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High frequency spinal cord stimulation in complex regional pain syndrome (CRPS) patients-a case series
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Introduction: Conventional Spinal Cord Stimulation (SCS) is an effective therapy for CRPS patients. High Frequency SCS (HF-SCS) at 10000 Hz is a new option for FBSS but there is no reported experience about its feasibility and efficacy in the treatment of CRPS. We assumed that HF-SCS might also be helpful in the treatment of upper limbs CRPS and report our experience. Materials/Methods: Three patients with upper limb CRPS type II with typical symptoms of burning pain, disability, skin alteration and hyperhidrosis underwent a 2-week trial of HF-SCS. Results: The first case is 43 year old man with a history of ruptured left brachial plexus treated by several surgeries. The patient had typical burning pain, skin and nail alterations, hyperalgesia, forearms temperature asymmetry and was unable to use his arm for daily life activities. He was implanted with two trial leads in the cervical spine and pain relief could be observed after one day of trial, recovery of ability after the second day, as well as disappearance of hyperalgesia. IPG implant was performed 8 months ago and the patient is nearly pain free (VAS 0-1) and has stopped analgesics and sleeping medication. The arm function is nearly normal. The second case is a 37 year old woman with right hand carpal tunnel syndrome who developed post-operative pain and hyperalgesia. Symptoms were equal to case one. A trial of HF-SCS was performed, with one lead implanted at the midline of the cervical spine. Within 2 days, there was complete pain relief, 80% relief of hyperalgesia and a significant improvement arm function. IPG implant was performed 6 months ago. The patient had a VAS score of 1-2, and has stopped sleeping medication and analgesics. The hand function is nearly normal. The third case is a 48 year old male who fractured his processus styloideus radii 7 years ago, resulting in several complications and surgeries including autologous nerve transplantation. Symptoms were equal to case one and two on his left arm. He underwent a cervical epidural lead trial (ANS, St. Jude Medical), which improved his condition. After a bike accident one year ago, the cervical lead dislocated and despite repositioning, pain relief could not be regained. Consequently, we tried the high-frequency SCS. The trial resulted in significant improvements in pain and function. We connected the medial cervical lead to the Nevro IPG. After 3 months the patient reported a VAS of 1-2, no NSAID use, and nearly normal function of the arm. Conclusions: Treatment of CRPS of the upper limbs with the highfrequency neuromodulation system is feasible and effective. Even in cases where conventional SCS fails, high frequency stimulation can significantly improve the clinical situation. Further controlled studies are necessary to confirm the value of high frequency stimulation in CRPS patients
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A randomized study of the effect of 5-year and lifetime hip fracture risk information on physician recommendations for management of low bone density
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Management of Hip Fractures in the Elderly
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Although risk prediction tools providing absolute fracture risk information are currently under development, little is known about US physicians' current thresholds for osteoporosis treatment or the potential effect of fracture risk information on treatment decisions. To investigate this, a random sample of US primary care physicians was surveyed. Treatment recommendations for 4 patient scenarios depicting postmenopausal women of varying ages, weights, and bone mineral density (BMD) were elicited. Physicians were randomly assigned to receive all scenarios with either a basic BMD report or an augmented BMD report containing 5-yr and lifetime absolute hip fracture risk estimates. Over 95% of physicians recommended prescription pharmacologic treatment of a 70-yr-old patient with osteoporosis. For 3 scenarios depicting women with T-scores of -1.01, treatment recommendations ranged from 30% to 44%. There were no statistically significant differences between physicians who received augmented and basic BMD reports, although those with augmented BMD reports were less likely to recommend prescription treatments. Physician specialty had inconsistent and small effects on recommendations. We conclude that nearly all of a random sample of US primary care physicians recommend pharmacologic treatment of osteoporosis, but a substantial minority also recommend treatment for patients who would not fit current guidelines. A BMD report including absolute hip fracture risk estimates did not change treatment recommendations
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Analysis of 13 early failures of the mobile bearing Oxford phase III unicompartmental knee prosthesis
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Surgical Management of Osteoarthritis of the Knee CPG
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The use of unicompartmental knee arthroplasty appears to be increasing despite a signiWcant number of early revisions. This study looks at a consecutive series of such procedures. We retrospectively reviewed thirteen patients who had a revision of a unicompartmental knee replacement between January 2003 and March 2008 inclusively. During the study period, a total of 141 UKAs were performed in the reporting unit, of those 9 were revised to TKA. The indication for revision to TKA was determined from clinical records and radiographs. All patients who underwent revision were followed up using Oxford Knee Score. No preoperative Oxford Knee Scores were available. The study group consisted of six men and seven women. The preoperative diagnosis was osteoarthritis in all cases. The mean follow-up time was 16.4 (plus or minus) 10.7 months (range: 2-36 months). The mean age of the patients at time of revision was 60.8 (plus or minus) 9.7 years (range: 50-77 years). All patients had undergone medial UKA. The mean time interval between primary surgery and revision surgery was 21.5 (plus or minus) 13.4 months (range: 5-48 months). The indications for revision included loosening of the tibial and/or femoral component (n = 7), progression of osteoarthritis to lateral compartment (n = 2), unexplained medial knee pain (n = 2) patellofemoral symptoms (n = 1), and insert dislocation (n = 1). The mean postoperative Oxford Knee Score at the latest follow-up evaluation was 14 (plus or minus) 6.5 (range: 5-26). For the majority of patients, UKA provides reliable and reproducible results. However, UKA is a demanding procedure that needs special experience and includes a risk of early failure. (copyright) Springer-Verlag 2009
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Treatment of ischiofemoral impingement: results of diagnostic injections and arthroscopic resection of the lesser trochanter
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PJI DX Updated Search
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Ischiofemoral impingement (IFI) is an often unrecognized cause of hip pain caused by abnormal contact between the lesser trochanter and the ischium. To date, surgical treatment for those whose pain is not relieved by activity modification and steroid injections has not been defined. This study describes our imaging protocol and reports the results of arthroscopic, lesser trochanteric resections that were performed to treat this condition. Seven patients with symptomatic, MRI-documented IFI had ultrasound injections of ropivicaine and steroid into their ischiofemoral space. The injections provided complete but only transient relief of their groin and buttock pain and thus, all seven ultimately had an arthroscopic resection of their lesser trochanter. All hips were evaluated preoperatively and at 3, 6 and 12 months postoperatively with Byrd's modified Harris hip scoring system. Average age of the seven patients was 46 years and there were five females and one male. Preoperative scores averaged 43 points. After surgery, all patients used crutches for 4-6 weeks, and had 6-week scores that averaged 58 points. The patients and their scores continued to improve and at 6 and 12 months, their scores averaged 86 and 91 points, and none had chronic hip flexor weakness or recurrence of their hip pain or snapping. Arthroscopic iliopsoas tenotomies in combination with a resection of the lesser trochanter will provide complete relief of the painful snapping, groin and buttock pain caused by ischiofemoral impingement
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Surgical correction of coxa vara: Evaluation of neck shaft angle, Hilgenreiner-epiphyseal angle for indication of recurrence
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Hip Fx in the Elderly 2019
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Background: Coxa vara is a hip deformity in which the femoral neck-shaft angle decreases below its normal value. Standard surgical treatment for this condition is corrective valgus osteotomy. Appropriate correction of the Hilgenreiner-epiphyseal angle is important to prevent recurrence. The purpose of this study is to: 1) evaluate the recurrence of the deformity at the latest follow up; and 2) find the appropriate angle of correction associated with the lowest recurrence. Methods: 34 hips in 31 patients who underwent surgery for treatment of coxa vara from 2005 to 2014 were included. Patient-reported outcomes, Hilgenreiner-epiphyseal angle, and neck-shaft angle were assessed preoperatively, postoperatively, and at latest follow-up. Results: The mean age at surgery was 10.99, with a range of 5â??30, years. Preoperative neck-shaft angle ranged from 60 to 100 degrees, and Hilgenreiner-epiphyseal angle ranged from 60 to 90 degrees. At the latest follow up, the neck-shaft angle ranged from 120 to 135 degrees and the Hilgenreiner-epiphyseal angle ranged from 22 to 35 degrees (p < 0.001). The Harris hip score improved from 47.20 (34â??66) to 79.68 (60â??100) (p < 0.001). There was no recurrence of deformities at the mean follow up of 37.87 months. Conclusion: Surgical correction of coxa vara in various pathologies can be done successfully with the Hilgenreiner-epiphyseal angle corrected to â?¤ 35 degrees or the neck shaft angle corrected to > 120 degrees in order to prevent recurrence of the deformity. Majority of the patients were reported improvement of hip function. However, a longer-term follow up is required to determine further outcomes regarding to recurrence of the deformity.
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1 |
Metabolic syndrome as a risk factor for total hip or knee replacement due to primary osteoarthritis: a prospective cohort study (the HUNT study and the Norwegian Arthroplasty Register)
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OAK 3 - Non-arthroplasty tx of OAK
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Objective: Biochemical changes associated with obesity may accelerate osteoarthritis beyond the effect of mechanical factors. This study investigated whether metabolic syndrome and its components (visceral obesity, hypertension, dyslipidemia and insulin resistance) were risk factors for subsequent total hip replacement (THR) or total knee replacement (TKR) due to primary osteoarthritis.
Design: In this prospective cohort study, data from the second survey of the Nord-Trondelag Health Study 2 (HUNT2) were linked to the Norwegian Arthroplasty Register for identification of the outcome of THR or TKR. The analyses were stratified by age (<50, 50-69.9 and >=70 years) and adjusted for gender, body mass index, smoking, physical activity and education.
Results: Of the 62,661 participants, 12,593 (20.1%) were identified as having metabolic syndrome, and we recorded 1,840 (2.9%) THRs and 1,111 (1.8%) TKRs during a mean follow-up time of 15.4 years. Cox regression analyses did not show any association between full metabolic syndrome and THR or TKR, except in persons <50 years with metabolic syndrome who had a decreased risk of THR (hazard ratio [HR] 0.58, 95% CI 0.40-0.83). However, when including only participants whose exposure status did not change during follow-up, this protective association was no longer significant. Increased waist circumference was associated with increased risk of TKR in participants <50 years (HR 1.62, 95% CI 1.10-2.39) and 50-69.9 years (HR 1.43, 95% CI 1.14-1.80). Hypertension significantly increased the risk of TKR in participants <50 years (HR 1.38, 95% CI 1.05-1.81), and this risk was greater for men.
Conclusion: This study found an increased risk of TKR in men <50 years with hypertension and persons <70 years with increased waist circumference. Apart from this, neither metabolic syndrome nor its components were associated with increased risk of THR or TKR due to primary osteoarthritis.
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A randomised trial of hip protector use by frail older women living in their own homes [with consumer summary]
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To investigate the efficacy and effectiveness of hip protectors in frail community living older women. DESIGN: Randomised controlled trial. SETTING: Aged care health services in New South Wales, Australia. PATIENTS: 600 women 74 years of age or more (mean age 83 years), who had two or more falls or one fall requiring hospital admission in the previous year, and who lived in their own homes. INTERVENTION: Use of hip protectors. MAIN OUTCOME MEASURES: Adherence with use of hip protectors, falls, incidence of hip fracture, and adverse effects of use of hip protectors. RESULTS: Adherence was approximately 53% over the duration of the study and hip protectors were worn at the time of 51% of falls in the intervention group. The risk of hip fracture when falling while wearing hip protectors, compared with a fall with no hip protectors in place, was significantly reduced (relative risk (RR) 0.23, 95% confidence interval (CI) 0.08 t o 0.67). On an intention to treat analysis, 21 and 22 hip fractures occurred in the intervention and control groups respectively (adjusted RR 0.92, 95% CI 0.51 to 1.68). Three users of hip protectors sustained a hip fracture while wearing properly applied protectors, while 16 hip protector users (5%) developed minor local complications. CONCLUSIONS: Hip protectors prevent hip fractures in community dwelling older women if worn at the time of a fall. The overall effectiveness of hip protectors was not established in this study, because of incomplete adherence with use of the protectors, and limited statistical power. Full text may be available at: http://injuryprevention.bmj.com/ NO
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The Composition of Adipose-Derived Regenerative Cells Isolated from Lipoaspirate Using a Point of Care System Does Not Depend on the Subject's Individual Age, Sex, Body Mass Index and Ethnicity
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Panniculectomy & Abdominoplasty CPG
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Uncultured, unmodified, autologous, adipose-derived regenerative cells (UA-ADRCs) are a safe and effective treatment option for various musculoskeletal pathologies. However, it is unknown whether the composition of the final cell suspension systematically varies with the subject's individual age, sex, body mass index and ethnicity. UA-ADRCs were isolated from lipoaspirate from n = 232 subjects undergoing elective lipoplasty using the Transpose RT system (InGeneron, Inc.; Houston, TX, USA). The UA-ADRCs were assessed for the number of nucleated cells, cell viability and the number of viable nucleated cells per gram of adipose tissue harvested. Cells from n = 37 subjects were further characterized using four-channel flow cytometry. The present study shows, for the first time, that key characteristics of UA-ADRCs can be independent of the subject's age, sex, BMI and ethnicity. This result has important implications for the general applicability of UA-ADRCs in regeneration of musculoskeletal tissue. Future studies must determine whether the independence of key characteristics of UA-ADRCs of the subject's individual age, sex, BMI and ethnicity only applies to the system used in the present study, or also to others of the more than 25 different experimental methods and commercially available systems used to isolate UA-ADRCs from lipoaspirate that have been described in the literature.
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Partial meniscectomy using needle arthroscopy associated with significantly less pain and improved patient reported outcomes at two weeks after surgery: A comparison to standard knee arthroscopy
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AMP (Acute Meniscal Pathology)
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Purpose: to compare immediate post-operative pain and patient-reported outcomes (PROs) after partial meniscectomy with needle (NA) vs. standard (SA) arthroscopy technique. Methods: A retrospective review of a consecutive series of patients who underwent partial meniscectomy before and after adoption of a needle arthroscopic technique was performed. Meniscus repairs, root repairs, and those with ligamentous injuries were excluded. Total milligram morphine equivalents (MMEs) consumed, Visual analog scale (VAS) pain, and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were compared pre-operatively and at 2 and 6-weeks postoperatively. Univariate analysis was used to compare results. Results: Nineteen patients were in each group (NA: 10 females, SA: 11 females). Mean ± SD age (NA 42.8 ± 8.4 vs. SA 47.6 ± 10.4 years, p = 0.13) and body mass index (NA 31.4 ± 5.6 vs. SA 35.1 ± 5.4 m/kg2, p = 0.06) were not significantly different. Seventeen (89%) patients in both groups had medial meniscus tears of the posterior horn. Preoperative Outerbridge score was significantly greater in the SA group (3.4 vs. 1.8, p = 0.002); however, preoperative VAS pain (NA 6.1 ± 1.7 vs. SA 6.1 ± 1.8, p = 0.98) and KOOS pain (NA 44 ± 17% vs. SA 37 ± 12.5%, p = 0.20) were similar. Amount of arthroscopic fluid used was significantly greater in the SA vs. NA group (1.4 ± 0.7 vs. 0.5 ± 0.3 L, p < 0.0001), but tourniquet time was equivalent (NA 20 ± 6 vs.16 ± 6 min, p = 0.11). VAS pain scores (NA 1.0 ± 1.1 vs. SA 2.6 ± 1.5, p = 0.0014), KOOS pain (NA 79 ± 15% vs. 58 ± 19%, p = 0.0006), and Quality of Life (QOL) scores (NA 70 ± 22% vs. SA 43 ± 24%, p = 0.001) were significantly better at 2-weeks post-op in the N group. By 6 weeks post-op, all PROs including VAS pain and KOOS scores were similar between groups. Conclusions: Adoption of a needle arthroscopic technique for partial meniscectomy was associated with significantly improved VAS and KOOS pain scores two-weeks post-operatively. Differences were not sustained at 6 weeks after surgery. Level of evidence: III, Retrospective Comparison Study.
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An approach to efficacy screening of mouthrinses: studies on a group of French products (II). Inhibition of salivary bacteria and plaque in vivo
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The aim of this study was to determine the value of screening studies to assess the efficacy of antiseptic mouthrinse products relative to proven products. The products tested were 6 antiseptic mouthrinses available in France. 4 contained chlorhexidine (Eludril, Hibident, Parodex and Prexidine) with Hibident considered the positive control. 1 product contained cetylpyridinium chloride (Alodont) and 1 hexetidine (Hextril). Saline was used as the negative control. The 1st study assessed the persistence of action of the products by recording salivary bacterial counts before and up to 7 h after single rinses. The 2nd study measured the inhibition of plaque regrowth, from a zero baseline, in the absence of tooth-brushing over a 4-day period. Both studies used blind randomised crossover designs balanced for residual effects. Salivary bacterial count reductions with time were highly significantly greater for Parodex to 5 h and Hibident and Prexidine to 7 h; There were no significant differences between the latter three chlorhexidine rinses except at 3 h, when decrements were significantly less with Parodex. Despite a mean trend in favour, Alodont, Eludril and Hextril were not significantly different from saline. Plaque inhibition by area and index was highly significantly different between products. Hibident, Parodex and Prexidine showed similar plaque inhibition and were significantly more effective than all other rinses. Eludril and Hextril were significantly more effective than saline but Alodont was not. Taken with the associated study in vitro and published reports on the same or similar products, it is apparent that efficacy of a product cannot be assumed merely because it contains a known active plaque inhibitor.(ABSTRACT TRUNCATED AT 250 WORDS)
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Postoperative immunosuppression markers and the occurrence of sepsis in patients with benign and malignant disease
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AAHKS (8) Anesthetic Infiltration
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Aim To investigate associations between the postoperative immune response and the levels of extracellular circulating DNA (cDNA), C-reactive protein (CRP), neutrophil/ lymphocyte (N/L) ratio, and regulatory T (Treg) cells in the peripheral blood and their role as potential predictors of postoperative septic complications. Methods This was a prospective observational study involving 115 adult patients who underwent elective surgery. Patients were divided into three groups: with benign disease, with malignant disease, and with malignant disease and administration of dexamethasone. Serum CRP levels, N/L ratio, monocyte human leukocyte antigen-DR (HLA-DR) expression, proportion of Treg cells, and cDNA levels were measured at different time points before and after surgery. Results All patients had increased CRP levels after surgery. Septic patients had higher serum CRP levels at baseline. Compared with the other groups, the dexamethasone group had significantly higher CRP levels before and after surgery, a significantly higher N/L ratio before surgery, a significantly lower rise in the N/L ratio after surgery, and a significantly lower HLA-DR expression at baseline, which remained stable after surgery. In the malignant-disease group, we observed a significant postoperative decrease in the HLA-DR expression. Conclusions Our results suggest that the immunosuppressive effect of surgery and the presence of a malignant disease may contribute to a higher risk of postoperative sepsis. Preoperative CRP levels may be a reliable predictor of sepsis in oncological patients.
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A systematic review of the evidence for single stage and two stage revision of infected knee replacement
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PJI DX Updated Search
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BACKGROUND: Periprosthetic infection about the knee is a devastating complication that may affect between 1% and 5% of knee replacement. With over 79 000 knee replacements being implanted each year in the UK, periprosthetic infection (PJI) is set to become an important burden of disease and cost to the healthcare economy. One of the important controversies in treatment of PJI is whether a single stage revision operation is superior to a two-stage procedure. This study sought to systematically evaluate the published evidence to determine which technique had lowest reinfection rates. METHODS: A systematic review of the literature was undertaken using the MEDLINE and EMBASE databases with the aim to identify existing studies that present the outcomes of each surgical technique. Reinfection rate was the primary outcome measure. Studies of specific subsets of patients such as resistant organisms were excluded. RESULTS: 63 studies were identified that met the inclusion criteria. The majority of which (58) were reports of two-stage revision. Reinfection rated varied between 0% and 41% in two-stage studies, and 0% and 11% in single stage studies. No clinical trials were identified and the majority of studies were observational studies. CONCLUSIONS: Evidence for both one-stage and two-stage revision is largely of low quality. The evidence basis for two-stage revision is significantly larger, and further work into direct comparison between the two techniques should be undertaken as a priority
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Laser phototherapy in the treatment of periodontal disease. A review
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Many studies in the literature address the effect of low-power lasers in the management of pathologies related to periodontal tissues. Due to the lack of standardized information and the absence of a consensus, this review presents the current status of laser phototherapy (LPT) in periodontics and discusses its benefits and limits in the treatment of periodontal disease. The literature was searched for reviews and original research articles relating to LPT and periodontal disease. The articles were selected using either electronic search engines or manual tracing of the references cited in key papers. The literature search retrieved references on wound and bone healing, analgesia, hypersensitivity, inflammatory process and antimicrobial photodynamic therapy. Each topic is individually addressed in this review. The current literature suggests that LPT is effective in modulating different periodontal disease aspects in vitro, in animals, and in simple clinical models. Further development of this therapy is now dependent on new clinical trials with more complex study designs. (copyright) 2010 Springer-Verlag London Ltd
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Clinical Results and Survivorship of the GENESIS II Total Knee Arthroplasty at a Minimum of 15 Years
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OAK 3 - Non-arthroplasty tx of OAK
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Background The purpose of this study was to examine the 15-year survivorship and long-term clinical outcomes of the GENESIS II total knee arthroplasty (TKA). Methods Patients who underwent TKA with the GENESIS II system between 1995 and 1999 were retrieved from our institutional database. We report a Kaplan-Meier survival analysis as well as Western Ontario and McMaster Universities Arthritis Index, the Short Form Health Survey-12 (SF-12), and the Knee Society Scores at a mean of 16 years. Results Four-hundred sixty-nine TKAs were performed with a mean patient age of 68 years. Patients were followed up prospectively for a mean of 16 years (range, 14.8-19.5 years). The Kaplan-Meier survival analysis at 15 years, with revision for any reason as the end point, was 96.4% (95.5%-97.3%). The Western Ontario and McMaster Universities Arthritis Index and the Knee Society Scores were significantly improved (P <.001) from the preoperative period to the latest follow-up. Patients had a significant improvement (P <.001) from the preoperative to the latest follow-up on the Physical Health Composite Score of the SF-12, but no change was noted on the Mental Health Composite Score of the SF-12. Conclusion The unique design features of the GENESIS II TKA system have remained a constant over the duration of its clinical use, a rarity for contemporary TKA systems which are often altered before the publication of long-term results. The GENESIS II continues to demonstrate excellent long-term survivorship and improvements in health-related outcomes at a mean of 15 years, representing the standard for TKA systems at our institution.
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Injuries in professional male football players in Kosovo: A descriptive epidemiological study
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AMP (Acute Meniscal Pathology)
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Background: The incidence and severity of football-related injuries has been found to differ strongly between professional leagues from different countries. The aims of this study were to record the incidence, type and severity of injuries in Kosovarian football players and investigate the relationship between injury incidence rates (IRs), players' age and playing positions. Methods: Players' age, anthropometric characteristics and playing positions, training and match exposure as well as injury occurrences were monitored in 11 teams (143 players) of Kosovo's top division during the 2013/14 season. The exact type, severity and duration of football-related injuries were documented following International Federation of Football Associations (FIFA) recommendations. Results: A total of 272 injuries were observed, with traumatic injuries accounting for 71 %. The overall injury IR was 7.38 (CI: 7.14, 7.63) injuries per 1,000 exposure hours and ~11x lower during training as opposed to matches. Strains and ruptures of thigh muscles, ligamentous injuries of the knee as well as meniscus or other cartilage tears represented the most frequent differential diagnoses. While no statistical differences were found between players engaged in different playing positions, injury IR was found to be higher by 10-13 % in younger (IR = 7.63; CI: 7.39, 7.87) as compared to middle-aged (IR = 6.95; CI: 6.41, 7.54) and older players (IR = 6.76; CI: 5.71, 8.00). Conclusions: The total injury IR in elite football in Kosovo is slightly lower than the international average, which may be related to lesser match exposure. Typical injury patterns agree well with previously reported data. Our finding that injury IR was greater in younger players is related to a higher rate of traumatic injuries and may indicate a more aggressive and risky style of play in this age group.
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Effect of etidronate disodium on the interactions between malignancy and bone
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MSTS 2018 - Femur Mets and MM
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This study was designed to assess the capacity of etidronate disodium (etidronate) to affect neoplastic involvement of bone by murine tumors. Using sublines of the Walker 256 carcinoma, differing in the pattern of bone involvement, etidronate was found to inhibit hypercalcemia caused by systemically acting humoral factors, to inhibit bone metastasis following inoculation of tumor cells into the abdominal aorta, and to reduce the invasion of bone adjacent to tumors. Etidronate was also found to prevent bone metastasis in syngeneic rat mammary carcinoma. Etidronate was found devoid of direct antineoplastic activity, whether administered intramuscularly, subcutaneously, or intravenously, in a series of murine tumors of different histological varieties. At the same time, it was shown that etidronate did not modify the antineoplastic activity of any of the major chemotherapeutic agents used in these studies, nor did it demonstrate any degree of immunosuppression. The experimental models used for this study should prove useful in evaluating agents that may affect the various types of bone involvement seen in neoplastic disease. The drug's apparent lack of interference with the antineoplastic activity of standard cytotoxic agents and its lack of immunosuppressive activity suggest that it may be readily adaptable to combination chemotherapy regimens.
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Advances in pain management: Game changers in knee arthroplasty
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AAHKS (5) Gabapentinoids
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Over the past 30 years there have been many improvements in implant fixation, correction of deformity, improved polyethylene wear, and survival after knee replacement. The work over the last decade has focused on less invasive surgical techniques, multimodal pain management protocols, more rapid functional recovery and reduced length of stay, aiming to minimise the side effects of treatment while maintaining function and implant durability. When combined and standardised these pre-, intra- and post-operative factors have now facilitated outpatient knee replacement procedures for unicompartmental replacement, patella femoral arthroplasty and total knee replacement (TKR). We have found liposomal bupivacaine, with potential for longer therapeutic action, to be a helpful adjunct and describe our current pain management program. The next step in our multimodal program is to improve the duration of patient satisfaction and reduce cost and length of stay after TKR.
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Patient classification systems and hospital costs of care for knee replacement in 10 European countries
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Surgical Management of Osteoarthritis of the Knee CPG
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Knee replacement is a common surgical procedure performed to relieve pain and disability from degenerative osteoarthritis. This study evaluates the ability of ten European diagnosis-related group (DRG) systems to explain variations in costs or in length of stay for knee replacements. We assessed three different models in predicting variation of cost and length of stay. The first model, M(D), included only DRG groups as explanatory variables; the second, M(P), used a set of patient-level variables; and the third, M(F), included all variables from both M(D) and M(P). The total number of DRGs used to group knee replacement is low, ranging from two to six. All DRG systems except one differentiate between primary knee replacement and revision surgery. Considerable differences exist in the rate of revision surgery. There is also high variation in mean cost (from euro 3809 to euro 8158) and in mean length of stay (LoS) (from 4.2 to 13.6 days). The explanatory power of DRGs varies from 21.5 to 72.5% with values of around 40% in most countries of the study. Findings suggest that DRG systems could be enhanced either by the inclusion of patient-level variables, by the use of measures of clinical outcome or by improving cost and administrative information
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Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine if exercise therapy is superior to arthroscopic partial meniscectomy for knee function in middle aged patients with degenerative meniscal tears.
DESIGN: Randomised controlled superiority trial.
SETTING: Orthopaedic departments at two public hospitals and two physiotherapy clinics in Norway.
PARTICIPANTS: 140 adults, mean age 49.5 years (range 35.7-59.9), with degenerative medial meniscal tear verified by magnetic resonance imaging. 96% had no definitive radiographic evidence of osteoarthritis.
INTERVENTIONS: 12 week supervised exercise therapy alone or arthroscopic partial meniscectomy alone.
MAIN OUTCOME MEASURES: Intention to treat analysis of between group difference in change in knee injury and osteoarthritis outcome score (KOOS<sub>4</sub>), defined a priori as the mean score for four of five KOOS subscale scores (pain, other symptoms, function in sport and recreation, and knee related quality of life) from baseline to two year follow-up and change in thigh muscle strength from baseline to three months.
RESULTS: No clinically relevant difference was found between the two groups in change in KOOS<sub>4</sub> at two years (0.9 points, 95% confidence interval -4.3 to 6.1; P=0.72). At three months, muscle strength had improved in the exercise group (P<=0.004). No serious adverse events occurred in either group during the two year follow-up. 19% of the participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit.
CONCLUSION: The observed difference in treatment effect was minute after two years of follow-up, and the trial's inferential uncertainty was sufficiently small to exclude clinically relevant differences. Exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term. Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis to consider supervised exercise therapy as a treatment option.
TRIAL REGISTRATION: www.clinicaltrials.gov (NCT01002794).
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The effects of iontophoresis in the treatment of musculoskeletal disorders - a systematic review and meta-analysis
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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This systematic review and meta-analysis is focusing on the evidences related to iontophoresis used to enhance the topical drug delivery through the skin in the treatment of inflammatory dysfunctions, acute soft tissue injuries and pain. A literature search in the databases, MEDLINE (PubMed), Pedro, and the Cochrane Database of Systematic Reviews was conducted. The methodological quality of the obtained studies was independently rated by two reviewers. Data were pooled from those studies in which the effect of iontophoresis treatment on pain was compared with a control or sham (placebo) intervention. Twenty four experimental studies evaluating the effectiveness of iontophoretic treatment were included. Based on comparable statistical outcome for pain, the results of ten studies could be pooled for metaanalysis. Although several clinical studies claimed an advanced healing process after iontophoresis, controversy on the healing efficacy of iontophoresis remains. The overall summary estimate of the pooled post treatment values for pain was -0.672 [95%CI: -0.970 to -0.375] favouring iontophoresis treatment (p < 0.0001). The observed trend between studies heterogeneity for the post treatment pain values was low to moderate (I(2) = 39.9%; p = 0.092). The results of the metaanalysis indicate quantitative evidence that iontophoresis is effective in the treatment of pain, however, the lack of solid research design in studies on iontophoresis makes it difficult to ensure that the improvements observed can be explained by the iontophoresis technique in se. (copyright) 2012 Bentham Science Publishers
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TP53 mutations and outcome in osteosarcoma: a prospective, multicenter study
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MSTS 2022 - Metastatic Disease of the Humerus
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PURPOSE: Mutations of the TP53 gene have been associated with resistance to chemotherapy as well as poor prognosis in many different malignancies. This is the first prospective study of the prognostic value of somatic TP53 mutations in patients with newly diagnosed extremity osteosarcoma.
PATIENTS AND METHODS: One hundred ninety-six patients with high-grade, nonmetastatic osteosarcoma of the extremities were enrolled from seven tertiary care institutions and observed prospectively for tumor recurrence (median follow-up duration, 44 months). All patients received neoadjuvant or adjuvant chemotherapy and surgery. Tumors were analyzed for the presence of TP53 mutations by polymerase chain reaction single-strand conformation polymorphism analysis and direct DNA sequencing. The association of the status of the TP53 gene with the risk of systemic recurrence was examined using survival analyses with traditional and histologic markers as prognostic factors.
RESULTS: Patient age was the only factor that varied with TP53 gene status (P = .05). No relationship was identified between TP53 status and systemic relapse (relative risk, 1.24; P = .41). Analyses based on missense or nonsense mutations gave similar results (P > .10). In multivariate analysis, large (> 9 cm) tumor size (relative risk, 1.9; P = .006) and poor histologic response (< or = 90% necrosis) to chemotherapy (relative risk, 2.14; P = .02) were the only significant independent predictors of systemic outcome.
CONCLUSION: We found no evidence that TP53 mutations predict for development of metastases in patients with high-grade osteosarcoma. Identification of other genes that influence chemotherapy response and clinical outcome in osteosarcoma is needed to facilitate further improvements in patient outcomes.
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Out-of-the-box pelvic surgery including iliopsoas resection for recurrent gynecological malignancies: Does that make sense? A single-institution case-series
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DOD - Acute Comp Syndrome CPG
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OBJECTIVE: To report morbidity and oncological outcomes in a consecutive series of lateral isolated recurrent gynecological cancer involving the pelvic side wall (PSW) including the iliopsoas muscle.
MATERIAL AND METHODS: We retrospectively evaluated a consecutive series between 6/2013 and 12/2015 of lateral isolated recurrent gynecological malignancies treated with a lateral endopelvic resection (LEPR). LEPR was defined as an en-bloc lateral resection of a pelvic tumor with sidewall muscle, and/or bone, and/or major nerve, and/or major vascular structure. Post-surgical complications, quality of life (QoL) and survivals were computed.
RESULTS: Seventy-four women with pelvic isolated relapse were admitted for surgery during the study period. Among them, 8 cases (10.8%) showed lateral isolated relapse involving the iliopsoas muscle and were treated with LEPR. R0 resection was achieved in 6/8 patients (75.0%), while the pathologic margins were microscopically and macroscopically positive in 1 patient (12.5%), respectively. There were no perioperative mortalities. Major postoperative complications occurred in 3 patients (37.5%) through peripheral neuropathies, thrombosis of the vascular graft and compartment syndrome of the leg. Median follow-up time was 21 months (range, 12-28). The 2-year overall survival (OS) was 88% improving up to 100% if R0 resection was achieved. In patients with positive pathologic margins (n = 2), the 2-year OS was 50%. All women showed an improved QoL after surgery.
CONCLUSION: LEPR with iliopsoas resection can be safely performed in selected cases with lateral isolated gynecological relapse involving the PSW and was associated with improved QoL and prolonged survival when an R0 resection was achieved.
Copyright © 2016 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.
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High tibial osteotomy: evolution of research and clinical applications--a Canadian experience
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Surgical Management of Osteoarthritis of the Knee CPG
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PURPOSE: This narrative review describes experiences at the Fowler Kennedy Sport Medicine Clinic (FKSMC) with high tibial osteotomy (HTO) for patients with varus gonarthrosis, with particular focus on research published from the unit that has guided practice. METHODS: The goals of surgery are to improve alignment of the weight bearing axis of the lower limb to lessen the load on the medial tibiofemoral compartment and thereby decrease these important risk factors for disease progression. The overall aims are to improve knee function and delay or even prevent the eventual need for arthroplasty. To achieve these aims, a medial opening wedge osteotomy is utilised, deliberately avoiding an over correction of the lower limb, but tailoring the angle of correction to an individual patient's characteristics. With such an approach, patients with a broad range of characteristics (including age, BMI and lateral compartment involvement) can benefit from the procedure. In addition, the HTO can be used with concomitant procedures to address specific presentations, such as large deformities and instability. RESULTS: The results suggest that correction to a slight valgus alignment produces approximately 50% reduction in medial compartment loads during gait with large, clinically important improvements in patient-reported outcomes at 2-years postoperatively. In patients with substantial bilateral varus deformity, unilateral surgery can lead to increased dynamic knee joint loads on the nonoperative limb after surgery. This means that such patients require the close monitoring of both limbs and consideration of a staged, bilateral procedure if necessary. In patients requiring bilateral surgery, similar results after bilateral HTO to those after unilateral surgery have been reported. For patients requiring large corrections, the need for a concomitant tibial tubercle osteotomy to reduce the potential for iatrogenic patella infera is considered. Finally, HTO procedures can also be used in patients with instability, either to alter both sagittal and coronal alignment to correct instability in complex ligament deficiencies or to undertake simultaneous HTO and ACL reconstruction. CONCLUSIONS: HTO is being used both alone and in conjunction with concomitant procedures with good clinical results. While continued investigation into patient selection and outcomes are required, current research indicates that HTO offers at least a partial solution for the patient with varus gonarthrosis to prolong the life of their native knee joint. LEVEL OF EVIDENCE: V
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Myth busters: An AOA symposium: AOA critical issues
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SR for PM on OA of All Extremities
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One of the goals of the annual American Orthopaedic Association (AOA) meeting is to address controversy, both in leadership and clinical practice. A panel of experts in their respective fields presented the background and literature behind three "myths" in orthopaedic management and made conclusions as to their validity. First, Dr. Kocher took on the myth of prophylactic pinning on the contralateral "normal" side for a patient with a slipped capital femoral epiphysis. Second, Dr. Probe evaluated the myth that all intertrochanteric fractures are best treated with intramedullary devices. Last, Dr. Foster and Dr. Silvestri tackled the myth that autograft is always the best choice for anterior cruciate ligament (ACL) reconstruction. All three of these topics are subjects of current debate. The panel's careful examination of the available data along with their expertise in the management of these problems is presented in this thought-provoking JBJS Critical Issues article
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Evaluation of a femoral stem with reduced stiffness. A randomized study with use of radiostereometry and bone densitometry
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Management of Hip Fractures in the Elderly
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BACKGROUND: Femoral stems with reduced stiffness were introduced in total hip arthroplasty to facilitate proximal load transfer and thereby reduce periprosthetic bone loss. Poor fixation and unacceptably high revision rates turned out to be a major problem with these prostheses. The purpose of the present study was to evaluate the early performance of a low-modulus stem (one that is less stiff) with the potential to address the problem of fixation by the use of a surface coating. The coating consisted of a titanium porous mesh proximally covered with a mixture of hydroxyapatite and tricalcium phosphate.METHODS: Thirty-nine men and twenty-six women (sixty-eight hips) with noninflammatory arthritis were studied. The patients were randomized to receive either a porous-coated composite stem with reduced stiffness (Epoch) or a stiff stem with a porous coating (Anatomic). Both stems were inserted without cement, had a ceramic coating on the proximal two-thirds, and were supplied with tantalum beads. At the time of the operation, tantalum markers were also placed into the proximal part of the femur. The patients were followed for up to two years after the operation and were evaluated with use of repeated radiostereometric measurements, measurements of bone-mineral density, conventional radiography, and Harris hip scores.RESULTS: Both stems showed optimum fixation with median subsidence and stem rotations that were close to zero. Repeated measurements of bone-mineral density revealed early loss of bone mineral in all Gruen regions in both treatment groups. The loss of bone mineral around the Epoch stems was significantly reduced at two years in Gruen regions 1, 2, 6, and 7 (p < 0.0005 to 0.04). Measurements on postoperative radiographs showed no difference in stem positioning or fill, but the Epoch stems had significantly more endocortical contact on both the anteroposterior (p < 0.0005) and the lateral radiograph (p = 0.02). At two years postoperatively, the Epoch stems had fewer sclerotic lines surrounding the stem (p = 0.002) and less sclerosis at the tip of the prosthesis (p = 0.001) compared with the Anatomic stems. The clinical results in terms of the Harris hip score, which was determined in all hips, and pain or discomfort, which was evaluated in thirty-seven hips treated at the same hospital, were not found to be different, with the numbers available.CONCLUSIONS: Contrary to previous studies of other designs with reduced stiffness, the Epoch stem achieved excellent primary fixation. Despite this rigid fixation, the proximal loss of bone-mineral density was less than that associated with the stem with a stiffer design. These results should encourage additional long-term studies with a larger patient population
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Historical development of alloplastic temporomandibular joint replacement after 1945 and state of the art
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Glenohumeral Joint OA
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The variety of temporomandibular joint (TMJ) prostheses and condylar reconstruction plates available is in contradiction to their rare application. This emphasizes that alloplastic TMJ reconstruction is still evolving. This article reviews the history of TMJ reconstruction. Medline as well as public and private libraries have been searched. Current systems are reviewed. Prosthetic devices can be differentiated into fossa-eminence prostheses, ramus prostheses and condylar reconstruction plates, and total joint prostheses. Fossa and total joint prostheses are recommended when the glenoid fossa is exposed due to excessive stress (degenerative disorders, arthritis, ankylosis, multiply operated pain patients). Singular replacement of the condyle is preferred as a temporary solution in ablative surgery. The use of prosthetic devices for long-term replacement should be restricted to selected cases, taking care to retain the disk, in order to prevent penetration into the middle cranial fossa. The term 'condylar reconstruction plate' reflects this more clearly than 'ramus prosthesis' which suggests permanent reconstruction. Long-term studies comparing the functional and aesthetic results of the various prostheses and condylar reconstruction plates are not available, which leaves the choice to personal experience. © 2009 International Association of Oral and Maxillofacial Surgeons.
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1 |
Understanding risks and complications in the management of ankle fractures
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DoD LSA (Limb Salvage vs Amputation)
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Ankle fracture (AF) is a common injury with potentially significant morbidity associated with it. The most common age groups affected are young active patients, sustaining high energy trauma and elderly patients with comorbidities. Both these groups pose unique challenges for appropriate management of these injuries. Young patients are at risk of developing posttraumatic osteoarthritis, with a significant impact on quality of life due to pain and impaired function. Elderly patients, especially with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection and failure of fixation. In the most severe cases, this can lead to amputation and mortality. Therefore, individualized approach to the management of AF is vital. This article highlights commonly encountered complications and discusses the measures needed to minimize them when dealing with these injuries.
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Synovial activation drives efficacy of anti-inflammatory effects of adipose-derived stem cells in experimental oa which is reflected by serum levels of S100a8/A9
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OAK Recommendation 9 Articles
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Background Synovitis is evident in a substantial subpopulation of patients with early osteoarthritis (OA). Recently we have shown that adipose derived stem cells (ASC) inhibit synovitis and joint destruction after local application to knee joints with experimental OA. Objectives To explore whether the efficacy of the anti-inflammatory effect of locally administered ASCs into experimentally induced osteoarthritic joints is stimulated by an inflammatory milieu. Methods ASCs were isolated from fat surrounding the popliteal lymph nodes. Murine OA was induced by either dissection of the anterior medial menisco-tibial ligament (DMM) or by injection of collagenase into murine knee joints (CIOA). CIOA clearly develops synovitis in contrast to DMM in which synovitis is scant. ASCs were injected into OA knee joints and OA phenotype was measured within 6 weeks after induction. Total knee joints were processed for histology. Synovitis and joint destruction was measured using an arbitrary score from 0-3. Synovial washouts were measured for S100A8/A9 and IL-1 using Luminex. Results The effect of local ASC treatment was first investigated in DMM in which synovitis is scant. ASCs (20X103) injected in knee joints at days 7 or 14 after induction of DMM, showed no effect on development of cartilage destruction or osteophyte formation at day 42. To investigate whether ASC need an inflammatory milieu to become protective they were locally injected in the CIOA model in which synovitis is severe. A day 7 intra-articular injection of ASC showed a clear protective effect on joint destruction at day 42. Injection of GFP-labeled ASC displayed a tight interaction with synovial lining macrophages. To study the effect on the inflammatory status within the joint, washouts of synovium were taken at various time-points (6 hrs, 48 hrs, day 14 and day 42) after ASC treatment. Protein levels of pro-inflammatory mediators IL-1 and S100A8/A9 were significantly decreased already 48 hrs after ASC injection (22% and 57% respectively) and rapidly declined thereafter. Histology showed that synovial thickness was significantly inhibited at day 14 (9%) and day 42 (35%) when compared to control treated OA joints and protected joint destruction (osteophyte formation inhibition 67%). Serum levels of S100A8/A9 which are strongly raised during CIOA, were inhibited by 85% at day 14 after ASC treatment. Next, we explored the anti-inflammatory effect of ASCs in a milder CIOA exhibiting less synovial inflammation. Synovial thickening at day 42 was 62% lower when compared to the former study. Injection of ASCs at day 7 after OA induction, only marginally inhibited synovial thickening and formation of osteophytes when measured at day 42 suggesting that severe synovial inflammation is needed for a clear anti-inflammatory effect of ASC. Serum levels of S100A8/A9 were low at day 14 (around 50 ng/ml compared to 800 ng/ml in CIOA with high synovitis) and not significantly altered by ASC treatment. Conclusions Our study indicates that the anti-inflammatory effects of ASCs after local administration in murine OA knee joints is stimulated by a severe inflammatory milieu. S100A8/A9 serum levels may predict the protective outcome of ASC treatment
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A trans-ethnic genome-wide association study identifies gender-specific loci influencing pediatric aBMD and BMC at the distal radius
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Distal Radius Fractures
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Childhood fractures are common, with the forearm being the most common site. Genome-wide association studies (GWAS) have identified more than 60 loci associated with bone mineral density (BMD) in adults but less is known about genetic influences specific to bone in childhood. To identify novel genetic factors that influence pediatric bone strength at a common site for childhood fractures,we performed a sex-stratified trans-ethnic genome-wide association study of areal BMD(aBMD) and bone mineral content (BMC) Z-scores measured by dual energy X-ray absorptiometry at the one-third distal radius, in a cohort of 1399 children without clinical abnormalities in bone health. We tested signals with P < 5 � 10-6 for replication in an independent, same-age cohort of 486 Caucasian children. Two loci yielded a genome-wide significant combined P-value: rs7797976 within CPED1 in females [P = 2.4 � 10-11, � =- 0.30 standard deviations (SD) per T allele; aBMD-Z] and rs7035284 at 9p21.3 in males (P = 1.2 � 10-8, β = 0.28 SD per G allele; BMC-Z). Signals at the CPED1-WNT16-FAM3C locus have been previously associated with BMD at other skeletal sites in adults and children. Our result at the distal radius underscores the importance of this locus at multiple skeletal sites. The 9p21.3 locus is within a gene desert, with the nearest gene flanking each side being MIR31HG and MTAP, neither of which has been implicated in BMD or BMC previously. These findings suggest that genetic determinants of childhood bone accretion at the radius, a skeletal site that is primarily cortical bone, exist and also differ by sex.
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1 |
Amputee Locomotion: Ground Reaction Forces During Submaximal Running With Running-Specific Prostheses
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DoD LSA (Limb Salvage vs Amputation)
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Individuals with lower extremity amputation must adapt the mechanical interactions between the feet and ground to account for musculoskeletal function loss. However, it is currently unknown how individuals with amputation modulate three-dimensional ground reaction forces (GRFs) when running. This study aimed to understand how running with running-specific prostheses influences three-dimensional support forces from the ground. Eight individuals with unilateral transtibial amputations and 8 control subjects ran overground at 2.5, 3.0, and 3.5 m/s. Ten force plates measured GRFs at 1000 Hz. Peak and average GRFs and impulses in each plane were compared between limbs and groups. Prosthetic limbs generated reduced vertical impulses, braking forces and impulses, and mediolateral forces while generating similar propulsive impulses compared with intact and control limbs. Intact limbs generated greater peak and average vertical forces and average braking forces than control subjects' limbs. These data indicate that the nonamputated limb experiences elevated mechanical loading compared with prosthetic and control limbs. This may place individuals with amputation at greater risk of acute injury or joint degeneration in their intact limb. Individuals with amputation adapted to running-specific prosthesis force production limitations by generating longer periods of positive impulse thus producing propulsive impulses equivalent to intact and control limbs.
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0 |
Self-management education programmes for rheumatoid arthritis
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SR for PM on OA of All Extremities
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This is the protocol for a review and there is no abstract. The objectives are as follows:To assess the benefits and harms of self-management education programmes for people with rheumatoid arthritis (RA)
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Bisphosphonates: Prevention of bone metastases in lung cancer
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MSTS 2018 - Femur Mets and MM
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In patients with lung cancer, bone is one of the most frequent sites of distant spread, with approximately 30% of patients developing skeletal metastases. About half of these patients will experience a skeletal-related event, the occurrence of which not only affects quality of life, but is also associated with poor prognosis. Bisphosphonates are currently the mainstay for treating bone metastases in patients with lung cancer, with proven beneficial effects on prevention and delay of skeletal complications. Their role in preventing the development of skeletal metastases, their anti-tumoral properties and their effect on survival remain to be elucidated. Other bone-targeted therapies are being investigated in phase II and III clinical trials and might expand the therapeutic arsenal in the near future. © 2012 Springer-Verlag Berlin Heidelberg.
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Large deformity correction in medial open-wedge high tibial osteotomy may cause degeneration of patellofemoral cartilage: A retrospective study
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OAK 3 - Non-arthroplasty tx of OAK
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To evaluate retrospectively any association between the degree of deformity correction by medial open-wedge high tibial osteotomy (HTO) and patellofemoral joint degeneration. We hypothesized that development of patellofemoral joint degeneration depended on the degree of intraoperative deformity correction.Fifty-seven patients who underwent medial open-wedge HTO for treatment of osteoarthritis in one knee were included in this study. Knees were classified into degeneration (D) and non-degeneration (ND) groups according to worsening of the patellar and/or femoral trochlear cartilage at the time of hardware removal (D group, 27 knees) and no degeneration or improvement (ND group, 30 knees). We compared pre- to post-surgery change in hip-knee-ankle angle (HKA) and medial-proximal-tibial angle (MPTA), open-wedge HTO correction angle, and arthroscopic findings between groups.Mean age, height, weight, and body mass index were 54.1 +/- 9.9 years, 160.4 +/- 8.7 cm, 66.4 +/- 12.1 kg, and 25.7 +/- 3.3 kg/m, respectively. Change in both HKA and MPTA differed significantly between groups. The MPTA cut-off values to predict patellofemoral degeneration were determined to be 10degree, associated with an AUC of 0.75 (95% confidence interval [CI] 0.62-0.87).This study evaluated retrospectively the effect of the correction angle during medial open-wedge HTO on patellofemoral joint degeneration. If deformity correction exceeds an MPTA of 10degree during open-wedge HTO, degeneration of patellofemoral joint needs to be considered.Level of evidence: Level IV.
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Burden of disease in adult patients with hypophosphatasia: Results from two patient-reported surveys
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Hip Fx in the Elderly 2019
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BACKGROUND: Hypophosphatasia (HPP) is a rare metabolic bone disease caused by loss-of-function mutation(s) in the tissue-nonspecific alkaline (TNSALP) phosphatase gene, which manifests as rickets and/or osteomalacia with systemic complications and affects patients of all ages. The burden of disease is poorly characterized in adult patients.
AIMS: We assessed patient-reported burden of disease using two surveys reasonably specific for HPP symptomatology, the Hypophosphatasia Impact Patient Survey (HIPS) and the Hypophosphatasia Outcomes Study Telephone interview (HOST).
METHODS: Patients with HPP were invited to participate via patient advocacy groups or their medical provider. Survey questions captured demography, HPP-related medical history, mobility, and health-related quality of life (using Short Form 12 [version 2] Health Survey [SF-12v2]) via internet report (HIPS) or telephone interview (HOST).
RESULTS: One hundred twenty-five adults responded (mean [standard deviation, SD] age: 45 [14.3] years). Eighty-four patients (67%) reported pediatric-onset of their symptoms. Common clinical features in the study population included pain (95% of patients), fractures (86% of patients) muscle weakness (62%) and unusual gait (52%). Use of assistive devices for mobility (60%) was also prevalent. Twenty-six percent of patients reported more than 10 fractures. Seventy-four percent of patients had undergone orthopedic/dental surgical procedures. The health profile of patients responding on the SF-12 showed a broad and substantial impact of HPP on health-related quality of life, with domains related to physical ability showing the greatest decrement compared to normative data.
CONCLUSIONS: In aggregate, these data indicate that HPP can confer a high burden of illness in adulthood.
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Radiographic predictors of visual outcome in orbital compartment syndrome
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DOD - Acute Comp Syndrome CPG
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PURPOSE: The goal of this study is to evaluate parameters on orbital CT as predictors of visual outcome in orbital compartment syndrome from retrobulbar hematoma or orbital cellulitis. The study will assess the assertion that certain patients are anatomically predisposed to vision loss in these conditions.
METHODS: A retrospective chart review of consecutive patients with the diagnosis of either orbital cellulitis or orbital hematoma from the clinic of a single provider in an academic practice from 2006 to 2009 was performed. Exclusion criteria included preexisting vision loss, lack of CT scan for analysis, or lack of 1-month follow up for final visual acuity. Measurements of final visual acuity, medial wall length, lateral wall length, distance from the globe to the apex, and a novel measurement of posterior globe tenting (stretch angle) were obtained. Patients were divided into 2 groups: normal visual acuity and vision loss. Statistical analysis was performed to identify significant differences between the 2 groups.
RESULTS: The normal vision group consisted of 11 patients, all with vision of 20/30 or better. The average length of the medial and lateral wall was 43.9 and 41.6 mm, respectively. The average distance from the globe to the apex was 26.3 mm in the uninvolved eye and 30.3 mm in the involved eye, resulting in an average difference of 4.18 mm. The average stretch angle measurement was 28.9degree in the uninvolved eye and 28.5degree in the involved eye, resulting in an average difference of 0.41degree. The vision loss group consisted of 4 patients, all with vision of count fingers or worse. The average length of the medial and lateral wall was 46.9 and 45.7 mm, respectively. The average distance from the globe to the apex was 32.2 mm in the uninvolved eye and 36.7 mm in the involved eye, resulting in an average difference of 4.50 mm. The average stretch angle measurement was 32.3degree in the uninvolved eye and 21.1degree in the involved eye, resulting in an average difference of 11.2degree. The difference in stretch angle between eyes in the vision loss and normal vision groups were found to be highly significant with a p value of less than 0.001. The difference between the 2 orbits for globe to apex is a rough measurement of proptosis and was not statistically different in the 2 groups (p = 0.71), whereas the length from the globe to the apex in the uninvolved eye was statistically different between the vision loss group and normal vision group (p = < 0.001).
CONCLUSIONS: Orbital compartment syndrome is a potentially vision-threatening condition. Minimal objective data are currently available in the literature to guide physicians in making clinical judgments regarding these patients. The results of this study indicate that comparing the novel stretch angle between the patient's 2 eyes and measuring the length from the globe to the orbital apex can help identify patients at risk for poor visual outcome. This study provides objective measurements that can aid ophthalmologists and radiologists in determining the relative threat to vision in patients presenting with orbital compartment syndrome from orbital cellulitis or retrobulbar hematoma. Hopefully, the data can help select patients that may benefit from more aggressive intervention and will ultimately result in superior visual outcomes.
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Successful Treatment of Secondary Aortoenteric Fistula with a Special Graft
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PJI DX Updated Search
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Aortoenteric fistula is an uncommon but life-threatening cause of gastrointestinal blood loss. We report a case of a 70-year-old man who presented to the emergency department with an episode of melena and infection in the left inguinal region. Diagnosis of secondary aortoenteric fistula was made between the left limb of the aortobifemoral graft and the descending colon. We performed excision of the infected graft and in situ silver acetate coating of prosthetic vascular graft replacement (aortoleft femoral) on the patient. This study reports a rare type of secondary aortoenteric fistula to the left colon, and it describes an unusual and successful surgical treatment. Antimicrobial coating of prosthetic vascular grafts may be a good alternative in the presence of graft infection associated with aortoenteric fistula because in situ grafts may carry an increased risk of reinfection
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Robotically assisted laparoscopic biliopancreatic diversion with duodenal switch. Initial experience of 42 cases
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background: Biliopancreatic diversion with duodenal switch (BPD/DS) is considered the most effective surgical option for morbidly obese patients. Numerous techniques have been described - open, laparoscopic, combination of open and laparoscopic, as well as robotically assisted. We describe our early experience of 42 robotically assisted laparoscopic BPD/DS and its feasibility as an alternative for treatment of morbid obesity. Methods: A retrospective review of a prospectively maintained database was conducted in all patients undergoing BPD/DS between December 2008 and February 2010. Outcomes and perioperative complications as well as advantage of robotically assisted approach were recorded and analyzed. Results: A total of 42 consecutive patients (F:M=30:12) were included in this study. Average age was 43.4 (20-60), BMI 50.2 (37- 70) and number of preoperative comorbidities 6.2 (3-10). Mean operative time was 322 (262-603 ) minutes without open conversion. There were no intraoperative or 30 day major postoperative complications (ie; anastomotic leak, hemorrhage, intraabdominal organ injury, and thromboembolic events) seen. A single patient experienced port site infection and another developed severe carpal tunnel syndrome exacerbation postoperatively. Average length of hospital stay was 3.4 (3-13) days. Two patients were readmitted within 30 days due to fluid retention and incarcerated umbilical hernia respectively. No BPD/DS related reoperation or mortality occurred in this series. Conclusion: Robotically assisted laparoscopic BPD/DS is a safe and feasible alternative for weight loss surgery. Improved ease of operation, visualization, and range of motion especially during creation of anastomosis are the advantages of this technique
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Acetaminophen, like conventional NSAIDs, may reduce synovitis in osteoarthritic knees
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To determine the extent to which treatment of patients with symptomatic knee osteoarthritis (OA) with non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (ACET) reduces total effusion volume and synovial tissue volume, as quantified by magnetic resonance imaging (MRI).
METHODS: Sequential pilot studies used subjects whose knee OA was treated with NSAIDs (n=10) or with ACET <or=4 g/day (n=20), respectively. After a five half-lives washout of their pain medication, the OA knee with the higher pain score >or=15 of 25 on the Western Ontario and McMaster Universities' pain scale underwent l.5T MRI. Effusion was quantified in axial short tau inversion recovery images; to measure synovial tissue volume, fat-suppressed T1-weighted axial images were obtained 3 min after i.v. injection of gadolinium contrast. After the initial MRI examination, patients resumed their customary pain medications until the severity of knee pain returned to baseline, when pain was again measured and the MRI was repeated.
RESULTS: Pain severity after washout was similar in subjects taking ACET and NSAIDs. Reinstitution of ACET resulted in a 50% decrease in the mean of pain scores (P=1.7 x 10(-12)) that was comparable with that seen after the reinstitution of NSAID (49%, P=6.0 x 10(-7)). The mean total effusion volume measured during the flare of knee pain induced by the withdrawal of the two drugs was comparable (ACET 16.9 ml, NSAID 16.2 ml; P=0.884). Significant decreases in mean total effusion volume were observed after reinstitution of both ACET (-4.5 ml, P=0.009) and NSAID (-3.3 ml, P=0.013); the difference between drugs was not significant. Analyses of synovial volume yielded similar results.
CONCLUSION: While uncontrolled and derived from small samples, these data suggest that ACET may have a significant anti-inflammatory effect in patients with knee OA, comparable with that achieved with NSAIDs, possibly through an effect on neurogenic inflammation. Joint pain is the clinical feature of OA that most often leads the affected individual to seek medical attention. Because many patients with OA improve symptomatically with the use of NSAIDs, it has been widely assumed that the pain of OA is due to synovial inflammation. However, the origins of OA pain are numerous and may vary from patient to patient and, within the same subject, from visit to visit. Although the articular cartilage is usually the site of the most obvious pathological changes in this disease, it is aneural and, therefore, is not the source of joint pain. However, in addition to the synovium, the subchondral bone, joint capsule, osteophytes, menisci, ligaments, periarticular tendons, entheses and bursae all contain nociceptive nerve endings, stimulation of which by chemical or physical mediators may be a basis for OA pain.
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0 |
Limb salvage with isolated perfusion for soft tissue sarcoma: Could less TNF-α be better?
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DOD - Acute Comp Syndrome CPG
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Background: The optimal dose of TNF-α delivered by isolated limb perfusion (ILP) in patients with locally advanced soft tissue sarcoma is still unknown. Patients and methods: Randomised phase II trial comparing hyperthermic ILP (38-40°) with melphalan and one of the four assigned doses of TNF-α: 0.5 mg, 1 mg, 2 mg, and 3/4 mg upper/ lower limb. The main end point was objective tumour response on MRI. Secondary end points were histological response, rate of amputation and toxicity. Resection of the remnant tumour was performed 2-3 months after ILP. The sample size was calculated assuming a linear increase of 10% in the objective response rates between each dose level group. Results: One hundred patients (25 per arm) were included. Thirteen per cent of patients had a systemic leakage with a cardiac toxicity in six patients correlated with high doses of TNF-α. Objective tumour responses were: 68%, 56%, 72% and 64% in the 0.5 mg, 1 mg, 2 mg and 3 or 4 mg arms, respectively (NS). Sixteen per cent of patients were not operated, 71% had a conservative surgery and 13% were amputated with no difference between the groups. With a median follow-up of 24 months, the 2 year overall and disease-free survival rates (95% CI) were 82% (73% to 89%) and 49% (39% to 59%), respectively. Conclusion: At the range of TNF-α doses tested, there was no dose effect detected for the objective tumour response, but systemic toxicity was significantly correlated with higher TNF-α doses. Efficacy and safety of low-dose TNF-α could greatly facilitate ILP procedures in the near future. © 2005 European Society for Medical Oncology.
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0 |
Bone Health Optimization in Orthopaedic Surgery
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Hip Fx in the Elderly 2019
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BACKGROUND: Osteoporosis is associated with adverse orthopaedic surgical outcomes. Bone health optimization is a preoperative intervention intended to reduce the likelihood of postoperative complications. We aimed to characterize a patient cohort referred for bone health optimization to test the hypothesis that poor bone quality is common in orthopaedic surgery and that many such patients meet guidelines for osteoporosis treatment.
METHODS: This retrospective study evaluated 124 patients referred for bone health optimization who were >=50 years of age and candidates for arthroplasty or thoracolumbar surgery. The Fracture Risk Assessment Tool (FRAX) risk factors and dual x-ray absorptiometry (DXA) results were collected. When available, opportunistic computed tomographic (CT) imaging and the trabecular bone score were evaluated. The World Health Organization (WHO) diagnostic and National Osteoporosis Foundation (NOF) treatment guidelines were applied.
RESULTS: All patients were referred by their orthopaedic surgeon; their mean age was 69.2 years, 83% of patients were female, 97% were Caucasian, and 56% had sustained a previous fracture. The mean historical height loss (and standard deviation) was 5.3 +/- 3.3 cm for women and 6.0 +/- 3.6 cm for men. The mean lowest T-score of the hip, spine, or wrist was -2.43 +/- 0.90 points in women and -2.04 +/- 0.81 points in men (p < 0.08). Osteoporosis (T-score of <=-2.5 points) was present in 45% of women and 20% of men; only 3% of women and 10% of men had normal bone mineral density. Opportunistic CT scans identified 60% of patients as likely having osteoporosis. The trabecular bone score identified 34% of patients with degraded bone microarchitecture and 30% of patients with partially degraded bone microarchitecture. The NOF threshold for osteoporosis treatment was met in 91% of patients. Treatment was prescribed in 75% of patients (45% anabolic therapy and 30% antiresorptive therapy).
CONCLUSIONS: Osteoporosis, degraded bone microarchitecture, prior fracture, and elevated fracture risk were common. Given the high prevalence of impaired bone health in this cohort, we believe that bone health screening, including FRAX assessment, should be considered in selected patients undergoing orthopaedic surgery as part of the preoperative optimization for all adults who are >=50 years of age.
LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Denosumab: benefits of RANK ligand inhibition in cancer patients
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MSTS 2018 - Femur Mets and MM
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PURPOSE OF REVIEW: RANK ligand (RANKL) plays a central role in the cancer-induced bone destruction that results from bone metastasis. The RANKL inhibitor denosumab was recently approved for the prevention of skeletal-related events (SREs) in patients with bone metastases from solid tumors. This review summarizes recent findings of the effects of RANKL inhibition and denosumab in the cancer setting.
RECENT FINDINGS: Preclinical data show that RANKL inhibition in combination with antitumor therapies has additive effects on preventing skeletal tumor progression. Preclinical breast cancer models also suggest RANKL may be involved in primary tumorigenesis and establishment of metastases in bone and other tissues. Pivotal clinical trial data with denosumab in advanced cancer patients across tumor types showed it was superior (breast and prostate) or noninferior trending toward superior (solid tumors/multiple myeloma) to zoledronic acid, in reducing the risk of developing an SRE and demonstrated a favorable safety profile. Denosumab has also demonstrated efficacy in the treatment of giant cell tumor of bone.
SUMMARY: Denosumab offers an important new treatment option for patients with solid tumors and bone metastases. The efficacy of RANKL inhibition with denosumab in other disease states in the cancer setting continues to be evaluated.
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Minimally invasive endoscopic ulnar nerve assessment and surgery for cubital tunnel syndrome patients - Relation between endoscopic nerve findings and clinical symptoms
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OAK 3 - Non-arthroplasty tx of OAK
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To minimize damage to healthy tissues, we have been performing endoscopically assisted cubital tunnel syndrome surgery based on endoscopic nerve findings since 1995. This is the first study to focus on endoscopic surgery for cubital tunnel syndrome based on endoscopic ulnar nerve findings and the subsequent postoperative clinical results. We analysed 82 upper extremities of 74 cubital tunnel syndrome patients who had undergone endoscopically assisted release surgery using the Universal Subcutaneous Endoscope system. Endoscopic observations of the ulnar nerve were made from a single 1- to 3-cm endoscopic portal incision at the cubital tunnel to 10 cm proximal and 10 cm distal. The abnormal nerve areas were identified and released based on nerve degeneration findings under endoscopic observation. The abnormal areas spread eccentrically from the entrapment point(s). In 82 diseased upper extremities, ulnar nerve entrapment occurred at the cubital tunnel. However, one extremity suffered from entrapment at the arcade of Struthers' in addition to the cubital tunnel. All patients showed improved clinical symptoms following surgery. There is no statistical relation between pre- and postoperative clinical scores of Dellon's Staging and abnormal nerve length findings. Cubital tunnel syndrome is usually caused by entrapment at the cubital tunnel; however, in some cases, there are other point entrapment(s). Our endoscopically assisted procedure avoids any damage to healthy tissues because the surgeon can observe the entrapment point(s) prior to release. Postoperative clinical recovery results clearly indicate that endoscopic nerve findings reveal entrapment points and ulnar nerve degeneration can spread maximally 10 cm distally and proximally from the entrapment point(s), even in clinically mild severity cases. All other possible entrapment points should, therefore, be observed and released using our procedure. © 2014, Asia Pacific Knee, Arthroscopy and Sports Medicine Society. Published by Elsevier (Singapore) Pte Ltd. All rights reserved.
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Relationship between oral condition and risk factors for jaw osteonecrosis in patients with hip fractures
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Dental Implant Infection
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Purpose : Antiresorptive agents, such as bisphosphonates, are useful for the prevention of the recurrence of hip fractures. However, their administration has a risk of antiresorptive agent-related osteonecrosis of the jaw (ARONJ), and risk factors include poor oral hygiene. It is difficult for an orthopedic surgeon to examine a patient's oral condition thoroughly. This study evaluated the relationship between risk factors for ARONJ and intraoral findings in hip fracture patients. Materials and Methods : We evaluated 79 patients (average age of 82.2 years) with hip fracture surgery who underwent an oral assessment by dentists. The risk assessments of the intraoral findings were classified into four levels (levels 0-3), with levels 2 and 3 requiring dental treatment intervention. Data that could be extracted as risk factors of ARONJ were also examined. Results : Level 1 was found most frequently (54.4%), followed by level 0 (35.4%), level 2 (8.9%), level 3 (1.3%). The area under the receiver operating characteristic curve for the number of risk factors for the two groups (dental treatment intervention required and unnecessary) and oral findings were 0.732. When the cut-off value was set to two risk factors, the specificity and sensitivity was 53.5% and 87.5%. Conclusions : For hip fracture patients with a more than 2 risk factors, dental visits are recommended to prevent ARONJ. This is a useful evaluation method that can be used to screen for ONJ from data obtained from other risk factors, even if it is difficult to evaluate the oral condition in hospitals where dentists are absent. J. Med. Invest. 67 : 328-331, August, 2020.
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The effectiveness of triamcinolone acetonide vs. procaine hydrochloride injection in the management of carpal tunnel syndrome: a double-blind randomized clinical trial
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVE: Corticosteroid injection into the carpal tunnel is frequently used for the treatment of carpal tunnel syndrome (CTS). Steroids are usually mixed with local anesthetics, which have positive effects that can aid the treatment of CTS by inhibiting the spontaneous discharge ability of excitable cells. The aim of this study was 3-fold: (1) to determine the efficacy of triamcinolone acetonide injection in the treatment of CTS, (2) to determine the efficacy of procaine hydrochloride (HCl) in the treatment of CTS, and (3) to compare the efficacy of triamcinolone acetonide and that of procaine HCl in the treatment of CTS. DESIGN: This prospective, randomized, double-blind clinical trial included 99 patients (120 median nerves) with clinical and electrophysiologic evidence of CTS. The 120 median nerves were randomly assigned to one of three groups: group 1 received 40 mg of triamcinolone acetonide, group 2 received 4 ml of 1% procaine HCl, and group 3 received both 40 mg of triamcinolone acetonide and 4 ml of 1% procaine HCl. Clinical and electrophysiologic evaluations were performed at the study onset and at 2 and 6 mos after treatment. RESULTS: At the study onset, there were no statistically significant differences between the groups with respect to distal motor latency, compound motor action potential, compound sensory action potential, sensory nerve conduction velocity, or visual analog scale score; however, distal motor latency, compound sensory action potential amplitude, sensory nerve conduction velocity, and visual analog scale scores improved significantly in each group 2 mos after treatment (P < 0.05), and these improvements persisted at 6 mos after treatment (P < 0.05). Significant differences were not observed between groups 1 and 2 or between groups 1 and 3 with respect to electrophysiologic findings at baseline or 2 or 6 mos after treatment (P > 0.05). Group 3 had better compound sensory action potential amplitude and sensory nerve conduction velocity scores than group 2 did at 6 mos (P < 0.05) and better visual analog scale scores than group 2 did at 2 and 6 mos (P < 0.05). CONCLUSIONS: Local procaine HCl injection and steroid injection effectively reduced the symptoms of CTS and equally improved electrophysiologic findings. As such, procaine HCl can be used in CTS patients in whom steroid use is contraindicated
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The differences of femoral neck geometric parameters: effects of age, gender and race
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Management of Hip Fractures in the Elderly
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This study aims at investigating the effects of age, sex, and ethnicity on five femoral neck geometric parameters (FNGPs): femoral neck periosteal diameter, cross-sectional area, cortical thickness, sectional modulus, and buckling ratio and found that the three factors would influence the FNGPs. INTRODUCTION: Bone geometry is one of the most important predictors of bone strength and osteoporotic fractures. This study aims at investigating the effects of age, sex, and ethnicity on five femoral neck geometric parameters (FNGPs): femoral neck periosteal diameter (W), cross-sectional area (CSA), cortical thickness (CT), sectional modulus (Z), and buckling ratio (BR). METHODS: In the studied 861 Caucasian subjects and 3,021 Chinese individuals, CSA, CT, and Z displayed trends of decrease with age, but W and BR showed increasing trends with age in both Chinese and Caucasian females and males (p < 0.05). W, CSA, CT, and Z were significantly higher (p <or= 0.001) in Caucasians than in Chinese and higher in males than in females except for BR between Chinese males and Chinese females. CONCLUSION: In conclusion, the differences of FNGPs according to gender and ethnicity provide important implications in the different prevalence of osteoporotic fracture among different gender and ethnic groups
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Nutritional assessment of residents in long-term care facilities (LTCFs): recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA
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HipFx Supplemental Cost Analysis
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Unintentional weight loss and Undernutrition are major problems among older people living in Long-Term Care Facilities (LTCF). Undernutrition manifests in LTCF particularly as weight loss and low Body Mass Index (BMI) and is associated with increased morbidity and mortality as well as with functional decline. There are many factors associated with poor nutritional status and affecting protein-energy intake and/or energy expenditure. These include age of 85 years or older, low nutrient intake, loss of ability to eat independently, swallowing and chewing difficulties, becoming bed-ridden, pressure ulcers, history of hip fracture, dementia, depressive symptoms and suffering from two or more chronic illnesses. Nutritional evaluation is an essential part of the Comprehensive Geriatric Assessment (CGA). This evaluation ranges from methods such as BMI to several validated tools such as Mini-Nutritional Assessment (MNA). After diagnosis, the management of undernutrition in LTCF requires a multidisciplinary approach which may involve dietary and environmental improvements and managing multiple co-morbidities, while avoiding polypharmacy as far as possible. Finally, the need for supplementation or artificial (tube) feeding may be considered taking into account the CGA and individual needs. This document presents a succinct review and recommendations of evaluation and treatment of undernutrition
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Proximal fibular osteotomy as a treatment for degenerative meniscal extrusion
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AMP (Acute Meniscal Pathology)
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Meniscal extrusion treatment is a key focus area for research and clinical study of degenerative knee pathology. The contact forces between the meniscus and the bones cause external displacements of the meniscus that are resisted by the circumferential fibres. The main risk factors for the excessive deformation of the meniscus are meniscal root tears, disruption of the circumferential fibres, knee malalignment and high body mass index. Prior research has shown meniscal extrusion to be a crucial determinant of successful procedures in knee osteoarthritis treatment. The characteristics of medial knee osteoarthritis are an increase in varus malalignment and the load transferred through the medial compartment. This is associated with greatest reduction of the joint space width over the medial meniscus body and an increase in contact forces acting on the meniscus, which results in increased extrusion of the medial meniscal body. Relocating the meniscus in its anatomic position restores the correct distribution of contact force across the knee joint, and prevents destruction of the cartilage. Thus, clinical and biomechanical research focus on improving surgical techniques that allow for diminished meniscal extrusion. Proximal fibula osteotomy is a relatively new technique which involves the removal of a 10 mm piece of fibula, 4–10 cm from the fibular head. This technique has been shown to reduce the knee-lever arm, load transferred through the medial compartment and increase the medial joint space width. We hypothesise that proximal fibular osteotomy could be an effective, simple, and minimally invasive treatment for degenerative meniscal extrusion.
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Earplug Umbilicoplasty: A Simple Method to Prevent Umbilical Stenosis in a Tummy Tuck
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Panniculectomy & Abdominoplasty CPG
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Objective: An aesthetically pleasing umbilicus is a vital component of patient satisfaction following an abdominoplasty. An umbilicus that is moderate to small is desired to achieve the best aesthetic result, but a small umbilicus has potential for stenosis. This article presents a method for umbilical stenting that creates a modest umbilicus, while preventing stenosis. Methods: All patients underwent abdominoplasty with an umbilical reconstruction using an inverted U-flap method between 2015 and 2017. An earplug was placed into the umbilicus at 2 weeks postoperatively for a total of 4 to 6 week. Patients were evaluated subjectively on the aesthetic outcome. Results: Twenty-one female patients were evaluated 6 weeks postsurgery. In all cases, both the patient and the surgeon were 100% satisfied with the final size. Umbilical size ranged from 1.8 to 2.2 cm. Conclusions: Use of an earplug for umbilical stenting is a simple and reproducible method to create an aesthetically pleasing umbilicus and avoid stenosis.
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Hand musculoskeletal disease and thyroid disease: Not only hypothyroidism
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The literature shows that hypothyroidism can induce carpal tunnel disease by edema of peritendinous tissue. Other epidemiological studies confirmed the high incidence of hand musculoskeletal disease among people affected by thyroid disease without identifying a possible pathogenesis of the phenomena. In a previously study on a population of 7963 patients undergoing total thyroidectomy in our Department, we observed that 4.8% of patients affected by DTC referred a past surgical decompression of carpal tunnel. In this prospective study, we evaluated the prevalence of Dupuytren's contracture, trigger finger, and carpal tunnel in a large series of patients referred to our thyroid service, with various thyroid disease and different levels of functions. We enrolled patients with euthyroid nodular diseases, toxic adenoma, Basedow disease, total thyroidectomy, hypothyroidism, and thyroiditis, and we divided this population in two groups: patients treated with L4 or L4-L3 and patient not treated. We evaluated the presence of hand musculoskeletal disease by a neurological and musculoskeletal examination after a standardized symptom questionnaire. The prevalence of hand musculoskeletal problems was analyzed with respect to thyroid function, thyroid autoantibody status, and thyroid hormonal therapy. The aim of this preliminary study was demonstrate that the high prevalence of hand disease in patients with thyroid disease not only is related to hypothyroidism but it significantly increases also in euthyroid patients treated with thyroid hormones. Our goal for the future is the genetic and molecular analysis of the specific cellular signaling response of peritendinous fat and peritendinous guaina to the exogenous and endogenous thyroid hormone, to identify this unknown pathogenetic mechanism
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Rehabilitation of reading in older individuals with macular degeneration: a review of effective training programs
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Upper Eyelid and Brow Surgery
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Macular degeneration (MD) is the most common cause of visual impairment among older adults. It severely affects reading performance. People with MD have to rely on peripheral vision for reading. In this review, we considered several training programs that aim to improve peripheral reading, with a focus on eccentric viewing, oculomotor control, or perceptual learning. There was no strong support in favor of one particular training method for rehabilitation of reading in MD, but there is evidence that older individuals with MD can be trained to improve reading performance, even within limited time.
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Current concepts in post-bariatric body contouring
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Reduction Mammoplasty for Female Breast Hypertrophy
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Background: The advent of bariatric surgery has led to a new subspecialty in plastic surgery for contouring the skin and fat remaining after massive weight loss. This field is increasingly recognized as a vital component to the multi-disciplinary treatment approach to care for the obese patient. The author sought to review key concepts in patient selection, technical advancements, and post-operative care in body contouring following weight loss surgery. Methods: A literature review in PubMed identified articles relevant to the care of massive weight loss patients presenting for plastic surgical contouring. These articles were combined with a retrospective review of the author's personal experience in management of these patients. Results: The best candidates for post-bariatric plastic surgery are those who have achieved weight loss stability with a BMI of 35 or less and who have adequate nutrition to heal the surgical excisions. Truncal deformity is the most common presenting complaint of massive weight loss patients, and the procedure of choice to address this region is a lower body lift. Post-operative care focuses on patient safety prioritizing in DVT prophylaxis and seroma prevention. Conclusions: Bariatric procedures routinely achieve sustained decreases in body mass index; however, the remaining skin in the massive-weight-loss patient serves as a reminder of their previous obese existence. Post-bariatric body contouring aims to correct this deformity and restore a sense of normalcy. By reshaping the body into its ideal proportions, the true success of the weight loss surgery is fully realized. © 2010 Springer Science + Business Media, LLC.
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Dermatitis due to orthopaedic implants
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AAHKS (2) Corticosteroids
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Orthopaedic implant related dermatitis is a rare complication. The present review compiles the analysis of current literature related with pathophysiology, diagnosis and management of orthopaedic implant related dermatitis. Currently there is no any standard for the diagnosis of orthopaedic implant related hypersensitivity i.e., dermatitis. However, tests like patch test, lymphocyte transformation test (LTT) have demonstrated efficacy among others. The management of orthopaedic implant related dermatitis includes the use of medication, replacement of implant with less allergic materials etc. However, further improvements in management of this case are needed to reach a final conclusion.
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One-step surgery with multipotent stem cells for the treatment of large full-thickness chondral defects of the knee
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Chondral lesions in athletically active patients cause considerable morbidity, and treatment with existing cell-based therapies can be challenging. Bone marrow has been shown as a possible source of multipotent stem cells (MSCs) with chondrogenic potential and is easy to harvest during the same surgical procedure.
PURPOSE: To investigate the clinical outcome in a group of active patients with large full-thickness chondral defects of the knee treated with 1-step surgery using bone marrow-derived MSCs and a second-generation matrix.
STUDY DESIGN: Case series; Level of evidence, 4.
METHODS: From January 2007 to February 2010, 25 patients (average age, 46.5 years) with symptomatic large chondral defects of the knee (International Cartilage Repair Society grade 4) who underwent cartilage transplantation with MSCs and a collagen type I/III matrix were followed up for a minimum of 3 years. The average lesion size was 8.3 cm(2). Coexisting injuries were treated during the same surgical procedure in 18 patients. All patients underwent a standard postoperative rehabilitation program. Preoperative and postoperative evaluations at 1-year, 2-year, and final follow-up included radiographs, magnetic resonance imaging (MRI), and visual analog scale (VAS) for pain, International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Marx, and Tegner scores. Seven patients underwent second-look arthroscopic surgery, with 4 consenting to a tissue biopsy.
RESULTS: No patients were lost at final follow-up. The average preoperative values for the evaluated scores were significantly improved at final follow-up (P < .001): VAS, 5.4 +/- 0.37 to 0.48 +/- 0.19; IKDC subjective, 37.92 +/- 4.52 to 81.73 +/- 2.42; KOOS pain, 61.04 +/- 3.95 to 93.32 +/- 1.92; KOOS symptoms, 55.64 +/- 3.23 to 89.32 +/- 2.32; KOOS activities of daily living, 63.96 +/- 4.48 to 91.20 +/- 2.74; KOOS sports, 34.20 +/- 5.04 to 80.00 +/- 3.92; KOOS quality of life, 32.20 +/- 4.43 to 83.04 +/- 3.37; Lysholm, 46.36 +/- 2.25 to 86.52 +/- 2.73; Marx, 3.00 +/- 0.79 to 9.04 +/- 0.79; and Tegner, 2.12 +/- 0.32 to 5.64 +/- 0.26. Patients younger than 45 years of age and those with smaller or single lesions showed better outcomes. The MRI scans showed good stability of the implant and complete filling of the defect in 80% of patients, and hyaline-like cartilage was found in the histological analysis of the biopsied tissue. No adverse reactions or postoperative complications were noted.
CONCLUSION: The treatment of large chondral defects with MSCs is an effective procedure and can be performed routinely in clinical practice. Moreover, it can be achieved with 1-step surgery, avoiding a previous surgical procedure to harvest cartilage and subsequent chondrocyte cultivation.
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Humeral shaft fractures: retrospective results of non-operative and operative treatment of 186 patients
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Humeral shaft fractures account for 1-3% of all fractures and 20% of the fractures involving the humerus. The aim of the current study was to compare the outcome after operative and non-operative treatment of humeral shaft fractures, by comparing the time to radiological union and the rates of delayed union and complications.
METHODS: All patients aged 16 years or over treated for a humeral shaft fracture during a 5-year period were included in this retrospective analysis; periprosthetic and pathological fractures were excluded. Radiographs and medical charts were retrieved and reviewed in order to collect data on fracture classification, time to radiographic consolidation and the occurrence of adverse events.
RESULTS: A total of 186 patients were included; 91 were treated non-operatively and 95 were treated operatively. Mean age was 58.7 +/- 1.5 years and 57.0% were female. In 83.3% of the patients, only the humerus was affected. A fall from standing height was the most common cause of the fracture (72.0%). Consolidation time varied from a median of 11-28 weeks. The rate of radial nerve palsy in both groups was similar: 8.8% versus 9.5%. In 5.3% of the operatively treated patients, the palsy resulted from the operation. Likewise, delayed union rates were similar in both groups: 18.7% following non-operative treatment versus 18.9% following surgery.
CONCLUSION: The data indicated that consolidation time and complication rates were similar after operative and non-operative treatment. A prospective randomised clinical trial comparing non-operative with operative treatment is needed in order to examine other aspects of outcome, meaning shoulder and elbow function, postoperative infection rates, trauma-related quality of life and patient satisfaction.
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The correlation between Salter's criteria for avascular necrosis of the femoral head and Kalamchi's prognostic classification following the treatment of developmental dysplasia of the hip
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Developmental Dysplasia of the Hip 2020 Review
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AIMS: The aim of this study was to evaluate the correlation between Salter's criteria and Kalamchi's classification of avascular necrosis in patients treated for developmental dysphasia of the hip (DDH). PATIENTS AND METHODS: The study involved a retrospective analysis of 123 patients (123 hips) with DDH treated by operative and non-operative reduction before the age of two years, with a minimum follow-up of ten years. Salter's criteria (S1 to S4) were determined from radiographs obtained at one to two years post-reduction, whilst the Kalamchi grade was determined from radiographs obtained at ten or more years of age. Early post-reduction radiographs were also used to evaluate the centre-head distance discrepancy (CHDD) and the occurrence of a dome-shaped deformity of the proximal femoral metaphysis (D-shaped metaphysis). The prognosis was described as good (Kalamchi grade K0 or KI), fair (Kalamchi grade KII) or poor (Kalamchi grade KIII or KIV) for analysis and correlation with the early Salter criteria, CHDD and D-shaped metaphysis. RESULTS: S1 and S2 criteria were predictive of a poor prognosis. The outcome following S3, S4 and S3 + S4 varied; 18 (40%) had a good prognosis, 17 (38%) a fair prognosis and ten (22%) a poor prognosis. A CHDD â?¥ 10% and a D-shaped metaphysis were also predictive of a poor prognosis. CONCLUSION: The Salter criteria were predictive of the Kalamchi grade of avascular necrosis in patients with DDH aged ten or more years after reduction of the hip. Cite this article: Bone Joint J 2017;99-B:1115-20.
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Does chondrolysis occur after corticosteroid-analgesic injections? An analysis of patients treated for adhesive capsulitis of the shoulder
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Glenohumeral Joint OA
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BACKGROUND: Clinical studies using continuous infusions of local anesthetics and basic science studies that model injections of local anesthetics have shown chondrotoxicity. However, clinical studies do not exist that have assessed for the risk of chondrolysis in nonarthritic joints exposed to single or intermittent corticosteroid or analgesic injections. Currently, there are no data available to guide the clinician on the safety of using these injections in clinical practice.
MATERIALS AND METHODS: A retrospective review of patients treated for adhesive capsulitis of the shoulder with at least 1 intra-articular injection of a corticosteroid and anesthetic was performed. The inclusion criteria were a diagnosis of adhesive capsulitis and a minimum 2-year follow-up. Prospective follow-up was performed to obtain patient-determined outcome scores, range of motion, and radiographs to determine the presence of chondrolysis.
RESULTS: Fifty-six patients with a mean age of 52.5 +/- 7.2 years were enrolled at a mean follow-up of 54 months. The mean number of injections performed was 1.5 +/- 0.7 (range, 1-4). At final follow-up, the mean Western Ontario Osteoarthritis of the Shoulder score was 91.4% +/- 14.2%; Disabilities of the Arm, Shoulder and Hand score, 6.7 +/- 9.6; Shoulder Pain and Disability Index score, 7.4 +/- 11.4; and Single Assessment Numeric Evaluation score, 92.7% +/- 10.1%. The Shoulder Activity Score was 8.3 +/- 4.7. Passive and active forward elevation, external rotation, internal rotation, and cross-body adduction showed no significant differences compared with the unaffected contralateral shoulder. There was no radiographic evidence of chondrolysis in any patient.
CONCLUSIONS: This study did not show chondrolysis in patients treated with an intra-articular corticosteroid and local anesthetic for adhesive capsulitis. The findings of this study do not support the cessation of using intra-articular analgesic-corticosteroid injections for the treatment of adhesive capsulitis.
LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.
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The first 6 weeks of recovery after primary total hip arthroplasty with fast track.[Erratum appears in Acta Orthop. 2018 Feb;89(1):140; PMID: 28914103]
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AAHKS (4) Acetaminophen
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Background and purpose - Fast-track protocols have been introduced worldwide to improve the recovery after total hip arthroplasty (THA). These protocols have reduced the length of hospital stay (LOS), and THA in an outpatient setting is also feasible. However, less is known regarding the first weeks after THA with fast track. We examined patients' experiences of the first 6 weeks after hospital discharge following inpatient and outpatient THA with fast track. Patients and methods - In a prospective cohort study, 100 consecutive patients who underwent THA surgery in a fast-track setting between February 2015 and October 2015 received a diary for 6 weeks. This diary contained various internationally validated questionnaires including HOOS-PS, OHS, EQ-5D, SF-12, and ICOAP. In addition, there were general questions regarding pain, the wound, physiotherapy, and thrombosis prophylaxis injections. Results - 94 patients completed the diary, 42 of whom were operated in an outpatient setting. Pain and use of pain medication had gradually decreased during the 6 weeks. Function and quality of life gradually improved. After 6 weeks, 91% of all patients reported better functioning and less pain than preoperatively. Interpretation - Fast track improves early functional outcome, and the PROMs reported during the first 6 weeks in this study showed continued improvement. They can be used as a baseline for future studies. The PROMs reported could also serve as a guide for staff and patients alike to modify expectations and therefore possibly improve patient satisfaction.
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Artificial intelligence detection of distal radius fractures: a comparison between the convolutional neural network and professional assessments
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Distal Radius Fractures
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Background and purpose - Artificial intelligence has rapidly become a powerful method in image analysis with the use of convolutional neural networks (CNNs). We assessed the ability of a CNN, with a fast object detection algorithm previously identifying the regions of interest, to detect distal radius fractures (DRFs) on anterior-posterior (AP) wrist radiographs.
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1 |
Reconstruction of the proximal femur with a modular resection prosthesis
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MSTS 2018 - Femur Mets and MM
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Background: Various megaprostheses are currently available for reconstruction of the proximal femur after tumor resection. This study evaluates the survival and complications of a modular megaprosthesis for reconstruction of the proximal femur. Materials and methods: We studied the medical files of 109 tumor patients (age range 16â??86 years) who underwent proximal femoral reconstruction with the MRP® megaprosthesis from 2002 to 2011. There were 70 patients with metastases, 34 patients with bone sarcomas, and five patients with hematological malignancies; 82 were primary and 27 were revision reconstructions. Mean follow-up was 2.5 years; 31 patients had a minimum five-year follow-up. We evaluated the survival and function of the patients, and the survival and complications of the megaprostheses. Results: Survival was significantly higher for the patients with bone sarcomas compared to those with metastases and hematological malignancies. Mean MSTS functional score was similar between patients with bone sarcomas and those with hematological malignancies and metastases, and between patients with primary and those with revision reconstructions. Overall survival of the MRP® megaprostheses was 74 % at 5 and 9 years. Fourteen (13.6 %) major complications occurred at a mean period of 1.4 years (range 3 months to 4.5 years); these included infection (5.8 %), dislocation (3.9 %), local recurrence (2.9 %), and acetabular fracture (1 %). Conclusion: MRP® megaprostheses are a valuable reconstruction option after tumor resection of the proximal femur.
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0 |
Patterns of distant organ metastases in esophageal cancer: A population-based study
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MSTS 2022 - Metastatic Disease of the Humerus
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Background: Esophageal cancer is the eighth most common cancer worldwide. The prognosis of esophageal cancer patients is dismal, especially those with distant organ metastasis. However, there are few studies describing the patterns of distant metastasis in esophageal cancer systematically. Methods: We gathered the data from Surveillance Epidemiology and End Results (SEER) database between 2010 and 2013. Categorical variables were analyzed by the Pearson Chi square test, and continuous variables were analyzed by the two-sample t test. Survival estimation and comparison among different variables were performed using Kaplan-Meier method. A multivariable logistic regression model was used to calculate odds ratios (OR) for sex, age, anatomical site, and histological type on specific metastases. Proportional hazards regression model was conducted to obtain adjusted hazard ratio (HRs) for different predictors of overall survival. Results: A total of 9,934 patients were eligible. Liver was the most common metastatic site in the patients of esophageal cancer and followed by lung, bone and brain. Some clinical features, including age, sex, histology type and histologic grade were independent risk factors for different sites of metastasis. Younger age, poorer differentiation, adenoma type and more metastatic sites might lead to poorer prognosis. Conclusions: Our findings revealed the patterns of metastasis in esophageal cancer, which could help clinicians to identify patients with metastasis and provide proper treatment.
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1 |
Vibrotactile sense in patients with different upper limb disorders compared with a control group
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background: Upper limb disorders (ULDs) are common, and so are the difficulties with regard to their specific diagnoses. According to diagnostic consensus criteria, specific diagnoses include neuropathy and muscular- and connective-tissue disorders (MCDs). There is a need for valid objective diagnostic tools to reveal underlying mechanisms for specific diagnoses. Objective: To investigate the possible differences in vibration perception threshold (VPT) and tolerance to suprathreshold stimulation (STS) between controls and specific diagnostic ULD patient groups with uni- and bilateral neuropathy and/or MCD. Methods: In 161 ULD patients and 40 controls, the VPT of the median, ulnar, and radial nerves innervating the hand was examined by vibrometry using the "method of limits". The tolerance to STS of the anterior forearm was tested in 128 of the patients and all controls. Results: The ULD patients in all diagnostic groups had significantly higher VPT (P < 0.05) in all the nerves in limbs, with and without diagnoses compared with controls. Only patient groups defined with neuropathy demonstrated significantly higher VPT in the limb with diagnoses compared with the contralateral limb without diagnoses. The highest VPTs were found in the patient group with unilateral neuropathy and MCD, and for the radial nerve, VPT was significantly higher than that for patients with unilateral MCD alone. These findings were confirmed by almost similar findings in STS responses. Conclusions: The ULD patients generally demonstrated increased VPT compared with controls, indicating a neurogenous component independent of specific ULD diagnosis. Contralateral significant findings in limbs without diagnoses compared with controls indicate central neurogenous affection and/or the possibility of certain exposures elevating VPT before a positive status of a limb diagnosis is attained. Significantly higher VPT values in limbs with neuropathy diagnoses compared with limbs without and not in MCD alone, may indicate peripheral sensibilization or nerve affection only in the group with a specific diagnosis of neuropathy. These findings underline the importance of specific diagnoses among ULD patients. (copyright) Springer-Verlag 2006
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Male reduction mammoplasty in serious gynecomastias
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Panniculectomy & Abdominoplasty CPG
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This article is a report on long-term followup of a total of 44 serious gynecomastia cases in the stages I-III (according to Deutinger). The treatment consisted of either a semicircular incision and subcutaneous mastectomy or a superiorly or an inferiorly based nipple transposition while performing male reduction mammoplasty. Aesthetically pleasing results could be obtained by a periareolar approach and mastectomy. This inconspicuous procedure is feasible even in massive gynecomastia cases (stage III) or in cases of male breast asymmetry. On the other hand, all cases with breast reduction plasty and nipple transposition resulted in wing-shaped, mainly broad scars, and subjectively unfavorable results. Consequently, we favor the semicircular approach in male reduction mammoplasty in treating serious gynecomastias. With regard to possible male breast cancer etiology, the histological specimen of the mammary gland in gynecomastia is excised prior to any additional liposuction for supplementary body contouring.
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Isolated pubic ramus fractures are serious adverse events for elderly persons: An observational study on 138 patients with fragility fractures of the pelvis type I (FFP type I)
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Hip Fx in the Elderly 2019
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Background: Fractures of the pubic ramus without involvement of the posterior pelvic ring represent a minority of fragility fractures of the pelvis (FFP). The natural history of patients suffering this FFP Type I has not been described so far. Material and methods: All patients, who were admitted with isolated pubic ramus fractures between 2007 and mid-2018, have been reviewed. Epidemiologic data, comorbidities, in-hospital complications, and one-year mortality were recorded. Of all surviving patients, living condition before the fracture and at follow-up was noted. Mobility was scored with the Parker Mobility Score, quality of life with the European Quality of Life 5 Dimensions 3 Level (EQ-5D-3L), subjective sensation of pain with the Numeric Rating Scale (NRS). Results: A consecutive series of 138 patients was included in the study. There were 117 women (84.8%) and 21 men (15.2%). Mean age was 80.6 years (SD 8.6 years). 89.1% of patients presented with comorbidities, 81.2% of them had cardiovascular diseases. Five patients (4%) died during hospital-stay. Median in-hospital stay was eight days (2–45 days). There were in-hospital complications in 16.5%, urinary tract infections, and pneumonia being the most frequent. One-year mortality was 16.7%. Reference values for the normal population of the same age are 5.9% for men and 4.0% for women. One-year mortality rate was 22.2% in the patient group of 80 years or above and 8.8% in the patient group below the age of 80. The rate of surviving patients living at home with or without assistance dropped from 80.5% to 65.3%. The median EQ-5D-Index Value was 0.62 (0.04–1; IQR 0.5–0.78). Reference value for the normal population is 0.78. Average PMS was 4 and NRS 3. Within a two-year period, additional fragility fractures occurred in 21.2% and antiresorptive medication was taken by only 45.2% of patients. Conclusion. Pubic ramus fractures without involvement of the posterior pelvis (FFP Type I) are serious adverse events for elderly persons. During follow-up, there is an excess mortality, a loss of independence, a restricted mobility, and a decreased quality of life. Pubic ramus fractures are indicators for the need to optimize the patient’s general condition.
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Pain management for rheumatoid arthritis and cardiovascular or renal comorbidity
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SR for PM on OA of All Extremities
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BACKGROUND: Pain in rheumatoid arthritis is common, is often multi-factorial and many different pharmacotherapeutic agents are routinely used for pain management. There are concerns that some of the pain pharmacotherapies currently used may increase the risk of adverse events in people with rheumatoid arthritis and concurrent cardiovascular or renal disease. OBJECTIVES: To systematically assess and collate the scientific evidence on the efficacy and safety of using pain pharmacotherapy in people with rheumatoid arthritis and cardiovascular or renal comorbidities. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 4); MEDLINE, from 1950; EMBASE, from 1980; the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE). We also handsearched the conference proceedings for American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) for 2008-09, and checked the websites of regulatory agencies for reported adverse events, labels and warnings. SELECTION CRITERIA: We considered randomised controlled trials and non-randomised studies comparing the efficacy and safety of pain pharmacotherapies in patients with rheumatoid arthritis, with and without comorbid cardiovascular or renal conditions.In addition, we also considered controlled before-after studies, interrupted time series, cohort and case control studies and case series (N >/= 20) to assess safety.For the purpose of our review, pain pharmacotherapy was defined as including simple analgesics (such as paracetamol), non-steroidal anti-inflammatory drugs (NSAIDs), opioids or opioid-like drugs (such as tramadol), and neuromodulators (including anti-depressants, anti-convulsants, and muscle relaxants). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the search results and planned to extract data and appraise the risk of bias of included studies. MAIN RESULTS: We did not identify any studies meeting our inclusion criteria. Many of the trials of NSAIDs explicitly excluded patients with cardiovascular or renal comorbidities.We did identify one trial that reported evidence in mixed populations (including both rheumatoid arthritis and osteoarthritis) taking either diclofenac or etoricoxib. In this study, the presence of cardiovascular disease increased the likelihood of a further cardiovascular event three-fold. Patients with two or more cardiovascular comorbidities showed a two-fold increased likelihood of adverse cardiovascular events. AUTHORS' CONCLUSIONS: There were no trials that specifically compared the efficacy and safety of pain pharmacotherapies for patients with rheumatoid arthritis, with and without comorbid cardiovascular or renal conditions.In the absence of specific evidence in rheumatoid arthritis, current guidelines recommend that NSAIDs be used with caution in the general rheumatoid arthritis population while highlighting the added need for extra vigilance in patients with established cardiovascular disease or risk factors for its development. Current guidelines regarding the use of NSAIDs and opioids in moderate to severe renal impairment should also be applied to the rheumatoid arthritis population.Further research is required to guide clinicians when treating pain in rheumatoid arthritis
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Fibrin sealants and platelet preparations in bone and periodontal healing
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Dental Implant Infection
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Fibrin sealants and platelet concentrates have been used alone or in association with bone substitutes to promote bone healing in orthopedic and oral surgery. Commercial fibrin sealants are homologous plasma-derived products that mimic the last step of a coagulation cascade, leading to a fibrin clot. They are used for topical hemostasis and tissue sealing and as melting agents for particulate bone substitutes. Infectious risk led to the development of autologous fibrin sealants from the patient's own plasma. However, their fabrication results in less reproducible or less satisfactory rheologic properties. The use of autologous products with high platelet concentrations, such as platelet-rich plasma, platelet concentrate, and platelet gels, has recently been suggested for combining the fibrin sealant properties with the growth factor effects of platelets. We describe the characteristics and limitations of fibrin sealants (commercial/autologous) and platelet preparations and review their effects on bone and periodontal healing as reported in experimental studies and clinical trials.
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Thrombolysis for Acute Lower Limb Ischaemia-A Prospective, Randomised, Multicentre Study Comparing Two Strategies
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DOD - Acute Comp Syndrome CPG
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Objectives: To test if initial high-dose, pulse-spray thrombolysis improves the early and late outcome of lower limb ischaemia as compared with low-dose infusion alone. Design: Prospective randomised multicentre study. Material and methods: Patients with acute and sub-acute (<30 days) lower limb ischaemia were randomised following angiography. Group 1 (n=58) received pulse-spray infusion of recombinant plasminogen activator (rt-PA, 15 mg/h) for 2 h followed by low-dose infusion if needed. Group 2 (n=63) were only treated with low-dose infusion (0.5 mg/h) of rt-PA for 48 h. Underlying lesions were corrected if required. Results: The study was stopped prematurely. Complications were equally frequent in both groups. More than 75% lysis was accomplished in 78 versus 67% of the patients (p=0.21). Primary endpoints (re-occlusion, incomplete lysis, life-threatening complication, amputation, or death) were reached in 24 versus 32% of the patients (p=0.35). Neither vascular patency nor clinical parameters differed during the first year, but re-interventions tended to be more frequent (p=0.040 at 1 month; p=0.090 at 1 year) and of a greater magnitude (p=0.028) in group 2. Conclusions: There was no obvious advantage with initial high-dose thrombolysis, which may be a type-2 error. A reduction of major re-interventions was recorded. © 2005 Elsevier Ltd. All rights reserved.
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Increased Long-term measurement variability with scanning laser polarimetry employing enhanced corneal compensation: an early sign of glaucoma progression
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Upper Eyelid and Brow Surgery
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PURPOSE: To investigate whether the intervisit standard deviation (ISD) of various scanning laser polarimetry parameters is increased, in progressing glaucoma. METHODS: GDx-variable corneal compensation (VCC) and GDx-enhanced corneal compensation (ECC) measurements, and Octopus G2 visual field tests, were performed at 6-month intervals on 27 healthy subjects and 52 consecutive glaucoma patients. One eye per participant was analyzed. Fifteen patients progressed (on the basis of visual field criteria) and 37 remained stable, during the 2.6+/-0.4 years follow-up. RESULTS: Baseline visual field indices and the stage of glaucoma did not differ between the glaucoma groups. No regression with time was found for any GDx parameter in any group. The ISD of GDx-ECC nerve fiber indicator (NFI), but not GDx-VCC NFI, was significantly higher in progression than in the stable glaucoma group (Mann-Whitney U test with Bonferroni correction, P=0.028). Also, several other ISD values tended to increase in the progressing group. Logistic regression analysis revealed that ISD of NFI [odds ratio (OR)=1.22, P=0.013], inferior average (OR=1.80, P=0.035), and average thickness along the measuring ellipse (OR=2.00, P=0.042), as determined with GDx-ECC (but not with GDx-VCC), all associated with visual field progression, independently of patient age. CONCLUSIONS: With GDx-ECC, increase of ISD is an early sign of glaucoma progression, precedes the development of detectable parameter changes, and is associated with visual field progression.
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Evaluation of immediate impact of cane use on energy expenditure during gait in patients with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: The aim of the present study was to assess the immediate impact of cane use on energy expenditure during gait in patients with knee OA analyzing VO(2).
METHODS: An observational, cross-sectional study was carried out on 64 symptomatic patients with a diagnosis of knee OA. The assessment of energy expenditure was performed through an analysis of expired gases using the portable K4 apparatus (Cosmed, Model K4 b2, Italy) during the six-min walk test (6MWT). Two tests were performed with a cane and two without a cane on two different days within a seven-day period.
RESULTS: The patients walked farther on the test without the cane (p<0.001). Oxygen expenditure (VO(2)) and the O(2) cost of walking at the end of the 6MWT increased approximately 50% and 80% during cane-assisted gait when compared to gait without the use of a cane (p<0.001). Pain (Borg scale) decreased approximately 20% at the end of the 6MWT with cane-assisted gait in comparison to gait without a cane (p<0.001).
CONCLUSION: Cane use causes an immediate increase in energy expenditure (VO(2)) during gait and O(2) cost of walking and an immediate decrease of pain during gait. It is necessary to do a more prolonged follow up in order to assess the impact of daily cane use on energy expenditure among these patients and determine whether adaptation occurs. Furthermore, it is necessary to study whether daily cane use has a positive impact on important parameters in these patients, such as pain, function and quality of life.
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Differences in prescription of narcotic pain medication after operative treatment of hip and ankle fractures in the United States and the Netherlands
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Management of Hip Fractures in the Elderly
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Background: Interactions between American and Dutch surgeons suggested differences in prescription habits for pain medication after fracture treatment. Methods: The percentages of 190 American [100 after hip open reduction and interal fixation (ORIF) and 90 after ankle ORIF] and 116 Dutch patients (69 after hip ORIF and 47 after ankle ORIF) receiving inpatient and outpatient prescriptions for narcotics were retrospectively compared between countries, to test the hypothesis that narcotics are prescribed more frequently in the United States as compared with the Netherlands after operative fracture treatment. Results: Among patients with hip fractures, 85% of American and 58% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 77% of American and none of the Dutch patients were prescribed narcotics (p < 0.001). The multivariate model including country accounted for 11% of the variation in inpatient narcotic prescription (p < 0.001), and the model including country and surgeon accounted for 55% of the variation in outpatient narcotic prescription (p < 0.001). Among patients with ankle fracture, 98% of American and 64% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 82% of American patients and 6% of Dutch patients were prescribed narcotics (p < 0.001). Predictors included country and surgeon and they accounted for 20% of the variation in inpatient narcotics prescription (p< 0.001) and 49% of the variation in outpatient narcotic prescription (p < 0.001). Conclusions: American patients are prescribed significantly more inpatient and outpatient narcotic pain medication than Dutch patients after operative treatment of hip and ankle fractures. Copyright (copyright) 2009 by Lippincott Williams & Wilkins
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Activation of the bile acid receptor GPBAR1 (TGR5) ameliorates interleukin-1beta (IL-1beta)- induced chondrocytes senescence
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OAK 3 - Non-arthroplasty tx of OAK
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Osteoarthritis is the most common chronic condition of the joint disease. Chondrocyte is the sole cell type in joint tissues. Senescence of chondrocytes is known to contribute to the causation of osteoarthritis. Local inflammatory cytokines- caused chondrocytes senescence is proposed to be one of the molecular mechanisms of osteoarthritis. In this study, we show that the bile acid receptor GPBAR1 (TGR5), a G protein couples bile acid receptor, plays important roles in protecting chondrocytes from interleukin 1beta (IL-1beta)- caused senescence. TGR5 is fairly expressed in cultured chondrocytes. Its expression is reduced in isolated chondrocytes from osteoarthritis patients, and IL-1beta treatment suppresses TGR5 expression. Activation of TGR5 by its synthetic agonist, INT-777, dramatically reduces senescence associated beta galactosidase activity by IL-1beta. Mechanistically, the action of INT-777 ameliorates IL-1beta- induced chondrocytes entry of G0/G1 arrest phase and exit of S and G2/M phases. INT-777 inhibits IL-1beta- induced expression of p21, PAI-1, and K382 acetylation of p53 as well as reduction of Sirt1. The knockdown of TRG5 abolished the protective role of INT-777 on these molecules. Collectively, our data indicates that activation of TGR5 is necessary for protection of IL-1beta- induced chondrocytes senescence.
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Clinical factors related to the efficacy and complications of orthopedic surgery for rheumatoid arthritis with infliximab
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DoD SSI (Surgical Site Infections)
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AIMS: To determine what clinical factors relating to efficacy besides complications of orthopedic surgery for patients treated with anti-tumor necrosis factor (TNF)-alpha therapy (infliximab), we analyzed the clinical data of 52 cases of orthopedic surgery, such as total hip arthroplasy (THA), total knee arthroplasty (TKA), total shoulder arthroplasy (TSA), total elbow arthroplasty (TEA), arthroscopic synovectomy, foot arthroplasty, spine surgery, hand surgery and fracture.
METHODS: We analyzed clinical factors including age, disease duration, preoperative C-reactive protein (CRP), disease activity score (DAS)-28, matrix metalloproteinase (MMP)-3, and rheumatoid arthritis particle-agglutination (RAPA) in 52 cases of rheumatoid arthritis (RA) undergoing orthopedic surgery. For complications of orthopedic surgery, signs of postoperative infection were recorded, including rubor, discharge, systemic infection and frequencies of wound dehiscence, as well as the incidence of any surgical complication requiring a secondary revision procedure were measured.
RESULTS: Signs of infection or surgical complications occurred in two of 52 patients (3.8%). There is significant correlation between RAPA and improvement of CRP 3 months after surgery; however, there is no correlation between infection and clinical factors including age, disease duration, preoperative CRP, MMP-3, RAPA and the period until surgery after infliximab infusion.
CONCLUSION: Infliximab did not increase the risk of either infections or surgical complications occurring in patients with RA within 1 year of orthopedic surgery. Improvement of CRP after surgery is likely to be due to infliximab for high RAPA in RA patients.
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Stacked Tantalum Cones as a Method for Treating Severe Distal Femoral Bone Deficiency in Total Knee Arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Severe bone loss in distal femur has traditionally been managed with bulk cementing, bone graft, metal augments, trabecular metal cones, and mega prosthesis. The authors present an alternative method using a stacked configuration of two tantalum cones to manage severe distal femoral bone loss. This study aims to evaluate the mid-term outcomes and possible complications in patients treated with this novel technique. We retrospectively analyzed the prospectively maintained records of 16 knees (in 16 patients) presenting with severe distal femoral bone deficiency due to septic loosening (5), giant cell tumor (GCT; 4), periprosthetic fracture (3), aseptic loosening (3), and distal femoral comminuted fracture with severe osteoarthritis (1). A standard medial parapatellar approach was taken in all our cases followed by preparation of distal femoral bone defect and use of two bridging tantalum trabecular metal cones to fill the defect, followed by implantation of rotating hinge knee prosthesis. At an average follow-up of 57 months (4.75 years), the average Knee Society Score was 74.56 (64-87) and the mean range of motion was 97.8 (70-120) degrees. Radiologically, all 16 knees showed good osteointegration with no evidence of progressive radiolucency or loosening. Complications included two patients with superficial infection (healed with antibiotics), and one with recurrence of GCT requiring tumor megaprosthesis reconstruction. The authors concluded that the stacked configuration of cones provides additional coverage and stability with good osteointegration and found it to be particularly useful in distal femoral GCTs and fracture situations. They recommend the use of stacked cones in selected cases of severe distal femoral deficiency.
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1 |
Decreasing mortality after femoral neck fracture treated with bipolar hemiarthroplasty during the last twenty years
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Management of Hip Fractures in the Elderly
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PURPOSE: The aim of our study was to investigate trends over time in the mortality of elderly patients after femoral neck fractures treated with bipolar hemiarthroplasty. METHODS: Altogether 487 cases of femoral neck fracture treated with bipolar hemiarthroplasty were observed during a 20-year period. Mortality rates were calculated for five years postoperatively. To account for the age distribution of the study population standardised mortality ratios (SMR) with respect to the age-specific mortality of the German population were determined and compared. Additional changes of the SMRs over time and the influence of the time delay before surgery on long-term mortality were evaluated. RESULTS: Femoral neck fractures treated with bipolar hemiendoprosthesis have a significant impact on mortality. Postoperative mortality is increased in patients of all age groups, but the effect diminishes in higher age groups. The influence on mortality was significantly greater for men than for women. The SMR has decreased from 3.52 before 1995 to 1.2 after 2006. Since 2006 there is no longer an increase in mortality after surgical treatment of a femoral neck fracture compared to general German population of the same age. CONCLUSION: Femoral neck fractures treated with bipolar hemiendoprosthesis result in a significantly increased mortality, however in our population this impact has significantly decreased over time. The effect on mortality is less in women and higher age groups than in men and younger patients. No influence of the time between accident and surgery on mortality could be detected
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MRSA harboring mecA variant gene mecC, France
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PJI DX Updated Search
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We describe human cases and clustered animal cases of mecA(LGA251)-positive methicillin-resistant Staphylococcus aureus in France. Our report confirms that this new variant has a large distribution in Europe. It may represent a public health threat because phenotypic and genotypic tests seem unable to detect this new resistance mechanism
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Breastfeeding pattern in the first month of life in women submitted to breast reduction and augmentation
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Reduction Mammoplasty for Female Breast Hypertrophy
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Objective: To describe the breastfeeding pattern in the first month of life in women submitted to two types of surgery - breast reduction and augmentation - and to compare it with the pattern exhibited by women who had no surgery. Methods: Controlled prospective cohort with 25 women submitted to reduction surgery, 24 submitted to augmentation surgery and 25 with no breast surgery, who gave birth at Hospital Israelita Albert Einstein, São Paulo, Brazil. The data were obtained from assessments carried out 48 to 72 hours, between the 5th and 7th days, and 30 days after delivery. The following tests were used for data analysis: chi-square test, Fisher's exact test, Kaplan-Meier curve and Cox regression. Results: The probability of an infant being on exclusive breastfeeding at the end of the first month of life was 29% in women with reduction surgery, 54% in those with augmentation surgery, and 80% in women who had no surgery. The probability of mixed breastfeeding being adopted during this same period amounted to 68% among women with reduction surgery, 32% in those with augmentation surgery, and only 16% among those without any breast surgery. The risk of an infant being on non-exclusive breastfeeding was five times greater in women submitted to reduction surgery when compared to those women with no surgery (p = 0.002). Among women with augmentation surgery, the risk of an infant being on non-exclusive breastfeeding was 2.6 times greater than that observed in infants whose mothers had no breast surgery (p = 0.075). Conclusion: Breast reduction and augmentation surgeries led to lower rates of exclusive breastfeeding in the first month of life. Copyright © 2010 by Sociedade Brasileira de Pediatria.
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Un-united fractures of the distal radius: a report of 12 cases
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Distal Radius Fractures
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The treatment of 12 distal radius nonunions in 11 patients over a 24-year period is presented. The average age of the patients was 55 years (range, 35-72 years). The comorbid medical conditions in the patients with these fractures included diabetes mellitus, peripheral vascular disease, psychiatric disorders, alcoholism, peripheral neuropathy, scleroderma, and morbid obesity. Nine of the un-united fractures in 8 patients had insufficient metaphyseal bone to allow internal fixation; 6 of these fractures were treated with a wrist arthrodesis. Three un-united fractures in 3 patients had sufficient supporting bone to permit correction of the nonunion and preservation of the radiocarpal joint. Three nonunions in 3 patients were treated without further surgery. Bony union was achieved in all 9 nonunions managed operatively (6 wrist arthrodeses and 3 open reductions).
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Singapore Health and Biomedical Congress, SHBC 2013
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MSTS 2018 - Femur Mets and MM
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The proceedings contain 327 papers. The special focus in this conference is on Health and Biomedicine. The topics include: Reducing the rate of postoperative endophthalmitis over 11 yearsÎ?Ã?Ã?results of a new intervention using intracameral antibiotics; corpus callosum morphology in first episode and chronic schizophrenia; differences in late cardiovascular mortality following acute myocardial infarction among three major Asian ethnicities; exploring relationship of retinal thickness on optical coherence tomography and visual acuity in patients with diabetic macular edema; medication reconciliation in outpatient hospital clinics; utilising discharge planning tools in an inpatient psychiatric rehabilitation services to promote positive clinical outcomes; sevenÎ?Ã?Ã?point subjective global assessment is more time sensitive than conventional subjective global assessment in detecting nutritional changes; Singapore hospice nurses perspectives about spirituality and spiritual care; enhanced infarct stabilisation and cardiac repair with an injectable PEGylatedÎ?Ã?Ã?fibrinogen hydrogel carrying vascular endothelial growth factor (VEGF); identification of tumour suppressive MicroRNAs in multiple myeloma by pharmacologic unmasking; use of a novel stereographic projection software to calculate precise area of peripheral nonÎ?Ã?Ã?perfusion and its correlation with manual grading; a protocol to reduce interÎ?Ã?Ã?reviewer variability in computed tomography measurement of orbital floor fractures; impact of genome wide supported psychosis susceptibility NRGN gene on thalamocortical morphology in schizophrenia; improved outcome of myeloma patients in a tertiary hospital; femoral neck fracturesÎ?Ã?Ã?factors affecting ambulatory status in elderly patients more than 65 years old who underwent hip hemiarthroplsty; exploratory factor analysis of the Zarit burden interview in a multiÎ?Ã?Ã?ethnic Asian community sample; prevalence, awareness, treatment and control of hypertension among Singapore elderly residential population; predictive factors of unscheduled 15Î?Ã?Ã?day hospital readmissions; lost in transitionÎ?Ã?Ã?newly qualified registered nurses and their transition to practice journey; national healthcare group clinical educators reflection on web2.0's application in enhancing teaching and lifelong learning in medical education; determinants of clarification studies in medical education research; hypoglycemia management of patients with type 2 diabetes in primary care setting; photographÎ?Ã?Ã?assisted dietary review amongst type 2 diabetics in primary care; exploring the feasibility of advanced care planning in persons with early cognitive impairment; roles of miRÎ?Ã?Ã?186 in circulating tumour cells (CTCs)Î?Ã?Ã?mediated metastasis in breast cancer; characterisation of the biological and clinical relevance of RUNX genes in natural killer TÎ?Ã?Ã?cell lymphoma; a randomised controlled trial comparing singleÎ?Ã?Ã?injection and continuous femoral nerve blocks with patientÎ?Ã?Ã?controlled analgesia; magnetic resonance imaging (MRI) changes in lower limbs in transition to frailty; prevalence of dilutional hyponatraemia in inpatients and outpatients in Singapore; a prospective randomised study on the patency period of the plastic antiÎ?Ã?Ã?reflux biliary stent; an academicÎ?Ã?Ã?practice collaboration through simulation learning; a multicentre study of physiotherapists' knowledge and perceptions in palliative care; post discharge pain experiences following total knee arthroplasty; characteristics of subjective QOL of elderly people with dementia in china and Japan; audit of readmissions to a palliative care unit in a tertiary hospital; factors affecting psychological distress in informal caregivers of Singapore elderly; prevalence of anaemia in patients on aspirin medication in a primary care setting; patient satisfaction with pharmacistÎ?Ã?Ã?managed hypertensionÎ?Ã?Ã?diabetesÎ?Ã?Ã?lipids clinic and its relation to medication adherence and beliefs about medication; anthropometric measures and cognition in the Singapore elderly; clinical ecision support for highÎ?Ã?Ã?priority drugÎ?Ã?Ã?drug interactions; a normative study on the national university health system aphasia screening test; a pilot study on the integration of a cognitiveÎ?Ã?Ã?behavioral therapyÎ?Ã?Ã?based computer game in the clinical treatment of childhood anxiety; barriers of wholeÎ?Ã?Ã?grain intake among healthcare workers in national healthcare group polyclinics; a novel approach to lead screening; effects of computed tomography contrast on bone scans; prevalence and predictors of employment among the Singaporean elderly; evaluating the impact of inpatient accelerated palliative radiation therapy programme in reducing inpatient hospitalisation; socioÎ?Ã?Ã?demographic correlates of positive mental health; unravelling the relationship between obesity, schizophrenia and cognition; relationship between measures of mental health and functional impairment in primary care; body mass index of elderly persons in Singapore; improving the influenza and pneumococcal vaccination rate of eligible patients with chronic heart failure; reducing near misses from packing errors in inpatient pharmacy; pharmacyÎ?Ã?Ã?led smoking cessation clinic in dermatology; investigation of high platelet count in random platelet unit and its viability; public attitudes towards mentallyÎ?Ã?Ã?ill persons in Singapore; revisiting the association between parental bonding and risk for psychopathology; pharmacist reviews and outcomes in nursing homes in Singapore; evaluation of the inpatient smoking cessation programme in tan Tock Seng hospital; community forums are effective in improving osteoporosis knowledge; profile of patients referred for podiatry services in primary care; novel use of tigecycline for multiple myeloma in vitroÎ?Ã?Ã?alternative nonÎ?Ã?Ã?mitochondrial pathways; linking human leucineÎ?Ã?Ã?rich repeat kinase 2 (LRRK2) gene mutation to cancer development; haploinsufficiency of TP53 in multiple myeloma; bioactive and conductive collagen scaffold for wound healing augmented by electrical stimulation; systematic discovery of novel cilia and ciliopathy genes through functional genomics in the zebrafish; extracellular matrixÎ?Ã?Ã?based biohybrid skin substitutes; enzyme sensor system for determination of total cholesterol in human serum; intestinal microbial study of gout patients; differences in gut microbiome between schizophrenic patients and healthy individuals; changes in gait associated with sarcopenia; noncultured cellular grafting for vitiligoÎ?Ã?Ã?a threeÎ?Ã?Ã?year followÎ?Ã?Ã?up study; bariatric surgery and its impact on sleep; clinicoÎ?Ã?Ã?epidemiological profile of moderate to severe paediatric atopic dermatitis; influenza vaccination of healthcare workers; a snapshot of audits in the phototherapy unit; a naturalistic longitudinal study in healthy children; retrospective study on autoimmune blistering disease in paediatric patients; association between CHA65S2 score and obstructive sleep apnoea; primary localised cutaneous amyloidosis; high STOPÎ?Ã?Ã?BANG scores herald adverse perioperative outcomes; neurobehavioral outcomes after traumatic brain injury; extended outcomes by dialysis modality selection in incident patients with endÎ?Ã?Ã?stage renal disease and ischaemic cardiomyopathy; laparoscopic gastrectomies in gastric cancer patients; survey on factors influencing medication adherence in psychiatric patients; serum brainÎ?Ã?Ã?derived neurotrophic factor and metabolic indices in patients with schizophrenia; outcomes of nonÎ?Ã?Ã?Tbitrauma patients in a surgical intensive care unit; evaluation of patients screened for MERSÎ?Ã?Ã?CoV infection at tan Tock Seng hospital, Singapore; thinking twice before using the LMA for obese and older patientsÎ?Ã?Ã?a prospective observational study; comparison study between two apheresis machines; diabetes knowledge in older adults with type 2 diabetes in Singapore; establishing an intensive care unit database; necrotising fasciitis of the head and neck; diabetic chronic kidney disease patients should increase protein intake; the skinÎ?Ã?Ã?endocrine axis in the manageme t of dermatology patients; dematiaceous mycoses of the skin in Singapore from 2003 to 2010; profile of hearing aids users in Singapore; factors that affect the degree of hearing loss at presentation and hearing aid usage; cross diagnostic comparisons of quality of life between schizophrenia and bipolar disorder patients; value of hearing questionnaire in predicting hearing impairment; utility of selfÎ?Ã?Ã?perception of hearing loss questions in predicting hearing impairment; burnout, challenges and supportive factors in hospital doctors; exploring stereotypes in healthcare professions; health sciences virtual hospital game as a learning tool in nursing education; application of the RIME framework for education administrators' competencies; bed exit alarm as a novel tool for fall prevention; when prolonged preoperative fasting is a myth; timeÎ?Ã?Ã?motion study for nursing aides activities in a psychiatric hospital; impact of an advanced practice nurseÎ?Ã?Ã?led heart failure clinic in a secondary hospital in Singapore; managing individuals with diabetes using the diabetes ambulatory stabilisation services (DASS); streamlining process flow for maintenance of 12Î?Ã?Ã?lead ECG machine in a cardiology ward; factors of rehabilitation outcomes in primary care physiotherapy; dietary intake of wholegrains of healthcare workers in national healthcare group polyclinics; management of patients with diabetes in two primary care podiatry clinics; preliminary evaluation of shoulder conditions in primary care physiotherapy; prevalence of alcohol problems among elderly in Singapore; prevalence and predictors of tobacco use in elderly Singaporeans; mortality predictors for operative hip fracture patients; a risk index to predict 30 days emergency hospital readmission; compliance of preoperative chest XÎ?Ã?Ã?rays in anaesthesia clinic; predictors of mortality in patients with chronic kidney disease; continuity of care issues in the Singapore health system; factors influencing patients adherence to followÎ?Ã?Ã?up post bariatric surgery; a snapshot of audits in the phototherapy unit; health screening perceptions in SingaporeÎ?Ã?Ã?a grounded theory study; interactive dashboard for monitoring operating theatre operational efficiency; reducing violence through the use of structured therapies; early home visits by care coordinators help to reduce hospital readmission rate; evaluation of a workplace nutrition programme at a hospital; a review of the use of electroencephalography in autism spectrum disorder in the past decade; an alternate plastic packaging to reduce threat of e coli contamination; spatial epidemiology of tuberculosis in Singapore; development of a polarised cellular model for Chikungunya virus infection; summerÎ?Ã?Ã?winter differences in total vitamin D concentrations in Singapore; effect of femoral nerve block on ambulation following total knee arthroplasty; development of a computerÎ?Ã?Ã?based objective grading system for facial paralysis; a preliminary finding of EEG differences of children with disruptive behaviour disorders in Singapore; sex hormone concentrations in Singaporean men; deciding where to allocate diabetic educational resources; pseudoexfoliation syndrome at a Singapore eye clinic; corneal thickness in Asian keratoconus patients; reasons influencing nonÎ?Ã?Ã?adherence to medications in psychiatric patients; pilot study on nurses' perceptions towards different aspects of learning; oral conditions among dependent communityÎ?Ã?Ã?dwelling elderly persons; knowledge of osteoporosis among Singapore adults in national healthcare group polyclinics (NHGP) settings and knowledge adequacy of diagnosis and treatment plans of elderly patients on discharge from tertiary hospital.
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0 |
Reasonable expectations following arthroscopic surgery
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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The primary determinant of the ultimate outcome of surgery is the nature of the underlying disease. The current applications of arthroscopic surgery to various disease entities are reviewed and the results that can reasonably be expected with each are summarized. As time goes on, the number of diseases that can be treated arthroscopically and the efficacy of treatment will continue to improve
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1 |
The Relationship Between Body Mass Index and Fatty Infiltration in the Shoulder Musculature
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Trial Systematic Review Project
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OBJECTIVE: Fatty infiltration in the rotator cuff muscles has been well studied in the setting of rotator cuff tendon tears to help predict outcomes of surgical repair. Fatty infiltration in the rotator cuff has also been independently correlated to the variables of age and sex. The purpose of our study was to determine if there is a relationship between body mass index and fatty infiltration in patients with no imaging evidence of rotator cuff tendinosis or tear.
METHODS: Radiology reports of all magnetic resonance imaging examinations of the shoulder were searched over a 2-year period. Studies with imaging findings of rotator cuff tendinosis, partial tear, or full thickness tear were excluded from the study, resulting in a total of 143 patients with normal rotator cuffs who were included in the study. These studies were reviewed by consensus by 2 fellowship-trained musculoskeletal radiologists who used the Goutallier 5-stage scoring system to grade the supraspinatus, infraspinatus, subscapularis, teres minor, teres major, and deltoid muscles.
RESULTS: Sex was shown not to be significantly associated with fatty infiltration with the exception of the deltoid muscle, which showed a statistically significant increase in fatty infiltration associated with female sex (P = 0.038). Age was shown to be a statistically significant predictor of fatty infiltration for all 6 muscles (P < 0.05). Body mass index was shown to be a statistically significant predictor of fatty infiltration for all of the evaluated shoulder musculature (P < 0.05) with the exception of the teres minor.
CONCLUSIONS: Our results suggest that increased body mass index is associated with increased fatty infiltration in the supraspinatus, infraspinatus, subscapularis, teres major, and deltoid muscles. This relationship could help guide the decisions of orthopedic surgeons when considering rotator cuff repair.
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0 |
A healthy outlook
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DoD PRF (Psychosocial RF)
|
The sense of coherence-a healthy outlook-can be thought of as a measure of positive health, that is, a factor promoting resilience which enables an individual to remain healthy. Based on National Population Health Survey (NPHS) data, three health measures were analyzed in relation to sense of coherence. The sense of coherence accounted for a substantial proportion of the total variance for two of the three measures. Theoretically, people with a healthy outlook are more able to cope successfully with trauma and stress. According to NPHS data, on average, those who reported at least one traumatic event had a lower sense of coherence than those who did not. For people who experienced trauma during childhood and young adulthood, yet had a strong sense of coherence, the impact of that trauma on their health was diminished.
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0 |
The role of a nurse in early trauma management
|
DoD PRF (Psychosocial RF)
|
Optimal care of the patient with multiple trauma injuries requires an enormous amount of effort which begins with planning and preparation of system development in which personnel are educated and trained. Guidelines must include all aspects of the patient's care and the team must be drilled well. Protocols for management should be customized to suit the facilities available and the needs of the patient. The Primary Survey provides basic data essential when life is threatened. The Secondary Survey provides detailed assessment of the various organ systems. Inclusion of Psycho-Social aspects achieves a holistic approach to the victims of Trauma. [References: 5]
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0 |
Prevention of falls in the elderly
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Hip Fx: Early-Weight Bearing Search
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The purpose of these symposium presentations was to examine the role of physical activity as a means of preventing hip fractures through the prevention of falls. Risk factor identification is necessary to develop preventive strategies. Risk factors related to physical activity and other risk factors for falls were identified. Intervention studies aimed at reducing, preventing or delaying falls were identified and discussed. A literature search from 1976-1994, identified 52 studies examining risk factors for falls, recurrent falls and/or falls resulting in injury. Nine intervention studies were identified with the primary outcome of falls. Physical activity-related risk factors for falls include limitations in general functioning, such as ambulation and mobility problems, difficulty or dependence in activities of daily living, and exposures to the risks of falling as indicated by the nature and frequency of daily activities. Impairments in gait and balance as well as neuromuscular and musculoskeletal impairments frequently underlie changes in physical activity in old age. Reduced activity level may occur as a result of these impairments, leading to further declines in physical functioning and an increased risk of falls. A relatively high level of activity in old age is also associated with risk of falls. Other risk factors for falls, such as cognitive impairment, visual deficits and medication use, may combine with physical activity-related risk factors to increase the risk of falls. Intervention studies directed at nursing home populations did not prevent falls but had other statistically and clinically significant outcomes. Studies among the community dwelling that targeted potential or current risk factors and included an exercise component reported a significant reduction in falls, prevented the onset of new disabilities and reduced baseline risk factors. Prevention of falls and subsequent injuries in the institutionalized population remains a challenge. Further development of interventions for community-dwelling elders that facilitate maintenance of physical activity without unduly increasing the risk of falls is also critical. The potential for maintenance of benefits gained from all fall interventions needs further examination
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0 |
Microsurgical reconstruction for post-traumatic defects of lower leg in the elderly: A comparative study
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DoD LSA (Limb Salvage vs Amputation)
|
BACKGROUND: Lower leg microsurgical reconstruction in the elderly is challenging, especially for post - traumatic defects. The present study aimed to evaluate the risk factors, management and outcome of free tissue transfer in patients older than 65 years of post-traumatic defects. METHODS: Retrospective chart review was performed for all patients older than 18 years undergoing free tissue transfer for post-traumatic lower leg reconstruction from April 2000 to November 2014. A comparative study was designed to identify risk factors and outcome. RESULTS: In total, 197 patients (ages 18-64) and 44 patients (ages >/=65, average 71.7+/-6.3) were included and allocated into cohort 1 and 2, respectively. Cohort 2 had a higher rate of diabetes mellitus and/or peripheral artery disease (46.6%, P<0.01). There was no significant difference in major flap complications, donor site complications and amputation rates (P>0.05). A higher rate of intensive care unit (ICU) admission was observed in cohort 2 (37.8%, P<0.01). Comparable limb salvage rates were recorded (97.1% and 95.6%, P=0.59) with an average follow-up of 25.9+/-30.1months in cohort 1 and 23.7+/-16.6months in cohort 2. CONCLUSION: Post-traumatic microsurgical free tissue transfer to the lower leg can be performed safely in patients older than 65 years with high success rate and manageable complications.
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0 |
A meta-analysis of European and Asian cohorts reveals a global role of a functional SNP in the 5' UTR of GDF5 with osteoarthritis susceptibility
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SR for PM on OA of All Extremities
|
We have performed a meta-analysis combining data for more than 11,000 individuals. It provides compelling evidence for a positive association between a functional single-nucleotide polymorphism (SNP) in the 5'-UTR of GDF5 (+104T/C; rs143383) and osteoarthritis (OA) in European and Asian populations. This SNP has recently been reported to be associated with OA in Japanese and Han Chinese populations. Attempts to replicate this association in European samples have been inconclusive, as no association was found in the case-control cohorts from the UK, Spain and Greece when studied individually. However, the pooled data of UK and Spain found an association of the T-allele with an odds ratio (OR) of 1.10. Although the European studies had adequate power to replicate the original findings from the Japanese cohort (OR = 1.79), these results suggest that the role of the GDF5 polymorphism may not be as strong in Europeans. To clarify whether the European studies were hampered by insufficient power, we combined new data from the UK and the Netherlands with the three published studies of Europe and Asia. The results provide strong evidence of a positive association of the GDF5 SNP with knee OA for Europeans as well as for Asians. The combined association for both ethnic groups is highly significant for the allele frequency model (P = 0.0004, OR = 1.21) and the dominant model (P < 0.0001, OR = 1.48). These findings represent the first highly significant evidence for a risk factor for the development of OA which affects two highly diverse ethnic groups
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1 |
Immediate efficacy of neuromuscular exercise in patients with severe osteoarthritis of the hip or knee: a secondary analysis from a randomized controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
|
OBJECTIVE: Knowledge about the effects of exercise in severe and endstage osteoarthritis (OA) is limited. The aim was to evaluate the efficacy of a neuromuscular exercise program in patients with clinically severe hip or knee OA.
METHODS: This was a randomized controlled assessor-blinded trial. Patients received an educational package (care-as-usual) only, or care-as-usual plus an 8-week neuromuscular exercise intervention (NEMEX-TJR). NEMEX-TJR was supervised by a physiotherapist, twice weekly for 1 h. The primary outcome was Activities of Daily Living (ADL) subscale from the Hip disability and Osteoarthritis Outcome Score (HOOS) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The secondary outcomes were the HOOS/KOOS subscales Pain, Symptoms, Sport and Recreation, and Joint-related Quality of Life. Exploratory outcomes were functional performance measures and lower limb muscle power.
RESULTS: Included were 165 patients, 56% female, average age 67 years (SD +/- 8), and a body mass index of 30 (SD +/- 5), who were scheduled for primary hip or knee replacement. The postintervention difference between mean changes in ADL was 7.2 points (95% CI 3.5 to 10.9, p = 0.0002) in favor of NEMEX-TJR compared with control. Second, there were statistically significant differences between groups in favor of NEMEX-TJR on all self-reported outcomes and most functional performance tests (walk, chair stands, and 1-leg knee bends). Stratified analyses according to joint revealed moderate effect size for ADL for hip patients (0.63, 95% CI 0.26 to 1.00). Corresponding effect size for knee patients was small (0.23 95% CI -0.14 to 0.60).
CONCLUSION: Feasibility of neuromuscular exercise was confirmed in patients about to have total joint replacement. Self-reported activities of daily living and objective performance were improved and pain reduced immediately following 8 weeks of neuromuscular exercise. While the effects were moderate in hip OA, they were only small in knee OA. ClinicalTrials.gov Identifier: NCT01003756.
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0 |
Fascia iliaca block, history, technique, and efficacy in clinical practice
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AAHKS (9/10) Regional Nerve Blocks
|
The facsia iliaca block (FIB) is a relatively new regional technique where local anesthetic is delivered within the fascia iliaca region. Indications for a FIB include surgical anesthesia to the lower extremity after knee, femoral shaft, hip surgery, management of cancer pain or pain secondary to inflammatory conditions of the lumbar plexus, as well as treatment of acute pain in the setting of trauma, fracture, or burns. The FIB may be performed using either a loss of resistance technique or an ultrasound (US)-guided technique; however, the use of US has become commonplace and resulted in improved femoral nerve and obturator nerve motor blocks. The main targets of the FIB are the predominant nerves contained in the fascia iliaca compartment (FIC), namely the femoral nerve and the lateral femoral cutaneous nerve. The FIB US guided technique is beneficial to patients and the possibility to perform FIB should be discussed and coordinated with surgical staff appropriately, considering its superiority to general or epidural anesthesia.
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0 |
Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures
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HipFx Supplemental Cost Analysis
|
Background: Various nerve blocks using local anaesthetic agents have been used in order to reduce pain after hip fracture, and subsequent surgery.Objectives: To determine the effects of nerve blocks (inserted either pre-operatively, operatively or post-operatively) that may be used to relieve pain after a hip fracture.Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 2), MEDLINE (1966 to May Week 2 2008), EMBASE (1988 to 2008 Week 21), CINAHL (1982 to May Week 4 2008) and reference lists of relevant articles.Selection criteria: Randomised and quasi-randomised trials involving the use of nerve blocks as part of the care of a hip fracture patient.Data collection and analysis: Two review authors independently assessed trials for inclusion, trial quality by use of a nine item scale and extracted data. Wherever appropriate, results of outcome measures were pooled.Main results: Seventeen randomised or quasi-randomised trials involving 888, mainly elderly and female, participants were included. Nine trials related to insertion of a nerve block pre-operatively and eight to peri-operative insertion.Nerve blocks resulted in statistically significant reductions in reported pain levels and in the quantity of parenteral or oral analgesia administered to control pain from the fracture or during surgery. There were few reported complications, none major, associated with nerve blocks. The limited data for other outcomes, such as medical complications and mortality, showed a general lack of differences between nerve block and control group participants. There were no notable adverse reactions or complications from the nerve blocks.Authors' conclusions: Because of the small number of participants included in this review, limitations in the measurement and reporting of outcomes and the differing types of nerve blocks and timing of insertion, it is not possible to determine if nerve blocks confer any significant clinical benefit when compared with other analgesic methods as part of the treatment of a hip fracture. They do, however, reduce the degree of pain experienced by the patient from the hip fracture and subsequent surgery. Further randomised trials with larger numbers of participants and full reporting of clinical outcomes would be justified
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0 |
Cross-sectional and longitudinal study of the impact of posterior meniscus horn lesions on adjacent cartilage composition, patient-reported outcomes and gait biomechanics in subjects without radiographic osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
|
Objective The aim of this study was to assess cross-sectional and longitudinal effects of meniscal lesions on adjacent cartilage T1Ï and T2 relaxation times, patient-reported outcomes and gait biomechanics. Design Thirty patients with no cartilage morphological defects reported by Whole Organ MRI Score (WORMS) magnetic resonance imaging (MRI) grading and no radiographic osteoarthritis (OA) (Kellgrenâ??-Lawrence (KL) â?¤ 1) were selected, 15 with posterior meniscus horn lesions and 15 matched controls without meniscal lesions. All were imaged on a 3T MR scanner for three consecutive years, except those who dropped from the study. Sagittal and frontal plane kinematic gait data were acquired at baseline. The Knee Injury and Osteoarthritis Outcome Score (KOOS) survey was taken each time. All images were automatically segmented and registered to an atlas for voxel-by-voxel cross-sectional and longitudinal analyses. Results Relaxation time comparisons between groups showed elevated T1Ï of the lateral tibia (LP) and elevated T2 of the medial tibia (MT) and LT at 1 and 2 years in the lesion group. Longitudinal comparisons within each group revealed greater relaxation time elevations over one and 2 years in the group with lesions. KOOS Quality of Life (QOL) was significantly different between the groups at all time points (P < 0.05), as were other KOOS subcategories. No significant differences in the frontal or sagittal biomechanics were observed between the groups at baseline. Conclusions Individuals with healthy cartilage and posterior meniscal horn lesions have increased relaxation times when compared to matched controls, increased relaxation time changes over 2 years, and consistently report a lower KOOS QOL, yet show no difference in gait biomechanics.
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0 |
Determinants of bone mineral density and risk factors for osteoporosis in healthy elderly women
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Distal Radius Fractures
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Bone mineral density (BMD) and risk factors for osteoporosis were assessed in 348 apparently healthy women over 70 years of age (mean 82.3 years). BMD was measured at both hips and the dominant distal radius. With stepwise multiple regression the best determinants of BMD, selected from anthropometric measurements, age, and years since menopause, were body weight and years since menopause (R2 between 0.07 and 0.20, p < 0.001). Risk and protective factors for osteoporosis were analyzed as indicator variables by multiple regression and corrected for confounding by age, years since menopause, and body weight. Significantly lower BMD at the hip was found in participants with impaired mobility (-5%) and users of loop diuretics (-5%). Use of thiazide(like) diuretics did not influence BMD significantly at any site. Users of oral corticosteroids had a significantly lower BMD at the hip and the distal radius (range -9.1 to -24.3%).
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1 |
Getting Better or Getting Well? The Patient Acceptable Symptom State (PASS) Better Predicts Patient's Satisfaction than the Decrease of Pain, in Knee Osteoarthritis Subjects Treated with Viscosupplementation
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OAK 3 - Non-arthroplasty tx of OAK
|
Background In the management of knee osteoarthritis (OA), patient-reported-outcomes (PROs) are being developed for relevant assessment of pain. The patient acceptable symptom state (PASS) is a relevant cutoff, which allows classifying patients as being in "an acceptable state" or not. Viscosupplementation is a therapeutic modality widely used in patients with knee OA that many patients are satisfied with despite meta-analyses give conflicting results.
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0 |
Anti-infective therapy in orthopaedics
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Successful treatment of musculoskeletal infection can be a challenge. It requires an understanding of clinical microbiology and anti-infective therapy, in addition to debridement and reconstructive surgery. In this article, the authors hope to provide practical guidelines for the prevention and appropriate diagnosis of orthopaedic infections. The essential elements of antibiotic selection, delivery, adverse effects, and drug interactions are outlined. Copyright 2002, Elsevier Science (USA). All rights reserved
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1 |
The use of AlloDerm in postmastectomy alloplastic breast reconstruction: part I. A systematic review
|
Acellular Dermal Matrix
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BACKGROUND: Postmastectomy alloplastic breast reconstruction is a common procedure that continues to evolve. Increasingly, AlloDerm is being used in both direct-to-implant and two-stage breast reconstruction. The objective of this systematic review was to summarize the outcomes from studies describing this use of AlloDerm, and to compare outcomes to those from studies reviewing non-AlloDerm alloplastic reconstruction. METHODS: A computerized search was performed across multiple databases. Studies involving patients undergoing alloplastic breast reconstruction with AlloDerm were included. A systematic review was performed to include randomized controlled trials, comparative observational studies, noncomparative observational studies, and case series. RESULTS: A systematic review of the literature revealed 14 studies that satisfied inclusion criteria. Both acute and long-term complication rates were obtained. No objective validated outcomes were reported. Ninety-three percent of included studies were level IV evidence. Complication rates were as follows: infection, 0 to 11 percent; hematoma, 0 to 6.7 percent; seroma, 0 to 9 percent; partial flap necrosis, 0 to 25 percent; implant exposure with removal, 0 to 14 percent; implant exposure with salvage, 0 to 4 percent; capsular contracture, 0 to 8 percent; and rippling, 0 to 6 percent. No study included a cost analysis. CONCLUSIONS: Complications using AlloDerm are comparable to those of non-AlloDerm alloplastic reconstructions. AlloDerm appears to confer a low rate of capsular contracture. A formal analysis is required to determine AlloDerm's cost effectiveness in use for direct-to-implant reconstructions. In addition, a randomized controlled trial comparing AlloDerm use to conventional two-stage reconstruction is currently absent from the literature.
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0 |
New oral anticoagulants after total knee arthroplasty: Clinical considerations for orthopaedic surgeons
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Surgical Management of Osteoarthritis of the Knee CPG
|
Patients who undergo total knee arthroplasty are at risk of developing venous thromboembolism. Thromboprophylaxis is widely accepted as standard of care in patients receiving total knee arthroplasty, but implementation of clinical practice guidelines is hampered by several barriers, including limitations of current agents. New anticoagulants in clinical development offer equivalent or superior efficacy and safety to existing anticoagulants and the added convenience of oral administration. To date, rivaroxaban is the only new oral anticoagulant with regulatory approval for total knee arthroplasty in the United States, although dabigatran and apixaban are approved in other countries. For total knee arthroplasty, neuraxial blockade offers advantages over general anesthesia and narcotic-based systemic analgesia, but it carries a risk of spinal hematoma if used in conjunction with antithrombotics. Clinical practice guidelines already exist for the use of neuraxial blockade with traditional antithrombotics, and similar evidence-based recommendations are required for the new oral anticoagulants. (copyright) 2013 Wolters Kluwer Health
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0 |
Results of internal fixation of Pauwels type-3 vertical femoral neck fractures
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Management of Hip Fractures in the Elderly
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BACKGROUND: It has been postulated that femoral neck fractures with a more vertical fracture line (i.e., a high Pauwels angle) may experience more shear forces and therefore may be predisposed to nonunion or loss of fixation. Although there is controversy regarding which fixation method is ideal, we are aware of no large clinical series in which the treatment outcomes of these fractures were evaluated. The purpose of this multicenter study was to evaluate a large consecutive series of high shear angle (>70 degrees) femoral neck fractures to learn more about the outcomes, complications, and performance of various internal fixation strategies. METHODS: Between January 1993 and January 2005, seventy-six Pauwels type-3 (Orthopaedic Trauma Association [OTA] type-31B2.3) femoral neck fractures were treated in seventy-five patients with a mean age of forty-two years. Fourteen patients were lost to follow-up. Sixty-two fractures in sixty-one patients were followed to union or revision surgery, with a mean duration of follow-up of twenty-four months. Thirty-seven fractures were treated with cannulated screws and twenty-five, with a fixed-angle device. The reduction quality, accuracy of implant placement, time to surgery, influence of capsular decompression, and rates of nonunion and osteonecrosis were evaluated. RESULTS: Fifty-nine (95%) of the fractures had good-to-excellent reduction, and three had a fair reduction. There was a nonunion of eight (14%) of the fifty-nine fractures with a good-to-excellent reduction and two of the three with a fair reduction. There was a septic nonunion of one fracture treated with a dynamic hip screw. There was an aseptic nonunion of seven (19%) of the thirty-seven fractures treated with screw fixation alone as compared with two (8%) of the twenty-five fractures treated with a fixed-angle device. Osteonecrosis occurred after treatment of seven (11%) of the sixty-two fractures. CONCLUSIONS: Despite timely, excellent reduction and accurate implant placement in the vast majority of cases, the nonunion rate was 19% for fractures treated with cannulated screws alone and 8% for those treated with a fixed-angle device. Although these failure rates are not significantly different, we believe that this study documents the challenging nature of this fracture pattern and the ideal fixation device remains undefined
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1 |
The Effectiveness of Neuromuscular Electrical Stimulation in Improving Voluntary Activation of the Quadriceps: A Critically Appraised Topic
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OAK 3 - Non-arthroplasty tx of OAK
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Clinical Scenario: Orthopedic knee conditions are regularly treated in sports-medicine clinics. Rehabilitation protocols for these conditions are often designed to address the associated quadriceps strength deficits. Despite these efforts, patients with orthopedic knee conditions often fail to completely regain their quadriceps strength. Disinhibitory modalities have recently been suggested as a clinical tool that can be used to counteract the negative effects of arthrogenic muscle inhibition, which is believed to limit the effectiveness of therapeutic exercise. Neuromuscular electrical stimulation (NMES) is commonly accepted as a strengthening modality, but its ability to simultaneously serve as a disinhibitory treatment is not as well established.
CLINICAL QUESTION: Does NMES effectively enhance quadriceps voluntary activation in patients with orthopedic knee conditions? Summary of Key Findings: Four randomized controlled trials (RCTs) met the inclusion criteria and were included. Of those, 1 reported statistically significant improvements in quadriceps voluntary activation in the intervention group relative to a comparison group, but the statistical significance was not true for another study consisting of the same sample of participants with a different follow-up period. One study reported a trend in the NMES group, but the between-groups differences were not statistically significant in 3 of the 4 RCTs. Clinical Bottom Line: Current evidence does not support the use of NMES for the purpose of enhancing quadriceps voluntary activation in patients with orthopedic knee conditions. Strength of Recommendation: There is level B evidence that the use of NMES alone or in conjunction with therapeutic exercise does not enhance quadriceps voluntary activation in patients with orthopedic knee conditions (eg, anterior cruciate ligament injuries, osteoarthritis, total knee arthroplasty).
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0 |
Sonographically guided percutaneous needle release of the carpal tunnel for treatment of carpal tunnel syndrome: preliminary report
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVES: The purpose of this study was to evaluate the effectiveness of a novel treatment procedure, sonographically guided percutaneous needle release of the carpal tunnel, for individuals with carpal tunnel syndrome. METHODS: Seventeen patients (89% female; mean age, 62 years; SD, 13.6 years) with a clinical diagnosis of carpal tunnel syndrome who had undergone a sonographically guided percutaneous needle release of the carpal tunnel at least 6 months before follow-up evaluation were retrospectively reviewed. At the follow-up evaluation, to ascertain previous and current symptoms as well as functional impairment, the patients filled out a hand diagram and a questionnaire. In addition, medical records were reviewed, and patients were queried regarding complications such as infection or nerve damage. Median nerve sonographic measurements and a physical evaluation were performed on a subset of 13 patients who came to the office for evaluation. RESULTS: Postprocedure sonography showed that patients had a significantly smaller (P = .03) cross-sectional area of the median nerve compared to pretreatment values. In addition, patients had significantly fewer symptoms (P < .0001), less functional impairment (P = .0002), and an improved hand diagram score (P < .0001). Postprocedure patients had grip strength that was 12 lb below average ( approximately 1 SD below) compared to grip strength norms. However, most patients (84.6%) had negative clinical diagnostic test results for carpal tunnel syndrome, and 86% said they were satisfied with the procedure. There were no procedure-related infections or nerve injuries. CONCLUSIONS: Of the patients with carpal tunnel syndrome who agreed to participate in this study, most had favorable symptomatic and functional outcomes. Sonographically guided percutaneous needle release of the carpal tunnel may be an alternative option to traditional surgical treatment of carpal tunnel syndrome
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0 |
Socioeconomic status of patients in a Swedish national self-management program for osteoarthritis compared with the general population - A descriptive observational study
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OAK 3 - Non-arthroplasty tx of OAK
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Background: First-line treatment for hip and knee osteoarthritis (OA) including education and supervised exercises, delivered as a self-management program, is considered one of the mainstays in OA treatment. However, the socioeconomic profile of the population that utilizes first-line treatment for hip and knee OA is unclear. The aim of this study was to describe the socioeconomic status (SES) of a population referred to a self-management program for OA, in comparison with that of the general Swedish population. Methods: This is a cross-sectional study including 72,069 patients with hip or knee OA enrolled in the National Quality Register for Better management of patients with Osteoarthritis (BOA) between 2008 and 2016, and registered before participation in a structured OA self-management program. A reference cohort (n = 216,207) was selected from the general Swedish population by one-to-three matching by year of birth, sex and residence. Residential municipality, country of birth, marital status, family type, educational level, employment, occupation, disposable income and sick leave were analyzed. Results: The BOA population had higher educational level than the reference group, both regarding patients with hip OA (77.5% vs 70% with â?¥10 years of education), and with knee OA (77% vs 72% with â?¥10 years of education). Their average disposable income was higher (median [IQR] in Euro (â?¬), for hip â?¬17,442 [10,478] vs â?¬15,998 [10,659], for knee â?¬17,794 [10,574] vs â?¬16,578 [11,221]). Of those who worked, 46% of patients with hip OA and 45% of the reference group had a blue-collar occupation. The corresponding numbers for knee OA were 51 and 44% respectively. Sick leave was higher among those with hip and knee OA (26%) than those in the reference groups (13% vs 12%). Conclusions: The consistently higher SES in the BOA population compared with the general population indicates that this self-management program for OA may not reach the more socioeconomically disadvantaged groups, who are often those with a higher disease burden.
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0 |
Spinal cord injury-related pain in rehabilitation: a cross-sectional study of relationships with cognitions, mood and physical function
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DoD PRF (Psychosocial RF)
|
Although psychological aspects of SCI-related pain have been investigated in those with chronic pain, little data is available regarding these factors in those early in the course of the injury. Using a sample admitted for SCI rehabilitation, this paper describes the relationships between usual pain intensity, mood, disability and both pain and SCI-related psychological factors. The sample were largely similar to other samples of individuals with SCI-related chronic pain in terms of mood, but were noted to be less catastrophic in their thinking about pain than a comparative pain clinic sample. They also reported SCI self-efficacy and acceptance scores consistent with other SCI samples. Compared with other SCI populations there were mixed findings in relation to physical disability. Consistent with previous findings in chronic pain SCI samples, usual pain intensity was found to have a strong relationship with symptoms of anxiety and depression, and pain-related life interference. SCI acceptance was significantly negatively associated with depression scores, pain catastrophizing was significantly positively associated with both anxiety and depression scores, and SCI self-efficacy was significantly negatively associated with both anxiety and depression scores. SCI self-efficacy was also significantly positively associated with physical function scores. These findings suggest that pain-related psychological factors may have importance even early in the clinical course following SCI, but that it is important, however, to consider more general SCI-related psychological factors alongside them. In addition, these findings suggest the possibility that early interventions based upon the cognitive behavioural treatment of pain may be integrated into SCI rehabilitation programmes.
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0 |
Cement penetration with pulsed lavage versus syringe irrigation in total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Twelve total knee arthroplasties were performed on 12 patients who had osteoarthritis. The freshly resected tibial plateaus and femoral condyles were divided in 2, and each half was subjected to different methods of preparation. One half of the specimen was irrigated with saline with a standard bulb syringe, while the other half was irrigated with pulsed lavage. Cement then was pressurized into the cut surfaces. Sections were analyzed using the Image Analysis Software Morphometry System. A significant increase in cement penetration and decrease in bone debris were found in pulsed lavage specimens as compared with controls (p < 0.05). The penetration of cement in total knee components can be significantly increased by using pulsed lavage of the cancellous surfaces
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0 |
Distal radioulnar joint instability (Galeazzi type injury) after internal fixation in relation to the radius fracture pattern
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Distal Radius Fractures
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PURPOSE: The purpose of this study was to classify Galeazzi type injuries and determine the association of residual instability after rigid fixation with the fracture pattern of the shaft of the radius, using a system that is based on anatomic landmarks of the radial shaft.
METHODS: The clinical records of 95 patients (72 men and 23 women) with Galeazzi type injuries requiring open reduction and internal fixation of the fractures were retrospectively reviewed. The mean follow-up was 6.8 years (range, 18 mo to 11 y) after injury. Sixty-nine fractures occurred in the distal third of the radial shaft (type I), 17 fractures were in the middle third (type II), and 9 fractures were in the proximal third of the shaft of the radius (type III). Gross instability of the distal radioulnar joint (DRUJ) was determined intraoperatively by manipulation after radial fixation as compared to the uninjured side.
RESULTS: Forty patients had DRUJ instability after internal fixation and were treated with temporary pinning with a K-wire placed transversely proximal to the sigmoid notch. Distal radioulnar joint instability after internal fixation was recorded in 37 type I fractures, 2 type II fractures, and 1 type III fracture.
CONCLUSIONS: Distal radioulnar joint instability following radial shaft fracture fixation is significantly higher in patients with type I fractures than in patients with type II or type III fractures. The location of the radius fracture can be sufficiently used for preoperative estimation of percentage chance of potential DRUJ instability after fracture fixation.
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