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Disparity between sensory nerve activity and psychophysical responses for air-puff stimulation of the index finger and palm in man
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Air-puff stimuli were delivered to five successive sites over the index finger and palm to obtain psychophysical responses and to record sensory nerve action potentials (SNAPs) from the median nerve at the wrist for elucidating psychoneural correlations across different locations of the glabrous hand. Magnitude estimations at each location evoked uniform subjective magnitudes for all stimulus locations. The time-integral of all
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Chronic intermittent hypoxemia in patients with OSAS leads to the reduction of the number of median nerve fibers
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Purpose: Intermittent hypoxemia is one of the burden of obstructive sleep apnoea syndrome (OSAS). Our aim is to investigate electrophysiologically the effect of chronic intermittent hypoxemia on motor unit number of the patients with OSAS. Methods: Sixty-two patients with OSAS and fifty-seven normal controls were included. Neurological examination in all patients revealed normal findings. Ninety-five subjects with a mean age of 45.3(plus or minus)10.6 (14-77) years were male and twenty-four with a mean age of 46.7(plus or minus)11.5 (25-70) years were female. According to apnea-hypopnea index (AHI), they were divided in two groups (group 1: AHI < 15 and group 2: AHI > 15.1). Motor and sensory conductions on median and ulnar nerves were measured and, those with normal conduction values were included, thus, carpal tunnel syndrome or polyneuropathy were excluded. According to automatically incremental method MUNE studies were completed by using Keypoint system (Dantec, Denmark). Results: There were no statistical differences between two groups in terms of peak amplitudes, distal latency of motor and sensory nerves (p < 0.5) and max values of M amplitudes. The mean max. M area was 50.8(plus or minus)20.4 (16.1-121.7) in group 1 and 48.6(plus or minus)20.05 (10.5- 111.4) in group 2 (p: 0.55). The mean motor conduction velocity of median nerve in NC and in patients with OSAS were 60.6(plus or minus)5.2 m/s (50-71.2) and 58.4(plus or minus)4.3 m/s (51.2-70.8), respectively (p: 0.010). The mean MUNE values in group 1 and in group 2 were 155.3(plus or minus)41.17 (ranged 46.6 and 251.7) and 127.7(plus or minus)40.2 (ranged 22.8 and 235), respectively (p < 0.000). Conclusion: The significant reduction of the motor nerve fibers estimated by MUNE method led the conclusion that chronic recurrent hypoxemia during sleep may be an independent risk factor for the decrease of motor units and subclinical neuropathy in patients with OSAS
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Single dose oral lornoxicam for acute postoperative pain in adults
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SR for PM on OA of All Extremities
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Background: Lornoxicam is one of the oxicam class of non-steroidal anti-inflammatory drugs (NSAIDs), producing analgesic and antipyretic effects in part through the non-selective inhibition of cyclo-oxygenase-1 and -2. It is prescribed for osteoarthritis, rheumatoid arthritis, acute lumbar-sciatica conditions and for postoperative pain management. Lornoxicam is available in 31 countries in Europe, the Middle East, Far East and South America, and is becoming more widely available.Objectives: To assess the efficacy, the time to onset of analgesia, the time to use of rescue medication and any associated adverse events of single dose oral lornoxicam in acute postoperative pain.Search methods: We searched CENTRAL, MEDLINE, EMBASE and PubMed to June 2009.Selection criteria: Single oral dose, randomised, double-blind, placebo-controlled trials of lornoxicam for relief of established moderate to severe postoperative pain in adults.Data collection and analysis: Studies were assessed for methodological quality and the data extracted by two review authors independently. Summed total pain relief over 6 hours (TOTPAR 6) was used to calculate the number of participants achieving at least 50% pain relief. These derived results were used to calculate, with 95% confidence intervals (CIs), the relative benefit compared to placebo, and the number needed to treat (NNT) for one participant to experience at least 50% pain relief over 6 hours. Numbers of participants using rescue medication over specified time periods, and time to use of rescue medication, were sought as additional measures of efficacy. Information on adverse events and withdrawals was collected.Main results: Three studies, with 628 participants, met the inclusion criteria; 434 participants were treated with various doses (2 mg to 32 mg) of lornoxicam, 118 with placebo, and 76 with other active therapies. All the participants had pain following third molar extraction, and study duration was 8 to 24 hours. The NNT for at least 50% pain relief over 6 hours after a single dose of lornoxicam 8 mg was 2.9 (2.3 to 4.0). There were insufficient data to analyse other doses or use of rescue medication. No serious adverse events or withdrawals were reported by any of the studies.Authors' conclusions: Oral lornoxicam is effective at treating moderate to severe acute postoperative pain, based on limited data. Adverse events did not differ significantly from placebo
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A radiological study of fractures of acrylic cement in relation to the stem of a femoral head prosthesis
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Management of Hip Fractures in the Elderly
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The incidence and prognostic significance of fractures of acrylic cement related to the stem of a femoral head prosthesis in total hip replacement are examined. These fractures are demonstrated when the cement has been rendered radio-opaque by the addition of barium sulphate. One and a half percent of the radiographs of 6,649 patients showed these fractures, which were sometimes associated with subsidence of the prosthesis. Fracture of the cement was usually evident at the six-month post-operative review, if it occurred at all. This radiological complication was devoid of symptoms in the majority of cases and tended to occur in patients with excellent functional recovery. In a minority of patients pain in the thigh during the first six months seemed likely to be explained by this fracture. Slight subsidence of the prosthesis in the cement bed appeared to result in a new and final position of stability. The prognosis was very good; only when separation of the fracture exceeded about 4 millimetres was the prognosis doubtful, in which case a chronic deep infection might be suspected. Possible mechanical and structural causes of fracture of the cement are discussed
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Once-weekly risedronate in men with osteoporosis: results of a 2-year, placebo-controlled, double-blind, multicenter study
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Management of Hip Fractures in the Elderly
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Male osteoporosis is increasingly recognized as a major public health issue. This multinational, 2-yr, randomized, double-blind, placebo-controlled study was conducted to determine the efficacy and safety of 35 mg once-a-week risedronate in men with osteoporosis. Patients had to be men >or=30 yr old, with lumbar spine T-score <or= -2.5 and femoral neck T-score <or= -1 SD or lumbar spine T-score <or= -1 and femoral neck T-score <or= -2 SD (based on young normal men). Patients were randomized 2:1 to risedronate 35 mg once a week or placebo for 2 yr; all patients took 1000 mg elemental calcium and 400-500 IU vitamin D daily. Lumbar spine BMD at month 24 using last observation carried forward was the primary endpoint. Other endpoints included lumbar spine BMD at time points other than month 24, proximal femur BMD, bone turnover markers (BTMs), new vertebral fractures, clinical fractures, and adverse event (AE) assessment. There were 284 men enrolled in the study. Treatment with risedronate resulted in a significant increase from baseline to endpoint in lumbar spine BMD compared with placebo (4.5%; 95% CI: 3.5%, 5.6%; p < 0.001). Few new vertebral and nonvertebral fractures were reported, with no differences in fracture rates between the two groups. There was a significant (p < 0.01) reduction from baseline in BTMs for the risedronate group compared with placebo at all time points. No apparent differences in the pattern or distribution of AEs including serious and upper gastrointestinal AEs were observed. Risedronate therapy was well tolerated during this 2-yr study and was rapidly effective as indicated by significant BTM decreases at month 3 and BMD increases at month 6 (the earliest time points tested). The effects of risedronate treatment on BMD and BTMs in this study were similar to those previously shown to be associated with fracture risk reductions in women with postmenopausal osteoporosis
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Effect of hyaluronic acids as chondroprotective in experimental model of osteoarthrosis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: to analyze the effects of hyaluronic acid of different molecular weights in an experimental model of osteoarthritis in rabbits.
METHODS: forty-four male California rabbits were divided randomly into three groups and underwent resection of the anterior cruciate ligament in his right knee. After three weeks of the surgical procedure began three weekly intra-articular injections of hyaluronic acid native (Polireumin())-PR, hyaluronic acid branched chain (Synvisc())-S and 0.9% saline-P. All animals were sacrificed after twelve weeks of surgery and tibial plateau infiltrated the knees were dissected. Histological cartilage of the support areas of the tibial plateaus were stained with Alcian Blue pH 1.0, Alcian Blue pH = 2.5 and toluidine blue for research on the amount of proteoglycans. The intensity of staining was quantified on a Zeiss microscope apparatus Imager Z2 MetaSystems and analyzed by software MetaferMsearch.
RESULTS: the effect of chondroprotetor hyaluronic acids used in the study was confirmed when compared to the control group, but the comparison made between them, there was no statistically significant difference regarding chondroprotetion.
CONCLUSION: the hyaluronic acids tested had chondroprotective effect, with no statistical difference with regard to the different molecular weights.
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Ambulatory arthroscopic knee surgery results of partial meniscectomy
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AMP (Acute Meniscal Pathology)
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In an open prospective study the results of arthroscopic partial meniscectomy were reviewed in 188 knees. Group I comprised of 139 (65%) knees with pure meniscus lesions without any ligament laxity, the remaining 49 (35%) knees in group II had anterior cruciate ligament (ACL) deficiency in addition to meniscus lesions. In group I, 93% had excellent to good and 7% had fair results by criteria of Tapper and Hoover. In group II, 75% had excellent to good and 25% had fair results. Arthroscopic knee surgery was a good method of identifying patients in group II who required anterior cruciate reconstruction. One hundred (53%) sedentary workers were able to return to work at a mean time of 3 weeks. Patients classified as heavy labour comprised of a group of 40 (21%) were able to return to their occupation in the mean time of 5 weeks. School and college students numbered 28 (14%) were able to go to their institutions in the mean time of 10 days. Twenty (9%) patients were professional or semi-professional athletes who were permitted sports training in 3 weeks and sports participation in 6 weeks on the average. There were no serious complications including wound infection, deep venous thrombosis (DVT) or loss of knee motion. The arthroscopic technique is reliable, cost effective and has high patient acceptance because of low morbidity and rapid return of good function to the knee joint.
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Retrospective assessment of vascular injuries: 23 years of experience
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DOD - Acute Comp Syndrome CPG
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PURPOSE: To analyze the operation methods, injury etiologies and localizations, post-operative complications and the reasons for mortality in patients who were admitted for peripheral vascular injuries to our clinics.
METHODS: From January 1979 to February 2002, 410 patients were operated for peripheral vascular injuries. Three hundred and one of the patients were male (73.5%) and 109 of them were female (26.5%), and their ages ranged between 1-88 (mean 35.5 years).
RESULTS: The most common etiological reason was firearm injuries in 163 patients (39.8%). The most common injured artery was the brachial artery (83 patients, 22.5%) among a total of 369 patients whereas the most commonly injured vein was the common femoral vein (60 patients, 23.4%) in a total of 256 patients. Isolated venous injuries were encountered in 41 patients whereas isolated arterial injuries were detected in 154 patients (37.5%). Hospital admission duration of the patients after trauma was approximately 3 hours.
CONCLUSION: The extremity-salvage rate in the group was 92.3%. The hospital stay period of the patients was 21.8 days. The mortality rate was 2.6% (11 patients).
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Nursing home residence and risk of hip fracture
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Management of Hip Fractures in the Elderly
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This population-based case-control study was performed to determine whether the high incidence of hip fractures in people living in nursing homes is explained by the generally poor physical and mental health status of institutionalized older people. The study, which was conducted between 1990 and 1991, involved 209 hip fracture cases and 207 controls randomly selected from the same population in Sydney, Australia. Data on potential confounders were collected by using an interviewer-administered questionnaire. The age- and sex-adjusted odds ratio for the association between nursing home residence and risk of hip fracture was 2.4 (95% confidence interval 1.4-4.3). However, after adjustment for multiple confounders, the odds ratio was 0.6 (95% confidence interval 0.2-1.6). It appears that living in a nursing home is not an independent risk factor for hip fracture
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Combined aesthetic interventions for prevention of facial ageing, and restoration and beautification of face and body
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Panniculectomy & Abdominoplasty CPG
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The Merz Institute of Advanced Aesthetics Expert Summit was held in Prague, Czech Republic, from 19â??20 November 2016. The meeting had a distinct advisory board character and invited aesthetic practitioners from all over the world to hear an international faculty present a range of keynote lectures and conduct live injection sessions with an emphasis on recent developments in combination aesthetic interventions for face and body rejuvenation and beautification. Aging is associated with changes in bones, muscles, ligaments, adipose tissue, and skin and, moreover, involves interactions among these tissue types. To achieve the most natural and harmonious rejuvenation of the face, all changes that result from the aging process should be corrected, which generally involves treatment with more than a single agent or technology. Presentations described innovative treatment algorithms for the face and body and focused on patientsâ?? desires for natural-looking rejuvenation and how this requires a three-dimensional approach combining products that relax the musculature, volumize, and re-drape the skin. Besides treating the aging face, these procedures are increasingly used to enhance facial features as well as to delay facial aging in younger patients. The presentations covered patients from different ethnicities as well as the treatment of non-facial areas, with a particular focus on the use of Ultherapy for skin lifting and tightening, and new aesthetic ® procedures such as Cellfina® and diluted Radiesse®. The current report provides a summary of key presentations from the meeting.
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Functional recovery of older people with hip fracture: does malnutrition make a difference?
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Hip Fx in the Elderly 2019
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AIM: To report a study of the effects of protein-energy malnutrition on the functional recovery of older people with hip fracture who participated in an interdisciplinary intervention.
BACKGROUND: It is not clear whether protein-energy malnutrition is associated with worse functional outcomes or it affects the interdisciplinary intervention program on the functional recovery of older people with hip fracture.
DESIGN: A randomized experimental design.
METHODS: Data were collected between 2002-2006 from older people with hip fracture (N = 162) in Taiwan. The generalized estimating equations approach was used to evaluate the effect of malnutrition on the functional recovery of older people with hip fracture.
RESULTS: The majority of older patients with hip fracture were malnourished (48/80, 60% in the experimental group vs. 55/82, 67% in the control group) prior to hospital discharge. The results of the generalized estimating equations analysis demonstrated that subjects suffering from protein-energy malnutrition prior to hospital discharge appeared to have significantly worse performance trajectories for their activities of daily living, instrumental activities of daily living, and recovery of walking ability compared with those without protein-energy malnutrition. In addition, it was found that the intervention is more effective on the performance of activities of daily living and recovery of walking ability in malnourished patients than in non-malnourished patients.
CONCLUSION: Healthcare providers should develop a nutritional assessment/management system in their interdisciplinary intervention program to improve the functional recovery of older people with hip fracture.
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Biomechanical analysis of lateral humeral condyle fracture pinning
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: The purpose of this study was to determine the optimum pin configuration and the number of pins needed to stabilize the Milch type II lateral humeral condyle fractures in a pediatric bone model. METHODS: Forty synthetic pediatric humeri were sectioned through the lateral distal humerus to simulate a Milch type II lateral condyle fracture. Each fracture was stabilized with 0.062-in K-wires in 1 of 5 configurations: 2 convergent pins, 2 parallel pins, 2 divergent 30-degree pins, 2 divergent 60-degree pins, and 3 divergent pins (n=8/group). Models were tested in extension, flexion, varus, and valgus by applying a translational force through the distal fragment at 0.5 mm/sec oscillating between 5 N and 50 N for 10 cycles. For internal and external rotation, constructs were tested at 0.5 degree/sec between ±1 Nm more than 10 cycles. The maximum force and torque values were also recorded. For bending loads, stiffness was calculated between 0.5 and 5 mm of displacement, whereas torsional stiffness was calculated between 1 degree and 10 degrees of rotation. Data for stiffness were analyzed with a 1-way analysis of variance and a 2-sample t test (P<0.05). RESULTS: Among 2-pin configurations, divergent (60 degrees) pins provided statistically greater stability than less divergent pins in torsional loading, and greater stability than parallel pins in valgus loading. Three divergent pins had statistically greater stability than all the 2-pin configurations in valgus and torsional loading, and tended to provide more secure fixation in varus loading. CONCLUSIONS: For 2-pin constructs, maximizing pin divergence at the fracture site provided greater stability in torsional loading and valgus loading. The addition of a third pin in a divergent orientation increases stability compared with 2-pin constructs in valgus, internal, and external rotation loading. CLINICAL RELEVANCE: Bicortical pins placed with maximum divergence and spread at the fracture site maximizes stability for 2-pin constructs in Milch type II lateral condyle fractures. If the stability of the fracture is questionable after 2 pins are inserted, the addition of a divergent third pin enhances the stability.
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CSF sTREM2 in delirium-relation to Alzheimer's disease CSF biomarkers Abeta42, t-tau and p-tau
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Hip Fx in the Elderly 2019
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BACKGROUND: Delirium and dementia share symptoms of cognitive dysfunctions, and mechanisms of neuroinflammation appear involved in both conditions. Triggering receptor expressed on myeloid cells 2 (TREM2) is linked to dementia and neurodegenerative disease. It encodes expression of an innate immune receptor in the brain expressed by microglia. The level of the soluble fragment of TREM2 (sTREM2) is reported to increase in the cerebrospinal fluid (CSF) already in prodromal and asymptomatic Alzheimer's disease.
METHODS: We analyzed the level of CSF sTREM2 in relation to delirium and dementia. The study included patients with or without pre-existing dementia who underwent acute hip fracture surgery (n = 120), and some of the patients developed delirium (n = 65). A medical delirium cohort (n = 26) was also examined. ELISA was used to determine the level of sTREM2 in CSF.
RESULTS: Delirium was associated with a higher level of CSF sTREM2 only among those without pre-existing dementia (p = 0.046, n = 15, n = 44), particularly among patients developing delirium after CSF sampling (p = 0.02, n = 7, n = 44). Between patients with dementia, there was no group difference, but the CSF sTREM2 level increased with waiting time for surgery (r<sub>S</sub> = 0.39, p = 0.002, n = 60) and correlated well with the CSF Alzheimer's disease biomarkers, Abeta42, and t-tau/p-tau (r<sub>S</sub> = 0.40, p = 0.002, r<sub>S</sub> = 0.46, p < 0.001/ r<sub>S</sub> = 0.49, p < 0.001, n = 60). Among patients with dementia, the level of Abeta38 and Abeta40 also correlated positively with sTREM2 in CSF (Abeta38<sub>MSD</sub>r<sub>S</sub> = 0.44, p = 0.001; Abeta40<sub>MSD</sub>r<sub>S</sub> = 0.48, p < 0.001; Abeta42<sub>MSD</sub>r<sub>S</sub> = 0.43, p < 0.001, n = 60).
CONCLUSION: The findings reinforce the involvement of neuroinflammation in delirium, yet with separate responses in patients with or without pre-existing dementia. Our findings support the concept of primed microglia in neurodegenerative disease and central immune activation after a peripheral trauma in such patients. A CSF biomarker panel of neuroinflammation might be valuable to prevent delirium by identifying patients at risk.
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Panniculectomy adjuvant to obesity surgery
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Panniculectomy & Abdominoplasty CPG
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Background: Many patients who qualify for obesity surgery have a moderate to large panniculus (grade 1-5). They can benefit from panniculectomy done concurrently with gastric bypass (GBP) or subsequently after significant weight reduction, usually 18 months after the GBP. Method: Over the last 8 years, 2,231 bariatric operations were performed at the Center. 577 panniculectomies were done, with 428 (74.2%) concurrent with the GBP and 149 (25.8%) subsequent to the GBP. Results: The redundant pannus weighed from 5 to 54.5 kg. Wound problems occured in 15.1% of panniculectomies. Transfusion was necessary in 1.9%. Hospital stay was 4 to 5 days, and was no greater than in patients that underwent the GBP alone. Those with grades 3-5 suffer more back-pain and problems of hygiene resulting from panniculitis. Conclusion: A very redundant panniculus compounds the patient's physical, social and emotional problems. Where cardiopulmonary and other medical status are satisfactory, a panniculectomy may be offered to patients with a symptomatic panniculus at the time of bariatric surgery, as a physically beneficial and cost-effective adjuvant.
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Ankle fractures in diabetic neuropathic arthropathy: can tibiotalar arthrodesis salvage the limb?
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DoD LSA (Limb Salvage vs Amputation)
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Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (> 95%). The arthrodesis failed because of avascular necrosis of the talus in only three patients (17.6%), who developed grossly unstable, ulcerated hindfeet, and required below-knee amputation.
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Aquatic exercise for the treatment of knee and hip osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Osteoarthritis is a chronic disease characterized by joint pain, tenderness, and limitation of movement. At present, no cure is available. Thus only treatment of the person's symptoms and treatment to prevent further development of the disease are possible. Clinical trials indicate that aquatic exercise may have advantages for people with osteoarthritis. This is an update of a published Cochrane review.
OBJECTIVES: To evaluate the effects of aquatic exercise for people with knee or hip osteoarthritis, or both, compared to no intervention.
SEARCH METHODS: We searched the following databases up to 28 April 2015: the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library Issue 1, 2014), MEDLINE (from 1949), EMBASE (from 1980), CINAHL (from 1982), PEDro (Physiotherapy Evidence Database), and Web of Science (from 1945). There was no language restriction.
SELECTION CRITERIA: Randomized controlled clinical trials of aquatic exercise compared to a control group (e.g. usual care, education, social attention, telephone call, waiting list for surgery) of participants with knee or hip osteoarthritis.
DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of the included trials. We analysed the pooled results using standardized mean difference (SMD) values.
MAIN RESULTS: Nine new trials met the inclusion criteria and we excluded two earlier included trials. Thus the number of participants increased from 800 to 1190 and the number of included trials increased from six to 13. Most participants were female (75%), with an average age of 68 years and a body mass index (BMI) of 29.4. Osteoarthritis duration was 6.7 years, with a great variation of the included participants. The mean aquatic exercise duration was 12 weeks. We found 12 trials at low to unclear risk of bias for all domains except blinding of participants and personnel. They showed that aquatic exercise caused a small short term improvement compared to control in pain (SMD -0.31, 95% CI -0.47 to -0.15; 12 trials, 1076 participants) and disability (SMD -0.32, 95% CI -0.47 to -0.17; 12 trials, 1059 participants). Ten trials showed a small effect on quality of life (QoL) (SMD -0.25, 95% CI -0.49 to -0.01; 10 trials, 971 participants). These effects on pain and disability correspond to a five point lower (95% CI three to eight points lower) score on mean pain and mean disability compared to the control group (scale 0 to 100), and a seven point higher (95% CI 0 to 13 points higher) score on mean QoL compared with control group (scale 0 to 100). No included trials performed a radiographic evaluation. No serious adverse events were reported in the included trials with relation to aquatic exercise.
AUTHORS' CONCLUSIONS: There is moderate quality evidence that aquatic exercise may have small, short-term, and clinically relevant effects on patient-reported pain, disability, and QoL in people with knee and hip OA. The conclusions of this review update does not change those of the previous published version of this Cochrane review.
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Embryonic natural orifi ce transluminal endoscopic surgery in the treatment of severe acute pancreatitis complicated by abdominal compartment syndrome
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DOD - Acute Comp Syndrome CPG
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BACKGROUND: The study aimed to estimate the value of embryonal natural orifice transluminal endoscopic surgery (ENOTES) in treating severe acute pancreatitis (SAP) complicated with abdominal compartment syndrome (ACS). METHODS: The patients, who were randomized into an ENOTES group and an operative group, underwent ENOTES and laparotomy, respectively. The results and complications of the two groups were compared. RESULTS: Enterocinesia was observed earlier in the ENOTES group than in the operative group. Acute Physiology and Chronic Health Evaluation II (APACHE II) score of patients in the ENOTES group was lower than that of the operative group on the 1st, 3rd and 5th post-operative day (P<0.05). The cure rate was 96.87% in the ENOTES group, which was statistically different from 78.12% in the operative group (P<0.05). There were significant differences in complications and mortality between the two groups (P<0.01). CONCLUSION: Compared with surgical decompression, ENOTES associated with flexible endoscope therapy is an effective and minimal invasive procedure with less complications.
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Once-weekly teriparatide increases bone mineral density in the distal 1/10 radius, but not in the distal 1/3 radius
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Distal Radius Fractures
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Teriparatide significantly increases bone mineral density (BMD) of the lumbar vertebrae and femur and has a strong effect in reducing the risk of bone fractures. However, few detailed investigations with dual-energy X-ray absorptiometry (DXA) of the effects of teriparatide on the radius have been reported; specifically, there are no reports of the use of once-weekly teriparatide. In this study, the effect of once-weekly teriparatide in increasing BMD was examined in the distal 1/10 of the radius and the distal 1/3 of the radius using a DXA system for the radius. In addition, the effect of radius positioning, especially accurate correction of rotation and inclination before and after administration of teriparatide, was evaluated in an assessment of its efficacy. It was found that when positioning was corrected, a significant increase in BMD in the distal 1/10 of the radius was observed after 6 months of once-weekly teriparatide. In the distal 1/3 of the radius, no significant increase of BMD was observed. This suggests that when DXA scans of the radius are analyzed with appropriate positioning, weekly teriparatide significantly increases BMD in the distal 1/10 of the radius, which is rich in cancellous bone.
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Age and dressing type as independent predictors of post-operative infection in patients with acute compartment syndrome of the lower leg
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DoD SSI (Surgical Site Infections)
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PURPOSE: The purpose of this study was to determine independent factors, including timing of fasciotomy, that confer an increased risk of post-operative surgical site infection (SSI) in patients presenting with acute compartment syndrome (ACS) of the lower extremity.
METHODS: A retrospective analysis was performed on a consecutive cohort of 53 adult patients requiring fasciotomy for lower-extremity fractures complicated by ACS presenting to a single Level I trauma center over a seven-year study period. The primary outcome measure was the incidence of SSI (as defined by the CDC) occurring within 12 months of fasciotomy. Explanatory variables including site of ACS, time of injury, time of fasciotomy, operative findings, and requirement for additional soft tissue coverage procedures were recorded for all patients. Multivariate regression was used to determine independent predictors of post-operative SSI.
RESULTS: post-operative SSI was detected in 16 (30.2%) patients. Compared to infection-free patients, patients with post-operative SSI had a significantly higher median age (52.0 vs. 37.0 years, p = 0.010), frequency of intra-operative myonecrosis at time of fasciotomy (31.2% vs. 5.4%, p = 0.021), and requirement for negative-pressure wound therapy [NPWT] (93.7% vs. 45.9%, p = 0.002). Multivariate logistic regression analysis confirmed that requirement for NPWT (odds ratio [OR], 17.10; 95% confidence interval [CI], 1.78-164.0; p = 0.014) and increasing age (OR, 1.07; 95% CI, 1.01-1.14; p = 0.037) were independent predictors of post-operative SSI. Timing of fasciotomy following injury was not independently related to the risk of SSI.
CONCLUSIONS: ACS occurs on a spectrum of disease severity that evolves variably over time. Increasing age of the patient and requirement for NPWT following fasciotomy are independent predictors of post-operative SSI following emergent fasciotomy for ACS. Further studies are required to inform optimal treatment strategies in such patients.
LEVEL OF EVIDENCE: Therapeutic, Level III.
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The effect of unilateral spinal anaesthesia and psoas compartment with sciatic block on the postoperative pain management in total knee artroplastic surgery
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AAHKS (8) Anesthetic Infiltration
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Purpose. This study was designed to investigate the effects of peripheral nerve block methods, applied through unilateral spinal anaesthesia on elderly patients to undergo total knee arthroplasty, on perioperative hemodynamic parameters and postoperative analgesia period. Materials and Method. 60 patients were randomly divided into two groups in the study. In group USA spinal anaesthesia was performed. In group PCS it was applied on psoas compartment block and sciatic nerve block. Results. Significantly higher intraoperative 60th and 90th minute mean arterial pressure values were ascertained in the PCS group compared to the USA group. The decrease observed in the 5th, 10th, and 20th minute MAP values in the USA group was statistically significant according to the control MAP value. Concerning within group comparisons, the decrease in 5th, 10th, and 20th minute heart rate values in the USA group was statistically significant compared with the control measurement value. The mean beginning time of sensory and motor blocks in the PCS group was found to be at a significantly advanced level compared with that in the USA group. Conclusions.The PCS block technique using bupivacaine hydrochloride ensured a higher haemodynamic efficiency in the perioperative period in high-risk elderly patients undergoing total knee arthroplasty. This trial is registered with ClinicalTrials.gov Identifier: NCT03021421.
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Extreme cobalt toxicity: Bearing the brunt of a failed ceramic liner
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PJI DX Updated Search
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Case: We present a case of systemic cobalt toxicity secondary to third-body wear of a cobalt-chromium (CoCr) femoral head following revision of a fractured ceramic bearing. Removal of the CoCr head was followed by resolution of much of the systemic symptoms. Conclusion: This case supports previous reports of cobalt toxicity secondary to catastrophic third-body wear of a CoCr femoral head following a fractured ceramic bearing. It also demonstrates the potential reversibility of many systemic sequelae associated with cobalt toxicity. To our knowledge, this case represents the highest documented blood cobalt level (45, 840 nmol/L)
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Distal humeral fixation of an intramedullary nail periprosthetic fracture
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Distal humeral periprosthetic fractures below intramedullary nail devices are complex and challenging to treat, in particular due to the osteopenic/porotic nature of bone found in these patients. Fixation is often difficult to satisfactorily achieve around the intramedullary device, whilst minimising soft tissue disruption. Descriptions of such cases in the current literature are very rare. We present the case of a midshaft humeral fracture treated with a locking compression plate that developed a nonunion, in a 60-year old female. This went on to successful union after exchange for an intramedullary humeral nail. Unfortunately, the patient developed a distal 1/5th humeral periprosthetic fracture, which was then successfully addressed with a single-contoured, extra-articular, distal humeral locking compression plate (Synthes) with unicortical locking screws and cerclage cables proximally around the distal nail tip region. An excellent postoperative range of motion was achieved
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Zoledronic acid and mineral metabolism
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MSTS 2018 - Femur Mets and MM
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Zoledronate is an antiresorptive agent of the group of bisphosphonates. It is indicated in the treatment of postmenopausal osteoporosis, glucocorticoid-induced osteoporosis, Raget's disease of the bone, and metastatic disease, but for the latter indication, the medication has another name and another posology. It is as potent as alendronate and risedronate, but its bioavailability is higher since it is administered intravenously. Half of the administered dose stays attached to the bone and this property permits it to be administered once a year. Zoledronate has demonstrated to reduce vertebral, non-vertebral, and hip fracture risk without delaying fracture consolidation. Besides, biopsies have showed that zoledronate increases trabecular number, reduces trabecular spacing, and improves trabecular connectivity. Moreover, it has demonstrated a reduction in mortality in patients who have had a femoral fracture. Although, in part, this property may be due to the fracture risk reduction, other studies suggest that this finding could be mediated by a direct action of zoledronate in the immunological system, among others. The main study examined the fracture risk reduction after three years of zoledronate, but later studies have shown that the medication continues to reduce fracture risk without increasing the risk of adverse events. However, nine years of treatment did not show any advantage compared to six years of treatment. The most common adverse reaction was post infusion syndrome. Other not so common side effects were hypocalcemia and a reduction in renal function, although these effects were transitory. Long-term side effects include atypical hip fracture and osteonecrosis of the jaw. They have a very low incidence and it has not been demonstrated that these effects are directly related to the chronic use of bisphosphonates. In summary, zoledronate is an effective and safe medication that, together with its other unique additional properties, leaves this medication as one of the best treatments for osteoporosis and other mineral metabolism diseases.
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Femoral fractures in adolescents: a comparison of four methods of fixation
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PJI DX Updated Search
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BACKGROUND: The optimal management of femoral fractures in adolescents is controversial. This study was performed to compare the results and complications of four methods of fixation and to determine the factors related to those complications. METHODS: We conducted a retrospective cohort study of 194 diaphyseal femoral fractures in 189 children and adolescents treated with elastic stable intramedullary nail fixation, external fixation, rigid intramedullary nail fixation, or plate fixation. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in terms of the length of the hospital stay, time to union, and complication rates, including loss of reduction requiring a reoperation, malunion, nonunion, refracture, infection, and the need for a reoperation other than routine hardware removal. RESULTS: The mean age of the patients was 13.2 years, and their mean weight was 49.5 kg. There was a loss of reduction of two of 105 fractures treated with elastic nail fixation and ten of thirty-three treated with external fixation (p < 0.001). At the time of final follow-up, five patients (two treated with external fixation and one in each of the other groups) had >or=2.0 cm of shortening. Eight of the 104 patients (105 fractures) treated with elastic nail fixation underwent a reoperation (two each because of loss of reduction, refracture, the need for trimming or advancement of the nail, and delayed union or nonunion). Sixteen patients treated with external fixation required a reoperation (ten because of loss of reduction, one for replacement of a pin complicated by infection, one for debridement of the site of a deep infection, three because of refracture, and one for lengthening). One patient treated with a rigid intramedullary nail required debridement at the site of a deep infection, and one underwent removal of a prominent distal interlocking screw. One fracture treated with plate fixation required refixation following refractures. A multivariate analysis with adjustment for baseline differences showed external fixation to be associated with a 12.41-times (95% confidence interval = 2.26 to 68.31) greater risk of loss of reduction and/or malunion than elastic stable intramedullary nail fixation. CONCLUSIONS: External fixation was associated with the highest rate of complications in our series of adolescents treated for a femoral fracture. Although the other three methods yielded comparable outcomes, we cannot currently recommend one method of fixation for all adolescents with a femoral fracture. The choice of fixation will remain influenced by surgeon preference based on expertise and experience, patient and fracture characteristics, and patient and family preferences
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Stability assessment of distal radius fractures
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Distal Radius Fractures
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A total of 112 consecutive cases of fractures of the distal radius managed conservatively were graded according to radiological criteria using the first radiograph. These criteria, as well as age over 60 years, were considered as gravity factors. A strong correlation was found between these criteria and the risk of secondary displacement, despite a correct initial reduction.
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Effect of exercise therapy compared with arthroscopic surgery on knee muscle strength and functional performance in middle-aged patients with degenerative meniscus tears: a 3-mo follow-up of a randomized controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: The aim of this study was to compare the effect of a 12-wk exercise therapy program and arthroscopic partial meniscectomy on knee strength and functional performance in middle-aged patients with degenerative meniscus tears.
DESIGN: A total of 82 patients (mean age, 49 yrs; 35% women) with a symptomatic, unilateral, magnetic resonance imaging-verified degenerative meniscus tear and no or mild radiographic osteoarthritis were randomly assigned to a supervised neuromuscular and strength exercise program or arthroscopic partial meniscectomy. Outcomes assessed 3 mos after intervention initiation were isokinetic knee muscle strength, lower extremity performance, and self-reported global rating of change.
RESULTS: Mean difference in isokinetic knee extension peak torque between the two groups was 16% (95% confidence interval, 7.1-24.0) (P < 0.0001), favoring the exercise group. Patients in the exercise group improved isokinetic knee extension peak by a mean of 25 Nm (range, 18-33 Nm) from baseline to follow-up. Furthermore, patients assigned to exercise therapy showed statistically significant improvements (P <= 0.002) in all other measured variables, with moderate to large effect sizes (0.5-1.3). Patients reported a similar and positive effect of both interventions.
CONCLUSION: A 12-wk supervised exercise therapy program yielded clinically relevant and statistically significant improvement in isokinetic quadriceps strength immediately after completion of the program, as compared with treatment with arthroscopic partial meniscectomy.
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The effects of lumbar plexus block and epidural block on total blood loss and postoperative analgesia in total hip arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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OBJECTIVES: In this study, the effects of lumbar plexus block and epidural block on total blood loss and postoperative analgesia in patients undergoing total hip arthroplasty (THA) under general anesthesia was documented. METHODS: The study included 45 patients undergoing THA under general anesthesia. Group GA (n=15) received general anesthesia, Group GA+E (n=15) received general anesthesia + epidural catheter and Group GA+LPB (n=15) received general anesthesia + lumbar plexus catheterization. Intraoperative blood transfusion (IOBT) requirements and intraoperative bleeding (IOB) were documented. Postoperative hemoglobin, hematocrit and total blood loss through the drains were also documented. All patients received patientâ?controlled analgesia through the IV route. Time to first analgesic requirement (TFAR), total IV morphine consumption (MORPH 24) and 24â?hour visual analogue scale (VAS) values were evaluated. RESULTS: TFAR was the lowest (8.7+/â?4.0 min.) in the GA group and highest (42.7+/â?14.4 min) in the GA+LPB group, and the GA+E group had lower values than the GA+LPB (32.3+/â?16.0 min) group (p<0.05). IOBT, IOB, and MORPH 24 average values were the lowest in the GA+LPB group and highest in the GA group, with GA+E in between (p<0.05). Postoperative first VAS values were significantly different between the GA group and the others (p<0.001). There was also a significant difference between the GA group and the others regarding postoperative average Hb values (p<0.02). CONCLUSION: THA using either regional technique provides less blood loss and better analgesia. We will consider LPB in our future cases in view of the lower intraoperative blood loss and better analgesia.
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Clinical outcomes and patient satisfaction following revision of failed unicompartmental knee arthroplasty to total knee arthroplasty are as good as a primary total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Background: With unicompartmental knee arthroplasty (UKA) being increasingly performed for medial compartment osteoarthritis (OA) of the knee, revision total knee arthroplasty (TKA) for failed UKA is expected to increase. Our primary aim is to evaluate patients in our tertiary institution who underwent revision of failed UKA to TKA to compare their pre-operative clinical scores (patient-reported outcome measures, PROMs) to those of primary TKA. Methods: Retrospective review of our institutional arthroplasty registry between 2001 and 2014 was performed. We identified 70 patients who underwent revision of UKA to TKA. The revision UKA to TKA patients was matched with 140 patients who underwent primary TKA for OA in terms of preoperative demographics, gender, age at time of surgery, body mass index (BMI), primary surgeon, and PROMs. Intra-operative data and postoperative complications or re-revision surgeries performed were reviewed. Results: In the revision UKA to TKA group, more stems, augments or constrained implants were used compared to primary TKA. A greater proportion of patients with metal-backed UKA revision to TKA required stems, augments or constrained implants as compared to all-polyethylene UKA revision to TKA, but not a significant proportion (P = 0.250). At two years postoperatively, there were no significant differences observed between the groups in terms of patient satisfaction and PROMs. Conclusions: This study showed similar outcomes following revision of failed UKA to TKA and primary TKA. There were significant improvements in PROMs for revision UKA to TKA, which is comparable to that of primary TKA.
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Treatment of lateral knee pain using soft tissue mobilization in four female triathletes
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OAK 3 - Non-arthroplasty tx of OAK
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STUDY DESIGN: Prospective case series.
BACKGROUND: These case reports present results of the treatment of lateral knee pain in four female amateur triathletes. The athletes were referred to the author's clinic with either a diagnosis of iliotibial band friction syndrome or patellofemoral pain syndrome, all four having symptoms for longer than seven months. Changes in training routines were identified as the possible cause of the overuse injuries that eventually developed into chronic conditions.
INTERVENTION: Treatment involved soft tissue mobilization of the musculotendinous structures on the lateral aspect of the knee.
RESULTS: At four weeks, three of the athletes improved 9 to 19 points on the Lower Extremity Functional Scale, 3 to 5 points on the Global Rating of Change Scale, and demonstrated improvement in hamstring and iliotibial band flexibility. At eight weeks the Global Rating of Change for these three athletes was a 7 ("a very great deal better") and they had returned to triathlon training with no complaints of lateral knee pain. One athlete did not respond to treatment and eventually underwent arthroscopic surgery for debridement of a lateral meniscus tear.
CONCLUSIONS: After ruling out common causes for lateral knee pain such as lateral meniscus tear, lateral collateral ligament sprain, patellofemoral dysfunction, osteochondral injury, biceps femoris tendonitis, iliotibial band friction syndrome or osteoarthritis, soft tissue restriction should be considered a potential source of dysfunction. In some cases soft tissue restriction is overlooked; athletes go undiagnosed and are limited from sports participation.
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Incidence of an Anomalous Course of the Palmar Cutaneous Branch of the Median Nerve During Volar Plate Fixation of Distal Radius Fractures
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Distal Radius Fractures
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PURPOSE: Volar plating of distal radius fractures using an approach through the flexor carpi radialis (FCR) sheath is commonplace. The palmar cutaneous branch of the median nerve (PCB) is considered to run in a position adjacent to, but outside, the ulnar FCR sheath. Anatomic studies have not identified anatomic abnormalities relevant to volar plating. The purpose of this study was to determine the frequency of anomalous PCB branches entering the FCR sheath during volar plating.
METHODS: This observational study involved 10 attending hand surgeons during a 7-month period (July 2015-January 2016). Surgeons assessed, documented, and reported any PCB anomalies that were encountered during volar plating through a trans-FCR approach.
RESULTS: There were 182 volar plates applied that made up the study group. There were 10 cases (5.5%) of anomalous PCBs entering the FCR sheath. In 4 cases, the PCB pierced the radial FCR sheath proximally, crossed beneath the tendon, and traveled distally on the ulnar side. In 4 other cases, the PCB entered the FCR sheath proximally on the ulnar or central aspect of the sheath and remained within the sheath, staying along the ulnar or dorsal side of the tendon. In 1 case, the PCB pierced the ulnar distal aspect of the sheath and split into 2 branches. In 1 case, the PCB ran within the sheath along the radial aspect of the FCR.
CONCLUSIONS: Anomalies in the course of the PCB are more common than often considered. These variants are at risk during volar surgical approaches to the wrist that proceed through the FCR sheath.
CLINICAL RELEVANCE: Although dissecting along the radial side of the FCR sheath may protect the PCB in most cases, care must be taken to identify anomalous branches (if present) and protect them during surgery.
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Acute ischemia and pink pulseless hand in 68 of 404 gartland type III supracondylar humeral fractures in children: Urgent management and therapeutic consensus
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Pediatric Supracondylar Humerus Fracture 2020 Review
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No consensus exists regarding pulseless otherwise well-perfused hand in pediatric Gartland type III fractures. The purpose of this retrospective study was to describe our strategy and to determine the guidelines of therapeutic consensus. PATIENTS AND METHODS: 404 children were treated for a type III supracondylar humeral fracture. Extension fractures-induced acute vascular injuries were noticed in 68 patients and nerve injuries were associated in 32 of them. The radial pulse was absent in all patients with two clinical situations at the initial presentation: well-perfused hand with 'pink and warm' hand in 63 patients and ischemia with 'white and cold' hand in five. Urgent closed reduction of the fracture and stabilization were performed in 63 patients with pink pulseless hand, and immediate surgical exploration in the five patients with ischemia. RESULTS: 63 patients with vascular injury had posterolateral displacement and 5 had posteromedial displacement. Sixty-three of 68 patients had posterolateral displacement of whom 28 had concomitant median nerve injury and 4 had a deficit to both median and ulnar nerves. The palpable radial pulse was immediately restored in 42 patients and between few hours to eleven days later in eighteen. Three patients with ischemia after unsuccessful reduction required immediate surgical exploration revealing incarceration of the brachial artery at the fracture site. Release and decompression of the brachial artery restored a normal limb perfusion. The five patients with primary ischemia underwent immediate open exploration and vascular repair. One of them had a compartment syndrome and required anterior fasciotomy. The restoration of blood flow with palpable radial pulse was observed in all patients. Full spontaneous nerve recovery was observed in all patients. At an average follow-up of 8.4 years, all patients had normal circulatory status, including a palpable radial pulse. DISCUSSION: This study highlighted the reliability of non invasive strategy with good outcomes. We recommend urgent closed reduction of fracture. Close observation and monitoring is mandatory if pulseless hand remains warm and well-perfused. If the patients develop blood circulation disturbances or compartment syndrome following closed reduction, immediate vascular exploration is recommend.
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Evidence for synovitis in active polymyalgia rheumatica: sonographic study in a large series of patients
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Glenohumeral Joint OA
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OBJECTIVE: To determine the frequency and localization of synovitis and enthesitis in patients with active, untreated polymyalgia rheumatica (PMR) by ultrasonography (US).
METHODS: Polyarticular sonographic evaluation was carried out in 50 consecutive patients with PMR at disease onset. Results were compared with 50 consecutive patients with seronegative spondyloarthropathies (SpA) and 50 with seronegative and seropositive rheumatoid arthritis (RA) at disease onset.
RESULTS: Synovitis and/or effusion was detected, in at least one joint, in 100% of patients with PMR. The most frequent alterations observed in patients with PMR were effusion in the subacromial-subdeltoid (SA-SD) bursa in 70% of patients, tenosynovitis of the long head of the biceps tendon (LHBT) in 68%, glenohumeral joint effusion in 66%, tenosynovitis of the flexor tendons in the carpal tunnel in 38%, radiocarpal effusion in 18%, wrist extensors tenosynovitis in 18%, coxofemoral joint effusion in 40%. knee effusion in 38%, and ankle effusion in 10%. Enthesitis and tendonitis of the anchoring tendons were relatively rare in all the articular sites. Comparison of the SpA and PMR patients showed that enthesitis (mostly in the elbow, knee, and heel) was significantly more frequent in SpA. There was a significant difference in glenohumeral and coxofemoral effusion between the PMR and SpA patients (66% vs 16% and 40% vs 14%, respectively). Comparison of PMR and RA patients showed no significant difference in the involvement of entheses, shoulder, hip, or wrist flexor tendons in the carpal tunnel. Synovitis of the elbow, knee, and wrist was significantly more frequent in the SpA and RA patients than in those with PMR.
CONCLUSION: Synovitis was detected in at least one site in 100% of patients with PMR. SA-SD bursitis, LHBT tenosynovitis, carpal tunnel syndrome, and glenohumeral, knee and hip synovitis were the most frequent alterations in PMR. Enthesitis was relatively rare at any articular site.
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Antibiotic-modified hydrogel coatings on titanium dental implants
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Dental Implant Infection
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Implant-associated infections represent an occasional but serious problem in dental and/or orthopaedic surgery. A possible solution to prevent the initial bacterial adhesion may be the coating of the implant surface with a thin layer of antibiotic-loaded biocompatible polymer. Hydrogels are one of the promising and versatile materials as antibiotic controlled release systems. In this work, antibiotic-modified poly(ethylene-glycol diacrylate) hydrogel coatings on titanium substrates were prepared by electrochemical polymerization and tested against methicillin resistant Staphylococcus aureus (ATCC 33591). Two different methods to load vancomycin and ceftriaxone were used. We show that the proposed titanium coatings displayed an interesting antibacterial activity, however, further studies on their effective cytotoxicity will furnish evidence of their real clinical efficacy.
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Effects of Bisphosphonate Therapy on Bone Mineral Density in Boys with Duchenne Muscular Dystrophy
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Hip Fx in the Elderly 2019
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The objective of this study was to estimate the comparative effectiveness of bisphosphonate therapy on bone mineral density (BMD) in patients with corticosteroid-treated Duchenne muscular dystrophy (DMD). A retrospective, comparative effectiveness study evaluating changes in BMD and fragility fractures in patients with DMD presenting to British Columbia Children's Hospital from 1989 to 2017 was conducted. Marginal structural generalized estimating equation models weighted by stabilized inverse-probability of treatment weights were used to estimate the comparative effectiveness of therapy on BMD. Of those treated with bisphosphonates (N = 38), 7 (18.4%), 17 (44.7%), and 14 (36.8%) cases were treated with pamidronate, zoledronic acid, or a combination of both, respectively, while 36 cases of DMD were untreated. Mean age of bisphosphonate initiation was 9.2 (SD 2.7) years. Mean fragility fractures declined from 3.5 to 1.0 following bisphosphonate therapy. Compared to the treated group, the untreated group had an additional 0.63-SD decrease (95% confidence interval [CI]: -1.18, -0.08, P = .026) in total BMD and an additional 1.04-SD decrease (95% CI: -1.74, -0.34; P = .004) in the left hip BMD, but the change in lumbar spine BMD (0.15, 95% CI: -0.36, 0.66; P = .57) was not significant. Bisphosphonate therapy may slow the decline in BMD in boys with corticosteroid-treated DMD compared to untreated counterparts. Total number of fragility fractures decreased following bisphosphonate therapy.
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Estimating probability of non-response to treatment using mixture distributions
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Management of Hip Fractures in the Elderly
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Repeat measurements of patient characteristics are often used to assess response to treatment. In this paper we discuss a normal mixture model for the observed change in the characteristic of interest in treated patients. The methods described can be used to estimate the overall proportion of non-response to treatment and also the probability that a patient has not responded to treatment given his or her observed change. The model parameters are estimated using maximum likelihood, and the delta method is used to construct a pointwise confidence band for the conditional probability that a patient is a non-responder to treatment. The work was initially motivated by analysis issues in the Fracture Intervention Trial (FIT), a randomized trial of the osteoporosis drug alendronate, and the method is illustrated with data from that study. We also evaluate key aspects of the estimation procedure with two simulation studies. In the first, the data generation model is the assumed normal mixture model, and in the second, the data are generated according to a shifted and scaled central t-distribution model suggested by the FIT data
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Anesthesia management for cesarean section during novel coronavirous epidemic
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Coronavirus Disease 2019 (COVID-19)
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Thirty-six puerperas who underwent emergency cesarean section at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 24, 2020 to February 9, 2020, who all wore medical surgical masks, were retrospectively included in this study. Anesthesia management was performed under tertiary medical protection measures. A dedicated anesthesia equipment was separately sterilized. Narcotic drugs were used for one patient only, and disposable medical supplies were used for anesthetic supplies. Contact transmission should be avoided when a neonate required resuscitation, and early isolation and nucleic acid testing were provided for the neonates. The rate of suspected cases of novel coronavirus (2019-nCoV) was 11% , and the rate of clinically diagnosed cases was 17% before surgery. The rate of clinically diagnosed cases of 2019-nCoV was 22%, the rate of confirmed cases was 8%, and the total positive rate of diagnosis was 31% after surgery. The rate of neuraxial anesthesia was 86%, the rate of general anesthesia was 14%, the time of spinal puncture was (15±7) min, the time of tracheal intubation under general anesthesia was (2.1±1.3) min, the operation time was (95±36) min, and blood loss was (276±166) ml. The Apgar score of newborns was 8.8 ± 0.5. There was 1 neonate whose mother was diagnosed as having 2019 novel coronavirous disease after operation, an oropharyngeal swab specimen was obtained at 36 h of birth, and the swab was tested positive for 2019-nCoV by nucleic acid testing. As of February 10, 2020, an anesthesiologist involved in the operation was diagnosed to have infection by 2019-nCoV. In conclusion, diagnosis of 2019 novel coronavirous disease during pregnancy is more difficult, it is necessary to perform anesthesia management for cesarean section under tertiary medical protection. Although the difficulty in anesthesia operation is increased under tertiary medical protection, anesthesiologists can carry out standardized anesthesia management and guarantee the safety of maternal and infants and anesthesiologists themselves as long as they are rigorously trained and adhere to protective protocols.
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Excess mortality following hip fracture: a systematic epidemiological review
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Hip Fx Time to Surgery
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This systematic literature review has shown that patients experiencing hip fracture after low-impact trauma are at considerable excess risk for death compared with nonhip fracture/community control populations. The increased mortality risk may persist for several years thereafter, highlighting the need for interventions to reduce this risk.Patients experiencing hip fracture after low-impact trauma are at considerable risk for subsequent osteoporotic fractures and premature death. We conducted a systematic review of the literature to identify all studies that reported unadjusted and excess mortality rates for hip fracture. Although a lack of consistent study design precluded any formal meta-analysis or pooled analysis of the data, we have shown that hip fracture is associated with excess mortality (over and above mortality rates in nonhip fracture/community control populations) during the first year after fracture ranging from 8.4% to 36%. In the identified studies, individuals experienced an increased relative risk for mortality following hip fracture that was at least double that for the age-matched control population, became less pronounced with advancing age, was higher among men than women regardless of age, was highest in the days and weeks following the index fracture, and remained elevated for months and perhaps even years following the index fracture. These observations show that patients are at increased risk for premature death for many years after a fragility-related hip fracture and highlight the need to identify those patients who are candidates for interventions to reduce their risk.
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Patterns and Causes of Amputation in Ayder Referral Hospital, Mekelle, Ethiopia: A Three-Year Experience
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DoD LSA (Limb Salvage vs Amputation)
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Background: Amputation is a surgical procedure for the removal of a limb which is indicated when limb recovery is impossible. There are different types of amputation, and their causes can vary from one area to the other. Therefor, the aim of this study is to find out the patterns and causes of amputations in patients presented to Ayder Referral Hospital, Mekelle, Ethiopia. Methods: the record of 87 patients who had amputation at different sites after admission to Ayder referral hospital, Mekelle, Ethiopia in three years period were reviewed retrospectively. Result: A total of 87 patients had amputation of which 78.2% were males. The age range was from 3 to 95 years, and the mean age was 40.6 in years. The most common indications were trauma (37.7%), tumor (24.1%), and peripheral arterial disease (PAD) (20.7%). The commonest type of amputation was major lower limb amputation (58.6%) which includes above knee amputation (35.6%)and below knee amputation (23%) followed by digital amputation (17.2%). There was 11.4% major upper limb amputation of which there was one patient who had re-amputation. Conclusion: Most of the indications for amputations in our setup are potentially preventable by increasing awareness in the society on safety measures both at home and at work and early presentation to health facilities.
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Locked volar plating for complex distal radius fractures: Patient reported outcomes and satisfaction
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Distal Radius Fractures
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BACKGROUND: Distal radius fractures are common. The increasing prevalence of osteoporosis contributes to frequently complex articular injuries sustained even after low energy falls. The best method of treating complex type C distal radius fractures is debated. Locked volar plating and external fixation are both widely used with good reported results. Measures of success are traditionally based on technical measurements or the perception of the surgeon. Patient reported measures of outcome are increasingly recognised as important markers of surgical success. We report our experience using locked volar plating for complex type C distal radius fractures as well as patient reported measures of success and satisfaction.
METHODS: Over a 12 month period we treated 21 patients with type C distal radius fractures using locked volar plating. These patients were followed up for at least 12 months and the outcome was assessed using clinical examination, grip strength measurements, radiographs and Patient Rated Wrist Evaluation (PRWE) scoring.
RESULTS: The 21 patients studied had an average age of 48 years. There were 8 men and 13 women. All of the fractures had united by 3 months. There were no cases of wound infection or tendon injury/irritation. Patients reported low pain scores, good patient rated wrist evaluation scores and high levels of satisfaction.
CONCLUSIONS: Locked volar plating for complex distal radius fractures produces good results when assessed using patient reported measures of outcome. Further work should address whether locked volar plating offers superior outcomes and patient satisfaction compared to external fixation.
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Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases
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DoD SSI (Surgical Site Infections)
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The treatment of intramedullary infections after nailing usually includes removal of the rod, debridement of the canal, and, in many cases, insertion of antibiotic-impregnated cement beads. These beads offer no mechanical support and are difficult to remove if left in place for more than 2 weeks. We present an alternative for filling the medullary canal's noncollapsible dead space with an antibiotic-impregnated cement rod. This rod can be custom-made at the time of surgery, using different diameter chest tubes as molds and embedding a 3-mm beaded guidewire within the cement. The smooth molded surface of this nail makes extraction of the cement rod relatively easy. The cement rod also provides some limited temporary support to the fracture or nonunion site while the infection is being treated. After 6 weeks, the rod can be removed and replaced with a definitive metal intramedullary nail, with or without bone grafting to treat the previously infected fracture or nonunion site. We retrospectively reviewed nine cases of intramedullary infection treated with antibiotic-impregnated molded cement rods. These included six femora, two tibiae, and one humerus. The cause of infection was lengthening or transport over nail in six cases, fixator-augmented nailing of osteotomies in two, and fracture fixation in one. The follow-up period after surgery ranged from 38 to 48 months. No recurrent infection occurred during this follow-up period, and no patient required antibiotics after the rod was removed. In all cases, the canal cultures were negative after rod removal. The cement rod was removed between 29 and 753 days after implantation. Fracture of the rod occurred in one case in which the rod was left in place for more than 1 year. We conclude that this method is a relatively simple and inexpensive alternative for the treatment of intramedullary infections.
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Pelvic reconstruction for severe periacetabular metastatic disease
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The functional outcome of acetabular reconstruction in 21 patients with severe acetabular deficiency was examined. The surgical indications were pain, immobility, and loss of indepedence. Surgical reconstruction included curettage, placement of an acetabular roof ring with screws crossing the defect, cementation of the defect, and cemented hip arthroplasty. Although three patients died within the first month, the mean postoperative survival was 14.5 +/- 4.0 months, with a 10.4 +/- 3.0-month period of independent living. Statistically significant postoperative improvements were seen in pain and mobility scores. Using the Musculoskeletal Tumor Society score for the lower extremity, a mean postoperative score of 14.2 of a total 30 was calculated. Low scores were attributed to the patients' overall disease, including the requirement of continued narcotic pain control, occupational restriction, and the presence of Trendelenburg limp. Surgical complications occurred in six patients and included three early postoperative deaths, two related to poor preoperative pulmonary function; two dislocations, one related to a late infection; one femoral nerve palsy; and one foot drop. Although associated with a high complication rate, acetabular reconstruction for metastatic disease can lead to marked improvement in pain control, function, independence, and quality of life in carefully selected patients
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1 |
Clodronate improves bone mineral density in postmenopausal breast cancer patients treated with adjuvant antioestrogens
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MSTS 2018 - Femur Mets and MM
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The effect of clodronate on bone mineral density (BMD) was studied in 121 post-menopausal breast cancer women without skeletal metastases. In addition, two antioestrogens, tamoxifen and toremifene, were compared in their action on bone mineral density. Patients were randomized to have an adjuvant antioestrogen treatment either 20 mg of tamoxifen or 60 mg of toremifene daily for 3 years. In addition all patients were randomized to have 1600 mg of oral clodronate daily or to act as control subjects. BMD of the lumbar spine and femoral neck were measured by dual-energy radiographic absorptiometry before therapy and at 1 and 2 years. At 2 years, clodronate with antioestrogens markedly increased BMD in the lumbar spine and femoral neck by 2.9% and 3.7% (P = 0.001 and 0.006 respectively). There were no significant changes in BMD in the patients given antioestrogens only. No significant differences were found between tamoxifen and toremifene on bone mineral density. Clodronate with antioestrogens significantly increased bone mass in the lumbar spine and femoral neck. Both antioestrogens, tamoxifen and toremifene, similarly prevented bone loss in the lumbar spine and femoral neck.
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Mild traumatic brain injury and posttraumatic stress disorder: investigation of visual attention in Operation Iraqi Freedom/Operation Enduring Freedom veterans
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Upper Eyelid and Brow Surgery
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Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) are prevalent dual impairments in veterans returning from the wars in Iraq and Afghanistan. Attention problems are a common self-reported complaint of veterans with mTBI, but relatively few studies have investigated the types and levels of behavioral attentional deficits present in veterans with mTBI and PTSD. The purpose of this study was to compare visual attentional performance between samples of veterans with both mTBI and PTSD (mTBI+PTSD), PTSD only, and a control group. Overall, the attentional responses of the mTBI+PTSD group were slower than those of the PTSD and control groups. The response times were also more variable, suggesting difficulty with attentional vigilance. Additionally, we found evidence of hemispheric asymmetries in attentional performance. Participants with mTBI+PTSD were less efficient in orienting visual attention to stimuli flashed to the left visual field (LVF), suggesting a right hemisphere deficit. Overall, we found that veterans who had sustained an mTBI and had a coexisting PTSD diagnosis displayed longer response times and were less accurate than the PTSD and control groups, especially when cues were presented to the LVF.
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Genetic mechanisms of knee osteoarthritis: a population-based longitudinal study
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Surgical Management of Osteoarthritis of the Knee CPG
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To describe the differences in knee structure and non-knee structural factors between offspring having at least one parent with a total knee replacement for severe primary knee osteoarthritis and age- and sex-matched controls with no family history of knee osteoarthritis, a population-based longitudinal study of 163 matched pairs (mean age 45 years, range 26 to 61) was performed at baseline and about 2 years later. Knee cartilage defect score (0 to 4), cartilage volume and bone size were determined with T1-weighted fat saturation magnetic resonance imaging. Body mass index (BMI), lower-limb muscle strength, knee pain, physical work capacity at 170 beats/minute (PWC170) and radiographic osteoarthritis were measured by standard protocols. In comparison with controls, offspring had higher annual knee cartilage loss (-3.1% versus -2.0% at medial tibial site, -1.9% versus -1.1% at lateral tibial site and -4.7% versus -3.7% at patellar site, all P < 0.05), a greater increase in medial cartilage defect score (+0.15 versus -0.01, P < 0.05) and a greater decline in PWC170 (-0.7 watts/kg versus -0.4 watts/kg, P < 0.01). There were no significant differences in change in BMI, lower-limb muscle strength, knee pain or tibial bone area between these two groups; however, the differences in knee cartilage loss and cartilage defect change decreased in magnitude and became non-significant after adjustment for baseline cartilage volume, tibial bone area, BMI and knee pain. This longitudinal study suggests that knee cartilage loss, change in cartilage defects and decrease in physical fitness all have roles in the development of knee osteoarthritis, which is most probably polygenic but may reflect a shared environment. Importantly, the cartilage changes are largely dependent on baseline differences in cartilage volume, tibial bone area, BMI and knee pain, suggesting that these factors might have a role in their initiation
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To what degree is the rise in US total knee replacement rates attributable to aging of the population?
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Surgical Management of Osteoarthritis of the Knee CPG
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Background/Purpose: In the past decade, total knee replacement (TKR) rates have increased resulting from multiple factors including the aging of the US population, rising prevalence of obesity and increased access to and demand for TKRs. To quantify the degree to which aging accounts for the observed increase in TKRs, we examined TKR rates, annual percent change (APC) and standardized incidence ratio (SIR) over 13 years among US adults aged >=18 years. Methods: Using 1997-2009 US Nationwide Inpatient Sample data - hospital discharge data for 44 states comprising 95% of all US hospital discharges - we estimated overall and age-specific (18-44, 45-64, 65-84, and >=85 years) annual hospital discharge rates, and APC for TKRs (ICD-9-CM procedure=81.54 [excludes revisions]). Also, we calculated overall and age-specific SIRs with 1997 and 2009 data to examine whether the rise in TKR rates from 1997 to 2009 was attributable solely to changes in the age distribution of the US population. Expected 2009 values, based on estimated 1997 TKR rates (# of TKR in 2007/# of people in 2000 US Census Population) were applied to population estimates from the 2010 US Census. SIRs were the ratio of observed to expected number of TKRs in 2009. Results: Among all US adults aged >= 18 years, approximately 1 and 3 per 1000 people had a TKR discharge in 1997 and 2009 respectively. TKR rates (per 1000 people) in 2009 were higher than 1997 for all age groups: 18-44=0.04 and 0.1; 45-64=1.1 and 3.1; 65-84=5.9 and 9.7; and >=85 years=2.2 and 3.1. The APC was 10% among all US adults (from 264,331[1997] to 620,192 [2009]); across age groups the largest APC was among those 45-64 years (21%) (18-44=11%; 65-84=7%; >=85=6%). The overall SIR was 2.1; age-specific SIRs were 2.4, 2.9, 1.6 and 1.4 for adults aged 18-44, 45-64, 65-84, and >=85 years respectively. Conclusion: From 1997 to 2009, overall TKR rates tripled representing an APC of 10%. Although TKR rates rose most rapidly among people aged 45-64 years (APC=21%), observed rates in both 1997 and 2009 were highest among those aged 65-84 years (5.9 and 9.7). SIRs indicated that rates were between approximately 1.5 to 3 times higher than would be expected if the rise was attributable to aging alone. In this analysis, we were unable to quantify the effect of increased prevalence of obesity, a major risk factor for knee osteoarthritis and subsequent TKRs, and increased access to and demand for TKRs on this increase but it is likely substantial
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Efficacy and safety of controlled-release oxycodone and standard therapies for postoperative pain after knee or hip replacement
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Standard therapy (ST) for postoperative pain after knee and hip replacement at the Hamilton Health Sciences Henderson Hospital consists of epidural analgesia or patient-controlled analgesia for the first 48 hours, followed by oral or parenteral analgesics, or both, on an as-needed basis. We compared the efficacy and safety of scheduled controlled-release (CR) oxycodone hydrochloride (OxyContin; Purdue Pharma, Pickering, Ont.) and ST for postoperative pain 48 hours after primary knee and hip replacement. METHODS: In 2 separate 3-week studies of similar design, pain intensity, pain relief, length of hospital stay, analgesic use and side effects of CR oxycodone (n = 70) and ST (n = 101) were evaluated. In the CR oxycodone trial, a dose de-escalation protocol was used. RESULTS: At the time of discharge from hospital, patients in the CR oxycodone group recorded lower mean (and standard deviation) pain intensity scores than the ST group (20.2 [17.9] v. 27.7 [21.5] mm on a 100-mm visual analogue scale; p = 0.021). Length of hospital stay was 5.5 and 6.4 days for the CR oxycodone and ST groups respectively (p < 0.001). CR oxycodone patients used less opioid (morphine equivalent) while in hospital than ST patients (p < 0.001), and the average number of daily administrations of analgesics in hospital was 2.1 and 3.5 for CR oxycodone and ST patients respectively (p < 0.001). ST patients reported more nausea and vomiting, pruritus and fever than the CR oxycodone patients, but less somnolence, constipation, dizziness, confusion and tachycardia. CONCLUSIONS: CR oxycodone every 12 hours is as effective as ST in treating postoperative pain but length of hospital stay was shorter and analgesic administration in the hospital was used less frequently, providing potential hospital cost savings and reduced use of health care resources
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Matching osteochondritis dissecans lesions in identical twin brothers
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Osteochondritis dissecans is a disorder of unknown etiology that can result in fragmentation of osteochondral surfaces, most commonly of the knee, shoulder, elbow, and ankle. This may lead to sequelae of pain and an inability to participate in desired activities. Multiple theories exist as to the true cause of the disorder, but none have been fully proven. One such proposed etiology is genetic causation. Familial cases of osteochondritis dissecans are rare, yet these cases offer support to growing evidence that may support a genetic link. This article describes osteochondritis dissecans lesions of the femoral trochlea in monozygotic (identical) twins. Both twins presented with similar symptoms 1 year apart. Neither twin had any clear inciting trauma. Magnetic resonance imaging revealed osteochondral lesions in similar positions of the lateral trochlear of the same knee in both brothers. Osteochondral autograft transfer and tibial tubercle anteromedialization were performed on both patients. An identical postoperative protocol was followed, and recovery with full return to sport was comparable for the brothers. To the authors' knowledge, only 1 other case report exists of osteochondritis dissecans lesions in monozygotic twins. Although debate continues regarding the true etiology of this disorder, cases of identical twins presenting with a similar disease process are highly suggestive of a genetic component and may lead to early identification and treatment of these lesions. Continued research in the area of osteochondritis dissecans and its genetic basis is needed to completely understand this disorder
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1 |
Antibodies to Borrelia burgdorferi in patients with carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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In a study of 94 consecutive patients with neurophysiologically verified carpal tunnel syndrome (CTS) 7/94 had IgG and 0/94 IgM serum titers to Borrelia burgdorferi above the 98th percentile value of age and sex matched controls (n = 127). The difference in prevalence of positive IgG serum titers in patients, compared to controls, was not statistically significant. Even in patients, living in an area, highly endemic for Lyme borreliosis, routine serological screening for borrelia infection does not seem indicated in the investigation of CTS
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0 |
Mycetoma in South India: Retrospective analysis of 13 cases and description of two cases caused by unusual pathogens: Neoscytalidium dimidiatum and Aspergillus flavus
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DoD LSA (Limb Salvage vs Amputation)
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Background Mycetoma is a chronic suppurative and/or granulomatous inflammatory lesion of skin, subcutaneous tissue, fascia, and tendons caused by the traumatic inoculation of either fungal (eumycotic) or bacterial (actinomycotic) organisms present in the soil. The disease is characterized by triad of tumefaction, discharging sinuses, and grains. Material and methods Thirteen new cases of biopsy proven mycetomas were analyzed, retrospectively, from January 2000 to October 2009. Clinical parameters, bone involvement, microbiological properties, and histopathological features were evaluated. Categorization into eumycotic or actinomycotic was based upon features on hematoxylin and eosin stained sections with special stains. Therapeutic outcome was presented wherever available. Results There were eight actinomycetomas and five eumycetoma cases including 11 men and two women. Foot and lower extremities were the most common site of involvement (9 of 13, 69%). Culture results were available in 8 of 13 cases (61.5%). Madurella mycetomatis, Neoscytalidium dimidiatum, and Aspergillus flavus were the isolates among eumycetomas whereas Acinomadura madurae, Actinomadura pelletieri, and Nocardia species were the isolates among actinomycetomas. Two cases had underlying bone involvement. On follow-up, four of five eumycetoma cases showed partial improvement following surgery and antifungal therapy, one had amputation of the lower leg. Of the actinomycetomas, six of eight had dramatic improvement following sulfamethoxazole-trimethoprim based therapy, one had complete cure, and one was lost to follow-up. Conclusion Strong clinical suspicion, exact categorization of lesion into eumycotic or actinomycotic along with culture correlation, is essential for prognosis and effective therapy. © 2010 The International Society of Dermatology.
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Uncemented total arthroplasty in old quiescent infection of the hip
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Management of Hip Fractures in the Elderly
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We reviewed the outcomes of 24 cases (24 patients) of uncemented total hip arthroplasty done to treat secondary osteoarthritis due to quiescent previous infection. There were 16 men and eight women aged from 24 to 78 years (mean, 50 yr). Eight patients had proven or probable tuberculous infection and the other 16 patients had a past history of septic hip. The patients were followed for between 2.5 and 7 years (mean, 4.5 yr). According to the Harris hip rating system, 18 of the patients had excellent or good results. Three patients had a preoperative erythrocyte sedimentation rate of 40 mm/h or higher and had a positive bacterial culture. Two of these patients developed reinfection. The other 21 patients had a preoperative erythrocyte sedimentation rate less than 40 mm/h and no reinfection postoperatively. There were five complications other than infection: dislocation with ipsilateral femoral shaft fracture, intraoperative femoral fracture, cup loosening, periprosthetic osteolysis, and nonunion of the greater trochanter. Uncemented total arthroplasty for old quiescent infection of the hip should be considered if the preoperative erythrocyte sedimentation rate is normal and a course of prophylactic antituberculous therapy is given in patients with an old tuberculous hip
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Comparison of Infection Risk with Corticosteroid or Hyaluronic Acid Injection Prior to Total Knee Arthroplasty
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AAHKS (2) Corticosteroids
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BACKGROUND: Recent studies have shown that intra-articular injections <=3 months before total knee arthroplasty increase the risk of periprosthetic joint infection. We are aware of no previous study that has differentiated the risk of periprosthetic joint infection on the basis of the type of medication injected. In addition, we are aware of no prior study that has evaluated whether hyaluronic acid injections increase the risk of infection after total knee arthroplasty. In this study, we utilized pharmaceutical data to compare patients who received preoperative corticosteroid or hyaluronic acid injections and to determine whether a specific injection type increased the risk of periprosthetic joint infection.
METHODS: Patients undergoing unilateral primary total knee arthroplasty were selected from a nationwide private insurer database. Ipsilateral preoperative injections were identified and were grouped by medication codes for corticosteroid or hyaluronic acid. Patients who had received both types of injections <=1 year before total knee arthroplasty were excluded. The outcome of interest was periprosthetic joint infection that occurred <=6 months following the total knee arthroplasty. The risk of periprosthetic joint infection was compared between groups (no injection, corticosteroid, hyaluronic acid) and between patients who received single or multiple injections. Statistical comparisons were performed using logistic regression controlling for age, sex, and comorbidities.
RESULTS: A total of 58,337 patients underwent total knee arthroplasty during the study period; 3,249 patients (5.6%) received hyaluronic acid and 16,656 patients (28.6%) received corticosteroid <=1 year before total knee arthroplasty. The overall infection rate was 2.74% in the no-injection group. Multivariable logistic regression showed independent periprosthetic joint infection risk for both corticosteroid (odds ratio [OR], 1.21; p = 0.014) and hyaluronic acid (OR, 1.55; p = 0.029) given <=3 months before total knee arthroplasty. There was no increased risk with injections >3 months prior to total knee arthroplasty. Direct comparison of corticosteroid and hyaluronic acid showed no significant difference (p > 0.05) between medications or between single and multiple injections.
CONCLUSIONS: Preoperative corticosteroid or hyaluronic acid injection <=3 months before total knee arthroplasty increased the risk of periprosthetic joint infection. There was no difference in infection risk between medications or between multiple and single injections. On the basis of these data, we recommend avoiding both injection types in the 3 months prior to total knee arthroplasty.
LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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The effect of pre-season dance training on physical indices and back pain in elite cross-country skiers: a prospective controlled intervention study
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To evaluate the effect of pre-season dance training on back pain, joint mobility, and muscle flexibility, and on speed and agility in elite cross-country skiers.METHODS: 26 skiers participated (mean (SD) age, 19 (3.9) years). An intervention group (n = 16) had 12 weeks of dance training; a control group (n = 10) did not dance; otherwise both groups followed a similar pre-season physical training programme. Joint mobility and muscle flexibility of the spine, hip, and ankle were measured. Two sports related functional tests (slalom and hurdle) were also done. All measurements/tests were carried out before and after the dancing period.RESULTS: Four (of six) subjects from the intervention group who initially complained of ski related back pain did not report back pain after the dance training; the three subjects with back pain from the control group were unchanged. At study onset the intervention group had a slightly impaired range of motion in the spine compared with the control group. After dance training, there was a better relation between kyphosis of the thoracic spine and lordosis of the lumbar spine, and a 7.1 degrees increase in hip flexion with the knee extended (p = 0.02). In the control group hip extension decreased by 0.08 m on average (p = 0.01). No positive effects of dance training on sports related functional tests were observed.CONCLUSIONS: Preseason dance training improved the range of hip motion and joint mobility and the flexibility of the spine. These improvements might explain the reduction in ski related back pain in the intervention group
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Custom Acetabular Cages Offer Stable Fixation and Improved Hip Scores for Revision THA With Severe Bone Defects
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PJI DX Updated Search
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BACKGROUND: Revision THA is particularly challenging in hips with severe acetabular bone loss. When the extent or geometry of the acetabular bone loss precludes more-straightforward techniques such as jumbo hemispheric cementless shells, reconstruction with morselized allograft protected by a custom cage may offer an alternative, but, to our knowledge, few series have reported on results with this approach. QUESTIONS/PURPOSES: For patients with severe (Paprosky IIIB) defects, we asked: do individualized custom cages result in (1) improved Harris hip scores; (2) restoration of hip center; and (3) a low incidence of surgical complications? METHODS: Twenty-six patients (26 hips) with a massive acetabular defect were involved in this study from 2003 to 2013. During this period, one patient was lost to followup and one died, leaving 24 patients (eight males, 16 females) in this retrospective analysis. The customized cages were individualized to each patient's bone defect based on rapid-prototype three-dimensional printed models. Mean followup was 67 months (range, 24-120 months). Harris hip scores were assessed before surgery and at each followup. Postoperative radiographs were evaluated for cage position, migration, and graft incorporation. Complications and reoperations were assessed by chart review. RESULTS: The mean Harris hip score improved from 36 (SD, 8; range, 20-49) to 82 (SD, 18; range, 60-96) (p < 0.001). Individualized custom cages resulted in generally reliable restoration of the hip center. No rerevisions have been performed. None of the cups showed radiographic migration, but one cage was believed to be loose, based on a circumferential 2-mm radiolucent line. Cancellous allografts appeared to be incorporated in 23 of 24 patients. One deep infection and one superficial infection were observed and treated with irrigation, debridement, and vacuum-sealing drainage. One dislocation and one suspected injury of the superior gluteal nerve also were observed and treated conservatively. CONCLUSIONS: Individualized custom cages using rapid prototyping and three-dimensional printing appeared to provide stable fixation and improved hip scores at short-term followup in this small, single-center series. As further improvements in the design and manufacturing process are made, future studies should evaluate larger patient groups for longer times, and, ideally, compare this approach with alternatives for these complex bone defects. LEVEL OF EVIDENCE: Level IV, therapeutic study
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Should We Question the External Validity of Database Studies? A Comparative Analysis of Demographics
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AMP (Acute Meniscal Pathology)
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PURPOSE: To define the external validity of national and institutional databases for common sports medicine procedures.
METHODS: Patient demographic data including age, sex, body mass index (BMI), and 4 racial categories were aggregated between 2007 and 2016 across 2 databases for 4 common sports medicine procedures: anterior cruciate ligament reconstruction, arthroscopic rotator cuff repair (RCR), partial meniscectomy (PMx), and both arthroscopic and open shoulder stabilization. The first database of interest was a prospectively collected institutional database. The second was the National Surgical Quality Improvement Program (NSQIP) database. Two-sample t tests were performed to examine mean differences (MDs) in age and BMI, and chi<sup>2</sup> testing was used to test differences in sex and race.
RESULTS: A total of 7,019 institutional and 108,881 NSQIP patients were examined. The NSQIP cohort was significantly older (MD, 1.40 years), included more female patients (42.60% female patients vs 35.67% female patients), and showed a different racial distribution compared with the institutional data (all P < .0001). The NSQIP PMx cohort (MD, 7.38 years) was significantly older and the NSQIP RCR cohort (MD, 1.97 years) was significantly younger than their institutional counterparts (all P < .0001). The NSQIP anterior cruciate ligament reconstruction cohort (MD, 2.53) showed a greater average BMI (P < .0001). The NSQIP RCR cohort (41.8% female patients vs 33.3% female patients) and PMx cohort (46.0% female patients vs 37.9% female patients) also included more female patients. Race was distributed variably between databases for each procedure code (all P < .0001).
CONCLUSIONS: Significant differences in age, BMI, sex, and race distributions were observed between an institutional database and the NSQIP database. This study underlines the importance of defining the generalizability of database research, particularly when significant demographic differences between databases may underlie differences in postoperative outcomes.
LEVEL OF EVIDENCE: Level III, cross-sectional study.
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Use of diuretics and risk of implant failure after primary total hip arthroplasty: A nationwide population-based study
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Introduction: Thiazid and loop diuretics have been associated with changes in bone mineral density and fracture risk. However, data on survival of prosthesis implants are lacking. We evaluated the association between diuretic use and the risk of revision after primary total hip arthroplasty (THA). Materials and methods: We conducted a nationwide population-based case-control study using medical databases in Denmark. In the Danish Hip Arthroplasty Registry, we identified 2491 cases that were revised after primary THA in the period 1995-2005 and who could be matched on age, gender and year of primary operation with 4943 non-revised THA controls. By means of conditional logistic regression, we estimated the relative risk (RR) of revision due to all causes and due to specific causes according to postoperative use of thiazid and loop diuretic, respectively. Results: The 10-year cumulated implant revision rate in the underlying cohort of 57,575 THA procedures from the Danish Hip Arthroplasty Registry was 8.9% (95% CI: 8.4-9.4). Postoperative thiazid diuretic use was not associated with neither the overall risk of revision nor revision due to specific causes compared to non-use. Postoperative loop diuretic use was associated with an adjusted RR of revision of 1.14 (95% CI; 0.98-1.32) compared with non-use. The adjusted RR of revision due to deep infection and periprosthetic fracture in loop diuretic users was 1.71 (1.15-2.55) and 6.39 (1.84-22.21), respectively. Loop diuretic use was not associated with risk of revision due to aseptic loosening, dislocation or miscellaneous causes. Discussion: Loop diuretics but not thiazides may be associated with an increased risk of revision following primary THA. Further studies are warranted in order to confirm this finding and clarify the nature of the association. (copyright) 2009 Elsevier Inc. All rights reserved
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Prospective comparative study of anterior cruciate ligament reconstruction using the double-bundle and single-bundle techniques
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Anterior Cruciate Ligament Injuries CPG
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BACKGROUND: The intent of double-bundle anterior cruciate ligament reconstruction is to reproduce the normal anterior cruciate ligament anatomy and improve knee joint rotational stability. However, no consensus has been reached on the advantages of this technique over the single-bundle technique. HYPOTHESIS: We hypothesized that double-bundle anterior cruciate ligament reconstruction could provide better intraoperative stability and clinical outcome than single-bundle reconstruction. TYPE OF STUDY: Cohort study; Level of evidence, 2. METHODS: Forty patients with anterior cruciate ligament injury in one knee were recruited; 20 were allocated to a double-bundle anterior cruciate ligament reconstruction group and 20 to a single-bundle anterior cruciate ligament reconstruction group. Intraoperative stabilities at 30 degrees of knee flexion were compared between the 2 groups using a navigation system. Clinical outcomes including Lysholm knee scores, Tegner activity scores, Lachman and pivot-shift test results, and radiographic stabilities were also compared between the 2 groups after a minimum of 2 years of follow-up. RESULTS: Intraoperative anterior and rotational stabilities after anterior cruciate ligament reconstruction in the double-bundle group were significantly better than those in single-bundle group (P = .020 and P < .001, respectively). Nineteen patients (95%) in each group were available at a minimum 2-year follow-up. Clinical outcomes including Lysholm knee and Tegner activity scores were similar in the 2 groups at 2-year follow-up (P > .05). Furthermore, stability results of the Lachman and pivot-shift tests, and radiologic findings at 2-year follow-up failed to reveal any significant intergroup differences (P > .05). CONCLUSION: Although double-bundle anterior cruciate ligament reconstruction produces better intraoperative stabilities than single-bundle anterior cruciate ligament reconstruction, the 2 modalities were found to be similar in terms of clinical outcomes and postoperative stabilities after a minimum of 2 years of follow-up
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Intermittent Internal Fixation with a Locking Plate to Preserve Epiphyseal Growth Function during Limb-Salvage Surgery in a Child with Osteosarcoma of the Distal Femur
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Pediatric Diaphyseal Femur Fractures 2020 Review
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Limb shortening is a problem associated with surgery for osteosarcoma of the lower extremity in adolescents, as the tumors frequently occur near the epiphysis. Herein we report the use of a less invasive stabilization system (LISS) and an intermittent fixation method to preserve the growth function of epiphysis in an 11-year-old patient with an osteosarcoma of the distal femur. The 11-year-old male presented with left knee enlargement and pain for 2 weeks, and magnetic resonance imaging (MRI) and biopsy were consistent with osteosarcoma of the left distal femur. After preoperative chemotherapy, en bloc tumor resection was performed with margins based on MRI findings preserving the epiphyseal growth plate, the tumor cavity was filled with inactivated bone and bone cement, and a LISS was used to stabilize the femur. Aggressive postoperative chemotherapy was given. Approximately 105 weeks after surgery radiography showed that the distal end of the plate had moved superior to the epiphysis along with bone growth. Locking screws were placed in the distal part of the LISS plate to stabilize the re-implanted bone, and external fixation was not needed. The patient was able to walk with the crutches 1 week postoperatively, and bear weight on the extremity 6 weeks postoperatively. At 6 years after surgery, the patient's height had increased 52 cm, shortening of the affected limb was only 1 cm, and the circumference of the affected limb was 2 cm smaller than that of the contralateral limb. There was no significant discomfort in the affected limb, and there was no gait abnormality. The patient could jump and run, and could participate in sports including basketball and badminton to the same degree as his peers. In summary, the novel method of bone reconstruction and fixation provided good results in a child with an osteosarcoma of the distal femur. This fixation method preserves the osteogenic function of the epiphysis and restored bone integrity simultaneously, and provides good functional recovery.
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0 |
The electrodiagnostic findings in peripheral neuropathy associated with monoclonal gammopathy
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The electrodiagnostic findings in 51 patients with monoclonal serum proteins of different etiologies and peripheral neuropathies are analyzed and the findings in an additional 10 patients with multiple myeloma are discussed. The nine patients with monoclonal gammopathy of undetermined significance had electrodiagnostic patterns consistent with either predominant axonal degeneration or demyelination. Almost all 15 patients with osteosclerotic myeloma had evidence of a demyelinating neuropathy. The 27 patients with primary systemic amyloidosis almost always displayed evidence of an axonal neuropathy with superimposed carpal tunnel syndrome in some cases. The 10 patients with multiple myeloma had heterogeneous findings. Electrodiagnostic studies can aid in classifying these patients and suggest the likelihood of a specific etiology
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1 |
Efficacy of preoperative skin traction for hip fractures: a single-institution prospective randomized controlled trial of skin traction versus no traction
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Hip Fx in the Elderly 2019
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BACKGROUND: Preoperative traction for hip fractures is of no benefit in semi-urgent surgery. However, its efficacy has not been assessed in cases in which emergency surgery was not possible. We evaluated the efficacy of preoperative skin traction for hip fractures in a level II trauma center in Japan where many patients undergo delayed surgery.
METHODS: We undertook a randomized controlled trial. Eighty-one patients were randomized to be treated with skin traction (41 patients), or bed rest (40 patients). Preoperative pain was assessed by use of a visual analogue scale and the number of analgesics required. Fracture reduction was measured on the basis of leg-length and neck-shaft angle discrepancies on the radiograph on admission, a day before surgery, and after surgery.
RESULTS: The mean time from admission to surgery was 7.5 days. Pain decreased markedly on the day after admission in both the traction and no-traction groups. No significant difference was found during the preoperative waiting period between the groups in either pain score or number of analgesics taken. No significant difference was found in radiographic data either before or after surgery, and satisfactory reduction was achieved after surgery irrespective of the use of skin traction.
CONCLUSIONS: In our single-institution prospective randomized controlled trial, preoperative skin traction for patients with hip fracture had no effect on pain relief before surgery or reduction of fracture displacement during surgery, irrespective of preoperative waiting time.
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Predicting Postoperative Mortality After Metastatic Intraspinal Neoplasm Excision: Development of a Machine-Learning Approach
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MSTS 2022 - Metastatic Disease of the Humerus
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Objective: Mortality following surgical resection of spinal tumors is a devastating outcome. Naïve Bayes machine learning algorithms may be leveraged in surgical planning to predict mortality. In this investigation, we use a Naïve Bayes classification algorithm to predict mortality following spinal tumor excision within 30 days of surgery. Methods: Patients who underwent laminectomies between 2006 and 2018 for excisions of intraspinal neoplasms were selected from the National Surgical Quality Initiative Program. Naïve Bayes classifier analysis was conducted in Python. The area under the receiver operating curve (AUC) was calculated to evaluate the classifier's ability to predict mortality within 30 days of surgery. Multivariable logistic regression analysis was performed in R to identify risk factors for 30-day postoperative mortality. Results: In total, 2094 spine tumor surgery patients were included in the study. The 30-day mortality rate was 5.16%. The classifier yielded an AUC of 0.898, which exceeds the predictive capacity of the National Surgical Quality Initiative Program mortality probability calculator's AUC of 0.722 (P < 0.0001). The multivariable regression indicated that smoking history, chronic obstructive pulmonary disease, disseminated cancer, bleeding disorder history, dyspnea, and low albumin levels were strongly associated with 30-day mortality. Conclusions: The Naïve Bayes classifier may be used to predict 30-day mortality for patients undergoing spine tumor excisions, with an increasing degree of accuracy as the model better performs by learning continuously from the input patient data. Patient outcomes can be improved by identifying high-risk populations early using the algorithm and applying that data to inform preoperative decision making, as well as patient selection and education.
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Addition of Clonidine to Ropivacaine in Adductor Canal Block
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AAHKS (8) Anesthetic Infiltration
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Total knee arthroplasty (knee replacement) is a common orthopedic procedure for osteoarthritis. This procedure is performed either under general anesthesia or spinal anesthesia; after the procedure in the recovery room, these patients undergo adductor canal block, which is a nerve block to provide 8â?14 hours of postoperative pain control. For this nerve block, 15â?20 ml of local anesthetic is combined with adjuvant medications to improve the quality of pain control as well as the duration of pain relief. The primary local anesthetic used for adductor canal block is ropivacaine, and the commonly used adjuvants are epinephrine and dexamethasone. There is conflicting data available in the literature regarding efficacy of addition of clonidine to the local anesthetic injection in peripheral nerve blocks, and there is no data assessing the efficacy of this medication in adductor canal blocks. Once the consent process is completed, patients are enrolled in two arms. Upon conclusion of surgery, a sealed and coded envelope with either clonidine or the placebo syringe will be given to the acute pain service staff performing the nerve block. This will be mixed with local anesthetic solution and injected in the adductor canal under ultrasound guidance. The primary outcome measure will be the duration of analgesia, which will be assessed as the time interval between placement of adductor canal block to the first request of opioid analgesic by patients (which will be obtained from hospital electronic medical records). Secondary outcomes will include: 1. Duration of sensory block, which will be assessed as the time interval between injection of local anesthetic and report of postoperative pain of 3 or more on an 11 point scale (0=no pain; 10= worst pain imaginable) by the patient (this will be assessed every 4 hours). 2. Duration of motor block, which will be assessed as the time interval between the onset of motor block to complete recovery of motor block by assessing straight leg raise strength (this will be assessed every 4 hours). 3. Cumulative 24 and 48 hour opioid analgesic use. 4. Postâ?block pain scores, evaluated by an 11 point pain score (0â?10), which will be done every 15 minutes for the first hour after surgery and every 4 hours thereafter for 24 hours.
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Predictors for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary nailing
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Hip Fx Time to Surgery
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PURPOSE: The aim of our study was to determine predictive factors and requirement for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary device. METHODS: Seventy-nine patients with extra capsular hip fractures treated with cephalo-medullary nailing were included in the study. Age, sex, ASA grade, timing of surgery, preoperative and postoperative haemoglobin, length of hospital stay, fracture type, number of units transfused and 30-day mortality were recorded. RESULTS: The mean age was 82.3 years. Forty-seven patients underwent a short nail and 32 patients a long nail; 53.4% patients required blood transfusion postoperatively. Transfusion was required in 71.8% of the long nails (p < 0.05), 65.8% patients above the age of 80 (p < 0.05), 100% of the patients with hemoglobin below 90 g/L and 20 patients with a ASA grade of 3 (p < 0.05). 78.5% patients with A2 fracture and 75% of A3 fractures needed blood transfusion (p > 0.05). Length of hospital stay in non-transfusion group was 13 days and in transfusion group was 19 days (p < 0.05). 55.1% operated within 36 h and 47.6% operated after 36 h of admission needed transfusion (p > 0.05). Thirty-day mortality in patients needing blood transfusion was 5% and in non-transfusion group was 3.7% (p > 0.05). CONCLUSION: Patient age, ASA grade, preoperative haemoglobin and length of nail are reliable predictors for perioperative blood transfusion in extra capsular hip fractures in elderly patients treated with cephalo-medullary nailing and reinforce a selective transfusion policy.
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0 |
Type of childhood maltreatment and the risk of criminal recidivism in adult probationers: a cross-sectional study
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DoD PRF (Psychosocial RF)
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BACKGROUND: Childhood maltreatment is strongly associated with delinquency and the repeated crime. Specific types of childhood maltreatment have been found to have differential effects on recidivism in juvenile offenders, but studies of adult probationers have not been performed. This study investigated the relationship between having a history of childhood maltreatment and mental-health problems and the independent contribution of specific types of maltreatment and mental-health problems to the criminal recidivism of adult probationers.
METHOD: This study included 183 adult probationers (107 males and 76 females) with a mean age of 40.1 (SD=11.8) years. Type of childhood maltreatment was assessed using the Childhood Trauma Questionnaire, which consists of five subscales (emotional neglect and abuse, physical neglect and abuse, and sexual abuse). Additionally, we used the Mini International Neuropsychiatric Interview to assess participants for the presence of psychiatric disorders and assessed levels of emotional dysregulation and resilience. Hierarchical logistic regression analysis was performed to determine whether the types of childhood maltreatment were independently associated with repeated crime, after adjusting for demographic factors and mental-health problems.
RESULTS: The overall prevalence of mental illness in the childhood maltreatment group was significantly higher than in the no childhood maltreatment group (56.1 % vs. 38.2 %, p=0.017). The maltreated group had a higher rate of major depressive disorder, a higher level of emotional dysregulation, and a lower level of resilience than the group that was not maltreated. Recidivism was uniquely associated with physical neglect (Adjusted Odds Ratio [AOR], 2.862; 95 % Confidence Interval [95 % CI], 1.213-6.752) and the presence of at least one psychiatric disorder (AOR, 3.791; 95 % CI, 1.703-8.443).
CONCLUSIONS: Childhood maltreatment deserves further attention in adult probationers because it is potentially associated with higher rates of psychiatric morbidity and recidivism. In particular, physical neglect during childhood plays a critical role in repeated crime, independent of mental-health problems for high-risk adults involved with the criminal justice system. Rigorous evaluations of the relevance of childhood maltreatment in the assessment and treatment of criminal offenders are needed.
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0 |
Effects of Nerve Block on Knee Function After Knee Replacement
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AAHKS (9/10) Regional Nerve Blocks
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Early physical therapy after knee surgery is very painful on top of pain from surgery. Pain following surgery can limit recovery. One way to treat pain is by giving intravenous (IV) pain medication with morphine. Another method is to use a â??nerve blockâ? which involves placing a thin catheter (tube) into the lower back near the nerves that sense pain in the knee and give a local anesthetic to numb the nerves. Sometimes both methods are used together. This research is being done to determine whether nerve blocks with a local anesthetic improve knee recovery in addition to providing pain relief as compared to IV pain medicine alone
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Scopolamine reduces the P35m and P60m deflections of the human somatosensory evoked magnetic fields
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Acetylcholine (ACh) is a potent neuromodulator in the brain with multiple, complex effects on neuronal function, most of which are mediated by muscarinic receptors. Generally, the most significant effect is excitation of pyramidal neurones and facilitation of responses to afferent stimulation. Much of the information on the ACh effects comes from studies utilizing in vitro or anesthetized in vivo preparations, while fewer data are available from awake animals or humans. We studied human somatosensory evoked magnetic fields (SEFs), which reflect summated postsynaptic currents in pyramidal neurones in area 3b, and in the opercular somatosensory cortex, when cholinergic transmission was modulated either by a central (scopolamine, 0.3 mg, i.v.) or peripheral (glycopyrrolate, 0.2mg, i.v.) muscarinic antagonist. A randomized, double-blind, cross-over design was employed. SEFs were elicited by right median nerve stimulation at the wrist with constant-current pulses above motor threshold. The first excitatory cortical response from area 3b (N20m) was not affected by the central muscarinic blockade, while later P35m and P60m deflections were significantly reduced. The responses from the opercular somatosensory cortex showed some tendency toward reduction, but no significant alterations. The results show that somatosensory cortical processing can be modulated by muscarinic transmission at a relatively early stage. Relative membrane hyperpolarization of pyramidal neurons due to scopolamine (caused by blocking an ACh-induced tonic depolarization) is discussed as a possible mechanism underlying the observed effects. (copyright) 2001 Lippincott Williams & Wilkins
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Nomogram for predicting overall survival in colorectal cancer with distant metastasis
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Colorectal cancer (CRC) is a major cancer burden, and prognosis is determined by many demographic and clinicopathologic factors. The present study aimed to construct a prognostic nomogram for colorectal cancer patients with distant metastasis.
METHODS: Colorectal cancer patients with distant metastasis diagnosed between 2010 and 2016 were selected from the Surveillance, Epidemiology, and End Results database. Cox proportional hazards regression was used to identify independent prognostic factors. A nomogram was constructed to predict survival, and validation was performed.
RESULTS: A total of 7099 stage IV colorectal cancer patients were enrolled in the construction cohort. The median overall survival was 20.0 (95% CI 19.3-20.7) months. Age at diagnosis, marital status, race, primary tumour site, tumour grade, CEA level, T stage, N stage, presence of bone, brain, liver and lung metastasis, surgery for primary site and performance of chemotherapy were independent prognostic factors. The nomogram was constructed and the calibration curve showed satisfactory agreement. The C-index was 0.742 (95% CI 0.726-0.758). In the validation cohort (7098 patients), the nomogram showed satisfactory discrimination and calibration with a C-index of 0.746 (95% CI 0.730-0.762).
CONCLUSION: A series of factors associated with the survival of CRC patients with distant metastasis were found. Based on the identified factors, a nomogram was generated to predict the survival of stage IV colorectal cancer patients. The predictive model showed satisfactory discrimination and calibration, which can provide a reference for survival estimation and individualized treatment decisions.
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Intravenous Lidocaine in Total Knee Replacement
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AAHKS (4) Acetaminophen
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OBJECTIVE: The aim of this study is to estimate the effectiveness of a preemptive bolus of intravenous lidocaine on reduction in acute pain, improvement on the range of movement, other rehabilitation parameters and functional scoring in the postâ?operative period after total knee replacement. DESIGN: This is a doubleâ?blinded, randomized, placeboâ?controlled trial. RECRUITMENT & SAMPLE SIZE: Over a oneâ?year period, suitable patients will be approached at the preâ?admission clinic and in the general ward before their operation. Informed consent will be obtained before enrollment. The sample size required is calculated to be 45 subjects per group. PATIENT CHARACTERISTICS: In order to minimize potential confounding factors, the demographic data of each subject will be collected during preoperative assessment, including: age, gender, duration of preoperative pain duration, preoperative NRS (movement) and NRS (rest). Both active and passive ROM of the knee will be assessed by the attending physiotherapist. RANDOMIZATION & BLINDING: Each subject will be assigned to either Lidocaine Group or Placebo Group. A randomization list will be established by a computerâ?generated random sequence before the study begins. An envelope containing the group assignment will be prepared, sealed, sequentially numbered, and allocated for each subject. A "blinded" anaesthetist will then prepare lidocaine or saline according to the group assigned for the attending anaesthetist. The subjects, the investigators, and all the parties involved in patient management or data collection will be blinded throughout the study period. INTERVENTION: For Lidocaine Group: a bolus of intravenous lidocaine of 2mg/kg over 5 mins will be given before skin incision. For Placebo Group: Normal Saline of equal volume will be given as bolus before skin incision. ANAESTHESIA & ANALGESIA: (I) PREâ?OPERATIVE: Routine preoperative assessment will be taken at the preâ?admission clinic or at the general ward; and standard fasting times (6 hours for solid food and 2 hours for clear liquid) will be ordered. No analgesics or sedatives will be given as preâ?medication. Holter machine will be used to document any arrhythmia preoperatively and will be attached to patient till Day 1 postoperatively. (II) INTRAâ?OPERATIVE: In addition to continuous ECG monitoring, BP, heart rate and SpO2 will be monitored at no longer than every 5 mins throughout the operation. Signs and symptoms of local anaesthetic toxicity will be assessed at 30 minute intervals. After establishing at least one patent intravenous cannula and ensuring the monitors are properly applied, Spinal Anaesthesia will be given by the attending anaesthetist under aseptic technique. The choice of equipment (Whitacre or Quincke Needle), technique (landmark or ultrasoundâ?guided), and approach (midline or paramedical) are at the discretion of the attending anaesthetist. An intrathecal dose of 2.2â?2.6ml 0.5% Heavy Bupivacaine with 15mcg of fentanyl will be given depending on the height of the patient. Vasopressors and intravenous ï¬?uids will be given as necessary to keep the patient's blood pressure within 20% of his/her baseline, and to keep the heart rate within normal range. Bolus of lidocaine or placebo will then be given over 5 minutes before skin incision. No Sedation will be given during operation in order to facilitate monitoring of systemic toxicity. No Systemic Analgesics will be given, including Paracetamol, NSAIDS, Ketamine and Opioids. The surgeries will be performed by the same team of orthopedic surgeons experienced in total knee replacement at a tertiary level university teaching hospital, using standardized surgical techniques. All patients will undergo posterior stabilized knee prosthesis. Standardized dose of LIA (40ml 0.75% Ropivacaine, 0.5ml 1 in 200,000 Adrenaline, 30mg Ketorolac in 60ml Normal Saline) will be administered by the orthopedic team. (III) POSTâ?OPERATIVE (PHASE I RECOVERY IN PACU): Upon completion of surgery, the patient will be transferred to PACU for further monitoring or at least 30 minutes. BP, heart rate, and SpO2 will be monitored every 5 minutes in addition to continuous ECG monitoring. Signs and symptoms of local anaesthetic toxicity will be assessed at 15 minute intervals. Pain will be evaluated every 5 mins using NRS. If the score is greater than 4/10, 2mg morphine will be given intravenously every 5 mins provided the patient has a respiratory rate of > 12/min and a sedation score of <1 until a NRS of < 4/10 is achieved. At which point, a patientâ?controlled analgesia (PCA) device will be connected to deliver morphine under a standardized regime: 1mg bolus with 5 mins lockout, an hourly maximum of 0.1mg/kg, and no background infusion. (IV) POSTâ?OPERATIVE (PHASE II RECOVERY IN WARD): Continuous ECG monitoring will continually be applied until Day 1 postoperatively. Signs and symptoms of local anaesthetic toxicity will be assessed clinically at 1â?hour intervals for 12 hours after operation. BP, heart rate, SpO2, and sedation score will be monitored at 1â?hour intervals while on PCA morphine; BP and heart rate will be monitored at 4â?hour intervals once PCA morphine is terminated. Postoperative analgesics will consist of: PCA Morphine for at least 2 days postoperatively, and will be terminated on postoperative Day 3 once NRS (movement) is less than 4/10 or when 24â?hour morphine consumption is less than 10mg. Standardized analgesic regime, depending on body weight, will be started immediately after operation. For body weight > 50kg, Oral paracetamol 1gram QID, and pregabalin 75mg nocte for 1 week celecoxib 200mg BD for 5 days. For body weight < 50kg, Oral paracetamol 1gram TDS, and pregabalin 50mg nocte for 1 week. celecoxib 200mg daily for 5 days. 0.1mg/kg of intramuscular Morphine will be provided as necessary as rescue analgesic for any breakthrough pain. Intravenous Ondansetron of 0.1mg/kg will be given as necessary for nausea and vomiting. Diet will be resumed on Postoperative Day 0. The rehabilitation programme will be standardized for all patients and be carried out by the same team of physiotherapists and occupational therapists with the goal of early mobilization on Postoperative Day 0.
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Treatment of chronic nonunions of the humerus with free vascularized fibula transfer: A report of thirteen cases
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Chronic nonunions of the humerus remain a challenging problem. We reviewed 13 cases of chronic nonunion of the humerus resulting from trauma or osteomyelitis treated with vascularized fibula transfer after failure of conventional treatment. Patient averages were 35 years of age, follow-up of 19 months, and 4.2 prior operations. Healing was obtained in 12 of 13 (92%) patients with an average healing time of 18 weeks and graft length of 12.5 cm. In total, 11 of 12 (91%) patients who united had good to excellent range of motion of their shoulder and elbow. There were eight complications in 7 of 13 patients (54%). Two patients developed fractures of the graft, and three had superficial infections at the harvest site requiring operative debridement. Two patients had median neurapraxia that resolved by 4 months. Two patients complained of intermittent pain at the donor site. No significant correlations were found between time to heal and other covariates. (copyright) 2009 by Thieme Medical Publishers
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Imaging of hip arthroplasty
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PJI DX Updated Search
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Imaging studies are central to the evaluation of persistent or recurrent symptoms after hip arthroplasty. The evaluation starts with radiographs and may be followed by arthrography, aspiration, scintigraphy, sonography, computed tomography, and MR imaging. Common etiologies of a painful or dysfunctional hip arthroplasty are mechanical loosening, polyethylene wear-induced osteolysis, adverse local tissue reaction to metal wear products, infection, fractures, heterotopic ossification, tendinopathy, and nerve injury. MR imaging with optimized protocols and dedicated techniques for metal artifact reduction is the most comprehensive imaging modality. In this article, we discuss and illustrate the imaging appearances of these conditions with a focus on the MR imaging evaluation
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The burden of health conditions for middle-aged and older adults in the United States: disability-adjusted life years
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Hip Fx in the Elderly 2019
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BACKGROUND: Many adults are living longer with health conditions in the United States. Understanding the disability-adjusted life years (DALYs) for such health conditions may help to inform healthcare providers and their patients, guide health interventions, reduce healthcare costs, improve quality of life, and increase longevity for aging Americans. The purpose of this study was to determine the burden of 10 health conditions for a nationally-representative sample of adults aged 50 years and older in the United States.
METHODS: Data from the 1998-2014 waves of the Health and Retirement Study were analyzed. At each wave, participants indicated if they were diagnosed with the following 10 conditions: cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure, diabetes, back pain, hypertension, a fractured hip, myocardial infarction, rheumatism or arthritis, and a stroke. Years lived with a disability and years of life lost to premature mortality were summed for calculating DALYs. Sample weights were utilized in the analyses to make the DALY estimates nationally-representative. Results for the DALYs were presented in thousands.
RESULTS: There were 30,101 participants included. Sex stratified DALY estimates ranged from 4092 (fractured hip)-to-178,055 (hypertension) for men and 13,621 (fractured hip)-to-200,794 (hypertension) for women. The weighted overall DALYs were: 17,660 for hip fractures, 62,630 for congestive heart failure, 64,710 for myocardial infarction, 90,337 for COPD, 93,996 for stroke, 142,012 for cancer, 117,534 for diabetes, 186,586 for back pain, 333,420 for arthritis, and 378,849 for hypertension. In total, there were an estimated 1,487,734 years of healthy life lost from the 10 health conditions examined over the study period.
CONCLUSIONS: The burden of these health conditions accounted for over a million years of healthy life lost for middle-aged and older Americans over the 16 year study period. Our results should be used to inform healthcare providers and guide health interventions aiming to improve the health of middle-aged and older adults. Moreover, shifting health policy and resources to match DALY trends may help to improve quality of life during aging and longevity.
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0 |
Late infection of hand implant after a dental procedure: a case report
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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A 78-year-old woman with a silicone implant in her first carpometacarpal joint had acute inflammation and lymphangitis beginning 24 hours after a dental root canal procedure. The infection resolved after implant removal and debridement of the residual carpometacarpal space. Although this is a rare event, the use of prophylactic antibiotics to protect implants in the hand should be reviewed
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0 |
Radio-ulnar dissociation. A review of twenty cases
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Distal Radius Fractures
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The results of treatment were reviewed for twenty patients who had sustained concomitant injuries of the lateral compartment of the radiohumeral joint and the ipsilateral distal radio-ulnar joint. The ages of the patients ranged from eight to seventy-four years (average, thirty-five years) and the duration of follow-up ranged from four months to twenty-seven years (average, 113 months). In fifteen patients, the injury of the wrist was diagnosed after a mean delay of seven years and eleven months (range, one month to twenty-six years). In all fifteen, the radial head injury was treated by excision, either initially or after some delay. After excision of the radial head, all fifteen patients complained of severe pain at the distal radio-ulnar joint. The results, on the basis of elbow and wrist scores of fair or better without complications, were satisfactory in only three patients. In the remaining five patients, in whom the injuries of both the elbow and the wrist had been identified at the initial evaluation, the radial head was either preserved or replaced. The results, on the basis of elbow and wrist scores of fair or better, were graded as satisfactory in four of these patients. Our data show that any injury to the lateral side of the elbow should prompt a careful evaluation of the ipsilateral distal radio-ulnar joint for associated instability.
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1 |
Outcomes of Inside-out Meniscal Repair in the Setting of Multiligament Reconstruction in the Knee
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Limited evidence exists for meniscal repair outcomes in a multiligament reconstruction setting. Purpose /Hypothesis: The purpose of this study was to assess outcomes and failure rates of meniscal repair in patients who underwent multiligament reconstruction compared with patients who underwent multiligament reconstruction but lacked meniscal tears. The authors hypothesized that the outcomes of meniscal repair associated with concomitant multiligament reconstruction would significantly improve from preoperatively to postoperatively at a minimum of 2 years after the index surgery. Secondarily, they hypothesized that this cohort would demonstrate similar outcomes and failure rates compared with the cohort that did not have meniscal lesions at the time of multiligament reconstruction.
STUDY DESIGN: Cohort study; Level of evidence, 3.
METHODS: Inclusion criteria for the study included radiographically confirmed skeletally mature patients of at least 16 years of age who underwent multiligamentous reconstruction of the knee without previous ipsilateral osteotomy, intra-articular infections, or intra-articular fractures. Patients were included in the experimental group if they underwent inside-out meniscal suture repair with concurrent multiligament reconstruction. Those included in the control group (multiligament reconstruction without a meniscal tear) underwent multiligament reconstruction but did not undergo any type of meniscal surgery. Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, Short Form-12 physical component summary and mental component summary, Tegner activity scale, and patient satisfaction scores were recorded preoperatively and postoperatively. The failure of meniscal repair was defined as a retear of the meniscus that was confirmed arthroscopically.
RESULTS: There were 43 patients (16 female, 27 male) in the meniscal repair group and 62 patients (25 female, 37 male) in the control group. Follow-up was obtained in 93% of patients with a mean of 3.0 years (range, 2.0-4.7 years). There was a significant improvement between all preoperative and postoperative outcome scores ( P < .05) for both groups. The meniscal repair group had significantly lower preoperative Lysholm and Tegner scores ( P = .009 and P = .02, respectively). There were no significant differences between any other outcome scores preoperatively. The failure rate of the meniscal repair group was 2.7%, consisting of 1 symptomatic meniscal retear. There was no significant difference in any postoperative outcome score at a minimum 2-year follow-up between the 2 groups.
CONCLUSION: Good to excellent patient-reported outcomes were reported for both groups with no significant differences in outcomes between the cohorts. Additionally, the failure rate for inside-out meniscal repair with concomitant multiligament reconstruction was low, regardless of meniscus laterality and tear characteristics. The use of multiple vertical mattress sutures and the biological augmentation resulting from intra-articular cruciate ligament reconstruction tunnel reaming may be partially responsible for the stability of the meniscal repair construct and thereby contribute to the overall improved outcomes and the low failure rate of meniscal repair, despite lower preoperative Lysholm and Tegner scores in the meniscal repair group.
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0 |
High tibial osteotomy
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Surgical Management of Osteoarthritis of the Knee CPG
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High tibial osteotomy (HTO) is a widely accepted and performed procedure to treat medial knee arthrosis. The aim of this review is to evaluate the different surgical options in medial knee arthrosis, focusing on indications, patient's selection, long-term follow-up and survival analysis of HTO. Comparison and pooling of results are challenging because of different evaluation systems, small cohort number, and different surgical techniques. No differences have been described between opening and closing wedged HTO in terms of outcomes. Excellent early survivorship and good clinical outcomes were reported also with concomitant procedures. Correct indications, preoperative workup/planning, and technique selection are essential in achieving good results. The choice between opening and closing wedge osteotomy, graft selection in opening wedge HTO, comparison between HTO and unicompartmental knee arthroplasty, and the results of revised HTO to total knee replacement are currently under debate and will be discussed in the present review
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0 |
Intra-articular administration of hyaluronic acid increases the volume of the hyaline cartilage regenerated in a large osteochondral defect by implantation of a double-network gel
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Implantation of PAMPS/PDMAAm double-network (DN) gel can induce hyaline cartilage regeneration in the osteochondral defect. However, it is a problem that the volume of the regenerated cartilage tissue is gradually reduced at 12 weeks. This study investigated whether intra-articular administration of hyaluronic acid (HA) increases the volume of the cartilage regenerated with the DN gel at 12 weeks. A total of 48 rabbits were used in this study. A cylindrical osteochondral defect created in the bilateral femoral trochlea was treated with DN gel (Group DN) or left without any implantation (Group C). In both Groups, we injected 1.0 mL of HA in the left knee, and 1.0 mL of saline solution in the right knee. Quantitative histological evaluations were performed at 2, 4, and 12 weeks, and PCR analysis was performed at 2 and 4 weeks after surgery. In Group DN, the proteoglycan-rich area was significantly greater in the HA-injected knees than in the saline-injected knees at 12 weeks (P = 0.0247), and expression of type 2 collagen, aggrecan, and Sox9 mRNAs was significantly greater in the HA-injected knees than in the saline-injected knees at 2 weeks (P = 0.0475, P = 0.0257, P = 0.0222, respectively). The intra-articular administration of HA significantly enhanced these gene expression at 2 weeks and significantly increased the volume of the hyaline cartilage regenerated by implantation of a DN gel at 12 weeks. This information is important to develop an additional method to increase the volume of the hyaline cartilage tissue in a potential cartilage regeneration strategy using the DN gel
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0 |
Effect of bacterial media on the evaluation of the antibacterial activity of a biomaterial containing inorganic antibacterial reagents or antibiotics
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Several studies have been performed to assess the effectivesness of the antibacterial coating of a biomaterial to reduce surgical site infection. However, evaluations of these materials are inconsistent, and therefore it is difficult to compare their antibacterial performance. In this study, we evaluated the influence of different media such as nutrient broth (NB), Mueller-Hinton broth (MHB) and fetal bovine serum (FBS) on the antibacterial activity of AgNO3- or gentamicin-added bone cement using a modified ISO 22196 standard to devise a method to evaluate the antibacterial activity of biomaterials in vitro. The antibacterial activity results against Staphylococcus aureus and Escherichia coil were different in each medium. The antibacterial activity of AgNO3 in FBS was lower than the other media, whereas the antibacterial activity of gentamicin in FBS was higher than in the other media. It was assumed that the fluctuating antibacterial activity was influenced by serum components. The results showed that the ISO 22196 antibacterial evaluation method is suitable to evaluate antibacterial biomaterials after modifying the medium to FBS
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Defining hip fracture with claims data: outpatient and provider claims matter
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Hip Fx in the Elderly 2019
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Summary: Medicare claims are commonly used to identify hip fractures, but there is no universally accepted definition. We found that a definition using inpatient claims identified fewer fractures than a definition including outpatient and provider claims. Few additional fractures were identified by including inconsistent diagnostic and procedural codes at contiguous sites. Introduction: Medicare claims data is commonly used in research studies to identify hip fractures, but there is no universally accepted definition of fracture. Our purpose was to describe potential misclassification when hip fractures are defined using Medicare Part A (inpatient) claims without considering Part B (outpatient and provider) claims and when inconsistent diagnostic and procedural codes occur at contiguous fracture sites (e.g., femoral shaft or pelvic). Methods: Participants included all long-stay nursing home residents enrolled in Medicare Parts A and B fee-for-service between 1/1/2008 and 12/31/2009 with follow-up through 12/31/2011. We compared the number of hip fractures identified using only Part A claims to (1) Part A plus Part B claims and (2) Part A and Part B claims plus discordant codes at contiguous fracture sites. Results: Among 1,257,279 long-stay residents, 40,932 (3.2%) met the definition of hip fracture using Part A claims, and 41,687 residents (3.3%) met the definition using Part B claims. 4566 hip fractures identified using Part B claims would not have been captured using Part A claims. An additional 227 hip fractures were identified after considering contiguous fracture sites. Conclusions: When ascertaining hip fractures, a definition using outpatient and provider claims identified 11% more fractures than a definition with only inpatient claims. Future studies should publish their definition of fracture and specify if diagnostic codes from contiguous fracture sites were used.
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0 |
Cementless coated and noncoated mathys acetabular cups: Radiographic and histologic evaluation
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Management of Hip Fractures in the Elderly
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This study evaluated 185 cementless Mathys coated and uncoated acetabular cups inserted for total hip replacement since September 1984. All of the cups were high-density polyethylene. Sixty were uncoated (group A), 96 were coated with hydroxyapatite (group B), and 29 were coated with titanium (group C). Cup survival was assessed clinically, histologically, and radiographically, and a computer-assisted EBRA method was used to evaluate cup migration. After a mean follow-up of 8 years, five cups in group A that had previously shown migration were revised as a result of aseptic loosening, while no loosening of hip sockets occurred in groups B and C. These results suggest that Mathys cups should be used only if coated with hydroxyapatite or titanium. Furthermore, the histologic evaluation in four cups from groups B and C revealed normal bone formation without inflammation or fibrotic tissue around the cups, promising long-term survival
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0 |
Management of arterial injuries produced by percutaneous femoral procedures
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: A significant number of vascular injuries occur with the use of percutaneous diagnostic and therapeutic procedures. This study was done to indicate the types of these injuries and their management. METHODS: Over a 30-month period, 55 patients required operation for vascular complications after percutaneous femoral procedures including infrarenal arteriography (six patients) and angioplasty (22 patients), coronary angiography (16 patients) and angioplasty (five patients), and aortic balloon pump insertion (six patients). RESULTS: The 14 iliac and 41 femoral artery injuries included 29 pseudoaneurysms, six lacerations with persistent bleeding, seven dissections, six occlusions, three ruptures, two arteriovenous fistulas, and two large hematomas. Control for all femoral and distal external iliac artery lesions was obtained solely through a groin incision in 45 (82%) patients. Our technique for exposure of the external iliac artery through the groin is described. A separate retroperitoneal incision was necessary in 10 patients because of proximal injury, massive pseudoaneurysm, morbid obesity, or heavily scarred groins. In this series 34 lateral suture repairs, 11 interposition or bypass grafts, four patch angioplasties, one endarterectomy, three thrombectomies, and two hematoma evacuations were performed. Although no limb loss occurred, we encountered nine wound complications, five myocardial infarctions, and two deaths. CONCLUSIONS: This experience shows the wide variety of vascular complications caused by percutaneous procedures and the different techniques necessary for their management.
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Distally-based vastus lateralis muscle flap: A salvage alternative to address complex soft tissue defects around the knee
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PJI DX Updated Search
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Repeated soft tissue injuries around the knee represent challenging clinical situations where functional prognosis of the joint is often poor, especially in the presence of total knee arthroplasty (TKA). When gastrocnemius muscle flap techniques have already been used and failed, therapeutic solutions become rare. The authors suggest a regional solution to salvage these cases by the transfer of distally-based vastus lateralis muscle flaps. Four clinical operations of this muscle flap transfer are described, with three around TKA revision and one case of a post-traumatic knee amputation resulting from a compound open knee injury. Technical details of the intervention are presented. In all cases, skin closure was achieved, even if distal marginal necrosis was seen in two cases related to the type of muscle flap vascularisation. Final joint mobility was always poor (45ð on average). Distally-based vastus lateralis muscle flaps represent a salvage procedure to correct iterative soft tissue defects around the knee that threaten short-term joint function. These muscle flaps do not require microsurgical anastomosis. é 2010 Elsevier Masson SAS. All rights reserved
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1 |
Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children
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Pediatric Supracondylar Humerus Fracture 2020 Review
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A retrospective review of 29 children with displaced supracondylar humerus fractures was performed. Fifteen patients treated with closed reduction and percutaneous pinning and 14 patients treated with open reduction and percutaneous pinning were evaluated at a minimum of 18 months (range 18-80 months). Results were graded according to the criteria of Flynn et al. (Flynn JC, Matthews JG, Benoit RL: Blind pinning of displaced supracondylar fractures of the humerus in children. J Bone Joint Surg [Am] 56:263-272, 1974) using both cosmetic and functional evaluations. Excellent or good results were obtained in 14 of the 15 fractures treated with closed reduction and percutaneous pinning and in 12 of the 14 fractures treated with open reduction and percutaneous pinning. The three fair cosmetic results were associated with inadequate reduction and residual medial angulation. Ten to 15 degrees of motion loss occurred in three older patients. One patient in each group had a minor pintract infection. There were no cases of iatrogenic nerve injury or myositis ossificans. The treatment goal in displaced supracondylar humerus fractures in children is anatomic reduction. If an anatomic reduction cannot be achieved with closed reduction, open reduction is indicated. This can be done without an increased risk of complications.
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18F-FLT PET does not discriminate between reactive and metastatic lymph nodes in primary head and neck cancer patients
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Reconstruction After Skin Cancer
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METHODSTen patients with newly diagnosed stage II-IV squamous cell carcinoma of the head and neck underwent (18)F-FLT PET before surgical tumor resection with lymph node dissection. Emission (18)F-FLT PET and CT images of the head and neck were recorded and fused, and standardized uptake values (SUVs) were calculated. From all 18 (18)F-FLT PET-positive lymph node levels and from 8 (18)F-FLT PET-negative controls, paraffin-embedded lymph node sections were stained and analyzed for the endogenous proliferation marker Ki-67 and for the preoperatively administered proliferation marker iododeoxyuridine. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for (18)F-FLT PET.RESULTSPrimary tumor sites were oral cavity (n=7), larynx (n=2), and maxillary sinus (n=1). Nine of the 10 patients examined had (18)F-FLT PET-positive lymph nodes (SUV(mean): median, 1.2; range, 0.8-2.9), but only 3 of these patients had histologically proven metastases. All metastatic lymph nodes showed Ki-67 and iododeoxyuridine staining in tumor cells. In the remaining 7 patients, there was abundant Ki-67 and iododeoxyuridine staining of B-lymphocytes in germinal centers in PET-positive lymph nodes, explaining the high rate of false-positive findings. The sensitivity, specificity, positive predictive value, and negative predictive value of (18)F-FLT PET were 100%, 16.7%, 37.5%, and 100%, respectively.CONCLUSIONIn head and neck cancer patients, (18)F-FLT PET showed uptake in metastatic as well as in nonmetastatic reactive lymph nodes, the latter due to reactive B-lymphocyte proliferation. Because of the low specificity, (18)F-FLT PET is not suitable for assessment of pretreatment lymph node status. This observation may also negatively influence the utility of (18)F-FLT PET for early treatment response evaluation of small metastatic nodes.UNLABELLEDRepopulation of clonogenic tumor cells is inversely correlated with radiation treatment outcome in head and neck squamous cell carcinomas. A functional imaging tool to assess the proliferative activity of tumors could improve patient selection for treatment modifications and could be used for evaluation of early treatment response. The PET tracer 3'-deoxy-3'-(18)F-fluorothymidine ((18)F-FLT) can image tumor cell proliferation before and during radiotherapy, and it may provide biologic tumor information useful in radiotherapy planning. In the present study, the value of (18)F-FLT PET in determining the lymph node status in squamous cell carcinoma of the head and neck was assessed, with pathology as the gold standard.
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Once-weekly oral alendronate 70 mg in patients with glucocorticoid-induced bone loss: a 12-month randomized, placebo-controlled clinical trial
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Management of Hip Fractures in the Elderly
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OBJECTIVE: Glucocorticoid-induced osteoporosis is the most common iatrogenic form of osteoporosis. We evaluated the efficacy and safety of once-weekly bisphosphonate therapy for prevention and treatment of bone loss in patients on glucocorticoid therapy.METHODS: We conducted a 12-month, multicenter, randomized, double-blind, placebo-controlled trial with 114 and 59 patients in the treatment and placebo arms, respectively. Participants were stratified according to the duration of prior oral glucocorticoid therapy at randomization. Participants received alendronate 70 mg once weekly (ALN OW) or placebo; all received supplemental daily calcium (1000 mg) and 400 IU vitamin D. Clinical evaluations were performed at baseline, 3, 6, 9, and 12 months.RESULTS: At 12 months, there was a significant mean percentage increase from baseline in the ALN OW group for lumbar spine (2.45%), trochanter (1.27%), total hip (0.75%), and total body (1.70%) bone mineral density (BMD). Comparing ALN OW versus placebo at 12 months, a significant treatment difference for the mean percentage change from baseline was observed for lumbar spine (treatment difference of 2.92%; p </= 0.001), trochanter (treatment difference 1.66%; p = 0.007), and total hip (treatment difference 1.19; p = 0.008) BMD. Biochemical markers of bone remodeling also showed significant mean percentage decreases from baseline.CONCLUSION: Over 12 months ALN OW significantly increased lumbar spine, trochanter, total hip, and total body BMD compared with baseline among patients taking glucocorticoid therapy. A significant treatment difference versus placebo was observed at 12 months for the mean percentage change from baseline for lumbar spine, trochanter, and total hip
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1 |
Long leg splinting for pediatric femur fractures
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Pediatric Diaphyseal Femur Fractures 2020 Review
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BACKGROUND: Pediatric femur fractures are frequently encountered injuries frequently treated with spica casting. Spica casting may, however, be expensive and burdensome to patients. A possible alternative is a long leg splint. METHODS: Patients aged 6 months to 5 years old who were treated for a femoral shaft fracture with a long leg splint extending above the waist were matched with a patient treated with a spica cast. RESULTS: At the time of healing, the alignment in the spica cast group was only significantly better than the alignment of the splint group with respect to coronal angulation.
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One hundred percent fascial approximation with sequential abdominal closure of the open abdomen
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DOD - Acute Comp Syndrome CPG
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BACKGROUND: Damage-control surgery and the recognition of the abdominal compartment syndrome have improved patient outcomes but at the cost of an open abdomen. Multiple techniques have been introduced to obtain fascial closure for the open abdomen to minimize morbidity and cost of care. We performed a modification of the vacuum-assisted closure (VAC) technique that provided constant fascial tension, hypothesizing this would result in a higher rate of primary fascial closure.
METHODS: After initial temporary closure of the abdomen after post-injury damage control or decompressive laparotomy for abdominal compartment syndrome, we began the sequential closure technique. The technique begins by covering the bowel with the multiple white sponges overlapped like patchwork, and the fascia is placed under moderate tension over the white sponges with #1-PDS sutures. Large black VAC sponges are placed on top of the white sponges and affixed with an occlusive dressing and standard suction tubing is placed. Patients are returned to the operating room for sequential fascial closure and replacement of the sponge sandwich every 2 days, with a resulting decrease in the fascial defect.
RESULTS: Fourteen patients underwent sequential abdominal closure during the study period: 9 owing to damage control surgery and 5 owing to secondary abdominal compartment syndrome. Average time to closure was 7.5 +/- 1.0 days (range 4-16) and average number of laparotomies to closure was 4.6 +/- 0.5 (range 3-8). All patients attained primary fascial closure.
CONCLUSION: We propose a modification of the previously described vacuum-assisted closure technique that achieves 100% fascial approximation in our limited experience. Further application and refinement of this technique may eliminate the need for delayed complex and costly reconstructive abdominal wall procedures for the open abdomen.
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0 |
Distal radioulnar joint injuries associated with fractures of the distal radius
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Distal Radius Fractures
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The most common cause of residual wrist disability after fractures of the distal radius is the distal radioulnar joint. The 3 basic conditions that produce radioulnar pain and limitation of forearm rotation are instability, joint incongruency, and ulnocarpal abutment. The last 2 entities initiate irreversible cartilage damage that eventually leads to degenerative joint disease. Early recognition and management in the acute stage aim at the anatomic reconstruction of the distal radioulnar joint including bone, joint surfaces, and ligaments in an effort to reduce the incidence of painful sequelae and functional deficit. This article provides a description and the treatment options of the distal radioulnar joint lesions that occur in association with fractures of the distal radius, and the results obtained with open and arthroscopic techniques. Both acute and chronic disorders are analyzed, and a prognostic and treatment oriented classification is presented Furthermore, the pathoanatomy and management of chronic distal radioulnar joint derangement after fracture of the distal radius are reviewed briefly.
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0 |
Reliability of a brief outpatient functional outcome assessment measure
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The stability of the musculoskeletal form of the Medical Rehabilitation Follow Along (MRFA) instrument was examined in 47 patients receiving outpatient rehabilitation services. The MRFA instrument was designed to provide information on quality of daily living, including physical function, pain, satisfaction, and emotional/psychological well-being. The instrument consists of thirty questions and can be administered as an interview or a written questionnaire. The MRFA instrument was developed using Rasch analysis procedures and is an extension of previous research involving the Functional Assessment Screening Questionnaire. Forty-seven patients completed the musculoskeletal form of the MRFA on two occasions separated by an interval of 1 to 7 days. The stability of responses was examined using the intraclass correlation coefficient (ICC) and kappa. ICC values for the sections of the MRFA instrument examining quality of daily living and physical functioning ranged from 0.74 to 0.97. ICC values for items assessing pain and feelings of well-being were more variable, ranging from 0.36 to 0.93. The kappa values displayed a similar pattern. The overall stability of the MRFA instrument was found to be adequate for gathering screening information in outpatient settings. Additional research is necessary to confirm the findings of this investigation and extend the results to a larger outpatient population
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0 |
Intensive physical therapy after hip fracture. A randomised clinical trialHip protectors in aged-care facilities: a randomized trial of use by individual higher-risk residents [with consumer summary]
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Management of Hip Fractures in the Elderly
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Abstract and full text may be available at: http://www.danmedbul.dk/portal/page/portal/danmedbul.dk/dmb_forside/PAST_ISSUE NOAbstract and full text may be available at: http://ageing.oxfordjournals.org/archive/ NO
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1 |
Changing trends in the use of cartilage restoration techniques for the patellofemoral joint: a systematic review
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: The patellofemoral (PF) joint contains the thickest articular cartilage in the human body. Chondral lesions to this area are often misdiagnosed and can predispose to secondary osteoarthritis if left untreated. Treatment options range from arthroscopic debridement to cartilage restoration techniques such as microfracture (MFx), autologous chondrocyte implantation (ACI), and osteochondral autograft transplantation. The purpose of this study was to systematically assess the trends in surgical techniques, outcomes, and complications of cartilage restoration of the PF joint.
METHODS: This review has been conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). The electronic databases PubMed, MEDLINE, and EMBASE were searched from January 1, 2007 to April 30, 2018. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. A two-proportion z test was used to determine whether the differences between the proportions of cartilage restoration techniques used from 2007 to 2012 and 2013-2018 were statistically significant.
RESULTS: Overall, 28 studies were identified, including 708 patients (824 knees) with a mean age of 39.5 +/- 10.5 years and a mean follow-up of 39.1 +/- 16.0 months. Majority of patients were treated with ACI (45.5%) and MFx (29.6%). A significant increase in the use of the third generation ACI occurred with a simultaneous decreased usage of the conventional MFx over the last 5 years (p < 0.001). All techniques had significant (p < 0.05) improvements in clinical outcomes. The overall complication rate was 9.2%, of which graft hypertrophy (2.7%) was the most prevalent.
CONCLUSIONS: ACI was the most common restoration technique. The use of third generation ACI has increased with a concurrent decline in the use of conventional MFx over the latter half of the past decade (p < 0.001). Overall, the various cartilage restoration techniques reported improvements in patient reported outcomes with low complication rates. Definitive conclusions on the optimal treatment remain elusive due to a lack of high-quality comparative studies.
LEVEL OF EVIDENCE: Level IV, Systematic Review of Level-II-IV studies.
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0 |
Kinesthetic, but not visual, motor imagery modulates corticomotor excitability
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The hypothesis that motor imagery and actual movement involve overlapping neural structures in the central nervous system is supported by multiple lines of evidence. The aim of this study was to examine the modulation of corticomotor excitability during two types of strategies for motor imagery: Kinesthetic Motor Imagery (KMI) and Visual Motor Imagery (VMI) in a phasic thumb movement task. Transcranial magnetic stimulation (TMS) was applied over the contralateral motor cortex (M1) to elicit motor evoked potentials (MEPs) in the dominant abductor pollicis brevis (APB) and abductor digiti minimi (ADM). In a separate experiment, transcutaneous electrical stimuli were delivered to the median nerve at the dominant wrist, to elicit F-waves from APB. Imagined task performance was paced with a 1 Hz auditory metronome, and stimuli were delivered either 50 ms before (ON phase), or 450 ms after (OFF phase), the metronome beeps. Recordings were also made during two control conditions: Rest, and a Visual Static Imagery (VSI) condition. Significant MEP amplitude facilitation occurred only in APB, and only during the ON phase of KMI. F-wave persistence and amplitude were unaffected by imagery. These results demonstrate that kinesthetic, but not visual, motor imagery modulates corticomotor excitability, primarily at the supraspinal level. These findings have implications for the definition of motor imagery, and for its therapeutic applications. (copyright) Springer-Verlag 2005
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1 |
Electrical stimulation for long-bone fracture-healing: A meta-analysis of randomized controlled trials
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MSTS 2018 - Femur Mets and MM
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Background: Bone stimulation represents a $500 million market in the United States. The use of electromagnetic stimulation in the treatment of fractures is common; however, the efficacy of this modality remains uncertain. We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate the effect of electromagnetic stimulation on long-bone fracture-healing. Methods: We searched four electronic databases (MEDLINE, EMBASE, CINAHL, and all Evidence-Based Medicine Reviews) for trials of electromagnetic stimulation and bone repair, in any language, published from the inception of the database to April 2008. In addition, we searched by hand seven relevant journals published between1980 and April 2008 and the bibliographies of eligible trials. Eligible trials enrolled patients with long-bone lesions, randomly assigned them to electromagnetic stimulation or a control group, and reported on bone-healing. Information on the methodological quality, stimulation device, duration of treatment, patient demographics, and all clinical outcomes were independently extracted by two reviewers. Results: Of 2546 citations obtained in the literature search, eleven articles met the inclusion criteria. Evidence from four trials reporting on 106 delayed or ununited fractures demonstrated an overall nonsignificant pooled relative risk of 1.76 (95% confidence interval, 0.8 to 3.8; p = 0.15; I2 = 60.4%) in favor of electromagnetic stimulation. Single studies found a positive benefit of electromagnetic stimulation on callus formation in femoral intertrochanteric osteotomies, a limited benefit for conservatively managed Colles fracture or for lower limb-lengthening, and no benefit on limb-length imbalance and need for reoperation in surgically managed pseudarthroses or on time to clinical healing in tibial stress fractures. Pain was reduced in one of the four trials assessing this outcome. Conclusions: While our pooled analysis does not show a significant impact of electromagnetic stimulation on delayed unions or ununited long-bone fractures, methodological limitations and high between-study heterogeneity leave the impact of electromagnetic stimulation on fracture-healing uncertain. Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence. Copyright © 2008 by The Journal of Bone and Joint Surgery, Incorporated.
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Standard open decompression in carpal tunnel syndrome compared with a modified open technique preserving the superficial skin nerves: a prospective randomized study
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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PURPOSE: A common surgical treatment for carpal tunnel syndrome is open carpal tunnel decompression. This involves skin incision followed by sharp dissection straight down through fat and palmar fascia to the transverse carpal ligament, which is then divided. The incidence of scar discomfort ranges from 19% to 61%, and its cause is not fully understood. We conducted a prospective randomized controlled trial to investigate whether preservation of superficial nerve branches crossing the incision site reduces the incidence and severity of postoperative scar pain after open carpal tunnel release. METHODS: Forty-two patients with bilateral idiopathic carpal tunnel syndrome (84 hands) were included in the study. The patients were randomized to determine which hand was to have carpal tunnel decompression using a technique that would try to preserve the superficial nerve branches. The other hand had open carpal tunnel decompression without any attempt to preserve the superficial nerve branches. An assessment of each hand in each patient was performed immediately before surgery and at 6 weeks, 3 months, and 6 months after surgery. This assessment was performed with a questionnaire based on the Patient Evaluation Measure. RESULTS: We found no evidence of a difference in scar pain between the 2 methods at 6 weeks, 3 months, and 6 months. There was a significant difference in the length of surgery between the 2 groups. CONCLUSIONS: Scar pain scores in this series of open carpal tunnel decompressions were similar, whether or not an attempt was made to identify and preserve superficial nerve branches crossing the wound
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1 |
Nipple-sparing mastectomy using a hemi-periareolar incision with or without minimal medial-lateral extensions; clinical outcome and patient satisfaction: A single centre prospective observational study
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Acellular Dermal Matrix
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BACKGROUND: Nipple-sparing mastectomy (NSM) is becoming a viable oncoplastic option. There is debate regarding the best approach that balances oncological safety with aesthetics. In this study, we describe an approach involving a hemi-periareolar incision and evaluate its safety and outcomes. METHODS: Patients treated at single center between 2012 and 2015 were observed prospectively. After a histologically negative subareolar biopsy, immediate reconstruction with implant and acellular dermal matrix was performed after NSM. Primary end points were wound complications and explantation. Secondary end points included local recurrence, quality of life, patient satisfaction, and esthetic outcome. RESULTS: Sixty-three patients were included with 92 procedures. Twenty-seven percent received chemotherapy and 12.7% received radiotherapy. Mean follow-up was 27.6 months. There were only 2 wound complications, and no recurrences. Mean outcome scores were promising (Breast Q = 88%, subjective esthetic = 9.2, objective esthetic = 9.3, hardening = 2.6). CONCLUSIONS: NSM via a hemi-periareolar incision is oncologically safe with a low-complication rate and high patients' satisfaction.
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0 |
ACL reconstruction and the implication of its tibial attachment for stability of the joint: anthropometric and biomechanical study
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Surgical Management of Osteoarthritis of the Knee CPG
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The planar topography of the anterior cruciate ligament (ACL) insertion was investigated and correlated to the use of the double-bundle/double tibial tunnel ACL reconstruction technique within the ACL tibial insertion area. The anteroposterior and mediolateral length of the tibial ACL attachment and the distances of the tibial insertion area from the anterior and posterior tibial borders were measured and the stability of the joint was tested using the double-bundle/double tibial tunnel ACL reconstruction technique. The anteroposterior length, 19.54 mm in men and 17.36 mm in women, of the ACL insertion, averaged approximately 40% of the total intercondylar anteroposterior dimension of the plateau. This broad distribution of insertion fibres ensures ligament tension and hence joint stability. The reported anteroposterior broad insertion of ACL fibres to the tibia is not sufficiently reproduced by the use of one or more bundles having a common tibial tunnel for the ACL reconstruction. In our view, this might be better achieved with two different bundles, with separate tunnels, and independent tensioning in different knee angles. This technique might achieve better results in human knee stability as opposed to other reported techniques
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0 |
Nutritional supplementation for hip fracture aftercare in older people
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SR for PM on OA of All Extremities
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Background: Older people with hip fractures are often malnourished at the time of fracture, and have poor food intake subsequently.Objectives: To review the effects of nutritional interventions in older people recovering from hip fracture.Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 3), MEDLINE and other major databases (to July 2008).Selection criteria: Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture.Data collection and analysis: Both authors independently selected trials, extracted data and assessed trial quality. We pooled data for primary outcomes.Main results: Twenty-four randomised trials involving 1940 participants were included. Outcome data were limited and many trials were methodologically flawed. Results from 23 trials are presented here.Ten trials evaluated oral multinutrient feeds: providing non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (16/244 versus 21/226; risk ratio (RR) 0.76, 95% confidence interval (CI) 0.42 to 1.37) or 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications) (46/126 versus 41/103; RR 0.76, 95% CI 0.55 to 1.04).Four heterogenous trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97). Nasogastric feeding was poorly tolerated.One trial examining nasogastric tube feeding followed by oral feeds found no evidence for an effect on mortality or complications.One trial of multinutrient intravenous feeding followed by oral supplements found a reduction in participants with complications (RR 0.21, 95% CI 0.10 to 0.46), but not in mortality (RR 0.11, 95% CI 0.01 to 2.00).Four trials testing increasing protein intake in an oral feed found no evidence for an effect on mortality (RR 1.42, 95% CI 0.85 to 2.37). Protein supplementation may have reduced the number of long term medical complications.Two trials, testing intravenous vitamin B1 and other water soluble vitamins, or oral 1-alpha-hydroxycholecalciferol (vitamin D) respectively, produced no evidence of effect.One trial, evaluating dietetic assistants to help with feeding, showed no statistically significant effect on mortality (RR 0.57, 99% CI 0.29 to 1.11).Authors' conclusions: Weak evidence exists for the effectiveness of protein and energy feeds. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding require further evaluation
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1 |
Seroma Rates Are Not Increased When Combining Liposuction With Progressive Tension Suture Abdominoplasty: A Retrospective Cohort Study of 619 Patients
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Panniculectomy & Abdominoplasty CPG
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Background: Several studies have demonstrated that progressive tension sutures (PTS) reduce seroma. Many fear that adding liposuction to abdominoplasty will increase seroma rates and avoid drainless abdominoplasty when performing concomitant liposuction. Objectives: We sought to identify whether liposuction increases seroma in PTS and non-PTS abdominoplasty. Methods: In this retrospective study, 619 patients underwent abdominoplasty between 2009 and 2017, of which 299 patients had drainless abdominoplasty with PTS and 320 had drain-based abdominoplasty. We compared complications among PTS patients with and without liposuction and among drain-based abdominoplasty patients with and without liposuction. Results: Demographics were similar between PTS and drain patients and between liposuction and nonliposuction PTS. Mean liposuction volume with PTS was 1592 +/- 1048 mL. Seroma in the PTS group was found to be 2.6%, which is consistent with previous data. PTS without liposuction had a rate of seroma of 6.67% compared to a rate of 2.2% with liposuction; these rates were not significantly different (P = 0.20). A total of 207 patients had drain-based abdominoplasty with liposuction, and 113 had it without liposuction. Seroma with liposuction was 9.17% and without liposuction was 6.19%, although these differences were not significant (P = 0.52). PTS lipoabdominoplasty had less seroma compared with drain-based lipoabdominoplasty (P = 0.01). Conclusions: Liposuction was performed in 80% of the patients, and patients with lipoabdominoplasty were not at a higher risk of seroma, in the drain group or the PTS group. More patients may allow validation that liposuction may actually be protective with PTS. Regardless, there is no increase in seroma with the addition of liposuction to PTS drainless abdominoplasty. Level of Evidence 3:
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0 |
Bone mineral density in women with systemic lupus erythematosus
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Management of Hip Fractures in the Elderly
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The aim of this cross-sectional study was to determine the prevalence of reduced bone mineral density (BMD) in a group of female SLE patients and to identify factors predictive of reduced BMD. Femoral neck (FN) and lumbar spine (LS) dual-energy X-ray absorptiometry results were evaluated in 79 pre- and postmenopausal women with SLE aged (mean, range) 49 (22-73) years). Variables evaluated were disease duration, SLEDAI, current and cumulative corticosteroid dose, Steinbrocker's functional classification, use of immunosuppressive agents, and history of fracture due to minor trauma. A T-score of < or = 1.0 was found in 61.9% at the LS and 48.3% at the FN, and 18 (23.7%) patients belonged to the category of osteoporosis at LS, compared to only three (5.4%) patients at FN. A statistical difference (P = 0.014) was found when comparing LS BMD in pre- and postmenopausal patients. LS BMD had a significant correlation with daily and cumulative steroid dose (P = 0.016 and 0.031, respectively). There was a significant difference in LS BMD between the daily steroid dose group receiving < or = 7.5 and those receiving > 7.5 mg/day (P = 0.008), and also in FN BMD comparing groups on 0 and > 7.5 mg/day (P = 0.022). There was significant difference in LS and FN BMD between patients in Steinbrocker classes I and III (P = 0.016 and 0.005, respectively). No significant correlation was found in either subgroup between BMD and other studied parameters. We concluded that the prevalence of reduced bone mass at LS is pronounced among postmenopausal women with SLE, in those with a high Steinbrocker functional classification and those on a high daily steroid dose. Therefore, these patients should be considered as a high-risk group deserving regular spinal BMD scans and therapy in time to prevent vertebral fractures
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0 |
Efficacy of intraarticular infliximab in patients with chronic or recurrent gonarthritis: a clinical randomized trial
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To evaluate the efficacy and safety of intraarticular infliximab compared with intraarticular methylprednisolone in patients with gonarthritis. METHODS: In 23 patients with recurrent gonarthritis despite previous intraarticular corticosteroid therapy, a total of 41 intraarticular injections (20 infliximab and 21 methylprednisolone) were performed in 28 knees. Initial therapy was randomly assigned, and crossover therapy was eligible within 3 months. The clinical effect was assessed during 6 months of followup. The primary outcome was eventâ?free survival, defined as the time after treatment until local retreatment was performed and/or nonimprovement of the knee joint score. Adverse effects were recorded during followup. RESULTS: All patients treated with intraarticular infliximab had an insufficient response. In contrast, 8 of the 21 intraarticular methylprednisolone injections were effective (P = 0.004). Between groups, no differences in the patients' age, disease duration, number of diseaseâ?modifying antirheumatic drugs, or previous intraarticular methylprednisolone were observed. Reported adverse effects were not related to therapy. CONCLUSION: Treatment with intraarticular infliximab injection was not effective in patients with a chronically inflamed knee joint. Intraarticular injection with methylprednisolone was superior despite previous intraarticular corticosteroid therapy. Further investigation is needed to provide these patients with a better alternative.
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0 |
Monoclonal gammopathy of undetermined significance and smoldering multiple myeloma: A review of the current understanding of epidemiology, biology, risk stratification, and management of myeloma precursor disease
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MSTS 2018 - Femur Mets and MM
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The term monoclonal gammopathy of undetermined significance (MGUS) was coined in 1978. The recent advances in our knowledge about MGUS and smoldering multiple myeloma (SMM) have helped us better understand the pathogenesis of myeloma. It seems that myeloma evolves from a precursor state in almost all cases. We do not completely understand the multistep process from the precursor state to myeloma, but studies like whole genome sequencing continue to improve our understanding of this process. The process of transformation may not be linear acquisition of changes, but rather a branched heterogeneous process. Clinical features that are prognostic of rapid transformation have been identified, but no specific molecular markers have been identified. Even with recent advances, multiple myeloma remains an incurable disease in the vast majority, and intervening at the precursor state provides a unique opportunity to alter the natural history of the disease. A limitation is that a vast majority of patients with precursor disease, especially low-risk MGUS, will never progress to myeloma in their lifetime, and treating these patients is not only unnecessary but may be potentially harmful. The challenge is to identify a subset of patients with the precursor state that would definitely progress to myeloma and in whom interventions will have a meaningful impact. As our understanding of the molecular and genetic processes improves, these studies will guide the selection of high-risk patients more appropriately and ultimately direct a tailored management strategy to either delay progression to symptomatic myeloma or even "cure" a person at this premalignant stage. © 2012 American Association for Cancer Research.
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0 |
Standardization of BMD T-Scores in the first five years after the menopause: do femoral neck-equivalent and older normative range T-Scores improve diagnostic agreement?
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Management of Hip Fractures in the Elderly
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Calculating T-scores using an older reference population reduces inconsistency between measurement sites when osteoporosis is diagnosed in the elderly. The present analysis in a younger, early postmenopausal cohort examined 5-yr consistency of normalization by local and femoral neck-equivalent T-scores. NHANES (femur) and Hologic (spine and forearm) references were applied to baseline, 1-, 2-, 3-, and 5-yr scans in 925 untreated women in a national cohort study, and alternative local and neck-equivalent scores calculated. The baseline prevalence of osteopenia/osteoporosis was 35.5%/4.1% (spine), 31.0%/1.2% (neck), 31.3%/1.2% (total hip), and 37.2%/2.5% (forearm). It increased to 54.6%/7% by combining sites. The prevalences at 5-yr were 57.2%/12.4% (spine), 51.9%/5.0% (neck), 46.6%/3.7% (total hip), 52.5%/7.4% (forearm), and 77.3%/17.8% (any). A T-score cut-off at the lowest of four sites of -1.65 for osteopenia and -3.37 for osteoporosis was equivalent in patient numbers to T<-1 and T<-2.5 at the femoral neck. The proportion of inconsistently classified subjects decreased from 48% to 42% (p<0.05) with neck-equivalent scores. No improvement remained after 5 yr. Kappa scores did not improve by the use of local or femoral neck scores. In conclusion, adjusted thresholds cannot remove the anatomic discrepancy between T-scores. To overcome this problem, risk-based diagnostic cut-offs must therefore be calculated separately for each measurement site and fracture localization
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