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Perioperative nerve injury after total knee arthroplasty: regional anesthesia risk during a 20-year cohort study
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Perioperative nerve injury (PNI) is one of the most debilitating complications after total knee arthroplasty (TKA). Although regional anesthesia (RA) techniques reduce pain and improve functional outcomes after TKA, they may also contribute to PNI. The objective of this study was to test the hypothesis that PNI risk differs among patients according to RA use during TKA. METHODS: All patients aged at least 18 yr who underwent elective TKA from January 1988 to July 2007 were retrospectively identified. The primary outcome variable was the presence of a new PNI documented within 3 months of the procedural date. Age, sex, body mass index, type of procedure, tourniquet time, type of anesthesia, and use of peripheral nerve blockade were evaluated as potential risk factors for PNI using multivariable logistic regression. RESULTS: Ninety-seven cases of PNI were identified among 12,329 patients. Overall incidence of PNI was 0.79% (95% CI, 0.64-0.96%). PNI was not associated with peripheral nerve blockade (odds ratio [OR], 0.97) or type of anesthesia (OR, 1.10 [neuraxial vs. general]; OR, 1.82 [combined vs. general]). Risk for PNI decreased with age (OR, 0.68 [per decade]; P < 0.001) but increased with tourniquet time (OR, 1.28 [per 30-min increase]; P = 0.003) and bilateral procedures (OR, 2.51; P < 0.001). Patients with PNI who underwent peripheral nerve blockade were less likely to have complete neurologic recovery (OR, 0.37; P = 0.03). CONCLUSIONS: Risk for PNI after TKA was unchanged by the use of RA techniques. This finding supports the notion that the known benefits of RA for patients undergoing TKA can be achieved without increasing risk of neurologic injury. However, in rare situations when PNI occurs, complete recovery may be less likely if it develops after peripheral nerve blockade
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Arthroscopically Assisted Reduction and Internal Fixation of Scaphoid Fractures, Delayed Unions, and Nonunions
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Distal Radius Fractures
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The unstable scaphoid fracture can be treated by a variety of different methods, including open reduction and internal fixation (ORIF), percutaneous fixation with either k-wires or cannulated screws, and arthroscopically assisted reduction and internal fixation (AARIF) with various cannulated screw systems. The drawbacks of ORIF include extensive soft-tissue dissection, disruption of the nondominant volar blood supply, division of the radioscaphocapitate and radioscapholunate ligaments and volar capsule, and prolonged rehabilitation. Percutaneous fixation avoids the aforementioned drawbacks, yet relies on fluoroscopic guidance alone to assure accurate reduction of the scaphoid fracture fragments and optimal positioning of the implant in the apex of the proximal pole. The technical limitations of plain radiography as well as fluoroscopy in detailed visualization of the oddly oriented scaphoid limit the accuracy of the percutaneous technique. AARIF avoids all the limitations of ORIF, yet allows direct visualization of the scaphoid fracture site and assures accurate reduction of the fragments before and during definitive arthroscopically assisted internal fixation. AARIF also assists in accurate targeting of the proximal pole apex or "sweet spot," in addition to allowing detection of concurrent pathology in the radiocarpal or midcarpal joints. Delayed unions and stable nonunions with normal intrascaphoid angles, even with ischemic proximal poles, can be treated with AARIF augmented with percutaneous cancellous bone grafting from the trapezial ridge plus autologous platelet-derived growth factor gel. © 2007 Elsevier Inc. All rights reserved.
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Comparison of quantitative ultrasound parameters with dual energy X-ray absorptiometry in pre- and postmenopausal women
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Management of Hip Fractures in the Elderly
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BACKGROUND: Quantitative ultrasound (QUS) has been claimed as an alternative technique for risk assessment of hip fractures associated with osteoporosis. However, reports concerning modest correlations between QUS parameters and dual energy X-ray absorptiometry (DXA) in women raise questions about the reliability of QUS technology to predict bone mineral density (BMD). Partially, the lack of stronger correlations may be due to heterogeneity in bone architecture deterioration which may be more pronounced in older than in younger women. Therefore, it was thought important to study QUS/DXA interrelationships in subgroups of pre- and postmenopausal women. METHODS: We studied 217 pre- and postmenopausal women between the ages of 25 and 75 years, who were referred for a BMD measurement because of osteoporosis in at least one family member either in the first or in the second degree. All women had a calcaneal QUS and a DXA measurement at the lumbar spine, total hip and femoral neck. RESULTS: The linear regression coefficients between the QUS parameters broadband ultrasound attenuation (BUA) and speed of sound (SOS) and DXA at the various sites in the group as a whole were 0.53 to 0.54 (P<0.0001). Significantly lower regression coefficients between BUA and DXA at the total hip and the femoral neck were found in premenopausal women (r=0.31 and 0.38, P<0.0001) compared to postmenopausal women (r=0.56 and 0.53, P<0.0001). For SOS there was no significant difference between the regression coefficients in the pre- and postmenopausal group. The overall prevalence of osteoporosis as assessed by DXA in the total group was 25% (6% in the pre- and 36% in the postmenopausal group). BUA failed to detect osteoporosis in all five premenopausal women but also in 20 out of 50 postmenopausal women with osteoporosis according to DXA measurements. SOS measurements were even worse in this respect. CONCLUSIONS: Linear regression coefficients between calcaneal QUS parameters and DXA are only modest considering a group of 25--75-year-old Dutch women. In the subgroup of premenopausal women correlations between BUA and BMD at the hip and femoral neck are worse compared to those in postmenopausal women. The predictive value of QUS parameters for BMD is limited, therefore it is not appropriate to use QUS as a surrogate for DXA
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Cartilage change after arthroscopic repair for an isolated meniscal tear
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Anterior Cruciate Ligament Injuries CPG
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To investigate the direct effect to the cartilage caused by the meniscal repair, we examined patients who underwent an isolated meniscal repair without any other abnormalities by arthroscopic examination. A total of 17 patients were examined by second-look arthroscopy after an average interval of 9 months from the meniscal repair, and have been evaluated the status of the repaired meniscus and of the relative femoral condylar cartilage. Changes in the severity of the cartilage lesion between at the time of meniscal repair and the time of the second-look arthroscopy were considered based on the status of the repaired meniscus. Regardless of the healing status of the repair site, it was possible to prevent degeneration in the cartilage in 9 of the 10 patients who demonstrated no degeneration in the meniscal body. Of the 7 patients who demonstrated degeneration in the meniscal body, progression in cartilage degeneration was noted as 1 grade in 2 patients and 2 grades in another 3 patients. Even in those in which stable fusion of the repair site was achieved, the condition of the inner meniscal body was not necessarily maintained favorably in all cases, indicating that degeneration in the meniscal body was a risk factor for cartilage degeneration. It was concluded that recovery could not be expected even at 9 months after the repair if the lesion had already demonstrated degeneration in the meniscal body at the time of repair
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Central nervous system interleukin-8 production following neck of femur fracture
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Management of Hip Fractures in the Elderly
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Aim: To establish a proinflammatory cytokine profile of the cerebrospinal fluid (CSF) following trauma. Background: Trauma is associated with a postinjury syndrome consisting of loss of weight and nitrogen, pyrexia, anorexia and fatigue. It has been proposed that cytokines are pathophysiologically involved in this syndrome but the site of action of these is unclear. Previous work in head injury models, supported by animal work, has suggested that one important site of action is the central nervous system (CNS). Methods: Women who had sustained neck of femur fractures were enrolled (trauma group). CSF was collected at the time of spinal anaesthetic. Women undergoing elective lower limb surgery were recruited as controls. CSF and serum were assayed for Interleukin (IL) 1, 2, 4, 6, 8, 10, 12, interferon gamma, and tumour necrosis factor by cytometric bead array. Results: In the trauma group, IL-8 was elevated in the CSF but not in the serum, while IL-6 was elevated in the serum but not in the CSF. IL-1(beta), associated with elevated IL-12, was also detected in the serum of three of 11 trauma patients but none of the nine controls. No other cytokines were consistently detected. Conclusions: This study raises the possibility that IL-8, acting in the CNS, plays a role in the postinjury syndrome. It is unclear as to the mechanism by which CNS IL-8 is produced in trauma but a physiological role is supported by the known ability of the CNS to produce IL-8 and the presence of receptors for its action in the CNS
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Low-frequency vibratory exercise reduces the risk of bone fracture more than walking: a randomized controlled trial
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Management of Hip Fractures in the Elderly
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BACKGROUND: Whole-body vibration (WBV) is a new type of exercise that has been increasingly tested for the ability to prevent bone fractures and osteoporosis in frail people. There are two currently marketed vibrating plates: a) the whole plate oscillates up and down; b) reciprocating vertical displacements on the left and right side of a fulcrum, increasing the lateral accelerations. A few studies have shown recently the effectiveness of the up-and-down plate for increasing Bone Mineral Density (BMD) and balance; but the effectiveness of the reciprocating plate technique remains mainly unknown. The aim was to compare the effects of WBV using a reciprocating platform at frequencies lower than 20 Hz and a walking-based exercise programme on BMD and balance in post-menopausal women. METHODS: Twenty-eight physically untrained post-menopausal women were assigned at random to a WBV group or a Walking group. Both experimental programmes consisted of 3 sessions per week for 8 months. Each vibratory session included 6 bouts of 1 min (12.6 Hz in frequency and 3 cm in amplitude with 60 degrees of knee flexion) with 1 min rest between bouts. Each walking session was 55 minutes of walking and 5 minutes of stretching. Hip and lumbar BMD (g.cm-2) were measured using dual-energy X-ray absorptiometry and balance was assessed by the blind flamingo test. ANOVA for repeated measurements was adjusted by baseline data, weight and age. RESULTS: After 8 months, BMD at the femoral neck in the WBV group was increased by 4.3% (P = 0.011) compared to the Walking group. In contrast, the BMD at the lumbar spine was unaltered in both groups. Balance was improved in the WBV group (29%) but not in the Walking group. CONCLUSION: The 8-month course of vibratory exercise using a reciprocating plate is feasible and is more effective than walking to improve two major determinants of bone fractures: hip BMD and balance
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How does exercise dose affect patients with long-term osteoarthritis of the knee? A study protocol of a randomised controlled trial in Sweden and Norway: the SWENOR Study
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: Osteoarthritis (OA) of the knee is characterised by knee pain, disability and degenerative changes, and places a burden on societies all over the world. Exercise therapy is an often-used modality, but there is little evidence of what type of exercise dose is the most effective, indicating a need for controlled studies of the effect of different dosages. Thus, the aim of the study described in this protocol is to evaluate the effects of high-dose versus low-dose medical exercise therapy (MET) in patients with knee OA.
METHODS AND ANALYSIS: This is a multicentre prospective randomised two-arm trial with blinded assessment and data analysis. We are planning to include 200 patients aged 45-85 years with symptomatic (pain and decreased functioning) and X-ray verified diagnosis of knee OA. Those eligible for participation will be randomly allocated to either high-dose (n=100) or low-dose (n=100) MET. All patients receive three supervised treatments each week for 12 weeks, giving a total of 36 MET sessions. The high-dose group exercises for 70-90 min compared with 20-30 min for the low-dose group. The high-dose group exercises for a longer time, and receives a greater number of exercises with more repetitions and sets. Background and outcome variables are recorded at inclusion, and outcome measures are collected after every sixth treatment, at the end of treatment, and at 6-month and 12-month follow-ups. Primary outcome is self-rated knee functioning and pain using the Knee Injury and Osteoarthritis Outcome Score (KOOS). The primary end point is at the end of treatment after 3 months, and secondary end points are at 6 months and 12 months after the end of treatment.
ETHICS AND DISSEMINATION: This project has been approved by the Regional Research Ethics Committees in Stockholm, Sweden, and in Norway. Our results will be submitted to peer-reviewed journals and presented at national and international conferences.
TRIAL REGISTRATION NUMBER: NCT02024126; Pre-results.
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Serine proteases of the complement lectin pathway and their genetic variations in ischaemic stroke
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DoD PRF (Psychosocial RF)
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Aims The aim of the current study was to assess the proteolytic activities of collectin-bound MASP-1 and MASP-2 in the blood of patients with ischaemic stroke, as well as the association of their six genetic polymorphisms (rs3203210, rs28945070, rs28945073 in MASP1 gene and rs2273343, rs12711521, rs147270785 in MASP2 gene) with this pathology. Methods In total, 250 patients and 300 healthy subjects were involved in this study. MBL-Associated serine protease (MASP)-1 and MASP-2 activities were measured using in-house developed immunofluorescent and enzyme-linked immunosorbent assays, respectively. Sequence specific primer PCR was used to study the association of MASP1 and MASP2 genetic polymorphisms with ischaemic stroke. Results The results obtained demonstrate that the activities of collectin-bound MASP-1 and MASP-2 in patients with ischaemic stroke are significantly higher than those in healthy subjects (p<0.001). According to the data obtained for genotyping, the rs3203210 polymorphism in the MASP1 gene and the rs147270785 polymorphism in the MASP2 gene are associated with ischaemic stroke (p<0.0001). Conclusions In conclusion we suggest that the complement lectin pathway serine proteases, MASP-1 and MASP-2, can be associated with ischaemic stroke development risk and may participate in pathological events leading to post-ischaemic brain damage. Moreover rs3203210 and rs147270785 single nucleotide polymorphisms in the MASP1 and MASP2 genes, respectively, are strongly associated with ischaemic stroke, and the minor rs3203210â??C and rs147270785â??A alleles of these polymorphisms may be considered as protective factors for ischameic stroke, at least in the Armenian population.
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Breast Reduction
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Reduction Mammoplasty for Female Breast Hypertrophy
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Breast reduction surgery, also known as reduction mammoplasty, is a procedure to reduce overall breast volume, maintain nipple-areola viability, and achieve a shape that is aesthetically pleasing. Before deciding if a patient is a candidate for this type of procedure, a detailed medical history, including the age of breast development, previous or anticipated pregnancies or breastfeeding, weight change, smoking history, and overall medical status should be obtained. The family history of breast cancer is important as well. Symptoms relating to breast weight such as neck, back, and shoulder pain are documented. Thorough preoperative assessment is essential, including physical examination of size, shape, elasticity, looseness, striae, rashes, bra strap grooving, any asymmetry, masses, and consistency. The position of the nipple-areola complex relative to the inframammary fold is assessed. Measurements are done from the sternal notch to the nipple and nipple to the inframammary fold to assess the degree of vertical correction. It is not uncommon for a patient with severe breast ptosis to present requesting reduction when they require a mastopexy or breast lift. Although reduction mammoplasty and mastopexy are fundamentally different, both operations require similar techniques. [1] [2]
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Efficacy of closed wound drainage after total joint arthroplasty: A prospective randomized study
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Surgical Management of Osteoarthritis of the Knee CPG
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The efficacy of closed suction drains following joint arthroplasty operations was prospectively evaluated in a randomized manner. All 88 patients allotted to primary knee or hip arthroplasty operations during a 6- month period were included in the study. Drains were used in 32 of 58 patients following total knee arthroplasty and in 18 of 30 total hip arthroplasties. No statistical difference was found in the hemoglobin levels measured following surgery and in the number of patients requiring blood transfusions between the two groups after total hip arthroplasty (P = .06). The power of the test to detect a difference of 2 g% in hemoglobin levels is 94%. Two patients from each group had a transient serous discharge for 3 to 4 days following surgery and none had wound infections. Significantly more blood transfusions were needed in patients with drains following total knee arthroplasty compared with patients without drains (0.7 unit per patient versus 0.2 unit per patient, P = .005) to maintain the same hemoglobin blood levels. Patients with no drains had significantly more transient sterile serous wound discharge than patients with drains (38.4% vs 12.5%, P = .02). Superficial wound infection necessitating antimicrobial medication developed in one patient with drains and in no patients in the other group. These results suggest that drains may not be needed following total hip arthroplasty. The more common serous wound discharge may be of some concern when drains are not used following total knee arthroplasty
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Hematogenous staphylococcal pneumonia secondary to soft tissue infection
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Staphylococcal pneumonia is rare, has a high mortality and morbidity rate, and occurs commonly during influenza epidemics (airborne) or during the course of right sided bacterial endocarditis in drug addicts (blood borne). In recent years, much emphasis has been given to the staphylococcal infections in intravenous drug abusers. This report describes ten patients with staphylococcal pneumonia resulting from soft tissue infection who were previously healthy and had no history of drug abuse. They were 12 to 45 years old. Eight were male patients. Soft tissue infection was community-acquired in nine and was most commonly located in the lower extremities. Three patients had diabetes. All presented with a clinical picture of acute pneumonia. Hemoptysis occurred in three. Chest roentgenogram showed multiple large or small round discrete densities in most of the patients. Lobar involvement was notably absent. Eight developed cavitary lesions in their lungs. The average length of hospital stay was 40 days. One patient died and six developed complications. Staphylococcal etiology should be suspected in patients with acute pneumonia who have soft tissue infection or have characteristic chest roentgenogram findings; antistaphylococcal agents should be included in the therapeutic regimens of such patients until the results of the cultures are known
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Rhinologic Procedures in the Era of COVID-19: Health-care Provider Protection Protocol
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Coronavirus Disease 2019 (COVID-19)
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INTRODUCTION: SARS-CoV-2 has been identified as the pathogen causing the outbreak of Coronavirus Disease 2019 (COVID-19) that started in Wuhan, China, in December 2019. SARS-CoV-2 has human-to-human transmission ability and universally contagious to all populations. The main transmission patterns are respiratory droplets transmission and contact transmission. The purpose of this study is to propose a protocol that may be used as a guide to reduce the incidence of COVID-19 infections among otolaryngology care teams. METHODS: A prospective cohort study was conducted to show the efficacy of our protocol to prevent transmission to health-care providers from March 11, 2020 through April 14, 2020. The protocol consisted of a series of protective measures that we applied to all health-care providers, then testing of our providers for COVID-19 using reverse transcription polymerase chain reaction along with immunoglobulin M (IgM) and immunoglobulin G (IgG) testing at the end of the study period to ensure effectiveness. RESULTS: Our protocol resulted in zero transmissions to our health-care providers during the duration of the initial study. We were involved in greater than 150 sinonasal, skull base, open airway, and endoscopy procedures during this study. At the conclusion of the initial 5 weeks, we had no health-care providers test positive for SARS-CoV-2. CONCLUSION: According to our proposed protocol, we were able to provide care for all patients in clinic, hospital, emergent, intensive, and surgical settings with no transmission of SARS-CoV-2 by symptomatology and post evaluation testing.
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0 |
Expert panel on anterior cruciate ligament case studies
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AMP (Acute Meniscal Pathology)
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Anterior cruciate ligament (ACL) reconstructions cannot, and should not, be considered "recipe-driven" or "cookie-cutter" operations. There are multiple variables that must be considered both pre- and intraoperatively in order to execute a successful procedure. The following case studies present a number of challenging situations, many of which do not have a straightforward, or only one, solution. The goal is to provide some real-life clinical situations in which the reader can "observe" an expert panel of ACL surgeons working through the problems - offering solutions based on science, experience, and intuition.
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Knee osteoarthritis prevalence in hospitalized elderly patients: a retrospective study
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OAK 3 - Non-arthroplasty tx of OAK
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This study aimed to determine the prevalence rate of knee osteoarthritis (OA) and the risk factors for OA in hospitalized elderly patients. We conducted this retrospective study in elderly patients (aged 65 years and older) who were hospitalized in the Geriatric Ward of General Hospital of Guangzhou Military Command of the People's Liberation Army between January 2011 and June 2013, including general condition, present history, past history, physical examination, X-ray results, and disease diagnosis. The prevalence, awareness, and treatment rates of knee OA in hospitalized elderly patients were calculated. Risk factors were computed using multiple logistic regression analysis. Of a total of 267 (17.4%) hospitalized elderly patients diagnosed with knee OA, the prevalence rate of OA was 9.95% in males and 37.76% in females. The rate of awareness among those with OA was 51.68%; the rate of treatment was 83.33%; and the rate of control was 77.39%. The medical expenses for both females (1143+/-315 yuan month-1) and males (1192+/-357 yuan month-1) in knee OA patients are higher than that of the non-knee OA group (989+/-274 yuan month-1, 1038+/-295 yuan month-1). The risk factors for knee OA include gender (OR=2.448), age (OR=1.124), transportation mode (OR= 8.972), exercise (OR=7.374), bowel evacuation position (OR=5.767), family history of knee OA (OR=2.195), and body mass index (OR=2.469). The prevalence of knee OA is unexpectedly high in hospitalized elderly patients, and the rates of awareness and treatment are less than desirable. Prevention and control measures should be taken in patients with concomitant risk factors.
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1 |
Bacteria in the apical 5 mm of infected root canals
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Ten freshly extracted teeth which had carious pulpal exposures and periapical lesions contiguous with the root apex were placed inside an anaerobic chamber and the apical 5 mm of the root canals cultured. In addition to anaerobic incubation, duplicate cultures were incubated aerobically. Fifty strains of bacteria from the 10 root canals were isolated and identified. The most prominent bacteria cultured from the 10 root canals were Actinomyces, Lactobacillus, black-pigmented Bacteroides, Peptostreptococcus, nonpigmented Bacteroides, Veillonella, Enterococcus faecalis, Fusobacterium nucleatum, and Streptococcus mutans. Of the 50 bacterial isolates, 34 (68%) were strict anaerobes. This study demonstrates the presence of predominantly anaerobic bacteria in the apical 5 mm of infected root canals in teeth with carious pulpal exposures and periapical lesions
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Subsequent fracture in nursing home residents with a hip fracture: a competing risks approach
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DoD SSI (Surgical Site Infections)
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OBJECTIVES: To determine the incidence and predictors of subsequent fracture in nursing home residents with a hip fracture, accounting for the competing risk of death.
DESIGN: Dynamic cohort study.
SETTING: Hebrew Rehabilitation Center, a 725-bed, long-term care facility in Boston, Massachusetts.
PARTICIPANTS: Long-term care residents with a surgically repaired hip fracture (1999-2006) followed through June 30, 2007, for the occurrence of subsequent fracture at any skeletal site.
MEASUREMENTS: Information on age, sex, anatomic location, type of repair, body mass index (BMI), comorbidities, functional status, cognitive status, and medication use were evaluated as potential risk factors for subsequent fracture.
RESULTS: The study included 184 residents with a baseline hip fracture. Thirty-nine residents (7 men, 32 women) experienced a subsequent fracture over a median follow-up of 1.1 years. After the baseline hip fracture, 6% of residents experienced a subsequent fracture within 6 months, 12% within 1 year, and 21% within 5 years. In addition, 23% of residents died within 6 months, 31% within 1 year, and 60% within 5 years. High functional status was associated with a five times greater risk of subsequent fracture (high vs low functional status, hazard ratio=5.10, P<.005). Age, sex, BMI, comorbidities, cognitive status, and medication use were not associated with subsequent fracture.
CONCLUSION: Hip fractures are a sentinel event in nursing home residents, with a high incidence of subsequent fracture and death occurring within 1 year. Identification of prefracture characteristics and postfracture complications associated with mortality should help guide secondary prevention efforts in nursing home residents.
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Immediate and Delayed Effects of Joint Loading Activities on Knee and Hip Cartilage: A Systematic Review and Meta-analysis
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AMP (Acute Meniscal Pathology)
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Background: The impact of activity-related joint loading on cartilage is not clear. Abnormal loading is considered to be a mechanical driver of osteoarthritis (OA), yet moderate amounts of physical activity and rehabilitation exercise can have positive effects on articular cartilage. Our aim was to investigate the immediate effects of joint loading activities on knee and hip cartilage in healthy adults, as assessed using magnetic resonance imaging. We also investigated delayed effects of activities on healthy cartilage and the effects of activities on cartilage in adults with, or at risk of, OA. We explored the association of sex, age and loading duration with cartilage changes. Methods: A systematic review of six databases identified studies assessing change in adult hip and knee cartilage using MRI within 48 h before and after application of a joint loading intervention/activity. Studies included adults with healthy cartilage or those with, or at risk of, OA. Joint loading activities included walking, hopping, cycling, weightbearing knee bends and simulated standing within the scanner. Risk of bias was assessed using the Newcastle–Ottawa Scale. Random-effects meta-analysis estimated the percentage change in compartment-specific cartilage thickness or volume and composition (T2 relaxation time) outcomes. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system evaluated certainty of evidence. Results: Forty studies of 653 participants were included after screening 5159 retrieved studies. Knee cartilage thickness or volume decreased immediately following all loading activities investigating healthy adults; however, GRADE assessment indicated very low certainty evidence. Patellar cartilage thickness and volume reduced 5.0% (95% CI 3.5, 6.4, I 2 = 89.3%) after body weight knee bends, and tibial cartilage composition (T2 relaxation time) decreased 5.1% (95% CI 3.7, 6.5, I 2 = 0.0%) after simulated standing within the scanner. Hip cartilage data were insufficient for pooling. Secondary outcomes synthesised narratively suggest knee cartilage recovers within 30 min of walking and 90 min of 100 knee bends. We found contrasting effects of simulated standing and walking in adults with, or at risk of, OA. An increase of 10 knee bend repetitions was associated with 2% greater reduction in patellar thickness or volume. Conclusion: There is very low certainty evidence that minimal knee cartilage thickness and volume and composition (T2 relaxation time) reductions (0–5%) occur after weightbearing knee bends, simulated standing, walking, hopping/jumping and cycling, and the impact of knee bends may be dose dependent. Our findings provide a framework of cartilage responses to loading in healthy adults which may have utility for clinicians when designing and prescribing rehabilitation programs and providing exercise advice.
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1 |
Reamed nailing of Gustilo grade-IIIB tibial fractures
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DoD LSA (Limb Salvage vs Amputation)
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Reamed intramedullary nailing was carried out on R57 Gustilo grade-IIIB tibial fractures in 55 patients. After debridement, there was substantial bone loss in 28 fractures (49%). The mean time to union was 43 weeks (14 to 94). When there was no bone loss, the mean time to union was 32 weeks; it was 45 weeks if there was bone loss. Fractures complicated by infection took a mean of 53 weeks to heal. Revision nailing was necessary in 13 fractures (23%) and bone grafting in 15 (26%). In ten fractures (17.5%) infection developed, in four within six weeks of injury and in six more than four months later. Of these, nine were treated successfully, but one patient required an amputation because of osteomyelitis. Our results indicate that reamed intramedullary nailing is a satisfactory treatment for Gustilo grade-III tibial fractures.
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Increased risks of hip fracture in diabetic patients of Taiwan: a population-based study
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Management of Hip Fractures in the Elderly
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OBJECTIVE: Using Taiwan's National Health Insurance claim data, we evaluated the age-, sex-, and urbanization-specific incidence density and relative risks of hip fracture in the diabetic population. RESEARCH DESIGN AND METHODS: Diabetic patients (n = 500,868) and an age- and sex-matched control group (n = 500,248) were linked to inpatient claims (1997-2002) to identify hospitalizations for nontransport accident hip fracture. The person-year approach with Poisson assumption and Kaplan-Meier analysis were used to estimate the incidence and the cumulative event rates. We also assessed the age-, sex-, and urbanization-specific relative risks of hip fracture in relation to diabetes with the Cox proportional hazard regression model. RESULTS: The overall incidences of hip fracture for diabetic men and women, respectively, were 3.01 and 6.75/1,000 person-years, which were higher than those for control men and women. There were significant interactions of diabetes and age and diabetes and urbanization statuses. Hazard ratios (HRs) of diabetic patients aged 35-44 years (men 2.45 [95% CI 1.65-3.64]; women 3.19 [1.39-7.33]) were higher than those of diabetic patients aged 55-64 years (men 1.90; women 2.81), but in diabetic men aged >74 years and diabetic women aged >84 years, the HRs were compared with null statistically (HRs 0.98 and 0.91, respectively). Diabetic patients living in rural areas tended to have higher HRs of hip fracture. CONCLUSIONS: In Taiwan, diabetes increased the risk of hip fracture in both sexes in all age-groups except in diabetic men aged >74 years and diabetic women aged >84 years. Higher HRs of hip fracture were disproportionately observed in younger diabetic patients and in those living in rural areas
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1 |
Evaluation of DepoFoam® bupivacaine for the treatment of postsurgical pain
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AAHKS (8) Anesthetic Infiltration
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An extended-release, multivesicular liposome-encapsulated form of the local anesthetic bupivacaine, DepoFoam® bupivacaine (proposed proprietary name EXPAREL�), is in development for use as part of a multimodal regimen for the treatment of postsurgical pain. Placebo- and active-controlled clinical trials in patients who have undergone either orthopedic or soft-tissue procedures indicate that a single local administration into the surgical site results in analgesic activity for up to 3-4 days and decreases the use of opioid rescue medication. The safety profile of DepoFoam bupivacaine appears to be similar to that of bupivacaine HCl, and adverse events are dose-related. © 2011 Future Medicine Ltd.
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Fracture of the tibia complicated by acute compartment syndrome
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DOD - Acute Comp Syndrome CPG
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A consecutive series of 32 patients with tibia fractures complicated by compartment syndrome was treated with fasciotomy. One group was also treated with closed reduction of the fracture and cast immobilization and compared with a comparable group treated with internal fixation without case immobilization after fasciotomy. All other patients were treated with fasciotomy and reduction followed with either external skeletal fixation, pins and plaster, or skeletal traction. Care of the open fasciotomy incisions, observation of the neurovascular status of the limb, and rehabilitation of the extremity were facilitated by internal fixation operations without subsequent external cast immobilization. The anatomic and functional results in this group were better than those treated with fasciotomy and cast immobilization. All fractures were united by 20 weeks. Complications in both groups were similar, although one deep infection, which was resolved with appropriate treatment, occurred in the group treated with internal fixation. Six open tibia fractures were treated with external skeletal fixation after fasciotomy; the results were less satisfactory, but the initial injuries were also more severe in this group. Patients with closed tibial fractures complicated by compartment syndromes should be treated expeditiously with fasciotomy, followed by stable internal fixation.
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0 |
Improvement in outcomes after implantation of a novel polyurethane meniscal scaffold for the treatment of medial meniscus deficiency
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AMP (Acute Meniscal Pathology)
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PURPOSE: Meniscal injury resulting in segmental loss of meniscal tissue is a major risk factor for the development of osteoarthritis. Tissue engineering strategies have provided scaffolds for meniscal regeneration in order to establish a treatment option for patients with limited opportunities for meniscal reconstruction. The purpose of this study was to assess the clinical and magnetic resonance imaging (MRI) results 2 years after implantation of a polyurethane scaffold for chronic segmental medial meniscus deficiency following partial medial meniscectomy.
METHODS: Eighteen patients were treated with arthroscopic implantation of an ActiFit( R) (Orteq Sports Medicine) polyurethane meniscal scaffold for meniscus deficiency of the medial meniscus. Patients were followed up at 6, 12, and 24 months. Clinical outcome was assessed using patient-reported outcome scores (KOOS, KSS, UCLA activity scale, VAS for pain). Radiological outcome was assessed using MRI at 6, 12, and 24 months by evaluating scaffold morphology, scaffold integration, and additional joint injury, as well as joint inflammation.
RESULTS: Eighteen patients with a median age of 32.5 years (range 17-49) were enrolled. Statistically significant improvements were present in all patients, but one at 2 years compared to baseline in all categories. Complete resorption of the scaffold occurred in one patient representing a failure to treatment. MRI showed abnormal signal intensity of the scaffold when compared to residual meniscal tissue but without synovitis or joint inflammation. Extrusion of the scaffold was present in four patients. No correlation between scaffold extrusion and clinical outcome was observed.
CONCLUSION: Arthroscopic implantation of a polyurethane meniscal scaffold in patients with chronic segmental medial meniscus deficiency is not only a safe procedure but leads to good clinical results at a 2-year follow-up. Scaffold extrusion did not appear to affect clinical outcome.
Level of evidence: Iv.
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0 |
Scarless treatment for gynecomastia
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Panniculectomy & Abdominoplasty CPG
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Gynecomastia is the most common breast problem in males, with an overall incidence as documented by Webster in The Navy Hospital admission in World War II as about 8 per 100000. The most common complain is embarrassment though some also have tenderness and pain. About 30-65% of boys have some breast development at puberty which lasts only a few months in the majority and in less than 8% it continues for more than three years. 30% of the middle aged man develop Gynecomastia with no obvious pathological cause and this figure rises to about 60% arround the seventh decade. For a problem which is relatively common wed describe our experience and present a case report of grade 2b Gynecomastia treated very successfully with liposuction. This is well illustrated in the pictures below.
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Appropriateness and total knee arthroplasty: an examination of the American Academy of Orthopaedic Surgeons appropriateness rating system
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OAK 3 - Non-arthroplasty tx of OAK
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Objective The American Academy of Orthopaedic Surgeons (AAOS) recently published appropriateness criteria for patients with knee osteoarthritis (OA) who are being considered for total knee arthroplasty (TKA). We evaluated the extent to which predictor variables used by the AAOS contribute to final classification, rated as â??appropriate,â? â??may be appropriateâ? or â??rarely appropriate.â? Methods The RAND/UCLA Appropriateness method was used by AAOS to develop 864 clinical vignettes, each incorporating eight evidence-based variables associated with TKA outcome or need. Variables included function-limiting pain severity, knee OA severity, knee motion and age among others. The contribution of each variable to the overall classification was determined using multinomial regression. A classification tree method was applied to determine the combinations of variables that contributed to final classification for each vignette. Results Multinomial regression indicated that patient age, knee motion, OA severity and location were the four most powerful predictors of final classification. Function limiting pain, knee instability and lower limb alignment contributed little to the final classification. The classification tree had an accuracy of 86.7% and the most important contributors to classification were age, knee OA severity and pattern. Conclusion Function limiting pain, the most frequent reason endorsed by patients seeking TKA does not meaningfully contribute to the newly developed AAOS appropriateness criteria. The system is highly dependent on traditional variables that surgeons consider when evaluating patients for TKA: patient age, knee OA severity, knee OA pattern and knee motion.
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0 |
Drug consumption in patients with hip fractures compared with controls
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Management of Hip Fractures in the Elderly
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All drugs in a prospective series of 309 consecutive patients with cervical fractures and 300 with trochanteric fractures were recorded and compared with an age- and sex-matched randomly selected group from the city population files. A greater consumption of drugs was observed in the hip fracture group compared with the control group. Significant differences were observed for men regarding selective beta 2-adrenergic stimulants and xanthines, laxatives, phenothiazines and anti-psychotic drugs, as well as anti-glaucoma drugs. Women with hip fractures had a significantly greater consumption of diuretics, laxatives, insulin, phenothiazines and other antipsychotic drugs
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PGE2 modulates the synthesis of OPG and RANKL in the articular cartilage of patients with knee osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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Aims: The system OPG/RANK/RANKL is the principal modulator of bone remodeling, although its regulation in the adjacent articular cartilage during OA is unknown. Our aim was to explore if PGE2 synthesis inhibition modulates OPG and RANKL synthesis in the cartilage of OA patients. We also investigated if PGE2 modify this system in human osteoarthritic chondrocytes (HOC) in culture. Methods: A 3-month controlled, clinical trial was carried out on 20 patients with severe knee OA scheduled for total knee replacement surgery (Mankin score 11.4(plus or minus)0.4). Ten patients were treated with Celecoxib (CBX) (200 mg/24h), while OA patients who did not want to be treated served as the control group (CTR). After surgery, the articular cartilage was processed for western blot, real time PCR and immunohistochemical studies. In human osteoarthritic chondrocytes (HOC) in culture we also examined the effects of PGE2 on OPG/RANK/RANKL synthesis, and explored which of its surface receptors was involved in the PGE2 action. Results: In the cartilage of OA patients, CBX did not modify OPG or RANK synthesis, while it significantly inhibited RANKL synthesis, thus increasing the ratio OPG/RANKL in comparison with CTR. By immunohistochemistry, we observed that OPG and RANKL were mainly expressed in chondrocytes in all cartilage zones, although a clear pericellular and extracellular signal was also observed. Unexpectedly, vessels crossing the tide mark, the tide mark-embedded chondrocytes, and some cells in the calcified cartilage, stained positively for RANKL. No differences in the protein distribution between the two groups of patients were observed. In HOC in culture, PGE2 elicited a dose and time-dependent increase in the synthesis of OPG and, to a significantly higher extent, those of RANKL. Confocal microscopy revealed that PGE2 induced RANKL transport to the cell membrane. EP2/ EP4 agonists reproduced PGE2 actions on OPG and RANKL induction, while EP1/EP3 agonists had no effect. Conclusions: These data indicate that PGE2 regulates the expression and the release of the key mediators of bone metabolisms by articular chondrocytes. Long-term NSAID treatment that inhibited local PGE2 concentration also inhibited the resorptive signal synthesized by chondrocytes, especially RANKL synthesis. The role of this mediator in OA cartilage metabolism is still unknown, although it would allow the cartilage to control the activity of subchondral bone cells in a paracrine fashion
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The identification of differentially expressed microRNA in osteoarthritic tissue that modulate the production of TNF-alpha and MMP13
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: To identify differentially expressed microRNAs (miRNAs) in human osteoarthritic (OA) cartilage and bone tissue and to determine their relevance to chondrocyte function. METHODS: Cartilage and bone was obtained from OA patients who underwent total knee joint replacement surgery or from post-mortem patients with no previous history of OA. MiRNA expression was quantified by real-time PCR (RT-PCR). Functional pathway analysis of miRNA was performed using Ingenuity Pathway Analysis. Primary chondrocytes were isolated by collagenase digestion and transfected with miRNA mimics and miRNA inhibitors using cationic lipid. Tumour Necrosis Factor-alpha (TNF-alpha) and Matrix metalloprotease 13 (MMP13) protein levels were measured by Enzyme-Linked ImmunoSorbent Assay (ELISA). RESULTS: In total we identified 17 miRNA that showed greater than 4-fold differential expression between OA and normal cartilage, and 30 miRNA that showed greater than 4-fold differential expression in OA bone. Functional pathway analysis of the predicted gene targets for miR-9, miR-98, which were upregulated in both OA bone and cartilage tissue, and miR-146, which was downregulated in OA cartilage, suggested that these miRNA mediate inflammatory functions and pathways. Over-expression of miR-9, miR-98 or miR-146 in isolated human chondrocytes reduced interleukin-1 beta (IL-1 beta) induced TNF-alpha production. Furthermore, inhibition and over-expression of miR-9 modulated MMP13 secretion. CONCLUSIONS: We have identified a number of differentially expressed miRNAs in late-stage human OA cartilage and bone. Functional analysis of miR-9, miR-98 and miR-146 in primary chondrocytes suggests a role in mediating the IL-1 beta induced production of TNF-alpha. MiR-9, upregulated in OA tissue, was found to inhibit secretion of the collagen type II-targeting metalloproteinase MMP13 in isolated human chondrocytes
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Is posterior knee arthroscopy using posterior portals necessary for orthopedic surgeons? The latest evidence on applications and techniques
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AMP (Acute Meniscal Pathology)
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Various uses of posterior knee arthroscopy have been shown, including all-inside repair of posterior meniscal lesions, posterior cruciate ligament (PCL) reconstruction or PCL avulsion fixation, extensile posterior knee synovectomy for pigmented villonodular synovitis or synovial chondromatosis, posterior capsular release in the setting of knee flexion contractures, and loose bodies removal. Posterior arthroscopy provides direct access to the posterior meniscal borders for adequate abrasion and fibrous tissue removal. This direct view of the knee posterior structures enables the surgeon to create a stronger biomechanical repair using vertical mattress sutures. During PCL reconstruction, posterior arthroscopy gives the surgeon proper double access to the tibial insertion site, which can result in less acute curve angles and the creation of a more anatomic tibial tunnel. Moreover, it gives the best opportunity to preserve the PCL remnant. Arthroscopic PCL avulsion fixation is more time-consuming with a larger cost burden compared to open approaches, but in the case of other concomitant intra-articular injuries, it may lead to a better chance of a return to pre-injury activities. The high learning curve and overcaution of neuromuscular injury have discouraged surgeons from practicing posterior knee arthroscopy using posterior portals. Evidence for using posterior portals by experienced surgeons suggests fewer complications. The evidence suggests toward learning posterior knee arthroscopy, and this technique must be part of the education about arthroscopy. In today's professional sports world, where the quick and complete return of athletes to their professional activities is irreplaceable, the use of posterior knee arthroscopy is necessary.
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A novel method of using elastic bionic fixation device for distal tibiofibular syndesmosis injury
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: To describe and evaluate the novel method of using elastic bionic fixation device in treating the distal tibiofibular syndesmosis (DTS) injury.
METHODS: From June 2013 to January 2014, 17 subjects with ankle fractures combined with DTS separation were treated by the elastic bionic fixation device. The syndesmotic parameters, healing, functional scores, and possible complications were recorded.
RESULTS: All patients had a mean follow-up of 23.35 +/- 4.39 months (range, 15-28 months). Syndesmotic parameters returned to normal after surgery and remained normal throughout the follow-up period. X-ray examinations at 12 months follow-up showed no cable breakage of the elastic bionic fixation device or instrument invalidation compared to that of immediate post-operative X-ray films. Besides, no signs of articular degeneration and arthritis were observed. Furthermore, change in bone density near the fibular fixing button or tibial screw nut was also not detected. Primary wound healing was observed in 16 patients, while the remaining one showed redness and swelling of lateral ankle incision and got wound healing after seven to ten days of antibiotic therapy and local radio frequency physiotherapy. All obtained excellent and good outcomes according to the AOFAS score at 12 months after surgery.
CONCLUSIONS: The use of elastic bionic fixation device appears to be a promising option in treating DTS injury because it can provide stable and reliable elastic fixation, good functional recovery, and relatively fewer complications.
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Diurnal and seasonal patterns in presentations with hip fracture-data from the national hip fracture database
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Hip Fx in the Elderly 2019
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PURPOSE: we set out to examine diurnal and seasonal variation in hip fracture presentations to question their origin and to consider their implications for the organisation of health services for older people.
METHODS: we used the National Hip Fracture Database to identify the time of presentation and surgery for 64,102 patients; all those older than 60 years who sustained this injury in England, Wales and Northern Ireland during 2014.
RESULTS: we found marked diurnal variation in rates of presentation, increasing sharply after 0800 hours and decreasing only after 1800 hours. Among people who sustained their hip fracture in hospital (n = 2,761) or in a care home (n = 12,141), there were peaks in presentations around 0900 and 1800 hours. Time of presentation had a very marked effect on whether surgery was delayed by more than 24 hours but less against the national guidelines of surgery within 36 hours or by the next day. There were 15.6% more presentations during December compared to all other months (9.5% versus 8.2%, P < 0.001), a pattern also found among people living in care homes (9.1% versus 8.3%, P < 0.001).
CONCLUSIONS: we have identified morning and evening peaks of presentation for inpatients and care home residents and a December increase in overall hip fracture numbers. These patterns warrant further investigation if those organising health services are to prevent this injury, and to provide appropriate beds and prompt operations for the people who sustain it.
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Variants of self-assembling peptide, KLD-12 that show both rapid fracture healing and antimicrobial properties
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DoD SSI (Surgical Site Infections)
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KLD-12 (KLD) is a 12-residue self-assembling peptide that can adopt nano-structures and is known for its tissue-engineering properties. Our objective was to introduce antimicrobial attribute to KLD which would help in preventing secondary infection associated with external application of such tissue engineering materials. Considering the net charge of KLD-12, varying number of cationic arginine residues were added to its N-terminus. KLD variants showed appreciable bactericidal properties without any significant increase in cytotoxicity against tested mammalian cells. Further, these variants adopted beta-sheet structures and self-assembled into nano-structures comparable to that of KLD. Interestingly, the KLD variants with two (KLD-2R) and three (KLD-3R) arginine residues added to its N-terminus showed significant osteogenic effect which was comparable or better than the original peptide as evident from the alkaline phosphatase activity assay, mineralized nodule formation and expression of different osteogenic genes. Particularly, application of KLD-2R in rats to the site of a drill-hole (0.8 mm diameter) that was created in the femur metaphysis displayed significantly higher bone regeneration compared to that of KLD. The results demonstrate a simple way to improve biological property of a self-assembling peptide with tissue engineering property.
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Use of appropriate initial treatment among adolescents and young adults with cancer
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MSTS 2022 - Metastatic Disease of the Humerus
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Background There has been little improvement in the survival of adolescent and young adult (AYA) cancer patients aged 15 to 39 years relative to other age groups, raising the question of whether such patients receive appropriate initial treatment. Methods We examined receipt of initial cancer treatment for a population-based sample of 504 AYAs diagnosed in 2007 2008 with acute lymphoblastic leukemia (ALL), Hodgkin s or non-Hodgkin s lymphoma, germ cell cancer, or sarcoma. Registry data, patient surveys, and detailed medical record reviews were used to evaluate the association of patient demographic, socioeconomic, and health care setting characteristics with receipt of appropriate initial treatment, which was defined by clinical specialists in AYA oncology based on adult guidelines and published literature available before 2009 and analyzed with multivariable logistic regression. All statistical tests were two-sided. Results Approximately 75% of AYA cancer patients in our sample received appropriate treatment, 68% after excluding stage I male germ cell patients who all received appropriate treatment. After this exclusion, appropriate treatment ranged from 79% of sarcoma patients to 56% of ALL patients. Cancer type (P < .01) and clinical trial participation (P = .04) were statistically significantly associated with appropriate treatment in multivariable analyses. Patients enrolled in clinical trials were more likely to receive appropriate therapy relative to those not enrolled (78% vs 67%, adjusted odds ratio = 2.6, 95% confidence interval = 1.1 to 6.4). Conclusions Except for those with early stage male germ cell tumors, approximately 30% (or 3 in 10) AYA cancer patients did not receive appropriate therapy. Further investigation is required to understand the reasons for this potential shortfall in care delivery.
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Making a virtue of necessity: managing the open abdomen
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DOD - Acute Comp Syndrome CPG
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BACKGROUND: The open abdomen, or laparostomy, is becoming increasingly used in the management of critically ill surgical patients.
METHODS: The published work on laparostomy is reviewed, in the light of personal experience, with particular attention to the history and pathophysiology associated with laparostomy.
RESULTS AND CONCLUSION: The combination of an inert plastic sheet in contact with the viscera, and the application of subatmospheric pressure on the wound, is an effective combination to maximize the prospects of delayed primary wound closure while minimizing the chance of fistula and ventral hernia. [References: 70]
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Mechanical Failure of Revision Knee Prosthesis at both Femoral and Tibial Modular Metaphyseal Stem Junctions
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PJI DX Updated Search
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INTRODUCTION: This is a report of a mechanical failure of an S-ROM revision total knee prosthesis. The prosthesis was used as a revision implant following deep peri-prosthetic infection in a morbidly obese male. The prosthesis failed on both the femoral and tibial sides at the modular metaphyseal stem junctions and required a further revision using the same type of implant after infection was excluded. CASE PRESENTATION: A 57 year old male had previously undergone a left total knee arthroplasty in 1999 for osteoarthritis. He acquired a late deep peri-prosthetic infection with a multi-resistant Staphylococcus epidermidis. The organism was sensitive to vancomycin and rifampicin. A two stage revision was undertaken after clinical signs of infection had resolved and blood parameters had normalized. Intra-operative gram stain was negative for micro-organisms and frozen section of deep tissue was less than five polymorphs per high power field. A cemented S-ROM prosthesis was implanted using a coronal tibial osteotomy and a lateral release for exposure. After three years of the second stage of revision, the patient again presented to the orthopaedic department after reportedly falling on a wet floor six weeks ago. CONCLUSION: Radiographically, there was a broken tibial wire, osteolysis and pedestal formation around both the femoral and distal tibial stem extensions. The prosthesis was bent at the proximal tibial sleeve and stem junction. The prosthesis was considered loose with mechanical failure. At implant removal, it was noted that the femoral and tibial components at the modular metaphyseal sleeve-stem junction were fractured. Surgeons should be cautious in the use of these implants in morbidly obese patients where the stresses generated maybe above the yield stress of the material and the frictional forces that may overcome the modular taper junction's locking mechanism
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Survival after hip fracture
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Management of Hip Fractures in the Elderly
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Although it is known that overall mortality is increased after hip fracture, the influence of hip fracture risk factors on the subsequent mortality and cause of death has not been well studied. The objective of this study was to establish the survival after hip fracture in women and to assess the impact of comorbidity on mortality. We identified a complete population-based set of 2,245 incident hip fracture cases and 4,035 randomly selected population-based controls among women 50-81 years old in Sweden and followed these subjects for an average of 5 years through the Swedish National Inpatient and Cause-of-Death Registers. Information on factors related to hip fracture was obtained through linkage to hospital discharge data and through a mailed questionnaire. We studied excess mortality of hip fracture patients compared to controls using survival curves and proportional hazard regression models. During follow-up, 896 hip fracture patients (40%) and 516 (13%) controls died. The relative risk (RR) of death, adjusted for age and previous hospitalization for serious disease, was 2.3 (95% CI 2.0-2.5). Although the highest mortality risks were in the 1st 6 months post-fracture, RRs for fractures versus controls were increased for at least 6 years. Increased mortality was apparent both in those with evidence of comorbidity and those without. Hip fracture patients have a substantially increased risk of death that persists for at least 6 years post-fracture. The relative excess mortality is independent of comorbidity and known hip fracture risk factors
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Neuropathy of motor branch of median or ulnar nerve induced by midpalm ganglion
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Two cases of neuropathy of a motor branch caused by a midpalmal ganglion are presented. In the first case the ganglion originated from the midcarpal joint, protruded into the thenar muscle, and compressed the motor branch of the median nerve. In the second case the ganglion, distal to the fibrous arch of the hypothenar muscles, originated from the third carpometacarpal joint and compressed the motor branch of the ulnar nerve. In both cases muscle weakness and finger deformity recovered well after resection of the ganglion. This clinical condition is rare compared with carpal tunnel syndrome and Guyon's tunnel syndrome, which are caused by a ganglion in the wrist
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Trends and Outcomes in the Treatment of Failed Septic Total Knee Arthroplasty: Comparing Arthrodesis and Above-Knee Amputation
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PJI DX Updated Search
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BACKGROUND: Options for treatment of a failed septic total knee arthroplasty (TKA) include arthrodesis and above-knee amputation (AKA). Little comparative data exist to help clinicians when considering these alternatives. METHODS: A national database was queried for patients who underwent either knee arthrodesis or AKA for an infected TKA between 2005 and 2012. Procedure volumes, postoperative complications, hospital charges, length of stay, and 90-day readmission rates were evaluated. RESULTS: A total of 2634 patients underwent arthrodesis and 5001 patients underwent AKA for septic TKA. The percentage of total patients who underwent AKA increased significantly throughout the study period compared to knee arthrodesis. Patients who underwent AKA tended to be older and have more medical comorbidities. Arthrodesis patients had a significantly higher rate of postoperative infection (14.5% vs 8.3%, P < .0001) and transfusion (55.1% vs 46.8%, P < .0001), whereas AKA patients had a higher rate of systemic complications (31.5% vs 25.9%, P < .0001) and in-hospital mortality (3.7% vs 2.1%, P < .0001). The AKA cohort had lower hospital charges ($79,686 vs $84,747, P = .004), longer length of stay (11 vs 7 days, P < .0001), and higher 90-day readmission rate (19.4% vs 16.9%). CONCLUSION: Our data suggest that there is an increasing trend toward AKA for the treatment of a failed infected TKA when compared to arthrodesis. Comparative analysis of the outcomes of these procedures should help the clinician when weighing these alternatives
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Open reduction and internal fixation of displaced intraarticular fractures of the distal radius. 31 patients followed for 3-7 years
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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We have used open reduction and internal fixation with a T-plate in 31 displaced, intraarticular fractures of the distal radius which were judged irreducaible or in which closed reduction failed. The mean followup time was 4 (3-7) years. The dorsal angulation, the radial length, the articular step-off and the intraarticular gap between fragments were substantially improved after surgery. 30 patients had excellent or good extraarticular alignment, and only 1 patient had a postoperative intraarticular step-off of 2 mm. The function was excellent or good in 26 patients at follow-up. Complications occurred in 6 patients: 1 compartment syndrome, 1 postoperative wound infection, 2 ruptures of the extensor pollicis longus tendon, and 2 patients had median nerve paresthesias
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1 |
Prepectoral implant reconstruction in the setting of post-mastectomy radiation
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Acellular Dermal Matrix
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Prepectoral breast reconstruction after mastectomy is a more commonly performed technique in recent years due to its numerous advantages over subpectoral breast reconstruction. This study reviews the current state of clinical outcomes for patients undergoing postmastectomy radiation therapy (PMRT) after prepectoral breast reconstruction. A comprehensive search of the literature was performed using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify all relevant studies. Outcome measures included demographics, mean follow-up, and complication measures. Three studies for a total of 175 breasts were identified. Average age was 49.3 years and BMI was 27.7 kg/m(2). Mean follow up was 18.1 months. A total of 3 (1.7%) hematomas and 4 (2%) seromas were reported. Surgical site infection was the most common complication reported with an overall reported 32 breasts with infections (18%). A total of 9 (5.1%) cases of wound dehiscence were reported. Mastectomy flap necrosis was found in 10 (5.7%) breasts. A total of 22 (12.6%) tissue expanders or implants required explantation. The review of the literature suggests that prepectoral breast reconstruction with acellular dermal matrices in the setting of post mastectomy radiation therapy is a safe and successful surgical option resulting in excellent clinical outcomes. Furthermore, there may be a reduction of capsular contracture and implant migration in this setting, relative to traditional submuscular techniques with PMRT.
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The extracompartmental tumoral invasion of extraskeletal myxoid chondrosarcoma induces distant metastasis
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MSTS 2022 - Metastatic Disease of the Humerus
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Background: Extraskeletal myxoid chondrosarcoma (EMC) is a rare malignant soft-tissue tumor and often shows extracompartmental tumoral invasion. The aim of our study was to investigate the clinical features, especially extra - compartmental tumoral invasion (ETI) of EMC. Patients and Methods: A total of 35 operative patients diagnosed with EMC were enrolled in this study from January 1980 to March 2018 in the Cancer Institute Hospital of The Japanese Foundation for Cancer Research. The operative procedure was principally wide excision. Univariate analysis assessed how clinicopathological factors (e.g. age, gender, tumor site, tumor size, histo - pathological grade, surgical margin, metastasis before operation, barrier invasion, local recurrence, metastasis after operation) influenced patient prognosis. We assessed how clinicopathological factors influenced ETI of EMC. Results: Among 35 patients, 10 patients showed ETI. The average followup was 5.57 (range=0.2-20 years). The 5- and 10-year overall survival was 91.3% and 71.2%, respectively. The 5- and 10-year overall survival of patients with M0 disease was 96.1% and 73.2%, respectively, while both were 75.0% for those with M1 disease, respectively. The patients with distant metastasis at first visit tended to have a poor prognosis (p=0.07). It is notable that all of the 10 patients with ETI had distant metastasis after surgery. Conclusion: Patients with distant metastasis at first visit tended to have a poor prognosis. ETI of EMC induced distant metastasis after surgery. Patients with ETI of EMC should, therefore, be carefully monitored over a prolonged period. Extraskeletal myxoid chondrosarcoma (EMC) is a rare softtissue malignancy characterized by uniform spindle cells arranged in a reticular growth pattern in abundant myxoid stroma (1, 2). The disease generally arises in the deep soft tissues of the proximal extremities and limbs and comprises multiple gelatinous nodules divided by fibrous septa but occurrence in several unusual regions such as the scrotum and finger have been reported (3-5). Considered to be slowgrowing, EMC is associated with relatively long survival but has a risk of local recurrence or distant metastasis (1,2, 6, 7). Histologically, the tumor is classified as a tumor of uncertain differentiation due to its lack of cartilaginous differentiation, although originally believed to be a variant of chondrosarcoma (3). The tumor is distinguished from other sarcomas by its unique histology and characteristic chromosomal translocation, typically t(9;22)(q22;q12.2), fusing Ewing sarcoma breakpoint region 1 (EWSR1) to nuclear receptor subfamily 4 group A member 3 (NR4A3) (genes formerly known as Ewing sarcoma (EWS) and chimerin (CHN), translocated in extraskeletal chondrosarcoma (TEC) or neuron-derived orphan receptor 1 (NOR1), respectively) (8-10). The fusion gene products are responsible for alterations in cellular growth and differentiation (11). To our knowledge, published reports documenting the clinical features of EMC are limited (12). EMC often exhibits extracompartmental tumoral invasion (ETI) (13). The aim of our study was to investigate the clinical features and ETI of EMC.
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0 |
Therapeutic strategies to target TGF-β in the treatment of bone metastases
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MSTS 2018 - Femur Mets and MM
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Bone is one of the most common organs to be affected in patients with metastatic cancer. These bone metastases are often accompanied by bone destruction, bone fractures, pain, and hypercalcemia. Transforming growth factor-β (TGF-β) is a major bone-derived factor that is released in active form upon osteoclastic bone resorption. TGF-β, in turn, stimulates bone metastatic cells to secrete factors that further drive osteolytic destruction of the bone adjacent to the tumor, categorizing TGF-β as a crucial factor responsible for driving the feed-forward vicious cycle of cancer growth in bone. Moreover, TGF-β activates epithelial-to-mesenchymal transition, increases tumor cell invasiveness and angiogenesis and induces immunosuppression. Blocking the TGF-β signaling pathway to interrupt this vicious cycle between tumor cells and bone offers a promising target for therapeutic intervention to decrease skeletal metastasis. In this review, preclinical and clinical data are evaluated for the potential use of TGF-β inhibitors in clinical practice to treat bone metastases. © 2011 Bentham Science Publishers.
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0 |
Electrophysiological phenotype of guillain-barre syndrome in Bangladesh related to the presence of serum IgG anti-GM1 antibodies
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Guillain-Barre syndrome (GBS) is an immunemediated neuropathy that may result to some extent in specific dysfunction of the nerve axons (AMAN/AMSAN) or the nerve myelin sheaths (AIDP). Antibodies to a variety of gangliosides that reside at the nerve axons and/or myelin sheaths are supposed to play a role in the pathogenesis. Antibodies to the ganglioside GM1 may have a direct pathogenic effect on nerve conduction and may determine in part the electrophysiological subtype. Very little information is available concerning the pathogenic mechanism of GBS from developing countries such as Bangladesh. This study aimed to investigate the electrophysiological subtypes related to the presence of anti-GM1 antibody in patients with GBS from Bangladesh. Enzyme linked immunosorbent assay was performed to detect serum IgG antibodies against GM1 ganglioside. Nerve conduction studies were conducted with a Nicolet Viking VIASYS mobile EMG machine on the day of admission, and sequentially for up to 52 weeks at different time interval by one of the co-authors (BI). Conventional motor nerve electrophysiology studies of the median, ulnar, tibial, and peroneal nerves were performed in 39 patients with GBS. The clinical and electrophysiological features were compared between the patients with (n = 20) and without (n = 19) IgG anti-GM1 antibodies. The results showed that eleven (55%) of the 20 IgG anti-GM1-positive patients had a history of diarrhea, but no seasonal prevalence was found. Patients with IgG anti-GM1 antibodies showed less frequent cranial nerve involvement (25%) and no sensory loss while patients with IgG anti-GM1 negative group showed high frequent cranial nerve involvement (53%, p < 0.001). A significantly higher proportion of AIDP cases were found among the IgG anti-GM1-negative patients compared with the IgG anti-GM1-positive group (26% vs. 10%, p < 0.01). The median nerve distal latency (DL) and compound muscle action potentials (CMAPs) duration were significantly longer in the anti-GM1-negative group from hospital admission to the 12th week of follow-up compared with that of the anti-GM1-positive group. A significant difference in disease severity and prognosis pattern was observed between GBS patients with the anti- GM1-positive group and the anti-GM1-negative group. In conclusion, anti-GM1 antibodies are associated with the electrophysiology findings of different nerves fibre, disease prognosis and clinical heterogeneity in GBS in Bangladesh
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0 |
Transscaphoid perilunate fracture-dislocation. Result of open reduction and pin fixation
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Sixteen patients with 17 transscaphoid perilunate fracture-dislocations were treated by open reduction and pin fixation. Open reduction was performed through a volar approach in only one wrist, a dorsal approach in nine wrists, and combined volar and dorsal approaches in seven wrists. Primary bone grafting was performed in four patients. The follow-up period was from five months to eleven years and two months, with an average of 2.69 years. Seven patients had median nerve injury and all recovered. Of the 17 wrists, the scaphoid fracture healed in 15. This injury should be treated by early open reduction through a dorsal incision and pinning of the scaphoid fragments in an anatomic position. Avascular necrosis of the proximal fragment is not an indication for further surgery as long as the fracture is well reduced with evidence of healing. This replacement of necrotic bone by new bone requires several years. Primary bone grafting is unnecessary
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0 |
Evolving Clinical Experiences in Aesthetic Hip Implant Body Contouring
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Hip augmentation increases the hip width utilizing fat transfer and/or subcutaneous implants, creating a more feminine hourglass shape. Custom hip implant surgery requires proper patient selection, correct body frame analysis, appreciation of hip aesthetics, understanding surgical anatomy, optimal aesthetic planning, a favorable implant design and fabrication, skilled surgical implant placement, diligent postoperative patient care, and proper complication management. OBJECTIVES: The authors sought to evaluate the pioneering clinical experience with cosmetic custom hip silastic implants. METHODS: A consecutive patient surgical series of patients seeking custom aesthetic hip implant surgery was tabulated. Similar hip analysis, implant design and fabrication, surgical technique, and postoperative follow-up were performed in 3 practices. RESULTS: The overall patient satisfaction rate (87%, 47 of 54 patients) was favorable. There was a total of 29 (54%) medical complications and 20 (37%) cosmetic complications (implant show). A total of 17 patients (31.5%) requested revision surgery secondary to implant show (n = 10) and an infected implant (n = 6). No patient experienced an acute implant infection, incisional scar hypertrophy, wound dehiscence, implant extrusion, parasthesias, muscle dysfunction, or hip joint injury. CONCLUSIONS: The utilization of hip implants represents a new type of body contouring implant that has some unique differences in anatomic location, implant design, and tissue pocket location. Their utilization is an evolving one in aesthetic body implants, for which clinical experience to date remains limited in number. The proper surgical placement, postoperative management, and treatment of complications to include revision surgery are essential to achieving a successful body contouring outcome.
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The influence of the acromioclavicular joint degeneration on supraspinatus outlet impingement and the acromion shape
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Glenohumeral Joint OA
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PURPOSE: To assess the anatomic association of acromioclavicular joint degeneration to supraspinatus outlet impingement and the acromion shape.
METHODS: Sagittal oblique magnetic resonance images of 49 shoulders in 49 patients were reviewed. 29 of them (mean age, 59 years) underwent surgery for impingement with or without rotator cuff tear (group 1), whereas the 20 controls (mean age, 27 years) were treated for shoulder instability without rotator cuff disease or acromioclavicular joint derangement (group 2). The supraspinatus outlet and the acromion shape of the 2 groups were compared.
RESULTS: The difference in the mean supraspinatus outlet between groups 1 and 2 was 11% (514 vs 577 mm[2], p=0.095) and between the subgroup (of group 1) with full thickness rotator cuff tears and group 2 was 17% (481 vs 577 mm[2], p=0.036). Six of the acromions in group 1 were type III (hooked) compared to none in group 2.
CONCLUSION: In severe acromioclavicular degeneration, distal clavicular excision is recommended, even in cases with an asymptomatic acromioclavicular joint, so as to prevent further osteophyte formation.
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0 |
Contrast sensitivity in asymmetric glaucoma
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Upper Eyelid and Brow Surgery
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We measured central contrast sensitivity in both eyes of 27 patients with asymmetric glaucomatous visual field loss or optic disc cupping. In 15 patients contrast sensitivity was less in the eye that by perimetry or ophthalmoscopy was the more severely damaged. In 10 patients contrast sensitivity was the same in the two eyes. In two patients, it was impaired more in the eye with the normal visual field. However, the latter two patients had ophthalmoscopic evidence of optic nerve damage (disc hemorrhage or large cup) in the eye with the lower contrast sensitivity, even though the visual field was normal. Asymmetry of contrast sensitivity was not found in normal control subjects. These results suggest that glaucoma does alter central vision, even when visual acuity remains normal and visual field defects are far from fixation. Contrast sensitivity may be impaired by a different mechanism than that which leads to visual dield loss. Although the two types of visual dysfunction often occur together, some patients may have more severe impairment of central vision (as measured by contrast sensitivity testing) in one eye and more severe loss of peripheral vision (as measured by perimetry) in the other eye.
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1 |
Intramedullary nailing versus submuscular plating in adolescent femoral fracture
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Treatment of Pediatric Diphyseal Femur Fractures CPG
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BACKGROUND: Femoral fractures in adolescents usually need operative treatment, but the optimal method is unclear. The purpose of this study is to compare intramedullary nailing (IN) and submuscular plating (SP) in adolescent femoral fractures. MATERIALS AND METHODS: We performed the prospective, comparison study of IN and SP in adolescent femoral shaft fractures at a mean age of 13.9 years (11-17.4). Twenty-two cases of IN and 23 cases of SP were followed for a minimum of 1 year. We compared radiological and clinical results, surgical parameters, and complications of two techniques. RESULTS: Bony union was achieved in all cases except one case of IN. Time to union was similar in both groups. None showed mal-union over 10 degrees or limb length discrepancy over 1 cm. None of SP group and 2 in IN group experienced re-operation; one patient had deep infection with nonunion. The other patient sustained mal-rotation. Both patients healed after revision procedure. All patients showed excellent or satisfactory results of Flynn's criteria. The time to full-weight bearing was shorter in IN (IN: 57.3 days, SP: 89.2 days, p<0.05). In surgical parameters, operative time seemed shorter in IN (IN: 94.7 min, SP: 104 min, p=0.095), and fluoroscopy time was shorter in IN (IN: 58s, SP: 109s, p<0.05) than SP group. CONCLUSION: Although both IN and SP yield good results and minimal complication in adolescent femoral fractures, IN may be advantageous in less need of fluoroscopy, technical easiness in reduction and early weight bearing
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Psychosocial stress as a predictor of injury in elite junior soccer: A latent growth curve analysis
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DoD PRF (Psychosocial RF)
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Objectives: To investigate by use of a latent growth curve analysis framework whether athletesâ?? individual levels and changes in hassle and uplift levels over a 10-week period could predict injury outcome in an elite junior soccer population. Design: A prospective design with repeated measurement points. Methods: Participants were 101 Swedish elite junior soccer players (67 males and 34 females). Ten sets of measures were taken on a weekly basis during which participants completed the Hassles and Uplifts Scale (HUS). Latent growth curve models were used to examine whether the level and change in psychological stress could predict the frequency of injury over the 10-week period. Results: The results show that injury occurrence was significantly associated with both the initial level of daily hassle and the change in daily hassle. High initial daily hassle levels and a smaller decrease in daily hassles were associated with injury occurrence. Moreover, injury occurrence was significantly associated with a greater decrease in daily uplift. Conclusions: The findings highlight the importance of focusing on state variables using prospective designs and appropriate analysis of within-person change to detect complex and dynamic associations across time in injury-prediction research. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Joint mobilization forces and therapist reliability in subjects with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: This study determined biomechanical force parameters and reliability among clinicians performing knee joint mobilizations.
METHODS: Sixteen subjects with knee osteoarthritis and six therapists participated in the study. Forces were recorded using a capacitive-based pressure mat for three techniques at two grades of mobilization, each with two trials of 15 seconds. Dosage (force-time integral), amplitude, and frequency were also calculated. Analysis of variance was used to analyze grade differences, intraclass correlation coefficients determined reliability, and correlations assessed force associations with subject and rater variables.
RESULTS: Grade IV mobilizations produced higher mean forces (P<0.001) and higher dosage (P<0.001), while grade III produced higher maximum forces (P = 0.001). Grade III forces (Newtons) by technique (mean, maximum) were: extension 48, 81; flexion 41, 68; and medial glide 21, 34. Grade IV forces (Newtons) by technique (mean, maximum) were: extension 58, 78; flexion 44, 60; and medial glide 22, 30. Frequency (Hertz) ranged between 0.9-1.1 (grade III) and 1.4-1.6 (grade IV). Intra-clinician reliability was excellent (>0.90). Inter-clinician reliability was moderate for force and dosage, and poor for amplitude and frequency.
DISCUSSION: Force measurements were consistent with previously reported ranges and clinical constructs. Grade III and grade IV mobilizations can be distinguished from each other with differences for force and frequency being small, and dosage and amplitude being large. Intra-clinician reliability was excellent for all biomechanical parameters and inter-clinician reliability for dosage, the main variable of clinical interest, was moderate. This study quantified the applied forces among multiple clinicians, which may help determine optimal dosage and standardize care.
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Orbital decompression: a comparison between trans-fornix/transcaruncular inferomedial and coronal inferomedial plus lateral approaches
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Upper Eyelid and Brow Surgery
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PURPOSE: To compare two techniques of orbital decompression for Graves orbitopathy, that is, the inferomedial transfornix/transcaruncular approach and the inferomedial plus lateral coronal approach. METHODS: Comparative interventional case series. A retrospective review of 53 patients (94 orbits) with Graves orbitopathy operated on over a 9-year period was performed. Forty-nine orbits were decompressed by the transfornix-transcaruncular approach and 45 by the coronal approach. Data obtained for all patients included computed tomography scans of the orbits, Snellen visual acuity measurements, visual fields, Hertel exophthalmometry, color vision testing, subjective testing for diplopia in the cardinal positions of gaze, and direct ophthalmoscopic or biomicroscopic examination of the optic disc. RESULTS: The mean proptosis reduction was 4.37 mm with the transfornix/transcaruncular approach and 5.76 mm with the 3-wall coronal approach. The rate of optic neuropathy reversal was similar with both techniques (90%). Induction of new diplopia occurred in 13.6% patients operated by the transfornix/transcaruncular approach and in 16.6% patients who underwent decompression by the coronal approach. CONCLUSIONS: The two techniques have similar effects on visual function and ocular motility. For the vast majority of patients with Graves who need orbital decompression, the coronal approach is unnecessary; the transconjunctival approach allows the same exposure to the medial, inferior, and lateral walls.
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Microstructure of the Distal Radius and Its Relevance to Distal Radius Fractures
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Distal Radius Fractures
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<b>Background</b> There is a paucity of information on the microstructure of the distal radius, and how this relates to its morphology and function. <b>Purpose</b> This study aims to assess the microanatomical structure of the distal radius, and relate this to its morphology, function, and modes of failure. <b>Methods</b> Six dry adult skeletal distal radii were examined with microcomputed tomography scan and analyzed with specialist computer software. From 3D and 2D images, the subchondral, cortical, and medullary trabecular were assessed and interpreted based on the overall morphology of the radius. <b>Results</b> The expanded distal radial metaphysis provides a wide articular surface for distributing the articular load. The extrinsic wrist ligaments are positioned around the articular perimeter, except on the dorsal radial corner. The subchondral bone plate is a 2 mm multilaminar lattice structure, which is thicker below the areas of the maximal articular load. There are spherical voids distally, which become ovoid proximally, which assist in absorbing articular impact. It does not have Haversian canals. From the volar aspect of the lunate facet, there are thick trabecular columns that insert into the volar cortex of the radius at the metaphyseal-diaphyseal junction. For the remainder of the subchondral bone plate, there is an intermediate trabecular network, which transmits the load to the intermediate trabeculae and then to the trabecular arches. The arches pass proximally and coalesce with the ridges of the diaphyseal cortex. <b>Conclusion</b> The distal radius morphology is similar to an arch bridge. The subchondral bone plate resembles the smooth deck of the bridge that interacts with the mobile load. The load is transmitted to the rim, intermediate struts, and arches. The metaphyseal arches allow the joint loading forces to be transmitted proximally and laterally, providing compression at all levels and avoiding tension. The arches have a natural ability to absorb the impact which protects the articular surface. The distal radius absorbs and transmits the articular impact to the medullary cortex and intermediate trabeculae. The medullary arches are positioned to transmit the load from the intermediate trabeculae to the diaphysis. <b>Clinical Relevance</b> The microstructure of the distal radius is likely to be important for physiological loading of the radius. The subchondral bone plate is a unique structure that is different to the cancellous and cortical bone. All three bone types have different functions. The unique morphology and microstructure of the distal radius allow it to transmit load and protect the articular cartilage.
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Psychological Resilience as a Predictor of Persistent Post-Concussive Symptoms in Children With Single and Multiple Concussion
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DoD PRF (Psychosocial RF)
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OBJECTIVES: To evaluate the relationship of psychological resilience to persistent post-concussive symptoms (PCS) in children with a history of single or multiple concussions, as well as orthopedic injury (OI). METHODS: Participants (N=75) were children, ages 8-18 years, who sustained a single concussion (n=24), multiple concussions (n=25), or an OI (n=26), recruited from a tertiary care children's hospital. All participants sustained injuries at least 6 months before recruitment, with an average time since injury of 32.9 months. Self-reported psychological resilience was measured using the Connor-Davidson Resilience Scale, and both self- and parent-reported PCS were measured using the Post-Concussion Symptom Inventory. Hierarchical regression analyses examined psychological resilience as a predictor of PCS, both as a main effect and as a moderator of group differences. RESULTS: Multiple concussions and low psychological resilience were both significant predictors of persistent PCS. Resilience was not a significant moderator of group differences in PCS. CONCLUSIONS: Sustaining multiple concussions may increase a child's risk of persistent PCS; however, high psychological resilience may serve as a protective factor, regardless of the number or type of injuries sustained. These findings provide support for developing and testing interventions aimed at increasing psychological resilience as a potential means of improving outcomes for children suffering from persistent PCS after concussion. (JINS, 2018, 24, 759-768).
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Increased Femoral Component Size Options Improves Manipulation Rate in Females and Knee Society Clinical Scores in Males
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: The gender-specific total knee arthroplasty (TKA) debate focuses on differences in distal femoral mediolateral to anteroposterior aspect ratio between males and females. However, randomized studies have been unable to demonstrate significant differences in outcomes utilizing gender-specific implants. No studies have examined the effect of intermediate femoral component sizes on outcome. We compared outcomes before and after intermediate sizing availability. MATERIALS AND METHODS: We identified 331 patients (413 knees) who underwent primary TKA between 2003 and 2004 with a single complete knee system. There were 121 males and 210 females. Three intermediate femoral sizes were added in March 2004 to the six initial options. Patients before March 2004 were assigned to group 1 (n=178), and after to group 2 (n=235). RESULTS: Follow-up averaged 8.5 years. Preoperative demographics and clinical scores were similar between groups. Knee Society (KS) clinical and functional scores improved in females in both groups, but there was no significant difference. Male patients in group 2 had a significant improvement in KS clinical scores compared to male patients in group 1 (group 1: 33.9, group 2: 41.1; p=0.01). Females in group 2 had significantly less need for manipulation, 1.9%, versus females in group 1, 8.7% (p=0.01). MUA rates were similar for men between groups. Overall, there were 19 revisions (4.6%) with no differences between groups or by genders. Once intermediate sizes were available, they were used in 48% of females and 13% of males. The average femoral component size for females in group 1 was 65 mm and decreased in group 2 to 62.5 mm. The average size of femoral components in males was 70 mm in both groups. CONCLUSIONS: Availability of intermediate size femoral component sizes was associated with a lower rate of manipulation in female patients. Greater KS clinical score improvement was observed in men after availability of additional femoral sizes.
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Traditional chinese herbal medicated bath therapies for osteoarthritis
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OAK Recommendation 9 Articles
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Purpose: Traditional Chinese Herbal Medicated Bath Therapies are considered to have anti-inflammatory effects, activate blood circulation to remove blood stasis and improve nullhemorheologicalsnull for arthritis. A comprehensive review of the literature is an important step for understanding its benefits for knee osteoarthritis (KOA). We systematically reviewed the literature on the effects of Herbal Medicated-bath Therapies in patients with KOA. Methods: We performed a comprehensive search of three universal Chinese databases and reference lists of published articles through November 2013. We included only randomized controlled trials (RCTs) using herbal medicated bath therapy for adult patients with KOA. The effect of the Herbal Medicated-Bath Therapy on clinical symptoms was measured with
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Effect of antibiotic treatment on bacterial attachment to a DePuy Enduron orthopedic implant
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND: The increasing incidence of bacterial infections in orthopedic surgery might be related to the increasing application of artificial devices. In most cases, bacteria multiply on the surface of implants in biofilms. Poor penetration of antibiotics, frequent necessity of prosthesis removal, chronic processes and financial costs emphasize the significance of preventive measures. METHOD: Adhesion of bacterial strains (two Staphylococcus aureus, two coagulase-negative staphylococci and two Pseudomonas aeruginosa strains isolated from orthopedic patients' wounds) to the surface of a polyethylene cup was investigated using an ultrasonic method. Results were compared to the adhesive ability of three Hungarian standard strains. The effect of antibiotic treatment (cefuroxime, cefotaxime, amoxicillin with clavulanic acid and amikacin) has been examined. RESULTS: The staphylococcal strains showed significantly higher adhesive ability than Pseudomonas strains. Antibiotic treatment significantly reduced the attachment of bacteria. The higher the concentration of the antibiotics, the higher was the decrease in bacterial adhesion. CONCLUSIONS: Antibiotic prophylaxis was proven to be effective against bacterial adhesion, and, if applied at the proper time at the highest tolerable dose, it might prevent the formation of biofilms
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0 |
Interobserver and intraobserver reliability of clinical assessments in knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Objective. Clinical examination of the knee is subject to measurement error. The aim of this analysis was to determine interobserver and intraobserver reliability of commonly used clinical tests in patients with knee osteoarthritis (OA). Methods. We studied subjects with symptomatic knee OA who were participants in an open-label clinical trial of intraarticular steroid therapy. Following standardization of the clinical test procedures, 2 clinicians assessed 25 subjects independently at the same visit, and the same clinician assessed 88 subjects over an interval period of 2-10 weeks; in both cases prior to the steroid intervention. Clinical examination included assessment of bony enlargement, crepitus, quadriceps wasting, knee effusion, joint-line and anserine tenderness, and knee range of movement (ROM). Intraclass correlation coefficients (ICC), estimated kappa (k), weighted kappa (k?), and Bland-Altman plots were used to determine interobserver and intraobserver levels of agreement. Results. Using Landis and Koch criteria, interobserver k scores were moderate for patellofemoral joint (k = 0.53) and anserine tenderness (k = 0.48); good for bony enlargement (k = 0.66), quadriceps wasting (k = 0.78), crepitus (k = 0.78), medial tibiofemoral joint tenderness (k = 0.76), and effusion assessed by ballottement (k = 0.73) and bulge sign (k? = 0.78); and excellent for lateral tibiofemoral joint tenderness (k = 1.00), flexion (ICC = 0.97), and extension (ICC = 0.87) ROM. Intraobserver k scores were moderate for lateral tibiofemoral joint tenderness (k = 0.60); good for crepitus (k = 0.78), effusion assessed by ballottement test (k = 0.77), patellofemoral joint (k = 0.66), medial tibiofemoral joint (k = 0.64), and anserine tenderness (k = 0.73); and excellent for effusion assessed by bulge sign (k? = 0.83), bony enlargement (k = 0.98), quadriceps wasting (k = 0.83), flexion (ICC = 0.99), and extension (ICC = 0.96) ROM. Conclusion. Among individuals with symptomatic knee OA, the reliability of clinical examination of the knee was at least good for the majority of clinical signs of knee OA.
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0 |
The osteoclast in bone metastasis: Player and target
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MSTS 2018 - Femur Mets and MM
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Bone metastases are frequently the final fate of breast and prostate cancer patients. According to the definition of metastasis as an incurable disease, to date there are no effective treatments for tumor-associated bone metastases and this represents a real challenge for the researchers in the field. The bone is a heterogeneous environment that represents a fertile soil for tumor cells, supporting their growth. Among the different cell types present in the bone, in this review we will focus our attention on the osteoclasts, which are crucial players in the so called â??vicious cycleâ?, a phenomenon triggered by tumor cells eventually leading to both tumor proliferation as well as bone deregulation, thus fueling the development of bone metastasis. The complex network, linking tumor cells to the bone by activating osteoclasts, represents a fruitful target for the treatment of bone metastases. In this review we will describe how tumor cells perturb the bone microenvironment by actively influencing osteoclast formation and activity. Moreover, we will describe the current antiresorptive drugs employed in the treatment of bone metastases as well as new, targeted therapies able to affect both cancer cells and osteoclasts.
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Younger patients, lower BMI, complete meniscus root healing, lower HKA degree and shorter preoperative symptom duration were the independent risk factors correlated with the good correction of MME in patients with repaired MMPRTs
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AMP (Acute Meniscal Pathology)
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PURPOSE: To evaluate the clinical and radiological outcomes of arthroscopically assisted tendon graft anatomic reinforced reconstruction of the medial meniscus posterior root tears (MMPRTs) and identify relevant factors affecting the correction of medial meniscal extrusion (MME).
METHODS: Fifty-three MMPRTs patients who underwent arthroscopically assisted tendon graft reconstruction of the meniscal root between 2018 and 2020 were evaluated retrospectively. the patients were divided into 2 groups according to the correction of MME (maintained MME group: 32 cases vs. increased MME group: 21 cases). The clinical and radiological outcomes of arthroscopically assisted tendon graft reconstruction of the meniscal root, including postoperative correction of MME and functional recovery of the knee were assessed in this study, and potential independent risk factors that could influence the correction of MME were also evaluated.
RESULTS: The functional recovery of the knee was significantly improved at the end of follow-up (P < 0.001; respectively), furthermore, a comparison of the final functional outcomes between the groups showed that the mean Lysholm score and IKDC score of the maintained MME group were significantly improved than those of increased MME group. 60.4% had good correction of MME, and patients with complete healing had better extrusion correction than those with partial healing and non-healing. Binary logistic regression models analysis indicated that the age (OR = 1.053, P = 0.048), BMI (OR = 1.376, P = 0.004), meniscus root healing status (OR = 7.701, P = 0.005), HKA degree (OR = 1.891, P = 0.011) and preoperative symptom duration (OR = 1.055, P = 0.013) were the independent risk factors correlated with correction of MME. Additionally, the ROC curve demonstrated the cut-off values of the Age, BMI, HKA degree and preoperative symptom duration were 46.0 years, 22.5 kg/m2, 3.2degree and 9.5 months, respectively, CONCLUSIONS: The arthroscopically assisted tendon graft anatomic reinforced reconstruction of the meniscal root showed clinical improvement and prevented the progression of postoperative MME. Additionally, younger patients, lower BMI, complete meniscus root healing, lower HKA degree and shorter preoperative symptom duration were the independent risk factors correlated with the good correction of MME in patients with repaired MMPRTs.
LEVEL OF EVIDENCE: Level IV.
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The fate of lateral femoral cutaneous nerve after surgical reduction of developmental dysplasia of the hip: preliminary results
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Developmental Dysplasia of the Hip 2020 Review
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This study aimed to determine the fate of the lateral femoral cutaneous nerve (LFCN) after anterior reduction of the hip with or without pelvic or proximal femoral osteotomy for acetabular dysplasia. Using the antidromic technique, recording the response using standard electromyography equipment, evaluation was made of the LFCN in 36 hips of 24 patients (18 female and six male). The response was absent in six patients (25%) and nine patients (37.5%) had a somatosensory evoked potential latency greater than 40 ms. There was no relationship between somatosensory evoked potential latency or absent response with the type of incision or procedure (P=0.229 and 0.794, respectively). LFCN injury after anterior open reduction of the hip has an unexpectedly high incidence in the young paediatric age group. Exposure of the nerve during surgery can negatively affect the nerve nutrition leading to neuropraxia.
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Open tibial fractures in children under 13 years of age - 10 years experience
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DoD SSI (Surgical Site Infections)
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Objective: To evaluate the results of treatment in children with open tibial fractures. Design: Retrospective review. Subjects: Eighty three children under 13 years of age treated for an open tibial fracture between 1989 and 1999. Main outcome measures: Patient demographics, mechanism of injury, fracture classification, treatment method, clinical outcome and complications. Results: Eighty one percent of children had an open tibial fracture as their only injury. According to the level of contamination, soft tissue injury and size of wound 46% were Gustilo grade I injuries, 30% grade II, and 22% (18) grade III (6 IIIa, 5 IIIb, 3 IIIc and 4 not otherwise specified). Sixteen fractures (19%) were treated using an external fixator and 65 (78%) using a cast. The average time to union was 15.5 weeks (range 9-31 weeks) for those treated with a frame and 10.4 weeks (range 5-40 weeks) for those treated with a cast. No deep infections, one delayed union and one non-union were recorded. Conclusions: Ninety four percent of these injuries were a result of a motor vehicle accident and involved a significant trauma-related energy transfer. Despite this the associated morbidity was low lending support to the literature, which suggests that open fractures of the tibia in younger children heal more predictably and with less complications than those occurring in adolescents or adults. © 2003 Elsevier Science Ltd. All rights reserved.
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Clinical experience with an active intravascular rewarming technique for near-severe hypothermia associated with traumatic injury
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DoD SSI (Surgical Site Infections)
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Hypothermia and acidosis are secondary causes of trauma-related coagulopathy. Here we report the case of a 72-year-old patient with severe trauma who suffered near-severe hypothermia despite the initiation of standard warming measures and was successfully managed with active intravascular rewarming. The patient was involved in a road traffic accident and was transported to a hospital. He was diagnosed with massive right-sided hemothorax, blunt aortic injury, burst fractures of the eighth and ninth thoracic vertebrae, and open fracture of the right tibia. He was referred to our hospital, where emergency surgery was performed to control bleeding from the right hemothorax. During surgery, the patient demonstrated progressive heat loss despite standard rewarming measures, and his temperature decreased to 32.4degreeC. Severe acidosis was also observed. A Cool Line R catheter was inserted into the right femoral vein and lodged in the inferior vena cava, and an intravascular balloon catheter system was utilized for aggressive rewarming. The automated target core temperature was set at 37degreeC, and the maximum flow rate was used. His core temperature reached 36.0degreeC after 125 min of intravascular rewarming. The severe acidosis was also resolved. The main active bleeding site was not identified, and coagulation hemostasis as well as rewarming enabled us to control bleeding from the vertebral bodies, lung parenchyma, and pleura. The total volume of intraoperative bleeding was 5,150 mL, and 20 units of red cell concentrate and 16 units of fresh frozen plasma were transfused. After surgery, he was transferred to the intensive care unit under endotracheal intubation and mechanical ventilation. His hemodynamic condition stabilized after surgery. The rewarming catheter was removed on day 2 of admission, and no bleeding, infection, or thrombosis associated with catheter placement was observed. Extubation was performed on day 40, and his subsequent clinical course was uneventful. He recovered well following rehabilitation and was discharged on day 46. These findings suggest that active intravascular rewarming should be considered as an aggressive, additional rewarming technique in patients with near-severe hypothermia associated with traumatic injury.
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Peripheral nervous system complications of cardiac surgery
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Surgical Management of Osteoarthritis of the Knee CPG
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We prospectively evaluated 245 consecutive patients from May to December 2013 who underwent cardiac surgery. Each patient had an interview and a neurological clinical examination during rehabilitation period. Patients with possible peripheral nervous system (PNS) complications underwent other examinations, particularly electrodiagnostic tests. Among 245 patients undergoing open heart surgery (coronary artery bypass grafting, valvular heart surgery, ascending aortic aneurysm repair), 15 (6.12%) developed the following 24 PNS complications: 3 brachial plexopathies, 3 carpal tunnel syndromes, 2 critical illness neuropathies, 2 worsening of signs or symptoms of pre-existing neuropathies, 2 involvement of X, 1 of IX and 1 of XII cranial nerves, 3 peroneal (at knee), 1 saphenous, 1 median (at Struthers ligament), 5 ulnar (at elbow) mononeuropathies. A preliminary analysis shows that diabetes is a strong risk factor for PNS complications (p=0.007 at chi-square test), while we did not find any correlation with other clinical conditions, population data (gender, age) or type of surgical intervention. The mononeuropathies of right arms can be related to ipsilateral vein cannulation; position of body and stretching from chest wall retraction may be the cause of left arm mononeuropathies (more frequent); the use of saphenous vein and position of the limbs may be the cause of leg mononeuropathies; surgical and anesthesia procedures may injure cranial nerves. Careful preoperative assessment and careful postoperative management may reduce risk of long term neurological complications after cardiac surgery
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1 |
The opposite hip in congenital dislocation of the hip
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Developmental Dysplasia of the Hip CPG
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A retrospective study of the development of the hip opposite a congenitally dislocated hip was carried out to identify at an early age those hips which would develop abnormally. Recognised radiological measurements were used showing the development of the joints with age. The development was compared with that of a control group of normal hips. Single measurements were shown to be unreliable in predicting the development of the hip. A simple hip ratio is proposed which predicts, at an early age and with a high degree of accuracy, the developmental outcome
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1 |
Ultrasound-Guided Genicular Nerve Block for Knee Osteoarthritis: A Double-Blind, Randomized Controlled Trial of Local Anesthetic Alone or in Combination with Corticosteroid
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Recently, several studies suggested that radiofrequency (RF) ablation of the genicular nerves is a safe and effective therapeutic procedure for intractable pain associated with chronic knee osteoarthritis (OA). Diagnostic genicular nerve block (GNB) with local anesthetic has been generally conducted before making decisions regarding RF ablation. Although GNB has been recently performed together with corticosteroid, the analgesic effects of corticosteroids for treating chronic pain remain controversial.
OBJECTIVES: The current study aims to assess the effects of combining corticosteroids and local anesthesia during ultrasound-guided GNB in patients with chronic knee OA.
STUDY DESIGN: A randomized, double-blinded institutional study.
SETTING: This study took place at Asan Medical Center in Seoul, Korea.
METHODS: Forty-eight patients with chronic knee OA were randomly assigned to either the lidocaine alone group (n = 24) or lidocaine plus triamcinolone (TA) group (n = 24) before ultrasound-guided GNB. Visual analog scale (VAS), Oxford Knee Score (OKS), and global perceived effects (7-point scale) were assessed at baseline and at 1, 2, 4, and 8 weeks after the procedure.
RESULTS: The VAS scores were significantly lower in the lidocaine plus TA group than in the lidocaine alone group at both 2 (P < 0.001) and 4 (P < 0.001) weeks after GNB. The alleviation of intense pain in the lidocaine plus TA group was sustained up to 2 weeks after the procedure, in accordance with the definition of a minimal clinically important improvement. Although a similar intergroup difference in OKSs was observed at 4 weeks (P < 0.001), the clinical improvement in functional capacity lasted for only one week after the reassessment of OKSs, in accordance with a minimal important change. No patient reported any postprocedural adverse events during the follow-up period.
LIMITATIONS: The emotional state of the patients, which might affect the perception of knee pain, was not evaluated. The follow-up period was 2 months; this period might be insufficient to validate the short-term effects of GNB.
CONCLUSIONS: Ultrasound-guided GNB, when combined with a local anesthetic and corticosteroid, can provide short-term pain relief. However, the clinical benefit of corticosteroid administration was not clear in comparison with local anesthesia alone. Given the potential adverse effects, corticosteroids might not be appropriate as adjuvants during a GNB for chronic knee OA.The study protocol was approved by our institutional review board (2012-0210), and written informed consent was obtained from all patients. The trial was registered with the Clinical Research Information Service (KCT 0001139).
KEY WORDS: Chronic pain, knee osteoarthritis, genicular nerve block, ultrasound, corticosteroid, local anesthetic, visual analog scale, Oxford Knee Score.
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In situ tele-thermographic measurements during PMMA spacer augmentation in temporary arthrodesis after periprosthetic knee joint infection
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PJI DX Updated Search
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Poly-Methylmethacrylate (PMMA) is widely-used in orthopaedic surgery in revision arthroplasty or as a spacer in temporary arthrodesis of periprostehtic knee joint infection during a two stage procedure. The intra-operative temperature behaviour, however, has not yet been quantified. It is known that high temperature induce thermally necrosis of surrounding bone tissue during polymerisation process. The aim was to evaluate the PMMA surface temperature during polymerisation phase in situ. We hypothesized, that temperature measured in vivo could become critical in terms of the induction of thermal bone necrosis during the polymerisation phase of PMMA. The PMMA surface was measured tele-thermographically in situ during knee arthroplasty revision surgery. Infrared pictures were analyzed for temperature peaks and changes. Measurements yielded maximum PMMA-surface-temperatures ranging from 101 to 110 degrees and a two-minute-plateau of > 100 degrees . Hot PMMA during the polymerisation phase could potentially induce tissue (bone) necrosis. Therefore temperature of PMMA of more than 70 degrees should be avoided. Cooling of the PMMA is highly recommendable
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Surgical Site Infection In Orthopaedic Implants And Its Common Bacteria With Their Sensitivities To Antibiotics, In Open Reduction Internal Fixation
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Hip Fx in the Elderly 2019
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BACKGROUND: Surgical site infection in orthopaedic implants is a major problem, causing long hospital stay, cost to the patient and is a burden on health care facilities. It increases rate of nonunion, osteomyelitis, implant failure, sepsis, multiorgan dysfunction and even death. Surgical site infection is defined as pain, erythema, swelling and discharge from wound site. Surgical site infection in orthopaedic implants is more challenging to the treating orthopaedic surgeon as the causative organism is protected by a biofilm over the implant's surface. Antibiotics cannot cross this film to reach the bacteria's, causing infection.
METHODS: This descriptive case series study includes 132 patients of both genders with ages between 13-60 years conducted at Orthopaedic Unit, Ayub Medical College, Abbottabad from 1st October 2015 to 31st March 2016. Patients with close fractures of long bones were included in the study to determine the frequency of surgical site infection in orthopaedic implants and the type of bacteria involved and their sensitivity to various antibiotics. All implants were of stainless steel. The implants used were Dynamic hip screws, Dynamic compression screws, plates, k-wires, Interlocking nails, SIGN nails, Austin Moore prosthesis and tension band wires. Pre-op and post-op antibiotics used were combination of Sulbactum and Cefoperazone which was given 1 hour before surgery and continued for 72 hours after surgery. Patients were followed up to 4 weeks. Pus was taken on culture stick, from those who developed infection. Results were entered in the pro forma.
RESULTS: A total of 132 patients of long bone fractures, who were treated with open reduction and internal fixation, were studied. Only 7 patients developed infection. Staphylococcus Aureus was isolated from all 7 patients. Staphylococcus aureus was sensitive to Linezolid, Fusidic Acid, and vancomycin. Cotrimoxazole, tetracycline, Gentamycin and Clindamycin were partially effective.
CONCLUSIONS: Surgical Site Infection is common in orthopaedic implants, occurring in 5.30% cases. Staphylococcus aureus is the common bacteria, causing it.
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Coronal alignment is a predictor of the rotational geometry of the distal femur in the osteo-arthritic knee
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: There is a lot of inter-individual variation in the rotational anatomy of the distal femur. This study was set up to define the rotational anatomy of the distal femur in the osteo-arthritic knee and to investigate its relationship with the overall coronal alignment and gender. Methods: CT-scans of 231 patients with end-stage knee osteo-arthritis prior to TKA surgery were obtained. This represents the biggest series published on rational geometry of the distal femur in literature so far. Results: The posterior condylar line (PCL) was on average 1.6(degrees) (SD 1.9) internally rotated relative to the surgical transepicondylar axis (sTEA). The perpendicular to trochlear anteroposterior axis ((perpendicular)TRAx) was on average 4.8(degrees) (SD 3.3(degrees)) externally rotated relative to the sTEA. The relationship between the PCL and the sTEA was statistically different in the different coronal alignment groups (p < 0.001): 1.0(degrees) (SD 1.8(degrees)) in varus knees, 2.1(degrees) (SD 1.8(degrees)) in neutral knees and 2.6(degrees) (SD 1.8(degrees)) in valgus knees. The same was true for the (perpendicular)TRAx in these 3 groups (p < 0.02).There was a clear linear relationship between the overall coronal alignment and the rotational geometry of the distal femur. For every 1(degrees) in coronal alignment increment from varus to valgus, there is a 0.1(degrees) increment in posterior condylar angle (PCL vs sTEA). Conclusion: The PCL was on average 1.6(degrees) internally rotated relative to the sTEA in the osteo-arthritic knee. The relationship between the PCL and the sTEA was statistically different in the different coronal alignment groups. Level of evidence: III. (copyright) 2012 Springer-Verlag Berlin Heidelberg
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High tibial open wedge valgus osteotomy stabilized with the tomofix™ plate fixator
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DoD SSI (Surgical Site Infections)
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Objective. Lateral transfer of the mechanical leg axis to unload the medial compartment in instances of osteoarthritis of the medial compartment and of genu varum. Indications. Medial unicompartmental osteoarthritis. Varus malalignment. of the lower limb. Varus malalignment in patients where reconstructive procedures of the medial compartment are planned. ACL deficiency/reconstruction accompanied by varus malalignment necessitating a valgus-extension osteotomy. Posterolateral instability and varus malalignment necessitating valgus-flexion osteotomy. Contraindications. Articular cartilage lesion grade III and IV of the lateral compartment. State after lateral meniscectomy. Morbid obesity. Acute or chronic infection. Poor soft-tissue condition on site of surgery. Reduced range of motion, particularly extension lag > 20°. Surgical Technique. Medial open wedge biplanar osteotomy of the proximal ibia consisting of a horizontal cut of the posterior two thirds of the tibia and a 135° angulated cut ascending anteriorly. The osteotomy ends 10 mm short of the lateral cortex. Gradual opening with a spreader. Fixation with the TomoFix™ plate fixator. Filling of the osteotomy gap with autogenous cancellous bone, if the opening is > 13 mm. Results. Between October 2000 and November 2003, an open wedge high tibial osteotomy stabilized medially with a TomoFix™ was performed in 262 patients (mean age 40 years). The average gap size was 10 mm. All patients were followed until healing of the osteotomy. Four patients required an evacuation of a hematoma, and one patient with an overcorrection underwent revision surgery 2 days after the index operation. No loss of correction was observed; a delayed union in four patients necessitated cancellous bone grafting. An infection 4 months postoperatively occurred in two patients; the implant was removed and the wound debrided; the subsequent course was uneventful. The plate fixator was removed in twelve patients after bony consolidation. © Urban & Vogel.
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Effectiveness of intraoperative periarticular cocktail injection for pain control and knee motion recovery after total knee replacement
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AMP (Acute Meniscal Pathology)
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Background: Pain control after total knee replacement (TKR) is pivotal in postoperative rehabilitation. Usage of epidural analgesia or parenteral opioids can cause undesirable side effects hampering early recovery and rehabilitation. These side effects can be avoided by infiltration of an analgesic cocktail locally. Our study was performed to evaluate the benefits of a particular cocktail combination in patients undergoing TKR with respect to pain and knee motion recovery. Methods: One hundred consecutive patients who underwent simultaneous bilateral TKR were enrolled and received an intraoperative periarticular cocktail injection in the right knee (intervention) and normal saline in the left knee (control). Postoperative pain was recorded using the visual analog scale for each knee, and the time taken to achieve 90° of knee flexion was noted for each side. Results: The cocktail injected knee had significantly less pain when compared with the control knee during the first 48 hours and significantly shorter period to achieve 90° of knee flexion. Conclusions: The use of intraoperative periarticular cocktail injection significantly reduces early postoperative pain and provides better early knee motion.
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Repeat 2-stage revision for recurrent infection of total hip arthroplasty
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PJI DX Updated Search
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Eleven patients who developed reinfection after 2-stage revision for infected total hip arthroplasty (THA) were treated with a repeat 2-stage rerevision. Of the 11 rerevisions, 4 were successful, with no recurrent infection at mean follow-up of 44 months. Reinfection occurred in 7 patients of whom 6 involved either a significantly compromised host or poor local wound status. Clinical symptoms of infection were controlled in 4 of the 7 reinfected cases with antibiotic therapy in 2, irrigation and debridement in 1, and a third 2-stage revision THA in 1. Repeat 2-stage treatment of infected THA is associated with a high failure rate. However, successful results can be achieved particularly if the host is not immunocompromised and healthy soft tissue coverage is present
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Simultaneous anterior cruciate ligament reconstruction and computer-assisted open-wedge high tibial osteotomy: a report of eight cases
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Anterior Cruciate Ligament Injuries CPG
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Eight patients, aged 37-50 years, with chronic anterior cruciate ligament (ACL) deficiency, medial compartment osteoarthritis and varus deformity underwent simultaneous arthroscopic ACL reconstruction and open-wedge high tibial osteotomy controlled by a computer navigation system. Despite preoperative planning, the surgeon may need to choose a different osteotomy site during the procedure, invalidating the previous plans. The intraoperative wire control for osteotomies is not precise. The navigation system can help obtain precise alignment during high tibial osteotomy. The average preoperative mechanical axis was 7.5 of varum (sd+/-1.17 degrees ), the average postoperative axis was 1.2 degrees of valgus (sd+/-1.04 degrees ) (p<0.01), and the average correction of the mechanical axis was 8.7 degrees (sd+/-0.76 degrees ). The site of the osteotomy was 3.9 cm (3.5-4.8 cm, sd+/-0.35 mm) from the articular line, with an inclination of 27.9 degrees (24-35, sd+/-4.8). The simultaneous use of these procedures allowed proper correction of the knee axis during the surgery. The surgery can be performed concomitantly with ACL reconstruction
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The triceps-flexor carpi ulnaris (TRIFCU) approach to the elbow
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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INTRODUCTION: Intra-articular fractures of the distal humerus frequently require internal fixation. Several approaches have been described, with the posterior approaches being most common. We present a new approach to the distal humerus via the lateral border of the triceps muscle. PATIENTS AND METHODS: The senior author has used this technique for fixation of intra-articular fractures of the distal humerus in 12 patients. RESULTS: The approach is equally useful for intra- and extra-articular fractures. No cases of postoperative ulna nerve neuropraxia have been encountered. There have been no postoperative wound complications. The exposure has allowed sufficient access to allow anatomically contoured plates to be easily applied to both sides of the distal humerus with confirmation of intra-articular fracture reduction. CONCLUSIONS: The approach has the advantages of leaving the muscular bed of the ulna nerve undisturbed, whilst still providing excellent exposure of the distal humerus. The triceps mechanism is not divided or split allowing rapid recovery of extensor function. Additionally, because of the natural carrying angle of the elbow, repositioning of the reflected triceps aponeurosis is easy
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Hyperhidrosis - Pathogenesis and treatment methods
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Panniculectomy & Abdominoplasty CPG
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Hyperhidrosis is a condition characterized by excessive sweating which may have a primary or secondary cause. The diagnosis is facilitated by the guidelines of the Canadian Hyperhidrosis Advisory Committee. Prior to initiating treatment, the severity of the condition is determined based on the Hyperhidrosis Disease Severity Scale or objective examinations (Minor test or gravimetric method). The therapeutic options depend on the type of hyperhidrosis and are divided into topical, systemic and procedural modalities. The first-line drugs are topical preparations including aluminium salts, glycopyrrolate 2% and tannic acid solutions. Systemic therapies are based primarily on anti-cholinergic and β-adrenolytic drugs. Procedural therapies include botulinum toxin treatment, iontophoresis, laser therapy as well as techniques based on microwaves and ultrasounds. If these modalities fail, the remaining option is surgery, including sympathectomy or surgical removal of sweat glands.
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Pediatric infiltration injury and compartment syndrome
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DOD - Acute Comp Syndrome CPG
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Pediatric intravenous infiltration injuries are relatively common, and pediatric compartment syndrome is relatively rare. We have reviewed the causes, means of diagnosis, and treatment of compartment syndrome. Neonatal compartment syndrome is distinguished from intravenous infiltration injuries in the neonate by its associated skin lesions and requires prompt decompression. [References: 20]
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Treatment of the irreducible hip
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Developmental Dysplasia of the Hip CPG
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"Irreducible" congenital dislocation of the hip should not be regarded as a special pathological entity. Thirty-eight cases with a previous and failed treatment attempt were reviewed. Recognition of the renal cause of "irreducibility" (iatrogenic or anatomopathological) and institution of an appropriate treatment protocol result in adequate reduction in the vast majority of cases. However, osteochondritis is not an uncommon finding when the results of secondary treatment are evaluated. The percentage of more severe cases is higher after open procedures
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Paternalism
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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J. S. is a sixty-five-year-old man who was treated at another hospital with arthroscopic debridement of an infection at the site of a right total knee replacement and was placed on long-term intravenous antibiotics. He signed out of that hospital against medical advice. One month later, he presented at our hospital with recurrent sepsis of his knee. Knee aspiration yielded frank pus with a white blood-cell count of 80,000 cells per cubic millimeter. Gram-staining demonstrated gram-positive cocci. The patient was placed on intravenous antibiotics. The patient appeared cachectic, reporting a sixty-pound (27.2-kilogram) weight loss over the past year. A metastatic workup, including a chest radiograph, an abdominal sonogram, prostate-specific antigen, a complete blood-cell count, erythrocyte sedimentation rate, and a purified-protein-derivative skin test, was negative; however, an occult neoplasm could not be excluded. The patient displayed episodes of confusion, disorientation, and argumentative behavior. Medical and psychiatric consults did not determine whether this behavior was due to previous substance abuse or a primary psychiatric disorder. Nevertheless, psychiatrists at our institution determined that the patient lacked decisional capacity. Attempts were made to salvage the knee replacement, and the patient underwent an extensive surgical debridement of the knee with insertion of drains. He was placed on intravenous antibiotics. The plan was for the patient to be managed with long-term oral suppressive antibiotics. After treatment, the patient was transferred to a skilled-nursing facility. Psychiatrists at the nursing facility deemed the patient to have decisional capacity, and the patient was permitted to leave the facility. He was discharged without antibiotics. Several weeks later, he presented at our hospital with a grossly purulent knee. The orthopaedic options were reviewed with the patient and his brother. Removal of the components was recommended. The patient did not want to "lose" his knee replacement, and he refused surgical intervention. We did not believe that the infection could be either controlled or eradicated with the components in place
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Physical activity and predisposition for hip fractures: a review
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Management of Hip Fractures in the Elderly
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Studies on the association between physical activity and hip fractures are reviewed. All the studies, which comprise four follow-up studies, one nested case-control study and 17 case-control studies, suggest a protective effect of physical activity with regard to hip fractures. The association is strong and consistent with physical activity in leisure, weaker with respect to physical activity at work. The association is present for physical activity from childhood to adult age, and it is consistent in study populations from the USA, Australia, Asia and Northern and Southern Europe, in spite of very different hip fractures incidences in these populations. The magnitude of the association is difficult to assess because of varying criteria for exposure, but to be among the physically active seems to reduce the risk of later hip fracture by up to 50%. It seems that even daily chores, such as climbing stairs and walking, protect against hip fracture
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Migration of a Broken Trochanteric Wire to the Popliteal Fossa
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PJI DX Updated Search
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Wires used in fracture fixation or elective procedures can migrate within the body, and some lethal complications have been reported in the literature. We report a case of knee discomfort caused by a broken cerclage wire that has migrated from the hip region to the popliteal fossa after trochanteric osteotomy used in revision hip surgery. The authors point to the potential risks of broken orthopedic hardware. é 2011 Elsevier Inc
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Results and long-term patient satisfaction after gluteal augmentation with platelet-rich plasma-enriched autologous fat
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Panniculectomy & Abdominoplasty CPG
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Background: Buttock augmentation is gaining increasing popularity in aesthetic surgery. The relatively high incidence of complications after silicone implant placement lead to the increased use of lipofilling techniques, yielding variable results with respect to graft take rate and long-term stability. Platelet-rich plasma (PRP) has been shown to have beneficial effects on wound healing and angiogenesis in the past. Therefore, we aimed at investigating the long-term results and patient satisfaction after PRP-enriched lipofilling for buttock augmentation. Methods: Twenty-four bilateral gluteal augmentations with PRP-enriched autologous fat were performed. Additionally, contour shaping was achieved by liposuction of the adjacent zones. Post-operative results and complications were recorded, and satisfaction with buttock shape was estimated by a patient questionnaire. Results: Mean follow-up time was 44 months, and mean amount of transferred fat was 481 cc for both sides. No seroma or hematoma formation, infection or liponecrosis were reported during the post-operative follow-up. Subjective patient satisfaction in general increased from preoperatively to 3 months postoperatively and declined only slightly in the long-term course. Satisfaction levels in general were specific for each patient. Patient recovery was quick, and the majority of patients returned to work within 10 days after surgery. Conclusions: PRP-enhanced lipofilling of the buttocks proved to be a safe procedure including a low complication rate and consistent results. However, subjective patient expectations have to be taken into account when choosing the indication. Further large volume studies are needed to elucidate the potential and benefit of PRP in this context. © Springer-Verlag Berlin Heidelberg 2013.
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A prospective study on the risk of glove fingertip contamination during draping in joint replacement surgery
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PJI DX Updated Search
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INTRODUCTION: The aim of this prospective study was to investigate the risk of contamination of surgical gloves during preparation and draping in joint replacement surgery. METHODS: During 46 hip and knee replacement procedures, the gloves of orthopaedic consultants (n=5) and registrars (n=3) were assessed for contamination immediately after draping by impression of gloved fingers on blood agar. Contamination was evaluated by the surgeon's grade, the type of procedure, the role of the assistant and the dominance of the hand. RESULTS: A total of 125 pairs of top gloves were examined (79 pairs from registrars and 46 pairs from consultants). Bacterial contamination was isolated on 19 pairs (15.2%) (16 pairs from registrars and 3 pairs from consultants, p=0.04). Coagulase negative staphylococci were the main isolates and contamination was considered low in all cases (1-5 colonies). Contamination was seen more on the dominant hand (16 gloves from dominant hands and 6 from non-dominant hands, p=0.04), on the index finger and thumb. More contaminated gloves were seen in hip arthroplasty procedures (16 pairs from total hip replacements vs 3 pairs from total knee replacements, p=0.02). CONCLUSIONS: Contamination of glove fingertips during draping in joint replacement procedures is more likely to occur among junior surgeons, in hip rather than knee arthroplasty procedures and on the dominant hand. It is therefore essential that surgeons of different grades replace gloves used in draping to avoid exposing patients to the risk of infection
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The effect of meniscal tears on cartilage loss of the knee: findings on serial MRIs
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: The relationship between meniscal tears and progressive loss of hyaline cartilage and osteoarthritis of the knee has been reported in the literature. The current treatment protocols for meniscal tears include conservative treatment, meniscal repair, and meniscectomy. Treatment plans are based on factors such as tear pattern, patient age, and associated pathology. The mechanism, pattern, and treatment of meniscal tears vary with age and activity level. Younger, more active patients often sustain more acute tears, which are more amenable to repair due to increased propensity for healing compared with older patients. It is unclear which patients or types of meniscal tears will go on to sustain cartilage loss or osteoarthritis.
OBJECTIVE: In our study, we aimed to determine magnetic resonance imaging (MRI) findings in patients with meniscal tears that may be predictive as a risk factor for future cartilage loss.
METHODS: A database was retrospectively searched for patients with >= 2 MRIs of the same knee over a 7-year period, with the initial report containing the keyword "meniscal tear." Follow-up examinations were then evaluated for cartilage loss.
RESULTS: Seventy-six meniscal tears were evaluated. Initial MRI findings associated with cartilage loss included subchondral bone marrow edema (P < 0.0001), meniscal extrusion (P < 0.001), radial meniscal tear (P = 0.017), and posterior horn meniscal tear (P = 0.031). In patients without meniscectomy, cartilage loss was observed in 38% (15/39) compared with 76% (28/37) in patients with meniscectomy, (P = 0.0001).
CONCLUSION: Subchondral bone marrow edema and meniscal extrusion were the strongest MRI predictors for cartilage loss in an untreated knee with a meniscal tear. There was significantly greater cartilage loss in patients post-meniscectomy at follow-up than in those who did not undergo meniscectomy.
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Palliative care for people with dementia
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DoD SSI (Surgical Site Infections)
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The number of people with dementia will rise dramatically over the next 20 years. Currently, one in three people over the age of 65 will die with dementia. A PubMed search using MeSH headings for 'dementia' AND 'palliative care' and for specific areas, i.e. enteral feeding. National reports, UK guidelines and policies were also consulted. Advanced dementia is now being perceived as a 'terminal illness' with a similar symptom burden and prognosis to advanced cancer. People with dementia have poor access to good quality end-of-life care. Interventions such as antibiotics, fever management policies and enteral tube feeding remain in use despite little evidence that they improve quality of life or other outcomes. Research is required on the effectiveness of 'holistic' palliative care, outcome measures and the impact on carers and families. © 2010 The Author.
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Vancomycin-supplemented impacted bone allografts in infected hip arthroplasty
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Management of Hip Fractures in the Elderly
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Bone allografts can store and release high levels of vancomycin. We present our results of a two-stage treatment for infected hip arthroplasty with acetabular and femoral impaction grafting using vancomycin-loaded allografts. We treated 29 patients (30 hips) by removal of the implants, meticulous debridement, parenteral antibiotic therapy and second-stage reconstruction using vancomycin-supplemented impacted bone allografts and a standard cemented Charnley femoral component. The mean follow-up was 32.4 months (24 to 60). Infection control was obtained in 29 cases (re-infection rate of 3.3%; 95% confidence interval 0.08 to 17) without evidence of progressive radiolucent lines, demarcation or graft resorption. One patient had a further infection ten months after revision caused by a different pathogen. Associated post-operative complications were one traumatic periprosthetic fracture at 14 months, a single dislocation in two hips and four displacements of the greater trochanter. Vancomycin-supplemented allografts restored bone stock and provided sound fixation with a low incidence of further infection. (copyright) 2005 British Editorial Society of Bone and Joint Surgery
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Reduction in narcotic use after primary total knee arthroplasty and association with patient pain relief and satisfaction
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Surgical Management of Osteoarthritis of the Knee CPG
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We examined the prevalence of narcotic use before and after total knee arthroplasty (TKA) and its association with post-TKA pain relief and satisfaction. Data on 6364 primary, unilateral TKA patients in a national registry were analyzed. Before TKA, 24% of patients were prescribed one form of narcotic. Of these, 14% reported continued narcotic use at 12 months after TKA, whereas the majority discontinued use. Only 3% of patients who did not use narcotics before TKA had a narcotics prescription at 12 months. Patients who used narcotics before TKA were more likely to have a narcotic prescription at 12 months post-TKA, reported greater pain at 12 months, and were more likely to be dissatisfied with TKA outcome. These findings have implications for patient pre-TKA counseling
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Fractures of the elbow: Supracondylar fractures
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Distal Radius Fractures
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Fractures about the elbow are second in frequency only to the distal radius. Trauma specialists should be familiar with the range of possible injuries, complications, and be confident in their diagnosis and management. © 2006 Sage Publications.
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Prevention and treatment of osteoporosis
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Management of Hip Fractures in the Elderly
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Osteoporosis develops in older adults when the normal processes of bone formation and resorption become uncoupled or unbalanced, resulting in bone loss. Fractures are the result of decreased bone mass and strength and, in the case of wrist and hip fractures, usually involve a fall. Osteoporosis prevention and treatment programs should then focus on strategies that minimize bone resorption and maximize bone formation as well as on strategies that reduce falls. Optimal treatment and prevention of osteoporosis require modification of risk factors, particularly smoking cessation, adequate physical activity, and attention to diet, in addition to pharmacologic intervention. A number of pharmacologic options are now available to health care providers. This article focuses on US Food and Drug Administration-approved medications for osteoporosis and emphasizes the importance of using these agents as part of a comprehensive program that includes nonpharmacologic measures, complete diagnostic evaluation, and adequate follow-up with bone mineral density measurement
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Neuropsychiatric symptoms and the use of mind-body therapies
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DoD PRF (Psychosocial RF)
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OBJECTIVE: Neuropsychiatric symptoms affect 37% of US adults and present in many important diagnoses including posttraumatic stress disorder, traumatic brain injury, and chronic pain. However, these symptoms are difficult to treat with standard treatments, and patients may seek alternative options. In this study, we examined the use of mind-body therapies by adults with neuropsychiatric symptoms.
METHOD: We compared mind-body therapy use (biofeedback, energy healing, meditation, guided imagery, yoga, deep-breathing exercises, hypnosis, progressive relaxation therapy, qigong, and tai chi) between adults with and without neuropsychiatric symptoms (anxiety, depression, insomnia, headaches, memory deficits, attention deficits, and excessive daytime sleepiness) in the 2007 National Health Interview Survey (N = 23,393). Use of >= 1 of these therapies in the prior 12 months was the primary outcome of interest. We also examined prevalence and reasons for mind-body therapy use in adults with neuropsychiatric symptoms. We performed logistic regression to examine the association between neuropsychiatric symptoms and mind-body therapy use to adjust for sociodemographic and clinical factors.
RESULTS: Adults with >= 1 neuropsychiatric symptom used mind-body therapies more than adults without symptoms (25.3% vs 15.0%, P < .001). Prevalence increased with increasing number of symptoms (21.5% for 1 symptom, 32.4% for >= 3 symptoms, P < .001); differences persisted after adjustment for potential confounders (odds ratios, 1.39 [95% CI, 1.26-1.53] and 2.48 [95% CI, 2.18-2.82]). Reasons for mind-body therapy use among adults with >= 1 symptom included the ineffectiveness or expense of conventional medicine (30.2%). Most adults (nearly 70%) with >= 1 symptom did not discuss their mind-body therapy use with a conventional provider.
CONCLUSIONS: Adults with >= 1 neuropsychiatric symptom use mind-body therapies frequently; more symptoms are associated with increased use. Future research is needed to understand the efficacy of these therapies.
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Posterior percutaneous plating of the humerus
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Distal Radius Fractures
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OBJECTIVE: This is a prospective case series study, which was designed to evaluate the clinical outcome of posterior percutaneous plating of the humerus.
MATERIALS AND METHODS: From the year 2010 to 2011, 37 patients with middle and distal third humeral fractures who met the inclusion criteria were surgically treated by minimally invasive plate osteosynthesis through posterior approach. Their age ranged from 19 to 43 with an average of 27.8 years. Type of fractures varied from B to C, and all of them were traumatic.
RESULTS: Patients were followed up for a period varied from 12 to 24 months with an average of 18. There were no cases of intraoperative complications, infection or metal failure. Union was achieved in all of them within 16-21 weeks with an average of 18. Iatrogenic postoperative temporary neuropraxia of the radial nerve palsy was observed in two patients. All patients achieved normal range of shoulder and elbow motion within 3 months after surgery. The average Quick DASH score at 12-month follow-up was 30. According to patient's satisfaction, all of them returned to the usual pre-injury activity level within 6 months.
CONCLUSIONS: This study suggests that the principles of minimally invasive plate osteosynthesis can be applied safely through posterior approach of the humerus to treat middle and distal third humeral fractures. This approach has the advantage of preserving the triceps anatomy and function facilitating rapid postoperative rehabilitation.
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Triamcinolone acetonide reduces viability, induces oxidative stress, and alters gene expressions of human chondrocytes
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Patients with knee osteoarthritis (OA) are sometimes prescribed intra-articular injections of glucocorticoids (GCs), such as triamcinolone acetonide (TA). Whether GCs cause chondrotoxicity is not known. We wished to ascertain if TA induces toxicity by causing oxidative stress and alters expression of P21, growth differentiation factor (GDF)15, and cFos.
PATIENTS AND METHODS: Primary chondrocytes isolated from 10 OA patients undergoing total knee replacement surgery were incubated with TA (0, 1, 5, 10 mg/ml), with or without 100 micro M vitamin C for 7 and 14 days for viability assays and 48 h for oxidative stress and gene expression analyses.
RESULTS: TA significantly decreased chondrocyte viability and increased the ratio of oxidized glutathione to total glutathione suggesting an increase in oxidative stress. Vitamin C significantly increased the viability and decreased the oxidative stress of cells treated with 5 mg/ml TA. Expression of P21, GDF15, and cFos increased significantly when TA was added (5.17 +/- 2.4-, 4.96 +/- 3.1-fold for P21, 9.97 +/- 2.9- and 4.2 +/- 1.6-fold for GDF15, and 6.65 +/- 4.8-, 12.96 +/- 8.3-fold for cFos at 1, and 5 mg/ml TA, respectively).
CONCLUSIONS: TA induced chondrotoxicity by increasing oxidative stress and altering expressions of genes involved in cell death. The addition of vitamin C decreased oxidative stress and increased viability, suggesting that antioxidants might attenuate TA toxicity in cartilage.
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Infection associated with hematoma formation after shoulder arthroplasty
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Hematoma formation requiring operative treatment after shoulder arthroplasty may be associated with higher patient morbidity. We therefore determined whether there was an association of hematoma formation requiring operative treatment with deep infection after shoulder arthroplasty. Between 1978 and 2006, we performed 4147 shoulder arthroplasties in 3643 patients. Of these, 12 shoulders (0.3%) underwent reoperation for hematoma formation. The mean time interval from arthroplasty to surgery for the hematoma was 7 days (range, 0.5-31 days). Among nine cases in which cultures were taken, six had positive cultures; the organisms included Propionibacterium acnes in three, Staphylococcus epidermidis in one, Streptococcus species in one, and Staphylococcus epidermidis with Peptostreptococcus in one. The minimum followup was 12 months (mean, 68 months; range, 12 to 294 months). Two of the 12 patients eventually underwent resection arthroplasty for deep infection. The Neer score was excellent in one, satisfactory in six, and unsatisfactory in five patients. The data suggest hematoma formation after shoulder arthroplasty is often accompanied by positive intraoperative cultures. The surgeon should be aware of the high rate of unsatisfactory results associated with this complication as well as the possibility of developing a deep infection requiring additional surgery. LEVEL OF EVIDENCE: Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence
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Examination of sensory nerve fibers by needle recording in the carpal tunnel syndrome; use of the orthodromic method with special attention to the paresthetic forms
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The authors examined clinically, by EMG and by electrostimulation the motor and sensory fibers of the median nerve in 15 control hands (group A), 35 hands with the paresthetic form of CTS (group B), and 33 hands with CTS and pathologic DML (group C). The examination of the sensory fibers was performed on the first (thumb) to 4th digits separately by the orthodromic technique with monitoring the NAP by needle electrodes from the wrist. Two hundred fifty six responses were averaged out and always 4 stimulatory values were followed on the sensory fibers. The highest percentage of pathologic values by DSL in group B was on the first digit (thumb: 37%), in group C on the 3rd digit (93%). By DSCV the highest number of pathologic values in groups B and C was on the thumb (43 and 90 per cent respectively), for NAP duration in groups B and C on the third digit (26 and 60 per cent respectively). In the controls the mean amplitude of NAP fluctuated between 19-50 uV. The best parameters are considered: the DSL, DSCV, somewhat less the duration of NAP. In the paresthetic form of CTS pathologic values of sensory parameters fluctuated between 8.6-42.8 per cent, in the group with pathologic DML in the range of 24.2-93.3 per cent. If one considered pathologic an examination that had at least one pathologic sensory parameter at least on one digit, group B yielded 77 per cent, and group C 100 per cent of pathological results.(ABSTRACT TRUNCATED AT 250 WORDS)
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Regional bone mineral in healthy and osteoporotic women: a cross-sectional study
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Distal Radius Fractures
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Regional bone mineral content and density (BMC and BMD) was measured in six regions (head, arms, chest, spine, pelvis, and legs) using dual photon 153Gd absorptiometry (DPA) in 128 healthy women aged 21-77 years, and in 45 women presenting with Colles' fracture (mean age 65 years), 46 women with vertebral crush or wedge fracture (mean age 68 years), and 27 women with femoral neck-fracture (mean age 74 years). The age-related normal bone loss was generalized, uniformly distributed, and best described by a combination of a premenopausal linear and a postmenopausal exponential regression in all six regions. Looking at BMD, the overall expected bone loss from age 20 to age 80 was approximately 20% in all the regions. When the fracture patients were examined, we found also generalized bone deficit as the prominent feature, amounting to about 20% of the premenopausal level for Colles' and spinal fractures, and about 25% for femoral neck-fracture. However, there was a regional bias in the fracture patients, as the Colles' and spinal fracture patients had a preferential reduction in spinal and pelvic BMD, whereas the patients with femoral neck-fracture had a preferential reduction in pelvic and leg BMD. We conclude that age-related and osteoporotic bone loss is generalized. Furthermore, we propose that regional differences in osteoporotic bone loss are brought about by a simple biological variability of the range of (i) relative amount of trabecular and cortical bone, (ii) rate of loss in the two types of bone tissue, and (iii) time of onset of trabecular relative to cortical bone loss.
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Rotator cuff rehabilitation: current theories and practice
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Glenohumeral Joint OA
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A fully functioning, painless shoulder joint is essential to maintain a healthy, normal quality of life. Disease of the rotator cuff tendons (RCTs) is a common issue that affects the population, increasing with age, and can lead to significant disability and social and health costs. RCT injuries can affect younger, healthy patients and the elderly alike, and may be the result of trauma or occur as a result of chronic degeneration. They can be acutely painful, limited to certain activities or completely asymptomatic and incidental findings. A wide variety of treatment options exists ranging from conservative local and systemic pain modalities, to surgical fixation. Regardless of management ultimately chosen, physiotherapy of the RCT, rotator cuff muscles and surrounding shoulder girdle plays an essential role in proper treatment. Length of treatment, types of therapy and timing may vary if therapy is definitive care or part of a postoperative protocol. Allowing time for adequate RCT healing must always be considered when implementing ROM and strengthening after surgery. With current rehabilitation methods, patients with all spectrums of RCT pathology can improve their function, pain and quality of life. This manuscript reviews current theories and practice involving rehabilitation for RCT injuries.
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Effect of stabilization splint therapy on glenoid fossa remodeling in temporomandibular joint osteoarthritis
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Glenohumeral Joint OA
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PURPOSE: The aim of this study was to evaluate, by CBCT superimposition, bone changes (cortical bone intactness, sclerosis and subchondral cyst) in the glenoid fossa related to stabilization splint (SS) therapy for temporomandibular joint osteoarthritis (TMJ OA) patients and to compare the effects for two groups, one that had undergone SS therapy and the other that had not.
METHODS: This case-control study included 36 TMJ OA patients, 10 that had undergone SS therapy (the SS group) compared with 26 that had not (the non-SS group). Osseous changes in the glenoid fossa were evaluated based on superimposed CBCT images before and after treatment.
RESULTS: Improvements ranging from 57.5 to 100% were achieved in cortical bone integrity, sclerosis, and subchondral cyst for both groups, SS and non-SS. However, there were no statistically significant difference between the two groups (p>0.05). The non-SS group showed a significant decrease in the distances from the point of inflexion and the lowest point of the articular eminence to the reference line (p<0.05). On the other hand, the SS group showed an increase for the point of inflexion. The other measures showed no statistically significant differences in distance before treatment and after treatment, even though the average distance after treatment showed an overall increasing tendency.
CONCLUSION: SS therapy relieved excessive loading on the TMJ in the TMD OA patients, who showed, via CBCT superimposition, less bone resorption in the glenoid fossa.
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Pentoxifylline for intermittent claudication
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SR for PM on OA of All Extremities
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Background: Intermittent claudication (IC) is a symptom of peripheral arterial occlusive disease (PAD). It is associated with high morbidity and mortality. Pentoxifylline is one of many drugs used to treat IC. Pentoxifylline decreases blood viscosity, improves erythrocyte flexibility, and increases microcirculatory flow and tissue oxygen concentration.Many studies have evaluated the efficacy of pentoxifylline in treating PAD but the results of these studies are very variable.Objectives: To determine the efficacy of pentoxifylline in improving the walking capacity (that is pain-free walking distance and the total (absolute, maximum) walking distance) of patients with stable intermittent claudication, Fontaine stage II.Search methods: The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched January 2011) and CENTRAL (2011, Issue 1). In addition, we searched MEDLINE (Week 2 January 2011) and EMBASE (2011 Week 03). ClinicalTrials.gov and Current Controlled Trials were searched for ongoing or unpublished trials.Selection criteria: All double blind, randomised controlled trials (RCTs) comparing pentoxifylline to placebo or any other pharmacological intervention in patients with IC Fontaine stage II.Data collection and analysis: Included studies were assessed separately by two review authors. Data were matched and disagreements resolved by discussion. The quality of the studies was assessed using the Jadad score and the Cochrane risk of bias tool. Results relating to pain-free walking distance (PFWD) and total walking distance (TWD) were collected. Studies were compared based on the duration and dose of pentoxifylline.Main results: Twenty-three studies with 2816 participants were included in this review. There was considerable heterogeneity between the included studies with regards to multiple variables including duration of treatment, dose of pentoxifylline, baseline walking distance and patient characteristics, and therefore pooled analysis was not possible. The quality of the included studies was generally low. There was very large variability in the reported findings between the individual studies. In a total of 17 studies which compared pentoxifylline with placebo, of which 14 reported TWD and 11 reported PFWD, the difference in percentage improvement in TWD for pentoxifylline over placebo ranged from 1.2% to 155.9%, and for PFWD the difference ranged from -33.8% to 73.9%. Testing for statistical significance of these results was generally not possible due to the lack of data. There was no statistically significant difference in ankle brachial pressure index (ABI) between the pentoxifylline and placebo groups. Pentoxifylline was generally well tolerated.Authors' conclusions: Given the generally poor quality of the published studies and the large degree of heterogeneity in the interventions and the results, the overall benefit of pentoxifylline for patients with Fontaine class II intermittent claudication remains uncertain. Pentoxifylline is generally well tolerated.  Based on the totality of the available evidence, it is possible that pentoxifylline could have a place in the treatment of IC as a means of improving walking distance and as a complimentary treatment assuming all other essential measures such as lifestyle change, exercise and treatment for secondary prevention have been taken into account. However, the response to pentoxifylline should be assessed on an individual basis
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Spinal infection in intravenous drug abusers
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The number of intravenous (IV) drug abusers has been increasing in recent years. They are generally younger and healthier than the typical patient with a spinal infection. Reviewing the English language literature, there are only a few articles discussing the relationship between IV drug abuse and spinal infection. We studied 21 IV drug abusers with spinal infection. All were male, 19 were in their 30s and 40s with a mean age of 44 years. The mean follow-up period was 41 months after surgical intervention. Mild and severe neurologic deficit were seen in 5 and 13 patients (Frankel Grade C in 5, Grade D in 8), respectively. The overall positive culture rate was 17 out of 21 (81%). Twelve patients were infected with Staphylococcus aureus and 3 with Pseudomonas aeruginosa. Two had Mycobacterium tuberculosis. All were treated with anterior debridement and strut bone grafting with or without posterior instrumentation, laminectomy and abscess excision, or with additional discectomy. All patients with neurologic deficit recovered to a normal status. At the most recent follow-up, all the spine segments had fused and no one complained of any recurrent back pain. There were no postoperative complications. Physicians need to be more alert to the possibility of spinal infection in IV drug abusers with back pain. In addition to Staphylococcus aureus, Pseudomonas aeruginosa and Mycobacterium tuberculosis may be seen among IV drug abusers. (copyright) 2007 Lippincott Williams & Wilkins, Inc
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Medical care at mass gatherings: emergency medical services at large-scale rave events
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DoD PRF (Psychosocial RF)
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OBJECTIVE: The objective of this study was to develop comprehensive guidelines for medical care during mass gatherings based on the experience of providing medical support during rave parties.
METHODS: Study design was a prospective, observational study of self-referred patients who reported to First Aid Stations (FASs) during Dutch rave parties. All users of medical care were registered on an existing standard questionnaire. Health problems were categorized as medical, trauma, psychological, or miscellaneous. Severity was assessed based on the Emergency Severity Index. Qualified nurses, paramedics, and doctors conducted the study after training in the use of the study questionnaire. Total number of visitors was reported by type of event.
RESULTS: During the 2006-2010 study period, 7,089 persons presented to FASs for medical aid during rave parties. Most of the problems (91.1%) were categorized as medical or trauma, and classified as mild. The most common medical complaints were general unwell-being, nausea, dizziness, and vomiting. Contusions, strains and sprains, wounds, lacerations, and blisters were the most common traumas. A small portion (2.4%) of the emergency aid was classified as moderate (professional medical care required), including two cases (0.03%) that were considered life-threatening. Hospital admission occurred in 2.2% of the patients. Fewer than half of all patients presenting for aid were transported by ambulance. More than a quarter of all cases (27.4%) were related to recreational drugs.
CONCLUSIONS: During a five-year field research period at rave dance parties, most presentations on-site for medical evaluation were for mild conditions. A medical team of six healthcare workers for every 10,000 rave party visitors is recommended. On-site medical staff should consist primarily of first aid providers, along with nurses who have event-specific training on advanced life support, event-specific injuries and incidents, health education related to self-care deficits, interventions for psychological distress, infection control, and disaster medicine. Protocols should be available for treating common injuries and other minor medical problems, and for registration, triage, environmental surveillance and catastrophe management and response.
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Sight-threatening Graves' orbitopathy: twenty years' experience of a multidisciplinary thyroid-eye outpatient clinic
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Upper Eyelid and Brow Surgery
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CONTEXT: Sight-threatening Graves' orbitopathy affects 3 to 5% of patients with Graves' orbitopathy. OBJECTIVES: To describe the management of patients with sight-threatening Graves' orbitopathy seen in a multidisciplinary thyroid-eye outpatient clinic dedicated to Graves' orbitopathy (GO). PATIENTS AND METHODS: We enrolled all patients with sight-threatening GO (dysthyroid optic neuropathy and corneal ulcer as defined in the EUGOGO statement) seen and treated in our GO multidisciplinary thyroid-eye outpatient clinic over the last two decades. RESULTS: 31 patients (median age 51 years old) including 24 women (77%) and 58% active smokers. This population represented 47 cases (case = eye) of sight-threatening GO. Dysthyroid optic neuropathy (DON) occurred in 40 eyes, corneal ulcer in 15 eyes and both in 8. At presentation, the clinical features of DON were reduced visual acuity (85%), visual field defects (85%), optic disc swelling (42%) and reduced colour vision (100%). At one year, surgical orbital decompression (OD) was performed in 82.5% of DON cases. Only 7 eyes with DON were treated with pulses of intra-venous glucocorticoids. For 10 patients, several therapeutic strategies (OD n = 4, punctal plug n = 1, amniotic membrane graft n = 2, tarsorrhaphy n = 2, botulinum toxin injection = 3, eyelid surgery n = 2) were used to treat corneal ulcer. For each ophthalmological parameter, more than 85% of DON cases had recovery or improvement after treatment. For visual acuity in corneal ulcer, it was 71.4%. CONCLUSION: We report 47 cases of sight-threatening GO. Orbital decompression was performed in the majority of DON cases and several therapeutic strategies were necessary to treat corneal ulcer. The results are satisfactory in sight-threatening Graves' orbitopathy due to multidisciplinary management. This article is protected by copyright. All rights reserved.
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Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study
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Hip Fx in the Elderly 2019
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OBJECTIVES: To identify a cut point in annual surgeon volume associated with increased risk of complications after primary elective total hip arthroplasty and to quantify any risk identified.
DESIGN: Propensity score matched cohort study.
SETTING: Ontario, Canada.
PARTICIPANTS: 37,881 people who received their first primary total hip arthroplasty during 2002-09 and were followed for at least two years after their surgery.
MAIN OUTCOME MEASURE: The rates of various surgical complications within 90 days (venous thromboembolism, death) and within two years (infection, dislocation, periprosthetic fracture, revision) of surgery.
RESULTS: Multivariate splines were developed to visualize the relation between surgeon volume and the risk for various complications. A threshold of 35 cases a year was identified, under which there was an increased risk of dislocation and revision. 6716 patients whose total hip arthroplasty was carried out by surgeons who had done <= 35 such procedure in the previous year were successfully matched to patients whose surgeon had carried out more than 35 procedures. Patients in the former group had higher rates of dislocation (1.9% v 1.3%, P=0.006; NNH 172) and revision (1.5% v 1.0%, P=0.03; NNH 204).
CONCLUSIONS: In a cohort of first time recipients of total hip arthroplasty, patients whose operation was carried by surgeons who had performed 35 or fewer such procedures in the year before the index procedure were at increased risk for dislocation and early revision. Surgeons should consider performing 35 cases or more a year to minimize the risk for complications. Furthermore, the methods used to visualize the relationship between surgeon volume and the occurrence of complications can be easily applied in any jurisdiction, to help inform and optimize local healthcare delivery.
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Exploring Factors Influencing Low Back Pain in People With Nondysvascular Lower Limb Amputation: A National Survey
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Chronic low back pain (LBP) is a common musculoskeletal impairment in people with lower limb amputation. Given the multifactorial nature of LBP, exploring the factors influencing the presence and intensity of LBP is warranted. OBJECTIVE: To investigate which physical, personal, and amputee-specific factors predicted the presence and intensity of LBP in persons with nondysvascular transfemoral amputation (TFA) and transtibial amputation (TTA). DESIGN: A retrospective cross-sectional survey. SETTING: A national random sample of people with nondysvascular TFA and TTA. PARTICIPANTS: Participants (N = 526) with unilateral TFA and TTA due to nondysvascular etiology (ie, trauma, tumors, and congenital causes) and a minimum prosthesis use of 1 year since amputation were invited to participate in the survey. The data from 208 participants (43.4% response rate) were used for multivariate regression analysis. METHODS (INDEPENDENT VARIABLES): Personal (ie, age, body mass, gender, work status, and presence of comorbid conditions), amputee-specific (ie, level of amputation, years of prosthesis use, presence of phantom-limb pain, residual-limb problems, and nonamputated limb pain), and physical factors (ie, pain-provoking postures including standing, bending, lifting, walking, sitting, sit-to-stand, and climbing stairs). MAIN OUTCOME MEASURES (DEPENDENT VARIABLES): LBP presence and intensity. RESULTS: A multivariate logistic regression model showed that the presence of 2 or more comorbid conditions (prevalence odds ratio [POR] = 4.34, P = .01), residual-limb problems (POR = 3.76, P < .01), and phantom-limb pain (POR = 2.46, P = .01) influenced the presence of LBP. Given the high LBP prevalence (63%) in the study, there is a tendency for overestimation of POR, and the results must be interpreted with caution. In those with LBP, the presence of residual-limb problems (beta = 0.21, P = .01) and experiencing LBP symptoms during sit-to-stand task (beta = 0.22, P = .03) were positively associated with LBP intensity, whereas being employed demonstrated a negative association (beta = -0.18, P = .03) in the multivariate linear regression model. CONCLUSIONS: Rehabilitation professionals should be cognizant of the influence that comorbid conditions, residual-limb problems, and phantom pain have on the presence of LBP in people with nondysvascular lower limb amputation. Further prospective studies could investigate the underlying causal mechanisms of LBP. LEVEL OF EVIDENCE: II.
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