MATERIAL AND METHODS: This is an observational, cross-sectional study of patients with symptomatic knee OA referred from first care medical centers to Rheumatology departments. RESULTS: We included 1210 patients (Argentina 398, Brazil 402, Mexico 410; mean age 61.8 [12] years; 80.8% females). Knee OA pain lasted for 69 months; the duration and severity of the last episode were 190 days and (SD 5.2 [3.3]; 74% had functional limitations, but very few patients lost their job because of knee OA. Around 71% had taken medications, but 63% relied on their own pocket to afford knee OA cost. Most demographic and clinical variables differed across countries, particularly the level of pain, disability, treatment, and access to care. The variable country of origin influenced the level of pain, disability, and NSAIDs use in logistic regression models; age, pain, treatment, and health care access influenced at least 2 of the models. CONCLUSIONS: The burden of knee OA in Latin American depends on demographic, clinical, and therapeutic variables. The role of such variables differs across countries. The level of certain variables is significantly influenced by country of origin and health care system.

Unicompartmental knee arthroplasty compares favorably to total knee arthroplasty in the same patient

Surgical Management of Osteoarthritis of the Knee CPG

There are several surgical management options for medial knee arthritis, and it is often difficult to decide whether a unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA) is appropriate. Few studies have compared UKAs and TKAs in the same patient. We identified 23 patients with osteoarthritis who had a TKA on one side and a UKA on the other. The preoperative values of the 2 knees were not statistically different. Strict criteria were used to determine whether a UKA could be performed (functional anterior cruciate ligament, minimal deformity, and minimum changes in other compartments). Preoperative radiographs were reviewed to confirm that the knee undergoing TKA had medial compartment disease only. Knee Society scores, radiographic analysis, and patient preferences were recorded for all patients. Average follow-up was 46 months (range, 7.2-148 months) and 42 months (range, 11.5-59.8 months) for TKA and UKA, respectively. We found little or no difference in outcomes between the 2 procedures, except for an improved range of motion with the UKA compared with the TKA (123 degrees +/-9 degrees vs 119.8 degrees +/-7 degrees, respectively). Knee Society scores improved from 45.9 to 89.7 in UKA and from 42.4 to 90.3 in TKA. Of the 23 patients, 11 expressed no preference between either knee and 12 preferred the unicompartmental knee; no patient preferred the total knee. With appropriate patient selection, UKAs are a successful option for patients with osteoarthritis

Knee strength maintained despite loss of lean body mass during weight loss in older obese adults with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: The effects of weight loss on muscle function in older adults have not been well studied. This study determined the effects of a 6�month weight�loss intervention on muscle strength and quality in older obese adults with knee osteoarthritis. METHODS: Participants were randomized to a weight loss (WL) (n = 44, 70 +/� 6 years) or weight stable (WS) (n = 43, 69 +/� 6 years) group. The WL intervention consisted of weekly educational meetings, a meal replacement diet, and a three�session�per�week structured exercise program to achieve 10%�12% weight loss. The WS intervention included bimonthly group meetings and newsletters. Body composition and knee extensor strength were measured at baseline and after intervention. RESULTS: The WL group decreased body weight, lean body mass, fat mass, and percent body fat (p <.001 for all). Concentric extension strength increased 25% in WL (p >.05), whereas eccentric extension decreased 6% in WS (p =.028). Concentric muscle quality (strength per kg body weight or lean body mass) increased in WL (p <.05), whereas eccentric muscle quality decreased in WS (p <.05). Changes in lean body mass and fat mass were inversely associated with changes in most muscle strength and quality measures (p <.05). Men and women did not differ in response to the intervention in knee strength outcomes. CONCLUSIONS: Hypocaloric dieting in combination with exercise training had beneficial effects on muscle strength/quality, despite loss of lean body mass in this sample of older men and women. Greater fat loss was associated with greater gains in muscle strength and quality. More studies are needed regarding the mechanisms by which loss of fat mass increases muscle strength and quality.

Performance-based and self-assessed measures of visual function as related to history of falls, hip fractures, and measured gait time. The Beaver Dam Eye Study

Management of Hip Fractures in the Elderly

OBJECTIVE: The purpose of the study is to report relationships between visual function parameters and falls, hip fractures, and gait time in adults. DESIGN: Population-based study. PARTICIPANTS: The 3722 persons who participated in the 5-year follow-up of the Beaver Dam Eye Study cohort. MAIN OUTCOME MEASURES: The visual functions measured at the examination were best-corrected visual acuity, current binocular acuity, near acuity, contrast sensitivity, and visual threshold to light. Information on falls and hip fractures was obtained by structured interview. Gait time was measured by standardized protocol. RESULTS: History of falls and hip fractures increased with age, as did time to walk a measured course. Falls were more commonly reported for all persons who had poorer visual function, although not all relationships were significant in persons less than 60 years of age. In persons 60 years of age and older, hip fractures after the age of 40 were significantly related to all measures of visual function. Time to walk a measured course was significantly related to all measures of visual function. CONCLUSIONS: These data indicate a consistent relationship between falls, fractures, gait time, and visual functions. Longitudinal data are necessary to accurately determine temporal relationships and to determine the likelihood of a causal association. In the interim, these data suggest that improving visual function may have benefits such as decreased traumatic events and improved mobility

Results of a Multicenter Open-Label Randomized Trial Evaluating Infusion Duration of Zoledronic Acid in Multiple Myeloma Patients (the ZMAX Trial)

MSTS 2018 - Femur Mets and MM

Zoledronic acid, an intravenous (IV) bisphosphonate, is a standard treatment for multiple myeloma (MM) but may exacerbate preexisting renal dysfunction. The incidence of zoledronic acid-induced renal dysfunction may correlate with infusion duration. In this randomized, multicenter, open-label study, 176 patients with MM, at least one bone lesion, and stable renal function with a serum creatinine (SCr) level <3 mg/dL received zoledronic acid 4 mg (in 250 mL) as a 15- or 30-minute IV infusion every 3-4 weeks. At month 12, 20% (17 patients) in the 15-minute and 16% (13 patients) in the 30-minute arm experienced a clinically relevant but nonsignificant SCr-level increase (P = 0.44). By 24 months, the proportion of patients with a clinically relevant SCr-level increase was similar between arms (15-minute 28% [24 patients] vs 30-minute 27% [23 patients], P = 0.9014). Median zoledronic acid end-of-infusion concentrations were higher with the shorter infusion (15-minute 249 ng/mL vs 30-minute 172 ng/mL), and prolonging the infusion beyond 15 minutes did not influence adverse events related to zoledronic acid. For patients with MM, the safety profile of IV zoledronic acid is similar between those receiving a 15- or 30-minute infusion; therefore, determining the appropriate infusion duration of zoledronic acid should be based on individual patient considerations. © 2011.

Steroids in Total Knee Arthroplasty

AAHKS (2) Corticosteroids

Adequate pain control after total knee replacement (TKA) is of great importance not only to maximize patient comfort, but also to ensure optimal outcomes after surgery. This study is designed to assess whether the use of two small doses of intravenous (IV) steroids around the time of surgery decrease a patient's pain or use of pain medication. Secondly, the investigators will also determine if the use of these steroids as part of a multimodal pain management strategy leads to improved patient outcomes, including pain, nausea and vomiting, knee function and length of stay in the hospital after surgery. The study will compare the effect of two different doses of IV dexamethasone given preoperatively before TKA, when compared to placebo.

Management of Distal Third Comminuted Humerus Shaft Fracture by LCP Using Posterior Approach

Distal Radius Fractures

Distal third comminuted humerus shaft fractures are challenging injuries to treat because of complex anatomy and fracture patterns. Functional bracing, operative treatment with intramedullary nails or conventional plates also has limitation of inadequate fixation in the distal third comminuted humerus shaft fractures. Locking compression plate (LCP) has been introduced to overcome this problem. Our aim of this study was to assess the effectiveness of osteosynthesis of distal third comminuted humerus shaft fractures by LCP using posterior approach. This prospective observational study was conducted from July 2015 to June 2018 at Mymensingh Medical College Hospital (MMCH) and National Institute of Traumatulogy & Orthopaedic Rehablitation (NITOR), Dhaka, Bangladesh. Thirty three patients were operated on for comminuted fractures of distal third humerus. Two cases were excluded from the evaluation of final out come due to their discontinued follow up. Treatment included open reduction and LCP fixation by posterior mid line approach. The range of motion of the shoulder and elbow were evaluated according to the criteria by modified Constant and Murley scoring system. Union was achieved in all the patients after a mean of 17 weeks (range 12-24 weeks). Deep infection, nonunion, malunion, implant failure or permanent nerve injury did not occur in any of the patients. Three patients had transient radial nerve palsy. Four patients developed superficial infections. All patients were relieved pain postoperatively. Shoulder range of motion was excellent in 20 patients & elbow range of motion was excellent in 21 patients. Functional out come were excellent in 11 & good in 16 patients which constituted 87% satisfactory results. Treatment with open reduction and LCP fixation by posterior approach is a safe and effective option in distal third comminuted humeral fractures.

Expression of the chemokine receptor CXCR4 correlates with a favorable prognosis in patients with adenocarcinoma of the lung

MSTS 2018 - Femur Mets and MM

UNLABELLED: The relation between CXCR4 expression and the clinicopathological characteristics of lung cancer and patient prognosis is not well understood and remains controversial. We therefore investigated the relationship between CXCR4 expression and prognosis in patients with adenocarcinoma of the lung. METHODS: We used semi-quantitative real time reverse transcription polymerase chain reaction to assess expression of CXCR4 mRNA in tumor samples from 79 patients with adenocarcinoma of the lung. We then correlated CXCR4 mRNA levels with known clinicopathological factors. We also used immunohistochemical staining to determine the subcellular localization of expressed CXCR4. RESULTS: Within samples of tumor tissue, the cytosol and nucleus of tumor cells stained positively for CXCR4. By contrast, cells from normal tissue were negative for CXCR4. The 5-year disease-free survival rate among patients expressing higher levels of CXCR4 mRNA was significantly better than among those expressing lower levels (P=0.0003 by log-rank test). Multivariate Cox proportional hazard analyses revealed, male (Hazard ratio, 2.96; 95% CI, 1.22-7.56; P=0.012), lymph node metastasis (Hazard ratio, 3.61; 95% CI, 1.06-13.4; P=0.040), and CXCR4 (Hazard ratio, 0.36; 95% CI, 0.13-0.94; P=0.037) to be independent factors affecting the 5-year disease-free survival rate. CONCLUSION: Higher levels of CXCR4 expression by tumor cells are an independent predictor of a better prognosis in patients with adenocarcinoma of the lung.

Serum copper levels in elderly patients with femoral-neck fractures

Management of Hip Fractures in the Elderly

The serum copper levels of 46 elderly patients with fractures of the femoral neck were assayed and found to be significantly lower than those of a group of controls matched for age and sex. These findings are consistent with nutritional copper deficiency which may contribute to the development of fractures by reducing bone strength

Artificial skin for closure and healing of wounds created by skin cancer excisions

Reconstruction After Skin Cancer

BACKGROUND: A dermal regeneration template indicated for life-threatening third-degree burn injuries is a product with potential application to smaller wounds to aid in healing and closure of complex excision sites. OBJECTIVE: To assess the effectiveness of dermal regeneration template for closure of skin cancer excision sites that would have otherwise required complicated closures. METHODS: Five patients, 61-84 years old, with skin cancer surgery yielding a total of six wounds were treated with the dermal regeneration template to close and heal their wounds. RESULTS: Four of five patients had complete healing (five of six wounds) with cosmetically acceptable results. The one treatment failure was application of the dermal regeneration template over exposed skull where inadequate neodermis formed. Successful healing was observed in five complex skin cancer excision sites including two wounds in previously irradiated grafted skin, a large and deep temporal defect, a wide excision in the supraclavicular region, and an excision down to cartilage on the antihelix of the ear. No infections were noted, although in four of five patients prophylactic oral antibiotics (either erythromycin or cephalexin) were prescribed postoperatively for 1-2 weeks. CONCLUSION: The product simplified wound care, subjectively appeared to decrease pain and postoperative bleeding, and yielded cosmetically acceptable wound repair. Autografting was not necessary; wounds healed in 2-4 months by epithelialization over neodermis after removal of the silicone layer. Furthermore, the product was a convenient long-term dressing and healing device for wounds where complex repairs, autografts, and/or flaps would otherwise be considered for closure.

Comparison of a simple clinical risk index and quantitative bone ultrasound for identifying women at increased risk of osteoporosis

Management of Hip Fractures in the Elderly

Osteoporosis is a growing problem in Asia, and early identification of at risk subjects for preventive measures is likely the most cost-effective method for managing this disease in developing countries. Patients with low bone mineral density (BMD) have a high risk of future fracture. However, access to BMD measurements is limited in many areas of Asia, and inexpensive methods of targeting high-risk patients for BMD measurements would be valuable. We compared two methods, a simple clinical risk assessment tool, the Osteoporosis Self-assessment Tool for Asians (OSTA), and quantitative bone ultrasound (QUS) in identifying subjects with low BMD by DXA in 722 southern Chinese postmenopausal women recruited from the community in Hong Kong. Using the published cutoff value of -1 (versus 0 or higher) for OSTA to identify subjects with femoral neck BMD T-score < or =-2.5, basing on our local population peak young mean value, the sensitivity and specificity was 88% and 54% respectively. The optimal cutoff T-score of -2.35 for QUS yielded sensitivity and specificity values of 81% and 65%, respectively. The AUC for QUS was 0.78, which was not significantly different from that of 0.80 for OSTA. Both OSTA and QUS correlated significantly with BMD at the femoral neck (0.62 and 0.36, respectively, P both <0.001). When these cut-off values were used to identify subjects with either lumbar spine or femoral neck BMD T-score < or =-2.5, the sensitivity and specificity was 79% and 60%, respectively, for OSTA, and 69% and 70%, respectively, for QUS. Combining QUS with OSTA improved the sensitivity to 91%, but the specificity was reduced to 44%. We conclude that the simple clinical risk assessment tool OSTA is a free and effective method for identifying subjects at increased risk of osteoporosis, and its use could facilitate the appropriate and more cost-effective use of bone densitometry in developing countries

Trigeminal trophic syndrome

Reconstruction After Skin Cancer

Trigeminal trophic syndrome (TTS) is a rare cause of facial ulceration, which is believed to develop after insult to the trigeminal ganglia or other parts of the peripheral/central nervous system in the trigeminal pathway. The pathogenesis of TTS is poorly understood. Developing a better understanding of TTS will allow early recognition and improved treatment. Although the ulcers develop predominantly on the ala nasi, the literature on ulcer locations is limited. In this article, we review the epidemiologic aspects of TTS, expand on our knowledge of the anatomic location of the ulcers, and discuss current theories for its aetiology and briefly review the approaches to its management. © 2007 The Authors Journal compilation © 2007 European Academy of Dermatology and Venereology.

Primary and revision total hip replacement using the Robodoc system

Management of Hip Fractures in the Elderly

The ROBODOC system was designed to address potential human errors in performing cementless total hip replacement. The system consists of a preoperative planning computer workstation (called ORTHODOC) and a five-axis robotic arm with a high speed milling device as an end effector. The combined experience of the United States Food and Drug Administration multicenter trial and the German postmarket use of the system are reported. The United States study is controlled and randomized with 136 hip replacements performed at three centers (65 ROBODOC and 62 control). Followup was 1 year on 127 hip replacements and 2 years on 93 hip replacements. No differences were found in the Harris hip scores or the Short Form Health Survey outcomes questionnaire. Length of stay also was not different, but the surgical time and blood loss were greater in the ROBODOC group. This was attributed to a learning curve at each center. Radiographs were evaluated by an independent bone radiologist and showed statistically better fit and positioning of the femoral component in the ROBODOC group. Complications were not different, except for three cases of intraoperative femoral fracture in the control group and none in the ROBODOC group. The German study reports on 858 patients, 42 with bilateral hip replacements and this includes 30 revision cases for a total of 900 hip replacements. The Harris hip score rose from 43.7 to 91.5. In these cases the surgical time declined quickly from 240 minutes for the first case to 90 minutes. No intraoperative femoral fractures occurred in 900 cases. Other complications were comparable with total hip replacements performed using conventional techniques. The ROBODOC system is thought to be safe and effective in producing radiographically superior implant fit and positioning while eliminating femoral fractures

Non-synonymous WNT16 polymorphisms alleles are associated with different osteoarthritis phenotypes

OAK 3 - Non-arthroplasty tx of OAK

Hereditary factors have a strong influence on osteoarthritis (OA). The Wnt pathway is involved in bone and cartilage homeostasis. Hence, we hypothesized that allelic variations of WNT16 could influence the OA phenotype. We studied 509 Caucasian patients undergoing joint replacement due to severe primary OA. Radiographs were used to classify the OA as atrophic or hypertrophic. Two nonsynonymous polymorphisms of WNT16 (rs2707466 and rs2908004) were analyzed. The association between the genotypes and the OA phenotype was analyzed by logistic regression and adjusted for age and body mass index. A genotype-phenotype association was found in the sex-stratified analysis. Thus, there was a significant difference in the genotypic frequencies of rs2707466 between hypertrophic and atrophic hip OA in males (p = 0.003), with overrepresentation of G alleles in the hypertrophic phenotype (OR 2.08; CI 1.28-3.38). An association in the same direction was observed between these alleles and the type of knee OA, with G alleles being more common in the hypertrophic than in atrophic knee phenotypes (p = 0.008; OR 1.956, CI 1.19-3.19). Similar associations were found for the rs2908004 SNP, but it only reached statistical significance for knee OA (p = 0.017; OR 0.92, CI 0.86-0.989). This is the first study attempting to explore the association of genetic variants with the OA phenotype. These data suggest the need to consider the OA phenotype in future genetic association studies of OA.

Female sex is associated with a lower risk of bone metastases and favourable prognosis in non-sex-specific cancers

MSTS 2022 - Metastatic Disease of the Humerus

BACKGROUND: The objectives were to investigate the disparity in the prevalence of bone metastases (BM) between the sexes and to assess the effect of female sex on the development and prognosis of BM. METHODS: Cases of invasive non-sex-specific cancers diagnosed between 2010 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) program were used. The prevalence of BM was calculated by combining the prevalence of BM among different cancers. Multivariable logistic regression and proportion hazard regression were conducted to investigate the effect of female sex, and the results were pooled by meta-analysis. RESULTS: The pooled prevalence of BM among male and female patients was 2.3% (95% CI: 1.6-3.2%) and 1.8% (95% CI: 1.2-2.6%), respectively. The pooled prevalence of BM dramatically decreased for patients aged 11-40 years old, plateaued for patients aged 41-90 years old and increased for patients aged > 90 years old in both male and female patients. Meta-analysis suggested that female sex had a protective effect on the development of BM (pooled OR = 0.80; 95% CI: 0.75-0.84; p < .001) and a favourable prognosis for respiratory system cancers (pooled HR = 0.81; 95% CI: 0.71-0.92; p < .001). However, no significant associations existed for other cancers. Male non-sex-specific cancer patients and those with male-leaning genetic variations or hormonal status have a greater likelihood of developing BM than female patients. CONCLUSIONS: Female sex was associated with fewer BM in various non-sex-specific cancers, and the effect was constant with changes in age. Female sex showed a protective effect exclusively on the prognosis of respiratory system cancers.

Local metronidazole application in maintenance patients. Clinical and microbiological evaluation

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The purpose of this investigation was to evaluate the clinical and microbiological effect of local antibiotic therapy in comparison with subgingival scaling and root planing in a randomized semi-masked study. Forty-six recall patients who completed systematic periodontal therapy 6 to 24 months prior to the study were enrolled. The inclusion requirements were at least one site with probing depth > or = 5 mm in each quadrant, no scaling, and no antibiotic therapy during the last 6 months. After randomization each patient received 2 different treatments: in 2 quadrants metronidazole 25% dental gel was applied subgingivally to the pockets at day 0 and day 7; scaling and root planing was carried out in the 2 other quadrants, one at day 0 and in the remaining quadrant at day 7. Subgingival microbiological samples were taken from each patient before treatment and on days 21, 91, and 175 after the treatment. The analyses were carried out by indirect immunofluorescence assay. At all treated sites probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP) were recorded on days 0, 21, 91, and 175. Both treatments resulted in PD reduction and CAL gain. PD reduction was statistically significant (P < 0.01) for both treatment modalities after 6 months. The CAL gain was not significant for either treatment. There was no statistical significance between scaling and antibiotic therapy. Treponema denticola, Porphyromonas gingivalis, and Prevotella intermedia were significantly reduced after therapy; however, there were no statistically significant differences between treatments. If Actinobacillus actinomycetemcomitans was present before therapy, it was also present after treatment in both groups. The conclusion is that, in recall patients, local application of metronidazole and scaling and root planing showed similar clinical and microbiological effects without statistically significant differences

Serum leptin level in geriatric patients with hip fractures: possible correlation to biochemical parameters of bone remodeling

Management of Hip Fractures in the Elderly

Osteoporosis and hip fractures are a major public health problem. Since leptin was suggested to be involved in bone remodeling, its possible involvement in fracture formation/prevention was evaluated, by determination of serum leptin level in geriatric population with hip fracture, and evaluation the relationships with biochemical parameters of bone remodeling. We studied 250 geriatric patients with hip fracture admitted to Sapir Medical Center and underwent operative treatment. Among them 172 females and 78 males, with a mean age of 81 years. Serum leptin level of this total population distributed between 1 and 134ng/ml. 40% of patients were in the normal range of our laboratory (10-40ng/ml), 40% had decreased leptin level (<10ng/ml) and 20% had higher leptin level (>40ng/ml). No correlation was detected between serum leptin level and vitamin D-25(OH)D3, which was under normal range in 60% of the patients. Leptin also did not correlate to ICTP level, which was high in 80% of the patients, suggesting an extensive bone resorption in this population. Evaluation of leptin level in female versus male suggests that leptin level is higher in females than males also in this age (28.4ng/ml vs. 14.4ng/ml, p<0.001). However, no difference were detected in either ICTP, or 25(OH)D3, which are involved in bone remodeling. The higher leptin levels in women was accompanied by higher serum levels of glucose, albumin, Ca, cholesterol, Na and FT4. Comparison of 50 patients with the lowest leptin levels (mean of 3.4ng/ml) to 50 patients with highest leptin levels (mean of 34ng/ml), did not indicate differences in both 25(OH)D3 and ICTP between these two populations in spite of the highly significant difference in leptin levels. The high range of serum leptin concentration in these geriatric patients with hip fracture of both sexes, and the absence of any correlation between leptin and the tested parameters of bone resorption and Ca metabolism, teleopeptide type I collagen (ICTP) and 25(OH)D3, does not support a direct massive involvement of serum leptin in hip fracture of the very old population

Early infectious outcomes after addition of fluoroquinolone or aminoglycoside to posttrauma antibiotic prophylaxis in combat-related open fracture injuries

DoD SSI (Surgical Site Infections)

BACKGROUND: We examined combat-related open extremity fracture infections as a function of whether posttrauma antimicrobial prophylaxis included expanded Gram-negative (EGN) coverage. METHODS: Military personnel with open extremity fractures sustained in Iraq and Afghanistan (2009-2014) who transferred to participating hospitals in the United States were assessed. The analysis was restricted to patients with a U.S. hospitalization period of =7 days. Prophylaxis was classified as narrow (e.g., IV cefazolin, clindamycin, and/or amoxicillin-clavulanate) or EGN, if the prophylactic regimen included fluoroquinolones and/or aminoglycosides. RESULTS: The study population included 1,044 patients, of which 585 (56%) and 459 (44%) received narrow and EGN coverage, respectively (p < 0.001). Skin and soft-tissue infections (SSTIs) were more common among patients who received narrow prophylaxis compared to EGN coverage (28% vs. 22%; p = 0.029), whereas osteomyelitis rates were comparable between regimens (8%). Similar findings were noted when endpoints were measured at 2 and 4 weeks postinjury. There was no significant difference related to length of hospitalization between narrow and EGN regimens (median: 34 and 32 days, respectively) or operating room visits (median: 5 and 4). A higher proportion of EGN coverage patients had Gram-negative organisms isolated that were not susceptible to fluoroquinolones and/or aminoglycosides (49% vs. 40%; p < 0.001). In a Cox proportional model, narrow prophylaxis was independently associated with an increased risk of extremity SSTIs (hazard ratio: 1.41; 95% confidence interval: 1.09-1.83). DISCUSSION: Despite seeing a small benefit with EGN coverage related to a reduction of SSTIs, it does not decrease the risk of osteomyelitis, and there seems to be a cost of increased antibiotic resistance associated with use. Overall, our findings support the current post-combat trauma antibiotic prophylaxis guidelines, which recommend the use of cefazolin or clindamycin with open fractures. LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level II; Therapy, level IV.

(i) The surgical management of rheumatoid arthritis of the shoulder and elbow

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

The management of the rheumatoid shoulder and elbow is a challenging problem. In this review we aim to summarise the main management options for shoulder and elbow disease placing particular emphasis on surgical treatment. We believe that by using the techniques available and with good patient selection excellent results can be achieved, reducing the patients pain and also providing independence for activities of daily living. (copyright) 2007

Tibial slope and gaps balance in knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Introduction The success of total knee arthroplasty relies on the appropriate limb alignment with balanced flexion and extension gaps. Saggital plane cuts are involved and posterior slope require restoring the original. Materials and methods From September 2006 to January 2009, 173 primary CR total knee arthroplasties were performed. Hospital records and radiographs were available for 136 patients (158 knees). The average age at the time of surgery was 69.4 years. The diagnoses included osteoarthritis in 146 knees (95 %). A retrospective review was performed by an independent observer to determine whether a posterior cruciate ligament release had been done; whether a manipulation had been done; and the range of motion noted at 6 weeks and at the time of the most recent follow-up. The posterior tibial slope was measured on X-ray lateral view using a calibrated picture. Results The median tibial slope was 4(degrees). The posterior cruciate ligament was released in 38 % knees. The posterior cruciate ligament was released in 46 % of the knees with<4(degrees) of tibial slope and 29 % where slope>4(degrees). Manipulation was performed in 5 cases (2 in<4(degrees) and 3 in>4(degrees)), and they not relied on PC release. At the most recent evaluation the ROM was better in the patients with<4(degrees)of posterior slope (115(degrees)) than it was in the patients with>4(degrees) of slope (110(degrees)). The patients who did not have a posterior cruciate ligament release had similar ranges of motion regardless of the tibial slope

The Association of Recreational and Competitive Running With Hip and Knee Osteoarthritis: A Systematic Review and Meta-analysis

OAK 3 - Non-arthroplasty tx of OAK

Study Design Systematic review and meta-analysis. Background Running is a healthy and popular activity worldwide, but data regarding its association with osteoarthritis (OA) are conflicting.

Risk factors for hip fracture in US men aged 40 through 75 years

Management of Hip Fractures in the Elderly

Relatively few studies have examined risk factors for hip fracture among men. This study analyzes data from the Health Professionals Follow-up Study, a prospective study of approximately 50,000 men who were between the ages of 40 and 75 years in 1986. Body mass index, smoking status, and alcohol consumption were not associated with hip fracture in this population. However, age and height were related to hip fracture. Men who were 65 and older had a significantly higher risk of sustaining a hip fracture than younger adults. Men 6 feet or taller were more than twice as likely to sustain a hip fracture as those under 5 feet, 9 inches

Pharmacogenomics: Current state-of-the-art

MSTS 2018 - Femur Mets and MM

The completion of the human genome project 10 years ago was met with great optimism for improving drug therapy through personalized medicine approaches, with the anticipation that an era of genotype-guided patient prescribing was imminent. To some extent this has come to pass and a number of key pharmacogenomics markers of inter-individual drug response, for both safety and efficacy, have been identified and subsequently been adopted in clinical practice as pre-treatment genetic tests. However, the universal application of genetics in treatment guidance is still a long way off. This review will highlight important pharmacogenomic discoveries which have been facilitated by the human genome project and other milestone projects such as the International HapMap and 1000 genomes, and by the continued development of genotyping and sequencing technologies, including rapid point of care pre-treatment genetic testing. However, there are still many challenges to implementation for the many other reported biomarkers which continue to languish within the discovery phase. As technology advances over the next 10 years, and the costs fall, the field will see larger genetic data sets, including affordable whole genome sequences, which will, it is hoped, improve patient outcomes through better diagnostic, prognostic and predictive biomarkers. © 2014 by the authors; licensee MDPI, Basel, Switzerland.

Microdrilled cartilage defects treated with thrombin-solidified chitosan/blood implant regenerate a more hyaline, stable, and structurally integrated osteochondral unit compared to drilled controls

Osteochondritis Dissecans 2020 Review

This study analyzed the long-term cartilage and subchondral bone repair of microdrilled defects treated with chitosan glycerol-phosphate/blood implant, using thrombin (Factor IIa) to accelerate in situ solidification. We also evaluated the cartilage repair response to six smaller microdrill holes compared with two larger holes. Bilateral knee trochlear cartilage defects were created in n=8 skeletally mature rabbits, drilled with six proximal 0.5 mm and two distal 0.9 mm holes, then covered with in situ-solidified IIa-implants (treated) or with IIa-alone (control). After 6.5 months of repair, cartilage repair tissues were analyzed by histological scoring and histomorphometry for hyaline matrix characteristics and osseous integration. Subchondral repair bone was analyzed by 3D microcomputed tomography and compared to acute defects (n=6) and intact trochlea (n=8). Implant-treated cartilage repair tissues had higher structural integrity through the entire defect (p=0.02), twofold higher percent staining for glycosaminoglycan (p=0.0004), and ~24% more collagen type II staining over the smaller drill holes (p=0.008) compared with controls. Otherwise, hole diameter had no specific effect on cartilage repair. The subchondral bone plate was partially restored in treated and control defects but less dense than intact trochlea, with evidence of incomplete regeneration of the calcified cartilage layer. More residual drill holes (p=0.054) were detected in control versus treated defects, and control defects with more than 40% residual holes presented abnormally thicker trabeculae compared with treated defects. Low osteoclast numbers after 6.5 months repair suggested that bone was no longer remodeling. The subchondral bone plate surrounding the defects exhibited a significant thickening compared with age-matched intact trochlea. These data suggest that debridement and drilling can lead to long-term subchondral bone changes outside the cartilage defect. Compared with drilled controls, chitosan implants solidified with thrombin elicited a more hyaline and structurally integrated osteochondral unit, features needed for long-term durability.

Comparative study of anterolateral approach versus posterior approach for total hip replacement in the treatment of femoral neck fractures in elderly patients

Management of Hip Fractures in the Elderly

OBJECTIVE: To compare the clinical outcome of anterolateral minimally invasive approach versus conventional posterior approach for total hip replacement against femoral neck fractures in elderly patients. METHODS: The retrospective study was carried out on 42 patients who suffered from displaced femoral neck fractures (19 cases of Garden type III, 23 cases of Garden type IV) treated by total hip replacement via anterolateral minimally invasive approach or conventional posterior approach by the same experienced surgeon. The average age of the patients was 78.1 years (range: 65-89 years). They were divided into anterolateral mini-invasive group (22 cases) and posterior group (20 cases). The mean time of follow-up was 13 months (range: 6-36 months). The anterolateral approach described by Hardinge goes through between anterior 1/3 and posterior 2/3 of the gluteus medius muscle, reaching the femoral neck from anterior capsule. The traditional posterior approach described by Moore (Southern incision) goes through the insertions of short external rotation muscles, reaching the femoral neck from posterior capsule. The related variables under observation were length of incision, operation time, postoperative limp, length of hospital stay and bed stay and dislolcation rate. RESULTS: The length of the skin incision varied between 7 cm and 12 cm with the anterolateral minimally invasive technique, compared to 15-22 cm in the conventional procedure. It took less time (average 15 minutes) to complete the anterolateral minimally invasive approach (72 min+/-15 min), compared with the conventional approach (87 min+/-10 min). The average Harris hip score was 91.23+/-10.20 in anterolateral approach, 90.03+/-11.05 in the posterior approach. The average length of hospital stay for patients with the anterolateral approach was (6.4+/-2.2) days (range: 4-9 days), while that in posterior approach was (9.2+/-3.1) days (range: 6-13 days). The average length of bed stay was (3.4+/-1.1) days (range: 2-5 days) in anterolateral group and (6.2+/-2.8) days (range: 3-10 days) in posterior group. No patients in anterolateral group experienced dislocation. One (5%) hip in posterior approach had dislocation. CONCLUSIONS: Anterolateral mini-invasive approach can decrease trauma, operation time, length of hospital stay and bed stay and rehabilitation time. The stability and minimal muscular damage permit the acceleration of postoperative rehabilitation, which can subsequently reduce the perioperative risk in the treatment of femoral neck fractures in the elderly undergoing total hip replacement

The Impact of Intra-articular Depot Betamethasone Injection on Insulin Resistance Among Diabetic Patients With Osteoarthritis of the Knee: A Case-Control Study

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: The aim of this study was to evaluate the impact of intra-articular corticosteroid injection (IACI) of depot betamethasone at the knee joint on insulin resistance (IR). METHODS: Patients with type 2 diabetes, non-insulin treated, with painful osteoarthritis of the knee were requested to participate in our study. After consent, demographic, clinical, and laboratory parameters were documented in addition to fasting blood glucose (FBG) and fasting blood insulin levels just prior to IACI of 1 mL of depot betamethasone. Fasting blood glucose and fasting blood insulin levels were repeated the next day following the IACI and 8 days later. Age- and sex-matched group of patients with type 2 diabetes from the same clinic were recruited as a control group (case-control study). Insulin resistance was calculated using Homeostasis Model Assessment-Insulin Resistance. Mann-Whitney U test, chi test, and Wilcoxon signed rank tests were used for statistical analysis. RESULTS: Eleven patients were recruited in the patients' group and 10 patients in the control group. Median FBG in the patients' group at baseline was 148 +/- 51 mg/dL, and median IR was 5.12 +/- 2.46. One day following the IACI, median FBG level was 247 +/- 104 mg/dL (P = 0.004, compared with baseline), with median IR of 20.8 +/- 7.01 (P = 0.0039). The median ratios of blood glucose and IR 1 day following the IACI compared with baseline were 1.7 and 4.1, respectively. Eight days following the IACI, mean FBG and IR levels were not significantly different from baseline. CONCLUSIONS: Intra-articular corticosteroid injection of betamethasone at the knee joint among patients with diabetes was associated with a significant increase in IR levels compared with baseline levels, 1 day following the injection. The mean percentage of increase in IR was higher than that for FBG levels.

Endoscopic aesthetic facial surgery: technique and results

Panniculectomy & Abdominoplasty CPG

The endoscopic approach to forehead and midface lifting has become popular method of face rejuvenation with minimal incisions. We have performed 67 endoscopic facelift procedures in the last four years. Forehead lifting technique included five small scalp incisions, wide subperiosteal elevation, endoscopic myotomy and forehead tissue fixation with srews, superficial temporal fascia (STF) suture to deep temporal fascia (DTF). Midface lifting technique included temporal 2.5 cm and 1.5 cm vertical intraoral incision, midface subperiosteal undermining and midface elevation with cable sutures Bichat's fat to DTF. Age mediana of patients who underwent endoscopic front lift was 46, patients who had endoscopic front lift and midface lift procedure age mediana was 40. Postoperative complication rate was 7.5% and included frontal branch weakness (n=2), hematoma (n=1), infraorbital nerve paresthesia (n=1) and asymmetrical smile (n=1). The main question is the quality of the results. We have reviewed 49 patients who were followed 6 months or more. Preoperative and postoperative life-size photographs were analyzed. The mean elevation mediana at medial canthus was 2.2 mm, at medial limbus 2.3 mm, at lateral limbus 2.5 mm, at lateral canthus 2.9 mm. Midface - lift effect resulted cheek elevation from 1.07 till 4.71 mm lip corner elevation 1.03 mm to 3.27 mm. We observed cheek elevation, improving nasolabial line, increasing volume of malar region, elevating lip angles in patients after endoscopic midface lift. We have found that important advantage of subperiosteal midface lift, when performed in conjunction with endoscopic brow lift, is its ability to move the cosmetic eye unit, proportionally, leading to a harmonious facial appearance. Endoscopic facelift is effective procedure for face rejuvenation especially for eyebrows and cheek elevation.

Lymphedema: A Significant Risk Factor for Infection and Implant Failure After Total Knee Arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Lymphedema is characterized by fluid buildup and swelling, leading to skin fibrosis and recurring soft-tissue infections. There is a paucity of data examining the impact of lymphedema in total knee arthroplasty (TKA). The purpose of this study was to review the outcomes of TKA in patients with lymphedema compared with a matched cohort with primary osteoarthritis. METHODS: One hundred forty-four knees underwent primary TKA with a preceding diagnosis of ipsilateral lymphedema. The mean follow-up was 7 years. A blinded 1:2 match of knees with lymphedema to a group of knees without lymphedema undergoing primary TKA was performed. Matching criteria included sex, age, date of surgery, and body mass index. The mean follow-up for the comparison cohort was 8 years. RESULTS: Lymphedema increased revision hazard ratio [HR] 7.60; P < 0.001), reoperation (HR, 2.87; P < 0.001), and infection (HR, 6.19; P < 0.001) in addition to periprosthetic fracture (P = 0.04) and tibial component loosening (P = 0.01). The mean time to infection trended toward later time points in knees with lymphedema (19 versus 2 months, P = 0.25). DISCUSSION: Lymphedema increased the risk of revision, reoperation, and infection. These data highlight the need for appropriate patient counseling and the need for further investigation into the effects of preoperative and postoperative optimization of lymphedema management in the TKA setting. LEVEL OF EVIDENCE: Therapeutic Level III.

Evaluation of centrifugation technique and effect of epinephrine on fat cell viability in autologous fat injection

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Centrifugation helps refine autologous fat for use as an injectable filler, but the process can be injurious to fat cells. Epinephrine may be harmful to fat cells. OBJECTIVE: We studied the effects of different centrifugation levels and epinephrine dosages on fat cell viability. METHODS: Autologous fat was obtained from 8 patients who underwent lipoplasty, and the fat samples were centrifuged for 1, 3, and 5 minutes at 1500, 3000, and 5000 revolutions per minute (RPM), respectively, with uncentrifuged fat used as a control. Fat was also obtained from 8 patients undergoing autologous fat injection who had received anesthesia in a mixture of Hartman solution and a 2% lidocaine solution. The samples were mixed with epinephrine at ratios of 1:100,000, 1:200,000, and 1:400,000; a sample without epinephrine served as a control. The samples were centrifuged at 3000 RPM for 3 minutes. Fat cell viability for both experiments was evaluated by the number of surviving cells. RESULTS: Cell survival rates were significantly lower for the groups centrifuged at 1500 and 3000 RPM for more than 5 minutes and for the group centrifuged at 5000 RPM for more than 1 minute. There was no significant difference in survival rates among the samples mixed with different ratios of epinephrine. CONCLUSIONS: Centrifugation with 3000 RPM for 3 minutes is recommended. The effect of epinephrine on fat cell viability is negligible.

The role of long term outpatient continuous peripheral nerve catheters in the treatment of non-healing wounds

Surgical Management of Osteoarthritis of the Knee CPG

Introduction: Non-healing wounds and the pain associated with them can be difficult to manage. Traditionally, medications have been the mainstay of treatment, but continuous peripheral nerve catheters (CPNCs) are proving to be an effective alternative. For the last two years, we have treated multiple patients suffering from a variety of non-healing wounds successfully using CPNCs and here we present three cases exemplifying this success. Material and Methods/Results: The first case is a 52 year old female with diabetes mellitus and peripheral vascular disease and a seven year history of non-healing foot ulcers. For 6.5 years, her pain was treated unsuccessfully with high dose opioids, limiting her visit compliance, and ability to function independently. In 5/2011, we placed an infra-gluteal sciatic CPNC with continuous infusion (2 mL/hr 0.2% ropivicaine) and patient controlled boluses (10 mL every 90 min), maintaining it from 5/2011-1/2012. During her weekly debridement visits, her catheter was bolused with 2% Lidocaine, providing surgical analgesia in a clinical setting. Over these eight months, her compliance with wound care visits, independence, and quality of life vastly improved, and her ulcers healed completely. The second case involves a healthy 43 year old man who developed a large wound on his left medial knee after falling from his bike. A distal femoral CPNC was placed initially for post operative pain control following an incision and debridement/wound VAC placement, but was kept in over the following 4.5 months of rehab, dressing changes, and skin grafts. His catheter was maintained in the same manner as the first case. Throughout this time, he never required any narcotics and his wound completely healed. The final case involves an 81 year old man with metastatic prostate cancer and chronic venous insufficiency who suffered from poorly treated lower extremity chronic wounds for over a year. An infra-gluteal sciatic CPNC was placed and over the following two months, his narcotic requirements decreased and ulcers shrank. Although he elected to remove his catheter after a superficial wound infection before his ulcers completely healed, his current quality of life and narcotic requirements are much better than prior to the placement. Discussion: CPNCs provide highly effective analgesia and facilitate patient compliance while avoiding the problems associated with opioid use. In addition to pain control, CPNCs have the theoretical benefits of increased tissue perfusion and oxygenation through sympathectomy induced vasodilation (1), anti-inflammatory effects (2), and may attenuate resulting pain sequelae, including phantom limb syndrome (if an amputation is required) (3). Given the favorable risk / benefit of regional anesthetic techniques, its theoretical advantages, its ease of use in the outpatient setting, and our ever-growing population of patients with non-healing wounds, we not only advocate further research in this promising field, but also the increased use of these catheters in clinical practice

[Non-pharmacological treatments for osteoarthritis: unavoidable and essential]

OAK 3 - Non-arthroplasty tx of OAK

The optimal treatment of osteoarthritis requires the combination of pharmacological and non-pharmacological treatments. The non-pharmacological treatments recommended by the medical and scientific associations are information, education, weight management (especially in case of overweight) and physical activity. Antalgic and anti-inflammatory pharmacological treatments should be used to facilitate the recovery and regular physical activity that is central in the management of osteoarthritis patients. It should include aerobic cardio-respiratory, resistance, flexibility and neuromuscular reprogramming and be associated with cognitive-behavioral therapies. Health professionals have to promote the activity and to inform their patients about the benefits, not only about the symptoms of osteoarthritis, but also about their overall health.

Why do we use arthroscopy for distal radius fractures?

Distal Radius Fractures

The management of distal radius fractures needs to be adapted to the increasingly complex traumas in patients with greater functional requirements. The goal remains to restore normal anatomy in order to preserve function. A pre-operative assessment using x-rays and thin-slice CT scans with three-dimensional reconstructions enables the best possible understanding of the fracture prior to surgery and planning of the pre-operative strategy. Arthroscopy is a technique that allows visualisation of the bone fragments and their displacement, as well as their reduction. It is the only tool that allows diagnostic and prognostic assessment of the associated injuries. Arthroscopy is the gold standard for identifying and grading scapholunate injuries. It allows treatment of the lesions where necessary and a dynamic appreciation of the stability of the osteosynthesis. Recognition of articular fragmentation patterns and instability features can therefore aid treatment choice to prevent poor outcomes due to malunion and degenerative arthritis. We recommend arthroscopic-assisted internal fixation for articular fractures for any active patient, not only for young adults, displaced or a gap by more than 2 mm, potential scapholunate ligament injuries, and fractures of the ulnar styloid. A strong initial learning and a minimal experience are recommended to avoid the complications of this invaluable procedure.

Patella resurfacing in total knee replacement: functional evaluation and complications

Surgical Management of Osteoarthritis of the Knee CPG

Three different knee replacements, with three trochlear designs, were prospectively evaluated clinically and radiographically for patellar function and presence of patellar complications. They included the Insall-Burstein (IB) I and the IB-II (posterior cruciate ligament substituting) and the Meniscal Bearing Knee (MBK; posterior cruciate ligament recession). The trochlea of the IB-I was short and shallow with an anterior sharp edge of the intercondylar box (later modified to a smoother edge) and the femoral component had a prominent "shoulder." In the IB-II the trochlea was deeper to allow for soft tissue clearance. In the MBK the trochlea was more prolonged, with R and L components and the "shoulder" was less prominent. In all the cases the patella was resurfaced with an all polyethylene dome prosthesis. Knees with tibiofemoral problems were excluded. From the data of the present study the following conclusions can be drawn: (a) The most frequent problem was impingement (clunks) with the early version of the IB-I. Smoothening of the anterior edge significantly reduced the incidence of clunks to 5% in the modified IB I. (b) With the IB-II deepening the trochlea for soft tissue clearance improved the degree, not the incidence of clunks (4.5%), compared to the modified IB I. (c) With the MBK clunks were very rare and patellar function improved. (d) Throughout the three series patellar stress fractures and instability were rare and loosening or wear not evident. (e) Normal function (including stairs ascending and descending) can be expected in over 80% of category A patients. (f) Of the various radiological parameters only patella baja was correlated with symptoms in the IB prostheses. (g) We still prefer the dome design because is more tolerant and with cold flow may better conform to the trochlea increasing contact area

Minimally displaced fractures of the greater tuberosity: Outcome of non-operative treatment

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Background: Minimally displaced (<3 mm) and non-displaced fractures of the proximal humerus are a common source of disability; nevertheless, there is no agreement on the recommended rehabilitation program in these patients. The purpose of this study was to evaluate the outcome of this group of patients and describe the rehabilitation protocol we have used for the treatment of this injury. Methods: We retrospectively analyzed the records of patients diagnosed with minimally displaced (<3 mm) fractures of the greater tuberosity who were admitted to our institute between June 2007 and May 2008. Patients were treated with a three-phase protocol. In the first phase, patients were immobilized in a sling for 3 weeks. In the second phase, pendular and active assisted exercises were begun 3 to 6 weeks after the injury. In the third phase, active exercises were commenced starting 6 weeks after injury. Results: Sixty-nine patients matched our inclusion and exclusion criteria. At an average follow-up of 31 months (range, 26-41 months), the average Constant score improved from 40 points (range, 33-58 points) to 95 points (range, 75-100 points). Average satisfaction score improved from 4.2 of 10 (range, 2-6) to 9.5 of 10 (range, 7-10). The reported average duration of pain and decreased range of motion from the time of injury was 8.1 months (range, 1-24 months). Conclusions: When the diagnosis of a minimally displaced fracture of the proximal humerus is made, the patient can be reassured that a favorable outcome is anticipated with a staged rehabilitation protocol. Nevertheless, clinicians and patients should be aware that full recovery from the injury may take an average of 8 months. (copyright) 2013 Journal of Shoulder and Elbow Surgery Board of Trustees

A randomized controlled trial comparing acetaminophen, acetaminophen and ibuprofen, and acetaminophen and codeine for postoperative pain relief after Mohs surgery and cutaneous reconstruction

Reconstruction After Skin Cancer

BACKGROUND: There are no population-based data comparing analgesics after Mohs micrographic surgery (MMS) and reconstruction. OBJECTIVE To compare the efficacy in pain management of three analgesic combinations. METHODS: In a randomized, double-blind, controlled study, patients undergoing MMS and reconstruction for head and neck skin cancers received 1,000 mg of acetaminophen (Ac), 1,000 mg Ac plus 400 mg ibuprofen (Ib), or 325 mg Ac plus 30 mg codeine (Co) immediately after surgery and every 4 hours for up to four doses. Patients rated their pain on a visual analog scale (VAS) 0, 2, 4, 8, and 12 hours after surgery and recorded medication-related side effects. RESULTS: The Ac+Ib group had the lowest pain scores (mean change from baseline/immeditely prior to surgery) at each postoperative recorded time interval and a significantly smaller change from baseline pain scores than the Ac+Co group at 4 hours (p=.005) and the Ac group at 8 hours (p=.02). Ac+Ib was also superior in pain control for patients with surgical areas smaller than 10 cm(2) . Complications in the Ib+Ac group were significantly lower than in the Ac+Co group but not the Ac group. CONCLUSIONS: The combination of Ac+Ib is superior to Ac alone or Ac+Co in controlling postoperative pain after MMS and cutaneous reconstruction.

Audit of morbidity and mortality following neck of femur fracture using the

Management of Hip Fractures in the Elderly

AIMS: The aims of this study were to compare the morbidity and mortality data for patients undergoing surgical fixation of a fractured neck of femur (during a 6-month period) to the predicted morbidity and mortality rates obtained from the POSSUM (Physiological and Operative Severity Score for the enUmeration of Morbidity and Mortality) scoring system, adapted for orthopaedic patients. The predictive accuracy of the orthopaedic POSSUM system is evaluated for this population. The 1-year mortality for the males and females of the study group (mean ages) is compared to the 1-year mortality of male and female New Zealanders of the same age. METHODS: Physiological and operative data was collected from patient notes; patient morbidity and mortality were obtained at 30 days and at 1 year postoperatively. The data were analysed with the orthopaedic POSSUM scoring system. RESULTS: 225 complete datasets were obtained. The mean age of the patients was 83 years; 75% were female. The observed 30-day morbidity and mortality rates were 58% and 12% respectively. The observed 1-year mortality was 38% for males (mean age 79 years) and 29% for females (mean age 84 years). New Zealand census data predicts 7% and 6.4% mortality respectively based on these mean ages. CONCLUSIONS: The POSSUM system allocates patients into groups of varying risk. The observed data shows higher numbers of complications, including death, in patients allocated into higher risk groups. The 1-year mortality is much higher than that predicted based on mean patient age from the New Zealand abridged life table

Examining shibboleths of hip rehabilitation protocols using in vivo contact pressures from an instrumented hemiarthroplasty

Management of Hip Fractures in the Elderly

This study uses acetabular contact pressure data from the immediate post-operative period to examine some of the commonly held beliefs about early phase hemiarthroplasty rehabilitation. Data were obtained from an instrumented femoral head prosthesis implanted in an 82-year-old man (height 1.6 m; weight 54.5 kg) with a displaced left hip fracture. Data were collected daily during the two weeks of immediate post-operative hospitalisation. The shibboleths being examined are related to the functional activities: sit-to-stand, ambulation, and stair-climbing. Results support beliefs about rising from a chair: lower pressures were created when rising from a 62 cm hip chair (1.4 MPa) than from a 48 cm standard chair (7.09 MPa); and less pressure was created when rising from a 62 cm hip chair with operated leg out in front (1.21 MPa) than when rising from the same chair with feet together (2.96 MPa). Gait training beliefs are challenged by the study findings: there was no significant difference between touch weight bearing, partial weight bearing, and weight bearing as tolerated; and use of a very commonly used post-operative gait sequence (walker, then operated leg, then non-operated leg) generated a greater peak pressure than an 'incorrect' sequence (walker, then non-operated leg, then operated leg). Limited early post-operative stairs data prevented definitive conclusions from being reached about stair-climbing in the early post-operative period. However, examination of data from one year post-operatively demonstrates that unassisted reciprocal gait on stairs creates large (15.52 MPa) acetabular contact pressures