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1 | Effects of a home-based occupational therapy telerehabilitation via smartphone for outpatients after hip fracture surgery: A feasibility randomised controlled study | Hip Fx in the Elderly 2019 | INTRODUCTION: This study aimed to investigate the effects of a home-based occupational therapy telerehabilitation (TR) via smartphone in enhancing functional and motor performance and fall efficacy for outpatients receiving day hospital rehabilitation after hip fracture surgery in Hong Kong. METHODS: This was a feasibility randomised controlled trial with two groups - an experimental group and a comparison group - and a sample of 31 older adults attending a geriatric day hospital who had undergone hip fracture surgery within 12 weeks of diagnosis. Patients were assessed at baseline, immediately after a three-week intervention and at three-week post-intervention follow-up for motor performance, activities of daily living (ADL) functioning and fall efficacy. The experimental group received a home programme using the Caspar Health e-system and a mobile app for smartphones, while the comparison group received paper-and-pencil instructions for the home programme on a weekly basis for three weeks. RESULTS: Compared to the comparison group, significant improvements in fall efficacy and instrumental ADL performance at post intervention and follow-up were found in the experimental group. However, in the comparison group, inadequate social support was a factor contributing to better muscle strength testing in both the affected and non-affected legs. There were no significant differences between the two groups in regard to the other variables. DISCUSSION: This study supports the potential use of TR via smartphone as an alternative home programme for use in occupational therapy practice with older adults after hip fracture surgery. |
0 | Therapeutic ultrasound for osteoarthritis of the knee or hip | SR for PM on OA of All Extremities | BACKGROUND: Osteoarthritis is the most common form of joint disease and the leading cause of pain and physical disability in the elderly. Therapeutic ultrasound is one of several physical therapy modalities suggested for the management of pain and loss of function due to osteoarthritis (OA). OBJECTIVES: To compare therapeutic ultrasound with sham or no specific intervention in terms of effects on pain and function safety outcomes in patients with knee or hip OA. SEARCH STRATEGY: We updated the search in CENTRAL, CINAHL, EMBASE, MEDLINE and PEDro up to 23 July 2009, checked conference proceedings, reference lists, and contacted authors. SELECTION CRITERIA: Studies were included if they were randomised or quasi-randomised controlled trials that compared therapeutic ultrasound with a sham intervention or no intervention in patients with osteoarthritis of the knee or hip. DATA COLLECTION AND ANALYSIS: Two independent review authors extracted data using standardized forms. Investigators were contacted to obtain missing outcome information. Standardised mean differences (SMDs) were calculated for pain and function, relative risks for safety outcomes. Trials were combined using inverse-variance random-effects meta-analysis. MAIN RESULTS: Compared to the previous version of the review, four additional trials were identified resulting in the inclusion of five small sized trials in a total of 341 patients with knee OA. No trial included patients with hip OA. Two evaluated pulsed ultrasound, two continuous and one evaluated both pulsed and continuous ultrasound as the active treatment. The methodological quality and the quality of reporting was poor and a high degree of heterogeneity among the trials was revealed for function (88%). For pain, there was an effect in favour of ultrasound therapy, which corresponded to a difference in pain scores between ultrasound and control of -1.2 cm on a 10-cm VAS (95% CI -1.9 to -0.6 cm). For function, we found a trend in favour of ultrasound, which corresponded to a difference in function scores of -1.3 units on a standardised WOMAC disability scale ranging from 0 to 10 (95% CI -3.0 to 0.3). Safety was evaluated in two trials including up to 136 patients; no adverse event, serious adverse event or withdrawals due to adverse events occurred in either trial. AUTHORS' CONCLUSIONS: In contrast to the previous version of this review, our results suggest that therapeutic ultrasound may be beneficial for patients with osteoarthritis of the knee. Because of the low quality of the evidence, we are uncertain about the magnitude of the effects on pain relief and function, however. Therapeutic ultrasound is widely used for its potential benefits on both knee pain and function, which may be clinically relevant. Appropriately designed trials of adequate power are therefore warranted |
0 | Biochemical and histological evidence that carcinoma of the prostate is associated with increased bone resorption | MSTS 2018 - Femur Mets and MM | We have investigated the hypothesis that carcinoma of the prostate with skeletal metastases is associated with increased bone resorption. In 54 affected patients a close correlation was observed between serum activity of alkaline phosphatase and urinary excretion of hydroxyproline (r = +0.818; P less than 0.001), comparable to that seen in Paget's disease of bone. The administration of synthetic salmon calcitonin (100 U subcutaneously) induced a significant fall in serum calcium and urinary excretion of hydroxyproline, proportional to the prevailing rate of bone turnover, as assessed by serum alkaline phosphatase or hydroxyprolinuria. Administration of the diphosphonate, etidronate, also decreased hydroxyprolinuria, suggesting that urinary hydroxyproline reflected increased rates of bone resorption in this disorder. Histology of bone in sites adjacent to and distant from skeletal metastases showed increased histological indices of bone resorption. These results suggest that the skeletal disease associated with prostatic carcinoma is characterized by generalized increases in bone resorption as well as focal increases in bone formation. |
0 | Sauve-Kapandji operation for disorders of the distal radioulnar joint | Distal Radius Fractures | A series of 13 patients is reported in which a Sauve-Kapandji procedure consisting of arthrodesis of the articulation between the radius and ulna combined with resection of the collum ulnae was used to treat posttraumatic caput ulnae syndrome. Among the nine female and four male patients whose median age was 42 years (range: 23 to 77 years), nine sustained a distal fracture that had healed with shortening of the radius or with subluxation of the caput ulnae. Median postoperative observation time was 16 months (range: six to 27 months). Preoperatively, all patients had persistent medial wrist pain and restricted pronation-supination. At follow-up, ten patients were without symptoms and three others had improved significantly. No patient suffered from pain from the site of the resection. A significant improvement in pronation-supination of 45 degrees and flexion-extension of 25 degrees were found. Hand grip strength improved significantly during rehabilitation. At follow-up, the average hand grip strength on the operated wrists was 69% compared to the uninjured side. |
1 | Uncemented Miller-Galante total knee replacement. The influence of alignment on clinical and radiological outcome in a 5 to 8-year follow-up | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | Sixty-one primary uncemented Miller-Galante total knee replacements were implanted in 55 patients between June 1988 and December 1990. The results of routine radiological and clinical follow up carried out at an average of 1.3 years and 6.2 years after operation were used for evaluation. The Knee Society clinical score improved from 47.8 points before operation to 83.3 points one year after, and had progressed further to 87.6 points at the recent follow-up. The functional score improved from 45 points before operation to 75.23 points at early follow up, and 81.3 points at the recent review. Although radiological analysis showed that the femoral and tibial components overall were placed perpendicular to the mechanical axis of the limb, sufficient correction of the mechanical axis was not achieved to within +/- 10 mm deviation from the centre of the knee in 22 cases, with varus or valgus deformity remaining. No early or late infection occurred in this series. The uncemented Miller-Galante total knee replacement shows good biological fixation of both components. Wear of the metal-backed patellar and tibial polyethylene lead to a revision rate of 19% after 5 years |
0 | Cost-effectiveness of a Staphylococcus aureus screening and decolonization program for high-risk orthopedic patients | PJI DX Updated Search | We conducted a Markov decision analysis to assess the cost savings associated with a preoperative Staphylococcus aureus screening and decolonization program on 365 hip and knee arthroplasties and 287 spine fusions. A 2-way sensitivity analysis was also used to calculate the needed reduction in surgical site infections to make the program cost saving. If cost of treating an infected hip or knee arthroplasty is equal to the cost of a primary knee arthroplasty, then the screening program needs to result in a 35% reduction in the revision rate, or a relative revision rate of 65% for patients in the screening program, to be cost saving. For spine fusions, the reduction in the revision rate to make the program cost saving is only 10%. Universal Staphylococcus aureus screening and decolonization for hip and knee arthroplasty and spinal fusion patients needs to result in only a modest reduction in the surgical site infection rate to be cost saving |
0 | A randomized trial of three antibiotic regimens for the treatment of pyelonephritis in pregnancy | Patrick’s pharmacoepidemiology project | OBJECTIVE: To compare the effectiveness of three antibiotic regimens for the treatment of acute pyelonephritis in pregnancy. METHODS: One hundred seventy-nine pregnant women earlier than 24 weeks' gestation who had acute pyelonephritis were randomized to 1) intravenous (i.v.) ampicillin and gentamicin, 2) i.v. cefazolin, or 3) intramuscular ceftriaxone. All participants then completed 10-day courses of oral cephalexin after primary treatment. A urine culture was performed on admission and 5-14 days after completion of therapy. Surveillance for persistent or recurrent infection and obstetric complications continued until delivery. On the basis of a two-sided hypothesis test and with alpha = .025, 60 subjects were needed in each group for statistical power greater than 80% to detect a difference between ceftriaxone and other antibiotics if hospital length of stay differed by 1 or more days. RESULTS: The treatment groups were similar in age, parity, temperature, gestational age, and initial white blood cell count. There were no statistically significant differences in length of hospitalization, hours until becoming afebrile, days until resolution of costovertebral angle tenderness, or infecting organism. There were no statistically significant differences in birth outcomes between the three groups. The average (standard deviation) age at delivery was 38.8 +/- 3.6 weeks. The average birth weight was 3274 +/- 523 g. Eleven (6.9%) of 159 subjects delivered prematurely. Escherichia coli was the most common uropathogen isolated (137 of 179, 76.5%). Blood cultures were positive for organisms in 15 cases (8.4%). At follow-up examination within 2 weeks of initial therapy, eight (5.0%) of 159 subjects had urine cultures positive for organisms. Ten women (6.3%) had cultures positive for organisms later in their antepartum course, and 10 other participants (6.3%) developed recurrent pyelonephritis. CONCLUSION: There are no significant differences in clinical response to antimicrobial therapy or birth outcomes among subjects treated with ampicillin and gentamicin, cefazolin, or ceftriaxone for acute pyelonephritis in pregnancy before 24 weeks' gestation |
0 | The armamentarium to battle the recalcitrant nasolabial fold | Panniculectomy & Abdominoplasty CPG | The nasolabial fold is the consequence of thinning of the skin, ptosis or deposition of fat laterally, and presence of excess skin. The ideal procedure for combatting this defiant and undesirable aging change would be to eliminate the excess skin, add to the thickness of the skin under the crease, and shield the bands from adherence to the dermis, with or without repositioning or resection of the fat laterally. However, under particular conditions, the patient or physician may choose alternative techniques. These include injection of fat, addition of fat graft, or direct excision. Patients with extremely thin skin are better candidates for direct excision, whereas those with thicker skin may more suitably benefit from fat injection or fat graft. |
0 | Circulating acute phase mediators and skeletal muscle performance in hospitalized geriatric patients | Glenohumeral Joint OA | BACKGROUND: There is growing evidence for the significant involvement of inflammatory processes in the development of muscle wasting in old age. Therefore, any disease accompanied by inflammation can be threatening to the muscle function in geriatric patients.
METHODS: Sixty-three hospitalized geriatric patients (42 female, 21 male; mean age 84.2 +/- 5.7 years) were monitored weekly for muscle function (grip strength, fatigue resistance, shoulder extension strength, and hip extension strength) and for concentration of circulating C-reactive protein (CRP), fibrinogen, interleukin 6 (IL-6), and tumor necrosis factor-alpha alpha (TNF-alpha).
RESULTS: On the basis of circulating CRP and fibrinogen concentrations, 42 patients were categorized on admission as inflammatory and 21 as noninflammatory. Inflammatory patients presented significantly weaker grip strength, shoulder extension strength, and a worse fatigue resistance than did noninflammatory patients. These muscle functions were negatively correlated with the concentrations of circulating CRP and IL-6, but not with fibrinogen or TNF-alpha. In noninflammatory patients, the fatigue resistance improved significantly during the first week of hospitalization. In patients admitted with inflammation, no improvement of muscle function was observed. Patients who remained inflammatory for 2 weeks or more presented a significant worsening of fatigue resistance.
CONCLUSIONS: Geriatric hospitalized patients presenting with inflammation show significantly worse muscle functions, which do not improve during hospitalization despite adequate treatment of the primary disease. Reduced strength and fatigue resistance are significantly related to the concentration of circulating CRP and IL-6. Standard treatment of the underlying illness and classic physical therapy are not sufficient to normalize the skeletal muscle strength and fatigue resistance in these hospitalized patients. |
0 | Critical incident identification in common orthopaedic injury | Distal Radius Fractures | OBJECTIVE: To identify the occurrence of any critical incidents in the 50 consecutive patients with common orthopaedic injury (distal radius fractures) treated in a District General Hospital of United Kingdom.
METHODS: All patients admitted with distal radius fracture and subjected to manipulation/closed reduction under anaesthesia or surgical interventions were included in this study. Patients who were manipulated in Accident and Emergency were excluded.
RESULTS: Although a very common fracture to treat in orthopaedic practice, a radial fracture can be associated with significant critical incidents during its management. Nineteen critical incidences in 50 patients treated for their distal radius fracture were identified. Three occurred while consultants were operating, whereas 16 took place during surgery by trainees.
CONCLUSION: A critical incident identification form has been formulated which can be incorporated in any procedure for training and evaluation purpose. |
1 | Evaluation of moderate and severe blepharoptosis correction using the interdigitated part of the frontalis muscle and orbicularis oculi muscle suspension technique: A cohort study of 235 cases | Upper Eyelid and Brow Surgery | BACKGROUND: Blepharoptosis is defined as an abnormally low-lying upper eyelid margin in the primary gaze, causing vertical narrowing of the palpebral fissure. It is difficult to achieve consistently satisfactory results in moderate or severe cases despite many surgical methods being available to correct them. METHODS: Between January 2001 and December 2014, a retrospective cohort study was conducted using medical records and perioperative photographs of 235 patients. All the patients, having presented with moderate or severe bilateral or unilateral blepharoptosis, underwent blepharoptosis correction with the interdigitated orbicularis oculi-frontalis muscle flap suspension technique and contemporaneous double-eyelid surgery. The results, including complications, were followed up and evaluated. RESULTS: The mean age of the patients was 17.4 years (range 3-50 years). The follow-up period ranged from 6 months to 8 years, with a mean follow-up of 13 months. Long-term postoperative complications included undercorrection (3.0%), overcorrection (0.7%) and eyelid fold deformity (4.0%). No ectropion, entropion, fornix conjunctival prolapse or exposure keratitis was noted. CONCLUSIONS: Blepharoptosis correction with interdigitated orbicularis oculi-frontalis muscle flap suspension is an effective technique for the management of moderate or severe blepharoptosis. The results demonstrated very low complication rates and substantial cosmetic and functional improvement using simple manipulation. |
0 | Tibial component fixation in total knee arthroplasty: a comparison of pegged and stemmed designs | Surgical Management of Osteoarthritis of the Knee CPG | This study compares midterm radiographic, functional, and quality-of-life outcomes in patients receiving a cemented tibial component that has either a short intramedullary stem or one that has a pegged tibial component. A cohort of 181 patients received 225 NexGen cruciate-retaining implants (84 stemmed, 141 pegged) during total knee arthroplasty, with annual follow-up examinations for up to 7 years. Both types of tibial components were associated with excellent radiographic and clinical results with no radiographic evidence of implant loosening or osteolysis. Clinical outcomes included improvement in joint function and patient function, as well as quality of life. Survival analysis showed 98% survival at 7 years with both implants. Pegged tibial components offered comparable midterm radiographic, functional, and quality-of-life results to stemmed components |
0 | Southland Hospital's experience with the Austin Moore hemiarthroplasty | Management of Hip Fractures in the Elderly | AIM: The assessment of hospital performance with reference to patients who receive Austin Moore hemiarthroplasty for neck of femur fractures and the assessment of patients at medium term follow up. METHODS: A retrospective review of 103 Austin Moore hemiarthroplasties in 101 patients. This review spans an 11 year period at this institution. A clinical follow up of survivors including pain, x-ray and Harris hip score to evaluate their current position. RESULTS: Mean hospital stay remained unchanged at 39.13 days. Also unchanged were the percentage of patients returning home at 44.6%. The time to surgery improved significantly over the review period being on average 2.8 days. Medium term follow up of surviving patients (16 patients) showed 14 patients with poor Harris hip scores. Radiographic analysis did not explain the clinical outcome. CONCLUSIONS: Whilst at this institution, total time to surgery improved total hospital stay and percentage discharged home remained unchanged. Medium term surviving Austin Moore patients should be followed as their hip function may deteriorate excessively with time. The predicted increase in patient load will further pressure the current resources making substantial improvements more difficult |
0 | Comparing Intra-articular Corticosteroid to Intra-articular Ketorolac Knee Injections | OAK 3 - Non-arthroplasty tx of OAK | This study will compare the efficacy of intraâ?articular betamethasone injection to intraâ?articular ketorolac injection for symptomatic treatment of knee osteoarthritis in an equivalence study using a doubleâ?blinded, randomized, controlled design. Patients will be recruited from orthopaedic clinics at St. Luke's University Health Network. A total of 448 patients will be recruited (224 in each group) to receive an administration of an intraâ?articular betamethasone or ketorolac injection. The primary outcome is change in pain as assessed by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Secondary outcomes include Knee Injury and Osteoarthritis Outcome (KOOS) and Knee Outcome Survey â? Activities of Daily Living (KOSâ?ADL) scores and physical exam findings. Statistical analyses include repeated measures analysis of variance (ANOVA) (primary outcome) and selected ANOVA and nonparametric tests as deemed appropriate (secondary outcomes), with p < .05 denoting significance for all comparisons, and no adjustment for multiple testing. |
0 | Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation of hip, pelvic and long bone fractures: a systematic review and network metaâ?쳌analysis | Pediatric Supracondylar Humerus Fracture 2020 Review | This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To review systematically the optimal administration and relative efficacy of pharmacological interventions for preventing blood loss in definitive surgical fixation of the hip, pelvic and long bones. |
0 | Intravenous paracetamol (acetaminophen) | Dental Implant Infection | Intravenous paracetamol (rINN)/intravenous acetaminophen (USAN) is an analgesic and antipyretic agent, recommended worldwide as a first-line agent for the treatment of pain and fever in adults and children. In double-blind clinical trials, single or multiple doses of intravenous paracetamol 1 g generally provided significantly better analgesic efficacy than placebo treatment (as determined by primary efficacy endpoints) in adult patients who had undergone dental, orthopaedic or gynaecological surgery. Furthermore, where evaluated, intravenous paracetamol 1 g generally showed similar analgesic efficacy to a bioequivalent dose of propacetamol, and a reduced need for opioid rescue medication. In paediatric surgical patients, recommended doses of intravenous paracetamol 15 mg/kg were not significantly different from propacetamol 30 mg/kg for the treatment of pain, and showed equivocal analgesic efficacy compared with intramuscular pethidine 1 mg/kg in several randomized, active comparator-controlled studies. In a randomized, noninferiority study in paediatric patients with an infection-induced fever, intravenous paracetamol 15 mg/kg treatment was shown to be no less effective than propacetamol 30 mg/kg in terms of antipyretic efficacy. Intravenous paracetamol was well tolerated in clinical trials, having a tolerability profile similar to placebo. Additionally, adverse reactions emerging from the use of the intravenous formulation of paracetamol are extremely rare (<1/10 000). [table: see text]. |
0 | Bone mineral density and urine calcium excretion among subjects with and without nephrolithiasis | Management of Hip Fractures in the Elderly | BACKGROUND: Bone mineral density (BMD) is reduced among patients with idiopathic hypercalciuria (IH) and nephrolithiasis. To disentangle effects of diet, stone formation, and physiology upon BMD, we studied vertebral and femoral neck BMD among relatives of hypercalciuric stone formers, and contrasted those with to those without stones. METHODS: Among 59 subjects from 11 families, vertebral and femoral neck BMD, diet calcium intake, urine excretions of calcium, sodium, ammonium, titratable acid, sulfate, urea nitrogen, and serum levels of calcitriol and markers of bone turnover were studied. RESULTS: Stone formers (SF) consumed less calcium than non-stone formers (NSF). Spine and femoral neck BMD z-scores varied inversely with urine calcium loss and urine ammonium excretion among SF but not NSF. No correlations of BMD z-score were found for bone markers, calcitriol, or any of the other measurements. CONCLUSION: SF consumed less calcium, presumably to prevent more stones, and displayed a bone mineral responsiveness to calcium loss and ammonium excretion not present among NSF, who ate more calcium. Lowered calcium consumption in IH, perhaps in response to stone formation, alters bone responses in a direction that can predispose to mineral loss and eventual fracture |
0 | Evaluation of the risk of systemic fat mobilization and fat embolus following liposuction with dry and tumescent technique: an experimental study on rats | Panniculectomy & Abdominoplasty CPG | BACKGROUND: Clinical studies have revealed that liposuction causes systemic fat mobilization. However, the degree of the risk it causes is not clear. In this study we investigated the risk of systemic fat mobilization and fat embolus in rats following liposuction using dry and tumescent techniques. METHODS: At the end of the procedures, the rats were sacrificed and specimens were obtained from the lungs, kidneys, liver, brain, and skin. Histological examinations of the specimens were carried out. Liposuction was not performed in the control group (n = 8), but blood and tissue specimens for histological examinations were obtained. RESULTS: We found signs of fat embolus in both blood specimens and histological examinations of tissue samples in the study groups. However, the results of the examinations were normal in the control group. Although there were no fat particles in the blood before liposuction, blood specimens obtained following the procedures and in the long-term had fat particles. |
0 | Renal disease in hematological malignancies | MSTS 2018 - Femur Mets and MM | Hematological malignancies can affect the kidneys in different ways. There may be direct invasion by the tumor cells, or the malignancy may act indirectly via immunologically mediated mechanisms. Primary renal lymphoma (PRL) without evidence of extrarenal spread has also been reported. The existence of this entity, however, has been questioned, because the kidneys do not normally contain lymphoid tissue. Renal involvement is rare in leukemias, and in some leukemias, renal dysfunction is usually found during the blastic crisis. Renal infiltration of leukemic cells has been recognized in some patients. In addition, some types of hematological neoplasia are associated with severe hypercalcemia that can lead to nephrocalcinosis. Renal involvement is one of the major manifestations of multiple myeloma (MM) and is an important cause of renal failure in the elderly. Renal failure occurs in more than 50 of MM patients, and is usually caused by the so-called myeloma kidney. Tumor lysis syndrome (TLS) is an oncological emergency characterized by a combination of metabolic disorders observed at the start of treatment of hematological malignancies. TLS may also be associated with the advancement of aggressive lymphomas and leukemias. The syndrome is frequently associated with renal dysfunction. Bone marrow transplantation for treatment of selected hematological neoplasms can be complicated by renal failure resulting from a variety of causes. Early renal injury most often results from infection and its subsequent treatment. Late renal injury after bone marrow transplantation, characterized by a syndrome similar to the hemolytic uremic syndrome, is called bone marrow transplant (BMT) nephropathy. This article reviews the clinical and pathological features of renal injury in hematological malignancies. © 2011 The Hong Kong Society of Nephrology. |
0 | Prediction of bone strength from cancellous structure of the distal radius: can we improve on DXA? | Distal Radius Fractures | Recent studies show that structural parameters of bone, obtained from computerized image analysis of radiographs, can improve the noninvasive determination of bone strength when used in conjunction with bone density measurements. The present study was designed to assess the ability of image features alone to predict the mechanical characteristics of bones. A multifactorial model was used to incorporate simultaneously a number of characteristics of the image, including periodicity and spatial orientation of the trabeculae. Fifteen pairs (29 specimens) of unembalmed human distal radii were used. The cancellous bone structure was determined using computerized spectral analysis of their radiographic images and the bones were tested to failure under compression. Multilayered perceptron neural networks were used to integrate the various image parameters reflecting the periodicity and the spatial distribution of the trabeculae and to predict the mechanical strength of the specimens. The correlation between each of the isolated image parameters and bone strength was generally significant, but weak. The values of mechanical parameters predicted by the neural networks, however, had a very high correlation with those observed, namely 0.91 for the load at fracture and 0.93 for the ultimate stress. Both these correlations were superior to those obtained with dual-energy X-ray absorptiometry and with the cross-sectional area from CT scans: 0.87 and 0.49 respectively. Our observation suggests that image parameters can provide a powerful noninvasive predictor of bone strength. The simultaneous use of various parameters substantially improved the performance of the system. The multifactorial architecture applied is nonlinear and possibly more effective than traditional multicorrelation methods. Further, this system has the potential to incorporate other non-image parameters, such as age and bone density itself, with a view to improving the assessment of the risk of fracture for individual patients. |
0 | Clinical features and survival analysis of different subtypes of patients with breast cancer brain metastases | MSTS 2018 - Femur Mets and MM | BACKGROUND AND OBJECTIVE: The brain is one of the most common metastatic sites of breast cancer. Brain metastases develop in 10%-15% of patients with breast cancer and are associated with poor prognosis. The purpose of this retrospective study was to analyze the clinical characteristics and survival of patients with brain metastases due to breast cancer of different subtypes and to identify the prognostic factors that affect clinical outcome.
METHODS: A total of 89 patients with breast cancer brain metastases diagnosed between October 1997 and July 2008 at Sun Yat-sen University Cancer Center were included in this study. Among the 89 patients, the number of luminal A, luminal B, human epidermal growth factor receptor 2 (HER-2), and triple-negative (TN) subtypes were 30, 20, 16, and 14, respectively; 9 patients had an unknown subtype. The clinical characteristics, pathologic features, and prognostic factors were analyzed both at the initial diagnosis and at the diagnosis of brain metastases. Endocrine therapy for patients with luminal subtypes was further studied.
RESULTS: The median age of patients was 46 years (range 28-74 years). The median survival time was 8.0 months (range, 0-80 months), the 1-year survival rate was 32% and the 5-year survival rate was 4%. The time to brain metastasis differed according to clinical stage at the initial diagnosis, and the time for patients with the luminal A subtype was the longest (P < 0.001). Multivariate analysis demonstrated that performance status score > 1, multiple brain metastases and without whole brain radiotherapy (WBRT) in combination with chemotherapy were associated with poor prognosis. Compared with the luminal A subtype, features of the HER-2 and TN subtypes included early metastases, rapid progression after first-line treatment (8.0 months vs. 11.0 months), and poor overall survival (25.0 months vs. 63.0 months). The luminal A subtype showed a tendency for good prognosis and slow growth. Tamoxifen could improve the survival of luminal A/B subtypes (median survival 24.0 months vs. 7.0 months, respectively, P = 0.002).
CONCLUSIONS: The prognosis of brain metastases from breast cancer was poor, especially in patients with HER-2 and TN subtypes. Generally, WBRT in combination with chemotherapy was the standard treatment modality. Patients with the luminal subtypes could benefit from tamoxifen. |
0 | Nonpharmacological approaches to improve bone health and reduce osteoporosis | Management of Hip Fractures in the Elderly | PURPOSE OF REVIEW: With an aging population, osteoporosis has become a public health concern and an area of increased awareness among both patients and medical practitioners. Timely screening and pharmacologic treatment of low bone mass effectively reduces fracture risk. Nonpharmacologic interventions, however, deserve equal emphasis both in the prevention and treatment of osteoporosis. RECENT FINDINGS: Recent advances in bone biology have established that exercise in the form of short, repetitive mechanical loading leads to the greatest gains in bone strength. As demonstrated by both observational and randomized exercise intervention trials, these gains are best achieved in childhood but can be maintained in adulthood with continued regular weight-bearing exercise. In the later years, evidence supports the implementation of balance training to decrease fall risk, especially in elderly patients with low bone mass. Following an osteoporotic fracture, a multidisciplinary rehabilitation program with an emphasis on early mobilization, fall prevention, use of orthoses, and noninvasive surgical procedures is emerging as a promising approach. SUMMARY: Clinically, these findings should imply greater emphasis on high impact exercise during skeletal growth and on maintenance of weight bearing and balance training in the later years. Future research should examine the effect of these interventions on fracture prevention |
0 | Pilon fractures: Assessment and treatment | DoD LSA (Limb Salvage vs Amputation) | The treatment of high-energy intra-articular fractures of the tibial plafond involves many potential complications. A protocol, which includes immediate ORIF of the fractured fibula and the application of a spanning external fixator followed by delayed ORIF of the tibia, has been developed. This protocol recognizes the importance of the surrounding soft tissues and is based on sound principles and thorough clinical experience. This protocol allows the soft tissues to recover before definitive fixation of the tibia is undertaken and permits early mobilization of the ankle joint during the healing process. This protocol avoids prolonged use of the external fixation, therefore minimizing the risks of pin-site infection and joint stiffness. The use of this protocol appears more widely accepted for treatment of pilon fractures as treatment now turns towards ORIF and away from the use of external fixators. |
0 | Predictors of Delirium in Octogenarian Patients Hospitalized for a Hip Fracture | Hip Fx in the Elderly 2019 | INTRODUCTION: Since delirium is a major complication that can arise after a patient with a hip fracture has been hospitalized, it is considered to be one of the most common geriatric conditions. Therefore, its prevention and early detection are essential for reducing both the length of the patient's stay in the hospital and complications during the hospitalization process.
OBJECTIVE: To identify and analyze the predictors for developing delirium in octogenarians who were admitted to hospital for a hip fracture.
METHODOLOGY: A prospective study conducted with a sample of 287 patients aged 80 years and older (mean age 87.2 +/- 3.2 years; 215 women, 72 men), recruited from the Trauma Unit of the University Hospital of Leon (Spain). Further, 71.1% of the patients lived in a family member's home, while the other 28.9% lived in a nursing home. After observing each patient's interactions with their doctor in a clinical setting, the data for this study were obtained by reviewing the selected patients' charts. The variables analyzed were sociodemographic information (age, sex, and place of residence), medical information (type of hip break and surgical intervention), cognitive impairment (MMSE score), functional level (Barthel Index score), and clinical information (pharmacological, comorbidities, complications, and the diagnosis and assessment of the severity of delirium in a patient). The univariate and multivariate logistic regression analysis showed a significant relationship between acute confusional state and the following variables: anemia, American Society of Anesthesiologists (ASA) III and IV patients, state of cognitive frailty and functional level, a urinary tract infection, changes in the visual field, renal arterial occlusion, and the type and dosage of drugs administered (this variable was identified in the multivariate model). The inverse relationship between anemia and acute confusional state is surprising.
CONCLUSION: This research shows that clinical observation of acute confusional state is necessary but not sufficient for addressing this condition early and adequately in older adults who have been hospitalized for a hip fracture. |
0 | Single-Injection Adductor Canal Block With Multiple Adjuvants Provides Equivalent Analgesia When Compared With Continuous Adductor Canal Blockade for Primary Total Knee Arthroplasty: A Double-Blinded, Randomized, Controlled, Equivalency Trial | AAHKS (2) Corticosteroids | BACKGROUND: Peripheral nerve blockade is used to provide analgesia for patients undergoing total knee arthroplasty. This study compared a single-injection adductor canal block (SACB) with adjuvants to continuous adductor canal blockade (CACB). The hypothesis was that the 2 groups would have equivalent analgesia at 30 hours after neural blockade.
METHODS: This was a double-blinded, randomized, controlled, equivalency trial. Sixty patients were randomized to either the SACB group (20 mL of 0.25% bupivacaine, 1.67 mcg/mL of clonidine, 2 mg of dexamethasone, 150 mcg of buprenorphine, and 2.5 mcg/mL of epinephrine) or the CACB group (20 mL 0.25% of bupivacaine injection with 2.5 mcg/mL of epinephrine followed by an 8 mL/h infusion of 0.125% bupivacaine continued through postoperative day 2). The primary outcome was movement pain scores at 30 hours using the numeric rating scale (NRS). The secondary outcomes included serial postoperative NRS pain scores (rest and movement every 6 hours), opioid consumption, time to first opioid administration, ability to straight leg raise, patient satisfaction, length of stay, and the incidence of nausea/vomiting.
RESULTS: An intention-to-treat analysis included 59 patients. The NRS pain scores with movement were equivalent at 30 hours (SACB 5.5 +/- 2.8 vs CACB 5.7 +/- 2.9 [mean NRS +/- standard deviation]; mean difference 0.2 [-1.5 to 1.0 {90% confidence interval}]). All NRS pain scores were equivalent until 42 hours (rest) and 48 hours (rest and movement) with the CACB group having lower pain scores. Other secondary outcomes were not statistically different.
CONCLUSION: An SACB provides equivalent analgesia for up to 36 hours after block placement when compared with a CACB for patients undergoing total knee arthroplasty, though a CACB was favored at 42 hours and beyond. |
0 | Laser-assisted arthroscopic ulnar shortening | DOD - Acute Comp Syndrome CPG | The purpose of this study is to evaluate arthroscopic ulnar shortening with the holmium: yttrium-aluminum-garnet (Ho:YAG) laser for the treatment of ulnocarpal abutment syndrome (UAS). This is a retrospective review of the experience of a single surgeon using this technique between 1994 and 2000. Unloading the ulnocarpal joint is the recognized treatment of UAS. Ulnar shortening via a diaphyseal osteotomy and plating (USO) has been used with good results; however, nearly 50% of patients will require hardware removal. Researchers have reported similar results between open distal ulnar resection (the wafer procedure) and USO for the treatment of UAS. Researchers have also reported similar results with mechanical arthroscopic distal ulnar resections (arthroscopic wafer distal ulnar resection [AWP]) for UAS. Eleven patients who underwent Ho:YAG laser-assisted arthroscopic distal ulnar resection were retrospectively evaluated. The average follow-up time was 31 months, with a range of 7 to 61 months. Evaluation using Darrow's criteria revealed 64% excellent (7 of 11), 18% good (2 of 11), 9% fair (1 of 11), and 9% poor (1 of 11) results. The average return to work time was 4.7 months, with a range of 1.5 to 16 months. Complications included 1 repeat surgery for ulnocarpal scar formation, 2 cases of transient tendonitis, and 1 portal site erythema without drainage that was treated with antibiotics. One patient (the one with a poor result) has not returned to work for unrelated reasons, Ï?-square analysis (P < .05) was unable to identify a statistical difference between the reported results of arthroscopic wafer procedures, USOs, and open wafer procedures. We concluded that Ho:YAG laser-assisted arthroscopic ulna shortening procedures show similar results to those reported for arthroscopic wafer procedures, open wafer procedures, and USOs. Return to work times are similar to those reported by other researchers, as is the return to preoperative occupation rate. There is no need for late removal of hardware, as is sometimes associated with USO. Our experience has been that the Ho:YAG laser removes hyaline cartilage and subchondral bone rapidly and with little debris, and thus facilitates the ulna shortening procedure. |
1 | Ultrasound-guided suprainguinal fascia iliaca compartment block versus periarticular infiltration for pain management after total hip arthroplasty: a randomized controlled trial | AAHKS (8) Anesthetic Infiltration | BACKGROUND AND OBJECTIVES: Fascia iliaca compartment block (FICB) has been shown to provide excellent pain relief in patients undergoing total hip arthroplasty (THA). However, the analgesic efficacy of FICB, in comparison with periarticular infiltration (PAI) for THA, has not been evaluated. This randomized, controlled, observer-blinded study was designed to compare suprainguinal FICB (SFICB) with PAI in patients undergoing THA via posterior approach.
METHODS: After institutional review board approval, 60 consenting patients scheduled for elective THA were randomized to one of two groups: ultrasound-guided SFICB block or PAI. The local anesthetic solution for both the groups included 60 mL ropivacaine 300 mg and epinephrine 150 micro g. The remaining aspects of perioperative care, including general anesthetic and non-opioid multimodal analgesic techniques, were standardized. An investigator blinded to group allocation documented pain scores at rest and with movement and supplemental opioid requirements at various time points. Patients were evaluated for sensory changes and quadriceps weakness in the operated extremity.
RESULTS: There were no differences between the groups with respect to demographics, intraoperative opioid use, duration of surgery, recovery room stay, nausea scores, need for rescue antiemetics, time to ambulation and time to discharge readiness as well as 48 hours postoperative opioid requirements. The pain scores at rest and with movement also were similar at all time points. Significantly more patients in the SFICB group experienced muscle weakness at 6 hours after surgery.
CONCLUSIONS: Under the circumstances of our study, in patients undergoing THA, SFICB provided the similar pain relief compared with PAI, but was associated with muscle weakness at 6 hours postoperatively.
Trial registration number: Nct02658240. |
1 | Autologous blood use in reduction mammaplasty: is it justified? | Reduction Mammoplasty for Female Breast Hypertrophy | A study was undertaken to evaluate the current use of autologous blood predonation within 3 weeks of reduction mammaplasty in our institution. A retrospective study of 153 consecutive patients undergoing reduction mammaplasty between April of 1987 and October of 1992 was analyzed. Nine patients were excluded because of inadequate data, leaving 81 patients in the autologous blood predonation study group and 63 patients in the control group. The two groups were similar with regard to age, preintervention hemoglobin levels, technique of reduction mammaplasty, average number of grams excised per side, estimated blood loss, and duration of hospital stay. Those in the study group, despite preoperative iron therapy initiated just prior to the time of autologous blood donation, had significantly lower preoperative hemoglobin levels (p < 0.001). Seventy-two percent of those patients who donated blood preoperatively received all their blood intraoperatively or within 1 day of surgery. Eleven percent received 1 of their 2 units donated, and the remaining 17 percent were not transfused. Despite 83 percent of the study group patients receiving all or some of their predonated blood, their postoperative hemoglobin levels were not significantly different from those of the control group. We concluded that under our current program, autologous blood predonation for reduction mammaplasty is not beneficial to the patient in the immediate perioperative period. |
0 | Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy-A prospective study | Panniculectomy & Abdominoplasty CPG | BACKGROUND: Both physiologic and excisional procedures have been described for the treatment of lymphedema. However, there exist few reports that combine these procedures. The objective of this study was to evaluate the effectiveness of combining vascularized lymph node transfer (VLNT) with suction-assisted lipectomy (SAL) in a staged manner for the treatment of extremity lymphedema. METHODS: Patients with unilateral late stage II lymphedema (International Society of Lymphology), who consented to staged surgical treatment, were evaluated prospectively. Between 2014 and 2015, 12 female patients with upper (n = 6) or lower (n = 6) extremity lymphedema completed the treatment protocol. Primary outcomes evaluated included limb size and number of infectious episodes. In addition, compression garment usage was analyzed. RESULTS: The overall circumference reduction rate was on average 37.9% after VLNT and increased to 96.4% after SAL. While all patients had experienced at least one infectious episode prior to surgical treatment, only one patient did so after VLNT and none after SAL. All patients were able to eventually discontinue compression therapy. CONCLUSION: VLNT followed by SAL can allow patients with late Stage II lymphedema achieve near normal limb size and eradication of infectious episodes. At follow-up, these desirable outcomes were maintained well after discontinuation of compression therapy. |
0 | The science of bone cement: A historical review | Surgical Management of Osteoarthritis of the Knee CPG | The use of PMMA bone cement has been a key factor in the advent of joint replacement as a surgical option. Despite revolutionary changes in joint replacement technology for the treatment of hip and knee arthritis, the use of PMMA bone cement in its intraoperative application has not significantly changed since Harris' description of third generation cement technique. Future answers to questions regarding cemented implant longevity may lie in the further improvement of existing PMMA technology and standardization of the manufacturing of PMMA bone cement intraoperatively |
0 | Prosthesis survivorship and clinical outcome of the Austin Moore hemiarthroplasty: An 8-year mean follow-up of a consecutive series of 500 patients | Management of Hip Fractures in the Elderly | The results of a consecutive series of 500 patients treated with Austin Moore hemiarthroplasty prosthesis are reported. The range of follow-up was from 5-12 years and the mean was 8 years. Only 10 patients were lost to follow-up and 398 (81%) patients died within the follow-up period. The mean age of the patient population was 82 years, and 85% were women. The cumulative survivorship of the prosthesis was calculated at 94% (95% CI 90-96%) at 5 years and 83% (95% CI 65-94%) at 12 years. A total of 66 secondary operations of any type were required in 46 (9%) patients. Revision of the Austin Moore prosthesis was performed in 23 cases (5%). Of the long-term survivors contacted for follow-up, 66 (81%) had no pain or minimal pain, whilst 5 (6%) reported constant pain in the hip. The revision rates in our series were higher for younger patients, those from their own home and with good pre-fracture mobility and mental function. For the frail elderly with a displaced intracapsular fracture this prosthesis can still be recommended. This paper presents the largest consecutive series, with the longest follow-up, currently available |
1 | The health burden of breast hypertrophy | Reduction Mammoplasty for Female Breast Hypertrophy | Women seeking consultation for the surgical relief of symptoms associated with breast hypertrophy have been the focus of many studies. In contrast, little is known about those women with breast hypertrophy who do not seek symptomatic relief. The purpose of this study was to describe the health burden of breast hypertrophy by using a set of validated questionnaires and to compare women with breast hypertrophy who seek surgical treatment with those who do not. In addition, this latter group was compared with a group of control women without breast hypertrophy. Women seeking consultation for surgery were recruited from 14 plastic-surgery practices. Control subjects were recruited by advertisements in primary-care offices and newspapers. Women were asked to complete a self-report questionnaire that included the European Quality of Life (EuroQol) questionnaire, McGill Pain Questionnaire, Multidimensional Body Self Relations Questionnaire (MBSRQ), the Short Form-36 (SF-36) questionnaire, and questions regarding breast-related symptoms, comorbidities, and bra size. Descriptive statistics were compiled for three groups of women: (1) hypertrophy patients seeking surgical care, (2) hypertrophy control subjects (those whose reported bra-cup size was a D or larger), and (3) normal control subjects (those whose reported bra-cup size was an A, B, or C). The multiple linear regression method was used to compare the health burdens across groups while adjusting for other variables. Two hundred ninety-one women seeking surgical care and 195 control subjects were enrolled in the study. The 184 control subjects with bra-cup information available were further separated into 88 hypertrophy control subjects and 96 normal control subjects. In the control group, bra-cup size was correlated with health-burden measures, whereas in the surgical candidates, it was not. When scores were compared across the three groups, significant differences were found in all health-burden measures. The surgical candidates scored more poorly on the EuroQol utility, McGill pain rating index, MBSRQ appearance evaluation, physical component scale of the SF-36, and on breast symptoms than did the two control groups. In addition, the hypertrophy control subjects scored more poorly than the normal control subjects. With multiple linear regression analysis incorporating important potential confounders, the poorer scores in the surgical candidates remained statistically significant. It was concluded that breast hypertrophy in those seeking surgical care and those not seeking surgery has a significant impact on women's quality of life as measured by validated and widely used self-report instruments including the EuroQol, MBSRQ, McGill Pain Questionnaire, and the SF-36. Likewise, a new assessment instrument for breast-related symptoms also demonstrated greater symptomatology in women with breast hypertrophy. |
0 | Zoledronic acid: a review of its use in the management of bone metastases and hypercalcaemia of malignancy | MSTS 2018 - Femur Mets and MM | UNLABELLED: Zoledronic acid (Zometa) is an effective inhibitor of osteoclast-mediated bone resorption. Zoledronic acid demonstrated efficacy in the reduction of skeletalrelated events (SREs) in patients with multiple myeloma or bone metastases secondary to breast cancer, prostate cancer or other solid tumours, or hypercalcaemia of malignancy. Zoledronic acid was effective in patients with multiple myeloma or metastatic breast cancer with osteolytic or mixed bone lesions. The proportion of patients who experienced an SRE was similar during 12 months of treatment with zoledronic acid 4mg or pamidronic acid 90mg, but significantly fewer patients receiving zoledronic acid required radiotherapy to bone. Furthermore, in patients with breast cancer and osteolytic lesions, median time to a first SRE was more than 4 months longer with zoledronic acid than with pamidronic acid. In the multiple event analysis in a 12-month extension study (total study duration was 25 months) in patients with breast cancer, zoledronic acid was superior to pamidronic acid, with an 18% reduction in the risk of experiencing an SRE. Both drugs were associated with a slight reduction in pain. Zoledronic acid 4mg, compared with placebo, significantly reduced the proportion of patients with prostate cancer bone metastases experiencing an SRE, particularly pathological fractures after 15 months' treatment. The drug also significantly delayed the onset of skeletal complications compared with placebo in patients with prostate cancer and other solid tumours including non-small cell lung cancer. When administered as a single 15-minute intravenous infusion, zoledronic acid 4mg was significantly more effective than pamidronic acid administered as a 2-hour infusion in the treatment of severe hypercalcaemia of malignancy, as assessed by complete responses measuring normalised serum calcium concentrations at day 10 after a single dose. Furthermore, zoledronic acid normalised serum calcium concentrations significantly faster than pamidronic acid, and the duration of response and median time to relapse were approximately twice as long in zoledronic acid recipients than in pamidronic acid recipients. Zoledronic acid is well tolerated and has a similar tolerability profile to pamidronic acid. The most commonly reported adverse events included flu-like symptoms (fever, arthralgias, myalgias and bone pain), fatigue, gastrointestinal reactions, anaemia, weakness, dyspnoea and oedema.
CONCLUSION: In conjunction with antitumour therapy, zoledronic acid should be considered for routine use to reduce skeletal complications in patients with advanced malignancies involving bone. In patients with hypercalcaemia of malignancy, zoledronic acid is expected to become the treatment of choice. [References: 51] |
0 | Bone-preserving hip arthroplasties as an alternative to conventional hip replacement for young patients - A review article | Hip Fx: Early-Weight Bearing Search | Hip replacement is one of the most successful orthopedics' procedures in terms of restoring quality of life. In the past, indications for hip replacement were restricted to elderly people, but nowadays advances in bioengineering technology have driven development of hip implants with less wear and loosening and therefore with longer longevity. Early wear and loosening as well as stress shielding and bone preservation are considered as major issues especially when dealing with young patients. The main reason for this is the fact that younger patients might require one or more hip revision procedures during the course of their life due to their age and high activity level. Especially in young patients it could be an advantage to use primary implants that are more bone preserving and allow more physiological load transfer which cause no or minimal stress shielding at the proximal femur. The two options which exist today are hip resurfacing which preserves the femoral head and various short stem prostheses which transfer the forces in the femur more proximally and more physiologically. This review looks at the options which are available today in bone preserving hip arthroplasties. (copyright) 2010 World Scientific Publishing Company |
0 | Characterization of diabetic osteoarthritic cartilage and role of high glucose environment on chondrocyte activation: toward pathophysiological delineation of diabetes mellitus-related osteoarthritis | OAK 3 - Non-arthroplasty tx of OAK | OBJECTIVE: To examine the relationship between osteoarthritis (OA) and type 2 diabetes mellitus (DM).
METHODS: OA cartilage from DM and non-DM patients undergoing knee replacement were stimulated by IL-1beta for 24 h and release of interleukin-6 (IL-6) and prostaglandin E2 (PGE2) was measured. Primary cultured murine chondrocytes were stimulated for 24 and 72 h with or without IL-1beta (5 ng/mL) under normal-glucose (5.5 mM) or high-glucose (25 mM) conditions. The expression and release of pro-inflammatory mediators (IL-6, cyclooxygenase 2 [COX2]/PGE2) were analyzed by quantitative RT-PCR and ELISA/EIA. Glucose uptake was assessed with ((14)C)-2-deoxyglucose. Reactive oxygen species (ROS) and nitric oxide (NO) production were measured. To analyze the mechanism of IL-1beta-induced inflammation, cells were pretreated or treated with inhibitors of glucose transport (cytochalasin B), the polyol pathway (epalrestat), mitochondrial oxidative stress (MitoTEMPO) or nitric oxide synthase (l-NAME).
RESULTS: With IL-1beta stimulation, IL-6 and PGE2 release was greater in human DM than non-DM OA cartilage (2.7- and 3-fold, respectively) (P < 0.05). In vitro, with IL-1beta stimulation, IL-6 and COX2 mRNA expression, IL-6 and PGE2 release, and ROS and NO production were greater under high-than normal-glucose conditions in cultured chondrocytes. IL-1beta-increased IL-6 release was reduced with cytochalasin B, epalrestat, L-NAME or MitoTEMPO treatment (-45%, -62%, -38% and -40%, respectively).
CONCLUSION: OA cartilages from DM patients showed increased responsiveness to IL-1beta-induced inflammation. Accordingly, high glucose enhanced IL-1beta-induced inflammation in cultured chondrocytes via oxidative stress and the polyol pathway. High glucose and diabetes may thus participate in the increased inflammation in OA. |
0 | Single-dose cefuroxime with gentamicin reduces Clostridium difficile-associated disease in hip-fracture patients | Management of Hip Fractures in the Elderly | Antibiotic-associated Clostridium difficile diarrhoea may complicate recovery from surgery for proximal femoral fracture. We undertook a four-year case-control study to evaluate a change in antibiotic prophylaxis in our department. During the period January 2003 to January 2005, patients received three doses of prophylactic cefuroxime (1.5g). We then introduced a new regimen, comprising of one single dose of cefuroxime (1.5g) with gentamicin (240mg) at induction. Prior to the change in prophylaxis, 912 patients underwent surgery for neck of femur fracture, and from March 2005 to March 2007, 899 patients had surgery under the new regimen. Thirty-eight patients developed C. difficile infection (4.2%) in the initial group, compared with 14 patients (1.6%) in the group with the new regimen (P=0.009). The incidence of C. difficile infection increased throughout the rest of the hospital over the same time period. Patients with C. difficile infection had a statistically significant increase in antibiotic exposure, inpatient stay, morbidity and inpatient mortality. The main challenges regarding prophylactic antibiotic selection are infection due to meticillin-resistant Staphylococcus aureus (MRSA) and C. difficile-associated diarrhoea. We advocate the use of the new regimen as an alternative to multiple-dose cephalosporin antibiotics for the prevention of C. difficile infection in this group of high-risk patients |
0 | Fractures in patients with osteopetrosis, insights from a single institution | DoD SSI (Surgical Site Infections) | PURPOSE: Osteopetrosis is a hereditary skeletal disorder in which defective osteoclast function leads to abnormally hard and brittle bones. This study aims to describe the pattern of fractures occurring in this group of patients, possible complications, and strategies to avoid them.
METHODS: This is a case series of six osteopetrotic patients with a total of 12 fractures managed in our institution over a period of nine years. Patient records were also reviewed for complications both intra- and post-operatively.
RESULTS: The majority of the fractures involved the femur, with three of these being peri-implant in nature. Other bones involved include the tibia, humerus, patella, fifth metatarsal, and proximal phalanx of the toe. There was a high rate of complications while managing these patients: three patients had peri-implant stress fractures, three with retained broken screws, and one case each of delayed union, non-union, and surgical site infection.
CONCLUSION: Osteopetrosis fractures present a unique challenge to the orthopedic surgeon. Careful pre-operative planning should be undertaken before proceeding with surgery in these cases. |
0 | Incidence of complex regional pain syndrome type I after fractures of the distal radius | Distal Radius Fractures | Aim of this study was to analyse the incidence CRPS-I after a fracture of the distal radius and to analyse risk factors. Patients who visited the Emergency Unit of the University Hospital, with a fracture of distal radius were asked to participate. As risk factors for CRPS-I, number of repositions (with or without local anaesthesia), additional cast changes and pain during the cast period, were assessed. In a structured interview social life events (SLEs) and psychological and/or psychiatric history were assessed. The patients filled out the Symptom Checklist-90 (SCL-90). In total 88 patients participated in the study. One female (1%, 95% CI: 0.2 to 6%), age 69 years with the following characteristics developed CRPS-I: one set of local anaesthetics, one repositioning attempt, no additional cast changes, average pain scores, no life events and her total score on the SCL-90 of 117, was slightly above average. Based on the results of this study it is concluded that the incidence of CRPS-I may be low (1%, 95% CI: 0.2 to 6%) after fractures of the distal radius. Further the risk factors described in literature play a minor role in the development of CRPS-I. |
1 | Efficacy and safety of intravenous bisphosphonates beyond two years | MSTS 2018 - Femur Mets and MM | Background: Metastatic bone disease, a common complication of malignancy, causes significant morbidity in affected patients. Intravenous bisphosphonates (IBPs) have shown efficacy in preventing skeletal morbidity, however few studies have investigated their efficacy and safety in cancer patients beyond 2 years of use. This retrospective study documents long term clinical use of IBPs among a variety of patient populations and clinical settings. Methods: This study is a multi-center retrospective chart review of patients who received IBPs (Pamidronate or Zoledronic Acid) for more than 24 months. Patients were at least 18 years of age and had tumor-associated bone disease. Data analysis focused on skeletal related events (SREs) and drug related toxicities such as renal failure and osteonecrosis of the jaw (ONJ). Results: Ninety-two patients were included with the most common diagnosis being multiple myeloma. A total of 44 SREs occurred among 23 patients. Mean time to first SRE was 515 days. The rate of skeletal events in the first 2 years of treatment was 0.70, while skeletal morbidity rate (SMR) in subsequent years was 0.16. Thirteen patients experienced renal toxicity; most patients' renal function normalized after brief or permanent cessation of IBP therapy. ONJ was associated with 5 patients. Conclusion: Continuation of IBP therapy for skeletal metastasis after 2 years of treatment may improve skeletal morbidity. Similar to the first 2 years of treatment, significant toxicities such as renal failure and ONJ are uncommon. © Internet Scientific Publications, LLC. |
0 | How often is functional range of motion obtained by manipulation for stiff total knee arthroplasty? | Surgical Management of Osteoarthritis of the Knee CPG | Purpose: To evaluate how often manipulation under anesthesia (MUA) can achieve functional flexion (greater-than or equal to) 90 degrees and identify predictor for successful outcome of MUA for stiff total knee arthroplasty (TKA). Methods: Demographic data, range of motion, and surgical and anesthetic information of 143 MUAs were retrospectively analyzed from 2000 to 2011. Results: One-hundred thirty-six out of 143 patients (95 %) improved mean range of motion (ROM) from pre-MUA 62 (plus or minus) 17(degrees) to final ROM 101 (plus or minus) 21(degrees) (p < 0.001). Flexion (greater-than or equal to) 90 degrees was achieved in 74% (106/143) of patients. Regional anesthesia was identified as predictor of successful MUA outcome (p = 0.007, OR: 8.5, 95 % CI: 1.2-66.7). Conclusions: Although the proportion of patients regaining flexion (greater-than or equal to) 90 degrees following MUA was less than those patients with simple overall ROM increase, the functional flexion (greater-than or equal to) 90 degrees was achieved in the vast majority of patients with stiff TKA following MUA. (copyright) 2014 SICOT aisbl |
0 | Simple in situ decompression for idiopathic cubital tunnel syndrome using minimal skin incision | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Cubital tunnel syndrome is one of the most frequently occurring compression neuropathy in the upper limb next to carpal tunnel syndrome. Recent minimal invasive technique has prompted us to gain clinical experience with simple in situ decompression with minimal skin incision for idiopathic cubital tunnel syndrome. Sixty six consecutive patients with cubital tunnel syndrome were treated using minimal skin incision technique. The mean age of the patients was 49.7 (range: 15-77) years and average follow up period was 23.9 months (range: 12-60 months). The severity of ulnar neuropathy was classified according to the McGowan classification: there were 17 in grade I, 47 in grade II and 2 in grade III. A preoperative nerve conduction study was done by inching method, which revealed motor conduction delay around the medial epicondyle. All operations were carried out in a day surgery unit under local anesthetics. The postoperative outcome was evaluated by Messina classification. The mean duration of the operation was 12 minutes. The technique was highly satisfactorily esthetic for all. Over 80% of the patients were completely satisfied with the procedure taking into consideration their symptoms. Postoperative outcome measures and patient satisfactions (pain, return to normal activities and work, scar and pillar tenderness) were comparable with published series of anterior transposition. The overall satisfactory results were recorded 81% in the patients of McGowan stage I and II. There were 2 cases of hematoma as a postoperative complication. This procedure is comparably effective alternative which involves less surgical trauma, morbidity and rehabilitation time with good surgical outcomes especially in mild and moderate degrees. Minimal skin incision is a simple, safe and effective method to treat patients with idiopathic cubital tunnel syndrome |
0 | Return to Play in National Football League Players After Operative Jones Fracture Treatment | DoD SSI (Surgical Site Infections) | BACKGROUND: Jones fractures commonly occur in professional athletes and operative treatment remains the standard of care in this patient population. In our clinical experience, an aggressive postoperative rehabilitation protocol for National Football League (NFL) players with an average return to play (RTP) between 8 and 10 weeks can have successful outcomes with few complications. The purpose of this study was to quantify RTP and rate of complications, including nonunion, refracture, and reoperation among a cohort of NFL players with operatively treated Jones fractures.
METHODS: Between 2004 and 2014, 25 consecutive NFL players who underwent acute Jones fracture fixation by a single surgeon were reviewed. Operative treatment for the majority of patients involved fixation with a Jones-specific intramedullary screw and iliac crest bone marrow aspirate with demineralized bone matrix injected at the fracture site. Additionally, our protocol involved the use of noninvasive bone stimulators, application of customized orthoses, and an aggressive patient-specific rehabilitation protocol. Patient demographics were recorded along with position played, seasons played after surgery, RTP, and complications. RTP was defined as the ability to play in a single regular-season NFL game after surgery. At the time of surgery, average age for all patients was 24.0 years and BMI 31.0.
RESULTS: Player positions included 8 wide receivers, 4 linebackers, 4 tight ends, 2 defensive tackles, 2 cornerbacks, 1 offensive tackle, 1 center, 1 tackle, 1 defensive end, and 1 quarterback. Seventy-six percent of players underwent operative fixation during their first 3 seasons. Forty-eight percent were diagnosed before or during their rookie (first) season.RTP was 100% for all players and 80% were still playing at time of publication. Three patients (12.0%) refractured and required revision surgery. Time until RTP was influenced by other variables and difficult to measure because many surgeries were performed early in the offseason. All 9 players who underwent surgery between July and October, and were therefore eligible to return to play in the same season, had an average RTP of 8.7 weeks (range 5.9-13.6).
CONCLUSION: With an appropriately placed intramedullary screw and an aggressive rehabilitation protocol, early RTP was achievable with a low refracture rate in professional athletes. All NFL players in this series were able to return to play after surgery. We observed that these injuries were more likely to occur in the first 3 seasons of play and in wide receivers, linebackers, and tight ends. This at-risk subset of players may benefit from improved preventative measures.
LEVEL OF EVIDENCE: Level IV, retrospective case series. |
0 | High levels of osteoprotegerin and soluble receptor activator of nuclear factor kappa B ligand in serum of rheumatoid arthritis patients and their normalization after anti-tumor necrosis factor alpha treatment | Surgical Management of Osteoarthritis of the Knee CPG | OBJECTIVE: To test the hypotheses that 1) proinflammatory cytokines affect osteoprotegerin (OPG) and soluble receptor activator of nuclear factor kappa B ligand (sRANKL) production and therefore the OPG and sRANKL levels differ in rheumatoid arthritis (RA) patients in comparison with healthy individuals; and 2) anti-tumor necrosis factor alpha (anti-TNF alpha) therapy influences OPG and sRANKL levels. METHODS: Sera were obtained from healthy individuals or RA patients receiving the combination of infliximab and methotrexate. Peripheral blood mononuclear cells (PBMCs) and synovial fluid mononuclear cells (SFMCs) were isolated from RA patients. Fibroblast-like synoviocytes (FLS) were isolated from synovial tissue obtained at total knee replacement in RA patients. Supernatants from cells stimulated with cytokines were collected after culture in vitro. Concentrations of OPG and sRANKL were determined by enzyme-linked immunosorbent assays. RESULTS: A strong positive correlation between OPG concentration and age was observed in healthy individuals but not in RA patients. The OPG and sRANKL levels were higher in RA patients than in healthy controls. Cultured FLS spontaneously secreted much higher amounts of OPG than PBMCs or SFMCs. Proinflammatory cytokines enhanced OPG production. Anti-TNF alpha treatment resulted in the normalization of serum OPG and sRANKL levels in RA patients without influencing the OPG:sRANKL ratio. CONCLUSION: Although higher serum levels of OPG and sRANKL are present in RA patients than in healthy individuals, the ratio of OPG:sRANKL is similar. There is an age-dependent increase of OPG but not sRANKL levels in healthy subjects. Anti-TNF alpha treatment results in the normalization of elevated levels of OPG and sRANKL in RA patients |
0 | Assessing the impact of osteoporosis on the burden of hip fractures | Management of Hip Fractures in the Elderly | The aim of the study was to determine the number of hip fractures within defined countries for 2010 and the proportion attributable to osteoporosis. The number of incident hip fractures in one year in countries for which data were available was calculated from the population demography in 2010 and the age- and sex-specific risk of hip fracture. The number of hip fractures attributed to osteoporosis was computed as the number of hip fractures that would be saved assuming that no individual could have a femoral neck T-score of less than -2.5 SD (i.e., the lowest attainable T-score was that at the threshold of osteoporosis (=-2.5 SD). The total number of new hip fractures for 58 countries was 2.32 million (741,005 in men and 1,578,809 in women) with a female-to-male ratio of 2.13. Of these 1,159,727 (50 %) would be saved if bone mineral density in individuals with osteoporosis were set at a T-score of -2.5 SD. The majority (83 %) of these "prevented" hip fractures were found in men and women at the age of 70 years or more. The 58 countries assessed accounted for 83.5 % of the world population aged 50 years or more. Extrapolation to the world population using age- and sex-specific rates gave an estimated number of hip fractures of approximately 2.7 million in 2010, of which 1,364,717 were preventable with the avoidance of osteoporosis (264,162 in men and 1,100,555 in women). We conclude that osteoporosis accounts for approximately half of all hip fractures. Strategies to prevent osteoporosis could save up to 50 % of all hip fractures. (copyright) 2012 Springer Science+Business Media New York |
0 | Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate | Management of Hip Fractures in the Elderly | The results were retrospectively analyzed of 47 subtrochanteric fractures of the femur treated with a 95 degrees condylar blade-plate to establish whether two different surgical techniques yielded different results. Before 1981, treatment consisted of extensive visualization of the fracture lines, permitting anatomic reduction of all fragments, stable internal fixation with the blade-plate, and optional autologous bone grafting as recommended by the AO group. Twenty-four fractures were treated accordingly and constituted Group I of this study. In 1981, visualization of the fracture lines was abandoned, especially at the medial cortex; an indirect reduction technique was used to gain optimal alignment and stability without aiming at anatomic reduction, and bone grafting was discontinued. Twenty-three patients were treated accordingly and constituted Group II. The use of prophylactic antibiotics as a routine for all major trauma was instituted at the time the surgical technique was changed. Thus, only two of the 24 patients in Group I received antibiotics as opposed to 20 of the 23 patients in Group II. Average time to bony union for those fractures that healed primarily was 5.4 months in Group I and 4.2 months in Group II. Delayed or nonunion was 16.6% in Group I and 0% in Group II, and the infection rate was 20.8% versus 0% in the two groups. The four cases with a delayed union were aseptic, but three of the four nonunions were infected. The functional end result was comparable for both groups.(ABSTRACT TRUNCATED AT 250 WORDS) |
0 | Current perception threshold for assessment of the neurological components of hand-arm vibration syndrome: a review | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Current perception threshold (CPT) has been proposed as a quantitative method for assessment of peripheral sensory nerve function. The aim of this review of selected reports is to provide an overview of CPT measurement for the assessment of the neurological component of hand-arm vibration syndrome (HAVS). The CPT values at 2000 Hz significantly increased for patients with HAVS. This result supports the previous histological findings that demyelination is found predominantly in the peripheral nerves in the hands of men exposed to hand-arm vibration. Diagnostic sensitivity and specificity were high for severe cases of Stockholm sensorineural (SSN) stage 3 compared with non-exposed controls, but not high for mild cases of SSN stage 1 or 2 and for carpal tunnel syndrome associated with HAVS. However, there are only a few studies on the diagnostic validity of the CPT test for the neurological components of HAVS. Further research is needed and should include diagnostic validity and standardizing of measurement conditions such as skin temperature |
0 | Augmentation of Achilles tendon repair with extracellular matrix xenograft: a biomechanical analysis | DoD LSA (Limb Salvage vs Amputation) | Achilles tendon rupture is a frequent injury in athletes and the general public. Cases of chronic rupture or poor tendon quality secondary to tendinopathy are challenging to repair primarily. Commercially available extracellular matrix materials have been utilized in recent years to augment tendon repair. Augmentation of Achilles tendon with extracellular matrix xenograft results in reduced repair site gapping and increased peak failure load in a cadaveric model featuring simulated physiologic loads. Controlled laboratory study. Ten matched pairs of fresh-frozen human lower extremities amputated just below the knee were obtained and each Achilles tendon was sharply tenotomized. One randomly selected specimen from each matched pair underwent Achilles repair using a 4-strand Krackow technique with extracellular matrix xenograft augmentation (TissueMend Soft Tissue Repair Matrix), while the opposite tendon underwent suture repair alone as a control. Each tendon was then subjected to 1000 sinusoidal tensile loading cycles to 86 N during which repair site gapping was monitored, followed by distraction to failure. One pair was used to evaluate the effects of graft orientation and not included in the analysis. Significantly less gapping was noted in the augmented tendon group at all time points after the 10th load cycle (P < .05). The mean repair site gapping after 1000 cycles of loading was 4.0 mm (range, 3.1-5.0 mm) in the augmented group and 6.5 mm (range, 4.1-8.6 mm) in the suture-only group. The ultimate failure load was 821 N (range, 613-1021 N) in the augmented group and 392 N (range, 322-481 N) in the suture-only group (P < .01). The augmentation of Achilles tendon repair with extracellular matrix xenograft decreases gapping and increases load to failure immediately after surgery in a cadaveric model. Tendon repair augmentation may allow more aggressive early rehabilitation, particularly in cases of chronic rupture or poor tendon quality. Further work is necessary to define indications for extracellular matrix graft augmentation of tendon repairs. |
1 | Acromion and glenoid shape: Why are they important predictive factors for the future of our shoulders? | Glenohumeral Joint OA | The shape of the acromion differs between patients with degenerative rotator cuff tears and individuals without rotator cuff pathology.It can be assessed in the sagittal plane (acromion type, acromion slope) and in the coronal plane (lateral acromion angle, acromion index, critical shoulder angle).The inter-observer reliability is better for the measurements in the coronal plane.A large lateral extension (high acromion index or high critical shoulder angle) and a lateral down-sloping of the acromion (low lateral acromion angle) are associated with full-thickness supraspinatus tears.The significance of glenoid inclination for rotator cuff disease is less clear.The postulated patho-mechanism is the compression of the supraspinatus tendon between the humeral head and the acromion. Bursal side tears might be caused by friction and abrasion of the tendon. Articular side tears could be due to impairment of the gliding mechanism between tendon fibrils leading to local stress concentration. Further research is needed to understand the exact pathomechanism of tendon degeneration and tear. Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160076. Originally published online at www.efortopenreviews.org. |
0 | The risk of injury to neurovascular structures from distal locking screws of the Unreamed Humeral Nail (UHN): A cadaveric study | The Treatment of Pediatric Supracondylar Humerus Fractures AUC | When performing distal interlocking of an intramedullary humeral nail, there is risk of iatrogenic injuring to the neurovascular structures. Our cadaveric study with frozen sections through the distal humerus presents the anatomic relationship of the different neurovascular bundles and the trajectories used for the implantation of the three distal interlocking screws of the AO-UHN. The middle lateromedial pin was in direct contact with the radial nerve in 3 out of 10 cases, with the ulnar nerve in 3 out of 10 cases and with the brachial artery in 1 out of 10 cases. We recommend using only the two anteroposterior screws for distal interlocking, avoiding the lateromedial locking option. If this lateromedial locking screw is needed to gain adequate stability, it should be introduced under visual control. (copyright) 2007 Elsevier Ltd. All rights reserved |
0 | Childhood maltreatment and migraine (part II). Emotional abuse as a risk factor for headache chronification | DoD PRF (Psychosocial RF) | OBJECTIVES: To assess in a headache clinic population the relationship of childhood abuse and neglect with migraine characteristics, including type, frequency, disability, allodynia, and age of migraine onset.
BACKGROUND: Childhood maltreatment is highly prevalent and has been associated with recurrent headache. Maltreatment is associated with many of the same risk factors for migraine chronification, including depression and anxiety, female sex, substance abuse, and obesity.
METHODS: Electronic surveys were completed by patients seeking treatment in headache clinics at 11 centers across the United States and Canada. Physician-determined data for all participants included the primary headache diagnoses based on the International Classification of Headache Disorders-2 criteria, average monthly headache frequency, whether headaches transformed from episodic to chronic, and if headaches were continuous. Analysis includes all persons with migraine with aura, and migraine without aura. Questionnaire collected information on demographics, social history, age at onset of headaches, migraine-associated allodynic symptoms, headache-related disability (The Headache Impact Test-6), current depression (The Patient Health Questionnaire-9), and current anxiety (The Beck Anxiety Inventory). History and severity of childhood (<18 years) abuse (sexual, emotional, and physical) and neglect (emotional and physical) was gathered using the Childhood Trauma Questionnaire.
RESULTS: A total of 1348 migraineurs (88% women) were included (mean age 41 years). Diagnosis of migraine with aura was recorded in 40% and chronic headache (>or=15 days/month) was reported by 34%. Transformation from episodic to chronic was reported by 26%. Prevalence of current depression was 28% and anxiety was 56%. Childhood maltreatment was reported as follows: physical abuse 21%, sexual abuse 25%, emotional abuse 38%, physical neglect 22%, and emotional neglect 38%. In univariate analyses, physical abuse and emotional abuse and neglect were significantly associated with chronic migraine and transformed migraine. Emotional abuse was also associated with continuous daily headache, severe headache-related disability, and migraine-associated allodynia. After adjusting for sociodemographic factors and current depression and anxiety, there remained an association between emotional abuse in childhood and both chronic (odds ratio [OR] = 1.77, 95% confidence intervals [CI]: 1.19-2.62) and transformed migraine (OR = 1.89, 95% CI: 1.25-2.85). Childhood emotional abuse was also associated with younger median age of headache onset (16 years vs 19 years, P = .0002).
CONCLUSION: Our findings suggest that physical abuse, emotional abuse, and emotional neglect may be risk factors for development of chronic headache, including transformed migraine. The association of maltreatment and headache frequency appears to be independent of depression and anxiety, which are related to both childhood abuse and chronic daily headache. The finding that emotional abuse was associated with an earlier age of migraine onset may have implications for the role of stress responses in migraine pathophysiology. |
1 | Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial | AMP (Acute Meniscal Pathology) | Importance: There is a paucity of high-quality evidence about the long-term effects (ie, 3-5 years and beyond) of arthroscopic partial meniscectomy vs exercise-based physical therapy for patients with degenerative meniscal tears.
Objectives: To compare the 5-year effectiveness of arthroscopic partial meniscectomy and exercise-based physical therapy on patient-reported knee function and progression of knee osteoarthritis in patients with a degenerative meniscal tear.
Design, Setting, and Participants: A noninferiority, multicenter randomized clinical trial was conducted in the orthopedic departments of 9 hospitals in the Netherlands. A total of 321 patients aged 45 to 70 years with a degenerative meniscal tear participated. Data collection took place between July 12, 2013, and December 4, 2020.
Interventions: Patients were randomly allocated to arthroscopic partial meniscectomy or 16 sessions of exercise-based physical therapy.
Main Outcomes and Measures: The primary outcome was patient-reported knee function (International Knee Documentation Committee Subjective Knee Form (range, 0 [worst] to 100 [best]) during 5 years of follow-up based on the intention-to-treat principle, with a noninferiority threshold of 11 points. The secondary outcome was progression in knee osteoarthritis shown on radiographic images in both treatment groups.
Results: Of 321 patients (mean [SD] age, 58 [6.6] years; 161 women [50.2%]), 278 patients (87.1%) completed the 5-year follow-up with a mean follow-up time of 61.8 months (range, 58.8-69.5 months). From baseline to 5-year follow-up, the mean (SD) improvement was 29.6 (18.7) points in the surgery group and 25.1 (17.8) points in the physical therapy group. The crude between-group difference was 3.5 points (95% CI, 0.7-6.3 points; P < .001 for noninferiority). The 95% CI did not exceed the noninferiority threshold of 11 points. Comparable rates of progression of radiographic-demonstrated knee osteoarthritis were noted between both treatments.
Conclusions and Relevance: In this noninferiority randomized clinical trial after 5 years, exercise-based physical therapy remained noninferior to arthroscopic partial meniscectomy for patient-reported knee function. Physical therapy should therefore be the preferred treatment over surgery for degenerative meniscal tears. These results can assist in the development and updating of current guideline recommendations about treatment for patients with a degenerative meniscal tear.
Trial Registration: ClinicalTrials.gov Identifier: NCT01850719. |
0 | Effects of dexamethasone on local infiltration analgesia in total knee arthroplasty: a randomized controlled trial | PJI DX Updated Search | PURPOSE: Intraoperative local infiltration analgesia has gained increasing popularity in joint replacement surgery. Because there is considerable variation among drug combinations, analgesic effects of each drug are not well understood. The purpose of this study was to clarify the efficacy of the addition of steroid to local anaesthetics in local infiltration analgesia during total knee arthroplasty. METHODS: Forty patients were randomly allocated to the steroid or control group. Patients in the steroid group received peri-articular injection of ropivacaine, dexamethasone and isepamicin, while dexamethasone was omitted from the analgesic mixture in the control group. Primary outcome was pain severity at rest using 100 mm visual analogue scale. RESULTS: Pain severity in the steroid group was lower than control group and there were significant differences between groups at post-operative day 1 and 3. Reduction in post-operative pain was associated with a decrease in serum C-reactive protein and interleukin 6 in drainage fluid. The number of patients who were able to perform straight leg raise within post-operative day 2 was 15/20 in the steroid group, which was significantly higher than the control group 5/20. CONCLUSION: Adding steroid to local anaesthetics in local infiltration analgesia reduced inflammation both locally and systemically, resulting in significant early pain relief and rapid recovery in total knee arthroplasty |
0 | Oral inflammation and bacteremia: implications for chronic and acute systemic diseases involving major organs | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | Gingivitis and periodontitis are both highly prevalent gum diseases characterized by an accumulation of a polymicrobial biofilm (dental plaque) around teeth and inflammation in adjacent soft tissues. During dental procedures, even tooth brushing, these bacteria and their components, such as endotoxin, can easily disseminate into the systemic circulation through minor or major gingival injuries. Particularly in immuno-compromised subjects or patients with preexisting pathologic conditions, bacteremia may lead to bacterial infection of distant organs, which may cause immunological reactions. Oral bacteria and endotoxins have been found in sepsis, infective endocarditis, lung infection, liver disease and many other potentially lethal disorders. This article presents a review of the possible pathologic consequences of bacteremia originating in the oral cavity and points out the most commonly affected organs as well as preventive and treatment measures. At the present time, plaque control by subjects and/or dental professionals is one of the most effective means to prevent the onset and progression of oral bacteremia-induced systemic diseases |
0 | Distal femoral osteotomy for genu valgus correction | Surgical Management of Osteoarthritis of the Knee CPG | Osteotomy is a classic operation for the treatment of unicompartimental osteoarthrosis of the knee. It has often been presented as a possible alternative to prosthetic joint replacement, but the indications depend on the stage and articular diffusion of the degenerative changes, on the associated pathology, and on the patient's profile. These are very different, in most cases, from the indications of uni or total knee replacement. A relatively new technique in performing the open-wedge distal femoral osteotomy for the correction of the genu valgus will be illustrated here, with particular attention given to a "step by step" description of the details of operation. Copyright (copyright) 2012 by Lippincott Williams & Wilkins |
0 | Early results with the Genesis II Posterior Stabilized High Flexion knee prosthesis. A one year follow-up study | Surgical Management of Osteoarthritis of the Knee CPG | The aim of this prospective study was to assess the range of motion (ROM) achieved with the Genesis II Posterior Stabilized High Flexion knee prosthesis. The ROM was compared with that of a historical study group with the standard PS insert and an identical study design. Sixty three patients with primary knee osteoarthritis (37 female, 26 male; average age: 67.0 years, average BMI 31.2) underwent primary cemented TKA with a PS high flex insert. The surgery was performed by one senior author using a mini-midvastus approach. During the follow-up no statistically significant difference in maximal flexion was found between 14 weeks (average flexion = 120 degrees, SD = 11.2) and 65 weeks postoperatively (average flexion = 122 degrees, SD = 8.9). The radiographic evaluation showed no influence of the implant positioning on the final flexion. Compared to the results obtained in a 5 year follow-up study of 100 cases in combination with the PS standard insert, the improvement in final flexion range found in this study did not appear not to be great enough to generally recommend the PS high flex insert in terms of a proven higher flexion result |
0 | Temperature of the human knee - A review | AAHKS (2) Corticosteroids | BACKGROUND: Temperature measurement of the knee joint has a long tradition in medical thermometry. However, neither a standard for recording knee temperature nor agreed values of knees in healthy subjects or in articular disease are available. AIM OF THE STUDY: To compute available data on knee temperature from the literature including the conditions of temperature recording, measurement sites and temperature values. METHOD: A literature search was performed in the databases Medline and Embase using the search terms "skin temperature" or "intra-articular temperature" and "knee". Only papers written in English or German related to humans were considered for inclusion. The following data were extracted from included papers: Surface (skin) temperature, intra-articular temperature, site of measurement for skin or intra-articular temperature, measurement device, number of investigated knees, diagnosis of investigated subjects, biographic data of investigated subjects, room temperature, time of acclimatisation. If possible, temperature values were pooled if they have been recorded under similar conditions. RESULTS: In total, the database included temperature measurements from 3463 knee joints, comprising data from 876 healthy subjects, 629 patients with osteoarthritis (OA), 512 patients with rheumatoid arthritis (RA), 67 patients with non rheumatoid and other non specified inflammatory arthritis have been investigated. 86 patients suffered from joint inflammation caused by trauma, and 96 patients had various injuries of ligaments and other fibro-cartilagenous tissues of the knee. 131 temperature measurements were performed during surgery and 285 after surgery. 33 patients suffered from algodystrophy, 200 patients were investigated during or after various methods of cryotherapy and 50 subjects during heat treatment. Only pattern description without temperature values was reported in 5700 other subjects with various knee disorders. Based on contact temperature measurements, the mean temperature of the anterior knee in healthy subjects was 30.5 ± 1.1°C. Determined with radiometers, the corresponding mean temperature was 28.7 ± 0.6°C (95% confidence interval: 27.9 to 29.5). In thermal images from healthy subjects, the mean temperature of the anterior knee was 29.5 ± 1.6°C (95% confidence interval: 28.5 to 30.5°C) and 33,1 ± 0.0 °C of the posterior knee. The side difference of temperature was 0.2 ±1°C for both the anterior and the posterior knee. Mean intra-articular temperature varied between measurements recorded during knee surgery (29.9 ± 4.4 °C; 95% confidence interval: 23.0 to 36.8), in patients with rheumatoid arthritis (35,1 ± 0.7 °C; 95% confidence interval: 34.2 to 36.0°C) or osteoarthritis (33,5 2,7°C; 95% confidence interval: 30.1 to 36.9) and healthy subjects (32.6 ± 0.9°C; 95% confidence interval: 31.5 to 33.7). Measurements with contact thermometers revealed in patients with rheumatoid arthritis a mean temperature of 32.5 ± 0.9°C (95% confidence interval: 31.4 to 33.9°C) for the anterior knee, while the corresponding temperature recorded with infrared thermal images was 30.5 ± 0.8°C (95% confidence interval: 27.8 to 33.1 °C). In osteoarthritis patients, contact thermometers obtained a mean anterior knee temperature of 31.3 ± 1,3°C and temperature measurements from infrared thermograms revealed a mean temperature of 30.7 ± 1.3°C (95% confidence interval: 29.4 to 32.0 °C). CONCLUSION: Knee temperatures vary with respect to the method of temperature determination and between different health conditions of the knee joint. Moreover, mean knee temperature describes the condition of the knee incompletely and should be supplemented with a description of the temperature distribution. |
0 | Altered expression of chondroitin sulfate structure modifying sulfotransferases in the articular cartilage from adult osteoarthritis and Kashin-Beck disease | OAK 3 - Non-arthroplasty tx of OAK | OBJECTIVE: To investigate the expression of enzymes involved in chondroitin sulfate (CS) sulfation in the articular cartilage isolated from adult patients with osteoarthritis (OA) and Kashin-Beck disease (KBD), using normal adults as controls.
METHODS: Articular cartilage samples were collected from normal, OA and KBD adults aged 38-60 years old, and divided into three groups with six individual subjects in each group. The morphology and pathology grading of knee joint cartilage was examined by Safranin O staining. The localization and expression of enzymes involved in CS sulfation (CHST-3, CHST-11, CHST-12, CHST-13, carbohydrate (N-acetylgalactosamine 4-sulfate 6-O) sulfotransferase 15 - CHST-15, and uronyl 2-O-sulfotransferase - UST) were examined by immunohistochemical (IHC) staining and semi-quantitative analysis.
RESULTS: Positive staining rates for anabolic enzymes CHST-3, CHST-12, CHST-15, and UST were lower in the KBD and OA groups than those in the control group. Meanwhile, reduced levels of CHST-11, and CHST-13 in KBD group were observed, in contrast to those in OA and control groups. The expressions of all six CS sulfation enzymes were less detected in the superficial and deep zones of KBD cartilage compared with control and OA cartilage.
CONCLUSION: The reduced expression of the CS structure modifying sulfotransferases in the chondrocytes of both KBD and OA adult patients may provide explanations for their cartilage damages, and therapeutic targets for their treatment. |
1 | Ethnoracial variations in acute PTSD symptoms among hospitalized survivors of traumatic injury | DoD PRF (Psychosocial RF) | Ethnoracial minority status contributes to an increased risk for posttraumatic stress disorder (PTSD) after trauma exposure, beyond other risk factors. A population-based sampling frame was used to examine the associations between ethnoracial groups and early PTSD symptoms while adjusting for relevant clinical and demographic characteristics. Acutely injured trauma center inpatients (N = 623) were screened with the PTSD Checklist. American Indian and African American patients reported the highest levels of posttraumatic stress and preinjury cumulative trauma burden. African American heritage was independently associated with an increased risk of higher acute PTSD symptom levels. Disparities in trauma history, PTSD symptoms, and event related factors emphasize the need for acute care services to incorporate culturally competent approaches for treating these diverse populations. (PsycINFO Database Record (c) 2016 APA, all rights reserved) |
0 | Assessment of donor site morbidity for free radial forearm osteocutaneous flaps | DoD SSI (Surgical Site Infections) | PURPOSE: Assessment of donor site morbidity and recipient site complications following free radial forearm osteocutaneous flap (FRFOCF) harvest and evaluation of patient perceived upper limb disability for free radial forearm osteocutaneous versus fasciocutaneous flaps (FRFF).
METHODS: First a case series was undertaken of 218 patients who underwent an FRFOCF at two tertiary referral centers between February 1998 and November 2010. Outcomes included forearm donor site morbidity and recipient site complications. Second, the disability of the arm, shoulder, and hand (DASH) questionnaire assessing patient perceived arm disability was administered by phone to 60 consecutive patients who underwent an FRFOCF or FRFF.
RESULTS: Mean patient age was 63 years with male predominance (62.8%). Median bone length harvested was 8 cm (range, 3-12 cm) with prophylactic plating of the radius following harvest. Donor site morbidity included fracture (1 patient, 0.5%) and sensory neuropathy (5 patients, 2.3%). Mean DASH scores were comparative between groups and to established normative values. Mandibular malunion rate was 3.2% and hardware extrusion at the recipient site occurred in 15.6%.
CONCLUSION: Reluctance to perform FRFOCF by surgeons usually centers on concerns regarding potential donor site morbidity and adequacy of available bone stock; however, we identified minimal objective or patient perceived donor site morbidity or recipient site complications following harvest of FRFOCFs. Mild wrist weakness and stiffness are common but do not impede ability to perform activities of daily living. Data from this and other reports suggest this flap is particularly useful for midfacial and short segment mandibular reconstruction. |
1 | A systematic review of conservative treatment of carpal tunnel syndrome | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | OBJECTIVE: To assess the effectiveness of conservative therapy in carpal tunnel syndrome. DATA SOURCES: A computer-aided search of MEDLINE and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) from January 1985 to May 2006. REVIEW METHODS: RCTs were included if: (1) the patients, with clinically and electrophysiologically confirmed carpal tunnel syndrome, had not previously undergone surgical release, (2) the efficacy of one or more conservative treatment options was evaluated, (3) the study was designed as a randomized controlled trial. Two reviewers independently selected the studies and performed data extraction using a standardized form. In order to assess the methodological quality, the criteria list of the Cochrane Back Review Group for systematic reviews was applied. The different treatment methods were grouped (local injections, oral therapies, physical therapies, therapeutic exercises and splints). RESULTS: Thirty-three RCTs were included in the review. The studies were analysed to determine the strength of the available evidence for the efficacy of the treatment. Our review shows that: (1) locally injected steroids produce a significant but temporary improvement, (2) vitamin B6 is ineffective, (3) steroids are better than non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics, but they can produce side-effects, (4) ultrasound is effective while laser therapy shows variable results, (5) exercise therapy is not effective, (6) splints are effective, especially if used full-time. CONCLUSION: There is: (1) strong evidence (level 1) on efficacy of local and oral steroids; (2) moderate evidence (level 2) that vitamin B6 is ineffective and splints are effective and (3) limited or conflicting evidence (level 3) that NSAIDs, diuretics, yoga, laser and ultrasound are effective whereas exercise therapy and botulinum toxin B injection are ineffective |
0 | Breast cancer survivors: psychosocial concerns and quality of life | DoD PRF (Psychosocial RF) | PURPOSE: To describe the psychosocial concerns and quality of life of breast cancer survivors evaluated 2 and 3 years after primary treatment.
METHODS: A sample of 139 breast cancer survivors who had been interviewed during the first year after primary treatment participated in a mailed survey at 2 years (N = 69) and 3 years (N = 70) after initial surgery. A random sample of these survivors were also interviewed in person. The mailed questionnaire included standardized instruments to assess quality of life (QL), rehabilitation needs, and psychological distress. Additional survey questions were developed to examine post-surgical recovery, employment and insurance problems, social support, and existential concerns. The in-person interviews expanded on these questions and systematically compared these patients' rehabilitation needs to those which existed at the time of an interview 1 year after surgery.
RESULTS: The 2 and 3 year participants in this follow-up study did not differ from each other on their prior assessments with standardized QL instruments during the first year after surgery, nor did they differ from the full study sample of 227 women. The scores on the Profile of Mood States and the Functional Living Index-Cancer were the same for the 2 and 3 year survivor groups and did not differ from the previous assessments at 1 year after initial treatment. The scores on the Cancer Rehabilitation Evaluation System showed a significant decline in Global Quality of Life, Sexual Functioning and Marital Functioning between the 1 year and 3 year evaluations. For the 2 year sample only Sexual Functioning showed a deterioration between the 1 and 2 year evaluations. Using the RAND 36-Item Health Survey 1.0, the breast cancer survivors were compared with patients from the Medical Outcomes Study. The breast cancer survivors demonstrated higher levels of functioning in many dimensions (role functioning, social functioning, pain, and general health) than the patients with chronic medical conditions. In spite of relatively good physical and emotional functioning on this generic measure of health status and quality of life, these breast cancer survivors reported a number of important and severe rehabilitation problems that persisted beyond one year after primary treatment. Especially frequent were problems associated with physical and recreational activities, body image, sexual interest, sexual function, and problems with dating for those who were single.
CONCLUSIONS: Breast cancer survivors appear to attain maximum recovery from the physical and psychological trauma of cancer treatment by one year after surgery. A number of aspects of QL and rehabilitation problems worsen after that time. Nevertheless, breast cancer survivors rate their QL more favorably than outpatients with other common medical conditions, and they identify many positive aspects from the cancer experience. |
0 | Hyaluronidase production in Streptococcus milleri in relation to infection | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | One hundred and seven (41%) of 262 isolates of Streptococcus milleri, from human sources, produced hyaluronidase. Hyaluronidase production was commoner in beta haemolytic isolates 32 of 39 (82%), many of which were of Lancefield group F. But hyaluronidase was also found in alpha and non-haemolytic isolates, and in groups A, C, G, and non-groupable isolates. There was a strong association between hyaluronidase production and isolation from known internal abscesses (48/58, 83%) compared with isolates from the normal flora of uninfected sites (24/97, 25%). Isolates from 15 patients with endocarditis were uniformly negative, although 13 of 25 (52%) isolates from dental plaque produced the enzyme. Production of hyaluronidase may therefore be an important determinant in the pathogenicity of infection by S milleri and could be helpful in predicting the likelihood of deep purulent lesions in isolates from blood culture |
1 | Which analgesic mixture is appropriate for periarticular injection after total knee arthroplasty? Prospective, randomized, double-blind study | AAHKS (8) Anesthetic Infiltration | PURPOSE: Although the analgesic effect of periarticular injection after total knee arthroplasty (TKA) has been well documented, the gold standard for drug combination has not yet been established. In this study, the analgesic effects of six different drug combinations were compared.
METHODS: A total of 256 patients undergoing TKA for primary osteoarthritis were randomized into one of six groups: a control group (saline solution, epinephrine, and cefazolin, n = 42), Group 1 (ropivacaine, n = 43), Group 2 (ropivacaine + morphine, n = 43), Group 3 (ropivacaine + ketorolac, n = 42), Group 4 (ropivacaine + morphine + ketorolac, n = 43), and Group 5 (ropivacaine + morphine + ketorolac + methylprednisolone, n = 43). Pain level assessed by visual analogue scale (VAS) and opioid consumption were primary outcomes. The incidence of complications, range of motion (ROM), C-reactive protein (CRP) value, and the amount of post-operative blood drainage were also compared.
RESULTS: Patients in Groups 4 and 5 complained less pain than the control group for the first 12 h after surgery, and the patients in the other groups showed less pain only during the initial 6 h after surgery. Groups 4 and 5 also showed less opioid consumption than the control group during the 24 h period after surgery. Patients in Group 5 showed no significant difference in VAS score and opioid consumption compared with Group 4, but they had lower CRP value and greater ROM than any other groups at post-operative day 2 and day 4.
CONCLUSION: The combination of ropivacaine, morphine, and ketorolac showed a significantly stronger and sufficiently synergistic analgesic effect without adding methylprednisolone in periarticular injection after TKA. The clinical relevance of the study is that the combination of ropivacaine, morphine, and ketorolac can be a good option for periarticular injection following TKA in terms of synergistic analgesic effect and efficiency of drug combination. |
0 | The Efficacy of Bisphosphonates in the Prevention of Vertebral, Hip, and Nonvertebral-Nonhip Fractures in Osteoporosis: A Network Meta-Analysis | Management of Hip Fractures in the Elderly | Objective: To evaluate the efficacy of available bisphosphonate therapies regarding the prevention of vertebral, hip, and nonvertebral-nonhip fractures in postmenopausal women with osteoporosis. Methods: Eight randomized placebo controlled trials investigating the effects of zoledronic acid (1 study), alendronate (3), ibandronate (1), risedronate (2), and etidronate (1) in terms of fractures with a follow-up of 3 years (or 2 years if used for registration purposes) were identified with a systematic literature search. The endpoints of interest were morphometric vertebral fractures, hip fractures, and nonvertebral-nonhip fractures. Results of all trials were analyzed simultaneously with a Bayesian network meta-analysis by which the relative treatment effect of 1 intervention to another can be obtained in the absence of head-to-head evidence. Given the estimated treatment effects and their uncertainty, the Bayesian approach allowed for calculations of the probability of which bisphosphonate is best in terms of overall fracture reductions by weighting the impact of each by type of fracture on costs, quality of life, and incidence. Results: There is a 79% probability that zoledronic acid shows the greatest reduction in vertebral fractures of all bisphophonates compared. Zoledronic acid showed a relative risk (RR) of 0.30 (95% Credible Interval 0.23-0.37) relative to placebo, an RR of 0.55 (0.41-0.76) relative to alendronate, an RR of 0.50 (0.36-0.70) relative to risedronate, and an RR of 0.58 (0.37-0.92) relative to ibandronate. Regarding hip fractures, there is a 47% probability that zoledronic acid shows the greatest risk reduction, followed by alendronate (36%) and risedronate (11%). RRs of zoledronic acid relative to placebo, alendronate, and risedronate were 0.58 (0.41-0.82), 0.95 (0.54-1.68), and 0.73 (0.37-1.44), respectively. Risedronate showed the greatest reduction in nonvertebral-nonhip fractures, followed by zoledronic acid. The RR of zoledronic acid relative to risedronate was 1.28 (0.87-1.90). Overall, there was a 94% probability that zoledronic acid showed the greatest reduction in any fracture. Weighting the impact of the different type of fractures by incidence, cost, or quality of life showed similar results. Conclusion: Of the available bisphosphonates for osteoporosis, zoledronic acid has the highest probability of offering the best overall fracture protection. (copyright) 2011 Elsevier Inc |
1 | Is self-reported pain an appropriate outcome measure in ergonomic- epidemiologic studies of work-related musculoskeletal disorders? | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Of the various overlapping approaches used to define outcome in ergonomic-epidemiologic studies of work-related musculoskeletal disorders, the most widely used are clinical diagnostic entities, whose criteria derive either from clinical examination (consisting of clinical tests in conjunction with symptoms and clinical history or from findings of special investigations, such as nerve conduction testing. Problems with the use of clinical diagnostic entities as surveillance tools relate to their high definitional variability, to the unknown test attributes and performance in worker populations, and to their lack of field utility. Other approaches to define outcome such as impairment and disability evaluations are seldom used; there are problems with existing instruments in disentangling multiple determinants. The use of subjective measures (self-reported pain) may be the most valuable approach to measuring outcome in population-based surveys. This approach has high capacity (can be used in large populations) and good field utility, has been supported by evidence of construct validity in some ergonomic-epidemiologic studies, and is able to assimilate the diverse and overlapping symptom patterns characteristic of some work-related musculoskeletal disorders. Traditional biases against subjective measures are evident in the literature, but these measures have also been badly used in many studies, with insufficient attention being paid to potential confounders and effect modifiers. Measurement of factors that influence pain perception and reporting need to be incorporated in ergonomic-epidemiologic studies and controlled for in analysis. Outcome definitions should be made more explicit |
0 | Factors influencing patient survival in a group of men with prostate cancer in Yaoundé, Cameroon | MSTS 2022 - Metastatic Disease of the Humerus | Purpose: We evaluated the survival time of patients with stage D cancer of the prostate (CaP) in Yaounde, Cameroon, so as to lay the groundwork for evaluating patient management and outcomes in such communities in sub-Saharan Africa. Patients and Materials: A cohort of 200 patients was recruited at diagnosis and followed over a 171 month period. They had a standard work-up and staging protocol except for the absence of bone scan. Treatment was offered after they were staged following the Whitemore ABCD-system. Standard statistical analysis was performed for quantitative variables and graphs developed for continuous variables. Pearson correlation and Chi-square tests were used to evaluate associations between variables. The Kaplan-Meier product-limit method was used to estimate survival functions and log-rank test to compare data from complete survival curves. The statistical significance level was fixed at p values less than or equal to 0.05. Results: The mean age of our patients was 67 years and 41.5% of them were in the 60-69 year-bracket. Survival was worse for those 66 years and older (p = 0.013). Patient survival correlated with tumor differentiation such that a Gleason score of 6 or greater meant diminished survival time (p = 0.014). For the entire group, median overall survival was 40.5 months, 44% at 5 years and 17% at 10 years. Patients who received multi-modal therapy (complete androgen ablation by surgical and medical means, and radiation to the pelvis and metastatic sites) seemed to have the best survival (p < 0.001) although patient stratification into treatment groups was not randomized. A comparison of survival of African-American cohorts and this group showed no statistical significance (p = 0.1). Conclusion: Survival of patients with prostate cancer in Yaounde is just as low as in African-Americans. Survival is worse however, for men older than 66 years in Yaounde. A call for comparative and collaborative clinical trials is made. |
0 | Palmar lipomas associated with compression of the median nerve | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | The records of five patients who had had a palmar mass associated with altered sensibility in the distribution of the median nerve were reviewed retrospectively. Three-dimensional imaging (computerized tomography or magnetic resonance imaging) proved useful for establishment of the diagnosis of a lipoma and planning of the operative procedure. Treatment included release of the transverse carpal ligament, excision of the tumor, and exploration of the carpal canal and the median nerve and its distal digital branches. At an average of twenty-four months postoperatively, all patients had a complete return of sensibility and resolution of the discomfort |
0 | Robot-assisted treatment of unstable pelvic fractures with a percutaneous iliac lumbar double rod fixation combined with a percutaneous pelvic anterior ring INFIX fixation | DoD SSI (Surgical Site Infections) | OBJECTIVE: To investigate the clinical effect of robot-assisted treatment of unstable pelvic fractures through a percutaneous iliac lumbar double rod fixation combined with a percutaneous pelvic anterior ring INFIX (internal fixator) fixation.
METHODS: This was a retrospective analysis of 17 cases of unstable anterior and posterior pelvic ring fractures treated between April 2016 and October 2018 by the third Ti-robot system produced in China. The posterior ring was supported with an iliac lumbar double rod fixation and the anterior ring with an INFIX fixation. Operation time and peri-operative bleeding were recorded. The reduction of pelvic fracture displacement was evaluated by Matta score, the post-operative results were evaluated according to Majeed score, and the complications were recorded.
RESULTS: Twelve males and five females, aged 21-71 years (mean 40.1 +/- 3.8 years) were followed up for three to 12 months, (median 6.7 months). Tile typing showed seven B1 type, two B2 type, and eight C1 type cases. Operation time was 90-160 minutes (mean 112.9 +/- 16.8 minutes), bleeding was 80-150 mL (mean 105.9 +/- 20.6 mL). X-ray three to five days after operation was evaluated by Matta score as excellent in 15 and good in two cases. Majeed score at last follow-up was 85-98 points, excellent in 17 cases. Two cases of lower extremity deep vein thrombosis received an inferior vena cava filter. The filters were removed after two weeks. One case showed incision fat liquefaction healing and the wound healed three weeks after surgery.
CONCLUSION: Orthopedic robot-assisted treatment of unstable pelvic fractures by a percutaneous iliac lumbar double rod fixation and a percutaneous pelvic anterior ring INFIX fixator was minimally invasive and feasible. A prospective study is needed. |
0 | Immunoparesis in newly diagnosed Multiple Myeloma patients: Effects on overall survival and progression free survival in the Danish population | MSTS 2022 - Metastatic Disease of the Humerus | Immunoparesis (hypogammaglobulinemia) is associated to an unfavorable prognosis in newly diagnosed Multiple myeloma (MM) patients. However, this finding has not been validated in an unselected population-based cohort. We analyzed 2558 newly diagnosed MM patients in the Danish Multiple Myeloma Registry representing the entire MM population in Denmark from 2005–2013. Two-thousand two hundred and fifty three patients (90%) presented with reduction below lower normal levels of at least one uninvolved immunoglobulin. Using multivariable Cox regression we found that high age, high ISS score, high LDH and IgA MM were associated to both shorter overall survival and progression free survival. Furthermore, bone marrow plasma cell % was associated to short progression free survival. Immunoparesis had no independent significant effect on OS (HR 0.9 (95%CI: 0.7;1.0; p = 0.12)). Likewise, the number of suppressed immunoglobulins or the relative degree of suppressed uninvolved immunoglobulins from lower normal level (quantitative immunoparesis) was not associated to OS in the multivariable analysis. However, quantitative immunoparesis with at least 25% reduction (from lower normal level) of uninvolved immunoglobulins was associated to shorter PFS for the entire population. The impact of quantitative immunoparesis on PFS was present irrespective of calendar periods 2005–2008 and 2009–2013. Our population-based study does not confirm that immunoparesis at diagnosis is an independent prognostic factor regarding OS. However, quantitative immunoparesis is associated to a shorter PFS. |
0 | Effect of hormone replacement therapy on bone mineral density in postmenopausal women with mild primary hyperparathyroidism. A randomized, controlled trial | Management of Hip Fractures in the Elderly | BACKGROUND: Most patients with primary hyperparathyroidism are postmenopausal women. The presence of osteopenia in persons with mild primary hyperparathyroidism is considered an indication for parathyroidectomy. No prospective, controlled trials have assessed medical therapies for osteopenia in primary hyperparathyroidism.OBJECTIVE: To examine the effects of estrogen-progestin therapy (hormone replacement therapy) on bone mineral density and biochemical indices in postmenopausal women with mild primary hyperparathyroidism.DESIGN: Double-blind, randomized, placebo-controlled trial.SETTING: University teaching hospital.PATIENTS: 42 postmenopausal women with mild primary hyperparathyroidism.INTERVENTION: Patients were randomly assigned to receive either conjugated estrogens, 0.625 mg/d, and medroxyprogesterone, 5 mg/d, or placebo.MEASUREMENTS: Bone mineral densities of the total body, lumbar spine, proximal femur (femoral neck, Ward triangle, trochanter), and proximal forearm were measured every 6 months using dual-energy x-ray absorptiometry. Biochemical indices of bone turnover and calcium metabolism were measured at baseline, 6 months, and 2 years.RESULTS: In the placebo group, bone mineral densities of the total body and the proximal forearm decreased significantly from baseline (mean +/- SE, -2.3% +/- 0.7% [p = 0.005] and -3.5% +/- 1.2% [p = 0.01], respectively). At the other sites, bone mineral density also tended to decline. In the hormone replacement therapy group, bone mineral density increased from baseline in the total body (1.3% +/- 0.4%; P = 0.004), lumbar spine (5.2% +/- 1.4%; p = 0.002), and femoral neck (3.4% +/- 1.5%; p = 0.05). The between-group differences in bone mineral density at the end of the study ranged from 3.6% to 6.6% and were significant at all sites (P > 0.001 and P < 0.05) except for the Ward triangle (p = 0.06). In the hormone replacement therapy group, serum alkaline phosphatase levels decreased by 22% (p = 0.0004 compared with baseline), urinary hydroxyproline excretion decreased by 42% (p = 0.0004), urinary N-telopeptide excretion decreased by 54% (p = 0.001), and urinary calcium excretion decreased by 45% (p = 0.007). Hormone replacement therapy did not change levels of serum ionized calcium or intact parathyroid hormone.CONCLUSIONS: Although hormone replacement therapy has little effect on serum calcium levels, it suppresses bone turnover, reduces urinary calcium excretion, and increase bone mineral density throughout the skeleton in postmenopausal women with mild primary hyperparathyroidism. This therapy is thus an important management option for these patients |
1 | Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement | Management of Hip Fractures in the Elderly | In a prospective trial of 278 patients aged over 65 years, treatment of displaced subcapital fractures was randomly allocated to closed reduction and internal fixation with a sliding compression screwplate, Moore hemiarthroplasty, or total hip treatment with a Howse semicaptive prosthesis. One year after operation there was little difference between the three groups in mortality (25 per cent) or general complications. The revision rate within the first year was highest for internal fixation (25 per cent), but many of the replacements also required a further anaesthetic for reduction of a dislocation (Moore, 11 per cent; Howse 12.5 per cent). Total hip replacement resulted in the least pain and most mobility at 1 year, while hemiarthroplasty was worst in these respects. We conclude that internal fixation and particularly primary total hip replacement should be given serious consideration in the management of the elderly patient with a displaced subcapital fracture |
0 | Variations of the analgesia nociception index during propofol anesthesia for total knee replacement | Surgical Management of Osteoarthritis of the Knee CPG | OBJECTIVE: The Analgesia Nociception Index (ANI) monitor (Mdoloris Medical System, Lille, France) measures the relative parasympathetic tone as a surrogate for the anti-nociception/nociception balance during general anesthesia. The aims of this observational study were to test whether ANI could early detect hemodynamic reactivity ("HemodR") during propofol anesthesia, measure pain in conscious patients after surgery and determine ANI predictive thresholds. METHODS: After institutional approval and informed consent, adult patients scheduled for total knee replacement have been included. Propofol was administered using a target-controlled infusion device and sufentanil was administered at induction and in case of "HemodR", defined as a 20% increase of heart rate (HR) or systolic blood pressure (SBP). Data were collected before start of surgery ("NoStim"), in case of "HemodR" and after awakening before and after pain had been treated by truncular analgesia. Non parametric test were performed. Thresholds were determined using a ROC curve analysis. Results are presented as median (interquartile range). RESULTS: 27 patients have been analysed. ANI decreased from 82 (30) at "NoStim" to 47 (22) at "HemodR", while HR increased moderately from 61 (14) to 65 (18) and SBP increased significantly from 91 (16) to 151 (25). ROC curve analysis led to a threshold of 63 for "HemodR" detection (Se=80%, Sp=88%, AUC=0.92), while ANI performance in awake patients was lower. DISCUSSION: ANI measures during propofol anesthesia are coherent with the evolution of the analgesia/nociception balance while its performance decrease in awake patients. Further clinical validation should focus on demonstrating the benefit of maintaining ANI over 63 during surgery |
0 | Arthroscopic mosaicplasty: Long-term outcome and joint degeneration progression | Osteochondritis Dissecans 2020 Review | Background: This study aims to document the long-term results in a group of patients treated with arthroscopic mosaicplasty for knee cartilage lesions, both in terms of clinical outcome and joint degeneration progression, evaluated by radiographs. Methods: 26 patients (19 men and 7 women, mean age 29years, mean BMI 23) treated arthroscopically with mosaicplasty for cartilage defects of the femoral condyles (mean/median/mode size 1.9 standard deviation, SD 0.6cm2) were prospectively evaluated at 12years follow-up. The clinical outcome was analyzed with IKDC and Tegner scores. Range of motion, transpatellar and suprapatellar circumferences were also measured. Radiographs with weight-bearing antero-posterior and Rosenberg projections were used for radiological evaluation in 18 patients, applying both Kellgren-Lawrence score and a direct joint line measurement to assess osteoarthritis. Results: A significant improvement in all clinical scores was obtained from the basal evaluation to the 12-year follow-up (IKDC subjective score from 36.8 standard deviation, SD 13.0 to 77.3 standard deviation, SD 20.6, P. <. 0.0005; Tegner score from 2.9 standard deviation, SD 1.3 to 5.2 standard deviation, SD 2.5, P. <. 0.0005), and better results in patients with a higher pre-injury activity level and those requiring fewer plugs. The radiographic evaluation showed significantly poorer Kellgren-Lawrence scores and a reduction of the joint line in the treated compartments. Knees with 3-4 plugs presented a significantly higher joint degeneration level with respect to those implanted with 1-2 plugs. Conclusions: Mosaicplasty is an effective surgical option for small lesions of the femoral condyles. Although joint degeneration progression was present at 12. years, this did not affect significantly the clinical outcome which was satisfactory at long-term follow-up. Level of evidence: IV, case series. |
0 | The Functional Status Index: reliability and validity of a self-report functional disability measure | Management of Hip Fractures in the Elderly | Practical, reliable and valid functional assessment instruments are needed to assist health providers in planning a patient's discharge from hospital and determining the need for rehabilitation or longterm care. In addition, such instruments can be used in clinical and epidemiological research. Several methods of assessing functional performance are available. Patient self-report offers many advantages: cost, speed of obtaining assessments and the potential for assessing a wide range of complex functional dimensions. Criticisms of this approach center around the degree to which the data are a reliable and valid reflection of patient function. We developed a Functional Status Index (FSI) and assessed its validity in 47 patients with hip fracture by comparing it to the results of objective functional performance tests. Our results indicate that patient self-report of function, if conducted with a structured, standardized format, yields data with considerable reliability and validity |
0 | Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA | PJI DX Updated Search | BACKGROUND: The impact of specific baseline comorbid conditions on the relative risk of postoperative mortality and periprosthetic joint infection (PJI) in elderly patients undergoing TKA has not been well defined. QUESTIONS/PURPOSES: We calculated the relative risk of postoperative mortality and PJI associated with 29 comorbid conditions in Medicare patients undergoing TKA. PATIENTS AND METHODS: The Medicare 5% sample was used to calculate the relative risk of 90-day postoperative mortality and PJI as a function of 29 preexisting comorbid conditions in 83,011 patients who underwent primary TKA between 1998 and 2007. RESULTS: The independent risk factors for 90-day postoperative mortality (in decreasing order of significance) were congestive heart failure, metastatic cancer, renal disease, peripheral vascular disease, cerebrovascular disease, lymphoma, cardiac arrhythmia, dementia, pulmonary circulation disorders, and chronic liver disease. The independent risk factors for PJI (in decreasing order of significance) were congestive heart failure, chronic pulmonary disease, preoperative anemia, diabetes, depression, renal disease, pulmonary circulation disorders, obesity, rheumatologic disease, psychoses, metastatic tumor, peripheral vascular disease, and valvular disease. CONCLUSIONS: We believe this information important when counseling elderly patients regarding the risks of mortality and PJI after TKA and risk-adjusting publicly reported TKA patient outcomes |
1 | Infection after primary anatomic versus primary reverse total shoulder arthroplasty | Glenohumeral Joint OA | BACKGROUND: Deep periprosthetic infection is a serious complication after total shoulder arthroplasty (TSA) and is associated with suboptimal clinical results. This retrospective study aimed to determine whether a difference in infection rate existed after primary anatomic TSA (aTSA) and primary reverse TSA (rTSA).
METHODS: A TSA database was retrospectively reviewed to identify primary TSAs performed from 2004 to 2012 and isolate cases of confirmed deep periprosthetic infection. Data collected included age, sex, preoperative diagnosis, previous nonarthroplasty operative history, implant type, and infecting organism.
RESULTS: From 814 primary TSAs performed, deep periprosthetic infections were confirmed in 16 shoulders. Infections occurred in 6 aTSAs and 10 rTSAs, with no significant difference among the prosthesis types. Pathogens included Staphylococcus spp, Propionibacterium acnes, and Escherichia coli. In the subgroup of shoulders with no previous operations, no significant difference in infection rate was found among the prosthesis types. Shoulders with previous nonarthroplasty operations undergoing primary TSA exhibited a significantly higher (P = .016) infection rate compared with shoulders with no operative history. Both aTSA and rTSA performed in previously operated-on shoulders demonstrated higher infection rates compared with shoulders with no prior operative intervention. The infection rate was significantly higher (P = .016) in the rTSA group.
CONCLUSIONS: There is no difference in infection rate after primary aTSA and primary rTSA in shoulders that have not undergone previous operative interventions. Infection is more likely to develop in shoulders undergoing primary rTSA that have had one or more nonarthroplasty operative procedures. |
0 | IARC monographs programme on the evaluation of carcinogenic risks to humans | Surgical Management of Osteoarthritis of the Knee CPG | 6.1 Exposure data: A wide range of metals and their alloys, polymers, ceramics and composites are used in surgically implanted medical devices and prostheses and dental materials. Most implanted devices are constructed of more than one kind of material (implants of complex composition). Since the early 1900s, metal alloys have been developed for these applications to provide improved physical and chemical properties, such as strength, durability and corrosion resistance. Major classes of metals used in medical devices and dental materials include stainless steels, cobalt-chromium alloys and titanium (as alloys and unalloyed). In addition, dental casting alloys are based on precious metals (gold, platinum, palladium or silver), nickel and copper and may in some cases contain smaller amounts of many other elements, added to improve the alloys' properties. Orthopaedic applications of metal alloys include arthroplasty, osteosynthesis and in spinal and maxillofacial devices. Metallic alloys are also used for components of prosthetic heart valve replacements, and pacemaker casings and leads. Small metallic parts may be used in a wide range of other implants, including skin and wound staples, vascular endoprostheses, filters and occluders. Dental applications of metals and alloys include fillings, prosthetic devices (crowns, bridges, removable prostheses), dental implants and orthodontic appliances. Polymers of many types are used in implanted medical devices and dental materials. Illustrative examples are silicones (breast prostheses, pacemaker leads), polyurethanes (pacemaker components), polymethacrylates (dental prostheses, bone cements), poly(ethylene terephthalate) (vascular grafts, heart valve sewing rings, sutures), polypropylene (sutures), polyethylene (prosthetic joint components), polytetrafluoroethylene (vascular prostheses), polyamides (sutures) and polylactides and poly(glycolic acids) (bioresorbables). Ceramic materials based on metal oxides (alumina, zirconia) find use in joint replacements and dental prostheses. Other materials based on calcium phosphate are used as bone fillers and implant coatings. Pyrolytic carbon applications include heart valves and coatings for implants. Composites are used mainly in dental fillings. Although precise numbers are not available, many millions of people worldwide have implanted devices, which may remain in place for years. Foreign bodies, such as bullets and pellets from firearms and metallic fragments from explosions, may penetrate and remain in human tissues for long periods of time. Internal exposure to constituents, including lead (from bullets and pellets) and depleted uranium (from shell and missile fragments), may result. 6.2 Human carcinogenicity data: Sixteen case reports have described neoplasms originating from bone or soft connective tissue in the region of metal implants. An analytical study did not report an increased risk for soft-tissue sarcoma after metal implants. No association with dental amalgam was found in a case-control study in Australia. The 30 case reports of breast cancer following silicone implants for cosmetic breast augmentation appear unlikely to correspond to an excess of breast cancer. All five cohort studies involving a total of more than 18 000 women treated with surgical prostheses made of silicone (or polyurethane-coated silicone) for cosmetic breast augmentation conducted in Canada, Denmark, Sweden and the United States consistently found no evidence of increased risk of breast cancer. The combined results of the four largest cohort studies show a 25% reduction in risk. Similar results were reported by a large case-control study including more than 2000 cases and 2000 controls in the United States. All cohort studies were based on subjects exposed to implanted silicone at an early age, usually between the ages of 30 and 40 years, so that the number of breast cancer cases observed in each study was relatively small. Except for the case-control study in the United States, only limited allowance was made for potential confounding factors, although no clear evidence has emerged as to the relevance of any such factor to a possible association between implanted silicone and breast cancer risk. Three of the studies considered the issue of latency, with observation periods of up to 10 years or more, but even in the group of women with follow-up of 10 years or more, there was no suggestion of increased risk. The risk of cancer following surgical implantation of silicone prostheses for breast reconstruction after breast cancer was considered in a study in France. The results of this study suggest no excess risk of second primary breast or other cancer, distant metastases, local recurrence or death from breast cancer. The reduced risks for breast cancer found in the cohort and case- control studies are unlikely to be due to chance, and no bias that would explain these findings has been identified. Four cohort studies of women with surgical breast implants in Denmark, Sweden and the United States reported on cancers at sites other than the breast. None of these studies found an increased risk for all cancers combined. Two studies reported increased risk for lung cancer, but these results were based on a total of only nine observed cases. For no other cancer site was there consistent evidence of an increased risk, although the statistical power to detect an increased risk of rare neoplasms, including soft-tissue sarcomas, was small. Out of the large number of patients with orthopaedic implants of complex composition (metal with bone cement with or without polyethylene), a total of 35 cases have been reported of malignant neoplasms arising from the bone or the soft tissue in the region of an implant. Fourteen cohort studies of patients following total knee or total hip replacement from six countries were performed to investigate cancer incidence in these populations. Two of the studies from Finland and two studies from Sweden were partially overlapping. One study included only patients with metal-on-metal implants, five studies included only patients with polyethylene-on-metal implants, while the remaining studies included patients with mixed or unspecified types of implant. One study showed a small increase in overall cancer incidence, while the remaining studies showed overall decreases. Four of these studies suggested an excess risk for specific cancers, including Hodgkin's disease, non-Hodgkin lymphoma, leukaemia and kidney cancer. However, results of the other studies were not consistent with this observation. In one small cohort study from Denmark of patients with a finger or hand implant, an increased risk of lymphohaematopoietic cancer was observed. Additionally, two case-control studies, one including cases with soft-tissue sarcoma and the other including lymphoma and leukaemia, were carried out in the United States. The latter overlaps with one of the cohort studies. Neither of these studies showed an association with the presence of implants of complex composition. Most of the studies did not have information on possible confounding variables such as immunosuppressive therapy or rheumatoid arthritis for the lymphomas and analgesic drugs for kidney cancer. The follow-up in most of the studies may have been too short to evaluate cancer occurring many years after exposure; in some studies with longer follow-up, the numbers of long-term survivors were low. Thirteen cases of breast cancer and one case of plasmacytoma have been reported in patients with cardiac pacemakers. Ten cases of different neoplasms have been reported at the site of non-metallic foreign bodies. Eight cases of sarcoma have been reported at the site of vascular grafts. No conclusions can be drawn from these case reports. Twenty-three cases of sarcomas, twenty-three cases of carcinomas and seven cases of brain tumours have been reported at the site of metallic foreign bodies, mainly bullets and shrapnel fragments. 6.3 Veterinary studies: Despite the large number and variety of both metallic and non-metallic internal fixation devices used in dogs in recent decades, only about 60 cases of sarcomas, primarily of bone, have been reported. In addition, four cases of sarcomas at the site of other foreign bodies have been reported in dogs. One case-control study found no association between metallic implants used to stabilize fractures in dogs and the development of bone or soft-tissue tumours. In contrast, at least 563 cases of vaccine-associated sarcomas in cats have been reported in just six years, with an estimated annual incidence of 1-13 per 10 000 vaccinated cats. Vaccine-associated sarcomas have been mostly associated with administration of recently introduced feline vaccines containing adjuvant. Tumours that develop at vaccination sites are morphologically different from those that develop at non-vaccination sites. A cohort study found that cats developed sarcomas in a shorter time at sites used for vaccination than at non- vaccination sites and that there was an increased risk for sarcoma development with increased numbers of vaccines at a given site. 6.4 Animal carcinogenicity data: Chromium metal powder was tested in rats by intramuscular and intrarenal administration, in mice and rats by intrapleural and intraperitoneal administration, in rats and rabbits by intraosseous implantation and in mice, rats and rabbits by intravenous injection. No increase in tumour incidence was observed in these studies, although most studies had limitations in design, duration or reporting |
0 | Minor injury resulting in lower-limb loss in diabetic patients | DoD LSA (Limb Salvage vs Amputation) | Objective: to identify diabetic patients who had undergone recent amputation of the lower limb, and in whom a possibly avoidable minor injury to the foot had caused infection and gangrene necessitating surgical intervention. Design: questionnaires, administered to consecutively admitted recent lower-limb amputees, addressing demographic, socio-economic and medica data and containing specific questions on circumstances or events that might have caused a foot lesion that started the infection, gangrene and eventually amputation. Setting: department of orthopaedic rehabilitation in a rehabilitation hospital. Patients: 218 recent, lower-limb amputees - due to occlusive arterial disease, with or without diabetes - admitted for prosthetic rehabilitation during 30 months (January 1989 to June 1991). Results: 56 diabetic and 10 non-diabetic amputees were identified in whom a minor injury had caused the sequence leading to amputation which could have been avoided by adequate attention to the feet and their care. Conclusions: All diabetic individuals need education regarding self-care and attention to the feet, irrespective of their demographic or socio-economic variables and disease severity. The view is expressed that such an education particularly when linked to the provision of necessary health services would be able to reduce the risk of amputation in diabetes mellitus considerably. |
0 | [Implantation of Gamma nail and proximal femoral nail for the treatment of femoral intertrochanteric fractures in the elderly: a randomized follow-up for 131 cases] | Management of Hip Fractures in the Elderly | OBJECTIVE: To compare the clinical effect between Gamma nail and proximal femoral nail (PFN) on the treatment for femoral intertrochanteric fractures in the elderly. METHODS: A total of 131 cases (39 males and 92 females; aged 70-81 years, mean age of 76 years) with femoral intertrochanteric fractures were collected from the Department of Orthopaedics, the Affiliated Changhai Hospital of the Second Military Medical University of Chinese PLA from January 2005 to January 2008. Femoral intertrochanteric fractures were classified based on AO system, including type A1 (n=56) and type A2 (n=75). All cases were randomly divided into Gamma nail group (n=65) and PFN group (n=66). Pre- and post-operative blood loss, blood transfusion volume, operating time, and length of stay were recorded, while the complications were detected following nail implantation. Functional changes of injured limbs were detected after 9 months. RESULTS: At 9 months after following up, there was no significant difference in blood loss, blood transfusion volume, operating time, and length of stay between the two groups before and after implantation (P > 0.05). Furthermore, complications did not occur during or after implantation. Six cases in the PFN group had infection in which of them had diabetes mellitus. There were no complications such as cutting out of femoral head, femoral shaft fractures, breakage of internal device or pushing out phenomenon. All cases got bone union at the final follow-up of nine months and did not get nonunion, delayed union of fractures or shortening of injured extremity. CONCLUSION: Gamma nail and PFN have equal effect on the treatment of femoral intertrochanteric fractures in the elderly. Copyright © 2011 Elsevier B. V., Amsterdam. All Rights Reserved |
0 | The epidemiology of revision anterior cruciate ligament reconstruction in adults from Ontario, Canada | PJI DX Updated Search | Objectives: The morbidity associated with revision anterior cruciate ligament reconstruction (ACLR) is largely unknown. The objective of this study was to determine the rate of and risk factors for re-revision, re-operation, and re-admission following revision ACLR in the general population. Methods: All patients who underwent first revision ACLR in Ontario, Canada from January 2004 to December 2010 were identified and followed to December 2012. Exclusions included age (<16 years), previous osteotomy, or multiligament knee reconstruction. The main outcome was re-revision ACLR. Secondary outcomes included re-operation [irrigation and debridement (I&D), meniscectomy, manipulation under anesthesia (MUA), contralateral ACLR, and total knee arthroplasty (TKA)], and re-admission within 90 days of surgery. Survival to re-revision was determined using the Kaplan-Meier (KM) approach. A Cox proportional hazards model or logistic regression were used to determine the influence of patient factors (age, sex, neighborhood income quintile, and comorbidity), surgical factors (graft choice, concurrent meniscal procedure, and fixation method), and provider factors (surgeon volume, surgeon years in practice, and hospital status) on outcomes. A post-hoc analysis was performed to determine the influence of the aforementioned factors on overall post-operative infection risk, including both operative and nonoperative cases. Results: Overall, 827 patients were included (median age: 30 years; 58.8% males). Single stage revisions comprised 92.9% of cases, and a meniscal procedure (repair or debridement) was performed in 45.3% of cases. The re-revision rate at a mean follow-up of 4.8ñ2.2 years was 4.4%, and the five-year survival rate was 95.4% (Figure 1). The rates of I&D, meniscectomy, contralateral ACLR, and re-admission were 0.8%, 3.1%, 3.4%, and 4.1%, respectively. MUA and TKA were rare. Young age significantly increased contralateral ACLR risk (risk decreased by 5.1% with each year of age above 16 years, p=0.02), but not re-revision ACLR risk. Low surgeon annual volume of revision ACLR [<4 revisions/year: odds ratio (OR) 1.2, p=0.02)] and male sex (OR 13.3, p=0.01) significantly increased overall infection risk, while male sex also influenced I&D risk. No other factors significantly influenced re-revision, re-operation, or re-admission risk. Conclusion: Re-revision, re-operation, and re-admission rates following revision ACLR are low. The risk of I&D, overall infection, and contralateral ACLR were influenced by male sex, low surgeon volume, and young age, respectively. This is the first study of this magnitude to determine rates of and risk factors for morbidity following revision ACLR, providing clinicians with reference data from the general population |
0 | Denosumab in men receiving androgen-deprivation therapy for prostate cancer | Distal Radius Fractures | BACKGROUND: Androgenâ?deprivation therapy is wellâ?established for treating prostate cancer but is associated with bone loss and an increased risk of fracture. We investigated the effects of denosumab, a fully human monoclonal antibody against receptor activator of nuclear factorâ?kappaB ligand, on bone mineral density and fractures in men receiving androgenâ?deprivation therapy for nonmetastatic prostate cancer. METHODS: In this doubleâ?blind, multicenter study, we randomly assigned patients to receive denosumab at a dose of 60 mg subcutaneously every 6 months or placebo (734 patients in each group). The primary end point was percent change in bone mineral density at the lumbar spine at 24 months. Key secondary end points included percent change in bone mineral densities at the femoral neck and total hip at 24 months and at all three sites at 36 months, as well as incidence of new vertebral fractures. RESULTS: At 24 months, bone mineral density of the lumbar spine had increased by 5.6% in the denosumab group as compared with a loss of 1.0% in the placebo group (P<0.001); significant differences between the two groups were seen at as early as 1 month and sustained through 36 months. Denosumab therapy was also associated with significant increases in bone mineral density at the total hip, femoral neck, and distal third of the radius at all time points. Patients who received denosumab had a decreased incidence of new vertebral fractures at 36 months (1.5%, vs. 3.9% with placebo) (relative risk, 0.38; 95% confidence interval, 0.19 to 0.78; P=0.006). Rates of adverse events were similar between the two groups. CONCLUSIONS: Denosumab was associated with increased bone mineral density at all sites and a reduction in the incidence of new vertebral fractures among men receiving androgenâ?deprivation therapy for nonmetastatic prostate cancer. (ClinicalTrials.gov number, NCT00089674.) |
0 | A retrospective comparative study of bilateral total knee replacement staged at a one-week interval | Surgical Management of Osteoarthritis of the Knee CPG | The clinical results of bilateral total knee replacement staged at a one-week interval during a single hospital admission were compared with bilateral total knee replacements performed under the same anaesthetic and with bilateral total knee replacements performed during two separate admissions. The data were retrospectively reviewed. All operations had been performed by the same surgeon using the same design of prosthesis at a single institution. The operative time and length of stay for the one-week staged group were comparable with those of the separate admission group but longer than for the patients treated under one anaesthetic. There was a low rate of complications and good clinical outcome in all groups at a mean follow-up of four years (1 to 7.2). The group staged at a one-week interval had the least blood loss (p = 0.004). With appropriate patient selection, bilateral total knee replacement performed under a single anaesthetic, or staged at a one-week interval, is a safe and effective method to treat bilateral arthritis of the knee |
0 | Interventions for the treatment of decreased bone mineral density associated with HIV infection | Management of Hip Fractures in the Elderly | BACKGROUND: Decreased bone mineral density (BMD) occurs more commonly in patients with HIV than in the general population, making this group more susceptible to fragility fractures. However, bone loss is under-treated in patients with HIV. OBJECTIVES: To assess the effects of interventions aimed at increasing bone mineral density in HIV-infected adults. SEARCH STRATEGY: We searched MEDLINE, EMBASE, LILACS, The Cochrane Library, Meeting Abstracts, AIDSTRIALS, ACTIS, Current Controlled Trials, National Institutes of Health Clinical Trials Registry, and CenterWatch (search date July 2006). SELECTION CRITERIA: Randomised trials comparing any pharmacological or non-pharmacological therapy with placebo, no treatment, or an alternative therapy, with the goal of increasing bone mineral density in adult (age 18 years or over) patients with HIV. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial eligibility and quality, and extracted data. Where data were incomplete or unclear, conflicts were resolved with discussion and/or trial authors were contacted for further details. MAIN RESULTS: Three completed randomised-controlled studies examined the role of alendronate in patients with HIV and osteopenia or osteoporosis. When all three studies were combined, much heterogeneity was seen (p<0.0001), most likely due to different populations and interventions. A sensitivity analysis showed that in two studies without heterogeneity (p=0.11), alendronate, calcium and vitamin D improved lumbar BMD after one year when compared with calcium and vitamin D (weighted mean difference +2.65 95% confidence interval (CI) 0.80, 4.51 percent). However the alendronate group did not have less fragility fractures, relative risk (RR) 1.28 (95% CI 0.20, 8.21), or osteoporosis, RR 0.50 (95% CI 0.24, 1.01). Adverse events were not significantly different between groups, RR 1.28 (95% 0.20, 8.21). One randomised-controlled study done in patients with AIDS wasting found that after three months, testosterone enanthane improved lumbar BMD compared to placebo by +3.70 (95% CI 0.48, 6.92) percent, but progressive resistance training did not improve lumbar BMD (+0.40 95% CI -2.81, 3.61 percent). No group in this study had any adverse effects. AUTHORS' CONCLUSIONS: The very limited data reviewed showed that bisphosphonate therapy andin those with AIDS wasting syndrome, testosteronemay be safe and possibly effective methods to improve bone mineral density in HIV patients. The available studies are small, of short duration, and not powered to detect changes in WHO categories and fracture rates.Larger studies using bisphosphonates are currently underway. The role of colecalciferol, androgen replacement in women, and growth hormone are also under investigation. DRUG-BASED AND NON-DRUG-BASED INTERVENTIONS TO IMPROVE THE BONE MINERAL DENSITY IN PATIENTS LIVING WITH HIV: Osteoporosis is caused by bone loss, and people who have the condition are at higher risk of having a fracture. Measuring a person's bone mass density (BMD) is a way to measure his or her risk of having a fracture due to fragile bones. Decreased BMD is much more common in HIV patients than in the general population. The cause of this decrease is not certain, but it may be because of the HIV infection itself or because of the antiretroviral medications that patients with HIV take. Although patients with HIV often get fractures because of their sometimes more fragile bones, it has been shown that this bone loss is often not effectively treated in this population. This review examines the randomised controlled trials investigating treatments for bone loss in patients with HIV infection.Three trials examined the use of the drug alendronate to improve BMD in patients with HIV. These three studies were quite different from each other in terms of the populations studied and the interventions used, but even similar studies did not always have heterogeneity. A fourth study examined the use of testosterone in male patients with HIV and AIDS wasting syndrome. The four studies in this review were limited by the fact they were all very small and lasted a short amount of time, and thus they were unable to detect prevention of fractures or changes in number of patients with osteoporosis. There were also further compromises in study design. However, the limited available data show that there may be safe and perhaps effective treatments in the form of alendronate for patients with HIV who have decreased bone mineral density and, in those with AIDS wasting syndrome, testosterone.Larger studies further examining the issue of decreased BMD are currently underway |
0 | Clinical features of snake bite in southern Iran | DOD - Acute Comp Syndrome CPG | We attempt to describe the clinical features of venomous snake bites in southern Iran. In this study the complication rate has been markedly reduced compared with other developing countries. The availability of antivenom at primary health-care centres and rapid transportation facilities may change the morbidity associated with snake bites. |
0 | A comparison of anterior compartment pressures in competitive runners and cyclists | DOD - Acute Comp Syndrome CPG | Anterior compartment pressure was measured in 10 competitive runners and in 10 competitive cyclists who were asymptomatic for compartment syndrome. Pressures were measured at rest, after exercise at 80% VO2max, after maximal exercise, and 15 minutes after both exercise bouts. No difference in compartment pressure was found after exercise at 80% VO2max in runners and cyclists. Total creatinine phosphokinase enzyme levels measured before and after exercise at 80% VO2max showed a 10-fold increase in runners as compared to cyclists. Anterior compartment pressure measured after maximal exercise was significantly greater in runners as compared to cyclists. Compartment pressure showed no increase from resting values during cycling at 80% VO2max or maximal exercise. These findings suggest that patients with chronic anterior compartment syndrome may be able to cycle without elevation of compartment pressure and concomitant pain as an alternative exercise to maintain a continued degree of fitness and training. Compartment pressures should be measured during cycling in patients with chronic compartment syndrome to determine its efficacy as a method for maintenance of cardiorespiratory fitness. |
1 | Interview data versus questionnaire data in the diagnosis of carpal tunnel syndrome in epidemiological studies | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | AIMS: In most epidemiological studies on carpal tunnel syndrome (CTS), the case definition is based on questionnaire data with or without neurophysiological testing. The aim of this study was to test if the use of questionnaire data results in misclassification of cases. METHODS: In two studies, involving 940 and 311 participants, respectively, the people indicating CTS symptoms (tingling) in a questionnaire were clinically interviewed. In a subpopulation (n = 404), all went through an interview regardless of their questionnaire answers. RESULTS: Only 35-45% of the participants reporting tingling once a week or more in the questionnaire actually had symptoms consistent with CTS when interviewed. The remaining 55-65% had no or infrequent symptoms or symptoms because of other disorders. Few potential CTS cases were missed. The positive predictive values were 0.48 (95% CI = 0.30-0.66) and 0.52 (95% CI = 0.38-0.67) on the right and left hands, respectively. The sensitivities, specificities and negative predictive values ranged from 0.87 to 1.00. CONCLUSIONS: Questionnaire information overestimates the prevalence of CTS symptoms. However, asking about tingling in a questionnaire is a simple and sensitive first step to detect potential CTS cases, but symptoms should be confirmed by interview |
0 | The cost of hospitalizing hip fracture patients has increased despite shorter hospitalization time | HipFx Supplemental Cost Analysis | The cost and time of hospitalization were analysed for 4161 hip fractures in 3898 patients aged 40 years or over treated in a Danish municipality from 1970 to 1985. The mean hospitalization time decreased from 32 to 21 days (P less than 0.0005). This tendency was most pronounced for patients who were treated with osteosynthesis. However, the annual number of fractures increased from 134 to 367. Consequently, the bed use rose 79 per cent. As the number of hip fractures is predicted to increase further, the total number of bed-days required by these patients will probably also continue to increase. In addition, the standard expense per day for a hospitalized orthopaedic patient increased from 372 to 2982 DKK. Thus, the mean expense per patient was 12,000 DKK in 1970 versus 63,000 in 1985, i.e. the total expense increased 1433 per cent. After adjustment for price indexes the increase was 362 per cent. The total cost of acute hospital care of hip fractures in Denmark was estimated to be greater than 0.5 billion DKK in 1985 |
0 | Salvage of infected non-union of the tibia with an Ilizarov ring fixator | PJI DX Updated Search | PURPOSE: To review outcomes of 24 patients who underwent Ilizarov ring fixation for infected nonunion of the tibia. METHODS: Medical records of 21 men and 3 women aged 13 to 74 (mean, 38) years who underwent Ilizarov ring fixation for infected non-union of the tibia were reviewed. The mean bone defect was 3.3 (range, 2-5) cm. The mean time from injury to presentation was 11.9 (range, 1-36) months. The mean number of previous surgeries was 2 (range, 0-14). A local flap was used in 2 patients and a free flap was used in one patient. Nine of the patients underwent Ilizarov ring fixation without soft tissue and bony resection, as inadequate stability was the reason for non-union. Patients were assessed using the Association for the Study and Application of the Method of Ilizarov criteria. RESULTS: Patients were followed up for a mean of 11 (range, 8-46) months. Functional outcome was excellent in 8 patients, good in 12, fair in 2, and failure in one, whereas bone union outcome was excellent in 6 patients, good in 14, fair in one, and poor in 2. The mean time to union was 8 (range, 3-31) months. The mean external fixation index was 4.2 (range, 1.5-15.7) cm/month. Complications encountered were pin tract infection (n=5), re-fracture (n=2), soft tissue impingement by Ilizarov rings (n=2), recurrence of wound infection (n=1), mal-union (n=1), and mortality (n=1). CONCLUSION: Ilizarov ring fixation is a viable option for infected non-union of the tibia. Adequate assessment of bone union is crucial before removal of fixator to prevent re-fracture |
1 | Concentrated Bone Marrow Aspirate for the Treatment of Chondral Injuries and Osteoarthritis of the Knee: A Systematic Review of Outcomes | OAK 3 - Non-arthroplasty tx of OAK | BACKGROUND: Bone marrow aspirate concentrate (BMAC) has emerged as a novel treatment for pathology of the knee. Despite containing a limited number of stem cells, BMAC serves as a source of growth factors that are thought to play an important role as a result of their anabolic and anti-inflammatory effects. To our knowledge, there is no systematic review regarding the outcomes of bone marrow aspirate concentrate used for the treatment of chondral defects and osteoarthritis of the knee.
PURPOSE: To perform a systematic review on the outcomes of bone marrow aspirate concentrate for the treatment of chondral defects and osteoarthritis of the knee.
STUDY DESIGN: Systematic review; Level of evidence, 4.
METHODS: A systematic review of the literature was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE from 1980 to present. Inclusion criteria were as follows: use of BMAC for treatment of chondral defects and osteoarthritis of the knee, English language, and human studies. We excluded cadaveric studies, animal studies, basic science articles, editorial articles, surveys, and studies that did not include the knee. After applying inclusion and exclusion criteria, studies were evaluated for efficacy and safety of BMAC for treatment of articular cartilage knee pathologies.
RESULTS: Eleven studies were considered. Of these, 5 were prospective studies, 1 was a retrospective study, 2 were case series, and 3 were case reports. Three comparative studies (2 with level 2 evidence, 1 with level 3 evidence) were found in our search; none of them were randomized. Three studies investigated the clinical efficacy of BMAC in the treatment of osteoarthritis, and 8 studies evaluated the efficacy of BMAC on focal cartilage injuries. All 3 studies regarding osteoarthritis and all 8 studies regarding focal chondral defects reported good to excellent overall outcomes with the use of BMAC.
CONCLUSION: Although a growing interest for biological alternatives of treating knee pathology has been observed in the past few years, there still remains a paucity of high-quality studies. The studies included in this systematic review reported varying degrees of beneficial results with the use of BMAC with and without an additional procedure for the treatment of chondral defects and early stages of osteoarthritis. Most articles present the use of BMAC as a safe procedure and report good results. |
1 | Radiological changes ten years after St. Georg Sled unicompartmental knee replacement | Surgical Management of Osteoarthritis of the Knee CPG | Failure of a unicompartmental knee replacement (UKR) may be caused by progressive osteoarthritis of the knee and/or failure of the prosthesis. We have examined the fate of the other compartments of the knee by radiological assessment 10 years after operation. A total of 50 UKRs were performed on 45 carefully selected patients between 1989 and 1992. Fifteen patients died, two patients were lost to follow-up and two knees were revised. Standard long-leg weight-bearing anteroposterior views of the knee and skyline views of the patellofemoral joint were taken pre-operatively and at 8 months and 10 years after operation. The radiographs of the remaining 30 knees were reviewed three times by blind and randomized assessment to measure the progression of osteoarthritis within the joints. Two knees showed evidence of progression of osteoarthritis within the patellofemoral joint and three knees showed some progression of the opposite tibiofemoral compartment--but only on one of the radiological grading systems used for assessment. It is concluded that progression of arthritis in the unreplaced compartments is not a significant problem after fixed bearing UKR |
0 | The Liverpool Mark II knee prosthesis. A preliminary report | Surgical Management of Osteoarthritis of the Knee CPG | This is a preliminary report of the results of knee joint replacements using the Liverpool Mark II knee joint system which consists of a bicondylar prosthesis and a set of stereotactic instruments. The prosthesis has been developed from Gunston's concept, and the special instruments ensure its accurate insertion through meniscectomy-type incisions placed on either side of the patella. Particular features of the prosthesis are near-normal articulation, and the simplicity of the operation. Sixty-two knee replacements were implanted in forty-two patients between the spring of 1974 and January 1977. After the operation fifty-six knees were painless and four others produced only slight pain. Full extension was obtained in fifty-eight knees, and none showed a valgus or varus deformity. Collateral laxity was absent in all knees. There were two failures. These early results are most encouraging |
0 | Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee--the MOVE consensus | SR for PM on OA of All Extremities | OBJECTIVES: Exercise is an effective and commonly prescribed intervention for lower limb osteoarthritis (OA). Many unanswered questions remain, however, concerning the practical delivery of exercise therapy. We have produced evidence-based recommendations to guide health-care practitioners. METHODS: A multidisciplinary guideline development group was formed from representatives of professional bodies to which OA is of relevance and other interested parties. Each participant contributed up to 10 propositions describing key clinical points regarding exercise therapy for OA of the hip or knee. Ten final recommendations were agreed by the Delphi technique. The research evidence for each was determined. A literature search was undertaken in the Medline, PubMed, EMBASE, PEDro, CINAHL and Cochrane databases. The methodological quality of each retrieved publication was assessed. Outcome data were abstracted and effect sizes calculated. The evidence for each recommendation was assessed and expert consensus highlighted by the allocation of two categories: (1) strength of evidence and (2) strength of recommendation. RESULTS: The first round of the Delphi process produced 123 propositions. This was reduced to 10 after four rounds. These related to aerobic and strengthening exercise, group versus home exercise, adherence, contraindications and predictors of response. The literature search identified 910 articles; 57 intervention trials relating to knee OA, 9 to hip OA and 73 to adherence. The evidence to support each proposition is presented. CONCLUSION: These are the first recommendations for exercise in hip and knee OA to clearly differentiate research evidence and expert opinion. Gaps in the literature are identified and issues requiring further study highlighted |
0 | A nested case-control analysis of self-reported physical functioning after total knee replacement surgery in the 45 and Up Study Cohort | Surgical Management of Osteoarthritis of the Knee CPG | OBJECTIVES: The rate of total knee arthroplasty surgery (TKA) is rising in Australia despite varying impacts of TKA on physical function (PF) in population-based studies. There are potentially modifiable risk factors that could enhance PF after TKA, so we evaluated (1) the levels of PF in persons with TKA and the rest of the population, (2) potentially modifiable characteristics of those reporting poor PF after TKA. DESIGN: Nested case-control study. SETTING: Population-based cohort study in New South Wales, Australia. PARTICIPANTS: Members of a large (n=267 151) cohort study recruited by a self-completed, mailed questionnaire from 2006 to 2008. After exclusions (for hip arthroplasty, partial TKA, missing important variables and mismatching TKA status between self-reported and hospital record data), this study included 205 148 participants. PRIMARY AND SECONDARY OUTCOMES: Primary outcome, Medical Outcomes Study Physical Function scale (MOS-PF). Secondary outcome, dispensings of analgesics or anti-inflammatory drugs. RESULTS: We found 2916 TKA participants and 202 232 participants with no TKA (confirmed across datasets). Persons with TKA had a lower MOS-PF (59.9, 95% CI 58.5 to 60.6) than those without TKA (83.8, 95% CI 83.7 to 83.9). In the matched analysis, the TKA group had a lower MOS-PF (59.9, 95% CI 59.9 to 62.4) than those without TKA (68.4, 95% CI 67.8 to 69.0). In persons with TKA, lower levels of MOS-PF were associated with low self-rated health, high psychological distress, comorbidity, greater age, recent treatment for osteoarthritis and use of paracetamol. Women had an MOS-PF that was 11.6 points (95% CI 9.5 to 13.8) lower than men. CONCLUSIONS: Several modifiable risk factors have been identified to influence PF in persons receiving TKA, with notable differences between sexes. The importance of these risk factors should be examined in incident TKA to test if early identification and intervention for individuals can improve outcomes |
0 | Lateral release for patellofemoral arthritis | Surgical Management of Osteoarthritis of the Knee CPG | PURPOSE: To determine the outcome of treatment of patients with symptomatic patellofemoral osteoarthritis by closed lateral patellar retinacular release. TYPE OF STUDY: Retrospective study. METHODS: Fifty patients who underwent 53 lateral retinacular release procedures between 1995 and 1999 for the treatment of symptomatic patellofemoral arthritis were assessed by questionnaire comprising the Oxford knee score, a visual analogue scale (VAS, 0-10) for pain, and questions relating to level of patient satisfaction. Patients were included in this study whether or not tibiofemoral arthritis was present, but lateral release was performed only in those for whom the anterior knee pain of patellofemoral arthritis appeared to predominate. RESULTS: The average patient age was 53 years (range, 27 to 79 years). There were 14 men (28%) and 36 women (72%). Follow-up was a mean of 31 months (range, 12 to 65 months). Four patients underwent total knee replacement at 7, 14, 16, and 18 months after lateral release for recurrence of symptoms. In the remaining 49 knees, mean pain VAS was 3.8 +/- 2.8. In 39 knees (80%), patients judged that they had experienced a reduction in pain compared with their preoperative state (2 were pain free), 8 (16%) were unchanged, and 2 (4%) were worse. The average Oxford knee score was 27 (range, 12-48). At follow-up, 33% of patients were very satisfied, 26% satisfied, and 41% dissatisfied with their knee. The presence of tibiofemoral disease did not affect any of the outcome measures. Two patients developed superficial infections of the arthroscopic port sites. There were no cases of hemarthrosis. CONCLUSIONS: Arthroscopic lateral release is effective in reducing the pain of symptomatic patellofemoral osteoarthritis and gives reasonable rates of patient satisfaction irrespective of the presence of tibiofemoral arthritis |
0 | Serum albumin and fixation failure with cannulated hip screws in undisplaced intracapsular femoral neck fracture | Hip Fx in the Elderly 2019 | Introduction Internal fixation of undisplaced intracapsular femoral neck fractures with cannulated hip screws is a widely accepted surgical technique, despite reported failure rates of 12%-19%. This study determined whether preoperative serum albumin levels are linked to fixation failure. Methods We retrospectively reviewed 251 consecutive undisplaced intracapsular femoral neck fracture patients treated with cannulated hip screws in a district general hospital. Preoperative albumin levels were measured, and the fixation technique, classification and posterior tilt on radiography assessed. Fixation failure was defined as a screw cut, avascular necrosis (AVN) or non-union. Results Of the patients, 185 were female and 66 male. The mean age was 77 years (range 60-101 years). Thirty seven (15%) patients had fixation failure: 10 (4%) due to AVN; 12 (5%) due to non-union; and 15 (6%) due to fixation collapse. Low serum albumin levels were significantly associated with failure (p=0.01), whereas gender (p=0.56), operated side (p=0.62), age (p=0.34) and screw configuration (p=0.42) were not. A posterior tilt angle greater than 20degree on lateral radiography significantly predicted failure (p=0.002). Conclusions Preoperative serum albumin is an independent predictor of cannulated hip screw fixation failure in undisplaced femoral neck fractures. Nutritional status should therefore be considered when deciding between surgical fixation and arthroplasty to avoid the possibility of revision surgery, along with an increased risk of morbidity and mortality. |
0 | Horse-play: survey of accidents with horses | Management of Hip Fractures in the Elderly | Horse-riding is increasing in popularity. During 1971 and 1972 154 patients had horse-related injuries of sufficient severity to warrant admission to the Radcliffe Infirmary. The injuries sustained are more common and more severe than generally appreciated and are comparable to those sustained by motor-cyclists. Supervision of children is often insufficient and protective leg and head gear is commonly quite inadequate, even when worn |
0 | Focal MIBI uptake is a better indicator of active myeloma than diffuse uptake | MSTS 2022 - Metastatic Disease of the Humerus | PURPOSE: Technetium-99m 2-methoxyisobutylisonitrile (MIBI) imaging has been proposed as a front-line investigation to detect bone disease both before and after the treatment of myeloma. In this study, we have compared the pattern of MIBI uptake (focal and diffuse) between patients with proven myeloma and a cohort of patients without myeloma, in order to identify the uptake pattern that best correlates with disease activity.
METHODS: Nineteen scans were taken in 16 consecutive patients (nine males and seven females: aged 39-71 yr) with active myeloma. A further 20 scans (10 subjects having MIBI myocardial perfusion scintigraphy and 10 subjects having MIBI parathyroid adenoma localisation studies), comprised the control (non-myeloma) cohort. Scans were evaluated in a double-blinded fashion by two observers for any diffuse skeletal MIBI uptake (homogeneous uptake in spine, sternum and/or long bones), and/or abnormal focal uptake (patchy, focal or tubular uptake in the skeleton or soft tissues).
RESULTS: The pattern of MIBI uptake was significantly different in the myeloma-positive subjects and the control cohort. Focal uptake was highly discriminatory, being seen in 15 of 19 (79%) scans of the myeloma-positive group as opposed to one of 20 (5%) scans of the control group (P < 0.0001). In contrast, diffuse uptake was seen in 17 of 19 (89%) scans in patients with myeloma, and in 11 of 20 (55%) of the control cohort (P = 0.02). Using multiple logistic regression analysis, any focal uptake was significantly predictive for active myeloma (P = 0.0007) but diffuse uptake was not (P = 0.15). Diffuse uptake alone, without focal uptake, was found in four of 19 scans with myeloma and in 10 of 20 without active myeloma, but was not significantly associated with absence of active myeloma (P = 0.06). Using the criteria of Pace et al. for positivity (diffuse activity >50% myocardial activity), we demonstrated improved specificity from 45% to 100%, but significantly impaired sensitivity for presence of myeloma (79% vs. 37%, P = 0.02).
CONCLUSION: Our study thus illustrates that the presence of any focal uptake of MIBI is useful in indicating active myeloma whereas diffuse uptake is not. |
0 | Neurobehavioral disorders | DoD PRF (Psychosocial RF) | Neurobehavioral disorders are composed of a large group of behavioral impairments seen in association with brain disease (e.g., stroke, multiple sclerosis, dementia, and neuro-oncological conditions), transient as well as permanent brain impairments (e.g., metabolic and toxic encephalopathies), and/or injury (e.g., trauma, hypoxia, and/or ischemia). The neurorehabilitative assessment and management of such disorders is often poorly addressed in the context of overall neurological, psychiatric, and rehabilitative care. Too often, more basic, yet critical, aspects of behavioral assessment and treatment are not addressed or only superficially addressed by evaluating clinicians. Physicians often overly rely on pharmacological interventions as initial and/or sole treatment approaches rather than taking a pragmatic biopsychosocial approach that focuses on holistic disease state management. This chapter provides readers with an overview of the common behavioral impairments associated with brain dysfunction due to disease, injury, or toxicity. Details regarding the nature of impairments such as localization-related syndromes, affective disorders and personality disorders, among others are expounded. Principles of neurobehavioral assessment and treatment are examined including general guidelines for eliciting a history and physical, behavioral analysis, and functional behavioral assessment. General treatment caveats are provided including discussion of impairment and disability adaptation, and creation of positive behavioral supports. The topic of pharmacological management of neurobehavioral disorders is covered in numerous other references including Chapter 33 of this text. |
1 | Perioperative antibiotics in radical cystectomy with ileal conduit urinary diversion: efficacy and risk of antimicrobial prophylaxis on the operation day alone | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | OBJECTIVE: To determine the optimum schedule for perioperative antimicrobial prophylaxis (AMP) for bladder cancer patients submitted to radical cystectomy with ileal conduit urinary diversion. METHODS: We studied 77 consecutive bladder cancer patients who underwent radical cystectomy with ileal conduit. The 1-day group (n = 33) received pre-, intra- and postoperative administrations of 2 g of piperacillin on the operation day alone; the 3-day group (n = 44) received antibiotics for 3 days or more (same schedule as the 1-day group on the operation day and every 12 h thereafter). The study was designed and postoperative complications including surgical-site infection (SSI) were defined according to the modified Centers for Disease Control and Prevention criteria. RESULTS: No significant differences were found between the 1-day group and 3-day group in terms of total SSI (18.1% vs 20.5%), superficial incisional SSI (12.1% vs 13.6%), deep incisional SSI (12.1% vs 13.6%), space SSI (12.1% vs 11.4%), postoperative ileus (18.2% vs 11.4%), febrile urinary tract infections (15.2% vs 15.9%) or pneumonia (3.0% vs 4.3%), respectively. In both groups, disease stage and patients' underlying conditions such as diabetes did not have an influence on the incidence of postoperative complications. CONCLUSION: One-day AMP had equivalent efficacy to that of the standard prophylaxis protocol for preventing septic complications following radical cystectomy with ileal conduit. This finding supports the hypothesis that delivery of antibiotics on the operation day is critical in this setting |
0 | Age- and Sex-Related Changes in Bone Microarchitecture and Estimated Strength: A Three-Year Prospective Study Using HRpQCT | Distal Radius Fractures | Although projections from cross-sectional studies have shown that bone loss leading to osteoporosis begins around menopause in women and later in life in men, this has not been examined longitudinally in population-based studies using high-resolution technology capable of distinguishing cortical (Ct) and trabecular (Tb) bone microarchitecture. The aim of this 3-year prospective study was to investigate age- and sex-related changes in bone compartment-specific geometry, volumetric bone mineral density (vBMD), microarchitecture, and estimated strength. The distal radius and tibia were imaged at baseline and after 3 years (median 3.0; range, 2.7 to 3.9 years) using high-resolution peripheral computed tomography (HRpCT) in an age- and sex-stratified, population-based, random sample of white men and women (n = 260) aged 21 to 82 years. In general, at the radius and tibia there was a moderate annual increase in cortical thickness (Ct.Th) that seemed to offset the increase in cortical porosity (Ct.Po), resulting in net annual increase in cortical vBMD (Ct.vBMD) in premenopausal women and young men. With advancing age, postmenopausal women displayed significant bone loss with decreased trabecular vBMD (Tb.vBMD) (due to loss of entire trabeculae) and Ct.vBMD (manifested as increase in Ct.Po and decrease in Ct.Th) at the radius, and a decline in Ct.vBMD (with increasing Ct.Po) at the tibia, resulting in loss of estimated bone strength. In contrast, men had a lower rate of bone loss with advancing age with smaller increases in Ct.Po at both the skeletal sites. In summary, the pattern of bone loss in men and women was discrepant, with women losing more bone than men with aging, although with a dominance of cortical over trabecular bone loss at the peripheral sites in both sexes. This conforms to epidemiological evidence that most fractures occurring in old age are predominantly at cortical peripheral sites, with women having a higher incidence of fractures than men at any given age. © 2016 American Society for Bone and Mineral Research. |
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