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A Novel Low-Cost Surgical Simulation Tool for Pinning Supracondylar Humerus Fractures

Pediatric Supracondylar Humerus Fracture 2020 Review

BACKGROUND: Simulation-based training is one way to improve basic competence for surgical trainees and thus improve patient safety. Closed reduction and percutaneous pinning of a supracondylar humerus fracture is a common procedure that encompasses many basic orthopaedic skills and has been identified as a residency milestone. Despite this, no quantitative tools exist to help learners attain this basic skill. This study seeks to validate a quantitative, low-cost simulation-based training tool for teaching orthopaedic surgery trainees the fundamentals of fracture stabilization with pins. METHODS: Two low-cost models were developed with simulated cancellous bone blocks and cortical bone sheets: a pinning agility tool to teach pin placement and redirection, and a low-cost construct stability tool to replicate pinning. A high-cost construct stability tool was cut using a pediatric supracondylar humerus model to simulate pinning a real fracture. Construct stability was assessed by adding weight until â?¼1.6â??mm of displacement was observed. Participants were tested naively on all 3 models and then completed a training session using only the low-cost models. Performance following training was then assessed and compared with fellowship-trained pediatric orthopaedic surgeons. Participants also rated their preintervention and postintervention confidence, skill, and knowledgeability. RESULTS: A total of 18 novice trainees participated (10 PGY1 and PGY2 orthopaedic surgery residents and 8 medical student members of the orthopaedic surgery interest club), whereas the reference group consisted of 7 orthopaedic surgery attendings. The subjects significantly improved their scores on both the low-cost (P=0.002) and high-cost (P<0.001) construct stability tools after the training with only the low-cost tools. Compared with the attending benchmark, trainee scores improved on the high-fidelity model from 31% preintervention to 86% postintervention and their pinning times decreased by 38%. Trainees reported increased knowledge, skill, and confidence after the intervention (P<0.001). CONCLUSIONS: A novel, low-cost simulation model and training session for supracondylar humerus fracture pinning resulted in improved performance in stabilizing a supracondylar humerus model and increased trainee knowledgeability, confidence, and skill. LEVEL OF EVIDENCE: Level II-economic.

Differential CXC receptor expression in colorectal carcinomas

MSTS 2018 - Femur Mets and MM

In this study, we aimed to assess the expression profile of chemokine receptors CXCR1-4 in inflammatory and malignant colorectal diseases and corresponding hepatic metastases of synchronous and metachronous origin to elucidate their role in colorectal cancer (CRC) progression and metastasis. Chemokine receptor expression was assessed by quantitative real-time PCR, immunohistochemistry (IHC) and Western blot analysis in resection specimens from patients with ulcerative colitis (UC, n = 25), colorectal adenomas (CRA, n = 8), different stages of CRC (n = 48) as well as colorectal liver metastases (CRLM) along with their corresponding primary colorectal tumours (n = 16). While none of the chemokine receptors were significantly upregulated or downregulated in UC or CRA tissues, CXC receptors 1, 2 and 4 demonstrated a significant increase in expression in all tumour stages of CRC specimens with CXCR4 correlating with tumour grading (P < 0.05). On the other hand, CXCR3 showed no significant upregulation in either tumour stage, but significant overexpression in CRLM. While CXCR4 demonstrated significant upregulation in both tumour entities, IHC analysis revealed that the predominate cell type expressing CXCR4 in CRC is represented by tumour cells, whereas in CRLM the majority of positive CXCR4 signals is due to hepatocytes along the tumour invasion front. In conclusion, our findings show a very differential expression pattern of the four receptors in colorectal carcinomas and their corresponding liver metastases with prominent expression profiles that indicate a potential role in the pathogenesis of CRC.

Multicentric giant cell tumor of bone: synchronous and metachronous presentation

MSTS 2022 - Metastatic Disease of the Humerus

A 27-year-old man treated 2.5 years ago for synchronous multicentric giant cell tumor of bone located at the right proximal humerus and the right 5th finger presented now with complaints of pain in his right hip and wrist of two-month duration. Radiology and magnetic resonance revealed multicentric giant cell tumor lesions of the right proximal femur, the left ileum, the right distal radius, and the left distal tibia. The patient has an eighteen-year history of a healed osteosarcoma of the right tibia that was treated with chemotherapy, resection, and allograft reconstruction. A literature review establishes this as the first reported case of a patient with synchronous and metachronous multicentric giant cell tumor who also has a history of osteosarcoma.

Effect of interleukin 6 â??174G>C gene polymorphism on opioid requirements after total hip replacement

AAHKS (4) Acetaminophen

Objective: In recent years, increasing attention has been paid to the contribution of genetic factors to variability in patient pain threshold and the efficacy of pain management. One of the genes implicated in pain pathology and treatment response is interleukin 6 (IL6). The aim of the present study was to evaluate the association between IL6 (rs1800795: â??174G>C) and opioid requirements in patients after total hip replacement (THR). Methods: A total of 196 patients eligible for the study (126 women, 70 men) were subjected to THR. The THR procedure was performed using spinal anaesthesia after implementing routine peri-operative monitoring. After the procedure each patient was individually observed, and the patient-specific chart of dynamic changes in pain perception was recorded, using the five-level Verbal Rating Scale (VRS). The multimodal analgesic treatment after THR was defined by the operating surgeons after considering indications and contraindications to the use of different groups of drugs (opioid and non-opioid analgesics). Postoperative pain was controlled by the patient-controlled analgesia method and VRS during the day-time, as well as night-time nurse-controlled analgesia. All medication adjustments were recorded in the individual patient files. In the case of moderate pain intensity (VRS-assessed), a patient was administered the non-opioid analgesic drug, and for high intensity pain the opioid. The analysis of pain relief therapy included information on the drugs applied, mode of dosing (single or multiple), daily dose, route of administration, and drug refusal due to the absence of pain recorded each study day, i.e. on the day of surgery and recovery in the postoperative room (day 0), and then daily from day 1 to day 6. Polymorphism rs1800795:G>C in the promoter region of the IL6 gene (â??174G>C) was determined using the PCRâ??RFLP method. Results: The patients carrying at least one IL6 â??174G allele (GG homozygote and GC heterozygote) were administered opioids significantly more often on days 0 (p = 0.0029), 3 (p = 0.019) and 4 (p = 0.031) after surgery compared with CC homozygous patients. Those patients also required a significantly higher opioid dose on days 3 (p = 0.029) and 4 (p = 0.030). Multivariate analysis demonstrated that the presence of the â??174G allele was an independent factor predisposing patients to the administration of opioids during the first 24 h [p = 0.001, odds ratio (OR) 7.1, 95 % confidence interval (CI) 2.17â??22.7], on day 3 (p = 0.01, OR 2.79, 95 % CI 1.25â??6.26) and day 4 (p = 0.01, OR = 2.61, 95 % CI 1.17â??5.79). Conclusion: The presence of the G allele IL6 gene (â??174G>C) polymorphism was found to be an independent factor predisposing to a higher dose and more frequent administration of opioids in the first days after total hip replacement.

Clinical ability of pattern electroretinograms and visual evoked potentials in detecting visual dysfunction in ocular hypertension and glaucoma

Upper Eyelid and Brow Surgery

OBJECTIVE: To assess the presence of normal or abnormal pattern electroretinogram (PERG) and visual evoked potential (VEP) responses in patients with ocular hypertension or open-angle glaucoma (OAG). DESIGN: Retrospective, cross-sectional, case-control study. PARTICIPANTS: Eighty normal control subjects (mean age, 51.77+/-6.04 years; 80 eyes), 68 ocular hypertension patients (mean age, 51.58+/-7.12; 68 eyes; intraocular pressure [IOP] < 18 mmHg under pharmacological treatment; Humphrey field analysis [HFA] 24/2 mean deviation [MD] > -2 decibels [dB]), and 84 OAG patients (mean age, 52.77+/-5.28; 84 eyes; IOP < 18 mmHg under pharmacological treatment; HFA 24/2 mean deviation between -2 and -23 dB) were enrolled. METHODS: Simultaneous recording of PERGs and VEPs using high-contrast (80%) 15' checkerboard stimuli reversed at the rate of 2 reversals per second. MAIN OUTCOME MEASURES: Pattern electroretinogram P50 and VEP P100 implicit times were considered delayed when exceeding the limit of mean values of controls plus 2 standard deviations (SDs). Pattern electroretinogram P50 to N95 and VEP N75 to P100 amplitudes were considered reduced when exceeding the limit of mean values of controls minus 2 SDs. RESULTS: Pattern electroretinogram: P50 implicit times were delayed in 58 of 68 (85.30%) ocular hypertension eyes and 83 of 84 (98.80%) OAG eyes; P50 to N95 amplitudes were reduced in 47 (69.12%) ocular hypertension eyes and 84 (100%) OAG eyes. Visual evoked potential: P100 implicit times were delayed in 58 (85.30%) ocular hypertension eyes and 84 (100%) OAG eyes; reduced N75 to P100 amplitudes were observed in 39 (57.35%) ocular hypertension eyes and 73 (86.90%) OAG eyes. Ocular hypertension eyes showed no significant correlations (Pearson test, P>0.01) between electrophysiological parameters and age, IOP before or under medical treatment, HFA, and corneal thickness values. Significant correlations (P<0.01) were observed in OAG eyes between electrophysiological results and HFA values. Pattern electroretinogram and VEP responses were normal in all control eyes. CONCLUSIONS: Combined PERG/VEP recordings identified a large percentage of ocular hypertension eyes with impairment of the innermost retinal layers, notwithstanding normal optic disc morphology and normal HFA. In OAG eyes, PERG P50 to N95 amplitude and VEP P100 implicit time showed the highest sensitivity/specificity for the detection of a visual dysfunction. The presence of abnormal PERG and/or VEP responses did not allow a clearcut separation between ocular hypertension and OAG eyes.

Delivery parameter variations and early clinical outcomes of volumetric modulated arc therapy for 31 prostate cancer patients: An intercomparison of three treatment planning systems

MSTS 2018 - Femur Mets and MM

We created volumetric modulated arc therapy (VMAT) plans for 31 prostate cancer patients using one of three treatment planning systems (TPSs) - ERGO++, Monaco, or Pinnacle - and then treated those patients. A dose of 74 Gy was prescribed to the planning target volume (PTV). The rectum, bladder, and femur were chosen as organs at risk (OARs) with specified dose-volume constraints. Dose volume histograms (DVHs), the mean dose rate, the beam-on time, and early treatment outcomes were evaluated and compared. The DVHs calculated for the three TPSs were comparable. The mean dose rates and beam-on times for Ergo++, Monaco, and SmartArc were, respectively, 174.3 ± 17.7, 149.7 ± 8.4, and 185.8 ± 15.6 MU/min and 132.7 ± 8.4, 217.6 ± 13.1, and 127.5 ± 27.1 sec. During a follow-up period of 486.2 ± 289.9 days, local recurrence was not observed, but distant metastasis was observed in a single patient. Adverse events of grade 3 to grade 4 were not observed. The mean dose rate for Monaco was significantly lower than that for ERGO++ and SmartArc (P < 0.0001), and the beam-on time for Monaco was significantly longer than that for ERGO++ and SmartArc (P < 0.0001). Each TPS was successfully used for prostate VMAT planning without significant differences in early clinical outcomes despite significant TPS-specific delivery parameter variations. © 2013 Shinichi Tsutsumi et al.

Efficacy of Proprioceptive Neuromuscular Facilitation in Older Women With Gonarthrosis

OAK 3 - Non-arthroplasty tx of OAK

Patients will be divided into two groups: group perform proprioceptive neuromuscular facilitation and other group submit performing resistance exercises.

Comparison of radiographic absorptiometry with dual-energy x-ray absorptiometry and quantitative computed tomography in normal older white and black women

Management of Hip Fractures in the Elderly

Bone mineral density (BMD) of the phalanges of the hand was measured by the technique of radiographic absorptiometry (RA) in 199 older postmenopausal women previously determined to have normal BMD by dual-energy x-ray absorptiometry (DXA) and quantitative computed tomography (QCT). The average age of the women was 66.8 +/- 4.9 years, and they were 19.9 +/- 6.7 years postmenopause. In the 54 black women, phalangeal BMD was 11.7% greater than in the 145 white women, a difference comparable to that found using DXA at the radial midshaft, the lumbar spine, and femoral neck. A correlation matrix comparing BMD measured by RA to BMD measured by DXA and QCT indicates that, in general, RA was related to the various DXA and QCT measurement sites as well as these sites were related to each other. When results for RA, DXA, and QCT obtained in our cohort of older women were compared to available reference data for peak adult bone mass, the average difference (SD units) from peak value was greatest for RA (-1.77 radius, -1.24 spine, -2.13 femoral neck, -2.34 QCT spine, and -2.71 phalanges). We conclude that RA is an acceptable measure of phalangeal BMD and that the data in our cohort can serve as reference data for older white and black women aged 55-75 years. Once the ability of RA to predict future fracture occurrence has been demonstrated, it could be rapidly deployed as a low-cost, widely available bone mass measurement technique

Uncemented or cemented revision stems? Analysis of 2,296 first-time hip revision arthroplasties performed due to aseptic loosening, reported to the Swedish Hip Arthroplasty Register

Dental Implant Infection

Background and purpose - Uncemented stems are increasingly used in revision hip arthroplasty, but only a few studies have analyzed the outcomes of uncemented and cemented revision stems in large cohorts of patients. We compared the results of uncemented and cemented revision stems. Patients and methods - 1,668 uncemented and 1,328 cemented revision stems used in first-time revisions due to aseptic loosening between 1999 and 2016 were identified in the Swedish Hip Arthroplasty Register. Kaplan-Meier analysis was used to investigate unadjusted implant survival with re-revision for any reason as the primary outcome. Hazard ratios (HR) for the risk of re-revision were calculated using a Cox regression model adjusted for sex, age, head size, concomitant cup revision, surgical approach at primary and at index revision surgery, and indication for primary total hip arthroplasty. Results - Unadjusted 10-year survival was 85% (95% CI 83-87) for uncemented and 88% (CI 86-90) for cemented revision stems. The adjusted HR for re-revision of uncemented revision stems during the first year after surgery was 1.3 (CI 1.0-1.6), from the second year the HR was 1.1 (CI 0.8-1.4). Uncemented stems were most often re-revised early due to infection and dislocation, whereas cemented stems were mostly re-revised later due to aseptic loosening. Interpretation - Both uncemented and cemented revision stems had satisfactory long-term survival but they differed in their modes of failure. Our conclusions are limited by the fact that femoral bone defect size could not be investigated within the setting of the current study.

Trends in the surgical treatment of pathologic proximal femur fractures among musculoskeletal tumor society members

MSTS 2018 - Femur Mets and MM

Background: Several strategies for the treatment of pathologic proximal femur fractures are practiced but treatment outcomes have not been rigorously compared. Questions/purposes: Major variations in the use of intramedullary fixation, extramedullary/plate-screw fixation, and endoprosthetic reconstruction techniques for pathologic proximal femur fractures in patients with skeletal metastases are reported. The clinical and surgical variables that influence this choice differ among treating surgeons. To characterize the technique preferences and to identify areas of consensus regarding specific clinical presentations, we administered an online survey to the Musculoskeletal Tumor Society (MSTS) membership. We also tested whether responses correlated with the respondents' years in practice and asked about the indications for wide tumor resection and the role of tumor debulking and adjuvant cementation. Methods: A 10-minute, web-based survey was sent via email to 244 MSTS members. The survey queried participants' musculoskeletal oncology training and experience and presented case scenarios illustrating different combinations of four variables that influence decision-making: cancer type, estimated patient survival, fracture displacement, and anatomic region of involvement. Results: Forty-one percent (n = 98) of MSTS members completed the survey. Intramedullary nail fixation (IMN; 45%) and proximal femur resection and reconstruction (34%) were the most commonly recommended techniques followed by long-stem cemented hemiarthroplasty/cemented hemiarthroplasty (15%) and open reduction and internal fixation (7%). Most respondents (56%) recommended use of cementation with IMN. Differences of opinion on recommended treatment were associated with variations in cancer type, fracture displacement, and anatomic region of involvement. Conclusions: Our online survey showed a trend among MSTS members for selecting IMN and arthroplasty-related techniques to treat pathologic fractures of the proximal femur, but major differences in preferred operative technique exist. Prospective studies are needed to develop consistent, evidence-based treatment recommendations. © 2012 The Association of Bone and Joint Surgeons®.

Perioperative complications in elective surgery in patients with rheumatoid arthritis treated with biologics

Surgical Management of Osteoarthritis of the Knee CPG

We retrospectively investigated the influence of biological agents on delayed wound healing and the occurrence of postoperative surgical site infection (SSI) in patients after surgery for rheumatoid arthritis. The patients were divided into two groups-those with and without treatment with biological agents (276 and 278 joints, respectively)-and adverse events (delay in wound healing and SSI) were investigated. Wound healing was delayed in 11.4% of total knee arthroplasty (TKA) operations, 16.7% of total ankle arthroplasty operations, and 9.7% of foot surgeries in the treatment group, and in 5.5% of TKA operations, 12.5% of total elbow arthroplasty operations, and 5.7% of foot surgeries in the non-treatment group. The difference in the incidence of delayed wound healing between the two groups was not statistically significant. In the treatment group, postoperative superficial and deep infection developed in one and two joints, respectively. In the non-treatment group, superficial infection developed in one joint. There was no statistically significant difference between the two groups. These findings suggest that the use of biological agents may not affect the incidence of postoperative adverse events related to wound healing and SSI

A Retrospective Cohort Study of QuickDASH Scores for Three Hand Therapy Acute Upper Limb Conditions

Distal Radius Fractures

Introduction: The QuickDASH is a valid and reliable outcome measure widely used to assess the function and pain in arm, shoulder, and hand disabilities. A recent study introduced a QuickDASH 80% cut point test to gauge patients at risk of poor outcomes. However, the utility of this test has not been validated. Purpose: To determine typical QuickDASH scores for three upper limb conditions and to test the sensitivity and specificity of the QuickDASH 80% cut point test in predicting patients at risk of poor outcomes. Methods: This is a retrospective study with a total of 406 patient records for whom QuickDASH scores were examined. The sensitivity and specificity of the QuickDASH 80% cut point test was investigated for three acute upper limb conditions seen in hand therapy: surgical distal radius fracture, nonsurgical lateral epicondylitis, and carpal tunnel release. Results: Typical scores were determined for three upper limb conditions. The QuickDASH 80% cut point test per upper limb condition returned poor sensitivity between 28.57% and 41.67%. Conclusion: The results did not support the QuickDASH 80% cut point test as a predictor of final outcome in these three patient populations. Patients with the worse initial 20% scores were not correctly classified as worse 20% final scores. This study provides summary data from three upper limb conditions to provide clinicians with comparison data to establish goals and educate patients.

Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing

DoD SSI (Surgical Site Infections)

INTRODUCTION: Treatment of lower extremity segmental bone loss is difficult. Masquelet et al. proposed a two-stage technique: first, debridement and filling of bone loss with an acrylic spacer; second, bone reconstruction by filling with cancellous bone in the space left free (following cement removal) inside the so-called self-induced periosteal membrane. In the originally described technique, the fracture site is stabilized by an external fixator, which remains in place throughout the bone healing process, i.e., often longer than 9 months with all the known disadvantages of this type of assembly. Following the principle of two-stage reconstruction, we modified the technique by reconstructing around an intramedullary-locking nail placed in the first stage. HYPOTHESIS: This technique prevents the mechanical complications related to external fixator use and provides faster resumption of weight-bearing. PATIENTS AND METHODS: Twelve patients were operated for segmental tibial bone loss greater than 6cm resulting from injury (four cases) or aseptic necrosis (one case) or septic necrosis (seven cases). All the patients were operated on in an emergency setting and the first stage was performed before the 2nd week. A free muscle flap (ten patients) or a pediculated fasciocutaneous flap (two patients) was necessary during this first step to cover the site and provide good conditions for secondary bone growth. The follow-up was 39.5 months (range, 12-94 months). RESULTS: Complete weight-bearing was resumed at a mean 4 months. After the second step, all the patients except one had apparently healed (complete weight-bearing with no pain). Five septic complications occurred after the second step, in one case leading to reconstruction failure. Four other patients had infectious complications successfully treated (as of the last follow-up) either by changing the nail in two cases or by prolonged antibiotic therapy in two other cases, with no graft loss. DISCUSSION: The use of the intramedullary nail facilitates the Masquelet technique by allowing the patient to resume weight-bearing more quickly and avoiding secondary fractures. However, the risk of sepsis remains high but can be controlled without compromising the final bone union in four cases out of five. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Malignant bone and soft tissue tumors of the shoulder girdle. A retrospective analysis of 30 operated cases

MSTS 2022 - Metastatic Disease of the Humerus

From 1988 to 1995, 30 patients (16 men) with malignant bone (n 23) and soft tissue (n 7) tumors of the shoulder girdle underwent surgery in our department. The mean age was 34 (6-80) years. 26 patients had primary and 4 had metastatic lesions. The average follow-up period was 3 (2-8) years, at the end of which 18 patients showed no evidence of disease, 2 were alive with disease, and 10 had died (9 because of tumor). 25 of the operations were limb-sparing procedures, while the other 5 were major amputations. Radical resection was performed in 4 patients, wide resection in 25 and marginal resection in 1. Local recurrence was observed in 2 patients. 10 patients with stage IIB tumors of the proximal humerus underwent extraarticular humeral and glenoid resection. Reconstruction was performed with either a modular or an improvised implant. Following surgery, those patients had a concave contour of the shoulder and poor abduction ability. Overall functional outcome was good in 18 patients, moderate in 11 and poor in 1. No correlation was found between functional outcome and reconstruction technique.

Vacuum-assisted closure therapy increases local interleukin-8 and vascular endothelial growth factor levels in traumatic wounds

DOD - Acute Comp Syndrome CPG

BACKGROUND: Clinical observations are suggesting accelerated granulation tissue formation in traumatic wounds treated with vacuum-assisted closure (VAC). Aim of this study was to determine the impact of VAC therapy versus alternative Epigard application on local inflammation and neovascularization in traumatic soft tissue wounds. METHODS: Thirty-two patients with traumatic wounds requiring temporary coverage (VAC n = 16; Epigard n = 16) were included. At each change of dressing, samples of wound fluid and serum were collected (n = 80). The cytokines interleukin (IL)-6, IL-8, vascular endothelial growth factor (VEGF), and fibroblast growth factor-2 were measured by ELISA. Wound biopsies were examined histologically for inflammatory cells and degree of neovascularization present. RESULTS: All cytokines were found to be elevated in wound fluids during both VAC and Epigard treatment, whereas serum concentrations were negligible or not detectable. In wound fluids, significantly higher IL-8 (p < 0.001) and VEGF (p < 0.05) levels were detected during VAC therapy. Furthermore, histologic examination revealed increased neovascularization (p < 0.05) illustrated by CD31 and von Willebrand factor immunohistochemistry in wound biopsies of VAC treatment. In addition, there was an accumulation of neutrophils as well as an augmented expression of VEGF (p < 0.005) in VAC wound biopsies. CONCLUSION: This study suggests that VAC therapy of traumatic wounds leads to increased local IL-8 and VEGF concentrations, which may trigger accumulation of neutrophils and angiogenesis and thus, accelerate neovascularization.

Final trial report of sentinel-node biopsy versus nodal observation in melanoma

Reconstruction After Skin Cancer

BACKGROUND: Sentinel-node biopsy, a minimally invasive procedure for regional melanoma staging, was evaluated in a phase 3 trial.METHODS: We evaluated outcomes in 2001 patients with primary cutaneous melanomas randomly assigned to undergo wide excision and nodal observation, with lymphadenectomy for nodal relapse (observation group), or wide excision and sentinel-node biopsy, with immediate lymphadenectomy for nodal metastases detected on biopsy (biopsy group). Results No significant treatment-related difference in the 10-year melanoma-specific survival rate was seen in the overall study population (20.8% with and 79.2% without nodal metastases). Mean (± SE) 10-year disease-free survival rates were significantly improved in the biopsy group, as compared with the observation group, among patients with intermediate-thickness melanomas, defined as 1.20 to 3.50 mm (71.3 ± 1.8% vs. 64.7 ± 2.3%; hazard ratio for recurrence or metastasis, 0.76; P=0.01), and those with thick melanomas, defined as >3.50 mm (50.7 ± 4.0% vs. 40.5 ± 4.7%; hazard ratio, 0.70; P=0.03). Among patients with intermediate-thickness melanomas, the 10-year melanoma-specific survival rate was 62.1 ± 4.8% among those with metastasis versus 85.1 ± 1.5% for those without metastasis (hazard ratio for death from melanoma, 3.09; P<0.001); among patients with thick melanomas, the respective rates were 48.0 ± 7.0% and 64.6 ± 4.9% (hazard ratio, 1.75; P=0.03). Biopsy-based management improved the 10-year rate of distant disease-free survival (hazard ratio for distant metastasis, 0.62; P=0.02) and the 10-year rate of melanoma-specific survival (hazard ratio for death from melanoma, 0.56; P=0.006) for patients with intermediate-thickness melanomas and nodal metastases. Accelerated-failure-time latent-subgroup analysis was performed to account for the fact that nodal status was initially known only in the biopsy group, and a significant treatment benefit persisted.CONCLUSIONS: Biopsy-based staging of intermediate-thickness or thick primary melanomas provides important prognostic information and identifies patients with nodal metastases who may benefit from immediate complete lymphadenectomy. Biopsy-based management prolongs disease-free survival for all patients and prolongs distant disease-free survival and melanoma-specific survival for patients with nodal metastases from intermediate-thickness melanomas. (Funded by the National Cancer Institute, National Institutes of Health, and the Australia and New Zealand Melanoma Trials Group; ClinicalTrials.gov number, NCT00275496.).

Assessment of early tibiofemoral joint space width changes after anterior cruciate ligament injury and reconstruction: a matched case-control study

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Progression of primary knee osteoarthritis (OA) is often quantified by measuring structural alterations of the joint such as those in tibiofemoral joint space width (JSW) over time. Limited information is available regarding changes that occur during the onset and progression of posttraumatic OA (PTOA) that are often associated with anterior cruciate ligament (ACL) injury. Furthermore, there is a paucity of information regarding JSW changes in healthy patients, making JSW interpretation challenging during early PTOA progression. PURPOSE: To evaluate tibiofemoral JSW after ACL injury, ACL reconstruction, and rehabilitation compared with healthy, matched controls. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 39 ACL-injured patients and 32 matched controls were evaluated. Injured patients were assessed at presurgical baseline and after ACL reconstruction (mean follow-up, 46 months), as were controls. Bilateral, standing, fluoroscopy-assisted, and posterior-anterior metatarsal-phalangeal view knee radiographs were obtained at each visit and JSW was measured. RESULTS: The JSW differences between knees in control patients were not significantly different and did not change over time. Baseline JSW differences in the ACL group were significantly different than in controls. Three patients (7.9% of total) had an increased JSW difference, and 1 patient (2.6%) had a decreased medial JSW difference. In the lateral compartment, 6 patients (15.8%) had a decreased JSW difference. At follow-up, 2 patients in the ACL group (5%) had a decreased medial JSW difference, and 3 (7.9%) had a significantly increased difference in relation to controls. Lateral compartment analyses revealed 7 (18.4%) patients with a significantly decreased JSW difference and no patients with an increased difference compared with controls. CONCLUSION: One third of ACL-injured knees underwent significant JSW change soon after injury; consequently, evaluation of within-knee JSW changes over time in ACL-injured patients may not be appropriate with a study based on case-control analysis. The JSWs in the healthy knee of ACL-injured patients do not change over time, allowing this knee to be used as a control for the injured knee. This is important when evaluating the earliest stages of PTOA after ACL injury, when patients are asymptomatic and intervention may be most beneficial.

Resveratrol does not improve cartilage formation by osteoarthritic chondrocytes

Surgical Management of Osteoarthritis of the Knee CPG

Purpose: Resveratrol is a phytoalexin stilbene produced naturally by plants including red grapes and peanuts. Many studies have established that resveratrol can exert a broad range of biological activities including suppression of inflammatory signaling and activation of sirtuins. It has been shown that resveratrol suppresses IL-1(beta)-induced inflammatory signaling in chondrocytes and it prevented cartilage damage in experimentally induced osteoarthritis (OA) ((beta)y anterior cruciate ligament transection) in rabbits. The aim of this study was to investigate the effects of resveratrol on cartilage formation by osteoarthritic chondrocytes. Methods: OA chondrocytes were isolated from articular cartilage obtained from patients undergoing knee arthroplasty. At passage 2, chondrocytes were seeded at high density (1.26null106 cells per cm(2)) on type II collagen-coated culture inserts in a 96-wells transwell system. The cells were precultured for five days without any treatment, after which, they were either or not supplemented with 50 mM resveratrol (RSV) and/or 20 mM nicotinamide (NAM) to inhibit sirtuin activation. At day 7, 5 ng/ml IL-1(beta) was added after which the cells were cultured for another 3 days. Cytotoxicity was determined by measuring LDH release into the culture medium, cartilage turnover by glycosaminoglycan (GAG) content and release into the culture medium by the DMMB assay and DNA content using a Picogreen assay. Results: Treatment with IL-1(beta) increased the amount of LDH released into the culture medium. Co-treatment of IL-1(beta) with RSV suppressed this increase, while co-treatment of IL-1(beta) with RSV and NAM showed no suppression. Treatment with RSV increased the total production of GAG compared to baseline (P < 0.01), however, 12% was incorporated in the matrix and 82% was released into the medium. Treatment with NAM resulted in 23% of the GAGs incorporated in the matrix. Treatment with IL-1(beta) decreased GAG production and GAG incorporation (18%; P < 0.05). Co-treatment of IL-1(beta) with RSV increased both the total GAG production and the incorporation (20%) compared to IL-1(beta) treatment alone (P < 0.01). Co-treatment with IL-1(beta), RSV and NAM had no effect on total GAG production compared to baseline, but decreased GAG incorparation to 19% (P < 0.05). (Figure presented) Conclusions: Resveratrol could suppress the adverse effects of IL-1(beta) treatment. This was dependent on sirtuin activation as co-treatment of IL-1(beta) and RSV with NAM abolished the protective effects of RSV. Although resveratrol increased the total production of GAGs, it is not a promising compound for cartilage regeneration as it inhibited GAG incorporation into the matrix and promoted release

In Vitro Evaluation of ¹⁸⁸Re-HEDP: A Mechanistic View of Bone Pain Palliations

MSTS 2018 - Femur Mets and MM

Skeletal metastasis is common in advanced stages of various cancers, particularly of the prostate and breast carcinoma. ¹⁸⁸Re-HEDP (1-hydroxyethane 1, 1-diphosphonic acid) is a clinically established radiopharmaceutical for bone pain palliation of osseous metastasis, and it takes advantage of high bone affinity. The present work aims at elucidating the possible mechanisms of cell killing by ¹⁸⁸Re-HEDP in osteosarcoma cells and biodistribution studies in mice.¹⁸⁸Re-HEDP complex was prepared by using lyophilized HEDP kits prepared in-house. In vitro cellular uptake in mineralized bone matrix was found to be 13.41%+/-0.46% (at 2 hours), which was reduced to 2.44%+/-0.12% in the presence of excess amounts of unlabeled HEDP ligand. Uptake of ¹⁸⁸Re-HEDP in bones of normal Swiss mice in vivo and mineralized bone in vitro indicated its affinity toward the bone matrix. The study also revealed that cellular toxicity and G2/M cell cycle arrest were dose dependent. At higher doses, G2/M cell cycle arrest was observed, which might be the major cause of cell death and a possible mechanism of bone pain relief.

Revision total hip arthroplasty in deficient proximal femur using a distal load-bearing prosthesis

Management of Hip Fractures in the Elderly

Eleven revision total hip replacements (THR) were performed with the use of transfemoral distally fixing stems. Nine Wagner and two Link cementless stems were used. The mean age of the patients was 62 years (range 44-78) and in mean they had undergone 2.4 previous hip operations. The mean follow-up was 43 months in nine patients and two patients had a new revision during the follow-up. The reasons for these revisions were loosening of stems in association with proximal lysis and periprosthetic fracture in eight cases, proximal femoral resection after infection in one case, loosening and deficient proximal bone in one case and proximal intraoperative fracture in a dysplastic hip after previous intertrochanteric osteotomy in one patient. The subsidence of the stem varied from 0 to 40 mm and two stems were revised during the first year because stability was lost due to subsidence. In those nine cases who were not revised the mean Harris hip score was 74 points. The final results were excellent in two, good in three, fair in two and poor in four cases. Our results suggest that revision total hip arthroplasty in cases where the proximal femur is deficient after lysis, old infection or fracture, using a distal load bearing stem gives satisfactory results in more than half of cases

Management of non-traumatic acute limb ischemia and predictors of outcome in 270 thrombembolectomy cases

DOD - Acute Comp Syndrome CPG

Aim. Acute limb ischemia (ALI) is one of the most potentially devastating but treatable diseases, resulting from a sudden obstruction in the arterial flow. The aim of this study was to examine the outcome of thromboembolectomy, and to determine the risk factors associated with limb loss and mortality in ALI. Methods. A retrospective chart review of 270 patients on whom thromboembolectomy was performed between September 2002 and December 2009 due to ALI. Of these, 146 (54.1%) were men and mean age was 64.3. Results. Etiology was embolic in 63.3% of cases. Late thromboembolectomy after 72 hours was performed in 57.8% of patients. On admission 38.9% of patients had grade IIb ischemia; grade III ischemia was present in 9.6% of patients. Failure of first thromboembolectomy developed in 21.1% of patients and bypass surgery was performed on 25.2% of patients. Amputation and mortality rates were 7.4% and 8.5% respectively. Binary logistic regression analysis revealed that risk factors of limb loss were thromboembolectomy failure, high ischemic stage, high level of plasma creatinine kinase and compartment syndrome on admission and predictors of mortality were congestive heart failure, ischemic heart disease, reperfusion injury and longer ischemic time. Conclusion. In ALI, thromboembolectomy is highly protective against amputation, as well as mortality, even in delayed cases with more than one week in the clinical absence of tissue necrosis. At least, it provides partial limb salvage. In addition, patients must be given a chance for limb salvage in the case of stage 3 ischemia, too.

2008 Otto Aufranc Award: component design and technique affect cement penetration in hip resurfacing

Management of Hip Fractures in the Elderly

Either excessive or insufficient cement penetration within the femoral head after hip resurfacing influences the risk of femoral failures. However, the factors controlling cement penetration are not yet fully understood. We determined the effect of femoral component design and cementation technique on cement penetration. Six retrieved femoral heads were resurfaced for each implant (BHR, ASR, Conserve Plus, DuROM, ReCAP) using the manufacturers' recommendations for implantation. In addition, the BHR was implanted using the Conserve Plus high-viscosity cementation technique, "BHR/hvt," and vice versa for the Conserve, "Conserve/lvt." The average cement penetration was highest with BHR (65.62% +/- 15.16%) compared with ASR (12.25% +/- 5.12%), Conserve Plus(R) (19.43% +/- 5.28%), DuROM (17.73% +/- 3.96%), and ReCAP (26.09% +/- 5.20%). Cement penetration in BHR/hvt remained higher than all other implants equaling 36.7% +/- 6.6%. Greater femoral component design clearance correlated with cement mantle thickness. Femoral component design in hip resurfacing plays a major role in cement penetration

The distal radius fracture: concomitant fractures and their relevancy

Pediatric Supracondylar Humerus Fracture 2020 Review

BACKGROUND: The distal radius keeps heading the list of commonly fractured bones. Although little is known about the frequency and localization of accompanying fractures as well as their influence on the total course of in-patient treatment. OBJECTIVE: This study is supposed to show the influence of concomitant fractures. These fractures should be identified as risk factors for a prolonged stay to improve the in hospital treatment. METHODS: We retrospectively reviewed 721 patients with distal radius fracture. Frequency and localization of concomitant fractures, AO-type, patient age as well as duration of in-hospital treatment were analyzed. RESULTS: Out of 721 patients 124 (17.2%) had one or more concomitant fractures (CF). The most common CF were proximal femur fractures, pelvic ring fractures and humerus fractures. Compared to patients without CF, these patients showed a significant increase in duration of post operative hospital stay (5.2 vs. 12.5 days, p=0.0001). CONCLUSIONS: Patients presenting a concomitant fracture should be thoroughly cared for by their physicians and therapists. Especially an early and focused mobilization and a well-timed relocation for further medical treatment are important to reduce avoidable treatment days in the acute care hospital.

Role of fluconazole in the long-term suppressive therapy of fungal infections in patients with artificial implants

Surgical Management of Osteoarthritis of the Knee CPG

With the increased use of artificial implants the management of related infections has become an important challenge. Normally an infected implant would be removed. In many cases this might be contraindicated and drug treatment remains as the only alternative. As microbiological eradication is often impossible, especially in fungal infections at artificial implants (FIAI) long-term suppressive therapy might be required. The objective of this study was to determine the therapeutic value of fluconazole (F) in the management of FIAI. Clinical data of 56 patients (pts) with proven or suspected fungal infections and artificial implants (FIAI) subsequently treated with F were analyzed retrospectively. FIAI caused by species with intrinsic resistance to F have been excluded from the study. The following implants were involved: prosthetic valve endocarditis (PVE) 25 pts (44.6 %), intraocular lenses (IL) 9 pts (16.1%), ventriculoperitoneal shunts (VPS) 6 pts (10.7%), knee prostheses (KP) 5 pts (8.9%), biliary stents (BS) 4 pts (7.1%), venous access devices (VAS) 3 pts (5.4 %), urinary stents (US) 2 pts (3.6 %), breast implant and pacemaker 1 patient (1.8%) each. Underlying diseases were valve insufficiency (in PVE), cataract surgery (in IL), prematurity in newborns (in VPS), arthrosis (in KP), biliary obstruction (in BS), cystic fibrosis (in VAS), and obstructive renal calculi (in US). Candida species (C. spp.) were the most frequently detected causative agents with C. parapsilosis as the leading cause (n = 19; 33.9%). Furthermore C. albicans (n = 15; 26.8%), C. spp. and fungi not further specified (n = 8; 14.3%), C. tropicalis (n = 3; 5.4%), C. glabrata (n = 3; 5.4%), and C. lusitaniae (n = 1; 1.8%) were identified. Acremonium kiliense has been detected in 4 pts (7.1%), Cryptococcus neoformans in 2 pts (3.6 %). Histoplasma capsulatum was identified in 1 patient (1.8 %). The maximum duration of treatment with F was lifelong with a maximum recorded duration of 4,5 years. The maximum dosage used was 750 mg/d or 50 mg/kg BW in premature infants. No major adverse events were observed. In conclusion, especially the excellent safety profile as well as the documented therapeutic experience justify the use off as long- term suppressive therapy in FIAI. Higher dosages and even life-long treatment may be needed

Parastomal hernia-repair using mesh and an open technique

Panniculectomy & Abdominoplasty CPG

Introduction: Parastomal hernia occurs in 35%-50% of patients who have had a stoma formed, whether for the digestive tract or the urinary tract. There are many repair techniques including primary repair and repair using different types of mesh prosthesis, and the surgical approach may be open or laparoscopic. However, all techniques suffer the disadvantage of a high index of hernia recurrence. Patients and Methods: This study included 125 patients from the stoma clinic at our hospital. Hernia repair was performed on 25 of these patients who had a terminal colostomy because of either cancer or inflammatory disease. Preoperative colon preparation involved a cathartic, an evacuating enema, and antibiotic therapy in the preoperative period. The repair was conducted via an anterior approach, dissecting the skin around the stoma in the way a plastic surgeon handles an umbilical scar during abdominoplasty, in order to enter the hernia site. The hernial sac was left intact to form a bed on which to lay a lightweight polypropylene mesh, and this was then fixed to the deep face of the aponeurosis all around the stoma, with sutures placed in a U-shape with 1/0 or 2/0 non-absorbent material. The mesh was also fixed to the external surface of the colon with simple sutures of 3/0 polyglycocolic acid. A closed supra-aponeurotic drain was left in situ, and the skin was closed with 3/0 nylon. Results: Of the corpus, 50 patients presented with parastomal hernia (40%), and 25 of them underwent surgery. These patients were followed for a period of 12 months, on average (range: 8-24 months). After operation, 2 patients (8%) experienced hernia recurrence and underwent further surgery to reinforce the abdominal wall with a new insertion of mesh prosthesis; 2 patients (8%) suffered surgical wound infection; and 2 patients (8%) developed a seroma. There was no rejection of the mesh, erosion of the colon, or fistula formation. Conclusions: Inserting a mesh prosthesis by this technique is a safe effective treatment for parastomal hernia, adding another option to the available repair solutions. Prospective and comparative studies are required to reinforce this study, and they should ideally include a greater number of patients in the study corpus. © 2007 Société Internationale de Chirurgie.

Minimally invasive dual incision with mini plate internal fixation improves outcomes over 30 months in 20 patients with Sanders type III calcaneal fractures

DoD SSI (Surgical Site Infections)

BACKGROUND: Calcaneal Sanders type III or higher fractures traditionally have been treated with open reduction and internal fixation (ORIF); however, ORIF has associated complications. We investigated a combination of minimally invasive dual incision and internal fixation using mini plates for treating Sanders type III calcaneal fractures. METHODS: Twenty patients with Sanders type III intra-articular calcaneal fractures with a posterior subtalar articular displacement > 2 mm were included. Surgical outcomes were assessed by visual analogue scale (VAS) pain score, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and calcaneal geometry, including Bohler and Gissane angles. RESULTS: The Bohler angle, Gissane angle, and height and length of the calcaneus were increased following treatment. Based on the AOFAS score, 80% of cases had excellent or good outcomes. The mean postoperative VAS pain score was 1.6. Complications such as malunion or a screw positioning deviation occurred in 6 patients, and one patient experienced delayed wound healing. There were no wound infections. CONCLUSIONS: These results indicate that minimally invasive dual incision with mini plate internal fixation may be an effective alternative to ORIF for treating Sanders type III calcaneal fractures. Advantages include improvement of calcaneal geometry and a lower rate of wound infections.

Liposuction in benign symmetric lipomatosis: sense or senseless?

Panniculectomy & Abdominoplasty CPG

Benign symmetric lipomatosis is a rare form of typical fat distribution in the shoulders, the arms, and the neck that can compromise the respiratory, nutritional, and psychological status of the patient. Alcoholism, malignant tumors of the upper airways, endocrine tumors, hypothyroidism, diabetes, and hypertriglyceridemia are often associated with its occurrence. Surgical removal via lipectomy or liposuction can give good cosmetic results, although recurrences often occur. Liposuction has become the first choice to treat this disorder in patients with smaller masses. We have operated on four such cases in which liposuction failed and surgical excision had to be performed. We present a summary of the clinical characteristics of all four patients and discuss the different treatment options.

Hfe C282Y homozygosity is associated with an increased risk of total hip replacement for osteoarthritis in men but not women

Surgical Management of Osteoarthritis of the Knee CPG

Purpose: The evidence for an association between mutations in HFE gene related to hemochromatosis and risk of hip or knee osteoarthritis is inconsistent. Total joint replacement is considered a surrogate measure for symptomatic end-stage osteoarthritis. This study aimed to examine the relationship between HFE gene mutations and risk of total hip and knee replacement in a population-based cohort. Methods: The Melbourne Collaborative Cohort Study is a prospective cohort study that commenced recruitment in 1990. Participants born in Australia, New Zealand, the United Kingdom, or Ireland (n = 27,848) were genotyped for the HFE C282Y variant. Total hip and knee replacements for osteoarthritis during 2001-2009 were ascertained from the Australian Orthopaedic Association National Joint Replacement Registry. Hazard ratios (HRs) and confidence intervals (CIs) were obtained from Cox regression. Results: Compared to those with no C282Y variant, C282Y homozygotes were at increased risk of total hip replacement (HR 1.94, 95% CI 1.04- 3.62). The association was stronger for men (HR 3.34, 95% CI 1.48-7.52) than for women (HR 1.22, 95% CI 0.46-3.27) (p for interaction = 0.21). Only 3 C282Y homozygotes had total knee replacements; the HR was 0.51 (95% CI 0.16-1.57). C282Y/H63D compound heterozygosity was not related to the risk of total hip or knee replacement. Conclusions: HFE C282Y homozygosity was associated with increased risk of total hip replacement for osteoarthritis for men but not for women. The mechanism for this is unknown and the findings need to be confirmed in future studies

Intraarterial injection chemotherapy for advanced hepatocellular carcinoma using drug delivery system

MSTS 2018 - Femur Mets and MM

Intraarterial injection chemotherapy using delivery system has been widely used in metastatic disease of the liver. We utilized this system in advanced hepatocellular carcinoma (HCC) and evaluated the results. Sixty two cases with advanced HCC underwent hepatic arterial injection chemotherapy using drug delivery system during a 2 years period from 1990. The access catheter was placed in the hepatic artery via the axillary artery (59 cases) or the femoral artery (3 cases) and an injection port was implanted in the subclavian or iliac region. Epirubicin 30 mg/body and mitomycin C 4 mg/body were used every other week, and Lipiodol 1 ml/body was added every 4 weeks. The materials were subdivided into 3 groups: 1) 28 cases with tumor thrombus in the major portal pedicle, 2) 21 cases with poor liver function (Child C), and 3) 13 cases with recurrence after surgery or transarterial embolization. In all cases the procedures were successfully performed. The cumulative survival rate of one year was 45.7% in total, 17.3% in group 1, 54.9% in group 2, and 90.9% in group 3. The mean survival approximated 10 months. The survival rate in groups 2 and 3 was significantly higher than that in group 1. We conclude that an intraarterial injection chemotherapy using drug delivery system is a treatment of choice in advanced HCC with poor liver function and in recurrent HCC after surgery or transarterial embolization.

Meniscus Induced Cartilaginous Damage and Non-linear Gross Anatomical Progression of Early-stage Osteoarthritis in a Canine Model

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: The predictable outcome of the anterior cruciate ligament transection (ACLT) canine model, and the similarity to naturally occurring osteoarthritis (OA) in humans, provide a translatable method for studying OA. Still, evidence of direct meniscus-induced cartilaginous damage has not been identified, and gross-anatomical blinded scoring of early-stage OA has not been performed. OBJECTIVE: A gross anatomical observation and statistical analysis of OA progression to determine meniscus induced cartilaginous damage, to measure the macroscopic progression of OA, and to address matters involving arthroscopic and surgical procedures of the knee. METHOD: Unblinded assessment and blinded scoring of meniscal, tibial, femoral, and patellar damage were performed for control and at four time points following unilateral ACLT: 3-week (N=4), 8-week (N=4), 12-week (N=5), and 25-week (N=4). Mixed-model statistics illustrates damage (score) progression; Wilcoxon rank-sum tests compared time-point scores; and Wilcoxon signed-rank tests compared ACLT and contralateral scores, and meniscus and tibia scores. RESULT: Damage was manifest first on the posterior aspect of the medial meniscus and subsequently on the tibia and femur, implying meniscal damage can precede, coincide with, and aggravate cartilage damage. Damage extent varied chronologically and was dependent upon the joint component. Meniscal damage was evident at 3 weeks and progressed through 25-weeks. Meniscal loose bodies corresponded to tibial cartilage damage location and extent through 12 weeks, followed by cartilage repair activity after complete meniscal degeneration. CONCLUSION: This study provides additional information for understanding OA progression, identifying OA biomarkers, and arthroscopic and meniscectomy procedures.

Ten-year survival of cemented total knee replacement in patients aged less than 55 years

Surgical Management of Osteoarthritis of the Knee CPG

We report the ten-year survival of a cemented total knee replacement (TKR) in patients aged < 55 years at the time of surgery, and compare the functional outcome with that of patients aged > 55 years. The data were collected prospectively and analysed using Kaplan-Meier survival statistics, with revision for any reason, or death, as the endpoint. A total of 203 patients aged < 55 years were identified. Four had moved out of the area and were excluded, leaving a total of 221 TKRs in 199 patients for analysis (101 men and 98 women, mean age 50.6 years (28 to 55)); 171 patients had osteoarthritis and 28 had inflammatory arthritis. Four patients required revision and four died. The ten-year survival using revision as the endpoint was 98.2% (95% confidence interval 94.6 to 99.4). Based on the Oxford knee scores at five and ten years, the rate of dissatisfaction was 18% and 21%, respectively. This was no worse in the patients aged < 55 years than in patients aged > 55 years. These results demonstrate that the cemented PFC Sigma knee has an excellent survival rate in patients aged < 55 ten years post-operatively, with clinical outcomes similar to those of an older group. We conclude that TKR should not be withheld from patients on the basis of age

Three-dimensional knee joint contact forces during walking in unilateral transtibial amputees

OAK 3 - Non-arthroplasty tx of OAK

Individuals with unilateral transtibial amputations have greater prevalence of osteoarthritis in the intact knee joint relative to the residual leg and non-amputees, but the cause of this greater prevalence is unclear. The purpose of this study was to compare knee joint contact forces and the muscles contributing to these forces between amputees and non-amputees during walking using forward dynamics simulations. We predicted that the intact knee contact forces would be higher than those of the residual leg and non-amputees. In the axial and mediolateral directions, the intact and non-amputee legs had greater peak tibio-femoral contact forces and impulses relative to the residual leg. The peak axial contact force was greater in the intact leg relative to the non-amputee leg, but the stance phase impulse was greater in the non-amputee leg. The vasti and hamstrings muscles in early stance and gastrocnemius in late stance were the largest contributors to the joint contact forces in the non-amputee and intact legs. Through dynamic coupling, the soleus and gluteus medius also had large contributions, even though they do not span the knee joint. In the residual leg, the prosthesis had large contributions to the joint forces, similar to the soleus in the intact and non-amputee legs. These results identify the muscles that contribute to knee joint contact forces during transtibial amputee walking and suggest that the peak knee contact forces may be more important than the knee contact impulses in explaining the high prevalence of intact leg osteoarthritis.

Prophylaxis of medial compartment gonarthrosis in varus knee - current state of knowledge

OAK 3 - Non-arthroplasty tx of OAK

The progression of gonarthrosis results in reduction of physical activity. One of the factors that increase the risk of osteoarthrosis may be joint overload related to the malalignment of the mechanical axis of the lower extremity. The medial compartment (MC) of the knee is particularly susceptible to overload due to the external knee adduction moment (EKAM). Varus knee malalignment contributes to increased EKAM and thus results in increased MC loading. The purpose of this study is to present methods described in current literature aimed at reducing the disproportion in the distribution of loads on articular surfaces of medial and lateral knee compartments in people with varus knee malalignment.

Prevalence and Health Care Usage of Knee Pain in South Australia (SA): A Population Based Study

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: It is known that South Australia (SA) has the highest rate of knee arthroscopy use of any state in Australia, however Level 1 evidence demonstrates that knee arthroscopy in patients with uncomplicated knee osteoarthritis confers no benefit. In SA, which patients are presenting with knee pain and what treatments are they receiving? AIMS: To determine the prevalence, persistence and treatment modalities of knee pain in SA. METHODS: This study analysed data from the North-West Adelaide Health Study (1999-2015), a longitudinal, population based cohort study of people aged 18 years and over (n=4060), initially randomly selected from the north-west region of Adelaide, SA. It incorporated clinic assessments, self-completed questionnaires and telephone interviews to collect demographic, anthropometric and biochemical data over 4 main stages (1, 2, 3 and NW15). Data were linked to Medical Benefits Scheme (MBS) data. RESULTS: In stages 3 and NW15 of the NWAHS, 30-35% of participants reported knee pain (n=803, 452). Demographic variables associated with knee pain included older age and lower educational level, while risk factors included obesity and high waist circumference. In the 12 months preceding NW15, 33% of participants with knee pain/stiffness consulted a GP for their knee pain, 10.2% an orthopaedic surgeon, and 12.6% a physiotherapist. Between 2011 and 2015, 3.0% the cohort underwent a knee arthroscopy, and 3.1% underwent knee magnetic resonance imaging. CONCLUSION: Knee pain affects large proportions of the SA population. Knee pain was persistent with underuse of non-pharmacological treatments and high use of specialist referral. This data supports the need for a national strategy to effectively manage osteoarthritis. This article is protected by copyright. All rights reserved.

Donor site morbidity with reamer-irrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single centre 204 case series

DoD SSI (Surgical Site Infections)

Donor site morbidity and complication rate using the reamer-irrigator-aspirator (RIA) system for intramedullary, non-structural autogenous bone graft harvesting were investigated in a retrospective chart and radiographic review at a University affiliated Level-1 Trauma Centre. 204 RIA procedures in 184 patients were performed between 1/1/2007 and 12/31/2010. RIA-indication was bone graft harvesting in 201 (98.5%), and intramedullary irrigation and debridement in 3 (1.5%) cases. Donor sites were: femur - antegrade 175, retrograde 4, tibia - antegrade 7, retrograde 18. Sixteen patients had undergone two RIA procedures, two had undergone three procedures, all using different donor sites. In 4 cases, same bone harvesting was done twice. Mean volume of bone graft harvested was 47 +/- 22ml (20-85 ml). The complication rate was 1.96% (N=4). Operative revisions included 2 retrograde femoral nails for supracondylar femur fractures 6 and 41 days postoperatively (antegrade femoral RIA), 1 trochanteric entry femoral nail (subtrochanteric fracture) 17 days postoperatively (retrograde femoral RIA) and 1 prophylactic stabilization with a trochanteric entry femoral nail for intraoperative posterior femoral cortex penetration without fracture. In our centre, the RIA technique has a low donor site morbidity and has been successfully implemented for harvesting large volumes of nonstructural autogenous bone graft.

Therapeutic alliance between physiotherapists and patients with knee osteoarthritis consulting via telephone: a longitudinal study

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVES: Explore therapeutic alliance between physiotherapists and patients with knee osteoarthritis during telephone consultations. Specifically, i) describe and compare physiotherapist and patient ratings; ii) determine if alliance changes over time, and; iii) evaluate if individual characteristics are associated with alliance. METHODS: Secondary analysis of 84 patients in the intervention arm of a randomised controlled trial who completed 5-10 consultations with one of 8 physiotherapists via telephone over 26 weeks, involving education, advice, and prescription of a strengthening and physical activity program. Therapeutic alliance was measured after the second (week 4) and final consultations (week 26) using the Working Alliance Inventory (Short Form). RESULTS: Patient and physiotherapist ratings of the alliance were high. At week 4, patients rated the overall alliance, and all three sub-scales, higher than therapists. At 26 weeks, patients rated the "task" sub-scale higher than therapists. Patient ratings for the "goal" sub-scale decreased over time, while physiotherapist ratings for total alliance and "bond" sub-scale increased. For patients, living with others, consulting with a therapist with no previous experience delivering care remotely, having more telephone consultations, and higher self-efficacy was associated with greater alliance ratings. Therapists were more likely to perceive a stronger alliance if they had less clinical experience and when treating patients who were younger and had higher self-efficacy. CONCLUSIONS: Physiotherapist perceptions of the therapeutic alliance tended to be lower than those of patients early in treatment, however differences were small and of unclear clinical significance. Some sub-groups of patients rate the alliance more strongly than others. This article is protected by copyright. All rights reserved.

Risk factors for fracture in nonosteoporotic men and women

Management of Hip Fractures in the Elderly

CONTEXT AND OBJECTIVE: It is not known which factors are associated with fracture in nonosteoporotic elderly. The aim of this study was to assess the association between fall-related risk factors and fracture risk in men and women without osteoporosis. DESIGN: This study was part of the ongoing Dubbo Osteoporosis Epidemiology Study, which was designed as a prospective population-based cohort investigation. PARTICIPANTS: At baseline, 924 women and 723 men aged 60+ yr did not have osteoporosis [bone mineral density (BMD) T-scores > -2.5]. The individuals have been followed for up to 15 yr. MAIN OUTCOME MEASURES: Atraumatic fractures were prospectively identified through radiologists' reports. RISK FACTORS: At baseline, femoral neck BMD (FNBMD) was measured by dual energy x-ray absorptiometry (DXA); history of fall, postural stability, and quadriceps strength was obtained. RESULTS: During the follow-up period, among the nonosteoporotic group, 221 women and 105 men had sustained a fracture, accounting for 55 and 74% of total fractures in the entire Dubbo Osteoporosis Epidemiology Study sample, respectively. The following factors were independent risk factors for any fracture: in women, age per sd (hazard ratio, 1.2; 95% CI, 1.0-1.3), postural sway per sd (1.1, 1.0-1.2), FNBMD per sd (1.6, 1.3-1.9), fall in the previous 12 months (2.1, 1.6-2.7), and prior fracture (1.8, 1.2-2.7); in men, age (1.4, 1.1-1.6), postural sway (1.2, 1.0-1.3), FNBMD (1.2, 1.0-1.5), and fall in the previous 12 months (1.9, 1.2-3.0). Exposure to at least one of the risk factors could account for 49% (women) and 39% (men) of any fractures in this population. CONCLUSION: In nonosteoporotic elderly, the combination of low BMD, advancing age, fall during the last 12 months, and prior fracture could identify a subgroup of individuals with high risk of fracture

The impact and consequences of hip fracture in Ontario

Management of Hip Fractures in the Elderly

OBJECTIVES: To assess the magnitude and the burden of hip fracture on the health care system, including time trends in hip fracture rates, in-hospital death rates, length of hospital stay (LHS) and discharge destination. DESIGN: A retrospective study of discharge abstracts. SETTING: The Province of Ontario. PATIENTS: All patients (n = 93,660) over the age of 50 years and with a diagnosis of hip fracture discharged from hospital between 1981 and 1992 (excluding transfers). MAIN OUTCOME MEASURES: Age-sex standardized hip fracture rates per 1000 population, in-hospital death rates and age-adjusted mean LHS. RESULTS: The overall hip fracture rate was 3.3 per 1000 persons (1.7 per 1000 men and 4.6 per 1000 women). There was no change in rates between 1981 and 1992 (p = 0.089), but there have been increases in the numbers of hip fractures. There was no change in the in-hospital death rate over time (p = 0.78). The age-adjusted mean LHS in 1981 was 28.6 days compared with 22.2 days in 1992. The numbers of hip fractures will increase from 8490 in 1990 to 16 963 in 2010. CONCLUSIONS: Despite stable age-adjusted rates of hip fractures, the doubling of the number of hip fractures by the year 2010 due to an aging population will become an increasing burden on the health care system

An effective antibiotic cover for the prevention of endocarditis following dental and other post-operative bacteraemias

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Pre- and post-extraction blood cultures were taken from 242 patients. The post-extraction ones were taken from 100 unpremedicated patients, from 42 with an erythromycin estolate cover, and from 100 patients after protection with pyrrolidino methyl tetracycline. The 100 post-extraction blood cultures from unpremedicated patients gave 64 positive results which yielded 155 strains, 88 of which were not aerobes. One hundred and fifteen representative strains were tested for sensitivity to 22 antibiotics. Of the 42 patients who received the erythromycin orally, 16 yielded positive blood cultures of mixtures of aerobes and anaerobes and of the 100 given one intravenous injection of the tetracycline three only developed a bacteraemia of a single type of aerobe. The serum concentrations obtained with the tetracycline given intravenously were 15 to 20 times higher than the serum levels obtained with the erythromycin given orally. There is a strong indication for using this kind of efficient antibiotic cover for dental extractions and other operative procedures known to be followed by a bacteraemia

Periodontal bacteremia and various vascular diseases

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

BACKGROUND AND OBJECTIVE: Weak oral bacteria, such as periodontal bacteria, have been found in various vascular lesions, including atheroma, the thrombus of the occluded artery of Buerger's disease, the abdominal aortic aneurismal wall and varicose veins. Serum titer levels of each bacterium are now available and have shown a significant relationship between severity and individual differences. MATERIAL AND METHODS: The Medline and Tokyo Medical and Dental University databases were searched to identify the literature currently available on oral bacteria and vascular diseases. RESULTS: It is estimated that lymph vessel openings trap bacteria en route from the mouth to the bloodstream and then carry them to the vein of the venous angle near the supraclavicular area. In the case of periodontal bacteria, a typical bacterium, such as Porphyromonas gingivalis, strongly activates platelets and makes them mass, including the bacteria without phagocytosis. Simultaneously, cytokines and serotonin are discharged. Platelet engulfment was clearly demonstrated by electron microscopy analysis. An animal study using rats showed the formation of a small arterial thrombus after continuous intravenous infusion of P. gingivalis for 2-4 wk. CONCLUSION: Weak oral bacteria, such as periodontal bacteria, may play an important role in the development of various vascular diseases, such as Buerger's disease, atherosclerosis and varicose veins, through bacteremia

Clinical Features and Risk Factors of Skeletal-Related Events in Genitourinary Cancer Patients with Bone Metastasis: A Retrospective Analysis of Prostate Cancer, Renal Cell Carcinoma, and Urothelial Carcinoma

MSTS 2018 - Femur Mets and MM

OBJECTIVE: The objective of the present study was to report the incidence of skeletal-related events (SREs) and identify risk factors for SREs in patients with genitourinary cancer with newly diagnosed bone metastasis. METHODS: This retrospective study included 180 patients with bone metastasis from prostate cancer (PCa; n = 111), renal cell carcinoma (RCC; n = 43), and urothelial carcinoma (UC; n = 26). Clinical factors at the time of diagnosis of bone metastasis were evaluated with Cox proportional hazards regression analysis to identify independent risk factors for SREs. RESULTS: During follow-up, 29 (26%) patients with PCa, 30 (70%) with RCC, and 15 (58%) with UC developed SREs. Treatment with bone-modifying agents (BMAs) before the development of SREs and within 6 months from the diagnosis of bone metastasis significantly delayed the time to first SRE as compared to nonuse of BMAs. Multivariate analysis identified type of primary cancer (PCa vs. RCC, PCa vs. UC), performance status, and bone pain as significant independent predictive risk factors for SREs. CONCLUSIONS: Treatment with BMAs significantly delayed the development of first SREs. The identified predictors of SREs might be useful to select patients who would benefit most from early treatment with BMAs.

Intercarpal ligament injuries associated with fractures of the distal part of the radius

Distal Radius Fractures

BACKGROUND: Soft-tissue injuries of the wrist are often not recognized in patients with distal radial fractures, yet scapholunate injuries have been reported to occur in association with as many as 54% of distal radial fractures. The true prevalence and natural history of intercarpal ligament injury are not known. METHODS: This prospective observational study assessed the prevalence and one-year outcome of intercarpal ligament injuries in non-osteoporotic patients with displaced fractures of the distal part of the radius. The study group consisted of fifty-one patients (twenty-seven women and twenty-four men) with a median age of forty-one years (range, twenty to fifty-seven years). Patients underwent standard fracture treatment and, in addition, wrist arthroscopy was performed to identify associated carpal injuries. No ligamentous injuries were treated. Patients were reviewed at one year and underwent physical and radiographic evaluation. Patients were analyzed according to the status of the scapholunate ligament at the time of the injury and were graded with use of a modification of the Geissler classification system: Group I consisted of ten patients with a grade-3 scapholunate ligament injury, and Group II consisted of forty-one patients with a grade-0, 1, or 2 injury. RESULTS: Patients with an increase in ulnar variance of >2 mm at the time of the injury had a fourfold increase in the risk of sustaining a grade-3 scapholunate ligament injury (p = 0.01). Radiographically, at one year, patients in Group I (grade-3 injuries) had a greater amount of static and dynamic scapholunate dissociation and a significantly greater increase in the scapholunate angle in comparison with the uninjured wrist (p = 0.006) than did those in Group II. Intra-articular fractures were associated with a twofold increase in the prevalence of scapholunate dissociation as seen radiographically at one year. The prevalence of subjective pain on examination was significantly greater in Group I than in Group II (p = 0.009). There were no significant differences between the two groups with respect to objective outcome according to range of motion and hand grip and tip pinch strengths. Lunotriquetral injuries were uncommon and did not correlate with the scapholunate injuries, fracture grade, or configuration. CONCLUSIONS: Grade-3 scapholunate ligament tears can be associated with ulnar positive variance at the time of initial presentation of a distal radial fracture and can be associated with more scapholunate joint pain at one year. These injuries could lead to scapholunate dissociation at the time of follow-up, particularly in patients with intraarticular fractures.

A convex lateral tibial plateau for knee replacement

Surgical Management of Osteoarthritis of the Knee CPG

Unicompartmental knee replacements have not performed as well in the lateral compartment as in the medial. This may be because the tibial components have flat or slightly concave surfaces which match the medial plateau but not the convex lateral plateau. The aim of this study was to find the optimal radius for a convex lateral tibial component. Twelve normal lateral tibial plateau were retrieved at knee replacement, and their surface contour in their mid sagittal plane was determined. The optimal circle was fitted and its radius measured. A series of different shaped tibial components were superimposed. From published information about the position of the femoral condyle relative to the tibia in different degrees of flexion, the flexion gap at these angles was determined. The average radius of the lateral tibial plateau was 40 mm. However, as the surface was polyradial it was not clear if this average radius would be optimal. In full flexion, a flat tibial plateau distracted the knee by 8 mm (p<0.001). A 75 mm radius spherical tibial plateau did not alter the knee kinematics significantly and gave rise to a change in joint distraction of 1.5 mm. Spherical tibial plateau of 50 mm and 25 mm radii significantly altered knee kinematics (p<0.001) and resulted in changes in distraction of 3 mm and 4 mm respectively. The optimal shape for a unicompartmental lateral tibial plateau is likely to be a spherical dome with radius of about 75 mm. The incorporation of this shape in the lateral side of a total knee replacement might improve its flexion

Clinical trials of endosseous implants: issues in analysis and interpretation

Dental Implant Infection

The majority of contemporary endosseous dental implant systems are based on designs and materials that, over the last three decades, have proved to be predictably reliable. With proper surgical and prosthetic protocols, rates of implant loss have been held to 15% or less over a 5-year period. This information was obtained largely through longitudinal descriptive studies, primarily aimed at obtaining implant survival rates under ideal clinical conditions, with strict inclusion and exclusion criteria for admitting patients into the studies. It is important to emphasize that under conditions of routine clinical practice, where patient selection may be more relaxed than in clinical trials and clinicians attempt to stretch the limits of current technology, the survival rates may not necessarily match those reported in the literature. Since "surviving" implants may exhibit characteristics likely to lead to eventual loss of the implant, for example severe osseous defects, such implants may not necessarily be considered successful. Successful implants should fulfill a list of other criteria considered essential for long-term survival. Differences in implant design preclude some of these criteria from being uniformly applied to all systems. There is a need to identify criteria for success that can be applied to the majority of implant systems. Implants that fail to meet these criteria should be considered failures. Since failure rates may include "failed" as well as "failing" ("ailing") implants, the two categories should be listed separately. From a practical standpoint, implant failures can be grouped into "early" failures, primarily the result of surgical and/or postoperative complications, and "late" failures that arise during and following the restorative phase. The ability of individual systems to achieve excellent success rates, despite some major differences in their design from other systems, suggests that some requirements, initially considered essential for success, may not be as critical as originally believed. Examples include the need for submerging implants during initial wound healing or the need for stress breaking devices. On the other hand, a basic requirement for implant success, such as primary stability at the time of insertion and following loading of the implant, may be the unifying principle behind the need for adequate bone volume and density, longer or wider implants, and the 3 to 6-month delay recommended before implants are placed in function. With relatively low failure rates, a large number of patients may have to be included in long-term clinical trials before a statistically significant association can be established between failure rates and potential contributing factors. For the same reasons, and to avoid type 2 errors, large populations may be needed to show that two systems have comparable success rates. Proving the superiority of one system over another may require fewer subjects. Given the overall low failure rate and the tendency of failures to cluster in individual subjects, failure rates could be markedly affected by the attrition of a few critical subjects. Additional research is needed to validate methods in current use for the clinical determination of osseointegration, and the diagnosis and treatment of occlusal trauma and microbial infections around implants. Also, more reliable methods are needed for the identification of the primary cause(s) of implant morbidity; i.e., infection or occlusal factors.

Impaired postural balance in the morning in patients with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Postural balance (PB) is frequently used as an outcome measure in clinical and research settings when assessing patients with knee osteoarthritis (OA). Pain and stiffness is known to affect PB, and is elevated in the morning and evening in OA patients. The aim of this study was to explore if time-of-day affects PB control in knee OA patients. Centre Of Pressure (COP) excursion was measured (100Hz) by force plate technique at selected time-points (9.00 a.m., 12.30 p.m. and 4.00 p.m.) during a single day in 32 knee OA patients aged 66.0 (10.3) years. A rigorous protocol was followed to ensure comparable testing conditions across time-points. PB control was quantified by the COP variables: velocity moment (mm(2)/s), total sway area (mm(2)), total sway length (mm) and confidence ellipse area (mm(2)). A two-way mixed-effects model showed that PB significantly improved between 9.00 a.m. and 12.30 p.m. in three out of four COP variables. The observed improvement was 11.9% (p=0.011) for velocity moment, 12.2% (p=0.011) for total sway area and 9.4% (p<0.001) for total sway length. PB appears to be impaired in the morning relative to midday in knee OA patients. Thus, it is recommended that time of assessment is standardized between sessions when assessing PB in clinical and research settings in knee OA patients.

Efficacy and safety of ¹⁵³Sm-EDTMP as treatment of painful bone metastasis: a large single-center study

MSTS 2018 - Femur Mets and MM

PURPOSE: The purpose of this study is to assess the efficacy of ¹⁵³Sm-EDTMP (Quadramet) in a clinical setting. METHODS: We have conducted a retrospective study of all consecutive patients (pts) treated with ¹⁵³Sm-EDTMP for painful bone metastases. At each visit (before and after treatment), four parameters were collected: (i) pain assessment according to the 10-step visual analogue scale (VAS), (ii) sleep disturbance related to pain, (iii) dose of analgesic medication, and (iv) answer to the following closed question "Do you think you obtained a benefit from treatment?" Success of treatment was defined by the combination of these four parameters. RESULTS: Three hundred seventy consecutive ¹⁵³Sm-EDTMP treatments for painful bone metastases were given. Patients had the following primary tumors: breast carcinoma (153), prostate carcinoma (155), lung carcinoma (27), or other cancers (35). Fifty-eight percent of the patients had received previous external osseous radiotherapy. Ninety-seven percent of the patients were treated with concomitant analgesics and 61% were treated with diphosphonates. A clinical benefit was described in 55.0% of cases at D30. Treatment was more effective in cases of breast and prostate cancers compared with other types of primary cancers. Patients described a benefit at D30 in 62, 58, 6, and 38% of cases of breast, prostate, lung, and other cancers. The subjective efficacy was accompanied by a decrease in analgesic intake in 35.0% of cases. CONCLUSION: ¹⁵³Sm-EDTMP therapy is an effective supportive treatment in patients who suffer from bone metastases, especially in patients with breast or prostate cancer.

Roentgenographic measurement of angle between shaft and distal epiphyseal growth plate of radius

Distal Radius Fractures

To assess the accuracy of the use of the growth plate to shaft angle (GP-S) in the fractured distal radius, two prospective studies were performed. The first intraobserver study was made by three different observers who measured the GP-S angles of anteroposterior and lateral views of 62 wrist radiographs on two different occasions. The results showed a 95% concordance for a 5° tolerance on anteroposterior views and 7° on lateral views. The second, an interobserver study with six different observers, showed the same results. The results favored the use of the distal radius GP-S angle. It is an easy and accurate measurement that can be useful for the assessment of distal forearm deformities in children.

Pelvis and hip joint injuries as a reconstructive factors in car-to-pedestrian accidents

Management of Hip Fractures in the Elderly

The pelvic girdles of 371 pedestrian victims of road traffic accidents were evaluated during postmortem examinations. Additionally, 144 hip joints were opened. The pelvic injuries were found in 28% of the pedestrians hit exclusively in their upright position and 52% of the victims run over by a vehicle. The side of the body hit by a car was determined on the basis of the location of blood suffusions within the subcutaneous tissues and muscles of lower limbs as well as the character of injuries found in the knee and upper ankle joints. The findings were verified with the data from court records. It was shown that the injuries of the sacroiliac joints or vertical fractures of the posterior parts of iliac bones were useful parameters for determining the side (left or right) of the body hit by a vehicle. Moreover, it was found that a direct impact on the hip region was evidenced by the ipsilaterally localized fractures of the iliac ala, central hip fractures and intraosseous blood suffusions within the greater trochanter of the femur. The external dislocations of the hip joints (always) and bilateral injuries to the sacroiliac joints (usually) were observed in the victims run over by vehicles

A double-blind comparison of piroxicam mane with piroxicam nocte in patients awaiting hip and/or knee joint replacement

AAHKS (4) Acetaminophen

Thirty-three patients (9 males and 24 females) awaiting hip or knee joint replacement received 8 weeks treatment with piroxicam 20 mg mane or piroxicam 20 mg nocte. Patients were allocated to each treatment group in random order and initiated therapy with a one week placebo period. Active treatment was double blinded throughout. Efficacy and safety were evaluated for all patients where data was available. Both piroxicam 20 mg mane and piroxicam 20 mg nocte were effective (as judged by reduction in pain at breakfast, lunch, evening meal and the number of times awoken by pain at night). Side effects were few with both dosage regimen and similar to placebo. In this study, piroxicam 20 mg o.d. was a well tolerated and effective agent when given either in the morning or at night.

Triple nerve block at the knee for foot and ankle surgery performed by the surgeon: difficulties and efficiency

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Combined nerve blocks at the knee can provide safe anesthesia below the knee avoiding the potential complications of general or spinal anesthesia while reducing the need for opioids in the postoperative period. This study presents the outcomes of a large series of patients that underwent foot and ankle surgery receiving a triple nerve block at the knee. MATERIALS AND METHODS: Three hundred eighty patients underwent foot and ankle surgery receiving anesthesia with triple nerve block at the knee (tibial, common peroneal and saphenous nerve). Surgery included a variety of bone and soft tissue procedures. The nerve block was performed by an orthopaedic surgeon in the lateral decubitus position. RESULTS: The successful nerve block rate was 91 percent. There was no need to convert to general or spinal anesthesia, although 34 patients (9%) needed additional analgesia intraoperatively. Complete anesthesia required 25 to 30 minutes from the time of performing the block. No complication occurred secondary to the use of the anesthetic agent (ropivacaine 7.5%). Postoperative analgesia lasted from 5 to 12 hours, reducing the need of additional analgesics. Hospitalization averaged 1.4 days (from 0 to 5) with the majority of patients discharged the day after the operation (248/380). A high satisfaction rate was reported by the patients with no adverse effects and complications. CONCLUSION: We found triple nerve block at the knee to be a safe and reliable method of regional anesthesia providing low morbidity, high success rate, long acting analgesia, and fewer complications than general or spinal anesthesia. It is a simple method that can be performed by the orthopaedic surgeon

Fatigue strength of PMMA bone cement mixed with gentamicin and barium sulphate vs pure PMMA

Dental Implant Infection

Barium sulphate is added to polymethylmethacrylate (PMMA) bone cement as a radiopacifier. Gentamicin is an antibiotic added to bone cement to treat or prevent infection in arthroplasty. This study investigated the combined effect of barium sulphate and gentamicin sulphate on the fatigue strength of PMMA bone cement. Three different formulations were studied: pure PMMA, PMMA with barium sulphate added and PMMA with barium sulphate and gentamicin sulphate added. Before testing all specimens were stored in water at 37 degrees C for at least 15 days to season the PMMA and to elute the antibiotic. Fatigue tests were performed following a previously validated procedure. The slope part of the Wohler diagram was obtained and a rough endurance limit was estimated for all three formulations. The experimental data showed that the addition of barium sulphate to PMMA bone cement affected the fatigue strength of the material, whereas addition of gentamicin sulphate to the radiopaque PMMA had no effect on the fatigue properties of the bone cement. While PMMA with barium sulphate added was confirmed to have a reduced fatigue strength when compared with plain PMMA, no detrimental effect was found for the addition of gentamicin sulphate to radiopaque PMMA.

Prospective analysis of changes in corneal topography after upper eyelid surgery

Upper Eyelid and Brow Surgery

PURPOSE: Some patients note a decrease in visual acuity in the operated eye after eyelid surgery. Although, the most common cause for this change is dry eye syndrome, it has been hypothesized that the symptom of blurred vision may result from a change in the corneal curvature. The study was conducted to determine if there is a change in corneal curvature after upper eyelid surgery. METHODS: Standard keratometry and corneal videokeratography (CVK) were performed 1 and 3 months after blepharoplasty (18 lids) and ptosis repair (24 lids). Pre- and postoperative images from CVK data were digitally subtracted for quantitative evaluation. RESULTS: After ptosis repair, the average dioptric change as measured by keratometry and by CVK was approximately 0.60 diopters (D); of note, nearly 30% of these patients showed transient astigmatic changes greater than 1.00 D; After blepharoplasty, the average dioptric change as measured by keratometry and by CVK was approximately 0.55 D; of note, only 11% of patients showed astigmatic changes greater than 1.00 D. CONCLUSION: Repositioning of the upper eyelid after ptosis repair or blepharoplasty may result in visually significant astigmatic changes in the central and peripheral cornea and may alter the patient's spectacle or contact lens correction.

Chemoprophylaxis with oral amoxycillin against bacterial endocarditis: when should second doses be administered after dentistry?

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The adequacy of serum bactericidal activity after oral amoxycillin given as prophylaxis against infective endocarditis was studied using a double blind randomised protocol in healthy volunteers having dentistry. One hour before their procedure 38 patients received 3 g amoxycillin syrup and 12 received matching placebo. Venous blood samples were drawn before and one and nine hours after dosing and serum amoxycillin concentrations determined using a standard bioassay. Samples containing amoxycillin had inhibitory titres measured against two reference isolates of viridans streptococci known to have caused infective endocarditis. The susceptibility to amoxycillin of one strain was high and the other low, respective minimal bactericidal and inhibitory concentrations being 0.08 and 0.04 mumol/l (0.03 and 0.015 microgram/ml) and 2.74 and 1.37 mumol/l (1 and 0.5 microgram/ml). Amoxycillin was detected in only post-treatment samples of patients given the active drug. There were no significant correlations between one or nine hour drug concentrations and age or physical characteristics, nor was there any relation to preceding food consumption. Correlations between drug concentrations at one and nine hours were weak (r = 0.34; p less than 0.05), but between corresponding drug concentrations and serum inhibitory titres there were consistent correlations (r = 0.46-0.48; p less than 0.005). Against the low susceptibility reference isolate bactericidal amoxycillin concentrations were encountered in only 20 of the 38 nine hour samples (95% confidence limits 34% and 66%). When repeat doses of amoxycillin are indicated after dentistry they should be given about four hours later, not eight hours later as commonly practised

Study of straight metatarsal osteotomy for the treatment of plantar callosities

DoD SSI (Surgical Site Infections)

Backround and Aims: To evaluate the outcome of transverse distal metatarsal osteotomies for intractable plantar callosity without hammer toe deformity and associated toe corns. Material and Methods: Twenty-five plantar callosities were treated in 19 feet of 13 patients (mean age 48 years, 5 male, 8 female) with transverse distal metatarsal osteotomy. Results: Twenty-four of the osteotomies united primarily, one after revision. After a 7-year follow-up, 23 of the callosities had healed, two of them after an oblique reosteotomy. Eight hammer toe deformities had developed in the involved rays of four feet. Eight plantar callosities had developed outside the operated rays in five feet. Hallux valgus was a frequent finding in both operated and non-operated feet. Conclusion: It seems that transverse distal metatarsal osteotomy is an effective treatment of intractable plantar callosities. Harmful hammer toe deformities and transfer lesions below adjacent metatarsal heads tend to develop over time.

Anaerobic flora in endodontic infections

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Microbiological and clinical data from 56 patients with endodontic infections were evaluated. Samples were collected using autoclaved paper points. Specimens were processed for isolation of aerobic and anaerobic bacteria. Antimicrobial sensitivity and resistance profiles of the recovered isolates was also performed. Forty nine positive cultures (87.5%) were obtained from the 56 consecutive necrotic root canal systems which were sampled. A total of 69 aerobic bacteria and 21 anaerobic bacteria were recovered. Aerobic bacteria were isolated from 35 patients (72%), anaerobic bacteria from 3 (6%) and mixed aerobic and anaerobic bacteria from 11 patients (22%). The most common aerobic isolate was Klebsiella pneumoniae. The predominant anaerobic isolate was Bacteroides species. One isolate was recovered from 25 patients (51%) whereas in the remaining 24 patients (49%) more than 1 isolate were recovered. These data illustrate the polymicrobial nature of endodontic infections in half the patients studied and the role of anaerobic bacteria in a quarter of them

Importance of non-regional lymph nodes in assigning risk in primary metastatic prostate cancer

MSTS 2022 - Metastatic Disease of the Humerus

Objective: To determine the prognostic relevance of non-regional lymph node (NRLN) metastases presenting synchronously with bone metastases in metastatic prostate cancer (mPCa) for guiding treatment decisions based on oligometastatic definitions. Patients and Methods: Patients diagnosed with mPCa between 2004 and 2013 were identified from the Surveillance, Epidemiology and End Results database and were grouped by metastatic sites into only NRLN, only bone, bone + NRLN and other sites ± bone/NRLN metastases. Multivariate Cox and competing risk regression analyses were performed to compare the risks of all-cause mortality (ACM) and prostate cancer-specific mortality (PCSM) associated with bone + NRLN metastases before and after propensity-score matching to patients with only bone metastases. This was complemented with landmark and supplementary analyses. Results: Of 17 167 patients with mPCa identified, 63.1% presented with only bone metastases, while bone and NRLN metastases co-occurred in 8.9% of the cohort. On multivariate analyses, after adjusting for potential confounders (clinical and sociodemographic), patients with bone + NRLN metastases had a significantly higher risk of ACM (hazard ratio [HR] 1.161, 95% confidence interval [CI] 1.084–1.243; P < 0.001) and PCSM (subdistribution HR 1.149, 95% CI 1.067–1.237; P < 0.001) compared with patients with only bone metastases. Landmark analyses limited to survivors of =6 and =12 months again showed a significantly increased risk of ACM for patients presenting with bone + NRLN metastases compared with patients with only bone metastases. In a subsequent 1:1 propensity-score-matched cohort of patients with bone + NRLN metastases and only bone metastases, the bone + NRLN group had higher multivariate-adjusted hazard rates for ACM (HR 1.202, 95% CI 1.102–1.311; P < 0.001) and PCSM (subdistribution HR 1.146, 95% CI 1.044–1.259; P = 0.004). Conclusions: Patients with concomitant NRLN and bone metastases have a higher risk of death, NRLN and bone metastases therefore representing a high-risk feature, when compared with patients with bone metastases alone. The current therapeutic stratification of ‘low-’ vs ‘high-volume’ disease does not account for this phenomenon, and patients requiring aggressive combination therapy may not receive maximum therapeutic benefit as a consequence.

Lateral elbow instability

Pediatric Supracondylar Humerus Fracture 2020 Review

Lateral elbow stability utilises a combination of bony and soft tissue constraints. Lateral elbow instability is usually associated with an episode of elbow dislocation. Isolated lateral ligament complex insufficiency results in posterolateral rotatory instability (PLRI), The most common presentation is lateral elbow discomfort and a sensation of instability, without recurrent dislocation. The lateral pivot shift test is unreliable for diagnosing PLRI when the patient is awake due to significant apprehension. Stress radiographs, fluoroscopy, computed tomography and arthroscopy are all useful investigations to confirm the diagnosis of lateral instability. Surgical treatment is indicated for functional instability. All associated fractures need to be addressed. In severe cases, the medial structures and the posterolateral capsule may also require reconstruction. Copyright © 2014, Asia Pacific Knee, Arthroscopy and Sports Medicine Society.

The Exeter Universal cemented femoral component at 15 to 17 years: an update on the first 325 hips

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The first 325 Exeter Universal stems (309 patients) implanted at the originating centre were inserted between March 1988 and February 1990 by a group of surgeons with differing experience. In this report we describe the clinical and radiological results at a mean of 15.7 years (14.7 to 17.3) after operation with no loss to follow-up. There were 97 patients (108 hips) with replacements still in situ and 31 (31 hips) who had undergone a further procedure. With an endpoint of revision for aseptic loosening, the survivorship at 17 years was 100% and 90.4% for the femoral and acetabular component, respectively. The mean Merle D'Aubigne and Postel scores at review were 5.4 (SD 0.97) for pain and 4.5 (SD 1.72) for function. The mean Oxford score was 38.4 (SD 9.8) (0 to 48 worst-to-best scale) and the mean combined Harris pain and function score was 73.2 (SD 16.9). Radiological review showed excellent preservation of bone stock in the proximal femur and no failures of the femoral component

Bone Graft Necessity in Opening-Wedge High Tibial Osteotomy

OAK 3 - Non-arthroplasty tx of OAK

Opening�Wedge High Tibial Osteotomy is a classic procedure,but the use of autologous bone graft from iliac crest causes pain and bleeding. Bone union occur even without bone graft, but no clinical trials compared results of the twoo procedures.

Intra-articular hyaluronic acid in the treatment of knee osteoarthritis: a Canadian evidence-based perspective

OAK 3 - Non-arthroplasty tx of OAK

Osteoarthritis (OA) is a chronic condition characterized by a loss of joint cartilage and is a major cause of disability in Canada, with an estimated CN$195 billion annual cost. Knee OA leads to persistent pain and loss of function, and treatment goals primarily focus on symptom relief and retention of function. Intra-articular hyaluronic acid (IAHA) has therapeutic benefits, and numerous recently published meta-analyses (MAs) and commentaries have highlighted new evidence on the role of IAHA therapy for knee OA. A diverse, multidisciplinary group of specialists met independently in closed sessions to review findings from eight MAs with literature search end dates no earlier than 2012 to address controversies surrounding IAHA therapy for mild-to-moderate knee OA within the Canadian treatment context. Outcomes from a total of eight MAs were reviewed, and consistent and statistically significant improvements in pain, function and stiffness up to 26 weeks were found with IAHA therapy compared with IA placebo or controls, regardless of MA size or trial quality. These findings are in line with those of a Cochrane review, another recent systematic review and patient satisfaction survey. Overall, three MAs reported outcomes based on molecular weight (MW), with the two reporting effect sizes showing significantly improved pain outcomes for higher compared with lower MW HAs. Recent evidence suggests that HA therapy is well tolerated with no increased risk of serious adverse events compared with placebo and the full therapeutic effect of IAHA therapy appears to have considerable clinical importance, consisting of the combined IA placebo and HA therapeutic effects. IAHA therapy is a well-tolerated and effective option for patients with mild-to-moderate knee OA failing first-line pharmacological therapy.

Motor control in old age: evidence of impaired low-level inhibition

Upper Eyelid and Brow Surgery

In the masked prime task, responses to supraliminal targets are influenced by previously presented subliminal primes. When targets follow primes immediately, positive compatibility effects are obtained such that performance is better when prime and target are compatible (mapped to the same response) than when they are incompatible (mapped to opposite responses). In young adults, this pattern reverses with longer interstimulus intervals (negative compatibility effect). These effects reflect an activation-followed-by-inhibition process: Primes trigger an initial activation of their corresponding motor response, which is subsequently inhibited. The present study demonstrates that healthy older adults (M = 76 years) show a substantial positive compatibility effect with a short prime-target interval, but they fail to produce reliable negative compatibility effects with longer intervals, indicating an age-related impairment in low-level motor control.

Risk factors of cardiovascular disease in GH-deficient adults with hypopituitarism: A preliminary report

AAHKS (2) Corticosteroids

Background: We estimated the influence of GH deficiency (GHD) in adults on chosen risk factors of cardiovascular disease and bone density. Material/Methods: Fifty-four adults (mean age: 50.4 years) with hypopituitarism were studied. We measured blood pressure, body mass index, waist-to-hip ratio, total body fat, and bone mineral density and the serum levels of lipids, glucose, insulin, pituitary hormones, estradiol, testosteron, and thyroxine, and the excretion of free cortisol in 24-h urine. GHD was confirmed with the insulin intravenous test (IIT) with a GH response to IIT of <3 μg/ml. The control group consisted of 73 healthy adults. Results: Increased levels of LDL-cholesterol and triglycerides and decreased levels of HDL-cholesterol in the GHD group were observed. Fasting serum glucose and insulin levels were significantly higher in the GHD group than in controls. Significant differences in the QUICKI and FIRI indexes were observed. Twenty-three percent of the hypopituitary patients were hypertensive and 65% were obese. The percentage of total body fat was significantly higher in the studied group than in controls. Thirty-seven percent of the GHD patients were osteoporotic and 23% were osteopenic. Conclusions: An atherogenic lipid profile, insulin resistance, obesity, and increased body and trunk fat in GHD adults may cause the higher risk of cardiovascular disease in these patients. GHD adults should receive human recombinant GH along with conventional replacement therapy. This may be a useful method in protecting against early onset of atherosclerosis, metabolic disturbances, and osteoporosis, especially in young patients. © Med Sci Monit, 2006.

Acupuncture for the treatment of chronic knee and back pain

OAK 3 - Non-arthroplasty tx of OAK

Introduction: Because the efficacy of acupuncture was not reliably substantiated by scientific data, the Joint Federal Committee initiated a project comparing the effectiveness of acupuncture to guideline�oriented conventional therapy for chronic pain. Four large, randomized studies were conducted as part of the "German Acupuncture Trials" (GERAC). Methods: For the studies on gonarthrosis and lumbalgia, 2,201 patients were randomised in eleven German states (399 outpatient practices) to verum acupuncture, sham acupuncture and guideline�oriented conventional therapy. Primary outcome parameter was pain�dependent scores six months after randomization. Parallel to the randomized studies, a Germany�wide cohort study was conducted from which several samples were drawn to determine severe adverse events (367,646 patients) and the efficacy of acupuncture under conditions of everyday medical practice. Results: 10 to 15 acupuncture sessions, verum as well as sham, alleviated symptoms more effectively than conventional therapy. The outcomes were comparable to the pain dependent scores of patients in the knee and back�pain cohort samples. Discussion: Body needle acupuncture is an effective method of pain reduction. Because of the results in GERAC, the Joint Federal Committee of Physicians and Health Insurance Plans (G�BA) has recommended that acupuncture for both indications be treated as a covered benefit under German public health insurance plans.

Long-term effects of structum administration (according to data from multicenter trial)

OAK 3 - Non-arthroplasty tx of OAK

AIM: To evaluate duration of a clinical response to the drug structum in patients with osteoarthrosis (OA) of the knee and hip joints as well as structum effects on OA course and that of concomitant diseases. MATERIAL AND METHODS: The duration of a clinical response to structum after the end of the treatment and its effect on OA and concominant diseases course were studied for 12 months in 9 centers participating in the study of the drug efficacy and tolerance in patients with gon� and coxarthrosis in an open multicenter randomized controlled 6�month trial. Out of 555 patients with OA of the knee and hip joints enrolled in the first study, the examination covered 373 patients: 159 patients of the test group treated for 6 months with structum and 214 controls. By basic clinical parameters the groups were similar. Clinical examination was made after structum treatment and 12 months later and included assessment of the number of exacerbations, hospitalizations, outpatient consultations, days of temporary disability for OA, pain in the joints while walking and at rest by the visual scale, Leken's functional index, x�ray pictures of the joints, administration of nonsteroidal anti�inflammatory drugs (NSAID), exacerbations of concomitant diseases (gastrointestinal diseases, arterial hypertension, ischemic heart disease). RESULTS: An overall functional Leken's index in patients with gon� and coxarthrosis given structum 12 months after the treatment did not reach the initial values as well as pain and daily need in NSAID. Structum effect in patients with knee joint OA persisted for 4.6 months, in hip joint OA��4.1 months; in patients with stage I�II the effect lasted longer than in stage III (5.2 and 4.6 months vs 4.17 and 3.24 months, respectively. Even short�term therapy with structum reduced the number of further exacerbations, hospitalizations and visits to their doctor. 12 months after structum therapy the effect persisted in 40% patients. Frequency of exacerbations of the concomitant diseases was less than in patients on continuous NSAID. CONCLUSION: Structum is a highly effective drug against OA as it acts long, reduces frequency of exacerbations, hospitalizations, visits to the doctor, duration of disability, NSAID requirement and improves the course of some concomitant diseases.

Short term therapeutic effects of ozone in the management of pain in knee osteoarthritis: A Meta-analysis

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Ozone therapy has been widely used to decrease pain related to osteoarthritis, but the effectiveness of this treatment has not been evaluated. OBJECTIVE: To evaluate the effectiveness of ozone therapy in the reduction of pain in patients with knee OA, according to the type of intervention and duration of the effect. TYPE: Meta-analysis LITERATURE SURVEY: We performed an online search using PUBMED, DIALNET, SCIELO, MEDIGRAPHIC and ISCO3 databases. We searched for articles published up to January 2018. PARTICIPANTS: We selected eight studies including a total of 355 patients and 363 controls. METHODOLOGY: Only randomized controlled trials that assessed the efficacy of intra-articular or peri-articular infiltrations with ozone to treat knee osteoarthritis in humans were included in the analysis. The results are expressed as standardized mean difference and 95% CI. The meta-analysis was performed in accordance with the statement of Preferment Reporting Items for Systematic Reviews and Meta-Analyses. SYNTHESIS: Therapeutic effects were compared between ozone treatment and placebo (d=-0.81, IC 95% -1.06 to -0.55, I² =34.79 p(Q)=.47) or other non-invasive treatments. No significant effects were found in favor of the ozone treatment when compared with the use of hyaluronic acid or platelet-rich plasma. However, the use of ozone had a significant short-term benefit reducing knee pain (d=-2.26, IC95% -2.26 a -3.72, I² =97, p(Q)<.001). Pain relief benefits lasted between 3-6 months. CONCLUSION: Our results indicate that intra-articular infiltrations of ozone can be used as an optional effective treatment for the management of pain related to knee osteoarthritis. There are short term effect benefits that peak at around one month of treatment, with a gradual decline in efficacy after 3-6 months of treatment. More studies are needed to improve our understanding the efficacy of this interventional treatment. This article is protected by copyright. All rights reserved.

Is restricted femoral navigation sufficient for accuracy of total knee arthroplasty?

Surgical Management of Osteoarthritis of the Knee CPG

A total knee arthroplasty performed with navigation results in more accurate component positioning with fewer outliers. It is not known whether image-based or image-free-systems are preferable and if navigation for only one component leads to equal accuracy in leg alignment than navigation of both components. We evaluated the results of total knee arthroplasties performed with femoral navigation. We studied 90 knees in 88 patients who had conventional total knee arthroplasties, image-based total knee arthroplasties, or total knee arthroplasties with image-free navigation. We compared patients' perioperative times, component alignment accuracy, and short-term outcomes. The total surgical time was longer in the image-based total knee arthroplasty group (109 +/- 7 minutes) compared with the image-free (101 +/- 17 minutes) and conventional total knee arthroplasty groups (87 +/- 20 minutes). The mechanical axis of the leg was within 3 degrees of neutral alignment, although the conventional total knee arthroplasty group showed more (10.6 degrees ) variance than the navigated groups (5.8 degrees and 6.4 degrees , respectively). We found a positive correlation between femoral component malalignment and the total mechanical axis in the conventional group. Our results suggest image-based navigation is not necessary, and image-free femoral navigation may be sufficient for accurate component alignment

An analysis of the feasibility of home rehabilitation among elderly people with proximal femoral fractures

Management of Hip Fractures in the Elderly

OBJECTIVE: To evaluate the feasibility and predictors of success of home-based rehabilitation (HBR) in older adults after hip fracture. DESIGN: Prospective inception cohort study with 12 months of follow-up. SETTING: Acute and subacute care with follow-up in a community setting in Italy. PARTICIPANTS: Community-dwelling older adults (N=199) aged 70 years or older, discharged from an acute orthopedic unit after repair of a nontraumatic proximal femoral fracture. INTERVENTIONS: Patients' choice of pursuing HBR or institutional-based rehabilitation (IBR). MAIN OUTCOME MEASURES: Proportion of subjects discharged home for rehabilitation. Rates of institutionalization assessed at 3, 6, and 12 months postdischarge. Mean changes of the Barthel Index from baseline and proportion of subjects who regained their prefracture levels of function at the time of follow-up in the 2 intervention groups (HBR, IBR). RESULTS: Ninety-nine (49.7%) patients chose HBR, and the rest (50.3%) were discharged to a rehabilitation facility. With regard to the baseline characteristics, the 2 patient groups (HBR, IBR) differed with respect to living arrangement (P< or =.001), prefracture functional status in basic (Barthel Index, P=.033; Katz Index, P=.041) and instrumental activities of daily living (IADLs) (P=.041), and occurrence of delirium (P=.022). During the follow-up, the number of subjects institutionalized at 3, 6, and 12 months was 52, 26, and 22, respectively. In the multiple logistic regression model, the only significant variable affecting the choice of IBR at discharge was the absence of relatives at home (odds ratio [OR], 6.7; 95% confidence interval [CI], 3.33-13.46; P< or =.001), whereas a prefracture functional impairment in more than 3 IADLs (at 12 mo: OR=3.99; 95% CI, 1.57-10.18; P=.004), the absence of relatives at home (at 12 mo: OR=8.81; 95% CI, 2.47-31.46; P=.001), and delay to surgery longer than 3 days (at 12 mo: OR=5.51; 95% CI, 1.28-23.81; P=.022) resulted in significant risk factors for long-term institutionalization. Compared with subjects who received traditional rehabilitation, those discharged home showed--after controlling for prefracture Barthel Index score, IADLs, cognitive status and age--a slightly lower functional decline and a higher rate of recovery during the follow-up (mean change in Barthel Index score +/- standard deviation at 12 mo: HBR, -11.2+/-24.7 vs IBR, -23.7+/-28.5; P=.015). CONCLUSIONS: In an unselected population of hip-fractured older adults previously living in the community, HBR seems to be a feasible alternative to IBR in those subjects living with relatives

Treatment of staphylococcal prosthetic joint infections with debridement, prosthesis retention and oral rifampicin and fusidic acid

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

There is growing evidence of the efficacy of treating early staphylococcal infections of prosthetic joints with surgical debridement and prosthesis retention, combined with oral antibiotic regimens that include rifampicin in combination with a fluoroquinolone. With rising rates of fluoroquinolone-resistant staphylococci, evidence concerning the efficacy of alternative combinations of antibiotics is required. Twenty patients with staphylococcal prosthetic joint infections who had been treated with surgical debridement and prosthesis retention, and a combination of rifampicin and fusidic acid were analysed. The mean duration of symptoms before initial debridement was 16 (range 2-75) days. The median time of follow-up was 32 (range 6-76) months. Treatment failure occurred in two patients. The cumulative risk of treatment failure after 1 year was 11.76% (95% CI 3.08-39.40%). Two patients had their treatment changed because of nausea. Ten of 11 patients with infections involving methicillin-resistant Staphylococcus aureus had successful outcomes. Debridement without prosthesis removal, in combination with rifampicin and fusidic acid treatment, was effective and should be considered for patients with early staphylococcal prosthetic joint infections, including those with infections involving fluoroquinolone-resistant organisms

Metastatic fractures of long bones

MSTS 2022 - Metastatic Disease of the Humerus

Forty-two patients with a total of 52 metastatic fractures of long bones were analysed retrospectively with regard to the type of treatment, complications, general mobility and survival. Endoprosthetic replacement appeared to be better than osteosynthesis in the proximal femur, and this method should also be considered in pathological fractures of the distal femur. Nailing is indicated in fractures of the shafts of long bones in the lower limb, and also in the humerus. Osteosynthesis with a plate has only limited indications. Cement should be added to an osteosynthesis or replacement of a pathological fracture in order to achieve immediate stability. On the whole, the life expectancy of these patients has improved; five in our series lived for more than 6 years after the treatment of their metastases. The method of surgical treatment therefore needs more consideration.

Gait analysis and electromyography in fixed- and mobile-bearing total knee replacement: a prospective, comparative study

Surgical Management of Osteoarthritis of the Knee CPG

PURPOSE: The theoretical superiority of mobile-bearing total knee arthroplasties (TKAs) has not yet been proven in clinical studies. The aim of the current study was to compare and to analyse in a patient population that had received either a fixed or a mobile TKA differences in gait analysis electromyography and clinical scores. METHODS: In a prospective, randomized, patient- and observer-blinded clinical study, 33 patients with primary osteoarthritis of the knee were included. All patients received a Genesis II total knee replacement. Sixteen patients received a mobile and 17 a fixed-bearing cruciate retaining Genesis II TKA. Clinical and quality-of-life scores, electromyography and gait analysis were applied preoperatively and postoperatively with a follow-up of 24 months. RESULTS: In both groups, improvements from pre- to postoperative were detected. whereas the results of gait analysis and electromyography did not show any differences. The results from the clinical and the quality-of-life scores improved from pre- to postoperative, while the Knee Society Score showed a superiority of the mobile-bearing group (mean 159 +/- 28) over the fixed-bearing group (mean 134 +/- 41). CONCLUSION: No functional advantage of mobile over fixed-bearing TKA was detected, although the mobile-bearing group had better clinical results for which a reason could not be found. These results only apply to cruciate retaining mobile-bearing TKA with a bearing which allows both rotation and anteroposterior translation

Analgesic effect of raloxifene on back and knee pain in postmenopausal women with osteoporosis and/or osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

To assess the effect of raloxifene on bone and joint pain, 24 postmenopausal women with back or knee pain or both were randomly divided into two groups, based on the chronological sequence of consultation, to be treated with 60 mg raloxifene and 1 microg alfacalcidol (RA)/day (group RA) or 1 microg alfacalcidol alone (A)/day (group A), respectively, for 6 months. Pain following knee loading (KL) by standing up from a chair and bending the knee by squatting, knee and spine loading (KSL) by walking horizontally and ascending and descending stairs, and spine loading (SL) by lying down supine on a bed and leaving the bed to stand was evaluated by electroalgometry (EAM), based on measurement of the fall of skin impedance, and a visual rating scale (VRS), recording subjective pain on a scale of 0�100 between no pain and unbearable pain. The two groups showed no significant difference as to age, indices of mineral metabolism, back and knee pain, and bone status. RA gave a significantly greater analgesic effect than A by both EAM (P = 0.0158) and VRS (P = 0.0268) on overall comparison of the mean response to all modalities of exercise loading. Paired comparison between pretreatment and posttreatment indicated a significant effect of RA by both EAM (P = 0.0045) and VRS (P = 0.0017), but not that of A. The analgesic effect was more clearly noted on combined knee�spine loading (KSL) and spine loading (SL) than simple knee loading (KL). Monthly comparison of the analgesic effect indicated a significantly better analgesic effect in the fifth month by VRS. RA effect greater than A was more evident by EAM than VRS and during months 3�6 than during 1�2 months, suggesting a slowly progressive effect of RA. Pain evaluation by EAM and VRS mostly gave parallel results, except for a few occasions such as knee loading and spine loading by sitting up and leaving a bed, when EAM detected a positive effect but VRS failed to do so. RA appeared to be more effective on bone and joint pain than A in postmenopausal women according to both EAM and VRS measurements.

Partial lateral patellar facetectomy as an alternative to lateral release in total knee arthroplasty (TKA)

Surgical Management of Osteoarthritis of the Knee CPG

This study presents the selective use of partial patellar lateral facetectomy for maltracking during primary TKA, as an alternative to lateral release. Twenty three partial facetectomies were performed out of 191 TKAs (12%). Balanced tracking was achieved in 22 knees. At follow-up 2 patients had persistent anterior knee pain. Mean Knee Society score (KSS) was 94 and mean functional KSS was 86. Mean patellar score was 28. Patellar tilt angles were within 2 degrees in all but one knee. Patellar translation was within 2 mm in all cases. No complications were recorded. A control group of 46 matched patients had similar functional and radiographic results. If tracking is not satisfactory at the conclusion of TKA, our method of choice would be partial lateral facetectomy

Techniques for direct radiographic visualization during closed pinning of supracondylar humerus fractures in children

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

After reduction of a displaced supracondylar humerus fracture, the distal humerus must be easy to visualize; radiographic techniques in which the forearm overlaps the distal humerus make interpretation of fracture reduction difficult. Eighteen patients with displaced supracondylar humerus fractures were treated with reduction that was maintained manually with a variant of Dunlop's extension traction. This allows direct fluoroscopic evaluation of Baumann's angle, the contour of the distal humerus, the pin insertion site, and the angle of pin insertion. In young patients with a thin distal humerus and swollen elbow, the easiest pin placement may be achieved by inserting the pin on the lateral view (after the anteroposterior view confirms a satisfactory reduction)

PET/CT dose planning for volumetric modulated arc radiation therapy (VMAT) -comparison with conventional approach in advanced prostate cancer patients

MSTS 2018 - Femur Mets and MM

Molecular imaging is the only way of defining biological target volume (BTV) for externalbeam radiation therapy (EBRT) and may be used for advanced targeting in dose planning and dose painting. There are, however, no reports about the EBRT response when dose planning is based on BTV target definition in advanced prostate cancer. Clinical and biochemical results of two clinically equal group of patients with advanced prostate cancer patients were compared. Both groups were treated with volumetric modulated arc therapy (VMAT) based on target definition by PET/CT (1^st group) or conventional imaging (2^nd group). Biochemical relapse occurred in 16.6% (in 1 out of 6) of the patients in the first group and 50% (3 out of 6) patients in the second group during the follow up period. Clinical manifestation of disease occurred in 33% (2 out of 6) patients of the first group and in 5 out of 6 (83,3%) patients in the second one. 4 patients in the first group had no biochemical relapse and no clinical manifestation during the follow up period. The difference in the duration of progression free period was statistically significant between the groups (p<0.010) being in the first group 16.5±5.4 (10-24) months and 4.6±2.9 (2-10) months in the second one. Because patients with PET/CT based VMAT had lower incidence of biochemical relapse, less clinical manifestations and longer, statistically significant duration of progression free period as compared to patients treated with VMAT based on conventional imaging, our preliminary results suggest introducing BTV definition based on PET imaging for VMAT in the EBRT of prostate cancer.

Direct and indirect costs of non-vertebral fracture patients with osteoporosis in the US

HipFx Supplemental Cost Analysis

Osteoporosis is a condition marked by low bone mineral density and the deterioration of bone tissue. One of the main clinical and economic consequences of osteoporosis is skeletal fractures. To assess the healthcare and work loss costs of US patients with non-vertebral (NV) osteoporotic fractures. Privately insured (aged 18-64 years) and Medicare (aged >/=65 years) patients with osteoporosis (ICD-9-CM code: 733.0x) were identified during 1999-2006 using two claims databases. Patients with an NV fracture (femur, pelvis, lower leg, upper arm, forearm, rib or hip) were matched randomly on age, sex, employment status and geographic region to controls with osteoporosis and no fractures. Patient characteristics and annual healthcare costs were assessed over the year following the index fracture for privately insured (n = 4764) and Medicare (n = 48 742) beneficiaries (Medicare drug costs were estimated using multivariable models). Indirect (i.e. work loss) costs were calculated for a subset of privately insured, employed patients with available disability data (n = 1148). All costs were reported in $US, year 2006 values. In Medicare, mean incremental healthcare costs per NV fracture patient were $US13 387 ($US22 466 vs $US9079; p < 0.05). The most expensive patients had index fractures of the hip, multiple sites and femur (incremental costs of $US25 519, $US20 137 and $US19 403, respectively). Patients with NV non-hip (NVNH) fractures had incremental healthcare costs of $US7868 per patient ($US16 704 vs $US8836; p < 0.05). Aggregate annual incremental healthcare costs of NVNH patients in the Medicare research sample (n = 35 933) were $US282.7 million compared with $US204.1 million for hip fracture patients (n = 7997). Among the privately insured, mean incremental healthcare costs per NV fracture patient were $US5961 ($US11 636 vs $US5675; p < 0.05). The most expensive patients had index fractures of the hip, multiple sites and pelvis (incremental costs of $US13 801, $US9642 and $US8164, respectively). Annual incremental healthcare costs per NVNH patient were $US5381 ($US11 090 vs $US5709; p < 0.05). Aggregate annual incremental healthcare costs of NVNH patients in the privately insured sample (n = 4478) were $US24.1 million compared with $US3.5 million for hip fracture patients (n = 255). Mean incremental work loss costs per NV fracture employee were $US1956 ($US4349 vs $US2393; p < 0.05). Among patients with available disability data, work loss accounted for 29.5% of total costs per NV fracture employee. The cost burden of NV fracture patients to payers is substantial. Although hip fracture patients were more costly per patient in both Medicare and privately insured samples, NVNH fracture patients still had substantial incremental costs. Because NVNH patients accounted for a larger proportion of the fracture population, they were associated with greater aggregate incremental healthcare costs than hip fracture patients

Cigarette smoke extracts induced the colon cancer migration via regulating epithelial mesenchymal transition and metastatic genes in human colon cancer cells

MSTS 2018 - Femur Mets and MM

There was considerable evidence that exposure to cigarette smoke is associated with an increased risk for colon cancer. Nevertheless, the mechanism underlying the relationship between cigarette smoking and colon cancer remains unclear. Moreover, there were only a few studies on effects of complexing substance contained in cigarette smoke on colon cancer. Thus, we further investigated whether cigarette smoke extract (CSE) affects the cell cycle, apoptosis and migration of human metastatic colon cancer cells, SW-620. MTT assay revealed that SW-620 cell proliferation was significantly inhibited following treatments with all CSEs, 3R4F, and two-domestic cigarettes, for 9 days in a concentration-dependent manner. Moreover, CSE treatments decreased cyclin D1 and E1, and increased p21 and p27 proteins by Western blot analysis in SW-620 cells. Additionally, the treatment of the cells with CSE contributed to these effects expressing by apoptosis-related proteins. An increased migration or invasion ability of SW-620 cells following CSE treatment was also confirmed by a scratch or fibronectin invasion assay in vitro. In addition, the protein levels of E-cadherin as an epithelial maker were down-regulated, while the mesenchymal markers, N-cadherin, snail, and slug, were up-regulated in a time-dependent manner. A metastatic marker, cathepsin D, was also down-regulated by CSE treatment. Taken together, these results indicate that CSE exposure in colon cancer cells may deregulate the cell growth by altering the expression of cell cycle-related proteins and pro-apoptotic protein, and stimulate cell metastatic ability by altering epithelial-mesenchymal transition (EMT) markers and cathepsin D expression. �� 2016 Wiley Periodicals, Inc. Environ Toxicol 32: 690-704, 2017.

Micromonas (Peptostreptococcus) micros: unusual case of prosthetic joint infection associated with dental procedures

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Micromonas (Peptostreptococcus) micros is frequently associated with periodontal disease as well as respiratory, gastrointestinal and female genitourinary tract infections, but only rarely has been reported as a pathogenic agent of prosthetic joint infections. Here we describe a case of a 63-year-old woman with prosthetic joint infection of total hip arthroplasty caused by the anaerobic species Micromonas micros, associated with tooth extraction. Samples obtained intraoperatively and from the oral cavity were positive for the presence of M. micros by culture and by real-time PCR. This case report indicates that infections of prosthetic joints can be associated with dental procedures and that sensitive molecular techniques are necessary for their routine diagnostic

The association between erosive hand osteoarthritis and subchondral bone attrition of the knee: The Framingham Osteoarthritis study

OAK 3 - Non-arthroplasty tx of OAK

Objective: To examine whether erosive hand osteoarthritis (OA) is associated with knee subchondral bone attrition (SBA) and systemic bone mineral density (BMD). Methods: Associations of MRI-defined knee SBA with radiographic erosive hand OA were evaluated in 1253 Framingham participants using logistic regression with generalised estimating equations. We also examined the association between the number of erosive OA finger joints and SBA adjusted for the number of non-erosive OA finger joints. Associations between erosive hand OA and femoral neck BMD were explored in 2236 participants with linear regression. Analyses were adjusted for age, sex and body mass index. Results: Participants with erosive hand OA had increased odds of knee SBA (OR=1.60, 95% CI 1.07 to 2.38). The relation between the number of erosive OA finger joints and SBA became non-significant when adjusted for the number of non-erosive OA joints as a proxy for the burden of disease. There was a nonsignificant trend towards higher BMD in erosive hand OA compared with participants without hand OA. Conclusions: Erosive hand OA was associated with knee SBA, but the relation might be best explained by a heightened burden of disease. No signi ficant relation of erosive hand OA with BMD was found.

Use of external fixation for juxta-articular fractures in children

Distal Radius Fractures

In this article, the use of external fixation in the management of juxta-articular fractures in paediatric patients is discussed. Basic principles of Ilizarov technique are described for distal radial, distal femoral, distal humeral and distal tibial fractures. Common indications for external fixation in pediatric fractures are comminuted, complicated, and/or open fractures, particularly at the distal humerus, distal radius, distal femur and distal tibia. There are several benefits of external frame fixation in these type of injuries in children. This method avoids additional injury to the growth plate as K-wires are not placed through it. It enables careful reduction without interfragmentary compression and correct anatomic alignment. There is no soft tissue dissection and periosteal blood supply is preserved. External fixation ensures primary fracture stability even in presence of comminution and high adjustment capability. Immediate joint motion and early weight-bearing are further advantages. Joint bridging is an option in severe bone loss or soft tissue injuries.

The tumor microenvironment in prostate cancer: Elucidating molecular pathways for therapy development

MSTS 2018 - Femur Mets and MM

Mechanisms leading to the development of virulent prostate cancer are not confined to the cancer epithelial cell, but also involve the tumor microenvironment. Multiple signaling pathways exist between epithelial cells, stromal cells, and the extracellular matrix to support tumor progression from the primary site to regional lymph nodes and distant metastases. Prostate cancers preferentially metastasize to the skeleton, prompting considerable research effort into understanding the unique interaction between prostate cancer epithelial cells and the bone microenvironment. This effort has led to the discovery that signaling pathways involved in normal prostate and bone development become dysregulated in cancer. These pathways stimulate excessive cell growth and neovascularization, impart more invasive properties to epithelial cells, weaken antitumor immune surveillance, and promote the emergence of castrate-resistant disease. An improved understanding of the complex relationship between cancer epithelial cells and the organ-specific microenvironments with which they interact has created a powerful opportunity to develop novel therapies. © 2012 Tuca et al, publisher and licensee Dove Medical Press Ltd.

Analysis of Interlimb Asymmetry in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

Simultaneous bilateral TKA (SBTKA) has been a favored surgical solution due to reduced costs and patient suffering. The purpose of the present study was to investigate the risk factors of asymmetric recovery in patients who underwent SBTKA and whether that affected quality of life. A total of 187 patients undergoing SBTKA were included. During this study, patients underwent physical examination (knee swelling, active range of motion (ROM) of knee and quadriceps strength) and completed three surveys (VAS pain rating, Short Form-36 and requisite information lists in this study). Our results reveal interlimb asymmetries existed at least two years postoperatively. Between-limb differences in active ROM, quadriceps strength, and VAS pain scores were significantly detected in our study. Risk factors included being female, being older, and having high BMI and high levels of anxiety and depression; different diagnosis and different component size could be risk factors. Finally, interlimb differences in VAS pain scores and active ROM were negatively associated with SF-36 scores. However, interlimb differences in swelling and quadriceps strength were unrelated to SF-36 scores. Risk factors of asymmetric recovery should be evaluated and appreciated due to their significant impact on patients' quality of life. Before performing SBTKA, clinicians should consider possible risk factors and inform patients of asymmetric recovery between limbs, which could help decrease the unnecessary consultations and postoperative patient dissatisfaction.

How to treat multiple myeloma - A representative multicentre treatment survey

MSTS 2018 - Femur Mets and MM

Background: The present survey was undertaken to gain insights in the changes of disease management of multiple myeloma (MM) over time and the implementation of new guidelines into daily practice. Patients and Methods: Diagnosis and treatment of MM were evaluated based on a 3-month representative multicentre survey including 386 patients from 35 centres in Germany in 2008. The results were compared to similar surveys in 2004 and 2006. Results: At the time of first diagnosis, most patients (62.5%) were already in stage III (Durie-Salmon). The presence of deletion 13q was determined in 22% of patients only. However, determination of other prognostic factors has become increasingly well established. These include the levels of β2-microglobulin and serum albumin, each of which was determined in more than 2/3 of patients. Overall, 35% of patients were considered for high-dose chemotherapy. As a consequence of the development of innovative substances, there are remarkable shifts in first line, second line, and third line therapy with an increase in the use of bortezomib at all levels of therapy. Conclusions: Regarding diagnostic measures, deviations from recommended guidelines became evident. Also, high-dose chemotherapy with stem cell support was considered in a minority of patients only. Novel substances, however, were rapidly integrated into the treatment of MM. Copyright © 2010 S. Karger AG, Basel.

Epidemiology of fracture of the upper end of the humerus

Management of Hip Fractures in the Elderly

The age and sex specific indicence was calculated in 729 cases of fracture of the upper end of the humerus. The prevalence of other fractures and conditions in these patients was investigated. The age and sex specific incidence is as that of femoral neck fracture with a rapid increase with age, twice as fast in women as in men. Only fractures which include evulsion of the greater tuberosity deviate somewhat from that pattern. The more displaced fractures have a tendency to occur later in life. The prevalence of other fractures is about doubled in patients with fracture of the proximal end of the humerus as compared to age and sex matched controls. This is true for fracture of the distal end of the forearm and fracture of the upper end of the femur but also for other fractures. The prevalence of severe alcoholism was significantly greater than in controls. A history of gastric resection was in these patients about three times as frequent as in a control sample. We conclude that fracture of the upper end of the humerus must be assigned a prominent place in the category of bone fragility fractures

Oral hyaluronan relieves knee pain: a review

OAK 3 - Non-arthroplasty tx of OAK

Hyaluronan (HA) is a component that is particularly abundant in the synovial fluid. Randomized, double-blinded, placebo-controlled trials carried out between 2008 and 2015 have proven the effectiveness of HA for the treatment of symptoms associated with synovitis, and particularly, knee pain, relief of synovial effusion or inflammation, and improvement of muscular knee strength. The mechanism by which HA exerts its effects in the living body, specifically receptor binding in the intestinal epithelia, has gradually been clarified. This review examines the effects of HA upon knee pain as assessed in clinical trials, as well as the mechanism of these effects and the safety of HA.

Measurement of intracompartmental pressure with use of a new electronic transducer-tipped catheter system

DOD - Acute Comp Syndrome CPG

Laboratory and clinical tests were carried out to determine the clinical usefulness, validity, and safety of a new self-calibrating, battery-powered monitoring system for the measurement of intramuscular pressure with use of an electronic transducer-tipped catheter. The eight probes accurately recorded applied pressures ranging from zero to 160 millimeters of mercury (zero to 21.33 kilopascals). The system registered little temperature-induced drift (maximum, 1.25 millimeters of mercury [0.17 kilopascal]) between dry room temperature and 40 degrees Celsius. There were also minimum variations (range, -0.14 to 0.81 millimeter of mercury [0.02 to 0.11 kilopascal]) in the pressures recorded during a twenty-four-hour period. The resting pressure in the tibialis anterior muscle of twenty volunteers who had normal limbs was a mean (and standard deviation) of 13.1+/-8.3 millimeters of mercury (1.75+/-1.11 kilopascals). There was a good correlation between externally applied pressures (zero, twenty, forty, sixty, eighty, and 100 millimeters of mercury [zero, 2.67, 5.33, 8.00, 10.66, and 13.33 kilopascals] applied with use of antishock trousers) and the pressures measured in the tibialis anterior muscle of four volunteers (r = 0.997 to 0.999). The injection of sterile saline solution into the tibialis anterior muscle of a volunteer and the use of high-frequency recording during muscular activity showed a high degree of responsiveness and sensitivity to changes in intramuscular pressure. We also prospectively evaluated the clinical usefulness of the system and found it to be easy to assemble, calibrate, and use. Thus, this reusable, electronic transducer-tipped catheter system, which is based on a noninfusion technique, is simple, minimally traumatic, and highly precise. It is free of hydrostatic pressure artifacts and provides dynamic responses to changes in intramuscular pressure.

Tram system related cycling injuries

Pediatric Supracondylar Humerus Fracture 2020 Review

Introduction: Understanding of tram-system related cycling injuries (TSRCI) is poor. The aim of this study was to report the spectrum of injuries, demographics and social deprivation status of patients. Secondary aims included assessment of accident circumstances, effects of TSRCI on patientsâ?? confidence cycling, together with time off work and cycling. Methods: A retrospective review of patients presenting to emergency services across all hospitals in Edinburgh and West Lothian with tram related injuries between May 2009 and April 2016 was undertaken. Medical records and imagining were analysed and patients were contacted by telephone. Results: 191 cyclists (119 males, 72 females) were identified. 63 patients sustained one or more fractures or dislocations. Upper limb fractures/dislocations occurred in 55, lower limb fractures in 8 and facial fractures in 2. Most patients demonstrated low levels of socioeconomic deprivation. In 142 cases, the wheel was caught in tram-tracks, while in 32 it slid on tracks. The latter occurred more commonly in wet conditions (p = 0.028). 151 patients answered detailed questionnaires. Ninety-eight were commuting. 112 patients intended to cross tramlines and 65 accidents occurred at a junction. Eighty patients reported traffic pressures contributed to their accident. 120 stated that their confidence was affected and 24 did not resume cycling. Female gender (p < 0.001) and presence of a fracture/dislocation (p = 0.012) were independent predictors of negative effects on confidence. Patients sustaining a fracture/dislocation spent more time off work (median 5 days vs 1, p < 0.001) and cycling (median 57 days vs 21, p < 0.001). Conclusions: TSRCI occur predominantly in young to middle-aged adults with low levels of socioeconomic deprivation, most commonly when bicycle wheels get caught in tram-tracks. They result in various injuries, frequently affecting the upper limb. Traffic pressures are commonly implicated. Most patients report negative effects on confidence and a sizeable minority do not resume cycling. TSRCI can result in significant loss of working and cycling days.

Elbow fractures: distal humerus

Distal Radius Fractures

A distal humerus fracture can be a debilitating and difficult injury to treat. The anatomy of the distal humerus is highly complex, as it articulates with both the radius and ulna and allows for motion in multiple planes. Furthermore, comminution and osteopenia may render the metaphyseal-diaphyseal junction weak, making adequate stabilization difficult. Various methods of surgical fixation have been described, with bicolumnar plating being the most popular. Controversy over fixation techniques and the introduction of recently developed implants, including precontoured plates and locking plates, have led to renewed focus on biomechanical testing of various fixation constructs. Failure of adequate reconstruction or fixation can be addressed with adjunctive measures such as incorporation of structural bone grafts, external fixation, or, in certain instances, salvage with total elbow arthroplasty. The articular surface can also be injured from a shear force, resulting in fractures of the capitellum and trochlea in the coronal plane. This article presents a review of current literature concerning the diagnosis, classification, treatment, and outcome of distal humerus fractures.

Knee prosthesis in rheumatoid patients

Surgical Management of Osteoarthritis of the Knee CPG

Total knee arthroplasty is a reliable means to improve the quality of life not only in osteoarthritis, but also in rheumatoid patients. Specific aspects, like the low mechanical quality of bone tissue, the contemporary damage of several joints and the higher risk of complications, have to be taken into account in rheumatoid arthritis. The experience with 24 prostheses in 21 rheumatoid patients is reported and confirms the efficacy of this operation. Among the technical details discussed, stress is placed on the conservation of the posterior cruciate ligament, the use of cement, the procedure of patelloplasty instead of prosthetic replacement. Careful preoperative planning is required and resections, especially in the tibia, should be economical. The evaluation of the results according to the protocol of the America Knee Society shows a satisfactory increase both of the articular score (average from 36 to 88) and the functional score (average from 34 to 68)

Cleft maxillary distraction versus orthognathic surgery: Clinical morbidities and surgical relapse

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

BACKGROUND: This is the first randomized controlled study aiming to compare the postoperative clinical morbidities in cleft lip and palate patients treated with distraction osteogenesis versus conventional orthognathic surgery. METHODS: Twenty-nine cleft lip and palate patients with moderate maxillary hypoplasia requiring a maxillary Le Fort I advancement of 4 to 10 mm were randomized into two groups for either internal maxillary distractors or immediate fragment transposition using miniplates and screw fixation. Clinical morbidities were recorded using standardized questionnaires. Skeletal and dental relapses were assessed using lateral cephalometric landmarks. RESULTS: In the distraction group, two of 15 patients developed infection around the distractors and one patient had an occlusal relapse. Among the 14 patients who received conventional orthognathic surgery, the complications included intraoperative hemorrhage (n = 1), plate exposure leading to sinusitis (n = 1), and occlusal relapse (n = 1). In the skeletal relapses of the osteotomy group, a statistically significant vertical relapse of the A point was noted during the second to twelfth weeks when compared with the distraction group. A statistically significant horizontal relapse of the A and P points during the eighth to twelfth weeks was noted when the osteotomy group was compared with the distraction group. CONCLUSIONS: There were no major differences in the clinical morbidities between the osteotomy and distraction groups. Distraction provided better skeletal stability, whereas there was a significant amount of skeletal relapse in the first 12 weeks after conventional cleft maxillary osteotomy. Copyright (copyright)2006 by the American Society of Plastic Surgeons

Soft tissue reconstruction for calcaneal fractures or osteomyelitis

DoD SSI (Surgical Site Infections)

A systematic approach of the surgical management of a calcaneal fracture can minimize the potential of soft tissue complications. When reducing a closed calcaneal fracture, the incision used affects the postoperative complications. The L-shaped incision with the horizontal limb lying on the lateral glabrous junction ensures maximum blood flow to either side of the incision. Whether or not the wound can be closed primarily depends on the preexisting edema, the lost calcaneal height, and the delay between the fracture and reduction (Fig. 20). The wrinkle test is a good indicator that the incision can be closed primarily if the amount of height restored is minimal. If the edema is too great, steps should be taken to reduce it sufficiently to allow successful wound closure. If the wound, after reduction, is too wide to allow primary closure, an ADM flap laterally or an AHM flap medially should be used. For larger defects, a free flap should be considered. The three important steps to reconstruction of soft tissue defects around the calcaneus include good blood supply, a infection-free wound, and the simplest soft tissue reconstructive option that covers the wound successfully. Adequate blood supply can be determined by the use of Doppler. If the supply is inadequate, revascularization is necessary before proceeding. Achieving a clean wound requires aggressive debridement, intravenous antibiotics, and good wound care. Adjuncts that can help in achieving a clean wound include topical antibiotics (silver sulfadiazine), the VAC, and hyperbaric oxygen. Osteomyelitis has to be treated aggressively. Any suspicious bone has to be removed. Only clean, healthy, bleeding bone is left behind. Antibiotic beads can be useful when there is doubt as to whether the cancellous bone is infection-free. The beads are not a substitute for good debridement, however. Soft tissue reconstruction ranges from delayed primary closure to the use of microsurgical free flaps (Fig. 21). When bone or hardware is exposed, a muscle flap should cover the wound because of the extra blood supply it carries with it. The soft tissue option depends on the width of the wound. For wounds 1 cm wide or less, the options include allowing the wound to close by secondary intention (VAC), delayed primary closure, or a local muscle flap. For wounds 2 cm wide or less, allowing the wound to close by secondary intention (VAC) and a local muscle flap are the best options. For wider wounds, one has to assess whether the local muscle flap has sufficient bulk to close the defect. If it does, it is the simplest solution. If the local muscle is inadequate, a microsurgical free flap has to be used. The VAC sometimes can convert a large wound to a smaller wound so that a local muscle flap can be used. This procedure takes time, however, and adds to the cost of the repair.

Secondary wound healing. effective treatment concept after basal cell carcinoma resection in the central midface

Reconstruction After Skin Cancer

Plastic reconstruction of facial skin defects after tumor surgery is a commonly accepted principle. However, healing by secondary intention is discussed controversially. Here we describe a series of 22 patients after full thickness resection of basal cell carcinoma who underwent wound healing by secondary intention. A semipermeable membrane was used for wound dressing, which was changed on a weekly basis. No antibiotics or pain killers were necessary. Defects up to 2 cm, particularly those of concave subunits of the midface, entirely closed within 4-6 weeks, and secondary wound healing led to excellent functional and aesthetic results. Thus, secondary wound healing is a safe, effective and economic alternative to surgical reconstruction in selected facial areas. © Springer-Verlag 2012.

New concepts about liposuction of the legs

Panniculectomy & Abdominoplasty CPG

In this paper the author shows his experience in the treatment of lipodystrophies of the knees and ankles, on the last ten years. He analizes lipodystrophic deformities of the legs, as well as the proper liposuction technique used by him on the mentioned areas. Other authors ideas that were innovations on this subject are discussed here About 300 patients have been treated with this technique, and the more important details are discussed. The author considers that a lipodystrophic leg must be treated by undermining the knee and creating four facets in the ankle.

Advanced oral antibacterial/anti-inflammatory technology: A comprehensive review of the clinical benefits of a triclosan/copolymer/fluoride dentifrice

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

INTRODUCTION: Triclosan is a broad-spectrum antibacterial agent, marketed for use in oral products. It is effective against both gram-positive and gram-negative bacteria. PVM/MA is the non-proprietary designation for a polyvinylmethyl ether maleic acid copolymer. It has been demonstrated that there is a greater uptake of triclosan to enamel and buccal epithelial cells from the use of a fluoride dentifrice containing triclosan and the PVM/MA copolymer than from a dentifrice containing triclosan alone. This Supplement details the results of antibacterial, anti-inflammatory, and short- and long-term plaque and gingivitis studies with a triclosan/copolymer/ fluoride dentifrice. Additionally, the Supplement reviews studies on the effect of a triclosan/copolymer/fluoride dentifrice on periodontitis, calculus, caries, whitening and stain removal, oral malodor, and on the microflora. CONCLUSION: Clinical studies indicate that the use of a triclosan/copolymer/fluoride dentifrice (Colgate Total Toothpaste) may provide oral health benefits beyond those associated with "traditional" toothpaste use, in a manner that is safe and effective. Studies presented in this Supplement demonstrate that Colgate Total Toothpaste provides superior protection against plaque and gingivitis, caries, oral malodor, exhibits superior stain removal, and provides protection against the progression of periodontal disease

An update on the management of high-energy pilon fractures

DoD SSI (Surgical Site Infections)

High energy pilon fractures present a unique challenge to the patient and orthopaedic surgeon. Care for the soft tissue envelope is as important as management of this articular fracture. This article reviews the fundamental principles for treatment of the patient with severe pilon fracture. Staged operative care is emphasised to prevent wound and infectious complications which have historically plagued pilon fracture surgery. New innovations directed at improving results are discussed including biological planting and wound care using the vacuum assisted closure device. Lastly, validated outcomes are presented which highlight the severity of these injuries despite optimal care. [References: 57]

The Risk-Stratified Osteoporosis Strategy Evaluation study (ROSE): A Randomized Prospective Population-Based Study. Design and Baseline Characteristics

HipFx Supplemental Cost Analysis

The risk-stratified osteoporosis strategy evaluation study (ROSE) is a randomized prospective population-based study investigating the effectiveness of a two-step screening program for osteoporosis in women. This paper reports the study design and baseline characteristics of the study population. 35,000 women aged 65null80 years were selected at random from the population in the Region of Southern Denmark andnullbefore inclusionnullrandomized to either a screening group or a control group. As first step, a self-administered questionnaire regarding risk factors for osteoporosis based on FRAX^{(registered trademark)} was issued to both groups. As second step, subjects in the screening group with a 10-year probability of major osteoporotic fractures (greater-than or equal to)15 % were offered a DXA scan. Patients diagnosed with osteoporosis from the DXA scan were advised to see their GP and discuss pharmaceutical treatment according to Danish National guidelines. The primary outcome is incident clinical fractures as evaluated through annual follow-up using the Danish National Patient Registry. The secondary outcomes are cost-effectiveness, participation rate, and patient preferences. 20,904 (60 %) women participated and included in the baseline analyses (10,411 in screening and 10,949 in control group). The mean age was 71 years. As expected by randomization, the screening and control groups had similar baseline characteristics. Screening for osteoporosis is at present not evidence based according to the WHO screening criteria. The ROSE study is expected to provide knowledge of the effectiveness of a screening strategy that may be implemented in health care systems to prevent fractures

Complications of suction-assisted lipoplasty

Panniculectomy & Abdominoplasty CPG

The potentially fatal, surgical, and aesthetic complications of suction-assisted lipoplasty are discussed in this article. Prevention through early detection and risk management will be emphasized.

Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A prospective, randomized study

DoD SSI (Surgical Site Infections)

BACKGROUND: Irrigation of open fracture wounds is a commonly performed procedure, and irrigation additives have been used in an attempt to reduce the risk of infection. In vitro and animal studies have suggested that irrigation with detergent solution is more effective than irrigation with a solution containing antibiotic additives. This study was performed to compare the efficacy of those two solutions in the treatment of open fractures in humans. METHODS: Adult patients with an open fracture of the lower extremity were prospectively randomized to receive irrigation with either a bacitracin solution or a nonsterile castile soap solution. The patients were followed clinically to assess for the development of infection, healing of the soft-tissue wound, and union of the fracture. RESULTS: Between 1995 and 2002, 400 patients with a total of 458 open fractures of the lower extremity were entered into the study. One hundred and ninety-two patients were assigned to the bacitracin group (B), and 208 were assigned to the castile soap group (C). Outcomes were available for 171 patients with a total of 199 fractures in group B and 180 patients with a total of 199 fractures in group C. The mean duration of follow-up was 500 days. There was no difference between groups B and C in terms of gender, the Gustilo-Anderson grade of the open fracture, the time between the injury and the irrigation, smoking, or alcohol use. There were significant differences in the mean age (thirty-eight compared with forty-two years, p = 0.01), duration of follow-up (560 compared with 444 days, p = 0.01), prevalence of hypotension (23% compared with 14%, p = 0.04), and duration of treatment with intravenous antibiotics (eleven compared with nine days, p = 0.02). An infection developed at thirty-five (18%) of the 199 fracture sites in group B and at twenty-six (13%) of the 199 fracture sites in group C. This difference was not significant (p = 0.2). Bone-healing was delayed for forty-nine (25%) of the 199 group-B fractures and forty-six (23%) of the 199 group-C fractures (p = 0.72). Wound-healing problems occurred in association with nineteen group-B fractures (9.5%) and eight group-C fractures (4%). This difference was significant (p = 0.03). CONCLUSIONS: Irrigation of open fracture wounds with antibiotic solution offers no advantages over the use of a nonsterile soap solution, and it may increase the risk of wound-healing problems.

Protein and energy supplementation in elderly people at risk from malnutrition

Management of Hip Fractures in the Elderly

BACKGROUND: Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. OBJECTIVES: This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'. SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. MAIN RESULTS: Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea. AUTHORS' CONCLUSIONS: Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required. PROTEIN AND ENERGY SUPPLEMENTATION IN ELDERLY PEOPLE AT RISK FROM MALNUTRITION: Much emphasis is placed on the importance of good diet, usually in relation to concern about the health risks of obesity. However it has been generally agreed that the risk of undernutrition rather than overnutrition is the main cause for concern in elderly people, particularly those who are hospitalised or institutionalised. Malnutrition has been shown to have important effects on recovery in a broad range of patients and conditions. It has been associated strongly with impaired immune response, impaired muscle and respiratory function, delayed wound healing, overall increased complications, longer rehabilitation, greater length of hospital stay and increased mortality. Oral protein and energy supplements are potentially safer and easier to administer than nasogastric enteral feeds and are therefore particularly suited to elderly people and are also widely used. However, there may be problems with the willingness and ability of older people to consume oral supplements, and supplements may not be used effectively. Even if supplements are prescribed, they may not always be given, or are given but not consumed. In addition to taste, the composition and timing of administration in relation to meals may be important. Efforts also need to be made to provide normal meals and snacks which meet the needs of elderly people and to provide assistance with feeding if required.A total of 10,187 randomised participants from the 62 trials has been included. Maximum duration of intervention was 18 months. The reviewers suggest that supplementation appears to produce a small but consistent weight gain. There was no evidence in this updated review of a beneficial effect on mortality overall, but there may be a beneficial effect on mortality in people who are undernourished. Supplementation may also reduce the number of complications. The reported acceptance of supplements was variable between trials. Some adverse effects such as nausea or diarrhoea were reported. However, there were problems of study design and quality. More studies are required to confirm the beneficial effect on the number of complications, to establish whether there is a beneficial effect on mortality for undernourished elderly people and to provide evidence about whether protein and energy supplements can improve morbidity and functional status in frail older people

Expression of adiponectin in the subchondral bone of lumbar facet joints with different degrees of degeneration

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Osteoarthritis research has been most commonly performed in the setting of the articular cartilage of the knee. To the best of our knowledge, no studies have evaluated the role of adiponectin in osteoarthritis of the lumbar facet joint (FJOA). Therefore, in this study, we explored whether adiponectin was expressed in the lumbar facet joints and evaluated the role of adiponectin in FJOA. METHODS: We enrolled patients who underwent lumbar computed tomography (CT) and magnetic resonance imaging (MRI) at the Orthopedic Department of the First Affiliated Hospital of Nanchang from May 2015 to June 2016. Lumbar facet joints were obtained from 135 patients at the time of lumbar fusion surgery and divided into three groups according to the Weishaupt grade. Cytokine levels in the subchondral bones were evaluated by enzyme-linked immunosorbent assays (ELISAs), and adiponectin levels were determined by immunohistochemistry, western blotting, and quantitative polymerase chain reaction (qPCR). RESULTS: By ELISA, adiponectin levels were examined in the subchondral bone for lumbar facet joint, and adiponectin was found to be negatively correlated with BMI in 52 patients (p < 0.001, r = -0.861). By immunohistochemistry analysis, adiponectin was found to be expressed in the subchondral bone of the lumbar facet, whereas the cartilage area was negative for adiponectin expression. Immunostaining intensity and area was related to the degeneration of the lumbar facet joint, and, in our research, considerably decreased staining intensity and area were observed in more severely degenerated lumbar facet joints. Furthermore, the expression of adiponectin was also reduced in degenerated lumbar facet joints, and the level of decline corresponded to degeneration detected by western blotting and qPCR analysis (n = 27, p < 0.0001). CONCLUSIONS: Adiponectin expression was observed in the subchondral bone of the lumbar facet joint and decreased as the degree of degeneration increased. Thus, the results of this study provide new insights into the relationship between adiponectin and osteoarthritis.

ORIF of delayed unions and nonunions of distal humeral fractures. Surgical technique

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

BACKGROUND: The purpose of the present retrospective study was to evaluate the results of open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus. METHODS: Between 1976 and 2001, fifty-two patients with a delayed union (thirteen patients) or nonunion (thirty-nine patients) of the distal part of the humerus were treated with open reduction and internal fixation along with selective elbow joint arthrolysis and bone-grafting. The average time to presentation was eighteen months (range, two to 192 months) after the injury. Thirty-nine of the fifty-two patients had undergone an average of 1.6 previous operations. There were twenty-seven supracondylar, six transcondylar, thirteen intercondylar, two lateral condylar, and four medial condylar delayed unions or nonunions. The average duration of follow-up was thirty-three months (range, three to 198 months). RESULTS: Fifty-one of the fifty-two patients had healing of the delayed union or nonunion after the index operation; the average time to union was six months (range, two to twenty-four months). The average range of elbow motion increased from 71 degrees preoperatively to 94 degrees postoperatively. Complications included two superficial infections, two deep infections, and five cases of ulnar neuropathy. Fifteen patients (29%) needed additional surgery after the index procedure. Specifically, seven patients underwent removal of prominent hardware; six underwent hardware removal along with excision of heterotopic bone, ulnar neurolysis, and/or manipulation under anesthesia; one underwent irrigation and debridement; and one underwent compartment release. CONCLUSIONS: Open reduction through an extensile exposure and rigid internal fixation consistently results in healing of a delayed union or nonunion of the distal part of the humerus. An improved range of motion of the elbow can be achieved by securing the site of the nonunion and performing aggressive elbow joint arthrolysis and soft-tissue releases in patients with severe contractures