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Exploring drug delivery systems for treating osteoporosis
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MSTS 2018 - Femur Mets and MM
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Introduction: Osteoporosis (OP) is a major disease in elderly people; its complications and prevalence are rapidly increasing worldwide. It is associated with high fragility fracture mainly of hip, wrist and spine. With the rising lifespan worldwide, the number of hip fractures throughout globe will rise from 1.66 million in 1990 to 6.26 million by 2050. So there is a major problem in our society related to the bone diseases which needs to be addressed. Areas covered: This review gives knowledge about OP, its symptoms and problems associated with the existing therapies. It gives idea about various drug delivery systems for bone targeting. This review also gives a comprehensive compilation of the various in vitro and in vivo studies conducted till date and US FDA approved drugs for the treatment of OP. Expert opinion: Various drug delivery systems reduce the adverse effects of drugs and increase the availability of drugs to the target site mainly bones. Active researches are going on to improve the OP treatment, whose high prevalence and considerable functional and socioeconomic impact will raise formidable challenges in the near future. We should work on different targets rather than conventional therapies which will improve the overall treatment strategies. © Informa UK, Ltd.
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Complications in the Management of Distal Radius Fractures: How Do We Avoid them?
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Distal Radius Fractures
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PURPOSE OF THIS REVIEW: Distal radius fractures are one of the most common fractures in the upper extremity. The purpose of this review is to outline common complications that may arise when caring for distal radius fractures and to describe the treatment strategies when faced with such complications.
RECENT FINDINGS: Tendon complications are not uncommon after distal radius fractures. Recent literature highlights new plating technology for dorsal plating techniques. Moreover, new literature has outlined parameters for flexor tendon complications when using volar locking plates in an effort to avoid flexor tendon irritation and rupture. In summary, it is important to understand the various complications that can arise when treating distal radius fractures in an effort to avoid suboptimal outcomes.
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A patient-specific model of the biomechanics of hip reduction for neonatal Developmental Dysplasia of the Hip: Investigation of strategies for low to severe grades of Developmental Dysplasia of the Hip
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Developmental Dysplasia of the Hip 2020 Review
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A physics-based computational model of neonatal Developmental Dysplasia of the Hip (DDH) following treatment with the Pavlik Harness (PV) was developed to obtain muscle force contribution in order to elucidate biomechanical factors influencing the reduction of dislocated hips. Clinical observation suggests that reduction occurs in deep sleep involving passive muscle action. Consequently, a set of five (5) adductor muscles were identified as mediators of reduction using the PV. A Fung/Hill-type model was used to characterize muscle response. Four grades (1-4) of dislocation were considered, with one (1) being a low subluxation and four (4) a severe dislocation. A three-dimensional model of the pelvis-femur lower limb of a representative 10 week-old female was generated based on CT-scans with the aid of anthropomorphic scaling of anatomical landmarks. The model was calibrated to achieve equilibrium at 90° flexion and 80° abduction. The hip was computationally dislocated according to the grade under investigation, the femur was restrained to move in an envelope consistent with PV restraints, and the dynamic response under passive muscle action and the effect of gravity was resolved. Model results with an anteversion angle of 50° show successful reduction Grades 1-3, while Grade 4 failed to reduce with the PV. These results are consistent with a previous study based on a simplified anatomically-consistent synthetic model and clinical reports of very low success of the PV for Grade 4. However our model indicated that it is possible to achieve reduction of Grade 4 dislocation by hyperflexion and the resultant external rotation.
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Literature-guided recommendations for otolaryngologists during the COVID-19 pandemic: A contemporary review
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Coronavirus Disease 2019 (COVID-19)
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Objective: The objective of this study was to review the current literature and guidelines on management of the novel coronavirus 2019 (COVID-19 or 2019nCoV) with respect to the field of Otolaryngology. Design: Contemporary literature review. Methods: Systematic literature review of global medical literature databases and communications were queried to find all available literature recommendations, research, and guidelines applicable to otolaryngologists in the COVID-19 pandemic. Results: Guidance on personal protective equipment, office visits, and surgical scheduling, as well as recommendations for safe airway management and tracheotomy performance during the COVID-19 pandemic were compiled and interpreted. Conclusions: Little guidance exists for otolaryngologists who are among the highest risk groups during the rapidly evolving COVID-19 pandemic. This synthesis and compilation of global resources serve as a building block for further guidance during the epidemic. Level of Evidence: NA.
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Pseudoaneurysm of the distal thigh after manipulation of a total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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The authors describe a unique complication after manipulation of a stiff total knee arthroplasty in a 47-year-old man. Four days after undergoing manipulation under anesthesia (MUA), the patient presented with increasing pain and swelling of the affected knee and decreased hemoglobin/hematocrit. Computed tomographic angiogram revealed a ruptured pseudoaneurysm of a segmental branch of the deep femoral artery that was treated with embolization and anterior thigh compartment fasciotomy. Although many complications of MUA have been described, we present a novel finding of a ruptured pseudoaneurysm. Ruptured pseudoaneurysm should be included in the differential diagnosis whenever a patient presents with pain and swelling of the thigh after MUA given its potential morbidity
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Hip fractures: a future epidemic?
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Management of Hip Fractures in the Elderly
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Recent studies from the United Kingdom and Sweden have demonstrated a dramatic rise in the number of people with hip fractures. It is our hypothesis that New Zealand is experiencing a similar rise in the number of hip fractures. The number of elderly people (over age 65 years) admitted to public hospitals in New Zealand over a 38-year period was reviewed. In people over age 75 years, we observed a disproportionate increase in the number of fractures compared with the increase in population. The highest risk group was women over age 85 years. Because of the differing age-specific fracture rates, the proportion of females over age 85 increased from 17% in 1950 to 40% by 1987. Through weighted regression analysis of fracture rate and population predictions, the projected number of fractures in the year 2001 and 2011 was predicted. By 2011 the number of people sustaining hip fractures will more than double. The proportion of the very elderly (85+) will increase from 40 to 65%
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Performance of comorbidity measures for predicting outcomes in population-based osteoporosis cohorts
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Management of Hip Fractures in the Elderly
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The performance of five comorbidity measures, including the Charlson and Elixhauser indices, was investigated for predicting mortality, hospitalization, and fracture outcomes in two osteoporosis cohorts defined from administrative databases. The optimal comorbidity measure depended on the outcome of interest, although overall the Elixhauser index performed well. INTRODUCTION: Studies that use administrative data to investigate population-based health outcomes often adopt risk-adjustment models that include comorbidities, conditions that coexist with the index disease. There has been limited research about the measurement of comorbidity in osteoporotic populations. The study purpose was to compare the performance of comorbidity measures for predicting mortality, fracture, and health service utilization outcomes in two cohorts with diagnosed or treated osteoporosis. METHODS: Administrative data were from the province of Saskatchewan, Canada. Osteoporosis cohorts were identified from diagnoses in hospital and physician data and prescriptions for osteo-protective medications using case definitions with high sensitivity or high specificity. Five diagnosis- and medication-based comorbidity measures and five 1-year outcomes, including mortality, hospitalization (two measures), osteoporotic-related fracture, and hip fracture, were defined. Performance of the comorbidity measures was assessed using the c-statistic (discrimination) and Brier score (prediction error) for multiple logistic regression models. RESULTS: In the specific cohort (n = 9,849) for the mortality outcome, the Elixhauser index resulted in the largest improvement (8.96%) in the c-statistic and lowest Brier score compared to a model that contained demographic and socioeconomic variables, followed by the Charlson index (6.06%). For hospitalization, the number of different diagnoses resulted in the largest improvement (14.01%) in the c-statistic. The Elixhauser index resulted in significant improvements in the c-statistic for osteoporosis-related and hip fractures. Similar results were observed for the sensitive cohort (n = 28,068). CONCLUSIONS: Recommendations about the optimal comorbidity measure will vary with the outcome under investigation. Overall, the Elixhauser index performed well
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Quality assurance and adverse event management in regenerative medicine for knee osteoarthritis: Current concepts
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PRP (Platelet-Rich Plasma)
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The economic and human cost of knee osteoarthritis is forecast to increase. This will impact not only aging individuals, but also the working age members of emerging economies. The current treatment pathways are often costly, time-consuming, and insufficient to manage the degeneration of the knee over the ever-increasing lifespan of patients around the world. In response to the shortcomings of a focus on symptom management, international and high-impact regulators, researchers, clinicians, and most importantly patients, are increasingly interested in the possible management of knee osteoarthritis with novel therapies in the field of regenerative medicine treatments. Regenerative medicine is an emerging discipline whose adherents aim to use the tools of the human body to address underlying dysfunction, leading to lasting repair of damaged tissues and structures. The evidence base lacks consensus on issues related to safety, efficacy, cost-efficiency, and treatment specifications. In this current concepts review, we describe the potential impact of regenerative medicine for knee osteoarthritis and evaluate literature of the past decade for elements related to the quality of clinical research. Finally, we discuss strategies for improving the evidence base for the future. The results of the review reveal that the typical follow-up period for most clinical research into the area is between 6 and 12 months; local ethics board approval is commonly reported, and that Platelet-Rich Plasma is the most common option explored. However, several quality elements were lacking in this cohort of recent literature: cost efficacy data, long-term follow-up, and detailed adverse event reporting. In order to address these weaknesses in the literature, patient outcomes registries are needed, in order to satisfy the need for longer follow-up for individuals receiving regenerative treatments, in addition to further clinical trials which address larger and more diverse patient populations. Transparency will be of utmost importance in further research and clinical translation of regenerative medicine for knee osteoarthritis.
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Inner ear and facial nerve complications of acute otitis media, including vertigo
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Acute otitis media is one of the most common diagnoses made in children in the United States. Intracranial and extracranial (intratemporal) complications have greatly decreased in the antibiotic era, but still remain a challenge when they arise. This article addresses two intratemporal complications with significant associated morbidity: facial nerve paralysis/paresis, and labyrinthitis. Epidemiology, pathology, clinical diagnosis, and treatment options are discussed, focusing on an evidence-based approach to diagnosis and management. In addition, the future of treatment and current questions regarding otitis media are briefly discussed
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Effect of high body mass index on knee muscle strength and function after anterior cruciate ligament reconstruction using hamstring tendon autografts
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Increased body mass index (BMI) has been associated with poorer function in patients who have undergone anterior cruciate ligament (ACL) reconstruction. However, the effect of high BMI on muscle strength in these patients remained unclear. The current study aimed to compare knee muscle strength and Knee injury and Osteoarthritis Outcome Score (KOOS) in ACL-reconstructed patients with a variety of different BMIs.
METHODS: From November 2013 to March 2016, we prospectively enrolled 30 patients who underwent ACL reconstruction (18-60 years of age). Anthropometric parameters, body compositions, isokinetic muscle strength and KOOS were assessed preoperatively, and at post-operative 16th week and 28th week. The patients were stratified into two groups by BMI, i.e. normal BMI (18.5-24.9 kg/m<sup>2</sup>) and high BMI (>=25.0 kg/m<sup>2</sup>).
RESULTS: Twelve patients in the normal BMI group completed the follow-up, while sixteen patients did so in the high BMI group. In comparison of muscle strength between baseline and 28th week follow-up, the normal BMI group had significant increases in overall knee muscle strength, while the high BMI group only had increases in extensors of uninjured knee and flexors of the injured knee. However, there were significant increases in all KOOS subscales for the high BMI group. The high BMI patients reported increased KOOS, which may reflect the contribution of ligament stability in the presence of inadequate muscle strength.
CONCLUSIONS: The normal BMI patients had improvement in all knee muscle strength following ACL reconstruction, while high BMI patients only had increases in certain knee muscles. High BMI patients had a decreased quadriceps muscle symmetry index, as compared to their normal BMI counterparts. Increases in quadriceps muscle strength of the uninjured knee and ACL reconstruction were associated with improvements in KOOS in high BMI patients.
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Biomechanical robustness of a new proximal epiphyseal hip replacement to patient variability and surgical uncertainties: A FE study
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Management of Hip Fractures in the Elderly
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The biomechanical behaviour of current hip epiphyseal replacements is notably sensitive to the typical variability of conditions following a standard surgery. The aim of the present study was to assess the biomechanical robustness to the variability of post-operative conditions of an innovative proximal epiphyseal replacement (PER) hip device featuring a short, curved and cemented stem. The risk of femoral neck fractures, prosthesis fractures and aseptic loosening were assessed through a validated finite element procedure following a systematic approach. Risk changes due to anatomical variations were assessed mimicking extreme conditions in terms of femoral size and level of osteoporosis. Failure risks associated with surgical uncertainties were assessed mimicking extreme conditions in terms of uncertainties on the prosthesis position/alignment, cement-bone interdigitation depth, and friction between the prosthesis and the hosting cavity. The femoral neck strength increased after implantation from 9% to 49% and was most sensitive to changes of the anatomo-physiological variables. The risk of stem fractures was low in all studied configurations. The risk of stem loosening was low and most sensitive to surgical uncertainties. In conclusion, the new device can be considered an effective alternative to current epiphyseal replacements. Care is recommended in a proper seating of the prosthesis in the femur. (copyright) 2011 IPEM
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Influence of refractive correction on peripheral visual field in static perimetry
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Upper Eyelid and Brow Surgery
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PURPOSE: To determine the influence of refractive errors on peripheral visual field thresholds in automated static perimetry. METHODS: In 47 subjects (age 16-49 years), the difference of perimetric thresholds was tested in the peripheral visual field without and with contact lens correction, using a custom-made program (Goldmann stimulus size III) with the automated perimeter Octopus 2000 R. Refractive errors ranged from -16.75 to +12.5 diopters. Sixty-four test locations on three concentric rings between 30 degrees and 50 degrees in 19 hyperopic and 28 myopic eyes were tested. RESULTS: All rings in myopic eyes revealed a significant influence of refraction on the differential light sensitivity in the peripheral visual field. In hyperopic eyes only the inner ring showed a significant influence of refraction. The decrease in sensitivity, measured in dB/diopter, for the myopic inner ring was 0.75; for the myopic middle ring it was 0.46; for the myopic outer ring it was 0.22; and for the hyperopic inner ring it was 0.40. CONCLUSIONS: A significant association between refractive errors and differential light sensitivity exists in the peripheral visual field of myopic eyes. Therefore, contact lens wear is recommended when performing automated perimetry of the peripheral visual field of myopic patients with higher refractive errors.
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Review of 65 cases of infective endocarditis in Dunedin Public Hospital
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND AND AIM: Infective endocarditis remains a challenging disease to manage. The objective of this study was to evaluate the management of patients diagnosed with infective endocarditis presenting to a regional hospital. METHODS: During the years 1997 to 2002, 65 episodes of bacterial endocarditis in 62 patients (20 female, 42 male; age range from 7-89 yrs, median 68 yrs) classified as definite or possible according to the Duke criteria were reviewed retrospectively. The demographic data, predisposing factors, echocardiographic findings, culture results, complications and mortality were recorded and analysed. RESULTS: Forty-five episodes (69%) were definite endocarditis and 20 episodes (31%) were possible endocarditis. All cases had undergone transthoracic or transoesophageal echocardiograms with vegetations found in 59 (91%) episodes. There were 49 cases of native valve endocarditis, 21 (34%) of whom had either congenital or acquired valvular disease. Fifteen cases (23%) were prosthetic valve endocarditis. One case was automated implantable cardioverter defibrillator leads endocarditis. Preceding dental or surgical manipulation was observed in 7 cases (11%). Aortic valve (38/59, 64%) was the most common valve involved followed by mitral valve (21/59, 36%). Staphylococcus aureus accounted for 20 episodes (31%), Streptococcus viridans for 16 episodes (25%), Enterococcus faecalis for 5 episodes (8%), other organisms for 9 episodes (14%), and culture negative endocarditis (CNE) for 15 episodes (23%). The majority of the cases had single valve involvement (50/59, 85%); only 9 cases (15%) were double valve endocarditis. Ten cases (15%) needed urgent valve replacement. The overall in-hospital mortality rate was 20% (13/65), and at 6 months was 31% (20/65). Higher 6-month mortality was seen in patients with Staphylococcus aureus endocarditis or CNE. CONCLUSIONS: Despite major advances in diagnostic technology, improvement in antimicrobial selection and monitoring, and progress in surgical techniques, the morbidity and mortality of bacterial endocarditis remain high
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Salivary levels of immunoglobulin A in triathletes
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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We investigated whether the physical exercise of an olympic distance triathlon affected the salivary IgA excretion of triathletes, as a biomarker for mucosal immune defence. 42 triathletes participated in the study. It was found that the salivary flow rate was decreased significantly after the race, thereby resulting in a significant reduction of the total salivary IgA output. The salivary IgA concentration (mg IgA/ml) did not differ, but expressed as total salivary protein, a significant reduction was observed. This was on the account of the salivary protein concentration (mg protein/ml), which was significantly increased. In contrast to the IgA secretion, the salivary amylase activity was increased significantly after the race. Therefore, our data suggest that the exercise of a triathlon may decrease the level of IgA-mediated immune protection at the mucosal surface. As triathletes may during the race be exposed to micro-organisms present in the swimming water, a decreased IgA-mediated immunity during the race may pose triathletes at an increased risk of infections
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Developmental origins of osteoporosis: the role of maternal nutrition
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Management of Hip Fractures in the Elderly
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Osteoporosis is a major cause of morbidity and mortality through its association with age-related fractures. Although most effort in fracture prevention has been directed at retarding the rate of age-related bone loss, and reducing the frequency and severity of trauma among elderly people, evidence is growing that peak bone mass is an important contributor to bone strength during later life. The normal patterns of skeletal growth have been well characterised in cross-sectional and longitudinal studies. It has been confirmed that boys have higher bone mineral content, but not volumetric bone density, than girls. Furthermore, there is a dissociation between the peak velocities for height gain and bone mineral accrual in both genders. Puberty is the period during which volumetric density appears to increase in both axial and appendicular sites. Many factors influence the accumulation of bone mineral during childhood and adolescence, including heredity, gender, diet, physical activity, endocrine status, and sporadic risk factors such as cigarette smoking. In addition to these modifiable factors during childhood, evidence has also accrued that fracture risk might be programmed during intrauterine life. Epidemiological studies have demonstrated a relationship between birthweight, weight in infancy, and adult bone mass. This appears to be mediated through modulation of the set-point for basal activity of pituitary-dependent endocrine systems such as the hypothalamic-pituitary-adrenal (HPA) and growth hormone/insulin-like growth factor-1 (GH/IGF-1) axes. Maternal smoking, diet (particularly vitamin D deficiency) and physical activity also appear to modulate bone mineral acquisition during intrauterine life; furthermore, both low birth size and poor childhood growth, are directly linked to the later risk of hip fracture. The optimisation of maternal nutrition and intrauterine growth should also be included within preventive strategies against osteoporotic fracture, albeit for future generations
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Is the physician office of the wild, wild west of health care?
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Panniculectomy & Abdominoplasty CPG
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Elective, office-based surgery has captured the interest of consumers and, more recently, the attention of state health care regulatory agencies. In most states today, patients can undergo cosmetic surgery, liposuction, endoscopy, colonoscopy, microlaparoscopy, and various other procedures requiring sedation or anesthesia in physician offices even though no regulatory safeguards that would ordinarily benefit patients in accredited or licensed facilities exist. Media accounts of deaths and serious injuries associated with liposuction and anesthesia performed in physician offices resulted in legislative and regulatory initiates, such as those in California and New Jersey. Increased regulatory oversight, changes in patterns of reimbursement, and greater consumer awareness of safety and quality-of-care issues should aid in reducing the risks of office-based surgery.
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Comparison between 1-hour and 24-hour drain clamping using diluted epinephrine solution after total knee arthroplasty
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AAHKS (8) Anesthetic Infiltration
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A prospective study was conducted to determine the optimal clamping time in the drain-clamping method after total knee arthroplasty. In a randomized trial, 44 primary total knee arthroplasties were studied after the drain-clamping method using diluted epinephrine solution was applied for 1 hour or 24 hours. The mean blood loss into the drains was less in the 24-hour group compared with the 1-hour group (35 mL in the 24-hour group and 247 mL in the 1-hour group). No statistically significant difference was found in hemoglobin or hematocrit levels between the 2 groups after surgery. Only 1 patient (4.5%) in the 1-hour group and 2 patients (9.1%) in the 24-hour group received blood transfusion. There were significantly more complications in the 24-hour group (P <.05). Two patients (9.1%) in this group required additional surgery. One-hour clamping is preferable to 24-hour clamping in the drain-clamping method for minimizing complications.
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1 |
Concomitant factors leading to an atypical osteonecrosis of the jaw in a patient with multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Osteonecrosis of the jaw (ONJ) is a site specific osseous pathology, characterized by chronic exposed bone in the mouth, which needs to be reinforced periodically within the medical literature. ONJ is a clinical entity with many possible aetiologies and its pathogenesis is not well understood. The risk factors for ONJ include bisphosphonates treatments, head and neck radiotherapy, dental procedures involving bone surgery, and trauma. Management of ONJ has centred on efforts to eliminate or reduce severity of symptoms, to slow or prevent the progression of disease, and to eradicate diseased bone. This case describes a rare case of ONJ in a 64-year-old Caucasian male diagnosed with multiple myeloma stage III. The lesion was related to a traumatic injury during mastication. Eighteen months ago in the same area the molar 37 was extracted, achieving a complete satisfactory healing, when only 2 doses of zoledronic acid had been administered. Actinomyces bacterial aggregates were also identified in the microscopic analysis. The management of this osteonecrotic lesion included antibiotic treatment and chlorhexidine topical gel administration. The evolution was monitored every two weeks until patient's death. The authors provide a discussion of the etiology, pathogenesis, diagnosis, and management. This case report may shed light on the controversies about concomitant factors and mechanisms inducing ONJ.
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Minimally invasive unicondylar arthroplasty: eight-year follow-up
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Surgical Management of Osteoarthritis of the Knee CPG
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This retrospective study reports the senior author's (J.A.R.) results with minimally invasive unicondylar knee arthroplasty (UKA). A total of 136 UKAs were performed in 1992 for the treatment of unicondylar osteoarthrosis. The surgical technique involves a limited medial parapatellar incision that reduces perioperative morbidity and bone preparation techniques that emphasize preservation of bone for future arthroplasty procedures. At 8 years, 4% of Ahlback stage 2 and 3 patients had undergone revision. Minimally invasive UKA provides a low morbidity alternative treatment for symptomatic medial compartment osteoarthritis
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Incidence and risk factors of delirium in the elderly general surgical patient
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Hip Fx in the Elderly 2019
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Background This study evaluates the incidence of delirium and risk factors associated with delirium in elderly patients admitted to a general surgical ward. Methods Patients aged over 60 years who were admitted with an acute or elective general surgical diagnosis were eligible for this prospective cohort study. Risk factors associated with delirium were analyzed using univariate and multivariate analysis to identify those independently associated with delirium. Results A total of 209 patients were included in the study. The incidence of delirium was 16.9% (23.2% for acute admission, P <.001). Variables associated with delirium were dementia, presence of an urinary catheter, cognitive decline at admission measured with the mini-mental state examination, white blood cell count >10.0 � 109/L, and urea >7.5 mmol/L. Median length of hospital stay was 13 days (range 3-85) for patients with delirium versus 7 (range 1-54) for patients without (P =.002). Conclusions The incidence of delirium is high in elderly patients, especially after an acute admission, leading to an increase in length of hospital stay. To minimize delirium, associated risk factors must be identified and, if possible, treated. © 2014 Elsevier Inc. All rights reserved.
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Segmental fractures of the tibia treated by circular external fixation
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PJI DX Updated Search
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We have carried out a retrospective review of 20 patients with segmental fractures of the tibia who had been treated by circular external fixation. We describe the heterogeneity of these fractures, their association with multiple injuries and the need for multilevel stability with the least compromise of the biology of the fracture segments. The assessment of outcome included union, complications, the measurement of the functional IOWA knee and ankle scores and the general health status (Short-form 36). The mean time to union was 21.7 weeks (12.8 to 31), with no difference being observed between proximal and distal levels of fracture. Complications were encountered in four patients. Two had nonunion at the distal level, one a wire-related infection which required further surgery and another shortening of 15 mm with 8 degrees of valgus which was clinically insignificant. The functional scores for the knee and ankle were good to excellent, but the physical component score of the short-form 36 was lower than the population norm. This may be explained by the presence of multiple injuries affecting the overall score
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Does ifosfamide therapy improve survival of patients with dedifferentiated chondrosarcoma?
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MSTS 2022 - Metastatic Disease of the Humerus
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Background: Dedifferentiated chondrosarcoma remains a significant therapeutic challenge. Studies performed to date have not identified efficacious chemotherapy regimens for this disease. Questions/purposes: We sought to (1) evaluate the disease-specific survival at 2 and 5 years of patients with dedifferentiated chondrosarcoma; (2) assess the prognostic variables (both patient- and treatment-related), including the use of chemotherapy with ifosfamide, that relate to survivorship; and (3) assess specific toxicities associated with ifosfamide use. Methods: Data from 41 patients with dedifferentiated chondrosarcoma diagnosed and treated at the University of Texas MD Anderson Cancer Center from 1986 to 2010 were analyzed for demographics, treatments, oncologic outcomes, and prognostic variables. There were 14 women and 27 men. The mean age at diagnosis was 58 years (range, 26-86 years). Seven patients presented with metastasis. Surgical resection alone was performed in 11 patients; resection and chemotherapy in 26 patients; resection and radiotherapy in two patients; and resection, chemotherapy, and radiotherapy in two patients. Ifosfamide-based regimens were used for 16 patients. In general, ifosfamide was used when the tumor was located in the trunk or if cisplatin was discontinued as a result of toxicity. Minimum followup was 8 months (median, 68 months; range, 8-281 months). Survival was estimated using Kaplan-Meier plots and analyzed by using the Cox proportional hazards model. Results: Disease-specific survival rates at 2 and 5 years were 33% and 15%, respectively. Multivariate analysis revealed that treatment without ifosfamide-based chemotherapy was the only independent negative prognostic factor for disease-specific survival (hazard ratio, 0.4; 95% confidence interval, 0.17-0.92; p = 0.03). Ifosfamide was discontinued in a patient as a result of renal dysfunction and was decreased in dose in another patient who developed encephalopathy. Conclusions: In this small retrospective study, it appeared that ifosfamide-based adjuvant chemotherapy combined with surgical resection offered a treatment advantage compared with patients who did not receive the drug in patients with dedifferentiated chondrosarcoma, although disease-specific survival for patients who have this rare tumor remains dismal. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. © The Association of Bone and Joint Surgeons® 2013.
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Anaerobes in the upper respiratory tract in infancy
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Development of the indigenous microbiota begins on the surfaces of the human body after birth when infants are exposed to continuous person-to-person and environmental contacts with microbes. Anaerobes constitute a significant part of indigenous bacterial communities at different body sites. Pioneering anaerobic commensals are able to colonize and survive in the oral cavity during the first months of life. After teeth emerge, more attachment sites and potential niches are available for anaerobic bacterial colonization. Specific partner relationships influence the composition and stability of forming multigeneric communities, biofilms, where Fusobacterium nucleatum is of specific interest. In infancy, the oral colonization seems to be rather stable at species level, though not at clonal level. The colonization pattern in the nasopharynx is different from that in the oral cavity; anaerobes are absent from healthy nasopharynges but transiently colonize this anatomical site during infection. The most plausible origin for nasopharyngeal anaerobes is the oral cavity and, conceivably, saliva is the most likely transmission vehicle. Whether anaerobic bacteria colonize the nasopharynx just because of ecological changes favoring their growth or whether they could play an active role in the pathogenesis of respiratory infections is not known. (copyright) 2005 Elsevier Ltd. All rights reserved
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Combined Fractures of the Scaphoid and Distal Radius: Evaluation of Early Surgical Fixation (21 Patients with 22 Wrists)
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Distal Radius Fractures
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<b>Introduction</b> The purpose of this retrospective study, is to evaluate the clinical and functional results of early surgical fixation of the ipsilateral distal radius and scaphoid fractures in 22 of 21 patients. <b>Patients and
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Review of the long-term disability associated with hip fractures
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HipFx Supplemental Cost Analysis
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OBJECTIVES: To determine the proportion of hip fracture patients who experience long-term disability and to re-estimate the resulting burden of disease associated with hip fractures in Australia in 2003. METHODS: A literature review of the functional outcome following a hip fracture (keywords: morbidity, treatment outcome, disability, quality of life, recovery of function, hip fractures, and femoral neck fractures) was carried out using PubMed and Ovid MEDLINE. RESULTS: A range of scales and outcome measures are used to evaluate recovery following a hip fracture. Based on the available evidence on restrictions in activities of daily living, 29% of hip fracture cases in the elderly do not reach their pre-fracture levels 1 year post-fracture. Those who do recover tend to reach their pre-fracture levels of functioning at around 6 months. These new assumptions result in 8251 years lived with disability for hip fractures in Australia in 2003, a 4.5-fold increase compared with the previous calculation based on Global Burden of Disease assumptions that only 5% of hip fractures lead to long-term disability and that the duration of short-term disability is just 51 days. CONCLUSIONS: The original assumptions used in burden of disease studies grossly underestimate the long-term disability from hip fractures. The long-term consequences of other injuries may similarly have been underestimated and need to be re-examined. This has important implications for modelling the cost-effectiveness of preventive interventions where disability-adjusted life years are used as a measure of health outcome
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0 |
Low rate of Propionibacterium acnes in arthritic shoulders undergoing primary total shoulder replacement surgery using a strict specimen collection technique
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Glenohumeral Joint OA
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BACKGROUND: Propionibacterium acnes is a recognized pathogen in postoperative shoulder infections. A recent study reported growth of P acnes in 42% of glenohumeral joints in primary shoulder arthroplasty, concluding that P acnes may cause shoulder osteoarthritis. Whether these results reflect true bacterial infection or specimen contamination is unclear. Our prospective study aimed to determine the rate of P acnes infection in arthritic shoulders using a strict specimen collection technique.
METHODS: We used modified Oxford protocol to collect tissue specimens from the glenohumeral joint of 32 consecutive patients undergoing primary shoulder arthroplasty. Specimens were cultured specifically for P acnes. Diagnosis of P acnes infection required 2 or more positive cultures and histopathology compatible with infection.
RESULTS: Three of 32 patients had a positive culture for P acnes. Overall, 3.125% of specimens grew P acnes without histologic evidence of infection. There were no patients with P acnes infection. The difference in culture rates between patients with idiopathic osteoarthritis and those with a predisposing cause for osteoarthritis was not significant.
CONCLUSIONS: We found a low rate of positive cultures for P acnes, but no P acnes infection and no difference between types of osteoarthritis. These results do not support a cause-and-effect relationship between P acnes and osteoarthritis. The differing results from previous studies are likely explained by our strict specimen collection technique, reflecting different rates of contamination rather than infection. That P acnes contamination occurs in primary shoulder arthroplasty is concerning. Further studies are needed to assess the rates of contamination in shoulder surgery, its clinical effect, and to determine optimal antibiotic prophylaxis.
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"Salvage Microbiology": Detection of Bacteria Directly from Clinical Specimens following Initiation of Antimicrobial Treatment
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Surgical Management of Osteoarthritis of the Knee CPG
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Background:PCR coupled with electrospray ionization mass spectrometry (ESI-MS) is a diagnostic approach that has demonstrated the capacity to detect pathogenic organisms from culture negative clinical samples after antibiotic treatment has been initiated. [1] We describe the application of PCR/ESI-MS for detection of bacteria in original patient specimens that were obtained after administration of antibiotic treatment in an open investigation analysis.Methods:We prospectively identified cases of suspected bacterial infection in which cultures were not obtained until after the initiation of antimicrobial treatment. PCR/ESI-MS was performed on 76 clinical specimens that were submitted for conventional microbiology testing from 47 patients receiving antimicrobial treatment.Findings:In our series, 72% (55/76) of cultures obtained following initiation of antimicrobial treatment were non-diagnostic (45 negative cultures; and 10 respiratory specimens with normal flora (5), yeast (4), or coagulase-negative staphylococcus (1)). PCR/ESR-MS detected organisms in 83% (39/47) of cases and 76% (58/76) of the specimens. Bacterial pathogens were detected by PCR/ESI-MS in 60% (27/45) of the specimens in which cultures were negative. Notably, in two cases of relapse of prosthetic knee infections in patients on chronic suppressive antibiotics, the previous organism was not recovered in tissue cultures taken during extraction of the infected knee prostheses, but was detected by PCR/ESI-MS.Conclusion:Molecular methods that rely on nucleic acid amplification may offer a unique advantage in the detection of pathogens collected after initiation of antimicrobial treatment and may provide an opportunity to target antimicrobial therapy and "salvage" both individual treatment regimens as well as, in select cases, institutional antimicrobial stewardship efforts. 2013 Farrell et al
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Clinical outcomes and quality of life after total hip arthroplasty in adult patients with a history of infection of the hip in childhood: a mid-term follow-up study
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Hip Fx in the Elderly 2019
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BACKGROUND: Total hip arthroplasty for adult patients with a history of infection of the hip in childhood could be a more technically demanding procedure due to complicated anatomy and the possibility of reinfection. Here, we conducted a mid-term analysis of clinical outcomes in such patients after primary cementless total hip arthroplasty (THA).
METHODS: We reviewed 101 patients (101 hips; 51 men; mean age, 52.3 years) who underwent cementless THA between 2008 and 2015, at a mean of 24 years (range, 11-43) since the resolution of childhood hip infection. Patients were followed up for a mean of 6.1 years (range, 2.1-9.6). Clinical outcomes and quality of life after THA were assessed at final follow-up.
RESULTS: No cases of infection were reported during the follow-up, and patients showed significant improvement in Harris Hip Score, for which the mean score increased from 48.5 to 90 points; the modified Merle d'Aubigne and Postel (MAP) Hip Score; the Hip Dysfunction and Osteoarthritis Outcome Score; the SF-12; and mean limb length discrepancy, which decreased from 3.4 to 1.1 cm. During follow-up, four cases of prosthesis dislocation, three of transient sciatic paralysis, seven of femoral fracture, five of heterotopic ossification, and 19 of osteolysis were recorded. Revision surgery was performed for two patients, one for isolated loosening of the acetabular component and another for loosening of the femoral stem.
CONCLUSION: Cementless THA can effectively treat patients with a quiescent period of infection of the hip of more than 10 years, resulting in good functional outcomes and fewer complications. Risk of infection recurrence after THA in these patients seems extremely low.
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Effect of Lateral Gutter Osteophyte Resection on Correction of Varus Deformity in Arthroscopic Ankle Arthrodesis
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Recently, arthroscopic ankle arthrodesis has been performed for moderate-to-severe varus-deformed ankle osteoarthritis. However, the effect of osteophyte resection in the lateral gutter in arthroscopic ankle arthrodesis has not been clarified. We hypothesized that a varus-deviated ankle with lateral gutter osteophytes can be corrected by osteophyte resection. Methods: Thirty-nine ankles of 38 patients were included. The mean age of patients was 70.0 (45-83) years. The patients were divided into the following groups: group with an osteophyte in the lateral gutter (osteophyte) and group with no osteophytes (nonosteophyte). Preoperative and postoperative tibiotalar angle, tibial plafond angle, and tibiotalar angle under valgus stress, as well as the Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale, were recorded. Twelve ankles underwent lateral gutter osteophyte resection, whereas the other 27 ankles did not require osteophyte resection. Results: Preoperative tibiotalar angle was higher in the osteophyte group than in the nonosteophyte group (21.8 vs 11.2 degrees, P =.01). The tibiotalar angle in the preoperative valgus stress imaging was higher in the osteophyte group (12.9 vs 5.7, P <.01). However, the postoperative tibiotalar angle was similar between the 2 groups (7.1 vs 5.4, P =.183). JSSF ankle/hindfoot scale improved in both groups. Conclusion: Lateral gutter osteophyte resection enabled correction of the varus malalignment in arthroscopic ankle arthrodesis. Level of Evidence: Level III, retrospective comparative series.
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Mortality and rehabilitation following hip fracture. A study of 202 elderly patients
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Management of Hip Fractures in the Elderly
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We retrospectively analyzed 202 patients admitted between 1990 and 1994 with femoral neck or trochanteric fracture. The age of the patients ranged between 52 and 95 years and all 202 patients were surgically managed, with either screw fixation, screw and plate fixation or hemiarthroplasty, depending upon the fracture type and the patient's age. Overall, mortality was 18% during the first year, being higher in the elderly, and in patients with cardiorespiratory diseases. In addition, if the operation was delayed more than 3 days or if hemiarthroplasty was performed, the rate of death was higher. Rehabilitation was difficult if patient had cardiorespiratory diseases or had difficulty in walking before the operation
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1 |
The influence of anesthetic techniques on postoperative cognitive function in elderly patients undergoing hip fracture surgery: General vs spinal anesthesia
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Hip Fx in the Elderly 2019
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BACKGROUND: Hip fracture is common and morbid in elderly patients. Postoperative cognitive dysfunction (POCD) is also very common in these subjects undergoing surgery with an incidence which exceeds 40% in some reports. To date, the evidence is ambiguous as to whether anesthetic technique may affect the patients' outcome as far as postoperative cognitive function is concerned.
OBJECTIVE: The aim of this study was to compare the effect of general and subarachnoid (spinal) anesthesia on the development of POCD up to 30 days after surgery in elderly patients undergoing hip fracture surgery. Methods Subjects over 65 years with hip fracture undergoing surgery were recruited for this study. They were enrolled and randomized to receive either general anesthesia (GA group) or subarachnoid (spinal) anesthesia (S group). Cognitive function was assessed using a battery of neuropsychological tests undertaken preoperatively and at 30 days postoperatively. The incidence of delirium was examined during the same period and their functional status, in terms of activities of daily living was also recorded.
RESULTS: A total of seventy patients, 33 men and 37 females, mean age of 76 years were analyzed. Thirty-three patients received general anesthesia (GA group) and 37 subarachnoid (spinal) anesthesia (S group). The two groups of patients were similar with respect to baseline characteristics, comorbidities and perioperative data. The results of neuropsychological testing showed that there were no significant differences between the groups in eight out of ten neurocognitive tests at baseline and 30 days after surgery. There was a statistically significant decline of the Instrumental Activities of Daily Living Scale score in S group compared with group GA on the 30th postoperative day (p = 0.043). A significant decline was also present in Color-Word Task test in S group compared with group GA at baseline (p = 0.014) and 30 days postoperatively (p = 0.003). Postoperative delirium was present in four patients (12%) for the GA group, and in 10 patients (27%) for the group receiving subarachnoid anesthesia.
CONCLUSION: We concluded that the choice of anesthesia modality does not appear to influence the emergence of postoperative cognitive dysfunction in elderly patients undergoing hip fracture surgery.
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Revision total hip arthroplasty with a modular cementless femoral stem
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Hip Fx in the Elderly 2019
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We retrospectively reviewed 123 patients who underwent cementless THA with modular femoral stem designs for revision THA or conversion of failed ORIF and found 75 patients available for analysis. The Harris Hip Score (HHS) improved from 52 +/- 14 to 86 +/- 11 (P < 0.001). The femoral stem was re-revised in eight patients (11%). The mean time to re-revision was 1.1years (0.13-2.54). Reasons for re-revision included infection (n = 5, 7%), aseptic loosening (n = 2, 3%) and significant pain (n = 1, 1%). There were no failures of the modular junctions. PC stems had an increased rate of intraoperative fractures (PC 28% vs. STS 9%, P = 0.04). Modular cementless femoral stems provide acceptable mid-term results in revision THA.
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Role of Periarticular Liposomal Bupivacaine Infiltration in Patients Undergoing Total Knee Arthroplastyâ??A Meta-analysis of Comparative Trials
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AAHKS (9/10) Regional Nerve Blocks
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Background Over last 2 years, many trials have evaluated newly approved liposomal bupivacaine for periarticular infiltration in total knee arthroplasty (TKA) with mixed results. Our meta-analysis attempts to consolidate the results and make evidence-based conclusions. Methods Trails comparing periarticular infiltration of liposomal bupivacaine to conventional analgesic regimens for total knee arthroplasty published till June 2016 were searched in medical database. Comparisons were made for length of stay (LOS), postoperative pain scores, range of motion, and opioid consumption. Meta-regression was performed for LOS to evaluate various analgesic control subgroups. Results Sixteen trials were included in the final analysis. Liposomal bupivacaine group showed a shorter LOS (reported in 13 subgroups) than control group by 0.17 ± 0.04 days (random effects, P <.001, I2 = 84.66%). Meta-regression for various types of control showed a predictability (R2) of 73%, Ï?2 = 0.013 (random effects, P <.001, I2 = 45.16). Only femoral block subgroup attained statistically significant shorter LOS on splitting the control group. Numeric pain scores were lower for pooled control group and local anesthetic infiltration subgroup in immediate postoperative phase. Second postoperative day analgesia was statistically superior to overall clubbed controls and femoral block subgroup. Superiority and/or inferiority of liposomal bupivacaine could not be proven for opioid consumption and range of motion because of a small pooled sample size. Publication bias is likely for LOS (Egger test, X intercept = 2.42, P <.001). Conclusion Liposomal bupivacaine infiltration has questionable clinical advantage, as it marginally shortens patient's hospital stay especially in comparison with patients receiving analgesic femoral nerve block. Compared with conventional regimens, it can provide slightly superior yet sustained (till second postoperative day) perioperative analgesia. High heterogeneity suggests need for standardization of infiltration techniques for better predictability of results.
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Application of damage control orthopedics in 41 patients with severe multiple injuries
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DoD SSI (Surgical Site Infections)
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OBJECTIVE: To probe the feasibility and efficacy of damage control orthopedics (DCO) in treating severe multiple injuries.
METHODS: A retrospective analysis was made on the clinical data of 41 patients (31 males and 10 females, aged 18-71 years, mean: 36.4) with multiple injuries admitted to our department and treated by DCO from January 1995 to December 2005.
RESULTS: As a first-stage therapy, devascularization of internal iliac arteries was performed in 29 patients with pelvic fractures combined with massive bleeding, including ligation of bilateral internal iliac arteries in 21 patients and embolization of bilateral internal iliac arteries in 8. And early external fixation of pelvis was performed in 10 patients. Ten patients with severe multiple injuries combined with femoral fractures were managed with primary debridement and temporal external fixation and 2 patients with spinal fractures combined with spinal cord compression received simple laminectomy. Thirty-one patients received definite internal fixation after resuscitation in intensive care unit. The overall mortality rate was 12.1% (5/41) with an average injury severity score of 41.4. The main causes of death were hemorrhagic shock and associated injuries. Complications occurred in 7 patients including acute respiratory distress syndrome in 3 cases, thrombosis of right common iliac artery in 1, subphernic abscess in 2 and infection of deep wound in lower extremity in 1. After treatment, all the patients got cured.
CONCLUSIONS: Prompt diagnosis and integrated treatment are keys to higher survival rate in patients with severe multiple injuries. In this condition, DCO is an effective and safe option.
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Prosthetic joint infection due to Mycobacterium tuberculosis: report of three cases
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Prosthetic joint infection due to Mycobacterium tuberculosis is uncommon. We describe three patients with delayed tuberculous prosthetic joint infection and review the eight other cases reported in the English-language literature. Infection results from local reactivation, which can occur up to 40 years after the initial infection, or from hematogenous spread. The diagnosis is often delayed because it is not considered in the initial evaluation, because it is difficult to confirm microbiologically, or because other bacteria may be isolated from the synovial fluid and thus be considered the etiology of the infection. Treatment usually consists of removal of the prosthesis in addition to administration of antituberculous agents
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N<sup>6</sup> -methyladenosine-modified circRNA RERE modulates osteoarthritis by regulating beta-catenin ubiquitination and degradation
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AMP (Acute Meniscal Pathology)
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OBJECTIVES: N<sup>6</sup> -methyladenosine (m6A) is one of the most abundant internal RNA modifications. We investigated the role of m6A-modified circRERE in osteoarthritis (OA) and its mechanism.
MATERIALS AND METHODS: CircRERE and IRF2BPL were screened by microarrays. The role of m6A-modification in circRERE was examined by methylated RNA precipitation and morpholino oligo (MOs) treatment. The axis of circRERE/miR-195-5p/IRF2BPL/beta-catenin was determined using flow cytometry, western blotting and immunofluorescence in human chondrocytes (HCs) and corroborated using a mouse model of destabilization of medial meniscus (DMM) with intra-articular (IA) injection of adeno-associated viruses (AAV).
RESULTS: CircRERE was decreased in OA cartilage and chondrocytes compared with control. CircRERE downregulation was likely attributed to its increased m6A modification prone to endoribonucleolytic cleavage by YTHDF2-HRSP12-RNase P/MRP in OA chondrocytes. MOs transfection targeting HRSP12 binding motifs in circRERE partially reversed decreased circRERE expression and increased apoptosis in HCs treated with IL-1beta for 6 h. CircRERE exerted chondroprotective effects by targeting miR-195-5p/IRF2BPL, thus regulating the ubiquitination and degradation of beta-catenin. CircRere (mouse homologue) overexpression by IA-injection of AAV-circRere into mice attenuated the severity of DMM-induced OA, whereas AAV-miR-195a-5p or AAV-sh-Irf2bpl reduced the protective effects. The detrimental effects of AAV-sh-Irf2bpl on DMM-induced OA were substantially counteracted by ICG-001, an inhibitor of beta-catenin.
CONCLUSIONS: Our study is a proof-of-concept demonstration for targeting m6A-modified circRERE and its target miR-195-5p/IRF2BPL/beta-catenin as potential therapeutic strategies for OA treatment.
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Vascular complications in orthopaedic patients treated by orthopaedic microsurgeons
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Management of Hip Fractures in the Elderly
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Over a 20 year period, five patients experienced serious vascular complications involving major arterial insult during various routine orthopaedic procedures. The nature of the vascular damage necessitated immediate surgical repair which was performed successfully by an orthopaedic microsurgeon who was either a member of the initial surgical team or the hospital's Orthopaedic Unit. The purpose of this study is to illustrate not only the severity of these limb and/or life-threatening complications, but also to focus attention on the importance of the orthopaedic surgeon's ability to manage these serious injuries promptly. This suggests the need for Orthopaedic Units to have surgeons with adequate training in microvascular techniques, so as to be able to successfully manage these unexpected and serious complications. We conclude that the presence of a vascular surgeon or an orthopaedic surgeon trained in microvascular surgery represents an invaluable attribute to the orthopaedic team, and minimizes, if not eliminates the potentially disastrous outcome from these serious intraoperative vascular complications
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A predictable outcome of a preventable disease
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Infective endocarditis is a systemic illness that can present with a variety of non-specific clinical symptoms. Patients with certain underlying heart valve abnormalities are at increased risk for development of infective endocarditis while undergoing minor procedures, particularly those associated with bacteremia by pathogens that typically cause infective endocarditis. We present a case of infective endocarditis that developed after a dental procedure in a patient with a previously undetected congential bicuspid aortic valve
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Simultaneous bilateral total knee arthroplasties: Who decides?
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Surgical Management of Osteoarthritis of the Knee CPG
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The purpose of the current retrospective review was to compare the results of 1498 patients having 1090 simultaneous bilateral total knee arthroplasties and 958 unilateral total knee arthroplasties in a 3-year period, focusing on perioperative complications, length of hospital stay, and discharge disposition. Gender, age, diagnosis, and weight were similar between the groups. Patients undergoing simultaneous bilateral total knee arthroplasties had statistically significant higher amounts of intraoperative blood loss, with more patients requiring blood transfusion, and a higher average number of units of blood transfused compared with patients undergoing unilateral total knee arthroplasty. Overall, a significantly higher incidence of gastrointestinal complications was reported in patients who had simultaneous bilateral knee arthroplasties compared with patients who had unilateral knee arthroplasty. Comparing age subgroups within the unilateral group revealed significantly higher incidences of pulmonary, neurologic, cardiac, and genitourinary complications among patients 80 years or older versus patients younger than 80 years. Patients having simultaneous bilateral arthroplasties who were 80 years or older had significantly higher incidences of pulmonary, neurologic, and cardiac complications than patients younger than 80 years in that same group. These results suggest that age, not procedure, has a more significant role in the perioperative morbidity of total knee arthroplasty. Based on the results from the current study and previous literature documenting patient preference, patient satisfaction, efficacy, and outcomes comparable with those of patients having unilateral total knee arthroplasty, the authors continue to offer patients the option of simultaneous bilateral total knee arthroplasties
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Popliteal Pseudoaneurysm After Total Knee Arthroplasty Secondary to Intraoperative Arterial Injury With a Surgical Pin. Review of the Literature
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Surgical Management of Osteoarthritis of the Knee CPG
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Pseudoaneurysms of the popliteal artery after total knee arthroplasty are rare. Although many possible explanations are proposed in the literature, no intimate mechanism of injury to the artery is previously described. We report on a case of popliteal pseudoaneurysm after a total knee arthroplasty that presented clinically on the second postoperative day. Open vascular surgery with resection of the pseudoaneurysm and end-to-end bypass of contralateral saphena vein graft was successfully performed. At the time of the surgery, a hole was clearly identified on the anterior wall of the popliteal artery due to a perforation with a pin used during the knee arthroplasty. The patient had no further complications. (copyright) 2008 Elsevier Inc. All rights reserved
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The influence of three-dimensional computed tomography images of the shoulder in preoperative planning for total shoulder arthroplasty
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Glenohumeral Joint OA
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BACKGROUND: Arthritic changes to glenoid morphology can be difficult to fully characterize on both plain radiographs and conventional two-dimensional computer tomography images. We tested the hypothesis that three-dimensional imaging of the shoulder would increase inter-rater agreement for assessing the extent and location of glenoid bone loss and also would improve surgical planning for total shoulder arthroplasty.
METHODS: Four shoulder surgeons independently and retrospectively reviewed the preoperative computed tomography scans of twenty-four arthritic shoulders. The blinded images were evaluated with conventional two-dimensional imaging software and then later with novel three-dimensional imaging software. Measurements and preoperative judgments were made for each shoulder with use of each imaging modality and then were compared. The glenoid measurements were glenoid version and bone loss. The judgments were the zone of maximum glenoid bone loss, glenoid implant fit within the glenoid vault, and how to surgically address abnormal glenoid version and bone loss. Agreement between observers was evaluated with use of intraclass correlation coefficients and the weighted kappa coefficient (kappa), and we determined if surgical decisions changed with use of the three-dimensional data.
RESULTS: The average glenoid version (and standard deviation) measured -17 degrees +/- 2.2 degrees on the two-dimensional images and -19 degrees +/- 2.4 degrees on the three-dimensional images (p < 0.05). The average posterior glenoid bone loss measured 9 +/- 2.3 mm on the two-dimensional images and 7 +/- 2 mm on the three-dimensional images (p < 0.05). The average anterior bone loss measured 1 mm on both the two-dimensional and the three-dimensional images. However, the intraclass correlation coefficients for anterior bone loss increased significantly with use of the three-dimensional data (from 0.36 to 0.70; p < 0.05). Observers were more likely to locate mid-anterior glenoid bone loss on the basis of the three-dimensional data (p < 0.05). The use of three-dimensional data provided greater agreement among observers with regard to the zone of glenoid bone loss, glenoid prosthetic fit, and surgical decision-making. Also, when the judgment of implant fit changed, observers more often determined that it would violate the vault walls on the basis of the three-dimensional data (p < 0.05).
CONCLUSIONS: The use of three-dimensional imaging can increase inter-rater agreement for the analysis of glenoid morphology and preoperative planning. Important considerations such as the extent and location of glenoid bone loss and the likelihood of implant fit were influenced by the three-dimensional data.
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Epidural and intravenous fentanyl infusions are clinically equivalent after knee surgery
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Surgical Management of Osteoarthritis of the Knee CPG
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The management of postoperative pain with continuous epidural fentanyl infusion was compared with continuous intravenous fentanyl infusion. In a randomized, doubleblind protocol we prospectively studied 20 patients undergoing repair of the anterior cruciate ligament of the knee. The quality of analgesia and the incidence of side effects were documented. Compared with patients receiving continuous intravenous fentanyl infusion, at 18 h postoperatively patients given continuous epidural fentanyl infusion reported similar pain scores both at rest (22 +/- 25 vs 27 +/- 21, P = 0.52) and with ambulation (59 +/- 18 vs 56 +/- 22, P = 0.82). Plasma fentanyl levels were 1.8 +/- 0.4 and 1.7 +/- 0.4 ng/mL (P = 0.91) for the intravenous and epidural groups, respectively. There were no significant differences in the incidence of nausea, pruritus, or urinary retention. There was no respiratory depression in either group. We conclude that when compared with continuous intravenous fentanyl infusion, continuous epidural fentanyl infusion offers no clinical advantages for the management of postoperative pain after knee surgery
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Treating civilian gunshot wounds to the extremities in a level 1 trauma center: our experience and recommendations
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Gunshot wounds impose a continuous burden on community and hospital resources. Gunshot injuries to the extremities might involve complex soft tissue, bone, vascular, musculotendinous, and nerve injuries. A precise knowledge of anatomy is needed to evaluate and treat those injuries.
OBJECTIVES: To review our experience with gunshot wounds to the extremities.
METHODS: We retrospectively reviewed all civilian cases of gunshot wounds to the limbs treated in our institution during 2003-2005. Altogether, we evaluated 60 patients with 77 injuries.
RESULTS: Of the 60 patients 36 had fractures, 75% of them in the lower extremity and 81% in long bones. The most common fixation modality used was external fixation (33%), followed by intramedullary nailing (25%). This relatively high percentage of fracture treated with external fixation may be attributed to the comminuted pattern of the fractures, the general status of the patient, or the local soft tissue problems encountered in gunshot wounds. About one-fifth of the fractures were treated by debridement only without hardware fixation. We treated 10 vascular injuries in 8 patients; 6 of them were injuries to the popliteal vessels. Fractures around the knee comprised the highest risk factor for vascular injuries, since 5 of the 12 fractures around the knee were associated with vascular injury requiring repair or reconstruction. There were 13 nerve injuries (16.8%), most of them of the deep peroneal nerve (38%). Only three patients had concomitant nerve and vascular injuries. The overall direct complication rate in our series was 20%.
CONCLUSIONS: To successfully treat complex gunshot injuries a team approach is necessary. This team should be led by an orthopedic surgeon knowledgeable in the functional anatomy of the limbs.
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Technique and results of external fixation of complex carpal injuries
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Distal Radius Fractures
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This article reviews the current indications and technique of external fixation of the wrist for complex carpal trauma. The results obtained in 24 consecutive patients with an average follow-up of 2.4 years are also presented.
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Review: minimally invasive versus conventional dynamic hip screw fixation in elderly patients with intertrochanteric fractures: a systematic review and meta-analysis
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Management of Hip Fractures in the Elderly
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The classic dynamic hip screw fixation of intertrochanteric fractures may be associated with significant blood loss and soft tissue damage, which may worsen existing comorbidities of frail elderly patients. Recently, minimally invasive dynamic hip screw (MIDHS) technique was developed for osteosynthesis of intertrochanteric fractures. A highly sensitive search strategy was used to identify all published randomized or quasi-randomized controlled trials (RCTs/ qRCTs) and comparative observational studies comparing the MIDHS technique with the conventional dynamic hip screw (CDHS) technique in patients with intertrochanteric fractures. A pooled estimate of effect size was produced using both random and fixed effects models. Four RCTs/qRCTs and 2 retrospective comparative studies were identified. The MIDHS technique resulted in less blood loss, shorter hospitalization, lower pain level, faster fracture healing, and better hip function when compared with the CDHS technique. There was no significance difference between the 2 groups with regard to postoperative complications and implant position. The MIDHS technique may achieve perioperative benefits when compared with the CDHS technique
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The history and evolution of percutaneous pinning of displaced distal radius fractures
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Distal Radius Fractures
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This article discusses the history and evolution of percutaneous pinning of displaced distal radial articular fractures. Six distinct methods are examined from an historical viewpoint, focusing on problems associated with each technique. The evolution of the Kapandji technique to include arum nuts and the Rayhack technique to include an alignment jig and pin guide with locking set screws is presented also. [References: 33]
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Management of an epidural abscess after continuous epidural catheter infusion
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To increase awareness of the possibility of epidural infection after continuous epidural infusion. Outline the salient diagnostic features of epidural infection. Outline a strategy to manage epidural infection and minimize morbidity.
SETTING: Academic multidisciplinary pain clinic.
PATIENT: A patient with a left knee meniscal tear with a history of Chronic Regional Pain Syndrome Type I (CRPS I) of the left foot.
INTERVENTIONS: Attempted control of CRPS I symptoms with a tunnelled epidural catheter infusion.
RESULTS AND CONCLUSIONS: The patient developed an epidural abscess diagnosed on the 11th postoperative day. The catheter was removed and the patient was treated successfully with intravenous antibiotics.
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Comparison of Two Multimodal Pain Regimens Used for Postoperative Pain Control in Total Joint Arthroplasty Patients
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AAHKS (4) Acetaminophen
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Postoperative pain control following total joint arthroplasty results in improved patient mobilization, participation in physical therapy, and potentially reduced hospital costs. It was hypothesized that using a multimodal pain protocol focusing on periarticular injections including liposomal bupivacaine would have improved results when compared with a parenteral opioid-based regimen. The results showed a decrease in length of stay and rate of discharge to skilled nursing facilities with the implementation of a novel multimodal pain protocol. Furthermore, there was no change in patient satisfaction before and after the execution of the new protocol. It was concluded that using a multimodal pain protocol based on periarticular injections can lead to decreased length of stay and a decrease in transfer to skilled nursing facilities without a change in patient satisfaction.
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Reconstructive vascular surgery and the extent of tissue damage due to diabetic foot ulcers relates to risk of new ulceration in patients with PAD
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DoD LSA (Limb Salvage vs Amputation)
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OBJECTIVE: There is limited information regarding new ulceration following the healing of ischaemic foot ulcers in diabetic patients. Our aim is to study new ulcerations in the same foot as the previous ulcer(s) in patients with diabetes and severe peripheral artery disease (PAD). METHOD: Patients with diabetes and severe PAD who healed from previous ulcer(s) (Wagner grade 1-5, at or below the ankle), were recruited for the prospective study from the time of healing of their ulcer. Patients were followed up regarding new ulceration, and their treatments and ulcer status noted either directly or on examination of medical records. RESULTS: We analysed the data on 602 patients with diabetes and severe PAD with healed foot ulcers, either primarily (n=443, 74%) or after minor amputation (n=159, 26%). Of these 51% (n=305) had revascularisation before healing from the previous ulcer, 34% (n=202) developed a new ulcer on the same foot within 15 months (range 0-106). Amputation was required by 22% (n=45) of patients, with a new ulcer on the same foot. The median survival time of all patients (n=602) was 54 months. By regression analysis, a low maximal Wagner grade for the previous ulcer and reconstructive vascular surgery was related to a decreased risk of developing new ulcers in the same foot. CONCLUSION: Patients with diabetes and ischaemic foot ulcers have a high-risk for developing new ulcers and amputation in the same foot after healing. The extent of tissue involvement in the previous ulcer and reconstructive vascular surgery affected the risk for development of new ulcers.
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Five-year clinical, microbiological, and radiological outcome following treatment of peri-implantitis in man
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Background: The aim of this study was to evaluate the long-term outcome of a combined surgical and antimicrobial treatment of peri-implantitis lesions in humans. Methods: Nine partially dentate individuals with titanium implants demonstrating a marginal bone loss of (greater-than or equal to) three threads as compared to baseline measurements made from 1-year intra-oral radiographs, bleeding on probing, and/or suppuration from the peri-implant sulci were included in the study. In each individual, subgingival bacterial samples were obtained and subjected to microbiological analysis by culture. Surgical exposure of the lesions and cleaning of the implants using hydrogen peroxide were performed. The patients were given systemic antibiotics according to a susceptibility test of target bacteria. The treatment was evaluated clinically, microbiologically, and radiograpically at 6 months, 1 year, and 5 years. Results: Seven out of 26 implants with peri-implantitis at baseline were lost during the 5-year follow-up period despite a significant reduction in the presence of plaque and gingival bleeding. Four implants continued to lose bone, 9 had an unchanged bone level, and 6 gained bone. Five of the patients were treated with antibiotics directed against putative periodontopathogens, i.e., A. actinomycetemcomitans, P. intermedia, or P. gingivalis; three patients were treated for presence of enterics (E. coli and E. cloace); and, in one patient, treatment was directed against S. aureus. Conclusions: Despite treatment and retreatment, seven implants were lost. However, the applied surgical and antimicrobial treatment strategy for advanced peri-implantitis lesions was successful in 58% of the implants treated during the 5-year follow-up period. Smoking seemed to be a negative risk factor for treatment success
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1 |
Tangential views of the articular surface of the distal radius-aid to open reduction and internal fixation of fractures
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Distal Radius Fractures
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Open reduction and internal fixation of comminuted, displaced intra-articular or potentially unstable fractures of the distal radius with plate and screws has increasingly become a favoured treatment. Intra-operative assessment of fixation with the help of an image intensifier has always been difficult because of the anatomy of the distal radius. Imaging of the implants placed as distal as possible to achieve satisfactory fixation often shows the screws to be penetrating the joint. We describe two new radiographic views of the wrist joint, which we used intra-operatively in ten patients undergoing open reduction and internal fixation of distal radius fractures. Screws were thought to have been penetrating the joint in the standard lateral views of all of them and in the standard antero-posterior views of eight of them.However, no screw was seen penetrating the joint in these new views. It was hence possible to place the plate distal enough to enable the screws to engage the sub-chondral bone. We recommend the use of these views in the open reduction and internal fixation of distal radius fractures.
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What's ailing us? Prevalence and type of long-term disabilities among an insured cohort of orthodontists
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Occupational health risks are present in every profession. This article reviews 4 commonly mentioned conditions that might be health risks in orthodontics and dentistry--musculoskeletal problems, carpal tunnel syndrome, dermatoses and allergies, and psychosocial problems--and compares the reported prevalence rates with data from the American Association of Orthodontists Long-Term Disability Insurance Plan. There is an estimated 3.56% prevalence of long-term disability among orthodontists. The expected and actual specific conditions affecting orthodontists could differ from those of the general public or of general dentists and do not appear to equate with self-reported surveys. Suggestions for improved reporting are made. Orthodontists appear to be quite healthy compared with other insured populations and the general public. Most long-term disabilities among orthodontists appear to be chronic illnesses and not repetitive injuries or specific occupational hazards
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Preoperative pain, symptoms, and psychological factors related to higher acute pain trajectories during hospitalization for total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Objectives Unrelieved postoperative pain after total knee arthroplasty (TKA) is a significant problem. This longitudinal study investigated how preoperative pain intensity, as well as a comprehensive list of preoperative and perioperative factors, influenced the severity of acute average and worst pain after TKA. Methods Prior to surgery, 203 patients completed a demographic questionnaire, Lee Fatigue Scale, Fatigue Severity Scale, Hospital Anxiety and Depression Scale, and Brief Illness Perception Questionnaire. Brief Pain Inventory was completed prior to surgery as well as through postoperative days (POD) 0 to 4. Clinical data were extracted from medical records. Results Several factors were associated with higher levels of preoperative and postoperative pain. Lower preoperative average and worst pain intensity scores were associated with increases in average and worst postoperative pain from POD1 to POD4. A higher number of comorbidities, higher C-reactive protein values, and higher pain interference with function were associated with higher preoperative levels of average pain. Older age, higher fatigue levels, and higher scores on identity and emotional responses to osteoarthritis (OA) were associated with higher preoperative levels of worst pain. Lower perceived consequences of OA were associated with higher pain from POD1 to POD4. Males and patients with lower preoperative scores for average pain had higher worst pain following surgery. Discussion Patients at higher risk for more severe postoperative pain can be identified through an assessment of pain and other risk factors identified in this study. Future research needs to test the efficacy of interventions that modify patients' perceptions of living with OA and pain intensity before surgery on short and long term postoperative outcomes.
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The distal radial fracture in elderly women and the bone mineral density of the lumbar spine and hip
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Distal Radius Fractures
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The incidence of distal radial fractures in elderly women is high and is associated with osteoporosis and hip fracture. Osteoporosis can be detected by measuring the bone mineral density (BMD) of the lumbar spine or hip with dual energy X-ray absorptiometry. Low BMD of the lumbar spine or hip is a strong predictor for future vertebral deformities and hip fractures. At present, elderly women with a distal radial fracture are not investigated for osteoporosis on a routine basis. The BMD of the lumbar spine and hip were assessed in 94 women (mean age, 69 years) with a distal radial fracture. A low BMD was found in 85% of the patients, and osteoporosis was diagnosed in 51%. The mean BMD decreased by 0.04 SD per year and there was a significant relationship between post-menopausal status and decreased BMD of the hip. The BMD in patients treated with bisphosphonate medication increased significantly in 1 year. As more than half of the elderly women with a distal radial fracture have osteoporotic BMD values for the lumbar spine or hip, it is our opinion that such patients should be screened for osteoporosis.
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Dermatologic manifestations of Sjogren syndrome
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Background: Sjogren syndrome (SS) is a chronic autoimmune inflammatory disease that involves primarily the exocrine glands, resulting in their functional impairment. SS typically presents as dry eyes (xerophthalmia) and dry mouth (xerostomia). This process can manifest either as the independent phenomenon of primary SS or as secondary SS when found in the context of another autoimmune process, most commonly rheumatoid arthritis or systemic lupus erythematosus. Nearly half of the patients with SS develop cutaneous manifestations, which may include dry skin (xeroderma), palpable and nonpalpable purpura, and/or urticaria-like lesions. These cutaneous manifestations have been underemphasized because they are often overshadowed by the more prominent sicca symptoms. However, certain skin findings are of paramount clinical and prognostic importance as they confer an increased risk for the development of life-threatening conditions, including multisystem vasculitis and non-Hodgkin lymphoma. Objective and Conclusions: In this review, the cutaneous manifestations of primary SS are discussed, with an emphasis on those findings that portend an increased risk of mortality. (copyright) 2011 Canadian Dermatology Association
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Transient bacteremia induced by toothbrushing a comparison of the Sonicare toothbrush with a conventional toothbrush
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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PURPOSE: Several investigations have demonstrated toothbrush-induced bacteremias. Transient bacteremias are well tolerated by healthy individuals but may increase endocarditis risk in patients with cardiac conditions. This study assessed bacteremia levels after brushing with either the Sonicare electric toothbrush or a manual toothbrush. METHODS: Fifty healthy children receiving dental treatment under general anesthesia with oral intubation were randomly assigned to a manual or Sonicare group. Plaque levels and gingival health were scored and a blood sample collected. Teeth were brushed for 1 minute and a postbrushing blood sample was drawn. Samples were analyzed for aerobic and anaerobic bacterial growth. RESULTS: Gingival health and plaque scores did not differ between groups. No correlation was detected between plaque and gingival scores and occurrence of bacteremia. The frequency of bacteremia was 46% with manual brushing: 18% aerobic, 9% anaerobic and 73% both. This differed significantly (P = .022) with 78% bacteremias in the Sonicare group: 22% aerobic, 22% anaerobic and 56% both. CONCLUSIONS: The Sonicare induced significantly more bacteremias than manual toothbrushing. These results show that vigorous brushing increased bacteremia from one brushing but does not answer whether bacteremia incidence would decrease with a program of vigorous daily brushing; this should be clarified before recommending brushing methods for patients with compromised cardiac conditions
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Antimicrobial peptides and proinflammatory cytokines in periprosthetic joint infection
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PJI DX Updated Search
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BACKGROUND: Differentiation between septic and aseptic loosening of joint replacements is essential for successful revision surgery, but reliable markers for the diagnosis of low-grade infection are lacking. The present study was performed to assess intra-articular and systemic levels of antimicrobial peptides and proinflammatory cytokines as diagnostic markers for periprosthetic joint infection. METHODS: Fifteen consecutive patients with staphylococcal periprosthetic joint infections and twenty control patients with aseptic loosening of total hip and knee replacements were included in this prospective, single-center, controlled clinical trial. Expression of the antimicrobial peptides human beta-defensin-2 (HBD-2), human beta-defensin-3 (HBD-3), and cathelicidin LL-37 (LL-37) was determined by ELISA (enzyme-linked immunosorbent assay) in serum and joint aspirates. Proinflammatory cytokines were assessed in serum and joint aspirates with use of cytometric bead arrays. C-reactive protein in serum, microbiology, and histopathology of periprosthetic tissue served as the "gold standard" for the diagnosis of infection. RESULTS: The antimicrobial peptides HBD-3 and LL-37 were significantly elevated in joint aspirates from patients with periprosthetic joint infection compared with patients with aseptic loosening, and the area under the curve (AUC) in a receiver operating characteristic curve analysis was equal to 0.745 and 0.875, respectively. Additionally, significant local increases in the proinflammatory cytokines interleukin (IL)-1beta, IL-4, IL-6, IL-17A, interferon (IFN)-gamma, and tumor necrosis factor (TNF)-alpha were observed to be associated with infection. Logistic regression analysis indicated that the combination of an antimicrobial peptide with another synovial fluid biomarker improved diagnostic accuracy; the AUC value was 0.916 for LL-37 and IL-4, 0.895 for LL-37 and IL-6, 0.972 for HBD-3 and IL-4, and 0.849 for HBD-3 and IL-6. In contrast, the only antimicrobial peptides and cytokines in serum that showed a significant systemic increase in association with infection were HBD-2, IL-4, and IL-6 (all of which had an AUC value of <0.75). CONCLUSIONS: The present study showed promising results for the use of antimicrobial peptides and other biomarkers in synovial fluid for the diagnosis of periprosthetic joint infection, and analysis of the levels in synovial fluid was more accurate than analysis of serum
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Caregivers' misperception of the severity of hip fractures
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Hip Fx in the Elderly 2019
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Purpose: The aim of our study was to evaluate how the caregiver of a hip fracture patient perceives the patient's health status and autonomy in the period immediately preceding the acute event and whether these judgments are actually in line with the prognosis predicted by the medical team caring for the patient in the rehabilitation structure.
Patients and methods: We enrolled 147 patients of both sexes, aged >=65 years, who were referred to our center following surgical treatment of hip fractures of various nature. At the beginning of the rehabilitation program, each patient's caregiver was asked to complete the Blaylock Risk Assessment Screening Score (BRASS) questionnaire. The same questionnaire was compiled contemporaneously by the doctor taking care of the patient.
Results: Analysis of the data shows that the caregivers tend to assign lower scores than the doctor, with a mean difference in agreement with the Bland-Altman plot of -2.43, 95% CI=-2.93 to -1.93, t-test P<0.001. Furthermore, differences in objectivity emerge in the evaluation of the clinical problems of the patient in a borderline clinical condition.
Conclusion: This study revealed that caregivers systematically misperceive the clinical situation of hip fracture patients prior to the acute event. Altered perception of such an important factor can lead to a general lack of satisfaction with the outcome achieved by the patient at the end of the rehabilitation process. We therefore believe that an adequate, effective communication between the people making up the health care team and the patient's social and family network is the foundation of the rehabilitation process. It is precisely on this foundation that the individual's care and assistance need to be assembled.
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Overview of diabetic foot; novel treatments in diabetic foot ulcer
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DoD LSA (Limb Salvage vs Amputation)
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Foot ulcers are one of the main complications in diabetes mellitus, with a 15% life time risk in all diabetic patients. The problem and features are infection, ulceration, or gangrene. Neuropathy, poor circulation, and susceptibility to infection are the three major contributors to the development of diabetic foot; which when present, foot deformities or minor trauma can readily lead to ulceration and infection. Not all diabetic foots are preventable, but appropriate preventive measures can dramatically reduce their occurrences. Awareness of physicians about foot problems in diabetic patients, clinical examination and Para clinical assessment, regular foot examination, patient education, simple hygienic practices and provision of appropriate footwear combined with prompt treatment of minor injuries can decrease ulcer occurrence by 50%. Many different methods have been proposed and their goal is to accelerate the wound healing. These treatments other than standard therapy include local use of epidermal growth factor, vacuum-compression therapy (VCT), hyperbaric oxygen and peripheral Stem cell injection. Since all these treatments have a partial effect in ulcer improvement and amputation rate; so more effective treatments are essential. A novel drug for treatment of this complication is an herbal extract, ANGIPARSâ?¢, which has been studied in all steps of clinical trial. This new treatment by topical, oral and intravenous routs has had beneficial effects in the treatment of diabetic foot ulcer after one month. Angiogenesis is one of the considered mechanisms of action of this drug. Results of these clinical trials showed that this treatment can be superior to other treatments.
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Use of cyclical etidronate and prevention of non-vertebral fractures
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Management of Hip Fractures in the Elderly
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This study examined the effects of cyclical etidronate, when used in routine clinical practice, on the prevention of fracture. Information was obtained from 550 general practices in the UK that provide their medical records to the General Practice Research Database. A total of 7977 patients taking cyclical etidronate treatment and 7977 age-, sex- and practice-matched control patients with a diagnosis of osteoporosis were analysed. People taking cyclical etidronate had a significantly reduced risk of non-vertebral fracture (by 20%) and of hip fracture (by 34%) relative to the osteoporosis control patients. The relative risk of non-vertebral fracture was 0.80 (95% confidence interval 0.70-0.92), that of hip fracture 0.66 (0.51-0.85) and that of wrist fracture 0.81 (0.58-1.14). When fracture incidence rates were compared between the two groups, the rate of non-vertebral, hip and wrist fracture decreased significantly (P < 0.05) with increasing etidronate exposure. The results of this study complement and extend clinical observations supporting the anti-fracture efficacy of cyclical etidronate therapy
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Application of pedicle flaps for wound coverage of lower leg
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DoD LSA (Limb Salvage vs Amputation)
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This paper presents 11 clinical cases with soft tissue defect of lower leg and foot. The reconstructive surgery of the wounds involves 14 pedicle flaps: five of which are gastrocnemius; nine are sural flaps. The etiology of the defects is various: 6 of the patients are with deep burns of the lower limbs; 3 with deep frostbite; 2 with different trauma. The patients are aged between 27 and 79. The obtained results and the applied reconstructive methods in the treatment of soft tissue defects of the lower extremities are discussed.
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The ratio of osteocytic incorporation to bone matrix formation in femoral neck cancellous bone: an enhanced osteoblast work rate in the vicinity of hip osteoarthritis
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Management of Hip Fractures in the Elderly
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Recently it has been shown that an inactivating mutation in the TGFb-SMAD3 signaling pathway, which increases the conversion of osteoblasts to osteocytes, is accompanied by bone loss combined with increased osteocyte density. We hypothesized that increased matrix TGFb, known to occur in osteoarthritis, might cause the reverse of these effects in man. Because coxarthrosis (cOA) is associated with a reduced risk of femoral neck fracture, whole cross-section femoral neck biopsies were obtained from 11 patients with femoral neck fracture, 14 patients with cOA, and 22 age-and sex-matched controls. Lacunar density (Lc x mm2), osteocyte density (Ot x mm2), and cancellous wall width (Cn x W x Wi), were compared between cases of coxarthrosis, femoral neck fracture (FNF) and controls. In cOA, Lc.mm2 was reduced by 24% (P <0.001) while in FNF it was increased by 20% (P <0.001). Cn x W x Wi was increased in cOA by 22% (P <0.05) and in FNF was reduced by 27% (P <0.001). Lc x mm2 was inversely related to percentage cancellous bone area (adj. r2 = 0.373; P <0.01) and wall widths, r2 = 0.382, P <0.001. The reduction in osteocyte lacunar density coupled with increased wall width is consistent with a model of cOA effects on bone in which increased levels of matrix TGFb might prolong the effective lifespan or work rate of the osteoblast and delay its incorporation into the matrix as an osteocyte. One possible approach to strengthening bone in osteoporosis might be to enhance the effective lifespan of the osteoblast by modulating TGFb-related pathway activity in its local environment
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Reconstruction of large infected tibia defects
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DoD SSI (Surgical Site Infections)
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Twenty-nine patients are reported who underwent free tissue transfer reconstruction of contaminated tibia defects with both soft tissue defects and osteomyelitis. Infection was controlled through the use of a two-stage composite tissue reconstruction. In the first stage, the wounds were closed with the free muscle or skin flap. Bone defects were bridged with vascularized bone grafts within 6 to 12 weeks after soft tissue closure. Twenty patients underwent reconstruction using iliac crest, whereas nine patients were treated with fibular transfer. The follow-up period for 28 patients ranged from 10 months to 6 years until bone union was completed. The bone united smoothly in 22 patients, but union of the other six grafts was delayed and required additional cancellous bone grafting.
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Impact of Shoulder Sonography on Clinical Decision Making
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Trial Systematic Review Project
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OBJECTIVES: To assess the impact of musculoskeletal shoulder sonography (US) on clinical decision making.
METHODS: This Health Insurance Portability and Accountability Act-compliant retrospective study received Institutional Review Board approval with a waiver of informed consent. Consecutive musculoskeletal shoulder US examinations ordered over a 12-month period were retrospectively reviewed. The medical records of each patient were analyzed, recording immediate pre- and post-US treatment plans. Treatment plans were categorized as follows: 1, no further treatment; 2, conservative management/physical therapy; 3, therapeutic injection; 4, surgical intervention; 5, change in diagnosis; and 6, need additional imaging. Data were analyzed by nonparametric statistical methods.
RESULTS: A total of 935 patient examinations met inclusion criteria. Of 935 patients, 591 (63.2%) had a post-US treatment plan that differed from pre-US treatment, showing a statistically significant impact on patient treatment (P < .001). In 744 of the 935 examinations (79.6%), the treating physician initially prescribed conservative therapy as a treatment plan; 423 of those 744 patients (56.9%) were subsequently prescribed a more invasive form of treatment. Of the remaining 191 of 935 patients (20.4%) initially treated with invasive treatment, 101 (52.9%) received a change in the treatment plan after the US examinations, with 46 patients (24.1%) relegated to noninvasive treatment. Sonography also played a role in surgical planning, with 25 studies (2.7%) specifically performed to evaluate rotator cuff integrity when deciding between conventional and reverse shoulder arthroplasty.
CONCLUSIONS: Musculoskeletal shoulder US has a substantial impact on clinical decision making and patient treatment.
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Endoscopic carpal tunnel release. Chow technique
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The first cases using the set of instruments designed by James C. Y. Chow, MD, of Mount Vernon, Illinois, were performed in September of 1987 by the developer. His was the first written introduction of the technique of endoscopically assisted carpal tunnel release published by a US author. This technique has been practiced widely for 5 years. Serious complications can occur but may be avoidable
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Comparison of Femoral Nerve Catheter and Adductor Canal Block With Steroid Adjuvant in Total Knee Replacement (TKR)
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AAHKS (2) Corticosteroids
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A total of 80 patients who will undergo total knee arthroplasty will be randomized into two groups: Treatment groups Treatment details Femoral Group (40 patients) Continuous femoral nerve block (bolus: 0.5% Ropivacaine 10â?15 ml ; infusion of 0.15 % Ropivacaine 4â?6ml/h) Adductor Group (40 patients) Adductor canal block with steroid adjuvant (bolus: 0.5% Ropivacaine 10â?15ml; Dexamethasone 4mg) (Total 80 patients will be recruited) â? All patients will receive single shot tibial nerve block with local anaesthetics (0.5% Ropivacaine 5â?8ml) before surgery for analgesia of posterior knee. â? All patients will receive the same preemptive and postoperative multimodal medications for perioperative analgesia. â? All groups will receive standardized method of spinal anaesthesia and standardized method of intraoperative sedation for the surgery. â? Intravenous patient controlled analgesia (PCA) with morphine will be given for 48h to patient as rescue analgesia.
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Unipolar hemiarthroplasty versus bipolar hemiarthroplasty in patients with displaced femoral neck fractures: a four-year follow-up of a randomised controlled trial
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PJI DX Updated Search
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PURPOSE: The treatment of choice for a displaced femoral neck fracture in the most elderly patients is a cemented hemiarthroplasty (HA). The optimal design, unipolar or bipolar head, remains unclear. The possible advantages of a bipolar HA are a better range of motion and less acetabular wear. The aim of this study was to evaluate hip function, health related quality of life (HRQoL), surgical outcome and acetabular erosion in a medium-term follow-up. METHODS: One hundred and twenty patients aged 80 or more with a displaced fracture of the femoral neck (Garden III and IV) were randomised to treatment with a cemented Exeter HA using a unipolar or a bipolar head. All patients were able to walk independently, with or without aids, before surgery. Follow-ups were performed at four, 12, 24 and 48 months postoperatively. Assessments included HRQoL (EQ-5D index score), hip function (Harris hip score [HHS]) and radiological acetabular erosion. RESULTS: The mean EQ-5D index score was generally higher among the patients with bipolar hemiarthroplasties at the follow-ups with a significant difference at 48 months: unipolar HAs 0.59 and bipolar HAs 0.70 (p = 0.04). There was an increased rate of acetabular erosion among the patients with unipolar hemiarthroplasties at the early follow-ups with a significant difference at 12 months (unipolar HAs 20% and bipolar HAs 5%, p = 0.03). At the later follow-ups the incidence of acetabular erosion accelerated in the bipolar group, and there were no significant differences between the groups at the 24- and 48-month follow-ups. There was no difference in HHS or reoperation rate between the groups at any of the follow-ups. CONCLUSION: The bipolar HAs seem to result in better HRQoL beyond the first two years after surgery compared to unipolar HAs. Bipolar HAs displayed a later onset of acetabular erosion compared to unipolar HAs
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Nutrient patterns and risk of fracture in older subjects: Results from the Three-City Study
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Hip Fx in the Elderly 2019
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Summary: We investigated the association between nutrient patterns and risk of fractures in 1,482 older subjects. Patterns associated with higher intakes of Ca, P, vitamin B12, proteins and unsaturated fats, and moderate alcohol intake, provided by diets rich in dairies and charcuteries, were related to a lower risk of wrist and hip fractures. Introduction: The purpose of this study was to investigate the relationship between patterns of nutrient intake and the risk of fractures in older subjects. Methods: Among 1,482 participants from the Bordeaux sample of the Three-City (3C) Study who completed a 24-h dietary recall and a food frequency questionnaire, we examined the association between patterns of nutrient intake derived from principal component analysis and 8-year incidence of self-reported fractures of the hip, the wrist, and the vertebrae. Results: A "nutrient-dense" pattern rich in Ca and P, iron, vitamins B including B12, vitamins C and E, alcohol, proteins, and unsaturated fats, and characterized by a higher consumption of fruits and vegetables, meats and fish, cheese and milk, charcuteries, cereals, rice, pasta, and potatoes, was associated with a 19 % (95 % CI 2-34 %, P = 0.03) lower risk of wrist fractures. The same pattern was associated with a 14 % (95 % CI 2-25 %) lower risk of fractures at any site. A "south-western French" pattern rich in Ca, P, vitamins D and B12, retinol, alcohol, proteins, and fats-including unsaturated fats; poor in vitamins C, E, and K, carotenes, folates, and fibers; and related to a higher consumption of cheese, milk, and charcuterie and a lower consumption of fruits and vegetables was related to a 33 % lower risk of hip fractures (95 % CI 3-39 %, P = 0.03). Conclusions: Higher intakes of Ca, P, vitamin B12, proteins, and unsaturated fats and moderate alcohol, provided by dietary patterns rich in cheese, milk, and charcuteries, were related to a lower risk of wrist and hip fractures in our cohort. © 2012 International Osteoporosis Foundation and National Osteoporosis Foundation.
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Cortical index of the femoral neck
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Management of Hip Fractures in the Elderly
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The thickness of the medial cortex of the femoral neck does not decrease with age in the same way as other common parameters of bone mass. However, in women with fracture of the upper end of the femur, it is below normal. The variable, expressed as the cortical index of the femoral neck may have some use in predicting the risk of femoral neck fracture from routine films of the hip
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Dermal suspension flaps for McKissock's vertical bipedicle flap vs. classical McKissock's technique: comparison of aesthetic results and patient satisfaction
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Reduction Mammoplasty for Female Breast Hypertrophy
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McKissock's vertical bipedicle flaps technique is a common technique used in reduction mammaplasty. This technique includes a well-vascularised dermal-parenchymal pedicle for safe nipple-areola transposition, but it has been criticised as resulting in a flat breast with inadequate projection after long-term follow-up. Various techniques in which dermal suspension flaps are used have demonstrated decreased secondary ptosis. We used a dermal suspension flap technique for the vertical bipedicled flap of the McKissock's breast reduction and compared it with classical McKissock's technique by review of the patient charts, photographic analysis and patient-satisfaction questionnaire. Evaluations and measurements with postoperative photographs for the dermal brassiere group compared with the classical McKissock breasts were found to be statistically different. There were no differences in complication rates and patient satisfaction between the groups. McKissock's technique with dermal suspension flap is an easy and uncomplicated modification that provides additional advantages for prevention of the secondary ptosis of the reduced breasts in the long term.
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Differentiating Radiculopathy from Lower Extremity Arthropathy
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OAK 3 - Non-arthroplasty tx of OAK
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Low back and lower extremity pain are among the most common complaints encountered by physicians. Distinguishing pain due to primary extremity pathology versus lumbar radiculopathy can be challenging. Careful physical examination and appropriate imaging with plain radiographs and advanced studies as needed are important in determining the cause of lower extremity complaints. Over-utilization of advanced imaging may reveal otherwise asymptomatic spinal pathology and can lead to an incorrect diagnosis. In patients in whom surgical intervention is being considered by a spine or arthroplasty surgeon, intra-articular or epidural steroid injections may help to reveal the underlying cause of pain via short-term symptomatic relief. Additionally, patients presenting with vague lower extremity pain after recent or distant joint arthroplasty should be considered for potential failure or infection of their implant before assuming the symptoms are coming from the lumbar spine.
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Histologic evaluation of laser lipolysis comparing continuous wave vs pulsed lasers in an in vivo pig model
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Panniculectomy & Abdominoplasty CPG
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OBJECTIVES: To evaluate acute and delayed laser effects of subdermal lipolysis and collagen deposition using an in vivo pig model and to compare histologic findings in fatty tissue after continuous wave diode (CW) vs pulsed laser treatment. METHODS: Three CW lasers (980, 1370, and 1470 nm) and 3 pulsed lasers (1064, 1320, and 1440 nm) were used to treat 4 Gottingen minipigs. Following administration of Klein tumescent solution, a laser cannula was inserted at the top of a 10 x 2.5-cm rectangle and was passed subdermally to create separate laser "tunnels." Temperatures at the surface and at intervals of 4-mm to 20-mm depths were recorded immediately after exposure and were correlated with skin injury. Full-thickness cutaneous biopsy specimens were obtained at 1 day, 1 week, and 1 month after exposure and were stained with hematoxylin-eosin and trichrome stain. Qualitative and semiquantitative histopathologic evaluations were performed with attention to vascular damage, lipolysis, and collagen deposition. RESULTS: Skin surface damage occurred at temperatures exceeding 46 degrees C. Histologic examination at 1 day after exposure showed hemorrhage, fibrous collagen fiber coagulation, and adipocyte damage. Adipocytes surrounded by histiocytes, a marker of lipolysis, were present at 1 week and 1 month after exposure. Collagen deposition in subdermal fatty tissue and in reticular dermis of some specimens was noted at 1 week and had increased at 1 month. Tissue treated with CW laser at 1470 nm demonstrated greater hemorrhage and more histiocytes at damage sites than tissue treated with pulsed laser at 1440 nm. There was a trend toward more collagen deposition with pulsed lasers than with CW lasers, but this was not statistically significant. Histopathologic comparison between results of CW laser at 980 nm vs pulsed laser at 1064 nm showed the same trend. Hemorrhage differences may result from pulse duration variations. A theoretical calculation estimating temperature rise in vessels supported this hypothesis. CONCLUSIONS: Pulsed lasers with higher peak powers provided better hemostatic effects than CW lasers. The degree of lipolysis depended on wavelength, laser power, and energy density. Subdermal laser irradiation can stimulate collagen deposition in subdermal tissue and reticular dermis.
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Liposuction anesthesia techniques
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Panniculectomy & Abdominoplasty CPG
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Liposuction is a common and safe procedure that can be performed under several anesthesia techniques. The preanesthesia evaluation is a security and quality factor for the procedure. The use of new medications contributes to safer anesthesia, improves the satisfaction of the patient, and reduces the discharge time and the side effects associated with anesthesia. Selection of the best technique should take into account the characteristics of the patient, the extent and length of the surgery, the surgeon's preferences, and the anesthesiologist's skills. © 2005 Elsevier Inc. All rights reserved.
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Long-term effects of tibial plateau leveling osteotomy and tibial tuberosity advancement on tibial plateau subchondral bone density in dogs
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To evaluate long-term loading patterns using subchondral bone density (SBD) distribution of the tibial plateau after tibial plateau leveling osteotomy (TPLO) and tibial tuberosity advancement (TTA). STUDY DESIGN: Cross-sectional study. ANIMALS: Adult (> 2 years), medium to large breed dogs (>20 kg) that had been treated with TPLO or TTA at least 1 year prior to the study were recruited. A normal cohort of similar age and weight dogs with normal physical and orthopedic examinations served as control. METHODS: Dogs were sedated for computed tomography (CT) of the stifle, and DICOM (digital imaging and communications in medicine) files were processed for CT osteoabsorptiometry (CTOAM). Tibial plateaus were sampled at 6 zones, and CTOAM was used to determine regional and maximal areas of SBD as a marker of joint loading. RESULTS: Data were collected on 48 stifles in 31 dogs (15 TPLO, 11 TTA, 22 control). Lower Hounsfield unit (HU) values were measured in the caudal and mid-region of the lateral tibial plateau after TPLO and compared to normal. HU values did not differ between joints treated with TTA and those in the control group. CONCLUSION: TPLO may alter stifle load distribution relative to the normal control group. There were no differences between TTA and the control group. CLINICAL SIGNIFICANCE/IMPACT: Despite ongoing osteoarthritis (OA) in dogs after surgical intervention for cranial cruciate disease, changes in tibial SBD are minor and may not correlate with clinical function.
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Swellings of the sternoclavicular joint: review of traumatic and non-traumatic pathologies
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Glenohumeral Joint OA
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The sternoclavicular joint (SCJ) is an integral part of the shoulder girdle that connects the upper limb to the axial skeleton.Swelling of the SCJ is commonly due to trauma, degeneration, infections and other disease processes that affect synovial joints.This review also focuses on uncommon conditions that could affect the SCJ, including SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, Friedrich's disease and Tietze syndrome.The scope of this review is limited to the analysis of the current evidence on the various conditions affecting the SCJ and also to provide an algorithm to manage these conditions. Cite this article: EFORT Open Rev 2018;3:471-484. DOI: 10.1302/2058-5241.3.170078.
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Prophylactic antibiotics in hip fractures. A double-blind, prospective study
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Management of Hip Fractures in the Elderly
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Three hundred and seven patients, each of whom had a fracture of the proximal part of the femur, were studied in a randomized, double-blind fashion to determine whether perioperative administration of cephalothin would prevent postoperative infection. Major postoperative wound infections were significantly reduced in the cephalothin-treated group (4.7 per cent versus 0.7 per cent; p less than 0.05). There also was a reduction in the incidence of postoperative urinary-tract infections and a reduction in mean peak body temperatures. The duration of hospitalization was not affected and no hospital stay was prolonged by complications of antibiotic administration. However, in the cephalothin-treated group, a strong trend toward colonization by cephalothin-resistant organisms was noted
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Perception versus reality: The increasing american habitus and its impact on peri-operative management
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction: Obesity, defined as a body mass index (BMI) greater than 30 kg /m2, has increased significantly over the past twenty years in the United States 1, 2. As a result the rate of total joint replacements has steadily increased over time 3. For example, total knee arthroplasties (TKAs) are being performed in younger individuals and these patients have more comorbidities including diabetes mellitus, obesity, hypercholesterolemia, hypertension, and pulmonary disease 4. The primary aim of this study was to determine the demographic trends of patients undergoing primary TKA during three different time periods: 1989, 1999 and 2009 at our institution and to determine if it mirrors the changing demographics within the United States. Methods: All adult patients that have undergone unilateral primary TKA during the calendar years of 1989, 1999 and 2009 were identified via the Mayo Clinic Total Joint Registry database. Two hundred patients were randomly selected for each time period. A retrospective chart review of patient demographics, comorbidities, perioperative practice and postoperative outcomes was performed. We also studied the perception of experienced anesthesia providers regarding changes, or lack thereof, in patient demographics and perioperative care via a web-based survey. Results: During the three study periods a total of 590 patients were included for the analysis. Two hundred patients from 1989; one hundred and ninety-three patients from 1999 and one hundred and ninety-seven patients from 2009. A statistically significant increase in BMI was observed overtime in patients undergoing primary TKA (average BMI: 29.01 in 1989; 31.32 in 1999 and 32.28 in 2009 (p < 0.001)). There was an increase in the number of patients with recognized preexisting comorbidities such as hypertension, diabetes and obstructive sleep apnea. Despite the increase in patient comorbidities, the number of postoperative complications decreased and postoperative disposition (general medicine ward vs. ICU) did not change significantly. The administration of exclusively general anesthesia declined. On the other hand, combined general and regional anesthesia increased significantly. Our survey received 76 % response rate. The majority of anesthesia providers perceive that BMI has increased (average time in practice: 11 years) simultaneously with the number of comorbidities. This trend in body habitus and rise in comorbidities leads the majority of the practitioners to modify their perioperative anesthesia care. Discussion: The number of obese patients with comorbidities presenting for TKA at our institution is growing. Despite the fact that we are taking care of more complicated patients, a reduction in postoperative complications was detected. This could be explained by anesthesiology practice modifications including the increased implementation of regional anesthesia protocols, utilization of non-narcotic analgesics and short acting medications
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Cold saline lavage for removal of incarcerated porous ingrowth stems
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PJI DX Updated Search
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A patient with a history of total knee arthroplasty and 5 subsequent revisions presented with pain. His preoperative construct consisted of a revision implant with porous ingrowth stem extensions. He was indicated for revision surgery for a painful implant with progressive arthrofibrosis. The surgery proceeded uneventfully until we were unable to loosen the proximal portion of the ingrown femoral stem. After the distal femur was removed, a trephine was used to break the bone ingrowth from the distal portion of the stem. Flexible osteotomes were used to loosen the bone-prosthetic interface, but they were unable to penetrate deep enough, and they eventually bent under the applied loads. Nonflexible osteotomes were also used without success, and we were still unable to remove the stem from within the femur. Slap hammers, vice grips, and other devices were used to try to remove the stem, but attempts were unsuccessful. We hung a 3-liter bag of ice-cold (4ðC) saline and ran all 3 liters of saline, under gravity pressure, retrograde down the femoral shaft in an attempt to contract the metal and allow for the removal of the stem. We then attached a stem extension screw to the incarcerated femoral stem and were able to remove it with minimal effort using a back-slap device. We inspected the prosthesis and found no abnormalities of the stem to explain its incarceration and no iatrogenic perforations in the femur. This case demonstrates a useful technique that should be kept in a revision surgeon's armamentarium for the removal of incarcerated porous ingrowth stems
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Deepening of the superior sulcus after isolated lower transconjunctival blepharoplasty
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Panniculectomy & Abdominoplasty CPG
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Purpose: To retrospectively determine the incidence of deepening of the superior sulcus after isolated CO2 laser lower transconjunctival blepharoplasty. Methods: Retrospective case review and prospective measurement of the amount of fat resected in isolated laser lower blepharoplasty in 39 patients. Results: Significant deepening of the superior sulcus occurred in 10% of CO2 laser lower transconjunctival blepharoplasties. The amount of fat resected ranged from 0.4 to 0.9 ml per eyelid, with an average of 0.55 ml. Conclusions: Upper eyelid changes may be an overlooked result of CO2 laser lower transconjunctival blepharoplasty.
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Throwing shoulder injury involving the anterior rotator cuff: concealed tears not as uncommon as previously thought
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Glenohumeral Joint OA
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PURPOSE: In throwing athletes, partial rotator cuff tears are usually located posterior to the site of the common rotator cuff tears seen in the general nonthrowing population. However, they sometimes have tears located around the anterior aspect of the supraspinatus tendon. In this study we investigated the characteristics of anterior rotator cuff tears in throwing athletes. We then compared several factors between anterior tears and posterior tears to investigate those related to the presence of anterior tears or the occurrence of such tears.
METHODS: We divided 37 athletes with partial rotator cuff tears into those with anterior tears (n = 17) and those with posterior tears (n = 20). The clinical profile, range of motion and joint laxity with patient under general anesthesia, and operative findings were retrospectively compared between the 2 groups.
RESULTS: Among the 17 anterior rotator cuff tears, 12 tears were confined to the anterior one third of the supraspinatus tendon. Interestingly, concealed intratendinous degenerative tears were found in 6 shoulders. These appeared to be very shallow articular-side tears located around the attachment of the greater tuberosity, but severe tears were exposed after resection of the residual capsular portion of the tendon. Posterior capsular tightness was significantly related to the occurrence of anterior tears, whereas a greater tuberosity notch was significantly related to posterior tears.
CONCLUSIONS: Anterior rotator cuff tears are not uncommon in throwing athletes, and a concealed type of tear was a representative lesion. Different mechanisms may be involved in the development of anterior and posterior rotator cuff tears resulting from throwing injuries. Posterior capsular tightness might influence the occurrence of anterior tears.
LEVEL OF EVIDENCE: Level IV, prognostic case series.
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Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures
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Management of Hip Fractures in the Elderly
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Hemiarthroplasty is the most commonly used treatment for displaced femoral neck fractures in the elderly. There is limited evidence in the literature of improved functional outcome with cemented implants, although serious cement-related complications have been reported. We performed a randomized, controlled trial in patients 70 years and older comparing a cemented implant (112 hips) with an uncemented, hydroxyapatite-coated implant (108 hips), both with a bipolar head. The mean Harris hip score showed equivalence between the groups, with 70.9 in the cemented group and 72.1 in the uncemented group after 3 months (mean difference, 1.2) and 78.9 and 79.8 after 12 months (mean difference, 0.9). In the uncemented group, the mean duration of surgery was 12.4 minutes shorter and the mean intraoperative blood loss was 89 mL less. The Barthel Index and EQ-5D scores did not show any differences between the groups. The rates of complications and mortality were similar between groups. Both arthroplasties may be used with good results after displaced femoral neck fractures
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Intravenous zoledronate for osteoporosis: less might be more
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Hip Fx in the Elderly 2019
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Annual administration of 5 mg intravenous zoledronate is moderately effective in reducing fracture risk in older adults, decreasing the relative risk of clinical fracture by 33%. However, almost 10 years after its approval for use in clinical practice there remain very substantial uncertainties about the optimal treatment regimen, that is, the lowest dose and/or longest dosing interval that is efficacious. Several pieces of clinical research suggest that the current recommendation for annual administration of 5 mg zoledronate might represent overtreatment. Clinical trials to clarify the optimal use of zoledronate for reduction of fracture risk should be undertaken.
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Arthritis predicting factors in distal intraarticular radius fractures
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Distal Radius Fractures
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INTRODUCTION: Intra-articular malunion with step off and gap formation is claimed to be crucial for radiocarpal degeneration. In addition to well-defined intraarticular malunion, the shape of the distal radius is important for unaffected wrist function. In typical intra-articular fracture patterns with a dorsoulnar and palmar ulnar fragment, alterations of the shape of the articular surface, in a kind of a cavity, without obvious step off can be observed. The aim of the present study is to determine the residual articular deformity following intra-articular radius fractures and to analyze their impact on the final clinical and radiological outcome.
MATERIALS AND METHODS: Eighty one patients with dorsally displaced distal intraarticular radius fractures were followed up for a mean period of 9 years. Surgical treatment of all patients included open reduction, plate fixation and corticocancellous bone grafting. Radiological measurements included palmar tilt, radial inclination and radial shortening as defined by ulnar variance, intra-articular Stepps and the measurement of the anteroposterior distance of the radial joint surface. Clinical assessment included active range of motion (ARM) of the wrist, pain according to a visual analogue scale (VAS), grip power, working ability, Disability of Arm, Shoulder and Hand Score (DASH Score).
RESULTS: Articular malunion in the form of a cavity in the sagittal plane measured 4.8 mm, 1.3 mm more than on the non-injured side. Anteroposterior distance measured 20.6 mm, 2.1 mm more than on the non-injured side. Articular step-off and gap was noticed in 11 patients. At the final follow-up examination, there was a significant difference in articular cavity depth and the anteroposterior distance between arthritis stage I and II. Arthritis stage was associated with the range of motion (ROM) in the sagittal plane, but had no significant influence on the DASH, pain level, grip strength and ROM in the frontal plane.
CONCLUSION: ORIF leads to predictable results in the restoration of length and form of the distal radius. Increasing the articular cavity depth should be avoided to prevent degenerative arthritis at the radiocarpal joint at long-term follow-up visits.
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Unicondylar knee arthroplasty: intramedullary technique
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OAK 3 - Non-arthroplasty tx of OAK
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Unicondylar knee arthroplasty (UKA) is a challenging surgical procedure for many orthopedic surgeons when compared with total knee arthroplasty (TKA). Given the proven similarities in knee biomechanics between UKA and the native knee and recent evidence showing excellent survivorship and functionality, UKA is an excellent alternative to TKA in the appropriate patient. This article discusses the use of intramedullary guides for preparation in partial knee replacement surgery. The concerns of complications arising from cannulating the medullary canal and excessive bleeding have not been seen. The intramedullary UKA yields high levels of success and long-term outcomes, with excellent alignment.
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Detection of Mild Traumatic Brain Injury by Machine Learning Classification Using Resting State Functional Network Connectivity and Fractional Anisotropy
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DoD PRF (Psychosocial RF)
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Traumatic brain injury (TBI) may adversely affect a person's thinking, memory, personality, and behavior. While mild TBI (mTBI) diagnosis is challenging, there is a risk for long-term psychiatric, neurologic, and psychosocial problems in some patients that motivates the search for new and better biomarkers. Recently, diffusion magnetic resonance imaging (dMRI) has shown promise in detecting mTBI, but its validity is still being investigated. Resting state functional network connectivity (rsFNC) is another approach that is emerging as a promising option for the diagnosis of mTBI. The present work investigated the use of rsFNC for mTBI detection compared with dMRI results on the same cohort. Fifty patients with mTBI (25 males) and age-sex matched healthy controls were recruited. Features from dMRI were obtained using all voxels, the enhanced Z-score microstructural assessment for pathology, and the distribution corrected Z-score. Features based on rsFNC were obtained through group independent component analysis and correlation between pairs of resting state networks. A linear support vector machine was used for classification and validated using leave-one-out cross validation. Classification achieved a maximum accuracy of 84.1% for rsFNC and 75.5% for dMRI and 74.5% for both combined. A t test analysis revealed significant increase in rsFNC between cerebellum versus sensorimotor networks and between left angular gyrus versus precuneus in subjects with mTBI. These outcomes suggest that inclusion of both common and unique information is important for classification of mTBI. Results also suggest that rsFNC can yield viable biomarkers that might outperform dMRI and points to connectivity to the cerebellum as an important region for the detection of mTBI.
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Surgical desensitisation of the mechanoreceptors in Muller's muscle relieves chronic tension-type headache caused by tonic reflexive contraction of the occipitofrontalis muscle in patients with aponeurotic blepharoptosis
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Upper Eyelid and Brow Surgery
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Proprioceptively innervated intramuscular connective tissues in Muller's muscle function as exterior mechanoreceptors to induce reflex contraction of the levator and occipitofrontalis muscles. In aponeurotic blepharoptosis, since the levator aponeurosis is disinserted from the tarsus, stretching of the mechanoreceptors in Muller's muscle is increased even on primary gaze to induce phasic and tonic reflexive contraction of the occipitofrontalis muscle. It was hypothesised that in certain patients with aponeurotic blepharoptosis, the presence of tonic reflexive contraction of the occipitofrontalis muscle due to the sensitised mechanoreceptors in Muller's muscle, can cause chronic tension-type headache (CTTH) associated with occipitofrontalis tenderness. To verify this hypothesis, this study evaluated (1) what differentiates patients with CTTH from patients without CTTH, (2) how pharmacological contraction of Muller's smooth muscle fibres as a method for desensitising the mechanoreceptors in Muller's muscle affects electromyographic activity of the frontalis muscle, and (3) how surgical aponeurotic reinsertion to desensitise the mechanoreceptors in Muller's muscle electromyographically or subjectively affects activities of the occipitofrontalis muscle or CTTH. It was found that patients had sustained CTTH when light eyelid closure did not markedly reduce eyebrow elevation. However, pharmacological contraction of Muller's smooth muscle fibres or surgery to desensitise the mechanoreceptor electromyographically reduced the tonic contraction of the occipitofrontalis muscle on primary gaze and subjectively relieved aponeurotic blepharoptosis-associated CTTH. Over-stretching of the mechanoreceptors in Muller's muscle on primary gaze may induce CTTH due to tonic reflexive contraction of the occipitofrontalis muscle. Therefore, surgical desensitisation of the mechanoreceptors in Muller's muscle appears to relieve CTTH.
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Economic consequences of venous thromboembolism following major orthopedic surgery
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HipFx Supplemental Cost Analysis
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BACKGROUND: Venous thromboembolism (VTE) is a frequent and potentially costly complication of major orthopedic surgery. OBJECTIVE: To estimate the economic consequences of VTE following major orthopedic surgery. METHODS: Using a large healthcare claims database, we identified all patients who underwent total hip replacement, major knee surgery, or hip fracture repair from January 1993 to December 1998. Patients with clinical VTE (cases) were identified based on a diagnosis of deep vein thrombosis or pulmonary embolism within 90 days of surgery (index admission) and > or =1 prescription for warfarin or unfractionated heparin within 30 days of the date of initial VTE diagnosis. Each case was matched (using age and procedure type) to 2 randomly selected patients who did not have any claims for clinical VTE (matched controls). Utilization and billed charges were then examined over a 90-day period following admission. Cases were stratified based on whether VTE was first noted during the index admission or thereafter. RESULTS: A total of 11 960 patients were identified who underwent total hip replacement, major knee surgery, or hip fracture repair (n = 3171, 3955, 4834, respectively). Over a 90-day period, 259 patients (2.2%) developed clinical VTE. Most cases (61.8%) occurred after hospital discharge. For patients with in-hospital VTE, mean length of stay for the index admission was 4.5 days longer than that of matched controls (11.1 vs 6.6); by day 90, there was a 5.4-day difference in total hospital days. Mean billed charges for the index admission were 17,552 higher US dollars (52,037 US dollars vs 34,485 US dollars); the difference rose to 18,834 US dollars by day 90 (54,480 US dollars vs 35,646 US dollars). For patients who developed clinical VTE following hospital discharge, there was a 3.4-day difference in total hospital days at day 90 (10.2 vs 6.8) as a result of readmissions for VTE; mean total billed charges at day 90 were 5765 US dollars higher (41,411 US dollars vs 35,646 US dollars). CONCLUSIONS: Among patients who have undergone major orthopedic surgery, the economic consequences of VTE are substantial, regardless of the setting in which it occurs
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Exposure to abuse, neglect, and household dysfunction among adults who witnessed intimate partner violence as children: implications for health and social services
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DoD PRF (Psychosocial RF)
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Intimate partner violence (IPV) damages a woman's physical and mental well-being, and indicates that her children are likely to experience abuse, neglect and other traumatic experiences. Adult HMO members completed a questionnaire about adverse childhood experiences (ACEs) including childhood abuse, neglect, and household dysfunction. We used their responses to retrospectively assess the relationship between witnessing intimate partner violence and experiencing any of the 9 ACEs and multiple ACEs (ACE score). Compared to persons who grew up with no domestic violence, the adjusted odds ratio for any individual ACE was approximately two to six times higher if IPV occurred (p < 0.05). There was a powerful graded increase in the prevalence of every category of ACE as the frequency of witnessing IPV increased. In addition, the total number of ACEs was increased dramatically for persons who had witnessed IPV during childhood. There was a positive graded risk for self-reported alcoholism, illicit drug use, i.v. drug use and depressed affect as the frequency of witnessing IPV increased. Identification of victims of IPV must include screening of their children for abuse, neglect and other types of adverse exposures, as well as recognition that substance abuse and depressed affect are likely consequences of witnessing IPV. Finally, this data strongly suggest that future studies, which focus on the effect of witnessing IPV on long-term health outcomes, may need to take into consideration the co-occurrence of multiple ACEs, which can also affect these outcomes.
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Molecular analysis of aortic intimal hyperplasia caused by Porphyromonas gingivalis infection in mice with endothelial damage
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND AND OBJECTIVE: Porphyromonas gingivalis infection is thought to be a significant etiological factor in the development of cardiovascular diseases. However, scant definitive evidence has been presented concerning the pathological molecular mechanisms of these disorders. In the present study, we performed a molecular analysis of the developmental mechanisms of aortic intimal hyperplasia induced by P. gingivalis. MATERIAL AND METHODS: The effects of P. gingivalis-induced bacteremia on intimal hyperplasia were evaluated using a mouse model of aortic hyperplasia created by photochemical-induced endothelial cell injury. Alterations of gene expression profiles in injured blood vessels of the mice were extensively analyzed using DNA microarray assays to identify the key molecules involved in P. gingivalis-induced hyperplasia. In addition, human aneurismal specimens from patients with or without P. gingivalis infection were analyzed histochemically. RESULTS: Intravenous administration of P. gingivalis dramatically induced intimal hyperplasia in the mouse model. Concomitantly, S100 calcium-binding protein A9 (S100A9) and embryonic isoform of myosin heavy chain (SMemb), a proliferative phenotypic marker of smooth muscle cells, were significantly overexpressed on the surfaces of smooth muscle cells present in the injured blood vessels. Similarly, increased expressions of S100A9 and SMemb proteins were observed in aneurismal specimens obtained from P. gingivalis-infected patients. CONCLUSION: We found that bacteremia induced by P. gingivalis leads to intimal hyperplasia associated with overexpressions of S100A9 and SMemb. Our results strongly suggest that oral-hematogenous spreading of P. gingivalis is a causative event in the development of aortic hyperplasia in periodontitis patients
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Traditions and myths in hip and knee arthroplasty
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Dental Implant Infection
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BACKGROUND AND PURPOSE: Traditions are passed on from experienced surgeons to younger fellows and become "the right way to do it". Traditions associated with arthroplasty surgery may, however, not be evidence-based and may be potentially deleterious to both patients and society, increasing morbidity and mortality, slowing early functional recovery, and increasing cost., METHODS: We identified selected traditions and performed a literature search using relevant search criteria (June 2014). We present a narrative review grading the studies according to evidence, and we suggest some lines of future research., RESULTS: We present traditions and evaluate them against the published evidence. Preoperative removal of hair, urine testing for bacteria, use of plastic adhesive drapes intraoperatively, and prewarming of the operation room should be abandoned-as should use of a tourniquet, a space suit, a urinary catheter, and closure of the knee in extension. The safety and efficacy of tranexamic acid is supported by meta-analyses. Postoperatively, there is no evidence to support postponement of showering or postponement of changing of dressings to after 48 h. There is no evidence to recommend routine dental antibiotic prophylaxis, continuous passive motion (CPM), the use of compression stockings, cooling for pain control or reduction of swelling, flexion of at least 90 degrees as a discharge criterion following TKA, or having restrictions after THA. We present evidence supporting the use of NSAIDs, early mobilization, allowing early travel, and a low hemoglobin trigger for transfusion., INTERPRETATION: Revision of traditions and myths surrounding hip and knee arthroplasty towards more contemporary evidence-based principles can be expected to improve early functional recovery, thus reducing morbidity, mortality, and costs.
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Outcome of childhood leukaemia survivors and necrosis of the femoral head treated with autologous mesenchymal stem cells
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AAHKS (2) Corticosteroids
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Purpose: Corticoid-induced osteonecrosis (ON) of femoral head can lead to severe hip joint impairment and hip replacement, with negative impact in young survivors of acute lymphoblastic leukaemia (ALL) with long life expectancy. We aim to improve quality of life in these patients with a novel approach. Methods/patients: Based on the regenerative capacities of mesenchymal stem cells (MSCs), we performed locally implanted autologous cell therapy in two adolescents suffering of bilateral femoral ON. This required a simple, minimally invasive surgical procedure. Results: Both patients experienced significant pain relief and restoration of gait kinematic values. Radiographic evaluation showed cessation of hip collapse. No toxicities/complications were observed after a 4-year follow-up. Conclusions: Our preliminary results suggest that autologous MSCs can be considered as a novel treatment for children and young adults with ON after overcoming ALL. It may avoid hip replacement and improve quality of life of leukaemia survivors.
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Two-year outcome of early deep MRSA infections after primary total knee arthroplasty: a joint registry review
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PJI DX Updated Search
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The aim of this study is to determine the success rate in eradication of early methicillin-resistant Staphylococcus aureus (MRSA) prosthetic joint infection. Rate of prosthesis retention and functional outcome between patients with prosthesis retention and prosthesis revision were compared. All patients who underwent primary total knee arthroplasty between May 1998 and September 2008 at our institution developing early deep MRSA infection were included. Patient demographics, time from infection to initial arthrotomy, successful eradication of infection and functional outcome of patients with a knee prosthesis at 2 years were studied. Open arthrotomy, debridement, and change of liner successfully treated 33.3% of infections. All remaining infections went onto treatment with 2-stage revision with a success rate of 88%. Overall 92% of patients had a well-functioning knee prosthesis at 2 years
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Vitamin D status, trunk muscle strength, body sway, falls, and fractures among 237 postmenopausal women with osteoporosis
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Management of Hip Fractures in the Elderly
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The aim of this study was to identify factors associated with fractures in patients with postmenopausal osteoporosis. The overall hypothesis was that trunk muscle strength, body sway and hypovitaminosis D would influence daily activities and the likelihood of falls and fractures. - In 237 women (mean age 62.9+/-7.4 years) osteoporosis was defined by a T-score at the femoral neck below -2.5 SD. Trunk muscle strength was determined using isokinetic dynamometry and body sway was measured according to Lord et al. Limitations in everyday life were assessed and the history of falls was documented. A fracture was defined as a vertebral height reduction of more than 20% or at least 4 mm. The assessment was carried out using the Spine Deformity Index (SDI) and was confirmed by an experienced radiologist. Pearson coefficients of correlation were calculated. - After correction for age, significant associations were found for body sway and 25-hydroxyvitamin D (p<0.001), body sway and falls (p<0.001), body sway and rib fractures (p<0.01), trunk muscle strength and limitations in everyday life (p<0.001), trunk muscle strength and SDI (p<0.001), trunk muscle strength and bone density (p<0.001), and bone density and 25-hydroxyvitamin D (p<0.001). No significant correlation was found for trunk muscle strength and 25-hydroxyvitamin D (p=0.712). - Findings suggest that hypovitaminosis D is associated with increased body sway and an elevated risk for falls and falls-related fractures. Musculoskeletal rehabilitation should include strengthening exercises for the trunk muscles and training of neuromuscular co-ordination and balance
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1 |
Predictors of psychological distress following serious injury
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DoD PRF (Psychosocial RF)
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Posttraumatic psychological distress was assessed in 109 survivors of serious physical injury during acute hospitalization and at 3 months postdischarge. Participants had an average of 4.4 injuries, with a mean injury severity score of 15.5, denoting moderate to severe injuries. Using the Impact of Event Scale (IES), the mean total IES score in-hospital was 22.5 and at 3 months postdischarge was 30.6. Approximately 32% of individuals experienced high levels of distress in-hospital, and this increased to 49% at 3 months postdischarge. The regression model that best explained the variance in posttraumatic psychological distress at 3 months postdischarge included greater psychological distress during hospitalization, a positive drug/alcohol screen on hospital admission, younger age, and the lack of anticipating problems returning to normal life activities. These findings suggest that factors present during acute hospitalization may be used to identify individuals at risk for increased psychological distress, several months following serious physical injury.
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Cartiform Implantation for focal cartilage defects in the knee: A 2-year clinical and magnetic resonance imaging follow-up study
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Osteochondritis Dissecans 2020 Review
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The purpose of this study was to evaluate clinical and magnetic resonance imaging (MRI) outcomes in patients who underwent cryopreserved viable osteochondral allograft (CVOCA) implantation for focal cartilage defects in the knee at a minimum of 2-years postoperatively. This is a retrospective follow-up study of twelve patients who underwent CVOCA implantation from 2013 to 2015 by a single surgeon for a International Cartilage Repair Society (ICRS) grade 3 or 4 chondral defect. Patient-reported outcome (PRO) measurements and MRI were obtained 2-years postoperatively. Collected PRO measures included: International Knee Documentation Committee (IKDC) form; Visual Analog Scale (VAS) pain score; Veterans RAND 12-Item Health Survey (VR-12); Knee Injury and Osteoarthritis Outcome Score (KOOS); and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC). Patients completed a standard return to work and sports/recreation survey. A blinded, fellowship-trained musculoskeletal radiologist independently evaluated each MRI to determine the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Mean follow-up was 2.1 years (2.0-2.3). There were 6 women and 6 men with a mean age of 46.2 ± 11.9 years. Mean PRO scores were: IKDC 72.6 ± 17.4; VAS 2.9 ± 2.8; WOMAC 84.2 ± 15.1; KOOS- Pain 83.8 ± 18.5, Symptoms 77.6 ± 16.0, ADL 88.0 ± 16.9, Sports/Rec 67.7 ± 33.3, QOL 54.8 ± 24.2; and VR-12 PCS 45.0 ± 8.5 and MCS 51.1 ± 9.5. The mean MOCART score was 59.5 ± 12.9. To our knowledge, this is the largest study to report clinical and MRI outcomes of CVOCA implantation in the knee. With positive functional outcomes and lack of failures at 2-year follow-up, CVOCA is a promising treatment option for focal chondral defects in the knee. STUDY DESIGN: Retrospective case series, Level of evidence 4.
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Relationship between severity of knee osteoarthritis and radiography findings of lower limbs: A cross-sectional study from the TOEI survey
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OAK 3 - Non-arthroplasty tx of OAK
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Objective This study aimed to compare radiographic parameters among radiographic severity of the medial knee osteoarthritis and between men and women in a rural Japanese population. Methods We measure nine radiographic parameters of the whole lower extremity in participants with neutral or varus alignment. Results Age and body mass index were related to the knee osteoarthritis severity. The knee osteoarthritis depended on not only varus alignment in the whole leg, but also varus deformity of proximal tibial condyle and the tibial plateau inclination, especially in women. Conclusion We must consider the difference of tibial condyle morphology and tibial plateau inclination before onset of the knee osteoarthritis.
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Patient-Specific Instrument Can Improve Functional and Radiographic Results during Learning Curve for Oxford Unicompartmental Knee Arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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The true value of use of patient-specific instrumentation (PSI) systems by inexperienced surgeons during their learning curve to improve the clinical and radiographic outcome of unicompartmental knee arthroplasty (UKA) has not been previously studied. Fifty patients with a mean age of 64.3 years undergoing surgery for Oxford UKA were prospectively divided into two groups. Twenty-five patients were operated on by a surgeon with no prior experience in UKA using a PSI system and the other 25 patients by an experienced surgeon using a conventional procedure. Patients were scored using joint range of motion (ROM), the Knee Society Score (KSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the 12-item Short-Form (SF-12) before and 3 months and 2 years after surgery. Impact of use of PSI was measured by comparing clinical and radiographic outcome, complications, and implant survival. No evidence of poorer clinical outcome was seen in any subscale of KSS, KOOS, and SF-12 for inexperienced surgeons using PSI (p = 0.45, p = 0.32, and p = 0.61, respectively). No difference was found between the two procedures in precision of radiographic alignment of components (p = 0.53). No complication occurred in any group. PSI may improve precision of component alignment during the learning curve of surgeons, thus achieving functional results similar to those of more experienced surgeons using a conventional procedure.
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Incidence of knee cartilage surgery in Norway, 2008-2011
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AMP (Acute Meniscal Pathology)
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Objective: A systematic and long-term data collection on the treatment of focal cartilage defects (FCDs) of the knee is needed. This can be achieved through the foundation of a National Knee Cartilage Defect Registry. The aim of this study was to establish the nationwide burden of knee cartilage surgery, defined as knee surgery in patients with an FCD. We also aimed to identify any geographical differences in incidence rates, patient demographics or trends within this type of surgery. Setting: A population-based study with retrospective identification of patients undergoing knee cartilage surgery in Norway through a mandatory public health database from 2008 to 2011. Participants: We identified all patients undergoing cartilage surgery, or other knee surgery in patients with an FCD. All eligible surgeries were assessed for inclusion on the basis of certain types of ICD-10 and NOMESKO Classification of Surgical Procedures codes. Primary and secondary outcome measures: The variables were diagnostic and surgical codes, geographic location of the performing hospital, age and sex of the patients. Yearly incidence and incidence rates were calculated. Age-adjusted incidences for risk ratios and ORs between geographical areas were also calculated. Results: A total of 10 830 cases of knee cartilage surgery were identified, with slight but significant decreases from 2008 to 2011 (p<0.0003). The national incidence rate was 56/100 000 inhabitants and varied between regions, counties and hospitals. More than 50% of the procedures were palliative and nearly 400 yearly procedures were reparative or restorative. Conclusions: Knee cartilage surgery is common in Norway, counting 2500 annual cases with an age-adjusted incidence rate of 68.8/100 000 inhabitants. There are significant geographical variations in incidence and trends of surgery and in trends between public and private hospitals. We suggest that a national surveillance system would be beneficial for the future evaluation of the treatment of these patients.
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0 |
Comparison of two different methods for performing combination analysis of force and posture risk factors in an epidemiological study
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVES: This study aimed to introduce a method of simultaneous combination analysis of multiple exposure parameters for large epidemiological studies of work-related upper-extremity musculoskeletal disorders (MSD) and compare this analysis method with the conventionally used job-level combination analysis method when applied in exposure-response analysis of work-related upper-extremity MSD. METHODS: Health outcome [carpal tunnel syndrome (CTS)] and physical exposure (forceful exertion and hand/wrist postures) data for 733 subjects were obtained from the baseline period of a 3-year work-related upper-extremity MSD study. Determinations of CTS cases were done based on a set of defined criteria. Physical exposure variables of several different types of forceful exertions and three different hand/wrist postures were collected onsite, processed, and analyzed using both a simultaneous combination and job-level combination analysis method. RESULTS: The commonly used job-level combination analysis method resulted in significantly different combination exposure distributions compared to the simultaneous combination analysis method, although the absolute differences were small. Both methods showed some significantly higher combined force-posture exposures among CTS cases than non-cases. CONCLUSIONS: The simultaneous combination method provides more realistic distribution information on combined exposure parameters compared to the job-level combination method that has been commonly used in epidemiological studies. The newly developed simultaneous combination analysis method needs to be used in larger scale work-related upper-extremity MSD epidemiological studies to test its predictive power compared to the job-level combination analysis method
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0 |
SEOM guidelines for the treatment of bone metastases from solid tumours
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MSTS 2018 - Femur Mets and MM
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Bone metastases are a common and distressing effect of cancer, being a major cause of morbidity in many patients with advanced stage cancer, in particular in breast and prostate cancer. Patients with bone metastases can experience complications known as skeletal-related events (SREs) which may cause significant debilitation and have a negative impact on quality of life and functional independence. The current recommended systemic treatment for the prevention of SREs is based on the use of bisphosphonates: ibandronate, pamidronate and zoledronic acid- the most potent one- are approved in advanced breast cancer with bone metastases, whereas only zoledronic acid is indicated in advanced prostate cancer with bone metastases. The 2011 ASCO guidelines on breast cancer, recommend initiating bisphosphonate treatment only for patients with evidence of bone destruction due to bone metastases. Denosumab, a fully human antibody that specifically targets the RANK-L, has been demonstrated in two phase III studies to be superior to zoledronic acid in preventing or delaying SREs in breast and prostate cancer and non-inferior in other solid tumours and mieloma; it's convenient subcutaneous administration and the fact that does not require dose adjustment in cases of renal impairment, make this agent an attractive new therapeutic option in patients with bone metastases. Finally, in a phase III study against placebo, denosumab significantly increased the median metastasis-free survival in high risk non-metastatic prostate cancer, arising the potential role of these bone-modifying agents in preventing or delaying the development of bone metastases.
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