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Ptosis repair in aesthetic blepharoplasty

Upper Eyelid and Brow Surgery

It is important to recognize ptosis of the upper eyelids in patients who are contemplating aesthetic blepharoplasty. When ptosis is present, it should be corrected simultaneously with the blepharoplasty.

The vastus medialis muscle

OAK 3 - Non-arthroplasty tx of OAK

The vastus medialis muscle ensures the stability and the correct position of the patella. Weakness of the muscle compromises this balance and causes a patellar ascension resulting in pain, especially when climbing or descending stairs. Consequences of this deficiency are a relative instability of the knee, often unconscious because present for a very long time with compensation by other muscles, in particular the tensor of the fascia latae, explaining the pains of the external side of thigh (strip tibial ilio), the hip region (muscle body) and further away from the leg muscles. Very common pathology, simple diagnosis and treatment, the hypotrophy of the vast internal deserves to be recognized to avoid the local consequences like knee osteoarthritis and remotely on the whole body statics.

Coagulation aggravates blood-induced joint damage in dogs

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: Joint bleeding due to trauma, major joint surgery, or hemophilia leads to joint damage. It is unclear if there are differences between coagulating blood and anticoagulated blood with respect to joint degeneration, especially in vivo. Therefore, we undertook this study to evaluate in a canine in vivo model whether intraarticular exposure to coagulating blood is more destructive than exposure to anticoagulated blood, and whether inflammation plays a role in the cartilage- damaging process. METHODS: In 7 dogs the left knees were injected with coagulating blood 4 times a week during weeks 1 and 4, and the right knees were injected with saline. In 7 other dogs, anticoagulated heparinized blood was injected, and heparinized saline was used as control. Ten weeks after the last injection, cartilage matrix turnover and synovial inflammation were analyzed. To study inflammation-independent cartilage damage, explants of cartilage from at least 6 human donors per group were exposed in vitro to coagulating and anticoagulated blood, plasma, and serum for 4 days. Cartilage matrix turnover was determined after a recovery period of 12 days. RESULTS: Canine knees injected with coagulating blood showed more disturbed proteoglycan turnover than knees injected with anticoagulated blood. Synovial inflammation was present only after intraarticular injections with coagulating blood. In in vitro experiments, exposure of human cartilage explants to coagulating blood resulted in more damage than did exposure to anticoagulated blood, while exposure to plasma and serum did not alter cartilage matrix turnover. CONCLUSION: This study shows that coagulating blood causes more long-lasting in vivo joint damage than anticoagulated blood, thereby suggesting that along with joint bleeding in hemophilia, exposure to intraarticular blood should also be avoided during surgery and trauma to prevent joint damage.

Use of Bisphosphonates in the Treatment of Multiple Myeloma

MSTS 2018 - Femur Mets and MM

Bone pain is the single most common presenting complaint in myeloma. Although first-line chemotherapy has a marked effect on bone pain, skeletal disease frequently continues to progress throughout the course of the disease and the incidence of skeletal events remains high. The underlying pathology in myeloma constitutes mainly increased osteoclastic activity but also reduced osteoblastic activity. Any agent that inhibits osteoclast activity potentially provides some degree of skeletal protection although only the bisphosphonates have achieved widespread use. Bisphosphonates are potent inhibitors of osteoclast-mediated bone resorption and evidence of bone protection and modification of skeletal disease progression has been greatest with clodronate and pamidronate. The MRC VIth Myeloma Trial is, to date, by far the largest randomised placebo-controlled trial of bisphosphonates in myeloma. Current evidence suggests that bisphosphonate treatment should begin as early as possible and continue indefinitely, and probably should be considered for all patients with myeloma. The additional costs of clodronate therapy in the management of myeloma patients were around 17% higher than in controls which is moderate when considering the significant reductions in hypercalcaemic episodes and in vertebral and non-vertebral fractures.

The peri-operative management of the rheumatoid patient undergoing total knee arthroplasty: A review of literature

AAHKS (2) Corticosteroids

Rheumatoid arthritis is the commonest inflammatory arthropathy, and affects synovium, cartilage and bone. Despite recent improvements with disease modifying biological agents, progressive joint destruction may continue eventually leading to the need for joint arthroplasty. The knee joint is involved in 90% of patients with rheumatoid arthritis, and total knee arthroplasty is being performed in many patients to alleviate pain and recover function. However, complications are not uncommon. In this review of the literature we look at pre-operative, intra-operative and post-operative factor that need to be taken into account to reduce the risk of complications in these patients. Due to the systemic nature of rheumatoid arthritis, a multi-disciplinary approach is crucial. This includes addressing medical and pharmacological issues, and anesthetic concerns pre-operatively, and anticipating and preventing relevant complications postoperatively.

A dose-response study of a novel method of selective tissue modification of cellular structures in the skin with nanosecond pulsed electric fields

Panniculectomy & Abdominoplasty CPG

BACKGROUND AND OBJECTIVES: This study describes the effects of nanosecond pulsed electric fields (nsPEF) on the epidermis and dermis of normal skin scheduled for excision in a subsequent abdominoplasty. NsPEF therapy applies nanosecond pulses of electrical energy to induce regulated cell death (RCD) in cellular structures, with negligible thermal effects. Prior pre-clinical studies using nsPEF technology have demonstrated the ability to stimulate a lasting immune response in animal tumor models, including melanoma. This first-in-human-use of nsPEF treatment in a controlled study to evaluate the dose-response effects on normal skin and subcutaneous structures is intended to establish a safe dose range of energies prior to use in clinical applications using nsPEF for non-thermal tissue modification. STUDY DESIGN/MATERIALS AND METHODS: Seven subjects with healthy tissue planned for abdominoplasty excision were enrolled. Five subjects were evaluated in a longitudinal, 60-day study of effects with doses of six nsPEF energy levels. A total of 30 squares of spot sizes 25mm(2) or less within the planned excision area were treated and then evaluated at 1 day, 5 days, 15 days, 30 days, and 60 days prior to surgery. Photographs were taken over time of each treated area and assessed by three independent and blinded dermatologists for erythema, flaking and crusting using a 5-point scale (0?=?low, 4?=?high). Punch biopsies of surgically removed tissue were processed and evaluated for tissue changes using hematoxylin and eosin, trichome, caspase-3, microphthalmia transcription factor, and elastin stains and evaluated by a dermatopathologist. The skin of two subjects received additional treatments at 2 and 4?hours post-nsPEF and was evaluated in a similar manner. RESULTS: Most energy settings exhibited delayed epidermal loss followed by re-epithelization by day 15 and a normal course of healing. Histologic analysis identified the appearance of activated caspase-3 at two and four hours after nsPEF treatment, but not at later time points. At the 1-day time point, a nucleolysis effect was observed in epidermal cells, as evidenced by the lack of nuclear staining while the epidermal plasma membranes were still intact. Cellular structures within the treatment zone such as melanocytes, sebaceous glands, and hair follicles were damaged while acellular structures such as elastic fibers and collagen were largely unaffected except for TL6 which showed signs of dermal damage. Melanocytes reappeared at levels comparable with untreated controls within 1 month of nsPEF treatment. CONCLUSIONS: The selective effect of nsPEF treatment on cellular structures in the epidermal and dermal layers suggests that this non-thermal mechanism for targeting cellular structures does not affect the integrity of dermal tissue within a range of energy levels. The specificity of effects and a favorable healing response makes nsPEF ideal for treating cellular targets in the epidermal or dermal layers of the skin, including treatment of benign and malignant lesions. NsPEF skin treatments provide a promising, non-thermal method for treating skin conditions and removing epidermal lesions. © 2019 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

A novel approach to the treatment of chronic tendon pathology using the fast procedure: A pilot study

Surgical Management of Osteoarthritis of the Knee CPG

Objective: Chronic tendinopathy remains one of the most challenging orthopedic conditions to treat. The objective of the study is to determine early efficacy of the 'fasciotomy and surgical tenotomy' (FAST) procedure for chronic patellar tendinosis, Achilles tendinosis, rotator cuff tendinosis, lateral epicondylitis, and plantar fasciitis. Design: A pilot study. Setting: Private Practice, Sports Medicine Clinic. Participants: Eighteen patients with chronic tendon issues who failed conservative treatment. Interventions: Patients electively underwent an innovative new tenotomy procedure called FAST. Percutaneous microresection of pathologic tissue is aspirated under ultrasound guidance using a special probe (TX1) while delivering ultrasonic impulses. The procedure is performed under local anesthesia. Main Outcome Measures: Outcome measures included a patient satisfaction survey, visual analog score (VAS), Disability of the Arm, Shoulder, and Hand (DASH) score for the shoulder, Khujala patellofemoral score for the knee, and the Functional Foot Index (FFI) for the foot at the pre-procedure visit and then measured 2 weeks post-op. Ultrasound images were reviewed prior to the procedure, during the procedure, and at the 2 week follow up. Results or Clinical Course: The average age of the patients was 48.2 (SD (plus or minus) 15.2) years and the average duration of symptoms was 6.4 (SD (plus or minus) 2.8) months. There was a statistically significant improvement in the VAS score (p < .05) as well as overall improvement in each respective outcome measure (p = .0004). Differences in ultrasound images were seen immediately after the procedure in all the patients. Of the 18 patients, 16 patients (89%) were satisfied with the procedure at the 2 week follow up visit. The only complication was soreness after the procedure. Conclusions: Preliminary results have shown that using this novel procedure for chronic tendon pathology provides a safe, effective, minimally invasive treatment option for patients. A longer follow up will further determine the effectiveness of the procedure

Open Wedge High Tibial Osteotomy and Combined Arthroscopic Surgery in Severe Medial Osteoarthritis and Varus Malalignment: Minimum 5-Year Results

OAK 3 - Non-arthroplasty tx of OAK

Purpose: To evaluate the radiologic and functional outcomes of medial open wedge high tibial osteotomy (HTO) combined with arthroscopic procedure in patients with medial osteoarthritis. Materials and Methods: From June 1996 to March 2010, 26 patients (32 knees) who underwent medial open wedge osteotomy and arthroscopic operation for medial osteoarthritis were retrospectively reviewed. Measurements included hip-knee-ankle (HKA) angle, femorotibial angle, medial proximal tibial angle, posterior tibial slope angle, and Kellgren-Lawrence grade. Clinical evaluation was performed using Lysholm knee scoring scale and knee and function score of the American Knee Society. Results: Differences between the mean preoperative and postoperative measurements were significant in all angles including the HKA angle (-5.7degree and +5.5degree), femorotibial angle (-1.9degree and +9.8degree), and medial proximal tibial angle (82.9degree and 90.5degree) (p<0.05). Mean Lysholm knee scoring scale was 63.6 preoperatively and 88.7 at the last follow-up, mean Knee Society knee score was 61.2 and 86.6, and mean function score was 59.3 and 87.2, respectively. All differences were significant (p<0.05). Conclusions: Medial open wedge HTO in combination with arthroscopic procedure is an effective treatment method for medial osteoarthritis to treat varus deformity and an intra-articular lesion.

Selective monitoring of vitamin D2 and D3 supplementation with a highly specific 25-hydroxyvitamin D3 immunoassay with negligible cross-reactivity to 25-hydroxyvitamin D2

Management of Hip Fractures in the Elderly

BACKGROUND: The effects of vitamin D2 and D3 supplementation on circulating concentrations of 25(OH)D3 require reliable analytical tools for specific determination of 25(OH)D3 and 25(OH)D2. We have developed a highly specific 25-OH Vitamin D3 ELISA with negligible cross-reactivity towards 25(OH)D2. METHODS: 25(OH)D3 concentrations were measured in several study participants; 1) 641 healthy men and women; 2) 39 postmenopausal women receiving 400-800 IU vitamin D3 daily for 4 months; 3) 45 men and women with hip fracture receiving 1000 IU vitamin D2 daily for 3 months. RESULTS: This 25-OH Vitamin D3 ELISA had minimal cross-reactivity to 25(OH)D2, (0.7%), and demonstrated a high correlation (r2 = 0.93) with 25(OH)D3 determined by HPLC. 25(OH)D3 increased by 14% in subjects receiving vitamin D3 for 4 months (p < 0.01), whereas there was no significant change in 25(OH)D3 levels in those receiving vitamin D2. CONCLUSIONS: We report that 25(OH)D3 ELISA was used for evaluation of 25(OH)D3 concentrations in subjects receiving vitamin D2 and D3 supplementation. The increase of 25(OH)D3 in circulation with vitamin D3 supplementation and lack of increase with vitamin D2 supplementation suggest that this assay has sufficient sensitivity and specificity to be used as a reliable measurement of nutritional vitamin D3 status in humans

Treatment of malignant bone tumours by extracorporeally irradiated autograft-prosthetic composite arthroplasty

MSTS 2018 - Femur Mets and MM

Autogenous bone graft which has been either autoclaved or irradiated is commonly used in oriental countries as an alternative to allograft. We started to use the technique of extracorporeal irradiation of the resected specimen and reimplantation (ECIR) in 1991. There was, however, a high incidence of fracture of the irradiated bone and loss of articular cartilage. In an attempt to reduce these complications, we combined the irradiated autograft with a conventional arthroplasty. Between 1995 and 1998, 14 patients underwent limb salvage by this method. Seven had an osteosarcoma, two bony metastases, three a chondrosarcoma, one a malignant fibrous histiocytoma, and one a leiomyosarcoma. Ten tumours were located in the proximal femur, two in the proximal humerus, and two in the distal femur. One patient who had a solitary metastasis in the proximal part of the left femur died from lung metastases 13 months after operation. The remaining 13 patients were alive and without evidence of local recurrence or distant metastases at a mean follow-up of 43 months (28 to 72). Postoperative palsy of the sciatic nerve occurred in one patient, but no complications such as wound infection, fracture, or nonunion were seen. All host-irradiated bone junctions healed uneventfully within eight months. Using the Enneking functional evaluation system, the mean postoperative score for all 14 patients was 80% (57 to 93). The use of irradiated autograft prosthesis composites reduces the complications of ECIR and gives good functional results. It may be a good alternative in limb-salvage surgery, especially in countries where it is difficult to obtain allografts.

Importance of antiresorptive therapies for patients with bone metastases from solid tumors

MSTS 2018 - Femur Mets and MM

Patients with bone metastases are at risk of skeletal-related events such as pathologic fractures, spinal cord compression, the need for orthopedic surgery to bone, and palliative radiotherapy for severe bone pain. Antiresorptive therapies have demonstrated efficacy for reducing the risk of skeletal-related events and ameliorating bone pain. Despite the well documented clinical benefits of antiresorptive therapies, patient benefits can be limited or compromised by nonadherence with scheduled therapy. Potential reasons for poor compliance include lack of understanding of how antiresorptive therapies work, neglecting the importance of bone health in maintaining quality of life, and being unaware of the potentially debilitating effects of skeletal-related events caused by bone metastases. Indeed, patients may stop therapy after bone pain subsides or discontinue due to generally mild and usually manageable adverse events, leaving them at an increased risk of developing skeletal-related events. In addition, the cost of antiresorptive therapy can be a concern for many patients with cancer. Medical care for patients with cancer requires a coordinated effort between primary care physicians and oncologists. Patients' medical care teams can be leveraged to help educate them about the importance of adherence to antiresorptive therapy when cancer has metastasized to bone. Because primary care physicians generally have more contact with their patients than oncologists, they are in a unique position to understand patient perceptions and habits that may lead to noncompliance and to help educate patients about the benefits and risks of various antiresorptive therapies in the advanced cancer setting. Therefore, primary care physicians need to be aware of various mechanistic and clinical considerations regarding antiresorptive treatment options. © 2012 Talreja, publisher and licensee Dove Medical Press Ltd.

Dental surgery before liver transplantation: Is it really necessary?

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

A detailed dental examination and surgical treatment of oral septic foci are recommended in patients awaiting liver transplantation (LT). This standard procedure is based on the idea that patients with untreated dental disease may have an increased risk for posttransplant infections. Aim of this study was to evaluate the influence of dental diseases and pre-LT treatment on the infection rates in patients after LT. Patients and Methods: From April 2003 until November 2009, 216 patiens (154m, 51(plus or minus)11yrs) underwent LT in our centre. The underlying causes were alcohol (45.4%), alcohol + viral hepatitis (6.5%), viral hepatitis (15.3%), biliary tract diseases (14.8%) and others. The patients were divided into 4 groups. Group 1: patients with bad dental status and following dental surgery; group 2: patients with bad dental status without dental treatment; group 3: patients with good dental status; group 4: no pre-LT dental council available. The medical data were assessed on patients' records and analyzed retrospectively. Results: Mean follow-up after LT was 43(plus or minus)28 months. 58 patients (27%) belonged to group 1, 43 patients (20%) to group 2, 54 patients (25%) to group 3 and 61 patients (28%) to group 4. Bacterial infections, mostly cholangitis and pneumonia, were observed in 49% of all transplanted patients 0-72 months (mean 12 months) after LT. In 46% enterococcus spp. was the most detectable pathogen in the blood and different tissues. However, there was no significant difference in the frequency of bacterial infections and the pathogen spectrum in the 4 different groups. 68 patients died 0-63 months after LT, thereby 25 patients due to bacterial sepsis. Furthermore, significant (p < 0.001) more patients with alcohol toxic liver cirrhosis suffered from a bad dental status in comparison to patients with other liver diseases. Conclusions: With regard to these results, we have to think over the standard procedure that every patient with bad dental status has to undergo surgical treatment pre-LT. Especially due to the coagulation disorders the patients are at an increasing bleeding risk. Therefore, no benefit can be expected from prophylactic teeth extraction

Clinical research update: zoledronate

MSTS 2018 - Femur Mets and MM

The prolonged administration of bisphosphonates can reduce the frequency of morbid skeletal events in patients with metastatic breast carcinoma or multiple myeloma. The development of more potent bisphosphonates will simplify current therapeutic schemes and could improve the therapeutic effectiveness of bisphosphonate therapy. Zoledronate (CGP-42446) is the most potent of the clinically tested compounds. It is a cyclic third-generation bisphosphonate that is 100-850 times more active than pamidronate in several in vivo and in vitro pharmacological test systems. The first therapeutic trial with zoledronate has been performed in patients with tumor-induced hypercalcemia (corrected calcium [Ca] > 2.75 mmol/L after rehydration). In a Phase I multicenter trial, it was shown that a single infusion was already effective at dose levels of 0.02 and 0.04 mg of zoledronate/kg bodyweight, thus 1.2 and 2.4 mg total dose for an average 60-kg individual. Five of 5 patients became normocalcemic after a dose of 0.02 mg/kg, and 14 of 15 (93%) after a dose of 0.04 mg/kg. The median time to normalization of serum Ca was 2 days and the median duration of action was 33 days, suggesting that zoledronate has a faster onset and a longer duration of action than other clinically tested bisphosphonates. Zoledronate was well tolerated; the only side effect was an increase in body temperature in 30% of the cases, which was probably not drug-related in many patients. A Phase I trial also has been initiated in patients with lytic bone metastases. Zoledronate was given as monthly short infusions (5-30 minutes) at doses between 0.1-8.0 mg. There was an analgesic effect and even at low doses (2 mg and above), the effects on the biochemical markers of bone resorption appeared to be greater than after 90-mg pamidronate infusions. These initial human data suggest that zoledronate can be administered as convenient short intravenous infusions and lead to a more marked and a more prolonged inhibition of bone resorption than is currently possible with available compounds. Future trials will have to determine whether prolonged treatment with this extremely potent bisphosphonate also can have a greater effect on the morbidity of bone metastases. [References: 4]

Efficacy of a modified coagulation factor substitution for total hip arthroplasty in patients with end-stage haemophilic arthropathy

DoD SSI (Surgical Site Infections)

Total hip arthroplasty (THA) is an effective treatment for end-stage haemophilic arthropathy, and substitution therapy plays a key role in the success of THA. The aim of this study was to evaluate the efficacy of a modified coagulation factor substitution regime in THA. Nineteen haemophiliac patients (20 hips) who received primary cementless THA were enrolled. Based on World Federation of Haemophilia (WFH) guideline, a modified coagulation factor substitution regime was adopted. Blood loss, implant survival rates and complications were reviewed, retrospectively. The mean age at surgery was 29.7 years (15-49 years) and the mean follow-up period was 91 months (43-151 months). Mean total blood loss, external blood loss and hidden blood loss were 3543 (1494-7576), 1435 (600-3440), and 2110 ml (534-4402), respectively. Mean intraoperative blood loss and postoperative drainage were 715 (300-2000) and 713 ml (200-2950), respectively. Mean red blood cell transfusion used was 5 U (0-14). All prostheses were found to have bony ingrowth. One patient had hematoma formation in the thigh and one with a lower limb deep vein thrombosis, postoperatively. Other complications included one skin ulcer, one femur splitting fracture, and one transient neuropraxia. Intraoperative blood loss and wound drainage, in our study, were similar to that in haemophiliac patients and nonhaemophilic patients in literature. This supports the efficacy of the modified coagulation factor substitution strategy in our study.

Influences of preservation at various temperatures on liposuction aspirates

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Aspirated fat is not only a filler material but also an abundant source of adipose-derived stem cells. The aim of this study was to assess degeneration of aspirated fat during preservation and optimize the preservation method for lipoaspirates. METHODS: Aspirated fat was preserved at room temperature for 1, 2, 4, and 24 hours (n = 10 each); at 4 degrees C for 1, 2, and 3 days (n = 14 each); or at -80 degrees C for 1 month (n = 3). Morphologic changes were assessed with scanning electron microscopy. Adipose-derived stem cell yield was measured after 1 week of culture. For aspirated fat preserved at room temperature, damaged adipocytes were assessed by measuring the oil volume ratio after centrifugation (n = 6) and glycerol-3-phosphate-dehydrogenase activity in washing solution (n = 4). Cell surface marker expression was examined by flow cytometry (n = 3). RESULTS: Although the scanning electron microscopic assay indicated no remarkable anatomical changes based on preservation methods, oil volume significantly increased in fat preserved at room temperature for 4 hours. Adipose-derived stem cell yield was significantly reduced by preservation at room temperature for 24 hours and by preservation at 4 degrees C for 2 or 3 days. Flow cytometric analysis suggested that the biological properties of adipose-derived stem cells did not significantly change at 4 degrees C up to 3 days. The cells were isolated from cryopreserved fat, but the yield was much less than that from fresh aspirated fat. CONCLUSIONS: Aspirated fat should be transplanted as quickly as possible if it is preserved at room temperature. For adipose-derived stem cell isolation, aspirated fat can be stored or transported overnight if it is preserved at 4 degrees C without adipose-derived stem cell yield loss or changes in biological properties.

Use of extendable total femoral replacements in children with malignant bone tumors

MSTS 2018 - Femur Mets and MM

Although rarely required, extendable reconstruction devices for replacing the entire femur offer children with malignant bone tumors the opportunity of a nearly normal development by overcoming an expected leg length discrepancy. Femoral integrity can be restored, allowing most patients to walk without the use of aids. There are no data available to provide evidence regarding long term results and morbidity in such patients. Six patients (range 2-12 years of age), three with osteogenic osteosarcoma and three with Ewing's sarcoma, were treated between 1988 and 1996 with custom made Stanmore extendable prosthetic total femoral replacements. One patient died 12 months after surgery because of complications relating to pulmonary metastasis. The remaining five patients were observed between 2.7 and 8.9 years (average, 5 years). No tumor recurrence has been recorded and no amputation has been performed. All surviving patients underwent an average of 9.4 operative procedures (range, 4-16 procedures) including 6.4 extension procedures (range, 3-10 procedures), and one prosthetic revision (range, 0-3 procedures). Five revisions in two patients were necessary because of infection, loosening of the prosthesis, mismatch between femoral head and acetabulum, or full extension of the extending mechanism. The functional results were measured in accordance with the Musculoskeletal Tumor Society rating score, with an average result of 77.3%. Total femoral replacement in a growing individual achieves good functional results yet has various risks for an uncertain outcome. Careful selection of the patient and realistic appraisal of the long term prospects are essential for successful treatment.

Time to onset of bisphosphonate-related osteonecrosis of the jaws: a multicentre retrospective cohort study

MSTS 2018 - Femur Mets and MM

Objectives: Osteonecrosis of the jaw (ONJ) is a potentially severe adverse effect of bisphosphonates (BP). Although the risk of ONJ increases with increasing duration of BP treatment, there are currently no reliable estimates of the ONJ time to onset (TTO). The objective of this study was to estimate the TTO and associated risk factors in BP-treated patients. Subjects and Methods: Retrospective analysis of data from 22 secondary care centres in seven countries relevant to 349 patients who developed BP-related ONJ between 2004 and 2012. Results: The median (95%CI) TTO was 6.0 years in patients treated with alendronate (n = 88) and 2.2 years in those treated with zoledronate (n = 218). Multivariable Cox regression showed that dentoalveolar surgery was inversely associated, and the use of antiangiogenics directly associated, with the TTO in patients with cancer treated with zoledronate. Conclusions: The incidence of ONJ increases with the duration of BP therapy, with notable differences observed with respect to BP type and potency, route of administration and underlying disease. When data are stratified by BP type, a time of 6.0 and 2.2 years of oral alendronate and intravenous zoledronate therapy, respectively, is required for 50% of patients to develop ONJ. After stratification by disease, a time of 5.3 and 2.2 years of BP therapy is required for 50% of patients with osteoporosis and cancer, respectively, to develop ONJ. These findings have significant implications for the design of future clinical studies and the development of risk-reduction strategies aimed at either assessing or modulating the risk of ONJ associated with BP.

A study on prescribing patterns in the management of arthritis in the department of orthopaedics

OAK 3 - Non-arthroplasty tx of OAK

Arthritis is an acute or chronic inflammation of joint, often accompanied by pain, swelling and stiffness and resulting from infection, injury. Pain is the most common symptom and is associated with bad functional outcomes. Different kinds of arthritis are, widely spread among the population that make them a clinical problem. Among those osteoarthritis (OA) is a chronic, degenerative disorder of multifactorial aetiology, characterized by loss of articular cartilage and periarticular bone remodelling. OA causes joint pain, typically worse with weight bearing and activity, and stiffness after inactivity. There is no cure, and gradual, although slow, progression is most common. Whereas, Rheumatoid arthritis (RA) is an autoimmune disorder of unknown etiology characterized by symmetric, erosive synovitis and, in some cases, extraarticular involvement.

New trends in the treatment of bone metastasis

MSTS 2018 - Femur Mets and MM

Bone metastasis is often the penultimate harbinger of death for many cancer patients. Bone metastases are often associated with fractures and severe pain resulting in decreased quality of life. Accordingly, effective therapies to inhibit the development or progression of bone metastases will have important clinical benefits. To achieve this goal understanding the mechanisms through which bone metastases develop and progress may provide targets to inhibit the metastases. In the past few years, there have been advances in both understanding the mechanisms through which bone metastases develop and how they impact bone remodeling. Additionally, gains in promising clinical strategies to target bone metastases have been developed. In this prospectus, we will discuss some of these advances. © 2007 Wiley-Liss, Inc.

Expression of specific pathways in the inflamed synovial membrane of osteoarthritis patient: Identification of new potential key intermediates

Surgical Management of Osteoarthritis of the Knee CPG

Purpose: Synovitis is a key factor in osteoarthritis (OA) pathophysiology, contributing to both patient symptoms and disease progression. In this study, using an original methodology comparing normal/reactive (N/R) and inflammatory (I) synovial membranes zones, we investigated the gene expression profiles of synovial cells from these areas and identified differentially regulated pathways. Methods: Synovial cells (SC) were isolated from OA synovial specimens obtained from 12 patients undergoing knee replacement. The inflammatory status of the synovial membrane was characterized by the surgeon according to macroscopic criteria including the synovial vascularization, the villi formation and the hypertrophic aspect of the tissue. At the surgery time, the synovial membrane was dissected and biopsies from N/R and I areas cultured separately for a period of 7 days. Total RNA was extracted using the RNeasy Mini Kit. RNA purity and quality were evaluated using the Experion RNA StdSens Analysis kit (Bio-rad Laboratories). Gene expression profiling between N/R and I areas was performed using Illumina's multi-sample format Human HT-12 BeadChip (Illumina Inc.). Differential analysis was performed with the BRB array tools software. Class Comparison test between N/R and I areas was based on paired t-test where N/R and I were paired for each patient. The biological relevance of up- and down-regulated genes was analyses with Ingenuity Pathways Analysis (Ingenuity(plus or minus) Systems). Western blot was performed to confirm certain intermediate expression. Results: From among 47000 probes, 17500 were filtered out. Probes with a p-value below than 0.005 were chosen and classified as up- or downregulated ones. By this way, 896 differentially expressed genes between N/ R and I zones were identified. Among these, 576 genes were upregulated (I/ NR > 1.5) and 320 downregulated (I/NR < 0.75). With Ingenuity Pathways Analysis, a significant number of the top ranking differentially expressed genes were identified as inflammatory, Wnt and angiogenic pathways. Interleukin (IL)-6 and -8, chemokines (CXCL1, CXCL2, CXCL5, CXCL6, CXCL16) and arachidonate 5-lipoxygenase (ALOX5) were identified as the most upregulated in I zones in the inflammatory pathway. Interestingly, the alarmin S100A9 was found strongly upregulated in this pathway. Wnt5A and LRP (Low density lipoprotein receptor-related protein) 5 were upregulated whereas FZD (Frizzled homolog) 2 and DKK (dickkopf homolog) 3 were downregulated in the Wnt signaling pathway. Finally, stanniocalcin (STC)-1, an intermediate in angiogenesis was identified as the most upregulated gene in I zones compared to N/R zones. This difference of expression was confirmed at the protein level. Conclusions: Using a unique culture system, this study is the first to identify different expression pattern between two areas of synovial membrane from the same OA patient. These differences concern several key pathways involved in OA pathogenesis, i.e. inflammation, Wnt and angiogenesis. This analysis also provided interesting information regarding new potent intermediates as S100A9 and STC-1. They could be potential targets for chondroitin sulfate, one of the most used molecules in the management of OA. New experiments are being perfomed at the moment to elucidate the potential effect of this molecule on these specific differentially expressed genes in the same culture system

A randomized prospective controlled trial of antibiotic prophylaxis in intraoral bone grafting procedures: single-dose clindamycin versus 24-hour clindamycin prophylaxis

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

PURPOSE: The objective of this study was to compare the efficacy of a single oral dose of clindamycin with a 24-h protocol of clindamycin administration in local buccal onlay grafting procedures. MATERIAL AND METHODS: A prospective randomized study in 124 patients was performed. Eligible patients were randomized to receive antibiotic prophylaxis either as a single dose (group I) or over a 24-h period (group II). In both groups prophylaxis started with an oral dose of 600 mg clindamycin 1 h before surgery, followed by either placebo or 300 mg clindamycin every 6 h. The primary endpoint of this study was wound infection at the receptor site within 8 weeks after surgery. Secondary outcome measurements included postoperative infections at the donor site and adverse events as a result of antibiotic administration. RESULTS: The mean age of the patients was 35.9+/-10.1 years (range 18-59 years). Infections at the receptor site were seen in two patients (3.2%, 95% CI 0-7.6%) of the single-dose group and in three patients (4.8%, 95% CI 0-10.1%) of the 24-h group. Infection at the donor site occurred in four patients (6.4%, 95% CI 0-12.5%) of the single-dose group and in two patients (3.2%, 95% CI 0-7.6%) of the 24-h group. Postoperative infections were predominantly caused by alpha-hemolytic streptococci sensitive to penicillin. CONCLUSIONS: No statistically significant difference was found between the prophylactic single dose of clindamycin and the 24-h regimen of clindamycin with regard to postoperative infection in patients undergoing local bone augmentation procedures

Surgical treatment of metastatic pathological fracture of major long bones

MSTS 2018 - Femur Mets and MM

The surgical treatment used in 50 metastatic fractures was osteosynthesis in 42 and endoprosthesis operation in 4 cases. Of the patients, 52% died of the malignant disease within 3 mth, and 70% within 6 mth. Only 14% were still alive after 1 yr. Of the different types of tumor, mammary carcinoma proved to have the best prognosis as regards survival. By means of stable fixing of various parts of the femur, or of an endoprosthesis operation. 60% of patients were rapidly released from confinement to bed; most often, however, walking was only possible with crutches because bony union only occurred in 7 cases. The majority of these involved mammary carcinoma. The fractures had mostly occurred during the final stage of the disease. However, it appeared difficult to give a reliable prognosis in individual cases. Accordingly, osteosynthesis or endoprosthesis as treatment for metastatic fracture of the femur is indicated if the general condition of the patient permits operation. In fractures of other long bones, operative treatment is occasionally indicated.

Increasing age-adjusted incidence of hip fractures in Finland: the number and incidence of fractures in 1970-1991 and prediction for the future

Management of Hip Fractures in the Elderly

Hip fractures in the elderly are a worldwide epidemic, and aging of the populations is increasing the burden of these fractures on the health care systems. To improve the knowledge of whether the number of hip fractures is increasing even more rapidly than can be accounted for by the demographic changes only, all patients who were admitted to Finnish hospitals in 1970, 1975, 1980, 1985, 1988, and 1991 for primary treatment of first hip fracture were selected from the National Hospital Discharge Register. There was a steady, average 7.7% annual increase in the total number of hip fractures in Finland during this period so that the number of fractures was 2239 in 1970 and 6071 in 1991. The proportion of patients aged 60 years or more increased steadily from 75% in 1970 to 91% in 1991. In 1991, 74% of the patients were women. Across the study period, the age-adjusted total incidence of hip fractures also increased in both women and men 50 years of age and over. This increase was more pronounced in men. Thus, the increasing incidence of hip fractures in Finland was not only due to the fact that the population was aging but also due to the increasing age-adjusted incidence. We conclude that the number of hip fractures in Finland is increasing more rapidly than can be accounted for by the demographic changes only and this will seriously challenge the Finnish health care system in the future

Complex regional pain syndrome type I: incidence and risk factors in patients with fracture of the distal radius

Distal Radius Fractures

OBJECTIVE: To examine the incidence and predictors of complex regional pain syndrome type I (CRPS I) after fracture of the distal radius. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: A consecutive sample of patients (N=90) with fracture of the distal radius treated by closed reduction and casting. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Occurrence of CRPS I, occurrence of pain, wrist and hand range of motion, radiographic measures, Patient-Rated Wrist Evaluation, Hospital Anxiety and Depression Scale, and Medical Outcomes Study 36-Item Short-Form Health Survey at baseline and 1, 3, 6, and 9 months follow-up. RESULTS: CRPS I occurred in 29 patients (32.2%) with a mean delay +/- SD of 21.7+/-23.7 days from cast removal. Univariate analyses found significant differences between patients with CRPS I and patients without CRPS I at baseline for sex (P=.021), socioeconomic level (P=.023), type of trauma (P=.05), pain at rest and activity (P=.006 and P<.001, respectively), wrist dorsiflexion and pronation (P=.002 and P=.001, respectively), finger flexion (P=.047), thumb opposition (P=.002), function of the hand (P<.001), and physical quality of life (QOL) (P=.013). Logistic regression showed that risk for CRPS I was higher in cases of women (odds ratio [OR]=5.774; 95% confidence interval [CI], 1.391-23.966), medium and low energy trauma patients (OR=7.718; 95% CI, 1.136-52.44), patients with a Medical Outcomes Study 36-Item Short-Form Health Survey physical functioning score <40 (OR=4.931; 95% CI, 1.428-17.025), and patients with Patient-Rated Wrist Evaluation pain subscale score >16 (OR=12.192; 95% CI, 4.484-43.478). CONCLUSIONS: CRPS I occurs frequently during the third and fourth week after cast removal, especially in women who report severe pain and impairment of physical QOL. Additional prospective studies are required to verify these findings in comminuted and operated fractures of the distal radius.

Arthrofibrosis after

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Stiffness with decreased range of motion (ROM) has been described as a frustrating complication after TKA. If all methods of physiotherapeutic treatment have been exhausted trying to develop ROM, manipulation under anaesthesia (MUA) can be discussed. The aim of the present study was to show the effect of MUA and to determine the influence of BMI, number of previous surgical procedures, pre-MUA ROM and timing of MUA for the results after MUA in regard to absolute flexion and gain in flexion. METHODS: 858 patients underwent TKA at our institution between 2004 and 2009. 39 of these patients underwent MUA because of postoperative knee stiffness. The data were retrospective analysed for the influence of BMI, pre-MUA flexion (</>/= 70 degrees ), timing of MUA (>/</= 30 days after TKA) and number of previous surgery on the results after MUA (absolute Flexion/gain in flexion). RESULTS: The prevalence for stiffness after TKA was 4.54%. There was a statistically significant improvement in flexion not only directly after MUA but also 6 weeks after MUA. Patients with two or more previous operations before TKA showed statistically significant worse results six weeks after MUA in absolute flexion and gain in flexion(p = 0.039) than patients with one or two previous operations. No statistical significance in absolute flexion (p = 0.655) and gain in flexion (p = 0.328) after MUA between "early" and "late" was detected. The stiffer knees with a flexion below 70 degrees showed significantly worse results (p = 0.044) in absolute flexion six weeks after MUA, but they also had statistical statistically better results with regard to gain in flexion (p </= 0.001). CONCLUSION: MUA is a good instrument for improving ROM after TKA. The time between TKA and MUA seems less important, so different types of physiotherapeutic treatment could be tried before the procedure is started. MUA in patients with many previous operations and a flexion of less than 70 degrees before MUA is not as effective as in other patients, but they also benefit from MUA

Surgical versus conservative interventions for treating anterior cruciate ligament injuries

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Rupture of the anterior cruciate ligament (ACL) is a common injury, mainly affecting young, physically active individuals. The injury is characterised by joint instability, leading to decreased activity, which can lead to poor knee-related quality of life. It is also associated with increased risk of secondary osteoarthritis of the knee. It is unclear whether stabilising the knee surgically via ACL reconstruction produces a better overall outcome than non-surgical (conservative) treatment. OBJECTIVES: To assess the effects of surgical versus conservative interventions for treating ACL injuries. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (18 January 2016), the Cochrane Central Register of Controlled Trials (2016, Issue 1), MEDLINE (1946 to January Week 1 2016), MEDLINE In-Process & Other Non-Indexed Citations (18 January 2016), EMBASE (1974 to 15 January 2016), trial registers (February 2016) and reference lists. SELECTION CRITERIA: We included randomised controlled trials that compared the use of surgical and conservative interventions in participants with an ACL rupture. We included any trial that evaluated surgery for ACL reconstruction using any method of reconstruction, type of reconstruction technique, graft fixation or type of graft. DATA COLLECTION AND ANALYSIS: Three review authors independently screened all titles and abstracts for potentially eligible studies, for which we then obtained full-text reports. Two authors then independently confirmed eligibility, extracted data and assessed the risk of bias using the Cochrane 'Risk of bias' tool. We used the GRADE approach to assess the overall quality of the evidence. MAIN RESULTS: We identified one study in which 141 young, active adults with acute ACL injury were randomised to either ACL reconstruction followed by structured rehabilitation (results reported for 62 participants) or conservative treatment comprising structured rehabilitation alone (results reported for 59 participants). Built into the study design was a formal option for subsequent (delayed) ACL reconstruction in the conservative treatment group, if the participant requested surgery and met pre-specified criteria.This study was deemed at low risk of selection and reporting biases, at high risk of performance and detection biases because of the lack of blinding and at unclear risk of attrition bias because of an imbalance in the post-randomisation exclusions. According to GRADE methodology, the overall quality of the evidence was low across different outcomes.This study identified no difference in subjective knee score (measured using the average score on four of the five sub-scales of the KOOS score (range from 0 (extreme symptoms) to 100 (no symptoms)) between ACL reconstruction and conservative treatment at two years (difference in KOOS-4 change from baseline scores: MD -0.20, 95% confidence interval (CI) -6.78 to 6.38; N = 121 participants; low-quality evidence), or at five years (difference in KOOS-4 final scores: MD -2.0, 95% CI -8.27 to 4.27; N = 120 participants; low-quality evidence). The total number of participants incurring one or more complications in each group was not reported; serious events reported in the surgery group were predominantly surgery-related, while those in conservative treatment group were predominantly knee instability. There were also incomplete data for total participants with treatment failure, including subsequent surgery. In the surgical group at two years, there was low-quality evidence of far fewer ACL-related treatment failures, when defined as either graft rupture or subsequent ACL reconstruction. This result is dominated by the uptake by 39% (23/59) of the participants in the conservative treatment group of ACL reconstruction for knee instability at two years and by 51% (30/59) of the participants at five years. There was low-quality evidence of little difference between the two groups in participants who had undergone meniscal surgery at anytime up to five years. There was low-quality evidence of no clinically important between-group differences in SF-36 physical component scores at two years. There was low-quality evidence of a higher return to the same or greater level of sport activity at two years in the ACL reconstruction group, but the wide 95% CI also included the potential for a higher return in the conservative treatment group. Based on an illustrative return to sport activities of 382 per 1000 conservatively treated patients, this amounts to an extra 84 returns per 1000 ACL-reconstruction patients (95% CI 84 fewer to 348 more). There was very low-quality evidence of a higher incidence of radiographically-detected osteoarthritis in the surgery group (19/58 (35%) versus 10/55 (18%)). AUTHORS' CONCLUSIONS: For adults with acute ACL injuries, we found low-quality evidence that there was no difference between surgical management (ACL reconstruction followed by structured rehabilitation) and conservative treatment (structured rehabilitation only) in patient-reported outcomes of knee function at two and five years after injury. However, these findings need to be viewed in the context that many participants with an ACL rupture remained symptomatic following rehabilitation and later opted for ACL reconstruction surgery. Further research, including the two identified ongoing trials, will help to address the limitations in the current evidence, which is from one small trial in a young, active, adult population.

Comparison of gene expression profiles predicting progression in breast cancer patients treated with tamoxifen

MSTS 2018 - Femur Mets and MM

BACKGROUND: Molecular signatures that predict outcome in tamoxifen treated breast cancer patients have been identified. For the first time, we compared these response profiles in an independent cohort of (neo)adjuvant systemic treatment naive breast cancer patients treated with first-line tamoxifen for metastatic disease. METHODS: From a consecutive series of 246 estrogen receptor (ER) positive primary tumors, gene expression profiling was performed on available frozen tumors using 44K oligoarrays (n = 69). A 78-gene tamoxifen response profile (formerly consisting of 81 cDNA-clones), a 21-gene set (microarray-based Recurrence Score), as well as the HOXB13-IL17BR ratio (Two-Gene-Index, RT-PCR) were analyzed. Performance of signatures in relation to time to progression (TTP) was compared with standard immunohistochemical (IHC) markers: ER, progesterone receptor (PgR) and HER2. RESULTS: In univariate analyses, the 78-gene tamoxifen response profile, 21-gene set and HOXB13-IL17BR ratio were all significantly associated with TTP with hazard ratios of 2.2 (95% CI 1.3-3.7, P = 0.005), 2.3 (95% CI 1.3-4.0, P = 0.003) and 4.2 (95% CI 1.4-12.3, P = 0.009), respectively. The concordance among the three classifiers was relatively low, they classified only 45-61% of patients in the same category. In multivariate analyses, the association remained significant for the 78-gene profile and the 21-gene set after adjusting for ER and PgR. CONCLUSION: The 78-gene tamoxifen response profile, the 21-gene set and the HOXB13-IL17BR ratio were all significantly associated with TTP in an independent patient series treated with tamoxifen. The addition of multigene assays to ER (IHC) improves the prediction of outcome in tamoxifen treated patients and deserves incorporation in future clinical studies.

Clinical and prognostic features in unilateral femoral neuropathies

Management of Hip Fractures in the Elderly

We have examined the clinical features of patients with femoral neuropathy and the factors that influence the prognosis. Of 80 consecutive patients referred for neurophysiological evaluations of proximal lower limb weakness, 32 fulfilled strict inclusion criteria and had adequate information, including estimates of axon loss (AxL) by stimulation of the bilateral femoral nerve. In 31, the Kaplan-Meier method was used to describe the time course of the outcome, while logistic regression was employed to determine the contributing factors. Excellent, satisfactory, and poor outcomes were seen in 10 (31%), 11 (34%), and 10 (31%) patients, respectively. Logistic regression analysis of seven factors demonstrated that the estimate of AxL was the only significant variable. The best prognostic factor was an estimate of AxL < or = 50%, with all patients fulfilling this criterion showing improvement with 1 year; fewer than half the patients with AxL > 50% should be expected to improve. This study clearly shows that, irrespective of the cause of femoral neuropathy, functional improvement is seen in 2 out of 3 patients within 2 years and that the estimate of AxL is the only factor influencing prognosis

Ovarian conservation at the time of hysterectomy for benign disease

Management of Hip Fractures in the Elderly

OBJECTIVE: Prophylactic oophorectomy is often recommended concurrent with hysterectomy for benign disease. The optimal age for this recommendation in women at average risk for ovarian cancer has not been determined. METHODS: Using published age-specific data for absolute and relative risk, both with and without oophorectomy, for ovarian cancer, coronary heart disease, hip fracture, breast cancer, and stroke, a Markov decision analysis model was used to estimate the optimal strategy for maximizing survival for women at average risk of ovarian cancer. For each 5-year age group from 40 to 80 years, 4 strategies were compared: ovarian conservation or oophorectomy, and use of estrogen therapy or nonuse. Outcomes, as proportion of women alive at age 80 years, were measured. Sensitivity analyses were performed, varying both relative and absolute risk estimates across the range of reported values. RESULTS: Ovarian conservation until age 65 benefits long-term survival for women undergoing hysterectomy for benign disease. Women with oophorectomy before age 55 have 8.58% excess mortality by age 80, and those with oophorectomy before age 59 have 3.92% excess mortality. There is sustained, but decreasing, benefit until the age of 75, when excess mortality for oophorectomy is less than 1%. These results were unchanged following multiple sensitivity analyses and were most sensitive to the risk of coronary heart disease. CONCLUSION: Ovarian conservation until at least age 65 benefits long-term survival for women at average risk of ovarian cancer when undergoing hysterectomy for benign disease

Management of dental trauma to a developing permanent tooth during endotracheal intubation

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Anesthesiologists consistently work in the mouth of patients but are not exposed to comprehensive education of teeth, the surrounding structures, and intraoral prosthesis. One of the most common adverse events related to anesthesia is perioperative dental damage. To minimize these dental injuries, a preoperative assessment of patient's dentition and intra-oral tissues should be undertaken

Fractures in lower limbs with prior amputation. A study of ninety cases

Management of Hip Fractures in the Elderly

Eighty-five lower-limb amputees with ninety subsequent fractures of the residual limb were studied retrospectively. Most of the fractures were managed by non-operative methods, with the exception of unstable intertrochanteric fractures and displaced fractures of the femoral neck. Indications for operative and non-operative treatment in below-the-knee and above-the-knee amputees are outlined. No indication was found for reamputation through the fracture site. Before fracture, all amputees used a prosthesis. After healing of the fracture, 97 per cent of the patients with amputation below the knee and 82 per cent of those with amputation above the knee resumed use of a prosthesis

Falls: A modifiable risk factor for the occurrence of hip fractures in the elderly

Management of Hip Fractures in the Elderly

The objective of the study was to examine the clinical and demographic features of patients with hip fractures presenting to the Accident and Emergency Department, the University Hospital of the West Indies (UHWI). The study involved all patients with hip fractures registered in the Trauma Registry at the UHWI between January 1, 1998 and December 31, 2001. They were assessed retrospectively for age, gender, associated extrinsic and intrinsic factors, cause of the fall, location when fracture occurred and the site of the femur that was fractured. One hundred and fifty-two persons were identified There were one hundred and eleven women and forty-one men. Seventy-eight per cent of the falls occurred in the over sixty-five-year age group. Ninety per cent of the patients had a fall associated with their fracture. Most of the falls occurred at the patients' homes. This study indicated that falling at home was the commonest associated factor for the occurrence of hip fractures and preventive measures may lead to reductions in the frequency of hip fractures seen in the emergency room

Postoperative efficacies of femoral nerve catheters sited using ultrasound combined with neurostimulation compared with neurostimulation alone for total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND AND OBJECTIVE: Neurostimulation is commonly used to perform femoral nerve block. Ultrasound can be used to identify nerve structures and guide needle placement. The aim of this study was to compare postoperative analgesic efficiency when femoral nerve catheters were sited using ultrasound (in-plane approach) combined with neurostimulation or neurostimulation alone, for total knee arthroplasty. METHOD: Ninety-three patients were enrolled in this prospective, randomized, blind study to receive a continuous femoral nerve block performed using conventional neurostimulation or ultrasound guidance combined with neurostimulation. The primary endpoint was the postoperative 48 h total local anaesthetic consumption. Other outcomes included visual analogue scale scores at rest, after 12, 24 and 48 h; total oral opioid dose; onset time of femoral block; procedural time; knee flexion and complications. Results are expressed with medians (25-75th percentiles), mean +/- SD and n (%), as appropriate. RESULTS: The onset time of sensory and motor block was faster in the ultrasound group [11 (6-17) min] than in the conventional group [16 (11-23) min, P = 0.009]. Total local anaesthetic dose was reduced [299 +/- 45 vs. 333 +/- 48 ml, (difference = 34.0 ml, 95% confidence interval 15.6-52.5 ml), P = 0.0003] and the time to the first analgesic request was lengthened [11 (7-13) vs. 7 (4-12) h, P = 0.034] in the ultrasound group. Visual analogue scale scores at 12, 24 and 48 h were lower in the ultrasound group as well as visual analogue scale scores during knee flexion at 48 h [14.5 (11.0-23.0) vs. 28.5 (21.0-43.5) mm, P < 0.0001]. Total oral morphine doses were 20 (0-40) vs. 40 (20-60) mg (P = 0.0065). Durations of hospital stay were comparable in both groups. CONCLUSION: Continuous perineural femoral catheter placement using ultrasound combined with neurostimulation and an in-plane approach reduces total doses of local anaesthetic, morphine consumption and improves postoperative pain management by comparison with neurostimulation alone

Comparison of therapeutic duration of therapeutic ultrasound in patients with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

[Purpose] The aim of study was to compare different durations of ultrasound in patients with knee osteoarthritis. [Subjects and

Multiple myeloma biology: lessons from the 5TMM models

MSTS 2018 - Femur Mets and MM

Multiple myeloma (MM) is a B cell neoplasm characterized by the monoclonal proliferation of plasma cells in the bone marrow, the development of osteolytic lesions and the induction of angiogenesis. These different processes require three-dimensional interactions, with both humoral and cellular contacts. The 5TMM models are suitable models to study these interactions. These murine models originate from spontaneously developed myeloma in elderly mice, which are propagated by in vivo transfer of the myeloma cells into young syngeneic mice. In this review we report on studies performed in the 5TMM models with special emphasis on the homing of the myeloma cells, the characterization of the migrating and proliferating clone and the identification of the isotype switch variants. The bone marrow microenvironment was further targeted with osteoprotegerin (OPG) to block the RANK/RANKL/OPG system and with potent bisphosphonates. Both treatments resulted in a significant protection against myeloma-associated bone disease, and they decreased myeloma disease, as evidenced by a lower tumor load and an increased survival of the mice. These different studies demonstrate the strength of these models, not only in unraveling basic biological processes but also in the testing of potentially new therapeutic targets. [References: 64]

Triceps fascial tongue exposure for total elbow arthroplasty: surgical technique and case series

Pediatric Supracondylar Humerus Fracture 2020 Review

During a posterior approach to the elbow, the triceps muscle body and tendon insertion must be addressed during exposure. Several methods exist including performing an olecranon osteotomy. The triceps fascial tongue exposure, originally described by Van Gorder in 1940, provides an excellent view of the joint while causing minimal trauma to the extensor mechanism facilitating tendon healing, and easy intraoperative conversion from fracture fixation to a total elbow arthroplasty if a fracture is not able to be reconstructed. Using a standard posterior approach to the elbow, a triceps tongue is created. A distally based flap of the triceps tendon approximately 10 cm long and 2 to 3 cm wide is created and a remnant of the tendon is kept on all sides to secure a meticulous repair with nonabsorbable figure-of-eight sutures at the conclusion of the case. In our case series, 29 patients underwent 30 total elbow arthroplasties. There were no triceps-related failures. This surgical technique is a useful alternative surgical exposure to the posterior elbow for fractures and arthroplasty.

Cone-beam imaging in dentistry

Dental Implant Infection

Cone-beam imaging has gained broad acceptance in dentistry in the last 5 years. The purpose of this review is to describe the use in dentistry and consider issues requiring further development. Cone-beam machines emit an x-ray beam shaped liked a cone rather than a fan as in conventional computed tomography (CT) machines. After this beam passes through the patient the remnant beam is captured on an amorphous silicon flat panel or image intensifier/charge-coupled device (CCD) detector. The beam diameter ranges from 4 to 30 cm and exposes the head in one pass around the patient capturing from 160 to 599 basis images. These images are used to compute a volume from which planar or curved reconstructions can be extracted in any orientation. Voxels are isotropic and can be as small as 0.125 mm. 3-D images of bone or soft tissue surfaces can also be generated. In dentistry the most common indications for cone-beam imaging are assessment of the jaws for placement of dental implants, evaluation of the temporomandibular joints for osseous degenerative changes, examination of teeth and facial structures for orthodontic treatment planning, evaluation of the proximity of lower wisdom teeth to the mandibular nerve prior to extraction, and evaluation of teeth and bone for signs of infections, cysts, or tumors. Cone-beam images have largely replaced conventional tomography for these tasks. The effective dose from cone-beam imaging ranges from 6 to 477 microSv. The cost of the equipment is relatively low, about $150,000 to $300,000. Issues to be considered are the training of individuals making and interpreting cone-beam images, as well as means to further reduce patient exposure.

Height and lower extremity length as predictors of hip fracture: results of the NHANES I Epidemiologic Follow-up Study

Management of Hip Fractures in the Elderly

The relationship between height, lower extremity length (LEL), and hip fracture was examined in 4264 women followed for 22 years. Greater height predicted fracture among younger women, whereas LEL predicted risk for all ages. LEL is a better predictor of hip fracture risk than height among older women. INTRODUCTION: The significance of height as a risk factor for hip fracture is controversial. Age-related height loss, caused by nonpathological processes and vertebral deformities, may confound the relationship between standing height and hip fracture. In contrast, LEL might be less subject to age-related changes and thus be a better index of fracture risk for older individuals. METHODS: We evaluated data available from 4264 white women who participated in the NHANES I Epidemiologic Follow-up Survey. There were 203 incident hip fractures over the 22-year follow-up period. The effect of height and LEL on hip fracture risk was determined for three age groups: 40-59, 60-69, and 70-74 year olds. RESULTS: After controlling for potential confounders, the hazard ratio (HR) for hip fracture for each SD greater standing height was 1.81 for the youngest age group (p = 0.002), 1.29 for 60-69 year olds (p = 0.02), and 1.10 for 70-74 year olds (p = 0.49). In contrast, LEL predicted hip fracture risk for all age groups, with HRs of 1.43 (p = 0.02), 1.30 (p = 0.002), and 1.33 (p = 0.02), respectively. Similarly, higher tertile of standing height did not confer increased hip fracture risk among the oldest women, but higher tertile of LEL did. Among women that were 70-74 years old, those in the highest tertile of LEL had a 1.83-fold (p < 0.05) greater risk of hip fracture than those in the lowest tertile. CONCLUSIONS: The results support the hypothesis that LEL is a better predictor of hip fracture than standing height among older women, the group at highest risk for these fractures

Short intramedullary wiring for displaced metaphyseal fractures of the radius in children

Distal Radius Fractures

There is still debate about the proper treatment of completely displaced metaphyseal fractures of the distal radius in children. Although historically these fractures were treated by closed reduction and casting, some authors have reported that up to 25% of these injuries re-displaced early in the cast despite good initial reduction. Since 2000 we have used closed reduction and percutaneous stabilisation with a short intramedullary wire, using a percutaneous technique, in children with completely displaced metaphyseal fractures of the distal radius. We retrospectively analysed the records of 100 children who were treated in our departments during a six-year period (2000-2005). Of these, 45 had early re-displacement of their fractures after an initial conservative treatment. Our results suggest that closed reduction and short intramedullary wiring of these injuries allows adequate stabilization, maintains the alignment in the cast, reduces the need for follow-up radiographs, with a low rate of infections and complications, while healing occurs. © 2013, Acta Orthopædica Belgica.

Clinical evaluation of optic atrophy in patients with neurological disorders

Upper Eyelid and Brow Surgery

OBJECTIVE: Optic atrophy is a pathological term applied to optic nerve shrinkage from any process that produces degeneration of axons in the anterior visual system (the retino-geniculate pathway). The pathologist can make the diagnosis of optic atrophy by direct observation of the histopathological changes in the optic nerve. The clinician is restricted to indirect evidence by observing the optic nerve as it enters the eye and through testing its function. METHODS: Fifty patients with bilateral or unilateral optic atrophy, were collected randomly from several teaching hospitals in Baghdad, Iraq, between August 1998 and June 1999. Those patients included in this study had ophthalmoscopic abnormalities of the optic disc in addition to defective visual function that could be localized to the optic nerve. RESULTS: The defects in visual function varied between patients according to the disease process and duration of illness. Eight-seven percent of patients had visual acuity impairment, 74.4% had visual field defect, 58.5% had impairment in color perception, 64% had defective pupillary response to light and 88.4% had prolonged visual evoked potential (VEP) responses. CONCLUSION: Patients who met the criteria for optic atrophy have different and unequal changes in optic nerve functions, ranging from 58.5% for color saturation test to 88.4% for VEP. Forty percent of patients with optic atrophy were discovered accidentally.

Comparative evaluation of the efficiency of conducting individual and professional hygiene in prosthetics for dental implants

Dental Implant Infection

Under our supervision, there were 92 patients with included and terminal defects of the dentition, who underwent prosthetics based on dental implants of the "DIO" system at the Department of Orthopedic Direction FPK TGSI Control group (13) of the patient, "manual toothbrush" - during the entire study period, patients used only a manual toothbrush to clean the crowns on implants; The second group (30) of patients who were prescribed a "manual toothbrush + interdental brush", corresponding to the size of the proximal space of the orthopedic construction; The third group (49) of patients who were prescribed a "manual toothbrush + interdental brush + irrigator", in addition to a manual toothbrush, were prescribed an interdental brush and an oral irrigator, an irrigator Waterpik WP-660 (Aquarius) was prescribed for the oral cavity after brushing teeth twice per day for 3-5 minutes, the power of the water jet of the irrigator corresponded to mode 2. An index assessment of the amount of plaque in the area of a fixed structure on implants was carried out using a simplified index of oral hygiene (IGR-U) (J. R. Vermillion, 1964) The condition of the gums in the area of dental implants was assessed based on the Gingival Index (GI) - Loe & Silness, 1963. Thus, at the beginning of the study in all three groups, the HI was low and corresponded to good implant hygiene. After 3 and 6 months, the values of those indices were significantly worse, and corresponded to the unsatisfactory hygiene of the implants. In groups 2 and 3, throughout the entire study, HI indices were optimal and corresponded to good and satisfactory implant hygiene. The indicators of the 3rd group, in which the whole complex of individual and professional methods was applied, were the most positive throughout the study, in comparison with other groups. Analysis of the results of the Gingival Index study showed that the indicator increased in all observation groups. In group 2 patients using manual dental and interdental brushes for cleaning the structure, by the end of the study period the index value increased to 0.95 ± 0.05 points, which corresponded to mild gingivitis of the gums in the area of implants, i.e. there was slight hyperemia and individual punctate bleeding of the gums at the probing sites. Patients of the 3rd group, using an irrigator, had minimal index values at all periods of the study, and the index values were interpreted as "normal gums", that is, no signs of gingivitis were recorded.

A 21 % conversion rate to total knee arthroplasty of a first-generation patellofemoral prosthesis at a mean follow-up of 9.7 years

OAK 3 - Non-arthroplasty tx of OAK

Purpose: To evaluate the mid- to long-term results of the Richardsâ?? type II patellofemoral arthroplasty (PFA) in terms of functional scores, number and type of complications, patient satisfaction and survival. Methods: We retrospectively studied patients that received a Richardsâ?? type II PFA at our institution between 1998 and 2007. Patients with a functioning PFA at the time of this study were evaluated. Outcomes included survival rates with endpoint loss of prosthesis, number and type of complications, Knee Society Scores (KSS) and Visual Analogue Scale (VAS) for pain. In addition, patients were asked how surgery influenced their original symptoms. Results: Twenty-four patients (33 prostheses) were included. Follow-up ranged from 2.2 to 18.8 years with a mean of 9.7 years. Survival at 10 years was 73 % (95 % CI, 57â??93 %). Median KSS score was 163 (range, 110â??200). Median VAS Pain was 30 (range, 0â??80) and VAS Satisfaction median was 90 (range, 50â??100). Thirteen (62 %) PFAs were rated excellent, six (28 %) as good and two (10 %) as fair. Twelve (36 %) of the cases required further surgery within 4 years after implantation. Seven of these (21 %) were converted to TKA after a mean time of 5.5 years, five out of seven were converted because of ongoing tibiofemoral osteoarthritis (TFOA). Conclusions: We found a rate of 21 % (7/33) conversion of the Richardsâ?? II PFA to TKA after a mean of 5.5 years; 71 % (5/7) of cases were because of TFOA. We strongly advise not to use PFA if there is any sign of joint disease in other compartments than patellofemoral.

Effect of sucrose and glucose on the susceptibility of Streptococcus mutans to cephalosporins

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The effect of the type of sugar used as substrate on the susceptibility of Streptococcus mutans to antibiotics was evaluated. Thirty strains, grown in excess of sucrose (s-MIC) and in excess of glucose (g-MIC), were tested for susceptibility to four cephalosporins. About 21% of the strains were sensitive in the presence of sucrose and resistant in the presence of glucose, whereas only 3% of the strains showed the opposite situation. The mean values of the s-MICs of the four cephalosporins were significantly lower than those of the g-MICs. These findings may also be explained by the synthesis, in excess of sucrose, of insoluble glucan by Streptococcus mutans which increases the interbacterial distance and promotes antibiotic diffusion. Given the susceptibility of Streptococcus mutans grown in excess of sucrose to cefotaxime and cefepime, these antibiotics may be used in the primary prevention of infective endocarditis, when subjects predisposed to endocarditis need invasive dental therapy

Five-Year Follow-up of Knee Joint Distraction: Clinical Benefit and Cartilaginous Tissue Repair in an Open Uncontrolled Prospective Study

OAK 3 - Non-arthroplasty tx of OAK

Objective: In end-stage knee osteoarthritis, total knee arthroplasty (TKA) may finally become inevitable. At a relatively young age, this comes with the risk of future revision surgery. Therefore, in these cases, joint preserving surgery such as knee joint distraction (KJD) is preferred. Here we present 5-year follow-up data of KJD. Design: Patients (n = 20; age <60 years) with conservative therapy resistant tibiofemoral osteoarthritis considered for TKA were treated. Clinical evaluation was performed by questionnaires. Change in cartilage thickness was quantified on radiographs and magnetic resonance images (MRI). The 5-year changes after KJD were evaluated and compared with the natural progression of osteoarthritis using Osteoarthritis Initiative data. Results: Five-years posttreatment, patients still reported clinical improvement from baseline: Î?WOMAC (Western Ontario and McMaster Universities Arthritis Index) +21.1 points (95% CI +8.9 to +33.3; P = 0.002), Î?VAS (visual analogue scale score) pain â??27.6 mm (95%CI â??13.3 to â??42.0; P < 0.001), and minimum radiographic joint space width (JSW) of the most affected compartment (MAC) remained increased as well: Î? +0.43 mm (95% CI +0.02 to +0.84; P = 0.040). Improvement of mean JSW (x-ray) and mean cartilage thickness (MRI) of the MAC, were not statistically different from baseline anymore (Î? +0.26 mm; P = 0.370, and Î? +0.23 mm; P = 0.177). Multivariable linear regression analysis indicated that KJD treatment was associated with significantly less progression in mean and min JSW (x-ray) and mean cartilage thickness (MRI) compared with natural progression (all Ps <0.001). Conclusions: KJD treatment results in prolonged clinical benefit, potentially explained by an initial boost of cartilaginous tissue repair that provides a long-term tissue structure benefit as compared to natural progression. Level of evidence, II.

The results of total knee prosthesis in patients with gonarthrosis

Surgical Management of Osteoarthritis of the Knee CPG

Objective: To analyze the results of total knee prosthesis TKP in patients with rheumatic diseases. Material and Methods: 48 patients (42 women, 6 men) with 3-4 radiographic stage of gonarthrosis and persistent joint pain, average age 63.7(plus or minus)19.9 years. The first group consisted of 24 patients with primary osteoarthritis (OA). The second (n=24) group with knee OA on the background of rheumatoid arthritis (RA). In each group, 12 (50 %) patients were treated with nonsteroidal anti-inflammatory drugs (NSAIDs), course 2 days before surgery and after surgery in a stable average daily dose of diclofenac, the other half of patients received

The current state of ptosis repair: a comparison of internal and external approaches

Upper Eyelid and Brow Surgery

PURPOSE OF REVIEW: Posterior approach ptosis repair has made a resurgence over the last decade. The purpose of this review is to examine the history of posterior approach ptosis repair and the events that have led to its current favorable status. RECENT FINDINGS: The evolution of the posterior and anterior approach ptosis surgeries has resulted in two favored techniques for involutional ptosis repair: the Muller muscle-conjunctiva resection (MMCR) and the external levator advancement. Each procedure has strong and prominent proponents in the oculoplastic surgery community. Recently, the MMCR has converted surgeons who have previously favored the external levator advancement. A number of factors have influenced this recent elevation of the MMCR including differing opinions on the cause of involutional ptosis, the mechanism by which the MMCR works, the predictability and speed of the MMCR, and the current reimbursements for ptosis repair by insurance companies. SUMMARY: The recent preference for posterior approach ptosis surgery, in particular the MMCR, is multifactorial. In order to understand the evolution of opinions about the procedure, a historical knowledge of involutional ptosis and ptosis repair is necessary.

Randomized controlled trials of proximal femoral nail antirotation in lateral decubitus and supine position on treatment of intertrochanteric fractures

Management of Hip Fractures in the Elderly

The objective of this study was to compare the clinical results and complications of proximal femoral nail antirotation (PFNA) on treatment of intertrochanteric fractures in 120 elderly Chinese patients using Randomized Controlled Trials (RCTs). Totaly 120 cases enrolled were randomly assigned to a lateral decubitus position group and supine position group. The hospital stay, operating time, intraoperative blood loss, length of incision, X-ray fluoroscopy time, and out-of-bed activity time in the lateral decubitus position group were significantly lower than those in the supine position group. There was not statistical significance on union time and Harris values in the two position groups. Moreover, only complications of superficial wound infection were observed in the lateral decubitus position group, but two complications of deep venous thrombosis and wound deep infection were found in the supine position group. The present findings suggested that PFNA applied in elderly patients with intertrochanteric fracture can get satisfactory effects, and the treatment of intertrochanteric fractures using lateral decubitus position showed a satisfactory clinical outcome and a lower radiological complication rate

Missed musculoskeletal injuries in a University Hospital in Riyadh: Types of missed injuries and responsible factors

Management of Hip Fractures in the Elderly

Eighty missed musculoskeletal injuries in 51 patients in King Khalid University Hospital are analysed. The diagnostic failure rate was 0.6 per cent of all injured patients seen in the emergency room and 6 per cent of admissions under orthopaedic care. The three commonest sites of missed injury were the knee (16 injuries), the foot and ankle (14 injuries) and the hip and pelvis (13 injuries). Twenty-four (47 per cent) presented initially with multiple injuries. In 48 of these patients (60 per cent) there were one or more complaints related to the missed injury. Factors responsible for inadequate diagnosis included breaking of clinical routine, inadequate clinical examination, ignoring the patient's complaints and positive physical signs, and lack of or misinterpreted and inadequate X-rays

Tibial baseplate fracture associated with polyethylene wear and osteolysis after total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

INTRODUCTION Fracture of the tibial baseplate following total knee arthroplasty is very rare given the developments in modern prosthesis design. Tibial baseplate fracture secondary to polyethylene wear, osteolysis and component malalignment in an elderly obese patient is reported in the present article. PRESENTATION OF CASE A 69-year-old woman had undergone total knee arthroplasty eleven years prior to presentation and reported nine months of chronic pain, which was caused by a neglected fracture of the baseplate. DISCUSSION We discuss the prevention of implant fracture after total knee arthroplasty and address the risk factors associated with this complication. CONCLUSION The present case emphasizes the importance of properly informing patients and encouraging them to report such complaints immediately to allow for early revision and prevention of component fracture, especially in patients with risk factors such as obesity and component, malalignment. (copyright) 2013 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. All rights reserved

Fractures of the distal humerus operated on using the Lambda plate: report of 75 cases at 9.5 years follow-up

Distal Radius Fractures

INTRODUCTION: The study sought to assess the functional results and complications of osteosynthesis using the Lambda() plate (Zimmer, Etupes, France) in treating fracture of the distal extremity of the humerus. MATERIALS AND METHODS: The initial series comprised 115 patients (116 fractures), treated between 1992 and 2008. Forty-one (mainly foreigners) were lost to follow-up. The final series thus comprised 74 patients (75 fractures): 44 female and 30 male, with a mean age of 46+/-23 years (range, 16-95 years), 22 (29%) being aged 65 years or over. According to AO classification, 22 of the fractures of the distal extremity of the humerus (29%) were diaphyseal-metaphyseal, corresponding to a particular grade of type A2, 12 (16%) were type A2 or A3, six (8%) type B, and 35 (47%) type C. Eight were open fractures: seven grade 1 and one grade IIa on Gustilo's classification. The Lambda() plate is an inverted Y shape, with a stem of up to ten holes and sectile arms that can be remodeled to adapt perfectly to the type of fracture and the shape of the distal end of the humerus. A posterior approach was used in all cases: in 26 cases, an extra-articular transolecranal approach and otherwise a transtricipital approach, either vertical for diaphyseal-metaphyseal fracture or inverted V for type-C fracture. RESULTS: Mean follow-up was 115+/-64 months (range, 24-227 months). There were no cases of infection, non-union of olecranial osteotomy or disassembly of the internal fixation; there was, on the other hand, one case of non-union of the lateral condyle and one of the distal extremity of the humerus, two cases of dysesthesia in the ulnar nerve territory and one in the radial nerve territory (following preoperative paralysis), and four cases of stiffness requiring surgical arthrolysis between 6 and 12 months postoperatively. At follow-up, mean active elbow flexion was 133degree+/-13degree (range, 90degree-150degree) and active extension -12degree+/-14degree (range, -45degree-0degree). Mean elbow flexion range of motion exceeded 100degree in 58 patients (77%), was between 50degree and 100degree in 16 (21%) and was less than 50degree in one. Mean Mayo Elbow Performance Score (MEPS) was 97+/-7 points (range, 40-100), and mean Quick DASH Score (converted as a score out of 100) was 10+/-18 (range, 0-54). There were 67 excellent results (MEPS, 90-100 points), five good (75-89), two moderate and one poor. The 35 type-C fractures displayed no significant differences from the series as a whole (P=1.24 for MEPS). CONCLUSION: Osteosynthesis using the Lambda() plate gave excellent medium-term results in terms of both fixation stability and recovery of elbow function after fracture of the distal extremity of the humerus, even in elderly osteoporotic patients. LEVEL OF EVIDENCE: Level IV: retrospective study.

Revision of a total hip arthroplasty with a Harris-Galante porous- coated acetabular component inserted without cement: A follow-up note on the results at five to twelve years

MSTS 2018 - Femur Mets and MM

Fifty-seven revision total hip arthroplasties in fifty-six patients were performed with a Harris-Galante porous-coated acetabular component by one surgeon, and the patients were followed prospectively for a mean of seven years (range, five to twelve years). A trochanteric osteotomy was performed in forty hips, and a posterior approach with an extended anterior capsulectomy was used in the other seventeen. The acetabular defect was classified as segmental in seven hips, cavitary in twenty-three, and combined in twenty-one; six hips had no notable defect. A bulk allograft was used in eleven hips, and morseled cancellous-bone allograft or autogenous graft was used in thirty-four hips; twelve hips did not have bone-grafting. Both the femoral and the acetabular component were revised in forty-five hips, and only the acetabular component was revised in twelve. Thirty-nine hips (68 per cent) had a good or excellent clinical result according to the Harris hip score. The acetabular component was well fixed in the fourteen hips that had a fair result and the four hips that had a poor result. The acetabular component was considered to have migrated if there was a change in the angle of the cup of 5 degrees or more or a change in the horizontal or vertical position of the cup of more than three millimeters. Despite varying degrees of bone loss, no acetabular component had radiographic evidence of loosening at the latest follow-up examination. No component was revised and no revisions were scheduled. One hip was debrided for a late metastatic infection, but the component was well fixed and was not revised. There were no complications related to the use of screws for fixation. These mid-term results confirm the early success of acetabular revisions performed with fixation of a titanium fiber-metal-coated hemispherical component with multiple screws and no cement.

Lipofilling of the upper eyelid to treat paralytic lagophthalmos

Dental Implant Infection

Lagophthalmos is one of the most unpleasant and dangerous conditions that affect patients with facial palsy. The lack of ocular protection leads to corneal problems (such as conjunctival infections, acute and chronic keratitis, corneal ulcerations, and blindness). A dynamic reanimation of blinking eyelids is the therapeutic gold standard. However, success is not guaranteed with these dynamic techniques; even if results are good, blinking is usually restored within a year of the initial operation. Procedures that act more rapidly and have a higher success rate are needed. We proposed that lipofilling of the upper eyelid would improve eye closure, exploit the advantages of using autologous fat, and avoid the risks of exposure or migration associated with loading the lid with gold. Between 2012 and September 2018, we did upper eyelid lipofilling procedures for 75 patients with unilateral facial palsy. The main favourable result of lipofilling of the upper lid was the immediate improvement in corneal discomfort. Everybody described a partial to total increase in corneal comfort postoperatively. In the treatment of paralytic lagophthalmos, lipofilling of the upper eyelid produces favourable aesthetic and functional results, ocular health is restored, and the patients' quality of life is improved. Copyright © 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Diagnosis and management of smoldering multiple myeloma: the razorâ??s edge between clonality and cancer

MSTS 2018 - Femur Mets and MM

Smoldering multiple myeloma (SMM) is a rare plasma cell disorder, and as the disease is asymptomatic, diagnosis is often incidental. SMM is characterized by increased marrow infiltration by clonal plasma cells and/or elevated serum M-protein in the absence of a myeloma-defining event (MDE). In recent years, SMM has gained increased attention owing to a broadening of the criteria for MDE, which include apart from the CRAB criteria, three additional parameters. Survival advantage may be offered by early treatment in the high-risk subset, based on a single trial. In this review, we assess the risk factors and models for progression to multiple myeloma. A review of our diagnostic and management approaches to SMM is presented.

The role and clinical benefits of high-intensity focused electromagnetic devices for non-invasive lipolysis and beyond: A narrative review and position paper

Panniculectomy & Abdominoplasty CPG

BACKGROUND: In 2018, the first device to use high-intensity focused electromagnetic (HIFEM) technology to non-invasively build muscle was brought to market. Even more recently, the first HIFEM and radiofrequency combination device designed to both build muscle and eliminate fat cells came into use (HIFEM+). In view of the increase in recently published original data pertaining to HIFEM, an advisory board recently convened to discuss the group's clinical experiences with this technology. AIM: Communicate an advisory group's recommendations for the current use of HIFEM+ technology for aesthetic indications. METHODS: An advisory board meeting to discuss challenges and opportunities for HIFEM devices in aesthetic medicine took place in November 2020, via remote conference. The expert advisory board consisted of a group of senior aesthetic physicians regularly treating patients with non-invasive body contouring devices. A narrative review of the literature and key recommendations from the meeting are presented herein. RESULTS: To date, the combined results of several clinical studies (including over 500 patients and 30 investigators) support that patients treated with HIFEM+ experience on average, 30% less fat, 25% more muscle, 19% reduction in abdominal separation and up to 5.9 cm reduction in waist circumference. Moreover, HIFEM+ induces a 30% increase in satellite cell content, which is similar to the 36% increase observed following twelve weeks of exercise. CONCLUSIONS: The advisory board unanimously agreed on several messages related to HIFEM technology, including that the pairing of HIFEM and radiofrequency (HIFEM+) enables a higher intensity of muscle stimulation and lipolysis, compared to HIFEM alone.

Functional disabilities and satisfaction after total knee arthroplasty in female Asian patients

Surgical Management of Osteoarthritis of the Knee CPG

This study was conducted to investigate functional disabilities and patient satisfaction in Korean patients after total knee arthroplasty (TKA). Of 372 female patients who had undergone TKA with a follow-up longer than 12 months, 261 patients (70.2%) completed a questionnaire designed to evaluate functional disabilities, perceived importance, and patient satisfaction. The top 5 severe functional disabilities were difficulties in kneeling, squatting, sitting with legs crossed, sexual activity, and recreational activities. The top 5 in order of perceived importance were difficulties in walking, using a bathtub, working, recreation activities, and climbing stairs. Severities of functional disabilities were not found to be correlated with perceived importance. The 23 patients (8.8%) dissatisfied with their replaced knees had more severe functional disabilities than the patients satisfied for most activities. The dissatisfied patients tended to perceive functional disabilities in high-flexion activities to be more important than the satisfied

Postoperative analgesia and functional recovery after total-knee replacement: comparison of a continuous posterior lumbar plexus (psoas compartment) block, a continuous femoral nerve block, and the combination of a continuous femoral and sciatic nerve block

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND AND OBJECTIVES: Continuous femoral nerve block is a well-accepted technique for regional analgesia after total-knee replacement. However, many patients still experience considerable pain at the popliteal space and at the medial aspect of the knee. The goal of this study is to evaluate whether a psoas compartment catheter provides better postoperative analgesia than a femoral nerve catheter does and whether it is as effective as the combination of a femoral and a sciatic nerve catheter and, thus, improves functional outcome. METHODS: Ninety patients who underwent total-knee replacement under standardized general anesthesia participated in this prospective randomized study. Group FEM received a continuous femoral nerve block, group FEM/SCI received a combination of a femoral and a sciatic continuous nerve block, and group PSOAS received a continuous psoas compartment block. Patient-controlled analgesia with piritramide was available for 48 hours. Maximal bending and extending of the knee and walking distance was assessed during the first 7 days. A standardized telephone survey was conducted after 9 to 12 months to evaluate residual pain and functional outcome. RESULTS: Postoperative opioid consumption during 48 hours was significantly less in the FEM/SCI group (median: 18 mg; 25th/75th percentile: 6/40) compared with the FEM group (49 mg; 25/66) and the PSOAS group (44 mg; 30/62) (P =.002). Postoperative pain scores were not different, and no differences occurred with respect to short-term or long-term functional outcome. CONCLUSION: The FEM/SCI catheter is superior to FEM and PSOAS catheter with respect to reduced analgesic requirements after total-knee replacement, but functional outcome does not differ with those 3 continuous regional analgesia techniques

Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United Kingdom

DOD - Acute Comp Syndrome CPG

OBJECTIVE: To investigate current practice in the diagnosis and management of chronic exertional compartment syndrome (CECS) of the lower leg among orthopedic surgeons in the United Kingdom. DESIGN: Questionnaire survey. SETTING: Secondary care (NHS and private). PARTICIPANTS: Two hundred six orthopedic surgeons affiliated with one of the following specialist associations: British Association of Sports and Exercise Medicine (BASEM), United Kingdom Association of Doctors in Sport (UKADIS), British Orthopedic Sports and Trauma Association (BOSTA) and British Orthopedic Foot Surgery Society (BOFSS). INTERVENTIONS: Self-administered questionnaire. MAIN OUTCOME MEASURES: Current practice in diagnosis and treatment of CECS. RESULTS: Sixty percent (124/206) of the surveyed population replied and 53% (66/124) see patients with CECS. To confirm the diagnosis, 83% (55/66) use intra-compartmental pressure measurements (ICPs). Of these, 42% use maximal ICP during exercise greater than 35 mmHg as a criterion for anterior CECS diagnosis and 35% use Pedowitz's modified criteria. Of all the respondents, 88% would be willing to adopt a National Framework document for diagnosis, 30% (20/66) always try conservative treatment following diagnosis, 93% (57/60) perform superficial fasciotomy as the first line surgical procedure, 55% (33/60) use a one incision technique for anterior fasciotomy and 60% (36/60) undertake a repeat fasciotomy following failed decompression. CONCLUSIONS: There is agreement among orthopedic surgeons on the role of ICPs for diagnosis and the choice of fasciotomy as a first-line surgical procedure. In contrast, there is a divergence of opinions regarding the ICP diagnostic thresholds, the role of conservative management and the surgical techniques for fasciotomy and failure of decompression.

Postoperative joint infections in rheumatoid arthritis patients on methotrexate therapy

AAHKS (2) Corticosteroids

The effect of low dose methotrexate (MTX) on postoperative complications in rheumatoid arthritis patients undergoing elective total joint arthroplasty was observed prospectively in 32 patients. Patients were assigned to discontinue MTX the week prior to and during the week of surgery (Group 1, n=19) or to continue MTX throughout the perioperative period (Group 2, n=13). Nineteen patients in Group 1 had 26 procedures, with no postoperative infections. Thirteen patients in Group 2 had 16 procedures, with 4 postoperative infections: 2 infected prostheses, 1 infected joint fusion, and 1 deep wound infection (P=.03). No patient had a postoperative flare of rheumatoid arthritis. Temporary discontinuation of MTX prior to joint arthroplasty appears to decrease the risk of postoperative infection.

New body contouring technique in male: the muscular sculpture

Panniculectomy & Abdominoplasty CPG

UNLABELLED: Optimal male body contouring considers the entire body and drapes tight skin over the muscles. Males have pride in the appearance of their muscular development. There should be a deliberate effort to achieve an athletic body contour that reveals superficial musculature and selectively highlights adherences. We describe a new technique of male body contouring to achieve tight skin that very well reveals muscular bulk and accentuates adherences; minimal observable scars; a male muscular and athletic body, even for patients who are not, nor have been in the past, bodybuilders. Normal-weight and overweight patients need one operative step, in which the fat is removed and the muscles are sculpted at the same time by using selective liposuction, and if necessary, the fat is repositioned through lipofilling. The ex-obese patients need two operative steps: in the first, we perform abdominoplasty with inguinal scar (to remove the excess abdominal tissue and to lift the pubis) and periareolar scar (to breast lift and reduction); in the second, we sculpt the muscles and the adherences by selective liposuction. In all male patients, the authors strive to achieve a trapezoid chest and sculpted pectoralis major muscle, pronounced alba and semilunar lines, evident muscular bulk, and adherences in both the abdomen and extremities. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Radiation Exposure During Operative Fixation of Pediatric Supracondylar Humerus Fractures: Is Lead Shielding Necessary?

Pediatric Supracondylar Humerus Fracture 2020 Review

BACKGROUND: Factors that impact radiation exposure during operative fixation of pediatric supracondylar humerus (SCH) fractures have been investigated; however, no studies have measured the equivalent dose at the patient's radiosensitive organs. Our hypothesis was that intraoperative fluoroscopy exposes pediatric patients to a significant radiation load and lead shielding of radiosensitive organs is important. The goal of the study was to quantify the patient's radiation exposure during the procedure by measuring the radiation load at the thyroid and gonads. METHODS: A prospective quality improvement project of radiation exposure during percutaneous fixation of isolated SCH fractures was performed over a 4-week period. The c-arm image intensifier was used as the operating table and radiation dosimeters were positioned over the thyroid and gonadal lead shields. Fluoroscopy times were recorded, doses were calculated, and the dosimeters were analyzed. To assure that the prospective cohort was representative of a larger population of SCH fractures, demographics and fluoroscopy time of the prospective cohort were compared with a 12-month retrospective cohort in which dosimetry was not performed. RESULTS: Prospective cohort-18 patients with type 2 (8) and type 3 (10) fractures were prospectively studied with intraoperative measurement of thyroid and gonadal radiation equivalent doses. Mean age was 4.9 years (1.9 to 9.5 y) and mean weight was 21.4 kg (13.1 to 33.5 kg). Mean fluoroscopy time was 65.0 seconds (25.3 to 168.4 s), and absorbed skin dose at the elbow was 0.47 mGy (0.18 to 1.21 mGy). The radiation dosimeters overlying the thyroid and gonads measured minimal radiation indicating equivalent doses of <0.01 mSv for all patients in the prospective cohort.Retrospective cohort-163 patients with type 2 (60) and type 3 (103) fractures were retrospectively studied. The mean age was 5.5 years (0.02 to 13.7 y) and weight was 21.6 kg (2.0 to 71.9 kg). Mean fluoroscopy time was 74.1 seconds (10.2 to 288.9 s), and absorbed skin dose at the elbow was 0.53 mGy (0.07 to 2.07 mGy).There were no statistically significant differences between the cohorts. CONCLUSIONS: The smaller prospective cohort had fluoroscopy times and radiation doses that were not statistically different from the larger retrospective cohort, suggesting that the dosimeter measurements are representative of intraoperative radiation exposure during fixation of pediatric SCH fractures. The equivalent dose to the thyroid and gonads was minimal and approximates daily background radiation. Shielding of radiosensitive organs is appropriate when practical to minimize cumulative lifetime radiation exposure, particularly in smaller patients and when longer fluoroscopy times are anticipated. LEVEL OF EVIDENCE: Level 2.

Initial promising results of the dynamic locking blade plate, a new implant for the fixation of intracapsular hip fractures: Results of a pilot study

Management of Hip Fractures in the Elderly

Introduction: The osteosynthesis of intracapsular hip fractures results in a 19-48% failure rate. Only when the anatomical reduction is secured by stable fixation, revascularisation of the femoral head can take place and the fracture can heal by primary osteonal reconstruction. The common implants lack rotational and/or angular stability. Also the relative large volume of the implants within the femoral head compromises the (re)vascularisation. The combination of an anatomical reduction and a low volume, dynamic implant, providing angular and rotational stability seem to be crucial factors in the treatment of intracapsular hip fractures. This assumption formed the starting point for the development of the dynamic locking blade plate (DLBP), a new implant for the internal fixation of intracapsular hip fractures. This report describes the first clinical results of the new implant. Patients and methods: Internal fixation with the DLBP was performed in 25 consecutive patients with an intracapsular hip fracture within 24 h from admission. Failure of fixation, due to non-union, avascular necrosis, implant failure or secondary displacement of the fracture, was the primary outcome measurer. Functional outcome was assessed by the Harris Hip Score. Results: Following internal fixation of intracapsular hip fractures with the DLBP, a failure rate of 2 out of 25 patients and excellent functional results were seen after a follow-up of more than 2 years. Conclusion: The initial clinical results of the DLBP are promising and justify the start of a randomised controlled trial. (copyright) Springer-Verlag 2010

The utility of portable dual-energy X-ray absorptiometry of the wrist in patients referred to a bone health clinic: a pilot study

Distal Radius Fractures

Fifty white female patients referred to a bone health care clinic were studied. Patients with a history of fracture were excluded. At the time of hip and spine dual-energy X-ray absorptiometry (DXA), those willing underwent portable dual-energy X-ray absorptiometry (pDXA) of the wrist. The mean age of the patients was 57 yr. Bone mineral density (BMD) assessment was performed on each patient at four different sites: posterior-anterior lumbar spine, nondominant hip, the distal radius and ulna, and the proximal radius and ulna of the nondominant arm. Comparison of the pDXA results with that of the conventional DXA results showed the highest correlation between pDXA of the distal radius and ulna (DR + U) and the DXA of the femoral neck and lumbar spine. By defining a pDXA (DR + U) T-score </= -1 as a positive test and DXA T-score </=-1 as the presence of disease, we obtained a specificity of 93% and a sensitivity of 82% for decreased lumbar spine bone density (positive predictive value 97% and the negative predictive value 70%) and a specificity of 100% and a sensitivity of 83% (positive predictive value is 100% and the negative predictive value is 70%) for decreased femoral neck bone density.

Factors associated with prolonged length of stay following a total knee replacement in patients aged over 75

Surgical Management of Osteoarthritis of the Knee CPG

PURPOSE: The aim of this study was to examine factors associated with a prolonged length of stay (LOS) in patients over 75 undergoing a total knee replacement (TKR). METHODS: Patients over 75 undergoing a TKR at our institution from January 2008 to February 2009 were identified (n = 112). Patient and operative factors previously shown to affect length of stay were identified. Patient notes were reviewed for details on each of these and data analysed for their effect on length of stay. Discrete data were analysed for their effect on post-operative length of stay using either the Mann-Whitney U test or the Kruskall-Wallis test and continuous data analysed with the Spearman's rank correlation coefficient. RESULTS: The following factors were associated with length of stay at the 95 % confidence level: patient age, pre-operative mobility and the use of walking aids, BMI, whether the patient was able to mobilise within 24 or 48 hours of the surgery, the day on which the patient first walked ten metres and achieved 90 degrees active knee flexion, pre and post-operative haemoglobin and the need for a blood transfusion. CONCLUSIONS: Pre-operative use of walking aids, peri-operative haemoglobin concentration, failure to mobilise early following the operation and post-operative complications (including the need for a blood transfusion) seem to be the significant factors associated with a prolonged stay in hospital in the over 75 year olds

The high-superior-tension technique: evolution of lipoabdominoplasty

Panniculectomy & Abdominoplasty CPG

Because abdominoplasty is associated with complications such as seroma and necrosis as well as epigastric bulging and a suprapubic scar located too high, the demand for this procedure is not as high as it otherwise might be. However, although these negative effects were common many years ago, their incidence has decreased dramatically with modern abdominoplastic techniques. One approach using a combination of abdominoplasty and liposuction or lipoabdominoplasty has resolved many of the problems faced with earlier techniques, offering aesthetically pleasing results and excellent reliability. The keys to successful lipoabdominoplasty, first developed as the high-superior-tension technique, are extensive liposuction, preservation of lymphatic trunks, preaponeurotic epigastric dissection, major muscle fascia plication, two high-tension paraumbilical sutures, hypogastric tension sutures, and closure of the dead spaces. The most recent updates to this technique are described in this article.

Fifteen-year survival and osteolysis associated with a modular posterior stabilized knee replacement: A concise follow-up of a previous report

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

We report the results of a consecutive series of total knee arthroplasties with use of a modular posterior stabilized prosthesis after a mean follow-up of twelve years (range, ten to eighteen years). In the five years since the original publication of our study, two additional knees were revised; one was revised for aseptic loosening and one, for polyethylene wear with tibial osteolysis. With mechanical failure as an end point, the fifteen-year survival was 96.8%. With failure defined as any reoperation, the fifteen-year survival was 90.6%. Osteolysis occurred in eight of the 117 knees with a minimum ten-year follow-up. With the relatively small number of subjects, no significant association was identified between polyethylene thickness or sterilization method and osteolysis. A significant association was identified between younger patient age and osteolysis. We continue to routinely implant a similar modular posterior stabilized total knee prosthesis. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. Copyright (copyright) 2009 by The Journal of Bone and Joint Surgery, Incorporated

Categorization of major and minor complications in the treatment of patients with resectable rectal cancer using short-term pre-operative radiotherapy and total mesorectal excision: a Delphi round

DoD SSI (Surgical Site Infections)

BACKGROUND: To properly balance the benefit (reduction of local recurrence) of short-term pre-operative radiotherapy for resectable rectal cancer against its harm (complications), a consensus concerning the severity of complications is required. The aim of this study was to reach consensus regarding major and minor complications after short-term radiotherapy followed by total mesorectal excision in the treatment of rectal carcinoma, using the Delphi technique. METHODS: A Delphi round was performed in cooperation with 21 colo-rectal surgeons from the Netherlands, United Kingdom and Sweden. The key-question was: 'Which of the predefined complications, caused or substantially aggravated by radiotherapy, are so important (major) that they might lead to the decision to abandon short-term pre-operative radiotherapy (5 x 5Gy) when treating patients with resectable rectal cancer (T1-3N0-2M0)?' RESULTS: After three rounds, consensus was reached for 37 (68%) of 54 complications of which 13 were considered major and 24 considered minor. The following complications were considered to be major: mortality, anastomotic leakage managed by relaparotomy, anastomotic leakage resulting in persisting fistula, postoperative haemorrhage managed by relaparotomy, intra-abdominal abscess without healing tendency, sepsis, pulmonary embolism, myocardial infarction, compartment syndrome of the lower legs, long-term incontinence for solid stool, long-term problems with voiding, pelvic fracture with persisting pain, and neuropathy with persisting pain (legs). Three of 17 complications without consensus showed a tendency to be considered as major: perineal wound dehiscence managed by surgical treatment, small bowel obstruction leading to relaparotomy and long-term incontinence for liquid stool. CONCLUSION: The 13 major and three 'accepted as major' complications can be used to properly balance the benefit and harm of short-term pre-operative radiotherapy in resectable rectal cancer. This may eventually lead to improved treatment strategies for these patients.

Plate osteosynthesis versus intramedullary nailing for both forearm bones fractures

DoD SSI (Surgical Site Infections)

Purpose: Given the continuing improvements in nail implants, intramedullary nailing could become an alternative treatment option to osteosynthesis for the treatment of fractures in both forearm bones, with the proper indication. The aim of this prospective study was to evaluate and compare the results of plate osteosynthesis and intramedullary nailing for the treatment of diaphyseal fractures in both forearm bones. Methods: Sixty-seven patients (mean age, 41 years; range, 22-76 years) of this prospective study were divided into two groups according to treatment randomly: ORIF group (plate osteosynthesis) and IMN group (intramedullary nail). The results were assessed on the basis of the time to union, functional recovery (range of motion and functional outcomes [Grace and Eversmann rating system and DASH]), restoration of the ulna and the radial bow, operating time, exposure time to fluoroscopy, complications, and patient satisfaction. The ratio of the magnitude of the maximum radial bow on the injured side to that on the contralateral side (i.e., "the ratio of the contralateral side") was determined to evaluate the effectiveness of radial bow restoration between groups. Results: The time to union and the exposure time to fluoroscopy were significantly shorter in ORIF group than in IMN group. The presence of butterfly segment and severe displacement were factors leading to the increase in the time of union in IMN group. No intergroup differences were observed in the restoration and magnitude of the maximum radial bow on the injured side. However, ORIF group showed a significantly improved ratio of the contralateral side compared to IMN group. In terms of the location of maximum radial bow and ratio of the contralateral side, significant differences were found between groups. The functional outcomes did not significantly differ between the two groups, irrespective of the time of assessment. All patients achieved union in both groups, with the exception of a single case of nonunion in IMN group and one case of refracture after implant removal in ORIF group. Conclusion: Based on the significant differences in the ratio of the contralateral side, plate osteosynthesis resulted in a more excellent extent of restoration to the conditions prior to the injury. Nevertheless, such significant differences in the restoration of the bow had no effect on the final clinical outcome. If the indication is properly selected, our results suggested intramedullary nailing can be acceptable and effective treatment options for fractures in both forearm bones. © 2013 Springer-Verlag.

Supracondylar humerus fractures in children: a comparison of experiences

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

The most common elbow lesions found in pediatric practice are supracondylar fractures. We compared two groups of 34 patients each with a supracondylar humerus fracture grade III (Gartland classification). The first group was treated with percutaneous pinning with Kirschner wires, with patients in a supine position, sometimes preceded by transkeletal traction. The second group was treated with percutaneous pinning with Kirschner wires, with patients in a prone position, within 6 h of the trauma. No statistically significant differences with regard to clinical outcomes and neurovascular complications were revealed in the comparison. Therefore, we can state that both treatment techniques used are valid

Treatment for displaced intracapsular fracture of the proximal femur

Management of Hip Fractures in the Elderly

We performed a prospective, randomised trial comparing three treatments for displaced intracapsular fractures of the hip in 280 patients aged 65 to 79 years. The mean patient survival was significantly higher in the group undergoing reduction and internal fixation (79 months) compared with that with a cemented Thompson hemiarthroplasty or a cemented Monk bipolar hemiarthroplasty (61 months and 68 months, respectively). After three years, 32 of 93 patients (34.4%) who had undergone fixation had local complications, necessitating further intervention in 28 (30%). There were no significant differences in the functional outcome in survivors, who were reviewed annually to five years. Either reduction and internal fixation or cemented hemiarthroplasty may be offered as alternative treatments for a displaced intracapsular fracture in a mobile and mentally competent patient under the age of 80 years. The choice of procedure by the patient and the surgeon should be determined by the realisation that the use of internal fixation is associated with a 30% risk of failure requiring further surgery. If this is accepted, however, hemiarthroplasty is avoided, which, in our study has a significantly shorter mean survival time. The use of a bipolar prosthesis has no significant advantage

Comparison of simultaneous bilateral with unilateral total knee arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: The aim of this study was to compare simultaneous bilateral total knee arthroplasty (BTKA) and unilateral total knee arthroplasty (UTKA) in terms of morbidity, clinical and radiological findings and quality of life. METHODS: The study included 48 simultaneous BTKAs (46 females, 2 males; mean age: 64.00 +/- 8.31 years) and 53 UTKAs (46 females, 7 males; mean age: 64.40 +/- 7.45 years) performed between November 2007 and June 2012. Groups were compared with respect to comorbidity, complications, blood transfusion, hospital stay, clinical and radiological (American Knee Society Score) findings and quality of life (SF-36). RESULTS: Three patients in the BTKA group and 1 in the UTKA group required intensive care admission due to pulmonary embolism; 2 cases occurred within the first postoperative 30 days. One BTKA patient died in the early postoperative period and 1 patient from the BTKA and 1 from the UTKA group died within 1 year. Hospital stay, perioperative blood transfusion parameters and mortality rates were significantly different in favor of UTKA and revision operation rates in favor of BTKA (p<0.05). All patients had improved knee and function scores and SF-36 scores. However, there was no significant difference between the groups (p>0.05). CONCLUSION: Simultaneous BTKA should be considered in selected patients under 70 years of age with good compliance and no comorbid disease.

Prevalence of Deep Venous Thrombosis in Abdominoplasty Patients after COVID-19 Convalescence: An Alarming Flag

Panniculectomy & Abdominoplasty CPG

BACKGROUND: The incidence of thrombotic manifestations during aesthetic procedures may be overwhelming, as it may endanger patients' lives. Lipoabdominoplasty is one of the precarious aesthetic treatments with risk for thrombosis. COVID-19 convalescent patients may have an abnormally high rate of thrombotic events, which should be studied further. Patients with a history of COVID-19 infection who undergo the aesthetic procedure may have a greater risk of thrombosis than non-COVID-19 patients who undergo lipoabdominoplasty. METHODS: Thirty-seven patients who underwent lipoabdominoplasty were followed retrospectively for the occurrence of thrombotic events postoperatively and their relationship to previous COVID-19 infection. The study design comprised an examination of their medical records for prior COVID-19 infection, a history of thrombotic events before, during, or following COVID-19 infection, and D-dimer levels during and after COVID-19 infection. Thrombotic signs were studied in COVID-19 convalescent and non-COVID-19 patients following lipoabdominoplasty. The universal prophylactic measures for anticoagulation were followed. RESULTS: Four patients out of 37 (10.18%) had thrombotic manifestations, with a high incidence in the COVID-19 convalescent group. The occurrence rate in COVID-19 patients was 30.7%, much higher than the global rate (0.2%). The presence of D-dimers was discovered to be abundant. CONCLUSION: Additional precautions should be taken to closely monitor patients with a prior history of COVID-19 infection who seek aesthetic surgery, particularly riskier procedures such as lipoabdominoplasty.

Epidemiological investigation of osteoarthritis in middle-aged Mongolian and senior residents of the inner Mongolia autonomous region

OAK 3 - Non-arthroplasty tx of OAK

Background: To investigate the prevalence and characteristics of osteoarthritis (OA) in Mongolian middle-aged and senior residents of the Inner Mongolia autonomous region, compared with the prevalence of OA in different regions, to understand the OA-associated factors and provide theoretical evidences for intervention and prevention. Objectives: Thereby the prevalence, distribution characteristics and correlative factors of OA in Mongolian middle-aged and senior residents in the Inner Mongolia autonomous region were investigated in this study. Materials and Methods: Rural and urban residents in Hohhot, Baotou and Erdos were selected using stratified, multi-stage and cluster random sampling. 2000 residents aging over 45 filled out questionnaires, underwent specialized physical and X-ray examinations. The factors affecting OA were analyzed by the multivariate unconditional logistic regression. Results: Obtained total of 1877 questionnaires were completed. 93% of the residents were unaware of OA-related issues. The prevalence of radiological OA and clinical OA (neck OA: 36.72%; waist OA: 44.02%; knee OA: 12.43%; hand OA: 6.83%) were 62.17% and 56.15%, respectively. Urban residents were more subjected to cervical spine (Ï?2 = 8.92, P = 0.005) and less to lumbar spine disease (Ï?2 = 10.32, P = 0.004) compared to rural ones. The prevalence of OA in knees and hands of females (Ï?2 = 8.65, P = 0.003) was significantly higher than males (Ï?2 = 4.37, P = 0.042). The prevalence of OA in postmenopausal females was slightly higher than males (Ï?2 = 3.86, P = 0.052), with no statically significant difference. The risks of OA obviously increased with age. The residents with hypertension, diabetes and atherosclerosis were more subjected to OA. Conclusions: The prevalence of OA in Mongolian middle-aged and senior residents in part of the Inner Mongolia autonomous region was similar to the other ethnic groups. The prevalence of OA was affected by age, gender, location, hypertension, diabetes, atherosclerosis and osteoporosis. The residents need further educations about OA prevention and treatment. © 2013, Kowsar. All Rights Reserved.

Is the infection rate in primary THA increased after steroid injection?.[Erratum appears in Clin Orthop Relat Res. 2013 Nov;471(11):3724]

AAHKS (2) Corticosteroids

BACKGROUND: Injection of the hip is performed for diagnostic and therapeutic reasons. Articular cartilage deterioration and increased risk of prosthetic infection have been reported with steroid injections. However, the literature contains contradictory reports on an increased risk of infection after a subsequent THA. QUESTIONS/PURPOSES: We asked whether intraarticular steroid injection increased the rate of infection of a subsequent THA. METHODS: We retrospectively reviewed records of 175 patients in whom intraarticular steroid injections were given under strictly aseptic conditions using a lateral approach within 1 year before THA. These patients were matched with others from our database who had not received an injection for comorbidities, and for American Society of Anesthesiologists score, age, BMI, sex, type of implant, and year of THA. RESULTS: We found no differences in the rate of deep or superficial infection between the two groups. One patient in the injected group and one in the control group had a late chronic infection. In three patients in the injected group and one in the control group, one of the intraoperative cultures was positive. Five patients in the injected group and seven in the control group had superficial infections develop. In seven patients in the injected group and five in the control group, there was prolonged wound drainage (> 5 days). None of these patients had a deep wound infection at latest followup. CONCLUSIONS: When used in strictly aseptic conditions, intraarticular steroid injection of the hip did not increase the risk of infection in patients subsequently undergoing THA. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Interventions for increasing ankle range of motion in patients with neuromuscular disease

Management of Hip Fractures in the Elderly

BACKGROUND: Reduced ankle dorsiflexion range of motion, or ankle equinus, is a common and disabling problem for patients with neuromuscular disease. Clinicians devote considerable time and resources implementing interventions to correct this problem although few of these interventions have been subject to rigorous empirical investigation. OBJECTIVES: To assess the effect of interventions to reduce or resolve ankle equinus in people with neuromuscular disease. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (August 2009), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2009), MEDLINE (1966 to August 2009), EMBASE (1980 to August 2009), CINAHL 1982 to August 2009), AMED (1985 to August 2009) and The Physiotherapy Evidence Database (PEDro) (1929 to August 2009). We searched the reference lists of identified articles and also contacted known experts in the field to identify additional or unpublished data. SELECTION CRITERIA: Randomised controlled trials evaluating interventions for increasing ankle dorsiflexion range of motion in neuromuscular disease. Outcomes included ankle dorsiflexion range of motion, functional improvement, foot alignment, foot and ankle muscle strength, health-related quality of life, satisfaction with the intervention and adverse events. DATA COLLECTION AND ANALYSIS: Two authors independently selected papers, assessed trial quality and extracted data. MAIN RESULTS: Four studies involving 149 participants met inclusion criteria for this review. Two studies assessed the effect of night splinting in a total of 26 children and adults with Charcot-Marie-Tooth disease type 1A. There were no statistically or clinically significant differences between wearing a night splint and not wearing a night splint. One study assessed the efficacy of prednisone treatment in 103 boys with Duchenne muscular dystrophy. While a daily dose of prednisone at 0.75 mg/kg/day resulted in significant improvements in some strength and function parameters compared with placebo, there was no significant difference in ankle range of motion between groups. Increasing the prednisone dose to 1.5 mg/kg/day had no significant effect on ankle range of motion. One study evaluated early surgery in 20 young boys with Duchenne muscular dystrophy. Surgery resulted in increased ankle dorsiflexion range at 12 months but functional outcomes favoured the control group. By 24 months, many boys in the surgical group experienced a relapse of achilles tendon contractures. AUTHORS' CONCLUSIONS: There is no evidence of significant benefit from any intervention for increasing ankle range of motion in Charcot-Marie-Tooth disease type 1A or Duchenne muscular dystrophy. Further research is required. INTERVENTIONS FOR INCREASING ANKLE FLEXIBILITY IN PEOPLE WITH NEUROMUSCULAR DISEASE: Loss of ankle flexibility is a common problem for people with neuromuscular disease. It can cause foot deformity, pain and problems walking. The purpose of this review was to assess the evidence regarding the effectiveness of interventions for improving ankle flexibility in people with neuromuscular disease. Four studies were included in the review involving a total of 149 participants. Two studies showed that wearing a night splint was no more effective than not wearing a night splint for increasing ankle flexibility in 26 people who had Charcot-Marie-Tooth disease type 1A. One study showed corticosteroids (prednisone) did not significantly improve ankle flexibility in 103 boys with Duchenne muscular dystrophy and the other study showed that while orthopaedic surgery initially increased ankle flexibility in 20 young boys with Duchenne muscular dystrophy this was not sustained in the long term. This review shows that, currently, there is limited evidence supporting any intervention for improving ankle flexibility in patients with Charcot-Marie-Tooth disease type 1A and Duchenne muscular dystrophy. More research is needed

Clinical benefit in patients with metastatic bone disease: results of a phase 3 study of denosumab versus zoledronic acid

MSTS 2018 - Femur Mets and MM

BACKGROUND: Patients with metastatic bone disease are living longer in the metastatic stage due to improvements in cancer therapy, making strategies to prevent the aggravation of bone disease and its complications, such as skeletal-related events (SREs) and pain, increasingly important. PATIENTS AND RESULTS: In this phase 3 trial in patients with advanced cancer (excluding breast and prostate cancer) or multiple myeloma, denosumab reduced the risk of radiation to bone by 22% relative to zoledronic acid (P = 0.026), prevented worsening of pain and pain interference (2-point increase in Brief Pain Inventory score; P < 0.05 versus zoledronic acid), and reduced the frequency of a shift from no/weak opioid analgesic use to strong opioids (P < 0.05 versus zoledronic acid at months 3-5). Denosumab delayed the time to moderate-to-severe pain compared with zoledronic acid in patients with mild or no pain at the baseline (P = 0.04), supporting early treatment. Health-related quality-of-life scores were similar in both groups. The number needed to treat to avoid one SRE for denosumab was 3 patient-years versus placebo and 10 patient-years versus zoledronic acid. CONCLUSION: The use of denosumab was associated with better prevention of the complications of metastatic bone disease secondary to solid tumors or multiple myeloma versus zoledronic acid.

Double-tapered conical taper in primary and revision surgery: rationale and short-term follow-up

MSTS 2022 - Metastatic Disease of the Humerus

Background: The new double-conical tapered stem is a novel cementless modular system, which is indicated for both primary and revision surgeries. It has been designed with different angles at the proximal (5°) and distal sections (1° 36’) in order to obtain optimal fixation by proximal and distal fit and fill of the femoral canal. Aim: The aim of this prospective study was to evaluate the short-term clinical and radiographic outcomes of primary and revision hip surgery with the new double-conical stem. Methods: 61 stems were implanted (December 2013 to September 2016) in 42 cases of primary and in 19 cases of revision surgery. The mean age of patients was 64.7 (17–94; standard deviation [SD] 21.9) years. Results: The mean body mass index of the patients was 24.6 (17–34.6). In 3 cases of developmental dysplasia of the hip we performed femoral shortening osteotomy. The mean follow-up was 26 (8–40) months. 3 patients died due to causes unrelated to surgery. Postoperative complications included 3 hip dislocations, 2 infections and 1 case of stem explant for metastatic tumour. For all other cases, at the last follow-up radiographs showed no loosening, no radiolucent lines nor subsidence. The mean Harris Hip Score significantly improved from 45 (range 35–58) preoperatively to 87 (range 75–94). Leg length discrepancy was found in 10% of cases but never >1 cm. Conclusions: Radiographic analysis showed the bone-stem contact full at 2 levels of taper. The double-tapered prosthetic stem can therefore be usefully employed both in primary and in revision surgeries.

Treatment of pneumonia in elderly patients

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Pneumonia represents the leading cause of infection-related death and the fifth cause of overall mortality, in the elderly. Several risk factors for acquiring pneumonia in older age have been reported, such as alcoholism, lung and heart diseases, nursing home residence and swallowing disorders. The clinical characteristics of pneumonia in the elderly differ substantially compared with younger patients, and the severity of the disease is strongly associated with increased age and age-related comorbidities. Streptococcus pneumoniae is the leading pathogen responsible for pneumonia in elderly; enteric Gram-negative rods should be considered in nursing-home-acquired pneumonia, as well anaerobes in patients with aspiration pneumonia. Antimicrobial therapy should take into account the most recent guidelines, which are briefly presented in this review. A special consideration should be given to the preventive measures, including vaccination, oral care and nutrition. (copyright) 2006 Ashley Publications

Distal Radius Fractures: External Fixation and Supplemental K-Wires

Distal Radius Fractures

The primary treatment goal for fractures of the distal radius is fracture reduction and stabilization to permit restoration of pain-free wrist function. Recognition of fracture instability based on the radiographic evaluation of fragment comminution and displacement is the focus of current classifications. Although closed reduction and cast immobilization remain a reliable treatment method for stable fractures, similar management for unstable fractures is prone to failure. Ligamentotaxis employing a spanning external fixator in conjunction with supplemental Kirschner wires has proved to be a reliable means of maintaining an accurate reduction of unstable fractures. Successful uncomplicated treatment of distal radius fractures with external fixation is related directly to precise, reproducible surgical technique. The frequently reported pin-related complications can be reduced significantly by several key steps to surgical application. Open bicortical half pin placement avoids soft tissue, tendon, and nerve iatrogenic injuries, and minimizes the risk of unicortical pin insertion that can result in metacarpal or radial shaft fractures or subsequent loosening or infection. Pin inflammation and superficial infection often can be resolved by oral antibiotics, physician pin care, and gauze dressing. Properly applied ligamentotaxis will allow healing of the distal radius fracture without complications related to overdistraction [12,13]. External fixation frames have been modified to allow for early wrist range of motion during the acute healing phase in an attempt to prevent potential residual wrist stiffness. Despite this attractive concept, there appears to be no significant additional benefit to dynamic fixation of these fractures compared with the traditional static wrist immobilization until completion of union. Although ligamentotaxis is effective in restoring length and inclination, it will not restore articular congruity consistently in fractures characterized by marked articular displacement. Restoration of articular congruity can be accomplished by open treatment [14]. Additional stability with improved restoration of volar tilt can be accomplished by closed manipulation in conjunction with multiple percutaneous smooth K-wires inserted from the volar aspect of the radial styloid into the intact dorsal ulnar cortex of the proximal shaft. Excessive flexion or ulnar deviation should be avoided, as these positions potentate the risk of median nerve compression at the wrist level. External fixation with supplemental K-wires is an excellent method for stabilizing displaced unstable distal radius fractures. When properly used, complications can be minimized, and an excellent radiographic and functional recovery can be achieved. Meticulous attention to surgical detail and a comprehensive postoperative program are the key components to a reliable and reproducibly successful recovery. © 2006 Elsevier Inc. All rights reserved.

Patients treated with surgical irrigation and debridement for infection after ACL reconstruction have a high rate of subsequent knee surgery

OAK 3 - Non-arthroplasty tx of OAK

Objectives The purpose of this cross-sectional study was to describe the rates of additional surgery and patient-reported outcomes in patients who underwent surgical irrigation and debridement (I&D) for infection following anterior cruciate ligament reconstruction (ACLR) and test the hypothesis that additional surgery is associated with worse patient-reported outcomes. Methods Patients diagnosed with a postoperative infection following ACLR (defined as one requiring surgical treatment with either a deep or superficial I&D) were identified from a prospective cohort. Both primary and revision ACLRs were included, as well as any graft type (autografts and allografts). Patient-reported outcomes (International Knee Documentation Committee [IKDC], Knee Injury and Osteoarthritis Outcome Score [KOOS] and Marx activity level) and subsequent surgeries were collected at 2-year and 6 year follow-up from the initial ACLR surgery. Baseline demographics and 2-year and 6-year outcomes (from initial ACLR) were compared between patients who did or did not undergo additional surgery subsequent to I&D using Wilcoxon rank-sum tests for continuous variables and Fisher's exact tests for categorical variables. Results Twenty-one of 3210 ACLR patients (0.7%) had a postoperative infection requiring surgical I&D. This group consisted of 12 men and 9 women, mean (SD) age of 25.8 (11.3) years, 18 primary and 3 revision ACLRs and 16 autografts and 5 allografts. The mean time from ACLR to the surgical I&D was 39 days. In these patients, IKDC scores improved from 44±17 prior to initial ACLR to 83±16 at 6-year follow-up (p<0.001). While all KOOS scores improved from baseline to final follow-up, activity level decreased from 11±6 to 7±5 points (p<0.001). Follow-up related to subsequent surgery was obtained on 20 of 21 patients (95%). Forty per cent of the infection group (n=8 of 20) underwent additional surgery following their I&D, with three patients (15%) undergoing revision ACLR and one patient (5%) undergoing total knee arthroplasty. Patients who underwent additional surgery had lower Marx activity at 2 years compared with patients who had no subsequent surgeries (4±3vs 9±5 points, p=0.018). Conclusion Patients who undergo I&D for an infection following ACLR have a high rate of additional surgery but still attain reasonable clinical outcomes 6 years after ACLR. Level of evidence IV

Complete ejection of a ring sequestrum 8 years after external fixation of the tibia

DoD SSI (Surgical Site Infections)

On the day of scheduled debridement for a persistent pin tract infection, a 23-year old man presented himself carrying a small bony ring sequestrum that had spontaneously ejected from his tibial wound 1 week earlier. Eight years prior to presentation, he was treated for an open crural fracture which was stabilised with an external fixator. Revision of the operation notes revealed that the placement of this external fixator was performed without predrilling.

Arthroscopy-assisted versus standard intramedullary nail fixation in diaphyseal fractures of the humerus

Pediatric Supracondylar Humerus Fracture 2020 Review

PURPOSE: The aim of this study was to assess applicability of arthroscopic technique in intramedullary nail fixation of humerus shaft fractures and to compare with conventional nailing in terms of its effects on perioperative and postoperative intra-articular complication rates as well as on clinical and functional outcomes. METHODS: This prospective randomized controlled clinical trial included 40 patients (12 females and 28 males) indicated for surgery between either undergo arthroscopy-assisted (Arthroscopy-assisted intramedullary nailing [AIMN]; n = 20) or conventional (Intramedullary nailing [IMN]; n = 20) anterograde intramedullary nailing. Two groups were compared in terms of mean number of fluoroscopic shootings until the guide wire was inserted, time for union, length of hospital stay, and complication rates. Shoulder functions were assessed by Constant and American Shoulder and Elbow Surgeons (ASES) score. RESULTS: Groups did not significantly differ in terms of age, gender, and mechanism of injury, length of hospital stay, union rate, and mean union time ( p > 0.05). Mean ASES and Constant scores were found to be statistically significantly higher in AIMN group than that in IMN group ( p = 0.000 and p = 0.002, respectively). Mean number of fluoroscopic shootings until the guide wire was inserted was 2.15 in AIMN group, which was significantly lower compared to 4.2 of IMN group ( p = 0.000). CONCLUSIONS: Arthroscopy-assisted technique may be an applicable and safe method owing to its cosmetic advantages and more satisfactory postoperative shoulder functions subsequent to less injury to deltoid, rotator cuff, and other soft tissue, as compared to conventional anterograde approach.

Prosthetic septic arthritis secondary to Prevotella bivia bacteremia in a patient with polymyalgia rheumatica

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Prevotella bivia is gram-negative anaerobic bacteria previously classified in the genus Bacteroides and usually reported in obstetric and gynecologic infections. To our knowledge, there has been only 2 descriptions of infectious arthritis secondary to this bacterium. We report the first case of a spontaneous prosthetic septic arthritis caused by Prevotella bivia in a patient with long-lasting polymyalgia rheumatica. (copyright) 2008 Lippincott Williams & Wilkins, Inc

Clinical experience in the therapy of bites from exotic snakes in Berlin

DOD - Acute Comp Syndrome CPG

Since there are nearly no indigenous poisonous snakes in Germany, snake bites by poisonous snakes are rare. Most serious snake bites reported to poison information centres or treated at hospitals are caused by exotic snakes that are kept in private households. Only few types of antivenom are stored in emergency depots in Germany including polyvalent antivenoms from commercial sources. Since experience with the treatment of poisonous snake bites is limited, the records of the Intensive Care Unit and the Poison Information Centre of the Universitatsklinikum Rudolf Virchow from 1980-1991 were evaluated. During this period, 51 snake bites were reported. Eleven patients who had been bitten by exotic poisonous snakes were treated in intensive care. In eight of the cases, ethanol (blood levels on admission 1.2-4.2 g-1) had played an important role in the cause of the bite. A moderate to severe local inflammation at the site of the bite followed by oedema and necrosis was typical. One patient developed respiratory failure, probably because of the neurotoxic effects of the snake venom and a compartment syndrome necessitating fasciotomy. Haemolysis was observed in four patients and coagulopathy in six patients. All patients received polyvalent antivenom within 2-12 h of the snake bite. Despite serious coagulopathy in two of the patients and respiratory arrest in one, all survived without sequelae.

Osgood Schlatter lesion: histologic features of slipped anterior tibial tubercle

Osteochondritis Dissecans 2020 Review

No study reports the histological features of the various zone of the anterior tubercle of the tibia in the different stages of the Osgood-Schlatter (O-S) lesion. For this reason we carried on an histological study. Specimens were taken from 13 patients with O-S lesion prior to surgery. In 4 cases in the apophyseal stage lesions were present in an altered fibrocartilage anterior to the ossification centre. In 9 cases in the epiphyseal stage varying degrees of reparative tissues were observed in the bed of the fragment of the secondary ossification centre. In 3 of them a zone of lesion was observed within the fibrocartilage anterior to the ossification centre. These results suggest that the slippage of the patellar tendon insertion may be progressive and caused by pathological fibrocartilage.

Overexpression of CXCR4 is significantly associated with cisplatin-based chemotherapy resistance and can be a prognostic factor in epithelial ovarian cancer

MSTS 2018 - Femur Mets and MM

The chemokine receptor 4 (CXCR4) plays an important role in the growth, angiogenesis and metastasis of various cancers, including epithelial ovarian cancer (EOC). However, the correlation between CXCR4 and the clinical response of EOC patients to chemotherapy remains unknown. 124 EOC patients were recruited to assess the relationship between CXCR4 and the response to cisplatin-based chemotherapy. The results showed that patients with a higher CXCR4 expression had a significantly lower chemosensitivity, a poorer progression-free survival and a lower overall survival than those with lower CXCR4 expression. In addition, knockdown of CXCR4 by small interfering RNA suppressed cell proliferation and resulted in G1/S arrest, increased apoptosis and chemosensitivity in both cisplatin-sensitive A2780 cells and cisplatin-resistant cell A2780/cis in vitro. Our data suggest that CXCR4 is one of the key molecules in cisplatin-based chemotherapy for EOC patients and that CXCR4 inhibition is a potential strategy to address the chemoresistance of EOC.

Systematic review and pooled analysis of the rate of carpal tunnel syndrome after prophylactic carpal tunnel release in patients with a distal radius fracture

Distal Radius Fractures

The aim of this study was to determine the rate of carpal tunnel syndrome (CTS) in patients with a volar plated distal radius fracture (DRF), with or without prophylactic carpal tunnel release (CTR). The PubMed database was searched for studies reporting on CTS in patients with a DRF fixed by a volar plate. Selected patients were those who underwent prophylactic CTR versus patients who did not. Pooled rates of CTS were calculated using inverse - variance weighting assuming a random effects model. Tests for heterogeneity were applied. In this study, 172 patients in the CTR group and 1839 patients in the non-CTR group were included. The pooled rate for CTS in the CTR group was 28.1% (95% CI: 11.8% to 48.2%) while it was 4.4% (95% CI: 3.1% to 6.0%) in the non-CTR group. CTR is of no prophylactic value for postoperative CTS in volar plated DRF patients.

Open reduction and internal fixation for supracondylar humerus fractures in children

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Eight hundred sixty-two supracondylar humerus fractures were treated between January 1984 and July 1997. Sixty-five (8%) patients were managed with open reduction and internal fixation with pins. The remaining 797 patients (92%) were managed with either casting, closed reduction with or without percutaneous pinning, or traction. Of the 65 patients managed with open reduction, 46 (71%) of these fractures were irreducible, 16 (24%) had associated vascular compromise, eight (12%) were open, and one was associated with a postreduction nerve palsy and nonanatomic reduction. According to the criteria of Flynn et al. 18 (55%) elbows were rated excellent, eight (24%) were rated good, three (9%) were rated fair, and four (12%) were rated poor after an average of 5.8 months postinjury. This study indicates that highly satisfactory results can be obtained in severely displaced fractures managed with open reduction in these situations

Higher Knee Flexion Moment During the Second Half of the Stance Phase of Gait Is Associated With the Progression of Osteoarthritis of the Patellofemoral Joint on Magnetic Resonance Imaging

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Patellofemoral joint OA is highly prevalent and a major source of pain and dysfunction. The biomechanical factors associated with the progression of PFJ OA remain unclear. METHODS: Three-dimensional gait analyses were performed at baseline. Magnetic resonance imaging of the knee (high-resolution, 3-D, fast spin-echo sequence) was used to identify PFJ cartilage and bone marrow edema-like lesions at baseline and a 1-year follow-up. The severity of PFJ OA progression was defined using the modified Whole-Organ Magnetic Resonance Imaging Score when new or increased cartilage or bone marrow edema-like lesions were observed at 1 year. Peak external knee flexion moment and flexion moment impulse during the first and second halves of the stance phase of gait were compared between progressors and nonprogressors, and used to predict progression after adjusting for age, sex, body mass index, and presence of baseline PFJ OA. RESULTS: Sixty-one participants with no knee OA or isolated PFJ OA were included. Patellofemoral joint OA progressors (n = 10) demonstrated significantly higher peak knee flexion moment (P = .01) and flexion moment impulse (P = .04) during the second half of stance at baseline compared to nonprogressors. Logistic regression showed that higher peak knee flexion moment during the second half of the stance phase was significantly associated with progression at 1 year (adjusted odds ratio = 3.3, P = .01). CONCLUSION: Peak knee flexion moment and flexion moment impulse during the second half of stance are related to the progression of PFJ OA and may need to be considered when treating individuals who are at risk of or who have PFJ OA. STUDY DESIGN: Controlled laboratory study, longitudinal design. OBJECTIVE: To examine whether baseline knee flexion moment or impulse during walking is associated with the progression of osteoarthritis (OA) with magnetic resonance imaging of the patellofemoral joint (PFJ) at 1 year.

A novel and effective strategy for the isolation of adipose-derived stem cells: minimally manipulated adipose-derived stem cells for more rapid and safe stem cell therapy

Panniculectomy & Abdominoplasty CPG

Adipose-derived stem cells are an ideal mesenchymal stem cell population for regenerative medical application. The isolation procedure is performed by mechanical isolation under a laminar air flow bench without using serum or animal-derived reagents; cells were characterized by flow cytometric analysis. Cell availability is improved compared with enzymatic digestion procedures. The adipose-derived stem cell mechanical isolating procedure presented here is easier, safer, cheaper, and faster than traditional currently performed enzymatic procedures.

Forearm fractures as predictors of subsequent osteoporotic fractures

Management of Hip Fractures in the Elderly

To assess the ability of distal forearm fractures to predict future fractures, we conducted a population-based retrospective cohort study among the 1288 residents (243 men, 1045 women) of Rochester, Minnesota age 35 years or older who experienced their first distal forearm fracture in 1975-94. During 9664 person-years of follow-up, 548 patients experienced 1109 subsequent fractures, excluding 195 that occurred on the same day as the index forearm fracture. The cumulative incidence of any subsequent fracture was 55% by 10 years and 80% by 20 years following the initial distal forearm fracture. Compared to expected fracture rates in the community, the risk of a hip fracture following the index forearm fracture was increased 1.4-fold in women (95% CI, 1.1-1.8) and 2.7-fold in men (95% CI, 0.98-5.8). In women, the risk of hip fracture differed by age, as we had found in a previous study. Women over age 70 had a 1.6-fold increase (95% CI, 1.2-2.0) in subsequent hip fracture risk whereas women who sustained their first forearm fracture before age 70 years did not have significantly increase risk. By contrast, vertebral fractures were significantly increased at all ages, with a 5.2-fold increase (95% CI, 4.5-5.9) in risk among women and a 10.7-fold increase (95% CI, 6.7-16.3) among men following a first distal forearm fracture. The increased risk in men suggests that a sentinel forearm fracture should not be ignored. Among the women, we also found a missed opportunity for intervention as hormone replacement therapy was underutilized

Chemokine receptors in head and neck cancer: association with metastatic spread and regulation during chemotherapy

MSTS 2018 - Femur Mets and MM

Head and neck carcinomas are histologically and clinically heterogeneous. While squamous cell carcinomas (SCC) are characterized by lymphogenous spread, adenoid cystic carcinomas (ACC) disseminate preferentially hematogenously. To study cellular and molecular mechanisms of organ-specific metastasis, we used SCC and ACC cell lines and tumor tissues, obtained from patients with primary or metastatic disease. Comprehensive analysis at the mRNA and protein level of human chemokine receptors showed that SCC and ACC cells exhibited distinct and nonrandom expression profiles for these receptors. SCC predominantly expressed receptors for chemokines homeostatically expressed in lymph nodes, including CC chemokine receptor (CCR) 7 and CXC chemokine receptor (CXCR)5. No difference in expression of chemokine receptors was seen in primary SCC and corresponding lymph node metastases. In contrast to SCC, ACC cells primarily expressed CXCR4. In chemotaxis assays, ACC cells were responsive to CXCL12, the ligand for CXCR4. Exposure of ACC cells to cisplatin resulted in upregulation of CXCR4 on the cell surface, which was repressed by the transcriptional inhibitor, alpha-amanitin. Treatment of ACC cells with CXCL12 resulted in the activation of Akt and ERK1/2 pathways. Furthermore, CXCL12 suppressed the rate of apoptosis induced by cisplatin in ACC cells, suggesting that signaling via CXCR4 may be part of a tumor cell survival program. Discrimination of the chemokine receptor profile in SCC and ACC in vitro and in tissues provided insights into their distinct biologic and clinical characteristics as well as indications that chemokine receptors might serve as future therapeutic targets in these malignancies.

Osteomalacia as a contributing factor in fracture of the femoral neck in the elderly in Quatar

Management of Hip Fractures in the Elderly

Eighty-seven patients with femoral neck fractures were investigated for possible evidence of osteomalacia. Eighteen patients were under the age of 50, or had sustained the fracture following severe injury. No evidence of osteomalacia was demonstrated in this group. In the remaining 69 patients the fracture was associated with a trivial injury, and in some patients no history of injury could be obtained. Only 16 (23.2%) of these showed evidence of osteomalacia; in 7 (10.1%) the disease was suspected. This occurred more often in women than men, and in trochanteric rather than cervical fractures

Comparison of the clinical outcomes after total knee arthroplasty with the LCS rotating platform mobile bearing knee system and the PFC sigma RP-F mobile bearing knee system

OAK 3 - Non-arthroplasty tx of OAK

Background: We compared clinical outcomes after total knee arthroplasty with the Low Contact Stress (LCS) rotating platform mobile bearing knee system and the Press Fit Condylar Sigma rotating platform high flexion (PFC Sigma RP-F) mobile bearing knee system. Methods: Fifty cases of total knee arthroplasty were performed with the PFC Sigma RP-F mobile bearing knee system and sixty-one cases were performed with the LCS mobile bearing total knee arthroplasty. The average duration of follow-up was 2.9 years. Results: The mean Hospital for Special Surgery (HSS) knee score was 62.1 (range, 52 to 75) in the LCS group and 61.9 (range, 50 to 74) in the Sigma RP-F group preoperatively, and 90.1 (range, 84 to 100) in the LCS group and 89.8 (range, 83 to 100) in the Sigma RP-F group at the final follow-up. The mean preoperative flexion contracture was 6.7° (range, 0° to 10°) in the LCS group and 9.3° (range, 0° to 15°) in the Sigma RP-F group preoperatively. The mean range of motion was 124.6° (range, 105° to 150°) in the LCS group and 126.1° (range, 104° to 145°) in the Sigma RP-F group at the final follow-up. Conclusions: After a minimum duration of follow-up of two years, we found no significant differences between the two groups with regard to the range of knee motion or the clinical or radiographic results. © 2012 by The Korean Orthopaedic Association.

Surgery of primary melanomas

Reconstruction After Skin Cancer

Surgery remains the mainstay of melanoma therapy, regardless of the tumor site. Only the early diagnosis combined with proper surgical therapy currently gives patients affected by this malignancy the chance for a full cure. The main goal of surgical therapy is to provide the local control of the disease and to secure long-term survival of the patient without reasonable functional and esthetic impairment. The recommended method of biopsy-excisional biopsy, as an initial diagnostic and, to some extent, therapeutic procedure-is performed under local anesthesia as an elliptical incision with visual clear margins of 1-3 mm and with some mm of subcutaneous tissue. The extent of radical excision of the primary tumor (or scar after excisional biopsy) is based on the histopathologic characteristics of the primary tumor and usually consists of 1-2 cm margins with primary closure. The philosophy behind conducted randomized clinical trials has been to find the most conservative surgical approach that is able to guarantee the same results as more demolitive treatment. This has been the background of the trials designed to define the correct margins of excision around a primary cutaneous melanoma. Much less definition can be dedicated to the surgical management of patients with non-cutaneous melanomas. © 2010 by the authors; licensee MDPI, Basel, Switzerland.

Exercise therapy for multiple sclerosis

Management of Hip Fractures in the Elderly

BACKGROUND: No intervention has proven effective in modifying long-term disease prognosis in Multiple Sclerosis (MS) but exercise therapy is considered to be an important part of symptomatic and supportive treatment for these patients. OBJECTIVES: To assess the effectiveness of exercise therapy for patients with MS in terms of activities of daily living and health-related quality of life. SEARCH STRATEGY: We searched the Cochrane MS Group Trials Register (searched: March 2004), Cochrane Central Register of Controlled Trials (CENTRAL) "The Cochrane Library Issue 2, 2004", MEDLINE (from 1966 to March 2004), EMBASE (from 1988 to March 2004 ), CINAHL (from 1982 to March 2004), PEDro (from 1999 to March 2004). Manual search in the journal 'Multiple Sclerosis' and screening of the reference lists of identified studies and reviews. We also searched abstracts published in proceedings of conferences. SELECTION CRITERIA: Randomised Controlled Trials (RCTs) that reported on exercise therapy for adults with MS, not presently experiencing an exacerbation; outcomes that include measures of activity limitation or health-related quality of life or both. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and methodological quality of the included trials. Disagreements were resolved by discussion. The results were analysed using a best-evidence synthesis based on methodological quality. MAIN RESULTS: Nine high-methodological-quality RCTs(260 participants) met the inclusion criteria. Six trials focussed on comparison of exercise therapy versus no exercise therapy, whereas three trials compared two interventions that both met our definition of exercise therapy. Best evidence synthesis showed strong evidence in favour of exercise therapy compared to no exercise therapy in terms of muscle power function, exercise tolerance functions and mobility-related activities. Moderate evidence was found for improving mood. No evidence was observed for exercise therapy on fatigue and perception of handicap when compared to no exercise therapy. Finally, no evidence was found that specific exercise therapy programmes were more successful in improving activities and participation than other exercise treatments. No evidence of deleterious effects of exercise therapy was described in included studies. AUTHORS' CONCLUSIONS: The results of the present review suggest that exercise therapy can be beneficial for patients with MS not experiencing an exacerbation. There is an urgent need for consensus on a core set of outcome measures to be used in exercise trials. In addition, these studies should experimentally control for 'dose' of treatment, type of MS and should include sufficient contrast between experimental and control groups. THE IMPACT OF EXCERCISE THERAPY FOR MULTIPLE SCLEROSIS: MS is a chronic disease of the central nervous system. The variable distribution of the damage in the myelin sheath of nerves may lead to loss of strength, sensation, co-ordination and balance causing severe and progressive limitations of function in daily life. To date, there is no effective treatment for MS, however, a number of studies suggest that exercise interventions aimed to improve daily functioning of patients with MS are effective. Nine randomized controlled trials of exercise therapy for MS patients were included in this review six of which used no therapy as the comparator. There was strong evidence in favor of exercise therapy, compared to no therapy, regarding muscle function and mobility while no evidence was found of improved fatigue, in one study only. No one specifically targeted exercise program was more successful than others. No eleterious effects were described in the included studies

Long-term results of revision total hip arthroplasty with improved cementing technique

Management of Hip Fractures in the Elderly

We performed 83 consecutive cemented revision total hip arthroplasties in 77 patients between 1977 and 1983 using improved cementing techniques. One patient (two hips) was lost to follow-up. The remaining 76 patients (81 hips) had an average age at revision of 63.7 years (23 to 89). At the final follow-up 18 hips (22%) had had a reoperation, two (2.5%) for sepsis, three (4%) for dislocation and 13 (16%) for aseptic loosening. The incidence of rerevision for aseptic femoral loosening was 5.4% and for aseptic acetabular loosening 16%. These results confirm that cemented femoral revision is a durable option in revision hip surgery when improved cementing techniques are used, but that cemented acetabular revision is unsatisfactory

The effect of vitamin D receptor and estrogen receptor gene polymorphisms on bone mineral density in healthy and osteoporotic postmenopausal Jordanian women

Management of Hip Fractures in the Elderly

Many studies have reported an association between Vitamin D receptor (VDR) and estrogen receptor (ER) genes polymorphisms and low bone mineral density (BMD). In this report, we present a VDR and ER genotype analysis of case control study performed on postmenopausal Jordanian women. The study composed of 150 osteoporotic women (>-2.0 SD, mean age 62.07, range 54.06-70.08 yrs) and 80 normal healthy postmenopausal women (mean age 60.77, range 53.41-68.13 yrs) with bone density measurement done on lumbar spine and femoral neck. Polymorphisms detected by restriction fragment length polymorphisms (RFLP) using ApaI, BsmI, TaqI & FokI enzymes for vitamin D receptor and PvuII and XbaI for estrogen receptor were investigated. The frequencies of alleles were following Hardy-Weinberg equilibrium and genotype frequency was similar to reported gene frequencies in Caucasian population. BsmI, PvuII and FokI RFLP genotypes showed significant difference at lumbar spine in healthy subjects and in ApaI and XbaI genotypes in patients. Femoral neck T-score showed significant difference in the PvuII and XbaI RFLP genotype in postmenopausal women with symptomatic fractures. Our study further confirms the potential role of ER and VDR polymorphisms in contribution to low BMD in osteoporotic postmenopausal women, a larger study is needed to increase the power of statistics and to show the effect of other candidate genes. (copyright)

Postoperative MR evaluation of chondral repair in the knee

Surgical Management of Osteoarthritis of the Knee CPG

Articular cartilage abnormalities of the knee are a cause of significant patient morbidity. Several surgical techniques have been developed to treat these lesions to improve patient symptoms and to delay or prevent the development of osteoarthritis. MRI has been shown to be an accurate non-invasive test for the evaluation of articular cartilage injuries and for evaluating the postoperative knee following chondral repair. As these surgical repair techniques become more commonly performed, is important for radiologists to be familiar with the surgical techniques and the MRI appearance of the postoperative knee including both normal and abnormal findings. In this article, these chondral repair techniques will be reviewed as well those normal and abnormal MRI findings following these surgeries. (copyright) 2005 Elsevier Ireland Ltd. All rights reserved

Lipopolysaccharide associates with pro-atherogenic lipoproteins in periodontitis patients

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

INTRODUCTION: Periodontitis patients are known to suffer from endotoxemia, which may be among the major risk factors for atherosclerosis. In health, lipopolysaccharide (LPS) is mainly carried with high density lipoprotein (HDL) particles. Shift of LPS toward lipoproteins with lower densities may result in less effective endotoxin scavenging. Our aim was to determine plasma LPS activity and lipoprotein-distribution before and after treatment in periodontitis patients. PATIENTS AND METHODS: Very low and intermediate density (VLDL-IDL), low density (LDL), HDL 2, HDL3, and lipoprotein-deficient plasma (LPDP) were isolated by sequential ultracentrifugation. Patients included 34 subjects aged 53.5 +/- 8.3 years, before and 6 months after periodontal treatment. RESULTS: The mean LPS distribution decreased among lipoprotein classes as follows: VLDL-IDL 41.3 +/- 12.1%, LPDP 25.0 +/- 7.0%, HDL3 13.1 +/- 5.2%, LDL 11.5 +/- 3.7%, and HDL2 9.2 +/- 2.8%. Plasma and VLDL-IDL-associated LPS correlated positively, and LDL- and HDL-associated LPS negatively with clinical periodontal parameters and plasma cytokine concentrations. Mean plasma LPS activity increased after periodontal treatment from 44.0 +/- 17.0 to 55.7 +/- 24.2 EU/ml (P = 0.006). No significant changes were found in LPS lipoprotein distribution and lipoprotein compositions after the treatment. CONCLUSIONS: Endotoxemia increases with severity of periodontitis. In periodontitis, LPS associates preferentially with the pro-atherogenic VLDL-IDL fraction. Periodontal treatment has only minor effects on plasma LPS activity or distribution, which reflects persistence of the disease

The management of failed ankle replacement

Surgical Management of Osteoarthritis of the Knee CPG

Advances in the design of the components for total ankle replacement have led to a resurgence of interest in this procedure. Between January 1999 and December 2004, 16 patients with a failed total ankle replacement were referred to our unit. In the presence of infection, a two-stage salvage procedure was planned. The first involved the removal of the components and the insertion of a cement spacer. Definitive treatment options included hindfoot fusion with a circular frame or amputation. When there was no infection, a one-stage salvage procedure was planned. Options included hindfoot fusion with an intramedullary nail or revision total ankle replacement. When there was suspicion of infection, a percutaneous biopsy was performed. The patients were followed up for a minimum of 12 months. Of the 16 patients, 14 had aseptic loosening, five of whom underwent a revision total ankle replacement and nine a hindfoot fusion. Of the two with infection, one underwent fusion and the other a below-knee amputation. There were no cases of wound breakdown, nonunion or malunion. Management of the failed total ankle replacement should be performed by experienced surgeons and ideally in units where multidisciplinary support is available. Currently, a hindfoot fusion appears to be preferable to a revision total ankle replacement