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Negative pressure pulmonary edema in healthy cosmetic surgery patients
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Panniculectomy & Abdominoplasty CPG
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Anesthetic complications are uncommon in young and healthy patients undergoing cosmetic surgery. We report 2 cases of negative pressure pulmonary edema (NPPE) in young patients, 1 who underwent rhinoplasty and another who underwent augmentation mammaplasty and suction-assisted lipoplasty of the thighs and buttocks This rare and potentially fatal complication requires admission to an intensive-care unit and delayed discharge. Although cases of NPPE have been reported in the medical and anesthetic literature, NPPE in plastic surgery has never been reported previously.
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One half of patients reports persistent pain three months after orthopaedic surgery
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To determine persistent post-surgical pain prevalence after orthopaedic surgery with its impact on patient quality of life and to assess factors related to it.
STUDY DESIGN: Cross-sectional cohort study.
PATIENTS: A questionnaire was mailed to 2100 patients undergoing orthopaedic surgery in our teaching hospital.
METHODS: Pain prevalence 3 months after surgery, pain intensity, a neuropathic pain component using the DN4 questionnaire and its impact on patient quality of life were assessed.
RESULTS: One thousand two hundred and ninety-two patients answered our questionnaire. Among them, 48% suffered from chronic pain. This pain had a neuropathic component in 43%, which was responsible for analgesic overconsumption and increases in sleep disturbance and sick leave. Arthrodesis, knee arthroplasty and leg fracture were linked to increased chronic post-surgical pain (OR=2.7, OR=1.8, OR=1.9, respectively; P<0.05). Elbow surgery, meniscectomy, amputation and neurolysis were linked to increased neuropathic pain.
CONCLUSIONS: Chronic, post-surgical pain is common after orthopaedic surgery, leading to analgesic consumption and sleep disturbance. Patients at high risk for developing chronic post-surgical pain must be identified preoperatively. The development of postoperative pain clinics should be one way to respond to this public health problem.
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Classification criteria and severity assessment in work-associated upper extremity disorders: Methods matter
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Work-associated musculoskeletal disorders of the upper extremity are common and disabling. Research on these disorders is needed and requires valid methods of classification of the disorders for epidemiologic studies and measurement of their impact on functional status. This commentary discusses the methodologic aspects of classification and functional status assessment in upper extremity musculoskeletal disorders. (C) 2000 Wiley-Liss, Inc
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Altered Wnt and NF-kappaB Signaling in Facet Joint Osteoarthritis: Insights from RNA Deep Sequencing
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TO: WNT2 Pathway Modulator
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Facet joint osteoarthritis is common lumbar osteoarthritis characterized by facet joint cartilage degeneration. However, the molecular basis of facet joint osteoarthritis remains largely undetermined. In the current study, we collected facet joint tissue samples from 10 control patients and 48 patients with facet joint osteoarthritis (20 patients with moderate degeneration and 28 with severe degeneration). The control patients underwent internal fixation of the lumbar spine due to vertebral fracture. RNA deep sequencing was performed, and Bioinformatic tools were applied. Among top 30 enriched signaling pathways, we focused on two inflammation-related signaling pathways, Wnt and NF-kappaB signaling pathways. Subsequently, using the quantitative RT-PCR analysis, we confirmed that in Wnt signaling pathway, the mRNA levels of Dickkopf WNT Signaling Pathway Inhibitor 2 (DKK2), Sex-determining Region Y-box 17 (SOX17), MYC, Cyclin D1, Calcium/Calmodulin Dependent Protein Kinase II Alpha (CAMK2A), and Wnt Family Member 11 and 5 were increased in facet joint osteoarthritis, while the mRNA levels of WNT Inhibitory Factor 1, Casein Kinase 1 Alpha 1, Transcription Factor 7/Lymphoid Enhancer Binding Factor 1 (TCF7/LEF1), and VANGL Planar Cell Polarity Protein 2 were decreased. In NF-kappaB signaling pathway, the mRNA levels of C-C Motif Chemokine Ligand 4 (CCL4) and C-C Motif Chemokine Ligand 4 Like 2 (CCL4L2) were increased, while the mRNA levels of BCL2 Related Protein A1 were decreased. These results suggest that Wnt and NF-kappaB signaling may be altered in the process of facet joint cartilage degeneration. The present study will expand our understanding of the molecular bases underlying facet joint osteoarthritis.
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Lactase gene c/t(-13910) polymorphism, calcium intake, and pQCT bone traits in Finnish adults
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Distal Radius Fractures
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Genetic lactase nonpersistence may influence calcium intake and thereby bone health. We investigated in the Cardiovascular Risk in Young Finn Study whether young adults aged 31-46 years with the C/C(-13910) genotype are more susceptible to reduced bone phenotypes, low-energy fractures, and low calcium intake than subjects with other lactase genotypes. We also analyzed the gene-environment interactions on bone with calcium intake and physical activity. Peripheral quantitative computed tomography bone traits were measured from the distal and shaft sites of the radius and tibia. The total number of those subjects whose nondominant forearm was measured and the lactase genotype was defined was 1551. Information on diet, lifestyle factors, and fractures was collected with questionnaires. The mean intake of calcium was the lowest in men with the C/C(-13910) genotype (P = 0.001). Men with the T/T(-13910) genotype had ~3% higher trabecular density at the distal radius and distal tibia compared to other lactase genotypes (P = 0.03 and 0.02, respectively). In women, we found no evidence of the gene effect at the radius and tibia. No major interactions of the C/T(-13910) polymorphism with calcium intake or physical activity on bone phenotypes were found in either sex. In conclusion, the C/T(-13910) polymorphism was associated with trabecular density at the distal radius and tibia in men. These differences may be due to the differences in calcium intake between the lactase genotypes.
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The Use of Continuous Wound Infusion Analgesia in Total Knee Arthroplasty
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AAHKS (8) Anesthetic Infiltration
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Continuous local wound infusion analgesia is a relatively new way of managing postâ?operative pain, whereby a local anesthetic is continuously infused into the surgical area. Some studies and users have reported decreased pain, decreased opioid use, decreased postâ?operative nausea and vomiting, decreased length of stay, and improved patient and caregiver satisfaction with the use of continuous local wound infusion analgesia, when compared to placebo, or usual care, in arthroplasty and other surgical interventions. Hypotheses: Primary: The Onâ?Q PainBuster (continuous wound infusion analgesia) in TKA will result in improved patient pain control, compared to usual care. Secondary: â? Pain scores postâ?operatively will be better than usual care. â? Fewer narcotics will be ingested postâ?operatively than with usual care. â? Postâ?op nausea and vomiting will be less than usual care. â? Length of stay will be shorter compared to usual care. â? Patient satisfaction will be greater than satisfaction with usual care. â? Postâ?operative infection rates will be no different between groups. â? Fall rates will be no different between groups. â? Subjects will participate in physical therapy the day of surgery. â? Nursing Intensity requirements will be less with the wound infusion due to fewer requests for pain medication.
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Cross-sectional study of pain and disability at knee replacement surgery for osteoarthritis in 299 patients
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: To evaluate pain and disability at the time of knee replacement surgery for osteoarthritis. METHODS: In this multicenter cross-sectional study, 299 patients at 12 orthopedic surgery centers in Lyon, France were evaluated on the day before knee replacement surgery. Pain severity was assessed on a visual analog scale (VAS) and function using the Lequesne index and the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: There were 207 women and 92 men with a mean age of 73 years. Mean (+/-SD) VAS pain score upon walking was 55.8+/-24mm. Compared to patients with very severe disability (Lequesne index>12), those with mild-to-severe disability (Lequesne index<or=12) were more likely to be older than 70 years (odds ratio [OR], 2.85; 95% confidence interval [95%CI], 1.25-5) and male (OR, 2.5; 95%CI, 1.3-5); they were less likely to have a body mass index>27kg/m(2) (OR, 2.2; 95%CI, 1.3-3.3) and to engage in sporting activities (OR, 3.3; 95%CI, 1.4-10). CONCLUSION: Patients about to undergo knee replacement surgery had high levels of pain and disability, with little variation across centers. Nevertheless, the severity of pain and disability may depend in part on age, gender, body mass index, and sporting activities, which probably influence the decision to perform knee replacement surgery
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Discoid Lateral Meniscus
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AMP (Acute Meniscal Pathology)
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PURPOSE OF REVIEW: Discoid lateral meniscus (DLM) is a well-known meniscus variant, and comprises excess and thickened meniscal tissue, altered collagen ultrastructure, and peripheral instability. This article presents a comprehensive review on current knowledge of DLM, focusing on pathology in parallel with surgical techniques and outcomes.
RECENT FINDINGS: A paradigm shift in surgical management of DLM is taking place as knee surgeons are seeing more patients with long-term sequelae of partial lateral meniscectomy, the standard treatment for DLM for many years. Surgical treatment has evolved alongside the understanding of DLM pathology. A new classification system has been proposed and optimal surgical techniques described in recent years. This article highlights up-to-date evidence and techniques in management of both acute DLM tears and joint restoration following subtotal meniscectomy for DLM. Surgical management of DLM must be tailored to individual pathology, which is variable within the diagnosis of DLM. We present an algorithm for management of DLM and discuss future directions for the understanding and treatment of this debilitating condition.
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Arthrodesis in the charcot foot: A systematic review
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DoD SSI (Surgical Site Infections)
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The Charcot foot is a condition characterized by a progressive derangement of the foot. The type of deformity and patient clinical conditions will lead to the proper surgical approach among exostectomy, arthrodesis (through external and/or internal fixation) and amputation. Many authors report good clinical outcomes performing the arthrodesis in Charcot foot; however, the choice of the most appropriate hardware is still an issue. The aim of this study is to analyze the outcomes of different hardware in midfoot and hindfoot Charcot arthrodesis.
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Galactosemia: A treatable metabolic disorder
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Patrick’s pharmacoepidemiology project
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Galactosemia is a rare metabolic disorder. It has good prognosis, if detected in neonatal period or early infancy. Two cases of classic galactosemia are presented. One case was detected in neonatal period. Early intervention has led to normal development till now. The second case was diagnosed at 1 year of age. Elimination of milk from diet is quite simple and effective treatment modality
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Serum IgG reactive with oral anaerobic microorganisms associated with infections of endodontic origin
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Numerous species of bacteria have been implicated with infections of endodontic origin. The purpose of this study was to compare the levels of serum IgG antibodies reactive with a panel of 10 oral anaerobic microorganisms implicated in infections of endodontic origin. Serum samples were collected from 4 patient groups that included healthy patients without endodontic or periodontal disease, patients with chronic adult periodontal disease, patients with endodontic disease and patients with combined endodontic-periodontal disease. When Prevotella intermedia was allowed to react with sera from the 4 patient groups, significant pairwise differences were shown between the healthy group and each of the other 3 groups. In addition, there was a significant difference between the periodontal disease group and the combined endodontic-periodontal disease group. When Porphyromonas gingivalis was allowed to react with sera from the 4 patient groups, significant pairwise differences were shown between the healthy group and the periodontal disease group, the healthy group and the combined endodontic-periodontal disease group, the endodontic disease group and the periodontal disease group and the endodontic disease group and the combined endodontic-periodontal disease group. The results of this investigation support other studies that associate P. intermedia with both endodontic disease and chronic adult periodontal disease. The results also support studies that implicate P. gingivalis as a periodontopathogen
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High fracture probability with FRAX(registered trademark) usually indicates densitometric osteoporosis: Implications for clinical practice
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Management of Hip Fractures in the Elderly
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Summary Most patients designated as high risk of fracture using fracture risk assessment tool (FRAX(registered trademark)) with femoral neck bone mineral density (BMD) (i.e., 10-year major osteoporotic fracture probability exceeding 20% or hip fracture exceeding 3%) have one or more T-scores in the osteoporotic range; conversely, almost no high risk patients have normal T-scores at all bone mineral density measurement sites. Introduction We determined the agreement between a FRAX(registered trademark) designation of high risk of fracture [defined as 10-year major osteoporotic fracture probability ((greater-than or equal to)20%) or hip fracture probability ((greater-than or equal to)3%)] and the WHO categorizations of bone mineral density according to T-score. Methods Ten-year FRAX(registered trademark) probabilities calculated with femoral neck BMD were derived using both Canadian and US white tools for a large clinical cohort of 36,730 women and 2,873 men age 50 years and older from Manitoba, Canada. Individuals were classified according to FRAX fracture probability and BMD T-scores alone. Results Most individuals designated by
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Adaptation of Turkish version of the questionnaire Quick Disability of the Arm, Shoulder, and Hand (Quick DASH) in patients with carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The aim of this study was to assess the reliability and validity of the Turkish version of the Quick Disability of the Arm, Shoulder, and Hand (Quick DASH) scale in patients with carpal tunnel syndrome (CTS). Sixty nine patients with idiopathic CTS were included. The Quick DASH questionnaire consists of three subscales including disability/symptom, and work and sports/performing arts. Quick DASH was administered after translation process to subjects twice a week for testing reliability. The validity was based on correlating Quick DASH with the Boston Questionnaire, visual analogue scale-pain (VAS-pain), and pinch and grip strength tests. Reliability of the Turkish version of the Quick DASH scale was very good with high internal consistency (Cronbach's alpha 0.84 for disability/symptom subscale, 0.937 for work subscale, and 0.926 for sports/performing arts subscale) and test-retest reliability (intraclass correlation coefficient 0.931 for disability/symptom subscale, 0.925 for work subscale, and 0.779 for sports/performing arts subscale). The disability/symptom subscale had moderate correlations with the VAS-pain and grip strength test and good correlation with the pinch strength test. The work subscales had moderate correlations with VAS-pain, and pinch and pinch grip strength tests. A high correlation was found between the disability/symptom and work subscales with Boston symptom severity and Boston functional status subscores. The Turkish version of Quick DASH was reliable and valid for evaluating symptoms and functional disability in patients with CTS. Our results suggest that Quick DASH could be preferred as it is a simple and easy scale to use
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Instrumented gait analysis in patients with medial osteoarthritis of the knee after mobile-bearing unicompartmental knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Unicompartmental knee arthroplasty (UKA) is an effective treatment for patients with medial osteoarthritis of the knee joint. Instrumented gait analysis provides an objective measure to quantify and qualify postoperative changes of gait. The purpose of this study was to evaluate standardized instrumented gait analysis for functional recovery and gait as an outcome of mobile-bearing UKA in patients with medial osteoarthritis of the knee. Methods: Twenty-one patients with isolated medial osteoarthritis of the knee joint received mobile-bearing UKA. They were examined by a gait analysis before surgery and after an average follow-up time of seven months. Gait analysis was performed on a treadmill with six infrared-cameras to identify changes of gait characteristics (e.g., velocity, stride time, stride length, knee adduction and hip abduction). Results: Mean velocity (chosen by individuals) increased from 0.61 to 0.76 m/s and further significant advancements, particularly in the knee adduction and the hip abduction were detected. Time and length of strides improved significantly as well as the clinical scores American Knee Society Score (AKSS), Oxford-12, Hannover Functional Ability Questionnaire for Osteoarthritis (FFbH-OA) Score and Devane Score. Conclusion: Mobile-bearing UKA can restore physiological axis of the leg and improve gait and function of the knee joint. The combination of instrumented gait analysis with clinical scores constitutes an eligible measuring instrument to quantify and qualify changes in patientsâ?? gait patterns.
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The cost of fall related presentations to the ED: a prospective, in-person, patient-tracking analysis of health resource utilization
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HipFx Supplemental Cost Analysis
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We prospectively collected data on elderly fallers to estimate the total cost of a fall requiring an Emergency Department presentation. Using data collected on 102 falls, we found the average cost per fall causing an Emergency Department presentation of $11,408. When hospitalization was required, the average cost per fall was $29,363. INTRODUCTION: For elderly persons, falls are a major source of mortality, morbidity, and disability. Previous Canadian cost estimates of seniors' falls were based upon administrative data that has been shown to underestimate the incidence of falls. Our objective was to use a labor-intensive, direct observation patient-tracking method to accurately estimate the total cost of falls among seniors who presented to a major urban Emergency Department (ED) in Canada. METHODS: We prospectively collected data from seniors (>70 years) presenting to the Vancouver General Hospital ED after a fall. We excluded individuals who where cognitively impaired or unable to read/write English. Data were collected on the care provided including physician assessments/consultations, radiology and laboratory tests, ED/hospital time, rehabilitation facility time, and in-hospital procedures. Unit costs of health resources were taken from a fully allocated hospital cost model. RESULTS: Data were collected on 101 fall-related ED presentations. The most common diagnoses were fractures (n = 33) and lacerations (n = 11). The mean cost of a fall causing ED presentation was $11,408 (SD: $19,655). Thirty-eight fallers had injuries requiring hospital admission with an average total cost of $29,363 (SD: $22,661). Hip fractures cost $39,507 (SD: $17,932). Among the 62 individuals not admitted to the hospital, the average cost of their ED visit was $674 (SD: $429). CONCLUSIONS: Among the growing population of Canadian seniors, falls have substantial costs. With the cost of a fall-related hospitalization approaching $30,000, there is an increased need for fall prevention programs
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Analgesia after total knee replacement: local infiltration versus epidural combined with a femoral nerve blockade: a prospective, randomised pragmatic trial
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AAHKS (9/10) Regional Nerve Blocks
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In a randomised controlled pragmatic trial we investigated whether local infiltration analgesia would result in earlier readiness for discharge from hospital after total knee replacement (TKR) than patient-controlled epidural analgesia (PCEA) plus femoral nerve block. A total of 45 patients with a mean age of 65 years (49 to 81) received a local infiltration with a peri-articular injection of bupivacaine, morphine and methylprednisolone, as well as adjuvant analgesics. In 45 PCEA+femoral nerve blockade patients with a mean age of 67 years (50 to 84), analgesia included a bupivacaine nerve block, bupivacaine/hydromorphone PCEA, and adjuvant analgesics. The mean time until ready for discharge was 3.2 days (1 to 14) in the local infiltration group and 3.2 days (1.8 to 7.0) in the PCEA+femoral nerve blockade group. The mean pain scores for patients receiving local infiltration were higher when walking (p = 0.0084), but there were no statistically significant differences at rest. The mean opioid consumption was higher in those receiving local infiltration. The choice between these two analgesic pathways should not be made on the basis of time to discharge after surgery. Most secondary outcomes were similar, but PCEA+femoral nerve blockade patients had lower pain scores when walking and during continuous passive movement. If PCEA+femoral nerve blockade is not readily available, local infiltration provides similar length of stay and similar pain scores at rest following TKR.
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High healing rate of stable femoral condyle osteochondritis dissecans in young patients placed in a hinged knee brace locked in extension: a retrospective study
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Osteochondritis Dissecans 2020 Review
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We report the rate of stable femoral condyle osteochondritis dissecans (OCD) lesion healing in adolescents using a locked hinged knee brace for a minimum of 6 weeks or until pain free, followed by physical therapy. Patients aged 5-18 at the time of a primary diagnosis of femoral condyle OCD were reviewed. Patients who presented with an unstable lesion necessitating surgery, lacked follow-up >6 months after diagnosis or before symptoms resolution, or were noncompliant were excluded. We assessed progression to surgery, association between surgery and lesion size, lesion grade, symptoms, laterality, and patient factors. Lesion width and depth and condyle size were measured on X-ray and MRI, and the scaled size of the lesion relative to the condyle was calculated. Sixty-four patients were included: 12.5% (n = 8; 50% female; mean age = 12.5 ± 1.0 years) progressed to surgery and 87.5% (n = 56; 20% female; mean age=11.5 ± 1.9 years) healed. No significant effects were identified between groups. The surgical group compared to the non-surgical group was braced for a similar amount of time (72.6 ± 51.4 vs. 54.9 ± 23.2 days; P = 0.09), presented initially with a similar lesion size (322.5 ± 298.7 vs. 211.2 ± 178.4 mm2; P = 0.14), and had a similar proportion of Grade 1 lesions (63% vs. 85%; P = 0.11). Female sex (P = 0.04) and longer time in the brace (P = 0.04) were associated with progression to surgery.
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Side effects during continuous epidural infusion of morphine and fentanyl
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Surgical Management of Osteoarthritis of the Knee CPG
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Respiratory effects, nausea, somnolence, and pruritus were compared during a 48-hr period of continuous epidural morphine (n = 34) and fentanyl (n = 32) infusion in 66 patients following elective total replacement of the hip or knee joint. Respiratory effects were assessed by PaCO2. Side effects were assessed by visual analogue scale and considered to be present when the score was above 30. Assessment was made at preoperative visits then 3, 6, 12, 24, 36, and 48 hr after the epidural injection. The bolus dose and subsequent infusion rate were 3,900 +/- 1,300 micrograms and 427 +/- 213 micrograms.hr-1 for morphine, and 85 +/- 46 micrograms and 56 +/- 27 micrograms.hr-1 for fentanyl. Pain relief was similar in both groups. In the morphine group, PaCO2 elevation and nausea occurred over a period of more than 12 hr (P less than 0.05). In the fentanyl group, there was no PaCO2 change, and nausea was confined to the first few hours. Nausea was more severe (P less than 0.01 at six hours and more frequent (24 hr cumulative incidence, 53 vs 28%, P less than 0.05) in the morphine group. Somnolence was prominent within several hours in two-thirds of patients in both groups. Somnolence continued to decline thereafter in the morphine group, but it was demonstrable in approximately half of the patients throughout the second day in the fentanyl group. The incidence was higher in the fentanyl group at the 48th hr (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Abnormal achromatic and chromatic contrast sensitivity in neurofibromatosis type 1
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Upper Eyelid and Brow Surgery
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PURPOSE: Neurofibromatosis type 1 (NF1) is a monogenic disorder with the majority of patients presenting subtle to moderate cognitive impairments. Visuospatial deficits are considered to be one of the hallmark characteristics of their cognitive profile. However, low-level visual processing has not been previously investigated. Our aim was to study contrast perception in these patients to assess the function of early visual areas. METHODS: Contrast sensitivity was tested in 19 children and adolescents with NF1 and 33 control children and adolescents and 12 adults with NF1 and 24 control adults. The tasks used probed two achromatic spatiotemporal frequency channels and chromatic red-green and blue-yellow pathways. RESULTS: Individuals with NF1 showed significant contrast sensitivity deficits for the achromatic higher spatial frequency channel [F((1),(8)(3)) = 36.1, P < 0.001] and for the achromatic low spatial high temporal (magnocellular) frequency channel [F((1),(7)(2)) = 8.0, P < 0.01]. Furthermore, individuals with NF1 presented a significant deficit in chromatic red-green (parvocellular) contrast sensitivity (P < 0.01) but not in blue-yellow (koniocelular) sensitivity. The decrease in achromatic sensitivity for higher spatial frequency was observed throughout the visual field, in both central and peripheral locations. In contrast, central contrast sensitivity for the magnocellular-biased condition was relatively preserved and only peripheral sensitivity was affected. Interestingly, the same pattern of deficits was found in both age groups tested. CONCLUSIONS: These findings showed that contrast sensitivity is impaired in patients with NF1, associating for the first time abnormal low-level vision to the cognitive profile of this disorder.
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Short-term radiographic result of cementless hemiarthroplasty using tapered wedge-shaped femoral component in older patients with femoral neck fractures
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Hip Fx in the Elderly 2019
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Objective: To evaluate the short-term radiographic results of cementless hemiarthroplasty using a tapered wedge-shaped femoral component in elderly patients with displaced femoral neck fracture. Specifically, the authors assessed the prevalence of intraoperative crack and rate of subsidence associated with tapered wedge-shaped femoral component in patients with femoral neck fracture. Material and Method: Medical records were reviewed of 154 patients that underwent cementless hemiarthroplasty using tapered wedge-shaped femoral component between January 2009 and December 2012. Ninety-five patients had immediate postoperative and 12-month or greater postoperative follow-up radiographs available for reviewing. The average length of radiographic follow-up was 29.8 months. Radiographs from these 95 patients were reviewed to evaluate for intraoperative crack, stability, and subsidence of the femoral component. Results: From 154 patients, 30 (19.5%) had intraoperative crack of the femoral neck, all of whom were successfully treated with cerclage wiring. The majority of intraoperative crack (86.7%) occurred in patients who were implanted with Corail® stem. Five patients (5.3%) had subsidence greater than 2 mm. Mean subsidence in these five patients was 5.4 mm. No patient was revised due to femoral stem loosening. Conclusion: Cementless hemiarthroplasty using a tapered wedge-shaped femoral component design is a viable option for treating femoral neck fracture in elderly patients. However, tapered wedge-shaped femoral component, particularly the Corail® stem, is associated with a high incidence of intraoperative crack in these patients population.
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Oral–Gut Microbiota, Periodontal Diseases, and Arthritis: Literature Overview on the Role of Probiotics
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AMP (Acute Meniscal Pathology)
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Periodontal diseases are oral inflammatory diseases affecting the tissues supporting and surrounding the teeth and include gingivitis and periodontitis. Oral pathogens may lead to microbial products spreading into the systemic circulation and reaching distant organs, while periodontal diseases have been related to low-grade systemic inflammation. Gut and oral microbiota alterations might play a role in the pathogenesis of several autoimmune and inflammatory diseases including arthritis, considering the role of the gut–joint axis in the regulation of molecular pathways involved in the pathogenesis of these conditions. In this scenario, it is hypothesized that probiotics might contribute to the oral and intestinal micro-ecological balance and could reduce low-grade inflammation typical of periodontal diseases and arthritis. This literature overview aims to summarize state-of-the-art ideas about linkages among oral–gut microbiota, periodontal diseases, and arthritis, while investigating the role of probiotics as a potential therapeutic intervention for the management of both oral diseases and musculoskeletal disorders.
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The associations between cognitive dysfunction, stress biomarkers, and administered anesthesia type in total knee arthroplasties: Prospective, randomized trial
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AAHKS (9/10) Regional Nerve Blocks
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Background: Postoperative cognitive dysfunction (POCD) is a serious complication associated with total knee arthroplasty (TKA) and has been shown to increase the length of hospital stay, cause functional impairment, and morbidity. Objectives: We aimed to determine whether POCD is associated with the use of general or regional anesthesia in patients undergoing TKA. Our hypothesis was that POCD would be reduced in the group that received regional analgesia without any sedations. Our secondary hypothesis was POCD would be associated with biomarkers of surgical stress. Study Design: Randomized controlled study between general and spinal anesthesia. Setting: Single-centered, university hospital, from January to October 2017. Methods: A total of 112 patients were assessed for eligibility, and a total of 57 patients completed the study. We divided the patients into general and regional anesthesia groups. Blood samples were obtained preoperatively at the first intraoperative, the third and the 24th postoperative hour. C-reactive protein (CRP), cortisol, insulin, and blood glucose levels were tested. We used 4 neurocognitive tests that were administered 1 day before operation, 7 days and 30 days after operation. Main outcome measures were neurocognitive tests scores for regional anesthesia without sedation and general anesthesia groups. Cortisol, glucose, insulin, and CRP levels. Results: Patients who received regional anesthesia showed significantly higher Mini-Mental State Examination (MMSE) scored compared with the general anesthesia at the seventh day (P = 0.037). In the general anesthesia group, patients showed significantly higher variations for the Stroop number difference. There were negative correlations between MMSE scores measured at postoperative day 7 and the 1-hour intraoperative cortisol measurements (r = -0.302; P = 0.022) and 3-hour postoperative cortisol measurements (r = -0.295; P = 0.026). Limitations: A limitation was the small number of patients. Conclusions: We demonstrate that regional anesthesia results in better neurocognitive test scores than general anesthesia in patients undergoing TKA. Patients who received regional anesthesia showed lower cortisol, higher insulin, and lower glucose levels. We recommend that patients who undergo arthroplasty surgeries should receive regional anesthesia to avoid POCD at the early stages of the postoperative period.
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Extra-articular distal radius malunion: The phosphate cement alternative
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Distal Radius Fractures
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UNLABELLED: Five consecutive patients (mean age: 40.4 yrs (range, 19-58 yrs)), with symptomatic distal radius malunion underwent corrective opening wedge osteotomy using phosphate cement as an alternative to bone autograft, at a mean 9 months (4-16mo) of fracture. Internal fixation used a plate placed just above the distal radioulnar joint, with soft-tissue release. Radiographic and functional parameters were measured before surgery, and at 6 months and 1 year. At a mean 32.4 months (range, 16-47mo), all patients were satisfied and all the osteotomies were united. At 1 year's follow-up, wrist range of motion reached 75% compared to the contralateral side. Two biopsies performed during plate removal showed osteoid tissue at the cement-bone junction. It is reasonable to consider injectable phosphate cement as a viable alternative to bone grafting in conjunction with surgical correction of distal radius malunion.
LEVEL OF EVIDENCE: level IV.
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Geriatric consultation in elderly hip fracture patients
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Management of Hip Fractures in the Elderly
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Introduction.- To assess the effects of the assignment of a part-time geriatric consultant to the trauma unit of the Hospital of Segovia for patients over 75 admitted for surgical treatment of hip fracture. Methods.- Control group (188 patients admitted in 2007 received traditional care) was compared with intervention group (60 patients admitted between January and May 2011 evaluated daily by a geriatric consultant). SPSS 11 was the statistics program used to analyse results. Results.- Statistically relevant differences between intervention and control group were: - same age (mean 85.97 SD 6.131, 20% < 80 years, 57% 80-90 years and 23% > 90 years) and sex (76% female); - reduction of average stay of 13.46 to 11.45 (P 0.040) and preoperative hospital stay of 4.62 to 3.82 (P 0.012). Intervention group showed the following characteristics: - 15.5% received only medical management and no patient proposed for surgery was refused. Ten percent died at hospital; - comorbidity: 31% neurological disease, 68% dementia, 27% visual impairment, 31.7% hearing impairment, 58.2% heart disease, 30% pulmonary disease, 33.9% diabetes, 45% malnutrition, 27% rheumatic disease, 31% previous fracture; - complications: 26% heart failure, 26% respiratory infection, 18% urinary tract infection, 53% blood transfusion; - before fracture, 27% could walk down the street on their own, 21% walked with a cane and 7.4% with one person, 11.8% could only walk at home with a cane, 17.6% with a walker, 7.4% with one person aid and 3.2% couldn't stand up. At discharge, 1.5% walk down the street with a cane, 7.7% with a cane at home, 21.2% with a walker at home, 3.8% with one person aid, 25% transferred with personal aid and 40% couldn't stand up; - 57.8% lived at home. Ten patients (16%) required admission to a nursing home at discharge, only one patient (1.7%) to a public nursing home. Conclusions.- Most patients admitted for surgical treatment of hip fracture are very old, with important disability and comorbidity. Geriatric intervention can reduce hospital stay and preoperative time by evaluating patients early and daily. Effects have no relationship with early discharge to neither rehabilitation units nor nursing homes
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Gender-specific associations between soy and risk of hip fracture in the Singapore Chinese Health Study
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Management of Hip Fractures in the Elderly
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Although there is some epidemiologic evidence that soy may reduce risk of osteoporotic fracture in women, it is not known whether this risk reduction also occurs for men. The authors examined gender-specific associations between soy intake and hip fracture risk in the Singapore Chinese Health Study, a prospective cohort of 63,257 Chinese living in Singapore. At recruitment between 1993 and 1998, each subject was administered a food frequency questionnaire and questions on medical history and lifestyle factors. As of December 31, 2006, 276 incident cases of hip fracture in men and 692 cases in women were identified via linkage with hospital discharge databases. For both genders, hip fracture risk was positively associated with cigarette smoking and was inversely associated with body mass index. There was a statistically significant association of tofu equivalents, soy protein, and isoflavones with hip fracture risk among women but not among men. Compared with women in the lowest quartile of intakes for tofu equivalents (<49.4 g/day), soy protein (<2.7 g/day), and isoflavones (<5.8 mg/1,000 kcal/day), those in the second-fourth quartiles exhibited 21%-36% reductions in risk (all P < 0.036). Risk levels were comparable across the second, third, and fourth quartiles of soy intake categories
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Analysis of hip dysplasia and spinopelvic alignment in cerebral palsy
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Developmental Dysplasia of the Hip 2020 Review
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BACKGROUND CONTEXT: Knowledge of sagittal spinopelvic parameters and hip dysplasia is important in cerebral palsy (CP) patients because these parameters differ from those found in the general population and can be related to symptoms. PURPOSE: The purpose of this study was to analyze sagittal spinopelvic alignment and determine its relation to hip dysplasia in CP patients. STUDY DESIGN: Radiological analysis was conducted on patients with CP. PATIENT SAMPLE: Fifty-four patients with CP and 24 normal controls were included in this study. OUTCOME MEASURES: Participants underwent radiographs of the whole spine. METHODS: The patient and control groups comprised 54 CP patients and 24 volunteers, respectively. All underwent lateral radiography of the whole spine and hip joint anteroposterior radiography. The radiographic parameters examined were sacral slope, pelvic tilt, pelvic incidence, S1 overhang, thoracic kyphosis, thoracolumbar kyphosis, lumbar lordosis, sagittal balance, center edge angle, acetabular angle, and migration index. Statistical analysis was performed to identify significant differences and correlations between the two groups. RESULTS: Sacral slope, thoracolumbar kyphosis, lumbar lordosis, sagittal balance, acetabular angle, and migration index were significantly higher in CP patients, whereas pelvic tilt, S1 overhang, and center edge angle were significantly lower (p<.05). Correlation analysis revealed that pelvic incidence, sacral slope, pelvic tilt, and S1 overhang were related to each other and that thoracolumbar kyphosis was related to the thoracic kyphosis and lumbar lordosis (p<.05). For spinal and pelvic parameters, lumbar lordosis was related to sacral slope, pelvic incidence, pelvic tilt, and S1 overhang; for hip dysplasia parameters, center edge angle and acetabular angle were found to be interrelated (p<.05). Regarding symptoms, pelvic tilt, S1 overhang, and thoracolumbar kyphosis were found to be correlated with symptom severity in patients. However, no hip dysplasia parameters were found to be related to hip or spinal symptoms. CONCLUSIONS: This study found significant differences between CP patients and normal controls in terms of spinopelvic alignment and hip dysplasia. Furthermore, relationships were found between the sagittal spinopelvic parameters and hip dysplasia, and correlations were found between sagittal spinopelvic parameters and pain.
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Posttraumatic elbow deformities in children
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Pediatric Supracondylar Humerus Fracture 2020 Review
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In the last 20 years 49 children with gross posttraumatic elbow deformities have been treated in our hospital: 19 patients with an overlooked radial head dislocation, 12 children with a radial condyle deformity and 19 patients with a severe radial head deformity. Secondary treatment: In the majority of cases secondary surgical procedures led to unsatisfying results. Only 4 patients with a pseudarthrosis of the radial condyle were treated secondarily. Surgical fixation led to good functional results but was not able to remove the joint deformity. Overlooked radial head dislocations were treated by ulnar osteotomy in 17 cases. We were able to follow up 13 of these: a redislocation had taken place in 8 of them. Functional impairment was found in 6 redislocated cases and in 2 children with a correct position of the radial head. In patients with gross radial head deformities arthrolysis was performed. The radial head had to be taken out in 7 cases. Functional results of pro- and supination were unsatisfactory. Initial treatment and causes: Persistent dislocations of the radial head had been overlooked initially. In 9 out of 12 cases with a radial condyle deformity a conservatively treated dislocated fracture had led to a pseudarthrosis. In the remaining 2 cases the fracture fragments had been fixated in an incorrect position. Radial head deformities were seen after dislocated radial head fractures which had been treated by open reduction, internal fixation, longterm immobilization (6-8 weeks) and excessive physiotherapy. CONCLUSION: In 47 out of 49 cases posttraumatic deformities were either caused by delayed an neglected treatment or traumatic and excessive therapy methods. An adequate initial diagnosis and therapy can prevent more than 90 % of severe posttraumatic elbow deformities in children.
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Emerging role of long noncoding RNAs in recurrent hepatocellular carcinoma
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Dental Implant Infection
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Hepatocellular carcinoma (HCC) remains one of the most frequent types of liver cancer and is characterized by a high recurrence rate. Recent studies have proposed that long non-coding RNAs (lncRNAs) are potential biomarkers in several recurrent tumor types. It is now well understood that invasion, migration, and metastasis are important factors for tumor recurrence. Moreover, some of the known risk factors for HCC may affect the expression levels of several types of lncRNAs and thus affect the recurrence of liver cancer through lncRNA regulation. In this paper, we review the biological functions, molecular mechanisms, and roles of lncRNAs in HCC and summarize current knowledge about lncRNAs as potential biomarkers in recurrent HCC.
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A National Multicenter Study on overall survival in elderly metastatic castrate-resistant prostate cancer patients treated with Radium-223
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Radium-223 prolongs overall survival (OS) and delays time to the first symptomatic skeletal events in patients with symptomatic metastatic castration-resistant prostate cancer (mCRPC). There is a lack of evidence on the safety and efficacy of Radium-223 treatment in the very elderly population.
AIMS: Aim of this multicentre study is to analyze mCRPC patients treated with Radium-223 in terms of OS and to assess whether there are differences between young and elderly, as well as to verify efficacy and safety in patients >= 75 years of age.
METHODS: 430 mCRPC patients of six Italian Centres were analyzed in this multicenter retrospective study. At baseline and after each cycle were collected clinical and diagnostic patients' parameters. The whole cohort was divided into two groups based on the age of the patients (< 75 years old and >= 75 years old).
RESULTS: 47% of the patients were < 75 years old and 53% were >= 75 years old. The primary outcome, OS, does not show significant differences between the two subgroups if other basal parameters are considered. Considering clinical covariates in univariate models (p < 0.05) several clinical aspects have an impact on OS, except for age (p = 0.072). Age continues to have no significant impact on the OS (p = 0.274) even in multivariate models in the two groups. The toxic effects are similar in the two groups.
CONCLUSIONS: Radium-223 prolongs survival in both younger and older patients at the same baseline condition and is a good option in the symptomatic mCRPC setting compared to other agents.
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The Impact of Resident Postgraduate Year Involvement in Body-Contouring and Breast Reduction Procedures: A Comprehensive Analysis of 9638 Patients
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Reduction Mammoplasty for Female Breast Hypertrophy
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Given the rising popularity in body-contouring procedures (BCPs) in the United States, it is important to assess the currently unknown association between resident involvement and postoperative complications. As such, the aim of this study was to evaluate the impact of resident involvement on outcomes in BCPs using a large national database. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed (2006-2012) to identify patients undergoing BCPs, using relevant Current Procedural Terminology codes. Outcome measures included postoperative complications, hospital length of stay, and operation time.Multivariate regression models were used to assess the impact of resident involvement and resident experience on outcomes. RESULTS: A total of 9638 cases were identified, of which 3311 involved resident participation.Resident involvement was associated with significantly higher rates of complications (7.8% vs 4.4%; P = 0.003) and longer operation times (180.7 vs 171.9 minutes; P = 0.005). For each year increase of resident postgraduate year, there was a significant decrease in odds of complications (odds ratio, 0.906; P = 0.013) and operative time (-2.7 minutes; P = 0.001). CONCLUSIONS: Resident involvement in BCPs was associated with an increased rate of overall complications in a large, national database. However, the clinical significance of these outcomes may be debated. Increased postgraduate year experience as a surgical resident was inversely associated with overall complications. Guided resident autonomy and earlier exposure to BCPs could lead to an optimization of clinical outcomes and resident education.
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Activities of clotting, fibrinolytic, and anticoagulant components of plasma hemostasis in patients with degenerative diseases of large joints
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OAK 3 - Non-arthroplasty tx of OAK
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Analysis of plasma hemostasis parameters was carried out in 110 patients with degenerative diseases of hip or knee joints hospitalized for initial endoprosthetics. Molecular markers of clotting and fibrinolysis and physiological anticoagulants were studied. Activities of all components of plasma hemostasis were normal in 29.4% patients. In 54.1% patients, high clotting activity was compensated for by adequate fibrinolysis activity. High thrombin formation was compensated for by high consumption of physiological anticoagulants in 10.1% patients. In 6.4% patients, high clotting activity was not paralleled by high fibrinolytic activity. © 2012 Springer Science+Business Media, Inc.
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The role of activity, adherence, and off-loading on the healing of diabetic foot wounds
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DoD LSA (Limb Salvage vs Amputation)
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The etiology of diabetic foot ulcerations is commonly associated with the presence of peripheral neuropathy and repetitive trauma due to normal walking activities to areas of the foot exposed to moderate or high pressure. The goal of any treatment plan should include as a central tenet the mitigation or modulation of this activity and/or pressure. While numerous studies have detailed the potential pressure off-loading properties of various treatment modalities, subsequent studies have suggested that, if easily removable, these therapies will likely not be used for the majority of steps taken each day. This serves to explain at least in part the often disappointing results of both these pressure off-loading technologies and advanced wound-healing therapies. This article reviews these data and suggests that an amalgam of effective pressure relief coupled with strategies to reduce nonadherence to this therapy could yield a potentially favorable clinical result. Copyright ©2006 by the American Society of Plastic Surgeons.
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Nutritional issues in nursing home care
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HipFx Supplemental Cost Analysis
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The most common nutritional problems in nursing home residents are weight loss and concomitant protein energy undernutrition. Although the causes of weight loss in these patients can usually be treated, they are rarely identified in the nursing home. Depression and adverse drug effects are the most common causes of weight loss. We discuss the appropriate use of feeding tubes in the nursing home and the early use of enteral feeding to prevent the development of severe protein energy undernutrition. Vitamin deficiencies, especially folate and pyridoxine deficiencies, frequently develop in nursing home residents. Hip fractures are often associated with vitamin D deficiency. Trace mineral deficiencies (for example, zinc deficiency) can aggravate immune deficiency and slow wound healing. Inadequate fluid intake leads to dehydration, hypotension, and, in persons with diabetes mellitus, hyperosmolarity. Finally, food intake itself can cause postprandial hypotension (which in turn may precipitate falls), produce electrolyte shifts, and result in aspiration pneumonia. Physical activity programs are an important component of nursing home care that may have an effect on nutritional status, and simple, cost-effective programs may be as beneficial as high-technology programs. Careful attention to the nutritional intake of nursing home residents is both a clinical and a quality-of-life issue
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1 |
The use of bisphosphonates in patients with breast cancer
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: Bone is the most common site of breast cancer metastases. Skeletal metastases may be associated with harmful and painful events such as fractures, spinal cord compression, and hypercalcemia. By inhibiting osteoclasts and bone resorption, bisphosphonates can interrupt the process of bone destruction and decrease the risk of skeletal complications.
METHODS: A review of the literature was undertaken regarding the use of bisphosphonates in breast cancer management, with particular attention to prospective, randomized clinical trials that have influenced the treatment of bone metastases.
RESULTS: Large prospective, randomized trials have demonstrated that bisphosphonates are effective in reducing skeletal-related complications from metastatic breast cancer.
CONCLUSIONS: For many patients with osseous lesions from breast cancer, bisphosphonate therapy is a useful intervention in managing their disease. Bisphosphonates are the treatment of choice for hypercalcemia of malignancy and bisphosphonates reduce the risk of pathologic fractures, spinal cord compromise, the need for radiation or surgery to bone, and bone pain. [References: 49]
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The effects of low level laser in clinical outcome and neurophysiological results of carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVES: Carpal tunnel syndrome (CTS) is the most common neuropathy that can be diagnosed with confidence by the nerve conduction study (NCS). One of the recent treatments of CTS is the application of low power laser (LPL) therapy. The present study evaluates the effects of LPL irradiation through NCS and clinical signs and symptoms. METHODS: A total of 80 patients were included in this study. Diagnosis of CTS was based on both clinical examination and electromyographic (EMG) findings. Patients were randomly assigned into two groups. Test group (group A) underwent laser therapy (9-11 joules/cm2) over the carpal tunnel area. Control group (group B) received sham laser therapy. Pain, hand grip strength, median proximal sensory and motor latencies, transcarpal median sensory nerve conduction (SNCV) were recorded. After fifteen sessions of irradiation (five times per week), parameters were recorded again and clinical symptoms were measured in both groups. Pain was evaluated by Visual Analog Scale (VAS; day-night). Hand grip was measured by Jamar dynometer. Paired t-test and independent sample t-test were used for statistical analysis. RESULTS: There was a significant improvement in clinical symptoms and hand grip in group A (p < 0.001). Proximal median sensory latency, distal median motor latency and median sensory latencies were significantly decreased (p < 0.001). Transcarpal median SNCV increased significantly after laser irradiation (p < 0.001). There were no significant changes in group B except changes in clinical symptoms (p < 0.001). CONCLUSIONS: Laser therapy as a new conservative treatment is effective in treating CTS paresthesia and numbness and improves the subjects' power of hand grip and electrophysiological parameters
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1 |
Effect of an orally formulated processed black cumin, from Iranian traditional medicine pharmacopoeia, in relieving symptoms of knee osteoarthritis: A prospective, randomized, double-blind and placebo-controlled clinical trial
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OAK 3 - Non-arthroplasty tx of OAK
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AIM: Osteoarthritis is a global health problem, especially for the elderly. A good replacement for non-surgical treatments is the use of traditional medicines. We selected a revere plant (Nigella sativa L.), a widely utilized medicinal herb for the treatment of inflammatory conditions, from the Iranian traditional medicine (ITM) pharmacopoeia with proven anti-inflammatory and analgesic actions.
METHODS: We performed a prospective, randomized, double-blind, and placebo-controlled clinical trial, in order to investigate whether the herb is useful in alleviating the symptoms of knee osteoarthritis. American College of Rheumatology clinical criteria were the basis of diagnosis, while the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire was considered as the main outcome measure. One hundred and ten eligible patients were assigned to receive a placebo or an active intervention (2 g/day of processed N. sativa seed powder in divided doses). Acetaminophen tablets were the rescue medicine. Finally, 40 patients in the placebo group and 37 patients in the active group completed the trial and were included in the statistical analysis.
RESULTS: Both cohorts demonstrated statistically significant within-group differences (P < 0.05) in some subscales that were more prominent in the active group without any considerable adverse effects. Nevertheless, KOOS score results and the mean number of acetaminophen tablets used by patients showed no statistically significant between-group differences.
CONCLUSIONS: It can be concluded that future programmed studies with larger sample sizes, longer follow-up periods, and other forms of N. sativa seeds as an active intervention is necessary to evaluate its efficacy in relieving the symptoms of knee osteoarthritis.
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Patient-specific instrumentation for total shoulder arthroplasty: not as accurate as it would seem
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Glenohumeral Joint OA
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BACKGROUND: There is an increasing body of literature suggesting that the use of patient-specific instrumentation (PSI) in total shoulder arthroplasty (TSA) results in improved positioning of the glenoid component. The aim of this in vivo study was to assess the accuracy of PSI of the glenoid component in TSA in a consecutive series at a single center.
METHODS: Eleven consecutive TSAs (7 TSAs and 4 reverse TSAs) were performed using custom-made patient-specific positioning guides for the glenoid component. Each patient had preoperative computed tomography scans and guides produced to allow 0degree of glenoid inclination and version in anatomic TSAs and 10degree of inferior inclination for reverse TSAs. Postoperative computed tomography imaging was performed to determine accuracy of component implantation. Patients were observed to the 1-year mark.
RESULTS: For the conventional TSA group, the mean version was measured at 8degree +/- 10degree retroversion and 1degree +/- 4degree inclination. For reverse TSAs, mean version was 10degree +/- 10degree retroversion and -1degree +/- 5degree inclination. There were 5 cases classified as outliers in terms of version (>10degree anteversion or retroversion). We had a mean correction of version of 22degree +/- 9degree and 17degree +/- 9degree in inclination compared with preoperative measurements.
CONCLUSION: Our results suggest that the in vivo accuracy of PSI-guided glenoid positioning is not as successful as suggested in the literature.
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A comparison of 0.2 and 0.5 mg intrathecal morphine for postoperative analgesia after total knee replacement
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AAHKS (4) Acetaminophen
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The optimal dose of intrathecal morphine for postoperative analgesia after major surgery is a matter of debate, with some uncertainty concerning the therapeutic potential and safety of intrathecal morphine in the dose range 0.3-1.0 mg. This randomised double-blind study compared the efficacy and side-effect profile of 0.2 mg and 0.5 mg intrathecal morphine in 70 patients undergoing knee replacement surgery. The primary endpoint was the number of patients requiring rescue analgesia (tramadol) during the first 24 h postoperatively. Secondary endpoints included consumption of tramadol and the incidence of adverse effects. Fewer patients in the 0.5-mg group required rescue analgesia in the first 24 h than in the 0.2-mg group (16 (48%) vs 28 (85%), respectively; p = 0.003). Median (IQR [range]) tramadol consumption was lower in the 0.5-mg group than in the 0.2-mg group (0 (0-100 [0-350]) mg vs 100 (50-100 [0-350]) mg, respectively; p = 0.02). The incidence of adverse effects was similar in both groups. This study has demonstrated that 0.5 mg intrathecal morphine produces better analgesia than 0.2 mg after knee replacement without any increase in side-effects.
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Outcome of antimicrobial therapy in documented biofilm-associated infections: A review of the available clinical evidence
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Dental Implant Infection
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Numerous laboratory findings indicate that microbial biofilms may be encountered in several types of human infections, affecting the activity of antimicrobial agents. We evaluated the clinical evidence regarding the effectiveness of antimicrobial therapy for infections documented to be biofilm-associated, by performing a review of 15 relevant studies, excluding dental and eye infections. In a clinical trial, a significant difference was noted in the effectiveness of antibacterial agents used for catheter-related urinary tract infections in which substantial bacterial adherence on uroepithelial cells was observed. In case series and case reports, 28 patients with biofilm-associated infections documented by electron microscopy scanning were identified. Infection sites included ear, urinary tract, CNS, bloodstream and foreign body implantation site. Pseudomonas and Staphylococcus spp. were the predominant microorganisms among the bacterial or fungal causative pathogens. In 24 cases, infections related to the presence of foreign bodies. Treatment failure or recurrence was noted in all eight patients in whom targeted antimicrobial therapy was instituted before foreign body removal. Foreign body removal coupled with antimicrobial therapy was effective in all ten relevant cases. In four cases of native tissue urinary tract infections, the outcome of the initial antimicrobial therapy was poor. The limited available relevant clinical evidence indicates that conventional antimicrobial therapy alone is not adequately effective against documented biofilm-associated infections. Although some regimens might be more appropriate in this setting, further research on novel therapeutic strategies is needed to improve the outcome of patients with biofilm-associated infections. © 2009 Adis Data Information BV. All rights reserved.
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Clinical characteristics and prognostic factors in Chinese patients with classical Hodgkin's lymphoma involving extranodal sites: a retrospective single-center
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MSTS 2022 - Metastatic Disease of the Humerus
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<b>Objectives</b>: To analyze the clinical characteristics and prognostic factors in Chinese patients with classical Hodgkin's lymphoma (cHL) involving extranodal sites. <b>Methods</b>: Clinical features and outcomes of 68 patients diagnosed with cHL involving extranodal sites from April 2003 to November 2017 were analyzed retrospectively. The data was compared with that of 76 cHL patients without extranodal involvement in the same period. <b>Results</b>: (1) Extranodal involvement was common in Chinese cHL patients. The most common sites were lung (44.1%) and bone (33.8%), followed by bone marrow, liver, pericardium, pleura and other sites. (2) With a median follow-up period of 4.58 years, the 5-year overall survival (OS) of 68 patients with extranodal involvement was significantly poorer than that of 76 patients with only nodal involvement (81.4% vs. 92.8%, p = 0.018). (3) In univariate analysis, lymphocytopenia (p = 0.027), elevated lactate dehydrogenase (LDH) (p = 0.026) and involved lymph node region (LNR) >=4 (p = 0.044) predicted inferior freedom from progression (FFP) with significant difference. Elder age (p = 0.010), elevated LDH (p = 0.013), elevated platelet (p = 0.044), involved LNR >= 4 (p = 0.047) were also statistically significant in OS. Extranodal sites and number of extranodal sites showed no significant difference in FFP and OS. Factors with p-value smaller than 0.100 were evaluated in multivariate analysis, turning out that lymphocytopenia was the only independent adverse prognostic factor in FFP (p = 0.039; HR = 2.595) and OS (p = 0.028; HR = 4.993). <b>Conclusion</b>: Extranodal involvement was frequent in Chinese cHL patients, with lung to be the most commonly involved site. Lymphocytopenia was the only independent adverse prognostic factor.
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MRI detection of forearm soft tissue injuries with radial head fractures
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Distal Radius Fractures
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BACKGROUND: This study aims to evaluate the incidence of forearm soft tissue abnormalities associated with radial head fracture severity based on the Mason classification system.
METHODS: Eighteen patients (age 18-45 years) were prospectively evaluated with elbow radiographs and magnetic resonance imaging (MRI) following longitudinal forearm trauma. MRI was performed within 10 days of the initial injury. Radiographs and MR images were evaluated in a blinded fashion by two musculoskeletal radiologists.
RESULTS: Thirteen of 18 patients presented with Mason type I radial head fractures. In all patients with Mason type I fractures, the interosseous membrane (IOM) was intact. Two patients had Mason type II fractures with associated partial and compete tearing of the IOM and three patients had Mason type III fractures with complete tearing of the IOM. Edema was noted in the pronator quadratus in six of 13 type I injuries and seen in all type II and III injuries. No structural forearm soft tissue abnormalities were present in patients with Mason type I injuries. The presence of edema within the pronator quadratus correlated with distal forearm pain.
CONCLUSIONS: The severity of radial head fracture correlates with longitudinal forearm injury evidenced by the presence of IOM tearing. The findings suggest patients with Mason type II or III fractures of the radial head should undergo further evaluation of the forearm for associated soft tissue injuries. Edema within the pronator quadratus was present following forearm trauma regardless of the severity of fracture and was related to symptomatic forearm pain.
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Combined circular external fixation and open reduction internal fixation with pro-syndesmotic screws for repair of a diabetic ankle fracture
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DoD LSA (Limb Salvage vs Amputation)
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The surgical management of ankle fractures among the diabetic population is associated with higher complication rates compared to the general population. Efforts toward development of better methods in prevention and treatment are continuously evolving for these injuries. The presence of peripheral neuropathy and the possible development of Charcot neuroarthropathy in this high risk patient population have stimulated much surgical interest to create more stable osseous constructs when open reduction of an ankle fracture/dislocation is required. The utilization of multiple syndesmotic screws (pro-syndesmotic screws) to further stabilize the ankle mortise has been reported by many foot and ankle surgeons. In addition, transarticular Steinmann pins have been described as an adjunct to traditional open reduction with internal fixation (ORIF) of the ankle to better stabilize the talus, thus minimizing risk of further displacement, malunion, and Charcot neuroarthropathy. The authors present a unique technique of ORIF with pro-syndesmotic screws and the application of a multi-plane circular external fixator for management of a neglected diabetic ankle fracture that prevented further deformity while allowing a weight-bearing status. This techniqu may be utilized for the management of complex diabetic ankle fractures that are prone to future complications and possible limb loss.
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1 |
Effect of surgical delay on bacterial colonization in proximal humeral fractures
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DoD SSI (Surgical Site Infections)
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Postoperative infection is a severe complication after proximal humeral fracture surgical treatment. The aim of this study was to determine if the surgical delay could modify the number and type of bacteria on the surgical site. A two stages study was set up. In the first stage the effect of delay was simulated in 20 patients affected by proximal humeral fracture treated conservatively. In a second stage, the effect of delay was measured in 20 patients that underwent surgery. In stage 1, three skin culture swabs were taken in correspondence of the deltopectoral approach, the day of the fracture (day 0), the day after (day 1), and five days after fracture (day 5). In stage 2, skin swab cultures were taken the day of trauma and immediately before surgery and cultured on various media suitable for aerobic and anaerobic bacteria. The number of bacteria increased over the course of the study, from day 0 to day 5, both considering the total number of colony-forming units and individual species of pathogen bacteria. The second stage of the study confirmed these data. An increasing number of bacteria was observed in patients that underwent surgery later than 2 days from trauma. The delay of surgery increased bacterial colonization of the skin in the deltopectoral approach area including common pathogenic bacteria such as Staphylococcus aureus, coagulase-negative staphylococci and Propionibacterium acnes. This might justify the correlation between delay to surgery and risk of infection. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:942-948, 2016.
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Avascular necrosis of the femoral head in sickle cell syndrome: a report of 5 cases
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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The course and management of avascular necrosis of the femoral head (AVNFH) in six hips of 5 sickle cell syndrome patients (3 with Hb SS, 1 with Hb SC and 1 with Hb S/beta+-thalassaemia) are described. Two patients (aged 13 and 17 years) presented with Perthes- and osteochondritis dessicans-type lesions. These hips progressed to roller-bearing-type joints with good function and no pain following conservative management of weight restriction and rest. Three patients (aged 14, 22 and 30 years at original presentation) suffered whole-head necrosis. Initially, these 3 patients had four hip joints replaced, two cemented-stemmed types, one cemented double-cup and one uncemented hemi-arthroplasty. All four joints failed and were revised 21-61 months after the original operation. One of the revision hips has now failed and is awaiting further surgery. These results demonstrate that it is very difficult to achieve a successful hip arthroplasty in the sickle cell syndrome patient
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Probabilistic Approach for Determining the Material Properties of Meniscal Attachments In Vivo Using Magnetic Resonance Imaging and a Finite Element Model
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PJI DX Updated Search
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The material properties of in vivo meniscal attachments were evaluated using a probabilistic finite element (FE) model and magnetic resonance imaging (MRI). MRI scans of five subjects were collected at full extension and 30 degrees , 60 degrees , and 90 degrees flexion. One subject with radiographic evidence of no knee injury and four subjects with Kellgren-Lawrence score of 1 or 2 (two each) were recruited. Isovoxel sagittal three-dimensional cube sequences of the knee were acquired in extension and flexion. Menisci movement in flexion was investigated using sensitivity analysis based on the Monte Carlo method in order to generate a subject-specific FE model to evaluate significant factors. The material properties of horn attachment in the five-subject FE model were optimized to minimize the differences between meniscal movements in the FE model and MR images in flexion. We found no significant difference between normal and patient knees in flexion with regard to movement of anterior, posterior, medial, and lateral menisci or changes in height morphology. At 90 degrees flexion, menisci movement was primarily influenced by posterior horn stiffness, followed by anterior horn stiffness, the transverse ligament, and posterior cruciate ligament. The optimized material properties model predictions for menisci motion were more accurate than the initial material properties model. The results of this approach suggest that the material properties of horn attachment, which affects the mobile characteristics of menisci, could be determined in vivo. Thus, this study establishes a basis for a future design method of attachment for tissue-engineered replacement menisci
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Mesenteric visceral lipectomy using tissue liquefaction technology reverses insulin resistance and causes weight loss in baboons
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Visceral obesity is associated with diabetogenic and atherogenic abnormalities, including insulin resistance and increased risk for cardiometabolic diseases and mortality. Rodent lipectomy studies have demonstrated a causal link between visceral fat and insulin resistance, yet human omentectomy studies have failed to replicate this metabolic benefit, perhaps owing to the inability to target the mesentery. OBJECTIVES: We aimed to demonstrate that safe and effective removal of mesenteric fat could be achieved in obese insulin-resistant baboons using tissue liquefaction technology. SETTING: Southwest National Primate Research Center, San Antonio, Texas. METHODS: Tissue liquefaction technology has been developed to enable mesenteric visceral lipectomy (MVL) to be safely performed without disturbing the integrity of surrounding nerves and vessels in the mesentary. After an initial MVL optimization study (n = 3), we then performed MVL (n = 4) or sham surgery (n = 2) in a cohort of insulin-resistant baboons, and the metabolic phenotype was assessed via hyperinsulinemic-euglycemic clamps at baseline and 6 weeks later. RESULTS: MVL led to a 75% improvement in glucose disposal at 6-weeks follow-up (P = .01). Moreover, despite removing only an average of 430 g of mesenteric fat (~1% of total body mass), MVL led to a 14.4% reduction in total weight (P = .001). Thus, these data demonstrate that mesenteric fat can be safely targeted for removal by tissue liquefaction technology in a nonhuman primate, leading to substantial metabolic improvements, including reversal of insulin resistance and weight loss. CONCLUSIONS: These data provide the first demonstration of successful adipose tissue removal from the mesentery in a mammal. Importantly, we have demonstrated that when MVL is performed in obese, insulin-resistant baboons, insulin resistance is reversed, and significant weight loss occurs. Therefore, trials performing MVL in humans with abdominal obesity and related metabolic sequelae should be explored as a potential clinical tool to ameliorate insulin resistance and treat type 2 diabetes.
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Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Purpose: In view of the positive outcome of orthodontic treatment using rapid maxillary expansion (RME) on sleep-disordered breathing, we generated data on RME in children with obstructive sleep apnea (OSA) by evaluating objective and subjective data over a 36-month follow-up period, to determine whether RME is effective in the long-term treatment of OSA. We selected all patients with dental malocclusions and OSA syndrome (OSAS) confirmed by polysomnography. Methods: Ten of the 14 children who completed the 12-month therapeutic trial using RME were enrolled in our follow-up study. The study was performed 24 months after the end of the RME orthodontic treatment. We enrolled all children presented with deep, retrusive or crossbite at the orthodontic evaluation. All subjects underwent an overnight polysomnography at the baseline, after 1 year of treatment and 24 months after the end of the orthodontic treatment. The children's mean age was 6.6(plus or minus)2.1 years at entry and 9.7(plus or minus)1.6 years at the end of follow-up. Results: After treatment, the apnea hypopnoea index (AHI) decreased and the clinical symptoms had resolved by the end of the treatment period. Twenty-four months after the end of the treatment, no significant changes in the AHI or in other variables were observed. Conclusions: RME may be a useful approach in children with malocclusion and OSAS, as the effects of such treatment were found to persist 24 months after the end of treatment. (copyright) 2011 Springer-Verlag
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Menopause and Rheumatic Disease
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OAK 3 - Non-arthroplasty tx of OAK
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Menopause occurs naturally in women at about 50 years of age. There is a wealth of data concerning the relationship of menopause to systemic lupus erythematosus, rheumatoid arthritis, and osteoarthritis; there are limited data concerning other rheumatic diseases. Age at menopause may affect the risk and course of rheumatic diseases. Osteoporosis, an integral part of inflammatory rheumatic diseases, is made worse by menopause. Hormone replacement therapy has been studied; its effects vary depending on the disease and even different manifestations within the same disease. Cyclophosphamide can induce early menopause, but there is underlying decreased ovarian reserve in rheumatic diseases.
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Assessment of clinical risk factors to validate the probability of osteoporosis and subsequent fractures in Korean women
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Management of Hip Fractures in the Elderly
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This cross-sectional, observational study was designed to identify clinical risk factors of osteoporosis and fractures in Korean women to validate the probability of osteoporosis and subsequent fractures. A total of 1541 Korean women were recruited nationally. Fracture history of any site, risk factors of osteoporosis, and fall-related risk factors were surveyed and physical performance tests were conducted. Peripheral dual-energy X-ray absorptiometry was used to measure calcaneus bone mineral density (BMD). The number of positive responses on the modified 1-min osteoporosis risk test was related to the risk of osteoporosis. The frequency of osteoporosis was higher in those with a height reduction of >4 cm and a reduced body mass index (BMI). Multivariate analysis showed that older age and lower BMI were related to higher relative risk of osteoporosis. Time required to stand up from a chair and questions related to fall injury were significantly related to clinical fracture history of any site. Multivariate analysis showed that the relative risk of fractures at any site was higher in older subjects with a lower T-score and parental hip fracture history. This study shows that age and BMI are the most significant clinical risk factors for osteoporosis and that age, BMD, and parental history of hip fracture are highly applicable risk factors for validating the probability of osteoporotic fractures in Korean women
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Catastrophic failure after open reduction internal fixation of femoral neck fractures with a novel locking plate implant
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To determine if the use of a novel proximal femoral locking plate could reduce the incidence of femoral neck shortening and improve clinical outcomes after open reduction internal fixation (ORIF) for femoral neck fractures as compared with historical controls. DESIGN: Single surgeon, retrospective case-control study. SETTING: Academic level I trauma center. PATIENTS/PARTICIPANTS: Twenty-one femoral neck fractures treated with the posterolateral femoral locking plate (Synthes, Inc, Paoli, PA) were eligible for inclusion. Eighteen met inclusion/exclusion criteria with a mean follow-up of 16 months. INTERVENTION: ORIF of femoral neck fracture with the posterolateral femoral locking plate. This consists of a side plate with multiple locking screws directed into the femoral head at converging/diverging angles and a single shaft screw. Intraoperative compression was achieved with partially threaded screws before locking screw insertion. MAIN OUTCOME MEASUREMENTS: Maintenance of reduction was assessed by comparing immediate postoperative and final follow-up radiographs. Clinical outcome was assessed with Harris Hip Scores after 1 year. Complications and secondary operations were noted. RESULTS: Seven (36.8%) of 18 patients experienced catastrophic failure. Five of these patients required total hip replacement, whereas the remaining 2 died before further treatment. The remaining 11 patients (61.1%) achieved bony union; the average displacement of the center of the head did not differ when compared with historical controls (0.78 mm inferiorly, 1.62 mm medially, and 2.4 degrees of increased varus vs. 0.86 mm, 1.23 mm, and 0.6 degree). Complications in this group include 1 instance of screw fracture, 2 total hip replacements, and a peri-implant subtrochanteric femur fracture. The average patient age and proportion of displaced fractures did not differ between the historical control and experimental groups. Fracture displacement was strongly associated with catastrophic failure in the experimental group only. Average Harris Hip Scores was significantly worse compared with that of historical controls (67.9 vs. 84.7, P = 0.05)
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Chronic kidney disease can increase the risk of preoperative deep vein thrombosis in middle-aged and elderly patients with hip fractures
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Hip Fx in the Elderly 2019
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Background: Preoperative deep vein thrombosis (DVT) is a common complication in patients with hip fractures. Chronic kidney disease (CKD) as a frequent comorbidity in middle-aged and elderly patients with hip fractures is known to promote a proinflammatory and prothrombotic state. We aimed to identify whether CKD can increase the risk of DVT in middle-aged and elderly patients with hip fractures, as well as identify other risk factors.
Patients and methods: We retrospectively studied 248 middle-aged and elderly patients with hip fractures who were admitted to our hospital from January 2016 to June 2017, meeting all the inclusion criteria. Doppler ultrasonography was used to diagnose DVT. Patients with CKD were classified into five stages according to the Kidney Diseases Outcomes Quality Initiative. We identified whether CKD could increase the occurrence of preoperative DVT in middle-aged and elderly patients with hip fractures and further investigated other independent risk factors for preoperative DVT by using univariate and multivariate analyses.
Results: The mean estimated glomerular filtration rate was 125.7+/-41.4 mL/min/1.73 m<sup>2</sup>. Briefly, 82.3% (n=204) had been diagnosed with normal kidney function, 11.7% (n=29) with mildly decreased kidney function, and 6.0% (n=15) with stage 3 and 4 CKD. In addition, of the 248 patients, 11.7% (n=29) developed DVT before surgery. Independent predictors of preoperative DVT identified by multivariate analyses were age, prolonged bedridden time, increased levels of fibrinogen, and lower estimated glomerular filtration rate.
Conclusion: CKD can increase the risk rate of preoperative DVT in middle-aged and elderly patients with hip fractures. Additionally, age, prolonged bedridden time, and increased levels of fibrinogen were also independent risk factors for preoperative DVT in these patients. We should take preventive measures for these patients with risk factors in order to reduce the incidence of preoperative DVT.
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Avascular necrosis of femoral head associated with connective tissue disease in Nigerians: Case series
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PJI DX Updated Search
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BACKGROUND: Avascular Necrosis (AVN) or osteonecrosis has been frequently reported among Nigerians with sickle cell disease. Other known aetiologies include connective tissue diseases, alcohol, fat embolism, juvenile arthritis and pregnancy. Connective tissue disease (CTD) are uncommonly reported among Nigerians. OBJECTIVE: To report the cases of three Nigerian female patients with radiological evidence of AVN associated with connective tissue diseases and inflammatory arthritis who presented to a rheumatology hospital in Lagos, Nigeria. METHODS: The first patient was a 36-year-old woman who was initially diagnosed as systemic lupus erythematosus (SLE). After four years of treatment, she presented with intense pain in the left hip, which on radiograph showed AVN. She was initially treated with NSAIDS and narcotic analgesics. She eventually had a left hip replacement. The second patient was a 44-year-old female, who had presented seven years earlier with features of SLE. She had attended the clinic irregularly. She later developed pain in both hips and shortening of left lower limb over the preceding three years. Radiographs confirmed AVN. She was treated with analgesics. The third patient was an 18-year-old female undergraduate who had rheumatoid arthritis (RA) and later developed bilateral hip pain which on radiograph showed bilateral AVN. She was placed on analgesics and then referred for orthopaedic surgery. CONCLUSION: Osteonecrosis may be associated with connective tissue diseases. A high index of suspicion is needed for the diagnosis, especially in SLE and RA patients with prolonged hip pain not responding to immunosuppressive
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Improving stability of elastic stable intramedullary nailing in a transverse midshaft femur fracture model: biomechanical analysis of using end caps or a third nail
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Pediatric Diaphyseal Femur Fractures 2020 Review
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BACKGROUND: Elastic stable intramedullary nailing (ESIN) is accepted widely for treatment of diaphyseal femur fractures in children. However, complication rates of 10 to 50 % are described due to shortening or axial deviation, especially in older or heavier children. Biomechanical in vitro testing was performed to determine whether two modified osteosyntheses with end caps or a third nail could significantly improve the stability in comparison to classical elastic stable intramedullary nailing in a transverse femur fracture model. METHODS: We performed biomechanical testing in 24 synthetic adolescent femoral bone models (Sawbones®) with a transverse midshaft (diaphyseal) fracture. First, in all models, two nails were inserted in a C-shaped manner (2 � 3.5 mm steel nails, prebent), then eight osteosyntheses were modified by using end caps and another eight by adding a third nail from the antero-lateral (2.5-mm steel, not prebent). Testing was performed in four-point bending, torsion, and shifting under physiological 9° compression. RESULTS: The third nail from the lateral showed a significant positive influence on the stiffness in all four-point bendings as well as in internal rotation comparing to the classical 2C configuration: mean values were significantly higher anterior-posterior (1.04 vs. 0.52 Nm/mm, p < 0.001), posterior-anterior (0.85 vs. 0.43 Nm/mm, p < 0.001), lateral-medial (1.26 vs. 0.70 Nm/mm, p < 0.001), and medial-lateral (1.16 vs. 0.76 Nm/mm, p < 0.001) and during internal rotation (0.16 vs. 0.11 Nm/°, p < 0.001). The modification with end caps did not improve the stiffness in any direction. CONCLUSIONS: The configuration with a third nail provided a significantly higher stiffness than the classical 2C configuration as well as the modification with end caps in this biomechanical model. This supports the ongoing transfer of the additional third nail into clinical practice to reduce the axial deviation occurring in clinical practice.
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A Survey of High- and Low-Energy Acetabular Fractures in Elderly Patients
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Hip Fx in the Elderly 2019
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Introduction: Geriatric patients represent 14% of acetabular fractures and are the fastest growing subset of patients affected by this injury in the US. Treatment outcomes have been reported as inferior to those achieved in younger patients after high-energy (HE) acetabular trauma. This study aimed to compare detailed demographic characteristics and clinical outcomes in elderly patients (�65 years of age) treated in a tertiary North American trauma center for acetabular fractures after both high- and low-energy mechanisms of injury. Methods: Patients (�65 years of age) diagnosed with an acetabular fracture were identified over a 7-year period. Patient and injury characteristics were extracted from our institutional trauma database. Length of stay, intervention, operative details, disposition, complications, readmissions, and mortality were analyzed. Results: One hundred nine patients were identified for inclusion. Low-energy mechanisms (simple falls) were found in 64 (58.7%) and HE mechanisms in 45 (41.3%) patients. The HE cohort was younger (74.6 vs 80.7 years; P <.001), had a higher male predominance (76% vs 56%; P =.10), a lower Charlson comorbidity index (1.29 ± 1.49 vs 2.16 ± 1.76; P =.01), and a higher injury severity score (19.90 ± 15.33 vs 6.46 ± 3.57; P <.001). Fracture patterns, described according to the Letournel-Judet classification, were similar between the 2 groups. Thirty-day mortality was significantly higher in the HE group (26.7% vs 3.1%; P <.001); however, the 1-year mortality rates were not statistically different (31.1% vs 25.0%; P =.20). Discussion: Patients with acetabular fractures sustained due to HE accidents demonstrate significantly higher 30-day mortality rate than patients with low-energy fractures, but similar mortality 1 year after the injury, despite having a much lower mean age and fewer comorbidities. Conclusion: Medical efforts made during initial hospital admission may have the biggest impact on survivorship following acetabular fracture.
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Circumstances of falls causing hip fractures in the elderly
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Management of Hip Fractures in the Elderly
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A prospective analysis was performed on 832 patients to determine the circumstances surrounding falls leading to hip fracture within a homogeneous, elderly urban population. Special emphasis was placed on the season of year, time of day, location of fall, and other circumstances in which the fracture occurred. All patients were community dwelling, cognitively intact, previously ambulatory elderly who sustained a femoral neck or intertrochanteric fracture. Most fractures occurred at home, particularly in patients who were older, less healthy, and poorer ambulators. More than 75% of fractures resulted from a fall while the patient was standing or walking. Most falls occurred during daylight hours with a peak seen in the afternoon. No seasonal variation in the incidence of hip fractures was observed
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Clinical Considerations for the Use Lower Extremity Arthroplasty in the Elderly
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AAHKS (2) Corticosteroids
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There is an increase in the aging population that has led to a surge of reported cases of osteoarthritis and a greater demand for lower extremity arthroplasty. This article aims to review the current treatment options and expectations when considering lower extremity arthroplasty in the elderly patient with an emphasis on the following subjects: (1) updated clinical guidelines for the management of osteoarthritis in the lower extremity, (2) comorbidities and risk factors in the surgical patient, (3) preoperative evaluation and optimization of the surgical patient, (4) surgical approach and implant selection, and (5) rehabilitation and life after lower extremity arthroplasty.
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Late Nontraumatic Dissociation of the Femoral Head and Trunnion in a Total Hip Arthroplasty
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PJI DX Updated Search
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Background. Modular total hip arthroplasties are increasingly popular because customisation allows optimal restoration of patient biomechanics. However, the introduction of component interfaces provides greater opportunities for failure. We present a case of late nontraumatic dissociation of the head-neck interface, more than 10 years after insertion. Case Description. A 58-year-old woman had a left metal-on-metal total hip arthroplasty in 2002 for hip dysplasia. Following an uneventful 10-year period, she presented to hospital in severe pain after standing from a seated position, and radiographs demonstrated complete dissociation of the modular femoral head from the stem, with the femoral head remaining in its cup. There was no prior trauma or infection. Mild wear and metallosis were present on the articulating surface between the femoral head and trunnion. Soft tissues were unaffected. Discussion and Conclusions. This is the latest occurrence reported to date for nontraumatic component failure in such an implant by more than 7 years. The majority of cases occur in the context of dislocation and attempted closed reduction. We analyse and discuss possible mechanisms for failure, aiming to raise awareness of this potential complication and encouraging utmost care in component handling and insertion, as well as the long term follow-up of such patients
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Comparative study between computer assisted-navigation and conventional technique in minimally invasive surgery total knee arthroplasty, prospective control study
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Surgical Management of Osteoarthritis of the Knee CPG
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Background: Both Minimally Invasive surgery (MIS) and Computer-Assisted Surgery (CAS) are useful in Total Knee Arthroplasty (TKA). Minimally invasive total knee arthroplasty was associated with decreased blood loss, shorter hospital stays, and increased range of motion. Computer-assisted surgery in total knee arthroplasty was developed to improve the positioning of implants during surgery. Objective: To evaluate radiographic results relative to component position and limb alignment when using a navigation system compared with conventional technique in MIS-TKA. Material and Method: A prospective control study was performed in 180 patients who underwent total knee arthroplasty by one surgeon. All patients were randomly divided into two groups, Conventional and Navigation TKA. Intra-, post-operative data, and postoperative limb alignment were recorded for comparison in both groups. Results: The postoperative mechanical axis was within 3(degrees) of neutral mechanical alignment in 94% of the navigation group and 87% in conventional group (p = 0.13). Registration time of navigation group is 13.58 minutes. No statistical significant difference was found in tourniquet time and postoperative blood loss in both groups. Conclusion: The use of navigation in total knee arthroplasty increases accuracy in limb and implants alignment, and does not increase complications and surgical times
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Radiographic evaluation of Baumann angle in Chinese children and its clinical relevance
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Normal Baumann angles in 98 children aged 2 to 13 years and abnormal Baumann angles in 71 children with supracondylar humeral fractures were evaluated. In healthy children, Baumann angles ranged from 64(degrees)to 80(degrees)(72.4(degrees)(plus or minus) 4.6(degrees)) in boys and from 65(degrees)to 81(degrees)(72.9(degrees)(plus or minus) 5.9(degrees)) in girls. A significant negative relation (P < 0.01) between Baumann angle and carrying angle was noted, but there were no significant differences in Baumann angles between boys and girls (P > 0.05) and no significant correlation of Baumann angle with increasing age (P > 0.05). In patients with fractures, the Baumann angle measured after immediate reduction correlated well with the carrying angle measured after union or at final follow-up (P < 0.01). This angle measured after reduction may be used to predict the final carrying angle so that cubitus varus deformity can be effectively prevented
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Changes in body heat during hip fracture surgery: a comparison of spinal analgesia and general anaesthesia
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Management of Hip Fractures in the Elderly
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Postoperative hypothermia initiates an increased oxygen demand in the postoperative period and may endanger patients with restricted cardiopulmonary reserves. In order to compare net heat losses and gains, we studied 28 women undergoing hip fracture surgery, using either general anaesthesia or spinal analgesia. The superficial and central temperatures were followed in the per- and postoperative period. Total body heat was calculated from temperature measurements. Temperature changes were unrelated to the type of anaesthesia. Large net heat losses occurred on transfer to the recovery room
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Pennsaid therapy for osteoarthritis of the knee: a systematic review and metaanalysis of randomized controlled trials
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SR for PM on OA of All Extremities
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OBJECTIVE: To systematically review published randomized controlled trials (RCT) evaluating a new topical diclofenac solution (Pennsaid) in patients with osteoarthritis (OA) of the knee. METHODS: RCT were identified by searching electronic data sources as well as by contact with the manufacturer of Pennsaid. Details of study demographics, methodology, quality, and outcomes were analyzed. A metaanalysis evaluating the efficacy and safety of Pennsaid in OA of the knee was performed. RESULTS: Four RCT were analyzed in this systematic review (3 published reports and one published abstract). Mean trial duration was 8.5 weeks. Generally, these RCT were of excellent quality. The mean Jadad quality score was 4.5 out of 5. Many indicators of high quality in a RCT were found in these RCT, including adequate descriptions of the methods used for randomization, blinding, and allocation concealment. In comparison to a vehicle control placebo (VCP), the standardized mean differences (SMD) for the WOMAC pain, stiffness, and physical function subscales, as well as for patient global assessment, were all statistically significant in favor of Pennsaid, with SMD ranging from 0.30 to 0.39. Pennsaid was as safe as VCP, with the only exception that it was more likely to result in minor skin dryness at the site of application (relative risk 1.7). In a 12 week equivalence trial that used the WOMAC subscales to compare treatment response, Pennsaid was as effective as oral diclofenac, but was much better tolerated. CONCLUSION: Pennsaid is an effective topical NSAID in patients with OA of the knee. Apart from minor localized skin reactions, Pennsaid was as safe as VCP. It is not known whether the favorable results of Pennsaid can be extrapolated to other topical NSAID preparations. Pennsaid deserves further consideration when the existing treatment guidelines for OA of the knee are updated
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Intravenous Versus Oral Acetaminophen in Primary Total Hip Arthroplasty
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AAHKS (2) Corticosteroids
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This is a single center, prospective, randomized controlled study. 60 subjects will be recruited (see #6 Recruitment and Compensation below). On the day of surgery, subjects will be randomized to receive either the study intervention (intravenous acetaminophen and placebo tablets) or the control intervention (intravenous saline and active acetaminophen tablets). The Investigational Drug Service will prepare each intervention package, which will include one intravenous and one oral medication dose. Only one of these routes will be active (determined by randomization). Subjects will receive doses of both an intravenous and oral study drug every 6 hours in order to maintain blinding, and will receive a total of 4 doses of each (at 0, 6, 12 and 18 hours). The dose of acetaminophen in all cases will be 1000 mg. The volume of intravenous acetaminophen (and saline) will be 100 mL. The oral dose will consist of two (2) tablets of 500 mg each (or two matching placebo tablets). All subjects will receive a standardized anesthetic regimen for total hip arthroplasty, as follows: A) Preoperative phase Subjects will receive the following preoperative multimodal drugs: â? Pregabalin 75 mg PO â? Celecoxib 200 mg PO â? The interventional drugs, both IV and PO . The time that these drugs are administered will be recorded as time zero. Patients will then receive a spinal anesthetic with 12.5 mg of isobaric bupivacaine. No peripheral nerve blocks will be performed. B) Intraoperative phase All subjects will be receive propofol infusion beginning at 50 mg/kg/min and titrated to a Richmond Agitationâ?Sedation Scale score of â?1 to â?3 (drowsy to moderate sedation). Dexamethasone 10 mg IV and ketamine 0.25 mg/kg IV up to 40 mg total will be administered as part of the standard multimodal regimen. If required, subjects may receive fentanyl 25 mcg IV as needed to treat discomfort. No joint infiltration will be performed by the surgeon. C) Postoperative phase In the Postâ?Anesthesia Care Unit (PACU), subjects will have an intravenous patientâ?controlled analgesia (IVPCA) device connected and loading doses of hydromorphone administered by the PACU nurse as necessary (0.2 mg q 8 min prn). On the floor, subjects will receive: â? Pregabalin 75 mg PO BID until discharge â? Celecoxib 200 mg PO BID until discharge â? Dexamethasone 10 mg IV x 1 on postoperative day 1 (24 hours after the first dose) â? Intravenous patientâ?controlled analgesia (IVPCA) with hydromorphone (0.2 mg q 8 min). The remaining 3 intervention packages (IV and PO) will be administered at 6, 12 and 18 hours following the first dose. At time point 24 hours (i.e. the fifth dose of acetaminophen), all subjects will begin to receive 975 mg of oral acetaminophen, continuing every six hours until discharge.
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PPARG , atranscription factor, regulates cartilage/bone development and homeostasis through the PTEN-AKT pathway
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Surgical Management of Osteoarthritis of the Knee CPG
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Aims: Long bones develop through a strict coordinated process of endochondral ossification within the growth plate resulting in the replacement of cartilage by bone and defect in this coordinated process may result in skeletal abnormalities such as dwarfism, kyphosis and also agerelated defects such as osteoarthritis (OA) and osteoporosis
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Patient satisfaction after total knee arthroplasty is affected by their general physical well-being
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: We hypothesise that patients with a worse post-operative generic physical health, and those with a subclinical improvement, will have a greater rate of dissatisfaction with their total knee arthroplasty (TKA) despite improvement in their knee function. Methods: Prospectively complied data for 2,330 primary TKA were used. Patient demographics, comorbidity, and pre- and post-operative (1 year) Oxford knee scores (OKS) and Short Form (SF-) 12 scores were collected. Patient satisfaction was also assessed 1 year post-operatively. The satisfaction rate of patients with a poor post-operative SF-12 physical component summary (PCS score) ((less-than or equal to)40 points) and those with a subclinical improvement (<4 points) in the score were compared to those with a score of more than 40 and a clinically significant improvement, respectively. Results: More than half of the patients (n = 1,220) had a poor post-operative SF-12 PCS, and a third (n = 722) had a subclinical improvement in their general physical health after TKA. These patients were more likely to be older in age, suffer with concomitant back pain, and pain in other joints, and have a significantly worse pre-operative mental well-being score (SF-12) and OKS (all p < 0.04 on regression analysis). Both groups had a clinically significant improvement in their OKS post-operatively (p < 0.001), but it was 10 and 8 points less, respectively, than those patients with a SF-12 PCS of more than 40, and a clinical significant improvement in their PCS score (p < 0.001). Logistic regression analysis demonstrated that patients who had a poor post-operative SF-12 PCS (odds ratio 7.9, p < 0.001) and those with a subclinical improvement in their general physical health (odds ratio 5.1, p < 0.001) after TKA were significantly less likely to be satisfied. Conclusion: Despite benefitting from a significant improvement in their OKS after TKA, patients with a poor post-operative SF-12 PCS and those with a subclinical improvement in their general physical well-being are significantly less likely to be satisfied at 1 year. Level of evidence: Retrospective comparative study, Level III. (copyright) 2013 Springer-Verlag Berlin Heidelberg
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Single versus staged epidural injections of 0.75% bupivacaine: pharmacokinetic and pharmacodynamic effects
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AAHKS (8) Anesthetic Infiltration
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Epidural anesthesia may be performed as a single injection or by staged doses. Thirty patients undergoing primary total hip replacement were randomly assigned to have epidural anesthesia using a single injection or a staged technique with 25 mL of 0.75% bupivacaine. Arterial plasma bupivacaine concentrations were significantly higher in the single injection group for the first 15 min but were not significantly different thereafter. Peak bupivacaine concentrations did not differ significantly between groups, but the time to achieve the peak concentration was delayed by staging injections (P = 0.001). Hemodynamic effects were similar between groups. Resolution of thoracic sensory block through T12 and duration of motor block measured by Bromage scale were both significantly longer in the staged injection group (P < 0.01). The method of epidural injection may affect resolution of neural block and the time to reach peak arterial plasma concentration of local anesthetic.
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Admission of nursing home residents to a hospital internal medicine department
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Management of Hip Fractures in the Elderly
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Objective: Hospitalization of nursing home residents is costly and potentially exposes residents to iatrogenic disease and psychological harm. Design and Setting: In this study, we analyzed the data from the Basic Minimum Data Set of patients hospitalized from the nursing home who were discharged from all the internal medicine departments at the National Health Service hospitals in Spain between 2005 and 2008, according to the data provided by the Ministry of Health and Consumer Affairs. Results: Between January 2005 and December 2008, 2,134,363 patients were admitted to internal medicine departments in Spain, of whom 45,757 (2.1%) were nursing home residents. Overall, 7898 (17.3%) patients died during hospitalization, 2442 (30.91%) of them in the first 48 hours. The following variables were the significant predictors of in-hospital mortality in multivariate analysis: age (odds ratio [OR] 1.02, 95% confidence intervals [CI] 1.02-1.03), female gender (OR 1.13, 95% CI 1.13-1.17), dementia (OR 1.09, 95% CI 1.03-1.16), previous feeding tube (OR 1.34, 95% CI 1.09-1.79), malignant disease (OR 2.03, 95% CI 1.86-2.23), acute infectious disease (OR 1.18, 95% CI 1.12-1.25), pressure sores (OR 1.88, 95% CI 1.62-1.95), acute respiratory failure (OR 2.00, 95% CI 1.90-2.10), and nosocomial pneumonia (OR 2.5, 95% CI 2.23-2.72). Conclusions: Two of every 100 patients admitted to internalmedicine departments came from nursing homes. The rate of mortality is very high in these patients, with almost one third of patients dying in the first 48 hours, which suggests that many of these transfers were unnecessary. The cost of these admissions for 1 year was equivalent to the annual budget of a 300- to 400-bed public hospital in Spain. The mechanism of coordination between nursing homes and public hospitals must be reviewed with the aim of containing costs and facilitating the care of patients in the last days of life. (copyright) 2012 American Medical Directors Association, Inc
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Current perspectives in mesenchymal stem cell therapies for osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Osteoarthritis (OA) is a degenerative joint disease most commonly occurring in the ageing population. It is a slow progressive condition resulting in the destruction of hyaline cartilage followed by pain and reduced activity. Conventional treatments have little effects on the progression of the condition often leaving surgery as the last option. In the last 10 years tissue engineering utilising mesenchymal stem cells has been emerging as an alternative method for treating OA. Mesenchymal stem cells (MSCs) are multipotent progenitor cells found in various tissues, most commonly bone marrow and adipose tissue. MSCs are capable of differentiating into osteocytes, adipocytes, and chondrocytes. Autologous MSCs can be easily harvested and applied in treatment, but allogenic cells can also be employed. The early uses of MSCs focused on the implantations of cell rich matrixes during open surgeries, resulting in the formation of hyaline-like durable cartilage. More recently, the focus has completely shifted towards direct intra-articular injections where a great number of cells are suspended and injected into affected joints. In this review the history and early uses of MSCs in cartilage regeneration are reviewed and different approaches in current trends are explained and evaluated.
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Single institution early experience with the bundled payments for care improvement initiative
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DoD SSI (Surgical Site Infections)
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The Centers for Medicare &Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physicianhospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle. For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.
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Treatment for displaced intracapsular fracture of the proximal femur. A prospective, randomised trial in patients aged 65 to 79 years
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Hip Fx in the Elderly 2019
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We performed a prospective, randomised trial comparing three treatments for displaced intracapsular fractures of the hip in 280 patients aged 65 to 79 years. The mean patient survival was significantly higher in the group undergoing reduction and internal fixation (79 months) compared with that with a cemented Thompson hemiarthroplasty or a cemented Monk bipolar hemiarthroplasty (61 months and 68 months, respectively). After three years, 32 of 93 patients (34.4%) who had undergone fixation had local complications, necessitating further intervention in 28 (30%). There were no significant differences in the functional outcome in survivors, who were reviewed annually to five years. Either reduction and internal fixation or cemented hemiarthroplasty may be offered as alternative treatments for a displaced intracapsular fracture in a mobile and mentally competent patient under the age of 80 years. The choice of procedure by the patient and the surgeon should be determined by the realisation that the use of internal fixation is associated with a 30% risk of failure requiring further surgery. If this is accepted, however, hemiarthroplasty is avoided, which, in our study has a significantly shorter mean survival time. The use of a bipolar prosthesis has no significant advantage.
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Load distribution in early osteoarthritis
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AMP (Acute Meniscal Pathology)
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Total knee replacement is an accepted standard of care for the treatment of advanced knee osteoarthritis with good results in the vast majority of older patients. The use in younger and more active populations, however, remains controversial due to concerns over activity restrictions, implant survival, and patient satisfaction with the procedure. It is in these younger patient populations that alternatives to arthroplasty are increasingly being explored. Historically, osteotomy was utilized to address unicompartmental pain from degeneration and overload, for example, after meniscectomy. Utilization rates of osteotomy have fallen in recent years due to the increasing popularity of partial and total knee arthroplasty. This article explores the indications and outcomes of traditional unloading osteotomy, as well as newer options that are less invasive and offer faster return to function.
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Making health care safer: a critical analysis of patient safety practices
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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OBJECTIVES: Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events. This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety. SEARCH STRATEGY AND SELECTION CRITERIA: Patient safety practices were defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions. Potential patient safety practices were identified based on preliminary surveys of the literature and expert consultation. This process resulted in the identification of 79 practices for review. The practices focused primarily on hospitalized patients, but some involved nursing home or ambulatory patients. Protocols specified the inclusion criteria for studies and the structure for evaluation of the evidence regarding each practice. Pertinent studies were identified using various bibliographic databases (e.g., MEDLINE, PsycINFO, ABI/INFORM, INSPEC), targeted searches of the Internet, and communication with relevant experts. DATA COLLECTION AND ANALYSIS: Included literature consisted of controlled observational studies, clinical trials and systematic reviews found in the peer-reviewed medical literature, relevant non-health care literature and "gray literature." For most practices, the project team required that the primary outcome consist of a clinical endpoint (i.e., some measure of morbidity or mortality) or a surrogate outcome with a clear connection to patient morbidity or mortality. This criterion was relaxed for some practices drawn from the non-health care literature. The evidence supporting each practice was summarized using a prospectively determined format. The project team then used a predefined consensus technique to rank the practices according to the strength of evidence presented in practice summaries. A separate ranking was developed for research priorities. MAIN RESULTS: Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery. Many patient safety practices drawn primarily from nonmedical fields (e.g., use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment. The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; Use of maximum sterile barriers while placing central intravenous catheters to prevent infections; Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; Asking that patients recall and restate what they have been told during the informed consent process; Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; Use of pressure relieving bedding materials to prevent pressure ulcers; Use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications; Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections. CONCLUSIONS: An evidence-based approach can help identify practices that are likely to improve patient safety. Such practices target a diverse array of safety problems. Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care
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Estrogens: Protective or risk factors in brain function?
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DoD PRF (Psychosocial RF)
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Over the past century, the average lifespan of women has increased from 50 to over 80 years, but the age of the menopause has remained fixed at 51 years. This "change of life" is marked by a dramatic and permanent decrease in circulating levels of ovarian estrogens. Therefore, more women will live a greater proportion of their lives in a chronic hypoestrogenic state. Ovarian steroid hormones are pleiotropic and have multiple, diverse, and possibly opposing actions in different contexts. In light of recent reports of the possible health risks of hormone replacement therapy (HRT) on several different physiological systems, the question of whether estrogens are protective or risk factors must be carefully re-evaluated. © 2003 Elsevier Science Ltd. All rights reserved.
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Extra-articular Mimickers of Lateral Meniscal Tears
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AMP (Acute Meniscal Pathology)
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CONTEXT: Lateral meniscus tears are a common entity seen in sports medicine. Although lateral-side knee pain is often the result of a meniscus injury, several extra-articular pathologies share signs and symptoms with a meniscus tear. It is critical for the clinician to be able to identify and understand extra-articular pathologies that can present similar to a lateral meniscus tear.
EVIDENCE ACQUISITION: Data were collected through a thorough review of the literature conducted through a MEDLINE search for all relevant articles between 1980 and February 2010.
STUDY TYPE: Clinical review.
RESULTS: Common extra-articular pathologies that can mimic lateral meniscal tears include iliotibial band syndrome, proximal tibiofibular joint instability, snapping biceps femoris or popliteus tendons, and peroneal nerve compression syndrome or neuritis. The patient history, physical examination features, and radiographic findings can be used to separate these entities from the more common intra-articular knee pathologies.
CONCLUSIONS: In treating patients who present with lateral-sided knee pain, clinicians should be able to recognize and treat extra-articular pathologies that can present in a similar fashion as lateral meniscus tears.
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Recovery, age, and gender effects on hand dexterity after a distal radius fracture. A 1-year prospective cohort study
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Distal Radius Fractures
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Study Design: A prospective cohort study. Introduction: Physical factors that predict hand dexterity and the recovery of hand dexterity after a distal radius fracture (DRF) have not yet been examined. Purpose of the Study: The first objective was to evaluate the recovery of hand dexterity comparing the injured and uninjured hands during the year after a DRF. The second objective was to determine the effect of age and sex on hand dexterity of the injured hand. Methods: Hand dexterity was examined bilaterally for the manipulation of 3 different sized objects (small, medium, and large) using the NK hand dexterity test. The measurements took place at 3, 6, and 12 months after DRF. Generalized linear modeling was performed, with age and sex as covariates, to assess changes over time, and between sides. Results: Overall, 242 patients with DRF (45 males and 197 females) with a mean age of 60.2 years with SD of 11.26, participated in the study. Statistical differences in hand dexterity were found between the injured and uninjured hands across all time intervals (P <.001). The effect size for the deficit between the injured and uninjured hands decreased across the time intervals and ranged from 0.19 to 0.38 for large objects, from 0.17 to 0.25 for medium objects, and from 0.11 to 0.32 for small objects. For each 1-year increase in age, hand dexterity scores were 0.3-0.4 seconds slower. Sex had much less effect, with annual increases of 0.1 seconds in hand dexterity scores. Conclusions: Scores on the NK dexterity test improved between 3 and 6 months and then worsened between 6 and 12 months; at no point did dexterity equal the uninjured side. Greater attention to measuring and treating dexterity may be needed to provide a complete recovery after DRF. Scores will be affected by age and sex. Level of Evidence: Prognosis, 2a.
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Outcome and structural integrity after arthroscopic rotator cuff repair using 2 rows of fixation: minimum 2-year follow-up
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Optimizing the Management of Full-Thickness Rotator Cuff Tears
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BACKGROUND: Although arthroscopic repairs of the rotator cuff are becoming increasingly popular, security of fixation remains a concern. Two-row repairs have been described, but clinical outcome reports have primarily involved open techniques. HYPOTHESIS: An arthroscopic repair technique that uses 2 rows of fixation produces satisfactory outcome and structural integrity by ultrasonography. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Forty-eight patients (52 shoulders) with a full-thickness, but fully reducible, rotator cuff tear who met the inclusion criteria were treated with an arthroscopic rotator cuff repair using 2 rows of suture anchors. The mean tear size was 2.47 cm (range, 1-4 cm). Patients were evaluated by subjective functional assessment (L'Insalata Shoulder Rating Questionnaire), clinical examination, including measured strength testing, and ultrasonography. RESULTS: At a mean follow-up of 30 months (minimum of 2 years), functional scores improved from a mean of 42 preoperatively to 93 postoperatively (P < .001). Active range of motion was increased in all measured planes (P < .001). Strength was also increased in elevation (P < .001), external rotation (P < .001), and internal rotation (P = .033). Nine of the 52 shoulders (17%) had evidence of retear or persistent defect on postoperative ultrasonography. There were no differences detected in functional scores between those with an intact repair and those with a defect, but those with an intact repair were stronger in elevation (P = .006) and external rotation (P = .001). CONCLUSION: An arthroscopic 2-row rotator cuff repair produces excellent functional outcome and repair integrity comparable with previously reported open repairs. Presence of a defect after repair did not appear to affect patient-reported function and return to preinjury activity but did affect measured strength
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Ultrasound plus low-level laser therapy for knee osteoarthritis rehabilitation: a randomized, placebo-controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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This study evaluated the synergistic effects of ultrasound (US) and low-level laser therapy (LLLT) with or without therapeutic exercises (TE) in women with knee osteoarthritis. Forty-two Caucasian women with knee osteoarthritis were allocated into three groups: (1) the placebo group who did not perform TE, but the prototype without emitting light or ultrasonic waves was applied, (2) the US + LLLT group in which only the prototype was applied and (3) the TE + US + LLLT group that performed TE before the prototype was applied. However, 35 women completed the full clinical trial. Pressure pain thresholds (PPT) using an algometer and functional performance during the sit-to-stand test were carried out. The average PPT levels increased for US + LLLT (41 +/- 9 to 54 +/- 15 N, p < 0.01) and TE + US + LLLT (32 +/- 8 to 45 +/- 9 N, p < 0.01) groups. The number of sit-to-stands was significantly higher for all groups. However, the change between pre-treatment and post-treatment (delta value) was greater for the US + LLLT (4 +/- 1) and TE + US + LLLT groups (5 +/- 1) than for the placebo group (2 +/- 1) with a significant intergroup difference (p < 0.05). This study showed reduced pain and increased physical functionality after 3 months of US + LLLT with and without TE.
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The Glasgow Prognostic Score predicts poor survival in cisplatin-based treated patients with metastatic nasopharyngeal carcinoma
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Several inflammation-based prognostic scoring systems, including Glasgow Prognostic Score (GPS), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) have been reported to predict survival in many malignancies, whereas their role in metastatic nasopharyngeal carcinoma (NPC) remains unclear. The aim of this study is to evaluate the clinical value of these prognostic scoring systems in a cohort of cisplatin-based treated patients with metastatic NPC.
METHODS: Two hundred and eleven patients with histologically proven metastatic NPC treated with first-line cisplatin-based chemotherapy were retrospectively evaluated. Demographics, disease-related characteristics and relevant laboratory data before treatment were recorded. GPS, NLR and PLR were calculated as described previously. Response to first-line therapy and survival data were also collected. Survival was analyzed in Cox regressions and stability of the models was examined by bootstrap resampling. The area under the receiver operating characteristics curve (AUC) was calculated to compare the discriminatory ability of each scoring system.
RESULTS: Among the above three inflammation-based prognostic scoring systems, GPS (P<0.001) and NLR (P = 0.019) were independently associated with overall survival, which showed to be stable in a bootstrap resampling study. The GPS consistently showed a higher AUC value at 6-month (0.805), 12-month (0.705), and 24-month (0.705) in comparison with NLR and PLR. Further analysis of the association of GPS with progression-free survival showed GPS was also associated independently with progression-free survival (P<0.001).
CONCLUSIONS: Our study demonstrated that the GPS may be of prognostic value in metastatic NPC patients treated with cisplatin-based palliative chemotherapy and facilitate individualized treatment. However a prospective study to validate this prognostic model is still needed.
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Intraosseous wire fixation versus rigid osseous fixation of mandibular fractures: a preliminary report
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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While wire osteosynthesis has been the accepted modality to use with open reduction of mandibular fractures, several authors have suggested the use of more rigid techniques to achieve the same result while also eliminating adverse effects associated with prolonged maxillomandibular fixation. Few studies have directly compared the two techniques in a prospective manner. The purpose of this paper was to evaluate complications seen with wire osteosynthesis versus a small bone plating system in management of mandibular fractures. The results suggest that small bone plating systems similar to the one used in this study may serve as a suitable alternative to wire osteosynthesis for the management of mandibular parasymphysis, body, and angle fractures. The length of the procedure, the length of hospital stay, and patient comfort were comparable with the two techniques. Factors that may contribute to failure are: location of the fracture, poor patient compliance, length of time from the trauma to the repair, antibiotic choice, and most importantly, operator skill and experience
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Ligasure impact() might reduce blood loss, complications, and re-operation occurrence after abdominoplasty in massive-weight-loss patients: A Comparative Study
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND AND AIMS:: The most effective dissection technique for raising the flap in abdominoplasty is still controversial, particularly in high-risk massive-weight-loss patients. LigaSure Impact() vessel-sealing system (Medtronic, Dublin, Ireland) is an energy device commonly used among different surgical specialties to reduce morbidity and implement outcomes. The aim of this study was to investigate the effectiveness of LigaSure Impact in abdominoplasty compared with the conventional techniques, diathermia. MATERIAL AND METHODS:: Patients underwent primary abdominoplasty after massive weight loss at a single center from 1 January 2008 to 31 May 2015 and were retrospectively reviewed. A total of 94 patients eligible for the study were divided into two groups on basis of the dissection technique: LigaSure Impact group (29 patients) and the conventional technique group (65 patients). Total intraoperative blood loss was the primary endpoint. Duration of the operation, perioperative complications and re-operation were recorded as secondary endpoints. RESULTS:: Baseline characteristics were well balanced between the groups. Significant differences were found in intraoperative blood loss favoring LigaSure Impact group (259.6 +/- 198.8 mL vs 377.9 +/- 190.0 mL, p = 0.004) and blood transfusion rates (13.8% vs 35.4%, p = 0.047). In contrast, operative time was significantly longer in LigaSure Impact group (168.6 +/- 121.2 vs 179.7 +/- 57.6 min, p = 0.005), while a tendency to shorter hospital stay was found in LigaSure Impact group (3.6 +/- 1.1 days vs 4.6 +/- 3.2 days, p = 0.081). Overall complications occurrence, Clavien-Dindo grade II (24.1% vs 55.4%) and grade III (13.8% vs 30.8%) complications were significantly lower in LigaSure Impact group (respectively, p = 0.005, p = 0.007, p = 0.016). Late (>30 days) re-operation rate was significantly lower in the LigaSure Impact group (6.9% vs 27.70%, p = 0.0028). Specific wound complications showed no significant difference. CONCLUSION:: LigaSure Impact vessel-sealing system may be beneficial in improving abdominoplasty outcomes in massive-weight-loss patients because it might reduce blood loss, need for transfusions, complications, and re-operations.
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Distal biceps tendon repair: anchor versus transosseous suture fixation
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Distal Radius Fractures
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Suture anchor fixation and transosseous suture fixation were compared in 12 fresh-frozen cadaveric radii using either No. 2 braided polyester suture or single Mainstay 3.5-mm threaded anchors (made at the time by Howmedica, Rutherford, NJ) with No. 2 suture. Suture fixation failed at a mean strength of 162 N (range, 129-179 N), anchor fixation at 136 N (range, 121-150 N). Neither technique is strong enough to safely allow immediate biceps activity. Nevertheless, suture anchor fixation to the radial tuberosity offers a lower but clinically comparable strength to transosseous suture fixation while limiting postoperative risks.
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Bone tumors in a tertiary care hospital of south India: A review 117 cases
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MSTS 2018 - Femur Mets and MM
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Background: Bone tumors remain a daunting challenge to orthopedic surgeons. The challenge is heightened in developing countries due to limited diagnostic and therapeutic facilities as well as due to ignorance. The published literature on this subject is sparse in our environment. Objective: To determine the pattern of bone tumors including their relative frequencies, age and sex distributions, anatomical sites of occurrence and clinico-pathological characteristics as seen in a tertiary care hospital of south India. Materials and Methods: This is a retrospective review of all the histologically confirmed bone tumors seen at JSS Medical College and Hospital, Mysore over an 8 year period: 2002 to 2009. Results: A total of 117 patients (aged 5 to 82 years) with a mean of age of 26.87 years were studied. Seventy-six patients (64.96%) were males and 41 (35.04%) were females. The peak age incidence for primary bone tumors was in the age group of 11-20 years and that for metastatic bone tumors was more than 60 years. Sixty-seven (57.26%) of the tumors were benign. Among these, osteochondroma was the most common, accounting for 26 cases (22.22%) followed by Giant cell tumor (24 cases, 20.51%). Osteosarcoma accounted for 35.14% (13 cases) of all the primary malignant tumors in the study. Lower end of femur was the most common site for primary bone tumors and accounted for 30 cases (25.64%) followed by upper end of tibia and fibula (24 cases, 20.51%). The most common site for metastatic bone tumors was upper end of femur including hip joint followed by spine. Conclusion: This study showed that primary bone tumors are mainly benign, occurred predominantly in the second decade of life with a male preponderance. Osteochondroma and osteosarcoma are the most common benign and primary malignant bone tumors, respectively. The most common primary foci for metastatic bone tumor are from the respiratory tract.
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Electrical stimuli in the central nervous system microenvironment
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Electrical stimulation to manipulate the central nervous system (CNS) has been applied as early as the 1750s to produce visual sensations of light. Deep brain stimulation (DBS), cochlear implants, visual prosthetics, and functional electrical stimulation (FES) are being applied in the clinic to treat a wide array of neurological diseases, disorders, and injuries. This review describes the history of electrical stimulation of theCNSmicroenvironment; recent advances in electrical stimulation of the CNS, including DBS to treat essential tremor, Parkinson's disease, and depression; FES for the treatment of spinal cord injuries; and alternative electrical devices to restore vision and hearing via neuroprosthetics (retinal and cochlear implants). It also discusses the role of electrical cues during development and following injury and, importantly,manipulation of these endogenous cues to support regeneration of neural tissue. Copyright (copyright) 2014 by Annual Reviews. All rights reserved
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Beta-2 microglobulin in peritoneal dialysis patients: Serum levels and peritoneal clearances
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Beta-2 microglobulin (B2M) is amyloidogenic in long-term hemodialysis patients, with amyloid deposition manifesting as lytic bone lesions, carpal tunnel syndrome, destructive arthropathies, tenosynovitis, and pathologic fractures. To study the behavior of this protein in the peritoneal dialysis population, serum levels of B2M from 14 chronic peritoneal dialysis (CPD) patients (4 IPD, 10 CAPD) were compared to those of 15 chronic hemodialysis patients, and peritoneal clearances were measured in 9 CAPD patients. Standard cuprophan dialyzers were used for hemodialysis. Serum B2M levels were significantly lower in the peritoneal dialysis group (mean (plus or minus) SD 73.2 (plus or minus) 20.9 mg/L) than in the hemodialysis group (100.3 (plus or minus) 24.7 mg/L, p < .004). When CAPD patients alone were compared to the hemodialysis patients, lower serum B2M levels were again apparent, with mean 68.7 (plus or minus) 16.4 mg/L (p (less-than or equal to) .002). Mean serum B2M in IPD patients (84.6 (plus or minus) 28.9 mg/L) did not differ statistically from either the CAPD or the hemodialysis group. Peritoneal clearance of B2M, urea nitrogen, and creatinine over a 6 h exchange were obtained in 9 CAPD patients without peritonitis. Mean clearance ((plus or minus)SD) of B2M was 0.9 (plus or minus) 0.4 ml/min/1.73 m(2), and creatinine 4.2 (plus or minus) 0.8 ml/min/1.73 m(2). Mean loss of B2M via the peritoneal cavity was 19.9 (plus or minus) 6.6 mg/2 L-exchange/1.73 m(2) (range 7.7 to 26.2 mg/2 L-exchange/1.73 m(2)). Decreased serum B2M in peritoneal dialysis patients is consistent with increased clearance by the peritoneal membrane versus standard cellulosic hemodialysis membranes. Whether use of CPD rather than hemodialysis can prevent or even treat dialysis-associated amyloidosis (A(B2M)) remains speculative
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The growth kinetics of synovial fibroblastic cells from inflammatory and noninflammatory arthropathies
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AMP (Acute Meniscal Pathology)
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The growth kinetics of subcultured human synovial fibroblasts from 16 patients with inflammatory and noninflammatory arthropathies were studied in antibiotic free media. The experimental design allowed a clear distinction between the growth rates and final saturation densities achieved. The effects of refeeding and of the serum concentration were evaluated for each line. Inflammatory lines achieved significantly higher final saturation densities and growth rates than noninflammatory lines for most protocols, but the differences between rheumatoid and nonrheumatoid groups were less marked. Inflammaroty fibroblasts demonstrated a greater independence to nutritional and growth stimulatory factors in their microenvironment than noninflammatory fibroblasts.
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Contraindications to the repositioning of fractured or dislocated limbs in the fields
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Distal Radius Fractures
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Supracondylar fractures of the femor or humerus and fractures of the radius, ulna, tibia or fibula, plus crush injuries of the limbs, most likely should not be manipulated in the field because of the potential for traumatizing adjacent nerves, veins and arteries. An emergency splinting system that allows immobilization without repositioning has been developed. Furthermore, fractures in or about the elbow, wrist, knee, or ankle should not be subjected to reduction in the field, unless there are compelling reasons to justify the risk of producing significant additional trauma. Conservative immobilization without repositioning may yield a more positive prognosis for the patient.
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Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial
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Hip Fx in the Elderly 2019
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INTRODUCTION: The number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.
AIM: To investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.
PATIENTS AND METHODS: In this randomised controlled trial involving patients aged >=70years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.
RESULTS: The study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (+/-6.9)years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12h compared with controls (p<0.001 and p=0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3+/-4.0 vs. 5.7+/-5.2mg, p<0.001) and in the subgroup with dementia (2.1+/-3.3 vs. 5.8+/-5.0mg, p<0.001).
CONCLUSION: Patients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.
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Secondary prevention program for osteoporotic fractures and long-term adherence to bisphosphonates
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Management of Hip Fractures in the Elderly
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Summary: Our purpose was to assess the impact of a secondary prevention program for osteoporotic fractures in patients with fragility fracture and to determine its effect on long-term compliance with bisphosphonate treatment. Persistence with bisphosphonate use was 71%. Attending follow-up visits was the only variable significantly associated with adherence to bisphosphonates. Introduction: The aim of this study is to assess the impact a secondary prevention program for osteoporotic fractures in a prospective cohort of patients with at least one fragility fracture and to determine the effect of this intervention on long-term compliance with bisphosphonate treatment. Methods: All patients older than 50 years with a fragility fracture attended at the emergency department over a 2-year period were appointed for a clinical visit through a telephone call. Two follow-up controls at 4 and 12 months were scheduled. After a mean of 4 years, a telephone survey was conducted to assess compliance with treatment. Results: Of 683 eligible patients, 380 (55.6%) were visited at the hospital. Previous treatment with bisphosphonates was recorded in 17.9% of patients. DXA scan was considered normal in 61 patients and revealed osteopenia in 184 and osteoporosis in 135. Pharmacological treatment was indicated in 90% of patients (alendronate in 76%). Among 241 patients who participated in the survey, eight patients had new fractures (four were on treatment with bisphosphonates and four had discontinued treatment). Of 187 patients in which bisphosphonates were prescribed at the initial visit, 133 (71.1%) continued using bisphosphonates. Attendance of scheduled visits was associated with adherence to bisphosphonates (odds ratio, 3.33;95% confidence interval, 2.99-3.67). Conclusions: The efficacy of the program to recruit patients was 55%. In patients visited at the hospital, treatment with bisphosphonates increased from 17.9% to 76%. Persistence with bisphosphonate use after a mean of 4 years was 71%. Attending follow-up visits was significantly associated with adherence to bisphosphonates. (copyright) International Osteoporosis Foundation and National Osteoporosis Foundation 2010
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Optimal timing of operations to treat fractures of the femoral neck with endoprotheses: CRP as a parameter of postoperative immunologic reaction
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Hip Fx Time to Surgery
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Background: The optimal time to perform endoprosthesis of hip fractures in the elderly is still under discussion. CRP as an objective marker of postoperative inflammatory reaction should give an indication if early or late surgery is favored. Methods: CRP values from 122 patients with no complications after hip arthroplasty of femoral neck fractures were analyzed in context with the time between the trauma and the operation. Results: In early surgery within 24 h after trauma the CRP values were significantly lower than in delayed surgery. Conclusion: The lower postoperative inflammatory reaction after early surgery of hip fractures provides a better outcome when treated with arthroplasty. © 2011 Springer-Verlag.
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Prevention and rehabilitation of overuse injuries of the elbow
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Rehabilitation from injury and prevention of injury are terms that describe differing aspects of the same challenge. The clinician must be continually aware of the principles of rehabilitation and their order of priority (prevent further damage, restore motion, restore strength, reestablish coordination) while supervising patients' progress toward their goals. If patients are made aware of these principles at an early stage, and taught to take as much responsibility as possible for their own rehabilitative course, they will be more likely to reach their own ideal compromise of safety and speed of progress. In addition to helping with rehabilitation from injury, knowledge and self-awareness that patients obtain during this process may help in the prevention of future injuries
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Effectiveness of Periarticular Injection After Bipolar Hemiarthroplasty for Displaced Femoral Neck Fracture in Elderly Patients: A Double Blinded Randomized, Controlled Study
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Hip Fx in the Elderly 2019
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BACKGROUND: Bipolar hemiarthroplasty is a standard treatment for displaced femoral neck fracture in elderly with a normal acetabulum. Several studies have shown controversial results regarding postoperative visual analogue scale, opioid consumption, and the effectiveness of periarticular injection in hip arthroplasty. The purpose of this study is going to identify the effectiveness of periarticular injection after bipolar hemiarthroplasty compared with the patients treated with conventional pain control.
METHODS: A prospective, randomized, controlled study was performed for displaced femoral neck fracture in elderly who underwent bipolar hemiarthroplasty from 2017 to 2019. Patients were classified into two groups: Periarticular injection (PAI) group and nonperiarticular injection (non-PAI) group. All patients were recorded pain score (VAS) during admission. Morphine usage was collected in both groups including its side effects.
RESULTS: There was no difference in demography, intraoperative parameters, ambulatory status, and length of stay in both groups. Postoperative VAS at 8,16, 24, 60 hours, and before discharge in the non-PAI group was significantly higher than the PAI group (P = .001, P = .006, P = .002, P = .003, and P = .001, respectively). Morphine consumption at 8 hours after surgery was significantly higher in the non-PAI group than the PAI group (P = .001).
CONCLUSIONS: Intraoperative, periarticular injection may be used as an adjunctive pain management in bipolar hemiarthroplasty for displaced femoral neck fracture in elderly.
LEVEL OF EVIDENCE: level I, Prospective Randomized Controlled Trial.
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Risedronate and ergocalciferol prevent hip fracture in elderly men with Parkinson disease
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Management of Hip Fractures in the Elderly
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BACKGROUND: There is a high incidence of hip fractures in patients with Parkinson disease (PD). Bone mineral density (BMD) is decreased in patients with PD, correlating with the immobilization-induced bone resorption and hypovitaminosis D with compensatory hyperparathyroidism. OBJECTIVE: To evaluate the effectiveness of risedronate, an inhibitor of bone resorption, on osteoporosis and the risk of hip fractures in elderly men with PD. METHODS: This was a 2-year, randomized, double-blind, placebo-controlled trial. In a prospective study of patients with PD, 121 patients received a daily dose of 2.5 mg risedronate and vitamin D2 1,000 IU for 2 years, and the remaining 121 received placebo and vitamin D2 1,000 IU. Incidence of hip fractures was compared between the two groups. RESULTS: Nine patients sustained hip fractures in the placebo group, and three hip fractures occurred in the risedronate group. The relative risk of a hip fracture in the risedronate group vs the placebo group was 0.33 (95% CI, 0.09 to 1.20). BMD increased by 2.2% in the risedronate group and decreased by 2.9% in the placebo group (p < 0.0001). Urinary deoxypyridinoline, a bone resorption marker, decreased by 46.7% in the risedronate group and by 33.0% in the placebo group. CONCLUSION: Treatment with risedronate and vitamin D2 increases bone mineral density in elderly men with Parkinson disease and reduces the risk of hip fractures
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Tibial Component Fixation in Total Knee Arthroplasty. A Comparison of Pegged and Stemmed Designs
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Management of Hip Fractures in the Elderly
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This study compares midterm radiographic, functional, and quality-of-life outcomes in patients receiving a cemented tibial component that has either a short intramedullary stem or one that has a pegged tibial component. A cohort of 181 patients received 225 NexGen cruciate-retaining implants (84 stemmed, 141 pegged) during total knee arthroplasty, with annual follow-up examinations for up to 7 years. Both types of tibial components were associated with excellent radiographic and clinical results with no radiographic evidence of implant loosening or osteolysis. Clinical outcomes included improvement in joint function and patient function, as well as quality of life. Survival analysis showed 98% survival at 7 years with both implants. Pegged tibial components offered comparable midterm radiographic, functional, and quality-of-life results to stemmed components. (copyright) 2007 Elsevier Inc. All rights reserved
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Big-five personality traits and ego-resilience in amputee soldiers
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DoD PRF (Psychosocial RF)
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The present study was conducted to see the relationship of personality traits and ego-resilience in soldiers with amputation. The research also took into consideration age, nature of amputation related differences in resilience. Urdu translated versions of scales; Ego Resilience Scale (Block & Kremen, 1996) and NEO-Personality Inventory -Revised Urdu Version (Costa & McCrae, 1992) were used in study. The sample comprised of 92 men soldiers (age ranged 20-50) with amputation. The findings revealed that ego- resilience was negatively related to neuroticism and positively related with extraversion, openness, agreeableness, and cconscientiousness. Extraversion positively predicted the ego-resilience. Implications of the findings for future research on Pakistani soldiers with amputation are discussed. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Harmonic scalpel versus electrocautery in breast reduction surgery: a randomized controlled trial
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Reduction Mammoplasty for Female Breast Hypertrophy
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METHODSThirty-one patients were evaluated in a matched-pair design, with random (blinded) assignment of one side to the Harmonic Scalpel, with the other side defaulting to electrocautery. Main outcome measures were: (1) resection/hemostasis time, (2) drainage volume, and (3) postoperative pain. The authors also compared the learning curves, operative time versus specimen weights, complications, and costs for the devices.RESULTSThere was a statistically significant (but not clinically significant) difference between the median times for the Harmonic Scalpel (33 minutes) and electrocautery (31 minutes) (p=0.02). There was no statistical difference in drainage scores, and pain scores were equivalent. The analysis of specimen weight versus resection/hemostasis time showed no correlation. There were more complications on the breasts reduced with the Harmonic device, but due to the small sample size, the complication results were not statistically significant. Start-up costs for the devices were comparable, but the per-procedure cost for the Harmonic device was considerably higher.CONCLUSIONSThe Harmonic Scalpel is roughly equivalent to electrocautery in breast reduction surgery in terms of resection/hemostasis time, serous drainage, and postoperative pain. Though the Harmonic device may be excellent for other surgical procedures, its high cost suggests that surgeons and institutions can confidently forgo its use in breast reduction surgery.CLINICAL QUESTION/LEVEL OF EVIDENCETherapeutic, II.BACKGROUNDThe authors hypothesized that the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio) might outperform electrocautery in bilateral breast reduction surgery, possibly resulting in (1) shorter operative times, (2) lower postoperative fluid drainage rates, and (3) reduced postoperative pain scores.
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No association between the aluminium content of trabecular bone and bone density, mass or size of the proximal femur in elderly men and women
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Management of Hip Fractures in the Elderly
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BACKGROUND: Aluminium is considered a bone toxic metal since poisoning can lead to aluminium-induced bone disease in patients with chronic renal failure. Healthy subjects with normal renal function retain 4% of the aluminium consumed. They might thus also accumulate aluminium and eventually be at risk of long-term low-grade aluminium intoxication that can affect bone health. METHODS: We therefore examined 62 patients with femoral neck fractures or osteoarthritis of the hip (age range 38-93), with the aim of examining whether aluminium in bone is associated with bone-mineral density (BMD), content (BMC) or width of the femoral neck measured by dual-energy X-ray absorptiometry (DXA). During operations bone biopsies were taken from the trabecular bone of the proximal femur. The samples were measured for their content of aluminium using a mass spectrometer. RESULTS: No significant association between the aluminium content in bone and femoral neck BMD, BMC or width could be found after multivariate adjustment. CONCLUSION: Our results indicate that the accumulated aluminium content in bone during life does not substantially influence the extent of osteoporosis
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Effect of prostaglandin E1 infusion during and after total hip arthroplasty under hypotensive anesthesia on postoperative liver function and hemorrhage
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AAHKS (8) Anesthetic Infiltration
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We evaluated the effects of prostaglandin E1 (PGE1) on the liver function and hemorrhage after total hip arthroplasty (THA). Twenty patients with normal liver function were randomly divided into two groups. The patients were anesthetized with spinal anesthesia using 0.5% bupivacaine 4 ml and epidural anesthesia. The laryngeal mask was inserted after administrations of 1.5â?2 mg.kgâ?1 of propofol and 0.8 mg.kgâ?1 of succinylcholine. PGE1 was infused in the PGE1 group at a rate of 0.01 microgram.kgâ?1.minâ?1 (PGE1 group) during and after the operation (30â?40 hrs). GOT and GPT values were evaluated before, and at the end of operation, and on 1, 4 and 7 postoperative days in each group. The amount of hemorrhage was measured at the end of operation and on 1, 2, 3 and 4 postoperative days in each group. GOT values on 1 and 4 postoperative days in PGE1 group were significantly lower than those in the control group. GPT values on 1, 4 and 7 postoperative days in PGE1 group were also significantly lower than those in the control group. The amount of bleeding during the operation and postoperative hemorrhage did not differ significantly between the two groups. These results suggest that PGE1 may prevent postoperative liver damage, but it may not affect the amount of postoperative bleeding.
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A prospective study comparing mobile-bearing versus fixed-bearing type in total knee arthroplasty using the free-hand-cutting technique
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OAK 3 - Non-arthroplasty tx of OAK
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The mobile-bearing knee prosthesis was claimed to get more flexion in the laboratory testing and may provide better functional outcome than the conventional fixed-bearing prosthesis in patients. To prove this hypothesis in the patients between those two type prosthesis about flexion and functional out come was our study goal. The prospective randomized control trial. The Free-Hand-Cutting technique underwent TKR (100 mobile bearing and 100 fixed bearing). Post operative clinical outcomes were compared in range of movement, Knee Society Score, Function Knee Score and Oxford Knee Score at 2 months, 6 months, 1 year and 2 years. The mobile-bearing type prosthesis provided more flexion than the fixed-bearing knee prosthesis. But the same clinical out come was observed. The mobile-bearing type prosthesis gave more functional out come but not significant in daily patient activity compare to the fixed bearing knee prosthesis.
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Assessment of Low-Grade Meniscal and Cartilage Damage of the Knee at 7 T: A Comparison to 3 T Imaging With Arthroscopic Correlation
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: The aim of this study was to compare the assessment of low-grade meniscal tears and cartilage damage in ultrahigh-field magnetic resonance imaging (MRI) at 7 T to routine clinical MRI at 3 T.
MATERIALS AND METHODS: This study was approved by the local ethics committee, and written informed consent was obtained from each patient. Forty-one patients with suspected meniscal damage or mild osteoarthritis (Kellgren-Lawrence score, 0-2) received 7 T as well as routine clinical 3 T consecutively. The imaging protocol at both field strengths consisted of PD-weighted imaging with more than doubled resolution at 7 T. Images were read blinded regarding field strength and patient characteristics by 3 readers with different experience in musculoskeletal MRI (3 years, 6 years, and 10 years) according to a modified whole-organ MRI score of the knee in osteoarthritis and the Score of the International Cartilage Repair Society. Arthroscopic reports as a criterion standard were available for 12 patients. A multifactorial mixed model analysis was performed.
RESULTS: The mean cumulated diagnostic score at 7 T was significantly closer to the criterion standard compared with 3 T in patients where criterion standard was available (P < 0.001). In all 41 patients, the damages were rated more severely at 7 T reflected by a mean higher cumulative score in cartilage (P < 0.001) and in the meniscus (P < 0.001). No difference in interreader variability between 3 T and 7 T was observed. Imaging acquisition time was nearly identical.
CONCLUSIONS: Morphologic imaging of cartilage and meniscal damage of the knee in ultrahigh-field MRI at 7 T with PD-weighted TSE sequences seemed to have a significantly higher diagnostic accuracy than 3 T and can be performed with equal acquisition times while exploiting higher resolution of 7 T.
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Radiation osteitis and insufficiency fractures after pelvic irradiation for gynecologic malignancies
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MSTS 2018 - Femur Mets and MM
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Damage to the pelvic bones after radiotherapy for gynecological malignancies is uncommon with megavoltage radiotherapy. It can be misdiagnosed as bony metastases and is a diagnosis of exclusion. We report 12 women, who were treated for endometrial or cervical carcinoma who developed osteitis, femoral head or neck necrosis, or insufficiency fractures of the acetabulum, pubic symphysis or sacroiliac bones after radiotherapy. Many had multiple areas of bone damage. The prescribed external beam dose ranged from 40.0 to 61.2 Gy. All but one patient developed bony discomfort or pain as a symptom. Bony changes of the pelvic girdle appeared between 6 months and 8 years after irradiation. Radiographic studies including plain films, CT or bone scans were performed in these patients and showed correlative changes. Bone scans showed increased radionuclide uptake in affected bones. The subsequent favorable clinical course and outcome with resolution of symptoms confirmed the diagnosis of radiation osteitis. Therapy recommendations are conservative with avoidance of weight-bearing, use of analgesics and physical therapy. Femoral head necrosis/fractures required arthroplasty. Proper shielding, use of multifield technique, treatment of all fields per day, and awareness of tolerance doses are recommended.
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Acupuncture for the treatment of chronic knee and back pain
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OAK 3 - Non-arthroplasty tx of OAK
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Introduction: Because the efficacy of acupuncture was not reliably substantiated by scientific data, the Joint Federal Committee initiated a project comparing the effectiveness of acupuncture to guidelineâ?oriented conventional therapy for chronic pain. Four large, randomized studies were conducted as part of the "German Acupuncture Trials" (GERAC). Methods: For the studies on gonarthrosis and lumbalgia, 2,201 patients were randomised in eleven German states (399 outpatient practices) to verum acupuncture, sham acupuncture and guidelineâ?oriented conventional therapy. Primary outcome parameter was painâ?dependent scores six months after randomization. Parallel to the randomized studies, a Germanyâ?wide cohort study was conducted from which several samples were drawn to determine severe adverse events (367,646 patients) and the efficacy of acupuncture under conditions of everyday medical practice. Results: 10 to 15 acupuncture sessions, verum as well as sham, alleviated symptoms more effectively than conventional therapy. The outcomes were comparable to the pain dependent scores of patients in the knee and backâ?pain cohort samples. Discussion: Body needle acupuncture is an effective method of pain reduction. Because of the results in GERAC, the Joint Federal Committee of Physicians and Health Insurance Plans (Gâ?BA) has recommended that acupuncture for both indications be treated as a covered benefit under German public health insurance plans.
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