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Update on Selective Regional Analgesia for Hip Surgery Patients
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AAHKS (8) Anesthetic Infiltration
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In hip surgery, regional anesthesia offers benefits in pain management and recovery. There are a wide range of regional analgesic options; none have shown to be superior. Lumbar plexus block, femoral nerve block, and fascia iliaca block are the most supported by published literature. Other techniques, such as selective obturator and/or lateral femoral cutaneous nerve blocks, represent alternatives. Newer approaches, such as quadratus lumborum block and local infiltration analgesia, require rigorous studies. To realize long-term outcome benefits, postoperative regional analgesia must be tailored to the individual patient and last longer.
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How myeloma cells escape bisphosphonate-mediated killing: development of specific resistance with preserved sensitivity to conventional chemotherapeutics
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MSTS 2018 - Femur Mets and MM
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Although amino-bisphosphonates (N-BPs) induce apoptosis of myeloma cells in vitro, most in-vivo studies fail to demonstrate a corresponding antitumour effect. This discrepancy might reflect the development of resistance to the antitumour effects of N-BP in myeloma cells when they are exposed to N-BP for a prolonged time. To test this hypothesis, two N-BP-sensitive human myeloma cell lines were continuously exposed to increasing concentrations of the N-BP alendronate for 6 weeks. During this treatment period, 10 out of 10 sublines developed reduced apoptotic and antiproliferative responses to alendronate treatment. This de novo alendronate resistance was accompanied by resistance to another N-BP (zoledronate) but not to an inhibitor of 3-hydroxy-3-methylglutaryl CoA reductase or Fas ligand. Importantly, N-BP-resistant myeloma cells also remained sensitive to conventional myeloma chemotherapeutics (melphalan, doxorubicin and vincristine). Further analysis of the N-BP-resistant cells revealed an increased activity of the N-BP-specific target enzyme farnesyl pyrophosphate synthase, without upregulation of its gene transcription. Our results suggest that continuous exposure of myeloma cells to alendronate leads to the development of N-BP resistance. This is associated with an increased activity of farnesyl pyrophosphate synthase and does not evolve from defective apoptotic pathways. Importantly, the antitumour effects of conventional myeloma chemotherapeutics are preserved in the N-BP-resistant myeloma cells.
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Treatment of fractures of the femur with the Grosse-Kempf rod
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DoD SSI (Surgical Site Infections)
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Intramedullary rod placement provides excellent fixation for many fractures of the femur. It also carries a high union rate, a low infection rate, and a shortened hospital stay for the patient. Certain fractures of the femur are not suitable for fixation with a standard intramedullary and alone. Use of the Grosse-Kempf rod, with interlocking screws, allows for stable fixation for long oblique fractures, spiral fractures, comminuted fractures, segmental fractures, fractures with a butterfly fragment, and fractures located in the proximal or distal shaft of the femur. The Louisiana State University (LSU) Orthopedic experience in the use of the Grosse-Kempf rod is presented in this article. We have treated a total of 60 fractures of the femur in 58 patients with this fixation system. This series consists of 58 acute fractures, one established nonunion, and one established infected nonunion. All patients in the group of acute fractures and who have had adequate follow up and time have healed. This group consists of 29 healed fractures and four fractures which are healing, but have recently had the static screw removed. Eight patients were lost to follow up, two died of causes unrelated to the treatment, and 17 have been placed recently and have not had time to heal. There was one instance of wound infection in the acute fracture group, associated with the distal screws, but this has not required rod removal. The Grosse-Kempf rod provides the treating physician with another option in the treatment of fractures of the femur not suitable for use by the standard intramedullary rod. The procedure is difficult, but we have found it to be reliable in treatment of difficult fractures.
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0 |
Role of Fresh Osteochondral Allografts for Large Talar Osteochondral Lesions
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Osteochondritis Dissecans 2020 Review
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Osteochondral lesions of the talus, large or small, present a challenge to the treating orthopaedic surgeon. These cartilage and bony defects can cause substantial pain and functional disability. Surgical treatment of small lesions of the talus has been thoroughly explored and includes retrograde drilling, arthroscopic débridement and marrow stimulation, osteochondral autografting from cartilage/bone unit harvested from the ipsilateral knee (mosaicplasty), and autologous chondrocyte implantation. Although each of these reparative, replacement, or regenerative techniques has various degrees of success, they may be insufficient for the treatment of large osteochondral lesions of the talus. Large-volume osteochondral lesions of the talus (>1.5 cm in diameter or area >150 mm) often involve sizable portions of the weight-bearing section of the talar dome, medially or laterally. To properly treat these osteochondral lesions of the talus, a fresh structural osteochondral allograft is a viable treatment option.
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Arthroscopic Repair of Isolated Partial- and Full-Thickness Upper Third Subscapularis Tendon Tears: Minimum 2-Year Outcomes After Single-Anchor Repair and Biceps Tenodesis
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Trial Systematic Review Project
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PURPOSE: To investigate outcomes of arthroscopic single-anchor repair and biceps tenodesis of partial- and full-thickness tears of the upper third subscapularis (SSC).
METHODS: Thirty-three patients with arthroscopically confirmed isolated SSC tears, Lafosse type I (>50% of the tendon thickness involved), or type II were included. All patients underwent arthroscopic subcoracoid decompression, coracoplasty if the coracohumeral distance was narrowed, biceps tenodesis, and a single-anchor repair of the upper third SSC. No other reconstructive procedures were performed. Subjective evaluations included American Shoulder and Elbow Surgeons, Short-Form 12, Quick Disabilities of the Arm, Shoulder and Hand, Single Assessment Numeric Evaluation, and visual analog scale pain scores preoperatively and at minimum 2 years postoperatively.
RESULTS: Thirty-one patients (n = 25 male, n = 6 female) were included in the final collective, because 2 patients refused participation. Minimum 2-year follow-up data were available for 28 of the 31 patients (90.3%). The mean age at the time of surgery was 54.8 (range, 36-71) years. The mean follow-up was 4.1 (range, 2.0-8.0) years. The results of all outcome measures improved significantly postoperatively compared with preoperative scores (P < .05). Patients with single-anchor repair of type II SSC tears (n = 17) had a significantly higher mean postoperative American Shoulder and Elbow Surgeons score (93.7 +/- 10.8) than patients with single-anchor repair of type I SSC tears (n = 11; 86.7 +/- 10.9; P = .027).
CONCLUSIONS: Arthroscopic single-anchor repair of upper third SSC tendon tears led to improved function and decreased pain with high patient satisfaction. Outcomes of full-thickness upper third SSC tears were more favorable compared with outcomes of high grade partial-thickness upper third SSC tears.
LEVEL OF EVIDENCE: Level IV, retrospective therapeutic case series.
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Revisional Charcot foot and ankle surgery
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DoD LSA (Limb Salvage vs Amputation)
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Charcot neuroarthropathy is often a devastating diabetic foot complication that poses a great risk for limb loss and can have a significant impact on a patient's quality of life in the presence of multiple existing comorbidities. It is a progressive and debilitating condition characterized by joint dislocation, pathologic fracture(s), and extensive destruction of the foot or ankle architecture secondary to dense peripheral neuropathy. This pathologic process can be idiopathic, secondary to acute trauma or previous surgery, or attributable to repetitive "microinjury." Once the Charcot process has been initiated, continued ambulation results in progressive collapse and deformity. Severe deformities can have an impact on the patient's ambulatory status, and when associated with instability, ulceration, or infection, there is greater risk for a major limb amputation.
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Scaphoid fracture epidemiology
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Management of Hip Fractures in the Elderly
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BACKGROUND: The current available literature related to scaphoid fracture epidemiology is inconsistent. The aim of this study was to describe the epidemiology of true scaphoid fractures in a defined adult population. METHODS: Using a prospective database, we identified all patients who sustained a radiographically confirmed acute fracture of the scaphoid over a 1-year period. Age, gender, mechanism of injury, the Herbert fracture classification, and associated injuries were recorded and analyzed. RESULTS: There were 151 scaphoid fractures diagnosed giving an annual incidence of 29 per 100,000 (95% confidence interval, 25-34). The median age of males was significantly younger when compared with females (p = 0.002), with a male (n = 105) predominance seen (p 0.001). Low-energy falls from a standing height were most common (40.4%), but with males being significantly more likely to sustain their fracture after a high-energy injury (p 0.001). The most common fracture was Herbert classification B2 (n =55, 36.4%), with unstable fractures more common in younger patients (p = 0.025) following a high-energy injury (p = 0.042). CONCLUSIONS: We have reported the epidemiology of true scaphoid fractures, with young males at risk of sustaining a fracture. Knowledge of the true incidence of scaphoid fractures and an understanding of the demographic risk factors are essential when assessing the suspected scaphoid fracture, particularly when considering further imaging modalities
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Reduced penetrance in hereditary motor neuropathy caused by TRPV4 Arg269Cys mutation
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Management of Hip Fractures in the Elderly
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Incomplete penetrance has rarely been reported in Charcot-Marie-Tooth disease. Our aim is to describe reduced penetrance in a hereditary motor neuropathy pedigree due to mutation in the transient receptor potential vallinoid 4 (TRPV4) gene. The pedigree comprised two affected members, the proband aged 44 years and her affected daughter aged 7 years, and seven additional related subjects, three of whom were subclinical gene mutation carriers aged 9, 40 and 70 years. Clinico-electrophysiological studies, MRI of lower-limb musculature and genetic testing of the TRPV4 were performed. The proband presented with a moderate facio-scapulo-peroneal syndrome, whereas her symptomatic daughter suffered from severe congenital spinal muscular atrophy with arthrogryposis, laryngomalacia, and vocal cord paresis. Electrophysiological evaluation revealed a pure motor axonal neuropathy. In the proband, MRI showed extensive and widespread fatty atrophy of lower-leg musculature, whereas in thigh musculature there was just mild distal fatty infiltration of vastus lateralis. Genetic testing revealed a heterozygous Arg269Cys mutation in the TPRV4 gene. In all three mutation carriers results from clinical and electrophysiological examination, and MRI of foot and lower-leg musculature were normal. We conclude that non-penetrance may be an integral feature of neuropathic syndromes associated with TRPV4 gene mutation. (copyright) 2011 Springer-Verlag
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Bleeding complications from femoral and sciatic nerve catheters in patients receiving low molecular weight heparin
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Surgical Management of Osteoarthritis of the Knee CPG
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After knee replacement surgery, the use of continuous local anesthetic infusions in femoral and sciatic peripheral nerve catheters is an effective analgesic option. Limited data are available concerning the safety of peripheral nerve infusions in patients receiving low molecular weight heparin thromboprophylaxis. We report three cases of bleeding at femoral and sciatic catheter sites in patients receiving a single daily dose of enoxaparin (40 mg). In all cases, some bleeding was noticed before catheter removal; in one case involving catheter removal 3 h after enoxaparin administration, massive thigh swelling occurred. Physical therapy and discharge from the hospital were delayed in two cases but no other complications were seen. More data are needed to determine if it is necessary to use the same guidelines for managing peripheral nerve infusion catheters in patients receiving enoxaparin as with epidurals and other types of central nerve catheter infusions
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The incidence of proximal femoral fractures in an English county
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Management of Hip Fractures in the Elderly
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We have studied the incidence of fractures of the proximal femur in one English county from 1968 to 1991. Numbers have increased steadily, but the age-specific incidence has remained relatively unchanged since 1981. The increase is due to the rise in the population most at risk; this is likely to continue causing a 20% increase in demand for treatment by the year 2000. Suitable allocation of resources must be planned
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Outcomes of non-arthroplasty surgical treatment of proximal humeral head fractures
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Pediatric Supracondylar Humerus Fracture 2020 Review
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OBJECTIVE: This study aimed to assess the outcomes of patients with humeral head fractures treated by reduction and osteosynthesis. METHOD: A total of 53 shoulders (52 patients) with humeral head fractures were operated between October 1996 and December 2009. Patients previously treated with primary arthroplasty and/or those who had less than two years follow-up were excluded. A total of 34 shoulders of 34 patients were therefore reassessed. In the sample studied, 23 patients were male and mean age was 47 years. Cases were assessed based on the UCLA score. RESULTS: Mean post-operative follow-up was 50 months. Twelve patients evolved with excellent outcome, seven good, five regular, and ten with poor outcome (55.8% satisfactory and 44.2% unsatisfactory outcomes). Mean UCLA score was 26 points. Mean post-operative range of motion measurements was 117° elevation, 36° LR and L1 MR. At the immediate post-operative radiography, anatomic reduction was evident in 17 patients (50%). Necrosis was detected in 18 patients, six Grade II and 12 Grade III cases. Female gender and anatomically reduced fractures were statistically better at UCLA scale (p = 0.01 and p = 0.0001 respectively). CONCLUSIONS: Female patients had a higher mean UCLA score than male patients (p = 0.01). Anatomically reduced fractures had higher UCLA scores (p = 0.0001) and lower necrosis rate (p = 0.0001). Reconstruction of humeral head fractures had a satisfactory outcome in 55.8% of cases and should be indicated in young and active patients.
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Effacement of the fat in the proximal carpal tunnel on MR imaging: A useful indirect indicator of carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Objective: The objective of this study is to determine the diagnostic usefulness of the effacement of fat in the proximal carpal tunnel in patients with and without carpal tunnel syndrome (CTS). The current literature evaluates several MRI features of CTS that are based on median nerve signal and morphology characteristics. However, the usefulness of MRI evidence of fat pad effacement as an indirect sign of CTS has not been described. Materials and Methods: Institutional review board approval was obtained for this HIPAA-compliant study. Informed consent was waived. The case group consisted of cases of median neuropathy at the wrist diagnosed on MRI examinations from the previous 2 years and proven with electromyography (EMG), which was considered the reference standard. The control group consisted of a series of consecutive subjects with wrist MRIs performed for other reasons than CTS. A history of prior surgery or trauma was an exclusion criterion for both groups. The presence of fat pad was evaluated on axial T1-weighted or non-fat-suppressed proton density-weighted images dorsal to the tendons of flexor digitorum profundus and ventral to the carpal bones at the level of the pisotriquetral joint in the proximal carpal tunnel. One musculoskeletal fellowship-trained radiologist and one radiology resident, both blinded to the clinical findings, evaluated the images independently. Sensitivity, specificity, and interobserver variability was calculated. Results: From the 16 cases of median neuropathy at the wrist proven with EMG, two were excluded due to history of prior carpal tunnel release and one case was excluded due to trauma. Finally, the case group consisted of 13 cases (female:male, 12:1; median (plus or minus) interquartile range [IQR], 49 (plus or minus) 37 years) and the control group consisted of 16 cases (female:male, 9/7; median (plus or minus) IQR, 49 (plus or minus) 35 years). All studies were done using 1.5- and 3-T magnets. Effacement of the fat in CTS was found in 100% (13/13) cases and in 44% (7/16) of control subjects, resulting in sensitivity, specificity, and accuracy of 100%, 56%, and 76%, respectively. There was an excellent agreement between the two readers ((kappa) = 0.86). Conclusion: The previously undescribed sign of effacement of the fat in the proximal carpal tunnel is a valuable indicator for median neuropathy. Apart from morphologic characteristics of the median nerve and T2 signal abnormality, this sign should also be reported or taken into account while suggesting a diagnosis of CTS
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Natural history and treatment outcomes of childhood hip disorders
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Developmental Dysplasia of the Hip CPG
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Normal hip joint growth and development occur as a result of a genetically determined balance of growth of the acetabular and triradiate cartilages and the presence of a well located centered spheric femoral head. The majority of acetabular development is determined by age 8 years. This is a watershed age for prognosis in many pediatric hip disorders. Hip joint growth and development and how these are affected by the disease process and treatment interventions profoundly affect outcome. Outcomes of these disease processes (congenital hip dislocation and dysplasia, Legg-Calve-Perthes disease and slipped capital femoral epiphysis), is multifactorial but profoundly influenced by the age at the disease onset (birth to the adolescent growth spurt), and the effects of treatment on the relationship between femoral head and acetabular development. The natural history of many of these childhood hip disorders is the development of degenerative joint disease. Degenerative joint disease and clinical disability may develop in these conditions despite standard up to date treatment interventions. In most of the hip diseases discussed, patients usually do well clinically for many years regardless of treatment
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Relationship between femoral component rotation and total knee flexion gap balance on modified axial radiographs
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Surgical Management of Osteoarthritis of the Knee CPG
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Using modified axial radiographs, we investigated the relationship between femoral component rotation and flexion gap balance in 70 consecutive knees with varus osteoarthritis 1 year after they underwent cruciate-ligament-retaining total knee arthroplasty with the measured resection technique. We measured (1) the condylar twist angle, defined as the angle between the posterior condylar axis and the clinical epicondylar axis, and (2) the liftoff angle (LOA), defined as the angle between the posterior condylar axis and the tibial cutting surface. There was a significant positive correlation between the postoperative condylar twist angle (mean, 2.6 degrees ) and the postoperative LOA (mean, 1.8 degrees ). Our data suggest that a more accurate method of identifying the clinical epicondylar axis would lead to a smaller LOA as measured on modified axial radiographs
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False primary osteoarthritis
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Glenohumeral Joint OA
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In most cases, osteoarthritis is â??primitiveâ? favored by several risk factors (age, sex, obesity, trauma). However, unusual localization of osteoarthritis (ankle, wrist, shoulderâ?¦), atypical patient characteristic (young subject in particular) or the severity of osteoarthritis can lead us to continue the investigations in search of a uncommon etiology. Indeed, osteoarthritis can be associated with microcrystal disease, linked to a metabolic disease or endocrine pathology. Osteoarthritis can also be endemic affecting a population living in the same territory and related to the environment or genetic, associated with a dysmorphic phenotype of variable severity. In these cases, osteoarthritis can be severe, affects young subjects and frequently leads to significant functional limitation.
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Surgical management of gynecomastia - A 10-year analysis
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Reduction Mammoplasty for Female Breast Hypertrophy
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Background: Gynecomastia is defined as the benign enlargement of the male breast. Most studies on surgical treatment of gynecomastia show only small series and lack histopathology results. The aim of this study was to analyze the surgical approach in the treatment of gynecomastia and the related outcome over a 10-year period. Patients and methods: All patients undergoing surgical gynecomastia corrections in our department between 1996 and 2006 were included for retrospective evaluation. The data were analyzed for etiology, stage of gynecomastia, surgical technique, complications, risk factors, and histological results. Results: A total of 100 patients with 160 operations were included. Techniques included subcutaneous mastectomy alone or with additional hand-assisted liposuction, isolated liposuction, and formal breast reduction. Atypical histological findings were found in 3% of the patients (spindle-cell hemangioendothelioma, papilloma). The surgical revision rate among all patients was 7%. Body mass index and a weight of the resected specimen higher than 40 g were identified as significant risk factors for complications (p < 0.05). Conclusions: The treatment of gynecomastia requires an individualized approach. Caution must be taken in performing large resections, which are associated with increased complication rates. Histological tissue analysis should be routinely performed in all true gynecomastia corrections, because histological results may reveal atypical cellular pathology. © 2007 Société Internationale de Chirurgie.
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Full-mouth therapy versus individual quadrant root planning: a critical commentary
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND: This commentary compares the abilities of full-mouth disinfection (FDIS), full-mouth root planing (FRP), and partial-mouth disinfection (PDIS) to improve periodontal health. FDIS consists of 4 quadrants of root planing completed within 24 hours with adjunctive chlorhexidine therapies (e.g., rinsing, subgingival irrigation, tongue brushing). FRP denotes 4 quadrants of root planing performed within 24 hours, and PDIS refers to root planing individual quadrants of the dentition, spaced 2 weeks apart. A basic premise of administering full-mouth therapy (FDIS or FRP) is to eliminate or reduce bacterial reservoirs within the oral cavity that could inhibit optimal healing of treated sites or cause periodontal disease initiation or progression. METHODS: Controlled clinical trials that compared the abilities of PDIS and full-mouth root planing with and without adjunctive chlorhexidine chemotherapy to alter periodontal status were reviewed. RESULTS: Several studies conducted at one treatment center indicated that FDIS and FRP attained greater therapeutic improvements than PDIS with respect to decreasing probing depths (PD), gaining clinical attachment (CAL), diminishing bleeding upon probing, and reducing the subgingival microflora. However, the magnitude of PD reductions and gains of clinical attachment must be carefully interpreted, because initial PD measurements were usually determined after scaling and root planing, which may have caused the results to be overstated. Furthermore, in studies that addressed the utility of FDIS, it was not possible to determine if benefits induced beyond PDIS were due to FRP or administration of multifaceted intraoral chlorhexidine treatments ora combination of both therapies. One investigation that had protocol limitations indicated that similar results were attained by FRP with and without adjunctive chemotherapy. In contrast, recent studies from 2 other treatment centers indicated that there were no significant differences when the efficacy of quadrant-by-quadrant root planing was compared to FRP or FDIS with regard to PD reduction, gains of clinical attachment, and impact on the magnitude and quality of the immune response. POSSIBLE CLINICAL IMPLICATIONS: Conceptually, full-mouth therapy (FRP or FDIS) could reduce the number of patient visits and facilitate more efficient use of treatment time. In addition, there appears to be no major adverse reactions to full-mouth root planing with or without adjunctive chemotherapy. However, small study populations and non-corroborating data from different treatment centers indicate that additional randomized clinical trials are needed to determine if full-mouth therapy provides clinically relevant improvements beyond PDIS
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A prospective study of factors affecting recovery from musculoskeletal injuries
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DoD PRF (Psychosocial RF)
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PURPOSE: Research suggests the importance of psychosocial factors in recovery from musculoskeletal injuries. The objective of this study was to identify predictors of recovery among U.S. Marines who had musculoskeletal injuries of the back, knee, or shoulder.
METHODS: A sample of 134 participants was assessed at baseline and followed for 1 year to determine outcome information.
RESULTS: The strongest predictor of injury recovery at the 1-year follow-up was recovery expectations. In a multivariate logistic model with key demographic and psychosocial factors controlled, individuals who had high recovery expectations at baseline were over five times as likely to be recovered at follow-up as individuals who had low expectations (OR = 5.18, p\.01).
CONCLUSIONS: This finding is consistent with a large body of research that has linked recovery expectations with better recovery outcomes in patients with musculoskeletal injuries as well as with research linking recovery expectations with better outcomes across a wide range of medical conditions.Applied to military populations, interventions designed to modify recovery expectations may have the potential to improve rates of return to duty and to reduce rates of disability discharge.
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Cervical hip fractures do not occur in arthrotic joints: A clinicoradiographic study of 256 patients
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Hip Fx in the Elderly 2019
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We studied endogenic factors for the occurrence of cervical hip fractures in 256 patients. 230 underwent hemiarthroplasty, and 26 were treated with internal fixation or without surgery. The condition of the fractured hip and of the ipsilateral knee, as well as the mobility of the patient before the fracture, were studied in all 256 patients. The removed femoral heads were examined, photographed and radiographs were taken with sensitive film. The acetabulum and the femoral head were macroscopically normal in all 230 cases and there was no radiographic evidence of arthrosis. 64% of the patients were fully mobile before the fracture, 34% were mobile with the aid of a cane and 2% were dependent. In 88%, the ipsilateral knee was normal both clinically and radiographically, and in 12%, there was moderate arthrosis. When comparing the mobility before the fracture and the condition of the ipsilateral hip and knee in 100 patients having a cervical fracture with 100 patients having a trochanteric fracture matched for age and sex, we found that a normal hip joint was sine qua non while a normal ipsilateral knee and a fully mobile individual were important additional conditions for the occurrence of a cervical hip fracture, instead of a trochanteric one, after a fall in an elderly person.
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Altered cortical microarchitecture in patients with monoclonal gammopathy of undetermined significance
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Distal Radius Fractures
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Patients with monoclonal gammopathy of undetermined significance (MGUS) are at increased fracture risk, and we have previously shown that MGUS patients have altered trabecular bone microarchitecture compared with controls. However, there are no data on whether the porosity of cortical bone, which may play a greater role in bone strength and the occurrence of fractures, is increased in MGUS. Thus, we studied cortical porosity and bone strength (apparent modulus) using high-resolution peripheral quantitative computed tomography imaging of the distal radius in 50 MGUS patients and 100 age-, gender-, and body mass index-matched controls. Compared with controls, MGUS patients had both significantly higher cortical porosity (+16.8%; P < .05) and lower apparent modulus (-8.9%; P < .05). Despite their larger radial bone size, MGUS patients have significantly increased cortical bone porosity and reduced bone strength relative to controls. This increased cortical porosity may explain the increased fracture risk seen in MGUS patients.
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The prognostic analysis of different metastatic patterns in extensive-stage small-cell lung cancer patients: A large population-based study
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MSTS 2022 - Metastatic Disease of the Humerus
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Aim: To analyze the metastasis patterns and prognosis differences for extensive-stage small-cell lung cancer patients. Methods: Log-rank tests were used to calculate and compare survival estimates. Cox regression analyses were used to evaluate the prognosis factors. Results: The liver was the most common metastatic site, and lung was the least common. In two metastatic sites, liver and bone metastases were the most common combination of sites. An isolated liver metastasis had the worst overall survival (OS) and cancer-specific survival (CSS) among metastatic sites (both p < 0.001). Liver and lung metastases were associated with worse CSS (p < 0.039) and OS (p < 0.015). However, for patients with three metastatic sites showed no statistical differences in their CSS and OS (all, p > 0.05). Conclusion: Extensive-stage small-cell lung cancer patients with metastasis to the liver alone or in combination with other organs appear to have worse outcomes.
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Factors associated with stair climbing ability in patients with knee osteoarthritis and knee arthroplasty: a systematic review
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Surgical Management of Osteoarthritis of the Knee CPG
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Abstract Purpose: People with knee osteoarthritis (OA) report ongoing limitations in climbing stairs, even after total knee arthroplasty (TKA). The aim of this systematic review was to synthesise the available evidence of factors affecting stair climbing ability in patients with knee OA before and after TKA. Method: A systematic search was conducted of common electronic databases. All English language abstracts where stair-climbing was assessed in patients with either knee OA or at least 6 months after TKA, and a relationship to any physical, psychological or demographic factors was reported. Results: Thirteen studies were included in the final review, nine investigated a knee OA population, and four investigated a TKA population. For patients with knee OA there was consistent and convincing evidence that greater stair-climbing ability was related to stronger lower limb muscles and less knee pain. For patients with TKA there was much less research, and no conclusions could be reached. Conclusions: For people with knee OA there is evidence that some physical, demographic and psychosocial factors are related to stair-climbing ability. However, the evidence for similar relationships in the TKA population is scarce and needs more extensive research. Implications for Rehabilitation People with knee osteoarthritis experience difficulty when climbing stairs, and this remains challenging even after knee replacement. For people with knee osteoarthritis, a range of physical, demographic and psychosocial factors contribute to stair-climbing ability, however, evidence for similar relationships in the TKA population is scarce. Rehabilitation that is multi-faceted may be the best approach to improve stair-climbing in people with knee osteoarthritis
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Predictors of long-term survival after hip fractures?-5-year results of a prospective study in Germany
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Hip Fx in the Elderly 2019
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The incidence of hip fractures is increasing due to demographic transition. Data on long-term survival and influencing factors are sparse. Our prospective observational study with 395 patients shows a survival of 38% after 5 years. Significant risk factors were male gender, higher age, lower Barthel Index, lower Charlson Comorbidity Score, lower Mini-Mental State Examination, and delirium during hospitalization.
PURPOSE: The incidence of hip fractures is increasing due to demographic transition. Until now, they are associated with poor results and high mortality rates. Data on long-term survival and influencing factors are sparse. Therefore, a prospective observational study was conducted.
METHODS: Patients >= 60 years with hip fracture were included in this prospective study between 2009 and 2011. Demographic parameters, as well as ASA Score, pre-fracture Barthel Index and EQ-5D, Mini-Mental State Examination, Charlson Comorbidity Score, fracture type, type of surgical treatment, place of discharge, and arising complications were registered. Outcome parameter was survival during a 5-year follow-up period.
RESULTS: A total of 539 patients attended to our emergency room during the period of recruitment. The recruitment rate was 75%. A total of 402 patients were included; 7 were lost to follow-up, and 152 (38%) survived the study period. The mortality was more than 25% in the first year after fracture. Subsequently, it was between 7 and 9% per year. In the multivariate analysis, significant risk factors for dying were male gender (p = 0.002), higher age (p < 0.001), lower Charlson Comorbidity Score (p = 0.033), lower Barthel Index (p = 0.024), lower Mini-Mental State Examination (p = 0.002), and occurrence of delirium during hospitalization (p = 0.008).
CONCLUSION: Our results confirm poor results of geriatric patients after hip fracture. While early results might be influenced by optimal fracture care, long-term results seem to be determined by not changeable patient factors. Nevertheless, more than one third of surviving patients after 5 years justify the elaborate treatment algorithms for these fragile patients.
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1 |
Psychometric assessment of patients with chronic upper extremity pain attributed to workplace exposure
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DoD PRF (Psychosocial RF)
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Upper extremity pain attributed to workplace exposure is a growing concern in medicine today. This study was undertaken to investigate the psychological findings in patients with chronic upper extremity pain attributed to workplace exposure. Sixty-three consecutive patients were evaluated. All patients underwent a history and physical examination by a hand surgeon and a psychological evaluation by a licensed psychologist, including a Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Physical and psychological findings were then compared. Forty-one patients (65%) showed abnormalities on MMPI-2 examination (tscore > 70 = 97% confidence). This result is far above what generally would be expected in medical patients. When physical findings were grouped with psychological findings, 5 distinct groups were identified: 1 patient had normal physical and psychological results, 6 patients had normal physical findings but abnormal psychological assessments, 21 patients had abnormal physical findings but normal psychological assessments, 28 patients had both abnormal physical and psychological findings, and 7 patients had abnormal physical results but invalid MMPI-2 evaluations due to purposeful attempts to deny psychological symptoms. Identification of these groups may have diagnostic, prognostic, and treatment value. In addition, identification of these groups may help clarify several aspects of the debate over the role of psychosocial factors in the development and maintenance of chronic upper extremity pain that patients attribute to workplace exposure.
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Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: A randomized clinical trail
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Objective: To compare the efficacy of conservative medical care with chiropractic care in the treatment of carpal tunnel syndrome. Design: Two- group, randomized, single-blind trial with 9 wk of treatment and a 1-month follow-up interview. Setting: Wolfe-Harris Center for Clinical Studies at Northwestern College of Chiropractic in Bloomington, Minnesota. Patients: Ninety-one of 96 eligible subjects who reported symptoms that were confirmed by clinical exam and nerve conduction studies. Interventions: Interventions included ibuprofen (800 mg 3 times a day for 1 wk, 800 mg twice a day for 1 wk and 800 mg as needed to a maximum daily dose of 2400 mg for 7 wk) and nocturnal wrist supports for medical treatment. Chiropractic treatment included manipulation of the soft tissues and bony joints of the upper extremities and spine (three treatments/week for 2 wk, two treatments/week for 3 wk and one treatment/week for 4 wk), ultrasound over the carpal tunnel and nocturnal wrist supports. Main Outcome Measures: Outcome measures were pre- and postassessments of self-reported physical and mental distress, nerve conduction studies and vibrometry. Results: There was significant improvement in perceived comfort and function, nerve conduction and finger sensation overall, but no significant differences between groups in the efficacy of either treatment. Conclusions: Carpal tunnel syndrome associated with median nerve demyelination but not axonal degeneration may be treated with commonly used components of conservative medical or chiropractic care
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Outcomes of Joint Preservation Procedures for Cartilage Injuries in the Hip: A Systematic Review and Meta-analysis
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Osteochondritis Dissecans 2020 Review
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BACKGROUND: The detection and management of chondral injuries of the hip, especially in a younger patient population, may preempt joint degeneration. Although the outcomes of preservation techniques have been well described for other weightbearing joints, such as the knee, evidence for hip joint preservation after procedures such as microfracture and autologous chondrocyte implantation remains in its infancy. PURPOSE: To evaluate outcomes of joint preservation procedures in the hip, including the success rate and patient-reported outcomes (PROs). STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: This review was performed using the terms "hip arthroscopy," "microfracture," "autologous chondrocyte implantation," "fibrin glue," "osteochondral transfer," and variations thereof in 5 electronic databases, yielding 325 abstracts. After the application of eligibility criteria, 19 articles were included. Weighted means were calculated for PROs, and pooled estimates were calculated for age, follow-up, chondral lesion size, and success of hip preservation procedures with a random-effects proportion meta-analysis. RESULTS: A total of 1484 patients (1502 hips) were identified across 19 studies (mean age, 38.0 ± 1.3 years; mean follow-up, 31.8 ± 9.6 months). Hip joint preservation techniques demonstrated a high success rate, ranging from 85.6% to 99.7%. The mean pooled chondral lesion size was 2.5 ± 0.3 cm(2) (95% CI, 1.9-3.0 cm(2)). Microfracture was the most frequent technique, utilized by 11 studies, and demonstrated an 89.6% success rate (95% CI, 82.4%-96.7%). The highest pooled success rate was exhibited by autologous membrane-induced chondrogenesis in 3 studies (99.7% [95% CI, 99.0%-100.0%]). All PROs demonstrated a statistically significant increase postoperatively, including the modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score-Activities of Daily Living and Hip Outcome Score-Sports-Specific Subscale (all P < .05). The visual analog scale for pain also demonstrated a statistically significant decrease of 37.2% (P < .05). CONCLUSION: Hip preservation procedures demonstrate a high success rate, with microfracture representing the most frequently utilized cartilage preservation technique in the peer-reviewed literature. PROs significantly improved after surgery. Further investigation of hip preservation modalities with long-term follow-up is required to create evidence-based clinical recommendations and treatment algorithms.
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Ultrasound evaluation of carpal tunnel syndrom in primary hypothyroidism
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background A bilateral carpal tunnel syndrome (CTS) is relatively commonly connected to hypothyroidism and presents in 5 to 10% of hypothyroid patients. Ultrasound imaging is a method of choice in early recognition of dynamic changes of median nerve in subclinical stages of CTS. Objectives Monitoring of ultrasound detectable changes of median nerve in transverse section level of carpal tunnel in patients with autoimmune hypothyroidisms. Methods A cross sectional comparative study on patients with autoimunne hypothyroidism, where transverse section breadth of median nerve in its entrance to carpal tunnel (Cross Sectional Area, CSA) was measured. CSA values over 0,098cm2 were considered abnormal according to American Journal of Roentgenology. Values were compared with the control group of healthy subjects based on gender and BMI. Difference between groups were statistically evaluated by unpaired T-test. Results Totally of 38 patients (mean age 64,68 yrs, 10 males/28 females, mean BMI 25,37 kg/m2, mean TSH 6,23 mU/l, fT4 15,28 pmol/l) were included in the study. The control group consists of 24 subjects (mean age 48,54 yrs, 13 males/11 females, BMI 25,00 kg/m2, mean TSH 1,54 mU/l, mean fT4 15,58 pmol/l). CSA was significantly higher in patients (mean 0.088 cm2) in comparison with controls (mean 0.071 cm2, p=0,002). In 3 hypothyroid patients pathological increase of CSA (mean 0,1 3cm2,7.8%) were presenting symptomatology. Conclusions Ultrasound findings have documented occurrence of subclinical and clinical CTS in patients with primary hypothyroidism. If CTS occurs, the thyroidal status should be evaluated to exclude possible hypothyroidism. Ultrasound examination of CSA enables the treatment effect monitoring in soft tissue structures in carpal tunnel area and it is an appropriate method for a long term evaluation of hypothyroid patients with this complication
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1 |
Distal radius malunion increases risk of persistent disability 2 years after fracture: a prospective cohort study
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Distal Radius Fractures
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BACKGROUND: Studies concerning the relationship between distal radius fracture malunion and a persistent arm-related disability have produced conflicting results.
QUESTIONS/PURPOSES: We investigated (1) how arm-related disability changes during the first 2 years after a fracture and (2) whether fracture malunion causes persistent disability.
METHODS: One hundred twenty-three patients with distal radius fractures, treated with closed reduction and casts or external or percutaneous pin fixations, completed the DASH questionnaire at baseline, 3 months, 6 months, 1 year, and 2 years after fracture. Radiographic measurements were made at 1 year. Using a definition of malunion as ulnar variance of 1 mm or more and dorsal tilt greater than 10degree, the patients were classified into three groups: no malunion (n = 35), malunion involving either ulnar variance or dorsal tilt (n = 65), and malunion involving ulnar variance and dorsal tilt (n = 23). The changes in the DASH scores with time (baseline to 2 years), in relation to malunion, were analyzed using generalized estimating equations adjusted for age, sex, fracture type (extraarticular or intraarticular), and treatment method.
RESULTS: The mean change in DASH scores from baseline to 2 years was worse for patients with malunions involving ulnar variance and dorsal tilt than for patients with no malunions (mean difference, 13; 95% CI, 1.4-25) and for patients with malunions involving either ulnar variance or dorsal tilt (mean difference, 13; 95% CI, 2.2-24).
CONCLUSION: After distal radius fracture, arm-related disabilities are more likely to persist at least 2 years in patients with fractures that healed with shortening and dorsal angulation than in patients with only shortening or dorsal angulation or without malunion.
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Elbow fracture in children at saiful anwar general hospital, nine years experiences
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Pediatric Supracondylar Humerus Fracture 2020 Review
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AIM: The frequency, incidence, and types of fracture of the elbow are different between children and adult. The epidemiology of elbow fracture in children has been the subject of a limited number of studies. This study aims to observe the pattern of elbow fractures in children 18 years of age and younger, during a nine years period. METHODS: This is a retrospective study about elbow fracture cases in children 18 years old and younger treated in Saiful Anwar General Hospital Malang in the period of June 2009 until December 2018. The data obtained from the medical record include the age at the time of accidents, fracture site, type of lesion and ipsilateral injuries, time of accidents, and the mechanism of injury. RESULTS: There is a total of 99 elbow fracture, and there are 62 male (63%) and 37 female patients (37%). The mean age for the entire group is 7.3 years (8.1 years for male and 7.1 years for female). Most cases are supracondylar fracture (n = 77, 78%). The supracondylar fracture is composed of 17 fracture classified to type II, and 60 fracture to type III as classified by Gartland. The most common etiology of fracture is associated with sports, recreational activities, and fall from height of less than two meters. Nerve injury involving the median, radial, and ulnar nerve is seen in eight patients with type III supracondylar fracture. Associated brachial artery injury is seen in four patients with type III supracondylar fractures. A group of 78 patients (79%) were treated surgically and 21 patients (21%) were treated conservatively. CONCLUSION: The incidence of elbow fracture in children treated in Saiful Anwar General Hospital during a nine years period is 99 patients, with supracondylar fracture Gartland type III being the leading type of this group. Male patients are more common than female patients. Nerve injury was seen in 13.33% of cases and brachial artery injury was seen 6.67% with type III supracondylar fracture. Most of the elbow fracture in our institution were treated operatively.
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Carpal tunnel pressure alters median nerve function in a dose-dependent manner: A rabbit model for carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background: An in vivo animal model for carpal tunnel syndrome (CTS) is presented which allows for graded application of pressure to the median nerve within the carpal canal. We hypothesized that such pressure would cause electrophysiologic changes in the median nerve in a dose-related manner, with NCS/EMG changes consistent with CTS in humans. Methods: In 40 New Zealand white rabbits, ranging from 2 to 2.5 kg, angioplasty catheters were placed in the carpal tunnel in the forepaws and pressures ranging from 50 to 80 mm Hg applied to one side while the contralateral side served as the control and remained uninflated. Pressure was applied until a 15% increase in distal motor latency was obtained for 2 consecutive weeks by nerve conduction studies. Results: All the experimental limbs exhibited a 15% increase in distal motor latency. None of the control limbs showed a significant increase in distal motor latency. In the experimental animals the 15% delay was achieved in approximately 4-5 weeks in the 50-70 mm Hg groups and in approximately 1 week in the 80 mm Hg group. Conclusion: This new animal model for CTS demonstrates a direct cause and effect relationship between carpal tunnel pressure and median nerve dysfunction. We anticipate that this in vivo model with clinically relevant outcomes will facilitate identification of injury mechanisms, and will serve as a basis for future development of novel interventions and treatments. (copyright) 2004 Orthopaedic Research Society. Published by Elsevier Ltd. All rights reserved
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0 |
Drawing on Israel's Experience Organizing Volunteers to Operationalize Drive-Through Coronavirus Testing Centers
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Coronavirus Disease 2019 (COVID-19)
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To increase the country's capacity to test and track suspected coronavirus disease 2019 (COVID-19) cases, Israel launched drive-through testing centers in key cities, including Tel Aviv, Jerusalem, Be'er Sheva, and Haifa. This article examines the challenges that the national emergency medical services and volunteers faced in the process of implementing drive-through testing centers to offer lessons learned and direction to health-care professionals in other countries.
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Risk factors for cervical and trochanteric hip fractures in elderly women: A population-based 10-year follow-up study
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DoD PRF (Psychosocial RF)
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We evaluated the contribution of lifestyle-related factors, calcaneal ultrasound, and radial bone mineral density (BMD) to cervical and trochanteric hip fractures in elderly women in a 10-year population-based cohort study. The study population consisted of 1,681 women (age range 70-73 years). Seventy-two percent (n = 1,222) of them participated in the baseline measurements. Calcaneal ultrasound was assessed with a quantitative ultrasound device. BMD measurements were performed at the distal and ultradistal radius by dual-energy X-ray absorptiometry. Forward stepwise logistic regression analysis was used to find the most predictive variables for hip fracture risk. During the follow-up, 53 of the women had hip fractures, including 32 cervical and 21 trochanteric ones. The fractured women were taller and thinner and had lower calcaneal ultrasound values than those without fractures. High body mass index (BMI) was a protective factor against any hip fractures, while low functional mobility was a risk factor of hip fractures. Specifically, high BMI protected against cervical hip fractures, while low physical activity was a significant predictor of these fractures. Similarly, high BMI protected against trochanteric fractures, whereas low functional mobility and high coffee consumption were significant predictors of trochanteric fractures. Cervical and trochanteric hip fractures seem to have different risk factors. Therefore, fracture type should be taken into account in clinical fracture risk assessment and preventative efforts, including patient counseling. However, the study is not conclusive due to the limited number of observed fractures during follow-up, and the results have to be confirmed in future studies. © 2010 Springer Science+Business Media, LLC.
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Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVES: Our aim was to clarify the distribution of hip pain in patients with osteoarthritis of the hip secondary to developmental dysplasia of the hip (DDH). METHODS: We retrospectively studied 443 hips in 369 patients with osteoarthritis secondary to DDH; mean age was 61 years, and follow-up rate was 84 %. Hip pain was defined as preoperative pain that was relieved 3 months after total hip arthroplasty. RESULTS: Distribution of pain originating in the hip was 89 % (393 hips) to the groin, 38 % (170 hips) to the buttock, 33 % (144 hips) to the anterior thigh, 29 % (130 hips) to the knee, 27 % (118 hips) to the greater trochanter, 17 % (76 hips) to the low back, and 8 % (34 hips) to the lower leg. When the groin, buttock, and greater trochanter were combined as the hip region, 95 % (421 hips) of pain was located in the hip region. On the other hand, when the anterior thigh, knee, lower leg, and low back were combined as the referral region, 55 % (242 hips) showed referred pain. CONCLUSIONS: We suggest that rheumatologists be aware of hip disease masquerading as knee pain or low back pain
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High rate of infection control with one-stage revision of septic knee prostheses excluding MRSA and MRSE
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PJI DX Updated Search
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BACKGROUND: The rate of infection control for one-stage revision of infected knee arthroplasties is unclear as are the factors influencing infection control. Such factors include duration of infection and the type of infected prosthesis. QUESTIONS/PURPOSES: We therefore determined: (1) the rate of infection control with one-stage revision of septic knee prostheses, (2) the clinical knee scores that can be achieved, (3) whether the duration of infection or the type of prosthesis influence the level of infection control, and (4) whether different types of prostheses influence the knee scores. METHODS: We retrospectively reviewed prospectively collected data from 63 patients who underwent one-stage revisions of septic knee endoprostheses (six unicondylar, 37 primary total knee replacement prostheses, and 20 hinged knee endoprostheses) between 2004 and 2006. All were treated locally and systemically with microorganism-specific antibiotics. For this study we excluded patients with Methicillin-resistant Staphylococcus aureus and Methicillin-resistant Staphylococcus epidermidis or unknown microorganisms. The patients were examined for infection every 3 months and Oxford and Knee Society scores were assessed at the same time. The minimum followup was 24 months (mean followup, 36 months; range, 24-70 months). RESULTS: None of the patients with replacement unicondylar and primary total knee replacement prostheses had recurrence of infection. Three of the 20 patients with the hinged infected knee prostheses had recurrences; these three patients had chronic infections and had undergone two to three revision operations during at least a 5-year period. The likelihood of infection control was influenced by the duration of infection. The mean Knee Society knee score 24 months after surgery was 72 points (range, 20-98 points), the Knee Society function score was 71 points (range, 10-100 points), and the Oxford-12 knee score was 27 points (range, 13-44 points). CONCLUSIONS: One-stage revision of septic knee prostheses achieved an infection control rate of 95% and higher knee scores than reported for two-stage revisions. Higher rates of recurrent infection appeared to be associated with long-term chronic infections of hinged prostheses
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1 |
Medial femoral condyle width and osteochondritis dissecans: cause or effect and the implications for osteochondral allograft transplantation
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Osteochondritis Dissecans 2020 Review
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Introduction: Anecdotally, patients with osteochondritis dissecans (OCD) have larger medial femoral condyles widths (MFCW), making it difficult finding size-matched orthotopic condyles for osteochondral allograft transplantation. Objectives: (1) measure MFCW and tibial plateaus width (TPW) using magnetic resonance imaging (MRI) in patients with OCD of the MFC and (2) compare MFCWs and MFCW/TPW of patients with OCD to age and sex-matched controls. Methods: We identified 111 patients with OCD of the MFC that had MRIs available for review. 115 age-matched patients that had MRIs for conditions that did not include medial compartment pathology served as controls. MFCW and TPW were measured on MRIs; MFCW/TPW ratio was calculated. Patients were assigned to 4 groups based on age. A student t test statistic was used to compare MFCW and MFCW/TPW between the 4 groups as well as to the age and sex matched controls. Results: The 111 OCD patients (70 males, mean age: 25.7) had a mean MFCW of 29.3 mm. The 115 control patients (74 men, mean age: 25.6) had a mean MFCW of 24.8 mm. Men with OCD had wider MFCs compared to women (P < .001). For both the OCD and control populations, there was no statistical significance between MFCW and age. Overall, when controlling for age and sex, OCD patients had larger MFCWs than controls (P < .001). Conclusions: Uniform widening of the MFC in OCD patients lends evidence that a wider MFC might be causal in the development of OCD.
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Predicting knee cartilage loss using adaptive partitioning of cartilage thickness maps
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OAK 3 - Non-arthroplasty tx of OAK
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This study investigates whether measures of knee cartilage thickness can predict future loss of knee cartilage. A slow and a rapid progressor group was determined using longitudinal data, and anatomically aligned cartilage thickness maps were extracted from MRI at baseline. A novel machine learning framework was then trained using these maps. Compared to measures of mean cartilage plate thickness, group separation was increased by focusing on local cartilage differences. This result is central for clinical trials where inclusion of rapid progressors may help reduce the period needed to study effects of new disease-modifying drugs for osteoarthritis. © 2013 Elsevier Ltd.
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Antibiotic-loaded cement articulating spacer for 2-stage reimplantation in infected total knee arthroplasty: a simple and economic method
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Surgical Management of Osteoarthritis of the Knee CPG
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We presented a simple and economic method of preparing articulating antibiotic-loaded cement spacers for treatment of infection after total knee arthroplasty. From 1996 to 2004, 28 infected total knee arthroplasties were treated with 2-stage reimplantation. Static spacers were used in 7 knees, and articulating spacers were used in 21 knees. A minimum of 2 years' follow-up after final treatment was evaluated. In the static group, 1 (14%) knee had recurrence of infection. In the articulating group, 2 (9%) knees had recurrence of infection with the original organism. Patients receiving articulating spacer had better range of motion, better knee score, and less bone loss than patients with static spacer
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General versus spinal anaesthesia in proximal femoral fracture surgery - treatment outcomes
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Hip Fx in the Elderly 2019
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BACKGROUND: Proximal femoral fractures are a major public health problem because of the increasing proportion of elderly individuals in the general population. The mode of choice for anaesthesia in surgical treatment of these fractures is still debated in terms of better postoperative outcome. The aim of our study was to compare the effect of general over spinal anaesthesia on mortality in proximal femoral fracture surgery.
PATIENTS AND METHODS: This study was a retrospective analysis of 115 patients aged at least 70 years who underwent surgery for proximal femoral fracture. The survey was conducted from 1 January to 31 December 2015 at the General Hospital Karlovac, Croatia. Patients were divided into two groups: group 1 - general anaesthesia and group 2 - spinal anaesthesia. The primary outcome measure was the effect of mode of anaesthesia, general versus spinal, on mortality within 30 days, six months and one year after surgery.
RESULTS: General anaesthesia (EndoTracheal Anaesthesia) was administered in 77 patients (67%; group I - ETA) and spinal anaesthesia in 38 patients (33%; group 2 - SPIN). Both groups had more female than male patients: 69 patients (89.6%) in the ETA group and 32 patients (84.2%) in the SPIN group were female. The mean age in the ETA group was 82.91 years and in the SPIN group was 80.18 years. ASA II status was more common in patients in the SPIN group (25 patients [65.8%]). The average time from hospitalisation to surgery was 53.44 hours in the ETA group and 53.33 hours in the SPIN group. There was no significant difference between groups in the number of comorbidities, or intraoperative and postoperative complications. There was no statistically significant difference in mortality between the groups. Mortality after surgery in the ETA and SPIN groups, respectively, was as follows: 10.4% and 10.5% at 30 days, 23.4% and 15.8% at six months, and 32.5% and 31.6% at one year.
CONCLUSION: The results indicate that the mode of anaesthesia (general vs spinal) has no effect on postoperative mortality, and that the mode of anaesthesia should be applied on an individual basis in correlation with associated comorbidities.
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A progressive exercise and structured advice program does not improve activity more than structured advice alone following a distal radial fracture: a multi-centre, randomised trial
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Distal Radius Fractures
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QUESTION: Does a program of exercise and structured advice implemented during the rehabilitation phase following a distal radial fracture achieve better recovery of upper limb activity than structured advice alone?
DESIGN: A phase I/II, multi-centre, randomised, controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis.
PARTICIPANTS: Thirty-three adults (25 female, mean age 54 years) following distal radial fracture managed in a cast.
INTERVENTION: The experimental intervention was a 6-week program of progressive exercise and structured advice implemented over three consultations by a physiotherapist. The control intervention was a program of structured advice only, delivered by a physiotherapist over three consultations.
OUTCOME MEASURES: The primary outcome was upper limb activity limitations, assessed by the Patient-Rated Wrist Evaluation and the shortened version of the Disabilities of the Arm, Shoulder and Hand outcome measure (QuickDASH). The secondary outcomes were wrist range of movement, grip strength and pain. All measures were completed at baseline (week 0), after the intervention (week 7) and at 6 months (week 24).
RESULTS: There were no significant between-group differences in upper limb activity as measured by the Patient-Rated Wrist Evaluation at week 7 and week 24 assessments (mean difference -4 units, 95% CI -10 to 2; mean difference 0 units, 95% CI -3 to 3, respectively), or QuickDASH at week 7 and week 24 assessments (mean difference -5 units, 95% CI -16 to 6; mean difference 0.3 units, 95% CI -6 to 7, respectively). The secondary outcomes did not demonstrate any significant between-group effects.
CONCLUSION: The prescription of exercise in addition to a structured advice program over three physiotherapy consultations may convey no extra benefit following distal radial fracture managed in a cast.
TRIAL REGISTRATION: ACTRN12612000118808. [Bruder AM, Shields N, Dodd KJ, Hau R, Taylor NF (2016) A progressive exercise and structured advice program does not improve activity more than structured advice alone following a distal radial fracture: a multi-centre, randomised trial.Journal of Physiotherapy62: 145-152].
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Computer-aided Design of Distal Femoral Osteotomy for the Valgus Knee and Effect of Correction Angle on Joint Loading by Finite Element Analysis
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: Lateral open-wedge distal femoral osteotomy (DFO) has been used to treat valgus deformity of the knee, with good clinical outcomes. However, there is a lack of biomechanical studies regarding the angle of correction. The objective of this study was to apply computer-aided design (CAD) for osteotomy planning in a three-dimensional (3D) anatomical model and to assess the biomechanical differences among the varying correction angles on joint loading by finite element analysis (FEA).
METHODS: To model different angles of lateral open-wedge DFO correction, the CAD software package Mimics 21.0 was used to accurately simulate the operated knee. The femur was cut to 0degree, 2degree, 4degree, 6degree, 8degree, and 10degree of varus (equivalent to hip-knee-ankle angles of 180degree, 178degree, 176degree, 174degree, 172degree, and 170degree, respectively). The original knee model and the corrected models were processed by FE software. Then, the FE models were subjected to an axial force to obtain the von Mises stress (VMS) and shear stress distributions within the femoral cartilages and menisci.
RESULTS: Under a compressive load of 740 N, the highest VMS in lateral and medial compartments of the intact knee model was 3.418 and 3.303 MPa. The maximum value of both the VMS and the shear stress in the lateral compartment decreased as the varus angle increased, but the corresponding values in the medial compartment increased. When the hip-knee-ankle (HKA) angle was 180degree, the VMS in the lateral and medial compartments was balanced (3.418 and 3.303 MPa, respectively). Meanwhile, when the HKA angle was 178degree (3.488 and 3.625 MPa, respectively), the shear stress in the lateral and medial compartments was balanced. In addition, the magnitude of change in the stress was significantly higher in the medial compartment (90.9%) than in the lateral compartment (19.3%).
CONCLUSION: The optimal correction angle of the valgus knee is close to neutral alignment or slightly varus (0degree - 2degree). Overcorrection is not recommended, as it can result in a steep increase of the stress within the medial compartment and may accelerate the process of medial compartment OA.
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Stories That Heal: Understanding the Effects of Creating Digital Stories With Pediatric and Adolescent/Young Adult Oncology Patients
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DoD PRF (Psychosocial RF)
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The purpose of this philosophical hermeneutic study was to determine if, and understand how, digital stories might be effective therapeutic tools to use with children and adolescents/young adults (AYA) with cancer, thus helping mitigate suffering. Sixteen participants made digital stories with the help of a research assistant trained in digital storytelling and were interviewed following the completion of their stories. Findings from this research revealed that digital stories were a way to have others understand their experiences of cancer, allowed for further healing from their sometimes traumatic experiences, had unexpected therapeutic effects, and were a way to reconcile past experiences with current life. Digital stories, we conclude, show great promise with the pediatric and AYA oncology community and we believe are a way in which the psychosocial effects of cancer treatment may be addressed. Recommendations for incorporating digital stories into clinical practice and follow-up programs are offered.
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1 |
Topical NSAIDs for chronic musculoskeletal pain in adults
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Use of topical nonsteroidal anti-inflammatory drugs (NSAIDs) to treat chronic musculoskeletal conditions has become widely accepted because they can provide pain relief without associated systemic adverse events. This review is an update of 'Topical NSAIDs for chronic musculoskeletal pain in adults', originally published in Issue 9, 2012.
OBJECTIVES: To review the evidence from randomised, double-blind, controlled trials on the efficacy and safety of topically applied NSAIDs for chronic musculoskeletal pain in adults.
SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and our own in-house database; the date of the last search was February 2016. We also searched the references lists of included studies and reviews, and sought unpublished studies by asking personal contacts and searching online clinical trial registers and manufacturers' web sites.
SELECTION CRITERIA: We included randomised, double-blind, active or inert carrier (placebo) controlled trials in which treatments were administered to adults with chronic musculoskeletal pain of moderate or severe intensity. Studies had to meet stringent quality criteria and there had to be at least 10 participants in each treatment arm, with application of treatment at least once daily.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion and extracted data. We used numbers of participants achieving each outcome to calculate risk ratio and numbers needed to treat (NNT) or harm (NNH) compared to carrier or other active treatment. We were particularly interested to compare different formulations (gel, cream, plaster) of individual NSAIDs. The primary outcome was 'clinical success', defined as at least a 50% reduction in pain, or an equivalent measure such as a 'very good' or 'excellent' global assessment of treatment, or 'none' or 'slight' pain on rest or movement, measured on a categorical scale.
MAIN RESULTS: We identified five new studies for this update, which now has information from 10,631 participants in 39 studies, a 38% increase in participants from the earlier review; 33 studies compared a topical NSAID with carrier. All studies examined topical NSAIDs for treatment of osteoarthritis, and for pooled analyses studies were generally of moderate or high methodological quality, although we considered some at risk of bias from short duration and small size.In studies lasting 6 to 12 weeks, topical diclofenac and topical ketoprofen were significantly more effective than carrier for reducing pain; about 60% of participants had much reduced pain. With topical diclofenac, the NNT for clinical success in six trials (2343 participants) was 9.8 (95% confidence interval (CI) 7.1 to 16) (moderate quality evidence). With topical ketoprofen, the NNT for clinical success in four trials (2573 participants) was 6.9 (5.4 to 9.3) (moderate quality evidence). There was too little information for analysis of other individual topical NSAIDs compared with carrier. Few trials compared a topical NSAID to an oral NSAID, but overall they showed similar efficacy (low quality evidence). These efficacy results were almost completely derived from people with knee osteoarthritis.There was an increase in local adverse events (mostly mild skin reactions) with topical diclofenac compared with carrier or oral NSAIDs, but no increase with topical ketoprofen (moderate quality evidence). Reporting of systemic adverse events (such as gastrointestinal upsets) was poor, but where reported there was no difference between topical NSAID and carrier (very low quality evidence). Serious adverse events were infrequent and not different between topical NSAID and carrier (very low quality evidence).Clinical success with carrier occurred commonly - in around half the participants in studies lasting 6 to 12 weeks. Both direct and indirect comparison of clinical success with oral placebo indicates that response rates with carrier (topical placebo) are about twice those seen with oral placebo.A substantial amount of data from completed, unpublished studies was unavailable (up to 6000 participants). To the best of our knowledge, much of this probably relates to formulations that have never been marketed.
AUTHORS' CONCLUSIONS: Topical diclofenac and topical ketoprofen can provide good levels of pain relief beyond carrier in osteoarthritis for a minority of people, but there is no evidence for other chronic painful conditions. There is emerging evidence that at least some of the substantial placebo effects seen in longer duration studies derive from effects imparted by the NSAID carrier itself, and that NSAIDs add to that.
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Postoperative pain control by intra-articular local anesthesia versus femoral nerve block following total knee arthroplasty: impact on discharge
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AAHKS (8) Anesthetic Infiltration
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INTRODUCTION: The goal of this retrospective study was to compare pain control following total knee arthroplasty (TKA) on a perioperative protocol of local anesthesia (LA) versus the more classical femoral nerve block (FNB) technique.
HYPOTHESIS: Fitness for discharge would be achieved earlier using the LA protocol.
MATERIALS: Ninety-eight consecutive TKA patients operated on by a single surgeon were included with no selection criteria. In the study group (49 patients), 200 mL ropivacaine 5% was injected into the surgical wound and an intra-articular catheter was fitted to provide continuous infusion of 20 mL/h ropivacaine for 24h. The control group (49 patients) received ropivacaine FNB. Discharge fitness (independent walking, knee flexion>90degree, quadricipital control, pain on VAS<=3) and hospital stay were assessed.
RESULTS: Discharge fitness was achieved significantly earlier in the study group (4.2+/-2.6 versus 6.7+/-3.2 days; P=0.0003), with significantly shorter mean hospital stay (6.1+/-3.4 versus 8.8+/-3.5 days; P=0.0002). The complications rate did not differ between study and control groups.
DISCUSSION: Although retrospective, this study indicates that the LA protocol improves management of post-TKA pain and accelerates rehabilitation, thereby, reducing hospital stay. The acceleration effect may be due to the absence of quadriceps inhibition.
LEVEL OF EVIDENCE: Level III - Case control study.
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0 |
The exstrophy-epispadias complex: is aesthetic appearance important?
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Panniculectomy & Abdominoplasty CPG
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OBJECTIVE: To show the relevance of cosmetic appearance in the adequate treatment of patients with exstrophy-epispadias complex (EEC), and to indicate that surgery by experienced teams can improve the long-term treatment forecast and the patient's body image. PATIENTS AND METHODS: From 1978 to 2002, 71 patients diagnosed with EEC were treated in the authors' institution; 24 (aged 2-23 years) were selected to undergo different surgical procedures. The criterion for surgery considered interviews conducted by the psychology team with the parents and children. The plastic surgery and paediatric urology teams carried out the procedures jointly; the follow-up was 0.33-7 years. RESULTS: Five female patients and six male had abdominoplasty to treat multiple scars; eight had intermittent catheterization conduits repositioned from the right iliac fossa to the umbilicus. Six female patients had plastic surgery of the external genitalia and three had a broad mobilization of the urogenital sinus. Thirteen male patients had a small penis and had the corpora cavernosa fully mobilized and the penis reconstructed. Five female patients and one male had anterior osteotomy. One patient with no left testis had it replaced and one patient with uterine prolapse had the uterus fixed to the posterior abdominal wall. Six patients had a second procedure, in two because the outcome of the initial operation was poor and in the others to complement the initial treatment. In all but one patient there was an improvement in the objective criteria, e.g. school absences, difficulty in establishing long-lasting social relationships and refusal to participate in sports activities. However, none of the patients would attempt sexual intercourse. CONCLUSIONS: Body image, self-esteem, sexuality, sexual function and fertility are deemed crucial by adolescents; in patients with EEC customised surgical procedures can give a satisfactory aesthetic outcome, and be a further reason for adequately following occasional urinary complications and renal function, to avoid loss to follow-up.
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Evaluation of patient-specific acetabular jig for cup placement in total hip arthroplasty
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Developmental Dysplasia of the Hip 2020 Review
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Introduction: Acetabular cup placement holds a significant importance in longevity of the total hip prosthesis and hence is an important modifiable factor determining complication rates. Aseptic loosening and hip dislocation are two most important complication related to faulty cup placement, which by standard method is largely dependent upon eyeballing and surgeonâ??s judgement. We intend to evaluate a selfâ?designed, lowâ?cost, patientâ?specific acetabular jig to guide cup placement in total hip arthroplasty. Methods: It was a prospective randomized control study. 36 patients were categorized in to groupâ?A & groupâ? B through computerised randomisation. In groupâ?A, CT based preâ?operative templating was done using mimics and 3â?matics software and a virtually designed acetabular jig was printed using 3D printer and used intraâ?operatively to guide cup placement. In groupâ?B, standard method of cup placement was used. Angle of inclination and anteversion were calculated on postâ?operative xâ?rays and compared between two groups along with blood loss, surgical duration, acetabular offset and hip length. Results: In groupâ?A, angle of inclination and anteversion were in centre of range of safe zone in which hip is maximally stable with more precision in creating hip centre as compared to groupâ?B without any significant increase in surgical time or blood loss. Conclusion: Virtual preâ?operative templating and cup placement using virtually designed, patient specific acetabular jig decrease chances of malpositioning of cup and recreates hip centre close to anatomical one preventing any limb length discrepancies especially in cases where anatomy has been distorted like bony ankylosis and developmental dysplasia of hip.
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Sexual Functioning, Desire, and Satisfaction in Women with TBI and Healthy Controls
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DoD PRF (Psychosocial RF)
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Traumatic brain injury (TBI) can substantially alter many areas of a person's life and there has been little research published regarding sexual functioning in women with TBI. Methods. A total of 58 women (29 with TBI and 29 healthy controls) from Neiva, Colombia, participated. There were no statistically significant differences between groups in sociodemographic characteristics. All 58 women completed the Sexual Quality of Life Questionnaire (SQoL), Female Sexual Functioning Index (FSFI), Sexual Desire Inventory (SDI), and the Sexual Satisfaction Index (ISS). Results. Women with TBI scored statistically significantly lower on the SQoL (p < 0.001), FSFI subscales of desire (p < 0.05), arousal (p < 0.05), lubrication (p < 0.05), orgasm (p < 0.05), and satisfaction (p < 0.05), and the ISS (p < 0.001) than healthy controls. Multiple linear regressions revealed that age was negatively associated with some sexuality measures, while months since the TBI incident were positively associated with these variables. Conclusion. These results disclose that women with TBI do not fare as well as controls in these measures of sexual functioning and were less sexually satisfied. Future research is required to further understand the impact of TBI on sexual function and satisfaction to inform for rehabilitation programs.
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Home-going: prognostic factors concerning the major goal in treatment of elderly hip fracture-patients
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Management of Hip Fractures in the Elderly
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Two hundred and forty-one hip fracture patients over 70 years of age still living at home at the moment of the accident were followed prospectively until three months postoperatively. The patients were admitted to the department over a five year period (1978-1983). One hundred and forty-four patients returned home. In order to predict whether an elderly hip fracture patient will be able to return home within three months, the following prognostic factors will have to be taken into account: pre-operative functional status (p = 0.0001), ambulatory capacity at discharge (p = 0.0001), age (p = 0.001), presence of relatives at home to return to (p = 0.02) and general medical postoperative complications (p = 0.0006). In this respect it was noted that sex, fracture type or mechanical complication with possible operation do not significantly influence the home-going rate within three months after surgery (p greater than 0.05)
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Treatment of Die-Punch Fractures with 3D Printing Technology
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Distal Radius Fractures
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Purpose: We evaluated the feasibility, accuracy and effectiveness of applying three-dimensional (3D) printing technology for preoperative planning for die-punch fractures. Methods: A total of 107 patients who underwent die-punch fracture surgery were enrolled in the study. They were randomly divided into two groups: 52 cases in the 3D model group and 55 cases in the routine group. A 3D digital model of each die-punch fracture was reconstructed in the 3D group. The 3D digital model was imported to a 3D printer to build the full solid model. The operation time, blood loss volume, and the number of intraoperative fluoroscopy were recorded. Follow-up was performed to evaluate the patients' surgical outcomes. Results: Treatment of die-punch fractures using the 3D printing approach reduced the number of intraoperative fluoroscopy, blood loss volume, and operation time, but did not improve wrist function compared to those in the routine group. The patients wanted the doctor to use the 3D model to introduce the condition and operative plan because it was easier for them to understand. The orthopedic surgeons thought that the 3D model was useful for communicating with their patients, but their satisfaction with the preoperative plan was much lower than the benefit of using the 3D model to communicate with their patients. Conclusions: 3D printing technology produced more accurate morphometric information for orthopedists to provide personalized surgical planning and communicate better with their patients. However, it is difficult to use widely in the department of orthopedics.
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An uncommon cause of cemented unicompartmental knee arthroplasty failure: Fracture of metallic components
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OAK 3 - Non-arthroplasty tx of OAK
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Purpose: Despite good overall clinical results, unicompartmental knee replacements (UKR) are not without their problems and failures have been reported. The most common causes of UKR failure are component loosening, poor patient selection, poor surgical technique, polyethylene wear and progression of arthritis in other compartments. The purpose of this study is to present a series of atraumatic fractures of metallic components in a UKR treated in a single orthopaedic centre. Method: Since 1999, 121 failed unicompartmental knee arthroplasties have been referred to our centre. In six of these, atraumatic breakage of a metal component in the cemented UKR was seen and included in this study. Pre-operative alignment, BMI and implant longevity were documented. The femoral implant failed in 4 patients and the tibial implant in a further 2. Results: All the femoral implant fractures occurred within 3 years of UKR surgery (mean: 22.2 months, SD: 10.6 months). Tibial implant breakage occurred at a mean of 8.5 years (SD: 2.4 months) following UKR. All patients were treated with conversion to a navigated total knee replacement. A primary total knee arthroplasty was used in all cases with one patient requiring a tibial component incorporating a wedge and stem following breakage of the original UKR tibial implant. Conclusion: Fracture of the metallic components is a potential cause of failure of unicompartmental knee arthroplasty. In our experience, the incidence of this complication was 4.9 % of all UKR failures. Patients with a BMI greater than 30 and a progressive deterioration in limb alignment were at greater risk. Level of evidence: IV. © 2012 Springer-Verlag.
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Age of first exposure to tackle football and chronic traumatic encephalopathy
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DoD PRF (Psychosocial RF)
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Objective: To examine the effect of age of first exposure to tackle football on chronic traumatic encephalopathy (CTE) pathological severity and age of neurobehavioral symptom onset in tackle football players with neuropathologically confirmed CTE. Methods: The sample included 246 tackle football players who donated their brains for neuropathological examination. Two hundred eleven were diagnosed with CTE (126 of 211 were without comorbid neurodegenerative diseases), and 35 were without CTE. Informant interviews ascertained age of first exposure and age of cognitive and behavioral/mood symptom onset. Results: Analyses accounted for decade and duration of play. Age of exposure was not associated with CTE pathological severity, or Alzheimer's disease or Lewy body pathology. In the 211 participants with CTE, every 1 year younger participants began to play tackle football predicted earlier reported cognitive symptom onset by 2.44 years (p < 0.0001) and behavioral/mood symptoms by 2.50 years (p < 0.0001). Age of exposure before 12 predicted earlier cognitive (p < 0.0001) and behavioral/mood (p < 0.0001) symptom onset by 13.39 and 13.28 years, respectively. In participants with dementia, younger age of exposure corresponded to earlier functional impairment onset. Similar effects were observed in the 126 CTE-only participants. Effect sizes were comparable in participants without CTE. Interpretation: In this sample of deceased tackle football players, younger age of exposure to tackle football was not associated with CTE pathological severity, but predicted earlier neurobehavioral symptom onset. Youth exposure to tackle football may reduce resiliency to late-life neuropathology. These findings may not generalize to the broader tackle football population, and informant-report may have affected the accuracy of the estimated effects. Ann Neurol 2018;83:886â??901.
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Graft choice in the management of unstable scaphoid nonunion: A systematic review
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SR for PM on OA of All Extremities
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Purpose To systematically compare outcomes between corticocancellous (CC) and cancellous-only (C-only) bone grafts for unstable scaphoid nonunions. Methods The English-language literature was searched using PubMed, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library with the following keywords: scaphoid, nonunion, malunion, unstable, collapse, humpback, dorsal intercalated segment instability, and deformity. Studies whose patient populations were characterized as possessing unstable scaphoid nonunion and/or collapse deformity or who met radiological definitions of such deformity were included. The union rate, interval to union, clinical assessments, strength, range of motion, correction of deformity, pain, and return to activity were analyzed. Results Twenty-three studies published between the beginning of 1987 and the end of 2013 met the eligibility criteria and contained 604 patients. The union rate was statistically equivalent for C-only (95%) and CC grafts (92%). However, the frequency-weighted mean interval to union was significantly shorter for C-only (11 wk) than for CC grafts (16 wk). CC grafts were associated with a significantly higher frequency-weighted mean Mayo wrist score (86) than C-only grafts (80), whereas C-only grafting provided significantly greater improvement of wrist flexion. Of the 3 measures of carpal geometry analyzed, CC grafts significantly improved the scapholunate and radiolunate angles more than C-only grafts. Conclusions Based on retrospective data from uncontrolled studies, C-only grafts provide the shortest interval to union for unstable scaphoid nonunions. CC grafts are associated with consistent deformity correction and superior Mayo wrist scores. Type of study/level of evidence Therapeutic IV. (copyright) 2014 ASSH . Published by Elsevier, Inc. All rights reserved
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Tibial tubercle fractures in adolescents: A review of the literature
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DOD - Acute Comp Syndrome CPG
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Treatment of tibial tubercle fractures in adolescents produce good clinical and radiographic results, regardless of the type of fracture. There is a tendency of fractures with intraarticular involvement or a posterior metaphyseal component to have high complication rates and associated injuries, which may warrant advanced imaging or arthroscopic evaluation. Complications appear to be more common than expected but without a significant effect on final outcome.
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Efficacy of steroid addition to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis
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AAHKS (2) Corticosteroids
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BACKGROUND: Total knee arthroplasty (TKA) has been reported to be the most successful treatment for patients with advanced osteoarthritis, however, early postoperative pain has become an unresolved issue. The aim of this Meta-analysis is to evaluate the efficacy and safety of steroid addition to multimodal cocktail periarticular injection (MCPI) in patients undergoing TKA.
METHOD: Clinical randomized controlled trials concerning the efficacy and safety of MCPI containing steroids in TKA published up to December 2014 were retrieved from PubMed, Cochrane library, EMbase databases. The methodological quality of the included studies was assessed by the 12-item scale. Data analysis was performed using StataSE12.0.
RESULTS: Six randomized controlled trials involving a total of 567 patients were assessed; the steroid group included 305 patients, and the control group included 262 patients. The meta-analysis showed that MCPI with steroids in TKA significantly reduced postoperative pain; duration of time required to perform straight-leg raising and length of hospital stay was (P < 0.05). Neither the early postoperative nor the long-term range of motion of knee showed any statistical difference between the non-steroid and steroid group (P >0.05). For safety, steroids did not increase the incidence of postoperative infection and wound oozing (P >0.05); no tendon rupture was reported up to now. In addition, steroids did not decrease the postoperative drainage through the reduction of prostaglandins (P >0.05).
CONCLUSION: For patients undergoing TKA, the addition of steroids to MCPI improved the analgesic effect and was proved to be highly safe. The duration of time required to perform straight-leg raising and length of hospital stay was significantly reduced. However, MCPI with steroids neither increased the early postoperative range of motion (ROM) or the long-term ROM of knee, nor did it reduce the postoperative drainage. However, the best results are acquired in patients without any altered immunological status.
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Sexually dimorphic tibia shape is linked to natural osteoarthritis in STR/Ort mice
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: Human osteoarthritis (OA) is detected only at late stages. Male STR/Ort mice develop knee OA spontaneously with known longitudinal trajectory, offering scope to identify OA predisposing factors. We exploit the lack of overt OA in female STR/Ort and in both sexes of parental, control CBA mice to explore whether early divergence in tibial bone mass or shape are linked to emergent OA.
METHOD: We undertook detailed micro-CT comparisons of trabecular and cortical bone, multiple structural/architectural parameters and finite element modelling (FEM) of the tibia from male and female STR/Ort and CBA mice at 8-10 (pre-OA), 18-20 (OA onset) and 40 + weeks (advanced OA) of age.
RESULTS: We found higher trabecular bone mass in female STR/Ort than in either OA-prone male STR/Ort or non-prone CBA mice. Cortical bone, as expected, showed greater cross-sectional area in male than female CBA, which surprisingly was reversed in STR/Ort mice. STR/Ort also exhibited higher cortical bone mass than CBA mice. Our analyses revealed similar tibial ellipticity, yet greater predicted resistance to torsion in male than female CBA mice. In contrast, male STR/Ort exhibited greater ellipticity than both female STR/Ort and CBA mice at specific cortical sites. Longitudinal analysis revealed greater tibia curvature and shape deviations in male STR/Ort mice that coincided with onset and were more pronounced in late OA.
CONCLUSION: Generalised higher bone mass in STR/Ort mice is more marked in non OA-prone females, but pre-OA divergence in bone shape is restricted to male STR/Ort mice in which OA develops spontaneously.
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Two-stage reimplantation in infected total knee arthroplasty
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DoD SSI (Surgical Site Infections)
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Twenty-one infected total knee arthroplasties (TKA) in 21 patients were treated from September 1980 through October 1987. Of these, 15 were followed for more than one year. Treatment of these patients consisted of thorough debridement of all infected tissue and components; a cement spacer was used in ten patients. The cement was impregnated with antibiotics. This procedure was followed for an average of 4.2 weeks with intravenous antibiotics and TKA utilizing antibiotic-impregnated cement. Five patients had rheumatoid arthritis and ten had osteoarthritis. The organisms included Staphylococcus coagulase negative (seven patients), Streptococcus group B (two patients), Streptococcus bovis (one patient), Enterococcus (one patient), Staphylococcus coagulase positive and Bacillus circulans (one patient), Staphylococcus coagulase negative and Enterococcus (one patient), Staphylococcus coagulase negative and Pseudomonas aeruginosa (one patient), and Clostridium perfringens (one patient). Of the 15 patients, 12 appeared to be free of infection, two were obvious failures and required knee fusion, and one was suspected of having continued infection at five years and was treated elsewhere. Eleven patients with revision TKA were available for follow-up examinations at an average of 2.9 years (range, one to six years). One patient died five years after reimplantation but had been functioning well. One patient functioning at three years postreimplantation did not return for a later follow-up examination. The average knee score (modification of the Hospital for Special Surgery Knee Score) was 75.5 points (range, 48-94); average flexion was (81° (range, 52°-120°), and average extension was +6° (range, 0°-30°). Roentgenograms were highly suspicious for loosening in one patient with suspected chronic infection. Complications included deep venous thrombosis in four patients, high probability of pulmonary embolus in two patients, superficial wound dehiscence in three patients, greater than six days of serous or hematoma drainage in four patients, and an intraoperative medial femoral condyle fracture in one patient. Two-stage TKA had an overall success rate of 80% and a 90% success rate (not statistically significant) when an antibiotic cement spacer was used.
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Characteristics and psychosocial needs of victims of violent crime identified at a public-sector hospital: data from a large clinical trial
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DoD PRF (Psychosocial RF)
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OBJECTIVE: This study explores the feasibility of recruiting acutely injured public-sector crime victims into a research protocol and identifies baseline characteristics associated with posttraumatic distress in the enrolled sample (N=541).
METHOD: Assertive research tracking methods were used to enroll participants, who completed baseline interviews. Descriptive statistics were used to define characteristics of the sample and prevalence of psychosocial problems and posttraumatic distress. Multiple regression analysis was performed to identify predictors of posttraumatic distress.
RESULTS: A high percentage (78%) of eligible victims completed baseline interviews within 1 month of victimization. The sample was largely male, ethnic minority, unemployed and living below the poverty level. Trauma symptoms were highly prevalent, with three quarters having significant posttraumatic distress. Female gender, preexisting psychiatric disorder, trauma history, case management needs and employment status were predictive of greater symptomatology. Stabbing victims had lower distress.
CONCLUSIONS: Comprehensive mental health and case management services that proactively engage disadvantaged victims are needed to meet the complex problems of this population.
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Carpal tunnel syndrome in renal dialysis patientsCARPALTUNNELSYNDROM BEI DIALYSEPATIENTEN
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Report on the carpal tunnel syndrome in chronically dialysed patients with terminal renal insufficiency. The frequency among the surgical patients (9 patients out of 191 from January 1981 until October 1983), the operation method and the postoperative results are presented. The origin of nerve compression is discussed from a personal point of view as well as according to bibliographical data. The preferred treatment is the surgical splitting of the transversal carpal ligament, because the operation results are good and complications did not occur
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Study of Intra-articular DLX105 Applied to Patients With Severely Painful Osteoarthritis of the Knee
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OAK 3 - Non-arthroplasty tx of OAK
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Treatment options for patients suffering from osteoarthritis remain limited. TNFâ?alpha has been identified as a major proâ?inflammatory component inducing and perpetuating peripheral hyperalgesia and cartilage degeneration in various preclinical studies. DLX105 is an antibody fragment of comparably low molecular weight, associated with an exceptional local biodistribution pattern upon intraâ?articular injection. In addition, due to its short systemic half life as compared to conventional monoclonal antibodies, systemic exposure to DLX105 upon intraâ?articular administration is low. This study is designed to determine the safety and local tolerability profile of single intraâ?articular injections of ESBA105 as well as to define DLX105's effect size and effect duration in reducing pain of patients suffering from severely painful osteoarthritis of the knee. The study will be conducted in two sequential parts. In a first part, 4 different doses of DLX105 will be compared in a sequential, escalating scheme against placebo treatment in a total of 24 patients. In the second part of the study, two doses of DLX105 chosen based on safety data from the first part will be compared to placebo treatment in a total of 102 patients.
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Non-HACEK gram-negative bacillus endocarditis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND: Infective endocarditis caused by non-HACEK (species other than Haemophilus species, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kingella species) gram-negative bacilli is rare, is poorly characterized, and is commonly considered to be primarily a disease of injection drug users. OBJECTIVE: To describe the clinical characteristics and outcomes of patients with non-HACEK gram-negative bacillus endocarditis in a large, international, contemporary cohort of patients. DESIGN: Observations from the International Collaboration on Infective Endocarditis Prospective Cohort Study (ICE-PCS) database. SETTING: 61 hospitals in 28 countries. PATIENTS: Hospitalized patients with definite endocarditis. MEASUREMENTS: Characteristics of non-HACEK gram-negative bacillus endocarditis cases were described and compared with those due to other pathogens. RESULTS: Among the 2761 case-patients with definite endocarditis enrolled in ICE-PCS, 49 (1.8%) had endocarditis (20 native valve, 29 prosthetic valve or device) due to non-HACEK, gram-negative bacilli. Escherichia coli (14 patients [29%]) and Pseudomonas aeruginosa (11 patients [22%]) were the most common pathogens. Most patients (57%) with non-HACEK gram-negative bacillus endocarditis had health care-associated infection, whereas injection drug use was rare (4%). Implanted endovascular devices were frequently associated with non-HACEK gram-negative bacillus endocarditis compared with other causes of endocarditis (29% vs. 11%; P < 0.001). The in-hospital mortality rate of patients with endocarditis due to non-HACEK gram-negative bacilli was high (24%) despite high rates of cardiac surgery (51%). LIMITATIONS: Because of the small number of patients with non-HACEK gram-negative bacillus endocarditis in each treatment group and the lack of long-term follow-up, strong treatment recommendations are difficult to make. CONCLUSION: In this large, prospective, multinational cohort, more than one half of all cases of non-HACEK gram-negative bacillus endocarditis were associated with health care contact. Non-HACEK gram-negative bacillus endocarditis is not primarily a disease of injection drug users
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Anterior Cruciate Ligament Reconstruction and Lateral Plasty in High-Risk Young Adolescents: Revisions, Subjective Evaluation, and the Role of Surgical Timing on Meniscal Preservation
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AMP (Acute Meniscal Pathology)
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BACKGROUND: In adolescents, the rate of meniscal injury at the time of anterior cruciate ligament (ACL) reconstruction, the rate of ACL graft revision, and clinical outcomes has not yet been investigated.
HYPOTHESIS: In patients younger than 16 years, the rate of meniscal injuries at the time of ACL reconstruction increases with time from injury. The mid-term revision rate and reoperation rate after ACL reconstruction with hamstrings and lateral tenodesis are lower than those reported in literature for isolate ACL reconstruction.
STUDY DESIGN: Case series.
LEVEL OF EVIDENCE: Level 4.
METHODS: Patients younger than 16 years who underwent ACL reconstruction with hamstring and lateral tenodesis, with a follow-up >=2 years were included. The number of meniscal lesions was stratified according to the delay between injury-to-surgery (<3, 3-12, >12 months). All reoperations, Lysholm score, Knee Injury and Osteoarthritis Outcome Score subscales for pain (at rest and during activity), and return to sport were collected.
RESULTS: A total of 151 patients (mean age 14.8 +/- 1.2 years) were included. Patients undergoing surgery at <3 months after injury had a lower meniscal injury rate (36%) than those treated at 3 to 12 months (55%) and >12 months (63%) after injury (P = 0.04). Medial meniscal lesions were more likely to be repaired when surgery was performed <3 months after injury (91%). Subjective follow-up data were available for 132 patients, and 19 were lost to follow-up. At 6.0 +/- 2.6 years, 6% of patients underwent ACL revision; 1 of 20 (5%) patients with posterior tibial slope >=12degree and 4 of 45 (9%) patients with Tegner level >=8. Nine new meniscal procedures were performed; 19% of repaired menisci underwent meniscectomy. Good or excellent Lysholm score was reported by 88% of patients; 56% of patients with concurrent lateral meniscectomy had pain during activity, 91% returned to sport, and 79% were still participating at final follow-up.
CONCLUSION: Patients younger than 16 years undergoing ACL reconstruction within 3 months from injury had the lowest rate of meniscal injuries. ACL reconstruction with lateral tenodesis had low revision rate (6%) and good or excellent clinical outcomes in 88% of young adolescents.
CLINICAL RELEVANCE: Sport physicians should be aware that adolescent patients undergoing ACL reconstruction within 3 months after injury have the lowest rate of meniscal injuries; the mid-term revision rate of ACL reconstruction with lateral plasty is lower than 10% and the patients' perceived outcomes are good with almost all patients returning to sport activity.
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Does ramosetron reduce postoperative emesis and pain after TKA?
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AAHKS (4) Acetaminophen
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Background Current pain management protocols involving many anesthetic and analgesic drugs reportedly provide adequate analgesia after TKA. However, control of emetic events associated with the drugs used in current multimodal pain management remains challenging. Questions/purposes We determined (1) whether ramosetron prophylaxis reduces postoperative emetic events; and (2) whether it influences pain levels and opioid consumption in patients managed with a current multimodal pain management protocol after TKA. Methods We randomized 119 patients undergoing TKA to receive either ramosetron (experimental group, n = 60) or no prophylaxis (control group, n = 59). All patients received regional anesthesia, preemptive analgesic medication, continuous femoral nerve block, periarticular injection, and fentanyl-based intravenous patient-controlled analgesia. We recorded the incidence of emetic events, rescue antiemetic requirements, complete response, pain level, and opioid consumption during three periods (0-6, 6-24, and 24-48 hours postoperatively). The severity of nausea was evaluated using a 0 to 10 VAS. Results The ramosetron group tended to have a lower incidence of nausea with a higher complete response and tended to have less severe nausea and fewer rescue antiemetic requirements during the 6- to 24-hour period. However, the overall incidences of emetic events, rescue antiemetic requirements, and complete response were similar in both groups. We found no differences in pain level or opioid consumption between the two groups. Conclusions Ramosetron reduced postoperative emetic events only during the 6- to 24-hour postoperative period and did not affect pain relief. More efficient measures to reduce emetic events after TKA should be explored. © The Association of Bone and Joint Surgeons® 2012.
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Erratum: Survivorship Analysis and Clinical Outcomes of Transtibial Pullout Repair for Medial Meniscus Posterior Root Tears: A 5- to 10-Year Follow-up Study (Arthroscopy: The Journal of Arthroscopic and Related Surgery (2018) 34(2) (530–535), (S0749806317310939) (10.1016/j.arthro.2017.08.266))
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AMP (Acute Meniscal Pathology)
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In the article “Survivorship Analysis and Clinical Outcomes of Transtibial Pullout Repair for Medial Meniscus Posterior Root Tears: A 5- to 10-Year Follow-up Study,” published in the February 2018 issue (Arthroscopy 2018;34:530-535), one of the study characteristics was reported incorrectly in Table 1. The table incorrectly showed the number of males included in the study as 76 and the number of females as 15. The correct number of males was 15 and the correct number of females was 76. The author would like to apologize for any inconvenience caused. The amended table is presented below. [Table presented]
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Secondary surgery following brachial plexus injuries
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The favourable treatment of post-traumatic brachial plexus lesions based on our experience of 362 cases over a 12 year period is reported. Twenty- five percent of the patients needed secondary operations. The spectrum of the latter consisted of arthrodesis, tenodesis, and musculotendinous transfer, including free neurovascular tissue transfer partially innervated by nerve transposition. Functionally, secondary tendon transfer can help to improve the effect of nerve repair techniques. To restore shoulder function the trapezius transfer (n = 22) has been used mainly; elbow flexion has been regained by pedicled latissimus dorsi translocation (n = 22), triceps-to- biceps transfer (n = 18), bipolar latissimus muscle transfer, and free neurovascular tissue transfer (n = 8). The Steindler flexorplasty was performed in four plexopathies, and finally a pedicled serratus muscle transfer was used. A unipolar latissimus dorsi transfer results in an ability to lift 10-15 kg, whilst the bipolar latiSsimus transfer and the triceps-to- biceps transfer produced a maximal strength of 5-8 kg. Epitrochlear flexor- pronator mass transfer produced a strength of 2-5 kg, whereas free neurovascular latissimus dorsi transfer developed a maximal muscular strength of 2-4 kg in the unipolar variation and 1-2 kg for the bipolar LD. In 97 secondary procedures to the lower arm and hand the following secondary operations were indicated: in 29 cases of radial nerve palsy transfers according to Merle d'Aubigne, a further 21 wrist tenodeses and 8 wrist arthrodeses were performed. To restore median nerve function, coupling tendon transfer (n = 4) and free neurovascular gracilis transfer (n = 3) were selected. Ulnar nerve palsy was corrected by seven Zancolli procedures. To improve rotation, two pronation plasties were applied. For dynamic opponensplasty the superficial flexor of the ring finger was the primary choice (n = 8). Static fusions between the first and second metacarpal bones served as a static opponensplasty of the thumb ray. Motor-driven orthoses should be reserved for boosting any voluntary muscle contraction or for frustrating cases in which restoration of useful pinch with the previously described surgical procedures is impossible. Improving the function of the formerly paralysed upper extremity in patients with a brachial plexus injury results in a greater independence in everyday activities and a superior psychological status
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0 |
Proximal Tibiofibular Joint: An overview
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OAK 3 - Non-arthroplasty tx of OAK
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Proximal tibiofibular joint is a frequently neglected joint which can be a source of lateral knee pain. Open surgery is the current mainstay of surgical management of proximal tibiofibular joint disorders. The proximal tibiofibular arthroscopy allows access to the joint and adjacent important ligamentous structures. This forms the basis of further development of arthroscopic procedures for a variety of pathologies.
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Prognostic factors for refractory pheochromocytoma and paraganglioma after <sup>131</sup>I-metaiodobenzylguanidine therapy
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MSTS 2022 - Metastatic Disease of the Humerus
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OBJECTIVE: Given the rarity of refractory pheochromocytoma and paraganglioma (PPGL), outcomes and prognostic factors after <sup>131</sup>I-metaiodobenzylguanidine (<sup>131</sup>I-mIBG) treatment still remain unclear. Therefore, this study evaluated whether baseline characteristics at initial <sup>131</sup>I-mIBG therapy and imaging response to repeated <sup>131</sup>I-mIBG therapy could be prognostic factors for refractory PPGL.
METHODS: All patients [n = 59 (male/female = 35/24), median age; 49.3 years] with refractory PPGL who received <sup>131</sup>I-mIBG therapy at our institution between September 2009 and September 2019 were retrospectively reviewed for the effects of the following factors on overall survival: age, sex, hypertension, diabetes mellitus, palpitations, constipation, cancer pain, catecholamines values, past history of therapy (external beam radiation for bone metastasis, operation, and chemotherapy), metastasis sites, and response to <sup>131</sup>I-mIBG treatments.
RESULTS: Throughout the follow-up period, 18 patients died from disease exacerbation. The estimated 5- and 10-year survival rates were 79.4% and 67.2% from the initial diagnoses of refractory PPGL and 68.5% and 49.9% from the first <sup>131</sup>I-mIBG therapy, respectively. The multivariate Cox proportional hazards model showed that progressive disease (PD) [hazard ratio (HR) 96.3, P = 0.011] and constipation (HR 8.2, P = 0.024) were adverse prognostic factors for overall survival after initial <sup>131</sup>I-mIBG therapy. The log-rank test demonstrated that PD in response to <sup>131</sup>I-mIBG therapies (P < 0.0001) and constipation (P < 0.01) were correlated with poor survival rates.
CONCLUSIONS: Response to repeated <sup>131</sup>I-mIBG treatment can be a strong predictor of prognosis after initial <sup>131</sup>I-mIBG therapy for refractory PPGL. Repeated <sup>131</sup>I-mIBG therapy may be a good option for controlling refractory PPGL.
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MR Imaging in Postreduction Assessment of Developmental Dysplasia of the Hip: Goals and Obstacles
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Developmental Dysplasia of the Hip 2020 Review
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Developmental dysplasia of the hip is a spectrum disorder of hip development that ranges in severity from abnormal acetabular morphology to complete hip dislocation. While treatment with a Pavlik harness is highly effective in infants younger than 6 months, older infants and children and those with orthotic failure often warrant surgical reduction and placement of a spica cast, which limits subsequent imaging evaluation. Magnetic resonance (MR) imaging has been described in the evaluation of the adequacy of hip reduction for more than 2 decades, but the practice is still not widespread and is performed routinely at relatively few centers. MR imaging is a robust tool for outcome assessment after hip reduction and placement of a spica cast, facilitating multiplanar confirmation of concentric reduction independent of an ossific nucleus or orthopedic hardware. Excellent image contrast of soft tissues allows identification of obstacles to concentric reduction, which may be extra-articular or intra-articular. Extra-articular obstacles include tightening of the adductor muscles and tightening of the iliopsoas tendon with constriction of the joint capsule. Intra-articular obstacles include limbus formation, labral inversion, an enlarged pulvinar, and hypertrophy of the ligamentum teres and/or the transverse acetabular ligament. Intravenous contrast material administration may demonstrate altered epiphyseal blood flow and help identify patients at risk for early ischemia. Imaging technique and image interpretation can be optimized to facilitate the performance of postreduction MR imaging studies where they may be of benefit. (©)RSNA, 2016.
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The use of an electronic health record system reduces errors in the National Hip Fracture Database
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Hip Fx in the Elderly 2019
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Aim to compare the validity of data submitted from a UK level 1 trauma centre to the National Hip Fracture Database (NHFD) before and after the introduction of an electronic health record system (EHRS). Patients and methods a total of 3224 records were reviewed from July 2009 to July 2017. 2,133 were submitted between July 2009 and October 2014 and 1,091 between October 2014 and July 2017, representing data submitted before and after the introduction of the EHRS, respectively. Data submitted to the NHFD were scrutinised against locally held data. Results use of an EHRS was associated with significant reductions in NHFD errors. The operation coding error rate fell significantly from 23.2% (494/2133) to 7.6% (83/1091); P < 0.001. Prior to EHRS introduction, of the 109 deaths recorded in the NHFD, 64 (59%) were incorrect. In the EHRS dataset, all the 112 recorded deaths were correct (P < 0.001). There was no significant difference in the error rate for fracture coding. In the EHRS dataset, after controlling for sample month, entries utilising an operation note template with mandatory fields relevant to NHFD data were more likely to be error free than those not using the template (OR 2.69; 95% CI 1.92-3.78). Conclusion this study highlights a potential benefit of EHR systems, which offer automated data collection for auditing purposes. However, errors in data submitted to the NHFD remain, particularly in cases where an NHFD-specific operation note template is not used. Clinician engagement with new technologies is vital to avoid human error and ensure database integrity.
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Factors affecting the incidence of surgical site infection after geriatric hip fracture surgery: a retrospective multicenter study
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Hip Fx in the Elderly 2019
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BACKGROUND: Geriatric hip fracture is a common type of osteoporotic fracture with high mortality and disability; surgical site infection (SSI) can be a devastating complication of this injury. By far, only a few studies identified easily remediable factors to reduce infection rates following hip fracture and less researches have focused on geriatric patients. The objective of this study was to identify potentially modifiable factors associated with SSI following geriatric hip fracture surgery.
METHODS: This retrospective, multicenter study involves three level I hospitals. A total of 1240 patients (60 years or older) underwent hip surgery with complete data were recruited between January 2016 and June 2018. Demographics information, medications and additional comorbidities, operation-related variables, and laboratory indexes were extracted and analyzed. Receiver operating characteristic (ROC) analysis was performed to detect the optimum cut-off value for quantitative data. Univariate and multivariate logistic analysis model were performed respectively to identify the independent predictors.
RESULTS: Ninety-four (7.58%) patients developed SSI in this study, and 76 (6.13%) had superficial infection, while 18 (1.45%) were diagnosed with deep infection. Results of univariate and multivariate analysis showed age > 79 years (OR, 2.60; p < 0.001), BMI > 26.6 kg/m<sup>2</sup> (OR, 2.97; p < 0.001), operating time > 107 min (OR, 2.18; p = 0.001), and ALB < 41.6 g/L (OR, 2.01; p = 0.005) were associated with an increased incidence of SSI; drainage use (OR, 0.57; p = 0.007) could reduce the incidence of wound infection for patients after geriatric hip fracture.
CONCLUSION: Accurate modifiable variables, operating time > 107 min, serum albumin < 41.6 g/L, BMI > 26.6 kg/m<sup>2</sup>, and age > 79 years could be applied to distinguish geriatric patients with high-risk of postoperative surgical site infection.
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Liposuction - A surgical procedure in dermatology
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Panniculectomy & Abdominoplasty CPG
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Liposuction is an integral part of the wide range of surgical procedures in dermatology. Dermatologists established tumescent local anesthesia in combination with the use of micro-cannulas; especially dermatologists from Germany and Austria actively designed and developed these new techniques. In this position paper, we discuss the history, various interdisciplinary aspects, the significance, and the treatment indications for this procedure as well as its role within dermatologic training programs and research. For quality reasons, members of the Germany Society of Dermatologic Surgery and the Austrian Society of Dermatologic Surgery discuss several fundamental professional aspects as well as the historical development of liposuction. © 2012 Blackwell Verlag GmbH, Berlin.
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Trauma Simulation Training Increases Confidence Levels in Prehospital Personnel Performing Life-Saving Interventions in Trauma Patients
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DoD LSA (Limb Salvage vs Amputation)
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Introduction. Limited evidence is available on simulation training of prehospital care providers, specifically the use of tourniquets and needle decompression. This study focused on whether the confidence level of prehospital personnel performing these skills improved through simulation training. Methods. Prehospital personnel from Alachua County Fire Rescue were enrolled in the study over a 2- to 3-week period based on their availability. Two scenarios were presented to them: a motorcycle crash resulting in a leg amputation requiring a tourniquet and an intoxicated patient with a stab wound, who experienced tension pneumothorax requiring needle decompression. Crews were asked to rate their confidence levels before and after exposure to the scenarios. Timing of the simulation interventions was compared with actual scene times to determine applicability of simulation in measuring the efficiency of prehospital personnel. Results. Results were collected from 129 participants. Pre- and postexposure scores increased by a mean of 1.15 (SD 1.32; 95% CI, 0.88-1.42; P < 0.001). Comparison of actual scene times with simulated scene times yielded a 1.39-fold difference (95% CI, 1.25-1.55) for Scenario 1 and 1.59 times longer for Scenario 2 (95% CI, 1.43-1.77). Conclusion. Simulation training improved prehospital care providers' confidence level in performing two life-saving procedures.
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Three-dimensional MRI shows cartilage defect extension with no separation from the meniscus in women in their 70 s with knee osteoarthritis
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AMP (Acute Meniscal Pathology)
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The positional relationship between cartilage defects and the meniscus is poorly understood for osteoarthritis of the knee. Our purpose was to clarify how cartilage defects extend and their association with the meniscus location during osteoarthritis progression. The subjects were women in their 70 s who were registered in the Kanagawa Knee Study. We obtained 3D MRI images of the tibial surfaces with menisci in subjects with cartilage area ratios < 0.95 and examined the morphological association between cartilage defects and the medial meniscus (MM) by viewing the defects according to the cartilage area ratio at the medial tibial region. Of the 561 Kanagawa Knee Study subjects, 45 were included in the analyses, and 11 had a cartilage area ratio < 0.95 at the medial tibia. Significant differences were observed in the localization of cartilage defects among 9 subregions, with cartilage defects occurring predominantly in the middle external subregion. The inner margin of the MM contacted the cartilage defect in 7 knees and crossed the cartilage defect in 4 knees but was never found separated from the cartilage defect. The cartilage defects occurred from the middle external subregion and extended to the surrounding area without separating from the inner margin of the MM.Trial registration UMIN, UMIN000032826; 1 September 2018.
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CD34 and SMA expression of superficial zone cells in the normal and pathological human meniscus
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AMP (Acute Meniscal Pathology)
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The aim of this study was to evaluate histological changes in torn (0.5-27 weeks after injury) and osteoarthritic (OA) knee menisci versus normal menisci after PAS-AB, SAF-O-FG, and immunostaining for CD34, CD31, and smooth muscle actin (SMA). Cell layers in the superficial zone and the cell density in the deep zone of the menisci were counted. In the superficial zone of normal menisci, cells expressing CD34 were demonstrated. CD34(+) CD31(-) cells were absent in OA menisci and disappeared in torn menisci as a function of time. In contrast, an increase of SMA(+) cells combined with an increase of cell layers was observed in the superficial zone of torn menisci. SMA(+) cells were absent in normal and OA menisci. The predominant tissue type in torn menisci evolved from fibrocartilage-like to fibrous-like tissue as a function of time, whereas in OA menisci it became cartilage-like. The response of the superficial zone was reflected by the decrease of CD34(+) and the increase of SMA(+) cells in torn menisci and the transformation of a fibrous-like into a cartilage-like surface layer in OA menisci. These results potentially illustrate the contribution of CD34(+) cells to the homeostasis of meniscus tissue.
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Incidence of and risk factors for femoral fractures in the gap between hip and knee implants
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Hip Fx in the Elderly 2019
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PURPOSE: The purpose of this study was to analyse the incidence of interprosthetic femoral fractures and describe risk factors for them.
METHODS: Between 2009 and 2015, we selected patients who were carrying two implants (hip and knee) in the same femur. We collected demographic and clinical data and performed a radiological evaluation to analyse the gap between implants-the femoral canal area and total femoral area-in the axial plane. We defined interprosthetic fracture as that corresponding to a Vancouver type C fracture and types 1 and 2 according to the Su classification.
RESULTS: We studied 68 patients who had total knee arthroplasty (TKA), and 44 patients who had total hip arthroplasty (THA); 24 patients an intramedullary nail. We found six interprosthetic fractures (8.8 %), all in patients with a non-cemented THA. There was a tendency towards statistical difference (p = 0.08). Patients with an additional implant at the proximal femur were statistically less likely to have an interprosthetic fracture (p = 0.04). In radiological results, we found more interprosthetic fractures in patients who had an increased femoral canal area in the axial plane just distal to the tip of the hip implant.
CONCLUSIONS: Identifying risk factors for this specific type of fracture may facilitate their prevention. Better implant stability and the presence of a gap between stems in a lower canal zone appear to hinder the occurrence of interprosthetic fractures.
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Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy with matched controls
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To investigate long-term radiographic and patient-relevant outcome of isolated limited meniscectomy with regard to type of meniscal tear and extent of surgical resection.
METHODS: We studied 155 patients with intact cruciate ligaments (mean +/- SD age 54 +/- 12 years) who had undergone meniscectomy an average of 16 +/- 1 years earlier. The patients were examined using standardized radiography and validated self-administered questionnaires. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to quantify knee-related symptoms, and the definition of a symptomatic knee was determined. We used 68 control subjects matched for age, sex, and body mass index to calculate the relative risks (RRs).
RESULTS: Radiographic tibiofemoral osteoarthritis (OA) (Kellgren/Lawrence grade > or =2) was present in 66 index knees (43%), of which 39 (59%) were considered to be symptomatic according to the KOOS. In total, 77 patients (50%) had a symptomatic index knee. In a multivariate model, degenerative meniscal tears were associated with both radiographic OA (P = 0.030) and combined radiographic and symptomatic OA (P < or = 0.015). The RRs for combined radiographic and symptomatic OA after degenerative and traumatic types of meniscal tear were 7.0 (95% confidence interval [95% CI] 2.1-23.5) and 2.7 (95% CI 0.9-7.7), respectively, compared with matched controls.
CONCLUSION: An isolated meniscal tear treated by limited meniscectomy is associated with a high risk of radiographic and symptomatic tibiofemoral OA at 16-year followup. Factors associated with worse outcome were degenerative meniscal lesions and extensive resections. We suggest that degenerative meniscal tears may be associated with incipient OA, and that the meniscal tear signals the first symptom of the disease.
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Variation of cell and matrix morphologies in articular cartilage among locations in the adult human knee
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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OBJECTIVE: Understanding of articular cartilage physiology, remodelling mechanisms, and evaluation of tissue engineering repair methods requires reference information regarding normal structural organization. Our goals were to examine the variation of cartilage cell and matrix morphology in different topographical areas of the adult human knee joint. METHODS: Osteochondral explants were acquired from seven distinct anatomical locations of the knee joints of deceased persons aged 20-40 years and prepared for analysis of cell, matrix and tissue morphology using confocal microscopy and unbiased stereological methods. Differences between locations were identified by statistical analysis. RESULTS: Medial femoral condyle cartilage had relatively high cell surface area per unit tissue volume in the superficial zone. In the transitional zone, meniscus-covered lateral tibia cartilage showed elevated chondrocyte densities compared to the rest of the knee while lateral femoral condyle cartilage exhibited particularly large chondrocytes. Statistical analyses indicated highly uniform morphology throughout the radial zone (lower 80% of cartilage thickness) in the knee, and strong similarities in cell and matrix morphologies among cartilage from the femoral condyles and also in the mediocentral tibial plateau. Throughout the adult human knee, the mean matrix volume per chondron was remarkably constant at approximately 224,000 microm(3), corresponding to approximately 4.6 x 10(6) chondrons per cm(3). CONCLUSIONS: The uniformity of matrix volume per chondron throughout the adult human knee suggests that cell-scale biophysical and metabolic constraints may place limitations on cartilage thickness, mechanical properties, and remodelling mechanisms. Data may also aid the evaluation of cartilage tissue engineering treatments in a site-specific manner. Results indicate that joint locations which perform similar biomechanical functions have similar cell and matrix morphologies; findings may therefore also provide clues to understanding conditions under which focal lesions leading to osteoarthritis may occur
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Outcome of patients with anterior cruciate ligament injuries selected for conservative treatment
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Anterior Cruciate Ligament Injuries CPG
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In this retrospective study, 24 patients with acute isolated complete anterior cruciate ligament (ACL) ruptures selected for conservative treatment were re-examined a median of 45 months after injury. Selection for conservative treatment was made after careful patient information, taking into consideration desire for physical activity at work or leisure, interest in sports and muscular fitness. The reference group for the evaluation methods used included 50 students and 22 patients selected for surgical augmentation and reconstruction. In a subjective evaluation, the conservatively treated patients were satisfied, but objectively they had low functional scores and the pivot shift sign was often positive. Arthrometry showed that these patients had an increased anterior displacement of the tibia in relation to the femur in their injured knees. The patients who had a clearly positive pivot shift sign (grades III and IV) had an increased anterior laxity not only in the injured knees but also in the uninjured knees
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Altered Sensorimotor Integration With Cervical Spine Manipulation
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Objective: This study investigates changes in the intrinsic inhibitory and facilitatory interactions within the sensorimotor cortex subsequent to a single session of cervical spine manipulation using single- and paired-pulse transcranial magnetic stimulation protocols. Method: Twelve subjects with a history of reoccurring neck pain participated in this study. Short interval intracortical inhibition, short interval intracortical facilitation (SICF), motor evoked potentials, and cortical silent periods (CSPs) were recorded from the abductor pollicis brevis and the extensor indices proprios muscles of the dominant limb after single- and paired-pulse transcranial magnetic stimulation of the contralateral motor cortex. The experimental measures were recorded before and after spinal manipulation of dysfunctional cervical joints, and on a different day after passive head movement. To assess spinal excitability, F wave persistence and amplitudes were recorded after median nerve stimulation at the wrist. Results: After cervical manipulations, there was an increase in
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Preoperative 99mTc-MDP scintimetry of femoral neck fractures
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Management of Hip Fractures in the Elderly
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Preoperative 99mTc-MDP-scintimetry was performed in 117 patients with femoral neck fractures. Scintimetry was shown to be superior to visual evaluation. The ratio was calculated of the uptake in the femoral head of the fractured side over that in the unfractured side, with compensation for the increased trochanteric femoral activity found on the fractured side. A ratio above 0.90 correlated well with uneventful healing in both undisplaced and displaced fractures. Preoperative scintimetry is of great value in the choice of primary treatment of femoral neck fractures
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How well do radiographic absorptiometry and quantitative ultrasound predict osteoporosis at spine or hip? A cost-effectiveness analysis
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Management of Hip Fractures in the Elderly
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Dual energy X-ray absorptiometry (DXA) is widely accepted as the reference method for diagnosis and monitoring of osteoporosis and for assessment of fracture risk, especially at hip. However, axial-DXA is not suitable for mass screening, because it is usually confined to specialized centers. We propose a two-step diagnostic approach to postmenopausal osteoporosis: the first step, using an inexpensive, widely available screening technique, aims at risk stratification in postmenopausal women; the second step, DXA of spine and hip is applied only to potentially osteoporotic women preselected on the basis of the screening measurement. In a group of 110 healthy postmenopausal woman, the capability of various peripheral bone measurement techniques to predict osteoporosis at spine and/or hip (T-score < -2.5SD using DXA) was tested using receiver operating characteristic (ROC) curves: radiographic absorptiometry of phalanges (RA), ultrasonometry at calcaneus (QUS. CALC), tibia (SOS.TIB), and phalanges (SOS.PHAL). Thirty-three women had osteoporosis at spine and/or hip with DXA. Areas under the ROC curves were 0.84 for RA, 0.83 for QUS.CALC, 0.77 for SOS.PHAL (p < 0.04 vs RA) and 0.74 for SOS.TIB (p < 0.02 vs RA and p = 0.05 vs QUS.CALC). For levels of sensitivity of 90%, the respective specificities were 67% (RA), 64% (QUS.CALC), 48% (SOS.PHAL), and 39% (SOS.TIB). In a cost-effective two-step, the price of the first step should not exceed 54% (RA), 51% (QUS.CALC), 42% (SOS.PHAL), and 25% (SOS.TIB). In conclusion, RA, QUS.CALC, SOS.PHAL, and SOS.TIB may be useful to preselect postmenopausal women in whom axial DXA is indicated to confirm/exclude osteoporosis at spine or hip
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Strong association of MRI meniscal derangement and bone marrow lesions in knee osteoarthritis: data from the osteoarthritis initiative
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AMP (Acute Meniscal Pathology)
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INTRODUCTION: Meniscal damage is common in knee Osteoarthritis (OA) and predictive of structural progression, suggesting that their disruption plays a role in the development of OA. The bone marrow lesion (BML) is associated with pain and is a strong risk factor for structural progression. These lesions are associated with abnormal loading in a knee joint. Therefore, our hypothesis was that in those with symptomatic knee OA, large BMLs would be associated with ipsi-compartmental meniscal derangement.
METHODS: This was a cross-sectional study of a subsample of the Osteoarthritis Initiative where one set of magnetic resonance (MR) images from each participant was scored for tibiofemoral BMLs and meniscal derangement. We performed chi-squared tests comparing the prevalence of large BMLs in those with ipsi-compartmental meniscal derangement and those without.
RESULTS: 160 Participants had a mean age of 61 (+/-9.9), mean BMI of 30.3 (+/-4.7) and 50% were female. 79% of medial and 39% of lateral menisci showed MRI (Magnetic Resonance Imaging) derangement. In those with medial meniscal MRI derangement, 44% had large medial BMLs while in those without medial meniscal derangement, 0% had large BMLs. Similar results were seen in the lateral compartment.
CONCLUSION: Medial and lateral MRI meniscal derangement are highly prevalent in symptomatic knee OA and BMLs are highly associated with ipsi-compartmental MRI meniscal derangement.
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Does overweight and obesity influence the clinical outcome and the quality of life at five years following primary total knee replacement?
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: The purpose of this study was to investigate whether there is an association between the preoperative body mass index in total knee replacement patients and the effect three to five years postoperative. Methods: 197 patients who had undergone primary total knee replacement in the period 1.1.2005-31.12.2006 participated in a three-five years of follow-up study. Outcome measures were self-rated health (SF-36), which consists of eight strands and two component scores, physical component score and mental component scores and the Knee Society rating system (KSS) (knee score and function scores), and improvement of the two KSS scores from baseline to follow-up. Results: Whit Ordinal logistic regression (adjusted for gender, age, basic disease and surgical procedure) were found statistically significant association between body mass index and nine of the fourteen outcome measures. For all outcome measures were found OR >1. With a difference in body mass index of 1kg/m(2) increases the risk of lower scores from a minimum of 2% OR 1.02 (0.97-1.07) p=0.5 (mental component score) to maximum 14% OR 1.14 (1.08-1.21) p<0.001 (KSS function score). With a difference in body mass index on 5kg/m(2) increases the risk of lower scores from a minimum of 9% OR 1.09 (mental components scores) to a maximum of 96% OR 1.96 (KSS function scores). With a difference in body mass index of 10kg/m2 rises risk of worse score with minimum 19% OR 1.19 (mental component score) to a maximum of 284% OR 3.84 (KSS function score). Conclusions: There is a clear association between body mass index and efficacy 3-5 years following primary total knee replacement. More than half of the Outcome measures were statistically significant and the outcomes that were not statistically significant are clinically interesting. High body mass index increases the risk of poor outcome after total knee Arthroplasty
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Secular trends in hospital emergency department visits for dental care in Kansas City, Missouri, 2001-2006
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Objectives. We determined the trends, risk factors, and costs of emergency department (ED) visits for dental complaints during a six-year period in Kansas City, Missouri (KCMO). Methods. We used de-identified hospital discharge data from all facilities serving KCMO during 2001-2006. Using the International Classification of Diseases, Ninth Revision codes, we determined both counts and rates of ED visits related to toothache or tooth injury and analyzed the discharge diagnosis and costs of these visits. We used multivariable regression analysis to assess risk factors for the ED visits for dental complaints. Results. We found a significant increasing trend in dental complaint visits during the six-year period (from 13.1% to 19.0%, p<0.01). Dental caries accounted for 20.4%, pulpitis or periapical abscess accounted for 14.8%, dental injury accounted for 8.7%, temporomandibular joint (TMJ) disorders accounted for 1.5%, and all other unspecified dental diseases accounted for 54.6% of the ED visits for dental complaints. The mean charge was approximately $360 per visit and was highest for TMJ disorders ($747) and lowest for unspecified other dental diseases ($277). Self-pay (38.3%) and Medicaid (32.3%) constituted the majority of the payment sources. Multivariable regression analysis indicated that self-payers, nonwhite people, adults, people with lower family income, and weekends were associated with increased use of ED visits for dental complaints. Conclusions. There was a significant increasing trend in dental complaint-related ED visits. EDs have become an important site for people with dental problems to seek urgent care, particularly for individuals who self-pay or are on Medicaid. (copyright)2011 Association of Schools of Public Health
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Deltoid detachment consequent to open surgical repair of massive rotator cuff tears
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Optimizing the Management of Full-Thickness Rotator Cuff Tears
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Deltoid detachment is one of the complications in open rotator cuff repair. Although it is often described, the actual prevalence, time at which it occurs and the predisposing causes are still unknown. We prospectively studied 112 patients with massive rotator cuff tears with a mean age of 67. The surgical approach was performed with a lateral para-acromial incision. Clinical assessment was performed with Constant's method. Of the 112 patients, 9 (8%) had deltoid detachment. It occurred about 3 months after surgery. Of the nine patients, two underwent revision surgery for the deltoid trans-bone reattachment. At the follow-up, the patients with deltoid detachment had a mean increase of only 5.5 points in the Constant score compared to that of 16.9 obtained by the control group. Deltoid reattachment, performed on the two patients, provided a mean increase of 7 points only with respect to the post-operative control at the 4th month. Considering the unsatisfactory functional result consequent to deltoid detachment and the slight improvement obtained with the reattachment, we recommend the following: use suture thread thicker than #2, do not use a simple stitch and avoid extending acromioplasty to the lateral margin of the acromion
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Clinical results after treatment for bidirectional patellar subluxation: Minimum 2-years follow-up
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DoD SSI (Surgical Site Infections)
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BACKGROUND: We describe the preliminary clinical results of a patellar stabilization technique to treat bidirectional patellar subluxation (BPS).
METHODS: Patients: six patients (one male, five females; mean age 30.2years) underwent this procedure with a minimum of 24months follow-up. Patients were assessed for clinical instability, patellar complications, and need for revision surgery. Patient functional outcomes were evaluated using the criteria of Crosby and Insall and the Kujala Anterior Knee Pain Scale at the time of final follow-up. Patient satisfaction was assessed using a subjective questionnaire.
OPERATIVE TECHNIQUE: A semitendinosus tendon autograft is coursed through a transverse tunnel in the distal quadriceps tendon. The medial and lateral aspects of the graft are passed from the quadriceps tendon within subfascial tunnels to the MPFL attachment site and lateral epicondyle, respectively. The graft is fixed in 60degree of knee flexion with suture anchors.
RESULTS: Surgery for recurrent instability was performed in one case. There were no cases of infection, quadriceps tendon rupture, or patella fracture. At average follow-up of 29.2months (range, 24 to 38months), outcomes were good to excellent in 4/6 of cases. Kujala scores improved significantly from 33.3 (range, three to 58) preoperatively to 70.8 (range, 39 to 96) postoperatively (p<0.05). 5/6 patients reported being satisfied to completely satisfied with their result.
CONCLUSION: Patients undergoing bidirectional patellar stabilization with a single tendon graft showed improved postoperative functional scores. The technique is successful in reducing pain and restoring bidirectional patellar stability at 2-years follow-up.
LEVEL OF EVIDENCE: IV, retrospective case series.
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Application of the Goes double-skin peri-areolar mastopexy with and without implants: A 14-year experience
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Reduction Mammoplasty for Female Breast Hypertrophy
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Peri-areolar mastopexy is commonly used for mild ptosis requiring no more than 3cm of nipple elevation. The nature of areolar scar and gland remodelling inherent to a circular skin reduction prompts circumspection when correcting more moderate-to-severe cases. The purpose herein is to convey the reproducibility and applicability of the Goes double-skin peri-areolar mastopexy without mesh, for breast ptosis requiring nipple elevation of 4-9cm, in a series outside the work of the principal innovator. A series of 217 consecutive patients underwent circumareolar eccentric skin excision based on four cardinal landmarks, deepithelialised dermal sleeve and glandular reshaping with and without implants (174 augmentation-mastopexies and 43 mastopexies). Implantation and implant change involved the use of saline implants placed in the subpectoral space. Average nipple elevation was 5.1cm in the augmentation-mastopexy group and 6.5cm in the mastopexy group. There were major complications in 4.4% of breasts and occurred only in the mastopexy-augmentation group. There was no nipple loss, serious infection or haematoma. There were minor complications in 13.1% of breasts (11.8% in the mastopexy-augmentation group, and 18.6% in the mastopexy group). A minimal (10%) areolar necrosis occurred on a breast in one patient undergoing augmentation-mastopexy for tubular breasts with micromastia. Revision rate was 4% for the entire series. Based on the principles of circular skin design with fixed skin landmarks, internal breast shaping and special attention when augmentation is done simultaneously, the peri-areolar double-skin mastopexy can be safe, effective and reproducible when applied to cases of increasing complexity.
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Skeletal related events in patients with bone metastasis arising from non-small cell lung cancer
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DoD PRF (Psychosocial RF)
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Purpose: The skeleton is one of the most common sites of metastasis in patients with non-small cell lung cancer (NSCLC). Metastasis increases the risk of skeletal-related events (SREs). The purpose of this study is to evaluate the incidence of SREs and the factors associated with the development of SREs in patients with bone metastases (BM) arising from NSCLC. Methods: A cohort study was carried out involving 95 patients with BM associated with NSCLC who were enrolled between 2007 and 2011. Clinical and sociodemographic data were extracted from the physical and electronic records. The association between exposure variables and outcome (SREs) was assessed using crude odds ratio (OR). Survival analysis of patients with BM was conducted using the Kaplan-Meier method. A log-rank test was used to assess differences between the curves of those who did and did not experience SREs. Results: Sixty-two out of 95 patients with BM (65.3Â %) showed evidence of at least one SRE. Multiple analysis revealed that patients with a history of smoking (OR = 6.76; 95% CI = 1.3â??33.0; p < 0.01), performance status â?¥2 (OR = 3.38; 95% CI = 1.2â??9.3; p < 0.01), and multiple BM (OR = 3.31; 95% CI = 1.1â??9.9; p < 0.03) were at greater risk of SREs. Median survival time was 4.6Â months (95% CI = 2.9â??6.2) in patients who experienced SREs and 6.8Â months (95% CI = 2.2â??11.4) in patients who did not, a statistically significant difference (p = 0.03). Conclusion: Patients with NSCLC are more likely to experience SREs if they have poor performance status, a history of smoking or multiple BM. Global survival was shorter in patients who suffer SREs.
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Fracture incidence rates in Norwegian children, The Tromsø Study, Fit Futures
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Summary: This study describes childhood fracture rates in Norway, a country known for high fracture rates in the adult population. Fracture rates correspond with other reports from Scandinavia, although with a slightly higher proportion in girls. Indications of increased vulnerability during stages of puberty require further exploration. Introduction: Fractures are common injuries during childhood. Incidence rates and patterns vary, but population-based data are scarce. The aim of this study was to describe the sex-, age- and maturation-specific incidence of fractures in a representative population-based sample from a region in Norway. Methods: All fractures in the population based convenient cohort Fit Futures, comprising 961 adolescents under 18Â years, were recorded retrospectively from the local hospital. Details on individualâ??s age and fracture site were recorded. A radiologist confirmed all fractures. Results: In the period from birth to cohort scanning, the register recorded 316 fractures in 253 individuals. Fractures were more common in boys (35%) than in girls (31%). The overall annual fracture incidence was 204 per 10,000 persons-year under the age of 18 and 205 under the age of 16. The majority of fractures involved the upper extremities and the most common site of fracture was the forearm with 24% of the fractures followed by phalanges with 23% of the fractures. Fractures peaked in girls at sexual maturation stage 3. Boys had a peak in stage 2. Timing of subsequent fractures was also consistent with stages of sexual maturation. Conclusions: The overall incidence of fractures in childhood in Northern Norway corresponds with other reports from Scandinavia, although the proportion of fractures in girls is higher than in other studies. Both sexes seem especially vulnerable at stages related to sexual maturation. Whether this reflects bone vulnerability or other changes related to puberty requires further investigation.
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Patient- and hospital-related determinants on subjective evaluation of medical treatment outcome of severely injured patients
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DoD PRF (Psychosocial RF)
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Aim: The importance of subjective evaluation of medical treatment has been neglected so far. Therefore, the objective of this study is to identify determinants of subjective evaluation of medical treatment outcome in terms of severely injured patients. Subjects and methods: A written questionnaire was sent to 121 seriously injured patients, who were hurt predominantly by traffic or work-related accidents and were treated between 1996 and 2001 in two hospitals in North Rhine-Westphalia. Using bi- and multivariate analysis, significant determinants on a dichotomized index of subjective evaluation of medical treatment outcome were analyzed. Results: Logistic regressions identified one significant determinant on subjective treatment outcome of severely injured patients: trust of patient in physician. Conclusion: This finding confirms the importance of psychosocial aspects in physician-patient interactions concerning the subjective evaluation of medical treatment outcome. Therefore this result emphasizes the importance of social sciences in medical education especially for surgeons. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Four-octyl itaconate improves osteoarthritis by enhancing autophagy in chondrocytes via PI3K/AKT/mTOR signalling pathway inhibition
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AMP (Acute Meniscal Pathology)
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Osteoarthritis (OA) is a highly prevalent and chronic disorder that is associated with a substantial social and economic burden. Itaconate, as an important regulator of cellular inflammation, is a metabolite synthesised by an enzyme encoded by immune-responsive gene 1. However, there are few studys regarding the effects of itaconate on OA. Here, we show the effect of the cell-permeable itaconate derivative 4-octyl itaconate (OI) on OA. OI attenuates the chondrocyte apoptosis induced by interleukin 1ß (IL-1ß) in vitro, indicating that OI protect chondrocytes against apoptosis. Moreover, OI ameliorates the chondrocyte autophagy inhibition induced by IL-1ß via the inhibition of PI3K/AKT/mTOR signalling pathway. Finally, OI enhances autophagy and reduces cartilage degradation in a rat model of OA established by destabilization of medial meniscus (DMM). In summary, our findings reveal that OI is involved in regulating the progression of OA. The above results shed light on the treatment of OA.
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Results of total hip replacement in renal transplant recipients
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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A vascular necrosis of the femoral head associated with steroid immunosuppression is a cause of significant morbidity in renal transplant recipients. We review the results of 30 total hip replacements in 20 renal transplant recipients with a mean follow-up of 6.3 years. The mean age at the time of surgery was 35 years. The average Hospital for Special Surgery Hip Score was 17 points before operation and 32 points after operation. Fourteen hips were rated excellent and 12 hips rated good. There were four failures--one hip was revised for symptomatic loosening and three prosthesis were removed for infection. Twenty-seven of the hip replacements were subjectively rated as satisfactory by the patient. There was no significant difference in post-operative hip scores between cemented and uncemented prostheses. Total hip replacement in renal transplant recipients in this study has shown good long term result with a revision rate of about 3%. Late infection was a major problem with an incidence of 13%. Prophylactic antibiotics must be used whenever there is a risk of haematogenous seeding from transient bacteremia in these immunosuppressed patients. Use of uncemented prosthesis may make future revision arthroplasty easier
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Upper body lift
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Panniculectomy & Abdominoplasty CPG
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An upper body lift is needed whenever a massive weight loss patient presents with a "dropped out" lateral inframammary crease. It is a combination of a brachioplasty, upper-back resection, and breast reconstruction. The operation is designed to reverse the particular deformity a patient presents with. This article describes three patterns of resection, one for males and two for females.
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Sex differences in pain and psychological functioning in persons with limb loss
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DoD PRF (Psychosocial RF)
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UNLABELLED: Sex differences in pain are frequently reported in the literature. However, less is known about possible sex differences in the experience of pain secondary to a disability. The current study explored these issues in persons with limb loss (n = 335, 72% men) who were recruited as part of a postal survey. Participants provided ratings of phantom limb pain (PLP), residual limb pain (RLP), and general pain intensity. Participants also completed measures of pain-related interference, catastrophizing, coping, and beliefs. Results indicated that a greater proportion of males than females (86% vs 77%, respectively) reported the presence of PLP; however, this difference was no longer prominent when cause of limb loss was controlled. No sex differences were found in the presence of RLP, or in average intensity ratings of PLP or RLP. In contrast, females reported greater overall average pain intensity and interference than males. Females also endorsed significantly greater catastrophizing, use of certain pain-coping strategies, and beliefs related to several aspects of pain. This study did not find prominent sex differences in pain specific to limb loss. However, several sex differences in the overall biopsychosocial experience of pain did emerge that are consistent with the broader literature.
PERSPECTIVE: The current study contributes to the literature on sex differences in the experience of pain. Although males and females with limb loss did not significantly differ in their disability-specific pain, sex differences in their broader experience of pain were significant and are worthy of future clinical and empirical attention.
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Trabecular bone density of the proximal tibia as it relates to failure of a total knee replacement
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Surgical Management of Osteoarthritis of the Knee CPG
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The relationship between post-operative bone density and subsequent failure of total knee replacement (TKR) is not known. This retrospective study aimed to determine the relationship between bone density and failure, both overall and according to failure mechanism. All 54 aseptic failures occurring in 50 patients from 7760 consecutive primary cemented TKRs between 1983 and 2004 were matched with non-failing TKRs, and 47 failures in 44 patients involved tibial failures with the matching characteristics of age (65.1 for failed and 69.8 for non-failed), gender (70.2% female), diagnosis (93.6% OA), date of operation, bilaterality, pre-operative alignment (0.4 and 0.3 respectively), and body mass index (30.2 and 30.0 respectively). In each case, the density of bone beneath the tibial component was assessed at each follow-up interval using standardised, calibrated radiographs. Failing knees were compared with controls both overall and, as a subgroup analysis, by failure mechanism. Knees were compared with controls using univariable linear regression. Significant and continuous elevation in tibial density was found in knees that eventually failed by medial collapse (p < 0.001) and progressive radiolucency (p < 0.001) compared with controls, particularly in the medial region of the tibia. Knees failing due to ligamentous instability demonstrated an initial decline in density (p = 0.0152) followed by a non-decreasing density over time (p = 0.034 for equivalence). Non-failing knees reported a decline in density similar to that reported previously using dual-energy x-ray absorptiometry (DEXA). Differences between failing and non-failing knees were observable as early as two months following surgery. This tool may be used to identify patients at risk of failure following TKR, but more validation work is needed
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e-Knee: the electronic knee prosthesis
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Surgical Management of Osteoarthritis of the Knee CPG
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Tibiofemoral forces determine polyethylene wear and affect the longevity of total knee prostheses. Previously, investigators relied on theoretic data from mathematical models to predict mechanical forces in the knee. Predictions of tibiofemoral forces are highly variable because of the complex interplay of the muscles involved in activities. Ideally, knee forces should be directly measured. An electronic total knee prosthesis (e-Knee) was developed to directly measure tibiofemoral compressive and tensile forces in vivo. After 13 years of research and development, the e-Knee was implanted into a patient in 2004. Tibiofemoral force data were collected intraoperatively and throughout the postoperative period during activities of daily living and during exercise. Direct measurement of knee forces can lead to a better understanding of the stresses seen following total knee arthroplasty. Information generated by the e-Knee will aid in the improvement of implant design and patient care
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Two Techniques for Retrograde Flexible Intramedullary Fixation of Pediatric Femur Fractures: All-Lateral Entry Versus Medial and Lateral Entry Point
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Pediatric Diaphyseal Femur Fractures 2020 Review
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BACKGROUND: Multiple techniques for flexible intramedullary nailing (FIMN) of pediatric femur fractures have been described. To our knowledge, no study has compared combined medial-lateral (ML) entry versus all-lateral (AL) entry retrograde nailing. This study compares surgical outcomes, radiographic outcomes, and complication rates between these 2 techniques. METHODS: A retrospective review of a consecutive series of patients treated by retrograde, dual FIMN of femur fractures was performed from 2005 to 2012. Demographics and operative data were recorded. Radiographs were analyzed for fracture pattern, fracture location, percent canal fill by the nails, as well as shortening and angulation at the time of osseous union. Rates of symptomatic implants and their removal were noted. Data were compared between patients treated with medial and lateral entry (ML group) nailing and those treated with all-lateral entry (AL group) nailing using the Student t test and correlation statistics. RESULTS: Of the 244 children with femoral shaft fractures treated with retrograde FIMN using Ender stainless steel nails, 156 were in the ML group and 88 were in the AL group. There were no statistical differences in sex (74% vs. 82% males), age (8.0 vs. 8.6 y), weight (29.4 vs. 31.1 kg), or fracture pattern between the 2 groups. The average total anesthesia time was less in the AL group (133 vs. 103 min) (P<0.0001). There was no difference between the techniques in shortening (3.9 vs. 3.0 mm), coronal angulation (2.9 vs. 2.6 degrees), or sagittal angulation (3.3 vs. 2.7 degrees) at union. In the AL group, there was a correlation between canal fill and reduced shortening at union. No differences were found in the presence or degree of varus alignment, procurvatum deformity, or recurvatum angulation between the constructs. There were 5 malunions in the AL group and 9 malunions in the ML group (5.7% vs. 5.8%, P=1). The incidence of having a healed femur fracture with >10 degrees of valgus was higher in the AL group (0% vs. 3.4%) (P=0.04). There were no differences between the groups in the rate of symptomatic implant removal or surgical complications. CONCLUSIONS: The AL entry technique for FIMN of pediatric femur fractures is 30 minutes faster without worse final fracture alignment, additional complications, or increased rates of symptomatic implants. When using the AL technique, specific attention should be paid to percentage of canal fill and ensuring that the fracture is not reduced in a valgus position. LEVEL OF EVIDENCE: Level III-therapeutic.
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Pain after use of the central third of the patellar tendon for cruciate ligament reconstruction. 33 patients followed 2-3 years
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Anterior Cruciate Ligament Injuries CPG
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We performed reconstruction of the anterior cruciate ligament in 33 patients using the central third of the patellar tendon. In 20 patients we did an arthroscopically-assisted procedure, while 13 patients had an additional mini-arthrotomy through the gap in the patellar tendon. After 2-3 years the subjective knee function, according to the Lysholm score, was excellent or good in 18 knees and fair or poor in 15 knees, mainly due to anterior knee pain. Although 18 patients complained about anterior knee pain, only 1 patient required further surgery. After the operation the patella had a lower position. A flexion contracture was found in 7 patients, and 13 had heterotopic bone formation at the apex of the patella. Although stability was restored in 31 of the 33 reconstructed knees, anterior knee pain was a frequent complication. There were no correlations between the anterior knee pain and patellar height, flexion contracture or heterotopic bone formation
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Functional results following vascularized versus nonvascularized bone grafts for wrist arthrodesis following excision of giant cell tumors
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DoD SSI (Surgical Site Infections)
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Purpose: Wrist arthrodesis after resection of a giant cell tumor of the distal radius can be performed using a vascularized free fibular transfer (VFFT) or a nonvascularized structural iliac crest transfer (NICT). The purpose of this study was to compare the union times, functional outcomes, and complications after these procedures. Methods: We identified 27 patients at 2 centers: 14 underwent VFFT, and 13 NICT. The 2 groups were comparable for age, sex, and tumor grade. We assessed functional outcomes of the wrist with the Toronto Extremity Salvage Score, Musculoskeletal Tumor Society 1987 and 1993 scores, and Disabilities of the Arm, Shoulder, and Hand scores. Results: Two local recurrences occurred in the VFFT group and 1 in the NICT group. The VFFT group had 3 patients who had already undergone or were planning to undergo surgery for improved appearance, hardware removal, or tendon release. In the NICT group, 2 infections required debridement, one of which went on to free fibular transfer, but there were no reoperations for nonunion or donor site morbidity. The surgical time was significantly shorter for NICT. Functional scores showed no differences between groups on any of the parameters studied for the upper limb. Conclusions: Both VFFT and NICT were effective surgical techniques for wrist fusion after distal radial resection for giant cell tumor. Vascularized free fibular transfer should be considered when a major skin defect is anticipated, because it allows the inclusion of a vascularized skin paddle, or when the osseous defect is too long (> 10 cm) for NICT. We were unable to demonstrate a difference in upper limb functional scores between VFFT and NICT. Because the surgical time is significantly shorter and the reoperation rate is lower for NICT, we recommend NICT whenever possible. Type of study/level of evidence: Therapeutic III. © 2013 American Society for Surgery of the Hand.
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Warm-needling plus Tuina relaxing for the treatment of carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVE: To probe into quick and effective therapies for carpal tunnel syndrome. METHODS: Totally 98 cases of carpal tunnel syndrome were randomly divided into a treatment group and a control group. The treatment group received warm-needling plus Tuina relaxing, while the control group was treated by hormone block therapy and drug medication. RESULTS: The cure rate was 81.7% in the treatment group and 47.4% in the control group, with a significant difference between the two groups (P < 0.01). CONCLUSION: Acupuncture plus Tuina manipulation is a simple therapy for carpal tunnel syndrome, but with remarkable therapeutic effects
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Bone regeneration 6 years after impaction bone grafting: A PET analysis
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Management of Hip Fractures in the Elderly
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Background: Impacted morselized bone allograft in revision total hip arthroplasty for prosthetic loosening has gained widespread clinical use during the last decades. The clinical results are good but little is known about the bone regeneration in the graft. Patients and methods: 5 patients were revised with impaction of morselized frozen allograft and a cemented total hip arthroplasty (THA) due to loosening and osteolysis of a primary THA. We used positron emission tomography ([18F]-fluoride PET) to produce quantitative images of new bone formation in the allograft surrounding the femur stem 6 years after surgery. Results: The 5 patients had previously been analyzed by [18F]-fluoride PET during the first year after surgery (Sorensen et al. 2003). During the first year, bone formation proceeded through the graft layer and reached the cement layer surrounding the femoral stems. The clinical and radiographic results were excellent at 6 years. PET analyses at 6 years showed that the bone metabolism was significantly reduced in most areas of the proximal femur, compared to the elevated activity during the first year after surgery, and also normalized compared to the contralateral healthy femur. Graft bone metabolism distal to the stem tip remained slightly increased. Small patchy areas of increased uptake remained along the proximal femoral stem, probably reflecting small volumes of fibrous healing. Interpretation: The metabolism of the allografted bone had normalized compared to native bone, indicating full regeneration throughout the graft - and a good long-term prognosis for implant fixation. Copyright(copyright) Taylor & Francis 2007. all rights reserved
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Ultrashort echo time Cones double echo steady state (UTE-Cones-DESS) for rapid morphological imaging of short T2 tissues
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AMP (Acute Meniscal Pathology)
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Purpose: In this study, we aimed to develop a new technique, ultrashort echo time Cones double echo steady state (UTE-Cones-DESS), for highly efficient morphological imaging of musculoskeletal tissues with short T2s. We also proposed a novel, single-point Dixon (spDixon)-based approach for fat suppression. Methods: The UTE-Cones-DESS sequence was implemented on a 3T MR system. It uses a short radiofrequency (RF) pulse followed by a pair of balanced spiral-out and spiral-in readout gradients separated by an unbalanced spoiling gradient in-between. The readout gradients are applied immediately before or after the RF pulses to achieve a UTE image (S+) and a spin/stimulated echo image (S-). Weighted echo subtraction between S+ and S- was performed to achieve high contrast specific to short T2 tissues, and spDixon was applied to suppress fat by using the intrinsic complex signal of S+ and S-. Six healthy volunteers and five patients with osteoarthritis were recruited for whole-knee imaging. Additionally, two healthy volunteers were recruited for lower leg imaging. Results: The UTE-Cones-DESS sequence allows fast volumetric imaging of musculoskeletal tissues with excellent image contrast for the osteochondral junction, tendons, menisci, and ligaments in the knee joint as well as cortical bone and aponeurosis in the lower leg within 5 min. spDixon yields efficient fat suppression in both S+ and S- images without requiring any additional acquisitions or preparation pulses. Conclusion: The rapid UTE-Cones-DESS sequence can be used for high contrast morphological imaging of short T2 tissues, providing a new tool to assess their association with musculoskeletal disorders.
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