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Impact of selected medical conditions on self-reported lower-extremity function in Mexican-American elderly

Management of Hip Fractures in the Elderly

OBJECTIVE: To examine the independent impact of common medical conditions on lower-extremity function in Mexican-American elderly. DESIGN: Cross-sectional study using a probability sample of non-institutionalized Mexican Americans aged 65 or older. SETTING: The five Southwestern states, Texas, New Mexico, Arizona, Colorado and California. PARTICIPANTS: All subjects were interviewed in person (n = 2,873) or by proxy (n = 177) in their homes during late 1993 and early 1994. MAIN OUTCOME MEASURES: Respondents were asked whether they could perform four activities related to lower-extremity function without help: walking across a small room, getting from a bed to a chair, walking up and down stairs, and walking half a mile. A summary measure of lower body disability created from these four items was regressed on seven common medical conditions plus five control variables using multiple logistic regression. RESULTS: Adjusted Odds Ratios (OR) suggested that impaired lower-extremity function was associated with previous diagnosis of hip fracture (OR = 4.28), stroke (OR = 3.47), lower extremity arthritis (OR = 2.60), heart attack (OR = 2.29), diabetes (OR = 2.03) and obesity (OR = 1.50). Impaired lower-extremity function was significantly associated with older age (75+ years old), gender (female) and marital status (unmarried). In addition, there was a linear increase in the risk of function loss by number of medical conditions. CONCLUSIONS: It appears that Mexican-American elderly diagnosed with medical conditions, especially stroke and hip fracture, have a high risk for lower-extremity dysfunction. These findings have implications for efforts to prevent or reduce lower-extremity dysfunction, as well as for the provision of community-based long-term care services for Mexican-American elderly

Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?

DoD SSI (Surgical Site Infections)

OBJECTIVE: To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo-Anderson type IIIB open tibial diaphyseal fractures. DESIGN: Retrospective comparative cohort study over a 2-year period. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis. INTERVENTION: Time to initial debridement and definitive management. MAIN OUTCOME MEASUREMENT: Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant. RESULTS: Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion. CONCLUSIONS: Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic synovectomy of the elbow for rheumatoid arthritis

Surgical Management of Osteoarthritis of the Knee CPG

The short-term assessment of 14 arthroscopic synovectomies of the elbow in 11 patients with rheumatoid arthritis showed that 93% achieved a short-term rating of excellent or good on the Mayo Elbow Performance Score. At the most recent assessment at an average of 42 months, however, only 57% maintained excellent or good results; four had required total elbow replacement. Although rehabilitation is facilitated by an arthroscopic procedure the results deteriorate more rapidly than after open synovectomy. This may be due to the limitations of the arthroscopic technique and is consistent with experience of the similar procedure in the knee. Recognition of the short-term gain and the potential for serious nerve injury should be considered when offering arthroscopic synovectomy

A prospective evaluation of 2 different pain management protocols for total hip arthroplasty

AAHKS (4) Acetaminophen

Pain management after total hip arthroplasty has improved dramatically in the past decade. However, most protocols use opioid medications for pain control. In the current study, 100 patients were prospectively selected to receive a traditional narcotic-based patient-controlled analgesia protocol or a nonnarcotic oral protocol for pain management after primary total hip arthroplasty. Therapy programs were similar for both groups. Postoperatively, patients were followed daily for opioid use, medication adverse effects, pain control, and overall satisfaction. The nonnarcotic oral group showed lower mean pain scores during the first 24 hours after surgery. The satisfaction rate was high in both groups. Both protocols provided adequate pain control after total hip arthroplasty; the nonnarcotic pain management protocol resulted in significantly decreased opioid consumption and fewer adverse effects.

Characteristics and use patterns of chronic hydrocodone users

Surgical Management of Osteoarthritis of the Knee CPG

Hydrocodone/acetaminophen is the most frequently-prescribed pain treatment. This study identifies the frequency of chronic hydrocodone therapy and assesses use patterns and characteristics of chronic users. Patients, ages 18-64, initiating hydrocodone (2006-2009) with continuous eligibility (n=424,810) were selected from a nationwide, privately-insured, de-identified claims database (N=10,368,494). Patients with an average daily dose exceeding 20mg during any 90-day period in the 15 months following hydrocodone initiation were identified as chronic. Hydrocodone users without a 90-day period exceeding this threshold were considered non-chronic. Characteristics of chronic and non-chronic users were compared descriptively using chi-square and t-tests. 8,355 users, 2% of the sample, were identified as chronic users. Chronic users averaged 16.0 mg/day (vs. 0.7) during the 15-month evaluation period, filling over 6-times more hydrocodone prescriptions than non-chronic users (12.5 vs. 1.9), at higher doses (68.3% vs. 36.2% at >5mg). Additionally, chronic users were more likely to receive prescriptions for non-hydrocodone short-acting opioids (50.2% vs. 24.8%). Seventy-five percent of chronic users had (greater-than or equal to)1 diagnosis of back pain, neuropathic pain, and/or osteoarthritis. Finally, chronic users had more pain-related diagnoses such as insomnia (6.1% vs. 3.0%) and mental health conditions (29.6% vs. 17.6%); hip/knee replacements or spinal surgeries (15.2% vs. 1.7%); and liver-related conditions (3.7% vs. 2.5%). (All comparisons significant at p<0.0001.) These findings suggest that many hydrocodone/acetaminophen patients receive high doses for a sustained period and that chronic users have higher incidence of certain comorbidities, including liver-related conditions potentially associated with sustained acetaminophen use. Knowledge regarding the characteristics and treatment patterns of chronic hydrocodone users may help inform clinicians and optimize pharmacotherapy including consideration of extended-release opioid use in this population

Open wedge high tibial osteotomy

Surgical Management of Osteoarthritis of the Knee CPG

Osteotomy is a classic operation in the treatment of unicompartmental osteoarthrosis of the knee. It has often been presented as a possible alternative to prosthetic joint replacement, but the indications depend on the stage and articular diffusion of the degenerative changes and on the patient's profile and are very different in most cases from the indications for unicompartmental or total knee replacement. A relatively new technique of high tibial osteotomy will be illustrated in this article with careful step-by-step presentation of all the details of the operation. Compared to the Coventry lateral closing wedge osteotomy, this technique turns upside down the method of correction of the varus deformity and adds a wedge medially. It is based on a special dedicated system of instruments and plates developed by Puddu et al in the early 1990s. Copyright (copyright) 2012 by Lippincott Williams & Wilkins

Examining sex differences in knee pain: the multicenter osteoarthritis study

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To determine whether women experience greater knee pain severity than men at equivalent levels of radiographic knee osteoarthritis (OA). DESIGN AND METHODS: A cross-sectional analysis of 2712 individuals (60% women) without knee replacement or a recent steroid injection. Sex differences in pain severity at each Kellgren-Lawrence (KL) grade were assessed by knee using visual analog scale (VAS) scale and Western Ontario and McMaster Universities Arthritis Index (WOMAC) with and without adjustment for age, analgesic use, Body mass index (BMI), clinic site, comorbid conditions, depression score, education, race, and widespread pain (WSP) using generalized estimating equations. Effect sizes (Cohen's d) were also calculated. Analyses were repeated in those with and without patellofemoral OA (PFOA). RESULTS: Women reported higher VAS pain at all KL grades in unadjusted analyses (d = 0.21-0.31, P < 0.0001-0.0038) and in analyses adjusted for all covariates except WSP (d = 0.16-0.22, P < 0.0001-0.0472). Pain severity differences further decreased with adjustment for WSP (d = 0.10-0.18) and were significant for KL grade <=2 (P = 0.0015) and 2 (P = 0.0200). Presence compared with absence of WSP was associated with significantly greater knee pain at all KL grades (d = 0.32-0.52, P < 0.0001-0.0008). In knees with PFOA, VAS pain severity sex differences were greater at each KL grade (d = 0.45-0.62, P = 0.0006-0.0030) and remained significant for all KL grades in adjusted analyses (d = 0.31-0.57, P = 0.0013-0.0361). Results using WOMAC were similar. CONCLUSIONS: Women reported greater knee pain than men regardless of KL grade, though effect sizes were generally small. These differences increased in the presence of PFOA. The strong contribution of WSP to sex differences in knee pain suggests that central sensitivity plays a role in these differences.

Interventions for treating acute elbow dislocations in adults

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

This is the protocol for a review and there is no abstract. The objectives are as follows:To assess the effects (benefits and harms) of interventions for treating acute simple elbow dislocations in adults.We aim to compare: 1. different methods of closed reduction; 2. different types of post-reduction splinting (functional brace versus plaster cast); 3. different durations of immobilisation, including compared with no immobilisation or early mobilisation; 4. operative (e.g. repair of soft-tissue structures) versus non-operative intervention (typically, closed reduction and immobilisation); 5. different types of surgery, specifically side of repair of soft-tissue structures, and use of external fixation

Comparative study on Chinese medicine and western medicine for treatment of osteoarthritis of the knee in Caucasian patients

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To compare the efficacy, safety and tolerability of different therapies in Caucasian patients with osteoarthritis (QA) of the knee. METHODS: Seventy�five cases (90 knee joints) of osteoarthritis were randomly divided into 3 groups, western medicine group, traditional Chinese medicine (TCM) group, integrated Chinese and western medicine group. The western medicine group were treated with oral administration of Glucosamine Sulfate, oral administration and external application of non�steroid anti�inflammatory agent, ultrasound physiotherapy, etc. The TCM group were treated with oral administration of J uanbi Decoction, acupuncture and moxibustion, cupping, massage of acupoint and ear acupuncture. The integrated Chinese and western medicine group were treated with oral administration of Glucosamine Sulfate, oral administration and external application of non�steroid anti�inflammatory agent, acupuncture and moxibustion, cupping, massage of acupoint and ear acupuncture. The intensity of knee joint pain on walking, resting and standing, the nocturnal pain, stiffness, the maximum walking distance and the daily living ability were monitored after 30 days, 60 days and 90 days of treatment. RESULTS: After 90 days of treatment, the integrated Chinese and western medicine group was better than other two groups in improvement of percentages in self pain assessment with visual analog scale (VAS), pain and stiffness measured by WOMAC scale, pain and maximum walking distance measured by Lequesne scale (P < 0.05 or P < 0.01). There were no significant differences in the therapeutic effects between the TCM group and the western medicine group. All of these three treatments were well tolerated, and no severe adverse events were found. CONCLUSION: Combined TCM and western medicine treatment has rapid and definite therapeutic effect in reducing pain and improving mobility of knee joints and daily living ability in Caucasian patients of knee osteoarthritis.

Hip fracture protocols: what have we changed?

Management of Hip Fractures in the Elderly

Early surgical intervention is thought to reduce in-hospital morbidity and mortality as well as short-term mortality rates for elderly patients with hip fractures. However, hip fractures are also thought to be a symptom of progressive decline in elderly patients with multiple medical comorbidities. A measured approach to medical optimization, which may preclude rapid surgical intervention, is often required to improve the patient's ability to resume a prefracture standard of living. Of late, new models of geriatric hip-fracture care have emerged, most of which entail early involvement of geriatricians and interdisciplinary care pathways, while continuing to focus on rapid surgical treatment

The risk of symptomatic knee osteoarthritis after arthroscopic meniscus repair vs partial meniscectomy vs the general population

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To compare consultation rate for knee osteoarthritis (OA) after meniscus repair, arthroscopic partial meniscectomy (APM), and in general population, respectively. METHOD: We identified patients aged 16-45 years having had meniscus surgery due to traumatic meniscus tear in 1998-2010 in southern Sweden by a healthcare register. Patients were followed from surgery until a diagnosis of knee OA, relocation, death, or December 31st, 2015. We studied the consultation rate for knee OA compared to the general population. RESULTS: We identified 2,487 patients diagnosed with traumatic meniscus tear (mean [SD] age 30.5 [8.6] years); 229 (9.2%) of them had had meniscus repair. The absolute risk of having consulted for knee OA during the study was 17% after APM, 10.0% after meniscus repair, and 2.3% in the general population. Hazard ratio (HR) (95% confidence interval (CI)) for knee OA after repair vs APM was: 0.74 (0.48, 1.15). Excluding cases with OA within 2 years post-surgery, yielded the HR of 0.51 (0.27, 0.96). The consultation rate for knee OA standardized to the general population was then 42 per 10,000 person-years (95% CI 12, 71) in the meniscus repair group, 118 per 10,000 person-years (95% CI 101, 135) after APM, and 20 per 10,000 person-years (95% CI 19.9, 20.1) in the general population. CONCLUSION: The point estimates suggests about 25-50% lower risk of consultation for knee OA after meniscus repair as compared to APM. However, the consultation rate for knee OA after repair was still at least two times higher as compared to the general population.

Surgical complications after intestinal transplantation in infants and children--UK experience

DOD - Acute Comp Syndrome CPG

UNLABELLED: Surgical complications have a significant impact on morbidity and mortality following intestinal transplantation (ITx). Birmingham Children's Hospital commenced intestinal transplantation in 1993 and the following surgical strategies evolved: (a) pretransplant abdominal tissue expanders, 1998; (b) combined en-bloc reduced liver and intestinal transplantation (CRLITx), 1998; (c) staged abdominal closure, 2001; (d) preservation of graft duodenal artery, 2005. AIM: An internal audit was performed to document the surgical complications after ITx and to evaluate strategies in the management and prevention of complications. METHODS: A retrospective analysis of the medical records from January 1993 to June 2007 was conducted to identify surgical complications, evaluate management strategies, and report outcome following ITx. RESULTS: Forty-six children underwent 49 ITx (9 isolated intestinal, 39 combined liver and intestinal [CLITx], and 1 multivisceral transplant). Twenty three children had CRLITx since 1998, although there were none before 1997. The median donor: recipient weight ratio in CLITx was 2.2:1 (range, 0.67:1-6.70:1). Twenty-six children experienced 29 (59%) surgical complications: portacaval shunt thrombosis (n = 2, none alive); graft duodenal stump leakage (n = 3, 2 alive); spontaneous bowel perforation(n = 6, 2 alive); sub-acute bowel obstruction (n = 6, all alive); abdominal compartment syndrome ([ACS], n = 4, 2 alive); pancreatic leak (n = 3, 2 alive); biliary complications (n = 22, 17 alive ) failed staged abdominal closure with wound sepsis requiring skin grafting into the bowel (n = 1, alive), wound dehiscence (n = 1, alive), anastomotic leak (n = 1, alive) and intra-abdominal bleeding (n = 1,alive), primary nonfunction (n = 1, 1 died). Following the complications of ACS in children with primary abdominal closure and graft duodenal stump leaks in 2004, we modified our strategies in 2005 to include staged abdominal closure with recipient to donor weight mismatch, and preservation of the gastroduodenal artery during donor organ procurement in addition to pre transplant abdominal tissue expansion. Fifteen children with recipient and donor weight mismatch subsequently required staged closure of the abdomen and none of them developed ACS. Twelve children had gastroduodenal artery preserved and none developed graft duodenal stump leaks. Twenty-four of the 46 (52%) are alive 6 months to 10 years post transplant. CONCLUSION: Evolving strategies may avoid or reduce surgical complications commonly seen after intestinal transplantation and thus contribute to an improved outcome. Copyright 2010 Elsevier Inc. All rights reserved.

Breast reduction using liposuction with tumescent local anesthesia and powered cannulas

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Having large, heavy breasts can be a problem for women. The widely accepted method of breast reduction is excision, but this procedure often leads to a large number of unwanted side effects and complications. There is, therefore, a need for an effective technique that produces fewer of these undesirable features. OBJECTIVE: A study was conducted to evaluate the safety and efficacy of liposuction using tumescent local anesthesia (TLA) and powered cannulas. METHODS: One hundred fifty-one women were treated. Exact measurements of volume and ptosis were performed before the procedure and at intervals of 6 weeks and 4 months after the procedure. RESULTS: The average volume of the breast removed was 53%. Fat was abundant in elderly women and more easily removed because of the progressive fatty involution of the breast. Ptosis reduction was sufficient in women of all ages, with an average of 3.0 cm achieved after 4 months. Patient satisfaction was high, no serious complications were seen, and down-time was minimal. Pre- and postoperative mammograms were taken 1 year after the procedure and showed no new calcifications. CONCLUSION: Liposuction using TLA and powered cannulas is a safe and effective treatment modality for breast reduction.

30-day Readmissions and Reoperations after Total Elbow Arthroplasty: A National Database Study

DoD SSI (Surgical Site Infections)

PURPOSE: The purpose of this study was to determine the rate of short-term complications after TEA and identify predictors of readmission and reoperation. We hypothesized that TEA performed for acute elbow trauma would have higher rates of 30-day readmission and reoperation than TEA for osteoarthritis. METHODS: Using the National Surgical Quality Improvement (NSQIP) database years 2011-2017, we identified patients undergoing TEA for fracture, osteoarthritis, or inflammatory arthritis. Patient demographics, comorbidities, reoperations and readmissions within thirty days of surgery were analyzed. Potential predictors of reoperation and readmission in the model include: age, sex, race, body mass index (BMI), diabetes, hypertension, chronic obstructive pulmonary disease (COPD), congestive heart failure, smoking, bleeding disorders, American Society of Anesthesiologists (ASA) classification, wound classification, operative time, and indication for surgery. RESULTS: A total of 414 patients underwent TEA from 2011-2017. Of these patients, 40.6% underwent TEA for fracture, 37.0% for osteoarthritis, and 22.7% for inflammatory arthritis. The overall rate of unplanned readmission was 5.1% (21 patients). The rate of unplanned reoperations was 2.4% (10 patients). Infection was the most common reason for both unplanned readmission and reoperation. The rate of reoperation and readmission was not significantly associated with any of the three operative indications: fracture, osteoarthritis, or inflammatory arthritis. A multiple logistic regression analysis found increased BMI to be associated with lower odds of an unplanned readmission (OR=0.883, 95% CI: 0.798 to 0.963, p=0.0035), wound classification >3 associated with increased odds of an unplanned reoperation (OR=16.531, 95% CI: 1.300 to 167.960, p=0.0144) and total local complications (OR=17.587, 95% CI: 2.207 to 132.019, p=0.0057). Patients who were not functionally independent were more likely to experience local complications (OR=4.181, 95% CI: 0.983 to 15.664, p=0.0309) than functionally independent patients. CONCLUSIONS: The 30-day unplanned reoperation rate after TEA was 2.4%, and the unplanned readmission rate was 5.1%. Low BMI was predictive of readmission. Wounds classified as contaminated or dirty were predictive of reoperation. Dependent functional status and contaminated wounds were predictive of local complications. The indication for TEA (fracture versus OA versus RA) was not found to be a risk factor for reoperation or readmission after TEA.

Effectiveness of Dry Needling in Knee Osteoarthritis Compared to Conventional Treatment

OAK 3 - Non-arthroplasty tx of OAK

Randomized clinical trial in patients with knee osteoarthritis. Sixty patients will be evaluated, divided in two groups (30 in each). One group A will be treated by dry needling in the vast internal and the other group B will be treated with a standardized treatment protocol (electrotherapy and manual therapy). The investigators want to observe which technique is the most effective in osteoarthritis.

Antibacterial and antiplaque effects of a novel, alcohol-free oral rinse with cetylpyridinium chloride

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Antimicrobial agents are commonly incorporated into hygiene products for the treatment and prevention of plaque and gingivitis. Recently, a new alcohol-free rinse containing 0.07% cetylpyridinium chloride (CPC) in a high bioavailable matrix (Crest Pro-Health Rinse) was introduced to provide antiplaque and antigingivitis benefits. This paper reviews results from an in vitro pre-clinical study and an in vivo clinical study evaluating the antibacterial and antiplaque benefits of this CPC rinse technology. In the in vitro experiment, a no-alcohol 0.065% high bioavailable CPC prototype rinse was evaluated for its hostility against a broad range of microorganisms commonly associated with plaque and gingivitis. The rinse demonstrated greater than 99% germ kill for all organisms tested individually as well as in whole saliva. The benefit of this antibacterial action on plaque inhibition was assessed in a clinical trial. A double-blinded, 3-period, 6-sequence crossover study was conducted evaluating the antiplaque effect of the novel 0.07% high bioavailable, alcohol-free CPC rinse versus a positive control (Listerine Cool Mint containing essential oils) and a negative control (placebo CPC rinse). A modification of the Addy 4-day plaque model was used for this evaluation. Plaque was measured at baseline (Day 1) of each treatment period and at Day 4 using the Turesky modification of Quigley-Hein index. During the treatment period, subjects brushed only their lingual surfaces twice daily for up to 60 seconds. Following brushing, subjects used 20 mls of the mouthrinse product for 30 seconds in the morning and evening. Fifty-five subjects completed the study. For non-brushed sites, both the essential oils and CPC rinse exhibited a 25% reduction in plaque vs. placebo after four days of product usage, which was statistically significant (p < 0.0001). Both treatments also exhibited a statistically significant benefit versus placebo (p<0.0001) for brushed sites (>38% plaque reduction). These data support the antibacterial action of the high bioavailable, alcohol-free CPC rinse and demonstrate antiplaque effects for Crest Pro-Health Rinse that are "at least as good as" the leading essential oils antiseptic, making it well-suited for a broad range of patients, particularly those who are sensitive to products containing alcohol

Adrenal function after upper femoral fracture in elderly people: persistence of stimulation and the roles of adrenocorticotrophic hormone and immobility

Management of Hip Fractures in the Elderly

Previous work has shown persistent elevations in plasma cortisol concentration following upper femur fracture in elderly people. To investigate this phenomenon further, we measured plasma cortisol and adrenocorticotrophin (ACTH) and performed overnight dexamethasone suppression tests in carefully characterized patients and controls (mobile and immobile). There was no difference in cortisol or ACTH, either basally or after dexamethasone, between the mobile and immobile controls. At 2 and 8 weeks after injury, basal plasma cortisol was significantly higher than in either control group and was not related to an index of the patients' mobility potential. The ACTH concentrations also tended to be raised after injury, but the differences in concentration between injured and control subjects did not reach statistical significance. At both 2 and 8 weeks after injury, the post-dexamethasone cortisol concentration was significantly higher in the fracture patients, particularly the least mobile. Our results show that the elevation in plasma cortisol concentration in elderly femur-fracture patients, which may persist for at least 8 weeks after injury, is not explained by immobility and is probably mediated by an increased central drive to the hypothalamic-pituitary-adrenal axis

Symptomatic multifocal osteonecrosis. A multicenter study. Collaborative Osteonecrosis Group

AAHKS (2) Corticosteroids

Osteonecrosis of the femoral head frequently occurs in a young population (mean age, approximately 35 years) and may lead to disabling arthritis requiring hip arthroplasty surgery. This disease is compounded when it has concurrent involvement of other joints. Multifocal osteonecrosis is defined as disease involving three or more anatomic sites. The purpose of this study was to review the demographic, clinical, radiographic staging patterns, and treatment options in patients with multifocal osteonecrosis to facilitate earlier diagnosis and optimize treatment. Twenty-one centers participated by submitting completed data forms on patients under their care after review of their databases. One hundred one patients were identified. Patient demographics, associated diseases, corticosteroids and other medications used, presenting joints, and symptomatology were evaluated. Radiographs and magnetic resonance imaging scans or both were used to diagnose and stage osteonecrotic lesions. Ninety-two of the 101 (91%) patients had a history of corticosteroid therapy. Twelve patients (of 14 tested) were found to have a coagulation disorder. All 101 patients had femoral head involvement. Osteonecrosis also was seen in the knee (96%), shoulder (80%), ankle (44%), and seven other sites. Overall, 631 joints were involved (6.2 lesions per patient). Bilaterality was common: hips, 98%; knees, 86%; and shoulders, 83%. Most lesions (69%) were in a precollapse stage at the time the patients presented for treatment. In eleven patients, the knee was the sole presenting symptomatic joint, and the shoulder and ankle were the sole presenting symptomatic joints in five and four patients, respectively. An improved understanding of the epidemiology, pathogenesis, and etiology of multifocal osteonecrosis will facilitate the diagnosis and treatment of this disease. In patients with osteonecrosis of the hip, all symptomatic joints should be evaluated with radiographs. In patients with osteonecrosis presumably not involving the femoral head, the patient's femoral heads should be evaluated radiographically, regardless of whether the hips are symptomatic. [References: 58]

Resuspension of mild to moderate jawline laxity using a minimally invasive technique

Panniculectomy & Abdominoplasty CPG

BACKGROUND. A practical approach for superficial musculoapponeurotic system plication and neck lift is indicated for early aging changes of jawline. METHODS. A single or series of small punches or single incisions at the earlobe and then minor undermining to lift the superficial musculoapponeurotic system followed by removal of skin laxity in neck and jowl result in a seamless scar via a simple V to Y closure. RESULTS AND CONCLUSION. A minimally invasive procedure was performed easily under local anesthesia in an office/ambulatory surgery center setting.

Circulating plastic adherent mesenchymal stem cells in aged hip fracture patients

Management of Hip Fractures in the Elderly

We examined the presence of circulating plastic adherent multipotent mesenchymal stem cells (MSCs) in fracture patients. Three patient groups (n = 10-18) were evaluated, including elderly females with a femoral neck fracture treated with cemented hemiarthroplasty, an age- and sex-matched group with hip osteoarthritis (OA) treated with cemented total hip arthroplasty (THA), and younger adults with surgically treated lower extremity fractures. The presence of circulating MSCs pre- and postoperatively was compared to bone marrow (BM) MSCs from the same subjects. Criteria for identifying MSCs included cell surface markers (CD105+, CD73+, CD90+, CD45-, CD14-), proliferation through several passages as well as osteogenic, chondrogenic, and adipogenic differentiation. Plastic adherent MSCs were found in peripheral blood (PB) from 22% of hip fracture patients, 46% of younger fracture patients, and in none of 63 pre- and postmenopausal women with hip OA. When detectable, circulating MSCs appeared between 39 and 101 h after fracture. PB derived MSCs did not differ from BM derived MSCs, except for a small population (<15%) of CD34+ cells among PB derived MSCs. This initial study indicates mobilization of MSCs into the circulation in response to fracture, even in very old patients, while circulating MSCs were not detectable before or after elective THA

The nonoperative treatment of osteochondritis dissecans of the knee

Osteochondritis Dissecans 2020 Review

PURPOSE OF REVIEW: The purpose of this review is to update the reader on the controversial subject of osteochondritis dissecans (OCD) with a focus on nonoperative treatment indications, methods, and success rate. RECENT FINDINGS: Work by an international multicenter study group ROCK (Research in OsteoChondritis of the Knee) will be reviewed including new classifications systems of healing, arthroscopy, radiographs, and MRI, along with new evidence on off-loading bracing compared to restricted weight bearing. SUMMARY: The paucity of evidence behind OCD treatment of the knee can lead to confusion for doctors, patients, and parents. The present review will bring more clarity to the subject.

Minimal detectable change for mobility and patient-reported tools in people with osteoarthritis awaiting arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

Background: Thoughtful use of assessment tools to monitor disease requires an understanding of clinimetric properties. These properties are often under-reported and, thus, potentially overlooked in the clinic. This study aimed to determine the minimal detectable change (MDC) and coefficient of variation per cent (CV%) for tools commonly used to assess the symptomatic and functional severity of knee and hip osteoarthritis. Methods. We performed a test-retest study on 136 people awaiting knee or hip arthroplasty at one of two hospitals. The MDC95 (the range over which the difference [change] for 95% of patients is expected to lie) and the coefficient of variation per cent (CV%) for the visual analogue scale (VAS) for joint pain, the six-minute walk test (6MWT), the timed up-and-go (TUG) test, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS) subscales were calculated. Results: Knee cohort (n = 75) - The MDC 95 and CV% values were as follows: VAS 2.8 cm, 15%; 6MWT 79 m, 8%; TUG +/-36.7%, 13%; KOOS pain 20.2, 19%; KOOS symptoms 24.1, 22%; KOOS activities of daily living 20.8, 17%; KOOS quality of life 26.6, 44. Hip cohort (n = 61) - The MDC95 and CV% values were as follows: VAS 3.3 cm, 17%; 6MWT 81.5 m, 9%; TUG +/-44.6%, 16%; HOOS pain 21.6, 22%; HOOS symptoms 22.7, 19%; HOOS activities of daily living 17.7, 17%; HOOS quality of life 24.4, 43%. Conclusions: Distinguishing real change from error is difficult in people with severe osteoarthritis. The 6MWT demonstrates the smallest measurement error amongst a range of tools commonly used to assess disease severity, thus, has the capacity to detect the smallest real change above measurement error in everyday clinical practice. © 2014 Naylor et al.; licensee BioMed Central Ltd.

Central sensitization as a determinant of patientsâ?? benefit from total hip and knee replacement

OAK 3 - Non-arthroplasty tx of OAK

Background: Discrepancies exist between osteoarthritic joint changes and pain severity before and after total hip (THR) and knee (TKR) replacement. This study investigated whether the interaction between pre-operative widespread hyperalgesia and severity of radiographic osteoarthritis (OA) was associated with pain severity before and after joint replacement. Methods: Data were analysed from 232 patients receiving THR and 241 receiving TKR. Pain was assessed pre-operatively and at 12 months post-operatively using the WOMAC Pain Scale. Widespread hyperalgesia was assessed through forearm pressure pain thresholds (PPTs). Radiographic OA was evaluated using the Kellgren and Lawrence scheme. Statistical analysis was conducted using multilevel models, and adjusted for confounding variables. Results: Pre-operative: In knee patients, there was weak evidence that the effect of PPTs on pain severity was greater in patients with more severe OA (Grade 3 OA: Ã? = 0.96 vs. Grade 4: Ã? = 4.03), indicating that in these patients higher PPTs (less widespread hyperalgesia) was associated with less severe pain. In hip patients, the effect of PPTs on pain did not differ with radiographic OA (Grade 3 OA: Ã? = 3.95 vs. Grade 4: Ã? = 3.67). Post-operative: There was weak evidence that knee patients with less severe OA who had greater widespread hyperalgesia benefitted less from surgery (Grade 3 OA: Ã? = 2.28; 95% CI â??1.69 to 6.25). Conversely, there was weak evidence that hip patients with more severe OA who had greater widespread hyperalgesia benefitted more from surgery (Grade 4 OA: Ã? = â??2.92; 95% CI â??6.58 to 0.74). Conclusions: Widespread sensitization may be a determinant of how much patients benefit from joint replacement, but the effect varies by joint and severity of structural joint changes. Significance: Pre-operative widespread hyperalgesia and radiographic osteoarthritis (OA) severity may influence how much patients benefit from joint replacement. Patients undergoing knee replacement with less severe OA and greater widespread hyperalgesia benefitted less from surgery than patients with less hyperalgesia. Patients undergoing hip replacement with more severe OA and greater widespread hyperalgesia benefitted more than patients with less hyperalgesia.

Cement-within-cement revision of infected total hip replacement; disappointing results in 10 retrospective cases

Dental Implant Infection

INTRODUCTION: This retrospective analysis evaluates 10 patients with a late infection of a cemented total hip arthroplasty (THA) treated with two-stage revision with retention of the original well-fixed femoral cement mantle., METHODS: Clinical, laboratory, and radiological outcomes were evaluated. The average age at the first-stage revision procedure was 61.5 years (range 38-80 y). The mean follow-up period was 26 months (range 5-54 m)., RESULTS: Successful eradication of the primary microorganism was achieved in 2 patients. These patients had negative cultures at second stage and did not show any signs of infection during follow-up. The other 8 patients were considered as failures. In 3 patients, the femoral cement mantle was removed after the first stage due to recurrent infection in Girdlestone situation. In 2 patients, cultures showed the same micro-organism at first and second stage, treated with 3 months of antibiotics after second stage. 2 patients showed negative cultures at second stage but still had recurrent infection afterwards. These where treated with debridement and implant retention (DAIR) and 3 months of antibiotics. 1 patient was treated with suppressive antibiotics for persistent prosthetic joint infection after second stage, despite DAIR and therapeutic antibiotic treatment., CONCLUSIONS: Based on this study, results of two-stage revision with retention of femoral cement mantle are disappointing in treatment of infected THA. Therefore, more research is required to determine which patients are appropriate for cement-within-cement revision.

Ultrasound-assisted lipoplasty learning curve

Panniculectomy & Abdominoplasty CPG

Ultrasound-assisted lipoplasty is currently one of the newest techniques available to aesthetic surgeons. Plastic surgery organizations have undertaken the challenge of teaching proper ultrasound techniques and protocols via a series of ultrasound task force credentialing courses. The purpose of this article is to share our learning curve experiences with this technique. Our intent is to aid others with their learning curve so that more predictable early results are obtained. Between April 25, 1997, and July 15, 1997, a total of 84 patients comprising 150 anatomic sites underwent ultrasound-assisted lipoplasty at Naval Medical Center, Portsmouth, VA. These procedures were performed by four different plastic surgeons, with most cases (n=59) and procedures (n=114) performed by the senior author (M.L.Z.). The morbidity involved with these cases was early and consisted of three seromas and one focal area of iatrogenic epidermal abrasion. Follow-up has ranged from 7 to 10 months; there are no dissatisfied patients nor any patients currently scheduled for secondary corrective procedures. Our conclusions are (1) ultrasound-assisted lipoplasty is a safe and efficacious procedure; (2) there is a steep learning curve to the procedure, which we believe involves a minimum of 30 patients and requires great attention to detail in terms of volume of infused tumescent solution, and ultrasonic aspiration times; and (3) volume for volume, morbidity associated with this procedure should be no greater than with traditional tumescent lipoplasty.

Post-Acute Rehabilitation After Total Knee Replacement: A Multicenter Randomized Clinical Trial Comparing Long-Term Outcomes

OAK 3 - Non-arthroplasty tx of OAK

Objective: To evaluate the long-term benefit of providing a post-acute, outpatient group exercise program for patients following primary total knee replacement (TKR) surgery for osteoarthritis. Methods: A multicenter randomized clinical trial was conducted in 12 Australian public and private hospital centers. A total of 422 participants, ages 45â??75 years, were randomly allocated prior to hospital discharge to the post-acute group exercise program or to usual care and were assessed at 6 weeks, 6 months, and 12 months after surgery. The main outcomes were operated knee pain and activity limitations at 12 months using the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. Secondary outcomes included health-related quality of life (Short Form 12 health survey), knee extension and flexion strength, stair-climb power, 50-foot walk speed, and active knee range of motion. Results: While both allocation groups achieved significant improvements in knee pain and activity limitations over the 12-month followup period, there were no significant differences in these main outcomes, or in the secondary physical performance measures, between the 2 treatment allocations. Twelve months after TKR, 69% and 72% of participants allocated to post-acute exercise and usual acute care, respectively, were considered to be treatment-responders. While population normative values for self-report measures of pain, activity limitation, and health-related quality of life were attained 12 months after TKR, marked deficits in physical performance measures remained. Conclusion: Providing access to a post-acute group exercise program did not result in greater reductions in long-term knee pain or activity limitations than usual care. Patients undergoing primary TKR retain marked physical performance deficits 12 months after surgery.

Symptomatic flexion instability in posterior stabilized primary total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Flexion instability in posterior-stabilized total knee arthroplasty is a relatively uncommon but distinct problem that is often underdiagnosed and may require surgical management. This retrospective study evaluated the authors' management strategy and assessed the results of revision surgery. The authors identified 19 knees that underwent revision for isolated flexion instability after primary posterior-stabilized total knee arthroplasty. All patients had typical symptoms and signs of flexion instability, which include diffuse pain, especially when negotiating stairs, a sense of instability without giving way, recurrent joint effusions, and diffuse periarticular tenderness. Knee Society scores were used to assess pain and function. Complete revision was performed in 11 knees, femoral revision with a thicker insert was performed in 1 knee, and isolated tibial polyethylene insert exchange was performed in 7 knees. Postoperatively, all patients reported improvement in instability symptoms and signs associated with improvement in mean Knee Society scores. Revision surgery with careful gap balancing is successful in the management of isolated flexion instability in posterior-stabilized total knee arthroplasty. Isolated tibial polyethylene insert exchange may have a role in selected patients where component malalignment and malrotation is ruled out and a thicker and/or semiconstrained insert can be used, while limiting the resultant flexion contracture to less than 5(degrees)

Biochemical markers and bone mineral density in patients with hip fractures in men

Management of Hip Fractures in the Elderly

The purpose of this study was to determine whether males with hip fractures have associated decreased gonadal function. Second void urine and serum samples were obtained from 25 male hip fracture patients (mean age+/-SD, 78.5+/-5.9 years) and 19 age- and gender-matched controls (77.6+/-6.2 years). Serum levels of luteinizing hormone (LH), total testosterone (Te), total estradiol (E2), dehydroepiandrosterone sulfate (DHEAS), 1,25(OH)2D3, N-mid osteocalcin (OC(N-mid)), type I collagen degradation products (S-CTx) and urinary levels of pyridinoline (Pyr), deoxypyridinoline (Dpyr) and type I collagen degradation products (U-CTx) were measured. Bone mineral density (BMD) of the L2-4 spine, femoral neck, trochanter, Ward's triangle, distal one third portion of the radius and ultradistal radius were also measured in the fracture group. Serum levels of LH, E2, Te, DHEAS, 1,25(OH)2D3 and OCN-mid in the fracture group were not statistically different from those in the control group. Levels of urinary Pyr, CTx and S-CTx in the fracture group increased significantly compared with those in the control group. In the fracture group, serum levels of Te correlated positively with distal one third portion of the radius BMD and ultradistal radius BMD. U-CTx and S-CTx correlated negatively with all the BMD measurement sites in the hip region and with the radius BMD. An imbalance between bone resorption and bone formation was evident in male hip fracture patients. However, male patients with hip fractures did not show associated decreased gonadal function in this study

Consensus-based management of differentiated thyroid cancer in a tertiary care set-up

MSTS 2018 - Femur Mets and MM

Introduction: This study describes the experience of a tertiary care hospital in the management of differentiated thyroid cancer. Thyroid cancer accounts for less than 1% of all human malignancy. Nevertheless, it is the commonest endocrine malignancy constituting 90% of endocrine cancers. It is the commonest cancer in Saudi Arabian women second to breast cancer. This fact makes differentiated thyroid cancer an important tumor and a challenging disease. Methods: The medical records of patients diagnosed to have differentiated thyroid cancer in King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia between 1st January 2000 and 30th September 2006 were reviewed retrospectively. The data included patient's demographic details, clinical diagnoses, co-morbid conditions, relevant investigations, imaging studies, medical and surgical treatment offered, types of surgeries performed, radioactive iodine therapy given, and the complications and outcome of management. Management of these patients follows a clinical care pathway set up by the hospital Thyroid Cancer Group representing various multidisciplinary team members. Results: One hundred and eight medical records were reviewed. Of these, 72 (66.7%) patients were females and 36 (33.3%) were males. Median age for the females was 40 years, and for males 45 years. Ninety patients (83.3%) had a papillary carcinoma, four patients (3.7%) had a follicular carcinoma and fourteen patients (13%) had other types, namely medullary thyroid carcinoma, anaplastic carcinoma and lymphoma. A total of 78 patients underwent various forms of surgery in our hospital and the remaining patients underwent operation in the district hospitals before they were referred to our centre for further management. Complications included bleeding (1.8%), voice changes (4.5%), and hypocalcaemia (3.8%). The overall outcome showed that 99 patients (91.7%) were alive and well at the time of analysis, 4 patients (3.7%) died and 5 patients (4.6%) were lost to follow up. Conclusions: This hospital-based epidemiological study, the largest one done in the western part of Saudi Arabia, showed that differentiated thyroid cancer behavior and the management approach we adopt is not different from other centres of excellence. In spite of the relatively higher number of redo surgery we performed in these patients, yet the incidence of recurrent laryngeal nerve injury and hypocalcaemia are similar to what is published in the literature. © 2010 Surgical Associates Ltd.

The risk of subsequent joint arthroplasty after primary unilateral total knee arthroplasty, a 10-year study

Surgical Management of Osteoarthritis of the Knee CPG

The purposes of this study were to determine the probabilities of subsequent lower extremity arthroplasty after index knee arthroplasty for osteoarthritis and to evaluate the demographic as well as radiographic factors that may predict progression to arthroplasty in the contralateral knee. Between 1984 and 1994, 646 patients, aged 40 to 75 years, with a primary cruciate-retaining knee were identified. The 10-year probability of having a contralateral knee after index knee was 36%. When grade 4 radiographic changes were present, the probability increased to 70%. Demographic factors played no role in the risk of future contralateral knee. The radiographic grade of the contralateral knee at the time of index surgery was found to correlate strongly with the future risk of contralateral total knee

Femoral pathological fracture as the first clinical manifestation of papillary thyroid carcinoma in a primigravida

MSTS 2018 - Femur Mets and MM

Papillary thyroid carcinoma is the most common differentiated type of thyroid malignancy. It is largely a loco-regional disease with a high tendency to metastasize to regional cervical lymph nodes. Distant hematogenous metastases are very rare and primarily include lungs and bones. Distant bone metastases are present in approximately 1.7% of patients with differentiated thyroid malignancy. Sternum, ribs, and spine are the most frequent sites of osseous metastases. Up to our knowledge, we report the first occurrence of an extra nodal metastasis of papillary thyroid carcinoma to a femoral bone presenting as a pathological fracture in a 21-year-old 37-week primigravida. We report this case because of its unusual site of metastasis and atypical presentation during pregnancy. Moreover, we briefly elaborate on the management of such uncommon cases.

Effect of saracatinib on pulmonary metastases from hepatocellular carcinoma

MSTS 2018 - Femur Mets and MM

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Src is involved in multiple processes of cancer metastasis; however, its significance in HCC is not well defined. In the present study, overexpression of Src phosphorylation (Y416) was observed in the highly metastatic MHCC97H cell line; additionally, through inhibition of Src kinase activation, HCC cell proliferation, migration, invasion and colony formation were significantly reduced in vitro. Tumour growth was not affected in the orthotopic xenograft HCC model, but the metastasic potential was inhibited as revealed by reduced lung metastasic foci after administration of saracatinib. Phosphorylation level of Src pathway signalling molecules, such as Src, FAK and Stat3, were also reduced in vitro and in vivo, as a result of the anti-metastasic effects caused by saracatinib treatment. In conclusion, we demonstrated the pro-metastasic role of Src in HCC, and further experiments suggest the use of the Src inhibitor in combination with cytotoxic agents and other anticancer treatments to improve HCC prognosis.

Rupture of atherosclerotic popliteal artery pseudo-aneurysm following total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Introduction: Injury to the popliteal artery following total knee arthroplasty (TKA) occurs in about 0.03 to 0.17% of cases. Although total knee arthroplasty is considered an effective treatment option for severe osteoarthritis and rheumatoid arthritis of the knee, the close proximity of the popliteal artery to the knee joint poses a risk for its injury, which can result into a neuropathic foot or limb loss. Pseudoaneurysms do occur following TKA and can lead to vessel occlusion or rupture, causing large popliteal haematomas. No clear mechanism has been attributed to the mode of popliteal artery injury during TKA although direct trauma and tourniquet injury have been shown to be among the commonest associated modes. Atherosclerosis has been shown to weaken vascular walls and predispose to aneurysm formation in various arteries of the body. Mild trauma to an already weakened vessel wall could therefore predispose to pseudo-aneurysm formation, with subsequent rupture. Various vascular reconstructive techniques have been employed to reconstruct the popliteal artery following injury, including direct repair, popliteal artery bypass using a reverse saphenous vein graft, and percutaneous transluminal angioplasty with stent insertion. Case report: We report a case of a 67-year-old female hypertensive who presented with a three-day history of a pulsatile, painful, progressive swelling in the left popliteal fossa two weeks after a left TKA. She had previously undergone right TKA one year earlier, and received anticoagulation as prophylaxis for deep-vein thrombosis following the recent TKA. Doppler ultrasound was suggestive of a ruptured pseudo-aneurysm of the left popliteal artery, with good perfusion of the distal limb. Radiographs showed calcifications of the popliteal artery above the knee, with a total knee-replacement implant in situ. Via an S-incision in the popliteal fossa, the popliteal fossa was dissected and the artery found to be severely atherosclerotic and calcified, with an anteriorly ruptured pseudo-aneurysm causing a large haematoma involving the knee cavity. We evacuated the popliteal haematoma, performed aneurysmectomy and reconstructed the popliteal artery using an ipsilateral reverse saphenous vein graft. Good lower limb perfusion and function was achieved with no sensory or motor loss. Conclusion: Injury of the popliteal vessels although uncommon, continues to elude surgeons during TKA. A careful pre-operative assessment of the popliteal vessels prior to TKA is important as a prerequisite to minimising vascular injury. Extra caution should be taken to avoid popliteal artery injury during TKA where a high index of suspicion of atherosclerosis exists. Prompt diagnosis and vascular repair are important in limiting morbidity and saving the limb

Porous-coated anatomic uncemented total hip arthroplasty. A 10-17-year follow-up

Management of Hip Fractures in the Elderly

A total of 91 PCA total hip arthroplasties were analysed with a mean follow-up of 13.5 years. Thirty-one cups and six stems were revised. If the patients excluded from the follow-up study are included (113 hips), the cumulative probability of having revision of any prosthetic component for any cause was 16.0% (0.1%-31.9%) at 14 years in the "best case" scenario. Thigh pain (17 hips) was correlated with unstable fixation. Radiographic loosening occurred in 21 cups and 12 stems. Cup loosening was related to acetabular polyethylene wear equal to or more than 2mm per year and also to cup size and thereby polyethylene thickness. Stem loosening was related to poor femoral canal filling. Fifty hips had femoral osteolysis which was related to polyethylene wear of more than 2mm, poor femoral filling and unstable fixation. (copyright) Wichtig Editore, 2005

Pediatric humeral condyle fractures

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Condylar and epicondylar fractures differ from other pediatric upper extremity fractures because of the anatomy and ossification of the distal humerus. These fractures are prone to nonunion,and initial deformities do not remodel well. Radiographic diagnosis and severity are difficult to determine, and adjunct studies, particularly arthrography and MRI, often are needed. The correlation of an intact cartilaginous hinge and subsequent fracture stability has helped identify fractures at risk for displacement and nonunion,prompting closer follow-up or more aggressive initial treatment. Although many humeral condylar fractures can be treated successfully with cast immobilization, operative treatment often is warranted. Specific treatment recommendations continue to evolve. The general trend is toward treating more fractures and nonunions with surgical fixation while using less invasive techniques

Acute pain service: The journey in a developing country setting

AAHKS (4) Acetaminophen

Background: In India, acute pain service (APS) is in nascent stage because of lesser importance given to pain management. After establishing an APS in our hospital, we conducted a prospective audit (2008-2011) with an aim to regularly assess the efficacy of techniques on pain scores, muscle power, and adverse effects. Methods: The audit was undertaken in three phases. An assessment of the existing system and recommendation to modify the APS was undertaken in phase I. In phase II, an APS team was constituted and audits were conducted at six monthly intervals for formation of the protocol. Subsequently in phase III, yearly audits were undertaken that led to the development of a final APS. Results: There was a steady increase in the number of patients availing APS in intravenous patient-controlled analgesia (IVPCA), epidural analgesia (EA), and continuous peripheral nerve block (CPNB). At the same time, the average visual analogue score (VAS) decreased significantly as the year progressed. While the VAS score did not differ significantly between EA and CPNB, it was less compared with IVPCA. Introduction of regional analgesic techniques played a major role in improving the pain scores. Conclusion:: Implementation of APS resulted in reduced pain scores in our surgical patients. Proper planning, role allocation, formation, and adherence to protocols as well as undertaking regular audit resulted in improving the quality of APS.

Incidence of bradycardia during recovery from spinal anaesthesia: influence of patient position

Surgical Management of Osteoarthritis of the Knee CPG

We administered 0.5% plain bupivacaine 4 ml intrathecally (L2-3 or L3-4) in three groups of 20 patients, according to the position in which they were nursed in the post-anaesthesia care unit (PACU): supine horizontal, 30 degrees Trendelenburg or hammock position (trunk and legs 30 degrees elevated). Patients were observed until anaesthesia descended to less than S1. The incidence of severe bradycardia (heart rate < 50 beat min-1) in the PACU was significantly higher in patients in the Trendelenburg position (60%) than in the horizontal (20%, P < 0.01) or hammock (10%, P < 0.005) position. After 90 min, following admission to the PACU, only patients in the hammock position did not have severe bradycardia. In this late phase, the incidence of severe bradycardia in the Trendelenburg group was 35% (P < 0.005) and 10% in patients in the supine horizontal position. In four patients, severe bradycardia first occurred later than 90 min after admission to the PACU. The latest occurrence of severe bradycardia was recorded 320 min after admission to the PACU. We conclude that for recovery from spinal anaesthesia, the Trendelenburg position should not be used and the hammock position is preferred

Combined Meniscus and Osteochondral Allograft Transplantation: Minimum Two-Year Follow-up with an Analysis of Failures

Osteochondritis Dissecans 2020 Review

Objectives: The purpose of this investigation was to report mid- and long-term follow-up on the clinical outcomes of patients undergoing combined MAT and osteochondral allograft procedures for symptomatic knee pain in the setting of meniscal deficiency and focal cartilage damage. We hypothesized that patients undergoing combined MAT and osteochondral allograft will demonstrate improved pain and functional scores following surgery. Methods: This was a prospective case series. Thirty two patients with a minimum two-year follow-up were identified who initially presented with persistent symptoms following meniscectomy and an isolated International Cartilage Repair Society (IRCS) Grade 3 or 4 defect of the femoral condyle underwent combined MAT and fresh osteochondral allograft transplantation. Demographic and intra-operative data, including condylar defect size, was recorded as well as pre- and post-operative International Knee Documentation Committee (IKDC), Short Form-12 (SF-12), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Lysholm scores. Pre- and post-operative data was compared with paired t-tests while the association between functional scores and condylar defect size, age, gender, and involved compartment were analyzed with regression analysis. An alpha value of 0.05 was set as significant with Bonferroni correction utilized in the case of multiple comparisons. Results: Average follow up was 4.2 years (range 2-11). Mean condylar defect size was 4.7 ± 2.0 cm2 at the time of index procedure. Lysholm, IKDC, and all KOOS subdomains showed significant improvement from pre- to post-operatively (p 0.001). Patients with a condylar defect of less than 4 cm2 had a significantly greater increase in pre- versus post-operative IKDC (p = 0.010), Lysholm (p = 0.018), and KOOS (p = 0.016) versus those with greater than 4 cm2. Femoral condyle defect size was also significantly inversely correlated with post-operative IKDC (p = 0.015), KOOS (p = 0.003), and Lysholm score (p = 0.010). Patient satisfaction with the procedure was 82%. Conclusion: Patients undergoing combined MAT and osteochondral allograft showed improved functional scores following surgery. There was an inverse association between post-operative functional scores and the size of the condylar defect.

Inguino-scrotal hernia detection in the early phase of a bone scan

Management of Hip Fractures in the Elderly

A case report of a large inguino-scrotal hernia detected in the early phase of a radionuclide bone scan is presented

Effectiveness of home-based physiotherapy on pain and disability in participants with osteoarthritis of knee: an observational study

OAK 3 - Non-arthroplasty tx of OAK

[Purpose] The objective of this observational study was to examine the effect of home physiotherapy on pain and disability in participants with knee osteoarthritis. [Participants and

Three-screw versus two-screw fixation of distal fragment in fifth metacarpal neck fractures stabilized with locking plate

Distal Radius Fractures

Fifth metacarpal neck fracture commonly requires open reduction and internal fixation. Locking plate was widely adopted in the treatment of fifth metacarpal neck fracture as first-line choice for fixation. Patients with fifth metacarpal neck fracture receiving locking plate fixation were included for analysis. Features of internal fixation including number of distal and proximal locking screws, diameter of the screws and usage of lag screws were recorded. Clinical and radiographic outcomes included final volar angulation, grip strength, Michigan Hand Outcomes Questionnaire (MHQ) and range of motion (ROM) of fifth metacarpophalangeal joint. Three-screw fixation was less frequently presented in the group with increased volar angulation (>=30 degrees). Consistently, three-screw fixation of distal fragment could improve the prognosis compared with two-screw fixation (MHQ 95.4 +/- 5.1 versus 80.4 +/- 12.3, ROM 83.5 +/- 7.2 versus 69.6 +/- 7.7). In conclusion, the metacarpal head should be fixed by three locking screws instead of two locking screws.

Femoral neck fractures in an elderly white South African population

Management of Hip Fractures in the Elderly

In a retrospective survey of 184 patients treated for fracture of the femoral neck follow-up was obtained in 170; all were over 50 years of age and the male to female ratio was 1:5. The 12-month mortality rate was 20% and only 50% walked normally. Displaced fractures showed a higher morbidity and mortality rate than non-displaced fractures. Prognostic factors which may assist selection of the optimum treatment for individual patients are identified

Pamidronate induces bone formation in patients with smouldering or indolent myeloma, with no significant anti-tumour effect

MSTS 2018 - Femur Mets and MM

Twelve patients with smouldering or indolent multiple myeloma (MM) received 12 courses of intravenous pamidronate as a single agent to evaluate both the antitumour and bone metabolism effects. One patient achieved minor response, eight had stable disease, and three - all indolent MM - showed disease progression. Serum interleukin 6 (IL-6), IL-1beta and Oncostatin-M remained stable throughout the study, while tumour necrosis factor-alpha increased. Bone density significantly increased after four and 12 courses compared with baseline. Markers for bone resorption and bone formation decreased with treatment. These results suggest that pamidronate treatment reduces bone turnover in smouldering or indolent MM, but has no significant antitumour effect.

Results from the first decade of research conducted by the research on adverse drug events and reports (RADAR) project

MSTS 2018 - Femur Mets and MM

Introduction: In 1998, a multidisciplinary team of investigators initiated the Research on Adverse Drug events And Reports (RADAR) project, a post-marketing surveillance effort that systematically investigates and disseminates information describing serious and previously unrecognized serious adverse drug and device reactions (sADRs). Objective: Herein, we describe the findings, dissemination efforts, and lessons learned from the first decade of the RADAR project. Methods: After identifying serious and unexpected clinical events suitable for further investigation, RADAR collaborators derived case information from physician queries, published and unpublished clinical trials, case reports, US FDA databases and manufacturer sales figures. Study selection: All major RADAR publications from 1998 to the present are included in this analysis. Data extraction: For each RADAR publication, data were abstracted on data source, correlative basic science findings, dissemination and resultant safety information. Results: RADAR investigators reported 43 serious ADRs. Data sources included case reports (17 sADRs), registries (5 sADRs), referral centers (8 sADRs) and clinical trial reports (13 sADRs). Correlative basic science findings were reported for ten sADRs. Thirty-seven sADRS were described as published case reports (5 sADRs) or published case-series (32 sADRs). Related safety information was disseminated as warnings or boxed warnings in the package insert (17 sADRs) and/or 'Dear Healthcare Professional' letters (14 sADRs). Conclusion: An independent National Institutes of Health-funded post-marketing surveillance programme can supplement existing regulatory and pharmaceutical manufacturer-supported drug safety initiatives. © 2013 Springer International Publishing Switzerland.

Association between preoperative anaemia and blood transfusion with long-term functional and quality of life outcomes amongst patients undergoing primary total knee arthroplasty in Singapore: a single-centre retrospective study

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: Preoperative anaemia affects up to one-third of patients undergoing total knee arthroplasty (TKA) and is associated with increased blood transfusion and prolonged hospitalisation. Prior studies have associated preoperative anaemia with poorer functional recovery after total hip arthroplasty. However, the association between preoperative anaemia and functional outcomes following TKA is unknown. We aim to determine whether preoperative anaemia and perioperative blood transfusion affect health-related quality of life (HRQoL) and functional outcomes following TKA. METHODS: Retrospective analysis of 1994 patients who underwent primary unilateral TKA from 2013 to 2014 was performed. Anaemia was defined according to the World Health Organisation definition. Baseline and 6-month postoperative HRQoL was assessed with the 36-Item Short Form Survey (SF-36), while function was assessed with Oxford Knee Score (OKS) and Knee Society Function Score (KSFS). Physical function (PF), role physical (RP), bodily pain (BP), social function (SF) and role emotional (RE) domains of SF-36, OKS and KSFS demonstrated significant change greater than the minimal clinically important difference between baseline and 6 months. Analysis of covariance (ANCOVA) was performed to identify predictors of 6-month scores. RESULTS: The incidence of preoperative anaemia was 22.3%. 4.3% of patients received blood transfusions. Preoperative anaemia and perioperative blood transfusion did not significantly affect SF-36, KSFS and OKS scores at 6 months postoperatively. Poor baseline SF-36, KSS and OKS scores and high BMI >= 37.5 kg/m² are consistently associated with lower scores at 6 months. CONCLUSION: Preoperative anaemia and perioperative blood transfusion did not significantly affect HRQoL and functional outcomes following primary TKA. Poor baseline and obesity were associated with poorer outcomes.

Functional performance of mobile versus fixed bearing total knee prostheses: A randomised controlled trial

OAK 3 - Non-arthroplasty tx of OAK

Purpose: The primary goal of this study was to assess the difference in active flexion between patients with a mobile versus a fixed bearing, cruciate retaining, and total knee arthroplasty. The study was designed as a randomised controlled multi-centre trial. Methods: Participants were assigned to interventions by using block-stratified, random allocation. Outcome parameters were active flexion, passive flexion, and Knee Society Score (KSS). Outcome parameters were assessed preoperatively and at 3, 6, and 12 months postoperatively by an independent nurse. Results: Ninety-two patients from one centre were included, 46 in each group. Active flexion was comparable for the two groups, 99. 9° for the mobile bearing group and 101° for the fixed bearing group with a baseline controlled difference of 1. 0 (95% CI -3. 9 to 5. 8, n. s.). The Clinical KSS was comparable between the two bearing groups (Mobile 90. 0 vs. fixed 92. 4, n. s.). The functional KSS showed a difference that was attributable to the stair climbing subscore, which showed a difference in favour of the fixed bearing design between preoperative and 3 months (7. 3 point difference; 95% CI 2. 3-12. 5; P = 0. 005) as well as 12 months (4. 8 point difference; 95% CI 0. 1-9. 6; P = 0. 045). Conclusions: There were no short-term differences in active flexion between fixed bearing and mobile bearing total knee arthroplasty. Level of evidence: I. © 2011 The Author(s).

Preoperative range of motion and applications of continuous passive motion predict outcomes after knee arthroplasty in patients with arthritis

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: This study evaluated the clinical efficacy of continuous passive motion (CPM) following knee arthroplasty and determined the predictors of effect sizes of range of motion (ROM) and functional outcomes in patients with knee arthritis. METHODS: A comprehensive electronic database search was performed for randomized controlled trials (RCTs), without publication year or language restrictions. The included RCTs were analyzed through meta-analysis and risk of bias assessment. Study methodological quality (MQ) was assessed using the Physiotherapy Evidence Database (PEDro) scale. Inverse-variance weighted univariate and multivariate metaregression analyses were performed to determine the predictors of treatment outcomes. RESULTS: A total of 77 RCTs with PEDro scores ranging from 6/10 to 8/10 were included. Meta-analyses revealed an overall significant favorable effect of CPM on treatment success rates [odds ratio: 3.64, 95% confidence interval (CI) 2.21-6.00]. Significant immediate [postoperative day 14; standard mean difference (SMD): 1.06; 95% CI 0.61-1.51] and short-term (3-month follow-up; SMD: 0.80; 95% CI 0.45-1.15) effects on knee ROM and a long-term effect on function (12-month follow-up; SMD: 1.08; 95% CI 0.28-1.89) were observed. The preoperative ROM, postoperative day of CPM initiation, daily ROM increment, and total application days were significant independent predictors of CPM efficacy. CONCLUSION: Early CPM initiation with rapid progress over a long duration of CPM application predicts higher treatment effect on knee ROM and function. The results were based on a moderate level of evidence, with good MQ and potential blinding biases in the included RCTs. An aggressive protocol of CPM has clinically relevant beneficial short-term and long-term effects on postoperative outcomes.II.

Patterns of osteolysis around total hip components inserted with and without cement

Management of Hip Fractures in the Elderly

We reviewed the radiographs of 137 patients (137 hips) who had been managed with a total hip arthroplasty, with insertion of an extensively porous-coated femoral component without cement, because of osteoarthrosis or avascular necrosis. A porous-coated acetabular component had been inserted with cement in sixty-three of these patients (Group A) and without cement in seventy-four patients (Group B). The radiographs were examined for osteolysis, either directly adjacent to the joint or at locations remote from the joint. The mean duration of follow-up was 105 months (range, fifty-four to 142 months). The rate of osteolysis of the acetabulum in the unrevised hips in which the acetabular component had been inserted with cement was 37 per cent (nineteen of fifty-one). The osteolysis was most frequently of the linear type, a pattern that was associated with a high prevalence of loosening in the hips that had a cemented cup (30 per cent [nineteen of sixty-three]). The rate of acetabular osteolysis (18 per cent [thirteen of seventy-one]) in the patients who had a cup that had not been inserted with cement and that had not been revised was not as high as that associated with the surviving cups that had been inserted with cement (p < 0.05). The osteolysis associated with the cups that had not been inserted with cement was localized and expansile, and it was not associated with loosening of the component. However, it produced more loss of bone than did the linear pattern of osteolysis around the cemented cups. The patients in whom the cup had been inserted without cement also had a higher prevalence of osteolysis in the femur than the patients in whom the cup had been cemented (32 per cent [twenty-three of seventy-one] compared with 12 per cent [six of fifty-one]; p < 0.01). Osteolysis occurred more frequently in younger patients than in older ones; the mean age was fifty years for the patients who had osteolysis compared with fifty-nine years for those who did not (p < 0.02). With both types of fixation of the cup, osteolysis was restricted to the bone in the periprosthetic region that was in direct continuity with the joint (the so- called effective joint space). With the type of porous-coated stems used in this series, the effective joint space of the femur rarely extended distal to zones IA and 7A as defined by Gruen et al. As the osteolysis associated with porous-coated acetabular components is not symptomatic unless it becomes extensive enough tn cause a fracture of the bone, postoperative management of these patients should include annual radiographic evaluations

Oral disease burden in patients undergoing prosthetic heart valve implantation

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

BACKGROUND: Valvular heart disease predisposing to endocarditis and requiring prosthetic valve implantation is common among the elderly. Spontaneous bacteremias associated with acute or chronic oral/odontogenic infections may represent a far greater cumulative risk for the development of endocarditis than do occasional health care procedures administered in a professional setting. METHODS: To determine the oral disease burden in patients undergoing mechanical or bioprosthetic heart valve implantation, we performed a comprehensive clinical and radiographic regional examination on 156 consecutive patients, with emphasis on identifying acute and chronic oral/odontogenic infections and conditions. RESULTS: The mean number of remaining teeth in the cohort was 19.32; of these, 1.07 were carious, involving a mean number of 2.51 tooth surfaces. In addition, 15.38% of the patients had evidence of acute or chronic periapical abscesses, and 43.6% of the patients had moderate to advanced periodontitis. CONCLUSIONS: In view of the substantial morbidity and mortality associated with prosthetic valve endocarditis and based upon the high incidence of dental disease identified in patients undergoing valvular operations, routine preoperative dental assessment should be deemed a "medical necessity" by third-party payors. Appropriate therapeutic intervention should be initiated whenever possible before valve implantation

Diagnosis and classification of mandibular osteomyelitis

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

To establish a unified classification system for mandibular osteomyelitis, various diagnostic terms were critically assessed and clinicopathologic findings of the lesions were carefully reviewed. We recommend classifying mandibular osteomyelitis into bacterial osteomyelitis and osteomyelitis associated with the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. Other diagnostic terms were excluded because they were not appropriate for classification. Diagnostic criteria for bacterial osteomyelitis are suppuration and osteolytic change. The lesions are easily cured by antibiotic treatments. Mandibular osteomyelitis in SAPHO syndrome is characterized by nonsuppuration and a mixed pattern on radiography, with solid type periosteal reaction, external bone resorption, and bone enlargement. The presence of osteomyelitis in other bones, arthritis, or skin diseases (palmoplantar pustulosis, pustular psoriasis, and acne) strongly suggests this syndrome. Antibiotic therapy is usually ineffective and the symptoms of SAPHO syndrome are often persistent

Microbiology of burn wound infections

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

One of the most complicated issues that surgeons face, in the care of burn patients, is infection. This includes both superficial and systemic infections. Systemic infection is the leading cause of death in this population. This article will look to review the microbiology of burn wound infections with particular emphasis on classification, host response to burn wound infections, antimicrobial agents, and modern treatment practices

The effect of either topical menthol or a placebo on functioning and knee pain among patients with knee OA

OAK 3 - Non-arthroplasty tx of OAK

Osteoarthritis (OA) is a common health problem with symptoms including reduced functioning and joint pain. Protracted pharmacological management of knee OA is associated with side effects including gastrointestinal, renal, and neurological dysfunction. Menthol gels have been used with limited empirical support to relieve pain and improve functioning among individual with OA. The purpose of this study was to compare the ability to complete functional tasks and knee pain while completing functional tasks among patients with knee OA after topical application of either 3.5% menthol gel or an inert placebo gel. Twenty individuals with knee OA volunteered to complete 2 data collection visits 1 week apart. Subjects underwent the same data collection at each visit including the performance of functional tasks and self-reporting knee pain while performing each task. The functional tasks included a 6-Minute Walk (6-MW), the Timed Get Up and Go (TUG), 30-second timed chair stand (TCS), and time to ascend (Up stairs) and descend (Down stairs) a flight of stairs. Subjects reported their knee pain immediately following each functional task using a 100-mm visual analog scale. These assessments of pain and functioning were measured twice at each subject visit: upon arrival at the facility without any intervention and again during the same visit after random application to the OA knee of 5 mL of 3.5% menthol gel or 5 mL of an inert gel. There were no significant between-group differences or time by treatment interaction in performance of any of the functional tasks, or measures of pain, at any of the data collection time points. However, there were significant withingroup differences. Scores on the 6-MW, TCS, and Down stairs functional tasks improved significantly following the application of menthol gel. Scores on the Down stairs functional task improved significantly following application of the placebo gel. The menthol intervention resulted in significant reductions in pain during the TUG, TCS, Up stairs, and Down stairs tasks. The placebo condition did not result in any significant changes in pain during the functional tasks. There were no differences detected in functional tasks or pain following the placebo and menthol conditions. These findings provide partial support regarding the efficacy of menthol gel to improve functioning and reduce pain among knee OA patients. Copyright © 2013 The Section on Geriatrics of the American Physical Therapy Association.

Using viscosupplementation to treat knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

This article provides physicians specializing in nonsurgical sports medicine with an overview of viscosupplementation as a treatment for osteoarthritis (OA) pain. Osteoarthritis is a painful, disabling condition that is becoming more prevalent in patients and is generally treated using conservative nonpharmacologic measures. If conservative measures are unsuccessful at alleviating pain, current recommendations include prescribing acetaminophen and nonsteroidal anti-inflammatory drugs to patients. However, long-term use of these agents increases the risk for liver, cardiovascular, gastrointestinal, and/or renal complications in patients. Viscosupplementation is the term used for intra-articular injection of hyaluronic acid/hylans. Intra-articular injections of these agents have good safety profiles and have shown efficacy for treating knee OA pain. Viscosupplementation injections relieve pain for <= 26 weeks, which is longer than the short-term pain relief derived from nonsteroidal anti-inflammatory drugs and corticosteroid injections. Additionally, viscosupplementation administered to patients in earlier stages of OA may be more beneficial than when given later in the treatment of OA. As part of a multimodal algorithm, viscosupplementation combined with conventional therapy or other pharmacologic agents has been shown to be more effective at managing OA than conventional care alone. This article reviews the evidence for using viscosupplementation as part of a comprehensive program for managing OA in patients.

Regenerative medicine interventions for orthopedic disorders: Ethical issues in the translation into patients

OAK 3 - Non-arthroplasty tx of OAK

Regenerative medicine (RM) technologies, such as cell therapy, gene transfer and tissue engineering, are expected to move the field of orthopedics into a new era. Now that more and more attempts are underway to translate preclinical research into clinical studies, it is time to proactively discuss the ethical issues associated with first-in-human applications of RM interventions for musculoskeletal disorders. The design and launch of early clinical trials will be ethically challenging due to the specific features of RM in general, and the application for musculoskeletal disorders specifically. In this paper, we identify three sets of ethical issues that need to be addressed when considering initiating early clinical trials: assessment of risks and benefits; designing a study in terms of outcome measures and comparators; and participant selection. These issues are particularly emphasized in RM research that aims to apply these approaches in an early stage of degenerative musculoskeletal disorders. © 2013 Future Medicine Ltd.

Long-Term Efficacy of Distal Penile Circular Fasciocutaneous Flaps for Single Stage Reconstruction of Complex Anterior Urethral Stricture Disease

DOD - Acute Comp Syndrome CPG

Purpose: We determined the overall efficacy and predictors of success of the distal penile circular fasciocutaneous flap in the management of complex anterior urethral stricture disease not due to lichen sclerosus. Materials and Methods: We performed a retrospective review of all patients undergoing reconstruction of complex anterior urethral strictures without lichen sclerosus repaired from 1985 to 2006. Primary and overall stricture-free survival curves were estimated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to identify univariate and multivariate predictors of flap success. Results: A total of 124 patients met the inclusion and exclusion criteria. Median patient age was 48 years (range 16 to 83). Median followup was 7.3 years (range 1 month to 19.5 years). Median stricture length was 8.2 cm (range 0.5 to 24). At 1, 3, 5 and 10 years the overall estimated stricture-free survival rates were 95%, 89%, 84% and 79%, respectively. On multivariate analysis smoking (HR 4.0, 95% CI 1.2-12.9, p = 0.02), history of hypospadias repair (HR 4.4, 95% CI 1.3-14.6, p = 0.01) and stricture length 7 to 10 cm (HR 7.0, 95% CI 1.4-34.7, p = 0.02) were predictive of failure. Conclusions: Fasciocutaneous flap urethroplasty has good and durable success rates in the treatment of complex anterior urethral strictures. Predictors of failure included smoking, history of hypospadias repair and longer stricture length. © 2008 American Urological Association.

Effect of chlorhexidine varnish mouthguards on the levels of selected oral microorganisms in pediatric patients

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

PURPOSE: The effect of a chlorhexidine varnish delivery system on the levels of selected oral microorganisms was evaluated in caries active pediatric patients, ages 4 to 12 years old. METHODS: Forty-six patients were enrolled into the study when they had multiple carious surfaces and salivary mutans streptococci (MS) levels higher than 10(4) colony forming units (CFUs) per milliliter. This study incorporated a double-blind design and patients were randomly assigned to either the chlorhexidine treatment group or the placebo group. Complete-arch, vacuum-adapted mouthguards (0.02 in. polypropylene coping material) were custom fabricated and coated internally with either a 3.0% chlorhexidine varnish or a placebo varnish. Two pretreatment paraffin-stimulated saliva samples were obtained for culturing prior to varnish treatment. Saliva samples were also obtained immediately after treatment and once a month for up to three months after wearing the mouthguard appliances. Dental restorations were placed at most of these saliva collection visits. Mouthguards were reportedly worn for an average of 9.7 hours per night for approximately seven nights by 40 subjects (87%). RESULTS: After two months, and after three months, there was a significant reduction in MS levels immediately after the chlorhexidine varnish treatment. Total anaerobic and total facultative bacteria levels were not significantly affected. CONCLUSION: One week of nightly use of the chlorhexidine varnish mouthguard system is effective at reducing the number of MS in caries-active pediatric patients in the mixed and primary dentition for at least three months

A randomized controlled trial of osteopathic manipulative treatment following knee or hip arthroplasty

Management of Hip Fractures in the Elderly

CONTEXT: Preliminary study results suggest that osteopathic manipulative treatment (OMT) may reduce pain, improve ambulation, and increase rehabilitation efficiency in patients undergoing knee or hip arthroplasty. OBJECTIVE: To determine the efficacy of OMT in patients who recently underwent surgery for knee or hip osteoarthritis or for a hip fracture. DESIGN: Randomized controlled trial involving hospital and postdischarge phases. SETTING: Hospital- based acute rehabilitation unit. PATIENTS: A total of 42 women and 18 men who were hospitalized between October 1998 and August 1999. INTERVENTION: Patients were randomly assigned to groups that received either OMT or sham treatment in addition to standard care. Manipulation was individualized and performed according to study guidelines regarding frequency, duration, and technique. MAIN OUTCOME MEASURES: Changes in Functional Independence Measure (FIM) scores and in daily analgesic use during the rehabilitation unit stay; length of stay; rehabilitation efficiency -- defined as the FIM total score change per rehabilitation unit day; and changes in Medical Outcomes Study Short Form-36 scores from rehabilitation unit admission to 4 weeks after discharge. RESULTS: Of 19 primary outcome measures, the only significant difference between groups was decreased rehabilitation efficiency with OMT (2.0 versus 2.6 FIM total score points per day; p = 0.01). Stratified analyses demonstrated that poorer OMT outcomes were confined to patients with osteoarthritis who underwent total knee arthroplasty (length of stay, 15.0 versus 8.3 days; p = 0.004; rehabilitation efficiency, 2.1 versus 3.4 FIM total score points per day; p < 0.001). CONCLUSION: The OMT protocol used does not appear to be efficacious in this hospital rehabilitation population. Reprinted from JAOA, The Journal of the American Osteopathic Association. Copyright American Osteopathic Association. Permission given with the consent of the American Osteopathic Association

Early outcome of reamed interlocking nail for non-union of tibia

DoD SSI (Surgical Site Infections)

Aseptic non-union is a major problem following complicated fracture tibia, which carries significant morbidity and prolonged course of treatment. Plate fixation and autogenous bone grafting has been established as a method of treatment. However the risk of infection, implant failure and donor site morbidity are high. We reviewed twelve consecutive cases of established non-union tibia treated by closed reamed interlocking nail in our centre. All patients had clinical and radiological union at three months. Three patients were complicated with infection and one required removal of implant and re-reaming to eradicate infection. Reamed interlocking nailing is an alternative treatment for selected non-union of fracture tibia with promising results.

Regenerative medicine injection techniques for the hip pathology

AAHKS (2) Corticosteroids

Hip pain is a common complaint that can have both intra-articular and extra-articular origins. Three common causes of hip pain are hip osteoarthritis, iliopsoas tendinopathy, and gluteus medius tendinopathy. Current treatment plans range from conservative measures to surgical replacement. Traditionally, minimally invasive approaches with the use of corticosteroid and local anesthetic injections have served to manage symptoms of pain without altering disease progression. In addition, these agents have been associated with deleterious effects on bone, tendon, and cartilage health. Emerging regenerative medicine techniques are becoming increasingly popular for the management of hip pain, as they have been shown to improve clinical outcomes and potentially alter disease progression. Some of these techniques, such as injection of platelet-rich plasma, mesenchymal stem cells, and percutaneous needle fenestration, have been shown to promote healing of damaged tissue. These techniques are often augmented by the use of ultrasound imaging, which greatly increases ease and accuracy. This article reviews ultrasound-guided regenerative orthopedic injections specifically for hip joint osteoarthritis, gluteus medius tendinopathy, and iliopsoas tendinopathy.

Expression of CC chemokine receptor 9 predicts poor prognosis in patients with lung adenocarcinoma

MSTS 2018 - Femur Mets and MM

BACKGROUND: The CC chemokine receptor 9 (CCR9) plays an important role in tumorigenesis and metastasis in various cancers. Our previous studies have shown the aberrant expression of CCR9 in non-small cell lung cancer (NSCLC) cell lines, revealing that the CCR9-CCL25 axis modulates cell migration and invasion, and supports cancer cell survival by inhibiting apoptosis in vitro and in vivo. In the present study, we aimed to evaluate the expression and possible prognostic role of CCR9 in lung adenocarcinoma. METHODS: Immunohistochemical analysis of CCR9 expression was performed on 144 lung adenocarcinoma tissues and 30 adjacent normal lung parenchymal tissues. We assessed the correlation of CCR9 expression with clinicopathological characteristics and the prognosis of lung adenocarcinoma. RESULTS: The expression of CCR9 was increased in lung adenocarcinoma tissue compared with normal lung tissue. Moreover, such an expression was positively correlated with tumor size (p=0.032), lymph node metastasis (p=0.002) and advanced TNM stage (p=0.012). In addition, the patients with negative CCR9 expression exhibited a higher overall survival (OS) compared with those with positive CCR9 expression. Multivariate analysis showed that the CCR9 expression was an independent prognostic factor for the OS of patients with lung adenocarcinoma. CONCLUSIONS: We, for the first time, reported that CCR9 could be beneficial in predicting lymph node metastasis, and it might act as a novel prognostic biomarker for lung adenocarcinoma.

Incidence of meningitis or epidural abscesses in patients undergoing neuraxial block for removal of infected prosthesis in hips and knees

Surgical Management of Osteoarthritis of the Knee CPG

Introduction: The presence of localized infection or systemic sepsis is considered by some to be a relative contraindication to spinal or epidural anesthesia. Fear of seeding the CNS with systemic bacteria is the primary rationale for this belief. No current data exists to determine if there is indeed a correlation between neuraxial anesthesia and the development of meningitis or epidural abscesses. We designed a retrospective chart review to assess the correlation between the development of CNS infections and performance of neuraxial anesthesia in patients presenting for removal of infected joint prosthesis. Methods: Retrospective chart review on 708 medical records of patients admitted for removal of total hip and total knee prostheses over a 12 year period. Significant medical history (diabetes, prior MI, CRI, rheumatoid arthritis and hypertension), antibiotic use up to 6 months prior to admission, signs and symptoms of a pre-operative infection (i.e. fever defined as a temperature greater than 37.5A(degrees) C, chills, hypotension defined as a systolic BP <100 mmHg), an elevated WBC count defined as greater than 10.7 cells per nano liter and the results of cultures taken during admission were documented. Results: 242 patients were excluded from analysis when: lack of prosthesis removal (53/242); absence of neuraxial anesthesia (101/242); aseptic (78/242); transferred to another institution shortly after their surgery, making it impossible to determine if they developed meningitis or epidural abscesses (9/236). Ultimately, 466 patients were included. Mean age of patients was 65.7 years and mean length of hospital stay was 21 days. The profile of these patients is outline in Tables 1-3. Of note, 232 patients (49.8%) had joint pus expressed intraoperatively and 195 patients (41.8%) had positive Gram stains. 407 patients (87.3%) had positive joint cultures. We defined neuraxial infectious complications as the diagnosis of meningitis or epidural abscess in the inpatient postoperative period. No patients undergoing removal of total joint prostheses under neuraxial anesthesia developed a neuraxial infectious complication (95% CI 0.64%). Postoperative issues also documented included hematoma (1/466), back pain (2/466) and headaches (1/466). Discussion: Our findings suggest that the incidence of CNS infections following neuraxial anesthesia in patients with infected hip and knee prostheses is exceedingly low, at least within 21 days of administration of neuraxial blockade. Also, preoperative use of antibiotics in 50.4% of the patients may have been protective. Potential limitations to our review include: patientsa(euro)(trademark) verbal disclosure was often the only proof of antibiotic use; and the unavailability of the decision process by which the anesthesiologist chose GA over regional anesthesia, which may have presented a possible selection bias of our included patients. (Table presented)

Porous coated anatomic tricompartmental tibial components. The relationship between prosthetic position and micromotion

Surgical Management of Osteoarthritis of the Knee CPG

Micromotion of the tibial component, both as migration over time and as inducible displacement in response to external physiologic forces, was studied in 20 cases of gonarthrosis. The patients had Porous Coated Anatomic primary total knee arthroplasty and were followed for four years. All cases but one were clinically successful. Thirteen components were inserted without cement, while in seven, high-viscosity Palacos cement was used. Full postoperative weight bearing was allowed in all cases. During the first year, noncemented components migrated a mean of 2.6 mm, while cemented components migrated a mean of 1.1 mm. About 1 mm of migration of noncemented components was in the downward direction, i.e., subsidence occurred, mostly during the first year. After one year, the noncemented components had stabilized more than the cemented ones. There was a significant correlation between the migration after one year and the postoperative prosthetic position and alignment of the leg. A mean maximum inducible displacement (the total vector displacement of the prosthetic marker that moved the most) of 0.7 mm and 0.4 mm was found for noncemented and cemented components, respectively. The micromotion found was of the same magnitude as that for other cemented and noncemented prosthetic systems previously reported

Hybrid External Fixation for Arbeitsgemeinschaft für Osteosynthesefragen (AO) 43-C Tibial Plafond Fractures

OAK 3 - Non-arthroplasty tx of OAK

Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 43-C tibial plafond/pilon fractures represent a challenge for the treating orthopedic surgeon. We assessed the outcomes of using hybrid external fixation for this fracture type. The present prospective cohort study was started in August 2009 and ended by July 2012. Thirty consecutive patients (mean age 37.4 ± 10.7 years) with a type C tibial plafond fracture who had presented to our tertiary care orthopedic hospital were included. Motor vehicle accidents and fall from height were the cause of the fracture in 14 (46.7%) and 13 (43.3%) patients, respectively. A type C3 fracture was present in 25 patients (83.3%), and type C1 and C2 fractures were present in 2 (6.7%) and 3 (10.0%) patients, respectively. Nine fractures (30.0%) were open. Hybrid external fixation was used for all fractures. All fractures were united; clinical healing was achieved by a mean of 18.1 ± 2.2 weeks postoperatively and radiologic healing at a mean of 18.9 ± 1.9 weeks. The fixator was removed at a mean of 20.4 ± 2.0 weeks postoperatively. At a mean follow-up point of 13.4 ± 2.6 months, the mean modified Mazur ankle score was 84.6 ± 10.4. It was not associated with wound classification (p =256). The most commonly seen complication was ankle osteoarthritis (17 patients; 56.7%); however, it was mild in >50.0% of the affected patients. In conclusion, using hybrid external fixation for type C tibial plafond fractures resulted in good outcomes. However, this should be investigated further in studies with a higher level of evidence.

Reconstructive management of cranial base defects after tumor ablation

Reconstruction After Skin Cancer

Successful reconstruction after cranial base tumor ablation is paramount in preventing potentially life-threatening complications. The purpose of this study was to evaluate experiences of cranial base reconstruction and to identify reconstructive management principles that may assist in achieving successful cranial base reconstruction. All cranial base reconstructions performed by the Department of Plastic Surgery at the University of Texas M. D. Anderson Cancer Center between January of 1993 and September of 1999 were reviewed. Analyses were performed to assess the impact of location of defect, type of reconstruction, type of dural repair, and history of preoperative radiation and chemotherapy on rates of complications, and patient survival. The 77 patients who underwent cranial base reconstruction after tumor ablation during the study period had a mean age of 52 years (6 to 84 years). The mean follow-up period was 28.7 months (1 to 76 months). Squamous cell carcinoma, the most common histopathologic type, was present in 24 patients (31 percent), and 35 patients (45 percent) presented with recurrent disease. Location of defects involved region I (anterior) in 31 patients (40 percent), region II (anterior-lateral) in 18 (23 percent), region III (lateral-posterior) in six (8 percent), and more than one region in 22 (29 percent). Reconstructive methods included free flaps in 52 patients (68 percent), temporalis muscle flaps in 14 (18 percent), pericranial flaps in eight (10 percent), and other local flaps (two galeal, one scalp) in three (4 percent). Of the 52 free flaps, 18 (35 percent) were used in region I, 14 (27 percent) in region II, six (12 percent) in region III, and 14 (27 percent) in defects involving more than one region. Of the 14 temporalis muscle flaps, 13 (93 percent) were used for defects involving regions I or II and one (7 percent) was used for a defect involving region III. Of the 11 pericranial and other local flaps, nine (82 percent) were used in region I, one (9 percent) in region II, and one (9 percent) in a combination of regions II and III. Complications occurred in 21 patients (27 percent): three total flap losses (4 percent), three partial flap losses (4 percent), two cerebrospinal fluid leaks (3 percent), two cases of meningitis (3 percent), two abscesses (3 percent), five cases of delayed wound healing (6 percent), two hematomas (3 percent), one wound infection (1 percent), and one cerebrovascular accident (1 percent). Overall survival was 77 percent at 2 years and 58 percent at 4 years. The type of reconstruction, location of defect, type of dural repair, and history of preoperative radiation and chemotherapy had no significant association with the incidence of complications. Neither the type of reconstruction nor the location of defect showed a significant effect on patient survival. In this experience, local flaps, such as pericranial or temporalis muscle flaps, are good choices for reconstruction of smaller anterior or lateral cranial base defects. For defects that require larger amounts of soft tissue, free flaps are appropriate. With proper patient selection, successful cranial base reconstruction can be performed with either local or free flaps with a low incidence of complications.

Can a day 4 bone scan accurately determine the presence or absence of scaphoid fracture?

Distal Radius Fractures

STUDY OBJECTIVE: To evaluate the accuracy of day 4 bone scans in predicting the presence or absence of fracture in patients with "clinical scaphoid fracture." DESIGN: Prospective sensitivity study of ED patients with clinical scaphoid fractures. Each patient was immobilized in a thumb spica cast and had day 4 bone scans of both wrists and hands. Blinded day 4 bone scan results were ultimately compared with the diagnosis on day 14 when patients returned for repeat clinical examination and radiographs. In cases of equivocal radiographic or clinical examination results, a day 14 bone scan was performed. SETTING: Two tertiary care teaching hospital emergency departments. PARTICIPANTS: All ED patients older than 16 years with the diagnosis of clinical scaphoid fracture were eligible. RESULTS: Ninety-nine patients were enrolled and successfully completed the study protocol from October 1990 through November 1992. One patient had bilateral injury, for a total of 100 completed studies. Day 4 bone scans were 100% sensitive and 92% specific, for a positive predictive value of 65%, a negative predictive value of 100%, and accuracy of 93% (95% confidence interval, 88%, to 98%). Many other types of fractures were identified on the day 4 scans, including those of the triquetra, distal radius, capitate, hamate, trapezoid, trapezium, and metacarpals. CONCLUSION: Day 4 bone scans are an accurate means of ruling out scaphoid fracture. However, because of a significant number of false-positive scans at day 4, they do not reliably confirm the diagnosis of scaphoid fracture. The bone scans also permitted identification of several other wrist fractures that had not been radiographically apparent.

Total knee arthroplasty in patients with a history of illicit intravenous drug abuse

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: Injection drug users are at high risk for both infection with blood-borne pathogens, namely, human immune deficiency virus (HIV), hepatitis-B, -C virus, various bacterial infections, as well as early primary and secondary joint degeneration. When total knee arthroplasty (TKA) is anticipated the risk of septic complications is a major concern. The purpose of this study was to assess the clinical and radiographic outcome of patients with a history of intravenous drug use after total knee arthroplasty. The primary outcome was revision rate. Secondary outcomes were the Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Society Score (KSS) and radiographic loosening. METHODS: We retrospectively reviewed the records of 1,692 TKA performed or revised in our institution. Data of 18 TKA in 12 patients (11 male, 1 female; average age 42, range 23-62 years) with a history of intravenous opioid abuse were available for final analysis. RESULTS: The mean follow up was 125 (range 25-238) months. Seven patients required revision surgery due to periprosthetic joint infection after 62 months (range 5-159): one two staged revision, three arthrodesis and three amputations. The median prosthesis survival was 101 (95%-CI 48-154) months. CONCLUSION: Total knee arthroplasty in patients with a history of intravenous drug abuse is associated with major complications, including above-the-knee amputation. If permanent abstinence from intravenous drug abuse is doubtful, other therapeutic options including primary arthrodesis should be considered.

Recent advances in the management of multiple myeloma

MSTS 2018 - Femur Mets and MM

The management of multiple myeloma has undergone a major change during the past decade. Currently, patients < 65 years of age with advanced disease (stage II-III) are best treated with initial chemotherapy (3-4 cycles of vincristine, adriamycin and dexamethasone, or vincristine, adriamycin and methyl prednisolone, or thalidomide and dexamethasone followed by high dose chemotherapy with autologous peripheral blood stem cell transplantation. More than 50% of patients achieve complete response following this approach. The results of a number of nonrandomized and randomized studies indicate that treatment with high dose chemotherapy followed by autologous peripheral blood stem cell transplantation is associated with improved overall and event-free survival compared with conventional chemotherapy. The absence of chromosome 13 abnormalities, serum albumin levels > 3.5 g/dl and low serum b-2 microglobulin are associated with a better outcome. Almost all patients with significant bone disease or osteoporosis are candidates for therapy with bisphosphonates. About one-third of patients with relapsed or refractory myeloma benefit from therapy with thalidomide or bortezomib (a proteosome inhibitor). Recent work in the immunotherapy of myeloma suggests that some novel immune-based approaches might be useful in the management. The application of cytogenetics and molecular genetics, especially gene expression profiling, are likely to be areas of active research in future studies. © The National Medical Journal of India 2006.

Yoga-based exercise improves balance and mobility in people aged 60 and over: A systematic review and meta-analysis

OAK 3 - Non-arthroplasty tx of OAK

Objective: one-third of community-dwelling older adults fall annually. Exercise that challenges balance is proven to prevent falls. We conducted a systematic review with meta-analysis to determine the impact of yoga-based exercise on balance and physical mobility in people aged 60+ years. Methods: searches for relevant trials were conducted on the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, Allied and Complementary Medicine Database and the Physiotherapy Evidence Database (PEDro) from inception to February 2015. Trials were included if they evaluated the effect of physical yoga (excluding meditation and breathing exercises alone) on balance in people aged 60+ years. We extracted data on balance and the secondary outcome of physical mobility. Standardised mean differences and 95% confidence intervals (CI) were calculated using random-effects models. Methodological quality of trials was assessed using the 10-point Physiotherapy Evidence Database (PEDro) Scale. Results: six trials of relatively high methodological quality, totalling 307 participants, were identified and had data that could be included in a meta-analysis. Overall, yoga interventions had a small effect on balance performance (Hedges' g = 0.40, 95% CI 0.15-0.65, 6 trials) and a medium effect on physical mobility (Hedges' g = 0.50, 95% CI 0.06-0.95, 3 trials). Conclusion: yoga interventions resulted in small improvements in balance and medium improvements in physical mobility in people aged 60+ years. Further research is required to determine whether yoga-related improvements in balance and mobility translate to prevention of falls in older people. PROSPERO Registration number CRD42015015872.

Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Dextrose injection is reported to improve knee osteoarthritis (KOA)-related clinical outcomes, but its effect on articular cartilage is unknown. A chondrogenic effect of dextrose injection has been proposed. OBJECTIVE: To assess biological and clinical effects of intra-articular hypertonic dextrose injections (prolotherapy) in painful KOA. DESIGN: Case series with blinded arthroscopic evaluation before and after treatment. SETTING: Physical medicine and day surgery practice. PARTICIPANTS: Symptomatic KOA for at least 6 months, arthroscopy-confirmed medial compartment exposed subchondral bone, and temporary pain relief with intra-articular lidocaine injection. INTERVENTION: Four to 6 monthly 10-mL intra-articular injections with 12.5% dextrose. MAIN OUTCOME MEASURES: Visual cartilage growth assessment of 9 standardized medial condyle zones in each of 6 participants by 3 arthroscopy readers masked to pre-/postinjection status (total 54 zones evaluated per reader); biopsy of a cartilage growth area posttreatment, evaluated using hematoxylin and eosin and Safranin-O stains, quantitative polarized light microscopy, and immunohistologic cartilage typing; self-reported knee specific quality of life using the Western Ontario McMaster University Osteoarthritis Index (WOMAC, 0-100 points). RESULTS: Six participants (1 female and 5 male) with median age of 71 years, WOMAC composite score of 57.5 points, and a 9-year pain duration received a median of 6 dextrose injections and follow-up arthroscopy at 7.75 months (range 4.5-9.5 months). In 19 of 54 zone comparisons, all 3 readers agreed that the posttreatment zone showed cartilage growth compared with the pretreatment zone. Biopsy specimens showed metabolically active cartilage with variable cellular organization, fiber parallelism, and cartilage typing patterns consistent with fibro- and hyaline-like cartilage. Compared with baseline status, the median WOMAC score improved 13 points (P = .013). Self-limited soreness after methylene blue instillation was noted. CONCLUSIONS: Positive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA, suggesting disease-modifying effects and the need for confirmation in controlled studies. Minimally invasive arthroscopy (single-compartment, single-portal) enabled collection of robust intra-articular data. Level of evidence: Iv.

Superficialization Methods of Arteriovenous Fistula in Obese Patients: A Review of the Literature

Panniculectomy & Abdominoplasty CPG

BACKGROUND: The creation of an arteriovenous fistula in obese patients with end-stage-renal-disease, might not lead to a successful hemodialysis session, partly due to excess adipose tissue overlapping the enlarged vein. This review summarizes the available evidence on superficialization methods in studies dealing with obese patients. METHODS: An English-language literature search was undertaken in the MEDLINE/SCOPUS databases looking for publications that described procedures of salvaging autologous arteriovenous access in upper extremities of obese patients. Perioperative outcomes including technical and clinical success, mean vein depth reduction, wound complications and patency rates were compared within all identified techniques. RESULTS: We identified 12 prospective and 8 retrospective studies. A total of 1149 patients with a mean age 57.2 (range: 49-68) years and a mean BMI 35.8 (range: 28.2-40.8) kg/m(2) underwent mainly radial-cephalic and brachial-cephalic arteriovenous fistula superficialization procedures [transposition, 54%; elevation, 11.1%; lipectomy, 26.1%; liposuction, 2.4%; implantation of a venous window needle guide device, 6.4%]. Technical success was similar between all methods (=96%). However, successful cannulation was lower after liposuction and elevation (81.5% and 78.1% respectively). Transposition achieved lower mean vein depth reduction and clinical success when compared with lipectomy (4.9 mm vs. 8.8 mm and 90% vs. 92.7% respectively). Transposition and liposuction had the lowest and highest complication rate respectively (1.6% vs. 40.8%). Primary and secondary patency rates were lower with liposuction (51.8% and 76.6% respectively), while lipectomy and elevation achieved the highest primary patency rates (68.3% and 71.6% respectively) at 12 months. CONCLUSIONS: In obese patients, all superficialisation techniques report high technical success rates. Although limited by the design of individual published studies and lack of a standard for reporting outcomes, these results lead to satisfactory postoperative and early outcomes. In aggregate, lipectomy and transposition are more clinically effective and more durable procedures.

Hormone replacement therapy and the risk for first hip fracture. A prospective, population-based cohort study

Management of Hip Fractures in the Elderly

OBJECTIVE: To determine the relative risk for sustaining a first hip fracture after hormone replacement therapy. DESIGN: Prospective population-based cohort study with an average observation period of 5.7 years. SETTING: A prescription-based cohort in the Uppsala health care region in Sweden. PARTICIPANTS: The cohort (23 246 women) comprised virtually all women of 35 years of age and older who received noncontraceptive estrogens from April 1977 through March 1980. Comparisons were made with women in the background population. MEASUREMENTS: Follow-up through 1983 was done with regard to hospital admissions for a first cervical or trochanteric hip fracture. The observed number of cases was compared with that expected on the basis of person-years of observation in the cohort and incidence rates in the background population. Analyses were made in exposure categories, based solely on prescription data. MAIN RESULTS: During 133 022 person-years of observation, 163 cases of first hip fracture occurred, compared with the 205.5 expected, yielding an overall relative risk of 0.79 (95% CI, 0.68 to 0.93). The greatest protective effect (relative risk, 0.37; CI, 0.13 to 0.79) was found against trochanteric fracture among women receiving potent estrogens who were under 60 years of age at cohort entry. This group also had the highest proportion of treatments with combinations of estrogens and progestogen (41%). Treatment with less potent estrogens, mainly estriols, had no protective effect. Data indicated that the baseline risk for hip fracture was not lower in the cohort women than in the background population. CONCLUSIONS: Treatment with potent estrogens, both alone and possibly when combined with progestogens, reduces the risk for both cervical and trochanteric hip fractures within the first decade after menopause

Accelerated Bone Loss in Older Men: Effects on Bone Microarchitecture and Strength

Distal Radius Fractures

Accelerated bone loss (ABL) shown on routine dual-energy X-ray absorptiometry (DXA) may be accompanied by microarchitectural changes, increased cortical porosity, and lower bone strength. To test this hypothesis, we performed a cross-sectional study and used high-resolution peripheral quantitative computed tomography (HR-pQCT) scans (Scanco Medical AG, Bruttisellen, Switzerland) to measure estimated bone strength and microarchitecture in the distal radius and distal and diaphyseal tibia. We studied 1628 men who attended the year 14 exam of the Osteoporotic Fractures in Men (MrOS) study. We retrospectively characterized areal bone mineral density (aBMD) change from the year 7 to year 14 exam in three categories: "accelerated" loss, >=10% loss at either the total hip or femoral neck (n = 299, 18.4%); "expected" loss, <10% (n = 1061, 65.2%), and "maintained" BMD, >=0% (n = 268, 16.5%). The ABL cut-off was a safety alert established for MrOS. We used regression models to calculate adjusted mean HR-pQCT parameters in men with ABL, expected loss, or maintained BMD. Men who experienced ABL were older and had a lower body mass index and aBMD and experienced greater weight loss compared with other men. Total volumetric BMD and trabecular and cortical volumetric BMD were lower in men with ABL compared with the expected or maintained group. Men with ABL had significantly lower trabecular bone volume fraction (BV/TV), fewer trabeculae, and greater trabecular separation at both the distal radius and tibia than men with expected loss or who maintained aBMD, all p trend <0.001. Men with ABL had lower cortical thickness and lower estimated bone strength, but there was no difference in cortical porosity except at the tibia diaphyseal site. In summary, men with ABL have lower estimated bone strength, poorer trabecular microarchitecture, and thinner cortices than men without ABL but have similar cortical porosity. These impairments may lead to an increased risk of fracture. © 2018 American Society for Bone and Mineral Research.

Medial Meniscus Radial Tear: A Transtibial 2-Tunnel Technique

OAK 3 - Non-arthroplasty tx of OAK

Complete radial tears of the medial meniscus significantly decrease the meniscal tissue's ability to dissipate tibiofemoral loads and have been described as functionally similar to a total meniscectomy, predisposing patients to early osteoarthritis. At present, no consensus exists regarding the optimal surgical treatment of a radial meniscal tear. Current repair techniques have led to a reportedly high rate of incomplete healing or healing of the meniscus in a nonanatomic, gapped position, which compromises its ability to withstand hoop stresses. Improvement regarding the ability to repair and heal medial meniscus radial tears has the potential to result in enhanced preservation of the articular cartilage in the medial compartment of the knee. This technical description details a method for repairing radial tears of the medial meniscus using a transtibial 2-tunnel technique.

Proximal-row carpectomy for diseases of the proximal row

Distal Radius Fractures

Twelve patients were studied following proximal-row carpectomy. Four had a follow-up of twenty years or more. The lesions for which the operation was done included Kienbock's disease, perilunar dislocations, and fractures of the carpal scaphoid. The major complaint of pain was relieved following surgery, and a functional range of motion was obtained. Mild degenerative arthritis of the wrist was not a contraindication and progressive degenerative arthritis of the radial capitate articulation did not occur. The operation did not result in weakness and all of the patients resumed their preoperative occupations. After conservative measures fail, proximal-row carpectomy rather than arthrodesis should be considered for disorders of the proximal row of carpal bones.

Long-Term Quality-of-Life Outcomes after Body Contouring Surgery: Phase IV Results for the Body-QoL® Cohort

Panniculectomy & Abdominoplasty CPG

Background: Body contouring surgery (BCS) is becoming increasing popular for aesthetic and reconstructive purposes, particularly among patients with massive weight loss (MWL). However, data on quality of life (QoL) following the surgery are limited, especially long-term QoL. Objectives: The authors evaluated the effect of BCS on QoL and the durability of this effect over time. Methods: QoL was measured with the Body-QoL® instrument at 3 time points among consecutively treated patients: the day before BCS, 1 to 9 months postoperatively (short term), and 1 to 2.7 years postoperatively (long term). Total Body-QoL scores were compiled, as were scores for the instrument's main domains: body satisfaction, sex life, self-esteem and social performance, and physical symptoms. Scores were examined for the entire study population and separately for the cosmetic and MWL cohorts. Results: Fifty-seven of the 112 patients participated in the short-term assessment and 84 in the long-term assessment. Total Body-QoL scores increased significantly (P < 0.0001), from 44.0 ± 14.1 preoperatively to 85.5 ± 17.5 short-term postoperatively and to 84.4 ± 12.7 long-term postoperatively. Scores for the 2 postoperative assessments did not differ significantly. Similar results were observed for scores on each separate domain. Although preoperative scores were lower for the MWL cohort than the cosmetic cohort (33.9 ± 15.6 vs 46.1 ± 12.8; P = 0.0002), they improved substantially after BCS, approaching scores for the cosmetic cohort. Conclusions: QoL increases significantly after BCS. This favorable outcome remained stable throughout long-term follow-up and was true for the cosmetic and MWL cohorts.

Conservative Management of Minimally Displaced (â?¤2 mm) Fractures of the Lateral Humeral Condyle in Pediatric Patients: A Systematic Review

Pediatric Supracondylar Humerus Fracture 2020 Review

BACKGROUND: Fractures to the lateral humeral condyle are common in the pediatric population and can lead to complications related to displacement of the fracture fragment. The ideal treatment for minimally displaced fractures (measuring â?¤2 mm) is controversial. METHODS: A systematic review was performed identifying and evaluating studies related to displacement of lateral humeral condyle fractures in pediatric patients. Databases included in this review were PubMed, Biosis Preview, SPORTDiscus, PEDro, and EMBASE. We investigated the rate of subsequent displacement for minimally displaced fractures following immobilization, the time span in which fracture displacement occurs, and the complications related to displacement despite immobilization. RESULTS: Our review of the literature found 6 studies that matched the search criteria. The risk of subsequent displacement in minimally displaced fractures initially treated with immobilization was 14.9% with fracture displacement typically occurring within the first week following injury. Malunion, nonunion, and loss of motion were the most commonly identified complications following subsequent displacement. CONCLUSIONS: For minimally displaced fractures of the lateral humeral condyle, appropriate diagnosis of fracture stability and fracture displacement with close radiographic follow-up 1 week following injury dictate the success of conservative management. LEVEL OF EVIDENCE: Level II-systematic review of level-II or level-I studies with inconsistent results.

Arthroscopy under local anaesthesia

Surgical Management of Osteoarthritis of the Knee CPG

We studied 95 patients who underwent knee Arthroscopy under local anaesthesia between JANUARY 1995 till 1997. Materials used were 1% Xylocaine and 0.25% Bupivacaine of 20 mls each combined with midazolam 2 mg and IV pethidine 30 mgm for sedation. The patients were attached to monitors (pulse Oxymeter, ECG and BP and pulse recorders) and blood less field was created using a tornquet. The procedures lasted about 45 minutes. 90 out of 95 patients completed the procedures successfully without any complications. 2 developed respiratory embarrassments and were intubated and ventilated. 3 procedures abandoned and converted to general anaesthesia. The range of procedures done include meniscectomy, meniscal repair, synovial biopsy, debridement for osteoarthrosis, shaving of osteophytes, drilling of cartilage and bones and removal of loose bodies. This study is to show that knee arthroscopy under LA is a safe alternative in hospitals where GA time is limited

Correlation between Visual Field Index and Other Functional and Structural Measures in Glaucoma Patients and Suspects

Upper Eyelid and Brow Surgery

PURPOSE: To evaluate the correlation between visual field index (VFI) and both structural and functional measures of the optic disc in primary open angle glaucoma patients and suspects. METHODS: In this retrospective study, 162 glaucoma patients and suspects underwent standard automated perimetry (SAP), retinography, and retinal nerve fiber layer (RNFL) measurement. The optic disc was stratified according to the vertical cup/disc ratio (C/D) and sorted by the disc damage likelihood scale (DDLS). RNFL was measured with the optical coherence tomography. The VFI perimetry was correlated with the mean deviation (MD) and pattern standard deviation (PSD) obtained by SAP, and structural parameters by Pearson's correlation coefficients. RESULTS: VFI displayed strong correlation with MD (R = 0.959) and PSD (R = -0.744). The linear correlations between VFI and structural measures including C/D (R = -0.179, P = 0.012), DDLS (R = -0.214, P = 0.006), and RNFL (R = 0.416, P < 0.001) were weak but statistically significant. CONCLUSION: VFI showed a strong correlation with MD and PSD but demonstrated a weak correlation with structural measures. It can possibly be used as a marker for functional impairment severity in patients with glaucoma.

Articular cartilage regeneration in the knee

Surgical Management of Osteoarthritis of the Knee CPG

Purpose of review: Articular cartilage lesions in the active population are observed with increasing frequency and result from the significant acute and chronic joint stress associated with high-impact sports. Current surgical options for articular cartilage injury include repair (debridement), replacement (osteochondral autograft or allograft transplantation), and regeneration (autologous chondrocyte implantation). We describe the indications and technique for autologous chondrocyte implantation, and discuss its importance in the prevention of progressive chondropenia. Recent findings: Autologous chondrocyte implantation may provide autologous hyaline-like tissue for large chondral lesions, but limitations include possible periosteal hypertrophy and the need for a staged procedure. Researchers are now focusing on matrix articular cartilage implantation, which involves a biodegradable matrix seeded with chondrocytes to cover the defect. Matrix articular cartilage implantation can be done in a single procedure and does not require use of a periosteal flap. Summary: Early clinical results for articular cartilage regeneration techniques are encouraging. Long-term studies in this population will determine the efficacy of articular cartilage repair to reverse chondropenia and to prevent development of secondary arthritic degeneration. (copyright) Lippincott Williams & Wilkins

Surgical site infection following open reduction and internal fixation of a closed ankle fractures: A retrospective multicenter cohort study

DoD SSI (Surgical Site Infections)

BACKGROUND: Identification of risk factors for surgical site infection (SSI) after surgical ankle fractures was important, but related evidence was inadequate. This study was conducted to investigate the incidence and risk factors for SSI after open reduction and internal fixation (ORIF) of a closed ankle fractures. METHODS: Patients who underwent ORIF for a closed ankle fractures at 3 centers between July 2015 and January 2017 were included. Electronic medical recordings (EMR) and Picture Archiving and Communication Systems (PACS) were inquired for information on patients' clinical and radiographic characteristics. The potential factors include 4 aspects: demographics, injury-related, surgery-related and biochemical indictors. Factors related with SSI were analyzed by univariate and further by multivariate logistic regression model. RESULTS: During the hospitalization, 3.7% (46/1247) of patients developed SSI, with 1.12% (14/1247) for deep and 2.57% (32/1247) for superficial SSI. Approximately half of SSIs were caused by Methicillin-resistant Staphylococcus aureus (MRSA). After adjustment for confounding factors, higher body mass index (BMI), surgeon level (residents or treating surgeon), surgical duration>130mins, delayed surgery, preoperative TP < 60 g/L were significant risk factor or predictors for SSI occurrence. CONCLUSIONS: After comprehensive evaluation of patients medical conditions, immediate operation by a surgeon with more expertise could effectively reduce SSI occurrence.

Efficacy Study on Symptomatic Control of Patient With Knee Osteoarthritis Between 14% of Plai (Plaivana®) to Placebo Gels

OAK 3 - Non-arthroplasty tx of OAK

Osteoarthritis is the most common of the arthritides, affecting at least 20 million Americans, a number that is expected to double over the next two decades. currently available medical therapies primarily address the treatment of joint pain in patients with osteoarthritis.Analgesics as well as traditional and cyclooxygenaseâ?2â?selective nonsteriodal antiâ?inflammatory drugs (NSAIDs) have suboptimal effectiveness,and there is some question about their safety, especially in the light of recent reports of increased cardiovascular risk. Plai (Zingiber cassumunar Roxb.) belongs to family of Ginger. Plai essential cream also has an activity on scavenging H2O2 generated by ultrasound exposure. The dilutions of 1:2,000 and 1:1,000 (v:v) of plai cream presented H2O2 scavenging activity by reducing emissions of DCFHâ?fluorescence within U937 cells, compared with the cell control. Plai essential cream inhibited nitric oxide (NO) production in the macrophage cell line (J774), compared with untreated cells. However, high concentrations of plai cream (1:1 and 1:10), were toxic to U937 and J744 cell lines. Moreover, plai cream at dilutions of 1:1,000 and 1:2,000, significantly inhibited COX II activity in treated cells compared to the untreated cells. Three major compounds of plai essential cream were sabinene, terpinenâ?4â?ol and (E)â?1â?(3,4â?dimethyoxyphenyl) butadiene respectively.There have been many studies on the efficacy of Plai as an analgesic and antiâ?inflammatory when applied directly to the affected area. The majority of these studies have been carried out in Thailand as this is where the plant originates from and it is used extensively in Thai massage and herbal medicine. The antiâ?inflammatory activity of a compound found in Plai extracts was assessed and compared with aspirin, and two other lesser known antiâ?inflammatory drugs. The results obtained showed that the antiâ?inflammatory effect of the compound (compound D) mainly occurred in the acute phase of inflammation.Moreover, the antiâ?inflammatory affect of plai oil was twice as potent as Diclofenac. The Plai cream was shown to reduce swelling and pain significantly in athletic ankle sprain in the first 2â?3 days of the treatment. These findings suggest that topical plai cream is a safe and potentially useful drug for the treatment of painful OA of the joints, however, there has been no efficacious study on the plai cream namely Plaivana® for relieving symptoms in patient with OA knee joint before, therefore, this study is proposed. Subject selection and withdrawal criteria Number of subjects A sufficient number of subjects with OA of the knee will be screened in order to randomize at least 100 subjects (100 pairs) The study should provide 92 subjects (92 pairs) evaluable subjects, assuming that 10% of subjects will withdraw before having one the last assessment in the primary outcome variable. Objectives Primary To evaluate the pain control using VAS of Plai cream 14 gm/100 (Plaivana®) compared with placebo cream in patient with OA knee. Secondary â? To evaluate the WOMAC score of patients in the Plaivana® compared with the placebo groups. â? To compare the amount of acetaminophen tablet taking in both groups. â? To compare the side effect of Plaivana® with the placebo. Investigational plane Study Design This will be the phase III randomized, doubleâ?blind, placeboâ?controlled crossâ?over trial of 12 weeks duration. This study is designed to evaluate the efficacy of Plaivana® to placebo, in adults with OA of the knee. Randomization will be stratified by Kellgrenâ?Lawrence (KL) grading (grade 2 and 3) using Xâ?ray standing MTP technique. A total of 100 subjects (100 pairs of subjects) are planned for enrollment in this study. This study will be conducted over approximately 12 weeks. Patients and Methods Patients and study design This was the phase III randomized, doubleâ?blind, placeboâ?controlled crossâ?over trial of 12 weeks duration designed to evaluate the efficacy of Plaivana® to placebo, in adult with OA of the knee. A otal of 100 subjects (100 pairs of subjects) are planned for enrollment in this study. This was an 8 weeks period of study treatmentâ?control periods (4 weeks for treatment, two weeks for washâ?out and 4 weeks for placebo periods). The study was conducted in accordance with the Declaration of Helsinki, was approved by Khon Kaen University Ethics Committee for Human Research and informed consent was obtained from all patients. Study medication The essential plai cream has antiâ?inflammatory and antimicrobial effects (Wasuwat1989, Giwanon 2000, Pithayanukul 2007, and Tripathi 2008). Active chemicals of plai cream are composed of sabinene, alpha and gamma tepinenes, terpinen 4â?ol and (E)â?1â?(3,4â?dimethoxyphenyl butadiene (DMPBD). The DMPBD has a property of antiâ?inflammatory activity(Ozaki 1991, Jeenapongsa 2003). Plavina® 40 mg in 100 gm (contains DMPBD of â?¦%). This product was supplied in lacquered aluminum collapsible tube containing 100 gram cream packing. Treatment Assignment and dosing Subjects will be assigned to study treatment in accordance with the randomization schedule. Randomization will be stratified by KL grade (grade 2 or 3). At the Baseline/Randomization Visit, each subject will be randomly assigned to either Plaivana® or placebo creams. Plaivana® or placebo creams were applied three times around the index knee. The 2 inches in length of cream was topically applied to the skin around the index knee joint, then rubbing the cream until it dry. After applying the cream, patients should wash their hands and do not touch their eyes. Blinding This is a doubleâ?blind study. All study drugs will be blinded to the investigators and subjects. The study and placebo creams were prepared in the same lacquered aluminum collapsible tube containing 100 gram cream packing. Product Accountability In accordance with the standard requirements, the investigator must document the amount of investigational cream product dispensed and /or administered to study returned to the investigator. Product accountability records must be maintained throughout the course of the study. Treatment Compliance A drugâ?dispensing log will be maintained by the investigator. Subjects will be instructed at the baseline visit to record the dates on which they applied the cream from each lacquered aluminum collapsible tube and to bring the tube with them on study visit days. Subject compliance will be assessed based on the weight of returning tube, which will be collected and recorded in the Data Record Form. Subject will be asked to complete a diary card to capture daily applying doses of the cream. Concomitant Medications and Nonâ?drug therapies Subject was asked to complete a diary card to capture daily applying doses of the cream. Subject was asked to complete a diary to capture takes and changes in concomitant therapy during the study, including pain medication or nutritional supplements for OA related pain. Subjects were permitted to take acetaminophen (500 mg) three times or two tablets for pain every 4â?6 hours. Other topical analgesics, NSAID and COXâ?2 inhibitors are prohibiting. All concomitant medications or nutritional supplement taken during the study were also recorded. During washâ?out period Subjects were permitted to take only acetaminophen for OA pain for 7 days. Subjects maintained written diaries to record dosing of medications and nutritional supplements for OAâ?associated pain. STUDY ASSESSMENT AND PROCEDURES Subjects will be expected to attend the clinic a minimum of 6 times over period of approximately 12 weeks. The study consists of 7 phases: screen, treatment, followâ?up, washout, screening, treatment, and followâ?up. The study investigation will discuss with each subject in detail of the study objectives, its requirement and its restrictions. The screening 1st visit will include a formal review of the complete medical history, all concurrent medications, concomitant diseases, medication taken within the last month and all medications of interested in the exclusion criteria, and other eligibility req irement for the study including contraindication for plai cream. Eligible subject will further be determined by exclusion criteria such as severe pain defined as above 80 mm on the 100 mm VAS scale for pain, as identified by subject response to WOMAC pain subscale. If OA present in both knees the investigator will identify which knee will be Xâ?ray for the study entry, with preference for the knee with more severe pain (<80 mm on WOMAC pain sub scale) A radiograph of the index knee will be obtained using the MTP technique to evaluate JSW and KL grade. The minimum JSW must be at least 1.5 mm in the medial compartment and at least 2.5 mm in the corresponding lateral compartment with KL grade of 2 or 3. At the screening 1st visit, subject should be instructed to withhold OA medication for pain for 7 days for all NSAIDs or 24 hours for acetaminophen immediately prior to the baseline visit. At the 2nd visit subject will be randomized following stratification by KL grade. This visit, the following procedures will be completed: â? VAS â? WOMAC Subject will be received their first study or placebo cream, acetaminophen 500 mg for 40 tablets and daily record their symptoms. Efficacy Assessments Primary endpoint VAS: The primary endpoint is the change from baseline in VAS. This endpoint will be measured at visit 2â?13 (week 1â?12) Secondary endpoint WOMAC Score The WOMAC score is a triâ?dimensional, diseaseâ?specific, selfâ?administered health status measure, probing clinically important, subjectâ?relevant symptoms in the area of pain. The subject will answer WOMAC question on pain subscale, using the Linkert scale 0â?100 at screening 1st visit to determine eligibility for inclusion in the study. The subject will complete the entire WOMAC questionnaire during visit 2â?13 (week 1â?12) Safety Assessments Adverse events The investigator will be responsible for detecting, documenting and reporting events that meet the definition of adverse events. Definition of an adverse event is any unfavorable or unintended sign (including a clinically significant abnormal laboratory finding, for example; skin rash, swelling), symptom, or disease temporally associated with the use of a medicinal product, whether or not considered as an adverse event.Any adverse event should be documented on the patient chart and reported on the Adverse Event Form. Dropouts Reason for dropout The patients may dropâ?out of the study if they decide to do so, at any time and irrespective of the reason, or this may be the investigator decision. All dropouts must be documented and the investigator must give the reason. Data Analysis and statistical considerations Sample size determination The primary endpoint was the change from baseline in visual analog scale (VAS).The secondary endpoint was the Western Ontario McMaster score (WOMAC). These endpoints were measured every week for 9 weeks (4 weeks for each treatment periods and one week for washout period). This study is determined to demonstrate that Plaivana® is able to reduce the pain (VAS), functional score and stiffness score when compared to placebo cream. It is expected that Plaivana® will reduce the VAS by 1.23 (which considers Minimal Clinical Improvement Important, MCII) and SD was 4.39. The significant level is 95% or alpha at 5% of twoâ?sided test and power for detecting different is 80% or beta at 20%. Therefore, the sample size of 103 pairs of patient is needed. Adding 5% dropout rate, we would need approximately 108 pairs of patient (108 patients) to be randomized to each treatment group in the study. N pairs = ½(1+1/λ)[(Z1â?Î±/2+Z1â?Î²)2/D2pair +( Z2 1â?Î±/2)/2] Î?= number of controls:case = 1 D= Effect size =VAS difference/SDof VAS The VAS difference which minimal clinical improvement important was 1.23 and SDof VAS = 4.39, therefore the sample size was 103 pairs Hypothesis testing The null hypothesis to be tested is that the VAS in Plaivana® group is not different from the placebo group. Analysis population The primary analysis will be based on patients on intentâ?toâ?treat (ITT) p pulation, which will include all patients with baseline results of VAS, WOMAC score. Statistic methods The mean different of VAS in Plaivana® and placebo be analyzed by Z test, 95% CI of the mean different of VAS. The confident interval of the mean of VAS in each treatment group will be calculated. Other baseline factors such as WOMAC, Stiffness score and acetaminophen used will be analyses by ANOVA, student T test and Mc Nemar 's Chiâ?square. All statistical analyses were performed by using STATA Statistical Software: Release 10th. (StataCorp. 2007. Stata Statistical Software: Release 10th. College Station, TX: SataCorp.) Data Management The data collection will be done by research assistance using the DATA RECORD FORM SHEATH. Clinical data management will perform in according with the Good Clinical Practice Guidelines. Ethics The trial will be considered in accordance with: The Declaration of Helsinki adopted by the World Medical Assembly in June 1964, amended at Tokyo in October 1975, at Venice in October 1983 at Hong Kong in September 1989 and at Somerset West in October 1996. Before a subject included in the trial, the aims and methods of the trial are explained to the subject. The subject givens his/her consent in writing on an information and informed consent form. The investigator will submit the documents required by the regulations according to the Ethics Committee of Khon Kaen University and will obtain their opinion in writing. Subjects cannot be included until the approval of the Ethics Committee has been received. Quality controlâ?Quality assurance The investigator in charge of the study ensures the efficient organization and good quality of the study, notably he is responsible for protocol compliance, data collection and Good Clinical Practice in general. Data collection will be monitored throughout the study by the monitors after quality control by the investigator.

The Safety of Aesthetic Labiaplasty: A Plastic Surgery Experience

Panniculectomy & Abdominoplasty CPG

Background The demand for female aesthetic labiaplasty surgery continues to rapidly increase. Several questions have been raised regarding the safety and effectiveness of female aesthetic genital surgery. Objectives The purpose of this study is to review our experience with aesthetic labiaplasty and describe the type and frequency of complications that have been experienced. Methods A retrospective chart review was performed on all patients who had primary aesthetic labia minora reduction surgery from August 2007 to April 2014. A chart review of the electronic medical record was performed to examine demographic, procedural, and outcome data. Results In the study period, 113 patients underwent aesthetic labiaplasty. Of these, 29 patients (25.6%) had labiaplasty performed in combination with another procedure. A total of 15 patients (13.3%) reported transient symptoms, including swelling, bruising, and pain. There was one patient (0.8%) that experienced bleeding. Four patients (3.5%) required revision surgery. All revisions were performed to excise further tissue to address persistent redundancy or asymmetry. No major complications were reported. Conclusions In our experience, aesthetic surgery of the labia minora using an edge excision technique has a very low complication rate and provides satisfactory aesthetic outcomes for our patients. More studies examining the impact of labiaplasty on a woman's self-image and quality of life would add to our understanding of the motivations and expectations of women undergoing this aesthetic surgery. This information will allow us to help our patients make well-informed decisions when considering this aesthetic genital surgery. Level of Evidence 4 Risk.

Orthopaedic Resident Use of an Electronic Medical Record Template Does Not Improve Documentation for Pediatric Supracondylar Humerus Fractures

Pediatric Supracondylar Humerus Fracture 2020 Review

INTRODUCTION: Pediatric supracondylar humerus fractures are associated with a high incidence of nerve injury. Therefore, it is imperative that documentation be complete and accurate. This investigation compares orthopaedic resident history and physical (H&P) documentation of pediatric supracondylar fractures for completeness and accuracy with and without the use of an electronic medical record template. METHODS: The electronic medical record H&P documentation of 119 supracondylar humerus fractures surgically treated at a single pediatric institution was retrospectively reviewed. Templated and nontemplated groups were compared for documentation completeness and accuracy. Definitive diagnosis of a nerve palsy was made by a supervising orthopaedic attending surgeon. RESULTS: Forty-two cases had a templated H&P and 77 did not. The H&P documentation in the templated group was markedly more complete than that in the nontemplated group. However, the accuracy of the H&P documentation to identify nerve palsy was not statistically different between the two groups. Overall, the voluntary use of the orthopaedic template declined over time. CONCLUSION: Resident use of an orthopaedic template for documenting the H&P of pediatric supracondylar humerus fractures compared with nontemplated notes resulted in more complete documentation but only comparable accuracy. LEVEL OF EVIDENCE: III.

External fixation versus open reduction with plate fixation for distal radius fractures: a meta-analysis of randomised controlled trials

Distal Radius Fractures

BACKGROUND: Both external fixation and open reduction with internal fixation (ORIF) using plates have been recommended for treatment of distal radius fractures. We conducted a systematic review and meta-analysis of randomised controlled trials comparing external fixation to ORIF. METHODS: MEDLINE, EMBASE, and COCHRANE databases were searched from inception to January 2011 for all trials involving use of external fixation and ORIF for distal radius fractures. Eligibility for inclusion in the review was: use of random allocation of treatments; treatment arm receiving external fixation; and treatment arm receiving ORIF with plate fixation. Eligible studies were obtained and read in full by two co-authors who then independently applied the Checklist to Evaluate a Report of a Nonpharmacological Trial. Pooled mean differences were calculated for the following continuous outcomes: wrist range of motion; radiographic parameters; grip strength; and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Pooled risk ratios were calculated for rates of complications and reoperation. RESULTS: The literature search strategy identified 52 potential publications of which nine publications (10 studies) met inclusion criteria. Pooled mean difference for DASH scores was significantly less for the ORIF with plate fixation group (-5.92, 95% C.I. of -9.89 to -1.96, p < 0.01, I(2) = 39%). Pooled mean difference for ulnar variance was significantly less in the ORIF with plate fixation group (-0.70, 95% C.I. of -1.20 to -0.19, p < 0.01, I(2) = 0%), indicating better restoration of radial length for this group. Pooled risk ratio for infection was 0.37 (95% C.I. of 0.19-0.73, p < 0.01, I(2) = 0%), favouring ORIF with plate fixation. There were no significant differences in all other clinical outcomes. CONCLUSIONS: ORIF with plate fixation provides lower DASH scores, better restoration of radial length and reduced infection rates as compared to external fixation for treatment of distal radius fractures.

Functional outcome in patients with unstable distal radius fractures, volar locking plate versus external fixation: a meta-analysis

Distal Radius Fractures

The aim of this study was to compare bridging external fixation with volar locked plating in patients with unstable distal radial fractures regarding functional outcome. A systematic search was performed in the Cochrane Central Register of Controlled Trials, Medline and EMBASE. All randomized controlled trials that compared bridging external fixation directly with volar locked plating in patients with distal radial fractures were considered. Three reviewers extracted data independently from eligible studies using a data collection form. Studies in which the primary endpoint was measured on the disabilities of the arm shoulder and hand (DASH) score at 3, 6 and 12 months were included in the analysis. To this end, mean scores and standard deviations were extracted. The software package Revman 5 provided by the Cochrane Collaboration was used for data analysis. Three studies involving 174 patients were analyzed. Ninety patients were treated with an (augmented) bridging external fixator and 84 with a volar locking plate. Data were analyzed with the random effects model. The robustness of the results was explored using a sensitivity analysis. Patients treated with a volar locking plate showed significantly lower DASH scores at all times. A difference of 16 (p = 0.006), six (p = 0.008) and eight points (p = 0.06) was found at 3, 6 and 12 months follow-up, respectively. Patients treated with a volar locking plate showed significantly better functional outcome throughout the entire follow-up. However, this difference was only clinically relevant during the early postoperative period (3 months).

Stability and variability of knee kinematics during gait in knee osteoarthritis before and after replacement surgery

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Patients with knee osteoarthritis often feel unstable, suffering from buckling (giving way) or even falling. This study aimed at characterising such instability, and following it over time. METHODS: We investigated treadmill walking in knee osteoarthritis, focusing on angular velocity of sagittal plane knee movements. Knee osteoarthritis patients were followed 1 year after replacement surgery, and were compared to healthy peers. Subjects walked at increasing speeds, and maximum speed was registered. To quantify stability, we calculated short-term (lambda(S)) and long-term (lambda(L)) Lyapunov exponents (the exponential rate of divergence, in state space, of trajectories originating from nearest neighbours), as well as the variability of knee movements, the latter just after heel contact. At each measurement session, patients reported how often they had fallen in the preceding period. FINDINGS: Patients had lower maximum walking speed than controls, and walked with reduced variability, post-operatively even more so. Variability was positively related to number of falls. Pre-operatively, patients had higher lambda(S) at the unaffected side, which post-operatively normalized. INTERPRETATION: Slow walking may serve being more cautions. Reducing variability of sagittal knee kinematics appears to reduce fall risk, perhaps involving paying more attention and/or using cocontraction. The pre-operatively higher unaffected side lambda(S) could result from attempts to reduce the kinematic demands on the affected leg, "letting go" the unaffected leg. One year after the operation, this problem with unaffected lambda(S) had disappeared, suggesting recovery. Further study should include short-term and long-term stability, as well as a quantitative measure of perceived instability

Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures

DoD SSI (Surgical Site Infections)

BACKGROUND: Surgical site infection and other hospital-acquired infections cause significant morbidity after internal fixation of fractures. The administration of antibiotics may reduce the frequency of infections. OBJECTIVES: To determine whether the prophylactic administration of antibiotics in people undergoing surgical management of hip or other closed long bone fractures reduces the incidence of surgical site and other hospital-acquired infections. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to November 2009), EMBASE (1988 to December 2009), other electronic databases including the WHO International Clinical Trials Registry Platform (December 2009), conferences proceedings and reference lists of articles. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing any regimen of systemic antibiotic prophylaxis administered at the time of surgery, compared with no prophylaxis, placebo, or a regimen of different duration, in people with a hip fracture undergoing surgery for internal fixation or prosthetic replacement, or with any closed long bone fracture undergoing internal fixation. All trials needed to report surgical site infection. DATA COLLECTION AND ANALYSIS: Two authors independently screened papers for inclusion, assessed risk of bias and extracted data. Pooled data are presented graphically. MAIN RESULTS: Data from 8447 participants in 23 studies were included in the analyses. In people undergoing surgery for closed fracture fixation, single dose antibiotic prophylaxis significantly reduced deep surgical site infection (risk ratio 0.40, 95% CI 0.24 to 0.67), superficial surgical site infections, urinary infections, and respiratory tract infections. Multiple dose prophylaxis had an effect of similar size on deep surgical site infection (risk ratio 0.35, 95% CI 0.19 to 0.62), but significant effects on urinary and respiratory infections were not confirmed. Although the risk of bias in many studies as reported was unclear, sensitivity analysis showed that removal from the meta-analyses of studies at high risk of bias did not alter the conclusions. Economic modelling using data from one large trial indicated that single dose prophylaxis with ceftriaxone is a cost-effective intervention. Data for the incidence of adverse effects were very limited, but as expected they appeared to be more common in those receiving antibiotics, compared with placebo or no prophylaxis. AUTHORS' CONCLUSIONS: Antibiotic prophylaxis should be offered to those undergoing surgery for closed fracture fixation. [References: 68]

The Use of Navigation in Osteotomies Around the Knee

OAK 3 - Non-arthroplasty tx of OAK

Osteotomies around the knee for treating osteoarthritis or knee instability are currently well-established procedures. Success of these realignment procedures is based on the accuracy and the reliability of correction angles in the coronal and sagittal alignment. In this context of improving precision and adapting the correction to each patient, navigation is currently being widely used. The rationale for its use is based on understanding the advantages and limitations, technical principles, and potential pitfalls. This article describes these areas and the overall clinical outcomes of this system for knee osteotomies.

Incidence and Predictors of Hardware Failure After Instrumentation for Spine Metastasis: A Single-Institutional Series

MSTS 2022 - Metastatic Disease of the Humerus

OBJECTIVE: We report a retrospective analysis of hardware failure in patients requiring instrumentation for spinal metastasis. METHODS: In a retrospective study at a single institution, we identified 58 patients who underwent spinal instrumentation for metastasis from 2012 to 2018. Hardware failure was defined as screw pullout/loosening, cage migration, progressive kyphosis, or an otherwise-noticeable instrumentation deficit detectable on imaging. Risk factors for hardware failure with a P < 0.05 in in univariate were included in multivariate logistic regression models controlled for age, sex, and previously identified risk factors for hardware failure. RESULTS: In total, 58 patients required instrumentation for metastatic spine disease. Median age was 60.2 years (interquartile range 49.0-66.3), 38 patients (65.5%) were male, and median follow-up was 8.1 months (interquartile range 3.1-20.7). Eight patients (13.8%) developed signs of hardware failure during follow-up, of whom 2 patients (3.4%) underwent operative revision. In univariate analysis, Eastern Cooperative Oncology Group performance status >2 (P = 0.049) and multiple myeloma lesions (P = 0.010) were significant predictors of failure. Both factors maintained significance in a multivariate logistic regression model controlled for age, sex, history of spine radiation, and number of fused levels with P = 0.047; odds ratio 12.7 (95% confidence interval 1.03-156.4) for Eastern Cooperative Oncology Group performance status over 2 and P = 0.012; odds ratio 31.5 (95% confidence interval 2.2-460.0) for multiple myeloma lesions. CONCLUSIONS: The rate of hardware failure in this cohort was 13.8%, although operative revision rate was 3.4%. Spinal instrumentation in patients with poor preoperative functional status or multiple myeloma may be more likely to develop instrumentation failure.

Is There an Association Between a History of Running and Symptomatic Knee Osteoarthritis? A Cross-Sectional Study From the Osteoarthritis Initiative

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: Regular physical activity, including running, is recommended based on known cardiovascular and mortality benefits. However, controversy exists regarding whether running can be harmful to knees. The purpose of this study is to evaluate the relationship of running with knee pain, radiographic osteoarthritis (OA), and symptomatic OA. METHODS: This was a retrospective cross-sectional study of Osteoarthritis Initiative participants (2004-2014) with knee radiograph readings, symptom assessments, and completed lifetime physical activity surveys. Using logistic regression, we evaluated the association of history of leisure running with the outcomes of frequent knee pain, radiographic OA, and symptomatic OA. Symptomatic OA required at least 1 knee with both radiographic OA and pain. RESULTS: Of 2,637 participants, 55.8% were female, the mean +/- SD age was 64.3 +/- 8.9 years, and the mean +/- SD body mass index was 28.5 +/- 4.9 kg/m² ; 29.5% of these participants ran at some time in their lives. Unadjusted odds ratios of pain, radiographic OA, and symptomatic OA for those prior runners and current runners compared to those who never ran were 0.83 and 0.71 (P for trend = 0.002), 0.83 and 0.78 (P for trend = 0.01), and 0.81 and 0.64 (P for trend = 0.0006), respectively. Adjusted models were similar, except radiographic OA results were attenuated. CONCLUSION: There is no increased risk of symptomatic knee OA among self-selected runners compared with nonrunners in a cohort recruited from the community. In those without OA, running does not appear to be detrimental to the knees.

Rehabilitation of reading in older individuals with macular degeneration: a review of effective training programs

Upper Eyelid and Brow Surgery

Macular degeneration (MD) is the most common cause of visual impairment among older adults. It severely affects reading performance. People with MD have to rely on peripheral vision for reading. In this review, we considered several training programs that aim to improve peripheral reading, with a focus on eccentric viewing, oculomotor control, or perceptual learning. There was no strong support in favor of one particular training method for rehabilitation of reading in MD, but there is evidence that older individuals with MD can be trained to improve reading performance, even within limited time.

A randomized comparative study of topical versus intravenous tranexamic acid administration in enhanced recovery after surgery (ERAS) total knee replacement

OAK 3 - Non-arthroplasty tx of OAK

Background: The aim of this study was to compare the topical to IV tranexamic acid (TXA) administration of the same dose, given at the same time in patients who underwent TKR using an enhanced recovery after surgery (ERAS) regime. Methods: Ninety patients were randomized in control group, and IV and topical application groups received 1 g TXA. Results: Blood loss and transfusion requirements in control group were statistically higher compared to both TXA groups (p < 0.05). Length of stay was the same in all groups. Conclusions: TXA reduced significantly the blood loss and the need for transfusion in ERAS primary unilateral TKR.

MicroRNA-200b acts as a tumor suppressor in osteosarcoma via targeting ZEB1

MSTS 2022 - Metastatic Disease of the Humerus

Osteosarcoma is the most common type of cancer that develops in bone, mainly arising from the metaphysis of the long bones. MicroRNA (miR)-200b has been found to generally act as a tumor suppressor in multiple types of human cancers. However, the detailed role of miR-200b in osteosarcoma still remains to be fully understood. This study aimed to investigate the exact role of miR-200b in the progression of osteosarcoma and the underlying mechanism. Real-time reverse transcription-polymerase chain reaction data showed that miR-200b was significantly downregulated in osteosarcoma tissues compared to their matched adjacent nontumor tissues. Low miR-200b level was associated with the advanced clinical stage and positive distant metastasis. Besides, it was also downregulated in osteosarcoma cell lines (U2OS, Saos2, HOS, and MG63) compared to normal osteoblast cell line NHOst. In vitro study showed that restoration of miR-200b led to a significant decrease in proliferation, migration, and invasion of osteosarcoma cells. Moreover, ZEB1 was identified as a target gene of miR-200b, and its expression levels were negatively mediated by miR-200b in osteosarcoma cells. In addition, ZEB1 was significantly upregulated in osteosarcoma cells compared to the normal osteoblast cell line NHOst, and inhibition of ZEB1 expression also suppressed the proliferation, migration, and invasion in osteosarcoma cells. Finally, we showed that ZEB1 was frequently upregulated in osteosarcoma tissues compared to their matched adjacent normal tissues, and its expression was reversely correlated to the miR-200b levels in osteosarcoma tissues. Based on these findings, our study suggests that miR-200b inhibits the proliferation, migration, and invasion of osteosarcoma cells, probably via the inhibition of ZEB1 expression. Therefore, miR-200b/ZEB1 may become a potential target for the treatment of osteosarcoma.

Clavicular fracture non-union surgical outcome and complications

DoD SSI (Surgical Site Infections)

Symptomatic clavicular fracture non-union is rare. When it does occur, however, it may pose a difficult problem causing pain and functional impairment. The emphasis of this paper is on preopertive disabilities and the postoperative outcome and complications. Twenty patients with clavicular non-union treated operatively from 1989 to 1997 were reviewed, the average follow up was thirty-four months. Eleven fractures were midshaft, eight were lateral third and one medial third. A detailed proforma was completed with the patients documenting preoperative symptoms, outcome after surgery and complications. A literature search was carried out to find out the incidence of complications related to operating on post-traumatic clavicular non-union. All of the twenty fractures non-unions duly united after surgical intervention although three required early adjustment or change of metal work. The subjective and objective outcomes were good in 19 cases and poor in one. The postoperative complications included three implant failures, one stiff shoulder, two patients with numbness below the scar and one patient with an infected donor site wound. The literature search revealed that from 24 publications and 301 patients who had operations for clavicular non-union ther were 18 (6%) reported complications related to metal work, 45 (15%) reported complications related to soft tissues, seven (2%) complications related to the scar and 24 (8%) failures of union. Symptomatic clavicular non-union can cause severe disabilities. Good outcome, at low risk, can be expected from internal fixation and bone grafting of midshaft non-unions. Although there are only eight cases of lateral third clavicular non-unions, this is the largest series in the literature. Furthermore, the study clearly demonstrates both the difficulties treating this fracture surgically and a procedure to be avoided (acromio-clavicular bridging), which, again has not been previously addressed. [References: 31]

Effect of pamidronate on new vertebral fractures and bone mineral density in patients with malignant lymphoma receiving chemotherapy

Management of Hip Fractures in the Elderly

Background High doses of corticosteroids, and the use of alkylating agents like cyclophosphamide with subsequent hypogonadism, have been implicated in the pathogenesis of chemotherapy-induced osteoporosis. In this study, we evaluated whether intravenous pamidronate can prevent bone loss and reduce vertebral fractures in patients with malignant lymphoma who were receiving chemotherapy. Methods We enrolled 50 patients who had newly diagnosed stage III or IV malignant lymphoma. All patients were assigned randomly to receive either intravenous pamidronate or placebo. Pamidronate (30 mg per treatment) or placebo was given at 3-month intervals for 12 months. Five patients in the control group dropped out during the trial. The main outcomes were the incidence of vertebral fractures and changes in bone mineral density of the lumbar spine and proximal femur. Results During the 12-month study, 6 (30%) of the 20 patients in the control group and 1 (4%) of the 25 patients in the pamidronate group developed new vertebral fractures (P = 0.01). In the control group, the mean percentage changes in bone mineral density were -11.2% in the lumbar spine and -4.5% in the femoral neck. In contrast, pamidronate treatment led to minor losses of bone mineral density at both sites (-2.7% at the lumbar spine; -2.3% at the femoral neck). The difference between the groups was significant at the lumbar spine (P = 0.005). Conclusion Pamidronate reduces trabecular bone loss and the risk of new vertebral fractures in patients with malignant lymphoma receiving chemotherapy. (copyright) 2004 by Excerpta Medica Inc

The effect of age on the quality of life after knee replacement

Surgical Management of Osteoarthritis of the Knee CPG

Two-hundred and twenty-one consecutive patients over 50 years old who had undergone unilateral total knee replacement for osteoarthritis had their Quality Adjusted Life Years (QALYs) assessed using the Rosser index. The patients were divided into four groups by age: 51-60 years old; 61-70 years old; 71-80 years old; and 81-90 years old. The main outcome measures were Quality-of-Life gain (QoL gain) and QALYs formed from the Rosser index, post-operative complications, Guepar and HLS knee scores and a subjective analysis of outcome. Results: The oldest group had a poorer pre-operative quality of life (QoL) scores but no difference in gain compared to the other groups. There was no difference in the post-operative complication rates, nor in the subjective outcomes. The gain in QALY was 1.94 (S.E.M. (plus or minus) 0.81) for 51-60 years old, 1.76 ((plus or minus) 0.35) for 61-70 years old, 1.16 ((plus or minus) 0.11) for 71-80 years old and 1.02 ((plus or minus) 0.18) for 81-90 years old. The improvement in knee scores did not correlate with QoL gain. It was concluded that age is not a determining factor in the outcome following total knee replacement (TKR)

Contemporary management of metastatic bone disease: tips and tools of the trade for general practitioners

MSTS 2022 - Metastatic Disease of the Humerus

Metastatic bone disease has a significant effect on a patient's mortality and health-related quality of life. An aging US population and improved survival rates of patients with cancer have led to an increase in the incidence of symptomatic bony metastatic lesions that may require orthopaedic care. Skeletal-related events in neoplastic disease include pain, pathologic fracture, hypercalcemia, and neural compression, including spinal cord compression. The clinical evaluation and diagnostic study of a patient with a skeletal lesion of unknown etiology should be approached carefully. In patients with widespread metastatic disease, the treatment of a skeletal-related event may be limited to stabilization of the pathologic fracture or local disease control. The treatment of metastatic bone disease is guided by the nature of the skeletal-related event, the responsiveness of the lesion to adjuvant care, and the overall condition and survival expectations of the patient. Impending pathologic fractures are often more easily treated, with less morbidity and easier recovery for patients, than completed fractures. Quality of life is the most important outcome measure in these patients. When surgery is indicated, the approach, choice of fixation, and use of adjuvant should allow for immediate and unrestricted weight bearing. Because metastatic lesions to the skeleton have a limited capacity for spontaneous healing, surgical fixation should be durable for the life expectancy of the patient. In the epiphyseal region of long bones, replacement arthroplasty is generally preferred over internal fixation. Metaphyseal and diaphyseal regions can generally be addressed with intramedullary nailing or plate fixation with adjuvant. The specific treatment of acetabular lesions is dictated by the anatomy and the degree of bone loss. Spinal stability and neural compromise are important considerations in choosing a strategy for managing spine tumors. Effective surgical approaches to metastatic disease of the spine may include vertebral augmentation or open decompression and realignment of the spinal column with internal fixation. Radiation therapy is an important adjunctive modality in the treatment of metastatic bone disease. Medical management consists of symptom control, cytotoxic chemotherapy, and targeted therapy. Emerging technologies, including radiofrequency ablation, cementoplasty, and advances in intraoperative imaging and navigation, show promise in the treatment of metastatic bone disease.

Alendronate for the prevention and treatment of glucocorticoid-induced osteoporosis

Management of Hip Fractures in the Elderly

Background: Osteoporosis is a common complication of long-term glucocorticoid therapy for which there is no well-proved preventive or restorative treatment. Methods: We carried out two 48-week, randomized, placebo-controlled studies of two doses of alendronate in 477 men and women, 17 to 83 years of age, who were receiving glucocorticoid therapy. The primary end point was the difference in the mean percent change in lumbar-spine bone density from base line to week 48 between the groups. Secondary outcomes included changes in bone density of the hip, biochemical markers of bone turnover, and the incidence of new vertebral fractures. Results: The mean ((plus or minus)SE) bone density of the lumbar spine increased by 2.1(plus or minus)0.3 percent and 2.9(plus or minus)0.3 percent, respectively, in the groups that received 5 and 10 mg of alendronate per day (P<0.001) and decreased by 0.4(plus or minus)0.3 percent in the placebo group. The femoral-neck bone density increased by 1.2(plus or minus)0.4 percent and 1.0(plus or minus)0.4 percent in the respective alendronate groups (P<0.01) and decreased by 1.2(plus or minus)0.4 percent in the placebo group (P<0.01). The bone density of the trochanter and total body also increased significantly in the patients treated with alendronate. There were proportionally fewer new vertebral fractures in the alendronate groups (overall incidence, 2.3 percent) than in the placebo group (3.7 percent) (relative risk, 0.6; 95 percent confidence interval, 0.1 to 4.4). Markers of bone turnover decreased significantly in the alendronate groups (P<0.001). There were no differences in serious adverse effects among the three groups, but there was a small increase in nonserious upper gastrointestinal effects in the group receiving 10 mg of alendronate. Conclusions: Alendronate increases bone density in patients receiving glucocorticoid therapy

The anterior trochlear line as a reference for femoral component positioning in total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

PURPOSE: A new radiographic method using the anterior and posterior femoral condyles as a landmark to determine the rotational alignment of the femoral component in TKA had been developed. METHODS: The new radiograph presents an axial view of the distal femur. The patients were asked to lie in the supine position and flex the knee approximately 120 degrees to 130 degrees . Radiographs were applied at an inclination angle of 20 degrees to 30 degrees . The condylar twist angle (CTA), the external rotational angle between the posterior condylar (PC) line and the clinical transepicondylar axis (TEA), and the trochlear line angle (TLA), and the internal rotational angle between the anterior trochlear line and the clinical TEA were measured. Images were taken of 129 knees in 87 patients with osteoarthritis of the knee. The measurement values obtained using our method with those obtained using 3D reconstructed images from a 3-dimensional helical CT system (n = 35) were compared. RESULTS: The average CTA was 5.7 degrees +/- 2.8 degrees and the average TLA was -5.6 degrees +/- 3.2 degrees . The CTA was negatively correlated with the tibiofemoral angle (TFA). The average TLA was positively correlated with the TFA. The average difference between the TLA values obtained with this view and those obtained using the 3D-CT was 0.5 degrees +/- 1.6 degrees . The relationship between the radiograph and 3D-CT in TLA was higher than that in CTA. CONCLUSIONS: This radiographic technique allows easy and simultaneous measurement of the CTA and TLA and may provide an alternative method for assessing the TEA of the femur during preoperative planning for TKA

Biochemical markers of bone metabolism and prediction of fracture in elderly women

Management of Hip Fractures in the Elderly

We studied the ability of various markers of bone turnover to predict fracture in 1040 randomly recruited 75-year-old women. A total of 178 of the women sustained at least one fracture during follow-up (mean, 4.6 years). In elderly women, TRACP5b and urinary fragments of osteocalcin are promising new markers for prediction of fracture, in particular, vertebral fracture. INTRODUCTION: Biochemical markers reflecting bone turnover may improve the prediction of fractures. MATERIALS AND METHODS: The ability of 10 markers of bone turnover to predict fracture in 1040 elderly women in the Malmo OPRA study was studied. Serum bone-specific alkaline phosphatase and four different forms of serum osteocalcin (S-OC) were analyzed as markers of bone formation and serum C-terminal cross-linking telopeptides of type I collagen (S-CTX), serum TRACP isoform 5b (S-TRACP5b) and urinary free deoxypyridinoline (U-DPD) as markers of bone resorption. Two novel assays for osteocalcin fragments in urine (U-OC) were analyzed. Areal BMD (aBMD) was measured by DXA in the femoral neck and lumbar spine. RESULTS: In total, 231 fractures were sustained by 178 of the women during a 3- to 6.5-year (mean, 4.6 years) follow-up period. When women with prospective fractures were compared with women without fractures, S-TRACP5b, S-CTX, one S-OC, and one U-OC were higher in women with a fracture of any type (all p < 0.05), and all bone markers were higher in women with clinical vertebral fracture (all p < 0.05). Markers were not significantly elevated in women with hip fracture. When women within the highest quartile of a bone marker were compared with all others, S-TRACP5b and one U-OC predicted the occurrence of a fracture of any type (odds ratio [OR]), 1.55 and 1.53; p < 0.05). S-TRACP5b, the two U-OCs, and S-CTX predicted vertebral fracture (OR, 2.28, 2.75, 2.71, and 1.94, respectively; all p < 0.05), and the predictive value remained significant for S-TRACP5b and the two U-OCs after adjusting for aBMD (OR, 2.02-2.25; p < 0.05). Bone markers were not able to predict hip fracture. CONCLUSION: These results show that biochemical markers of bone turnover can predict fracture, and in particular, fractures that engage trabecular bone. S-TRACP5b and U-OC are promising new markers for prediction of fracture