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PCORI-1306-02918 Evaluation of Parent-based Programs to Support Children After Traumatic Injury
DoD PRF (Psychosocial RF)
Qualitative Phase I. Aim 1: Assess the feasibility of Link for Injured Kids through qualitative research with parents of previous injured children and social workers and pediatric trauma providers from the the children's hospitals. For phase 1 at UIHC, the investigators will hold focus groups with parents and pediatric health providers at the UIHC. The investigators will work with the Ul Pediatric Trauma Nurse Coordinator (Wetjen) to identify parents whose children were previously injured and treated at the UIHC in the past 12 months. These children are logged into the Trauma Alert system. UIHC: For the focus groups with providers, the investigators will invite emergency medicine physicians, nurses, pediatric psychiatrists and psychologists to participate in one focus group; and social workers and parent advocates to participate in the second focus groups. Participants identified with the assistance of Ms. Wetjen and Dr. Denning (Research Coordinator, Emergency Medicine) will be provided an introductory email about the study and an information sheet. Those interested in attending will be invited to attend the focus group session during a lunch hour. Blank Children's Hospital: Using the Iowa Trauma Database, Ms. Wetjen, UIHC Pediatric Nurse Trauma Coordinator will work with Blank Children's Hospital Pediatric Trauma Coordinator to identify parents whose children previously received an unintentional injury and were treated at the Blank Children's Hospital in the past 12 months. Focus groups will last approximately one hour, and will include open�ended questions about the various types of trauma experienced by children, the kinds of psychosocial consequences encountered by traumatized children, and the types of services perceived as available, accessible and acceptable to families particularly from rural Iowa. During the focus groups, participants will be provided a copy of the LPC for Injured Kids manual, and feedback will be solicited from participants about the content of the intervention and its applicability to families from rural Iowa. As a qualitative study, the sample will be adaptive and purposeful. The investigators anticipate holding the focus group with 6�10 participants. All sessions will be audiotaped and transcribed. Analysis will involve qualitative coding, content analysis, and triangulation. Phase II: Randomized Controlled Trial. Aim 2: Through a randomized trial, determine the range of potential psychosocial and behavioral health indicators possibly impacted by the newly developed Link for Injured Kids program. This will identify the types of outcomes which could include PTSD, depression, nonspecific distress, quality of life, absenteeism, school performance, coping skills, communication skills, and access to mental health. Eligibility: Children with unintentional injuries will be recruited to participate in the randomized trial. Children will be administered the Children's Orientation and Amnesia Test (COAT), which is a measure of orientation to self, place and memory, and those that pass the COAT with a score of at least 55 out of a possible 65 points, will be recruited into the study. One parent of the child will be recruited for participation. Children with intentional injuries will be excluded from the study. Inclusion and exclusion criteria are the same for both randomization groups. Exclusions include non�English speaking, diagnosis of intellectual deficit or psychosis, suicide attempt in the last year, and residential treatment placement in the last year. Sample Size. The investigators conducted sample size based on testing a moderate effect size of 0.5 standard deviation comparing Trauma Education vs Link. With an alpha of 0.05, a sample size of 134 parent�child dyads in each of the arms (n=268) has 100% power to examine comparisons. The investigators will oversample by 12% for a total n = 300. Recruitment, Screening and Randomization. The research team will review patient admission records morning and afternoon/evening to identify eligible patients (unintentional injury admissions between 10�17 years of age). The team will determine if the child meets inclusion criteria by reviewing information collected from EPIC, the electronic health record system at UIHC. A study team member will be texted if a child is admitted and meets eligibility criteria. The text will not contain identifying information, just a text like "A patient is added to the database." The research team will review the child's medical record to determine if he/she meet eligibility criteria and are going to be admitted. A brief information sheet will be included in the patient's admission packet describing the study and the potential for participation. On a daily basis, the research team will review each child's medical record to determine when the child is likely to be discharged. On the day of discharge or any convenient time recommended by the provider, a member of the research team will present to the child's room to determine if the child has an appropriate level of consciousness to complete the consent process (an orientation score of at least 55), and if appropriate recruit the dyad. The team member will discuss the study and complete the consent process with the dyad in�person. To minimize the possibility of coercion during the consent process, the research team will follow the consent document closely and stress to the dyad that the child's health care will not be affected by participation in the study. Randomization. After enrollment, each family will be randomly assigned on a rolling basis to either the Link or trauma education arms of the study. Intervention Training. Parents randomized to the intervention arm will be trained to offer Link to their child as needed. A 20 to 45 minute training session will be offered at the ED or in�patient ward in a private consultation room by a member of the research team. In addition, the investigators will offer training, if desired, at another location outside the hospital during a convenient time. A training manual will be offered to the family. The steps of Link will be taught. In Link 1, the parents will be taught to use reflective listening skills based on motivational interviewing to obtain information without invasive probing (found to be harmful in the practice of Critical Incident Stress Debriefing). Additionally, the parent will briefly assess current emotional response to the crisis using the modified Kessler�6 screener, a six�item tool that asks about feelings of sadness, nervousness, restlessness, hopelessness, effort, and worthlessness. In Link 2, the psychological first aid interventionist facilitates access to resources and further care if necessary to support their child. Resources are given to the family including a toll�free help line and support for advanced mental health care at UIHC and their local community. Trauma Education families will not be trained but be given a parent booklet, "So you've been in an accident." Data Collection. Data about the injury visit and follow�up visits will be collected from each enrolled child from the medical records. The investigators will collect nature of injury and body location using the International Classification of Diseases (ICD�9). Additional information collected will include length of stay, diagnostic procedures, mechanism of injury, initial vital signs, and any follow�up complications or co�morbidities. Information on injury severity will be recorded through the collection of abbreviated injury scale (AIS) and injury severity scale (ISS) scores. Baseline, 6�week, 3�month and 6�month surveys will be administered with parents and children in both Link and Trauma Education arms. The investigators will ask the child and parent to complete baseline surveys in the patient ward. Follow�up 6�week, 3�month and 6�month surveys will be conducted by self�administered mailed surveys or online. Questionnaires will measure depressive symptoms, symptoms of post traumatic stress disorder, social support, family communication, strengths and difficulties and quality of life and asks about any mental he lth or community resources they may have used since the last questionnaire. For follow�up, the research team will e�mail a link for the parent and the child to complete their surveys as well as mail a hard copy version of the questionnaire with a cover letter explaining that the survey can be completed on paper or online and a postage paid envelope. If completed online, the questionnaires will be done electronically using REDCap, a U of I supported online survey system. A telephone call will be placed to the dyad the day the hard copy questionnaire is mailed informing the dyad of the mailing. If an online or mailed questionnaire is not returned within 10 days the research team will attempt to contact the dyad by phone 6 times within a month to remind them of the questionnaire. After a month of no response, the investigators will resend the package or online link. If a dyad does not complete the 6�week questionnaire, they will still be asked to complete the 3�month and 6�month questionnaires. Analytic Plan The investigators will compare the effectiveness of the two intervention arms (Link and Trauma Education) to each other. The research team will examine several parent�related and child�related outcomes potentially impacted by the interventions, including symptoms of PTSD and depression, coping, family social support, quality of life, school outcomes, and contacts with mental health professionals. Outcomes may be continuous or categorical in nature. A number of comparisons will involve repeated measures of subjects (child or parent) across time. The investigators will first calculate t�tests and Wilcoxon rank sum tests to examine continuous outcomes (e.g., levels of depression, level of family social support), and chi�square tests for categorical outcomes (e.g., symptomatic for PTSD vs. asymptomatic). If randomization is not achieved, the investigators will pursue Generalized Linear Mixed Models (GLMM). As an example, for PTSD symptoms, the research team will examine 1) onset of symptoms at six weeks, and 2) changes measured from six weeks to three months and to six months. 1) For six�week measurements, the investigators will conduct a simple generalized linear model and include time�varying covariates to account for measures changed from baseline (e.g., coping, social support). 2) For changes from six weeks through six months, the GLMMs will account for clustering of repeated observations clustered within subjects over time.
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Serial nerve conduction studies in a single subject following clinically-successful carpal tunnel release
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
Introduction: The course of electrodiagnostic (EDX) recovery of distal median neuropathy following carpal tunnel release (CTR) is uncertain. The authors report serial EDX studies in a 54-year-old female following CTR. Objectives: To perform serial nerve conduction studies (NCSs) in a patient with clinically-successful CTR. Methods: Preoperative and then prospective Internal Review Board-approved testing of postoperative NCSs performed include the median (digits 1-4) and ulnar sensory and median motor nerves. NCSs were performed 4 days preoperatively and at 1, 2, 3, 4, 5, 7, 9, 14, 20, and 25 weeks postoperatively. Results: There was complete resolution of sensory symptoms on the same day as CTR. Post-CTR median sensory nerve action potential (SNAP) onset and peak latencies gradually became normal. Pre- CTR digit 2 SNAP amplitude was low with wrist stimulation but seemingly normal when stimulating mid-palm. Post-CTR median SNAP amplitude with wrist stimulation gradually improved while amplitude with mid-palm stimulation remained essentially unchanged. A decrease in the median distal motor latency (DML) was most prominent at the first postoperative NCS followed by gradual improvement. Conclusion: Despite sensory symptom resolution immediately post-CTR, the median SNAP latency and amplitude improved gradually over months in contrast to the median DML which improved more rapidly in the first week than later. The mechanism of improvement in median SNAP amplitude recording from digit 2 with wrist versus midpalm stimulation may be due to remyelination and repair of apparent conduction block of the median sensory fibers rather than decreased temporal dispersion of the SNAP since the onset and peak SNAP latencies improved in parallel
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The Rotaglide mobile bearing knee arthroplasty A 10- to 13-year review from an independent centre
AMP (Acute Meniscal Pathology)
The Rotaglide knee arthroplasty has a highly congruent mobile meniscal bearing allowing both rotation and antero-posterior translation. We reviewed 137 consecutive primary arthroplasties in 120 patients at mean 11.1 years (10-12.9) following surgery. No cases were lost to follow-up. Hospital for Special Surgery (HSS) and American Knee Society (AKSS) scores were recorded at a review clinic. Radiographs were assessed using the Knee Society's roentgenographic evaluation system. Forty-two patients had died, leaving 78 patients (87 knees) available for review. Sixty-four patients (70 knees) were assessed at a clinic and in 14 (17 knees) clinical outcomes were obtained via telephone and their most recent radiographs were assessed. There were three cases of aseptic loosening and one deep infection requiring revision surgery. Two meniscal bearings were replaced with thicker inserts, one following bearing fracture and one following bearing dislocation. Survival at 11 years for aseptic loosening was 97.6% (95% CI 94.3 to 1.0) and survival using re-operation for any cause was 95.3% (95% CI 90.8 to 99.8). The Rotaglide mobile-bearing total knee replacement demonstrates good survivorship and outcome scores at 11 years following surgery.
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Improving management of musculoskeletal disorders in primary care: the Joint Adventures Program
Glenohumeral Joint OA
Musculoskeletal disorders represent a large and growing clinical challenge to primary care clinicians. Unfortunately, there appears to be a gap in current training and continuing education to meet this challenge. We used script concordance within a continuing medical education program entitled "Joint Adventures" to assist family physicians to acquire the knowledge, skills, and tools they need to improve their management of musculoskeletal disorders. Program workshops were coordinated through a national continuing education program of the College of Family Physicians of Canada. A group of 54 experts in musculoskeletal disorders including family physicians, rheumatologists, and orthopedists developed cases for six areas of management that were identified by family physicians during a needs survey delivered at a national scientific congress in primary care. Script concordance methodology was used in the Joint Adventures workshop to address knowledge gaps or lack of group consensus in the six areas including (1) diagnosis of osteoarthritis, (2) treatment and management of osteoarthritis, (3) treatment and management of rheumatoid arthritis, (4) diagnosis and treatment of back pain, (5) diagnosis and treatment of fibromyalgia and diagnosis, and (6) treatment of shoulder pain. Each workshop session included 5-30 family physicians, a specialist expert, and a family physician facilitator. Before each session, a group needs assessment was conducted to identify which one or two of the six cases would be used. Perceived knowledge and skill acquisition, self-assessed change in practice, and satisfaction with the program were measured at the conclusion of each session and again at 3 months post program. All programs were delivered from March 2003 to September 2005. Six hundred and fifty family physicians from across Canada completed the program. In general, participants reached concordance with each case. Measures of knowledge and skill acquisition and self-assessed change in practice were significantly improved with high rates of program satisfaction. The Joint Adventures program provided family physicians with knowledge and skills that changed their care of musculoskeletal disorders. This was achieved using consensus that was sensitive to local needs. Further use should be evaluated in other areas of medical practice as well.
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Anterior knee pain: Symptom or syndrome?
Diagnosis and Treatment of Osteochondritis Dissecans AUC
A chief complaint for many patients is anterior knee pain. This is more common in females; the incidence is two to three times than that in males. The challenge for the physician is to determine the etiology, the diagnosis, and the best treatment. The goal of this article is to provide key elements of the history, physical examination, and treatment options to help assist in the management of patients with anterior knee pain or patellofemoral pain syndrome. Copyright (copyright) 2003 by Current Science Inc
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Comparison of 3 real-time, quantitative murine models of staphylococcal biofilm infection by using in vivo bioluminescent imaging
PJI DX Updated Search
Biofilm formation represents a unique mechanism by which Staphylococcus aureus and other microorganisms avoid antimicrobial clearance and establish chronic infections. Treatment of these infections can be challenging, because the bacteria in the biofilm state are often resistant to therapies that are effective against planktonic bacteria of the same species. Effective animal models for the study of biofilm infections and novel therapeutics are needed. In addition, there is substantial interest in the use of noninvasive, in vivo data collection techniques to decrease the animal numbers required for the execution of infectious disease studies. To ad- dress these needs, we evaluated 3 murine models of implant-associated biofilm infection by using in vivo bioluminescent imaging techniques. The goal of these studies was to identify the model that was most amenable to development of sustained infections that could be imaged repeatedly in vivo by using bioluminescent technology. We found that the subcutaneous mesh and tibial intramedullary pin models both maintained consistent levels of bioluminescence for as long as 35 d after infection, with no implant loss experienced in either model. In contrast, a subcutaneous catheter model demonstrated significant incidence of incisional ab- scessation and implant loss by day 20 after infection. The correlation of bioluminescent measurements and bacterial enumeration was strongest with the subcutaneous mesh model. Among the 3 models we evaluated, the subcutaneous mesh model is the most appropriate animal model for prolonged study of biofilm infections by using bioluminescent imaging
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Criteria for bone debridement in massive lower limb trauma
DoD SSI (Surgical Site Infections)
Adequate debridement remains the most important factor in prevention of chronic sepsis in cases of massive lower limb trauma. Despite treatment with chronic antibiotics, muscle flaps, hyperbaric oxygen, and/or free-tissue transfer, failures are common due to inadequate bone debridement. All bony fragments with marginal soft-tissue attachments and exposed bone without evidence of adequate blood flow must be removed during debridement for optimal results. Laser Doppler flowmetry (LDF) may be a useful adjunct for the assessment of bone viability during both initial and subsequent debridements. Preliminary data on eight patients have demonstrated that bone blood flow as determined by LDF is highly correlated with clinical outcome. In 13 cases, LDF has proved to be helpful in the management of chronic osteomyelitis.
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Factors associated with acute and chronic pain following traumatic spinal cord injuries
DoD PRF (Psychosocial RF)
Previous studies have estimated that between 25% and 45% of people with spinal cord injury report severe levels of chronic pain. Few studies have examined this longitudinally. This study examines the primary pain sites, intensity and variability of perceived pain in 76 patients, 6 weeks post injury and 45 patients from the same cohort, 8 year post discharge. Demographic information reveals a close similarity with the database (40,000) from Stover and Fine's cohort (1986). Data was assessed using visual analogue scales, measures were also taken of functional independence (FIM), emotional status and coping. At 6 weeks post injury, most pain is sited in the thoracic spine area, and in the upper and lower limbs. At 1 year post discharge, most pain is reported to be in the thoracic spine area, the lumbar region and the chest. Twenty-three per cent of the 6 week group reported that the intensity of their pain was severe, whilst at 1 year, 41% of the sample complained of severe pain. Factors associated with the pain at both time points were explored using correlational analyses. The emotional, functional and psychological factors that predict pain severity were explored using multiple regression analysis. Twenty-four per cent of those reporting moderate to severe pain at 6 weeks post injury were still reporting pain at 1 year post discharge. This study examines the relative contribution of psychological factors in reported pain.
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Insights into osteoarthritis from MRI
AMP (Acute Meniscal Pathology)
Magnetic resonance imaging (MRI) has added a new dimension to the study of osteoarthritis, a long-known degenerative joint disease with limited therapeutic options. It has advanced our understanding of joint pathophysiology and identifying that osteoarthritis as a simple 'wear and tear' process of the articular cartilage has indeed become a thing of the past. Recent work has focused on the study and validation of MRI scoring/quantification systems, as well as the identification of MRI predictors of symptoms/disease progression. The latter may serve to identify patients at greater risk for osteoarthritis disease progression to be enrolled in clinical trials. Like all imaging tools, MRI use has its associated problems. Structural changes seen in patients with osteoarthritis are often seen in asymptomatic subjects and this makes an MRI definition of osteoarthritis less straightforward. The ability to pick up multiple structural abnormalities simultaneously and high sensitivity in delineating structural changes can makes interpretation of true pathology more complicated. Although there has been much progress in the field of MRI in osteoarthritis, there remain many clinical/technical issues that need to be addressed. Until more data are obtained from clinical trials, the question of whether MRI is useful in therapeutics intervention in osteoarthritis remains unanswered. © 2011 The Authors. International Journal of Rheumatic Diseases © 2011 Asia Pacific League of Associations for Rheumatology and Blackwell Publishing Asia Pty Ltd.
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Multimodal Drug Infiltration in Total Knee Arthroplasty: is Posterior Capsular Infiltration Worth the Risk?
OAK 3 - Non-arthroplasty tx of OAK
Analgesic agents were bupivacaine, morphine, ketorolac and epinephrine. All patients received spinal anesthesia and patient controlled analgesia (PCA) for 24 hours post surgery. The surgical technique and postoperative medication protocols were identical in both groups. The visual analogue scale (VAS) for pain during activity and at rest, and morphine consumption were recorded at 6, 12, 18 and 24 hours postoperatively. LAI�related side effects, blood loss, length of hospital stay, and VAS for satisfaction were monitored. The reviewer was blinded to treatment groups.
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Scaffolds for partial meniscal replacement: An updated systematic review
PJI DX Updated Search
Introduction: Meniscectomy, a most common orthopaedic procedure, results in increased contact area of the articular surfaces of tibia and femur leading to early osteoarthritis. We systematically review the literature on clinical outcomes following partial meniscal replacement using different scaffolds. Sources of data: We performed a comprehensive search of Medline, CINAHL, Embase and the Cochrane Central Registry of Controlled Trials. The reference lists of the selected articles were then examined by hand. Only studies focusing on investigation of clinical outcomes on patients undergoing a partial meniscal replacement using a scaffold were selected. We then evaluated the methodological quality of each article using the Coleman methodology score (CMS), a 10 criteria scoring list assessing the methodological quality of the selected studies (CMS). Areas of agreement: Fifteen studies were included, all prospective studies, but only 2 were randomized controlled trials. Biological scaffolds were involved in 12 studies, 2 studies investigated synthetic scaffolds, whereas 1 remaining article presented data from the use of both classes of device. The mean modified CMS was 64.6. Areas of controversy: Several demographic and biomechanical factors could influence the outcomes of this treatment modality. Growing points: Partial replacement using both classes of scaffolds achieves significant and encouraging improved clinical results when compared with baseline values or with controls when present, without no adverse reaction related to the device. Research: There is a need for more and better designed randomized trials, to confirm with a stronger level of evidence the promising preliminary results achieved by the current research. © The Author 2013. Published by Oxford University Press. All rights reserved
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Hypopituitarism in the elderly: multifaceted clinical and biochemical presentation
Upper Eyelid and Brow Surgery
UNLABELLED: Hypopituitarism (HYPO) is a rare and under-investigated pathology in the elderly. AIM: to review our case records of patients > or =65 yrs with first diagnosis of anterior global hypopituitarism, in order to evaluate presentation symptoms, etiology, biochemical and hormonal pictures, pituitary morphology, and efficacy of therapy. PATIENTS: 15 patients (65-82 yrs) were studied: in 11 (73%) HYPO was secondary to pituitary macroadenoma (non-secreting in 10 and GH-secreting in 1); in 3 it was associated to empty sella, and in 1 to pituitary hypoplasia. RESULTS: major presenting symptoms were visual-field defects and asthenia (40%) but also memory and/or gait impairment and nausea (30%) and depression (20%) were significantly observed. Dyslipidemia (73%), anemia (20%) and severe hyponatremia (13%) were found. After starting substitutive therapy and clinical improvement, 10 patients with macroadenoma underwent uneventful neurosurgery, which improved visual alterations but not pituitary function. Immunohistochemistry showed positivity for FSH in one patient and for GH in one patient. Six out of the eight patients with a post-surgical tumor remnant required treatment (surgery/radiotherapy/somatostatin analogue treatment in the acromegalic patient). CONCLUSIONS: The diagnosis of HYPO is often delayed in the elderly, since symptoms may be ascribed to aging and associated comorbidities. In our series, most of the aspecific symptoms were retrospectively addressed to HYPO since their resolution/improvement with replacement therapy. The prevalent cause of HYPO remains non-functioning pituitary macroadenomas. Hyponatremia can be a life-threatening presenting symptom. Symptoms considered apparently aspecific in the elderly should be investigated in order to possibly diagnose an important treatable disorder as HYPO.
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A novel mechanism for induction of increased cortical porosity in cases of intracapsular hip fracture
Management of Hip Fractures in the Elderly
It has been suggested that, in hip fracture, the cortex on the inferoanterior (IA) to superoposterior (SP) axis is thinned and shows increased porosity. This is dependent on the presence of giant canals (i.e., diameter >385 microm), which are related to clusters of remodeling osteons. To investigate further the relationship between remodeling and bone loss, osteonal diameter (On.Dm), wall thickness (W.Th), osteoid width (O.Wi), and extent (OS) were measured in femoral neck biopsies from 12 female intracapsular hip fracture cases and 11 age- and gender-matched controls. Over 83% of giant canals were "composite" osteonal systems in which a single canal was surrounded by multiple packets of osteonal bone. Among smaller canals, over 80% of systems had a canal encircled by a single cement line containing one packet of bone ("simple"). Composites were nearly twice as prevalent in fractures (fracture cases 9.8 +/- 0.7/25 mm(2), controls 5.3 +/- 0.4/25 mm(2), p < 0. 0001), and were dependent (R(2) = 0.52) on femoral neck region (p = 0.0008) and the regional distribution of clusters of remodeling osteons (p = 0.0045). Both the inferior (I) and anterior (A) regions had an elevated number of composites (I: 263% of control values, p = 0.0054; A: 202% of control values, p = 0.0092). On.Dm was similar in fracture cases and controls (simple: fracture cases 183 +/- 3 microm, controls 191 +/- 4 microm; composites: fracture cases 446 +/- 13 microm, controls 460 +/- 13 microm). W.Th in simples was similar in fracture cases and controls (fracture cases 51 +/- 0.8 microm, controls 49 +/- 0.7 microm), but composites had significantly (p < 0. 0001) thinner walls, with the reduction in fracture cases (31%) being twice that of controls (12%, p < 0.0001). There were no differences in O.Wi. It was unusual for osteoid to fully surround the composite canal surface; OS was 38% lower in composite than simple canals (p < 0.0001). This study indicates that, in the femoral neck cortex, the principal remodeling deficit in hip fracture is specific to composite osteons. Hip fracture cases had zonal increases in composite osteon density with reduced bone formation. The data suggest that generation of composite osteons is a plausible mechanism leading to increasing porosity and trabecularization of the cortex, thus weakening the cortex in regions maximally loaded on fall impact
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Low skeletal muscle mass is associated with increased hospital expenditure in patients undergoing cancer surgery of the alimentary tract
MSTS 2022 - Metastatic Disease of the Humerus
Background: Low skeletal muscle mass is associated with poor postoperative outcomes in cancer patients. Furthermore, it is associated with increased healthcare costs in the United States. We investigated its effect on hospital expenditure in a Western-European healthcare system, with universal access. Methods: Skeletal muscle mass (assessed on CT) and costs were obtained for patients who underwent curative-intent abdominal cancer surgery. Low skeletal muscle mass was defined based on pre-established cut-offs. The relationship between low skeletal muscle mass and hospital costs was assessed using linear regression analysis and Mann-Whitney U-tests. Results: 452 patients were included (median age 65, 61.5% males). Patients underwent surgery for colorectal cancer (38.9%), colorectal liver metastases (27.4%), primary liver tumours (23.2%), and pancreatic/periampullary cancer (10.4%). In total, 45.6% had sarcopenia. Median costs were €2,183 higher in patients with low compared with patients with high skeletal muscle mass (€17,144 versus €14,961; P<0.001). Hospital costs incrementally increased with lower sex-specific skeletal muscle mass quartiles (P = 0.029). After adjustment for confounders, low skeletal muscle mass was associated with a cost increase of €4,061 (P = 0.015). Conclusion: Low skeletal muscle mass was independently associated with increased hospital costs of about €4,000 per patient. Strategies to reduce skeletal muscle wasting could reduce hospital costs in an era of incremental healthcare costs and an increasingly ageing population.
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The Association Between Hospital Length of Stay and 90-Day Readmission Risk for Femoral Neck Fracture Patients: Within a Total Joint Arthroplasty Bundled Payment Initiative
Hip Fx in the Elderly 2019
BACKGROUND: Hip arthroplasty is increasingly performed as a treatment for femoral neck fractures (FNFs). However, these cases have higher complication rates than elective total hip arthroplasties (THAs). The Center for Medicare and Medicaid Services has created the Comprehensive Care for Joint Replacement model to increase the value of patient care. This model risk stratifies FNF patients in an attempt to appropriately allocate resources, but the formula has not been disclosed. The goal of this study was to ascertain if patients with FNFs have different readmission rates compared to patients undergoing elective THA so that the resource utilization can be assessed. METHODS: We analyzed all patients undergoing THA at our institution during a 21-month period. Patients classified by a diagnosis-related group of 469 or 470 were included. Multivariate and survival analyses were performed to determine risk of 90-day readmission. RESULTS: Patients admitted for FNFs were older, had higher body mass indices, longer lengths of stay, and were more likely to be discharged to inpatient facilities than patients who underwent elective THA. Increased American Society of Anesthesiologists scores and FNF were also independent risk factors for 90-day readmission, and these patient were more likely to be readmitted during the latter 60 days following admission. CONCLUSION: Results suggest that patients who undergo an arthroplasty following urgent or emergent FNFs have inferior outcomes to those receiving an arthroplasty for a diagnosis of arthritis. Fracture patients should either be risk stratified to allow appropriate resource allocation or be excluded from alternative payment initiatives such as Comprehensive Care for Joint Replacement.
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Risk factors for anterior cruciate ligament injury: a review of the literature - part 1: neuromuscular and anatomic risk
SR for PM on OA of All Extremities
CONTEXT: Injuries to the anterior cruciate ligament (ACL) of the knee are immediately debilitating and can cause long-term consequences, including the early onset of osteoarthritis. It is important to have a comprehensive understanding of all possible risk factors for ACL injury to identify individuals who are at risk for future injuries and to provide an appropriate level of counseling and programs for prevention. OBJECTIVE: This review, part 1 of a 2-part series, highlights what is known and still unknown regarding anatomic and neuromuscular risk factors for injury to the ACL from the current peer-reviewed literature. DATA SOURCES: Studies were identified from MEDLINE (1951-March 2011) using the MeSH terms anterior cruciate ligament, knee injury, and risk factors. The bibliographies of relevant articles and reviews were cross-referenced to complete the search. STUDY SELECTION: Prognostic studies that utilized the case-control and prospective cohort study designs to evaluate risk factors for ACL injury were included in this review. RESULTS: A total of 50 case-control and prospective cohort articles were included in the review, and 30 of these studies focused on neuromuscular and anatomic risk factors. CONCLUSIONS: Several anatomic and neuromuscular risk factors are associated with increased risk of suffering ACL injury-such as female sex and specific measures of bony geometry of the knee joint, including decreased intercondylar femoral notch size, decreased depth of concavity of the medial tibial plateau, increased slope of the tibial plateaus, and increased anterior-posterior knee laxity. These risk factors most likely act in combination to influence the risk of ACL injury; however, multivariate risk models that consider all the aforementioned risk factors in combination have not been established to explore this interaction
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The economic cost of hip fractures among elderly women. A one-year, prospective, observational cohort study with matched-pair analysis. Belgian Hip Fracture Study Group
HipFx Supplemental Cost Analysis
BACKGROUND: We conducted a prospective study to assess the costs of initial hospitalization for a first hip fracture and to evaluate the excess costs attributable to the hip fracture during the one-year period following hospital discharge. METHODS: This investigation was designed as a one-year prospective cohort study with matched-pair analysis. Elderly women who were receiving care for a first hip fracture at four Belgian hospitals were matched, with respect to age and residence, with women (control subjects) with no history of hip fracture who lived in the same neighborhood. The initial hospitalization costs were tabulated from the hospital invoices. To estimate the costs during the year after hospital discharge, health-care services utilized by the hip-fracture patients and by the control subjects were recorded. We used the official reimbursement rates to assign a cost to these services, and the results are reported in United States dollars. RESULTS: The mean age of the 159 patients who had a hip fracture was 79.3 years, and that of the 159 control subjects was 78.7 years. The total mean cost of the initial hospitalization was $9534 for the hip-fracture patients. The total direct costs during the year after discharge averaged $13,470 for the hip-fracture patients and $6170 for the control subjects. Thus, the excess direct cost during the one-year period following hospital discharge averaged $7300 for the hip-fracture patients. The largest cost differences were attributable to nursing-home stays (31%), rehabilitation-center stays (31%), hospitalizations (16%), and home physical-therapy services (14%). Two-fifths of the excess costs were spent during the three months following hospital discharge. Moreover, we observed a shift in resource utilization after hospital discharge. CONCLUSIONS: Our one-year prospective study demonstrated that the costs of treating a hip-fracture patient are about three times greater than those of caring for a patient without a fracture. This study also highlights the savings to society if a hip fracture can be avoided
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A novel injectable hydrogel in combination with a surgical sealant in a rat knee osteochondral defect model
Diagnosis and Treatment of Osteochondritis Dissecans AUC
Osteochondral defects are frequent, painful, debilitating and expensive to treat, often resulting in poor results. The goal of the present study was to synthesize and characterize a novel biocompatible and biodegradable hydrogel comprised of poly(ethylene glycol), gelatin, and genipin, and examine the hydrogel as an injectable biomaterial in combination with a cyanoacrylate-based surgical sealant for cartilage repair. An osteochondral knee defect was generated in 24 rats, then the hydrogel, with or without a surgical sealant, was injected into the defect and followed for 14 days. The results demonstrated that the hydrogel is biocompatible and biodegradable, and that the cyanoacrylate-based surgical sealant is a relatively safe option for maintaining the hydrogel in the defect. This is the first study describing a cyanoacrylate-based surgical sealant in combination with a polymer hydrogel for cartilage repair
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Liposuction in arm lymphedema treatment
Panniculectomy & Abdominoplasty CPG
Breast cancer is the most common disease in women, and up to 38% develop lymphedema of the arm following mastectomy, standard axillary node dissection and postoperative irradiation. Limb reductions have been reported utilizing various conservative therapies such as manual lymph and pressure therapy. Some patients with long-standing pronounced lymphedema do not respond to these conservative treatments because slow or absent lymph flow causes the formation of excess subcutaneous adipose tissue. Previous surgical regimes utilizing bridging procedures, total excision with skin grafting or reduction plasty seldom achieved acceptable cosmetic and functional results. Microsurgical reconstruction involving lympho-venous shunts or transplantation of lymph vessels has also been investigated. Although attractive in concept, the common failure of microsurgery to provide complete reduction is due to the persistence of newly formed subcutaneous adipose tissue, which is not removed in patients with chronic non-pitting lymphedema. Liposuction removes the hypertrophied adipose tissue and is a prerequisite to achieve complete reduction. The new equilibrium is maintained through constant (24-hour) use of compression garments postoperatively. Long-term follow up (7 years) does not show any recurrence of the edema.
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Tolerability and Efficacy of 3 Approaches to Intra-articular Corticosteroid Injections of the Knee for Osteoarthritis: A Randomized Controlled Trial
OAK 3 - Non-arthroplasty tx of OAK
BACKGROUND: Several studies have been performed suggesting that a superolateral approach to cortisone injections for symptomatic osteoarthritis of the knee is more accurate than anteromedial or anterolateral approaches, but there are little data to correlate clinical outcomes with these results. Additionally, there are minimal data to evaluate the pain of such procedures, and this consideration may impact physician preferences for a preferred approach to knee injection. PURPOSE: To determine the comparative efficacy and tolerability (patient comfort) of landmark-guided cortisone injections at 3 commonly used portals into the arthritic knee without effusion. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Adult, English-speaking patients presenting to a sports medicine clinic with knee pain attributed to radiographically proven grades I through III knee osteoarthritis were randomized to receive a cortisone injection via superolateral, anteromedial, or anterolateral approaches. Patients used a visual analog scale (VAS) to self-report comfort with the procedure. Western Ontario and McMaster Universities Arthritis Index (WOMAC) 3.1 VAS scores were used to establish baseline pain and dysfunction prior to the injection and at 1 and 4 weeks follow-up via mail. RESULTS: A total of 55 knees from 53 patients were randomized for injection using a superolateral approach (17 knees), an anteromedial approach (20 knees), and an anterolateral approach (18 knees). The mean VAS scores for procedural discomfort showed no significant differences between groups (superolateral, 39.1 +/- 28.5; anteromedial, 32.9 +/- 31.5; anterolateral, 33.1 +/- 26.6; P = .78). WOMAC scores at baseline were similar between groups as well (superolateral, 1051 +/- 686; anteromedial, 1450 +/- 573; anterolateral, 1378 +/- 673; P = .18). The WOMAC scores decreased at 1 and 4 weeks for all groups, with no significant differences in reduction between the 3 groups. CONCLUSION: Other studies have shown that the superolateral portal is the most accurate. This study did not assess accuracy, but it showed that all 3 knee injection sites studied have similar overall clinical benefit at 4-week follow-up. Procedural pain was not significantly different between groups.
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Traumatic instability of the elbow - Anatomy, pathomechanisms and presentation on imaging
The Treatment of Pediatric Supracondylar Humerus Fractures AUC
Traumatic instability of the elbow is a common problem among patients presenting to emergency departments. As recurrent instability is more common than previously thought and the knowledge of the most frequent underlying causes increases, treatment of elbow instability is becoming increasingly sophisticated. Therefore, it is mandatory for the radiologist to be familiar with the important osseous and soft-tissue stabilisers of the elbow joint and to know the pathomechanisms that lead to a spectrum of joint instability. This article discusses the relevant anatomy in elbow stability with respect to imaging and function, states the mechanisms leading to elbow dislocation and displays the types of traumatic instability of the elbow on radiography, computed tomography, and magnetic resonance imaging. Key Points (bullet) Expert imaging helps the management of traumatic instability of the elbow (bullet) The lateral ulnar collateral ligament is the cornerstone for elbow stability (bullet) Soft-tissue disruption is important in posterolateral rotatory instability (bullet) Identification of small coronoid process fragments is essential for optimal surgical therapy (copyright) 2013 European Society of Radiology
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Yoga training application in overweight control of seniors with arthritis/osteoarthritis
SR for PM on OA of All Extremities
The subject of the paper is oriented on problems of senior revitalization and joints healing. The study reports the application and evaluation of an interventional yoga program for seniors with overweight in arthritis or osteoarthritis combination. The aim of the study is to accomplish significant changes in overweight reduce, pain reduce and self-concept optimization of participants after the yoga training. The experimental group (ES) was conducted from 58 persons from senior homes in the region of South Bohemia in Czech Republic. The control group (CS) was conducted from 54 persons from senior homes in the region of South Bohemia in Czech Republic. All the probands were disabled seniors with diagnosis of overweight with arthritis or osteoarthritis. ES and CS were compared before and after intervention movement program in somatic and psychological tests, e.g. BMI, measuring of diameters of 10 skin folds with callipers, self-perception gamut, and list of open sentences. In ES a significant discrepancy between input and check out BMI was perceptible. Significant positive changes in the reduction of diameters of 10 skin folds were recorded in female and male of ES after the yoga intervention. Psychological analyses after intervention movement program document shift from anxiety to state fair, from depressive moods to vitality, from fatigue to force and energy, from confusion and uncertainties to self-respect and self-esteem. The intervention program was running in three months cycles in several groups. Whole experiment was completed in one year
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Money or mental health: the cost of alleviating psychological distress with monetary compensation versus psychological therapy
DoD PRF (Psychosocial RF)
AbstractMoney is the default way in which intangible losses, such as pain and suffering, are currently valued and compensated in law courts. Economists have suggested that subjective well-being regressions can be used to guide compensation payouts for psychological distress following traumatic life events. We bring together studies from law, economic, psychology and medical journals to show that alleviating psychological distress through psychological therapy could be at least 32 times more cost effective than financial compensation. This result is not only important for law courts but has important implications for public health. Mental health is deteriorating across the world - improvements to mental health care might be a more efficient way to increase the health and happiness of our nations than pure income growth.
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Mental health of displaced and refugee children resettled in high-income countries: Risk and protective factors
DoD PRF (Psychosocial RF)
We undertook a systematic search and review of individual, family, community, and societal risk and protective factors for mental health in children and adolescents who are forcibly displaced to high-income countries. Exposure to violence has been shown to be a key risk factor, whereas stable settlement and social support in the host country have a positive effect on the child's psychological functioning. Further research is needed to identify the relevant processes, contexts, and interplay between the many predictor variables hitherto identified as affecting mental health vulnerability and resilience. Research designs are needed that enable longitudinal investigation of individual, community, and societal contexts, rather than designs restricted to investigation of the associations between adverse exposures and psychological symptoms. We emphasise the need to develop comprehensive policies to ensure a rapid resolution of asylum claims and the effective integration of internally displaced and refugee children. © 2012 Elsevier Ltd.
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Isobaric ropivacaine with or without dexmedetomidine for surgery of neck femur fracture under subarachnoid block
Hip Fx in the Elderly 2019
Background and Aims: Dexmedetomidine has a promising role as an intrathecal adjuvant. However it's role as an adjuvant to ropivacaine has not been evaluated extensively. This study is designed to find out the effect of addition of dexmedetomidine 5 mug to isobaric ropivacaine 18.75 mg on block characteristics and hemodynamic parameters in patients undergoing surgeries for fracture neck of femur under subarachnoid block (SAB). Material and Methods: Sixty-one American Society of Anesthesiologists (ASA) Class I or II patients between 18-60 years undergoing surgeries for fracture neck of femur under SAB were recruited and randomized into two groups. Thirty patients in Group RN received 2.5 ml isobaric ropivacaine 0.75% (18.75 mg) with 0.5 ml normal saline (NS) to make a total volume of 3 ml, while 31 patients in Group RD received 2.5 ml isobaric ropivacaine 0.75% with dexmedetomidine 5 mug diluted with NS to make a total volume of 3 ml. The block characteristics, hemodynamic parameters, and side effects were recorded in both the groups. Results: Patients in Group RD had significantly longer duration of sensory block (202.90 +/- 50.2 min) compared to Group RN (157.33 +/- 31.6 min), P < 0.001. Time to first rescue analgesia request was significantly longer in the Group RD compared to Group RN (265.16 +/- 71.4 min vs 203.67 +/- 35.6 min, respectively) (P < 0.001). However, the sensory block onset, maximum block height, time to two dermatomal regression, and motor block intensity remained unaltered. Incidence of side effects like hypotension, bradycardia, nausea, vomiting, and shivering were statistically similar in both the groups. Conclusion: Addition of 5 mug dexmedetomidine enhances the analgesic effect of intrathecal 18.75 mg isobaric ropivacaine for the conduct of fracture neck of femur surgeries with minimal adverse events.
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Evaluation of lower limb axial alignment using digital radiography stitched films in pre-operative planning for total knee replacement
OAK 3 - Non-arthroplasty tx of OAK
BACKGROUND: For patients with knee osteoarthritis, even slight anatomical variations in the femur or the tibia could affect total limb alignment during total knee replacement (TKR). Our hypothesis implies that the femoral valgus correction angle (VCA) in patients indicated for TKR, is variable and higher than the reported norm of 6degree utilized in most intramedullary instrumentation systems, and that tibial bowing may result to a disparity of the tibial mechanical axis to the anatomical axis. METHODS: Our study is a retrospective review of 216 pre-operative arthritic knees, which investigated the lower limb axial alignment using digitally-stitched films. Patients excluded from the study are those with history of previous tibial or femoral osteotomy, secondary gonarthrosis, rheumatoid arthritis, previous femoral or tibial fracture, patients for bilateral TKR, or history of hip surgery. RESULTS: The mean age was 68-years old (range 39-86 years). The mean VCA was 7degree (4.7-9.3) for men and 6.6degree (4.9-9) for women. However, 71 patients (33%) had more than 7degree VCA. Subsequently, 46 patients (21%) had tibial bowing producing an angle >1.5degree between its mechanical and anatomic axis. CONCLUSIONS: The 6degree standard when used as a guide may result in suboptimal prosthesis positioning during conventional TKR surgery. Therefore our findings suggest that the femoral valgus correction angle has a broad range, and using standard femoral intramedullary guides should not be overlooked.
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Protocol for the process and feasibility evaluations of a new model of primary care service delivery for managing pain and function in patients with knee osteoarthritis (PARTNER) using a mixed methods approach
OAK 3 - Non-arthroplasty tx of OAK
Introduction This protocol outlines the rationale, design and methods for the process and feasibility evaluations of the primary care management on knee pain and function in patients with knee osteoarthritis (PARTNER) study. PARTNER is a randomised controlled trial to evaluate a new model of service delivery (the PARTNER model) against a â?¬ usual care'. PARTNER is designed to encourage greater uptake of key evidence-based non-surgical treatments for knee osteoarthritis (OA) in primary care. The intervention supports general practitioners (GPs) to gain an understanding of the best management options available through online professional development. Their patients receive telephone advice and support for OA management by a centralised, multidisciplinary a â?¬ Care Support Team'. We will conduct concurrent process and feasibility evaluations to understand the implementation of this new complex health intervention, identify issues for consideration when interpreting the effectiveness outcomes and develop recommendations for future implementation, cost effectiveness and scalability. Methods and analysis The UK Medical Research Council Framework for undertaking a process evaluation of complex interventions and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) frameworks inform the design of these evaluations. We use a mixed-methods approach including analysis of survey data, administrative records, consultation records and semistructured interviews with GPs and their enrolled patients. The analysis will examine fidelity and dose of the intervention, observations of trial setup and implementation and the quality of the care provided. We will also examine details of a â?¬ usual care'. The semistructured interviews will be analysed using thematic and content analysis to draw out themes around implementation and acceptability of the model. Ethics and dissemination The primary and substudy protocols have been approved by the Human Research Ethics Committee of The University of Sydney (2016/959 and 2019/503). Our findings will be disseminated to national and international partners and stakeholders, who will also assist with wider dissemination of our results across all levels of healthcare. Specific findings will be disseminated via peer-reviewed journals and conferences, and via training for healthcare professionals delivering OA management programmes. This evaluation is crucial to explaining the PARTNER study results, and will be used to determine the feasibility of rolling-out the intervention in an Australian healthcare context. Trial registration number ACTRN12617001595303; Pre-results.
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Homeopathic arnica in bone marrow donation - 5 case reports
Surgical Management of Osteoarthritis of the Knee CPG
Introduction: Arnica montana is widely used as homeopathic dilution for treating wounds on account of its supposed abilities to control bruising, reduce swelling, and promote recovery. It is one of the widely used homeopathic preparations and is popular with patients undergoing surgery. For example, Arnica was shown to reduce effectively the pain and stiffness due to arthritis of the knee. In bone marrow (BM) donation, there is a well defined osseous lesion in healthy donors. In this report we could observe the effects of Arnica on the postoperative physical health in five allogenic BM donors. Methods: Five healthy BM donors conducting a self-medication with Arnica for BM donation could be evaluated and compared to a respective matched control group (n = 8) without homeopathic medication. BM was collected by repeated puncture of the iliac crest under general anesthesia. The physical (Figure presented) health status was examined by a standardized SF-36 questionnaire before, immediately and four weeks after BM donation. Results: In the Arnica group, the collection volume was found to be 1470 (plus or minus) 270 mL and the amount of CD34+ cells 3.9 (plus or minus) 1.1 null 10(Lambda)6 cells/kg BW recipient in comparison to 1432 (plus or minus) 148 mL and 4.1 (plus or minus) 1.8 null 10(Lambda)6 CD34+ cells/kg BW recipient in the matched control group. Preoperatively, the SF-36 scores for pain, physical function and general health were within a normal range (Arnica: 99 (plus or minus) 5, 98 (plus or minus) 2, 84 (plus or minus) 10, respectively; Control: 90 (plus or minus) 10, 99 (plus or minus) 2, 83 (plus or minus) 11, respecat tively). Immediately after surgery, the SF-36 scores were significantly altered in both groups (Arnica: 78 (plus or minus) 31, 54 (plus or minus) 26, 80 (plus or minus) 9, respectively; Control: 60 (plus or minus) 14, 62 (plus or minus) 21, 68 (plus or minus) 18, respectively). Especially, the SF-36 score for pain showed a tendency to lower values in the controls. After four weeks the SF-36 scores reached the normal range. Conclusions: In BM donation, donors receiving homeopathic arnica showed immediately after surgery a trend towards less postoperative pain. However, a significant difference was found only in comparison to the SF-36 scores determined preoperatively or after four weeks, comparable to the controls. Because Arnica is a safe and easy to use alternative compared to other treatments it seems helpful to consider the use of homeopathic arnica in BM donation
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Treatment of upper limb lymphedema with combination of liposuction, myocutaneous flap transfer, and lymph-fascia grafting: A preliminary study
Panniculectomy & Abdominoplasty CPG
Treatment of obstructive extremity lymphedema remains a challenge in reconstructive surgery, since none of the varieties of procedures have been demonstrated a reliable resolution for the lymphedema. In this report, we present the preliminary results of treatment of severe upper extremity lymphedema with combined liposuction, latissimus myocutaneous flap transfer, and lymph-fascia grafting in 11 patients. All patients had histories of radical mastectomy, irradiation therapy for breast cancer, and frequent onsets of erysipelas. Postoperative measurements in an average of 26 months follow up showed that significant decrease of circumferences of the arms on all levels at surgery side were achieved. The onsets of erysipelas were also reduced. There was no chronic lymphedema found in the donor leg after harvest of the lymph-fascia graft. The results suggest the strategy of liposuction, latissimus myocutaneous flap transfer, and lymph-fascia grafting may provide a useful method for treatment of the chronic upper extremity lymphedema with severe axillary scar contracture. © 2008 Wiley-Liss, Inc.
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Self reported non-vertebral fractures in rheumatoid arthritis and population based controls: incidence and relationship with bone mineral density and clinical variables
Management of Hip Fractures in the Elderly
OBJECTIVE: To compare the incidence of self reported non-vertebral fractures after RA diagnosis between female patients with RA and control subjects, and to explore possible associations between non-vertebral fractures and bone mineral density (BMD), disease, and demographic factors. METHODS: 249 women (mean age 63.0 years) recruited from a county register of patients with RA and population controls (n = 249) randomly selected after matching for age, sex, and residential area were studied. Data on previous non-vertebral fractures were obtained from a detailed questionnaire, and BMD was measured at the hip and spine. RESULTS: 53 (21.3%) patients with RA had had 67 fractures after RA diagnosis, the corresponding numbers for controls were 50 (20.1%) and 60 (odds ratio (OR) for paired variables for overall fracture history 1.09, 95% CI 0.67 to 1.77). The overall fracture rates per 100 patient-years were 1.62 and 1.45, respectively, but self reported hip fractures were increased in RA (10 v 2, OR 9.0, 95% CI 1.2 to 394.5). Patients with a positive fracture history had longer disease duration, were more likely to have at least one deformed joint, and had lower age and weight adjusted BMD than those with no fracture history. In logistic regression analysis, fracture history was independently related to BMD only. CONCLUSIONS: With the probable exception of hip fractures, non-vertebral fractures do not seem to be a substantial burden in RA. Similar independent relationships between levels of BMD and fracture history were found in patients with RA and in population based controls
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Minimal trauma fractures: lifting the specter of misconduct by identifying risk factors and planning for prevention
Management of Hip Fractures in the Elderly
Minimal trauma fractures are an unfortunate, yet not uncommon, event for frail elderly individuals in long term care facilities. These fractures result in significant morbidity including pain and loss of function along with significantly increased mortality. Further concern exists for the medico-legal issues raised after a minimal trauma fracture is discovered. The controversy at hand is whether such fractures are primarily the result of inadequate, careless, or abusive care practices. We build a case to the contrary. Although the data regarding this condition are limited, there exists a reasonable evidence base to identify an at-risk patient population. We present a representative case and subsequent literature review of minimal trauma fractures to illustrate the condition, including risk factors, mode of presentation, and patient outcomes. No direct research has been conducted on the pathophysiology of these fractures. Extrapolating from other similar conditions and likely associated comorbid illnesses, we explore possible physiologic explanations for their occurrence. Again, no direct investigation into prevention or treatment of minimal trauma fractures has been published. Instead, we consider a variety of pharmacologic and nonpharmacologic interventions that may modify the risk for minimal trauma fractures considering the previously identified risk factors and probable pathophysiologic changes leading to fracture development. We propose that reducing minimal trauma fractures in the frail elderly nursing home population will require careful staff education, close attention to identify at-risk patients, and implementation of select interventions aimed at preventing such fractures
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Posterior acetabular column and quadrilateral plate fractures: Fixation with tension band principles
DoD SSI (Surgical Site Infections)
Acetabular fractures can be classified into 5 simple and 5 associated fracture patterns. A significant amount of variation and complexity exists in these fractures patterns. Fractures of the posterior wall are the most common acetabular fractures. Comminution of the quadrilateral plate adds to fracture instability, and more rigid and stable internal fixation is mandatory. The goal of this study was to assess the results of reconstruction of comminuted posterior wall fractures of the acetabulum associated with quadrilateral plate fractures using the tension band technique. Twelve patients (9 men and 3 women) were included in the study. Mean patient age was 38.6 years (range, 24-47 years). Minimum follow-up was more than 2 years postoperatively. Reconstruction of the fracture included anatomic reduction of the fracture and fixation with a buttress plate for the posterior column and a prebent one-third tubular plate for the quadrilateral plate fracture. Clinical results were excellent in 58% of patients and good in 17% of patients. Radiologic results were excellent in 50% of patients and good in 17% of patients. Radiologically, based on the fracture gap postoperatively, 8 (66%) patients showed anatomic reduction, 2 (17%) showed good reduction, and 2 (17%) showed poor reduction. The study confirms that this method of reconstruction facilitates accurate and firm reduction of displaced posterior wall fractures of the acetabulum.
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Timing of Hip-fracture Surgery in Elderly Patients: Literature Review and Recommendations
Hip Fx in the Elderly 2019
The incidence of hip fractures is rapidly increasing with an aging population and is now one of the most important health concerns worldwide due to a high mortality rate. The effect of delayed surgery on postoperative outcomes has been widely discussed. Although various treatment guidelines for hip fractures in the elderly exist, most institutions recommend that operations are conducted as soon as possible to help achieve the most favorable outcomes. While opinions differ on the relationship between delayed surgery and postoperative mortality, a strong association between earlier surgery and improvement in postoperative outcomes (e.g., length of hospital stay, bedsore occurrence, return to an independent lifestyle), has been reported. Taken together, performing operations for hip fractures in the elderly within 48 hours of admission appears to be best practice. Importantly, however, existing evidence is based primarily on observational studies which are susceptible to inherent bias. Here, we share the results of a literature search to summarize data that helps inform the most appropriate surgical timing for hip fractures in the elderly and the effects of delayed surgery on postoperative outcome. In addition, we expect to be able to provide a more accurate basis for these correlations through a large-scale randomized controlled trial in the future and to present data supporting recommendations for appropriate surgical timing.
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Securing Transplanted Meniscal Allografts Using Bone Plugs Results in Lower Risks of Graft Failure and Reoperations: A Meta-analysis
AMP (Acute Meniscal Pathology)
BACKGROUND: Meniscal allograft transplant (MAT) is an important treatment option for young patients with deficient menisci; however, there is a lack of consensus on the optimal method of allograft fixation. HYPOTHESIS: The various methods of MAT fixation have measurable and significant differences in outcomes. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A single-arm meta-analysis of studies reporting graft failure, reoperations, and other clinical outcomes after MAT was performed. Studies were stratified by suture-only, bone plug, and bone bridge fixation methods. Proportionate rates of failure and reoperation for each fixation technique were pooled with a mixed-effects model, after which reconstruction of relative risks with confidence intervals was performed using the Katz logarithmic method. RESULTS: A total of 2604 patients underwent MAT. Weighted mean follow-up was 4.3 years (95% CI, 3.2-5.6 years). During this follow-up period, graft failure rates were 6.2% (95% CI, 3.2%-11.6%) for bone plug fixation, 6.9% (95% CI, 4.5%-10.3%) for suture-only fixation, and 9.3% (95% CI, 6.2%-13.9%) for bone bridge fixation. Transplanted menisci secured using bone plugs displayed a lower risk of failure compared with menisci secured via bone bridges (RR = 0.97; 95% CI, 0.94-0.99; P = .02). Risks of failure were not significantly different when comparing suture fixation to bone bridge (RR = 1.02; 95% CI, 0.99-1.06; P = .12) and bone plugs (RR = 0.99; 95% CI, 0.96-1.02; P = .64). Allografts secured using bone plugs were at a lower risk of requiring reoperations compared with those secured using sutures (RR = 0.91; 95% CI, 0.87-0.95; P < .001), whereas allografts secured using bone bridges had a higher risk of reoperation when compared with those secured using either sutures (RR = 1.28; 95% CI, 1.19-1.38; P < .001) or bone plugs (RR = 1.41; 95% CI, 1.32-1.51; P < .001). Improvements in Lysholm and International Knee Documentation Committee scores were comparable among the different groups. CONCLUSION: This meta-analysis demonstrates that bone plug fixation of transplanted meniscal allografts carries a lower risk of failure than the bone bridge method and has a lower risk of requiring subsequent operations than both suture-only and bone bridge methods of fixation. This suggests that the technique used in the fixation of a transplanted meniscal allograft is an important factor in the clinical outcomes of patients receiving MATs.
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Surgical treatment of multiple symmetric lipomatosis with ultrasound-assisted liposuction
Panniculectomy & Abdominoplasty CPG
Multiple symmetric lipomatosis (MSL) is a rare disease of unknown etiology, characterized by the presence of multiple, symmetrical, noncapsulated lipomas, mostly in the neck and upper trunk. To date, there is no effective medical treatment of MSL. Surgical treatment is based on 2 options, namely, lipectomy and/or liposuction. In this retrospective study, we compare traditional lipectomy with ultrasound-assisted liposuction. Our initial experience demonstrates that the ultrasound-assisted liposuction procedure can be applied to patients with MSL, allowing simultaneous treatment of multiple areas in a single session and the removal of a substantial amount of fat, thus improving aesthetic results. If lipomas are circumscribed and isolated, traditional lipectomy is probably to be preferred.
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Erratum: Correction: Haemophilus Parainfluenzae Septic Arthritis Following Primary All-Inside Meniscus Repair: A Case Report and Review of the Literature (The Iowa orthopaedic journal (2020) 40 1 (111-114))
AMP (Acute Meniscal Pathology)
[This corrects the article on p. 111 in vol. 40, PMID: 32742217.].
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Management of Morel-Lavallee Lesion Associated with Pelvic and/or Acetabular Fractures
DoD SSI (Surgical Site Infections)
OBJECTIVE: Management of Morel-Lavallee soft tissue lesion (MLL) in patients with associated pelvic and/or acetabular fractures is still under discussion. Especially, the sequence of treatment of MLL soft tissue management and osteosynthesis of pelvic and acetabular injury remains controversial. METHODS: We report all consecutive patients with MLL associated with pelvic ring and/or acetabular fractures during an 8-year period at our hospital. Surgical access and techniques were analyzed concerning complications and outcome. RESULTS: Altogether, 20 patients were included in the study. One patient was treated conservatively and MLL healed without complications; 19 patients had an operative treatment of MLL. In 15 patients debridement was performed within one day after injury and in four patients with delay of 5 days at least. Ten patients had surgery for an associated pelvic ring or acetabular fracture. In four of them MLL was operated before, in six patients simultaneously to osteosynthesis. In three patients, the same surgical approach for osteosynthesis and debridement of MLL was used; none of them showed postoperative complications. Altogether, in nine operated patients (47.4%) MLL healed without any complications. Nine operated patients presented prolonged wound healing, however, during long term follow-up, all patients showed complete healing of the MLL. One patient died during resuscitive surgical procedures. CONCLUSIONS: We recommend debridement for early and delayed treatment of MLL. Osteosynthesis during first debridement may be performed without adverse outcome. Identical surgical access for both procedures can be used. In case of repeated surgical debridement VAC( R) therapy may be a helpful tool for dead space reduction and wound conditioning.
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High-Flexion Mobile-Bearing Knees: Impact on Patellofemoral Outcomes in 159 Patients
Surgical Management of Osteoarthritis of the Knee CPG
Ethnic cultural demands of the patient have encouraged surgeons to use high-flexion designs. It has been speculated that these high-flexion designs may produce higher incidence of patellofemoral complications over conventional designs. We wish to report 5- to 7-year follow-up of this design with special emphasis on patellofemoral outcomes. We performed a prospective study involving 159 patients who underwent computer-assisted simultaneous bilateral total knee arthroplasty (TKA) with high-flexion design. Patients were evaluated clinically using Knee Society score (KSS), Western Ontario and McMaster University Osteoarthritis (WOMAC) score, and Hospital for Special Surgery patella score with a minimum follow-up period of 5 years. At last follow-up, mean scores were KSS (88.7), WOMAC (48.5), and HSS (86.7). All the scores improved postoperatively. Average preoperative range of motion was 108 degrees, which improved to 132 degrees postoperatively. There was no evidence of loosening or spin out in our study. Our study shows that TKA done using high-flexion rotating platform design results in near normal patellofemoral tracking patterns with improvement in function. The level of evidence of the study is IV
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The ankle brachial index in chronic spinal cord injury: a pilot study
DoD LSA (Limb Salvage vs Amputation)
BACKGROUND: Recent case reports implicate peripheral vascular disease (PVD) as an etiology for pressure ulcers (PU), failed myocutaneous flap surgeries, and amputation in spinal cord injury (SCI). Early detection of PVD is complicated by motor and sensory deficits in this population. The ankle-brachial index (ABI) is used to quantify PVD in the able-bodied population. We hypothesized that the ABI would be a useful screening tool for detecting PVD in patients with SCI. Differences in baseline blood pressure, as well as motor and sympathetic function, could potentially alter ABI, so values were studied in a sample of patients with SCI without risk factors or signs of PVD, and compared to those in able-bodied controls without PVD. METHODS: ABI values were measured in 15 healthy individuals with chronic complete SCI above the T6 level, who had no evidence for risk factors or physical findings of PVD, and compared with the values for a group of 10 able-bodied controls. RESULTS: No statistically significant difference in ABI was found between patients with SCI and the able-bodied comparison group. There was no statistically significant correlation between ABI and post-injury duration or incidence of PU. CONCLUSION: ABI may prove to be a useful screening device in individuals with SCI. Follow-up studies are needed to confirm these findings and to ascertain that the ABI correlates with presence and severity of PVD in patients with SCI who have risk factors and signs of PVD.
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Ultrastructural findings after the use of a CO2 laser in carpal tunnel surgery
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
The laser beam enables tissue cutting and care of the cut edges, which prevents an increased scar tissue formation. For this reason we have used the laser beam in carpal tunnel surgery for transection or sealing of the transverse carpal ligament since 1981 because scar tissue formation is for the most part the cause of recurrence. Scanning-electron microscopic studies of the carpal ligament show the difference between the laser and traditional cutting techniques. After using the laser beam, there is no normal tissue structure; the cut surface appears as uneven and rough in contrast to the cut surface of the cold knife
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Adductor canal block can result in motor block of the quadriceps muscle
Surgical Management of Osteoarthritis of the Knee CPG
OBJECTIVE: The block of nerves in the adductor canal is considered to cause a sensory block without a motor component. In this report, we describe a case of significant quadriceps muscle weakness after an adductor canal block (ACB). CASE REPORT: A 65-year-old female patient for ambulatory knee surgery was given an ACB for postoperative pain management. The block was performed under ultrasound guidance at the midthigh level using the transsartorial approach. Twenty milliliters of 0.5% ropivacaine was deposited adjacent to the anterior and posterior areas of the femoral artery. On discharge from the hospital, the patient realized that her thigh muscles were weak and she was unable to extend her leg at the knee. A neuromuscular examination indicated that the patient had no strength in her quadriceps muscle, along with sensory deficit in the medial-anterior lower leg and area in front of knee up to the midthigh. The weakness lasted 20 hours, and the sensory block lasted 48 hours before complete recovery. The optimal level and amount of local anesthetic for adductor canal block are currently not well defined. Proximal spread of local anesthetic and anatomical variation may explain our observation. CONCLUSIONS: Several studies have reported that ACB involves no motor blockade. However, our case report illustrates that the ACB can result in clinically significant quadriceps muscle paralysis. This report suggests that patients should be monitored vigilantly for this occurrence to decrease the risk of falls
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Incisionless Partial Medial Meniscectomy
AMP (Acute Meniscal Pathology)
Knee arthroscopy has evolved greatly from its inception in the twentieth century. Of the many arthroscopic knee surgeries, meniscectomy is the most commonly performed. Arthroscopic meniscectomy is the most common orthopaedic surgical procedure performed in the United States. We continue to develop more minimally invasive procedures, and the NanoScope has provided a new generation of possibilities. The system does not require the use of a standard incision or portal, and with the use of nanoinstruments, we can perform treatments as well as diagnostic arthroscopy without incisions. This technique provides an updated incisionless option to perform a partial medial meniscectomy.
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Double fixation of displaced patella fractures using bioabsorbable cannulated lag screws and braided polyester suture tension bands
PJI DX Updated Search
PURPOSE: To evaluate the effectiveness and safety of a new double fixation technique for displaced patellar fractures using bioabsorbable cannulated lag screws and braided polyester suture tension bands. METHODS: Fifteen patients (mean age of 46.2 years) with displaced transverse or comminuted patella fractures were enrolled in this prospective study. All of the patients were treated via the open reduction internal fixation (ORIF) procedure using bioabsorbable cannulated lag screws and braided polyester suture tension bands. The patients were followed post-surgery to evaluate (1) the time required for radiographic bone union, (2) the knee joint range of motion at the time of radiographic bone union, (3) the degree of pain assessed using the visual analogue scale (VAS), (4) the function of the knee using the Lysholm score and (5) the presence of any additional complications from the surgery. RESULTS: All of the patients were followed post-treatment for more than 1 year (range, 12-19 months; mean post-treatment follow up time, 14 months). The bone union of the fractures as seen radiographically occurred approximately 3 months from surgery in all cases without implant failure or redisplacement of the fractured site. The mean knee joint range of motion was from 0 to 134.6 degrees , and the mean VAS score was 0.7 at the time of bone union. The mean Lysholm scores at the time of bone union and 12 months post-surgery were 86.7 and 95.7, respectively. No postoperative complications, such as infection, dislocation or breakage of the implants, were observed. Moreover, all of the patients returned to their previous activity level. CONCLUSION: This new double fixation technique using bioabsorbable cannulated lag screws and braided polyester suture tension bands resulted in satisfactory outcomes for patella fractures without any obvious complications
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Total knee replacement and patellofemoral pain
Surgical Management of Osteoarthritis of the Knee CPG
BACKGROUND: The decision to resurface the patella or not during total knee replacement (TKR) is a controversial issue. During primary TKR some surgeons routinely resurface the patella, others operate a selective policy and a third group never resurfaces the patella. AIM: This study attempts to investigate the relationship of patellofemoral knee pain and TKR. MATERIALS AND METHODS: This was a prospective, non-randomised, multi-centre outcome study of 638 primary Insall Burstein II total TKRs, and their effect upon patellofemoral pain. Of those enrolled 378 knees had pre-operative patellofemoral pain; 236 of these underwent patella resurfacing and 142 did not. There were no statistically significant differences in the post-operative incidence of patellofemoral pain between the groups treated with resurfacing of the patella and those in which the patella was left intact. In those knees that developed patellofemoral pain after TKR there was no significant difference as to whether the knee had had resurfacing done or not. CONCLUSION: Given that the cost of patella resurfacing is not insubstantial and that there are well-known complications resulting from it, we conclude that the role of patellar resurfacing for patellofemoral pain in knee arthritis remains unclear
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Visual function of drivers and its relationship to road traffic accidents in Urban Africa
Upper Eyelid and Brow Surgery
AIM/BACKGROUND: Nigeria has one of the highest mortality rates from Road traffic accidents (RTAs). Prevention is a global priority. This study is aimed at acquiring information for effective policy formulation to improve safety on Nigerian roads. This is a cross sectional descriptive study in which consenting commercial drivers in a Nigerian motor parks were ophthalmically examined after an interview. Data analyzed with EPI-INFO version 6.0 statistical software using Chi square. P value < 0.05 was considered to be significant. RESULTS: The eyes of 400 commercial drivers were examined. Ages range from 25 to 62 years with mean of 37.8 years (SD +/- 9.1) 20% did not undergo any prior driving test and only one third of those who had (n = 120, 30.9%) had a prior eye test. Up to 45.5% (n = 182) had been involved in RTAs with alcohol intoxication and driver fatigue significantly associated. Depressants such as alcohol are commonly used. Visual impairment ((p = 0.46, chi (2) = 0.3, RR = 0.62), visual field defects (p > 0.05, chi(2) = 0.78, RR = 1.25) and color vision defects (p = 0.4, chi (2) = 0.77, RR = 1.23) were not significantly associated with occurrence of RTAs. However fatigue was found to be a predisposing factor in 28% of those who had RTAs. CONCLUSION: One out of every two commercial driver has been involved in an RTA in the past in Nigeria. Fatigue while driving should be avoided. Use of depressants while driving should be penalized. Blood alcohol content (BAC) levels should routinely be measured by road safety personnel in Nigeria. Periodic eye exams should be carried out for all commercial drivers before issuing or renewing licenses to drive and treatment for any ophthalmic conditions discovered enforced.
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Does Timing of Previous Intra-Articular Steroid Injection Affect the Post-Operative Rate of Infection in Total Knee Arthroplasty?
OAK 3 - Non-arthroplasty tx of OAK
Intra-articular steroid injections are widely used for symptomatic relief of knee osteoarthritis. This study used a national database to determine if there is an association between preoperative intra-articular knee injection at various time intervals prior to ipsilateral TKA and infection. The incidence of infection within 3 months (2.6%, OR 2.0 [1.6-2.5], P < 0.0001) and 6 months (3.41%, OR 1.5 [1.2-1.8], P < 0.0001) after TKA within 3 months of knee injection was significantly higher than our control cohort. There was no significant difference in patients who underwent TKA more than 3 months after injection. Ipsilateral knee injection within three months prior to TKA is associated with a significant increase in infection.
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Randomized clinical trials of constitutional acupuncture: a systematic review
SR for PM on OA of All Extremities
The aim of this systematic review is to compile and critically evaluate the evidence from randomized clinical trials (RCTs) for the effectiveness of acupuncture using constitutional medicine compared to standard acupuncture. Ten databases were searched through to December 2008 without language restrictions. We also hand-searched nine Korean journals of oriental medicine. We included prospective RCTs of any form of acupuncture with or without electrical stimulation. The included trials had to investigate constitutional medicine. There were no restrictions on population characteristics. Forty-one relevant studies were identified, and three RCTs were included. The methodological quality of the trials was variable. One RCT found Sasang constitutional acupuncture to be superior to standard acupuncture in terms of the Unified PD Rating Scale and freezing gate in Parkinson's disease (PD). Another two RCTs reported favorable effects of eight constitutional acupuncture on pain reduction in patients with herniated nucleus pulposi and knee osteoarthritis. Meta-analysis demonstrated positive results for eight constitutional acupuncture compared to standard acupuncture on pain reduction (weighted mean difference: 10 cm VAS, 1.69, 95% CI 0.85-2.54, P < 0.0001; heterogeneity: tau(2) = 0.00, chi(2) = 0.00, P = 0.96, I(2) = 0%). Our results provide suggestive evidence for the effectiveness of constitutional acupuncture in treating pain conditions compared to standard acupuncture. However, the total number of RCTs and the total sample size included in our analysis were too small to draw definite conclusions. Future RCTs should assess larger patient samples with longer treatment periods and appropriate controls
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Humeral fixation by press-fitting of a tapered metaphyseal stem: a prospective radiographic study
Glenohumeral Joint OA
BACKGROUND: The technique of shoulder arthroplasty requires a method for securely and durably fixing the humeral component in the medullary canal of the proximal part of the humerus. As an alternative to fixation by cementing or tissue ingrowth, we explored the effectiveness of using a prosthesis with a metaphyseal taper from the anatomic neck to the diaphysis. This component is designed to obtain press-fit fixation in the cancellous bone of the metaphysis rather than in the cortical bone of the diaphysis. We tested the hypothesis that this press-fit humeral stem, designed to respect the taper of the proximal part of the humeral canal, would be associated with a low rate of loosening in patients managed with primary shoulder arthroplasty for osteoarthritis. METHODS: A prospective study was conducted to evaluate the prevalence of radiolucent lines around press-fit humeral prostheses. One hundred and thirty-one patients with glenohumeral osteoarthritis were followed for a minimum of two years. A zonal method of evaluating radiolucent lines was established. Shift in position and subsidence were judged qualitatively. RESULTS: No component showed subsidence or a shift in position. Fifty shoulders (39%) had no radiolucency. Two shoulders had radiolucency around the proximal part of the prosthesis, and seventy-five had radiolucency at the distal tip. Eleven radiolucencies were > or =1 mm in width. A neutral stem orientation was significantly less likely to be associated with radiolucency (p = 0.026). The prevalence of radiolucent lines did not differ between patients managed with hemiarthroplasty and those managed with total shoulder arthroplasty, and it did not increase with longer periods of follow-up. CONCLUSIONS: In patients managed with shoulder arthroplasty, the fixation of a press-fit humeral component that has a tapered metaphyseal segment is comparable with that reported for cemented components and superior to that reported for press-fit cylindrical components. CLINICAL RELEVANCE: This type of fixation may provide an alternative to cementing of the humeral stem in individuals with glenohumeral osteoarthritis.
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Outcomes and quality of life issues in the pharmacological management of benign prostatic hyperplasia (BPH)
Reduction Mammoplasty for Female Breast Hypertrophy
Background: Benign prostatic hyperplasia (BPH) is a common disease of the aging male population. BPH treatment includes a variety of pharmacological and surgical interventions. The goal of this paper is to review the natural history of BPH, outcomes of pharmacological management, effects on quality of life (QoL), future pharmacotherapies, and associated patient-focused perspectives. Materials and methods: Medline searches for the keywords benign prostatic hyperplasia, BPH, alpha blockers, 5 alpha-reductase, and quality of life were performed. Relevant literature was reviewed and analyzed. Results: Alpha blockers, 5 alpha-reductase inhibitors, and phytotherapy are the three categories of pharmaceutical interventions currently available for BPH. Various clinical trials have shown that alpha blockers and 5 alpha-reductase inhibitors are safe, efficacious, and improve QoL in patients with BPH. The evidence for phytotherapeutics is not as convincing. The current armamentarium of pharmaceutical interventions are encompassed in these three classes of medications. New pharmacotherapies based on novel mechanisms are on the horizon. Conclusion: There are a variety of safe and efficacious medical therapies available for the management of BPH and it is important for the practicing physician to have an understanding of these pharmacotherapies and their potential impact on the patient. There is not enough evidence to make a recommendation regarding phytotherapy use. New classes of drugs for BPH will likely find their way into routine use. © 2007 Dove Medical Press Limited. All rights reserved.
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Subsartorial adductor canal vs femoral nerve block for analgesia after total knee replacement
AAHKS (8) Anesthetic Infiltration
Purpose: Providing effective analgesia for total knee arthroplasty (TKA) patients remains challenging. Femoral nerve block (FNB) offers targeted pain control; however, its effect on motor function, related fall risk and impact on rehabilitation has been the source of controversy. Adductor canal block (ACB) potentially spares motor fibres of the femoral nerve, but the comparative effect of the two approaches has not yet been well defined due to considerable variability in pain perception. Our study compares both single-shot FNB and ACB, side to side, in the same patients undergoing bilateral TKA.Methods: Sixty patients scheduled for bilateral TKA were randomised to receive ultrasound-guided FNB on one leg and ACB on the other, in addition to combined spinal epidural anaesthesia. The primary outcome was comparative postoperative pain in either extremity at six to eight, 24 and 48 hours postoperatively. Secondary comparative outcomes included motor strength (manually and via dynamometer), physical therapy milestones and patient satisfaction.Results: While pain levels were lowest at six to eight hours postoperatively and increased thereafter (P < 0.001), no significant differences were seen between extremities at any time point with regard to pain in the quantitative comparison using visual analogue scale (VAS) scores (P = 0.4154), motor strength (P = 0.7548), physical therapy milestones or patient satisfaction. However, in the qualitative comparison, a significant proportion of patients reported the leg receiving ACB to be more painful than that receiving FNB at 24 h [50.9 % (n = 30) vs 25.42 % (n = 15), P = 0.0168)].Conclusions: Although we could not confirm a benefit in motor function between ACB and FNB, given the equivalent analgesic potency combined with its potentially lower overall impact if neuropraxia should occur, ACB may represent an attractive alternative to FNB.
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Advanced renal cell carcinoma: Pathology and systemic therapy with a new role of zoledronic acid in management of skeletal metastases
MSTS 2018 - Femur Mets and MM
Renal race carcinoma (RCC) continues to represent a major therapeutic challenge. There is still observed the increased rate of incidence of RCC at the level of 2% per annum. Unfortunately, approximately 30% of patients develop distant metastases at first presentation. Progression of RCC accounts for additional 20% of cases with distant metastases to make up totally 50% of all RCC patients. The median survival of these patients is approximately 1 year, and the probability of survival at 2 years is 10% or even less. Metastatic RCC is extremly resistant to conventional chemotherapy. On the other hand, spontaneous regressions have been reported in some patients which suggests a role of immunity in fighting the malignancy. Thus, immunotherapy with infusions of interleukin-2 and interferon alfa have shown reproducible effects in patients with metastatic RCC. Some clinical trials have demonstrated the synergistic activity of the cytokines and anticancer agents (5-fluorouracil, vinblastine). The combination chemoimmunotherapy has revealed encouraging results of 15% to 45% response rate. Other studies have not confirmed the primary results. It has been estimated that bone metastases will develop in approximately 30% of patients with RCC. Bone metastases cause considerable skeletal morbidity, including bone pain, pathologic fractures, spinal cord compression, and hypercalcemia of malignancy. Bisphosphonates are the promising group of drugs with activity against activated osteoclasts which in turn lyse bone. Zoledronic acid provides clinical benefits for patients with bone metastases originating of RCC and other solid tumors. The drug delays the onset of skeletal-related events.
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Treatment options for the symptomatic post-meniscectomy knee
OAK 3 - Non-arthroplasty tx of OAK
PURPOSE: To provide a current review on the evidence for management of the symptomatic meniscus-deficient knee. METHODS: A literature review was performed detailing the natural history and origin of symptoms in a meniscus-deficient knee, in addition to strategies for non-surgical management, meniscus scaffolds, meniscus allograft transplantation (MAT), isolated cartilage repair, unloading osteotomies, meniscus prosthesis, and joint replacements which were revealed as treatment possibilities. RESULTS: Meniscus deficiency was recognized to lead to an early onset knee osteoarthritis (OA). A subset of patients develop post-meniscectomy syndrome: dull and nagging pain after a short pain-free interval subsequently to meniscectomy, which can be accompanied by transient effusions. Evidence for non-surgical management of post-meniscectomy knee pain is lacking. Two available meniscus scaffolds, indicated for symptomatic segmental meniscus deficiency, show pain relief at mid-term follow-up, and effect on joint preservation is unclear. MAT represents a durable solution for sub/total meniscus deficiency (80% survival at 10 years), but it is still considered a temporary solution for post-meniscectomy pain. MAT may also reduce the progression of OA. Isolated cartilage repair without a meniscus reconstruction is commonly performed, but better results were reported with preserved or reconstructed menisci. Osteotomies are used in the combination of misaligned knee and meniscus reconstruction or as pain solution for irreversible unilateral knee structural changes following a meniscectomy. Polycarbonate-urethane medial meniscus prosthesis is currently undergoing clinical trial. Joint replacements should be limited to later stages of post-meniscectomy OA. CONCLUSIONS: Post-meniscectomy pain syndrome and post-meniscectomy knee OA are common findings after meniscus resection. Short-term pain relief is provided by non-surgical management, mid-term pain relief by meniscus scaffolds, and long-term relief by MAT, though each has differing indications. In later stages, osteotomies and joint replacements are indicated.IV.
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Tai Chi is effective in treating knee osteoarthritis: a randomized controlled trial
OAK 3 - Non-arthroplasty tx of OAK
OBJECTIVE: To evaluate the effectiveness of Tai Chi in the treatment of knee osteoarthritis (OA) symptoms. METHODS: We conducted a prospective, single�blind, randomized controlled trial of 40 individuals with symptomatic tibiofemoral OA. Patients were randomly assigned to 60 minutes of Tai Chi (10 modified forms from classic Yang style) or attention control (wellness education and stretching) twice weekly for 12 weeks. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score at 12 weeks. Secondary outcomes included WOMAC function, patient and physician global assessments, timed chair stand, depression index, self�efficacy scale, and quality of life. We repeated these assessments at 24 and 48 weeks. Analyses were compared by intent�to�treat principles. RESULTS: The 40 patients had a mean age of 65 years and a mean body mass index of 30.0 kg/m(2). Compared with the controls, patients assigned to Tai Chi exhibited significantly greater improvement in WOMAC pain (mean difference at 12 weeks �118.80 mm [95% confidence interval (95% CI) �183.66, �53.94; P = 0.0005]), WOMAC physical function (�324.60 mm [95% CI �513.98, �135.22; P = 0.001]), patient global visual analog scale (VAS; �2.15 cm [95% CI �3.82, �0.49; P = 0.01]), physician global VAS (�1.71 cm [95% CI �2.75, �0.66; P = 0.002]), chair stand time (�10.88 seconds [95% CI �15.91, �5.84; P = 0.00005]), Center for Epidemiologic Studies Depression Scale (�6.70 [95% CI �11.63, �1.77; P = 0.009]), self�efficacy score (0.71 [95% CI 0.03, 1.39; P = 0.04]), and Short Form 36 physical component summary (7.43 [95% CI 2.50, 12.36; P = 0.004]). No severe adverse events were observed. CONCLUSION: Tai Chi reduces pain and improves physical function, self�efficacy, depression, and health�related quality of life for knee OA.
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Total hip arthroplasty with porous metal cups following acetabular fracture
Hip Fx in the Elderly 2019
Total hip arthroplasty (THA) after acetabular fracture presents unique challenges, including acetabular fixation. Twelve patients with a history of acetabular fracture underwent THA with porous metal cups. The average age was 57 years (range 24-88). THA was performed at an average 20 months from initial fracture. Average follow-up was 39 months (range 24-49). Average WOMAC scores improved from 32 to 79; UCLA scores improved from 1.75 to 5.25. There was one case of acetabular loosening in a renal transplant patient with rheumatoid arthritis. No other patients showed progressive radiolucent lines. At average three-year follow-up, porous metal components afforded improved clinical and radiographic outcomes in the majority of patients. Longer follow-up will determine whether porous metal is a durable option in the management of prior acetabular fracture.
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Time-dependent Functional Results Following HTO. Closing Wedge vs Opening Wedge Technique
OAK 3 - Non-arthroplasty tx of OAK
Determination of the time course of patient�relevant functional outcome and the time course of Range of Motion (ROM) following HTO. Comparison of the Opening wedge and Closing wedge methods. Time�dependent improvement in functional outcome following High tibial Osteotomy. Medial opening wedge vs Lateral closing wedge. A two�year prospective randomized study involving 70 patients. In a prospective randomized study, we plan to include 70 patients aged 30�60 years operated with valgus high tibial osteotomy. 2 groups: 35 opening wedge, and 35 closing wedge osteotomies. Data are collected by independent investigators (physiotherapists) preoperatively and at 3 months, 6 months, 1 year, and 2 years postoperatively. Knee injury and Osteoarthritis Outcome Score (KOOS) and ROM are determined at all follow�ups.
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A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures
Distal Radius Fractures
PURPOSE: External fixation and open reduction and internal fixation have been the traditional techniques for surgical fixation of unstable distal radius fractures. The existing literature has not identified which is superior, primarily because of the lack of comparative trials. We performed a comprehensive systematic review and meta-analysis of the current literature on external fixation and internal fixation of distal radius fractures to determine the dominant strategy based on available scientific evidence. METHODS: We searched MEDLINE and EMBASE for English-language articles published between 1980 and 2004 that satisfied predetermined inclusion and exclusion criteria. The outcomes of internal and external fixation were compared using continuous measures of grip strength, wrist range of motion, and radiographic alignment and categoric measures of pain, physician-rated outcome scales, and complication rates. Outcomes were pooled by random-effects meta-analysis and meta-regression analysis was used to control for patient age, presence of intra-articular fracture, duration of follow-up period, and date of publication. Sensitivity analyses were used to test the stability of the meta-analysis results under different assumptions. RESULTS: Forty-six articles were included in the review with 28 (917 patients) external fixation studies and 18 (603 patients) internal fixation studies. Meta-analysis did not detect clinically or statistically significant differences in pooled grip strength, wrist range of motion, radiographic alignment, pain, and physician-rated outcomes between the 2 treatment arms. There were higher rates of infection, hardware failure, and neuritis with external fixation and higher rates of tendon complications and early hardware removal with internal fixation. Considerable heterogeneity was present in all studies and adversely affected the precision of the meta-analysis. CONCLUSIONS: The current literature offers no evidence to support the use of internal fixation over external fixation for unstable distal radius fractures. Comparative trials using appropriately sensitive and validated outcome measurements are needed to guide treatment decisions. [References: 112]
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Functional Outcome and Analgesia in TKA: radiofrequency vs Continuous Adductor Canal Block
OAK 3 - Non-arthroplasty tx of OAK
The aim of this study is to compare the efficacy of two analgesia techniques in patients undergoing Total Knee Arthroplasty (TKA) on the functional recovery and pain control: Pulsed and Continuous Radiofrequency (PRF and TRF) applied respectively to the saphenous nerve and to the genicular nerves of the knee (femoral and sciatic branches) compared with Continuous adductor canal block with local anesthetics (CACB). The Null Hypothesis is that no difference exists in the functional recovery, in pain medication consumption and in postoperative exercise and physical performance between two groups of patients submitted to TKA with the two different modalities of analgesia. To test the null hypothesis we hypothesize as clinically relevant: � a reduction of 30% in the time needed to perform the Timed Up and Go test at 2 days after surgery � a reduction of 30% in pain medication consumption in the first 24 ore after surgery. To test the null Hypothesis, 40 patients are needed (20 for each group). The primary outcome measures will be: � the time required in the two groups (CACB�group and RF�group) to perform the Timed�Up and Go (TUG) test on the second postoperative day (POD2). TUG measures the time that a person takes to rise from a chair, walk three meters, turn around, walk back to the chair, and sit down. During the test, the person is expected to use any mobility aids that they would normally require. � the total morphine consumption by means of the patient�controlled analgesia pump over the first 24�h after surgery, which can be measured precisely through the record of the dose delivered by the PCA pump. With an alpha error of 0.05, a power of 80% and a standard deviation of 7 mg of morphine consumption per 24 h, 20 patients (10 in each group) will be required for the study to detect a mean difference of 10 mg of morphine between the two groups Secondary outcome measures include: Pain evaluation with the use of VAS at rest, VAS on walking and on knee flexion; functional outcome evaluation with the 6 min walk tests, degree of knee flexion, Scores obtained in self�assessment questionaire (WOMAC�Western Ontario and McMaster University questionaire for knee osteoarthritis and CHAMPS�Community Healthy Activities Model Program for Seniors). These values will be compared with baseline values recorded before surgery. It is hypothesized that PRF and TRF of the saphenous nerve and genicular nerves to the knee joint can improve the early and late functional recovery and the pain control after TKA when compared with the CACB
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Carpal tunnel syndrome due to an atypical deep soft tissue leiomyoma: The risk of misdiagnosis and mismanagement
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
BACKGROUND: Leiomyomas of the deep soft tissue are quite uncommon and occur even more rarely in upper extremity. CASE PRESENTATION: A 32-year old manual laborer man presented with a two-year history of numbness, tingling and burning pain in the palmar surface of the left hand and fingers. His medical history was unremarkable and no trauma episode was reported. According to the clinical examination and the result of median nerve conduction study (NCS) the diagnosis of carpal tunnel syndrome was established. Operative release of the transverse carpal ligament was subsequently performed but the patient experienced only temporary relief of his symptoms. MRI examination revealed a deep palmary located mass with well-defined margins and ovoid shape. Intraoperatively, the tumor was in continuity with the flexor digitorum superficialis tendon of the middle finger causing substantial compression to median nerve. Histopathological findings of the resected mass were consistent with leiomyoma. After two years the patient was pain-free without signs of tumor recurrence. CONCLUSION: Despite the fact that reports on deep soft tissue leiomyoma are exceptional, this tumor had to be considered as differential diagnosis in painful non-traumatic hand syndromes especially in young patients
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Fracture Patterns Differ Between Osteogenesis Imperfecta and Routine Pediatric Fractures
Pediatric Supracondylar Humerus Fracture 2020 Review
BACKGROUND: It is important to estimate the likelihood that a pediatric fracture is caused by osteogenesis imperfecta (OI), especially the least severe type of OI (type 1). METHODS: We reviewed records of 29,101 pediatric patients with fractures from 2003 through 2015. We included patients with closed fractures not resulting from motor vehicle accidents, gunshot wounds, nonaccidental trauma, or bone lesions. Patients with OI of any type were identified through International Classification of Diseases-9 code. We randomly sampled 500 pediatric patients in whom OI was not diagnosed to obtain a control (non-OI) group. We reviewed age at time of fracture, sex, fracture type, laterality, and bone and bone region fractured. Bisphosphonate use and OI type were documented for OI patients. Subanalysis of patients with type-1 OI was performed. The Fisher exact and Ï? tests were used to compare fracture rates between groups. P<0.05 was considered significant. Positive likelihood ratios for OI were calculated by fracture pattern. RESULTS: The non-OI group consisted of 500 patients with 652 fractures. The OI group consisted of 52 patients with 209 fractures. Non-OI patients were older at the time of fracture (mean, 9.0±5.0â??y) than OI patients (mean, 5.5±4.4â??y) (P<0.001). OI patients had more oblique, transverse, diaphyseal, and bilateral long-bone fractures than non-OI patients (all P<0.001). Non-OI patients had more buckle (P=0.013), metaphyseal (P<0.001), and physeal (P<0.001) fractures than OI patients. For patients with type-1 OI and long-bone fractures (n=18), rates of transverse and buckle fractures were similar compared with controls. Transverse humerus (15.2), olecranon (13.8), and diaphyseal humerus (13.0) fractures had the highest positive likelihood ratios for OI, and physeal (0.09) and supracondylar humerus (0.1) fractures had the lowest. CONCLUSIONS: Transverse and diaphyseal humerus and olecranon fractures were most likely to indicate OI. Physeal and supracondylar humerus fractures were least likely to indicate OI. Radiographic fracture pattern is useful for estimating likelihood of OI. LEVEL OF EVIDENCE: Level III.
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Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial
Hip Fx in the Elderly 2019
INTRODUCTION: Ambulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages. The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality. METHODS: The design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group). RESULTS: Time from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p<0.001), but the groups did not differ with regard to time from start of X-ray to start of surgery (mean 18.40 h in both groups). No significant differences between the groups were observed with regard to: time from arrival to start of surgery (p=0.07); proportion operated within 24h (79% PFTC, 75% A&E; p=0.34); length of stay (p=0.34); post-operative complications (p=0.75); and 4 month mortality (18% PFTC, 15% A&E p=0.58). CONCLUSION: PFTC improved time to X-ray and admission to a ward, as expected, but did not significantly affect time to start of surgery, length of stay, post-operative complications or mortality. These outcomes were probably affected by other factors at the hospital. Patients with either possible life-threatening conditions or life-threatening conditions prehospital were excluded.
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Changes in the bone mineral density in the acetabulum and proximal femur after cementless total hip replacement: alumina-on-alumina versus alumina-on-polyethylene articulation
Management of Hip Fractures in the Elderly
Our aim in this prospective study was to compare the bone mineral density (BMD) around cementless acetabular and femoral components which were identical in geometry and had the same alumina modular femoral head, but differed in regard to the material of the acetabular liners (alumina ceramic or polyethylene) in 50 patients (100 hips) who had undergone bilateral simultaneous primary total hip replacement. Dual energy X-ray absorptiometry scans of the pelvis and proximal femur were obtained at one week, at one year, and annually thereafter during the five-year period of the study. At the final follow-up, the mean BMD had increased significantly in each group in acetabular zone I of DeLee and Charnley (20% (15% to 26%), p=0.003), but had decreased in acetabular zone II (24% (18% to 36%) in the alumina group and 25% (17% to 31%) in the polyethylene group, p=0.001). There was an increase in the mean BMD in zone III of 2% (0.8% to 3.2%) in the alumina group and 1% (0.6% to 2.2%) in the polyethylene group (p=0.315). There was a decrease in the mean BMD in the calcar region (femoral zone 7) of 15% (8% to 24%) in the alumina group and 14% (6% to 23%) in the polyethylene group (p<0.001). The mean bone loss in femoral zone 1 of Gruen et al was 2% (1.1% to 3.1%) in the alumina group and 3% (1.3% to 4.3%) in the polyethylene group (p=0.03), and in femoral zone 6, the mean bone loss was 15% (9% to 27%) in the alumina group and 14% (11% to 29%) in the polyethylene group compared with baseline values. There was an increase in the mean BMD on the final scans in femoral zones 2 (p=0.04), 3 (p=0.04), 4 (p=0.12) and 5 (p=0.049) in both groups. There was thus no significant difference in the bone remodelling of the acetabulum and femur five years after total hip replacement in those two groups where the only difference was in the acetabular liner
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A multicenter randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair
Optimizing the Management of Full-Thickness Rotator Cuff Tears
Background: Controversy exists regarding the optimal technique for arthroscopic rotator cuff repair. The purpose of this multicenter, randomized, double-blind controlled study was to compare the functional outcomes and healing rates after use of single-row and double-row suture techniques for repair of the rotator cuff. Methods: Ninety patients undergoing arthroscopic rotator cuff repair were randomized to receive either a single-row or a double-row repair. The primary objective was to compare the Western Ontario Rotator Cuff Index (WORC) score at twentyfour months. Secondary objectives included comparison of the Constant and American Shoulder and Elbow Surgeons (ASES) scores and strength between groups. Anatomical outcomes were assessed with magnetic resonance imaging (MRI) or ultrasonography to determine the postoperative healing rates. Results: Baseline demographic data including age (p = 0.29), sex (p = 0.68), affected side (p = 0.39), and rotator cuff tear size (p = 0.28) did not differ between groups. The WORC score did not differ significantly between groups at any time point (p = 0.48 at baseline, p = 0.089 at three months, p = 0.52 at six months, p = 0.83 at twelve months, and p = 0.60 at twenty-four months). The WORC score at each postoperative time point was significantly better than the baseline value. The Constant score, ASES score, and strength did not differ significantly between groups at any time point. Logistic regression analysis demonstrated that a smaller initial tear size and double-row fixation were associated with higher healing rates. Conclusions: No significant differences in functional or quality-of-life outcomes were identified between single-row and double-row fixation techniques. A smaller initial tear size and a double-row fixation technique were associated with higher healing rates as assessed with ultrasonography or MRI. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. Copyright (copyright) 2012 by The Journal of Bone and Joint Surgery, Incorporated
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Three-dimensional joint kinematics of ACL-deficient and ACL-reconstructed knees during stair ascent and descent
Surgical Management of Osteoarthritis of the Knee CPG
Mechanical environmental changes in the knee are induced by altered joint kinematics under cyclic loading during activities of daily living after anterior cruciate ligament (ACL) injury. This is considered a risk factor in progressive cartilage degeneration and the early onset of osteoarthritis following ACL injury and even after reconstructive surgery. The purpose of this study was to examine 3D joint kinematics of ACL-deficient and ACL-reconstructed knees to health controls during stair ascent and descent. A 3D optical video motion capture system was used to record coordinate data from reflective markers positioned on subjects as they ascended and descended a custom-built staircase. Spatiotemporal gait and knee joint kinematic variables were calculated and further analyzed. The ACL-deficient knees exhibited a significant extension deficit compared to the ACL-intact controls. A more varus and internally rotated tibial position was also identified in the ACL-deficient knees during both stair ascent and descent. The ACL-reconstructed knees exhibited less abnormality in both spatiotemporal gait parameters and joint kinematics, but these variables were not fully restored to a normal level. The kinematic profiles of the ACL-reconstructed knees were more similar to those of the ACL-deficient knees when compared to the ACL-intact knees. This suggests that the ACL-reconstructed knees had been "under-corrected" rather than "over-corrected" by the reconstructive surgery procedure. Findings from this study may provide more insight with respect to improving ACL reconstruction surgical techniques, which may aid the early progression of cartilage degeneration in ACL-reconstructed knees. (copyright) 2011 Elsevier B.V
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Long-term outcome following total parathyroidectomy in patients with end-stage renal disease
MSTS 2018 - Femur Mets and MM
Long-term follow up (mean 3.8 years), following elective total parathyroidectomy in thirteen patients with end-stage renal disease is described. Nine patients are alive and all except two have measurable levels of intact parathyroid hormone (PTH). One patient is mildly hyperparathyroid with PTH levels of 143 pg/ml (normal 10-65 pg/ml). All patients did well as far as their bone and mineral metabolism were concerned and there were no fractures, bone pain or metastatic soft tissue calcification. Lumbar spine bone mineral density (BMD) increased above the baseline value and femoral neck bone density was significantly greater than a matched control group of non-parathyroidectomized dialysis patients (1.097 ± 0.140 versus 0.811 ± 0.148 g/cm2, Z-score 1.98 ± 1.64 versus -0.79 ± 1.07, p < 0.001). Two of the nine patients have been transplanted, both have good allograft function and show increases in BMD. We believe that these findings justify the complete removal of all parathyroid tissue for selected patients with chronic renal failure where medical therapy has failed and aluminium bone disease has been excluded. They also raise the possibility that PTH is necessary for bone loss to occur.
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Sonographic representation of bifid median nerve and persistent median artery
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
Bifid median nerve and persistent median arteries are natural anatomic variants that exist in a small percentage of the population. This case describes a young woman who was referred for electrodiagnostic (EDX) testing of her right upper extremity because of a one-year history of numbness, tingling, and discomfort in her right upper extremity consistent with carpal tunnel syndrome. Careful sonographic scanning (gray scale and power Doppler) and dynamic investigation revealed a bifid median nerve and associated persistent median artery (PMA). The awareness of a bifid median nerve and PMA is important when evaluating patients sonographically for diagnosis of upper extremity pathology, including enlargement due to carpal tunnel syndrome. Furthermore, as musculoskeletal sonography increases in clinical practice, it is important to raise awareness of this dual anatomic variant to ensure that appropriate evaluation and treatment are provided. The sonographic presentation of anatomic variations in this case along with a review of these anomalies is provided for translational clinical use. (copyright) The Author(s) 2011
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Osteoarthritis: Pathophysiology, Prevalence, Risk Factors, and Exercise for Reducing Pain and Disability
OAK 3 - Non-arthroplasty tx of OAK
Osteoarthritis (OA) is a disorder involving deterioration of articular cartilage and underlying bone and is associated with symptoms of pain and disability. The incidence of OA in the military increased over the period 2000 to 2012 and was the first or second leading cause of medical separations in this period. Risk factors for OA include older age, black race, genetics, higher body mass index, prior knee injury, and excessive joint loading. Animal studies indicate that moderate exercise can assist in maintaining normal cartilage, and individuals performing moderate levels of exercise show little evidence of OA. There is considerable evidence that among individuals who develop OA, moderate and regular exercise can reduce pain and disability. There is no firm evidence that any particular mode of exercise (e.g., aerobic training, resistance exercise) is more effective than another for reducing OA-related pain and disability, but limited research suggests that exercise should be lifelong and conducted at least three times per week for optimal effects.
0
Osteonecrosis of the Jaws (ONJ) after Bisphosphonate Treatment in Patients with Multiple Myeloma: Decreasing ONJ Incidence after Adoption of Preventive Measures
MSTS 2018 - Femur Mets and MM
Bisphosphonates (BPs) are administered to Multiple Myeloma (MM) patients with bone lytic lesion. Osteonecrosis of the Jaw (ONJ) is a complication reported since 2003 in patients treated with intravenous (IV) BPs such as zoledronic acid and pamidronate, with 6%-26.3% frequency in early literature series, before some preventive measures were recommended. We evaluated the occurrence of ONJ with and without dental preventive measures in MM patients treated with BPs in our centre between 1996 and 2015. Since 2005, MM patients (already under treatment or before treatment) underwent a baseline mouth assessment (dental visit, Rx orthopantomography, and eventual tooth avulsion or dental care if necessary) and were followed by a multidisciplinary team. We reviewed the charts of 119 MM patients receiving IV BPs, classified into 3 groups: (a) "historic group" (21 patients who had started BP treatment in years before the awareness of ONJ); (b) "screening group" (20 patients starting BPs without baseline evaluation); and (c) "prevention group" (78 patients starting therapy only after baseline preventive assessment and eventual dental care measures). ONJ was observed in 3/21 patients (14.2%) from group a, in 2/20 patients (10%) from group b, and in no patients from group c (0%). Notably, the median number of IV BP administrations decreased after 2005. Our data confirmed a meaningful reduction of ONJ risk in MM patients treated with BPs if preventive measures are applied. Both implementation of prevention measures and reduction of cumulative doses of IV BPs could have contributed to a decreased incidence of ONJ.
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Osteochondral scaffold reconstruction for complex knee lesions: a comparative evaluation
AMP (Acute Meniscal Pathology)
BACKGROUND: The primary aim of the present study is to evaluate the results obtained in challenging knee lesions with the implant of an osteochondral scaffold and concomitant treatment of all comorbidities. The secondary aim is to compare the results obtained with those found when a chondral scaffold was applied. MATERIALS AND METHODS: Patients affected by complex lesions of the knee articular surface were included. "Complex cases" were defined according to the following criteria: previous clinical history of intra-articular fracture, lesion located at the tibial plateau, concurrent knee axial realignment procedure, concurrent meniscal scaffold or allograft implantation, and multiple articular surface lesions treated. Thirty-three patients were treated with the implantation of an osteochondral scaffold. The results of a homogeneous group of 23 patients previously treated and prospectively evaluated after implantation of a chondral scaffold were analyzed and compared. RESULTS: IKDC subjective score improved significantly from pre-operative (40.4+/-14.1) to 12months' follow-up (69.6+/-17.0; p<0.0005) with a further improvement at the final evaluation at 24months (75.5+/-15.0; p=0.038). The same positive trend was confirmed by the VAS and Tegner scores. At final follow-up the group treated with the osteochondral scaffold presented a better subjective IKDC score with respect to the group treated with the chondral scaffold (p=0.034). CONCLUSIONS: A regenerative procedure to address the entire osteochondral unit, together with the treatment of all comorbidities, might offer good results also in complex cases otherwise doomed to non-biological resurfacing. LEVEL OF EVIDENCE III: Comparative study.
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20-year results of McKee-Farrar versus Charnley prosthesis
Management of Hip Fractures in the Elderly
The results of 107 consecutive McKee-Farrar and 70 Charnley total hip arthroplasties performed in 169 patients between 1975 and 1976 are reviewed. At an average followup of 20 years (range, 19-21 years), 29 patients with 20 McKee-Farrar and II Charnley prostheses were available for clinical and radiologic evaluation; 102 patients (107 hips) had died, 3 patients were lost to followup, and 5 patients 16 hips) were unavailable for review because of medical problems. There were 5 revisions for sepsis and 1 Girdlestone procedure for recurrent dislocation. Sixteen McKee-Farrar and 8 Charnley prostheses were revised for aseptic loosening, giving a 20-year aseptic probability of survival of 77% and 73%, respectively. Radiographic signs of loosening were present in 52% of the surviving prostheses. Clinical scores showed weak correlation with the radiographic loosening in both groups, and 18 McKee-Farrar and 8 Charnley prostheses were still considered satisfactory by the patients. The mean annual linear polyethylene wear was 0.12 mm. Osteolytic lesions were observed in association with 2 McKee-Farrar and 5 Charnley prostheses in surviving hips. The long term results of the McKee- Farrar prosthesis are comparable with those of the low friction arthroplasty in this series. Wear of the polyethylene bearing and accumulation of polyethylene particles in the periprosthetic tissue may become an increasing problem. Second generation all metal implants seem to be worth considering in patients with long life expectancy
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Evaluation of intra-operative abdominal wall perfusion in post-bariatric abdominal dermolipectomy
Panniculectomy & Abdominoplasty CPG
OBJECTIVE: Abdominal dermolipectomy after massive weight loss has become a standard procedure. However the complication rates such as wound necrosis or secondary healing complications are still high. In this context ischaemia or inadequate micro-perfusion are known as triggers of wound healing complications. Little is known about the regional perfusion patterns before and after post-bariatric abdominal dermolipectomy. This study focuses on assessment of intraoperative micro-perfusion patterns of the abdominal tissue. METHODS: The perfusion of the abdominal wall flap was monitored intra-operatively in 17 patients with an average BMI of 29.2 +/- 3.7 kg/m(2) after bariatric surgery. All patients underwent abdominal post-bariatric dermolipectomy after massive weight loss while applying the non-invasive O2C laser-spectrophotometer. The micro-perfusion parameters oxygen saturation (SO(2)), relative haemoglobin content (rHB) and relative blood flow (BF) were intra-operatively measured. RESULTS: The results of this study show that the part of the abdominal fat typically resected during dermolipectomy has the lowest SO(2) before surgery. Furthermore, the results demonstrate that previously well oxygenated parts in the median line of the abdominal fat undergo a significant decrease in oxygen saturation upon mobilisation and subsequent suturing, while the caudal wound edges show an increase of micro-perfusion parameters. CONCLUSION: Data show that micro-perfusion is worst in the median line of the cranial wound edge and is significantly altered after mobilisation. In addition an intra-operative increase of micro-perfusion in the caudal part of the wound edge, especially in the mons pubis area, can be measured.
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Increased cartilage volume after injection of hyaluronic acid in osteoarthritis knee patients who underwent high tibial osteotomy
OAK Recommendation 9 Articles
Purpose: High tibial osteotomy (HTO) is a surgical procedure used to correct abnormal mechanical loading of the knee joint; additionally, intra-articular hyaluronic acid injections have been shown to restore the viscoelastic properties of synovial fluid and balance abnormal biochemical processes. It was hypothesized that combining HTO with intra-articular hyaluronic acid injections would have benefit to improve the cartilage volume of knee joints. Methods: Forty patients with medial compartment knee osteoarthritis (OA) were randomly placed into 1 of 2 groups. The study group (n = 20) received 2 cycles (at 6-month intervals) of 5 weekly intra-articular hyaluronic acid injections after HTO operation. The control group (n = 20) did not receive any intra-articular injections after HTO surgery. Cartilage volume (primary outcome) was assessed by magnetic resonance imaging (MRI) pre-operatively and 1 year post-operatively. Treatment efficacy (secondary outcomes) was evaluated with the Western Ontario and McMaster Universities OA Index (WOMAC) and by the comparison of the total rescue medication (paracetamol/diclofenac) used (weeks 6, 12, 24, 48). Results: MRI studies showed a significant increase in total cartilage volume (p = 0.033), lateral femoral cartilage volume (p = 0.044) and lateral tibial cartilage volume (p = 0.027) in the study group. Cartilage volume loss was detected at the lateral tibial plateau in the control group. There were significant improvements after surgery in both groups for all subscales of WOMAC scores (p < 0.001) compared to the baseline. However, no difference was found between the two groups. The study group had significantly lower amounts of diclofenac consumption (p = 0.017). Conclusion: Based on the findings of the present study, intra-articular hyaluronic acid injections may be beneficial for increasing total cartilage volume and preventing the loss of lateral tibiofemoral joint cartilage after HTO. Level of evidence: Therapeutic study, Level I. 2013 The Author(s)
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Acupuncture for (sub)acute non-specific low-back pain
SR for PM on OA of All Extremities
This is the protocol for a review and there is no abstract. The objectives are as follows:The objectives of this systematic review are to determine the effects of acupuncture for (sub)acute non-specific low-back pain compared to no treatment, placebo/sham acupuncture or other sham procedures, other therapies, the addition of acupuncture to other therapies, and between various techniques of acupuncture
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Recent Approaches to the Manufacturing of Biomimetic Multi-Phasic Scaffolds for Osteochondral Regeneration
Osteochondritis Dissecans 2020 Review
Cartilage lesions of the knee are common disorders affecting people of all ages; as the lesion progresses, it extends to the underlying subchondral bone and an osteochondral defect appears. Osteochondral (OC) tissue compromises soft cartilage over hard subchondral bone with a calcified cartilage interface between these two tissues. Osteochondral defects can be caused by numerous factors such as trauma and arthritis. Tissue engineering offers the possibility of a sustainable and effective treatment against osteochondral defects, where the damaged tissue is replaced with a long-lasting bio-manufactured replacement tissue. This review evaluates both bi-phasic and multi-phasic scaffold-based approaches of osteochondral tissue regeneration, highlighting the importance of having an interface layer between the bone and cartilage layer. The significance of a biomimetic approach is also evidenced and shown to be more effective than the more homogenous design approach to osteochondral scaffold design. Recent scaffold materials and manufacturing techniques are reviewed as well as the current clinical progress with osteochondral regeneration scaffolds.
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Validity and Responsiveness of the Knee Injury and Osteoarthritis Outcome Score: A Comparative Study Among Total Knee Replacement Patients
OAK 3 - Non-arthroplasty tx of OAK
OBJECTIVE: To evaluate validity and responsiveness of the Knee Injury and Osteoarthritis Outcome Score (KOOS) in relation to other patient-reported outcome measures before and after total knee replacement (TKR). METHODS: Pre-TKR and 6-month post-TKR data from 1,143 patients in a US joint replacement cohort were used to compare the KOOS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the SF-36 Health Survey (SF-36). Validity was evaluated with multiple methods, including correlations of pre-TKR scale scores and analysis of variance models that used pre-TKR data to compare the relative validity of scales in discriminating between groups differing in assistive walking device use and number of comorbid conditions. Validity was also evaluated by using post-TKR minus pre-TKR change scores to assess relative validity of scales in discriminating between groups rating themselves as better, same, or worse (BSW) in their capability to do activities at 6 months. Responsiveness also was described using effect sizes and standardized response means. RESULTS: In support of convergent and discriminant validity, KOOS scale scores were worse for patients using an assistive device but only declined weakly with increasing comorbid conditions. While all knee-specific scales discriminated between BSW groups, the KOOS quality of life (QOL) scale was significantly better (P < 0.05) than all measures except the SF-36 physical component summary. KOOS QOL also had the highest effect size, while SF-36 measures had lower effect sizes and standardized response means. KOOS pain and symptoms scales discriminated better than WOMAC pain and stiffness scales among BSW groups. CONCLUSION: KOOS scales were valid and responsive in this cohort of US TKR patients. KOOS QOL performed particularly well in capturing aggregate knee-specific outcomes.
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Injectable bone cement augmentation for the treatment of distal radius fractures: a review
Distal Radius Fractures
Fractures of the distal radius often occur as a result of low-energy trauma and are frequently seen in osteoporotic patients. Many biomechanical studies and clinical case series have been carried out to investigate the effects on the fractured bones of different fixation methods such as cast immobilization, percutaneous pins, external fixators, or open reduction with internal fixation. In addition, the use of different bone cements as stand-alone solutions or as an adjunct to the aforementioned fixation methods is described as one possible way of increasing the performance of the fixation by reducing secondary dislocation of the fragments and allowing more intensive rehabilitation of the patients. This review aims to provide an overview of some of the main issues under discussion and a critical evaluation of the different treatments. [References: 42]
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Platelet-rich plasma versus hyaluronic acid in the treatment of knee osteoarthritis: A meta-analysis
PRP (Platelet-Rich Plasma)
BACKGROUND: This meta-analysis focuses on the controversial efficacy and safety of platelet-rich plasma (PRP) as compared with hyaluronic acid (HA) in the clinical treatment of knee osteoarthritis. We have attempted to provide an evidence-based medicine protocol for the conservative treatment of knee osteoarthritis. In addition, we included the latest relevant literature in this meta-analysis, and a staging study was conducted to compare the therapeutic effects of PRP and HA for knee osteoarthritis over different time periods. METHODS: An online computer search with "platelet-rich plasma" and "knee osteoarthritis" as search terms was conducted in the PubMed, EMBASE, and Cochrane Library databases. We conducted a quality assessment of the retrieved literature and extracted the following indicators: visual analog scale (VAS) score, subjective International Knee Documentation Committee (IKDC) score, Western Ontario and McMaster Universities (WOMAC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and adverse events. RevMan5.3 software was used to determine the effect sizes, and indicators were compared across studies at three different time points from the administration of treatment. RESULTS: A total of 14 randomized controlled trials (RCTs) involving 1350 patients were included. Long-term VAS, IKDC, WOMAC-Pain, WOMAC-Stiffness, WOMAC-Physical Function, and WOMAC-Total scores at each time point were higher in the PRP group than in the HA group. There were no significant differences in the remaining indicators between the two groups. CONCLUSION: Compared with HA, PRP offers obvious advantages in the conservative treatment of knee osteoarthritis. Treatment with PRP can reduce long-term pain and improve knee joint function with no additional risks. Therefore, PRP can be widely used for the conservative treatment of knee osteoarthritis.
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Osteochondritis dissecans of the lateral femoral condyle following total resection of the discoid lateral meniscus
Diagnosis and Treatment of Osteochondritis Dissecans AUC
PURPOSE: The purpose of this study was to describe the clinical presentation of 6 athletically active children with symptomatic osteochondritis dissecans (OCD) of the lateral femoral condyle following total resection for a torn discoid lateral meniscus and to discuss its cause. TYPE OF STUDY: Case series. METHODS: Six patients in whom OCD affecting the lateral femoral condyle developed after total resection of the discoid lateral meniscus participated in a detailed clinical, radiologic, and arthroscopic review. The average age at the time of meniscectomy was 9 years (range, 6 to 12 years). At a mean of 50 months (range, 36 to 65 months) after surgery they developed recurrent pain in the treated knee; all had radiologic abnormalities at the lateral femoral condyle consistent with OCD. Before the recurrence of pain, all patients had been continuously engaged in sports activity. Radiologic and arthroscopic findings of the OCD lesions were assessed. Clinical outcomes of surgical treatment for OCD were also documented. RESULTS: The radiographic evaluation showed all lesions to be in the central portion of the lateral femoral condyle on the anteroposterior views and posteriorly next to a line extending distally from the posterior femoral cortex on the lateral views. Arthroscopic evaluation revealed softening in 2 knees, a separated fragment in 2 knees, and a completely loose fragment in 2 knees. All lesions were treated surgically, including 2 drillings of the lesion, 2 fixations of separated fragment, and 2 excisions of loose bodies with drilling. At an average follow-up period of 51 months (range, 22 to 77 months), all patients but 1 were asymptomatic. CONCLUSIONS: Repeated impaction in sports activities on the immature osteochondral structures under altered mechanical force transmission after total resection of the discoid meniscus might be a predisposing factor in the development of OCD in the lateral femoral condyle
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All-cause in-hospital complications and urinary tract infections increased in obese patients undergoing total knee arthroplasty
PJI DX Updated Search
The aims of this study were to determine the rates of in-hospital complications, discharge disposition, and length of stay for patients with varying degrees of obesity. We identified 4718 patients who underwent TKA between 2007 and 2010. After adjusting for age, sex, race, education, Deyo-Charlson comorbidity index, insurance, and discharge disposition, obese patients were more likely to develop any in-hospital complication (6.4% vs. 4.8%, respectively; P = 0.0097; OR = 1.5). When analyzing specific in-hospital complications, obese patients were more likely to suffer urinary tract infections (P = 0.0029). They were also more likely to be discharged to a rehabilitation facility (P = 0.001). There was no significant difference in other postoperative complications. In summary, obese patients undergoing primary TKA are at increased risk for all-cause in-hospital complications and urinary tract infections and are more likely to be discharged to a rehabilitation facility
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A Tumor Suppressor Gene Product, Platelet-Derived Growth Factor Receptor-Like Protein Controls Chondrocyte Proliferation and Differentiation
Reduction Mammoplasty for Female Breast Hypertrophy
The platelet-derived growth factor receptor-like (PDGFRL) gene is regarded as a tumor suppressor gene. However, nothing is known about the molecular function of PDGFRL. In this study, we initially clarified its function in chondrocytes. Among all cell lines examined, the PDGFRL mRNA level was the highest in chondrocytic HCS-2/8 cells. Interestingly, the proliferation of chondrocytic HCS-2/8 cells was promoted by PDGFRL overexpression, whereas that of the breast cancer-derived MDA-MB-231 cells was inhibited. Of note, in PDGFRL-overexpressing HCS-2/8 cells, the expression of chondrocyte differentiation marker genes, SOX9, ACAN, COL2A1, COL10A1, and ALP, was decreased. Moreover, we confirmed the expression of PDGFRL mRNA in normal cartilage tissue and chondrocytes. Eventually, the expression of PDGFRL mRNA in condrocytes except in the case of hypertrophic chondrocytes was demonstrated in vivo and in vitro. These findings suggest that PDGFRL plays the different roles, depending upon cell types. Particularly, in chondrocytes, PDGFRL may play a new and important role which is distinct from the function previously reported. J. Cell. Biochem. 118: 4033-4044, 2017. (c) 2017 Wiley Periodicals, Inc.
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Early experiences with robot-assisted total knee arthroplasty using the digiMatch� ROBODOC® surgical system
OAK 3 - Non-arthroplasty tx of OAK
INTRODUCTION The use of robotics in total knee arthroplasty (TKA) has been shown to minimise human error, as well as improve the accuracy and precision of component implantation and mechanical axis alignment. The present study aimed to demonstrate that robot-assisted TKA using ROBODOC® is safe and capable of producing a consistent and accurate postoperative mechanical axis. METHODS We prospectively recruited 27 consecutive patients who underwent robot-assisted TKA between May and December 2012. Two patients were excluded from the study due to intraoperative technical problems with the robot. Long-leg radiography and computed tomography were performed prior to surgery, and used for mechanical axis measurements and component sizing. DigiMatchâ?¢ ROBODOC® Surgical System software version 4.3.6 (Curexo Technology Corp, Fremont, CA, USA) was used in all cases to perform bone cuts in accordance with the preoperative plan. RESULTS The postoperative coronal mechanical alignment was within 3 degrees, with a mean alignment of â??0.4 ± 1.7 degrees, confi rming the accuracy of the preoperative surgical plan and bone cuts. The mean operating time was 96 ± 15 min, and preoperative planning yielded 100% implant sizing accuracy. CONCLUSION Robotics has the potential to enable surgeons to consistently attain ideal postoperative alignment. The use of bone movement monitors and an integrated navigation system enhances the safety profi le of ROBODOC® by minimising errors. However, the role of the surgeon in TKA is still vital, as the surgeon is ultimately in charge of planning the surgery, its execution and ensuring soft tissue balance during TKA.
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Persistency with zoledronic acid is associated with clinical benefit in patients with multiple myeloma
MSTS 2018 - Femur Mets and MM
Zoledronic acid (ZOL), an intravenous bisphosphonate, has been shown to reduce and delay the incidence of skeletal-related events (SREs) in multiple myeloma (MM) patients with bone disease. A retrospective claims-based analysis was conducted that used two distinct US managed care databases to examine the relationship between persistency with ZOL and clinical benefit. Patients >18 years, diagnosed with MM, and with at least one claim for ZOL (or a claim for malignant bone disease and ZOL initiation within 30 days) between 1/1/2001 and 12/31/2006 were included. Patients were evaluated for incidence of SREs and for mortality. Treatment persistency was defined as the absence of a >45 day gap between ZOL administrations. Of 1,655 patients in this analysis, 1,060 received ZOL and 595 received no intravenous bisphosphonate therapy. Compared with patients not receiving bisphosphonate therapy, ZOL-treated patients had lower incidences of SREs (P < 0.0001) and death (P = 0.0001). Longer persistency with ZOL was associated with lower risks of SREs (P = 0.001), fracture (P = 0.003), and death (P = 0.002) versus shorter persistency. Patients who were persistent with ZOL for >=1.5 years had an incidence of 15.0 SREs and 6.2 fractures per 100 person-years. Patients who were persistent for 31-90 days had an incidence of 24.6 SREs and 14.0 fractures per 100 person-years, and patients not receiving intravenous bisphosphonates had an incidence of 32.2 SREs and 16.9 fractures per 100 person-years. These data from a real-world setting indicate that among MM patients, longer persistency with ZOL was associated with a lower risk of SREs and fracture.
1
Knee dislocations with vascular injuries
DoD LSA (Limb Salvage vs Amputation)
Any knee that is dislocated or that has both anterior and posterior cruciates and one collateral ligament torn should be carefully evaluated for neurologic and vascular injury. Reduction and immobilization should be performed. If the pulses are anything but normal, arrangements should be made to proceed to the operating room immediately. A one-shot arteriogram can be obtained in the operating room, but proceeding directly with popliteal artery exploration is reasonable if the pulses have not returned to normal. If the pulses have returned to normal, an arteriogram should be obtained. After the vascular repair has been done, a fasciotomy of the lower leg should be performed. In the young healthy active patient who does not have significant necrotic muscle or severe nerve injury, delayed reconstruction and early, very aggressive rehabilitation is recommended. Whether this treatment improves the results of this injury remains to be seen. Discussion with the vascular surgeon concerning the use of a tourniquet is recommended. If not functioning, the peroneal nerve is often severely stretched, and no treatment to date has been very encouraging. An ankle foot orthosis or tendon transfers to achieve dorsiflexion may be needed.
1
Microsurgical Advances in Extremity Salvage
DoD LSA (Limb Salvage vs Amputation)
The main goal of reconstructive microsurgery must be an optimal functional and esthetic reconstruction meeting the individual trauma site requirements with minimal donor site morbidity. The authors discuss new microsurgical options for extremity salvage: indications for reconstruction versus amputation, timing of free tissue transfer, reconstruction of soft tissue and bone, and functional muscle transfer. They discuss indications and contraindications for these procedures, along with emphasizing the important points of each. © 2012 Elsevier Inc.
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Internal derangement of the temporomandibular joint: radiologic staging with clinical, surgical, and pathologic correlation
Diagnosis and Treatment of Osteochondritis Dissecans AUC
The radiologic findings from 60 patients with 86 internally deranged temporomandibular joints (TMJ) upon whom sequential imaging procedures had been performed over a period of two months to ten years were analyzed and correlated with clinical, surgical (72 joints), and pathological observations. Internal derangement of the TMJ disc (meniscus) and osseous structures was found to be an irreversible and progressive disorder with characteristic stages. Internal derangements of the TMJ were divided into early (stage one), intermediate (stages two and three) and late stage (stages four and five) categories based upon radiologic findings obtained with radiography, lateral TMJ tomography and either two compartment arthrography or high field, surface coil MR. After sequential imaging studies, each patient and 72 deranged joints underwent surgical joint exploration and meniscectomy because of progressive joint disease and clinical disability. Surgically removed tissues underwent routine histological evaluation. Surgical and pathologic observations included disc displacement, deformity, hyalination, myxomatous degeneration, perforation of the disc attachments, capsular adhesions, synovitis and mandibular condyle lesions including osteochondritis dissecans (OCD), avascular necrosis (AVN), osseous remodeling and degenerative arthritis. There was excellent correlation between imaging studies and surgical observations. Internal derangement of the TMJ is an irreversible, generally progressive disorder which may be staged and followed with radiography, tomography and either two-compartment arthrography or high field, surface coil MR
0
Tesamorelin: A novel therapeutic option for HIV/HAART-associated increased visceral adipose tissue
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
Metabolic complications are common in treated HIV patients. Their etiology is multifactorial and the development of increased abdominal fat contributes to cardiovascular risk and impaired quality of life. Treated patients with fat mass distribution changes have relative growth hormone deficiency. Both pharmacologic and physiologic doses of growth hormone reduce the increased visceral adipose tissue and improve the associated abnormal lipid profiles in short-term studies. However, impaired glucose homeostasis changes and significant musculoskeletal toxicity occurs. A novel growth hormone-releasing factor analogue, tesamorelin, provides a physiologic means of restoring a normal growth hormone secretion profile and reduces increased visceral adipose tissue, improving both abnormal lipid profiles and patients' quality of life. Glucose homeostasis is generally well maintained. Cessation of treatment with either growth hormone or tesamorelin results in a prompt return of truncal obesity. Management strategies for the long-term maintenance of the reduced visceral adipose tissue have not yet been clarified and long-term effects on decreasing cardiovascular risks and improving clinical outcomes are uncertain. Copyright (copyright) 2011 Prous Science, S.A.U. or its licensors. All rights reserved
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Nipple-sparing mastectomy with implant reconstruction: the Westmead experience
Reduction Mammoplasty for Female Breast Hypertrophy
BACKGROUND: Nipple-sparing mastectomy (NSM) involves the removal of all breast tissue with preservation of the breast skin envelope and nipple-areola complex (NAC). The objective of this study was to report the outcomes from our initial experience with NSM. METHODS: We retrospectively analysed 87 women who underwent 118 NSMs between October 2008 and May 2012. RESULTS: Indications for NSM were 60 (51%) primary cancer, 15 (13%) residual/recurrent disease, 39 (33%) risk reduction and 4 (3%) benign pathology. Implant loss (n = 10) was associated with subcutaneous placement (P = 0.01), post-operative seroma and infection (P = 0.028, 0.001), skin flap necrosis (P = 0.007) and NAC loss (P = 0.027). Capsular contraction was related to adjuvant radiotherapy (P = 0.044). Local recurrence occurred in four patients, and NAC recurrence with invasive cancer occurred in one patient after a median follow-up of 30 months. CONCLUSION: Our Australian NSM series adds to the published literature supporting the oncological safety of NSM for early-stage breast cancer and risk reduction.
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Short-term Follow-up of Antibiotic-loaded Articulating Cement Spacers in Two-stage Revision of Infected Total Knee Arthroplasty: A Case Series
OAK 3 - Non-arthroplasty tx of OAK
Objective: Infection of total knee arthroplasty (TKA) is a rare but devastating complication. Two-stage revision is an effective treatment for late infected TKA. This study aimed to assess the short-term results of two-stage revision using articulating antibiotic-loaded spacers. Methods: Twenty-five patients (10 men and 15 women) were diagnosed with late infections after TKA and treated with two-stage revision from April 2006 to August 2010; 19 of these patients had TKA for osteoarthritis and 6 for rheumatoid arthritis. Median age was 64.9 (range, 56â??83) years. In the first-stage surgery, the prosthesis and all bone cement was removed. After thorough debridement, bone cement with vancomycin and tobramycin was put into a die cavity and made into temporary femoral and tibial spacers, respectively. In the cases of good knee range of motion, the temporary spacers were affixed to the bone surface using the same antibiotic bone cement. In the second surgery, gentamycin Refobacin Bone Cement with vancomycin was used to fix the prosthesis. After two-stage revision, patients were followed up clinically and radiologically at 1, 3, and 6 months, and then annually. Knee Society Score (KSS), knee function score, knee pain score, and knee range of motion (ROM) were assessed. Results: Among the group, all spacers were easily removed, and bone defect degree showed no obvious change compared with pre-implant, 24 (96%) patients had been debrided once, and 1 patient had been debrided twice before reimplant prosthesis. Mean follow-up was 64.2 (range, 52â??89) months. There was no infection recurrence at final follow-up. Compared with preoperative data, the KSS (66 [59, 71], 83 [80, 88] vs 46 [43, 57], P < 0.01), knee function score (43 [42, 49], 78 [73, 82] vs 32 [25, 37], P < 0.01), knee pain score (34 [33, 37], 42 [40, 45] vs 18 [16, 23], P < 0.01), and knee ROM (92° [86°, 96°], 94° [90°, 98°] vs 78° [67°, 86°], P < 0.01) were all improved during follow-up and at final visit. Three patients experienced complications in the interval period: one case had knee dislocation, one had knee instability, and one had a chip in the femoral component of the spacer. Conclusion: Using articulating antibiotic-loaded spacers showed benefits for treating infected TKA in selected patients. No infection recurrence was observed during follow-up.
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'Straight lateral traction' in selected supracondylar fractures of the humerus in children
The Treatment of Pediatric Supracondylar Humerus Fractures AUC
A method of treating completely displaced supracondylar fractures of the humerus in children by 'straight lateral traction', as originally used by John Dunlop, is recommended. The results in 26 children, selected because manipulation had failed to achieve reduction, is examined, and indicates that this treatment is satisfactory for some problem fractures, leading usually to good results in terms of resolution of complications and return of function. It also avoids the ugly deformities of the elbow which follow reliance on a single form of treatment for all supracondylar fractures. Failure of anatomical reduction by the appliance is shown to be in the plane of elbow movement, where normal physiological mechanisms correct the bone by remodelling. Where there is epiphyseal damage, deformities may occur with any form of treatment
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What is the Quality of Online Resources About Pain Control After Total Knee Arthroplasty?
AAHKS (4) Acetaminophen
BACKGROUND: With the growing opioid crisis in the United States, there has been a push to reduce the utilization of opioids in favor of multimodal analgesia options. The purpose of this study was to evaluate the quality of online resources that patients may use to learn about pain control after total knee arthroplasty (TKA). METHODS: We identified websites using a combination of search terms about TKA and pain control. A novel grading rubric was created with 25 maximum points, consisting of items that were deemed important for patients to know about the subject. Three authors then independently graded websites and the results averaged. Flesch-Kinkaid reading level was also evaluated. RESULTS: After identifying 166 unique websites, 32 met final inclusion criteria. The overall scores were low-4.7 of 25 total points (18.8%), written at an average 10th grade level. Subgroup scores were 50% for route of administration, 40% for types of analgesia, 23% for opioid-specific items, and 30% for general guidance. Only about half discussed the risks of opioid dependency. The top 3 website total scores ranged from 10.7-12.5 of 25 points. CONCLUSION: There is a paucity of online information for TKA patients to read about pain control. Most websites provide limited educational content, particularly about opioids. Higher quality information is needed to help patients make decisions with their physicians and to help combat the opioid epidemic. Given the lack of quality information available, there is an opportunity for subspecialty organizations to take a leadership role in such efforts.
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Age differences of visual field impairment and mutation spectrum in Danish choroideremia patients
Upper Eyelid and Brow Surgery
Visual prognosis is a crucial theme in the counselling of individuals affected by a progressive retinal dystrophy. Unfortunately prognostic predictions are hampered by large interindividual differences in disease courses even within well defined nosological entities. Ten patients from 8 families affected by choroideremia were studied. The clinical signs in our patients were rather uniform. Deterioration of the peripheral visual fields typically began in the second decade of life, and progressed during the following one or two decades. Esterman transformation of peripheral visual field measurements was chosen as the best single indicator of visual impairment. Noticeable age differences in residual visual fields among patients were demonstrated. The age difference between the mildest and the severest cases amounted to 25 years. One of the expectations of the exploration of disease genes, is the potential predictive value of mutation identification with regard to phenotypic variability. Different presumed causative mutations were identified. Nevertheless, all the mutations are predicted to cause premature stops during translation, resulting in a non-functional or missing protein. Consequently, the observed age variation in the photopic visual field degradation must be due to still unrecognized factors, either constitutional and/or environmental.
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Same-day X-ray reporting is not needed in well-supervised emergency departments
Distal Radius Fractures
OBJECTIVE: To evaluate the efficacy of a missed radiological abnormality follow-up system in a teaching hospital emergency department. METHODS: Prospective audit of all reported radiological abnormalities missed by Fremantle Hospital Emergency Department medical staff from 1 January 1997 to 31 December 1998. RESULTS: Of 29,724 radiological examination series, 459 abnormalities (1.5%) were not clearly documented as being identified in the medical record. The commonest missed abnormalities were incidental chest findings, distal wrist fractures with minimal or no displacement, radial head fractures and tibial plateau fractures. The most senior doctor undertaking initial film review was a junior medical officer in 242 cases (53%), a registrar in 96 cases (21%), and a consultant in 42 cases (9%). The most senior staff member was unknown in 79 cases (17%). One hundred and twenty-four missed abnormalities required a change in patient management (0.41% of total examinations, CI 0.34-0.48%). Ninety patients (73%) were referred to the patient's general practitioner for management. Seventeen patients (14%) returned to the emergency department for management. Thirteen patients (10%) were referred to a specialist clinic and in four cases (3%) the management of the patient was not recorded. No patient required re-admission to hospital. CONCLUSIONS: Missed radiological abnormalities in an emergency department with extended-hours emergency physician supervision can be managed non-urgently on an outpatient basis. Same-day reporting of radiographs is not required if adequate follow-up mechanisms for missed abnormalities exist.
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Hypercalcemia of malignancy: pathophysiology and implications for treatment
MSTS 2018 - Femur Mets and MM
As the most common metabolic consequence of cancer, hypercalcemia of malignancy is often encountered in patients with solid tumors, most often lung, head and neck, and breast carcinomas. Since the clinical consequences of hypercalcemia of malignancy may be fatal, an understanding of its pathogenesis and skeletal-related factors that may lead to hypercalcemia is important in directing therapy. It is also important to have reasonable expectations and goals outlined before initiating therapy in an individual patient. Interventions aimed specifically at osteoclast inhibition normalize serum calcium levels while treating the final common pathway responsible for the disorder; these include calcitonin, plicamycin, gallium nitrate, and the bisphosphonates. An important consequence of the advent of antiresorptive therapy has been the initiation of clinical trials aimed at preventing skeletal-related morbid events from bone metastases. These trials may ultimately prove to be the most significant benefit of osteoclast inhibitor therapy for patients.
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Anatomy and biomechanics of the lateral side of the knee
AMP (Acute Meniscal Pathology)
The posterolateral corner (PLC) of the knee is a critical element for a functional lower extremity. It consists of an array of complex ligamentous and musculotendinous structures. The primary function of the PLC is to resist varus and external rotation and posterior translation of the tibia. Injuries to these structures can cause significant disability and compromise activities of daily living and work, recreational, and sporting activities. A thorough understanding of the complex anatomy and biomechanics of the PLC will aid the clinician in this challenging diagnostic and therapeutic problem. The first section of this paper describes the anatomy of the PLC of the knee focusing on the intricate insertion sites of the individual structures. The second section discusses how the anatomy influences the biomechanics of the PLC. [References: 35]
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Diseases of the human breast: selective isolation and exposure of epithelia and their correlative surface features and histopathology
Reduction Mammoplasty for Female Breast Hypertrophy
Tissues from seventy-one patients were obtained within one-half hour of biopsy, mastectomy, or reduction mammoplasty and processed for scanning electron microscopy (SEM). Epithelial structures were detected by supravital staining with methylene blue and isolated by microdissection. Mammary lobules and ductules required bacterial collagenase digestion to remove the covering stroma for optimal visualization. Major histopathological categories were compared and correlated with the characteristics observed with methylene blue supravital staining and light microscopy and/or transmission electron microscopy as a function of surface features revealed by SEM. Mammary ducts can be readily distinguished from ductules and lobules by their characteristic surface epithelium. Duct epithelium undergoes a variety of changes in fibrocystic disease (FCD) and in carcinoma. Both apocrine and merocrine secretory activity was observed in the surface epithelium. Proliferation of both epithelial and stromal elements was observed in benign fibroadenomata. Intraductal carcinomas were distinguished by their relative lack of surface microvilli. SEM offers a practical tool in the potential identification of premalignant cells of the human breast epithelium.
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Sliding screw implants for extracapsular hip fractures
HipFx Supplemental Cost Analysis
Hip fractures are associated with significant mortality and morbidity for the patients, more dependent residual status, and increased socio-economic cost. Many hip-fracture patients experience severe functional impairment, and most never recover their pre-fracture level of function. Current research has sought to identify the most effective treatments to reduce the incidence of hip fractures, improve survival and quality of life, and minimize complications and disability. The treatment of these fractures in the elderly aims to return these people to their pre-fracture mobility and functional level. This article reviews the surgical treatment options for extracapsular hip fractures and discusses their associated advantages, disadvantages, and complications. Two types of implants are currently available: the dynamic hip screw (DHS), and the intramedullary hip nail with one or two sliding screws. In this review, no clear advantage of one implant over another for the treatment of extracapsular hip fractures was evident. Both the DHS and hip nails can be used successfully for the treatment of stable hip fractures; for unstable fractures and low subtrochanteric fractures, hip nails are preferred. Although hip nails are associated with limited exposure, lower blood loss and transfusion requirements, and shorter operative time, complications are more common with hip nails. Long-term survival and function are similar in the two approaches. Hip nails with two sliding screws do not seem to make the difference in clinical practice that is reported in biomechanical studies
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Treatment of periprosthetic supracondylar femoral fractures using the Ilizarov method (report of two cases)
Surgical Management of Osteoarthritis of the Knee CPG
Periprosthetic fractures are technically challenging problems for orthopaedic surgery, as they require the skills of reconstruction surgery as well as those of revision arthroplasty. Periprosthetic fractures in patients with total hip arthroplasty (THA) were reported to occur at a rate of 0.1%. The same ratio for patients with total knee arthroplasty is 0.35.5%. The patients with periprosthetic fractures have several medical conditions such as osteoporosis, neuropathy, rheumatoid arthritis. Non-operative treatment of periprosthetic femoral fractures in patients with total hip arthroplasty have high complication rates, and is not therefore choiced unless medical comorbidities preclude surgery. Internal fixation methods are the first choice for periprosthetic femoral fractures, it is not possible to apply of these methods in some conditions such as infection, poor quality of bone, the patients with general comorbidities and some configurations of the fracture. In this paper, periprosthetic femoral supracondylar fractures treated with Ilizarov method was presented in 2 cases. (copyright) 2013 OMU
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Risk-benefit profile for raloxifene: 4-year data From the Multiple Outcomes of Raloxifene Evaluation (MORE) randomized trial
Management of Hip Fractures in the Elderly
Posthoc analysis of the MORE osteoporosis treatment trial assessed risk-benefit profile of raloxifene in 7705 postmenopausal women. A major disease outcomes global index resulted in annual rates of 1.39% and 1.83% in the raloxifene and placebo groups, respectively (HR, 0.75; 95% CI, 0.62-0.92), compatible with a favorable risk-benefit profile for raloxifene for treating postmenopausal osteoporosis. INTRODUCTION: The Women's Health Initiative (WHI) trial reported overall risks that exceeded benefits from use of estrogen-progestin in healthy postmenopausal women. The objective of this posthoc analysis of the Multiple Outcomes of Raloxifene Evaluation (MORE) trial was to assess the safety profile of raloxifene, a selective estrogen receptor modulator indicated for the prevention and treatment of osteoporosis, using the global index method from the WHI trial. MATERIALS AND METHODS: A total of 7705 postmenopausal women (mean age, 67 years) were enrolled in the MORE osteoporosis treatment trial and randomly assigned to receive placebo or one of two doses of raloxifene (60 or 120 mg/day) for 4 years. A global index of clinical outcomes, defined as described for the WHI trial (the earliest occurrence of coronary heart disease, stroke, pulmonary embolism, invasive breast cancer, endometrial cancer, colorectal cancer, hip fracture, or death because of other causes) was applied to the MORE trial data. Physicians blinded to treatment assignment adjudicated events. Intention-to-treat survival analysis of time-to-first-event was performed using a proportional hazards model. RESULTS AND CONCLUSIONS: The annualized rate of global index events was 1.83% in the placebo group and 1.39% in the combined raloxifene dose groups (hazard ratio [HR], 0.75; 95% CI, 0.62-0.92). Analyzing individual dose groups separately yielded the same results (HR for 60 mg/day, 0.75; 95% CI, 0.60-0.96: HR for 120 mg/day, 0.75; 95% CI, 0.59-0.95). Subgroup analyses showed no significant interactions between age or hysterectomy status and the effect of raloxifene on the global index (interaction p > 0.1), whereas the global index risk reduction seemed to be greater in obese women compared with nonobese women (interaction p = 0.03). The significant 25% reduction in global index is compatible with a favorable risk-benefit safety profile when raloxifene is used for osteoporosis treatment in postmenopausal women. These results require confirmation in ongoing clinical trials
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Inferior fixation with a new pin design for external fixation: a randomized study in 50 patients operated on by the hemicallotasis technique
OAK 3 - Non-arthroplasty tx of OAK
BACKGROUND AND PURPOSE: Tibial osteotomy by the hemicallotasis technique (HCO) requires strong pin fixation. We compared pin fixation in HCO using a new self�drilling XCaliber pin (Orthofix) with optimized thread and tip design, with the commonly used standard pin (Orthofix). PATIENTS AND METHODS: 50 patients, mean age 51 (35�66) years, to be treated by HCO were randomized to standard pins or XCaliber pins. In the metaphyseal bone, hydroxyapatite�coated (HA�coated) pins were used in both types of pins. In the diaphyseal bone, non�coated pins were used. The torque forces for insertion and extraction (in Nm) were measured. RESULTS: The insertion torque was higher for both the proximal and distal standard pins (2.1 Nm (SD 0.9) and 7.0 Nm (1.3), respectively) than for the XCaliber pins (1.3 Nm (0.8) and 3.6 Nm (1.4)). The extraction torque force was higher for the proximal standard pins (4.3 Nm (3.1)) than for the proximal XCaliber pins (1.5 Nm (1.7)) (p < 0.001). The extraction torque for the distal standard pins was 1.9 Nm (2.0) and for the distal XCaliber pins it was 1.4 Nm (1.1). INTERPRETATION: The commonly used standard pin gives stronger fixation during the treatment of HCO.
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Sensitivities of sensory nerve conduction study parameters in carpal tunnel syndrome
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
It is generally accepted that median sensory nerve conduction studies are more sensitive than motor nerve conduction studies in the electrodiagnostic evidence of carpal tunnel syndrome (CTS). This study was conducted to compare the sensitivities of various parameters of sensory nerve conduction studies in the diagnosis of CTS. This prospective study included 88 consecutive patients (151 hands) with CTS and 106 control subjects. CTS was diagnosed clinically by two neurologists. Median sensory nerve responses with wrist stimulation were determined. The onset and peak latencies, peak-to-peak amplitudes, negative peak duration, and area were measured. The differences between the peak and onset latencies were also calculated as a measure of waveform temporal dispersion. Among each measured parameter, values between the 2.5th and the 97.5th percentile range of the control subjects served as the normal limits. Among the 151 hands with suspected CTS, five (3.3%) had normal electrodiagnostic studies and 146 (96.7%) had at least one abnormal electrodiagnostic study. Among the 146 hands with an abnormality, 138 had abnormal onset latency, 143 had abnormal peak latency, and 88 had abnormal difference between peak and onset latency. In addition, 87 had abnormal amplitude, 70 had abnormal duration, and 59 had abnormal area. The sensitivity was 91.4% for onset latency, 94.7% for peak latency, 58.3% for difference between peak and onset latency, 57.6% for amplitude, 46.4% for duration, and 39.1% for area. Our study shows that in patients with CTS, the most sensitive sensory nerve conduction parameter is the peak latency. Studying various additional sensory nerve conduction parameters did not significantly increase the diagnostic yield
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Evidence-based treatment of peripheral nerve compression
Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
Decision making in peripheral nerve surgery schould be related to evidence that the diagnostic testing and operative procedures are valid, reloaded, and effective. This article reviews the available evidence related to peripheral nerve compression in the upper and lower interesting