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0 | The cost-effectiveness of multi-component interventions to prevent delirium in older people undergoing surgical repair of hip fracture | Hip Fx in the Elderly 2019 | This article summarizes the detailed cost-effectiveness analysis of delirium prevention interventions in people undergoing surgical repair of hip fracture. We compared a multi-component delirium prevention intervention with usual care using a model based on a decision tree analysis. The model was used to estimate the incremental net monetary benefit (INMB). The robustness of the cost-effectiveness result was explored using deterministic and probabilistic sensitivity analyses. The multi-component prevention intervention was cost-effective when compared to usual care. It was associated with an INMB of 8,180 using a cost-effectiveness threshold of 20,000 per QALY. It remained cost-effective in the majority of the deterministic sensitivity analyses and was cost-effective in 96.4 % of the simulations carried out in the probabilistic sensitivity analysis. We have demonstrated the cost-effectiveness of a multi-component delirium prevention intervention that targets modifiable risk factors for delirium in older people undergoing surgical repair of hip fracture. It is an attractive intervention for practitioners and health care policy makers as they address the double burden of hip fracture and delirium. |
0 | Long-term follow-up of a prospective, double-blind, placebo-controlled randomized trial of clodronate in multiple myeloma | MSTS 2018 - Femur Mets and MM | Oral clodronate (1600 mg/d) has been shown to significantly reduce the incidence of skeletal complications in multiple myeloma. Preliminary analysis of a double-blind placebo-controlled trial of this treatment indicated that clodronate might prolong survival in patients without vertebral fractures at presentation. This issue was re-examined after further follow-up of the patients recruited into the Medical Research Council (MRC) VIth Myeloma Study. The trial examined the effects of clodronate on the natural history of skeletal disease in multiple myeloma; 619 patients were randomized between June 1986 and May 1992 commencing 15 d after the start of ABCM [adriamycin, BCNU (carmustine), cyclophosphamide, melphalan] chemotherapy or 43 d after ABCMP (ABCM + prenisolone); 535 patients who received clodronate or placebo were included in the analysis. The presence or absence of spinal fractures was assessed centrally from spinal X-rays; long-bone fractures were assessed locally. With a median follow-up of 8.6 years, there was no overall significant difference in survival between the two treatment groups (O/E, chi2 = 0.78, P = 0.38). Among the subgroup of 153 patients with no skeletal fractures at presentation there was a significant survival advantage (O/E, chi2 = 7.52, P = 0.006) in favour of the 73 patients receiving clodronate, with median survivals being, respectively, 59 months (95% CI 43-71 months) and 37 months (95% CI 31-52 months), and 5-year survivals being 46% and 35%. The original analysis of this study shows that there is a benefit in taking 1600 mg clodronate daily for patients with myelomatosis to prevent the development of new skeletal disease. Bearing in mind the limitations of subgroup analysis, the present study indicates that treatment may prolong survival in patients without overt skeletal disease at diagnosis. These observations, however, require confirmation in prospective clinical trials. |
1 | Determining the effectiveness of various treatment modalities in carpal tunnel syndrome by ultrasonography and comparing ultrasonographic findings with other outcomes | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Firstly, we aimed to determine the effectiveness of various treatment modalities using ultrasonography (US), and secondly, we aimed to assess the correlations between the ultrasonographic findings and electrophysiological tests, symptom severity, functional status and physical findings. 74 hands of 47 patients with carpal tunnel syndrome (CTS) were randomly treated by applying wrist splinting alone in the neutral position (23 hands), phonophoresis with corticosteroid (PCS) (28 hands) and phonophoresis with non-steroid anti-inflamatory drug (PNSAI) (23 hands). The cross-sectional area (CSA) of the median nerve (MN) was determined by ultrasound on the initial and at the 3 months after treatment. MN conduction studies were performed on the initial visit and 3 months after treatment. The patients completed the Boston symptom severity questionnaire. For clinical evaluation, we used Phalen's and Tinel's signs. We could find reduction in CSA of MN in PCS group (P < 0.001). The CSA of MN was inversely correlated with motor sensory and median nerve conduction velocity (NCV) (r = 0.421, r = 0.213, respectively). Statistically significant correlations were not detected between ultrasonographic parameters and clinical evaluation parameters (P > 0.05) and also between ultrasonographic parameters and BQ scores (P > 0.05). Although there was some improvement in clinical parameters, ultrasonographic parameters did not change in P-NSAI group. Conclusion: The most effective treatment modality was P-CS according to ultrasonographic and other findings. Although there were inverse correlations between the CSA of MN and sensory and motor MN conduction velocity, no relationship was found between symptom severity, functional status and US findings or electrophysiological studies |
0 | Revisions of extensive acetabular defects with impaction grafting and a cement cup | PJI DX Updated Search | Background: Loosening of acetabular components often leads to bony defects. Management of extensive acetabular bone loss in hip revision arthroplasty can be a tremendous challenge. Questions/purposes: We asked whether a reconstruction with impacted bone grafts will provide a durable and pain-free function in extensive acetabular defects. We specifically determined the (1) survival rates with the end point of revision for any reason, aseptic revision, and radiographic loosening; (2) visual analog scale (VAS) pain score, Harris hip score (HHS), and the Oxford Hip Questionnaire score (OHQS); (3) number of repeat revisions; (4) complications; and (5) radiographic loosening, wear, and radiolucencies. Patients and Methods: We retrospectively followed 25 patients (27 hips) with extensive acetabular defects. No patient was lost to followup. Two patients died during followup. Minimum followup was 3 years (mean, 8.8 years; range, 3-14.1 years). Results: Three patients (three hips) underwent repeat revision surgery and another two patients (two hips) had radiographically loose hips. The 10-year survival rate was 88% (95% confidence interval, 74.2%-100%) with the end point acetabular revision for any reason and 95% (95% confidence interval, 86.0%-100%) with the end point acetabular revision for aseptic loosening. The mean HHSs were 55 points before surgery and 72 points postoperatively. Conclusions: Acetabular reconstruction with impaction bone grafting and a cemented cup is a reliable technique with a 10-year survival rate of 88% in patients with extensive acetabular deficiencies. Level of Evidence: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence. é 2010 The Author(s) |
0 | Combined Elbow Release and Humeral Rotational Osteotomy in Arthrogryposis | Pediatric Supracondylar Humerus Fracture 2020 Review | PURPOSE: The purpose of this study was to determine if a simultaneous posterior elbow release and humeral osteotomy to correct both the elbow extension contracture and the humeral internal rotation contracture in children with arthrogryposis can produce similar results as a posterior elbow release alone. METHODS: This study was a retrospective chart review of consecutive patients with arthrogryposis treated surgically for elbow extension contracture between 2007 and 2014. A total of 43 procedures in 36 patients had adequate available follow-up data and were included in the study. The postoperative range of motion reported was measured at the early follow-up (3-6 months), midterm follow-up (between 1 and 2 years), and the most recent long-term follow-up (after 2 years) from the date of surgery. Patients were grouped into 2 groups (simultaneous and release) based on the necessity of performing an ipsilateral humeral rotation osteotomy at the time of the release. RESULTS: At early follow-up, patients in both groups increased their total arc of motion. There was a significant difference in extension and arc of motion at midterm follow-up (between 1 and 2 years) between the simultaneous and the release groups with the simultaneous group significantly losing both terminal extension and total arc of motion. At more than 2 years follow-up, there remained a statistically significant difference in arc of motion, with the release group having a significantly larger arc of motion. Patients who underwent dual plating had a much larger arc of motion at early follow-up than the K-wire or single-plate fixation group, despite having similar preoperative extension, flexion, and arc of motion. This difference was also significant at late follow-up. CONCLUSIONS: Patients with posterior release alone had significantly greater improvement in total arc of motion and significantly better elbow extension than patients who underwent a simultaneous humeral osteotomy. However, rigid fixation with early mobilization may yield results comparable with the release alone group. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV. |
1 | The Clinical Efficacy and Safety of the Sahastara Remedy versus Diclofenac in the Treatment of Osteoarthritis of the Knee: A Double-Blind, Randomized, and Controlled Trial | OAK 3 - Non-arthroplasty tx of OAK | Introduction. The Sahastara (SHT) remedy is a Thai traditional medicine that has been acknowledged in the Thai National List of Essential Medicine and has been used as an alternative medicine to treat knee osteoarthritis. Although SHT remedies have been used in Thai traditional medical practices for a long period of time, there are few reports on their clinical trials. Aim of the Study. To investigate the clinical efficacy and safety of the SHT remedy in treating OA of the knee when compared to diclofenac. |
0 | Clinical and immunological evaluation of zoledronate-activated Vgamma9gammadelta T-cell-based immunotherapy for patients with multiple myeloma | MSTS 2018 - Femur Mets and MM | OBJECTIVE: To evaluate the potential anti-tumor activity of zoledronate-activated Vgamma9gammadelta T cells in vivo, we initiated a pilot study involving administration of zoledronate-activated Vgamma9gammadelta T lymphocyte-activated killer (LAK) cells to patients with multiple myeloma.
MATERIALS AND METHODS: Subjects (n = 6) received four intravenous infusions at 2-week intervals of zoledronate-activated Vgamma9gammadelta T LAK cells generated from the culture of peripheral blood mononuclear cells (PBMCs) in the presence of zoledronate and interleukin-2. If the M-protein level in the patient's serum remained at baseline following four intravenous infusions, the patient underwent four more treatments at 4-week intervals. Subjects (n = 6) received a median of 0.99 x 10(9) Vgamma9gammadelta T LAK cells per infusion.
RESULTS: No serious treatment-related adverse effects were observed during the study period. The percentage of Vgamma9gammadelta T cells in PBMCs and absolute numbers of Vgamma9gammadelta T cells in peripheral blood, particularly those of CD45RA(-)CD27(-) effector memory (TEM) Vgamma9gammadelta T-cell subsets increased in all the patients. Percentages of Vgamma9gammadelta T cells and TEM Vgamma9gammadelta T cells in bone marrow also increased in all the patients so far tested. M-protein levels in the serum remained at baseline in four of six patients and increased in two of six patients. Soluble major histocompatibility complex class I chain-related antigen A was detected only in the serum of patients whose M-protein level increased.
CONCLUSION: Administration of zoledronate-activated Vgamma9gammadelta T LAK cells is a safe and promising immunotherapy approach for treatment of patients with multiple myeloma. |
0 | Radiographic changes at the elbow in primary osteoarthritis: A comparison with normal aging of the elbow joint | Glenohumeral Joint OA | A retrospective case-control study was undertaken to evaluate the pathologic radiographic changes that occur in primary osteoarthritis of the elbow. The radiographs of 50 patients with primary osteoarthritis of the elbow were compared with an age- and sex-matched control group to distinguish those features specific to elbow osteoarthritis from those occurring as a result of normal aging. We assessed 100 radiographs (50 anteroposterior and 50 lateral views) in both the study and control groups for 10 radiographic features. In the osteoarthritic group, osteophytes of the olecranon (96%), coronoid process (90%), radial head (86%), and coronoid and radial fossae (64%) were the most frequent findings. Joint space narrowing occurred predominantly at the radiocapitellar joint (58%) and was more common than at the ulnotrochlear joint (16%). Thickening of the olecranon fossa membrane was noted in 68%. In the age- and sex-matched control group, coronoid osteophytes occurred in 36% of cases, but the other features were rarely observed. © 2007 Journal of Shoulder and Elbow Surgery Board of Trustees. |
0 | Unicompartmental arthroplasty of the knee with the cemented MOD3(TM) prosthesis | Surgical Management of Osteoarthritis of the Knee CPG | A consecutive prospective series of 19 knees had unicompartmental arthroplasty between 1991 and 1992 for gonarthrosis and AVN. The MOD3(TM) prosthesis was used in all cases. A total follow-up evaluation was undertaken after 6 to 7.5 years (mean 6.5 years) in 18 patients (1 patient has died during the observation period). Complications included 1 technical failure, 2 cases of thromboembolic phenomena and 1 case of a late deep infection. Knee score averaged 84.3 (pre-operative 54.7) and functional score averaged 68.9 (pre-operative 34.6). There were no cases with aseptic loosening of the prosthesis. It is concluded that with the appropriate indications, the unicompartmental arthroplasty of the knee is an effective and predictable procedure to achieve pain reduction and improved quality of life in patients with monocompartmental arthritis. Furthermore, the cemented MOD3(TM) prosthesis yields results that are comparable to other unicompartmental prostheses in current use |
1 | Cemented Hemiarthroplasties Are Associated with a Higher Mortality Rate after Femoral Neck Fractures in Elderly Patients | Hip Fx in the Elderly 2019 | PURPOSE OF THE STUDY The postoperative outcomes of total hip replacement and hemiarthroplasty after femoral neck fractures in elderly patients were analysed to determine general and local complications as well as morbidity and mortality rates in order to detect risk profiles and assess the best individual treatment option. MATERIALS AND METHODS One hundred sixty-one femoral neck fractures among patients aged >= 65 years treated with cemented hemiarthroplasty (HA) or uncemented total hip arthroplasty (THA) between January 2005 and October 2013 were evaluated. In the presence of articular pathologies as well as a fracture type Garden III or IV, the indication for joint replacement was given. Criteria for performing hemiarthroplasty were previously limited mobility. Freely and fully mobilised patients and patients with manifested osteoarthritis received a cementless THA. A comparison of the observed complications was made, differentiating between general and surgery-specific hip-related complications. Furthermore, the mortality rates were analysed in relation to the respective surgical treatment. RESULTS Seventy cemented HA and ninety-one uncemented THA were performed. There was a high complication rate of approximately 19% in both surgical intervention groups. The patients were more likely to develop general complications (HA 12.8%; THA 10.8%) even though cardiopulmonary complications occurred more frequently in the cemented HA group. Four patients died after cemented hemiarthroplasty due to thromboembolic events (5.7% mortality rate), whereas no deaths occurred after total hip replacement. Surgery-specific complications rates were 7.8% in THA and 5.7% in HA patients. CONCLUSIONS THA in eldery patients with femoral neck fractures is associated with a higher complication rate, mostly of general medical entity. After cemented HA, our study reveals a high mortality rate due to thromboembolic events. For patients with multimorbidity in particular, these findings therefore suggest that uncemented THA should be considered to prevent lethal complications. Key words: femoral neck fracture; total hip arthroplasty; hemiarthroplasty; complications. |
1 | Complications in proximal tibial osteotomies in children with presentation of technique | DOD - Acute Comp Syndrome CPG | Proximal tibial osteotomies in children have been associated with a number of complications, including peroneal nerve palsies, compartment syndromes, deep and superficial infections, vascular injuries, iatrogenic fractures, apophyseal or growth plate damage, and recurrence of deformity. A retrospective review of the results of 22 children who had 30 primary and seven repeat proximal tibial osteotomies was performed to assess the frequency of complications at our institution. Using a specified technique that included prophylactic anterior compartment fasciotomy and distal fibulectomy, there were three superficial wound infections and one delayed union but no peroneal nerve palsies, vascular injuries, compartment syndromes, or fixation failures. There were no sequelae from the superficial infections. This is a lower rate of complications than previously reported in the literature and suggests a relationship to our current surgical technique and attention to detail. We believe that proximal tibial osteotomies can be performed successfully and safely in children when the surgeon recognizes the potential problems and takes steps to prevent them. |
0 | The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study | Surgical Management of Osteoarthritis of the Knee CPG | OBJECTIVE: To evaluate the effect of therapeutic education and functional readaptation (TEFR) on health-related quality of life (HRQL) in patients diagnosed with osteoarthritis on a waiting list for total knee replacement (TKR). METHODS: Randomized controlled trial of 9 months duration was conducted. One hundred consecutive outpatients (71 females, mean age 71 years (range 50-86), mean disease duration 11.84+/-10.52 months) were included. Patients were randomized in two groups. The intervention group received TEFR added to conventional (pharmacological) treatment (n=51). The control group received conventional (pharmacological) treatment only (n=49). The main outcome variable was self-reported HRQL measured by the Spanish version of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were general HRQL measured by Short Form Health Survey general questionnaire (SF-36), number of visits to general physicians and their cost. Assessments were done at baseline and at 9 months. MAIN RESULTS: Eighty patients completed the study. Significant improvement in the WOMAC function was found at 9 months in the TERF group with respect to the control group (P=0.035). Consumption of analgesics increased significantly in the TERF group compared with controls (P=0.036). Significant improvements in pain (P=0.027) measured by WOMAC and in bodily pain (P=0.043) and physical function (P=0.031), measured by SF-36, were observed in the intervention group with respect to baseline. CONCLUSIONS: The function dimension measured by WOMAC of patients who received both pharmacological treatment and TERF improved with respect to the control group receiving only pharmacological treatment. This suggests that a program of TEFR during the period on the waiting list for TKR may reduce the negative impact of this situation |
0 | The influence of platelet rich plasma on synovial fluid volumes, protein concentrations, and severity of pain in patients with knee osteoarthritis | PRPs for Lateral Epicondylitis/Elbow Tendinopathies | Knee pain is commonly seen in orthopedic and rehabilitation outpatient clinical settings. Patients with knee osteoarthritis (OA) are often complicated with joint soreness, swelling, weakness, and pain. These complaints are often caused by the excessive amount of synovial fluid (SF) accumulated in the bursae around the knee joint. This study was aimed to evaluate the effectiveness of platelet rich plasma (PRP) in treating patients with minor to moderate knee osteoarthritis (OA) combined with supra-patellar bursitis using a proteomic approach and clinical evaluation tool. In this study, 24 elderly patients with minor to moderate knee OA combined with supra-patellar bursitis were recruited. Musculoskeletal ultrasound was used for accurate needle placement for the aspiration of SF followed by subsequent PRP injections. Three monthly PRP injections were performed to the affected knees for a total of 3 months. Approximately after the 2nd PRP injection, significant decreases in SF total protein concentrations, volumes, and Lequesne index values were observed. SF proteins associated with chelation and anti-aging physiological functions such as matrilin, transthyretin, and complement 5 increased at least 2-fold in concentrations. Proteins associated with inflammation, such as apolipoprotein A-I, haptoglobin, immunoglobulin kappa chain, transferrin, and matrix metalloproteinase decreased at least 2-fold in concentrations. Therefore, at least two monthly PRP injections may be beneficial for treating patients with minor to moderate knee OA combined with supra-patellar bursitis. |
0 | Treatment of unstable distal radius fractures with the volar locking plate | Distal Radius Fractures | BACKGROUND: Open reduction and internal fixation using an interlocking plate system has gained popularity for the treatment of dorsally displaced distal radius fractures.
PURPOSE: To evaluate the functional and radiological results of treating unstable distal radius fractures with the volar locking plate.
PATIENTS AND METHODS: A retrospective review was conducted of patients from one institution using the volar locking plate to treat intra-articular and extra-articular distal radius fractures. Unstable distal radius fractures in 15 patients, comprising 3 men and 12 women with a mean age of 64.4 years (34-76 years), were treated with a volar locking compression plate (Acu-Loc distal radius plate system; Acumed, Oregon, USA) and followed up for a minimum of 1 year. Fractures were classified using the AO classification. Radiographic parameters of preoperative, postoperative, and final follow-up radiographs were compared. The time to initiation of active range of motion was determined. Final follow-up range of motion and complications were reported.
RESULTS: At final functional assessment, the scores of 5 patients were excellent, 7 patients good, and 3 patients fair according to Cooney's Clinical Scoring Chart. No non-union or infection occurred. Rupture of the flexor pollicis longus tendon occurred in 1 patient.
CONCLUSION: Treatment of unstable distal radius fractures with a volar locking plate leads to satisfactory results, provided the operative technique is carefully performed to prevent complications. |
0 | Residual fatigue in Guillain-Barre syndrome is related to axonal loss | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Objective: To determine the occurrence of residual loss of peripheral nerve axons by motor unit number estimation (MUNE) and conventional nerve conduction studies (NCS) in patients with and without severe fatigue. Methods: Thirty-nine patients at a median of 8 years (range 1-23 years) after diagnosis of Guillain-Barre syndrome were neurologically examined and divided in 2 subgroups based on the presence of severe fatigue (defined as a fatigue severity score (greater-than or equal to)5). All patients were investigated with standard NCS and MUNE. Normal values for MUNE were collected in 14 healthy controls. Results: MUNE of the thenar muscles was lower in the 15 patients with severe fatigue (median 125, interquartile range 65-141) compared with the 24 patients without severe fatigue (median 258, interquartile range 120-345) (p = 0.002). In the healthy controls, |
0 | Early results of femoral reconstruction with a tapered, cementless, modular stem | Hip Fx in the Elderly 2019 | Objective: The orthopedic surgeon is faced with various challenging problems on the femoral side while performing a revision total hip arthroplasty. Some of these challenges may arise acutely or even intra operatively with limited resources. The aim of this study is to evaluate clinical and radiological outcomes with a single revision modular system used for various indications, and to determine whether such a system achieved initial fixation, femoral offset restoration, stability, and leg length equalization. Methods: We prospectively followed 33 patients with 36 implants for various indications. Functional assessment was achieved using the Harris hip score (HHS). Hip stability, Leg length discrepancy, stem fixation, and offset restoration were evaluated radiographically. Follow up ranged from 24-87 months. Results: HHS increased from a preoperative mean of 22.1 to a mean of 71.6 postoperatively. The total number of patients who had dislocation is 5 (13.9%). Three stems were re-revised (9%). Subsidence of the femoral component was less than 5mm in 30 patients (83%). Leg length discrepancy was corrected to within 5mm in 53% of patients, Offset restoration was achieved in 39% of patients. No fractures at the body to stem junction were seen at latest follow up. Conclusions: Modular femoral stems are useful to address hip stability, leg length equalization, offset restoration, and distal fixation when revising a failed femoral component in the presence of significant proximal femur bone loss. These stems provide good clinical outcome in a simple, uniform, reproducible way. © 2014 DAR Publishers/University of Jordan. All Rights Reserved. |
0 | Paraesthesiae and tetany induced by voluntary hyperventilation. Increased excitability of human cutaneous and motor axons | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Anxiety can induce hyperventilation, and the resultant hypocapnia and hypocalcaemia can lead to paraesthesiae and tetany. To define the nature of the disturbance created in peripheral nerve, the excitability of cutaneous and motor axons was monitored in 6 normal subjects requested to hyperventilate until paraesthesiae developed in the hands, face and trunk. This occurred when alveolar PCO(2) (PACO(2)) had declined on average by 20 mmHg. Spontaneous EMG activity developed when PACO(2) had declined by a further 4 mmHg. Changes in the excitability of cutaneous and motor axons were measured from changes in the compound action potentials evoked by stimulation of the median nerve at the wrist and recorded over the digital nerves of the index finger and over the thenar muscles, respectively. As |
1 | Computer navigation vs conventional total knee arthroplasty: five-year functional results of a prospective randomized trial | Surgical Management of Osteoarthritis of the Knee CPG | Seventy-one patients were randomly allocated to undergo either computer-navigated or conventional arthroplasty. A statistically significant improvement in alignment was seen in the computer-navigated cohort. Five-year functional outcome was assessed using the Knee Society, Short Form-36, Western Ontario and McMaster Universities Osteoarthritis Index, and a patient satisfaction score. At 5 years, 46 patients were available for assessment (24 navigated and 22 conventional knees). No patients had undergone revision. No statistically significant difference was seen in any component of any measure of outcome between navigated and conventional cohorts. Longitudinal data showed function to be well maintained with no difference in functional score between 2 and 5 years in either cohort. Despite achieving better alignment, 5 years postoperatively, the functional outcome with computer-navigated knee arthroplasty appears to be no different to that implanted using a conventional jig-based technique |
0 | The Prevention and Treatment of Delirium in Elderly Patients Following Hip Fracture Surgery | Hip Fx in the Elderly 2019 | Osteoporotic hip fracture needs a specific approach and treatment, since elderly patients are at high risk for adverse outcomes after surgery. In particular, delirium often occurs in the peri-operative period, and it is associated with death, hospital-acquired complications, persistent cognitive impairments, poor functional recovery after surgery and increased healthcare costs. The pre-operative assessment of the risk factors for delirium improves the preventive measures. The delirium diagnostic tools should be included in the standard of orthogeriatric cure for hip fracture. Given the increasing complexity of the clinical pictures, we present a review of the available treatment options for delirium in patients with hip fracture. The metabolic pre-operative disorders and the management of co-morbid diseases are specific targets of treatment in order to optimize the outcomes after surgery. In particular, elderly patients with Alzheimer's disease are highly vulnerable to hip fracture and delirium, and they are severely frail with reduced physiologic reserves. An integrated approach combining environmental and pharmacological strategies is useful in the delirium treatment, with a close collaboration between the orthopedic and geriatric team. |
0 | Current concepts in carpal tunnel syndrome: A review of the literature | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Carpal tunnel syndrome is the most common entrapment neuropathy of the upper limb, occurring due to compression of the median nerve at the wrist. The condition has an estimated economic cost in excess of 2 billion. This article reviews the history, diagnosis and current management of this frequently encountered condition. (copyright) 2010 Springer-Verlag |
1 | Study to assess differences in outcome following open carpal tunnel decompressions performed by surgeons of differing grade | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | INTRODUCTION: Carpal tunnel decompression is the most commonly performed surgical procedure within a hand unit. Although very effective, the complications following the procedure can be significant. In an attempt to identify the causes of such complications, we assessed whether seniority of the surgeon impacts on outcome for open carpal tunnel decompression. PATIENTS AND METHODS: Data were jointly and prospectively gathered from two units from either side of the Atlantic - the Pulvertaft Hand Center, UK and the Curtis Hand Center, USA. The aim of the study was to assess outcome following carpal tunnel decompression. Completed data were gathered following open carpal tunnel decompression on 352 hands. Surgeons of a consultant grade had performed 123 of these procedures whilst surgical trainees had performed 229 of the procedures. Assessment was by Levine Katz questionnaire results, Semmes-Weinstein testing, grip strength and pinch grip strength testing performed both pre-operatively and 6 months' postoperatively. Complications following the procedure were also recorded. RESULTS: Mean results were found to be better in those patients where the surgeon was of a consultant grade. However, this was only found to be of statistical significance on Semmes-Weinstein testing. Complications following the procedure were also noted to be higher in the group of patients operated on by trainee grades. CONCLUSIONS: Our results show the carpal tunnel decompression performed by a surgeon of consultant grade offers slightly better results in objective neurological testing when compared with those performed by a more junior grade |
1 | Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy - worse or worth? | DoD SSI (Surgical Site Infections) | BACKGROUND: Controversy remains regarding timing in the management of complex traumatic lower extremity defects. Many authors recommend a definitive bony and soft tissue reconstruction within a critical period of 72 h, yet in many patients this may be impossible due to concomitant injuries or delayed referral. However, little data are available on the results of delayed flap reconstruction of complex traumatic extremity defects, especially using new technologies of wound coverage such as vacuum-assisted closure (VAC((R))) therapy which may reduce the disadvantages of conventional open wound therapy prior to a subsequent flap reconstruction.
METHODS: We retrospectively analysed the soft tissue reconstructions in 43 open extremity fractures during a 4-year period with special regard to complications, overall flap loss and wound infection.
RESULTS: A total of 29 male and 13 female patients with 33 open fractures of the lower and 10 of the upper extremity were included. All patients had been referred from a trauma centre at a mean interval of 19 days (range 1-96 days) after the trauma event with temporary VAC((R)) of their wounds after initial fracture fixation and initial debridement of necrotic tissue. Flap reconstruction was thus only possible later than 72 h and definitive wound closure was achieved at a mean time of 28 days (range 3-106 days). Overall, three pedicled flaps were lost and one of 38 microsurgical free flaps (2.6%) underwent necrosis, the cause of which was unrelated to treatment delay.
CONCLUSIONS: According to this study, the flap reconstructions performed beyond the frequently quoted critical interval yielded similar results to those of immediate reconstruction within the first 3 days, as reported in the literature. This strategy is in accordance with the principles of 'Damage Control Orthopaedics (DCO)' and may reduce the importance of emergency reconstructions, especially in poly-traumatised patients. |
1 | Reinnervated free muscle transplantation for extremity reconstruction | DoD LSA (Limb Salvage vs Amputation) | Reinnervated free muscle transplantation was used to rehabilitate severely impaired extremities in patients with brachial plexus palsy and for functional limb salvage in cases of traumatic muscle loss or radical excision of a malignant soft-tissue tumor. Fifty-eight reinnervated free muscle transplantations were implanted in 46 patients. Twenty-four patients had simultaneous reconstruction of two functions, such as finger and elbow flexion lost to brachial plexus palsy; 12 patients underwent double muscle transplantation; 15 patients received free muscle transplants for limb salvage after tumor excision in an extremity; 6 transplants replaced traumatic muscle loss; and 1 was used for reconstruction of finger flexion after poliomyelitis. Twenty-six latissimus dorsi, 25 gracilis, and 7 rectus femoris muscles were used as donors. All muscles survived. The postoperative follow-up ranged from 18 months to 4 years. The speed and extent of reinnervation of the transplanted muscle depended on the choice of recipient nerve, the patient's age, and the occurrence of postoperative vascular complications. Neurotization by the spinal accessory nerve or the posterior interosseous nerve resulted in the most rapid recovery. The administration of postoperative chemotherapy did not delay recovery of function. Free muscle transplantation is consistently successful and provides a functional extremity in severely handicapped patients. |
0 | Periodontitis and abdominal aortic aneurysms: a random association or a pathogenetic link? | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | A number of micro-organisms have been implicated in the development/progression of abdominal aortic aneurysms (AAAs), thus suggesting an infective theory of AAA pathogenesis. Periodontitis may be involved in the development of AAAs by means of introduction of subgingival plaque periodontal bacteria into the bloodstream and degeneration of the aortic wall. A different theory supports that the findings of periodontal pathogens in AAA biopsies are a secondary phenomenon with transient bacteremia leading to invasion of already formed AAAs. It is not yet clear whether the periodontopathic bacteria accelerate the growth/weakening of the aortic wall or whether they are secondary colonizers of AAAs. Clarification of the association between periodontal disease and AAAs in large-scale studies holds implications for a role for chemoprophylaxis/antibiotic treatment in the management of AAAs |
0 | C-reactive protein levels in patients with knee osteoarthritis and their relationship to the clinical parameters of the disease | OAK 3 - Non-arthroplasty tx of OAK | The aim of the present study was to investigate the relationship between CRP and clinical parameters of the disease, including quality of life of patients with knee osteoarthritis (KOA) in Bulgarian population. 132 patients (81% female) with symptomatic KOA (mean age of 63.45 years) and 31 healthy volunteers were included in the study. Their clinical characteristics were evaluated using the following questionnaires and scales: VAS, Lequesne Algofunctional Index, Western Ontano and McMaster University Osteoarthritis Index (WOMAC), Health Assessment Questionaire - Disability Index (HAQ-DI). CRP levels were measured in all participants. Patients with KOA had higher levels of C-reactive protein than the controls; however, CRP levels remained still in laboratory reference ranges. CRP levels correlated with pain assessed by VAS in the patient group. Groups of patients with elevated CRP values and normal CRP values differ statistically significant in their age, perceptions of pain assessed by VAS, disease activity and quality of life. CRP is a useful indicator in patients with KOA, which reflects pain and disease activity in general. |
1 | An audit on factors influencing infection in operated ankle fractures | DoD SSI (Surgical Site Infections) | A prospective 1-year audit was carried out on consecutive patients admitted to a district general hospital of the UK with ankle fractures needing open reduction internal fixation in order to analyse the factors affecting infection. Ninety seven percent patients had had their operative procedure within 24 h from the time of injury. Eighty four percent patients were discharged in less than 7 days period from the day of admission. All but one patient received antibiotic prophylaxis in accordance with local microbiology policy guidelines. Four out of 32 patients received therapeutic antibiotics for wound cellulitis/superficial infection. No patient had a deep infection, osteomyelitis or septic arthritis. Complex ankle trauma, post-radiography preliminary reduction of ankle fracture-dislocation in the emergency department, prolonged operating time, delayed surgery, persistent ankle swelling and unsupervised operation were common denominators in four cases with infection in ankle fracture fixation. © 2006 Springer-Verlag. |
0 | Lumbrical-interosseus motor latency-a useful test when the motor response of APB is absent | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Question: Is measurement of the lumbrical-interosseus latency a useful test in clinical routine? Background: The recording of lumbrical-interosseus latency is a sensitive test for carpal tunnel syndrome (CTS). The test has been shown to be especially useful in severe cases of CTS, when motor responses are absent from m abductor pollis brevis (APB). Method: As part of implementing the lumbrical-interosseus motor latency in clinical routine at our lab, we examined 20 healthy volonteers aged 21-75 years, and an additional 59 patients referred for carpal tunnel syndrome with conventional nerve conduction studies as well as the lumbrical-interosseus motor latency. Result: The sensitivity for CTS was slightly lower than our standard combination of CTS tests. However, in patients lacking median nerve motor responses from the APB, registration of the lumbrical motor response gave essential information about the diagnosis. This was the case for patients with severe CTS in our cohort, and also two additional patients (not in our cohort, but attending the outpatient clinic) with median-ulnar nerve anomaly and lack of median nerve innervation of the thenar muscles. Conclusion: The lumbrical-interosseus latency is a useful test for severe cases of CTS and other patients with absent median nerve motor response of APB |
0 | Prospective study on the incidence of bone metastasis (BM) and skeletal-related events (SREs) in Patients (pts) with Stage IIIB and IV Lung Cancer - CSP-HOR 13 | MSTS 2018 - Femur Mets and MM | BACKGROUND:: Bone metastasis (BM) is a frequent complication in patients with advanced lung cancer and it causes skeletal-related events (SREs). Our study aim is to prospectively investigate the incidence of BM, incidence and types of SRE, and predictive factors of BM and SREs. METHODS:: Newly diagnosed, advanced non-small-cell lung cancer (NSCLC) or small-cell lung cancer (SCLC) patients were enrolled into the study. Patients were followed up every 4 weeks to monitor the development of SREs. Treatment for lung cancer was performed at the discretion of the investigator. RESULTS:: Two hundred seventy-four patients were enrolled in this study between April 2007 and December 2009 from 12 institutions. Patients included 77 cases of SCLC and 197 of NSCLC (stage IIIB/IV = 73/124). Median follow-up time was 13.8 months. The incidence of BM at initial diagnosis was 48% in stage IV NSCLC and 40% in extensive stage (ED)-SCLC. Forty-five percent of patients who developed BM had SREs consisting of pathologic fracture (4.7%), radiation to bone (15.3%), spinal cord compression (1.1%), and hypercalcemia (2.2%). Multivariate analysis revealed that factors predicting BM are stage IV, performance status 1 or greater and higher bone alkaline phosphatase in NSCLC patients, higher lactate dehydrogenase, and lower parathyroid hormone-related peptide in SCLC patients. Factors predicting SREs were stage IV, age 64 or younger, and lower albumin in NSCLC patients. Multivariate analysis of SRE was not performed for SCLC because of the small number of events. CONCLUSION:: Predictive factors should be taken into consideration in future randomized studies evaluating BM and SREs. Copyright © 2013 by the International Association for the Study of Lung. |
0 | Frontozygomatic approach to intraorbital tumors | Upper Eyelid and Brow Surgery | We removed 12 intraorbital tumors (5 schwannomas, 3 meningiomas, 2 cavernomas, 1 pleomorphic adenoma, and 1 neuroblastoma) using the frontozygomatic approach. No patients died. Postoperatively, 1 patient developed transient ptosis, and 3 patients had mild enophthalmos. Two patients with a meningioma developed transient worsening of their visual acuity and visual field. The frontozygomatic approach for surgical treatment of intraorbital tumors provides a wide visual field exposing the entire optic nerve. This approach is indicated for large intraorbital tumors, tumors affecting the optic nerve or orbital apex, intraorbital tumors that have extended into the intracranial cavity, and intracranial tumors that have extended into the orbit. The operative procedure for intraorbital tumor is determined by the location of the lesion and by the direction of its growth. The procedure is applicable to all intraorbital tumors. It reduces discomfort for surgeons while providing a relatively wide surgical field. |
0 | Effect of teriparatide on bone mineral density and biochemical markers in Japanese women with postmenopausal osteoporosis: a 6-month dose-response study | Management of Hip Fractures in the Elderly | The dose-response efficacy and safety with three doses of teriparatide and placebo was assessed, using once-daily subcutaneous injections for 24 weeks, in Japanese postmenopausal women with osteoporosis at high risk of fracture for reasons of preexisting fracture(s), advanced age, and/or low bone mineral density (BMD). In this multicenter, randomized, placebo-controlled study, 159 subjects were randomized and 154 subjects were included for analysis. Teriparatide (10-microg, 20-microg, and 40-microg doses) showed a statistically significant increase with increasing treatment dose as assessed by the percent change of lumbar spine BMD from baseline to endpoint using Williams' test when compared with placebo (P < 0.001). The mean (+/-SD) percent change in lumbar spine, femoral neck, and total hip BMD with the 20-microg dose from baseline to endpoint was 6.40% +/- 4.76%, 1.83% +/- 7.13%, and 1.91% +/- 3.60%, respectively. Rapid and sustained increases in bone formation markers [type I procollagen N-terminal propeptide (PINP), type I procollagen C-terminal propeptide (PICP), and bone-specific alkaline phosphatase (BAP)], followed by late increases in a bone resorption marker [type I collagen cross-linked C-telopeptide (CTX)], were observed for the teriparatide treatment groups (20-microg, 40-microg), suggesting a persistent, positive, balanced anabolic effect of teriparatide. Optimal adherence was achieved by this daily self-injection treatment. Regarding safety, most of the adverse events were mild to moderate in severity. No study drug-or study procedure-related serious adverse events were reported during the treatment period. These results observed in Japanese patients may support the observation that teriparatide stimulates bone formation in patients with osteoporosis at a high risk of fracture |
0 | Effects of post-hospital Medicare home health and informal care on patient functional status | Management of Hip Fractures in the Elderly | OBJECTIVE: To examine the effect of post-hospital Medicare home health and informal care on the functional status of 755 Medicare beneficiaries six weeks after hospital discharge for treatment of stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fractures. STUDY SETTING/DATA SOURCES: Consecutive patients enrolled in the study between March 1988 and February 1989 prior to discharge from one of 52 hospitals in three cities. Data sources included patient interviews, medical records, and the Medicare Automated Data Retrieval System (MADRS). ANALYSIS: The effect of the two types of care on patients' subsequent functional status was estimated using a selectivity corrected least squares regression of functional status six weeks post-discharge on hours of informal care, Medicare home health expenditures, and patient prior functional and cognitive status. DATA COLLECTION/EXTRACTION METHODS: Patients were interviewed before hospital discharge and six weeks later. The patient's primary caregiver was interviewed by telephone six weeks post-discharge. Patient data included demographic characteristics, illness severity, cognitive status, functional status at discharge and six weeks later, post-discharge expenditures for Medicare home health, and hours of informal care. PRINCIPAL FINDINGS: More informal care after discharge was associated with greater patient functional impairment six weeks later. The amount of Medicare home health that patients used had a nonsignificant effect on subsequent functional status. CONCLUSIONS: Post-acute home care may maintain the patient at home and compensate for functional limitations, rather than promote restoration of function. Future studies are needed to examine the effects of specific types of care, services, and providers as well as factors that mediate their effects on patient functional outcomes |
0 | Hypoalbuminemia is a risk factor for predicting early postoperative complications after proximal humerus fracture fixation | Hip Fx in the Elderly 2019 | Background: Hypoalbuminemia is a marker for malnourishment and is associated with poor outcomes in the setting of hip fractures, periprosthetic joint fractures, and spine surgery. We hypothesized that hypoalbuminemia is associated with higher rates of early complication in patients undergoing surgical treatment for proximal humerus fractures.
Methods: Utilizing the ACS NSQIP database, all proximal humerus fractures treated with plate fixation were extracted from 2006 to 2015. Two cohorts were compared based on hypoalbuminemia (albumin <3.5 g/dL) versus normoalbuminemia (albumin >3.5 g/dL). Patient demographics and postoperative complications were analyzed with multivariable regression.
Results: Out of 916 patients undergoing PHF surgery, 290(31.7%) satisfied criteria for hypoalbuminemia (mean age: 65.9, female: 71%). Among 339 obese patients with BMI>30, 87 (25.7%) were hypoalbuminemic. Patients with hypoalbuminemia were overall at higher risk of any (29.7% vs 12.1%, p < 0.001), major (10.0% vs 2.4%, p < 0.001), and minor complications (24.1% vs 11.0%, p < 0.001) as well as readmissions (12.7% vs 5.1%, p < 0.001). Obese hypoalbuminemic patients had similar rates of complication as non-obese hypoalbuminemic patients. Multivariable regression showed that hypoalbuminemia had an odds ratio of 1.85(p = 0.003) for predicting any complication within 30 days of surgery.
Conclusion: Hypoalbuminemia is associated with higher risk for complications and readmission after PHFs. It occurs more frequently in patients with chronic disease and is predictive of malnourishment. Paradoxically, hypoalbuminemia is not uncommon in obese patients.
Level of evidence: III; Retrospective Cohort Study. |
1 | Adipose-Derived Stem Cell Treatments and Formulations | OAK 3 - Non-arthroplasty tx of OAK | This article analyzes the current literature on the use of adipose-derived stem cells (ASCs) to evaluate the available evidence regarding their therapeutic potential in the treatment of cartilage pathology. Seventeen articles were included and analyzed, showing that there is overall a lack of high-quality evidence concerning the use of ASCs. Most trials are case series with short-term evaluation. The most adopted approach consists of an intra-articular injection of the stromal vascular fraction (SVF) rather than the expanded cells. Based on the available data, no specific preparation method or formulation could be considered as the preferred choice in clinical practice. |
0 | Correlation Between Anatomic Landmarks and Bony Trough Position in Lateral Meniscal Allograft Transplant | AMP (Acute Meniscal Pathology) | Background: Determining the rotational axis of the bony trough during lateral meniscal allograft transplant (MAT) is difficult. The use of anatomic landmarks may help a surgeon determine the rotational alignment of the graft during the procedure.
Purpose: To investigate the association between the knee's anatomic landmarks and the position of the bony trough to prevent extrusion after lateral MAT.
Study Design: Cross-sectional study; Level of evidence, 3.
Methods: Enrolled were 44 patients who underwent lateral MAT between July 2000 and February 2011. The patients' mean age at the time of surgery was 30.8 years. Extrusion was measured on magnetic resonance imaging (MRI) scans at a mean of 3.6 months postoperatively, and patients were divided into an extrusion group (n = 15) and a no-extrusion group (n = 29). Three coronal MRI scans from each patient were selected, each from the region at the level of the tibial tuberosity (TT), the anterior bony trough, and the posterior bony trough. We measured the distance between the center of the anterior bony trough and the center of the TT (the TT distance) and the distance between the center of the posterior bony trough and the medial border of the lateral femoral condyle (LFC) (the LFC distance).
Results: The mean center of the anterior bony trough was in a more medial position relative to the center of the TT in the no-extrusion group (-2.9 +/- 4.8 mm) compared with the extrusion group (1.3 +/- 4.9 mm; P = .010). The mean center of the posterior bony trough was in a more medial position relative to the medial border of the LFC in the no-extrusion group (-1.7 +/- 3.9 mm) compared with the extrusion group (1.0 +/- 3.2 mm; P = .027). Both TT distance and LFC distance were significantly correlated with extrusion (P = .005 and .025, respectively). The cutoff value was -0.24 mm for the anterior bony trough and -0.58 mm for the posterior bony trough (negative values indicate that the trough was medial to the respective landmarks).
Conclusion: To prevent extrusion of the allograft, the center of the anterior bony trough needs to be aligned with the center of the TT, and the center of the posterior bony trough needs to be aligned with the medial border of the LFC. |
1 | Gender differences in expectations and outcomes for total shoulder arthroplasty: a prospective cohort study | Glenohumeral Joint OA | BACKGROUND: Gender has an impact on the expectations and the outcomes of orthopedic procedures. The data examining the effect of gender on total shoulder arthroplasty (TSA) are limited but suggest that women may have worse outcomes. We performed a prospective comparison between men and women with regard to expectations and midterm functional outcomes for TSA.
METHODS: The study prospectively enrolled 63 patients receiving a TSA with a minimum of 3 years of follow-up. The cohort included 36 men and 27 women with a mean age of 60.8 years for men (range, 37-79 years) and 66.4 years (P = .01) for women (range, 52-77 years.) Each patient was given a preoperative survey in which patients were asked to select 3 expectations they most hoped to gain from surgery. Functional outcomes were measured with American Shoulder and Elbow Surgeons and 12-Item Short Form Health Survey scores.
RESULTS: There were differences in expectations between the genders. Men chose exercise or participation in sports (24/36) whereas women chose to maintain daily routine and chores (18/27) (P < .01) as their top expectation. Both, however, chose to sleep through the night similarly as the next most important expectation. Each achieved their expectations at similar and high rates. American Shoulder and Elbow Surgeons and 12-Item Short Form Health Survey scores, respectively, increased significantly but did not differ between genders.
CONCLUSION: TSA results in excellent improvement of functional outcomes for both men and women without a significant difference at midterm follow-up. Men, on average, are younger and value participation in sports. Women hope to improve their ability to do their daily routine and chores. Both value sleeping through the night. |
0 | Impact of selected medical conditions on self-reported lower-extremity function in Mexican-American elderly | Management of Hip Fractures in the Elderly | OBJECTIVE: To examine the independent impact of common medical conditions on lower-extremity function in Mexican-American elderly. DESIGN: Cross-sectional study using a probability sample of non-institutionalized Mexican Americans aged 65 or older. SETTING: The five Southwestern states, Texas, New Mexico, Arizona, Colorado and California. PARTICIPANTS: All subjects were interviewed in person (n = 2,873) or by proxy (n = 177) in their homes during late 1993 and early 1994. MAIN OUTCOME MEASURES: Respondents were asked whether they could perform four activities related to lower-extremity function without help: walking across a small room, getting from a bed to a chair, walking up and down stairs, and walking half a mile. A summary measure of lower body disability created from these four items was regressed on seven common medical conditions plus five control variables using multiple logistic regression. RESULTS: Adjusted Odds Ratios (OR) suggested that impaired lower-extremity function was associated with previous diagnosis of hip fracture (OR = 4.28), stroke (OR = 3.47), lower extremity arthritis (OR = 2.60), heart attack (OR = 2.29), diabetes (OR = 2.03) and obesity (OR = 1.50). Impaired lower-extremity function was significantly associated with older age (75+ years old), gender (female) and marital status (unmarried). In addition, there was a linear increase in the risk of function loss by number of medical conditions. CONCLUSIONS: It appears that Mexican-American elderly diagnosed with medical conditions, especially stroke and hip fracture, have a high risk for lower-extremity dysfunction. These findings have implications for efforts to prevent or reduce lower-extremity dysfunction, as well as for the provision of community-based long-term care services for Mexican-American elderly |
1 | Outcome of tissue sparing surgical intervention in mine blast limb injuries | DoD LSA (Limb Salvage vs Amputation) | OBJECTIVE: To describe the pattern of mine blast limb injuries in civilian population of Kashmir, to evaluate the outcome of tissue sparing surgical intervention in these injuries and to determine the sensitivity of hand-held percutaneous Doppler for tissue viability. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Combined Military Hospital, Muzaffarabad and Islamic International Medical College Hospitals at Rawalpindi/Islamabad from November 1997 to May 2005. PATIENTS AND METHODS: One hundred and three patients who sustained mine blast injuries to upper or lower limbs, along side the line of control between the Indian-held Kashmir and Azad Kashmir, regardless of age and gender, were included in this study. Patients who already had amputation after injury at some other place were excluded. All patients were initially managed in emergency and had more than one surgical intervention. Transcutaneous Doppler was used to evaluate the vascularity of the remaining tissue. All patients were operated under spinal or general anaesthesia and had repeated debridements followed by skin cover by split skin graft, full thickness skin graft or rotational flaps. Every patient received at least 5 days course of antibiotics and tetanus prophylaxis. Postoperative rehabilitation and follow-up was conducted for at least 6 months after discharge from the hospital. RESULTS: Mean age of victims in this study was 22 years. Out of 103 patients, 72 (69.9%) received initial wound care in the peripheral primary health care centre but were not amputated while 31 patients (30%) were just dressed and referred for further treatment at tertiary care hospitals. Eighty-five patients (82.5%), out of the total, had some sort of traumatic amputation at presentation due to the original injury. That included loss of limb below knee in 19 (18.45%) patients, at distal tibiofibular region in 13 (12.6%), mid tarsal amputations in 39(37.9%), and hemi foot amputation in 15 (14.6%) patients. Nine (8.7%) patients had losses of two or less than two toes, 1 (0.97%) patient had injury at mid palmer region, and 5 (4.9%) patients had 2 fingers traumatic amputation. Eighteen (17.5%) patients had soft tissue ( with or without bony injury) injury only without any actual traumatic amputation. Infection rate was 27% in patients who did not have wound care in the periphery. Those who had wound toilet in-the peripheral hospital had infection rate of 16%. Two patients developed fulminating multi-resistant progressive infection requiring below knee amputation. CONCLUSION: Conservative wound debridement and early skin coverage by different means and preserving maximum soft tissues and bone results in functionally and cosmetically better limb in victims of land mine. |
0 | The short stem THA provides promising results in patients with osteonecrosis of the femoral head | AAHKS (2) Corticosteroids | Background: The short stem prosthesis showed good results in patients with primary osteoarthritis. However, there were a few studies about the short stem total hip arthroplasty (THA) in patients with osteonecrosis of the femoral head (ONFH). Objective: To evaluate the clinical and radiographic results of the short stem THA in patients with ONFH. The authors hypothesized that the short stem THA would be a promising procedure for patients with ONFH. Material and Method: The authors reviewed 120 osteonecrotic hips in 93 patients who underwent THA with Metha<sup>®</sup> short stem between November 2010 and February 2013. The appearance of bone trabeculae development and radiolucent line was reviewed using Gruenâ??s classification. The Harris hip score (HHS) was recorded at 6, 12, 24, and 36 months postoperative for evaluating the clinical results. Results: The mean age of patients was 44.4 years (18-68) with the mean BMI of 22.7 (15.1-32.5, SD 3.5). The average follow-up period was 29.2 months (20-47). The mean HHS was significantly improved from 43.9 (22.7-74, SD 7.7) preoperatively to 97.7 (85.9-100, SD 2.7) at 6-month postoperatively (p<0.01). The radiographic change around the stems showed bone trabeculae development at zone 1 (77 cases, 64.2%), 2 (27 cases, 22.5%), 3 (106 cases, 88.3%), 6 (120 cases, 100%), and 7 (115 cases, 95.8%). There was one case (0.8%) of 5 mm subsidence and the radiolucent line was observed in zone 1. There were six cases (5%) of intraoperative femoral fractures and were treated with cerclage wires with no further subsidence observed. There was one case (0.8%) of distal stem perforation that had stable bone ingrowth. No revision was required. Conclusion: The clinical and radiographic results of the short stem THA in patients with ONFH are generally satisfactory. Its design enables preservation of the bone stock and the bone trabeculae appear to confirm the assumption of proximal force transmission. The authors believe that the short stem THA is a promising procedure for patients with ONFH. |
0 | Cosmetic surgery growth and correlations with financial indices: A comparative study of the United Kingdom and United States from 2002-2011 | Reduction Mammoplasty for Female Breast Hypertrophy | Background: Over the past 10 years, there has been significant fluctuation in the yearly growth rates for cosmetic surgery procedures in both the United States and the United Kingdom. Objectives: The authors compare cosmetic surgical procedure rates in the United Kingdom and United States with the macroeconomic climate of each region to determine whether there is a direct relationship between cosmetic surgery rates and economic health. Methods: The authors analyzed annual cosmetic surgery statistics from the British Association of Aesthetic Plastic Surgeons and the American Society for Aesthetic Plastic Surgery for 2002-2011 against economic indices from both regions, including the gross domestic product (GDP), consumer prices indices (CPI), and stock market reports. Results: There was a 285.9% increase in the United Kingdom and a 1.1% increase in the United States in the number of procedures performed between 2002 and 2011. There were significant positive correlations between the number of cosmetic procedures performed in the United Kingdom and both the GDP ( r = 0.986, P < .01) and CPI ( r = 0.955, P < .01). Analysis of the US growth rates failed to show a significant relationship with any indices. UK interest rates showed a significant negative correlation ( r = -0.668, P < .05) with procedures performed, whereas US interest rates showed a significant positive correlation. Conclusions: Data from the United States and United Kingdom suggest 2 very different growth patterns in the number of cosmetic surgeries being performed as compared with the economy in each region. Economic indices are accurate indicators of numbers of procedures being performed in the United Kingdom, whereas rates in the United States seem independent of those factors. © 2013 The American Society for Aesthetic Plastic Surgery, Inc. |
0 | Identifying Dyslexia Risk in Student-Athletes: A Preliminary Protocol for Concussion Management | DoD PRF (Psychosocial RF) | Learning disability (LD) has been identified as a potential risk factor for a sport-related concussion, yet students with LD are rarely included in concussion research. Here, we draw special attention to dyslexia, a common but often underdiagnosed LD. Reading and learning problems commonly associated with dyslexia are often masked by protective factors, such as high verbal ability or general intelligence. Hence, high-achieving individuals with dyslexia may not be identified as being in a high-risk category. To ensure that students with dyslexia are included in LD concussion research and identified as LD in baseline testing, we provide athletic trainers with an overview of dyslexia and a preliminary screening protocol that is sensitive to dyslexia, even among academically high-achieving students in secondary school and college. |
0 | Low-molecular weight heparin for pulmonary embolism: a shot in the dark? | Management of Hip Fractures in the Elderly | Both meta-analyses included large numbers of patients from randomized controlled trials with objectively diagnosed PE or VTE. Quinlan has the advantage of only including trials of patients with documented PE, which more closely pertains to the patient in the clinical question. The study was of excellent quality and showed no difference in rates of recurrent PE or mortality. It supports a trend towards a decrease in recurrent PE with the use of LMWH vs. UFH, without an increased rate of adverse events. The study by van Dongen et al further supports the use of LMWH in the combined group of patients with PE or DVT. Van Dongen shows a decrease in any symptomatic VTE, major bleeding, and all cause mortality in this group |
0 | Volumetric findings of MRI after platelet rich plasma injection in knee osteoarthritis (A randomized clinical trial) | AMP (Acute Meniscal Pathology) | Introduction/Background: Most of studies have focused on subjective and clinical symptoms effect of PRP and fewer papers have studied its objective effect on cartilage. In this study, we investigated the effect of PRP on cartilage characteristics by special MRI sequencings. Material and method: In the double blind randomized clinical trial, patients with grades 1, 2 and 3 of osteoarthritis were included in this study. All of the knees divided to groups randomly and exercise was prescribed for all of knees. Beside, PRP was injected 2 courses with 4 weeks interval in PRP group. For all of patients before and 6 months after treatment VAS (visual analogue scale) and WOMAC (Western Ontario and McMaster Universities Arthritis Index) were fulfilled and MRI was performed. Sequencings of MRI were PD fat saturated (coronal and sagittal) and transverse TRUFISP 3D. Imaging was scored according to 4 cartilage's characteristics including, Patellofemoral cartilage volume, Subarticular bone marrow abnormality, Medial and lateral meniscal disintegrity and Synovitis. Results: Twenty-three knees in case group and 23 knees in control group were studied. All of patients were female with mean age 57.57 +/- 5.9 years old and mean BMI 28.49 +/- 3.24 (Kg/m2). Mean total WOMAC and VAS changes before and after treatment in control group were 11.61 +/- 1.3 and 8.5 +/- 1.1 respectively. In PRP group, mean total of WOMAC and VAS changes showed better improvement with 20 +/- 3.2 and 12.3 +/- 1.6 respectively (P-value < 0.05). In PRP group all of the radiologic variables except subarticular bone marrow abnormality had significantly improvement (P-value < 0.05). In comparison between 2 groups, Patellofemoral cartilage volume and synovitis had significantly changes in PRP group (P-value < 0.05). Conclusion: In this study, in addition to the effect of PRP on VAS and WOMAC, there is effect on radiologic characteristics (Patellofemoral cartilage volume and synovitis) significantly. For more evaluation, study with more sample size is recommended. Copyright © 2018 |
0 | Ultrasonographic findings in a large series of patients with knee pain | Osteochondritis Dissecans 2020 Review | Background: Musculoskeletal ultrasound (MSKUS) is becoming more and more popular in the evaluation of different musculoskeletal abnormalities. The aim of this retrospective study was to document the prevalence and spectrum of MSKUS findings at the painful knee. Materials and Methods: All the studies of MSKUS that were performed for the evaluation of knee pain during the previous 2 years at the Department of Radiology in Nazareth hospital were reviewed. Demographic and clinical parameters including age, gender, side, and MSKUS findings were documented Results: Two hundred and seventy-six patients were included in the review. In 21 of them, both knees were evaluated at the same setting (total number of knees evaluated was 297). One hundred and forty-four knees were of the left side. Thirty-three pathologies were identified. 34% of the studies were negative. The most common MSKUS findings were medial meniscal tear (MMT) (20%), Baker's cyst (BC) (16%), and osteoarthritis (OA) (11%). Only one knee of all the knees evaluated in our study showed synovitis. Fifty-three knees (18% of all the knees evaluated) had more than one imaging finding, mosty two and while some had three findings. The most common combination of findings was MMT and BC (8 knees), MMT with OA (8 knees), and MMT with fluid (6 knee). In 67% of the patients who had simultaneous bilateral knee evaluation, at least one knee had no abnormal findings and in 43%, both knees were negative Conclusions: MSKUS has the potential for revealing huge spectrum of abnormalities. In nearly 90% of the positive studies, degenerative/mechanical abnormalities were reported, with MMT, BC, and osteoarthritic changes being the most common. |
1 | Treatment and complications in orthopaedic trauma patients with symptomatic pulmonary embolism | DOD - Acute Comp Syndrome CPG | Objectives: The purpose of this study is to characterize the presentation, size, treatment, and complications of pulmonary embolism (PE) in a large series of orthopaedic trauma patients who developed PE after injury. Methods: We reviewed the records of orthopaedic trauma patients who developed a PE within 6 months of injury at 9 trauma centers and 2 tertiary care facilities. Results: There were 312 patients, 186 men and 126 women, average age 58 years. Average body mass index was 29.6, and average Injury Severity Score was 18. Seventeen percent received anticoagulation before injury, and 5% had a history of PE. After injury, 87% were placed on prophylactic anticoagulation and 68% with low-molecular weight heparin. Fifty-three percent of patients exhibited shortness of breath or chest pain. Average heart rate and O2 saturation before PE diagnosis were 110 and 94%, respectively. Thirty-nine percent had abnormal arterial blood gas, and 30% had abnormal electrocardiogram findings. Eighty-nine percent had computed tomography pulmonary angiography for diagnosis. Most clots were segmental (63%), followed by subsegmental (21%), lobar (9%), and central (7%). The most common treatment was unfractionated heparin and Coumadin (25%). Complications of anticoagulation were common: 10% had bleeding at the surgical site. Other complications of anticoagulation included gastrointestinal bleed, anemia, wound complications, death, and compartment syndrome. PE recurred in 1% of patients. Four percent died of PE within 6 months. Conclusions: This is the first large data set to evaluate the course of PE in an orthopaedic trauma population. The complications of anticoagulation are significant and were as common in patients with lower risk clots as those with higher risk clots. Level of evidence: III (retrospective). See Instructions for Authors for a complete description of levels of evidence. Copyright © 2014 by Lippincott Williams & Wilkins. |
1 | Bisphosphonate-induced osteonecrosis of the jaw | MSTS 2018 - Femur Mets and MM | OBJECTIVE: To review the risk of osteonecrosis of the jaw associated with bisphosphonates. DATA SOURCES: A MEDLINE search (1966-January 2007) and a search of International Pharmaceutical Abstracts (1970-January 2007) were conducted to identify relevant literature. Additional references were reviewed from selected articles. STUDY SELECTION AND DATA EXTRACTION: Articles related to bisphosphonate-induced osteonecrosis of the jaw were reviewed and summarized. Inclusion criteria required that articles be either case studies or case series that were reporting actual cases linking osteonecrosis of the jaw with bisphosphonate use. Articles that addressed sites of osteonecrosis not involving the jaw, teaching cases (fictitious patients), and a retrospective claims analysis paper were excluded from consideration. DATA SYNTHESIS: Bisphosphonates have recently been linked to osteonecrosis of the jaw, with the greatest incidence seen with the intravenous preparations zoledronic acid and pamidronate. Osteonecrosis refers to death of a part of the bone, resulting in decreased bone density. Although the majority of occurrences have been associated with the intravenous bisphosphonates, oral bisphosphonates have also been implicated. Other risk factors noted from reported cases include dental extraction or trauma to the jaw exposing part of the bone. It is difficult to determine an exact incidence of osteonecrosis of the jaw in the general population of patients prescribed bisphosphonates; however, the incidence in cancer patients is approximately 6-7%. CONCLUSIONS: Although discontinuation of intravenous bisphosphonates in cancer patients has been recommended, stopping oral bisphosphonates prior to dental work cannot be universally endorsed at this time, since it is unknown whether this is effective in reducing the risk of osteonecrosis of the jaw. Treatment of this condition is not well established; therefore, efforts should be directed toward prevention. Pharmacists may further counsel patients to practice good oral hygiene and regularly follow up with their dentist during therapy. Current evidence suggests limited surgical debridement with systemic and local antibiotics as treatments. |
0 | Pedicled Vascularized Bone Graft of the Distal Radius for Recalcitrant Nonunion of the Distal Humerus | Distal Radius Fractures | Objectives:To analyze the clinical and radiological outcomes of a series of patients treated with a pedicled vascularized bone graft (VBG) of the distal radius for the treatment of recalcitrant atrophic nonunions of the distal humerus.Design:Retrospective clinical study.Setting:University-affiliated teaching hospital.Patients:Fifteen patients with supracondylar humeral atrophic nonunions with at least 3 previous failed surgical interventions were included.Intervention:Debridement of the distal humerus nonunion through a posterior elbow approach with provisional fixation was performed. Then, a pedicled VBG was harvested from the distal radius and tunneled back into the humeral bone defect. Iliac crest was used as needed, both for the nonunion and to stabilize the radius. Finally, definitive fixation with 2 locked plates was performed.Main Outcome Measurements:Radiological results, complications, elbow range of motion, Mayo elbow performance score, and subjective pain were evaluated.Results:There were 4 male and 11 female patients, with a mean age of 51 (range, 28-73) years. The mean follow-up period was 46 (range, 37-72) months with a minimum of 3 years. Radiological consolidation was achieved in all patients. Elbow range of motion was >100 degrees in 11 patients and between 50 and 100 degrees in 4 patients. Preoperative Mayo scores were poor in all patients. At final follow-up, Mayo scores were excellent in 3, good in 9, and fair in 3 patients. The mean postoperative visual analog scale score was 1.2 (range 0-3).Conclusions:Pedicled VBG of the distal radius was shown to be a reliable and effective alternative for the treatment of recalcitrant atrophic nonunions of the distal humerus, when other methods have failed.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. |
0 | Automatic digital quantification of bone marrow myeloma volume in appendicular skeletons - clinical implications and prognostic significance | MSTS 2022 - Metastatic Disease of the Humerus | Multiple myeloma (MM) is a clonal plasma cell disorder originating in bone marrow. Whole body low-dose multidetector CT (MDCT) can depict bone marrow infiltration by myeloma cells into the adipose-rich fatty marrow of the appendicular skeleton. However, automated and objective volume measurement of bone marrow infiltration has not been established, and its clinical relevance remains unclear. We therefore developed novel CT post-processing software (MABLE software) and measured the total sum of CT values (cumulative CT value, cCTv) representing bone marrow infiltration, by combining volume and voxel-based CT values. The cCTv was greater in patients with symptomatic MM than in those with smouldering MM or monoclonal gammopathy of unknown significance. Patients with revised International Staging System (R-ISS) III had a higher cCTv than those with R-ISS I or II. Age, albumin, and M-protein levels independently predicted cCTv. Mixed graphical model analysis revealed direct relationships between cCTv and age or R-ISS. Tree-structured survival analysis and multivariate Cox analysis revealed that a cCTv greater than or equal to 4.4 was independently prognostic for overall survival. Anti-myeloma therapy reduced cCTv after treatment. These findings suggest that the automatically calculated cCTv reflects disease aggressiveness and is useful for accurate prognostic prediction in MM patients. |
0 | Patterns of CT use and surgical intervention in upper limb periarticular fractures at a level-1 trauma centre | Pediatric Supracondylar Humerus Fracture 2020 Review | OBJECTIVES: The universal availability of CT scanners has led to lower thresholds for imaging despite significant financial costs and radiation exposure. We hypothesised that this recent trend has increased the use of CT for upper limb periarticular fractures and led to more frequent operative management. METHOD: A 5-year retrospective study (01/07/2005-30/06/2010) was performed on all adult patients with upper extremity periarticular fractures (OTA: 11, 13, 21 and 23) admitted to a level-1 trauma centre. Patients were identified from the institution's prospectively maintained OTA classification database. RESULTS: A total of 1734 upper extremity periarticular fractures were identified in 1651 patients. 65% (1132/1734) were operated on. 32% (557/1734) had CT imaging and 78% (431/557) of these had operative management. CT use for all fractures and ages showed no change (0.56%/year, p = 0.210, r(2) = 0.457). Operative intervention increased at a rate of 2.17%/year (p = 0.004, r(2) = 0.959). Within each fracture type, CT rates showed no change. Operative management of proximal humerus and distal radius fractures became more frequent (6.30%/year, p = 0.002, r(2) = 0.969 and 0.96%/year, p = 0.046, r(2) = 0.784 respectively). Fractures around the elbow showed no change. In patients younger than 55 years, only proximal humerus fractures had more frequent imaging (3.17%/year, p = 0.023, r(2) = 0.866). In patients over 55 the frequency of CT scanning did not increase, but they were more frequently operated on (4.09%/year, p = 0.012, r(2) = 0.907). In older patients the rate of surgical intervention increased in all but the distal humerus region, Proximal humerus (6.19%/year, p = 0.015, r(2) = 0.894), proximal forearm (4.57%/year, p = 0.007, r(2) = 0.931) and distal radius (2.70%/year, p = 0.002, r(2) = 0.871). CONCLUSION: During the examined 5-year period no increases of in CT imaging frequency were observed. The significantly increased number of operations among older patients is unlikely to be driven by imaging frequency. |
0 | The distribution of vascular endothelial growth factor in human meniscus and a meniscal injury model | AMP (Acute Meniscal Pathology) | BACKGROUND: The meniscus plays an important role in controlling the complex biomechanics of the knee. Meniscus injury is common in the knee joint. The perimeniscal capillary plexus supplies the outer meniscus, whereas the inner meniscus is composed of avascular tissue. Angiogenesis factors, such as vascular endothelial growth factor (VEGF), have important roles in promoting vascularization of various tissues. VEGF-mediated neovascularization is beneficial to the healing of injured tissues. However, the distribution and angiogenic role of VEGF remains unclear in the meniscus and injured meniscus. We hypothesized that VEGF could affect meniscus cells and modulate the meniscus healing process.
METHODS: Menisci were obtained from total knee arthroplasty patients. Meniscal injury was created ex vivo by a microsurgical blade. VEGF mRNA and protein expression were detected by the polymerase chain reaction and immunohistochemical analyses, respectively.
RESULTS: In native meniscal tissue, the expression of VEGF and HIF-1alpha mRNAs could not be detected. However, VEGF and HIF-1alpha mRNAs were found in cultured meniscal cells (VEGF: outer > inner; HIF-1alpha: outer = inner). Injury increased mRNA levels of both VEGF and HIF-1alpha, with the increase being greatest in the outer area. Immunohistochemical analyses revealed that VEGF protein was detected mainly in the outer region and around injured areas of the meniscus. However, VEGF concentrations were similar between inner and outer menisci-derived media.
CONCLUSIONS: This study demonstrated that both the inner and outer regions of the meniscus contained VEGF. HIF-1alpha expression and VEGF deposition were high in injured meniscal tissue. Our results suggest that injury stimulates the expression of HIF-1alpha and VEGF that may be preserved in the extracellular matrix as the healing stimulator of damaged meniscus, especially in the outer meniscus. |
0 | Unusual appearance of an osteochondral lesion accompanying medial meniscus injury | AMP (Acute Meniscal Pathology) | An osteochondral lesion in the knee joint is caused by a focal traumatic osteochondral defect, osteochondritis dissecans, an isolated degenerative lesion, or diffuse degenerative disease. An osteochondral lesion with a cleft-like appearance accompanying medial meniscus injury is rare without trauma. We report the case of a 13-year-old boy who complained of right knee pain and swelling, with radiographic findings of an osteochondral defect. Arthroscopic inspection showed an osteochondral lesion in the medial condyle of the femur and tibial plateau accompanying a partial medial meniscus discoid tear. Partial meniscectomy was performed, and a microfracture procedure was carried out on the osteochondral defect. The patient was asymptomatic at 2 years' follow-up. This technique is a relatively easy, completely arthroscopic procedure that spares the bone and cartilage and has yielded a good clinical outcome in a skeletally immature patient who had an osteochondral lesion with a cleft-like appearance. |
1 | Trabecular metal in total knee arthroplasty associated with higher knee scores: a randomized controlled trial | Surgical Management of Osteoarthritis of the Knee CPG | BACKGROUND: Porous tantalum is an option of cementless fixation for TKA, but there is no randomized comparison with a cemented implant in a mid-term followup. QUESTIONS/PURPOSES: We asked whether a tibial component fixed by a porous tantalum system might achieve (1) better clinical outcome as reflected by the Knee Society Score (KSS) and WOMAC Osteoarthritis Index, (2) fewer complications and reoperations, and (3) improved radiographic results with respect to aseptic loosening compared with a conventional cemented implant. METHODS: We randomized 145 patients into two groups, either a porous tantalum cementless tibial component group (Group 1) or cemented conventional tibial component in posterior cruciate retaining TKA group (Group 2). Patients were evaluated preoperatively and 15 days, 6 months, and 5 years after surgery, using the KSS and the WOMAC index. Complications, reoperations, and radiographic failures were tallied. RESULTS: At 5-year followup the KSS mean was 90.4 (range, 68-100; 95% CI, +/- 1.6) for Group 1, and 86.5 (range, 56-99; 95% CI, +/- 2.4) for Group 2. The effect size, at 95% CI for the difference between means, was 3.88 +/- 2.87. The WOMAC mean was 15.1 (range, 0-51; 95% CI, +/- 2.6) for the Group 1, and 19.1 (range, 4-61; 95% CI, +/- 2.9) for Group 2. The effect size for WOMAC was -4.0 +/- 3.9. There were no differences in the frequency of complications or in aseptic loosening between the two groups. CONCLUSIONS: Our data suggest there are small differences between the uncemented porous tantalum tibial component and the conventional cemented tibial component. It currently is undetermined whether the differences outweigh the cost of the implant and the results of their long-term performance |
0 | Lesser tuberosity osteotomy with cerclage wire repair for total shoulder arthroplasty: Surgical technique | Glenohumeral Joint OA | Total shoulder arthroplasty has been widely accepted as an effective treatment for patients suffering from primary glenohumeral osteoarthritis. The traditional deltopectoral approach involves mobilization of the subscapularis tendon by tenotomy, followed by a soft-tissue repair of the tendon. The high prevalence of subscapularis dysfunction after total shoulder arthroplasty has stimulated much interest in alternative techniques for mobilizing the subscapularis tendon. There has been a recent shift toward using a lesser tuberosity osteotomy (LTO) during the deltopectoral approach to the glenohumeral joint. Reports indicate that this method enhances glenoid exposure, provides a stronger repair with desirable bone-to-bone healing, can be easily monitored radiographically, and results in lower rates of subscapularis dysfunction postoperatively. Previously described LTO techniques primarily involve suture repair in parallel rows of bone tunnels drilled along the medial and lateral borders of the osteotomy site. The current study describes a modified technique and early results for LTO repair, minimizing the number of drill holes by the use of cerclage wire fixation. Copyright © 2012 by Lippincott Williams & Wilkins. |
0 | Human cartilage-derived progenitor cells from committed chondrocytes for efficient cartilage repair and regeneration | PJI DX Updated Search | Articular cartilage is not a physiologically self-renewing tissue. Injury of cartilage often progresses from the articular surface to the subchondral bone, leading to pathogenesis of tissue degenerative diseases, such as osteoarthritis. Therapies to treat cartilage defects using autologous chondrocyte-based tissue engineering have been developed and used for more than 20 years; however, the challenge of chondrocyte expansion in vitro remains. A promising cell source, cartilage stem/progenitor cells (CSPCs), has attracted recent attention. Because their origin and identity are still unclear, the application potential of CSPCs is under active investigation. Here we have captured the emergence of a group of stem/progenitor cells derived from adult human chondrocytes, highlighted by dynamic changes in expression of the mature chondrocyte marker, COL2, and mesenchymal stromal/stem cell (MSC) marker, CD146. These cells are termed chondrocyte-derived progenitor cells (CDPCs). The stem cell-like potency and differentiation status of CDPCs were determined by physical and biochemical cues during culture. A low-density, low-glucose 2-dimensional culture condition (2DLL) was critical for the emergence and proliferation enhancement of CDPCs. CDPCs showed similar phenotype as bone marrow mesenchymal stromal/stem cells but exhibited greater chondrogenic potential. Moreover, the 2DLL-cultured CDPCs proved efficient in cartilage formation both in vitro and in vivo and in repairing large knee cartilage defects (6-13 cm(2)) in 15 patients. These findings suggest a phenotype conversion between chondrocytes and CDPCs and provide conditions that promote the conversion. These insights expand our understanding of cartilage biology and may enhance the success of chondrocyte-based therapies |
0 | Biomechanical evaluation of femoral anteversion in developmental dysplasia of the hip and potential implications for closed reduction | Developmental Dysplasia of the Hip 2020 Review | BACKGROUND: Earlier clinical reports have identified femoral anteversion as a factor associated with developmental dysplasia of the hip. This study investigates the biomechanical influence of femoral anteversion on severe dislocations and its effect on hip reduction using the Pavlik harness. METHODS: A computational model of an infant lower-extremity, representing a ten-week old female was used to analyze the biomechanics of anteversion angles ranging from 30° to 70° when severe dislocation was being treated with the Pavlik harness. Specifically, the effects and relationships between muscle passive response and femoral anteversion angle were investigated over a range of hip abduction and external rotation. FINDINGS: Results of this study suggest that increased femoral anteversion may decrease the success rate for treatment of high-grade developmental dysplasia of the hip when using the Pavlik harness. However, hip external rotation and decreased abduction in the harness may facilitate initial reduction in these cases. INTERPRETATION: This biomechanical study may help explain why dissections of newborn specimen with developmental dysplasia of the hip have shown normal distribution of femoral anteversion in contrast to studies of patients requiring surgery where greater frequency of increased femoral anteversion has been reported. This study also suggests that adjusting the Pavlik harness to increase external hip rotation and decrease hip abduction may facilitate initial reduction for severe dislocations with increased femoral anteversion. |
1 | Acellular Dermal Matrix-sparing Direct-to-implant Prepectoral Breast Reconstruction: A Comparative Study Including Cost Analysis | Acellular Dermal Matrix | INTRODUCTION: Refined mastectomy techniques, the advent of new technologies and materials such as acellular dermal matrix (ADM), cohesive gel silicone implants, and intraoperative tissue perfusion analysis, have fueled a resurgence in prepectoral breast reconstruction. This article aims to compare an immediate direct-to-implant prepectoral ADM-sparing approach with the traditional subpectoral 2-stage immediate reconstruction. A cost analysis within a Canadian-run single-payer system is also presented. METHODS: A retrospective 2-group comparative chart review study was performed (June 2015-January 2017) to identify all patients who underwent prepectoral direct-to-implant breast reconstruction using an ADM-sparing technique. The comparison group consisted of patients having undergone traditional 2-stage subpectoral reconstruction with ADM. All countable variables were included in the cost analysis, which was performed in Canadian dollars. RESULTS: A total of 77 patients (116 reconstructed breasts) were included. Both the prepectoral and subpectoral groups were comparable in size, demographics including age, diabetic and smoking status, and receiving neoadjuvant chemotherapy and postmastectomy radiotherapy. Patients having undergone direct-to-implant prepectoral reconstruction benefited from fewer follow-up visits (3.8 vs 5.4, respectively) and from less complications (24.7% vs 35.6%, respectively) including animation deformity. In addition, direct-to-implant prepectoral reconstruction costs 25% less than the 2-stage subpectoral reconstruction when all associated costs were considered. CONCLUSION: Prepectoral implant placement avoids many of the disadvantages of the traditional 2 stage subpectoral reconstruction, including pectoralis muscle dissection, animation deformity, and multiple surgeries. As the first comparative cost analysis study on the subject, our ADM-sparing direct-to-implant prepectoral reconstruction method costs 25% less than the traditional 2-stage subpectoral reconstruction with a comparable complication profile. |
0 | The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care | HipFx Supplemental Cost Analysis | BACKGROUND: The health implications of regional differences in Medicare spending are unknown. OBJECTIVE: To determine whether regions with higher Medicare spending achieve better survival, functional status, or satisfaction with care. DESIGN: Cohort study. SETTING: National study of Medicare beneficiaries. PATIENTS: Patients hospitalized between 1993 and 1995 for hip fracture (n = 614,503), colorectal cancer (n = 195,429), or acute myocardial infarction (n = 159,393) and a representative sample (n = 18,190) drawn from the Medicare Current Beneficiary Survey (MCBS) (1992-1995). EXPOSURE MEASUREMENT: End-of-life spending reflects the component of regional variation in Medicare spending that is unrelated to regional differences in illness. Each cohort member's exposure to different levels of spending was therefore defined by the level of end-of-life spending in his or her hospital referral region of residence (n = 306). OUTCOME MEASUREMENTS: 5-year mortality rate (all four cohorts), change in functional status (MCBS cohort), and satisfaction (MCBS cohort). RESULTS: Cohort members were similar in baseline health status, but those in regions with higher end-of-life spending received 60% more care. Each 10% increase in regional end-of-life spending was associated with the following relative risks for death: hip fracture cohort, 1.003 (95% CI, 0.999 to 1.006); colorectal cancer cohort, 1.012 (CI, 1.004 to 1.019); acute myocardial infarction cohort, 1.007 (CI, 1.001 to 1.014); and MCBS cohort, 1.01 (CI, 0.99 to 1.03). There were no differences in the rate of decline in functional status across spending levels and no consistent differences in satisfaction. CONCLUSIONS: Medicare enrollees in higher-spending regions receive more care than those in lower-spending regions but do not have better health outcomes or satisfaction with care. Efforts to reduce spending should proceed with caution, but policies to better manage further spending growth are warranted |
1 | The role of resiliency and coping strategies in occurrence of positive changes in medical rescue workers | DoD PRF (Psychosocial RF) | BACKGROUND: Working in the emergency services entails exposure to traumatic events; however, their effects can be both negative and positive. Among the factors determining posttraumatic growth (PTG) after an experienced trauma are the personal resources and coping strategies. The purpose of the research was to investigate the role of resiliency and coping strategies with stress in posttraumatic growth in a group of medical rescue workers.
MATERIALS AND METHODS: Data of 80 male medical rescuers who have experienced traumatic event in their worksite were analyzed. The Posttraumatic Growth Inventory, Resiliency Measurement Scale and Inventory to Measure Coping Strategies with Stress - Brief-Cope were used in the study. Statistical tests such as t test, correlation and path analysis were used.
RESULTS: The tested medical rescue workers revealed the medium level of PTG. Active coping, planning, turning to religion, seeking of social support, both emotional and instrumental, and self-distraction positively correlated with posttraumatic growth. A more significant role in the process of PTG appeared to be played by avoidance and emotional-focused strategies Although resiliency does not directly affect posttraumatic growth, it may strengthen it through the choice of coping strategies.
CONCLUSIONS: In the process of posttraumatic growth avoidance strategies seem to play more important role than strategies focusing on the problem. |
0 | Evaluation of a Permanent Synthetic Osteochondral Implant in the Equine Medial Femoral Condyle | PJI DX Updated Search | OBJECTIVE: To evaluate bone ingrowth, integration, and tolerance of a synthetic osteochondral implant in the medial femoral condyle (MFC) of normal horses. STUDY DESIGN: Experimental study. ANIMALS: Adult horses (n = 6). METHODS: Horses were anesthetized and bilateral femorotibial arthrotomies were performed for placement of 1 implant consisting of polycarbonate urethane with a titanium base in 1 MFC. The contralateral MFC served as a sham-operated control without reaming of cartilage or subchondral bone. Lameness evaluations and radiographs were performed pre-operatively with subsequent monthly lameness exams and radiographs at 6 months. Synovial fluid was collected for analysis from the adjacent femoropatellar joints pre-operatively and at several intervals post-operatively. Horses were euthanatized 6 months post-operatively. Stifles were harvested for gross and histologic evaluations. RESULTS: Two horses were never lame, 2 were mildly lame, and 1 exhibited moderate lameness. Synovial fluid inflammatory parameters of the adjacent femoropatellar joints were not significantly different. No significant changes occurred radiographically over time in either stifle. Histologic assessment of synovium from the medial femorotibial joint revealed no differences in inflammatory changes between implant and sham stifles. Integration and osteoconductivity of the implant were graded as good in 4 and 3 of 5 specimens, respectively. Complications included joint sepsis resulting in euthanasia (1 horse), persistent lameness (1 horse), incisional seromas (4 horses), and incisional dehiscence (2 horses). CONCLUSION: Results of this pilot study indicate that the implant was compatible with placement in the MFC of normal horses. Implant design allowed bone ingrowth within the titanium base and provision of a synthetic articular surface |
0 | Additional effect of iyengar yoga and EMG biofeedback on pain and functional disability in chronic unilateral knee osteoarthritis | OAK 3 - Non-arthroplasty tx of OAK | BACKGROUND: There are limited data about Iyengar Yoga and EMG biofeedback in knee OA, although the efficacy of EMG biofeedback in the rehabilitation of patients with quadriceps muscle weakness secondary to immobilization, contracture, and joint surgery has been well established.
MATERIALS AND METHODS: Thirty subjects who have fulfilled inclusion and exclusion criteria were selected and divided into two groups (Group A and B). Both the groups were treated with EMG biofeedback, knee muscle strengthening exercises, and TENS. Group A received additionally Iyengar Yoga for 8 weeks. Both groups were evaluated by Visual Analog Scale and Modified WOMAC-Western Ontario McMaster Universities Scale.
RESULTS: Patients in both groups experienced significant reduction in pain and improvement in functional ability. In VAS scale Group A showed reduction of 56.83% (P = 0.001) when compared with Group B 38.15% (P <= 0.001). In modified WOMAC Scale, Group A showed reduction of 59.21% (P = 0.001) when compared with Group B 34.08% (P = 0.001).
CONCLUSION: Adding Iyengar Yoga along with conventional therapy provides better results in chronic unilateral knee osteoarthritis in terms of pain and functional disability. |
1 | Patellofemoral Pain After Arthroscopy: Muscle Atrophy Is Not Everything | AMP (Acute Meniscal Pathology) | BACKGROUND: It remains unclear as to why patellofemoral pain (PFP) appears in some patients after knee arthroscopy and what influence the quadriceps muscle has on its onset.
PURPOSE: To compare muscle thickness, neuromuscular contractility, and quadriceps femoris muscle strength between patients who develop PFP after arthroscopic partial meniscectomy and a control group and to compare functional outcomes between these entities.
STUDY DESIGN: Cohort study; Level of evidence, 3.
METHODS: A prospective longitudinal cohort study was carried out on patients scheduled for arthroscopic partial meniscectomy. Patients were excluded if they had preoperative PFP, previous knee surgery, or additional surgical procedures (eg, meniscal repair or microfracture). The following were performed preoperatively: magnetic resonance imaging to quantify muscle thickness, surface electromyography to analyze electrical contractility, and an isokinetic study to assess the strength of the quadriceps femoris muscle. Patients also completed a Lysholm functional questionnaire. Six weeks after the index procedure, patients were questioned about the presence of PFP, and the same tests were repeated. The PFP group included patients who developed anterior knee pain postoperatively, while the control group included those who did not develop pain.
RESULTS: Of 90 initial study patients, 20 were included in the PFP group (23.8%) and 64 in the control group (76.2%); 6 patients were lost to follow-up. Both study groups were comparable on all of the analyzed preoperative variables. Patients in the PFP group had worse results in terms of muscle thickness (9.67 vs 16.55 cm<sup>2</sup>), electrical contractility (1226.30 vs 1946.11 microV), and quadriceps strength (12.27 vs 20.02 kg; all P < .001). They also presented worse functional results on the Lysholm score (63.05 vs 74.45; P < .001).
CONCLUSION: Patients who developed PFP after arthroscopic partial meniscectomy had more quadriceps femoris muscle atrophy as well as a greater decrease in electrical contractility and muscle strength at 6 weeks postsurgically as compared with a control group. The PFP group also had worse postoperative functional results. |
0 | The role of markers of bone remodeling in multiple myeloma | MSTS 2018 - Femur Mets and MM | Osteolytic bone disease is a frequent complication of multiple myeloma, resulting in skeletal complications that are a significant cause of morbidity and mortality. A characteristic feature of myeloma bone disease is that the lesions rarely heal and bone scans are often negative in myeloma patients who have extensive lytic lesions, offering very little in the follow-up of bone disease. X-rays are also of limited value in monitoring bone destruction during anti-myeloma or anti-resorptive treatment. Biochemical markers of bone turnover, such as N- and C-terminal cross-linking telopeptide of type I collagen (NTX, CTX/ICTP, respectively), and newer ones such as the tartrate resistant acid phosphatase isoform 5b, provide information on bone dynamics that in turn may reflect disease activity in bone. Several studies have shown bone markers to be elevated in myeloma patients and reflect the extent of bone disease, while in some of them bone resorption markers correlate with survival. These markers may also be helpful in identifying those patients likely to respond to bisphosphonate treatment, and monitoring the effectiveness of bisphosphonate therapy in the management of myeloma bone disease. This review attempts to summarize the existing data for the role of markers of bone remodeling in assessing the extent of bone destruction in myeloma and monitoring bone turnover during specific anti-myeloma treatment. We also discuss some novel markers that may be of particular interest in the near future. © 2004 Elsevier Ltd. All rights reserved. |
1 | Multimodal pain management for total hip arthroplasty | AAHKS (8) Anesthetic Infiltration | Multimodal pain management uses a variety of pharmacological agents administered at different perioperative times to target both peripheral and central nerve transduction and the various biochemical pathways, enzymes and receptors that signal painful stimuli and inflammation. This article reviews the role of patient-controlled analgesia, peripheral nerve blocks, local periarticular injections and extended-release epidural morphine injections that can be used in a multidisciplinary approach to analgesia. By decreasing narcotic consumption and improving pain control, multimodal pain management can reduce the numerous adverse effects associated with increased opioid use and improve mobility with physical therapy, both of which can have a direct effect on decreasing length of stay and reducing serious perioperative complications. © 2013 Elsevier Inc. |
1 | Interdisciplinary intervention for hip fracture in older Taiwanese: benefits last for 1 year | Management of Hip Fractures in the Elderly | BACKGROUND: Little is known about the effects of interventions for elderly patients with hip fracture in Asian countries, particularly beyond the short term. METHODS: Outcomes (service utilization, clinical outcomes, self-care ability, and depressive symptoms) were assessed at 1, 3, 6, and 12 months after discharge. Self-care ability (ability to perform activities of daily living [ADLs]), was measured by the Chinese Barthel Index. Depressive symptoms were measured by the Chinese Geriatric Depression Scale, short form. RESULTS: The experimental group (n = 80) had a significantly better ADL trajectory than the control group (n = 82) during the 1st year after discharge (p =.002). More participants in the experimental group than in the control group recovered their previous walking ability both at 6 months (81% vs 58%, respectively) and 12 months (84% vs 66%, respectively) after discharge. Overall, the odds ratio for the experimental group recovering their previous walking ability was 2.72 (p <.001) compared to the control group. The experimental group had significantly fewer depressive symptoms than the control group during the 1st year following discharge (p =.004). CONCLUSION: An interdisciplinary intervention for hip fracture with a discharge support component benefited elderly persons with hip fracture by improving both self-care ability and walking ability, and by decreasing depressive symptoms during the 1st year after hospital discharge |
0 | Distal femoral varus osteotomy for lateral osteoarthritis of the knee: a minimum ten-year follow-up | Surgical Management of Osteoarthritis of the Knee CPG | Distal femoral varus osteotomy (DFVO) may be indicated for symptomatic lateral compartment gonarthrosis associated with valgus deformity in younger, active patients. Thirty-three consecutive DFVOs (31 patients) with a minimum follow-up of ten years (mean 15.1, range 10-25) were reviewed. Fifteen DFVOs were converted to total knee arthroplasty (TKA) and one DFVO was awaiting TKA, reaching an overall failure rate of 48.5% at a mean of 15.6 years (range 6-21.5). Of the remaining 17 DFVOs, ten (58.8%) had good or excellent results, two (11.8%) had fair results and five (29.4%) had poor results. Mean modified Knee Society scores improved significantly (p < 0.01) from 36.8 preoperatively to 77.5 at one year post DFVO. DFVO is a viable treatment alternative for lateral compartment gonarthrosis. Conversion to TKA is expected to be required in approximately half of the patients at a mean of 15.6 years |
0 | Effect of intra-articular local anesthesia on articular cartilage in the knee | Surgical Management of Osteoarthritis of the Knee CPG | PURPOSE: To evaluate the hypothetical toxic effect of local anesthetics on the articular cartilage using patient data from autologous chondrocyte cultivation with different anesthesia types used for arthroscopic cartilage biopsy specimen procurement. METHODS: A retrospective analysis of patient data from the national autologous chondrocyte implantation registry and the corresponding hospital records was approved by the National Medical Ethics Committee. Articular cartilage biopsy specimens from the knees of 49 consecutive patients assigned for autologous chondrocyte implantation (aged 14 to 44 years) were procured from the non-weight-bearing articular surface during arthroscopy under general anesthesia (12 patients), spinal anesthesia (18 patients), or local anesthesia (intra-articular injection of 15 to 20 mL of 2% lidocaine hydrochloride) (19 patients). All the biopsy specimens were further manipulated following the same chondrocyte cultivation protocol. General patient data and surgery-related parameters, together with chondrocyte viability, population doublings, and chondrocyte morphology in biopsy specimens and primary cell cultures, were analyzed and compared across different types of anesthesia. RESULTS: Patients in the general, spinal, and local anesthesia groups showed no statistical differences in age (27 years, 29 years, and 32 years, respectively), duration of surgery (36 minutes, 37 minutes, and 39 minutes, respectively), weight of biopsy specimens (110 mg, 178 mg, and 130 mg, respectively), cell viability in cartilage biopsy specimens (67%, 69%, and 78%, respectively) or primary cultures (95%, 95%, and 95%, respectively), and population doublings (5.2, 5.2, and 5.2, respectively). Similar chondrocyte morphology in primary cell cultures was observed among the 3 groups. CONCLUSIONS: This retrospective study showed that a single intra-articular injection of lidocaine hydrochloride used for knee arthroscopy did not influence the viability, morphology, and cultivation potential of chondrocytes in articular cartilage biopsy specimens assigned for autologous chondrocyte implantation. LEVEL OF EVIDENCE: Level IV, retrospective comparative study |
0 | Anterior knee pain. The need for a specific diagnosis, stop calling it chondromalacia! | Diagnosis and Treatment of Osteochondritis Dissecans AUC | Clinically, chondromalacia of the patella is a collection of conditions that cause anterior knee pain. The clinical use of the term 'chondromalacia' to describe anterior knee pain is equal to employing the term 'interior derangement of the knee' to explain tibiofemoral pain. We must make more specific diagnoses if we are to institute treatment that will give reliable results. The term chondromalacia should be reversed for a pathologic description of asymptomatic softened articular cartilage on the medial central facet. The most common causes of anterior knee pain are the anterior knee pain of adolescence, malalignment syndromes, patella alta and patella baja, lateral hyperpressure syndrome, the odd facet syndrome, osteochondral injuries, and osteoarthritis. A careful history, knee examination, and arthroscopy will usually provide a specific diagnosis. In the case of circumscribed cartilage lesions, their precise location and size are important in determining the most reliable method of treatment. With a specific diagnosis and, if cartilage damage is present, a clear understanding of the nature and extent of the lesion, the physician can carry out specific treatment with reliable results |
1 | A comparison of malreduction after plate and intramedullary nail fixation of forearm fractures | Distal Radius Fractures | A study was performed to compare the degree of malreduction after intramedullary nail and plate fixation of the forearm and to determine if the degree of malreduction was clinically significant. Eight matched pairs of forearms, including the wrist and elbow joints, were harvested from cadaver upper extremities. The forearms were put through a full range of motion, and physiological loads were applied to simulate those during normal use. Standardized anteroposterior and lateral radiographs of each forearm were obtained with the specimen intact, and after an osteotomy and internal fixation of one bone, both bones, and with gap at the osteotomy sites. In each forearm pair, plating was randomly performed in one specimen and intramedullary nailing was performed in the matching contralateral specimen. Forearm architecture was assessed by quantification of the magnitude and location of maximum radial bow and radial angulation. In this study, plate fixation was superior to nail stabilization in restoration of the normal radial architecture. Plating did not change any of the radiographic indices (magnitude and location of maximum radial bow and radial angulation) at any stage of testing. None of the radiographic indices was changed by nailing of only one of the forearm bones. The magnitude of maximum radial bow and the radial angulation were changed by nailing both forearm bones after osteotomy and both forearm bones with a gap (p < 0.05). Despite this, both techniques were well within the limits of what is radiographically acceptable for reduction.(ABSTRACT TRUNCATED AT 250 WORDS) |
0 | The medial femoral condyle free corticoperiosteal flap versus traditional bone graft for treatment of nonunions of long bones: a retrospective comparative cohort study | Hip Fx in the Elderly 2019 | Fracture healing is a complex process and many factors change the local biology of the fracture and reduce the physiologic repair process. Since 1991 the free vascularised corticoperiosteal graft has been proposed to treat nonunions. In this study we compare the healing rate and the healing time of the free vascularised corticoperiosteal graft harvested from medial femoral condyle versus the traditional cancellous bone graft from the iliac crest combined with other biologic or pharmacologic factors. We performed a retrospective cohort study. The main measures of outcomes were the rate of bone union and the mean healing time from surgery. The authors performed 10 free vascularised corticoperiosteal grafts in the cohort A and 10 patients received traditional cancellous bone graft plus other biologic or pharmacologic treatment in the same period in the cohort B. The mean follow up in cohort A was 18.6 months with a healing rate of 100% (10/10). In cohort B the mean follow up was 22.5 month with a healing rate of 90%. The mean time to obtain union (healing time) in the group that was treated with the free flap procedure was significantly shorter, 3.2 months versus a mean time of 8.8 months in the other group. Some studies describe a high healing rate of recalcitrant nonunions with treatments different from vascularized bone flaps: it is difficult to compare the results of vascularized bone transfers with the results of other case series. Our groups are very homogeneous even if it is difficult to define correct inclusion criteria because there is still no agreement about what is defined a recalcitrant or difficult nonunion, and the number of trials of previous surgery before to perform a vascularized free flap. Even if our study cohort is small, we have demonstrated that the MFCCF generally seems to give a better healing chance with a shorter healing time compared to other treatments. |
0 | Relationship between retention of the posterior cruciate ligament and postoperative flexion in total knee arthroplasty | Surgical Management of Osteoarthritis of the Knee CPG | This study was conducted to retrospectively analyzed the outcome of 192 total knee arthroplasties in 132 patients with rheumatoid arthritis (118 women, 14 men). The Okayama Mark II prosthesis, which requires the posterior cruciate ligament (PCL) to be resected, was used in 83 knees (group I), the Mark II prosthesis, which allows the PCL to be retained, was used in 68 knees (group II), and the new Okayama PCL-R prosthesis, which also allows the PCL to be retained, was used in 41 (group III). According to the Japanese Orthopaedic Association knee scoring system, the clinical outcome of groups I, II and III at 1 year after the operation were 64.9, 71.2 and 72.3 points, respectively, and the average flexion angles in each group at 1 year were 78.4, 92.6 and 101.3 degrees. Postoperative flexion in groups III was significantly greater than in groups I and II. These results suggest that postoperative flexion is greater when the posterior cruciate ligament is retained |
0 | Monopolar electrocautery dissection in ophthalmic plastic surgery | Upper Eyelid and Brow Surgery | Monopolar electrocautery in the cutting mode is a superb surgical technique in many types of oculoplastic surgery because it efficiently dissects tissue with excellent hemostasis. The purpose of this article is to define how monopolar electrocautery functions and point out specific steps of certain oculoplastic procedures in which electrocautery dissection is useful. We have found it to be a helpful adjunct in over 1,200 clinical cases. We review the problems with electrocautery reported in the literature and discuss ways to avoid them. |
1 | Factors affecting rates of infection and nonunion in intramedullary nailing | DoD SSI (Surgical Site Infections) | We report a retrospective study over five years to determine the incidence of infection and nonunion after intramedullary nailing in fractures of 214 long bones; 122 femoral, 75 tibial and 17 humeral. The indications for nailing were trauma (n = 161), pathological fracture (n = 30) and nonunion (n = 23). There were 30 open fractures. The overall rates of deep infection and nonunion were 3.8% and 14.2%, respectively. Using multiple logistic regression analysis, we determined the relationships between deep infection and nonunion and the pre- and peri-operative factors of age, ASA score, indication for nailing, the use of reaming, the use of antibiotics, whether the fracture was open and the operating time. Open fractures were found to be significantly associated with deep infection. The length of the operation may also affect the outcome. Opening of the fracture at the time of surgery and the ASA score were found to be significantly associated with the development of nonunion after intramedullary nailing. We have compared our findings with previously published data from large teaching hospital units. |
0 | Distal humerus fractures: a review of current therapy concepts | Pediatric Supracondylar Humerus Fracture 2020 Review | Fractures of the distal humerus in the adult comprise approximately one third of all humeral fractures. Successful management of distal humerus fractures depends on correct reduction of the fracture, reconstruction of the articular surface if needed, stability and rigidity of the fixation, and appropriate rehabilitation. In this review, we evaluated the available literature and highlighted current therapy concepts. We assessed the evolution of internal fixation and elbow arthroplasty focusing on the established surgical approaches against the background of a growing incidence of distal humeral fractures in an aging patient population. Therefore evaluating the aspect and influence of age-dependent comorbidities like osteoporosis on successful treatment. |
0 | Titanium elastic nailing in femoral diaphyseal fractures in children of 6-14 years age | Distal Radius Fractures | PURPOSE: The purpose of this study is to report our experience of fractures in children riding Hoverboards. METHODS: We undertook a prospective review of all children attending our hospital who sustained fractures whilst riding a Hoverboard. Data such as patient demographics, type of fracture sustained, treatment received, complications and outcome were collected. RESULTS: Twelve children, 5 males and 7 females with ages ranging from 5.5 to 15.3 years were included in this study. All patients sustained upper limb fractures and the distal radius was the commonest fracture site (30%). Surgery was required in 6 (50%) out of the 12 patients because the respective fractures were displaced. No patient had any ongoing complaints or disability at the last clinic review.  Conclusion : Children riding Hoverboards are predisposed to upper limb fractures and parents who purchase Hoverboards should be warned about this. |
0 | Psoas compartment block in children: Part I--description of the technique | Surgical Management of Osteoarthritis of the Knee CPG | BACKGROUND: Until recently only small series of psoas compartment blocks (PCB) in children have been reported. A high incidence of epidural spread as an important side effect was noted. A series of 100 consecutive blocks using new standardized landmarks is reported. METHODS: In 100 consecutive children (5.9-106 kg) PCB was performed using a nerve stimulator. In the lateral position, the needle was inserted between the medial 2/3 and the lateral 1/3 on a line from the spinous process of L4 to the posterior superior iliac spine. The blocks were performed by residents in training under supervision of one specific designated pediatric anesthetist. RESULTS: All blocks were clinically successful. In 64% only one attempt was necessary, in 26 patients two attempts were necessary and in 10 patients more than two attempts were necessary. In 16% a vascular puncture occurred. In one patient with a dense unilateral block a partial epidural spread occurred. No serious complications were observed during the perioperative period. CONCLUSIONS: The described new technique has a very high success rate with no relevant side effects. Although only one case of epidural spread occurred, PCB remains an invasive technique with the potential for serious complications |
0 | Periorbital Surgery: Forehead, Brow, and Midface | Upper Eyelid and Brow Surgery | Periorbital rejuvenation requires a careful understanding of the interplay between the eyelids, brow, forehead, and midface. Reversing periorbital signs of aging requires a correction of volume loss, soft tissue ptosis, and skin changes. Many surgical and nonsurgical techniques exist to treat the aging periorbital region; however, careful consideration of the patient's complaints and existing anatomy is critical to achieving a safe and esthetically pleasing outcome. |
0 | Alteration at transcriptional level of cardiac renin-angiotensin system by letrozole treatment | Reduction Mammoplasty for Female Breast Hypertrophy | INTRODUCTION: The use of aromatase inhibitors (AIs) for breast cancer led to a marked change in ventricular function. Since accumulating evidence indicates that overactivation of the cardiac renin-angiotensin system (RAS) plays an important role in the development of cardiovascular diseases such as hypertrophy and remodelling, we aimed to investigate whether letrozole alters the transcription level of RAS related genes in the cardiac tissue. METHODS: Twenty four rats were randomly divided into four groups (n = 6 per group): two groups were letrozole treated (1 and 2 mg/kg/day orally), one group was vehicle treated (DMSO) and one group was the control group without any treatment. 12 weeks after beginning treatment with letrozole, we examined the rate of transcription of renin, angiotensinogen, AngII type 1a and 1b (AT1a and AT1b) and type 2 receptors (AT2) in the rat heart using real-time polymerase chain reaction. RESULTS: The cardiac mRNA levels of several components of the RAS in the rats treated with letrozole were significantly increased including AT1a receptor (80%), renin (51%), and angiotensinogen (33%). Though not significant, AT2 receptor levels were observed to decrease with increasing doses of letrozole. CONCLUSIONS: Letrozole can induce significant changes in some RAS related genes. These alterations are important to understand the pathways and consequences beyond cardiac events induced by breast cancer treatments. |
0 | Utility and Cost Effectiveness of Routine, Histologic Evaluation of the Mastectomy Scar in Two-Stage, Implant-Based Reconstruction during Expander-to-Implant Exchange | Reduction Mammoplasty for Female Breast Hypertrophy | BACKGROUND: Routine histologic analysis of the mastectomy scar is well studied in the delayed breast construction population; no data regarding its utility in the immediate, staged reconstruction cohort have been published. METHODS: A retrospective review of all of the senior author's (C.D.C.) patients who underwent immediate, staged reconstruction was performed. The mastectomy scar was analyzed routinely at the time of expander-to-implant exchange. Six hundred forty-seven breasts were identified. The mastectomy scar, time between expander and permanent implant, average patient age, and mastectomy indication were calculated. A cost analysis was completed. RESULTS: All scar pathologic results were negative for in-scar recurrence. The majority, 353 breasts, underwent mastectomy for carcinoma, 94 for germline mutations, 15 for high-risk lesions, six for high family risk, and 179 for contralateral symmetry/risk reduction. The average age at mastectomy/expander placement was 47.7 +/- 10.3 years, and the average time between expander placement and implant exchange was 254 +/- 152 days. The total histologic charge per breast was $602. CONCLUSIONS: A clinically silent in-scar recurrence is, at most, a rare occurrence. Routine histologic analysis of the mastectomy scar can be safely avoided in the immediate, staged reconstruction cohort. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. |
0 | Acute limb ischemia in patients with COVID-19 pneumonia | Coronavirus Disease 2019 (COVID-19) | OBJECTIVES: The aim of our study is to describe the incidence and characteristics, as well as clinical outcomes of patients presenting and treated for acute limb ischemia (ALI) in patients with novel coronavirus (COVID-19) infection during the 2020 coronavirus pandemic. METHODS: This is a single center, observational cohort study. Data of all patients tested positive with COVID-19 and presented with ALI vascular diseases requiring urgent operative treatment were collected in a prospectively maintained database. For this series, successful revascularization of the treated arterial segment was defined as the absence of early (<30 days) re-occlusion, or major amputation or death �24 hours. Primary outcomes were successful revascularization, early (�30 days) and late survival (�30 days), postoperative (� 30 days) complications, and limb salvage. RESULTS: We evaluated 20 patients with ALI who were positive for COVID-19. Considering the period January-to-March, the incidence rate of patients presenting with ALI in 2020 was significantly higher than 2019 [23/141 (16.3%) vs. 3/163 (1.8%), P < 0.001)]. There were 18 (90%) male and 2 female patients. Mean age was 75 years ± 9 (range, 62-95). All patients had already been diagnosed with COVID-19 pneumonia. Operative treatment was performed in 17 (85%) patients. Revascularization was successful in 12/17 (70.6%) patients. Although successful revascularization was not significantly associated with the postoperative use of intravenous heparin (64.7% vs. 83.3%, P = 0.622), no patients receiving intravenous heparin required reintervention. There were 8 (40%) in-hospital mortalities. Age was significantly higher in those who died (years, 81 ± 10 vs. 71 ± 5, P = 0.008). The use of continued postoperative systemic heparin infusion was significantly associated with survival (0% vs. 57.1%, P = 0.042). CONCLUSIONS: In our preliminary experience, the incidence of ALI has significantly increased during COVID-19 pandemic in the Italian Lombardia region. Successful revascularization was lower than expected which we hypothesize is due to a virus-related hypercoagulable state. The use of prolonged systemic heparin may improve surgical treatment efficacy as well as improve limb salvage and overall mortality. |
0 | Salmonella septic arthritis complicating rheumatoid arthritis in a patient with total knee replacement | Surgical Management of Osteoarthritis of the Knee CPG | Objective and Importance: Salmonella septic arthritis (SSA) in any age group is a relatively rare disease. The prime objective of this communication is to report a relatively uncommon presentation of SSA in a prosthetic knee joint of a patient with rheumatoid arthritis. Clinical Presentation: We report a 51-year-old lady with rheumatoid arthritis and total knee replacement who, while on methotrexate and azathioprine, developed Salmonella enteritidis bacteraemia complicated by septic monoarthritis of the left prosthetic knee. The same organism, using pulsed-field gel electrophoresis typing method, was isolated from the blood, joint aspirate and stool. Intervention: She was aggressively treated with antibiotics by giving the maximum dose of ceftriaxone, 2 g intravenously every 8 h for 4 weeks. In addition, close drainage with syringe and needle was also done on a few occasions. She responded well to this regimen. Follow-up for approximately 1 year at the clinic has been uneventful. Conclusion: SSA in a patient with a history of diarrhoea and a recent visit to the Indian subcontinent should be investigated for salmonella infection. Adequate antibiotic therapy, with repeated close drainage of the joint, is recommended for SSA in a prosthetic joint |
0 | Treatment of low subcondylar fractures - A 5-year retrospective study | The Treatment of Pediatric Supracondylar Humerus Fractures AUC | The aim of the present study was to retrospectively review the treatment outcome of low subcondylar temporomandibular joint fractures. The retrospective analysis was performed on all patients treated for low subcondylar fractures (below the sigmoid notch) between 2006 and 2011. Patients were divided into two groups: the closed reduction group (maxillomandibular fixation, MMF) and the open reduction group (anteroparotid transmasseteric (APTM) approach). Out of 129 condylar fractures, a total of 37 patients met the inclusion criterion of a fracture below the sigmoid notch (low subcondylar). Ten patients (seven males and three females) were treated using the APTM approach, and 27 patients were treated conservatively by MMF. In the open reduction group, two patients (20%) had limited mouth opening that resolved following physiotherapy; the closed reduction group had a similar percentage (18.5%) of mouth opening limitation (below 35 mm). No facial nerve damage was noted. Adult patients suffering from low subcondylar fractures can be treated by open reduction and internal fixation using the APTM approach, which was found to be a safe and reproducible procedure with no facial nerve damage; however this is a surgical procedure with a shallow learning curve. (copyright) 2013 International Association of Oral and Maxillofacial Surgeons |
0 | Liposuction: Concepts, safety, and techniques in body-contouring surgery | Panniculectomy & Abdominoplasty CPG | Liposuction is the second most commonly performed cosmetic surgery in the United States and the most common surgical procedure in patients between the ages of 35 and 64; practitioners of medicine and surgery will undoubtedly encounter these patients in their practice. This brief review discusses the role of liposuction and fat transfer in aesthetic and reconstructive surgery, as well as key considerations, indications, and safety concerns. |
1 | One-stage versus two-stage bilateral unicompartmental knee replacement: a comparison of immediate post-operative complications | Surgical Management of Osteoarthritis of the Knee CPG | We retrospectively studied the major complications occurring after one- and two-stage bilateral unicompartmental knee replacements (UKR). Between 1999 and 2008, 911 patients underwent 1150 UKRs through a minimally invasive approach in our unit. Of these, 159 patients (318 UKRs) had one-stage and 80 patients (160 UKRs) had two-stage bilateral UKRs. The bilateral UKR groups were comparable in age and American Society of Anaesthesiology grade, but more women were in the two-stage group (p = 0.019). Mechanical thromboprophylaxis was used in all cases. Major complications were recorded as death, pulmonary embolus, proximal deep-vein thrombosis and adverse cardiac events within 30 days of surgery. No statistical differences between the groups were found regarding the operating surgeon, the tourniquet time or minor complications except for distal deep-vein thrombosis. The anaesthetic times were longer for the two-stage group (p = 0.0001). Major complications were seen in 13 patients (8.2%) with one-stage operations but none were encountered in the two-stage group (p = 0.005). Distal deep-vein thrombosis was more frequent in the two-stage group (p = 0.036). Because of the significantly higher risk of major complications associated with one-stage bilateral UKR we advocate caution before undertaking such a procedure |
0 | Clomethiazole Acute Stroke Study in ischemic stroke (CLASS-I): final results | Upper Eyelid and Brow Surgery | BACKGROUND AND PURPOSE: A previous trial (the Clomethiazole Acute Stroke Study) generated the hypothesis that clomethiazole is effective in patients with a major ischemic stroke (total anterior circulation syndrome), and this was tested in the present study. METHODS: A total of 1198 patients with major ischemic stroke and a combination of limb weakness, higher cortical dysfunction, and visual field deficits were randomly assigned to clomethiazole (68 mg/kg IV over 24 hours) or placebo. The study drug was initiated within 12 hours of symptom onset. Functional outcome and neurological recovery were assessed at days 7, 30, and 90, with the proportion of patients with a Barthel Index > or =60 at last follow-up as the primary outcome measure. RESULTS: The patients were randomly assigned equally, and the two treatment groups were well matched for baseline characteristics, including stroke severity (mean National Institutes of Health Stroke Scale score 16.9+/-5.2). Ninety-six percent were classified as total anterior circulation syndrome. The proportion of patients reaching a Barthel Index score of > or =60 was 42% in the clomethiazole-treated group and 46% in the placebo-treated group (odds ratio, 0.81; 95% CI, 0.62 to 1.05; P=0.11). There was no evidence of efficacy on any secondary outcome variables (modified Rankin Score, National Institutes of Health Stroke Scale, Scandinavian Stroke Scale, and 30-day CT infarct volumes) compared with placebo. Subgroup analysis showed a similar lack of treatment effect in patients treated early (<6 hours) and in those treated later (6 to 12 hours). Somnolence was an expected pharmacological effect of clomethiazole, and this occurred during treatment as an adverse event in half of the patients randomly assigned to study drug. CONCLUSIONS: The target population was selected, and sufficient drug was given to produce the expected pharmacological effect in the brain. Clomethiazole does not improve outcome in patients with major ischemic stroke. |
0 | Correlation between osteoporosis and degeneration of intervertebral discs in aging rats | OAK 3 - Non-arthroplasty tx of OAK | This study examined the correlation between osteoporosis and the degeneration of intervertebral discs. Sprague-Dawley rats were maintained up to 22 or 28 months. The femoral bone, tibial bone and lumbar vertebra were histologically studied and the expression of collagen type II and X in intervertebral discs was immunohistochemiscally determined. Several indices for the degeneration of intervertebral discs and osteoporosis and the correlation among them were then analyzed. Close correlations were found among the indices for the degeneration of intervertebral discs, including the relative area of the vascular bud, the ratio of the uncalcified and the calcified layers, the expression of collagen type II and X. The correlation with collagen type X was negative. There existed positive correlations among the indices for osteoporosis, including the thickness ratio of cortical bone, the relative area of bone trabecula, the density of femoral and vertebral body bones, and the maximum stress and strain on bone. Analysis on the relationship of osteoporosis and the disease on disc showed that the indices of osteoporosis were negatively correlated with the indices of the degeneration of intervertebral discs but the expression of collagen type X was positively correlated, with the density of vertebral body bones having the strongest dependence on collagen type X. The maximum stress and strain bore no correlation with the degeneration of intervertebral discs. These results suggest that osteoporosis was negatively correlated with the degeneration of intervertebral discs. © Huazhong University of Science and Technology and Springer-Verlag Berlin Heidelberg 2012. |
0 | Proximal Row Carpectomy Using Decellularized Dermal Allograft: Preliminary Results | AMP (Acute Meniscal Pathology) | Objective The purpose of this study was to evaluate the short-term outcomes of patients undergoing proximal row carpectomy (PRC) with interposition arthroplasty using a decellularized dermal allograft. Methods Patients with a minimum of 1-year follow-up after undergoing a PRC using decellularized dermal allograft were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as well as the modified Likert scale for patient satisfaction. Nine of ten (90%) consecutive patients who were treated using this surgical technique were available for follow-up. Results At a mean follow-up of 18 months, a total of nine patients achieved a mean flexion-extension arc of 113 degrees, pronosupination of 170.5 degrees, grip strength of 68 Ibs and pinch strength of 17 Ibs. Relative to the contralateral side, these values were 95, 100, 84 and 82%, respectively. There was significant improvement in the mean DASH score from 63.5 preoperatively to 23.8 postoperatively. Patient satisfaction postoperatively achieved a mean modified Likert score of 1.5. There was no evidence of radiocarpal joint space degeneration or dislocation in any of the patients. No patient suffered wound-related issues, foreign-body reaction to the graft, or other complications. Conclusion PRC with interposition arthroplasty using a decellularized dermal allograft in patients with degenerative changes at the lunate fossa or capitate demonstrates short-term outcomes comparable to what has been reported for routine PRC in patients without degenerative changes affecting the radiocapitate joint. This method of interposition arthroplasty expands the indications for PRC and may help avoid salvage, motion-sacrificing procedures in select patients with late-stage wrist arthritis. Level of Evidence This is a level IV, therapeutic study. |
0 | Classification and management of intra-articular fractures of the distal radius | Distal Radius Fractures | A classification of distal radial articular fractures is described, based on observations of consistent patterns of fracture fragmentation and displacement. The classification categorizes articular fractures into four types, with the medial complex assuming a pivotal position as the cornerstone of both the radiocarpal and distal radioulnar joints. The purpose of this classification is four-fold: (1) to afford identification and an understanding of the displacement characteristics of the major fracture components, (2) to provide practical and rational guidelines for the management of these injuries based on specific fracture patterns, (3) to emphasize the frequency of concurrent soft tissue and other skeletal injuries associated with the more severe types of articular disruption, and (4) to serve as a prognostic gauge for the varied spectrum of distal radius articular injury. Optimal management of distal radius fractures necessitates the differentiation of articular from extra-articular fractures as well as prompt detection of unstable injuries. While the majority of unstable fractures can be successfully managed by closed methods, a substantial and increasing number require open treatment for restoration of articular congruity as well as repair of concomitant soft tissue and skeletal injuries. In all cases, precise reduction of the key medial fragments is essential to maximum recovery. [References: 40] |
0 | Does surgical approach affect outcome after fixation of intra-articular fractures of distal humerus? Retrospective cohort study from a level-1 trauma centre in a metropolitan city | Pediatric Supracondylar Humerus Fracture 2020 Review | INTRODUCTION: Fractures around the distal humerus fractures make up to 2% of all fractures. Complex intra-articular distal humerus fractures present as challenge to restore of painless, stable and mobile elbow joint. Surgical exposure to all critical structures is of paramount importance to achieve anatomic reduction. Conflict still persists regarding the choice of ideal approach. In this study we compare the effect of surgical approach triceps lifting vs olecranon osteotomy on the functional outcome after fixation of distal humerus fractures. METHODS: Non-funded, non-commercial, retrospective cohort study was conducted on patients with closed distal humerus intra-articular fractures between 2010 and 2015â?¯at our tertiary care level-1 trauma and university hospital. Patients >18 years of age with closed complex intra-articular distal humerus fracture were operated using one of the two surgical approaches, either triceps lifting approach (Group1) or with olecranon osteotomy (Group 2). Functional evaluation using quick DASH scores at 1 year of follow-up. Study is registered with ID:NCT03833414 and work has been reported in line with the STROCSS criteria. RESULTS: Out of 43 patients 16 were treated with triceps lifting approach and 27 with olecranon osteotomy. The difference between the mean quick DASH score for both groups was not statistically significant (pâ?¯=â?¯0.52) although higher for group 1. Complications were comparable for both groups but 2 patients suffered delayed union of osteotomy site in group 2. CONCLUSION: Triceps lifting approach can be used equally efficiently for exposure of these complex distal humerus injuries with no comprise in visibility of articular fragments. |
0 | Twenty-year outcomes of a longitudinal prospective evaluation of isolated endoscopic anterior cruciate ligament reconstruction with patellar tendon autografts | OAK 3 - Non-arthroplasty tx of OAK | BACKGROUND: Long-term prospective follow-up studies of single-incision endoscopic anterior cruciate ligament (ACL) reconstruction are limited and may include confounding factors.
PURPOSE: This longitudinal prospective study reports the outcomes of isolated ACL reconstruction using middle-third patellar tendon autografts in 90 patients over 20 years.
STUDY DESIGN: Case series; Level of evidence, 4.
METHODS: Between January 1993 and April 1994, a total of 90 patients met study inclusion criteria: evaluation at 1, 2, 3, 4, 5, 7, 10, 15, and 20 years after surgery. Exclusion criteria were associated ligamentous injuries requiring surgery, previous meniscectomy or meniscal injuries requiring more than one-third meniscectomy, chondral injuries, and an abnormal contralateral knee.
RESULTS: At 20 years, 32 (36%) patients had sustained another ACL injury: 8 (9%) to the index limb and 27 (30%) to the contralateral limb (3 injuring both knees). The mean International Knee Documentation Committee (IKDC) score was 86. Of the patients, 50% participated in strenuous/very strenuous activities, and kneeling pain was present in 63%. Radiographic degenerative change was found in 61%; 20% had IKDC grade C, and 0% had grade D. The IKDC clinical examination revealed that 95% had a normal/nearly normal knee. Significant sex differences existed: when compared with male patients, female patients were less likely to reinjure the reconstructed ACL (18% vs 2%, respectively; P = .01), reported poorer IKDC subjective scores (90 vs 83, respectively; P = .03), had more activity-related pain (20% vs 57%, respectively; P = .02), and were less likely to participate in strenuous activities (66% vs 35%, respectively; P = .009). ACL graft survival was not related to age. Patients <18 years old had an increased odds ratio (3.2) for rupturing the contralateral ACL. A coronal graft angle <17degree increased the risk of failure compared with an angle >17degree (77% vs 96% survival, respectively) by a factor of 8.5.
CONCLUSION: Injuries more commonly occurred in the contralateral ACL than in the reconstructed ACL graft, and the most significant predictor of a contralateral ACL injury was age <18 years. The most significant predictor of an ACL graft rupture was a coronal graft angle <17degree. Female patients had lower rerupture rates, poorer subjective scores, and decreased participation in strenuous activities, putting the graft at a lower risk of failure. Kneeling pain remained persistent over 20 years. Radiographic osteoarthritis was evident in 61% of patients, but symptomatic osteoarthritic symptoms were rarely reported. |
0 | Knee extensor and flexor strength in elderly women after recent hip fracture: assessment by the Cybex 6000 dynamometer of intra-rater inter-test reliability | Management of Hip Fractures in the Elderly | The reliability of knee extensor and flexor strength measurements was assessed in 20 women (aged 68-88 years) who had experienced a hip fracture two to four weeks before but who were otherwise healthy. Using the Cybex 6000 isokinetic dynamometer, isokinetic knee extensor and flexor strength (peak torque, total work and power) at 30 and 120 degree/second and isometric knee extensor and flexor strength (peak torque) were measured by the same examiner in both legs, successively, on four separate days within one week. Compared with the non-involved leg, the median reduction in peak extensor and flexor torque of the involved leg was 50% (p <0.001). With the protocol used, no significant change in muscle strength occurred during the test period Individual coefficients of variation (CVs) were calculated for each muscle strength variable. Depending on whether torque, work or power were measured, the median CVs of extensor and flexor strength measurements of the non-involved leg ranged from 5.6-14.6% and 10.8-28.6%, respectively. The corresponding CVs for the involved leg were 10.9-22.1% and 13.0-35.2%. Substantial variability between individual CVs were found for all strength variables. In conclusion, although muscle strength measurements may be applicable when comparing larger groups of hip fracture patients, the large CVs may be a limitation in monitoring individual patients. This finding should be taken into consideration when planning individual training programmes |
0 | Knee arthroplasty rating | Surgical Management of Osteoarthritis of the Knee CPG | A number of rating systems used to evaluate the results of total knee arthroplasty exist. Many of these systems are based on different concepts, and might be expected to give divergent results. To see if this was so, the authors examined a consecutive series of 235 posterior stabilized knee arthroplasties recording the results according to five rating systems: HSS (The Hospital for Special Surgery), Brigham, Freeman, BOA (British Orthopaedic Association), and the VENN diagram. In spite of their apparent differences, all point systems and the BOA gave almost identical results, while the VENN diagram proved to be the most stringent. The authors suggest that any of the current point systems may be used to 'score' arthroplasties, but the results should also be rated with the VENN diagram in order to see the quality of the arthroplasty and a comparison between the different series |
0 | Underlying mechanisms and therapeutic strategies for bisphosphonate-related osteonecrosis of the jaw (BRONJ) | MSTS 2018 - Femur Mets and MM | Bisphosphonates (BPs), with a non-hydrolysable P-C-P structure, are cytotoxic analogues of pyrophosphate, bind strongly to bone, are taken into osteoclasts during bone-resorption and exhibit long-acting anti-bone-resorptive effects. Among the BPs, nitrogen-containing BPs (N-BPs) have far stronger anti-boneresorptive effects than non-N-BPs. In addition to their pyrogenic and digestive-organ-injuring side effects, BP-related osteonecrosis of jaws (BRONJ), mostly caused by N-BPs, has been a serious concern since 2003. The mechanism underlying BRONJ has proved difficult to unravel, and there are no solid strategies for treating and/or preventing BRONJ. Our mouse experiments have yielded the following results. (a) N-BPs, but not non-N-BPs, exhibit direct inflammatory and/or necrotic effects on soft tissues. (b) These effects are augmented by lipopolysaccharide, a bacterial-cell-wall component. (c) N-BPs are transported into cells via phosphate transporters. (d) The non-N-BPs etidronate (Eti) and clodronate (Clo) competitively inhibit this transportation (potencies, Clo>Eti) and reduce and/or prevent the N-BP-induced inflammation and/or necrosis. (e) Eti, but not Clo, can expel N-BPs that have accumulated within bones. (f) Eti and Clo each have an analgesic effect (potencies, Clo>Eti) via inhibition of phosphate transporters involved in pain transmission. From these findings, we propose that phosphate-transporter-mediated and inflammation/infection-promoted mechanisms underlie BRONJ. To treat and/or prevent BRONJ, we propose (i) Eti as a substitution drug for N-BPs and (ii) Clo as a combination drug with N-BPs while retaining their anti-bone-resorptive effects. Our clinical trials support this role for Eti (we cannot perform such trials using Clo because Clo is not clinically approved in Japan). |
0 | Radiofrequency chondroplasty may not have a long-lasting effect in the treatment of concomitant grade II patellar cartilage defects in humans | AMP (Acute Meniscal Pathology) | The effect of radiofrequency chondroplasty on cartilage tissue is not well studied. This prospective pilot study investigates the effect of radiofrequency chondroplasty on International Cartilage Repair Society (ICRS) grade II patellar cartilage defects using high-resolution magnetic resonance imaging (MRI) with T2 mapping. Six consecutive patients were treated for ICRS grade II patellar cartilage defects using radiofrequency chondroplasty. Before surgery and at defined follow-ups (2 weeks, 4 and 12 months) a high-resolution morphological 3 Tesla MRI with quantitative T2 mapping was performed. At baseline MRI, global T2 values of cartilage defects were increased (46.8 ms ± 9.7) compared to healthy cartilage (35.2 ms ± 4.5) in the same knee which served as reference. Two weeks after treatment, global T2 values (39.2 ms ± 7.7) of the defect areas decreased. However, global T2 values of the defect areas increased beyond the preoperative levels at 4 months (47.4 ms ± 3.1) and 12 months (51.5 ms ± 5.9), respectively. Zonal T2 mapping revealed that the predominant changes in T2 values occurred at the superficial cartilage layer. T2 mapping appears to be an ideal method to monitor cartilage degeneration after chondroplasty. Based on the small sample size of this pilot study, radiofrequency chondroplasty may cause cartilage damage and may not have a long-lasting effect in the treatment of grade II patellar cartilage defects. In five out of six patients, postoperative cartilage damage was observed on quantitative MRI. This study was therefore terminated before completion. We recommend only addressing the pathology which indicated arthroscopy and leaving concomitant cartilage lesions untreated. |
0 | Direct medical costs attributable to osteoporotic fractures | Management of Hip Fractures in the Elderly | Osteoporotic fractures are a major cause of morbidity in the elderly, the most rapidly growing segment of our population. We characterized the incremental direct medical costs following such fractures in a population-based cohort of men and women in Olmsted County, Minnesota. Cases included all County residents 50 years of age and older with an incident fracture due to minimal or moderate trauma between January 1, 1989 and January 1, 1992. For each case, a control of the same age (+/- 1 year) and sex who was attended in the local medical system in the same year was identified. Total incremental costs (cases - controls) in the year after fracture were estimated. Unit costs for each health service/procedure were obtained through the Mayo Cost Data Warehouse, which provides a standardized, inflation-adjusted estimate reflecting the national average cost of providing the service. Regression analysis was used to identify factors associated with incremental costs. There were 1263 case/control pairs; their average age was 73.8 years and 78% were female. Median total direct medical costs were $761 and $625, respectively, for cases and nonfracture controls in the year prior to fracture, and $3884 and $712, respectively, in the year following fracture. The highest median incremental costs were for distal femur ($11756) and hip fractures ($11241), whereas the lowest were for rib fractures ($213). Although hip fractures resulted in more incremental cost than any other fracture type, this amounted to only 37% of the total incremental cost of all moderate-trauma fractures combined. Regression analyses revealed that age, prior year costs and type of fracture were significant predictors of incremental costs (p<0.03 for all comparisons). The incremental costs of osteoporotic fractures are therefore substantial. Whereas hip fractures contributed disproportionately, they accounted for only one-third of the total incremental cost of fractures in our cohort. The use of incremental costs in economic analyses will provide a more accurate reflection of the true cost-effectiveness of osteoporosis prevention |
0 | Influence of treatment with APD-bisphosphonate on the bone lesions in the mouse 5T2 multiple myeloma | MSTS 2018 - Femur Mets and MM | The effects of the treatment of multiple myeloma (MM) with APD-bisphosphonate on bone destruction, the dissemination pattern of the MM, and toxicity for normal and malignant cells were investigated in an animal model, the 5T2 MM. This mouse MM very closely resembles the human disease, including the typical bone lesions. It was demonstrated by radiography, microradiography, and histologic investigation that the treatment of the 5T2 MM with APD-bisphosphonate protected the mice against a loss of bone to a significant extent. It seemed that the treatment with APD not only diminished the bone destruction by the MM but also led to the formation of new bone in already-affected bone tissue. The growth pattern of the MM was not substantially influenced by the treatment, even though there was an indication that APD exerts some cytotoxic effect on the MM cells. |
0 | Axonal excitability in HNPP | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Hereditary neuropathy with liability to pressure palsies is an autosomal dominant disorder due to a 1.5 Mb deletion in chromosome 17p11.2-p12 resulting in reduced expression of the PMP22 gene, the same gene that is duplicated in CMT1A. HNPP generally presents with an increased susceptibility to pressure palsies although phenotype within one family is variable. Nerve conduction studies show prolonged distal latencies and histopathologically dysmyelination, with characteristic tomaculi, is seen. The underlying pathophysiology of the disorder however is still not well understood. Methods: Axonal excitability studies were performed on four patients with genetically and biopsy proven HNPP. All subjects had been symptomatic on at least one occasion. Excitability testing of motor axons was performed by stimulating the median nerve at the wrist and elbow and recording from the thenar muscles and forearm flexors respectively. Excitability studies were performed using the TROND protocol of QTRACs. Comparisons were made with seven age-matched control subjects. Results: Motor thresholds were significantly greater in all HNPP patients and strength duration time constants were longer for HNPP subjects. Studies stimulating the median nerve at the wrist showed fanning out of the threshold electrotonus graph with a notch in the depolarising direction. These changes in threshold electrotonus were not present with stimulation at the elbow. Conclusion: There are changes in axonal excitability in HNPP, some of which resemble those observed in CMT1A. The changes are not uniform along the nerve |
0 | Bilateral lateral congenital discoid cartilage | AMP (Acute Meniscal Pathology) | Congenital discoid cartilage is an interesting anomaly. Though rare on the medial side, lateral semilunar cartilage involvement is fairly frequent. It is believed that discoid lateral menisci are probably more frequent than statistics indicate. Many remain symptomless or are probably not diagnosed. A case in a 12 year old school boy is described. After pneumarthrography, surgical treatment plus physiotherapy led to a complete cure. Most cases present during childhood or adolescence. The usual symptoms are pain, instability and snapping. The snapping is due to rolling ahead of the cartilage on extending femoral condyles and then sudden slipping backwards. This mechanism places a considerable horizontal strain on the meniscus which finally ruptures. At this stage it may give rise to hemarthrosis. |
0 | Epidemiology of basketball injuries among adults presenting to ambulatory care settings in the United States | DoD PRF (Psychosocial RF) | OBJECTIVE: Little information exists that examines the epidemiology of injuries among adults who engage in sports and recreational activities. The purpose of this study is to examine basketball-related injuries among adults presenting to ambulatory settings in the United States. DESIGN: Retrospective review of medical records. SETTING: Emergency departments, outpatient departments, and physicians' offices in the United States. PATIENTS: Nationally representative sample of adults presenting to ambulatory care settings in the United States for treatment of injuries incurred while playing basketball. MAIN OUTCOME MEASURES: Body site injured, type of injury, ambulatory treatment site, and utilization of diagnostic testing. RESULTS: An annual average of 507,000 adults were treated in an ambulatory care setting for injuries related to playing basketball. The majority of these patients sought treatment in physicians' offices. Females had a much lower rate of visits (0.8/1000) for basketball-related injuries than males (5.7/1000); African American males had a rate 2.7 times higher than white males. The most common injuries were sprains and strains to the lower leg and/or ankle region and fractures of the hand, wrist, or fingers. Specific analyses of patients presenting to the emergency department diagnosed with sprain/strain injuries to the lower leg/ankle region revealed that 93% of these patients received an x-ray procedure. CONCLUSIONS: Basketball injuries constitute a significant portion of ambulatory medical care use in the United States each year, particularly among young adult males and African American males. Better surveillance of adult participation in sports and recreational activities is needed to better identify risk and protective factors for injuries. © 2007 Lippincott Williams & Wilkins, Inc. |
0 | Outwardly rectifying deflections in threshold electrotonus due to K(+) conductances | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | A transient decrease in excitability occurs regularly during the S1 phase of threshold electrotonus to depolarizing conditioning stimuli for sensory and, less frequently, motor axons. This has been attributed to the outwardly rectifying action of fast K(+) channels, at least in patients with demyelinating diseases. This study investigates the genesis of this notch in healthy axons. Threshold electrotonus was recorded for sensory and motor axons in the median nerve at the wrist in response to test stimuli of different width. The notch occurred more frequently the briefer the test stimulus, and more frequently in sensory studies. In studies on motor axons, the notch decreased in latency and increased in amplitude as the conditioning stimulus increased or the limb was cooled. Low-threshold axons displayed profound changes in strength-duration time constant even though the threshold electrotonus curves contained no detectable notch. When a 1.0 ms current was added to subthreshold conditioning stimuli to trigger EMG, the notch varied with the timing and intensity of the brief current pulse. This study finds no evidence for an outwardly rectifying deflection due to K(+) channels, other than the slow accommodation attributable to slow K(+) currents. In normal motor axons, a depolarization-induced notch during the S1 phase of threshold electrotonus is the result of the conditioning stimulus exceeding threshold for some axons. The notch is more apparent in sensory axons probably because of the lower slope of the stimulus-response curve and their longer strength-duration time constant rather than a difference in K(+) conductances. This may also explain the notch in demyelinating diseases. (copyright) 2007 The Authors. Journal compilation (copyright) 2007 The Physiological Society |
0 | Biological knee reconstruction for combined malalignment, meniscal deficiency, and articular cartilage disease | Surgical Management of Osteoarthritis of the Knee CPG | PURPOSE: The aim of this study was to analyze patient-reported outcomes in those undergoing the triad of simultaneous osteotomy, meniscal transplantation, and articular cartilage repair. METHODS: Patients undergoing simultaneous meniscal transplantation, distal femoral or proximal tibial osteotomy, and articular cartilage surgery by a single surgeon (B.J.C.) were analyzed. Meniscal transplantation was performed using bone-in-slot techniques. Distal femoral and high tibial osteotomies were performed for valgus and varus malalignment, respectively. Microfracture, autologous chondrocyte implantation, and osteochondral autograft or allograft were performed for articular cartilage disease. Validated patient-reported and surgeon-measured outcomes were collected. Preoperative and postoperative outcomes and medial versus lateral disease were compared using Student t tests. RESULTS: Eighteen participants (mean age, 34 +/- 7.8 years; symptomatic patients, 7.4 +/- 5.6 years; 2.4 +/- 1.0 surgical procedures before study enrollment; mean follow-up, 6.5 +/- 3.2 years) were analyzed. Two thirds of participants had medial compartment pathologic conditions and one third had lateral compartment pathologic processes. At final follow-up, there were statistically significant clinically meaningful improvements in International Knee Documentation Committee (IKDC) subjective classification, Lysholm score, and 4 Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores. Postoperative 12-item short form (SF-12) physical and mental component scores were not significantly different from preoperative scores. The Kellgren-Lawrence classification grade was 1.5 +/- 1.1 at 2.5 +/- 3.0 years after surgery. There was a significantly higher preoperative SF-12 physical composite score (PCS) in participants with lateral compartment pathologic conditions (v medial compartment conditions) (P = .011). Although there were 13 reoperations in 10 patients (55.5% reoperation rate), only one patient was converted to knee arthroplasty (5.6%) and one to revision cartilage surgery and meniscal transplantation (5.6% revision rate). The most common complication was arthrofibrosis (16.7%). CONCLUSIONS: Statistically significant and clinically meaningful improvements in validated patient-reported clinical outcome scores at long-term follow-up were observed in 18 participants undergoing combined meniscal transplantation, osteotomy, and articular cartilage surgery. Although there was a low rate of cartilage or meniscal revision (or both) and total knee arthroplasty, there was a high rate of reoperation. There was no significant difference in outcomes between participants with medial versus lateral pathologic conditions. LEVEL OF EVIDENCE: Level IV, therapeutic case series |
1 | Latissimus dorsi transfer for treatment of irreparable rotator cuff tears | Optimizing the Management of Full-Thickness Rotator Cuff Tears | Massive rotator cuff tendon ruptures are not uncommon in older patients. We propose the transfer of the latissimus dorsi muscle for treatment of irreparable ruptures associated with functional impairment and chronic pain. Five women and 11 men were so treated and reviewed with an average follow-up of 26 months. The mean age was 60 years. Four patients also had subscapularis deficiency. Results were assessed with the Constant score and the Oxford shoulder score. Humeral head position was analysed. Statistical analysis was performed by the Wilcoxon non-parametrical test. The Constant score increased by 24.2% (p = 0.001) with all parameters showing improvement. Nine patients showed improved humeral head positioning in internal rotation. Three of four patients with a deficient subscapularis had unfavourable results. Latissimus dorsi transfer for the treatment of irreparable massive rotator cuff tears leads to a substantial clinical improvement. An intact subscapularis tendon is mandatory |
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