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Effects of Therapeutic Exercises in Elderly Women With Knee Osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Knee Osteoarthritis is a degenerative disease associated with muscle weakness, arthralgia, rigidity and postural instability. Therapeutic exercise can reduce pain and improve muscle strength and postural balance, however benefits from association with pompage is not known. This study aims to evaluate the effects of therapeutic exercise on pain, muscle strength and postural balance in elderly women with knee osteoarthritis. Methodology: Almost randomized controlled trial, in which were included elderly between 60 and 80 years diagnosed with knee osteoarthritis, randomized into two groups with 11 participants each. Intervention group held strengthening exercises for flexors and knee extensors, balance training, and manual knee pompage for 12 weeks. Control Group received educational lectures. Arthralgia was estimated by pain subscale of the questionnaire Western Ontario McMaster Universities Osteoarthritis Index and (WOMAC); muscle strength was assessed by the isokinetic dynamometer HUMAC® NORM Testing & Rehabilitation System and the postural balance by the Biodex Balance SD postural stability protocol (Biodex Medical Systems, Inc. New York, USA). The Student t test was used for statistical analysis.

Supine Extensile Approach to the Anterolateral Humerus

Pediatric Supracondylar Humerus Fracture 2020 Review

The radial nerve is at risk of injury during surgical approaches to the humeral shaft. Previous authors have described an anterolateral approach to the humerus limited by the radial nerve, requiring that distal dissection be carried anterior into a neurovascularly crowded interval. A novel extensile approach is described using a neuromuscular bridge to protect the radial nerve, thus enabling safe distal extension of the anterolateral humerus approach. The authors present a case series of 7 patients who required an extensile humeral exposure. To date, there have been no complications, including loss of reduction, malunion, nonunion, or nerve palsy.

The Painful Total Knee Arthroplasty

PJI DX Updated Search

There are many causes of residual pain after total knee arthroplasty (TKA). Evaluation and management begins with a comprehensive history and physical examination, followed by radiographic evaluation of the replaced and adjacent joints, as well as previous films of the replaced joint. Further workup includes laboratory analysis, along with a synovial fluid aspirate to evaluate the white blood cell count with differential as well as culture. Advanced imaging modalities may be beneficial when the diagnosis remains unclear. Revision surgery is not advisable without a clear diagnosis, as it may be associated with poor results

Addition of Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee and Adductor Canal Block to Periarticular Injection Enhances Postoperative Pain Control in Total Knee Arthroplasty: A Randomized Controlled Trial

AAHKS (9/10) Regional Nerve Blocks

BACKGROUND: Periarticular injections (PAIs) are becoming a staple component of multimodal joint pathways. Motor-sparing peripheral nerve blocks, such as the infiltration between the popliteal artery and capsule of the posterior knee (IPACK) and the adductor canal block (ACB), may augment PAI in multimodal analgesic pathways for knee arthroplasty, but supporting literature remains rare. We hypothesized that the addition of ACB and IPACK to PAI would lower pain on ambulation on postoperative day (POD) 1 compared to PAI alone. METHODS: This triple-blinded randomized controlled trial included 86 patients undergoing unilateral total knee arthroplasty. Patients either received (1) a PAI (control group, n = 43) or (2) an IPACK with an ACB and modified PAI (intervention group, n = 43). The primary outcome was pain on ambulation on POD 1. Secondary outcomes included numeric rating scale (NRS) pain scores, patient satisfaction, and opioid consumption. RESULTS: The intervention group reported significantly lower NRS pain scores on ambulation than the control group on POD 1 (difference in means [95% confidence interval], -3.3 [-4.0 to -2.7]; P < .001). In addition, NRS pain scores on ambulation on POD 0 (-3.5 [-4.3 to -2.7]; P < .001) and POD 2 (-1.0 [-1.9 to -0.1]; P = .033) were significantly lower. Patients in the intervention group were more satisfied, had less opioid consumption (P = .005, postanesthesia care unit, P = .028, POD 0), less intravenous opioids (P < .001), and reduced need for intravenous patient-controlled analgesia (P = .037). CONCLUSIONS: The addition of IPACK and ACB to PAI significantly improves analgesia and reduces opioid consumption after total knee arthroplasty compared to PAI alone. This study strongly supports IPACK and ACB use within a multimodal analgesic pathway.

Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma of bone: Clinicopathologic features of 5 cases

MSTS 2018 - Femur Mets and MM

Pseudomyogenic hemangioendothelioma (PHE) is an uncommon mesenchymal tumor of intermediate malignant potential with characteristic clinicopathologic and genetic features. Although bone involvement accompanies nearly one-fourth of reported cases of soft tissue PHEs, primary intraosseous PHE is rare. Herein, we report five cases of primary intraosseous PHEs. Male to female ratio was 4:1, with an average age of 28years (age range, 5-44years). Radiologically, tumors presented as lytic lesions in the proximal femur (two), diaphysis of the tibia (one), distal radius (one) and vertebrae (one). Multifocal lesions were observed in four cases. Histopathologic examination revealed plump spindle cells and prominent nucleoli. New bone formation was noted in three cases. Immunohistochemically, all tumors were positive for CD31 and negative for CD34. Pan Cytokeratin (CK) (AE1/3) was positively expressed in all, except a single tumor, in which CK7 and Cam5.2 were expressed. INI1/SMARCB1 was completely retained in all tumors. A single patient underwent surgical resection. During follow-up, two cases showed no evidence of disease within two and five years, respectively. Differential diagnosis of a PHE of bone includes osteoblastoma, epithelioid angiosarcoma, metastatic carcinoma, metastatic rhabdomyosarcoma, and epithelioid sarcoma. Caution must be exercised as pan CK (AE1/3) might not be expressed; therefore, the use of other cytokeratins, such as Cam5.2 is recommended. Awareness of such an entity in bone is the key to the diagnosis.

Acupuncture for carpal tunnel syndrome

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Acupuncture was used to treat a 51-year-old 'lollipop lady' (school crossing patrol officer), with severe carpal tunnel syndrome (CTS) affecting her dominant hand, and co-existing cervical spondylosis. I postulate that her symptoms were work related. She responded well to acupuncture, which provided good symptomatic treatment rather than cure and allowed her to continue working whilst she awaited surgical release

Femoral shaft osteotomy for obligate outward rotation due to SCFE

Pediatric Diaphyseal Femur Fractures 2020 Review

Slipped capital femoral epiphysis (SCFE) is an adolescent disease that leads to retroversion of the femoral neck and shaft, relative to the head. Observing that patients with SCFE must walk with an outward foot progression angle and externally rotate the leg in order to flex the hip, we have been performing a femoral shaft rotational osteotomy wherein we rotate the lower femur 45° inward, relative to the upper femur. By correcting retroversion, our goal is to improve functional hip and knee motion, thereby mitigating the effects of SCFE impingement. This is a retrospective review of five hips in four patients (two boys and two girls), average age 14.7 years (range 11 + 7â??18 years) who underwent femoral midshaft rotational osteotomy for correction of acquired retroversion of the femur secondary to severe SCFE. We compared clinical findings at the outset to those at an average follow-up of 46 months (range 24â??74 months). Pre- and post-gait analysis was performed in three patients. Two of the patients underwent elective arthroscopic osteochondroplasty to alleviate residual FAI: contralateral arthroscopy is pending in one. The first patient in this series received a hip arthroplasty, 62 months after his osteotomy, at age 23. Following midshaft osteotomy, all patients experienced improvement in comfort, gait and activities of daily living. With the patella neutral, they had improved range of hip flexion from an average preoperative flexion of <25° to a postoperative flexion of >90°. Two patients (both male) had delayed union and some loss of correction, secondary to broken interlocking screws; each healed with reamed, exchange nailing. The interlocking screws have since been redesigned and enlarged. Femoral shaft rotational osteotomy restores the functional range of hip motion, while correcting obligate out-toeing and improving knee kinematics. This procedure is technically straightforward, permitting progressive weight bearing, while avoiding the risk of AVN. Osteochondroplasty for residual FAI can be deferred, pending the outcome. Level of evidence III: retrospective seriesâ??no controls.

Importance of Ki-67 in human epidermal growth factor receptor 2 positive breast cancer

MSTS 2022 - Metastatic Disease of the Humerus

Purpose: The aim of this study was to evaluate the importance of Ki-67 in Human Epidermal Growth Factor Receptor 2 (Her-2) positive breast cancer patients. Methods: We reviewed the records of patients diagnosed with Her-2-positive non-metastatic breast cancer between 2005 and 2011. Paraffin-embedded tissue samples were stained with MIB-1 mouse monoclonal antibody to find Ki-67 levels. Patients were grouped as low Ki-67 <20% and high Ki-67 =20%. Demographic and clinical features were compared. Results: One hundred and six patients were included in the study. Median follow up time was 41 months (range 15-100). Median age was 49.5 years (range 29-79). Twenty-nine patients (27.4%) were in the Ki-67 low group. Demographic features were similar in both groups. Lymphovas-cular invasion was more frequent in the Ki-67 high group, and hormone receptor (HR) positivity was more frequent in the Ki-67 low group (p=0.03, p=0.03, respectively). Recurrence rate was not significantly different in both groups (p=0.36). T stage (p=0.02), stage (p<0.01), lymphovascular invasion (p=0.02), ER status (p=0.02), and HR status (p<0.01) were related with recurrence. In multivariate analysis, stage and HR negativity were independent factors for recurrence (p<0.01, p=0.01, respectively). Recurrence sites were also similar in both groups. Survival rates at the third year for Ki-67 low group and Ki-67 high group were 94% and 92%, respectively. Conclusion: Her-2 positive patients with low Ki-67 and high Ki-67 had similar demographic and pathologic features except lymphovascular invasion and HR status. HR status was an important f actor f or disease course. Clinical course was determined by HR status rather than Ki-67.

Management of musculoskeletal complications of hemophilia

AAHKS (4) Acetaminophen

Prophylactic treatment from ages 2 to 18 years could prevent the development of hemophilic arthropathy if the concentration of the patient's deficient factor is kept from falling below 1% of normal. Early treatment is of paramount importance because the immature skeleton is very sensitive to the complications of hemophilia. Major hemarthrosis and chronic hemophilic synovitis should be treated aggressively to prevent hemophilic arthropathy. When advanced hemophilic arthropathy is present with severe disability, the aim should be to restore function while minimizing the risk to the patient. Joint debridement is an effective method to achieve this goal, especially around the elbow or ankle, and can be considered an alternative to knee replacement in the younger age groups. Proximal tibial valgus osteotomy is a reliable treatment method for painful genu varum of the mobile hemophilic knee. Supramalleolar tibial varus osteotomy is an attractive alternative to the more commonly used surgical option of arthrodesis. Finally, joint replacement can usually be relied on to restore both mobility and function in a diseased joint. The potential benefits of joint replacement must always be weighed against the long-term sequelae, however, especially loosening and consequent revision surgery.

Surgery-induced changes and early recovery of hip-muscle strength, leg-press power, and functional performance after fast-track total hip arthroplasty: a prospective cohort study

PJI DX Updated Search

BACKGROUND: By measuring very early changes in muscle strength and functional performance after fast-track total hip arthroplasty (THA), post-operative rehabilitation, introduced soon after surgery, can be designed to specifically target identified deficits. OBJECTIVES: Firstly, to quantify changes (compared to pre-operative values) in hip muscle strength, leg-press power, and functional performance in the first week after THA, and secondly, to explore relationships between the muscle strength changes, and changes in hip pain, systemic inflammation, and thigh swelling. DESIGN: Prospective, cohort study. SETTING: Convenience sample of patients receiving a THA at Copenhagen University Hospital, Hvidovre, Denmark, between March and December 2011. PARTICIPANTS: Thirty-five patients (65.9 +/- 7.2 years) undergoing THA. MAIN OUTCOME MEASURES: Hip muscle strength, leg-press power, performance-based function, and self-reported disability were determined prior to, and 2 and 8 days after, THA (Day 2 and 8, respectively). Hip pain, thigh swelling, and C-Reactive Protein were also determined. RESULTS: Five patients were lost to follow-up. Hip muscle strength and leg press power were substantially reduced at Day 2 (range of reductions: 41-58%, P<0.001), but less pronounced at Day 8 (range of reductions: 23-31%, P<0.017). Self-reported symptoms and function (HOOS: Pain, Symptoms, and ADL) improved at Day 8 (P<0.014). Changes in hip pain, C-Reactive Protein, and thigh swelling were not related to the muscle strength and power losses. CONCLUSIONS: Hip muscle strength and leg-press power decreased substantially in the first week after

Gutâ??joint axis: The role of physical exercise on gut microbiota modulation in older people with osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Osteoarthritis (OA) is considered one of the most common joint disorders worldwide and its prevalence is constantly increasing due to the global longevity and changes in eating habits and lifestyle. In this context, the role of gut microbiota (GM) in the pathogenesis of OA is still unclear. Perturbation of GM biodiversity and function, defined as â??gut dysbiosisâ??, might be involved in the development of inflammaging, one of the main risk factors of OA development. It is well known that physical exercise could play a key role in the prevention and treatment of several chronic diseases including OA, and it is recommended by several guidelines as a first line intervention. Several studies have shown that physical exercise could modulate GM composition, boosting intestinal mucosal immunity, increasing the Bacteroidetesâ??Firmicutes ratio, modifying the bile acid profile, and improving the production of short chain fatty acids. Moreover, it has been shown that low intensity exercise might reduce the risk of gastrointestinal diseases, confirming the hypothesis of a strict correlation between skeletal muscle and GM. However, up to date, there is still a lack of clinical trials focusing on this research field. Therefore, in this narrative, we aimed to summarize the state-of-the-art of the literature regarding the correlation between these conditions, supporting the hypothesis of a â??gutâ??joint axisâ?? and highlighting the role of physical exercise combined with adequate diet and probiotic supplements in rebalancing microbial dysbiosis.

Intermediate-Term Outcome After Distal Radius Fracture in Patients With Poor Outcome at 1 Year: A Register Study With a 2- to 12-Year Follow-Up

Distal Radius Fractures

PURPOSE: Most patients recover well from a distal radius fracture (DRF). However, approximately one-fifth have severe disability after 1 year when evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. In the present study, we evaluated this subgroup of patients in our register with an inferior outcome. We hypothesized that the patient-reported outcome would improve with time. METHODS: Since 2001, patients 18 years and older with a DRF, at the Department of Orthopedics, Skane University Hospital (Lund, Sweden) are prospectively registered in the Lund Wrist Fracture Register. We have previously defined a DASH score above 35 at the 1-year follow-up as the cutoff of major disability. Between 2003 and 2012, 17% of the patients (445 of 2,571) in the register exceeded this cutoff. Three hundred eighty-eight were women and 57 men and the mean age was 69 years (range, 18-95 years). One-fourth had been surgically treated. In December 2014, 2 to 12 years after the fracture, a follow-up DASH questionnaire was sent to the 346 of 445 patients still alive. RESULTS: Seventy-three patients (27%) had initially been treated surgically and 196 (73%) nonsurgically for their DRF. Two hundred sixty-nine of 346 patients (78%) returned the follow-up DASH questionnaire at 2 to 12 years (mean, 5.5 years) after the fracture. The overall median DASH score improved from 50 at 1 year to 36 at the 2- to 12-year follow-up, (P < .05). Forty-seven percent had improved to a score below the cutoff 35, but 53% remained at a high suboptimal level. CONCLUSIONS: The subjective outcome after a DRF improves over time for patients with an inferior result at 1 year, but more than half of the patients continue to have major disability. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Vertebral body fracture of the lumbar spine in elderly women: more severe in osteoarthritis of the knee than in femoral neck fracture

Management of Hip Fractures in the Elderly

This study investigated bone fragility by comparing fractures of the vertebral body of the spine in elderly women receiving total knee replacement (TKR) (group 1) due to severe osteoarthritis of the knee and those with femoral neck fractures (group 2) attributable to osteoporosis. Forty-two women each were selected retrospectively for group 1 and prospectively for group 2. Patient age ranged from 64-83 years. Vertebral body fractures of the lumbar spine were significantly more severe in group 1 than in group 2 (P<.001). Patients undergoing TKR due to osteoarthritis of the knee had systemic bone fragility, which included the spine

A new arthroscopic-assisted drilling method through the radius in a distal-to-proximal direction for osteochondritis dissecans of the elbow

Distal Radius Fractures

We developed a new arthroscopic-assisted drilling method through the radius in a distal-to-proximal direction for osteochondritis dissecans (OCD) of the elbow. Only 1 drill hole is created in the radius by use of a single 1.8-mm K-wire inserted from the shaft of the radius approximately 3 cm distal to the humeroradial joint into the joint, which allows drilling of the entire OCD lesion. The forearm is supinated so that the tip of the K-wire is at the lateral side of the lesion in the humeral capitellum, and drilling is performed at 30 degrees elbow flexion. The flexion angle is changed from 30 degrees to 60 degrees to 90 degrees to 120 degrees while maintaining supination, to drill in 4 sites (1 site for each angle of flexion) of the lateral side of the OCD lesion. Next, we move the forearm from supination to pronation so that the tip of the K-wire is placed in the medial side of the lesion in the humeral capitellum, and as with the lateral side, drilling is performed in 4 sites. With this technique, the entire OCD lesion can be vertically drilled under arthroscopic guidance. This method is minimally invasive, and an early return to sports could be possible.

THA for a Fractured Femoral Neck: Comparing the Revision and Dislocation Rates of Standard-head, Large-head, Dual-mobility, and Constrained Liners

Hip Fx in the Elderly 2019

BACKGROUND: THA is a reasonable surgical option for some patients with fragility fractures of the femoral neck, but it has the risk of prosthesis dislocation. The prosthesis combination that reduces the risk of dislocation and the rate of revision surgery is not known. QUESTIONS/PURPOSES: In patients receiving primary THA for a femoral neck fracture, does (1) the rate of all-cause revision or (2) the reason for revision and rate of revision for dislocation differ among THA with a standard head size, large head size, dual mobility (DM), or constrained liner? (3) Is there a difference in the revision risk when patients are stratified by age at the time of surgery? METHODS: Data were analyzed for 16,692 THAs performed to treat fractures of the femoral neck reported in the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from January 2008 to December 2018, as this included the first use of DM prostheses. The AOANJRR includes information on more than 98% of arthroplasty procedures performed in Australia. Most patients were female (72%) and the mean age was 74 years +/- 11. There were 8582 standard-head prostheses, 5820 large-head prostheses, 1778 DM prostheses, and 512 constrained prostheses identified. The cumulative percent revision (CPR) was determined for all causes as well as CPR for dislocation. The time to the first revision was described using Kaplan-Meier estimates of survivorship, with right censoring for death or closure of the database at the time of analysis. The unadjusted CPR was estimated each year of the first 10 years for standard heads, 10 years for large heads, 8 years for constrained liners, and 7 years for DM prostheses, with 95% confidence intervals using unadjusted pointwise Greenwood estimates. The results were adjusted for age, sex, femoral fixation, and head size where appropriate and were considered by age groups < 70 and >= 70 years. RESULTS: When adjusted for age, sex, femoral fixation and head size, there was no difference in the rate of all-cause revision at 7 years for any of the four groups. There was no difference in the rate of all-cause revision when patients were stratified by < 70 or >= 70 years of age. Dislocation was the most common reason for revision (32%). When analyzing revision for dislocation alone, large-head THA had a lower rate of revision for dislocation compared with standard head (HR 0.6 [95% CI 0.4 to 0.8]; p < 0.001) and DM prostheses had a lower rate of revision for dislocation than standard head for the first 3 months (HR 0.3 [95% CI 0.1 to 0.7]; p < 0.004) but not after this time point. CONCLUSION: The Australian registry shows that there is no difference in the rate of all-cause revision for standard-head, large-head, DM prostheses or constrained liner THA after femoral neck fractures for all patients or for patients stratified into younger than 70 years and at least 70 years of age groups. Dislocation is the most common cause of revision. Large-head prostheses are associated with a lower revision risk for dislocation and DM prostheses have a lower rate of revision for dislocation than standard heads for the first 3 months only. Surgeons treating a femoral neck fracture with THA might consider a large head size if the diameter of the acetabulum will allow it and a DM prosthesis if a large head size is not possible. The age, life expectancy and level of function of patients with femoral neck fractures minimizes the potential long-term consequences of these prostheses. The lack of significant differences in survival between most prosthesis combinations means surgeons should continue to look for factors beyond head size and prosthesis to minimize dislocation and revision surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

The role of hyperbaric oxygen therapy in orthopedics and rheumatological diseases

Pediatric Supracondylar Humerus Fracture 2020 Review

Hyperbaric oxygen therapy (HBOT) has been investigated as a primary/adjunctive treatment for a number of injuries and medical conditions including traumatic ischemia, necrotizing soft tissue injuries, non-healing ulcers and osteoradionecrosis, but the results are controversial. There is insufficient evidence to support or reject the use of HBOT to quicken healing or to treat the established non-union of fractures. However, in patients with fibromyalgia, HBOT reduces brain activity in the posterior cortex and increases it in the frontal, cingulate, medial temporal and cerebellar cortices, thus leading to beneficial changes in brain areas that are known to function abnormally. Moreover, the amelioration of pain induced by HBOT significantly decreases the consumption of analgesic medications. In addition, HBOT has anti-inflammatory and oxygenatory effects in patients with primary or secondary vasculitis. This review analyzes the efficacy and limitations of HBOT in orthopedic and rheumatologic patients.

The safety of office-based surgery: Review of recent literature from several disciplines

Panniculectomy & Abdominoplasty CPG

Objective: To review recent literature pertaining to adverse outcomes and mortality associated with office-based surgery. Study Selection: Representative articles from the general and plastic surgery, medical, health regulatory, and dermatology literature. Data Extraction: Information regarding which surgical treatments should be performed, which specialties should perform them, what level of anesthesia is appropriate, and who should administer it was assessed, with particular attention to issues of patient safety. Conclusions: Office-based surgery is safe and cost-effective. We caution against attempts to prohibit or severely restrict this important aspect of medical care.

Associations of child maltreatment and intimate partner violence with psychological adjustment among low SES, African American children

DoD PRF (Psychosocial RF)

OBJECTIVE: This study assessed the unique and interactive effects of child maltreatment and mothers' physical intimate partner violence (IPV) status on low-SES African American children's psychological functioning. METHODS: Mothers were recruited from a large, inner-city hospital, and those who met eligibility criteria were asked to complete a lengthy face-to-face interview while their child was assessed separately but concurrently. The sample included 152 mother-child dyads. The children's mean age was 10 years, and 45% were male. Multivariate linear regression analyses tested the main and interactive effects of child maltreatment and mothers' exposure to physical IPV on children's psychological functioning (internalizing and externalizing symptoms, traumatic stress symptoms), while controlling for covariates. RESULTS: Children who experienced child maltreatment and children whose mothers experienced physical IPV had higher levels of psychological distress than their respective counterparts. Post hoc analysis of significant interaction effects indicated that child maltreatment was associated with internalizing and externalizing problems and traumatic stress only when mothers reported higher levels of physical IPV. This finding did not hold true for youth whose mothers did not acknowledge elevated rates of physical IPV. CONCLUSIONS: African American youth from low-SES backgrounds who are maltreated and whose mothers experience physical IPV are at particularly high risk for psychological distress. Targeted prevention and intervention programs are needed for these poly-victimized youth.

Can Structural Joint Damage Measured with MR Imaging Be Used to Predict Knee Replacement in the Following Year?

Surgical Management of Osteoarthritis of the Knee CPG

Purpose To assess whether magnetic resonance (MR) imaging-based cross-sectional measures of structural joint damage can be used to predict knee replacement during the following year. Materials and Methods Participants were drawn from the Osteoarthritis Initiative, a longitudinal observational study that includes 4796 participants who have knee osteoarthritis or are at risk. The HIPAA-compliant protocol was approved by the institutional review boards of all participating centers, and written informed consent was obtained from all participants. During the 5 years of follow-up, 199 knees underwent knee replacement and were matched with 199 control knees that did not undergo knee replacement. Knees were matched according to radiographic disease stage and patient sex and age. All knees that underwent knee replacement and had MR images available from the year before surgery were included. MR images were assessed for cartilage damage, bone marrow lesions, meniscal damage, meniscal extrusion, synovitis, and effusion prior to reported knee replacement. Conditional logistic regression was applied to assess the risk of knee replacement. Analyses were performed on a compartmental and knee level. Results Participants had a mean age +/- standard deviation of 64.2 years +/- 8.4 (range, 47-82 years) and were predominantly women (232 of 398 participants, 58.3%). Risk for knee replacement was significantly increased for knees that exhibited two or more subregions with severe cartilage loss (odds ratio [ OR odds ratio ], 16.5; 95% confidence interval [ CI confidence interval ]: 3.96, 68.76), more than two subregions with bone marrow lesions ( OR odds ratio , 4.00; 95% CI confidence interval : 1.75, 9.16), medial meniscal maceration ( OR odds ratio , 1.84; 95% CI confidence interval : 1.13, 2.99), effusion ( OR odds ratio , 4.75; 95% CI confidence interval : 2.55, 8.85), or synovitis ( OR odds ratio , 2.17; 95% CI confidence interval : 1.33, 3.56), but not extrusion ( OR odds ratio , 1.00; 95% CI confidence interval : 0.60,1.67), when compared with knees that did not exhibit these features as the reference standard. Conclusion Apart from meniscal extrusion, all features of tissue abnormalities at MR imaging were related to clinical prognosis and could be used to predict knee replacement in the following year. (c) RSNA, 2014 Online supplemental material is available for this article

Osteodensitometry in healthy postmenopausal women

Management of Hip Fractures in the Elderly

(1) Osteodensitometry is the standard method for measuring bone mineral density. Since the 1990s, diagnosis of osteoporosis has been defined, by convention, by a bone density T score cut-off of less than -2.5. This threshold, based on population statistics, is appropriate for the diagnosis of osteoporosis in Caucasian postmenopausal women in Europe and North America but may not be suitable for other populations. (2) To determine whether measurement of bone mineral density is useful in the prevention of fractures in postmenopausal women, we reviewed the relevant literature using our established in-house methodology. (3) Two meta-analyses of cohort follow-up studies involving tens of thousands of women showed a statistically increased risk of fracture in women with low bone density, especially in those with osteoporosis diagnosed by means of osteodensitometry. However, the majority of postmenopausal fractures occur in women without osteoporosis. (4) Routine bone density measurement has no proven impact on fracture prevention. (5) Some drugs designed for primary fracture prevention have been tested in postmenopausal women selected on the basis of their bone mineral density. In these patients, alendronic acid and raloxifene were both effective in the prevention of asymptomatic vertebral fractures: about 2 fractures prevented per 100 women treated for 3 to 4 years. A rather shaky retrospective subgroup analysis suggests that alendronic acid can also prevent symptomatic fractures in women with osteoporosis diagnosed by means of osteodensitometry. The screening for osteoporosis in postmenopausal women, or exposing large numbers of women to the adverse effects of these drugs. (6) Severe osteoporosis in postmenopausal women is defined by the presence of both low bone mineral density and a history of fragility fractures following low-energy trauma. Alendronic acid is the best-assessed drug in these women, preventing about 3 symptomatic vertebral fractures and 1 hip fracture when 100 patients are treated for 3 years. After a first fracture, women should be asked questions designed to assess the severity of the trauma, and should undergo osteodensitometry to document osteoporosis before exposure to the potential adverse effects of bisphosphonates

Orthostatic intolerance during early mobilization after fast-track hip arthroplasty

AAHKS (8) Anesthetic Infiltration

BACKGROUND: Early postoperative mobilization is a cornerstone in fast-track total hip arthroplasty (THA), but postoperative orthostatic intolerance (OI) may delay early recovery or lead to fainting, falls, and prosthesis dislocation or fracture. However, the prevalence and pathophysiology of OI has not been established after THA. This study evaluated the cardiovascular response and tissue oxygenation to mobilization before and after surgery in relation to OI in fast-track THA patients. METHODS: OI and the cardiovascular response to standing were evaluated with a standardized mobilization protocol, before, 6, and 24 h after surgery in 26 patients undergoing THA with spinal anaesthesia and an opioid-sparing analgesic regime. Haemoglobin, fluid balance, and opioid use were recorded. Systolic (SAP) and diastolic (DAP) arterial pressure, heart rate (HR), stroke volume (SV), cardiac output (CO), and systemic vascular resistance were measured non-invasively (Nexfin()) and cerebral ( ) and muscle tissue oxygenation by non-infrared spectroscopy. RESULTS: No patients demonstrated OI before surgery, whereas 11 (42%) and five (19%) patients experienced OI 6 and 24 h after surgery, respectively. OI was associated with decreased orthostatic responses in SAP, DAP, SV, CO, and compared with orthostatic tolerant patients (P<0.05). There was no difference in postoperative haemoglobin concentrations or opioid use between orthostatic intolerant and tolerant patients. CONCLUSIONS: Early postoperative OI is common in patients undergoing THA and is associated with an impaired cardiovascular orthostatic response and decreased cerebral oxygenation.

Ethnic disparity in the treatment of women with established low bone mass

Management of Hip Fractures in the Elderly

OBJECTIVE: To assess the extent of bone-health treatment and to test for racial differences in that treatment among black and white women with documented low bone mass. METHODS: All women who underwent central dual-energy X-ray absorptiometry testing at the Washington, DC Veterans Affairs Medical Center (VAMC) from January 1, 1998 through October 15, 2001 were identified via the VAMC's computerized patient record system. Self-administered questionnaires measuring patient demographics, fracture history, and presence of appropriate bone-health treatments were mailed to those with T scores < or = -1.0 (n=110). RESULTS: Seventy-five women (68%) completed the survey (mean 61 years old, 55% white and 35% black). There were no statistically significant differences between black and white women in smoking (71% nonsmokers), avoiding excess alcohol (95%), or exercising regularly (68%). Eighty-one percent reported taking calcium supplements, 71% vitamin D supplements, and 56% antiresorptive medications; whites were significantly more likely than blacks to be taking calcium supplements (90% v 69%, p=.048) and antiresorptive drugs (71% v 35%, p=.004). The racial difference in antiresorptive medication use remained significant after adjusting for bone loss severity and prior fractures (odds ratio 3.71; 95% confidence interval 1.24, 11.0). CONCLUSION: Women with low bone mass treated at the Washington, DC VAMC reported high rates of bone-building behaviors and the use of calcium and vitamin D supplements and somewhat lower rates of antiresorptive drug use. Whites were more likely than blacks to be taking calcium supplements and antiresorptive drugs. The causes of these disparities should be identified in future studies

The success of single débridement and primary closure of acute postoperative infections after open reduction and internal fixation

DoD SSI (Surgical Site Infections)

Background: The development of surgical site infection in the presence of hardware after open reduction and internal fixation is an ongoing dilemma. There are no evidence-based guidelines to guide the number of surgical débridements and irrigations before definitive wound closure. The purpose of the present study was to assess the prevalence of infection resolution using a single debridement and primary wound closure in the acute postoperative infection and to identify risk factors for failure of single débridements and primary wound closure. Methods: We retrospectively reviewed 61 postoperative infections (60 patients) after open reduction and internal fixation of fractures that were treated with a single débridement and primary closure. For the analysis, the cases were categorized as the success group (n=29) and the failure group (n=32). Data were collected from a review of the patients' medical record. Variables were compared between the two groups using univariate and multivariate logistic regression analysis. Results: Twenty-nine infections (48%) in 28 patients achieved successful outcome after single débridement and primary closure without hardware removal. Risk factors for treatment failure, identified by multivariate analysis, were Orthopaedic Trauma Association (OTA) classification B and C fractures (odds ratio=2.489; 95% confidence interval=1.085, 5.713; P=0.031) and C-reactive protein at admission (odds ratio=1.019; 95% confidence interval=1.004, 1.034; P=0.014). Conclusions: Acute postoperative infection after open reduction and internal fixation treated by single débridement with primary closure and hardware retention is successful in only half of the infections. This result may be improved by patient selection based on certain risk factors. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Using Care Bundles to Improve Surgical Outcomes and Reduce Variation in Care for Fragility Hip Fracture Patients

Hip Fx in the Elderly 2019

Introduction: Fragility hip fractures constitute a large proportion of orthogeriatric admissions to orthopedic wards. This study looked at reducing variation in care in fragility hip fracture patients using a novel approach with care bundles. The care bundle comprises 5 elements targeted at providing adequate analgesia, early mobilization, improving recognition of delirium, and decreasing rates of urinary infections. Methods: A total of 198 patients who sustained a fragility hip fracture during the intervention period were included in the study. The primary outcome measure was compliance in applying the bundle to the study population, and secondary outcome measures were in-hospital mortality, acute length of stay, delirium and duration of delirium, and urinary tract infections. Results: During the 12-month intervention period, compliance to the bundle of care was 47% (n = 92) based on the â??all-or-noneâ? approach. This was 28% higher than the preintervention rate. Overall, there was an increased rate of compliance across all individual elements of the bundle in the intervention group when compared to the preintervention group (P =.01). The most significant clinical result was a 10.5% reduction in â??in-hospital mortalityâ? in the intervention group (P <.001). Conclusion: This study demonstrated that the implementation of specific care bundle in patients with fragility hip fracture significantly reduces variation in care.

Description of an orthopedic-geriatric model of care in Australia with 3 years data

Management of Hip Fractures in the Elderly

AIM: Orthopedic-geriatric units have been established worldwide to improve the care of older patients admitted with fractures. This study describes one type of orthopedic-geriatric model which has been implemented in Victoria, Australia, named the Orthopedic Aged Care and Rehabilitation Service (OARS) and evaluates patient characteristics and outcomes including inpatient mortality. METHODS: Eight hundred and thirty-four consecutive admissions under OARS between May 2003 and May 2006 were analyzed. RESULTS: Mean age was 76.6 years, the majority of patients were female (73%) and had come from home (77%). Fractured neck of femur represented 51% of all fractures managed by OARS followed by lower limb fractures (20%) and upper limb fractures (13%). The majority of patients required inpatient rehabilitation (49% of patients overall and 61% specifically for fractured neck of femur). Inpatient mortality for all fractures was 2.5% and specifically 3.5% for fractured neck of femur. CONCLUSION: The OARS model involves close liaison between orthopedic and geriatric teams and promotes a multidisciplinary approach. Mortality rate for fractured neck of femur was lower than the state average, suggesting that combined orthopedic-geriatric care can improve outcomes

Reconstruction of orbital floor blow-out fractures with autogenous iliac crest bone: a retrospective study including maxillofacial and ophthalmology perspectives

DoD SSI (Surgical Site Infections)

This is a 10-year retrospective study of patients with an isolated unilateral orbital floor fracture reconstructed with an autogenous iliac crest bone graft. The following inclusion criteria applied: isolated orbital floor fracture without involvement of the orbital rim or other craniofacial injuries, pre-/post-operative ophthalmological/orthoptic follow-up, pre-operative CT. Variables recorded were patient age and gender, aetiology of injury, time to surgery, follow-up period, surgical morbidity, diplopia pre- and post-operatively (Hess test), eyelid position, visual acuity, and the presence of en-/or exophthalmos (Hertel exophthalmometer). Twenty patients met the inclusion criteria. The mean age was 29 years. The mean follow up period was 26 months. No patient experienced significant donor site morbidity. There were no episodes of post-operative infection or graft extrusion. Three patients had diplopia in extremes of vision post-operatively, but no interference with activities of daily living. One patient had post-operative enophthalmos. Isolated orbital blow-out fractures may be safely and predictably reconstructed using autogenous iliac crest bone. The rate of complications in the group of patients studied was low. The value of pre- and post-operative ophthalmology consultation cannot be underestimated, and should be considered the standard of care in all patients with orbitozygomatic fractures, in particular those with blow-out fractures.

Magnetic resonance imaging assessment of gluteal fat grafts

Panniculectomy & Abdominoplasty CPG

BACKGROUND: One goal of lipoplasty is to create a round and projected buttock contour. Despite multiple papers evaluating lipoinjection, controversies still remain. METHODS: This report describes a series of patients who underwent liposuction, gluteal lipoinjection, and evaluation with magnetic resonance imaging (MRI). From January 2003 to January 2004, the patients scheduled for contour surgery by the investigators were evaluated using MRI, photographic records, and gluteal circumference measurement 1 week before surgery, then 2 weeks and 3 months after the procedure. A statistical analysis was performed for 10 patients who received, on the average, a 350-ml injection of fat obtained during liposuction. RESULTS: Gluteus muscle volume increased, reaching a higher level 2 weeks after the injection than the level 3 months afterward (p < 0.001). The gluteal circumference, modified 2 weeks after surgery by about 1 to 3 cm, came back to previous values 3 months after the procedure (p < 0.05), a phenomena interpreted as reabsorption and resolution of the postoperative edema. There is no correlation between the gluteus muscle volume obtained by MRI and the gluteal circumference (p > 0.05). CONCLUSIONS: The findings led to the conclusion that enhancement of the gluteal contour after fat injection results from survival of the injected tissue 3 months after the surgery, which was objectively evaluated by MRI as having a calculated reabsorption rate of 24% to 36%.

Minimally invasive total knee arthroplasty: a systematic review

SR for PM on OA of All Extremities

The concept of minimally invasive total knee arthroplasty surgery evolved to reduce quadriceps muscle strength loss and improve clinical outcome following total knee replacement. We performed a systematic review of the published literature on Minimally Invasive Total Knee Arthroplasty (MITKA) and analyzed the reported surgical outcomes. Twenty-eight studies published from January 2003 to June 2008 that met the inclusion criteria were evaluated using the modified Coleman Methodology Score (CMS). At a mean CMS of 60, most studies reporting on outcome of MITKA are of moderate scientific quality. Patients undergoing MITKA tend to have decreased postoperative pain, rapid recovery of quadriceps function, reduced blood loss, improved range of motion (mostly reported as a short-term gain) and shorter hospital stay compared with patients undergoing standard total knee arthroplasty. These benefits, however, need to be balanced against the incidence of increased tourniquet time and increased incidence of component malalignment in the MITKA group. So far, the evidence based knowledge regarding results of MITKA comes from prospective studies of moderate quality with short follow up periods. Multicenter studies with longer follow-ups are needed to justify the long-term advantages of MITKA over standard total knee arthroplasty

Fragility fracture-related direct medical costs in the first year following a nonvertebral fracture in a managed care setting

HipFx Supplemental Cost Analysis

The objective of this study was to estimate the fracture-related direct medical costs during the first year following a fragility nonvertebral fracture in a managed care setting. This was a retrospective cohort study conducted among patients (aged 45+ years) with a primary diagnosis for a fragility nonvertebral fracture between July 1, 2000, and December 31, 2000, using MarketScan, an integrated administrative, medical, and pharmacy claims database. All patients had 6 months of observation prior to their fracture and 12 months following a nonvertebral fracture. Fracture-related direct medical costs were evaluated in the 12-month period following fracture diagnosis using 2003 Medicare fee schedule payments. The costs per fracture per year (PFPY) for specific nonvertebral fracture sites were determined, as well as costs by type of care (i.e., outpatient, inpatient, and other). A total of 4,477 women and men fulfilled the inclusion criteria. The sample was comprised of 73% women and the mean age was 70 years. The most prevalent nonvertebral fracture sites were wrist/forearm (37%), hip (25%), and humerus (15%). Mean total costs per patient per year were highest for fractures of the hip ($26,856), femur ($14,805), tibia ($10,224), and pelvis ($10,198). On average, 84% of the annual fracture-related costs were inpatient; 3% were outpatient, and 13% were long-term care and other costs. In a patient population aged 45+ years, the first month following a nonvertebral fracture has a major impact on medical care costs. The most costly nonvertebral fracture sites were hip, femur, and tibia fractures

Hip fracture programs: are they effective?

Hip Fx in the Elderly 2019

This manuscript will evaluate the published evidence on efficacy of organized hip fracture programs to determine if they improve patient outcomes. A detailed literature search was conducted to find manuscripts published in the past 20 years about organized hip fracture care programs. Seventeen programs with published results were identified from this detailed search and these were evaluated and synthesized in the following manuscript. Organized hip fracture programs offer significant benefits to patients, care providers and health systems. The more complex program designs have a more profound effect on improvement in outcomes for hip fracture patients. Most programs have reported reduced length of stay, reduced in-hospital mortality rates, and reduced complications. Some programs have reported reduced costs and reduced readmission rates after implementing an organized hip fracture program.

The use of the 3-mm K-Wire to supplement reduction of humeral supracondylar fractures in children

DoD SSI (Surgical Site Infections)

BACKGROUND: Most children with humeral supracondylar fractures can be treated with simple closed reduction and cross-fixation with Kirschner (K)-wires. However, in a small proportion of cases, an acceptable closed reduction cannot be obtained, and open reduction becomes necessary. An alternative to open reduction is the use of a temporary 3-mm K-wire to manipulate and reduce the distal fragment. This report introduces the method of manipulation, as well as indications, and draws comparisons with complete close reduction cases. METHODS: Of 118 patients, 76 (64.4%) were managed with the standard closed reduction method and additional K-wire fixation to secure a good alignment (group 1). In the remaining 42 cases (35.6%), acceptable reduction could not be achieved by closed methods alone, and another temporary 3-mm K-wire was used to manipulate the distal fragment. After reduction of the fracture with the additional wire, standard cross K-wires were inserted to stabilize the fracture (group 2). As long as there was contact at the fracture site in cases of humeral supracondylar fracture, the traditional closed method was used easily to achieve excellent restoration. However, for cases in which the fracture site was totally displaced, and contact at the fracture site via traction was unsuccessful, a 3-mm K-wire was used to perform supplemental restoration treatment. All the patients, after the operation, were temporally immobilized with a long-arm splint for about 3 weeks. The fixation K-wires were removed after the radiograph had shown callus formation over the fracture site. Then the operation indications, operation methods and time, complications, and differences in range of motion were analyzed for these two sets of patients. RESULTS: The average group 1 surgery time was 18 minutes (range, 9-32 minutes), whereas the average surgery time for group 2 was 33 minutes (range, 15-45 minutes). Three cases in group 1 were complicated with ulnar nerve injury caused by the fixation wire. There were no ulnar nerve injuries in group 2. However, the ulnar nerve injury complication rates for the two groups (3 in 76 for group 1; 0 in 40 for group 2) did not reach statistical difference (p = 0.5502, Fisher's exact test). The union times for the two groups were almost the same (average, 3 weeks; range, 2-5 weeks). The 3-mm K-wire manipulation reduction cases and the closed reduction cases seemed to yield the same healing results in all aspects, except for the longer surgery time in group 2 (p < 0.0001). Both groups achieved satisfactory results. CONCLUSIONS: The closed reduction method should be used for children with humeral supracondylar fractures, whenever possible. The 3-mm K-wire manipulation method reduces the probability that open reduction will be required in some severe cases. This is a simple method without complications. The prognosis is the same as for closed reduction cases.

Hospital Characteristics, Inpatient Processes of Care, and Readmissions of Older Adults with Hip Fractures

Hip Fx in the Elderly 2019

OBJECTIVES: To determine hospital-level predictors of readmission after hip fracture or potentially related inpatient care processes. DESIGN: Retrospective cohort study. SETTING: U.S. acute care hospitals. PARTICIPANTS: Fee-for-service Medicare beneficiaries who underwent hip fracture surgery between 2007 and 2009 (N = 458,526). MEASUREMENTS: Information was obtained on hospital case volumes, teaching status, bed count, nurse staffing, and technological capabilities from Medicare files, and multivariable logistic regression was used to measure the association between these factors and an endpoint of readmission or death at 30 days and between these factors and the timing of surgery. RESULTS: Participants treated in the highest-volume hospitals (>175 cases for the study period) had lower odds of readmission or death at 30 days than those treated in low-volume hospitals (<=12; adjusted odds ratio (aOR) = 0.87, 95% confidence interval (CI) = 0.83-0.92, P < .001). Higher nurse skill mix (aOR = 0.88, 95% CI = 0.8-0.96; P = .007) and higher ratio of nurses to beds (aOR = 0.98; 95% CI = 0.97-0.99; P < .001) were also associated with better 30-day outcomes. Greater hospital case volume was associated with lower odds of surgical delay beyond 48 hours. CONCLUSION: Better nurse staffing and higher case volumes are associated with lower rates of readmission and mortality after hip fracture surgery; individuals treated at high-volume centers experienced fewer delays in treatment, potentially indicating better inpatient care processes.

Assessment and reliability of the World Health Organisation quality of life (WHO QOL-BREF) questionnaire in total hip replacement patients

Hip Fx in the Elderly 2019

Background: Several functional scoring tools are available to evaluate the outcomes of total hip replacements (THRs) for diseased or damaged hips. Majority of these scores were devised in western countries and their cross-cultural compatibilities are rarely demonstrated. The World Health Organisation quality of life (WHO QOL-BREF) questionnaire with 4 domains, is one of the best known multilingual instruments for such assessment. Its reliability has never been demonstrated for THRs and the present study was conceptualised for the same. Methods: THRs done over 6 years were followed up retrospectively. Revision THRs and hemiarthroplasties were excluded. All the cases were done by a single senior arthroplasty surgeon. Clinical examination was done and questionnaires for WHO QOL-BREF and Harris Hip scores were given to the patients. Results: The number of patients included in the study was 96 with 115 operated hips. The average age of these patients was 41.40 years ranging from 17 to 80 years. There was strong male preponderance in our series of patients with 90 THRs. The mean score of domain 1 was 70.8 (SD 21.6), domain 2: 72.4 (SD 18.8), domain 3: 74.7 (SD 16.8) and domain 4: 75.4 (SD 14.8); showed significant functional improvement post THR in domain 2 (P = 0.0001), domain 3 (P = 0.0010) and domain 4(P = 0.0001), when compared to scores of general healthy population. Similarly, the scores were significantly improved in all domains as compared to cohorts of post-operative acetabular and hip fractures. The score was found to be a reliable tool with Cronbach's alpha of 0.912 and strong correlation was present with the standard Harris hip scores (p = 0.000). Conclusion: WHO QOL-BREF is a potent tool to assess the quality of life in patients undergoing THRs. It can be used as a single index of measurement and it is simple, reproducible and reliable.

Extending the role of liposuction in body contouring with ultrasound- assisted liposuction

Panniculectomy & Abdominoplasty CPG

The initial experience with ultrasound-assisted liposuction in treating difficult fibrous areas, such as gynecomastia, hitherto not uniformly responsive to traditional suction-assisted lipoplasty, has led to the evolution and improvement of ultrasound-assisted liposuction techniques. This prospective study examined 114 consecutive patients treated with ultrasound- assisted liposuction over a 13-month period, from September of 1996 to September of 1997. The means by which this procedure helps achieve fat contouring differs from that of suction-assisted lipoplasty. Ultrasound- assisted liposuction removes fat through a fat emulsification process termed 'cavitation,' whereas suction-assisted lipoplasty achieves contouring through the mechanical avulsion of fat. The technique for the use of ultrasound- assisted liposuction has changed significantly from our initial series of patients to our current technique. To optimize the benefits of both ultrasound-assisted and traditional suction-assisted lipoplasty, we use a three-stage technique consisting of infiltration, ultrasound-assisted sculpturing, and suction-assisted lipoplasty for evacuation and final contouring. This has decreased our operative time, minimized complications, and optimized our body contouring results. Data were collected intraoperatively, including treatment times, treatment volumes, and treatment areas for both suction-assisted and ultrasound-assisted lipoplasty. A total of 114 patients were treated with ultrasound-assisted liposuction between September of 1996 and September of 1997. There were 23 male patients and 91 female patients. In general, the average total volume removed with this procedure decreased by about 50 percent throughout the series, whereas the suction-assisted lipoplasty volume increased correspondingly by 50 percent. Overall, suction-assisted lipoplasty volume was approximately two times ultrasound-assisted liposuction volume in the same area. Exceptions to this include the dense fibrous areas such as the back and male breast, where aspiration volumes were approximately equal. The total ultrasound-assisted liposuction treatment times were reduced after our initial 30 patients, and suction-assisted lipoplasty times increased. Total aspiration rates in our later patients averaged 36.2 cc/per minute for ultrasound-assisted and 58.4 cc/per minute for suction-assisted lipoplasty, whose rates were approximately 1.5 to 2 times faster than for ultrasound-assisted liposuction in most areas. After using this technology in our initial series of 30 patients, it became apparent that ultrasound was not a substitute for suction-assisted lipoplasty but rather a natural complement. We have found that the marriage of the techniques enhances results and minimizes complications, such as seromas, which have been reported to be 11.4 percent with ultrasound-assisted liposuction alone and are 2.6 percent in our series.

Cytocompatibility with osteogenic cells and enhanced in vivo anti-infection potential of quaternized chitosan-loaded titania nanotubes

PJI DX Updated Search

Infection is one of the major causes of failure of orthopedic implants. Our previous study demonstrated that nanotube modification of the implant surface, together with nanotubes loaded with quaternized chitosan (hydroxypropyltrimethyl ammonium chloride chitosan, HACC), could effectively inhibit bacterial adherence and biofilm formation in vitro. Therefore, the aim of this study was to further investigate the in vitro cytocompatibility with osteogenic cells and the in vivo anti-infection activity of titanium implants with HACC-loaded nanotubes (NT-H). The titanium implant (Ti), nanotubes without polymer loading (NT), and nanotubes loaded with chitosan (NT-C) were fabricated and served as controls. Firstly, we evaluated the cytocompatibility of these specimens with human bone marrow-derived mesenchymal stem cells in vitro. The observation of cell attachment, proliferation, spreading, and viability in vitro showed that NT-H has improved osteogenic activity compared with Ti and NT-C. A prophylaxis rat model with implantation in the femoral medullary cavity and inoculation with methicillin-resistant Staphylococcus aureus was established and evaluated by radiographical, microbiological, and histopathological assessments. Our in vivo study demonstrated that NT-H coatings exhibited significant anti-infection capability compared with the Ti and NT-C groups. In conclusion, HACC-loaded nanotubes fabricated on a titanium substrate show good compatibility with osteogenic cells and enhanced anti-infection ability in vivo, providing a good foundation for clinical application to combat orthopedic implant-associated infections

Coagulase-negative staphylococci

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Coagulase-negative staphylococci, long considered to be harmless commensals or contaminants, have emerged as major pathogens as medical technology has advanced. They are a major cause of intravenous-catheter-associated bacteremia, endocarditis, otitis media, and infection of joint prostheses, vascular grafts, cardiac pacemakers, cerebrospinal fluid shunts, postoperative wounds, the urinary tract, and the eye. Therapy includes removal of infected foreign bodies and administration of appropriate antimicrobial agents

Fibrin-based biomaterial systems to enhance anterior cruciate ligament healing

PRP (Platelet-Rich Plasma)

Anterior cruciate ligament (ACL) tears are a common and potentially career-ending injury, particularly for athletes and soldiers. Partial and complete ruptures of this ligament cause instability in the knee, and the ACL does not have the capacity for healing due, in part, to its position within the highly thrombolytic synovial fluid environment of the knee joint. Traditional methods of ACL reconstruction, such as graft replacement, restore stability but do not prevent the development of post-traumatic osteoarthritis. To enhance therapeutic treatment options, novel fibrin-based technologies and repair techniques have been recently explored and show promise for improved patient outcomes. Through modification of existing surgical methods, such as the use of fibrin glues incorporating growth factors and cells and the implementation of scaffolds containing platelet-rich plasma, platelet-rich fibrin and other blood derivatives, surgeons are attempting to overcome the shortcomings of traditional treatments. This mini-review will detail current efforts using fibrin-based treatments and discuss opportunities to further enhance ACL healing.

Popliteal Pseudoaneurysm After Total Knee Arthroplasty. A Report of 3 Cases

Surgical Management of Osteoarthritis of the Knee CPG

Although the incidence of vascular injuries after total knee arthroplasty is quite low, clinical outcome could be significantly impaired. Quick response and accurate management are important to achieve the best possible outcome. We present 3 cases of popliteal pseudoaneurysm formation after total knee arthroplasty and their treatment by endovascular stenting together with a review of literature. (copyright) 2012 Elsevier Inc.

Reliability of clinical outcome measures in Charcot-Marie-Tooth disease

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

We assessed inter- and intra-rater reliability of outcome measures in Charcot-Marie-Tooth disease (CMT) patients. In 40 CMT patients, we assessed reliability of Overall Neuropathy Limitations Scale (ONLS), 10-m timed walk (T10MW), 9-hole-peg test (9-HPT), maximal voluntary isometric contraction (MVIC) of arm (elbow flexion, hand-grip, and three-point pinch) and leg (knee extension, foot dorsiflexion/plantar flexion). Reliability was substantial for ONLS, excellent for T10MW and 9-HPT. For MVIC, inter and intra-rater reliability was excellent for hand contractions; for leg contractions, intra-rater agreement was moderate to substantial, whereas inter-rater agreement was poor. An ad hoc device was produced to immobilize the foot and MVIC reliability was re-assessed in 26 CMT patients, resulting in excellent inter-rater and intra-rater reliability for foot dorsiflexion, and clear inter-rater improvement for foot plantar flexion. All outcome measures appear adequate for CMT assessment. Use of an immobilization device improves foot MVIC reliability, preventing biased findings in patients with greater strength

Orthopedic complications. Compartment syndrome, fat embolism syndrome, and venous thromboembolism

DOD - Acute Comp Syndrome CPG

Specialized education in the care of orthopedic patients includes an understanding of the common complications for which patients require monitoring. With a socioeconomic backdrop of decreasing hospital stays and prospective payment, patient care must be managed proactively. For all three complications presented, there are unique sets of risk factors that, when present, contribute to a high index of suspicion for morbidity. Clusters of symptoms have also been discussed representing the expected normal patterns. With this knowledge as a foundation, clinical application is essential to incorporate other salient aspects of individual situations. Nurses diagnose and treat human responses to health problems. The end result of human responses to injury or orthopedic conditions can be the development of complications. Stringent adherence to patient monitoring protocols can promote timely nursing interventions to prevent, minimize, or detect complications or treatment side effects. Although definitive treatment is often physician directed, nurses are in a key role to impact final patient outcomes. [References: 58]

Lateral Opening-wedge Distal Femoral Osteotomy: Pain Relief, Functional Improvement, and Survivorship at 5 Years

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Distal femoral varus osteotomy may be used to treat valgus knee malalignment or to protect a knee compartment in which cartilage restoration surgery (such as osteochondral or meniscus allografting) has been performed. Medial closing-wedge osteotomy has demonstrated good success in treatment of osteoarthritis in published series, but few studies have evaluated distal femoral lateral opening-wedge osteotomy in terms of correction of deformity, pain and function, and survivorship. QUESTIONS/PURPOSES: (1) Does lateral opening-wedge osteotomy lead to accurate correction? (2) What pain and function levels do patients experience after lateral opening-wedge osteotomy? (3) What are the nonunion, complication, and reoperation rates after lateral opening-wedge osteotomy? METHODS: Between 2000 and 2010, we performed 40 distal femoral osteotomies. Two knees (two patients) underwent a medial closing-wedge osteotomy and were excluded from the present study. Thirty-eight knees (97%) in 36 patients were lateral opening-wedge varus-producing osteotomies; of those, 31 knees (82%) in 30 patients had followup at a minimum of 2 years (mean, 5 years; SD, 2; range, 2-12 years) and comprised the study population. The indications for osteotomy included symptomatic lateral compartment arthritis with clinical valgus deformity or a cartilage or meniscal defect in the lateral compartment with clinical valgus alignment. The study population was stratified into two groups based on reason for osteotomy: patients with isolated symptomatic lateral compartment arthritis (arthritis group; 19 knees [61%]) and patients who underwent joint preservation procedures including osteochondral allograft transplantation or meniscal allograft transplantation (joint preservation group; 12 knees [39%]). Data collection from our institution's osteotomy database included patient demographics, lower extremity coronal alignment, and operative details. Pain and function were measured preoperatively and postoperatively using the International Knee Documentation Committee (IKDC) score. Time to radiographic union, complications, and reoperations were recorded. RESULTS: Twenty-one of 31 knees had postoperative radiographic data available for review. Of these, seven of 15 knees in the arthritis group and three of six knees in the joint preservation group were within the correction goal of +/- 3degree from neutral mechanical alignment. In the arthritis group, the mean IKDC total score improved from 47 (SD, 15) preoperatively to 67 (SD, 10) postoperatively. In the joint preservation group, the mean IKDC total score improved from 36 (SD, 12) preoperatively to 62 (SD, 18) postoperatively. One nonunion occurred in the arthritis group. No postoperative complications were experienced. Ten knees in the arthritis group and six knees in the joint preservation group had additional surgery after the osteotomy, consisting primarily of hardware removal, arthroscopy for cartilage-related conditions, or conversion to arthroplasty. Survivorship at 5 years, with conversion to arthroplasty as the endpoint, was 74% in the arthritis group and 92% in the joint preservation group. CONCLUSIONS: Lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than expected, but the procedure was associated with improved knee pain and function scores. Our clinical and radiographic results are comparable to published series evaluating medial closing-wedge distal femoral osteotomy. Achieving our desired correction of +/- 3degree from neutral alignment was clinically difficult. An improved method of preoperative templating and refinement of the intraoperative technique may improve this. Future studies with more patients and longer followup will provide clarity on this topic. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients

Hip Fx in the Elderly 2019

One hundred elderly patients who had an intertrochanteric femoral fracture were randomized to treatment with a compression hip-screw with a plate (fifty patients) or a new intramedullary device, the intramedullary hip-screw (fifty patients). All patients were followed prospectively for one year or until death. A detailed assessment of the functional status and the plain radiographs of the hip was performed one, three, six, and twelve months postoperatively. The two treatment groups were strictly comparable. The operative time needed to insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw with the plate (p = 0.02), but use of the intramedullary hip-screw was associated with less estimated intraoperative blood loss (p = 0.011). The prevalence of perioperative complications, such as bronchopneumonia, cardiac failure, and urinary tract infection, was comparable in the two treatment groups. There were one intraoperative fracture of the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the intramedullary hip-screw. One patient had pulling-out of the compression hip-screw on the seventh postoperative day. Four patients had a trochanteric wound hematoma, without infection, after insertion of an intramedullary hip-screw. All but one of the fractures healed. The one non-union, which was in a patient who had a compression hip-screw, was treated with a hemiarthroplasty. The mortality rate was similar in the two treatment groups. The patients who had an intramedullary hip-screw had, on the average, significantly better mobility at one (p < 0.0001) and three months (p = 0.0013) postoperatively. This difference was no longer seen at six and twelve months, although the patients who had an intramedullary hip-screw still had significantly better walking ability outside the home at those time-periods (p = 0.05). The compression hip-screw was removed from two patients because of pain in the mid-portion of the thigh, which had begun after consolidation of the fracture. Fourteen patients who had an intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at twelve months postoperatively. Cortical hypertrophy was significantly related to the use of two interlocking screws (p = 0.02). Six of these patients also had pain in the mid-portion of the thigh, and the nail had been locked with two screws in five of them. Three of the six patients had the hardware removed because of the pain, and the symptoms resolved. A seventh patient had pain without cortical hypertrophy. The intramedullary hip-screw device was associated with significantly less sliding of the lag-screw and subsequent shortening of the limb in the region of the thigh (p = 0.012 and 0.019, respectively); these differences were more pronounced when the unstable fractures in the two treatment groups were compared (p < 0.001).

Greater tissue mineralization heterogeneity in femoral neck cortex from hip-fractured females than controls. A microradiographic study

Management of Hip Fractures in the Elderly

In addition to bone quantity, bone quality affects bone strength. Bone quality depends in part on the degree of mineralization of bone tissue (DMB). The relationship between the DMB distribution and the risk of osteoporotic hip fractures remains incompletely investigated. Here, our aim was to compare DMB distribution in femoral neck cortex specimens from 23 women with hip fractures (age, 65-96years) and 14 control women (age, 75-103years). Mineralization was determined using quantitative microradiography. We evaluated the following parameters of DMB frequency histograms, for both osteons and interstitial tissue: mode (oDMB(Al)mode and intDMB(Al)mode, respectively); 25th (oDMB(Al)q25, intDMB(Al)q25), 50th (oDMB(Al)q50, intDMB(Al)q50), and 75th (oDMB(Al)q75, intDMB(Al)q75) percentiles; and interquartile range (oDMB(Al)iqr, intDMB(Al)iqr). For each specimen, we also calculated the variance of pixel mineral content for osteons and interstitial tissue (oDMB(Al)var and intDMB(Al)var).We used nonparametric tests to compare frequency histogram parameters between hip-fractured women and controls and Fisher's test to compare variances between groups.All frequency histogram parameters for osteons and interstitial tissue except the 25th percentile, and the variances of pixel mineral content in osteons and interstitial tissue, were significantly different between hip-fractured women and controls, indicating greater heterogeneity of mineralization in the hip-fracture patients than in the controls.These cross-sectional data suggest that bone fragility may be related to greater DMB heterogeneity in osteons and interstitial tissue. (copyright) 2011 Elsevier Inc

Safety of bilateral total knee arthroplasty in morbidly obese patients

Surgical Management of Osteoarthritis of the Knee CPG

There has been an increase in the prevalence of morbid obesity and the demand for total knee arthroplasty (TKA). Physicians must help patients with bilateral knee arthritis to make informed decisions regarding whether to undergo staged, sequential, or simultaneous TKA. The purpose of this study was to evaluate the perioperative complications of 2-team simultaneous bilateral TKA in the morbidly obese. The authors performed a retrospective review of the records at a single tertiary hospital from 1997 to 2007 and identified 35 morbidly obese (body mass index [BMI] greater than 40 kg/m(2)) patients who had undergone unilateral TKA, as well as 42 morbidly obese and 79 nonobese (BMI less than 30 kg/m(2)) patients who underwent simultaneous bilateral TKA. Clinical, operative, and postoperative variables and complication rates were recorded. Clinical variables were similar between the morbidly obese TKA patients. The bilateral group had significantly increased operative times (132.4 vs 115.5 minutes; P<.01), intravenous fluids (2556.1 vs 2114.7 mL; P=.03), percentage transfused (64.2% vs 11.4%; P<.01), days in the hospital (3.6 vs 3.2 days; P=.03), and discharge rates to rehabilitation facility (72.7% vs 48.6%; P=.01). Major and minor complications were few and comparable, with the need for manipulation under anesthesia in unilateral TKA (11.4%; P=.04) as the only significant difference between groups, including when comparing bilateral nonobese TKAs with bilateral morbidly obese TKAs. The authors feel that morbidly obese patients may undergo 2-team simultaneous bilateral TKA after careful discussion regarding some of the differences in short-term outcomes

Anaerobic osteomyelitis and arthritis in a military hospital: a 10-year experience

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

PURPOSE: The methods of collecting, transporting, cultivating, and identifying aerobic bacteria in bone and joint infections have improved markedly since the early 1980s. In addition, many of the anaerobes have been reclassified and renamed. The purpose of this study was to provide more current information regarding the incidence of recovery of anaerobic bacteria from clinical specimens of infected bone and joint. MATERIALS AND METHODS: Specimens from 73 infected bone specimens and 65 infected joints inoculated on media supportive for aerobic and anaerobic bacteria showed bacterial growth. RESULTS: One hundred fifty-seven organisms (2.2 isolates/specimen), consisting of 122 anaerobic bacteria (1.7 isolates/specimen) and 35 facultative or aerobic bacteria (0.5 isolate/specimen), were recovered from the 73 bone specimens. Anaerobic bacteria were recovered with aerobe or facultative bacteria in 24 (33%) instances. The predominant anaerobes were Bacteroides species (49 isolates), anaerobic cocci (45), Fusobacterium species (11), Propionibacterium acnes (7), and Clostridium species (6). Conditions predisposing to bone infections were vascular disease, bites, contiguous infection, peripheral neuropathy, hematogenous spread, and trauma. Pigmented Prevotella and Porphyromonas species were mostly isolated in skull and bite infections (7 of 19), members of the Bacteroides fragilis group in hand and feet infection (12 of 16), and Fusobacterium species in skull, bite, and hematogenous long bone infections. Seventy-four organisms (1.1 isolates/specimen), consisting of 67 anaerobic bacteria (1.0 isolate/specimen) and 7 facultative or aerobic bacteria (0.1 isolate/specimen), were isolated from 65 joint specimens. The predominant anaerobes were P. acnes (24 isolates), anaerobic cocci (17), Bacteroides species (10), and Clostridium species (5). Predisposing conditions to joint infection were trauma, prior surgery, presence of a prosthetic joint, and contiguous infection. P. acnes isolates were associated with prosthetic joints, members of the B. fragilis group with hematogenous spread, and Clostridium species with trauma. The clinical presentation of these cases is discussed. CONCLUSION: These data highlight the importance of anaerobic bacteria in bone and joint infection

Evidence-based value of subcutaneous surgical wound drainage: the largest systematic review and meta-analysis

PJI DX Updated Search

BACKGROUND: The purpose of this study was to determine the evidenced-based value of prophylactic drainage of subcutaneous wounds in surgery. METHODS: An electronic search was performed. Articles comparing subcutaneous prophylactic drainage with no drainage were identified and classified by level of evidence. If sufficient randomized controlled trials were included, a meta-analysis was performed using the random-effects model. Fifty-two randomized controlled trials were included in the meta-analysis, and subgroups were determined by specific surgical procedures or characteristics (cesarean delivery, abdominal wound, breast reduction, breast biopsy, femoral wound, axillary lymph node dissection, hip and knee arthroplasty, obesity, and clean-contaminated wound). Studies were compared for the following endpoints: hematoma, wound healing issues, seroma, abscess, and infection. RESULTS: Fifty-two studies with a total of 6930 operations were identified as suitable for this analysis. There were 3495 operations in the drain group and 3435 in the no-drain group. Prophylactic subcutaneous drainage offered a statistically significant advantage only for (1) prevention of hematomas in breast biopsy procedures and (2) prevention of seromas in axillary node dissections. In all other procedures studied, drainage did not offer an advantage. CONCLUSIONS: Many surgical operations can be performed safely without prophylactic drainage. Surgeons can consider omitting drains after cesarean section, breast reduction, abdominal wounds, femoral wounds, and hip and knee joint replacement. Furthermore, surgeons should consider not placing drains prophylactically in obese patients. However, drain placement following a surgical procedure is the surgeon's choice and can be based on multiple factors beyond the type of procedure being performed or the patient's body habitus. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II

Efficacy of a specially designed hip protector for hip fracture prevention and compliance with use in elderly Hong Kong Chinese

Management of Hip Fractures in the Elderly

BACKGROUND: Hip protectors, while effective in prevention of hip fractures, have been designed for a Caucasian body build and may not be suitable for Asian subjects living in a subtropical climate. OBJECTIVE: Hip protectors and accompanying shorts were specially designed for use for the Chinese body build and subtropical climate, and tested for compliance and efficacy in fracture prevention. METHOD: A pragmatic study examining compliance with the wearing of hip protectors, and effectiveness in preventing hip fractures (using a case control design), in 302 subjects wearing hip protectors and 352 control subjects. RESULTS: Overall compliance varied from 55 to 70%. The relative risk for hip fracture was 0.18 (0.04-0.79), relative risk reduction 82%, and the number of subjects needing to wear a hip protector to prevent one fracture was 33 (19-117). CONCLUSION: Hip protectors adapted for use in Chinese people appear to reduce hip fractures in routine clinical practice

Is intralesional treatment of giant cell tumor of the distal radius comparable to resection with respect to local control and functional outcome?

Distal Radius Fractures

BACKGROUND: A giant cell tumor is a benign locally aggressive tumor commonly seen in the distal radius with reported recurrence rates higher than tumors at other sites. The dilemma for the treating surgeon is deciding whether intralesional treatment is adequate compared with resection of the primary tumor for oncologic and functional outcomes. More information would be helpful to guide shared decision-making. QUESTIONS/PURPOSES: We asked: (1) How will validated functional scores, ROM, and strength differ between resection versus intralesional excision for a giant cell tumor of the distal radius? (2) How will recurrence rate and reoperation differ between these types of treatments? (3) What are the complications resulting in reoperation after intralesional excision and resection procedures? (4) Is there a difference in functional outcome in treating a primary versus recurrent giant cell tumor with a resection arthrodesis? METHODS: Between 1985 and 2008, 39 patients (39 wrists) were treated for primary giant cell tumor of the distal radius at two academic centers. Twenty patients underwent primary intralesional excision, typically in cases where bony architecture and cortical thickness were preserved, 15 underwent resection with radiocarpal arthrodesis, and four had resection with osteoarticular allograft. Resection regardless of reconstruction type was favored in cases with marked cortical expansion. A specific evaluation for purposes of the study with radiographs, ROM, grip strength, and pain and functional scores was performed at a minimum of 1 year for 21 patients (54%) and an additional 11 patients (28%) were available only by phone. We also assessed reoperations for recurrence and other complications via chart review. RESULTS: With the numbers available, there were no differences in pain or functional scores or grip strength between groups; however, there was greater supination in the intralesional excision group (p=0.037). Tumors recurred in six of 17 wrists after intralesional excision and none of the 15 after en bloc resection (p=0.030). There was no relationship between tumor grade and recurrence. There were 12 reoperations in eight of 17 patients in the intralesional excision group but only one of 11 patients (p=0.049) who underwent resection arthrodesis with distal radius allograft had a reoperation. There were no differences in functional scores whether resection arthrodesis was performed as the primary procedure or to treat recurrence after intralesional excision. CONCLUSIONS: Resection for giant cell tumor of the distal radius with distal radius allograft arthrodesis showed a lower recurrence rate, lower reoperation rate, and no apparent differences in functional outcome compared with joint salvage with intralesional excision. Because an arthrodesis for recurrence after intralesional procedures seems to function well, we believe that intralesional excision is reasonable to consider for initial treatment, but the patient should be informed about the relative benefits and risks of both options during the shared decision-making process. Because arthrodesis after recurrence functions similar to the initial resection and arthrodesis, an initial treatment with curettage remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss. LEVEL OF EVIDENCE: Level III, therapeutic study.

Antinociceptive effects of lacosamide on spinal neuronal and behavioural measures of pain in a rat model of osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Introduction: Alterations in voltage-gated sodium channel (VGSC) function have been linked to chronic pain and are good targets for analgesics. Lacosamide (LCM) is a novel anticonvulsant that enhances the slow inactivation state of VGSCs. This conformational state can be induced by repeated neuronal firing and/or under conditions of sustained membrane depolarisation, as is expected for hyperexcitable neurones in pathological conditions such as epilepsy and neuropathy, and probably osteoarthritis (OA). In this study, therefore, we examined the antinociceptive effect of LCM on spinal neuronal and behavioural measures of pain, in vivo, in a rat OA model. Methods: OA was induced in Sprague Dawley rats by intraarticular injection of 2 mg of monosodium iodoacetate (MIA). Sham rats received saline injections. Behavioural responses to mechanical and cooling stimulation of the ipsilateral hind paw and hindlimb weight-bearing were recorded. In vivo electrophysiology experiments were performed in anaesthetised MIA or sham rats, and we recorded the effects of spinal or systemic administration of LCM on the evoked responses of dorsal horn neurones to electrical, mechanical (brush, von Frey, 2 to 60 g) and heat (40°C to 50°C) stimulation of the peripheral receptive field. The effect of systemic LCM on nociceptive behaviours was assessed. Results: Behavioural hypersensitivity ipsilateral to knee injury was seen as a reduced paw withdrawal threshold to mechanical stimulation, an increase in paw withdrawal frequency to cooling stimulation and hind limb weight-bearing asymmetry in MIA-treated rats only. Spinal and systemic administration of LCM produced significant reductions of the electrical Aβ- and C-fibre evoked neuronal responses and the mechanical and thermal evoked neuronal responses in the MIA group only. Systemic administration of LCM significantly reversed the behavioural hypersensitive responses to mechanical and cooling stimulation of the ipsilateral hind paw, but hind limb weight-bearing asymmetry was not corrected. Conclusions: Our in vivo electrophysiological results show that the inhibitory effects of LCM were MIA-dependent. This suggests that, if used in OA patients, LCM may allow physiological transmission but suppress secondary hyperalgesia and allodynia. The inhibitory effect on spinal neuronal firing aligned with analgesic efficacy on nociceptive behaviours and suggests that LCM may still prove worthwhile for OA pain treatment and merits further clinical investigation.

Rheumatoid arthritis of the forefoot

Surgical Management of Osteoarthritis of the Knee CPG

Severe and often debilitating involvement of the forefoot is seen frequently in patients with rheumatoid arthritis. The combination of destructive synovitis and weight bearing leads to a spectrum of disorders causing pain, deformity, and eventual loss of function. In addition, advances in total knee and total hip arthroplasty have placed added importance on preserving the ability of the foot and ankle to bear weight and allow functional ambulation. This article reviews the epidemiology, pathophysiology, clinical presentation, physical examination, and treatment of rheumatoid arthritis of the forefoot

1H-nuclear magnetic resonance studies of human synovial fluid in arthritic disease states as an aid to confirming metabolic activity in the synovial cavity

AMP (Acute Meniscal Pathology)

1. A 1H-n.m.r. method was used to measure concentrations of valine, alanine, lactate, acetate, hyaluronan and lipids in synovial fluid obtained, during the normal course of examination from the knee joints of patients attending rheumatology and orthopaedic clinics. Fluid was available from 16 patients with osteoarthritis, 18 patients with rheumatoid arthritis, four patients with meniscal tear and one patient each with systemic lupus erythematosis, mono-arthritis, synovitis and loose bodies. Four normal specimens were obtained for comparison. 2. Valine, alanine and acetate levels all showed a normal Gaussian distribution, reflecting the distributions within the serum of the sample population. 3. Lactate concentrations divided into two distinct patterns. At concentrations below 2.5 mmol/l the lactate levels showed a Gaussian distribution, reflecting the distribution in normal serum. The normal synovial fluid specimens belong to this distribution. Above 2.5-3.0 mmol/l, lactate levels were asymmetric in distribution with a long tail at higher concentrations. These high levels of lactate can be explained by the generation of lactate through anaerobic metabolism within the synovial cavity. This metabolic process is triggered by a general inflammatory condition such as in rheumatoid arthritis. 4. The distribution of n.m.r.-observable lipid concentrations in rheumatoid arthritis and osteoarthritis each shows a normal distribution and the mean concentration is significantly higher in rheumatoid arthritis. 5. An increased n.m.r.-observable hyaluronan concentration is associated with an inflammatory situation. 6. It is concluded that raised levels of lactate and n.m.r.-observable hyaluronan and lipids are useful markers to aid the clinical distinction between rheumatoid arthritis and osteoarthritis.(ABSTRACT TRUNCATED AT 250 WORDS)

Parosteal osteosarcoma dedifferentiating into telangiectatic osteosarcoma: importance of lytic changes and fluid cavities at imaging

MSTS 2022 - Metastatic Disease of the Humerus

PURPOSE: This study was performed to assess the imaging findings in cases of parosteal osteosarcoma dedifferentiated into telangiectatic osteosarcoma. Parosteal osteosarcoma is a low-grade well-differentiated malignant tumor. Dedifferentiation into a more aggressive lesion is frequent and usually visible on imaging as a central lytic area in a sclerotic mass. Only one case of differentiation into a telangiectatic osteosarcoma has been reported. As it has practical consequences, with a need for aggressive chemotherapy, we looked for this rather typical imaging pattern. MATERIALS AND METHODS: Review of 199 cases of surface osteosarcomas (including 86 parosteal, of which 23 were dedifferentiated) revealed lesions suggesting a possible telangiectatic osteosarcoma on imaging examinations in five cases (cavities with fluid). Histology confirmed three cases (the two other only had hematoma inside a dedifferentiated tumor). There were three males, aged 24, 28, and 32. They had radiographs and CT, and two an MR examination. RESULTS: Lesions involved the distal femur, proximal tibia, and proximal humerus. The parosteal osteosarcoma was a sclerotic, regular mass, attached to the cortex. A purely lytic mass, partially composed of fluid cavities was easily detected on CT and MR. It involved the medullary cavity twice, and remained outside the bone once. Histology confirmed the two components in each case. Two patients died of pulmonary metastases and one is alive. CONCLUSION: Knowledge of this highly suggestive pattern should help guide the initial biopsy to diagnose the two components of the tumor, and guide aggressive treatment.

Fifteen years of experience with Integral-Leg-Prosthesis: Cohort study of artificial limb attachment system

PJI DX Updated Search

Integral-Leg-Prosthesis (ILP) is a comparatively new attachment system that allows direct skeletal docking of artificial limbs. Between January 1999 and December 2013, 69 patients with transfemoral amputation were fitted with ILPs by a single German surgeon. Device design iterations and surgical techniques evolved during these years. For the purposes of comparison, patients receiving the first two designs and procedure iterations were placed in group 1 and the patients fitted with the final design were placed in group 2. Infection rate and planned and unplanned surgical interventions were statistically compared using Fisher exact test. Data demonstrated that the high rate of stoma-associated infections seen in group 1 was dramatically reduced in group 2. Of the 39 patients with 42 implants in group 2, none had operative interventions secondary to infection. All group 2 patients remained infection-free without the use of antibiotics by following a simple but defined wound-hygiene protocol. We concluded that the final iteration of the osseointegrated intramedullary device with a low energy surface at the soft tissue and prosthesis interface allowed a biologically stable skin stoma that remained infection-free without chronic use of antibiotics. The reduction in the infection rate was attributed to the clinically based, empirically driven changes in design and surgical techniques

Relationship between radiologic morphology of the bone lengthening formation and its complications

DoD SSI (Surgical Site Infections)

The objective was to study the different types of lengthened bone regeneration and their development during the various phases of the process to correlate them with patient factors and the surgical technique used, and to establish a possible relation between the development of the bone lengthening formation and the problems or complications. The authors studied the radiographs of a random group of 55 patients taken at three points during the course of treatment. The callus was classified with regard to its transverse diameter and the presence or absence of hypodense areas. The overall callus type was significantly influenced by the etiology, the osteotomy site, and the percentage lengthened. The percentage by which the limb was lengthened at the beginning of the process influences the overall morphology of the callus. Poor callus had been lengthened the most, atrophic callus the least. There was a correlation between the morphology of the overall callus at the end of treatment and the percentage lengthened, and between the percentage lengthened and the presence of bands at the end of treatment. The authors also found a significant correlation between age and the appearance of bands at the end of distraction. A central band was found among younger patients. The type of osteotomy affected the overall callus at the end of distraction and at the end of treatment and also influenced the transverse diameter. All the elongations with poor bone formation at the end of treatment were found to have undergone a diaphyseal osteotomy. The most common complication at the first follow-up and at the end of distraction was angulation. The diameter of the callus and the presence of bands at the end of treatment were significantly related to the complications. Fracture occurred in the first 2 weeks after removal of the external fixator in 88% of cases and in the third and fourth week in the rest. However, the segment had no significant influence on the appearance of complications. Lengthened callus with incomplete trabecular formations and hypodense areas at the end of the treatment has a high risk of fracture at the end of treatment. Callus with axial deviation, hypodense areas, or an insufficient transverse diameter during the lengthening procedure must be manipulated so that it reaches the maturing phase in better condition.

Rheumatoid arthritis is associated with higher ninety-day hospital readmission rates compared to osteoarthritis after hip or knee arthroplasty: a cohort study

PJI DX Updated Search

OBJECTIVE: To examine whether an underlying diagnosis of rheumatoid arthritis (RA) or osteoarthritis (OA) impacts the 90-day readmission rates after total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: We analyzed prospectively collected data from an integrated health care system, Total Joint Replacement Registry, of adults with RA or OA undergoing unilateral primary THA or TKA during 2009-2011. Adjusted logistic regression models for 90-day readmission were fit. Odds ratios with 95% confidence intervals (95% CIs) were calculated. Study year was an effect modifier for the outcome; therefore separate analyses were conducted for each of the 3 study years. RESULTS: Of the 34,311 patients, 496 had RA and 33,815 had OA. Comparisons of RA and OA patients, respectively, were 73% and 61% women, 45% and 70% white, and patients had a mean age of 61 versus 67 years (P < 0.001). Crude 90-day readmission rates for RA and OA were 8.5% and 6.7%, respectively. The adjusted odds of 90-day readmission increased from year to year for RA compared to OA patients, from 0.89 (95% CI 0.46-1.71) in 2009 to 1.34 (95% CI 0.69-2.61) in 2010, and to 1.74 (95% CI 1.16-2.60) in 2011. The 2 most common readmission reasons were joint prosthesis infection (10.2%) and septicemia (10.2%) in RA and joint prosthesis infection (5.7%) and other postoperative infection (5.1%) in OA. CONCLUSION: RA is a risk factor for 90-day readmission after primary THA or TKA. An increasing risk of readmissions noted in RA in 2011 is concerning and indicates that further studies should examine the reasons for this increasing trend

Male Body Contouring

Panniculectomy & Abdominoplasty CPG

Men are increasingly turning to dermatologists and plastic surgeons to request procedures that correct or enhance physical features. With the advent of this emerging new patient population, alterations in preexisting aesthetic techniques, gender-specific uses of existing devices and overall approaches need to be revisited and adapted to obtain results that are suitable for the male patient. Recently, body contouring has become one of the most sought out procedures by men. Although the majority of clinical studies involving body contouring esthetics are performed with female patients, gains from such studies can be extrapolated to men. Body contouring can be broadly classified as non-invasive or invasive, depending on the modality used. Non-invasive contouring is most frequently performed with devices that target subcutaneous adipose with focused electrical or thermal energy, including low-level laser, cryolipolysis, ultrasonography, and radiofrequency. Invasive body contouring modalities useful for male body contouring include liposuction, pectoral and abdominal wall etching, jawline fillers, synthetic deoxycholic acid injections, and solid silicone implants. The purpose of this review is to bring attention to the unique aspects, strategies, and modalities used in aesthetic body contouring for the male patient.

Limb pain and swelling

DOD - Acute Comp Syndrome CPG

Limb pain and swelling is one of the 'Top 20' presentations in acute medicine. Patients present mainly with lower limb signs and symptoms, but upper limb presentations also occur and should be investigated and managed in a similar way. The causes can be divided into those producing bilateral changes, including fluid overload from cardiac or renal failure, low serum albumin or dependency oedema due to immobility, and those with primarily unilateral signs and symptoms that include disorders of the arterial, venous and lymphatic systems. An acutely painful limb, which may result from trauma, acute ischaemia or an infection, is an emergency requiring urgent assessment and treatment, including surgical care. Other common presentations of limb pain and swelling include cellulitis, Baker's cyst and haematoma, and musculoskeletal pain due to osteoarthritis, crystal and septic arthritis. Ambulatory (outpatient) management of stable patients with deep vein thrombosis or cellulitis is now the rule in most acute medical units. © 2013 Elsevier B.V. All rights reserved.

Periarticular infiltration for pain relief after total hip arthroplasty: a comparison with epidural and PCA analgesia

AAHKS (4) Acetaminophen

PURPOSE: Epidural and intravenous patient-controlled analgesia (PCA) are established methods for pain relief after total hip arthroplasty (THA). Periarticular infiltration is an alternative method that is gaining ground due to its simplicity and safety. Our study aims to assess the efficacy of periarticular infiltration in pain relief after THA. METHODS: Sixty-three patients undergoing THA under spinal anaesthesia were randomly assigned to receive postoperative analgesia with continuous epidural infusion with ropivacaine (epidural group), intraoperative periarticular infiltration with ropivacaine, clonidine, morphine, epinephrine and corticosteroids (infiltration group) or PCA with morphine (PCA group). PCA morphine provided rescue analgesia in all groups. We recorded morphine consumption, visual analog scale (VAS) scores at rest and movement, blood loss from wound drainage, mean arterial pressure (MAP) and adverse effects at 1, 6, 12, 24 h postoperatively. RESULTS: Morphine consumption at all time points, VAS scores at rest, 6, 12 and 24 h and at movement, 6 and 12 h postoperatively were lower in infiltration group compared to PCA group (p < 0.05), but did not differ between infiltration and epidural group. There was no difference in adverse events in all groups. At 24 h, MAP was higher in the PCA group (p < 0.05) and blood loss was lower in the infiltration group (p < 0.05). CONCLUSIONS: In our study periarticular infiltration was clearly superior to PCA with morphine after THA, providing better pain relief and lower opioid consumption postoperatively. Infiltration seems to be equally effective to epidural analgesia without having the potential side effects of the latter.

Prospective outcome study of 360 patients treated with liposuction, lipoabdominoplasty, and abdominoplasty

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Patient-reported data, including effects on quality of life, have not been previously prospectively evaluated in liposuction patients, or in abdominoplasty patients treated simultaneously with liposuction. This prospective outcome study was undertaken to evaluate and compare liposuction and abdominoplasty from the patient's perspective. METHODS: From 2002 to 2007, in-person interviews were conducted with 360 patients who attended a follow-up appointment at least 1 month after surgery, from a total of 551 consecutive patients treated with ultrasonic liposuction and/or abdominoplasty (response rate, 65.3 percent). Questions were asked in six categories: patient data, indications, recovery, results, complications, and psychological effects. Responses were analyzed in three groups: liposuction alone (n = 219), combined liposuction and abdominoplasty (n = 128), and abdominoplasty alone (n = 13). RESULTS: For most recovery indices, liposuction patients recovered significantly more quickly than lipoabdominoplasty patients (p </= 0.01) and had less discomfort (pain ratings, 6.1 of 10 and 7.5 of 10, respectively; p < 0.001). The result ratings for lipoabdominoplasty (9.0 of 10) and abdominoplasty (8.7 of 10) were higher than for liposuction alone (7.8 of 10; p < 0.001). Overall, 85.8 percent of patients reported improved self-esteem and 69.6 percent reported an improved quality of life. CONCLUSIONS: : Liposuction and abdominoplasty, either alone or in combination, provide high levels of patient satisfaction (88.8 percent overall). The combined procedure is similar in discomfort level to abdominoplasty alone (both 7.5 of 10) and produces the highest level of patient satisfaction (99.2 percent), with 97.6 percent of patients saying they would undergo the operation again and 99.2 percent recommending it to others. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Ultrasound evaluation of patients with moderate and severe carpal tunnel syndrome

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

The objective of this study is to determine cut-off points for the crosssectional areas of the median nerve proximal and distal to carpal tunnel in moderate and severe Carpal Tunnel Syndrome (CTS) and compare the results of our study with those available in the literature. Forty-three patients with upper limb pain other than CTS and 36 patients with idiopathic CTS enrolled into the study. The diagnosis and categorization of CTS were based on electrophysiologic criteria of the American Academy of Neurology. Median nerve cross-sectional areas were measured. Arithmetic mean values and standard deviation of each variable were measured. Student t-test and chi-squared test were applied to compare continuous and dichotomous variables between CTS and non-CTS control groups. Ultimately the diagnostic performances of the test characteristics including sensitivity, specificity, positive and negative predictive values were measured. Mean cross-sectional area of the nerve is higher in moderate than severe CTS proximal and distal to carpal tunnel. We accepted cut-off points of 11.5 mm(2) and 13.5 mm(2) for cross-sectional areas of the proximal and distal portions of carpal canal respectively. The sensitivity, specificity, positive and negative predictive values for the proximal inlet are 83%, 90.7%, 65.5% and 55.7%; and for the distal outlet are 36.1%, 93%, 81.2% and 63.4% respectively. We suggest that ultrasound is a good diagnostic modality for patients referred to tertiary care centers which categorized as moderate CTS

The prevalence of cardiac valvular pathosis in patients with systemic lupus erythematosus

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The purpose of this study was to determine the prevalence of valvular pathosis in a population of patients with SLE, to assess the candidacy of such patients for antibiotic prophylaxis before dental treatment. The hospital records of 112 patients with SLE were reviewed and screened for endocarditis, heart murmurs, and other valvular pathosis. Two of the 112 patients had confirmed cases of bacterial endocarditis. This prevalence is comparable to endocarditis prevalence rates in patients with prosthetic valves and is also three times that in patients with rheumatic heart disease. The high prevalence of endocarditis in this population of patients with SLE suggests that according to present perspectives on patient management, patients with SLE should be considered for antibiotic prophylaxis before dental therapies associated with formation of a bacteremia

Aesthetic Refinement of the Abdominal Donor Site after Autologous Breast Reconstruction

Panniculectomy & Abdominoplasty CPG

BACKGROUND: The abdominal donor site has consistently demonstrated excellent aesthetic outcomes when used for autologous breast reconstruction. However, a consistent point of dissatisfaction is the location and appearance of the abdominal donor-site scar, which can be a frequent cause of distress for the patient. The authors consider the appearance of the donor-site to be as important to the overall reconstructive effort as that of the breast, and believe it worthwhile to achieve an aesthetically pleasing result. Thus, the authors present here their technique for aesthetic revision of the abdominal donor site after autologous breast reconstruction. METHODS: This is a series of 51 patients who underwent autologous tissue breast reconstruction with deep inferior epigastric perforator flaps. All patients subsequently underwent abdominal donor-site revision during the second stage of their reconstruction, including excision and lowering of the abdominal scar, and liposuction of the abdomen and mons pubis to achieve optimum contouring. RESULTS: The donor-site scars were lowered an average of 5.93 cm (range, 5 to 7 cm). The average procedural time was 27 minutes. No wound dehiscence, seromas, hematomas, or infections were reported postoperatively. CONCLUSIONS: With this report, the authors put forth a new obtainable standard for autologous tissue breast reconstruction donor-site aesthetics, and propose a conceptual shift that includes the trunk aesthetic unit as an integral part of the overall reconstructive outcome. The authors' results here demonstrate that this is a safe, successful, and reproducible procedural adjunct to the second stage of breast reconstruction.

The Masquelet technique combined with the muscle flap for use in emergency management of acute Gustilo type III trauma of the lower limb with segmental bone loss:Case series

DoD SSI (Surgical Site Infections)

BACKGROUND: Gustilo-Anderson type III traumas have been described as high-energy injuries with severe bone defects and extensive soft tissue damage, which remain a challenging entity, due to an inherent risk of infection, nonunion and even amputation. The emergency management of such severe trauma presents additional difficulties. Our study attempts to retrospectively evaluate the Masquelet technique combined with the muscle flap for the management of Gustilo type III trauma of the lower limb with segmental bone loss in emergencies and assess key points of success in this technique. MATERIAL AND METHODS: From June 2014 to December 2017, 17 patients of Gustilo type IIIA/B/C trauma of lower limb with segmental bone loss, were recruited for our studies. All the cases experienced thorough debridement, stabilization of fracture and antibiotic-impregnated cement spacer insertion. When necessary, muscle flap surgeries were performed immediately. After wound healing, cement spacers were removed, and cancellous bone was filled to repair bone defects. Procedures were performed by two experienced orthopedic surgeons. RESULTS: Among the patients studied, retrograde translocations of the medial head of the gastrocnemius were performed in 5 cases, medial hemimuscular flaps of soleus in 3 cases, and medial head of the gastrocnemius combined with medial hemimuscular flaps of soleus in 4 cases. One patient developed a necrotic soleus flap and was treated with the cross-leg flap. Using a mean 28.2 months of follow-up, results were analyzed radiologically and clinically. Failures (include infection and nonunion) were not noted. And all the patients returned to full weight bearing without pain. According to the Paley fracture healing score, 15 patients showed excellent results and 2 patients displayed good results regarding bone outcomes. When considering functional outcomes, 14 patients exhibited excellent results and 3 patients displayed good results. CONCLUSIONS: The muscle flap is synergistic with the Masquelet technique in the emergency management of severe complex fractures. The combination of both techniques in emergency surgery demonstrates an alternative option for the treatment of acute Gustilo type III trauma of the lower limb with segmental bone loss, which can effectively prevent bone infection and amputation. We also demonstrate that firm fixation is key to the Masquelet technique.

Function and quality of life following medial unicompartmental knee arthroplasty in patients 60 years of age or younger

PJI DX Updated Search

INTRODUCTION: UKA is an appropriate bone-sparing solution for focal advanced knee osteoarthritis in young patients. As the expectations of patients younger than 60 years of age are different from those in an older population, we aimed to evaluate quality of life and the quality of sports activity after UKA in this population. PATIENTS AND METHODS: Sixty-five UKAs in 62 patients younger than 60 (mean age: 54.7 years; mean BMI: 28 kg/m(2)) performed between 1989 and 2006 were included. At last follow-up (minimum 2 years), before the objective evaluation, patients were asked to fill in a KOOS questionnaire and a specific sports questionnaire including the UCLA score and questions from the Mohtadi score. RESULTS: With a mean follow-up of 11.2+/-5 years (range, 2-19 years), the KOOS score was higher than 75 points in 90% of the patients for the quality-of-life categories but also for the score's four other categories: 83.4% of the patients had resumed their sports activities and the mean UCLA score was 6.8 (range, 4-9); 90% of the patients reported no or slight limitation during sports activities. The function KSS improved from 52+/-4 to 95+/-3 points postoperatively and the Knee KSS from 50+/-4 to 94+/-4 points. With three patients undergoing revision for an isolated insert exchange, one for septic loosening and three for osteoarthritis in the external compartment, the 12-year Kaplan-Meier survivorship was 94%. DISCUSSION AND CONCLUSION: These results confirmed that UKA can provide good patient-rated outcomes, which is very important in this demanding population. As for TKA, wear remains a problem in this active population. LEVEL OF EVIDENCE: Therapeutic study, level IV

Do ceramic femoral heads reduce taper fretting corrosion in hip arthroplasty? A retrieval study

PJI DX Updated Search

Background: Previous studies regarding modular head-neck taper corrosion were largely based on cobalt chrome (CoCr) alloy femoral heads. Less is known about head-neck taper corrosion with ceramic femoral heads. Questions/purposes: We asked (1) whether ceramic heads resulted in less taper corrosion than CoCr heads; (2) what device and patient factors influence taper fretting corrosion; and (3) whether the mechanism of taper fretting corrosion in ceramic heads differs from that in CoCr heads. Methods: One hundred femoral head-stem pairs were analyzed for evidence of fretting and corrosion using a visual scoring technique based on the severity and extent of fretting and corrosion damage observed at the taper. A matched cohort design was used in which 50 ceramic head-stem pairs were matched with 50 CoCr head-stem pairs based on implantation time, lateral offset, stem design, and flexural rigidity. Results: Fretting and corrosion scores were lower for the stems in the ceramic head cohort (p = 0.03). Stem alloy (p = 0.004) and lower stem flexural rigidity (Spearman's rho = -0.32, p = 0.02) predicted stem fretting and corrosion damage in the ceramic head cohort but not in the metal head cohort. The mechanism of mechanically assisted crevice corrosion was similar in both cohorts although in the case of ceramic femoral heads, only one of the two surfaces (the male metal taper) engaged in the oxide abrasion and repassivation process. Conclusions: The results suggest that by using a ceramic femoral head, CoCr fretting and corrosion from the modular head-neck taper may be mitigated but not eliminated. Clinical Relevance: The findings of this study support further study of the role of ceramic heads in potentially reducing femoral taper corrosion. © 2013 The Author(s)

Cost-effectiveness of referrals to high-volume hospitals: an analysis based on a probabilistic Markov model for hip fracture surgeries

Management of Hip Fractures in the Elderly

Previous studies suggest that German hospitals that perform a high volume of hip fracture surgeries have a lower mortality rate and shorter length of stay than low-volume hospitals. The goal of this paper was to determine the long-term cost-effectiveness (over 20 years) of referring hip fracture surgeries to high-volume hospitals, based on data from previous studies. From a societal perspective, the cost-effectiveness ratio was 15,530 Euro per QALY (quality-adjusted life year) (95% confidence interval 9,864-33,048 Euro), while total annual costs to the statutory health insurance amounted up to 19.6 million Euro. The referral of hip fracture surgeries to high-volume hospitals is thus likely to be cost-effective in Germany

Lumbar Epidural Corticosteroid Injection Reduces Subacute Pain and Improves Knee Function in the First Six Weeks After Total Knee Arthroplasty: A Double-Blinded Randomized Trial

AAHKS (2) Corticosteroids

BACKGROUND: Pain control immediately following total knee arthroplasty (TKA) has been a focus for orthopaedists. However, control of subacute pain, which may persist up to 3 months, is usually not optimized. The efficacy of epidural corticosteroids in reducing pain after surgery is documented, but data on their efficacy in controlling subacute pain after TKA are lacking. Our aim was to investigate the efficacy of an epidural corticosteroid in controlling pain in the first 3 months following TKA using a double-blinded randomized clinical trial. METHODS: One hundred and eight patients with osteoarthritis of the knee who underwent TKA and received analgesic drugs through an epidural catheter for 48 hours were randomized to receive either 40 mg (1 mL) of triamcinolone acetonide plus 5 mL of 1% lidocaine, or 6 mL of 1% lidocaine alone before catheter removal. The outcomes of interest were pain level during motion and at rest, knee function, and range of motion, which were recorded up to 3 months after surgery. Multilevel regression models were used to estimate the differences between groups. RESULTS: The corticosteroid + lidocaine group had a lower average level of pain during motion compared with the lidocaine-only group, as measured by a visual analog scale (VAS), from day 3 to 7 weeks postoperatively (p < 0.05). At 7 weeks, the mean difference was -7 points (95% confidence interval [CI], -12.8 to -1.0 points; p = 0.033). The corticosteroid + lidocaine group also had a better mean overall modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 6 weeks postoperatively (28 compared with 33 points; 95% CI, -8.6 to -0.6 points; p = 0.03). There was no difference between the groups in the level of pain at rest and knee range of motion during the 3-month period (p > 0.05). CONCLUSIONS: Lumbar epidural corticosteroid injection reduced pain during motion for 7 weeks and provided better knee function at 6 weeks postoperatively compared with lidocaine alone. There was no difference detected with respect to pain at rest and knee range of motion during the 3-month follow-up. Epidural corticosteroids could improve patient satisfaction during the early weeks of recovery after TKA. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intra-articular injuries of the elbow: pitfalls of diagnosis and treatment

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Poor results in treating fractures and dislocations about the elbow may be avoided if the surgeon is aware of the possible injuries, examines good radiographs of both elbows, and treats the injury promptly and appropriately. A displaced fracture of the lateral or medial condyle of the humerus should be suspected if there is a flake fracture of the adjoining metaphysis; open reduction and internal fixation give better results than closed reduction. A shear fracture of the capitulum humeri can only be seen on a lateral radiograph; excision of the fragment, followed by mobilization, is sufficient for a good functional result. Dislocation of the elbow in a child may avulse the medial epicondyle, which sometimes lodges in the joint; it is essential to recognize this and remove the fragment without delay to avoid early degenerative arthritis. An apparently isolated fracture of the ulna should alert the surgeon to the possibility of a dislocation of the radial head; the dislocation and the fracture must be reduced and stabilized to conserve elbow function

Staged Suprapectoral Expander/Implant Reconstruction without Acellular Dermal Matrix following Nipple-Sparing Mastectomy

Acellular Dermal Matrix

BACKGROUND: Since the introduction of nipple-sparing mastectomy as an oncologically safe procedure for the treatment of breast cancer, reconstructive efforts for immediate staged expander/implant reconstruction have focused on submuscular implantation with or without acellular dermal matrix. Suprapectoral reconstruction without acellular dermal matrix has received little attention in the reconstructive literature of nipple-sparing mastectomy. METHODS: Between 2005 and 2015, 155 patients (250 breasts) underwent nipple-sparing mastectomy with prepectoral staged expander/implant reconstruction using thick mastectomy skin flaps without acellular dermal matrix. Patients with different breast sizes, including those patients with very large breasts who required a primary mastopexy, were considered candidates for the suprapectoral reconstruction. Tumor-related data, comorbidities, and preoperative or postoperative radiation therapy were evaluated for correlation with the final outcome. RESULTS: Patients were followed up for an average of 55.5 months (range, 138.1 to 23.6 months). The tumor recurrence rate was 2.6 percent. Adverse outcomes such as capsular contracture, implant dystopia, and rippling were studied. Aesthetic outcome, based on a three-point evaluation scale, showed 53.6 percent of patients as having a very good result, 31.6 percent showing a good result, 9 percent showing a fair result, and 5.8 percent showing a poor result. CONCLUSIONS: The suprapectoral two-stage expander/implant reconstruction without acellular dermal matrix in nipple-sparing mastectomy has certain advantages with respect to breast shape, less morbidity related to expansion, ease of reconstruction, and cost effectiveness. These advantages have to be weighed against those of subpectoral reconstruction with acellular dermal matrix to determine the method of choice. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Carpal tunnel syndrome: the new 'industrial epidemic'

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

1. Symptoms of carpal tunnel syndrome (CTS) include numbness, tingling, and decreased sensation in the fingers. 2. The main occupational causes of CTS include repetitive wrist flexion and extension, strong gripping with ulnar deviation, impact forces on the palm, and vibratory forces. 3. Conservative treatment includes a metal-reinforced splint that prevents flexion and extension of the wrist. Surgical treatment may be needed for severe symptoms. 4. Prevention of CTS requires early diagnosis, job reassignment, and tool redesign

Influence of different prophylactic antibiotic regimens on implant survival rate: A retrospective clinical study

Dental Implant Infection

Background: The routine use of antibiotics in oral implant treatment seems to be widespread. The pre- or postoperative use of antibiotics in conjunction with implant surgery and its correlation with failure and success rates are poorly documented in the literature. The debate regarding overprescription of antibiotics raises the need for a critical evaluation of proper antibiotic coverage in association with implant treatment. Purpose: The purpose of this study was to compare the implant survival rate following a 1-day single-dose preoperative antibiotic regimen with that following a 1-week postoperative antibiotic protocol. Materials and Methods: The study included 868 consecutively treated patients. A total of 3,021 implants were placed. The population was split into two categories, either receiving a 1-day single-dose administration only, or a 1-week postoperative administration of antibiotics. Healing was evaluated at second-stage surgery (6 months for the upper jaw, 3 months for the lower jaw). Failure was defined as removal of implants because of non-osseointegration. Statistical analyses were performed with analysis of variance and the Scheffé test, with a significance level of 5% for comparison of data. Results: No significant differences with regard to complications and implant survival were found in the study. Conclusion: Based on the present data, a more restrictive regimen consisting of a 1-day dose of prophylactic antibiotic in conjunction with routine implant procedures is recommended. ©2005 BC Decker Inc.

Self-reported upper extremity health status correlates with depression

Distal Radius Fractures

Background: The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is the most widely used upper extremity-specific health-status measure. The DASH score often demonstrates greater variability than would be expected on the basis of objective pathology. This variability may be related to psychosocial factors. The purpose of the present study was to investigate the correlation between the DASH score and psychological factors for specific diagnoses with relatively limited variation in objective pathology. Methods: Two hundred and thirty-five patients with a single, common, discrete hand problem known to have limited variations in objective pathology completed the DASH questionnaire, the Eysenck Personality Questionnaire-Revised (EPQ-R) to assess neuroticism, the Center for Epidemiologic Studies-Depression (CES-D) scale to quantify depressive symptoms, and the Pain Anxiety Symptoms Scale (PASS). Forty-five patients had carpal tunnel syndrome, forty-four had de Quervain tenosynovitis, forty-eight had lateral elbow pain, and seventy-one had a single trigger finger. In addition, twenty-seven patients were evaluated six weeks after a nonoperatively treated fracture of the distal part of the radius. Relationships between psychosocial factors and the DASH score were determined. Results: A significant positive correlation between the DASH score and depression was noted for all diagnoses (r = 0.38 to 0.52; p < 0.01 for all). The DASH score also correlated with pain anxiety for four of the five diagnoses (carpal tunnel syndrome, r = 0.40; de Quervain tendinitis, r = 0.46; lateral elbow pain, r = 0.42; and trigger finger, r = 0.24) (p < 0.05 for all). The DASH score was not correlated with neuroticism for any diagnosis. There was a highly significant effect of depression (as measured with the CES-D score) on the DASH score for all diagnoses. Both the CES-D score (F = 62.68, p < 0.0001) and gender (F = 11.36, p < 0.001) were independent predictors of the DASH score. Conclusions: Self-reported upper extremity-specific health status as measured with the DASH score correlates with depression and pain anxiety but not neuroticism. These data support the contention that psychosocial factors have a strong influence on health-status measures. Copyright © 2006 by The Journal of Bone and Joint Surgery, Incorporated.

Active surveillance of Streptococcus pneumoniae bacteremia in Italian children

Patrick’s pharmacoepidemiology project

There are few data published regarding the incidence of Streptococcus pneumoniae bacteremia in Italian children. A 14-month surveillance study was conducted in 10 paediatric hospitals to investigate the rate of Sp bacteremia in children aged less than 5 years. The serotype prevalence and antimicrobial susceptibility of isolates were determined. A total of 55 Sp isolates were obtained from 4576 blood cultures (incidence rate, 1.2%). In order of frequency, the most common serotypes were 14, 23F, 19F, 9V, 1. Serotypes in the 7-valent conjugate pneumococcal vaccine (4, 6B, 9V, 14, 18C, 19F, 23F) accounted for 70% of isolates under 2 years of age, and 58% in the interval between 2 and 5 years of age. �© 2006 Elsevier Ltd. All rights reserved

Correlation between anatomical parameters of intertubercular sulcus and retroversion angle of humeral head

MSTS 2022 - Metastatic Disease of the Humerus

OBJECTIVE: To obtain anatomical data on intertubercular sulcus of humerus, evaluate the correlation between intertubercular sulcus and retroversion angle of humeral head, to guide the positioning of torsion angle of prosthesis during total shoulder arthroplasty and provide references for shoulder prosthesis design. METHODS: Using a Siemens Ultrahigh speed 64- rows multi-slices spiral CT scanner and 20 dried adult humeral specimens (intact specimen, no fractures or pathological damage), of these, left lateral in 10 cases, right lateral in 10 cases, male or female all inclusive, specimens are all provided by Anatomy Department of Weifang Medical College, scan ranged from the highest point of humeral head to the distal ends of trochlea. And scanned data were subjected to statistical analysis. RESULTS: There is a linear correlation between the distance from intertubercular sulcus to central axis line of humeral head, position angle of intertubercular sulcus and retroversion angle of humeral head at the beginning slice of intertubercular sulcus. There is a linear correlation between position angle of intertubercular sulcus and retroversion angle of humeral head at the slice of surgical neck. CONCLUSION: There is a linear correlation between position of intertubercular sulcus and retroversion angle of humeral head, in total shoulder arthroplasty, using intertubercular sulcus as anatomical landmark will help to accurately position torsion angle of individualized prosthesis. Position angle of intertubercular sulcus is an objective, flexible positioning indicator.

Osteochondral autologous transplantation for the treatment of full-thickness cartilage defects of the shoulder: results at nine years

Glenohumeral Joint OA

We describe the outcome at a mean follow-up of 8.75 years (7.6 to 9.8) of seven patients who had undergone osteochondral autologous transplantation for full-thickness cartilage defects of the shoulder between 1998 and 2000. These patients have been described previously at a mean of 32.6 months when eight were included. One patient has been lost to follow-up. The outcome was assessed by the Constant shoulder score and the Lysholm knee score to assess any donor-site morbidity. Standard radiographs and MR scores were obtained and compared with the pre-operative findings and the results from the previous review. No patient required any further surgery on the shoulder. The mean Constant score improved significantly until the final follow-up (p = 0.018). The Lysholm score remained excellent throughout. There was a significant progression of osteoarthritic changes from the initial surgery to the first and final follow-up but this did not appear to be related to the size of the defect, the number of cylinders required or the Constant score (p = 0.016). MRI showed that all except one patient had a congruent joint surface at the defect with full bony integration of all osteochondral cylinders. The results have remained satisfactory over a longer period with very good objective and subjective findings.

Knee Extensor Rate of Torque Development Before and After Arthroscopic Partial Meniscectomy, With Analysis of Neuromuscular Mechanisms

AMP (Acute Meniscal Pathology)

Study Design Descriptive, prospective single-cohort longitudinal study. Background Though rapid torque development is essential in activities of daily living and sports, it hasn't been specifically tested by most physical therapists or incorporated into rehabilitation programs until late in the treatment process. Little evidence is available on quadriceps torque development capacity before and after arthroscopic knee surgery.

No Difference in Recovery of Patient-Reported Outcome and Range of Motion between Cruciate Retaining and Posterior Stabilized Total Knee Arthroplasty: A Double-Blind Randomized Controlled Trial

OAK 3 - Non-arthroplasty tx of OAK

Both from the perspective of the individual and from a socioeconomic point of view (e.g., return to work), it is important to have an insight into the potential differences in recovery between posterior cruciate ligament retaining (PCR) and posterior stabilized (PS) total knee arthroplasty (TKA) implants. The primary aim of this study was to compare the speed of recovery of patient-reported outcome between patients with a PCR and PS TKA during the first postoperative year. The secondary aim was to compare the effect on range of motion (ROM). In a randomized, double-blind, controlled, single-center trial, 120 adults diagnosed with osteoarthritis of the knee were randomized into either the PCR or PS group. Primary outcome was speed of recovery of patient-reported pain and function, measured with the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), with a follow-up of 1â??year. Main secondary outcome measure was ROM. A generalized estimating equations (GEE) analysis was used to assess whether there was a difference over time between groups ("p-value for interaction"). Between 2008 and 2011, 59 participants received a PCR TKA (mean age, 70.3 years [SDâ??=â??7.7]; mean body mass index [BMI], 30.5â??kg/m2 [SDâ??=â??5.4]) and 55 participants a PS TKA (mean age, 73.5 years [SDâ??=â??7.0]; mean BMI, 29.2â??kg/m2 [SDâ??=â??4.4]). Six patients (two PCR and four PS) were excluded because of early drop-out, so 114 patients (95%) were available for analysis. In between group difference for total WOMAC score was -1.3 (95% confidence interval [CI]: -5.6 to 3.1); p-value for interaction was 0.698. For ROM, in between group difference was 1.1 (95% CI: -2.6 to 4.7); p-value for interaction was 0.379. These results demonstrated that there are no differences in speed of recovery of WOMAC or ROM during the first postoperative year after PCR or PS TKA.

A Randomized Study of Exercise and Fitness Trackers in Obese Patients After Total Knee Arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

Functional limitations persist in obese patients after total knee arthroplasty (TKA). This study assessed the effect of an exercise program (EP) and fitness trackers (FT) in obese patients with TKA. Sixty patients 1 year after orthopedic surgery were recruited and received a 16-week tailored EP; half were randomized to receive an FT. FT had no measurable effect compared with EP alone. EP improved knee range of motion, strength, and quality-of-life scores. This study provides preliminary evidence that a 16-week EP in obese individuals 1 year post TKA is feasible and effective in improving function and quality of life.

Effectiveness of low-level laser therapy for patients with carpal tunnel syndrome: design of a randomized single-blinded controlled trial

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

BACKGROUND: Carpal tunnel syndrome is the most common neuropathy in the upper extremity, resulting from the compression of the median nerve at wrist level. Clinical studies are essentials to present evidence on therapeutic resources use at early restoration on peripheral nerve functionality. Low-level laser therapy has been widely investigated in researches related to nerve regeneration. Therefore, it is suggested that the effect of low-level laser therapy associated with other conservative rehabilitation techniques may positively affect symptoms and overall hand function in compressive neuropathies such as carpal tunnel syndrome. The aim of this study is to evaluate the effectiveness of low-level laser therapy in addition to orthoses therapy and home orientations in patients with carpal tunnel syndrome. METHODS/DESIGN: Patients older than 18 years old will be included, with clinical diagnosis of carpal tunnel syndrome, excluding comorbidies. A physiotherapist will conduct intervention, with a blinding evaluator. Randomization will be applied to allocate the patients in each group: with association or not to low-level laser therapy. All of them will be submitted to orthoses therapy and home orientations. Outcome will be assessed through: pain visual analogic scale, Semmes Weinstein monofilaments threshold sensibility test, Pinch Gauge, Boston Carpal Tunnel Questionnaire and two point discrimination test. DISCUSSION: This paper describes the design of a randomized controlled trial, which aim to assess the effectiveness of conservative treatment added to low-level laser therapy for patients with carpal tunnel syndrome. TRIAL REGISTRATION: Brazilian Clinical Trials Registry (ReBec) - 75ddtf / Universal Trial Number: U1111-1121-5184

Subcapital femoral neck fracture following successful trochanteric fracture treatment with a dynamic hip screw: a report of five cases

Management of Hip Fractures in the Elderly

A subcapital femoral neck fracture complicating a healed trochanteric fracture is rare. Such cases are managed in a rather heterogeneous manner, i.e. there exists a mixture of cases treated by either fixed angle devices or dynamic compression screws. We describe 5 patients who developed subcapital femoral neck fractures after healed trochanteric fractures treated with dynamic compression screws. The subjects' clinical data, operative records, and radiographs have been studied retrospectively and the literature reviewed. The risk factors for such a complication include being of advanced age, female, osteoporotic, and having a small femoral head and neck, and a basicervical type of fracture

Septic complications after interlocking nailing of the tibia

DoD SSI (Surgical Site Infections)

Infection, the primary cause of nonunion and unsatisfactory results in operative fracture treatment, occurs with unsettling frequency in spite of modern surgical methods and antibiotics. In the literature we find infection rates after interlocking nailing (IN) of tibial fractures between 1% (Vecsei, 1981) and 6.3% (4.2% deep infections, Jenny, 1993). In this paper a retrospective study of 334 open and closed tibial fractures treated with Grosse & Kempf Nails (G & K Nails) is presented. There were 5 cases (1.5%) of manifest osseus infection. These cases are classified according to the type of infection, the visible site of infection and predisposing factors for infection. Possible reasons for the infectious process, our therapeutic guidelines and results in the treatment of septic complications of nailed tibia fractures will be discussed.

Favorable radiographic outcomes using the expandable proximal femoral nail in the treatment of hip fractures - A randomized controlled trial

Hip Fx in the Elderly 2019

Aim: To compare the functional and radiographic results of dynamic hip screw (DHS) and expandable proximal femoral nail (EPFN) in the treatment of extracapsular hip fractures. Methods: A randomized controlled trial of sixty hip fracture patients. Outcomes included mortality, residency, independence, mobility, function and radiographic results at a minimum of 1 year. Results: Twenty-nine EPFN patients demonstrated fewer cases of shaft medialization or femoral offset shortening compared to the 31 DHS patients. Mortality, complications and functional outcomes were similar. Conclusion: EPFN provides stable fixation of pertrochanteric hip fractures and prevents neck shortening that is commonly observed after DHS fixation. © 2014 Prof. P K Surendran Memorial Education Foundation.

Surgical treatment for meniscal injuries of the knee in adults

AMP (Acute Meniscal Pathology)

BACKGROUND: Injuries to the knee menisci are common and operations to treat them are among the most common procedures performed by orthopaedic surgeons. OBJECTIVES: To evaluate the effects of common surgical interventions in the treatment of meniscal injuries of the knee. The four comparisons under test were: a) surgery versus conservative treatment, b) partial versus total meniscectomy, c) excision versus repair of meniscal tears, d) surgical access, in particular arthroscopic versus open. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE and bibliographies of published papers. Date of the most recent search: August 1998. SELECTION CRITERIA: All randomised and quasi-randomised trials which involved the above four comparisons or which compared other surgical interventions for the treatment of meniscal injury. DATA COLLECTION AND ANALYSIS: Trial inclusion was agreed by both reviewers who independently assessed trial quality, by use of a 12 item scale, and extracted data. Where possible and appropriate, data were presented graphically. MAIN RESULTS: Three trials, involving 260 patients, which addressed two (partial versus total meniscectomy; surgical access) comparisons were included. Partial meniscectomy may allow a slightly enhanced recovery rate as well as a potentially improved overall functional outcome including better knee stability in the long term. It is probably associated with a shorter operating time with no apparent difference in early complications or re-operation between partial and total meniscectomy. The long term advantage of partial meniscectomy indicated by the absence of symptoms (symptoms or further operation at six years or over: 14/98 versus 22/94; Peto odds ratio 0.55, 95% confidence interval 0.27 to 1.14) or radiographical outcome was not established. The results available from the only trial comparing arthroscopic with open meniscectomy were very limited in terms of patient numbers and length of follow-up. However it is likely that partial meniscectomy via arthroscopy is associated with shorter operating times and a quicker recovery. REVIEWER'S CONCLUSIONS: The lack of randomised trials means that no conclusions can be drawn on the issue of surgical versus non-surgical treatment of meniscal injuries, nor meniscal tear repair versus excision. In randomised trials so far reported, there is no evidence of difference in radiological or long term clinical outcomes between arthroscopic and open meniscal surgery, or between total and partial meniscectomy. Partial meniscectomy seems preferable to the total removal of the meniscus in terms of recovery and overall functional outcome in the short term. [References: 7]

Ultrasonographic evaluation of radial nerve injuries associated with pediatric chronic monteggia lesions

Pediatric Supracondylar Humerus Fracture 2020 Review

Introduction: To determine the ultrasonographic evaluation of the radial nerve (RN) before correction of chronic pediatric Monteggia lesions in patients with suspected nerve injury. Methods: Twelve consecutive children with Monteggia lesions were investigated. The cross-sectional area (CSA) of the nerve and the nerve-to-skin (N-S) distance were determined by ultrasonography at 3 levels: 5 cm proximal to the humeroradial joint (L_prox), a horizontal line through the humeroradial joint (L_mid), and 2.5 cm distal to the humeroradial joint (L_dist). Results: The CSA was greater on the injured side than on the unaffected side at L_prox and at L_mid (P < 0.01), but no difference was noted for posterior interosseous nerve (PIN) at L_dist (P = 0.445). The N-S values were greater on the unaffected side than on the injured side (P < 0.01), but there was no difference at L_dist in superficial RN and PIN. Discussion: Ultrasonography allowed the preoperative assessment of the severity of RN injuries in chronic pediatric Monteggia lesions. Muscle Nerve 59:326â??330, 2019.

Postoperative acute compartment syndrome in the nonoperated "well leg": implications to orthopaedic nursing

DoD - ACS - Interrater Reliability

Acute compartment syndrome after fractures and injuries and in operated limbs is a dreadful complication and is well known to orthopaedic nursing community. Acute compartment syndrome in a nonoperated leg after an orthopaedic procedure has been infrequently reported and discussed. It has been more commonly discussed in colorectal, gynecologic, and urologic practice. It is vital to realize the possibility of this iatrogenic injury on the nonoperated limb. The article reviews the literature to identify and discuss the risk factors for this limb-threatening condition and thus the implications to orthopaedic nursing. [References: 17]

Clinical-electrophysiological correlations in the carpal tunnel syndrome

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

56 patients with carpal tunnel syndrome (CTS) with 84 hands affected were investigated. All patients were assessed clinically and electromyographically in order to find out whether there is a correlation between clinical signs and/or symptoms and the EMG data. A highly significant correlation was found between sensory deficit (hypoesthesia to touch and/or pain) and the amplitude of SAP and a significant correlation between motor deficits (weakness and/or atrophy) and distal motor latency

Influences of preservation at various temperatures on liposuction aspirates

Panniculectomy & Abdominoplasty CPG

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

Arthroscopic repair of osteochondritis dissecans of the femoral condyles with metal staple fixation: a report of 28 cases

Diagnosis and Treatment of Osteochondritis Dissecans AUC

In a retrospective clinical study we evaluated the outcome of arthroscopic repair of osteochondritis dissecans (OCD) of the femoral condyles with metal stable fixation. Twenty-eight knees of 26 patients (mean age 20 years) with OCD of the knee were treated by fixation of the fragments with Hoffmann's dynamic metal staples arthroscopically and by additional arthrotomy in 7 knees. At follow-up (mean 4 years, 1-7) patients were interviewed for any residual symptoms and underwent a routine clinical and radiographic examination. The clinical results were based on the grading scale of Lysholm. The 17 knees which did not require further surgery showed 13 instances of complete healing, 3 of partial healing, and 1 of nonhealing. The 11 knees which had reoperations showed 2 instances of complete healing, 5 of partial healing, and 4 nonhealing. There was no significant difference between early or late surgery, and results were not related significantly to site of the lesion, handling of the fragment and the crater, percutaneous drilling, or type of fragmentation. Clinical grading of 13 knees was as excellent, 11 good, and 4 fair. Broken stables were observed in 9 knees, and they were removed from 5 knees. Complete healing was thus achieved in one-half and partial healing in one-third of cases. The metal staples used here fit for use in the arthroscopic fixation of the OCD of the knee, although the staples had a marked liability to break

Recordings from human dorsal column nuclei using stimulation of the lower limb

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Responses from the surface of the dorsal column nuclei and the dorsal surface of the spinal cord were recorded using monopolar electrodes after stimulation of the lower limbs (common peroneal nerve at the knee and posterior tibial nerve at the ankle) in patients undergoing neurosurgical operations for spasmodic torticollis. Those responses were smaller in amplitude than responses to stimulation of the upper limbs (median nerve at the wrist), and the waveforms differed. The negative deflection that is prominent in the response to stimulation of the upper limbs is more variable, broader, and relatively smaller in amplitude than the response to upper limb stimulation. Another difference between responses to upper and lower limb stimulation was that multiple peaks were superimposed on the initial response to stimulation of the lower limbs, but were not as consistently seen in the responses to upper limb stimulation. The negative peak in the response from the dorsal column nuclei to lower limb stimulation was about the same latency as the P(27) peak in the far-field response (somatosensory evoked potential) to stimulation of the peroneal nerve

Ipsilateral patellofemoral arthroplasty and autogenous osteochondral femoral condylar transplantation

Surgical Management of Osteoarthritis of the Knee CPG

The aim of this study was to report the results of ipsilateral patellofemoral arthroplasty and autologous osteochondral transplantation for patellofemoral arthritis and focal full-thickness chondral defects of the femoral condyles. The size of the condylar cartilage defects ranged from as small as 10 x 9 mm to as big as 24 x 7 mm. The mean Knee Society function score improved from 49 to 93, and the clinical score improved from 47 to 95. The mean patellofemoral pain score improved from 12 to 49, and the patellofemoral function score increased from 16 to 42. There have been no radiographic signs of progressive tibiofemoral cartilage degeneration. Combining patellofemoral arthroplasty and autologous osteochondral transplantation is a reasonable short-term approach to this condition

Distal motor axonal dysfunction in amyotrophic lateral sclerosis

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Nerve conduction slowing in amyotrophic lateral sclerosis (ALS) is usually caused by loss of fast motor axons. We studied the frequency, extent, and distribution of prominently prolonged distal motor latencies in ALS. We reviewed results of median, ulnar, and tibial nerve conduction studies in 91 patients with ALS, 24 with lower motor neuron disorders, and 36 with axonal neuropathy. Coincidental carpal tunnel syndrome was found for 4 (4.4%) of the ALS patients who were excluded from analyses. Markedly prolonged distal latencies (>125% of the upper limit of normal) were found only in the median nerve of ALS patients (9%), and in none of the disease controls. Excitability studies suggested membrane depolarization in some ALS patients. Our results show that approximately 10% of ALS patients shows prominently prolonged median distal latency, which cannot be explained by axonal loss and carpal tunnel lesion. The distal nerve conduction slowing may partly be caused by membrane depolarization possibly due to motor neuronal degeneration in ALS. We suggest that recognition of the pattern of distal motor axonal dysfunction predominant in the median nerve is clinically important, and could provide additional insights into the pathophysiology of ALS

A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores

DoD LSA (Limb Salvage vs Amputation)

BACKGROUND: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems. METHODS: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation. RESULTS: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation. CONCLUSIONS: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.

Resident and Program Director Perceptions of Aesthetic Training in Plastic Surgery Residency: An Update

Panniculectomy & Abdominoplasty CPG

Background: This is the third survey exploring the quality of cosmetic training in plastic surgery residency. We focused on determining: (1) the applied modalities and extent of resident exposure; and (2) resident confidence in performing variable cosmetic procedures. Objectives: To analyze trends in resident exposure and confidence in aesthetic plastic surgery procedures from the standpoint of program directors (PDs) and residents. Methods: The survey was developed and e-mailed to 424 residents enrolled in the ASAPS Residents Program and 95 PDs. Both independent and integrated programs were included. The questions were posed in a five-point ranking format. Univariate statistical analysis was used to examine all aspects. The results were analyzed in relation to our previous surveys in 2008 and 2011. Results: Thirty-three PDs (34.7%) and 224 (52.8%) residents responded. Residents felt most confident with abdominoplasty, breast reduction, and augmentation-mammaplasty. Facial aesthetic procedures, especially rhinoplasty and facelift, were perceived as "challenging." The three most preferred modalities of aesthetic education were, in descending order, residents' clinic, staff cosmetic patients, and cadaver dissections. Both residents and PDs felt a need for more training especially in facial procedures. Only 31.5% of residents who planned to focus on cosmetic surgery felt ideally prepared integrating cosmetic surgery into their practice (compared to 50% in previous surveys). Conclusions: Despite improvements observed from 2008 to 2011 published surveys, there are still challenges to be met especially in facial cosmetic procedures. It is suggested that resident clinics and cadaver courses be universally adopted by all training programs.

Association between drug-specific indicators of prescribing quality and quality of drug treatment: A validation study

Hip Fx in the Elderly 2019

Purpose: To evaluate the concurrent validity of three European sets of drug-specific indicators of prescribing quality Methods: In 200 hip fracture patients (â?¥65years), consecutively recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was assessed according to a gold standard as well as to three drug-specific indicator sets (Swedish National Board of Health and Welfare, French consensus panel list, and German PRISCUS list). As gold standard, two specialist physicians independently assessed and then agreed on the quality for each patient, after initial screening with STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) and START (Screening Tool to Alert to Right Treatment). Results: According to the Swedish, French, and German indicator sets, 82 (41%), 54 (27%), and 43 (22%) patients had potentially inappropriate drug treatment. A total of 141 (71%) patients had suboptimal drug treatment according to the gold standard. The sensitivity for the indicator sets was 0.51 (95% confidence interval: 0.43; 0.59), 0.33 (0.26; 0.41), and 0.29 (0.22; 0.37), respectively. The specificity was 0.83 (0.72; 0.91), 0.88 (0.77; 0.94), and 0.97 (0.88; 0.99). Suboptimal drug treatment was 2.0 (0.8; 5.3), 1.9 (0.7; 5.1), and 6.1 (1.3; 28.6) times as common in patients with potentially inappropriate drug treatment according to the indicator sets, after adjustments for age, sex, cognition, residence, multi-dose drug dispensing, and number of drugs. Conclusions: In this setting, the indicator sets had high specificity and low sensitivity. This needs to be considered upon use and interpretation.

Macroscopic and histopathologic analysis of human knee menisci in aging and osteoarthritis

AMP (Acute Meniscal Pathology)

OBJECTIVE: Meniscus lesions following trauma or associated with osteoarthritis (OA) have been described, yet meniscus aging has not been systematically analyzed. The objectives of this study were to (1) establish standardized protocols for representative macroscopic and microscopic analysis, (2) improve existing scoring systems, and (3) apply these techniques to a large number of human menisci. DESIGN: Medial and lateral menisci from 107 human knees were obtained and cut in two different planes (triangle/cross section and transverse/horizontal section as well) in three separate locations (middle portion, anterior and posterior horns). All sections included vascular and avascular regions and were graded for (1) surface integrity, (2) cellularity, (3) matrix/fiber organization and collagen alignment, and (4) Safranin-O staining intensity. The cartilage in all knee compartments was also scored. RESULTS: The new macroscopic and microscopic grading systems showed high inter-reader and intra-reader intraclass correlation coefficients. The major age-related changes in menisci in joints with no or minimal OA included increased Safranin-O staining intensity, decreased cell density, the appearance of acellular zones, and evidence of mucoid degeneration with some loss of collagen fiber organization. The earliest meniscus changes occurred predominantly along the inner rim. Menisci from OA joints showed severe fibrocartilaginous separation of the matrix, extensive fraying, tears and calcification. Abnormal cell arrangements included decreased cellularity, diffuse hypercellularity along with cellular hypertrophy and abnormal cell clusters. In general, the anterior horns of both medial and lateral menisci were less affected by age and OA. CONCLUSIONS: New standardized protocols and new validated grading systems allowed us to conduct a more systematic evaluation of changes in aging and OA menisci at a macroscopic and microscopic level. Several meniscus abnormalities appear to be specific to aging in the absence of significant OA. With aging the meniscal surface can be intact but abnormal matrix organization and cellularity were observed within the meniscal substance. The increased Safranin-O staining appears to represent a shift from fibroblastic to chondrocytic phenotype during aging and early degeneration.

Inflammatory myopathy associated with mixed connective tissue disease and scleroderma renal crisis

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Mixed connective tissue disease is a rheumatological syndrome with neuromuscular manifestations that may include inflammatory myopathy and carpal tunnel syndrome. We report a patient who presented with an inflammatory myopathy and bilateral carpal tunnel syndrome prior to the diagnosis of a connective tissue disorder. Early in the course of treatment, a syndrome of acute renal failure developed. Knowledge of this syndrome, scleroderma renal crisis, and its possible relation to corticosteroid treatment is important to clinicians involved in the management of patients with inflammatory myopathies

Arteriovenous fistulae for hemodialysis

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Primary arteriovenous fistulae remain the gold standard for hemodialysis access. The radiocephalic or Brescia-Cimino fistula is the autologous fistula of choice, with a primary success rate of nearly 93% and a 1 -year patency rate of up to 82%. Alternative arteriovenous fistulae include the snuff box fistula and a brachiobasilic fistula with a 1-year patency rate of up to 90%. Complications include thrombosis, infection, arterial steal syndrome, venous hypertension, aneurysms, and congestive heart failure. Despite these complications, arteriovenous fistulae provide good long-term hemodialysis access

Use of an articulated external fixator for fractures of the tibial plafond

DoD SSI (Surgical Site Infections)

We performed a prospective study of forty-nine displaced fractures of the tibial plafond in forty-eight patients managed, at three centers, with an articulated external fixator placed medially across the ankle joint. Forty ankles had interfragmental screw fixation of a reduced articular fracture, and fourteen ankles had bone-grafting. The average duration of external fixation was twelve weeks. All of the fractures healed (one after delayed bone-grafting). There were no infections in any of the operative or traumatic wounds over the tibia. Two wound infections over the fibula resolved with treatment. Eight patients were managed with antibiotics for a pin-site infection, and two patients had curettage and debridement of a pin site in the hindfoot after removal of the fixator. Thirty patients (thirty-one ankles) completed two-year data sheets at an average of thirty months after the injury. The average ankle score was 67 points. Twenty-one patients had grade-0 or 1 osteoarthrosis and nine had grade-2 or 3. One ankle had been treated with an arthrodesis. These data suggest that the prevalence of early complications associated with severe fractures of the tibial plafond and their treatment can be decreased with use of an articulated external fixator combined with limited internal fixation. We concluded that this technique of external fixation is a satisfactory technique for the treatment of these fractures.

A Pilot Study of Computed Tomography-Detected Asymptomatic Pulmonary Filling Defects After Hip and Knee Arthroplasties

PJI DX Updated Search

We asked what the incidence of asymptomatic filling defects is on routine multidetector computed tomography (MDCT) in primary hip (total hip arthroplasty [THA]) and knee arthroplasties (TKA) patients. We prospectively performed MDCT scans on the first postoperative day for THA (n = 21)/TKA (n = 27). Patients underwent routine postoperative care, and data were collected for symptoms such as tachycardia or shortness of breath. More patients undergoing TKA had positive computed tomography scans than those undergoing THA: 11 (41%) vs 1 (5%), respectively. All patients diagnosed with a filling defect were discharged from the hospital without treatment of symptomatic pulmonary embolism. Our study demonstrates a high rate of abnormal MDCT early after lower extremity arthroplasty, the clinical importance of which may be benign. © 2012 Elsevier Inc

The cost of nocturia in Europe

Management of Hip Fractures in the Elderly

Hypothesis / aims of study Nocturia is common and can have a profoundly negative effect on those living with the condition, mainly due to its impact on sleep. Nocturia is the leading cause of sleep disruption in adults aged (greater-than or equal to)55 years, but the consequence of poor sleep as a result of nocturia is often overlooked. Poor sleep leads to deficits in daily functioning, productivity and overall quality of life (QoL). The sleep fragmentation experienced by people with nocturia, especially when difficulties falling back to sleep are encountered, might help to explain the wide-ranging negative impact of the condition. Since nocturia is believed to be an inevitable part of the aging process and not a serious medical condition, it is often regarded as a trivial 'QoL problem' which does not require treatment. It is therefore important to conduct a cost-of-illness calculation to investigate the economic consequences of nocturia. If there is significant cost to society caused by nocturia, the disease is no longer only relevant for the affected individual/family - it becomes a wider societal concern. This may impact upon the perception of nocturia and be of relevance in consideration of whether proactive treatment or 'watchful waiting' is the most appropriate strategy. US data show that failing to treat nocturia leads to a large economic burden on society; however, these results cannot be translated to Europe as healthcare systems are very different in the USA and in Europe. Therefore, the aim of this study was to establish the cost implications of failing to treat nocturia in a European context. Reduced work productivity and increased falls are the two main sources of cost associated with nocturia which require consideration when calculating the economic burden of the condition. Study design, materials and methods Based on the Epidemiology of LUTS (EpiLUTS) data, (greater-than or equal to)12.9% of men and 15% of women experience severe nocturia ((greater-than or equal to)3 voids/night) at least 'often'. European data on working hours and average salaries were obtained from EUROstat. The impact of nocturia on work productivity was calculated using published data from population surveys of both absenteeism and productivity in professionally active adults with nocturia compared with controls. The work productivity and activity impairment questionnaire was used (1). The net impairment of 9.19% (0% = maximum productivity; 100% = total loss of work productivity) was based on subjects who had (greater-than or equal to)1 void/night in the population survey; however, to ensure a modest estimate, this level of impairment was attributed to those who had (greater-than or equal to)3 voids/night in this study. To assess the impact of nocturia on falls we estimated the proportional population risk from a study on hip fractures in elderly ((greater-than or equal to)65 years) nocturia patients, showing a prevalence of 1.38% and 1.52% per year for men and women, respectively (2). This was applied to the estimated EU mean cost of hospitalization for a hip fracture (8500 (euro)) (3) to establish the total cost attributable to nocturia. Results Based on prevalence rates from the EpiLUTS study, approximately 7 million men and 8 million women aged between 40 and 65 years have (greater-than or equal to)3 voids/night in Europe (defined as EU-15: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden and the UK). Table 1 shows the estimated loss of productivity per year for men and women living with severe nocturia based on a reduction in work productivity of 9.19%. In total, nocturia costs approximately (euro)29 billion per year. Of the 24 million men and 33 million women (greater-than or equal to)65 living in EU-15, approximately 3 million men and 5 million women suffer from (greater-than or equal to)3 voids/night (severe nocturia) according to the EpiLUTS data. Applying the proportional population risk of breaking the hip due to severe nocturia ((greater-than or equal to)3 voids/night) approximately 43,000 men and 76,000 women per year will break a hip in EU-15 due to nocturia (see Table 2). The estimated total cost of hospitalization for hip fractures due to severe nocturia per year in EU-15 is approximately (euro)1 billion. Interpretation of results It is difficult to conduct a cost of illness study in Europe because the European countries are very different. However, it is still interesting to compare the cost of nocturia in Europe with that in the USA. Since it was necessary to use many average values in our calculations, we have been as conservative as possible with the values incorporated into the model. Prevalence data used were for individuals with (greater-than or equal to)3 voids/night (severe nocturia only). Although the prevalence rate (12.9% of men and 15% of women) is based on a sample of individuals aged 40-99 years and includes people above working age, it is still lower than in most other epidemiology studies. In addition, only hip fracture data were used for falls. These numbers are more reliable because a hip fracture must be treated in hospital and there are studies correlating nocturia and hip fractures. The current study, therefore, presents a conservative estimate because all other types of falls are not included. Lastly, the estimate is based upon data from the EU-15 countries only, since these have a more similar price level than some of the wider European Union countries (eg Bulgaria), and the average values therefore do not cover extreme outliers. Concluding message These findings demonstrate that nocturia represents a very significant economic burden for EU-15 society, especially due to a decrease in productivity. This cost estimate challenges preconceived notions about nocturia that it should not be treated because it is a natural part of the aging process. The costs associated with nocturia indicate that whether or not nocturia is treated is not just a matter of relevance for the QoL of affected individuals, but is a wider societal concern.(Table presented)