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Placement of an anatomic tibial tunnel significantly improves the medial meniscus posterior extrusion at 90° of knee flexion following medial meniscus posterior root pullout repair
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AMP (Acute Meniscal Pathology)
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PURPOSE: The purpose of this study was to evaluate the influence of tibial tunnel position in pullout repair for a medial meniscus (MM) posterior root tear (MMPRT) on postoperative MM extrusion. METHODS: Thirty patients (median age 63 years, range 35-72 years) who underwent transtibial pullout repairs for MMPRTs were included. Three-dimensional computed tomography images of the tibial surface were evaluated using a rectangular measurement grid for assessment of tibial tunnel position and MM posterior root attachment. Preoperative and postoperative MM medial extrusion (MMME) and posterior extrusion (MMPE) at 10° and 90° knee flexion were measured using open magnetic resonance imaging. RESULTS: Tibial tunnel centers were located more anteriorly and more medially than the anatomic center (median distance 5.8 mm, range 0-9.3 mm). The postoperative MMPE at 90° knee flexion was significantly reduced after pullout repair, although there was no significant reduction in MMME or MMPE at 10° knee flexion after surgery. In the correlation analysis of the displacement between the anatomic center to the tibial tunnel center and improvements in MMME, and MMPE at 10° and 90° knee flexion, there was a significant positive correlation between percentage distance and improvement of MMPE at 90° knee flexion. CONCLUSION: This study demonstrated that the nearer the tibial tunnel position to the anatomic attachment of the MM posterior root, the more effective the reduction in MMPE at 90° knee flexion. Our results emphasize that an anatomic tibial tunnel should be created in the MM posterior root to improve the postoperative MMPE and protect the articular cartilage in a knee flexion position. Placement of an anatomic tibial tunnel significantly improves the MMPE at 90° of knee flexion after MM posterior root pullout repair.IV.
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Fifteen-year survival and osteolysis associated with a modular posterior stabilized knee replacement: A concise follow-up of a previous report
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PJI DX Updated Search
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We report the results of a consecutive series of total knee arthroplasties with use of a modular posterior stabilized prosthesis after a mean follow-up of twelve years (range, ten to eighteen years). In the five years since the original publication of our study, two additional knees were revised; one was revised for aseptic loosening and one, for polyethylene wear with tibial osteolysis. With mechanical failure as an end point, the fifteen-year survival was 96.8%. With failure defined as any reoperation, the fifteen-year survival was 90.6%. Osteolysis occurred in eight of the 117 knees with a minimum ten-year follow-up. With the relatively small number of subjects, no significant association was identified between polyethylene thickness or sterilization method and osteolysis. A significant association was identified between younger patient age and osteolysis. We continue to routinely implant a similar modular posterior stabilized total knee prosthesis. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. Copyright é 2009 by The Journal of Bone and Joint Surgery, Incorporated
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Retrograde femoral nailing: a focus on the knee
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DoD SSI (Surgical Site Infections)
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A consecutive series of 23 patients with reamed retrograde femoral nails was reviewed. Nails were placed through the intercondylar notch with a minimal incision. Nineteen patients with retrograde femoral nails were available at an average follow-up of 19.3 months. The union rate was 100% with no infections or malunions. No second surgeries were required for union. Knee range of motion averaged 109 degrees and was greater in those patients with shaft fractures (117 degrees) than in those with supracondylar-intercondylar fractures (91.3 degrees) (P=.02). Pain (0-3 scale) averaged 0.36. Hospital for Special Surgery knee scores averaged 80.4 (90% good or excellent results). Minor knee pain (55%) and secondary surgeries (35%) were common. The only fair or poor results were in patients with preexisting osteoarthritis. A literature review of 14 papers and abstracts was conducted. Exposure, often extensive initially, is more recently percutaneous. The infection rate is acceptable (0-14%), with knee sepsis uncommon. Lower union rates were observed for supracondylar femur fractures (80%-84%) than for femoral shaft fractures (85%-100%) after a single surgery. Second surgeries are common (14%-60%). Varus/valgus malunion, common (12%-29%) with the initial extrarticular entry site, occurs less with the intercondylar entry site. The antegrade femoral nail allows for better control of proximal shaft fractures, while the retrograde femoral nail is more reliable in controlling distal shaft fractures. Rotational malunion still remains a problem. Mild knee pain is common (13%-60%). The treatment of supracondylar femur nonunions with retrograde femoral nailing is disappointing.
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Treatment of persistent infection after anterior cruciate ligament surgery
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Surgical Management of Osteoarthritis of the Knee CPG
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Infection after anterior cruciate ligament reconstruction that persists despite debridement is a challenging problem with limited information available in the literature. Our purpose was to determine whether an aggressive protocol would be effective in treating these persistent infections. This is a retrospective review of five consecutive patients with persistent septic arthritis of the knee after anterior cruciate ligament reconstruction. All patients previously had one to three irrigation and debridement procedures that failed to control the infection. Our treatment protocol consists of arthrotomy, complete synovectomy, removal of any implants, graft removal, and curettage of the femoral and tibial tunnels. Cultures are obtained from many sources (joint fluid, synovial lining, graft, and bone) and antibiotic therapy is given for 6 weeks. At a median followup time of 20 months (range, 6-27 months) infection was controlled in all patients. Three of five infections (60%) were polymicrobial. In these cases, different organisms were cultured from multiple tissue samples. Tunnel osteomyelitis was present in three of five patients (60%). Persistent septic arthritis of the knee after anterior cruciate ligament reconstruction can be controlled with a protocol based on radical debridement. Polymicrobial infections may be present and multiple cultures from different sources are required to identify all pathogens
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Tumescent liposuction in Germany: history and new trends and techniques
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Panniculectomy & Abdominoplasty CPG
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Due to the developments and changes of tumescent solution, infiltration technique, and cannulas, we perform tumescent liposuction today using up to 6-8 l tumescent solution. Total aspirate measures up to 9 l, pure fat aspired up to 5 l. Tumescent liposuction of extended areas can still be done as an outpatient procedure. The condition of patients intra- and postoperatively as well as results has improved and the predictability of outcome is more certain.
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Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shockwave and alendronate
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Management of Hip Fractures in the Elderly
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BACKGROUND AND PURPOSE: Extracorporeal shockwave therapy (ESWT) and alendronate are reported effective in early osteonecrosis of the femoral head (ONFH). We hypothesized that joint effects of ESWT and alendronate may produce superior results. This prospective study compared the results of ESWT and alendronate with that of ESWT without alendronate in early ONFH.PATIENTS AND METHODS: Forty-eight patients with 60 hips were randomly divided into tow groups. There were 25 patients with 30 hips in group A and 23 patients with 30 hips in group B. Both groups showed similar demographic characteristics. All patients were treated with 6,000 impulses of ESWT at 28 KV (equivalent to 0.62 mJ/mm(2)) to the affected hip as a single session. Patients in group B also received alendronate 70 mg per week for 1 year, whereas patients in group A did not. The evaluations included clinical assessment, radiograph and MR image of the affected hip. Both groups were compared statistically using paired t, Mann-Whitney and Chi square tests with statistical significance at P < 0.05. The primary end point is the need for total hip arthroplasty (THA). The secondary end point is the improvement in pain and function of the hip. The third end point is the progression or regression of the lesion on image study.RESULTS: The overall clinical outcomes were improved in 83%, unchanged in 7% and worsened in 10% for group A; and improved in 77%, unchanged in 13% and worsened in 10% for group B. THA was performed in 10% of group A and 10% of group B (P = 1.000). Significant improvements in pain and function of the hip were noted in both groups (P < 0.001), however, the differences between the two groups were not significant (P = 0.400, 0.313). On MR images, the lesions showed progression in 10%, regression in 47% and unchanged in 43% in group A, and progression in 7%, regression in 53% and unchanged in 40% in group B (P = 0.830).CONCLUSION: ESWT and alendronate produced comparable result as compared with ESWT without alendronate in early ONFH. It appears that ESWT is effective with or without the concurrent use of alendronate. The joint effects of alendronate over ESWT in early ONFH are not realized in short-term
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Genetic parameters for bone strength, osteochondrosis and meat percentage in Finnish Landrace and Yorkshire pigs
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Osteochondrosis (OC) is a major factor causing joint problems that affect animal welfare and pork production profitability. Strong bones are also important in the slaughtering process, especially as broken bones can lead to rejections of parts of the carcass. In this study, 326 Finnish Yorkshire and 464 Finnish Landrace test station pigs were examined post mortem for bone strength and osteochondral lesions. The objective was to estimate genetic parameters for OC and bone strength and their genetic and phenotypic correlations with carcass meat percentage. Two formulas were used for lean meat percentage, the first one (Hennessy meat-%) comprising two fat thickness measurements and one muscle depth measurement, and the second one (test station meat-%) also including the weight of lean meat in ham. Finnish Yorkshire had stronger bones than Finnish Landrace on average, but also more OC in the proximal end of the humerus (36%) and the distal end of the femur (51%) than Finnish Landrace (29% and 31% OC in the humerus and femur, respectively). By using the data on both breeds, the OC heritability estimated was 0.05 in the humerus and 0.26 in the femur. The estimated heritability of bone strength was also moderate (0.26). Test station meat-% showed higher heritability (0.40) than meat-% based on the Hennessy formula (0.29). Genetic correlations between meat percentage and the other studied traits were weak and associated with high standard errors. The results show that a mild form of OC is common in both Finnish pig breeds; bone strength and OC in the distal end of the femur are moderately heritable and can be improved through selection; and selection for high meat percentage does not seem to affect bone strength or OC
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1 |
Rheumatism and the menopause
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Rheumatic problems at or around the menopause include arthralgia and general rheumatic pains, aggravation or first appearance of rheumatoid or osteoarthritis, backache and carpal tunnel syndrome caused by fluid retention. This article looks at such menopausal conditions and describes how to diagnose and manage them
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Complications in the Cosmetic Dermatology Patient: A Review and Our Experience (Part 2)
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Over recent decades, the options available to patients for cosmetic rejuvenation have expanded dramatically. The range of options commonly available to patients now includes neuromodulators, fillers, sclerotherapy, chemical peels, lasers, lights and other energy devices, and liposculpture and continues to grow. Like all therapeutic interventions, these cosmetic dermatologic procedures are not without risk. Timely recognition of complications and intervention are paramount for optimal patient outcomes. OBJECTIVE: Part 1 of this review focused on the common complications that may result from injectable cosmetic procedures. The second part will discuss the complications of chemical peels, lasers, light and energy devices, and fat removal/sculpture procedures. MATERIALS AND METHODS: A MEDLINE search was performed on cosmetic dermatology complications from 1989 to 2015, and results are summarized. Practical considerations of these complications are also provided. RESULTS: Reports of complications after neuromodulator, injectable hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, polymethylmethacrylate, sclerotherapy, fat transfer, liposuction, cryolipolysis, chemical peels, lasers, and light sources, such as Q-switched laser, intense pulsed light, and nonablative and ablative resurfacing lasers, were found. CONCLUSION: Review of the literature revealed multiple management options for potential complications of the multitude of cosmetic dermatology procedures now available to patients.
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Comparison of knee function in patients with a healed fracture of the femoral shaft fixed with retrograde and antegrade intramedullary nailing
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND. Despite extensive current knowledge about fractures of the femoral shaft, the choice between antegrade and retrograde intramedullary (IM) nailing with respect to the future function of the joint serving to introduce the nail continues to raise controversy. To compare knee function in patients with a healed fracture of the femoral shaft fixed by antegrade vs. retrograde IM nailing. MATERIAL AND METHODS. The study involved a group of 65 individuals with traumatic fractures of the femoral shaft who underwent stabilisation with IM nails in the years 2001-2010. Thirty-two cases were retrograde nails (Group R) and 33 antegrade nails (Group A). Patient age at trauma ranged from 19 to 91 years (mean: 47). Knee function was assessed in both groups with the KOOS, KSS1 and KSS2 scoring systems. RESULTS. Knee function as assessed with KOOS differed significantly between retrograde and antegrade nailing, with a greater incidence of poor and fair results in the former and more excellent outcomes in the latter group (p=0.0133). As regards KSS1 and KSS2, there were no significant differences between the groups (p=0.1947, p=0.4038). The range of motion was 86-125 degrees in Group R and 121-125 degrees in Group A. Knee pain was reported by 37.5% of the patients treated with retrograde nailing and 39.4% of those who had the IM nail inserted via the antegrade approach (p=0.22). The mean time to bone union was 180 days in Group R and 219 days in Group A (p=0.25). Age and presence of osteoarthritis at trauma significantly lowered the KOOS (p=0.0027, p= 0.005) and KSS (p=0.0002, p=0.002) scores, as well as the knee range of motion (p=0.0014, p=0.004) CONCLUSIONS. 1. Knee function following retrograde and antegrade IM nailing to stabilise femoral shaft fractures was comparable. 2. The choice of IM nailing method should not be based solely on orthopaedic indications, but also on the severity of osteoarthritis present at trauma.
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0 |
Peri-operative pain management: Assuring a happy patient
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AAHKS (9/10) Regional Nerve Blocks
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Total knee arthroplasty (TKA) is one of the most commonly performed procedures in the United States. Poorly controlled pain and opioid side effects are associated with worse outcomes. As the prescription opioid epidemic progresses, strategies to provide adequate analgesia while minimizing opioid use are rapidly being developed. Recent efforts have focused on multimodal pain regimens, which combine several opioid and non-opioid classes of analgesic medications and interventions. In this review, we summarize the current best evidence for major components of MPRs as applied to TKA and provide a description of our practice and MPR for use in our practice.
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1 |
Hemiarthroplasty versus internal fixation in super-aged patients with undisplaced femoral neck fractures: a 5-year follow-up of randomized controlled trial
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Hip Fx in the Elderly 2019
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INTRODUCTION: There were higher rates of revision, complication, non-union, delayed union, and poorer functional outcomes reported in super-aged patients of undisplaced femoral neck fractures treated with internal fixation. Therefore, we designed this randomized comparative study aiming to compare the effectiveness and long-term follow-up results of hemiarthroplasty (HA) with that of multiple cannulated screws (MCS).
MATERIALS AND METHODS: Eligible participants were randomly assigned into two groups for different methods of operation (hemiarthroplasty group and internal fixation group). The related indexes and data of two groups were collected for comparative analysis during the average follow-up period of 38.68 +/- 28.24 months.
RESULTS: There were only two patients performed reoperation in HA group, and the reoperation rate of HA group (5.41%, 2/37) was significantly lower than that of IF group (21.4%, 9/41) (P value = 0.000). The comparison of survival curves for reoperation showed significant differences between two groups (P value = 0.031). The results of Cox proportional hazards model suggested that only operation method significantly affected the occurrence of reoperation (P value = 0.049). The results of survival analysis showed that there was no significant difference in survival time between two groups (P value = 0.682). And in the Cox proportional hazards model, only age significantly affected the occurrence of death (P value = 0.000). The average Harris scores of two groups were all above 75 points, and there was no significant difference in Harris scores between the two groups (P value greater than 0.05). But in the early term follow-up, the excellent and good rate of hip joint function in HA group was significantly higher than that in IF group (P value less than 0.05).
CONCLUSIONS: Hemiarthroplasty with less postoperative complications, low reoperation rate and better function recovery in early stage provide a good choice for the treatment of super-aged patients with nondisplaced femoral neck fracture.
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1 |
Occult fractures of the proximal femur: MR imaging
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Management of Hip Fractures in the Elderly
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Coronal T1-weighted magnetic resonance (MR) images were obtained on a 1.5-T system in 23 patients in whom there was a high clinical suspicion of hip fracture although initial radiographs were normal. MR imaging correctly demonstrated fracture in nine of nine patients; the precise configuration of the fracture line was delineated in eight patients. MR imaging was useful in excluding fractures in 14 of 14 patients, who were subsequently followed up clinically for a minimum of 3 months. Radionuclide scans were positive in four of four patients with fractures and equivocal in one patient who was subsequently demonstrated to have no fracture. Additional imaging studies were requested by clinicians in all cases in which the bone scan was positive. The results of this study suggest that MR imaging can provide a rapid, cost-effective, and anatomically precise diagnosis of hip fracture in patients with normal or equivocal initial radiographs. The specificity of the diagnosis achieved can obviate supplemental imaging examinations, with their attendant additional expense and radiation exposure
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Surgical technique: Unicondylar osteoallograft prosthesis composite in tumor limb salvage surgery
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: After resecting tumors confined to one femoral condyle, a unicondylar osteoarticular allograft can be used for reconstruction without sacrificing the uninvolved condyle. However, unicondylar osteoarticular allografts have been associated with a high rate of joint degeneration. We describe a unicondylar osteoallograft prosthesis composite reconstruction replacing only one side of the joint to reduce compartment degeneration and avoid contamination of the tibia, but the survival, function, and complications of a unicondylar osteoallograft prosthesis composite are unclear.
DESCRIPTION OF TECHNIQUE: We located a bone resection plane intraoperatively as planned before surgery using a computer-assisted navigation system. The tumor then was removed en bloc and the unicondylar defect filled with a size-matched allogeneic unicondyle. The allograft cartilage was removed. Thereafter, the condyle of the femoral component was resurfaced with a unicompartmental knee prosthesis to form a unicondylar osteoallograft prosthesis composite, however the tibia was left undisturbed. Navigation allowed precise apposition between the unicondylar osteoallograft prosthesis composite and host bone to ensure mechanical alignment and congruency of the joint surface before fixation with a plate.
METHODS: We retrospectively reviewed 12 patients who underwent unicondylar osteoallograft prosthesis composite reconstructions after unicondylar resection for tumors. One patient died from tumor-related causes without unicondylar osteoallograft prosthesis composite failure after 18 months. We observed the survival rate of unicondylar osteoallograft prosthesis composite reconstruction and related complications. Function and radiographs also were documented according to the Musculoskeletal Tumor Society (MSTS) functional scoring system and the International Society of Limb Salvage radiographic scoring system. The minimum followup was 8 months (median, 37 months; range, 8-65 months).
RESULTS: At last followup, 10 of the 12 unicondylar osteoallograft prosthesis composite reconstructions were still in place. Three reconstructions failed owing to two local recurrences (both treated with amputation) and there was one infection (treated with revision and maintenance of the implant at last followup). The average MSTS functional score at last followup was 27 points and the radiographic score 91%.
CONCLUSIONS: Our observations suggest unicondylar osteoallograft prosthesis composite reconstruction might be a reliable technique with relatively few major complications and at least short-term maintenance of the tibial cartilage.
LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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1 |
The effect of prior stressful experience on coping with war trauma and captivity
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DoD PRF (Psychosocial RF)
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The study assessed the implications of childhood life events, Holocaust background, combat experiences, war captivity and negative post-captivity life events in the mental status of ex-POWs (164) and comparable controls (184), 18 years after the war. Findings confirm the association between stressful life events in the course of the life span and five outcomes: PTSD, intrusion and avoidance tendencies, psychiatric symptomatology, and impaired social functioning. Different life events have different effects. War captivity made the strongest contribution to all dependent variables.
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Medication review with a focus on fracture prophylaxis among patients suffering collum femoris fractures
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HipFx Supplemental Cost Analysis
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Study objectives: The aim of this study was to investigate the intervention on collum femoris fracture patients by clinical pharmacists at an orthopaedic surgery ward regarding fracture prophylaxis with calcium and vitamin D, and to evaluate medication reviews performed by clinical pharmacists. Methods: Patients > 65 years old admitted to the Orthopaedic Surgery ward at Vejle and Give Hospitals, Denmark, from December 2007 to December 2008 with collum femoris fractures were included in the survey. The intervention consisted of a medication review by the clinical pharmacists with special focus on fracture prophylaxis with calcium and vitamin D, and recommendations were followed up 2-3 days later. Results: Of the 159 medication reviews performed, 124 fulfilled the indication of fracture prophylaxis by commencing relevant treatment. Review of the medication resulted in 164 recommendations in 107 (67%) of the 159 patients (1.5 recommendations/patient with recommendations). Of the recommendations, 52% were accepted. The most frequent types of recommendations were 'untreated indication' and 'overdose'. The majority of the recommendation type 'untreated indication' was related to treatment with calcium and vitamin D, while the most frequent recommendation categorised as 'overdose' was associated to a reduction in the use of benzodiazepines or other indirectly associated fracture prophylactic interventions. Conclusion: This study showed that the medication reviews with a specific focus on fracture prophylactic treatment performed by clinical pharmacists led to an increase in compliance with guidelines. The results emphasise that the clinical pharmacist contributes with professional competence regarding the patients' medication. Hence, it is relevant to include clinical pharmacy as a professional collaborator at hospitals in Denmark when new medication-related tasks are considered
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Increasing incidence of hip fractures in Finland
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Management of Hip Fractures in the Elderly
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The incidence of hip fracture in Finland was studied for the year 1988. During 1988, 6139 patients were treated for a fresh hip fracture. Three out of four hip fracture patients were women, and the occurrence of cervical fractures was 2.8 times and that of trochanteric fractures 2.5 times more common in women than in men. The incidence rates of hip fractures per 100,000 were 174 in women, 70 in men and 123 in the whole population. The mean hospitalization time for fresh hip fractures was 33 days for cervical fractures and 38 days for trochanteric fractures. The costs of primary hospitalizations due to fresh hip fractures in 1988 were estimated at US $66 million
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Does the number or quality of pluripotent bone marrow stem cells decrease with age?
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Management of Hip Fractures in the Elderly
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In the next 25 years, as the 37 million baby boomers age, we can expect a 400% increase in total joint arthroplasties that will challenge surgeons, the healthcare system, and the scientific community. The burden may be eased if we are able to manipulate side population stem cells and enhance peri-prosthetic bone remodeling thereby reducing the incidence of revisions. Therefore, as a preliminary question, we asked if the number and quality of side population stem cells, with the ability to proliferate into multiple cell lineages for long periods, correlates with age and can be evaluated in peripheral blood. Using flow cytometry we analyzed the quantity and quality of side population stem cells from bone marrow and peripheral blood in 54 patients (20 under 60 years of age, 34 over) undergoing THA. The total side population of stem cells decreased with age, but their long-term repopulating ability (quality) remained constant. The total count of side population stem cells in marrow correlated with the number found in peripheral blood. If these populations can be manipulated, periprosthetic remodeling may be beneficially enhanced. (copyright) 2007 Lippincott Williams & Wilkins, Inc
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Reproducibility of the surveillance effect to decrease nosocomial infection rates
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PJI DX Updated Search
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OBJECTIVE: To investigate whether the reduction effect due to participation in a nosocomial infection surveillance system for laboratory-confirmed central venous catheter (CVC)-associated primary bloodstream infection (BSI), ventilator-associated pneumonia (VAP), and surgical site infection (SSI) is reproducible for different time periods, independent of confounding factors that might occur during a specific time period. METHODS: Data from the German national nosocomial infection surveillance system from the period January 1997 through June 2008 were used. CVC-associated BSI data and SSI data were analyzed for 3 starting periods, and VAP data were analyzed for 2 starting periods. Monthly infection rates were calculated for the following 36 months, and relative risks comparing the first and third surveillance years of each period were calculated. RESULTS: A total of 2,399 CVC-associated BSI cases from 267 intensive care units, 3,637 VAP cases from 150 intensive care units, and 829 SSIs following 3 different procedures from 113 departments were analyzed. A significant reduction in VAP was shown for both starting periods investigated (overall relative risk [RR], 0.80 [95% CI, 0.74-0.86]). A significant reduction in CVC-associated BSI was demonstrated for 2 of 3 starting periods (overall RR, 0.83 [95% CI, 0.75-0.91]). A significant reduction in SSI was found for 2 starting periods for knee prosthesis insertion (overall RR, 0.56 [95% CI, 0.38-0.82]), for all of the 3 starting periods for cesarean delivery (overall RR, 0.75 [95% CI, 0.61-0.93]), and for none of the 3 starting periods for endoscopically performed cholecystectomy (overall RR, 0.89 [95% CI, 0.62-1.27]). CONCLUSIONS: The surveillance effect, manifest as a significant reduction of nosocomial infection rates between the first and third years of participation in a surveillance system, was observed independently from the calendar year in which the surveillance activities started
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Injury hospitalization as a marker for emergency medical services use in elderly patients
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HipFx Supplemental Cost Analysis
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BACKGROUND: The elderly utilize emergency medical services (EMS) at a higher rate than younger patients, yet little is known about the influence of injury on subsequent EMS utilization and costs. OBJECTIVE: To assess injury hospitalization as a potential marker for subsequent EMS utilization and costs by Medicare patients. METHODS: This observational study analyzed a retrospective cohort of all Medicare patients (> or = 67 years old) with an International Classification of Diseases, Ninth Revision (ICD-9) injury diagnosis admitted to 125 Oregon and Washington hospitals during 2001 and 2002 who survived to hospital discharge. The numbers of EMS transports and the total EMS costs were compared one year before and one year following the index hospitalization. RESULTS: There were 30,655 injured elders in our cohort. Their median ICD-9-based injury severity score was 0.97, with 4.1% meeting a definition of serious injury and 37% having hip fractures. The mean (range) numbers of EMS transports before and after the injury were 0.5 (0-45) and 0.9 (0-56), for an unadjusted incidence rate ratio (IRR) of 1.7 (95% confidence interval [CI] 1.7-1.8). The increase in EMS utilization following an injury hospitalization was even greater after adjusting for risk period and other model predictors (IRR 2.4, 95% CI 2.3-2.5). Annual mean EMS costs rose 74% following the injury hospitalization, from $211 to $367 per person. The greatest increase was in nonemergent EMS use, accounting for 67% of the increase in the number of uses. Institutionalization in a skilled nursing or rehabilitation facility either before or after injury was strongly associated with the need for EMS care. CONCLUSION: An injury hospitalization in the elderly serves as a sentinel marker for an abrupt increase in EMS utilization and costs, even after accounting for confounders
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The Effect of Total Knee Arthroplasty on Physical Activity and Body Mass Index: An Analysis of the Osteoarthritis Initiative Cohort
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OAK 3 - Non-arthroplasty tx of OAK
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Introduction: Preliminary analysis of accelerometry measurements has shown physical activity may not increase significantly after total knee arthroplasty (TKA). This study evaluates the effect of TKA on physical activity accelerometry measurements and body mass index (BMI). Methods: Using the multicenter Osteoarthritis Initiative (OAI) database, a cohort of patients with physical activity level accelerometry measurements and BMI before and after TKA was identified. Physical activity levels and BMI were acquired at pre-TKA and post-TKA accelerometry visits 2 years apart. Survey scores pertaining to knee functionality and quality of life were also analyzed before and after knee surgery. Each patient included in the study had a unilateral TKA completed between these 2 accelerometry visits. Accelerometry measurements, BMI of the patients, and survey scores relating to knee functionality and pain relief from before and after TKA were compared using paired samples t tests. Results: Twenty-three patients from the OAI database were identified for the paired analysis. They were evaluated at a mean postoperative follow-up of 15 months. There were no statistically significant differences between the post-TKA group and pre-TKA group for the accelerometry variables and BMI, though patients experienced a significant improvement in knee function and pain relief measures included in this analysis. Discussion: Although TKA can successfully restore function and relieve pain, there remains no good evidence that neither physical activity nor BMI improve postoperatively. Conclusion: No significant differences in physical activity and BMI were observed after TKA in this study.
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Efficacy, Safety, and Pharmacokinetics of Femoral Nerve Block With EXPAREL in Total Knee Arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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On Day 0, eligible subjects will be randomized in a 1:1:1 ratio to receive a single dose of either EXPAREL 133 mg in 10 mL expanded in volume with 10 mL of normal saline for a total volume of 20 mL (Group 1); EXPAREL 266 mg in 20 mL (Group 2); or placebo 20 mL (Group 3). Study drug (EXPAREL or placebo) will be administered in a blinded manner via an ultrasound guided singleâ?dose femoral nerve block at least 1 hour prior to surgery. Prior to placement of the prosthesis, 8 mL of bupivacaine hydrochloride (HCl) (0.5%) diluted with 8 mL of normal saline will be administered by the surgeon as a periarticular infiltration to the posterior capsule (8 mL medially and 8 mL laterally). Postsurgical assessments will include pain intensity scores using a 10â?cm visual analog scale (VAS); total postsurgical opioid consumption; overall benefit of analgesia score (OBAS) questionnaire; subject satisfaction with overall analgesia using a 5â?point Likert scale; neurological assessment; sensory function assessment; motor function assessment; the study physical therapy assessments (ie, timed walk, timed up and go, and stair climbing tests); discharge readiness; unscheduled phone calls or office visits related to pain; 12â?lead ECGs; vital sign measurements; and clinical laboratory tests. Adverse events will be recorded from the time the informed consent form (ICF) is signed through postsurgical Day 29. Followâ?up visits will be scheduled for all subjects on postsurgical Days 6 and 10. A followâ?up phone call will be made on postsurgical Day 29. Pharmacokinetic (PK) parameters will be estimated from plasma bupivacaine measurements using nonâ?compartmental analysis based on the sampling schedule of baseline (prior to the nerve block) through postsurgical Day 10.
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The thigh's lateral skin (saddle bags): histomorphometric study of interest to liposuction
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Panniculectomy & Abdominoplasty CPG
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Study of the thigh's lateral skin ("saddle bags") in cadavers made it possible to evaluate its regional characteristics. Sex or race were not reported but the age group most appropriate to liposuction was considered. In this way, authors believed that as per standards established at the time, results as to the skin retraction in liposuction, will be able to be analyzed in a comparative way in the future.
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0 |
Juvenile idiopathic arthritis: The paediatric perspective
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Dental Implant Infection
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Paediatric rheumatology is a relatively new specialty that has developed rapidly over the last 30 years. There have been major advances, which have included improvements in the classification and management of juvenile idiopathic arthritis (JIA). The former has led to enhanced international collaboration with disease registries, multicentre research and the development of new therapeutic agents. This has resulted in improved disease control and remission induction in many. There is, however, still significant morbidity associated with JIA during childhood, adolescence and adulthood, and challenges for the future include early identification of those with a poorer prognosis, appropriate administration of safe therapies and optimizing outcomes as young people move through adolescence into adulthood. © Springer-Verlag 2006.
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The effect of acupressure therapy on pain, stiffness and physical functioning of knees among older adults diagnosed with osteoarthritis: A pilot randomized control trial
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OAK 3 - Non-arthroplasty tx of OAK
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Introduction: Osteoarthritis (OA) is one of the most common and fast-growing chronic diseases among older adults. The aim of this study was to assess the effect of acupressure therapy on pain, stiffness, and physical functioning of a knee affected by osteoarthritis. Methods: A single-blind pilot randomized control trial was conducted on 51 older adults with OA of the knee living in one of 3 nursing homes. Nursing homes were randomly allocated to one of three study groups; acupressure therapy, placebo, and routine care. The intervention group received acupressure therapy on eight acupoints. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score and the separate WOMAC subscales were used to evaluate pain, stiffness and physical functioning of knees. Results: A one-way ANOVA revealed that WOMAC index was not significantly different at the baseline between the three groups (P = 0.296). After intervention, ANOVA showed significant differences between groups in regard to total WOMAC index, pain and physical dysfunction (p < 0.001). Post hoc comparisons revealed that participants receiving acupressure showed a significant decrease in total WOMAC index, pain and physical dysfunction (p < 0.001). Indeed ANCOVA detected a difference in means of pain (p â?¤ 0.001), stiffness (p = 0.038) and physical dysfunction (p â?¤ 0.001) in three groups. Conclusion: Acupressure may be an effective intervention for reducing the pain, stiffness, and improving the function of knees with osteoarthritis.
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Extraperitoneal Bladder Injuries Associated With Pelvic Fracture Requiring Internal Fixation: What Is the Evidence?
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DoD SSI (Surgical Site Infections)
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Traumatic bladder injuries are commonly associated with pelvic fractures. While the majority of intraperitoneal bladder injuries are surgically repaired, extraperitoneal bladder injuries (EBIs) can be managed nonoperatively in the absence of complex injury patterns such as bladder neck injury or presence of bone spicules in the bladder. Concern for pelvic hardware contamination is one of the most common reasons for repairing EBIs at the time of orthopedic interventions for pelvic fracture (usually open reduction and internal fixation). However, given the inconsistent and limited evidence, practice patterns are different and largely depend on surgeon preferences and institutional management. In this review, we explore the roots for this concern and summarize the current evidence on risk of pelvic hardware infection with nonoperative management of EBIs.
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Risk factors for Parkinson disease and the path analysis: One-to-one paired design
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DoD PRF (Psychosocial RF)
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Background: Parkinson disease (PD) results from the reduce of neurotransmitter dopamine that transmits intracellular information in brain caused by some reasons, then leads to the dynamic disequilibrium with another neurotransmitter of acetylcholine which is relatively hyperactive. The main causes for PD are still unclear. Objective: To screen out the risk factors of PD by means of univariate analysis and multivariate Logistic regression analysis, and investigate the manner of actions between various factors and PD, so as to provide clues for the etiological study of PD. Design: A paired design, Logistic regression analysis, path analysis. Setting: Department of Scientific Research, Shandong Institute of Physical Education. Participants: Totally 157 PD patients were selected from the Department of Neurology, Qilu Hospital of Shandong University from November 2001 to October 2002. Inclusive criteria: PD was diagnosed according to the standard set by the Fourth National Seminar on Extrapyramidal Disease, Parkinsonian syndromes caused by stroke, carbon monoxide poisoning, encephalitis, drugs, etc. were excluded. Another 157 patients treated in the same department at the same period were selected as the control group, they were the same in sex as those in the patient group, within 3 years older or younger than those in the patient group, and without PD or other extrapyramidal diseases. Methods: 1 The general conditions were investigated in all the subjects, including general conditions, social behavioral factor, environmental factor, genetic factor, life events, and previous disease; There were 12 main variables, including educational level, family history, mental labour, contact to insecticides, living place before school-age, smoking index, drinking index, tea-drinking index, history of brain trauma, history of cardiovascular disease, history of diabetes mellitus, and history of depression. 2 SAS6.12 software and SPSS 10.0 software were used in the conditional Logistic regression analysis and path analysis respectively. Main Outcome Measures: The results of 12-variable univariate and multivariate analyses; Correlation between main variables and PD; Effects of the factors. Results: All the subjects were involved in the analysis of results. 1 The results of Logistic regression analysis showed that family history, mental labour, insecticides, drinking index and history of depression all had significant positive correlations with PD (univariate analysis: OR=1.405 - 5.429, P < 0.05-0.01; multivariate analysis: OR=2.029-6.754, P < 0.05-0.01), whereas smoking had significant negative correlations with PD [univariate analysis: odd ratio (OR)=0.765, P < 0.05; multivariate analysis: OR =0.489, P < 0.01]. 2 The path analysis showed that family history, mental labour, insecticides, smoking, drinking and history of depression had direct effects on PD occurrence [(path coefficient= -0.218 to 0.204, P < 0.05 - 0.01)]; Insecticides could cause PD indirectly on the basis of family history (genetic susceptibility) (path coefficient=0.946, P < 0.01); Insecticides could also cause PD by drinking (path coefficient=0.165, P < 0.01); Drinking could cause PD indirectly on the basis of family history (path coefficient=0.043, P < 0.01). Conclusion: The main risk factors of PD are family history, history of depression, drinking, mental labour and insecticides, whereas the protective factor is smoking. PD attack has genetic susceptibility, insecticides and drinking can cause PD on the basis of PD family history. The risk of PD can be decreased by reducing the occasion for contacting the environmental risk factors.
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Fall characterictics, functional mobility and bone mineral density as risk factors of hip fracture in the community-dwelling ambulatory elderly
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Hip Fx in the Elderly 2019
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Hip fracture is the most serious consequence of osteoporosis, frequently occurring in the elderly; however, no research has been performed to identify the fall characteristics, functional mobility and bone mineral density (BMD) concurrently as risk factors. We investigated the risk factors of hip fractures using a multifactorial approach for a further preventive strategy. This age- and sex-matched case-control study was conducted in a community-based general hospital. A total of 252 consecutive community-dwelling ambulatory elderly, aged between 65 and 85 years, were studied: 127 patients (faller with hip fracture) and 125 controls (faller without hip fracture). Body mass index (BMI), predisposing medical conditions, fall characteristics, functional mobility and BMD of the hip were evaluated by direct interview and clinical examination. In the final model of multivariate regression analysis, risk factors for hip fracture were direct hip impact (adjusted odds ratio (OR), 4.9; 95% confidence interval (CI), 2.7-8.8), previous stroke (adjusted OR, 2.9; 95% CI, 1.3-6.3), sideways fall (adjusted OR, 2.5; 95% CI, 1.6-3.9), functional mobility (a decrease of 1 SD; adjusted OR, 2.0; 95% CI, 1.1-3.5), BMI (a decrease of 1 SD; adjusted OR, 1.8; 95% CI, 1.1-2.8) and femoral neck BMD (a decrease of 1 SD; adjusted OR, 1.7; 95% CI, 1.0-2.8). The effect of risk factors remained the same in different analysis sets, and adding or removing femoral neck BMD did not change other risk factors, though BMD was significantly correlated with functional mobility and BMI. Importantly, both sideways fall and direct hip impact are independent predictors of hip fracture. From these results, we suggest a preventive strategy of hip fracture in the elderly: besides the maintenance of BMD, keeping an appropriate body weight and maintaining a physically active lifestyle might be crucial.
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Antibiotic prophylaxis for joint replacement surgery: The current practice in Britain
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Although over a hundred thousand hip and knee joint replacement procedures are now undertaken in Britain every year, deep infection following surgery remains a concern. Measures to minimise this risk of infection include administration of prophylactic antibiotics but unfortunately with the lack of national guidelines, much variability exists between each hospital's local prescribing policies. We undertook a national survey to highlight this by interviewing Orthopaedic trainees at 52 randomly selected hospitals. A structured telephone questionnaire was used. Although all the hospitals were found to prescribe antibiotic prophylaxis, only 33 of the hospitals surveyed had strict local guidelines in place. Most hospitals administer cephalosporins (46), with only a few still relying on penicillins (3). Only four of the surveyed hospitals administer any prohylaxis against methicillin resistant staphyloccus aureus, such as Teicoplanin. Our results highlight the need for national guidelines to be implemented to improve our practice of joint replacement surgery. (copyright) 2008 Springer-Verlag
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The treatment of severe postmenopausal osteoporosis : a review of current and emerging therapeutic options
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Management of Hip Fractures in the Elderly
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Several chemical entities have shown their ability to reduce axial and/or appendicular fractures in patients with osteoporosis. Since patients who have experienced a previous fracture are at high risk for subsequent vertebral or hip fracture, it is of prime importance to treat such patients with medications that have unequivocally demonstrated their ability to reduce fracture rates in patients with prevalent fractures. Results obtained with calcium and vitamin D, in this particular population, are not fully satisfactory and these medications are probably better used in conjunction with other therapeutic regimens. Bisphosphonates have shown their ability to reduce vertebral (alendronate, risedronate, ibandronate) and non-vertebral (alendronate, risedronate) fractures in patients with established osteoporosis. Raloxifene has also shown similar properties, notwithstanding its effect on non-vertebral fractures, which has only been derived from a post hoc analysis limited to patients with prevalent severe vertebral fractures at baseline. This compound also has interesting non-skeletal benefits, including effects on the breast and heart. Teriparatide, a bone-forming agent, promptly reduces the rate of vertebral and all non-vertebral fractures, without significant adverse effects. Strontium ranelate, the first agent shown to concomitantly decrease bone resorption and stimulate bone formation, has also shown its ability to reduce rates of vertebral and non-vertebral fractures in patients with established osteoporosis. It significantly reduces hip fractures in elderly individuals at high risk for such events. Its safety profile is also excellent
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Closed reduction of colles fractures: comparison of manual manipulation and finger-trap traction: a prospective, randomized study
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Distal Radius Fractures
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BACKGROUND: An optimal outcome of closed treatment of a Colles fracture may depend on accurate reduction and adequate immobilization. It has been suggested that the use of finger-trap traction results in a better reduction and a lower rate of redisplacement than manual manipulation does, but to our knowledge these concepts have never been evaluated scientifically. We compared these two methods in a prospective, randomized controlled trial.
METHODS: Two hundred and twenty-three patients with 225 displaced Colles-type fractures were randomized to treatment with closed reduction with either finger-trap traction (112 patients) or manual manipulation (111 patients). The fractures were assessed radiographically by measurement of the radial angle, dorsal tilt, and radial shortening before reduction, immediately after reduction, and at one and five weeks after reduction.
RESULTS: The groups were comparable with regard to age, sex, side of injury, fracture grade, and amount of displacement at presentation. No significant differences were found between the alignment of the fractures in the two treatment groups at any time. With dorsal tilt of <10 degrees and radial shortening of <5 mm considered acceptable, the two techniques both produced an 87% rate of satisfactory reductions. However, the percentages of fractures in an acceptable alignment were only 57% and 50% at one week after finger-trap traction and manual manipulation, respectively, and only 27% and 32% at five weeks. The failure rates did not differ significantly between the two groups.
CONCLUSIONS: The two methods of fracture reduction did not differ with regard to the eventual position of the fracture or the rate of failure. Although closed reduction was successful for the majority of fractures, most redisplaced substantially during the period of cast immobilization.
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Effect of sex and age on the ratio of cervical to trochanteric hip fracture. A meta-analysis of 16 reports on 36,451 cases
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Management of Hip Fractures in the Elderly
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We analyzed 15 published reports and our own data. In women, the ratio of cervical to trochanteric fractures (C/T) evolved in 3 periods. 1) Before the age of 50 years, the annual incidence of cervical fracture is close to that of trochanteric fracture. 2) Between 50 and 60 years, cervical fracture increases markedly, and the C/T ratio is well above unity at an age when the fracture incidence is still very low. 3) This imbalance progressively diminishes to reach unity in the very old, as the result of a progressive increase in trochanteric fractures. In men, cervical fractures are progressively more common with increasing age, and the C/T ratio exceeds unity after 70 years of age. In both genders, the incidence of cervical fracture is thus greater than that of trochanteric fracture during a limited period of time, in the perimenopausal period for women and in elderly men. Several hypotheses on the mechanics of falls and bone strength have been advanced, without any satisfactory explanation for the C/T sex and age changes
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New anti-resorptives and antibody mediated anti-resorptive therapy
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MSTS 2018 - Femur Mets and MM
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The ageing population and an increase in both the incidence and prevalence of cancer pose a healthcare challenge, some of which is borne by the orthopaedic community in the form of osteoporotic fractures and metastatic bone disease. In recent years there has been an increasing understanding of the pathways involved in bone metabolism relevant to osteoporosis and metastases in bone. Newer therapies may aid the management of these problems. One group of drugs, the antibody mediated anti-resorptive therapies (AMARTs) use antibodies to block bone resorption pathways. This review seeks to present a synopsis of the guidelines, pharmacology and potential pathophysiology of AMARTs and other new anti-resorptive drugs. We evaluate the literature relating to AMARTs and new anti-resorptives with special attention on those approved for use in clinical practice. Denosumab, a monoclonal antibody against Receptor Activator for Nuclear Factor Kappa-B Ligand. It is the first AMART approved by the National Institute for Health and Clinical Excellence and the US Food and Drug Administration. Other novel anti-resorptives awaiting approval for clinical use include Odanacatib. Denosumab is indicated for the treatment of osteoporosis and prevention of the complications of bone metastases. Recent evidence suggests, however, that denosumab may have an adverse event profile similar to bisphosphonates, including atypical femoral fractures. It is, therefore, essential that orthopaedic surgeons are conversant with these medications and their safe usage.
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Regional anesthesia or patient-controlled analgesia and compartment syndrome in orthopedic surgical procedures: A systematic review
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AAHKS (8) Anesthetic Infiltration
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A systematic review of the literature on the use of regional anesthesia (RA) and patient-controlled analgesia (PCA) was conducted in patients who require orthopedic extremity procedures to determine whether either analgesic technique contributes to a delayed diagnosis of compartment syndrome (CS). A total of 34 relevant articles (28 case reports and six research articles) were identified. Of all case report articles published after 2009, the majority (75%) concluded that RA does not put the patient at an increased risk of a delayed diagnosis of CS. Of these, only two relevant prospective research studies focusing on RA or PCA and their relationship to CS were identified. Neither study resulted in any cases of CS. However, both had relatively small sample sizes. Given the lack of evidence identified in this systematic review, prospective studies or large-scale retrospective data reviews are needed to more strongly advocate the use of one modality of analgesia over the other in this patient population.
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The effect of lumbosacral plexus blocks on the early postoperative cognitive functions
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Surgical Management of Osteoarthritis of the Knee CPG
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Background and aims: Postoperative cognitive dysfunction (POCD) is a fairly common situation especially in elderly patients undergoing major surgery.Whether the effects of anesthesia tecniques on the development of
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Amniotic membrane-derived stem cells help repair osteochondral defect in a weight-bearing area in rabbits
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Upper Eyelid and Brow Surgery
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Our study evaluated the use of amniotic membrane-derived stem cells for repairing osteochondral defects in a weight-bearing area in rabbits. Twenty-four 3-month-old male or female New Zealand white rabbits were selected. The rabbits were randomly divided into 3 groups of eight, according to the treatment received for an experimentally inflicted femoral medial malleolus lesion, group I received a human acellular amniotic membrane seeded with bone marrow-derived mesenchymal stem cells (HAAM-BMSCs) implant; group II received a simple HAAM implant and the control group received no experimental lesion or treatment. The rabbits were sacrificed at 12 and 24 weeks after the procedures (4 rabbits in each time-point) and the cartilage repair status in each animal was evaluated under the microscope. The tissue of the HAAM-BMSCs group grew well covering an area in the visual field that was significantly larger than that of the HAAM group (p<0.05). The percentage of collagen II-positive area in the HAAM-BMSC group was significantly higher than that in HAAM group (p<0.05). The number of chondrocytes determined by toluidine blue staining was higher in the HAAM-BMSC group than that in the HAAM group (p<0.05). The Wakitani scores of the HAAM and HAAM-BMSC groups were significantly higher (worse) than those of the normal control group (p<0.05), but the score in the HAAM-BMSC group was significantly lower than that in the HAAM group (p<0.05). The Wakitani scores in the HAAM-BMSC group were not different between the two time-points taken. Based on our findings, the amniotic membrane-derived stem cells had a good therapeutic effect in repairing the osteochondral defects in the weight-bearing area, and the number of chondrocytes in the injured area was increased significantly, which accelerated the repair of the damaged tissue in rabbits.
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The efficacy and safety of pomalidomide in relapsed/refractory multiple myeloma in a â??real-worldâ?쳌 study: Polish Myeloma Group experience
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MSTS 2018 - Femur Mets and MM
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Background: Patients with relapsed/refractory multiple myeloma (RRMM) have poor prognosis. Pomalidomide is an immunomodulatory compound that has demonstrated activity in MM patients with disease refractory to lenalidomide and bortezomib. Objectives: Participants of clinical trials are highly selected populations; therefore, the aim of this study was to present observations from real practice that might provide important information for practitioners. Patients and Methods: We analyzed retrospectively 50 patients treated with pomalidomide in 12 Polish sites between 2014 and 2017. Median age was 63Â years, median time since diagnosis 4.5Â years and median number of prior regimens 4. Results: The overall response rate was 39.1%. Median progression-free survival (PFS) and overall survival (OS) were 10.0 and 14.0Â months, respectively. Previous treatment with immunomodulatory drugs, bortezomib or stem cell transplant had no impact on PFS and OS. Most frequent grade 3/4 treatment-emergent adverse events were hematologic (neutropenia 24.0%, thrombocytopenia 10.0%, anemia 8.0%). Most common grade 3/4 non-hematologic toxicities were respiratory tract infection (14.0%) and neuropathy (4.0%). Conclusions: This real-world data have confirmed that pomalidomide is an active drug in RRMM and support results of published clinical trials and other real-world studies.
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1 |
Time to reconsider post arthroscopic osteonecrosis of the knee: a systematic review
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AMP (Acute Meniscal Pathology)
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The etiology of post-arthroscopic osteonecrosis of the knee (PAONK) is still unknown. The aims of this systematic review were to analyze the main characteristics of patients who developed osteonecrosis after arthroscopy. We considered for inclusion in the review case reports, case series, retrospective and prospective clinical trial, that involved patients who developed osteonecrosis of the knee within 1 year of arthroscopy for meniscal lesion or anterior cruciate ligament rupture with or without chondropathy. In all cases, there was a pre-operative magnetic resonance imaging that excluded the presence of osteonecrosis. We used the MINORS criteria to estimate the risk of bias. A total of 13 studies that involved 125 patients were included in the review. Only 14 out of 55 patients performed the pre-operative MRI after the "window period", which we considered 6 weeks between the onset of symptoms and positive MRI findings. A diagnosis of PAONK was made for 55 patients within 1 year of surgery. Of these, 29% was treated conservatively, while 71% repeated surgery. Osteonecrosis after knee arthroscopy is a reality and surgeon shouldn't underestimate the persistence or re-emergence of symptoms after arthroscopy. It may be due to subchondral insufficiency fractures in osteopenic bone, without evidence of necrosis. However, there are not elements enough to differentiate clinical and radiological characteristics of PAONK from SPONK. Terminology should be simplified, distinguishing subchondral insufficiency fractures of the knee as a precursor of primary osteonecrosis of the knee.
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Temporary scaphocapitate fixation with or without radial shortening for adolescent Kienbock's disease
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Distal Radius Fractures
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We performed temporary scaphocapitate joint fixation with or without radial shortening osteotomy, depending on the ulnar variance, in adolescent Kienbock's disease. The aim of the current study was to evaluate the radiological and clinical results and compare our results with those of other previously reported methods. Temporary scaphocapitate fixation alone or fixation accompanied by radial shortening osteotomy has been performed in three patients since 2003. All six patients were males, and their mean age at surgery was 15.5 years. The fixation was performed using two Kirschner-wires in closed methods, and the shortening of the radius was performed using the volar approach and secured with a plate. Radial shortenings of 4, 2, and 7 mm were applied. Radiological findings of Kienbock's disease, including ulnar variance and carpal height ratio, were investigated at the final follow-up by simple radiography and MRI. Clinical results of pain, range of wrist motion, and grip strength were also evaluated. The mean age at the final follow-up of six patients was 22 years, and the follow-up period was 6.8 years. Sclerosis or fragmentation of all the lunates in the simple radiographs improved, and the carpal height ratio increased to 0.5 at the final follow-up. The signal intensities on the final MRI were all normalized. The final visual analog scale scores decreased to 1.2, and wrist ranges of motion were all statistically significantly increased. In addition, grip strength increased to 69% of that of the normal side at the final follow-up. We suggest that temporary scaphocapitate joint fixation is a recommendable option with or without radial shortening, depending on the ulnar variance, in adolescent Kienbock's disease.
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Aspiration pneumonia in elderly patients with hip fractures before and after surgery
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Management of Hip Fractures in the Elderly
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Purpose: There have been few reports about dysphagia in elderly patients with hip fractures. This study examined the incidence rate and risk factors of aspiration pneumonia before and after hip surgery. Method(s): The medical records of all patients over 65 years old, who were hospitalized for fall-related hip fractures and subsequently received hip surgery between January 2008 and December 2009, were retrospectively reviewed. Patients were divided into 2 groups according to the presence or absence of aspiration pneumonia from the onset to one month after hip surgery. Demographics, past medical history, X-ray finding, and laboratory values were investigated. Result(s): Of the 145 patients (78 with intertrochanteric fractures and 67 with femoral neck fractures) aged 67-96 years (mean (plus or minus) SD, 82.9 (plus or minus) 7.2 years) in this study, 22 patients (15.2%) suffered aspiration pneumonia. Serum albumin levels in the pneumonia group (3.34 (plus or minus) 0.43) were significantly lower than those in the non-pneumonia group (3.80 (plus or minus) 0.45). The risk factors for developing aspiration pneumonia were albumin, total protein and hemoglobin levels. No significant relationship was observed between aspiration pneumonia and other factors-including age, sex, type of fractures, diabetes mellitus, dementia, psychiatric disorders and previous stroke history. Conclusion: It is expected that early and thorough precautions lessen the risk of aspiration pneumonia. These precautions include oral hygiene, indirect swallowing training and modifying the diet for dysphagic patients. Furthermore, nutritional support should be given to elderly patients with hip fractures
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Relations between upper limb soft tissue disorders and repetitive movements at work
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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To make a preliminary assessment of whether upper limb soft tissue disorders might be associated with activities at work, we have conducted a case-control study of subjects attending orthopedic clinics in three cities. All subjects between the ages of 16 and 65 years, in whom defined soft tissue conditions of the upper limb were diagnosed by the participating orthopedic surgeons, were invited to take part. Controls were subjects attending the same clinics within the same age range whose clinical diagnosis did not include disease of the upper limb, cervical or thoracic spine. Information concerning repetitive movements of the upper limbs at work was elicited by questionnaire. Five hundred eighty cases and 996 controls were studied, representing 96% and 93%, respectively, of those invited to participate. The diagnoses of the cases included soft tissue conditions affecting the shoulder, elbow, forearm, wrist, thumb, hand, and fingers. The diagnoses of the controls included traumatic, degenerative, and inflammatory conditions, mostly of the legs and lower back. Women predominated among the cases (70%) and men among the controls (56%). Of 221 female cases with injury to the wrist and forearm, 32 were cleaner/domestics (14.5%) compared to 35 to 439 controls (8%), a difference statistically significant at the 2 1/2% level. Other jobs significantly overrepresented (5% level) among female cases with injuries at various anatomical sites included hairdressers, secretary/temps, assembly line workers, and machine operators (type unspecified). Among male cases, electricians were significantly overrepresented (5% level). Jobs for which there was a suggestion (p < 0.1) of overrepresentation among cases included butchers and teacher/lecturers (both males only) and the combined job groups (chosen a priori for analysis) of keyboard operators, machine operators, and music teachers (all three jobs, females only)
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1 |
Carpal and Guyon tunnel syndrome in burns at the wrist
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A series of 22 patients with burns of the upper extremities have been evaluated by clinical and electromyographic (EMG) studies. As suggested by others, a significantly higher incidence of carpal tunnel syndrome and sensory involvement of the ulnar nerve was discovered. Those findings suggest that we pay more attention to the median and ulnar nerves at the wrist level in burns and treat them when compression is demonstrated by clinical and EMG evaluation
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Long PHILOS plate fixation in a series of humeral fractures
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Distal Radius Fractures
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AIM: The purpose of the article is to highlight a specific fracture pattern encountered by us in the osteoporotic upper humerus. We present our results of management of such metadiaphyseal fractures of the upper humerus with less invasive plating. The additional steps taken to improve final outcome and the reasoning behind each are discussed.
PATIENTS AND METHODS: In our department, a total of 13 fractures (in 12 patients) were managed for a metadiaphyseal fracture of the upper humerus between 2010 and 2013. There were 2 males and 10 females. The average age in the cohort was 74.3 (52-95) years. In 9 fractures, the fracture line was extending above the surgical neck. All patients were managed with a locking compression plate (long PHILOS or LCP) using two approach windows (proximal deltopectoral and a distal anterior or lateral). Patients were evaluated for clinical outcome using the Quick DASH score and assessed for radiological union, complications or re-operations retrospectively.
RESULTS: The mean follow-up was 14.3 months (4-36). All fractures were united, and there was no evidence of avascular necrosis or non-union. Two patients showed varus collapse of the anatomical head of which one patient needed change of screws at 12 weeks from index surgery. In patients, when a distal lateral window was used, 2 patients out of 4 had radial nerve palsy post-operatively. In the rest, when the plate was twisted by 45degree to allow anterior placement using the brachialis split, none had radial nerve injury.
CONCLUSION: The osteoporotic bone failing under a low-energy mechanism seemed to dictate this fracture pattern. The fracture is either a bending wedge or a long spiral with or without a large butterfly and often extends into the humeral head. The fractures are better managed surgically, a primary reduction allowing contact of fragments is essential, and using an anterior window distally with a 45degree contoured plate will achieve good plate placement as well as decreases the risk of radial nerve injury considerably compared to total lateral plate positioning.
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Cellular mediators secreted by interfacial membranes obtained at revision total hip arthroplasty
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Management of Hip Fractures in the Elderly
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The interfacial membrane between implant and host-bone in aseptically loose total hip arthroplasties has a potential role in the etiology of local bone resorption and loosening of the prosthetic component. Inflammatory/potential "bone-resorbing" agents (cytokines/mediators) released by the cells of the interfacial membranes of loosened uncemented and cemented total hip arthroplasties were measured. Synovial tissues from patients with acute femoral neck fractures, patients with osteoarthritis, and cadavers without joint disorders were used as control subjects. Control synovial tissue from osteoarthritic patients secreted the highest levels of prostaglandin E2, interleukin-8, and tumor necrosis factor alpha. Interleukin-1 alpha was the only cytokine whose levels were elevated as much as 4-fold around uncemented implants compared with cemented implants, and up to 16-fold compared with control synovial tissue. An apparent inverse relation between interleukin-1 alpha and interleukin-6 interfacial membranes of total hip arthroplasties compared with control synovial tissues suggests a complex cellular mechanism through a cytokine/prostaglandin cascade; this may regulate the observed bone resorption in aseptic loosening
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Traumatic radial head dislocation in a child with no other associated dislocation/fracture
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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We present a case report of a 5-year-old girl who presented with a traumatic isolated anteromedial dislocation of her left radial head, without any associated fractures or dislocations in the ipsilateral limb. This is a rare elbow injury and a condition that is easily missed on initial presentation. (copyright) Springer-Verlag 2005
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The usefulness of dual energy X-ray and laser absorptiometry of the calcaneus versus dual energy X-ray absorptiometry of hip and spine in diagnosing manifest osteoporosis
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Management of Hip Fractures in the Elderly
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INTRODUCTION: Osteoporosis is a major health problem. Dual energy X-ray absorptiometry (DXA) of the hip and spine is the worldwide standard in diagnosing osteoporosis. Measurement of bone mineral density (BMD) with dual energy X-ray and laser absorptiometry of the calcaneus (Calscan) might be a good alternative. Advantages of the Calscan are that it is quick, widely available and manageable. In this study we compared BMD expressed in T-scores measured by DXA and Calscan. The aim of this study was to define threshold T-scores on the Calscan that could exclude or predict osteoporosis correctly in comparison with DXA. MATERIALS AND METHODS: Patients > or =50 years attending our emergency department with a fracture were offered osteoporosis screening at our fracture and osteoporosis outpatient clinic (FO-Clinic) and enrolled in this study. BMD was measured at the hip and spine using DXA and at the calcaneus using Calscan. A T-score measured by DXA < or =-2 standard deviations (SD) below the reference population was defined as manifest osteoporosis and was the treatment threshold. RESULTS: During a 10-month study period, 182 patients were screened with both devices. The mean DXA-T-score was -1.63 SD (range -4.9 to 2.1) and Calscan T-score -1.91 SD (range -5.3 to 1.4). There was a significant correlation between both devices (r = 0.47, P < 0.01). Using an upper threshold for the Calscan T-score of -1.3 SD, 47 patients could be classified as non-osteoporotic with 89.3% sensitivity (95% CI 80.0-95.3%). Using a lower threshold for the Calscan T-score of -2.9 SD, 34 patients could be classified by the Calscan as osteoporotic with 90.7% specificity (95% CI 83.5-95.4). The remaining 101 patients could only be correctly classified by DXA-T-scores. CONCLUSION: Although DXA is the established modality worldwide in measuring BMD it is restricted to specialized centres. Peripheral bone densitometers like the Calscan are widely available. When BMD measurements with DXA were compared to Calscan measurements it was possible to correctly classify 81 of 182 patients based on the Calscan T-score. Of these 81 patients 34 could be classified as manifest osteoporotic and 47 as non-osteoporotic. Therefore the Calscan seems to be a promising technique which might be used as a screening device at a FO-Clinic, especially when DXA is not easily available
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Sonography of the rotator cuff of the shoulder
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Glenohumeral Joint OA
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A standardized program for ultrasound examination of the rotator cuff is described in details, the results are presented and the advantages of the method are pointed out. From 1986 to 1999 in the First Clinic of Orthopedics and Traumatology - Pleven, 476 shoulders with degenerative or posttraumatic injuries of the so-called "third shoulder joint" were examined. Cuff-scanning was performed on Picker LS2400 and Siemens SI machines with linear transducers 5.0, 7.5 and 10Mhz in real time. Patient's age ranged from 18 to 74 years with an average age 58,9 years. Ultrasound findings for the rotator cuff were classified according to formal criteria (thinning or disappearing of the cuff); structural changes (diminished ecogenicity, hyperechogenic areas or mixed picture with or without visible interrupting of the cuff contour); dynamic changes. For the diagnosis "defect", "rotator cuff tear" respectively, two-criterion model was applied. One of the formal criteria - the step-like deforming of the border area of the rotator cuff near to sub-acromial bursa we observed to be a sure sign for defect in the cuff. The interruption of the contour borderline was an indication exclisively for partial tear of the cuff in the area towards the bursa. Thinning and narrowing of the cuff was observed in partial as well as in fullthickness lesions. Direct location of the deltoid muscle over the humeral head, popular as "balding" of the head, was a sign of full thickness tear of the cuff. Structural changes was observed as both hypoechogenic and hyperechogenic areas in 76% of the shoulders examined. The hyperechogenic zones were signs mostly of calcification in the cuff and rarely sign of a lesion. Foci with diminished echogenicity were exclusive indication for a cuff tear. Changes in the long belly of the biceps muscle (thickening and most rarely thinning or absence) was found in more than 42% of the shoulders examined. Subluxation of the tendon toward tuberculum minus was found in only few cases and that was a proof for a lesion in the so-called "rotator interval".
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Trabecular bone microstructure is impaired in the proximal femur of human immunodeficiency virus-infected men with normal bone mineral density
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Distal Radius Fractures
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Background: There is evidence that human immunodeficiency virus (HIV) infection and antiretroviral therapy (ART) are independent risk factors for osteoporosis and fracture which is not solely explained by changes in bone mineral density. Thus, we hypothesized that the assessment of trabecular microstructure might play an important role for bone quality in this population and might explain the increased fracture risk. In this study, we have assessed bone microstructure in the proximal femur using high-resolution magnetic resonance imaging (MRI) as well as in the extremities using high resolution peripheral quantitative computed tomography (HR-pQCT) in HIV-infected men and healthy controls and compared these findings to those based on areal bone mineral density (aBMD) derived from dual X-ray absorptiometry (DXA) which is the standard clinical parameter for the diagnosis of osteoporosis.
Methods: Eight HIV-infected men and 11 healthy age-matched controls were recruited and informed consent was obtained before each scan. High-resolution MRI of the proximal femur was performed using fully balanced steady state free precession (bSSFP) on a 3T system. Three volumes of interest at corresponding anatomic locations across all subjects were defined based on registrations of a common template. Four MR-based trabecular microstructural parameters were analyzed at each region: fuzzy bone volume fraction (f-BVF), trabecular number (Tb.N), thickness (Tb.Th), and spacing (Tb.Sp). In addition, the distal radius and distal tibia were imaged with HR-pQCT. Four HR-pQCT-based microstructural parameters were analyzed: trabecular bone volume fraction (BV/TV), Tb.N, Tb.Th, and Tb.Sp. Total hip and spine aBMD were determined from DXA.
Results: Microstructural bone parameters derived from MRI at the proximal femur and from HR-pQCT at the distal tibia showed significantly lower bone quality in HIV-infected patients compared to healthy controls. In contrast, DXA aBMD data showed no significant differences between HIV-infected patients and healthy controls.
Conclusions: Our results suggest that high-resolution imaging is a powerful tool to assess trabecular bone microstructure and can be used to assess bone health in HIV-infected men who show no differences to healthy males by DXA aBMD. Advances in MRI technology have made microstructural imaging at the proximal femur possible. Further studies in larger patient cohorts are clearly warranted.
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Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures
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Pediatric Supracondylar Humerus Fracture 2020 Review
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There is an increasing interest in intramedullary nailing for humeral fractures. Starting with diaphyseal fractures, now also proximal metaphyseal fractures of the humerus can be nailed with satisfying results. Basic ideas for humeral nailing are less invasive approaches to the humerus, less soft tissue damage, e.g. lower rates of radial nerve palsy, closed reduction and the biomechanical aspects of a central implant with elastic fixation properties. Nailing of diaphyseal humeral shaft fractures is an equivalent alternative to plating; nailing of proximal metaphyseal humeral fractures is still new and needs more reliable scientific data to clear its advantages compared to other fixation techniques. Nailing of distal metaphyseal humeral fractures is no serious option at the moment. Angular stable interlocking systems show better fixation qualities for proximal fractures or fracture components. Although in very osteoporotic bone cutouts are registered. Static interlocking is advisable. High torsional stability of the fracture fixation has to be achieved, since significant torsional load occurs during the usual movement of the upper limbs. As there is an important learning curve, possible complications of intramedullary nailing have to be kept in mind and avoided by a careful operation technique.
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1 |
Proprioception after knee arthroplasty. The influence of prosthetic design
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Surgical Management of Osteoarthritis of the Knee CPG
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It is recognized that awareness of joint position in the knee deteriorates because of aging, anterior cruciate injury, or osteoarthrosis. Proprioception was studied in osteoarthritic and prosthetic knees, including both posterior cruciate ligament (PCL)-retaining and PCL-sacrificing designs. An improvement in proprioception was observed after knee arthroplasty. A PCL-retaining prosthesis was found to confer a greater improvement than a PCL-sacrificing design
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Small-dose intrathecal clonidine and isobaric bupivacaine for orthopedic surgery: a dose-response study
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Surgical Management of Osteoarthritis of the Knee CPG
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We examined the dose-response relationship of intrathecal clonidine at small doses (<or=150 microg) with respect to prolonging bupivacaine spinal anesthesia. We aimed for establishing doses of intrathecal clonidine that would produce clinically relevant prolongation of spinal anesthesia and pain relief without significant side effects. Eighty orthopedic patients were randomly assigned to intrathecally receive isobaric 0.5% bupivacaine, 18 mg, plus saline (Group 1), clonidine 37.5 microg (Group 2), clonidine 75 microg (Group 3), and clonidine 150 microg (Group 4). Duration of the sensory block (regression below level L1) was increased in patients receiving intrathecal clonidine: 288 +/- 62 min (Group 1, control), 311 +/- 101 min in Group 2 (+8%), 325 +/- 69 min in Group 3 (+13%), and 337 +/- 78 min in Group 4 (+17%) (estimated parameter for dose 0.23 [95% confidence interval -0.05-0.50]). Duration of pain relief from intrathecal clonidine administration until the first request for supplemental analgesia was significantly prolonged: 295 +/- 80 min (Group 1, control), 343 +/- 75 min in Group 2 (+16%), 381 +/- 117 min in Group 3 (+29%), and 445 +/- 136 min in Group 4 (+51%) (estimated parameter for dose 1.02 [95% confidence interval 0.59-1.45]). Relative hemodynamic stability was maintained and there were no between-group differences in the sedation score. We conclude that small doses of intrathecal clonidine (<or=150 microg) significantly prolong the anesthetic and analgesic effects of bupivacaine in a dose-dependent manner and that 150 microg of clonidine seems to be the preferred dose, in terms of effect versus unwarranted side effects, when prolongation of spinal anesthesia is desired
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Three trajectories of activity limitations in early symptomatic knee osteoarthritis: a 5-year follow-up study
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: Knee osteoarthritis (OA) is a leading cause of activity limitations. The knee OA population is likely to consist of subgroups. The aim of the present study was to identify homogeneous subgroups with distinct trajectories of activity limitations in patients with early symptomatic knee OA and to describe characteristics of these subgroups.
METHODS: Follow-up data over a period of 5 years of 697 participants with early symptomatic knee OA from the Cohort Hip and Cohort Knee (CHECK) were used. Activity limitations were measured yearly with the Western Ontario and McMaster Universities Osteoarthritis Index. Latent class growth analyses identified homogeneous subgroups with distinct trajectories of activity limitations. Multivariable regression analyses examined differences in characteristics between the subgroups.
RESULTS: Three subgroups were identified. Participants in Subgroup 1 ('good outcome'; n=330) developed or displayed slight activity limitations over time. Participants in Subgroup 2 ('moderate outcome'; n=257) developed or displayed moderate activity limitations over time. Participants in subgroup 3 ('poor outcome'; n=110) developed or displayed severe activity limitations over time. Compared with the 'good outcome' subgroup, the 'moderate outcome' and 'poor outcome' subgroups were characterised by: younger age, higher body mass index, greater pain, bony tenderness, reduced knee flexion, hip pain, osteophytosis, >=3 comorbidities, lower vitality or avoidance of activities.
CONCLUSIONS: Based on the 5-year course of activity limitations, we identified homogeneous subgroups of knee OA patients with good, moderate or poor outcome. Characteristics of these subgroups were consistent with existing knowledge on prognostic factors regarding activity limitations, which supports the validity of this classification.
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The biology of mesenchymal stem/stromal cells in the treatment of osteoarthritis
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AMP (Acute Meniscal Pathology)
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Introduction: Osteoarthritis affects the whole joint and is usually treated using pain relief for many years followed by arthroplasty. Mesenchymal stem/stromal cells have the potential to form cartilage and bone and have been investigated for their capacity to repair these tissues, but until recently there has been no strong rationale for their use in the treatment of age-related, idiopathic osteoarthritis. Objectives: The aim of this review is to explore the origins of cell therapy for joint diseases and how the early work in cartilage repair has built toward the possibility of an injectable mesenchymal cell approach for osteoarthritis. Methods: A broad selection of publications has been identified relating to cartilage repair, mesenchymal cell biology, meniscal cartilage repair, and osteoarthritis therapeutics. Primary studies as well as several systematic reviews and meta-analyses have been included. Results: Cell therapies for cartilage lesions have been shown to be successful for traumatic injury but will be difficult to adapt for the treatment of idiopathic osteoarthritis. However the biological understanding of mesenchymal cells as a reservoir for trophic factors has led to their use as an injectable therapy. These studies have provided good evidence that sustained pain reduction can be achieved by injecting mesenchymal cells into the osteoarthritic joint, with some evidence also for functional improvement. Exosomes derived from mesenchymal may provide a scalable alternative to the cell therapy approach in future. Conclusions: Mesenchymal cells have potential as a possible injectable cell therapy for idiopathic osteoarthritis and should be further explored through larger-scale, carefully designed clinical trials.
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WHO/ILO work-related burden of disease and injury: Protocol for systematic reviews of exposure to occupational ergonomic risk factors and of the effect of exposure to occupational ergonomic risk factors on osteoarthritis of hip or knee and selected other musculoskeletal diseases
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Glenohumeral Joint OA
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BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing a joint methodology for estimating the national and global work-related burden of disease and injury (WHO/ILO joint methodology), with contributions from a large network of experts. In this paper, we present the protocol for two systematic reviews of parameters for estimating the number of disability-adjusted life years from osteoarthritis of hip or knee, and selected other musculoskeletal diseases respectively, attributable to exposure to occupational ergonomic risk factors to inform the development of the WHO/ILO joint methodology.
OBJECTIVES: We aim to systematically review studies on exposure to occupational ergonomic risk factors (Systematic Review 1) and systematically review and meta-analyze estimates of the effect of exposure to occupational ergonomic risk factors on osteoarthritis of the hip or knee, and selected other musculoskeletal diseases respectively (Systematic Review 2), applying the Navigation Guide systematic review methodology as an organizing framework, conducting both systematic reviews in tandem and in a harmonized way.
DATA SOURCES: Separately for Systematic Reviews 1 and 2, we will search electronic academic databases for potentially relevant records from published and unpublished studies, including Medline, EMBASE, Web of Science and CISDOC. We will also search electronic grey literature databases, Internet search engines and organizational websites; hand-search reference lists of previous systematic reviews and included study records; and consult additional experts.
STUDY ELIGIBILITY AND CRITERIA: We will include working-age (>=15years) workers in the formal and informal economy in any WHO and/or ILO Member State, but exclude children (<15years) and unpaid domestic workers. The included occupational ergonomic risk factors will be any exposure to one or more of: force exertion; demanding posture; repetitiveness; hand-arm vibration; lifting; kneeling and/or squatting; and climbing. Included outcomes will be (i) osteoarthritis and (ii) other musculoskeletal diseases (i.e., one or more of: rotator cuff syndrome; bicipital tendinitis; calcific tendinitis; shoulder impingement; bursitis shoulder; epicondylitis medialis; epicondylitis lateralis; bursitis elbow; bursitis hip; chondromalacia patellae; meniscus disorders; and/or bursitis knee). For Systematic Review 1, we will include quantitative prevalence studies of any exposure to occupational ergonomic risk factors stratified by country, gender, age and industrial sector or occupation. For Systematic Review 2, we will include randomized controlled trials, cohort studies, case-control-studies and other non-randomized intervention studies with an estimate of the relative effect of any exposure with occupational ergonomic risk factors on the prevalence or incidence of osteoarthritis and/or selected musculoskeletal diseases, compared with the theoretical minimum risk exposure level (i.e., no exposure).
STUDY APPRAISAL AND SYNTHESIS METHODS: At least two review authors will independently screen titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. At least two review authors will assess risk of bias and the quality of evidence, using the most suited tools currently available. For Systematic Review 2, if feasible, we will combine relative risks using meta-analysis. We will report results using the guidelines for accurate and transparent health estimates reporting (GATHER) for Systematic Review 1 and the preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA) for Systematic Review 2. PROSPERO registration number: CRD42018102631.
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Past and recent physical activity and risk of hip fracture
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Management of Hip Fractures in the Elderly
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A population-based case-control study was conducted to examine the effects of past and recent physical activity on the risk of hip fracture in women. Cases included females aged 55-84 years with a first diagnosis of hip fracture in 1989 in metropolitan Toronto, Canada. Controls were a population-based random sample frequency matched by 5-year age groups. Data were collected on 381 cases and 1,138 controls by self-administered mailed questionnaires or telephone interviews. Past activity was calculated as a compilation of activity scores at ages 16, 30, and 50 years. Recent activity was defined as activity in the past year for controls and activity in the year before fracture for cases. Multiple logistic regression was used to control for age, previous fracture, obesity, smoking, osteoporosis, epilepsy, stroke or Parkinson's disease, daily intake of dietary calcium, and duration of use of supplemental calcium, fluoride, and estrogen. After recent activity was adjusted for, statistically significant effects were found for women who in the past had been active (odds ratio estimate (OR) = 0.66, 95% confidence interval (CI) 0.45-0.96) or very active (OR = 0.54, 95% CI 0.33-0.88). After past activity was adjusted for, a similar protective effect was found for women who were moderately active recently (OR = 0.61, 95% CI 0.41-0.90), but women who were very active recently were not protected from hip fracture (OR = 1.15, 95% CI 0.72-1.83). This study showed evidence of independent protective effects of past physical activity and of moderate levels of recent physical activity on the risk of hip fracture in postmenopausal women
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The lived experience of working in a mortuary
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DoD PRF (Psychosocial RF)
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A four year action research study was undertaken in an attempt to foster change in the current management of sudden deaths in the Accident and Emergency Departments in South Africa. During the phase of interviewing bereaved families and health professionals it became apparent that there was a need to involve mortuary staff as victims of sudden deaths have to undergo an autopsy. The researcher chose an interpretive hermeneutic phenomenological research approach to explore the lived experience of working in a mortuary. The mortuary is a place of mystery, sadness, grief or repulsion and we all hope, while we are alive, we will never need to visit. For families who have lost a loved one to a sudden death, this becomes a reality. Working in a mortuary is an extremely stressful experience which is made worse in South Africa due to the large number of people dying sudden violent deaths due to trauma. The themes which emerged from the interviews with mortuary staff were; secondary trauma for families, delays by health professionals and dehumanised mortuary staff. There is a need for a change in the way bereaved families are being managed as well as revision of the environment for the staff working in mortuaries.
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ISBI Practice Guidelines for Burn Care
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DOD - Acute Comp Syndrome CPG
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>Practice guidelines (PGs) are recommendations for diagnosis and treatment of diseases and injuries, and are designed to define optimal evaluation and management. The first PGs for burn care addressed the issues encountered in developed countries, lacking consideration for circumstances in resource-limited settings (RLS). Thus, the mission of the 2014â??2016 committee established by the International Society for Burn Injury (ISBI) was to create PGs for burn care to improve the care of burn patients in both RLS and resource-abundant settings. An important component of this effort is to communicate a consensus opinion on recommendations for burn care for different aspects of burn management. An additional goal is to reduce costs by outlining effective and efficient recommendations for management of medical problems specific to burn care. These recommendations are supported by the best research evidence, as well as by expert opinion. Although our vision was the creation of clinical guidelines that could be applicable in RLS, the ISBI PGs for Burn Care have been written to address the needs of burn specialists everywhere in the world.
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The Clinical Value of Diffusion Weighted Magnetic Resonance Imaging in Diabetic Foot Infection
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Osteomyelitis is a common complication in the diabetic foot which can be concluded with amputation. The purpose of this study was to evaluate the role of diffusion-weighted MRI (DWI) in the diagnosis of osteomyelitis in the diabetic foot ulcer (DFU). METHODS: Thirty patients with type 2 diabetes mellitus having DFU were enrolled. DWI and conventional MRI were obtained. Apparent Diffusion Coefficient (ADC) measurements were made by transferring the images to the workstation. The measurements were made from a total of three points of the osteomyelitis or nearest bone to injury area and adjacent soft tissue. RESULTS: Our patients comprised 9 (30%) females and 21 (70%) males of mean age 58.7 years (range, 41-78 years). The levels of ADC were significantly low and ESR were significantly high in group 1 (patients with osteomyelitis; n=9) when compared to the group 2 (patients without osteomyelitis; n=11) (p=0.022 and p=0.014, respectively). Mean bone ADC value was statistically lower than adjacent soft tissue ADC value in group 1 (0.75+/-0.16 x 10-3 mm2/s and 0.90+/-0.15 x 10-3 mm2/s, respectively; p=0.04). CONCLUSION: It is suggested that DWI contributes to conventional MRI with short imaging time and no requirement of contrast agent. Therefore, DWI may be an alternative diagnostic method for evaluation of DFU and detection of osteomyelitis.
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The distribution of occupations in two populations with upper limb pain
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Occupations of two geographically distinct populations of patients with upper limb pain were examined. Relative risks for being in an occupation were calculated for subjects with epicondylitis, carpal tunnel syndrome, and pain syndromes in one population and nonspecific occupational overuse syndrome (OOS) in the other. Population A subjects (806 female, 154 male Auckland clinic referrals) with epicondylitis and carpal tunnel syndrome had higher rates of manual occupations compared with the Auckland employed population, consistent with previous research. Both Population A and Population B subjects (1,188 female, 499 male national notifications to the Department of Labour) with pain syndrome or nonspecific OOS had increased rates of clerical occupations. Relative risks ranged from 2.24 (95% CI 1.69,2.97) to 3.92 (3.50 ,4.40). Word processor operators, data-entry operators, and mail sorters were overrepresented in both populations. An unexplained association between nonspecific upper arm pain and being in some clerical occupations requires further research
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Hip fracture incidence before and after the fluoridation of the public water supply, Rochester, Minnesota
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Management of Hip Fractures in the Elderly
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Recent ecological comparison studies have suggested a positive association between fluoridation and hip fracture. Using data from the Rochester Epidemiology Project, we found the incidence of hip fracture for the 10 years before the fluoridation of the Rochester, Minn, public water supply was 484 per 100,000, compared with 450 per 100,000 in the following 10 years. When the effects of calendar time and age were controlled for, the relative risk associated with fluoridation was 0.63. These ecologic trend data suggest that the fluoridation of public water supplies is not associated with an immediate increase in rates of hip fracture. Further studies of this association at the individual level are clearly required before public policy decisions can be made
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Fast and easy preoperative estimation of cancellous bone mineral density in patients with proximal femur fractures
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Hip Fx in the Elderly 2019
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INTRODUCTION: Postoperative complications after hip fractures in osteoporotic bone such as implant cutout can be reduced by the use of specially designed implants or additional cement augmentation. It is not yet clear at which degree of osteoporosis, patients will profit from implant augmentation or specially designed implants for geriatric patients. As the surgeon ideally should obtain information on local bone quality at the site of implant anchorage already preoperatively, the aim of the study was to develop an easily applicable radiographic method to estimate bone quality in those patients.
MATERIALS AND METHODS: 75 patients with unilateral hip fracture were included. Preoperatively, a CT scan with a calibration device was conducted. Postoperatively, DXA scans were performed. The proposed method measures local cancellous bone mineral density in the contralateral and uninjured femoral head. As a control, 15 young and healthy non-osteoporotic subjects were included. Inter- and intraobserver reliability was investigated for a subgroup of 20 patients.
RESULTS: Study group patients had a mean BMD measured by CT scans of 194.2 mg/cm(3) (SD 40.4). There was a statistically significant correlation with data from DXA scans (r = 0.706, p < 0.001). The control group was significantly younger and showed a significantly higher BMD when compared to the study group (p < 0.001). Reliability evaluation showed no statistically significant difference in inter- and intraobserver measurements. Interclass correlation proved to be very high.
CONCLUSION: The proposed method is an easily applicable, reliable and useful tool to estimate bone quality preoperatively using the contralateral hip as a reference. Obtained data may facilitate the decision-making towards the use of further therapeutic measures to improve implant anchorage in osteoporotic bone such as bone cement augmentation. Thus, our method allows for a more individualized surgical treatment of hip fracture patients adapted to the estimated cancellous bone quality of the patient.
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Effect of New York State regulatory action on benzodiazepine prescribing and hip fracture rates
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Management of Hip Fractures in the Elderly
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BACKGROUND: Medicare Part D excludes benzodiazepines from coverage, and numerous state government policies limit use of benzodiazepines. No data indicate that such policies have decreased the incidence of hip fracture. OBJECTIVE: To assess whether a statewide policy that decreased the use of benzodiazepines among elderly persons by more than 50% has decreased the incidence of hip fracture. DESIGN: A quasi-experiment comparing changes in outcomes before and after a policy change in a study U.S. state (New York) and a control state (New Jersey). SETTING: Two U.S. state Medicaid programs, 1988-1990. PATIENTS: Medicaid enrollees in New York (n = 51 529) and New Jersey (n = 42 029) who received or did not receive a benzodiazepine. MEASUREMENTS: Benzodiazepine prescribing and hazard ratios for hip fracture, adjusted for age and eligibility category. INTERVENTION: A statewide policy, implemented in New York in 1989, that required triplicate forms for benzodiazepine prescribing to allow surveillance by health authorities. RESULTS: The triplicate prescription policy immediately resulted in a 60.3% (95% CI, -66.3% to -54.2%) reduction in benzodiazepine use among women and 58.5% (-64.3% to -52.8%) among men. Benzodiazepine use in New Jersey remained stable. Hazard ratios for hip fracture that were adjusted for age and eligibility category did not change in New York or New Jersey when the periods before and after use of the triplicate prescription policy were compared (change from 1.2 to 1.1 among female benzodiazepine recipients [P = 0.70], 1.3 to 1.1 [P = 0.08] among female nonrecipients, 0.8 to 1.1 [P = 0.56] among male recipients, and 1.1 to 1.3 [P = 0.46] among male nonrecipients). LIMITATIONS: Information was lacking on race, benzodiazepine dose, and other potential determinants of continued benzodiazepine prescribing. CONCLUSIONS: Policies that lead to substantial reductions in the use of benzodiazepines among elderly persons do not necessarily lead to decreased incidence of hip fracture. Limitations on coverage of benzodiazepines under Medicare Part D may not achieve this widely assumed clinical benefit
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Prostate cancer
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MSTS 2018 - Femur Mets and MM
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Prostate cancer is the second commonest cause of death from malignancy amongst men in the Western world. Whilst screening for prostate cancer could reduce this mortality rate, it is controversial as most screen-detected cancers are low risk and many more men require treatment than lives saved. Current evidence suggests screening in men with little co-morbidity is beneficial if treatment is stratified to the extent and risk of the detected disease. Treatment should be aimed at disease stage and risk of metastases, and be balanced against the patient's co-morbidities. Observational protocols (such as 'active surveillance') should be used for men with low-risk locally confined tumours or significant co-morbidity. Radical treatments (such as radical prostatectomy or radiotherapy) should be used in men with intermediate or high-risk disease that is either confined within the prostate or at risk of local invasion/spread within the pelvis (locally advanced). Less morbid approaches are being developed for locally confined tumours. These include radiotherapy through seed implants (brachytherapy) and targeted focal therapy to obliterate regions of the prostate (delivered using high-intensity focussed ultrasound, cryotherapy or photo-thermal (Tookad) energy). These approaches are less radical and so are likely to have lower cure rates and less side effects than radical treatments. In high-volume, poorly differentiated or locally advanced tumours, it is likely that multimodal treatments are needed to obtain the highest rates of disease cure or control. Current combinations include radical surgery followed by adjuvant radiotherapy or neo-adjuvant androgen deprivation treatment (ADT) before radical radiotherapy. Ongoing trials are evaluating the benefit of adding chemotherapy and other agents to these combinational regimens. Metastatic prostate cancer is initially treated with ADT in the form of surgical or medical castration. The latter may be continuous or intermittent. Almost all men with ADT-treated metastatic prostate cancer will develop castrate-resistant disease, if they live long enough. There are now many options for the treatment of castrate-resistant prostate cancer, including first- and second-line chemotherapy, immunotherapy (sipuleucel-T), further anti-androgens (abiraterone acetate and enzalutamide) and specific bone-targeted treatments. It is likely that there will be more treatment options for advanced prostate cancer over the next few years. © 2013 Published by Elsevier Ltd.
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The clinical relevance and management of monoclonal gammopathy of undetermined significance and related disorders: Recommendations from the European Myeloma Network
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MSTS 2018 - Femur Mets and MM
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Monoclonal gammopathy of undetermined significance is one of the most common pre-malignant disorders. IgG and IgA monoclonal gammopathy of undetermined significance are precursor conditions of multiple myeloma; lightchain monoclonal gammopathy of undetermined significance of light-chain multiple myeloma; and IgM monoclonal gammopathy of undetermined significance of Waldenström's macroglobulinemia and other lymphoproliferative disorders. Clonal burden, as determined by bone marrow plasma cell percentage or M-protein level, as well as biological characteristics, including heavy chain isotype and light chain production, are helpful in predicting risk of progression of monoclonal gammopathy of undetermined significance to symptomatic disease. Furthermore, alterations in the bone marrow microenvironment of monoclonal gammopathy of undetermined significance patients result in an increased risk of venous and arterial thrombosis, infections, osteoporosis, and bone fractures. In addition, the small clone may occasionally be responsible for severe organ damage through the production of a monoclonal protein that has autoantibody activity or deposits in tissues. These disorders are rare and often require therapy directed at eradication of the underlying plasma cell or lymphoplasmacytic clone. In this review, we provide an overview of the clinical relevance of monoclonal gammopathy of undetermined significance. We also give general recommendations of how to diagnose and manage patients with monoclonal gammopathy of undetermined significance. © 2014 Ferrata Storti Foundation.
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No clinically meaningful weight changes in a young cohort following total joint arthroplasty at 3-year follow-up
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Total joint arthroplasty (TJA) is one of the most successful operations. There is little in the literature regarding weight change following TJA, particularly in a young cohort.
METHODS: Retrospective analysis of 181 primary total hip arthroplasty (THA) and 185 primary total knee arthroplasty (TKA) patients was conducted. We reviewed preoperative and post-operative weights and post-operative body mass index at 3 and 6 months, 1 year, 2 and 3 years. We evaluated expected versus actual weight gain, and performed subgroup analyses of obese versus non-obese patients and active duty versus civilian patients. We used a minimal clinically meaningful weight change from baseline of >=5%.
RESULTS: One hundred and fifty-one (41.3%) patients were active duty military service members with the mean age of 53 +/- 11.1 years. In TKA patients, statistically significant differences were found in mean weights at 3 months (-1.8%, P <= 0.0001) and 2 years (+1.9%, P = 0.0006). In THA patients, statistically significant weight gains were found at 6 months (+1.1%, P = 0.006). For obese TKA patients, significant weight changes were observed at 3 months (-2.5%, P <= 0.0001), and none in the obese THA group. There were no statistical or clinically meaningful weight changes in the non-obese TKA or THA groups. There was a clinically meaningful weight gain in active duty TKA patients at 3 years (5.18%, P = 0.17).
CONCLUSION: Despite a theoretical ability to lose weight following TJA, patients maintain their preoperative weight following TJA. We found a clinically meaningful weight gain at 3 years post-operatively only in active duty TKA patients. Overall, however, we found no clinically significant weight changes following TJA at 3-year follow-up.
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0 |
Osteonecrosis of the jaws in patients treated with intravenous bisphosphonates (BRONJ): A concise update
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MSTS 2018 - Femur Mets and MM
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Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a severe complication seen most frequently in patients on intravenous bisphosphonates treatment for malignant diseases. High potency bisphosphonates are generally implicated and risk factors also include dental extractions. Prevention is of paramount importance. Management is controversial but there is little evidence basis and the consensus is to be conservative. Recent advances in this area are summarised in this concise review. [References: 43]
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1 |
Patient satisfaction with two different methods of umbilicoplasty
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Creating a youthful appearing umbilicus as part of an abdominoplasty enhances the overall result. Various different methods have been reported as producing equally good results. METHODS: Twenty-five patients undergoing abdominoplasty were divided into two groups: 12 patients had round umbilicoplasty and 13 had an inverted U flap inset. Three independent surgeons assessed the aesthetic outcome of the two different techniques in specially designed clinics by using four-point ordinal scales, which were also used by the patients for subjective self-assessment. RESULTS: Surgical assessment demonstrated equally good results with both methods, whereas the inverted U flap was the favorite method for reconstruction among patients (p < 0.029). Fifty-eight percent of patients in the round method group were conscious that they had umbilicoplasty, as opposed to only 15 percent in the inverted U flap group. Twenty-five percent of patients in the round group preferred their old umbilicus compared with this new one. None of the patients in the inverted U flap group preferred their old umbilicus. CONCLUSIONS: The authors discuss the surgical technique of the inverted U flap. This is currently the method of choice in recreating the umbilicus at the time of abdominoplasty.
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0 |
Alignment factors affecting the medial meniscus extrusion increases the risk of osteoarthritis development
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: Varus alignment is known as one of the major causes of medial compartment osteoarthritis (OA). Medial meniscus extrusion also plays a critical role in the in the development of OA. However, studies on the exact relationship between alignment parameters and medial meniscus extrusion are limited. Therefore, this study aimed to investigate this relationship in patients with knee OA.
METHODS: Based on a retrospective analysis of the outpatient magnetic resonance imaging (MRI) database, 190 knees were identified to be examined using weight-bearing, whole-leg radiographs and MRIs within 3 months from the first consultation. Subsequently, various parameters of lower leg alignment were measured, which affected the knee varus in radiographs. Finally, a statistical analysis was performed to assess the relationships between the OA grade, distance of medial meniscus extrusion (MME), and alignment parameters; hip-knee-ankle angle (HKAA), percentage of mechanical axis (% MA), medial proximal tibial angle (MPTA), and joint line convergence angle (JLCA). The subjects were divided according to the presence or absence of MME (Group A: MME distance below 3 mm, Group B: MME distance 3 mm and above) to assess the differences in each alignment parameter correlated with MME distance between the groups.
RESULTS: MME distance significantly increased with OA grade progression. HKAA, % MA, MPTA, and JLCA significantly correlated with medial meniscus extrusion distance (r = - 0.21, - 0.23, - 0.16, 0.3, respectively). Multiple regression analysis of each significant alignment combined with age, sex, and body mass index revealed that HKAA, % MA, MPTA, and JLCA were significant independent factors of MME distance (P = 0.008, 0.0026, 0.011, 0.0001, respectively). These significant findings were reinforced in group B. In contrast, the correlation between alignment parameters and medial meniscus extrusion distance was not significant in group A.
CONCLUSION: Varus alignment factors are related to MME distance especially in extruded meniscus knees, as the OA grade progressed. Therefore, the coexistence of varus alignment and MME can be the risk factors for OA progression. As the low MPTA was an independent alignment factor for generating varus alignment, patients with osteoarthritis of the knee with both, low MPTA and MME could be the appropriate candidates for early intervention by high tibial osteotomy.
Level of evidence: Iii.
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0 |
Retained posterior horn of the medial meniscus
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AMP (Acute Meniscal Pathology)
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The incidence of a symptomatic retained posterior fragment of the medial meniscus in 2 different groups of patients with medial meniscectomy is compared. If the original surgery was done through one capsular incision, there was a 9.5% incidence of symptomatic retained posterior fragment as compared to 0.2% incidence if the original surgery was performed through 2 capsular incisions. For total excision of the meniscus medial meniscectomy should be performed through 2 capsular incisions.
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Improvement in joint manifestations in a patient with mucopolysaccharidosis type 1 (MPS I) treated with etanercept
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Surgical Management of Osteoarthritis of the Knee CPG
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Case Report: The purpose of this abstract is to present a patient recently diagnosed with MPS I who had improvement in her dysostosis multiplex symptoms during treatment with etanercept for a presumed diagnosis of Juvenile Rheumatoid Arthritis (JRA). KG is a 12 year old female who first presented to our genetics clinic at age 9. She had been diagnosed with Noonan syndrome previously, due to her cardiac valve abnormalities, short stature, and facial features. Sequencing of Noonan gene panel identified a variant in the SOS1 gene which was felt to confirm her diagnosis. At 7 years old she had decreased range of motion in her shoulders and stiffness in a number of other joints. This led to a diagnosis of JRA for which she was treated with etanercept. When she presented to our clinic we felt Noonan and JRA did not explain her phenotype. An arthritis survey was not consistent with her diagnoses.We also found that the patient's unaffected mother carried the same SOS1 variant, now known to be a common Hispanic polymorphism. KG was lost to follow up with genetics for 2 years during which time she developed bilateral knee contractures and worsening claw deformity of her hands. Her mother discontinued etanercept, but when KG began experiencing pain and inflammation in her knees, it was restarted. KG subsequently had significant improvement in these symptoms as well as improved range of motion. When she represented, she'd developed coarsening of her facial features, and hepatomegaly. These new features suggested a storage disorder and MPS type I was confirmed through enzymatic and molecular testing. MPS I is a prototypic lysosomal storage disease with a spectrum of disease severity. Current treatment for MPS I includes enzyme replacement therapy, hematopoietic stem cell transplantation, physical therapy, surgery for contractures and decompression for nerve entrapments. Animal studies suggest that storage of dermatan sulfate, an endotoxin-like molecule, in MPS incites an inflammatory response via the tumor necrosis factor pathway. Etanercept is a competitive inhibitor of TNF-(alpha). To our knowledge, Etanercept has never been reported as being used to treat skeletal manifestations of MPS I. The benefit to our patient with etanercept suggests a new area of treatment for MPS associated dysostosis multiplex
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0 |
A prospective cohort study to predict fall risk in patients with recent hip fracture
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Management of Hip Fractures in the Elderly
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Background and Purpose: Little is known about the prevalence of falls and the related risk factors in patients who have undergone surgery following a hip fracture. This prospective cohort study aims to assess the relationship between potential risk factors and fall incidence in this patient population. There is an increased risk of recurrent falls and hip fractures in elderly who has suffered the first hip fracture. Identification on potential recurrent fallers at early stage is thus important for improving health outcomes in these individuals as well as reducing the economic burden on the public health care system. Methods: This was a prospective cohort study. Sixty-six older adults (age S65 years) who had sustained a hip fracture and were referred to Tung Wah Eastern Hospital for rehabilitation post-surgery participated in the study. After completion of the inpatient rehabilitation program, fall risk factors were assessed by using the Physiological Profile, and the guidelines on fall prevention adopted by the Hong Kong Hospital Authority. Follow-up information on falls and related injuries was collected on a monthly basis by telephone interview. Mann-Whitney U tests (for continuous and ordinal variables) and Chi-square tests (for nominal variables) were used to compare the variables of interest between fallers and non-fallers. For those variables that showed a significant between-group difference, receiver operating characteristic (ROC) curves were constructed to determine the optimal cutoff score. Univariate logistic regression analyses were then conducted to identify the odds ratio of each fall-related risk factor. Results: A new fall incident was reported by 8 patients during the follow-up period. Seven of them had one fall and one of them had two falls. Logistic regression analyses revealed that age (OR 5.7;95% CI: 1.05 e 30.87), ankle dorsi-flexor muscle strength (OR 7.235; 95% CI: 1.325 e 39.497), knee extensor muscle strength (OR 7.88; 95% CI: 1.438 e 43.139), visual acuity (OR 8.6; 95% CI: 1.564 e 47.303), postural sway while standing on foam with eyes open (OR 10.562; 95% CI: 1.228 e 92.397), Maximum Balance score (OR 6.67; 95% CI: 1.225 e 36.283), were significant predictors of falls. In addition those who had received extended rehabilitation had lower risk of falls than those who had not received any extended rehabilitation (OR 6.36; 95% CI: 1.16 e 34.81). Conclusion: Advanced age, lower extremity muscle strength, visual acuity, standing balance were significant intrinsic factors that contributed to falls among those patients who had recently undergone a hip surgery following the first hip fracture. In addition, those extended rehabilitation also had lower risk of falls than those who had not received the same service. The results point to the potential importance of training leg muscle strength and balance in our rehabilitation programs, in order to prevent falls in this patient population
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0 |
Dynamic hip screw and compression plate fixation of ipsilateral femoral neck and shaft fractures
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Management of Hip Fractures in the Elderly
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PURPOSE: To evaluate surgical outcomes of ipsilateral femoral neck and shaft fractures. METHODS: Between April 1997 and September 2004, 29 men and 8 women (mean age, 37 years) underwent fixation of femoral neck and shaft fractures using a dynamic compression plate plus a dynamic hip screw or screws. There were 30 femoral neck and 7 pertrochanteric fractures. Functional results were assessed according to the Friedman and Wyman classification. RESULTS: The mean follow-up period was 49 months. Of the femoral neck fractures, 34 united in a mean of 4 months; 33 of them healed anatomically and one with a 6-degree varus angulation. No osteonecrosis of the femoral head was noted. Of the femoral shaft fractures, 32 united in a mean of 6 months, 5 were non-unions (2 persisted even after revision surgery). Seven patients developed infections (5 superficial and 2 deep), which resolved with debridement and antibiotic treatment. Functional results were good in 29 patients, fair in 5, and poor in 3. CONCLUSION: The use of dynamic hip screws and compression plates for ipsilateral femoral neck and shaft fractures is reliable in achieving bone union with few complications
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0 |
Lateral unicompartmental knee arthroplasty relieves pain and improves function in posttraumatic osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Posttraumatic arthritis secondary to lateral tibial plateau fracture malunion causes pain and limited function for patients. It is sometimes technically challenging to correct malalignment in these patients with advanced arthritis using osteotomies. Lateral unicompartmental knee arthroplasty (UKA) may be an option to treat such patients.
QUESTIONS/PURPOSES: We asked whether UKA for lateral posttraumatic osteoarthritis (1) reliably alleviates pain and improve function, (2) restores lower limb alignment, and (3) is as durable as UKA for primary lateral osteoarthritis.
PATIENTS AND METHODS: We retrospectively reviewed 13 patients with lateral cemented UKA (mean age at surgery, 50.1 years) treated at two institutions between 1985 and 2007. We obtained Knee Society scores and evaluated radiographs for evidence of implant loosening or progression of arthritis in the medial compartment. Minimum followup was 3 years (mean, 10.2 years; range, 3-22.1 years).
RESULTS: Mean Knee Society knee score improved from 51 points (range, 29-75 points) preoperatively to 88 points (range, 65-100 points) at last followup, suggesting the procedure relieved pain. Mean function score improved from 51 points (range, 10-89 points) preoperatively to 87 points (range, 35-100 points) at last followup. The mean hip-knee-ankle angle was 188degree preoperatively (range, 184degree-193) and 185degree (range, 183degree-188degree) at last followup. Prosthesis survivorship was 100% at 5 and 10 years and 80% at 15 years.
CONCLUSIONS: Despite the limited number of indications and technical considerations, our observations suggest lateral UKA is a reasonable option for treating lateral arthritis secondary to malunited fractures.
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0 |
Fracture of the cobalt-chromium modular femoral neck component in total hip arthroplasty
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PJI DX Updated Search
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Total hip prostheses using cervico-metaphyseal modularity were designed to better replicate the geometry of the native extra-medullary femur. However, they are associated with numerous complications including corrosion, disassembly, pseudotumours and, most notably, fractures of the modular neck. All reported cases of modular neck fractures occurred with titanium components (Ti-6Al-4V). To prevent this weakness, manufacturers developed modular necks made of cobalt-chromium (Co-Cr). We report a fracture of a long, 8ð varus, Co-Cr modular neck connected to a 36-mm short (-3.5mm) femoral head. The fracture occurred 22 months post-implantation in a woman who had a low level of physical activity and a body mass index of 28.7 kg/m<sup>2</sup>. To our knowledge, this case is the first reported instance of Co-Cr modular neck fracture. It may challenge the wisdom of further developing this modularity design, as our patient had none of the known risk factors for modular neck fracture. In addition, cases of pseudotumour have been reported with Co-Cr modular necks subjected to fretting corrosion, which contributed to the fracture in our patient. é 2014 Elsevier Masson SAS
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0 |
Short-term postoperative mortality events in patients over 80 years of age with hip fracture: analysis at a single institution with limited medical resources
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Management of Hip Fractures in the Elderly
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BACKGROUND: Lethal events represent the most important complication in the treatment of hip fracture in elderly patients. Despite the increasing chance for treatment of such conditions, few data regarding risk factors associated with lethal events have been determined for ordinary hospitals with limited medical and human resources, particularly in Japan. METHODS: The incidence of postoperative lethal events and related preoperative risk factors in extremely elderly patients (>80 years) with hip fracture were retrospectively analyzed in our hospital for the past 2 years. RESULTS: Lethal events occurred in 11 (10.7%) of 103 patients within 3 months postoperatively. In both univariate and multivariate analyses, an elevated number of co-morbidities and preoperative respiratory dysfunction were identified as significant risk factors. Delay in surgery was not a risk factor for lethal events. CONCLUSIONS: A valid reason for delay is the need to stabilize concurrent medical conditions due to multiple co-morbidities in extremely elderly patients with hip fracture. Considering the limited resources and extreme age of the subjects, the mortality rate in the present study was quite acceptable. Patients, families of patients, and physicians should recognize the increased risk of mortality for patients with significant risk factors in the surgical treatment of hip fracture
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0 |
Dexamethasone and postoperative hyperglycemia in diabetics undergoing elective hip or knee arthroplasty: a case control study in 238 patients
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AAHKS (4) Acetaminophen
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Background: Dexamethasone has been routinely used in the pre-operative setting to enhance analgesia and decrease the incidence of nausea and vomiting in patients undergoing primary arthroplasty. However, dexamethasone has the potential to increase blood glucose levels postoperatively, which is a known risk factor for complications after total joint arthroplasty. The aim of this study was to analyze the effect of dexamethasone administration on post-operative blood glucose levels in diabetic patients after primary hip and knee arthroplasty.
Methods: This study was a retrospective review of 238 diabetic patients who underwent primary hip and knee arthroplasty between May 1, 2014 and September 30, 2016 at a single urban academic medical center. A total of 77 patients (32.4%) received dexamethasone and 161 (67.7%) did not. Oral hyperglycemic agents were held during the inpatient stay and blood glucose was controlled either with sliding scale insulin or home insulin regimens were continued. All analyses were adjusted for age, BMI, gender, type of diabetes, pre-operative diabetic medication, type of surgical procedure, and pre-operative HgbA1c level. The primary outcome was post-operative hyperglycemia within 72 h of surgery defined as any blood glucose level greater than or equal to 200 mg/dL.
Results: Post-operative hyperglycemia was observed in 17.1 and 20.6% of the measurements during the first 24 and 72 h respectively. After controlling for confounding variables, patients who received dexamethasone had 4.07 (95% CI: 2.46, 6.72) and 3.08 (95% CI: 2.34, 4.04) higher odds of post-operative hyperglycemia in the first 24 and 72 h respectively.
Conclusions: Dexamethasone administration in diabetic patients undergoing primary arthroplasty increases post-operative hyperglycemia during the first 24 and 72 h. While our data did not investigate causation, dexamethasone use in this patient population should be thoughtfully considered, as post-operative hyperglycemia is a known risk factor for complications.
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0 |
Is the Addition of a Polyol to Hyaluronic Acid a Significant Advance in the Treatment of Osteoarthritis?
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OAK 3 - Non-arthroplasty tx of OAK
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Viscosupplementation with intra-articular injections of hyaluronic acid is recommended as a second line treatment for knee OA, after failure of non-pharmacological modalities and usual pain killers. Nevertheless there are still controversies regarding clinical relevance of its effects. Research is looking for the best way to improve the performance of viscosupplementation in order to obtain a faster, longer-lasting and more pronounced effect. Antioxidants have been assessed in combination with hyaluronic acid because the injected hyaluronate is rapidly degraded by the reactive oxygen species, present in large amounts in the OA synovial fluid, limiting its residence time into the joint. Sorbitol and mannitol which have intrinsic free radical scavenger properties have been the most studied antioxidants. Sodium hyaluronate and polyols develop together a complex based on a dense network of hydrogen bonds which do not modify the visco-elsatic properties of hyaluronic acid. The oxygen free radicals neutralization by mannitol has been proven to delay the degradation of both linear and cross-linked HA in several in vitro models of oxidative stress. The antioxidant effect of these polyols may also play a role in accelerating onset of analgesia, as demonstrated in a double blind controlled trial comparing a mannitol-modified viscosupplement to regular hyaluronic acid. The addition of mannitol and sorbitol to hyaluronic acid does not alter the safety and local tolerability. In summary, adding a polyol to hyaluronic acid may improve the effects of viscosupplementation by reducing the rate of degradation of HA leading to a faster effect on pain relief without increasing the risk of adverse effect.
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1 |
Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: Carpal tunnel syndrome is caused by entrapment of the median nerve and results in pain, tingling and numbness in the wrist and hand. It is a common condition in general practice. Effectiveness of treatment by intracarpal corticosteroid injection has never been investigated in general practice. The objective of this study was to determine if corticosteroid injections for carpal tunnel syndrome provided by general practitioners are effective. METHODS: In this study 69 participants with a clinical diagnosis of carpal tunnel syndrome were recruited from 20 general practices. Short-term outcomes were assessed in a randomised, placebo-controlled trial. Long-term results were assessed in a prospective cohort-study of steroid responders. Participants were randomised to intracarpal injections of 1 ml triamcinolonacetonide 10 mg/ml (TCA) or 1 ml NaCl (placebo). Non-responders to NaCl were treated with additional TCA injections. Main outcomes were immediate treatment success, mean score of the Symptom Severity Scale (SSS) and Functional Status Scale (FSS) of the Boston carpal tunnel questionnaire, subjective improvement and proportion of participants with recurrences during follow-up. Duration of follow-up was twelve months. RESULTS: The TCA-group (36 participants) had better outcomes than the NaCl-group (33 participants) during short-term assessment for outcome measures treatment response, mean improvement of SSS-score (the mean difference in change score was 0.637 {95% CI: 0.320, 0.960; p < 0.001}) and FSS-score (the mean difference in change score was 0.588 {95% CI: 0.232, 0.944; p = 0.002}) and perceived improvement (p = 0.01). The number to treat to achieve satisfactory partial treatment response or complete resolution of symptoms and signs was 3 (95% CI:1.83, 9.72).49% of TCA-responders (17/35) had recurrences during follow-up. In the group of TCA-responders without recurrences (51%, 18/35) outcomes for SSS-score and FSS-score deteriorated during the follow-up period of 12 months (resp. p = 0.008 and p = 0.012). CONCLUSIONS: Corticosteroid injections for CTS provided by general practitioners are effective regarding short-term outcomes when compared to placebo injections. The short-term beneficial treatment effects of steroid injections deteriorated during the follow-up period of twelve months and half of the cohort of steroid-responders had recurrences. TRIAL REGISTRATION: Current Controlled Trials ISRCTN53171398
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Pilot trial of bone-targeted therapy with zoledronate, thalidomide, and interferon-? for metastatic renal cell carcinoma
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND. The purpose of the study was to evaluate the efficacy and safety of a bone-targeted regimen consisting of zoledronate, thalidomide, and interferon-? in patients with renal cell carcinoma and bone metastases. METHODS. Eligible patients had radiographic evidence of bone metastasis. Impending pathologic fractures or spinal cord compressions must have been controlled by surgery or radiation therapy before enrollment. Zoledronate (4 mg) was given intravenously every 4 weeks, thalidomide (300 mg) was given orally once a day, and interferon-? (100 µg) was given subcutaneously once a week. Patients were evaluated for time to skeletal-related events, the appearance of calcification in osteolytic metastases, and levels of the bone formation/resorption markers. RESULTS. Fifteen patients were treated between November 2002 and November 2003; 12 had previously undergone surgery, radiation, or embolization for their bone metastases; 11 had more than 3 sites of bone involvement; and 9 also had nonosseous metastases in the lung, liver, lymph node, pancreas, or adrenal gland. The median time to progression was 8.3 weeks (range, 2.1-48 weeks). The median time to a skeletal-related event was 12.0 weeks (range, 3.9-46.4 weeks). Two patients discontinued treatment because of adverse drug reactions (1 deep venous thrombosis and 1 myocardial infarction). Two patients experienced pain improvement and developed calcification in osseous metastases; these patients also showed favorable changes in bone marker levels. CONCLUSIONS. In this pilot study a bone-targeted regimen combining zoledronate, thalidomide, and interferon-? was well tolerated and might provide clinical benefit for a small subset of patients with renal cell carcinoma and bone metastases. © 2006 American Cancer Society.
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1 |
U-shaped association of body mass index in early adulthood with unintentional mortality from injuries: A cohort study of Swedish men with 35 years of follow-up
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DoD PRF (Psychosocial RF)
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Objectives: To investigate the doseâ??response association between body mass index (BMI) in young adulthood and the risk of mortality caused by unintentional injuries. Methods: We performed a cohort study including 7 43 398 men identified by linkage of the Multigeneration Register and the Military Service Conscription Register. Cox regression models were used to examine crude and adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) of the relationships between BMI at age 18â??20 years and the risk of death from all unintentional injuries as well as from specific unintentional injuries. We then estimated the population attributable fractions (PAFs)â??the proportion of unintentional deaths that was attributable to underweight, overweight and obesity in this population-based cohort. Results: During 35.9 years of follow-up, 6461 deaths occurred from unintentional injuries, including 3064 deaths from road injury, 978 from poisoning, 503 from falls, 243 from fire and 348 from drowning. Underweight subjects had a higher risk of mortality in all unintentional injuries (HR, 1.05; 95% CI, 1.03â??1.10) and mortality in burns (HR, 1.65; 95% CI, 1.13â??2.40) compared with BMI between 18.5 and 22.5 kg mâ??² (reference group). BMI > 25 kg mâ??² was associated with increased risk of death from all unintentional injuries (HR, 1.36; 95% CI, 1.12â??1.65) and road accidents (HR, 1.50; 95% CI, 1.14â??1.97). Estimates of PAF suggested that 4.4% of the mortality in Swedish men caused by unintentional injuries could have been avoided if BMI values were kept between 18.5 and 22.5 kg mâ??². Conclusions: A U-shaped association was observed between BMI and risk of unintentional death. Both underweight and overweight were associated with increased mortality risk for all unintentional injuries and for subtype causes. Our study suggests that BMI might be a significant target for preventive interventions on deaths caused by unintentional injuries. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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Extra-thyroid congenital abnormalities associated with thyroid dysgenesis in Turkey
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Developmental Dysplasia of the Hip 2020 Review
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A higher frequency of extra-thyroidal congenital malformations (ETCM) has been reported in children with congenital hypothyroidism (CH) compared with the general population. The most commonly reported one, congenital cardiac malformation (CCM), is reported to be in the range of 2-29% which is much higher than in normal population with a prevalence of 0.8%. Our aim is to investigate the frequency and type of additional ETCM in children with congenital hypothyroidism due to thyroid dysgenesis (TD) born between 1991 and 2013. We included 41 children with confirmed primary CH due to TD and excluded patients with Down syndrome. Age at diagnosis ranged from 4 days to 4 years. The aetiology of TD was determined with thyroid ultrasound and scintigraphy. Malformations were identified by physical examination, echocardiography abdominal/renal ultrasound and X-ray. Twenty-seven of the 41 patients had ectopic thyroid (66%), 12 had thyroid agenesis (29%) and 2 had hemiagenesis (5%). A high level of ETCM (48%, n:20) was observed. Nine patients had more than one system malformation. The most frequent malformation was CCM (22% n:9), consisting of atrial septal defect (15%, n:6), mitral insufficiency (5%, n:2), pulmonary stenosis (2%, n:1). There was a high prevalence of ETCM in patients with thyroid dysgenesis especially cardiac. Patients at least should be screened for cardiac anomalies.
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1 |
Experimental comparisons of passive and powered ankle-foot orthoses in individuals with limb reconstruction
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Ankle-foot orthoses (AFO) are commonly prescribed to provide functional assistance for patients with lower limb injuries or weakness. Their passive mechanical elements can provide some energy return to improve walking ability, but cannot restore plantar flexor push-off. Powered AFOs provide an assistive torque about the ankle to address the limitations of passive devices, but current designs have yet to be implemented on a large scale clinically. PURPOSE: To compare passive AFOs to a new untethered, powered AFO design in a clinical population with lower limb reconstruction. METHODS: A crossover study design, conducted on three individuals with lower limb reconstruction, compared gait mechanics at a standardized speed (based on leg length) in 4 AFO conditions: 1. None (shoes only), 2. Blue Rocker (BR, Allard, USA), 3. Intrepid Dynamic Exoskeletal Orthosis (IDEO), and 4. PowerFoot Orthosis (PFO BionX Medical Technologies, Inc.). The PFO was a custom, battery-powered device whose damping and power were capable to being tuned to meet patient needs. Subjects performed biomechanical gait analysis and metabolic testing at slow, moderate and fast speeds. Dependent variables included total limb power (calculated using a unified deformable segment model), mechanical work, mechanical efficiency, ankle motion, net metabolic cost across three speeds, and performance measures were calculated. Effect sizes (d) were calculated and d > 0.80 denoted a large effect. RESULTS: Net positive work (d > 1.17) and efficiency (d > 1.43) were greatest in the PFO. There were large effects for between limb differences in positive work for all conditions except the PFO (d = 0.75). The PFO normalized efficiency between the affected and unaffected limbs (d = 0.50), whereas efficiency was less on the affected limb for all other conditions (d > 1.69). Metabolic rate was not consistently lowest in any one AFO condition across speeds. Despite some positive results of the PFO, patient preferred their daily use AFO (2 IDEO, 1 BR). All participants indicated that mass and size were concerns with using the PFO. CONCLUSIONS: A novel PFO resulted in more biomimetic mechanical work and efficiency than commercially-available and custom passive AFO models. Although the powered AFO provided some biomechanical benefits, further improvements are warranted to improve patient satisfaction.
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0 |
Rehabilitation options for patients with an isolated meniscal tear, a narrative review
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AMP (Acute Meniscal Pathology)
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Meniscal injury is one of the comments injuries around the knee; it can occur in different age groups, but rarely in children. Commonly it is caused by a twisting knee injury, which could be presented later by swelling, pain, and mechanical symptoms. Management options for such injuries usually depend on the patient's activity needs and, on the pattern, or type of the meniscal tear. There is a general agreement that conservative management should be kept for low demand patients and stable tear patterns. However, surgical management should be offered for high demand patients, and if the tear has a complex pattern or causing significant mechanical symptoms that affect patients’ daily activities. Physiotherapy and rehabilitation programs are mandatory regardless of the treatment plan chosen for the patients for the sake of regaining knee motion, muscle strength, and helping the patient to return to the preinjury activity level as fast as possible.
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Rotation arc of pedicled anterolateral thigh flap for abdominal wall reconstruction: How far can it reach?
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Panniculectomy & Abdominoplasty CPG
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PURPOSE: The aim of this study was to elucidate the extent to which pedicled anterolateral thigh (ALT) flaps can reach in reconstruction of abdominal wall defects. METHODS: A total of 60 pedicled ALT flaps were raised from cadavers and were experimentally transferred to the abdominal region. The distance between the umbilicus and the most cranial point of the flap after transfer was defined as cranially reachable distance (CRD). Three issues were evaluated: (1) the difference in the CRD when the flap pedicle was positioned superficial or deep into the rectus femoris (RF) and sartorius (SA) muscles; (2) the difference in the CRD in those cases where the main artery of RF arises from the descending branch of the lateral femoral circumflex artery, and is preserved or severed; and (3) maximum values of CRD. RESULTS: (1) CRD was significantly greater when the pedicle was passed deep into the muscles (-2.5 +/- 3.8 SD cm) compared with superficial (-5.8 +/- 3.3 SD cm), indicating placement of pedicles beneath the two muscles enables additional extension. (2) CRD was significantly greater for the severed condition (-0.3 +/- 4.0 SD cm) than for the preserved condition (-3.3 +/- 4.1 SD cm), indicating severing the main artery of RF allows additional extension. (3) Out of the 60 specimens, the CRD was cranial to the umbilicus in 17 flaps, indicating pedicled ALT flaps can reach the umbilicus in less than one-third (17/60) of cases. CONCLUSION: Pedicled ALT flaps can reliably reach regions inferior to the umbilicus. However, for defects superior to the umbilicus, other reconstructive options should be considered.
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0 |
The Analgesic Effect of Obturator Nerve Block Added to a Femoral Triangle Block After Total Knee Arthroplasty: A Randomized Controlled Trial
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND AND OBJECTIVES: Total knee arthroplasty (TKA) is associated with severe pain, and effective analgesia is essential for the quality of postoperative care and ambulation. The analgesic effects of adding an obturator nerve block (ONB) to a femoral triangle block (FTB) after TKA have not been tested previously. We hypothesized that combined ONB and FTB will reduce opioid consumption and pain compared with those of a single FTB or local infiltration analgesia (LIA).
METHODS: Seventy-eight patients were randomized to combined ONB and FTB, single FTB, or LIA after primary unilateral TKA. The primary outcome was morphine consumption during the first 24 postoperative hours. Secondary outcomes included morphine consumption during the first 48 postoperative hours, pain at rest and passive knee flexion, nausea and vomiting, cumulated ambulation score, and Timed Up and Go test.
RESULTS: Seventy-five patients were included in the analysis. The total intravenous morphine consumption during the first 24 postoperative hours was 2 mg (interquartile range [IQR], 0-15) in the combined ONB and FTB group, 20 mg (IQR, 10-26) in the FTB group (P = 0.0007), and 17 mg (IQR, 10-36) in the LIA group (P = 0.002). The combined ONB and FTB group displayed reduced pain, nausea, and vomiting compared with the other groups. The ambulation tests showed no statistically significant differences between the groups.
CONCLUSIONS: Addition of ONB to FTB significantly reduced opioid consumption and pain after TKA compared with a single FTB or LIA, without impaired ambulation.
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0 |
Reappraising entrapment neuropathies-Mechanisms, diagnosis and management
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The diagnosis of entrapment neuropathies can be difficult because symptoms and signs often do not follow textbook descriptions and vary significantly between patients with the same diagnosis. Signs and symptoms which spread outside of the innervation territory of the affected nerve or nerve root are common. This Masterclass provides insight into relevant mechanisms that may account for this extraterritorial spread in patients with entrapment neuropathies, with an emphasis on neuroinflammation at the level of the dorsal root ganglia and spinal cord, as well as changes in subcortical and cortical regions. Furthermore, we describe how clinical tests and technical investigations may identify these mechanisms if interpreted in the context of gain or loss of function. The management of neuropathies also remains challenging. Common treatment strategies such as joint mobilisation, neurodynamic exercises, education, and medications are discussed in terms of their potential to influence certain mechanisms at the site of nerve injury or in the central nervous system. The mechanism-oriented approach for this Masterclass seems warranted given the limitations in the current evidence for the diagnosis and management of entrapment neuropathies. (copyright) 2013 Elsevier Ltd
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1 |
The impact of response on bone-directed therapy in patients with multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Significant benefits for zoledronic acid (ZOL) over clodronate acid (CLO) were seen in the Medical Research Council Myeloma IX randomized trial. ZOL significantly reduced skeletal-related events (SREs), and improved progression-free survival and overall survival (OS), making it the bisphosphonate of choice for newly diagnosed myeloma patients. In this analysis of Myeloma IX data, we have investigated the impact of response on bone disease in 1111 transplant-eligible patients. At posttransplant day 100, complete response (CR) was seen in 48% of patients, very good partial response (VGPR) in 20%, and partial response (PR) in 23%. For patients in VGPR or less, ZOL was superior to CLO in reducing SREs (P = .048), whereas for patients in CR, both agents were equivalent (P = .83). For OS, ZOL was associated with a significant benefit in patients in PR (P = .0091). No difference in OS was seen with patients in CR (P = .91) or VGPR (P = .74). These findings indicate that response category posttransplant may influence the impact of bisphosphonate therapy.
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Fluconazole resistance of Candida krusei
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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We present a case of young male treated for a recurrence of Acute Non Lymphoid Leukemia who presented a colonization by C. krusei during prophylaxis with Fluconazole. The fever episode, which he developed while neutropenic, was resolved with the addition of Amphotericin B after the failure of empiric antibiotic therapy. No isolation was performed in blood cultures. A second cycle of antiblastic chemotherapy was needed because of the resistance shown to the first. Despite the prophylaxis with Fluconazole a stream of C. krusei grew in all the blood cultures collected while febrile. Amphotericin B administered did not control the fungemia. We discuss the resistance of C. krusei to Fluconazole
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Finite element comparison of retrograde intramedullary nailing and locking plate fixation with/without an intramedullary allograft for distal femur fracture following total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: Periprosthetic distal femur fracture after total knee arthroplasty due to the stress-shielding phenomenon is a challenging problem. Retrograde intramedullary nail (RIMN) or locking plate (LP) fixation with/without a strut allograft has been clinically used via less invasive stabilization surgery (LISS) for the treatment of these periprosthetic fractures. However, their biomechanical differences in construct stability and implant stress have not been extensively studied, especially for the osteoporotic femur.
METHODS: This study used a finite-element method to evaluate the differences between RIMN, LP, and LP/allograft fixation in treating periprosthetic distal femur fractures. There were sixteen variations of two fracture angles (transverse and oblique), two loading conditions (compression and rotation), and four bony conditions (one normal and three osteoporotic). Construct stiffness, fracture micromotion, and implant stress were chosen as the comparison indices.
RESULTS: The LP/allograft construct provides both lateral and middle supports to the displaced femur. Comparatively, the LP and RIMN constructs, respectively, transmit the loads through the lateral and middle paths, thus providing more unstable support to the construct and high stressing on the implants. The fracture pattern plays a minor role in the construct stabilization of the three implants. In general, the biomechanical performances of the RIMN and LP constructs were comparable and significantly inferior to those of the LP/allograft construct. The bone quality should be evaluated prior to the selection of internal fixators.
CONCLUSIONS: The LP/allograft construct significantly stabilizes the fracture gap, reduces the implant stress, and serves as the recommended fixation for periprosthetic distal femur fracture.
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Flexible intramedullary nailing of subtrochanteric fractures of the femur. A multicenter analysis
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Management of Hip Fractures in the Elderly
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In a retrospective, multicenter analysis, 79 subtrochanteric fractures of the femur were treated with flexible intramedullary nails. Seventy fractures were traumatic in origin, three were pathologic, and six occurred in spinal cord patients. All of the fractures healed, and there were no fixation failures. Thirteen patients (16%) required adjunctive internal fixation, bone grafts, or postoperative traction. Shortening greater than 1 cm occurred in four patients (5%). Reoperation with one week of surgery was necessary in eight patients (10%). The single greatest complication was knee complaints, which occurred in 17 patients (21.5%). However, only six of these patients required revision prior to fracture union. In one patient a deep wound infection developed, which eventually healed without evidence of osteomyelitis. All patients who were ambulatory before their fracture were able to bear weight
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Enhancement of joint fluid with intravenously administered gadopentetate dimeglumine: technique, rationale, and implications
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AMP (Acute Meniscal Pathology)
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This study reports findings on joint fluid enhancement after intravenous administration of gadopentetate dimeglumine. Ten subjects were studied: two asymptomatic volunteers and eight patients with suspected meniscal tears. The subjects underwent imaging at 1.5 T before, immediately after, and 42-60 minutes after intravenous administration of gadopentetate dimeglumine. The rate of fluid enhancement was assessed in three subjects, and the effects of exercise were studied. All subjects exhibited enhancement of joint fluid. Mean fluid enhancement for patients was 137% on initial and 262% on delayed images obtained after exercise. Exercise increased the rate and degree of fluid enhancement and distributed contrast material uniformly throughout the joint. The arthrographic effect of the fluid enhancement increased the number of perceived cartilage defects. This study documents enhancement of joint fluid in healthy subjects and in those with effusions. The arthrographic effect may provide a more convenient alternative to intraarticular injection of gadopentetate dimeglumine for MR arthrography.
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Using TENS for pain control: The state of the evidence
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SR for PM on OA of All Extremities
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Transcutaneous electrical nerve stimulation (TENS) is a nonpharmacological intervention that activates a complex neuronal network to reduce pain by activating descending inhibitory systems in the central nervous system to reduce hyperalgesia. The evidence for TENS efficacy is conflicting and requires not only description but also critique. Population-specific systemic reviews and meta-analyses are emerging, indicating both HF and LF
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Orientin inhibits inflammation in chondrocytes and attenuates osteoarthritis through Nrf2/NF-kappaB and SIRT6/NF-kappaB pathway
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Osteoarthritis (OA) is the most common form of degenerative joint disease. and chondrocyte inflammation plays an important role in OA development. The natural flavonoid compound Orientin (Orientin) has anti-inflammatory bioactive properties in the treatment of various diseases. Studies have not explored whether Orientin modulates OA progression.
PURPOSE: In our study, we researched the anti-osteoarthritis effects of Orientin, as well as the potential mechanisms that underlie its action.
STUDY DESIGN: Effects of Orientin on OA were detected in chondrocytes and OA mouse model.
METHODS: Effects of Orientin on murine chondrocytes treated with interleukin-1beta (IL-1beta) were evaluated using qPCR, western blot analysis, ELISA and immunofluorescent staining in vitro. In vivo, We established a standard OA model by performing the destabilized medial meniscus (DMM) surgery on C57BL/6 mice, and assessed healing effect of Orientin by X-ray imaging, histopathological analysis, immunohistochemical staining.
RESULTS: A significant suppression in IL-1beta-mediated pro-inflammatory mediators and the degradation of cartilage extracellular matrix (ECM) was observed in vitro after a treatment with Orientin. In addition, Orientin abrogated DMM surgery induced cartilage degradation in mice. Mechanistic studies showed that Orientin suppressed OA development by downregulating activation of NF-kappaB by activating Nrf2/HO-1 axis and SIRT6 signaling pathway.
CONCLUSION: The study indicates that Orientin inhibits inflammation of chondrocytes and ECM degradation, which are key contributors to OA progression. Effects of Orientin are mediated through Nrf2/NF-kappaB and the SIRT6/NF-kappaB pathways. These results provide evidence that Orientin serves as a potentially viable compound for the treatment of OA. This article is protected by copyright. All rights reserved.
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New developments in the treatment of osteoarthritis â?? Focus on biologic agents
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AAHKS (2) Corticosteroids
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Osteoarthritis (OA) is one of the most common diseases around the world. Medical, social, and financial consequences oblige clinicians, surgeons, and researchers to focus on finding the best treatment option, to eradicate and stop this degenerative joint disease, in order to avoid surgical options which in many instances are over-indicated. Noninvasive treatments, such as anti-inflammatory drugs, physiotherapy, orthotic devices, dietary supplements, have demonstrated lack of effectiveness. The possibility to perform intra-articular injections with hyaluronic acid, corticosteroids, or the newest but criticized treatment based on platelet-rich plasma (PRP) has changed the management of OA disease. The use of PRP has led to many differences in treatment since there is a lack of consensus about protocols, indications, number of doses, cost-effectiveness, and duration of the treatment. Many publications have suggested efficacy in tendon injuries, but when PRP has been indicated to treat cartilage injuries, things are more inconsistent. Some authors have reported their experience treating OA with PRP, and it seems that, if well indicated, it is an option as a supplementary therapy. Therefore, we need to understand that OA is a mechanical disease which not only produces changes in radiographs, but also affects the quality of life. Pathogenesis of OA has been well explained, providing us new knowledge and future possibilities to improve the clinical approach. From basic science to surgery, there is a great field we all need to contribute to, because the general population is aging and total joint replacements should not be the only solution for OA. So herein is an actual review of the developments for treating OA with biologics, intended to be useful for the population inside orthopedics who could be called bio-orthopedists, since OA is a molecular homeostasis disbalance between catabolism and anabolism triggered by mechanical stress.
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Childhood trauma and resilience in old age: applying a context model of resilience to a sample of former indentured child laborers
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DoD PRF (Psychosocial RF)
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OBJECTIVES: Psychological resilience has been rarely investigated in elderly populations. We applied a more comprehensive model of trauma-specific coping and resilience, which included Ungar's context model and included decentral factors of resilience (i.e., environments that provide resources to build resilience).
METHOD: We assessed resilience in a cohort of former Swiss indentured child laborers (N = 74; 59% males) at two time points; first at the mean age of 80 years and then again 20 months later. At each time point, the following measures of resilience were assessed: resilience indicators of life satisfaction and lack of depression. In addition, resilience predictors of trauma exposure, perceived social support, dysfunctional disclosure of traumatic experiences, social acknowledgment as a victim, and self-efficacy; and decentral resilience factors of education, income, number of children, and physical health were measured.
RESULTS: Using path-analysis, we found that life satisfaction and lack of depression were predicted by dysfunctional disclosure, social support, and self-efficacy at various significance levels. Change scores of resilience were predicted by higher trauma exposure, social acknowledgment as a victim, and an interaction between the two. The model for decentral factors also fitted, with physical health and income predicting the resilience indicators.
CONCLUSION: Applying this comprehensive resilience model in a sample of older adults revealed meaningful findings in predicting resilience at a single time point and over time. Atypical coping strategies, such as perceived social acknowledgment as a victim and disclosure, may be particularly important for former victims who have suffered institutional abuse.
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Interventions for preoperative smoking cessation
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Management of Hip Fractures in the Elderly
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BACKGROUND: Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions. OBJECTIVES: The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation at the time of surgery and 12 months postoperatively and on the incidence of postoperative complications. SEARCH STRATEGY: The specialized register of the Cochrane Tobacco Addiction Group was searched using the free text and keywords (surgery) or (operation) or (anaesthesia) or (anesthesia). MEDLINE, EMBASE and CINAHL were also searched, combining tobacco- and surgery-related terms. Most recent search April 2010. SELECTION CRITERIA: Randomized controlled trials that recruited people who smoked prior to surgery, offered a smoking cessation intervention, and measured preoperative and long-term abstinence from smoking and/or the incidence of postoperative complications. DATA COLLECTION AND ANALYSIS: The authors independently assessed studies to determine eligibility. Results were discussed between the authors. MAIN RESULTS: Eight trials enrolling a total of 1156 people met the inclusion criteria. One of these did not report cessation as an outcome. Two trials initiated multisession face to face counselling at least 6 weeks before surgery whilst six used a brief intervention. Nicotine replacement therapy (NRT) was offered or recommended to some or all participants in seven trials. Five trials detected significantly increased smoking cessation at the time of surgery, and one approached significance. Subgroup analyses showed that both intensive and brief intervention significantly increased smoking cessation at the time of surgery; pooled RR 10.76 (95% confidence interval (CI) 4.55 to 25.46, two trials) and RR 1.41 (95% CI 1.22 to 1.63, five trials) respectively. Four trials evaluating the effect on long-term smoking cessation found a significant effect; pooled RR 1.61 (95% CI 1.12 to 2.33). However, when pooling intensive and brief interventions separately, only intensive intervention retained a significant effect on long-term smoking cessation; RR 2.96 (95% CI 1.57 to 5.55, two trials).Five trials examined the effect of smoking intervention on postoperative complications. Pooled risk ratios were 0.70 (95% CI 0.56 to 0.88) for developing any complication; and 0.70 (95% CI 0.51 to 0.95) for wound complications. Exploratory subgroup analyses showed a significant effect of intensive intervention on any complications; RR 0.42 (95% CI 0.27 to 0.65) and on wound complications RR 0.31 (95% CI 0.16 to 0.62). For brief interventions the effect was not statistically significant but CIs do not rule out a clinically significant effect (RR 0.96 (95% CI 0.74 to 1.25) for any complication, RR 0.99 (95% CI 0.70 to 1.40) for wound complications). AUTHORS' CONCLUSIONS: There is evidence that preoperative smoking interventions including NRT increase short-term smoking cessation and may reduce postoperative morbidity. The optimal preoperative intervention intensity remains unknown. Based on indirect comparisons and evidence from two small trials, interventions that begin four to eight weeks before surgery, include weekly counselling, and use NRT are more likely to have an impact on complications and on long-term smoking cessation. CAN PEOPLE BE HELPED TO STOP SMOKING BEFORE THEY HAVE SURGERY?: Smoking is a well-known risk factor for complications after surgery. Studies of interventions to encourage smokers to stop smoking before their operation show that short- and long-term quitting can be achieved. Evidence from two small trials indicates that interventions that begin four to eight weeks before surgery, which include weekly counselling and use NRT, support smoking cessation and may reduce complication rates. Brief interventions support short-term smoking cessation but there is insufficient evidence from this review to determine whether they reduce complications. This may be due to the longer period of pre-operative abstinence that can be achieved when interventions begin four to eight weeks before surgery
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Osteochondrosis and arthrosis in pigs. VI. Relationship to feed level and calcium, phosphorus and protein levels in the ration
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MSTS 2018 - Femur Mets and MM
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Eight feeding experiments, each involving 48 boars or gilts, were carried out. Feed level, Ca, P and protein levels were varied within practical physiological limits. The animals were slaughtered at close to 100 kg live weight. Lesions in joints and bones were of a noninfectious, nonrachitic nature and of the osteochondrosis and arthrosis type. Ten to 12 g Ca and approx. 10 g P/kg ration gave histomorphologically seemingly more optimum structure of the spongious bone tissue and a higher ash percentage in bones than 7 g Ca and 6 g P, or unbalanced mineral levels in the ration. However, there was no significant difference in degree or incidence of joint and bone lesions between mineral groups. Neither were there such differences present between feed level groups or protein level groups. This may, for the feed level groups, be partly due to the low feed level pigs having a longer period of time during which they were highly susceptible to the development of lesions. The low feed level animals had longer long bones at 100 kg live weight than the high feed level animals. The length of the vertebral column was, however, approximately similar in the 2 feed level groups. The angles of the condyles and head of the femur according to the length axis were influenced by feed level or growth rate, most probably by an effect on the endochondral ossification.
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Analysis of effectiveness of therapeutic exercise for knee osteoarthritis and possible factors affecting outcome
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: There are numerous reports and evidences to suggest that exercise therapy is effective for knee osteoarthritis (knee OA). However, there is a lack of sufficient research concerning the factors influencing its application and effectiveness. The purposes of this study were to evaluate effects of the mode of treatment delivery on the improvement of symptoms in knee OA, and to analyze potential risk factors affecting improvement after exercise therapies.
METHODS: The 209 women applicants diagnosed with knee OA were randomly allocated into either a group performing group exercise in a class or a group performing home exercise. The 90 min exercise program was performed under the guidance of physiotherapists as a group exercise therapy. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) of the subjects of both groups before and after intervention was compared to examine the effect of exercise therapy. In addition, body mass index, knee range of motion (ROM), the femorotibial angle from radiographs, OA severity from Kellgren-Lawrence grade, and meniscus abnormality and subchondral bone marrow lesions from MRI findings were statistically analyzed as factors that may affect exercise therapy.
RESULTS: A significantly greater improvement in WOMAC was observed in the subjects of group exercise (81 subjects) as compared with the subjects of home exercise (122 subjects). There was a significantly high proportion of subjects with knee flexion contracture among the subjects participating in group exercise that showed only minor symptom improvement (p < 0.05). In addition, exercise therapy proved to be highly effective for subjects with limited quadriceps muscle strength (p < 0.05).
CONCLUSIONS: When prescribing exercise therapy for knee OA, evaluation of a subject's ROM and muscle strength is important in deciding whether to commence exercise therapy and what type of exercise therapy to apply; it is also important in predicting the effect of exercise therapy.
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A measurement system for evaluation of shape changes and proportions after cosmetic breast surgery
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Evaluation of changes in breast shape, particularly "upper pole fullness," "breast projection," and "bottoming out," has been made difficult by the lack of an accepted definition of these entities and no standardized system for measurements and comparison. Three-dimensional imaging is impractical for most surgeons and limited in providing evidence-based assessments.
METHODS: Using standardized photographs and computer imaging software to match size and orientation, breast shape and size are measured and compared before and after cosmetic breast surgery. Practical landmarks and analysis allow assessment of results using standard two-dimensional frontal and lateral views. A horizontal plane at the level of maximum postoperative breast projection and a vertical plane dropped from the sternal notch serve as the reference planes. Breast projection, upper pole projection, lower pole level, nipple level, lower pole width, breast parenchymal ratio, and lower pole ratio (a measure of the boxiness of the lower pole) are defined and measured.
RESULTS: These simple measurements may be easily used by surgeons to evaluate the effectiveness of their techniques in breast augmentation, mastopexy, augmentation/mastopexy, and reduction. Claims regarding changes in breast projection, upper pole projection, and breast mound elevation may be objectively evaluated.
CONCLUSION: This measurement system provides a highly practical means with which to quantitate breast shape changes after surgery and assess surgical results using well-defined references.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
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Retroacetabular stress-shielding in THA
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Management of Hip Fractures in the Elderly
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We conducted a randomized clinical trial to compare periacetabular bone density changes after total hip arthroplasty using press-fit components with soft and hard liner materials. Bone density changes were assessed using quantitative computed tomography-assisted osteodensitometry. Twenty press-fit cups with alumina ceramic liners and 20 press-fit cups with highly cross-linked polyethylene liners were included; the nonoperated contralateral side was used as the control. Computed tomography scans were performed postoperatively and 1 year after the index operation. At the 1-year followup, we found no differences of periacetabular bone density changes between the alumina and polyethylene liner cohorts. However, we observed marked periacetabular cancellous bone density loss (up to -34%) in both cohorts. In contrast, we observed only moderate cortical bone density changes. The decrease of periacetabular cancellous bone density with retention of cortical bone density after THA suggests stress transfer to the cortical bone
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