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Perceptual completion across the vertical meridian and the role of early visual cortex

Upper Eyelid and Brow Surgery

Perceptual completion can link widely separated contour fragments and interpolate illusory contours (ICs) between them. The mechanisms underlying such long-range linking are not well understood. Here we report that completion is much poorer when ICs cross the vertical meridian than when they reside entirely within the left or right visual hemifield. This deficit reflects limitations in cross-hemispheric integration. We also show that the sensitivity to the interhemispheric divide is unique to perceptual completion: a comparable task which did not require completion showed no across-meridian impairment. We propose that these findings support the existence of specialized completion mechanisms in early visual cortical areas (V1/V2), since those areas are likely to be more sensitive to the interhemispheric divide.

Classification and management of carpal dislocations

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

A classification and plan of management for carpal dislocations are presented, based upon the following basic premises: perilunate and lunate dislocations are different stages of the same injury and are therefore managed identically; displacement may be either dorsal or volar; anatomic restoration of the 3 key elements (scaphoid, lunate, and capitate) is essential. Following initial closed reduction, rotary subluxation of the scaphoid and intercalary segment instability must be specifically looked for and corrected in the patient with perilunate or lunate dislocation without fracture of the scaphoid. In transscaphoid perilunate dislocation, anatomic reduction of the scaphoid fracture and maintenance of that reduction is necessary to prevent nonunion of the fracture and/or late dorsiflexion instability of the carpus. As with all ligamentous injuries, early diagnosis and treatment are essential. Failure to obtain or maintain anatomic position by closed methods is an indication for open reduction and internal fixation. Combined dorsal and volar approaches are recommended for perilunate and lunate dislocations. In some cases of transscaphoid perilunate dislocations, a limited Russe approach to stabilize the scaphoid fracture may be sufficient. Frequent concomitant injuries include median nerve damage, osteochondral fractures of the carpal bones, and fracture of the radial styloid. Isolated rotary subluxation of the scaphoid without perilunate dislocation is a more subtle injury which may require special radiographic views, and also demands early diagnosis and treatment

Primary total knee arthroplasty infected with Serratia marcescens

Surgical Management of Osteoarthritis of the Knee CPG

We report an unusual case of a Serratia marcescens infection of total knee arthroplasty 4 weeks after the procedure following aspiration carried out on the ward (contrary to local protocol). This was successfully treated with thorough wound debridement, irrigation, change of the polyethylene liner and systemic antibiotics using intravenous meropenem for 3 weeks followed by oral ciprofloxacin for another 3 weeks. Our patient made an uneventful recovery and there was no reported recurrence of infection at 8 months of follow-up. We are unsure as to whether the infection was introduced at the time of the joint aspiration or was a complication of the initial procedure despite all the standard aseptic measures taken at the time of surgery

Deformation of articular cartilage during static loading of a knee joint - Experimental and finite element analysis

AMP (Acute Meniscal Pathology)

Novel conical beam CT-scanners offer high resolution imaging of knee structures with i.a. contrast media, even under weight bearing. With this new technology, we aimed to determine cartilage strains and meniscal movement in a human knee at 0, 1, 5, and 30. min of standing and compare them to the subject-specific 3D finite element (FE) model. The FE model of the volunteer's knee, based on the geometry obtained from magnetic resonance images, was created to simulate the creep. The effects of collagen fibril network stiffness, nonfibrillar matrix modulus, permeability and fluid flow boundary conditions on the creep response in cartilage were investigated. In the experiment, 80% of the maximum strain in cartilage developed immediately, after which the cartilage continued to deform slowly until the 30. min time point. Cartilage strains and meniscus movement obtained from the FE model matched adequately with the experimentally measured values. Reducing the fibril network stiffness increased the mean strains substantially, while the creep rate was primarily influenced by an increase in the nonfibrillar matrix modulus. Changing the initial permeability and preventing fluid flow through noncontacting surfaces had a negligible effect on cartilage strains. The present results improve understanding of the mechanisms controlling articular cartilage strains and meniscal movements in a knee joint under physiological static loading. Ultimately a validated model could be used as a noninvasive diagnostic tool to locate cartilage areas at risk for degeneration. © 2014 Elsevier Ltd.

Infusion of ibandronate once every 3 months effectively decreases bone resorption markers and increases bone mineral density in Chinese postmenopausal osteoporotic women: A 1-year study

Management of Hip Fractures in the Elderly

The efficacy and safety of intravenous ibandronate were evaluated in postmenopausal osteoporosis women in China. In this multicenter, positive drug-controlled study, 158 postmenopausal osteoporotic women were randomized to receive 2 mg ibandronate given intravenously once every 3 months or 70 mg alendronate given orally once per week. All women also received supplemental calcium (500 mg) and vitamin D (200 IU) daily. One hundred fifty-one patients completed the 1-year study. Ibandronate produced mean increases in bone mineral density (BMD) by 4.27% at the lumbar spine, 3.48% at the femoral neck, and 2.03% at the trochanter. Mean increases in BMD by 4.24% at the lumbar spine, 2.72% at the femoral neck, and 2.99% at the trochanter were observed in the alendronate group. No significant difference was found between the two groups in BMD in all sites measured. Significant decreases in serum c-telopeptide of type I collagen (CTX) and alkaline phosphatase (ALP) were found in the two groups after 1 and 3 months of treatment, respectively; these serum CTX and ALP levels were then maintained at the decreased levels throughout the study period (12 months). No changes of stature were found in the patients of the two groups. Adverse events were similar in the two groups, except more mild muscle pain was observed in the first month after infusion of ibandronate than with oral alendronate (P<0.001). The results observed in Chinese patients may support the observation that intravenous ibandronate significantly reduced bone resorption and increased BMD with good tolerance in Chinese postmenopausal osteoporotic women. Use of intravenous ibandronate possibly could potentially improve compliance as compared with other oral bisphosphonates because it may avoid the peptic side effects of oral bisphosphonate. (copyright) The Japanese Society for Bone and Mineral Research and Springer 2009

Patient-Controlled Drug Delivery for Acute Postoperative Pain Management: A Review of Current and Emerging Technologies

AAHKS (4) Acetaminophen

Postoperative pain management has dramatically improved with the advent of patient-controlled analgesia (PCA) delivery. The optimal PCA system would encompass several key characteristics, including consistent efficacy across a number of surgeries; safety of both the analgesic drug delivered and the delivery system; ease of setup, maintenance, and administration; patient comfort during analgesic delivery; avoidance of analgesic gaps; minimal invasiveness; and it would be associated with high patient satisfaction. Existing PCA modalities (using intravenous or epidural routes) encompass some of these characteristics (e.g., they have demonstrated efficacy across a number of surgeries); however, they are limited by the need for an indwelling catheter and the time and resources required for system setup and use. Device programming-related medication errors by hospital staff are an unfortunate risk, and could lead to significant harm. New PCA technologies are on the horizon that address some of the limitations to existing modalities; however, the added complexity of these newer systems are a concern, and their benefits and drawbacks remain to be assessed. These technologies include "smart" intravenous PCA infusion pumps to improve the safety of analgesic administration; needle-free options, such as the fentanyl HCl iontophoretic transdermal system for transdermal delivery; and a number of PCA devices for intranasal delivery, as well as several new options for patient-controlled regional analgesia. This review will discuss the benefits and drawbacks of both existing and emerging PCA modalities in the context of the ideal PCA system, and provide a critical evaluation of their use in postoperative settings. © 2008 American Society of Regional Anesthesia and Pain Medicine.

Unipolar hemiarthroplasty versus bipolar hemiarthroplasty in the most elderly patients with displaced femoral neck fractures: a randomised, controlled trial

Management of Hip Fractures in the Elderly

PURPOSE: Hemiarthroplasty (HA) is generally considered to be the treatment of choice in the most elderly patients with a displaced fracture of the femoral neck. However, there is inadequate evidence to support the choice between unipolar HA or bipolar HA. The primary aim of this study was to analyse the outcome regarding hip function and health-related quality of life (HRQoL) in patients randomised to either a unipolar or bipolar HA. The secondary aim was to analyse the degree of acetabular erosion and its influence upon outcome. METHODS: One hundred twenty patients with a mean age of 86 years and an acute displaced fracture of the femoral neck were randomly allocated to treatment by either unipolar or bipolar HA. Outcome measurements included hip function (Harris Hip Score, HHS), HRQoL (EQ-5D) and acetabular erosion. The patients were summoned at four and 12 months for follow-up. RESULTS: There were no significant differences between the groups regarding complications. The HHS scores were equal at both follow-ups, but there was a trend towards better HRQoL in the bipolar HA group at four months, EQ-5D (index) score 0.62 vs 0.54 (p = 0.06). Twenty percent of the patients in the unipolar HA group displayed acetabular erosion at the 12-month follow-up compared to 5% in the bipolar HA group (p = 0.03), and there were trends towards worse hip function and HRQoL among patients with acetabular erosion compared to those without: HHS scores 70.4 and 79.3, respectively (p = 0.09), and EQ-5D (index) scores 0.48 and 0.63, respectively (p = 0.13). CONCLUSION: Unipolar HA and bipolar HA appeared to produce equivalent clinical outcomes after one year, but the significantly higher incidence of acetabular erosion in the unipolar HA group may imply that bipolar HA should be the preferred treatment

Platelet-rich plasma injections for knee osteoarthritis: Systematic review of duration of clinical benefit

PRP (Platelet-Rich Plasma)

Both researchers and clinicians have exhibited growing interest in the use of platelet-rich plasma (PRP) and other autologous products for a variety of clinical conditions. Newly published data suggest that PRP injections can be an effective complement to conventional management strategies for knee osteoarthritis (OA) and chondropathy. Using a systematic review approach, we sought to synthesize the published data on the duration of clinical effect of PRP on knee OA and chondropathy. We systematically searched PubMed for all reports published in any language between the earliest available date and July (fourth week) of 2015 using the following key words: platelet, rich, plasma, knee, and osteoarthritis. If double-blind randomized, controlled trials were not available, we included other clinical trials and observational studies. We further searched for the association of the same keywords (platelet, rich, plasma, knee) and chondropathy. After reviewing abstracts, we acquired full-text papers where appropriate. We categorized the level of evidence for the duration of treatment efficacy according to Guyatt and coauthors. Twenty-four relevant studies encompassing 2,385 patients were included in the review. Studies reported clinical outcomes from intra-articular injection of PRP or recounted autologous products. The results showed a consistent improvement in patient pain scores and functional indexes for 6 months after initiation of injections. The residual clinical effect was typically observed beyond 6 months of follow-up in most of the studies. Pain and functional scores decreased after 12 months of follow-up but remained higher than the base scores in the majority of studies. Some suggested that annual injections improved treatment outcomes after 18 months of follow-up. Data from available clinical reports suggest that the PRP administration results in decreased pain and enhanced functional status. The duration of beneficial clinical effects after administration of PRP or recounted autologous products for patients with knee OA and chondropathy was stable up to 6 months following completion of regenerative therapy. The pain and functional scores worsened after 12 months of follow-up but were still better than pre-injection scores according to the majority of publications. The analysis is limited by the wide variability of available studies.

Comparison of Bone Mineral Density Changes Around Short, Metaphyseal-Fitting, and Conventional Cementless Anatomical Femoral Components

Management of Hip Fractures in the Elderly

We investigated the incidence and degree of stress shielding and clinical and radiographic results in 2 groups of patients. Fifty patients (60 hips) in each group were enrolled for a randomized study. One group received a short, metaphyseal-fitting femoral component and another group received a conventional metaphyseal- and diaphyseal-filling femoral component. The mean follow-up was 3.35 years in both groups. Bone mineral density was significantly increased in femoral zone 1 but slightly decreased in zone 7 in the short, metaphyseal-fitting stem group. In the conventional metaphyseal- and diaphyseal-fitting stem group, bone mineral density was markedly decreased in both zones 1 and 7. Clinical and radiographic results were similar between the 2 groups. No hip in either group required revision of the component. (copyright) 2011 Elsevier Inc.

The anti-nociceptive action of magnesium during continuous femoral nerve block. Is it associated with prophylactic anticoagulant or adverse hypotensive effects following TKR surgery?

AAHKS (8) Anesthetic Infiltration

Objectives: The aim of this study was to evaluate the effect of using magnesium in conjunction with bupivacaine following unilateral Total Knee Replacement (TKR) on onset and duration of femoral block and to find out whether its local absorption can affect the serum level of magnesium, the hemodynamic parameters and coagulation profile over a period of 24 hours. Methods: Fifty patients, ASA physical status II and III, undergoing unilateral TKR surgeries under general anesthesia were studied. Following extubation, the patients were randomly allocated into one of two groups; BMG: where patients received 20 ml of bupivacaine 0.25% and 500mg of magnesium sulphate and BG: where patients received 20 ml of bupivacaine 0.25%. The onset and duration of block was compared between both groups. When patients started to feel pain, loading was started followed by continuous infusion of bupivacaine 0.25% and magnesium 5 ml/hr (1 ml= 50 mg of MgSO4) in BMG group and bupivacaine only in BG group. The serum level of magnesium, the coagulation profile, blood pressure and complications were followed up. Results: The onset of femoral block was shorter and duration was longer in BMG group when compared to BG group. Serum magnesium levels in BMG group increased significantly at 24 hour and no changes in MAP were detected among both groups. The platelet and coagulation tests were comparable between both groups and no side effects were detected. Conclusion: The use of magnesium in femoral nerve block reduced the onset and prolonged the duration without reported neurological insults. Following continuous infusion, the blood levels of magnesium increased significantly at 24 hour. Also, magnesium infusion did not show any significant hemodynamic disturbances or anticoagulant effects.

A staged approach with vincristine, adriamycin, and dexamethasone followed by bortezomib, thalidomide, and dexamethasone before autologous hematopoietic stem cell transplantation in the treatment of newly diagnosed multiple myeloma

MSTS 2022 - Metastatic Disease of the Humerus

Bortezomib-based regimens have significant activities in multiple myeloma (MM). In this study, we tested the efficacy of a total therapy with a staged approach where newly diagnosed MM patients received vincristine/adriamycin/ dexamethsone (VAD). VAD-sensitive patients (=75% paraprotein reduction) received autologous hematopoietic stem cell transplantation (auto-HSCT), whereas less VAD-sensitive patients (<75% paraprotein reduction) received bortezomib/thalidomide/dexamethasone (VTD) for further cytoreduction prior to auto-HSCT. On an intention-to-treat analysis, a progressive increase of complete remission (CR) rates was observed, with cumulative CR rates of 48% after HSCT. Seven patients progressed leading to three fatalities, of which two had central nervous system disease. The 3-year overall survival and event-free survival were 75.1% and 48.3%, respectively. Six patients developed oligoclonal reconstitution with new paraproteins. In the absence of anticoagulant prophylaxis, no patients developed deep vein thrombosis. The staged application of VAD+/-VTD/auto-HSCT resulted in an appreciable response rate and promising survivals. Our approach reduced the use of bortezomib without compromising the ultimate CR rate and is of financial significance for less affluent communities. © 2010 The Author(s).

A comparison of sensory and motor loss after a femoral nerve block conducted with ultrasound versus ultrasound and nerve stimulation

AAHKS (9/10) Regional Nerve Blocks

BACKGROUND: Controversy exists regarding the need for nerve stimulation when performing an ultrasound (US)-guided peripheral nerve block. We tested the hypothesis that the quality of a femoral nerve block (FNB) performed with US is equivalent to an FNB performed with US and nerve stimulation. METHODS: One hundred seven patients undergoing unilateral total knee arthroplasty were randomized to receive either a US-guided FNB (group US) or a US-guided FNB with nerve stimulation (group USNS). Thirty milliliters of bupivacaine 0.5% was injected in both groups. At 10, 20, 30, and 40 mins after block placement, blinded motor and sensory examinations were conducted. Secondary outcomes included time to perform the block, the number of needle redirections, and 24-hrs intravenously administered morphine equivalent consumption. RESULTS: There were no significant differences in the proportion of patients with either a partial or complete block. At 40 mins, 95.7% of the USNS subjects had a partial or complete sensory block of the femoral nerve (complete in 71.7% and partial in 24%) compared with 88.1% of US subjects (complete in 69% and partial in 19.1%; odds ratio, 2.97; P = 0.19). There were more needle redirections in group USNS (4.1 vs 1.1, P < 0.001), with a higher percentage of patients requiring 2 or more needle attempts (44.2% vs 18.9%, P < 0.01). The time to perform the block in group USNS was longer (188 vs 148 secs, P = 0.01). CONCLUSION: The addition of nerve stimulation to a US-guided FNB did not change preoperative block efficacy.

Definitive management of open pilon fractures with fine wire fixation

DoD SSI (Surgical Site Infections)

INTRODUCTION: The BOAST (British Orthopaedic Association Standards for Trauma) guidelines advise that open pilon fractures amongst other open lower limb fractures need to be treated at a specialist centre with Orthoplastic care. The purpose of this study was to determine clinical outcomes in patients with open pilon fractures treated as per BOAST guidelines alongside a treatment protocol which consisted of early wound debridement and spanning external fixation, delayed soft tissue coverage with a flap when necessary and delayed definitive fixation with the use of a Fine Wire Fixator. MATERIAL AND METHODS: We conducted a retrospective analysis of open pilon fractures treated between 2014 and 2019. All patients were included for the assessment of the rate of infection and fracture healing. Functional outcome assessment was performed in all patients according to the American Orthopaedic Foot and Ankle Score (AOFAS) at 12 months post injury. RESULTS: There were 20 patients including 16 males and 4 females. The mean age was 50.45 years. Initial wound with bone debridement and application of a spanning external fixator was performed within an average of 13.5 hours. The mean time from primary surgery to definitive fixation was 24.5 days. There were 3 patients with Gustilo Type I injuries, 6 with Type II, 4 Type with type IIIa and 7 with Type IIIb injuries. Average time to bone union was 10.4 (Range: 2-18) months. The mean AOFAS score was 74.2 (Range: 28-97). A Taylor Spatial Frame was used on 18 patients, while 2 patients had an Ilizarov frame. A corticotomy was performed on 4 patients with critical bone defect post debridement. There was 1 case of deep infection and 9 cases of superficial infection. There were also 4 cases of delayed union which required bone grafting from their femur using a RIA (Reamer Irrigation Aspirator). CONCLUSION: Our study suggests that the use of staged wound debridement including relatively aggressive bone debridement in conjunction with systemic and local antibiotics, external fixators and patient tailored conversion from spanning external fixator to fine wire frame achieves low rates of wound infection and complications for patients with open pilon fractures.

Reducing the economic impact of carpal tunnel surgery

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

A nurse-led carpal tunnel service was started in Leicester in 1999. Many developments in the service have been patient-driven. A large proportion of our patients are not salaried and many had expressed concerns about the amount of time taken off work after surgery. This therefore prompted us to encourage immediate hand function after surgery. Subsequently, in 494 patients studied prospectively, we have seen 93% of patients return to work by 2 weeks and 99% by 4 weeks. This has obvious benefits in terms of reducing loss of income. Furthermore there is potential for considerable economic savings

Rofecoxib for osteoarthritis

Management of Hip Fractures in the Elderly

BACKGROUND: Editor's note: The anti-inflammatory drug rofecoxib (Vioxx) was withdrawn from the market at the end of September 2004 after it was shown that long-term use (greater than 18 months) could increase the risk of heart attack and stroke. Further information is available at www.vioxx.com.Osteoarthritis is a chronic disease of the joints, characterised by joint pain, stiffness and loss of physical function. Its onset is age-related and occurs usually between the ages of 50 and 60. It is the commonest cause of disability in those aged over 65, with OA of the knee and/or hip affecting over 20 per cent of the elderly population. OBJECTIVES: To establish the efficacy and safety of rofecoxib in the management of OA by systematic review of available evidence. SEARCH STRATEGY: We searched the following databases up to August 2004: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, National Research Register, NHS Economic Evaluation Database, Health Technology Assessment Database. The bibliographies of retrieved papers and content experts were consulted for additional references. SELECTION CRITERIA: All eligible randomised controlled trials (RCTs) were included. No unpublished RCTs were included in this edition of the review. DATA COLLECTION AND ANALYSIS: Data were abstracted independently by two reviewers. A validated checklist was used to score the quality of the RCTs. Comparable trials were pooled using fixed effects model. MAIN RESULTS: Twenty-six RCTs were included. The comparators were placebo, diclofenac, ibuprofen, naproxen, nimesulide, nabumetone, paracetamol, celecoxib and Arthrotec. The evidence reviewed indicated that rofecoxib was more effective than placebo (patient global response RR 1.75 95% CI: 1.35, 2.26) but was associated with more adverse events (RR 1.32 95% CI 1.11, 1.56). There were no consistent differences in efficacy between rofecoxib and any of the active comparators at equivalent doses. Endoscopic studies indicated that compared to ibuprofen 800mg three times a day, rofecoxib caused fewer erosions and gastric ulcers at doses of 25mg and 50mg; the difference in duodenal ulcers was evident only at a dose of 25mg. Rofecoxib 50mg also caused more endoscopically observed ulcers greater than rofecoxib 25mg (RR 2.48 CI: 1.21, 5.11). Very few of the trials reported overall rates of GI adverse events although rofecoxib was found to cause fewer GI events than naproxen. Only one of the nine trials comparing rofecoxib to celecoxib reported on the overall rates of GI events and this was a comparison of the higher recommended dose of rofecoxib with the lower recommended dose of celecoxib. Similarly, the three trials in older hypertensive patients that examined the cardiovascular safety of rofecoxib and celecoxib used non-comparable doses; the results of these studies indicated that rofecoxib caused more patients to have oedema and a clinically significant increase in systolic blood pressure. This difference between rofecoxib and celecoxib was not evident in studies conducted in more general populations. AUTHORS' CONCLUSIONS: Rofecoxib was voluntarily withdrawn from global markets in October 2004 therefore there are no implications for practice concerning its use. There remains a number of questions over both the benefits and risks associated with Cox II selective agents and further work is ongoing. ROFECOXIB FOR OSTEOARTHRITIS: Editor's note: The anti-inflammatory drug rofecoxib (Vioxx) was withdrawn from the market at the end of September 2004 after it was shown that long-term use (greater than 18 months) could increase the risk of heart attack and stroke. Further information is available at www.vioxx.com.Does Rofecoxib work for treating osteoarthritis and how safe is it? To answer this question, scientists found and analyzed 26 studies. These studies included over 20 000 people with osteoarthritis and lasted up to 1 year. Studies compared people taking rofecoxib at 12.5, 25 or 50 mg once a day to people taking a placebo (sugar pill) or other NSAIDs such as diclofenac, ibuprofen, naproxen, nimesulide, nabumetone, paracetamol (Tylenol), celecoxib or Arthrotec. These studies provide the best evidence we have today.What is osteoarthritis and how could rofecoxib help? Osteoarthritis (OA) is the most common form of arthritis that can affect the hands, hips, shoulders and knees. In OA, the cartilage that protects the ends of the bones breaks down and causes pain and swelling. Rofecoxib is often referred to as a 'COX II inhibitor' and is one of the new non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to decrease pain and inflammation. Other NSAIDS, such as naproxen (Naprosyn) are also prescribed but they come with warnings that they may cause stomach problems such as ulcers, bleeds and sores that can be serious. Rofecoxib is thought to be safer on the stomach than other NSAIDS.Rofecoxib was taken off the market in October 2004. A study had shown that people taking rofecoxib to prevent colon cancer had more heart attacks and strokes than people taking a sugar pill.What did studies testing rofecoxib in OA show? Studies showed people taking rofecoxib improved more than people taking a sugar pill.Three studies showed that . 29 out of 100 people felt better overall with a sugar pill . 53 out of 100 people felt better overall with rofecoxib at 12.5 mg per day.Studies also showed that improvements were about the same whether people took rofecoxib or a different NSAID.How safe was it in the studies? Very few studies recorded and reported stomach problems. When rofecoxib was compared to a sugar pill, more people taking rofecoxib had kidney problems, water retention and high blood pressure but the number of people with stomach problems was about the same.When compared to other NSAIDs, less people taking 25 or 50 mg rofecoxib had stomach problems than when taking ibuprofen (800 mg three times a day) or naproxen. Rofecoxib also caused less diarrhea than arthrotec.What is the bottom line? Rofecoxib was withdrawn from the world wide market in October 2004 and is no longer available.When considering which non-steroidal anti-inflammatory drug (NSAID) to use, it must be remembered that the effects and safety of a drug is different among people and depends on the drug. The effect and safety also depends on the dose and how it acts in the body.There are still questions about the effects and safety of other Cox-II inhibitors and more research is being done

Carpal tunnel syndrome caused by cysticercosis

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

We present a case of carpal tunnel syndrome (CTS) due to compression of the median nerve within the carpal tunnel, caused by cysticercosis. Nerve conduction studies revealed severe CTS. Magnetic resonance imaging suggested an inflammatory mass compressing the median nerve in carpal tunnel. The histological diagnosis was consistent with cysticercosis. The case resolved with conservative treatment. Such solitary presentation of entrapment median neuropathy as CTS caused by cysticercosis is extremely rare. To our knowledge, this is the only case of its kind reported in literature till date

Patients with impending abdominal compartment syndrome do not respond to early volume loading

DOD - Acute Comp Syndrome CPG

BACKGROUND: It is recommended that patients with impending abdominal compartment syndrome (ACS) should be volume loaded to insure the adequate preload. We evaluated our prospective resuscitation database to determine how patients who developed ACS differ from non-ACS patients in response to early volume loading. METHODS: Over 36 months, 152 consecutive high-risk patients were resuscitated by a standard intensive care unit (ICU) protocol that escalates interventions in nonresponders. Interventions, responses, and outcomes are prospectively collected and the characteristics of ACS and non-ACS patients were compared. RESULTS: Twenty-three patients (15%) developed ACS and were decompressed 8 +/- 1 hours after ICU admission. The ACS and non-ACS patients had similar demographics and injury severity. The severity of pre-ICU shock tended to be greater in the ACS patients. During the first 8 hours of ICU resuscitation, patients who developed ACS received more blood transfusions (11 +/- 2 versus 2 +/- 0.2 units; P<0.05) and crystalloids (13 +/- 2 versus 4 +/- 0.3 L; P<0.05). As a result, pulmonary capillary wedge pressure increased more in the ACS patients (20 +/- 1.5 versus 15 +/- 0.5 mm Hg; P<0.05), but comparatively the cardiac index did not (3.2 +/- 0.2 versus 4.2 +/- 0.1 L/min/m(2); P<0.05) and the ACS patients developed pathologic elevations of gastric regional CO(2) pressures (70 +/- 7 versus 48 +/- 1 mm Hg P<0.05). CONCLUSIONS: Conventional preload directed resuscitation to enhance cardiac function is not effective in patients with impending ACS, and this traditional resuscitation strategy is detrimental in this subgroup of patients.

Comparative adherence to weekly oral and quarterly intravenous bisphosphonates among patients with limited heath literacy who sustained distal radius fractures

Distal Radius Fractures

Individuals with limited health literacy (HL) are less likely to obtain preventive care. We designed a study to compare adherence to weekly oral and quarterly intravenous bisphosphonates among patients with low HL. The study enrolled a total of 432 female patients who presented with a distal radius fracture caused by low�energy trauma. Participant HL was measured using the Newest Vital Sign tool, and patients were randomized to weekly oral or quarterly intravenous bisphosphonate groups. Subjects in the intravenous bisphosphonate group received intravenous injections of 3 mg ibandronate every 3 months, and those in the oral bisphosphonate group self�administered 70 mg alendronate orally once each week for 12 months. The adherence to weekly oral or quarterly intravenous bisphosphonates was analyzed by HL level. The rate of adherence to quarterly intravenous bisphosphonates was significantly higher than that for weekly oral bisphosphonates in patients with inadequate HL (73 vs. 46%, p = 0.001), whereas no significant differences were observed between HL groups in adherence to intravenous bisphosphonate. Conversely, the rate of adherence to orally administered bisphosphonates was significantly lower in patients with inadequate HL than in those with appropriate HL (46 vs. 65%, p = 0.005). After controlling for confounding variables, inadequate HL, the presence of comorbidities, and weekly oral bisphosphonates were associated with a higher likelihood of nonadherence to osteoporosis treatment. Thus patients with limited health literacy can achieve rates of adherence to quarterly intravenous bisphosphonates, as opposed to weekly oral bisphosphonates, similar to rates among patients with appropriate literacy.

The direct and indirect costs to society of treatment for end-stage knee osteoarthritis

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: Although total knee arthroplasty for end-stage osteoarthritis is a cost-effective procedure, payers are focusing on its indications and cost because of its high and growing use. Improvements in pain and physical function from total knee arthroplasty could yield benefits in the form of increased work life and lower disability payments. The purpose of this study was to estimate the value of total knee arthroplasty from a societal perspective, including the costs and benefits to patients, employers, and payers. METHODS: A Markov model was used to estimate the value of total knee arthroplasty for patients with end-stage osteoarthritis of the knee by comparing direct and indirect costs between surgical and nonsurgical treatment scenarios. Direct costs included all medical costs for surgical and nonsurgical treatment of osteoarthritis of the knee. Indirect costs were related to lost wages due to an inability to work, lower earnings, or receipt of disability payments. Direct and indirect costs and quality-of-life measures were incorporated into the Markov model to estimate the impact of total knee arthroplasty on costs over patients' lifetimes and quality-adjusted life years. The assumptions used in the model were developed with use of claims and survey data as well as clinical expert opinion and the peer-reviewed literature. RESULTS: Compared with nonsurgical treatment, total knee arthroplasty increased lifetime direct costs by a mean of $20,635 (net present value in 2009 U.S. dollars). These costs were offset by societal savings of $39,565 from reduced indirect costs, resulting in a lifetime societal net benefit from total knee arthroplasty of $18,930 per patient. Eighty-five percent of these savings originated from increased employment and earnings, with the remaining 15% from fewer missed workdays and lower disability payments. CONCLUSIONS: The estimated lifetime societal savings from the more than 600,000 total knee arthroplasties performed in the U.S. in 2009 were estimated to be approximately $12 billion. These societal savings primarily accrued to patients and employers. The study demonstrates the importance of a societal perspective when considering the costs and benefits of total knee arthroplasty and policies that will affect access to this procedure

Geriatric-specific triage criteria are more sensitive than standard adult criteria in identifying need for trauma center care in injured older adults

Hip Fx in the Elderly 2019

Study objective We evaluate the sensitivity of Ohio's 2009 emergency medical services (EMS) geriatric trauma triage criteria compared with the previous adult triage criteria in identifying need for trauma center care among older adults. Methods We studied a retrospective cohort of injured patients aged 16 years or older in the 2006 to 2011 Ohio Trauma Registry. Patients aged 70 years or older were considered geriatric. We identified whether each patient met the geriatric and the adult triage criteria. The outcome measure was need for trauma center care, defined by surrogate markers: Injury Severity Score greater than 15, operating room in fewer than 48 hours, any ICU stay, and inhospital mortality. We calculated sensitivity and specificity of both triage criteria for both age groups. Results We included 101,577 patients; 33,379 (33%) were geriatric. Overall, 57% of patients met adult criteria and 68% met geriatric criteria. Using Injury Severity Score, for older adults geriatric criteria were more sensitive for need for trauma center care (93%; 95% confidence interval [CI] 92% to 93%) than adult criteria (61%; 95% CI 60% to 62%). Geriatric criteria decreased specificity in older adults from 61% (95% CI 61% to 62%) to 49% (95% CI 48% to 49%). Geriatric criteria in older adults (93% sensitivity, 49% specificity) performed similarly to the adult criteria in younger adults (sensitivity 87% and specificity 44%). Similar patterns were observed for other outcomes. Conclusion Standard adult EMS triage guidelines provide poor sensitivity in older adults. Ohio's geriatric trauma triage guidelines significantly improve sensitivity in identifying Injury Severity Score and other surrogate markers of the need for trauma center care, with modest decreases in specificity for older adults.

A novel scale for describing visual outcomes in patients following resection of lesions affecting the optic apparatus: the Unified Visual Function Scale

Upper Eyelid and Brow Surgery

OBJECTIVE Historically, descriptions of visual acuity and visual field change following intracranial procedures have been very rudimentary. Clinicians and researchers have often used basic descriptions, such as "improved," "worsened," and "unchanged," to describe outcomes following resections of tumors affecting the optic apparatus. These descriptors are vague, difficult to quantify, and challenging to apply in a clinical perspective. Several groups have attempted to combine visual acuity and visual fields into a single assessment score, but these are not user-friendly. The authors present a novel way to describe a patient's visual function as a combination of visual acuity and visual field assessment that is simple to use and can be used by surgeons and researchers to gauge visual outcomes following tumor resection. METHODS Visual acuity and visual fields were combined into 3 categories designed around the definitions of legal blindness and fitness to drive in Canada. The authors then applied the scale (the Unified Visual Function Scale, or UVFS) to their previously published case series of perisellar meningiomas to document and test overall visual outcomes for patients undergoing tumor resection. The results were compared with previously documented visual loss scales in the literature. RESULTS Using the UVFS the authors were able to capture the overall visual change; the scale was sensitive enough to define the overall visual improvement or worsening quantitatively, using categories that are clinically relevant and understandable. CONCLUSIONS The UVFS is a robust way to assess a patient's vision, combining visual fields and acuity. The implementation of pre- and postoperative assessment is sensitive enough to assess overall change while also providing clinically relevant information for surgeons, and allows for comparisons between treatment groups.

Posttraumatic stress disorder among Cambodian refugees in New Zealand

DoD PRF (Psychosocial RF)

The author's objective was to determine the amount of trauma, prevalence and diagnostic features of posttraumatic stress disorder (PTSD), and to study the relationship between PTSD and demographic variables, trauma experiences, coping style and post-migration stresses among adult Cambodian refugees in New Zealand. Information on basic sociodemographic data, trauma experiences, posttraumatic stress symptoms, General Health Questionnaire 28-item version (GHQ-28) scores, coping style, and post-migration stresses were gathered from 223 adult Cambodian refugees living in Dunedin, New Zealand. Most subjects had experienced multiple, severe traumas. The prevalence of PTSD was 12.1%. The most frequently reported posttraumatic stress symptom was recurrent intrusive recollection of trauma. There was a significant association between PTSD and amount of trauma, coping style, and post-migration stresses.

Short-Term Results after Total Trapeziectomy with a Poly-L/D-Lactide Spacer

Glenohumeral Joint OA

Background Proximal migration of the first metacarpal can be seen after total trapeziectomy and various techniques have been described to prevent this subsidence. Purpose We hypothesized the insertion of a poly-L/D-lactide spacer to prevent proximal migration of the first metacarpal without the need of an additional ligament reconstruction, allowing early mobilization and less demanding rehabilitation. Patients and Methods Ten thumbs were treated with a total trapeziectomy and insertion of a poly-L/D-lactide scaffold. Clinical and radiological evaluation was performed after 6 months and 1 year. Patient satisfaction, pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, mobility of the thumb, and strength were assessed. Results Pain according to the visual analog scale decreased (p = 0.01) and QuickDASH score decreased (p = 0.02) significantly after 1 year. Radiological evaluation after 12 months showed a collapse of the scaphometacarpal distance of 45% (p = 0.01). Osteolysis of the distal scaphoid pole and/or proximal metacarpal was seen in 6 out of 10 cases. Because of the osteolysis, the use of the poly-L/D-lactide scaffold was discontinued in our practice. Conclusion In this limited series, total trapeziectomy with the use of the poly-L/D-lactide scaffold provides significant pain reduction and improvement of overall function. Radiographic evaluation shows significant collapse of the scaphometacarpal distance after 1 year and frequent signs of osteolysis. We do not encourage the use of the poly-L/D-lactide scaffold with total trapeziectomy before long-term clinical and radiological follow-ups of the osteolysis are available.

Patella pain syndromes and chondromalacia patellae

Surgical Management of Osteoarthritis of the Knee CPG

Patellar pain must be separated from other causes of internal derangement of the knee by a careful history and precise examination followed by appropriate investigations. Once the cause of the pain is determined, malalignment or malposition of the patella must be sought. The Merchant view of the patellar femoral joint is recommended in this regard to demonstrate patellar incongruence. The malalignment syndrome may or may not show the pathologic changes described as "chondromalacia" and respond particularly well after proximal patellar realignment. In the remaining cases, pain may be caused by overuse, trauma, the odd-facet syndrome, an abnormal femoral ridge, or degenerative arthritis. This group of cases should be managed conservatively if possible because the results of surgical treatment are often disappointing. In selected cases some improvement may occur after excision of abnormal cartilage, tibial tubercle elevation, patellar replacement, or patellectomy

An approach for the treatment of penile carcinoma

MSTS 2018 - Femur Mets and MM

One hundred cases were studied in detail using lymphangiograms (LAG), anatomic dissections, and/or microscopic evaluation. LAG performed via the dorsal lymphatics of the penis demonstrate the existence of specific lymph node center, the so-called sentinel lymph node (SLN). This appears to be the primary site of metastases from penile carcinoma. The SLN is visualized radiographically, on the antero-posterior view, at the junction of the femoral head and the ascending ramus of the pubis. Anatomically, the SLN is part of the lymphatic system around the superficial epigastric vein. Forty-six SLN biopsies were performed with 15 positive for metastatic disease. In these 15 patients, an inguinofemoroiliac dissection was performed; in 12 cases there was no involvement of other lymph nodes. Lymphatic channels draining into the iliac lymph nodes without first draining into the sentinel lymph node were never demonstrated, nor were the inguinal-femoral lymph nodes involved in the absence of SLN involvement. On this bases, we recommend preliminary bilateral SLN biopsy to be followed by inguinofemoroiliac dissection when biopsy of the SLN biopsy to be followed by inguinofemoroiliac dissection when biopsy of the SLN is positive. When biopsy of the SLN is negative for metastatic disease, no further surgical therapy is immediately indicated. With negative SLN, 5-year survival was 90%. When SLN alone was involved, 5-year survival was 70%. Five-year survival was 50% with both SLN and other inguinal nodes involved. When iliac metastases were also present, 3-year survival was 20%.

Evaluation of pregnancy outcomes from the Tysabri® (natalizumab) pregnancy exposure registry: A global, observational, follow-up study

Developmental Dysplasia of the Hip 2020 Review

Background: Patients with multiple sclerosis (MS) or Crohn's disease (CD) being treated with natalizumab (Tysabri®, Biogen) who are planning to become pregnant or discover they are pregnant after exposure to natalizumab are currently advised to balance the potential benefits and potential risks of exposure when considering treatment options. This study was undertaken to evaluate pregnancy outcomes of women with MS or CD who were exposed to natalizumab at any time within 3 months prior to conception or during pregnancy. A pregnancy registry was created to better understand the effect of natalizumab exposure on pregnancy outcomes. Methods: The Tysabri Pregnancy Exposure Registry was a global, observational exposure registration and follow-up study. Evaluations included spontaneous abortions (<22 weeks gestational age), fetal losses (�22 weeks gestational age), ectopic pregnancies, elective or therapeutic terminations, stillbirths, birth defects, and live births. Birth defects were reviewed and coded in accordance with the Metropolitan Atlanta Congenital Defects Program (MACDP) classification of birth defects. Results: A total of 369 patients with MS and 7 patients with CD were enrolled prospectively, of whom 355 patients (99.4 %; 349 MS and 6 CD) had known pregnancy outcomes (including 8 twin sets). The spontaneous abortion rate was 9.0 % (n = 32; 95 % confidence interval [C. I.], 6.3-12.5 %). An independent advisory committee review determined the major birth defect rate to be 5.05 % (16 of 316 live births + 1 elective abortion; 95 % C. I., 2.9-8.1 %). The mean gestational age of the live-born infants was 38.3 weeks, and the mean birth weight was 3158.3 g. Conclusions: Although the overall rate of birth defects was higher than that observed by the MACDP, these registry outcomes showed no specific pattern of malformations that would suggest a drug effect, and the spontaneous abortion rate was consistent with that of the general population. Trial registration: ClinicalTrials.gov NCT00472992(11 May 2007).

Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery

Panniculectomy & Abdominoplasty CPG

Breast reconstruction with adipocutaneous free flap from the abdominal wall combines the benefits of abdominoplasty to those of a prosthesis-free breast reconstruction. The deep inferior epigastric artery perforator (DIEP) flap is supplied by intramuscular perforators from the deep inferior epigastric artery (DIEA). It consists of the dissection of perforating branches of the DIEA within the rectus abdominis muscle, thus sparing both muscle and fascia. Preoperative imaging in the planning of DIEP flap surgery has been shown to facilitate faster and safer surgery. This review article aims to discuss advantages and drawbacks of current imaging modalities for mapping the course of perforating vessels in the planning of DIEP flap surgery, and to present state-of-the-art imaging techniques.

Unicondylar unicompartmental replacement for osteoarthritis of the knee

AAHKS (8) Anesthetic Infiltration

Unicompartmental knee replacement is an attractive concept that offers several potential advantages over bicompartmental or tricompartmental replacement, including preservation of bone stock, of the anterior and posterior cruciate ligaments, of the patellofemoral joint, and of the normal opposite compartment. Of our first 100 consecutive knees that had unicompartmental arthroplasty for osteoarthritis and were followed for two to six years (average, three and one-half years), eighty-eight were medial and twelve were lateral replacements. The ages of the patients at the time of operation ranged from forty-six to eighty-five years, with an average age of seventy-one years. At follow-up, pain relief was good to excellent in 92 per cent of the knees. The average amount of flexion was 114 degrees (range, 90 to 140 degrees); one-half of the knees had at least 120 degrees of flexion. The average flexion contracture was 1 degree. There were no infections and no peroneal palsies. At the time of writing, three failures had required revision. Radiolucent lines at the bone-cement interface were present around 8 per cent of the femoral components and 27 per cent of the tibial components. Two femoral components subsided in obese patients. There was no tibial loosening in the series. The most common complications, per anserinus bursitis, occurred in 12 per cent of the knees and was treated satisfactorily by injection of local anesthetics and steroids. Surgical technique must be precise to prevent subluxation of the tibia on the femur due to either improper positioning of the components or too tight a fit (too much pressure) between them. We view unicompartmental replacement as an attractive alternative for the treatment of unicompartmental osteoarthritis in elderly patients. However, we are strong advocates of proximal tibial osteotomy for unicompartmental osteoarthritis associated with a varus deformity in selected patients.

Uncemented total hip arthroplasty in osteonecrosis: a 2- to 10-year evaluation

AAHKS (2) Corticosteroids

All patients undergoing uncemented total hip arthroplasty for end stage hip disease related to osteonecrosis of the femoral head were assessed prospectively between November 1983 and October 1992. The results of clinical evaluation using the Harris Hip score and radiographic assessment of fixation were analyzed to identify features of success or failure that may be unique to this population. Four different stem types and 4 different acetabular components were used. Sixty-four patients had 98 hips implanted during the time of the study. The 42 male and 22 female patients averaged 41 years of age (range, 21-69 years). Average followup was 87.3 months (7.3 years; range, 31-134 months). The cause of osteonecrosis was corticosteroids (42 hips), alcohol (27 hips), trauma (5 hips), and other (24 hips). Three patients (5 hips) have died and 4 patients (6 hips) are lost to followup. At last followup 65 of 87 hips (75%) remained radiographically stable and clinically functional, 18 of 87 (21%) have been revised, and 4 were failing (osteolysis). Of the 22 hips with revision or impending failure, 4 were for technical reasons on the femoral side and 18 were for acetabular wear. Patient factors such as weight or underlying disease state did not seem to influence the ability to achieve stable fixation or contribute to accelerated failure. Failures related primarily to problems of first generation devices including accelerated wear of acetabular components, technical issues of femoral component placement (undersizing of components or femoral fracture), and the use of noncircumferentially coated femoral components. Age may be a factor in early failure. This 10-year experience with total hip arthroplasty for the patient with end stage hip disease due to osteonecrosis suggests that uncemented total hip arthroplasty can be applied predictably to this younger, potentially more active patient population.

Efficacy of oral etidronate for skeletal diseases in Japan

MSTS 2018 - Femur Mets and MM

Etidronate is an oral bisphosphonate compound that is known to reduce bone resorption through the inhibition of osteoclastic activity. The efficacy of etidronate for involutional (postmenopausal and senile) and glucocorticoid-induced osteoporosis, as well as that for other skeletal diseases, was reviewed in Japanese patients. Cyclical etidronate treatment (200 mg or 400 mg/day for 2 weeks about every 3 months) increases the lumbar bone mineral density (BMD) in patients with involutional osteoporosis and prevents incident vertebral fractures in patients with glucocorticoid-induced osteoporosis. The losses of the lumbar BMD in patients with liver cirrhosis and the metacarpal BMD in hemiplegic patients after stroke are prevented, and the lumbar BMD is possibly increased, preventing fragile fractures in adult patients with osteogenesis imperfecta type I. Furthermore, proximal bone resorption around the femoral stem is reduced and some complications may be prevented in patients who undergo cementless total hip arthroplasty. Oral etidronate treatment may also help to transiently relieve metastatic cancer bone pain followed by a decrease in abnormally raised bone resorption in patients with painful bone metastases from primary cancer sites, such as the lung, breast and prostate. Thus, oral etidronate treatment is suggested to be efficacious for osteoporosis, as well as other skeletal diseases associated with increased bone resorption, in Japanese patients. Randomized controlled trials needed to be conducted on a large number of patients to confirm these effects.

Application of medial column classification in treatment of intra-articular calcaneal fractures

DoD SSI (Surgical Site Infections)

BACKGROUND: There are many types of treatments for calcaneal fractures, including conservative treatment, conventional surgical treatment, and minimally invasive surgery. The choice of specific treatment options is still controversial. Open reduction and internal fixation are currently the most commonly used surgical procedures in the clinic. A good fracture reduction effect can be achieved by using the lateral extension incision of the calcaneus; however, many studies have reported a high incidence of postoperative incision complications. Although there are many methods for the classification of intra-articular calcaneal fractures, it is generally believed that the computed tomography (CT) classification proposed by Sanders has high application value in the selection of treatment methods and evaluation of prognosis of calcaneal fractures. However, this method has no clear guiding significance for the choice of surgical incision and surgical plan. AIM: To explore the application and clinical efficacy of medial column classification in the treatment of intra-articular calcaneal fractures. METHODS: From July 2017 to July 2018, 91 patients, including 60 males and 31 females aged 27 to 60 years, were enrolled. All participants had closed intra-articular calcaneal fracture, and their surgical options were selected under the guidance of medial column classification. The patients' fractures were classified according to the Sanders classification: Type II, 35 cases; Type III, 33 cases; and Type IV, 23 cases. Among them, 53 patients had medial column displacement (shortened varus) and underwent open reduction and internal fixation with L-lateral incision of the calcaneus; 38 patients had no displacement of the medial column and underwent open reduction and internal fixation with tarsal sinus incision. The calcaneus Bohler angle, Gissane angle, length, width, height, and step thickness of the articular surface were evaluated by X-ray and three-dimensional CT before and after surgery and at the last follow-up. Foot function recovery was assessed by the Maryland foot scoring criteria. RESULTS: All patients were followed for 5 to 14 mo, with an average of 10.5 +/- 2.9 mo. The fractures of all patients healed, and the healing time was 10 to 19 wk, with an average of 10.8 +/- 1.5 wk. One patient developed wound infection 1 wk after surgery and was actively debrided and implanted with antibiotic calcium sulfate to control the infection. The patient's fracture healed 5 mo after surgery. One patient developed a sural nerve injury, and the symptoms disappeared 3 mo after surgery. The patients were assessed according to the Maryland foot scoring system: Excellent in 77 cases, good in 10, and fair in 4. The excellent and good rate was 95.6%. CONCLUSION: Medial column classification can effectively guide the surgical selection for intra-articular fractures of the calcaneus.

Young women's social and occupational development and mental health in the aftermath of child sexual abuse

DoD PRF (Psychosocial RF)

We examined social role functioning and depressive symptoms of young adults who were abused as children in data from a longitudinal community sample. Sexually abused women and men were more depressed during their senior year of high school, and this difference was more pronounced 2 years later. We then examined a mediational model to determine whether social functioning explained the course of depressive symptoms over this transitional period. Focusing only on young women, for whom the prevalence of abuse was much higher, results indicated that two-thirds of the effect of abuse on depressive symptoms was explained by experiences and choices in the domains of work, education and intimate relationships. Having less supportive intimate relationships and lower rates of attendance at 4-year colleges were particularly important. Findings reveal the key role played by early adult interpersonal and occupational development in perpetuating the mental health impact of childhood trauma.

The impact of music therapy versus music medicine on psychological outcomes and pain in cancer patients: a mixed methods study

DoD PRF (Psychosocial RF)

Purpose: The purpose of this study was to compare the impact of music therapy (MT) versus music medicine (MM) interventions on psychological outcomes and pain in cancer patients and to enhance understanding of patients' experiences of these two types of music interventions. Methods: This study employed a mixed methods intervention design in which qualitative data were embedded within a randomized cross�over trial. Thirty�one adult cancer patients participated in two sessions that involved interactive music making with a music therapist (MT) and two sessions in which they listened to pre�recorded music without the presence of a therapist (MM). Before and after each session, participants reported on their mood, anxiety, relaxation, and pain by means of visual analogue and numeric rating scales. Thirty participants completed an exit interview. Results: The quantitative data suggest that both interventions were equally effective in enhancing target outcomes. However, 77.4 % of participants expressed a preference for MT sessions. The qualitative data indicate that music improves symptom management, embodies hope for survival, and helps connect to a pre�illness self, but may also access memories of loss and trauma. MT sessions helped participants tap into inner resources such as playfulness and creativity. Interactive music making also allowed for emotional expression. Some participants preferred the familiarity and predictability of listening to pre�recorded music. Conclusions: The findings of this study advocate for the use of music in cancer care. Treatment benefits may depend on patient characteristics such as outlook on life and readiness to explore emotions related to the cancer experience.

Operative treatment of distal radial fractures with locking plate system-a prospective study

Distal Radius Fractures

The aim of this study was to determine the results of operative treatment of distal radial fractures with a 2.4-mm locking plate system in a single tertiary teaching hospital. Seventy-five patients were recruited into the study between May 2004 and November 2006. There were 41 males and 34 females, with a mean age of 51. Seventy-five percent of patients had AO type C fractures. All patients were allowed free active mobilisation of the wrist joint immediately after surgery. They were followed up at two weeks, three months, six months, one year and two years. Assessments of pain, motion, grip strength, and standard radiographs were performed. The Gartland and Werley functional scores, the modified Green and O'Brien score, and the disabilities of the arm, shoulder and hand (DASH) scores were recorded. The radiographic results at the final follow-up showed a mean of 18degree of radial inclination, 5degree of volar tilt, 1.3-mm radial shortening, and no articular incongruity. Twenty-nine percent of patients showed grade 1 osteoarthritic changes and 6% had grade 2 changes in their final follow-up radiographs. An excellent or good result was obtained in 98% and 96% of patients according to the Gartland and Werley, and modified Green and O'Brien scores, respectively. The mean DASH score was 11.6, indicating a high level of patient satisfaction. Internal fixation of distal radial fractures with a 2.4-mm locking plate system provided a stable fixation with good clinical outcomes and patient satisfaction.

Osteoporosis: from early fracture prevention to better bone health with strontium ranelate

Management of Hip Fractures in the Elderly

Given its increasing incidence and serious complications, osteoporosis requires safe and effective long-term treatment. Strontium ranelate (SR) is an osteoporosis treatment with a unique mode of action, which was launched in 2004. It has been investigated in the Spinal Osteoporosis Therapeutic Intervention (SOTI) and the TReatment Of Peripheral OSteoporosis (TROPOS) trials, two major 3-year multinational placebo-controlled Phase III randomized clinical trials. In SOTI, SR treatment reduced the risk of vertebral fracture by 41% (20.9 vs 32.8%; P < 0.001); in TROPOS, it reduced the risk of non-vertebral fracture by 16% (11.2 vs 12.9%; P = 0.04) and the risk of hip fracture in patients at high risk by 36% (4.3 vs 6.4%; P = 0.046). Unlike anti-resorptive agents, SR produced steady and significant BMD increases that correlated directly with decreases in vertebral and hip fracture risk. Preplanned analysis of the pooled dataset from SOTI and

Bone scanning with 99Tc(m) compounds in metastasizing mammary carcinoma

MSTS 2018 - Femur Mets and MM

A comparison of 3 compounds for bone scanning was carried out in 9 patients with metastatic mammary carcinoma for evaluating their effectiveness. The best results were obtained with 99Tc(m) diphosphonate. For the other 2 compounds tested, 99Tc(m) polyphosphate and 99Tc(m) pyrophosphate, no difference could be demonstrated.

Predictive value of bone scintigraphy for the detection of joint involvement in Behcet's disease: Dermatologists' perspectives

Glenohumeral Joint OA

BACKGROUND: Behcet's disease (BD) is a multisystemic inflammatory disease with articular involvement. Non-specific arthralgia without objective signs of arthritis, such as swelling or effusion, is common in such patients. Thus, an accurate diagnosis of joint involvement may be challenging for dermatologists. OBJECTIVES: To evaluate the validity of (99m)Tc-methylene diphosphonate (Tc-99m-MDP) bone scintigraphy for joint involvement assessment in patients with BD. MATERIALS AND METHODS: In 211 patients with BD who had scintigraphic evaluations due to joint symptoms, agreement between bone scintigraphy findings and clinically evaluated joint complaints was retrospectively assessed using Cohen's kappa (kappa) statistic. A patient subset (n = 104) showing agreement between joint complaints and scintigraphy results was re-evaluated by a rheumatologist to determine the level of diagnostic specificity attained by combining bone scintigraphy with clinical examinations of dermatologists. RESULTS: The total kappa value (211 patients) was 0.604, indicating fair agreement between joint complaints and scintigraphy results. Individual analysis of eleven joint categories revealed statistically significant correlations for wrist (kappa = 0.677), shoulder (kappa = 0.661), and foot joints (kappa = 0.618). Of the 104 referrals to a rheumatologist, 95 (91.34%) were confirmed as having BD-associated articular involvement. Joint acral areas (e.g., foot, hand, wrist and shoulder) that had the highest kappa value correlations also ranked highest in diagnostic specificity. CONCLUSION: Bone scintigraphy presents a simple and useful option for dermatologists to assess joint involvement in BD patients, especially for specific anatomic sites.

Vibration absorbing brace for study of work-related upper extremity musculoskeletal disorders

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

The use of hand-held power tools can result in absorption of significant vibration energy by the worker's hand and arm, and is a causal factor in the development of various muskuloskeletal disorders (MSD's) such as carpal tunnel syndrome (CTS) and hand-arm vibration syndrome (HAYS). A novel brace incorporating vibration damping materials is proposed that could reduce this energy absorption, resulting in lower incidence of vibration-related occupational MSD's. The National Occupational Research Agenda (NORA) has identified this type of injury as a priority research area. The proposed brace will have utility in the top three NORA-sponsored areas for research tools and approaches: clinical assessment of exposure to environmental vibration; practical use as improved personal protective gear; and evaluating the effects of reduced vibration exposure on MSD incidence. Clinical test results for prototype braces on human volunteers are reported: splints with piezoelectric material showed a median improvement of 12% in vibration damping as compared to otherwise identical nonpiezoelectric splints (median allowable error of +/- 1.5%). The use of these splints to further study how the hand-arm system absorbs vibration energy is also discussed

MRI study of medial meniscus degeneration of osteoarthritic knees with or without posterior root tear

AMP (Acute Meniscal Pathology)

PURPOSE: The purpose of this study was to compare the medial meniscus (MM) degeneration, meniscus extrusion, and tibial joint inclination by using MRI to consider the pathogenesis of posterior root tear (PRT) in medial-type knee osteoarthritis (KOA) both with and without medial meniscus posterior root tear (MMPRT). METHODS: This study used open MRI with flexion sagittal view and included 324 medial-type osteoarthritic knees with a Kellegren-Lawrence grade of 2 or less. Following the exclusion process, 151 knees were selected for MRI analysis. MM degeneration grading was performed according to Jerosch by 5 degrees of 0-4 in four different portions from anterior to posterior. MM medial extrusion (MMME), MM posterior extrusion (MMPE), medial tibial medial slope (MTMS), and medial tibial posterior slope (MTPS) were measured according to previous studies. RESULTS: MM degeneration in the anterior portion to MCL averaged 1.72 +/- 0.67 in the PRT group (n = 48) and 1.40 +/- 0.78 in the non-PRT group (n = 103). The degeneration grade was statistically higher in the PRT group than in the non-PRT group (p = 0.050). There was no difference in MM degeneration in the other three portions. MMME averaged 4.02 +/- 1.12 mm in the PRT group and 3.11 +/- 1.11 mm in the non-PRT group. MMPE averaged 4.22 +/- 0.87 mm in the PRT group and 2.83 +/- 1.12 mm in the non-PRT group. Both MMME and MMPE in the PRT group were statistically larger than those in the non-PRT group (p < 0.001). There was no difference in MTMS between the two groups. MTPS averaged 6.34 +/- 2.25degree in the PRT group and 5.28 +/- 2.23degree in the non-PRT group. The MTPS of the PRT group was statistically larger than that of the non-PRT group (p = 0.007). CONCLUSION: The severity of MM degeneration, extrusion of MM, and degree of tibial slope were compared between medial-type KOA with and without PRT using an open MRI. MM degeneration was more severe anteriorly in the PRT group. The PRT group showed larger MMME and MMPE with greater MTPS. LEVEL OF EVIDENCE: III. Retrospective cohort study.

Board Certification in Cosmetic Surgery: An Evaluation of Training Backgrounds and Scope of Practice

Panniculectomy & Abdominoplasty CPG

BACKGROUND: The American Board of Cosmetic Surgery (ABCS) offers a certification process for physicians desiring third-party credentials in aesthetic surgery. This study aims to examine the training backgrounds and scope of practice of ABCS-certified physicians. METHODS: The ABCS online directory was used to identify diplomates. Additional board certifications were identified using the American Board of Medical Specialties physician database. Scope of training was defined using American Council for Graduate Medical Education or Commission on Dental Accreditation requirements for residency training programs. Scope of practice was determined using ABCS physician profiles and professional websites. RESULTS: Three hundred forty-two ABCS-certified physicians were included in the study. Two-hundred twelve (60.2 percent) also held American Board of Medical Specialties board certifications. Over half (62.6 percent) of ABCS diplomates advertised surgical operations beyond the scope of their American Council for Graduate Medical Education or Commission on Dental Accreditation training. Specialties with the highest prevalence of practicing beyond scope of training were internal medicine [n = 2 (100 percent)], general surgery [n = 69 (95.8 percent)], obstetrics and gynecology [n = 17 (85 percent)], otolaryngology [n = 65 (59.1 percent)], dermatology [n = 16 (51.6 percent)], and oral and maxillofacial surgery [n = 30 (50 percent)]. The most commonly offered out-of-scope procedures were liposuction (59.6 percent), abdominoplasty (50.0 percent), breast augmentation (49.7 percent), and buttock augmentation (36.5 percent). CONCLUSIONS: ABCS-certified physicians include internists and dermatologists, who market themselves as board-certified cosmetic surgeons, and the majority of ABCS members perform complex aesthetic procedures outside the scope of their primary residency training. Patients who rely on ABCS certification when selecting a cosmetic surgeon may not understand the scope of that physician's training experience and qualifications.

Rehabilitation following carpal tunnel release

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

BACKGROUND: Various rehabilitation treatments may be offered following carpal tunnel syndrome (CTS) surgery. The effectiveness of these interventions remains unclear. OBJECTIVES: To review the effectiveness of rehabilitation following CTS surgery compared with no treatment, placebo, or another intervention. SEARCH METHODS: On 3 April 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register (3 April 2012), CENTRAL (2012, Issue 3), MEDLINE (January 1966 to March 2012), EMBASE (January 1980 to March 2012), CINAHL Plus (January 1937 to March 2012), AMED (January 1985 to April 2012), LILACS (January 1982 to March 2012), PsycINFO (January 1806 to March 2012), PEDRO (29 January 2013) and clinical trials registers (29 January 2013). SELECTION CRITERIA: Randomised or quasi-randomised clinical trials that compared any postoperative rehabilitation intervention with either no intervention, placebo or another postoperative rehabilitation intervention in individuals who had undergone CTS surgery. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, extracted data and assessed the risk of bias according to standard Cochrane methodology. MAIN RESULTS: In this review we included 20 trials with a total of 1445 participants. We studied different rehabilitation treatments including: immobilisation using a wrist orthosis, dressings, exercise, controlled cold therapy, ice therapy, multimodal hand rehabilitation, laser therapy, electrical modalities, scar desensitisation, and arnica. Three trials compared a rehabilitation treatment to a placebo comparison; three trials compared rehabilitation to a no treatment control; three trials compared rehabilitation to standard care; and 14 trials compared various rehabilitation treatments to one another.Overall, the included studies were very low in quality. Eleven trials explicitly reported random sequence generation and, of these, three adequately concealed the allocation sequence. Four trials achieved blinding of both participants and outcome assessors. Five studies were at high risk of bias from incompleteness of outcome data at one or more time intervals. Eight trials had a high risk of selective reporting bias.The trials were heterogenous in terms of the treatments provided, the duration of interventions, the nature and timing of outcomes measured and setting. Therefore, we were not able to pool results across trials.Four trials reported our primary outcome, change in self reported functional ability at three months or longer. Of these, three trials provided sufficient outcome data for inclusion in this review. One small high quality trial studied a desensitisation program compared to standard treatment and revealed no statistically significant functional benefit based on the Boston Carpal Tunnel Questionnaire (BCTQ) (MD -0.03; 95% CI -0.39 to 0.33). One moderate quality trial assessed participants six months post surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and found no significant difference between a no formal therapy group and a two-week course of multimodal therapy commenced at five to seven days post surgery (MD 1.00; 95% CI -4.44 to 6.44). One very low quality quasi-randomised trial found no statistically significant difference in function on the BCTQ at three months post surgery with early immobilisation (plaster wrist orthosis worn until suture removal) compared with a splint and late mobilisation (MD 0.39; 95% CI -0.45 to 1.23).The differences between the treatments for the secondary outcome measures (change in self reported functional ability measured at less than three months; change in CTS symptoms; change in CTS-related impairment measures; presence of iatrogenic symptoms from surgery; return to work or occupation; and change in neurophysiological parameters) were generally small and not statistically significant. Few studies reported adverse events. AUTHORS' CONCLUSIONS: There is limited and, in general, low quality evidence for the benefit of the reviewed interventions. People who have had CTS surgery should be informed about the limited evidence of the effectiveness of postoperative rehabilitation interventions. Until the results of more high quality trials that assess the effectiveness and safety of various rehabilitation treatments have been reported, the decision to provide rehabilitation following CTS surgery should be based on the clinician's expertise, the patient's preferences and the context of the rehabilitation environment. It is important for researchers to identify patients who respond to a certain treatment and those who do not, and to undertake high quality studies that evaluate the severity of iatrogenic symptoms from the surgery, measure function and return-to-work rates, and control for confounding variables

Execution accuracy of bone resection and implant fixation in computer assisted minimally invasive total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

While computer assisted total knee arthroplasty (TKA) has been documented to increase the surgical accuracy in the planning process, there is little information about the accuracy in execution processes. We aimed to determine the accuracy of execution processes for bone resections and implant fixation in TKAs performed with the techniques of computer assisted navigation and minimally invasive surgery. Execution deviations, defined as the differences between planned targets and executed results, were evaluated for bone resections and implant fixation in 107 TKAs. In tibia resection, the mean resection thickness, coronal alignment, and sagittal alignment were 0.2 mm smaller, 0.3(degrees) more valgus, 0.3(degrees) less posterior slope than the planned, respectively. In femur resection, the mean resection thicknesses in the medial and lateral femoral condyles, coronal alignment, and sagittal alignment were 0.6 mm smaller, 0.8 mm smaller, 0.1(degrees) more varus, and 0.7(degrees) less posterior slope than the planned, respectively. In implant fixation, the mean coronal alignment and degree of extension was 0.7(degrees) more valgus and 1.6(degrees) decrease than the planned, respectively. Only the occurrence of unacceptable executions in implant fixation had significant effects on the final coronal alignment. The density of a bone and the quality of saw blade had significant effect on the accuracy of bone resections. Execution deviations from planned alignment commonly occur in computer-assisted minimally invasive TKA, resulting typically from the techniques of bone resections and implant fixation, and this information should be considered to improve the surgical accuracy of navigated TKAs. (copyright) 2009 Elsevier B.V. All rights reserved

Myobacterium bovis peri-prosthetic hip infection with successful prosthesis retention following intravesical BCG therapy for bladder carcinoma

PJI DX Updated Search

Systemic dissemination and peri-prosthetic infection of Mycobacterium bovis (M. bovis) following intravesical Bacillus Calmette-Guerin (BCG) therapy presents a rare but significant complication of treatment for non-muscle invasive bladder carcinoma. We present a patient with Mycobacterium bovis infection of a prosthetic hip nine months following BCG therapy for bladder cancer. The debridement and (implant) prosthesis retention approach in conjunction with anti-tuberculous medication (DAIR) employed in this case, allowed the same prosthesis to be retained. This case report highlights the importance of physician awareness of the possibility BCG peri-prosthetic infections

Laboratory and clinical characteristics of Staphylococcus lugdunensis prosthetic joint infections

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Staphylococcus lugdunensis is a coagulase-negative staphylococcus that has several similarities to Staphylococcus aureus. S. lugdunensis is increasingly being recognized as a cause of prosthetic joint infection (PJI). The goal of the present retrospective cohort study was to determine the laboratory and clinical characteristics of S. lugdunensis PJIs seen at the Mayo Clinic in Rochester, MN, between 1 January 1998 and 31 December 2007. Kaplan-Meier survival methods and Wilcoxon sum-rank analysis were used to determine the cumulative incidence of treatment success and assess subset comparisons. There were 28 episodes of S. lugdunensis PJIs in 22 patients; half of those patients were females. Twenty-five episodes (89%) involved the prosthetic knee, while 3 (11%) involved the hip. Nine patients (32%) had an underlying urogenital abnormality. Among the 28 isolates in this study tested by agar dilution, 24 of 28 (86%) were oxacillin susceptible. Twenty of the 21 tested isolates (95%) lacked mecA, and 6 (27%) of the 22 isolates tested produced beta-lactamase. The median durations of parenteral beta-lactam therapy and vancomycin therapy were 38 days (range, 23 to 42 days) and 39 days (range, 12 to 60 days), respectively. The cumulative incidences of freedom from treatment failure (standard deviations) at 2 years were 92% (+/-7%) and 76% (+/-12%) for episodes treated with a parenteral beta-lactam and vancomycin, respectively (P=0.015). S. lugdunensis is increasingly being recognized as a cause of PJIs. The majority of the isolates lacked mecA. Episodes treated with a parenteral beta-lactam antibiotic appear to have a more favorable outcome than those treated with parenteral vancomycin

Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma: a prospective randomized study

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

BACKGROUND: Heterotopic ossification around the elbow can result in pain, loss of motion, and impaired function. We hypothesized that a single dose of radiation therapy could be administered safely and acutely after elbow trauma, could decrease the number of elbows that would require surgical excision of heterotopic ossification, and might improve clinical results. METHODS: A prospective randomized study was conducted at three medical centers. Patients with an intra-articular distal humeral fracture or a fracture-dislocation of the elbow with proximal radial and/or ulnar fractures were enrolled. Patients were randomized to receive either single-fraction radiation therapy of 700 cGy immediately postoperatively (within seventy-two hours) or nothing (the control group). Clinical and radiographic assessment was performed at six weeks, three months, and six months postoperatively. All adverse events and complications were documented prospectively. RESULTS: This study was terminated prior to completion because of an unacceptably high number of adverse events reported in the treatment group. Data were available on forty-five of the forty-eight patients enrolled in this study. When the rate of complications was investigated, a significant difference was detected in the frequency of nonunion between the groups. Of the nine patients who had a nonunion, eight were in the treatment group. The nonunion rate was 38% (eight) of twenty-one patients in the treatment group, which was significantly different from the rate of 4% (one) of twenty-four patients in the control group (p = 0.007). There were no significant differences between the groups with regard to the prevalence of heterotopic ossification, postoperative range of motion, or Mayo Elbow Performance Score noted at the time of study termination. CONCLUSIONS: This study demonstrated that postoperative single-fraction radiation therapy, when used acutely after elbow trauma for prophylaxis against heterotopic ossification, may play a role in increasing the rate of nonunion at the site of the fracture or an olecranon osteotomy. The clinical efficacy of radiation therapy could not be determined on the basis of the sample size. Further research is needed to determine the role of limited-field radiation for prophylaxis against heterotopic ossification after elbow trauma

TSG-6 - a double-edged sword for osteoarthritis (OA)

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: To explore mechanisms underlying the association of TSG-6 with osteoarthritis (OA) progression. METHODS: TSG-6-mediated heavy chain (HC) transfer (TSG-6 activity) and its association with inflammatory mediators were quantified in knee OA (n=25) synovial fluids (SFs). Paired intact and damaged cartilages from the same individuals (20 tibial and 12 meniscal) were analyzed by qRT-PCR and immunohistochemistry (IHC) for gene and protein expression of TSG-6 and components of Inter-alpha-Inhibitor (IalphaI) and TSG-6 activity +/- spiked in IalphaI. Primary chondrocyte cultures (n=5) +/- IL1beta or TNFalpha were evaluated for gene expression. The effects of TSG-6 activity on cartilage extracellular matrix (ECM) assembly were explored using quantitative hyaluronan (HA)-aggrecan binding assays. RESULTS: TSG-6 activity was significantly associated (R > 0.683, P < 0.0002) with inflammatory mediators including TIMP-1, A2M, MMP3, VEGF, VCAM-1, ICAM-1 and IL-6. Although TSG-6 protein and mRNA were highly expressed in damaged articular and meniscal cartilage and cytokine-treated chondrocytes, there was little or no cartilage expression of components of the IalphaI complex (containing HC1). By IHC, TSG-6 was present throughout lesioned cartilage but HC1 only at lesioned surfaces. TSG-6 impaired HA-aggrecan assembly, but TSG-6 mediated HA-HC formation reduced this negative effect. CONCLUSIONS: TSG-6 activity is a global inflammatory biomarker in knee OA SF. IalphaI, supplied from outside cartilage, only penetrates the cartilage surface, restricting TSG-6 activity (HC transfer) to this region. Therefore, unopposed TSG-6 in intermediate and deep regions of OA cartilage could possibly block matrix assembly, leading to futile synthesis and account for increased risk of OA progression.

Variability in the Approach to Total Hip Arthroplasty in Patients With Displaced Femoral Neck Fractures

PJI DX Updated Search

The aim of this study was to determine the degree of variability in implants, approaches, and associated complication rates in randomized controlled trials (RCTs) evaluating primary total hip arthroplasty (THA) as an intervention for displaced femoral neck fractures. We searched 2 medical databases for RCTs involving THA for femoral neck fractures published between June 2000 and June 2010. All analyses were descriptive. Nine RCTs met our inclusion criteria. We identified variability in both the surgical approach and choice of prosthesis. Trials generally standardized to head sizes of 28 mm or greater and cemented prostheses. Surgical experience varied across studies. Dislocation rates varied from 0% to 22%. There is considerable variability in RCTs evaluating THA for femoral neck fractures. Standardization toward optimal outcomes for femoral neck fractures is needed. © 2012 Elsevier Inc

Effect of mucin and glucose on proteolytic and glycosidic activities of Streptococcus oralis

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The production of glycosidase and protease activities, which may play a role in the degradation of human glycoproteins, by Streptococcus oralis strains isolated from endocarditis, septicaemia or the oral cavity was investigated with a range of fluorogenic substrates. The pH optima of the proteases ranged from 6.0 to 9.3 and the pH optima for the glycosidases were lower (4.5-6.0), although the pH range over which both groups of enzymes acted was broad. Growth in a minimal medium supplemented with glucose resulted in repression of glycosidase activities and elevated proteolytic activity. Bacteria from cultures supplemented with porcine gastric mucin (PGM), a model glycoprotein, exhibited higher levels of glycosidase activity, while proteolytic activity was suppressed and glycoprotein-derived monosaccharides were transported at significantly higher rates than those observed for cells grown in media with glucose. PGM-derived cells also exhibited high levels of N-acetylneuraminate pyruvate-lyase, the first intracellular enzyme in the pathway of sialic acid catabolism. Taken together, these data indicate that S. oralis strains produce a range of proteolytic and glycosidic enzymes that may play a role in the degradation of host-derived glycoproteins

Clinical and MRI findings associated with false-positive knee MR diagnoses of medial meniscal tears

AMP (Acute Meniscal Pathology)

OBJECTIVE: The objective of our study was to determine if false-positive MR diagnoses of a medial meniscal tear are more common with specific clinical variables, tear type or location, or MRI findings of a longitudinal tear. MATERIALS AND METHODS: We reviewed the records of 559 patients who underwent knee MR examinations and arthroscopy. We compared the positive predictive values (PPVs) of an MR diagnosis of a medial meniscal tear for differences in tear location or type, delay between knee injury and MRI, delay between MRI and arthroscopy, and the presence of an anterior cruciate ligament (ACL) tear. We also retrospectively reviewed the MR examinations of 50 longitudinal tears to compare the PPVs of various MRI findings of a longitudinal tear. RESULTS: There was no association between either the delay between injury and MRI or the delay between MRI and arthroscopy and false-positive diagnoses. The PPV of 64% (32/50) for longitudinal tears was lower than the values of 83% (15/18) to 100% (116/116) for other types of medial meniscal tears. False-positive diagnoses of medial meniscal tears were more common in patients who had a prior episode of acute trauma (p = 0.004) or an ACL tear (p < 0.0001). Review of longitudinal tears revealed a decreased PPV when MRI showed signal contacting only the superior surface (p = 0.016) or when MRI showed signal contacting the surface at the meniscocapsular junction (p = 0.004). Four of the 18 menisci with a false-positive diagnosis of a longitudinal tear had a healed ACL tear noted at arthroscopy. CONCLUSION: False-positive MR diagnoses of medial meniscal tears are more common for longitudinal tears than other tear types and are also more common with MR abnormalities at either the superior surface or the meniscocapsular junction. Spontaneous healing of longitudinal tears accounts for some false-positive MR diagnoses.

Knee function after arthroscopic meniscectomy. A prospective study

AMP (Acute Meniscal Pathology)

In a prospective study, operation under arthroscopy was done in 100 consecutive patients (11 women and 89 men) with a lesion of one meniscus. Meniscectomy was done in 86 patients with medial meniscus tears and in 14 with lateral tears. After 2 weeks, 85 patients were back at work.

A Novel Supra-Brow Combined with Infra-Brow Lift Approach for Asian Women

Upper Eyelid and Brow Surgery

BACKGROUND: Direct brow lift surgery remains popular among Asian women despite its disadvantages. The traditional direct brow lift by a supra-brow incision is not suitable for Asian women because of their unique facial features, such as higher eyebrows, wider upper eyelids, and more orbital fat. Therefore, we designed a novel brow lift technique via a supra-brow combined with an infra-brow approach for Asian women. METHODS: An area of skin above and below the eyebrow was measured, demarcated, and surgically removed. The redundant orbicularis oculi muscle (OOM) was excised while keeping the frontalis muscle intact. The OOM in the inferior flap was elevated and sutured to the frontalis muscle. In cases of puffy eyelids, orbital fat was partially removed through an infra-brow incision. Finally, a series of modifications were performed to reduce post-operative scarring. RESULTS: A total of 496 patients underwent this surgery from July 2009 to December 2013 and 432 patients were followed up for at least 6 months after surgery. Post-operative scars, in most patients (428/432), were inconspicuous. There were no facial nerve injuries documented and eight patients reported transient forehead numbness. The height of the palpebral fissure was increased but there was no marked increase observed of the distance between the upper eyelid edge and the eyebrow. In follow-up visits, 409 out of 432 patients (94.7 %) were satisfied with their surgical results. CONCLUSIONS: This new brow lift technique via a supra-brow combined with an infra-brow approach provided a simple and safe surgical repair of lateral brow ptosis, upper eyelids hooding, and crows' feet in Asian women. The surgical outcomes were predictable and the scars were inconspicuous. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of Clinical and Radiologic Results Between Partial Meniscectomy and Refixation of Medial Meniscus Posterior Root Tears: A Minimum 5-Year Follow-up

AMP (Acute Meniscal Pathology)

PURPOSE: To compare the clinical and radiologic results of partial meniscectomy with those of refixation in patients with medial meniscus posterior root tears (MMPRTs) at a minimum 5-year follow-up. METHODS: Between 2005 and 2009, patients with MMPRTs who had been followed up for at least 5 years after a partial meniscectomy (group M, n = 20) or pullout repair (group R, n = 37) were recruited. The mean follow-up duration was 67.5 months in group M and 72.0 months in group R. Clinical assessments, including the Lysholm score and International Knee Documentation Committee (IKDC) Subjective Knee Form score, and radiographic assessments, including the Kellgren-Lawrence (K-L) grade and medial joint space width, were evaluated preoperatively and at final follow-up. We compared the preoperative results with the final results in each group, and we compared the final results of groups M and R. Five-year survival rates were also evaluated. RESULTS: The mean Lysholm score (P = .039) and IKDC score (P = .037) improved significantly. However, the width of the medial joint space (P < .001) and K-L grade (P < .001) worsened significantly in both groups. When we compared the final results, group R had significantly better Lysholm scores (P = .002) and IKDC scores (P < .001) than group M. Group R showed less K-L grade progression (P = .005) and less medial joint space narrowing (P < .001) than group M. The rate of conversion to total knee arthroplasty was 35% in group M, whereas there was no conversion to total knee arthroplasty in group R. The 5-year survival rates in groups M and R were 75% and 100%, respectively (P < .001). CONCLUSIONS: For MMPRTs, refixation was more effective than partial meniscectomy in terms of the clinical and radiologic outcomes and survival for at least 5 years' follow-up. Refixation slowed the progression of arthritic changes compared with partial meniscectomy, although it did not prevent the progression of arthrosis completely. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Sensory deficits of a nerve root lesion can be objectively documented by somatosensory evoked potentials elicited by painful infrared laser stimulations: A case study

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Somatosensory evoked potentials (SEPs) in response to painful laser stimuli were measured in a patient with a unilateral sensory deficit due to radiculopathy at cervical levels C7 and C8. Laser evoked potentials (LEPs) were compared with SEPs using standard electrical stimulation of median and ulnar nerves at the wrist and mechanical stimulation of the fingertips by means of a mechanical stimulator. Early and late ulnar and median nerve SEPs were normal. Mechanical stimulation resulted in w shaped early SEPs from all five fingertips with some degree of abnormality at the fourth and fifth digits of the affected hand. Late LEPs were completely absent for stimulations at affected dermatomes and normal in the unaffected control dermatomes. The border between skin areas with normal or absent LEPs was very sharp and fitted the dermatomes of intact C6 and damaged C7 and C8 nerve roots. It is suggested that pain dermatomes are narrower than tactile dermatomes because thin fibres of the nociceptive system, activated by laser stimuli, probably do not overlap between adjacent spinal segments to the same extent as thick fibres of the mechanoreceptive system, activated by standard electrical or mechanical stimulation

Uveal Melanoma Therapies: quality of Life Effects

Reconstruction After Skin Cancer

Purpose: To assess quality of life after different treatments for uveal melanoma. Methods: Quality of life questionnaires were given to a randomized sample of 80 patients stratified according to the treatment (enucleation, 1131 plaque, helium irradiation, iridocyclochoroidectomy), and visual acuity. All patients were less than 60 years old with more than 3 years of follow-up. Results: Work performance decreased in 50% after enucleation and 60% in low vision group. After eye-wall resection, 90% had difficulty with night driving. Among enucleation cases, 80% were happy with the appearance and movement of the prosthesis. Eyelash loss was a cosmetic problem in 60% of helium treatment. Conclusion: Radiation treatment with preserved vision maintains better life quality in uveal melanoma.

Clinical quality indicators: infection prophylaxis for total knee arthroplasty

PJI DX Updated Search

Clinical quality indicators have a strong influence on reducing the overall financial impact, improving the outcomes, and minimizing the adverse events among patients undergoing elective total knee arthroplasty. In today's era of healthcare reform and increasing healthcare costs, it is important for orthopaedic nurses to be aware of the vital role clinical quality indicators play in the perioperative and postoperative settings

The mark coventry award: Patellofemoral arthroplasty results in better range of movement and early patient-reported outcomes than TKA

OAK 3 - Non-arthroplasty tx of OAK

Background: Controversy exists over the surgical treatment for severe patellofemoral osteoarthritis. We therefore wished to compare the outcome of patellofemoral arthroplasty (PFA) with TKA in a blinded randomized controlled trial. Questions/purposes: In the first 2 years after surgery: (1) Does the overall gain in quality of life differ between the implants based on the area under the curve of patientreported outcomes (PROs) versus time? (2) Do patients obtain a better quality of life at specific points in time after PFA than after TKA? (3) Do patients get a better range of movement after PFA than after TKA? (4) Does PFA result in more complications than TKA? Methods: Patients were eligible if they had debilitating symptoms and isolated patellofemoral disease. One hundred patients were included from 2007 to 2014 and were randomized to PFA or TKA (blinded for the first year; blinded to patient, therapists, primary care physicians, etc; quasiblinded to assessor). Patients were seen for four clinical followups and completed six sets of questionnaires during the first 2 postoperative years. SF-36 bodily pain was the primary outcome. Other outcomes were range of movement, PROs (SF- 36, Oxford Knee Score [OKS], Knee injury and Osteoarthritis Outcome Score [KOOS]) as well as complications and revisions. Four percent (two of 50) of patients died within the first 2 years in the PFA group (none in the TKA group), and 2% (one of 50) became ill and declined further participation after 1 year in the PFA group (none in the TKA group). The mean age at inclusion was 64 years (SD 8.9), and 77% (77 of 100) were women. Results: The area under the curve (AUC) up to 2 years for SF-36 bodily pain of patients undergoing PFA and those undergoing TKA was 9.2 (SD 4.3) and 6.5 (SD 4.5) months, respectively (p = 0.008). The SF-36 physical functioning, KOOS symptoms, and OKS also showed a better AUC up to 2 years for PFA compared with TKA (6.6 [SD 4.8] versus 4.2 [SD 4.3] months, p = 0.028; 5.6 [SD 4.1] versus 2.8 [SD 4.5] months, p = 0.006; 7.5 [SD 2.7] versus 5.0 [SD 3.6] months, p = 0.001; respectively). The SF-36 bodily pain improvement at 6 months for patients undergoing PFA and those undergoing TKA was 38 (SD 24) and 27 (SD 23), respectively (p = 0.041), and at 2 years, the improvement was 39 (SD 24) and 33 (SD 22), respectively (p = 0.199). The KOOS symptoms improvement at 6 months for patients undergoing PFA and those undergoing TKA was 24 (SD 20) and 7 (SD 21), respectively (p < 0.001), and at 2 years, the improvement was 27 (SD 19) and 17 (SD 21), respectively (p = 0.023). Improvements from baseline for KOOS pain, SF-36 physical functioning, and OKS also differed in favor of PFA at 6 months, whereas only KOOS symptoms showed a difference between the groups at 2 years. No PRO dimension showed a difference in favor of TKA. At 4 months, 1 year, and 2 years, the ROM change from baseline for patients undergoing PFA and those undergoing TKA was (-7° [SD 13°] versus -18° [SD 14°], p < 0.001; -4° [SD 15°] versus -11° [SD 12°], p = 0.011; and -3° [SD 12°] versus -10° [SD 12°], p = 0.010). There was no difference in the number of complications. During the first 2 postoperative years, there were two revisions in patients undergoing PFA (one to a new PFA and one to a TKA). Conclusions: Patients undergoing PFA obtain a better overall kneespecific quality of life than patients undergoing TKA throughout the first 2 years after operation for isolated patellofemoral osteoarthritis. At 2 years, only KOOS function differs between patients undergoing PFA and those undergoing TKA, whereas other PRO dimensions do not show a difference between groups. The observations can be explained by patients undergoing PFA recovering faster than patients undergoing TKA and the functional outcome being better for patients undergoing PFA up to 9 months. Patients undergoing PFA regain their preoperative ROM, whereas patients undergoing TKA at 2 years have lost 10° of ROM. We found no differences in complications.

Survival of patients with hormone refractory prostate cancer in the prostate specific antigen era

MSTS 2022 - Metastatic Disease of the Humerus

Purpose: The historically reported 12 to 18-month duration of survival of patients with hormone refractory prostate cancer is not consistent with current clinical experience. Furthermore, to our knowledge patient survival after serum prostate specific antigen (PSA) progressively increases from a nadir despite castrate testosterone has not been previously reported. For this reason we studied overall survival and the clinical variables that influence survival in patients with hormone refractory prostate cancer. Materials and Methods: The study focused on 254 patients with prostate cancer on androgen deprivation therapy. Hormone refractory prostate cancer was defined as the first in a series of PSA elevations despite castrate levels of testosterone. The duration of survival in the hormone refractory phase was calculated from the date of the first PSA elevation to the date of death. Results: Median survival after hormone refractory prostate cancer developed in patients initially staged with and without skeletal metastasis was 40 and 68 months, respectively. Six of more than 25 input variables were retained as significant in the final Cox model. Variables associated with longer survival were lower nadir PSA, younger age, higher pretreatment testosterone, no history of obstructive uropathy, no history of tobacco use (past or current) and lower alkaline phosphatase. Conclusions: Historical reports of survival in hormone refractory prostate cancer underestimate current survival observations. The likely explanations of this observation include delayed enrollment in clinical trials from which most survival data are derived, PSA lead time in staging and improved supportive care. Models predicting survival in patients with hormone refractory prostate cancer should consider multiple variables.

Osteochondral Allograft Transplantation of the Knee: Analysis of Failures at 5 Years

AMP (Acute Meniscal Pathology)

BACKGROUND: Osteochondral allograft transplantation (OAT) is being performed with increasing frequency, and the need for reoperations is not uncommon. PURPOSE: To quantify survival for OAT and report findings at reoperations. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A review of prospectively collected data of 224 consecutive patients who underwent OAT by a single surgeon with a minimum follow-up of 2 years was conducted. The reoperation rate, timing of reoperation, procedure performed, and findings at surgery were reviewed. Failure was defined by revision OAT, conversion to knee arthroplasty, or gross appearance of graft failure at second-look arthroscopic surgery. RESULTS: A total of 180 patients (mean [+/-SD] age, 32.7 +/- 10.4 years; 52% male) who underwent OAT with a mean follow-up of 5.0 +/- 2.7 years met the inclusion criteria (80% follow-up). Of these, 172 patients (96%) underwent a mean of 2.5 +/- 1.7 prior surgical procedures on the ipsilateral knee before OAT. Forty-eight percent of OAT procedures were isolated, while 52% were performed with concomitant procedures including meniscus allograft transplantation (MAT) in 65 (36%). Sixty-six patients (37%) underwent a reoperation at a mean of 2.5 +/- 2.5 years, with 32% (21/66) undergoing additional reoperations (range, 1-3). Arthroscopic debridement was performed in 91% of patients with initial reoperations, with 83% showing evidence of an intact graft; of these, 9 ultimately progressed to failure at a mean of 4.1 +/- 1.9 years. A total of 24 patients (13%) were considered failures at a mean of 3.6 +/- 2.6 years after the index OAT procedure because of revision OAT (n = 7), conversion to arthroplasty (n= 12), or appearance of a poorly incorporated allograft at arthroscopic surgery (n = 5). The number of previous surgical procedures was independently predictive of reoperations and failure; body mass index was independently predictive of failure. Excluding the failed patients, statistically and clinically significant improvements were found in the Lysholm score, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Short Form-12 physical component summary at final follow-up ( P < .001 for all), with inferior outcomes (albeit overall improved) in patients who underwent a reoperation. CONCLUSION: In this series, there was a 37% reoperation rate and an 87% allograft survival rate at a mean of 5 years after OAT. The number of previous ipsilateral knee surgical procedures was predictive of reoperations and failure. Of the patients who underwent arthroscopic debridement with an intact graft at the time of arthroscopic surgery, 82% experienced significantly improved outcomes, while 18% ultimately progressed to failure. This information can be used to counsel patients on the implications of a reoperation after OAT.

Carpal tunnel syndrome: reconciling "demand management" with clinical need

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Purchasers of surgical services are seeking justification for operative interventions with increasing frequency. This paper seeks to identify all relevant data currently available for carpal tunnel decompression; one of the commonest operative interventions in hand surgery. Such data, as is available, would suggest carpal tunnel decompression rates in the United Kingdom are relatively low, with fairly prolonged preoperative duration of symptoms

Popliteal artery injury: Royal Perth experience and literature review

DoD LSA (Limb Salvage vs Amputation)

BACKGROUND: Popliteal artery injury is uncommon but poses a significant challenge in Australian trauma care. Blunt trauma and knee dislocations appear to be associated with higher amputation rates. The aim of the present study was to review the authors' experience with this condition and discuss the best approach to investigation and management. METHODS: The medical records of all patients with popliteal artery injury (n = 19) who were entered prospectively onto the Royal Perth Hospital Trauma Registry from 1995 to 2003 were reviewed. Their demographic data, investigations, primary operative procedures, fasciotomy, primary and secondary amputation rates and mortality were determined. RESULTS: There were 17 male and two female patients with a median age of 34 years (range 17-62 years). Most patients (84%) were under 40 years in age. Blunt trauma was the commonest cause of popliteal artery injury (68.4%), and 84.6% of the patients had associated skeletal injury. The amputation rate in the present study was 26.3% (5/19). There were no intraoperative or in-hospital deaths. Three of 13 patients (23%) with blunt trauma underwent amputation, compared to two of six (33.3%) with penetrating injury. Two of three amputee patients in the blunt trauma group had dislocated knees. CONCLUSION: Despite technical improvements in management of popliteal artery injury, a high amputation rate is still seen, especially in patients with one or more of the following factors: extensive soft-issue injury, associated skeletal trauma, knee dislocation, and prolonged ischaemia time. Measures to reduce the amputation rate, ranging from more prompt diagnosis to modified surgical treatment techniques, are discussed.

Severe bilateral carpal tunnel syndrome in juvenile chronic arthritis

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Carpal tunnel syndrome, although rare, is known to occur in children mainly because of genetic or metabolic disorders. The clinical findings are variable and include symptoms of burning pain, tingling, numbness, and weakness or atrophy in the hands of the patients. It is usually diagnosed by demonstration of prolonged distal latency times during the electrodiagnostic studies. Reported here is a patient with juvenile chronic arthritis and a diagnosis of severe bilateral carpal tunnel syndrome, the first patient reported in the literature, to the best of the authors' knowledge

Anaesthesia for joint replacement surgery

AAHKS (9/10) Regional Nerve Blocks

With the ageing population, there is increasing demand for joint replacement surgery. Common joint replacement surgeries include hip, knee, elbow and ankle replacement. Elderly patients with multiple co-morbidities presenting for joint replacement surgery often pose challenges to our anaesthetic management. Careful preoperative assessment, perioperative anaesthetic plan and postoperative analgesic management can facilitate success of the surgery and avoid complications. © 2011 Elsevier Ltd. All rights reserved.

Stress moderates the effect of childhood trauma and adversity on recent drinking in treatment-seeking alcohol-dependent men

DoD PRF (Psychosocial RF)

OBJECTIVE: This study sought to clarify the relationship between childhood trauma and adversity with later alcohol consumption and the moderating effects of adult psychosocial stress. METHOD: Seventy-seven recently abstinent alcohol-dependent men attending residential treatment programs were assessed. Childhood trauma/adversity was assessed with the Childhood Trauma Questionnaire (CTQ), drinks per drinking day (DDD) with the Timeline Follow Back, and chronic psychosocial stress with the UCLA Stress Interview. Drinking and stress were retrospectively assessed for 6 months prior to the present treatment episode. Direct associations between childhood trauma/adversity and alcohol consumption and the moderating effects of recent psychosocial stress were assessed. All measures were considered as continuous variables. RESULTS: Pretreatment drinking severity (DDD) was associated with CTQ Total score (p = .009) and the Emotional Abuse (p < .001) and Physical Abuse (p < .01) subscales. UCLA Total Stress significantly moderated the effects of CTQ Total score on drinking severity (p = .04). Whereas higher CTQ scores were significantly associated with a greater amount of pretreatment drinking in participants with high UCLA stress scores (p = .01), CTQ scores were not associated with the amount of drinking in those with low UCLA stress scores (p = .63). CONCLUSIONS: Childhood trauma predicts drinking severity in alcohol-dependent men, and this effect is stronger in participants with ongoing stress in adult life. These findings suggest that early childhood trauma/adversity may sensitize stress-response systems.

Degenerative arthritis of the knee secondary to ochronosis: A case report

Surgical Management of Osteoarthritis of the Knee CPG

Alkaptonuria is a rare disease in which a deficiency in the homogentisate 1, 2-dioxygenase enzyme results in a buildup of homogentisic acid. Ochronosis, the deposition of excess homogentisic acid in connective tissue, causes brownish-black pigmentation and weakening of the tissue ultimately resulting in chronic inflammation, degeneration, and osteoarthritis. There is currently no definitive cure for alkaptonuric ochronosis, and management is usually symptomatic. However, total joint replacements in severe cases of ochronotic osteoarthritis have comparable outcomes to osteoarthritic patients without ochronosis. We report a case of a patient with ochronotic arthritis of the knee treated with total knee arthroplasty

No Learning Curve of the Direct Superior Approach in Total Hip Arthroplasty

Hip Fx in the Elderly 2019

OBJECTIVES: To assess the learning curve of the direct superior approach (DSA) for total hip arthroplasty (THA) and to compare surgical, clinical, and radiological results with a matched control group using the mini posterior approach (MPA). METHODS: A prospective cohort study was performed from October 2016 to May 2017 including our first 52 patients undergoing THA using the DSA. Patients with primary osteoarthritis or osteonecrosis and a body mass index (BMI) < 35 who were eligible for surgery were included. As a control group, 52 patients who underwent the MPA were included, matched based on age, BMI, and ASA classification. In the DSA group, damage to the iliotibial tract and the distal external rotators, including the external obturator and quadriceps femoris muscles, was avoided. Outcome measures were collected, including surgical time, blood loss, postoperative pain, length of stay, implant position, use of walking aids, patient reported outcome measures (PROM), and complications. Unpaired t-tests were used to analyze differences between the DSA and the MPA group in surgical time, blood loss, length of stay, and acetabular and femoral component position. chi² -tests were used to analyze mobility and the number of complications. Two-way repeated measures ANOVA was used to analyze pain scores and PROM between the DSA and the MPA groups. RESULTS: The mean surgical time of 61 min (SD 8) in the DSA group was longer (P < 0.001) compared to that in the MPA group, 46 min (SD 12). No differences were found in blood loss, postoperative pain, or mean length of stay in the hospital. After 6 weeks, 94% of the patients in the DSA group were able to walk inside their home without walking aids compared to 90% in the MPA group. The mobility scores were not different after follow up of 6 weeks and 1 year (P = 0.12 and P = 0.36 respectively). All PROM improved postoperatively in both the DSA and the MPA group (P < 0.01). Acetabular cup and femoral stem position were not compromised by the DSA. Complications included two Vancouver B2 periprosthetic fractures in the DSA group, of which there was one surgical-related fracture and one fracture after a traffic accident. Complications in the MPA group included one periprosthetic fracture, two hip dislocations, and one ischial neuropathy. No infections or thromboembolic events were observed. The 1-year complication rate was not different between the MPA and DSA groups (P = 0.40). CONCLUSION: The DSA can be safely introduced as no learning curve in the prosthesis position or the complication rate was found.

Comparative analysis of visual field and image distortion in 30° and 70° arthroscopes

AMP (Acute Meniscal Pathology)

PURPOSE: There have been very few attempts to compare the visual fields and image distortion in arthroscopes. To better understand the images generated using existing arthroscopes, we performed image-mapping experiments to assess field of view and image distortion. The purpose of this study was to quantify and compare the visual fields obtained using 30° and 70° arthroscopes and assess image distortion in each arthroscope. METHODS: A complete arthroscopy system was used in this study. To perform this quantitative analysis, we created a customized measurement device that consisted of three parts: (1) distance marker, (2) chessboard pattern, and (3) angle marker. Three observers collectively assessed the appropriate position of the arthroscope during simulation. For each scope, ten simulations were performed at distances between 1 and 3 cm. Using the obtained arthroscope images, field of view and image distortion were measured and calculated. RESULTS: The field of view of the 70° arthroscope was 5, 10, and 15 mm wider in diameter in comparison with the 30° arthroscope at 1, 2, and 3 cm, respectively. Moreover, the 70° arthroscope had less 0.66, 0.13, and 0.26 pixels of root-mean-square distance than the 30° arthroscope at 1, 2, and 3 cm, respectively. The 70° arthroscope also contained 0.78 pixels less at the maximal error than the average 30° arthroscope. Therefore, the 70° arthroscope demonstrated less distortion than the 30° arthroscope. There was no significant difference between the two scopes with respect to median curvature measurement at 1-cm distance. CONCLUSION: The 70° arthroscope demonstrates technical advantages over the 30° arthroscope, including a wider field of view and a less image distortion at the periphery. A wide angle and less image distortion can help better orient the surgeon within the joint cavity when a panoramic picture is needed to repair rotator cuff tears, in case of hip arthroscopy, or while treating the lesions of posterior horn of medial meniscus.

What Is the Failure Rate After Arthroscopic Repair of Bucket-Handle Meniscal Tears? A Systematic Review and Meta-analysis

AMP (Acute Meniscal Pathology)

BACKGROUND: Meniscal repair has become the treatment of choice for meniscal tears, especially in the subset of bucket-handle meniscal tears (BHMTs). However, a comprehensive estimate of the corresponding failure rate is not available, thus maintaining doubts about the healing potential of these tears. Furthermore, a wide range of factors to predict high failure rates have been reported but with conflicting evidence. PURPOSE: To determine the failure rate after arthroscopic repair of BHMTs as reported in the literature, compare this with the failure rate of simple meniscal tears extracted from the same studies, and analyze the influence of factors previously reported to be predictive of meniscal repair failure. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: A systematic search was conducted by 2 independent reviewers using principal bibliographic databases (PubMed, Scopus, Cochrane Library, and EMBASE). After a stepwise exclusion process, 38 articles met the inclusion criteria. Failure rate data were analyzed with a random-effects proportional meta-analysis (weighted for individual study size), and forest plots were constructed to determine any statistically significant differences between BHMTs versus simple tears (longitudinal, radial, or horizontal), medial versus lateral BHMTs, isolated procedures versus repairs with concomitant anterior cruciate ligament reconstruction, and tears in red-red versus red-white zones. Moreover, a meta-regression analysis was conducted to evaluate the effect of patient age and sex, suture technique (in-out or all-inside), time from injury to surgery, mean number of stitches, and length of follow-up on failure rates. RESULTS: The pooled failure rate was 14.8% (95% CI, 11.3%-18.3%; I² = 77.2%). A total of 17 studies provided failure rates of both BHMT repairs (46/311 repairs) and simple tear repairs (54/546 repairs), demonstrating a significantly higher failure rate for BHMT repairs (risk ratio [RR] = 1.50; 95% CI, 1.05-2.15; I² = 0%; P = .03). Medial BHMT repairs (RR = 1.94; 95% CI, 1.25-3.01; I² = 0%; P = .003) and isolated repairs (RR = 1.77; 95% CI, 1.15-2.72; I² = 0%; P = .009) had statistically higher risk of failure, but no statistically significant difference was found between tears in red-red versus red-white zones. Among the other factors evaluated with meta-regression, only the mean number of stitches showed a statistically significant effect on failure rates. CONCLUSION: Based on the currently available literature, this systematic review provides a reasonably comprehensive analysis of failure rate after arthroscopic BHMT repair; failure is estimated to occur in 14.8% of cases. Medial tears and isolated repairs were the 2 major predictors of failure.

An in vivo histopathological comparison of single and double pulsed modes of a fractionated CO(2) laser

Panniculectomy & Abdominoplasty CPG

INTRODUCTION: Studies examining the histopathological changes that occur in human skin following fractional laser treatment have been performed mainly in animals or abdominal tissue prior to abdominoplasty. This study looks at the effect of double pulse fractional CO(2) laser compared to single pulse treatments to assess differences in tissue injury in the face and abdomen. METHODS: Twelve healthy subjects randomized into two groups, had two 1 cm(2) areas (infraumbilical and forehead) treated with the fractional CO(2) laser (Deep Fx, Lumenis). Settings used were 15 mJ double pulse, and 30 mJ single pulse, 300 Hz, 10% density and compared to the historic control of 15 patients treated at 15 mJ single pulse [Bailey et al. (2011), Lasers Surg Med 43: 99-107]. Treated sites were biopsied and analyzed with H&E and TUNEL staining to measure width and depth of the microthermal zones (MTZ) of ablation. RESULTS: When comparing 15 mJ double pulse to single pulse there were significant differences both in depth (abdominal skin, P = 0.002 and facial skin, P = 0.001) and width (facial skin, P = 0.0002) of MTZ. When comparing double pulsing at 15 mJ with single pulsing at 30 mJ there were significant differences between MTZ depths in the abdomen (P < 0.01) but not in either the MTZ depth (P = 0.69) or the width in the face (P = 0.502). DISCUSSION: This study demonstrates the differences between histopathological laser injury patterns in the face compared to the abdomen when single pulsing is used. It also demonstrates that double pulsing at 15 mJ is statistically similar to single pulsing at 30 mJ in the face. We think this could have ramifications for clinical practice where by double pulsing at lower energies may result in better clinical outcomes than increasing energies or using multiple passes at single pulse. Clinical studies needs to be performed to investigate this further.

Primary cemented hemiarthroplasty for unstable intertrochanteric fractures in elderly severe osteoporotic patients

Hip Fx in the Elderly 2019

OBJECTIVE: To evaluate the outcome of unstable intertrochanteric fractures with primary cemented hemiarthroplasty (HA) in elderly severe osteoporotic patients. MATERIAL AND METHODS: In January 2009 to July 2017, 277 patients were selected according to inclusion criteria and results were analyzed prospectively. According to AO/OTA Classification, only type 31-A2.2(148 cases) and 31-A2.3(129cases) were included. 53 cases were males and 224 cases were females. The mean age was 75.4 years. The mean follow-up period was 50 months. The Harris Hip Score (HHS) and perioperative index (including the time duration of the surgery, intraoperative blood loss, postoperatively weight bearing time, implant complications) were analyzed clinically. RESULTS: Follow-up evaluations were performed at 6 weeks, 3, 6, 9 and 12 months, and every year thereafter (mean 50 months). The average duration of surgery was 43.2 min (range 21-65 min), with a mean blood loss of 225.8 ml (range 70-425 ml). All patients were out of the bed and mobile with help of walker with average of 3.3 days (range 1-5 days). The average duration of hospital stay was 12.3 days. Average HHS improved from 83.7 (range 63-90) at 6 months follow up to 90.3 (range 74-92) at final follow up. CONCLUSION: For the severe osteoporotic elderly with unstable fractures, bipolar hemiarthroplasty is an effective method to treat the unstable intertrochanteric fractures in the severe osteoporotic elderly. It can decrease complications, reduce mortality, improve the patient's life quality, and reduce family burden. In Summation, when deciding on treatment methods for intertrochanteric fractures several factors must be considered, which are (included but not limited to) the type of fracture, the patient's age, health status, severity of osteoporosis. As long as there was no absolute contraindication for surgery, it is appropriate to have surgery and to restore function as early as possible.

Pediatric running injuries

Osteochondritis Dissecans 2020 Review

As more children have become involved in athletic activities and running, there has been a significant increase in overuse injuries. The young athlete with open growth plates is vulnerable to unique overuse injuries involving the apophyses, articular cartilage, and growth plate. The physician caring for these young athletes needs to be aware of these conditions to diagnose and treat them appropriately. Physicians should also be aware of the risk of overtraining and overuse injury in athletes participating in year-round sports and competition. Current guidelines for overuse injury prevention in young athletes are primarily based on consensus and expert opinion. Further research is needed to provide evidence-based guidelines for overuse injury prevention in young athletes and runners. © 2010 Elsevier Inc.

Three-Dimensional Bioprinting of Cartilage by the Use of Stem Cells: A Strategy to Improve Regeneration

AMP (Acute Meniscal Pathology)

Cartilage lesions fail to heal spontaneously, leading to the development of chronic conditions which worsen the life quality of patients. Three-dimensional scaffold-based bioprinting holds the potential of tissue regeneration through the creation of organized, living constructs via a "layer-by-layer" deposition of small units of biomaterials and cells. This technique displays important advantages to mimic natural cartilage over traditional methods by allowing a fine control of cell distribution, and the modulation of mechanical and chemical properties. This opens up a number of new perspectives including personalized medicine through the development of complex structures (the osteochondral compartment), different types of cartilage (hyaline, fibrous), and constructs according to a specific patient's needs. However, the choice of the ideal combination of biomaterials and cells for cartilage bioprinting is still a challenge. Stem cells may improve material mimicry ability thanks to their unique properties: the immune-privileged status and the paracrine activity. Here, we review the recent advances in cartilage three-dimensional, scaffold-based bioprinting using stem cells and identify future developments for clinical translation. Database search terms used to write this review were: "articular cartilage", "menisci", "3D bioprinting", "bioinks", "stem cells", and "cartilage tissue engineering".

A coordination project for improvement of osteoporosis medication use among patients who sustained an osteoporotic fracture: The Israeli experience

Hip Fx in the Elderly 2019

Objectives: The aim of this study was to examine whether coordination between healthcare providers at an inpatient rehabilitation facility and healthcare providers in a community setting improves osteoporosis medication use in the community. Methods: In 2012, a coordination project between an inpatient geriatric rehabilitation facility located in north-central Israel and general practitioners in the community setting was initiated. In this retrospective pseudo-experimental study, we compared osteoporosis medication use among patients who were hospitalized at the facility following an osteoporotic fracture during 2011â??2012, and who constituted the control group (n=120), and patients who were hospitalized at the facility during 2013â??2015, and who constituted the trial group (n=129). Data were collected from the patients' records and from records of the health maintenance organization concerning medications issued to the patients by pharmacies. Results: Differences were observed between the trial and the control group in osteoporosis medication management by healthcare providers, both at the inpatient rehabilitation facility and in the community, suggesting favorable trends. However, osteoporosis medication use in the community was slightly lower in the trial group, then in the control group (32.8% vs. 34.2%, respectively). A regression analysis indicated that the only variable predicting use of osteoporosis medications in the community was a previous diagnosis of osteoporosis in the community. Conclusions: The study results indicate that mere coordination between the healthcare settings is insufficient in order to ensure continued care in the community, emphasizing the need for an osteoporosis coordinator.

Old displaced fracture of the scaphoid. An unusual cause of carpal tunnel syndrome

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

The case of a 37-year-old man with carpal tunnel syndrome and a palpable mass in the proximal wrist is reported. Roentgenograms revealed an old middle-third scaphoid fracture with the proximal pole displaced into the proximal carpal tunnel. Excision of this mass led to a complete resolution of the patient's carpal tunnel problem

The rationale for the new infective endocarditis guidelines

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Given the terrible consequences of infectious endocarditis (IE), it has become a time-honored strategy to use antibiotics as prophylaxis against IE for invasive procedures associated with bacteremia with endocarditis-causing organisms. The evidence supporting this approach has come predominantly from animal models of endocarditis or observational human studies. Prompted by the desire to realistically assess the evidence base for a health policy with global implications and against the backdrop of increasing microbial resistance to antibiotics, a careful review of all available data regarding the effectiveness of prophylaxis against IE was performed. This reanalysis prompted a new set of recommendations for IE prevention, published in 2007 by the American Heart Association, which represented a marked divergence from 50 years of prior publications. The rationale and underpinning evidence for the new recommendations are reviewed here, with an eye to the gaps in the available evidence and the need for future research

Carpal tunnel syndrome

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

INTRODUCTION: Carpal tunnel syndrome is a neuropathy caused by compression of the median nerve within the carpal tunnel. However, the severity of symptoms and signs does not often correlate well with the extent of nerve damage. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, non-drug treatments, surgical treatments, and postoperative treatments for carpal tunnel syndrome? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 53 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, carpal tunnel release surgery (open and endoscopic), diuretics, internal neurolysis, local and systemic corticosteroids, massage therapy, nerve and tendon gliding exercises, non-steroidal anti-inflammatory drugs (NSAIDs), pyridoxine, therapeutic ultrasound, and wrist splints

3D Printing of a Double Network Hydrogel with a Compression Strength and Elastic Modulus Greater than those of Cartilage

AMP (Acute Meniscal Pathology)

This article demonstrates a two-step method to 3D print double network hydrogels at room temperature with a low-cost ($300) 3D printer. A first network precursor solution was made 3D printable via extrusion from a nozzle by adding a layered silicate to make it shear-thinning. After printing and UV-curing, objects were soaked in a second network precursor solution and UV-cured again to create interpenetrating networks of poly(2-acrylamido-2-methylpropanesulfonate) and polyacrylamide. By varying the ratio of polyacrylamide to cross-linker, the trade-off between stiffness and maximum elongation of the gel can be tuned to yield a compression strength and elastic modulus of 61.9 and 0.44 MPa, respectively, values that are greater than those reported for bovine cartilage. The maximum compressive (93.5 MPa) and tensile (1.4 MPa) strengths of the gel are twice that of previous 3D printed gels, and the gel does not deform after it is soaked in water. By 3D printing a synthetic meniscus from an X-ray computed tomography image of an anatomical model, we demonstrate the potential to customize hydrogel implants based on 3D images of a patient’s anatomy.

Fasciotomy wounds associated with acute compartment syndrome: A systematic review of effective treatment

DOD - Acute Comp Syndrome CPG

Background: Compartment syndrome of the limbs can occur in patients following limb trauma. The only definitive treatment is fasciotomy, i.e. a surgical procedure where the fascia is cut to relieve tension or pressure. The fasciotomy wounds created must be left open until the swelling has reduced enough to allow for closure of the wounds. The resulting wounds can be difficult to manage, and the wounds often cannot be closed without the use of split thickness skin grafts. Objectives: To identify the best available evidence on the effectiveness of treatment options for managing fasciotomy wounds acquired due to treatment for acute compartment syndrome in the limbs. Inclusion criteria: Types of participants: Patients of either gender and any age who has acquired a fasciotomy wound as a result of treatment for acute compartment syndrome of the limb occurring as a result of injury (excluding compartment syndrome resulting from burns). Types of intervention(s): Studies that evaluate the effectiveness of different options for treating fasciotomy wounds. Types of studies: Quantitative studies including randomized controlled trials, cohort studies and case series. Types of outcomes: Outcomes considered were the duration for wound closure, rate of wound healing without the need for skin grafting, degree of scaring, length of stay, wound infection and dehiscence rates, neurological deficit rates and pain. Search strategy The search strategy aimed to find both published and unpublished studies using a comprehensive three-step search strategy. Studies published in English language, with human subjects, from January 1960 to June 2012 were considered for inclusion. Critical appraisal was conducted by two independent reviewers. Data collection: Data were extracted from papers included in the review using the standardized data extraction tools from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. Data analysis: Quantitative data were pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. Effect sizes expressed as odds ratio (for categorical data) and their 95% confidence intervals were calculated for analysis. Heterogeneity was assessed statistically using the standard Chi-square. Where statistical pooling was not possible the findings were presented in narrative form including tables and figures. Results: The systematic review found 32 studies that met the protocol criteria and passed critical appraisal (one randomized controlled trial, eight cohort studies and 23 case series). The 32 studies examined a wide variety of different wound treatment and closure techniques and greatly varied in the number and method of outcomes measured. As a result only the randomized controlled trial results and only four of the cohort studies could be meta-analyzed. Conclusions: The systematic review found limited evidence on which to base practice decisions. The single randomized controlled trial should be replicated to confirm findings before practice change can be confidently recommended. The limited available evidence suggested that the vessel loop shoelace technique achieved wound closure quicker and with less need for split thickness skin graft than a negative pressure wound treatment system such as Vacuum Assisted Closure®. A negative pressure wound treatment system, such as Vacuum Assisted Closure®, appeared to achieve wound closure quicker than using the traditional saline soaked gauze with less need for split thickness skin grafts to achieve closure. Implications for practice: Clinicians should consider selecting a dynamic type of wound closure device to increase the chances of closing the fasciotomy wound without the need for split thickness skin graft. There are a variety of techniques and devices but the strongest available research supports the use of the vessel loop shoelace technique. Care must be taken when using any type of dynamic closure device to leave the wound open and free of pressure for the first few days to avoid the risk of a recurrence of the compartment syndrome. Negative pressure wound therapy should be used with care in fasciotomy wound treatment as the risk of requiring a split thickness skin graft to achieve wound closure is higher than with vessel loop shoelace technique. Saline soaked gauze is not recommended for use with fasciotomy wounds. Implications for research: Further research is required to compare different wound treatment techniques with each other and to combine different techniques together. Outcome measures should be standardized in future research, both in terms of what is included and how these are measured. This will improve the possibilities for meta-analysis of study results in the future. © The authors 2014.

Unipolar versus bipolar hemiarthroplasty for the treatment of femoral neck fractures in the elderly

HipFx Supplemental Cost Analysis

This paper presents the short term results of an ongoing prospective randomized trial comparing a cemented unipolar with a cemented bipolar hemiarthroplasty for the treatment of displaced femoral neck fractures in the elderly. Forty-seven patients with an average age of 77 years completed 6-month followup. Outcomes at 6 weeks, 3 months and 6 months were assessed by completion of a patient oriented hip outcome instrument and by functional tests of walking speed and endurance. No differences in the postoperative complication rates or lengths of hospitalization were seen between the two groups. Patients treated with a bipolar hemiarthroplasty had greater range of hip motion in rotation and abduction and had faster walking speeds. However, no differences in hip rating outcomes were found. These early results suggest that use of the less expensive unipolar prosthesis for hemiarthroplasty after femoral neck fracture may be justified in the elderly

Relationship between years in the trade and the development of radiographic knee osteoarthritis and MRI-detected meniscal tears and bursitis in floor layers. A cross-sectional study of a historical cohort

OAK 3 - Non-arthroplasty tx of OAK

Objectives: An increased risk of developing knee disorders including radiographic knee osteoarthritis (OA) have been shown among workers with kneeling working demands. There may also be a dose-related association between duration of employment in occupations with kneeling work and development of radiographic knee OA and magnetic resonance imaging (MRI)-detected meniscal tears and bursitis. Design: A cross-sectional study of a historical cohort. Setting: Members of the trade unions for floor layers and graphic designers in Denmark. Participants: 92 male floor layers and 49 graphic designers aged 36-70 years were randomly selected among participants from a clinical and radiographic study of 156 floor layers and 152 graphic designers. Outcome measures: Radiographic tibiofemoral (TF) and patellofemoral (PF) knee-OA and MRI-detected meniscal tears and bursitis. Results were adjusted for age, earlier knee traumas, sports activities and body mass index in logistic regression models. Association between TF OA and years in the floor-laying trade was graphically examined by a restricted cubic spline with four knots. Results: Increase in number of years with exposure to kneeling work is associated with radiographic TF knee OA with ORs 0.7, 95% CI 0.07 to 4.42; OR 1.89, 95% CI 0.29 to 12.3; OR 4.82, 95% CI 1.38 to 17 for <20 years, 20-30 years and >30 years of kneeling work, respectively. MRI-verified medial meniscal tears was increased among subjects with kneeling work with OR 1.96, 95% CI 0.79 to 4.88 to OR 4.73, 95% CI 1.16 to 19.4 but was not associated with duration of employment. Periarticular bursitis was increased in subjects with <20 years of kneeling working activity. Lateral meniscal tears and PF knee OA were not associated with duration of kneeling working activity or with kneeling work in general. Conclusions: The findings suggest a doseeresponse relationship for radiographic TF knee OA in floor layers with a significant amount of kneeling work and an increase of MRI-verified medial meniscal tears among workers with kneeling work.

The Patella Pro study - effect of a knee brace on patellofemoral pain syndrome: design of a randomized clinical trial (DRKS-ID:DRKS00003291)

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Patellofemoral pain syndrome (PFPS) is a frequent cause of anterior knee pain predominantly affecting young female patients who do not have significant chondral damage. Development of PFPS is probably multifactorial, involving various knee, hip, and foot kinematic factors. Biomechanical studies have described patellar maltracking and dynamic valgus (functional malalignment) in patients with patellofemoral pain syndrome. The literature provides evidence for short-term use of nonsteroidal anti-inflammatory drugs; short-term medially directed taping; and exercise programs focusing on the lower extremity, hip, and trunk muscles. Evidence supporting the use of patellar braces is limited because previous studies have been low quality. The aim of this article is to publish the design of a prospective randomized trial that examines the outcomes of patients with PFPS after treatment with a new patellar brace (Patella Pro) that applies medially directed force on the patella. METHODS/DESIGN: For this multicenter trial, 156 patients (adolescents and young adults) with PFPS were recruited from orthopedic practices and orthopedic hospitals and randomly allocated to 3 months of supervised physiotherapy in combination with the Patella Pro brace or supervised physiotherapy alone. The primary outcome measures are pain (numerical analog scale); knee function (Kujala score and Knee Injury and Osteoarthritis Outcome Score); and self-reported perception of recovery at baseline, 6 weeks, 3 months, and 1 year. DISCUSSION: Only limited evidence for the use of a patellar brace for the treatment of PFPS exists in the literature. Disputable evidence for the use of orthoses for PFPS patients has been presented in one meta-analysis, in which only one of three studies found the effect of a medially directed patellar brace to be significant. Because of these low-quality studies, the authors concluded that this evidence should be regarded as limited, and we feel there is a need for further well-designed studies to evaluate the effect of patellar bracing on PFPS-related pain. The Patella Pro study is a prospective randomized trial in which supervised physiotherapy in combination with a patellar brace is compared with supervised physiotherapy alone. This trial started in April 2012 and finished in October 2013. TRIAL REGISTRATION: DRKS-ID:DRKS00003291, January 3rd, 2012.

Long-term assessment of gait biomechanics in patients with total knee arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Purpose: Clinical and radiographic improvements following Total Knee Arthroplasty (TKA) are sustained for up to 15 years following surgery. In contrast, much less is known about the knee biomechanics in the longterm after TKA. Biomechanical characteristics of gait may be associated with functional outcome and longevity of the prosthesis, however it is not clear what may be expected of knee biomechanics greater than 2 years following TKA. It is possible that potentially deleterious biomechanical changes are incremental, and therefore that identification of these changes may create opportunities for intervention that delays further surgery. Therefore, the aim of this study was to assess the knee biomechanics of patients at one and seven years following TKA during level walking. Methods: Forty patients were assessed twelve months following total knee arthroplasty for knee osteoarthritis (age = 69.1(plus or minus)8.0 years, height = 165.5(plus or minus)11.5 cm, weight = 86.4(plus or minus)17.5 kg, 22 males). All participants received the same posterior stabilised prosthesis. Thirty-four of these patients were reassessed 7 years post-TKA. At both assessments, participants' knee biomechanics were measured during walking at two speeds (self-selected and maximum pace) using an 8 camera Vicon motion analysis system (Vicon Systems, Oxford, UK). The biomechanical variables of interest were the maximum knee flexion during stance, flexion excursion during stance, maximum knee extension during stance, maximum knee flexion during swing, maximum knee flexion moment, maximum knee extension moment and maximum knee adduction moment. These variables were compared between assessments using paired t-test with an adjusted significance level of p<0.01. To establish whether the patients who returned were representative of the entire cohort, an independent t-test was calculated to compare these variables at the one year assessment between the patients who completed the 7 year assessment and those who didn't. Participants also completed the American Knee Society Knee Score and the Total Knee Function Questionnaire. Results: All patients in the initial cohort achieved good to excellent outcome on the American Knee Society Score (mean = 79.7 out of 100), and 78% were 'more than satisfied' with their TKA as measured by the Total Knee Function Questionnaire. Eighteen participants of the original sample were able to complete the biomechanical assessment seven years following TKA. Participants who did not complete the assessment had undergone recent orthopaedic surgery (5), developed neurological disease (5), or other illness (6) that affected walking. None of the original cohort had undergone TKA revision. Between the first and seventh post-operative year there was no change in walking speed either at self-selected (p = 0.98) or maximum pace (0.39). There was also no change in any of the knee angle variables or peak moments at either self-selected or maximum pace (Table 1). Participants who completed testing at seven years were not different in age (p = 0.30), height (p = 0.43) or weight (p = 0.76) from the initial cohort. There were also no differences in walking speed, knee angles or moments. Conclusions: In patients without co-morbidities that affect gait, knee biomechanics at 12 months following TKA were unchanged for up to 7 years, even when patients were challenged to walk at maximal pace. Whilst it is possible that the patients who returned had better outcomes than those who did not, these findings nonetheless suggest that a significant proportion of patients may not be at risk of biomechanicalrelated prosthesis failure with greater time since surgery. A large proportion of patients were unable to complete testing, but all for reasons other than issues with the operated TKA. This adds support to recent evidence that co-morbidities and the integrity of other joints in the lower limb may influence outcome more than the index TKA. (Table Presented)

Meniscus Tears: Treatment in the Stable and Unstable Knee

AMP (Acute Meniscal Pathology)

Basic science research and follow-up studies after meniscectomy have provided convincing evidence of the importance of preservation of the meniscus in decreasing the risk of late degenerative changes. Whether in a stable or an unstable knee, if a meniscus tear cannot be repaired, a conservative partial meniscectomy should be undertaken to preserve as much meniscal tissue as possible. When feasible, repair should be carried out in young patients with an isolated meniscus tear, despite healing rates that are significantly lower than those obtained when meniscus repair is done with anterior cruciate ligament (ACL) reconstruction. The incidence of successful healing is inversely related to the rim width and tear length. In general, meniscus repair should be limited to patients under 50 years of age. Vertical longitudinal tears, including bucket-handle tears, are most amenable to repair. Some radial split tears can be repaired. In an ACL-deficient knee, meniscus repair is more prone to failure if not performed in conjunction with an ACL reconstruction, and is not recommended. Meniscal allograft surgery is investigational but may hold promise for selected patients.

Epidemiology of highly endemic multiply antibiotic-resistant shigellosis in children in the peruvian amazon

Patrick’s pharmacoepidemiology project

OBJECTIVE. Our goal was to estimate the impact of a Shigella vaccine in an area where shigellosis is endemic by characterizing the disease burden and antibiotic-resistance profiles of isolates and by determining the prevalence of Shigella flexneri serotypes. PATIENTS AND METHODS. We conducted a 43-month-long prospective, community-based diarrheal disease surveillance in 442 children <72 months of age in the Peruvian Amazon between October 1, 2002, and April 15, 2006. RESULTS. The incidence of diarrheal disease was 4.38 episodes per child-year. The incidence rate for shigellosis was 0.34 episodes per child-year in children <72 months of age and peaked in children between 12 and 23 months at 0.43 episodes per child-year. Maternal education at or beyond the primary grade level, piped water supply, weight-for-age z score, and improved water-storage practices were the most significant determinants of disease in this community with living conditions comparable to many rural areas in the developing world. CONCLUSIONS. Children living in this region had a 20-fold higher rate of disease incidence detected by active surveillance as those recently estimated by passive detection. Most symptomatic disease was caused by S flexneri, although the diversity of serotypes will require a multivalent vaccine to have a significant impact on the burden of disease caused by shigellosis. Several other public health disease-control interventions targeted at water source and improved storage, nutritional interventions, and improved maternal education seem to have a greater impact than a univalent S flexneri 2a vaccine. Copyright �© 2008 by the American Academy of Pediatrics

Surface Arthroplasty for Treating Primary and/or Secondary Shoulder Osteoarthrosis by Means of the Hemicap-Arthrosurface() System

Glenohumeral Joint OA

OBJECTIVE: To present the surgical technique for the He-miCAP-Arthrosurface() system and evaluate our results from this technique for treating primary and/or secondary shoulder osteoarthrosis. METHOD: Between June 2007 and June 2009, 10 shoulders of 10 patients (nine with primary osteoarthrosis and one with avascular necrosis of the humeral head) underwent surface arthroplasty using the HemiCAP-Arthrosurface() system to correct the problem. The follow-up time ranged from six to 29 months (mean of 17 months). The patients' ages ranged from 62 to 73 years (mean of 67.5 years). Six patients were female and four patients were male. The patients were followed up weekly for the first month after the surgical procedure and every three months thereafter. The clinic evaluation was done using the criteria of the University of California at Los Angeles (UCLA) and a visual analogue pain scale. RESULTS: All the patients said that they were satisfied with the results from the surgical treatment, with a mean UCLA score of 30 points and a mean analogue pain score of two points. CONCLUSION: The HemiCAP-Arthrosurface() system for shoulder surgery for a specific group of patients is a technique that preserves the bone stock with good functional and antalgic results.

Periprosthetic knee infection: ten strategies that work

PJI DX Updated Search

Periprosthetic joint infection (PJI) is one of the most serious complications following total knee arthroplasty (TKA). The demand for TKA is rapidly increasing, resulting in a subsequent increase in infections involving knee prosthesis. Despite the existence of common management practices, the best approach for several aspects in the management of periprosthetic knee infection remains controversial. This review examines the current understanding in the management of the following aspects of PJI: preoperative risk stratification, preoperative antibiotics, preoperative skin preparation, outpatient diagnosis, assessing for infection in revision cases, improving culture utility, irrigation and debridement, one and two-stage revision, and patient prognostic information. Moreover, ten strategies for the management of periprosthetic knee infection based on available literature, and experience of the authors were reviewed

Management of stroke in cancer

MSTS 2022 - Metastatic Disease of the Humerus

Cerebrovascular disorders, including brain infarction, brain hemorrhage, and cerebral venous thrombosis, can occur as an early sign of cancer, but typically occur late in the clinical course. These disorders are due to a variety of pathogenic mechanisms, including coagulation disorders associated with the cancer, invasion or compression of vessels from tumor in or adjacent to the brain, and the adverse effects of cancer therapy. The appropriate therapy for these cerebrovascular disorders is empiric in most instances, because as yet there are no prospective treatment trials for them. A review of the existing literature reveals that improvement in patient quality of life and prevention of further cerebrovascular events can be obtained in some clinical situations. Copyright © 2008 by Current Medicine Group LLC.

Corrective osteotomy for volar instability of the distal radioulnar Joint associated with radial shaft malunion

Distal Radius Fractures

Volar instability of the distal radioulnar joint is an uncommon wrist disorder. We report three cases of recurrent volar instability of the distal radioulnar joint secondary to fracture of the radial shaft. In all cases, X-rays showed a volar apex deformity of the radial shaft. Opening wedge osteotomy and iliac bone grafting was performed on the distal diaphysis of the radius instead of on the radial shaft, in order to adjust the distal radioulnar joint more easily. Pre-operative dislocations and painful clunks disappeared in all three patients. However, slight instability of the distal radioulnar joint remained in all cases. Osteoarthritis of the distal radioulnar joint was noted in one patient 31 months after the operation. All of the patients were satisfied with the results and did not desire further operations.

Association between thigh muscle strength four years after partial meniscectomy and radiographic features of osteoarthritis 11 years later

AMP (Acute Meniscal Pathology)

BACKGROUND: Meniscus injury and meniscectomy both entail increased risk of knee osteoarthritis (OA). Thigh muscle weakness is a suggested mediator of OA but there is little evidence of its importance for knee OA development after meniscectomy. This study aimed to examine the association between thigh muscle strength after partial meniscectomy in middle-aged subjects with a non-traumatic meniscal tear and later radiographic knee OA changes. METHODS: Thirty-four out of 45 participants in an exercise-trial underwent testing for isokinetic thigh muscle strength 4 years after arthroscopic partial meniscectomy and had radiographic examination 11 years later (15 years post-surgery, mean age at follow-up of 57 years (range 50-61)). Outcomes were grade of joint space narrowing and osteophyte score in the medial tibiofemoral compartment of the operated knee and the contralateral knee. We tested the association between muscle strength at baseline and the radiographic outcomes at follow-up using logistic regression analyses adjusted for sex and overweight. RESULTS: At follow-up, 33/34 subjects had joint space narrowing and 27/34 subjects had osteophytes in the operated knee, in the contralateral knee joint space narrowing was found in 23 subjects. In the operated knee baseline knee extensor and flexor strength were negatively associated with grade of joint space narrowing at follow-up (OR 0.972 and 0.956, p = 0.028 and 0.026, respectively) and also with osteophyte score (OR 0.968 and 0.931, p = 0.017 and 0.011, respectively). In the contralateral knee longitudinal associations between strength and radiographic OA features were similar, OR 0.949-0.972, p < 0.05. CONCLUSION: The finding that stronger thigh muscles 4 years after meniscectomy were associated with less severe osteoarthritic changes in the medial tibiofemoral compartment of both the operated and contralateral knee 11 years later, may suggest that strong thigh muscles can help to preserve joint integrity in middle-aged subjects at risk of knee OA.

Loss of normal knee motion after anterior cruciate ligament reconstruction is associated with radiographic arthritic changes after surgery

Anterior Cruciate Ligament Injuries CPG

BACKGROUND: Meniscectomy and articular cartilage damage have been found to increase the prevalence of osteoarthritis after anterior cruciate ligament reconstruction, but the effect of knee range of motion has not been extensively studied. HYPOTHESIS: The prevalence of osteoarthritis as observed on radiographs would be higher in patients who had abnormal knee range of motion compared with patients with normal knee motion, even when grouped for like meniscal or articular cartilage lesions. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We prospectively followed patients at a minimum of 5 years after surgery. The constant goal of rehabilitation was to obtain full knee range of motion as quickly as possible after surgery and maintain it in the long term. Range of motion and radiographs were evaluated at the time of initial return to full activities (early follow-up) and final follow-up according to International Knee Documentation Committee (IKDC) objective criteria. A patient was considered to have normal range of motion if extension was within 2 degrees of the opposite knee including hyperextension and knee flexion was within 5 degrees . Radiograph findings were rated as abnormal if any signs of joint space narrowing, sclerosis, or osteophytes were present. RESULTS: Follow-up was obtained for 780 patients at a mean of 10.5 +/- 4.2 years after surgery. Of these, 539 had either normal or abnormal motion at both early and final follow-up. In 479 patients who had normal extension and flexion at both early and final follow-up, 188 (39%) had radiographic evidence of osteoarthritis versus 32 of 60 (53%) patients who had less than normal extension or flexion at early and final follow-up (P = .036). In subgroups of patients with like meniscal status, the prevalence of normal radiograph findings was significantly higher in patients with normal motion at final follow-up versus patients with motion deficits. Multivariate logistic regression analysis of categorical variables showed that abnormal knee flexion at early follow-up, abnormal knee extension at final follow-up, abnormal knee flexion at final follow-up, partial medial meniscectomy, and articular cartilage damage were significant factors related to the presence of osteoarthritis on radiographs. Abnormal knee extension at early follow-up showed a trend toward statistical significance (P = .0544). Logistic regression showed the odds of having osteoarthritis were 2 times more for patients with abnormal range of motion at final follow-up; these odds were similar for those with partial medial meniscectomy and articular cartilage damage. CONCLUSION: The prevalence of osteoarthritis on radiographs in the long term after anterior cruciate ligament reconstruction is lower in patients who achieve and maintain normal knee motion, regardless of the status of the meniscus

Revision total hip arthroplasty in younger patients: indications, reasons for failure, and survivorship

PJI DX Updated Search

Increasing numbers of total hip arthroplasty (THA) procedures are being performed on younger patients, and the incidence of revision THA in this population is also increasing. The goals of our retrospective study were to survey the surgical indications and reasons for failure and survivorship of revision THA in patients aged < 50 years. We identified 139 cases of revision THA performed over a 6-year period in patients aged < 50 years. The most common reason for revision was aseptic loosening, followed by acetabular liner wear with or without osteolysis. We found an overall 10-year survivorship of 76%. When survivorship was stratified by the indication for revision surgery, revision for wear demonstrated the best 10-year survivorship, while revision for instability or infection exhibited poor survivorship

Randomized comparison between sevoflurane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery

Management of Hip Fractures in the Elderly

BACKGROUND AND OBJECTIVE: This prospective, randomized study was conducted to compare unilateral spinal block using small doses of hyperbaric bupivacaine and single-agent anaesthesia with sevoflurane in elderly patients undergoing hip surgery. METHODS: Thirty patients (> 65 yr) undergoing hip fracture repair were randomly allocated to receive unilateral spinal anaesthesia with hyperbaric bupivacaine 7.5 mg 0.5% (Group Spinal, n = 15) or volatile induction and maintenance anaesthesia with sevoflurane (Group SEVO, n = 15). General anaesthesia was induced by increasing the inspired concentration to 5%. A laryngeal mask airway was placed without muscle relaxants, and the end-tidal concentrations of sevoflurane were adjusted to maintain cardiovascular stability. Hypotension (decrease in systolic arterial pressure > 20% from baseline), hypertension or bradycardia (heart rate < 50 beats min(-1)) requiring treatment, and the length of stay in the postanaesthesia care unit was recorded. Cognitive functions were evaluated the previous day, and 1 and 7 days after surgery with the Mini Mental State Examination test. RESULTS: Hypotension occurred in seven patients of Group Spinal (46%) and in 12 patients of Group SEVO (80%) (P = 0.05). Phenylephrine was required to control hypotension in three spinal patients (21%) and four SEVO patients (26%) (n.s.). SEVO patients had lower heart rates than spinal patients from 15 to 60 min after anaesthesia induction (P = 0.01). Bradycardia was observed in three SEVO patients (22%). Discharge from the postanaesthesia care unit required 15 (range 5-30) min in Group Spinal and 55 (15-80) min in Group SEVO (P = 0.0005). Eight patients in Group Spinal (53%) and nine patients in Group SEVO (60%) showed cognitive decline (Mini Mental State Examination test decreased > or = 2 points from baseline) 24 h after surgery (n.s.). Seven days after surgery, confusion was still present in one patient of Group Spinal (6%) and in three patients of Group SEVO (20%) (n.s.). CONCLUSIONS: In elderly patients undergoing hemiarthroplasty of the hip, induction and maintenance with sevoflurane provide a rapid emergence from anaesthesia without more depression of postoperative cognitive function compared with unilateral spinal anaesthesia. This technique represents an attractive option when patient refusal, lack of adequate co-operation or concomitant anticoagulant therapy contraindicate the use of spinal anaesthesia

Active treatment of segmental defects of long bones with established infection: A prospective study

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Twenty-nine patients with chronically infected segmental defects of the tibia (15 cases), femur (7 cases), humerus (5 cases), and radius (2 cases) were treated during a six-year period (1975-1980). The defects were due to hematogenous osteomyelitis in six cases and trauma (vehicular accidents, crushing injuries, and gunshot wounds) in 23 cases. In 12 cases exposed bone was present owing to soft tissue and skin losses. Treatment consisting of stabilization of the fragments, thorough debridement, continuous irrigation, and cancellous bone grafting allowed early mobilization and achieved bony union with control of infection in all cases. Good to fair functional results were obtained in 22 of the 29 involved extremities

Pilates increases isokinetic muscular strength of the elbow flexor and extensor muscles of older women: A randomized controlled clinical trial

Pediatric Supracondylar Humerus Fracture 2020 Review

Introduction The number of elderly people is growing and the practice of physical exercise, such as Pilates, contributes to increased muscular strength and functional autonomy in this population. Objective: To verify the influence of Pilates on the isokinetic muscular strength of the elbow flexors and extensors, and on the functionality of the upper limbs, of older women. Method Thirty volunteers were randomized into two groups-Pilates group (PG) and Control Group (CG). The PG exercises were performed twice weekly for 12 weeks. Evaluations were performed pre and post-intervention, for isokinetic muscular strength of the elbow flexors and extensors and functionality of the upper limbs. Results In the intra-group comparison, the PG improved strength of the elbow extensors and the functionality of the upper limbs (p < 0.05). When comparing the post-intervention moment, the PG was superior to the CG in all variables (p < 0.05), with a large effect size (d > 0.80). Conclusion Pilates increases the isokinetic muscular strength of the elbow flexors and extensors, in addition to the functionality of the upper limbs, in older women.

Superior pedicle technique of reduction mammaplasty: a stepwise approach

Reduction Mammoplasty for Female Breast Hypertrophy

Numerous surgical options for breast reduction have been described, but in the current healthcare environment, efficiency is of the utmost importance. In this Featured Operative Technique, the authors describe an efficient, reproducible, and simple method for minimal to moderate reduction mammaplasty that utilizes a superior pedicle. The surgical maneuvers were developed and conveyed to the senior author (W.G.S.) by Dr John Bostwick. This approach preserves superior and medial breast fullness while providing appropriate resection of the breast parenchyma to ameliorate symptoms and produce a smaller, lifted breast with a more youthful appearance. The surgical technique maintains a reliable blood supply to the nipple-areola complex (NAC) from the internal mammary artery and its perforators, and involves minimal transposition of the NAC. The authors reviewed the charts of 62 consecutive patients who underwent this procedure and found the complication rate to be 11.3%. Complications included 1 hematoma, 1 standing cone deformity, 3 soft-tissue infections, 8 incisional breakdowns, and 1 unilateral necrosis of the NAC.

Rehabilitation of the Knee Following Sports Injury

AMP (Acute Meniscal Pathology)

Rehabilitation of a knee injury is done in a criterion-based progression that is based on individual progress from one phase to another and not on a prespecified period of time. If the rehabilitation deviates from this approach, the body will react with adverse affects such as inflammation, pain, and further injury. Delay in the entire rehabilitation program will delay the athlete in meeting goals and returning to play. Phase I focuses on restoration of range of motion, pain modulation, inflammatory control, modification of activities, and gait training. Phase II is characterized by gaining full range of motion, demonstration of normal gait pattern, basic to advanced strengthening and flexibility, appropriate cardiovascular conditioning, and proprioception retraining. Phase III allows functional return to prior activity level. This phase includes a sport/occupational-specific functional progression. Utilizing a trained rehabilitation specialist will allow the athlete/individual an effective and efficient return to prior level of function. © 2010.

Compensatory growth of adipose tissue after partial lipectomy: involvement of serum factors

Panniculectomy & Abdominoplasty CPG

The regulation of body weight/fat was studied by investigating mechanisms for compensatory adipose tissue growth after removal of bilateral epididymal fat pads from male adult Wistar rats. Food intake during the first 4 weeks and energy expenditure on Days 8-10 postsurgery were not different between lipectomized and sham operated rats. During Days 29-31 post surgery, a small (2.4%) but significant (P < 0.05) increase in heat production per metabolic body size was detected in lipectomized as compared with sham operated rats. The carcass composition of lipectomized and sham operated rats was not significantly different 16 weeks after surgery. The compensatory growth was fat pad-specific: mesenteric, retroperitoneal, and inguinal fat pads, but not perirenal fat pads, were heavier in lipectomized rats than in sham operated rats as early as 4 weeks postsurgery. Examination of fat cell size distribution in the compensating pads indicated a shift toward larger cells in retroperitoneal fat, but not in inguinal fat of lipectomized as compared with sham operated rats. Serum from lipectomized rats, but not media conditioned by exposure to retroperitoneal fat pads from lipectomized rats, stimulated proliferation of preadipocytes in vitro more than that from sham operated rats. Thus, compensatory adipose tissue growth after lipectomy may be mediated, in part, by blood-borne factors that are derived from tissues other than adipose tissue.

Long-term results of arthroscopic excision of unstable osteochondral lesions of the lateral femoral condyle

Diagnosis and Treatment of Osteochondritis Dissecans AUC

The purpose of this study was to evaluate the long-term functional and radiological outcomes of arthroscopic removal of unstable osteochondral lesions with subchondral drilling in the lateral femoral condyle. We reviewed the outcome of 23 patients (28 knees) with stage III or IV osteochondritis dissecans lesions of the lateral femoral condyle at a mean follow-up of 14 years (10 to 19). The functional clinical outcomes were assessed using the Lysholm score, which improved from a mean of 38.1 (SD 3.5) pre-operatively to a mean of 87.3 (SD 5.4) at the most recent review (p = 0.034), and the Tegner activity score, which improved from a pre-operative median of 2 (0 to 3) to a median of 5 (3 to 7) at final follow-up (p = 0.021). The radiological degenerative changes were evaluated according to Tapper and Hoover's classification and when compared with the pre-operative findings, one knee had grade 1, 22 knees had grade 2 and five knees had grade 3 degenerative changes. The overall outcomes were assessed using Hughston's rating scale, where 19 knees were rated as good, four as fair and five as poor. We found radiological evidence of degenerative changes in the third or fourth decade of life at a mean of 14 years after arthroscopic excision of the loose body and subchondral drilling for an unstable osteochondral lesion of the lateral femoral condyle. Clinical and functional results were more satisfactory

A risk assessment tool (OsteoRisk) for identifying Latin American women with osteoporosis

Management of Hip Fractures in the Elderly

OBJECTIVE: To develop a simple and easy-to-use tool for identifying osteoporotic women (femoral neck bone mineral density [BMD] T-scores<or=-2.5) in Latin America. DESIGN: Retrospective study involving review of medical records. SETTING: Osteoporosis clinics in 6 Latin American countries. PATIENTS: Postmenopausal women ages >or=50 in Latin America who had femoral neck BMD measurements. MEASUREMENTS AND MAIN RESULTS: A risk index was developed from 1,547 patients based on least square regression using age, weight, history of fractures, and other variables as predictors for BMD T-score. The final model was simplified by reducing the number of predictors; sensitivity and specificity were evaluated before and after reducing the number of predictors to assess performance of the index. The final model included age, weight, country, estrogen use, and history of fractures as significant predictors for T-score. The resulting scoring index achieved 91% sensitivity and 47% specificity. Simplifying the index by using only age and weight yielded similar performance (sensitivity, 92%; specificity, 45%). Three risk categories were identified based on OsteoRisk, the index using only age and body weight: high-risk patients (index <=-2; 65.6% were osteoporotic), moderate-risk patients (-2< index <=1; 26.7% were osteoporotic), and low-risk patients (index>1; 8% were osteoporotic). Similar results were seen in a validation sample of 279 women in Brazil. CONCLUSION: Age and weight alone performed well for predicting the risk of osteoporosis among postmenopausal women. The OsteoRisk is an easy-to-use tool that effectively targets the vast majority of osteoporotic patients in Latin America for evaluation with BMD

Aberdeen Colles' fracture brace as a treatment for Colles' fracture. A multicentre, prospective, randomised, controlled trial

Distal Radius Fractures

We carried out a randomised, prospective, multicentre clinical trial of the treatment of Colles' fractures. A total of 339 patients was placed into two groups, those with minimally displaced fractures not requiring manipulation (151 patients) and those with displaced fractures which needed manipulation (188 patients). Treatment was by either a conventional Colles' plaster cast (a control group) or with a prefabricated functional brace (the Aberdeen Colles' fracture brace). Similar results were obtained in both groups with regard to the reduction and to pain scores but the brace provided better grip strength in the early stages of treatment. This was statistically significant after five weeks for both manipulated and non-manipulated fractures. At the tenth day the results were statistically significant only in manipulated fractures. There was no significant difference in the functional outcome between the two treatment groups. However, younger patients and those with less initial displacement had better functional results.

Radiographic wear assessment in a total knee prosthesis. 5- to 9-year follow-up study of 158 knees

Surgical Management of Osteoarthritis of the Knee CPG

One hundred fifty-eight Porous-Coated Anatomic (Howmedica, Rutherford, NJ) primary total knee prostheses were evaluated clinically and radiographically to measure the remaining thickness of the plastic insert. Anteroposterior radiographs were taken with the beam guided parallel to the tibial plate by a fluoroscope. The knees were forced into varus and valgus, and the heights of the medial and lateral joint spaces, respectively, were measured with a digitizing table. Plastic insert wear could be calculated after correction with a magnification error factor, established by dividing the projected width of the tibial plate by the true size of the used component. After a mean follow-up period of 84 months (range, 58-116 months), wear was significantly higher for patients with osteoarthritis than rheumatoid arthritis and was 1.4 mm versus 0.7 mm medially (P < .0001) and 0.7 mm versus 0.4 mm laterally (P = .01). Wear was not correlated to thickness of the plastic insert or length of follow-up period. Young age or varus alignment contributed slightly to the amount of wear