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Evaluation of blood loss during tumescent liposuction in Orientals
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: There are high risks from general anesthesia and excessive bleeding associated with traditional liposuction using the dry or wet method. The blood loss has been estimated to be between 15% and 45%. The tumescent technique permits liposuction of more than 3,000 ml of fat totally by local anesthesia without sedation. The blood loss is reported to be less than 1% of aspirate. OBJECTIVE: To examine the blood loss during liposuction using tumescent technique in Chinese patients compared with that of Caucasians as published in the literature. METHODS: Hemoglobin values of patient's preoperative venous blood and infranatant of aspirate were measured in 45 consecutive cases of liposuction using the tumescent technique from May 1996 to June 1997. RESULTS: A total of 30 patients completed the study. The average blood loss was estimated to be 1.08% of aspirate. CONCLUSION: From this study, we found the blood loss in Chinese patients is comparable with that in Caucasians. Tumescent liposuction is a safe dermatologic cosmetic surgical procedure without the need of blood transfusion and general anesthesia.
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Predictors of deep venous thrombosis in patients admitted to rehabilitation clinics after major orthopaedic surgery
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Management of Hip Fractures in the Elderly
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BACKGROUND: Venous thromboembolism (VTE) is a frequent complication of major orthopaedic surgery; prolonged prophylaxis with anticoagulants is standard of care. However, late manifestation of VTE is common and little is known about the predictors of late deep vein thrombosis (DVT) and the distribution of proximal and distal DVT and isolated calf muscle vein thrombosis (MVT). PATIENTS AND METHODS: 482 patients admitted to a rehabilitation clinic (RC) after total hip or knee replacement (THR; TKR) or hip fracture surgery (HFS) underwent complete compression ultrasound (CCUS) screening for VTE within 72 hours after admission into RC. Predictors of VTE were evaluated. RESULTS: DVT was prevalent in 74 events (14.7 %), consisting of 13 (2.7 %) proximal DVT, 17 (3.5 %) distal DVT and 41 (8.5 %) MVT, respectively. Multivariate analyses established history of VTE (OR for proximal DVT 7.0; 95 %-CI 1.9 - 25.9; OR for any DVT 3.9; 95 %-CI 1.7 - 8.9), female gender (OR 3.3; 95 %-CI 1.0 - 10.6), coronary artery disease (OR 3.8; 95 %-CI 1.1 - 12.9) and cancer (OR 8.0; 95 %-CI 1.8 - 35.5) as independent VTE predictors for proximal DVT. For MVT, age (OR 2.4; 95 %-CI 1.2 - 5.0) and a history of musculo-skeletal disease (OR 2.6; 95 %-CI 1.1 - 5.8) or autoimmune disease (OR 3.9; 95 %-CI 1.0 - 15.4) were found to be independent predictors. CONCLUSIONS: This study confirms well-known predictors of VTE and high rates of postoperative VTE despite optimal thromboprophylaxis. In addition, independent risk factors for proximal DVT and MVT were identified. The data support the concept or continuing thromboprophylaxis during rehabilitation after major orthopaedic surgery because a considerable percentage of patients had asymptomatic DVT at RC on admission. However, significant differences in the individual risk profile and the distribution pattern of DVT and MVT exist, which could be used for a more individualized thromboprophylaxis strategy
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Osseous metastases from renal cell carcinoma: embolization and surgery for restoration of function. Work in progress
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MSTS 2018 - Femur Mets and MM
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Five patients underwent preoperative embolization of osseous metastases from renal cell carcinoma. The group consisted of four men and one woman who ranged in age from 46 to 79 years. The lesions were located in the pubic ramus and acetabulum, proximal femur, femoral midshaft, proximal humerus, and proximal tibia. All embolizations were performed within 24 hours of surgery. The internal fixation and tumor curettage was accomplished with estimated perioperative blood loss ranging from 10 ml to 1,250 ml. All patients had significant restoration of function following surgery. We suggest that preoperative embolization is an important and efficacious adjunct in the management of hypervascular renal cell osseous metastases.
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Factors Influencing patient experience and satisfaction following surgical management of ankle fractures
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Hip Fx in the Elderly 2019
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BACKGROUND: Patient feedback is increasingly important to inform and develop effective healthcare within the United Kingdom. In order to optimise patient experience of ankle fracture care in our unit, we sought to identify elements of practice associated with poor patient experience and low levels of satisfaction.
METHODS: Adult patients with closed ankle fractures requiring fixation over a ten month period were prospectively identified. Prior to discharge all patients completed the Picker Patient Experience Questionnaire (PPE-15), satisfaction visual analogue scale (VAS: 0-10) and a demographic questionnaire. Operative delay and cancellation episodes were similarly noted. PPE-15 and satisfaction VAS data were collected concurrently from a control group of elective hip and knee arthroplasty patients.
RESULTS: 52 patients (23 males) of average age 47 years (17-86) underwent ankle fracture fixation. Median pre-operative length of stay (LOS) was 3days (IQR 1-6). Ankle fracture patients had significantly worse experiences compared to arthroplasty patients (p<0.05 across all 15 PPE domains). Once pre-operative length of stay exceeded 3days patients reported more areas of concerns (6 of 15) than those waiting 3days or less (4 of 15) (p=0.02). Cancelled patients reported significantly worse experiences, with satisfaction VAS of 7 (versus 9 in those not cancelled [p=0.005]), and median of 6 PPE-15 domains of concern (versus 3.5 [p=0.03]).
CONCLUSIONS: Efforts to improve the healthcare experience of patients with ankle fractures should be focused on improving processes that minimise cancellation of surgery and the communication around delay management.
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Impaired muscle function with aging. A background factor in the incidence of fractures of the proximal end of the femur
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Management of Hip Fractures in the Elderly
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Muscle biopsy material from vastus lateralis musculus quadriceps was obtained during surgery from 43 66-100-year-old female and nine 70-89-year-old male patients with fresh hip fractures. Before the accident, 18 women and two men were clinically healthy, and in the others, one-third had cardiovascular, one-third locomotor, and one-third neurologic disorders. Twelve women lived in institutions. The other women and all of the men lived in their own homes. A striking finding was a more advanced reduction in muscle fiber size in the vastus lateralis, especially in the fast twitch (FT) fibers. The reduction occurred in preaccident clinically healthy fracture patients. With advancing age, the proportions of the slow twitch (ST) and FT fibers remained the same. Well-maintained, enzymatic metabolic capacity, moderate neuropathic changes, and absence of myopathic changes indicate that the quality of the muscle tissue is relatively well preserved, even in elderly patients with hip fractures. Muscle fiber atrophy and weakness in muscle strength may be attributable in part to a low physical activity and are possibly reversible with exercise in some individuals
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Should we routinely analyze reduction mammaplasty specimens?
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Reduction mammaplasty is one of the most common plastic surgery procedures. Preoperative imaging and histopathology protocols vary among countries and institutions. We aimed to analyze the incidence of occult breast cancer and high-risk lesions in reduction mammaplasty specimens. We also analyzed whether patients with abnormal histopathology differed from the study population in terms of demographics.
PATIENTS AND METHODS: In total, 918 women who underwent reduction mammaplasty from January 2007 to December 2011 were retrospectively reviewed for demographics, preoperative imaging, further preoperative examinations, pathology reports, and postoperative follow-up.
RESULTS: Abnormal histopathological findings were revealed in 88 (10%) patients with a mean age of 49.5 +/- 10.2 years. The incidence of breast cancer was 1.2%, and the incidence of high-risk lesions (atypical ductal and lobular hyperplasia and lobular carcinoma in situ) was 5.5%. Age and specimen weights were significantly higher in patients with abnormal histopathology. Eighty-one percent of patients with abnormal histopathology had normal preoperative imaging revealing two high-risk and two cancer findings. Two patients developed breast cancer in the same breast in which the high-risk lesion was originally detected.
CONCLUSION: Women with abnormal histopathology cannot be sufficiently detected preoperatively. Therefore, histopathological analysis of reduction mammaplasty specimens seems mandatory. Reduction mammaplasty combined with subsequent histopathological examination offers a sufficient chance of detecting cancer and risk-increasing lesions that merits the cost of histopathology.
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Persistent median artery and compression neuropathy
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Two cases are presented, each with a large persistent unthrombosed median artery associated with carpal tunnel syndrome. It is noted that in cases such as these, excision of the unthrombosed median artery is not indicated because it may sometimes substantially contribute to the circulation of the hand
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Radiocarpal dislocation: A retrospective study of 14 patients
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Distal Radius Fractures
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INTRODUCTION: Radiocarpal dislocation (RCD) is defined as total loss of contact between the carpal and radial joint surfaces. The condition is rare, with few published series. The aim of the present study was to assess functional results of RCD surgery, notably without ligament reconstruction., HYPOTHESIS: Functional outcome of RCD surgery is satisfactory for everyday use of the wrist., MATERIALS AND METHODS: A retrospective study was performed for the period January 2012 to July 2017. Inclusion criteria comprised: RCD on preoperative X-ray, in adult patients, with a minimum 6months' follow-up; exclusion criteria comprised: unclosed growth plate, and distal radial epiphyseal fracture with large displacement. RCD type was assessed on Dumontier's classification. Functional results were assessed as postoperative range of wrist motion, grip strength (Jamar R), and QuickDASH and Green-O'Brien (modified by Cooney) functional scores., RESULTS: Fourteen patients were followed up at a mean 31months (range, 7-60months). Three showed type I RCD and 11 type II. All were treated surgically; no ligament sutures were performed. Mean flexion was 63degree (range, 20-90degree), extension 51degree (25-90degree), pronation 79degree (60-90), supination 80degree (50-90), and grip strength 27.9kg (8-40). Mean QuickDASH and modified Green-O'Brien scores were respectively 25.6 (4.54-40.9) and 74 (35-100)., DISCUSSION: The present functional results were satisfactory and comparable to those of the literature, despite no use of radiocarpal ligament suture in type-1 RCD., LEVEL OF EVIDENCE: IV. Copyright © 2019 Elsevier Masson SAS. All rights reserved.
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Comparative outcomes of total joint arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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A prospective pre- and postoperative general health/quality-of-life factor comparison, using the Rand SF-36 Health Status Questionnaire (TyPE Specification, Quality Quest [Health Outcomes Institute, Minneapolis, MN]), was carried out on a consecutive series of patients with diagnosed osteoarthritis undergoing total hip and knee arthroplasty between March 1991 and March 1994. Study groups consisted of 85 total hip arthroplasty patients, 93 total knee arthroplasty patients, and 65 single-stage bilateral total knee arthroplasty patients, all treated at the same specialty hospital, under the care of three senior orthopaedic surgeons. The average patient age was 69 years. Significant improvements in quality-of-life measures including physical functioning, social functioning, role functioning/physical problem, role functioning/emotional problem, mental health, energy/fatigue, pain, and change in health were noted in all hip and knee arthroplasty patients 6 months, 1 year, and 2 years after surgery (P < .05). There appeared to be no significant differences in quality-of-life measures between hip and knee arthroplasty patients. Results therefore indicate that total hip and knee arthroplasty significantly improve the functional status and quality of life among patients suffering from osteoarthritis
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Factors affecting the outcome of hemi hip arthroplasty in elderly patients with femoral neck fractures
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Hip Fx in the Elderly 2019
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The outcome of hemi hip arthroplasty is affected by many factors. Which factors may affect the outcome remains a controversial topic. The aim of this study was to assess the factors that may have the greatest influence on patientsâ?? postoperative outcome. 258 patients underwent HA from January 2006 to December 2012 were included, consisting of 187 women (72.5%) and 71 men (27.5%) with a mean age of 85.140 ± 4.370. Ordinal logistic regression analysis was used to analyze the related factors included postoperative complications and genÂeral conditions. Hip function was evaluated by Harris Hip Score. An older age (P = 0.007, odds ratio [OR] = 1.12) was associated with a lower postoperative HHS. A higher BMI (P = 0.005, OR = 1.22) was associated with a lower postoperative HHS. The ASA score (Pâ?¤0.001, OR = 3.23) of the high group was associated with a poor prognosis compared to the low group. When the patients had more comorbidities, they had poor functional outcomes (P<0.05, OR = 3.76, 8.81). Regarding patients with diabetes, joint function was worse postoperatively for those with diabetes than those without diabetes (P<0.001, OR = 1.19). Patients with an older age, a high BMI, a high ASA score, and more comorbidities may have a poorer functional outcome. In those with hypertension, CHD, diabetes, and COPD, the main negative factor affecting the prognosis is diabetes.
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Reconstruction of fingertip defects with great toe pulp grafts
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DoD LSA (Limb Salvage vs Amputation)
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Various methods have been used to treat fingertip defects that are caused when distal parts are amputated. In this study, we used the pulp graft harvested from the lateral aspect of the great toe. Between September 2004 and August 2006, the great toe pulp graft were performed on 16 patients. The ages of patients ranged from 4 to 58 years. The average follow-up duration was 28 months. Complete graft take was observed in 13 of 16 patients. Partial necrosis was observed in 2 patients, and total necrosis in 1 patient. The pulp graft was painless and the color and texture of the graft were similar to the adjacent skin. Semmes-Weinstein monofilament and 2-point discrimination tests showed good recovery of fingertip sense. The scar of the fingertip was assessed by Vancouver Scar Scale and Cold intolerance by Visual Analog Scale and the results were satisfactory and also improved with time. The recipient site wasclosed with little scar. There were no gait disturbances. To conclude, the great toe pulp graft can provide soft-tissue and sensory recovery in fingertip defects.
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A comparison of rheumatoid arthritis in Australia and China
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A comparison was made of two series of consecutive outpatients with a presumptive diagnosis of rheumatoid arthritis (RA) attending referral centres in Melbourne and Shanghai. No significant differences were observed in disease onset, course, presence of antinuclear antibodies (ANA), or seropositivity. In the Australian series there was a higher frequency of nodules, Raynaud's phenomenon, carpal tunnel syndrome, and 'classical' in comparison with 'definite' disease, and a lower frequency of lymphadenopathy and hepatomegaly. Joint tenderness and soft tissue swelling tended to be more marked in the Chinese series, while deformity and limited range of movement were less severe. Drug therapy was similar overall but influenced by drug availability. Peptic ulceration was recorded in 28% of the Australian series but in only 6% of the Chinese; although 25% of the Chinese were receiving antacids and 6% antiulcerants. X-rays of hands and feet showed more severe disease in the Australian series. The older age group and longer duration of the disease in the Australian patients, who had more chronic and less active disease, may have influenced some of these results
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Ceramic-on-ceramic total hip arthroplasty: minimum of six-year follow-up study
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PJI DX Updated Search
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BACKGROUND: This study examines the clinical and radiologic results of ceramic-on-ceramic total hip arthroplasties with regard to wear, osteolysis, and fracture of the ceramic after a minimum follow-up of six years. METHODS: We evaluated the results of a consecutive series of 148 primary ceramic-on-ceramic total hip arthroplasties that had been performed between May 2001 and October 2005 in 142 patients. The mean age was 57.2 years (range, 23 to 81 years). The mean follow-up period was 7.8 years (range, 6.1 to 10.1 years). Preoperative diagnosis was avascular necrosis in 77 hips (52%), degenerative arthritis in 36 hips (24.3%), femur neck fracture in 18 hips (12.2%), rheumatoid arthritis in 15 hips (10.1%), and septic hip sequelae in 2 hips (1.4%). Clinical results were evaluated with the Harris hip score, and the presence of postoperative groin or thigh pain. Radiologic analysis was done with special attention in terms of wear, periprosthetic osteolysis, and ceramic failures. RESULTS: The mean Harris hip score improved from 58.3 (range, 10 to 73) to 92.5 (range, 79 to 100) on the latest follow-up evaluation. At final follow-up, groin pain was found in 4 hips (2.7%), and thigh pain was found in 6 hips (4.1%). Radiologically, all femoral stems demonstrated stable fixations without loosening. Radiolucent lines were observed around the stem in 25 hips (16.9%), and around the cup in 4 hips (2.7%). Endosteal new bone formation was observed around the stem in 95 hips (64.2%) and around the cup in 88 hips (59.5%). No osteolysis was observed around the stem and cup. There were 2 hips (1.4%) of inclination changes of acetabular cup, 2 hips (1.4%) of hip dislocation, 1 hip (0.7%) of ceramic head fracture, and 1 hip (0.7%) of squeaking. The Kaplan-Meier survival rate of the prostheses was 98.1% at postoperative 7.8 years. CONCLUSIONS: The ceramic-on-ceramic total hip arthroplasty produced excellent clinical results and implant survival rates with no detectable osteolysis on a minimum six-year follow-up study. The ceramic-on-ceramic couplings could be a reasonable option of primary total hip arthroplasty for variable indications
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Open reduction and internal fixation with 90-90 plating of bicolumn distal humeral fractures
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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A bicolumn intra-articular fracture is the most challenging distal humeral fracture to treat. Open reduction and internal fixation of these fractures is best achieved using either 90-90 medial-lateral or parallel opposing plates. Either technique can be used to treat most patients, although in some instances, one technique may be preferred over another. The goal of treatment is accurate anatomic restoration and stable fixation that will permit early range of motion
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Firearm Ownership Among Military Veterans With PTSD: A Profile of Demographic and Psychosocial Correlates
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DoD PRF (Psychosocial RF)
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Post-traumatic stress disorder (PTSD), a condition that disproportionately affects military veterans, is associated with heightened rates of aggression and suicide. Although experience with firearms is common among this population, virtually nothing is known regarding who is more likely to own a firearm and whether firearm ownership is differentially associated with psychological and behavioral risk factors among veterans with PTSD. Of 465 veterans (79% male) entering PTSD treatment, 28% owned a firearm (median number of firearms among owners = 3, range = 1-40). Firearm owners reported higher income were less likely to be unemployed, and were more likely to be male, Caucasian, married, and living in permanent housing. Ownership was associated with higher combat exposure and driving aggression, yet lower rates of childhood and military sexual trauma, suicidal ideation, and incarceration. Ownership was not associated with previous suicide attempt, arrest history, number of traumas experienced, PTSD symptoms, or depression. Together, among a sample of treatment-seeking military veterans with PTSD, those who owned a firearm appeared to demonstrate greater stability across a number of domains of functioning. Importantly though, routine firearm safety discussions (e.g., accessibility restrictions; violence risk assessments) and bolstering of anger management skills remain critical when working with this high-risk population.
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Bilateral periprosthetic stress fractures in a juvenile chronic arthritis patient secondary to bilateral genu valgum
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Surgical Management of Osteoarthritis of the Knee CPG
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Lateral insufficiency fractures following total hip replacement have been reported with the femoral stems positioned in varus, together with osteopenia of the lateral femoral cortex. Any abnormal alignment of the lower limbs, such as genu valgum, will alter the load distribution across the femoral cortices, and repetitive loading during walking will predispose the bones to stress fractures at any stress riser point, such as the tip of a femoral component. Bilateral femoral stress fractures post total hip replacements have not been previously described. We present a 55-year-old woman, diagnosed with juvenile idiopathic arthritis, who had undergone bilateral total hip replacements and bilateral knee replacements. The knees 15 years postoperatively were in valgus and the left knee was extremely stiff, flexing to just 5. The patient presented with bilateral thigh pain, with plain radiographs confirming bilateral periprosthetic fractures of the femur at the tip of well-fixed femoral components. There was no history of injury and her hips were functioning well up to this time. The patient required revision of both hips to long-stem uncemented components, bypassing the fractures, and revision of both knees to stemmed semi-constrained implants, thereby correcting the alignment of both lower limbs. Both fractures healed and the patient is currently pain-free and mobile with walking aids. Surgeons must remain aware that when implants are in situ, abnormal alignments will lead to abnormal forces, and stress fractures are likely to occur at any stress riser around the implant. Avoiding malalignment will avoid this complication
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The reliability of measurements taken from computer-stored digitalised x-rays of acute distal radius fractures
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Distal Radius Fractures
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Sixteen observers measured eight anatomical parameters on digitalised images of six acute distal radial fractures using the Patient Archiving Communication System software and repeated the measurements at least 2 weeks later. Inter- and intraobserver reliability was calculated using intraclass correlation coefficients and tolerance limits. The highest interobserver agreement was demonstrated in the dorsal tilt (intraclass correlation coefficient 0.858; tolerance limit 14.2 degrees ). When compared with the results of a study looking at observer reliability in measurement of healed distal radial fractures, the reliability of computerised measurements is not significantly different from those achieved by manual techniques (dorsal tilt interobserver tolerance limits on computer system 16 degrees , compared to 15 degrees using ruler and protractor). These results suggest that the recommended radiological reduction limits for distal radius fractures of <10 degrees change in palmar tilt, <2 mm radial shortening, <5 degrees change in radial angle and a <1 to 2 mm articular step cannot be reliably measured.
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Complications of a cable grip system
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Management of Hip Fractures in the Elderly
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From a group of 643 total hip arthroplasties, 98 patients required trochanteric osteotomies, and in 68 the trochanteric osteotomies were repaired with the Dall-Miles cable grip system (Howmedica, Rutherford, NJ). Trochanteric nonunion occurred in 17 of these patients (25%), with fraying and fragmentation of the cable present in 15 (88%). Of the 51 patients with radiographic union, 18 (35%) also had signs of fraying and fragmentation. Bone destruction around the cable in the area of the lesser trochanter was seen in seven patients (10%). Large deposits of metal debris at the inferior border of the acetabulum were seen in eight hips (12%). Multifilament cable did not appear to offer significant advantages over standard monofilament wire, and the potential problems of fraying fragmentation, and free-floating metallic debris must be considered
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The effect of high dose antibiotic impregnated cement on rate of surgical site infection after hip hemiarthroplasty for fractured neck of femur: a protocol for a double-blind quasi randomised controlled trial
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Mortality following hip hemiarthroplasty is in the range of 10-40% in the first year, with much attributed to post-operative complications. One such complication is surgical site infection (SSI), which at the start of this trial affected 4.68% of patients in the UK having this operation. Compared to SSI rates of elective hip surgery, at less than 1%, this figure is elevated. The aim of this quasi randomised controlled trial (RCT) is to determine if high dose antibiotic impregnated cement can reduce the SSI in patients at 12-months after hemiarthroplasty for intracapsular fractured neck of femur.
METHODS: 848 patients with an intracapsular fractured neck of femur requiring a hip hemiarthroplasty are been recruited into this two-centre double-blind quasi RCT. Participants were recruited before surgery and quasi randomised to standard care or intervention group. Participants , statistician and outcome assessors were blind to treatment allocation throughout the study. The intervention consisted of high dose antibiotic impregnated cement consisting of 1 gram Clindamycin and 1 gram of Gentamicin. The primary outcome is Health Protection Agency (HPA) defined deep surgical site infection at 12 months. Secondary outcomes include HPA defined superficial surgical site infection at 30 days, 30 and 90-day mortality, length of hospital stay, critical care stay, and complications.
DISCUSSION: Large randomised controlled trials assessing the effectiveness of a surgical intervention are uncommon, particularly in the speciality of orthopaedics. The results from this trial will inform evidence-based recommendations for antibiotic impregnated cement in the management of patients with a fractured neck of femur undergoing a hip hemiarthroplasty. If high dose antibiotic impregnated cement is found to be an effective intervention, implementation into clinical practice could improve long-term outcomes for patients undergoing hip hemiarthroplasty.
TRIAL REGISTRATION: Current Controlled Trials: ISRCTN25633145.
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Prevalence of Developmental Dysplasia of the Hip in Chinese Adults: A Cross-sectional Survey
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Developmental Dysplasia of the Hip 2020 Review
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BACKGROUND: The prevalence of developmental dysplasia of the hip (DDH) is unknown in China. We aimed to determine the prevalence of DDH in Chinese adults. METHODS: In this study, we performed a cross-sectional survey of a nationally representative sample of Chinese adults. All participants underwent questionnaire investigation, physical examination, and X-ray examination. Factors associated with DDH were analyzed with logistic regression. RESULTS: We invited 29,180 individuals aged 18 years and over to participate, randomly selected from 18 primary sampling units (street districts in urban areas and townships in rural areas). The survey and examination were completed in 25,767 people (10,296 men and 15,471 women). DDH was diagnosed in 391 people, yielding an overall DDH prevalence of 1.52%. Based on this information, we estimate the number of individuals with DDH in China to be approximately 16.05 million. DDH prevalence increased with age (odds ratio = 1.53 [1.03-2.27], P = 0.036), was significantly higher among women than men (2.07% vs. 0.75%, P< 0.001), and was higher among rural residents than urban residents (1.75% vs. 1.29%, P< 0.001). Economic development was independently associated with the presence of DDH. There was no evidence of an association between body mass index alone, education, or current smoking or drinking and risk of DDH (P > 0.05). CONCLUSIONS: DDH has become an important public health problem. Special attention should be paid to residents with DDH. Screening for DDH should be performed in China.
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Compartment syndromes
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DoD - ACS - Interrater Reliability
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Compartment syndrome occurs when pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischaemia. Two distinct conditions are recognized: acute and chronic (exertional) compartment syndromes. Differences in aetiology, pathophysiology and management are elaborated on in this article. [References: 16]
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Predictors of complications following breast reduction surgery: A National Surgical Quality Improvement Program study of 16,812 cases
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Panniculectomy & Abdominoplasty CPG
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Background: Breast reduction is one of the most common procedures performed by plastic surgeons. Despite good outcomes and high patient satisfaction, there are little national data on the predictors that lead to complications in this patient population. We accessed a national outcomes database to examine these factors. Methods: This is a retrospective study examining the National Surgical Quality Improvement Program database from 2006 to 2015. Patients who underwent primary breast reduction were identified. Patients who underwent any cancer-related procedures were excluded. We identified patient-related and procedure-related factors for analysis. Univariate and multivariate logistic regression analyses were used to identify independent predictors of complications. Results: In total, 16,812 individual cases were identified. The overall complication rate for the cohort was 6.2%, and the major complication rate was 3.0%. Diabetes, bleeding disorder, hypertension, obesity, smoking, steroid use, and prolonged operative time were associated with increased risk of complications (p < 0.05). Concurrent body contouring was a predictor of increased major complications; however, liposuction was not. Conclusions: Common surgical risk factors are associated with complications in breast reduction surgery. Although liposuction is not an independent risk factor, concurrent body contouring is associated with increased complications. Surgeons should be aware of these associations when discussing breast reduction with patients.
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Injuries in Aleppo, Syria; first population-based estimates and characterization of predominant types
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DoD PRF (Psychosocial RF)
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BACKGROUND: Despite the growing burden of injuries worldwide, Syria and many other Arab countries still lack population-based estimates of different types of injuries. This study aims to provide first population-based estimates of major injuries in Syria and characterize groups at increased risk.
METHODS: An interviewer-administered population-based survey of adults 18-65 years residing in Aleppo, Syria was conducted in 2004. The study sample involved 2038 household representatives in Aleppo (45.2% men, mean age 35.3 +/- 12.1, response rate 86%). We inquired about participants self-reported injuries in the past year that required medical attention as well as injuries among their household members. When reported, injuries were further assessed according to type, place, and outcome.
RESULTS: Overall, there was 153 self-reported injuries in the past year (77.3 per 1000 adult respondents, 93.1 per 1000 in men and 64.4 per 1000 in women, p = 0.02). Other than gender, injuries differed by age (the older age group being least affected), and place of occurrence, as men were more likely to sustain traffic injuries and be injured outside the home. Injuries were reported among 236 household members (21.0 per 1000), and were slightly more frequent in children than adults (22.0 per 1000 for children, and 19.7 per 1000 for adults, p = 0.2). Traffic injuries, falls, and poisoning (food) were by far the most common types of injury experienced by participants as well as their household members. Falls and traffic injuries seem to have caused most morbidity for the injured, while burns, although not frequently reported, were associated with an unfavorable outcome in the majority of cases.
CONCLUSION: This information provides baseline information about the burden of different injuries in Syria, and the sociodemographic factors related to them.
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Effect of therapeutic exercise on knee osteoarthritis after intra-articular injection of botulinum toxin type A, hyaluronate or saline: A randomized controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To study the effect of therapeutic exercise on knee osteoarthritis after injection of botulinum toxin type A, hyaluronate or saline.
METHODS: Sixty participants with knee osteoarthritis were randomly assigned to 3 groups: injection of saline (control) (group A), botulinum toxin type A (group B), or hyaluronate (group C). All participants received therapeutic exercise. Western Ontario and McMaster Universities Osteoarthritis Index questionnaire score, visual analogue scale pain scale, and Medical Outcomes Study 36-item Health Survey were conducted at baseline, and at the end of the 4th and 8th weeks.
RESULTS: At end of the 4th and 8th weeks, the scores on the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire and visual analogue scale were higher in the control group. There were significant differences in Physical Component Summary-36 and Mental Component Summary-36 scores between the 3 groups (p <0.05) at the end of the 4th and 8th weeks, but not between groups A (control) and C (hyaluronate) at the end of the 4th week. No changes were seen on magnetic resonance imaging and X-ray images of the affected knees after the intervention.
CONCLUSION: Therapeutic exercise plus botulinum toxin type A or hyaluronate injection can significantly reduce pain and improve knee functioning. Botulinum toxin type A plus therapeutic exercise appears to be more effective.
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Natural history of squeaking after total hip arthroplasty
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Hip Fx Time to Surgery
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BACKGROUND: In recent years, a number of alternative bearing surfaces, such as ceramic on ceramic, are being used in THA. Squeaking after THA is a recently recognized complication; however, its incidence is unknown. QUESTIONS/PURPOSES: Find the incidence of squeaking; when it ensues; activities associated to squeaking; its natural history, and outcome of revisions for squeaking. METHODS: A prospective observational study between 2002 and 2007; yield 1486 ceramic-on-ceramic THA performed at our institution. All patients were followed up by office visits or by phone, to obtain information regarding squeaking, pain and function. Minimum followup was 2.5 years (mean, 5.5 years; range, 2.5-7.9 years). RESULTS: Ninety-five of the 1486 hips (6%) developed squeaking after THA, 39 females (44%) and 49 males (56%) with an average age of 49.9 years. Squeaking began on average 19.7 months after surgery but not associated with pain or functional impairment in any patient. Squeaking could be heard during walking (38%), ascending stairs (24%), bending forward (21%), and other activities (18%), was constant in 26% of the patients and intermittent in 74%. The intensity and frequency remained similar over time in 70% of the patients. CONCLUSIONS: Squeaking is a real phenomenon that occurred in about 6% of our patients. The etiology for this problem remains elusive and is likely to be multifactorial in nature. Squeaking, when developed, does not seem to be self-limited and persists in the majority. Nine patients underwent revision arthroplasty for squeaking. No fractures or other implant-related issues were observed. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
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The history of fetal therapy
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Panniculectomy & Abdominoplasty CPG
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The Fetal Treatment Center founded by Michael Harrison is credited as the birthplace of fetal surgery. His trainees in pediatric surgery subsequently founded fetal centers throughout the United States. In Europe, the advent of minimally invasive fetal surgical techniques led to the establishment of treatment centers led predominantly by perinatologists. More recently, perinatologists in North America have begun to play a greater role in the field of fetal intervention. Intrauterine transfusion for the treatment of hemolytic disease of the fetus/newborn was the first successful fetal intervention. Although not subjected to the rigors of clinical trials, this treatment has withstood the test of time. Interventions for other fetal disease states such as twin-twin transfusion and repair of fetal myelomeningocele were investigated in animal models followed by randomized clinical trials before widespread adoption. Tracheal occlusion for diaphragmatic hernia is still currently being investigated as the next promising step in fetal intervention. © 2014 by Thieme Medical Publishers, Inc.
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Porcine small intestine submucosa augmentation of surgical repair of chronic two-tendon rotator cuff tears. A randomized, controlled trial
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Optimizing the Management of Full-Thickness Rotator Cuff Tears
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BACKGROUND: Evidence to justify the use of porcine small intestine submucosa to augment repairs of large and massive rotator cuff tears is based on favorable results found in studies of Achilles tendon and infraspinatus tendon repairs in canines. The purpose of this study was to determine the effectiveness of a small intestine submucosal patch to augment the repair of chronic two-tendon rotator cuff tears in humans. METHODS: Thirty shoulders with a chronic two-tendon rotator cuff tear that was completely repairable with open surgery were randomized to be treated with either augmentation with porcine small intestine mucosa or no augmentation. All patients completed a PENN shoulder-score questionnaire preoperatively and at the time of the latest follow-up (at an average of fourteen months). Magnetic resonance imaging showed that nine shoulders had a large tear and twenty-one had a massive tear. All patients underwent a magnetic resonance imaging scan with intra-articular gadolinium one year after the repair to assess the status of the rotator cuff. RESULTS: The rotator cuff healed in four of the fifteen shoulders in the augmentation group compared with nine of the fifteen in the control group (p = 0.11). The median postoperative PENN total score was 83 points in the augmentation group compared with 91 points in the control group (p = 0.07). Healing of the defects in both groups demonstrated a strong correlation with the patients' clinical scores. The median postoperative PENN total score was 96 points in the group with a healed repair and 81 points in the group with a failed repair (p = 0.007). The percentage change between the preoperative and postoperative patient satisfaction scores was 400% in the group with a healed repair, and 50% in the group with a failed repair (p = 0.04). CONCLUSIONS: Augmentation of the surgical repair of large and massive chronic rotator cuff tears with porcine small intestine submucosa did not improve the rate of tendon-healing or the clinical outcome scores. On the basis of these data, we do not recommend using porcine small intestine submucosa to augment repairs of massive chronic rotator cuff tears done with the surgical and postoperative procedures described in this study
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A study of the relationship between meniscal injury and bone microarchitecture in ACL reconstructed knees
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Anterior cruciate ligament (ACL) tears increase the risk of developing knee osteoarthritis. This risk increases further with concurrent meniscus injury. The role of bone changes during knee osteoarthritis development are not well-understood, but may be important to its etiology.
PURPOSE: To explore the effects of ACL tears on bone mineral density (BMD) and bone microarchitecture at five years post-op and their relationship to meniscal pathology, using high-resolution peripheral quantitative computed tomography (HR-pQCT).
METHODS: Twenty-eight participants with unilateral ACL reconstructions five years prior and no evidence of clinical or radiographic osteoarthritis were recruited. All participants represented one of three meniscus statuses: meniscus intact, meniscus repair, or meniscectomy. BMD and bone microarchitecture of the subchondral bone plate and adjacent trabecular bone were assessed using HR-pQCT, and percent-differences between the injured and contralateral knee were determined.
RESULTS: Subchondral bone plate thickness in the lateral femoral condyle was higher in the reconstructed knee (9.0%, p=0.002), driven by the meniscus repair and meniscectomy groups (15.2% to 15.4%, p<0.05). Trabecular BMD was lower in the reconstructed knee in the medial femoral condyle (-4.8% to -7.6%, p<0.05), driven by all meniscus statuses. In the lateral compartments, few differences in trabecular bone were found. However, accounting for meniscus status, the meniscus intact group had lower trabecular BMD throughout both femur and tibia.
CONCLUSIONS: Five years post-op, reconstructed knees demonstrated detectable differences in BMD and bone microarchitecture, despite having normal radiographs. Meniscus damage affected primarily the lateral compartment, warranting further investigation to determine if these changes relate to osteoarthritis development.
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Breast cancer anti-estrogen resistance 3 inhibits transforming growth factor beta/Smad signaling and associates with favorable breast cancer disease outcomes
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MSTS 2018 - Femur Mets and MM
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INTRODUCTION: This study helps to define the implications of breast cancer anti-estrogen resistance 3 (BCAR3) in breast cancer and extends the current understanding of its molecular mechanism of action. BCAR3 has been shown to promote cell proliferation, migration and attachment to extracellular matrix components. However, in a cohort of metastatic breast cancer patients who received tamoxifen treatment, high BCAR3 mRNA levels were associated with favorable progression-free survival outcome. These results suggest that, besides its established roles, BCAR3 may have additional mechanisms of action that regulate breast cancer aggressive phenotype. In this study, we investigated whether BCAR3 is a novel antagonist of the canonical transforming growth factor beta (TGFbeta) pathway, which induces potent migration and invasion responses in breast cancer cells.
METHODS: We surveyed functional genomics databases for correlations between BCAR3 expression and disease outcomes of breast cancer patients. We also studied how BCAR3 could regulate the TGFbeta/Smad signaling axis using Western blot analysis, coimmunoprecipitation and luciferase assays. In addition, we examined whether BCAR3 could modulate TGFbeta-induced cell migration and invasion by using an automated imaging system and a confocal microscopy imaging-based matrix degradation assay, respectively.
RESULTS: Relatively low levels of BCAR3 expression in primary breast tumors correlate with poor distant metastasis-free survival and relapse-free survival outcomes. We also found a strong correlation between the loss of heterozygosity at BCAR3 gene alleles and lymph node invasion in human breast cancer, further suggesting a role for BCAR3 in preventing disease progression. In addition, we found BCAR3 to inhibit Smad activation, Smad-mediated gene transcription, Smad-dependent cell migration and matrix digestion in breast cancer cells. Furthermore, we found BCAR3 to be downregulated by TGFbeta through proteasome degradation, thus defining a novel positive feedback loop mechanism downstream of the TGFbeta/Smad signaling pathway.
CONCLUSION: BCAR3 is considered to be associated with aggressive breast cancer phenotypes. However, our results indicate that BCAR3 acts as a putative suppressor of breast cancer progression by inhibiting the prometastatic TGFbeta/Smad signaling pathway in invasive breast tumors. These data provide new insights into BCAR3's molecular mechanism of action and highlight BCAR3 as a novel TGFbeta/Smad antagonist in breast cancer.
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A lateral meniscus tear incarcerated behind the popliteus tendon: A case report
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PJI DX Updated Search
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A 51-year-old male, sustained an injury to his left knee after being pinned between his motorcycle and a road barrier. In the ER, the patient complained of medial knee pain, and had a significant joint effusion. MRI demonstrated an ACL injury, medial meniscal tear, bone bruising and impaction at the lateral femoral condyle and tibial plateau, and a tear of the posterior horn of the lateral meniscus that was displaced behind the popliteus. Unfortunately, the patient also presented with a deep vein thrombosis and thus could not proceed to the operating room for two months. During this time, scar tissue developed around the lateral meniscus.The purpose of this report is to present an unusual variant of a common injury pattern previously unreported where the posterior horn of the lateral meniscus became incarcerated behind the popliteus tendon and was left in place. It is likely that our patient will develop osteoarthritis in the future, but considering the circumstances he received a favorable early clinical outcome. Early recognition and a mobile fragment are essential restoring a patient's original anatomical features and achieving an optimal clinical outcome. é 2009 Elsevier B.V
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Hip fracture as a complication of hospitalization
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Management of Hip Fractures in the Elderly
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This work seeks to assess the possible contribution of hospitalization to hip fractures sustained in an acute care hospital and to determine the need for hospital care for these patients at the time of the fracture. Between 1988 and 1997 there was an average of 399 falls and four in-hospital hip fractures per year. For 14 percent, no predisposing factors for falling were noted, 38 percent of the fractures occurred within the first three days and 47 percent during the first week of hospitalization. Original admission did not seem warranted for 10 percent and 48 percent no longer required inpatient care at the time of the fracture. Most fractures occur early during hospitalization; some patients seem to have no predisposing factors for falling and about one-half may not require hospitalization at the time, all implicating hospitalization as a causative factor
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Immediate breast reconstruction with anatomical implants following mastectomy: The radiation perspective
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Acellular Dermal Matrix
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Immediate implant-based breast reconstruction followed by postmastectomy radiation therapy (PMRT) is controversial because of the risk of compromised treatment plans and concerns regarding cosmetic outcomes. We evaluated the effects of immediate direct-to-implant breast reconstruction with anatomical implants on the quality of PMRT delivered by 3-dimensional conformal radiotherapy (3D-CRT). In this retrospective, single-institution study, patients who had undergone reconstruction with direct anatomic implant, performed by a single surgeon, received 3D-CRT between 2008 and 2013. For each patient, 2 plans (including or excluding internal mammary nodes [IMN]) were created and calculated. The primary end point was the dose distribution among reconstructed breasts, heart, lungs, and IMNs, and between right and left breasts. Of 29 consecutive patients, 11 received right-sided and 18 received left-sided PMRT to a total dose of 50Gy. For plans excluding IMN coverage, mean Dmean for right and left reconstructed breasts was 49.09Gy (98.2% of the prescribed dose) and 48.51Gy (97.0%), respectively. For plans including IMNs, mean Dmean was 49.15Gy (98.3%) for right and 48.46Gy (96.9%) for left reconstructed breasts; the mean IMN Dmean was 47.27Gy (right) and 47.89Gy (left). Heart Dmean was below 1.56Gy for all plans. Mean total lung volume receiving a dose of = 20Gy was 13.80% to 19.47%. PMRT can be delivered effectively and safely by 3D-CRT after direct-to-implant breast reconstruction with anatomical implants, even if patients require IMN treatment.
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The Sauve-Kapandji procedure for posttraumatic wrist disorders: further experience
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Distal Radius Fractures
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A prospective survey was conducted to evaluate the outcome of the Sauve-Kapandji procedure for posttraumatic wrist disorders. Eighty four patients were treated, all with posttraumatic disorders of the distal radioulnar joint, 73 as an isolated procedure, 11 in combination with another wrist procedure. There was significant pain decrease and high patient satisfaction (74%). The range of motion increased in the flexion/extension arc from 109 degrees to 124 degrees (p = 0.006) and, in those with limited forearm rotation, from 71 degrees to 134 degrees (p = 0.006). According to the Mayo Clinic wrist score, we obtained 20 excellent, 34 good, 18 fair and 12 poor results. Complications were rare.
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Study of Effectiveness of rMV (Repeated Muscle Vibration) in Knee Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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The rehabilitation protocols in knee osteoarthritis are often difficult to be applied in elderly patients because they are long lasting and need the constant participation of patients. To rapidly improve the motor performances of patients it is possible to use the mechanical vibration applied to individual muscles using a protocol called "repeated muscle vibration" (rMV). The purpose of this singleâ?blind randomized placeboâ?controlled study is to evaluate the effectiveness of the repeated muscle vibration (rMV) in terms of increasing the ability of the patients affected by knee osteoarthritis, compared to an ineffective treatment, considered as a placebo. Each subject, randomly assigned to either the group 1 (study group) or placeboâ?treatment (group 2)is administered 3 daily applications of rMV of 10 minutes each, for 3 consecutive days. Between two successive applications it's observed a break of at least 15 seconds. The probe of the specific instrument (Cro ® System) is placed near the superoâ?medial margin of the patella, on both quadriceps. Patients in group 2 (control group) are subjected to a treatment with muscle released in which the probe of the same instrument is approached to the quadriceps, without making contact. The instrument in these conditions emits a buzz but not provokes muscle vibration. The primary outcome of the study is to determine the changing in patients' ability (as measured by WOMAC scale = Western Ontario and McMaster Universities Osteoarthritis Index) . The secondary outcomes of the study are the assessment of changing of patients' balance and risk of falling (as measured by the Tinetti scale) and assessment of changing of patients' quality of life (as measured by EQâ?VAS= EuroQuality of Lifeâ?VAS scale).Outcome measures are administered at baseline (T0), at the end of the treatment protocol (T1), at 1 month (T2), 3 months (T3) after the end of treatment and 6 months (T4) after the end of the treatment.
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Evaluation of prognostic scoring systems for spinal metastases in 196 patients treated during 2005–2010
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MSTS 2022 - Metastatic Disease of the Humerus
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Purpose: Estimating the survival time of patients with spinal metastases based on pre-treatment parameters is important for the best choice of therapy. Following two previous studies, this sequel analyzes possible changes in the impact of various parameters and scoring systems and includes a comparison to the previous dataset for the purpose to find the most predictive parameters and scores for this patient group. Methods: Included were 196 patients retrospectively with confirmed spinal metastases treated between 2005 and 2010 (35 % surgery, 65 % conservative). Possible prognostic factors [primary tumor, Karnofsky Performance Scale (KPS), visceral metastases, number of bone metastases, pathological fracture and neurologic status] and six scoring systems (Tokuhashi original/revised, Tomita, van der Linden, Bauer original and modified) were analyzed using Kaplan–Meier curves and Cox-regression models. Results: Median overall survival was 7 months with 9 % of all patients alive at the time of analysis. Stepwise multivariate analysis showed significant influence on survival for visceral metastases (p < 0.0001), primary tumor (p < 0.0001), KPS (p < 0.0001) and number of spinal metastases (p = 0.0271). All scoring systems significantly predicted longer survival at a better score (absolute scores, p < 0.001) in this dataset. Significant differentiation between the prognostic groups was seen only for the Tokuhashi original, the Bauer original and modified scores (p < 0.001). In comparison to the previous dataset with varying age, gender and primary tumor distribution, the Bauer original and modified scores were the least influenced by the different patient collectives. Conclusions: The Bauer modified score has shown consistent impact on predicting the remaining survival in patients with spinal metastases and is simultaneously simple in clinical use.
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Patient Mortality in Geriatric Distal Femur Fractures
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Hip Fx in the Elderly 2019
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Objectives: To estimate 1-year mortality rates in elderly patients who undergo operative treatment for distal femur fractures and identify potential risk factors for mortality. Design: Retrospective chart review. Setting: Level 1 and Level 2 trauma centers. Patients/Participants: Two hundred eighty-three elderly patients (average age 76.0 years ± 9.8) who sustained distal femur fractures between 2002 and 2012. Intervention: Fracture fixation of the distal femur. Main Outcome Measure: Survival up to 1 year after surgery. Results: The 1-year mortality rate for distal femur fractures in elderly patients was 13.4%. There were no statistically significant differences in overall mortality between native bone and periprosthetic fractures, intramedullary nail or open reduction internal fixation, or across Orthopaedic Trauma Association fracture classifications. Overall patient mortality was significantly higher at 30 days (P = 0.036), 6 months (P = 0.019), and 1 year (P = 0.018), when surgery occurred more than 2 days from the injury. Mean Charlson Comorbidity Index scores were significantly lower in survivors versus nonsurvivors at all time intervals (30 days, P = 0.023; 6 months, P = 0.001 and 1 year P � 0.001). A time to surgery of more than 2 days, regardless of baseline illness, did not result in improved survivability at 1 year. Conclusions: Overall mortality for distal femur fractures was 13.4% in the elderly population. A surgical treatment more than 2 days after injury was associated with increased patient mortality.
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Arthritis increases the risk for fractures--results from the Women's Health Initiative
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To examine the relationship between arthritis and fracture. METHODS: Women were classified into 3 self-reported groups at baseline: no arthritis (n = 83,295), osteoarthritis (OA; n = 63,402), and rheumatoid arthritis (RA; n = 960). Incident fractures were self-reported throughout followup. Age-adjusted fracture rates by arthritis category were generated, and the Cox proportional hazards model was used to test the association between arthritis and fracture. RESULTS: After an average of 7.80 years, 24,137 total fractures were reported including 2559 self-reported clinical spinal fractures and 1698 adjudicated hip fractures. For each fracture type, age-adjusted fracture rates were highest in the RA group and lowest in the nonarthritic group. After adjustment for several covariates, report of arthritis was associated with increased risk for spine, hip, and any clinical fractures. Compared to the nonarthritis group, the risk of sustaining any clinical fracture in the OA group was HR 1.09 (95% CI 1.05, 1.13; p < 0.001) and HR 1.49 (95% CI 1.26, 1.75; p < 0.001) in the RA group. The risk of sustaining a hip fracture was not statistically increased in the OA group (HR 1.11; 95% CI 0.98, 1.25; p = 0.122) compared to the nonarthritis group; however, the risk of hip fracture increased significantly (HR 3.03; 95% CI 2.03, 4.51; p < 0.001) in the RA group compared to the nonarthritis group. CONCLUSION: The increase in fracture risk confirms the importance of fracture prevention in patients with RA and OA
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Physical effects of trauma and the psychological consequences of preexisting diseases account for a significant portion of the health-related quality of life patterns of former trauma patients
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DoD PRF (Psychosocial RF)
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BACKGROUND: Health-related quality of life (HRQoL) is known to be significantly affected in former trauma patients. However, the underlying factors that lead to this outcome are largely unknown. In former intensive care unit (ICU) patients, it has been recognized that preexisting disease is the most important factor for the long-term HRQoL. The aim of this study was to investigate HRQoL up to2 years after trauma and to examine the contribution of the trauma-specific, ICU-related, sociodemographic factors together with the effects of preexisting disease, and further to make a comparison with a large general population.
METHODS: A prospective 2-year multicenter study in Sweden of 108 injured patients. By mailed questionnaires, HRQoL was assessed at 6 months,12 months, and 24 months after the stay in ICU by Short Form (SF)-36, and information of preexisting disease was collected from the national hospital database. ICU-related factors were obtained from the local ICU database. Comorbidity and HRQoL (SF-36) was also examined in the reference group, a random sample of 10,000 inhabitants in the uptake area of the hospitals.
RESULTS: For the trauma patients, there was a marked and early decrease in the physical dimensions of the SF-36 (role limitations due to physical problems and bodily pain). This decrease improved rapidly and was almost normalized after 24 months. In parallel, there were extensive decreases in the psychologic dimensions (vitality, social functioning, role limitations due to emotional problems,and mental health) of the SF-36 when comparisons were made with the general reference population.
CONCLUSIONS: The new and important finding in this study is that the trauma population seems to have a trauma-specific HRQoL outcome pattern.First, there is a large and significant decrease in the physical dimensions of the SF-36, which is due to musculoskeletal effects and pain secondary to the trauma. This normalizes within 2 years, whereas the overall decrease in HRQoL remains and most importantly it is seen mainly in the psychologic dimensions and it is due to preexisting diseases.
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Functional discharge readiness and mobility following total knee arthroplasty for osteoarthritis: a comparison of analgesic techniques
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AAHKS (9/10) Regional Nerve Blocks
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OBJECTIVE: To determine if functional discharge readiness and mobility following total knee arthroplasty (TKA) for osteoarthritis is delayed after femoral nerve block (FNB) with or without patient-controlled analgesia (PCA) opioid compared with PCA opioid alone.
METHODS: We analyzed secondary outcomes from a randomized controlled trial with 200 patients undergoing unilateral TKA. Experimental group 1 received single-injection FNB with intravenous PCA opioid, experimental group 2 received continuous FNB, and the control group received PCA opioid alone. FNB was administered using bupivacaine. Patients followed a structured TKA pathway. Discharge readiness outcomes included achievement of 90degree knee flexion, independent walking, and stair climbing, and were assessed daily before discharge or day 6, whichever came first. Mobility outcomes included the Timed Up and Go (TUG) test, the 6-Minute Walk Distance (6MWD), and self-reported physical function, and were assessed at weeks 2 and 12. TUG was also assessed on days 3 to 6, postoperation.
RESULTS: Both FNB groups (77%) were more likely to achieve 90degree knee flexion compared with the control group (59%); odds ratio (OR) 2.3, 95% confidence interval (95% CI) 1.1, 4.8 for single-injection FNB, and OR 2.3, 95% CI 1.1, 4.9 for continuous FNB. There were no significant differences in independent walking and stair-climbing ability before discharge, TUG, 6MWD, or self-reported physical function, between the FNB groups compared with the control group.
CONCLUSION: After TKA, FNB (single-injection with PCA opioid or continuous) does not delay achievement of 90degree knee flexion or other measures of functional discharge readiness and mobility compared with PCA opioid alone.
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Management of myeloma-associated renal dysfunction in the era of novel therapies
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MSTS 2018 - Femur Mets and MM
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Multiple myeloma (MM) is a plasma cell neoplasm often associated with renal impairment (RI), with myeloma cast nephropathy recognized as the most common cause. While RI is present in over 50% of MM patients at some point in their disease course, it is associated with higher tumor burden, more aggressive disease, diminished quality of life, development of complications and increased mortality. The introduction of novel therapies, including bortezomib, lenalidomide and thalidomide, has revolutionized the management of MM. They are now considered first-line therapies in induction, maintenance and salvage therapy for MM. In addition to their anti-MM effect, they can improve outcome in patients with RI, especially when combined, and bortezomib with dexamethasone may have a renal protective effect. This review focuses on the use of these agents in patients with MM and RI, and evaluates their efficacy, safety, need for dose adjustment and impact on RI. © 2012 Expert Reviews Ltd.
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Management of the Galeazzi fracture
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Distal Radius Fractures
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Fifty-one adults with Galeazzi fractures were treated by operation and the results compared in cases treated early, late and after inadequate initial treatment. We conclude that in cases treated up to 10 weeks after injury, immobilisation with the forearm in full supination in an above elbow cast helps to maintain stability of the inferior radioulnar joint. The distal end of the ulna should only be excised after 6 months, and if the symptoms warrant it. In patients who were inadequately treated initially, the distal end of the ulna should be excised at the time of the operation on the radius, but a poor result is the inevitable outcome. Union, or nonunion of the ulnar styloid did not affect the end result.
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Tourniquet use for civilian extremity trauma
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DOD - Acute Comp Syndrome CPG
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BACKGROUND Unlike in the military setting, where the use of tourniquets has been well established, in the civilian sector their use has been far less uniform. The purpose of this study was to examine the outcomes associated with the use of tourniquets for civilian extremity trauma. STUDY DESIGN Adult (â?¥18 years) patients admitted to our institution with an extremity injury requiring tourniquet application from January 2007 to June 2014 were retrospectively reviewed. The primary outcome analyzed was limb loss. Secondary outcomes included death, hospital length of stay, and complications. RESULTS There were 87 patients who met inclusion criteria. Average age was 35.3 years, 90.8% were male, and 66.7% had penetrating injuries, with a median Injury Severity Score (ISS) of 6. Tourniquets were placed in the prehospital setting in 50.6%, in the emergency department in 39.1%, and in the operating room in 10.3% of patients. The windlass type Combat Application Tourniquet was the most commonly used type (67.8%), followed by a pneumatic system (24.1%) and self-made tourniquet (8.0%). The median duration of use was 75 minutes (interquartile range, 91) with no differences between groups (p = 0.547). Overall, 80.5% had a vascular injury (70.1% arterial), and a total of 99 limb operations were performed, including 15 amputations. Fourteen amputations (93.3%) occurred at the scene or were directly attributed to the extent of tissue damage with a median Mangled Extremity Severity Score (MESS) of 7 (interquartile range, 2). In the remaining patient, the tourniquet was lifesaving but likely contributed to limb loss. Seven patients sustained 13 other complications; however, none was directly attributed to tourniquet use. CONCLUSION Tourniquet use in the civilian sector is associated with a low rate of complications. With the low complication rate and high potential for benefit, aggressive use of this potentially lifesaving intervention is justified. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.
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Comparative study of systemic intravenous and regional intravenous administration of prophylactic antibiotic in lower extremity orthopaedic surgery
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PJI DX Updated Search
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In this study, we describe a technique for the delivery of regional antibiotic prophylaxis in patients undergoing reconstructive surgery in the lower extremities and compare the tissue antibiotic concentrations achieved by this technique with those achieved by standard systemic intravenous prophylaxis. The efficacy of a regional route for antibiotic prophylaxis in lower extremity orthopaedic procedures was investigated in 20 patients and compared with the standard systemic intravenous method in 45 patients using a second generation cephalosporin (ceforanide). The antibiotic (2 g) was given intravenously as the standard systemic prophylaxis at different intervals (10, 20 min and 2 h) before tourniquet inflation. The same dose of antibiotic was injected intravenously into the ipsilateral foot after the inflation of tourniquet. Samples of bone, fat and muscle were collected during the operation and assayed for ceforanide by a microbiological method. None of the patients experienced local or systemic adverse following the regional administration of ceforanide, or infections during the postoperative and follow-up period. Peak tissue levels of the systemic antibiotic were observed when the antibiotic was given 20 min before tourniquet inflation. For all tissue samples, the antibiotic levels were significantly higher when the antibiotic was given regionally (P < 0.001). The results of this study suggest that the regional administration could be a useful route for prophylaxis during lower extremity orthopaedic procedures when they are carried out under tourniquet control. é 2009 Springer-Verlag
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Treatment of a High-Risk Diabetic Patient with Peripheral Vascular Disease and Osteomyelitis
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PJI DX Updated Search
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We report a case of calcaneal osteomyelitis that was surgically resected from a patient with diabetes and peripheral vascular disease. A 91-year-old male with history of type 2 diabetes, peripheral vascular disease, balloon angioplasty, and recent (2 months ago) stent of the superficial femoral artery presented to the emergency department with a left heel wound infection probed to bone. The patient reported having been on intravenous Zosyn for several months via an outside infectious disease provider for clinical suspicion of osteomyelitis, but noted no improvement. This report includes information regarding the clinical examination and imaging findings, which were used to assess this high-risk patient. Our patient underwent a partial calcanectomy and completed a 6-week course of intravenous antibiotics. The purpose of this case report is to illustrate limb preservation in a high-risk patient with compromised vascular supply who underwent a partial calcanectomy for treatment of calcaneal osteomyelitis. The patient underwent surgical resection of the calcaneus without complications and healed unremarkably with the ability to ambulate while wearing an ankle foot orthosis with a custom shoe. This report was authorized for publication as an educational report to contribute to generalizable knowledge and does not include any patient health information
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Comparison of traditional and Dorgan's lateral crosswiring of supracondylar humerus fractures in children
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objectives: To evaluate the outcomes of traditional medial-lateral and Dorgan's lateral cross-wiring of supracondylar humerus fractures in children. Methods: In our retrospective study, we evaluated 51 children in the Department of Orthopedic Surgery, Harran University Medical Faculty, Sanliurfa, Turkey between February 2005 and January 2009. Group 1 (traditional) included 25 (16 male and 9 female, mean age 6.5 ± 3.3 years) and group 2 (Dorgan's lateral) included 26 (19 male and 7 female, mean age 7.1 ± 2.8 years) patients. Functional and cosmetic results were evaluated according to Flynn et al's criteria. Preoperative and postoperative neurologic examination was performed. The mean follow-up periods were 18.4 ± 1.7 months in group 1 and 16.3 ± 1.7 months in group 2. Results: The neurologic, functional, and cosmetic results of 51 patients were reviewed. There were no statistically significant differences found between the groups for gender, age, follow-up periods, fracture types, neurological or function, and cosmetic results. Although postoperative iatrogenic ulnar nerve injuries occurred in 2 (8%) patients treated with the traditional medial-lateral (group 1) cross-wiring technique, no nerve injury occurred in the Dorgan's lateral group (group 2). Conclusion: We recommend Dorgan's lateral crosswiring technique as it is as effective as the traditional medial-lateral cross-wiring technique, and prevents iatrogenic ulnar nerve injuries.
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Evidence of trochlear dysplasia in patellofemoral arthroplasty designs
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Surgical Management of Osteoarthritis of the Knee CPG
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PURPOSE: The design of the trochlear compartment is crucial in patellofemoral arthroplasty (PFA), because 78 % of patients with isolated patellofemoral arthritis present concomitant trochlear dysplasia with patellar maltracking and therefore remain predisposed to post-operative patellar subluxation and dislocation. The study investigated whether current PFA implants are designed with anatomic trochlear parameters such as the sulcus angle, lateral facet height and groove orientation. METHODS: Five trochlear components of commercially available PFA implants were scanned, and the generated three-dimensional surfaces were measured using engineering design software. The mediolateral trochlear profiles were plotted at various flexion angles (0 degrees , 15 degrees , 30 degrees and 45 degrees ) to deduce the following variables: sulcus angle, height of lateral facet and trochlear groove orientation. RESULTS: Four specimens had sulcus angle >144 degrees in the 45 degrees of flexion, and all five specimens had sulcus angle >143 degrees in 30 degrees of flexion. Three specimens had a facet <5 mm high through the entire range of early flexion (0 degrees -30 degrees ), and two specimens had a facet <5 mm high beyond early flexion (30 degrees -45 degrees ). The trochlear groove was oriented laterally in all specimens (range 1.6 degrees -13.5 degrees ). CONCLUSION: Current PFA trochlear components are not always designed with anatomic parameters, and some models exhibit characteristics of trochlear dysplasia. Surgeons are therefore advised to implant components with a deep sulcus, particularly in patients with history of patellofemoral disorders, and to adapt the surgical technique and extensor mechanism if the component implanted has a shallow sulcus, to ensure normal patellar tracking. LEVEL OF EVIDENCE: III
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Evaluation of tamoxifen doses with and without fluoxymesterone in advanced breast cancer
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MSTS 2018 - Femur Mets and MM
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From a group of 108 female patients with measurable and/or evaluable metastatic breast carcinoma, 52 were randomized to receive tamoxifen and 56 to receive tamoxifen and fluoxymesterone. The fluoxymesterone dose, given orally twice a day, was 7 mg/m2 body surface area. The tamoxifen dose per patient, also given orally twice a day, ranged from 2 to 100 mg/m2 body surface area. Eighty-five percent of the patients had received previous chemotherapy and 60% previous hormone therapy. The complete and partial remission rate was better with the tamoxifen and fluoxymesterone regimen (p = 0.016), with remission rates of 15% for tamoxifen alone and 38% for the combination. The tamoxifen and fluoxymesterone regimen appeared to have higher remission rates in all subsets of pretreatment variables. Duration of remission with each regimen was similar, but the overall time to treatment failure for tamoxifen and fluoxymesterone was longer than for tamoxifen alone (180 versus 64 days, p = 0.01). Median survival with the combination was 380 days compared to 330 days for tamoxifen. No significant dose-response relationships emerged. Side effects were not different between dose levels or regimens except for the androgen effects in the tamoxifen and fluoxymesterone combination. These results suggest that there is no major dose-response effect for doses ranging from 2 to 100 mg/m2 body surface area given twice daily in this largely (94%) postmenopausal pretreated patient group, and that the tamoxifen and fluoxymesterone regimen is superior to tamoxifen alone.
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Interaction between calcium intake and menarcheal age on bone mass gain: an eight-year follow-up study from prepuberty to postmenarche
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Management of Hip Fractures in the Elderly
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Both late menarcheal age and low calcium intake (Ca intake) during growth are risk factors for osteoporosis, probably by impairing peak bone mass. We investigated whether lasting gain in areal bone mineral density (aBMD) in response to increased Ca intake varies according to menarcheal age and, conversely, whether Ca intake could influence menarcheal age. In an initial study, 144 prepubertal girls were randomized in a double-blind controlled trial to receive either a Ca supplement (Ca-suppl.) of 850 mg/d or placebo from age 7.9-8.9 yr. Mean aBMD gain determined by dual energy x-ray absorptiometry at six sites (radius metaphysis, radius diaphysis, femoral neck, trochanter, femoral diaphysis, and L2-L4) was significantly (P = 0.004) greater in the Ca-suppl. than in the placebo group (27 vs. 21 mg/cm(2)). In 122 girls followed up, menarcheal age was recorded, and aBMD was determined at 16.4 yr of age. Menarcheal age was lower in the Ca-suppl. than in the placebo group (P = 0.048). Menarcheal age and Ca intake were negatively correlated (r = -0.35; P < 0.001), as were aBMD gains from age 7.9-16.4 yr and menarcheal age at all skeletal sites (range: r = -0.41 to r = -0.22; P < 0.001 to P = 0.016). The positive effect of Ca-suppl. on the mean aBMD gain from baseline remained significantly greater in girls below, but not in those above, the median of menarcheal age (13.0 yr). Early menarcheal age (12.1 +/- 0.5 yr): placebo, 286 +/- 36 mg/cm(2); Ca-suppl., 317 +/- 46 (P = 0.009); late menarcheal age (13.9 +/- 0.5 yr): placebo, 284 +/- 58; Ca-suppl., 276 +/- 50 (P > 0.05). The level of Ca intake during prepuberty may influence the timing of menarche, which, in turn, could influence long-term bone mass gain in response to Ca supplementation. Thus, both determinants of early menarcheal age and high Ca intake may positively interact on bone mineral mass accrual
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Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation
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DoD SSI (Surgical Site Infections)
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PURPOSE: To evaluate healing rates and complications in patients treated with temporary external fixation (EF) and subsequent open reduction and internal fixation (ORIF) for high-energy distal femur or proximal tibia fractures.
METHODS: Retrospective analysis of prospectively collected data 1999 to 2005. Demographic data and injury severity score were obtained from medical records. Factors reviewed included perioperative complications (nonunion, postoperative infection, loss of fixation) and time to radiographic and clinical union.
RESULTS: Forty-seven patients with 16 distal femur and 36 proximal tibia fractures were treated using temporary EF. Patients subsequently underwent ORIF (mean time from EF to ORIF = 5 days, range 1-23 days). Thirty-five fractures were open (Gustilo I = 8, II = 6, IIIA = 3, IIIB = 13, IIIC = 5) and 17 closed. Forty patients with 44 fractures reached 1-year follow-up. Of these, 36 patients with 40 (91%) fractures had healed both radiographically and clinically. The mean postoperative follow-up time was 14 months (range 3-68). Eight (16%) deep infections occurred, all in open fractures (Gustilo I = 2, IIIB = 3, IIIC = 3), with one patient requiring above knee amputation. Other complications included one hematoma, two malunions, one fixation failure, and one pin site infection. One patient died as a result of a stroke.
CONCLUSIONS AND SIGNIFICANCE: Temporary bridging EF offers the advantage of early soft tissue and bone stabilization without the potential local risks of immediate ORIF in severely injured soft tissues, or the potential systemic risks in a severely traumatized patient. The 16% infection rate in this study, all occurring in open fractures, falls within the reported range for grade III open fractures (15%-20%). We conclude that the initial treatment of high-energy periarticular knee fractures with bridging EF, followed by planned conversion to internal fixation is a safe option in patients who are unsuitable for initial definitive surgery.
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No advantage to rhBMP-2 in addition to autogenous graft for fracture nonunion
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DoD SSI (Surgical Site Infections)
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Bone morphogenetic proteins are a necessary component of the fracture healing cascade. Few studies have delineated the efficacy of iliac crest bone graft and recombinant human bone morphogenetic protein 2 (rhBMP-2), especially, in comparison with the gold standard treatment of nonunion, which is autogenous bone graft alone. This study compared the outcome of patients with fracture nonunion treated with autogenous bone graft plus rhBMP-2 adjuvant vs patients treated with autogenous bone graft alone. A total of 118 consecutive patients who were to undergo long bone nonunion surgery with autogenous bone graft (50) or autogenous bone graft plus rhBMP-2 (68) were identified. Surgical intervention included either harvested iliac autogenous bone graft or autogenous bone graft plus 1.5 mg/mL of rhBMP-2 placed in and around the site of nonunion. No differences were found in the distribution of nonunion sites included within each group. Twelve-month follow-up was obtained on 100 of 118 patients (84.7%). Analyses of demographic characteristics (including tobacco), medical comorbidities, previous surgeries, and nonunion type (atrophic vs hypertrophic) did not differ. Postoperative complication rates did not differ. The percentage of patients who progressed to union did not differ. Mean time to union in the autogenous bone graft plus rhBMP-2 group was 6.6 months (+/-3.9) vs 5.4 (+/-2.7) months in the autogenous bone graft-only group (P=.06). Rates of revision (16.2% for rhBMP-2 plus autogenous bone graft vs 8% for autogenous bone graft) did not differ statistically (P=.19), nor did 12-month scores of pain and functional assessment. Although rhBMP-2 is a safe adjuvant, there was no benefit seen when rhBMP-2 was added to autogenous bone graft in the treatment of long bone nonunion. Given its high cost, rhBMP-2 should be reconsidered as an aid to autogenous bone graft in the treatment of nonunion.
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Tibiofemoral loss of contact area but no changes in peak pressures after meniscectomy in a Lapine in vivo quadriceps force transfer model
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AMP (Acute Meniscal Pathology)
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PURPOSE: The menisci are thought to modulate load transfer and to absorb shocks in the knee joint. No study has experimentally measured the meniscal functions in the intact, in vivo joint loaded by physiologically relevant muscular contractions. METHODS: Right knee joints of seven New Zealand white rabbits were loaded using isometric contractions of the quadriceps femoris muscles controlled by femoral nerve stimulation. Isometric knee extensor torques at the maximal and two submaximal force levels were performed at knee angles of 70°, 90°, 110°, and 130°. Patellofemoral and tibiofemoral contact areas and pressure distributions were measured using Fuji Presensor film inserted above and below the menisci and also with the menisci removed. RESULTS: Meniscectomy was associated with a decrease in tibiofemoral contact area ranging from 30 to 70% and a corresponding increase in average contact pressures. Contact areas measured below the menisci were consistently larger than those measured on top of the menisci. Contact areas in the patellofemoral joint (PFJ), and peak pressures in tibiofemoral and PFJs, were not affected by meniscectomy. Contact areas and peak pressures in all joints depended crucially on knee joint angle and quadriceps force: The more flexed the knee joint was, the larger were the contact areas and the higher were the peak pressures. CONCLUSIONS: In agreement with the literature, removal of the menisci was associated with significant decreases in tibiofemoral contact area and corresponding increases in average contact pressures, but surprisingly, peak pressures remained unaffected, indicating that the function of the menisci is to distribute loads across a greater contact area.
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Adult-onset Still's disease; clinical and laboratory features, treatment and progress of 45 cases
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Surgical Management of Osteoarthritis of the Knee CPG
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The clinical and laboratory features, treatment, prognosis, complications and disability of 45 patients with adult-onset Still's disease were studied. Sixty per cent of the patients were female. Median age at onset was 25 years and median observation period after onset was 41 months. For 28 patients detailed data were available of the first month of illness. In only 43 per cent of these did the disease present with the classical triad of fever, arthritis and rash, although in the whole group eventually, fever with temperatures of 40(degrees)C or more occurred in 84 per cent, arthritis in 98 per cent, and the typical rash in 82 per cent. In 32 per cent of the patients with rash, this was pruritic. Other features seen frequently were: lymphadenopathy (71 per cent), splenomegaly (36 per cent), pleuritis and/or pneumonitis (31 per cent), pericarditis (22 per cent), leucocytosis (98 per cent) and hepatic abnormalities (84 per cent). The high spiking fever was was reduced to normal in six of 21 cases (29 per cent) by aspirin, in 19 of 27 cases (70 per cent) by indomethacin and in six of seven cases (86 per cent) by naproxen. In 16 of 21 cases (76 per cent) glucocorticoids reduced the systemic and/or joint symptoms. In three patients who remained febrile on glucocorticoids, indomethacin reduced temperature to normal. Eight patients whose joint disease improved on steroids later developed severe joint destructions. Thirteen patients received one or several slow-acting antirheumatic drugs. Only in eight of 18 trials (44 per cent) with one of these drugs did symptoms and signs improve. Fifty-one per cent of the 45 patients had self-limiting disease and 49 per cent had persistent disease with continuous activity for at least one year. At the time of evaluation 47 per cent of the 45 patients were in remission without medication, 33 per cent were in remission while on medication and 20 per cent had active disease. Three life-threatening complications occurred: two patients developed signs of cardiac tamponade and one almost died from diffuse intravascular coagulation. Disability was determined primarily by the course of the arthritis. At the time of review 43 per cent of the 45 patients had no joint destruction (Group 1), 24 per cent had destruction of at least one joint, but had no evidence of disease of the root joints (Group 2) and 33 per cent had destruction in at least one root joint (Group 3). Patients in Group 3 generally suffered from a more widespread polyarthritis than patients in Group 2. Sixty-seven per cent of the Group 3 patients required hip or knee arthroplasty, and only 13 per cent of the 15 Group 3 patients were in ARA functional class IV. This study shows that the course of the arthritis in adult-onset Still's disease varies markedly, and that severe widespread polyarthritis is common
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The effect of graft height mismatch on contact pressure following osteochondral grafting: a biomechanical study
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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HYPOTHESIS: Incongruity of the articular cartilage following osteochondral transplantation affects surface contact pressure. STUDY DESIGN: An 80 N load was applied for 120 seconds to the femoral condyles of 10 swine knees. Contact pressures were measured using Fuji prescale film. Seven conditions were tested: (1) intact articular surface; (2) 4.5-mm diameter defect; (3) grafted with 4.5-mm diameter plug elevated 1 mm above adjacent cartilage; (4) plug elevated 0.5 mm; (5) plug flush; (6) plug sunk 0.5 mm below surface; and (7) sunk 1.0 mm. CONCLUSIONS: Peak contact pressures were significantly (P <.001) elevated by approximately 20% after defect creation and were reduced to normal when plugs were flush. There were large and significant (P<.001) increases in pressure with plugs elevated 1 and 0.5 mm. Contact pressures with plugs sunk 0.5 and 1 mm were significantly (P <.01) higher than intact cartilage but were significantly (P <.01) lower than an empty defect. Clinical Relevance: Normal contact pressures and patterns can be duplicated with flush articular surface grafts. However, small incongruities, particularly when the plug is elevated, can lead to significantly increased pressure. This reinforces the importance of articular surface congruity in the initial biomechanical state following osteochondral implantation
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The proximal tibia donor site in cleft alveolar bone grafting: experience of 75 consecutive cases
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DoD SSI (Surgical Site Infections)
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BACKGROUND: The optimum donor site for cleft alveolar bone grafting is still debated. Donor site morbidity is an important factor in deciding the site for harvest of cancellous bone. Use of the proximal tibia as donor site is associated with few complications. The occurrence of a proximal tibia fracture following cancellous bone harvest from this site, prompted a review of the last 75 consecutive cases carried out at our unit.
MATERIAL AND METHOD: The medical notes of 75 consecutive patients undergoing cleft alveolar bone graft were reviewed and postal questionnaires were sent to patient's parents and family physicians. The review focused on donor site morbidity.
RESULTS: Fracture of the proximal tibia, a hitherto unreported complication, occurred in two out of 75 cases (2.7%) within our series. Post-operative mobilization was achieved rapidly with normal joint function and donor site healing progressed satisfactorily in all cases. In 1 out of 75 cases the graft was repeated at a later date due to recipient site infection. The incidence of other morbidity was low with most representing local complications only. Length of hospital stay was 3 days (range 2-5 days).
CONCLUSION: Based on our findings we feel that the proximal tibia offers a reliable site for harvest of sufficient quantities of good quality cancellous bone. Recommendations are made as to the technique of bone harvest, to minimize the fracture risk.
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Total knee replacement in a patient with myelodysplasia and bronchectasis
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction: Regional anesthesia may be preferred in a subject with bronchectasis. However, patients with myelodysplastic syndrome and bronchectasis may represent a unique challenge for neuraxial anesthesia due to low platelet counts and concerns for bleeding. We report a case of a subject with myelodysplastic syndrome with low platelet counts and bronchectasis who received peripheral nerve blocks for total knee replacement surgery (TRK). Case report: An 86 y/o man with a history of myelodysplastic syndrome, chronic bronchectasis, HTN, OSA, type II DM, hyplerlipidemia, Parkinson's disease, and CAD s/p stent presented for a revision of a right total knee arthroplasty. His platelet count at admission was 47 x103/mL and he received 2 U of platelets the day prior to surgery. Pre-operatively the platelet count was 73 x103/mL. The decision was made to proceed with surgery under regional anesthesia. A right sciatic nerve block and femoral nerve block were performed under ultrasound guidance and nerve stimulation. Additionally, an obturator nerve block and lateral femoral cutaneous nerve block were performed under ultrasound guidance. A total of 45ml of 0.5% ropivacaine with epinephrine 1:300K was injected: 15ml for the right sciatic nerve block, 15ml for the femoral nerve block, 10ml for the obturator nerve block, and 5ml for the lateral femoral cutaneous nerve block. Complete sensory analgesia and motor block were achieved. The patient underwent successful revision of total knee replacement with excellent post-operative pain control during his hospital stay. Discussion: The minimal platelet count at which one can safely administer regional anesthesia remains controversial. Minimal suggested platelet counts based on limited data and expert opinion for neuraxial procedures vary from 80-100 x103/mL. The British Committee for Standards in Haematology have guidelines for platelet transfusions and recommend that the platelet count should be raised to at least 50 x103/mL for lumbar puncture and epidural anesthesia.1 Conservatively, these suggestions have also been adopted for peripheral nerve blocks. In this case we believe that the risk of bleeding from reduced platelets was less than the potential complication of general anesthesia in this patient. In addition, our case demonstrates that peripheral nerve blocks can provide adequate surgical anesthesia in TKA
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Arthroscopic observation was useful to detect loosening of the femoral component of unicompartmental knee arthroplasty in a recurrent hemoarthrosis
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AMP (Acute Meniscal Pathology)
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A case of recurrent hemarthrosis of the knee after a mobile-bearing unicompartmental knee arthroplasty (UKA; Oxford UKA) is described. A 58-year-old man met with a road traffic accident 10 months after UKA. He developed anteromedial pain and hemarthrosis of the knee joint 1 month after the accident, which required multiple aspirations. Physical examination showed no instability. Plain radiograph revealed no signs of loosening. All laboratory data, including bleeding and coagulation times, were within normal limits. Diagnostic arthroscopy demonstrated loosening of the femoral component. Any intraarticular pathology other than nonspecific synovitis was ruled out. The loose femoral component and polyethylene meniscal bearing were revised. Since then, hemarthrosis has not recurred.
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Graded inhibition of retrograde axonal transport by compression of rabbit vagus nerve
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Effects of experimental compression at different pressures on retrograde axonal transport were studied in rabbit vagus nerve. Proteins in the sensory neurones were radiolabelled by injection of [(3)H]leucine into the nodose ganglion. Sixteen hours after labelling, a small compression chamber and/or ligatures were applied around the cervical part of the vagus nerve for 8 h. Compression of the vagus nerve at 20, 30 and 200 mm Hg pressure induced a graded inhibition of both retrograde and anterograde transport of the radiolabelled proteins. Neither retrograde nor anterograde transport was affected by the presence of the non-inflated chamber. The results indicate that compression at pressures similar to those found in human carpal tunnel syndrome can block retrograde axonal transport. The consequences of inhibition of retrograde and anterograde axonal transport for the metabolism in the nerve cell bodies are discussed
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Limb-length measurement in total hip arthroplasty using a calipers dual pin retractor
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Management of Hip Fractures in the Elderly
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Background: Limb-length inequality is not uncommon after total hip arthroplasty (THA) and may cause subjective problems for patients. During THA a stable reference point must be established to determine changes in leg length. Several methods have been useful in minimizing the incidence and magnitude of this problem. The equalization of leg-length discrepancy during THA can be achieved through the use of a simple measuring device, the calipers dual pin retractor (CDPR). Materials and methods: The CDPR was developed to establish a fixed point on the pelvis that would remain constant throughout the procedure and from which the distance to the greater trochanter could be measured prior to dislocation of the hip. Limb lengths were measured in 56 patients undergoing primary THA, between 2004 and 2006. The CDPR was used in all cases. Results: The preoperative diagnoses were osteoarthritis in 44 patients, osteonecrosis in five, and rheumatoid arthritis in seven. Average postoperative limb-length inequality was 4.2 mm. None of the patients had to use shoe lifts for equalization of limb lengths or complained of limb-length inequality. Conclusion: This method of measurement is beneficial with most THA approaches, and the technique is helpful for minimizing limb-length inequality during THA
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Supination and Pronation Strength Deficits Persist at 2-4 Years after Treatment of Distal Radius Fractures
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Distal Radius Fractures
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Forearm rotation is a key function in the upper extremity. Following distal radius fracture, residual disability may occur in tasks requiring forearm rotation. The objectives of this study are to define pronation and supination strength profiles tested through the range of forearm rotation in normal individuals, and to evaluate the rotational strength profiles and rotational strength deficits across the testing range in a cohort of patients treated for distal radius fracture associated with an ulnar styloid base fracture. In a normative cohort of 29 subjects the supination strength profile showed an increasing linear relationship from supination to pronation. Twelve subjects were evaluated 2-4 years after anatomical open reduction and volar plate fixation of a distal radius fracture. The injured wrist was consistently weaker (corrected for hand dominance) in both supination and pronation strength in all testing positions, with the greatest loss in 60 degrees supination. Mean supination strength loss across all testing positions was significantly correlated with worse PRWE scores, highlighting the importance of supination in wrist function.
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Lest we forget
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Coronavirus Disease 2019 (COVID-19)
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The severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) pandemic has caused shockwaves throughout the US healthcare system. Nowhere has coronavirus 19 (COVID-19) caused more infections than in New York, where there have been over 26,500 infections. Resources have been appropriately allocated towards combating this outbreak, but where does this leave patients with severe non-COVID-19 diseases? Herein we provide the views of a liver transplant surgeon and transplant hepatologist in New York.
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Reporting functional outcome after knee arthroplasty and regional anesthesia: a methodological primer
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AAHKS (9/10) Regional Nerve Blocks
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The introduction of ultrasound guidance for regional anesthesia has resulted in an explosion of interest in its use for postoperative analgesia, particularly for orthopedic surgery. Regional anesthesia demonstrates unequivocal superiority compared with systemic opioids with respect to analgesia, reduced opioid consumption, increased patient satisfaction, and earlier achievement of discharge criteria. Improved acute postoperative analgesia can facilitate effective rehabilitation. Investigators are in the early stages of reporting the effects of regional anesthesia on functional outcome. Recent studies reporting functional outcomes have been plagued with sample sizes of inadequate power to generate meaningful results. Furthermore, the functional outcome measures are used inappropriately in terms of clinically meaningful difference, assessment intervals, and/or duration of follow-up. This report aims to address these issues by discussing functional outcomes used in the physiotherapy or orthopedic literature and their appropriate utilization, so that future research into the effects of regional anesthesia can be methodologically sound. Outcomes discussed include those that are physical-performance-based (ie, range of motion, quadriceps strength, Timed Up and Go test, 6-Minute Walk Test, Stair Time, and Self-paced Walk Test) and those that are self-reported (ie,Western Ontario and McMaster Universities Osteoarthritis Index, Knee Osteoarthritis Severity Score, Lower Extremity Function Scale).
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Trinion Meniscal Screw
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AMP (Acute Meniscal Pathology)
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Abstract: All-inside meniscal repair devices require no accessory incisions, allow faster repairs, and are widely used. The purpose of this study was to determine the in vitro load to failure strength of one new recently released meniscal repair device. Using an established protocol, a vertical longitudinal tear 3 mm from the meniscus periphery was created in 15 porcine menisci and each tear repaired by a single 10-mm Trinion meniscal screw. This repair was pulled apart with loads parallel to the repair axis. Loads to failure and modes of failure were evaluated. The mean load to failure was 38.9 N (SD ± 9.04) (range, 23.1 to 55.2 N). Two modes of failure were observed: puling out of the inner piece (6 of 15) and of the outer (peripheral) rim (9 of 15). No devices broke. The Trinion meniscal screw is a dual-head design made of trimethylene carbonate, poly L-lactic acid, and poly D, L lactic acid. Its load to failure is similar to other tested devices. The mechanisms of failure were consistent with other all-inside meniscal repair devices. The material properties of a repair device are only one indication of device performance and may not correlate with clinical results. © 2006 Arthroscopy Association of North America.
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Differences between men and women in the rate of use of hip and knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Previous studies suggest that, for some conditions, women receive fewer health care interventions than men. We estimated the potential need for arthroplasty and the willingness to undergo the procedure in both men and women and examined whether there were differences between the sexes. METHODS: All 48,218 persons 55 years of age or older in two areas of Ontario, Canada, were surveyed by mail and telephone to identify those with hip or knee problems. In these subjects, we assessed the severity of arthritis and the presence of coexisting conditions by questionnaire, documented arthritis by examination and radiography, and conducted interviews to evaluate the subjects' willingness to undergo arthroplasty. The potential need for arthroplasty was defined by the presence of severe symptoms and disability, the absence of any absolute contraindications to surgery, and clinical and radiographic evidence of arthritis. The estimates of need were then adjusted for the subjects' willingness to undergo arthroplasty. RESULTS: The overall response rates were at least 72 percent for the questionnaires and interviews. As compared with men, women had a higher prevalence of arthritis of the hip or knee (age-adjusted odds ratio, 1.76; P<0.001) and had worse symptoms and greater disability, but women were less likely to have undergone arthroplasty (adjusted odds ratio, 0.78; P<0.001). Despite their equal willingness to have the surgery, fewer women than men had discussed the possibility of arthroplasty with a physician (adjusted odds ratio, 0.63). The numbers of people with a potential need for hip or knee arthroplasty were 44.9 per 1000 among women and 20.8 per 1000 among men. After adjustment for willingness to undergo the procedure, the numbers were 5.3 per 1000 for women and 1.6 per 1000 for men. CONCLUSIONS: There is underuse of arthroplasty for severe arthritis in both sexes, but the degree of underuse is more than three times as great in women as in men
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Mobile and fixed-bearing (all-polyethylene tibial component) total knee arthroplasty designs: surgical technique
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Proponents of mobile-bearing total knee arthroplasty believe that it has potential advantages over a fixed-bearing design in terms of diminished wear and improved motion and/or function, but these advantages have not been demonstrated in a randomized clinical comparison to our knowledge. We conducted a patient-blinded, prospective, randomized clinical trial to compare mobile-bearing and fixed-bearing cruciate-substituting total knee arthroplasties of the same design. METHODS: Patients between the ages of sixty and eighty-five years were prospectively randomized to receive a cruciate-substituting rotating-platform design or a fixed-bearing design with an all-polyethylene tibial component. There were no significant differences in the demographic characteristics (mean age, 72.2 years; mean American Society of Anesthesiologists score, 2.7; mean body mass index, 31.8 kg/m2) or preoperative clinical or radiographic measures between the groups. Routine clinical and radiographic follow-up measures included the Knee Society score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Short Form-36 (SF-36) outcome measures. RESULTS: The results of 312 arthroplasties (136 with an all-polyethylene tibial component and 176 rotating-platform designs) in 273 patients were analyzed at a minimum of two years (mean, forty-two months) postoperatively. Although there was significant improvement in both groups, there was no significant difference between the groups with regard to the mean postoperative range of motion (110.9 degrees and 109.1 degrees , respectively; p = 0.21), the mean KSS clinical score (90.4 and 88.2 points; p = 0.168), or the mean KSS pain score (44.9 and 43.1 points; p = 0.108) at this follow-up point. There were ten revisions: seven because of infection, one because of patellar fracture, one because of instability, and one because of aseptic loosening. CONCLUSIONS: The two designs functioned equivalently at the time of early follow-up in this low-to-moderate-demand patient group. The rotating-platform design had no significant clinical advantage over the design with the all-polyethylene tibial component
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A new inguinal approach for the obturator nerve block: anatomical and randomized clinical studies
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Obturator nerve block is highly recommended for knee surgery in addition to a femoral nerve block. The main disadvantage of the classic approach at the pubic tubercle is low patient acceptance due to pain and discomfort. The authors hypothesized that the use of a new inguinal obturator nerve block technique would reduce pain and discomfort in patients. METHODS: The inguinal approach was simulated in five fresh cadavers. Injection of latex was performed in two cadavers. The location of the needle and the extent of latex solution were analyzed. Fifty patients scheduled to undergo arthroscopic knee surgery were randomly assigned to receive obturator nerve block using either the inguinal (n = 25) or the pubic tubercle approach (n = 25). RESULTS: In all cadavers, the needle was close to the obturator nerve branches, which were surrounded by the latex solution. In the clinical study, visual analog scale pain scores and discomfort of block placement were significantly lower in the inguinal group compared with the pubic tubercle group (P < 0.01). In the inguinal group, there was a significant decrease in block performance time (P < 0.05) and in bolus of propofol and fentanyl used for the procedure (P < 0.01). Twenty minutes after application of the block, adductor strength decrease, occurrence, and location of cutaneous distribution of the obturator nerve were not significantly different between the groups. The incidence of minor complications was significantly increased in the pubic tubercle group (P < 0.05). No major complications were observed. CONCLUSIONS: The new inguinal approach decreases patient discomfort and pain of block placement as well as the time and sedation and analgesics required for a similar quality of sensory and motor block compared with the pubic tubercle approach
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Introductory remarks
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Distal Radius Fractures
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The cause of osteoporosis, a condition in which bone mass is decreased to a point where structural failure may occur, is unknown; many factors that contribute to the development of osteoporosis are known.Bone mass increases until the late twenties, the time when people attain peak bone mass. For a time after peak bone mass is reached, bone loss and formation are approximately equal. Soon after that, probably in the early thirties, an uncoupling of bone synthesis and bone resorption occurs, and a net loss of bone mass begins, a process that can ultimately result in osteoporosis.Bone loss occurs most rapidly in white females immediately after menopause. The bone most affected is the spongy, trabecular bone of the vertebrae and pelvis and the ends of long bones.Osteoporosis is classified into two syndromes, which are not distinct but have overlapping features and may have the same pathogenetic mechanism. Type I, or postmenopausal osteoporosis, is associated with estrogen deficiency and is characterized by loss of trabecular bone in the vertebrae and the distal radius (the wrist). Vertebral fractures and wrist fractures (also called Colles' fractures) result. Type II, or senile osteoporosis, is age-related, occurs in men as well as women, and is characterized by fractures of the hip and humerus. There is a loss of cortical as well as trabecular bone.Estrogen deficiency, increasing age, smoking, high alcohol intake, large amounts of caffeine and protein, and lean body mass favor decreased bone density, whereas estrogen replacement after menopause, adequate dietary calcium, and moderate amounts of weight-bearing exercise tend to favor increased bone density.Standard X-rays, computed tomography, single and dual photon absorptiometry, and neutron activation analysis are noninvasive techniques used in evaluating osteoporosis.Calcium, estrogen, and calcitonin are approved drug therapies for osteoporosis.
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Self-management education programmes for osteoarthritis
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OAK Recommendation 9 Articles
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Background: Self-management education programmes are complex interventions specifically targeted at patient education and behaviour modification. They are designed to encourage people with chronic disease to take an active self-management role to supplement medical care and improve outcomes.Objectives: To assess the effectiveness of self-management education programmes for people with osteoarthritis.Search methods: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PyscINFO, SCOPUS and the World Health Organization (WHO) International Clinical Trial Registry Platform were searched, without language restriction, on 17 January 2013. We checked references of reviews and included trials to identify additional studies.Selection criteria: Randomised controlled trials of self-management education programmes in people with osteoarthritis were included. Studies with participants receiving passive recipients of care and studies comparing one type of programme versus another were excluded.Data collection and analysis: In addition to standard methods we extracted components of the self-management interventions using the eight domains of the Health Education Impact Questionnaire (heiQ), and contextual and participant characteristics using PROGRESS-Plus and the Health Literacy Questionnaire (HLQ). Outcomes included self-management of osteoarthritis, participant's positive and active engagement in life, pain, global symptom score, self-reported function, quality of life and withdrawals (including dropouts and those lost to follow-up). We assessed the quality of the body of evidence for these outcomes using the GRADE approach.Main results: We included twenty-nine studies (6,753 participants) that compared self-management education programmes to attention control (five studies), usual care (17 studies), information alone (four studies) or another intervention (seven studies). Although heterogeneous, most interventions included elements of skill and technique acquisition (94%), health-directed activity (85%) and self-monitoring and insight (79%); social integration and support were addressed in only 12%. Most studies did not provide enough information to assess all PROGRESS-Plus items. Eight studies included predominantly Caucasian, educated female participants, and only four provided any information on participants' health literacy. All studies were at high risk of performance and detection bias for self-reported outcomes; 20 studies were at high risk of selection bias, 16 were at high risk of attrition bias, two were at high risk of reporting bias and 12 were at risk of other biases. We deemed attention control as the most appropriate and thus the main comparator.Compared with attention control, self-management programmes may not result in significant benefits at 12 months. Low-quality evidence from one study (344 people) indicates that self-management skills were similar in active and control groups: 5.8 points on a 10-point self-efficacy scale in the control group, and the mean difference (MD) between groups was 0.4 points (95% confidence interval (CI) -0.39 to 1.19). Low-quality evidence from four studies (575 people) indicates that self-management programmes may lead to a small but clinically unimportant reduction in pain: the standardised mean difference (SMD) between groups was -0.26 (95% CI -0.44 to -0.09); pain was 6 points on a 0 to 10 visual analogue scale (VAS) in the control group, treatment resulted in a mean reduction of 0.8 points (95% CI -0.14 to -0.3) on a 10-point scale, with number needed to treat for an additional beneficial outcome (NNTB) of 8 (95% CI 5 to 23). Low-quality evidence from one study (251 people) indicates that the mean global osteoarthritis score was 4.2 on a 0 to 10-point symptom scale (lower better) in the control group, and treatment reduced symptoms by a mean of 0.14 points (95% CI -0.54 to 0.26). This result does not exclude the possibility of a clinically important benefit in some people (0.5 point reduction included in 95% CI). Low-quality evidence from three studies (574 people) showed no signficant difference in function between groups (SMD -0.19, 95% CI -0.5 to 0.11); mean function was 1.29 points on a 0 to 3-point scale in the control group, and treatment resulted in a mean improvement of 0.04 points with self-management (95% CI -0.10 to 0.02). Low-quality evidence from one study (165 people) showed no between-group difference in quality of life (MD -0.01, 95% CI -0.03 to 0.01) from a control group mean of 0.57 units on 0 to 1 well-being scale. Moderate-quality evidence from five studies (937 people) shows similar withdrawal rates between self-management (13%) and control groups (12%): RR 1.11Â (95% CI 0.78 to 1.57). Positive and active engagement in life was not measured.Compared with usual care, moderate-quality evidence from 11 studies (up to 1,706 participants) indicates that self-management programmes probably provide small benefits up to 21 months, in terms of self-management skills, pain, osteoarthritis symptoms and function, although these are of doubtful clinical importance, and no improvement in positive and active engagement in life or quality of life. Withdrawal rates were similar. Low to moderate quality evidence indicates no important differences in self-management , pain, symptoms, function, quality of life or withdrawal rates between self-management programmes and information alone or other interventions (exercise, physiotherapy, social support or acupuncture).Authors' conclusions: Low to moderate quality evidence indicates that self-management education programmes result in no or small benefits in people with osteoarthritis but are unlikely to cause harm.Compared with attention control, these programmes probably do not improve self-management skills, pain, osteoarthritis symptoms, function or quality of life, and have unknown effects on positive and active engagement in life. Compared with usual care, they may slightly improve self-management skills, pain, function and symptoms, although these benefits are of unlikely clinical importance.Further studies investigating the effects of self-management education programmes, as delivered in the trials in this review, are unlikely to change our conclusions substantially, as confounding from biases across studies would have likely favoured self-management. However, trials assessing other models of self-management education programme delivery may be warranted. These should adequately describe the intervention they deliver and consider the expanded PROGRESS-Plus framework and health literacy, to explore issues of health equity for recipients
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0 |
An frontalis sling operation using an autogenous en-bloc, fan-shaped tensor fascia lata graft for blepharoptosis
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Upper Eyelid and Brow Surgery
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This article presents a modification of the frontalis sling operation for severe blepharoptosis with poor levator function. The fascia or other suspension materials are usually used in strip form to avoid a mass under the skin and lid-crease obliteration in the frontal sling operations. However, the 'strip-sling technique' carries the risk of some complications including irregular eyelid contour, unstable fixation and loss of elevating power in the follow-up period. To overcome these complications and to enhance elevating power transmission between the tars and the frontal muscle, the autogenous tensor fascia lata graft was designed to be en bloc and fan-shaped. This technique was used in nine patients (12 eyelids) who presented with different aetiologies. They had an average follow-up of 13.5 months. Although all the patients achieved favourable results with good eyelid opening, the patients who had traumatic ptosis were more prone to complications including lagophtalmos and pulling away problem. This modification appears to increase the surface contact area between the frontalis muscle, the fascia lata graft and the tarsus. This increased contact enhances tarsus elevation in ptotic eyelids and is associated with satisfactory results.
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1 |
Direct Anterior Approach for Total Hip Arthroplasty in the Lateral Decubitus Position: Our Experiences and Early Results
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Hip Fx in the Elderly 2019
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BACKGROUND: The direct anterior approach (DAA) for total hip arthroplasty (THA) is typically performed in the supine position using a specially designed operating room table, which makes this approach more accessible to orthopedic surgeons. We attempted to perform this procedure in the lateral decubitus position on an ordinary operation table to avoid dependence on a special operating room table. There is an obvious absence of literature regarding this subject.
METHODS: A total of 248 patients (295 hips) were recruited for primary THAs from July 1, 2014 to December 31, 2014. In total, 126 hips (42.7%) underwent THAs using the DAA in the lateral decubitus position. The technical feasibility and early results were evaluated.
RESULTS: The orientation of the acetabular component was 16.5degree +/- 4.9degree anteversion and 43.3degree +/- 3.5degree abduction. Intraoperative proximal femoral fracture occurred in one hip. The superficial wound complications occurred in 2 hips and the hematoma in one hip while in hospital. The lateral femoral cutaneous nerve injury was noted in 43 hips. The early dislocation occurred in 2 hips. Heterotopic ossification was Brooker class I in 5 hips and class II in 1 hip. No aseptic loosening, postoperative periprosthetic fracture, and deep infection occurred in our series.
CONCLUSION: The DAA for THA in the lateral decubitus position may be a valuable alternative if the DAA in the supine position is difficult to implement owing to absence of a special operating room table. This technique also seems to provide satisfactory clinical and radiographic outcomes with an acceptable complication in our early follow-up.
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0 |
Clinical observation on fire needles at bones combined with cupping and Tuina for knee osteoarthritistis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To explore a better therapy for knee osteoarthritis. METHODS: One hundred cases were randomly divided into a comprehensive group and an acupuncture group, 50 cases in each one. The comprehensive treatment of fire needles at bones combined with cupping and Tuina on local area of affected knee was applied in the comprehensive group. The Ashi points were mainly selected in the fire needles at bones therapy, once every other day. The cupping and Tuina therapy was adopted once a day. The conventional acupuncture was applied in the acupuncture group, in which Dubi (ST 35), Neixiyan (EXâ?LE 4), Xuehai (SP 10), Liangqiu (ST 34) and so on were selected, once a day. Ten days of treatment were taken as a treatment course in both two groups, and totally 1 to 2 courses was required. The pain score of joint before and after the treatment was observed and efficacy was assessed in two groups. RESULTS: Compared before the treatment, the pain score of joint after the treatment was obviously improved in two groups (both P<0.05), and the score in the comprehensive group was lower than that in the acupuncture group (P<0.05). The clinical cured rate was 38.0% (19/50), which was superior to 20.0% (10/50) in the acupuncture group. CONCLUSION: The comprehensive treatment of fire needles at bones combined with cupping and Tuina, considered as a better therapy for knee osteoarthritis, could improve joint pain, swelling and action function, which is superior to the conventional acupuncture.
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0 |
Complications following one-bone forearm surgery for posttraumatic forearm and distal radioulnar joint instability
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Glenohumeral Joint OA
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Purpose: To present the outcomes after one-bone forearm (OBF) surgery for chronic posttraumatic forearm and distal radioulnar joint instability. Methods: We conducted a retrospective chart review to study patients who underwent OBF surgery because of a traumatic etiology. We collected patient demographics, surgical technique, preoperative and postoperative range of motion, final grip strength, and complications from the medical records. Patients were asked to complete the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, a 0- to 10-point pain scale, and a 0- to 10-point treatment satisfaction scale. Results: There were 5 male and 5 female patients, with a mean age of 32 years at the time of OBF surgery (range, 17-44 y). The mean number of procedures before OBF surgery was 3.6 (range, 2-7); 4 patients had undergone a Darrach procedure and 3 patients had undergone a Sauvé-Kapandji procedure. The median clinical follow-up duration was 6 years (range, 1-17 y). Wrist and elbow range of motion did not change remarkably before and after surgery. Of 8 primary OBF surgeries, 3 resulted in nonunion. Of 10 patients, 4 experienced painful impingement of the remaining proximal radius on adjacent bone and soft tissue and required a total of 7 procedures after OBF surgery. The median follow-up duration for patient-rated outcomes was 10 years (range, 5-21 y; n = 7). The median Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 77, the median pain score was 7, and the median satisfaction score was 7. Conclusions: In our experience, complications after OBF surgery are common. Although wrist and elbow range of motion were spared, pain persisted and functional outcomes were poor. One-bone forearm surgery is our last resort for a chronically painful and unstable forearm. Type of study/level of evidence: Therapeutic IV. © 2013 American Society for Surgery of the Hand.
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0 |
The importance of ultrasound in diagnosis of carpal tunnel syndrome in Iraqi subjects
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Aim: This study was designed to evaluate the use of ultrasound in diagnosis carpal tunnel syndrome. Patients & Methods: This study enrolled 50 patients with symptomatic carpal tunnel syndrome and 100 healthy volunteers as a control, with age & sex matched,at the period from December 2008 till May 2009 in Al yarmouk Teaching Hospital. Nerve conduction studies were assessed by using the Micromed Elctromyographic machine while the ultrasonic examinations were done by using high resolution sonography of 5-13 MHz linear array transducer Siemens. Results: This study showed that cross sectional area of median nerve equal to or more than 0.092 cm(2) in 90.8% of patients, which is highly suggestive of carpal tunnel syndrome in all symptomatic subjects with carpal tunnel syndrome. The other findings of carpal tunnel syndrome detected by ultrasonography were decrease in echogenisty of median nerve with flattening of median nerve & flexor retniculum bowing at wrist. Conclusion: From the end results we can conclude that ultrasonography should be the first diagnosis procedure considered in subjects with typical clinical features of carpal tunnel syndrome
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0 |
Autogenous osteochondral graft transplantation for steroid-induced osteonecrosis of the femoral condyle: A report of three young patients
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Osteochondritis Dissecans 2020 Review
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Steroid-induced osteonecrosis of the femoral condyle is a relatively uncommon condition and is often difficult to select appropriate treatment especially in young patients. Three young men (aged 25, 18, and 24) presented with severe pain and dysfunction of the knee diagnosed as steroid-induced osteonecrosis of the femoral condyle by magnetic resonance imaging (MRIs). Full-thickness cartilage defects sized 20 Ã? 10, 15 Ã? 10, and 30 Ã? 20 mm respectively were classified as International Cartilage Repair Society Grade IV lesions and treated with osteochondral autograft transplantation. They were treated successfully with osteochondral autograft transplantation certificated by post-operative MRI and second look arthroscopy.
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0 |
Intraoperative passive knee kinematics during total knee arthroplasty surgery
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OAK 3 - Non-arthroplasty tx of OAK
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Surgical navigation systems for total knee arthroplasty (TKA) surgery are capable of capturing passive three-dimensional (3D) angular joint movement patterns intraoperatively. Improved understanding of patient-specific knee kinematic changes between pre and post-implant states and their relationship with post-operative function may be important in optimizing TKA outcomes. However, a comprehensive characterization of the variability among patients has yet to be investigated. The objective of this study was to characterize the variability within frontal plane joint movement patterns intraoperatively during a passive knee flexion exercise. Three hundred and forty patients with severe knee osteoarthritis (OA) received a primary TKA using a navigation system. Passive kinematics were captured prior to (pre-implant), and after prosthesis insertion (post-implant). Principal component analysis (PCA) was used to capture characteristic patterns of knee angle kinematics among patients, to identify potential patient subgroups based on these patterns, and to examine the subgroup-specific changes in these patterns between pre- and post-implant states. The first four extracted patterns explained 99.9% of the diversity within the frontal plane angle patterns among the patients. Post-implant, the magnitude of the frontal plane angle shifted toward a neutral mechanical axis in all phenotypes, yet subtle pattern (shape of curvature) features of the pre-implant state persisted.
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1 |
Augmentation of Meniscal Repair With Platelet-Rich Plasma: A Systematic Review of Comparative Studies
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AMP (Acute Meniscal Pathology)
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BACKGROUND: The effect of platelet-rich plasma (PRP) augmentation for meniscal repair (MR) is unclear, as current evidence is limited to small, mostly nonrandomized studies.
PURPOSE: To systematically review the literature to evaluate the efficacy and safety of MR with PRP augmentation.
STUDY DESIGN: Systematic review; Level of evidence, 3.
METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies (level of evidence 1-3) that compared the clinical efficacy of MR performed with versus without PRP. The search phrase used was platelet-rich plasma meniscus. Patients were assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the visual analog scale (VAS) for pain, the Lysholm score, the Knee injury and Osteoarthritis Outcome Score (KOOS), the subjective International Knee Documentation Committee (IKDC) score, and treatment failure.
RESULTS: We identified 6 studies (2 studies with level 1 evidence; 4 studies with level 3 evidence) that met inclusion criteria, for a total of 309 patients undergoing MR with PRP (mean age, 31.9 years) and 445 patients without PRP augmentation (mean age, 29.6 years). The mean follow-up was 32.8 months (range, 12-72 months). Overall, 17.0% of PRP patients experienced MR failure compared with 22.1% of non-PRP patients. No differences in VAS, Lysholm, or subjective IKDC scores were found between groups except in 1 study, in which postoperative subjective IKDC scores were significantly better in the PRP group (P < .01). Another study found significantly better postoperative WOMAC scores among PRP patients, and 2 studies found significantly better KOOS subscores among PRP patients.
CONCLUSION: There are a limited number of high-quality studies comparing outcomes and healing rates between patients undergoing MR with versus without PRP augmentation. Based on the available evidence, patients undergoing MR with PRP augmentation experience similar clinical outcomes at midterm follow-up when compared with conventional MR, and additional studies are needed to determine the efficacy of MR augmented with PRP.
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0 |
Single-cell RNA sequencing in osteoarthritis
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AMP (Acute Meniscal Pathology)
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Osteoarthritis is a progressive and heterogeneous joint disease with complex pathogenesis. The various phenotypes associated with each patient suggest that better subgrouping of tissues associated with genotypes in different phases of osteoarthritis may provide new insights into the onset and progression of the disease. Recently, single-cell RNA sequencing was used to describe osteoarthritis pathogenesis on a high-resolution view surpassing traditional technologies. Herein, this review summarizes the microstructural changes in articular cartilage, meniscus, synovium and subchondral bone that are mainly due to crosstalk amongst chondrocytes, osteoblasts, fibroblasts and endothelial cells during osteoarthritis progression. Next, we focus on the promising targets discovered by single-cell RNA sequencing and its potential applications in target drugs and tissue engineering. Additionally, the limited amount of research on the evaluation of bone-related biomaterials is reviewed. Based on the pre-clinical findings, we elaborate on the potential clinical values of single-cell RNA sequencing for the therapeutic strategies of osteoarthritis. Finally, a perspective on the future development of patient-centred medicine for osteoarthritis therapy combining other single-cell multi-omics technologies is discussed. This review will provide new insights into osteoarthritis pathogenesis on a cellular level and the field of applications of single-cell RNA sequencing in personalized therapeutics for osteoarthritis in the future.
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0 |
Similar outcomes between two-stage revisions for infection and aseptic hip revisions
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PJI DX Updated Search
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PURPOSE: Two-stage revision hip arthroplasty using an antibiotic-loaded spacer is the most widely performed procedure for infected hip arthroplasties. The clinical outcome of this type of surgery compared with aseptic joint revision with exchange of femoral and acetabular components is still controversial due to the relative lack of medium- to long-term follow-up. Therefore, we analysed clinical and radiological outcomes of septic two-stage revisions compared with aseptic hip revision surgeries. METHODS: In this retrospective study we assessed 82 consecutive patients who underwent two-stage revision for septic total hip (45 patients) or one-stage aseptic revision arthroplasty (37 patients). The average follow-up was 53 months for the aseptic group and 55 months for the septic group. For clinical evaluation, we used the Harris Hip Score (HHS) and the Merle d'Aubigne and Postel score. The postoperative pain level was determined with the visual analogue pain scale. RESULTS: The surgeries were performed 124 months (aseptic group) and 119 months (septic group) after primary total hip arthroplasty on average. The main indications for aseptic revision surgeries were aseptic loosening (96%), dislocation (2.2%), and periprosthetic fracture (2.2%). In the clinical outcome patients achieved 75.5 points in the aseptic group and 73.4 points in the septic group in the Harris Hip Score. The Merle d'Aubigne and Postel Score revealed 12.5 points for the aseptic group and 13.1 points for the septic group. Mean level of persisting pain was 0.8 (aseptic group) and 0.4 (septic group) on the visual analogue scale (VAS). Overall survival in the aseptic group was 85.6% at 9.8 years 82.7% at 10.1 years for the septic group, with a repeat revision rate of 8.1% and 6.7%, respectively. CONCLUSIONS: Performing aseptic acetabular and femoral revision hip arthroplasty showed equal clinical outcomes in relation to septic two-stage revision hip surgeries. Our results showed a tendency for better outcome in comparison with the information given in the literature for septic and nonseptic exchange arthroplasties, including a lower rate of re-revisions
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0 |
Total joint replacement: a consideration for antimicrobial prophylaxis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Infection is the principal and most devastating complication of total joint replacement, resulting in long periods of hospitalization, staggering costs, loss of the implant, disastrous physical impairment, and even death. Staphylococcus aureus and Staphylococcus epidermidis account for more than 50% of late infections. Animal studies have shown that joint implants are at a high risk of becoming infected via a metastatic hematogenous route during transient bacteremias. Because cephalosporins have been established as the perioperative and intraoperative agents of choice to prevent infections related to total joint replacement, oral cephalosporins are the drugs of choice to minimize the potential for the metastatic infection of prosthetic joints associated with transient dental bacteremias. Clindamycin is preferred for patients who are allergic to the cephalosporins or who may have a cross-allergy between penicillin and the cephalosporins
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0 |
Arthroscopic treatment of osteochondral knee defects with resorbable biphasic synthetic scaffold: clinical and radiological results and long-term survival analysis
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AMP (Acute Meniscal Pathology)
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Purpose: The aim of our study is to evaluate the long-term results in patients treated with a fully arthroscopic TruFit system for osteochondral lesions of the femoral condyle, analyzing the clinical and radiological outcomes, survival rate, complications, and correlations. Methods: The study included all patients treated with the TruFit system with a full-thickness focal lesion of the knee cartilage (grade IV according to the ICRS classification), entirely arthroscopically with a minimum follow-up of five years. All patients were evaluated clinically prior to surgery (T0) and at two consecutive follow-ups (T1 36.4 ± 17.03 months and T2 101.63 ± 19.02 months), using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Hospital for Special Surgery Score (HSS). At the final follow-up, the magnetic resonance imaging (MRI) was evaluated by two orthopaedists using the magnetic resonance observation of cartilage repair tissue (MOCART) score. Results: The sample was formed of 21 patients, of which 14 were males (67%) and 7 females (33%), with a mean age of 51.29 ± 10.70. Of the 21 patients, two underwent prosthetic knee replacement at 24 and 65 months, respectively. At T0, the HSS and the KOOS score were, respectively, 60.71 ± 11.62 and 57.71 ± 6.11. For both clinical values, a significant improvement was noted between T0 and T1 (p < 0.05) and between T0 and T2 (p < 0.05). At the final follow-up, the MOCART value was found to be 45.78 ± 5.27. Conclusions: The study results highlighted the safety and potential of the arthroscopic TruFit system procedure, which offered a good clinical outcome with stable results at long-term follow-up although we found no correlations between the MRI and clinical results.
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0 |
Effect of distraction arthroplasty on osteoarthritic goat models of the articular cartilage
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Osteoarthritis (OA) is the most common knee degenerative disease, the number of OA patients increases along with the increase of life expectancy. Distraction arthroplasty is a less invasive alternatif for OA management by releaving mechanical stress while maintaining intermitten joint fluid pressure changes, thus halting the OA destructive cycle and inducing repair. This study aims to evaluate the anatomical and histopathological changes after distraction arthroplasty on osteoarthritic animal models. Methods: The study was performed on 32 goat stiffle joint (16 goats) with mechanically induced OA by lateral meniscectomy. During the study 6 goats were decreased. Distraction arthroplasty was performed using external fixation on 10 knees for 4 weeks, and the contralateral knees left untreated. The knees were anatomically and histopathologically examined using International Cartilage Repair Society (ICRS) staging and Osteoarthritis Research Society International (OARSI) scoring. The differences of the anatomical and histopathological changes are tested for significance using the Wilcoxon test. Results: There was anatomical and histopathological worsening of the OA on treated knees. The anatomical difference assessed using ICRS stage gave median values of 1.5 and 2.5 respectively (p < 0.002). The histopathological difference assessed using OARSI scoring was significant (6 vs 10; p < 0.002). Conclusion: Distraction arthroplasty in OA goat models in this study, worsens the OA instead of inducing repair. Further studies are required to find out a convincing biological basis of distraction arthroplasty as an alternative treatment for OA.
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1 |
Yoga for stress reduction and injury prevention at work
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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At work employees face numerous psychological stressors that can undermine their work performance. These stressors, stemming from a variety of possible causes, have enormous health and financial impacts on employees as well as employers. Stress has been shown to be one of the factors leading to musculo-skeletal disorders (MSDs) such as: include back pain, carpal tunnel syndrome, shoulder or neck tension, eye strain, or headaches. Yoga is an ancient form of exercise that can reduce stress and relieve muscular tension or pain. Practicing yoga at the workplace teaches employees to use relaxation techniques to reduce stress and risks of injury on the job. Yoga at the workplace is a convenient and practical outlet that improves work performance by relieving tension and job stress
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0 |
Irreversible inhibition of DELTA16HER2 is necessary to suppress DELTA16HER2-positive breast carcinomas resistant to Lapatinib
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MSTS 2018 - Femur Mets and MM
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HER2 tyrosine kinase receptor is a validated target in breast cancer therapy. However, increasing evidence points to a major role of DELTA16HER2 splice variant commonly coexpressed with HER2 and identified as a clinically important HER2 molecular alteration promoting aggressive metastatic breast cancer. Consistently, mice transgenic for the human DELTA16HER2 isoform (DELTA16HER2 mice) develop invasive mammary carcinomas with early onset and 100% penetrance. The present study provides preclinical evidence that DELTA16HER2 expression confers de novo resistance to standard anti-HER2-therapies such as Lapatinib and acquired resistance to the selective Src inhibitor Saracatinib in breast cancer. Of note, Dacomitinib, an irreversible small molecule pan-HER inhibitor, was able to completely suppress DELTA16HER2-driven breast carcinogenesis. Thus, only Dacomitinib may offer benefit in this molecularly defined patient subset by irreversibly inhibiting DELTA16HER2 activation.
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1 |
The long-term consequences of war: the experience of World War II
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DoD PRF (Psychosocial RF)
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Seven hundred and thirty-one World War II and Korean War veterans completed a questionnaire about their experiences and their current psychological reactions to the war. Nineteen percent scored above the cut-off points for both the General Health Questionnaire and the (war-related) Impact of Event Scale, demonstrating that, even over 50 years after the event, many veterans still experience problems relating to their war experiences. Psychological distress was in part directly related to particular experiences, but intrusion and avoidance both played an important role as mediating variables. Other factors, such as prisoner of war (POW) status, type of service, rank, and illness were also considered. The findings indicate that the effects of a traumatic experience such as war can persist into later life.
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0 |
(ii) Shoulder and elbow imaging
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Pediatric Supracondylar Humerus Fracture 2020 Review
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The shoulder is a ball and socket joint, the stability of which is conferred predominantly by surrounding soft tissue. The majority of clinical symptoms in the shoulder are either instability related or impingement syndrome in the subacromial area.The elbow is a complex hinge joint with three individual articulations. It is surrounded by a number of tendons and, like the shoulder, joint stability is maintained by multiple ligaments. Trauma, tendinopathy and systemic diseases can affect the elbow joint.Imaging plays an invaluable role in patient management. The plain radiograph, although being a very useful baseline investigation having reasonable clinical use, has its limitations. The mainstay of shoulder and elbow imaging is US and MRI.The following article outlines common and slightly uncommon shoulder and elbow pathologies and their imaging appearances.
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0 |
The technique of mammaplasty
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Reduction Mammoplasty for Female Breast Hypertrophy
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It is much easier to perform a corrective operation in cases of atrophic and ptotic breast. The authors transpose the breast after a wide resection of skin and after exposure of the pectoralis fascia. It is unnecessary to remove any glandular or fat tissue; on the contrary, all this tissue should be brought up on the pectoralis fascia, under the supra-areolar skin, and there used to form a normal breast again. If the available fat and glandular tissue is too scarce, one can implant a paraffin plug, or a globe of glass, which is very well tolerated in the retromammary space.
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0 |
New technologies in knee arthroplasty
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PJI DX Updated Search
|
Advances in surgical technique and implant design have increased the treatment options available to joint reconstruction surgeons. New technologies for component alignment such as custom cutting blocks and disposable cutting blocks hold the potential for more anatomic component positioning and less instrument turnover which may decrease infection rates. Improved component alignment may also be obtained with the use of computer-assisted surgery. Utilization of bone-sparing designs such as patellofemoral, unicompartmental, and bicompartmental knee arthroplasty allow for the surgeon to customize treatment based on patient symptoms by addressing each compartment individually. Gender-specific designs may be useful in the setting of populations which deviate from standard dimensions that are available in traditional unisex designs. New higher-conforming bearing designs such as rotating platform bearings allow for more natural knee kinematics, while also limiting polyethylene wear by decreasing contact stress. Newer interfaces for cementless fixation utilizing porous coated surfaces allows for biologic component fixation which has the potential to increase interface durability and implant survivorship. These new materials, designs, and techniques are challenging the traditional "gold standard" cemented total knee arthroplasty and have the potential for developing a more durable and naturally feeling prosthetic knee. Further study is required to identify which patients are most appropriate for each new technology
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1 |
Heterogenic control groups in randomized, controlled, analgesic trials of total hip and knee arthroplasty
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AAHKS (4) Acetaminophen
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INTRODUCTION: Postoperative analgesic interventions are often tested adjunct to basic non-opioid analgesics in randomized controlled trials (RCTs). Consequently, treatment in control groups, and possible assay sensitivity, differs between trials. We hypothesized that postoperative opioid requirements and pain intensities vary between different control groups in analgesic trials.
EVIDENCE ACQUISITION: Control groups from RCTs investigating analgesic interventions after total hip and knee arthroplasty were categorized based on standardized basic analgesic treatment. Morphine consumption 0 to 24 hours postoperatively, and resting pain scores at 6 and 24 hours for subgroups of basic treatments, were compared with ANOVA. In an additional analysis, we compared pain and opioid requirements in trials where a non-steroidal anti-inflammatory drug (NSAID) was administered as an intervention with trial where NSAID was administered in a control group.
EVIDENCE SYNTHESIS: We included 171 RCTs employing 28 different control groups with large variability in pain scores and opioid requirements. Four types of control groups (comprising 78 trials) were eligible for subgroup comparisons. These subgroups received "opioid" alone, "NSAID + opioid", "acetaminophen + opioid", or "NSAID + acetaminophen + opioid", respectively. Morphine consumption and pain scores varied substantially between these groups, with no consistent superior efficacy in any subgroup. Additionally, trials administering NSAID as an intervention demonstrated lower pain scores and opioid requirements than trials where NSAID was administered in a control group.
CONCLUSIONS: Analgesic treatment in RCT control groups varies considerably. Control groups receiving various combinations of opioid, NSAID and acetaminophen did not differ consistently in pain and opioid requirements. Pain and opioid requirements were lower in trials administering NSAID as an intervention compared with trials administering NSAID in a control group.
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0 |
Reconstruction of traumatic tubular bone defects using vascularized fibular graft
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DoD SSI (Surgical Site Infections)
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Large segmental bone defects due to major trauma constitute a major challenge for the orthopaedic surgeon, especially when combined with poor or lost soft tissue envelope. Vascularized fibular transfer is considered as the gold standard for the reconstruction of such defects of the extremities due to its predictable vascular pedicle, long cylindrical shape, and tendency to hypertrophy, and resistance to infection. Vascularized bone grafts remain viable throughout the healing period and are capable of inducing rapid graft union without prolonged creeping substitution, osteogenesis and hypertrophy at the reconstruction site, and fight with infection. The ?bular graft can be transferred solely, or as a composite flap including muscle, subcutaneous tissue, skin and even a nerve segment in order to reconstruct both bone and soft tissue components of the injury at single stage operation. Such a reconstruction can even be performed in the presence of local infection, since vascularized bone and adjacent soft tissue components enhances the blood ?ow at the traumatized zone, allowing for the delivery of antibiotics and immune components to the infection site. In an effort to preserve growth potential in pediatric patients; the fibular head and proximal growth plate can be included to the graft. This practice also enables to reconstruct the articular ends of various bones, including distal radius and proximal ulna. Apart from defect reconstruction, vascularized fibular grafts also proved to be a reliable in treating atrophic nonunions, reconstruction of osteomyelitic bone segments. These grafts are superior to alternative reconstructive techniques, as bone grafts with intrinsic blood supply lead to higher success rates in reconstruction and accelerate the repair process at the injury site in cases where blood supply to the injury zone is defective, poor soft tissue envelope, and local infection at the trauma zone.
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0 |
Is there a lower incidence of deep venous thrombosis after joint replacement in rheumatoid arthritis?
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Surgical Management of Osteoarthritis of the Knee CPG
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Patients with rheumatoid arthritis (RA) and osteoarthritis (OA) were compared for the incidence of deep venous thrombosis (DVT) after total hip replacement (THR). RA patients after total knee replacement (TKR) were also compared for the incidence of DVT. The relative risk of OA patients developing DVT after THR was 2.3 times that of RA patients. In RA patients after TKR, the chance of DVT was 4.8 times greater than after THR, implying that added stress in knee surgery can overcome the inherent protection RA patients may have. Although salicylates may be protective, firm conclusions regarding the effect of drugs, including corticosteroids on the development of DVT could not be made
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1 |
Arthroscopic debridement and decompression for selected rotator cuff tears. Clinical results, pathomechanics, and patient selection based on biomechanical parameters
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Optimizing the Management of Full-Thickness Rotator Cuff Tears
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Clinical results of arthroscopic rotator cuff debridement and decompression in 25 patients are presented. Additionally, a fluoroscopic study of 14 patients with known massive rotator cuff tears reveals four kinematic patterns in patients with major cuff deficiencies. Biomechanical models are used to support further the clinical impression that certain rotator cuff tears are amenable to arthroscopic debridement and decompression without repair. Specific indications for arthroscopic debridement and decompression are developed and presented
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0 |
Improving Sexual Satisfaction in Persons with Spinal Cord Injuries: Collective Wisdom
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DoD PRF (Psychosocial RF)
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Sexuality is an important part of life, and it is necessary for clinicians to have a specific format in which to address sexual issues with their patients. A systematic approach to working with patients with spinal cord injury (SCI) to improve their sexual functioning and response is presented. Nonjudgmental communication about sexual concerns is followed by a detailed pre- and postinjury medical, psychosocial, and sexual history. If preexisting sexual issues are present, it is recommended that the patient be referred for assessment and treatment of these separate from the patient's SCI-related concerns. Physical examination, with special attention to issues that could impact the patient's sexuality, is followed by a detailed neurologic assessment with specific attention to the T11-L2 and S3-5 spinal segments. Education of the patient with regard to his or her sexual potential and the need to be flexible in his or her sexual repertoire is followed by self-exploration and practice. Routine follow-up is suggested after patient's initial sexual exploration. Treatment of confounding and iatrogenic factors related to SCI is followed by more sexual experience. Afterwards the clinician is encouraged to use simple techniques to treat sexual issues and follow-up with the patient to assess the outcome. A structured program utilizing vibratory stimulation with or without midodrine is described as a way to achieve ejaculation and potentially orgasm, and techniques for treating severe autonomic dysreflexia are discussed. If these interventions do not alleviate the patient's sexual concerns, the clinician should refer the patient for more specialized consultation.
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Hemi-field and full-field form-deprivation induce timing changes in multifocal ERG responses in chick
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Upper Eyelid and Brow Surgery
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In animal models hemi-field deprivation results in localised, graded vitreous chamber elongation and presumably deprivation induced localised changes in retinal processing. The aim of this research was to determine if there are variations in ERG responses across the retina in normal chick eyes and to examine the effect of hemi-field and full-field deprivation on ERG responses across the retina and at earlier times than have previously been examined electrophysiologically. Chicks were either untreated, wore monocular full-diffusers or half-diffusers (depriving nasal retina) (n = 6-8 each group) from day 8. mfERG responses were measured using the VERIS mfERG system across the central 18.2o� 16.7o (H � V) field. The stimulus consisted of 61 unscaled hexagons with each hexagon modulated between black and white according to a pseudorandom binary m-sequence. The mfERG was measured on day 12 in untreated chicks, following 4 days of hemi-field diffuser wear, and 2, 48 and 96 h after application of full-field diffusers. The ERG response of untreated chick eyes did not vary across the measured field; there was no effect of retinal location on the N1-P1 amplitude (p = 0.108) or on P1 implicit time (p > 0.05). This finding is consistent with retinal ganglion cell density of the chick varying by only a factor of two across the entire retina. Half-diffusers produced a ramped retina and a graded effect of negative lens correction (p < 0.0001); changes in retinal processing were localized. The untreated retina showed increasing complexity of the ERG waveform with development; form-deprivation prevented the increasing complexity of the response at the 2, 48 and 96 h measurement times and produced alterations in response timing. Form-deprivation and its concomitant loss of image contrast and high spatial frequency images prevented development of the ERG responses, consistent with a disruption of development of retinal feedback systems. The characterisation of ERG responses in normal and deprived chick eyes across the retina allows the assessment of concurrent visual and retinal manipulations in this model. Ophthalmic & Physiological Optics © 2013 The College of Optometrists.
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Outcomes of people with a fractured hip and dementia who reside in a specialized nursing home
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Hip Fx in the Elderly 2019
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Fifteen persons who had Alzheimer's disease and experienced a fractured hip were described in relationship to age, sex, type of fracture, type of surgery, length of hospital stay, time between fracture and surgery, and physical therapy to outcomes. Sixty-four percent of the subjects did not receive physical therapy in the hospital while 86% did receive therapy in the nursing home. At 1 year seven persons were deceased. Six of the remaining subjects were ambulating with or without assistance.
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The effects of surgically removing subcutaneous fat on the metabolic profile and insulin sensitivity in obese women after large-volume liposuction treatment
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Panniculectomy & Abdominoplasty CPG
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The aim of this study was to identify the effects of surgically removing subcutaneous fat on the metabolic profile and insulin sensitivity in obese women after large-volume liposuction treatment. An open clinical trial with a non-intervention parallel group was carried out on 12 young, obese women. After randomization, six volunteers were selected to the surgical intervention consisting of large-volume liposuction; the other six women were considered as the non-intervention group. Metabolic profiles and insulin tolerance tests to assess insulin sensitivity were performed on all volunteers before intervention or non-intervention and 21-28 days afterwards. There were a significant decrease in glucose (4.9 ± 0.4 vs. 4.6 ± 0.2mmol/l, p < 0.05) and uric acid (250.8 ± 56.2 vs. 224.0 ± 53.4 μmol/l, p < 0.05) levels after liposuction; insulin sensitivity improved after the surgical intervention (4.3 ± 0.9 vs. 5.3 ± 0.8%/min, p = 0.046). In conclusion, surgical removal of subcutaneous fat by large-volume liposuction led to an improvement in insulin sensitivity and a decrease in glucose and uric acid concentrations.
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1 |
Weight change and change in tibial cartilage volume and symptoms in obese adults
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: There is a paucity of data examining the effects of weight change on knee joint structures and symptoms. This study examined the effect of weight change on change in knee cartilage volume and symptoms in an obese cohort.
METHODS: 112 obese subjects (Body Mass Index >=30 kg/m(2)) were recruited from various community sources to examine the effect of obesity on musculoskeletal health. Tibial cartilage volume, determined by MRI, and knee symptoms, determined by the Western Ontario and McMaster Osteoarthritis Index (WOMAC) were collected at baseline and an average of 2.3 years later.
RESULTS: Percentage weight change was associated with change in medial tibial cartilage volume (beta -1.2 mm(3), 95% CI -2.3 to -0.1 mm(3), p=0.03) that was consistent throughout the spectrum of weight loss through to mild weight gain. Percentage weight change was not associated with change in the lateral tibial (p=0.93) or patella (p=0.32) cartilage volumes. Percentage weight change was associated with change in all WOMAC subscales (all p<=0.01): pain (beta -1.8 mm, 95% CI -3.2 to -0.4 mm), stiffness (beta -1.6 mm, 95% CI -2.5 to -0.7 mm) and function (beta -6.9 mm, 95% CI -11.6 to -2.1 mm).
CONCLUSIONS: The linearity of effect implies that weight loss is associated with reduced medial cartilage volume loss and improved knee symptoms, while weight gain is associated with increased medial cartilage volume loss and worse knee symptoms. These results suggest that in obese people, small amounts of weight change may have the potential for a disease modifying effect on both knee joint structure and symptoms. While weight loss is an important primary management strategy in obese individuals, avoidance of further weight gain should also be a clinical goal.
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Microsurgical breast reconstruction in thin patients: The impact of low body mass indices
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Reduction Mammoplasty for Female Breast Hypertrophy
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Abstract Background The purpose of this investigation was to examine patients with low body mass index (BMI) regarding the feasibility to perform autologous breast reconstruction in such patients, as well as to determine optimal donor sites and evaluate outcomes accordingly. Patients and Methods All patients undergoing microsurgical breast reconstruction were divided into three cohorts based on BMI. Group 1 included patients with BMI greater than or equal to 22 kg/m2 and was defined "low-normal BMI." Patients with BMI 22 to 25 kg/m2 were placed in Group 2, labeled as "high-normal BMI." Group 3, defined as "overweight," included patients with BMI greater than 25 kg/m2, but less than 30 kg/m2. Patients were then analyzed based on demographics, breast cancer history, intraoperative details, complications, and revisionary surgeries. F-tests, chi-square goodness-of-fit tests, and Freeman-Halton extension of the Fisher exact tests were used for statistical analysis. Results During the study period, a total of 259 reconstructions were performed. Group 1 included 30 patients (n = 49 flaps), Group 2 included 58 patients (n = 98 flaps), and Group 3 included 69 patients (n = 112 flaps). Patients undergoing nipple-areolar sparing mastectomy were more likely to be in Groups 1 (39% [n = 19]) and 2 (37% [n = 37]) as compared with Group 3 (14.2% [n = 16]) (p < 0.001) as compared with the overweight cohort. Patients with increasing BMI were more likely to undergo abdominally based free flaps as compared with alternative donor sites (Group 1 = 2.26, Group 2 = 7.9, Group 3 = 27 [p < 0.001]). Conclusions Abdominally based free flaps are possible in the majority of patients, however alternative harvest sites have to be used more frequently in low BMI patients.
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Hematological malignancies and the bone (myeloma excluded)
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MSTS 2018 - Femur Mets and MM
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Bone involvement is a rare event in lymphomas, except in patients with adult T-cell leukemia/lymphoma associated with HTLVI. It is usually characterised by lytic bone lesions located in the metaphysis of long bones or in the axial skeleton. The occurrence of bone lesions reflects a progression of the disease affecting the prognosis that is related to lymphoma histologic features and staging. Bone lesions may occur in some lymphoproliferative disorders such as LLC or Waldenstrom's disease, or in myeloproliferative disorders. They may reflect a progression to a more aggressive disorder with a worse prognosis. The treatment of hematologic malignancies presenting with bone lesions and/or hypercalcemia is similar to the treatment of the systemic disease. In primary lymphomas of bone presenting with an isolated bone lesion, local treatment with radiation therapy and/or surgical ablation is required, and adjuvant chemotherapy may improve the prognosis of these located lymphomas. Glucocorticoid therapy and bisphosphonates are effective in treating associated hypercalcemia. Except for myeloma and ATL, the underlying mechanisms responsible for bone involvement in hematologic malignancies remain poorly understood. The unusual occurrence of bone lesions in these diseases probably implies distinct pathogenic mechanisms, but one can speculate that an increased expression of RANK/RANKL, the common final pathway in bone resorption, may be involved. [References: 51]
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Activity of N-acetyl-ß-hexosaminidase and its isoenzymes in serum and synovial fluid from patients with different arthropathies
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AMP (Acute Meniscal Pathology)
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Objective. To evaluate the activity of N-acetyl-ß-hexosaminidase (HEX) and its isoenzymes in the serum and synovial fluid of healthy volunteers and patients with an injury to the anterior cruciate ligament and/or meniscus (ACL) osteoarthritis (OA), juvenile idiopathic arthritis (JIA) and rheumatoid arthritis (RA). Methods. The activity of HEX and its isoenzymes was determined according to Zwierz et al. method. Protein content was determined by the biuret method. Results. The specific activity of HEX and its isoenzymes in the serum of patients with JIA showed a tendency to increase in comparison to the reference group. The specific activity of total HEX in the serum of RA patients was significantly increased in comparison to control. Our results show, that specific activity of HEX in synovial fluid, in the reference group 4.2 ± 0.21 µkat/kg protein (0.25 unit/mg protein), is similar to activity in normal temporomandibular joint fluid (0.3 unit/mg protein). Therefore, we included this group in our research. In patients with OA and ACL injuries, HEX and its isoenzymes showed a tendency to increase in the specific activity in synovial fluid. The specific activity of HEX and its isoenzymes in the synovial fluid of patients with RA and JIA was significantly elevated in comparison to the control and the remaining groups. Conclusion. In the synovial fluid of patients with JIA and RA, the specific activity of HEX and its isoenzymes significantly increased in comparison to control and patients with diseases of a non-inflammatory etiology (OA and ACL). In the synovial fluid of control and diseased groups, HEX constituted a higher percent of total proteins than in serum. © Copyright Clinical and Experimental Rheumatology 2006.
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Postliposuction histologic alterations of adipose tissue
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Panniculectomy & Abdominoplasty CPG
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The author studied seven patients who received suction assisted lipectomy prior to classic abdominal dermolipectomies. The liposuction sessions were performed 180, 150, 60, 30, 15, 12, 8, and 5 days before the abdominoplasties. Histologic studies disclosed extensive amounts of dead adipocytes and free fat within the aspirated area. The pockets left behind were filled with serum hemorrhagic material and evolved to the healing process. Collagen synthesis was increased initially then followed by gradual decrease and a remodeling process. Our findings suggest that liposuction techniques preserve some vessels and nerves, but the final resolution may take several months or years, depending on the amount of tissue damage.
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The psychosocial difficulties in brain disorders that explain short term changes in health outcomes
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DoD PRF (Psychosocial RF)
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BACKGROUND: This study identifies a set of psychosocial difficulties that are associated with short term changes in health outcomes across a heterogeneous set of brain disorders, neurological and psychiatric.
METHODS: Longitudinal observational study over approximately 12 weeks with three time points of assessment and 741 patients with bipolar disorders, depression, migraine, multiple sclerosis, parkinson's disease, stroke and traumatic brain injury. The data on disability was collected with the checklist of the International Classification of Functioning, Disability and Health. The selected health outcomes were the Short Form 36 and the World Health Organization Disability Assessment Schedule. Multilevel models for change were applied controlling for age, gender and disease severity.
RESULTS: The psychosocial difficulties that explain the variability and change over time of the selected health outcomes were energy and drive, sleep, and emotional functions, and a broad range of activities and participation domains, such as solving problems, conversation, areas of mobility and self-care, relationships, community life and recreation and leisure.
CONCLUSIONS: Our findings are of interest to researchers and clinicians for interventions and health systems planning as they show that in addition to difficulties that are diagnostic criteria of these disorders, there are other difficulties that explain small changes in health outcomes over short periods of time.
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