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Evaluation of Information Sources in Plastic Surgery Decision-making
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Reduction Mammoplasty for Female Breast Hypertrophy
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Background Today, patients can access a myriad of information sources regarding plastic surgery procedures prior to meeting with a surgeon. Despite their widespread use, the role of these sources in a patient's decision-making remains undefined. We hypothesized that the physician remains the key information source for patients making surgical decisions in plastic surgery, but that other sources may deliver important insights and prove helpful to varying degrees. We also explored motivations for this outside information search and any differences in perceived value among patients. Methods We administered a survey regarding various information sources to our breast reconstruction, reduction, and abdominoplasty patients. Responses were compared between surgery groups and demographic groups. Ordinal logistic regression analysis was used to determine the impact of patient characteristics on helpfulness rank of different sources. Results Survey results were obtained from 58 patients, of whom 10 (17.2%) had abdominoplasty, 35 (60.3%) breast reconstruction, and 13 (22.4%) breast reduction. The most popular information sources prior to the first surgical appointment were Internet searches (56.9%) and family/friends/other patients (39.7%). After the initial appointment, the most useful sources were plastic surgeons (84.5%), and the Internet (36.2%). Most patients (73.5%) still sought outside information after their appointment. On a Likert-type scale of helpfulness, plastic surgeons ranked 4.28/5, followed by the web-based patient education platform, 3.73 and the Internet, 3.6. A total of 63% of participants listed plastic surgeons as their single most important source of information. In ordinal logistic regression analysis, non-white race was significantly associated with higher rank of surgeon helpfulness (p < 0.05). Relative to low-income patients, income $50-100k (p < 0.05) and $100k+ (p < 0.05) were associated with lower rank of surgeon helpfulness. Conclusions Most patients seek outside information prior to visiting with a surgeon from the Internet, social media, or family and friends. Patients consider plastic surgeons their most valuable information source overall, though still in need of supplementation for varying reasons. Additionally, certain demographic differences affect patient perception of information sources, and this is an important factor for surgeons to consider as they approach educating patients.
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1 |
Electrolyte disorders and aging: Risk factors for delirium in patients undergoing orthopedic surgeries
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DoD PRF (Psychosocial RF)
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Background: At present, the exact mechanism of postoperative delirium has not been elucidated. The purpose of this study was to analyze the incidence of delirium in patients undergoing orthopedic surgeries and to explore possible related factors. Methods: This is a retrospective study. We used 582 patients who had undergone orthopedic surgery between January 2011 and December 2014. The surgeries consisted of 155 cases of internal fixation for intertrochanteric fracture (IFIF), 128 cases of femoral head replacement (FHR), 169 cases of total hip arthroplasty (THA) and 130 cases of total knee arthroplasty (TKA). Among the 582 patients, 75 developed postoperative delirium (an incidence of 12.9%). The demographics of the patients, which included age, gender, operation duration and blood loss, were statistically analyzed with univariate logistic regression analysis and then multivariate logistic regression. To investigate the influences of different electrolytes disorders for postoperative delirium, the Chi-square test was used. Results: Multivariate logistic regression analysis indicated that postoperative delirium incidence in patients aged 70â??79 years and in patients aged â?¥ 80 years was higher than that in patients aged < 70 years, odds ratio (OR) values were 6.33 and 26.37, respectively. In addition, the incidence of postoperative delirium in the group of patients with electrolyte disorders was higher than that in the normal group (OR, 2.38). There were statistically significant differences between the delirium group and the non-delirium group in the incidences of the sodium and calcium disorders. Conclusions: Aging and postoperative electrolyte disorders (hyponatremia and hypocalcemia) are risk factors for postoperative delirium in patients undergoing orthopedic surgeries. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Current treatments of isolated articular cartilage lesions of the knee achieve similar outcomes
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Osteochondritis Dissecans 2020 Review
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BACKGROUND: Many surgical techniques, including microfracture, periosteal and perichondral grafts, chondrocyte transplantation, and osteochondral grafts, have been studied in an attempt to restore damaged articular cartilage. However, there is no consensus regarding the best method to repair isolated articular cartilage defects of the knee. QUESTIONS/PURPOSES: We compared postoperative functional outcomes, followup MRI appearance, and arthroscopic examination after microfracture (MF), osteochondral autograft transplantation (OAT), or autologous chondrocyte implantation (ACI). METHODS: We prospectively investigated 30 knees with MF, 22 with OAT, and 18 with ACI. Minimum followup was 3 years (mean, 5 years; range, 3-10 years). We included only patients with isolated cartilage defects and without other knee injuries. The three procedures were compared in terms of function using the Lysholm knee evaluation scale, Tegner activity scale, and Hospital for Special Surgery (HSS) score; modified Outerbridge cartilage grades using MRI; and International Cartilage Repair Society (ICRS) repair grade using arthroscopy. RESULTS: All three procedures showed improvement in functional scores. There were no differences in functional scores and postoperative MRI grades among the groups. Arthroscopy at 1 year showed excellent or good results in 80% after MF, 82% after OAT, and 80% after ACI. Our study did not show a clear benefit of either ACI or OAT over MF. CONCLUSIONS: Owing to a lack of superiority of any one treatment, we believe MF is a reasonable option as a first-line therapy given its ease and affordability relative to ACI or OAT. LEVEL OF EVIDENCE: Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Geriatric rehabilitation following fractures in older people: a systematic review
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Management of Hip Fractures in the Elderly
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Abstract and full text may be available at: http://www.hta.ac.uk/project/htapubs.asp NO
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Cost-effectiveness of diet and exercise interventions to reduce overweight and obesity
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SR for PM on OA of All Extremities
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OBJECTIVE: To analyze whether two dietary weight loss interventions--the dietary approaches to stop hypertension (DASH) program and a low-fat diet program--would be cost-effective in Australia, and to assess their potential to reduce the disease burden related to excess body weight. DESIGN: We constructed a multi-state life-table-based Markov model in which the distribution of body weight influences the incidence of stroke, ischemic heart disease, hypertensive heart disease, diabetes mellitus, osteoarthritis, post-menopausal breast cancer, colon cancer, endometrial cancer and kidney cancer. The target population was the overweight and obese adult population in Australia in 2003. We used a lifetime horizon for health effects and costs, and a health sector perspective for costs. We populated the model with data identified from Medline and Cochrane searches, Australian Bureau of Statistics published catalogues, Australian Institute of Health and Welfare, and Department of Health and Ageing. OUTCOME MEASURES: Disability adjusted life years (DALYs) averted, incremental cost-effectiveness ratios (ICERs) and proportions of disease burden avoided. ICERs under AUS$50,000 per DALY are considered cost-effective. RESULTS: The DASH and low-fat diet programs have ICERs of AUS$12,000 per DALY (95% uncertainty range: Cost-saving- 68,000) and AUS$13,000 per DALY (Cost-saving--130,000), respectively. Neither intervention reduced the body weight-related disease burden at population level by more than 0.1%. The sensitivity analysis showed that when participants' costs for time and travel are included, the ICERs increase to AUS$75,000 per DALY for DASH and AUS$49,000 per DALY for the low-fat diet. Modest weight loss during the interventions, post-intervention weight regain and low participation limit the health benefits. CONCLUSION: Diet and exercise interventions to reduce obesity are potentially cost-effective but have a negligible impact on the total body weight-related disease burden
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1 |
Comprehensive Comparison of Liposomal Bupivacaine with Femoral Nerve Block for Pain Control Following Total Knee Arthroplasty: An Updated Systematic Review and Meta-Analysis
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AAHKS (9/10) Regional Nerve Blocks
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To compare the efficacy of liposomal bupivacaine (LB) and femoral nerve block following total knee arthroplasty, we conducted this systematic review and meta-analysis. 11 trials with 2,908 patients were included in this study. The pooled data demonstrated that total morphine consumption equivalents during the hospital stay was significantly increased in FNB group. In addition, LB has significantly better outcome in view of the postoperative functional recovery, such as the odds of fall, the incidences of straight leg rise (SLR), the number of patients who can walk independently in the day of surgery,the ambulation distance at POD1, the number of patients discharged at POD1. Consistent with the faster functional recovery, liposomal bupivacaine shortens the length of hospital stay. However, there was no significant difference between LB and FNB in terms of Visual Analogue Score (VAS) during the hospital stay. All in all, liposomal bupivacaine has significantly better outcome in view of the postoperative functional recovery and the length of hospital stay compared with femoral nerve block following the total knee arthroplasty.
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A Prospective, Matched Comparison of Health-Related Quality of Life in Bariatric Patients following Truncal Body Contouring
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Massive weight loss after bariatric surgery can lead to excess skin associated with functional and aesthetic sequelae. Access to the benefit provided by body contouring procedures may be limited by insurance approval, which does not consider health-related quality of life. The aim of this study was to quantify the benefit in health-related quality of life for patients who undergo body contouring procedures after massive weight loss. METHODS: Patients evaluated for postbariatric body contouring procedures were systematically identified and prospectively surveyed using the BODY-Q. Health-related quality-of-life change for each functional scale was compared between those who underwent body contouring procedures (operative group, preoperatively versus postoperatively) and those who did not (nonoperative group, preoperatively versus resurvey) using t tests. Propensity score matching allowed the authors to balance baseline demographics, comorbidities, physical symptoms, and risk factors between cohorts. RESULTS: Fifty-seven matched patients were analyzed (34 operative versus 23 nonoperative). No significant difference in age, body mass index, time between surveys, or preoperative BODY-Q scores existed between cohorts. The surgical group demonstrated a significant improvement in 10 out of 11 BODY-Q functional scales. The nonoperative group realized no improvements and, in the interim, had a significant deterioration in four BODY-Q scales. CONCLUSIONS: Postbariatric body contouring procedures represent a critical and final step in the surgical weight loss journey for patients and are associated with significant improvements in health-related quality of life. Further deterioration in psychosocial and sexual health-related quality of life occurs in patients who do not undergo body contouring procedures following bariatric surgery. This study provides prospective comparative data that validate the field's standard intervention and justification for insurance approval. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.
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Humeral capitellum fracture combined with humeral lateral column injury: A novel classification system and treatment algorithm
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Shear humeral capitellum fracture (CF) treatment can be complicated by comminution of the distal lateral humeral column (LHC). Although treatment with a 3.5 mm posterolateral distal humerus plate with support (PDHPWS) has been proposed, its indications have not yet been outlined. The purpose of this study was to describe a classification system for this fracture pattern and provide a therapeutic algorithm to avoid complications associated with PDHPWS fixation. METHODS: Thirty-four patients who underwent surgical treatment for CF with LHC comminution were enrolled. The humeral capitellum angle (α angle) measured on the sagittal view of computed tomography reconstructions corresponded to the height of the LHC fracture line; based on this height, the severity of LHC injury was categorized as subtype L (low fracture line, 60° < α < 90°), subtype M (moderate fracture line, 45° < α < 60°) or subtype H (high fracture line, α < 45°). The therapeutic algorithm was countersunk compression screws for subtype L, lateral buttressing combined with/without an anterior antiglide mini-fragment plate for subtype M and a dorsolateral anatomical locking plate for subtype H. At the end of the follow-up period, the treatment outcome was evaluated by radiography and an assessment of the range of motion. A functional assessment was carried out using the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: The mean age of patients in this cohort was 49.6 ± 14.6 years, and the mean follow-up duration was 48.9 ± 34.6 months. There were 10 cases classified as subtype L, with a mean α angle of 80.6 ± 8.8°. The mean α angle for the 13 cases classified as subtype M was 52.1 ± 4.6° and that for the 11 cases classified as subtype H was 24.1 ± 22.4°. All fractures healed uneventfully, and implant removal was required in 8 cases (one subtype M and seven subtype H). The average MEPS in the three subgroups was 84.5 (subtype L), 87.3 (subtype M) and 78.2 (subtype H), while the average DASH score was 13.9 (subtype L), 11.6 (subtype M) and 21.5 (subtype H). Compared with the other subtypes, subtype H showed the smallest improvement in mean elbow function (112.7° in flexion, 13.6° in extension, 66.4° in pronation and 71.4° in supination). No cases of heterotopic ossification or avascular necrosis of the capitellum developed in any group. CONCLUSION: By analyzing the fracture morphology, a substantial portion of CFs with mild to moderate LHC comminution could be successfully managed by a simpler and less aggressive method with fewer complications than PDHPWS. LEVELS OF EVIDENCE: Level IV; Case Series; Treatment Study.
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Restoration of thumb opposition by transposing the flexsor pollicis brevis muscle: Thirteen-year clinical application
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background: To repair late median nerve injury, many methods have been used in the past years. The aim of this study was to review a thirteen-year experience in restoration of thumb opposition by transposing flexor pollicis brevis muscle. Methods: From July 1992 to August 2005, 63 patients without thumb opposition because of late median never injury were treated by transposing the flexor pollicis brevis muscle. All the patients had received primary nerve repair after the jnjury. The interval between the injury and the second operation was (1.87(plus or minus)2.31) years (6 months to 4.2 years). The patients were followed up for 3 to 48 [months mean (22.93(plus or minus)2.31) months]. A functional evaluation system designed in 1992 were used to estimate the outcomes of the patients. Results: All the patients gained excellent functional results without complications and disabilities during follow-up. Conclusions: Restoration of thumb opposition by transposing flexsor pollicis brevis muscle has the following advantages: 1. Operative trauma is minimal; 2. It is not necessary to transpose other tendons; 3. Except for the thumb in opposition, movements of other fingers and the wrist are not restricted postoperatively
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Effects of lateral wedge insole on static and dynamic balance in patients with moderate medial knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND AND OBJECTIVE: Knee osteoarthritis (OA) is associated with diminished joint proprioception, balance deficits and increased risk of falls. Patients with medial knee osteoarthritis are at higher risk of balance deficits and falling due to the development of secondary varus deformity. Therefore, it is of great clinical importance to identify the treatment methods that could improve balance in knee OA. The purpose of this study was to evaluate the effects of Lateral Wedge Insole (LWI) on static and dynamic balance in patients with moderate medial knee osteoarthritis. METHODS: Thirty patients with moderate medial knee OA participated in this semi-experimental interventional study. Patients were recruited from orthopedic and rheumatology clinics of the university. For each patient, the static and dynamic balance were assessed in two conditions including wearing shoes with flat insole and wearing shoes with lateral wedge insole, using a Prokin stabilometer. The balance variables were the anteroposterior and mediolateral velocity and standard deviation of the center of pressure (COP) displacement, and total stability indices. Patients performed two familiarization trials, then, three actual trials with at least 30 s interval for each test. FINDINGS: Wearing LWIs resulted in significant decreases in the anteroposterior (static:1.78mm/s, dynamic:6.63mm/s) and mediolateral velocity of COP (static:1.53mm/s, dynamic:5.58mm/s) in compression to wearing shoes with flat insole (p<0.001). The anteroposterior (static:1.04 mm, dynamic:1.57mm) and mediolateral SD of the COP (static:1.58mm, dynamic:2.02mm) were also decreased after using LWIs (p<0.007). Except for the anteroposterior stability index, other balance indices were also significantly improved (p<0.05). CONCLUSION: Our findings suggest that using a LWI improve static and dynamic balance in patients with moderate medial knee OA.
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Thirty-day postoperative complications and mortality following total knee arthroplasty: incidence and risk factors among a national sample of 15,321 patients
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PJI DX Updated Search
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BACKGROUND: The purpose of this investigation was to determine the incidence rates of, and identify risk factors for, thirty-day postoperative mortality and complications among more than 15,000 patients who underwent a primary unilateral total knee arthroplasty as documented in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). METHODS: The NSQIP database was queried to identify patients who had undergone primary unilateral total knee arthroplasty between 2006 and 2010. Patient demographics, medical history, and surgical characteristics were recorded, as were thirty-day postoperative complications, mortality, and length of hospital stay. Complications were divided into categories, which included major systemic complications (complications requiring complex medical intervention) and major local complications (including deep wound infection and peripheral nerve injury). Univariate testing and multivariate logistic regression analysis were used to identify significant independent predictors of the outcome measures. RESULTS: A total of 15,321 individuals underwent primary unilateral total knee arthroplasty. The mean age (and standard deviation) of the patients was 67.3 +/- 10.2 years. Obesity (a body mass index [BMI] of >/=30 kg/m(2)) was documented in 61.2% of cases, 18.2% of patients had diabetes, and 50% were graded as Class 3 or higher on the basis of the American Society of Anesthesiologists (ASA) classification system. The thirty-day mortality rate was 0.18%, and 5.6% of the patients experienced complications. Patient age (odds ratio [OR] = 1.12; 95% confidence interval [CI] = 1.06 to 1.17) and diabetes (OR = 2.99; 95% CI = 1.35 to 6.62) were independent predictors of mortality. A BMI of >/=40 kg/m(2) was an independent predictor of postoperative complications (OR = 1.47; 95% CI = 1.09 to 1.98). Patient age of eighty years or older, an ASA classification of >/=3, and an operative time of >135 minutes influenced the development of any postoperative complication as well as major and minor systemic complications. Cardiac disease (OR = 4.32; 95% CI = 1.01 to 18.45) and a BMI of >/=40 kg/m(2) (OR = 2.01; 95% CI = 1.02 to 3.97) were associated with minor local complications. CONCLUSIONS: Patient age and diabetes increased the risk of mortality after primary total unilateral knee arthroplasty. Predictive factors impacting the development of postoperative complications included an ASA classification of >/=3, increased operative time, increased age, and greater body mass
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The efficacy of adductor canal blockade after minor arthroscopic knee surgery - A randomised controlled trial
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Surgical Management of Osteoarthritis of the Knee CPG
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Background Adductor canal blockade (ACB) has been demonstrated to be effective in the treatment of post-operative pain after major knee surgery. We hypothesised that the ACB would reduce pain and analgesic requirements after minor arthroscopic knee surgery. Methods Seventy-two patients scheduled for minor knee surgery were enrolled in this placebo-controlled, blinded trial. The patients were randomised to receive an ACB with either 30 ml ropivacaine 7.5 mg/ml (n = 36) or saline (n = 35) in addition to a basic analgesic regimen with paracetamol and ibuprofen. Primary outcome measure was pain during standing at 2 h after surgery. Secondary outcomes were pain at rest, while standing and after a 5-m walk; opioid consumption and opioid-related side effects 0-24 h after surgery. Results Pain scores {median [interquartile range (IQR)]}, regarding primary outcome were 15 (0-26) mm in the ropivacaine vs. 17 (5-28) mm in the control group, 95% confidence interval (CI) (-10 to 4) mm, P = 0.41. Ketobemidone consumption 0-2 h post-operatively [median (IQR)] was lower in the ropivacaine vs. The control group: 0.0 (0.0-2.5) mg vs. 2.5 (0.0-5.0) mg, 95% CI: -2.5 to 0 mg, P = 0.01. No differences were observed for any other outcome. Conclusion No significant analgesic effect of the ACB could be detected after minor arthroscopic knee surgery with a basic analgesic regimen with acetaminophen and ibuprofen, except from a minor reduction in immediate requirements for supplemental opioids. Clinicaltrials.gov Identifier: NCT01254825. (copyright) 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
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1 |
Efficacy of antibiotic prophylactic regimens for the prevention of bacterial endocarditis of oral origin
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Despite the controversy about the risk of individuals developing bacterial endocarditis of oral origin, numerous Expert Committees in different countries continue to publish prophylactic regimens for the prevention of bacterial endocarditis secondary to dental procedures. In this paper, we analyze the efficacy of antibiotic prophylaxis in the prevention of bacteremia following dental manipulations and in the prevention of bacterial endocarditis (in both animal models and human studies). Antibiotic prophylaxis guidelines remain consensus-based, and there is scientific evidence of the efficacy of amoxicillin in the prevention of bacteremia following dental procedures, although the results reported do not confirm the efficacy of other recommended antibiotics. The majority of studies on experimental models of bacterial endocarditis have verified the efficacy of antibiotics administered after the induction of bacteremia, confirming the efficacy of antibiotic prophylaxis in later stages in the development of bacterial endocarditis. There is no scientific evidence that prophylaxis with penicillin is effective in reducing bacterial endocarditis secondary to dental procedures in patients considered to be "at risk". It has been suggested that there is a high risk of severe allergic reactions secondary to prophylactically administered penicillins, but, in reality, very few cases have been reported in the literature. It has been demonstrated that antibiotic prophylaxis could contribute to the development of bacterial resistance, but only after the administration of several consecutive doses. Future research on bacterial endocarditis prophylactic protocols should involve the re-evaluation of the time and route of administration of antibiotic prophylaxis, and a search for alternative antimicrobials
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An updated systematic review of health state utility values for osteoporosis related conditions
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Management of Hip Fractures in the Elderly
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Introduction: An important component of cost effectiveness models in the field of osteoporosis is the set of Health State Utility Values (HSUVs) used for key fracture outcomes. This paper presents a review of HSUVs for key osteoporotic states (hip, wrist, shoulder, clinical, and morphometric vertebral fractures, established osteoporosis, and interaction of several fractures). It provides an update to the systematic review conducted by Brazier et al. (Osteoporos Int 13(10):768-776, 2002). Materials and methods: A systematic search was undertaken of the main literature databases for HSUVs for established osteoporosis, vertebral, hip, wrist, and shoulder fractures were identified. Studies meeting the inclusion criteria were reviewed in terms of the patient population, the method of describing health (if not obtained directly from patients), the method of valuing health states and the source of values. Results: Estimates of Health State Utility Values were found across the osteoporosis conditions from 27 studies. A wide range of empirical estimates were found, partly due to differences in valuation technique (VAS, SG, TTO), descriptive system and differences in respondents (population or patient), the perspective of the task (own health or a scenario), sample size, and study quality. Conclusion: The paper provides a set of multipliers representing the loss in HSUVs for use as a "reference case" in cost-effectiveness models. (copyright) 2009 International Osteoporosis Foundation and National Osteoporosis Foundation
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Osteoarthritis from long-distance running?
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OAK 3 - Non-arthroplasty tx of OAK
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Long distance running has become a fashionable recreational activity. This study investigated the effects of external impact loading on bone and cartilage introduced by performing a marathon race. Seven beginners were compared to six experienced recreational long distance runners and two professional athletes. All participants underwent magnetic resonance imaging of the hip and knee before and after a marathon run. Coronal T1 weighted and STIR sequences were used. The pre MRI served as a baseline investigation and monitored the training effect. All athletes demonstrated normal findings in the pre run scan. All but one athlete in the beginner group demonstrated joint effusions after the race. The experienced and professional runners failed to demonstrate pathology in the post run scans. Recreational and professional long distance runners tolerate high impact forces well. Beginners demonstrate significant changes on the post run scans. Whether those findings are a result of inadequate training (miles and duration) warrant further studies. We conclude that adequate endurance training results in adaptation mechanisms that allow the athlete to compensate for the stresses introduced by long distance running and do not predispose to the onset of osteoarthritis. Significant malalignment of the lower extremity may cause increased focal loading of joint and cartilage.
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Distal humerus hemiarthroplasty of the elbow for comminuted distal humeral fractures in the elderly patient
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Distal Radius Fractures
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BACKGROUND: The purpose of our study was to evaluate the objective and subjective outcomes, as well as the radiographic results after elbow hemiarthroplasty (HA) for comminuted distal humerus fractures in elderly patients.
METHODS: Ten female patients with a mean age of 75.2 years were treated with elbow HA either for osteoporotic, comminuted distal humerus fractures (n = 8) or for early failed osteosynthesis of distal humerus fractures (n = 2). The mean follow-up period was 12.1 months. All patients were examined and evaluated using the Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder, and Hand score. Radiographic postoperative outcomes were assessed performing anteroposterior and lateral radiographs of the injured elbow.
RESULTS: According to the Mayo Elbow Performance Score, nine patients achieved "good" to "excellent results" and only one patient revealed a "fair" clinical outcome. The mean Disabilities of the Arm, Shoulder, and Hand score was 11.5 (range, 0-30). The flexion of the affected elbow was 124.5degree (range, 95-140degree), the extension deficit was 17.5degree (range, 5-30degree), the pronation was 80.5degree (range, 60-90degree), and the supination was 79.5degree (range, 50-90degree). The following postoperative complications were seen: one triceps weakness, one transient ulnar nerve irritation, one superficial wound infection, and two heterotopic ossifications. None of the patients required explantation of the prosthesis. There was no evidence of loosening, radiolucency, or proximal bone resorption, whereas one patient developed progressive osteoarthritis of the proximal ulnar and radial articulation.
CONCLUSIONS: Elderly patients treated with elbow HA revealed good to excellent short-term clinical outcomes. A high rate of complications occurred but most complications found were minor and reoperation rate was low. Our results must be regarded as a report on our first experience with HA. As cartilage wear is just a question of time especially in active patients, we cautiously recommend HA only for elderly and multimorbid low-demand patients.
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Total knee arthroplasty in a patient with thrombocytopenia-absent radius syndrome
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Surgical Management of Osteoarthritis of the Knee CPG
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Thrombocytopenia-absent radius (TAR) syndrome is a rare genetic condition with a complex inheritance pattern. This syndrome is classically characterized by hypomegakaryocytic thrombocytopenia as well as bilateral absent radii, shortened ulna, and radially deviated 5-digit hands. During infancy, the predominant manifestations are hemorrhagic complications. Later in life, the bleeding disorder typically improves, but the musculoskeletal abnormalities become of greater concern because of the effects on quality of life. Although the classic musculoskeletal manifestations of TAR syndrome involve the upper extremity, multiple lower-extremity abnormalities have been described, especially dysplasia of the knee. Knee abnormalities include genu varum, varying degrees of laxity or stiffness, patellar abnormalities, concave distal femur, convex medial tibial plateau, and/or absence of the anterior cruciate ligament and posterior cruciate ligament. Several management strategies for lower-extremity abnormalities in TAR syndrome have been described, especially for pediatric patients. Management strategies have not halted the natural progression of knee disease in these patients, and the effect that these knee abnormalities have in adulthood is unclear. Management of knee abnormalities in adults with TAR syndrome is poorly described in the current literature. The authors report a 59-year-old patient with TAR syndrome and knee abnormalities who underwent successful total knee arthroplasty. The patient was followed to the 3-year postoperative visit. At various postoperative time points (7 weeks, 6 months, 1 year, and 3 years), Knee Society Scores and 12-Item Short Form Health Survey scores were recorded. Radiographs obtained at each clinical visit showed well-positioned, well-fixed components. The authors concluded that total knee arthroplasty may be a safe and effective surgical intervention for adults with TAR syndrome and associated knee osteoarthritis
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Evaluation of arthrography and arthroscopy for lesions of the posteromedial corner of the knee
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AMP (Acute Meniscal Pathology)
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Injuries of the posteromedial corner of the knee joint were evaluated using the results of clinical, arthrographic, and arthroscopic examinations in 137 surgically treated patients (137 knees) with injuries of the ACL (acute in 61, chronic in 76). The accuracy of each diagnosis was confirmed by determining the site of the injury during the arthrotomy. A tear of the posteromedial corner of the medial meniscus was present in 40 patients, and an accurate diagnosis was made in 29 patients by clinical examination, in all 40 patients by arthrography, and in 38 patients by arthroscopy. Injury of the posterior oblique ligament was noted in 37 patients, and an accurate diagnosis was made in 15 patients by clinical examination, in 35 patients by arthrography, and in 8 patients by arthroscopy. Lesions of the posterior oblique ligament which were not detected in the arthroscopic examination alone were either rupture at the attachment to the femur or longitudinal tears in the meniscofemoral or meniscotibial portion. The results revealed that arthrography is an important means of evaluation in the diagnosis of injuries of the posteromedial corner of the knee joint.
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Idiopathic Genu Valgum and Its Association With Obesity in Children and Adolescents
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND:: Obesity as a cause of lower extremity deformity in children has been well established. This deformity is most often seen as tibia vara, however, at our institution we have observed more obese children and adolescents over age 7 years with excessive or progressive idiopathic genu valgum. Our hypothesis is that children with idiopathic genu valgum have high rates of obesity which impact the severity of their disease. METHODS:: Retrospective review of existing data was performed on 66 consecutive children/112 limbs over age 7 years with idiopathic genu valgum, seen from 2010 to 2013. Children with known metabolic or skeletal disease were excluded. Genu valgum was defined as mechanical axis in zone II or III and mechanical tibiofemoral angle �4 degrees on standing anteroposterior radiograph of the lower extremities. Body mass index (BMI) was calculated and classified by Center for Disease Control percentiles. Skeletal maturation was rated by closure of pelvic and peri-genu physes. Severity of genu valgum was also assessed by femoral and tibial mechanical axes and the mechanical axis deviation. RESULTS:: Mean patient age was 12.2±2.2 years. 47% of patients had BMI�30 and 71% were categorized as obese (>95th percentile). No sex differences were identified. Skeletal maturation explained 25% of the variance in the mechanical axis deviation and 22% of the mechanical tibiofemoral angle. BMI predicted 9.8% of the tibial valgus. Because of its skewed distribution, BMI percentile was a less useful parameter for assessment. CONCLUSIONS:: The 71% obesity rate found in our children with idiopathic genu valgum is significantly higher than the normal population. Higher BMI is associated with more tibial valgum but skeletal maturation was the main predictor of overall valgus severity. This suggests that obesity may play a role in the etiology of idiopathic genu valgum which progresses with skeletal maturation, thereby increasing the risk of osteoarthritis in adulthood. LEVEL OF EVIDENCE:: Level III.
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Expression of high molecular weight cysteine proteinase inhibitor in ovarian cancer tissues: regulation of cathepsin B expression by placental CPI
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MSTS 2018 - Femur Mets and MM
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Mouse polyclonal antibodies against placental cysteine proteinase inhibitor (CPI) react with the placental 67 kDa CPI on Western blots, and CPI present in ovarian cancer homogenate and serum was shown by double immunodiffusion to react with the same antiserum. By immunohistochemical staining, positive expression of high molecular weight CPI was observed on the tumour cell surface in serous and endometrioid ovarian carcinomas with metastasis. Normal endometrioid tissue was not stained with anti-placental CPI antibodies. Cathepsin B and pro-cathepsin B median levels in ovarian cancer tissue homogenates increased progressively with FIGO stage of the disease. The enzyme level decreased 22-fold after treatment of tissue homogenates with 5 nM purified CPI. These results provide evidence that addition of CPI reduces the levels of cysteine-type cathepsins to those of normal non-cancerous values.
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Are younger patients undergoing TKAs appropriately characterized as active?
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OAK 3 - Non-arthroplasty tx of OAK
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Background: The use of TKAs in young patients is increasing. Demographic characteristics and activity levels among this patient group may affect implant selection, performance, and survivorship. Patient age (� 55 years) and preoperative diagnosis have been used to define this patient group, with the presumption that these patients are more active than older patients with similar indications for TKA. Questions/purposes: We questioned whether (1) demographic features of young patients support high activity expectations after TKA, and (2) preoperative or postoperative functional activity measures support projections that young patients are active after TKA. Methods: We retrospectively compared demographic characteristics (gender, BMI, diagnosis) and functional activity profile (as determined by preoperative and postoperative UCLA activity score and functional subscores of The Knee Society and WOMAC instruments) for 150 patients 55 years old or younger (181 TKAs) and 262 patients who were between 65 to 75 years old (314 TKAs) at the time of surgery. Results: Younger patients having TKAs were significantly more likely than older patients to be female (74% versus 60%, p < 0.001) and to have diagnoses other than osteoarthritis (18% versus 3%, p < 0.001). BMI was significantly greater among younger female patients than among other age and gender combinations (35 kg/m2 versus 31 kg/m2, p < 0.001). Male patients had higher mean postoperative UCLA activity scores (5.5 versus 4.4, p < 0.001), Knee Society function subscores (80.2 versus 66.4, p < 0.001), and WOMAC function subscores (82.8 versus 74.2, p < 0.01) compared with female patients, but these were not different in older versus younger patients. Conclusions: Sustained high activity levels are not likely to be a principal cause of revision TKAs among younger patients when considering age and diagnosis alone. Determining the effect of activity on survivorship of prosthetic designs and techniques should be based on measured functional activity instead of using age and diagnosis as surrogates for activity. Level of Evidence: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence. © 2013 The Association of Bone and Joint Surgeons®.
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Radiographs Versus Radiographic Measurements in Distal Radius Fractures
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Distal Radius Fractures
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Surgeons use radiographic measures of deformity to help make treatment decisions in distal radius fractures. Precise threshold values are sometimes offered as a guide to treatment. The purpose was to evaluate if agreement on treatment recommendations would improve if surgeons were provided with radiographs rather than precise numeric radiographic measurements. We randomized 259 surgeons to review the scenarios of 30 consecutive adult patients with a distal radius fracture treated at our emergency department either with radiographs (135 surgeons) or with radiographic measurements (124 surgeons). Interrater reliability was measured with the Fleiss' generalized Kappa. Factors associated with a recommendation for operative treatment were sought in bivariate and multivariable analyses. Surgeons that received measurements only recommended operative treatment significantly more often, but were less likely to agree than surgeons evaluating actual radiographs. Patient factors - radiographic factors in particular - had a greater influence on treatment recommendation than surgeon factors. Agreement on treatment recommendations improved if surgeons were provided with radiographs instead of just measurements. There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery.
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Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review
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SR for PM on OA of All Extremities
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The aim of this article is to provide an updated systematic review on the 8 most commonly used surgical procedures to treat trapeziometacarpal osteoarthritis. A thorough literature search was performed using predetermined criteria. A total of 35 articles fulfilled the inclusion criteria. Nine of these 35 articles were not included in previous systematic reviews. Systematic evaluation demonstrated the following: (1) there is no evidence that trapeziectomy or trapeziectomy with tendon interposition is superior to any of the other techniques. However, when interposition is performed, autologous tissue interposition seems to be preferable. (2) Trapeziectomy with ligament reconstruction or trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is not superior to any of the other techniques. However, follow-up in the studies with a higher level of evidence was relatively short (12 mo); therefore, long-term benefits could not be assessed. In addition, trapeziectomy with LRTI seems associated with a higher complication rate. (3) Because the studies on thumb carpometacarpal (CMC) arthrodesis were of less methodological quality and had inconsistent outcomes, we are not able to conclude whether CMC arthrodesis is superior to any other technique. Therefore, high-level randomized trials comparing CMC arthrodesis with other procedures are needed. Nevertheless, findings in the newly included studies did show that nonunion rates in the literature are on average 8% to 21% and, complications and repeat surgeries are more frequent following CMC arthrodesis. (4) A study on joint replacement showed that total joint prosthesis might have better short-term results compared to trapeziectomy with LRTI. However, high-level randomized trials comparing total joint prosthesis with other procedures are needed. In addition, there is no evidence that the Artelon spacer is superior to trapeziectomy with LRTI. We conclude that, at this time, no surgical procedure is proven to be superior to another. However, based on good results of CMC arthrodesis and total joint prostheses, we postulate that there could be differences between the various surgical procedures. Therefore randomized clinical trials of CMC arthrodesis and total joint prostheses compared to trapeziectomy with long follow-up (>1 y) are warranted
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Cutaneous findings in chronic lymphocytic leukaemia
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Reconstruction After Skin Cancer
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Background: Chronic lymphocytic leukaemia (CLL) is a malignancy characterized by clonal expansion of B lymphocytes with distinct morphology and immunophenotype. The dermatological literature relating to CLL is sparse. A global descriptive survey of a large number of CLL patients has not previously been published. Objectives: To report the spectrum of dermatological conditions seen in a large series of CLL patients. Methods: Skin complications in patients with established CLL were identified retrospectively from clinical and photographic records, principally a database of over 750 consecutive cases. These events were classified, enumerated and compared. Results: Forty patients with 125 skin manifestations were identified and studied. Forty-one manifestations had documented clinical or histological atypia. In 21 of these 41 complications there had been no prior immunosuppressive therapy. We observed that cutaneous malignancies frequently presented atypically both clinically and histologically. There were 18 patients with 56 instances of basal cell carcinoma (BCC) or squamous cell carcinoma (SCC), and clinical atypia was more common with SCC than with BCC. Other cutaneous findings included varicella zoster (n = 6), leukaemia cutis (n = 3), acute graft-versus-host disease (n = 5), cutaneous drug eruptions (n = 9), multiple warts (n = 3), herpes simplex (n = 3), cutaneous T-cell lymphoma (n = 2), eosinophilic folliculitis (n = 2), malignant melanoma (n = 2) and Merkel cell tumour (n = 2). Conclusions: We have identified a range of dermatological conditions in CLL patients, with a tendency to atypical presentations. The atypia was independent of prior chemotherapy.
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Autoantibody specificities of immune complexes sequestered in articular cartilage of patients with rheumatoid arthritis and osteoarthritis
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AMP (Acute Meniscal Pathology)
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To define autoantibody specificities of immune complexes sequestered in articular cartilage of patients with rheumatoid arthritis and osteoarthritis, extracts were obtained from articular cartilage specimens from 16 patients with rheumatoid arthritis, 11 patients with osteoarthritis, and 6 normal controls. Radioimmunoassays of the extracts revealed that rheumatoid cartilage contained 37 times more IgM and 14 times more IgG than did normal cartilage extracts. In addition, osteoarthritic cartilage contained 3 times more IgM and IgG than the normal tissues. IgM rheumatoid factor was found in 13 of 16 rheumatoid cartilage extracts but in none of 11 osteoarthritic or 6 normal control extracts. IgG rheumatoid factor was detected in 4 of 7 seropositive rheumatoid but in none of 5 osteoarthritic cartilage extracts. More than 60% of the rheumatoid cartilage extracts were positive for native and denatured collagen II antibodies. Surprisingly, 50% of the osteoarthritic specimens also contained significant titers of collagen antibodies. Similar results were obtained with osteoarthritic menisci extracts. These findings indicate that the immune complexes sequestered in rheumatoid cartilage contain autoantibodies that are probably synthesized locally by cells infiltrating the inflamed synovium. If immune complexes trapped in cartilage play an important role in cartilage damage, our findings would provide a possible pathogenic mechanism that explains the self-perpetuating and chronic nature of cartilage degradation in rheumatoid arthritis and osteoarthritis.
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Palmaris longus tendon transfer for augmentation of the thenar musculature in low median palsy
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The palmaris tendon may be lengthened by a distal strip of palmar fascia and transferred subcutaneously to the tendon of insertion of the abductor pollicis brevis for augmentation of thumbs elevation from the palm. The transfer attempts to duplicate abductor brevis function in the complex act of opposition. The palmaris has appropriate strength, excursion, and direction for this purpose. It is properly phased for pinch activity and requires minimal retraining. Twenty-eight cases of transfer have been performed successfully and without difficulty. The uses of the transfer have included cases of carpal tunnel syndrome with thenar atrophy, injury to thenar muscles, and direct trauma to the median nerve in the forearm
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Radiographic manifestations of bone metastases from renal carcinoma
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MSTS 2018 - Femur Mets and MM
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From 1964 to 1974, 1,668 patients with renal carcinoma were seen at the Mayo Clinic. Bone metastases were present in 167 of these patients (only lung metastatic involvement ranked higher in frequency). More than one-third of the patients with bone metastasis from renal carcinoma had this as a presenting lesion of occult renal tumor. This group constituted 4% of all patients with renal carcinoma evaluated during the study period. While most bone lesions were in the pelvis and lower lumbar spine, any bone may be involved. All patients with bone metastases from renal carcinoma have a poor prognosis. However, some bone lesions appeared as long as 10 or more years after the initial tumor. The most common radiographic features are a lytic destructive process with indistinct margins, erosion of the cortex, and frequent expansion into the soft tissues. Pathological features are common in the long bones, and calcifications are occasionally seen. The synovial joints are not affected. A well defined sclerotic margin is a common finding after radiation treatment, although it is not a reliable indicator of the stability of the lesion.
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MiR-1275 promotes cell migration, invasion and proliferation in squamous cell carcinoma of head and neck via up-regulating IGF-1R and CCR7
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MSTS 2018 - Femur Mets and MM
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PURPOSE: miRNAs can play vital role in migration, invasion and proliferation in Squamous cell carcinoma of head and neck (SCCHN). In our study, we attempted to validate the expression and function of miR-1275 in SCCHN, and we also identified the mechanism by which miR-1275 affects migration, invasion and proliferation of SCCHN.
METHODS: Real-time polymerase chain reaction (RT-PCR) was employed to evaluate the expression of miR-1275 in both SCCHN tissues and cell lines. The role of miR-1275 in SCCHN cells was verified by cell function experiments upon transfection with miR-1275 mimics and inhibitor. Western blot analysis was employed to test the target gene expression of miR-1275. Survival analysis was made with the information of SCCHN patients expressed miR-1275 from The Cancer Genome Atlas (TCGA) database.
RESULTS: miR-1275 expression was up-regulated in SCCHN tissues and advanced metastatic SCCHN cells. Increasing miR-1275 expression in SCCHN could promote cell migration, invasion and proliferation probably by upregulating Insulin-like growth factor 1 receptor (IGF-1R) and C-C chemokine receptor type 7(CCR7) protein levels, whereas inhibition of miR-1275 could lead the opposite effects, although others have already demonstrated that IGF-1R is a direct target of miR-1275. Survival analysis suggested that patients with lower miR-1275 expression may have a better outcome.
CONCLUSIONS: Herein we report for the first time that miR-1275 could act as a tumor-promoter in SCCHN possibly by regulating its target gene via novel miRNA mechanisms. MiR-1275 plays an important role in promoting SCCHN progression. The miR-1275 may be a potential therapeutic target for SCCHN treatment in the future.
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An economic evaluation of bupivacaine plus fentanyl versus ropivacaine alone for patient-controlled epidural analgesia after total-knee replacement procedure: a double-blinded randomized study
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND AND OBJECTIVES: Total-knee replacement (TKR) surgery is one of the most painful orthopedic procedures after surgery. Opioid has been commonly combined with a local anesthetic to improve the quality of pain relief, but the treatment has opioid-related side effects. This study compared the cost effectiveness of patient-controlled epidural analgesia (PCEA) with 0.0625% bupivacaine plus fentanyl (BF) 3 microg/mL versus 0.15% ropivacaine alone (R) during the first 48 hours after TKR procedure. METHODS: This prospective randomized double-blinded study was performed on 70 patients who underwent unilateral TKR procedure and received either BF or R after surgery. Visual analog scale (VAS) pain score at rest and upon movement, side effects, and cost of treatment were compared. RESULTS: Overall pain at rest and upon movement between groups was not significantly different (P = 0.58, 95% CI = 4.4 to -7.8 and P = 0.8, 95% CI = 6.4 to -8.2, respectively). Patients in the BF group experienced more pruritus and had more vomiting episodes than those in the R group (P = .015), whereas no difference occurred in other side effects. Nevertheless, patient satisfaction with pain management was higher in the BF group compared with that in the R group. In addition, pain treatment with bupivacaine and fentanyl was 18% less costly compared with ropivacaine alone. CONCLUSIONS: Considering the economic evaluation, we conclude that PCEA with 0.0625% bupivacaine plus fentanyl 3 microg/mL is more cost effective and provides more patient satisfaction than PCEA with ropivacaine alone. However, use of epidural ropivacaine alone causes fewer opioid-related side effects, particularly pruritus and vomiting
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Minimal clinically important differences of 3 patient-rated outcomes instruments
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Purpose: Patient-rated instruments are increasingly used to measure orthopedic outcomes. However, the clinical relevance of modest score changes on such instruments is often unclear. This study was designed to define the minimal clinically important differences (MCIDs) of the Disabilities of the Arm, Shoulder, and Hand (DASH), QuickDASH (subset of
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Functional outcome of PFC Sigma fixed and rotating-platform total knee arthroplasty. A prospective randomised controlled trial
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PJI DX Updated Search
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The aim of this study was to determine whether there is a difference in functional outcome between the PFC Sigma fixed-bearing and rotating-platform total knee replacement systems. One hundred twenty patients were randomised to receive either a fixed-bearing or rotating-platform PFC Sigma total knee replacement. Range of movement (ROM), Oxford knee score (OKS) and Knee Society score (KSS) were assessed independently before and one year after surgery. Weight-bearing X-rays were taken immediately and one year post surgery to determine the incidence of osteolysis and loosening. At a mean follow-up of 13.4 months there was no statistically significant difference in mean ROM, OKS and KSS between the two groups. There was no evidence of osteolysis or loosening in either of the groups and no revision for infection or implant failure. This study shows that there is no statistically significant difference in functional outcome between the two types of implants at short-term follow-up
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Second intention healing after Mohs micrographic surgery
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Reconstruction After Skin Cancer
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BACKGROUND: Although second intention healing has been used for many years in Mohs micrographic surgery, it has lost popularity. This is due to the long process and functional alteration of important anatomical units if certain wound healing factors are not carefully taken into consideration. OBJECTIVE: To review indications, contraindications, complications, advantages, disadvantages, as well as basic concepts of the wound healing process, wound care and antibiotic prophylaxis in the management of open wounds after Mohs surgery. METHODS: A short but comprehensive review of studies published in the literature dealing with second intention healing as a reconstruction alternative option in certain situations. CONCLUSIONS: Second intention healing is a simple and cost-effective method for reconstruction after Mohs micrographic surgery in well-defined cases. It allows adequate tumoral control with good to excellent functional and cosmetic results.
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When data conflict with practice: rethinking the use of prophylactic antibiotics before dental treatment
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Concern is growing about the overuse of antibiotics and the subsequent rise in antibiotic-resistant bacteria. Antibiotics are commonly used to prevent heart valve infections in susceptible patients undergoing dental or other surgical procedures. Although this practice has been standard for nearly 50 years, little evidence exists that it works. This Issue Brief summarizes a population-based study that challenges the link between dental procedures and heart valve infections, and illustrates the difficulty in incorporating new evidence into existing guidelines and longstanding practices
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Multicentric reticulohistiocytosis presenting with papulonodular skin lesions and arthritis mutilans
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Surgical Management of Osteoarthritis of the Knee CPG
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Multicentric reticulohistiocytosis is a rare multisystem disorder of unknown etiology that is characterized by erosive polyarthritis and papulonodular lesions on the skin, mucous membranes, and internal organs. We report the case of a 54-year-old female who was misdiagnosed as having rheumatoid arthritis and underwent numerous joint replacement surgeries for progressively destructive arthritis in her hands, shoulders, hips, and knees. The patient finally received a diagnosis of multicentric reticulohistiocytosis after histopathological examination of the patient's left knee arthroplasty which revealed a diffuse histiocytic infiltrate, multinucleated giant cells, and finely granulated eosinophilic cytoplasm with a ground-glass appearance
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Emerging role of ultrasound imaging associated to clinical neurophysiology as a supplementary diagnostics technique of peripheral nerves pathologies: A sicilian experience
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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PURPOSE To show the relevance of peripheral nerve ultrasound imaging as a supplementary technique in a clinical neurophysiological evaluation
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Meniscus repair and regeneration: review on current methods and research potential
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AMP (Acute Meniscal Pathology)
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Meniscus regeneration is an unsolved clinical challenge. Despite the wide acceptance of the degenerative consequences of meniscectomy, no surgical procedure has succeeded to date in regenerating a functional and long-lasting meniscal fibrocartilage. Research proposed a number of experimental approaches encompassing all the typical strategies of regenerative medicine: cell-free scaffolds, gene therapy, intra-articular delivery of progenitor cells, biological glues for enhanced bonding of reparable tears, partial and total tissue engineered meniscus replacement. None of these approaches has been completely successful and can be considered suitable for all patients, as meniscal tears require specific and patient-related treatments depending on the size and type of lesion. Recent advances in cell biology, biomaterial science and bioengineering (e.g., bioreactors) have now the potential to drive meniscus regeneration into a series of clinically relevant strategies. In this tutorial paper, the clinical need for meniscus regeneration strategies will be explained, and past and current experimental studies on meniscus regeneration will be reported.
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Total knee arthroplasty after opening- versus closing-wedge high tibial osteotomy. A 135-case series with minimum 5-year follow-up
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: High tibial osteotomy (HTO) is effective in treating isolated medial osteoarthritis of the knee, but subsequent deterioration is inevitable, and total knee arthroplasty (TKA) is then an option. The present study sought to compare TKA following medial opening-wedge HTO (OW-HTO) versus lateral closing-wedge HTO (CW-HTO) in terms of intraoperative data and clinical results. The study hypothesis was that there is no significant difference in clinical results or complications in TKA following OW-HTO or CW-HTO.
MATERIAL AND METHOD: A retrospective multicenter (9 centers) study was conducted for the French Society of Orthopedic Surgery and Traumatology (SoFCOT), including 135 TKAs following HTO (58 OW and 77 CW) at a minimum 5 years' follow-up. Mean interval between HTO and TKA was 134 months and was longer in case of CW-HTO (P<0.0001). Mean age at TKA was 65.4 years and older in case of CW-HTO (P=0.021). Tibial slope was greater in case of OW-HTO (P=0.024). Prior to TKA, 55.7% of patients could walk without canes, 98.4% found stairs difficult or impossible and only 19.1% could manage a walking distance greater than 1000m. Mean flexion was 110degree; 54.2% of patients showed frontal knee stability and 87.8% sagittal stability; 60.1% had a mechanical axis in varus, without difference according to OW- or CW-HTO.
RESULTS: Hardware was almost systematically removed (in 98.5% of cases): in the same step for OW-HTO (P=0.018) or often in 2 steps for CW-HTO. The primary approach was generally re-used (54.2%), but less frequently in the CW-HTO group (P=0.0004). Lateral or medial ligament release was not associated in respectively 78.2% and 79.7% of cases. The TKA implant was usually without stem (87.2%) and was fitted using a conventional technique (74.4%). At a mean 87 months' follow-up, 78.5% of patients could walk without canes, stairs were still difficult or impossible for 67%, and 74.1% could now walk further than 1000m; mean flexion was 110.5degree. Overall, 91.5% of patients showed frontal knee stability and 98.2% sagittal stability, without difference according to OW- or CW-HTO. There were 15 complications within 3 months, more often in the OW-HTO group (12.3%) although not significantly, and with no difference in severity. Late complications comprised loosening (5.5%) and infection (3.6%) and were more frequent in the CW-HTO group (12%) (P<0.05).
DISCUSSION: The study hypothesis was partially confirmed. The only technical differences concerned hardware removal, often performed in two steps in case of CW-HTO, and TKA approach, which differed from the primary approach in case of CW-HTO. Clinical results were comparable between OW- and CW-HTO, but late complications were more frequent in the CW-HTO group.
LEVEL OF EVIDENCE: III; comparative retrospective study.
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(vi) Focal resurfacing implants in the knee and partial knee replacements
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Osteochondritis Dissecans 2020 Review
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Treating the chronically painful knee has never been more challenging. We are now faced with a growing population of increasingly demanding patients presenting with knee pathology that is not responding to conservative measures. This has paved the way for revolutionary techniques to treat the knee, with the aim of preserving as much of the native joint as possible for as long as possible. Finding the best, evidence-based, surgical solutions for patients presenting with focal pathology within the knee is complex, given the multiple modalities of treatments available. It is therefore crucial for healthcare professionals and patients to be appraised of the available treatments and their outcomes, to enable fully informed decisions. This paper presents an overview of the current evidence and treatment options available when considering resurfacing implants and partial knee replacements in the treatment of focal lesions and arthritis in the knee.
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Does alendronate prevent collapse in osteonecrosis of the femoral head?
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Management of Hip Fractures in the Elderly
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Progression of collapse in osteonecrosis of the femoral head is related to the repair response, especially bone resorption around the necrotic region. A preliminary clinical study was done to determine whether systemic alendronate would prevent collapse and lead to pain relief in patients with osteonecrosis of the femoral head. Fourteen patients (20 hips) with osteonecrosis of the femoral head received daily administration of 5 mg alendronate (alendronate group) for 1 year. Eight patients (13 hips) with osteonecrosis of the femoral head did not receive alendronate (control group). All patients had measurements of biochemical markers of bone turnover at entry into the study, and the patients in the alendronate group repeated the measurements at 3 months, 6 months, and 12 months. All patients had clinical and plain radiographic examinations at entry into the study and at 3 months, 6 months, and 12 months. The alendronate group showed a greater decrease of biochemical marker of bone resorption than biochemical marker of bone formation. The alendronate group showed a lower frequency of collapse of the femoral head and reported less hip pain than the control group. Our results suggest alendronate has the potential to prevent collapse of the femoral head, even with extensive necrosis, presumably by inhibiting bone resorption in the necrotic region. LEVEL OF EVIDENCE: Therapeutic study, level II (prospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence
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Lack of agreement between computer navigation and post-operative 2-dimensional computed tomography (CT) measurements for component and limb alignment in total knee arthroplasty (TKA)
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OAK 3 - Non-arthroplasty tx of OAK
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Background: The purpose of this study was to assess the degree of mismatch between intraoperative navigation data using imageless computer navigation and post-operative CT scan measurements with respect to bone cuts, component and limb alignment during TKA. Methods: Intraoperative navigation data including bone cut verification and overall limb alignment during TKA was compared to postoperative CT measurements of component and limb alignment according to the Perth protocol. The proportion of cases with mismatch between navigation and CT measurements at two and three degree thresholds was identified. Results: In a total sample of 50 primary TKAs, 20% of cases showed a mismatch of more than two degrees between navigation and CT obtained measurements for coronal femoral alignment, 42% for femoral rotation, 16% for tibial component coronal alignment and 32% for overall limb alignment. Conclusion: Mismatch between intraoperative navigation data and postoperative CT measurements suggests that postoperative CT scan alignment data should be interpreted with caution. A surgeon should consider a multitude of factors when analysing component and limb alignment postoperatively.
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Linkage analysis of candidate genes as susceptibility loci for osteoarthritis-suggestive linkage of COL9A1 to female hip osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: To examine 11 candidate genes as susceptibility loci for osteoarthritis (OA). METHODS: A total of 481 families have been ascertained in which at least two siblings have had joint replacement surgery of the hip, or knee, or hip and knee for idiopathic OA. Each candidate gene was targeted using one or more intragenic or closely linked microsatellite marker. The linkage data were analysed unstratified and following stratification by sex and by joint replaced (hip or knee). RESULTS: The analyses revealed suggestive linkage of the type IX collagen gene COL9A1 (6q12-q13) to a subset of 132 families that contained affected females who were concordant for hip OA (female-hip) with a P-value of 0.00053 and logarithm of the odds (LOD) score of 2.33 [corrected P-value of 0. 0016, corrected LOD score of 1.85]. CONCLUSIONS: COL9A1 may therefore be a susceptibility locus for female hip OA. In addition, there was weak evidence of linkage to HLA/COL11A2 (6p21.3) in female hip OA with a corrected P-value of 0.016
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Aetiopathogenesis of cuff-tear arthropathy: Could juvenile joint laxity be considered a predisposing factor?
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Trial Systematic Review Project
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Purpose: Although many hypotheses have been formulated, aetiopathogenesis of cuff-tear arthropathy (CTA) is still motive for discussion. Since prevalence of CTA is notoriously higher in women, as is joint hypermobility, we hypothesised a possible correlation between the two conditions. Methods: One hundred thirty-three (n = 133) consecutive patients with glenohumeral osteoarthritis [48 men, 85 women; mean age (SD) 72.32 (7.05)] were divided into two groups: Groups 1 (CTA) and 2 (concentric shoulder arthropathy) comprised 71 (22 men, 49 women) and 62 (26 men, 36 women), respectively. The presence of current or previous joint hypermobility was assessed using two standardised methodologies: the Beighton criteria score, and a five-item self-report questionnaire. Data were submitted to statistical analysis. Results: A moderate association between Beighton criteria and the five-item self-report (f = 0.481, p < 0.001) was detected. Beighton criteria led to a diagnosis of joint hypermobility in 16 patients (22.5%) in Group 1 and 15 (24.2%) in Group 2. According to five-item self-report questionnaire, juvenile joint laxity was diagnosed in 11 (15.5%) and 12 (19.4%) patients in Groups 1 and 2, respectively. No significant association between groups and the Beighton criteria [?2(1) = 0.051, p = 0.82] and five-item self-report questionnaire [?2(1) = 0.67, p = 0.41] was found. Conclusion: Juvenile joint hyperlaxity is not a predisposing factor for cuff arthropathy. Further studies will be needed to explain CTA aetiopathogenesis. Levels of Evidence: III.
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The Terry Fox Research Institute Canadian Prostate Cancer Biomarker Network: an analysis of a pan-Canadian multi-center cohort for biomarker validation
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Refinement of parameters defining prostate cancer (PC) prognosis are urgently needed to identify patients with indolent versus aggressive disease. The Canadian Prostate Cancer Biomaker Network (CPCBN) consists of researchers from four Canadian provinces to create a validation cohort to address issues dealing with PC diagnosis and management.
METHODS: A total of 1512 radical prostatectomy (RP) specimens from five different biorepositories affiliated with teaching hospitals were selected to constitute the cohort. Tumoral and adjacent benign tissues were arrayed on tissue microarrays (TMAs). A patient clinical database was developed and includes data on diagnosis, treatment and clinical outcome.
RESULTS: Mean age at diagnosis of patients in the cohort was 61 years. Of these patients, 31% had a low grade (<=6) Gleason score (GS), 55% had GS 7 (40% of 3 + 4 and 15% of 4 + 3) and 14% had high GS (>=8) PC. The median follow-up of the cohort was 113 months. A total of 34% had a biochemical relapse, 4% developed bone metastasis and 3% of patients died from PC while 9% died of other causes. Pathological review of the TMAs confirmed the presence of tumor and benign tissue cores for > 94% of patients. Immunohistochemistry and FISH analyses, performed on a small set of specimens, showed high quality results and no biorepository-specific bias.
CONCLUSIONS: The CPCBN RP cohort is representative of real world PC disease observed in the Canadian population. The frequency of biochemical relapse and bone metastasis as events allows for a precise assessment of the prognostic value of biomarkers. This resource is available, in a step-wise manner, for researchers who intend to validate prognostic biomarkers in PC. Combining multiple biomarkers with clinical and pathologic parameters that are predictive of outcome will aid in clinical decision-making for patients treated for PC.
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Osteochondral allografts in the treatment of osteonecrosis of the knee
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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In summary, patients with spontaneous osteonecrosis of the knee requiring surgery were elderly and generally had late stage IV disease. They seemed to do better with osteotomy and debridement than with osteochondral allograft replacement because they could not tolerate restricted weight bearing. Patients with steroid-induced osteonecrosis did well initially after allograft replacement (6 to 18 months), especially in experiencing pain relief. However, because of the continuous use of high doses of steroids, revascularization of the allografts was poor, resulting in graft subsidence. Patients have better long-term results following osteotomy and debridement. Patients with traumatic osteonecrosis and osteochondritis dissecans had the best results following osteochondral allograft replacements. In conclusion, based on our series and others, our current surgical approach in the management of osteonecrosis of the knee is as follows: 1. In patients with spontaneous osteonecrosis with asymptomatic small lesions, nonsurgical treatment is recommended. For an asymptomatic or symptomatic large lesion with associated angular deformity, the active patient should have a tibial osteotomy for stages I and II and tibial osteotomy and debridement for stages III and IV. Less active patients with symptomatic stage III or IV disease should have unicompartmental or total knee prosthetic arthroplasty. 2. For steroid-induced osteonecrosis, osteochondral allografts are not recommended. If the patient's systemic disease has a limited prognosis, or if the patient has multijoint involvement, total knee or unicompartmental arthroplasty is warranted. If the patient has a good prognosis and is active, debridement with or without realignment should be performed. 3. For traumatic osteonecrosis in the younger patient or for osteochondritis dissecans, fresh osteochondral allograft replacement is recommended. High tibial osteotomy in combination with allograft replacement should also be done if there is associated malalignment. The realignment should be done prior to or simultaneously with the allograft (providing the osteotomy is done on the side of the joint opposite the allograft)
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Anterior knee pain after total knee arthroplasty: a narrative review
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Surgical Management of Osteoarthritis of the Knee CPG
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Anterior knee pain is one of the most common causes of persistent problems after implantation of a total knee replacement. It can occur in patients with or without patellar resurfacing. As a result of the surgical procedure itself many changes can occur which may affect the delicate interplay of the joint partners in the patello-femoral joint. Functional causes of anterior knee pain can be distinguished from mechanical causes. The functional causes concern disorders of inter- and intramuscular coordination, which can be attributed to preoperative osteoarthritis. Research about anterior knee pain has shown that not only the thigh muscles but also the hip and trunk stabilising muscles may be responsible for the development of a dynamic valgus malalignment. Dynamic valgus may be a causative factor for patellar maltracking. The mechanical causes of patello-femoral problems after knee replacement can be distinguished according to whether they increase instability in the joint, increase joint pressure or whether they affect the muscular lever arms. These causes include offset errors, oversizing, rotational errors of femoral or tibial component, instability, maltracking and chondrolysis, patella baja and aseptic loosening. In these cases, reoperation or revision is often necessary
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Synovial fluid biomarkers for periprosthetic infection
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PJI DX Updated Search
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BACKGROUND: We have previously described a unique gene expression signature exhibited by synovial fluid leukocytes in response to bacterial infection, identifying a number of potential biomarkers for infection. However, the diagnostic performance of these potential biomarkers in an immunoassay format is unknown. QUESTIONS/PURPOSES: We therefore evaluated the sensitivity, specificity, and accuracy of several potential synovial fluid biomarkers for infection, and compared them to current standards of testing for periprosthetic infection. METHODS: We prospectively collected synovial fluid from 14 patients classified as having a periprosthetic infection and 37 patients classified as having an aseptic failure. The synovial fluid samples were tested for 23 potential biomarkers for periprosthetic infection. We then determined differences in biomarker levels between infected and aseptic groups, then computed the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for select biomarkers, and finally compared those to current standard tests for infection. RESULTS: Twelve synovial fluid biomarkers had substantially higher average levels in the synovial fluid of infected versus aseptic patients. Synovial fluid levels of IL-1 were a mean of 258 times higher in patients with a periprosthetic infection compared to patients having revision for aseptic diagnoses. Synovial fluid IL-1 and IL-6 levels correctly classified all patients in this study with a sensitivity, specificity, positive predictive value, negative predictive value and accuracy equal to 1. Several markers tested in this study outperformed the ESR and CRP tests. CONCLUSIONS: Patients with a periprosthetic infection have elevated levels of numerous synovial fluid biomarkers, when compared to patients with aseptic diagnoses. Several of these biomarkers exhibited nearly ideal sensitivity, specificity, and accuracy in this study, suggesting that synovial fluid biomarkers could be a valuable tool for diagnosing periprosthetic infection. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence
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Hip ultrasonography in clinical practice
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Developmental Dysplasia of the Hip 2020 Review
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The current practice of hip ultrasonography for developmental dysplasia of the hip (DDH) is based on more than three decades of experience. During this time, professional medical organizations in the United States have addressed both the clinical practice and imaging aspects of early detection of DDH. Current evidence-based clinical practice recommendations come from the American Academy of Pediatrics and the American Academy of Orthopaedic Surgeons. Consensus imaging recommendations come from the American Institute of Ultrasound in Medicine, the American College of Radiology, Society for Pediatric Radiology and the Society of Radiologists in Ultrasound. In this review the author compares and contrasts the current guidelines and offers additional practice tips for those providing comprehensive hip ultrasound services to infants.
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Zoledronic acid down-regulates adhesion molecules of bone marrow stromal cells in multiple myeloma: a possible mechanism for its antitumor effect
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: Myeloma plasma cells interact with the bone marrow microenvironment which, in turn, supports their growth and protects them from apoptosis. In vitro studies have demonstrated the antitumor potential of zoledronic acid (ZOL) on myeloma cell lines, but few data are available on its effects on bone marrow stromal cells (BMSCs). The aim of the current study was to evaluate the antiproliferative and apoptotic effect of ZOL on BMSCs, as well as its effect on the expression of adhesion molecules.
METHODS: BMSCs, obtained from bone marrow mononucleated cells of 8 patients with multiple myeloma, were treated with increasing concentrations of ZOL for 3 days. Cytotoxic effect was analyzed by 3-(4-5-dimethylthiazol-2-yl)-2,5 diphenyltetrazolium bromide; thiazolyl blue (MTT) assay whereas the induction of apoptosis was evaluated by flow cytometric detection of fluorescein isothiocyanate-labeled annexin V, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay, and nuclear changes. Moreover, expression of CD106, CD56, CD50, CD49d, CD44, and CD40 was analyzed by flow cytometry. Data were evaluated by the Friedman test.
RESULTS: After 3 days of exposure at concentrations of 10(-4) to 10(-5) M, ZOL induced a decrease in proliferation (P < 0.0001) and an increase in apoptosis (P < 0.002). Analysis of culture supernatants showed that myeloma BMSCs expressed interleukin (IL)-6, negligible levels of tumor necrosis factor-alpha, and no IL-1beta. In vitro exposure to the lowest concentrations of ZOL decreased IL-6 production by BMSCs. Among the adhesion molecules, CD106, CD54, CD49d, and CD40, which were strongly expressed at baseline, showed a statistically significant reduction compared with controls after exposure to ZOL.
CONCLUSIONS: ZOL interfered with myeloma BMSCs by reducing proliferation, increasing apoptosis, and modifying the pattern of expression of adhesion molecules, especially those involved in plasma cell binding. These effects on BMSCs might explain the antitumor activity of ZOL.
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Infections after high tibial osteotomy
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PJI DX Updated Search
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PURPOSE: High tibial osteotomy is an established method in the treatment for knee osteoarthritis. Infections are a rare but severe complication that might endanger the clinical, radiological and functional outcome and might require several surgical revisions. METHODS: A systematic literature review was performed through PubMed until November 2011. Search terms were "HTO" or "(high) tibial osteotomy", alone or in combination with "infection(s)", "infected" or "septic". Only articles focussing on the infection treatment or analysis of risk factors for emergence of infection after high tibial osteotomy were included. RESULTS: A total of 26 studies could be identified. Seven studies were published before and 19 in or after 2000. One study had a level of evidence II, five level of evidence III and 20 level of evidence IV. Superficial infections were found in 1-9% and deep infections in 0.5-4.7% of the cases. Pin tract infections occurred in 2-71% of the cases. One study reported on a secondary bacterial arthritis in 4.5% of the cases. An oblique skin incision, non-smokers and a one-day hospitalization were found to be risk factors for infection emergence. Depending on the type of infection, treatment consisted of oral or systemic antibiotic therapy, alone or in combination with surgical revision, debridement and hardware removal. In some cases, antibiotic-loaded cement beads were inserted for local antibiotic therapy. CONCLUSION: Infections after high tibial osteotomy are rare. Current data about infection rates, infection localization, risk factors for emergence of infection and treatment options allow not for a generalization of conclusions. A large multi-centre study is required to develop a diagnostic and therapeutic algorithm. LEVEL OF EVIDENCE: IV
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Simultaneous bilateral breast reconstruction with the transverse rectus abdominus musculocutaneous free flap
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Panniculectomy & Abdominoplasty CPG
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Objective: The purpose of the study was to assess the results and morbidity associated with simultaneous bilateral TRAM free flap breast reconstruction and describe refinements in its surgical technique. Summary Background Data: Bilateral prophylactic total mastectomies might be an agreeable option for those patients at highest risk for breast cancer if autogenous tissue breast reconstruction could be performed with reasonable technical ease and acceptable morbidity. However, some surgeons harbor reservations regarding the extensiveness of the surgery, the associated morbidity, and the aesthetic quality of the resulting outcome. Methods: A multicenter retrospective review of clinical experience with 120 consecutive patients who underwent 240 simultaneous bilateral TRAM free flap breast reconstructions was developed. Results: The average operating time, including the time required for the breast ablative portion of the procedures, was 8.6 hours. The average length of hospitalization was 7.6 days. However, for the last 40 patients, these figures were reduced to 7.1 hours and 6.1 days, respectively. Nonautologous blood transfusions were needed in 33 cases (28%), but only 1 was required in the last 40 patients. Thromboses developed in six of 240 flaps (2.5%): 4 were arterial and 2 were venous. Re-exploration allowed us to restore circulation in five flaps, whereas one flap was unsalvageable and was replaced successfully with an alternate flap. An uncomplicated deep vein thromboses developed in one patient with a history of recurrent deep vein thromboses that had no adverse effect on her outcome. Minor complications developed in 18 patients (15%) (e.g., hematoma, partial wound necrosis, wound infection, or prolonged postoperative ileus) that did not affect the long-term outcome. Fourteen patients (11.6%) had abdominal wall weakness or hemias. Follow-up time averaged 37.2 months (range, 14-62 months). On last follow-up, patients' self-reported overall satisfaction with the procedure was 56% excellent, 40% good, and 4% fair. Conclusions: Simultaneous bilateral free flap reconstruction is technically feasible with a high rate of success and an acceptable morbidity. When performed by experienced surgeons, bilateral prophylactic total mastectomies combined with simultaneous bilateral TRAM free flap reconstruction may provide an adequate surgical option with aesthetically acceptable results for patients at high risk for breast cancer.
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Isolated traumatic dislocation of the hip. Long-term results in 50 patients
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Developmental Dysplasia of the Hip CPG
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From 1974 to 1989, we treated 50 patients with a simple dislocation of the hip: 38 were posterior dislocations and 12 were anterior. All dislocations primarily treated at our hospital were reduced by closed methods within three hours (mean 85 minutes (10 to 180)) and 43 were reviewed after an average follow-up of 8 years (2 to 17). It is widely held that isolated hip dislocation reduced within six hours gives an excellent outcome, but we found a significant number of complications. There were radiological signs of partial avascular necrosis in two, mild osteoarthritis in seven, and moderate degeneration in two. Heterotopic ossification was seen in four patients, but 29 of 33 MRI examinations were normal. Objective evaluation according to the Thompson and Epstein (1951) criteria showed fair and poor results in 3 of 12 anterior dislocations, but in 16 of 30 posterior dislocations. In six of the seven patients with no other severe injury, the hip had an excellent or good result; in only three of the eight patients with severe multiple injuries was this the case. The important factors in the long-term prognosis appear to be the direction of the dislocation and the overall severity of injuries
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Occupational medicine: carpal tunnel syndrome-a cumulative trauma disorder
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The Scientific Board of the California Medical Association presents the following inventory of items of progress in occupational medicine. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in occupational medicine that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Occupational Medicine of the California Medical Association and the summaries were prepared under its direction
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3-D analysis of breast morphology changes after inverted T-scar and vertical-scar reduction mammaplasty over 12 months
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Reduction Mammoplasty for Female Breast Hypertrophy
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One major objective of all types of breast reduction procedures is to achieve a long-lasting, stable and aesthetically pleasing three-dimensional (3-D) breast shape, but current surgical outcome evaluation is limited. This study compares the extent of soft-tissue oedema and breast tissue migration related to 3-D breast morphology changes after inverted T-scar and vertical-scar breast reduction over 12 months. 3-D breast surface scans of patients undergoing inverted T-scar (n = 52 breasts) and vertical-scar (n = 44 breasts) reduction mammaplasty were obtained preoperatively and 2-3 days, 1 week, 1 month, 3 months, 6 months, 9 months and 12 months postoperatively. 3-D images were analysed at each time point comparing distances, 3-D breast contour deviations (%), breast surface (cm2) and volume (cc) measurements including volumetric distribution between the upper portion (UP) and the lower portion (LP) of the breast (%). Total postoperative breast volume decreased by 11.7% (T-scar) and by 7.8% (vertical-scar) during the first 3 months (both p < 0.001) without relevant changes in the following months, indicating that soft-tissue oedema is resolved after 3 months. The T-scar (vertical-scar) group showed a preoperative UP to LP volumetric distribution of 43:57% (45:55%) versus 86:14% (91:9%) immediately after surgery. Breast tissue significantly redistributes (both p = 0.001) from the UP to the LP during the first postoperative year by 16.5% (T-scar) and 21% (vertical-scar), resulting in a final UP to LP ratio of 70:30% for both techniques, without further breast contour deviations (both p > 0.05) after 6 months (T-scar) and 9 months (vertical-scar). Breast morphological changes after reduction mammaplasty are completed after a period of 3-6 months in the T-scar group and 6-9 months in the vertical-scar group. © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
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Proline/arginine-rich end leucine-rich repeat protein converts stem cells to ligament tissue and Zn(II) influences its nuclear expression
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OAK 3 - Non-arthroplasty tx of OAK
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Our objective was to facilitate ligament tissue reconstruction by characterizing the mechanism of expression of ligament tissue. To accomplish this, we searched for proteins specific to the tissue and introduced them into mesenchymal stem cells. In the two-dimensional phosphorescent gel electrophoresis, the spots in common with the normal human ligament tissue were selected after removing the spots of the normal bone tissue from those of the ossified tissue in the spinal ligament. Proline/arginine-rich end leucine-rich repeat protein (PRELP) was identified in ligament-specific locations by liquid chromatography-tandem mass spectrometry. Transfection of PRELP into mouse mesenchymal stem cells yielded ligament-like connective tissue comprised of parallel fibers. Thus, expression of the PRELP protein could reconstruct the ligament tissue. Since zinc-related proteins were found with high incidence as a result of an array analysis of PRELP's ProtoArray, it was considered that there is a relationship to the zinc metabolism. Tissue induction was mediated by the tumor necrosis factor (TNF)-alpha via the zinc pathway. PRELP may be a useful gene in syndesmoplasty, provided zinc is present for tissue reconstruction. Chromosome division becomes active with the addition of zinc, and rapid tissue induction takes place in the presence of zinc and TNF-alpha. Currently, the reconstruction of a ruptured ligament tissue is difficult, but we expect that the PRELP protein expression may facilitate this process. This study describes the discovery of the gene responsible for the differentiation of stem cells into ligament tissue. This important finding may lead to treatments for gonarthrosis, cruciate ligament, and periodontal ligament ruptures, and ossification of the posterior longitudinal ligament.
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Central head perforation, or "cut through," caused by the helical blade of the proximal femoral nail antirotation
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Management of Hip Fractures in the Elderly
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Objective: This study was designed to investigate the specific type and incidence of implant failure in patients with a proximal femur fracture treated with a proximal femoral nail antirotation. This device has a helical-shaped blade as a neck-head holding device, instead of the lag screw used in other intramedullary nails. The advantage of the blade is believed to originate from bone impaction and a larger bone-implant interface in comparison with the lag screw design, with consequential greater mechanical resistance to torsion in the cancellous bone. Patients and Methods: This is a retrospective cohort study conducted at the state hospital of Winterthur, Switzerland. From December 2006 until November 2008, 210 consecutive patients were treated with a pertrochanteric femur fracture (OTA type 31-A1, 31-A2, and 31-A3) using a proximal femoral nail antirotation. One hundred and twelve patients were followed up clinically for a minimum of 12 months after discharge. Clinical and radiologic assessment of fracture healing and/or implant failure was investigated. Results: We report 7 cases of implant failure with a "Cut Through," defined as a postoperative central perforation of the spiral blade into the hip joint, without any displacement of the neck-head fragment. Conclusions: Cut through needs to be distinguished from the well-known anterocranial perforation combined with a varus displacement of the neck-head fragment, known as "Cut Out," seen with intramedullary nails utilizing lag screws. Copyright (copyright) 2012 by Lippincott Williams & Wilkins
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Limited value of ultrasound assessment in patients with poor outcome after carpal tunnel release surgery
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVE: To determine the value of ultrasonography in the assessment of patients with idiopathic carpal tunnel syndrome (CTS) and poor outcome after carpal tunnel release. METHODS: A total of 88 consecutive patients with CTS (104 hands) underwent open surgical release of the median nerve. Ultrasound (US) examination was performed blind to any patient's data. The median nerve area at tunnel inlet and outlet, the retinaculum distance, and the flattening ratio were measured. The main outcome variable was the patient's overall satisfaction using a five-point Likert scale (1 = worse, 2 = no change, 3 = slightly better, 4 = much better, 5 = cured) at 3 months postoperatively. Pre- and postoperative ultrasonographic findings in relation to clinical outcome were analysed. RESULTS: Improvement (scores 4 or 5 on the Likert scale) was recorded in 75 hands (72%). After carpal tunnel release, the cross-sectional area at tunnel inlet decreased from a mean of 14.2 to 13.3 mm2 in the group with clinical improvement and also from a mean of 12.5 to 11.6 mm2 in the group with no change or slight improvement. No significant changes in the cross-sectional area at tunnel outlet, retinaculum distance, and flattening ratio were observed. CONCLUSION: Reduction of the median nerve cross-sectional area at tunnel inlet at 3 months after carpal tunnel release was similar in patients reporting cure or great improvement and in those with slight or no improvement. Ultrasonography is of limited value in assessment of patients with poor outcome after median nerve release
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Carpal tunnel syndrome in pregnancy and lactation
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A retrospective study of 40 women with carpal tunnel syndrome developing in pregnancy and 18 women with carpal tunnel syndrome in the puerperium was undertaken. All the cases that developed in pregnancy occurred in the third trimester and resolved within two weeks of delivery. Those cases developing in the puerperium affected women who had breast-fed their infants and their symptoms lasted a mean of 5.8 months. These patients were older and more likely to be primiparous than if the condition occurred in pregnancy. All the pregnant women and none of the lactating women had symptoms of peripheral oedema. Spontaneous resolution with a good response to conservative measures occurred in both groups; only three cases were treated surgically. Residual clinical evidence of median nerve damage was present in 40% of all cases. Carpal tunnel syndrome which develops in pregnancy appears to be a separate clinical entity to that developing in the puerperium
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The main autoimmune and nonautoimmune etiologies of endogenous hyperthyroidism do not seem to influence the increased prevalence of morphometric vertebral fractures and osteoporosis in Portuguese men
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Distal Radius Fractures
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Objectives: The purpose of this study was to evaluate the effects of hyperthyroidism and their etiology on bone mineral density (BMD), on body soft tissue composition, on the prevalence of vertebral fractures detected by vertebral fracture assessment (VFA) and on the trabecular bone score (TBS).
Methods: From an initial population of 119 Portuguese men (78 with hyperthyroidism [HT]+ 41 controls [CTs]) admitted to the Endocrinology Department we selected 41 men aged over 50 with clinical hyperthyroidism to participate; each one was matched by age and height with a control person. BMD (g/cm<sup>2</sup>) at the lumbar spine, hip, radius 33% and whole body and the total body masses (kg) were studied by dual-energy X-ray absorptiometry (DXA). VFA with Genant semiquantitative method was used to detect fractures. The TBS was obtained from lumbar spine DXA images. No patient had been treated previously for hyperthyroidism or osteoporosis. Adequate statistical tests were used.
Results: In the hyperthyroidism group, total lean mass (CT 58.16 +/- 7.7 vs. HT 52.3 +/- 5.7, P = 0.03) and distal radius BMD (CT 0.769 +/- 0.05 vs. HT 0.722 +/- 0.08, P = 0.005) were lower; there was a significantly higher prevalence of osteoporosis (CT 9.7% vs. HT 29.3%, P = 0.015) and vertebral fractures (CT 2.4% vs. HT 24.4%, P = 0.007). TBS was similar in both groups (CT 1.328 +/- 0.11 vs. HT 1.356 +/- 0.11, P = not significant). Comparing patients with Graves' disease with patients with toxic goiter, there were no differences regarding BMD, BMD qualification, prevalence of fractures and TBS and just total lean mass was significantly lower in patients with Graves' disease.
Conclusions: These results suggest that in a group of hyperthyroid men aged over 50 there are significant decreases in cortical bone BMD and lean mass and a higher prevalence of osteoporosis and silent vertebral fractures, but the etiology of the hyperthyroidism does not seem to influence it. Besides the antithyroid drugs, some patients may benefit from bone-directed treatments.
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Risk factors for implant failure in reverse oblique and transverse intertrochanteric fractures treated with proximal femoral nail antirotation (PFNA)
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Hip Fx in the Elderly 2019
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BACKGROUND: The incidence of intertrochanteric hip fracture is expected to increase as the global population ages. It is one of the most important causes of mortality and morbidities in the geriatric population. The incidence of reverse oblique and transverse intertrochanteric (AO/OTA 31-A3) fractures is relatively low; however, the incidence of implant failure in AO/OTA 31-A3 fractures is relatively high compared with that in AO/OTA 31-A1 and A2 fractures. To date, the risk factors for implant failure in AO/OTA 31-A3 fractures treated with proximal femoral nail antirotation (PFNA) have remained ambiguous. The purpose of this study was to identify the predictive factors of implant failure in AO/OTA 31-A3 fractures treated with PFNA.
METHODS: The data of all patients who underwent surgery for trochanteric fractures at our institution between January 2006 and February 2018 were retrospectively reviewed. All AO/OTA 31-A3 fractures treated with PFNA were included. Logistic regression analysis of potential predictors of implant failure was performed. Potential predictors included age, sex, body mass index, fracture type, reduction method, status of posteromedial support and lateral femoral wall, reduction quality, tip-apex distance and position of the helical blade in the femoral head.
RESULTS: One hundred four (9.3%) patients with AO/OTA 31-A3 fractures were identified. Forty-five patients with AO/OTA 31-A3 fractures treated with PFNA were suitable for our study. Overall, implant failure occurred in six (13.3%) of forty-five patients. Multivariate analysis identified poor reduction quality (OR, 28.70; 95% CI, 1.91-431.88; p = 0.015) and loss of posteromedial support (OR, 18.98; 95% CI, 1.40-257.08; p = 0.027) as factors associated with implant failure.
CONCLUSIONS: Poor reduction quality and loss of posteromedial support are predictors of implant failure in reverse oblique and transverse intertrochanteric fractures treated with PFNA.
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Consequences of violence across the lifespan: Mental health and sleep quality in pregnant women
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DoD PRF (Psychosocial RF)
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OBJECTIVE: Research has demonstrated that exposure to violence and adversity has negative effects on both mental health and biobehavioral outcomes, such as sleep health. Research examining the relationship between past and recent violence exposure and mental health suggests that the effects of childhood adversity are especially pernicious, but to date, no studies have attempted to disentangle the direct, indirect and relative effects of past year versus childhood exposure to violence and adversity on sleep. The objective of the current study was to examine the direct effects of adverse childhood experiences (ACEs) and past year intimate partner violence (IPV) on different aspects of sleep health in pregnant women.
METHOD: A sample of high-risk pregnant women (n = 101) were interviewed. Mediation analysis with bias-corrected, bootstrapped confidence intervals was used to evaluate direct and indirect effects.
RESULTS: Findings indicated that while ACEs had significant direct effects on mental health, past year IPV had stronger effects on sleep quality, latency, and efficiency. ACEs did, however, indirectly affect subjective sleep quality via past year psychological IPV.
CONCLUSION: These findings suggest that sleep disturbance may be a regulatory stress response that is most clearly linked to past year violence and trauma. That is, though long-term sleep disturbance may be evident following childhood adversity, it is likely that this relationship is better explained by the role of childhood adversity in predicting adulthood revictimization or due to long-term mental health difficulties associated with early trauma. (PsycINFO Database Record
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Pain perception during the rehabilitation phase following traumatic hip fracture in the elderly is an important prognostic factor and treatment tool
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Management of Hip Fractures in the Elderly
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PURPOSE: To evaluate the role of pain perception on admission to geriatric rehabilitation on the functional recovery after rehabilitation treatment in elderly patients with hip fracture and on the length of stay. METHOD: One hundred and sixty-five community dwelling elderly 65-year-old and over (mean age of 78 years), following recent operated traumatic hip fracture without clinical evidence for another acute medical or surgical condition were assessed regarding age, sex, chronic medical conditions, pre-fracture functional status, type of fracture and of operation, pain perception, and cognitive status. Pain was measured using the Visual Analogue Score (VAS). Functional status was measured using the Functional Independence Measurement (FIM). Activities of Daily Living (ADL) were assessed using the Katz index. RESULTS: The average VAS score on admission was 7.38 +/- 1.20 and on discharge 3.67 +/- 1.18. Pain on admission inversely correlated to family support, function prior to fracture and cognitive status on admission, and correlated positively with depressed mood. With every increase of one point in VAS on admission above 4 points, the FIM on discharge decreased by 8.77 and the length of stay increased by 4.76 days. CONCLUSIONS: Pain intensity may add a valuable dimension for the prognostic evaluation of the patients with hip fractures. Inadequate early patient assessment and associated treatment impact on the patients' functional outcome, prolonged duration of rehabilitation treatment, and therefore, in addition to socio-economic effect, increase the cost to the local health care setting
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Strength training for partially paralysed muscles in people with recent spinal cord injury: A within-participant randomised controlled trial
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objectives: To determine whether strength training combined with usual care increases strength in partially paralysed muscles of people with recent spinal cord injury (SCI) more than usual care alone. Settings: SCI units in Australia and India. Methods: Thirty people with recent SCI undergoing inpatient rehabilitation participated in this 12-week trial. One of the following muscle groups was selected as the target muscle group for each participant: the elbow flexors, elbow extensors, knee flexors or knee extensors. The target muscle on one side of the body was randomly allocated to the experimental group and the same muscle on the other side of the body was allocated to the control group. Strength training was administered to the experimental muscle but not to the control muscle. Participants were assessed at baseline and 12 weeks later. The primary outcome was maximal isometric muscle strength, and the secondary outcomes were spasticity, fatigue and participants perception of function and strength. Results: There were no dropouts, and participants received 98% of the training sessions. The mean (95% confidence interval (CI)) between-group difference for isometric strength was 4.3 Nm (1.9-6.8) with a clinically meaningful treatment effect of 2.7 Nm. The mean (95% CI) between-group difference for spasticity was 0.03/5 points (?0.25 to 0.32). Conclusion: Strength training increases strength in partially paralysed muscles of people with recent SCI, although it is not clear whether the size of the treatment effect is clinically meaningful. Strength training has no deleterious effects on spasticity.
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Persistent detection of SARS-CoV-2 RNA in patients and healthcare workers with COVID-19
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Coronavirus Disease 2019 (COVID-19)
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BACKGROUND: Current guidelines for returning health care workers (HCW) to service after a positive SARS-CoV-2 RT-PCR test and ceasing of transmission precautions for patients is based on two general strategies. A test-based strategy that requires negative respiratory RT-PCR tests obtained after the resolution of symptoms. Alternatively, due to the limited availability of testing, many sites employ a symptom-based strategy that recommends excluding HCW from the workforce and keeping patients on contact precautions until a fixed period of time has elapsed from symptom recovery. The underlying assumption of the symptom-based strategy is that waiting for a fixed period of time is a surrogate for negative RT-PCR testing, which itself is a surrogate for the absence of shedding infectious virus. OBJECTIVES: To better understand the appropriate length of symptom based return to work and contact precaution strategies. STUDY DESIGN: We performed an observational analysis of 150 patients and HCW that transitioned from RT-PCR SARS-CoV-2 positive to negative over the course of 2 months at a US academic medical center. RESULTS: We found that the average time to transition from RT-PCR positive to negative was 24 days after symptom onset and 10 % remained positive even 33 days after symptom onset. No difference was seen in HCW and patients. CONCLUSIONS: These findings suggest until definitive evidence of the length of infective viral shedding is obtained that the fixed length of time before returning to work or ceasing contract precautions be revised to over one-month.
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Arthroscopic Posterior Ankle Ligament Anatomy
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AMP (Acute Meniscal Pathology)
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BACKGROUND: The purpose of this article is to document the normal arthroscopic appearance of the posterior ankle capsular and ligamentous structures, and variations in their anatomical relationships.
METHODS: 102 ankle arthroscopy videotapes were evaluated retrospectively for the configuration of the posterior capsuloligamentous structures. Based on these observations, the variations in the appearance and position of the posterior tibiofibular ligament (PTFL) and transverse (tibiofibular) ligament (TTFL) were documented. In addition, differences in the appearance of the flexor hallucis longus (FHL) were also noted.
RESULTS: All patients had evidence of both a PTFL and TTFL, which formed a labrum or meniscus-like addition to the posterior distal tibia. No patients demonstrated disruption of the PTFL; 3 had tears of the TTFL. We noted 4 distinct patterns of the PTFL and the TTFL. Thirty-four patients (33%) had a gap of >=2 mm between the 2 ligamentous structures. Thirty-three (32.4%) had a gap <2 mm between the PTFL and TTFL. Twenty-six (25.5%) had a confluence of the 2 ligaments without a gap. Nine (9%) demonstrated a sizable gap between the 2 ligaments, and the TTFL appeared as a "cord-like" structure.
CONCLUSION: To our knowledge, this is the first article to describe the variations in the arthroscopic normal posterior capsuloligamentous structures and FHL of the ankle.
LEVEL OF EVIDENCE: Level IV, case series.
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Tenascin-C levels in synovial fluid are elevated after injury to the human and canine joint and correlate with markers of inflammation and matrix degradation
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: We have previously shown the capacity of tenascin-C (TN-C) to induce inflammatory mediators and matrix degradation in vitro in human articular cartilage. The objective of the present study was to follow TN-C release into knee synovial fluid after acute joint injury or in joint disease, and to correlate TN-C levels with markers of cartilage matrix degradation and inflammation.
METHOD: Human knee synovial fluid samples (n = 164) were from a cross-sectional convenience cohort. Diagnostic groups were knee healthy reference, knee anterior cruciate ligament rupture, with or without concomitant meniscus lesions, isolated knee meniscus injury, acute inflammatory arthritis (AIA) and knee osteoarthritis (OA). TN-C was measured in synovial fluid samples using an enzyme-linked immunosorbent assay (ELISA) and results correlated to other cartilage markers. TN-C release was also monitored in joints of dogs that underwent knee instability surgery.
RESULTS: Statistically significantly higher levels of TN-C compared to reference subjects were observed in the joint fluid of all human disease groups and in the dogs that underwent knee instability surgery. Statistically significant correlations were observed between the TN-C levels in the synovial fluid of the human patients and the levels of aggrecanase-dependent Ala-Arg-Gly-aggrecan (ARG-aggrecan) fragments and matrix metalloproteinases 1 and 3.
CONCLUSIONS: We find highly elevated levels of TN-C in human knee joints after injury, AIA or OA that correlated with markers of cartilage degradation and inflammation. TN-C in synovial fluid may serve dual roles as a marker of joint damage and a stimulant of further joint degradation.
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Integrity of proximal femoral allografts: A serial radiographic analysis
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Management of Hip Fractures in the Elderly
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To assess the integrity of proximal femoral allografts, we reviewed annual post-operative radiographs of 26 patients (27 hips) with a mean follow-up of 10.0 years (range 6 to 15 years). Radiographs were examined for: graft resorption, implant loosening, host/graft union, trochanteric union and escape, and graft fracture. Our main objective was to document the first appearance, site, degree and progression of allograft resorption. Severe resorption occurred in two cases, at one and six years. Progression was recognized in two different patients at six (moderate to severe) and ten (mild to moderate) years. We observed a potential for allograft resorption at any time post-operatively, emphasizing the need for annual follow-up with radiographic review
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Neurological symptoms in patients with biopsy proven celiac disease
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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In celiac disease (CD), the gut is the typical manifestation site but atypical neurological presentations are thought to occur in 6 to 10% with cerebellar ataxia being the most frequent symptom. Most studies in this field are focused on patients under primary neurological care. To exclude such an observation bias, patients with biopsy proven celiac disease were screened for neurological disease. A total of 72 patients with biopsy proven celiac disease (CD) (mean age 51 +/- 15 years, mean disease duration 8 +/- 11 years) were recruited through advertisements. All participants adhered to a gluten-free diet. Patients were interviewed following a standard questionnaire and examined clinically for neurological symptoms. Medical history revealed neurological disorders such as migraine (28%), carpal tunnel syndrome (20%), vestibular dysfunction (8%), seizures (6%), and myelitis (3%). Interestingly, 35% of patients with CD reported of a history of psychiatric disease including depression, personality changes, or even psychosis. Physical examination yielded stance and gait problems in about one third of patients that could be attributed to afferent ataxia in 26%, vestibular dysfunction in 6%, and cerebellar ataxia in 6%. Other motor features such as basal ganglia symptoms, pyramidal tract signs, tics, and myoclonus were infrequent. 35% of patients with CD showed deep sensory loss and reduced ankle reflexes in 14%. Gait disturbances in CD do not only result from cerebellar ataxia but also from proprioceptive or vestibular impairment. Neurological problems may even develop despite strict adherence to a gluten-free diet
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Volar Barton's fractures with concomitant dorsal fracture in older patients
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Distal Radius Fractures
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PURPOSE: To describe a variant of Barton's volar articular shearing fracture of the distal radial articular surface with a subtle concomitant fracture of the dorsal metaphyseal cortex.
METHODS: This fracture pattern was observed in 6 women and 2 men with an average age of 67 years (range, 58-76 years). All 8 patients were treated with a volar plate and screws. The dorsal metaphyseal fracture was not recognized in 5 patients and a volar buttress plating technique using an intentionally undercontoured volar plate was used. In 3 patients the dorsal fracture line was identified before surgery and the plate was contoured to fit the volar surface of the distal radius.
RESULTS: All 5 patients treated with an undercontoured plate had loss of the normal palmar tilt of the distal radius (average,-9.4 degrees; range, 0 degrees to-22 degrees ) and dorsal translation of the distal radial articular fragments. For the entire group the palmar tilt averaged-5.9 degrees (range, 0.0 degrees to-22.0 degrees ), the ulnar inclination 19 degrees (range, 10 degrees -23 degrees ), and the ulnar variance-0.9 mm (range, 0.0 to-3.0 mm). All patients attained forearm supination of 80 degrees and the average pronation was 75 degrees (range, 45 degrees -80 degrees ). According to Sarmiento's modification of the system of Gartland and Werley there were 1 excellent, 6 good, and 1 fair results. The average Patient-Rated Wrist Evaluation score was 16 (range, 0-35).
CONCLUSIONS: Some fractures with an oblique volar marginal articular fracture of the distal radius and volar radiocarpal subluxation (known as Barton's fracture) may also have a fracture through the dorsal metaphyseal cortex. Failure to identify this fracture line can lead to dorsal translation and angulation of the distal radius articular surface, particularly when an undercontoured volar plate is used for internal fixation.
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Searching for the 'winner' hip fracture patient: the effect of modifiable and non-modifiable factors on clinical outcomes following hip fracture surgery
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Hip Fx in the Elderly 2019
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BACKGROUND: Various factors, other than the quality of surgery, may influence clinical outcomes of hip fracture patients. We aimed to evaluate the relative impact of several factors on functional outcome, quality of life, re-fracture and mortality rates following surgery for hip fractures.
METHODS: We studied 498 (62.2%) women and 302 (37.8%) men with a mean age of 81.3 years (range, 60-95) with hip fractures (femoral neck and pertrochanteric). The mean follow-up was 74 months (range 58-96). Various patient-related and surgery-related parameters were recorded and correlated to both objective and subjective mobility, functional recovery and quality of life scales. Mortality and re-fracture rates were also evaluated.
RESULTS: Using multiple regression analysis, age >80 years (p = 0.000; 95% CI, 1.077-1.143) and ASA score III and IV (p = 0.000; 95% CI, 2.088-3.396) (both non-modifiable factors) both proved to be independent (s.s.) factors affecting mortality rates. Age <80 years (p = 0.000; 95% CI, 0.932-0.974), surgery delay less (modifiable factor) than 48 hours (p = 0.046; 95% CI, 0.869-0.999), low dementia CDR index (p = 0.005; 95% CI, 0.471-0.891) (non-modifiable factor), and osteoporosis medical treatment (modifiable factor) (p = 0.006; 95% CI, 0.494-0.891) were shown to be independent (s.s.) factors affecting HOOS-symptoms. Osteoporosis medical treatment used proved to be an independent (s.s.) factor affecting HOOS-daily activities (p = 0.049; 95% CI, 0.563-1.000) and quality of life (E-Qol-5D) (p = 0.036; 95% CI, 0.737-1.325).
CONCLUSIONS: A hip fracture patient aged <80 years old, with an ASA I-II, with low dementia CDR index and on osteoporosis medication has a better chance of an improved outcome (winner patient).
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Dosage effects of extracorporeal shockwave therapy in early hip necrosis
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PJI DX Updated Search
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BACKGROUND: This study investigated the effects of different dosages of extracorporeal shockwave therapy (ESWT) in early osteonecrosis of the femoral head (ONFH). MATERIALS AND METHODS: Thirty-three patients (42 hips) were randomly divided into three groups. Group A (10 patients with 16 hips) received 2000 impulses of ESWT at 24 Kv to the affected hip. Group B (11 patients with 14 hips) and Group C (12 patients with 12 hips) received 4000 and 6000 impulses of ESWT respectively. The evaluations included clinical assessment, radiographs, dynamic contrast-enhanced MRI for microcirculation (Ktrans) and plasma volume (Vp), and blood tests for biomarker analysis (NO3, VEGF, BMP-2, osteocalcin, TNF-alpha, IL-6, substance P, CGRP, DKK-1 and IGF). RESULTS: Significant differences of pain and Harris hip scores were noticed between Group A and C in 6 months after ESWT (all P < 0.05). The pain score decreased, but not Harris hip score improved over the observation time period from 6 to 24 months. Total hip arthroplasty was performed in 3 patients (4 hips) in Group A, but none in Groups B and C. Group C showed significant changes in serum biomarkers for angiogenesis, osteogenesis, anti-inflammation, pain threshold and tissue regeneration between one week and one month after treatment (all P < 0.05). However, no significant changes in the infarction volume in image studies were noted in all groups (all P > 0.05). The post-treatment Ktrans and Vp in the peri-necrotic areas of Group B and C were significantly greater than pre-treatment data (both P < 0.05). CONCLUSIONS: High dosage ESWT is more effective in early stage ONFH. The systemic beneficial effects of ESWT may ultimately enhance angiogenesis with improvement of microcirculation of the peri-necrotic areas, that in turn, can improve subchondral bone remodeling and prevent femoral head collapse
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The hand
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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This article defines a comprehensive hand evaluation process that allows the therapist to identify and treat the many types of hand pathologies that can affect us as we age. The authors hope to provide s better understanding that pathology, even if it is related to aging and found more frequently in the elderly population, is not normal. Common age-related problems and their impact on the rehabilitation of patients presenting with symptoms of hand dysfunction is discussed
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Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthroplasties: a 40-year experience
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Pediatric Diaphyseal Femur Fractures 2020 Review
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AIMS: The goals of this study were to define the risk factors, characteristics, and chronology of fractures in 5417 revision total hip arthroplasties (THAs). PATIENTS AND METHODS: From our hospital's prospectively collected database we identified all patients who had undergone a revision THA between 1969 and 2011 which involved the femoral stem. The patients' medical records and radiographs were examined and the relevant data extracted. Post-operative periprosthetic fractures were classified using the Vancouver system. A total of 5417 revision THAs were identified. RESULTS: There were 668 intra-operative fractures, giving an incidence of 12%. Fractures were three times more common with uncemented stems (19%) than with cemented stems (6%) (p < 0.001). The incidence of intra-operative femoral fracture varied by uncemented stem type: fully-coated (20%); proximally-coated (19%); modular fluted tapered (16%) (p < 0.05). Most fractures occurred during the insertion of the femoral component (35%). One-third involved the diaphysis and 26% were of the calcar: 69% were undisplaced. There were 281 post-operative fractures of the femur (20-year probability = 11%). There was no difference in risk for cemented and uncemented stems. Post-operative fractures were more common in men < 70 years (p = 0.02). Periprosthetic fractures occurred earlier after uncemented revision of the femoral component, but later after a cemented revision. The most common fracture type was a Vancouver B1 (31%). Of all post-operative fractures, 24% underwent open reduction and internal fixation and 15% revision arthroplasty. CONCLUSION: In revision THA, intra-operative fractures occurred three times more often with an uncemented stem. Many were undisplaced diaphyseal fractures treated with cerclage fixation. While the risk of post-operative fracture is similar between uncemented and cemented components, they occur at notably different times depending on the type of stem fixation. TAKE HOME MESSAGE: In revision THA, intra-operative periprosthetic femoral fractures occur three times more often with uncemented stems. Many are non-displaced diaphyseal fractures treated with cerclage fixation. While postoperative fracture risks are equivalent between uncemented and cemented components, they occur at notably different time periods based on stem fixation type.
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Propoxyphene use and risk for hip fractures in older adults
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Management of Hip Fractures in the Elderly
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BACKGROUND: Published guidelines have identified propoxyphene as an inappropriate medication for use in aged patients. It is no more effective than acetaminophen, yet has been associated with the same adverse effects (AEs) associated with other opioid drugs. In particular, its central nervous system-related AEs, dizziness and sedation, may increase the risk for fracture resulting from falls in older adults. Nonetheless, US studies have reported widespread use of propoxyphene in the elderly US population. OBJECTIVE: The aim of this study was to examine the risk for fracture associated with propoxyphene use in older adults. METHODS: This prospective cohort study used a large administrative claims data set from adults aged > or =65 years. A time-varying (lagged) covariate defined each person as a propoxyphene user or nonuser based on propoxyphene exposure in the 14 days before each fracture event in the cohort. Another time-varying measure stratified propoxyphene users based on their mean daily dose of propoxyphene (high dose = >260 mg; low dose = < or =260 mg of propoxyphene hydrochloride or equivalent napsylate salt). Time-dependent Cox regression models were used to estimate the association between propoxyphene exposure and occurrence of hip fracture (using International Classification of Diseases, Ninth Revision, Clinical Modification code 820.xx). RESULTS: A total of 362,503 patients were included in the analysis. During a mean follow-up of 464 days, approximately 10% (37,569) of the sample had > or =1 propoxyphene prescription filled and approximately l% (5065) sustained a hip fracture. Propoxyphene users had a 2-fold higher risk for hip fracture (hazard ratio [HR] [95% CI], 2.05 [1.87-2.25]) compared with nonusers of analgesics. Multivariate analysis found a dose-response relationship between propoxyphene and hip fracture risk (low dose, HR [95% CI], 1.45 [1.26-1.67]; high dose, HR [95% CI], 2.05 [1.85-2.29]). Other opioid analgesics were associated with an increased risk for hip fractures. CONCLUSIONS: The results of this cohort database study suggest that propoxyphene use among adults aged > or =65 years is associated with increased risk for hip fracture and suggest a need for interventions to reduce propoxyphene use in older adults. Clinicians should be aware of the risk for hip fracture with other opioids as well and weigh them against potential benefits when prescribing for older adults
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Right impairment of temporal order judgements in dyslexic children
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Upper Eyelid and Brow Surgery
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This study investigates the spatial bias of visual attention measured by a temporal order judgement (TOJ) task and the influence of a high attentional load condition in a group of dyslexic children compared to a control group with normal reading skills (each group N=10). The TOJ task (T2) was placed after a shape discrimination task (T1). In a low attentional load block participants worked only on T2, whereas in the high attentional load block they were required to process both T1 and T2. Several t-tests were executed to compare performance between conditions and groups. In the low attentional load conditions, results in dyslexic children were significantly impaired for the right visual field compared to a control group. The high attentional load conditions did not enhance these effects and seems to provoke the same leftward bias in the control group.
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The severity of microvascular dysfunction due to compartment syndrome is diminished by the systemic application of CO-releasing molecule-3
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DOD - Acute Comp Syndrome CPG
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OBJECTIVES: To examine the protective effects of carbon monoxide (CO), liberated from a novel CO-releasing molecule (CORM-3), on the function of compartment syndrome (CS)-challenged muscle in a rodent model, thus providing for a potential development of a pharmacologic adjunctive treatment for CS.
METHODS: Wistar rats were randomized into 4 groups: sham (no CS), CS, CS with inactive CORM-3 (iCORM-3), and CS + CORM-3 (10 mg/kg intraperitoneally). CS was induced by elevation of intracompartmental pressure to 30 mm Hg through an infusion of isotonic saline into the anterior compartment of the hind limb for 2 hours. Both CORM-3 and iCORM-3 were injected immediately after fasciotomy. Microvascular perfusion, cellular tissue injury, and inflammatory response within the extensor digitorum longus muscle were assessed using intravital video microscopy 45 minutes after fasciotomy. Systemic levels of tumor necrosis factor alpha (TNF-alpha) were also measured.
RESULTS: Elevation of intracompartmental pressure resulted in significant microvascular perfusion deficits (23% +/- 2% continuously perfused capillaries in CS vs. 76% +/- 4% in sham, P < 0.0001; 55% +/- 2% nonperfused capillaries in CS vs. 13% +/- 2% in sham, P < 0.0001), significant increase in tissue injury (ethidium bromide/bisbenzimide of 0.31 +/- 0.05 in CS vs. 0.05 +/- 0.03 in sham, P < 0.0001) and adherent leukocytes (13.7 +/- 0.9 in CS vs. 1.8 +/- 0.5 in sham, P < 0.0001), and a progressive rise in systemic TNF-alpha. CORM-3 (but not iCORM-3) treatment restored the number of continuously perfused capillaries (57% +/- 5%, P < 0.001), diminished tissue injury (ethidium bromide/bisbenzimide of 0.07 +/- 0.01, P < 0.001), reversed the CS-associated rise in TNF-alpha, and decreased leukocyte adherence (0.6 +/- 0.3, P < 0.001).
CONCLUSIONS: CORM-3 displays a potent protective/anti-inflammatory action in an experimental model of CS, suggesting a potential therapeutic application to patients at risk of developing CS.
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Detection of focal cerebral hemisphere lesions using the neurological examination
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Upper Eyelid and Brow Surgery
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OBJECTIVE: To determine the sensitivity and specificity of clinical tests for detecting focal lesions in a prospective blinded study. METHODS: 46 patients with a focal cerebral hemisphere lesion without obvious focal signs and 19 controls with normal imaging were examined using a battery of clinical tests. Examiners were blinded to the diagnosis. The sensitivity, specificity, and positive and negative predictive values of each test were measured. RESULTS: The upper limb tests with the greatest sensitivities for detecting a focal lesion were finger rolling (sensitivity 0.33 (95% confidence interval, 0.21 to 0.47)), assessment of power (0.30 (0.19 to 0.45)), rapid alternating movements (0.30 (0.19 to 0.45)), forearm rolling (0.24 (0.14 to 0.38)), and pronator drift (0.22 (0.12 to 0.36)). All these tests had a specificity of 1.00 (0.83 to 1.00). This combination of tests detected an abnormality in 50% of the patients with a focal lesion. In the lower limbs, assessment of power was the most sensitive test (sensitivity 0.20 (0.11 to 0.33)). Visual field defects were detected in 10 patients with a focal lesion (sensitivity 0.22 (0.12 to 0.36)) and facial weakness in eight (sensitivity 0.17 (0.09 to 0.31)). Overall, the examination detected signs of focal brain disease in 61% of the patients with a focal cerebral lesion. CONCLUSIONS: The neurological examination has a low sensitivity for detecting early cerebral hemisphere lesions in patients without obvious focal signs. The finger and forearm rolling tests, rapid alternating movements of the hands, and pronator drift are simple tests that increase the detection of a focal lesion without greatly increasing the length of the examination.
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Problems of basic nursing care in acutely confused and non-confused hip-fracture patients
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Management of Hip Fractures in the Elderly
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Thirty-five patients operated on for femoral neck fracture were studied. Fifteen (42.9%) became acutely confused after surgery. Problems in the 14 components of basic nursing care (Henderson 1964), were identified by means of interviews with the patients and their caregivers. The quantitative analysis of the results showed that significantly more of the acutely confused patients had problems in nine out of 14 components of basic nursing care as compared with the non-confused patients. The qualitative analysis showed that the problems of the non-confused patients were mostly caused by the fracture and by hospitalisation. The same problems were also present among the acutely confused patients who, in addition, had problems which arose from the acute confusional state
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MicroRNA-183 attenuates osteoarthritic pain by inhibiting the TGFalpha-mediated CCL2/CCR2 signalling axis
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AMP (Acute Meniscal Pathology)
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AIMS: MicroRNA-183 (miR-183) is known to play important roles in osteoarthritis (OA) pain. The aims of this study were to explore the specific functions of miR-183 in OA pain and to investigate the underlying mechanisms.
METHODS: Clinical samples were collected from patients with OA, and a mouse model of OA pain was constructed by surgically induced destabilization of the medial meniscus (DMM). Reverse transcription quantitative polymerase chain reaction was employed to measure the expression of miR-183, transforming growth factor alpha (TGFalpha), C-C motif chemokine ligand 2 (CCL2), proinflammatory cytokines (interleukin (IL)-6, IL-1beta, and tumour necrosis factor-alpha (TNF-alpha)), and pain-related factors (transient receptor potential vanilloid subtype-1 (TRPV1), voltage-gated sodium 1.3, 1.7, and 1.8 (Nav1.3, Nav1.7, and Nav1.8)). Expression of miR-183 in the dorsal root ganglia (DRG) of mice was evaluated by in situ hybridization. TGFalpha, CCL2, and C-C chemokine receptor type 2 (CCR2) levels were examined by immunoblot analysis and interaction between miR-183 and TGFalpha, determined by luciferase reporter assay. The extent of pain in mice was measured using a behavioural assay, and OA severity assessed by Safranin O and Fast Green staining. Immunofluorescent staining was conducted to examine the infiltration of macrophages in mouse DRG.
RESULTS: miR-183 was downregulated in tissue samples from patients and mice with OA. In DMM mice, overexpression of miR-183 inhibited the expression of proinflammatory cytokines (IL-6, IL-1beta, TNF-alpha) and pain-related factors (TRPV1, Nav1.3, Nav1.7, Nav1.8) in DRG. OA pain was relieved by miR-183-mediated inhibition of macrophage infiltration, and dual luciferase reporter assay demonstrated that miR-183 directly targeted TGFalpha.
CONCLUSION: Our data demonstrate that miR-183 can ameliorate OA pain by inhibiting the TGFalpha-CCL2/CCR2 signalling axis, providing an excellent therapeutic target for OA treatment. Cite this article: Bone Joint Res 2021;10(8):548-557.
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The Relationship of Parathyroidectomy and Bisphosphonates With Fracture Risk in Primary Hyperparathyroidism: An Observational Study
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Hip Fx in the Elderly 2019
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BACKGROUND: The comparative effectiveness of surgical and medical treatments on fracture risk in primary hyperparathyroidism (PHPT) is unknown.
OBJECTIVE: To measure the relationship of parathyroidectomy and bisphosphonates with skeletal outcomes in patients with PHPT.
DESIGN: Retrospective cohort study.
SETTING: An integrated health care delivery system.
PARTICIPANTS: All enrollees with biochemically confirmed PHPT from 1995 to 2010.
MEASUREMENTS: Bone mineral density (BMD) changes and fracture rate.
RESULTS: In 2013 patients with serial bone density examinations, total hip BMD increased transiently in women with parathyroidectomy (4.2% at <2 years) and bisphosphonates (3.6% at <2 years) and declined progressively in both women and men without these treatments (-6.6% and -7.6%, respectively, at >8 years). In 6272 patients followed for fracture, the absolute risk for hip fracture at 10 years was 20.4 events per 1000 patients who had parathyroidectomy and 85.5 events per 1000 patients treated with bisphosphonates compared with 55.9 events per 1000 patients without these treatments. The risk for any fracture at 10 years was 156.8 events per 1000 patients who had parathyroidectomy and 302.5 events per 1000 patients treated with bisphosphonates compared with 206.1 events per 1000 patients without these treatments. In analyses stratified by baseline BMD status, parathyroidectomy was associated with reduced fracture risk in both osteopenic and osteoporotic patients, whereas bisphosphonates were associated with increased fracture risk in these patients. Parathyroidectomy was associated with fracture risk reduction in patients regardless of whether they satisfied criteria from consensus guidelines for surgery.
LIMITATION: Retrospective study design and nonrandom treatment assignment.
CONCLUSION: Parathyroidectomy was associated with reduced fracture risk, and bisphosphonate treatment was not superior to observation.
PRIMARY FUNDING SOURCE: National Institute on Aging.
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Comparison of radiographic joint space width and magnetic resonance imaging for prediction of knee replacement: A longitudinal case-control study from the Osteoarthritis Initiative
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OAK 3 - Non-arthroplasty tx of OAK
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Objective: To evaluate whether change in fixed-location measures of radiographic joint space width (JSW) and cartilage thickness by MRI predict knee replacement. Methods: Knees replaced between 36 and 60 monthsâ?? follow-up in the Osteoarthritis Initiative were each matched with one control by age, sex and radiographic status. Radiographic JSW was determined from fixed flexion radiographs and subregional femorotibial cartilage thickness from 3 T MRI. Changes between the annual visit before replacement (T0) and 2 years before T0 (T-2) were compared using conditional logistic regression. Results: One hundred and nineteen knees from 102 participants (55.5 % women; age 64.2 ± 8.7 [mean ± SD] years) were studied. Fixed-location JSW change at 22.5 % from medial to lateral differed more between replaced and control knees (case-control [cc] OR = 1.57; 95 % CI: 1.23â??2.01) than minimum medial JSW change (ccOR = 1.38; 95 % CI: 1.11â??1.71). Medial femorotibial cartilage loss displayed discrimination similar to minimum JSW, and central tibial cartilage loss similar to fixed-location JSW. Location-independent thinning and thickening scores were elevated prior to knee replacement. Conclusions: Discrimination of structural progression between knee pre-placement cases versus controls was stronger for fixed-location than minimum radiographic JSW. MRI displayed similar discrimination to radiography and suggested greater simultaneous cartilage thickening and loss prior to knee replacement. Key Points: â?¢ Fixed-location JSW predicts surgical knee replacement more strongly than minimum JSW. â?¢ MRI predicts knee replacement with similar accuracy to radiographic JSW. â?¢ MRI reveals greater cartilage thinning and thickening prior to knee replacement.
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Outcome of exact anatomic repair and coracoclavicular cortical lag screw in acute acromioclavicular dislocations
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Glenohumeral Joint OA
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BACKGROUND: The optimal surgical approach for acute acromioclavicular (AC) dislocations is still controversial. The purpose of this study is to analyze the outcome of anatomic repair or approximation of intra-articular and extra-articular damage.
METHODS: Fifty-six patients with Rockwood type-III, IV, and V acute AC dislocations followed up for an average of 76.6 months were evaluated. Direct repair of clavicular muscle attachments, AC joint, and repair or approximation of coracoclavicular (CC) ligaments was done. A CC of 4.5-mm cortical lag screw was used to protect the repair for 60 days. At the final follow-up, clinical assessment, radiographic analysis, function according to American Shoulder and Elbow Surgeons score, University of California-Los Angeles (UCLA) Shoulder Scale, Disabilities of Arm, Shoulder and Hand score, and the ability to return to previous work were used for evaluation.
RESULTS: At the time of final follow-up, the mean values of American Shoulder and Elbow Surgeons score, University of California-Los Angeles, and Disabilities of Arm, Shoulder and Hand scores were 91.3 +/- 6.1, 31.5 +/- 2.3, and 2.8 +/- 2.1, respectively. Reduction was maintained in all but two patients, and CC distance was not statistically different from that on the healthy side. Five patients had occasional pain during daily activities and one developed AC osteoarthritis. All patients maintained their previous jobs.
CONCLUSIONS: The anatomic repair of damage in AC dislocations is a reliable treatment although it is not always feasible. Approximating torn ligaments can still produce good results under the rigid CC screw protection.
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The accuracy of MRI for the diagnosis of ramp lesions
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AMP (Acute Meniscal Pathology)
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OBJECTIVES: To assess the diagnostic accuracy of MRI in diagnosing ramp lesions in patients with an acute lesion of the anterior cruciate ligament (ACL).
MATERIALS AND METHODS: All consecutive patients over 15 years of age who underwent surgical repair of the ACL at a single hospital between January and May 2019, with MRI data available, were included in this retrospective study, except patients who had previous knee surgery. The gold standard was arthroscopic evaluation. Two trained radiologists with 5 and 14 years of experience did a blinded review of the MRIs. The following pathological signs were studied: complete fluid filling between the capsule and the posterior horn of the medial meniscus, irregular appearance of the posterior wall of the medial meniscus, oedema of the capsule, fluid hyperintensity in contact with the medial meniscus and anterior subluxation of the medial meniscus. Logistic regressions in univariate then multivariate analysis were carried out and measures of diagnostic accuracy and interobserver agreement were calculated with R software (version 3.6).
RESULTS: Fifty-seven patients were included. Twelve had a ramp lesion diagnosed by arthroscopy (21%). Only complete fluid hyperintensity between the posterior horn of the medial meniscus and the capsule was significantly associated with ramp lesions (P value < 0.01). The diagnostic accuracy of this specific sign was moderate, with a specificity of 84%, sensitivity of 75%, PPV of 56%, NPV of 93% and a good level of inter-observer agreement (k = 0.79).
CONCLUSION: The complete fluid filling is the only significant pathological MRI sign for ramp lesions, with moderate accuracy.
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Clinical effects of buprenorphine during and after operation
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AAHKS (2) Corticosteroids
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The analgesic, respiratory and hormonal effects of two doses of buprenorphine were studied during and after operation in 20 patients undergoing total hip replacement. The drug provided analgesia of long duration. The analesic and hormonal effects of the drug were greater after i.m. than after i.v. administration. The postoperative analgesic requirement of women was less than that of men. The pharmacodynamic differences shown between the sexes and between the two routes of administration are discussed in relation to the pharmacokinetics of the drug.
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A comparison of wound closure techniques for total knee arthroplasty
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PJI DX Updated Search
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Four wound closure techniques for total knee arthroplasty were compared in a prospective, randomized, controlled, institutional review board-approved study with 75 subjects. The study compared tissue adhesives, stapling, and suturing with respect to procedure time and cost, together with functional and clinical outcome. Total knee arthroplasty closure time (capsule to cutaneous) favored staples at 26 s/cm, followed by adhesives (45 and 37 s/cm for 2-octyl and n-butyl-2, respectively) and, finally, subcuticular suturing at 54 s/cm (P < .0007). Reduced procedure time translated into intraoperative cost reduction where closure cost per centimeter was $70, $62, $57, and $75 for 2-octyl, n-butyl-2, staples, and sutures, respectively. No significant differences in infection, dehiscence, cosmesis, general health (SF-12v2 (QualityMetric Inc., Lincoln, RI)), and functional and clinical assessments (range of motion, Knee Society knee score, and pain) were observed
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External-beam radiation therapy combined with limb-sparing surgery in elderly patients (>70 years) with primary soft tissue sarcomas of the extremities : A retrospective analysis
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DoD LSA (Limb Salvage vs Amputation)
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PURPOSE: To report our experience with EBRT combined with limb-sparing surgery in elderly patients (>70 years) with primary extremity soft tissue sarcomas (STS). METHODS: Retrospectively analyzed were 35 patients (m:f 18:17, median 78 years) who all presented in primary situation without nodal/distant metastases (Charlson score 0/1 in 18 patients; >/=2 in 17 patients). Median tumor size was 10 cm, mainly located in lower limb (83%). Stage at presentation (UICC7th) was Ib:3%, 2a:20%, 2b:20%, and 3:57%. Most lesions were high grade (97%), predominantly leiomyosarcoma (26%) and undifferentiated pleomorphic/malignant fibrous histiocytoma (23%). Limb-sparing surgery was preceded (median 50 Gy) or followed (median 66 Gy) by EBRT. RESULTS: Median follow-up was 37 months (range 1-128 months). Margins were free in 26 patients (74%) and microscopically positive in 9 (26%). Actuarial 3 and 5year local control rates were 88 and 81% (4 local recurrences). Corresponding rates for distant control, disease-specific survival, and overall survival were 57/52%, 76/60%, and 72/41%. The 30-day mortality was 0%. Severe postoperative complications were scored in 8 patients (23%). Severe acute radiation-related toxicity was observed in 2 patients (6%). Patients with Charlson score >/=2 had a significantly increased risk for severe postoperative complications and acute radiation-related side effects. Severe late toxicities were found in 7 patients (20%), including fractures in 3 (8.6%). Final limb preservation rate was 97%. CONCLUSION: Combination of EBRT and limb-sparing surgery is feasible in elderly patients with acceptable toxicities and encouraging but slightly inferior outcome compared to younger patients. Comorbidity correlated with postoperative complications and acute toxicities. Late fracture risk seems slightly increased.
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Bone scintigraphy after osteochondral autograft transplantation in the knee: 13 patients followed for 4 years
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Osteochondritis Dissecans 2020 Review
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BACKGROUND AND PURPOSE: Autologous osteochondral transplantation (OCT) is an established method of treating articular cartilage defects in the knee. However, the potential for donor site morbidity remains a concern. Both the restoration of the original cartilage defect and the evolution of the donor site defects can be evaluated by bone scintigraphy. Thus, we performed a prospective bone scintigraphic evaluation in patients who were treated with OCT. PATIENTS AND METHODS: In 13 patients with a symptomatic articular cartilage defect, bone scintigraphies were obtained preoperatively, 1 year after osteochondral transplantation, and finally at an average follow-up of 4 (2.5-5.5) years. The evolution of scintigraphic activity was evaluated for both the recipient and the donor site. Parallel, clinical scoring was performed using the Lysholm knee scoring scale, the Cincinnati knee rating system, and the Tegner activity score. RESULTS: The bone scintigraphic uptake was elevated at the involved femoral condyle preoperatively, and gradually decreased to normal levels in 7 of 11 cases. The originally normal uptake at the trochlea increased 1 year after transplantation. Then, a gradual decrease in uptake occurred again at this donor site to remain elevated at the final scintigraphy. A correlation was found between elevated scintigraphic activity and the presence of retropatellar crepitus. The mean Lysholm and Cincinnati scores had increased 1 year after transplantation. The mean Tegner score had increased 3 years after transplantation. INTERPRETATION: Elevated bone scintigraphic activity from an osteochondral lesion in the knee can be restored with OCT. However, increased scintigraphic activity is introduced at the donor site, which becomes reduced with longer follow-up. The use of fairly large osteochondral plugs appears to correlate with retropatellar crepitus and increased scintigraphic activity, and is not therefore recommended.
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Cost-effectiveness analysis of goal-directed hemodynamic treatment of elderly hip fracture patients: before clinical research starts
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Management of Hip Fractures in the Elderly
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BACKGROUND: Health economic evaluations are increasingly used to make the decision to adopt new medical interventions. Before such decisions, various stakeholders have invested in clinical research. But health economic factors are seldom considered in research funding decisions. Cost-effectiveness analyses could be informative before the launch of clinical research projects, particularly when a targeted intervention is resource-intensive, total cost for the trial is very high, and expected gain of health benefits is uncertain. This study analyzed cost-effectiveness using a decision analytic model before initiating a large clinical research project on goal-directed hemodynamic treatment of elderly patients with hip fracture. METHODS: A probabilistic decision analytic cost-effectiveness model was developed; the model contains a decision tree for the postoperative short-term outcome and a Markov structure for long-term outcome. Clinical effect estimates, costs, health-related quality-of-life measures, and long-term survival constituted model input that was extracted from clinical trials, national databases, and surveys. Model output consisted of estimated medical care costs related to quality-adjusted life-years. RESULTS: In the base case analysis, goal-directed hemodynamic treatment reduced average medical care costs by euro1,882 and gained 0.344 quality-adjusted life-years. In 96.5% of the simulations, goal-directed hemodynamic treatment is less costly and provides more quality-adjusted life-years. The results are sensitive to clinical effect size variations, although goal-directed hemodynamic treatment seems to be cost-effective even with moderate clinical effect. CONCLUSION: This study demonstrates that cost-effectiveness analysis is feasible, meaningful, and recommendable before launch of costly clinical research projects
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Relationship between shaft bowing in the femur and tibia and bone mineral density in women with varus knee osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: Anterior and lateral shaft bowing of the femur and tibia in patients with varus knee osteoarthritis (OA) results in malalignment of the whole lower extremity, when the preoperative planning in total knee arthroplasty or high tibial osteotomy is performed on the knee radiograph. Previous studies reported that femoral shaft bowing in women was different from that in men. To our knowledge, no studies investigating the relationship between shaft bowing in the femur and tibia and bone mineral density (BMD) have been reported.We hypothesized that anterior and lateral shaft bowing in the femur and tibia was related with age, body mass index (BMI), and BMD in women with varus knee OA. The main aim of our study was to assess the relationship between anterior and lateral shaft bowing in the femur and tibia and BMD in women with varus knee OA. Methods: We enrolled 52 women between April 2010 and March 2011 at our institution. All patients had symptomatic primary varus knee OA. Anteroposterior and lateral whole leg radiographs were taken with the patients in a standing position. Femoral and tibial shaft was divided into five equal parts. In the coronal and sagittal planes, anterior and lateral shaft bowing of the femur and tibia were defined as the angulations between midlines drawn in the second and forth parts from the proximal femur and tibia. The Kellgren and Lawrence grades were grade 2 in 3 knees, grade 3 in 7 knees, and grade 4 in 42 knees. Limb alignment was expressed as the femorotibial angle (FTA) obtained from the anteroposterior radiograph. BMD values were measured in L2-L4 vertebrae and the femoral neck using a QDR-4500 (Hologic Inc., Bedford, MA, USA). The lumbar spine and femoral neck BMDs were analyzed using standard software. BMI was calculated as an index of obesity. Data are expressed as means and standard deviation. Significance was set at p < 0.05. We used Pearson's correlation coefficients to investigate the relationship between two continuous variables (bowing, age, BMI, and BMDs). Results: Mean age and BMI were 72.4 (plus or minus) 8.9 years and 26.6 (plus or minus) 4.4 kg/m(2), respectively. Mean FTA was 183.6 (plus or minus) 3.4 degree. Anterior femoral (Table presented) shaft bowing was positively correlated with age and negatively correlated with femoral neck BMD (r = 0.317, p = 0.022, and r = - 0.345, p = 0.012, respectively). Lateral femoral shaft bowing was not related with multivariate factors. Anterior tibial shaft bowing demonstrated a positive correlation with BMI (r = 0.283, p = 0.042). Lateral tibial shaft bowing was positively correlated with age and negatively correlated with femoral neck BMD (r = 0.364, p = 0.008, and r = - 0.293, p = 0.035, respectively). Conclusions: Karakas and Harma stated that anterior femoral shaft bowing was related with age. Our results showed that anterior femoral shaft bowing was correlated with age and femoral neck BMD. Contrary to our expectation, lateral femoral shaft bowing was not related with femoral neck BMD. Only anterior tibial shaft bowing was affected by BMI. Also, the relationship between anterior tibial shaft bowing and lumbar spine BMD might be associated with degenerative changes of the lumbar spine. Lateral tibial shaft bowing was correlated with age and femoral neck BMD, although anterior tibial shaft bowing was not related with femoral neck BMD. In Japanese, these results in the tibia might be associated with congenital tibia vara. The results from our small number of patients should be considered preliminary. However, if shaft bowing in the femur and tibia were related with BMD, the use of medication for osteoporosis might be a proper conservative approach to treatment
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Venous thromboembolism prophylaxis after total knee or hip replacement: treatment pattern and outcomes
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Management of Hip Fractures in the Elderly
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PURPOSE: To determine the thromboprophylactic treatment pattern and occurrence of venous thromboembolism (VTE), major bleeding, and wound infections in patients undergoing total knee replacement (TKR) or total hip replacement (THR). METHODS: From the PHARMO database, all patients >/= 18 years hospitalized for TKR or THR between January 2003 and September 2008 were selected. Patients with pharmacy data up to 3 months after hospitalization were included in the study cohort. Duration and type of thromboprophylaxis were assessed. VTE, major bleeding, and wound infections were identified by hospitalizations. Regarding VTE, timing of event in relation to thromboprophylaxis was determined. RESULTS: The study population included 2930 patients with TKR, 5332 patients with THR without hip fracture, and 289 patients with THR and hip fracture. Mean duration of thromboprophylaxis was about 30 (+/- 20) days for all procedures, with low-molecular-weight heparin being the most frequently used drug. During 3 months of follow-up, 1% to 2% of patients were hospitalized for an event. The most observed event was wound infection (58%), followed by major bleeding (29%), and VTE (13%). For wound infection and major bleeding, median time after surgery was about 19 days. Median time between surgery and VTE was 24 days for TKR and 60 days for THR. Eighteen of 23 VTE occurred during thromboprophylaxis. CONCLUSIONS: Although patients are often treated for fewer days than recommended, thromboprophylaxis after TKR and THR in the Netherlands is adequate. Only 5 of 23 VTE hospitalizations occurred off-treatment and might have been prevented. Furthermore, fewer than 1% of patients were hospitalized for bleeding
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Medial approach for popliteal artery injuries
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DoD LSA (Limb Salvage vs Amputation)
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OBJECTIVE: To evaluate the clinical application of the medial approach for repairing popliteal artery injuries. METHODS: From 2002 to 2008, 11 cases of popliteal artery injuries had been repaired via the medial approach. Of these cases, 8 had limb fractures, 1 had knee dislocation, and 2 had visceral injuries. Ten popliteal arteries were anastomosed directly while one was repaired with a great saphenous vein graft. RESULTS: The operation time ranged from 3 to 4 hours (averaging 3.6 hours). All the injured limbs survived. At the follow up, 8 legs recovered the full function, 2 had minor contracture, and 1 serious Volkmann's contracture without amputation. CONCLUSION: The medial approach for repair of the popliteal artery is effective, applicable, and more advantageous to the management of multi-injures.
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Vitamin D deficiency and osteopenia in the hemiplegic limbs of stroke patients
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Management of Hip Fractures in the Elderly
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BACKGROUND AND PURPOSE: Little is known about bone changes in hemiplegic stroke patients. We evaluated the vitamin D status and bone changes on the hemiplegic and intact sides of stroke patients. METHODS: Sera were collected from 87 hemiplegic stroke patients (42 outpatients and 45 inpatients) and from 28 control subjects. The sera were assayed for 25-hydroxyvitamin D (25-OHD). Bone density was measured bilaterally from radiographs of the hands. Diet and sunlight exposure were assessed for all subjects. RESULTS: Serum 25-OHD concentrations were lower in patients (9.1 +/- 4.9 ng/mL for outpatients, 5.9 +/- 4.1 ng/mL for inpatients) than in control subjects (21.6 +/- 3.1 ng/mL). The difference in serum 25-OHD between the two patient groups also was statistically significant. The patients' microdensitometric scores for osteopenia were higher on the hemiplegic side than on the non-hemiplegic side. The microdensitometric scores and their side-to-side differences in patients correlated negatively with the serum 25-OHD concentration and positively with the degree of paralysis. Dietary intake of vitamin D was below the recommended level in 72% of the patients, and 89% of the patients were considered sunlight-deprived. CONCLUSIONS: Bone mass was reduced significantly on the hemiplegic side in the stroke patients, which might increase the risk of hip fracture. Vitamin D deficiency and disuse are the probable causes of osteopenia in this population. The hypovitaminosis D might be corrected readily by routine use of vitamin D supplements
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Incidence of Infection and Inhospital Mortality in Patients With Chronic Renal Failure After Total Joint Arthroplasty
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Patients with chronic renal failure (CRF) may require total joint arthroplasty (TJA) to treat degenerative joint disease, fractures, osteonecrosis, or amyloid arthropathy. There have been conflicting results, however, regarding outcomes of TJA in patients with chronic renal disease. The aim of this case-controlled study was to determine the outcome of TJA in patients with CRF, with particular interest in the incidence of infections and inhospital mortality.
METHODS: We queried our electronic database to determine which patients among the 29,389 TJAs performed at our institution between January 2000 and June 2012 had a diagnosis of CRF. A total of 359 CRF patients were identified and matched for procedure, gender, age (+/-4 years), date of surgery (+/-2 years), and body mass index (+/-5 kg/m<sup>2</sup>) in a 2:1 ratio to 718 control patients.
RESULTS: The incidence of infection and inhospital mortality was not significantly different between the nondialysis CRF patients and controls, whereas it was significantly higher in dialysis-dependent end-stage renal failure patients compared to controls. Of the 50 CRF patients receiving hemodialysis, 10 (20%) developed surgical site infection, of which 4 (8%) were periprosthetic joint infection, and 4 (8%) died during hospital stay. The odds ratio for infection in the dialysis group was 7.54 (95% confidence interval: 2.83-20.12) and 10.46 (95% confidence interval: 1.67-65.34) for the inhospital mortality.
CONCLUSION: We conclude that end-stage renal failure patients receiving hemodialysis have higher postoperative infection and inhospital mortality rates after an elective TJA procedure, whereas nondialysis CRF patients have similar outcomes compared with the general TJA population.
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Polymorphisms in the Growth Differentiation Factor 5 (GDF 5) Gene in Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To identify the frequency of the rs143383 SNPin the GDF5 gene, which is located in the 5'-untranslated region of Turkish population with knee osteoarthritis (OA).
STUDY DESIGN: Acase-control study.
PLACE AND DURATION OF STUDY: Orthopedics and Traumatology Department, Bozok University Medical Faculty, Yozgat, Turkey, from 2012 to 2014.
METHODOLOGY: Patients diagnosed with OA(n=94) and patients who did not have joint complaints (n=279) were enrolled in this study. Patients diagnosed with osteoarthritis according to the 1986 American College of Rheumatology osteoarthritis criteria and Kellgren and Lawrence scores were investigated, based on age, gender, and X-ray findings. Blood samples were taken for the identification of GDF5 (rs143383) SNPs by PCR/RFLP, according to a standard protocol.
RESULTS: This study included 373 patients. The OAgroup (25.2%; n=94) was characterized by specific genotypes: TT (39.4%; n=37); heterozygotes (TC; 45.7%; n=43); and homozygotes (CC; 14.9%; n=14). The control group (74.8%; n=279) was comprised of TT(26.5%; n=74), TC (54.8%; n=153), and CC (18.6%; n=52) genotypes. An analysis of rs143383 SNP of the GDF5 gene polymorphism revealed that the rs143383 TTgenotype had a higher risk for OA(crude OR=1.798, 95% CI=1.010-2.941, p=0.021).
CONCLUSION: This study demonstrated that there is a correlation of +104T/C polymorphism in the 5'-UTR of GDF5 with knee OAin a Turkish population.
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Reliability and Validity Study of the Finnish Adaptation of Scoliosis Research Society Questionnaire Version SRS-30
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DoD PRF (Psychosocial RF)
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Study Design. A prospective clinical study to test and adapt a Finnish version of the Scoliosis Research Society 30 (SRS-30) questionnaire. Objective. The aim of this study was to perform cross-cultural adaptation and evaluate the validity of the adapted Finnish version of the SRS-30 questionnaire. Summary of Background Data. The SRS-30 questionnaire has proved to be a valid instrument in evaluating health-related quality of life (HRQoL) in adolescent and adult population with spine deformities in the United States. Multinational availability requires cross-cultural and linguistic adaptation and validation of the instrument. Methods. The SRS-30 was translated into Finnish using accepted methods for translation of quality-of-life questionnaires. A total of 274 adult patients with degenerative radiographic sagittal spinal disorder answered the questionnaire with sociodemographic data, RAND 36-item health survey questionnaire (RAND Corp. Health, Santa Monica, CA, US), Oswestry disability index, DEPS depression scale, and Visual Analog Scale (VAS) back and leg pain scales within 2 weeks' interval. The cohort included patients with and without previous spine surgery. Internal consistency and validity were tested with Cronbach α, intraclass correlation (ICC), standard error of measurement, and Spearman correlation coefficient with 95% confidence intervals (CIs). Results. The internal consistency of SRS-30 was good in both surgery and nonsurgery groups, with Cronbach α 0.853 (95% CI, 0.670 to 0.960) and 0.885 (95% CI, 0.854 to 0.911), respectively. The test-retest reproducibility ICC of the SRS-30 total and subscore domains of patients with stable symptoms was 0.905 (95% CI, 0.870-0.930) and 0.904 (95% CI, 0.871-0.929), respectively. The questionnaire had discriminative validity in the pain, self-image, and satisfaction with management domains compared with other questionnaires. Conclusion. The SRS-30 questionnaire proved to be valid and applicable in evaluating HRQoL in Finnish adult spinal deformity patients. It has two domains related to deformity that are not covered by other generally used questionnaires.
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Prepectoral Immediate Direct-to-Implant Breast Reconstruction with Anterior AlloDerm Coverage
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Acellular Dermal Matrix
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BACKGROUND: Staged subpectoral expander-implant breast reconstruction is widely performed. Disruption of the pectoralis major origin and the frequent occurrence of animation deformity and functional discomfort associated with subpectoral reconstruction remain ongoing concerns. Prepectoral single-stage direct-to-implant reconstruction resolves many of these issues. In this study, the authors explored the rationale for prepectoral single-stage implant-based breast reconstruction with anterior AlloDerm coverage as an alternative to the staged approach. METHODS: Seventy-three breasts in 50 patients were reconstructed using a single-stage direct-to-implant prepectoral approach with total anterior AlloDerm coverage during a 24-month period. The decision to proceed with single-stage reconstruction was predicated upon the adequacy of mastectomy skin flap blood flow based on indocyanine green fluorescence perfusion assessment. The patients were followed up for a maximum of 32 months. RESULTS: Ninety-seven percent of patients achieved complete healing within 8 weeks. There were 2 implant losses (2.7%) due to infection. Major seroma rate requiring repeated aspiration and drain insertion was 1.2%. There were no full-thickness skin losses. Capsular contracture was 0% in nonradiated patients. There were no cases of animation deformity. The authors were unable to establish significant correlation between complications and any of the usually stated risk factors, such as smoking, obesity, and large mastectomy weights, presumably due to the rigorous application of intraoperative skin perfusion assessment. CONCLUSION: Single-stage direct-to-implant reconstruction using a prepectoral approach appears to be a safe and effective means of breast reconstruction in many patients, assuming adequate skin perfusion is present.
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Female sexual dysfunction in patients with spinal cord injury: a study from Iran
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DoD PRF (Psychosocial RF)
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OBJECTIVES: We assess the prevalence of sexual dysfunction in patients with spinal cord injury (SCI), compare sexual function and sexual distress between female patients with SCI and gender-matched healthy controls, and address risk factors associated with sexual dysfunction among Iranian female patients with SCI.
SETTING: Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
METHODS: Eligible Iranian female patients with SCI were included in this cross-sectional study. They were asked to provide sociodemographic information, and complete the Female Sexual Function Index, Hospital Anxiety and Depression Scale and Female Sexual Distress Scale-Revised questionnaire.
RESULTS: Of the 105 patients participated in this study, the average age was 41.0 (s.d.=10.1) years. Women with SCI reported significantly higher levels of sexual dysfunction compared with normal controls. Approximately, 88% of SCI patients reported at least one type of sexual dysfunction, whereas only 37% of healthy controls reported sexual dysfunction. Lack of vaginal lubrication was reported more frequent in SCI patients compared with controls. Women with SCI reported a significantly higher level of sexual distress compared with healthy women. Sexual dysfunction was observed to be significantly higher in older patients, those with less education, patients with complete lesions, those with sexual distress and patients who were anxious and depressed.
CONCLUSION: Sexual dysfunction is highly prevalent among Iranian women with SCI. Sexual dysfunction is associated with age, education, symptoms of depression and anxiety and level of injury. Sexual counseling during the rehabilitation period may help to prevent sexual dysfunction following SCI.
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Magnetic resonance imaging of the knee: initial experience in a district general hospital
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AMP (Acute Meniscal Pathology)
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We present the results of a prospective study comparing the accuracy of magnetic resonance imaging with arthroscopy in the assessment of knee complaints. Using a low field strength magnet, MRI was able to achieve a high diagnostic accuracy within the setting of a district general hospital.
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Penetrating arterial trauma to the limbs: outcome of a modified protocol
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Penetrating arterial injuries to the limbs are common injuries in high volume trauma centers. Their overall surgical results reported in the literature are satisfactory - apart of those of the popliteal artery that still may lead to a significant incidence in amputations. With the present study we assessed our outcome with penetrating arterial injuries to the limb as to see if the direct involvement of vascular surgeons in the management of popliteal artery injuries leads to an improved (lowered) amputation rate. Results were benchmarked with our published results from previous years. METHODS: All patients sustaining penetrating arterial injuries to the limbs admitted to the Chris Hani Baragwanath Academic Hospital during an 18- month period ending in September 2011 were included in this study. Axillary, brachial and femoral artery injuries were operated on by the trauma surgeons as in the past. All popliteal artery injuries were operated on by the vascular surgeons (new). RESULTS: There were a total of 113 patients with 116 injuries, as some patients had multiple vascular injuries: 10 axillary, 47 brachial, 34 femoral and 25 popliteal artery injuries. Outcome of axillary, brachial and femoral artery injury repair were excellent and not significantly different from our previous reported experience. Injury to the popliteal artery showed a diminished re-exploration rate from 34% down to 10% (p = 0,049) and a decrease of amputation rate from 16% to 11% which was statistically not significant (p = 0,8). CONCLUSION: Penetrating arterial trauma to the axillary, brachial and femoral artery is followed by excellent results when operated by trauma surgeons. In the case of popliteal artery injury operated by the vascular surgeons, the results of this study do not show any statistically significant difference related to amputation rate from our previous reported studies when operated by trauma surgeons. Taking into consideration the diminished re-exploration rate and a tendency to a lower amputation rate, we feel that there is possible tendency of better outcome if operated by vascular surgeons. Multicenter studies with large number of enrolled patients will be required to prove the validity of this suggestion.
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A Comparative Study of Single-Port Laparoscopic Surgery Versus Robotic-Assisted Laparoscopic Surgery for Rectal Cancer
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DOD - Acute Comp Syndrome CPG
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Introduction. Conventional laparoscopic surgery is the treatment of choice for many abdominal procedures. To further reduce surgical trauma, new minimal invasive procedures such as single-port laparoscopic surgery (SPLS) and robotic assisted laparoscopic surgery (RALS) have emerged. The aim of this study was to compare the early results of SPLS versus RALS in the treatment of rectal cancer. Methods. We performed a retrospective analysis of prospectively collected data on patients who had undergone SPLS (n = 36) or RALS (n = 56) in the period between 2010 and 2012. Operative and short-term oncological outcomes were compared. Results. The RALS group had fewer patients with low rectal cancer and more patients with mid-rectal tumors (P =.017) and also a higher rate of intraoperative complications (14.3% vs 0%, P =.021). The rate of postoperative complications did not differ (P =.62). There were no differences in circumferential resection margins, distal resection margins, or completeness of the mesorectal fascia. The RALS group had a larger number of median harvested lymph nodes (27 vs 13, P =.001). The SPLS group had fewer late complications (P =.025). There were no locoregional recurrences in either of the groups. There was no difference in median follow-up time between groups (P =.58). Conclusion. Both SPLS and RALS may have a role in rectal surgery. The short-term oncological outcomes were similar, although RALS harvested more lymph nodes than the SPLS procedure. However, SPLS seems to be safer with regard to intraoperative and late postoperative complications.
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Bleeding Complications in Dermatologic Surgery
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Reconstruction After Skin Cancer
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Although the overall incidence is low, bleeding complications in dermatologic surgery can occur and be the source of significant patient morbidity. In this article, we summarize the key aspects of preoperative assessment of patients at risk for bleeding. A review of current issues and literature regarding safe continuation of anticoagulant and antiplatelet medications in dermatologic surgery patients is also presented. In addition, principles for management of bleeding events, should they occur, are also highlighted. © 2007 Elsevier Inc. All rights reserved.
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