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A comparison of three methods of wound closure following arthroplasty: a prospective, randomised, controlled trial
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Management of Hip Fractures in the Elderly
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We carried out a blinded prospective randomised controlled trial comparing 2-octylcyanoacrylate (OCA), subcuticular suture (monocryl) and skin staples for skin closure following total hip and total knee arthroplasty. We included 102 hip replacements and 85 of the knee.OCA was associated with less wound discharge in the first 24 hours for both the hip and the knee. However, with total knee replacement there was a trend for a more prolonged wound discharge with OCA. With total hip replacement there was no significant difference between the groups for either early or late complications. Closure of the wound with skin staples was significantly faster than with OCA or suture. There was no significant difference in the length of stay in hospital, Hollander wound evaluation score (cosmesis) or patient satisfaction between the groups at six weeks for either hips or knees. We consider that skin staples are the skin closure of choice for both hip and knee replacements
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The translated Danish version of the Western Ontario Meniscal Evaluation Tool (WOMET) is reliable and responsive
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AMP (Acute Meniscal Pathology)
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PURPOSE: The purpose of this study was to translate and cross-culturally adapt the Western Ontario Meniscal Evaluation Tool (WOMET) for use in Denmark and evaluate its test-retest reliability and comparative responsiveness.
METHODS: Sixty patients (mean age 50 years (range 19-71 years), females 57%) with meniscal injury scheduled for arthroscopic meniscal surgery at a small Danish hospital in the period from September 2017 to February 2018 were included in this study. The WOMET was translated into Danish using forward and backward translation. The WOMET was completed at baseline (pre-surgery), at 3 and 6 months postoperatively. Additionally, reliability was assessed at 3 months and 3 months plus 1 week, for patients with a stable symptom state (global response question) between test and retest. Comparative responsiveness was assessed between the WOMET and the Knee Injury and Osteoarthritis Outcome Score (KOOS4-aggregate score of 4 of the 5 KOOS subscales).
RESULTS: The Danish version of WOMET showed excellent test-retest reliability, intraclass correlation coefficient of 0.88 (95% CI 0.84-0.92) for the total score. The standard error of measurement was 125 points and the minimal detectable change was 347 points (i.e. 8% and 22% of the total score, respectively). The WOMET was responsive with an effect size (ES) of 1.12 at 6 months after surgery, which was comparable to the KOOS4 (ES 1.10).
CONCLUSION: The Danish version of the WOMET is a reliable and responsive measure of health-related quality of life in patients with meniscal pathology.
LEVEL OF EVIDENCE: Level II.
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Using Cumulative Load to Explain How Body Mass Index and Daily Walking Relate to Worsening Knee Cartilage Damage Over Two Years: The MOST Study
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Knee cartilage damage is often linked to mechanical overloading. However, cartilage requires mechanical load to remain healthy, suggesting that underloading may be detrimental. We examined knee overloading and underloading by defining cumulative load as the joint effects of body mass index (BMI) and daily walking, and examined the relation of cumulative load to worsening cartilage damage over two years. METHODS: We used data from the Multicenter Osteoarthritis Study. BMI and steps/day via accelerometry were measured at the 60-month visit. Cartilage damage on magnetic resonance imaging (MRI) was semi-quantitatively scored using WORMS at the 60-month and 84-month visits; worsening damage was defined as increased WORMS between visits. Risk ratios and 95% confidence intervals (RR[95%CI]) were calculated using binomial regression, adjusting for potential confounders. RESULTS: We included 964 participants (66.9 ± 7.5 years, 62% female, BMI: 29.7 ± 4.8 kg/m2 , 7153 ± 2591 steps/day). Participants with moderate (6000-7900) or high (>7900) steps/day and high BMI (>31 kg/m2 ) had 2.83[1.46-5.48] and 2.61[1.50-4.54] times the risk for worsening medial tibiofemoral damage, respectively, compared with those with similar steps/day and low BMI (18-27 kg/m2 ). Participants with low (<6000) steps/day and low BMI had 2.03[1.06-3.92] and 2.28[1.06-4.85] times the risk for worsening medial tibiofemoral and lateral patellofemoral damage, respectively, compared with those with high steps/day and low BMI. Effect estimates for other compartments did not reach statistical significance. CONCLUSIONS: This study provides preliminary evidence that both overloading and underloading may be detrimental to medial tibiofemoral cartilage, and underloading may be detrimental for lateral patellofemoral cartilage.
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Fixation of distal radial epiphyseal fracture: Comparison of K-wire and prebent intramedullary nail
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Distal Radius Fractures
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Objective: To compare the use of crossed K-wire and prebent intramedullary nail techniques for the fixation of distal radius metaphyseal fracture in children. Methods: Intraoperative and follow-up data for children with distal radius metaphyseal fracture, treated using crossed K-wire or prebent intramedullary nail fixation, were retrospectively analysed. Patient groups were matched for age, sex and clinical parameters (fracture location, affected side, fracture type). Results: Patients treated using prebent intramedullary nail fixation (n = 52) had significantly shorter surgery duration, fewer intraoperative X-radiographs, and lower prevalence of postoperative redisplacement and malalignment deformity than those treated using crossed K-wire fixation (n = 52). Both techniques resulted in similar postoperative complications and recovery of forearm rotation. Conclusions: Prebent intramedullary nail fixation has a better functional outcome than crossed K-wire fixation in the treatment of distal radial epiphyseal fracture in children.
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Median nerve stiffness measurement by shear wave elastography: a potential sonographic method in the diagnosis of carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVES: To measure the median nerve (MN) stiffness by quantitative shear wave elastography (SWE) at the carpal tunnel inlet and to determine whether SWE can be used in the diagnosis of carpal tunnel syndrome (CTS). METHODS: The study included 37 consecutive patients (60 wrists) with a definitive diagnosis of CTS and 18 healthy volunteers (36 wrists). The MN cross-sectional area (CSA) by ultrasound and stiffness by SWE were studied. The difference between CTS patients and controls, and the difference among subgroups based on electrodiagnostic tests were studied by the Student's t test. Interobserver variability and ROC analysis were performed. RESULTS: The MN stiffness was significantly higher in the CTS group (66.7 kPa) when compared to controls (32.0 kPa) (P < 0.001), and higher in the severe or extreme severity group (101.4 kPa) than the mild or moderate severity group (55.1 kPa) (P < 0.001). A 40.4-kPa cut-off value on SWE revealed sensitivity, specificity, PPV, NPV and accuracy of 93.3%, 88.9%, 93.3%, 88.9% and 91.7%, respectively. Interobserver agreement was excellent for SWE measurements. CONCLUSIONS: Median nerve stiffness at the carpal tunnel inlet is significantly higher in patients with carpal tunnel syndrome, for whom shear wave elastography appears to be a highly reproducible diagnostic technique. KEY POINTS: * Clinical examination is important for diagnosis of carpal tunnel syndrome * Shear wave elastography (SWE) offers new clinical opportunities within diagnostic ultrasound * SWE is highly reproducible in evaluation of median nerve stiffness * Median nerve stiffness is significantly increased in carpal tunnel syndrome * Elastography could become useful in diagnosis of carpal tunnel syndrome
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Relationship between cup position and obturator externus muscle in total hip arthroplasty
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PJI DX Updated Search
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BACKGROUND: It is often challenging to find the causes for postoperative pain syndromes after total hip replacement, since they can be very allotropic. One possible cause is the muscular impingement syndrome. The most commonly known impingement syndrome is the psoas impingement. Another recently described impingement syndrome is the obturator externus muscle impingement. The aim of this study is to analyze pathological conditions of the Obturator externus and to show possible causes. METHODS: 40 patients who had undergone a total hip replacement were subjected to clinical and MRI examinations 12 months after the surgery. The Harris Hip Score (HHS) was used to analyze pain and function. Additionally, a satisfaction score and a pain score (VAS) were determined. The MRI allowed for the assessment of the spatial relation between the obturator externus muscle and the acetabulum. Also measured were the acetabular inclination angle as well as the volume and cross-sectional area of the obturator externus muscle. RESULTS: The patients were assigned to 3 groups in accordance with their MRI results. Group 1 patients (n = 18) showed no contact between the obturator externus and the acetabulum. Group 2 (n = 13) showed contact, and group 3 (n = 9) an additional clear displacement of the muscle in its course. It was not possible to establish a connection between the imaging findings, the HHS, the VAS, and patient satisfaction. What was striking, however, was a significant difference between the median inclination angle in group 1 (40 degrees +/- 5.4 degrees ) and group 3 (49 degrees +/- 4.7 degrees ) (p < 0.05), and the corresponding image-morphological pathology. The average inclination angle in group 2 was 43.3 degrees +/- 3.8 degrees CONCLUSION: Contact between the obturator externus muscle and the caudal acetabula border occurs frequently, but is only rarely accompanied by a painful muscular impingement. The position of the acetabula must be seen as one of the main risk factors for contact between the acetabula border and the obturator. The hip replacement process must provide for sufficient osseous coverage of the caudal acetabula border. Furthermore, the retention of the transverse ligament may serve as protective cover for the incisura acetabuli
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Meniscal allograft transplantation. Part 2: systematic review of transplant timing, outcomes, return to competition, associated procedures, and prevention of osteoarthritis
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SR for PM on OA of All Extremities
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PURPOSE: To provide a systematic review of the literature regarding five topics in meniscal allograft transplantation (MAT): optimal timing for transplantation, outcomes, return to competition, associated procedures, and prevention of osteoarthritis. METHODS: A systematic literature search was conducted using the PubMed (MEDLINE), ScienceDirect, and EBSCO-CINAHL databases. Articles were classified only in one topic, but information contained could be reported into other topics. Information was classified according to type of study (animal, in vitro human, and in vivo human) and level of evidence (for in vivo human studies). Specific inclusion criteria were determined for the outcomes and prevention of osteoarthritis topics. RESULTS: Twenty-four studies were finally included: two optimal timing, seven outcomes, three return to competitive sport, 16 MAT and associated procedures, and 5 MAT and prevention of osteoarthritis (some studies were categorized in more than one topic). These studies corresponded to 2 animal studies and 31 in vivo human studies (1 level II, 1 level III, and 29 level IV). CONCLUSIONS: The principal conclusions were as follows: (a) there is no evidence to support that MAT has to be performed at the same time or immediately after meniscectomy to prevent development of postmeniscectomy syndrome; (b) MAT successfully improves symptoms, function, and quality of life at 7-to-14 years of follow-up (level IV evidence); (c) the overall failure rate (need for knee arthroplasty) is 10-29 % at long-term follow-up; (d) MAT allows return to same level of competition in 75-85 % of patients at short- to mid-term follow-up (only three studies level IV evidence with small sample size); (e) associated cartilage procedures or anterior cruciate ligament reconstruction to MAT does not worsen the results; (f) MAT may prevent progression of cartilage damaged at long-term follow-up, but may not prevent degeneration in previously healthy cartilage. LEVEL OF EVIDENCE: Systematic review of level II-IV studies, Level IV
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Characterization of Meniscal Pathology Using Molecular and Proteomic Analyses
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Surgical Management of Osteoarthritis of the Knee CPG
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The meniscus is a complex tissue and is integral to knee joint health and function. Although the meniscus has been studied for years, a relatively large amount of basic science data on meniscal health and disease are unavailable. Genomic and proteomic analyses of meniscal pathology could greatly improve our understanding of etiopathogenesis and the progression of meniscal disease, yet these analyses are lacking in the current literature. Therefore, the objective of this study was to use microarray and proteomic analyses to compare aged-normal and pathologic meniscal tissues. Meniscal tissue was collected from the knees of five patient groups (n = 3/group). Cohorts included patients undergoing meniscectomy with or without articular cartilage pathology, patients undergoing total knee arthroplasty with mild or moderate-severe osteoarthritis, and aged-normal controls from organ donors. Tissue sections were collected from the white/white and white/red zones of posterior medial menisci. Expression levels were compared between pathologic and control menisci to identify genes of interest (at least a x1.5 fold change in expression levels between two or more groups) using microarray analysis. Proteomics analysis was performed using mass spectrometry to identify proteins of interest (those with possible trends identified between the aged-normal and pathologic groups). The microarray identified 157 genes of interest. Genes were categorized into the following subgroups: (1) synthesis, (2) vascularity, (3) degradation and antidegradation, and (4) signaling pathways. Mass spectrometry identified 173 proteins of interest. Proteins were further divided into the following categories: (1) extracellular matrix (ECM) proteins; (2) proteins associated with vascularity; (3) degradation and antidegradation proteins; (4) cytoskeleton proteins; (5) glycolysis pathway proteins; and (6) signaling proteins. These data provide novel molecular and biochemical information for the investigation of meniscal pathology. Further evaluation of these disease indicators will help researchers develop algorithms for diagnostic, therapeutic, and prognostic strategies related to meniscal disorders
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A High Amount of Local Adipose Tissue Is Associated with High Cortical Porosity and Low Bone Material Strength in Older Women
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Obesity is associated with increased risk of fractures, especially at skeletal sites with a large proportion of cortical bone, such as the humerus and ankle. Obesity increases fracture risk independently of BMD, indicating that increased adipose tissue could have negative effects on bone quality. Microindentation assesses bone material strength index (BMSi) in vivo in humans. The aim of this study was to investigate if different depots of adipose tissue were associated with BMSi and cortical bone microstructure in a population based group of 202 women, 78.2 ± 1.1 (mean ± SD) years old. Bone parameters and subcutaneous (s.c.) fat were measured at the tibia with an XtremeCT device. BMSi was assessed using the OsteoProbe device, and based on at least 11 valid reference point indentations at the mid-tibia. Body composition was measured with dual X-ray absorptiometry. BMSi was inversely correlated to body mass index (BMI) (r = -0.17, p = 0.01), whole body fat mass (r = -0.16,p = 0.02), and, in particular, to tibia s.c. fat (r = -0.33, p < 0.001). Tibia s.c. fat was also correlated to cortical porosity (Ct.Po; r = 0.19, p = 0.01) and cortical volumetric BMD (Ct.vBMD; r = -0.23, p = 0.001). Using linear regression analyses, tibia s.c. fat was found to be independent of covariates (age, height, log weight, bisphosphonates or glucocorticoid use, smoking, calcium intake, walking speed, and BMSi operator) and associated with BMSi (β = -0.34,p < 0.001), Ct.Po (β = 0.18, p = 0.01), and Ct.vBMD (β = -0.32, p < 0.001). BMSi was independent of covariates associated with cortical porosity (β = -0.14, p = 0.04) and cortical volumetric BMD (β = 0.21, p = 0.02) at the distal tibia, but these bone parameters could only explain 3.3% and 5.1% of the variation in BMSi, respectively. In conclusion, fat mass was independently and inversely associated with BMSi and Ct.vBMD, but positively associated with Ct.Po, indicating a possible adverse effect of adipose tissue on bone quality and bone microstructure. Local s.c. fat in tibia was most strongly associated with these bone traits, suggesting a local or paracrine, rather than systemic, negative effect of fat on bone.
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Updates and Advances in the Management of Lateral Meniscal Radial Tears: A Critical Analysis Review
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AMP (Acute Meniscal Pathology)
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Because of their increased mobility, lack of resistance to hoop stresses, and decreased blood supply, radial tears of the lateral meniscus are more troublesome to heal than vertical longitudinal tears. Given the success of meniscal root repairs, radial tears of the lateral meniscal body should be given strong consideration for repair because of a more reproducible ability to heal such lesions in young, active patients. Technique options that should be considered for the less common anterior radial tears of the lateral meniscus include outside-in repair, self-capturing suture-passing devices, and orthobiologic treatments to stimulate healing. Although a variety of suture techniques, including the double horizontal mattress and horizontal butterfly patterns, have demonstrated improvements in patient outcomes, evidence is still limited with regard to the ideal suture pattern for radial tears.
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Total knee replacement. Postacute phase in rehabilitation: Objectives and strategies in postacute treatment
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Surgical Management of Osteoarthritis of the Knee CPG
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Identification of a population with homogeneous characteristics is the fundamental introduction to elaborate a rehabilitation plan after operation of total knee arthroplasty (TKA). The main objectives of our rehabilitative protocol are: improvement of the preoperative clinical state, prevention and management of the common postoperative problems and complications. The first objective requires the improvement of the function of the operated knee (good articular excursion, muscular strengthening and recovery of ambulation and of gait pattern), as well as the reduction of pain. These protocol objectives are progressively achieved spreading postoperative rehabilitative strategies into four stages, during which patient should take instruction about the adoption of a correct life style
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Residential status and risk of hip fracture
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Management of Hip Fractures in the Elderly
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OBJECTIVE: to examine the association between residential status and risk of hip fracture in older people. DESIGN: population-based case-control study. SETTING: Auckland, New Zealand. SUBJECTS: a random sample of all individuals > or = 60 years, hospitalized with a fracture of the proximal femur between July 1991 and February 1994. Controls were age and gender frequency-matched to the cases, randomly selected from a random sample of general practitioners. MAIN OUTCOME MEASURES: radiographically-confirmed fracture of the proximal femur. Fractures sustained as a result of major trauma, such as in a motor vehicle crash, and those associated with pre-existing pathological conditions were excluded. RESULTS: individuals living in institutions were almost four times more likely to sustain a hip fracture [age- and gender-adjusted odds ratio (OR)=3.8; 95% confidence interval (CI): 3.0-4.8] than those living in private homes. After adjustment for potential confounding factors, the risk of hip fracture associated with living in an institution remained significantly increased (P< 0.0001), although the magnitude of the risk was somewhat diminished (OR=2.2; 95% (CI: 1.5-3.5). CONCLUSIONS: living in an institution is associated with an increased risk of hip fracture in older people. Specific factors that place these individuals at increased risk need to be identified, in order to develop intervention strategies
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Posterior interosseous nerve syndrome from thermal injury
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Distal Radius Fractures
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Background. Due to anatomical proximity to bone, the radial nerve is the most frequently injured major nerve of the upper extremity, frequently secondary to fractures (Li et al. (2013)). We describe an incidence when a branch of the radial nerve is injured as a result of a thermal injury. Observation. Radial nerve injury can occur anywhere along the anatomical course with varied etiologies, but commonly related to trauma. The most frequent site is in the proximal forearm involving the posterior interosseous branch. However, problems can occur at the junction of the middle and proximal thirds of the humerus and wrist radially. When the radial nerve is injured by a burn, a new rehabilitation dynamic arises. Not only does one agonize about the return of nerve function but also fret about the skin grafts that replaced the devitalized tissue housing that compartment. Discussion. Although posterior interosseous nerve syndrome has been described in the context of many different etiologies, it has not previously been discussed in relation to burn injuries. In this case, not only did the patient's rehabilitation involve aggressive therapy for return of sensation and function of the arm, but also prevention of contracture normally seen in replacement of full thickness burns.
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Gait during hydrokinesitherapy following total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose. To obtain gait parameters during hydrotherapy (HT) in patients who were referred for rehabilitation after primary total knee arthroplasty (TKA). Method. The study had a cohort prospective design. Patients who had undergone TKA followed a HT rehabilitation programme. Twenty-two consecutive patients were enrolled. Four of them dropped out for various reasons, independently of HT. Therefore 18 patients could be evaluated (5 men and 13 women). Eighteen age-matched healthy volunteers were the control subjects. Nine patients had a right TKA and nine a left TKA. On the average HT duration was 18.4 days (SD 1.4). Results. The patients presented with a mean speed of 912 (SD 275) meters per hour (m/h) at the baseline. At the last session the mean speed was 1330 (SD 416) m/h. The mean stance duration was 1.75 s (SD 0.34) on the operated side and 1.83 s (SD 0.41) on the non-operated side. By contrast, the mean swing duration was 1.10 s (SD 0.25) on the operated side and 1.13 s (SD 0.34) on the non-operated side. The step duration was the same on both sides. At the beginning of HT the mean stance/swing ratio was 1.94 on the operated side, whereas it was 1.77 on the non-operated side. In the controls the ratio was 1.46. At the beginning the mean stride length was 0.526 m (SD 0.147) and the value became 0.556 (SD 0.138) after 18 training sessions. At the individual level, recovery occurred in a non-linear fashion (Best Fitting, 7th-grade Fourier finite series). Conclusions. The study design permits accurate definition of stride parameters during rehabilitation which allows optimization of the programme. Increase in speed and regain of balance are the main targets of a HT programme and are monitored on a daily basis
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Regulation of gbpC expression in Streptococcus mutans
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Streptococcus mutans, the principal causative agent of dental caries, produces four glucan-binding proteins (Gbp) that play major roles in bacterial adherence and pathogenesis. One of these proteins, GbpC, is an important cell surface protein involved in biofilm formation. GbpC is also important for cariogenesis, bacteremia, and infective endocarditis. In this study, we examined the regulation of gbpC expression in S. mutans strain UA159. We found that gbpC expression attains the maximum level at mid-exponential growth phase, and the half-life of the transcript is less than 2 min. Expression from PgbpC was measured using a PgbpC-gusA transcriptional fusion reporter and was analyzed under various stress conditions, including thermal, osmotic, and acid stresses. Expression of gbpC is induced under conditions of thermal stress but is repressed during growth at low pH, whereas osmotic stress had no effect on expression from PgbpC. The results from the expression analyses were further confirmed using semiquantitative reverse transcription-PCR analysis. Our results also reveal that CovR, a global response regulator in many Streptococcus spp., represses gbpC expression at the transcriptional level. We demonstrated that purified CovR protein binds directly to the promoter region of PgbpC to repress gbpC expression. Using a DNase I protection assay, we showed that CovR binds to DNA sequences surrounding PgbpC from bases -68 to 28 (where base 1 is the start of transcription). In summary, our results indicate that various stress conditions modulate the expression of gbpC and that CovR negatively regulates the expression of the gbpC gene by directly binding to the promoter region
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Large fresh osteochondral allografts for the hip: growing the evidence
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Osteochondritis Dissecans 2020 Review
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INTRODUCTION: Articular cartilage lesions of the hip are difficult to effectively treat. Osteochondral allograft (OCA) transplantation in the knee has been associated with long-term success, but OCA for the hip has not been extensively studied. Here, we present the clinical and radiological outcomes from a cohort of 10 patients treated with fresh OCA transplants for large osteochondral defects of the femoral head and/or acetabulum. METHODS: 10 patients who had undergone osteochondral allograft transplantation of the femoral head and/or acetabulum at our institution between 2013 and 2016 were identified from our Institutional Review Board-approved registry. Hip disability and Osteoarthritis Outcome Score (HOOS) was used to track patient progress. RESULTS: 10 patients with an average clinical follow-up of 1.4 years were included in this study. 4 patients were treated solely with OCA plugs for femoral head defects, while the remaining 6 received femoral OCA plugs and at least 1 concomitant procedure for additional intraarticular pathology. 7 patients (70%) had successful functional outcomes, while 3 (30%) had unsuccessful outcomes and were subsequently converted to total hip arthroplasty (THA) 5 to 29 months after OCA. CONCLUSIONS: OCA transplantation can be an effective treatment strategy for young, healthy individuals with articular cartilage lesions of the hip. Smoking, avascular necrosis aetiology, acetabular involvement and concomitant procedures may be risk factors for unsuccessful outcomes necessitating salvage with THA. Long-term clinical studies to refine indications and determine functional outcomes and survival rates are warranted.
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Minimally Invasive Versus Open Distal Fibular Plating for AO/OTA 44-B Ankle Fractures
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Open reduction and internal fixation (ORIF), the standard treatment for unstable ankle fractures, has well-known wound complications. Minimally invasive surgery (MIS) has been proposed to decrease these complications. The objectives of this study were to describe an algorithm of MIS for fibular plating and compare the radiographic restoration of fibular anatomy, functional outcomes, and complications between ORIF and MIS for ankle fractures.
METHODS: This retrospective study included 71 patients with AO/OTA 44-B ankle fractures treated by a single surgeon. ORIF group consisted of 34 patients (54.5-month follow-up) and MIS group was composed of 37 patients (55.9-month follow-up). Among 37 MIS patients, 13 patients were treated with minimally invasive percutaneous plate osteosynthesis and 24 patients with minimally invasive trans-fracture approach according to our MIS algorithm. Operative outcomes were evaluated and compared between the 2 groups by radiographic measurements, functional assessment, and complications.
RESULTS: The MIS group had less blood loss but longer operative time and greater exposure to fluoroscopy. Radiographic measurements revealed similar union time, fibular length, talocrural angle, medial clear space, and tibiofibular clear space in both groups. Lower visual analogue pain score was observed in the MIS group in the early postoperative period. At last follow-up, there were no significant differences regarding pain score, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and range of motion between the 2 groups. Total complication rate was significantly higher in the ORIF group.
CONCLUSION: Patients with AO/OTA 44-B fractures treated with MIS fibular plating achieved similar radiographic and functional outcomes but had less pain in the early postoperative period and fewer wound complications compared with those treated with ORIF.
LEVEL OF EVIDENCE: Level III, retrospective comparative study.
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Assessment of clinical and MRI outcomes after mesenchymal stem cell implantation in patients with knee osteoarthritis: a prospective study
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Cartilage regenerative procedures using the cell-based tissue engineering approach involving mesenchymal stem cells (MSCs) have been receiving increased interest because of their potential for altering the progression of osteoarthritis (OA) by repairing cartilage lesions. The aim of this study was to investigate the clinical and magnetic resonance imaging (MRI) outcomes of MSC implantation in OA knees and to determine the association between clinical and MRI outcomes.
DESIGN: Twenty patients (24 knees) who underwent arthroscopic MSC implantation for cartilage lesions in their OA knees were evaluated at 2 years after surgery. Clinical outcomes were evaluated according to the International Knee Documentation Committee (IKDC) score and the Tegner activity scale, and cartilage repair was assessed according to the MRI Osteoarthritis Knee Score (MOAKS) and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score.
RESULTS: The clinical outcomes significantly improved (P < 0.001 for both). The cartilage lesion grades (as described in MOAKS [grades for size of cartilage-loss area and percentage of full-thickness cartilage loss]) at follow-up MRI were significantly better than the preoperative values (P < 0.001 for both). The clinical outcomes at final follow-up were significantly correlated with the MOAKS and MOCART score at follow-up MRI (P < 0.05 for all).
CONCLUSIONS: Considering the encouraging clinical and MRI outcomes obtained and the significant correlations noted between the clinical and MRI outcomes, MSC implantation seems to be useful for repairing cartilage lesions in OA knees. However, a larger sample size and long-term studies are needed to confirm our findings.
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Quantitative analysis of the difference between an intact complete discoid lateral meniscus and a torn complete discoid meniscus on MR imaging: a feasibility study for a new classification
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To determine the quantitative difference between an intact complete discoid lateral meniscus (CDLM) and a torn CDLM on MR imaging.
MATERIALS AND METHODS: Between May 2005 to November 2009, 137 patients with a CDLM (107 intact CDLM and 30 torn CDLM) and 92 patients with a normal meniscus were included in this study. The evaluated parameters were the height of the posterior horn of the lateral and medial menisci on the sagittal images and their ratio as assessed by two observers twice at an interval of 1 month. Each parameter was analyzed based on the Kruskal Wallis test, and the analysis using the mixed model. Intraclass correlation coefficient (ICC) was used to determine the interobserver reliabilities at session 2.
RESULTS: The mean heights of the posterior horn of the lateral and medial menisci on the sagittal images for an intact CDLM, a torn CLDM, and a normal meniscus were 6.5, 7.3, 5.7 and 6.6, 6.4, 6.7 mm at session 1, respectively. The mean heights of the posterior horn of the lateral and medial menisci on the sagittal images for an intact CDLM, a torn CDLM, and a normal meniscus for both observers were 6.5, 7.2, 5.7 and 6.6, 6.3, 6.8 mm at session 2, respectively. The ratio of the height of the lateral to the height of the medial meniscus for an intact CDLM at both sessions for both observers was 1.0. The ratios were 1.2 and 0.8 for a torn CDLM and for a normal meniscus, respectively, at both sessions for observer 1. The ratios were 1.2 and 0.9 for a torn CDLM and for a normal meniscus, respectively, at session 2 for observer 2. The heights of the posterior horn of the lateral meniscus on the sagittal images and the ratios of the heights of the lateral to the medial menisci in all three groups were statistically significantly different for both sessions (p < 0.0001). The interobserver ICCs for each parameter of both an intact CDLM and a torn CDLM at session 2 showed high correlations (p < 0.0001).
CONCLUSION: The height of the lateral meniscus and the ratio of the height of the lateral to the height of the medial meniscus for a torn CDLM were significantly higher than those for an intact CDLM.
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Percutaneous brachial artery access for coronary artery procedures: Feasible and safe in the current era
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DOD - Acute Comp Syndrome CPG
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Background: Percutaneous vascular access for coronary intervention is currently achieved predominately via the radial route, the femoral route acting as a backup. Percutaneous trans-brachial access is no longer commonly used due to concerns about vascular complications. This study aimed to investigate the safety and feasibility of percutaneous brachial access when femoral and radial access was not possible. Methods: This is a retrospective data analysis of patients who attended a single tertiary cardiology centre in the UK between 2005 and 2014 and had a coronary intervention (coronary angiogram or PCI) via the brachial route. The primary endpoints were procedural success and the occurrence of vascular complications. Results: During the study period 26602 patients had a procedure (15655 underwent PCI and 10947 diagnostic angiography). Of these, 117 (0.44% of total) had their procedure performed via the brachial route. The procedure was successful in 96% (112/117) of cases. 13 (11%) patients experienced post procedural complications, of which 2 (1.7%) were serious. There were no deaths. Conclusion: Percutaneous trans-brachial arterial access is feasible with a high success rate and without evidence of high complication rate in a rare group of patients in whom femoral or sometimes radial attempts have failed.
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Antimicrobial activity of calcium hydroxide liners on Streptococcus sanguis and S. mutans
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The antimicrobial activity of 10 calcium hydroxide liners on Streptococcus sanguis and S. mutans was studied. One hundred plates of tryticose soy agar-sheep red blood cells (10%), each with four distinct 3 mm diameter wells, were divided into two groups of 50. One group was inoculated with S. sanguis and the second group with S. mutans. A 4 mg liner was placed in each of three wells; the fourth well was left empty as a control. Plates were incubated at 37 degrees C and observed at 24 hours, 48 hours, and 7 days. All liners inhibited growth of both organisms. The inhibitory zones for S. mutans were larger than inhibitory zones for S. sanguis for all tested liners. Life Fast Set material had significantly less inhibitory effect on S. mutans. VLC Dycal, Life, and Life Fast Set materials had significantly less inhibitory effect on S. sanguis at p = 0.05
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0 |
Capsular closure to prevent posterior dislocation after primary total hip arthroplasty through the posterior approach
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Management of Hip Fractures in the Elderly
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Posterior dislocation remains the most frequent early complication after Total Hip Arthroplasty (THA) carried out through a posterior approach. In our experience, the preservation of the capsule and its closure after insertion of the prosthetic components significantly reduced our rate of posterior dislocation. We compared 2 groups of patients similar in size (186 versus 174 cases) and characteristics: all cases were done by one surgeon, with the same surgical technique, the same implants and the same post-operative care. The only difference between the 2 groups was the capsulectomy in the group 1 and the capsular closure in group 2. In this retrospective study, 22 dislocations were noted in group 1 (capsulectomy), but only one dislocation in group 2 (capsular closure). This additional technique preventing posterior dislocation after THA seemed to be efficient
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Vascularized os pisiform for reinforcement of the lunate in Kienböck's disease: An average of 12 years of follow-up study
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Glenohumeral Joint OA
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Purpose: Little is known about the long-term results of vascularized bone transplantation for Kienböck's disease. This retrospective study investigated the long-term results of vascularized pisiform transfer. Methods: We reviewed 23 patients to analyze results after vascularized pisiform transposition to a cored-out lunate for Lichtman stages II and III. Patients with ulnar-minus variance received additional radial shortening. Results: Pain improved in 20 of 23 patients. Range of motion increased significantly relative to preoperative values but was only 80% that of opposite side. Grip power was 84% of the contralateral hand. At follow-up evaluation the mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 15.3 ± 17.9 and the mean Cooney score was 82.4 ± 10.0. Radiologically, out of 20 patients with preoperative x-rays Lichtman stage was unchanged in 11, improved in 3, and progressed in 6 patients. No patient showed radiologic signs of arthritis before surgery. At follow-up evaluation osteoarthritis was found in 7 of 22 patients. The majority of degenerative changes were of low grade and were seen at the radiocarpal joint. Conclusions: The results show high patient satisfaction and good function after vascularized bone transplantation for Kienböck's disease. In the long term vascularized pisiform transfer prevented lunate collapse in 16 of 22 patients. Copyright © 2005 by the American Society for Surgery of the Hand.
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Association of plasma n-6 and n-3 polyunsaturated fatty acids with synovitis in the knee: The MOST study
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OAK 3 - Non-arthroplasty tx of OAK
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In osteoarthritis (OA) the synovium is often inflamed and inflammatory cytokines contribute to cartilage damage. Omega-3 polyunsaturated fatty acids (n-3 PUFAs) have anti-inflammatory effects whereas omega-6 polyunsaturated fatty acids (n-6 PUFAs) have, on balance, proinflammatory effects. The goal of our study was to assess the association of fasting plasma phospholipid n-6 and n-3 PUFAs with synovitis as measured by synovial thickening on contrast enhanced (CE) knee MRI and cartilage damage among subjects in the Multicenter Osteoarthritis Study (MOST).MOST is a cohort study of individuals who have or are at high risk of knee OA. An unselected subset of participants who volunteered obtained CE 1.5. T MRI of one knee. Synovitis was scored in six compartments and a summary score was created. This subset also had fasting plasma, analyzed by gas chromatography for phospholipid fatty acid content, and non-CE MRI, read for cartilage morphology according to the Whole-Organ Magnetic Resonance Imaging Score (WORMS) method. The association between synovitis and cartilage morphology and plasma PUFAs was assessed using logistic regression after controlling for the effects of age, sex, and BMI.472 out of 535 subjects with CE MRI had complete data on synovitis, cartilage morphology and plasma phospholipids. Mean age was 60 years, mean BMI 30, and 50% were women. We found an inverse relation between total n-3 PUFAs and the specific n-3, docosahexaenoic acid with patellofemoral cartilage loss, but not tibiofemoral cartilage loss or synovitis. A positive association was observed between the n-6 PUFA, arachidonic acid, and synovitis.In conclusion, systemic levels of n-3 and n-6 PUFAs which are influenced by diet, may be related to selected structural findings in knees with or at risk of OA. Future studies manipulating the systemic levels of these fatty acids may be warranted to determine the effects on structural damage in knee OA. © 2012 Osteoarthritis Research Society International.
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Fluoroscopy-guided reduction and fibular nail fixation to manage unstable ankle fractures in patients with diabetes: A retrospective cohort study
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OAK 3 - Non-arthroplasty tx of OAK
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Aims: Patients with diabetes are at increased risk of wound complications after open reduction and internal fixation of unstable ankle fractures. A fibular nail avoids large surgical incisions and allows anatomical reduction of the mortise. Patients and Methods: We retrospectively reviewed the results of fluoroscopy-guided reduction and percutaneous fibular nail fixation for unstable Weber type B or C fractures in 24 adult patients with type 1 or type 2 diabetes. The re-operation rate for wound dehiscence or other indications such as amputation, mortality and functional outcomes was determined. Results: Two patients developed lateral side wound infection, one of whom underwent wound debridement. Three other patients required re-operation for removal of symptomatic hardware. No patient required a below-knee amputation. Six patients died during the study period for unrelated reasons. At a median follow-up of 12 months (7 to 38) the mean Short Form-36 Mental Component Score and Physical Component Score were 53.2 (95% confidence intervals (CI) 48.1 to 58.4) and 39.3 (95% CI 32.1 to 46.4), respectively. The mean Visual Analogue Score for pain was 3.1 (95% 1.4 to 4.9). The mean Ankle Osteoarthritis Scale total score was 32.9 (95% CI 16.0 to 49.7). Conclusion: Fluoroscopy-guided reduction and fibular nail fixation of unstable ankle fractures in patients with diabetes was associated with a low incidence of wound and overall complications, while providing effective surgical fixation.
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1 |
Applications of Bayesian statistical methodology to clinical trial design: A case study of a phase 2 trial with an interim futility assessment in patients with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Development of new pharmacological treatments for osteoarthritis that address unmet medical needs in a competitive market place is challenging. Bayesian approaches to trial design offer advantages in defining treatment benefits by addressing clinically relevant magnitude of effects relative to comparators and in optimizing efficiency in analysis. Such advantages are illustrated by a motivating case study, a proof of concept, and dose finding study in patients with osteoarthritis. Patients with osteoarthritis were randomized to receive placebo, celecoxib, or 1 of 4 doses of galcanezumab. Primary outcome measure was change from baseline WOMAC pain after 8 weeks of treatment. Literature review of clinical trials with targeted comparator therapies quantified treatment effects versus placebo. Two success criteria were defined: one to address superiority to placebo with adequate precision and another to ensure a clinically relevant treatment effect. Trial simulations used a Bayesian dose response and longitudinal model. An interim analysis for futility was incorporated. Simulations indicated the study had >=85% power to detect a 14-mm improvement and <=1% risk for a placebo-like drug to pass. The addition of the second success criterion substantially reduced the risk of an inadequate, weakly efficacious drug proceeding to future development. The study was terminated at the interim analysis due to inadequate analgesic efficacy. A Bayesian approach using probabilistic statements enables clear understanding of success criteria, leading to informed decisions for study conduct. Incorporating an interim analysis can effectively reduce sample size, save resources, and minimize exposure of patients to an inadequate treatment.
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Modified classification and single-stage microsurgical repair of posttraumatic infected massive bone defects in lower extremities
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DoD LSA (Limb Salvage vs Amputation)
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Posttraumatic infected massive bone defects in lower extremities are difficult to repair because they frequently exhibit massive bone and/or soft tissue defects, serious bone infection, and excessive scar proliferation. This study aimed to determine whether these defects could be classified and repaired at a single stage. A total of 51 cases of posttraumatic infected massive bone defect in lower extremity were included in this study. They were classified into four types on the basis of the conditions of the bone defects, soft tissue defects, and injured limb length, including Type A (without soft tissue defects), Type B (with soft tissue defects of 10 � 20 cm or less), Type C (with soft tissue defects of 10 � 20 cm or more), and Type D (with the limb shortening of 3 cm or more). Four types of single-stage microsurgical repair protocols were planned accordingly and implemented respectively. These protocols included the following: Protocol A, where vascularized fibular graft was implemented for Type A; Protocol B, where vascularized fibular osteoseptocutaneous graft was implemented for Type B; Protocol C, where vascularized fibular graft and anterior lateral thigh flap were used for Type C; and Protocol D, where limb lengthening and Protocols A, B, or C were used for Type D. There were 12, 33, 4, and 2 cases of Types A, B, C, and D, respectively, according to this classification. During the surgery, three cases of planned Protocol B had to be shifted into Protocol C; however, all microsurgical repairs were completed. With reference to Johner-Wruhs evaluation method, the total percentage of excellent and good results was 82.35% after 6 to 41 months of follow-up. It was concluded that posttraumatic massive bone defects could be accurately classified into four types on the basis of the conditions of bone defects, soft tissue coverage, and injured limb length, and successfully repaired with the single-stage repair protocols after thorough debridement. © 2013 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.
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Association of knee injuries with accelerated knee osteoarthritis progression: data from the Osteoarthritis Initiative
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: We aimed to evaluate whether a recent knee injury was associated with accelerated knee osteoarthritis (OA) progression.
METHODS: In the Osteoarthritis Initiative, we studied participants free of knee OA on their baseline radiographs (Kellgren/Lawrence [K/L] <2). We compared 3 groups as follows: 1) individuals with accelerated progression of knee OA: defined as having at least 1 knee that progressed to end-stage knee OA (K/L grade 3 or 4) within 48 months, 2) common knee OA progression: at least 1 knee increased in radiographic scoring within 48 months (excluding those defined as accelerated knee OA), and 3) no knee OA: no change in K/L grade in either knee. At baseline, participants were asked if their knees had ever been injured, and at each annual visit they were asked about injuries during the prior 12 months. We used multinomial logistic regressions to determine whether a new knee injury was associated with the outcome of accelerated knee OA or common knee OA progression, after adjusting for age, sex, body mass index, static knee malalignment, and systolic blood pressure.
RESULTS: A knee injury during the total observation period was associated with accelerated knee OA progression (n = 54; odds ratio [OR] 3.14) but not common knee OA progression (n = 187; OR 1.08). Furthermore, a more recent knee injury (within a year of the outcome) was associated with accelerated (OR 8.46) and common knee OA progression (OR 3.12).
CONCLUSION: Recent knee injuries are associated with accelerated knee OA. Most concerning is that certain injuries may be associated with a rapid cascade toward joint failure in less than 1 year.
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Body mass index and recovery of activities of daily living in older patients with femoral fracture: An analysis of a national inpatient database in Japan
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Hip Fx in the Elderly 2019
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Objective: To evaluate the effects of body mass index (BMI) on recovery of activities of daily living (ADL) in older Asian patients with femoral fracture registered in a nationwide inpatient database in Japan. Methods: We retrospectively analyzed data of patients aged â?¥65 years with acute femoral fracture between April 2014 and November 2017 in the Diagnosis Procedure Combination database. Patients were classified into the following categories based on BMI (kg/m2): underweight (<18.5); normal weight (18.5â??22.9); overweight (23â??27.4); obese (â?¥27.5); and missing data. Demographic data included age, sex, type of fracture, comorbidities, and Barthel Index (BI). The primary outcome was BI at discharge and secondary outcomes were the overall complication rate and discharge to home. Results: In total, data for 13,348 patients were extracted from the database, of whom 80.3 % were female. At discharge, underweight patients had lower BI than overweight or obese patients. In multivariable analysis, underweight and missing BMI data were associated with lower BI at discharge (partial regression coefficients â??2.324 and â??5.763, respectively). In contrast, overweight and obese were correlated with higher BI (3.080 and 5.732, respectively). Underweight was independently associated with a higher overall complication rate (odds ratio 1.195) and a lower rate of discharge to home (odds ratio 0.865). Conclusions: Underweight was associated with poorer performance in ADL, higher risk of complications, and lower rate of discharge to home in older Asian patients with femoral fracture. Overweight and obese had positive effects on ADL.
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Brown Syndrome Following Upper Eyelid Ptosis Repair
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Upper Eyelid and Brow Surgery
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Brown syndrome is characterised by impaired supraduction worse in adduction due to a restricted superior oblique tendon passing through the trochlea. A few reports have previously described Brown syndrome after upper eyelid surgery, including blepharoplasty and ptosis repair. The authors describe two additional cases of Brown syndrome following ptosis repair. The first case is a 65-year-old woman with new-onset vertical binocular diplopia following bilateral levator advancement surgery. Ocular motility examination demonstrated moderate impairment of elevation in adduction. The second case is a 35-year-old woman who presented with new-onset intermittent binocular diplopia following right upper lid ptosis repair. Examination revealed large vertical fusional amplitudes and a large left intermittent hyperphoria in an alignment pattern consistent with Brown syndrome. Despite presenting after surgery, these cases differ in mechanism. The first case likely occurred due to intraoperative impairment of the superior oblique tendon sheath or trochlea, whereas the second case represented an unmasking of a long-standing, previous vertical strabismus that was consistent with a Brown syndrome pattern.
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Preclinical identification of TTR-related amyloidosis (hereditary and wild type) with 99mTc-DPD scintigraphy: A cohort study of 12.400 subjects
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Purpose: We have previously shown that 99mTc-3,3-diphosphono-1,2- propanodicarboxylic acid (99mTc-DPD) scintigraphy has a high affinity for TTRinfiltrated myocardium, allowing an accurate diagnosis of both mutant and wildtype cardiac amyloidosis. The potential role of this method as preclinical screening tool has not yet been evaluated. This study aimed to evaluate prevalence and diagnostic implications of incidental myocardial uptake among patients who underwent scintigraphy for oncologic or rheumatologic reasons. Methods:We retrospectively analysed all DPD scintigraphies performed between 2008 and May 2013 in outpatients referred to our Nuclear Medicine Unit for oncologic or rheumatologic reasons and assessed clinical and instrumental details of patients with incidental myocardial tracer uptake. Results: Incidental myocardial uptake was detected in 45 subjects (0.36%): 28 males (62%), median age 81 [77-84]. Prevalence was higher among men and increased progressively with age: age (less-than or equal to)60, 0 patients; age 61-70, men 4% and women 2%; age 71-80, men 22% and women 20%; age (greater-than or equal to)81, men 36% and women 16%. Fourteen of the 45 patients agreed to undergo a cardiological evaluation. Among these, 11 (79%) were males with a median age of 82 [70 - 88] years. Four were symptomatic for dyspnea (NYHA II). One patient had a pacemaker. Carpal tunnel syndrome had been previously diagnosed in 3 cases. None of them had overt neurologic symptoms. ECG was abnormal in all cases, showing atrial fibrillation in 4 patients, left anterior hemiblock in 2, isolated ST-T abnormalities in 4, abnormal Q waves in 3 and low QRS voltage in 1 case. Echocardiographically, increased left ventricular (LV) wall thickness was detected in all patients (LV wall thickness 14 [IQR 13-15] mm). LV nullhypertrophynull was completely unexplained by hypertension or valvular heart disease in 10 cases and was out of proportion in the remaining 4. Genetic analysis was performed in 6 cases and documented an Ile68Leu TTR mutation in a single patient. Endomyocardial biopsy was performed in the 5 patients in which no mutation was found and detected TTR-related myocardial amyloid infiltration in all. These patients received a final diagnosis of wild-type TTR-related amyloidotic cardiomyopathy (Senile Systemic Amyloidosis, SSA). Conclusions: DPD scintigraphy appears to be specific for a preclinical identification of patients affected by TTR-related amyloidotic cardiomyopathy (mainly the form related to the deposition of wild-type TTR) and can be useful for non-invasive screening of subjects at risk for this disease
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Effect of a continuous peripheral nerve block on the inflammatory response in knee arthroplasty
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AAHKS (2) Corticosteroids
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BACKGROUND AND OBJECTIVES: Experimental nerve block in animals inhibits the inflammatory response. The purpose of this study was to determine to what extent a 48-hour local anesthetic block of all afferent and efferent nerve fibers of the knee area has an impact on postoperative inflammatory response.
METHODS: Twelve patients scheduled for primary total knee arthroplasty received spinal anesthesia, and then were randomly allocated to either patient-controlled analgesia with morphine (n = 6) or a combination of continuous lumbar plexus and sciatic nerve blocks (continuous peripheral nerve block; CPNB) with ropivacaine 0.2% for 48 hours. Blood samples were collected before surgery and at 3, 8, 24, and 48 hours after surgical incision to measure plasma glucose, serum insulin and cortisol, C-reactive protein, interleukin-6, and leukocyte count. Pain visual analog scale at rest and on knee flexion were recorded and complications classified.
RESULTS: Visual analog scale was lower in the CPNB group at rest and on knee flexion on postoperative days 1 and 2 (P < .05). There were no differences in circulating levels of glucose, insulin, and cortisol. C-reactive protein and leukocyte count were lower in the CPNB group (P < .05). There was a positive correlation between the peak leukocyte count and the inflammatory markers (P < .03). Three patients in the patient-controlled analgesia group and one in the CPNB group had complications requiring conservative management.
CONCLUSIONS: Continuous lumbar plexus and sciatic nerve blocks with ropivacaine contribute to the attenuation of the postoperative inflammatory response.
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1 |
Heroin-related compartment syndrome: An increasing problem for acute care surgeons
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DOD - Acute Comp Syndrome CPG
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Heroin use has been increasing in the United States with the rate of heroin overdose nearly quadrupling in the last 10 years. Heroin overdose can occasionally lead to compartment syndrome (CS) because of extended periods of immobility and pressure tissue injury. Heroin-related compartment syndrome (HRCS) has previously been described, but has been limited to isolated case reports. We sought to examine our experience with HRCS in the climate of rising rates of heroin use among the general population. Medical records of all patients undergoing operative decompression for a CS at our academic medical center over a six-year period (2010-2015) were examined. Patient demographics, operation performed, and etiology were recorded. Cases of HRCS were identified, and clinical outcomes examined. A total of 213 patients undergoing fasciotomy were identified. Twenty-two of these patients had HRCS. Heroin was the second most common etiology of CS after trauma. Only one case of HRCS presented during the first three years of the study period, with the remaining 95 per cent of cases occurring within the last three years. The most common single location for HRCSs was gluteal (31.8%); 36 per cent of HRCS patients needed dialysis and 27 per cent suffered complications such as tissue loss. The incidence of HRCS has increased dramatically over the past several years and is now the second most common etiology for CS in our patient population. Patients with HRCS may present with severe manifestations of CS and different body areas affected.
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Survivorship of the native hip joint after percutaneous repair of acetabular fractures in the elderly
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Management of Hip Fractures in the Elderly
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Our purpose was to examine survivorship of the native hip joint in patients ages 60 and over who underwent percutaneous reduction and fixation of acetabular fractures. A retrospective review at a University Level I Trauma Center was performed. Our institutional trauma database was reviewed. Patients aged 60 or older treated with percutaneous reduction and fixation of acetabular fractures between 1994 and 2007 were selected. 79 consecutive patients with 80 fractures were identified. Rate of conversion to total hip arthroplasty were used to construct a Kaplan-Meier curve showing survivorship of the native hip joint after treatment. 75 fractures had adequate clinical follow-up with a mean of 3.9 years (range 0.5-11.9 years). Average blood loss was 69 cc and there were no postoperative infections. 19/75 (25%) were converted to total hip arthroplasty at a mean time of 1.4 years after the index procedure. Survivorship analysis demonstrated a cumulative survival of 65% at 11.9 years of follow-up. There were no conversions to arthroplasty beyond 4.7 years postoperatively. There were no statistically significant associations between conversion to arthroplasty and age, sex, closed vs. limited open reduction, and simple vs. complex fracture pattern. Percutaneous fixation is a viable treatment option for patients age 60 or greater with acetabular fractures. Rates of conversion to total hip arthroplasty are comparable to open treatment methods and if conversion is required, soft tissues are preserved for future surgery
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0 |
Patella Dislocation
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Osteochondritis Dissecans 2020 Review
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In brief Whenever a patient has a patella dislocation, osteochondral fractures should be considered. A case study involving a 17-year-old swimmer whose knee was injured playing baseball details a patella dislocation that was accompanied by a defect of the medial patellar facet and a lateral impaction lesion of the lateral femoral gutter-both producing loose bodies. Careful physical examination and a radiographic series that includes anteroposterior, lateral, notch, and sunrise patella views assist in making an accurate diagnosis and guide the clinician to the appropriate treatment. Treatment involves a knee stabilizer followed by aggressive quadriceps strengthening. Loose bodies require arthroscopic surgery.
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B-vitamin mixture improves the analgesic effect of diclofenac in patients with osteoarthritis: a double blind study
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Surgical Management of Osteoarthritis of the Knee CPG
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According to the high consumption of the mixture of B vitamins and diclofenac in several countries, this combination has constituted a frequently used option in pain therapy from inflammatory origin. Although the evidence obtained from inflammatory pain animal models has shown the existence of analgesic synergy between diclofenac and the B vitamins mixture, the corresponding clinical evidence is scarce. A double-blind, randomized clinical trial study was designed to characterize the analgesic effect and safety of diclofenac and B vitamins against diclofenac alone in patients with severe osteoarthritis. Forty eight patients programmed to total knee arthroplasty with a pain level >/=7 in a 1-10 cm visual analogue scale were allocated to receive a single intramuscular injection of sodium diclofenac (75 mg) alone or combined with thiamine (100 mg), pyridoxine (100 mg) and cyanocobalamin (5 mg), and the pain level was evaluated during 12 h post-injection. Diclofenac+B vitamins mixture showed a superior analgesic effect during the assessed period and also a better assessment of the pain relief perception by patients than diclofenac alone. This study constitutes a clinical support on the improvement of the analgesic effect of diclofenac by B vitamins in patients with osteoarthritis programmed to total knee arthroplasty, as a clinical model of inflammatory pain
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Prophylactic antibiotic therapy for chronic bronchitis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND: The use of prophylactic antibiotics to reduce the frequency and severity of acute exacerbations of chronic bronchitis is controversial. OBJECTIVES: To determine if prophylactic antibiotics reduce the frequency of exacerbations and/or days of disability in subjects with chronic bronchitis. SEARCH STRATEGY: We searched the Cochrane Airways Group Register of Clinical Trials and the bibliographies of relevant articles. SELECTION CRITERIA: Randomised controlled trials of prophylactic antibiotics in patients with chronic bronchitis and/or COPD were selected. DATA COLLECTION AND ANALYSIS: The eligibility of studies for inclusion was evaluated by three independent reviewers. MAIN RESULTS: Nine trials involving 1055 subjects were included in the analysis. All were performed before 1970. Concealment of allocation was assessed as clearly adequate in only 3 studies. The likelihood of having a exacerbation at any time during the course of the study was decreased with treatment (Relative Risk 0.91, 95% Confidence Intervals (CI) 0.84, 0.99). There was a small reduction in the number of exacerbations per patient per year with prophylactic antibiotics but this was not statistically significant ( Weighted Mean Difference (WMD) -0.15, 95%CI -0.34, 0.04 ). There was a modest but significant reduction of 22% in the number of days of disability per patient per month treated ( WMD -0.95, 95%CI -1.89 to - 0.01 ). A parallel reduction in the days of disability for each exacerbation (WMD -2.08, 95% CI -4.08 to -0.07) was seen. There was a small increase in adverse effects with antibiotics. REVIEWER'S CONCLUSIONS: Prophylactic antibiotics in chronic bronchitis / COPD have a small but statistically significant effect in reducing the days of illness due to exacerbations of chronic bronchitis. They do not have a place in routine treatment because of concerns about the development of antibiotic resistance and the possibility of adverse effects. The available data are over 30 years old, so the pattern of antibiotic sensitivity may have changed and there is a wider range of antibiotics in use
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Relationship between change in femoral neck bone mineral density and hip fracture incidence during treatment with strontium ranelate
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Management of Hip Fractures in the Elderly
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OBJECTIVE: Strontium ranelate (SR) increases bone mineral density (BMD) in postmenopausal osteoporotic women and reduces vertebral and non-vertebral fracture incidence. Hip fracture reduction has also been observed during 3-year treatment with SR in osteoporotic women at high risk of hip fracture. The objective of this study is to analyse the association between BMD changes and hip fracture incidence during treatment with SR. MATERIAL AND METHODS: In this post-hoc analysis, 465 women aged over 74 years with low BMD at the femoral neck (T-score < or = -2.4 according to NHANES normative values) were selected from the population of a recently published study (the Treatment of Peripheral Osteoporosis Study - TROPOS). BMD was assessed at the femoral neck at baseline and after a follow-up of 3 years. Hip fractures were reported by study investigators. RESULTS: After adjusting for age, body mass index, femoral neck BMD at baseline and number of prevalent vertebral fractures, we found that for each 1% increase in femoral neck BMD observed after 3 years, the risk to experience a hip fracture after 3 years decreased by 7% (95% CI: 1-14%) (p = 0.04). In patients experiencing a hip fracture over 3 years of treatment with SR, femoral neck BMD increased by (mean [SE]) 3.41 (1.02)% compared to 7.23 (0.81)% in patients without hip fracture (p = 0.02). CONCLUSION: In this post-hoc analysis of women undergoing 3 years of SR treatment, an increase in femoral neck BMD is associated with a decrease in hip fracture incidence
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Surgical site infections in patients of orthopedic - trauma unit in district hospital in 2008-2012
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Hip Fx in the Elderly 2019
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THE PURPOSE OF THE STUDY: The purpose of this study was to evaluate the prevalence and structure of surgical site infections in the Department of Orthopaedis - Trauma Unit in Regional Hospital. St. Luke in Tarnow in 2008-2012.
MATERIALS AND METHODS: Data analysis included 7189 patients operated in 2008-2012. The data collection and analysis used standard statistical tools and definitions for nosocomial infections issued by the U.S. Centers for Disease Control and Prevention (CDC).
RESULTS: In the study group it was 91 cases of SSI (surgical site infection), including 35 patients (38%) with post-operative open reduction of long bone fracture (FX), 16 (18%) with reduction of closed fractures (CR), 15 patients (16%) undergoing hip endoprosthesis (HPRO), 13 (14%) with open reduction surgery of small bones (OR-OTHER), 4 (4%) after knee endoprosthesis surgery (KPRO), and 8 (9%), after treatments of other infections (OTHER). The latter have not been taken into account in the further analysis due to the small number and variety of surgical procedures. The incidence of SSI was for: FX from 2.6 (2008) to 4.1 (2011); CR from 1.2 (2012) 4.8 (2008), HPRO from 0.7 (2012) to 1.3 (2009 r.), OR-OTHER from 0 (2009) to 4.5 (2010); KPRO from 0 (2010-2012) to 2.1 (2009). Among the etiological factors isolated from clinical materials derived from patients diagnosed with infections dominated Gram-positive bacteria, especially Staphylococcus-aureus: HPRO-40%, KPRO-75% FX-46%, OR-OTHER-62%, CR-63%, OTHER -38%. Strains resistant to methicillin (MRSA) were not reported.
CONCLUSION: Prevention measures implemented in many areas of the potential impact on risk factors for SSI, has helped to achieve in 2012, the lowest rate of infection for all the analyzed procedures in the last 5 years. Conducting targeted surveillance of surgical site infection keeps morbidity associated with SSI at an acceptably low level and allows for precise planning of the preventive measures in this area.
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0 |
Peripheral motor axons of SOD1(G127X) mutant mice are susceptible to activity-dependent degeneration
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OAK 3 - Non-arthroplasty tx of OAK
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Motor neuron disorders may be associated with mitochondrial dysfunction, and repetitive electrical impulse conduction during energy restriction has been found to cause neuronal degeneration. The aim of this study was to investigate the vulnerability of motor axons of a presymptomatic late-onset, fast-progression SOD1(G127X) mouse model of amyotrophic lateral sclerosis to long-lasting, high-frequency repetitive activity. Tibial nerves were stimulated at ankle in 7 to 8-month-old SOD1(G127X) mice when they were clinically indistinguishable from wild-type (WT) mice. The evoked compound muscle action potentials and ascending compound nerve action potentials were recorded from plantar muscles and from the sciatic nerve, respectively. Repetitive stimulation (RS) was carried out in interrupted trains of 200-Hz for 3h. During the stimulation-sequence there was progressive conduction failure in WT and, to a lesser extent, in the SOD1(G127X). By contrast, 3 days after RS the electrophysiological responses remained reduced in the SOD1(G127X) but recovered completely in WT. Additionally, morphological studies showed Wallerian degeneration in the disease model. Nerve excitability testing by "threshold-tracking" showed that axons recovering from RS had changes in excitability suggestive of membrane hyperpolarization, which was smaller in the SOD1(G127X) than in WT. Our data provide proof-of-principle that SOD1(G127X) axons are less resistant to activity-induced changes in ion-concentrations. It is possible that in SOD1(G127X) there is inadequate energy-dependent Na(+)/K(+) pumping, which may lead to a lethal Na(+) overload.
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0 |
More Than Epiphyseal Osteochondromas: Updated Understanding of Imaging Findings in Dysplasia Epiphysealis Hemimelica (Trevor Disease)
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Osteochondritis Dissecans 2020 Review
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OBJECTIVE: The purpose of this article is to discuss approaches to imaging dysplasia epiphysealis hemimelica in the context of recent advances in the understanding of the underlying pathophysiologic profile of this entity, which may result in pain, growth disturbance, and early development of osteoarthritis. CONCLUSION: Dysplasia epiphysealis hemimelica was first characterized as a skeletal disorder with osteochondromas characteristically involving epiphyses on one side of the same lower extremity. Upper extremity involvement was subsequently recognized. Previously conceptualized as epiphyseal osteochondromatosis, recent investigations have uncovered differences between these osteocartilaginous lesions and osteochondromas.
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Pharmacological agents and bone healing
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AAHKS (2) Corticosteroids
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Osteoporosis is the most common alteration of bone metabolism. It derives from an increase in bone resorption with respect to bone formation and is characterized by microarchitectural alterations, decreased bone mass and increased risk of fracture. The coupling between bone formation and resorption is a fundamental concept in skeletal metabolism, and it explains how a certain amount of removed tissue can be replaced by the same amount of new bone. Various substances used to treat osteoporosis may also be used for orthopaedic conditions such as fracture healing, implant fixation, bone grafts and osteonecrosis. Fracture healing consists in the replacement of the lost bone by a tissue that has the same biomechanical properties as those preceding the fracture. The repair process is triggered by the local response to the tissue injury that damaged the continuity of bone. The duration of each phase of the healing process can vary significantly, depending on the site and characteristics of the fracture, on patient related factors and on the treatment choice. While most of the fractures heal with conventional treatment, they can also cause permanent damage and complications, especially in a certain kind of patients. Osteoporosis and old age may contribute in delaying or impairing the reparative process. In animal models the healing process is slower in older and/or ovariectomized animals. Biomechanical tests have also shown that bone strength is compromised in human osteoporotic cadaver bone. The same problems were highlighted in the surgical treatment of fractures in osteoporotic patients. Mainly in the treatment of hip fractures there is an increased risk of cut-out, re-fractures and implant failure in patients with osteoporosis. Preclinical studies have shown that certain pharmacological agents (bisphosphonates, strontium ranelate, teriparatide) may enhance osseointegration and stimulate reparative processes. They may be administered systemically and/or used locally at the fracture site on the implant surface. The aim of fracture treatment is to restore bone biomechanical properties and to allow restoring normal function at the affected site. If the new pharmacological approaches could be translated into clinical benefit and offered to patients with osteoporosis or other factors that put at risk the process of healing (subjects with severe loss of substance or fractures at high risk of complications), they could represent a valuable aid in the treatment of fractures.
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Human genetics in Burma
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Developmental Dysplasia of the Hip CPG
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Contrary to earlier reports from Asia, trisomy 21 is common in Burma and other chromosome abnormalities are found. A variety of dominant, recessive and X-linked genetic disorders occur. Twins are found in 1% of births and MZ and DZ twins are equally common. Thalassaemia and meningomyelocele are relatively common while congenital dislocation of the hip and phenylketonuria are very rare. The intensity of inbreeding had been measured by survey and found to be F = 0.0005 in Rangoon and F = 0.0015 in villages around Hlegu
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Reconstruction of the segmental mandibular defect: Current state of the art
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MSTS 2018 - Femur Mets and MM
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PURPOSE OF REVIEW: This article reviews literature pertaining to advances in the reconstruction of segmental mandibular defects in the context of an established standard of care, microvascular transfer of free osteocutaneous flaps. RECENT FINDINGS: Most literature reiterates established reconstructive techniques. Exceptions include the use of computer-assisted modeling to preoperatively design the excision of both the mandible and fibula segments and to produce a template for contouring the neomandible, the design of new flaps, distraction osteogenesis and techniques for dealing with osteonecrosis. SUMMARY: The microvascular transfer of free osteocutaneous flaps remains the standard of care, with the fibula flap the clear favorite. Review of the evolution of this flap for segmental mandibular reconstruction provides the bulk of the literature. Improvement on this standard of practice continues to be elusive, in large part because of the effects of associated radiation. Tissue engineering holds promise but no current practical application is available. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.
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The Effect of Vitamin C on Wound Healing In Mandibular Fracture Patients
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Distal Radius Fractures
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In a prospective, randomized clinical trial of de novo mandibular fracture patients requiring intraoral surgical repair with plating, the investigators will: 1. Compare the effects of supplemental vitamin C to placebo on soft tissue wound healing, measured by a) biomarkers of soft tissue repair (Procollagen I and III, Matrix Metalloâ?Proteinases 1,2,3 & 9, Câ?reactive protein, neutrophil count, Interleukins 6 & 8, TBARS and TEAC) and b) clinical outcomes (wound dehiscence and Wound Score). Hypothesis1: Supplemental vitamin C will improve soft tissue healing postâ?mandibular fracture, measured by improved procollagen I, other biomarker levels and clinical outcomes, compared to placebo. Rationale. The clinical literature describes impaired soft tissue wound healing in mandibular fracture patients, including wound infection, wound dehiscence, and plate exposure. Vitamin C is a necessary coâ?factor for the production of types I and III collagen, as well as procollagen, the precursor to collagen, via the hydroxylation of proline and lysine. In the setting of vitamin C deficiency, collagen production is abnormal leading to defective vessel and connective tissue formation with degradation of unstable collagen molecules.90â?91,34, 63, 108,109 The investigators will collect a robust set of clinical outcomes including clinician evaluation and Wound Healing Score to measure soft tissue healing. Biomarkers of soft tissue wound healing will be used to measure biochemical healing pathways as well. As a precursor to collagen, procollagen I and III are widely used biomarkers of collagen production in wound healing research. The investigators will assess these levels at baseline and at 3 to 5weeks postâ?operatively to evaluate the effect of vitamin C on collagen production. In addition, the antioxidant effects of vitamin C are critical during the ordered phases of wound healing, from the inflammatory phase (including the initial hemostatic cascade) to the proliferative phase. Antioxidant depletion during these phases results in imbalanced proteolytic enzyme cascades (including matrix metalloproteinases or MMPs) with resulting tissue destruction as well as an overâ?exuberant inflammatory milieu. Further, the antioxidant deficit resulting from vitamin C deficiency results in diminished monocyte and neutrophil chemotaxis and diminished bacteriocidal oxidative burst capabilities. Thus, the investigators will additionally measure the effects of vitamin C supplementation on proteolytic enzyme pathways (MMPs) and systemic markers of infection and inflammation (neutrophil count, câ?reactive protein level, interleukins (IL) 1 and 6). Finally, the investigators will use indicators of oxidative stress at baseline and 6 weeks to measure the effects of vitamin C supplementation on antioxidant capacity (TBARS and TEAC). 2. Compare the effects of supplemental vitamin C to placebo on bone repair, measured by a) biomarkers of bone repair (alkaline phosphatase, TRACP 5b, osteocalcin, RANKL, osteoprotegerin, and carboxy terminal collagen crosslinks) and b) clinical outcomes (radiologic imaging and pain). Hypothesis 2: Supplemental vitamin C will improve bone healing postâ?mandibular fracture, measured by improved biomarkers of bone healing and more robust radiological bone imaging, compared to placebo. Rationale. A body of literature, from animal studies to randomized clinical trials, supports the notion that vitamin C is necessary for bone health and healing. Multiple animal studies demonstrate that vitamin C promotes bone formation / mineralization, strengthens developing callous, and supports bone maintenance. Further, a number of studies show that supplemental vitamin C prevents fracture in menopausal women and may be protective against arthritis.10,11,12,69 Several well done randomized controlled clinical trials have shown that supplemental vitamin C diminishes regional pain syndrome after distal radius fractures and less robust data suggests this for foot and ankle fractures. Wellâ?done randomized controlled clinical trials are neede to develop Vitamin C guidelines in traumatic facial fracture. The investigators will collect a comprehensive set of biochemical, clinical, and radiological outcome measures to evaluate bony healing after mandibular fracture. The biomarker evaluation will include assessment of osteoblast and osteoclast number (alkaline phosphatase and TRACP 5b respectively), osteoblast activity (osteocalcin), osteoclast differentiation (receptor activator for nuclear factor, B ligand or RANKL and osteoprotegerin or decoy receptor for RANKL) and osteoclast activity (carboxy terminal collagen crosslinks). The investigators will measure clinical outcomes about 1 and 3 to 5 weeks postoperatively. Finally, each subject will undergo a nonâ?contrast CT of the mandible 3to 5 weeks postâ?operatively for radiological evaluation of bone healing. The CT scan may or may not be standard of care.30,36,135 3. Determine the effects of supplemental vitamin C on soft tissue and bone healing by smoking status in patients with traumatic mandibular fracture. Hypothesis 3: Current smokers will have a higher prevalence of vitamin C deficiency than nonsmokers at baseline, and vitamin C supplementation will improve soft tissue and bone healing more in smokers than nonsmokers. Rationale. Despite clinical evidence for smokingâ?related impairment in wound healing, much is unknown about the pathophysiologic mechanisms underlying this effect.21. It is postulated that after injury, smoking impedes the inflammatory phase of wound healing by diminishing cellular chemotactic responsiveness, migratory function, and oxidative bacterial killing, and by creating an imbalance in proteaseâ?protease inhibitor relationships. The proliferative phase of wound healing is also potentially impaired by smoking, with diminished fibroblast proliferation and migration resulting in decreased collagen production.124â?30 Increases in oxidative stress and hypoxia further diminish healing in smokers.62,74,76,102 Vitamin C is postulated to be an important contributor to the diminished wound healing evidenced in smokers. Both population and experimental studies have shown smokers are more likely to be deficient in Vitamin C, with 25% of female smokers and 30% of male smokers having severe deficiency. This deficiency is likely secondary to a systemic depletion by the many reactive oxygen species in tobacco smoke as well as a diet lacking antioxidants. The investigators will evaluate the effects of vitamin C on wound healing in current versus non smokers with detailed assessment of tobacco use. This project assembles a multidisciplinary team with expertise in wound healing, maxillofacial surgery, medical effects of tobacco use, fracture repair, biomechanics of bone, and conduct of clinical trials. The proposed work will define specific effects of supplemental Vitamin C on soft tissue and bone healing, with additional attention to smoking status in patients with mandibular fractures. For the many patients who are at high risk for vitamin C deficiency and poor wound healing, this investigation will provide critical knowledge of the role of oxidative stress and antiâ?oxidants in the mechanisms of impaired healing. These data will provide pilot data to support randomized controlled trials of interventions to improve postâ?operative wound healing in patients suffering from mandibular and other traumatic fractures. Establishing the safety and efficacy of supplemental Vitamin C in the periâ?operative setting will improve wound healing outcomes for thousands of patients undergoing traumatic fracture surgery and could be a transformative step in treatment guidelines for any smoker undergoing surgery.
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Neuromuscular electrical stimulation in the treatment of knee osteoarthritis: a systematic review and meta-analysis
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SR for PM on OA of All Extremities
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OBJECTIVE: To assess the effectiveness of surface neuromuscular electrical stimulation in the treatment of knee osteoarthritis. DESIGN: Systematic review and meta-analysis of randomized controlled and controlled clinical trials METHODS: Studies were identified from databases (MEDLINE, EMBASE, CINAHL, Sports Discus, PEDro and the Cochrane Library) searched to January 2011 using a battery of keywords. Two reviewers selected studies meeting inclusion criteria. The methodological quality of the included studies was assessed using the Thomas Test and the strength of the evidence was then graded using the Agency for Health Care Policy and Research guidelines. Data were pooled and meta-analyses were performed. RESULTS: Nine randomized controlled trials and one controlled clinical trial, studying a total of 409 participants (n = 395 for randomized controlled trials, and n = 14 for controlled trial) with a diagnosis of osteoarthritis were included. Inconsistent evidence (level D) was found that neuromuscular electrical stimulation has a significant impact on measures of pain, function and quadriceps femoris muscle strength in knee osteoarthritis. CONCLUSION: The role of neuromuscular electrical stimulation in the treatment of knee osteoarthritis is ambiguous. Therefore, future work is needed in this field to clearly establish the role of neuromuscular electrical stimulation in this population
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Effect of a chemotherapeutic agent delivered by an oral irrigation device on plaque, gingivitis, and subgingival microflora
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Sixty-six adults were examined in a double-bind study which examined the effect of an antimicrobial agent delivered by an oral irrigating device. Each subject received a randomized half mouth dental prophylaxis. The Gingival Index, gingival crevicular fluid volume, Plaque Index, Modified Papillary Bleeding Index, probing pocket depth, and probing attachment levels were determined at baseline, 3 weeks, and 6 weeks. The composition of the subgingival microflora in the prophied and non-prophied quadrants was examined by phase contrast microscopy and by immunofluorescence. This study demonstrates that an antimicrobial product delivered by an oral irrigating device could result in significant reductions in plaque, bacterial cell counts, and gingival bleeding and may, therefore, be an effective adjunct to normal oral hygiene
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Clinical features and treatment response of light chain (AL) amyloidosis diagnosed in patients with previous diagnosis of multiple myeloma (MM)
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Introduction: Both multiple myeloma (MM) and (AL) amyloidosis are clonal plasma cell proliferative disorders. While AL rarely nullprogressesnull to MM, probably due to the shorter survival of AL patients, patients with MM have been reported to develop overt AL at a higher frequency. We conducted this study to identify and describe the clinical features, diagnosis, treatment patterns and response, and outcome among patients diagnosed with AL following an initial diagnosis of MM. Patients and Methods: Of the 354 patients identified from a prospectively maintained database who carried a diagnosis of both MM and AL during the interval between January 1990 and December 2008, 44 patients had a histologic diagnosis of AL, at least 6 months after the diagnosis of MM. The organ involvement and treatment response (organ and hematologic) for AL as well as MM response to treatment were assessed according to conventional criteria. Results: The median age at diagnosis of MM and AL was 63 years (range, 42-82) and 68 years (range, 45-86), respectively; 27 (61%) were males. The median time to AL diagnosis after MM diagnosis was 41 months (range, 7.6-134). The estimated median follow up from diagnosis of MM and AL is 15.5 years and 10 years, respectively and 39 (89%) patients have died. The median overall survival (OS) from diagnosis of MM and AL was 68.6 months and 9.1 months, respectively. At the time of AL diagnosis, 33 (75%) patients had developed typical features suggestive of AL [heart failure (12), paresthesias (11), nephrotic range proteinuria (9), elevated alkaline phosphatase and hepatomegaly (2), fatigue (7), weight loss (5), macroglossia (4) and periorbital ecchymoses (1)]; while others developed atypical features (3) (7%) or had an incidental finding of AL (8) (18%) [autopsy (2), unexplained cytopenia (2), mild proteinuria (1) and no symptoms (3)]. Cumulatively, amyloid deposits were revealed by biopsy of: bone marrow (23) (52%), subcutaneous abdominal fat (17) (39%), organ (10) (23%) and carpal tunnel tissue (6) (14%). Organ involvement, treatment response and hematologic status of MM at AL diagnosis were assessed for the evaluable patients. None, 1 and >1 organ involvement occurred in 5 (11%), 28 (64%) and 9 (20%) patients, respectively at AL diagnosis or follow up; while AL as the cause of neuropathy was questionable in 2. The organs involved were: heart (14, including 8 with >1 organ involvement), nerves (11), kidney (10), soft tissue (6), lung (5), GI (1) and liver (1). The hematologic status of MM at AL diagnosis included SD (22), progression (10), PR (3), VGPR (3) and not evaluable (6). The subsequent hematologic and organ response did not differ significantly among those who had a treatment change or started (20) (45%) compared with those who did not have a treatment change (20) (45%) at AL diagnosis [excluding those lost to follow up (2) or diagnosed at autopsy (2)]; although more patients (8/10) who had biochemically progressive MM belonged to the former group. The best hematologic response to treatment(s) after AL diagnosis (28) (64%) was: SD (17), PR (3), VGPR (6), CR (1), and progression (1); and not evaluable in others. The organ response (excluding patients with carpal tunnel surgery) to treatment(s) (18) (41%) was: progression (11), stable (4) and organ improvement (3). More patients with an improved (2/3) and stable (1/4) organ response had hematologic PR or better than those with progression (0/11) of organ disease. Five (11%) patients were alive at last follow up; and had either isolated kidney (3) and soft tissue (macroglossia) (1) or no organ involvement (1). All patients with an organ improvement, and 2/5 patients alive, had received
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Serum metal ion levels after rotating-hinge knee arthroplasty: Comparison between a standard device and a megaprosthesis
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PJI DX Updated Search
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Purpose: The effects of systemic metal ion exposure in patients with implants made of common prosthetic alloys continue to be a matter of concern. The aim of the study was to determine the measurement values of cobalt (Co), chromium (Cr) and molybdenum (Mo) in serum following rotating-hinge knee arthroplasty. Methods: Blood was taken from 25 patients [mean follow-up 35 (range nine to 67) months] treated with megaprostheses (n=17) or standard rotating-hinge devices (n=8) and analysed using electrothermal graphite furnace atomic absorption spectrometry (ET-ASS). Results: Determining the concentrations of metal ions following rotating-hinge knee arthroplasty revealed increments for Co and Cr but not Mo. Metal ion release was significantly higher in patients with megaprostheses compared to a standard rotating-hinge knee device (Co p=0,024; Cr p=0.025). Conclusion: The authors believe there might be an additional metal ion release from the surface of the prosthesis and not only from the articulating surfaces because, in cases of rotating-hinge knee prosthesis, there is a metal-on-polyethylene articulation and not a direct metal-on-metal junction. Nevertheless, long-term studies are required to determine adverse effects of Co, Cr and Mo following total hip replacement and total knee arthroplasty. é 2011 Springer-Verlag
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Clinical Study of Non-inferiority With Participants Diagnosed With Primary Knee OA (GLACIAL)
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OAK 3 - Non-arthroplasty tx of OAK
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This phase III clinical study will be conducted in Brazilian research sites. It will be included in the study 314 participants diagnosed with primary knee OA according to the classification criteria of the ACR. After a washout period, the participants will be randomized to receive the combination of glucosamine sulfate + chondroitin sulfate of bovine origin of Eurofarma Laboratorios S.A. (N= 157) or the combination of glucosamine sulfate + chondroitin sulfate of Zodiac Pharmaceuticals S.A. Condroflex ® (N = 157). The treatment period of the study will be of 24 weeks. Each participant will perform seven visits to the research site. The main evaluations will be the improve of pain in the target knee by questionnaire Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and quality of life by SFâ?12 questionnaire.
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[Effect of perioperative use of selective cyclooxygenase-2 inhibitor on postoperative pain, bleeding volume and functional recovery of the knee joints after joint replacement of both knees]
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Surgical Management of Osteoarthritis of the Knee CPG
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Aim: To evaluate the effect of preoperative and postoperative use of a kind of selective cyclooxygenase-2 (COX-2) inhibitor, Rofecoxib, on postoperative pain, bleeding volume and functional recovery of the knee joints after joint replacement of both knees, and observe its safety and effectiveness in decreasing the postoperative use of opiate drugs. Methods: In the Arthritis Clinic & Research Center, Peking University People' s Hospital, 30 patients (5 males and 25 females) who prepared to receive joint replacement of both knees were selected from February to April 2002. Then the randomized, double-blind, placebo controlled study was conducted. The patients were assigned to 2 groups: 1 Rofecoxib group: 25 mg Rofecoxib were taken orally 1 to 2 hours before the anesthesia induction. During the operation, extradural anesthesia and general anesthesia were adopted. After the operation, patient-controlled epidural analgesia was used consecutively for 3 days, and 25 mg oral Rofecoxib were given consecutively for 7 days since the third day after the operation. 2 Placebo group: Oral placebo was given 1 to 2 hours before the anesthesia induction and consecutively for 7 days since the third day after the operations, the rest was identical with the Rofecoxib group. The primary observational indexes were amended numerical pain rating scores, analgesic satisfactory degrees, operative and postoperative bleeding volume, the preoperative/postoperative range of motion (ROM) of the troubled knee joints and the preoperative/postoperative knee scores and functional scores of the troubled knee joints. Results: There was no significant difference in the baseline data between the two groups (P > 0.05), and they were comparable. The use of Rofecoxib could significantly decrease the pain scores at rest 24 hours after the operations and both at rest and after mobilization 48 hours after the operations (P < 0.05); It could also decrease the intramuscular use of fentanvl on the 1st day after operation (chi2 = 3.84, P = 0.042), thus decrease the use of opiate drugs. In Rofecoxib group, the patients' overall analgesic satisfactory degree could reach 100% in III or IV degree 24 hours after the operations (15/15), significantly higher than that of Placebo group, which was 60% (9/15) (chi2 = 6.71, P = 0.006). The bleeding volumes during the operations in Rofecoxib group and Placebo group were (754.7 +/- 330.9) mL and (653.7 +/- 461.5) mL (t = -0.689, P = 0.497). The drainage volumes of the left knee joints after the operations in Rofecoxib group and Placebo group were (870.3 +/- 392.5) mL and (814.5 +/- 314.1) mL (t = -0.430, P = 0.671); The drainage volumes of the right knee joints after the operations in both groups were (861.0 +/- 411.9) mL and (685.3 +/- 349.9) mL (t = -1.259, P = 0.218). The active ROMs of the patients in Rofecoxib group were higher than those of the Placebo group when leaving hospital 2 weeks after the operations, but only passive ROMs had significant difference (P < 0.001), and the difference of active ROMs was not significant (P > 0.05); After 2 years' postoperative follow-up, the. difference of ROM was not significant (P > 0.05); There was difference in the preoperative ROM between the two groups, especially the right knee joints (P < 0.05). The calculation and comparison of the preoperative and 2 years' follow-up knee scores and functioual scores by t-test showed no difference between the two groups. There were no such complications as wound haematoma, haemarthrosis, gastroduodenal perforation, stress ulcer and bleeding after the operations. Conclusion: The perioperative use of Rofecoxib, a kind of the specific COX-2 inhibitor, can effectively reduce the postoperative pain after joint replacement of both knees, meanwhile it will not increase the risk of Non-steroidal anti-inflammatory drugs (NSAIDs) such as upper gastroduodenal upset and increase bleeding volume, so it can help patients increase the ROM of the troubled joints in an early time, but there is not any advantage in long-term ROM and function to the joints. Copyright © 2011 Elsevier B. V., Amsterdam. All Rights Reserved
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Intramedullary versus extramedullary fixation for subtrochanteric femur fractures
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DoD SSI (Surgical Site Infections)
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OBJECTIVES: Both intramedullary and extramedullary internal fixation has been advocated for the treatment of subtrochanteric femur fractures. Is there clinical evidence to recommend one method of internal fixation over the other?
DATA SOURCES: A search of MEDLINE (1950 to June 2007), CINAHL (1982 to June 2007), and EMBASE (1980 to June 2007) was performed. Results were limited to English language studies. References from eligible studies were reviewed to identify additional studies.
STUDY SELECTION: Studies were selected for review based on the following criteria: comparison and observational studies examining the use of intramedullary and/or extramedullary implants for the fixation of subtrochanteric femur fractures, inclusion of intertrochanteric hip fractures with subtrochanteric extension, exclusion of pure intertrochanteric and intracapsular hip fractures, and exclusion of pathologic fractures.
DATA EXTRACTION: The following outcomes were extracted from eligible studies: operative time, operative blood loss, intraoperative complications, postoperative medical complications, number of patients transfused, wound complications, failure of fixation, rate of nonunion, length of hospital stay, and functional recovery.
DATA SYNTHESIS: Three level I and 9 level IV studies were identified and used in the systematic review of outcomes for intramedullary and extramedullary fixation for subtrochanteric fractures. Three level I studies were used to calculate a pooled relative risk for failure of fixation with a 95% confidence interval. An analysis of heterogeneity between pooled studies was conducted.
CONCLUSIONS: There is grade B evidence that operative time is reduced and that fixation failure is reduced with the use of intramedullary implants for subtrochanteric fractures. Future studies should perform subgroup analysis according to the type of population sampled (ie, young versus elderly) and subtrochanteric fracture type.
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ISHKS joint registry: A preliminary report
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are the most widely practiced surgical options for arthritis all over the world and its application is rising in India. Indian Society of Hip and Knee Surgeons (ISHKS) has established a joints registry and has been collecting data for last 6 years. MATERIALS & METHODS: All members of ISHKS are encouraged to actively participate in the registry. A simple two page knee and hip form can be downloaded from the website www.ishks.com. The information collected includes patient demographics, indication for surgery, implant details and in case of revision arthroplasty: the details of implants removed and the cause of failure of primary arthroplasty. These forms are mailed to the central registry office and the data is fed in computerized registry. Data collection started in October 2006. RESULTS: Joint registry is a very important initiative of ISHKS and till date, have data of 34,478 TKAs and 3604 THAs, contributed by 42 surgeons across India. Some important observations have emerged. Data of 34,478 TKAs was assessed: These included 8612 males (25%) and 25,866 females (75%). Average age was 64.4 years (Osteoarthritis range: 45 to 88 years; Rheumatoid arthritis range: 22 to 74 years). Average body mass index was 29.1 (Range: 18.1 to 42.9). The indication for TKA was osteoarthritis in 33,444 (97%) and rheumatoid arthritis in 759 (2.2%). Total of 3604 THA procedures were recorded. These included 2162 (60%) male patients and 1442 (40%) female patients. Average age was 52 years (Range 17 to 85 years) and average BMI was 25.8 (Range: 17.3 to 38.5). The indications for THA was AVN in 49%. CONCLUSION: The registry will become more meaningful in years to come. Active participation of all arthroplasty surgeons across India is vital for the success of the joints registry
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Impact of slow recovery and poor functional outcomes on direct and indirect costs after total knee replacement in osteoarthritis patients
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Surgical Management of Osteoarthritis of the Knee CPG
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Background/Purpose: About 15-30% of patients with osteoarthritis (OA) who undergo total knee replacement (TKR) have little or no improvement after the surgery. The aim of our study is to determine the impact of slow recovery and poor functional outcomes on TKR-related costs. Methods: PEAKS (Patient Expectations About Knee Surgery Study) is a prospective cohort of patients with OA who underwent TKR. We followed patients for 6 months after surgery, and collected sociodemographic data, TKR-related costs, and clinical outcomes (the Western Ontario McMaster (WOMAC) pain and function scale). The economic analysis was conducted using a societal perspective based on 2007 US dollars. Direct medical costs were estimated using the Medicare Reimbursement Prospective Payment System; hospital bills were adjusted by cost-to-charge ratios reported to Medicare. Average wholesale price was used for drugs costs. Productivity losses (patients and relatives) were calculated using time lost from work multiplied by estimated wage per occupation reported by the Bureau Labor of Statistics for Texas. We defined improvement as either absolute (minimal clinically important difference (MCID), 20-point change), or relative (20%, 50% or 70% improvement in WOMAC (WOMAC20, 50 and 70)). Incremental cost-effectiveness ratios (ICERs) for each level were calculated, assuming a hypothetical non-TKR cohort where WOMAC scales and OA-related costs prior to surgery remained stable. We stratified WOMAC in four severity levels: none-to-mild (0 to <=25), mild-to-moderate (>25 to <=50), moderate-to-severe (>50 to <=75), and severe-to-extreme (>75 to <=100). TKR-related costs were calculated for each level at 3 and 6 months post-surgery. Results: 218 patients were included; 65% were female, 69% were white, mean age was 65(plus or minus)9 years. Mean total costs were null$24,000(plus or minus)10,000. At 6 months 91% of patients improved, 61% showed a MCID and 80% WOMAC20 response. Figure 1 shows ICERs for WOMAC at 6 months. The ICERs for MCID, WOMAC20, WOMAC50, WOMAC70 were null$39000, null$30000, null$41000 and null$67000, respectively. TKR-related costs were higher in patients with poor function and worse pain (moderate-to-extreme level, WOMAC score >50 points) at 3 and 6 months, in comparison to better levels of function and pain. Conclusion: TKR remains a cost-effective intervention at low and high levels of improvement. Patients with worse pain and function outcomes had higher TKR-related costs, suggesting that peri-operative interventions that can lead to a fast recovery and improve TKR outcomes might be cost-effective by decreasing subsequent costs
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Introduction of an MR-based semi-quantitative score for assessing partial meniscectomy and relation to knee joint degenerative disease: data from the Osteoarthritis Initiative
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AMP (Acute Meniscal Pathology)
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OBJECTIVES: To develop an MR-based semi-quantitative meniscus scoring technique for postoperative assessment of the degree of meniscal resection, to test its reproducibility, and to study the relationship between the amount of resection and degenerative disease burden.
METHODS: We studied the right knee of 135 participants from the Osteoarthritis Initiative that underwent meniscal surgery an average of 14 years previously. The amount of meniscal resection was assessed on baseline 3.0-T MRIs and calculated as meniscus resection score (MenRS) with a range of 0 to 18. Knee abnormalities at baseline and 48 months were graded using a modified Whole-Organ Magnetic Resonance Imaging Score (WORMS). Subjects were also stratified according to meniscal resection performed after injury versus without preceding injury. Statistical analysis included intra-class correlation coefficient (ICC) to determine reproducibility as well as regression models and partial correlations to correlate MenRS with WORMS outcomes.
RESULTS: ICC values for intra- and inter-observer reproducibility of MenRS were 0.980 and 0.977, respectively. Overall, the amount of meniscal resection showed a significant correlation with baseline WORMS grades: higher MenRS was associated with higher total WORMS grades (p = 0.004) and cartilage (p = 0.004) and ligament (p < 0.001) subscores. However, no significant association between MenRS and change in WORMS grades over 48 months was found. The relationship between MenRS and baseline WORMS grades did not change after adjusting for a reported history of knee injury.
CONCLUSIONS: Postoperative assessment of the knee following partial meniscectomy using the newly developed MenRS showed excellent reproducibility and significant cross-sectional correlation with WORMS gradings.
KEY POINTS: * The newly developed semi-quantitative MR-based meniscal resection score demonstrated excellent reproducibility. * A significant correlation between the amount of meniscal resection measured using the newly developed score and the degree of overall knee joint degenerative disease and cartilage defects was found.
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Methodological Quality of Economic Evaluations Alongside Trials of Knee Physiotherapy
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: The methodological quality of an economic evaluation performed alongside a clinical trial can be underestimated if the paper does not report key methodological features. This study discusses methodological assessment issues on the example of a systematic review on cost-effectiveness of physiotherapy for knee osteoarthritis.
METHODS: Six economic evaluation studies included in the systematic review and related clinical trials were assessed using the 10-question check-list by Drummond and the Physiotherapy Evidence Database (PEDro) scale.
RESULTS: All economic evaluations were performed alongside a clinical trial but the studied interventions were too heterogeneous to be synthesized. Methodological quality of the economic evaluations reported in the papers was not free of drawbacks, and in some cases, it improved when information from the related clinical trial was taken into account.
CONCLUSIONS: Economic evaluation papers dedicate little space to methodological features of related clinical trials; therefore, the methodological quality can be underestimated if evaluated separately from the trials. Future economic evaluations should follow more strictly the recommendations about methodology and the authors should pay special attention to the quality of reporting.
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Rehabilitation parameters in total knee replacement patients undergoing epidural vs. conventional analgesia
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Surgical Management of Osteoarthritis of the Knee CPG
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Epidural analgesia for total knee replacement (TKR) surgery has been proposed as a means of enhancing patient comfort, thereby expediting rehabilitation and reducing hospital stay. This study was done to determine differences in rehabilitation parameters of range of motion and mobility in patients receiving epidural vs. conventional (intravenous) analgesia following TKR surgery. Chart reviews were done of 52 patients who underwent consecutive unilateral TKR, with 26 patients in each analgesia group. There were 21 males and 31 females, ages 24-88 years (median 65), with diagnoses of osteoarthritis (45), rheumatoid arthritis (4), and other (3). The surgeon, procedure, type of prosthesis, and physical therapy protocol were the same for all subjects. Demographics, range of motion, distance walked, assistance required for gait and transfers, assistive device, and exercise competence data were studied at the first postoperative day and at time of discharge. No significant difference was found in the length of stay at the p < .05 level. Significant differences at the first postoperative day favored the epidural group: in knee flexion range--median difference was 0.26 rad [95% confidence interval (CI): 0.09-0.52, p < .05] ie., 15 degrees (95% CI: 5-30); in total range of motion--median difference was 0.30 rad (95% CI: 0.09-0.58, p < .05), ie., 17 degrees (95% CI: 5-33); and in assistance required for gait and transfers (p < .05). At discharge, the epidural group required significantly less assistance (p < .05). There was a trend toward greater walking distance in the epidural group, who walked a median of 15.2 m farther than the conventional analgesia group.(ABSTRACT TRUNCATED AT 250 WORDS)
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Culture change in pain management after hip and knee replacement in north estonia medical centre
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction: Quality markers of postoperative care are- pain control, early mobilization and minimal side effects. Methods: We audited 50 consecutive hip and knee replacement patients in terms of pain scores, mobility and side effects. Initially epidural (EPI) group and after implementing nullEnhanced Recovery Programnull (ERP group) were followed for 24 hours arter operation. Results: 24 in EPI group had VAS 24 h 4-10 versus only 3 in ERP group. Mobilisation was difficult in nearly half of the EPI group patients versus only 4 ERP group. Conclusion: After implementing ERP in our hospital the VAS 24 h improved, patients were mobilised earlier. Side effects became different in nature and minor in severity. 48 hour follow up could give us even better results
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Correction to: The role of intra-articular administration of Fetuin-A in post-traumatic knee osteoarthritis: an experimental study in a rat model (Journal of Experimental Orthopaedics, (2019), 6, 1, (25), 10.1186/s40634-019-0194-4)
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OAK 3 - Non-arthroplasty tx of OAK
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Following publication of the original article (Pappa et al. 2019), the authors opted to correct the middle initial of co-author Despina N. Perrea from S to N. The original article has been corrected.
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1 |
Ultrasound-guided shoulder joint injections
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Glenohumeral Joint OA
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Subacromial bursa (SAB) and glenohumeral joint (GHJ) injections are commonly performed for shoulder pain and dysfunction. For patients with rotator cuff or impingement syndromes, the SAB injection may provide temporary relief of pain and increase shoulder mobility, as well as help confirm the diagnosis. Likewise, for patients with calcific tendonitis or arthritis of the GHJ, injection of the GHJ may be therapeutic. Although these procedures are usually performed "blindly" without image guidance, inadvertent extra-articular injections have been frequently reported; therefore, many practitioners use fluoroscopy for confirmation of proper needle placement. Avoiding the problems associated with radiation, ultrasound (US) guidance offers an alternative, real-time imaging modality that can also ensure accurate needle placement. This paper presents techniques of SAB and GHJ injections that are suitable for US guidance. A posterolateral approach targeting the SAB between the acromion and the greater tuberosity of the humerus will be introduced, as the authors find this approach simple and effective. For the GHJ, a traditional posterior approach and an alternative rotator interval approach will be described. With proper training, clinicians should be able to incorporate US-guided joint injections into their practice. © 2009 Elsevier Inc. All rights reserved.
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Comprehensive surgical management of arthritic knee
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Surgical Management of Osteoarthritis of the Knee CPG
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Total knee arthroplasty is not the only available surgical option for arthritic knees. It varies according to patient's age and severity of the disease. 105 arthritic knees were surgically treated at the Joint Replacement Centre of Army Hospital (R&R) in last 4 years. 77 knees were osteoarthritic and 28 were rheumatoid. 24 of these were treated by arthroscopic debridement, 7 underwent unicondylar knee replacement and 74 underwent total knee replacement using Freeman Samuelsun (F/S) or Low Contact Stress (LCS) implants. The indications, contraindications, results and complications of these procedures are discussed
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0 |
A case of carpal tunnel syndrome caused by accessory palmaris longus muscle
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A rare case of carpal tunnel syndrome caused by bilateral accessory palmaris longus muscles in a 48-year-old female is reported. The median nerves of this patient were compressed by the abnormal muscles, which originated from the medial side of the normal palmaris longus tendon and inserted in the hypothenar region. Clinical symptoms were improved by excision of the abnormal muscles
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0 |
Lower limb nerve blocks
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Surgical Management of Osteoarthritis of the Knee CPG
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Peripheral nerve blocks are increasingly used for a wide range of surgical procedures involving the lower limb. A number of techniques can be used to provide anaesthesia and highly effective postoperative analgesia - in particular following lower limb arthroplasty - that may result in improved functional recovery and shorter in-patient stay. Ultrasound-guided nerve localization offers several potential advantages when performing femoral, popliteal and distal sciatic nerve block; however, neurostimulation remains a useful and widely used aid to lower limb regional anaesthesia practice. (copyright) 2010 Elsevier Ltd. All rights reserved
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0 |
Determinants of bone mineral density in older men
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AAHKS (2) Corticosteroids
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Osteoporosis is a significant health problem and contributor to disability and premature mortality among older men. Incidence rates for hip fracture have stabilized in women, but continue to increase in men. A major risk factor for hip fracture is bone mineral density level. The determinants of bone mineral density (BMD) are well defined in women, but not in men. The primary goal of the current research was to increase our understanding of the determinants of BMD of the proximal femur in a large community-based sample of older male volunteers. Eligibility requirements included age of 50 years or older, ambulatory, and not having undergone a bilateral hip replacement. Five hundred twenty-three men, mean mean age 66.6 years, met all eligibility requirements and participated in the Study of Osteoporotic Risk in Men or STORM. Information on demographics, medical history, anthropometry, leisure-time and occupational physical activity, muscular strength, cigarette smoking, alcohol consumption, dietary calcium intake, and medication use (thiazide diuretics and glucocorticoids) were obtained by questionnaire, interview, and examination, BMD of the proximal femur (femoral neck, greater trochanter, and Ward's triangle) was measured by dual-energy X-ray absorptiometry using the Hologic QDR-1000 and QDR-2000. The cross-sectional determinants of BMD included age, blond hair color, current body weight, thiazide diuretic use, historical physical activity, and quadriceps strength. Several variables commonly thought to be determinants of BMD were not related to BMD in this population of older men, including current cigarette smoking, alcohol consumption, current leisure-time physical activity, dietary calcium intake, vitamin D use, and caffeine intake. However, failure to find associations among BMD and some of the potential determinants may be due to lack of statistical power. Identification of the determinants of BMD could lead to the development of interventions aimed at maximizing BMD in men and could potentially decrease the risk of hip fractures.
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0 |
Time-dependent improvement in functional outcome following LCS rotating platform knee replacement
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND AND PURPOSE: Long-term follow-up studies after total knee replacement (TKR) using an LCS rotating platform have shown survival rates of up to 97%. Few studies have evaluated short-term functional outcome and its improvement over time. We determined the time course of functional outcome as evaluated by the knee injury and osteoarthritis outcome score (KOOS) over the first 4 years after TKR using the LCS mobile bearing. PATIENTS AND METHODS: 50 unselected patients (mean age 70 (40-85) years, 33 women) with osteoarthritis in one knee underwent TKR with an LCS mobile bearing. Data were collected by an independent investigator preoperatively and at 6 weeks, 3 months, 6 months, 1 year, 2 years and 4 years postoperatively. KOOS, a self-assessment function score validated for this purpose, and range of motion (ROM) were determined at all follow-ups. RESULTS: The mean KOOS pain score increased from 43 before surgery to 66 at 6 weeks and 88 at 2 years. It was 84 at 4 years. The mean KOOS activities of daily living score (ADL) increased from 49 before surgery to 73 at 6 weeks, then gradually to 90 at 2 years. It decreased to 79 at 4 years. Mean passive ROM was 112 degrees before surgery, 78 degrees at departure from hospital, and then gradually increased to 116 degrees at 2 years and 113 degrees at 4 years. INTERPRETATION: Recovery after TKR is time-dependent. Most of the expected improvement in pain and function is achieved at 6 months postoperatively, but some further improvement can be expected up to 2 years postoperatively. ROM will also gradually improve up to 2 years after TKR, and reach the same level as before surgery
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0 |
Soft tissue balance changes depending on joint distraction force in total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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The influence of joint distraction force on intraoperative soft tissue balance was evaluated using Offset Repo-Tensor for 78 knees that underwent primary posterior-stabilized total knee arthroplasty. The joint center gap and varus ligament balance were measured between osteotomized surfaces using 20, 40 and 60 lbs of joint distraction force. These values were significantly increased at extension and flexion as the distraction force increased. Furthermore, lateral compartment stiffness was significantly lower than medial compartment stiffness. Thus, larger joint distraction forces led to larger varus ligament balance and joint center gap, because of the difference in soft tissue stiffness between lateral and medial compartments. These findings indicate the importance of the strength of joint distraction force in the assessment of soft tissue balance, especially when using gap-balancing technique.
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0 |
Evaluation of bone mineral density and fat-lean distribution in patients with multiple myeloma in sustained remission
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MSTS 2018 - Femur Mets and MM
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To study the usefulness of bone mineral density (BMD) in the follow-up of myeloma (MM) patients, BMD was evaluated in 44 MM patients in sustained remission for at least 2 years (35.4 +/- 10.5 months) after high-dose or conventional chemotherapy in a retrospective study. Patients never received bisphosphonates before or during the follow-up. Patients underwent lumbar spine (LS) BMD and a whole body (WB) BMD testing before therapy and at least once in the remission period. At baseline, mean LS BMD was 0.863 +/- 0.026 g/cm2, mean lumbar Z-score was -1.45 SD. LS BMD significantly increased from baseline by 5 +/- 1.8%, 9.3 +/- 1.7%, and 14 +/- 1.9% at 1, 2, and 3 years, respectively. The percentage of patients with a T-score below 2.5 SD decreased from 39% at baseline to 18.5% at 3 years. Compared with baseline, WB BMD decreased by -2.8 +/- 0.5%, -2.6 +/- 0.7%, and -1.7 +/- 0.6% at 1, 2, and 3 years, respectively. Mean percentage change of the fat compartment increased from baseline by +28.4 +/- 7.1% at the trunk, and +17.1 +/- 5% in peripheral areas at 3 years. In conclusion, in MM patients in remission after chemotherapy, LS BMD progressively increased after a mean follow-up of 3 years. These patients never received bisphosphonates, so this increase was related to the anti-myeloma treatment. The major effect on BMD was observed at the LS, which is primarily composed of trabecular bone containing the bone marrow. Interestingly, a drastic increase of the fat content was also observed. These results underlined that BMD and fat-lean evaluation could be of interest in the follow-up of MM patients.
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0 |
Frontalis Muscle Contraction and the Role of Visual Deprivation and Eyelid Proprioception
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Upper Eyelid and Brow Surgery
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PURPOSE: To determine if frontalis muscle contraction can be induced by manipulating visual and eyelid proprioceptive inputs through simulating visual deprivation and ptosis. METHODS: Volunteers without prior eyelid or forehead pathologic study were recruited for this nonrandomized, prospective study. Baseline and study phase brow positions were documented. The first phase was to simulate visual deprivation and the second to simulate ptosis. The dominant eye was used for each phase. As a proxy to simulate visual field deprivation, a black contact lens was placed on the eye, which reduced vision to light perception. As a proxy to simulate ptosis, an external eyelid weight was placed on the upper eyelid. Brow position ratios were calculated at various points along the brow and statistical analysis was performed. RESULTS: Fifteen subjects participated. The average brow position ratio was 1.00 +/- 0.08 for the visual deprivation group, which was not different from baseline (p = 0.86). The average brow position ratio for the external eyelid weight group was 1.13 +/- 0.07, which was statistically significant compared with baseline and the visual deprivation group (p < 0.001). CONCLUSIONS: Inducing visual deprivation with a black contact lens does not lead to a change in brow position. However, placing an external eyelid weight does lead brow elevation, with an average increase of 13% from baseline. This suggests a likely role for proprioceptive or sensory inputs in frontalis muscle contraction in the setting of eyelid ptosis.
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0 |
Madelung's Disease: Revision of 59 Surgical Cases
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Madelung's disease (MD) is a rare disease, more common in Mediterranean countries and associated with alcohol abuse. However, MD etiology remains not completely understood. OBJECTIVE: The aim of this study was to investigate clinical features, treatment options and outcomes in patients with MD treated in our plastic surgery department. METHODS: We retrospectively reviewed 59 cases of MD operated on between 2004 and 2013. Demographic information, location of the deposits, associated pathology and habits, number and type of surgeries performed, surgical complications and disease evolution were analyzed. RESULTS: Ninety percent of the patients were males. Active or past history of alcohol abuse was reported by 86%. The main affected areas were anterior and posterior neck. A total of 230 surgical procedures were performed. Open surgery was used on 192 occasions (83.5%), liposuction alone on 30 procedures (13%) and lipectomy combined with liposuction on 8 interventions (3.5%). Surgical complications were found in 41 procedures (17.8%). Twenty-three patients (39%) were identified as having disease recurrence of the operated site in a mean time of 3.8 years. Alcohol consumption was not clearly associated with disease recurrence. CONCLUSIONS: Demographic characteristics of the studied cohort stand for published data. It is our opinion that lipectomy/dermolipectomy provides better aesthetic and functional results. Lipectomy procedures allow a thorough excision, correct identification of noble structures and careful hemostasis. Liposuction techniques, even ultrasound-assisted ones, had limited efficacy for the treatment of large masses. A long follow-up period is recommended considering the high propensity and mean time to recurrence. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Lifestyle and osteoporosis in middle-aged and elderly women: Chiba bone survey
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HipFx Supplemental Cost Analysis
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Osteoporosis causes an enormous health and economic impact in Japan. We investigated the relation between lifestyle and bone fracture in middle-aged and elderly women. This was a population-based, multicenter, cross-sectional survey for postmenopausal osteoporosis in Chiba City, Japan (Chiba bone survey). This survey included 64,809 Japanese women aged > 40 years. All participants underwent anthropometric measurements including bone mineral density (BMD) and completed a structured, nurse-assisted, self-administered questionnaire also including patient lifestyle. Bone fracture during the recent 5 years was observed in 5.3%, and the fracture group had significantly higher age, BMI, and prevalence of delivery, family histories of kyphosis and hip fracture, diabetes mellitus (DM), dyslipidemia, kidney disease, exercise, fall, and osteoporosis, and had significantly lower BMD and proportion of menstruating participants. Logistic regression analysis revealed that bone fracture was closely associated with not only low bone mass but also age, fall, family histories of kyphosis and hip fracture, DM, kidney disease, menopause, and lifestyle factors of dieting, exercise, and alcohol. Women's health care focusing on lifestyle-related fracture risks such as dieting, exercise, and alcohol appears necessary to prevent bone fracture in postmenopausal osteoporosis
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0 |
Ipsilateral supracondylar fracture of humerus and forearm bones in children
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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A total of 34 children with ipsilateral supracondylar fractures of the humerus and forearm were studied over an 8-year period. Of these, 19 patients had fractures of the distal quarter of the forearm bones while eight patients had a distal radial epiphyseal injury. Five of the patients had undisplaced supracondylar fractures. One patient had an anterior supracondylar fracture. All forearm fractures were treated by closed reduction. Nine displaced supracondylar fractures which could not be reduced by closed manipulation were treated by olecranon pin traction in two cases and by percutaneous pinning in seven cases. Excellent or good results were found in 29 children after an average follow-up of 3.8 years
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1 |
MRI findings in simultaneous bilateral meniscal lesions
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AMP (Acute Meniscal Pathology)
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This study investigates concurrent lesions of the knee that may be associated with bilateral simultaneous meniscal lesions. The MRI images of the knees of 22 patients with this condition were examined in detail. The results suggest a degenerative cause.
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0 |
Plasma B vitamins, homocysteine, and their relation with bone loss and hip fracture in elderly men and women
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Management of Hip Fractures in the Elderly
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CONTEXT: Elevated homocysteine is a strong risk factor for osteoporotic fractures among elders, yet it may be a marker for low B-vitamin status. OBJECTIVE: Our objective was to examine the associations of plasma concentrations of folate, vitamin B12, vitamin B6, and homocysteine with bone loss and hip fracture risk in elderly men and women. DESIGN: This was a longitudinal follow-up study of the Framingham Osteoporosis Study. SETTING: Community dwelling residents of Framingham, MA, were included in the study. PARTICIPANTS: A total of 1002 men and women (mean age 75 yr) was included in the study. MAIN OUTCOME MEASURES: Baseline (1987-1989) blood samples were used to categorize participants into plasma B-vitamin (normal, low, deficient) and homocysteine (normal, high) groups. Femoral neck bone mineral density (BMD) measured at baseline and 4-yr follow-up was used to calculate annual percent BMD change. Incident hip fracture was assessed from baseline through 2003. RESULTS: Multivariable-adjusted mean bone loss was inversely associated with vitamin B6 (P for trend 0.01). Vitamins B12 and B6 were inversely associated with hip fracture risk (all P for trend < 0.05), yet associations were somewhat attenuated and not significant after controlling for baseline BMD, serum vitamin D, and homocysteine. Participants with high homocysteine (>14 micromol/liter) had approximately 70% higher hip fracture risk after adjusting for folate and vitamin B6, but this association was attenuated after controlling for vitamin B12 (hazard ratio = 1.49; 95% confidence interval 0.91, 2.46). CONCLUSIONS: Low B-vitamin concentration may be a risk factor for decreased bone health, yet does not fully explain the relation between elevated homocysteine and hip fracture. Thus, homocysteine is not merely a marker for low B-vitamin status
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0 |
Increased hip internal abduction moment and reduced speed are the gait strategies used by women with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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The purpose of this study was to identify the gait strategies in women with mild and moderate knee osteoarthritis (OA). Forty women diagnosed with OA of the knee and 40 healthy women participated in the study. Toe-out progression angle, trunk lateral lean, hip internal abduction moment and gait speed were measured using Qualisys ProReflex System and two force plates. Principal component analysis was applied to extract features from the gait waveforms data that characterized the waveforms main modes of temporal variation. Discriminant analysis with a stepwise model was conducted to determine which strategies could best discriminate groups. According to the discriminant model, the PC2 of the internal abduction moment of the hip and the gait speed were the most discriminatory variables between the groups. The OA group showed decreased gait speed, decreased hip internal abduction moment during the loading response phase, and increased hip internal abduction moment during the mid and terminal stance phases. Interventions that may increase hip internal abduction moment, such as the strengthening of the hip abductors muscles, may benefit women with knee OA. Training slower than normal gait speeds must be considered in light of potential adverse implications on overall physical function, daily tasks, and safety.
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0 |
Impairments of Gestalt perception in the intact hemifield of hemianopic patients are reflected in gamma-band EEG activity
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Upper Eyelid and Brow Surgery
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Gamma-band responses (GBRs) are associated with Gestalt perception processes. In the present EEG study, we investigated the effects of perceptual grouping on the visual GBR in the perimetrically intact visual field of patients with homonymous hemianopia and compared them to healthy participants. All observers were presented either random arrays of Gabor elements or arrays with an embedded circular arrangement. For the hemianopic patients, the circle was presented in their intact hemifield only. For controls, the hemifield for the circle presentation was counterbalanced across subjects. The participants were instructed to detect the circle by pressing a corresponding button. A wavelet transform based on Morlet wavelets was employed for the calculation of oscillatory GBRs. The early evoked GBR exhibited a larger amplitude and shorter latency for the healthy group compared to hemianopic patients and was associated with behavioral measures. The late total GBR between 200 and 400ms after stimulus onset was significantly increased for Gestalt-like patterns in healthy participants. This effect was not manifested in patients. The present findings indicate deficits in the early and late visual processing of Gestalt patterns even in the intact hemifield of hemianopic patients compared to healthy participants.
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0 |
Combined femoral and sciatic nerve block vs combined femoral and periarticular infiltration in total knee arthroplasty: a randomized controlled trial
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AAHKS (8) Anesthetic Infiltration
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This study tests the null hypothesis that there is no difference between sciatic nerve block (SNB) and periarticular anesthetic infiltration (PI) as adjuncts to femoral nerve blockade (FNB) in total knee arthroplasty in terms of postoperative opioid requirements. Fifty-two patients undergoing total knee arthroplasty were randomized to receive either (a) combined FNB-SNB or (b) combined FNB-PI. Average morphine consumption in the first 24 (20 vs 23 mg) and 48 hours (26 vs 33 mg) showed no significant difference. Visual Analogue Scale scores, knee flexion (60degree vs 67.5degree) and extension lag (0degree vs 5degree) were comparable. Anesthetic time, surgical time, and length of hospital stay (5.5 vs 6 days) were similar. This study showed no significant difference between the 2 groups. The PI offers a practical and potentially safer alternative to SNB.
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0 |
Unilateral permanent loss of vision after nefopam administration
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Surgical Management of Osteoarthritis of the Knee CPG
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Acute glaucoma angle closure is a rare complication of anaesthesia and multimodal analgesia. However it is a medical emergency, hence any delay in its treatment may have catastrophic consequences. We present a case of postoperative glaucoma, which had evolved to permanent blindness. We also reviewed the French pharmacovigilance database between 1996 and 2006 and found four other cases of acute glaucoma angle closure in postoperative period possibly related to the administration of nefopam
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0 |
Ethnic differences in preoperative function of patients undergoing total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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The prevalence of osteoarthritis is high in all ethnic and demographic groups. The timing of surgery is important because poor preoperative functional status is related to poor postoperative function. The aim of our study was to compare the preoperative knee function in patients of Asian origin with that of Caucasians living in the same community. We carried out a prospective study of 63 consecutive Asian patients and 63 age- and gender-matched Caucasian patients undergoing total knee arthroplasty. Preoperative Knee Society Clinical Rating System scores were recorded as a separate knee score and knee function score. The mean preoperative knee score in Asian patients was 37.6 compared with 41.5 in Caucasians (p<0.12); this difference was not statistically significant. The mean preoperative knee function score in Asian patients was 32.5 compared with 45.0 in Caucasians (p<0.00015); this difference was highly statistically significant. We conclude that patients of Asian origin undergoing total knee arthroplasty have lower preoperative knee function than Caucasians do. Cultural beliefs and social support partially explain this discrepancy, but health care providers must attempt to educate patients and close family members about the importance of timing the surgery to obtain the optimum benefits of pain relief and function
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0 |
Role of mtDNA haplogroups in the prevalence of osteoarthritis in different geographic populations: A meta-analysis
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SR for PM on OA of All Extremities
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Methods: Published English or Chinese literature from PubMed, Web of Science, SDOS, and CNKI was retrieved up until April 15, 2014. Case-control or cohort studies that detected the frequency of mtDNA haplogroups in OA patients and controls were included. The quality of the included studies was evaluated by the Newcastle-Ottawa Scale (NOS) assessment. A metaanalysis was conducted to calculate pooled odds ratio (OR) with 95% confidence interval (CI) through the random or fixed effect model, which was selected based on the between-study heterogeneity assessed by Q test and I(2) test. Subgroup analysis was performed to explore the origin of heterogeneity.Results: A total of 6 case-control studies (10590 cases and 7161 controls) with an average NOS score of 6.9 were involved. For the analysis between mtDNA haplogroup J and OA, random model was selected due to high heterogeneity. No significant association was found initially (OR = 0.73, 95%CI: 0.52-1.03), however, once any study from UK population was removed the association emerged. Further subgroup analysis demonstrated that there was a significant association in Spain population (OR = 0.57, 95%CI: 0.46-0.71), but not in UK population. Also, subgroup analysis revealed that there was a significant correlation between cluster TJ and OA in Spain population (OR = 0.70, 95%CI: 0.58-0.84), although not in UK population. No significant correlation was found between haplogroup T/cluster HV/cluster KU and OA.Conclusions: Our current meta-analysis suggests that mtDNA haplogroup J and cluster TJ correlate with the risk of OA in Spanish population, but the associations in other populations require further investigation.Background: Osteoarthritis (OA) is the most common form of arthritis and has become an increasingly important public-health problem. However, the pathogenesis of OA is still unclear. In recent years, its correlation with mtDNA haplogroups attracts much attention. We aimed to perform a meta-analysis to investigate the association between mtDNA haplogroups and OA
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0 |
Short-term outcomes of one-stage bilateral total hip arthroplasty in young patients (< 30 years old)
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DoD SSI (Surgical Site Infections)
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Total hip arthroplasty is one of the best treatments for restoring function and activity in young patients with advanced joint diseases. One-Stage Bilateral Total Hip Arthroplasty (BTHA) offers many advantages, which are important to younger patients and diminished costs and time in comparison with sequential THA. There is currently much concern about the safety of this procedure. The current study was designed to provide more information regarding THA in patients aged 30 years old or younger. Between April 2010 and September 2015, arthroplasty procedures were performed on 180 patients at the surgical centers of Erfan and Milad, Tehran, Iran. The patients that were entered in the study included those with bilateral hip involvement of Avascular Necrosis (AVN), Rheumatoid Arthritis (RA), Juvenile Rheumatoid Arthritis (JRA), Slipped Capital Femoral Epiphysis (SCFE), and Developmental Dysplasia of the Hip (DDH). The patients underwent one-stage bilateral total hip arthroplasties through the direct lateral approach. Standardized questionnaires were used to obtain mean Postel-Merle d'Aubigne (PMA) score, Oxford Hip Score (OHS), Visual Analogue Scale (VAS) Score, and Modified Harris Hip Score (MHHS), both preoperatively and post-operatively to evaluate functional outcomes. All patients were in the American Society of Anesthesiology (ASA) category 1 or 2. All complications were followed closely for a period of 4.67+/-0.54 years. From 141 males and 39 females, 84 patients had been recognized as ASA 1, and 96 as ASA 2. Mean age of patients was 27.04+/-2.74 years old (range: 16 to 30). The mean operation time and the average length of hospital stay were 156+/-23 minutes and 5.20+/-2.44 days, respectively. Overall, 3 patients developed unilateral temporary peroneal nerve palsy (1.66%), 2 intraoperative fracture (1.11%), and 2 patients (1.11%) showed deep vein thrombosis. There was no wound infection. Regarding the functional scores in the diagnosis of patients, improvement was better in AVN than, RA, JRA, SCFE, and DDH, respectively. There were significant differences between diagnosis and every functional score, individually (P<0.05). The current results showed that one-stage bilateral THA led to improvement in hip function and stable implant fixation at short to midterm follow up, which suggests the efficacy of one-stage cementless THA in bilateral advanced arthritis in patients younger than 30 years old.
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0 |
Prolonged survival after complete resection of disseminated melanoma and active immunotherapy with a therapeutic cancer vaccine
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Reconstruction After Skin Cancer
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PURPOSE: The curative effect of surgery in certain patients with metastatic melanoma suggests the presence of endogenous antitumor responses. Because melanoma is immunogenic, we investigated whether a therapeutic cancer vaccine called Canvaxin (CancerVax Corporation, Carlsbad, CA) could enhance antitumor immune responses and thereby prolong survival. PATIENTS AND METHODS: Of 263 patients who underwent complete resection of American Joint Committee on Cancer stage IV melanoma, 150 received postoperative adjuvant vaccine therapy and 113 did not. The overall survival (OS) for the two groups was compared by Cox regression. Further survival analysis was performed by matched-pair analysis according to three prognostic variables: sex, metastatic site, and number of tumor-involved organ sites. RESULTS: Five-year OS rates were 39% for vaccine and 19% for nonvaccine patients. On multivariate analysis, vaccine therapy was the most significant prognostic variable in this cohort (P =.0001). Analysis of 107 matched pairs of vaccine and nonvaccine patients revealed a significant OS advantage for vaccine therapy (P =.0009): 5-year OS was 39% for vaccine patients versus 20% for nonvaccine patients. There was a significant delayed-type hypersensitivity (DTH) response to adjuvant vaccine therapy (P =.0001), and OS was significantly correlated with DTH to vaccine (P =.0001) but not with DTH to purified protein derivative (PPD), a control antigen. CONCLUSION: Prolonged survival was observed in patients who received postoperative active immunotherapy with Canvaxin therapeutic cancer vaccine. The correlation of survival with vaccine-DTH responses but not PPD-DTH indicates a treatment-specific effect. These findings suggest that adjuvant active specific immunotherapy should be considered after cytoreductive surgery for advanced melanoma.
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0 |
Intraoperative electroneurodiagnostics to detect a second granuloma in the cubital area of median nerves affected by leprosy: A new approach to prevent incomplete surgery
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A recent work reports on the necessity to localize the most proximal site of leprous ulnar neuritis with intraoperative electroneurodiagnostics. In the present study we wanted to verify the applicability of this method on leprous median nerves. In six patients, seven median nerves were exposed at the wrist, all showing a typical leprous granuloma there. Spinal roots C5 to Th1 were then stimulated intraoperatively, evoking efferent mixed nerve compound action potentials (NCAPs) which were registered from the nerve's surface. No recordings could be obtained on the granuloma in all patients, neither distally nor shortly proximal from it, nor even farther central at the forearm's proximal third where the median nerve exits the cubital area. Prior to dissecting the nerves in this precarious region, they were exposed at the arm's distal third, looking inconspicuous in all cases. Recordings could finally be obtained there, and subsequent exposure further proximal showed no increase in amplitude of the NCAPs, but there was a sharp decrease distally. In all cases, subsequent dissection of the cubital area revealed a second leprous granuloma extending variably from the distal third of the arm to the two heads of the pronator teres muscle, requiring microsurgical release. Intraoperative spinal root stimulation is an effective method to detect a second leprous granuloma and to avoid incomplete surgery in median nerves affected by leprosy
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0 |
Weight-bearing-line analysis in supramalleolar osteotomy for varus-type osteoarthritis of the ankle
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: We determined the preoperative and postoperative passing points of the mechanical axis of the lower limb at the level of the tibial plafond using a new method involving a full-length standing posteroanterior radiograph that includes the calcaneus (a hip-to-calcaneus radiograph) and correlated them to the clinical results after supramalleolar osteotomy for ankle osteoarthritis.
METHODS: We reviewed the hip-to-calcaneus radiographs of fifty lower limbs of forty-one patients treated for lower limb malalignment at our institution. The mechanical axis point of the ankle was the point at which the mechanical axis divides the coronal length of the plafond, expressed as a percentage. Four independent observers performed all measurements twice. Supramalleolar tibial osteotomy was performed in twenty-seven ankles (twenty-four patients) to treat moderate varus-type osteoarthritis of the ankle. The mean follow-up period was 2.8 years (range, two to 5.3 years). Clinical assessment was based on the American Orthopaedic Foot & Ankle Society (AOFAS) scale.
RESULTS: Interobserver and intraobserver reliability in identifying the mechanical ankle joint axis point were very high. The mean postoperative mechanical axis point was 50% (range, 13% to 70%) in ankles for which the preoperative point was <=0%, whereas the mean postoperative point was 81% (range, 48% to 113%) in ankles for which the preoperative point was >0%. The mean change in AOFAS score was significantly less for patients with a preoperative point of <=0% than for those with a preoperative point of >0% (p=0.004). Improvement was significantly greater in ankles with a postoperative mechanical ankle joint axis point of >=80% than in ankles with a postoperative mechanical ankle joint axis point of <60% (p=0.030).
CONCLUSIONS: Traditional tibial correction resulted in great variation in the locations of the postoperative mechanical ankle joint axis point. In ankles with the preoperative point more medial than the tibial plafond, the point was insufficiently moved to the lateral side, and the clinical outcomes were less satisfactory.
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0 |
Long-Term Outcomes After Distal Scaphoid Fractures: A 10-Year Follow-Up
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Distal Radius Fractures
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PURPOSE: The aim of this study was to evaluate the functional, clinical, and radiological outcome 10 years after distal scaphoid fractures.
METHODS: From a prospective epidemiological study on posttraumatic radial-sided wrist pain, we evaluated 41 cases of distal scaphoid fractures. All cases had been treated nonsurgically in a thumb spica cast. Patients were examined using radiographs, magnetic resonance imaging and computed tomography at the time of injury and with computed tomography after a median of 10 years (range, 8-11 years). Fractures were classified according to a modified Prosser classification system. The primary outcome was assessment of self-reported function using Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Reported Wrist Evaluation (PRWE). Secondary outcomes were clinical status (range of motion and grip and pinch strength) and to evaluate fracture healing and arthritis in the scaphotrapezium-trapezoid (STT) joint.
RESULTS: Functional impairment and pain scores at follow-up were low: median DASH score 2, median PRWE 0, and median visual analog scale (VAS) pain score 0. We found no impairment in range of motion or strength. We found 26 type I fractures, 12 type IIA, 1 type IIC, and 2 type IV. There was 1 asymptomatic nonunion in a type I fracture. Computed tomography revealed arthritis in the STT joint in 7 out of 41 wrists, none of which caused clinical symptoms.
CONCLUSIONS: From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function as well as good wrist motion and strength. The risk for development of posttraumatic STT arthritis was low.
TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.
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Biochemical stress evaluation after medial parapatellar and subvastus approach in total knee replacement
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: Even if different surgical approaches for total knee arthroplasty are well known since decades, the standard medial parapatellar incision remains the most common one; general agreement about significant advantages with minimally invasive techniques is lacking. Furthermore, the surgical stress effect on the organism has always been analyzed through blood inflammatory parameters. This study aim was to compare the standard and subvastus approaches, using the salivary cortisol in particular as measure for systemic surgery-related stress. METHODS: Fifteen operations were performed in a consecutive series; clinical (Knee Society Knee Scoring System., a questionnaire score, range of motion, tourniquet time, intra-operative bleeding) and biochemical factors (salivary and hematic cortisol, C-reactive protein, muscular creatine phosphokinase levels) were evaluated. The final follow-up was at two months after the operation. RESULTS: No significant differences were observed in most of the parameters; however, the subvastus group had a sharper and earlier functional improvement trend than the standard one. On the other side, it increased the CPK levels significantly. CONCLUSIONS: In our experience, the medial subvastus approach, firstly associated with greater surgical stress, has then been characterized by a more favorable functional improvement trend. Moreover, the salivary cortisol measurement has proved to be a non-invasive and reliable method to evaluate the systemic surgery-related stress.
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1 |
Favorable coagulation profile with fondaparinux after hip surgery in elderly patients
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Management of Hip Fractures in the Elderly
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Twenty-three patients with fondaparinux prophylaxis over 75 years of age who underwent hip fracture surgery were enrolled in the study. Fondaparinux sodium (2.5 mg) was administered subcutaneously 6 h postoperatively and then every 24 h for 28 days. Coagulation and inflammatory parameters were measured preoperatively, then 10 h, 2, 7, and 28 days postoperatively. Increased D-dimers, positive acute phase proteins, and IL-6, and decreased negative acute phase proteins were observed preoperatively (P < 0.05). Maximum values were reached 10 h postoperatively for IL-6 and D-dimer, and on postoperative days 2 and 7 for positive acute phase proteins (P < 0.05). Transferrin, prealbumin and antithrombin levels were lowest 10 h postoperatively and on postoperative day 2 (P < 0.05). Increased D-dimers, IL-6, and positive acute phase proteins, and decreased negative acute phase proteins persisted until postoperative day 28 (P < 0.05). Prothrombin fragments (F1 + 2) reached peak levels preoperatively and decreased gradually until postoperative day 28. Fondaparinux promoted the inhibition of thrombin generation, as documented by negative correlation between F1 + 2 and FXa inhibition (r = -0.46; P < 0.001). Fondaparinux-induced FXa inhibition increased gradually until postoperative day 28. This increase correlated positively with antithrombin activity (r = 0.4; P < 0.05). Fondaparinux prophylaxis counteracted pro-thrombogenic effect associated with hip fracture and subsequent surgery without severe bleeding complications
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0 |
Cell-sheet technology combined with a thienoindazole derivative small compound TD-198946 for cartilage regeneration
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BMAC (Bone Marrow Aspirate Concentrate)
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Articular cartilage is a permanent tissue, with poor self-regenerative capacity. Consequently, a tissue engineering approach to cartilage regenerative therapy could greatly advance the current treatment options for patients with cartilage degeneration and/or defects. A successful tissue engineering approach would require not only induction of chondrogenic differentiation, but also suppression of subsequent endochondral ossification and chondrocyte dedifferentiation. We previously reported that direct injection of the thienoindazole derivative, TD-198946, into the knee joints of mice halted the progression of osteoarthritis; the compound induced chondrogenic differentiation without promoting endochondral ossification. In the present study, we applied TD-198946 to a cell-based cartilage reconstruction model, taking advantage of the cell-sheet technology. Cartilaginous cell-sheets were generated by culturing mouse and canine costal chondrocytes and human mesenchymal stem cells with TD-198946 on temperature-responsive dishes. The transplanted cell-sheets were then successfully used to promote the reconstruction of permanent cartilage, with no evidence of chondrocyte hypertrophy in the knee articular cartilage defects created in mice and canines. Thus, TD-198946 is a promising candidate for cell-based cartilage reconstruction therapies, enabling us to avoid any concern surrounding the use of scaffolds or cytokines to stimulate regeneration.
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0 |
Muscle relaxants for pain management in rheumatoid arthritis
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SR for PM on OA of All Extremities
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Background: Pain management is a high priority for patients with rheumatoid arthritis (RA). Muscle relaxants include drugs that reduce muscle spasm (for example benzodiazepines such as diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan) and non-benzodiazepines such as metaxalone (Skelaxin) or a combination of paracetamol and orphenadrine (Muscol)) and drugs that prevent increased muscle tone (baclofen and dantrolene). Despite a paucity of evidence supporting their use, antispasmodic and antispasticity muscle relaxants have gained widespread clinical acceptance as adjuvants in the management of patients with chronic musculoskeletal pain.Objectives: The aim of this review was to determine the efficacy and safety of muscle relaxants in pain management in patients with RA. The muscle relaxants that were included in this review are the antispasmodic benzodiazepines (alprazolam, bromazepam, chlordiazepoxide,cinolazepam, clonazepam, cloxazolam, clorazepate, diazepam, estazolam, flunitrazepam, flurazepam, flutoprazepam, halazepam, ketazolam, loprazolam, lorazepam, lormetazepam, medazepam, midazolam, nimetazepam, nitrazepam, nordazepam, oxazepam, pinazepam, prazepam, quazepam, temazepam, tetrazepam, triazolam), antispasmodic non-benzodiazepines (cyclobenzaprine, carisoprodol, chlorzoxazone, meprobamate, methocarbamol, metaxalone, orphenadrine, tizanidine and zopiclone), and antispasticity drugs (baclofen and dantrolene sodium).Search methods: We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 4th quarter 2010), MEDLINE (1950 to week 1 November 2010), EMBASE (Week 44 2010), and PsycINFO (1806 to week 2 November 2010). We also searched the 2008 to 2009 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of reference lists of relevant articles.Selection criteria: We included randomised controlled trials which compared a muscle relaxant to another therapy (active, including non-pharmacological therapies, or placebo) in adult patients with RA and that reported at least one clinically relevant outcome.Data collection and analysis: Two blinded review authors independently extracted data and assessed the risk of bias in the trials. Meta-analyses were used to examine the efficacy of muscle relaxants on pain, depression, sleep and function, as well as their safety.Main results: Six trials (126 participants) were included in this review. All trials were rated at high risk of bias. Five cross-over trials evaluated a benzodiazepine, four assessed diazepam (n = 71) and one assessed triazolam (n = 15). The sixth trial assessed zopiclone (a non-benzodiazepine) (n = 40) and was a parallel group study. No trial duration was longer than two weeks while three single dose trials assessed outcomes at 24 hours only. Overall the included trials failed to find evidence of a beneficial effect of muscle relaxants over placebo, alone (at 24 hrs, 1 or 2 weeks) or in addition to non-steroidal anti-inflammatory drugs (NSAIDs) (at 24 hrs), on pain intensity, function, or quality of life. Data from two trials of longer than 24 hours duration (n = 74) (diazepam and zopiclone) found that participants who received a muscle relaxant had significantly more adverse events compared with those who received placebo (number needed to harm (NNTH) 3, 95% CI 2 to 7). These were predominantly central nervous system side effects, including dizziness and drowsiness (NNTH 3, 95% CI 2 to 11). Authors' conclusions: Based upon the currently available evidence in patients with RA, benzodiazepines (diazepam and triazolam) do not appear to be beneficial in improving pain over 24 hours or one week. The non-benzodiazepine agent zopiclone also did not significantly reduce pain over two weeks. However, even short term muscle relaxant use (24 hours to 2 weeks) is associated with significant adverse events, predominantly drowsiness and dizziness
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1 |
Ultrasonography for meniscal injuries in knee joint: a systematic review and meta-analysis
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AMP (Acute Meniscal Pathology)
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INTRODUCTION: The aim of the paper is to systematically review the diagnostic accuracy of ultrasonography for meniscal injuries in knee joint.
EVIDENCE ACQUISITION: A search of PubMed and Web of Science was performed up to January 2015. Only studies for diagnosis meniscal injuries by ultrasonography were included. The results were meta-analyzed by pooling estimates of sensitivity, specificity, diagnostic odds ratio (DOR), and constructing the summary receiver operating characteristic (SROC) curves.
EVIDENCE SYNTHESIS: Twenty-one studies met the selection criteria for inclusion in the analysis. The pooled estimates for sensitivity, specificity, and area under curve (AUC) of ultrasonography diagnosis were 0.775 (95% CI: 0.747-0.801), 0.838 (95% CI: 0.818-0.857), and 0.9107 (95% CI: 0.8625-0.9589), respectively. For lateral meniscus diagnosis and medial meniscus diagnosis, the AUC was 0.9812 (95% CI: 0.9592-1.000) and 0.8997 (95% CI: 0.7313-1.000), respectively. However, in diagnosis by magnetic resonance imaging (MRI), the AUC was 0.9421 (95% CI: 0.8760-1.000). The ultrasonography inter-observer agreement resulted in a moderate reliability, with the kappa value ranged from 0.381 to 0.482.
CONCLUSIONS: We found the diagnostic accuracy of ultrasonography for meniscal injuries was good. No evidence showed MRI had better accuracy than ultrasonography diagnosis. We recommend ultrasonography should be routinely used for evaluation of meniscal injuries in knee joint.
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0 |
A left knee wound complication by non-Hodgkins lymphoma in bilateral total knee arthroplasties
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Surgical Management of Osteoarthritis of the Knee CPG
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A 70-year-old woman with a history of bilateral primary knee osteoarthritis presented with a left knee wound complication, a non-Hodgkins lymphoma, after bilateral total knee arthroplasties. After exploring several etiologies, the evidence in this unusual case suggests a coincidental preexisting lymphoma
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0 |
Median nerve compression in Weill-Marchesani syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Weill-Marchesani syndrome is a rare, generalized disorder of connective tissue manifested by short stature, brachymorphia, and spherophakia. Inheritance is autosomal recessive. In the less than 50 reported cases, joint stiffness in the hands and thenar atrophy have been noted in adults. A kindred is reported here in which release of multiple trigger fingers and bilateral carpal tunnel syndrome in childhood has improved hand function in a brother and sister
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Knee salvage in revision arthroplasty after massive bone loss of the femur condyles (>/=Engh III) with a single-modular-hinged knee revision implant
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PJI DX Updated Search
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PURPOSE: Massive bone loss of the femur condyles in revision arthroplasty often requires modular-hinged revision implants to restore a stable joint situation. In the present series, the outcome after knee revision surgery using a single modular-hinged revision implant in patients with severe bone defects (>Engh III) is investigated. METHODS: Sixty patients with severe bone defects (>/=Engh III) after failed primary and revision knee arthroplasty were included. Medium follow-up was 47 (range 10-84) months after knee revision surgery. Medium patient age was 70 (range 33-87) years at the time of surgery. An average of 2.3 prior knee operations per patient was performed. 70 % of the patients required the knee revision implant after two-stage revision because of a deep implant infection. RESULTS: Estimated 5 year extremity survival was 95 and 65 % implant survival. Reasons for implant revision in decreasing order were reinfection (30 %), aseptic loosening (13 %), and periprosthetic fracture (9.8 %). The average active range of motion in the knee joint was 88 degrees (range 40 degrees -115 degrees ) for flexion. An extension deficit of a mean of -6 degrees was (range -50-5 degrees hyper-extension) observed. Patient age influenced the functional results significantly in terms of reduced walking distances and decreased modified WOMAC score. CONCLUSION: In consideration of this complex study, population acceptable functional results can be achieved using a modular knee revision endoprosthesis. In younger patients (<60 years), satisfying results in terms of walking ability and overall satisfactory can be expected. The outcome in older multimorbid patients is worse. Yet, operation in these patients can be feasible to restore enough mobility for daily household activities
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1 |
Therapeutic effects of short-term monochromatic infrared energy therapy on patients with knee osteoarthritis: A double-blind, randomized, placebo-controlled study
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OAK 3 - Non-arthroplasty tx of OAK
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STUDY DESIGN: Randomized, double-blind, placebo-controlled study. OBJECTIVES: To examine the short-term therapeutic effects of monochromatic infrared energy (MIRE) on participants with knee osteoarthritis (OA). Patients were assessed according to the International Classification of Functioning, Disability and Health. BACKGROUND: MIRE is commonly used in therapy for patients with peripheral neuropathies. However, research has not focused intensively on the therapeutic effects of MIRE in patients with knee OA. METHODS: This study enrolled 73 participants with knee OA. Participants received six 40-minute sessions of active or placebo MIRE treatment (890-nm wavelength; power, 6.24 W; energy density, 2.08 J/cm2/min; total energy, 83.2 J/cm2) over the knee joints for 2 weeks. International Classification of Functioning, Disability and Health-related outcomes were collected weekly over 4 weeks using the Knee injury and Osteoarthritis Outcome Score, Lysholm Knee Scale, Hospital Anxiety and Depression Scale, Multidimensional Fatigue Inventory, Chronic Pain Grade questionnaire, World Health Organization Quality of Life-brief version, and OA Quality of Life Questionnaire. Data were analyzed by repeated-measures analysis of variance. RESULTS: No statistically significant differences were found for the interaction of group by time for Knee injury and Osteoarthritis Outcome Score scores, including pain, other symptoms, function in daily living, function in sport and recreation, and knee-related quality of life. Scores on the Lysholm Knee Scale, Hospital Anxiety and Depression Scale, Multidimensional Fatigue Inventory, Chronic Pain Grade questionnaire, World Health Organization Quality of Life-brief version, and OA Quality of Life Questionnaire also showed no significant differences between the 2 groups at any of the 4 follow-up assessments. CONCLUSION: Short-term MIRE therapy provided no beneficial effects to body functions, activities, participation, and quality of life in patients with knee OA. LEVEL OF EVIDENCE: Therapy, level 1b-. Copyright © 2012 Journal of Orthopaedic & Sports Physical Therapy.
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0 |
Distribution of clinical symptoms in carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
|
OBJECTIVE: To determine the distribution of clinical symptoms based on the gender and age of patients with Carpel Tunnel Syndrome (CTS). STUDY DESIGN: A cross-sectional observational study. PLACE AND DURATION OF STUDY: Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia, from April 2009 to June 2011. METHODOLOGY: Two hundred and twenty seven subjects with carpal tunnel syndrome symptom were recruited. CTS was diagnosed based on the clinical history and examination. For further confirmation of CTS symptoms, nerve conduction studies (NCS) were conducted. RESULTS: There were 67 (29.5%) males and 160 (70.5%) females with mean age of 47.79 +/- 5.53 years. Distributions of symptoms were 34.3% at the level of whole three lateral fingers, 14.9% were at the level of hand and forearm, was common in males compared to females. However, 48.8% symptoms at the level of whole hand, and 11.3% at the tips of the three lateral fingers were common in females compared to males. Distribution of symptoms in the whole three lateral fingers (41.6%) were significantly higher (p = 0.0001) in patients who were more than 50 years of age and symptoms at the level of wrist region (12.7%) were significantly higher (p = 0.001) in patients with age group less than 50 years. CONCLUSION: The distribution of CTS symptoms at the level of whole of three lateral fingers, hand and forearm were higher in males compared to females, and symptoms at the lateral three tips of the fingers and whole hand were common in females compared to males. Furthermore, the symptoms in whole three lateral fingers were higher in patients with more than 50 years of age and at the level of wrist region were higher in patients with age less than 50 years
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0 |
Return to Sport After Tibial Shaft Fractures: A Systematic Review
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DoD SSI (Surgical Site Infections)
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CONTEXT: Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods. OBJECTIVE: To determine the current evidence for the treatment of and return to sport after tibial shaft fractures. DATA SOURCES: OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014. STUDY SELECTION: Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non-English language were excluded. STUDY DESIGN: Systematic review.Level 4. DATA EXTRACTION: The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis. RESULTS: A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, -83.36 to -55.64; P < 0.01). Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P < 0.01). CONCLUSION: The general principles are to undertake surgical management for displaced fractures and to attempt nonsurgical management for undisplaced fractures. Primary surgical intervention of undisplaced fractures, however, may result in higher return rates and shorter return times, though this exposes the patient to the risk of surgical complications, which include surgical site infection and compartment syndrome.
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0 |
Tailor therapy according to patient needs and anatomical site when treating primary hyperhidrosis
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Panniculectomy & Abdominoplasty CPG
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Hyperhidrosis is a disorder of excessive sweating, with most cases involving the axillae, palms and soles. The choice of nonsurgical or surgical treatment should be tailored to the individual needs of the patient and anatomical site affected. © 2012 Springer International Publishing AG. All rights reserved.
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0 |
Cytochrome p450 and glutathione transferase expression in human breast cancer
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Reduction Mammoplasty for Female Breast Hypertrophy
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PURPOSE: The cytochrome P-450 (CYP) and glutathione S-transferase (GST) enzyme systems may influence the biological effects of carcinogens, including estrogens. As such, these enzymes may predict the developmental risk of breast cancer, as well as be potential targets for chemoprevention. The purpose of this study was to compare the expression of GST-Pi and CYPs 1A1, 2B6, 2E1, and 3A4 in paired samples of normal and malignant breast tissue from patients with breast cancer and women undergoing reduction mammoplasty.
EXPERIMENTAL DESIGN: Expression of CYPs 1A1, 2B6, 2E1, 3A4, and GST-Pi was quantified in breast tissue from 33 patients with breast cancer and in 17 women without history of cancer who underwent reduction mammoplasty. The expression of CYP 1A1, 2B6, 2E1, 3A4, and GST-Pi was quantified by immunoblotting.
RESULTS: CYP 1A1, 2E1, and 3A4 expression was significantly lower (P < 0.05) in malignant tissue as compared with morphologically normal adjacent tissue. Conversely, GST-Pi expression was marginally lower in the normal tissue (P = 0.08). No significant difference in enzyme expression was seen between the tissue from reduction mammoplasty and normal tissue from breast cancer patients. There was a trend for higher expression of CYP 2B6 and GST-Pi in the estrogen receptor expressing tumors than those tumors without expression (P > 0.28).
CONCLUSION: The expression of these enzymes was similar in morphologically normal breast tissue from patients with or without breast cancer. The expression of CYPs was down-regulated in the tumor tissue. The clinical significance of CYP alterations in breast cancer will need further characterization.
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Resilience in family caregivers of persons with acquired brain injury
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DoD PRF (Psychosocial RF)
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Purpose/Objective: The authors' purpose was to develop the Questionnaire of Resilience in Caregivers of Acquired Brain Injury (QRC-ABI) and explore its psychometric properties The QRC-ABI was developed to measure the process of resilience, including resilient factors that, according to the literature, are the most relevant for caregivers. Research Method/Design: This is a cross-sectional study of Spanish primary caregivers of individuals with ABI. It included 237 caregivers (77.6% women and 21.1% men) who completed the QRC-ABI, the Posttraumatic Growth Inventory (Weiss & Berger, 2006), the World Health Organization Quality of Life-BREF (Skevington, Lotfy, O'Connell, & the WHOQOL Group, 2004) assessment, and the Positive Aspects of Caregiving (Tarlow et al., 2004) assessment. Results: An item pool of 36 items was developed, from which 17 were finally selected based on a consensus among researchers and adequate symmetry indexes and kurtoses. Confirmatory factor analysis of the QRC-ABI confirmed a hierarchical solution in which 4 resilience dimensions were explained by a broader general resilience factor. The internal consistency of each scale was >.80. Convergent validity was supported through positive correlations of the QRC-ABI with quality of life, positive aspects of caregiving, and posttraumatic growth, and a negative correlation with perceived burden. Conclusion/Implications: The new QRC-ABI showed good reliability and validity. Our results are consistent with previous studies that have argued that resilient qualities are important for a healthy and positive adaptation to the challenging adversities faced by caregivers of individuals with ABI. Future interventions based on resilience should promote these factors in caregivers.
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0 |
Lack of metabolic bone disease in patients with fracture of the femoral neck
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MSTS 2018 - Femur Mets and MM
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To examine the widely held belief that osteoporosis and osteomalacia are pathogenetic factors in femoral neck fracture, we compared such patients with vertebral fracture patients and controls. Cortical bone was measured in hand X-rays and cancellous bone in iliac crest biopsies, which were also used to assess osteoid, tetracycline and resorbing surface. The vertebral fracture patients were found to have a reduction of 53% and 41% in cancellous and cortical bone respectively compared to the controls, while in the much older femoral fracture patients the reductions were 19% and 16%. Three femoral fracture patients had mild osteomalacia from identifiable causes; a further one had fluorosis of bone and one had metastatic carcinoma; with the exception of these the osteoid covered surface of bone was less than in vertebral fracture patients and controls. We conclude that pathologic osteoporosis and osteomalacia are not major factors in the pathogenesis of femoral neck fractures, though the normal age related reduction in bone mass may contribute. There may be another age related factor weakening the femoral neck. It was also noted that when assessed by a sensitive histochemical technique for osteoclast identification, bone resorption was not increased in either of the fracture groups.
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0 |
Cost analysis of intra-articular sodium hyaluronate treatment in knee osteoarthritis patients who failed conservative treatment
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Failed conservative treatments of knee osteoarthritis (OA) in the elderly have traditionally been treated with TKA (Total Knee Arthroplasty). Although TKA is a gold standard and cost-effective treatment in elderly patients, it should be considered as the last resource for patients with pain that cannot be controlled by the usual conservative therapeutic approaches. Numerous studies showed that intra-articular Sodium Hyaluronate (IA-HA) (Hyalgan) is effective for treatment in various stages of knee OA. OBJECTIVES: To compare cost of treatment between two groups of knee OA patients who failed conservative treatments. The first group includes the patients who responded to IA-HA treatment leading to delay or cancel surgical treatments (response group). The second group includes the patients who did not respond to IA-HA treatment and they had to undergo surgical procedures (non-response group). MATERIAL AND METHOD: A cost analysis from the retrospective data in Police General Hospital from year 2001-2004. One hundred and eighty three patients with knee OA (208 knees) who failed conservative treatments and did not have contraindications for surgery were enrolled. All patients were treated with one course of three IA-HA injections (500-730 KDA, Hyalgan) at weekly intervals and followed up for a minimum 2-year period. In case of successful treatment (response group), repeated doses were recommended. If the patients did not improve in the average Western Ontario and McMaster Universities Osteoarthritis Index (the average WOMAC) score within one month after completion of the injections, they would be classified as a non-response group and the surgical procedures would be considered. Cost of direct medical costs (drugs), hospitalization, and resource utilization were recorded and analyzed. RESULTS: One hundred and forty six patients (164 knees) responded to the treatment and did not need any surgical procedures within the 2-year follow-up period. Thirty-seven patients (44 knees) did not respond and needed surgical procedures. In the response group, 83 patients repeated the second course of treatment and 14 patients repeated the third course. The total average cost for the response group were 47,044.18 Baht per patient, which was an average cost of IA-HA; 12,240.41 Baht and an average cost of other medications following the injection of 34, 803.77 Baht. The ratio of the IA-HA cost and medications following the injection cost was 1:2.84. In the non-response group, the total average cost was 144,884 Baht per patient including average cost of surgery of 135,559.95 Baht per patient or 113,993.59 Baht per knee and cost of IA-HA treatment of 9,324 Baht per patient, which was only 6.44% of the total costs of treatment. However, when considered in the response group, the IA-HA treatment provided cost saving from cancellation or delayed surgical procedures at 63.26%. CONCLUSION: IA-HA should be considered as a medical intervention before surgical procedures in knee OA patients who failed conservative treatments. Even though the cost of IA-HA treatment would increase the total costs of treatment and some patients might fail, it was only 6.44% of the total costs. On the other hand, if patients responded to IA-HA treatment, then the surgical procedures were not required. This treatment could save the cost from cancellation or delayed surgical procedures at 63.26%
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