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Arthroscopic debridement of acute periprosthetic septic arthritis of the knee

Surgical Management of Osteoarthritis of the Knee CPG

PURPOSE: To evaluate the efficacy of a treatment protocol including arthroscopic irrigation and debridement in resolving acute periprosthetic septic arthritis of the knee. TYPE OF STUDY: Retrospective review. METHODS: During a 1-year period, patients presenting with acute septic arthritis of the knee after total knee arthroplasty were screened for suitability for treatment with an arthroscopic debridement protocol consisting of (1) arthroscopic debridement and synovectomy with at least 12 L of antibiotic irrigant, (2) suction drainage until minimum output, (3) repeat arthroscopy for fever persisting beyond 48 hours, and (4) intravenous antibiotics for 6 weeks. Only previously well-functioning arthroplasties presenting within 7 days of symptom onset in patients without immunocompromising factors and with radiographically stable prosthetic components were selected for this treatment protocol. Five knees in 4 patients met the inclusion criteria and were examined clinically and radiographically at minimum 36-month follow-up. RESULTS: The mean follow-up interval was 41 months (range, 36 to 43 months). No knee had been revised or had revision planned for infection, although 1 had undergone tibial insert exchange for polyethylene wear. Follow-up radiographs showed no prosthetic loosening, and Knee Society scores averaged 88 (range, 75-95) in the 4 retained knees, 3 of which were subjectively thought to have returned to their preinfection level of functioning. All knees were infected with a single organism not considered highly virulent. No patients required oral suppressive antibiotics for their knees. CONCLUSIONS: Early aggressive arthroscopic debridement as part of a treatment protocol of acute periprosthetic knee septic arthritis with well-fixed and functioning implants can be an effective treatment option in selected cases. LEVEL OF EVIDENCE: Level IV study (no, or historical control group)

Is the NHANES III Femoral Neck Database Discordant With the Total Hip and Trochanteric Region Databases?

Management of Hip Fractures in the Elderly

The results of dual-energy X-ray absorptiometry (DXA) testing frequently leads to a significant clinical treatment decision, based on T-score or Z-score results. Using the nearly universally accepted World Health Organization (WHO) criteria, which in turn are based on the validity of the population database, a flawed database may lead to an incorrect and deleterious clinical categorization. We have observed that the Hologic National Health and Nutrition Examination Survey III (NHANES III) femoral neck scores are frequently disproportionately low compared with scores in the other major hip regions and that the discordance is statistically significant. Although the WHO now uses the femoral neck T-score (in postmenopausal women and men 50 yr or older), many clinicians still use the lowest (worst) T-score in any 1 of 3 major scan regions-femoral neck, total hip, or lumbar spine-suggesting that patient misclassification may occur, leading to the potential for unnecessary pharmacologic intervention. (copyright) 2009 The International Society for Clinical Densitometry

Undertreatment of osteoporosis in men with hip fracture

Management of Hip Fractures in the Elderly

BACKGROUND: Women are not aggressively treated for osteoporosis after hip fracture; the treatment status of men with hip fracture has not been extensively studied. OBJECTIVE: To evaluate the outcome and treatment status of men with hip fracture. METHODS: Data from medical records were obtained for 363 patients (110 men and 253 women) aged 50 years and older with atraumatic (low-energy) hip fracture who were admitted to St Luke's Episcopal Hospital between January 1, 1996, and December 31, 2000. Surveys were mailed to surviving patients. Main outcome variables were osteoporosis treatments (antiresorptive or calcium and vitamin D) at hospital discharge, current osteoporosis treatments at 1- to 5-year follow-up, bone mineral density testing, mortality, current disability, and living arrangements (home or institution). RESULTS: The mean age for men was 80 years vs 81 years for women. Most fractures (89% for men and 93% for women) resulted from falls from a standing height. At hospital discharge, 4.5% of men (n = 5) had treatment of any kind for osteoporosis, compared with 27% of women (n = 69) (P<.001). The 12-month mortality was 32% in men, compared with 17% in women (P =.003). Surveys were usable from 168 (87%) of 194 survivors. At 1- to 5-year follow-up, 27% (12/44) of men were taking treatment of any kind for osteoporosis, compared with 71% (88/124) of women (P<.001). Of those treated, 67% (8/12) of men and 32% (28/88) of women were taking calcium and vitamin D only. At 1- to 5-year follow-up, 11% of men had a bone mineral density measurement, compared with 27% of women. After hospital discharge, the number of men and women who required wheelchairs, walkers, and canes and who lived in institutions increased significantly. CONCLUSIONS: The burden of hip fracture is illustrated by the high incidence of postfracture disability and the high mortality rate in both men and women. Nevertheless, few men receive antiresorptive treatment

Survivorship analysis of hemiarthroplasties

Management of Hip Fractures in the Elderly

From 1976 until 1988, 679 hemiarthroplasties were inserted for displaced femoral neck fractures. Two hundred two were of the Austin Moore design (one-piece, noncemented), 209 of the Christiansen design (trunion bearing, cemented), and 268 of the Hastings design (bipolar, cemented). Five years after the hemiarthroplasty, the cumulative proportion of prostheses surviving was 90%, declining to 85% after ten years. A survivorship analysis indicated that the cemented bipolar Hastings prosthesis and old age (75 years or older) were two variables associated with significantly less failures. The survivorship analysis did not indicate that the group differences were influenced by improvements in surgical techniques over time. Gender and social setting had no influence on the survival of prostheses. Cemented bipolar hemiarthroplasty should be considered as an alternative in the internal fixation of displaced femoral neck fractures in the elderly

Pre-emptive injection of peri-articular-multimodal drug for post-operative pain management in total knee arthroplasty: a double-blind randomized clinical trial

OAK 3 - Non-arthroplasty tx of OAK

Purpose: Severe post-operative pain is one of the main problems after total knee arthroplasty. In this study, we investigated the effect of a peri-articular multimodal drugs injections pre-emptively on post-operative pain control and knee functions following total knee arthroplasty. Methods and materials: This study was a double-blind randomized clinical trial. Eligible cases including 137 patientsâ??aged 30 to 80 years oldâ??were randomly divided into one of two groups: the drug group received a cocktail consisting of bupivacaine hydrochloride, morphine sulphate, epinephrine, and ketorolac. The control group received epinephrine only. The injections were given 15 minutes before incision. Joint range of motion (ROM) and the severity of pain by using visual analog scale (VAS) of 1 to 10 and patientâ??s facial expression, were assessed in the pre-operative visit, after 24 hours, 48 hours, and six weeks after operation. Knee Society score (KSS) was recorded before the operation, six weeks, and six months after the operation for each patient. Results: The data of VAS showed no significant difference between the groups before operation but there was statistically significant difference between the two groups at 24 hours, 48 hours, and six weeks after the operation. In KSS, difference was not significant between the two groups before the operation and six months after surgery while our results showed a statistically significant difference between groups six weeks after the operation. In ROM, there was no significant difference between the groups before operation. There was a statistically significant difference between the two groups at 24 hours, 48 hours and six weeks after the operation. Complications were recorded at six weeks after surgery. Conclusion: Peri-articular multimodal injection including bupivacaine, morphine, and ketorolac preferably with pre-emptive injection method provided proper post-operative pain relief, less opioid consumption, and better early rehabilitation following TKA at 48 hours after surgery. Level of study: Level I.

The effects of strengthening, neuromuscular and lumbopelvic stabilization exercises on strength, physical function and symptoms in men with mild knee osteoarthritis: A pilot study

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To investigate the effects of strengthening, neuromuscular and lumbopelvic stabilization exercises on strength, symptoms and physical function in men with mild knee osteoarthritis. METHODS: A total of 17 men with mild knee osteoarthritis participated in this study. Subjects underwent clinical and radiographic examinations and isokinetic strength evaluations and completed the Western Ontario & McMaster Universities questionnaire before and after an intervention program comprising strengthening, neuromuscular and lumbopelvic stabilization exercises twice per week for eight weeks. RESULTS: After the intervention program, subjects exhibited significant reductions in pain (P = 0.009), improvements in physical function (P = 0.015) and quadriceps and hip abductor strength. There was no change in hamstring and hip adductor strength or stiffness after the intervention program. CONCLUSIONS: An eight-week supervised exercise therapy program comprising strengthening, neuromuscular and lumbopelvic stabilization exercises may help reduce muscle weakness, pain and disability in men with early knee osteoarthritis.

Surgical Site Infections after Open Reduction Internal Fixation for Trauma in Low and Middle Human Development Index Countries: A Systematic Review

DoD SSI (Surgical Site Infections)

BACKGROUND: Musculoskeletal trauma represents a large source of morbidity in low and middle human development index countries (LMHDICs). Open reduction and internal fixation (ORIF) of traumatic long bone fractures definitively manages these injuries and restores function when conducted safely and effectively. Surgical site infections (SSIs) are a common complication of operative fracture fixation, although the risks of infection are ill-defined in LMHDIC. PATIENTS AND METHODS: This study reviewed systematically all studies describing SSI after ORIF in LMDHICs. Studies were reviewed based on their qualitative characteristics, after which a quantitative synthesis of weighted pooled infection rates based on available patient-level data was performed to estimate published incidence of SSI. RESULTS: Forty-two studies met criteria for qualitative review and 32 studies comprising 3,084 operations were included in the quantitative analysis. Among 3,084 operations, the weighted pooled SSI rate was 6.4 infections per 100 procedures (95% confidence interval [CI] 4.6-8.2 infections per 100 procedures). Higher rates of infection were noted among the sub-group of open fractures (95% CI 13.9-23.0 infections per 100 procedures). Lower extremity injuries and procedures utilizing intra-medullary nails also had slightly higher rates of infection versus upper extremity procedures and other fixation devices. CONCLUSIONS: Reported rates of SSI after ORIF are higher in LMHDICs, and may be driven by high rates of infection in the sub-group of open fractures. This study provides a baseline SSI rate obtained from literature produced from LMHDICs. Infection rates are highly dependent on fracture sub-types.

Imaging of the pharynx and larynx

Reconstruction After Skin Cancer

Imaging of the pharynx and larynx forms an integral part of head and neck radiology. This article attempts to provide a basic understanding and overview of the cross sectional anatomy, techniques and common pathologies affecting the pharynx and larynx. The emphasis is on squamous cell carcinoma, which comprises a major part of the imaging workload. Local staging and patterns of tumour spread are discussed using illustrations and tables. © 2007 The British Institute of Radiology.

Relationship between 99Tcm-MDP uptake and bone mineral density in patients with prostatic carcinoma

MSTS 2018 - Femur Mets and MM

Seventeen men with prostatic carcinoma were investigated with quantitative bone scintigraphy and quantitative computed X-ray tomography before orchiectomy and up to 6 months after this operation. The uptake of 99Tcm-labelled methylene disphosphonate (99Tcm-MDP) and bone mineral density (BMD) were determined for each vertebra from Th10 to L4. Ten patients had normal scintigrams. No change in MDP uptake or BMD was seen after 6 months in these patients. Of the seven patients with abnormal scintigrams, one patient had a clinical sign of progression with an increase in both MDP uptake and BMD. The remaining six patients showed stable or improved clinical status. For their abnormal vertebrae a decrease in MDP uptake was seen, while BMD varied in different ways after 6 months. For the normal vertebrae in these patients with metastatic involvement, no change in MDP uptake was seen. However, the BMD values showed a decrease, indicating a generalized increase in bone resorption at sites distant from the metastases.

Delayed/non-union of upper limb fractures with bisphosphonates: systematic review and recommendations

Distal Radius Fractures

BACKGROUND: Bisphosphonates (BPs) are widely used for the treatment of osteoporosis. Oversuppression of bone turnover with BPs may paradoxically limit the reserve capacity of bone to heal. The aim of this review was to study the predisposition of some patients to delayed/non-union of upper limb fractures associated with BPs and give recommendations on how they should be treated. METHODS: A systematic search of two electronic databases was conducted to identify relevant studies for inclusion. All relevant studies found were included and assessed through methodology criteria predetermined by two independent reviewers. RESULTS: Six papers comprising of three case reports, one nested case control study, one restrospective review and one randomized clinical trial were used. In comparative studies of pre-fracture BP use, a 6-day delay in average healing times was reported among BP users. There was no elevation in risk of non-union. Post-fracture BP use was associated with an approximate doubling of the risk of non-union. Timing of BP therapy initiation following a fracture was not associated with a difference in healing times. An atypical ulna fracture treated conservatively resulted in non-union, there was no effect of type of surgical treatment on distal radius fracture healing and there was insufficient evidence to comment on humeral fracture treatment. CONCLUSIONS: Differences in union time between BP users and non-users are not significant enough to change current practice patterns and do not outweigh the benefits of BP therapy. There is no evidence to encourage early surgical management of BP-related upper limb fractures.

Volar locking plate fixation of distal radius fractures: use of an intra-operative 'carpal shoot through' view to identify dorsal compartment and distal radioulnar joint screw penetration

Distal Radius Fractures

INTRODUCTION: We report our experience using a 'carpal shoot through' view of the distal radius to identify dorsal compartment screw penetration intra-operatively when performing volar plating of the distal radius. METHODS: A prospective study of 42 patients (mean age 56 years) with acute distal radius fractures treated with open reduction internal fixation was undertaken. Surgical fixation was performed using a volar locking plate in all patients. After plate application, inclined posteroanterior and lateral radiographs were taken followed by the carpal shoot through view. RESULTS: In six cases (14 %), the carpal shoot through view revealed dorsal screw protrusion, which was not detectable on standard PA and lateral views. In one case, a screw had penetrated the distal radioulnar joint (DRUJ), which was only apparent on the shoot through view. The overall screw exchange rate was 17 %. CONCLUSIONS: Using the hand and carpus to minimise the contrast in X-ray penetration, the dorsal cortex of the distal radius may be imaged intra-operatively and dorsal compartment screw penetration detected in cases with significant multifragmentation when screw measurement is difficult. This view potentially reduces the risk of post-operative pain and extensor tendon injury and also provides excellent visualisation of the DRUJ.

Genetic determination of bone mineral density: Evidence for a major gene

Management of Hip Fractures in the Elderly

This study was designed to test the hypothesis of a major gene influence on the variation in bone mineral density (BMD). BMD and bone mineral content at the lumbar spine and femoral neck were measured in 330 men and 413 women, aged 18-90 yr, from 107 nuclear and complex families (including 5 large pedigrees with 194 individuals who were identified through an index case with moderately high BMD at the femoral neck (z-score, (greater-than or equal to)1.28)). After adjusting for age and body weight, familial factors accounted for up to 72% of the total variation in BMD. In complex segregation analysis, for all variables examined the best-fitting most parsimonious model consistently suggested the Mendelian transmission of a major gene locus with significant residual correlations among siblings. This genetic model suggested that the proportion of a total variance (adjusted for significant covariates) attributable to a putative major gene effect ranged between 0.30 (plus or minus) 0.09 for femoral neck BMD and 0.53 (plus or minus) 0.07 for the principal component obtained on BMD and corresponding bone mineral content measures. These findings clearly support the hypothesis that a large component of the variance in BMD is under genetic control, with strong evidence for a major gene locus influencing BMD transmission

Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

OBJECTIVES: To compare the clinical and radiographic results for locked intramedullary (IM) nails and plates used in the treatment of humeral diaphyseal fractures. DESIGN: Prospective randomization by sealed-envelope technique of eighty-four patients into two study groups: those treated by intramedullary nailing (IMN group; n = 38) and those treated by compression plating (PLT group; n = 46). SETTING: Patients admitted consecutively to a university-affiliated Level I trauma center. PATIENT/PARTICIPANTS: All skeletally mature patients admitted to Harborview Medical Center with acute humeral shaft fractures requiring surgical stabilization. Fractures of the diaphysis were defined as being at least three centimeters distal to the surgical neck and at least five centimeters proximal to the olecranon fossa. INTERVENTION: Treatment with locking antegrade intramedullary humeral nails (Russell-Taylor design [Smith and Nephew Richards]) or with 4.5-millimeter dynamic compression and limited contact dynamic compression plates (AO design [Synthes]). MAIN OUTCOME MEASUREMENTS: Clinical outcome measurements included fracture healing, radial nerve recovery, infection, and elbow and shoulder discomfort. Radiographic measurements included fracture alignment, time to healing, delayed union, and nonunion. RESULTS: Follow-up averaged thirteen months. Forty-two fractures (93 percent) in the PLT group were healed by sixteen weeks versus thirty-three fractures (87 percent) in the IMN group (p = 0.70). Shoulder pain and a decrement in shoulder range of motion (ROM) were significant associations with IMN (p = 0.007 for both variables) but not with PLT. A decrement in elbow ROM was significantly associated with PLT (p = 0.03), especially for fractures of the distal third of the diaphysis, whereas elbow pain was not (p = 0.123). The sum of other complications demonstrated nearly equal prevalence for both treatment groups. CONCLUSIONS: For patients requiring surgical treatment of a humeral shaft fracture, intramedullary nailing and compression plating both provide predictable methods for achieving fracture stabilization and ultimate healing

Trends in arthroscopy-documented cartilage injuries of the knee and repair procedures among 15-60-year-old patients

OAK 3 - Non-arthroplasty tx of OAK

We validated a registry-based method of identifying patients with knee cartilage injury and estimated temporal changes in the incidence of arthroscopy-documented cartilage injuries of the knee and the proportion leading to repair procedures in Denmark. After excluding patients with diagnosed osteoarthritis, we identified 21,392 patients aged 15-60 years with a first recorded procedure code indicating knee cartilage injury in the Danish National Registry of Patients (DNRP) from 1996 to 2011. Using the surgical descriptions of arthroscopy findings in medical records as gold standard, the positive and negative predictive value of procedure codes for knee cartilage injury was 88% and 99%, respectively. The arthroscopy-documented overall incidence of cartilage injury of the knee was 40/100,000 person-years (py) [95% confidence interval (CI): 39.5-40.6] during the period 1996-2011. The arthroscopy-documented age-standardized annual incidence of knee cartilage injury increased from 22 (95% CI: 20.5-23.7) in 1996 to 61 (95% CI: 58.7-64.0) in 2011, per 100,000 py. An increase occurred in all age groups and both sexes. Only 1/6 (17%) patients with knee cartilage injury had a repair procedure. The validity of procedure codes for knee cartilage injury in the DNRP is high. The arthroscopy-documented incidence of knee cartilage injuries increased substantially during the 15-year period.

Acute limb ischaemia

DOD - Acute Comp Syndrome CPG

� Clinical assessment is essential before imaging. � Patients with motor or significant sensory loss need immediate surgical intervention without delay for imaging. � There is no evidence of significant difference in clinical outcome for any of the different thrombolysis techniques. � Mechanical thrombectomy may debulk thrombus but adjuvant lysis is often required. � Percutaneous aspiration can be useful to treat distal embolus. © 2004 The British Institute of Radiology.

Rheumatologic manifestations of hepatic diseases

MSTS 2018 - Femur Mets and MM

A possible link is suggested between hepatic diseases and rheumatic disease. Polyarthralgia and polyarthritis may be seen during the prodromal period of acute viral hepatitis, especially in hepatitis B virus (HBV). The symptoms of arthritis, mild, localized or generalized, mostly involve the small joints of hands. Joint symptoms frequently precede the onset of jaundice, no residual joint deformities. Circulating immune complexes are believed to play a causative role in the development of vasculitis and arthritis. Hemochromatosis is an antosomal recessive disorder of iron. About 43%-81% of patients with hemochromatosis have arthritis. The common extrahepatic manifestations of autoimmume hepatitis are arthralgia and skin rash. The reported prevalence of symptomatic inflammatory arthropathy in patients with primary biliary cirrhosis ranges from 4% to 50%. Skeletal involvement with Wilson's disease is common. Such patients may complain of pain and stiffness, mainly in the knee, wrist, or other large joints. Shwachman's syndrome is a disorder of pancreatic exocrine. Symmetric bone lesions have been reported in 10% to 15% of patients. They are involved predominantly at the femoral neck. Rheumatic symptoms are seen in one third of adult patients with cystic fibrosis and arthritis in 2.5% to 12% of patients. The arthritis caused by pancreatic panniculitis is usually symmetrical and involves the small joints of the hand, wrist, and feet, but may involve such larger joints as the elbow, ankle, and knee.

No evidence of infection after retrograde nailing of supracondylar femur fracture in gunshot wounds

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

BACKGROUND: The aim of the study was to determine whether osteomyelitis of the femur or septic arthritis of the knee develops after retrograde intramedullary nailing of the femur performed within 7 days of supracondylar femur fracture, secondary to gunshot wounds, without skin defects. METHODS: Fifteen patients with a mean age of 27.8 years (range, 18-52 years), with supracondylar fractures of the femur due to gunshot wounds and without skin defects. Retrograde intramedullary nails were inserted through the intercondylar notch of the femur. We evaluated whether osteomyelitis of the femur or ipsilateral septic arthritis of the knee joint developed postoperatively. RESULTS: None of the patients who were followed up for a mean period of 11.7 months (range, 9-16 months) showed evidence of ipsilateral septic arthritis of the knee or osteomyelitis of the femur. CONCLUSION: Retrograde intramedullary nailing of the femur can be performed in patients with supracondylar fractures of the femur due to gunshot wounds, and without skin defects, in the first 7 days after the trauma. Neither osteomyelitis of the femur nor septic arthritis of the knee develops in these patients

Postarthroscopy osteonecrosis of the knee

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: Spontaneous subchondral osteonecrosis of the knee joint confined to a localized area of one condyle can occur after arthroscopic procedures. Meniscal tears, arthroscopic meniscectomy, and radiofrequency chondroplasty are aetiological factors in the development of osteonecrosis. The aim of this study was to investigate whether the incidence of osteonecrosis increased when mechanical or radiofrequency chondroplasty was used in conjunction with arthroscopic meniscectomy. METHODS: In this prospective clinical trial, arthroscopic meniscectomy was the primary treatment in 75 patients (mean age 40 +/- 13) with stage II and III degenerative changes on the articular cartilage. Patients had to meet the following criteria: 1) have preoperative MRI and plain film radiographs showing no evidence of osteonecrosis; 2) be symptomatic for at least 6 weeks before the preoperative MRI; and 3) have arthroscopically confirmed stage II or III chondral lesion. A preoperative MRI was performed for all patients. For treatment of chondral lesions, debridement with a shaver or chondroplasty with a monopolar RF energy system was used. Patients were divided into three treatment groups. Partial meniscectomy of the medial or lateral (or both) menisci was performed on all patients, but patients in group 2 additionally received mechanical debridement of the chondral lesion, and those in group 3 were additionally treated with RF chondroplasty. Patients in group 1 were treated with partial meniscectomy alone. Patients were re-examined after 6 months, at which time a repeat MRI was performed. RESULTS: Development of osteonecrosis was detected during the postoperative MRIs of five patients: two in group 1, two in group 2, and one in group 3. CONCLUSION: The addition of mechanical or RF chondroplasty to meniscectomy did not increase the number of patients with osteonecrosis. Also, RF chondroplasty, which is commonly proposed to be an aetiological factor, resulted in a decrease in the number of patients that developed osteonecrosis. Level of evidence: Ii.

Is a femoral component applicator useful in total knee replacement?

Surgical Management of Osteoarthritis of the Knee CPG

The benefit of using an applicator to insert the femoral component during total knee arthroplasty in preventing flexion of the femoral component in the sagittal angle was evaluated in a prospective, consecutive, single-surgeon series. In group I (60 knee replacements) the applicator was used. In group II (64 knees) the femoral component was implanted without an applicator. In all these cases, the femoral cuts were precisely done using cutting blocks. Postoperative X-rays were studied to evaluate the flexion angle of the femoral component in the sagittal plane. Alpha, beta and peg angles of the two groups were compared. It was found that in the group where the applicator was used, there were a slightly higher proportion of patients with values lying within the mean values (two-tailed P value of 0.0009). Our study statistically confirmed that the use of an applicator during femoral component insertion does significantly decrease the incidence of tilt of the femoral component in the sagittal angle

Daily and intermittent oral ibandronate normalize bone turnover and provide significant reduction in vertebral fracture risk: results from the BONE study

Management of Hip Fractures in the Elderly

Increasing evidence suggests that a high rate of bone turnover is associated with low bone mineral density (BMD) and is strongly linked to fracture risk. Measurement of biochemical markers of bone turnover is therefore becoming a more widely used endpoint in clinical trials in postmenopausal osteoporosis. This multinational double-blind, fracture-prevention study enrolled 2946 postmenopausal women with osteoporosis. Patients were randomized to receive placebo or oral ibandronate administered daily (2.5 mg/day) or intermittently (20 mg every other day for 12 doses every 3 months). The primary endpoint was the incidence of new vertebral fractures after 3 years. Secondary outcome measures included changes in the rate of bone turnover as assessed by biochemical markers and increases in spinal and hip BMD. Daily and intermittent oral ibandronate significantly reduced the risk of vertebral fractures by 62% and 50%, respectively, and produced significant and sustained reductions in all the measured biochemical markers of bone turnover. By 3 months, the rate of bone turnover was reduced by approximately 50-60%, and this level of suppression was sustained throughout the remainder of the study. In summary, oral ibandronate, given daily or with a between-dose interval of >2 months, normalizes the rate of bone turnover, provides significant increases in BMD and a marked reduction in the incidence of vertebral fractures. Thus, intermittent ibandronate has potential to become an important alternative to currently licensed bisphosphonates in postmenopausal osteoporosis

Chondroblastoma in pelvis and extremities- a signle centre study of 177 cases

MSTS 2022 - Metastatic Disease of the Humerus

Introduction: Chondroblastoma is a rare benign bone tumour that usually occurs in children and young adults. They are cartilaginous tumours arising in the epiphysis or apophysis of a long bone. The tumour is classified as benign, although rare cases of pulmonary metastases have been reported. The aims of this study were to describe clinical, radiographic characteristics of chondroblastoma; to analyse the local recurrence rate and complications associated with surgery. Material and methods: This retrospective study included 177 patients, who had been diagnosed with a chondroblastoma in extremity between 1990 and 2015. Results: The most common site was proximal tibia 20%, followed by proximal humerus 19%, proximal femur 18%, distal femur 16% and foot 15%. One patient has died of the disease and one patient is alive after being operated for lung metastases. There was local recurrence in 25/177 (14%) patients. The median time to local recurrence was 10 months (range 3-158 months). The most common site for local recurrence was proximal tibia (22.2%). The proximal femur was the location in 32/178 (18%) of the cases. 18/32 (56%) were in the greater trochanter and 14/32 (44%) in the femoral head. The mean age was lower in tumours located in femoral head when compared to the greater trochanter; 19.5 years and 13.9 years respectively (p==0.004). Tumours located in greater trochanter were all curetted without further complications. Local recurrence was seen more often in femoral head tumours, though without statistical significance; 3/14 (21%) and none, respectively (p==0.073). Conclusions: Chondroblastoma is a rare benign to intermediate grade bone tumour with a potential to metastasise. Femoral head chondroblastoma is rare, presenting 4.5% of all chondroblastoma cases. Around 50% of the chondroblastoma in femoral head. occur in patients with open growth plates.

Postoperative chemoradiotherapy and cetuximab for high-risk squamous cell carcinoma of the head and neck: radiation Therapy Oncology Group RTOG-0234

Reconstruction After Skin Cancer

PATIENTS AND METHODS: Eligibility required pathologic stage III to IV SCCHN with gross total resection showing positive margins and/or extracapsular nodal extension and/or two or more nodal metastases. Patients were randomly assigned to 60 Gy radiation with cetuximab once per week plus either cisplatin 30 mg/m(2) or docetaxel 15 mg/m(2) once per week.RESULTS: Between April 2004 and December 2006, 238 patients were enrolled. With a median follow-up of 4.4 years, 2-year overall survival (OS) was 69% for the cisplatin arm and 79% for the docetaxel arm; 2-year disease-free survival (DFS) was 57% and 66%, respectively. Patients with p16-positive oropharynx tumors showed markedly improved survival outcome relative to patients with p16-negative oropharynx tumors. Grade 3 to 4 myelosuppression was observed in 28% of patients in the cisplatin arm and 14% in the docetaxel arm; mucositis was observed in 56% and 54%, respectively. DFS in this study was compared with that in the chemoradiotherapy arm of the RTOG-9501 trial (Phase III Intergroup Trial of Surgery Followed by Radiotherapy Versus Radiochemotherapy for Resectable High Risk Squamous Cell Carcinoma of the Head and Neck), which had a hazard ratio of 0.76 for the cisplatin arm versus control (P = .05) and 0.69 for the docetaxel arm versus control (P = .01), reflecting absolute improvement in 2-year DFS of 2.5% and 11.1%, respectively.CONCLUSION: The delivery of postoperative chemoradiotherapy and cetuximab to patients with SCCHN is feasible and tolerated with predictable toxicity. The docetaxel regimen shows favorable outcome with improved DFS and OS relative to historical controls and has commenced formal testing in a phase II/III trial.PURPOSE: To report results of a randomized phase II trial (Radiation Therapy Oncology Group RTOG-0234) examining concurrent chemoradiotherapy and cetuximab in the postoperative treatment of patients with squamous cell carcinoma of the head and neck (SCCHN) with high-risk pathologic features.

Prospective Randomized Trial of Dermabond Prineo in Total Knee Arthroplasty

AAHKS (2) Corticosteroids

The DERMABOND PRINEO (Ethicon, Johnson and Johnson, Somerville, New Jersey) system is a unique two�part skin closure system that consists of: a 2�octyl cyanoacrylate topical skin adhesive for proven strength and microbial protection in vitro, and a flexible, self�adhesive polyester mesh for excellent approximation and healing. It is aimed to add strength and protection when closing medium to long incisions. In addition, it is designed to replace the use of subcuticular sutures or staples, with greater holding strength, with the potential to reduce skin closure time. Various studies have evaluated the outcomes of different closure devices, however, there are no reports assessing the length of closure times using DERMABOND PRINEO (Ethicon, Johnson and Johnson, Somerville, New Jersey) Knotless Tissue Control Devices during superficial closure in orthopaedic surgery. Huemer et al. (1) performed an observational study of 180 patients who had 224 excisional body�contouring surgeries utilizing Dermabond Prineo for superficial closure. Authors concluded that this closure type enables the surgeon to perform a quick and smooth skin closure. However, 4 patients (1.8%) developed local allergic reactions, which necessitated early removal and topical corticosteroid treatment. Parvizi et al.(2) performed an open, prospective, randomized clinical study of superficial wound closure on 60 patients undergoing abdominoplasty with either Dermabond Prineo or conventional superficial closure. They found significantly lower price ($134.79 cheaper) and significantly better Hollander Cosmesis Scale scores in Dermabond Prineo cohort. In addition, there was a significantly better cosmetic outcome at 6 and 12 months after surgery. The use of Dermabond Prineo may be able to decrease operative time and costs in other surgical fields, such as orthopedics. Careful patient allergy history is necessary to avoid adhesive allergic reactions.

The effects of radioisotope therapy and radiotherapy in subjects with breast cancer with bone metastases

MSTS 2018 - Femur Mets and MM

Background: Metastatic bone disease is found in 80-90% of patients examined after death and is a serious problem in everyday practice. The aim of the study was the evaluation of the survival time of patients with bone metastases in relation to the prognostic group and applied treatment. Material and Methods: The authors analyzed 84 patients treated in the Radiotherapy Division of Lower Silesian Oncology Centre during the years 1997-2004, Radioisotope treatment was conducted in the Department of Nuclear Medicine of the 4th Military Clinical Hospital in WrocÅ?aw. The average age of the patients was 53.1 years, The women differed in staging at the moment of diagnosis. The patients were divided into two groups with different clinical prognoses. In addition to systemic treatment (biphosphonates, chemotherapy or hormonotherapy), 32 (38,1%) patients were treated with teletherapy and 20 (23.8%) underwent radioisotope therapy. In 32 (38.1%) patients both methods were applied. The analysis of results included the estimation of overall survival (OS) meaning the time of survival from the onset of disease to one of the end points. End points of the observation were defined by the authors as the patient's death or last control visit. The Kaplan-Meier method was used. Results: The outcomes of the observation are closely connected with particular prognostic groups. The Kaplan-Meier's diagrams presented here indicate that teletherapy combined with radioisotope therapy was the most beneficial for the patients with metastases in bones and other organs. Conclusions: The best effects of the treatment measured by overall survival were obtained with combined treatment: radiotherapy and radioisotopes, in the group with bone and extra-skeletal metastases. Copyright © 2006 Via Medica.

Compartment syndrome in infants and toddlers

DOD - Acute Comp Syndrome CPG

PURPOSE: To study the cause, diagnosis, treatment and outcome of acute compartment syndrome in infants and toddlers aged <3 years. METHODS: Fifteen patients aged <3 years with acute compartment syndrome were identified from two large pediatric trauma centers over a fifteen-year period. All children underwent fasciotomy. The mechanism of injury, time of injury, time to diagnosis, compartment pressures, time to fasciotomy, and outcome at the time of the latest follow-up were recorded. RESULTS: Nine (60 %) of fifteen patients developed compartment syndrome secondary to trauma, four (4/15, 27 %) due to infection, and two (2/15, 13 %) due to intravenous infiltration. The average time from injury or hospital admission to fasciotomy was 31.8 h (range 2.9-136.3 h). In general, the functional outcome was excellent at the latest follow-up with thirteen (13/15, 87 %) patients having an excellent outcome. No cases of Volkmann's ischemia were noted at the time of fasciotomy, even when performed as late as 5 days after injury. CONCLUSIONS: Compared to the general pediatric population, the diagnosis of compartment syndrome in infants and toddlers may be further delayed, i.e., >24 h after injury. Despite delays in diagnosis and time to treatment, the present study shows that outcomes in infants and toddlers remain favorable even when fasciotomy is performed 48-72 h after injury. LEVEL OF EVIDENCE: Case series, level IV.

Eleven-year implant survival rates of the all-polyethylene and metal-backed modular Optetrak posterior stabilized knee in bilateral simultaneous cases

Surgical Management of Osteoarthritis of the Knee CPG

A prospective randomized study was conducted to determine if a design change in the articular surface geometry introduced in the Optetrak total knee to increase prosthetic joint conformity and further reduce polyethylene stress had any impact on implant survival, particularly when the all-polyethylene version of the implant was used. Forty-seven patients undergoing bilateral simultaneous total knee arthroplasties were randomized for the side, receiving an all-polyethylene tibial component and followed up for a mean 11.6 years. Survival rates for the all-polyethylene and metal-backed modular versions of the implant were both 98%, excluding a single case of deep infection. Survival rates with revision for aseptic loosening as an end point were 100%. The increase in tibial and femoral radii in the coronal plane of the Optetrak posterior stabilized knee did not result in a reduced implant survival rate in either the metal-backed modular or all-polyethylene versions of the implant

Titanium elastic nailing radius and ulna fractures in adolescents

Distal Radius Fractures

Over the last 40 years, anatomic reduction with plate stabilization has become the standard in adult patients with diaphyseal fractures of the radius and ulna. When operative fixation has been indicated in skeletally immature patients with these fractures, a variety of techniques have been reported, with intramedullary fixation becoming increasingly accepted. There is currently significant variability in the treatment of adolescents with forearm fractures. The purpose of this study was to investigate the clinical and radiographic outcomes in the adolescent population after intramedullary fixation of both bone forearm fractures. A retrospective review identified 32 patients 12-18 years of age who had undergone intramedullary fixation of both forearm bones in the past 20 years at our institution. Galeazzi, Monteggia, radial head, and distal metaphyseal fractures were excluded. Radiographic evaluation was performed to determine union and postoperative radial bow. Clinical follow-up was carried out for postoperative complications and range of motion of the wrist, forearm, and elbow. The mean age of the patients was 14.1 years. A total of 19 fractures were closed injuries, nine were grade 1, three were grade 2, and one fracture was a grade 3b. Of the patients, 15.6% had limited postoperative range of motion. All patients in the older age group, 15-18 years of age, had a normal range of motion. A decrease in radial bow was not associated with limitation in motion. There was a 98% union rate, and all unions occurred by 7.5 months. Only three major complications occurred, two refractures and one ulnar hardware migration, and subsequent radius nonunion occurred in the one grade 3b injury. Flexible intramedullary nailing of both bone forearm fractures provides reliable bony union and excellent postoperative clinical results in adolescents. Level of evidence, IV. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.

A review of the factors influencing antimicrobial prescribing

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

There are multiple benefits of appropriate antimicrobial prescribing: it has a direct impact on clinical outcomes, avoids adverse effects, is cost effective and, perhaps most importantly, it helps to prevent the emergence of resistance. However, any physician can prescribe antibiotics, which is not the case with other clinically relevant drugs. There is great variability in the prescribing physician's (PP) training, motivation, workload and setting, including accessibility to infectious diseases consultants and/or diagnostic techniques, and therefore there is a high risk of inappropriate prescription. Many antibiotic prescribing errors occur around the selection and duration of treatment. This includes a low threshold for the indication of antibiotics, delayed initiation of treatment when indicated, limited knowledge of local antimicrobial resistance patterns by the PPs, errors in the final choice of dose, route or drug and a lack of de-escalation. Similarly, the prescription of prophylactic antibiotics to prevent surgical site infections, despite being commonly accepted, is suboptimal. Factors that may explain suboptimal use are related to the absence of well-defined protocols, poor knowledge of prophylactic protocols, miscommunication or disagreement between physicians, logistical problems, and a lack of audits. A proper understanding of the prescribing process can guide interventions to improve the PP's practices. Some of the potential interventions included in a stewardship program are education in antimicrobial prescribing, information on the local resistance patterns and accessibility to a qualified infectious diseases consultant

Normal values for trabecular and cortical bone in the radius measured by computed tomography

Distal Radius Fractures

Quantities related to the amount of trabecular bone in the distal radius and cortical bone in the radius mid-shaft have been measured in 262 normal adults of both sexes aged 21-89 years by computed tomography (CT). A special-purpose CT system (ISOTOM) which incorporated a source of 125I (29 keV) was used to make the measurements. The relationships between these quantities and age, weight, height and surface area have been evaluated, and the results have been used to draw conclusions on the significance of values measured in female patients with osteoporosis, Colles' fracture of the wrist and generalised osteoarthritis.

Osteochondritis dissecans of the knee: a practical guide for surgeons

OAK 3 - Non-arthroplasty tx of OAK

UNLABELLED: Osteochondritis Dissecans (OCD) is a condition for which the aetiology remains unknown. It affects subchondral bone and secondarily its overlying cartilage and is mostly found in the knee. It can occur in adults, but is generally identified when growth remains, when it is referred to as juvenile OCD. As the condition progresses, the affected subchondral bone separates from adjacent healthy bone, and can lead to demarcation and separation of its associated articular cartilage. Any symptoms which arise relate to the stage of the disease. Early disease without separation of the lesion results in pain. Separation of the lesion leads to mechanical symptoms and swelling and, in advanced cases, the formation of loose bodies. Early identification of OCD is essential as untreated OCD can lead to the premature degeneration of the joint, whereas appropriate treatment can halt the disease process and lead to healing. Establishing the stability of the lesion is a key part of providing the correct treatment. Stable lesions, particularly in juvenile patients, have greater propensity to heal with non-surgical treatment, whereas unstable or displaced lesions usually require surgical management. This article discusses the aetiology, clinical presentation and prognosis of OCD in the knee. It presents an algorithm for treatment, which aims to promote healing of native hyaline cartilage and to ensure joint congruity. TAKE HOME MESSAGE: Although there is no clear consensus as to the best treatment of OCD, every attempt should be made to retain the osteochondral fragment when possible as, with a careful surgical technique, there is potential for healing even in chronic lesions Cite this article: Bone Joint J 2016;98-B:723-9.

Leg strength and hip fracture morbidity - Results of 4 separate case studies

Management of Hip Fractures in the Elderly

The purpose is to examine the importance of ipsilateral leg strength in mediating hip fracture disability. Leg strength measures were recorded and analyzed for 4 separate data sets: (1) 35 patients hospitalized for acute hip fractures; (2) 72 hip replacement surgical candidates with prior hip fracture histories; (3) 30 hip fracture patients followed prospectively for six months after hospital discharge; (4) 23 hip fracture cases interviewed two years after hospital discharge. (1) 78% of patients with acute hip fracture exhibited leg weakness on the injured side, and 41% exhibited knee extensor muscle weakness on the injured side; (2) 79% of patients readmitted for hip surgery, had deficient muscle power of the previously fractured leg and 33% had specific evidence of knee extensor weakness; (3) Interlimb knee extensor strength differentials greater than 10%, more commonly due to strength deficits on the injured side than the uninjured side, were present in 80% of cases examined six months post surgery, and affected walking speed. (4) knee extensor strength of the affected leg predicted the subject's walking speed, as did leg strength two years post surgery. The conclusion is that knee extensor strength deficits of the affected leg are common features of hip fracture patients, and may contribute to, or perpetuate, functional disability. (copyright) World Scientific Publishing Company

Unrecognized acetabular component rotation with formation of a pseudoarticulation after total hip arthroplasty

Management of Hip Fractures in the Elderly

We report an unusual case of an 82-year-old woman who presented with bilateral knee pain and advanced tibial-femoral and patellofemoral arthrosis. A preoperative total lower extremity film revealed an unrecognized, asymptomatic, dislocated right total hip arthroplasty with a rotated acetabular component that likely occurred 12 years earlier. The dislocated prosthetic femoral head appeared to be articulating with a pseudoacetabulum that had formed superiorly and laterally to the acetabular cup. The patient was unaware of any incident where she noticed an acute change after her hip arthroplasty surgery. We believed the patient to have a chronically dislocated hip that was pain free and quite functional for many years, an unusual condition that has not been reported previously in the literature

Skeletally mature patients with bilateral distal radius fractures have more associated injuries

Management of Hip Fractures in the Elderly

Bilateral distal radius fractures are rare injuries and only a handful of case reports exist. Understanding the demographic variables and associated injuries in patients with these fractures may improve awareness and treatment of concomitant injuries. We determined the differences in mode of trauma and associated injuries between skeletally mature and skeletally immature patients with bilateral distal radius fractures. We retrospectively reviewed the records of 93 patients with bilateral distal radius fractures. We compared demographic data, fracture patterns, mode of injury, treatment modality, and associated injuries for skeletally mature and immature patients. The mean age of all patients sustaining a bilateral injury was 22.5 years and 61 (71%) were male. Of the 51 (55%) skeletally immature patients, 37 (73%) were male, and 44 (86%) sustained a low-energy mechanism of injury. Of the 42 (45%) skeletally mature patients, 29 (69%) were male, and 37 (88%) sustained a high-energy mechanism of injury. Skeletally mature patients had a 38% rate of associated injuries versus 4% found in skeletally immature patients. Skeletally mature patients sustained bilateral distal radius fractures through higher-energy mechanisms and presented with more frequent associated injuries compared with the skeletally immature patients

Prognostic value of CC-chemokine receptor seven expression in patients with metastatic renal cell carcinoma treated with tyrosine kinase inhibitor

MSTS 2018 - Femur Mets and MM

BACKGROUND: CC-chemokine receptor seven (CCR7), a G-protein coupled receptor normally facilitating immune cells lymphatic homing, has recently been identified on several cancer cells in promoting invasion and lymphatic specific metastasis by mimicking normal leukocytes. As tyrosine kinase inhibitors for metastatic renal cell carcinoma (mRCC) mostly emphasized on vascular inhibition, whether the CCR7 expressing tumor cells with potential lymphatic invasion function could have an impact on mRCC patient's drug response and survival, was unknown. METHODS: In this study, in a clinical aspect, we retrospectively investigated the prognostic and predictive impact of tumoral CCR7 expression in 110 mRCC patients treated with sunitinib and sorafenib, and its correlation with pre- or post-administration lymphatic involvement. Immunohistochemistry on tissue microarrays were conducted for CCR7 expression evaluation. RESULTS: Kaplan-Meier and univariate analyses suggested high tumoral CCR7 expression as an adverse prognosticator for mRCC patients' overall survival (OS), which was further confirmed in the multivariate analyses (P=0.002, P=0.003 for bootstrap). This molecule could be combined with Heng's risk model for better patient OS prediction. High tumoral CCR7 expression was also an independent dismal predictor for patients' progression free survival (PFS) (P=0.010, P=0.013 for bootstrap), and correlated with poorer best drug response. Moreover, a possible correlation of CCR7 high expression and patients' baseline and post-administration lymph node metastasis was found. CONCLUSIONS: High tumoral CCR7 expression correlated with potential lymphatic involvement and poor prognosis of mRCC patients treated with tyrosine kinase inhibitors. Further external validations and basic researches were needed to confirm these results.

Giant cell tumor of hard palate

MSTS 2022 - Metastatic Disease of the Humerus

The giant cell tumors usually present in epiphysis of long bones. These are uncommon tumors in head and neck region. These tumors have benign historical features but can be aggressive locally and even can metastasise to lungs. This rare tumor in hard palate is being reported here which was excised transpalatly.

Local peroperative treatment with a bisphosphonate improves the fixation of total knee prostheses: a randomized, double-blind radiostereometric study of 50 patients

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Postoperative migration of a joint prosthesis is related to the risk of late loosening. We have previously reported that oral treatment with clodronate reduced migration of the cemented NexGen total knee prosthesis during the first postoperative year, as measured by radiostereometry (RSA). Oral bisphosphonate treatment is sometimes unpleasant, and local treatment will enable higher local concentrations. We now report the results of local peroperative treatment with another bisphosphonate, ibandronate, with the same prosthesis. METHODS: This is a double-blind, randomized study of 50 patients using RSA with maximal total point motion (MTPM) as primary effect variable. 1 mg ibandronate (1 mL) or 1 mL saline was applied to the tibial bone surface 1 min before cementation. RSA examination was done on the first postoperative day, and at 6, 12, and 24 months. RESULTS: One ibandronate-treated patient died of unrelated causes, and 1 control patient refused to come for follow-up, leaving 24 patients in each group for analysis. There were no cases of aseptic loosening. By repeated measures ANOVA, migration (MTPM) was reduced by local application of ibandronate (p=0.006). The effect was most pronounced at 6 months, with a reduction from 0.45 to 0.32 mm (95% CI for reduction: 0.04-0.21 mm). At 12 months, the migration from the postoperative examination was reduced from 0.47 to 0.36 mm (95% CI for reduction: 0.02-0.20 mm). At 24 months, the reduction was from 0.47 to 0.40 mm (95% CI: -0.01-0.16 mm). INTERPRETATION: This is the first study to show improvement of prosthesis fixation by local pharmacological treatment in humans. The treatment appears to be safe, cheap, and easy to perform. However, the improvement in postoperative stability was not greater than with systemic clodronate treatment

Evaluation of the prognostic significance of nm23/NDP kinase and cathepsin D in anal carcinomas. An immunohistochemical study

MSTS 2018 - Femur Mets and MM

Reduced expression of nm23/NDP kinase and increased expression of cathepsin D seem to be correlated with a high metastatic potential for a variety of malignancies. Nm23/NDP kinase and cathepsin D have been correlated with several clinical variables, including survival in 96 patients with squamous cell carcinoma of the anal canal. Immunohistochemical methods were used on paraffin-embedded biopsies. Seventy-six (79%) anal carcinomas were nm23/NDP kinase positive, whereas 35 (36%) and 28 (29%) of the cases were cathepsin D positive in tumor cells and stromal cells, respectively. We have found no indication that the extent of cathepsin D staining has any prognostic significance. The overall survival of patients with tumours positive for nm23/NDP kinase in the cytoplasm was significantly shorter than that of patients with anal carcinomas negative for nm23/NDP kinase.

Bone mineral density and singh index predict bone mechanical properties of human femur

Management of Hip Fractures in the Elderly

The aim of our study was to assess the predictive value of the Singh index (SI), which estimates bone architecture, and bone density (BMD) when dealing with the mechanical competence of bone and to analze possible differences in bone properties between gender in humans. The relationship between SI, BMD, and mechanical competence was analyzed in 106 bone cylinders from 37 human femoral heads obtained during hip-joint replacement surgery for low energy fracture or for osteoarthritis. Bones from osteoporotic patients are less dense and more brittle compared with bones from osteoarthritic patients, as expected. Among osteoporotic patients female bones were more brittle than those from males, although BMD was similar. In osteoarthritic patients there were no significant differences among sexes. Bone mechanical competence varies according to BMD and to SI categories. Thus, our study suggests that bone strength is predicted by both BMD and bone architecture

The use of a low-profile Ilizarov external fixator in the treatment of complex fractures and non-unions of the distal femur

DoD SSI (Surgical Site Infections)

The aim of this study was to assess the effectiveness of a modified (low-profile) Ilizarov fixation in the treatment of complex fractures of the distal femur such asseptic or aseptic non-unions following previous surgeries, osteoporotic fractures, and high-grade open fractures. Ten male patients with a mean age of 50 years (range, 22-72 years) were treated with a modified Ilizarov fixator. The system was composed of tensioned olive wires attached to four 5/8 rings (two proximal and two distal to the fracture line) connected to each other with three rods. The fixator was not extended to the proximal femur nor across the knee to the tibia, and no Schanz screws were used. The main outcomes evaluated were union, time in fixator and IOWA knee score. Time in the fixator averaged 158 days (range, 125-180). Mean follow-up was 74 months (range, 24-108 months). All fractures united without major complications. One case healed with a 3 degrees varus angulation at the fracture site. The mean IOWA score was 83.8 (range, 70-98). Although superficial pin-tract infection was observed at 10 pin sites, no patient developed deep infection requiring premature pin removal. There was breakage of one wire, which was replaced under anaesthesia, and one patient presented a patella fracture after a fall, which healed after tension-band wire fixation. Considering the high union and low complication rates, we suggest the use of a low-profile Ilizarov fixator in the management of certain distal femoral fractures and non-unions that may be difficult to manage using other means of fixation.

Relationships with serum parathyroid hormone in old institutionalized subjects

Management of Hip Fractures in the Elderly

OBJECTIVE AND BACKGROUND: Old people in residential care are at the highest risk of any group for hip fracture. This may relate to their high prevalence of hyperparathyroidism. There are few data, however, on relationships with serum parathyroid hormone (PTH) in these individuals. This study therefore examined complex associations with serum PTH in nursing home and hostel residents. DESIGN: Cross-sectional analysis. PATIENTS: One hundred and forty-three nursing home and hostel residents of median age 84 years. MEASUREMENTS: Serum PTH, 25-hydroxyvitamin D (25OHD), 1,25-dihydroxyvitamin D (1,25-(OH)2D), plasma creatinine, phosphate, calcium, albumin, Bsm-1 vitamin D receptor genotype, age, weight and use of frusemide or thiazide. RESULTS: The statistical models determined accounted for half the interindividual variation in serum PTH. Heavier weight was associated with both the prevalence of secondary hyperparathyroidism and the serum concentration of PTH. Novel interactions with serum PTH were identified between: weight and 25OHD; 25OHD and phosphate; and phosphate and thiazide diuretic use. Plasma phosphate was associated with PTH independently of calcium and 1,25-(OH)2D. There was no independent association between PTH and nuclear vitamin D receptor genotype. CONCLUSIONS: Heavier weight is associated with both the prevalence and severity of secondary hyperparathyroidism and consistent with animal models of secondary hyperparathyroidism, phosphate may relate to serum PTH independently of 1,25-(OH)2D or calcium

Severe oral hemorrhage and sepsis following bone marrow transplant failure

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Aplastic anemia is a failure of all the cellular components of the bone marrow and, untreated, usually results in death from bleeding and/or infection within 4 months. Treatment by bone marrow transplantation offers the only means of survival. When a bone marrow graft fails, the patient is extremely susceptible to severe infection and/or hemorrhage. In this case, a bone marrow transplantation in a 34-year-old white man with aplastic anemia failed. Among the medical problems that subsequently developed were severe, prolonged and life-threatening oral bleeding and infection

Efficacy of tapentadol ER for managing moderate to severe chronic pain

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Chronic non-cancer-related pain affects a large proportion of the adult population and is often difficult to manage effectively. Although opioid analgesics have been used to relieve chronic pain of different etiologies, opioids are associated with a range of side effects that may reduce patient quality of life and lead to reduced compliance with treatment.Tapentadol is a centrally acting analgesic with 2 mechanisms of action, mu-opioid receptor agonism and norepinephrine reuptake inhibition, that is available in an extended-release formulation for the management of chronic pain. OBJECTIVE: To review the efficacy of tapentadol extended release (ER) for the management of moderate to severe chronic nociceptive and neuropathic pain. METHODS: Efficacy results are summarized for four 15-week phase 3 studies of tapentadol ER in patients with moderate to severe chronic osteoarthritis knee pain (2 studies; ClinicalTrials.gov Identifiers: NCT00421928 and NCT00486811), low back pain (NCT00449176), and pain related to diabetic peripheral neuropathy (DPN; NCT00455520); a one-year phase 3 study of tapentadol ER in patients with moderate to severe chronic osteoarthritis pain or low back pain (NCT00361504); and a pooled analysis of data from the 15-week studies in patients with osteoarthritis knee pain or low back pain. A summary of the comparative tolerability for tapentadol ER and the active comparator used in these studies, oxycodone controlled release (CR), is provided. RESULTS: Results of these studies showed that tapentadol ER (100 - 250 mg bid) was effective for the management of moderate to severe chronic osteoarthritis knee pain, low back pain, and pain related to DPN. Tapentadol ER (100 - 250 mg bid) has been shown to provide comparable pain relief to oxycodone HCl CR (20 - 50 mg bid) for chronic osteoarthritis knee pain and low back pain over up to one year of treatment. Tapentadol ER (100 - 250 mg bid) was associated with an improved tolerability profile, particularly gastrointestinal tolerability profile, and with lower rates of treatment discontinuations and adverse event-related discontinuations compared with oxycodone HCl CR (50 - 250 mg bid) over up to one year of treatment in patients with osteoarthritis knee pain and low back pain. LIMITATIONS: Differences in the design and duration of these phase 3 studies may limit comparisons of the efficacy results; nevertheless, this summary of efficacy results demonstrates the broad efficacy of tapentadol ER for different types of nociceptive and neuropathic pain. CONCLUSIONS: Tapentadol ER (100 - 250 mg bid) is effective for moderate to severe osteoarthritis pain, low back pain, and pain related to DPN and provides efficacy similar to that of oxycodone HCl CR (20 - 50 mg bid) for patients with osteoarthritis and low back pain. Tapentadol ER treatment has been associated with better gastrointestinal tolerability and compliance with therapy than oxycodone CR, which suggests that tapentadol ER may be a better option for the long-term management of chronic pain.

Patient and Perioperative Variables Affecting 30-Day Readmission for Surgical Complications After Hip and Knee Arthroplasties: A Matched Cohort Study

OAK 3 - Non-arthroplasty tx of OAK

Background Changes in reimbursement for total hip and knee arthroplasties (THA and TKA) have placed increased financial burden of early readmission on hospitals and surgeons. Our purpose was to characterize factors of 30-day readmission for surgical complications after THA and TKA at a single, high-volume orthopedic specialty hospital. Methods Patients with a diagnosis of osteoarthritis and who were readmitted within 30 days of their unilateral primary THA or TKA procedure between 2010 and 2014. Readmitted patients were matched to nonreadmitted patients 1:2. Patient and perioperative variables were collected for both cohorts. A conditional logistic regression was performed to assess both the patient and perioperative factors and their predictive value toward 30-day readmission. Results Twenty-one thousand eight hundred sixty-four arthroplasties (THA = 11,105; TKA = 10,759) were performed between 2010 and 2014 at our institution, in which 60 patients (THA = 37, TKA = 23) were readmitted during this 5-year period. The most common reasons for readmission were fracture (N = 14), infection (N = 14), and dislocation (N = 9). Thirty-day readmission for THA was associated with increased procedure time (P = .05), length of stay (LOS) shorter than 2 days (P = .04), discharge to a skilled nursing facility (P = .05), and anticoagulation use other than aspirin (P = .02). Thirty-day readmission for TKA was associated with increased tourniquet time (P = .02), LOS <3 days (P < .01), and preoperative depression (P = .02). In the combined THA/TKA model, a diagnosis of depression increased 30-day readmission (odds ratio 3.5 [1.4-8.5]; P < .01). Conclusion Risk factors for 30-day readmission for surgical complications included short LOS, discharge destination, increased procedure/tourniquet time, potent anticoagulation use, and preoperative diagnosis of depression. A focus on risk factor modification and improved risk stratification models are necessary to optimize patient care using readmission rates as a quality benchmark.

Does routine carpal tunnel release during fixation of distal radius fractures improve outcomes?

Distal Radius Fractures

OBJECTIVE: This case-control study was designed to test the hypothesis whether carpal tunnel release (CTR) during fixation of distal radius 23-C2 AO fractures improves outcomes. METHODS: Thirty-five consecutive patients who sustained distal radius fractures of the dominant hand participated in this study. Patients were allocated into two groups: (a) The ORIF + CTR (16 patients (11 males and 5 females)); (b) the ORIF and NOT CTR 19 patients (12 males and 7 females). Patient assessment included visual analogic scale of pain (VAS), the subjective Mayo Wrist Score (MWS), electromyograms (EMG) at 3 month and 6 months from the day of injury and complications. All patients had the same physiotherapy treatment algorithm following surgery. Patient follow up took place at 1 month, 3, 6, and 12 months. RESULTS: A the T12 month follow up point the VAS average was 0.8 (range 0-3) in ORIF + CTR group compared to 1.2 (range 0-3) in the ORIF and NOT CTR. The MWS average was 98.7 (range 95-100) in ORIF + CTR group versus 97.6 (range 95-100) in ORIF no CTR group. There was no statistical significance (p > 0.5) between the two groups during the follow up period. Patients in the sixth month of ORIF + CTR had no suffering of the median nerve, while 31.58% of patients in ORIF and no CTR found to have carpal tunnel syndrome. CONCLUSIONS: Routine release of the transverse carpal ligament at the time of fracture fixation may reduce the incidence of postoperative median nerve dysfunction.

Efficacy and tolerability of once-monthly oral ibandronate in postmenopausal osteoporosis: 2 year results from the MOBILE study

Management of Hip Fractures in the Elderly

BACKGROUND: Reducing bisphosphonate dosing frequency may improve suboptimal adherence to treatment and therefore therapeutic outcomes in postmenopausal osteoporosis. Once-monthly oral ibandronate has been developed to overcome this problem. OBJECTIVE: To confirm the 1 year results and provide more extensive safety and tolerability information for once-monthly dosing by a 2 year analysis. METHODS: MOBILE, a randomised, phase III, non-inferiority study, compared the efficacy and safety of once-monthly ibandronate with daily ibandronate, which has previously been shown to reduce vertebral fracture risk in comparison with placebo. RESULTS: 1609 postmenopausal women were randomised. Substantial increases in lumbar spine bone mineral density (BMD) were seen in all treatment arms: 5.0%, 5.3%, 5.6%, and 6.6% in the daily and once-monthly groups (50 + 50 mg, 100 mg, and 150 mg), respectively. It was confirmed that all once-monthly regimens were at least as effective as daily treatment, and in addition, 150 mg was found to be better (p<0.001). Substantial increases in proximal femur (total hip, femoral neck, trochanter) BMD were seen; 150 mg produced the most pronounced effect (p<0.05 versus daily treatment). Independent of the regimen, most participants (70.5-93.5%) achieved increases above baseline in lumbar spine or total hip BMD, or both. Pronounced decreases in the biochemical marker of bone resorption, sCTX, observed in all arms after 3 months, were maintained throughout. The 150 mg regimen consistently produced greater increases in BMD and sCTX suppression than the 100 mg and daily regimens. Ibandronate was well tolerated, with a similar incidence of adverse events across groups. CONCLUSIONS: Once-monthly oral ibandronate is at least as effective and well tolerated as daily treatment. Once-monthly administration may be more convenient for patients and improve therapeutic adherence, thereby optimising outcomes

Alkalisation of lignocaine-adrenaline reduces the amount of pain during subcutaneous injection of local anaesthetic

Panniculectomy & Abdominoplasty CPG

A double blind, randomised controlled trial was performed to compare the amount of pain experienced after subcutaneous infiltration of lignocaine with adrenaline, and the same anaesthetic buffered to pH 7.1-7.3, in patients undergoing liposuction (n = 8), blepharoplasty (n = 7), mammaplasty (n = 6), and in volunteers (n = 10). A linear analogue pain scale was used to access pain. In all four groups the buffered solution caused significantly less pain (p < 0.001 except for mammaplasty - p = 0.02).

Quality of life in individuals with patellofemoral pain: A systematic review including meta-analysis

OAK 3 - Non-arthroplasty tx of OAK

Objective: The aim of this systematic review is to describe QoL in individuals with PFP, and determine the impact of PFP interventions on QoL. Methods: Five databases were searched for studies reporting QoL in individuals with PFP, with mean age under 50 years. Data were pooled based on QoL tool (e.g. Knee Injury and Osteoarthritis Outcome Score [KOOS] QoL subscale, Short-Form 36 item health survey [SF-36]) using random-effects models, or through narrative synthesis where inadequate data were available. Results: Individuals with PFP, had worse KOOS-QOL scores (pooled mean: 47[95% CI: 34 to 61] and health-related QoL (pooled SF-36 PCS and MCS: 47[95% CI: 41 to 53] and 54[95% CI: 47 to 62], respectively) compared with pain-free controls and population norms. Physical interventions were associated with improvements in knee- and health-related QoL in individuals with PFP in repeated measures studies. However, the effect of physical interventions compared to a control treatment was conflicting. Conclusion: Individuals with PFP aged under 50 years, have markedly reduced knee- and health-related QoL compared to pain-free controls and population norms. Knee- and health-related QoL may improve following intervention, but it is unclear if these improvements are greater than that which occur in a control group.

Denosumab (XGEVA): Assessment from a pharmacist's perspective

MSTS 2018 - Femur Mets and MM

Skeletal-related events (radiation to bone, pathologic fracture, surgery to bone and spinal cord compression) often occur in patients with bone metastases secondary to solid tumours. A recent approach to treatment is the subcutaneous RANK ligand (RANKL) inhibitor, denosumab. RANKL is like bisphosphonates a key mediator of osteoclast-mediated bone loss and destruction in patients with bone metastases. A recent integrated analysis of three phase 3 studies that evaluated its efficacy in patients with bone metastases secondary to solid tumours versus the intravenous bisphosphonate zoledronic acid found that it was superior to the active control. Denosumab significantly delayed the median time to first skeletal-related event (SRE) by 8.2 months compared with zoledronic acid (p<0.0001). It also reduced the risk of a first SRE by 17% (p<0.0001), and reduced the risk of first and subsequent SREs by 18% (p<0.001). Adverse events were generally similar between the two treatment arms, however, in contrast with zoledronic acid, denosumab did not require monitoring or dose modification/withholding based on renal status. Incidence of acutephase reactions was also lower in the denosumab treatment arm. Hypocalcaemia was, however, more commonly associated with denosumab. Osteonecrosis of the jaw occurred at a similar rate with both treatment options (p=0.13). Disease progression and overall survival were also similar when the two treatments were compared. This review considers the evidence to support the use of currently available treatment options to prevent skeletal-related events and considers their practical application from the perspective of the hospital pharmacist.

Ewing's sarcoma: Ten-year experience with adjuvant chemotherapy

MSTS 2018 - Femur Mets and MM

Since May 1970, 67 consecutive patients with primary (nonmetastatic) Ewing's sarcoma were treated with adjuvant chemotherapy (CT) in addition to radiation therapy (RT) or surgery for the primary tumor. The first 19 patients were treated with four-drug sequential CT (T-2). The second protocol was a seven-drug induction combination CT (T-6) followed by T-2 maintenance CT; in both protocols CT was continued for 18 months. The current protocol (T-9) consists of combination CT given continuously for a period of 9 months. Of the entire group of 67 patients, 47 (70%) had axial and proximal lesions (pelvis, spine, rib, humerus, and femur) and 20 (30%) had distal lesions (forearm, leg, and fott); 53/67 (79%) are surviving free of disease 12-118 months (median 41 months) from the start of treatment. Fifteen of 23 (65%) patients with axial lesions, 19/24 (79%) patients with proximal lesions, and 19/20 (95%) patients with distal lesions are free of disease. Disease-free survivors include 28/39 (72%) male patients and 25/28 (89%) female patients. Thirty-four patients had RT, and 33 had surgery or surgery and RT, in addition to chemotherapy, for local treatment. The disease-free survival rate was 76% in the RT group and 82% in the surgery group; failure in the RT group was attributable to local recurrence in 7/34 (21%) patients. Recent experience with T-9 CT has demonstrated that CT given prior to RT or surgery can cause a great reduction in the size of the primary tumor while allowing the pathologically-eroded bone to heal prior to the initiation of RT; this also allows the high-risk patient with an axial primary (pelvis or spine) to tolerate the aggressive CT needed to prevent distant metastases. In addition to dramatically increasing survival in patients with Ewing's sarcoma, combination CT has helped achieve permanent local control. The superior survival rates for all sites of primary tumor are attributable to the early use of aggressive combination CT.

Improved Methods to Measure Outcomes After High Tibial Osteotomy

OAK 3 - Non-arthroplasty tx of OAK

Observational studies suggest high tibial osteotomy produces substantial improvements in knee loading and stability that can limit the progression of joint damage; decrease pain; improve function and quality of life; and delay the need for knee replacement surgery. It can be cost-effective in knee osteoarthritis. However, systematic reviews and clinical practice guidelines are unable to provide strong recommendations, because limited high-level evidence supports its therapeutic value versus other treatments. We describe findings suggesting it can improve outcomes important to knee joint structure and function, patient quality of life, and health care systems. Future clinical trials are warranted and required.

Two-dimensional/three-dimensional EOSâ?¢ imaging is reliable and comparable to traditional X-ray imaging assessment of knee osteoarthritis aiding surgical management

OAK 3 - Non-arthroplasty tx of OAK

Background: X-ray imaging is the gold standard for assessing lower limb conditions and preoperative planning. A novel low-radiation-dose EOS� imaging system enables full-length weight-bearing imaging in one session and three-dimensional (3D) reconstruction. Thus, it can improve assessment of limb deformities, preoperative planning and follow-up with lower radiation exposure. The objective of this study was to measure lower limbs from EOS� images to determine its accuracy and reproducibility in comparison with long-leg X-ray images. Methods: Over a one-year period, twenty patients (forty lower limbs) with knee osteoarthritis were recruited from clinic. Thirty-five (five excluded due to knee prosthesis) two-dimensional- (2D) EOS�, 3D EOS� and X-ray images were measured independently by four observers, measuring lower limb angles and lengths. On average, twelve weeks later, observers repeated measurements on 2D EOS� and X-ray images. Results: A t-test comparing 2D EOS� with X-ray images showed no significant difference in all angle and length measurements (P > 0.05). When analysing observers separately, all measurements showed no significant difference, apart from the femoral anatomic-mechanical angle (fAMA) from observer 2 (2D EOS� fAMA 6.21° vs. X-ray fAMA 7.10°, P = 0.02). Intra-observer intraclass correlation coefficient (ICC) for 2D EOS� and X-ray was 1.00 and 1.00, respectively, and inter-observer ICC was 1.00 and 0.99, respectively. A t-test comparing 2D- with 3D EOS� images showed no significant difference in all measurements. A t-test comparing 3D EOS� with X-ray images showed no significant difference in all measurements. Conclusion: This study showed the EOS� imaging system to be a valid alternative method of imaging lower limbs for alignment, measurements and preoperative arthroplasty planning.

Bisphosphonates for Breast Cancer: Questions Answered, Questions Remaining

MSTS 2018 - Femur Mets and MM

Bone is an important organ that is essential to adult hematopoiesis, electrolyte balance, and locomotion. Individuals who have metastatic breast cancer involving the bone are at increased risk for skeletal complications and those who have a history of early-stage breast cancer may be at increased risk for fragility fractures. Maintaining bone integrity is critical to control the morbidity and mortality associated with fractures and other skeletal complications. The bisphosphonates have been shown to be efficacious in decreasing the risk for skeletal complications in cancer and in osteoporosis. The article reviews the use of bisphosphonates in patients who have breast cancer. © 2007 Elsevier Inc. All rights reserved.

Panniculectomy as an integral part of pelvic operation is an underutilized technique in patients with morbid obesity

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Panniculectomy integrated into pelvic procedures mandated in morbidly obese patients is a well described technique. Nevertheless, the abdominal cavity in such patients is generally approached through a vertical incision, frequently by forcibly pulling the panniculus inferiorly. Such a vertical approach has been associated with significant wound morbidity. STUDY DESIGN: Patients were offered removal of excess abdominal skin without cosmetic intent. The mean weight of patients was 126 kg and the body mass index ranged from 29.4 to 59.9. The object of this study was to discover whether or not operative access was facilitated and whether or not wound morbidity was reduced. Fifteen patients had significant medical problems and nine of the 16 had an umbilical hernia. RESULTS: Removal of the panniculus seemed to facilitate access to the abdomen, provided excellent exposure, and certainly allowed ready repair of the umbilical hernia with a Blake technique. All but one of the wounds healed by first intention, and in that patient, an 8 cm segment was easily resutured. The operative time was acceptable. There was no increased blood loss associated with the panniculectomy, but of note is the fact that the hematocrit level decreased in five patients on days 2 to 5 postoperatively without hematoma formation. CONCLUSIONS: Conservative panniculectomy to facilitate access to the pelvic area seems to be an advantageous procedure, with good wound healing, and deserves a randomized prospective study comparing it to a vertical incisional approach to validate its technical superiority.

Total knee arthroplasty in motivated patients with knee osteoarthritis and athletic activity approach type goals: a conceptual decision-making model

Surgical Management of Osteoarthritis of the Knee CPG

Knee osteoarthritis is one of the most common disabling medical conditions. With longer life expectancy the number of total knee arthroplasty (TKA) procedures being performed worldwide is projected to increase dramatically. Patient education, physical activity, bodyweight levels, expectations and goals regarding the ability to continue athletic activity participation are also increasing. For the subset of motivated patients with knee osteoarthritis who have athletic activity approach type goals, early TKA may not be the best knee osteoarthritis treatment option to improve satisfaction, quality of life and outcomes. The purpose of this clinical commentary is to present a conceptual decision-making model designed to improve the knee osteoarthritis treatment intervention outcome for motivated patients with athletic activity approach type goals. The model focuses on improving knee surgeon, patient and rehabilitation clinician dialogue by rank ordering routine activities of daily living and quality of life evoking athletic activities based on knee symptom exacerbation or re-injury risk. This process should help establish realistic patient expectations and goals for a given knee osteoarthritis treatment intervention that will more likely improve self-efficacy, functional independence, satisfaction and outcomes while decreasing the failure risk associated with early TKA

Effect of fracture on bone turnover markers: a longitudinal study comparing marker levels before and after injury in 113 elderly women

Management of Hip Fractures in the Elderly

In this longitudinal, prospective, and population-based study (n = 1044), seven BTMs were assessed before and after trauma in 113 elderly women (85 with fractures). Markers were not altered in the immediate postfracture period but were clearly elevated during fracture repair. Recent fracture should thus be taken into account when markers are used in clinical practice. INTRODUCTION: Fracture may influence the levels of bone turnover markers (BTM) and have implications for their use in clinical practice. In this longitudinal, prospective, and population-based study, we assessed prefracture levels of BTMs and compared them with postfracture levels of the same individuals immediately after fracture and during fracture repair. This is the first study in which the effect of fracture on bone markers has been evaluated with prefracture samples available. MATERIALS AND METHODS: Serum and urine were collected at the emergency unit from 85 women (77.9 +/- 1.8 yr) who sustained a fracture after low-energy trauma and 28 controls (77.8 +/- 2.0 yr) with similar trauma but no fracture. All were participants of the Malmo OPRA study (n = 1044), and pretrauma samples were collected 1.05 +/- 0.85 yr before. Bone turnover was assessed by seven different BTMs reflecting different stages of bone metabolism {C-terminal cross-linked telopeptides of type I collagen [S-CTX], S-TRACP5b, N-terminal propeptides of type I collagen [S-PINP], serum osteocalcin (S-OC[1-49] and S-TotalOC), urinary deoxypyridinoline [U-DPD], and urinary osteocalcin [U-OC]}. RESULTS: BTMs sampled within a few hours after fracture were not altered from preinjury levels. Both bone formation and bone resorption markers were, however, significantly increased 4 mo after fracture. The elevation was most pronounced after hip fracture. Bone turnover remained elevated up to 12 mo after fracture. CONCLUSIONS: We believe this study extends our knowledge on the skeletal postfracture metabolic processes. In addition, it may provide a basis for future means to monitor pharmacological intervention promoting fracture healing

Changes in the RANK ligand/osteoprotegerin system are correlated to changes in bone mineral density in bisphosphonate-treated osteoporotic patients

Management of Hip Fractures in the Elderly

INTRODUCTION: Since the soluble receptor activator of the NF-kappaB ligand (sRANKL) as well as the endogenous anti-resorptive cytokine osteoprotegerin (OPG) are produced by osteoblasts and given that these cells undergo significant changes during antiresorptive treatment, we hypothesized that treatment with bisphosphonates (BP) would be accompanied by changes in serum OPG and sRANKL levels.METHODS: In a prospective, randomized controlled trial of previously untreated postmenopausal women with osteoporosis, oral BP therapy (daily doses of either 10 mg alendronate or 5 mg risedronate) in combination with calcium/vitamin D was compared to calcium/vitamin D treatment alone (control group). Follow-up at 2, 6 and 12 months was completed for 56 patients. Standardized spinal X-rays were performed at baseline, and DEXA measurements at the femoral neck and trochanter were made at baseline and after 1 year. Serum OPG and sRANKL levels were measured with a polyclonal antibody-based ELISA system.RESULTS: After 1 year, there was a non-significant loss in neck and trochanteric bone mineral density (BMD) in the CTR group and a mean increase of 3.3% and 4.6% in the combined BP group (both p<0.0001), respectively. Serum levels of C-terminal telopeptides of type I collagen (sCTX) and osteocalcin decreased by 12% and 10% at 12 months in the CTR group and by 43% and 23% in the combined BP group, respectively (all significant). OPG serum levels in the CTR group decreased significantly by 9% at 2 months (p<0.005) and remained below pre-treatment levels at later time points. Both the alendronate- and risedronate-treated patient groups showed unaltered OPG levels after 2 months, but they had significantly increased serum levels at 6 and 12 months. Levels of sRANKL were unchanged throughout the treatment period. Univariate regression analysis demonstrated that changes in serum OPG levels after 12 months of BP treatment were positively and better correlated to BMD changes (trochanter: r=0.59, p<0.0001; neck: r=0.50, p<0.001) than those of sCTX, which showed the expected negative correlation to BMD change (trochanter: r=-0.35, p=0.03; neck: r=-0.23, p=0.16). With multiple regression analyses at 12 months, R2 values for 1-year changes in trochanteric BMD of 0.33 (OPG alone) and 0.23 (sCTX alone) were significantly improved to the 0.57 when OPG and sCTX changes were combined (p<0.001). Results for the femoral neck were also statistically significant R2=0.35, p<0.001). BMD and OPG changes in the CTR group were not correlated with each other.CONCLUSIONS: We conclude that with BP treatment, changes in serum OPG levels, unlike changes in sCTX levels, are positively correlated to changes in BMD response. The BP-related changes in serum OPG levels during treatment could result from effects on osteoclastogenesis and osteoclast apoptosis as well as from a direct stimulatory effect on osteoblastic OPG production. These changes in OPG levels may be used to predict the individual response of patients to BP treatment

The clinical effectiveness of self-care interventions with an exercise component to manage knee conditions: A systematic review

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: Treatment of knee conditions should include approaches to support self-care and exercise based interventions. The most effective way to combine self-care and exercise has however not been determined sufficiently. Therefore the aim was to evaluate the clinical effectiveness of self-care programmes with an exercise component for individuals with any type of knee conditions. METHODS: A keyword search of Medline, CINAHL, Amed, PsycInfo, Web of Science, and Cochrane databases was conducted up until January 2015. Two reviewers independently assessed manuscript eligibility against inclusion/exclusion criteria. Study quality was assessed using the Downs and Black quality assessment tool and the Cochrane Risk of Bias Tool. Data were extracted about self-care and exercise intervention type, control intervention, participants, length of follow-up, outcome measures, and main findings. RESULTS: From the 7392 studies identified through the keyword search the title and abstract of 5498 were screened. The full text manuscripts of 106 studies were retrieved to evaluate their eligibility. Twenty-one manuscripts met the inclusion/exclusion criteria. CONCLUSION: The treatment potential of combined self-care and exercise interventions has not been maximised because of limitations in study design and failure to adequately define intervention content. Potentially the most beneficial self-care treatment components are training self-management skills, information delivery, and goal setting. Exercise treatment components could be strengthened by better attention to dose and progression. Modern technology to streamline delivery and support self-care should be considered. More emphasis is required on using self-care and exercise programmes for chronic condition prevention in addition to chronic condition management.

Associations for change in physical and psychological factors and treatment response following exercise in knee osteoarthritis: an exploratory study

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: Understanding how changes in physical and psychological factors following therapeutic exercise are associated with treatment outcome could have important implications for refining rehabilitation programs for knee osteoarthritis (OA). The objective of this study was to examine the association of changes in these factors with changes in pain and function after an exercise program for people with knee OA. METHODS: In total, 152 people with knee OA completed an exercise program consisting of lower extremity strengthening, stretching, range of motion, balance and agility, and aerobic exercises. The change from baseline to the 2-month followup was calculated for physical and psychological factors, including self-reported knee instability, quadriceps strength, knee and ankle range of motion, lower extremity muscle flexibility, fear of physical activity, anxiety, and depressive symptoms. Treatment response was defined as a minimum of a 20% improvement from baseline in both a numerical knee pain rating scale and the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale. The association of each factor with treatment response was examined with logistic regression mutually adjusted for age, sex, body mass index, radiographic severity, and exercise group. RESULTS: Change in self-reported knee instability (odds ratio [OR] 1.67 [95% confidence interval (95% CI) 1.13-2.47]) and fear of physical activity (OR 0.93 [95% CI 0.88-1.00]) were the only 2 factors that were significantly associated with treatment response after adjustment for covariates. CONCLUSION: Improvement in knee instability and fear of physical activity were associated with increased odds of a positive treatment response following therapeutic exercise in subjects with knee OA.

Dorsal versus transgluteal approach for hip hemiarthroplasty: an analysis of early complications in seven hundred and four consecutive cases

Dental Implant Infection

PURPOSE: Hemiarthroplasty (HA) is an established treatment for femoral neck fractures of the elderly. Several surgical approaches are currently used including dorsal and transgluteal. It is still unclear whether one approach may be advantageous. We compared early complication rates after dorsal and transgluteal approaches., METHODS: We retrospectively analysed a cohort including 704 consecutive patients who received HA for femoral neck fracture; 212 male and 492 female patients were included, and the mean age was 80.4 years (SD 9.8 years). In 487 patients a dorsal and in 217 a transgluteal approach was chosen. In all patients an Excia stem with self-centring bipolar head manufactured by Aesculap (Tuttlingen, Germany) was used. We evaluated early postoperative complications including dislocation, infection, haematoma, seroma and perioperative fracture. Complication rates after dorsal and transgluteal approaches were calculated and compared by the chi-square test., RESULTS: After a dorsal approach 10.5 % [confidence interval (CI) 7.7-13.2 %] of the patients suffered one or more early complications. Following a transgluteal approach this proportion was 9.7 % (CI 5.7-13.6 %), which was not significantly different (p = 0.75). The predominant complication after a dorsal approach was dislocation (3.9 %; CI 2.2-5.6 %). The dislocation rate after a transgluteal approach was significantly lower (0.5 %; CI 0-1.4 %). Postoperative haematoma however was seen after a transgluteal approach in 5.5 % (CI 2.5-8.6 %), which was significantly more frequent than after a dorsal approach (1.2 %; CI 0.2-2.2 %). The frequency of the other types of complications did not significantly differ., CONCLUSIONS: The rate of early surgical complications after dorsal and transgluteal approaches is not significantly different. However, the dorsal approach predisposed to dislocation, whereas the transgluteal approach predisposed to haematoma.

Radiotherapy in the treatment of osteoblastoma - A report of five consecutive cases

MSTS 2022 - Metastatic Disease of the Humerus

Osteoblastomas are rare, locally aggressive bone tumours, usually not giving distant metastases. The basic method of treatment is surgery. Radiotherapy is used for unresectable, recurrent and aggressive tumours or after an incomplete excision. We report five patients (age: 16-55 years). In 4 cases the lesions were located in long bones and in 1 case in the pelvis. In all cases curettages were performed, but in 3 we applied postoperative irradiation (45-50 Gy) because of non-radical surgery and aggressive histopathological form. The mean follow-up period was 28.3 months. In the group of irradiated patients we observed partial regression and pain relief in 2 cases and tumour and pain level stagnation in 1 case. We observed no pain relief in patients treated by surgery alone.

Evaluation of the articular cartilage of the knee joint: value of adding a T2 mapping sequence to a routine MR imaging protocol

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: To determine whether the addition of a T2 mapping sequence to a routine magnetic resonance (MR) imaging protocol could improve diagnostic performance in the detection of surgically confirmed cartilage lesions within the knee joint at 3.0 T. MATERIALS AND METHODS: This prospective study was approved by the institutional review board, and the requirement to obtain informed consent was waived. The study group consisted of 150 patients (76 male and 74 female patients with an average age of 41.2 and 41.5 years, respectively) who underwent MR imaging and arthroscopy of the knee joint. MR imaging was performed at 3.0 T by using a routine protocol with the addition of a sagittal T2 mapping sequence. Images from all MR examinations were reviewed in consensus by two radiologists before surgery to determine the presence or absence of cartilage lesions on each articular surface, first by using the routine MR protocol alone and then by using the routine MR protocol with T2 maps. Each articular surface was then evaluated at arthroscopy. Generalized estimating equation models were used to compare the sensitivity and specificity of the routine MR imaging protocol with and without T2 maps in the detection of surgically confirmed cartilage lesions. RESULTS: The sensitivity and specificity in the detection of 351 cartilage lesions were 74.6% and 97.8%, respectively, for the routine MR protocol alone and 88.9% and 93.1% for the routine MR protocol with T2 maps. Differences in sensitivity and specificity were statistically significant (P < .001). The addition of T2 maps to the routine MR imaging protocol significantly improved the sensitivity in the detection of 24 areas of cartilage softening (from 4.2% to 62%, P < .001), 41 areas of cartilage fibrillation (from 20% to 66%, P < .001), and 96 superficial partial-thickness cartilage defects (from 71% to 88%, P = .004). CONCLUSION: The addition of a T2 mapping sequence to a routine MR protocol at 3.0 T improved sensitivity in the detection of cartilage lesions within the knee joint from 74.6% to 88.9%, with only a small reduction in specificity. The greatest improvement in sensitivity with use of the T2 maps was in the identification of early cartilage degeneration.

Skeletal response in rats following the implantation of hypercalcemia-producing Leydig cell tumors

MSTS 2018 - Femur Mets and MM

The effect of Rice H-500 Leydig cell tumor tissue on bone in rats was assessed by morphometric analysis and tetracycline labeling of the lower femoral metaphyses. The rats in which tumor was implanted showed hypercalcemia, increased osteoclastic bone resorption, inhibition of bone formation with reduction in the bone apposition rate, and a loss in trabecular volume compared with the control rats. There was no evidence of tumor metastasis to bone. The results are consistent with the hypothesis that the Leydig cell tumor secretes a humoral factor capable of causing systemic bone resorption.

Is physical activity a risk factor for primary knee or hip replacement due to osteoarthritis?

Surgical Management of Osteoarthritis of the Knee CPG

Aim: To estimate prospectively any association between measures of physical activity and the risk of either primary knee or hip replacement due to osteoarthritis. Methods: Eligible subjects (39,023) were selected from participants in a prospective cohort study recruited during 1990-1994. Primary knee and hip replacement for osteoarthritis during 2001-2005 was determined by linking the cohort records to the National Joint Replacement Registry. A total physical activity level was computed, incorporating both intensity and frequency for different forms of physical activity obtained by questionnaire at baseline attendance. Results: There was a dose-response relationship between total physical activity level and the risk of primary knee replacement [hazards ratio (HR) 1.04, 95% confidence interval (95%CI) 1.01-1.07 for an increase of 1 level in total physical activity]. Although vigorous activity frequency was associated with an increased risk of primary knee replacement (HR 1.42 (95% CI 1.08-1.85) for 1-2 times/week and 1.24 (95%CI 0.90-1.71) for (greater-than or equal to)3 times/ week), the P for trend was marginal (continuous HR 1.08 (95%CI 1.00- 1.16), P = 0.06). The frequency of less-vigorous activity or walking was not associated with the risk of primary knee replacement, nor was any measure of physical activity associated with the risk of primary hip replacement. Conclusions: Increasing levels of total physical activity are positively associated with the risk of primary knee but not hip replacement due to osteoarthritis. Physical activity might affect the knee and hip joints differently depending on the pre-existing health status and anatomy of the joint, as well as the nature of physical activity performed

Clinical effectiveness of antibiotic-impregnated cement spacers for the treatment of infected implants of the hip joint

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

It is difficult to treat an infected implant of the hip joints, as it requires long-term treatment and eventually may lead to amputation or arthrodesis, involving immeasurable physical and psychological suffering for the patient. We utilized antibiotic-impregnated cement spacers for 17 infections after total hip arthroplasty and bipolar arthroplasty with good clinical results. We thoroughly removed any foreign material and formed an antibiotic-impregnated cement spacer into a shape similar to that of the implants. This enabled high-concentration antibiotics to act on the infected sites. It also can prevent leg-length discrepancy and atrophy of bones or muscles. Although cement spacers have been reported to have problems regarding shape and strength, we achieved good results with cement spacer molds in the present study. All revision surgeries were performed using a two-stage procedure. No infection has recurred at a mean follow-up of 3 years 2 months

Danger zones for flexor tendons in volar plating of distal radius fractures

Distal Radius Fractures

PURPOSE: To define a danger zone for volar plates using magnetic resonance imaging by analyzing the position of the flexor tendons at risk around the watershed line. METHODS: We analyzed 40 wrist magnetic resonance images. The location of the flexor pollicus longus (FPL) and index flexor digitorum profundus (FDPi) tendons was recorded at 3 and 6 mm proximal to the watershed line of the distal radius. We measured the distance between the volar margin of the distal radius and the FPL and FDPi tendons, and the coronal position of the tendons. RESULTS: At a point 3 mm proximal to the watershed line, FPL and FDPi were located on average 2.6 and 2.2 mm anterior to the volar margin of the distal radius. This distance increased to 4.7 and 5.3 mm at a point 6 mm proximal to the watershed line. The FPL and FDPi were located at 57% and 42% of the total width of the distal radius from the sigmoid notch at 3 mm from the watershed, and at 66% and 46% at 6 mm from the watershed. CONCLUSIONS: Surgeons should be aware of the close proximity of the flexor tendons to the volar cortex of the distal radius proximal to the watershed line and their radial to ulnar position. Three millimeters proximal to the watershed line, plate placement more than 2 mm anterior to the volar cortex or the use of plates thicker than 2 mm poses a high risk for directly contacting flexor tendons. CLINICAL RELEVANCE: This article may prove to be helpful in avoiding flexor tendon injury during volar plate fixation.

In vivo acetabular contact pressures during rehabilitation, Part II: Postacute phase

Management of Hip Fractures in the Elderly

The authors conducted a two-part study to compare in vivo acetabular contact pressures during the acute and postacute phases of rehabilitation in a single subject with a pressure-instrumented femoral prosthesis. This report compares six common hip rehabilitation activities for resultant in vivo hip pressure magnitudes during the first 5 years after discharge from an acute care hospital. These activities were full, partial, touch-down, and non-weight-bearing ambulation and isometric hip abduction and straight-leg-raising exercises. A pressure-instrumented femoral endoprosthesis implanted in a 73-year-old woman who had sustained a femoral neck fracture provided data for the activities. The activities were rank ordered and compared over time according to peak pressure magnitude. Prescribed weight bearing and exercise type were not good predictors of hip peak pressures in this patient. Maximum pressures occurred by 1 year postdischarge for most activities, with a tendency to stabilize or decline thereafter. Resisted isometric hip abduction exercise demonstrated the most variation over time. The results suggest that hip pressures may be limited by controlling muscle force and movement velocity during postoperative hip rehabilitation activities

The classic nail in the therapy of trochanteric fractures.A prospective, controlled study

HipFx Supplemental Cost Analysis

In a prospective controlled study we analysed the classic nail, a new intramedullary implant for the fixation of peritrochanteric fractures. By means of lateral bending of 4 degrees, unreamed implantation is generally possible. Our collective of 85 patients was characterized by elderly mean age (82.3 years), a predominance of female patients (4.3 : 1), a minor trauma aetiology without relevant additional injuries, and a high rate of concomitant disease (92%). Only 31A-type femur fractures were treated, with a low specific complication rate of 13%, whereby operative revision was necessary in only two patients (3%). A good anatomic reconstruction and full weight-bearing with the osteosynthesis was achieved in the majority of patients. No secondary shaft fractures and only one case of cutting out was observed. The mortality (30 days: 18%, 6 months: 25%) as well as the high rate of unspecific complications (20%) were caused by the patients' multiple morbidity. Deficits in the Merle d'Aubigne score at follow-up after 6 months can be interpreted within the same context. Nevertheless, 85% could return to their former social environment and only 15% became dependent on a nursing institution in connection with the fracture treatment

Early experience with bilateral continuous femoral nerve block and single injection spinal anesthesia for bilateral total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Background and aims: Total knee arthroplasty (TKA) and bilateral total knee arthroplasty (BTKA) are commonly performed surgeries in the United States. Regional anesthesia has been found effective in reducing perioperative complications and improving pain control in unilateral TKA, but not in

Neuromuscular versus quadriceps strengthening exercise in patients with medial knee osteoarthritis and varus malalignment: a randomized controlled trial

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To compare the effects of neuromuscular exercise (NEXA) and quadriceps strengthening (QS) on the knee adduction moment (an indicator of mediolateral distribution of knee load), pain, and physical function in patients with medial knee joint osteoarthritis (OA) and varus malalignment. METHODS: One hundred patients with medial knee pain, mostly moderate-to-severe radiographic medial knee OA, and varus malalignment were randomly allocated to one of two 12-week exercise programs. Each program involved 14 individually supervised exercise sessions with a physiotherapist plus a home exercise component. Primary outcomes were peak external knee adduction moment (3-dimensional gait analysis), pain (visual analog scale), and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index). RESULTS: Eighty-two patients (38 [76%] of 50 in the NEXA group and 44 [88%] of 50 in the QS group) completed the trial. There was no significant between-group difference in the change in the peak knee adduction moment (mean difference 0.13 Nm/[body weight x height]% [95% confidence interval (95% CI) -0.08, 0.33]), pain (mean difference 2.4 mm [95% CI -6.0, 10.8]), or physical function (mean difference -0.8 units [95% CI -4.0, 2.4]). Neither group showed a change in knee moments following exercise, whereas both groups showed similar significant reductions in pain and improvement in physical function. CONCLUSION: Although comparable improvements in clinical outcomes were observed with both neuromuscular and quadriceps strengthening exercise in patients with moderate varus malalignment and mostly moderate-to-severe medial knee OA, these forms of exercise did not affect the knee adduction moment, a key predictor of structural disease progression.

Levofloxacin vs. ciprofloxacin plus phenethicillin for the prevention of bacterial infections in patients with haematological malignancies

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

An open-label randomised clinical trial was designed to compare the efficacy and tolerance of levofloxacin and ciprofloxacin plus phenethicillin for the prevention of bacterial infections in patients with high-risk neutropenia, and to monitor the emergence of antimicrobial resistance. Adult patients (n = 242) scheduled to receive intensive treatment for haematological malignancies were assigned randomly to receive oral prophylaxis with either levofloxacin 500 mg once-daily (n = 122), or ciprofloxacin 500 mg twice-daily plus phenethicillin 250 mg four-times-daily (n = 120). The primary endpoint was failure of prophylaxis, defined as the first occurrence of either the need to change the prophylactic regimen or the initiation of intravenous broad-spectrum antibiotics. This endpoint was observed in 89 (73.0%) of 122 levofloxacin recipients and in 85 (70.8%) of 120 ciprofloxacin plus phenethicillin recipients (RR 1.03, 95% CI 0.88-1.21, p 0.71). No differences were noted between the two groups with respect to secondary outcome measures, including time to endpoint, occurrence of fever, type and number of microbiologically documented infections, and administration of intravenous antibiotics. A questionnaire revealed that levofloxacin was tolerated significantly better than ciprofloxacin plus phenethicillin. Surveillance cultures indicated the emergence of viridans group (VG) streptococci resistant to levofloxacin in 17 (14%) of 122 levofloxacin recipients; in these cases, the prophylactic regimen was adjusted. No bacteraemia with VG streptococci occurred. It was concluded that levofloxacin and ciprofloxacin plus phenethicillin are equally effective in the prevention of bacterial infections in neutropenic patients, but that levofloxacin is tolerated better. Emergence of levofloxacin-resistant VG streptococci is of concern, but appears to be a manageable problem

Effects of mild hypothermia on blood coagulation in patients undergoing elective plastic surgery

Panniculectomy & Abdominoplasty CPG

BACKGROUND: The aim of this prospective, controlled study was to evaluate the effects on coagulation function of active patient warming during elective plastic surgery. METHODS: Seventy-six patients undergoing elective plastic surgery (additive and reductive mastoplasty, rhinoplasty, and liposuction) were either covered with standard sterile drapes (control group, n = 38) or actively warmed during surgery with countercurrent fluid warming and forced-air skin warming (treatment group, n = 38). Complete evaluation of the coagulation activity was performed 1 hour before general anesthesia was induced and then at the end of surgery. RESULTS: Although no differences in preoperative core temperature were observed (36.0 +/- 0.5 degrees C in the control group and 36.1 +/- 0.4 degrees C in the treatment group; p = 0.12), core temperature was lower at the end of surgery in the control group (34 +/- 1.0 degrees C) than in the treatment group (36 +/- 0.6 degrees C) (p = 0.0005). No differences in prothrombin time and fibrinogen plasma concentrations were observed between the two groups. At the end of surgery, control group patients showed significantly larger activated partial thromboplastin times (36.8 +/- 3.5 seconds) and bleeding times (8.1 +/- 1.6 minutes) as compared with patients maintained normothermic during surgery (34.0 +/- 2.9 seconds and 4.3 +/- 1.1 minutes; p = 0.0005 and p = 0.0005, respectively). CONCLUSION: Actively maintaining intraoperative normothermia allows patients to maintain normal coagulation function during elective plastic surgery lasting longer than 2 hours, potentially reducing the occurrence of bleeding-related complications after plastic surgery.

Long term use of analgesics and risk of osteoarthritis progressions and knee replacement: Propensity score matched cohort analysis of data from the Osteoarthritis Initiative

OAK 3 - Non-arthroplasty tx of OAK

Objectives: To determine the association between the long-term use of analgesics and progression of osteoarthritis (OA) as evidenced by up to 3-years follow-up worsening of radiographic Kellgren-Lawrence (KL) grade and incidence of knee replacement (KR). Design: Using nearest neighbor matching of the propensity scores with caliper in the Osteoarthritis Initiative (OAI) cohort, 173 index (Analgesic +) and 173 referent (Analgesic -) subjects were included. Analgesic + and - subjects had analgesics in all and none of their visits, respectively. Analgesic + and - subjects were balanced in their demographics, baseline, first, second and third year body mass index (BMI), Western Ontario and McMaster (WOMAC) total score, Physical and Mental health summary scales (SF-12), Physical Activity Scale for the Elderly (PASE) and Charleston Comorbidity Scale. Analgesic + and - subjects were also matched for baseline radiographic KL grade. Interval increase in the KL grade and incidence of KR were defined as the outcome. Results: Included subjects had average 6.5 years of follow-up. By the third year, 44 subjects had an interval increase in the KL grade; 29 in Analgesic + and 15 among Analgesic - subjects (P = 0.024). By the eighth-year, 41 subjects had their first KR; 29 in Analgesic + and 12 among Analgesic - subjects (P = 0.005). Hazard Ratio (HR) of OA progression and KR for Analgesic + subjects was 1.91 (1.02-3.57) and 2.57 (1.31-5.04), respectively. Conclusions: Long-term use of analgesics may be associated with radiographic progression of knee OA and increased risk of future KR.

Absorbable polyglycolide pins in internal fixation of fractures in children

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Absorbable implants made of synthetic biodegradable polymers were recently introduced clinically in internal fixation of fractures. In this prospective study of 71 pediatric patients with a variety of displaced physeal or nonphyseal fractures, self-reinforced polyglycolide pins 1.5 or 2.0 mm in diameter were used instead of Kirschner wires to fix the fragments. The majority of patients (45 children) had a fracture affecting the distal humerus. Mean age of the patients was 9.8 years (range 2-15 years). Follow-up averaged 15.8 months. In 62 patients (87%), an exact reduction of the fracture could be maintained until union. Among the remaining patients, six had minor inaccuracies or redisplacements of the fracture position, but in three patients with supracondylar fractures of the humerus breakage of the pins resulted in a severe redisplacement that necessitated a change in treatment method. With the exception of supracondylar fractures of the humerus, these preliminary results of polyglycolide pin fixation were deemed satisfactory. The fundamental advantage of this method is that no hardware removal procedures are required

Injuries caused by small wheel devices

Distal Radius Fractures

We wanted to look for characteristics in injuries caused by rollerblades, skateboards and unmotorized kick scooters in order to recommend more targeted injury prevention. From September 2000 we did a two-year prospective registration of all small wheel device injuries attending Bergen Accident and Emergency Department's surgical unit. We registered a total of 273 injuries, and found an obvious difference in injury pattern between the three. Rollerbladers were more prone to fractures in their hands and arms, especially distal radial fractures, but also scaphoid fractures. This fracture is seldom in children, but not in child injuries caused by small wheel devices. Skateboarders were susceptible to ankle sprains and had the lowest injury severity among the three activities. Kick scooter users got mostly wound injuries, but had a high frequency of distal radial fractures with volar angulation, the Smith-type of fracture. There were also differences in user groups; 2/3 of injured rollerbladers were boys, mostly aged 12, a typical, injured skateboarder was a young male aged 13, and an injured kick scooter user was either an 11-year-old girl or boy. The use of effective wrist braces could have prevented most injuries in both rollerblading and kickscootering. Due to the high susceptibility of small wheel devices to uneven grounds resulting in falls, these activities should be prohibited in traffic and darkness. Preventive advice should preferably reach children aged 11 to 13. © Society for Prevention Research 2006.

Striking a balance between bleeding and thrombotic tendencies for surgery

Surgical Management of Osteoarthritis of the Knee CPG

Case: A 69-year-old Caucasian lady with osteoarthritis presented prior to knee arthroplasty with prolonged prothrombin time (PT) of 26 s (INR 2.4) and activated partial thromboplastin time (aPTT) of 92.1 s. History revealed easy bruising and menorrhagia since menarche requiring transfusion. She had two pregnancies delivered vaginally, the second required hysterectomy for bleeding. In her 40s, she was diagnosed with immune thrombocytopenic purpura (ITP). She underwent splenectomy with reported splenomegaly. Current studies revealed platelet count of 120 000 lL with normal hemoglobin and serum chemistry. She has no petechiae, lymphadenopathy or hepatomegaly. PT/aPTT mixing studies did not correct and Russell Viper Venom Time showed lupus anticoagulant effect. Factors X, II, and fibrinogen were normal and Factor V was borderline low. A von Willebrand (vWD) panel revealed moderately severe type 1 vWD. Serum protein electropheresis showed 3 g IgM kappa monoclonal protein and marrow showed lymphoplasmacytic infiltration diagnostic of Waldenstrom macroglobulinemia (WM). A requisition error resulted in a Factor II genetic study instead of only Factor II level which demonstrated heterozygous prothrombin G20210A mutation. Prior to surgery, she required therapy for ITP, vWD, WM, and prothrombin gene mutation. Her ITP and vWD predisposed her to bleeding while her prothrombin gene mutation to thrombosis. In addition, her WM and surgery imposed bleeding and thrombotic risks. Preoperatively, she underwent plasmapheresis and received prophylactic vWF replacement. Postoperatively, she received prophylactic vWF replacement as well as standard prophylactic warfarin for four weeks. During the perioperative course, her PT and aPTT remained mildly prolonged without untoward bleeding or thrombotic event. Discussion: A clinically important bleeding diathesis secondary to interference with clotting factor and platelet function in WM has been reported. Reduced activities of coagulation factors (I, V, VII,

Tibial plateau fractures in the elderly

DOD - Acute Comp Syndrome CPG

In light of an ever-aging population, the incidence of osteoporotic fractures continues to rise. The challenges of reduction and fixation in osteopenic bone are well known to orthopaedic surgeons. Treatment of tibial plateau fractures in elderly patients must be individualized to the patient and his injury. Low-energy fractures in low-demand patients may best be treated nonoperatively with early mobilization. Higher-energy patterns or higher-demand patients should lead to stronger consideration of surgical treatment. Open reduction and internal fixation and definitive external fixation, with traditional external fixation or circular fixation are options. While arthroplasty has been used for many other osteopenic fractures, especially those of the proximal femur, the benefits and indications of acute arthroplasty for tibial plateau fractures are unknown. Soft-tissue compromise, prosthetic infection, and integrity of the extensor mechanism about arthroplasty components are concerns. The exact indications and benefits of each treatment remain unknown. We reviewed these treatments and the published data that support them.

The role of postoperative blood recovery for patients with femoral neck fracture

Management of Hip Fractures in the Elderly

Postoperative blood recovery in eighty elderly patients (11 male, 69 female) treated for femoral neck fracture was prospectively studied. Twenty-eight patients underwent hemiarthroplasty for intracapusular fracture and 52 underwent Dynamic Hip Screw fixation for extracapsular femoral neck fracture. The mean blood drainage in the postoperative period and the mean drop in haemoglobin level was higher in the DHS group as compared to the hemiarthroplasty group. Mean drainage in the first 6 postoperative hours was 150 ml (range: 10-450 ml) in the DHS group, versus 50 ml in the hemiarthroplasty group (range: 10-100 ml). Out of 52 cases of the dynamic hip screw fixation group, only 10 patients received autologous blood transfusion (19%), among which the drains collected more than 150 ml in only 4 (7%). The blood drainage in this group occurred in the first 6 hours only. Supplementary cross matched bank blood was transfused to patients in the DHS group (8%). Among 28 patients in the hemiarthroplasty group, only 6 patients received autologous blood reperfusion (21%), among which the drains collected more than 150 ml in only 4 (14%). Overall, only six patients out of 28 in the hemiarthroplasty and 10 out 52 in the DHS group had enough blood in their drains to warrant re-perfusion. We conclude that the routine use of Bellovac drains after femoral neck fracture surgery is not necessary and is not cost effective

Incidence of bacteraemia following teeth extraction at the dental clinic of the University of Benin Teaching Hospital, Benin city, Nigeria

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

170 patients attending the Oral and Maxillofacial Surgery Clinic of the University of Benin Teaching Hospital, Benin City, Nigeria, were screened bacteriologically, to determine the prevalence of bacteraemia following dental extraction procedures. 5 ml of blood was collected from each patient before and after the extraction. Post-operative bacteraemia occurred in 55 (32.4%) of the 170 patients screened. 61 (78.2%) of the 78 isolates obtained in the survey were facultative anaerobes while 17 (21.8%) were obligate anaerobes. Amongst the facultative anaerobes, the most frequently isolated bacterial genus was Staphylococcus (19, 24.4%) followed by Streptococcus spp. (16, 20.5%) and - haemolytic Streptococcus spp. (10, 12.8%). Bacteriodes spp. (8, 10.3%) was the most frequently isolated anaerobe followed by Peptostreptococcus spp. (5, 6.4%) and clostridium spp. (4, 5.16%). The occurrence of bacteriaemia increased with duration of extraction and number of teeth extracted. It also occurred more frequently when teeth were extracted because of inflammatory dental disease. (copyright) 2008 Academic Journals

Nocturia is an age-independent risk factor for hip-fractures in men

Management of Hip Fractures in the Elderly

AIMS: Nocturia is a highly prevalent symptom in the elderly and a common reason for interrupted sleep resulting in dizziness, worse daytime functioning and higher risk of falls. The aim of this study was to determine the role of nocturia as a risk factor for hip-fractures in men. METHODS: Men aged 40-80 years participating in a health-screening survey in Vienna between 2000 and 2003 entered the study. In parallel to the investigation all men completed the International Prostate Symptom Score (IPSS). In 2008, files of all Austrian public hospitals were screened whether these men were admitted with the diagnosis of a hip-fracture. Chi(2)-test and logistic regression analyses were used to study the association of nocturia to hip-fractures. RESULTS: A total of 1,820 men (52 +/- 9 years) with a mean follow-up of 6.2 years entered this analysis. Hip-fractures occurred in 24 men (1.3%). The occurrence of hip-fractures increased from 0.9% (no nocturia) to 1.0% (nocturia once) to 2.7% (nocturia twice or more). This trend was significant (P = 0.03, chi(2)-test). Even after adjusting for age, men with nocturia of >or=2 were at increased risk (OR 1.36; 95% CI 1.03-1.80, P = 0.03) for developing a hip-fracture. The IPSS was not correlated to the occurrence of hip-fractures (p for trend 0.61). CONCLUSIONS: Nocturia of >or=2 is an age-independent risk factor for hip-fractures in men. The high frequency of nocturia in elderly men paralleled with the significant morbidity and even mortality of hip-fractures underline the clinical importance of this association

Patient Reported Outcomes After Radiation Therapy for Bone Metastases as a Function of Age: A Secondary Analysis of the NCIC CTG SC-Twenty-Three Randomized Trial

MSTS 2022 - Metastatic Disease of the Humerus

PURPOSE: To explore the age difference in response and patient-reported outcomes in patients with cancer having bone metastases undergoing palliative radiotherapy. METHODS: Patients completed the European Organisation for Research and Treatment of Cancer (EORTC) Quality-of-Life (QOL) Bone Metastases module (QLQ-BM22), EORTC QOL Core-15-Palliative (QLQ-C15-PAL), and Dexamethasone Symptom Questionnaire (DSQ) before a single 8-Gy radiation treatment, on days 10 and 42 after treatment. Patient demographics, performance status, analgesic consumption, BM22, C15, and DSQ were compared with multivariant analysis between patients under 75 years and 75 years and older. Multiple linear regression models were used to assess the differences between age-groups, adjusting for baseline demographics and primary disease sites. RESULTS: There were 298 patients (170 male) with 209 (70%) less than 75 years of age. Most common primary cancer sites include lung, prostate, and breast. At baseline, younger patients had better performance status, consumed more analgesic, and reported worse scores in nausea, insomnia, and functional interference, while older patients more commonly had prostate cancer. There were no significant differences in the incidence of radiation-induced pain flare; response to radiation; changes from baseline for BM22, C15-PAL; and DSQ, nor overall survival at day 42 between the 2 groups. Responders to radiation in the elderly group reported better improvement in physical and emotional domains when compared with nonresponders. CONCLUSIONS: In patients with cancer having bone metastases undergoing palliative radiotherapy, there was no significant difference in general with age in response to radiation and patient-reported outcomes. Palliative radiotherapy should be offered to elderly patients when needed.

Perceptions and performance of exercise in people with knee osteoarthritis in the Middle East: are they different to countries in the developed world? A qualitative study in Jordan

OAK 3 - Non-arthroplasty tx of OAK

Background: Culture and lifestyle could justify the variability in clinical patterns of knee osteoarthritis (OA) and was reported to affect exercise adherence.Objective: To explore perceptions and aspects influencing exercise adherence in people with knee OA in Jordan (a developing country) as they might be different from those reported in the developed world.Methods: Fourteen participants were included in the study (13 females, one male). One focus group and seven in depth semi-structured interviews were conducted. The discussions were audio-taped and transcribed. Framework analysis was used and data were interpreted using the socio-ecological model.Results: At the individual level, knowledge of the role of exercise in knee OA and personal factors influenced exercise performance and adherence. At the sociocultural level, cultural attitudes and beliefs and social interaction affected exercises adherence. At the organizational/political level, suboptimal service delivery process, inappropriate delivery of home exercises, accessibility of services affected exercise adherence. Opportunities for improving service delivery were also reported. At the environmental level, geography and weather affected adherence.Conclusions: Understanding the interaction of health-related behavior with individual, social/cultural, organizational, and environmental aspects would improve exercise adherence and equip physiotherapists with knowledge and resources to facilitate the implementation of patient-centered services.

Percutaneous plating of the proximal humerus

Pediatric Supracondylar Humerus Fracture 2020 Review

Percutaneous plating was developed in an attempt to address the issues of humeral head necrosis associated with open reduction through an extensive approach and insufficient primary stability associated with previous attempts at limited exposure with minimal internal fixation. Our minimally invasive approach consists of 2 separate mini-incisions. The proximal incision is a direct anterolateral deltoid-splitting approach of <5 cm that exposes the humeral head and tuberosities. The distal incision of 1 to 2 cm exposes the humeral shaft and distal part of the plate. Before plate insertion underneath the deltoid, the axillary nerve must absolutely be identified and protected to prevent entrapment. The block guide attachment to the plate cannot be safely used as it stretches directly the nerve at the distal edge. With our approach, indirect reduction techniques are needed to achieve good reduction. Ideal fracture types include 2-part surgical neck fractures, isolated greater tuberosity fractures, and all valgus-type injuries. With increased experience, indications can be extended to many 3-part fractures and some 4 parts. Good outcomes can be expected if patients are well selected. © 2013 by Lippincott Williams & Wilkins.

Epidermal growth factor receptor is associated with the onset of skeletal related events in non-small cell lung cancer

MSTS 2018 - Femur Mets and MM

Background: Bone metastasis and skeletal related events (SREs) are common in non-small cell lung cancer (NSCLC). Patients with mutant epidermal growth factor receptor (EGFR) could benefit from tyrosine kinase inhibitors (TKIs). However, it is unclear whether SRE is influenced by EGFR status. We aimed to evaluate the correlation of EGFR status and TKIs with the incidence of SREs. Methods: We conducted a retrospective study of stage IV NSCLC patients with bone metastasis. Incidence rate of SREs was collected and was compared using chi-square test. Logistic-regression analysis was used to identify the risk factors predicting the incidence of SREs. Results :410 eligible patients were enrolled in the study. 49.0% were detected with EGFR mutation. 49.8% of patients received EGFR-TKIs therapy prior to the onset of SREs. 42.7% experienced at least one SRE. Patients who were treated with TKIs held lower incidence of SREs than patients who were not treated with TKIs (23.5% vs 61.7%, p < 0.001). Multivariate analysis showed that poor performance status (OR 5.550, 95%CI 2.290-13.450; p < 0.001) and mutant EGFR (OR 3.050, 95%CI 1.608- 5.787, p=0.001) were independent risk factors predicting the onset of SREs, while the usage of TKIs (OR 0.102, 95%CI 0.054-0.193, p < 0.001) was a protective factor of SREs in NSCLC patients with bone metastasis. Conclusions: This study indicates that the incidence of SREs is common in both patients with and without EGFR mutation. Poor performance ability and mutant EGFR imply higher risks of SREs, while the usage of TKIs may be a protective factor of SREs. Copyright: Huang et al.

Comparison of local recurrence and distant metastases between breast cancer patients after postmastectomy radiotherapy with and without immediate TRAM flap reconstruction

MSTS 2018 - Femur Mets and MM

BACKGROUND: The purpose of this study was to compare the local recurrence and distant metastasis of postmastectomy radiotherapy for breast cancer patients with and without immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. METHODS: Between March of 1997 and October of 2001, 191 breast cancer patients received postmastectomy radiotherapy: 82 patients had TRAM flap reconstruction (TRAM flap group) and 109 patients did not (non-TRAM flap group). The mean radiation dose to the chest wall or entire TRAM flap, axillary area, and lower neck was 50 Gy (range, 48 to 54 Gy). The median follow-up period was 40 months. RESULTS: The percentages of chest wall recurrence were 3.7 percent (three of 82) in the TRAM flap group and 1.8 percent (two of 109) in the non-TRAM flap group (p = 0.653). The percentages of distant metastases were 12.2 percent (10 of 82) in the TRAM group and 15.6 percent (17 of 109) for the non-TRAM group (p = 0.67). The percentages of acute radiation dermatitis according to Radiation Therapy Oncology Group scoring criteria (TRAM flap group versus non-TRAM flap group) were as follows: grade I, 74 of 82 (90 percent) versus 93 of 109 (85 percent); grade II, seven of 82 (9 percent) versus 13 of 109 (12 percent); grade III, one of 82 (1 percent) versus three of 109 (3 percent) (p = 0.558). In the TRAM flap group, the increased percentage of fat necrosis was 8 percent. No flap loss was detected. CONCLUSIONS: There were no significant differences in the incidences of complication, locoregional recurrence, and distant metastasis between the TRAM flap and non-TRAM flap patients. The authors' results suggest that immediate TRAM flap reconstruction can be considered a feasible treatment for breast cancer patients requiring postmastectomy radiotherapy.

Abdominoplasty combined with other intraabdominal procedures

Panniculectomy & Abdominoplasty CPG

One hundred three patients underwent abdominoplasty combined with other intraabdominal procedures including 67 tubal ligations, 34 total abdominal hysterectomies and 2 cholecystectomies, from January 1983 to July 1991. The patients were divided into two groups, those undergoing the standard or total abdominoplasty and those undergoing limited abdominoplasty with or without liposuction in delimited areas. In this series of 103 patients, we found only two minor complications and only three patients were transfused with autologous units of blood. When performed by well-schooled surgical teams, abdominoplasty may be combined with intraabdominal procedures with gratifying results. Between January 1983 and July 1991, well trained surgical teams performed either standard abdominoplasty or miniabdominoplasty on 103 patients who also underwent tubal ligation, total abdominal hysterectomy, or cholecystectomy to determine whether surgeons can effectively combine abdominoplasty with other intraabdominal procedures. Prescribed preoperative procedures included respiratory exercises. Physicians advised patients to stop smoking 2 weeks before surgery. Physicians also instructed them not to take any aspirin or other drugs with anticoagulant effects 2 weeks before surgery. Tubal ligation patients who also underwent standard abdominoplasty were in the operating room for 3 hours and for 2 hours if they underwent miniabdominoplasty. Total abdominal hysterectomy patients were in the operating room for either 3-4 hours (standard abdominoplasty) or 2.5-3 hours (miniabdominoplasty). Surgeons performed cholecystectomy in those patients who only underwent standard abdominoplasty. They were in the operating room for 4-5 hours. The combination of intraabdominal procedure and standard abdominoplasty increased the time in the operating room by 40-90 minutes. Number of days in the hospital for standard abdominoplasty patients included 2-3 for tubal ligation, 5 for total abdominal hysterectomy, an 5-7 for cholecystectomy. Miniabdominoplasty patients were in the hospital 1-2 days for tubal ligation and 5 days for total abdominal hysterectomy. Only 2 minor complications occurred: a seroma and a minor skin slough. 3 patients required transfusion of autologous units of blood and non of them lost more than 500 ml of blood. The physicians encouraged all patients to become ambulatory soon after the operation and to wear elastic stockings to prevent thromboembolic events. As a result, none of the patients suffered a pulmonary embolism. In conclusion, good surgical teams can safely and effectively combine abdominoplasty with intraabdominal procedures. eng

Subchondral bone microarchitecture in ACL reconstructed knees of young women: A comparison with contralateral and uninjured control knees

OAK 3 - Non-arthroplasty tx of OAK

Anterior cruciate ligament (ACL) tears are a common sports-related knee injury that increases the risk of developing post-traumatic osteoarthritis (OA). During OA progression bone microarchitecture changes in the affected knee, however, little is known about bone microarchitecture in knees with early stage OA. The purpose of this study is to investigate in a cohort of females predisposed to develop OA how bone microarchitecture in ACL reconstructed knees differs from uninjured contralateral knees as well as healthy control knees and how this relates to early changes in OA. Bone microarchitecture was directly assessed in ACL reconstructed knees of injured female participants (n = 15) with a median age of 25.4 years (age range: 22.5â??28.5) and compared to their uninjured contralateral knees, as well as to a healthy age-matched female control sample (n = 14) with a median age of 25.2 years (age range: 22.2â??27.1). ACL reconstructed knees had lower trabecular bone mineral density (compared to contralateral: â??7.7% to â??10.4%, p < 0.05; control knees: â??7.1% to â??13.9%, p < 0.05) and altered trabecular bone microarchitecture in the medial femur compared to contralateral and control knees. The subchondral bone plate in the lateral femur was thicker in ACL reconstructed knees compared to contralateral (29.6%, p = 0.009) and control knees (47.9% to 53.7%, p < 0.05). Contralateral knees did not differ from control knees. Loss of trabecular bone and increased subchondral bone plate thickness in the ACL-reconstructed knees are consistent with changes associated with OA progression. Most differences in bone microarchitecture were found in the femur, with few differences in the tibia. The bone microarchitecture of contralateral knees did not differ from control knees in our participants, suggesting the potential to use them as control references in future longitudinal studies.

The incidence of proximal deep vein thrombosis following total knee arthroplasty in an Asian population: a Doppler ultrasound study

Surgical Management of Osteoarthritis of the Knee CPG

PURPOSE: To investigate the incidence of deep vein thrombosis (DVT) following total knee arthroplasty in an Asian population. METHODS: A prospective study of 149 consecutive cases of total knee arthroplasty done for osteoarthritis was conducted over a 5-year period. All patients underwent duplex ultrasonographic assessment of the lower limbs within the first postoperative week. RESULTS: The incidence of proximal DVT was found to be 4.38% in this study. Symptomology was statistically significant in predicting the presence of proximal DVT in all cases. General anaesthesia was associated with a statistically significant-higher incidence of DVT as compared with regional anaesthesia. There was a significant association between a sedentary lifestyle and the development of DVT. CONCLUSION: The incidence of proximal DVT in Asian patients after total knee arthroplasty is higher than that previously reported for this demographic group

Adipose derived mesenchymal stem cell therapy in the treatment of isolated knee chondral lesions: design of a randomised controlled pilot study comparing arthroscopic microfracture versus arthroscopic microfracture combined with postoperative mesenchymal stem cell injections

OAK 3 - Non-arthroplasty tx of OAK

INTRODUCTION: The management of intra-articular chondral defects in the knee remains a challenge. Inadequate healing in areas of weight bearing leads to impairment in load transmission and these defects predispose to later development of osteoarthritis. Surgical management of full thickness chondral defects include arthroscopic microfracture and when appropriate autologous chondrocyte implantation. This latter method however is technically challenging, and may not offer significant improvement over microfracture. Preclinical and limited clinical trials have indicated the capacity of mesenchymal stem cells to influence chondral repair. The aim of this paper is to describe the methodology of a pilot randomised controlled trial comparing arthroscopic microfracture alone for isolated knee chondral defects versus arthroscopic microfracture combined with postoperative autologous adipose derived mesenchymal stem cell injections. METHODS AND ANALYSIS: A pilot single-centre randomised controlled trial is proposed. 40 participants aged 18-50 years, with isolated femoral condyle chondral defects and awaiting planned arthroscopic microfracture will be randomly allocated to a control group (receiving no additional treatment) or treatment group (receiving postoperative adipose derived mesenchymal stem cell treatment). Primary outcome measures will include MRI assessment of cartilage volume and defects and the Knee Injury and Osteoarthritis Outcome Score. Secondary outcomes will include further MRI assessment of bone marrow lesions, bone area and T2 cartilage mapping, a 0-10 Numerical Pain Rating Scale, a Global Impression of Change score and a treatment satisfaction scale. Adverse events and cointerventions will be recorded. Initial outcome follow-up for publication of results will be at 12 months. Further annual follow-up to assess long-term differences between the two group will occur. ETHICS AND DISSEMINATION: This trial has received prospective ethics approval through the Latrobe University Human Research Ethics Committee. Dissemination of outcome data is planned through both national and international conferences and formal publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: Australia and New Zealand Clinical Trials Register (ANZCTR Trial ID: ACTRN12614000812695).

Surgery for third ventricular tumors

Upper Eyelid and Brow Surgery

A broad array of tumors of the central nervous system may arise within the third ventricular region, including gliomas; subependymal giant cell astrocytomas; meningiomas; pineal region tumors; and cysts, including ependymal, arachnoid, epidermoid, and suprasellar tumors (i.e., macroadenomas, craniopharyngiomas, meningiomas, and optic gliomas). The clinical presentation varies with tumor location in and around the third ventricle. Tumors of the inferior portion of the anterior third ventricle can cause endocrine complaints, including diabetes insipidus and hypopituitarism as well as visual field impairment. Tumors of the superior portion of the anterior third ventricle result in obstructive hydrocephalus and cognitive memory deficits. Tumors of the posterior third often create outflow obstruction and hydrocephalus, and pineal region tumors are associated with Parinaud syndrome. Multiple surgical approaches may be considered in resecting tumors of the third ventricular region, including transcortical or interhemispheric transcallosal, interforniceal, transforaminal, orbitozygomatic subfrontal, or infratentorial supracerebellar. Each approach has strengths and weaknesses, and the choice is often made according to the surgeon's experience and comfort level. The goals of surgery must be carefully considered so as to minimize neurologic morbidity or mortality. Finally, adjuvant chemotherapy and/or radiation therapy may play a significant role in treating tumor after tissue diagnosis.

Changes in impairment and function after static progressive splinting for stiffness after distal radius fracture

Distal Radius Fractures

The purpose of this study was to describe changes in range of motion, grip strength, and function in subjects treated with static progressive splinting for stiffness after distal radius fracture. A retrospective review was conducted on 25 patients; outcomes reviewed included wrist/forearm motion, grip strength and Disability of the Arm, Shoulder, and Hand (DASH) scores. The Wilcoxon-Signed Rank test was used to assess differences between pre-/postsplinting outcome measurements. Spearman correlation coefficients were calculated for the DASH scores with each of the other measurements. Wrist extension and flexion improved 18.6 (p<0.0001) and 11.4 degrees (p<0.0001), respectively. Forearm pronation and supination improved 20.0 (p<0.0001) and 14.5 degrees (p<0.0001), respectively. Grip strength improved 24.5 pounds (p=0.0012). The median DASH score improved from 43 to 19 (p>0.0001). DASH scores demonstrated a significant negative correlation with wrist extension (r=-0.50, p=0.011) and forearm supination (r=-0.47, p=0.02). Increased wrist extension and supination correlated with better functional outcome as reflected by the DASH scores.

Combinations of bupivacaine, fentanyl, and clonidine for lumbar epidural postoperative analgesia: a novel optimization procedure

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: The authors developed and applied a method to optimize the combination of bupivacaine, fentanyl, and clonidine for continuous postoperative lumbar epidural analgesia. METHODS: One hundred eighteen patients undergoing knee or hip surgery participated in the study. Postoperative epidural analgesia during 48 h after surgery was optimized under restrictions dictated by side effects. Initially, eight combinations of bupivacaine, fentanyl, and clonidine (expressed as drug concentration in the solution administered) were empirically chosen and investigated. To determine subsequent combinations, an optimization model was applied until three consecutive steps showed no decrease in pain score. For the first time in a clinical investigation, a regression model was applied when the optimization procedure led to combinations associated with unacceptable side effects. RESULTS: The authors analyzed 12 combinations with an allowed bupivacaine concentration range of 0-2.5 mg/ml, a fentanyl concentration range of 0-5 microg/ml, and a clonidine concentration range of 0-5 microg/ml. The best combinations of bupivacaine, fentanyl, and clonidine concentrations were 1.0 mg/ml-1.4 microg/ml-0.5 microg/ml, 0.9 mg/ml-3.0 microg/ml-0.3 microg/ml, 0.6 mg/ml-2.5 microg/ml-0.8 microg/ml, and 1.0 mg/ml-2.4 microg/ml-1.0 microg/ml, respectively, all producing a similarly low pain score. The incidence of side effects was low. The application of the regression model to combinations associated with high incidence of motor block successfully directed the optimization procedure to combinations within the therapeutic range. CONCLUSIONS: The results support further study of the combinations of bupivacaine, fentanyl, and clonidine mentioned above for postoperative analgesia after knee and hip surgery. This novel optimization method may be useful in clinical research

Free vascularized fibular grafting following failed core decompression for femoral head osteonecrosis

AAHKS (2) Corticosteroids

The results of treatment of femoral head osteonecrosis with free vascularized fibular grafting (FVFG) following failed core decompression (core decompression-FVFG [CD-FVFG] group: 32 hips) were reviewed and compared with those of a control group that underwent FVFG only (54 hips). Outcome was considered unsuccessful if total hip arthroplasty was subsequently performed. Total hip arthroplasty was performed in 15 and 20 hips of the CD-FVFG and control groups, respectively. When considering age, sex, and presence of bilateral disease, patients with previous core decompression did not have a significantly different failure rate from patients with FVFG only. However, patients with preoperative stage V osteonecrosis or corticosteroid use had worse outcomes after vascularized fibular grafting if they had a previous core decompression of the femoral head.

The Impact of Human Lipoaspirate and Adipose Tissue-Derived Stem Cells Contact Culture on Breast Cancer Cells: Implications in Breast Reconstruction

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Autologous fat transfer in the form of lipoaspirates for the reconstruction of the breast after breast cancer surgery is a commonly used procedure in plastic surgery. However, concerns regarding the oncologic risk of nutrient-rich fat tissue are widely debated. Previous studies have primarily focused on studying the interaction between adipose-derived stem cells (ASCs) and breast cancer cells. METHODS: In this study, we performed a comprehensive analysis of the paracrine- and contact-based interactions between lipoaspirates, ASCs and breast cancer cell lines. An inverted flask culture method was used to study the contact-based interaction between lipoaspirates and breast cancer cells, while GFP-expressing breast cancer cell lines were generated to study the cell-cell contact interaction with ASCs. Three different human breast cancer cell lines, MCF-7, MDA-MB-231 and BT-474, were studied. We analyzed the impact of these interactions on the proliferation, cell cycle and epithelial-to-mesenchymal (EMT) transition of the breast cancer cells. RESULTS: Our results revealed that both lipoaspirates and ASCs do not increase the proliferation rate of the breast cancer cells either through paracrine- or contact-dependent interactions. We observed that lipoaspirates selectively inhibit the proliferation of MCF-7 cells in contact co-culture, driven by the retinoblastoma (Rb) protein activity mediating cell cycle arrest. Additionally, ASCs inhibited MDA-MB-231 breast cancer cell proliferation in cell-cell contact-dependent interactions. Quantitative real-time PCR revealed no significant increase in the EMT-related genes in breast cancer cells upon co-culture with ASCs. CONCLUSION: In conclusion, this study provides evidence of the non-oncogenic character of lipoaspirates and supports the safety of clinical fat grafting in breast reconstruction after oncological surgical procedures. In vivo studies in appropriate animal models and long-term post-operative clinical data from patients are essential to reach the final safety recommendations.

Anatomical plate configuration affects mechanical performance in distal humerus fractures

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

BACKGROUND: Because of strong loads acting in the elbow joint, intraarticular fractures with a methaphyseal comminuted fracture site at the distal humerus demand a lot from the osteosynthetic care. Ambiguities arise concerning to the anatomic position of the implants and the resulting mechanic performance. The aim of this biomechanical study was to compare the performance of different anatomical plate configurations for fixation of comminuted distal humerus fractures within one system. METHODS: In an artificial bone model two perpendicular and one parallel plating configuration of a dedicated elbow plating system were compared with respect to system rigidity (flexion and extension) and dynamic median fatigue limit (extension). The flexion tests were conducted under 75 degrees and the extension tests under 5 degrees . Furthermore, the relative displacements were recorded. As a fracture model an AO C 2.3-fracture on an artificial bone (4th Gen. Sawbone) was simulated via double osteotomy in sagittal and transversal plane. FINDINGS: Large differences in mechanical performance were observed between flexion and extension loading modes. In extension the parallel configuration with lateral and medial plates achieved the highest bending stiffness and median fatigue limit. In flexion the highest bending stiffness was reached by the construct with a medial and a postero-lateral plate. Failure of the implant system predominantly occurred at the screw-bone interface or by fatigue of the plate around the screw holes. INTERPRETATION: All three plate configurations provided sufficient mechanical stability to allow early postoperative rehabilitation with a reduced loading protocol. Although the individual fracture pattern determines the choice of plate configuration, the parallel configuration with lateral and medial plates revealed biomechanical advantages in extension only

Sonographic evaluation of osteoarthritic femoral condylar cartilage. Correlation with operative findings

Surgical Management of Osteoarthritis of the Knee CPG

Femoral condylar cartilage abnormalities were evaluated in patients treated with total knee arthroplasty, and real-time ultrasonic images were correlated with the abnormalities seen in the corresponding gross pathologic specimens. Subjective impressions of abnormalities on the images recorded on film correlated well with pathologic findings. Thickness measurements were easily made in normal images but proved difficult at sites of cartilage damage where the cartilage-bone and cartilage-soft-tissue interfaces became less clear. This study suggests that with further technologic refinement, this technique may provide a rapid and cost-effective method of assessing the integrity of femoral condylar cartilage

A phase 3 trial of the efficacy and safety of oral recombinant calcitonin: The Oral Calcitonin in Postmenopausal Osteoporosis (ORACAL) trial

Management of Hip Fractures in the Elderly

The Oral Calcitonin in Postmenopausal Osteoporosis (ORACAL) study was a randomized, double-blind, double-dummy, active- and placebo-controlled, multiple-dose, phase 3 study to assess the efficacy and safety of oral recombinant calcitonin for treatment of postmenopausal osteoporosis. A total of 565 women age 46 to 86 (mean 66.5) years were randomized (4:3:2) to receive oral recombinant salmon calcitonin (rsCT) tablets (0.2 mg/d) plus placebo nasal spray, synthetic salmon calcitonin (ssCT) nasal spray (200 IU/d) plus placebo tablets, or placebo (placebo tablets plus placebo nasal spray), respectively for 48 weeks. All women received calcium ((greater-than or equal to)1000 mg/d) and vitamin D (800 IU/d). Women randomized to oral rsCT had a mean (plus or minus) SD percent increase from baseline in lumbar spine bone mineral density (BMD) (1.5% (plus or minus) 3.2%) that was greater than those randomized to ssCT nasal spray (0.78% (plus or minus) 2.9%) or placebo (0.5% (plus or minus) 3.2%). Lumbar spine BMD change in those receiving nasal calcitonin did not differ from placebo. Oral rsCT treatment also resulted in greater improvements in trochanteric and total proximal femur BMD than ssCT nasal spray. Reductions in bone resorption markers with oral rsCT were greater than those observed in ssCT nasal spray or placebo recipients. Approximately 80% of subjects in each treatment group experienced an adverse event, the majority of which were mild or moderate in intensity. Gastrointestinal system adverse events were reported by nearly one-half of women in all treatment groups and were the principal reason for premature withdrawals. Less than 10% of women experienced a serious adverse event and no deaths occurred. Overall, oral rsCT was superior to nasal ssCT and placebo for increasing BMD and reducing bone turnover. Oral rsCT was safe and as well tolerated as ssCT nasal spray or placebo. Oral calcitonin may provide an additional treatment alternative for women with postmenopausal osteoporosis. Copyright (copyright) 2012 American Society for Bone and Mineral Research

Comparison of a mobile with a fixed-bearing unicompartmental knee implant

Surgical Management of Osteoarthritis of the Knee CPG

Two well-matched groups of patients with unicompartmental knee arthroplasties were compared. The first 51 knees were treated with a fixed-bearing knee implant and the second 50 knees were treated with a mobile meniscal-bearing implant. Followup was 7.7 years for the patients with fixed-bearing implants and 6.8 years for patients with mobile-bearing implants. Both groups functioned well clinically. Radiographic analysis with 3-foot standing views taken preoperatively showed both groups had an average varus alignment of -2(degrees). Postoperatively patients with fixed-bearing implants had an average +2.6(degrees) alignment and the patients with mobile-bearing implants had +5.5(degrees) alignment, which was significantly different. Survivorship analysis based on component loosening and revision showed a 99% survival for the meniscal-bearing implant and 93% survival for the fixed-bearing implant at 11 years. However, the fixed-bearing knee implants failed significantly more often because of tibial component failure, in six of eight knees, at an average of 6.3 years. The mobile-bearing implants showed a trend to fail because of arthritic degeneration in the lateral compartment, at an average of 10 years, although not statistically significant. The mobile-bearing implants had no tibial component failures. These differences may be attributable to implant design or surgical technique

Malnutrition in hip fracture patients: an intervention study

Management of Hip Fractures in the Elderly

AIMS: To investigate whether a nutritional intervention in older women and men with femoral neck fracture had an effect on postoperative complications during hospitalization and on nutritional status at a four-month follow-up. METHODS: The design was a randomized controlled trial. The present study sample consisted of 157 patients aged 70 years and above with femoral neck fracture. The nutritional intervention included, among other things, a nutritional journal to detect nutrition deficiencies and protein-enriched meals for at least four days postoperatively. Further, at least two nutritional and protein drinks were served each day during the whole hospitalization and other factors that would influence the patient's nutrition were also considered and dealt with. Postoperative complications were registered and patients were assessed using the Mini Nutritional Assessment (MNA) scale, including body mass index (BMI), on admission and at a four-month follow-up. RESULTS: Malnutrition was common and low MNA scores were associated with postoperative complications such as delirium and decubitus ulcers. There were significantly fewer days of delirium in the intervention group, seven patients in the intervention group developed decubitus ulcers vs. 14 patients in the control group and the total length of hospitalization was shorter. There were no detectable significant improvements regarding nutritional parameters between the intervention and the control group at the four-month follow-up but men improved their mean BMI, body weight and MNA scores in both the intervention and the control groups while women deteriorated in both groups. CONCLUSIONS: Malnutrition was common among older people with hip fractures admitted to hospital. The nutritional intervention might have contributed to the patients suffering fewer days with delirium, fewer decubitus ulcers and shorter hospitalization but did not improve the long-term nutritional status, at least not in women. RELEVANCE TO CLINICAL PRACTICE: This nutritional intervention, which was included in a multifactorial multidisciplinary intervention, is inexpensive and relatively easy to implement. It has significant effects on complications but no long-term effect on nutritional parameters, at least not in women

Posterior-stabilized total knee arthroplasty: a matched pair analysis of a classic and its evolutional design

OAK 3 - Non-arthroplasty tx of OAK

Background Total knee arthroplasty (TKA) designs continue to be modified to optimize patient's outcome. This study was designed to compare clinical and radiological results of classic worldwide used TKA posterior-stabilized (PS) design to those of its recent evolution. Methods A consecutive group of 100 patients undergoing TKA using a classic cemented fixed-bearing PS TKA system was matched by age, gender, body max index to 100 patients having the newer cemented fixed-bearing PS design, both by the same manufacturer. Patients were assessed preoperatively, at 12 months and at 24 months minimum follow-up (range, 24-46) in a standard prospective fashion. The outcome assessments used were the Oxford Knee Score, the Knee Society Score, range of motion, and a satisfaction survey. A 2-sample t test comparing the 2 groups was performed. Results No patients were lost at follow-up. At 2-year follow-up, differences in clinical and radiological Knee Society Score (P =.09), Oxford Score (P =.08), and overall satisfaction rate did not reach statistical significance. Implant group 2 showed a statistically significant decrease in postoperative anterior knee pain (P =.006). At final follow-up, 16% of group 1 knees achieved > 130° flexion compared with 37% in group 2 (P =.0009). There were 2 revisions for any reason in group 1 and none in group 2. Conclusions Design modifications applied to the newer TKA system allowed greater flexion and lower patellofemoral complications but did not appear to achieve better overall clinical scores.

Establishment of a surgically-induced model in mice to investigate the protective role of progranulin in osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Destabilization of medial meniscus (DMM) model is an important tool for studying the pathophysiological roles of numerous arthritis associated molecules in the pathogenesis of osteoarthritis (OA) in vivo. However, the detailed, especially the visualized protocol for establishing this complicated model in mice, is not available. Herein we took advantage of wildtype and progranulin (PGRN)-/- mice as examples to introduce a protocol for inducing DMM model in mice, and compared the onset of OA following establishment of this surgically induced model. The operations performed on mice were either sham operation, which just opened joint capsule, or DMM operation, which cut the menisco-tibial ligament and caused destabilization of medial meniscus. Osteoarthritis severity was evaluated using histological assay (e.g. Safranin O staining), expressions of OA-associated genes, degradation of cartilage extracellular matrix molecules, and osteophyte formation. DMM operation successfully induced OA initiation and progression in both wildtype and PGRN-/- mice, and loss of PGNR growth factor led to a more severe OA phenotype in this surgically induced model.