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Spinal motor neuron excitability during the cutaneous silent period
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The physiologic mechanisms generating the cutaneous silent period (CSP) remain uncertain. It is not known whether the CSP occurs because of inexcitability of the spinal motor neuron. We, therefore, assessed excitability of the motor neuron during the CSP using F-wave responses. H- reflexes were also elicited during the CSP. Electrical stimulation to the fifth digit produced the CSP in the voluntarily contracting abductor pollicis brevis muscle (APB). Median nerve stimulation at the wrist elicited control F or H responses during isometric APB contraction (condition 1) and in resting muscle (condition 2). Control amplitudes were compared to those elicited in the midst of the CSP. In Condition 1, F-wave amplitudes and frequency during the CSP were unchanged compared with controls. However, F-waves were increased in amplitude and frequency during the CSP (P < 0.001) relative to responses elicited in resting muscle (condition 2). H-reflexes during the CSP were suppressed (P < 0.001) compared with controls elicited during contraction (condition 1), but facilitated relative to the resting state (condition 2) in which no H-reflexes were elicitable. We conclude that spinal motor neurons remain excitable to antidromic volleys at the same time that the corticospinal volley is inhibited to produce the CSP. Moreover, motor neuron excitability appears to be increased during the CSP compared to the relaxed state
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Characterization of an innovative intramedullary nail for diaphyseal fractures of long bones
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Distal Radius Fractures
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In this paper, an innovative design of nail for fractures occurring on long bones has been investigated. Its functioning is based essentially on sliding of conical surfaces, located in a spindle and in holding pins. Spindle and holding pins are connected together by a sleeve. The sliding transforms the rotational and translational motion of the spindle to a radial expansion of the holding pins, protruding inside the intramedullary canal. In order to evaluate mechanical behavior of the prosthesis different benchmarks and tests were numerically performed by an FE code.
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A Non-Enzymatic Method to Obtain a Fat Tissue Derivative Highly Enriched in Adipose Stem Cells (ASCs) from Human Lipoaspirates: Preliminary Results
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Panniculectomy & Abdominoplasty CPG
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Adipose tissue possesses phenotypic gene expression characteristics that are similar to human mesenchymal stem cells (hMSCs). Nevertheless, the multilineage potential may be inhibited, and cells may not expand adequately to satisfy the requirements of Good Manufacturing Practice (cGMP). An autologous hMSC-enriched fat product would fulfil the void from a biomedical and clinical perspective. In this study, we suggest a novel mechanism using a closed system without enzymes, additives or other modifications, which will produce non-expanded, accessible material. This decentralized fat product, unlike unprocessed lipoaspirates, adequately encloses the vascular stroma with adipocytes and stromal stalks along with their vascular channels and lumina. This fat product contained hASCs and fewer hematopoietic elements such as lipoaspirates, which were digested enzymatically according to flow cytometric investigations, and molecular analysis also showed significant hASC uniformity within the cells of the stromal vascular tissue. Moreover, the fat product produced a higher quantity of hASCs similar to hMSCs in isolation with the typical characteristics of an osteogenic, chondrogenic and adipogenic lineage. Interestingly, these properties were evident in the non-enzymatic derived adipose tissue, as opposed to hASCs in isolation from the enzymatically digested lipoaspirates, suggesting that the aforementioned procedure may be an adequate alternative to regenerate and engineer tissue for the treatment of various medical conditions and promote efficient patient recovery.
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Psychological or physiological: Why are tetraplegic patients content
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DoD PRF (Psychosocial RF)
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Objective: To assess the effects of spinal cord injury (SCI) on perceived health-related quality of life (QOL). Background: SCI is physically disabling, socially handicapping, and romantically limiting. Nevertheless, little is known about post-SCI neurocognitive and psychosocial life. Better understanding of the cognitive and emotional worlds of SCI patients is essential to better address and meet their needs and expectations. Methods: Twenty subjects with high-cord (T6 and above) complete (American Spinal Injury Association [ASIA] A) SCI (High SCI) were compared with 10 subjects with low-cord (T7 and below) ASIA A SCI (Low SCI) and with 11 Able-Bodied control subjects. Satisfaction with Life and Short Form-36 instruments were used to assess physical and emotional aspects of QOL. Analyses of variance were used to assess potential differences across groups. Results: Overall, satisfaction with life was the same among the groups. Expectedly, High SCI and Low SCI subjects reported lower physical functioning than Able-Bodied subjects (p < 0.0001). But, oddly, there were no differences in perceived physical role, physical health, or social functioning. Furthermore, High SCI subjects reported better perceived mental health than Able-Bodied control subjects (p = 0.004) and a trend over Low SCI subjects (p = 0.06), better perceived emotional role in society (p = 0.02), and greater vitality (p = 0.01) than Low SCI subjects and Able-Bodied subjects. Conclusions: Despite severe physical impairment and disability and frequent medical complications, subjects with complete spinal cord injury at high anatomic levels report better than average quality of life, being overall content. Reasons for these findings are unclear. Psychological adaptive reactions are likely, but the possible role of physiologic and neurocognitive changes needs further exploration. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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A prospective study evaluating incision placement and wound healing for tibial plafond fractures
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DoD SSI (Surgical Site Infections)
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OBJECTIVES: To report the soft tissue complications after fixation of tibial plafond fractures to test the validity of the recommendation that a 7-cm skin bridge represents the minimum safe distance between surgical incisions.
DESIGN: Prospective observational cohort.
SETTING: Level 1 Trauma Center.
PATIENTS: A total 42 patients with 46 tibial plafond fractures.
INTERVENTION: All injuries had a minimum of 2 surgical approaches for operative management of the tibial plafond and associated fibula fracture (if applicable). Two low-energy injuries had single-stage open reduction internal fixation of the tibia and fibula, and the remaining high- energy fractures had a 2-staged approach to management.
MAIN OUTCOME MEASUREMENTS: The surgical approaches used, length of the incisions, distance between the incisions, and overlap between the incisions were recorded. Wound healing was assessed in the outpatient clinic over a 3-month period.
RESULTS: Two surgical approaches were used in 32 fractures, and 3 approaches were used in 14 fractures. The mean width of the skin bridge was 5.9 cm. The majority of the skin bridges were 5.0 to 5.9 cm (n = 25) or 6.0 to 6.9 cm (n = 16). Only 17% of the skin bridges were greater than 7.0 cm. Soft tissue complications occurred in 4 (9%) of 46 fractures. Healing of 2 anterolateral incisions was complicated by eschars that ultimately resolved with local wound care. One posterolateral fibular incision failed to heal until the fibular plate was removed. One patient required subsequent surgical procedures for infection.
CONCLUSIONS: Despite a measured skin bridge of less than 7 cm in 83% of instances, the soft tissue complication rate was low in this group of tibial plafond fractures. With careful attention to soft tissue management and surgical timing, incisions for tibial plafond fractures may be placed less than 7 cm apart, allowing the surgeon to optimize exposures on the basis of injury pattern.
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Determining the incidence of postoperative delirium in elderly patients who undergo orthopaedic surgical interventions in Turkey
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Hip Fx in the Elderly 2019
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OBJECTIVE: To determine the incidence of postoperative delirium in elderly patients having undergone orthopaedic surgical interventions.
METHODS: The cross-sectional study was conducted at the traumatology clinic of GATA Haydarpasa Training and Research Hospital in Istanbul, Turkey, from April 2014 to April 2015 and comprised patients who underwent orthopaedic surgical interventions. The subjects included were aged >65 years, had no mental disorders, no acute cerebrovascular disease, no known history of delirium and/or dementia. Data was collected using a self-generated questionnaire, mini mental state examination and delirium rating scale. SPSS 18 was used for data analysis.
RESULTS: Of the 60 participants, 39(65%) were female and 21(35%) were male. The overall mean age was 77.07+/-8.66 years. Besides, 22(36.7%) patients hadmoderate cognitive impairment preoperatively, and 51(85%) had no delirium postoperatively while 9(15%) had delirium.
CONCLUSIONS: Degree of cognitive impairment,advanced age and type of surgery were determined to be risk factors for delirium.
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Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults
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SR for PM on OA of All Extremities
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Background: Amputee pain may present in a body part that has been amputated (phantom pain) or at the site of amputation (stump pain), or both. Phantom pain and stump pain are complex and multidimensional and the underlying pathophysiology remains unclear. The mainstay treatments for phantom pain and stump pain are predominately pharmacological. The condition remains a severe burden for those who are affected by it. There is increasing acknowledgement of the need for non-drug interventions and Transcutaneous Electrical Nerve Stimulation (TENS) may have an important role to play. TENS has been recommended as a treatment option for phantom pain and stump pain. To date there has been no systematic review of available evidence and the effectiveness of TENS for phantom pain and stump pain is currently unknown.Objectives: To assess the analgesic effectiveness of TENS for the treatment of phantom pain and stump pain following amputation in adults.Search methods: We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, PsycINFO, AMED, CINAHL, PEDRO and SPORTDiscus (February 2010).Selection criteria: Only randomised controlled trials (RCTs) investigating the use of TENS for the management of phantom pain and stump pain following an amputation in adults were included.Data collection and analysis: Two review authors independently assessed trial quality and extracted data. It was planned that where available and appropriate, data from outcome measures were to be pooled and presented as an overall estimate of the effectiveness of TENS.Main results: No RCTs that examined the effectiveness of TENS for the treatment of phantom pain and stump pain in adults were identified by the searches.Authors' conclusions: There were no RCTs on which to judge the effectiveness of TENS for the management of phantom pain and stump pain. The published literature on TENS for phantom pain and stump pain lacks the methodological rigour and robust reporting needed to confidently assess its effectiveness. Further RCT evidence is required before such a judgement can be made
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Capitellocondylar total elbow arthroplasty
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Sixty-nine non-constrained capitellocondylar metal-to-plastic total elbow-replacement prostheses were implanted in sixty-four patients with rheumatoid arthritis. These patients were followed for an average of 3.5 years. Postoperative flexion and pronation were significantly improved, but no significant increase in postoperative extension or supination could be demonstrated. Based on a rating system evaluating pain and function, there were 87 per cent good or excellent results. The complication rate based on the total number of prostheses implanted was 39 per cent. Eight patients required revision of the arthroplasty: four for dislocation of the prosthesis, two for sepsis, one for loosening, and one for a fracture. Eight other asymptomatic patients showed minimum radiolucent lines adjacent to the ulnar component. No patient demonstrated radiolucent lines adjacent to the humeral component
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Periprosthetic infections after shoulder hemiarthroplasty
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PJI DX Updated Search
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BACKGROUND: To examine the rates and predictors of deep periprosthetic infections after shoulder hemiarthroplasty. METHODS: We used prospectively collected institutional registry data on all primary shoulder hemiarthroplasty patients from 1976-2008. We estimated survival free of deep periprosthetic infections using Kaplan-Meier survival curves. Using univariate Cox regression analyses, we examined the association of patient-related factors (age, sex, body mass index), comorbidity (Deyo-Charlson index), American Society of Anesthesiologists grade, underlying diagnosis, and implant fixation with the risk of infection. RESULTS: A total of 1,349 patients, with a mean age of 63 years (SD, 16 years), 63% of whom were women, underwent 1,431 primary shoulder hemiarthroplasties. Mean follow-up was 8 years (SD, 7 years). Fourteen deep periprosthetic infections occurred during the follow-up, confirmed by medical record review. The most common organisms were Staphylococcus aureus, coagulase-negative Staphylococcus, and Propionibacterium acnes, each accounting for 3 cases (21% each). The 5-, 10-, and 20-year prosthetic infection-free rates were 98.9% (95% confidence interval [CI], 98.3%-99.5%), 98.7% (95% CI, 98.1%-99.4%), and 98.7% (95% CI, 98.1%-99.4%), respectively. None of the factors evaluated were significantly associated with risk of prosthetic infection after primary shoulder hemiarthroplasty, except that an underlying diagnosis of trauma was associated with a significantly higher hazard ratio of 3.18 (95% CI, 1.06-9.56) for infection compared with all other diagnoses (P = .04). A higher body mass index showed a non-statistically significant trend toward an association with higher hazard (P = .13). CONCLUSION: The periprosthetic infection rate after shoulder hemiarthroplasty was low, estimated at 1.3% at 20-year follow-up. An underlying diagnosis of trauma was associated with a higher risk of periprosthetic infection. These patients should be observed closely for development of infection
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Macrodystrophia lipomatosa: Radiographic diagnosis
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Macrodystrophia lipomatosa is a rare form of localized gigantism characterized by progressive overgrowth of all the mesenchymal elements with a disproportionate increase in the fibroadipose tissues. This congenital abnormality occurs most frequently in the distribution of the median nerve in the upper extremity and in the distribution of the plantar nerves in the lower extremity. It is usually recognized at birth or in the neonatal period. As the patient grows, the deformity begins to mechanically interfere with joint function, vascular supply, and innervation. Six cases are described with emphasis on the radiographic findings which differentiate this entity from other forms of local gigantism. These findings include a predominately distal involvement, enlargement of the phalanges and soft tissue elements of the digit, and lucencies within the soft tissues
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Pachydermodactyly in a young girl: Cutaneous manifestation of a psychiatric disorder?
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Introduction: Pachydermodactyly is a benign painless fibromatosis of unknown origin, typically occurring in otherwise well young men, affecting the skin overlying the radial and lunar aspects of the proximal interphalangeal joints of second to fourth digits of both hands. Case report: A 15-year-old female with a personal history of attention deficit hyperactivity disorder and tricotillomania presented a 3-year history of progressive painless swelling localized to the radial and ulnar sides of her second to fourth fingers of the left hand. She had been previously referred to the rheumathologist with clinical suspicion of rheumatoid arthritis, which was ruled out because of lack of local inflammatory signs and presence of soft tissue swelling with normal underlying bones and no signs of synovitis in a radiograph. A skin biopsy was performed, showing marked hyperkeratosis and acanthosis. After a careful clinical interview, the patient revealed a frequent compulsive habit of chewing and sucking the fingers of the left hand, which was probably involved in the development of cutaneous lesions. Discussion: Our case differs from the typical clinical picture of pachydermodactyly in the sex of the patient and the unilateral distribution of the lesions. Although the exact etiology of this condition is unknown, it has been associated with carpal tunnel syndrome, tuberous sclerosis, and familial atrophia maculosa varioliformis cutis. The repetitive trauma related to behavioral disturbances, such as obsessive compulsive disorder and Asperger syndrome, has also been evoked as a posssible ethiopathogenic factor. However, skin changes may persist even if the putative precipitating physical activity is ceased, and topical and intralesional steroids appear to be ineffective
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Minimally Invasive Closed Reduction and Internal Fixation With Screws for Distal Radius Fracture
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Distal Radius Fractures
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Distal radius fracture is defined as a fracture within 3 cm of the distal articular surface. When radius fracture and ulnar styloid process fracture occur together, internal fixation is generally not pursued; however, adverse events may occur after reduction with external fixation, including unstable fracture fragments, malalignment, and loss of radial inclination and ulnar deviation, leading to wrist function impairment. The commonly used treatment methods for distal radius fracture include internal fixation with steel plate, internal fixation with Kirschner wire, and external fixation. Open reduction and internal fixation (ORIF) has disadvantages. For example, the pronator teres is incised in palmar ORIF and in situ suturing of the muscle is not possible in most patients after implantation of the titanium plate. Even when suturing is possible, the strength of the pronator teres will decrease after surgery, and a second surgery is needed to remove the titanium plate. Dorsal ORIF is also disadvantageous because more tendons and thin soft tissue may be encountered during surgery. In addition, tendon sheath injury is inevitable, leading to myotenositis, tendon adhesion, and even tendon rupture. Thus, internal fixators should be taken out as early as possible. Satisfactory wrist function outcomes have been achieved with external fixators, in particular with dynamic external fixators. However, although external fixation has good fixing effects, it provides poor lateral stability, resulting in injury to the superficial branch of the radial nerve, screw channel infection, screw channel fracture, screw loosening, and even Sudeck's atrophy. Internal fixation with Kirschner wire generates minimal surgical trauma, but this technique does not provide sufficient strength for fixation and is therefore rarely used at present. There is an urgent need to develop a more stable fixation method for distal radius fracture. Minimally invasive surgery avoids the tissue damage and impairment of physiological function caused by open surgery because of its precise location techniques. Brachial plexus anesthesia allows surgeons to avoid large incisions and excessive bleeding. There are no palmar or dorsal incisions in minimally invasive surgery for distal radius fractures, so the structures surrounding the wrist joint are not iatrogenically damaged, which theoretically improves wrist function recovery. During Câ?arm fluoroscopyâ?assisted minimally invasive closed reduction, either no surgical incision or an incision only 0.5 cm in length is made at the wrist joint; the fracture fragments are reduced with fully threaded headless cannulated compression screws. Repair stability is assessed with the Câ?arm fluoroscopic Xâ?ray system. This method is theoretically feasible for distal radius fractures. The fracture fragments are fixed with fully threaded, cannulated, variableâ?pitch, headless compression screws, which can increase fragment stability. Therefore, the investigators hypothesize that Câ?arm fluoroscopyâ?assisted minimally invasive closed reduction will fix distal radius fractures and allow patients to perform wrist function exercises as early as possible. Our previous studies have confirmed that minimally invasive closed reduction and internal fixation with fully threaded headless cannulated compression screws has precise therapeutic effects for distal radius fractures. This method can improve wrist function, and has therapeutic effects similar to those of conventional open reduction and internal fixation with titanium plates. The results of these previous studies are shown in Table 1. However, it is not clear whether minimally invasive closed reduction and internal fixation with fully threaded headless cannulated compression screws has advantages over conventional open reduction and internal fixation with titanium plates for distal radius fracture repair. In this study, the investigators hypothesized that minimally invasive closed reduction and internal fixation with fully threaded headless cannulated compression screws provid s better stability than conventional methods, and can effectively promote the early recovery of wrist function. Under conditions of no cutting of fracture fragments, no blood supply compromise in the fracture fragments, and no destruction of the local microenvironment, and with Câ?arm fluoroscopy assistance, the investigators will perform minimally invasive closed reduction, pressurizing the fracture fragments with fully threaded headless cannulated compression screws, and will investigate whether this method of distal radius fracture repair provides satisfactory stability and allows early wrist function recovery. Safety assessment Adverse events should be accurately recorded, including time of onset, severity, duration, and measures taken. The known possible adverse events include bone nonunion, displaced fracture, wrist joint pain, Sudeck's syndrome, primary or secondary tendon injury, shoulderâ?hand syndrome, traumatic arthritis of the wrist joint, implant failure, malunion, infection, septicemia, and thrombosis. Any of the following will be considered a severe adverse event: death, prolonged hospital stay, mutilation, fatal reaction, or teratogenicity. Any adverse event occurring during the trial will be reported to the researchers in charge and to the ethics committee within 24 hours. Data management Data from the trial will be kept in a secure, locked storage area with limited access for later review by a biostatistician, a researcher in charge. Statistical analysis All data will be statistically processed with SPSS 11.0 software (SPSS, Chicago, IL, USA). Normally distributed measurement data will be expressed as mean and SD. Nonâ?normally distributed measurement data will be expressed as lower quartile (q1), median, and upper quartile (q3). The numeration data will be expressed as constituent ratios. The Mannâ?Whitney U nonâ?parametric test will be used to compare age and course of disease between the experimental and control groups. The chiâ?square test will be used to compare sex differences between the two groups. The Mannâ?Whitney U nonâ?parametric test will also be used to compare imaging parameters (for example, angle, height, and length), PRWE scores, healing time of fracture, and VAS scores. The chiâ?square test will also be used to compare the effective rate between the two groups. An alpha level of 0.05 (twoâ?sided) will be considered statistically significant.
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Involvement of the proximal radial ulnar joint in partial radial head fractures: a novel three-dimensional computed tomography scan evaluation method
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Distal Radius Fractures
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Background: Partial radial head fractures (PRHF) can involve the proximal radioulnar joint (PRUJ) or be restricted to the 'safe zone' (SZ) during forearm rotation. The objective of the present study was to develop an assessment method for PRUJ involvement in radial head fractures using axial computed tomography (CT) scans.
Methods: The area of the radial head in contact with the PRUJ zone was identified, and defined on 18 cadaveric elbows CT scans; the quantitative relationship between PRUJ zone and radial tuberosity was established. Then, four evaluators validated it on PRHF CT scan axial views, classifying the fractures as involving the PRUJ or not.
Results: Using the radial tuberosity as the 0degree of a 360degree circle, the SZ was within 108degree to 212degree clockwise for a right elbow and counter clockwise for the left elbow. Fifty-five consecutive (30 men, 25 women, mean age of 49 years) partial radial head fracture CT scans were classified: four in the SZ only, three in the PRUJ zone and 48 in both the PRUJ and SZ. The kappa for the inter- and intra-observer agreement was 0.517 and 0.881, respectively.
Conclusions: Ninety-three percent of partial radial head fractures will involve the PRUJ and the geometric model developed allows their classification, potentially helping surgeons decide on optimal treatment.
Level of evidence: Retrospective basic science study. Level III: anatomic study, imaging.
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Demonstration of a lumbar hernia on the flow phase of a Tc-99m MDP three-phase bone scan
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Management of Hip Fractures in the Elderly
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A 95-year-old woman was evaluated for possible hip fracture after she had fallen. The vascular and blood pool images of the three-phase bone scan show activity extending lateral to the abdominal wall after injection with Tc-99m MDP. The four-hour static images are clear in this area. Results of physical examination showed a nonreducible lumbar hernia of the right side of the lower abdomen, which explains the appearance of the early scans
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Patient-Reported Outcomes After Platelet-Rich Plasma, Bone Marrow Aspirate, and Adipose-Derived Mesenchymal Stem Cell Injections for Symptomatic Knee Osteoarthritis
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PRP (Platelet-Rich Plasma)
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Objective: The objective of this study was to compare platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and adipose-derived mesenchymal stem cell (MSC) injections in the treatment of osteoarthritis (OA) of the knee using functional scores.
Methods: A total of 89 patients with painful knee OA were included in this study. Patients were assigned to one of the 3 treatments according to severity of OA as indicated by symptoms and radiography to PRP (stage I), BMAC (stage II), or adipose-derived MSC (stage III). Clinical assessment was performed using the Knee Society Score, which combines the Knee Score, based on the clinical parameters, and the Functional Score, and IKDC score. Surveys were completed at preoperative and at 90, 180, and 265 days postoperative. The follow-up responses were compared with baseline and between treatment groups.
Results: Treatment with PRP, BMAC, and adipose-derived MSC included 29 (32.6%), 27 (30.3%), and 33 (37.1%) patients, respectively. For the total group, median age was 61 years (range: 22-84 years). Score values were comparable among treatment groups at baseline. Statistically significant improvement was observed in the 3 groups according to the 3 scores at all time points during follow-up compared with baseline. No difference was found among treatment type.
Conclusions: Our findings support previous reports and encourage further research on the use of these cost-effective treatments for OA of the knee.
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A clinical pathway for hip fractures in the elderly
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HipFx Supplemental Cost Analysis
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Hip fractures are common injuries in the elderly that can be associated with considerable morbidity and mortality. Although technical advances in the treatment of hip fractures have resulted in improved fracture fixation and surgical outcomes, establishment of a clinical pathway for hip fractures could result in a cost-effective standardization of care, maximal utilization of available resources, and a decrease in the incidence of perioperative complications. This article presents a clinical pathway for hip fractures in the elderly
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Proximal femoral allograft: Prognostic indicators
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DoD LSA (Limb Salvage vs Amputation)
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Between 1972 and 1999, the Orthopedic Oncology Service treated 150 patients with resection and allograft transplantation of the proximal femur. Of the group, 121 patients had malignant tumors of the proximal femur and 29 had benign disorders. Four types of allografts were used: osteoarticular (46 patients), allograft-prosthesis (73), intercalary (20), and allograft-arthrodesis (5). Only 16% of the patients died of disease and 3% required amputation. The overall success rate for the series was 77% with the best results for the allograft prosthetic (82%) and intercalary procedures (87%). Graft infection (15 patients), allograft fracture (26patients), and local recurrence (11 patients) most markedly affected outcome. With the exception of deaths of disease, no significant outcome difference occurred between the patients with malignant and benign disorders. In conclusion, allograft implantation especially for aggressive or malignant tumors of the proximal femur appears to be a competent system for therapy. © 2010 Elsevier Inc.
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Distal Radius Fractures: Choice of Treatment Procedures
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Distal Radius Fractures
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Background: Distal radius fractures are no longer injuries typical of elderly patients with osteoporosis. Driving at high speed and high-speed sports activities are responsible for causing such injuries in an increasing number of younger people. Although the kind of fracture suffered, bone density, and personal needs and requirements of patients demand an individualized treatment concept, a surgical approach for stabilization of the fracture is gaining wider recognition. Methods: The current treatment regimens for distal radius fractures are reviewed. Results: Good results can be achieved in certain specific forms of fracture by conservative treatment. The preconditions are that it is possible to perform a closed reduction of the fracture and that the limb can be kept in a plaster cast until bone healing has taken place. Furthermore, a conservative approach needs to be used in cases where surgery cannot be performed for a variety of reasons. Where surgery is performed, percutaneous methods are adequate if the fracture undergoes closed reduction, but a plaster cast cannot be applied because of metaphysial compression or injuries to the ligaments. Fixation with pins, concealed screws, and external fixation can all contribute to good healing results if the correct technique is used for the type of fracture treated. Open reduction and osteosynthesis with plates and screws combined with bone graft for defect filling is surgically quite demanding, but in patients exposed to manual stress, this approach is required for optimal reconstruction and rehabilitation. Depending on the fracture type, different approaches, such as the dorsal, palmar, or palmar with an additional dorsal incision, have to be used for plate placement. Stable osteosynthesis enables early functional rehabilitation. Conclusions: Even if it were possible to offer specific recommendations for treating different forms of distal radius fractures, factors that are decisive in the treatment concept are the general health, bone density, and the wishes of the patient. It is essential to take into consideration all these factors for a successful treatment of distal radius fractures.
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Metacarpophalangeal and metatarsophalangeal osteoarthritis in 49 dogs
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Glenohumeral Joint OA
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Although osteoarthritis (OA) is a common and debilitating condition in the canine patient, few data are available on OA of the metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints. Review of medical records of 49 dogs with a radiographic diagnosis of MCP or MTP OA presented over a 7-year period demonstrated that OA was an "incidental finding" for the majority of animals (n=35), while 14 dogs were identified as clinically lame as a result of MCP or MTP OA. Dogs that were clinically lame as a result of MCP or MTP OA were significantly more likely to have visible swelling over the affected digits. Five times as many dogs were diagnosed with MCP OA than with MTP OA, and the majority of dogs had radiographic changes on multiple digits. Review and scoring of radiographs (n=44 dogs) for six radiographic signs of OA followed by logistic regression analysis demonstrated that the two lateral digits of the front limb were significantly more likely to have osteophytosis and enthesophytosis than the two medial digits. Osteoarthritis of MCP and MTP joints has unique radiographic features that are not seen in the stifle, hip, shoulder, or elbow; these features can complicate accurate diagnosis, particularly differentiation from primary bone neoplasia. These data underscore the clinical relevance of this condition and provide useful information detailing which and how many digits are most commonly affected, potentially assisting discrimination between OA and neoplasia.
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Comparative analysis of intramedullary nail fixation versus casting for treatment of distal radius fractures
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Purpose: Intramedullary fixation is one treatment option for distal radius fractures. Our purpose was to compare the outcomes of intramedullary nailing to those of casting for these injuries. Methods: From 2006 to 2009, we reviewed 63 adult patients with isolated distal radius fractures. Thirty-one patients had surgical fixation with an intramedullary device (IMN group) within 4 weeks of the injury, and 32 (cast group) had casting as definitive treatment of the fracture. Clinical outcomes (grip strength; Disabilities of the Arm, Shoulder, and Hand scores; active wrist range of motion; and complications) and radiographic indices (radial inclination, radial height, ulnar variance, and tilt) of both groups were analyzed for the 1-, 2-, 4-, 6-, and 12-month follow-up periods. Results: The flexionextension arc was significantly higher in the IMN group than in the cast group at 2-, 6-, and 12-month follow-up. The IMN group exhibited significantly greater grip strength and lower DASH scores throughout the follow-up period. At final follow-up, all radiographic indices were significantly better in the IMN group than in the cast group. There was no significant difference between the initial reduction to final position in the IMN group, but the cast group showed an increase in ulnar variance and a significant change in dorsalvolar tilt. In addition, the cast group experienced more clinical complications in the delayed period compared to the IMN group. Conclusions: Intramedullary nail fixation, as compared to casting, results in less functional disability, not only in the early postoperative period but also up to a year after treatment. On the basis of our data, intramedullary fixation should be considered for patients with unstable extra-articular or simple intra-articular distal radius fractures. (copyright) 2012 American Society for Surgery of the Hand
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Surgical correction of gynecomastia
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Panniculectomy & Abdominoplasty CPG
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Gynecomastia, or persistent enlargement of the male breast, is a common occurrence during early sexual development. Typically, two types of tissue can be identified during this period of growth. Initially, a dense fibrous growth of supporting stroma and breast tissue forms directly under the areola, creating a prominent mass effect. A supporting fibrofatty stroma variably develops around the periphery of the breast, particularly as the body mass index of the patient increases. Treatment is directed at both of these tissue types and includes liposuction contouring along with direct excision of the fibrous subareolar tissue. Resection of redundant skin is performed as needed either immediately or in a delayed fashion. These various modalities can be used either alone or in combination to restore a normal chest wall contour to affected individuals, thus easing the emotional burden that is associated with the condition. © 2009 American Society of Plastic Surgeons.
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Identifying a combined biomarker for bisphosphonate-related osteonecrosis of the jaw
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: For this study, the aim was to identify combined biomarkers associated with bisphosphonate-related osteonecrosis of the jaw (BRONJ).
MATERIALS AND METHODS: Microarray data for GSE7116 were downloaded from the Gene Expression Omnibus database, which contains 26 samples, including without ONJ, and 5 healthy volunteers. The combined biomarkers were identified using principal component analysis, and the pathway enrichment analyses were performed using the DAVID online tool.
RESULTS: Two hundred differently expressed genes between groups were detected according to the significances. From functional annotation, Y-box binding protein 1 and heterogeneous nuclear ribonucleoprotein C were found to be included in the most significant 10 pathways. Ten combined gene sets were identified that were effective in classifying multiple myeloma (MM) with ONJ and MM without ONJ.
CONCLUSION: Identifying combined gene expression profiles is expected to contribute to more personalized management of BRONJ and to improve existing therapies, and it will be helpful in finding new therapies by identifying more predictive biomarkers.
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Range of motion of standard and high-flexion posterior cruciate-retaining total knee prostheses a prospective randomized study
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: The main goals of total knee arthroplasty are pain relief and improvement in function and the range of motion. The purpose of this study was to compare the ranges of motion of the knees of patients treated with a standard posterior cruciate-retaining total knee prosthesis in one knee and a high-flexion posterior cruciate-retaining total knee prosthesis in the other. METHODS: Fifty-four patients (mean age, 69.7 years) received a standard posterior cruciate-retaining total knee prosthesis in one knee and a high-flexion posterior cruciate-retaining total knee prosthesis in the contralateral knee. Five patients were men, and forty-nine were women. At a mean of three years postoperatively, the patients were assessed clinically and radiographically with the knee-rating systems of the Knee Society and the Hospital for Special Surgery and with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. RESULTS: The mean postoperative Knee Society and Hospital for Special Surgery knee scores were 93.7 and 89 points, respectively, for the knees with a standard posterior cruciate-retaining prosthesis, and they were 93.9 and 90 points, respectively, for the knees with a high-flexion posterior cruciate-retaining prosthesis. The mean postoperative WOMAC score was 22 points. Postoperatively, the mean ranges of motion without and with weight-bearing were 131 degrees (range, 90 degrees to 150 degrees) and 115 degrees (range, 75 degrees to 145 degrees), respectively, in the knees with a standard prosthesis and 133 degrees (range, 90 degrees to 150 degrees) and 118 degrees (range, 75 degrees to 145 degrees), respectively, in those with a high-flexion prosthesis. Patient satisfaction and radiographic results were similar in the two groups. No knee had aseptic loosening, revision, or osteolysis. CONCLUSIONS: After a minimum duration of follow-up of three years, we found no significant differences between the two groups with regard to the range of knee motion or the clinical or radiographic parameters
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Total knee arthroplasty in a group of patients less than 45 years of age
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Surgical Management of Osteoarthritis of the Knee CPG
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The long-term follow-up evaluation of total knee arthroplasty (TKA) in patients under age 45 is reviewed. One hundred three knees in 67 patients who had an average follow-up period of 7.2 years were retrospectively reviewed. Fifty-eight percent of the patients had rheumatoid arthritis, and 29% had juvenile rheumatoid arthritis. Thirteen percent of the patients had post-traumatic arthritis, avascular necrosis, hemochromatosis, or lupus. The results demonstrate that the success of TKA in this patient population are comparable to those for TKA in the elderly
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BMJ Open Hospital case volume and outcomes for proximal femoral fractures in the USA: An observational study
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Hip Fx in the Elderly 2019
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Objective: To explore whether older adults with isolated hip fractures benefit from treatment in highvolume hospitals. Design: Population-based observational study. Setting: All acute hospitals in California, USA. Participants: All individuals aged â?¥65 that underwent an operation for an isolated hip fracture in California between 2007 and 2011. Patients transferred between hospitals were excluded. Primary and secondary outcomes: Quality indicators (time to surgery) and patient outcomes (length of stay, in-hospital mortality, unplanned 30-day readmission, and selected complications). Results: 91 401 individuals satisfied the inclusion criteria. Time to operation and length of stay were significantly prolonged in low-volume hospitals, by 1.96 (95% CI 1.20 to 2.73) and 0.70 (0.38 to 1.03) days, respectively. However, there were no differences in clinical outcomes, including in-hospital mortality, 30-day re-admission, and rates of pneumonia, pressure ulcers, and venous thromboembolism. Conclusions: These data suggest that there is no patient safety imperative to limit hip fracture care to high-volume hospitals.
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Microincision aponeurotic ptosis surgery of upper lid
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Upper Eyelid and Brow Surgery
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The paper is a prospective study of 23 lids of 20 patients with upper lid aponeurotic ptosis operated using microincision technique in period 2005-2008. There were 7 males and 13 females. Age of the patients was 28-83 years (y), average 61 +/- 17 y, for female 63 +/- 13.4 y and for male 61 +/- 19 y. Inclusion criteria were: aponeurotic upper lid ptosis more than 2 mm, no other lid abnormalities, minimal dermatochalasis, no previous or concomitant lid surgery. The procedure was performed in local anesthesia through 10 mm cut. Aponeurosis was fixated to the tarsal plate with two sutures. Success was considered if operated lid height differed up to 0.5 mm of the other eye and margin-to-reflex distance was 2-4 mm in primary position. Postoperative results regarding contour, skin crease and lash position were good in all patients. Regarding height, 19/23 (83%) met criteria of 0.5 mm of the other eye and MRD 2-4 mm. In one bilateral procedure there was an asymmetry of 1 mm. Three patients with unilateral procedure had at least 1mm asymmetry comparing to the other eye. Reoperation was neccessary in two bilateral cases. Lid fold was symmetrical only in 7 patients (35%). The rest had slight to grose lid fold asymmetry. Complications were scarce, in early postoperative period there was hematoma in two patients lasting up to three weeks. Late failure was noticed in two cases 6 and 8 months postoperatively. Advantages are: less anesthetic results in less decreased levator function and more accurate assessment of eyelid position intraoperatively, less distortion of the lid due to less bleeding and edema, shorter operation time, less scarring and shortened recovery time. However it can be used only in selective cases.
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A new technique for reconstruction of the proximal humerus after three- and four-part fractures
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Glenohumeral Joint OA
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The results of proximal humeral replacement following trauma are substantially worse than for osteoarthritis or rheumatoid arthritis. The stable reattachment of the lesser and greater tuberosity fragments to the rotator cuff and the restoration of shoulder biomechanics are difficult. In 1992 we developed a prosthesis designed to improve fixation of the tuberosity fragments in comminuted fractures of the proximal humerus. The implant enables fixation of the fragments to the shaft of the prosthesis and the diaphyseal fragment using screws, washers and a special toothed plate. Between 1992 and 2003 we used this technique in 50 of 76 patients referred to our institution for shoulder reconstruction after trauma. In the remaining 26, reconstruction with a prosthesis and nonabsorbable sutures was performed, as the tuberosity fragments were too small and too severely damaged to allow the use of screws and the toothed plate. The Constant score two years post-operatively was a mean of 12 points better in the acute trauma group and 11 points better in the late post-traumatic group than in the classical suture group. We recommend this technique in patients where the tuberosity fragments are large enough to allow fixation with screws, washers and a toothed plate.
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Efficacy of individualized Chinese herbal medication in osteoarthrosis of hip and knee: a double-blind, randomized-controlled clinical study
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: The objective of this study was to determine the efficacy of individually designed herbal formulas according to the rules of Traditional Chinese Medicine (TCM) in patients with osteoarthritis of the hip and knee. DESIGN: This was a randomized, controlled, doubleâ?blind study with two parallel groups. SETTINGS/LOCATION: This study was conducted at the Universityâ?centre in Gars am Kamp/Austria and was organized by the Institute of TCM and Complementary Medicine of the Danube University Krems /Austria. SUBJECTS: The study comprised female and male patients with osteoarthritis of hip or knee aged between 45 and 75 years. INTERVENTIONS: Patients were randomized into a treatment with individualized, waterâ?based herbal decoctions prepared in a standardized cooking process (Verum group) or to a treatment with nonspecific presumably ineffective, waterâ?based herbal decoctions (Control group). OUTCOME MEASURES: The primary outcome was the comparison of change between the intervention groups in the Western Ontario and McMaster Universities lower limb global index questionnaire (WOMAC global index) between baseline and week 20. Secondary outcomes included subscales of WOMAC for pain (A), stiffness (B), and functional impairment (C) and general quality of life in the form of the SFâ?36 questionnaire. RESULTS: Altogether, 102 patients were randomized in this trial. The demographic and medical baseline characteristics were comparable in the 2 groups. The change of the WOMAC global index and all three subscales was significant in both groups between week 20 and baseline (verum group, global WOMAC: at baseline 47 [SDâ??±â??11.8] and at week 20: 24 (SDâ??±â??18.3); change of mean 23; pâ??>â??0.001; control group; global WOMAC: at baseline: 48 (SDâ??±â??14.7) and at week 20: 25 (SDâ??±â??18.3); change of mean 23; pâ??>â??0.001). However, there was no significant difference (pâ??=â??0.783) between the treatment groups. There were significant changes in the subscales "physical functioning," "bodily pain," "vitality," "socialâ?functioning," and "roleâ?physical" of the SFâ?36 in both study groups between 20 weeks and baseline, but again no significant difference between the groups. There were no drugâ?related serious adverse events. CONCLUSIONS: While the individual prescription consisting of medicinal herbs according to TCM diagnosis investigated in this trial tend to improve the osteoarthritis, the same effect was also achieved with the nonspecific prescription.
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One-Stage Exchange Arthroplasty for Fistulizing Periprosthetic Joint Infection of the Hip: An Effective Strategy
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Hip Fx in the Elderly 2019
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<b>Background:</b> Prosthetic hip infection (PHI) is a disastrous scenario after an arthroplasty. International guidelines contraindicate one-stage exchange arthroplasty for fistulizing chronic prosthetic hip infection (FCPHI), nevertheless few surgical teams, mostly from Europe, support one stage procedure for this indication. <b>Questions/Purposes:</b> Analysis of infection recurrence and implant failure of a series of FCPHIs treated with one stage arthroplasty. <b>Patients and Methods:</b> Sixty-six FCPHIs treated with one-stage exchange arthroplasty were prospectively followed up at least 2 years. Clinical, radiological and bacteriological signs suggestive of reinfection were sought, as well as implant failures and PHI related deaths.
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Electrodiagnostic evaluation of the ulnar nerve
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Electrodiagnostic methods and their significance for the diagnosis of a lesion of the ulnar nerve are discussed. For different lesion locations (upper arm, elbow, forearm, wrist, and palm), various electrodiagnostic methods are discussed. An overview of the existing literature is given. The diagnostic importance is reported herein, and aspects of applications are discussed. This review is intended to support the electrodiagnostic physician in the selection and application of the correct methods in the diagnosis of a lesion of the ulnar nerve. (copyright) 2007 by Begell House, Inc
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Magnetic resonance imaging assessment of gluteal fat grafts
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Panniculectomy & Abdominoplasty CPG
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Backgrounds: One goal of lipoplasty is to create a round and projected buttock contour. Despite multiple papers evaluating lipoinjection, controversies still remain. Methods: This report describes a series of patients who underwent liposuction, gluteal lipoinjection, and evaluation with magnetic resonance imaging (MRI). From January 2003 to January 2004, the patients scheduled for contour surgery by the investigators were evaluated using MRI, photographic records, and gluteal circumference measurement 1 week before surgery, then 2 weeks and 3 months after the procedure. A statistical analysis was performed for 10 patients who received, on the average, a 350-ml injection of fat obtained during liposuction. Results: Gluteus muscle volume increased, reaching a higher level 2 weeks after the injection than the level 3 months afterward (p < 0.001). The gluteal circumference, modified 2 weeks after surgery by about 1 to 3 cm, came back to previous values 3 months after the procedure (p < 0.05), a phenomena interpreted as reabsorption and resolution of the postoperative edema. There is no correlation between the gluteus muscle volume obtained by MRI and the gluteal circumference (p > 0.05). Conclusions: The findings led to the conclusion that enhancement of the gluteal contour after fat injection results from survival of the injected tissue 3 months after the surgery, which was objectively evaluated by MRI as having a calculated reabsorption rate of 24% to 36%. © 2006 Springer Science+Business Media, Inc.
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The clinical outcome and activity levels of patients under 55 years treated with distal humeral hemiarthroplasty for distal humeral fractures: minimum 2-year follow-up
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: The aim of the present study was to describe the clinical outcomes and activity levels of young patients after distal humeral hemiarthroplasty (DHH). METHODS: Six patients under 55 years (mean 44 years; range 29 years to 52 years) treated with DHH at a mean postoperative time of 81 months (range 24 months to 133 months) were studied retrospectively. Two other patients had been revised for aseptic loosening and were excluded. RESULTS: The mean Mayo Elbow Score (MEPS) (88), Subjective Elbow Value (SEV) (89), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) (12) and American Shoulder and Elbow Surgeons (ASES) elbow pain (6), function (23) and satisfaction scores (9) were satisfactory. The mean University of California, Los Angeles (UCLA) activity score was 7.2. CONCLUSIONS: Although only rarely indicated, DHH has satisfactory clinical outcomes in young patients and allows a higher level of function than is generally advised after total elbow arthroplasty.
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Clinical presentation and time-course of postoperative venous thromboembolism: Results from the RIETE Registry
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Hip Fx Time to Surgery
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There is little literature about the clinical presentation and time-course of postoperative venous thromboembolism (VTE) in different surgical procedures. RIETE is an ongoing, prospective registry of consecutive patients with objectively confirmed, symptomatic acute VTE. In this analysis, we analysed the baseline characteristics, thromboprophylaxis and therapeutic patterns, time-course, and three-month outcome of all patients with postoperative VTE. As of January 2006, there were 1,602 patients with postoperative VTE in RIETE: 393 (25%) after major orthopaedic surgery (145 elective hip arthroplasty, 126 knee arthroplasty, 122 hip fracture); 207 (13%) after cancer surgery; 1,002 (63%) after other procedures. The percentage of patients presenting with clinically overt pulmonary embolism (PE) (48%, 48%, and 50% respectively), the average time elapsed from surgery to VTE (22 +/- 16, 24 +/- 16, and 21 +/- 15 days, respectively), and the three-month incidence of fatal PE (1.3%, 1.4%, and 0.8%, respectively), fatal bleeding (0.8%, 1.0%, and 0.2%, respectively), or major bleeding (2.3%, 2.9%, and 2.8%, respectively) were similar in the three groups. However, the percentage of patients who had received thromboprophylaxis (96%, 76% and 52%, respectively), the duration of prophylaxis (17 +/- 9.6, 13 +/- 8.9, and 12 +/- 11 days, respectively) and the mean daily doses of low-molecular-weight heparin (4,252 +/- 1,016, 3,260 +/- 1,141, and 3,769 +/- 1,650 IU, respectively), were significantly lower in those undergoing cancer surgery or other procedures. In conclusion, the clinical presentation, time-course, and three-month outcome of VTE was similar among the different subgroups of patients, but the use of prophylaxis in patients undergoing cancer surgery or other procedures was suboptimal.
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Randomized controlled clinical trial on the evaluation of bacteriostatic and cariostatic effects of a novel povidone-iodine/fluoride foam in children with high caries risk
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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OBJECTIVE: To investigate the bacteriostatic and cariostatic effect of a novel povidone-iodine/fluoride foam in children at high risk for caries. METHOD AND MATERIALS: Sixty-one 6- to 9-year-old children with at least 1 active dental caries lesion were randomly assigned to 2 groups and treated weekly with either povidone-iodine/fluoride foam (n = 30, experimental group) or placebo fluoride foam (n = 31, control group) for 4 weeks. Stimulated saliva samples were collected for bacteriostatic assessment before each treatment and at 2 and 6 months during the experiment. In addition, laser fluorescence readings of the permanent first molars were taken for the evaluation of cariostatic effect before the treatment and at 2, 6, and 12 months during the experiment. RESULTS: Both groups showed a constant decrease of salivary mutans streptococci over 6 months. Significantly lower laser fluorescence readings were observed for both groups at the 6th month, although with a slight reverse at the 12th month. However, no statistically significant difference was achieved between the 2 groups either for salivary bacteria levels over 6 months or laser fluorescence readings within 1 year. CONCLUSION: As far as bacteriostatic and cariostatic effects are concerned, clinical application of povidone-iodine/fluoride foam shows no superiority over the regular fluoride foam during a 1-year period. Evidence is still lacking for the combination use of povidone-iodine and fluoride to achieve a better caries-prevention effect in a high-caries-risk population
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Validity of current electrodiagnostic techniques in the diagnosis of carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: Determining the validity of current median sensory nerve conduction techniques for diagnosis of carpal tunnel syndrome (CTS). METHODS: Eighty five patients with clinical diagnosis of CTS were compared with the same number of healthy people. The validity of electrodiagnostic tests were compared in a case-control manner. These electrodiagnostic techniques included long-segment, short-segment, 2-segment and relative slowing studies; as well as distoproximal ratio. Receiver Operating Characteristic (ROC) curve employed for comparison, determining the optimal cut-off points for each test. Validity was evaluated with likelihood ratio. RESULTS: Likelihood ratio (LHR) for Radial-median sensory latency difference was infinity, while LHR for ulnarmedian sensory latency difference was 16.9. Sensitivity of Two-segment method was 98.8% and mixed palmwrist median Nerve Conduction Velocity (NCV) study showed a sensitivity and specificity of 97.6%, 83.5% respectively. CONCLUSIONS: Radial-median latency difference study (optimal cut-off point >/=0.5) and study of wrist-segment NCV (optimal cut-off point <50.45) were the most valuable techniques in diagnosis of CTS, respectively. Median-ulnar latency difference study and disto-proximal ratio study had more diagnostic implication than long and short (mixed) segment technique in this regard
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1 |
Open reduction and internal fixation compared to closed reduction and external fixation in distal radial fractures: a randomized study of 50 patients
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Distal Radius Fractures
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BACKGROUND AND PURPOSE: In unstable distal radial fractures that are impossible to reduce or to maintain in reduced position, the treatment of choice is operation. The type of operation and the choice of implant, however, is a matter of discussion. Our aim was to investigate whether open reduction and internal fixation would produce a better result than traditional external fixation.
METHODS: 50 patients with an unstable or comminute distal radius fracture were randomized to either closed reduction and bridging external fixation, or open reduction and internal fixation using the TriMed system. The primary outcome parameter was grip strength, but the patients were followed for 1 year with objective clinical assessment, subjective outcome using DASH, and radiographic examination.
RESULTS: At 1 year postoperatively, grip strength was 90% (SD 16) of the uninjured side in the internal fixation group and 78% (17) in the external fixation group. Pronation/supination was 150 degrees (15) in the internal fixation group and 136 degrees (20) in the external fixation group at 1 year. There were no differences in DASH scores or in radiographic parameters. 5 patients in the external fixation group were reoperated due to malunion, as compared to 1 in the internal fixation group. 7 other cases were classified as radiographic malunion: 5 in the external fixation group and 2 in the internal fixation group.
INTERPRETATION: Internal fixation gave better grip strength and a better range of motion at 1 year, and tended to have less malunions than external fixation. No difference could be found regarding subjective outcome.
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0 |
Acute intestinal distress syndrome: the importance of intra-abdominal pressure
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DoD - ACS - Interrater Reliability
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This review article will focus primarily on the recent literature on abdominal compartment syndrome (ACS) as well as the definitions and recommendations published by the World Society for the Abdominal Compartment Syndrome (WSACS, www.wsacs.org). The risk factors for intra-abdominal hypertension (IAH) and the definitions regarding increased intra-abdominal pressure (IAP) will be listed, followed by a brief but comprehensive overview of the different mechanisms of end-organ dysfunction associated with IAH. Measurement techniques for IAP will be discussed, as well as recommendations for organ function support in patients with IAH. Finally, noninvasive medical management options for IAH, surgical treatment for ACS and management of the open abdomen will be briefly discussed. [References: 123]
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Carpal tunnel syndrome and acromegaly
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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50 patients with acromegaly and carpal tunnel syndrome have been examined electrophysiologically before and after transnasal operation of the pituitary adenoma. 32 of the 50 patients (64%) had symptoms of carpal tunnel syndrome. 13 of them had neurological deficits. 28 of the examined patients had pathological neurographical findings only. About 1 week post-operatively DL was decreased in 43%; in 10 out of 13 patients with neurological deficits DL decreased. GH was normalized in 80% and reduced to 5-10 micrograms/l in a further 10%. The investigation did not show whether the carpal tunnel syndrome only depended on a GH increase or on other factors also such as e.g., on the duration of symptoms or tissue changes. None of the patients had the transversal carpal ligament operated on. The coincidence between acromegaly and carpal tunnel syndrome was 64%. In 3 cases the carpal tunnel syndrome was the leading sign to the diagnosis of acromegaly
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Stress radiography for osteoarthritis of the knee: a new technique
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Surgical Management of Osteoarthritis of the Knee CPG
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Stress radiographs have been used for several years to detect the amount of varus/valgus knee laxity and to evaluate the degree of compartmental involvement in degenerative osteoarthritis. However, the popularity of these radiographic methods has been affected by their technical limits due to the x-ray exposure for the personnel involved and the variability of the stress forces applied. A device was developed with the aim to create a constant varus or valgus stress force to the knee with the patient in a supine position. The device does not require personal assistance during the actual film taking. Sixty consecutive patients where included in the study and measured prior to their total knee replacement. All patients had standard weight-bearing AP and lateral views as well as stress views in varus and valgus. Both knees were examined in full extension and 30 degrees of flexion. The joint space width in both the lateral and medial compartments were measured and subsequently compared with the standard weight-bearing films. A significant decrease in joint space distance in the affected compartment was found in the stress radiographs compared with the standard weight-bearing views. The medial compartment was best examined with the knee extended and varus stress force (P < 0.001) and for the lateral compartment 30 degrees of flexion proved to be more efficient (P < 0.01). In conclusion, this stress radiographic device offers a possibility to enhance the varus/valgus force in a standardized way compared to standard weight-bearing views of the knee. The reliability and reproducibility is high. It is suitable for clinical practice and a valuable tool in research
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Update on management of ovarian hyperstimulation syndrome
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DoD - ACS - Interrater Reliability
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Ovarian hyperstimulation syndrome (OHSS) is a relatively common complication of ovarian stimulation and can be life threatening. The pathophysiology of OHSS is characterized by increased capillary permeability, leading to leakage of fluid from the vascular compartment, with third-space fluid accumulation and intravascular dehydration. The increased intra-abdominal pressure indicated that OHSS may be considered a compartment syndrome. Vascular endothelial growth factor, also known as vascular permeability factor, has emerged as one of the mediators intrinsic to the development of OHSS. Conventional management is focused on supportive care until the spontaneous resolution of the condition. The standard of care for treatment-monitoring of appropriate clinical parameters, fluid balance management, thrombosis prophylaxis, and ascites treatment-should prevent severe morbidity in most cases. This review will cover inpatient and outpatient management. The potential therapeutic approach targeting the vascular endothelial growth factor system will be discussed.
Copyright © 2011. Published by Elsevier B.V.
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A simplified technique for polymethyl methacrylate cranioplasty: combined cotton stacking and finger fracture method
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DoD SSI (Surgical Site Infections)
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PRIMARY OBJECTIVE: Polymethyl methacrylate (PMMA) is one of the most frequently used cranioplasty materials. However, limitations exist with PMMA cranioplasty including longer operative time, greater blood loss and a higher infection rate. To reduce these disadvantages, it is proposed to introduce a new surgical method for PMMA cranioplasty.
RESEARCH DESIGN: Retrospective review of nine patients who received nine PMMA implants using combined cotton stacking and finger fracture method from January 2008 to July 2011.
METHODS AND PROCEDURES: The definitive height of skull defect was quantified by computer-based image analysis of computed tomography (CT) scans. Aesthetic outcomes as measured by post-reduction radiographs and cranial index of symmetry (CIS), cranial nerve V and VII function and complications (wound infection, hardware extrusions, meningitis, osteomyelitis and brain abscess) were evaluated.
MAIN OUTCOMES AND RESULTS: The mean operation time for implant moulding was 24.56 +/- 4.6 minutes and 178.0 +/- 53 minutes for skin-to-skin. Average blood loss was 169 mL. All post-operative radiographs revealed excellent reduction. The mean CIS score was 95.86 +/- 1.36%, indicating excellent symmetry.
CONCLUSIONS: These results indicate the safety, practicability, excellent cosmesis, craniofacial symmetry and stability of this new surgical technique.
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1 |
Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Results of a multicenter, prospective, randomized clinical trial
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Standard open reduction and internal fixation techniques have been successful in restoring osseous alignment for bicondylar tibial plateau fractures; however, surgical morbidity, especially soft-tissue infection and wound necrosis, has been reported frequently. For this reason, several investigators have proposed minimally invasive methods of fracture reduction followed by circular external fixation as an alternative approach. To our knowledge, there has been no direct comparison of the two operative approaches.
METHODS: We performed a multicenter, prospective, randomized clinical trial in which standard open reduction and internal fixation with medial and lateral plates was compared with percutaneous and/or limited open fixation and application of a circular fixator for displaced bicondylar tibial plateau fractures (Schatzker types V and VI and Orthopaedic Trauma Association types C1, C2, and C3). Eighty-three fractures in eighty-two patients were randomized to operative treatment (forty-three fractures were randomized to circular external fixation and forty to open reduction and internal fixation). Follow-up consisted of obtaining a history, physical examination, and radiographs; completion of the Hospital for Special Surgery (HSS) knee score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) General Health Survey; and recording of complication and reoperation rates.
RESULTS: There were no significant differences between the groups in terms of demographic variables, mechanism of injury, or fracture severity and/or displacement. However, patients in the circular fixator group had less intraoperative blood loss than those in the open reduction and internal fixation group (213 mL and 544 mL, respectively; p=0.006) and spent less time in the hospital (9.9 days and 23.4 days, respectively; p=0.024). The quality of osseous reduction was similar in the groups. There was a trend for patients in the circular fixator group to have superior early outcome in terms of HSS scores at six months (p=0.064) and the ability to return to preinjury activities at six months (p=0.031) and twelve months (p=0.024). These outcomes were not significantly different at two years. There was no difference in total arc of knee motion, and the WOMAC scores at two years after the injury were not significantly different between the groups with regard to the pain (p=0.923), stiffness (p=0.604), or function (p=0.827) categories. The SF-36 scores at two years after the injury were significantly decreased compared with the controls for both groups (p=0.001 for the circular fixator group and p=0.014 for the open reduction and internal fixation group), although there was less impairment in the circular fixator group in the bodily pain category (a score of 46) compared with the open reduction and internal fixation group (a score of 35) (p=0.041). Seven (18%) of the forty patients in the open reduction and internal fixation group had a deep infection. The number of unplanned repeat surgical interventions, and their severity, was greater in the open reduction and internal fixation group (thirty-seven procedures) compared with the circular fixator group (sixteen procedures) (p=0.001).
CONCLUSIONS: Both techniques provide a satisfactory quality of fracture reduction. Because percutaneous reduction and application of a circular fixator results in a shorter hospital stay, a marginally faster return of function, and similar clinical outcomes and because the number and severity of complications is much higher with open reduction and internal fixation, we believe that circular external fixation is an attractive option for these difficult-to-treat fractures. Regardless of treatment method, patients with this injury have substantial residual limb-specific and general health deficits at two years of follow-up.
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Surgical procedures in femoral neck fractures in Finland: a nationwide study between 1998 and 2011
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Hip Fx in the Elderly 2019
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PURPOSE: For femoral neck fractures, recent scientific evidence supports cemented hemiarthroplasty (HA) over uncemented HA and suggests that total hip arthroplasty (THA) should be performed more frequently. We report the current surgical trends in treating femoral neck fractures in Finland.
METHODS: The study was conducted using the Finnish National Hospital Discharge Register and included all Finns at least 50 years of age who underwent surgery for femoral neck fractures from 1998 through 2011. Age- and sex-specific incidence rates and annual proportion of each treatment method were calculated.
RESULTS: During 1998-2011, a total of 49,514 operations for femoral neck fracture were performed in Finland. The proportion of uncemented HA increased from 8.1% in 2005 to 22.2% in 2011. During the same time, the proportion of cemented HA decreased from 63.9 to 52.5%, internal fixation decreased from 23.2 to 16.1% and THA increased from 4.9 to 9.2%.
CONCLUSIONS: Between 2005 and 2011, the proportion of uncemented HA for femoral neck fractures increased markedly in Finland, while cemented HA and internal fixation declined. During this time, the use of THA nearly doubled. The current evidence-based guidelines for treatment of femoral neck fractures were mainly followed, but the increase in uncemented HA procedures contradicts recent scientific evidence.
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Development of a flow cytometric method to determine DNA ploidy of oesophageal cancer cells obtained by forceps biopsy samples during oesophago-gastro-duodenoscopy
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Reconstruction After Skin Cancer
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METHODSFreshly frozen forceps biopsy samples from 30 patients with oesophageal cancer were disaggregated. DNA was stained with propidium iodide and ploidy was determined by flow cytometry. To enhance sensitivity epithelial cells were simultaneously labelled with anti-cytokeratin antibodies. Results were compared with image analysis. To evaluate the sampling error, parallel measurements were done in 10 patients by image analysis on forceps biopsies obtained during endoscopy before surgery and on the resected tumour.RESULTSThe sensitivity to detect aneuploidy was lower for standard flow cytometry than for image analysis (13 versus 33%). The overall sensitivities were identical using a double labelling technique with additional cytokeratin-staining of the epithelial cells, but divergent results were obtained in 2 cases, where detection of aneuploidy was either possible with image analysis or with double labelling flow cytometry only. DNA content of samples gained by forceps biopsies and surgically resected tumours was concordant in 8 of 10 cases. In 2 patients, aneuploidy was detected only in the surgically resected tumour but not in the pre-operatively obtained forceps biopsies.CONCLUSIONSA flow cytometric method for routine determination of the DNA ploidy of cells obtained by forceps biopsies from patients with oesophageal cancer was developed and evaluated against image analysis. The technique allows the prediction of DNA content before tumour resection, and might be used for optimising therapy and the patient's quality of live.BACKGROUNDThe DNA content of oesophageal tumour cells is a prognostic factor in untreated patients. To investigate whether DNA ploidy is useful to select patients for neoadjuvant therapy it is of interest to develop a method allowing reliable flow cytometric analysis of the DNA content of tumour cells obtained by forceps biopsy during endoscopy before start of therapy.
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0 |
Clinical predictors of prolonged hospitalization in patients with hip fracture
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PJI DX Updated Search
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⢠Objective: To determine if common clinical variables can predict increased length of stay (LOS) in patients over 50 years of age with fall-related hip fracture. ⢠Methods: We retrospectively analyzed the records of 183 consecutive patients 50 years or older admitted with hip fracture to a 750-bed teaching hospital. Data collected included demographic information, type of fracture, major comorbidities, type of surgical procedure, various admission laboratory values, postoperative complications, and LOS. ⢠Results: The patients' mean age ñ SD was 80.2 ñ 10.2 years, 79% were female, and 85% were community dwellers. 90% of fractures involved the trochanteric region, and 92% underwent open reduction internal fixation. One patient died while 87% were discharged to an extended care facility or rehabilitation unit. On multivariable linear regression analysis, there were 6 independent predictors of increased LOS: postoperative respiratory failure (P < 0.001), postoperative infection (P < 0.001), postoperative cardiac complication (P = 0.001), postoperative delirium (P = 0.03), type of surgical procedure (P = 0.001), and admission platelet count (P = 0.004). ⢠Conclusion: Elderly patients with fall-related hip fractures with a low admission platelet count, who undergo total hip arthroplasty, or who develop postoperative respiratory failure, infection, cardiac dysfunction, or delirium have a longer hospital LOS. However, hospital morbidity is very low in this population, reinforcing the safety of surgical intervention in elderly patients with hip fracture
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The use of isolated patellar prostheses in Sweden 1977-1986
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Surgical Management of Osteoarthritis of the Knee CPG
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During 1977 to 1986, 106 patients had isolated patellar prostheses, with both patellar and femoral components, inserted in 20 different hospitals in Sweden. At follow up, 7 years (range 3 to 14 years) after operation, 9 patients had died so that 97 patients with operations on 113 knees were included in this study. Thirty-three (38 knees) had been operated on before or after a prosthesis had been inserted. At follow-up, 75% were satisfied with the operation; 83% had improved, 59% could walk without an aid and 44% had no, or only occasional, pain in the knee. These results encourage the use of an isolated patellar prosthesis in cases of advanced and disabling localised patellar arthrosis. There is no place for this operation in the treatment of chondromalacia
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A comparison of the use and non-use of closed suction wound drainage in open reduction and internal fixation of femoral shaft fractures
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DoD SSI (Surgical Site Infections)
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PURPOSE: The aim of this study was to determine if the routine use of closed suction wound drainage is justified following open reduction and internal fixation (ORIF) of femoral shaft fractures.
METHOD: This was a prospective comparative study of two study groups: those with post-operative closed suction drainage (WCSD) and those not with closed suction drainage (NWCSD).
RESULTS: Fifty-six patients, twenty-eight each for the two cohorts, were recruited for this study. Five patients (17.9%) in the WCSD group and only one patient (3.6%) in NWCSD group had surgical site infection (p = 0.20). Four patients (14.3%) in the WCSD group and nine (32.1%) in NWCSD group had wound dressing reinforcements (p = 0.21).
CONCLUSION: There was generally no statistically significant difference in the incidence of wound infections, strike through bloodstain with wound dressing reinforcement and duration of hospital stay in patients with and without closed suction wound drainage after ORIF of femoral shaft fractures. The duration of the injury may however influence the decision to use or not use wound drain after surgery.
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Can distal radius or vertebra fractures due to low-energy trauma be a harbinger of a hip fracture?
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Distal Radius Fractures
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OBJECTIVES: This study aims to investigate whether or not low-energy distal radius or vertebra fractures are harbingers of hip fracture.
PATIENTS AND METHODS: A total of 142 patients had surgical treatment due to hip fracture in our clinic between February 2013 and January 2017. The patients had low-energy fractures before hip fracture, and they received either medical treatment for osteoporosis or not before hip fracture developed.
RESULTS: Of 142 patients, 32 had distal radius, humeral neck, ankle, vertebra fractures and 15 had a second hip fracture. The patients were determined to have most frequently a distal radius and vertebra fracture before hip fracture. The treatment of osteoporosis was determined to be neglected in 58% of 47 patients in total who had a fracture previously.
CONCLUSION: Distal radius and vertebra fractures are the harbingers of a potential hip fracture. Physicians, especially orthopedists, who face with these fractures should be careful in terms of osteoporosis.
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The direct anterior approach in hemiarthroplasty for displaced femoral neck fractures
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Management of Hip Fractures in the Elderly
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PURPOSE: Hip replacement is the most common treatment for displaced femoral neck fractures in the elderly, and minimally invasive surgery is popular in the field of orthopaedic surgery. This study evaluated the outcome of monopolar hemiarthroplasty by the direct anterior approach over a postoperative period up to 2.5 years. METHODS: A total of 86 patients with displaced femoral neck fractures were included (mean age of 86.5 years). Surviving patients were reviewed three months (retrospectively) and one to 2.5 years (prospectively) after surgery. One-year mortality was 36 %. RESULTS: For all stems, implant positioning with respect to stem alignment, restoration of leg length and femoral offset was correct. Acetabular protrusion was observed in 55 % of the patients one to 2.5 years postoperatively. Subsidence and intraoperative periprosthetic fractures occurred in three patients (3 %) each. All revision stems for postoperative periprosthetic fractures could be implanted using the initial surgical technique without extension of the previous approach. The mean Harris hip score was 85 points at the one to 2.5-year follow-up; 85 % of the patients were satisfied with their hip and 57 % returned to their preoperative level of mobility. CONCLUSION: Based on these findings, hemiarthroplasty for hip fractures can be performed safely and effectively via the direct anterior approach with good functional outcome and high patient satisfaction
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Link Between Positive Clinician-Conveyed Expectations of Treatment Effect and Pain Reduction in Knee Osteoarthritis, Mediated by Patient Self-Efficacy
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: A prior knee osteoarthritis (OA) trial found that provider-conveyed expectations for treatment success were associated with pain improvement. We hypothesized this relationship was mediated by patient self-efficacy, since expectations of improvement may enhance one's ability to control health behaviors, and therefore health. Our aim was to examine whether self-efficacy was a mediator of the relationship observed in this trial.
METHODS: A secondary analysis of a 3-arm (traditional acupuncture, sham acupuncture, and wait list) trial for knee OA was conducted. Those in the acupuncture groups were equally randomized to acupuncturists trained to communicate a high or neutral expectation of treatment success (e.g., using language conveying high or unclear likelihood that acupuncture would reduce knee pain). A modified Arthritis Self-Efficacy Questionnaire and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale were administered. Linear regression analyses were used to examine whether patient self-efficacy mediated the relationship between provider communication style and knee pain at 3 months.
RESULTS: High-expectation provider communication was associated with patient self-efficacy, beta coefficient of 0.14 (95% confidence interval [95% CI] 0.01, 0.28). Self-efficacy was associated with WOMAC pain, beta coefficient of -9.29 (95% CI -11.11, -7.47), while controlling for the provider communication style. The indirect effect a x b of -1.36 for high versus neutral expectation (bootstrap 95% CI -2.80, -0.15; does not include 0), supports the conclusion that patient self-efficacy mediates the relationship between provider-communicated expectations of treatment effects and knee pain.
CONCLUSION: Our findings suggest that clinician-conveyed expectations can enhance the benefit of treatments targeting knee OA symptoms, mediated by improved patient self-efficacy.
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Fast 3D Isotropic Proton Density-Weighted Fat-Saturated MRI of the Knee at 1.5 T with Compressed Sensing: Comparison with Conventional Multiplanar 2D Sequences
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AMP (Acute Meniscal Pathology)
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PURPOSE: Compressed sensing (CS) is a method to accelerate MRI acquisition by acquiring less data through undersampling of k-space. In this prospective study we aimed to evaluate whether a three-dimensional (3D) isotropic proton density-weighted fat saturated sequence (PDwFS) with CS can replace conventional multidirectional two-dimensional (2D) sequences at 1.5 Tesla.
MATERIALS AND METHODS: 20 patients (45.2 +/- 20.2 years; 10 women) with suspected internal knee damage received a 3D PDwFS with CS acceleration factor 8 (acquisition time: 4:11 min) in addition to standard three-plane 2D PDwFS sequences (acquisition time: 4:05 min + 3:03 min + 4:46 min = 11:54 min) at 1.5 Tesla. Scores for homogeneity of fat saturation, image sharpness, and artifacts were rated by two board-certified radiologists on the basis of 5-point Likert scales. Based on these ratings, an overall image quality score was generated. Additionally, quantitative contrast ratios for the menisci (MEN), the anterior (ACL) and the posterior cruciate ligament (PCL) in comparison with the popliteus muscle were calculated.
RESULTS: The overall image quality was rated superior in 3D PDwFS compared to 2D PDwFS sequences (14.45 +/- 0.83 vs. 12.85 +/- 0.99; p < 0.01), particularly due to fewer artifacts (4.65 +/- 0.67 vs. 3.65 +/- 0.49; p < 0.01) and a more homogeneous fat saturation (4.95 +/- 0.22 vs. 4.55 +/- 0.51; p < 0.01). Scores for image sharpness were comparable (4.80 +/- 0.41 vs. 4.65 +/- 0.49; p = 0.30). Quantitative contrast ratios for all measured structures were superior in 3D PDwFS (MEN: p < 0.05; ACL: p = 0.06; PCL: p = 0.33). In one case a meniscal tear was only diagnosed using multiplanar reformation of 3D PDwFS, but it would have been missed on standard multiplanar 2D sequences.
CONCLUSION: An isotropic fat-saturated 3D PD sequence with CS enables fast and high-quality 3D imaging of the knee joint at 1.5 T and may replace conventional multiplanar 2D sequences. Besides faster image acquisition, the 3D sequence provides advantages in small structure imaging by multiplanar reformation.
KEY POINTS: . 3D PDwFS with compressed sensing enables knee imaging that is three times faster compared to multiplanar 2D sequences. . 3D PDwFS with compressed sensing provides high-quality knee imaging at 1.5 T. . Isotropic 3D sequences provide advantages in small structure imaging by using multiplanar reformations.
CITATION FORMAT: . Endler CH, Faron A, Isaak A et al. Fast 3D Isotropic Proton Density-Weighted Fat-Saturated MRI of the Knee at 1.5 T with Compressed Sensing: Comparison with Conventional Multiplanar 2D Sequences. Fortschr Rontgenstr 2021; 193: 813 - 821.
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Fixation using alternative implants for the treatment of hip fractures (FAITH-2): Design and rationale for a pilot multi-centre 2 × 2 factorial randomized controlled trial in young femoral neck fracture patients
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DoD SSI (Surgical Site Infections)
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Background: Femoral neck fractures in patients . 60 years of age are often very different injuries compared to low-energy, hip fractures in elderly patients and are difficult to manage because of inherent problems associated with high-energy trauma mechanisms and increased functional demands for recovery. Internal fixation, with multiple cancellous screws or a sliding hip screw (SHS), is the most common treatment for this injury in young patients. However, there is no clinical consensus regarding which surgical technique is optimal. Additionally, there is compelling rationale to use vitamin D supplementation to nutritionally optimize bone healing in young patients. This pilot trial will determine feasibility and provide preliminary clinical data for a larger definitive trial. Methods: We will conduct a multicenter, concealed randomized controlled pilot study, using a 2 ~ 2 factorial design in 60 patients aged 18.60 years with a femoral neck fracture. Eligible patients will be randomized in equal proportions to one of four groups: 1) SHS and vitamin D supplementation (4000 international units (IU) daily dose) for 6 months, 2) cancellous screws and vitamin D supplementation (4000 IU daily dose) for 6 months, 3) SHS and placebo, and 4) cancellous screws and placebo. Participants will be followed for 12 months post-fracture. Feasibility outcomes include initiation of clinical sites, recruitment, follow-up, data quality, and protocol adherence. Clinical outcomes, for both the pilot and planned definitive trials, include a composite of patient-important outcomes (re-operation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion), health-related quality of life and patient-reported function, fracture healing complications, and radiographic fracture healing. A priori success criteria have been established. If the pilot study is deemed successful, study participants will be included in the definitive trial and clinical outcomes for the pilot will not be analyzed. If the pilot study is not deemed successful, clinical outcome data will be analyzed. Discussion: Results of this study will inform the feasibility of a definitive trial. If clinical outcome data are analyzed, they will be disseminated through a publication and presentations. Trial registration: The FAITH-2 trial, described as a definitive trial, was registered at ClinicalTrials.gov (NCT01908751) prior to enrollment of the first participant.
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Changes in femur neck bone density in US adults between 1988-1994 and 2005-2008: demographic patterns and possible determinants
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Management of Hip Fractures in the Elderly
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SUMMARY: This analysis compares femur neck bone mineral density (FNBMD) and bone determinants in adults between National Health and Nutrition Examination Survey (NHANES) III (1988-1994) and NHANES 2005-2008. FNBMD was higher in NHANES 2005-2008 than in NHANES III, but between-survey differences varied by age, sex, and race/ethnicity. The likelihood that FNBMD has improved appears strongest for older white women. INTRODUCTION: Recent data on hip fracture incidence and femur neck osteoporosis suggest that the skeletal status of older US adults has improved since the 1990s, but the explanation for these changes remains uncertain. METHODS: The present study compares mean FNBMD of adults ages 20 years and older between the third (NHANES III, 1988-1994) and NHANES 2005-2008. Dual-energy X-ray absorptiometry systems (pencil beam in NHANES III, fan beam in NHANES 2005-2008) were used to measure hip BMD, and several bone determinants are compared between surveys to assess their potential role in explaining observed FNBMD differences. RESULTS: FNBMD was higher overall in NHANES 2005-2008 than in NHANES III, but between-survey differences varied by age, sex, and race/ethnicity. Although FNBMD differences in several groups were small enough (</=3%) to be attributable to use of different dual-energy X-ray absorptiometry (DXA) systems in the two surveys, variability in size and direction of the differences does not support artifactual differences in DXA methodology as the sole explanation. Several FNBMD determinants (body size, smoking, selected bone-active medications, self-reported health status, calcium intake, and caffeine consumption) changed in a bone-improving direction in older adults, but FNBMD in older non-Hispanic white women remained significantly higher in 2005-2008 even after adjusting for DXA methodology or for the selected bone determinants. CONCLUSION: The likelihood that FNBMD has improved appears strongest for older white women, but the reason for the improvement in this group remains unclear
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Trajectory of self-reported pain and function and knee extensor muscle strength in young patients undergoing arthroscopic surgery for meniscal tears: A systematic review and meta-analysis
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AMP (Acute Meniscal Pathology)
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OBJECTIVES: To investigate the trajectory of patient reported pain and function and knee extensor muscle strength over time in young individuals undergoing arthroscopic meniscal surgery.
DESIGN: Systematic review and meta-analysis METHODS: Six databases were searched up to October 13th, 2016.
PATIENTS AND INTERVENTION: People aged 30 years or younger undergoing surgery for a meniscal tear.
OUTCOMES: and comparator: (1) Self-reported pain and function in patients undergoing meniscal surgery compared to a non-operative control group (2). Knee extensor strength in the leg undergoing surgery compared to a healthy control group or the contra-lateral leg. Methodological quality was assessed using the SIGN 50 guidelines.
RESULTS: No studies were found on patient reported pain and function. Six studies, including 137 patients were included in the analysis on knee extensor muscle strength. Knee extensor muscle strength was impaired in the injured leg prior to surgery and was still reduced compared with control data up to 12 months after surgery (SMD: -1.16) (95% CI: -1.83; -0.49). All included studies were assessed to have a high risk of bias.
CONCLUSIONS: No studies were found comparing the trajectory of self-reported pain and function in patients undergoing arthroscopic surgery compared with non-operative treatments for young patients with meniscal tears. Knee extensor strength seemed to be impaired up to 12 months after surgery in young patients undergoing surgery for meniscal tears. The results of the present study should be interpreted with caution due to a limited number of available studies with high risk of bias including relatively few patients.
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A comprehensive microbiological evaluation of fifty-four patients undergoing revision surgery due to prosthetic joint loosening
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PJI DX Updated Search
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The diagnosis of a chronic prosthetic joint infection (PJI) is challenging, and no consensus exists regarding how best to define the criteria required for microbiological identification. A general view is that culture of periprosthetic biopsies suffers from inadequate sensitivity. Recently, molecular analyses have been employed in some studies but the specificity of molecular analyses has been questioned, mainly due to contamination issues. In a prospective study of 54 patients undergoing revision surgery due to prosthetic joint loosening, we focused on two aspects of microbiological diagnosis of chronic PJI. First, by collecting diagnostic specimens in a highly standardized manner, we aimed at investigating the adequacy of various specimens by performing quantitative bacteriological culture. Second, we designed and performed real-time 16S rRNA gene PCR analysis with particular emphasis on minimizing the risk of false-positive PCR results. The specimens analysed included synovial fluid, periprosthetic biopsies from the joint capsule and the interface membrane, and specimens from the surface of the explanted prosthesis rendered accessible by scraping and sonication. No antibiotics were given prior to specimen collection. Based on five diagnostic criteria recently suggested, we identified 18 PJIs, all of which fulfilled the criterion of >/=2 positive cultures of periprosthetic specimens. The rate of culture-positive biopsies from the interface membrane was higher compared to specimens from the joint capsule and synovial fluid, and the interface membrane contained a higher bacterial load. Interpretational criteria were applied to differentiate a true-positive PCR from potential bacterial DNA contamination derived from the reagents used for DNA extraction and amplification. The strategy to minimize the risk of false-positive PCR results was successful as only two PCR results were false-positive out of 216 negative periprosthetic specimens. Although the PCR assays themselves were very sensitive, three patients with low bacterial numbers in periprosthetic specimens tested negative by real-time PCR. This overall lowered sensitivity is most likely due to the reduced specimen volume used for PCR analysis compared to culture and may also be due to interference from human DNA present in tissue specimens. According to the protocol in the present study, 16S rRNA gene real-time PCR did not identify more cases of septic prosthetic loosening than did culture of adequate periprosthetic biopsies
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Restless Legs Syndrome in a Nigerian Elderly Population
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DoD PRF (Psychosocial RF)
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STUDY OBJECTIVES: The prevalence of restless legs syndrome (RLS) is highest in the elderly in Caucasian populations; the prevalence of RLS in elderly Africans is not known. This study aimed at determining the frequency and associations of RLS in a Nigerian elderly population.
METHODS: The study population comprised of 633 consecutive elderly individuals aged 65-105 years attending the general outpatient clinic of the State Hospital, Ilesa, for minor complaints and routine check-up. The diagnosis of RLS was made using the 2003 minimal criteria of the International Restless Legs Syndrome Study Group. Relevant sociodemographic and clinical data, including sleep duration, were also obtained.
RESULTS: Restless legs syndrome was found in 3.5% of the study population with a male-female ratio of 2:1. There was no significant age (p = 0.427) or gender (p = 0.178) influence on the prevalence of RLS except in the 75- to 84-year age group where there was significant male preponderance (p = 0.044). A strong independent association between RLS and sleep duration (OR, 3.229; 95% CI, 1.283-8.486; p = 0.013) and past history of head injury (OR, 4.691; 95% CI, 1.750-12.577; p = 0.002) was found.
CONCLUSIONS: Our finding support previous reports of a possible lower prevalence of RLS in Africans. Restless legs syndrome independently increases the odds of habitual sleep curtailment in elderly individuals. Head injury may be a risk factor for future RLS; this requires further investigation as indirect evidence for a possible link between RLS and traumatic brain injury exists.
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High Bilateral Amputations and Dismounted Complex Blast Injury (DCBI)
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DoD SSI (Surgical Site Infections)
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High, combat-related bilateral lower extremity amputations rarely occur in isolation. Dismounted complex blast injury is a devastating and life-threatening constellation of multisystem injuries most commonly due to dismounted contact with improvised explosive devices. Rapid damage control resuscitation and surgery are essential to improve patient survival and minimize both early complications and late sequelae. A coordinated team approach is essential to provide simultaneous airway management, volume resuscitation (ideally with whole blood or ratio transfusion), and immediate control of life-threatening hemorrhage. Temporary aortic or iliac vessel clamping during concurrent exploratory or vascular control laparotomy is frequently required. Stabilization of unstable pelvic fractures is then performed, followed by debridement and irrigation of all wounds, which should be left open, and subsequent provisional stabilization of long bone fractures. The goal of the initial surgical resuscitative endeavor is rapid concurrent control of all sources of hemorrhage to avoid the lethal triad of acidosis, hypothermia and coagulopathy. To this end, multiple surgeons or surgical teams should be utilized whenever feasible. Patients then require ongoing resuscitation followed by early and frequent return to the operating suite throughout the evacuation chain. Utilizing this approach, a high survival rate with reasonable functional outcomes is achievable despite the extreme severity of the DCBI pattern.
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Surgical techniques to improve cannulation of hemodialysis vascular access
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Panniculectomy & Abdominoplasty CPG
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OBJECTIVE: Successful access cannulation is of utmost importance for adequate hemodialysis treatment. Upper arm fistulae, obesity and deep or tortuous veins may impair needling and can cause significant complications and inconvenience for the patient. In the ultimate case, cannulation problems lead to temporary central vein catheter use for dialysis or even to irreversible access loss. Surgical access revision may enhance successful cannulation. METHODS: A systematic literature review of all publications related to hemodialysis vascular access, cannulation complications and treatment was performed. RESULTS: A total of 384 publications were identified, of which only 17 were related to treatment of cannulation complications in large patient populations. The clinical success rate of surgical intervention with vein elevation or transposition ranges from 85% to 91%. The 1-year primary and secondary patencies are 60% and 71%, respectively. Lipectomy results in an initial success rate of 100% with a primary and secondary patency of 71% and 98%, respectively, after 1 year of follow-up. CONCLUSION: Surgical revision to improve hemodialysis vascular access cannulation has a high clinical success rate with good long-term patency.
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Human adipose-derived mesenchymal stem cells for osteoarthritis: a pilot study with long-term follow-up and repeated injections
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OAK 3 - Non-arthroplasty tx of OAK
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AIM: This study aimed to evaluate the safety and therapeutic potential of autologous human adipose-derived mesenchymal stem cells (haMSCs) in patients with osteoarthritis.
MATERIALS & METHODS: Safety and efficacy of haMSCs were preclinically assessed in vitro and in BALB/c-nu nude mice. 18 patients were enrolled and divided into three dose groups: the low-dose, mid-dose and high-dose group (1 x 10<sup>7</sup>, 2 x 10<sup>7</sup> and 5 x 10<sup>7</sup> cells, respectively), provided three injections and followed up for 96 weeks.
RESULTS & CONCLUSION: The preclinical study established the safety and efficacy of haMSCs. Intra-articular injections of haMSCs were safe and improved pain, function and cartilage volume of the knee joint, rendering them a promising novel treatment for knee osteoarthritis. The dosage of 5 x 10<sup>7</sup> haMSCs exhibited the highest improvement (ClinicalTrials.gov Identifier: NCT01809769).
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Intramedullary nailing technique and its effect on union rates of tibial shaft fractures
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DOD - Acute Comp Syndrome CPG
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Seventy tibial shaft fractures treated by intramedullary nailing using two different techniques were compared. The first group (35 cases) was treated with a Herzog intramedullary nail following hand reaming and minimal traction. The second group (35 cases) had a Grosse and Kempf or AO nail inserted following power reaming and skeletal traction. Fracture patterns were similar in both groups. In the hand-reamed group, the mean time to union was 15.2 weeks with two delayed unions and no non-unions. In the power-reamed group, the mean time to union was 19.9 weeks with 10 delayed unions and two non-unions. These differences were statistically significant. Complications in the hand-reamed group included a Sudecks atrophy and one mal-union. In the power-reamed group, there were three transient foot drops, two compartment syndromes and one pulmonary embolus. This difference was not statistically significant. Our findings suggest that surgical technique has an important effect on the healing rates of nailed tibial shaft fractures. When intramedullary nailing is performed, minimal reaming is required and skeletal traction should be avoided if possible.
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Perioperative vitamin D levels correlate with clinical outcomes after ankle fracture fixation
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DoD SSI (Surgical Site Infections)
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INTRODUCTION: Hypovitaminosis D is common in patients undergoing orthopaedic trauma surgery. While previous studies have shown that vitamin D levels correlate with functional outcome after hip fracture surgery, the significance of vitamin D levels on outcomes after surgery in other orthopaedic trauma patients is unknown. The purpose of this study was to determine if vitamin D levels correlated with outcomes in ankle fracture patients.
MATERIALS AND METHODS: We reviewed a prospective registry of patients who underwent operative treatment for ankle fractures from 2003 to 2012. Preoperative serum 25-hydroxyvitamin D (25[OH]D) levels were measured, and the primary and secondary outcomes included foot and ankle outcome scores (FAOS) and ankle range of motion. Data were also collected on patient comorbidities, articular malreductions, and wound complications. Included patients had at least 12 months of clinical outcome data.
RESULTS: Ninety-eight patients operatively treated for ankle fractures met our inclusion criteria. Of these 98 patients, 36 (37%) were deficient in vitamin D (<20 ng/ml) and 31 (32%) had vitamin D insufficiency (<30 ng/ml, >=20 mg/ml). Patients with vitamin D deficiency were similar with regard to age, gender, and comorbidities compared to patients with vitamin D levels >=20. Univariate analysis revealed that patients with vitamin D deficiency had significantly worse FAOS with regard to symptoms (P = 0.017) and quality of life (P = 0.040) domains than patients with vitamin D levels >=20. Multivariate regression analysis suggested that vitamin D deficiency was a factor in inferior FAOS with regard to symptoms, activities of daily living, and quality of life.
CONCLUSIONS: In our group of patients with operative treated ankle fractures, preoperative vitamin D deficiency correlated with inferior clinical outcomes at a minimum of 1 year follow-up. Our study suggests that deficient vitamin D levels may result in worse outcomes in orthopaedic trauma patients recovering from fracture fixation.
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Development of a standardized process improvement protocol to address elevated health care-associated infection rates on an incented quality scorecard
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PJI DX Updated Search
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This practice forum report details a standardized improvement process that was created both to improve patient outcomes related to various hospital-acquired infections and to address leadership concerns related to incented qua BJC Learning Institutear retrospective review identified common issues to guide future interventions and confirmed that this methodology reduced the rate of recurrent infections across the health care system. Process tool samples are provided
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Mineralocorticoid receptor antagonists
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Reduction Mammoplasty for Female Breast Hypertrophy
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With an increasingly aging population, the need for effective treatment of cardiovascular diseases (eg, heart failure, hypertension, and ischemic heart disease) cannot be overemphasized. The vital importance of mineralocorticoid receptor antagonists for treating cardiovascular conditions has only been appreciated in the last decade. The re-emergence of mineralocorticoid receptor antagonists has provided clinicians with an important tool towards complete blockade of the renin-angiotensin-aldosterone axis. Copyright © 2007 by Current Medicine Group LLC.
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Group B streptococcal prosthetic joint infections: a retrospective study of 30 cases
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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OBJECTIVE: To describe the epidemiological, clinical, and laboratory characteristics of patients with group B streptococcal (GBS) prosthetic joint infections, their diagnoses, treatment, and long-term outcomes. METHODS: We conducted a retrospective cohort study including all patients hospitalized from January 1994 through May 2006 for a GBS prosthetic joint infection. RESULTS: The study included 30 patients, aged 35-87 (median 74) years with prosthetic hip (24) or knee (6) infections, 20 with at least one underlying disease. The route of infection was presumed to be hematogenous in 27 patients, and a portal of entry was identified in 9 (genitourinary tract 4, skin 2, gastrointestinal tract 2, oropharynx 1). All patients underwent surgery (6 debridement-synovectomy, 9 1-stage exchange arthroplasty, 8 2-stage exchange arthroplasty, 6 hip resection arthroplasty, and 1 knee arthrodesis) and received prolonged intravenous antibiotics. Four patients relapsed. One patient developed 2 other infections on her knee prosthesis. Two deaths were infection-related, and one was treatment-related. Nineteen patients followed for >/=2 years were cured. One patient was lost to follow-up and 3 died of causes unrelated to infection or treatment within 2 years. CONCLUSION: GBS prosthetic joint infections are mostly acute hematogenous infections that require prompt management for satisfactory outcome. Despite high antibiotic susceptibility, treatment failure is frequent because of the severity of the infection and patients' advanced age, underlying diseases, and relapses
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Endocrine-Metabolic Response in Patients Undergoing Multiple Body Contouring Surgeries After Massive Weight Loss
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: The endocrine-metabolic response to trauma is directly related to its magnitude, but little is known about the adverse effects of combined surgical procedures on morbidity. OBJECTIVES: The authors sought to evaluate risk factors by measuring the endocrine-metabolic response in patients who underwent multiple body-contouring surgeries after massive weight loss. METHODS: This prospective, randomized, interventional study included 46 massive weight loss patients who experienced a weight loss >30% of their body mass index (BMI) and were referred for body contouring surgery. Patients were randomly allocated to the control group (n = 10) or intervention group (n = 36), which in turn was divided into 3 subgroups (n = 12, each) according to BMI, surgical time, and scar length values. Blood samples were collected from all patients at different time points to assess biological stress markers. RESULTS: Levels of IL-6 in patients in the higher ranges of BMI and operating time and with more extensive scar length were significantly higher in the immediate postoperative period compared with baseline. Concentrations of noradrenaline were significantly higher 24 hours after surgery compared with baseline only in patients in the higher range of operating time. A higher level of IL-6 at 72 hours after surgery compared with baseline was associated with more extensive scar length. Levels of other biological stress markers did not significantly differ. CONCLUSIONS: The combination of surgical procedures did not significantly affect the concentrations of most biological stress markers. The variable of operating time most influenced increase in plasma concentrations of stress markers. LEVEL OF EVIDENCE: 1:
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Meniscal pathology and osteoarthritis of the knee
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AMP (Acute Meniscal Pathology)
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The relationship between meniscal tearing and degenerative joint disease was studied by macroscopic examination of 115 knees at necropsy. The incidence of meniscal pathology was 57 per cent. There was no overall difference in the severity and distribution of tibiofemoral degeneration, whether the meniscus was torn or normal. We found little evidence that degenerative meniscal tears cause osteoarthritis or vice versa.
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Who is lost to followup?: a study of patients with distal radius fractures
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Distal Radius Fractures
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Distal radius fractures are the most common upper extremity fracture, representing one-sixth of all fractures treated in emergency departments nationwide. Beyond the initial reduction and immobilization of these fractures, providing proper followup to ensure maintenance of the reduction and identify complications is necessary for optimal recovery of forearm and wrist functions. We sought to identify the clinical and demographic factors that characterize patients with distal radius fractures who do not return for followup and to assess the underlying causes for their poor followup rates. Compared with patients who were compliant with followup, those lost to followup had lower Physical and Mental Health scores on the SF-36 forms, more often were treated nonoperatively, and more likely had not surpassed secondary education. However, we found no difference between these two groups based on age, gender, mechanism of injury, marital status, or hand dominance. Early identification of patients who potentially are noncompliant can result in additional measures being taken to ensure the patient's return to the treating hospital and physicians. This in turn will prevent complications attributable to lack of followup and allow more accurate assessment of results, thereby improving patient outcomes.
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Arthroscopic management of intra-articular low-velocity gunshot wounds of the knee
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DoD SSI (Surgical Site Infections)
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This article reports on the arthroscopic management of intra-articular low-velocity gunshot wounds. Thirteen (12 men and 1 woman) patients comprised the study population treated over a 5-year period. All patients underwent arthroscopy within 24 hours of injury. Four patients had additional limited arthrotomies for internal fixation of associated fractures and removal of an embedded bullet. Allograft reconstruction as a delayed procedure was required in 1 patient with extensive bone deficiency of the medial femoral condyle. Two patients suffered cruciate ligament tears: one avulsion fracture of the femoral attachment of the posterior cruciate ligament and one avulsion tear of the tibial attachment of the anterior cruciate ligament. Meniscal damage was observed in 2 patients, one of which required a primary repair. No infections or operative complications occurred. Arthroscopic evaluation of the affected knees allowed debridement of osteochondral loose bodies, retained foreign materials and bullet fragments, and also aided in surgical decision making.
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Rehabilitation protocols in unstable trochanteric fractures treated with cephalomedullary nails in elderly: current practices and outcome
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Hip Fx in the Elderly 2019
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BACKGROUND: Optimal rehabilitation treatment after surgery for fixation of unstable trochanteric fractures is challenging in elderly patients.
PURPOSE: The objective of this study is to analyse the existing literature on available rehabilitation protocols with regards to permitting or restricting early weight bearing following fixation of unstable trochanteric fractures treated by the use of cephalomedullary nails in patients at least 65 years of age.
METHODS: A systematic review was performed based on the checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies published between 1948 and 2018 on elderly patients with unstable trochanteric fractures treated with cephalomedullary nails that offered information on the postoperative rehabilitation protocol have been selected. Subsequently, the results and complications have been analysed according to the protocols.
RESULTS: Fifteen of the 7056 initial articles have been selected for analysis. Authors who did not restrict weight bearing to their patients reported a shorter hospitalization time and a lower orthopaedic complication rate but a greater systemic complication rate, worse functional scores, and a higher reoperation and mortality rates. Those results should be taken with caution because of the heterogeneity of provided clinical information and the fact that none of the included studies considered the different rehabilitation protocols as study variables to analyse its influence on the results.
CONCLUSION: With evidence available to date, there is no clear agreement on the postoperative rehabilitation protocol following fixation of an unstable trochanteric fracture by cephalomedullary nail in the elderly.
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0 |
Retention treatment after periprosthetic total hip arthroplasty infection
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PJI DX Updated Search
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PURPOSE: The purpose of this study was to compare infection control rates between implant retention and two-stage revision and assess the effectiveness of retention treatment in THA. METHODS: Twenty-eight debridements with implant retention (retention group) and 65 staged revisions (removal group) were retrospectively analysed and risk factors that can contribute to failure of infection control were explored. RESULTS: For the retention and removal groups, infection control rates were 50% and 78% after initial treatment, and 68% and 82% at latest follow-up, respectively. There were no significant differences in the number of additional operative procedures, total length of hospital stay, and duration of treatment between groups. Infection of revision THA, polybacterial and S. aureus infection were identified as risk factors for infection control. CONCLUSIONS: Retention treatment can be considered an initial treatment option in selected cases of primary THA, with a single organism, non-S. aureus infection with 50% chance of infection control and no disadvantages in terms of additional procedure, hospital stay, and treatment duration
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0 |
Adamantinoma of long bones: a long-term follow-up study of 11 cases
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MSTS 2022 - Metastatic Disease of the Humerus
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The aim of this study was to evaluate the clinicopathological features and prognostic significances of 11 histologically proven adamantinoma cases based on an average 12,7 year long follow-up. The male: female ratio was 8:3, aged between 4 and 80 years (mean 29,3 years). The initial diagnosis at referral was other than adamantinoma in six patients (fibrous dysplasia, carcinoma metastasis, osteofibrous dysplasia, bone cyst, non-ossifying fibroma), referring to the differential diagnostic problems. All tumors were localized to the mid part of tibia. By histological evaluation, basaloid pattern on a background of fibrotic stroma dominated in six patients, while spindle and squamous features were less frequently seen. All adamantinoma were positive for cytokeratins often in coexpression with vimentin. No correlation was experienced between histology and clinical outcome. Intralesional curettage (2 pts) was followed by recurrence of the tumor. Wide resection was performed in eight patients with reconstruction using intercalary fibula autografts in seven patients. Reconstruction-related complications occurred in two third of the cases, all of them could however be controlled by repeated surgery. Six recurrences occurred in four patients, two of these recurrences occurred 20 and 16 years after initial surgery. One patient died 9 years after recognition of the tumor of pulmonary metastases. Adamantinoma of the long bones is a low grade malignant tumor, which clinical outcome is difficult to predict based on histology or surgical stage of the tumor. Wide surgical margin, e.g. resection the tumor reduces the rate of recurrence. This study underlines that recurrences do occur even decades after recognition the tumor, therefore a life-long follow-up of the patient is necessary.
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Reduction of spasticity in cerebral palsy by anodal transcranial direct current stimulation
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objective: To evaluate the anti-spasticity effects of anodal transcranial direct current stimulation (tDCS) in individuals with spastic cerebral palsy (CP). Material and Method: Forty-six children and adolescents with cerebral palsy were randomly assigned to either active (1 mA anodal) or sham (placebo) tDCS over the left primary motor cortex (M1) on five consecutive days. Both group also received routine physical therapy. Measures of spasticity and passive range of motion (PROM) were administered before treatment, immediately after treatment, and at 24-and 48-hours follow-up. Results: Participants assigned to active tDCS treatment evidenced significantly more pre-to immediately post-treatment reductions in spasticity than participants assigned to the sham (p = 0.004, p<0.001, and p = 0.004 for shoulder, wrist, and fingers respectively) and these improvement in spasticity maintained for at least 48 hours for wrist joints (p = 0.023). There was only one participant in the active tDCS condition developed erythematous rash. However, all participants tolerated the tDCS well without any serious adverse events. Conclusion: Anodal tDCS appeared to reduce CP-related spasticity (but not PROM) in the short term. Researches examine the long term benefits of this intervention on spasticity are warranted.
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Treatment with Huisheng oral solution inhibits the development of pulmonary thromboembolism and metastasis in mice with Lewis lung carcinoma
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MSTS 2018 - Femur Mets and MM
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The aim of this study was to investigate whether Huisheng oral solution (HSOS) has an inhibitory effect on the development of pulmonary thrombosis and metastasis in mice with Lewis lung carcinoma (LLC), and to explore the possible mechanisms involved. A mouse model of LLC was developed, and model mice were divided into either a treatment group or a control group to undergo treatment with HSOS or normal saline. Normal mice treated with saline were used as normal controls. On day 25 after treatment, blood samples were drawn from the eyes of half the mice in each group to determine blood cell counts and plasma levels of D-Dimer and vascular endothelial growth factor (VEGF), while heart blood samples were collected from the remaining mice to measure the rate of thrombin-induced platelet aggregation. For all mice, pathological analyses of the cerebrum, lung, mesentery, femoral vein, external iliac vein and spleen were performed. Tumors were weighed to assess the impact of HSOS treatment on tumor growth, and the number of thrombi, metastatic nodules and neovessels in the tumor tissue were counted. In addition, 24 normal New Zealand rabbits were divided into two groups and treated with either HSOS or normal saline to determine the rates of ADP-, collagen- or thrombin-induced platelet aggregation. Compared with the model group, HSOS treatment decreased the incidence of pulmonary thromboembolism and metastasis, the number of metastatic nodules, the plasma levels of D-dimer and VEGF, the rate of collagen-induced platelet aggregation in rabbits and the numbers of leukocytes and tumor neovessels (P<0.05 for all). It increased the thymus and spleen coefficients and the number of platelets (P<0.05 for all), but had no significant effect on thrombin-induced platelet aggregation in mice and rabbits, ADP-induced platelet aggregation in rabbits, or the number of red blood cells. The reduced rate of tumor growth was 9.7% in mice treated with HSOS. HSOS treatment effectively reduced the development of pulmonary thromboembolism and metastasis in mice bearing LLC via mechanisms possibly associated with ameliorating a blood hypercoagulable state, decreasing tumor angiogenesis and enhancing immunity.
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The use of clodronate in multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Bone metastases secondary to myeloma, are characterized by severe bone pain, pathological fractures, hypercalcaemia and hypercalciuria. Histological and biochemical investigations have shown a wide spectrum of abnormalities in bone turnover in patients with multiple myeloma. The increased osteoclast activity caused by various osteoclast activating factors secreted by myeloma cells, is responsible for the diffuse localized osteolytic lesions. These lesions are responsible for the symptoms and respond poorly to standard chemotherapy, justifying the use of a bone-sparing agent. Clodronate is a potent inhibitor of osteoclast activity and does not impair bone mineralization. Several studies have shown that clodronate can normalize serum calcium in hypercalcaemic patients with metastatic bone disease, and a similar response is seen in multiple myeloma. In a long-term (18 months) placebo-controlled study we have shown that clodronate, given orally at a daily dose of 1.6g, can decrease both the incidence of pathological fractures and the activity of osteoclasts, as judged by measurements in iliac crest biopsy. These results, along with those from two other studies, are promising and suggest that clodronate may inhibit the progression of osteolytic lesions in multiple myeloma. [References: 14]
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Denosumab
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MSTS 2018 - Femur Mets and MM
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Denosumab is an anti-receptor activator of nuclear factor (NF)-kappaB (RANK) ligand human monoclonal antibody studied as a treatment for postmenopausal osteoporosis (PMO) and bone destruction due to rheumatoid arthritis (RA) or metastatic cancers. As of February 2009, the candidate was undergoing US Food and Drug Administration review, and might be approved by October 2009. Late phase clinical trials demonstrated that denosumab possesses a similar safety profile to bisphosphonates and that it can be either equally or more effective than bisphosphonates at preventing bone loss due to PMO, RA or cancer treatment and metastases. ©2009 Landes Bioscience.
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1 |
Internal screw fixation compared with bipolar hemiarthroplasty for treatment of displaced femoral neck fractures in elderly patients
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Management of Hip Fractures in the Elderly
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BACKGROUND: Internal fixation and arthroplasty are the two main options for the treatment of displaced femoral neck fractures in the elderly. The optimal treatment remains controversial. Using data from the Norwegian Hip Fracture Register, we compared the results of hemiarthroplasty and internal screw fixation in displaced femoral neck fractures. METHODS: Data from 4335 patients over seventy years of age who had internal fixation (1823 patients) or hemiarthroplasty (2512 patients) to treat a displaced femoral neck fracture were compared at a minimum follow-up interval of twelve months. One-year mortality, the number of reoperations, and patient self-assessment of pain, satisfaction, and quality of life at four and twelve months were analyzed. Subanalyses of patients with cognitive impairment and reduced walking ability were done. RESULTS: In the arthroplasty group, only contemporary bipolar prostheses were used and uncemented prostheses with modern stems and hydroxyapatite coating accounted for 20.8% (522) of the implants. There were no differences in one-year mortality (27% in the osteosynthesis group and 25% in the arthroplasty group; p = 0.76). There were 412 reoperations (22.6%) performed in the osteosynthesis group and seventy-two (2.9%) in the hemiarthroplasty group during the follow-up period. After twelve months, the osteosynthesis group reported more pain (mean score, 29.9 compared with 19.2), higher dissatisfaction with the operation result (mean score, 38.9 compared with 25.7), and a lower quality of life (mean score, 0.51 compared with 0.60) than the arthroplasty group. All differences were significant (p < 0.001). For patients with cognitive impairment, hemiarthroplasty provided a better functional outcome (less pain, higher satisfaction with the result of the operation, and higher quality of life as measured on the EuroQol visual analog scale) at twelve months (p < 0.05). CONCLUSIONS: Displaced femoral neck fractures in the elderly should be treated with hemiarthroplasty
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Developing the Thai Siriraj Psoriatic Arthritis Screening Tool and validating the Thai Psoriasis Epidemiology Screening Tool and the Early Arthritis for Psoriatic Patients questionnaire
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OAK 3 - Non-arthroplasty tx of OAK
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To validate the Thai language version of the Psoriasis Epidemiology Screening Tool (PEST) and the Early Arthritis for Psoriatic Patients Questionnaire (EARP), as well as also to develop a new tool for screening psoriatic arthritis (PsA) among psoriasis (Ps) patients. This was a cross-sectional study. Ps patients visiting the psoriasis clinic at Siriraj Hospital were recruited. They completed the EARP and PEST. Full musculoskeletal history, examination, and radiography were evaluated. PsA was diagnosed by a rheumatologistâ??s evaluation and fulfillment of the classification criteria for psoriatic arthritis. Receiver operator characteristic (ROC) curves, sensitivity, and specificity were used to evaluate the performances of the tools. The Siriraj Psoriatic Arthritis Screening Tool (SiPAT) contained questions most relevant to peripheral arthritis, axial inflammation, and enthesitis, selected from multivariate analysis. Of a total of 159 patients, the prevalence of PsA was 78.6Â %. The ROC curve analyses of Thai EARP, PEST, and SiPAT were 0.90 (95Â % CI 0.84, 0.96), 0.85 (0.78, 0.92), and 0.89 (0.83, 0.95), respectively. The sensitivities of SiPAT, Thai EARP, and PEST were 91.0, 83.0, and 72.0Â %, respectively, while the specificities were 69.0, 79.3, and 89.7Â %, respectively. All screening questionnaires showed good diagnostic performances. SiPAT could be considered as a screening tool with its desirable properties: higher sensitivity and taking less time. Thai PEST and EARP could possibly be sequentially administered for people with a positive test from SiPAT to reduce the number of false positives.
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0 |
Evaluation of the knee joint morphology associated with a complete discoid lateral meniscus, as a function of skeletal maturity, using magnetic resonance imaging
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AMP (Acute Meniscal Pathology)
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INTRODUCTION: A discoid lateral meniscus (DLM) is associated with increased risk for meniscal tears and progression of knee joint osteoarthritis. Our aim was to differentiate knee joint morphology between patients with and without a DLM, as a function of skeletal maturity, using magnetic (MR) imaging.
MATERIALS AND METHODS: This was a retrospective analysis of MR images of the knee for 110 patients, 6-49 years of age. Of these, 62 were in the open physis group (38 with a DLM) and 48 in the closed physis group (23 with a DLM). The following morphological parameters were measured: anterior obliquity of the lateral tibial plateau (AOLTP), posterior obliquity of the lateral tibial plateau (POLTP), the lowest point of the lateral femoral condyle (LPLFC), and the posterior lateral condylar angle (PLCA).
RESULTS: Regardless of skeletal maturity, a DLM was associated with a greater inclination of the POLTP, lateralization of the LPLFC, and smaller PLCA (p < 0.001 for all compared to that of the control group). In the DLM group, the inclination of the AOLTP and the POLTP were significantly smaller (p < 0.001) and the LPLFC was more lateral (p < 0.001) in the closed physis group than in the open physis group. In the control group, the inclination of the POLTP was larger (p < 0.001) and the PLCA smaller (p = 0.019) in the open than in the closed physis group.
CONCLUSIONS: We identified a characteristic knee morphology among patients with a complete DLM using MR imaging, which was observed before physeal closure and persisted after skeletal maturity was attained. We also noted lateralization of the LPLFC in the presence of a DLM, with an increase in lateralization with skeletal maturation.
LEVEL OF EVIDENCE: Case-control study, III.
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0 |
Improving the outcomes: Developing cancer therapeutics
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MSTS 2018 - Femur Mets and MM
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Oncology therapeutics are less likely to reach the market than other therapeutics, at a higher cost, and only approximately one in ten cancer drugs in clinical development actually reach the market. To improve, there need to be new approaches to oncology research and development, based on understanding cancer biology and improving preclinical models and clinical trials, such as more use of biomarkers and evaluation of other targets including cancer stem cells and use of combination therapies. Biomarkers can be used to make early go/no-go decisions in drug development and can speed up drug development by selecting patients who will benefit and excluding patients likely to experience severe side effects, but they need validation before use. New approaches to preclinical and clinical trials can also speed up and improve the development of cancer therapeutics. © 2012 Future Medicine Ltd.
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Associations of varus thrust and alignment with pain in knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To investigate associations of varus thrust and varus static alignment with pain in patients with knee osteoarthritis (OA).
METHODS: This was a cross-sectional study of participants from a randomized controlled trial of vitamin D treatment for knee OA. Participants were video recorded while walking and scored for presence of varus thrust. Static alignment was measured on standard posteroanterior knee radiographs. Pain questions from the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire were used to assess symptoms. We calculated means for total WOMAC pain in relation to varus thrust and static varus alignment (i.e., corrected anatomic alignment<178 degrees). Ordinal logistic regressions were performed, with responses on individual WOMAC pain questions as the outcomes and varus thrust and varus alignment as the predictors.
RESULTS: There were 82 participants, 60% of whom were female. The mean+/-SD age was 65.1+/-8.5 years, and the mean+/-SD body mass index was 30.2+/-5.4 kg/m2. The mean total WOMAC pain score was 6.3 versus 3.9, respectively, in those with versus without definite varus thrust (P=0.007) and 5.0 versus 4.2 in those with versus without varus alignment (P=0.36). Odds ratios for pain with walking and standing were 4.7 (95% confidence interval 1.8-11.9) and 5.5 (95% confidence interval 2.2-14.2), respectively, in those with and those without definite varus thrust. There were no significant associations between varus alignment and responses to individual WOMAC pain questions. Sensitivity analyses suggested that varus classified using a more stringent definition might have been associated with pain on walking and standing.
CONCLUSION: In patients with knee OA, varus thrust, and possibly varus static alignment, were associated with pain, specifically during weight-bearing activities. Treatment of varus thrust (e.g., via bracing or gait modification) may lead to improvement of symptoms.
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0 |
Central pedicled breast reduction technique in male patients after massive weight loss
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Reduction Mammoplasty for Female Breast Hypertrophy
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Male patients after massive weight loss often suffer from redundant skin and soft tissue in the anterior and lateral chest region, causing various deformities of pseudogynecomastia. Techniques with free or pedicled nipple-areola complex (NAC) transposition are widely accepted. The authors present their approach to male breast reduction with preservation of the NAC on a central dermoglandular pedicle and a wide elliptical tissue excision of breast and lateral thorax tissue in combination with liposuction. Male breast reduction was performed on patients after moderate to massive weight loss due to diet or bariatric procedures. Former procedures included free nipple-areola grafts or inferior pedicled techniques for NAC preservation. As a modification, we performed a central pedicled breast reduction on nine male patients with excessive liposuction of the pedicle and a horizontal elliptical skin removal, allowing for sufficient tissue removal at the lateral thorax. From October 2010 until June 2011, nine male patients had central pedicled breast reconstructions after massive weight loss. Mean age was 29.1 years, mean preoperative body mass index was 29.2, and mean preoperative weight loss was 63.9 kg. The chest wall improvement was rated "very good" by eight patients. No major complications occurred in all nine patients. Male chest deformities after massive weight loss can be dealt by several approaches. The optimal scar positioning and the preservation of NAC may be the most challenging aspects of these procedures. Therefore, the preservation of the NAC on a central dermoglandular pedicle with a horizontal submammary scar course may optimize the esthetic outcome.
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Hip fractures: A review of predictors affecting Functional Independence Measure, ambulation and rehabilitation length of stay during inpatient rehabilitation in Singapore General Hospital
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Hip Fx in the Elderly 2019
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Osteoporotic hip fractures receiving surgery are common and early rehabilitation is needed in the acute hospital setting. In Singapore, many receive rehabilitation after hip surgery in a tertiary hospital, and various clinical variables may be predictors of functional outcomes. Methods: We retrospectively reviewed 68 patients who went through inpatient rehabilitation in Singapore General Hospital. The primary outcomes of this study were to identify predictors which affect Functional Independence Measure (FIM) efficiency and motor FIM gain at discharge. The secondary outcomes include predictors affecting ambulation distance at discharge and rehabilitation length of stay (RLOS). Results: Age, dementia and days from fracture to surgery are important predictors of FIM efficiency; age and FIM efficiency are important predictors of ambulation distance; and type of fracture is an important predictor of RLOS. Patients of age <75 (OR 2.419, p=0.002), absence of dementia (OR 2.570, p=0.045) and those who received surgery <3 days from fracture onset (OR 2.529, p=0.036) achieved greater FIM efficiency. Younger patients of age <75 (OR 23.177, p=0.030) and those with FIM efficiency of more than 7 points per week (OR 38.963, p=0.05) achieved greater ambulation distance at discharge. Type of hip fracture is an important predictor for RLOS, with neck of femur fracture patients having shorter RLOS (OR 7.186, p=0.005). Conclusion: Age, dementia, days from fracture to surgery and type of hip fractures are important predictors of early functional outcomes in inpatient rehabilitation setting.
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0 |
Fluoroscopic evaluation of contrast distribution within the adductor canal
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AAHKS (9/10) Regional Nerve Blocks
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Background and Objectives: This case series assesses the in vivo spread of contrast within the adductor canal in subjects who recently underwent a total knee arthroplasty. A previous analysis of profound leg weakness with a continuous adductor canal revealed contrast spread from the adductor canal to the femoral triangle with as little as 2 mL of volume. Methods: We enrolled 10 American Society of Anesthesiologists class II-III subjects. Maximum voluntary isometric contraction was measured to assess quadriceps strength before and after surgery. Contrast was then injected continuously via electronic pump into the adductor canal, and fluoroscopy was used to capture images after 1-mL increments. For analysis, the femur was divided into 8 equidistant sectors between the lesser trochanter and medial epicondyle. Results: Contrast did not reach the level of the lesser trochanter or the medial epicondyle of the femur in any subject. The greatest spread after 5 mL of contrast was 4 sectors. Sixty percent of subjects had contrast spread within either the same sector as the catheter tip or 1 sector distally. No subjects demonstrated additional proximal spread of contrast after 4 mL. Conclusions: This study reveals that in vivo continuous infusions within the adductor canal spread in both a cephalad and caudad direction in limited fashion. Although a previous report described proximal spread of injectate to the level of the common femoral nerve, this event is infrequent.
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A comparison of hip fracture incidence rates among elderly in Sweden by latitude and sunlight exposure
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Hip Fx in the Elderly 2019
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BACKGROUND: Research has shown that hip fracture risk increases with latitude; hypothetically due to reduced sunlight exposure and its effect on bone quality. Sweden, with large differences in latitude and UV radiation, is ideal to study in order to analyse the association between latitude and UV radiation on age- and sex-specific hip fracture rates among elderly.
METHOD: Aggregated (2006-2008) age- and sex-specific hip fracture data was obtained for each Swedish municipality as well as the municipality's latitudinal coordinates and aggregated (2006-2008) UV radiation levels. Pearson correlations were calculated between hip fracture incidence rates, latitude and UV radiation. Independent t tests were calculated on tertile-categorized latitudinal data in order to investigate the difference in hip fracture risk between these categories.
RESULTS: Statistically significant correlations were seen in all groups between hip fracture incidence rates and latitude as well as UV radiation. The independent t tests showed that this correlation was mainly due to high incidence rates in high latitude municipalities.
CONCLUSIONS: Statistically significant correlations are seen between hip fracture incidence rates and latitude as well as UV radiation in Sweden and the northern parts of Sweden have an increased risk of hip fractures compared to the middle and southern parts. To our knowledge this is the first study using a national discharge register that shows this relationship and provides a starting point for further research to investigate why populations in northern Sweden have a higher risk of hip fractures compared to other Swedish regions.
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Complications of pelvic ring fixation in patients requiring laparotomy
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Pelvic ring disruptions in blunt trauma are rarely an isolated finding. Many individuals needing operative pelvic fixation also require laparotomy for other injuries. Pelvic fixation can be performed by open reduction and internal fixation (ORIF) or external fixation (Ex-fix). Often when a laparotomy incision is present, ORIF is performed by extending this incision. We hypothesized ORIF performed by extending the laparotomy incision would result in higher rates of ventral hernia and wound complications versus Ex-fix.
METHODS: All patients admitted from 2004-June 2014 who underwent laparotomy and pelvic fixation either by ORIF through extension of a laparotomy incision (ORIF group) or definitive Ex-fix group were identified. Injury severity score, demographics, associated injuries, and complications were collected.
RESULTS: A total of 35 patients were identified who underwent laparotomy and pelvic fixation, 21 underwent Ex-fix, whereas 14 underwent ORIF through an extended laparotomy incision. There were no differences in injury severity score, demographics, associated injuries, or rate of ventral hernia. The ORIF group had more laparotomy incision infections (50.0% versus 4.8%, P < 0.01) and pelvic abscesses (42.9% versus 9.5%, P < 0.05). They required more procedures to address their complications (13 versus 5, P < 0.05).
CONCLUSIONS: Individuals who have undergone laparotomy and pelvic fixation are a complex group of patients with multiple injuries. These data suggest that when surgical repair of a pelvic ring disruption is indicated and the patient has undergone laparotomy, careful consideration to the method of fixation should be given.
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0 |
Parathyroid lipoadenomas: a rare cause of primary hyperparathyroidism
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To review one institution's experience with parathyroid lipoadenomas and to report the associated clinical characteristics. METHODS: We present a case series of parathyroid lipoadenomas. A parathyroid lipoadenoma was defined as a single adenoma with more than 50% fat on histologic examination in conjunction with primary hyperparathyroidism and resolution of hypercalcemia postoperatively. Patients who fulfilled the diagnostic criteria were identified from the surgical pathology files of the Mayo Clinic. RESULTS: Five cases of parathyroid lipoadenomas, including 1 oxyphil lipoadenoma, were identified during the period from 1971 to 2001. The clinical picture of the study subjects resembled that of a typical patient with primary hyperparathyroidism. Parathyroid lipoadenomas were identified in 3 women (60%) and 2 men (40%), and only 1 patient presented with possible hypercalcemia-related symptoms of nephrolithiasis and hip fracture, leading to diagnosis. The mean serum calcium concentration was 11.1 mg/dL. Preoperatively, all study subjects had elevation of serum parathyroid hormone levels. Two of 3 patients (67%) had the tumor identified preoperatively by neck ultrasonography. CONCLUSION: A parathyroid lipoadenoma is a rare cause of primary hyperparathyroidism. The clinical features of this pathologic entity are similar to those of the more common pathologic variants of parathyroid disease associated with primary hyperparathyroidism
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1 |
Outcomes of high-grade open calcaneus fractures managed with open reduction via the medial wound and percutaneous screw fixation
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DoD SSI (Surgical Site Infections)
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OBJECTIVE: To determine the clinical and functional outcomes of high-grade (types II and III) open calcaneus fractures managed with a protocol of modern wound care, open reduction via the medial hindfoot wound, and percutaneous screw fixation.
DESIGN: Retrospective clinical series of consecutively treated patients.
SETTING: Regional trauma center (level 2).
PATIENTS/PARTICIPANTS: Seventeen consecutive patients with open type II and III calcaneus fractures treated with fracture repair by a single surgeon.
INTERVENTION: Soft tissue debridement and modern wound care, reduction of calcaneus fractures through the open medial wound, and percutaneous screw fixation.
MAIN OUTCOME MEASUREMENTS: Patient demographics and injury data, radiographic analyses, complications of treatment, and hindfoot outcomes assessed with American Orthopaedic Foot and Ankle Surgeon and Maryland Foot Scores and general health with the Short Form 36 measurement at a minimum of 12 months post injury.
RESULTS: Seventeen patients were available for follow-up at >12 months, with 15 completing all outcome measures. Four fractures were graded as type II, 9 as type IIIA, and 4 as type IIIB. There was 1 deep infection, and 1 wound dehiscence, both in type III open injuries; both were successfully treated with local wound care, delayed closure, and appropriate antibiotics. Overall, 7 of 17 (41%) patients required secondary surgical procedures, including 4 hindfoot fusions (23.5%). The average American Orthopaedic Foot and Ankle Surgeon score was 77 (range, 32-95), and the Maryland Foot Score was 64 (range, 16-93). The physical and mental components of the Short Form 36 averaged 44.4 and 49.1, respectively.
CONCLUSIONS: Limb-threatening catastrophic complications are uncommon for high-grade open calcaneus fractures treated with modern soft-tissue care, fracture reduction using the medial open fracture wound, and percutaneously placed screw fixation. Limb and whole body functional outcomes are comparable to previously published reports of both closed and open calcaneus fractures.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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0 |
A new suction cannula
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Panniculectomy & Abdominoplasty CPG
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A new cannula has been designed that facilitates liposuction procedures by increasing the amount of fat tissue breakdown before aspiration. The cannula allows for greater application and opens up new horizons in aspirative surgery.
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0 |
Participation after Stroke and Traumatic Brain Injury: Results of a Pilot Study in Outpatient Neurorehabilitation in Vorarlberg
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DoD PRF (Psychosocial RF)
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Objective A multicentric study has reported on the sustained effects of outpatient neurorehabilitation in Germany. Different to Germany, the biopsychosocial model of disability, as described in the International Classification of Functioning, Disability and Health (published by the World Health Organization), is not incorporated into Austrian law. There is a need for objective measurement instruments for routine outcome evaluation of outpatient neurorehabilitation in Austria. The present examines the extent to which the instruments used for the German multicentric study are applicable in the Austrian rehabilitation context and if there are similar rehabilitation effects over time. Method In a multicentric observational study, patients of 4 Austrian outpatient neurorehabilitation centers for stroke or traumatic brain injury were asked to fill in a questionnaire. This was carried out 4 times throughout the program: on admission and discharge as well as on month 4 and 12 post rehabilitation. Additionally, clinical experts were asked to rate the patients' status at admission and discharge. Results and conclusions The results of 4 outpatient neurorehabilitation centers in Vorarlberg (Austria) suggest that the used measurement instruments are reasonable for the evaluation of outpatient neurorehabilitation in Austria, based on the ultimate goal participation and self-determined conduct of life. For routine outcome evaluation, fewer instruments should be used and adjustments should be made while assessing more severely affected patients.
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0 |
Eighty Percent Survival of Resurfacing Implants in the Knee After 10 Years: A Nationwide Cohort Study on 379 Procedures from the Danish Knee Arthroplasty Registry
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AMP (Acute Meniscal Pathology)
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Objective: Focal cartilage injuries are debilitating and difficult to treat. Biological cartilage repair procedures are used for patients younger than 40 years, and knee arthroplasties are generally reserved for patients older than 60 years. Resurfacing implants are well suited for patients in this treatment gap. The objective was to investigate the 10-year survival of resurfacing implants in the Danish Knee Arthroplasty Registry. Design: In this retrospective cohort study, patients treated with resurfacing implants were followed longitudinally in the Danish Knee Arthroplasty Registry from 1997 to 2020. The primary endpoint was revision surgery. The survival of the resurfacing implants was analyzed by Kaplan-Meier method. Results: A total of 379 resurfacing implant procedures were retrieved from the Danish Knee Arthroplasty Registry. The mean age and weight of patients were 50 years (SD = 11) and 84 kg (SD = 17), respectively. The indications for surgery were as follows: secondary osteoarthritis (42%), primary osteoarthritis (32%), and osteochondral lesions (20%). Within the follow-up period, 70 (19%) of the implants were revised to arthroplasties. The 1-, 5-, and 10-year revision-free survival estimation was 0.95 (95% CI 0.93-0.97), 0.84 (95% CI 0.80-0.88), and 0.80 (95% CI 0.75-0.84), respectively. The median time to revision was 2 years. Conclusion: The 10-year revision-free survival rate for resurfacing implants was 80%. Based on the revision rates, this treatment offers a viable alternative to biological cartilage repair methods in patients aged 40 to 60 years with focal cartilage pathology. Improved patient selection could further improve the implant survival rate. Further studies are needed to investigate this treatment method.
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0 |
Modern proximally tapered uncemented stems can be safely used in dorr type c femoral bone
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PJI DX Updated Search
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Cementless femoral fixation has become widely accepted in modern total hip arthroplasty. Treating patients who have a stovepipe-shaped femur (Dorr type C) with cementless implants has traditionally been challenging. We treated 53 consecutive patients (60 hips) who had type C bone with identical tapered, proximally coated implants and postoperative weight bearing as tolerated. At 6 weeks, all 60 hips had radiographically documented bony integration, and at 1 year, there was no evidence of fracture, subsidence, thigh pain, stress shielding, loose stems, or risk of failure. Of those patients, 40 (43 hips) had midterm follow-up (average, 6 years; range, 4-9 years); the findings were the same. We conclude that modern proximally tapered stems can be used with early weight bearing in patients with type C bone. é 2012 Elsevier Inc
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Prognostic factors for surgical outcomes including preoperative total knee replacement and knee osteoarthritis status in female patients with lumbar spinal stenosis
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PJI DX Updated Search
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Study Design: A retrospective clinical case series. Objective: To investigate knee osteoarthritis (KOA) and total knee replacement (TKR) status as prognostic factors for surgical outcomes in female patients with lumbar spinal stenosis (LSS). Summary of Background Data: There have been many reports on numerous prognostic factors for surgical outcomes in patients with degenerative lumbar conditions; however, there has been no report on the surgical outcome in patients who underwent spinal surgery with coexisting KOA and TKR. Methods: This study included 141 female patients (mean age, 67.6 y) who underwent spinal surgery for LSS between January 2006 and December 2010. At 1 year postoperatively, surgical outcomes were measured using the Oswestry disability index (ODI). Various clinical factors including KOA and TKR were analyzed as prognostic factors for surgical outcomes. Results: Mean average scores at preoperative evaluation were 26.1ñ6.6 in the no KOA group, 23.6ñ7.9 in the KOA group, and 30.4ñ6.7 in the TKR group (P<0.05). Mean average scores at postoperative 1 year were 13.8ñ8.5 in the no KOA group, 16.8ñ9.5 in the KOA group, and 21.4ñ5.7 in the TKR group (P<0.05, Mann-Whitney U test). Preoperative ODI scores were shown to be significantly affected by the TKR status only (P<0.05), and were significantly higher in the TKR patient group. ODI scores at postoperative 3 months were significantly correlated with the preoperative ODI and the operational level (P<0.05). At postoperative 1 year, ODI scores were shown to be affected by the operational level, the preoperative ODI, and the presence of advanced radiographic KOA (Kellgren/Lawrence grades III and IV) (P<0.05). Conclusions: A poor preoperative functional score, the presence of preoperative KOA, and longer operational levels were shown to be poor prognostic factors for the 1-year surgical outcome of LSS. Also, patients in the TKR group showed the worst ODI scores at preoperative and postoperative 1-year evaluations. Consideration of these factors when planning for spine surgery could be helpful in predicting the surgical outcomes of lumbar spinal surgery
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Nerve blocks for knee arthroplasty at queen elizabeth hospital (QEH), king's lynn-an audit of current practice
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Surgical Management of Osteoarthritis of the Knee CPG
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Background and aims: Role of femoral nerve block in knee arthroplasty is well established but evidence for sciatic block is weak.1 QEH practices combined femoral and sciatic blocks for knee arthroplasty. This audit aimed to observe the post-operative course of patients, specifically looking at post-op analgesia, patient satisfaction, block recovery and compliance with physiotherapy. Methods: Questionnaires were filled by anaesthetist for 34 patients undergoing knee arthroplasty who were followed up for 24 hours. Results: Out of 34 patients, 23 had femoral & high sciatic blocks (FS group) and 11 had femoral & ultrasound guided popliteal fossa blocks (FP group). There was no significant difference in the mean pain scores, analgesic consumption and patient satisfaction scores between the two. However, 5 patients had residual motor block in FS group compared to 1 in FP group and 7 patients had poor compliance with physiotherapy in the FS group compared to none in the FP group. Conclusions: Combination of femoral and sciatic nerve blocks provides good post-operative analgesia and high degree of patient satisfaction in the first 24 hours after knee arthroplasty. However, with regards to the type of sciatic block, ultrasound-guided popliteal block provides comparable analgesia with fewer incidences of motor block and better compliance with physiotherapy compared to high sciatic block. Other advantage of popliteal block is hamstring muscle sparing which aids early patient mobilization and physiotherapy
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Clinical and MRI evaluation of meniscal tears repaired with bioabsorbable arrows
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AMP (Acute Meniscal Pathology)
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BACKGROUND AND AIMS: Excision of meniscal tissue has been shown to increase the risk of degenerative changes of the knee joint. Whenever possible, meniscus repair has become the procedure of choice for treatment of meniscal tears.
MATERIALS AND METHODS: The present retrospective study evaluated the healing results of 77 meniscal ruptures treated with the an all-inside technique (Biofix meniscus arrow). The study group consisted of 73 patients with 77 longitudinal, vertical meniscal ruptures treated at Helsinki University Hospital between the beginning of January 1997 and the end of March 2001. The patients who had not received secondary surgery for failed repair during the follow-up period were examined clinically and with MRI.
RESULTS: Fifty-one out of 77 meniscal ruptures (66%) healed clinically. In repairs performed in conjunction with ligament reconstruction the healing rate was higher (79%) than in the isolated tears (56%). The poorest results were seen in the very long vertical tears with luxation of the meniscus (38% healing rate).
CONCLUSIONS: Bioabsorbable arrows offer a good alternative for treatment of meniscal ruptures, but the arrows alone do not seem to be sufficient to provide a reliable long-lasting result in the repair of very unstable meniscal ruptures.
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The clinical impact of preoperative body composition differs between male and female colorectal cancer patients
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MSTS 2022 - Metastatic Disease of the Humerus
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AIM: Patient body composition is an important indicator of metabolic status and is associated with cancer progression. Because body composition varies between men and women, we aimed to examine the difference in clinical impact of preoperative body composition according to sex.
METHOD: We used an integrated dataset of 559 colorectal cancer (CRC) patients. The association between preoperative body composition indices [body mass index (BMI), visceral to subcutaneous fat area ratio (VSR) and skeletal muscle index (SMI)] and patient outcome, clinicopathological factors and preoperative inflammation and nutritional status was analysed, comparing men and women.
RESULTS: Preoperative low BMI and low SMI in men was significantly associated with unfavourable overall survival (OS) [BMI: hazard ratio (HR) 2.22, 95% CI 1.28-4.14, P = 0.004; SMI: HR 2.54, 95% CI 1.61-4.07, P < 0.001] and high VSR in women was significantly associated with unfavourable OS (HR 1.79, 95% CI 1.03-3.02, P = 0.040). Additionally, low SMI in men was significantly associated with deeper tumour invasion and greater distant metastasis and high VSR in women was significantly associated with advanced age, right-sided tumour, lower total lymphocyte count and lower albumin levels. Interestingly, low BMI in men was significantly associated with deeper tumour invasion, but also with favourable inflammation and nutritional status (lower C-reactive protein and higher albumin).
CONCLUSION: The clinical impact of preoperative body composition differed between men and women: SMI in men and VSR in women were good prognosticators. Our findings may provide a novel insight for CRC treatment strategies.
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Safety and Efficacy of Operative Versus Nonsurgical Management of Distal Radius Fractures in Elderly Patients: A Systematic Review and Meta-analysis
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Distal Radius Fractures
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PURPOSE: To assess the safety and efficacy of operative versus nonsurgical treatment of distal radius fractures in elderly patients.
METHODS: We comprehensively searched the PubMed, Web of Science, and Cochrane Library databases for studies that satisfied predetermined inclusion and exclusion criteria. Outcomes of interest included pain level, grip strength, wrist range of motion, wrist functional assessment, radiographic parameters, and complications; we compared these using continuous measurements. We performed a systematic review and meta-analysis to assess operative versus nonsurgical procedures in patients aged 60 years and older.
RESULTS: Two randomized controlled trials and 6 retrospective studies were included. Meta-analysis did not detect statistically significant differences in pooled data for pain level, functional assessment, and wrist range of motion between the operative and nonsurgical groups. Grip strength was significantly greater in the operative group. The incidence of major complications requiring surgery and that of tendon injury were significantly higher in the operative group. Radiographic outcomes including volar tilt, radial inclination, and ulnar variance were significantly better in the operative group. Considerable heterogeneity was present in all studies and adversely affected the precision of the meta-analysis.
CONCLUSIONS: The current literature does not support the theory that operative management can provide better clinical outcomes for elderly patients with distal radius fractures. Although operative management can offer better radiographic outcomes and grip strength than can nonsurgical treatment, the risk of complications requiring surgical treatment is greater. Thus, indications for operative fixation should be considered carefully in the treatment of elderly patients.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.
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Bone and muscle mass after femoral neck fracture. A controlled quantitative computed tomography study of osteosynthesis versus primary total hip arthroplasty
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Hip Fx in the Elderly 2019
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The cortical bone mineral density (BMD), bone volume, bone mass and muscle volume of the thigh, and the BMD of the distal femur and proximal tibia were measured quantified by quantitative computed tomography (QCT) after an operation for a displaced femoral neck fracture. Twenty patients were randomized to osteosynthesis or total hip arthroplasty (THA). Both legs were scanned after 18 months, and the operated side was compared with the healthy side. Clinical assessment was performed with a Harris hip score. A reference group of 9 patients, who had undergone THA because of arthrosis, was chosen. In the fracture patients, we found a 9% decrease in bone mass and muscle volume of the middle femur. The BMD of the distal femur and proximal tibia showed a more marked osteopenia. There was no difference in these parameters between the two groups. In the reference group of operated arthrosis patients, we did not find any differences between sides postoperatively. After the operation, the fracture patients had a lower Harris score than the arthrosis patients, and this was most pronounced among those who had undergone osteosynthesis. The finding of a marked osteopenia after a femoral neck fracture, irrespective of treatment, but no bone loss after THA because of arthrosis, implies that patients with a femoral neck fracture are more sensitive to osteopenia, and that the bone loss is not proportional to the operative trauma.
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Opportunities for i.v. to oral switch in the management of infections: the role of quinolones
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Quinolones are an important group of drugs for the oral treatment of severe infections. We have shown that in patients with bacteremia the serum levels of fleroxacin are high enough to treat Gram-negative infections with one single oral dose per day. Thus for severe, quinolone-sensitive infections, such as bacteremic pyelonephritis, the switch from i.v. to oral may be done even on the first day of infection if the patient is not in shock and able to take oral medication. Staphylococcal infections have been successfully treated in animal models and non-randomized human studies with the combination of quinolone and rifampin. We have studied the influence of rifampin on the pharmacokinetics of fleroxacin in normal volunteers and no dose adjustment appears necessary. A single daily oral dose of fleroxacin (400 mg) and rifampin (600 mg) appears to be a promising therapeutic approach for staphylococcal infections and is the basis for an ongoing prospective randomized clinical trial comparing early switch to oral bitherapy with standard i.v. therapy. In conclusion, fleroxacin as a single drug or in combination with rifampin is a promising approach for switch from i.v. to oral therapy of severe Gram-negative and possibly staphylococcal infections
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Outcomes of levator resection at tertiary eye care center in Iran: a 10-year experience
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Upper Eyelid and Brow Surgery
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PURPOSE: To assess outcomes of levator resection for the surgical correction of congenital and acquired upper lid ptosis in patients with fair to good levator function and evaluation of the relationship between demographic data and success of this operation. METHODS: In a retrospective study, medical records of patients with blepharoptosis who had undergone levator resection over a 10-year period and were followed for at least 3 months were reviewed. RESULTS: Overall, 136 patients including 60 (44.1%) male and 76 (55.9%) female subjects with a mean age of 20 +/- 13.8 years (range, 2 to 80 years) were evaluated, of whom 120 cases (88.2%) had congenital ptosis and the rest had acquired ptosis. The overall success rate after the first operation was 78.7%. The most common complication after the first operation was undercorrection in 26 cases (19.1%), which was more prevalent among young patients (p = 0.06). Lid fissure and margin reflex distance (MRD(1)) also increased after levator resection (p < 0.001). Age, sex, type of ptosis, amblyopia, levator function, MRD(1), lid fissure and spherical equivalent were not predictive of surgical outcomes of levator resection. CONCLUSIONS: Levator resection has a high rate of success and few complications in the surgical treatment of congenital and acquired upper lid ptosis with fair to good levator function. Reoperation can be effective in most cases in which levator resection has been performed.
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Does a delay in transfer to a rehabilitation unit for older people affect outcome after fracture of the proximal femur?
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Management of Hip Fractures in the Elderly
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AIMS: To detemine the relationship between delay in transfer to rehabilitation wards and outcome for patients aged over 75 years with fracture of the proximal femur. METHODS: An observational study in a district general hospital of all patients admitted to hospital aged over 75 years with fracture of the proximal femur over 3 1/2 years. Outcome data collected included the number of patients discharged back to their usual residence and total hospital length of stay related to age, gender, usual residence and delay in transfer to a rehabilitation ward. RESULTS: 58% of 455 patients were transferred to a rehabilitation ward. For those patients who were transferred to a rehabilitation ward only age predicted discharge to a more dependent residence. The relative risk for discharge to a more dependent residence for people aged over 85 years compared to younger people was 1.47 (95% CI 1.15-1.88). Delay in transfer to rehabilitation was associated with a longer total hospital length of stay of 0.64 (95% CI 0.23-1.05) days per day of delay in transfer. CONCLUSIONS: Delay in transfer to a rehabilitation ward was associated with a disproportionate increase in total hospital length of stay for patients aged over 75 with fracture of the proximal femur
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