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Long-term social prognosis after hip fractures
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Management of Hip Fractures in the Elderly
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A long term follow-up study of 518 patients with hip fractures was undertaken 2.5 years after the operation. The total mortality was 35 per cent (180/518). The risk of social deterioration for patients admitted from home was 47 per cent (132/281). A statistical analysis showed this risk to be determined primarily by the age of the patient and secondarily by the placement of the patient on discharge from hospital. A thorough description of these factors is presented
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Prosthetic joint-associated infections treated with DAIR (debridement, antibiotics, irrigation, and retention): analysis of risk factors and local antibiotic carriers in 91 patients
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PJI DX Updated Search
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BACKGROUND AND PURPOSE: For prosthetic joint-associated infection (PJI), a regimen of debridement, antibiotics, irrigation, and retention of the prosthesis (DAIR) is generally accepted for acute infections. Various risk factors associated with treatment success have been described. The use of local antibiotic carriers (beads and sponges) is relatively unknown. We retrospectively analyzed risk factors in a cohort of patients from 3 hospitals, treated with DAIR for PJI. PATIENTS AND METHODS: 91 patients treated with DAIR for hip or knee PJI in 3 Dutch centers between 2004 and 2009 were retrospectively evaluated. The mean follow-up was 3 years. Treatment success was defined as absence of infection after 2 years, with retention of the prosthesis and without the use of suppressive antibiotics. RESULTS: 60 patients (66%) were free of infection at follow-up. Factors associated with treatment failure were: a history of rheumatoid arthritis, late infection (> 2 years after arthroplasty), ESR at presentation above 60 mm/h, and infection caused by coagulase-negative Staphylococcus. Symptom duration of less than 1 week was associated with treatment success. The use of gentamicin sponges was statistically significantly higher in the success group, and the use of beads was higher in the failure group in the univariate analysis, but these differences did not reach significance in the logistic regression analysis. Less surgical procedures were performed in the group treated with sponges than in the group treated with beads. INTERPRETATION: In the presence of rheumatoid arthritis, duration of symptoms of more than 1 week, ESR above 60 mm/h, late infection (> 2 years after arthroplasty), and coagulase-negative Staphylococcus PJI, the chances of successful DAIR treatment decrease, and other treatment methods should be considered
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An open-label, long-term safety and tolerability trial of diclofenac sodium 1% gel in patients with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To evaluate the longâ?term safety and tolerability of topical diclofenac sodium 1% gel (DSG) in the treatment of knee osteoarthritis (OA) for up to 12 months. METHODS: This was a multicenter openâ?label, extension of two 3â?month, randomized, doubleâ?blind studies of DSG in patients with knee OA (NCT ID: NCT00171691, "Safety of Diclofenac Sodium Gel in Knee Osteoarthritis"). To ensure adequate enrollment, some DSGâ?naïve patients with OA who had not participated in the doubleâ?blind studies were also enrolled. Patients applied 4 g DSG to 1 or both knees 4 times daily for 9 to 12 months. Safety was evaluated through adverse event (AE) reporting, physical examination, and laboratory investigations. Patients completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, stiffness, and physical function scales every 3 months to assess longâ?term effectiveness. RESULTS: The extension study enrolled 583 patients; 294 patients completed the study. Use of DSG was documented for 578 patients (safety population). The mean age was 62.3 years, and 63.7% of patients were women. Overall, 112 (19.4%) patients reported â?¥ 1 treatmentâ?related AE, and the only treatmentâ?related AE occurring in â?¥ 1% of patients was applicationâ?site dermatitis. Treatmentâ?related gastrointestinal, renalâ?function, hepaticâ?function, and cardiovascular AEs were reported by 3, 1, 2, and 0 patients, respectively. There were no serious AEs or deaths. At 1 year, improvements from baseline for WOMAC pain, stiffness, and physical function scale scores were 39.8%, 33.4%, and 36.9%, respectively. CONCLUSION: The longâ?term safety profile of DSG was consistent with previous 12â?week studies, and DSG remained effective for a 1â?year period.
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Satisfactory outcomes following combined unicompartmental knee replacement and anterior cruciate ligament reconstruction
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: There exist limited options for treatment of patients with combined medial compartment arthritis and anterior cruciate ligament (ACL) deficiency. Ideal treatment is one that offers lasting relief of symptoms not compromising any future surgery. Unicompartmental knee replacement has shown consistently good results in the relatively young and active population, but there is a high reported incidence of failure up to 20%, if performed in ACL-deficient knees. One of the recognized treatment modality is combined ACL reconstruction and unicompartmental arthroplasty. A systematic review was conducted looking at the demographics, techniques, complications and outcome of combined ACL reconstruction with unicompartmental knee arthroplasty.
METHODS: A systematic literature search within the online Medline, PubMed Database, EMBASE, Web of Science, Cochrane and Google Scholar was carried out until October 2016 to identify relevant articles. A study was defined eligible if it met the following inclusion criteria: the surgical procedure combined unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction; patient's clinical and/or functional outcomes were reported; any complications intra-operatively and post-operatively were reported; and the full-text articles, written in English, German, Italian, Dutch or Spanish, were available. Quality and risk of bias assessments were done using standardized criteria set.
RESULTS: A total of 8 studies met the inclusion criteria encompassing 186 patients who were treated with simultaneous ACL reconstruction and unicompartmental knee arthroplasty. The mean age was 50.5 years (range from 44 to 56) with a mean follow-up of 37.6 months (range from 24 to 60). There was an improvement in mean Oxford Score from 27.5 to 36.8. Complications reported included tibial inlay dislocation (n = 3), conversion to a total knee arthroplasty (n = 1), infection requiring two-stage revision (n = 2), deep-vein thrombosis (n = 1), stiffness requiring manipulation under anaesthesia (n = 1), retropatellar pain requiring arthroscopic adhesiolysis (n = 1).
CONCLUSION: Unicompartmental knee arthroplasty combined with ACL reconstruction can be a valid treatment option for selected patients, with combined medial unicompartmental knee osteoarthritis and ACL deficiency.
LEVEL OF EVIDENCE: Systematic Review of Level IV Studies, Level IV.
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Inhaled and nasal corticosteroid use and the risk of fracture
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Management of Hip Fractures in the Elderly
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Studies of the risk of fracture associated with inhaled corticosteroids are inconclusive and are limited to short-term effects. We assessed whether long-term use increases this risk. We conducted a case control study nested within a population-based cohort of all Quebec elderly dispensed respiratory medications and followed for at least 4 years during 1988-2001. There were 9,624 new cases of fracture of the hip or upper extremities and 191,622 age-matched control subjects (mean age of 81 years). The rate of any such fracture for current inhaled corticosteroid use was not elevated (rate ratio [RR], 0.97; 95% confidence interval [CI], 0.92-1.03). For upper-extremity fracture, the rate increased by 12% (RR, 1.12; 95% CI, 1.04-1.19) with every 1,000-microg increase in the daily dose of inhaled corticosteroids, but not for hip fracture (RR, 0.97; 95% CI, 0.88-1.07). Among subjects followed for over 8 years, the rate of hip fracture was only elevated with daily doses of more than 2,000 microg of inhaled corticosteroids (RR, 1.61; 95% CI, 1.04-2.50). The rate was not elevated at any dose of nasal corticosteroids. In conclusion, the long-term use of inhaled and nasal corticosteroids at the usual recommended doses is not associated with a risk of fracture in older patients with respiratory disease
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Atypical diaphyseal femoral fractures-new aspects
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MSTS 2018 - Femur Mets and MM
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Post menopausal osteoporotic fractures are a major public health concern worldwide with oral bisphosphonates favored for their prevention and treatment. Recent interest has centered on clinically observed, unusually sited femoral diaphyseal fractures, particularly attributed to alendronate. Their imaging presentations on routine radiographs, alternate imaging modalities, and associated pitfalls in nine fractures in six patients are selectively illustrated by seven fractures in four patients that serve to emphasize the following: (1) Bisphosphonates other than alendronate have been used for treating various bone diseases in children and men as well as osteoporotic women. (2) Effects may differ with each bisphosphonate's route of administration and prolongation of activity, despite discontinuation. Prior investigations and theoretical mechanisms of bisphosphonates as a class rather than with a specific alendronate association are reviewed to provide a broader basis for evaluating their recently observed clinical and radiographic complications. © ISS 2011.
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Risk of local recurrence after deltoid-sparing resection for osteosarcoma of the proximal humerus
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: The anatomy of the shoulder poses special challenges with regard to limb-sparing surgery. Resection of the deltoid muscle is considered by some surgeons to be necessary to achieve adequate margins for osteosarcoma of the proximal humerus. However, this can compromise the functional results after reconstruction of the shoulder. The goal of the current study was to determine whether deltoid-sparing resection can be safely performed for osteosarcoma of the proximal humerus.
METHODS: Between 1978 and 2005, 23 consecutive patients with high-grade nonmetastatic osteosarcoma of the proximal humerus underwent limb-sparing surgery with preservation of the deltoid muscle. All patients received neoadjuvant chemotherapy followed by surgery and postoperative chemotherapy. The mean follow-up was 90 months (range, 7 months-279 months).
RESULTS: The overall survival at 5 years was 77%. At the time of last follow-up, 14 (61%) of 23 of patients were alive without evidence of disease. Three (13%) patients developed local recurrence. Two of these patients had poor responses to chemotherapy, with tumor necrosis of 50% and 70%. The third patient had a pathologic fracture of the humerus. Positive surgical margins were associated with local recurrence, and 2 of 4 patients with a positive surgical margin developed local recurrence (P = .01).
CONCLUSIONS: Preservation of the deltoid muscle can be performed for carefully selected patients with osteosarcoma of the proximal humerus. Routine use of the procedure is not justified, because it may be associated with an elevated risk of recurrence. The risk of local recurrence appears to be related to positive surgical margins and possibly the percentage of tumor necrosis.
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MRI and biomechanics multidimensional data analysis reveals R2-R1? as an early predictor of cartilage lesion progression in knee osteoarthritis
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AMP (Acute Meniscal Pathology)
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Purpose: To couple quantitative compositional MRI, gait analysis, and machine learning multidimensional data analysis to study osteoarthritis (OA). OA is a multifactorial disorder accompanied by biochemical and morphological changes in the articular cartilage, modulated by skeletal biomechanics and gait. While we can now acquire detailed information about the knee joint structure and function, we are not yet able to leverage the multifactorial factors for diagnosis and disease management of knee OA. Materials and Methods: We mapped 178 subjects in a multidimensional space integrating: demographic, clinical information, gait kinematics and kinetics, cartilage compositional T1? and T2 and R2-R1? (1/T2–1/T1?) acquired at 3T and whole-organ magnetic resonance imaging score morphological grading. Topological data analysis (TDA) and Kolmogorov–Smirnov test were adopted for data integration, analysis, and hypothesis generation. Regression models were used for hypothesis testing. Results: The results of the TDA showed a network composed of three main patient subpopulations, thus potentially identifying new phenotypes. T2 and T1? values (T2 lateral femur P = 1.45*10-8, T1? medial tibia P = 1.05*10-5), the presence of femoral cartilage defects (P = 0.0013), lesions in the meniscus body (P = 0.0035), and race (P = 2.44*10-4) were key markers in the subpopulation classification. Within one of the subpopulations we observed an association between the composite metric R2-R1? and the longitudinal progression of cartilage lesions. Conclusion: The analysis presented demonstrates some of the complex multitissue biochemical and biomechanical interactions that define joint degeneration and OA using a multidimensional approach, and potentially indicates that R2-R1? may be an imaging biomarker for early OA. Level of Evidence: 3. Technical Efficacy: Stage 2. J. Magn. Reson. Imaging 2018;47:78–90.
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Mesotherapy and Injection Lipolysis
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Panniculectomy & Abdominoplasty CPG
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The first part of this article familiarizes the reader with the evolution of mesotherapy, injection lipolysis, and the use of phosphatidylcholine and deoxycholate for subcutaneous fat reduction. There is an emphasis on the underlying basic science of fat metabolism and the biochemistry of phosphatidylcholine, so that practitioners will be able to understand future published research on these topics. The second half details some personal experience with injection lipolysis. © 2009.
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Total ankle joint replacement
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Surgical Management of Osteoarthritis of the Knee CPG
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The ankle is an inherently stable, kinematically simple joint that bears tremendous compression forces with relative ease because of a large load-bearing surface area. Disabling disease of the ankle is less common than at the hip or knee joints, but is not rare. Ankle arthrodesis seems less than ideal as a technique of surgical treatment. Total ankle joint replacement seems to be a clinically possible alternative on the basis of experience with 76 procedures performed during a 31-month period. Continuing clinical experience is resulting in more gratifying results by the avoidance of technical errors and better selection of patients
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Treatment of complications in primary cementless total hip arthroplasty
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Management of Hip Fractures in the Elderly
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Five hundred eight consecutive cases (481 patients) treated with the extensively porous coated Anatomic Medullary Locking prosthesis were followed for an average of 9 years (range, 5-14 years). Thirty-one (6%) hips were lost to followup and 33 (7%) hips had complications that required revision surgery. The indications for revision were symptomatic stem loosening (six cases), symptomatic cup loosening (live cases), asymptomatic periarticular osteolysis (seven cases); trochanteric fracture through an osteolytic cyst (four cases), polyethylene fracture (live cases), sepsis (one case), and heterotopic ossification (one case). The surgical treatment of these complications is described. After these revisions, 11 (33%) cases had additional complications, most commonly a dislocation. Four required a second revision. Questionnaires and physical examinations were used to compare the outcome of the cases requiring revision with the outcome of those that did not. There were no differences in patient satisfaction between cases requiring revision surgery and those that did not (97% and 95% patient satisfaction, respectively). Function was also similar between the two groups, with 93% reporting increased function in each group
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Associations of clinical outcomes and MRI findings in intra-articular administration of autologous adipose-derived stem cells for knee osteoarthritis
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BMAC (Bone Marrow Aspirate Concentrate)
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Introduction: Clinical studies of intra-articular injection of mesenchymal stem cells for osteoarthritis (OA) indicate its efficacy. Here, we retrospectively investigated the associations of pretherapeutic magnetic resonance imaging (MRI) findings with the clinical outcomes up to 6 months, after intra-articular administration of adipose-derived stem cells (ASCs) to knee OA patients.
Methods: We first analyzed alterations of the visual analog scale (VAS) and knee injury and osteoarthritis outcome score (KOOS) in 57 knees of 34 patients from whom clinical scores were obtained before ASC therapy, and at 1, 3, and 6 months. Among the patients, we further examined MRI findings of 34 knees of 19 patients whose pretherapeutic MRI data were available.
Results: The mean improvement of VAS and KOOS-total during 6 months was 2.6 +/- 4.0 (from 6.1 +/- 2.5 to 3.5 +/- 2.9, P < 0.001) and 10.2 +/- 12.4 (from 54.4 +/- 12.7 to 64.6 +/- 13.8, P < 0.01), respectively. Scales related to pain and symptoms improved earlier than those related to activities of daily living (ADL) and sports/recreation. Improvement of VAS and KOOS-sports/recreation was significantly higher in patients with more severe cartilage lesions. Similarly, osteophyte lesions were associated significantly with improvement of VAS and KOOS-ADL, and BML was associated with KOOS-ADL and KOOS-sports/recreation.
Conclusions: In intra-articular administration of autologous ASCs for knee OA, improvement of VAS and KOOS-sports/recreation was significantly higher in patients with more severe cartilage lesions. Similarly, osteophyte lesions were associated significantly with improvement of VAS and KOOS-ADL, and BML was associated with KOOS-ADL and KOOS-sports/recreation. Clinical studies with larger numbers of patients and various kinds of data are necessary to predict therapeutic effects.
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Glycosaminoglycan Content of the Lateral Compartment Cartilage in Knees Conforming to the Indications for Oxford Medial Unicompartmental Knee Arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: The quality of the lateral compartment cartilage is important to preoperative evaluation and prognostic prediction of unicompartmental knee arthroplasty (UKA). Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) enables noninvasive assessment of glycosaminoglycan (GAG) content in cartilage. This study aimed to determine the GAG content of the lateral compartment cartilage in knees scheduled to undergo Oxford medial UKA.
METHODS: From December 2016 to May 2017, twenty patients (20 osteoarthritic knees) conforming to the indications for Oxford medial UKA were included as the osteoarthritis (OA) group, and 20 healthy volunteers (20 knees) paired by sex, knee side, age (+/-3 years), and body mass index (BMI) (+/-3 kg/m2) were included as the control group. The GAG contents of the weight-bearing femoral cartilage (wbFC), the posterior non-weight-bearing femoral cartilage (pFC), the lateral femoral cartilage (FC), and tibial cartilage (TC) were detected using dGEMRIC. The dGEMRIC indices (T1Gd) were calculated in the middle three consecutive slices of the lateral compartment. Paired t-tests were used to compare the T1Gd in each region of interest between the OA group and control group.
RESULTS: The average age and BMI in the two groups were similar. In the OA group, T1Gd of FC and TC was 386.7 +/- 50.7 ms and 429.6 +/- 59.9 ms, respectively. In the control group, T1Gd of FC and TC was 397.5 +/- 52.3 ms and 448.6 +/- 62.5 ms, respectively. The respective T1Gd of wbFC and pFC was 380.0 +/- 47.8 ms and 391.0 +/- 66.3 ms in the OA group and 400.3 +/- 51.5 ms and 393.6 +/- 57.9 ms in the control group. Although the T1Gd of wbFC and TC tended to be lower in the OA group than the control group, there was no significant difference between groups in the T1Gd in any of the analyzed cartilage regions (P value of wbFC, pFC, FC, and TC was 0.236, 0.857, 0.465, and 0.324, respectively).
CONCLUSIONS: The GAG content of the lateral compartment cartilage in knees conforming to indications for Oxford medial UKA is similar with those of age- and BMI-matched participants without OA.
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Non-operative strategies to manage pain in osteoarthritis during COVID-19 pandemic
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PRP (Platelet-Rich Plasma)
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Corona Virus Disease (COVID-19) has resulted in restriction of face-to-face consultations and mechanisms to access health care. Oesteoarthritis (OA) is one of the most common forms of musculoskeletal disease encountered and a leading cause of painful disability in adults and elderly. The assessment of the challenges and strategies encountered in the non-operative management of OA of knee care during the COVID-19 pandemic was done. A comprehensive review of the literature using suitable keywords such as 'COVID-19', 'OA', 'OA knee' 'knee joint' on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in May 2020 on developments and guidance during the current COVID-19 pandemic. The management of OA has been hampered by COVID-19 pandemic lock down with subsequent suspension of elective surgeries. Non-operative complementary therapy has been evaluated with National Institute for Health and Care Excellence (NICE) recommendations to guide management. Conservative strategies including judicial use of analgesia as recommended by NICE, supportive orthosis, patient education and advice using remote telecommunication consultations play an important role in the non-operative management of OA till elective surgery can safely resume.
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Meniscal root tears: significance, diagnosis, and treatment
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AMP (Acute Meniscal Pathology)
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Meniscal root tears, less common than meniscal body tears and frequently unrecognized, are a subset of meniscal injuries that often result in significant knee joint disorders. The meniscus root attachment aids meniscal function by securing the meniscus in place and allowing for optimal shock-absorbing function in the knee. With root tears, meniscal extrusion often occurs, and the transmission of circumferential hoop stresses is impaired. This alters knee biomechanics and kinematics and significantly increases tibiofemoral contact pressure. In recent years, meniscal root tears, which by definition include direct avulsions off the tibial plateau or radial tears adjacent to the root itself, have attracted attention because of concerns that significant meniscal extrusion dramatically inhibits normal meniscal function, leading to a condition biomechanically similar to a total meniscectomy. Recent literature has highlighted the importance of early diagnosis and treatment; fortunately, these processes have been vastly improved by advances in magnetic resonance imaging and arthroscopy. This article presents a review of the clinically relevant anatomic, biomechanical, and functional descriptions of the meniscus root attachments, as well as current strategies for accurate diagnosis and treatment of common injuries to these meniscus root attachments.
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Prevention of bone loss with risedronate in glucocorticoid-treated rheumatoid arthritis patients
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Management of Hip Fractures in the Elderly
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The aim of the study was to assess risedronate's effect on bone mineral density in postmenopausal women with rheumatoid arthritis receiving glucocorticoids. We carried out a two center, 2 year, double-masked, placebo-controlled trial with a third year of nontreatment follow-up. We studied 120 women requiring long-term glucocorticoid therapy at > 2.5 mg/day prednisolone randomized to treatment with daily placebo; daily 2.5 mg risedronate; or cyclical 15 mg risedronate (2 out of 12 weeks). At 97 weeks, bone mineral density was maintained at the lumbar spine (+1.4%) and trochanter (+0.4%) in the daily 2.5 mg risedronate group, while significant bone loss occurred in the placebo group (-1.6%, p = 0.03; and 4.0%, p < 0.005, respectively). At the femoral neck, there was a nonsignificant bone loss in the daily 2.5 mg risedronate group (-1.0%) while in the placebo group bone mass decreased significantly (-3.6%, p < 0.001). The difference between placebo and daily 2.5 mg risedronate groups was significant at the lumbar spine (p = 0.009) and trochanter (p = 0.02) but did not reach statistical significance at the femoral neck. Although not significantly different from placebo at the lumbar spine, the overall effect of the cyclical regimen was similar to that of the daily 2.5 mg risedronate regimen. Treatment withdrawal led to bone loss in the risedronate groups that was significant at the lumbar spine. A similar number of patients experienced adverse events (including upper gastrointestinal events) across treatment groups and risedronate was generally well tolerated. Thus risedronate preserves bone mass in postmenopausal women with rheumatoid arthritis receiving glucocorticoids while patients receiving a placebo have significant bone loss
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Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: a review of the National Trauma Data Bank
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DOD - Acute Comp Syndrome CPG
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INTRODUCTION AND OBJECTIVES: Lower extremity (LE) arterial trauma and its treatment may lead to extremity compartment syndrome (ECS). In that setting, the decision to perform fasciotomies is multifactoral and is not well delineated. We evaluated the outcomes of patients with surgically treated LE arterial injury who underwent early or delayed fasciotomies.
METHODS: The National Trauma Data Bank (NTDB) was retrospectively reviewed for patients who had LE arterial trauma and underwent both open vascular repair and fasciotomies. Exclusion criteria were additional non-LE vascular trauma, head or spinal cord injuries, crush injuries, burn injuries, and declaration of death on arrival. Patients were divided into those who had fasciotomies performed within 8h (early group) or >8h after open vascular repair (late group). Comparative analyses of demographics, injury characteristics, complications, and outcomes were performed.
RESULTS: Of the 1469 patient admissions with lower extremity arterial trauma that met inclusion criteria there were 612 patients (41.7%) who underwent fasciotomies. There were 543 and 69 patients in the early and late fasciotomy groups, respectively. There was no significant difference in age, injury severity, mechanism of injury, associated injuries, and type of vascular repair between the groups. A higher rate of iliac artery injury was observed in the late fasciotomy group (23.2% vs. 5.9%, P<.001). Patients in the early fasciotomy group had lower amputation rate (8.5% vs. 24.6%, P<.001), lower infection rate (6.6% vs. 14.5%, P = .028) and shorter total hospital stay (18.5 +/- 20.7 days vs. 24.2 +/- 14.7 days, P = .007) than those in the late fasciotomy group. On multivariable analysis, early fasciotomy was associated with a 4-fold lower risk of amputation (Odds Ratio 0.26, 95% CI 0.14-0.50, P<.0001) and 23% shorter hospital LOS (Means Ratio 0.77, 95% CI 0.64-0.94, P = .01).
CONCLUSION: Early fasciotomy is associated with improved outcomes in patients with lower extremity vascular trauma treated with surgical intervention. Our findings suggest that appropriate implementation of early fasciotomy may reduce amputation rates in extremity arterial injury.
Copyright © 2011 Elsevier Ltd. All rights reserved.
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Osteoporosis: exercise therapy, pre- and postdiagnosis
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Distal Radius Fractures
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The idiopathic, accelerated phase of bone loss associated with postmenopausal and surgically induced menopausal women is rapidly becoming a large public health problem due to the great expense involved in caring for those with vertebral, hip and distal radial fractures. The method of therapy with the least incidence of ill effects is physical exercise. This is a valid, appropriate alternative, but is, however, the most overlooked and unappreciated form of treatment. Studies have shown that bone mineral content can be increased, not just maintained as with the other forms of therapy. The question may then be asked: what about exercise therapy for women already clinically diagnosed? Would exercise increase their risk of fracture, and if not, what forms of exercise would be the most effective? Although osteoporosis prevention and treatment is a multifactorial process, it appears that extension exercises are one form of physical activity necessary to prevent further fracture once it has occurred. A review of the literature will address this conservative noninvasive approach to preventive and ongoing treatment of involutional osteoporosis. [References: 56]
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Zoledronic acid for prevention and treatment of osteoporosis
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HipFx Supplemental Cost Analysis
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INTRODUCTION: Osteoporosis (OP) is associated with a high risk of fracture and disability and with substantial medical costs. This paper is a review of the intravenous (i.v.) bisphosphonate zoledronic acid 5 mg (ZOL), used in the treatment and prevention of OP. AREAS COVERED: This is a review of the scientific literature, between 2003 and 2010, on the use of ZOL in patients with low bone mass or OP. EXPERT OPINION: ZOL, given as a single infusion once yearly, has proven efficacy in reducing risk of vertebral and hip fractures in postmenopausal women with OP. In men and women with a recent hip fracture, ZOL has been shown to reduce the incidence of future clinical fractures. Data also demonstrate an increase in bone mineral density in postmenopausal women with osteopenia, in men with OP, and in patients at risk for glucocorticoid-induced osteoporosis. The ZOL clinical program has shown this agent to be safe and generally well tolerated. Acute flu-like symptoms may occur following the first infusion of ZOL, but these are generally mild and transient, and decrease in frequency with subsequent infusions. Patients must have adequate renal function (creatinine clearance >/= 35 ml/min) and be adequately hydrated prior to infusion. With orally administered bisphosphonates, patient compliance and persistence with weekly or monthly dosing are frequently suboptimal. The ability to administer i.v. ZOL once yearly over 15 min for the treatment of OP provides the advantage of guaranteeing medication compliance for the duration of the dosing interval
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Management of moderate-to-severe Marcus-Gunn jaw-winking ptosis
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Upper Eyelid and Brow Surgery
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OBJECTIVE: To report the results of levator excision and frontalis suspension for moderate-to-severe Marcus-Gunn jaw-winking ptosis. DESIGN: A retrospective noncomparative case series. PARTICIPANTS: Twenty-four patients with moderate-to-severe Marcus-Gunn jaw-winking ptosis (21 unilateral and 3 bilateral) were treated surgically between 1978 and 1997 by one surgeon. INTERVENTION: Levator excision either in the involved eyelid or in both eyelids, followed by bilateral frontalis suspension, was performed. MAIN OUTCOME MEASURES: Postoperative improvement of jaw-winking was determined. The surgical results of ptosis surgery were assessed as good, fair, or poor based on habitual upper eyelid heights and symmetry. RESULTS: Postoperative follow-up periods ranged from 6 months to 153 months, with an average of 36.9 months. After levator excision in a total of 27 eyelids exhibiting jaw-winking, 10 eyelids (37.0%) showed complete resolution of jaw-winking, and 13 eyelids (48.2%) showed mild winking (1 mm or less) on the lateral jaw movement only (functionally and cosmetically not a problem). In four eyelids (14.8%), these results were not recorded. In the group of five patients undergoing bilateral frontalis suspension and levator excision only on the involved side, final results were good in two patients (40%) and poor in three (60%). Of the 19 patients who underwent bilateral levator excision, final results were good in 13 (68.4%) and fair in 6 (31.6%). CONCLUSIONS: For moderate-to-severe jaw-winking ptosis, bilateral frontalis suspension after bilateral levator excision generally provided satisfactory correction of both jaw-winking and ptosis.
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Exemestane as adjuvant treatment of early breast cancer: Intergroup Exemestane Study/Tamoxifen Exemestane Adjuvant Multicenter trials
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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This review summarizes the status of 2 major clinical trials involving exemestane, a nonsteroidal inactivator of aromatase. The first trial, Intergroup Exemestane Study (IES), has been previously reported. More than 4700 postmenopausal women were randomized to receive exemestane versus continued tamoxifen at 2-3 years into 5 years of adjuvant tamoxifen. In the hormone receptor-positive group, there was a one-third improvement in disease-free survival and a near survival advantage (P = 0.08) for the crossover strategy. The second trial is the Tamoxifen Exemestane Adjuvant Multicenter (TEAM) study. Recently, the design was modified to take into account the information from the IES. In the initial phase of TEAM, 7000 patients were randomized to receive 5 years of exemestane versus 5 years of tamoxifen. With the IES results, TEAM was modified so that 5 years of exemestane would be compared with 5 years of tamoxifen crossed over to exemestane. An additional 2500 patients have now been accrued. Updates of the IES and the first report of the TEAM might be available in 2006. The implications of these studies are discussed in this article
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A population-based comparison of the incidence of adverse outcomes after simultaneous-bilateral and staged-bilateral total knee arthroplasty
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PJI DX Updated Search
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BACKGROUND: It is unclear whether simultaneous-bilateral total knee arthroplasty is as safe as staged-bilateral arthroplasty is. We are aware of no randomized trials comparing the safety of these surgical strategies. The purpose of this study was to retrospectively compare these two strategies, with use of an intention-to-treat approach for the staged-bilateral arthroplasty cohort. METHODS: We used linked hospital discharge data to compare the safety of simultaneous-bilateral and staged-bilateral knee arthroplasty procedures performed in California between 1997 and 2007. Estimates were generated to take into account patients who had planned to undergo staged-bilateral arthroplasty but never underwent the second procedure because of death, a major complication, or elective withdrawal. Hierarchical logistic regression modeling was used to adjust the comparisons for patient and hospital characteristics. The principal outcomes of interest were death, a major complication involving the cardiovascular system, and a periprosthetic knee infection or mechanical malfunction requiring revision surgery. RESULTS: Records were available for 11,445 simultaneous-bilateral arthroplasty procedures and 23,715 staged-bilateral procedures. On the basis of an intermediate estimate of the number of complications that occurred after the first procedure in a staged-bilateral arthroplasty, patients who underwent simultaneous-bilateral arthroplasty had a significantly higher adjusted odds ratio (OR) of myocardial infarction (OR = 1.6, 95% confidence interval [CI] = 1.2 to 2.2) and of pulmonary embolism (OR = 1.4, 95% CI = 1.1 to 1.8), similar odds of death (OR = 1.3, 95% CI = 0.9 to 1.9) and of ischemic stroke (OR = 1.0, 95% CI = 0.6 to 1.6), and significantly lower odds of major joint infection (OR = 0.6, 95% CI = 0.5 to 0.7) and of major mechanical malfunction (OR = 0.7, 95% CI = 0.6 to 0.9) compared with patients who planned to undergo staged-bilateral arthroplasty. The unadjusted thirty-day incidence of death or a coronary event was 3.2 events per thousand patients higher after simultaneous-bilateral arthroplasty than after staged-bilateral arthroplasty, but the one-year incidence of major joint infection or major mechanical malfunction was 10.5 events per thousand lower after simultaneous-bilateral arthroplasty. CONCLUSIONS: Simultaneous-bilateral total knee arthroplasty was associated with a clinically important reduction in the incidence of periprosthetic joint infection and malfunction within one year after arthroplasty, but it was associated with a moderately higher risk of an adverse cardiovascular outcome within thirty days. If patients who are at higher risk for cardiovascular complications can be identified, simultaneous-bilateral knee arthroplasty may be the preferred surgical strategy for the remaining lower-risk patients
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Epidemiology of hip replacements in Korea from 2007 to 2011
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Hip Fx in the Elderly 2019
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We analyzed national data collected by the Health Insurance Review and Assessment Service in Korea from 2007 to 2011; 1) to document procedural numbers and procedural rate of bipolar hemiarthroplasty (BH), primary and revision total hip arthroplasties (THAs), 2) to stratify the prevalence of each procedure by age, gender, and hospital type, and quantified, 3) to estimate the revision burden and evaluate whether the burden is changed over time. Our final study population included 60,230 BHs, 40,760 primary THAs, and 10,341 revision THAs. From 2007 to 2011, both the number and the rate of BHs, primary THAs increased steadily, whereas there was no significant change in revision THAs. Over the 5 yr, the rate of BHs and primary THAs per 100,000 persons significantly increased by 33.2% and 21.4%, respectively. The number of revision THAs was consistent over time. The overall annual revision burden for THA decreased from 22.1% in 2007 to 18.9% in 2011. In contrast to western data, there were no changes in the number and rate of revision THAs, and the rates of primary and revision THAs were higher for men than those for women. Although 5 yr is a short time to determine a change in the revision burden, there have been significant decreases in some age groups.
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Autologous chondrocyte implantation for treatment of articular cartilage defects in the knee and ankle of football (soccer) players
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AMP (Acute Meniscal Pathology)
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Background: Autologous chondrocyte implantation (ACI) continues to evolve into one of the most efficient and common techniques for repair of articular cartilage defects. Significant progress has been made within the last decade regarding its application in the context of professional sports, such as football. This article provides a current overview of the application of ACI in the context of amateur and professional football. Methods: Clinical studies involving football players and other high-impact sports athletes treated with ACI were reviewed. The scientific and technical development of ACI was evaluated considering latest publications, and analyzed for treatment outcome parameters. Results: Football players reported good to excellent results after treatment with ACI or matrix-associated chondrocyte implantation (MACI). Activity scores and clinical knee and ankle scores were significantly improved after surgery. Great advances have been made in surgery specific rehabilitation algorithms, leading to shorter return to play times. New surgical techniques have been introduced, reducing the 2-stage design of ACI to only one surgical intervention, accelerating return to play time further while reducing morbidity. Conclusion: Surgical repair of focal articular cartilage defects via ACI in football players often provides successful return-to-competition and produces long lasting regeneration tissue, enabling players to continue their career on the pre-injury level of play. The technique itself is constantly evolving, addressing initial shortcomings and making it more widespread available to the recreational and professional athlete.
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Effect of ketorolac administered by a continuous femoral infusion with 0.125% bupivacaine after total knee replacement
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Surgical Management of Osteoarthritis of the Knee CPG
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Background: The purpose of this study was to determine whether administration of ketorolac as a component of femoral infusion via femoral catheter to patients who have undergone total knee replacement would enhance analgesia, and decrease PCA fentanyl use. Methods: All patients received 0.1 mg intrathecal morphine, an IV PCA fentanyl (2 ml bolus; 6-min lockout interval) and a continuous infusion of 0.125% bupivacaine at the rate of 4 ml/h via femoral catheter. A total of 60 patients were randomly allocated into three groups (n = 20 per group): 1) No ketorolac (Control group); 2) Ketorolac added to the IV PCA fentanyl on a 1.2 mg/ml per fentanyl 10 (mu)g/ml basis (K-PCA group); 3) Ketorolac added to the continuous femoral infusion of 0.125% bupivacaine (Ketorolac 2.4 mg/h) (K-infusion group). The outcome measures included the pain scores, demand dose, delivery dose, and missed attempts in the PACU, at 6 PM on the day of operation, at 9 AM and 6 PM on POD 1 and 2, respectively. The mean total consumption of fentanyl and ketorolac was also recorded. Results: There were no significant differences among the groups in the VAS pain scores at rest and on movement at any time period. The demands, deliveries and missed attempts were comparable over time among the groups. There were no differences among the groups in the total dose offentanyl administered (474 (plus or minus) 269; 426 (plus or minus) 282; 395 (plus or minus) 246 (mu)g). The total ketorolac consumption in the K-PCA and K-infusion groups were 51.1 (plus or minus) 33.8 and 120.0 (plus or minus) 0.0 mg, respectively (P < 0.05). Conclusion: There were no significant differences among the groups in the VAS pain scores. There were, however, a nonsignificant trend toward lower demands, deliveries and missed attempts over time in the following order: Control > K-PCA group > K-infusion group
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How Much are Emergency Medicine Specialists' Decisions Reliable in the Diagnosis and Treatment of Pediatric Fractures?
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Considering the importance of an early diagnosis and proper decision-making in regards to the treatment of pediatric distal radius and elbow fractures, this study examines emergency medicine specialists' accuracy in the diagnosis and treatment of these patients. METHODS: From 2012 and 2013, children less than 14 years old who were referred to an academic hospital emergency department with elbow or distal radius fractures were enrolled. Initially, patients were examined by an emergency medicine specialist and then they were referred to an orthopedic surgeon. Type of fracture and the proposed treatment of two specialists were compared. RESULTS: In total, there were 108 patients (54 patients in each group) with a mean age of 8.1±3.3 years. Identical diagnosis in 48 cases (88.9%) of distal radius and 36 cases (66.7%) of elbow trauma were observed. We found a difference between diagnosis of the two specialists in diagnosing lateral condyle of the humerus fracture in the elbow group and growth plate fracture in the distal radius fracture group, but the differences were not significant. Among 108 patients, 70 patients (64.8%) received identical treatment. CONCLUSION: Although the emergency medicine specialists responded similarly to the orthopedic specialists in the diagnosis of pediatric distal radius and elbow fractures, diagnosis of more complicated fractures such as lateral condylar humoral fractures, distal radius growth plate and for choosing the proper treatment option, merits further education.
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Failed cartilage repair for early osteoarthritis defects: a biochemical, histological and immunohistochemical analysis of the repair tissue after treatment with marrow-stimulation techniques
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Surgical Management of Osteoarthritis of the Knee CPG
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PURPOSE: To examine the entire repair tissue resulting from marrow-stimulation techniques in patients with early osteoarthritis. METHODS: The repair tissue and adjacent articular cartilage after failed marrow-stimulation techniques (microfracture and Pridie drilling) of 5 patients (47-65 years old) with cartilage defects and radiographic early osteoarthritis (Kellgren-Lawrence grading 1 and 2) was removed during total joint arthroplasty (mean time until analysis: 8.8 months), analysed by histology, polarized light microscopy, immunohistochemistry, biochemistry and by histological score systems. RESULTS: Macroscopic cartilage repair assessment revealed ICRS grades of II (nearly normal) and III (abnormal). Cartilage defects were mostly completely filled with a fibrocartilaginous tissue that had small and large fissures. Cartilage-specific stains of the repair tissue were more intense than the surrounding native cartilage but reduced compared with normal articular cartilage. The subchondral bone was incompletely restored. A new tidemark was absent. The repair tissue always showed positive immunoreactivity for types II and X collagen, and was sometimes positive for type I collagen. Proteoglycan contents of the repair tissue were generally higher than of the surrounding cartilage. The repair tissue was always more cellular than the adjacent articular cartilage. Histological scoring of the repair tissue revealed a mean Sellers score of 17.6 +/- 3.0 and an ICRS grading of 7-9. CONCLUSION: Failed marrow stimulation of articular cartilage defects in patients with early osteoarthritis is characterized by fibrocartilaginous repair. The balance of cell number to extracellular matrix is shifted towards an increased cell number in this tissue. Articular cartilage repair did not reach the quality of normal hyaline articular cartilage. LEVEL OF EVIDENCE: IV
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Poor outcomes for osteoporotic patients undergoing conversion total hip arthroplasty following prior failed dynamic hip screw fixation: a nationwide retrospective cohort study
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Hip Fx in the Elderly 2019
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OBJECTIVES: This study was performed to compare the long-term clinical and radiological outcomes of conversion total hip arthroplasty (CTHA) following prior failed InterTan nail (IT) fixation or dynamic hip screw (DHS) fixation in Asian patients with osteoporotic intertrochanteric hip fractures (IHFs) and to clarify which implant tends to be more favourable for CTHA.
METHODS: Records of consecutive Asian patients with osteoporosis who underwent conversion of failed primary unilateral IT or DHS fixation to THA from 2010 to 2013 were extracted from the comprehensive database of the China Pacific Insurance Company Ltd. All consecutive procedures were managed by high-volume surgeons. The primary endpoint was the clinical outcome. The secondary endpoint was the radiological outcome.
RESULTS: In total, 447 Asian patients with osteoporotic IHFs (DHS, n = 223; IT, n = 224) were assessed during a median follow-up of 46 months (range, 39-53 months). The two groups showed a significant difference in the Harris hip score at final follow-up and in the orthopaedic complication rate (DHS, 20.2%; IT, 9.8%).
CONCLUSION: Conversion to THA following prior failed DHS fixation tends to be associated with poorer clinical and radiological outcomes in Asian patients with osteoporotic IHFs than that following prior failed IT fixation.
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The P.F.C. sigma RP-F TKA designed for improved performance: A matched-pair study
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Surgical Management of Osteoarthritis of the Knee CPG
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The press fit condylar P.F.C. Sigma RP-F (rotating-platform, high flexion) knee is designed to provide a range of motion (ROM) of 155(degrees) without compromising wear, polyethylene contact stresses, patellofemoral tracking, or stability. The first 50 TKA surgeries using the Sigma RP-F knee performed at the author's institution were matched to 50 rotating-platform knees for age, sex, body mass index, preoperative diagnosis, duration of follow-up, and preoperative ROM to determine the effect of design on postoperative ROM. The mean increase in active ROM in the Sigma RP-F group was 17(degrees), compared with 6(degrees) in the rotating-platform group (P=.0011). The mean increase in active ROM in patients who had less than 120(degrees) of preoperative motion was 27(degrees) in the Sigma RP-F group, compared with 16(degrees) in the rotating-platform group (P=.006). With the new P.F.C. Sigma RP-F design, greater ROM can be achieved independent of preoperative ROM
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Which parameters affect medium- to long-term results after angular stable plate fixation for proximal humeral fractures?
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Glenohumeral Joint OA
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Background: Very little information on medium- to long-term results is available for surgically treated proximal humeral fractures. The aim of this prospective treatment study was to present long-term results after angular stable plate fixation of displaced proximal humeral fractures and to detect which specific patient- and fracture-related parameters affect the clinical outcome. Methods: We performed a prospective clinical and radiologic evaluation of 77 patients with a displaced proximal humeral fracture (28 Neer 2-part, 38 3-part, and 11 4-part fractures; 28 AO A fractures, 30 AO B fractures, and 19 AO C fractures) treated with angular stable plate fixation after a mean follow-up period of 96months (range, 74-133 months). We assessed outcomes with the Constant, University of California-Los Angeles (UCLA), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores and evaluated specific patient- and fracture-related parameters including complications. Results: The mean Constant, University of California-Los Angeles (UCLA), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were 79, 31, and 12 points. Reasons for revisions were implant-related impingement (n=13), screw perforation (n=10), infection (n=4), and secondary fracture displacement (n=1). There was a significant association between worse score results and occurrence of secondary fracture displacement, screw perforation, residual bone deformities, and a rotator cuff defect at follow-up. Conclusions: Good medium- to long-term results after angular stable plate fixation of displaced proximal humeral fracture can be expected. A reconstruction within a range of 15° in both anteroposterior and axillary views and <5-mm tuberosity displacement should be the aim of head-preserving surgery to prevent complications, such as secondary fracture displacement and screw perforation, and a less favorable long-term result.
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Is it safe to combine abdominoplasty and posterior vaginal repair in one surgical session?
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Panniculectomy & Abdominoplasty CPG
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UNLABELLED: Many multiparous women complain of protruded and pendulous abdomens and vaginal outlet relaxation which affect their sexual relationships with their male partners. This study included 47 patients who had these complaints. Some of these patients were working outside the homes and all were mothers of 2-5 children. Due of their home and job responsibilities, they did not have enough time or money for multiple surgeries in more than one session. MATERIAL AND METHODS: The age of these patients was 26-54 years and all patients had poor skin elasticity, pendulous excess subcutaneous fat and skin below the level of the anterior vulvar commissure, and a lax musculoaponeurotic anterior abdominal wall. Also, all patients had a relaxed vaginal outlet and 32 patients had rectocele. Careful perioperative assessment and management was done for each patient to ensure fitness for the long operation and to avoid complications. The combined surgical session consisted of two steps: abdominoplasty and posterior vaginal repair. All the patients were kept in the hospital for two days and they returned to their usual routines in the third week after surgery, and they resumed their sexual relationships with their male partners in the sixth week after surgery. RESULTS: There were no serious complications and this approach was convenient for the patients and their families. The recovery time of the combined surgical session was the same as that of just abdominoplasty, and significantly less than the sum of the recovery periods if the two surgeries had been performed in two sessions. The cost of the combined surgical session was significantly less than doing the surgeries in two sessions. All the patients had significant improvement in their sexual relationships.
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Short-term efficacy of recombinant human GH therapy in cured acromegaly patients with gh deficiency: A single-center experience
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The effectiveness and short-term safety of recombinant human GH (r-hGH) in acromegaly patients with GH deficiency (GHD) after treatment are not well established. The study includes ten subjects with acromegaly who had GHD treated with r-hGH for 6 months. Control groups consisted of ten age-, gender-, and BMI-matched healthy subjects and ten active acromegaly patients who were treatment nainullve. Body composition, quality of life (QoL), muscle strength, lipid profile, and cardiovascular risk factors were assessed in all subjects at baseline, and the same parameters were reassessed after 6 months of therapy with r-hGH in acromegaly with GHD. Repeat magnetic resonance imaging of the sella was performed in treated subjects. Optical colonoscopy was done and biopsies were taken from multiple sites for proliferation indices (Ki67). The median duration of GHD was 17.8 months and dose of r-hGH administered was 5.7(plus or minus)1.5 (mu)g/kg per day. There was improvement in bone mineral content (P=0.01), bone mineral density (P=0.04), muscle strength (P<0.001), total cholesterol (P=0.003), high-density cholesterol (P<0.001), and QoL null score (P=0.005), and reduction in low-density cholesterol (P=0.003) and triglyceride (P=0.004) after treatment. There was no change in lean body mass, total body fat, hsCRP, lipoprotein (a), and fibrinogen levels. There was a modest increase in plasminogen activator inhibitor 1 (P=0.002), but it was lower compared with healthy controls and treatment nainullve acromegalics (P=0.007). Six month-r-hGH therapy improves body composition, atherogenic lipid profile, QoL, and muscle strength in GHD patients who had acromegaly. Long-term prospective studies are needed to evaluate the effect of r-hGH therapy in these patients
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Knee arthroscopic surgery is beneficial to middle-aged patients with meniscal symptoms: a prospective, randomised, single-blinded study
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PJI DX Updated Search
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OBJECTIVE: There is no evidence that a knee arthroscopy is more beneficial to middle-aged patients with meniscal symptoms compared to other treatments. This randomised controlled trial aimed to determine whether an arthroscopic intervention combined with a structured exercise programme would provide more benefit than a structured exercise programme alone for middle-aged patients with meniscal symptoms that have undergone physiotherapy. METHOD: 150 out of 179 eligible patients, aged 45 to 64 (mean:54 +/- 5), symptom duration more than 3 months and standing X-ray with Ahlback grade 0, were randomised to: (1) a physiotherapy appointment within 2 weeks of inclusion that included instructions for a 3-month exercise programme (non-surgery group); or (2) the same as (1) plus, within 4 weeks of inclusion, knee arthroscopy for resection of any significant meniscal injuries (surgery group). The primary outcome was change in pain at 12 months, assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOSPAIN). RESULTS: In the Intention-To-Treat analysis, pain at 12 months was significantly lower in the surgery than in the non-surgery group. The change in KOOSPAIN was significantly larger in the surgery than in the non-surgery group (between-group difference was 10.6 points of change; 95% CI: 3.4 to 17.7, P = 0.004). The As-Treated analysis results were consistent with the Intention-To-Treat analysis results. CONCLUSION: Middle-aged patients with meniscal symptoms may benefit from arthroscopic surgery in addition to a structured exercise programme. Patients' age or symptom history (i.e., mechanical symptoms or acute onset of symptoms) didn't affect the outcome. TRIAL REGISTRATION: NCT01288768
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Radiographic evaluation of hip implants
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PJI DX Updated Search
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Serial radiographs are the mainstay in the longitudinal assessment of hip implants. The prosthesis, periprosthetic bone, and juxta-articular soft tissues are inspected for fracture, periosteal reaction, stress shielding, calcar resorption, osteolysis, bony remodeling, metallic debris, and heterotopic ossification. Comparison radiographs best confirm implant migration, subsidence, and aseptic loosening. Infection, particle disease, reaction to metal, and mechanical impingement are important causes of postsurgical pain, but in their earliest stages they may be difficult to diagnose using radiographs. This article addresses the role of radiography following hip arthroplasty
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Biomechanical models for the pathogenesis of specific distal upper extremity disorders
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: Knowledge of the pathogenesis of most disorders that occur in the distal upper extremity is generally lacking. The individual roles of postulated etiologic factors, such as biomechanical or psychosocial exposures, are poorly understood and their potential interactions even less so. This article proposes biomechanical or physiological models of pathogenesis for specific distal upper extremity disorders. METHODS: Tendon entrapment of the dorsal wrist compartments (tenosynovitis), peritendinitis, lateral epicondylitis, and carpal tunnel syndrome are common specific neuromusculoskeletal disorders of the upper extremities observed among workers. The normal anatomy and function of the targeted structures is considered the initial state; their pathology is considered the final state. Using biomechanical or physiological principles combined with clinical observations and experimental studies, pathways leading from the initial state to the final state are proposed. Each model defined a critical biomechanical or physiological attribute that was considered to best characterize 'dose.' Two temporal patterns of exposure (duration vs. repetition) were used to characterize 'dosage.' The roles of long-term exposure vs. unaccustomed work were mentioned, but not incorporated into the models. RESULTS: Compressive force transmitted to the extensor retinaculum was considered the critical factor in the model for tendon entrapment at the dorsal wrist compartments. Two models were proposed for lateral epicondylitis. One emphasized the role of eccentric exertions; the other emphasized contact pressure from the radial head. The model for peritendinitis relied on localized muscle fatigue. Seven plausible models were presented for carpal tunnel syndrome. CONCLUSIONS: It is possible to propose biologically plausible models of pathogenesis that are both coherent with current knowledge of tissue responses and consistent with clinical observations; however, more than one model was plausible for some conditions. Additional research is needed to determine which, if any, of the proposed models might be correct. Such models may be useful to health care providers and ergonomists in the context of primary, secondary, or tertiary prevention
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Once Annealed Highly Cross-Linked Polyethylene Exhibits Low Wear at 9 to 15 Years
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Hip Fx in the Elderly 2019
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A once annealed highly cross-linked polyethylene (HXLPE) was introduced in 1998. Concerns regarding its long-term performance and oxidative resistance exist because of the presence of retained free radicals. The authors studied 48 patients with 50 hip implants having an average age of 62 years. They were followed for 9 to 15 years. The purpose of this study was to determine linear wear rate and the incidence of osteolysis and/or mechanical failure. At an average follow-up of 12.2 years, the annual linear wear rate was 0.018 mm (SD, 0.024 mm). No mechanical failures or osteolysis have been found to date. The clinical performance of this HXLPE continues to meet expectations despite the presence of free radicals. [Orthopedics. 2016; 39(3):e565-e571.].
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Restorative Effect of Vitamin D Deficiency on Knee Pain and Quadriceps Muscle Strength in Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Both vitamin D deficiency and quadriceps muscle weakness are associated with knee osteoarthritis (KOA) and pain. The aim of this study was to determine the restorative effect of vitamin D deficiency on pain and quadriceps muscle strength in knee osteoarthritis. Patients with KOA aged >=30 years, the presence of knee pain for at least one month or longer and serum 25-hydroxyvitamin (25-OHD) deficiencies were recruited in the study.
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Inferiorly based parenchymal flap mammaplasty: a safe, reliable, and versatile technique for breast reduction and mastopexy
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Breast reduction and mastopexy are among the most frequent procedures in aesthetic breast surgery. Many approaches have been described, and various types of dermaglandular pedicles for the nipple-areola complex have been used. The authors present a technique suitable for either mastopexy or breast reduction whereby the superior or superomedial pedicle supplying the nipple-areola complex is combined with an inferior dermaglandular flap to restore the upper pole fullness, thereby improving breast shape and projection.
METHODS: From January of 2008 to January of 2010, 83 patients underwent inferiorly based parenchymal flap mammaplasty. Patients' ages ranged from 23 to 65 years. The mean follow-up period was 27 months. The inferior breast tissue that is usually removed in a superior/superomedial pedicle technique is spared and shaped as a small implant and stitched to the pectoralis major muscle. The superior/superomedial pedicle is used for the nipple-areola complex.
RESULTS: All the procedures were successful. No major complications were reported. All the patients were very satisfied with the shape, size, projection, and upper pole fullness of their breast postoperatively as reported by the questionnaire. Comparative evaluation test scores of a four-member jury were significantly higher regarding breast shape (p = 0.007), projection (p = 0.0041), and upper pole fullness (p = 0.0028).
CONCLUSIONS: The inferiorly based parenchymal flap mammaplasty is a safe, versatile, and reproducible technique. It demonstrates ease of pedicle shaping and breast remodeling in patients undergoing mastopexy and breast reduction.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Qigong Therapy for Individuals With Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OA is the leading cause of disability in the United States. Standard treatment for OA is drug therapy; however, cost, side effects, and varying levels of effectiveness warrant the need for development of new treatments. Qigong therapy, which involves deep meditation, breathing exercises, and the harnessing of energy, may be an effective treatment for OA. According to traditional Chinese medicine, Qi (Chi) is the "life force" that flows through the body and keeps people healthy and vital. In the practice of traditional Chinese medicine, arthritis is thought to be due to a blockage of the flow of Qi or a buildup of abnormal or damaging Qi. It is believed that releasing this buildup or breaking the blockage of Qi through Qigong therapy may relieve OA symptoms. Participants will be randomly assigned to receive five sessions of either Qigong therapy or sham treatment over a period of 2 weeks. During Qigong therapy, a therapist will send his or her Qi to the arthritic knees through touch and meditation. Similar body work will be performed during the sham treatment, but no Qi will be harnessed. Selfâ?report scales that measure pain, stiffness, anxiety, daily drug use, CAM use, and overall functioning will be used to assess participants. The assessments will occur at study start and at a 3â?month followâ?up visit.
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Low incidence of deep vein thrombosis after total hip replacement: an interim analysis of patients on low molecular weight heparin vs sequential gradient compression prophylaxis
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AAHKS (9/10) Regional Nerve Blocks
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The relative merits of compression and low molecular weight heparin (LMWH) as prophylaxis against DVT in hip arthroplasty have not been thoroughly investigated. We present an interim analysis of a study which compares the effects of LMWH and sequential gradient intermittent pneumatic compression on the development of DVT, and is intended to include 75 evaluable patients, of whom 47 have been treated to date. Fifty two patients were randomized to receive either a thigh length sequential compression device (SCD (R)) combined with full length T.E.D. (R) stockings (SCD/TED), or enoxaparin 40 mg subcutaneously daily. Both regimens were started the evening before surgery, and were continued until full mobilization (7â?8 days). Five patients withdrew at an early stage. The remaining 47 patients completed the study with ascending venography being performed on day 7â?8. Of the 47 patients, 21 were allocated to SCD/TED prophylaxis and 26 to the LMWH regimen. No significant differences were recorded between the two groups, in patient description or peroperative data. Venography was performed in all but 2 patients, for whom the procedure was contraindicated. No thrombosis was found in any of the patients and there were no clinical signs causing suspicion of DVT in any case. The predominance of pharmacological prophylaxis in Sweden led to some skepticism, expressed by some older patients, regarding use of the mechanical devices. This may have contributed to the early withdrawals. With a limited number of patients the finding of no DVT in both groups seems promising, and gives the impression that mechanical prophylaxis alone, using thigh length sequential gradient compression and T.E.D. stockings, is sufficient to prevent DVT in the high risk group undergoing hip arthroplasty. The contribution of early mobilization and regional anesthesia towards this low DVT rate remain to be determined. Copyright © 2011 Elsevier B. V., Amsterdam. All Rights Reserved.
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Acupuncture in Distal Radius Fracture Patients
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Distal Radius Fractures
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Distal radius fractures are very common, ranging between 17 and 20% of all diagnosed fractures, and are the most common fractures treated by orthopedic surgeons in adult patients. It is defined as a fracture of the distal radius, which is less than 2.5 cm from the radiocarpal joint. Usually it is the result of falling on the outstretched hand. These fractures occur in all age groups and a bimodal distribution is observed with a peak incidence predominantly young adult patients and another peak in older women. In order to achieve successful functional results in distal radius fracture both an adequate treatment and timely and specific rehabilitation are required. The distal radius fracture guidelines generally indicate that rehabilitation therapy should begin at four to six weeks post injury or surgery after cast or external fixator is removed initiating passive/active ranges of motion exercises for the fingers, wrist and forearm. Patients are encouraged to use the wrist at home for light activities. At nine to 12 weeks post injury patients can initiate grip strengthening. There is limited available literature on the effect of acupuncture in the treatment of fractures. Two case reports claim to have achieved an acceleration of bone healing and pain management of patients with proximal humerus fracture when treated with a combination of acupuncture, electroâ?acupuncture and herbal medicine. Another study concluded that electroacupuncture plus radiation therapy with infrared rays and passive exercises was clearly superior to therapy with only exercises after surgery for humerus fracture. There is a modality of acupuncture using low level laser therapy, which is useful for tissue regeneration in general and to stimulate acupuncture points. Current clinical research has confirmed the therapeutic usefulness of laser acupuncture in and equine laminitis and in humans in treating myofascial pain, tennis elbow, knee osteoarthritis and other musculoskeletal diseases. The low level laser therapy, is a type of noninvasively phototherapy that has been shown to modulate various biological processes depending on the power density, wavelength and frequency. A recent study using rats showed that laser stimulation of acupuncture point (located in the leg) caused a significant antinociceptive effect controlling the behavior induced in rats caused by pain after peritoneal injection of acetic acid and injection of formalin in rat paws. The effect is mediated by activation of the opioidergic and serotoninergic systems (5HTâ?1 and 5HTâ?2A receptors). Investigators will try to determine whether laser acupuncture has a positive effect on the rehabilitation of patients with distal radius fracture and to establish a safe therapy without adverse effects that may alleviate pain and restore the functionality of the joint as soon as possible. This study will be a prospective, longitudinal, randomized, doubleâ?blind trial which will include 32 volunteers. All patients with a diagnosis of distal radius fracture type 23â?A2, A3, B1, and B2 of the Orthopedic Trauma Association classification that comply with the inclusion criteria will be included. Patients will be randomly assigned to one of two groups: control or experimental group. The sessions will start as soon as the patient has their cast removed. Control group will receive conventional rehabilitation exercises and "fake" laser acupuncture (device turned off). Experimental group A will receive treatment with conventional rehabilitation plus real laser acupuncture on the following points: bilateral Hegu (IG4), ipsilateral Yangxi (IG5), ipsilateral Yangchi (SJ4), ipsilateral Yanggu (ID5), ipsilateral Waiguan (SJ15), ipsilateral Daling (PC7), contralateral Taixi (R3), contralateral Shenmai (V62) and contralateral Kunlun (V60). All patients will receive a total of 10 sessions with a frequency of 3 times a week. The laser that will be used in this study is a low level laser therapy device (980nm, 50 mW). Each acupuncture point will be irradiated for 30 seconds at 8,000 Hz. All patients will u dergo clinical evaluation to assess improvement using the Patientâ?Rated Wrist Evaluation Scale. Patients also will be evaluated with the Visual Analogue Scale. The investigators will also measure improvement in range of motion of the wrist (flexion, extension, radial deviation, ulnar deviation, pronation and supination) and grip strength. The first assessment will be made right before starting rehabilitation and acupuncture, the day of the 5th session, again on the day of the 10th session and finally one week after completing the 10 sessions. All evaluations should be performed by blinded investigator. The investigators will compare the two groups to determine the degree of improvement with each treatment modality used.
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Defining the lymphatic system of the anterior abdominal wall: an anatomical study
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Studies describing recent abdominoplasty modifications have reported a decreased incidence of seroma, attributed to preservation of abdominal lymphatics. However, there are limited anatomical data to support this hypothesis. The authors sought to characterize the lymphatic architecture of the abdominal wall and provide a conceptual basis for further refinement of abdominoplasty techniques. METHODS: Fifteen tissue samples from five patients undergoing abdominoplasty were sectioned and analyzed. Slides were stained with hematoxylin and eosin, CD31, and D2-40 and assessed by a pathologist and a plastic surgeon for the presence and number of lymphatics. Results were reported as mean percentage of lymphatic-specific antibody per analyzed area. RESULTS: Lymphatic vessels were observed in the dermis, superficial fascia, and loose areolar tissue but not in deep or superficial fat. The highest concentration was in the dermis (mean, 82.6 percent; range, 69 to 89.2 percent). The Scarpa fascia contained 9.4 percent of lymphatics (range, 7.0 to 11.4 percent), whereas the loose areolar tissue at the specimen base contained an average of 7.9 percent (range, 2.6 to 19.5 percent). These lymphatics were consistently located in the deepest third, with the Scarpa fascia lying an average of 34 percent of the total tissue thickness above muscle fascia. Lymphatic prevalence did not increase in specimens near the superficial epigastric vessels. CONCLUSIONS: Abdominoplasty flap lymphatics are most common in the dermis, with a significant proportion (approximately 17 percent) also appearing near fascial layers. This confirms the presence of deep lymphatic channels that could potentially be preserved during abdominoplasty or lipoabdominoplasty.
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Study on acupoint needle-embedding combined with postoperative systematic early mobilization in the prevention of DVT formation following elderly intertrochanteric fracture
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Hip Fx in the Elderly 2019
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Objective: To discuss clinical effect o f acupoint needleâ?embedding combined with postoperative systematic early mobilization in the prevention of DVT formation following elderly intertrochanteric fracture. Methods: 100 cases of patients were randomly divided into the experiment group of 51 cases and the control group of 49 cases. The treatment group adopted acupoint needleâ?embedding and systematic early mobilization. The control group adopted conventional nursing. The figures of the two groups in Dâ?dimer, APTT, PT, as well as body surface temperature, limb circumference of 5cm (centimeter) above the ankle, 10cm below the patella and 10cm above the patella of the two groups were compared. Results: Seven days after the operation, authors found Dâ?dimer, body surface temperature, limb circumference of 5cm (centimeter) above the ankle, 10cm below the patella and 10cm above the patella of the treatment group were significantly lower than those of the control group. Conclusion: The acupoint needleâ?embedding combined with postoperative systematic early mobilization could prevent DVT formation following elderly intertrochanteric fracture effectively.
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0 |
Scintigraphic study of the biological fixation of the Christiansen endoprosthesis with madreporic shank
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Management of Hip Fractures in the Elderly
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Biological fixation of the Christiansen endoprosthesis takes place gradually as a result of osteogenetic activity in the endosteal wall of the femur, which is subjected to mechanical stimulation by the madreporic shank of this prosthesis. The authors were able to monitor this biological process in 9 patients with the aid of bone scintigraphy
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0 |
Randomized phase II trial of denosumab in patients with bone metastases from prostate cancer, breast cancer, or other neoplasms after intravenous bisphosphonates
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MSTS 2018 - Femur Mets and MM
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PURPOSE: Patients with bone metastases and elevated urinary N-telopeptide (uNTx), representing excessive bone resorption, are at increased risk for skeletal-related events (SREs), cancer progression, and death. Osteoclast-mediated bone resorption is regulated by RANKL. We evaluated the effect of denosumab, a fully human monoclonal antibody against RANKL, in patients with bone metastases and elevated uNTx levels despite ongoing intravenous (IV) bisphosphonate (BP) therapy.
PATIENTS AND METHODS: Eligible patients had histologically confirmed malignancy, > or = 1 bone metastases, and uNTx levels higher than 50 nmol/L bone collagen equivalents (BCE)/mM creatinine despite IV BPs. They were stratified by tumor type and screening uNTx levels (50 to 100 or > 100 nmol/L BCE/mM creatinine), and randomly assigned to continue IV BPs every 4 weeks or receive subcutaneous denosumab 180 mg every 4 weeks or every 12 weeks.
RESULTS: Among 111 patients accrued, the primary end point of uNTx levels lower than 50 nmol/L BCE/mM creatinine (uNTx < 50) at week 13 was achieved by 49 (71%) of 69 patients in the denosumab arms, compared with 10 (29%) of 35 patients in the IV BP arm (P < .001). The proportion of patients with uNTx lower than 50 was maintained at week 25 (64% denosumab arms; 37% IV BP arm; P = .01). The incidence of SREs was six (8%) of 73 and six (17%) of 35 in the denosumab group and IV BP group, respectively. Rates of adverse events were similar between treatment groups.
CONCLUSION: Among patients with elevated uNTx despite ongoing IV BP therapy, denosumab normalized uNTx levels more frequently than the continuation of IV BP. Fewer patients receiving denosumab experienced on-study SREs than those receiving IV BPs.
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The curative effect of liposuction curettage in the treatment of bromhidrosis: A meta-analysis
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: We aimed to understand the curative effect of liposuction curettage (LC) in the treatment of bromhidrosis. METHODS: Relevant studies published before January 2017were searched from the PubMed, Embase, Cochrane Library, Wanfang, VIP, and China National Knowledge Infrastructure databases. Parameters including recurrence, complications, complete response, and overall response were assessed. Meta-analysis was performed using the R 3.12 statistical package. Odds ratio (OR) and 95% confidence interval (95% CI) were used for dichotomous data. Heterogeneity was assessed using Cochran's Q-statistic and I test. In addition, Egger's test was conducted to detect publication bias. RESULTS: Ten studies with a total of 1124 participants (545 cases and 579 controls) were included. There was no statistical difference in recurrence (OR = 1.19, 95% CI: 0.51-2.74), complete response (OR = 0.66, 95% CI: 0.25-1.74), or overall response (OR = 0.63, 95% CI: 0.21-1.87) between the case and control groups. The incidence of complications in the case group was lower than that in the control group (OR = 0.24, 95% CI: 0.08-0.67) and open excision group (OR = 0.11, 95% CI: 0.07-0.19). Publication bias existed for the recurrence index in the open excision group (t = 3.3979, P = .04), but no publication bias was found in other subgroups, indicating stable results. CONCLUSIONS: LC, which has fewer complications, can be considered the primary choice in the treatment of patients with bromhidrosis compared with other surgical procedures.
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Intra-synovialvs. Extra-synovial ropivacaine for pain relief after total knee arthroplasty-a prospective, randomized, double blind study
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Surgical Management of Osteoarthritis of the Knee CPG
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Background and aims: Comfort and lack of pain are important for optimal mobilization after knee replacement. In this study we evaluated the effect of intra-articular or extra-articular administration of the local anesthetic as postoperative supplement to high-volume local infiltration analgesia. Methods: Thirty six rheumatic patients of age 51-78 yrs with ASA 2-3 physical status scheduled for total knee arthroplasty were randomized into two groups in this double blind study. All patients received high-volume wound infiltration at the end of surgery with 300 mg ropivacaine, 30 mg ketorolac and 0,5 mg epinephrine (total volume 156 ml). Tunneled catheter was randomly placed extra-articularly or intra-articularly. Continuous infusion of Ropivacain 0,5% 2 ml/h was started immediately and was maintained during the 48 hours. Results: Ropivacaine administered intra-articularly did not improve analgesia at rest, during flexion, or during mobilization compared with extraarticular site of infusion (the lowest p=0,3672), but there was a tendency of improved analgesia during mobilization 60 h postoperatively (VAS 2,5(plus or minus)1, 6 vs. 4,0(plus or minus)2,3; p= 0,051). No difference between the groups was found regarding analgesic requirements (53(plus or minus) 21 mg of PCA morphine vs. 56(plus or minus)22 mg respectively). No complications ofpostoperative wound healing or toxic side effects were seen. Conclusions: Continuous infusion of ropivacaine through intra-articularly placed catheter did not improve analgesia postoperatively compared with extraarticular site of administration
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Safety and efficacy of risedronate in reducing fracture risk in osteoporotic women aged 80 and older: implications for the use of antiresorptive agents in the old and oldest old
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To determine the efficacy of risedronate in reducing vertebral fracture risk in women aged 80 and older with osteoporosis. DESIGN: Pooled analysis of data from three randomized, double-blind, controlled, 3-year-fracture-endpoint trials conducted from November 1993 to April 1998: Hip Intervention Program (HIP), Vertebral Efficacy with Risedronate Therapy-Multinational (VERT-MN), and VERT-North America (NA). SETTING: Office-based practices, research centers, and osteoporosis clinics in Europe, North America, and Australia. PARTICIPANTS: Osteoporotic (femoral neck bone mineral density T-score < -2.5 standard deviations or at least one prevalent vertebral fracture) women aged 80 and older. INTERVENTION: Patients received placebo (n=688) or risedronate 5 mg/d (n=704) for up to 3 years. All patients received 1,000 mg/d calcium and, if baseline levels were low, up to 500 IU/d vitamin D. MEASUREMENTS: Cumulative incidence of new vertebral fractures. RESULTS: After 1 year, the risk of new vertebral fractures in the risedronate group was 81% lower than with placebo (95% confidence interval=60-91%; P<.001). The number of women who needed to be treated to prevent one new vertebral fracture after 1 year was 12. This early onset of efficacy was consistent across the clinical programs, and antifracture efficacy was confirmed over 3 years. Risedronate was well tolerated, with a safety profile comparable with that of placebo. CONCLUSION: These findings provide the first evidence that, even in the very old, reducing bone resorption rate remains an effective treatment strategy for osteoporosis. Because each therapeutic agent used for the treatment of osteoporosis may have unique characteristics, the observations made in this study should not be assumed to apply to other bisphosphonates
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Dentists' knowledge and implementation of the 2007 American Heart Association guidelines for prevention of infective endocarditis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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OBJECTIVES: Our aim was to evaluate the knowledge and implementations of the 2007 American Heart Association guidelines for the prevention of infective endocarditis (IE) among practicing Israeli dentists, 12 months after their publication. STUDY DESIGN: A total of 118 dentists completed a questionnaire regarding required antibiotic prophylaxis for 10 specific cardiac patient subtypes before invasive dental treatment, prophylactic need in at-risk patients for IE in 10 dental procedures, and prophylactic regimen for nonallergic patients. RESULTS: Correct answer response for cardiac conditions was 81.3% (highest failure: mitral valve prolapse [MVP] with regurgitation). There was a consensus among the participants regarding antibiotic regimen for high-risk patients during several dental procedures, such as intraoral radiography, tooth extraction, and periodontal surgery, but a controversy for other procedures. The procedures of disagreement were endodontic treatment, tooth preparation with oral impressions, and restoration of class II caries lesion. Correct antimicrobial agent, dose, and timing were prescribed by 99%, 93.8%, and 100% of the respondents, respectively. CONCLUSIONS: Relatively high level of knowledge of the new guidelines was found among dentists, reflecting both familiarity of the practitioners with the guidelines and acceptance of guidelines. Prophylactic need is ambiguous during restorative, endodontic and prosthetic procedures. Educational resources should emphasize these guidelines, specifically the reduced risk level for MVP with regurgitation patients
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Treatment of adults with growth hormone (GH) deficiency with recombinant human GH
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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In a double blind, cross-over placebo-controlled trial, we studied the effects of 26 weeks of replacement therapy with recombinant human GH on body composition, metabolic parameters, and well-being in 10 patients with adult- onset GH deficiency (GHD). All patients received appropriate thyroid, adrenal, and gonadal replacement therapy. The dose of recombinant human GH was 0.25-0.5 U/kg (middle dot) week (0.013-0.026 mg/kg (middle dot) day) and was administered sc daily at bedtime. One patient was withdrawn from the study because of edema and atrial fibrillation. Body composition was estimated with three independent methods: computed tomography, bioelectric impedance, and total body potassium combined with total body water assessments. The Comprehensive Psychological Rating Scale and the Symptom Check List-90 were used to assess any change in psychopathology. After 26 weeks of treatment, adipose tissue (AT) mass decreased 4.7 kg (P < 0.001). Subcutaneous AT decreased by an average of 13%, whereas visceral AT was reduced by 30%. Muscle volume increased by 2.5 kg (5%; P < 0.05). According to the four-compartment model derived from assessments of total body potassium and total body water, body cell mass and extracellular fluid volume increased significantly by 1.6 and 3.0 kg, whereas body fat decreased by 6.1 kg. Results obtained by the bioelectric impedance technique were similar. The mean ((plus or minus)SD) concentrations of insulin-like growth factor-I increased from 0.26 (0.06) at baseline to 2.56 (1.55) and 2.09 (1.03) kU/L after 6 and 26 weeks of treatment. Calcium and serum phosphate, osteocalcin, and procollagen-III concentrations were significantly higher, and intact PTH concentrations were reduced after 6 and 26 weeks of treatment, respectively. Total and free T(3) concentrations were significantly increased after 6 and 26 weeks of treatment, whereas free T(4) concentrations were reduced at 6 weeks, but after 26 weeks, free T(4) concentrations had returned to pretreatment values. Finally, after 26 weeks of treatment, there was a decrease in the Comprehensive Psychological Rating Scale score (P < 0.05). The results show that GH replacement in GHD adults results in marked alterations in body composition, fat distribution, and bone and mineral metabolism and reduces psychiatric symptoms. Finally, we conclude that the observed beneficial effects of replacement therapy with GHD are of sufficient magnitude to consider treatment of GHD adults
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Ten years fracture risk assessment in prevalent patients with kidney transplantation
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Introduction and Aims: Several studies reported osteoporosis in renal transplant patients and in patients with kidney transplantation resulted an higher incidence of fractures than in general population. The aim of this study was the evaluation of bone loss as well of fracture risk in a population of patients with kidney transplantation of our Center. Methods: We performed a cross-sectional observational study on 82 prevalent renal transplant patients, 52 M and 30 W, of mean age of 56(plus or minus)11 years with clinically stable renal graft from more than 1 year (transplant age 121(plus or minus)76 months). In all patients we measured lumbar spine (LS), total femur(TF) and femoral neck (FN) bone mineral density (BMD, g/cm(2)) by dual energy x-ray absorptiometry (DEXA) and the ten years probability (%) of hip fracture (HF) and major osteoporotic fractures (vertebral, proximal humerus, distal femur, proximal tibia, pelvis, multiple rib: MOF) was measured by WHO fractures risk assessment tool (FRAX), including country and the main fracture risk factors (sex, BMI, previous fracture, parent fractured hip, current smoking, glucocorticoids, rheumatoid arthritis, alcohol 3 more units per day) and femoral neck BMD T score. Results: LS, TF and FN BMD mean values(plus or minus)SD were 878(plus or minus)126, 823(plus or minus)134 and 688(plus or minus)116 g/cm(2), with T score of -1.76(plus or minus)1.15, -1.24(plus or minus)0.98 and - 1.66(plus or minus)0.93. 43/82(52%) patients presented osteopenia (LS and/or TF and/or FN (<-1>-2.5 SD), 26/81(32%) were osteoporotic (LS and/or TF and/or FN <-2.5 SD) and only 13/81 patients (16%) were in the normal range (>-1<1 SD). 5/82 patients (6%, 4Wand 1 M) presented prevalent fractures (3 at the femoral and 2 at the vertebral level). BMI mean values were 24.8(2.5) kg/cm(2). 21/30 (70%) were postmenopausal W. All patients were on immunosuppressive treatment, in 17/82 (21%) of these non including steroid therapy. The 10 years % probability mean values of HF and MOF were 5.3(plus or minus) 5.1 and 12.6(plus or minus)7.3. 49% (41/82) of patients, 53%(23/52) of M and 43% (13/30) of F presented a >3% probability of HF and in the 24% (10/41) of these, 3 M(30%) and 7 F(70%) a > 20% probability of MOF was associated. In overall population 26/82 patients, 14/30 of F (47%) and 12/52 of M (23%) were on calcium and/or vitamin D therapy. Conclusions: Our study confirm an high prevalence of secondary osteoporosis in kidney transplantation and in a significative percentage of renal transplant patients resulted an increase of ten years probability of hip and major osteoporotic fractures for which treatment is recommended. Calcium and vitamin D therapy alone resulted inefficient to decrease the probability of HP and MOF and less utilized particularly in males. Different more active and standardized routine treatments are needed to decrease fracture risk in renal transplant patients
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1 |
Cartilage change after arthroscopic repair for an isolated meniscal tear
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AMP (Acute Meniscal Pathology)
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To investigate the direct effect to the cartilage caused by the meniscal repair, we examined patients who underwent an isolated meniscal repair without any other abnormalities by arthroscopic examination. A total of 17 patients were examined by second-look arthroscopy after an average interval of 9 months from the meniscal repair, and have been evaluated the status of the repaired meniscus and of the relative femoral condylar cartilage. Changes in the severity of the cartilage lesion between at the time of meniscal repair and the time of the second-look arthroscopy were considered based on the status of the repaired meniscus. Regardless of the healing status of the repair site, it was possible to prevent degeneration in the cartilage in 9 of the 10 patients who demonstrated no degeneration in the meniscal body. Of the 7 patients who demonstrated degeneration in the meniscal body, progression in cartilage degeneration was noted as 1 grade in 2 patients and 2 grades in another 3 patients. Even in those in which stable fusion of the repair site was achieved, the condition of the inner meniscal body was not necessarily maintained favorably in all cases, indicating that degeneration in the meniscal body was a risk factor for cartilage degeneration. It was concluded that recovery could not be expected even at 9 months after the repair if the lesion had already demonstrated degeneration in the meniscal body at the time of repair.
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What Is the Price and Claimed Efficacy of Platelet-Rich Plasma Injections for the Treatment of Knee Osteoarthritis in the United States?
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OAK 3 - Non-arthroplasty tx of OAK
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Platelet-rich plasma (PRP) injections are often used for the treatment of knee osteoarthritis (OA), despite clinical value and cost-effectiveness not being definitely established. PRP injections are considered as a potential means of reducing pain and improving function in patients with knee OA, in the hope of delaying or avoiding the need for surgical intervention. Centers that offer PRP injections usually charge patients out of pocket and directly market services. Therefore, the purpose of this study was to quantify the current (1) prices and (2) marketed clinical efficacy of autologous PRP injections for knee OA. A prospective cross-sectional study was performed based on 286 centers identified in the United States offering PRP injections for knee OA. A total of 179 (73.4%) centers were successfully contacted via e-mail or phone, using a simulated 52-year-old male patient with knee OA. Scripted questions were asked by the simulated patient to determine the current marketed prices and clinical efficacy, either reported as "good results" or "symptomatic improvement," claimed by each treating center. The mean price for a single unilateral knee same-day PRP injection was $714 with a standard deviation of $144 (95% confidence interval [CI]: $691-737, n = 153). The mean claim of clinical efficacy was 76% with a standard deviation of 11% (95% CI: 73.5-78.3%, n = 84). Out of the 84 clinics, 10 claimed "90 to 100% efficacy," 27 claimed "80 to 90%," 29 claimed "70 to 80%," 9 claimed "60 to 70%," 8 claimed "50 to 60%," and 1 claimed "40 to 60%." These findings provide a unique perspective on the PRP market for the treatment of knee OA that is valuable to physicians and health care providers in providing better education to patients on the associated costs and purported clinical benefits of PRP injections.
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Effect of increase in birth weight in a newborn on hip ultrasonography
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Developmental Dysplasia of the Hip 2020 Review
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Exposure to the pressure experienced by higher birth weight babies during the intrauterine period might cause hip dysplasia. The aim of this study is to determine the effect of birth weight in newborns on hip ultrasonography when the paternal and maternal risk factors are excluded. A total of 701 babies born at 38-42 gestational weeks were included in the study. Hip ultrasonography was performed within 7 days following birth using the Graf technique in the babies without risk factors for developmental dysplasia of the hip. Images obtained were controlled with respect to conformity to the Graf method and angular measurements were performed. According to the α and β angle values obtained, type 1A and 1B hips were categorized as mature; type 2A hips were categorized as immature; and type 2C, D, 3A, 3B, and 4 hips were categorized as pathological hips. The results obtained were analyzed for the effect of birth weight on the angular values and hip typing. The birth weight of the babies was 338,488 ± 48,241â??g (2030-6124â??g). It was determined that the birth weight had no effect on the values of α and β angles in the male babies (P=0.21, 0.76). It was determined that increasing birth weight decreased the α angle value (P=0.001) and caused no difference in the β angle value (P=0.057) in the female babies. It was found that birth weight had no effect on hip typing in both female and male babies (P=0.060, 0.22). Increases in birth weights caused decreases in ultrasonographic α angles only in female babies.
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Long term results with the interlocking uncemented long stem in revision hip arthroplasty: a mean 15-year follow-up
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Hip Fx in the Elderly 2019
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Stem fixation is difficult to achieve in severe proximal bone loss in revision hip surgery. In this study, we sought to present the results of distally-locked stem with screws (HUCKESTEP HIP stem) in 21 revision hips with mean follow-up period of 15 years. The preoperative mean Japanese Orthopaedic Association hip score had improved from 54 to 75 points. Further revisions were required for 2 stems, in one because of infection and the other because of screws fracture and subsidence. With removal of the stem for any reason as an end-point, the cumulative survival at 15 years was 90.4%. While this study had small number, the use of this interlocking stem for revision hips with extensive proximal bone defects provided satisfactory 15-year clinical and radiographic results.
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1 |
Intramedullary nailing for adult open tibial shaft fracture. An 85-case series
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DoD SSI (Surgical Site Infections)
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INTRODUCTION: Treatment of open tibial shaft fracture is controversial due to the risk of infection. We assessed results in a continuous series of open tibial shaft fractures treated by primary intramedullary nailing.
HYPOTHESIS: Factors can be determined for non-union and onset of infection following primary intramedullary nailing in open tibial shaft fracture.
PATIENTS AND METHOD: A retrospective study assessed open tibial shaft fractures treated by primary intramedullary nailing between January 2007 and December 2013. Fractures were classified on the AO and Gustilo classifications. Infection rates and time to union were compared.
RESULTS: Eighty-five patients (85 fractures) were included: 13 Gustilo type I, 43 type II, 19 type III-A and 10 type III-B. Eight patients had infection (9%). Healing and union were obtained after nail exchange and reaming in 5 cases, and after bone transport in 2. One patient showed non-union at last follow-up. Infection risk did not correlate with Gustilo (p=0.55) or AO type (p=0.69). The interval between trauma and wound debridement was significantly longer in infected patients (p=0.048). Eighty-three fractures (97.6%) healed, at a mean 6.9+/-6.1 months (range, 2-40). Non-union was associated with AO type (p=0.04), and showed a non-significant association with Gustilo type (p=0.06).
DISCUSSION: Time to treatment was the only factor influencing risk of infection. Non-union was related to AO comminution grade. Primary intramedullary nailing seemed reliable if treatment was early, with rigorous debridement. The advantages then are early resumption of weight-bearing and low patient burden.
LEVEL OF EVIDENCE: V, retrospective study.
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0 |
Time-lagged relationships between leadership behaviors and psychological distress after a workplace terrorist attack
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DoD PRF (Psychosocial RF)
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PURPOSE: The impact of leadership practices on employee health may be especially evident after extreme events that have physical, psychological, or material consequences for the members of an organization. In this prospective study, we aimed to examine the association between leadership behavior and psychological distress in employees who had experienced a workplace terror attack.
METHODS: Ten and 22 months after the 2011 Oslo bombing attack targeting their workplace, ministerial employees (n = 2272) responded to a questionnaire assessing fair, empowering, supportive, and laissez-faire leadership, as well as psychological distress. Cross-sectional and time-lagged associations between the constructs were tested using structural equation modeling.
RESULTS: Cross-sectionally, higher levels of supportive leadership were associated with lower levels of psychological distress. Longitudinally, negative relationships were found between psychological distress and subsequent ratings of fair and empowering leadership.
CONCLUSIONS: Supportive leadership was associated with employees' psychological health after trauma, but seems not to have long-term effects on subsequent psychological distress. Rather, psychological distress may lead the employees to perceive their leaders as more negative across time.
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Unnecessary Pre-Operative Cardiology Evaluation and Transthoracic Echocardiogram Delays Time to Surgery for Geriatric Hip Fractures
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Hip Fx in the Elderly 2019
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OBJECTIVE: Delays to surgery for geriatric hip fracture patients are associated with increased morbidity and mortality. The American Heart Association (AHA) and American College of Cardiology (ACC) Clinical practice guidelines (CPG) were created to standardize pre-operative cardiology consultation and transthoracic echocardiogram (TTE). This study's purpose is to determine if these practices are over utilized and delay time to surgery at a safety net hospital.
DESIGN: Retrospective review.
SETTING: Level 1 trauma center and safety net hospital PATIENTS:: Charts were reviewed for indications of preoperative cardiology consultation or TTE per AHA and ACC CPG in 412 admitted geriatric hip fracture patients.
INTERVENTION: Criteria meeting the AHA/ACC guidelines for preoperative TTE andcardiac consultations.
MAIN OUTCOME MEASUREMENTS: Time to surgical intervention RESULTS: : Despite 17.7% of patients meeting criteria, 44.4% of patients received cardiology consultation. Of those patients, 33.8% met criteria for receiving preoperative TTE, but 89.4% received one. Time to surgery was greater for patients receiving cardiology consultation (25.42+/-14.54 hours, p-value <0.001) versus those who did not (19.27+/-13.76, p-value <0.001), and for those receiving preoperative TTE (26.00+/-15.33 hours, p-value <0.001) versus those who did not (18.94+/-12.92, p-value <0.001).
CONCLUSIONS: Cardiology consultation and TTE are frequently utilized against AHA/ACC CPG. These measures are expensive and delay surgery, which can increase morbidity and mortality. These findings persisted despite limited resources available in a safety net hospital. Hospitals should improve adherence to CPG, or modify protocols.
LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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1 |
Higher cefazolin concentrations with intraosseous regional prophylaxis in TKA
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PJI DX Updated Search
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BACKGROUND: Prophylactic antibiotics reduce the risk of deep infection after primary TKA. However, conventional systemic dosing may not provide adequate tissue concentrations against more resistant organisms such as coagulase-negative staphylococci. Regional intravenous administration of antibiotics after tourniquet inflation achieves far higher tissue concentrations but requires foot vein cannulation. The intraosseous route may offer a rapid and reliable method of regional administration. QUESTIONS/PURPOSES: We compared tissue concentrations of cefazolin achieved with systemic versus regional intraosseous administration. METHODS: Twenty-two patients undergoing primary TKA were randomized into two groups. Group 1 received 1 g cefazolin systemically 10 minutes before tourniquet inflation. Group 2 received 1 g cefazolin intraosseously in 200 mL of normal saline through a tibial cannula after tourniquet inflation and before skin incision. Subcutaneous fat and femoral bone samples were taken at set intervals during the procedure and antibiotic concentrations measured using a validated technique involving high-performance liquid chromatography. RESULTS: The overall mean tissue concentration of cefazolin in subcutaneous fat was 186 ug/g in the intraosseous group and 11 ug/g in the systemic group. The mean tissue concentration in bone was 130 ug/g in the intraosseous group and 11 ug/g in the systemic group. These differences were consistent across all sample time points throughout the procedure. CONCLUSIONS: Intraosseous regional administration can achieve concentrations of antibiotic in tissue an order of magnitude higher than systemic administration. Further work is required to determine if this translates into increased efficacy in preventing infection, particularly against coagulase-negative staphylococci
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0 |
HIV/AIDS: occupational risk, attitude and behaviour of surgeons in southeast Nigeria
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Dental Implant Infection
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Our objective was to evaluate the level of occupational risk, attitude and behaviour of surgeons towards HIV-infected patients. A questionnaire survey of 264 randomly selected surgeons in training or in practice in five different health institutions in southeast Nigeria within a five-month period was carried out. A 94% response rate was obtained with completed questionnaires from 264 surgeons. The respondents included obstetricians and gynaecologists (n = 78), general surgeons (n = 121), orthopaedic surgeons (n = 40), dental surgeons (n = 10), ophthalmologists (n = 6), urologists (n = 5), and ear, nose and throat surgeons (n = 4). Of them, 31% (n = 82) were qualified surgeons in practice, while the remaining 69% (n = 182) were resident surgeons in training. In the past five years, 40.2% (n = 106) and 26% (n = 70) of the respondents reported needle-stick injuries and blood splash, respectively, during surgery. The majority of the victims were resident surgeons, obstetricians and gynaecologists, and orthopaedic surgeons. Level of clinical experience and high patient blood loss are likely to contribute to this observation. In all, 89% (n = 236) were engaged in the risky practice of operating on patients with open wounds in their hand and the wounds were contaminated with blood in 5% of cases. During surgical procedures, all (100%) respondents wore protective apron, 65.2% (n = 172) wore double gloves and 30.3% (n = 80) used protective goggles. The use of double gloves and protective eye wear increased remarkably over the past decade, probably because the fear of occupational transmission of HIV was substantial. In total, 83% (n = 220) of the respondents had some reservations about treating patients infected with HIV, while 13.3% (n = 35) viewed them with fear. The remaining 3.4% (n = 9) had a more positive attitude towards HIV-infected patients. Further, 92% advocated preoperative screening, with special precaution during surgery, if the results are positive. In addition, 79.5% were of the view that infected patients should not be discriminated against in treatment, provided necessary protective materials are available. To ensure provision of these protective materials, 91% (n = 240) and 89.4% (n = 236) of the respondents favoured involvement of government and insurance agencies, respectively. In order to achieve a greater commitment from surgeons in developing countries towards caring for HIV-infected patients, there is a need for a comprehensive AIDS management package that would offer specific preventive and psychological training in care of HIV patients and provide requisite funds and resources.
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A pre-operative group rehabilitation programme provided limited benefit for people with severe hip and knee osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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Abstract Purpose: To determine if a pre-operative group rehabilitation programme can improve arthritis self-efficacy for people with severe hip and knee osteoarthritis. Method: Single group, repeated measures design: 4-week baseline phase followed by a 6-week intervention phase of water exercise, and education with self-management strategies. The primary outcome was arthritis self-efficacy. The secondary outcomes were measures of pain (WOMAC), activity limitation (WOMAC), activity performance (30 s chair stand test, 10 m walk test) and health-related quality of life (EuroQol). Results: Twenty participants (10 knee osteoarthritis and 10 hip osteoarthritis) with a mean age of 71 years (SD 7) attended 92% (SD 10%) of the scheduled sessions. All measures demonstrated baseline stability between two time points for measurements at week 1 and measurements at week 4. After the 6-week intervention programme there were no significant improvements for arthritis self-efficacy. There was a 12% increase for fast walking speed (mean increase of 0.14 m/s, 95% CI 0.07, 0.22). There were no significant improvements for other secondary outcomes. Conclusions: A pre-operative water-based exercise and educational programme did not improve arthritis self-efficacy, self-reported pain and activity limitation, and health-related quality of life for people with hip and knee osteoarthritis who were candidates for joint replacement. While there was a significant increase in one measure of activity performance (walking speed), these findings suggest the current programme may be of little value. Implications for Rehabilitation This pre-operative group rehabilitation programme for people with severe hip and knee osteoarthritis did not change arthritis self-efficacy, pain, activity limitation and health-related quality of life. This programme may have little value in preparing people for joint replacement surgery. The optimal pre-operative programme requires further design and investigation
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The contribution of posttraumatic stress symptoms to chronic pain adjustment
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DoD PRF (Psychosocial RF)
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OBJECTIVES: To examine whether there are differences between non-trauma-exposed, trauma-exposed without posttraumatic stress symptoms (PSS), and trauma-exposed with PSS chronic musculoskeletal pain patients in vulnerability, protective, and pain-adjustment variables; to test the interactive relationship between PSS and the vulnerability and protective psychological variables across pain adjustment in the group of trauma-exposed-patients.
METHOD: Seven hundred and fourteen patients with chronic musculoskeletal pain were assessed. Of these, 346 patients (244 women and 102 men) completed the study (117 non-trauma-exposed, 119 trauma-exposed without PSS, and 110 trauma-exposed with PSS). The instruments used were the Stressful Life Event Screening Questionnaire Revised, Davidson Trauma Scale, Anxiety Sensitivity Index, Acceptance and Action Questionnaire, Pain Catastrophizing Scale, Fear-Avoidance Beliefs Questionnaire, Pain Anxiety Symptoms Scale, Pain Vigilance and Awareness Questionnaire, Resilience Scale, Chronic Pain Acceptance Questionnaire, Pain Numerical Rating Scale, Roland Morris Disability Questionnaire, and Hospital Anxiety and Depression Scale.
RESULTS: Eight ANCOVAs showed that there were statistically significant differences in vulnerability, protection, and pain adjustment variables between the trauma-exposed with PSS patients and the other 2 groups. The moderated multiple regression analyses showed that PSS added a significantly incremental variance to pain intensity, emotional distress, and disability when interacting with vulnerability and protection variables.
CONCLUSION: The current study supports the models of posttraumatic stress and chronic pain, such as the mutual maintenance and the shared vulnerability theories, providing an initial comprehensive framework for understanding the comorbidity of both disorders.
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Lower fracture risk in older men with higher sclerostin concentration-a prospective analysis from the minos study
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Sclerostin is a glycoprotein synthesized by osteocytes and it inhibits bone formation. Its relationship with fracture in older men has been rarely explored so far. We measured serum concentration of sclerostin (Quidel-TECOmedical,San Diego,CA) in 711 men aged 50 and older. Bone mineral density (BMD) was measured at the lumbar spine, hip and distal forearm (HOLOGIC 1000W). Serum sclerostin increased with age (r= 0.30, p<0.001). After adjustment for age, weight, height, current smoking, bioavailable estradiol and parathyroid hormone, BMD of all the skeletal sites correlated positively with serum sclerostin (r= 0.25 to 0.30, p<0.001) and increased by 0.27 to 0.51 SD /SD increase in sclerostin. In similar multivariable models, serum concentrations of osteocalcin, bone alkaline phosphatase, N-terminal propeptide of type I procollagen and C-terminal telopeptide of type I collegan (CTX-I) as well as urinary excretion of total and free deoxypyridinoline and CTX-I correlated negatively with serum sclerostin (r= -0.09 to -0.24, p<0.05 to 0.001) and decreased by 0.10 to 0.25 SD per SD increase in sclerostin. During 10 years of follow-up, 76 men sustained at least one fragility fracture. The distribution of fracture incidence per quintiles of sclerostin was as follows: 12.9% (lowest quintile), 15.2%, 13.1%, 6.7%, 5.3% (highest quintile) (p<0.005). We compared fracture risk in the two highest quintiles combined vs three lower quintiles combined using logistic regression adjusted for age, BMI, age and BMI interaction, BMD, bone width (for femoral neck and distal radius), prevalent fracture, prevalent falls, and severe abdominal aortic calcification. Men with higher sclerostin concentration had lower risk of fragility fracture (e.g., after adjustment for hipBMD,OR= 0.53, 95%CI: 0.29, 0.97; p<0.05). Similar results were obtained in the models adjusted for BMD and width of tubular bones (e.g., femoral neck, OR= 0.49, 95%CI: 0.27, 0.89; p<0.05). When the analysis was limited to 47 men who sustained major fragility fractures (vertebra, hip, femur, tibia, pelvis, proximal humerus, multiple ribs), the results were similar (e.g., lumbar spine: OR= 0.44, 95%CI: 0.19, 0.99, p<0.05). In conclusion, in older men, higher serum levels of sclerostin are associated with lower risk of fracture, higher BMD and lower levels of biochemical bone turnover markers
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Methods in obtaining split-thickness skin grafts from skin reduction surgery specimens
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: To devise a method for obtaining bacterial culture-negative split-thickness skin grafts from specimens removed from living donors undergoing skin reduction surgery. METHODS: Specimens were obtained from patients undergoing abdominal skin reduction surgery in inpatient and outpatient surgical settings. Skin specimens were cleaned in a method adapted from the former Yale Skin Bank's methods. The specimens were attached to the autoclave container for the dermatome using towel clips or sutures to provide tension. Normal saline clysis was injected subdermally and a Padgett Electric Dermatome was used to obtain skin grafts. These were then photographed and discarded. RESULTS: Eight specimens were obtained from seven women and one man. The mean age was 46.6 years and mean weight at time of surgery was 87.7 kg. Bacterial cultures obtained from all specimens were negative. All procured grafts were transparent, with visible dermis, suggesting that they could be used in a clinical setting. CONCLUSION: Bacterial culture-negative split-thickness skin grafts can be obtained from skin reduction surgery specimens, offering a potential source of split-thickness allograft during regional or national shortages.
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Load distribution in early osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Total knee replacement is an accepted standard of care for the treatment of advanced knee osteoarthritis with good results in the vast majority of older patients. The use in younger and more active populations, however, remains controversial due to concerns over activity restrictions, implant survival, and patient satisfaction with the procedure. It is in these younger patient populations that alternatives to arthroplasty are increasingly being explored. Historically, osteotomy was utilized to address unicompartmental pain from degeneration and overload, for example, after meniscectomy. Utilization rates of osteotomy have fallen in recent years due to the increasing popularity of partial and total knee arthroplasty. This article explores the indications and outcomes of traditional unloading osteotomy, as well as newer options that are less invasive and offer faster return to function.
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Meniscal extrusion in young athletes: associated knee joint abnormalities
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: The objective of our study was to assess the rate of meniscal extrusion and its connection with common meniscal and joint abnormalities.
MATERIALS AND METHODS: MR signs of meniscal extrusion were evaluated retrospectively in 24 rugby and soccer players (40 knees) who are currently free of pain in the knee, impaired mobility, and joint swelling. The control group consisted of 23 consecutive active individuals (36 knees) with no history of knee problems. The criterion for extrusion of the meniscus was defined as a distance of 3 mm or more between the peripheral border of the meniscus and the edge of the tibial plateau measured on coronal images.
RESULTS: Forty-eight percent of the athletes' knees and 30% of the control subjects' knees showed evidence of meniscal extrusion. Among the athletes, a significant association between meniscal extrusion and joint effusion (11 cases), meniscal tears (seven cases), and anterior cruciate ligament (ACL) tear (four cases) was found (p < or = 0.004). In the control group, no significant association was found between meniscal extrusion and joint effusion (three cases), meniscal tears (four cases), and ACL tears (two cases) (p = 1.00). A significant association was not found between degenerative change and meniscal extrusion in either the athletes (p = 0.23) or the control subjects (p = 1.00). The most commonly associated knee abnormality was joint effusion in 73% of knees with meniscal extrusion in athletes.
CONCLUSION: Meniscal extrusion is a common finding on MRI of athletes' knees. Meniscal extrusion in association with meniscal tear and joint effusion is postulated as a significant injury in athletes and its recognition as such in this group is important because it may prompt orthopedic intervention.
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MR Imaging with Metal-suppression Sequences for Evaluation of Total Joint Arthroplasty
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PJI DX Updated Search
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Metallic artifact at orthopedic magnetic resonance (MR) imaging continues to be an important problem, particularly in the realm of total joint arthroplasty. Complications often follow total joint arthroplasty and can be expected for a small percentage of all implanted devices. Postoperative complications involve not only osseous structures but also adjacent soft tissues-a highly problematic area at MR imaging because of artifacts from metallic prostheses. Without special considerations, susceptibility artifacts from ferromagnetic implants can unacceptably degrade image quality. Common artifacts include in-plane distortions (signal loss and signal pileup), poor or absent fat suppression, geometric distortion, and through-section distortion. Basic methods to reduce metallic artifacts include use of spin-echo or fast spin-echo sequences with long echo train lengths, short inversion time inversion-recovery (STIR) sequences for fat suppression, a high bandwidth, thin section selection, and an increased matrix. With care and attention to the alloy type (eg, titanium, cobalt-chromium, stainless steel), orientation of the implant, and magnetic field strength, as well as use of proprietary and nonproprietary metal-suppression techniques, previously nondiagnostic studies can yield key diagnostic information. Specifically, sequences such as the metal artifact reduction sequence (MARS), WARP (Siemens Healthcare, Munich, Germany), slice encoding for metal artifact correction (SEMAC), and multiacquisition with variable-resonance image combination (MAVRIC) can be optimized to reveal pathologic conditions previously hidden by periprosthetic artifacts. Complications of total joint arthroplasty that can be evaluated by using MR imaging with metal-suppression sequences include pseudotumoral conditions such as metallosis and particle disease, infection, aseptic prosthesis loosening, tendon injury, and muscle injury
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Rickets
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Reduction Mammoplasty for Female Breast Hypertrophy
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Rickets is disorder of a growing child arising from disorders that result in impaired apoptosis of hypertrophic cells and mineralization of the growth plate. Rickets due to nutritional causes remains an important global problem. The factors responsible for resurgence of rickets among dark-skinned infants living in developed countries include the following: residence in northern or southern latitudes, voluntary avoidance of exposure to solar ultraviolet B radiation, maternal vitamin D deficiency during pregnancy, and prolonged breastfeeding without provision of vitamin D supplements. Fibroblast growth factor 23 (FGF23), secreted by osteocytes, is an important regulator of serum phosphate and 1,25(OH)(2)D(3) levels. Hypophosphatemic rickets resulting from increased synthesis or under-catabolism of FGF23 is reviewed.
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Advances in oral anticoagulation treatment: The safety and efficacy of rivaroxaban in the prevention and treatment of thromboembolism
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PJI DX Updated Search
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Arterial and venous thromboembolic diseases are a clinical and economic burden worldwide. In addition to traditional agents such as vitamin K antagonists and heparins, newer oral agents - such as the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban, and the direct thrombin inhibitor dabigatran - have been shown to be effective across several indications. Rivaroxaban has been shown to have predictable pharmacokinetic and pharmacodynamic properties, including a rapid onset of action. In addition, there is no requirement for routine coagulation monitoring; and no dose adjustment is necessary for age alone, sex, or body weight. Rivaroxaban has successfully met primary efficacy and safety endpoints in large, randomized phase III trials across several indications, including: prevention of venous thromboembolism in orthopedic patients undergoing elective hip or knee replacement surgery; treatment of deep vein thrombosis and secondary prevention of deep vein thrombosis and pulmonary embolism; stroke prevention in patients with atrial fibrillation; and secondary prevention of acute coronary syndrome. Rivaroxaban and the other newer oral anticoagulants are likely to improve outcomes in the prevention and treatment of thromboembolic events, and will offer patients and physicians alternative treatment options. é The Author(s), 2012
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Risk for family rejection and associated mental health outcomes among conflict-affected adult women living in rural eastern Democratic Republic of the Congo
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DoD PRF (Psychosocial RF)
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Stigma due to sexual violence includes family rejection, a complex outcome including economic, behavioral, and physical components. We explored the relationship among conflict-related trauma, family rejection, and mental health in adult women living in rural eastern Democratic Republic of the Congo, who participate in a livestock-based microfinance program, Pigs for Peace. Exposure to multiple and different types of conflict-related trauma, including sexual assault, was associated with increased likelihood of family rejection, which in turn was associated with poorer mental health outcomes. Design of appropriate and effective interventions will require understanding family relationships and exposure to different types of trauma in postconflict environments.
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The impact of time to surgery after hip fracture on mortality at 30- and 90-days: Does a single benchmark apply to all?
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Hip Fx in the Elderly 2019
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INTRODUCTION: Delays to surgery after hip fracture have been associated with mortality Uncertainty remains as to what timing benchmark should be utilized as a marker of quality of care and how other patient factors might also influence the impact of time to surgery on mortality. The goal of this study was to determine how time to surgery affects 30- and 90-day mortality by age and to explore the impact of preoperative comorbid burden and sex.
PARTICIPANTS: We used population-based administrative data from a Canadian province collected from 01April2008 to 31March2015. Of 12,713 Albertans 50-years and older who experienced a hip fracture and underwent surgery within 100 h of admission, 11,996 (94.8%) provided data.
METHODS: Time to surgery was analyzed in hours from admission to surgery. Age and the interaction between age and time to surgery were evaluated using logistic regression. Charlson co-morbidity score and sex were also considered in the analysis. Survival was evaluated at 30-and 90-days post hip fracture using a provincial registry.
RESULTS: The average age of the cohort was 79.6 +/- 11.2 years and 8,412 (70.1%) were female. Overall, 586 (4.9%) patients died within 30-days and 1,023 (8.5%) died within 90-days of hip fracture. Mortality increased significantly with increasing time to surgery (30-day mortality odds ratio [OR] = 1.03; 95%CI 1.01-1.05: 90-day mortality OR = 1.03; 95% CI 1.01-1.04). Mortality also increased substantially with increasing age; those >=85 years were 19.63 (95% CI 6.83-67.33) and 15.66 (95%CI 7.20-37.16) times the odds more likely to die relative to those between 50-64 years of age at 30-days and 90-days postoperatively respectively. Further, those who were >=85 years were more significantly affected by increasing time to surgery than those who were 50-64 years of age at both 30-days (p = 0.04) and 90-days (p = 0.025) post-fracture. Males and those with a higher comorbid burden also had higher odds of dying after controlling for time to surgery (p < 0.001) CONCLUSION: Time to surgery following hip fracture may have a differential effect on 30- and 90-day survival dependent on age. Older patients appear to be at higher risk of dying with surgical delays than younger patients.
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Growth plate injuries and management
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Distal Radius Fractures
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The growth plate, or physis, is the name given to the area of cartilaginous tissue found between the epiphysis and metaphysis of skeletally immature bone. The developing growth plate is weaker than surrounding ossified bone and, therefore, at risk of injury before its closure. Previous studies have shown that fractures account for 10-25% of all paediatric injuries, with growth plate injuries accounting for 15-30% of all paediatric bony injury. The upper limb is most likely to be affected, with the distal radius found to be the most common site of fractures in children.The Salter-Harris classification describes growth plate injuries based upon location and likelihood of growth arrest. In addition to growth arrest, injury to the growth plate often stimulates bone repair, which can lead to limb length discrepancy, bone bridge formation between the metaphysis and epiphysis, and angulation of the bone. The treatment of growth plate fractures ranges from conservative management to operative fixation and bone grafting. Outcome is varied and dependent upon site and grade of the fracture as well as the age of the patient. Regardless of Salter-Harris classification, an important component of management is counselling the parents about the potential risk of future growth arrest and associated sequelae.
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Alterations in the chondroitin sulfate chain in human osteoarthritic cartilage of the knee
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine whether the structure of chondroitin sulfate (CS) in cartilage is reflected by the degree of cartilage degeneration in patients with osteoarthritis (OA) of the knee and to determine how CS biosynthesis affects cartilage degeneration.
DESIGN: Two osteoarthritic cartilage samples were obtained from medial femoral condyle (MFC) and lateral femoral condyle (LFC) of 24 knees with end-stage OA. The samples were assigned to two groups as follows: lesion and remote cartilage were adjacent to and remote from the osteoarthritic cartilage, respectively. Histological grade was determined according to the Mankin score. The CS concentration and chain length were determined using high-performance liquid chromatography (HPLC) and gel filtration chromatography, respectively. Expression of the gene encoding CS glycosyltransferase was evaluated using a real-time quantitative polymerase chain reaction (qPCR) assay. These results were compared between lesion and remote cartilage.
RESULTS: The Mankin score indicated that lesion cartilage was more degraded compared with remote cartilage. Although the CS levels varied among individuals, the mean CS concentration and chain length were significantly lower and shorter in lesion cartilage than in remote cartilage, respectively (concentration: 12.04 vs 14.84 mug/mg wet weight, P = 0.021; chain length: 5.36 vs 6.19 kDa, P = 0.026). Three genes encoding CS glycosyltransferases (CHPF, CSGALNACT1, CSGALNACT2) were expressed at lower levels in lesion cartilage.
CONCLUSIONS: In the osteoarthritic knee, the CS concentration and chain length were reduced closer to the more degraded cartilage with decreasing CS glycosyltransferase gene expression. Inhibition of CS glycosyltransferase gene expression may reduce CS chain length, which may contribute to OA progression.
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Management of bisphosphonate-related osteonecrosis of the jaw: a literature review
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MSTS 2018 - Femur Mets and MM
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Osteonecrosis of the jaw (ONJ) is a serious side effect of bisphosphonate use in patients with osteoporosis, Paget's disease, hypercalcemia of malignancy, metastatic bone disease and multiple myeloma, although recently this complication has also been reported in patients under non-bisphosphonate medication, such as denosumab and bevacizumab. The occurrence of ONJ is higher in oncology patients treated with high-dose iv bisphosphonates than in osteoporosis patients treated with oral bisphosphonates. Although multiple hypotheses have been proposed, the exact pathogenic mechanism of ONJ still remains unclear. As treatment protocols based on randomized controlled trials (RCTs) do not exist, we critically reviewed the existing data concerning the management of bisphosphonate-related osteonecrosis of the jaw, including the most recent data for the use of teriparatide and hyperbaric oxygen.
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Is antibiotic prophylaxis necessary in elective soft tissue hand surgery?
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Antibiotic prophylaxis for clean soft tissue hand surgery is not yet defined. Current literature focuses on overall orthopedic procedures, traumatic hand surgery, and carpal tunnel release. However, a paucity of data exists regarding the role of antibiotic prophylaxis in a broader variety of soft tissue hand procedures. The goal of the current study was to evaluate the rates of surgical site infection following elective soft tissue hand surgery with respect to administration of prophylactic antibiotics.A multicenter, retrospective review was performed on 600 consecutive elective soft tissue hand procedures. Procedures with concomitant implant or incomplete records were excluded. Antibiotic delivery was given at the discretion of the attending surgeon. Patient comorbidities were recorded. Outcomes were measured by the presence of deep or superficial infections within 30 days postoperatively. The 4 most common procedures were carpal tunnel release, trigger finger release, mass excision, and first dorsal compartment release. The overall infection rate was 0.66%. All infections were considered superficial, and none required surgical management. In patients who received antibiotic prophylaxis (n=212), the infection rate was 0.47%. In those who did not receive prophylaxis (n=388), the infection rate was 0.77%. These differences were not statistically significant (P=1.00)
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Association between low cortical bone mineral density, soft-tissue calcification, vascular calcification and chondrocalcinosis: a case-control study
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AMP (Acute Meniscal Pathology)
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OBJECTIVES: To examine the association between bone mineral density (BMD), soft-tissue calcification, vascular calcification and chondrocalcinosis (CC).
METHODS: A case-control study within the Genetics of Osteoarthritis and Lifestyle (GOAL) database (n=3170). All GOAL participants completed a questionnaire self-reporting current and early adult life exposures. Radiographs of knees, hands and pelvis were scored for osteoarthritis (OA), CC, pelvic vascular calcification, peri-articular knee calcification and metacarpal index (MCI-measure of cortical BMD). Calcaneal dual-energy X-ray absorptiometry (DEXA) was performed. Cases had radiographic CC, while controls did not have CC at any radiographed site. OR, 95% CI were used to measure association between risk factors and CC. Logistic regression was used to adjust for confounding and to estimate the adjusted OR (aOR).
RESULTS: Low MCI (aOR (95%) for CC in 1st tertile 1.41 (1.06 to 1.89), with 3rd tertile referent), soft-tissue calcification (aOR (95%) for CC 1.81 (1.36 to 2.42)), and vascular calcification (aOR (95%) for CC 1.76 (1.13 to 2.75)) independently associated with CC. There was a negative association between body mass index and CC (aOR (95%) for CC in 2nd and 3rd tertiles 0.68 (0.53 to 0.89), and 0.67 (0.51 to 0.88) respectively with 1st tertile referent). Age and OA associated with CC. However, only age and low MCI independently associated with CC at >1 joint. Self-reported meniscectomy, low cortical BMD, vascular calcification, and soft-tissue calcification independently associated with knee CC.
CONCLUSIONS: This study identifies several novel associations of CC including low cortical BMD. The association between vascular calcification, soft-tissue calcification, and CC suggests a generalised constitutional predisposition to calcium crystal formation.
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Clinical trials of bisphosphonates in multiple myeloma
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MSTS 2018 - Femur Mets and MM
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More than 80% of patients with multiple myeloma (MM) have osteolytic bone disease, which increases the risk of skeletal-related events (SREs) such as pathologic fracture, spinal cord compression, and the need for radiotherapy or surgery. Bone disease is primarily due to increased osteoclastic activity and impaired osteoblast activity. Bisphosphonates are pyrophosphate analogues with high bone affinity that can inhibit osteoclastic activity. Pamidronate and zoledronic acid are the most commonly used bisphosphonates in multiple myeloma. Other agents include ibandronate and clodronate. Bisphosphonates are associated with several adverse events, such as renal toxicity and osteonecrosis of the jaw. The optimal duration of bisphosphonate therapy has yet to be determined. Clinical trials are investigating tailored approaches to management based on treatment-related changes in levels of bone resorption markers.
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The Diagnosis of Infection in Metal-on-Metal Hip Arthroplasties
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PJI DX Updated Search
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BACKGROUND: Distinction of aseptic from septic hip arthroplasty failure can be challenging. Some studies report an increased incidence of septic failure with metal-on-metal (MoM) hip arthroplasties. The Musculoskeletal Infection Society (MSIS) have formulated criteria to facilitate the diagnosis of periprosthetic joint infection (PJI). In this study, we determined the prevalence and histologic features of septic MoM hip failure. METHODS: Overall, 104 cases of failed MoM hip arthroplasty, classified as septic or aseptic by MSIS microbiological criteria, were analyzed. The overall prevalence of septic failure was determined and the nature of the causative organisms noted. The extent of the neutrophil polymorph (NP) infiltrate in periprosthetic tissue in all cases was analyzed by hematoxylin-eosin and chloroacetate esterase staining. RESULTS: The prevalence of septic MoM hip arthroplasty failure was 6.7%. Infective organisms were coagulase-negative Staphylococcus in 4 cases; Staphylococcus aureus, Streptococcus, and Propionibacterium species were isolated in the remaining cases. Chloroacetate esterase staining facilitated identification of NPs. All cases of PJI contained more than 5 NPs per high-power field (HPF) on average. Four cases of aseptic MoM implant failure contained scanty or scattered NPs (less than 5 per HPF on average). CONCLUSION: The prevalence of PJI as a cause of MoM hip arthroplasty failure was relatively high compared to other hip bearing combinations; however, the organisms responsible were similar. Histologically, a minority of aseptic MoM implant failures contained some NPs, but the MSIS criteria for the histologic diagnosis of PJI (>5 NPs/HPF) correctly identified all microbiologically confirmed cases of septic failure
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Acetabular reinforcement ring in primary total hip arthroplasty: A minimum 10-year follow-up
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Management of Hip Fractures in the Elderly
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Introduction: We report the results of a titanium acetabular reinforcement ring with a hook (ARRH) in primary total hip arthroplasty (THA), which was introduced in 1987 and continues to be used routinely in our center. The favorable results of this device in arthroplasty for developmental dysplasia and difficult revisions motivated its use in primary THA. With this implant only minimal acetabular reaming is necessary, anatomic positioning is achieved by placing the hook around the teardrop and a homogenous base for cementing the polyethylene cup is provided. Materials and methods: Between April 1987 and December 1991, 241 THAs with insertion of an ARRH were performed in 178 unselected, consecutive patients (average age 58 years; range 30-84 years) with a secondary osteoarthrosis in 41% of the cases. Results: At the time of the latest follow-up, 33 patients (39 hips) had died and 17 cases had been lost to follow-up. The median follow-up was 122 months with a minimum of 10 years. Eight hips had been revised, leaving 177 hips in 120 living patients without revision. Six cups were revised because of aseptic loosening. Two hips were revised for sepsis. The mean Merle d'Aubigne score for the remaining hips was 16 (range 7-18) at the latest follow-up. For aseptic loosening, the probability of survival of the cup was 0.97 (95% confidence interval, 0.94-0.99). However, analysis of radiographs implied loosening in seven other cups without clinical symptoms. Conclusions: The results of primary THA using an acetabular reinforcement ring parallel the excellent results of these implants often observed in difficult primary and revision arthroplasty at a minimum of 10 years. Survivorship is comparable to modern cementless implants. Medial migration that occurs with loosening of the acetabular component seems to be prevented with this implant. Radiographic loosening signs can exist without clinical symptoms. (copyright) Springer-Verlag 2008
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Alarmins S100A8/S100A9 aggravate osteophyte formation in experimental osteoarthritis and predict osteophyte progression in early human symptomatic osteoarthritis
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AMP (Acute Meniscal Pathology)
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Objective Alarmins S100A8 and S100A9 are major products of activated macrophages regulating cartilage damage and synovial activation during murine and human osteoarthritis (OA). In the current study, we investigated whether S100A8 and S100A9 are involved in osteophyte formation during experimental OA and whether S100A8/A9 predicts osteophyte progression in early human OA. Methods OA was elicited in S100A9-/- mice in two experimental models that differ in degree of synovial activation. Osteophyte size, S100A8, S100A9 and VDIPEN neoepitope was measured histologically. Chondrogenesis was induced in murine mesenchymal stem cells in the presence of S100A8. Levels of S100A8/A9 were determined in plasma of early symptomatic OA participants of the Cohort Hip and Cohort Knee (CHECK) cohort study and osteophytes measured after 2 and 5 years. Results Osteophyte size was drastically reduced in S100A9-/- mice in ligaments and at medial femur and tibia on days 21 and 42 of collagenase-induced OA, in which synovial activation is high. In contrast, osteophyte size was not reduced in S100A9-/- mice during destabilised medial meniscus OA, in which synovial activation is scant. S100A8 increased expression and activation of matrix metalloproteinases during micromass chondrogenesis, thereby possibly increasing cartilage matrix remodelling allowing for larger osteophytes. Interestingly, early symptomatic OA participants of the CHECK study with osteophyte progression after 2 and 5 years had elevated S100A8/A9 plasma levels at baseline, while C-reactive protein, erythrocyte sedimentation rate and cartilage oligomeric matrix protein were not elevated at baseline. Conclusions S100A8/A9 aggravate osteophyte formation in experimental OA with high synovial activation and may be used to predict osteophyte progression in early symptomatic human OA. © 2014 BMJ Publishing Group Ltd & European League Against Rheumatism.
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Knee arthrodesis for failed total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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The use of arthrodesis to salvage failed total knee arthroplasty is reviewed in nine patients. Prosthetic failure was due to infection in six cases, aseptic loosening in two cases, and instability in one case. The techniques of arthrodesis included six Hoffman external fixators, two fluted intramedullary rods (3M-Orthopedic Products Division, St Paul), and one pulsing electromagnetic field stimulator. Arthrodesis was successful in eight of nine patients, averaging 5.4 months to union. All eight patients resumed a painfree functional level of activity. Meticulous surgical technique and appropriate method of arthrodesis are emphasized
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1 |
"Abdominoplasty with "En block" removal of the skin island: a safe and fast approach"
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Panniculectomy & Abdominoplasty CPG
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The aim of abdominoplasty is to restore a normal abdominal contour, with minimal signs of the surgery. The purpose of this study was to determine the feasibility, safety, and advantages of en block removal of a skin island before upper abdominal dissection during abdominoplasty. Five hundred-forty female patients who underwent abdominoplasties between January 2004 and December 2018 were retrospectively analyzed. In these cases, the planned skin resection was initially made en block, as done with an elliptic skin excision. In this way, symmetric skin removal is achieved. After the removal of this skin, epigastric skin undermining was easily achieved. The mean age of the patients was 41.4?y, and the mean body mass of index was 27.3?kg/m(2). The mean operative time for abdominoplasty only was 98?min. Eight patients had minor skin problems, 22 patients needed aspiration for seroma formation, and 7 patients needed scar revision surgery. There was only one hematoma postoperatively. The final position of the scar from the upper vulvar commissure was 8.9?cm. The results obtained were comparable to those of classical abdominoplasty, suggesting that en block removal of the skin before upper flap dissection is a safe maneuver. En block removal of skin island at the start of the surgery has the added advantage of a reduced operative time and acceptable aesthetic outcome, without an increase in complication rates. In cases of planned abdominoplasties, we suggest that removal of the abdominal skin at the beginning of the operation is a safe and feasible procedure.Abbreviation: PDS: polydioxanone.
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Cost-effectiveness of total knee replacement: A prospective cohort study
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OAK 3 - Non-arthroplasty tx of OAK
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Objective Total knee replacement (TKR) rates have significantly increased in the past decade. While the procedure itself might be costly, the cost-effectiveness and potential offset costs from patient and societal benefits have not been clearly established. The objective of this study was to perform an economic evaluation of TKR in patients with knee osteoarthritis (OA). Methods We conducted a 6-month prospective cohort study of 212 patients with knee OA who underwent TKR at a single hospital in Houston, Texas. We included patient-level data from hospital billing databases and the patients' self-reported direct and indirect costs. The clinical outcome measure was pain and function measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire; we used the minimum clinically important difference (MCID; �20-point change) and the WOMAC 20% (WOMAC20), 50% (WOMAC50), and 70% (WOMAC70) relative improvement criteria. Incremental cost-effectiveness ratios were estimated using direct and indirect costs and WOMAC improvement. A societal perspective was used and multiple sensitivity analyses were performed to assess the robustness of the principal analysis. Results The total incremental cost per TKR was 20,133. The incremental cost-effectiveness ratios (ICERs) for improvement at 6 months were 33,345, 25,255, 35,274, and 56,908 for the MCID, WOMAC20, WOMAC50, and WOMAC70, respectively. Best- and worst-case scenario sensitivity analyses did not have a significant impact on the ICERs. Patient time lost was the most influential variable in the multiway sensitivity analysis. Conclusion TKR is an effective intervention in reducing pain and improving functional status among patients with knee OA and is cost effective at both low and high levels of improvement. Copyright © 2014 by the American College of Rheumatology.
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Three unusual factors contributing to compressive median neuropathy in the distal forearm in a single patient
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Although there are varied aetiological factors responsible for compressive neuropathy of the median nerve in the carpal tunnel syndrome, it is rare to encounter several aetiological factors in a single case. This article reports a case in which three aetiological factors were present
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Top orthopedic sports medicine procedures
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AMP (Acute Meniscal Pathology)
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Orthopedic sports medicine is a subspecialty of Orthopedics that focuses on managing pathological conditions of the musculoskeletal system arising from sports practice. When dealing with athletes, timing is the most difficult issue to face. Typically, athletes aim to return to play as soon as possible and at the pre-injury level. This means that management should be optimized to combine the need for prompt return to sport and to the biologic healing time of the musculo-skeletal. This poses a great challenge to sport medicine surgeons, who need to follow with attention to the latest scientific evidence to offer their patients the best available treatment options. We briefly review the most commonly performed orthopedic sports medicine procedures, outlining the presently available scientific evidence on their indications and outcomes.
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Prospective Randomized Controlled Trial of Two Different Intramedullary Nails for Pertrochanteric Fractures of the Femur
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Hip Fx in the Elderly 2019
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The purpose of this prospective randomized trial was to assess whether an intramedullary nail is superior or not to another one in the treatment of pertrochanteric fractures. Eighty-one patients with a 31-A1 or A2 Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) pertrochanteric fracture were randomly allocated to fixation with either the Gamma R or the ENDOVIS R nail. In order to estimate the functional outcome the Parker-Palmer mobility score, Barthel Index, and EuroQol-5D (EQ-5D) were used. All patients were followed up at 1, 3, 6, and 12 months postoperatively. There was no statistical difference in Parker mobility score between groups. The statistical analysis revealed that there was no significant difference between the two patient groups as far as the operating time, the amount of blood transfused, and the latest functional outcome. Both kinds of intramedullary nails used in our study provide effective methods of treatment for intertrochanteric fractures in elderly patients. Our data showed slightly worse results for the ENDOVIS nail compared with the Gamma nail, but this did not reach a statistical significance.
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The impact of surgical treatment on the self-esteem of patients with breast hypertrophy, hypomastia, or breast asymmetry
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Currently, the concept of health includes not only the absence of disease but also a complete state of physical, psychological, and social well-being with increased emphasis on the importance of self-esteem. This study aimed to evaluate the impact of surgical treatment on the self-esteem of patients with breast asymmetry, breast hypertrophy, or hypomastia. METHODS: The Rosenberg Self-Esteem UNIFESP-EPM Scale was administered preoperatively and in the early and late postoperative periods to assess self-esteem. The sample comprised three groups of patients: the breast asymmetry group (n=35), the breast hypertrophy group (n=50), and the hypomastia group (n=40). RESULTS: Surgical treatment had a positive and similar impact on the self-esteem of the patients in the three study groups. CONCLUSIONS: Correction of breast asymmetry, breast hypertrophy, and hypomastia improved the patient's self-esteem. All three groups reported a similar increase in self-esteem (decrease in total scores) after breast reconstruction.
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Traumatic Brain Injury and Receipt of Prescription Opioid Therapy for Chronic Pain in Iraq and Afghanistan Veterans: Do Clinical Practice Guidelines Matter?
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DoD PRF (Psychosocial RF)
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Clinical practice guidelines admonish against prescribing opioids for individuals with chronic pain and traumatic brain injury (TBI) because of increased risk for adverse outcomes, yet no studies have described opioid prescribing patterns in these higher-risk patients. Between October 2007 and March 2015, 53,124 Iraq and Afghanistan veterans with chronic pain not prescribed opioids in the previous year were followed for 1 year after completing a Comprehensive TBI Evaluation within the Department of Veterans Affairs health care facilities. Veterans reporting the most severe TBI sequelae (eg, loss of consciousness >30 minutes) were significantly more likely to receive short-term and long-term opioid therapy than those with less severe or no TBI sequelae (P values <.001). In analyses adjusted for sociodemographic characteristics, military service, pain disability, and previous nonopioid treatment modalities, veterans with moderate to severe TBI had a significantly increased risk of receiving opioid therapy. Veterans with moderate to severe TBI and comorbid post-traumatic stress disorder and depression had an even greater risk of initiating long-term opioid therapy in the year after the Comprehensive TBI Evaluation (adjusted relative risk = 3.57 [95% confidence interval = 2.85â??4.47]). Higher-risk patients with chronic pain and TBI with mental health comorbidities may benefit from improved access to behavioral health and nonpharmacological therapies for chronic pain. Perspective: Paradoxically, veterans with greater TBI severity and comorbid mental health burden are more likely to be prescribed opioids for chronic pain. More vulnerable veterans may benefit from improved access to behavioral health and nonpharmacological modalities for chronic pain, because of the health and safety risks of opioids.
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The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more
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Surgical Management of Osteoarthritis of the Knee CPG
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Primary arthroplasty may be denied to very elderly patients based upon the perceived outcome and risks associated with surgery. This prospective study compared the outcome, complications, and mortality of total hip (TKR) and total knee replacement (TKR) in a prospectively selected group of patients aged >/= 80 years with that of a control group aged between 65 and 74 years. There were 171 and 495 THRs and 185 and 492 TKRs performed in the older and control groups, respectively. No significant difference was observed in the mean improvement of Oxford hip and knee scores between the groups at 12 months (0.98, (95% confidence interval (CI) -0.66 to 2.95), p = 0.34 and 1.15 (95% CI -0.65 to 2.94), p = 0.16, respectively). The control group had a significantly (p = 0.02 and p = 0.04, respectively) greater improvement in the physical well being component of their SF-12 score, but the older group was more satisfied with their THR (p = 0.047). The older group had a longer hospital stay for both THR (5.9 versus 9.0 days, p < 0.0001) and TKR (6.2 versus 8.3 days, p < 0.0001). The rates of post-operative complications and mortality were increased in the older group
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The prevalence of growth hormone deficiency in survivors of subarachnoid haemorrhage: results from a large single centre study
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AAHKS (2) Corticosteroids
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Objective: The variation in reported prevalence of growth hormone deficiency (GHD) post subarachnoid haemorrhage (SAH) is mainly due to methodological heterogeneity. We report on the prevalence of GHD in a large cohort of patients following SAH, when dynamic and confirmatory pituitary hormone testing methods are systematically employed. Design: In this cross-sectional study, pituitary function was assessed in 100 patients following SAH. Baseline pituitary hormonal profile measurement and glucagon stimulation testing (GST) was carried out in all patients. Isolated GHD was confirmed with an Arginine stimulation test and ACTH deficiency was confirmed with a short synacthen test. Results: The prevalence of hypopituitarism in our cohort was 19% and the prevalence of GHD was 14%. There was no association between GHD and the clinical or radiological severity of SAH at presentation, treatment modality, age, or occurrence of vasospasm. There were statistically significant differences in terms of Glasgow Outcome Scale (GOS; p = 0.03) between patients diagnosed with GHD and those without. Significant inverse correlations between GH peak on GST with body mass index (BMI) and waist hip ratio (WHR) was also noted (p < 0.0001 and p < 0.0001 respectively). Conclusion: Using the current testing protocol, the prevalence of GHD detected in our cohort was 14%. It is unclear if the BMI and WHR difference observed is truly due to GHD or confounded by the endocrine tests used in this protocol. There is possibly an association between the development of GHD and worse GOS score. Routine endocrine screening of all SAH survivors with dynamic tests is time consuming and may subject many patients to unnecessary side-effects. Furthermore the degree of clinical benefit derived from growth hormone replacement in this patient group, remains unclear. Increased understanding of the most appropriate testing methodology in this patient group and more importantly which SAH survivors would derive most benefit from GHD screening is required.
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Worker Role Interview: Toward validation of a psychosocial work-related measure
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DoD PRF (Psychosocial RF)
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Three studies were conducted to examine the validity of the Worker Role Interview (WRI), a semi-structured interview and rating scale designed to assess psychosocial capacity for return to work in injured workers. The first Rasch analysis study of 119 work-hardening clients with low back pain showed that scale items worked together to measure unidimensional construct, except for two work-environment items (work setting and boss); and the items were logically ordered representing the least to most psychosocial capacity for return to work. The second Rasch analysis study involved a refined scale applied to 55 work-hardening clients with diverse injuries. All items except perception of boss defined a unidimensional construct. The ordering of items was similar to that in the first study and similar across the low back and upper extremity injuries diagnostic groups. The third study of 42 work-hardening clients examined the predictive validity of the WRI A logistic regression showed that none of the variables predicted return to work. This initial series of studies present a theoretically based instrument, which shows promising psychometric qualities. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Hip fracture incidence in Stockholm 1972-1981
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Management of Hip Fractures in the Elderly
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We studied the incidence of cervical and trochanteric hip fractures in Stockholm, Sweden from 1972 through 1981. The material, selected from a computerized medical information register, consisted of 11 812 cervical fractures and 8094 trochanteric fractures. The incidence did not change in the age group 50-74 years. In males 75 years of age and older, the incidence of both fracture types caused by moderate trauma increased annually by 5-6 per cent. In females 75 years and older, the incidence of trochanteric fractures caused by moderate trauma increased annually by 6 per cent, whereas the incidence of cervical fractures increased only marginally
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Prevention of deep vein thrombosis in patients with hip fractures: low molecular weight heparin versus dextran
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Management of Hip Fractures in the Elderly
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A randomized open trial was undertaken to compare the antithrombotic efficacy of a low molecular weight heparin (LMWH; Sandoparin) with that of dextran 70 in patients undergoing surgery for hip fracture. One hundred thirteen patients received LMWH once daily subcutaneously at a fixed dosage while 103 patients received intravenous dextran 70. Postoperative deep vein thrombosis (DVT) was assessed by a diagnostic algorithm using the 125Iodine fibrinogen uptake test as screening and Duplex ultrasonography and/or ascending venography as confirming techniques for suspected DVT. The frequency of DVT was significantly lower in the LMWH group than in the dextran group (15.5 versus 32.6%, p less than 0.005). Proximal DVT was rare in both groups (LMWH: 2%, Dextran: 1%). Only one case of fatal fat pulmonary embolism was observed during the 10 day prophylaxis period in a patient receiving Dextran. Three cases of pulmonary embolism occurred later; one fatal event in the dextran group on day 14, and two cases in the LMWH group (one fatal and one non-fatal event) on day 14 and 17, respectively. There was no major bleeding complication in either group. We conclude that the LMWH we used is safe, was well tolerated, and has a significantly better thromboprophylactic effect than dextran 70
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Human blood-based anti-inflammatory solution inhibits osteoarthritis progression in a meniscal-tear rat study
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OAK 3 - Non-arthroplasty tx of OAK
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Current osteoarthritis (OA) research searches for treatments that modify the course of disease progression. Autologous Protein Solution (APS) is derived from whole blood and is a unique autologous therapy that contains high concentrations of white blood cells, platelets, and concentrated plasma, providing cytokines that can target the underlying mechanisms of disease progression. The APS Kit is currently under investigation for clinical use in the USA (NCT02262364). The aim of this study was to determine if APS has disease-modifying properties in the well-characterized rat meniscal tear-induced model of OA. Thirty male athymic rats underwent surgery to induce OA by a complete tear of the medial meniscus of the right knee. Seven days later, rats were administered 50 mul intra-articular (IA) APS from a human donor or phosphate buffered saline (PBS) control. Rats were euthanized 3 weeks following treatment and knee joints were processed for histological analysis. Collagen and cartilage degeneration were decreased by APS treatment, resulting in a significantly improved total joint score in APS-treated rats compared to those treated with the PBS control. No significant variations in gait analysis, weight gain, osteophyte score, or synovitis score were observed between APS- and PBS-treated animals. There were no adverse effects of APS reported in the study. Treatment with a single IA injection of APS reduced the cartilage degeneration that characterizes the progression of OA. Further studies are necessary to determine if APS can modify OA disease progression in humans. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2260-2268, 2017.
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Surgical treatment for early osteoarthritis. Part II: allografts and concurrent procedures
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SR for PM on OA of All Extremities
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Young patients with early osteoarthritis (OA) represent a challenging population due to a combination of high functional demands and limited treatment options. Conservative measures such as injection and physical therapy can provide short-term pain relief but are only palliative in nature. Joint replacement, a successful procedure in the older population, is controversial in younger patients, who are less satisfied and experience higher failure rates. Therefore, while traditionally not indicated for the treatment of OA, cartilage repair has become a focus of increased interest due to its potential to provide pain relief and alter the progression of degenerative disease, with the hope of delaying or obviating the need for joint replacement. The field of cartilage repair is seeing the rapid development of new technologies that promise greater ease of application, less demanding rehabilitation and better outcomes. Concurrent procedures such as meniscal transplantation and osteotomy, however, remain of crucial importance to provide a normalized biomechanical environment for these new technologies. LEVEL OF EVIDENCE: Systematic review, Level II
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Avascular necrosis of bone in Hodgkin's disease patients treated with combined modality therapy
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AAHKS (2) Corticosteroids
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Avascular necrosis of bone developed in eight patients with advanced Hodgkin's disease who had been treated with combined modality therapy and were in complete remission from their disease. A ninth patient not on protocol but treated with the combined modality program also developed avascular necrosis. The cumulative incidence was 10% among long-term survivors. The etiology is unclear. Prolonged corticosteroid administration has been implicated but usually in much larger doses than the patients in this series received. The possible roles of the other chemotherapeutic agents for Hodgkin's disease, and radiation are discussed. Considerable disability resulted for almost all patients. Three of seven patients primarily with avascular necrosis of the femoral heads had bilateral hip replacements with surgery anticipated in four others. The two patients primarily with humeral head involvement have limited use of their arms. This condition must be added to the known possible serious consequences of combination chemotherapy for Hodgkin's disease. It is uncertain if the frequency of avascular necrosis is higher in patients treated with both radiation and chemotherapy compared with chemotherapy alone. Further studies are needed from other institutions to clarify the frequency and cause of this problem.
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Spectroscopic limb monitoring in peripheral extracorporeal membrane oxygenation
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DOD - Acute Comp Syndrome CPG
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Limb-related complications are major contributors to extracorporeal membrane oxygenation-associated complications. Early detection of limb ischemia and or compartment syndrome is paramount to minimizing the adverse effects. With the absence of pulsatile flow, bedside Doppler examination of distal arterial waveforms is an impractical and an unreliable method of monitoring limb perfusion. We describe a new application of near-infrared spectroscopy monitoring of tissue oxygenation for the early detection of limb complications in extracorporeal membrane oxygenation.
Copyright © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
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Ligament and tendon injury to the elbow: Clinical, surgical, and imaging features
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Significant advances in the understanding of elbow anatomy, biomechanics, imaging, and surgical technique have been made over the last decade. Tendon injuries are often seen in athletes and physical laborers from repetitive eccentric overload. Ligament injuries are commonly seen in throwing athletes or after elbow dislocation. Magnetic resonance imaging has proven valuable for diagnosing and monitoring most of these soft tissue injuries, and effective surgical techniques have evolved to address them. This article describes typical clinical findings associated with ligament and tendon injuries in the elbow as well as common surgical therapies. The use of magnetic resonance imaging is highlighted throughout because this modality has revolutionized noninvasive evaluation of the elbow. (copyright) 2006 Lippincott Williams & Wilkins, Inc
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Curative resection for lung cancer in octogenarians is justified
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Reconstruction After Skin Cancer
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Background: Due to an increased life expectancy in a healthy aging population and a progressive incidence of lung cancer, curative pulmonary resections can be performed even in octogenarians. The present study aims to investigate whether surgery is justified in patients reaching the age of 80 years and older who undergo resection for non-small cell lung cancer (NSCLC). Methods: In this retrospective multi-centre analysis, the morbidity, mortality and long-term survival of 88 patients (24 females) aged =80 who underwent complete resection for lung cancer between 2000 and 2013 were analysed. Only fit patients with few comorbidities, low cardiopulmonary risk, good quality of life and a life expectancy of at least 5 years were included. Results: Curative resections from three thoracic surgery centres included 61 lobectomies, 9 bilobectomies, 6 pneumonectomies and 12 segmentectomies or wide wedge resections with additional systematic mediastinal lymphadenectomy in all cases. Final histology revealed squamous cell carcinoma [33], adenocarcinoma [41], large cell carcinoma [5] or other histological types [9]. Lung cancer stage distribution was 0 [1], I [53], II [17] and IIIA [14]. The overall 90-day mortality was 1.1%. The median hospitalisation and chest drainage times were 10 days (range, 5-27 days) and 5 days (range, 0-17 days), respectively. Thirty-six patients were complication-free (41%). In particular, pulmonary complications occurred in 25 patients (28%). In addition, 23 patients (26%) developed cardiovascular complications requiring medical intervention, while 24 patients (27%) had cerebrovascular complications, urinary tract infection and others. The median survival time was 51 months (range, 1-110 months), and the 5-year overall survival reached 45% without significance between tumour stages. Conclusions: Curative lung resections in selected octogenarians can be safely performed up to pneumonectomy for all tumour stages with a perioperative mortality, morbidity, and 5-year survival rate comparable to younger cohorts. Copyright © Journal of Thoracic Disease. All rights reserved.
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Antiprolactinemic approach in the treatment of metastatic breast cancer: a phase II study of polyneuroendocrine therapy with LHRH-analogue, tamoxifen and the long-acting antiprolactinemic drug cabergoline
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MSTS 2018 - Femur Mets and MM
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Despite the well-demonstrated stimulatory role of prolactin (PRL) on breast cancer cell growth and the possible existence of a PRL-dependency in estrogen-independent mammary tumors, the therapeutic role of the antiprolactinemic drugs in the treatment of human breast cancer has still to be investigated and defined. Previous preliminary studies have already shown that the concomitant administration of antiprolactinemic agents may enhance the efficacy of cancer chemotherapy for breast carcinoma, whereas their impact on the efficacy of the endocrine therapy is still unknown. At present, the classic endocrine therapy for breast cancer consists of anti-estrogens plus LHRH-analogue. The concomitant administration of antiprolactinemic drugs could enhance the efficacy of treatment by blocking not only the action of estrogens, but also that of another growth factor for breast cancer, such as PRL. The present phase II study was performed to evaluate the efficacy and tolerability of a polyneuroendocrine approach for breast cancer, consisting of LHRH-analogue plus the anti-estrogen tamoxifen plus a long-acting antiprolactinemic agent, cabergoline. The study included 14 consecutive metastatic breast cancer women, heavily pretreated with the standard anticancer therapies and for whom no other conventional treatment was available. The LHRH-analogue, triptorelin, was given intramuscularly at a dose of 3.75 mg every 28 days, tamoxifen was given orally at 20 mg/day and cabergoline was given orally at 0.5 mg once/week. The clinical response consisted of partial response (PR) in 4 out of 14 (29%) patients, including one who had progressed on a previous treatment with triptorelin plus tamoxifen alone. A stable disease (SD) was achieved in another 5 patients, whereas the other 5 patients had a progressive disease (PD). Mean serum levels of PRL significantly decreased on treatment within the first month of therapy, and its decline was significantly more evident in patients with PR or SD than in those with PD. The treatment was well-tolerated in all patients, and in particular no cabergoline-related toxicity occurred. This preliminary study would suggest that the association of the long-acting antiprolactinemic drug cabergoline may further enhance the efficacy of the classical endocrine therapy for advanced breast cancer with anti-estrogens plus LHRH-analogues.
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