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Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches. (copyright) W. S. Maney & Son Ltd 2011
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Monkey Bars are for Monkeys: A Study on Playground Equipment Related Extremity Fractures in Singapore
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Studies in Caucasian populations have shown that a significant percentage of childhood extremity fractures occur at the playground. There are no comparable studies in Asian populations. Thus this study sets out to determine the pattern of playground related extremity fractures in Asian populations and to suggest modifications to prevent or reduce these injuries. This study involved a retrospective review of 390 patients with these fractures who visited our Department from May 1997 to December 1998. This accounted for 19.5% of all fractures seen in the same period. The largest age group affected were the five through 12-year-old patients with a male to female ratio of 2:1. Monkey bars or upper body devices were the most common cause (66%). The most common fracture was supracondylar fractures (43%). Further studies to determine the actual dimensions of playground equipment will be carried to ascertain with greater certainty the safety of these equipment in our playgrounds
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Untreated congenital hip dysplasia in the Navajo
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Developmental Dysplasia of the Hip CPG
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Congenital hip dysplasia without dislocation was identified in 18 Navajo Indian children. Treatment had been declined and the children presented a unique opportunity to observe the natural course of hip dysplasia. In a follow-up period of three to 19 years (average, 11.2 years), none of the dysplastic hips were observed to progress to dislocation. In 15 of the children with dysplastic hips, the condition became roentgenographically normal in the course of normal growth and development. The other three children continued to show roentgenographic signs of hip dysplasia
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0 |
Cardiopulmonary complications of intramedullary fixation of long bone metastases
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MSTS 2022 - Metastatic Disease of the Humerus
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Intramedullary fixation of long bone metastases is an effective method of treating or preventing pathologic fractures. An important complication of this technique is the development of pulmonary embolism, which may occur at any number of steps during bone manipulation. Passage of normal marrow contents or tumor into the pulmonary circulation is thought to cause various biochemical, hemodynamic, or physical responses that lead to hypotension, arrythmia, and O2 desaturation. Death is a known risk of this procedure. Numerous surgical and anesthetic strategies have been developed to prevent or treat pulmonary embolic phenomena; however, the most important prophylaxis may be a heightened awareness of this possibility during any procedure that involves intramedullary manipulation of tumor containing bone. [References: 79]
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Trauma and event centrality: Valence and incorporation into identity influence well-being more than exposure
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DoD PRF (Psychosocial RF)
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Although the association between trauma exposure and posttraumatic stress disorder (PTSD) symptoms is well established, how such trauma is incorporated into identity, or the centrality of the negative event, is also of considerable importance in understanding the development of psychological symptoms. Alternatively, positive event centrality may have positive effects on well-being in the face of trauma. Thus, the current study examined associations between positive and negative event centrality, and both adaptive and maladaptive outcomes, above and beyond the impact of traumatic experience. A sample of 214 college students completed a series of self-report questionnaires. As anticipated, negative event centrality predicted PTSD and other maladaptive measures of functioning, even after controlling for traumatic experience. High levels of positive event centrality predicted adaptive, as opposed to maladaptive, psychological functioning. Results also suggested that both positive and negative event centrality predicted posttraumatic growth, controlling for traumatic experience. These findings suggest that assessing centrality of trauma may also be valuable in the prediction of psychological symptoms. The implications of these findings and proposals for future work are discussed further.
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Trauma, PTSD, and resilience: a review of the literature
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DoD PRF (Psychosocial RF)
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Based on the available literature, this review article investigates the issue of resilience in relation to trauma and posttraumatic stress disorder. Resilient coping to extreme stress and trauma is a multifaceted phenomena characterized as a complex repertoire of behavioral tendencies. An integrative Person x Situation model is developed based on the literature that specifies the nature of interactions among five classes of variables: (a) personality, (b) affect regulation, (c) coping, (d) ego defenses, and (e) the utilization and mobilization of protective factors and resources to aid coping. [References: 130]
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Nipple areola reconstructing reduction mammaplasty
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: The pigment density and texture of breast skin are not uniform. Especially in patients with massive breasts, lower pole skin can be significantly darker and coarser than the upper pole skin. Nipple areola reconstructing (NAR) reduction mammaplasty is a technical modification of the "free nipple" procedure in which the original nipple areola complex (NAC) is discarded and the new NAC is reconstructed from coarse pigmented lower pole skin using a modified skate flap purse-string technique.
OBJECTIVES: The authors review their initial clinical experience with NAR reduction mammaplasty.
METHODS: Between 2010 and 2012, 16 patients (31 breasts) underwent the NAR procedure, and these cases were retrospectively reviewed for patient demographics, preoperative topographic breast measurements, amount of reduction per breast, and complications. The operative goal was to obtain the smallest breast size that can be achieved with tension-free wound closure. Patient satisfaction was also assessed.
RESULTS: Breast reductions varied from 1150 to 2850 g/breast (average, 1590 g/breast), and patients were followed up for a minimum of 1 year (average, 15.9 months). No major local or systemic complications were encountered. Two patients required touch-ups for the correction of minor periareolar irregularities resulting mainly from the inversion of wound closure. At 1 year, average score for general satisfaction was 4.6, and the average score for NAC satisfaction was 3.9, on a scale from 1 (not satisfied) to 5 (extremely satisfied).
CONCLUSIONS: NAR reduction mammaplasty enables the surgeon to perform massive reductions, design different non-NAC-bearing glandular pedicles for breast shaping, and obtain tension-free closure without the fear of ischemic complications.
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Unplanned readmissions after primary total knee arthroplasty in Korean patients: Rate, causes, and risk factors
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DoD SSI (Surgical Site Infections)
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Background Unplanned hospital readmissions are indicators of the quality and performance of a health care system, but data on early readmission after primary total knee arthroplasty (TKA) in the Asian population are limited. The purpose of this study was to determine the causes, risk factors, and rate of unplanned readmission after primary TKA at a single institution in Korea. Methods We analyzed all primary TKAs from 2004 to 2013 using the data from our institutional electronic database. A total of 4596 TKAs were performed on 3049 patients. All unplanned readmissions within 30 and 90 days of discharge were identified, categorized into arthroplasty-related, medical, and other orthopedic causes. Results The overall unplanned readmission rate was 1.9% (n = 59) within 30 days and 3.3% (n = 101) within 90 days, and both the 30 and 90 day readmission rates remained stable over the entire study period. The majority of readmissions involved arthroplasty-related causes; the most common cause being wound problems, accounting for 22% (13/59) within 30 days and 24% (24/101) within 90 days. Age (P = 0.029) and hypertension (P = 0.021) were identified as risk factors for unplanned readmissions after TKA. Conclusion This study demonstrates that unplanned readmissions after TKA are not infrequent in Korean patients and has identified wound complication as the most frequent cause of unplanned readmissions. Optimized care systems should be established to minimize unplanned readmissions, particularly for patients with high risk factors.
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The Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures
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Glenohumeral Joint OA
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The combination of an irreparable tear of the rotator cuff and destructive arthritis of the shoulder joint may cause severe pain, disability and loss of independence in the aged. Standard anatomical shoulder replacements depend on a functioning rotator cuff, and hence may fail in the presence of tears in the cuff. Many designs of non-anatomical constrained or semi-constrained prostheses have been developed for cuff tear arthropathy, but have proved unsatisfactory and were abandoned. The DePuy Delta III reverse prosthesis, designed by Grammont, medialises and stabilises the centre of rotation of the shoulder joint and has shown early promise. This study evaluated the mid-term clinical and radiological results of this arthroplasty in a consecutive series of 50 shoulders in 43 patients with a painful pseudoparalysis due to an irreparable cuff tear and destructive arthritis, performed over a period of seven years by a single surgeon. A follow-up of 98% was achieved, with a mean duration of 39 months (8 to 81). The mean age of the patients at the time of surgery was 81 years (59 to 95). The female to male ratio was 5:1. During the seven years, six patients died of natural causes. The clinical outcome was assessed using the American Shoulder and Elbow score, the Oxford Shoulder Score and the Short-form 36 score. A radiological review was performed using the Sirveaux score for scapular notching. The mean American Shoulder and Elbow score was 19 (95% confidence interval (CI) 14 to 23) pre-operatively, and 65 (95% CI 48 to 82) (paired t-test, p < 0.001) at final follow-up. The mean Oxford score was 44 (95% CI 40 to 51) pre-operatively and 23 (95% CI 18 to 28) (paired t-test, p < 0.001) at final follow-up. The mean maximum elevation improved from 55degree pre-operatively to 105degree at final follow-up. There were seven complications during the whole series, although only four patients required further surgery.
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Treatment of unicameral bone cysts by subtotal resection without grafts
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Twenty-one patients were treated operatively for unicameral bone cysts by subtotal resection without any form of bone graft, and all but two patients had satisfactory, prompt healing. The rate of recurrence was 9%. Five patients were noted to have humeral shortening prior to any surgery, and in them the changes in the epiphyseal cartilage were noted preoperatively. Pathological fractures were thought to be the cause of the shortening in those cases
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When is hemiarthroplasty preferable to intramedullary prophylactic fixation of malignant lesions of the proximal femur?
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DoD SSI (Surgical Site Infections)
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Background: Malignant hip lesions can be managed operatively by intramedullary (IM) nail fixation and hemiarthroplasty. Methods: A retrospective review was performed on 86 patients who underwent hemiarthroplasty (n = 22) or IM nail fixation (n = 64) for prophylactic treatment of impending pathologic fracture due to malignant lesions of the hip. Cox proportional hazards and logistic regression modeling were performed to determine risk of death, fixation failure, pain relief, and return to ambulation without gait aids. Results: Median survival time after surgery was 8.8 months (with no difference in survival between hemiarthroplasty and IM nail [adjusted Hazard Ratio 1.40, CI 0.72, 2.53; P = 0.31]). Hemiarthroplasty was associated with lower risk of pathologic fracture, fixation failure, or reoperation (adjusted HR 0.02, CI < 0.001, 0.48; P = 0.01). Hemiarthroplasty did not increase odds of unassisted ambulation compared to IM nail fixation (adjusted Odds Ratio [OR] 2.23, CI 0.56, 9.71; P = 0.26). The strongest predictor of postoperative ambulation was preoperative ambulation without aids (adjusted OR 28.9, CI 7.37, 161; P < 0.001). Conclusions: There is no difference in survival or likelihood of unassisted ambulation after prophylactic femoral fixation with IM nails versus hemiarthroplasty in patients with metastatic disease of proximal femur.
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Postoperative analgesia by femoral nerve block with ropivacaine 0.2% after major knee surgery: continuous versus patient-controlled techniques
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND AND OBJECTIVES: This prospective study compared the efficacy and adverse effects after knee surgery of ropivacaine 0.2% administered as patient-controlled femoral analgesia (PCFA), as a continuous femoral infusion (Inf), or as both (PCFA+Inf). METHODS: Before general anesthesia, 140 adults scheduled to undergo major knee surgery received a sciatic/fascia iliaca nerve block with 0.75% ropivacaine (40 mL). After surgery, they were randomly assigned to receive, through the femoral catheter, an infusion of 0.2% ropivacaine administered as PCFA (boluses of 10 mL with a lockout time of 60 minutes), Inf (10 mL/h), or PCFA + Inf (5 mL/h plus boluses of 5 mL with a lockout time of 60 minutes). Pain was assessed at rest, on mobilization, and during physiotherapy using a visual analog scale (VAS). Additional use of intravenous (IV) analgesics was noted. RESULTS: Patients in all 3 groups experienced similar pain relief at rest, on mobilization, and after physiotherapy (P >.05). Additional use of analgesics and overall patient satisfaction (excellent or good in 80% of cases) were also similar in all groups. However, total postoperative ropivacaine consumption was lower in the PCFA group, 150 mL/48 h (90.5 to 210); than in the Inf group, 480 mL/48 h (478 to 480); and the PCFA + Inf group, 310 mL/48 h (280 to 340) (P <.05). Adverse events were similar in all 3 groups (hypotension, vomiting, insomnia). No paresthesia or motor block were observed. CONCLUSION: All 3 strategies provided effective pain relief. PCFA resulted in a lower consumption of ropivacaine (toxic and financial impact). PCFA + Inf does not improve postoperative analgesia
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Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial
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AAHKS (9/10) Regional Nerve Blocks
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BACKGROUND: Postoperative pain after total knee arthroplasty (TKA) can be difficult to manage and may delay recovery. Recent studies have suggested that periarticular infiltration with local anesthetics may improve outcome.
METHODS: 80 patients undergoing TKA under spinal anesthesia were randomized to receive continuous femoral nerve block (group F) or peri- and intraarticular infiltration and injection (group I). Group I received a solution of 300 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine by infiltration of the knee at the end of surgery, and 2 postoperative injections of these substances through an intraarticular catheter.
RESULTS: More patients in group I than in group F could walk < 3 m on the first postoperative day (29/39 vs. 7/37, p < 0.001). Group I also had significantly lower pain scores during activity and lower consumption of opioids on the first postoperative day. No differences between groups were seen regarding side effects or length of stay.
INTERPRETATION: Peri- and intraarticular application of analgesics by infiltration and bolus injections can improve early analgesia and mobilization for patients undergoing TKA. Further studies of optimal drugs, dosage, and duration of this treatment are warranted.
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Complications after treatment of tibial pilon fractures: prevention and management strategies
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DoD SSI (Surgical Site Infections)
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Complications after treatment of tibial pilon fractures can occur intraoperatively or in the early or late postoperative period. Perioperative complications include malreduction, inadequate fixation, and intra-articular penetration of hardware, all of which may be minimized by preoperative planning and meticulous operative technique. Wound complications can lead to deep infection, with potentially catastrophic consequences. The incidence of wound complications may be lessened by delaying surgery 5 to 14 days, until the posttraumatic swelling has subsided. Temporary fixation with a medial spanning external fixator is recommended if definitive internal fixation is delayed. Fracture blisters should be left undisturbed until the time of surgery. Incisions through blood-filled blisters should be avoided whenever possible. Limited incisions to achieve reduction and fixation should be made directly over fracture sites, to minimize soft-tissue stripping. An indirect reduction technique involving the use of ligamentotaxis and low-profile small-fragment implants that minimize tension on the incision should be used. Late complications, such as stiffness and posttraumatic arthritis, correlate with the severity of the initial injury and the accuracy of reduction. Loss of ankle motion can be minimized by early range-of-motion exercise after stable fixation has been achieved. Posttraumatic ankle arthrosis should be initially treated with anti-inflammatory medication, activity modification, and walking aids. Symptomatic patients often require an ankle arthrodesis. [References: 35]
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'Who', 'when' and 'how' in re-irradiation of recurrent painful bone metastases
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MSTS 2018 - Femur Mets and MM
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Re-irradiation of painful bony metastases is increasingly performed since patients are receiving better systemic treatments and having longer life expectancy, and may also be due to the increase use of initial single fraction radiotherapy. However, randomized control trial on the efficacy of re-irradiation is lacking. A recent meta-analysis concluded with a 58% response rate for pain relief by re-irradiation of symptomatic bone metastases. In this review, the effectiveness of re-irradiation in terms of clinical and economical aspects, and clinical questions on who, when, and how to re-irradiate would be discussed. A brief review of other treatment options and comparison with re-irradiation of bone metastases would be performed. © 2012 Elsevier GmbH. All rights reserved.
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Knee injuries produced by recreational sports follow a different pattern than casual injuries
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AMP (Acute Meniscal Pathology)
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Data was collected on 208 Chinese males who underwent knee arthroscopy following trauma in the period from January 1993 through December 1994. For the purpose of comparison and analysis, the patients were classified according to their sporting habits as sedentary patients, recreational athletes, or competitive athletes. There were no significant differences in age between the three groups (average age: 25.82 +/- 10.6; range: 12 to 73 years). A hemarthrosis was present in 122 patients, and an effusion in 35. The most common mechanism of injury was direct impact (105 patients), followed by a twisting injury (58 patients). The most common arthroscopic finding was an anterior cruciate ligament (ACL) tear (partial in-37 patients and complete in 43 patients). In both sedentary and athletic patients, a hemarthrosis was significantly associated with ACL and meniscal tears (p = 0.02). When comparing the pattern of arthroscopic pathology between sports and casual injuries, a significantly greater number of ACL tears (both complete and partial) were caused during sports activity (p = 0.032). Sports injuries also resulted in a significantly greater number of meniscal injuries (p = 0.028). However, sedentary patients suffered from a greater prevalence of tibial osteochondral fractures (10%) than did those in the sports group (5%) (p = 0.04).
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Morning self-efficacy predicts physical activity throughout the day in knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: The purpose of this study was to examine the within-day and cross-day prospective effects of knee osteoarthritis (OA) patients' self-efficacy to engage in physical activity despite the pain on their subsequent physical activity assessed objectively in their natural environment.
METHOD: Over 22 days, 135 older adults with knee OA reported their morning self-efficacy for being physically active throughout the day using a handheld computer and wore an accelerometer to measure moderate activity and steps.
RESULTS: Morning self-efficacy had a significant positive effect on steps and moderate-intensity activity throughout that day, above and beyond the effects of demographic background and other psychosocial factors as well as spouses' support and social control. The lagged effect of morning self-efficacy on the next day's physical activity and the reciprocal lagged effect of physical activity on the next day's self-efficacy were not significant. Positive between-person effects of self-efficacy on physical activity were found.
CONCLUSIONS: Future research should aim to better understand the mechanisms underlying fluctuations in patients' daily self-efficacy, and target patients' daily self-efficacy as a modifiable psychological mechanism for promoting physical activity. (PsycINFO Database Record
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Application of a semi-automatic cartilage segmentation method for biomechanical modeling of the knee joint
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AMP (Acute Meniscal Pathology)
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Manual segmentation of articular cartilage from knee joint 3D magnetic resonance images (MRI) is a time consuming and laborious task. Thus, automatic methods are needed for faster and reproducible segmentations. In the present study, we developed a semi-automatic segmentation method based on radial intensity profiles to generate 3D geometries of knee joint cartilage which were then used in computational biomechanical models of the knee joint. Six healthy volunteers were imaged with a 3T MRI device and their knee cartilages were segmented both manually and semi-automatically. The values of cartilage thicknesses and volumes produced by these two methods were compared. Furthermore, the influences of possible geometrical differences on cartilage stresses and strains in the knee were evaluated with finite element modeling. The semi-automatic segmentation and 3D geometry construction of one knee joint (menisci, femoral and tibial cartilages) was approximately two times faster than with manual segmentation. Differences in cartilage thicknesses, volumes, contact pressures, stresses, and strains between segmentation methods in femoral and tibial cartilage were mostly insignificant (p > 0.05) and random, i.e. there were no systematic differences between the methods. In conclusion, the devised semi-automatic segmentation method is a quick and accurate way to determine cartilage geometries; it may become a valuable tool for biomechanical modeling applications with large patient groups.
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The effect of a fracture protocol on hospital prescriptions after minimal trauma fractured neck of the femur: a retrospective audit
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Management of Hip Fractures in the Elderly
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Effective therapies for the treatment of osteoporosis and fracture have been available for a number of years. Despite this, there are numerous reports indicating very low uptake rates in those admitted to hospital with fracture. The aim of this retrospective audit was to assess the impact of a fracture protocol on inpatient prescriptions of osteoporosis therapy. A fracture protocol was arrived at by consensus and was based on recommendations from the Australian Fracture Prevention Summit, which included specific advice on the commencement in hospital of calcium, vitamin D, synthetic estrogen receptor modulators (SERMs) and bisphosphonates. We studied subjects who were treated for fractured neck of the femur at Royal Hobart Hospital from March 2002 to March 2004 and included 161 prior to the start of the protocol and 93 after. As compared to the baseline period, subjects after the introduction of the protocol had higher rates of in-hospital prescription for any treatment (58 vs. 36%, P <0.01), calcium (51 vs. 26%, P <0.01), vitamin D (48 vs. 29%, P <0.01) and oral bisphosphonates (24 vs. 5%, P <0.01), but not SERMs as expected (1 vs. 1%, P =0.70). Additional factors affecting the decision to start any treatment included in-hospital death (OR 0.16, 95% CI 0.05-0.49), dementia (OR 0.39, 95% CI 0.21-0.74), a trend for female sex (OR 1.79, 95%CI 0.96-3.36), but not age. In conclusion, a structural approach to changing hospital policy from the top down is effective at substantially increasing the usage of effective therapy after fractured neck of the femur
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Effect of combined exercise training on bone, body balance, and gait ability: a randomized controlled study in community-dwelling elderly women
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Management of Hip Fractures in the Elderly
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The purpose of this study was to investigate whether a 48-week multicomponent exercise program could improve the risk factors for fall and hip fracture. Fifty elderly women 65-70 years of age participated. These participants were divided into an exercise group (25 subjects) that attended an exercise program and a control group (25 subjects) that did not. The exercise program included stretching for 9 min, strength training for 10 min followed by 23 min of weight-bearing exercise at an intensity above 65%-75% of the maximal heart rate, and 18 min of balance and posture correction training. The program was conducted three times per week for 48 weeks. The 10-m maximal walk time, maximal step length, and eyes-open-one-legged-stand time in the exercise group improved significantly (P < 0.05). Concerning deoxypyridinoline, the exercise group achieved a significant improvement (P < 0.05) after the 48 weeks. Bone mineral density (BMD) of the femoral neck and trochanter in the exercise group was significantly increased after the exercise program; also body sway was significantly improved (P < 0.05). In conclusion, a multi-component exercise program with weight-bearing exercise at a moderate intensity and gait training may be effective in offsetting a decline in BMD and improving aggravation of bone resorption in this population. In addition, this program has a positive effect on postural stability and gait ability
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Diagnosis of deep vein thrombosis in elderly hip-fracture patients by using the duplex scanning technique
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Management of Hip Fractures in the Elderly
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To detect the incidence of preoperative and postoperative deep vein thrombosis (DVT) in elderly patients with hip fracture, 100 patients aged 65 years and older with either a subcapital or intertrochanteric hip fracture were evaluated by duplex beta-mode ultrasonography. Treatment was based on each scan result: if evidence for DVT was seen, the patient was therapeutically anticoagulated; lacking signs of DVT, patients were treated prophylactically. Before their operation, 77 patients (77%) had normal results of their scans, while DVT was diagnosed in 12 patients (12%). An additional 11 patients (11%) developed DVT after the operation. The total incidence of DVT in this series was 23%
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Role of low field MRI in detecting knee lesions
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AMP (Acute Meniscal Pathology)
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Objective The aim of this work is to evaluate the diagnostic accuracy of 0.3T sectoral MR imaging, compared with arthroscopy, for meniscal, cruciate ligaments and chondral knee lesions. Materials and Methods We conducted a retrospective study analyzing all the consecutive knees subjected to arthroscopy at our institution between January 2014 and June 2017 and preceded within 3 months by knee MR examination at our institution with 0.3 T equipment. Patients with history of a new trauma in the time interval between MR exam and arthroscopy were excluded from the study. Two independent experienced radiologists evaluated in double blind the MR findings of menisci, cruciate ligaments and articular cartilage. Both radiological findings were independently compared with those of the arthroscopic report considered as gold standard. For each of the examined targets we calculated the following parameters: sensitivity, specificity, accuracy, positive and negative predictive value; interobserver concordance statistically calculated using Cohen's Kappa test. Results 214 knees (95R/119L) of 214 patients (143M/71F) aged from 18 to 72 years (mean 44) were included and analyzed. We found a good diagnostic accuracy of the low field MR in identifying the injuries of the menisci (93%) and the crossed ligaments (96%), but a lower accuracy for the articular cartilage (85%). Sensitivity resulted 90% for menisci, 73% for ligaments and 58% for cartilage. Specificity was 91% for menisci, 97% for ligaments and 92% for cartilage. Inter-observer concordance resulted to be excellent for cruciate ligaments (K of Cohen's test = 0.832), good (K = 0.768) for menisci, modest to moderate for articular cartilage (K from 0.236 to 0.389) with worse concordance for tibial cartilage. Conclusions Low-field MR sectoral device with dedicated joint equipment confirms its diagnostic reliability for the evaluation of meniscal and cruciate ligaments lesions but is weak in evaluating low grade chondral lesions.
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Structural Allograft Transplantation for Osteochondral Lesions of the Talus
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Osteochondritis Dissecans 2020 Review
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INTRODUCTION: We describe the technique for structural allograft transplantation to treat large talar shoulder lesions. STEP 1 PATIENT SELECTION AND EDUCATION: The patient and surgeon must be prepared for a waiting time of unknown length and have a flexible schedule for when the graft is ready for implantation. STEP 2 PREOPERATIVE PLANNING AND APPROVAL: Inspect the graft for the correct approximate size, operative side, and quality of the cartilage surface prior to proceeding with surgery. STEP 3 SURGICAL APPROACH AND OSTEOTOMY: Make sure that the proposed osteotomy site exits into the tibial plafond and not at the axilla as this allows for easier access to the lesion. STEP 4 PREPARE RECIPIENT SITE: Measure the dimensions of the talar defect and its location from anterior to posterior along the talar shoulder at least twice. STEP 5 HARVEST GRAFT FROM DONOR TALUS: Err on the side of creating too large a graft that later can be trimmed instead of a graft that is initially too small. STEP 6 IMPLANT AND SECURE GRAFT INTO RECIPIENT SITE: Secure the graft with one or two 1.5 or 2.0-mm-diameter solid screws. STEP 7 REDUCE OSTEOTOMY SITE AND CLOSE: Ensure that there is no intra-articular step-off. STEP 8 POSTOPERATIVE CARE: After transitioning to a boot-brace, the patient should remove it to perform ankle range-of-motion exercises four to five times per day. RESULTS: In our series, there were eight patients with a mean age of thirty-one years (range, seventeen to forty-four years). WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.
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Sequential scintigraphy and orthoradiographic measurement of femoral shortening after femoral neck fracture
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Management of Hip Fractures in the Elderly
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The objective of the study was to assess scintigraphic patterns and femoral shortening after femoral neck fracture in order to select predictive parameters for late complications. Eighty-eight patients with osteosynthesized femoral neck fractures were followed for 2 years with regular scintigraphic evaluations and orthoradiographic measurements of femoral length shortening. Four different patient categories were identified with regard to the late outcome two different groups with uneventful healing and two different groups with late complications. Accordingly, a high scintigraphic uptake at 1 month may either point to an uneventful healing if combined with minor femoral shortening or indicate failure if combined with a high degree of femoral shortening. In contrast, low scintigraphic uptake may either reflect primary fracture healing if accompanied by minor femoral shortening or predict failure if a high degree of femoral shortening is present. Compared with using scintigraphy alone, combined scintigraphic evaluation and assessment of femoral shortening increased the accuracy for prediction of late failures from 80% to 93%. Early scintigraphic patterns after osteosynthesis of femoral neck fractures have to be validated with care. Radiographic assessment of femoral shortening, which is less invasive, gives better prognostic accuracy and should therefore be preferred for this purpose
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Impact of Intravenous Acetaminophen on Lengths of Stay and Discharge Status after Total Knee Arthroplasty
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AAHKS (4) Acetaminophen
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Postoperative pain remains difficult to control after total knee arthroplasty (TKA). While various modalities have been used, they have been associated with several side effects. For example, opioids have many side effects including: sedation, dizziness, nausea, vomiting, constipation, respiratory depression, and can lead to dependency. Recently, intravenous (IV) acetaminophen has been introduced as a method to manage postoperative pain. Therefore, the purpose of this study was to compare the postoperative outcomes of TKA patients who received oral acetaminophen versus IV acetaminophen. Specifically, this study evaluated: (1) the hospital lengths of stay (LOS) and (2) discharge dispositions. The Premier Database was used to review patients who underwent TKA from 2012 to 2015. A total of 134,216 TKA patients received oral acetaminophen, whereas 56,475 TKA patients received IV acetaminophen postoperatively. LOS were calculated as the number of days from the date of hospital admission to the date of discharge, and the discharge disposition was categorized as to home or to a skilled nursing facility (SNF). Compared with the oral group, the IV acetaminophen group had a 0.14 days shorter LOS (95% confidence interval [CI], -0.15 to -0.13; p<0.001) and 22% higher chance of being discharged home (odds ratio [OR]=1.22; 95% CI, 1.19-1.25; p<0.001). Also, compared with the oral group, the IV group had a 13% lower chance of being discharged to a SNF (OR=0.87; 95% CI, 0.85-0.90; p<0.001). This study demonstrated that TKA patients who received IV acetaminophen were associated with a significantly shorter hospital LOS as well as being discharged home and fewer patients had to go to SNF. This may lead to a reduction in the total cost of health care, while, at the same time, decreasing the resource use in patients who undergo TKA.
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Anterior lamellar recession for management of upper eyelid cicatricial entropion and associated eyelid abnormalities
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Upper Eyelid and Brow Surgery
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AIM: To evaluate the functional and aesthetic outcomes of upper eyelid cicatricial entropion (UCE) correction using anterior lamellar recession (ALR) with addressing the associated conditions including dermatochalasis, brow ptosis, blepharoptosis, and lid retraction. METHODS: Chart review of patients with upper lid cicatricial entropion who had undergone ALR from 2013 to 2016 was reviewed. Success was defined as the lack of any lash in contact with the globe, no need for a second procedure, and acceptable cosmesis at the final follow up. RESULTS: Sixty eight patients (97 eyelids) were operated by ALR with simultaneous correction of associated lid problems in each case when necessary. The mean follow-up time was 17.8mo (range, 6.0-24.0mo). Concomitantly, levator tucking was performed in 19 eyelids (19.6%), upper lid retractor recession in 18 eyelids (18.6%), and internal browpexy in 31 eyelids (32.0%). In 95.8% of patients (95%CI: 0.85-0.96), satisfactory functional and cosmetic outcome was achieved with a single surgical procedure. CONCLUSION: Based on the principles of lamellar recession and concurrently addressing the associated lid problems, this approach is an effective and safe treatment of UCE.
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The impact of glucocorticoid replacement regimens on metabolic outcome and comorbidity in hypopituitary patients
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AAHKS (2) Corticosteroids
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BACKGROUND: Hypopituitary patients with untreated GH deficiency and patients on inappropriately high doses of glucocorticoid (GC) share certain clinical features.
OBJECTIVE: The aim of the study was to examine the influence of GC substitution on clinical characteristics in hypopituitary patients before and after GH replacement therapy.
METHOD: A total of 2424 hypopituitary patients within the KIMS (Pfizer International Metabolic Database) were grouped according to ACTH status. Comparisons were performed between subjects on hydrocortisone (HC) (n = 1186), cortisone acetate (CA) (n = 487), and prednisolone/dexamethasone (n = 52), and ACTH-sufficient patients (AS) (n = 717) before and after 1 yr of GH treatment in terms of body mass index, waist and hip circumference, blood pressure, glucose, glycosylated hemoglobin (HbA1c), serum lipids, IGF-I, and comorbidity. Hydrocortisone equivalent (HCeq) doses were calculated, and measurements were adjusted for sex and age.
RESULTS: At baseline, the HC group had increased total cholesterol, triglycerides, waist circumference, and HbA1c, and the prednisolone/dexamethasone group had increased waist/hip ratio as compared with AS. After HCeq dose adjustment, the HC group retained higher HbA1c than the CA group. GC-treated patients showed a dose-related increase in serum IGF-I, body mass index, triglycerides, low-density lipoprotein cholesterol and total cholesterol levels. Subjects with HCeq doses less than 20 mg/d (n = 328) at baseline did not differ from AS in metabolic endpoints. The 1-yr metabolic response to GH was similar in all GC groups and dose categories. All new cases of diabetes (n = 12), stroke (n = 8), and myocardial infarction (n = 3) during GH treatment occurred in GC-treated subjects.
CONCLUSION: HCeq doses of at least 20 mg/d in adults with hypopituitarism are associated with an unfavorable metabolic profile. CA replacement may have metabolic advantages compared with other GCs.
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Induction oftolerance INA patientwitha history of exfoliative dermatitis to trimethoprim-sulfamethoxazole
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction Drug hypersensitivity with exfoliative dermatitis (ED) is generally considered a contraindication to graded drug challenge or attempted induction of tolerance.We describe successful induction of tolerance in a patient with ED to trimethoprim-sulfamethoxazole (TMP-SMX). Methods A 53 year old woman with a history of psoriatric arthritis on chronic prednisone; status post right knee arthroplasty; status post lumbar fusion; with recurrent methicillin- resistant staphylococcus aureus (MRSA) septic arthritis, prosthetic joint infection, and lumbar osteomyelitis was admitted for repeat lumbar fusion. Lumbar spine cultures grew MRSA sensitive to vancomycin, linezolid and TMP-SMX. Vancomycin was used for acute management of lumbar osteomyelitis. Infectious disease service determined that the patient needed lifelong antibiotic suppression with 160mgTMP-800mg SMX twice daily.Vancomycin was not recommended due to parenteral administration. Linezolid was not recommended due to parenteral administration, cost, and side effects, including hepatitis and thrombocytopenia. Due to the patient's history of ED toTMPSMX 1 month prior, Allergy/Immunology was consulted. Results Given the limited treatment options, a 10-day induction of tolerance to 160mg TMP- 800mg SMX was attempted with informed consent. The patient developed pruritus on day 10 when the dose was increased from 80mg TMP-400mg SMX to 160mg TMP-800mg SMX. On day 13 the patient had generalized erythema and relative eosinophilia. The protocol was stopped and prednisone was increased from 20mg to 60mg for 5 days. Eosinophilia resolved and the patient's skin returned to baseline. The Infectious Disease service felt that lifetime antibiotic suppression was medically necessary. Therefore, 4 weeks later induction of tolerance was attempted again, starting at 1/10th the previous starting dose and increasing at half the rate (Table 1). After the 80mgTMP-400mg SMX was achieved the protocol was slowed to advance by 2mg TMP-10mg SMX every other day. The protocol took 266 days. Weekly labs showed no eosinophilia, altered renal function or altered liver function. The patient's skin exam was unchanged. Conclusion To our knowledge, this is the first report of induction of tolerance in a patient with a previous history of ED to TMP-SMX. (Table presented)
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Revision total knee arthroplasty with modular components inserted with metaphyseal cement and stems without cement
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Surgical Management of Osteoarthritis of the Knee CPG
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The clinical and radiographic outcomes of 50 consecutive revision total knee arthroplasties in 47 patients, placed with metaphyseal cemented femoral and tibial components with press-fit cementless stems, were reviewed at 36-month average follow-up. Revision was performed for aseptic loosening (11/50), infection (17/50), periprosthetic fracture (8/50), component failure (6/50), instability (6/50), and malalignment (2/50). The press-fit cementless stems were 80 to 160 mm in length and tightly contacted the endosteum of the metadiaphyseal areas. Four (9%) knees were re-revised for infection, zero for aseptic loosening. The average modified Hospital for Special Surgery knee score improved from 49 to 87. One patient (2%) reported thigh pain, and 1 reported leg pain. Metaphyseal cemented revision total knee components with press-fit cementless femoral and tibial stems were not associated with significant thigh and leg pain
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1 |
A known technique for meniscal repair in common practice
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Anterior Cruciate Ligament Injuries CPG
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In this retrospective study, we calculated the healing rate of meniscal repairs performed with an outside-in technique. We describe complications encountered and evaluate some known criteria used in the decision to perform a meniscal repair instead of partial meniscectomy. Included is a brief description of the surgical technique and of the trauma type and the meniscal lesions that were repaired. The technique has a high degree of success (74% of the meniscal repairs survived during a mean follow-up of 3.5 years). Although there is a 25% complication rate, no serious or permanent complications were added by repairing menisci instead of performing a partial meniscectomy. For this reason we think saving even a relatively low percentage of menisci may be worthwhile. We can also conclude that an anterior cruciate ligament-deficient knee that is stable can still have a good result in meniscal repair, without performing cruciate reconstruction. In each case, however, individual patient issues such as age, activity level, and associated lesions have to be considered
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Ibandronate to treat skeletal-related events and bone pain in metastatic bone disease or multiple myeloma: a meta-analysis of randomised clinical trials
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MSTS 2018 - Femur Mets and MM
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OBJECTIVE: Randomised controlled trials (RCTs) have given contradictory results about the efficacy and safety of ibandronate in treating metastatic bone disease (MBD) or multiple myeloma. This review meta-analysed the literature to gain a more comprehensive picture.
DESIGN: Systematic review and meta-analysis of ibandronate compared with placebo or zoledronate.
DATA SOURCES: PubMed, EMBASE and the Cochrane Library databases were systematically searched to identify RCTs published up to March 2015 evaluating ibandronate to treat MBD or multiple myeloma.
REVIEW METHOD: 10 RCTs involving 3474 patients were included. Six RCTs were placebo-controlled and four compared ibandronate with zoledronate. The studies included in this review were mainly from European countries.
RESULTS: Intravenous ibandronate (6 mg) or oral drug (50 mg) decreased the risk of skeletal-related events compared to placebo (risk ratio (RR) 0.80, 95% CI 0.71 to 0.90, p=0.002). It also reduced the bone pain score below baseline significantly more than did placebo at 96 weeks (weighted mean difference -0.41, 95% CI -0.56 to -0.27, p<0.001). The incidence of diarrhoea, nausea and adverse renal events was similar between the ibandronate and placebo groups, but ibandronate was associated with greater risk of abdominal pain. Ibandronate was associated with similar risk of skeletal-related events as another bisphosphonate drug, zoledronate (RR 1.02, 95% CI 0.82 to 1.26, p=0.87). The incidence of nausea, jaw osteonecrosis and fatigue was similar for the two drugs, but the incidence of adverse renal events was significantly lower in the ibandronate group.
CONCLUSIONS: Ibandronate significantly reduces the incidence of skeletal-related events and bone pain in patients with MBD or multiple myeloma relative to placebo. It is associated with a similar incidence of skeletal-related events as zoledronate.
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Correction: Effect of early surgery vs physical therapy on knee function among patients with nonobstructive meniscal tears: The ESCAPE randomized clinical trial (JAMA - Journal of the American Medical Association (2018) 320:13) (1328-1337) DOI: 10.1001/jama.2018.13308)
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AMP (Acute Meniscal Pathology)
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Data Errors in Table 3: In the Original Investigation titled "Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial,"1 published in the October 2, 2018, issue, the upper limits of 95% CIs were incorrectly reported as positive rather than negative numbers in Table 3. The between-group differences for the arthroscopic partial meniscectomy vsphysical therapy groupsoverall, at6months, and at 24 months should have been reported as -5.9 (95%CI, -10.3 to -1.4), -8.2 (95%CI, -14.1 to -2.3), and -7.7 (95%CI, -14.0 to -1.3) points, respectively. Also, the P value for the between-group difference for the delayed arthroscopic partial meniscectomy vsphysical therapy group at6months should have been .009. This article was corrected online.
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Penile Lengthening, Girth, and Size Preservation at the Time of Penile Prosthesis Insertion
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Panniculectomy & Abdominoplasty CPG
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INTRODUCTION: Penile prosthetic devices are the gold standard treatment of medication-refractory erectile dysfunction. Inflatable penile prosthetic (IPP) devices have been available and used for more than four decades. Oftentimes, medical conditions causing erectile dysfunction also cause penile shortening, causing decreased patient quality of life. AIM: To identify and review all available penile lengthening procedures that can be performed at time of IPP insertion. METHODS: An extensive, systematic literature review was performed using PubMed searching for key terms penile lengthening, inflatable penile prosthesis, penile girth, corporoplasty, glans augmentation, and penile enhancement; all articles with subjective and/or objective penile length outcomes were reviewed. MAIN OUTCOME MEASURES: A review of various techniques for penile length and girth preservation and enhancement during penile prosthesis insertion. RESULTS: Several advanced and novel techniques were found for penile length preservation and enhancement at time of IPP insertion, including the sub-coronal IPP insertion technique, and adjuvant maneuvers during insertion, such as the sliding technique, modified sliding technique, multiple slice technique, and circumferential incision and grafting. Other adjuvant techniques that can enhance perception of increased length include ventral phalloplasty, suprapubic lipectomy, and suspensory ligament release. Further enhancement can be obtained using augmentation corporoplasty and glans augmentation with hyaluronic acid and other fillers. The different techniques vary in complexity and could require specialized training and experience. Maximum length gain appears to be limited by the length of the neurovascular bundles. CONCLUSION: Overall, surgical penile lengthening procedures at time of IPP insertion appear safe and effective for treatment of patients with penile shortening and severe erectile dysfunction. These therapies can significantly improve patient self-esteem and quality of life in properly selected patients. Tran H, Goldfarb R, Ackerman A, Valenxuela RJ. Penile Lengthening, Girth and Size Preservation at the Time of Penile Prosthesis Insertion. Sex Med Rev 2017;5:403-412.
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Fracture of the upper end of the ulna associated with dislocation of the head of the radius in children
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Distal Radius Fractures
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Dislocation of the head of the radius associated with fracture of the upper end of the ulna is a common elbow injury in children. The literature on diagnosis, however, is relatively limited. The injury can be misdiagnosed and consequently mismanaged. In the present series of 46 children, the age range was from 2.5 to 12 years. The dislocation of the radial head was lateral in 50% of the cases, posterolateral in 28.2%, anterolateral in 17.4%, and anterior in 4.3%. Thorough clinical and radiological examinations are essential. Simple bending of the upper end of the ulna may help to avoid missing an associated subluxation or dislocation of the radial head. The lower end of the forearm bones should be included in the roentgenographic examination; in 11 out of 46 children (26%) the dislocation of the elbow was associated with a fracture of the lower end of the ipsilateral radius and ulna. Closed reduction is the treatment of choice but if this fails, operative treatment should follow without delay. Posterior interosseous nerve palsy was noted in eight patients (17%), but recovered fully in all of the treated cases.
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High prevalence of vitamin D deficiency and reduced bone mass in Parkinson's disease
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Management of Hip Fractures in the Elderly
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Despite excessive hip fractures in patients with Parkinson's disease (PD), little is known about bone changes in these patients. We measured bone mineral density (BMD; Z scores) in PD patients and analyzed its relation to serum biochemical indices and sunlight exposure. We measured BMD in 71 patients in the second metacarpals and divided the patients into two groups according to functional independence; group 1, Hoehn and Yahr stages 1 and 2; and group 2, stages 3 to 5. In four of 20 patients in group 1 (20%), the Z score was less than -1.0, indicating osteopenia. In 51 patients in group 2, 31 (61%) had a Z score less than -1.0. The group 1 patients showed a normal mean serum level of 25-hydroxyvitamin D (25-OHD; 21.7 ng/ml), while most group 2 patients were in a deficiency range (group mean 8.9 ng/ml). Many group 2 patients were sunlight deprived. Both groups had elevated serum ionized calcium levels correlating positively with Hoehn and Yahr stage and markedly depressed serum 1,25-dihydroxyvitamin D (1,25-[OH]2D) concentrations, indicating that immobilization-induced hypercalcemia had inhibited 1,25-[OH]2D production. Z scores correlated positively with 25-OHD levels and negatively with parathyroid hormone concentration and Hoehn and Yahr stage. Vitamin D deficiency due to sunlight deprivation and hypercalcemia induces compensatory hyperparathyroidism, which contributes to reduced BMD in PD patients, particularly those who are functionally dependent. Low BMD increases risk of hip fractures in patients with PD but may be improved by vitamin D supplementation
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Somatosensory cortical plasticity to tactile stimuli and electro-cutaneous stimuli in carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Carpal tunnel syndrome (CTS) is caused by the compression of the median nerve sensorimotor fibers at the wrist, and it is considered as the most frequent type of nerve entrapment. Several studies investigated the changes in somatotopic representation in patients with CTS. This was by comparing the somatosensory cortical reorganization and responses to the electro-cutaneous stimuli/or to the mechanical stimuli, which applied to the affected and the intact hands' fingers. In addition, the comparison was just between the corresponding somatotopic maps of the hand digits at the primary somatosensory cortex (SI). However, we showed previously that the mechanical tactile stimulation evokes more cortical regions than the electro-cutaneous stimulation. Therefore, the primary aim of our study was to carry out a comprehensive comparison between the corresponding SI-somatotopic representation to mechanical stimuli and the corresponding SI-somatotopic representation to electro-cutaneous stimuli, in patients with CTS. The secondary aim was to examine the possible neural plasticity effect of CTS on the secondary somatosensory cortex (SII) and the sensorimotor cortex (SM). Index finger and little finger of both hands (affected vs. intact) were tested. The electrocutaneous stimuli were delivered to each finger by using ball-shaped electrode. The stimulus intensity was three times of the sensory threshold. The mechanical tactile stimulation was a skin indentation, of index and little fingers, by using round shape plastic piece that applied automatically by using a non-magnetic device. 306-channel superconducting quantum device (SQUID) was used to measure the somatosensory evoked fields (SEFs) of SI, SII and SM cortex
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Retained versus resected posterior cruciate ligament in mobile-bearing total knee replacement: a retrospective, clinical and functional assessment
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PJI DX Updated Search
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PURPOSE: Fully conforming, mobile-bearing total knee replacement (TKR) was initially designed using a posterior cruciate-sacrificing (CS) technique. Rotating-platform TKR that could also be performed retaining the posterior cruciate developed afterwards. The purpose of this study was to compare the clinical and functional outcomes of patients who had either cruciate-retaining (CR) or cruciate-sacrificing (CS) TKR at a minimum follow-up of 2 years with the same prosthetic design. METHODS: One hundred and two consecutive TKR (88 patients) were performed at the same institution either with CS (56 TKR-49 patients) or with CR (46 TKR-39 patients) technique. Patients were followed at a minimum of 2 years. Patients were evaluated for articular range of motion, complication rate (infection, loosening) and clinical outcome measures included the pain and functional components of the Knee Society Score. RESULTS: The two groups (CS, CR) were homogeneous. At final follow-up, no significant difference was seen between the two surgical techniques in terms of ROM, pain and functional level, and revision rate. CONCLUSIONS: This study showed that for this given mobile-bearing, fully conforming prosthetic design, sacrificing or resecting the PCL does not influence the clinical and functional outcomes at a minimum of 2-year follow-up. Surgeons may indifferently choose one of the two options (CS, CR) according to their preferences. LEVEL OF EVIDENCE: Case series, level IV
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Percutaneous compression plating for intertrochanteric fractures. Surgical technique, tips for surgery, and results
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Hip Fx in the Elderly 2019
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OBJECTIVE: Fixation of intertrochanteric fractures by a minimally invasive technique using the Percutaneous Compression Plate (PCCP) allowing anatomic reduction and immediate postoperative weight bearing.
INDICATIONS: Intertrochanteric fractures.
CONTRAINDICATIONS: Intertrochanteric fractures that cannot be reduced by closed manipulation, subtrochanteric and reverse oblique fractures (AO/OTA 31-A3).
SURGICAL TECHNIQUE: Placement of patient on a fracture table with a posterior reduction device (PORD) supporting the fracture. Reduction of the fracture by closed manipulation. Percutaneous insertion of the plate through a lateral proximal incision. Adaptation of the plate to the lateral aspect of the proximal femoral shaft with a bone clamp inserted through a second, more distal incision. Insertion of telescoping compression neck screw through the plate into the neck and securing of plate to the femoral shaft with three additional screws. Finally, completion of fracture fixation with second neck screw.
RESULTS: Of 130 patients with intertrochanteric fractures treated using the described technique at the Orthopedic Surgery Department Hadassah University Hospital, Jerusalem, Israel, between May 2000 and December 2001, 108 were available for this study. Patients' age averaged 81 years (+/- 8 years). Mean surgical time was 67 min and mean hospital stay 11.5 days. 40% of patients did not require a transfusion during hospitalization, while 8.3% needed more than three units of packed cells. Complications occurred in four patients: two implant failures that were successfully revised with a Compression Hip Screw, one nonunion treated with hip arthroplasty; the fourth patient had a shortening of 3 cm needing a heel lift. Three patients developed an infection, one requiring surgical debridement.
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Prospective clinical and radiological two-year results after patellofemoral arthroplasty using an implant with an asymmetric trochlea design
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OAK 3 - Non-arthroplasty tx of OAK
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Purpose: The purpose was to prospectively evaluate the two-year results after implantation of the Journey PFJ® (Smith & Nephew, Andover, MA). The authors hypothesized that patellofemoral arthroplasty would result in improved outcomes after 24 months in patients treated with an isolated procedure as well as in patients demonstrating concomitant patellofemoral instability (PFI), which were treated with a combined surgical procedure. Methods: Patients were included between 02/2006 and 08/2008. According to the history and clinical findings, patients were grouped into group I with no history or clinical signs of PFI, and patients with concomitant PFI were assorted to group II. Patients were then treated with an isolated (group I) or a combined (group II) surgical procedure to additionally treat the PFI. Visual analogue scale (VAS), Lysholm score and WOMAC score were recorded preoperatively, 6, 12 and 24 months postoperatively. Patellar height was evaluated according to the index of Caton-Deschamps (CDI), and osteoarthritic changes were evaluated according to Kellgren and Lawrence. Results: A total of 25 patients were enrolled, of them three discontinued interventions and were excluded from final analysis. An isolated implantation of the Journey PFJ® was performed in 14 patients (group I) and a combined procedure in 8 (group II). Daily pain and clinical scores significantly improved at 6, 12 and 24 months compared to preoperative values (P < 0. 05). Significant decrease (P = 0. 02) of mean CDI could be noticed. Significant increase in tibiofemoral OA within the medial but not in the lateral tibiofemoral joint was assessed (P = 0. 011; n. s.). Conclusions: Patellofemoral arthroplasty using the Journey® PFJ for treatment of significant patellofemoral OA demonstrated improved clinical scores at the 2-year follow-up in both groups. Comparing the primary OA (I) and OA + instability (II) groups, patients with patellofemoral OA treated with a combined procedure for concomitant stabilization of patellofemoral instability may benefit more from such a combined procedure, than patients treated with an isolated procedure for treatment of isolated patellofemoral OA. Level of evidence: Prospective case series, Level III. © 2012 Springer-Verlag.
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Compression plating versus hackethal nailing in closed humeral shaft fractures failing nonoperative reduction
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Prospectively, 40 patients with an average age of 45 (20-65) with closed transverse fractures of the middle one-third of the humerus without associated radial nerve palsy were treated. All had failed nonoperative reduction and were then operated on with either compression plating or intramedullary fixation with Hackethal nails and a postoperative ready-made fracture brace. These surgeries were performed at an average of 7 days (4-10) after closed reduction. The Hackethal nailing group consisted of 20 patients (17 men, 3 women) with a mean age of 47 years (22-64); within 2 days after surgery the patients were allowed to begin active and passive range-of-motion exercises of the elbow and the shoulder with the arm protected by a ready-made fracture brace; the average follow-up period for this group was 18 months (12-50). These patients (with one exception) required a second surgical procedure with a second anesthesia to remove the symptomatic nails; moreover, they had to be protected in a brace for 6 months. The compression plate group consisted of 20 patients (14 men, 6 women) with a mean age of 45 years (20-65); within 2 days after surgery the patient was allowed to begin the same rehabilitation program; in this group no braces were used postoperatively. All fractures treated with Hackethal nailing healed except for one delayed union. Functional results in this group were 12 excellent, 4 good, 1 fair, and 3 poor. All fractures treated by compression plating healed except in one case of delayed union.(ABSTRACT TRUNCATED AT 250 WORDS)
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Assessment of the Efficacy of Cryolipolysis on Saddlebags: A Prospective Study of 53 Patients
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Cryolipolysis is a noninvasive subcutaneous fat removal technique. Its efficacy has been demonstrated on various fatty areas but not yet on saddlebags. The main objective of this study was to demonstrate the efficacy, patient tolerance, and safety of cryolipolysis on the saddlebags. METHODS: This prospective study enrolled 53 patients with saddlebags. Patients with a history of liposuction or other surgical procedure on the saddlebag area and those on diet pills were excluded. The primary endpoint was a decrease in fat thickness at 3 and 6 months, as assessed by thigh circumference measurement and by ultrasound evaluation of subcutaneous fat. Pain associated with cryolipolysis was assessed using a visual analogue scale. Body mass index at the different time points and adverse events were recorded. All patients completed a satisfaction questionnaire at the end of the study. RESULTS: At 6 months, there was a mean decrease of 5.63 cm in thigh circumference; the mean decrease in fat layer thickness measured by ultrasound was 1.31 cm. The satisfaction questionnaire showed that 93.75 percent of patients were satisfied with the results. The mean visual analogue scale score was 1.66 of 10 after the session. Reversible skin changes such as postprocedure postinflammatory hyperpigmentation were observed in 8.33 percent of patients. CONCLUSIONS: Cryolipolysis is an effective technique for reducing saddlebag fat and is well tolerated by patients. A substantial risk of skin lesions, including postinflammatory hyperpigmentation that resolved after a few months, was observed. Cryolipolysis is a good alternative to liposuction in women with moderate, well-localized saddlebags. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Hyaluronan before osteoarthritis: About 339sportsmen
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OAK 3 - Non-arthroplasty tx of OAK
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Introduction: Physical activities, through traumas and intensity of practice expose the athletes to cartilage pain caused earlier compared to a population of sedentary people. Lesions at the origin of the pain may be traumatic or microtrauma however without meeting the radio-clinical osteoarthritis criteria defined by the American College of Rheumatology. Hyaluronic acid (HA) is commonly used in the treatment of knee osteoarthritis. It became legitimate to think that the mechanism of action of the product can lead to a pain relief of patients when used in other joints and pre-arthritic stage. As such, we use it in these indications for over 10. years. The objective of this study is to evaluate its effectiveness in the knee, hip and ankle and to identify prognostic factors. Method: Retrospective study analysing the effectiveness of the viscosupplementation through a questionnaire assessing pain, athletic/professional level, pain relief on a daily basis and satisfaction. All of the lesions have been classified Kellgren 0 and staging of the ICRS for the knee. Definition of the criteria for response on the sedation of pain, and the maintenance of the sport/professional level. We also searched factors prognostications for the knee, only joint with sufficient sample size expected (biometric data: sex, age, body mass index, sports and professional profile, used presentation and prior injected corticosteroid solution). Results: Three hundred and thirty-nine protocols have been realized to 332cartilaginous traumatic or microtraumatic degenerative lesions (279knees with single cartilaginous injury, 61patients with associated treated meniscal tear, 29hips, 31ankles) and seven painful after-effects of osteochondritis. The average age of patients was 39.30 (±. 14.38), 76% male; 83.2% had a sports profile with strong joint solicitation. Overall effectiveness was 49.85% (single chondral injury: 46.26%, chondral injury plus meniscal tear both treated: 60.66%, 44.82% for hip and 57.14% for the ankle). Four patients on seven treated for painful sequela of osteochondritis have been relieved. The rate of adverse events was 4.13%, represented by puncture pain or swelling reaction. In the knee, the stage lesion did not impact on efficiency ( P= 0.17), neither the presence of an associated meniscal tear non-treated ( P= 0.15); the pursuit of a support activity is correlated with a loss of efficiency ( P= 0.039). Discussion: This study is interesting as far as no study in vivo exists regarding the use of HA in support of isolated microtraumatic or traumatic chondral lesions except in the course of surgery of the meniscus with visualization of an arthroscopic cartilage injury. Efficiency appears interesting, almost equal to that found in the available studies on arthritis in these joints, although, because of the heterogeneity of the protocols and the results obtained, the estimation of a reliable response rate seems delicate. Conclusion: The use of HA for the treatment of the pain of single traumatic or microtraumatic cartilage injury appears safe, with an interesting efficiency to be confirmed by studies of high level of evidence. © 2013 Elsevier Masson SAS.
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Lateral femoral condyle insufficiency fractures: imaging findings, demographics, and analysis of outcomes
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To describe imaging characteristics and demographics of lateral femoral condyle insufficiency fractures (LFCIFs) and identify characteristics associated with progression to epiphyseal collapse.
MATERIALS AND METHODS: A retrospective review of 105 consecutive patients with LFCIF was performed (mean age 58.1 years) after excluding post-traumatic and pathological fractures. Lesion size and location, presence of bone marrow edema-like signal, soft tissue edema, chondrosis grade, and meniscus pathology were documented. Demographics were recorded from the electronic patient record. Follow-up MRI and/or radiographs were evaluated for healing/stability or progression to epiphyseal collapse. Bone mineral density was assessed from dual-energy x-ray absorptiometry (DEXA) scans and/or radiographs.
RESULTS: Fifty-six female and 49 male subjects were included. Female subjects were older at presentation (60.5 versus 56.3 years, p = .02). A total of 61.7% of the subjects with available DEXA and/or radiographs had osteopenia/osteoporosis. The central weight-bearing (61%) and outer condyle (54.3%) were most involved. High-grade chondrosis was present in >= 1 compartment in 70.5% including 42% in the lateral compartment. A total of 67.6% had >= 1 meniscus tear with similar frequency of medial and lateral tears (47.6% versus 41%). Bone marrow edema-like signal was present in all cases; soft tissue edema was present in 83.8%. Fifty-three subjects had available follow-up MRI (n = 24) and/or radiographs (n = 29). Increased age, fracture dimensions, presence of medial meniscus tears, and high-grade patellofemoral chondrosis were associated with progression (p <= .05).
CONCLUSION: LFCIFs are associated with meniscus tears, high-grade chondrosis, and osteopenia/osteoporosis with more global knee pathology present when compared with medial femoral condyle insufficiency fracture. Increased age, medial meniscus tears, fracture dimensions, and high-grade patellofemoral chondrosis were associated with progression.
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The Epidemiology of Meniscus Injury
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AMP (Acute Meniscal Pathology)
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Meniscus surgery is one of the most commonly performed orthopedic procedures worldwide. Modifiable risk factors for meniscus injury include body mass index, participation in athletics and occupation. Nonmodifiable risk factors include age, sex, lower extremity alignment, discoid meniscus, ligamentous laxity, and biconcave tibial plateau. Conditions commonly associated with meniscal injury are osteoarthritis, anterior cruciate ligament injury, and tibial plateau fractures. Tear type and location vary by patient age and functional status. Surgical management of meniscus injury is typically cost-effective in terms of quality-adjusted life years. The purpose of this review is to provide an overview of meniscal injury epidemiology by summarizing tear types and locations, associated conditions, and factors that increase the risk for meniscal injury. The economic burden of meniscus injury and strategies to prevent injury to the meniscus are also reviewed.
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Lack of nephrotoxicity by 6% hydroxyethyl starch 130/0.4 during hip arthroplasty: A randomized controlled trial
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AAHKS (2) Corticosteroids
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BACKGROUND: Hydroxyethyl starch (HES) is commonly used as plasma expander during surgery but may be nephrotoxic as seen in studies in patients with sepsis. The authors hypothesized that the possible nephrotoxicity of 6% HES 130/0.4 could be revealed by measurements of urinary excretion of neutrophil gelatinase-associated lipocalin (u-NGAL) in patients with normal renal function during hip arthroplasty. METHODS: In this randomized, double-blinded, placebo-controlled study, 40 patients referred for hip arthroplasty received either 6% HES 130/0.4 or isotonic saline 0.9%; 7.5 ml/kg during the first hour of surgery and 5 ml/kg during the following hours; 38 patients completed the study. U-NGAL, urine albumin, blood pressure, and plasma concentrations of creatinine, renin, NGAL, albumin, angiotensin-II, and aldosterone were measured before, during, and after surgery. U-NGAL was defined as primary outcome. RESULTS: There were no significant differences in U-NGAL (mean difference and 95% CI), plasma creatinine, and urine albumin during the study. U-NGAL and urine albumin increased significantly in both groups the morning after surgery but was normalized at follow-up after 10 to 12 days. Mean arterial pressure was significantly higher during the recovery period in the HES group compared with that in the control group (91 [13] and 83 [6] mmHg, mean [SD], P < 0.03). Plasma renin and angiotensin-II were nonsignificantly different in both groups, whereas plasma aldosterone was significantly lower in the HES group. Plasma albumin was reduced in both groups, but to a significantly lower level in the HES group. CONCLUSION: The study showed no evidence of a harmful effect of intraoperative infusion of 6% HES 130/0.4 on renal function in patients during hip arthroplasty.
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Setting priorities for research: a practical application of 'payback' and expected value of information
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Management of Hip Fractures in the Elderly
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BACKGROUND: Setting priorities for research using economic in addition to scientific criteria can ensure that resources are spent efficiently and equitably. OBJECTIVE: This study applies two priority setting methods 'payback' and expected value of information (EVI) to two research areas (osteoporosis and pressure ulcers) and where appropriate to four clinical trials: the Record Trial, the Vitamin D and Calcium Trial and the Hip Protector Trial (osteoporosis), and the Pressure Trial (wound care). METHODS: Two decision-analytic models were developed. For 'payback', the PATHS model was used to estimate the expected net benefits of conducting the four clinical trials. An EVI framework was applied to estimate the cost-effectiveness of conducting further research in the two disease areas investigated. RESULTS: The application of 'payback' suggests that the Record Trial and the Vitamin D and Calcium Trial would be cost-effective. The Hip Protector and the Pressure Ulcer Trial are cost-effective under certain assumptions concerning the likelihood of obtaining positive, negative or inconclusive results. The EVI method suggests that research would be potentially cost-effective in these areas in the populations considered. CONCLUSION: EVI provides strategic information for setting priorities for research between disease areas and study populations. 'Payback' provides information on the cost-effectiveness of specific research designs. However, further work in this area, particularly concerning the issue of implementation of research, is required
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1 |
Septum-Inferior-Medial (SIM)-Based Pedicle: A Safe Pedicle with Well-Preserved Nipple Sensation for Reduction in Gigantomastia
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Reduction in breasts with well-preserved nipple sensation and a viable nipple-areola complex (NAC) is one of the basic core concepts of reduction mammoplasty. Many techniques have been described with enthusiasm advocating full achievement of the aforementioned goals. The goal of this study is to introduce a novel technique that provides an intact neurovascular source to the nipple-areola complex for reduction in gigantic breasts.
PATIENTS AND METHODS: Twenty-six patients operated on from December 2010 through April 2015 were included in the study. The reduction was performed by isolating Wuringer's septum and the inferior pedicle in continuity with the medial pedicle to save the neurovascular supply to the NAC and its accompanying breast parenchyma. This pedicle is called as septum-inferior-medial-based pedicle. Inclusion criteria, marking and planning with detailed description of the surgical procedure are presented.
RESULTS: The overall satisfaction rate was high. Eighty percent of the patients rated their results. The results were as follows: 81% rated as 'very satisfied'; 19% rated as 'somewhat satisfied.' NAC sensation was intact in all cases at all time intervals even immediately after surgery.
CONCLUSION: The united pedicle technique provides an intact neurovascular source to the nipple-areola complex. Reduction with this pedicle is a safe procedure. Remodeling the gigantic breast can be accomplished without any restriction because of the flexibility of this pedicle. The very early results are promising, but long-term results needed to be evaluated.
LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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1 |
Correlation between magnetic resonance imaging and arthroscopic findings in the knee joint
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AMP (Acute Meniscal Pathology)
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BACKGROUND: The knee joint is the largest and the most complex joint of the human body. It is not covered by any thick muscular covering anteriorly.
OBJECTIVES: The purpose of this study was to explore the diagnostic capabilities of clinical examination, magnetic resonance imaging (MRI), and arthroscopy in traumatic disorders of the knee joint, to seek correlation between clinical findings, MRI findings and arthroscopic.
PATIENTS AND METHODS: A total of 26 patients with a presentation suggestive of traumatic knee pathology were studied prospectively. A detailed history was taken and relevant clinical examination was done, which was followed by MRI of the knee. The patients were scheduled for arthroscopy under general/spinal anesthesia, whenever indicated.
RESULTS: Keeping arthroscopic examination as standard, the correlation between clinical and arthroscopy showed a sensitivity of 80%, specificity of 86%, accuracy of 63.16%, negative predictive value of 93.48%; whereas MRI vs. arthroscopy showed a sensitivity of 74.42%, specificity of 93.10%, accuracy of 84.21%, and negative predictive value of 88.04%.
CONCLUSIONS: The clinical examination is an important and accurate diagnostic modality for evaluation of traumatic derangement of the knee joint. It is noninvasive, easy, available, and valuable diagnostic modality. The MRI is an accurate diagnostic modality. It can be used whenever there is an uncertain indication for arthroscopy. However, costs have to be kept in mind, especially in patients with low socio-economic status.
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Revision surgery for acetabular nonunion: Role and challenges to preservation of hip joint
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Hip Fx in the Elderly 2019
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Introduction. The non-union of the acetabulum is a very frequent complication in the Letournel classified associated fractures which involve mainly the posterior column. Both the diagnosis and the treatment are very difficult. In this short work we are presenting the revisitation of our case histories of 21 acetabular nonunions. Material. The study population is divided in 13 males and 8 females with an average age of 47.6 years (range 22-75). The diagnosis of nonunion was made at about 5.2 months (3-6) after surgery. In 16 cases the nonunion was due to the conservative treatment and in 5 cases to surgery. All of then were Letournel classified associated fractures. All patients underwent revision surgery with plates and screws and implant of allogenic bone splints and autogenic morcelized bone taken from the iliac crest, after about 2.3 weeks (1-3) from the diagnosis of acetabular nonunions. The chosen criteria for patient assessment, during clinical and radiological follow-ups were: Quality of life measured with the Short Form (12) Health Survey (SF-12), the functionality of the hip and quality of life measured with the Harris Hip Score (HHS) and by the Majeed Score (MJ), bone healing and post surgery complications. Results. All patients showed a relative increase of the SF-12, HHS, MJ scores after revision surgery. On average, all patients manifested heterotopic ossification and hip arthrosis within 24 months after revision surgery. All patients within 24 months from the revision surgery received total hip prosthesis. Only 1 patient manifested an infection after the PTA. Conclusion. The acetabular nonunions, although rare, represent a devastating complication for the patient's quality of life and the revision surgery. Revision surgery, unfortunately, does not offer great satisfaction in the functional recovery and long-term quality of life, but has to allow an anatomic dignity of the acetabulum and a subsequent prosthetization in safety of these patients.
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Local Continuous Wound Infusion of Anesthetics in the Management of Post-operative Pain After Total Hip Arthroplasty
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AAHKS (8) Anesthetic Infiltration
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Wound infiltration with local anesthetics is an analgesic technique that has been adopted for postâ?operative analgesia following a range of surgical orthopaedic procedures. Pain management by infusion of local aesthetic into wounds was found to improve pain, reduced opioid use and side effects, increase patient satisfaction, and shorten the hospital stay when compared to placebo or no treatment, but actually it was not definitively proven that wound infiltration provides additional analgesic or outcome benefit in the setting of a comprehensive multimodal analgesic approach. The hypothesis of this study is that a consistent amount of Levobupivacaine 0.5% for LCWI and LIA could provide a more extended postoperative analgesia for postâ?operative incident and rest pain with a better postâ?operative recovery and rehabilitation following THA, in the first 72 hours after surgery.
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Patellar resurfacing in posterior cruciate ligament retaining total knee arthroplasty (PATRES): design of a randomized controlled clinical trial
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PJI DX Updated Search
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BACKGROUND: Anterior knee pain may occur after total knee arthroplasty (TKA). Patellar resurfacing, which is considered to lower the incidence of anterior knee pain after TKA, remains controversial. In the present study clinical and radiological outcomes after TKA performed on patients with clinical and radiological signs of femorotibial and patellofemoral osteoarthritis (OA) with and without patellar resurfacing will be compared. METHODS/DESIGN: Fifty patients will be included in a randomized controlled trial. Patients scheduled for TKA with clinical and radiological signs of femorotibial and patellofemoral OA will be included. Arthritis of the patellofemoral joint was determined based on the preoperative Baldini and Merchant X-ray views, which is assessed by the orthopaedic surgeon who treats the patient. Exclusion criteria are rheumatoid arthritis, history of patellar fracture, tuberosity transposition, high tibial osteotomy (HTO), hip arthroplasty and posterior cruciate ligament insufficiency. Patients will be randomized to undergo TKA either with or without patellar resurfacing. Outcomes will be assessed preoperatively, at 6 weeks and at 6, 12, 18 and 24 months postoperatively. Primary outcome measure is the patellofemoral scoring system according to Baldini. Secondary outcome measures are the Knee Society clinical rating system (KSS) and the Knee Osteoarthritis Outcome Scale (KOOS) scores. Conventional weight-bearing radiographs, and views according to Baldini will be used to asses component loosening, wear, and patellofemoral problems including fracture or loosening of resurfaced patellae, subluxation and wear of non-resurfaced patellae. DISCUSSION: There is no consensus regarding patellar resurfacing during primary TKA. Current prospective studies fail to determine any differences in clinical outcome among patients after TKA with or without patellar resurfacing. This randomized controlled trial has been designed to determine the effectiveness of patellar resurfacing during TKA in patients undergoing TKA who have clinical and radiological signs of tibiofemoral and patellofemoral OA, using a specific patellofemoral outcome measurement. TRIAL REGISTRATION: Netherlands Trial Registry NTR3108
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Pre-operative traction for fractures of the proximal femur in adults (Cochrane review) [with consumer summary]
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Management of Hip Fractures in the Elderly
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BACKGROUND: Following a hip fracture, traction may be applied to the injured limb before surgery. OBJECTIVES: To evaluate the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1988 to 2006 Week 11), CINAHL (1982 to March 2006), the UK National Research Register (Issue 1, 2006), conference proceedings and reference lists of articles. SELECTION CRITERIA: All randomised or quasi-randomised trials comparing either skin or skeletal traction with no traction, or skin with skeletal traction for patients with an acute hip fracture prior to sur gery. DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, data were pooled. MAIN RESULTS: Ten randomised trials, mainly of moderate quality, involving a total of 1546 predominantly elderly patients with hip fractures, were identified and included in the review. Nine trials compared traction with no traction. Although limited data pooling was possible, overall this provided no evidence of benefit from traction, either in the relief of pain before surgery or ease of fracture reduction or quality of fracture reduction at time of surgery. One of these trials included both skin and skeletal traction groups. This trial and one other compared skeletal traction with skin traction and found no important differences between these two methods, although the initial application of skeletal traction was noted as being more painful and more costly. AUTHORS' CONCLUSIONS: From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. However, the evidence is also insufficient to rule out the potential advantages for traction, in particular for specific fracture types, or to confirm additional complications due to traction use. Further, high quality trials would be required to confirm or refute the absence of benefits of traction. Residents of some countries have free access to the full text of the systematic reviews in the Cochrane Library at: http://www.thecochranelibrary.com NO
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Longitudinal change in patellofemoral cartilage thickness, cartilage T2 relaxation times, and subchondral bone plate area in adolescent vs mature athletes
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OAK 3 - Non-arthroplasty tx of OAK
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Objective Patellofemoral cartilage changes have been evaluated in knee trauma and osteoarthritis; however, little is known about changes in patellar and trochlear cartilage thickness, T2 relaxation-time and subchondral bone plate area (tAB) during growth. Our prospective study aimed to explore longitudinal change in patellofemoral cartilage thickness, T2 and tAB in adolescent athletes, and to compare these data with those of mature (i.e., adult) athletes. Materials and methods 20 adolescent (age 16 ± 1 years) and 20 mature (46 ± 5 years) volleyball players were studied over 2-years (10 men and 10 women each group). 1.5T MRI 3D-VIBE and multi-echo spin-echo sequences were acquired at baseline and 2-year follow-up. Using manual segmentation and 3D reconstruction, longitudinal changes in patellar and trochlear cartilage thickness, patellar cartilage T2 (mono-exponential decay curve with five echoes [9.7â??67.9 ms]), and patellar and trochlear tAB were determined. Results The annual increase in both patellar and trochlear cartilage thickness was 0.8% (95% confidence interval [CI] 0.6, 1.0) and 0.6% (0.3, 0.9), for adolescent males and females respectively; the longitudinal gain in patellar and trochlear tAB was 1.3% (1.1, 1.5) and 0.5% (0.2, 0.8), and 1.6% (1.1, 2.2) and 0.8% (0.3, 0.7) for adolescent males and females, respectively (no significant between-sex differences). Mature athletes showed smaller gains in tAB, and loss of <1% of cartilage thickness annually. While no significant sex-differences existed in adolescent patellar T2 changes, mature males gained significantly greater T2 than mature females (p = 0.002â??0.013). Conclusions Patellar and trochlear cartilage thickness and tAB were observed to increase in young athletes in late adolescence, without significant differences between sexes. Mature athletes displayed patellar cartilage loss (and T2 increases in mature males), potentially reflecting degenerative changes.
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Ultrasound assessment of the efficacy of wound drains
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DoD SSI (Surgical Site Infections)
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We report the use of ultrasound in the assessment of the efficacy of wound drains in preventing wound haematoma. 171 patients with proximal femoral fractures who underwent AO dynamic hip screw or hemiarthroplasty were randomized as to whether or not they should receive wound drainage. Patients then underwent ultrasound examination on the 5th postoperative day to localize and quantify any wound haematomas. Results show that drains are effective in preventing wound collections, but only while in situ; following the removal of drains the size of resulting wound collections is the same whether the wound has been drained or not (Student's t-test; t = 0.19, NS). This study questions current theories on the mechanisms by which wound drainage is thought to influence wound healing.
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MRI study of the capitate, lunate, and lunate fossa with relevance to proximal row carpectomy
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Distal Radius Fractures
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PURPOSE: To study the articular morphology (radius of curvature), (diameter, depth, circularity, and percent of circle) of the capitate, proximal lunate, and the lunate fossa of the distal radius using both magnetic resonance imaging (MRI) scans and plain radiographs. The correlation between plain radiographs and MRI scans for these measurements will also be assessed.
METHODS: Twenty MRI scans and 17 sets of radiographs of asymptomatic volunteers were evaluated. Standardized surface landmarks were digitized and measured in both the sagittal and coronal planes. The parameters of interest were calculated from the digitized data using specialized software.
RESULTS: Using MRI data, we determined the radius of curvature of the capitate to be only 37% +/- 10 of the lunate fossa of the distal radius on the coronal (anteroposterior) view and to be 57% +/- 10 on the sagittal (lateral) view. In both planes, the proximal lunate had a significantly larger diameter and radius of curvature than did the capitate. The ratio of the radius of curvature of the proximal capitate to the proximal lunate on the coronal projection ranged from .366 to .811, and on the sagittal projection the values ranged from .46 to .71. Plain radiographs were not sufficiently accurate to determine the radius of curvature ratio of the capitate to the lunate or to the lunate fossa of the distal radius on the coronal view based on a comparison with MRI data. Plain radiography did not correlate with MRI for most clinically relevant parameters.
CONCLUSIONS: The articular morphology of the capitate does not closely correspond with that of the lunate fossa when compared with the proximal lunate articular surface. Based on observed variations in capitate morphology and the potential for associated alterations in joint contact forces after proximal row carpectomy, preoperative MRI may facilitate the selection of patients with more favorable capitate morphology.
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Home rehabilitation after hip fracture a randomized controlled study on balance confidence, physical function and everyday activities [with consumer summary]
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To investigate whether home rehabilitation can improve balance confidence, physical function and daily activity level compared to conventional care in the early phase after hip fracture. DESIGN: A randomized controlled study. SETTING: Geriatric rehabilitation clinic. SUBJECTS: One hundred and two community-dwelling elderly people. INTERVENTIONS: A geriatric, multiprofessional home rehabilitation programme focused on supported discharge, independence in daily activities, and enhancing physical activity and confidence in performing daily activities was compared with conventional care in which no structured rehabilitation after discharge was included. MAIN MEASURES: Falls efficacy, degree of dependency and frequency in daily activities, habitual physical activity and basic functional performance. RESULTS: When comparing status one month after discharge with baseline, the home rehabilitation group showed a higher degree of recovery in self-care (p < 0.0001), mobility (p = 0.002), locomotion (p = 0.0036) and domestic activities (p = 0.0098), as well as larger increase in balance confidence on stairs (p = 0.0018) and instrumental activities (mean increase home rehabilitation 19.7 and conventional care 7.1, p < 0.0001) compared with the conventional care group. At one month, a majority of the home rehabilitation participants (88%) took outdoor walks, compared with less than half (46%) of the conventional care group (p < 0.001) and were also more independent in o utdoor activities (p = 0.0014). CONCLUSIONS: This study indicates that home rehabilitation, focused on supported discharge and enhancing self-efficacy, improves balance confidence, independence and physical activity in community-dwelling older adults in the early phase after hip fracture. Full text may be available at: http://cre.sagepub.com/archive/ NO
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Poor finger dexterity but not elderly age is associated with increase risk of peritonitis in patients on peritoneal dialysis
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Introduction and Aims: More and more elderly patients requiring renal replacement therapy and whether they could self perform peritoneal dialysis (PD) exchange is the major concern. It is because PD related peritonitis is still the major cause for technique failure and mortality. Despite different educational programs, repeated training and technique assessment, the peritonitis rate has not been much reduced. Impairment of hand function (IHF) is plausible the cause for poor exchange technique. Herein, we prospective study the IHF and other factors, and its association with peritonitis risk in patients on long-term PD treatment. Methods: All prevalent and incident PD patients were recruited except patients required helper to perform dialysis exchange. Single occupational therapist performed all hand function assessment and was blinded to patients' clinical information. IHF was defined by the power grip strength, tripod pinch, lateral pinch and finger dexterity (unimanual and bimanual). Nerve conduction test was performed to look for underlying peripheral neuropathy and carpal tunnel syndrome. Patients after assessment were follow-up for 2 years and censored for onset of peritonitis, transplant, switched to hemodialysis or death. Cox regression model and Kaplan Meier analysis were used to analyse the risk factors for peritonitis and peritonitis free survival, respectively. Results: Total 152 (female=76) patients with age 57.6(plus or minus)12.5 yrs were recruited. There were 48 (32%) and 16 (11%) patients had DM and CVA, respectively. 81 (53.3%) and 72 (47.4%) patients were found to have PN and CTS, respectively. The average follow up time was 14.6(plus or minus)7.5 month. Throughout this period, 52 (34.2%) patients developed peritonitis. The peritonitis free survival at 12 month and 24 months were 74% and 61%, respectively. By multivariate analysis with the Cox regression model, only patients with CVA associated with a higher risk for peritonitis (RR 2.15, 95% confidence interval [CI], 0.95 to 4.92, p=0.06). Patients with age greater than 65 yrs (N= 51) did not have significantly increased risk (95% CI, 0.41 to 1.53, p=0.49). Whereas better finger dexterity conferred 12% protection (95% [CI], 0.79 to 0.99, p=0.03) from developing peritonitis. The interaction between the finger dexterity and CVA was not statistically significant (P=0.32). In Kaplan Meier analysis, patient with higher finger dexterity were also found to have higher peritonitis free survival (p=0.03). Other hand function parameters did not have effect on peritonitis risk. Conclusions: PD patients with IHF and history of CVA may associate with a higher risk of peritonitis. Elderly age with good hand function seems not having increased risk at all. Hand function assessment is better to be performed before and throughout the PD treatment so that peritonitis risk could be better surveillance
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Risk stratification for central conventional chondrosarcoma of bone: A novel system predicting risk of metastasis and death in the Cancer Registry of Norway cohort
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MSTS 2022 - Metastatic Disease of the Humerus
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Background and Objectives: Interobserver variability in histological grading of central conventional chondrosarcoma (CCCS) limits the quality of patient information and research progression. We aim to quantify known and new prognostic variables and propose a risk stratification model. Method: We selected 149 cases from the Cancer Registry of Norway. Cox proportional hazard models were estimated. Based on these results a dichotomous risk classification was proposed and presented by Kaplan-Meier estimates for rates of local recurrence, metastasis, and disease-specific survival. Results: The influence of axial skeletal location (Hazard ratio [HR] = 19.06), a soft tissue component =1 cm (HR = 13.45), and histological grade 3 (HR = 16.46) are all significant in predicting the rate of metastasis. The creation of a variable combining axial skeletal location and a soft tissue component =1 cm strongly predicts the risk of metastasis (HR = 14.02; P '.001) and death (HR = 2.74; P =.030) at multivariate analysis, making the histological grade insignificant. Together with metastasis at diagnosis (HR = 285.65; P '.001), this forms the basis of our proposed risk stratification, producing a small high-risk group (39 cases with 33% risk of metastasis) and a large low-risk group (103 cases with 2% risk of metastasis) without a histological grade. Conclusion: Axial skeletal location and a soft tissue component =1 cm combined divides a CCCS cohort into low- and high-risk groups without a histological grade.
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Effects of lateral-offset sole shoes on knee adduction moment in women with medial compartment knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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This study aimed to determine the impact of wearing a lateral-offset sole shoe (LOSS) on knee adduction moment (KAM) in patients with medial knee osteoarthritis (OA). From December 2012 to November 2016, patients with medial knee OA were recruited. Ninety-three knees (50 left, 43 right) of 93 female patients were analyzed. The first peak KAMs were measured with patients (i) walking barefoot; (ii) walking in conventional shoes; and (iii) walking in LOSSs. The patients had grade 1 (n = 19), grade 2 (n = 49), grade 3 (n = 20), and grade 4 (n = 5) knee OA. First peak KAMs differed significantly in all three conditions (p = 0.031). In the post hoc analysis, first peak KAMs were significantly lower during LOSS walking than during conventional shoe walking (p = 0.001), but there were no differences in peak KAMs between barefoot and LOSS walking (p = 0.784). In the subgroup analysis, patients with grades 2 and 3 OA showed significantly lower first peak KAMs during LOSS walking than during conventional shoe walking (p = 0.029 and p = 0.011, respectively). Both the peak eversion ankle angle and moment of barefoot walking showed a significant increase compared with LOSS and conventional shoe walking, while there was no significant difference between LOSS and conventional shoe walking (p = 0.612 and p = 0.197, respectively). Our results suggest that LOSS wearing caused significant KAM reductions compared with conventional shoe wearing. Since LOSS wearing does not cause changes in the peak eversion ankle angle and moment during the load response, it may be an effective method to reduce the KAM in women with knee OA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1694-1700, 2018.
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Unstated factors in orthopaedic decision-making: a qualitative study
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Total joint replacement (TJR) of the hip or knee for osteoarthritis is among the most common elective surgical procedures. There is some inequity in provision of TJR. How decisions are made about who will have surgery may contribute to disparities in provision. The model of shared decision-making between patients and clinicians is advocated as an ideal by national bodies and guidelines. However, we do not know what happens within orthopaedic practice and whether this reflects the shared model. Our study examined how decisions are made about TJR in orthopaedic consultations. METHODS: The study used a qualitative research design comprising semi-structured interviews and observations. Participants were recruited from three hospital sites and provided their time free of charge. Seven clinicians involved in decision-making about TJR were approached to take part in the study, and six agreed to do so. Seventy-seven patients due to see these clinicians about TJR were approached to take part and 26 agreed to do so. The patients' outpatient appointments ('consultations') were observed and audio-recorded. Subsequent interviews with patients and clinicians examined decisions that were made at the appointments. Data were analysed using thematic analysis. RESULTS: Clinical and lifestyle factors were central components of the decision-making process. In addition, the roles that patients assigned to clinicians were key, as were communication styles. Patients saw clinicians as occupying expert roles and they deferred to clinicians' expertise. There was evidence that patients modified their behaviour within consultations to complement that of clinicians. Clinicians acknowledged the complexity of decision-making and provided descriptions of their own decision-making and communication styles. Patients and clinicians were aware of the use of clinical and lifestyle factors in decision-making and agreed in their description of clinicians' styles. Decisions were usually reached during consultations, but patients and clinicians sometimes said that treatment decisions had been made beforehand. Some patients expressed surprise about the decisions made in their consultations, but this did not necessarily imply dissatisfaction. CONCLUSIONS: The way in which roles and communication are played out in decision-making for TJR may affect the opportunity for shared decisions. This may contribute to variation in the provision of TJR. Making the importance of these factors explicit and highlighting the existence of patients' 'surprise' about consultation outcomes could empower patients within the decision-making process and enhance communication in orthopaedic consultations
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Management of patellar clunk under local anesthesia
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Surgical Management of Osteoarthritis of the Knee CPG
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Open resection through a limited lateral incision for the treatment of patellar clunk syndrome associated with patellar tilt in total knee arthroplasty is described. The procedure is done under local anesthesia. Dynamic flexion and extension of the knee during surgery ensures that correct patellar tracking has been restored
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Blepharoptosis correction: levator aponeurosis-Muller muscle complex advancement with three partial incisions
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Upper Eyelid and Brow Surgery
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BACKGROUND: Ptosis of the upper eyelid, blepharoptosis, is defined as an abnormally low-positioned upper eyelid margin in the primary gaze, which results in narrowing of the palpebral fissure and opening. Blepharoplasty, including a double-eyelid fold operation, is the most common aesthetic operation in the East Asian population. Patients who want to undergo blepharoplasty often have mild to moderate blepharoptosis. METHODS: A retrospective review was conducted of the medical records and preoperative and postoperative photographs of 74 patients who underwent simultaneous blepharoptosis correction and double-eyelid surgery between January of 2007 and October of 2011. All patients had mild (1 to 2 mm) or moderate (3 to 4 mm) bilateral blepharoptosis and excellent or good levator function (>8 mm). All patients underwent levator aponeurosis-Muller muscle complex advancement through three partial incisions. RESULTS: A primary blepharoptosis operation was performed in 46 patients, with a secondary operation performed in 28 patients. Double-eyelid fold operations were performed in all cases. The average preoperative margin reflex distance 1 measured 0.8 +/- 0.19 mm. No intraoperative complications occurred. The average postoperative margin reflex distance 1 was 3.6 +/- 0.25 mm. There was a statistically significant difference between preoperative and postoperative distance values (p < 0.05). Excellent results occurred in 62 patients (83.8 percent), good results occurred in 11 (14.9 percent), fair results occurred in one (1.35 percent), and poor results did not occur. CONCLUSION: Blepharoptosis correction with levator aponeurosis-Muller muscle complex advancement through three partial incisions is an effective technique for young patients with mild to moderate blepharoptosis who do not want incision scars. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Doxycycline for osteoarthritis of the knee or hip
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Management of Hip Fractures in the Elderly
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BACKGROUND: Osteoarthritis is a chronic joint disease that involves degeneration of articular cartilage. Pre-clinical data suggest that doxycycline might act as a disease-modifying agent for the treatment of osteoarthritis, with the potential to slow cartilage degeneration. OBJECTIVES: To examine the effects of doxycycline compared with placebo or no intervention on pain and function in patients with osteoarthritis of the hip or knee. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library 2008, issue 3), MEDLINE, EMBASE and CINAHL up to 28 July 2008, checked conference proceedings, reference lists, and contacted authors. SELECTION CRITERIA: We included studies if they were randomised or quasi-randomised controlled trials that compared doxycycline at any dosage and any formulation with placebo or no intervention in patients with osteoarthritis of the knee or hip. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate. We contacted investigators to obtain missing outcome information. We calculated differences in means at follow-up between experimental and control groups for continuous outcomes and risk ratios for binary outcomes. MAIN RESULTS: We found one randomised controlled trial that compared doxycycline with placebo in 431 obese women. After 30 months of treatment, clinical outcomes were similar between the two treatment groups, with a mean difference of -0.20 cm (95% confidence interval (CI) -0.77 to 0.37 cm) on a visual analogue scale from 0 to 10 cm for pain and -1.10 units (95% CI -3.86 to 1.66) for function on the WOMAC disability subscale, which ranges from 17 to 85. These differences correspond to clinically irrelevant effect sizes of -0.08 and -0.09 standard deviation units for pain and function, respectively. The difference in changes in minimum joint space narrowing was in favour of doxycycline (-0.15 mm, 95% CI -0.28 to -0.02 mm), which corresponds to a small effect size of -0.23 standard deviation units. More patients withdrew from the doxycycline group compared with placebo due to adverse events (risk ratio 1.69, 95% CI 1.03 to 2.75). AUTHORS' CONCLUSIONS: The symptomatic benefit of doxycycline is minimal to non-existent. The small benefit in terms of joint space narrowing is of questionable clinical relevance and outweighed by safety problems. Doxycycline should not be recommended for the treatment of osteoarthritis of the knee or hip. DOXYCYCLINE FOR OSTEOARTHRITIS: This summary of a Cochrane review presents what we know from research about the effect of doxycycline on osteoarthritis. The review shows that in people with osteoarthritis:- Doxycycline probably will not improve pain or physical function.- Doxycycline probably causes side effects. We often do not have precise information about side effects and complications. This is particularly true for rare but serious side effects. What is osteoarthritis and what is doxycycline?Osteoarthritis (OA) is a disease of the joints, such as your knee or hip. When the joint loses cartilage, the bone grows to try and repair the damage. Instead of making things better, however, the bone grows abnormally and makes things worse. For example, the bone can become misshapen and make the joint painful and unstable. This can affect your physical function or ability to use your knee.Doxycycline is a type of antibiotic that seems to stop the process of damage to the joints. It is taken in pill form. Best estimate of what happens to people with osteoarthritis who take doxycycline:Pain- People with doxycycline and people with placebo are equally likely to respond to treatment (difference of 0%).- People who took doxycycline rated their pain to be 2 on a scale of 0 (no pain) to 10 (extreme pain) after 30 months. - People who took a fake medication (placebo) also rated their pain to be about 2 on a scale of 0 (no pain) to 10 (extreme pain) after 30 months. Physical function- People with doxycycline and people with placebo are equally likely to respond to treatment (difference of 0%).- People who took doxycycline rated their physical function to be about 36 on a scale of 17 (no disability) to 85 (extreme disability) after 30 months. - People who took a fake medication rated their physical function to be about 37 on a scale of 17 (no disability) to 85 (extreme disability) after 30 months. Side effects- 7 more people who took doxycycline withdrew or dropped out from the trial because of side effects (absolute difference of 7%).- 17 people out of 100 who took doxycycline withdrew or dropped out from the trial because of side effects (17%).- 10 people out of 100 who used a fake medication withdrew or dropped out from the trial because of side effects (10%). Serious harms- There was no difference in the number of people who experienced serious harms (difference of 0%). This could be the result of chance.- 14 people out of 100 who took doxycycline experienced serious harms (14%)- 14 people out of 100 who used a fake medication experienced serious harms (14%)
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Predictors of aromatase inhibitor discontinuation as a result of treatment-emergent symptoms in early-stage breast cancer
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Purpose: Aromatase inhibitors (AIs) are effective for treatment of hormone receptor-positive breast cancer, but adherence and persistence with therapy are poor. Predictors of treatment discontinuation are not clearly defined. It is unknown whether patients with intolerable toxicity from one AI are able to tolerate another. Patients and Methods: Women with early-stage breast cancer initiating AI therapy were enrolled onto a multicenter, prospective, open-label randomized trial of exemestane versus letrozole. Patients completed symptom questionnaires at baseline and serially during therapy. Patients who developed AIassociated intolerable symptoms and discontinued treatment were given the option to switch to the other study AI after a 2- to 8-week washout period. Results: Of the 503 enrolled women, 32.4% discontinued initial AI therapy within 2 years because of adverse effects; 24.3% discontinued specifically because of musculoskeletal symptoms. Median time to treatment discontinuation as a result of any symptom was 6.1 months (range, 0.1 to 21.2 months) and was significantly shorter in patients randomly assigned to exemestane (hazard ratio [HR], 1.5; 95% CI, 1.1 to 2.1; P = .02). Younger age and taxane-based chemotherapy were associated with higher likelihood of treatment discontinuation (HR, 1.4; 95% CI, 1.02 to 1.9; P =.04; and HR, 1.9; 95% CI, 1.00 to 3.6; P = .048, respectively). Of the 83 patients who chose to switch to the second AI, 38.6% continued the alternate AI for a median of 13.7 months. Conclusion: Premature discontinuation of initial AI therapy as a result of symptoms is common, although more than one third of patients may be able to tolerate a different AI medication. Additional research is needed to identify predictive tools and interventions for AI-associated treatment-emergent symptoms. (copyright) 2012 by American Society of Clinical Oncology
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Metallic Biomaterials: Current Challenges and Opportunities
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Dental Implant Infection
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Metallic biomaterials are engineered systems designed to provide internal support to biological tissues and they are being used largely in joint replacements, dental implants, orthopaedic fixations and stents. Higher biomaterial usage is associated with an increased incidence of implant-related complications due to poor implant integration, inflammation, mechanical instability, necrosis and infections, and associated prolonged patient care, pain and loss of function. In this review, we will briefly explore major representatives of metallic biomaterials along with the key existing and emerging strategies for surface and bulk modification used to improve biointegration, mechanical strength and flexibility of biometals, and discuss their compatibility with the concept of 3D printing.
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Characterization of Meniscal Pathology Using Molecular and Proteomic Analyses
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AMP (Acute Meniscal Pathology)
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The meniscus is a complex tissue and is integral to knee joint health and function. Although the meniscus has been studied for years, a relatively large amount of basic science data on meniscal health and disease are unavailable. Genomic and proteomic analyses of meniscal pathology could greatly improve our understanding of etiopathogenesis and the progression of meniscal disease, yet these analyses are lacking in the current literature. Therefore, the objective of this study was to use microarray and proteomic analyses to compare aged-normal and pathologic meniscal tissues. Meniscal tissue was collected from the knees of five patient groups (n = 3/group). Cohorts included patients undergoing meniscectomy with or without articular cartilage pathology, patients undergoing total knee arthroplasty with mild or moderate-severe osteoarthritis, and aged-normal controls from organ donors. Tissue sections were collected from the white/white and white/red zones of posterior medial menisci. Expression levels were compared between pathologic and control menisci to identify genes of interest (at least a x1.5 fold change in expression levels between two or more groups) using microarray analysis. Proteomics analysis was performed using mass spectrometry to identify proteins of interest (those with possible trends identified between the aged-normal and pathologic groups). The microarray identified 157 genes of interest. Genes were categorized into the following subgroups: (1) synthesis, (2) vascularity, (3) degradation and antidegradation, and (4) signaling pathways. Mass spectrometry identified 173 proteins of interest. Proteins were further divided into the following categories: (1) extracellular matrix (ECM) proteins; (2) proteins associated with vascularity; (3) degradation and antidegradation proteins; (4) cytoskeleton proteins; (5) glycolysis pathway proteins; and (6) signaling proteins. These data provide novel molecular and biochemical information for the investigation of meniscal pathology. Further evaluation of these disease indicators will help researchers develop algorithms for diagnostic, therapeutic, and prognostic strategies related to meniscal disorders.
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Korean type distal radius anatomical volar plate system: a preliminary report
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Distal Radius Fractures
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BACKGROUND: Distal radius fracture is the most common fracture of the upper extremity, and approximately 60,000 distal radius fractures occur annually in Korea. Internal fixation with an anatomical volar locking plate is widely used in the treatment of unstable distal radius fractures. However, most of the currently used distal radius anatomical plate systems were designed based on the anatomical characteristics of Western populations. Recently, the Korean-type distal radius anatomical volar plate (K-DRAVP) system was designed and developed based on the anatomical characteristics of the distal radius of Koreans. The purpose of this study was to evaluate the preliminary results of the new K-DRAVP system, and to compare its radiologic and functional results with those of the other systems.
METHODS: From March 2012 to October 2012, 46 patients with acute distal radius fractures who were treated with the K-DRAVP system at three hospitals were enrolled in this study. Standard posteroanterior and lateral radiographs were obtained to assess fracture healing, and three radiographic parameters (volar tilt, radial inclination, and radial length) were assessed to evaluate radiographic outcomes. The range of motion and grip strength, the Gartland and Werley scoring system, and the disabilities of the arm, shoulder and hand (DASH) questionnaire were used to assess clinical and functional outcomes.
RESULTS: All radiologic parameters were restored to normal values, and maintained without any loosening or collapse until the time of final follow-up. Grip strength was restored to 84% of the value for the unaffected side. The mean range of motion of the wrist at final follow-up was restored to 77%-95% of the value for the unaffected side. According to the Gartland and Werley scoring system, there were 16 excellent, 26 good, and 4 fair results. The mean DASH score was 8.4 points. There were no complications after surgery.
CONCLUSIONS: The newly developed K-DRAVP system could be used to restore and maintain good anatomical parameters, and provide good clinical outcomes with low complication rates. This system is a promising surgical option for the treatment of distal radius fractures in the Korean population.
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Sugammadex and stress-free extubation in the critically ill patients
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Surgical Management of Osteoarthritis of the Knee CPG
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Background and Goal of Study: Postoperative respiratory failure is not an uncommon complication after general anaesthesia. This is particularly common in people having high risk, emergency surgeries and in those who tolerate respiratory failure poorly. We present a case series of three patients who had neuromuscular blockade reversed postoperatively with Sugammadex, a selective rocuronium binding agent. Materials and Methods: Patient 1 is a man in his 60s who had an acute myocardial infarction a week earlier and is listed for an emergency below knee (BKA) and an above knee (AKA) amputation in a span of six days. He has a general anaesthetic on both occasions with the reversal agent being sugammadex for the BKA and neostigmine/glycopyrrolate for the AK A. His past history includes severe Ischemic Heart Disease, Peripheral vascular disease and moderate COPD. Patient 2 is a lady, 75 years old, who has an elective ENT panendoscopy and has a significant past history of Ischemic Heart Disease. Patient 3 is a lady who is 40 years old, but a severe COPD with previous hospital admissions. She is listed for an elective ENT panendoscopy as well. The last two patients were both reversed with Sugammadex. Results and Discussion: Patient 1 was stable throughout with both the heart rate and blood pressure within 10% around the initial values including extubation period with sugammadex. Although these were more than 10% when neostigmine/ glycopyrrolate were used. And he ends up reintubated in the recovery unit for respiratory failure and transferred to the ICU after the AKA surgery when neostigmine was used. In patients 2 and 3, who both had a MLT 6.0 endotracheal tube, sugammadex enabled us to extubate at deep paralysis and reversed from a profound block to a train-of-four in < 15 sec. They were extubated onto facemask and were spontaneously breathing in < 15 sec post extubation. They were both cardiostable throughout including at extubation without any residual paralysis. Conclusion(s): Sugammadex may have a role in high risk cardiac and pulmonary patients who tolerate extubation and residual paralysis poorly and may reduce the need for unplanned admission to ICU with significant cost implications
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Adolescent experience with traumatic injury and orthopaedic external fixation: Forever changed
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DoD PRF (Psychosocial RF)
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Background: More than 13 million adolescents sustain traumatic injuries yearly, resulting in functional disability, disfigurement, psychosocial problems, and fractures that are increasingly treated with orthopaedic external fixation devices. Little is known about the experiences of injured adolescents. Method: This longitudinal, qualitative descriptive study described the experiences of traumatically injured adolescents treated with external fixation devices. Results: Analysis of data from 26 open-ended, semistructured interviews with 5 male and 4 female adolescents revealed a struggle to return "to their old self" only to recognize that they were "forever changed." Major themes included what risk? (circumstances leading to the traumatic event), processing the event, suck it up and deal with it (strategies), space-age robot, and they'll do it themselves (pin care self-management). Conclusion: Their experiences affected all tasks of adolescence: independence from parents, accepting body image, peer relations, and forming an identity. Findings related to the use of self-administered analgesics, information technology, recall of detail, and gender differences in coping may lead to future interventions and lay the groundwork for future studies that may improve care of adolescents during acute recovery from traumatic injury. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Regional toxicity after isolated limb perfusion with melphalan and tumour necrosis factor- alpha versus toxicity after melphalan alone
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DOD - Acute Comp Syndrome CPG
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AIMS: To determine whether the addition of high-dose tumour necrosis factor-alpha (TNF alpha) to isolated limb perfusion (ILP) with melphalan increases acute regional tissue toxicity compared to ILP with melphalan alone.
METHODS: A retrospective, multivariate analysis of toxicity after normothermic (37--38 degrees C) and 'mild' hyperthermic (38--40 degrees C) ILPs for melanoma was undertaken. Normothermic ILP with melphalan was performed in 294 patients (70.8%), 'mild' hyperthermic ILP with melphalan in 71 patients (17.1%) and 'mild' hyperthermic ILP with melphalan combined with TNF alpha in 50 patients (12.0%). Toxicity was nil or mild (grades I--II according to Wieberdink et al.) in 339 patients (81.7%), and more severe acute regional toxicity (grades III--V) developed in 76 patients (18.3%). A stepwise logistic regression procedure was performed for the multivariate analysis of prognostic factors for more severe toxicity.
RESULTS: On univariate analysis, 'mild' hyperthermic ILP with melphalan plus TNF alpha significantly increased the incidence of more severe acute regional toxicity compared to normothermic and 'mild' hyperthermic ILP with melphalan alone (36% vs 16% and 17%; P=0.0038). However, after ILP using TNF alpha no grade IV (compartment compression syndrome) or grade V (toxicity necessitating amputation) reactions were seen. Significantly more severe toxicity was seen after ILPs performed between 1991 and 1994 compared with earlier ILPs (33%vs 14%P=0.0001). Also, women had a higher risk of more severe toxicity than men (22% vs 7%; P=0.0007). After multivariate analysis, prognostic factors which remained significant were: sex (P=0.0013) and either ILP schedule (P=0.013) or treatment period (P=0.0003).
CONCLUSIONS: Regional toxicity after 'mild' hyperthermic ILP with melphalan and TNF alpha was significantly increased compared to ILP with melphalan alone. This may be caused by increased thermal enhancement of melphalan due to the higher tissue temperatures (39--40 degrees C) at which the melphalan in the TNF alpha-ILPs was administered or by an interaction between high-dose TNF alpha and melphalan.
Copyright Harcourt Publishers Limited.
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Expression level of beta protein 1 mRNA in Chinese breast cancer patients: a potential molecular marker for poor prognosis
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MSTS 2018 - Femur Mets and MM
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Recent studies revealed high ectopic beta protein 1 (BP1) expression in breast cancer. Remarkably, up to 100% (18/18) of estrogen receptor (ER)-negative tumors and 89% (25/28) of tumors from African American women were BP1-positive. However, the role of BP1 in breast cancer development and its clinical significance still has not been well defined. In the present study, we analyzed the quantitative level of BP1 mRNA in breast carcinomas using real-time polymerase chain reaction and aimed to elucidate its association with tumor characteristics and patient prognosis. Our data showed that BP1 mRNA was expressed at significantly higher levels in tumors with lymph node metastasis, with a high histological grade, and in those that were of ER-negative status. Furthermore, overexpression of BP1 was significantly associated with poor outcome of patients harboring tumors with a high histological grade and negative ER. Using both in vitro and in vivo systems, we also showed that the transcript level of BP1 was positively correlated to the growth rate of breast tumor cells. Taken together, our results support the notion that BP1 might contribute to breast neoplastic transformation or tumor progression and suggest for the first time that BP1 mRNA level has potential as a prognostic predictor for breast cancer.
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Adverse outcomes of osteoporotic fractures in the general population
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Management of Hip Fractures in the Elderly
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Osteoporotic fractures exact a terrible toll on the population with respect to morbidity and cost, and to a lesser extent mortality, which will increase dramatically with the growing elderly population. Attention has focused on the 12-20% excess deaths after hip fracture, but most are caused by underlying medical conditions unrelated to osteoporosis. More important is fracture-related morbidity. An estimated 10% of patients are disabled by hip fracture, and 19% require institutionalization, accounting for almost 140,000 nursing home admissions annually in this country. Distal forearm and vertebral fractures less commonly result in nursing home placement, but about 10% of postmenopausal women have vertebral deformities that cause chronic pain, and a substantial minority have poor function after forearm fracture. These fractures interfere greatly with the activities of daily living, and all of them can have a substantial negative impact on quality of life. Annual expenditures for osteoporotic fracture care in the United States (dollar 17.5 million in 2002 dollars) are dominated by hip fracture treatment, but vertebral fractures, distal forearm fractures, and importantly, the other fractures related to osteoporosis contribute one-third of the total. Although all fracture patients are at increased risk of future fractures, few of them are currently treated for osteoporosis, and only a subset (i.e., those with vertebral fractures) are considered candidates for many clinical trials. Eligibility criteria should be expanded and fracture end-points generalized to acknowledge the overall burden of osteoporotic fractures
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Extending gerontological research through linking investigators' studies to public-use datasets
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Management of Hip Fractures in the Elderly
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PURPOSE: Public-use datasets can extend data collected by individual investigators in various ways: making external comparisons, providing additional data on individual respondents, and creating internal comparison groups. The authors describe the advantages and limitations of these methods and practical and conceptual issues in combining investigator-initiated and public-use datasets. DESIGN AND METHODS: These issues are illustrated with a study of functional decline among 674 patients following hospitalization for hip fracture that was augmented with data from a public-use dataset, the Established Populations for Epidemiologic Studies of the Elderly (EPESE). RESULTS: By creating an internal comparison group of EPESE respondents, frequency matched to hip fracture patients on age, sex, and baseline functional limitations, the authors formed a single dataset and performed multivariable analyses of factors associated with functional decline. IMPLICATIONS: Gerontological research may benefit by applying these methods to program evaluations and longitudinal analyses of health outcomes with numerous public-use datasets
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Lenalidomide plus high-dose dexamethasone versus lenalidomide plus low-dose dexamethasone as initial therapy for newly diagnosed multiple myeloma: an open-label randomised controlled trial
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MSTS 2018 - Femur Mets and MM
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Background: High-dose dexamethasone is a mainstay of therapy for multiple myeloma. We studied whether low-dose dexamethasone in combination with lenalidomide is non-inferior to and has lower toxicity than high-dose dexamethasone plus lenalidomide. Methods: Patients with untreated symptomatic myeloma were randomly assigned in this open-label non-inferiority trial to lenalidomide 25 mg on days 1-21 plus dexamethasone 40 mg on days 1-4, 9-12, and 17-20 of a 28-day cycle (high dose), or lenalidomide given on the same schedule with dexamethasone 40 mg on days 1, 8, 15, and 22 of a 28-day cycle (low dose). After four cycles, patients could discontinue therapy to pursue stem-cell transplantation or continue treatment until disease progression. The primary endpoint was response rate after four cycles assessed with European Group for Blood and Bone Marrow Transplant criteria. The non-inferiority margin was an absolute difference of 15% in response rate. Analysis was by modified intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00098475. Findings: 445 patients were randomly assigned: 223 to high-dose and 222 to low-dose regimens. 169 (79%) of 214 patients receiving high-dose therapy and 142 (68%) of 205 patients on low-dose therapy had complete or partial response within four cycles (odds ratio 1·75, 80% CI 1·30-2·32; p=0·008). However, at the second interim analysis at 1 year, overall survival was 96% (95% CI 94-99) in the low-dose dexamethasone group compared with 87% (82-92) in the high-dose group (p=0·0002). As a result, the trial was stopped and patients on high-dose therapy were crossed over to low-dose therapy. 117 patients (52%) on the high-dose regimen had grade three or worse toxic effects in the first 4 months, compared with 76 (35%) of the 220 on the low-dose regimen for whom toxicity data were available (p=0·0001), 12 of 222 on high dose and one of 220 on low-dose dexamethasone died in the first 4 months (p=0·003). The three most common grade three or higher toxicities were deep-vein thrombosis, 57 (26%) of 223 versus 27 (12%) of 220 (p=0·0003); infections including pneumonia, 35 (16%) of 223 versus 20 (9%) of 220 (p=0·04), and fatigue 33 (15%) of 223 versus 20 (9%) of 220 (p=0·08), respectively. Interpretation: Lenalidomide plus low-dose dexamethasone is associated with better short-term overall survival and with lower toxicity than lenalidomide plus high-dose dexamethasone in patients with newly diagnosed myeloma. Funding: National Cancer Institute, Rockville, MD, USA. © 2010 Elsevier Ltd. All rights reserved.
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What Is the Reliability and Accuracy of Intraoperative Fluoroscopy in Evaluating Anterior, Lateral, and Posterior Coverage During Periacetabular Osteotomy?
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Developmental Dysplasia of the Hip 2020 Review
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BACKGROUND: Periacetabular osteotomy (PAO) is an established treatment for acetabular dysplasia in the skeletally mature individual. Fluoroscopy is used intraoperatively for osteotomy completion and to judge fragment correction. However, a comprehensive study validating fluoroscopy to judge anterior, lateral, and posterior coverage in PAO has not been reported. QUESTIONS/PURPOSES: (1) Are radiographic and fluoroscopic measures of anterior, lateral, and posterior acetabular coverage reliable? (2) Do fluoroscopic measures of fragment correction accurately measure anterior, lateral, and posterior coverage when compared with postoperative radiographs? METHODS: We performed a retrospective study of patients undergoing PAO with a primary diagnosis of acetabular dysplasia. Between 2012 and 2014 two surgeons performed 287 PAOs with fluoroscopy. To be included in this retrospective study, patients had to be younger than 35 years old, have a primary diagnosis of dysplasia (not retroversion, Perthes, or skeletal dysplasia), have adequate radiographic and fluoroscopic imaging, be a primary PAO (not revision), and in the case of bilateral patients, only the first hip operated on in the study period was included. Based on these criteria, 46% of the PAOs performed were included here (133 of 287). A total of 109 (82%) of the patients were females (109 of 133), and the mean age of the patients represented was 24 years (SD, 7 years). Preâ? and postoperative standing radiographs as well as intraoperative fluoroscopic images were reviewed and lateral centerâ?edge angle (LCEA), Tönnis angle (TA), anterior centerâ?edge angle (ACEA), anterior wall index (AWI), and posterior wall index (PWI) were measured. Two fellowshipâ?trained hip preservation surgeons completed all measurements with one reader performing a randomized sample of 49 repeat measurements 4 weeks after the initial reading for purposes of calculating intraobserver reliability. Intraâ? and interrater reliability was assessed using an intraclass correlation coefficient (ICC) model. Agreement between intraoperative fluoroscopic and postoperative radiographic measures was determined by estimating the ICC with 95% confidence intervals and by Blandâ?Altman analysis. RESULTS: Intrarater reliability was excellent (ICC > 0.75) for all measures and good for postoperative AWI (ICC = 0.72; 95% confidence interval [CI], 0.48â?0.85). Interrater reliability was excellent (ICC > 0.75) for all measures except intraoperative TA (ICC = 0.72; 95% CI, 0.48â?0.84). Accuracy of fluoroscopy was good (0.60 < ICC < 0.75) for LCEA (ICC = 0.73; 95% CI, 0.55â?0.83), TA (ICC = 0.66; 95% CI, 0.41â?0.79), AWI (ICC = 0.63; 95% CI, 0.48â?0.74), and PWI (ICC = 0.72; 95% CI, 0.35â?0.85) and excellent (ICC > 0.75) for ACEA (ICC = 0.80; 95% CI, 0.71â?0.86). Blandâ?Altman analysis for systematic bias in the comparison between intraoperative fluoroscopy and postoperative radiography found the effect of such bias to be negligible (mean difference: LCEA 2°, TA 2°, ACEA 1°, AWI 0.02, PWI 0.11). CONCLUSIONS: Fluoroscopy is accurate in measuring correction in PAO. However, surgeons should take care not to undercorrect the posterior wall. Based on our study, intraoperative fluoroscopy may be used as an alternative to an intraoperative AP pelvis radiograph to judge final acetabular fragment correction with an experienced surgeon. However, more studies are needed including a properly powered direct comparative study of intraoperative fluoroscopy and intraoperative radiographs. Moreover, the impact of radiographic correction achieved during surgery should be studied to determine the implications for patientâ?reported outcomes and longâ?term survival of the hip. LEVEL OF EVIDENCE: Level IV, diagnostic study.
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Early outcomes of shoulder arthroplasty according to sex
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Glenohumeral Joint OA
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Hypothesis: Among patients undergoing shoulder arthroplasty (SA), female patients would have worse outcomes than their male counterparts. Methods: A multicenter prospective cohort of 2364 patients (1365 female and 999 male patients) treated with total SA or reverse total SA from 2007 to 2015 was retrospectively analyzed. Results were assessed using several validated outcome measures and range-of-motion testing. A multivariable analysis identified differences in preoperative values, postoperative values, and preoperative-to-postoperative improvements while adjusting for possible confounders. Results: The mean follow-up period was 45.9 ± 23.7 months in female patients and 46.4 ± 23.6 months in male patients. Women underwent SA at a significantly older age (70.8 ± 8.4 years) than men (67.6 ± 8.8 years, P <.01) and began with lower preoperative outcome scores and range-of-motion measurements: American Shoulder and Elbow Surgeons score (P <.01), Constant score (P <.01), Simple Shoulder Test score (P <.01), active abduction (P <.01), forward flexion (P <.01), and external rotation (P =.02). Postoperatively, both groups showed significant improvement. When we evaluated overall improvement from preoperative values, female patients showed increased improvements in the American Shoulder and Elbow Surgeons score (P =.04) and Simple Shoulder Test score (P <.01), as well as active forward elevation (P <.01) and external rotation (P =.02). However, the difference in improvements did not reach the minimal clinically important difference. Women had a higher incidence of component loosening (P =.03) and periprosthetic fractures due to falls (P =.01), whereas men showed a higher incidence of periprosthetic joint infections (P <.01). Conclusion: This study found that female patients undergo SA at an older age and begin with worse shoulder range of motion and outcome scores than male patients. Although women experienced a greater improvement postoperatively in outcome scores and range of motion, this improvement did not reach the minimal clinically important difference. These findings suggest that male and female patients can expect similar improvements in function after undergoing SA; however, the incidence of complications may vary depending on sex.
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Five to eight year results of the Johnson-Elloy (Accord) total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Between February 1982 and December 1985, 133 knees in 107 patients were replaced with a cemented Johnson-Elloy (Accord) total knee arthroplasty. Thirty-five knees were lost during the follow-up period because of death in 29, revision in 3, infection in 1, and refusal of follow-up evaluation in 2. The results of the remaining 98 knees in 76 patients with a 5-8 year follow-up period are presented. The procedure was carried out in all cases presenting for surgery, irrespective of pathology and degree of deformity. The range of flexion achieved as a mean of 93.5 degrees in the osteoarthritic group and 100 degrees in the rheumatoid arthritic group. Eighty-seven percent of the osteoarthritic group and 95% of the rheumatoid arthritic group achieved between 10 degrees and 50 degrees of rotation at 90 degrees of flexion, which was maintained for the duration of the study. Adequate stability in both groups, valgus-varus and rotation in extension, and anteroposterior in flexion was achieved. Survivorship was 97.7% at 80 months
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Exercise and weight loss in obese older adults with knee osteoarthritis: a preliminary study
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: The purposes of this pilot study were to determine if a combined dietary and exercise intervention would result in significant weight loss in older obese adults with knee osteoarthritis, and to compare the effects of exercise plus dietary therapy with exercise alone on gait, strength, knee pain, biomarkers of cartilage degradation, and physical function. DESIGN: Singleâ?blind, twoâ?arm, randomized clinical trial conducted for 24 weeks. SETTING: A university health and exercise science center. PARTICIPANTS: Twentyâ?four communityâ?dwelling obese older adults aged > or = 60 years, body mass index > or = 28, knee pain, radiographic evidence of knee osteoarthritis, and selfâ?reported physical disability. INTERVENTION: Randomization into two groups: exercise and diet (E&D) and exercise alone (E). Exercise consisted of a combined weight training and walking program for 1 hour three times per week. The dietary intervention included weekly sessions with a nutritionist utilizing cognitiveâ?behavior modification to change dietary habits to reach a group goal of an average weight loss of 15 lb (6.8 kg) over 6 months. MEASUREMENTS: All measurements were conducted at baseline and 3 and 6 months, except for synovial fluid analysis, which was obtained only at baseline and 6 months. In addition, weight was measured weekly in the E&D group. Physical disability and knee pain were measured by selfâ?report and physical performance was measured using the 6â?minute walk and stair climb tasks. Biomechanical testing included kinetic and kinematic analysis of gait and isokinetic strength testing. Synovial fluid was analyzed for levels of total proteoglycan, keratan sulfate, and interleukinâ?1 beta. RESULTS: Twentyâ?one of the 24 participants completed the study, with one dropout in the E&D group and two in the E group. The E&D group lost a mean of 18.8 lb (8.5 kg) at 6 months compared with 4.0 lb (1.8 kg) in the E group (P = .01). Significant improvements were noted in both groups in selfâ?reported disability and knee pain intensity and frequency as well as in physical performance measures. However, no statistical differences were found between the two groups at 6 months in knee pain scores or selfâ?reported performance measures of physical function. There was no difference in knee strength between the groups, with both groups showing modest improvements from baseline to 6 months. At 6 months, the E&D group had a significantly greater loading rate (P = .03) and maximum braking force (P = .01) during gait. There were no significant betweenâ?group differences in the other biomechanical measures. Synovial fluid samples were obtainable at both baseline and 6 months in eight participants (four per group). The level of keratan sulfate decreased similarly in both groups from an average baseline of 96.8 +/â? 37.1 to 71.5 +/â? 23 ng/microg total proteoglycan. The level of ILâ?1 decreased from 25.3 +/â? 9.8 at baseline to 8.3 +/â? 6.1 pg/mL. The decrease in ILâ?1 correlated with the change in pain frequency (r = â?0.77, P = .043). CONCLUSIONS: Weight loss can be achieved and sustained over a 6â?month period in a cohort of older obese persons with osteoarthritis of the knee through a dietary and exercise intervention. Both exercise and combined weight loss and exercise regimens lead to improvements in pain, disability, and performance. Moreover, the trends in the biomechanical data suggest that exercise combined with diet may have an additional benefit in improved gait compared with exercise alone. A larger study is indicated to determine if weight loss provides additional benefits to exercise alone in this patient population.
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Does periarticular injection have additional pain relieving effects during contemporary multimodal pain control protocols for TKA?: A randomised, controlled study
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AAHKS (2) Corticosteroids
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Although the analgesic effects of periarticular multimodal drug injection (PMDI) after TKA have been well documented, there is little information about additional pain relieving effects of PMDI incorporated to contemporary multimodal pain control protocols which have been proved to provide excellent analgesia. We performed a parallel-group, randomised, controlled study to determine whether PMDI provides additional clinical benefits on contemporary multimodal analgesic protocols including preemptive analgesics, continuous femoral nerve block, and IV-PCA. Eighty-seven patients were randomized to a PMDI group (n= 45) or to a No-PMDI group (n= 42). Pain level and opioid consumption were compared as primary outcomes. The incidences of narcotic and ropivacaine related side effects and complications, functional recovery, and satisfaction were also compared. The PMDI group experienced less pain during the operation night and the 1st postoperative day and showed lower opioid consumption over 24. h after surgery. However, the PMDI group had a higher VAS pain score on the 1st postoperative day than during the operation night. No group differences in side-effects and complication incidences, functional recovery, and satisfaction were found. This study demonstrates that PMDI provides additional pain relief and reduces opioid consumption only during the early postoperative period in patients managed by the contemporary pain management protocol following TKA. © 2011 Elsevier B.V.
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A novel oxido-viscosifying Hyaluronic Acid-antioxidant conjugate for osteoarthritis therapy: biocompatibility assessments
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OAK 3 - Non-arthroplasty tx of OAK
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To overcome the problem of fast degradation of Hyaluronic Acid (HA) in the treatment of osteoarthritis (OA), HA was protected against the oxidative stress generated by the pathology. Antioxidant conjugated HAs were synthesized and tested in vitro for their resistance in an oxidative environment mimicking OA. HA-4-aminoresorcinol (HA-4AR) displayed the interesting property of increasing in viscosity under oxidative conditions because of crosslinking induced by electron transfer. The novel HA polymer conjugate was shown to be biocompatible in vitro on fibroblast-like synoviocytes extracted from an arthritic patient. This HA conjugate was also assessed in vivo by intra-articular injection in healthy rabbits and was found to be comparable to the native polymer in terms of biocompatibility. This study suggests that HA-4AR is a promising candidate for a next generation viscosupplementation formulation.
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1 |
Conservative treatment of staphylococcal prosthetic joint infections in elderly patients
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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BACKGROUND: We report the outcome of debridement and prosthesis retention plus long-term levofloxacin/rifampicin treatment of prosthetic joint infections. METHODS: Staphylococcal prosthesis joint infections were defined by positive culture of joint aspirate, intraoperative debridement specimens, or sinus tract discharge in the presence of clinical criteria. Patients received long-term oral levofloxacin 500 mg and rifampicin 600 mg once per day. Sixty patients (age 74.6+/-8.4 years) were included. RESULTS: Coagulase-negative staphylococci were significantly more frequently isolated in the knee (78.6%; P=.00001). Of the Staphylococcus aureus isolates, 33.3% were methicillin-resistant. Time from arthroplasty to symptoms onset was higher (P=.03) in coagulase-negative staphylococci infections. Global failure was 35% (higher for the knee) and ranged from 16.6% to 69.2% (P=.0045) in patients with symptoms duration of less than 1 month to more than 6 months. A shorter duration of symptoms (P=.001) and time to diagnosis (P=.01) were found in cured patients versus patients showing failure. Among those with S. aureus infections, a higher failure rate was found with methicillin-resistance. CONCLUSIONS: Efficacy was higher in patients with shorter duration of symptoms, earlier diagnosis, hip infections, and methicillin susceptibility
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1 |
Early mortality after hip fracture: is delay before surgery important?
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Management of Hip Fractures in the Elderly
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BACKGROUND: Hip fracture is associated with high mortality among the elderly. Most patients require surgery, but the timing of the operation remains controversial. Surgery within twenty-four hours after admission has been recommended, but evidence supporting this approach is lacking. The objective of this study was to determine whether a delay in surgery for hip fractures affects postoperative mortality among elderly patients. METHODS: We conducted a prospective, observational study of 2660 patients who underwent surgical treatment of a hip fracture at one university hospital. We measured mortality rates following the surgery in relation to the delay in the surgery and the acute medical comorbidities on admission. RESULTS: The mortality following the hip fracture surgery was 9% (246 of 2660) at thirty days, 19% at ninety days, and 30% at twelve months. Of the patients who had been declared fit for surgery, those operated on without delay had a thirty-day mortality of 8.7% and those for whom the surgery had been delayed between one and four days had a thirty-day mortality of 7.3%. This difference was not significant (p = 0.51). The thirty-day mortality for patients for whom the surgery had been delayed for more than four days was 10.7%, and this small group had significantly increased mortality at ninety days (hazard ratio = 2.25; p = 0.001) and one year (hazard ratio = 2.4; p = 0.001). Patients who had been admitted with an acute medical comorbidity that required treatment prior to the surgery had a thirty-day mortality of 17%, which was nearly 2.5 times greater than that for patients who had been initially considered fit for surgery (hazard ratio = 2.3, 95% confidence interval = 1.6 to 3.3; p < 0.001). CONCLUSIONS: The thirty-day mortality following surgery for a hip fracture was 9%. Patients with medical comorbidities that delayed surgery had 2.5 times the risk of death within thirty days after the surgery compared with patients without comorbidities that delayed surgery. Mortality was not increased when the surgery was delayed up to four days for patients who were otherwise fit for hip fracture surgery. However, a delay of more than four days significantly increased mortality
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Degenerative meniscus: Pathogenesis, diagnosis, and treatment options
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AMP (Acute Meniscal Pathology)
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The symptomatic degenerative meniscus continues to be a source of discomfort for a significant number of patients. With vascular penetration of less than one-third of the adult meniscus, healing potential in the setting of chronic degeneration remains low. Continued hoop and shear stresses upon the degenerative meniscus results in gross failure, often in the form of complex tears in the posterior horn and midbody. Patient history and physical examination are critical to determine the true source of pain, particularly with the significant incidence of simultaneous articular pathology. Joint line tenderness, a positive McMurray test, and mechanical catching or locking can be highly suggestive of a meniscal source of knee pain and dysfunction. Radiographs and magnetic resonance imaging are frequently utilized to examine for osteoarthritis and to verify the presence of meniscal tears, in addition to ruling out other sources of pain. Non-operative therapy focused on non-steroidal anti-inflammatory drugs and physical therapy may be able to provide pain relief as well as improve mechanical function of the knee joint. For patients refractory to conservative therapy, arthroscopic partial meniscectomy can provide short-term gains regarding pain relief, especially when combined with an effective, regular physiotherapy program. Patients with clear mechanical symptoms and meniscal pathology may benefit from arthroscopic partial meniscectomy, but surgery is not a guaranteed success, especially with concomitant articular pathology. Ultimately, the long-term outcomes of either treatment arm provide similar results for most patients. Further study is needed regarding the short and long-term outcomes regarding conservative and surgical therapy, with a particular focus on the economic impact of treatment as well.
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1 |
Electrodiagnosis of mild carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Electrophysiologic tests have been reported to detect mild carpal tunnel syndrome (CTS). Such tests include (i) absolute palmar latency of median wrist segment; (ii) comparison of median and radial distal sensory latencies in digit I; (iii) comparison of median and ulnar distal sensory latencies in digit IV; (iv) comparison of median and ulnar palmar latencies; (v) comparison of median and ulnar sensory potential amplitudes in digits II and V. To clarify the clinical utility of these tests, the parameters of all five tests were determined across four carefully established patient subgroups: group A, controls; group B, CTS referrals with normal nerve conduction studies (NCS) and normal needle electromyography (EMG); group C, CTS referrals with abnormal NCS and normal EMG; group D, CTS referrals with abnormal NCS and abnormal EMG. Special attention was focused on patients in group B who represent the diagnostic dilemma. In group B, tests ii and iii each yielded abnormal results in 44% of hands, while the combination of tests ii and iii yielded abnormal results in 51% of hands
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0 |
Postmastectomy breast reconstruction with autologous tissue - Free flaps. Part II
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Panniculectomy & Abdominoplasty CPG
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Breast cancer is the most common tumor occurring in women. Loss of a breast is a profound traumatic experience. Since the breast is a symbol of femininity, beauty, and motherhood, mastectomy can result in serious disorders of psychological and aesthetic character. Advances in microsurgical techniques facilitated the development of various methods indispensable for performing even the most extensive reconstructions with achievement of a good final result, opening the possibility for effective rehabilitation and a return to normal psychosocial functioning. Postmastectomy breast reconstruction with free flaps has become the standard course of action, and the choice of flaps assures selection of the best method available for each patient. This paper is a review of the most important free tissue flaps used in postmastectomy breast reconstruction, including the free transverse rectus abdominis myocutaneous (TRAM), the deep inferior epigastric perforator (DIEP), the paraumbilical perforator (PUP), the superior and inferior gluteal, the Rubens, and the thigh lateral transverse and anterolateral thigh flaps. © Copyright by Wroclaw Medical University.
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Clinical experience with thalidomide and lenalidomide in multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Thal has antiangiogenic and immunomodulatory activity. Clinical research provided clear evidence that Thal belongs to the most active drugs for the treatment of multiple myeloma e.g. leading to decrease of monoclonal protein of at least 50 % in 30 % of patients with relapsed or refractory multiple myeloma. Randomized trials that were designed based on a large body of evidence from phase II trials determined that Thal significantly increases total response rate, progression-free and in some studies overall survival in combination regimens (dexamethason and or chemotherapy) for relapsed as well as newly diagnosed patients and was therefore approved for first-line treatment of Multiple Myeloma. Strict guidelines apply due to the teratogenic effects of Thal and to monitor and prevent other potential adverse events as neuropathy and thrombosis has been recognized by leading organizations as part of the treatment concept for patients with relapsed or refractory disease. The success of Thal has sparked the development of Thal analogues with Lenalidomide (Len) the most advanced compound which was approved for relapsed multiple myeloma. As Len has a lower incidence of polyneuropathy, constipation and somnolence compared to Thalidomid but at least equal if not higher efficacy Len is meanwhile used more frequently in clinical routine and has advantages in combination therapies with Bortezomib. Additional randomized studies will now define the status of Thal and Len for maintenance therapy and their optimal integration in multi-agent treatment regimen. © 2012 Bentham Science Publishers.
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Musculoskeletal problems as comorbidities
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Musculoskeletal comorbidities increasingly are prevalent and present specific research challenges and opportunities. Several definitions for musculoskeletal comorbidities exist depending on the patient population and research approach. Population studies document that musculoskeletal problems, defined as arthritis, are the most prevalent condition in the population as a whole and therefore a frequent comorbidity. As adults with disabilities age and as the population as a whole ages, musculoskeletal comorbidities will become increasingly common. Multiple research studies have begun examining the relationships of musculoskeletal conditions to other health conditions in pediatric, middle-aged, and older adults. Multiple specific research approaches are needed to understand predisposing risk factors, prevention, progression, consequences, and treatment strategies for these conditions. (copyright) 2007 Lippincott Williams & Wilkins, Inc
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Morphologic Characterization of Intraneural Flow Associated With Median Nerve Pathology
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A prospective cohort of 47 symptomatic patients who reported for nerve conduction studies and 44 asymptomatic controls was examined with sonography to evaluate the median nerve. Doppler studies of the median nerve were collected with handheld sonography equipment and a 12-MHz linear broadband transducer. Strict inclusion criteria were established for assessing 435 waveforms from 166 wrists. Two sonographers agreed that 245 waveforms met the a priori criteria and analyzed the corresponding data. Spectral Doppler waveforms provided direct quantitative and qualitative data for comparison with indirect provocative testing results. These Doppler data were compared between the recruitment groups. No statistical difference existed in waveforms between the groups (P < .05). Trending of the overall data indicated that as the number of positive provocative tests increased, the mean peak systolic velocity within the carpal tunnel (mid) also increased, whereas the proximal mean peak systolic velocity decreased. However, by using multiple provocative tests as an indirect comparative measure, researchers may find mean peak spectral velocity at the carpal tunnel inlet a helpful direct measure in identifying patients with carpal tunnel syndrome
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Palmaris profundus: one name, several subtypes, and a shared potential for nerve compression
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The palmaris profundus is a rare, but known anatomic variation which may lead to compression of the median nerve and/or its branches. Two patients with carpal tunnel syndrome are presented in whom a palmaris profundus was discovered at operation. In these cases, median nerve compression at the wrist was attributed to the course of the extra tendon and its local mass effect on the nerve (i.e., the palmaris profundus and median nerve shared a common sheath); more commonly, the resultant decreased available space for the median nerve within the carpal tunnel due to the presence of an accessory (10th) flexor tendon is thought to be responsible. Postoperative 3 Tesla magnetic resonance imaging (MRI) was performed to demonstrate the full course of the variant muscle; despite variations in the size and longitudinal extent of the accessory musculotendinous unit, an important similarity was noted: the intimate relationship of the median nerve and the palmaris profundus. These two cases and our review of the literature highlight the fact that one name (i.e. palmaris profundus) reflects several anatomic subtypes. However, the close relationship of the palmaris profundus with the median nerve in the forearm and the palm is a common theme which emphasizes the potential pathoanatomic consequences of this relationship: nerve compression
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Effectiveness of microwave disinfection of complete dentures on the treatment of Candida-related denture stomatitis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The effectiveness of microwave disinfection of maxillary complete dentures on the treatment of Candida-related denture stomatitis was evaluated. Patients (n = 60) were randomly assigned to one of four treatment groups of 15 subjects each; Control group: patients performed the routine denture care; Mw group: patients had their upper denture microwaved (650 W per 6 min) three times per week for 30 days; group MwMz: patients received the treatment of Mw group in conjunction with topical application of miconazole three times per day for 30 days; group Mz: patients received the antifungal therapy of group MwMz. Cytological smears and mycological cultures were taken from the dentures and the palates of all patients before treatment at day 15 and 30 of treatment and at follow-up (days 60 and 90). The effectiveness of the treatments was evaluated by Kruskal-Wallis and Mann-Whitney tests. Microbial and clinical analysis of the control group demonstrated no significant decrease in the candidal infection over the clinical trial. Smears and cultures of palates and dentures of the groups Mw and MwMz exhibited absence of Candida at day 15 and 30 of treatment. On day 60 and 90, few mycelial forms were observed on 11 denture smears (36.6%) from groups Mw and MwMz, but not on the palatal smears. Miconazole (group Mz) neither caused significant reduction of palatal inflammation nor eradicated Candida from the dentures and palates. Microwaving dentures was effective for the treatment of denture stomatitis. The recurrence of Candida on microwaved dentures at follow-up was dramatically reduced
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Soleal vein dilatation assessed by ultrasonography is an independent predictor for deep vein thrombosis after major orthopedic surgery
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OAK 3 - Non-arthroplasty tx of OAK
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Background Deep vein thrombosis (DVT) develops after major orthopedic surgery despite the current use of prophylaxis. DVT frequently develops in the soleal vein (SV) and might develop easily at the site of SV dilatation because of blood flow stasis. However, whether preoperative SV dilatation detected by ultrasonography predicts DVT after major orthopedic surgery remains unknown. Objective We examined whether SV dilatation detected by preoperative ultrasonography predicts DVT after major orthopedic surgery. Methods Ultrasonography was performed preoperatively and postoperatively in 243 patients with orthopedic diseases (mean age of 67 ± 13 years, 77% women) who underwent total hip arthroplasty (THA, n = 180) or total knee arthroplasty (TKA, n = 63). Presence of DVT was diagnosed by ultrasonography and SV diameter �10 mm was defined as SV dilatation. Patients with preoperative DVT were excluded. Results Sixty-nine patients (28%) developed postoperative DVT. SV dilatation was found in 24 patients (10%), and 16 (67%) of those patients had postoperative DVT. Multivariate logistic regression analysis showed that female gender [odds ratio (OR): 4.09, p = 0.004], TKA (OR: 2.52, p = 0.011), and SV dilatation (OR: 6.67, p < 0.001), but not presence of comorbidities, medications, or plasma D-dimer value, independently predict postoperative DVT. Subgroup analyses according to the operation site showed that female gender (OR: 3.27, p = 0.043) and SV dilatation (OR: 3.72, p = 0.022) were independent predictors of postoperative DVT in the THA group. SV dilatation (OR: 12.0, p = 0.027) was an independent predictor of postoperative DVT also in the TKA group. Conclusions In addition to gender and TKA, SV dilatation detected by ultrasonography is an independent predictor of DVT after major orthopedic surgery. Determination of SV diameter by ultrasonography before major orthopedic surgery is useful for assessing the risk of postoperative DVT.
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Prognostic impact of serum calcitonin and carcinoembryonic antigen doubling-times in patients with medullary thyroid carcinoma
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MSTS 2018 - Femur Mets and MM
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CONTEXT: After unsuccessful surgery, medullary thyroid carcinoma (MTC) may be fatal or remain stable for decades, and precise survival predictors are needed.
OBJECTIVE: This study assesses the prognostic value of calcitonin and carcinoembryonic antigen (CEA) doubling-times (DT).
DESIGN: This is a retrospective study on 65 MTC patients from 2.9-29.5 yr after surgery.
SETTING: Data registered in the database of the French Neuroendocrine Tumor Group were analyzed anonymously.
PATIENTS: All patients had abnormal calcitonin levels after total thyroidectomy and bilateral lymph node dissection.
INTERVENTION: Calcitonin and CEA serum levels were measured during routine disease follow-up.
MAIN OUTCOME MEASURE: To assess DT as prognostic factors, a patient population was extracted from the database.
RESULTS: When calcitonin DT was less than 6 months, 5- and 10-yr survivals were three of 12 (25%) and one of 12 (8%), respectively; when between 6 months and 2 yr, 5- and 10-yr survivals were 11 of 12 (92%) and three of eight (37%), whereas all 41 patients with calcitonin DT greater than 2 yr were alive at the end of the study. Tumor-Node-Metastasis (TNM) stage, European Organization for Research and Treatment of Cancer (EORTC) score, and calcitonin DT were significant predictors of survival by univariate analysis, but only calcitonin DT remained an independent predictor of survival by multivariate analysis (P = 0.002) with a proportion of variance explained (PVE) of 37.4%. Calcitonin DT was a better predictor than CEA (PVE 63.3% and 47.0%, respectively). Calcitonin DT calculated using only the first four measurements was also an independent predictor of survival (P < 0.000001; PVE 40.4%).
CONCLUSION: Calcitonin DT may be superior to initial clinical staging and among the most powerful prognostic indicators in MTC.
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The fate of intramuscularly injected fat autografts: an experimental study in rabbits
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Panniculectomy & Abdominoplasty CPG
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An experimental study was designed to assess the viability and revascularization of intramuscularly injected fat autografts. For the study, 18 rabbits were divided into two groups. In the first group, fat was injected intramuscularly (12 rabbits). Autologous fat was obtained from the inguinal area and subsequently injected into the thigh muscle. In the second group, physiologic saline was injected intramuscularly to determine the effects of cannulation and pressure on muscle tissue (6 rabbits). Fat autografts were performed on the right side of the animal, and the left side was used as the control. Scintigraphic imaging and histopathologic examination of the limbs were performed after injection of adipose tissue on days 15, 30, 45, 60, 90, and 120. On the technetium-99m ((99m)Tc) hexamethylpropylene amine oxime scintigraphy, whereas similar activity distribution was observed between the left and right thigh on days 15, 30, and 45, there was increased uptake at the right thigh on days 60, 90, and 120. This increased uptake indicates that there is viable fat tissue in this region. Histopathologic evaluation showed that microcysts resulting from degeneration of some adipocytes and inflammatory changes on day 15 additionally increased vascularity and fibrosis in some animals on day 30, as well as fibrosis, microcysties, and focal calcification areas in adipose tissue on day 45 and later. It was observed that adipose tissue survived in more than 50% of the graft area in all the animals. These findings show that fat autografts can survive in muscle tissue with less than 50% fibrotic change.
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Vastly undersampled isotropic projection steady-state free precession imaging of the knee: diagnostic performance compared with conventional MR
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Anterior Cruciate Ligament Injuries CPG
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PURPOSE: To compare a vastly undersampled isotropic projection steady-state free precession (VIPR-SSFP) sequence and routine magnetic resonance (MR) imaging for evaluating the cartilage, ligaments, menisci, and osseous structures of the knee in symptomatic patients. MATERIALS AND METHODS: All subjects signed written informed consent prior to participation in this prospective, HIPAA-compliant, institutional review board-approved study. VIPR-SSFP was added to the routine 1.5-T MR imaging performed on 95 symptomatic patients (52 men, 43 women; average age, 41.6 years) who subsequently underwent arthroscopic knee surgery. All MR examinations were independently reviewed twice by two musculoskeletal radiologists to detect cartilage lesions, anterior and posterior cruciate ligament tears, meniscal tears, and bone marrow edema lesions, first by using routine MR and second by using VIPR-SSFP. By using arthroscopy as the reference standard, the sensitivity and specificity of both MR protocols were calculated. The z test was used to compare sensitivity and specificity values. RESULTS: VIPR-SSFP had significantly higher specificity (P < .01) for helping detect cartilage lesions (92.2% for VIPR-SSFP and 88.4% for routine MR), while routine MR had significantly higher sensitivity (P = .02) and accuracy (P = .05) for helping detect lateral meniscal tears (73.2% sensitivity and 88.4% accuracy for VIPR-SSFP and 87.5% specificity and 93.2% accuracy for routine MR). There was no significant difference (P = .14 to >.99) between VIPR-SSFP and routine MR in the remaining sensitivity and specificity values. VIPR-SSFP helped detect 69.3% of bone marrow edema lesions identified at routine MR. CONCLUSION: VIPR-SSFP can provide important clinical information regarding the cartilage, ligaments, menisci, and osseous structures of the knee, but is less sensitive than conventional MR imaging at helping detect lateral meniscal tears and bone marrow edema lesions
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Low rate of infection control in enterococcal periprosthetic joint infections infection
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PJI DX Updated Search
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Background: Enterococcal periprosthetic joint infections (PJIs) are rare after joint arthroplasty. These cases are usually reported in series of PJIs caused by other pathogens. Because few studies have focused only on enterococcal PJIs, management and control of infection of these cases have not yet been well defined. Questions/Purposes: We asked (1) what is the proportion of enterococcal PJI in our institutes; and (2) what is the rate of infection control in these cases? Methods: We respectively identified 22 and 14 joints with monomicrobial and polymicrobial PJI, respectively, caused by enterococcus. The diagnosis of PJI was made based on the presence of sinus tract or two positive intraoperative cultures. PJI was also considered in the presence of one positive intraoperative culture and abnormal serology. We determined the proportion of enterococcal PJI and management and control of infection in these cases. Minimum followup was 1.5 years (mean, 3.2 years). Results: The proportion of monomicrobial enterococcal PJI was 2.3% (22 of 955 cases of PJI). Mean number of surgeries was two (range, 1-4). Initial irrigation and débridement was performed in 10 joints and eight patients needed reoperation. Seven of the 16 joints were initially managed using two-stage exchange arthroplasty and did not need further operation. Six patients had a definitive resection arthroplasty. Salvage surgeries (fusion and above-knee amputation) were performed in three cases (8%). The infection was ultimately controlled in 32 of the 36 patients. Conclusions: Management of enterococcal PJI is challenging and multiple operations may need to be performed to control the infection. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. é 2012 The Association of Bone and Joint Surgeonsî
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Rationale and design of a cohort study on primary ovarian insufficiency in female survivors of Hodgkin's lymphoma: influence on long-term adverse effects (SOPHIA)
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MSTS 2022 - Metastatic Disease of the Humerus
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INTRODUCTION: Hodgkin's lymphoma (HL) has become the prototype of a curable disease. However, many young survivors suffer from late adverse effects of treatment. Both chemotherapy (CT) and radiotherapy (RT) may induce primary ovarian insufficiency (POI), which has been associated with reduced bone mineral density (BMD), neurocognitive dysfunction and possibly cardiovascular disease (CVD). While the general assumption is that POI increases CVD risk, other hypotheses postulate reverse causality, suggesting that cardiovascular risk factors determine menopausal age or that biological ageing underlies both POI and CVD risk. None of these hypotheses are supported by convincing evidence. Furthermore, most studies on POI-associated conditions have been conducted in women with early natural or surgery-induced menopause with short follow-up times. In this study, we will examine the long-term effects of CT-induced and/or RT-induced POI on BMD, cardiovascular status, neurocognitive function and quality of life in female HL survivors.
METHODS AND ANALYSIS: This study will be performed within an existing Dutch cohort of HL survivors. Eligible women were treated for HL at ages 15-39 years in three large hospitals since 1965 and survived for >=8 years after their diagnosis. Women visiting a survivorship care outpatient clinic will be invited for a neurocognitive, cardiovascular and BMD assessment, and asked to complete several questionnaires and to provide a blood sample. Using multivariable regression analyses, we will compare the outcomes of HL survivors who developed POI with those who did not. Cardiovascular status will also be compared with women with natural POI.
ETHICS AND DISSEMINATION: This study has been approved by the Institutional Review Board of the Netherlands Cancer Institute and has been registered at 'Toetsingonline' from the Dutch Central Committee on Research involving Human Subjects (file no. NL44714.031.13). Results will be disseminated through peer-reviewed publications and will be incorporated in follow-up guidelines for HL survivors.
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Bilateral carpal tunnel syndrome associated to familial Mediterranean fever
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A unique case of bilateral severe carpal tunnel syndrome due to familial Mediterranean fever is reported. The syndrome was diagnosed by clinical examination and electrophysiological studies. Bilateral transverse carpal ligaments were released and the biopsy specimens revealed systemic type A amyloidosis. Up to our knowledge, the co-existence of bilateral carpal tunnel syndrome and familial Mediterranean fever has not been reported previously in the literature
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Palliative care in malignant haematology: An overview
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MSTS 2018 - Femur Mets and MM
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The majority of patients with haematologic neoplasias may experience troublesome symptoms and complicating clinical syndromes throughout all phases of disease. In this view, the patient's management should incorporate causal treatments and symptomatic measures. Therefore, among the current concepts concerning the comprehensive management of patients with haematological malignancies, palliative care should exert a more ever expanding role, although only scanty information are available on this topic. In this review we summarize the current knowledge deriving from the pertinent literature and give some recommendation on the symptoms management based on current guidelines and on the judgement of a group of haematologists and of a skilled algologist, all involved for a long time in this clinical setting. Copyright © Hellenic Society of Haematology.
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Bisphosphonates for steroid induced osteoporosis
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Management of Hip Fractures in the Elderly
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BACKGROUND: Corticosteroids are widely used in inflammatory conditions as an immunosuppressive agent. Diseases treated with corticosteroids include connective tissue diseases, asthma, inflammatory bowel disease and organ transplantation. Bone loss is a serious side effect of this therapy. Several studies have examined the use of bisphosphonates as a treatment for corticosteroid-induced osteoporosis and have reported varying magnitudes of effect. The best estimate of the magnitude of efficacy regarding bisphosphonate prevention of corticosteroid-induced bone loss is needed, before their use is advocated. OBJECTIVES: To assess the effects of bisphosphonates for the prevention and treatment of corticosteroid-induced osteoporosis. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group trials register, MEDLINE up to 1997 and EMBASE 1988-1997), and selected hand searching of reference lists was conducted. Hand searching of scientific abstracts from relevant meetings for the last five years was also done. An electronic search in Current Contents was done for the last six months. The Cochrane Controlled Trials Register (CCTR) will be searched for future updates.All languages were included in the search. For practical reasons only those in English were included, but all languages will be retrieved and translated for future updates. SELECTION CRITERIA: All controlled clinical trials (CCTs) dealing with prevention or treatment of corticosteroid-induced osteoporosis with bisphosphonates of any type and reporting the outcomes of interest were assessed. Trials had to involve adults only, and subjects had to be taking a mean steroid dose of 7.5 mg/day or more. DATA COLLECTION AND ANALYSIS: All data extraction was performed by two independent reviewers. Outcomes of interest included change in bone mineral density (BMD) at the lumbar spine and femoral neck at six and 12 months. If present, data on number of new fractures and withdrawals due to adverse effects were also extracted. All data extraction was performed by two independent reviewers. Both continuous and dichotomous data were analyzed using fixed effects models. When significant heterogeneity was present, a random effects model was used. MAIN RESULTS: A total of 13 trials, including 842 patients are included in this meta-analysis. Results are reported as a weighted mean difference of the percent change in BMD between the treatment and placebo groups, with trials being weighted by the inverse of their variance. The 95% confidence intervals (95% CI) are presented. At the lumbar spine, the weighted mean difference of BMD between the treatment and placebo groups was 4.3% (95% CI 2.7, 5.9). At the femoral neck, the weighted mean difference was 2.1% (95%CI 0.01, 3.8). Although there was a 24% reduction in odds of spinal fractures [OR 0.76 (95%CI 0.37, 1.53)], this result was not statistically significant. AUTHORS' CONCLUSIONS: Bisphosphonates are effective at preventing and treating corticosteroid-induced bone loss at the lumbar spine and femoral neck. Efficacy regarding fracture prevention cannot be concluded from this analysis, although bone density changes are correlated with fracture risk. BISPHOSPHONATES FOR TREATING OSTEOPOROSIS CAUSED BY THE USE OF STEROIDS: Corticosteroids are widely used to treat inflammation. Bone loss (osteoporosis) is a serious side effect of this therapy. We reviewed a total of 13 trials which included 842 patients. We found that the bone mineral density of the lumbar spine of patients taking bisphosphonate therapy improved 4.3% more than patients who had no treatment. At the femoral neck (top of the thigh bone), the bone mineral density improved 2.1% more in the treatment group. There was no difference in the number of spinal fractures between the the two groups. We found that bisphosphonates are effective at preventing and treating corticosteroid-induced bone loss at the lumbar spine and femoral neck. We do not have enough evidence to say whether or not bisphosphonates prevent fractures
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Staying Out of Trouble Performing Intramedullary Nailing of Forearm Fractures
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DoD - ACS - Interrater Reliability
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Pediatric diaphyseal forearm fractures occur commonly and often require reduction with stabilization. Intramedullary flexible nails provide an effective method for stabilizing and maintaining reduction of these fractures. There are a few specific technical pearls that can be implemented to improve efficiency of nail placement and minimize postoperative complications, such as painful hardware and compartment syndrome.
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