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Emergency management of type IIIB open tibial fractures
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DoD SSI (Surgical Site Infections)
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We present our therapeutic strategy for the treatment of type IIIB open tibial fractures. It involves emergency internal stabilisation of the bone by locked intra-medullary nailing when appropriate and skin cover using either a pedicled or free muscle flap. Where there is bone loss, a cancellous iliac graft is performed at the same time. Eighteen cases of type IIIB open tibial fractures treated between 1986 and 1995 were analysed. There were 17 men and 1 woman; the average age was 35 years. Each of the 18 patients underwent wound debridement as a primary emergency procedure with no secondary reoperation. Bone fixation was performed by locked intra-medullary nailing (AO nail, How Medica) 6-10 h after trauma. A primary cancellous iliac bone graft was performed in three cases. Cover was applied immediately after nailing (muscular pedicle flaps in 12 cases, muscular free flaps in 6 cases). Local flap cover led to two failures: both these fractures were followed by postoperative complications. The 6 free muscle flaps were successful. The average time to bone union was 6.5 months (range: 3-18.5 months) according to clinical criteria and 9 months (range: 4-27 months) according to radiological criteria. Out of the 18 fractures, 13 were primarily united (72.2% of cases); 3 involved osteitis and 2 nonunion. Sixteen patients were examined again with a mean follow-up of 4.8 years (range: 1-11 years). Six moderate malunions occurred; none needed surgical reoperation. Ankle motion was normal in 7 cases and reduced to below 50% in 9 cases when compared with the healthy ankle. Thirteen patients resumed their previous professional activities. This surgical strategy reduces bone union time, the number of operations and the time spent in hospital; it improves functional results.
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Rare case of simultaneous enterococcal endocarditis and prosthetic joint infection
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PJI DX Updated Search
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A 59-year-old man was admitted with a 3-month history of daily fevers as well as bilateral knee pain and swelling. Medical history was significant for bilateral knee arthroplasties 4 years prior to admission. Two sets of peripheral blood cultures as well as bilateral knee synovial fluid grew Enterococcus faecalis within 10 hours. Transoesophageal echocardiography revealed aortic and mitral valve vegetations suggestive of infectious endocarditis, with severe regurgitation secondary to large size. The patient's hospitalisation was complicated by acute heart failure, necessitating emergent mitral valve repair and aortic valve replacement, followed shortly thereafter by bilateral total knee arthroplasty resection with placement of antibiotic spacers. He was treated with intravenous penicillin and gentamicin for 4 months and recovered fully. He underwent repeat bilateral knee arthroplasties and was placed on amoxicillin for 6 months postoperatively, with no further evidence of infection
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Efficacy of multimodal perioperative analgesia protocol with periarticular medication injection in total knee arthroplasty: A randomized, double-blinded study
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AAHKS (8) Anesthetic Infiltration
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Pain control is necessary for successful rehabilitation and outcome after total knee arthroplasty. Our goal was to compare the clinical efficacy of periarticular injections consisting of a long-acting local anesthetic (ropivacaine) and epinephrine with and without combinations of an α2-adrenergic agonist (clonidine) and/or a nonsteroidal anti-inflammatory agent (ketorolac). In a double-blinded controlled study, we randomized 160 patients undergoing total knee arthroplasty to receive 1 of 4 intraoperative periarticular injections: Group A, ropivacaine, epinephrine, ketorolac, and clonidine; Group B, ropivacaine, epinephrine, and ketorolac; Group C, ropivacaine, epinephrine, and clonidine; Group D (control), ropivacaine and epinephrine. Compared with Group D, Group A and B patients had significantly lower postoperative visual analog pain scores and nurse pain assessment and Group C patients had a significantly greater reduction in physical therapist pain assessment. We found no differences in other parameters analyzed. © 2013 Elsevier Inc.
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A comparative study of the medial St Georg sled and kinematic total knee arthroplasties. Ten-year survivorship
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Surgical Management of Osteoarthritis of the Knee CPG
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We have studied the long-term outcome of 408 primary medial St Georg Sled unicompartmental arthroplasties of the knee and 531 primary Kinematic total knee arthroplasties using survivorship analysis. The operations were performed by a number of surgeons under the supervision of two consultants at one orthopaedic centre. Prospective clinical assessment was carried out before and at 2, 5, 8, 10, 12 and 15 years after operation. Failure was defined as follows: revision or removal of the implant; the presence of moderate or severe pain; or 'worst-case' with all patients lost to follow-up. Cumulative survival rates at ten years were calculated using life tables. The follow-up rate was 97%. At ten years, 25 medial sled arthroplasties and 20 Kinematic knee arthroplasties had been revised. With revision or removal as the survivorship endpoint at ten years there was a success rate of 87.5% for the medial sled and 89.6% for the Kinematic knee arthroplasty. When moderate or severe pain was included these rates became 79.4% for both arthroplasties. There was no statistically significant (p > 0.05) difference between the rates of survival for the two arthroplasties using either of the endpoint criteria. Good or excellent results were recorded for 77.9% of the medial sled knees and 75.1% for the Kinematic knees. The former had 93.8% of cases with a final range of movement in excess of 90 degrees compared with 83.7% for the Kinematic knees (p < 0.01). We conclude that at a single orthopaedic centre in the UK, the St Georg Sled medial compartment arthroplasty for appropriate specific indications offers predictable survivorship at ten years which is comparable with that of the Kinematic total knee arthroplasty
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Prevalence and risk factors of tendinitis and related disorders of the distal upper extremity among U.S. workers: comparison to carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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BACKGROUND: National estimates of tendinitis and related disorders of the distal upper extremity among U.S. workers have not been available with the exception of carpal tunnel syndrome. METHODS: The Occupational Health Supplement Data of the 1988 National Health Interview Survey were analyzed for tendinitis and related disorders of the hand/wrist and elbow (distal upper extremity) using the Survey Data Analysis (SUDAAN) software. RESULTS: Among the 30,074 respondents (statistically weighted population of 127 million) who had worked anytime during the previous 12 months, 0.46% (95% CI: 0.36, 0.56) reported that they experienced a "prolonged" hand discomfort which was called tendinitis, synovitis, tenosynovitis, deQuervain's disease, epicondylitis, ganglion cyst, or trigger finger, by a medical person. This corresponds to 588,000 persons (95% CI: 457,000; 712,000) reporting one of these disorders, 28% (or 164,000) of which were thought to be work-related by the medical person. Among various risk factors examined by multiple logistic regression analysis, bending/twisting of the hands/wrists at work and female gender were significantly associated with reporting of these disorders. CONCLUSIONS: By combining these cases with the previously reported cases of work-related carpal tunnel syndrome, we estimate that there were approximately 520,000 cases of work-related musculoskeletal disorders of the distal upper extremity among US workers in 1988
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Osteonecrosis of the jaws and bisphosphonates
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MSTS 2018 - Femur Mets and MM
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Osteonecrosis of the jaws associated with bisphosphonate therapy was first identified in 2003 as a condition typified by exposed bone that does not heal after 8 weeks. Other signs and symptoms, such as pain and infection, may or may not be present. There is a strong need for consensus on a case definition for this condition. This condition has occurred primarily among cancer patients treated with the aminobisphosphonates zoledronic acid and pamidronate. The etiology of this condition remains unknown; however, oral disease and trauma appear to be important risk factors. This condition appears to be rare in metabolic bone disease and Paget's disease, with an estimated prevalence of approximately 1 per 100,000 person-years. Thus, the benefits of bisphosphonate therapy appear to outweigh the risks. Recommendations have been established for the oral health management of patients with a history of bisphosphonate therapy. © Springer Science+Business Media, LLC 2008.
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Current Strategies in Anesthesia and Analgesia for Total Knee Arthroplasty
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AAHKS (9/10) Regional Nerve Blocks
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Total knee arthroplasty is associated with substantial postoperative pain that may impair mobility, reduce the ability to participate in rehabilitation, lead to chronic pain, and reduce patient satisfaction. Traditional general anesthesia with postoperative epidural and patient-controlled opioid analgesia is associated with an undesirable adverse-effect profile, including postoperative nausea and vomiting, hypotension, urinary retention, respiratory depression, delirium, and an increased infection rate. Multimodal anesthesia--incorporating elements of preemptive analgesia, neuraxial perioperative anesthesia, peripheral nerve blockade, periarticular injections, and multimodal oral opioid and nonopioid medications during the perioperative and postoperative periods--can provide superior pain control while minimizing opioid-related adverse effects, improving patient satisfaction, and reducing the risk of postoperative complications.
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Early complications after revision total hip arthroplasty with cemented dual-mobility socket and reinforcement ring
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PJI DX Updated Search
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Encouraged by the success of dual-mobility sockets in achieving implant stability in primary hip replacement, surgeons have started to use the implant in revision hip arthroplasty. However, very little is known yet about the postoperative complication rate of this type of implant when fixation in a reinforcement ring is required. In our department, 37 dual-mobility sockets were cemented in a reinforcement ring for revision hip arthroplasty in 36 patients over a period of two years. The mean follow-up period was 16 months (range, 6-27 months). Indications for revision hip arthroplasty included, among others, recurrent dislocation (3 cases) and implant loosening (9 cases) with extensive bone loss. We observed two single re-dislocations (5.40%), one infection and one mechanical failure of the reinforcement ring; the literature mentions dislocation rates of 2.7 to 10.6% after revisions not specifically for recurrent dislocation. Revision hip arthoplasty combining dual-mobility sockets with reinforcement ring fixation thus had a relatively low early postoperative complication rate in this challenging group of patients. The design therefore seems to be a valid alternative to constrained implants, especially in high-risk revision cases. Despite the short follow-up period, cemented dual-mobility sockets seem to be a valuable option when reinforcement rings need to be used, with an acceptable dislocation rate in this challenging group of patients. But long-term survival studies are mandatory to evaluate stability and fixation longevity
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A novel antibacterial modification treatment of titanium capable to improve osseointegration
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Dental Implant Infection
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BACKGROUND: Among the different causes of orthopedic and dental implant failure, infection remains the most serious and devastating complication associated with biomaterial devices., PURPOSE: The aim of this study was to develop an innovative osteointegrative and antibacterial biomimetic coating on titanium and to perform a chemical-physical and in vitro biological characterization of the coating using the SAOS-2 cell line. We also studied the antibacterial properties of the coating against both Gram-positive and Gram-negative bacteria strains., METHODS: An electrochemical solution containing silicon, calcium, phosphorous, sodium, and silver nanoparticles was used to obtain the antibacterial by Anodic Spark Deposition (ASD) treatment. Surface morphology was characterized using SEM and laser profilometry. A qualitative analysis of the chemical composition of the coating was assessed by EDS. The adhesion properties of the coating to the titanium bulk were performed with a 3-point bending test. SAOS-2 osteoblastic cell line spreading and morphology and viability were investigated. The bacterial adhesion and the antibacterial properties were investigated after 3 h and 24 h of incubation with Streptococcus mutans, Streptococcus epidermidis, and Escherichia coli bacterial strains., RESULTS: The proposed anodization treatment created a chemically and morphologically modified, adherent titanium oxide layer, characterized by a microporous morphology enriched by calcium, silicon, phosphorous, and silver. The preliminary biological characterization showed optimal SAOS-2 cell adhesion and proliferation as well as a strong antibacterial effect., CONCLUSIONS: Based on the results of this study, we believe that this novel biomimetic and antibacterial treatment hold promise for enhancing osteointegration while conferring strong antibacterial properties to titanium.
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Minimal Incision Protocols for Anesthesia, Pain Management, and Physical Therapy With Standard Incisions in Hip and Knee Arthroplasties. The Effect on Early Outcomes
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AAHKS (8) Anesthetic Infiltration
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Dramatic early outcomes with "minimal incision" surgery are attributed to patient selection, perioperative management, and the surgical procedure. This study was one on 50 patients in a single surgeon's practice who underwent total hip and total knee arthroplasties with standard incisions. The first 25 patients had standard perioperative management, whereas the second 25 had the anesthesia, pain management, and physical therapy protocols described for minimal incision surgery. A dramatic reduction in the time it took to achieve the goals for discharge was observed in the second group. Most patients with the "mini" protocols were ready for discharge within 24 hours. The implications of these results are discussed. © 2007 Elsevier Inc. All rights reserved.
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Meniscal Allograft Transplantation
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AMP (Acute Meniscal Pathology)
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Meniscal allograft transplantation provides treatment options for patients with a meniscus-deficient knee with lifestyle-limiting symptoms in the absence of advanced degenerative changes. Meniscal transplantation helps to restore the native biomechanics of the involved knee, which may provide chondroprotective effects and restoring additional knee stability. Improvements in pain, function, and activity level have been seen in appropriately selected patients undergoing transplantation. Although various surgical implantation options exist, the majority focus on reproducing native attachments of the meniscal roots to allow near normal mechanics. Although meniscal transplantation may serve as a salvage procedure for symptomatic patients with a meniscus-deficient knee, it may prevent or delay the necessity of a more invasive arthroplasty procedure.
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Therapeutic efficacy and Pharmacoeconomics evaulation of pamidronate versus zoledronic acid in multiple myeloma patients
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MSTS 2018 - Femur Mets and MM
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Sixty patients of multiple myeloma were randomized into two equal groups to receive Pamidronate and Zoledronic acid intravenously every month for a total of six months. The primary endpoint was to compare the therapeutic efficacy of both drugs by the resolution of hypercalcemia, prevention of skeletal related events and pathological fractures. The secondary endpoints were to assess patient compliance on the basis of quality of life score before and after treatment with Pamidronate and Zoledronic acid and to analyze the cost effectiveness of both drugs., Pamidronate was found to be more effective in the resolution of hypercalcemia as compared to Zoledronic acid, whereas Zoledronic acid reduced the overall proportion of skeletal related events (45.9%) in comparison with Pamidronate (54.1%). Overall Quality of life scores were not significantly influenced by either the response or the occurrence of adverse event but were statistically significant (P=0.000), with in the treatment groups. Patients on Zoledronic acid were more comfortable due to short administration time of l5minutes as compared to 2 hours of Pamidronate. The average cost of six months' treatment with Zoledronic acid was significantly higher (PKR=90, 000 or USD 1,052) in comparison with Pamidronate (PKR=39, 000 USD 456. Zoledronic acid reduced the risk of developing skeletal complications including hypercalcemia and was significantly more effective in reducing the incidence of hypocalcemia. The incidence of renal impairment among patients treated with Zoledronic acid was significantly higher, but severity of nephrotoxicity was more with Pamidronate. The most common adverse effects were pain, vomiting and fatigue in both treatment groups. Comparatively, Pamidronate was more effective in resolution of hypercalcemia, while Zoledronic acid have better therapeutic effects in reduction of skeletal related events and pathological fractures.
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Knee Pain Examined under Musculoskeletal Ultrasonography: Experience from a Community-based Rheumatology Practice – A Cross-sectional Study
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AMP (Acute Meniscal Pathology)
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Background: Diagnostic musculoskeletal ultrasonogram (MSUS) in musculoskeletal pain practice has increased. MSUS helps delineate extra-and intra-articular structures that are not visible on X-ray. Objective: Explore knee pain under ultrasonogram in a primary care rheumatology (PCR) facility. Methods: This cross-sectional study was performed over six months (January 1 and June 30, 2021) to explore knee pain in a community-based PCR setting. A physician registered in musculoskeletal (RMSK) ultrasonogram examined all patients and documented data in a prefabricated questionnaire. Statistical Package for the Social Sciences (SPSS, 28.0.1.1) was used to analyze data. Quantitative and categorical variables were presented with frequency and percentage. The Mann-Whitney-U test assessed the correlation between categorical variables; p<0.05 was considered statistically significant. Results: A total of 118 knees of 92 patients were included. Following are MSUS-depicted structural changes: medial joint line osteophytes (91.3%), medial femoral condyle (MFC), cartilage echogenicity (78.3%), synovial plica (76%), knee effusion (61.9%), synovial membrane thickening (54.3%), increased medial collateral ligament (MCL) thickness (42.4), reduced trochlear and MFC thickness (36.9%), Baker's cyst (35.8%), increased MFC thickness (31.5%), medial meniscal extrusion (MME) (27.2%), synovial hypertrophy (20.6%), increased trochlear cartilage thickness (20.6%), MM tear (18.5%), semitendinosus (SMT) bursitis (6.5%), loose body (6.5%), frond-like synovial mass (5.4%), MCL calcification (4.3%) and MM cyst (4.3%). There was a statistically significant correlation between the following variables: Knee effusion and synovial plica; reduced MFC thickness; MME and reduced MFC thickness and moderate osteophyte. Conclusion: High-frequency diagnostic ultrasound can depict knee pathology precisely. MSUS at the primary healthcare facility can minimize patient referral and burden over the tertiary setting and reduce overall expenditure.
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Bone viability of amputated limbs treated with hypothermia: assessment by evaluation of mRNA levels
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DoD LSA (Limb Salvage vs Amputation)
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We evaluated rat bone viability using a bone viability index (BVI). To evaluate hypothermic ischaemic bone injury, 21 amputated hind limbs of Fischer rats were preserved at hypothermia (4 degrees C) for 1, 3 and 6 hours. To evaluate hypothermic ischaemia/reperfusion injury, another 28 amputated limbs were transplanted to recipient rats after hypothermic ischaemia for 3 and 6 hours, respectively. Total RNA isolated from each tibia was fractionated by electrophoresis and hybridised with 32P-labelled cDNA of GAPDH, and the radioactivity of intact and degraded GAPDH mRNA measured. BVI was calculated as follows, BVI = [A / (A + B)] x 100, where A and B represent the radioactivities corresponding to intact and degraded GAPDH mRNA bands, respectively. In the hypothermic ischaemic insult group, BVIs were comparable to those of controls. However, in the 3-hour hypothermic ischaemia/reperfusion group, BVI was lower than that of the controls. Likewise, there was a significant difference between the 6-hour ischaemia/reperfusion group and controls. These results showed that bone viability decreased even after just a 3-hour hypothermic ischaemia/reperfusion.
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Risk and Protective Factors for Middle- and Long-Distance Running-Related Injury
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DoD PRF (Psychosocial RF)
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BACKGROUND: Despite a rapidly growing body of research, a systematic evidence compilation of the risk and protective factors for middle- and long-distance running-related injury (RRI) was lacking. OBJECTIVES: Our objective was to compile the evidence about modifiable and non-modifiable training-related and behavioral risk and protective factors for middle- and long-distance RRI. METHODS: We searched five databases (PubMed, CINAHL, MEDLINE, SPORTDiscus, and PsycINFO) for the dates 1 January 1970 to 31 December 2015, inclusive, for original peer-reviewed articles. The eligible designs were cross-sectional, case-control, longitudinal observational studies, and randomized controlled trials involving runners competing at distances from â?¥800Â m to â?¤42.2Â km. Outcomes were any specific and/or general RRI, and exposures included training-related and behavioral factors. We extracted authors and date, study design, injury type(s), descriptors and comparators for each exposure, and results and measures of association from the selected studies. Methodological quality was independently appraised using two separate checklists: a modified checklist for observational study designs and the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials. RESULTS: Among 73 articles eligible for inclusion, 19 (26.0%) and 30 (41.0%) were of high or satisfactory methodological quality, respectively. As a non-modifiable exposure, a history of previous injury was found to be associated with an increased risk of both general and specific RRI. In terms of modifiable exposures, irregular and/or absent menstruation was found to be associated with an increased risk of stress fracture development, whereas the use of oral contraceptives was found to be associated with a decreased risk. High clinical, methodological, and statistical heterogeneity meant it was not feasible to estimate a pooled effect size across similar studies. CONCLUSIONS: A history of previous injury was associated with an increased risk of both general and specific RRI. The use of oral contraceptives was found to be associated with a decreased risk of skeletal stress fracture. Conversely, irregular and/or absent menstruation was associated with an increased risk. The varied effect directions and/or a number of statistically insignificant results associated with the majority of factors hindered our ability to draw any definitive conclusions about their relationship to RRI risk.
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Thematic evidence of psychosocial thriving in childhood cancer survivors
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DoD PRF (Psychosocial RF)
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Advances in medical treatment for childhood cancer have resulted in dramatically increased survival rates and a growing population of long-term survivors. Until recently, researchers reported primarily negative psychosocial sequelae of childhood cancer. Emergent conceptual frameworks propose that the assumption of pathology or long-term deficits in functioning might obscure an understanding of the full range of outcomes. Using qualitative interview data (N = 50), the authors explore how cancer can lead to positive psychosocial outcomes, including thriving. The findings suggest that processes of coping, meaning making, and psychospiritual growth are intimately related to long-term psychosocial well-being. The results suggest that in the aftermath of a trauma such as childhood cancer, many outcomes are possible, including thriving.
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Clinical outcomes of conjunctiva-Müller muscle resection: association with phenylephrine test-negative blepharoptosis and dry eye syndrome
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Upper Eyelid and Brow Surgery
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OBJECTIVE: The aim of this study was to investigate the clinical outcomes of conjunctiva-Müller muscle resection (CMMR) in patients with mild to moderate ptosis, the factors related to successful procedures, and the influence of CMMR on dry eye symptoms and signs. METHODS: In a tertiary university hospital, the medical records of 30 patients who had CMMR were retrospectively reviewed, including the detailed preoperative and postoperative eyelid measurements, surgical outcomes, and dry eye evaluations. Inclusion criteria included older than 18 years, acquired ptosis, and no previous eyelid surgery or trauma. RESULTS: The surgery had a success rate of 86.7%. In the patients who responded to phenylephrine application with a marginal reflex distance 1 (MRD1) increase of more than 2 mm, the postoperative MRD1 correction was 2.41 ± 0.84 mm, whereas the postoperative MRD1 correction was 1.19 ± 0.78 mm in the group with responses of less than 2 mm. The postoperative MRD1 correction was 1.21 ± 0.80 mm in the group with a negative response. Seven patients complained of dry eye symptoms and showed a transiently significant aggravation in the Schirmer test and ocular surface disease index score after the procedure, which normalized within 2 months postoperatively. CONCLUSIONS: Responsiveness to phenylephrine is directly correlated with the postoperative results. Nevertheless, even in the patients with negative phenylephrine response, some degree of eyelid elevation can be expected. Damage to goblet cells after the procedure may result in defective tear production, leading to transient aggravation of dry eye symptoms.
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Examination of displaced acetabular fractures in adults treated qith open reduction and internal fixation
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Hip Fx in the Elderly 2019
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Background: The occurrence of acetabular fractures is growing at a fast pace globally owing to increased crashes in train and highway traffic and high-speed injuries. The incidence of acetabular fractures is growing at a fast pace globally owing to increased crashes in train and highway traffic and high-speed injuries. Method: Included in the research were 30 individuals between 18 and 60 years of age with locked displaced acetabular bones. Depending on the type of fracture, a single surgical approach such as the Kocher-Langenbeck, the ilio-inguinal, and the extended ilio-femoral approach was selected, with the expectation that fracture reduction and fixation could be fully accomplished by the one approach. Results: Of the 30 individuals, 12 were between the ages of 21-30 and 10 were between the ages of 31-40 and most were men engaged in road traffic accidents. The right-hand predominance was seen in 22 (73.33 percent) and left-sided injuries in 8 (26.66 percent). Fractures of the posterior wall were observed in 5 instances, while in 4 instances the transverse was observed. In 8 patients, combinations of both were observed. In more than 56 percent of studies, the results were outstanding and satisfactory in more than 30 percent of them. Conclusions: For a stronger knowledge of long-term outcomes, the current research requires further follow-up.
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Current concepts in the surgical management of acute diabetic foot infections
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DoD LSA (Limb Salvage vs Amputation)
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Diabetic foot complications are common, costly, and difficult to treat. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common reasons that lead to ulcers, infection, and hospitalization. Individuals with diabetes presenting with foot infection require optimal medical and surgical management to accomplish limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. Multiple classification systems have been recommended to ease the understanding and the management of these infections. Multi-disciplinary approach is the mainstay for a successful management. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health care systems. This article is an overview in how to medically and surgically approach the diabetic foot infection with emphasis in soft tissue infection.
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Surgical management of posttraumatic elbow arthrofibrosis
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Distal Radius Fractures
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BACKGROUND: Functional loss of motion is a frequent complication after elbow trauma. The purpose of this study was to determine the effectiveness of open elbow release in restoring functional elbow motion.
METHODS: A retrospective chart review of 177 adult patients who underwent open elbow release at our institution by the senior surgeon (D.P.H.) from 2003 to 2010 was performed. Seventy-seven of the elbow contracture releases were performed for posttraumatic elbow stiffness, with loss of flexion-extension. Burns and isolated proximal radioulnar exostosis resections were excluded. The mean age of patients was 45 years (range, 20-76 years), with 68 patients demonstrating radiographic evidence of heterotopic ossification (HO). The mean preoperative flexion-extension arc was 51 degrees. All patients were treated with the same surgical protocol, which included circumferential elbow capsulectomy, HO excision, hardware removal, and ulnar nerve neurolysis with submuscular anterior transposition.
RESULTS: At a mean follow-up of 12 months (range, 3-56 months), the mean elbow flexion-extension arc was 109 degrees representing a mean gain of 58 degrees. Sixty-nine percent (53 of 77 patients) achieved a minimum 100-degree functional elbow arc of motion. Six patients (8%) developed recurrent HO, with four undergoing secondary HO excision. One additional patient required manipulation under anesthesia in the early postoperative period. Complications included five infections, one postoperative fracture, one postoperative hematoma, and one radial head implant loosening.
CONCLUSION: Open elbow contracture release and HO excision is an effective means of restoring functional elbow range of motion with a low complication rate. Furthermore, recurrent HO formation and elbow arthrofibrosis respond well to repeat surgical excision and contracture release.
LEVEL OF EVIDENCE: IV, therapeutic study.
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The role of S100P in the invasion of pancreatic cancer cells is mediated through cytoskeletal changes and regulation of cathepsin D
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MSTS 2018 - Femur Mets and MM
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Up-regulation of S100P, a member of the S100 calcium-binding protein family, is an early molecular event in the development of pancreatic cancer and it is expressed at high levels in both precursor lesions and invasive cancer. To gain more insight into the molecular mechanisms underlying the functional roles of this protein, we stably overexpressed S100P in the Panc1 pancreatic cancer cell line and identified the consequent changes in global protein expression by two-dimensional difference in-gel electrophoresis. The observed changes in target proteins were confirmed by Western blot analysis and immunofluorescence, whereas their functional effect was investigated using motility and invasion assays. In this study, we have shown that overexpression of S100P led to changes in the expression levels of several cytoskeletal proteins, including cytokeratins 8, 18, and 19. We have also shown disorganization of the actin cytoskeleton network and changes in the phosphorylation status of the actin regulatory protein cofilin. Additionally, we have shown that overexpression of S100P leads to increased expression of another early pancreatic cancer marker, S100A6, as well as the aspartic protease cathepsin D, both of which are involved in cellular invasion. Functional studies showed that the increased invasive potential of S100P-overexpressing cells was at least partially due to the increase in cathepsin D expression. In summary, our data suggest that these changes could contribute to the metastatic spread of pancreatic cancer and may explain the devastating prognosis of this disease.
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(untitled)
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OAK 3 - Non-arthroplasty tx of OAK
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This Future Research Needs (FRN) project is a followup to the draft Comparative Effectiveness Review (CER) "Physical Therapy Interventions for Knee Pain Secondary to Osteoarthritis." The review was motivated by uncertainty around the effectiveness and comparative effectiveness of physical therapy (PT) treatments for adult patients with knee pain secondary to osteoarthritis (OA). The purpose of this FRN project is to identify and prioritize specific gaps in the current literature on PT for knee pain due to OA that would aid decisionmakers. We used a deliberative process to identify evidence gaps, translate gaps into researchable questions, and solicit stakeholder opinion on the importance of research questions. This report proposes specific research needs along with research design considerations that may be useful in advancing the field.
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Autologous Costal Cartilage Grafting for a Large Osteochondral Lesion of the Femoral Head: A 1-Year Single-Arm Study with 2 Additional Years of Follow-up
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Osteochondritis Dissecans 2020 Review
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BACKGROUND: There is currently no ideal treatment for osteochondral lesions of the femoral head (OLFH) in young patients. METHODS: We performed a 1-year single-arm study and 2 additional years of follow-up of patients with a large (defined as >3 cm 2 ) OLFH treated with insertion of autologous costal cartilage graft (ACCG) to restore femoral head congruity after lesion debridement. Twenty patients =40 years old who had substantial hip pain and/or dysfunction after nonoperative treatment were enrolled at a single center. The primary outcome was the change in Harris hip score (HHS) from baseline to 12 months postoperatively. Secondary outcomes included the EuroQol visual analogue scale (EQ VAS), hip joint space width, subchondral integrity on computed tomography scanning, repair tissue status evaluated with the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score, and evaluation of cartilage biochemistry by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and T2 mapping. RESULTS: All 20 enrolled patients (31.02 ± 7.19 years old, 8 female and 12 male) completed the initial study and the 2 years of additional follow-up. The HHS improved from 61.89 ± 6.47 at baseline to 89.23 ± 2.62 at 12 months and 94.79 ± 2.72 at 36 months. The EQ VAS increased by 17.00 ± 8.77 at 12 months and by 21.70 ± 7.99 at 36 months (p < 0.001 for both). Complete integration of the ACCG with the bone was observed by 12 months in all 20 patients. The median MOCART score was 85 (interquartile range [IQR], 75 to 95) at 12 months and 75 (IQR, 65 to 85) at the last follow-up (range, 24 to 38 months). The ACCG demonstrated magnetic resonance properties very similar to hyaline cartilage; the median ratio between the relaxation times of the ACCG and recipient cartilage was 0.95 (IQR, 0.90 to 0.99) at 12 months and 0.97 (IQR, 0.92 to 1.00) at the last follow-up. CONCLUSIONS: ACCG is a feasible method for improving hip function and quality of life for at least 3 years in young patients who were unsatisfied with nonoperative treatment of an OLFH. Promising long-term outcomes may be possible because of the good integration between the recipient femoral head and the implanted ACCG. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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The reduction of radiation mucositis by selective decontamination antibiotic pastilles: a placebo-controlled double-blind trial
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The aim of this study was to see if antibiotic pastilles could reduce radiation mucositis, pain, dysphagia and weight loss in patients undergoing radical radiotherapy for head and neck cancer. A total of 275 patients with T1-T4 tumours entered the study; 136 were allocated to suck four times daily a pastille containing amphotericin, polymyxin and tobramycin. The remaining 139 patients received an identical placebo. In all, 54 patients were unevaluable (24 active, 30 placebo). Bacteriological monitoring was carried out before and twice weekly during treatment. Both arms of the study were well balanced for T and N stage, age, sex and radiation dose (60 Gy). There was a slight imbalance in the site of disease which had no substantive effect on the results. The primary study end point was the percentage of patients who developed intermediate or thick pseudomembranes. No statistically significant difference was found in this end point, with 36% of patients in the active arm developing this type of membrane compared with 48% in the placebo arm (P = 0.118). The estimated odds ratio (placebo/active) of developing an intermediate or thick pseudomembrane was 1.59 (95% CI 0.89-2.82). However a more sensitive test comparing the worst recorded mucositis grade between the two arms was statistically significant (P = 0.009). This indicated that the active pastilles had a beneficial effect, but the magnitude was probably smaller than the trial was designed to detect. There was a reduction in mucositis distribution (P = 0.002), mucositis area (P = 0.028), dysphagia (P = 0.006) and weight loss (P = 0.009) in the active arm. There was a clear tendency for patients with positive cultures for aerobic Gram-negative bacteria (AGNB) (P = 0.003) and yeasts (P = 0.026) during treatment to have more severe mucositis. The active pastilles reduced the percentage of patients with yeast cultures (P = 0.003) but had less effect on AGNB. The benefit derived from the pastilles should materially increase patient tolerance to radical radiotherapy for head and neck cancer
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Primary lesions that may imitate metastatic tumors histologically: A selective review
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MSTS 2022 - Metastatic Disease of the Humerus
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Several primary pathologic entities in diverse anatomic locations have the potential to simulate metastatic neoplasms histologically. Their misinterpretation as such may result in needless and extensive clinical evaluations that are intended to detect a presumed malignancy at another site. More importantly, mistakes of this type can deprive patients of surgical excisions that could be curative. This presentation considers a review of selected primary lesions that can simulate metastases. They include hemangioblastoma, glioblastoma and meningioma with epithelial metaplasia, choroid plexus carcinomas, primary neuroendocrine carcinomas in unusual locations, special forms of sinonasal and salivary glandular adenocarcinoma, clear-cell thyroid carcinomas, unusual microscopic subtypes of pulmonary adenocarcinoma, epithelioid myomelanocytomas ("sugar tumors"), mesotheliomas, primary thymic carcinomas, endodermal choristomas of the interatrial myocardium, peripheral cholangiocarcinoma, adrenocortical carcinoma, adenocarcinomas of the urinary bladder, mucinous and "rhabdoid" tumors of the ovaries, rete testis adenocarcinomas, interdigitating dendritic-cell sarcoma of lymph nodes, selected sweat gland carcinomas, cutaneous Merkel cell carcinoma, primary dermal and subcutaneous melanoma, mucosal and visceral melanomas, epithelioid sarcoma, clear-cell sarcoma, and adamantinoma of long bones. Differential diagnostic observations are emphasized in reference to those lesions.
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Cross-sectional area of the median nerve characterized by ultrasound in patients with carpal tunnel syndrome before and after the release of the transverse carpal ligament
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The objective of this study was to evaluate the cross-sectional area of the median nerve by ultrasonography before and after release of the transverse carpal ligament in patients with carpal tunnel syndrome. An additional goal was to correlate the cross-sectional area following surgery with clinical symptoms. Eighteen patients and 22 wrists were evaluated. All patients underwent Paine's surgical technique for release of the transverse ligament. Cross-sectional area was calculated from sonograms taken at the pisiform bone level pre- and postsurgery. Postsurgical measurements were made at 4, 8, 12, and 96 weeks. Before surgery, the mean cross-sectional area was 19.7 mm2. The results following surgery were as follows: 4 weeks, 20.1 mm2; 8 weeks, 17.4 mm2; 12 weeks, 15.5 mm2; and 96 weeks, 13.5 mm2. Three patients remained clinically symptomatic at the time of their last follow-up visit. Cross-sectional area of the median nerve tends to increase 4 weeks after surgery for carpal tunnel syndrome, compared with the measurements taken prior to surgery, and then progressively decreases. There was no evidence of postprocedure correlation between the cross-sectional area of the median nerve and clinical symptoms. (copyright) The Author(s) 2013
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Results of treatment of displaced supracondylar humeral fractures in children by percutaneous lateral cross-wiring technique
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Seventy children with displaced type II and III supracondylar fractures of the humerus were managed with percutaneous lateral cross-wiring technique from January 2006 to January 2007. There were 54 boys and 16 girls with a mean age of 6.1 +/- 3.07 years. All patients were operated within 24 h after trauma using the Dorgans percutaneous lateral cross-wiring technique. Patients were followed up for a mean period of 6.1 +/- 2.6 months and assessed both radiologically for union; and functionally and cosmetically according to Flynn's criteria. All patients achieved solid union. Functionally, all patients achieved satisfactory results, while cosmetically, 91.4% of patients had satisfactory results and 8.6% had unsatisfactory results. The most frequently occurring complications were minor pin tract infection in six patients, deep infection in two patients, and 32 patients suffered excessive granulation tissue formation mostly around the proximal pin. There was no iatrogenic neurological injury either for the ulnar or for the radial nerves. The obtained results and minor complications reported signify this technique as a viable treatment method for displaced type II and III supracondylar fractures in children
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Dislocation/subluxation of meniscal bearing elements after New Jersey low-contact stress total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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From October 1985 to April 1986, 43 consecutive New Jersey low-contact stress total knee arthroplasties (TKAs) were performed for degenerative arthritis of the knee. At the one-year follow-up examination, 91% of the patients had good to excellent results based on the Hospital for Special Surgery scoring system. Four patients, however, sustained dislocation/subluxation of the meniscal bearing elements. Three of these occurred within 13 days postoperatively, and one patient sustained a dislocation at six months postoperatively. These four patients were treated with revision TKA. Despite following the precise technique in performance of this procedure, a 9.3% incidence of dislocation/subluxation of the meniscal bearing elements occurred
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Reduction in daily hydrocortisone dose improves bone health in primary adrenal insufficiency
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AAHKS (2) Corticosteroids
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OBJECTIVE: Individuals with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) receive life-long glucocorticoid (GC) replacement therapy. Current daily GC doses are still higher than the reported adrenal cortisol production rate. This GC excess could result in long-term morbidities such as osteoporosis. No prospective trials have investigated the long-term effect of GC dose changes in PAI and CAH patients.
METHODS: This is a prospective and longitudinal study including 57 subjects with PAI (42 women) and 33 with CAH (21 women). Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry at baseline and after 2 years. Subjects were divided into three groups (similar baseline characteristics) depending on changes in daily hydrocortisone equivalent dose (group 1: unchanged 25.2+/-8.2 mg (mean+/-S.D., n=50); group 2: increased 18.7+/-10.3 to 25.9+/-12.0 mg (n=13); group 3: decreased 30.8+/-8.5 to 21.4+/-7.2 mg (n=27)).
RESULTS: Subjects in group 1 showed normal lumbar and femoral Z-scores which were unchanged over time. Group 2 subjects showed a significant decrease in femoral neck Z-scores over time (-0.15+/-1.1 to -0.37+/-1.0 (P<0.05)), whereas group 3 subjects showed a significant increase in lumbar spine and hip Z-scores (L1-L4: -0.93+/-1.2 to -0.65+/-1.5 (P<0.05); total hip: -0.40+/-1.0 to -0.28+/-1.0 (P<0.05)). No changes in BMI over time were seen within any group. Reduction in GC dose did not increase the risk of adrenal crisis.
CONCLUSION: This study demonstrates for the first time that cautious reduction in hydrocortisone equivalent doses leads to increases in BMD, whereas dose increments reduced BMD. These data emphasize the need for the lowest possible GC replacement dose in AI patients to maintain health and avoid long-term adverse effects.
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The cost of treating osteoporotic fractures in the United Kingdom female population
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HipFx Supplemental Cost Analysis
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Osteoporotic fractures represent a significant burden to society. The costs of osteoporotic fractures to the UK health care system have not previously been accurately described. In this paper, we quantify the health care and social care costs of fractures occurring in women aged 50 years and over in the UK. We used a variety of data sources. For acute hospital hip fracture costs existing published estimates were used whilst for social care costs a survey of resource use among fracture patients before and after hip fracture was utilized. We undertook a case-control study using the General Practice Research Database to estimate primary care costs. From these data we estimated that the cost of a hip fracture is about 12,000 Pounds, with non-acute hospital costs representing the larger proportion. The other fractures were less expensive, at 468 Pounds, 479 Pounds and 1338 Pounds for wrist, vertebral and other fractures, respectively. For all fractures the annual cost to the UK is 727 million Pounds. Assuming each male hip fracture costs the same as a female fracture, including these would increase the total costs to 942 million Pounds
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Discoid lateral meniscus incidence during knee arthroscopy
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AMP (Acute Meniscal Pathology)
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Discoid meniscus is a morphological anomaly of the lateral meniscus that appears in 1-5% of meniscectomies. A precise diagnosis remains diffi cult to make, and many dilemmas hinder eff ective treatment. To evaluate the incidence of discoid meniscus in patients who underwent knee arthroscopy, as well as the discoid meniscus type, follow-up problems, combined knee lesions, and postoperative results. T is retrospective study included 1357 patients who received knee arthroscopy during the period between January 2007 and December 2013. We analysed the discoid meniscus incidence, sex distribution, type distribution (Monllau classifi cation), noted preoperative symptomatology, rupture incidence and type (O’Connor classifi cation), anomaly presence and other intra-articular lesion correlations. The IKDC score was used to evaluate the operative treatment results. The DLM incidence was 1.03%. The most common type of discoid meniscus was complete 5 (35.71%). The dominant symptom was pain, which was reported by 12 (85.71%) patients. Eleven (78.57%) patients exhibited ruptures, and the most common type was horizontal, which was reported in 4 (36.36%) cases. The number of ruptures was signifi cantly higher in patients older than 18 (9 patients; 90%), compared to those younger than 18 (2 patients; 40%). Operative treatment resulted in an improvement for all patients in terms of subjective symptom reduction. The incidence of DLM in our study was 1.03%, and the dominant symptom was pain in the knee (85.71%). The most common lesion of the meniscus was a horizontal split, primarily in patients older than 18 years. Patients also presented with joint intra-articular lesions; the most common type was ACL rupture. In all patients, an improved postoperative IKDC score was reported.
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Biomechanics of Lower Limbs during Walking among Candidates for Total Knee Arthroplasty with and without Low Back Pain
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OAK 3 - Non-arthroplasty tx of OAK
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The effect of joint pathologies, such as unilateral knee osteoarthritis (UKOA) or low back pain (LBP), on bilateral gait symmetry has gained increased attention during the past decade. This study is the first to compare gait patterns between patients with UKOA and LBP in combination and with UKOA only. Temporal, kinematic, and kinetic variables were measured bilaterally during gait stance phase in 31 subjects with UKOA and LBP (Group I) and 11 subjects with only UKOA (Group II). Group I patients exhibited less hip rotation in the affected limb (A) than in the nonaffected (NA) limb during walking in contrast to Group II patients. Group I patients had minimal bilateral differences in hip abduction and flexion, but Group II patients displayed significantly larger values in the NA limb compared to the A limb for both parameters. Hip flexion patterns were significantly different between Groups I and II. Subjects in both groups adapted gait patterns that minimized vertical ground reaction force, knee flexion motion, and stance time on the UKOA affected limb. The distinct kinematic gait patterns that were revealed in this study may provide clinical value for assessment of patients with UKOA in conjunction with LBP.
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The effect of body mass index on the risk of post-operative complications during the 6 months following total hip replacement or total knee replacement surgery
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PJI DX Updated Search
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OBJECTIVE: To assess the effect of obesity on 6-month post-operative complications following total knee (TKR) or hip (THR) replacement. DESIGN: Data for patients undergoing first THR or TKR between 1995 and 2011 was taken from the Clinical Practice Research Datalink. Logistic regression was used to assess whether body mass index (BMI) was associated with 6-month post-operative complications [deep vein thrombosis or pulmonary embolism (DVT/PE), myocardial infarction (MI), stroke, respiratory infection, anaemia, wound infection, urinary tract infection or death] after controlling for the effects of age, gender, smoking, drinking, socio-economic status (SES), co-morbidities and medications. RESULTS: 31,817 THR patients and 32,485 TKR patients were identified for inclusion. Increasing BMI was associated with a significantly higher risk of wound infections, from 1.6% to 3.5% in THR patients (adjusted P < 0.01), and from 3% to 4.1% (adjusted P < 0.05) in TKR patients. DVT/PE risk also increased with obesity from 2.2% to 3.3% (adjusted P < 0.01) in THR patients and from 2.0% to 3.3% (adjusted P < 0.01) in TKR patients. Obesity was not associated with increased risk of other complications. CONCLUSION: Whilst an increased risk of wound infection and DVT/PE was observed amongst obese patients, absolute risks remain low and no such association was observed for MI, stroke and mortality. However this is a selected cohort (eligible for surgery according to judgement of NHS GPs and surgeons) and as such these results do not advocate surgery be given without consideration of BMI, but indicate that universal denial of surgery based on BMI is unwarranted
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Platelet-Rich Plasma Versus Corticosteroid Injections for the Treatment of Recalcitrant Lateral Epicondylitis: A Cost-Effectiveness Markov Decision Analysis
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PRPs for Lateral Epicondylitis/Elbow Tendinopathies
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BACKGROUND: Both platelet-rich plasma (PRP) and corticosteroid injections may be used to treat lateral epicondylitis. We evaluated the cost-effectiveness of PRP injections versus corticosteroid injections for the treatment of recalcitrant lateral epicondylitis.
METHODS: Markov modeling was used to analyze the base-case 45-year-old patient with recalcitrant lateral epicondylitis, unresponsive to conservative measures, treated with a single injection of PRP or triamcinolone 40mg/mL. Transition probabilities were derived from randomized controlled trials, quality-of-life (QOL) values from the Tufts University Cost-Effectiveness Analysis Registry reported using Disabilities of the Arm, Shoulder and Hand (DASH) scores, and costs from institution financial records. Analyses were performed from healthcare and societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICER), reported as United States Dollars/quality-adjusted-life-years (USD/QALY) and net monetary benefits (NMB) to represent the values of an intervention in monetary terms. Willingness-to-pay thresholds were set at $50,000 and $100,000. Deterministic and probabilistic sensitivity analyses were performed over 10,000 iterations.
RESULTS: Both PRP and triamcinolone 40mg/mL injections were considered cost-effective interventions from a healthcare and societal perspective below the WTP threshold of $50,000. From a healthcare perspective, PRP injections were dominant compared to triamcinolone 40mg/mL injections, with an ICER of -$5,846.97/QALY. PRP injections provided a NMB of $217,863.98, while triamcinolone 40mg/mL provided a NMB of $197,534.18. From a societal perspective, PRP injections were dominant compared to triamcinolone 40mg/mL injections, with an ICER of -$9,392.33/QALY. PRP injections provided a NMB of $214,820.16, while triamcinolone 40mg/mL provided a NMB of $193,199.75.
CONCLUSIONS: Both PRP and triamcinolone 40mg/mL injections provided cost-effective treatments from healthcare and societal perspectives. Overall, PRP injections were the dominant treatment with the greatest NMB for recalcitrant lateral epicondylitis over the time horizon of five years.
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The Northwestern Abdominoplasty Scar Model: A Novel Human Model for Scar Research and Therapeutics
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Panniculectomy & Abdominoplasty CPG
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There is a growing interest in the development and evaluation of therapeutic agents that improve the cosmetic appearance of scars. Existing nonhuman animal models to study scarring, while valuable, have well-acknowledged limitations, as it is accepted that the biology of human scarring differs significantly from scarring in other species. Moreover, human clinical trials of scarring require large numbers of subjects to achieve statistical power and are plagued by inherent intersubject variability because of the complex nature of wound healing in human beings. As a better alternative, we have developed the Northwestern Abdominoplasty Scar Model-a novel human clinical model that permits analysis of up to 20 cutaneous scars in a single subject and allows for not only visual scar comparison, but also histologic and molecular analyses of factors involved in scarring and wound healing. We have utilized this model in 5 early phase clinical trials designed to test the safety and efficacy of a variety of scar therapeutics without any complications to date. The model not only is applicable to scar therapeutics, but also can be utilized for other applications, such as the testing of implantable biomaterials, injectable products, therapies such as lasers, or even for in vivo study of wound healing processes in humans.
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Risedronate sodium therapy for prevention of hip fracture in men 65 years or older after stroke
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Management of Hip Fractures in the Elderly
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BACKGROUND: There is a high incidence of hip fractures in patients after hemiplegic stroke. Bone mineral density is decreased on the hemiplegic side in patients after stroke, correlating with the immobilization-induced bone resorption, the degree of paralysis, and hypovitaminosis D. The purpose of this study is to evaluate the effectiveness of risedronate sodium, an inhibitor of bone resorption, on osteoporosis and the risk of hip fractures in men 65 years or older after stroke. METHODS: We conducted an 18-month randomized double-blind trial. Of 280 male patients 65 years or older who were poststroke, 140 received a daily dose of 2.5 mg risedronate sodium and the other 140 received placebo. Incidence of hip fractures in the 2 groups was compared. RESULTS: Ten patients sustained hip fractures in the placebo group, and 2 hip fractures occurred in the risedronate group. The relative risk of a hip fracture was 0.19 (95% confidence interval, 0.04-0.89). The number of patients needing the treatment was 16 (95% confidence interval, 9-32). Bone mineral density increased by 2.5% in the risedronate group and decreased by 3.5% in the placebo group (P<.001). Urinary deoxypyridinoline, a bone resorption marker, decreased by 58.7% in the risedronate group and by 37.2% in the placebo group. CONCLUSION: Treatment with risedronate increases bone mineral density and reduces hip fractures in elderly men who are poststroke
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Effect of lower limb malalignment in the frontal plane on transverse plane mechanics during gait in young individuals with varus knee alignment
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Varus knee alignment has been identified as a risk factor for the progression of medial knee osteoarthritis (OA). This study tested the hypothesis that not only frontal plane kinematics and kinetics but also transverse plane lower extremity mechanics during gait are affected by varus malalignment of the knee. Methods: Eighteen, otherwise healthy children and adolescents with varus malalignment of the knee were studied to examine the association between static varus malalignment and functional gait parameters. Kinematic data were collected using a Vicon motion capture system (Vicon Motion Systems, Oxford, UK). Two AMTI force plates (Advanced Mechanical Technology, Inc., Watertown, MA, USA) were used to collect kinetic data. Results: The results indicated that changes in transverse plane mechanics occur concomitantly with changes in knee malalignment in the frontal plane. A mechanical consequence of varus knee malalignment is obviously an increased endorotation of the foot (internal foot placement) and an increased internal knee rotation (tibia rotation) during stance phase. The linear correlation between the maximum external knee adduction moment in terminal stance and the internal knee rotation in terminal stance ( r= 0.823, p<. 0.001) shows that this transverse plane gait mechanics is directly in conjunction with intrinsic compressive load on the medial compartment during gait. Conclusions: Understanding factors that influence dynamic knee joint loading in healthy, varus malaligned knees may help us to identify risk factors that lead to OA. Thus, three-dimensional gait analysis could be used for clinical prognoses regarding the onset or progression of medial knee OA. © 2014 Elsevier B.V.
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Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Displaced paediatric supracondylar humeral fractures pose a significant risk of neurovascular injury and consequently have traditionally been treated as a surgical emergency. Recently, the need for emergency surgery has been questioned. We wished to analyse our experience at a large UK tertiary paediatric trauma centre.
METHODS: A retrospective case note review was performed on patients with Gartland Grades 2 and 3 supracondylar fractures observed in a 2-year period from July 2008 to July 2010. We divided children into those treated before 12 h (early surgery) and after 12 h (delayed surgery). Analysis was undertaken using Fisher's exact test.
RESULTS: Of the 137 patients, 115 were included in the study; median time-to-surgery was 15:30 (range 2:45-62:50); thirty-nine children were treated before 12 h and 76 patients after. In the early surgery group, three children (7.7%) developed a superficial pin-site infection, four children (10.3%) required open reduction, five children (12.8%) sustained an iatrogenic nerve injury, and two children (5%) required reoperation. In the delayed surgery group, one child (1.3%) had a superficial pin-site infection, four children (5.3%) required open reduction, seven children (9.2%) sustained an iatrogenic nerve injury, and two children (2.6%) reoperation. Bivariate analysis of our data using Fisher's exact t test revealed no statistically significant difference between early and delayed surgery groups with regard to infection rates (p = 0.1), iatrogenic nerve injury (p = 0.53) or need for open reduction (p = 0.44).
CONCLUSION: Our results indicate that delayed surgery appears to offer a safe management approach in the treatment of displaced supracondylar fractures, but it is important that cases are carefully evaluated on an individual basis. These results indicate that patient transfer to a specialist paediatric centre, often with consequent surgical delay, is a safe management option and also negates the obligation to carry out these procedures at night.
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Long-term results of hybrid alumina-on-alumina total hip arthroplasty: 10-14-Year results
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Hip Fx in the Elderly 2019
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Between 2000 and 2004, 89 hybrid alumina-on-alumina hip replacements were performed by a single surgeon. There were 46 men and 43 women with an average age of 51 years. All patients were followed up for a minimum of 10 years. Prior to surgery, the mean Harris hip score (HHS) was 44 points (35-55). Following surgery, the HHS improved to an average of 94 points (87-100). There was no significant decline in pain and function even into the second decade following hip replacement. At final follow-up, the average UCLA activity score was 7.3 (range: 3-10). No osteolysis was observed at a mean radiographic follow-up of 123 months. One patient (2 hips) required revision surgery for bilateral femoral component loosening at 11.2 years and 11.9 years, respectively. There were no cases of ceramic fractures or squeaking in this series. Survivorship at 13.5 years with implant revision for any reason as the end point was 96.2%. Consequently, hybrid alumina-on-alumina total hip arthroplasty in this series provided reliable and durable and functioned well into the second decade with low wear rates and high survivorship. © 2014 Elsevier Inc.
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The need for multi-disciplinary management of combined orthopaedic and genito-urinary injuries
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DoD SSI (Surgical Site Infections)
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Introduction: Combined pelvic ring disruptions and genito-urinary injuries can be potentially devastating. An array of debilitating and lifelong complications can result from such injuries. Early and expert management of patients presenting with these injuries is therefore imperative to minimise the risk of complications developing. Materials and methods: We present the case histories of six patients referred to the trauma-orthopaedic service in our institution over a six-month period. Each had a combination of bony pelvic and genito-urinary injuries. One patient presented primarily to the reporting hospital, the other five were tertiary referrals. Results: Four patients were admitted under the combined care of the trauma-orthopaedic team and the genito-urinary team in our institution within 24 h of their injuries. All of these patients had their primary orthopaedic and genito-urinary injuries addressed or fixed at or within 9 days. The other two patients experienced significant delays in their transfer. In the former group, three went on to enjoy largely uneventful recoveries with no long-term sequelae. Both patients in the latter category endured difficult and complicated recoveries. Discussion: This paper illustrates the complicated nature of injuries in these patients and highlights the importance of early and adequate diagnosis and treatment. A multi-disciplinary approach in a suitable centre of expertise should be adopted for the care of patients with fractures of the pelvic ring and genito-urinary injuries. © 2009 Springer-Verlag.
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An uncemented iso-elastic monoblock acetabular component: Preliminary results
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DoD SSI (Surgical Site Infections)
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Little is known about the clinical application of highly cross-linked polyethylene (HXLPE) blended with vitamin E. This study evaluates an uncemented iso-elastic monoblock cup with vitamin E blended HXLPE. 112 patients were followed up for 2. years. 95.5% completed the follow-up. The mean VAS score for patient satisfaction was 8.8 and the mean Harris Hip Score was 94.2. In 7 cases initial gaps behind the cup were observed, which disappeared completely during follow-up in 6 cases. The mean femoral head penetration rate was 0.055. mm/year. No adverse reactions or abnormal mechanical behavior was observed with the short term use of vitamin E blended HXLPE. This study shows the promising performance of this cup and confirms the potential of vitamin E blended HXLPE.
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A comparison of the lidocaine patch 5% vs naproxen 500 mg twice daily for the relief of pain associated with carpal tunnel syndrome: a 6-week, randomized, parallel-group study
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVES: Carpal tunnel syndrome (CTS) is a common entrapment neuropathy caused by median nerve compression. This pilot clinical trial was designed to compare the safety and effectiveness of the lidocaine patch 5% to that of naproxen 500 mg twice daily for the treatment of neuropathic pain associated with CTS. METHODS: In this 6-week, randomized, parallel-group, open-label, multicenter study, participants from 2 practice sites, aged 18 to 75 years with clinical/electrodiagnostic evidence of CTS, were randomized to receive up to 3 lidocaine 5% patches every 24 hours or naproxen 500 mg twice daily for 6 weeks. Outcome assessments included mean changes between baseline and Week 6 average pain intensity (Brief Pain Inventory [BPI]: Question 5, Average Pain Intensity [API]), an Investigator Clinical Global Impression of Improvement (CGI-I) over the course of the treatment period and a comparison of patient satisfaction (Clinical Global Assessment of Treatment [CGAT]). RESULTS: One hundred patients were randomized in this study, 52 in the lidocaine patch 5% group and 48 in the naproxen 500 mg twice daily group. Significant reductions in API scores were observed between baseline and Week 6 for both lidocaine patch 5% (P < .0001) and naproxen 500 mg twice daily (P = .0004); however, there were no statistically significant differences between treatments (P = .083). There was a significant (P = .016) difference in the CGI-I for lidocaine patch 5% (51.1%) compared with naproxen 500 mg twice daily (24.3%). Whereas 71.8% of the lidocaine patch 5% patients reported being "satisfied" to "very satisfied" with the treatment, only 63.2% of naproxen 500 mg twice daily patients reported likewise, although the difference was not statistically significant. Both treatments were well tolerated. Two patients reported treatment-related adverse events in the lidocaine patch 5% group and 6 in the naproxen 500 mg twice daily group, all of which were considered mild or moderate in severity. CONCLUSIONS: This study demonstrates that the lidocaine patch 5% is effective in significantly relieving the pain associated with CTS and is well tolerated. The patch may offer patients an effective, nonsystemic, noninvasive treatment for the management of their symptoms. Further controlled studies are warranted
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[Evaluation of the hip joint after Kee-Farrar total hip arthroplasty from the aspect of certain clinical biomechanical criteria]
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Management of Hip Fractures in the Elderly
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Hundred hips in 84 arthritic patients after Mc Kee-Farrar total hip arthroplasty were reviewed. Biomechanical measurements in operated, arthritic non-operated and normal hips were compared. The moment of adductive forces, adductive forces, the strength of abductors, Hamacher-Roesler index and Woźny coefficient were determined. In nonoperated arthritic hips these measurements were abnormal. They were close to normal values in operated hips with negative Trendelenburg sign
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Efficacy and safety of risedronate 150 mg once a month in the treatment of postmenopausal osteoporosis
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Management of Hip Fractures in the Elderly
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Fragility fractures that occur as a result of osteoporosis are frequently associated with chronic pain and decreased quality of life as well as significant morbidity and mortality. Fracture reduction, however, is often less than optimal due to poor compliance with medications. Studies have demonstrated that risedronate, a heterocyclic nitrogen containing bisphosphonate can reduce vertebral, nonvertebral, and hip fracture incidence in postmenopausal women, in men, and in subsets of older patients at great risk of falls and fragility. The mechanism, efficacy, dosing options, and tolerability of risedronate are reviewed
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The effects of therapeutic exercise on the balance of women with knee osteoarthritis: a systematic review
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SR for PM on OA of All Extremities
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OBJECTIVE: The objective of this review was to examine evidence regarding the effects of therapeutic exercise on the balance of women with knee osteoarthritis (OA). METHODS: The search was conducted in Pubmed, Medline, Lilacs, SciELO, ISI web of knowledge, PEDro and the Cochrane Collaboration. We used the keywords: "knee", "balance", "women" and "rehabilitation" in combination with "osteoarthritis". We selected randomized controlled clinical trials published in English, Portuguese and Spanish over the last 10 years. To verify the methodological quality of selected clinical trials, the PEDro Scale was applied. RESULTS: A total of 20 studies were found in the electronic search. Of these, only 9 met the inclusion criteria and were analyzed in full. Eight of these 9 studies were classified as having high methodological quality on the PEDro Scale. Although the methods and interventions regarding balance varied widely in these studies, most found significant improvement in the balance of women with knee OA. CONCLUSION: Since the studies included in this systematic review were of high methodological quality, we can conclude that the therapeutic exercises they used improved the balance of women with knee OA
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Post-traumatic osteoarthritis diagnosed within 5 years following ACL reconstruction
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: The purpose was to calculate the incidence of osteoarthritis in individuals following Anterior Cruciate Ligament Reconstruction (ACLR) in a large, national database and to examine the risk factors associated with OA development. METHODS: A commercially available insurance database was queried to identify new diagnoses of knee OA in patients with ACLR. The cumulative incidence of knee OA diagnoses in patients after ACLR was calculated and stratified by time from reconstruction. Odds ratios were calculated using logistic regression to describe factors associated with a new OA diagnosis including age, sex, BMI, meniscus involvement, osteochondral graft use, and tobacco use. RESULTS: A total of 10,565 patients with ACLR were identified that did not have an existing diagnosis of OA, 517 of which had a documented new diagnosis of knee OA 5Â years after ACL reconstruction. When stratified by follow-up time points, the incidence of a new OA diagnosis within 6Â months was 2.3%; within a 1-year follow-up was 4.1%; within 2Â years, follow-up was 6.2%, within 3Â years, follow-up was 8.4%; within 4Â years, follow-up was 10.4%; and within 5Â years, follow-up was 12.3%. Risk factors for new OA diagnoses were age (OR 2.44, Pâ??<â??0.001), sex (OR 1.2, Pâ??=â??0.002), obesity (OR 1.4, Pâ??<â??0.001), tobacco use (ORâ??=â??1.3, Pâ??=â??0.001), and meniscal involvement (OR 1.2, Pâ??=â??0.005). CONCLUSION: Approximately 12% of patients presenting within 5 years following ACLR are diagnosed with OA. Demographic factors associated with an increased risk of a diagnosis of PTOA within 5Â years after ACLR are age, sex, BMI, tobacco use, and concomitant meniscal surgery. Clinicians should be cognizant of these risk factors to develop risk profiles in patients with the common goal to achieve optimal long-term outcomes after ACLR.III.
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0 |
Antibiotic-loaded bone cement spacer usage combined with membrane induction in infected gap non-unions: A case series
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DoD SSI (Surgical Site Infections)
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Objective: To explore the clinical effects upon gap nonunion of antibiotic-loaded bone cement spacer combined with membrane induction on infected bone defects.
Methods: The data of 16 patients with infected bone defects admitted in General Hospital of Shenyang Military Area Command from January 2009 to January 2011 were analyzed retrospectively. There were 12 males and 4 females aged between 24-63 years age (average 43.1 +/- 9.7) who had received antibiotic laiden bone cement spacer treatment. Stage-1, debridement and anti-biotic treatment with intraoperative preparation of customized bone cement spacers (antibiotics and bone cement spacer) with or without internal or external fixation Stage-2, removal of spacer and repair of bone defects using membrane-induced technique and internal fixation at bone defects site.
Results: Sixteen patients were followed up for 39-98 months, (67.2 +/- 20.4) on average. All patients with infected bone defects were healed. X-ray showed that fractures had healed and the new bone formed at graft site was more radio opaque than that of adjacent bone segments. The healing time was 6 to 10 months, (7.4 +/- 1.1) on average. There was no recurrence of infection or deformity.
Conclusion: The antibiotic-loaded cement spacer can control the local infection while maintaining the limb length and increasing the stability, reducing the contracture of bone and soft tissue, creating conditions for subsequent repair and reducing the infection rate of bone defects.
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0 |
Mucopolysaccharidosis I: Management and treatment guidelines
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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OBJECTIVE. Disease management for mucopolysaccharidosis type I has been inconsistent because of disease rarity (~ 1 case per 100 000 live births), phenotypic heterogeneity, and limited therapeutic options. The availability of hematopoietic stem cell transplantation and the recent introduction of enzyme replacement therapy for mucopolysaccharidosis I necessitate the establishment of system-specific management guidelines for this condition
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A well-fixed femoral stem facing a failed acetabular component: to exchange or not? A 5- to 15-year follow-up study
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PJI DX Updated Search
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INTRODUCTION: There is no consensus about the necessity of exchanging a stable femoral component during revision total hip arthroplasty (RTHA) when only the acetabular component requires replacement. Sparing the femoral component reduces morbidity, but can make acetabular replacement technically more difficult. Moreover, the outcome of the retained femoral component is also a question, especially with older implants. HYPOTHESIS: Isolated acetabular component RTHA results in lower surgical morbidity, and does not increase the risk of later femoral complications. PATIENTS AND METHODS: Eighty-nine patients, mean age 68, underwent surgery (anterior approach on traction table) for isolated acetabular component revision between 1994 and 2005. The femoral component had been implanted a mean 10.5 years before revision. RESULTS: Fifteen patients died, mean age 84.5. Eleven patients, mean age 81.3, were lost to follow-up and four underwent revision due to a subsequent infection (range 14 months - 11 years). Fifty-nine patients were evaluated after a mean 8.6 years (range 4 - 15 years). At follow-up the mean Harris score was 89.2 [IC=6.89; 44 - 100] and the mean Merle d'Aubigne score was 15.3 [IC=1.57; 11 - 18]. Five patients (5.6%) underwent surgery again due to postoperative dislocation. Six patients underwent surgery for recurrent acetabular loosening due to allograft resorption. The size of the bone defects did not increase the risk of these failures (P>0.6). Fractures occurred in two femoral components 6 and 9 years after revision. Polyethylene wear occurred in three patients requiring two repeat revisions at 6 and 7 years. In both cases the femoral component included a titanium head, which caused the wear. Implant survival at 8.6 years was 85.16 +/- 0.117% all causes of revision combined, 88.47 +/- 0.113% if infectious causes were excluded and 93.6 +/- 0.07% if only cases of acetabular component failure were taken into account. CONCLUSION: Intermediate term outcomes are satisfactory if stable femoral components are retained. Nevertheless, this procedure should be performed in situations of correctly oriented modular components. In single piece (monoblock) femoral implants, or in implants with a history of failure, this technique should be restricted to elderly and/or fragile patients. LEVEL OF EVIDENCE: Level IV, Retrospective study
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1 |
Pain management for total knee arthroplasty: Single-injection femoral nerve block versus local infiltration analgesia
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Surgical Management of Osteoarthritis of the Knee CPG
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Background: Pain is one of the major concerns of patients underwent Total Knee Arthroplasty (TKA); appropriate pain management is a key factor in patient's early physical fitness to move, physiotherapy, and most importantly, patient satisfaction. Objectives: In this study the analgesic effect of single injection femoral nerve block (SFNB) was compared with local infiltration analgesia (LIA). Patients and Methods: Forty patients who underwent TKA under spinal anesthesia were randomized to receive single femoral nerve block (group F) or intra-periarticular infiltration (group I). Group F received single injection 20cc ropivacaine (10mg/cc) and in group I, a combination of 300mg ropivacaine, 30mg ketorolac and 0.5mg epinephrine diluted to a volume of 150cc and locally injected in and around the knee joint in 3 stages. Postoperative pain intensity measured by Visual Analog Scale (VAS). Morphine consumption, mobilization time and patients' satisfaction evaluated as well. Results: Group I had significantly lower morphine consumption in the first postoperative day (10 vs. 12.5mg, P-value < 0.05). Within 6 hours postoperatively, VAS score was statistically lower in group I compared to group F (3 vs. 4, P-value < 0.05). However, within 12 hours it was statistically higher in group I than group F (6 vs. 5, P-value < 0.05). Other parameters were not statistically different in two groups. Conclusions: Both methods LIA and SFNB provided excellent pain relief and lower morphine consumption following TKA. LIA is a surgeon-controlled analgesic technique, which can be used to enhance patients' satisfaction and reduce the pain in the very early postoperative period by surgeon independently. (copyright) 2013, Iranian Red Crescent Medical Journal
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Stage-I osteochondritis dissecans versus normal variants of ossification in the knee in children
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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BACKGROUND: Juvenile osteochondritis dissecans (OCD) has a better prognosis than the adult type. OBJECTIVE: We postulated that the excellent prognosis of juvenile OCD could be explained, at least in part, by the erroneous diagnosis of some developmental variants of ossification as stage-I OCD. MATERIALS AND METHODS: Knee MRIs of 38 children, ages 7.5-17.7 years (mean and median age 13 years), were retrospectively reviewed to look for features that might separate normal variants of ossification from stage-I OCD. These included age, gender, site, configuration of the lesion, residual cartilaginous model and presence of edema. RESULTS: Twenty-three patients (32 condyles) had ossification defects with intact articular cartilage suggestive of stage-I lesions. No stage-II lesions were seen in the posterior femoral condyles. Accessory ossification centers were seen in 11/16 posterior condyles and 3/16 central condyles. Spiculation of existing ossification was seen in 12/16 posterior condylar lesions and 1/16 central condyles. There was a predominance of accessory ossifications and spiculations in the patients with 10% or greater residual cartilaginous model. No edema signal greater than diaphyseal red-marrow signal was seen in the posterior condyles. Clinical follow-up ranged from 0.5 to 38 months, with clinical improvement in 22 out of 23 patients. CONCLUSION: Inclusion of normal variants in the stage-I OCD category might explain, in part, the marked difference in published outcome between the juvenile and adult forms of OCD. Ossification defects in the posterior femoral condyles with intact overlying articular cartilage, accessory ossification centers, spiculation, residual cartilaginous model, and lack of bone-marrow edema are features of developmental variants rather than OCD
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0 |
Infective endocarditis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Infective Endocarditis (IE) is a known and a well-described complication of congenital and acquired heart disease. Its onset may be related to a procedure (which is commonly dental) or to poor dental hygiene. Use of antibiotics prior to the procedure prevents IE. General awareness of dental hygiene and use of prophylactic antibiotic is as much a responsibility of the Pediatrician as it is of the Pediatric Cardiologist. This article reviews the changing epidemiology, pathophysiology, clinical manifestations, and the microbiology of IE. Duke criteria for diagnosis of IE and the role of echocardiography in diagnosis of IE are discussed. There is special emphasis on the prevention of IE
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High tibial osteotomy: our experience with hemicallotasis method
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Surgical Management of Osteoarthritis of the Knee CPG
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Despite the many progresses and ever better outcomes in knee arthroplasty, surgical osteotomy in this area of the body is still commonly used. Valgus high tibial osteotomy (HTO) through external fixator progressive distraction (hemicallotasis) has given good results in the treatment of varus knee deformities. Such surgical techinque, once all controindications and favorable factors have been identified, allows to progressively correct the deformity with extreme precision without using internal fixation devices or bone grafts. The positive outcomes in all 24 subjects included in our study affected with varus knees and initial medial osteoarthritis confirm the validity of this osteotomy technique
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The effect of exercise training programs on bone mass: a meta-analysis of published controlled trials in pre- and postmenopausal women
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Management of Hip Fractures in the Elderly
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With the aging of the population, the medical and social costs of skeletal fragility leading to fractures will cause an immense burden on society unless effective prophylactic and therapeutic regimens can be developed. Exercise is suggested as a possible regimen against involutional bone loss. The purpose of the present meta-analysis is to address a quantitative review of the randomized controlled trials (RCTs) and nonrandomized controlled trials (CTs) on the effects of exercise training programs on bone mass, measured as bone mineral density (BMD) or bone mineral content (BMC), of the lumbar spine (LS) and the femoral neck (FN) in pre- and postmenopausal women. The literature from 1966 through December 1996 was searched for published RCTs and CTs. Study treatment effect is defined as the difference between percentage change in bone mass per year in the training group and the control group. Overall treatment effects (OTs) with the 95% confidence intervals of these study treatment effects were calculated using inverse-variance weighting. Of the 62 articles identified, 25 met the inclusion criteria and were maintained for further analyses. The weighted OTs for the RCTs showed very consistently that the exercise training programs prevented or reversed almost 1% of bone loss per year in both LS and FN for both pre- and postmenopausal women. The two OTs that could be calculated for strength training programs did not reach significance. The OTs for the CTs were almost twice as high as those for the RCTs, which gives an indication of the confounding introduced by the nonrandom allocation of the subjects to groups
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ORIF of Distal Humerus Fractures with Modern Pre-contoured Implants is Still Associated with a High Rate of Complications
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: The purpose of this study was to identify complications after operative treatment of distal humerus fractures with anatomic, pre-contoured, locking distal humeral plates. We hypothesized that these fractures have high complication rates despite the use of these modern implants. MATERIALS AND METHODS: Between 2010 and 2018, 43 adult patients with a distal humerus fracture underwent open reduction and internal fixation (ORIF) at a Level I trauma center. Pre-operative variables, including medical comorbidities, mechanism of injury, open or closed fracture, AO/OTA fracture classification (Type A, B, or C), and nerve palsy, were recorded. Intra-operative variables including surgical approach, ulnar nerve transposition, and plate configuration were recorded. Anatomic, pre-contoured, locking distal humeral plates were used in all patients. Various plating systems were used based on surgeon preference and fracture pattern. Post-operative complications including infection, nonunion, malunion, painful implants, nerve palsy, heterotopic ossification, stiffness, and post-traumatic arthritis were recorded. RESULTS: Most fractures were Type C (53%). The posterior olecranon osteotomy approach (51%) and parallel plate configuration (42%) were used in most cases. At a mean follow-up of 15 months, the complication rate was 61% (26/43 patients). Among all patients, 49% (21/43 patients) required a reoperation. Elbow stiffness (19%) was the most common complication followed by nerve palsy (16%). There were four fracture nonunions (9%), deep infections (9%), painful implants (9%), post-traumatic arthritis (9%), and heterotopic ossification (9%). CONCLUSIONS: Distal humerus fractures treated with ORIF utilizing anatomic, pre-contoured, locking distal humeral plates have a high complication rate, with many requiring reoperation. LEVEL OF EVIDENCE: Therapeutic Level IV.
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The outcomes of total knee arthroplasty in morbidly obese patients: a systematic review of the literature
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OAK 3 - Non-arthroplasty tx of OAK
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Introduction: The increasing prevalence of obesity has led to an increase in total knee arthroplasties (TKAs) being undertaken in patients with a higher body mass index (BMI). TKA in morbidly obese patients can be technically challenging due to numerous anatomical factors and patient co-morbidities. The long-term outcomes in this patient group are unclear. This systematic review aims to compare the long-term revision rates, functional outcomes and complication rates of TKAs in morbidly obese versus non-obese patients. Methods: A search of PubMed, EMBASE and PubMed Central was conducted to identify studies that reported revision rates in a cohort of morbidly obese patients (BMI â?¥ 40 kg/m2) that underwent primary TKA, compared to non-obese patients (BMI â?¤ 30 kg/m2). Secondary outcomes included Knee Society Objective Scores (KSOS), Knee Society Functional Scores (KSFS), and complication rates between the two groups. The difference in revision rates was assessed using the Chi-squared test. The Wilcoxon signed-rank test was used to compare pre-operative and post-operative functional scores for each group. KSOS and KSFS for morbidly obese and non-obese patients were compared using the Mannâ??Whitney test. Statistical significance was defined as p â?¤ 0.05. Results: Nine studies were included in this review. There were 624 TKAs in morbidly obese patients and 9,449 TKAs in non-obese patients, average BMI values were 45.0 kg/m2 (range 40â??66 kg/m2) and 26.5 kg/m2 (range 11â??30 kg/m2) respectively. The average follow-up time was 4.8 years (range 0.5â??14.1) and 5.2 years (range 0.5â??13.2) respectively, with a revision rate of 7% and 2% (p < 0.001) respectively. All functional scores improved after TKA (p < 0.001). Pre- and post-operative KSOS and KSFS were poorer in morbidly obese patients, however, mean improvement in KSOS was the same in both groups and comparable between groups for KSFS (p = 0.78). Overall complication rates, including infection, were higher in morbidly obese patients. Conclusions: This review suggests an increased mid to long-term revision rate following primary TKA in morbidly obese patients, however, these patients have a functional recovery which is comparable to non-obese individuals. There is also an increased risk of perioperative complications, such as superficial wound infection. Morbidly obese patients should be fully informed of these issues prior to undergoing primary TKA.
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1 |
Glucosamine and chondroitin: an appropriate adjunct treatment of symptomatic osteoarthritis of the knee
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OAK 3 - Non-arthroplasty tx of OAK
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Osteoarthritis (OA) is a leading cause of disability in the United States. Current treatment focuses on symptom relief and improving a patient's overall function. Pharmacological treatments aim to correct symptomatic complaints as well as structural problems in OA. Glucosamine (sulfate or hydrochloride) and chondroitin sulfate have been linked as an optional treatment in OA for several years. There is controversy, however, surrounding their use and efficacy. The American Academy of Orthopaedic Surgeons published clinical practice guidelines in 2008 that recommended against the use of glucosamine and chondroitin sulfate (p. ii). Despite conflicting results on the degree of efficacy, the most current research suggested that glucosamine and chondroitin sulfate have the potential to provide pain-relieving benefits as well as possibly decrease the effects of joint space narrowing. The purpose of this article was to document the most current research evidence on the use and efficacy of glucosamine and chondroitin sulfate supplements for patients with symptomatic OA of the knee as well as create an evidence-based, best practice educational tool describing a treatment algorithm for nurse practitioners treating a patient with symptomatic OA of the knee.
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The diagnosis and treatment of growth hormone deficiency in adults
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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PURPOSE OF REVIEW: This review summarizes the recent published information regarding efficacy and complications of growth hormone replacement therapy. Several recent reports have monitored patients for periods of up to 10 years. Additionally, a consensus conference has been held regarding needed improvements in diagnostic testing and the recommendations of consensus panels regarding diagnostic criteria and laboratory test utilization are summarized. RECENT FINDINGS: Long-term studies show growth hormone can be administered safely and that muscle strength and function as well as lipoprotein abnormalities and low-bone mineral density show sustained improvement over extended periods of time. The complications that occur are generally dose-dependent and once attenuated do not tend to recur. Long-term safety studies regarding improvement in cardiovascular mortality and/or worsening prognosis for patients who develop malignancies are available only in the form of observational studies and randomized controlled long-term trial information is not yet available. The studies reported provide a means for clinicians to ascertain the patients who are likely to derive the greatest benefit from growth hormone when the appropriate diagnostic testing and treatment paradigms are utilized
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Endoscopic Superficialisation of Haemodialysis Arteriovenous Fistulas in Obese Patients - Safety, Feasibility, and Outcomes
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Panniculectomy & Abdominoplasty CPG
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OBJECTIVE: The aim was to evaluate the safety and feasibility of endoscopic superficialisation (ES) in patients with deeply located cephalic veins in well matured arteriovenous fistulae (AVF) and to present functional outcomes. METHODS: All patients with cannulation difficulties due to a deep lying cephalic vein of more than 6 mm but with an otherwise matured AVF with a straight needle access segment of at least 6 cm were included in this retrospective study. Procedure related safety, defined as completion of ES with no need for conversion to open surgery, and feasibility in terms of cephalic vein depth reduction were assessed. The primary endpoint was three successfully performed haemodialysis sessions using the endoscopically superficialised AVF during a minimum follow up of 12 months. RESULTS: From June 2013 to August 2017, 12 patients with a mean body mass index of 33.5 ± 3.9 kg/m(2) underwent ES as a second stage procedure following radiocephalic (n = 5) or brachiocephalic AVF (n = 7) creation. All procedures were conducted endoscopically. Ultrasound imaging 12 weeks post-operatively documented a reduction in the depth of the cephalic vein from a mean of 10.1 ± 1.4 mm to 4.3 ± 0.8 mm. The mean duration of the ES was 69 ± 26.0 min with 67% performed under locoregional anaesthesia. In all but one patient with a cephalic vein of poor wall quality leading to recurrent haematoma, haemodialysis was performed successfully following ES. CONCLUSIONS: Endoscopic superficialisation of the cephalic vein is a safe and effective technique. Providing good functional results, ES represents an alternative approach for second stage superficialisation in obese patients.
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History of osteochondral allograft transplantation
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Osteochondritis Dissecans 2020 Review
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Osteochondral defects or injuries represent the most challenging entities to treat, especially when occur to young and active patients. For centuries, it has been recognized that such defects are almost impossible to treat. However, surgeons have never stopped the effort to develop reliable methods to restore articular cartilage and salvage the endangered joint function. Osteochondral allograft transplantation in human was first introduced by Eric Lexer in 1908. Since that era, several pioneers have been worked in the field of osteochondral allotransplantation, presenting and developing the basic research, the methodology and the surgical techniques. Herein we present in brief, the history and the early clinical results of osteochondral allograft transplantation in human.
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1 |
Dual mobility cups hip arthroplasty as a treatment for displaced fracture of the femoral neck in the elderly. A prospective, systematic, multicenter study with specific focus on postoperative dislocation
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Management of Hip Fractures in the Elderly
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INTRODUCTION: Displaced fractures of the femoral neck in the elderly are best treated with arthroplasty. The type of arthroplasty to be used, either hemi- or total hip arthroplasty, remains controversial as total hip replacements potentially have a higher rate of dislocation. HYPOTHESIS: Dual mobility cups have a low dislocation rate when used to manage acute fractures of the femoral neck. PATIENTS AND METHODS: In a multicenter prospective study conducted in France over an inclusion time of 3 months, all displaced fractures of the femoral neck treated with arthroplasty were operated on with insertion of a dual mobility cup. Patients had clinical and radiological assessment at 3, 6, and 9 months postoperative. RESULTS: Two hundred and fourteen hips in 214 patients with a mean age of 83 years (range, 70-103 years) were included. None of the patients was lost to follow-up. The mortality rate after 9 months was 19%. Two patients (1%) had early postoperative infection successfully treated with lavage and antibiotics. Three patients (1.4%), operated through a posterior approach, presented one postoperative dislocation, all of which were posterior. Reduction was performed through closed external manipulation under general anesthesia. There was no recurrence of dislocation. DISCUSSION: This low rate of dislocation after acute total hip replacement using dual mobility design cups favorably compares with hemiarthroplasties. Dual mobility cups might therefore be considered a valuable option to prevent postoperative dislocation when treating displaced intracapsular fractures of the proximal femur in elderly patients if a total hip replacement is recommended. Further study is needed before extending the indications for total hip arthroplasty following a fracture of the femoral neck, to assess the potential cost and complications of a longer procedure with its potential acetabular complication, and weigh them against the potential benefits
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Efficacy of multimodal, systematic non-surgical treatment of knee osteoarthritis for patients not eligible for a total knee replacement: a study protocol of a randomised controlled trial
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Surgical Management of Osteoarthritis of the Knee CPG
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INTRODUCTION: It is recommended that non-operative treatment of knee osteoarthritis (KOA) should be individually tailored and include multiple treatment modalities. Despite these recommendations, no one has yet investigated the efficacy of combining several non-surgical treatment modalities in a randomised controlled study. The purpose of this randomised controlled study is to examine if an optimised, combined non-surgical treatment programme results in greater improvements in pain, function and quality of life in comparison with usual care in patients with KOA who are not eligible for total knee arthroplasty (TKA). METHODS AND ANALYSIS: This study will include 100 consecutive patients from the North Denmark Region not eligible for TKA with radiographic KOA (K-L grade >/=1) and mean pain during the previous week of </=60 mm (0-100). The participants will be randomised to receive either a 12-week non-surgical treatment programme consisting of patient education, exercise, diet, insoles, paracetamol and/or NSAIDs or usual care (two information leaflets containing information on KOA and advice regarding the above non-surgical treatment). The primary outcome will be the change from baseline to 12 months on the self-report questionnaire Knee Injury and Osteoarthritis Outcome Score (KOOS)(4) defined as the average score for the subscale scores for pain, symptoms, activities of daily living and quality of life. Secondary outcomes include the five individual KOOS subscale scores, pain on a 100 mm Visual Analogue Scale, EQ-5D, self-efficacy, pain pressure thresholds, postural control and isometric knee flexion and knee extension strength. ETHICS AND DISSEMINATION: This study was approved by the local Ethics Committee of The North Denmark Region (N-20110085) and the protocol conforms to the principles of the Declaration of Helsinki. Data collection will be completed by April 2014. Publications will be ready for submission in the summer of 2014. TRIAL REGISTRATION NUMBER: This study is registered with http://clinicaltrials.gov (NCT01535001)
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Ultrasound assessment of the anatomic landmarks for spinal anesthesia in elderly patients with hip fracture: A prospective observational study
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Hip Fx in the Elderly 2019
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Tuffier line is a common landmark for spinal anesthesia. The 10th rib line has been suggested as a new landmark to predict the intervertebral levels. We evaluated the accuracy of these 2 anatomic landmarks for identifying the L4-L5 intervertebral space using ultrasonography in elderly patients with hip fracture.Seventy-nine elderly patients scheduled for hip fracture surgery under spinal anesthesia were included. In the lateral decubitus position with the fracture side up, the L4-L5 intervertebral space was identified alternately using Tuffier line, a line drawn between the highest points of both iliac crests, and the 10th rib line. The 10th rib line, an imaginary line that joints the 2 lowest points of the rib cage, passes through the L1-L2 intervertebral space or the body of L2. The L4-L5 intervertebral space was determined by the counting-down method from the 10th rib line. Then, the estimated intervertebral spaces were evaluated using ultrasonography. The L4-L5 intervertebral space was correctly identified in 47 (59%) patients with Tuffier line and 45 (57%) patients with the 10th rib line (P = .87). The estimation ratio related to the intervertebral levels was not different between the 2 landmarks (P = .40). The wrong identifications of intervertebral level with Tuffier line and the 10th rib line was observed in the following order: L3-L4 intervertebral space: 27% vs 24%, L5-S1 intervertebral space: 9% vs 16%, and L2-L3 intervertebral space: 5% vs 3%, respectively.Tuffier line and the 10th rib line may be unreliable to estimate the intervertebral space for spinal anesthesia in elderly patients with hip fracture.
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Comparative responsiveness of outcome measures for total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: The aim of this study was to compare the responsiveness of various patient-reported outcome measures (PROMs) and clinician-reported outcomes following total knee arthroplasty (TKA) over a 2-year period. METHODS: Data were collected in a prospective cohort study of primary TKA. Patients who had completed Forgotten Joint Score-12 (FJS-12), Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, EQ-5D, Knee Society Score and range of movement (ROM) assessment were included. Five time points were assessed: pre-operative, 2 months, 6 months, 1 year and 2 years post-operative. RESULTS: Data from 98 TKAs were available for analysis. Largest effect sizes (ES) for change from pre-operative to 2-month follow-up were observed for the Knee Society Score (KSS) Knee score (1.70) and WOMAC Total (-1.50). For the period from 6 months to 1 year the largest ES for change were shown by the FJS-12 (0.99) and the KSS Function Score (0.88). The EQ-5D showed the strongest ceiling effect at 1-year follow-up with 84.4% of patients scoring the maximum score. ES for the time from 1- to 2-year follow-up were largest for the FJS-12 (0.50). All other outcome measures showed ES equal or below 0.30. CONCLUSION: Outcome measures differ considerably in responsiveness, especially beyond one year post-operatively. Joint-specific outcome measures are more responsive than clinician-reported or generic health outcome tools. The FJS-12 was the most responsive of the tools assessed; suggesting that joint awareness may be a more discerning measure of patient outcome than traditional PROMs
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Development of a novel decellularized meniscal scaffold for use in tissue engineering
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AMP (Acute Meniscal Pathology)
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INTRODUCTION: Approximately 1 million meniscal surgeries are performed each year in the United States.1 Given the poor intrinsic healing capacity of the meniscus, arthroscopic partial meniscectomy is commonly performed for patients with clinical dysfunction following meniscal tear. While short-term clinical results are often favorable, these patients progress towards significant and often debilitating degenerative osteoarthritis. In an attempt to improve outcomes in patients with meniscal injuries, a number of biological approaches for enhancing the healing response following meniscal repair have been reported in the literature. However, functional tissue healing with preservation of meniscal size, geometry, and composition, does not consistently occur with any of the currently available treatment options for avascular meniscal defects, often leading to meniscal resection and a knee doomed to OA.2 Novel approaches are therefore needed to enhance primary healing following meniscal repair, or to provide a scaffold for meniscal regeneration following partial meniscectomy. Decellularized scaffolds composed of extracellular matrix (ECM) have been utilized for a number of tissue engineering applications given the critical roles of the native ECM for tissue regeneration. The optimal scaffold for an engineered tissue should mimic the in vivo functions of the ECM, including structural support and regulation of cell survival, proliferation, morphogenesis, and differentiation. Accordingly, there is growing evidence to support the potential utility of ECM-derived scaffolds for use in meniscal tissue regeneration and repair. The purpose of the present study was to develop a novel ECM-derived scaffold for promotion of meniscal tissue healing and repair, and to assess the cytocompatibility of the scaffold in vitro. We hypothesized that decellularized meniscal tissue could be processed into a cytocompatible, ECM-derived scaffold for promotion of meniscal fibrocartilage-like tissue production using an in vitro model for meniscal repair. Methods: All procedures were performed with ACUC approval. Decellularization: Grossly normal menisci (n=18) were harvested from the stifles of adult dogs (donor) euthanatized for reasons unrelated to this study. Medial and lateral menisci were minced into 1-3 mm2 pieces and decellularized with a combination of physical agitation and chemical treatments including 2% deoxycholic acid, 2% Triton X-100, 0.1% EDTA, 2% sodium dodecyl sulfate and 10 mM Tris ACS reagent. Following decellularization, menisci were treated with 0.1% peracetic acid and then washed in PBS with centrifugation. For wash protocol 1, scaffolds were washed up to 3X in PBS with centrifugation. For wash protocol 2, washing and centrifugation were repeated until SDS levels in the rinse water were no longer detected using a spectrophotometric assay. Evaluation of tissue biochemical content (dsDNA, glycosaminoglycan (GAG), and hydroxyproline (HP)) and histology were performed on treated and untreated tissues. Scaffold Fabrication: Decellularized tissue was flash frozen in liquid nitrogen and powdered using a grinder into a micronized meniscal scaffold. The resultant scaffold was lyophilized for 12 h and packaged for sterilization by exposure to UV light for a minimum of 48-72 hours. Cytotoxicity Testing: Cytotoxicity was evaluated in two studies. First, to determine if treated scaffolds washed using wash protocol 1 (n=8) or wash protocol 2 (n=12) leached anything that was cytotoxic, canine dermal fibroblasts (DFB, 1.6xl06 cells) were seeded onto 12 well plates, and scaffold material was placed into 8.0um filter well inserts that did not allow contact between the scaffold and the cells. Cell viability was assessed using the Alamar Blue assay after 3 days of culture. Second, to determine if direct contact with the washed scaffold was cytotoxic, meniscal fibrochondrocytes (MFC, 1.3xl06 cells) and synoviocytes (SYN, 4.4xl05 cells) were seeded directly on the ECM scaffold with (n=3/cell type) or without (n=3/cell type) prior p atelet rich plasma (PRP) treatment. Pellet cultures of MFC (n=3) and SYN (n=3) were used as culture controls. Cell viability was assessed after 8 days using the Alamar Blue assay. In Vitro Cytocompatibility: Grossly normal menisci (n=4) were harvested from the stifle of an adult mongrel dog (recipient) euthanatized for reasons unrelated to this study. Full-thickness cylindrical defects were created in the cranial (anterior) and caudal (posterior) portions of the inner 2/3 of the meniscus using a 2 mm biopsy punch. Menisci were bisected into 2 portions which were then randomly assigned for treatment and packed with either a whole blood clot as the Standard-of-Care treatment (SOC, n=4) or with a meniscal ECM scaffold combined with leukocyte-poor PRP into a paste (ECM-PRP, n=4). Venous blood was collected from a donor research hound and PRP was prepared using the Angel System (Arthrex Inc., Naples, FL). One-half of the menisci were randomly seeded with canine MFC (lxlO6). After cell seeding, menisci were incubated at 37°C for 1 h before adding complete serum-free culture medium in order to promote cellular adherence and diffusion into the defects. Menisci were cultured at 37°C for 42 days and then collected for histologic evaluation. Statistical Analyses: Data (mean±SD) were compared for statistically significant differences between groups using t-test withp<0.05 considered statistically significant. Results: Decellularization: DNA content was significantly reduced (15.43±8.635 vs. 26.26±8.01 ng/mg dry wt; p<0.001) and histology showed effective cell and nuclear removal from treated menisci, with no differences between medial and lateral menisci. When standardized to the dry weight of the tissue, tissue GAG content significantly (p<0.001) decreased and tissue HP content significantly (p=0.009) increased in the decellularized meniscal scaffold compared to native control tissue. Further, the GAG:HP ratio was significantly (p<0.001) lower in the decellularized meniscal scaffold compared to the native control tissue, indicating the loss of GAG by the tissue during scaffold creation. Cytotoxicity: Scaffolds washed using wash protocol 1 were cytotoxic to DFBs in monolayer culture. However, scaffolds washed using wash protocol 2 were not cytotoxic to DFBs in monolayer culture. Further, the washed decellularized meniscal scaffold, with or without the addition of PRP, was not cytotoxic to MFC and SYN cells. In Vitro Cytocompatibility: After 42 days of culture, histological evaluation showed normal tissue architecture and cellularity of recipient menisci in both treatment groups, with evidence of mononuclear, spindle-shaped cells present within the defects of both seeded and non-cell seeded samples. Discussion: In this initial study, medial and lateral menisci were effectively processed into an ECM-derived scaffold that was cytocompatible for meniscal fibrochondrocytes and synoviocytes based on cell culture experiments and histologic evaluation using an in vitro model for meniscal repair. On histology, spindle-shaped cells were noted within the defects of non-cell seeded ECM-PRP treated menisci, suggesting cellular survival, migration, and proliferation within the scaffold. Further studies are necessary to elucidate the scaffold's potential to guide meniscal fibrochondrogenesis and promote integrative tissue repair. SIGNIFICANCE: We report a safe and effective method for decellularization and micronization of meniscal tissue for fabrication of a novel, ECM-derived scaffold for use in tissue engineering. Evaluation of the scaffold's potential to promote functional, meniscal fibrocartilage-like tissue repair is currently under investigation.
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1 |
Bilateral occurrence and morphologic analysis of complete discoid lateral meniscus
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AMP (Acute Meniscal Pathology)
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PURPOSE: The aim of the study was to investigate and analyze bilateral incidence and morphology of complete discoid lateral meniscus (DLM) with possible relation to tears and symptoms in knee joints.
MATERIALS AND METHODS: Thirty-eight consecutive patients with symptomatic or already-torn complete DLM on magnetic resonance imaging in a unilateral knee underwent diagnostic arthroscopy on both knee joints upon agreement. The presence and shape of complete DLM as well as presence and pattern of tear were recorded accordingly.
RESULTS: In total, 89.5% (34 of 38 patients) showed bilateral complete DLM, and 84.2% yielded bilateralism with identical shape. Cape-slab was the most frequent shape, comprising 68.8% of patients with identically-shaped bilateral DLM overall. Tear patterns were more frequent, in the order of longitudinal, simple horizontal, radial, and degenerative; however, the morphological shape of complete DLM was not significantly related to tear incidence or pattern. Meniscus tears and knee symptoms occurred in the contralateral knee with incidences of 32.4% and 26.5% in patients with bilateral complete DLM, respectively.
CONCLUSION: Based on these findings, more aggressive warning on the presence of discoid pathology and the need for evaluation on the contralateral knee should be considered during consultation with patients with symptomatic complete DLM in a unilateral knee in the outpatient clinic.
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0 |
The Ideal Thigh: A Crowdsourcing-Based Assessment of Ideal Thigh Aesthetic and Implications for Gluteal Fat Grafting
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Panniculectomy & Abdominoplasty CPG
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Background: As the popularity of aesthetic gluteoplasty continues to grow, there is renewed focus on defining the ideal buttocks. However, the literature lacks studies characterizing an ideal thigh, despite the impact of thigh contour on overall gluteal aesthetic. Objectives: The authors performed the first population analysis of the characteristics of perception of attractive thighs, to identify a role for fat grafting of the thigh in gluteoplasty. Methods: Survey images were digitally modified to create thighs of varying widths and angles relative to fixed buttocks. Thigh-to-buttock ratios and the buttock-thigh junction were studied. Data were stratified and analyzed according to age, gender, and ethnicity of the respondents. Amazon Mechanical Turk was used as a novel crowdsourcing platform for surveying aesthetic preferences. Results: A total of 1034 responses were included of whom 54.4% were male, and 45.6% were female. All age groups and ethnicities were represented. Overall, 43.8% of respondents preferred the widest buttock-thick junction angle on posterior view. There was no clear preference between larger or smaller thigh-to-hip ratios on lateral view. Conclusions: Characteristics of the ideal thigh include wider thighs with greater horizontal projection, creating a more natural contour from the augmented buttock. These findings represent a paradigm shift from the traditionally assumed preference for slender thighs. Plastic surgeons should carefully consider thigh anatomy in their gluteal augmentation patients, as simultaneous thigh augmentation may lead to a more aesthetically pleasing outcome. Further research is needed into best practices and techniques to attain ideal thigh proportions.
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0 |
Iatrogenic type A aortic dissection during cardiac surgery
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DOD - Acute Comp Syndrome CPG
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We reviewed our experience of intraoperative type A aortic dissection during cardiovascular surgery. From January 1998 to May 2009, intraoperative aortic dissection occurred in 10 of 3421 cardiac surgical patients (M:F=4:6, 62.4±8.0 years). Preoperative diagnoses were valvular heart disease (n=6), ischemic heart disease (n=2), combined disease (n=1) and aortic aneurysm (n=1). All underwent total circulatory arrest (TCA) with retrograde cerebral perfusion and the torn aorta was replaced (n = 8) or repaired (n=2). Iatrogenic type A dissection occurred in 0.29% of patients. It was related with cannulation of ascending aorta (n=4), axillary artery (n=2), aortic root (n=2), and femoral artery (n=1) and aortotomy repair (n = 1). Mortality rate was 40% (4/10). After adoption of routine intraoperative transesophageal echocardiography, mortality rate decreased from 75% (3/4) to 17% (1/6) (P=0.190). We initiated TCA before achieving deep hypothermia in three of four non-survivors. There was a trend of increased mortality when the disease extended beyond aortic arch (67%, 4/6 vs. 0%, 0/4; P=0.076). Although intraoperative aortic dissection occurred in <0.3% of our patient population, mortality was high, especially when it extended beyond the arch vessels. Better results were expected when early recognition and proper treatment under deep hypothermic circulatory arrest could be performed. © 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
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0 |
Categorization of two-photon microscopy images of human cartilage into states of osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: The degeneration of articular cartilage is part of the clinical syndrome of osteoarthritis (OA) and one of the most common causes of pain and disability in middle-aged and older people(1). However, the objective detection of an initial state of OA is still challenging. In order to categorize cartilage into states of OA, an algorithm is presented which offers objective categorization on the basis of two-photon laser-scanning microscopy (TPLSM) images.
METHODS: The algorithm is based on morphological characteristics of the images and results in a topographical visualization. This paper describes the algorithm and shows the result of a categorization of human cartilage samples.
RESULTS: The resulting map of the analysis of TPLSM images can be divided into areas which correspond to the grades of the Outerbridge-Categorization. The algorithm is able to differentiate the samples in coincidence with the macroscopic impression.
CONCLUSION: The method is promising for early OA detection and categorization. In order to achieve a higher benefit for the physician the method must be transferred to an endoscopic setup for an application in surgery.
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0 |
Bone formation blocking closure of the expanded distal fins during removal of a Seidel humeral nail
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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The authors report the case of a young patient in which, during removal of a Seidel nail four years after healing of a mid shaft fracture of the humerus, bone formation into the central canal of the nail through the peripheral slots, prevented the three spread distal fins of the nail to close. The nail could only be extracted by forceful use of the extracting instrument, fortunately without complication
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0 |
The lack of correlation between radiographic findings and cartilage integrity
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Surgical Management of Osteoarthritis of the Knee CPG
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Total knee arthroplasty is a common treatment of osteoarthritis, although unicompartmental knee arthroplasties are frequently used to retain unaffected compartments. Joint space width (JSW) is a major factor in determining treatment. We examined the relationship between JSW and cartilage quality in 60 patients undergoing total knee arthroplasty to assess its accuracy in representing cartilage degradation. Radiographic JSW was recorded, whereas the unaffected compartment of each tibial plateau was examined postoperatively using Collins, Mankin, and Kellgren and Lawrence scores. No correlation was seen between visual or histologic grading and JSW. Histology more accurately represented cartilage quality, yet it is impractical to obtain preoperatively; thus, JSW is the main mode of assessment. However, using JSW solely to indicate unicompartmental knee arthroplasty may overlook disease in apparently unaffected compartments
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0 |
Morphometric analysis of anatomical implant forms for minimally invasive acetabular fracture osteosynthesis
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Management of Hip Fractures in the Elderly
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Anatomical implants enable minimally invasive osteosynthesis (MIO) and represent ideal complements of computer-assisted surgical workflows. This 3D morphometric study analyzes anatomical implant forms (AIF) for acetabular fracture osteosynthesis (AFO). Materials and Three-dimensional pelvis models were created from clinical CT data of 99 European-Caucasian patients (50 females, 49 males). The mean age of the patients was 60.1 years (range: 20-89; SD 10.8). Definition of a referential region of interest (ROI) corresponding to an AIF for AFO was followed by automated ROI computation for each of the 198 hemipelvises. Three-dimensional statistical modeling and analysis of the resulting 198 homologous ROIs consisted of thin-plate spline transformation, generalized Procrustes fit, and principal component analysis. The mean ROI length was 18.2 cm (range: 16.1-20.1 cm; SD 0.76). The first principal component (PC1) mainly modeled the ROI length, which correlated well with body height (r = 0.325; p < 0.001). PC1 comprised 47.4% of the overall ROI form variation. PC2 primarily influenced the ROI curvature in the anterior-posterior (inlet) view. Curvatures were more pronounced in female patients compared to males (p < 0.001). There was no gender-specific ROI size variation. PC1-4 contained 80.2% of the total ROI form variation. Left and right ROI forms displayed symmetry. This 3D morphometric study demonstrates the feasibility of anatomical implants for minimally invasive acetabular fracture osteosynthesis. Implant size/length is by far the most important variable of form variation. The necessity of gender-specific implant forms requires further investigation. The non-fractured, contralateral hemipelvis can be used for preoperative surgical planning. Ultimately, the plate design will depend on prospective implant fit tests based on the required fit as defined by the clinician
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0 |
Ten-year survival and seven-year functional results of cementless Oxford unicompartmental knee replacement: A prospective consecutive series of our first 1000 cases
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Dental Implant Infection
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BACKGROUND: Cementless fixation is an alternative to cemented unicompartmental knee replacement (UKR), with several advantages over cementation. This study reports the ten-year survival and seven-year clinical outcome of cementless Oxford unicompartmental knee replacement (OUKR)., METHODS: This prospective study describes the clinical outcome and survival of the first 1000 consecutive cementless medial OUKRs implanted at two centres for recommended indications., RESULTS: The 10-year survival was 97% (CI 95%: 92-100%), with 25 knees being revised. The commonest reason for revision was progression of arthritis laterally, which occurred in nine knees, followed by primary dislocation of the bearing, which occurred in six knees. There were two dislocations secondary to trauma and a ruptured ACL, and two tibial plateau fractures. Although there were no definite cases of aseptic loosening, two early revisions were related to tibial fixation: one for pain and a radiolucent line and one for incomplete seating of the component with a radiolucent line. There were four revisions for pain, but the cause of the pain was uncertain: in one there was tibial overhang and in two there was patellofemoral degeneration, which possibly contributed to the pain. There were no deep infections. The mean OKS improved from 23 (SD 8) to 42 (SD 7) at a mean follow-up of 7.0years (p<0.001). There was no significant difference in survival or clinical outcome between the designer and independent centre., CONCLUSIONS: The cementless OUKR is a safe and reproducible procedure with excellent 10-year survival and clinical results in the hands of both designer and independent surgeons. Copyright © 2018. Published by Elsevier B.V.
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0 |
Radiological decision aid to determine suitability for medial unicompartmental knee arthroplasty: Development and preliminary validation
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OAK 3 - Non-arthroplasty tx of OAK
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Aims An evidence-based radiographic Decision Aid for meniscal-bearing unicompartmental knee arthroplasty (UKA) has been developed and this study investigates its performance at an independent centre. Patients and Methods Pre-operative radiographs, including stress views, from a consecutive cohort of 550 knees undergoing arthroplasty (UKA or total knee arthroplasty; TKA) by a single-surgeon were assessed. Suitability for UKA was determined using the Decision Aid, with the assessor blinded to treatment received, and compared with actual treatment received, which was determined by an experienced UKA surgeon based on history, examination, radiographic assessment including stress radiographs, and intra-operative assessment in line with the recommended indications as described in the literature. Results The sensitivity and specificity of the Decision Aid was 92% and 88%, respectively. Excluding knees where a clear pre-operative plan was made to perform TKA, i.e. patient request, the sensitivity was 93% and specificity 96%. The false-positive rate was low (2.4%) with all affected patients readily identifiable during joint inspection at surgery. In patients meeting Decision Aid criteria and receiving UKA, the five-year survival was 99% (95% confidence intervals (CI) 97 to 100). The false negatives (3.5%), who received UKA but did not meet the criteria, had significantly worse functional outcomes (flexion p < 0.001, American Knee Society Score - Functional p < 0.001, University of California Los Angeles score p = 0.04), and lower implant survival of 93.1% (95% CI 77.6 to 100). Conclusion The radiographic Decision Aid safely and reliably identifies appropriate patients for meniscal-bearing UKA and achieves good results in this population. The widespread use of the Decision Aid should improve the results of UKA.
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1 |
Satisfaction, Adherence and Health-Related Quality of Life with Transdermal Buprenorphine Compared with Oral Opioid Medications in the Usual Care of Osteoarthritis Pain
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Osteoarthritis (OA) causes substantial pain and reduced health-related quality of life (HRQL). Although opioid analgesics are commonly used, the relative benefits of different opioids are poorly studied. Transdermal buprenorphine (TDB) offers an alternative to oral opioids for the treatment of moderate-to-severe chronic pain. This observational study of people with OA pain assessed satisfaction, HRQL and medication adherence.
METHODS: Patients in the UK with self-reported knee and/or hip OA who had been receiving one or more of TDB, co-codamol (an oral paracetamol/codeine combination) and tramadol for at least 1 month completed an online or telephone questionnaire. Medication satisfaction scores, HRQL scores (Short-Form 36 [SF-36]), medication adherence (Morisky Medication Adherence Scale [MMASTM]), adverse events and treatment discontinuations were recorded. Linear and logistic regression models were used to compare the treatment effect of TDB with co-codamol or tramadol.
RESULTS: Overall, 966 patients met the inclusion criteria; 701 were taking only one of the target medications (TDB: 85; co-codamol: 373; tramadol: 243). The largest age group was 50-59 years and 76.0 % of patients were female. The TDB group was younger, with more male patients, therefore the statistical models were adjusted for age and sex. Medication satisfaction scores were significantly higher in the TDB group than the other two groups (TDB vs. co-codamol: 3.56, 95 % confidence interval [CI] 1.90-6.68, p < 0.0001; TDB vs. tramadol: 3.22, 95 % CI 1.67-6.20, p = 0.0005). Physical Component Summary scores for HRQL and mean adherence were also higher in the TDB group, while Mental Component Summary HRQL scores were similar across the three groups.
CONCLUSIONS: Patients with knee and/or hip OA pain treated with TDB were more satisfied and more adherent with their medication, and reported higher Physical Component Summary HRQL scores than those treated with co-codamol or tramadol, although demographic differences were observed between groups.
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1 |
Liposomal Bupivacaine Injection Technique in Total Knee Arthroplasty
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AAHKS (8) Anesthetic Infiltration
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Liposomal bupivacaine has gained popularity for pain control after total knee arthroplasty (TKA), yet its true efficacy remains unproven. We compared the efficacy of two different periarticular injection (PAI) techniques for liposomal bupivacaine with a conventional PAI control group. This retrospective cohort study compared consecutive patients undergoing TKA with a manufacturer-recommended, optimized injection technique for liposomal bupivacaine, a traditional injection technique for liposomal bupivacaine, and a conventional PAI of ropivacaine, morphine, and epinephrine. The optimized technique utilized a smaller gauge needle and more injection sites. Self-reported pain scores, rescue opioids, and side effects were compared. There were 41 patients in the liposomal bupivacaine optimized injection group, 60 in the liposomal bupivacaine traditional injection group, and 184 in the conventional PAI control group. PAI liposomal bupivacaine delivered via manufacturer-recommended technique offered no benefit over PAI ropivacaine, morphine, and epinephrine. Mean pain scores and the proportions reporting no or mild pain, time to first opioid, and amount of opioids consumed were not better with PAI liposomal bupivacaine compared with PAI ropivacaine, morphine, and epinephrine. The use of the manufacturer-recommended technique for PAI of liposomal bupivacaine does not offer benefit over a conventional, less expensive PAI during TKA.
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1 |
Mild Traumatic Brain Injury, PTSD, and Psychosocial Functioning Among Male and Female U.S. OEF/OIF Veterans
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DoD PRF (Psychosocial RF)
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This study examined the unique and combined relationship between mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) with psychosocial functioning in a cohort of 1,312 U.S. male and female veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) enrolled in the Veterans After-Discharge Longitudinal Registry (Project VALOR). We assessed mTBI with structured screening questions reflective of current TBI classification standards and PTSD via the SCID-IV PTSD module; all other variables were assessed by self-report questionnaires. We identified significant diagnostic group differences in psychosocial functioning for both sexes. Individuals with PTSD, with or without a history of mTBI, reported significantly worse psychosocial functioning than individuals with mTBI alone or neither mTBI nor PTSD (males, eta(2) p = .11, p < .001; females, eta(2) p = .14, p < .001), even after adjusting for demographics and severity of chronic pain. The results suggested that veterans experiencing PTSD, regardless of whether they had a history of mTBI, were at increased risk for long-term psychosocial impairment. Further research examining possible benefits from improved access to resources and treatment to address these needs would be valuable.
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0 |
Rehabilitation of older adults with hip fracture: cognitive function and walking abilities
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To investigate the association between baseline cognitive function and the achievement of walking independence and its maintenance at 1 year in a population of older adults who underwent post-hip fracture (HF) surgery rehabilitation. DESIGN: Prospective cohort study. SETTING: Department of rehabilitation and aged care. PARTICIPANTS: Three hundred six older adults admitted for post-HF surgery rehabilitation. MEASUREMENTS: All participants aged 65 and older who were completely unable to walk on admission but able to walk before fracture were stratified according to Mini-Mental State Examination score (0-15=moderately severe or severe cognitive impairment (CI), 16-23=mild to moderate CI, >/=24=no CI). Walking ability was defined according to the corresponding Barthel Index subitem, with walking independence at discharge being defined as a score of 12 or more out of 15. Walking ability 1 year after discharge was ascertained by telephone interviews with participants or proxies. RESULTS: At discharge, 29.6% of participants with moderately severe or severe CI (n=24), 51.9% with mild to moderate CI (n=56) and 78.6% of participants without CI (n=92) were able to walk independently. Among those who achieved walking independence and were alive at 1 year, 12 participants with moderately severe or severe CI (57.1%), 31 with mild to moderate CI (57.7%) and 73 without CI (78.9%) were still capable of walking independently. CONCLUSION: Although less frequently than in individuals with better cognitive function, walking independence is achievable after HF surgery rehabilitation, and can be maintained at 1 year also in those with moderately severe or severe CI
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0 |
Dissociation of mobile-bearing patellar component in low contact stress patellofemoral arthroplasty, its mechanism and management: two case reports
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Surgical Management of Osteoarthritis of the Knee CPG
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INTRODUCTION: Isolated patellofemoral osteoarthritis can be treated with patellofemoral arthroplasty. CASE PRESENTATION: We present two cases of isolated patellofemoral osteoarthritis treated with Low Contact Stress patellofemoral arthroplasty; in both cases the polyethylene mobile-bearing of the patellar component dissociated from the metal backing. One patient had a revision to a Richards patellofemoral prosthesis, and in the second patient the arthroplasty was converted to a total knee prosthesis because of clinically important femorotibial osteoarthritis. CONCLUSION: The possible failure mechanisms are described. We suggest avoiding the use of a metal-backed mobile-bearing patellar component due to the risk of dissociation
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1 |
Predictors of Patient-Reported Function and Pain Outcomes in Operative Ankle Fractures
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DoD SSI (Surgical Site Infections)
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Background: Risk factors associated with short-term functional outcomes in patients with operative ankle fractures have been established. However, no previous studies have reported the association between these risk factors and functional outcomes outside of the first postoperative year. We identified predictors of functional and pain outcomes in patients with operative ankle fractures using the Patient Reported Outcomes Measurement System (PROMIS) physical function (PF) and pain interference (PI) measures. Methods: We retrospectively reviewed a multicenter cohort of patients =18 years old who underwent operative management of closed ankle fractures from 2001 to 2013 with a minimum of a 2-year follow-up. Patients with pilon variants, Maisonneuve fractures, Charcot arthropathy, prior ankle surgery, and chronic ankle fractures were excluded. Patients meeting inclusion criteria were contacted and evaluated using the PROMIS PF and PI computerized adaptive tests. Patient demographic and injury characteristics were obtained through a retrospective chart review. Univariate and multivariate regression models were developed to determine independent predictors of physical function and pain at follow-up. Included in this study were 142 patients (64 women, 78 men) with a mean age of 52.7 years (SD = 14.7) averaging 6.3 years of follow-up (range 2-14). Results: Patients had a mean PF of 51.9 (SD = 10.0) and a mean PI of 47.8 (SD = 8.45). Multivariate analysis demonstrated that independent predictors of decreased PF included higher age (B = 0.16, P =.03), higher American Society of Anesthesiologists (ASA) class (B = 10.3, P <.01), and higher body mass index (BMI; B = 0.44, P <.01). Predictors of increased PI included higher ASA class (B = 11.5, P <.01) and lower BMI (B = 0.41, P <.01). Conclusion: At follow-up, increased ASA class, increased BMI, and higher age at time of surgery were independently predictive of decreased physical function. Factors that were associated with increased pain at follow-up include lower BMI and higher ASA class. ASA class had the strongest effect on both physical function and pain. Level of Evidence: Level IV, case series.
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0 |
Efficacy of home-based virtual cycling training on bone mineral density in ambulatory children with cerebral palsy
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Pediatric Supracondylar Humerus Fracture 2020 Review
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The 12-week home-based virtual cycling training (hVCT) improved lower limb muscle strength and areal bone mineral density (aBMD) than the control program in children with cerebral palsy (CP). A muscle strengthening program, rather than general physical activity, is more specific in enhancing aBMD for these children. A novel hVCT is an effective and efficient strategy that enhances lower limb bone density in these children. INTRODUCTION: This is the first study to assess the efficacy of a novel hVCT program on bone density for children with spastic CP using a well-designed randomized controlled trial. METHODS: Twenty-seven ambulatory children with spastic CP, aged 6-12 years, were randomly assigned to the hVCT group (n=13) or control group (n=14). Outcome measures-motor function [Gross Motor Function Measure-66 (GMFM-66)], muscle strength (curl up scores and isokinetic torque of knee extensor and flexor muscle) and aBMD of the lumbar and distal femur-were administered before and immediately after the 12-week intervention. RESULTS: Analysis of covariance results show that the hVCT group had greater distal femur aBMD and isokinetic torques of knee extensor and flexor muscles than the control group at posttreatment (p<0.05). However, curl up scores, GMFM-66, and lumbar aBMD at posttreatment did not differ between the two groups. CONCLUSIONS: Analytical findings suggest that the muscle strengthening program is more specific in enhancing bone density for children with CP than general physical activity. Thus, the proposed 12-week hVCT protocol is an effective and efficient strategy for improving lower limb aBMD in these children.
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1 |
Vibration perception thresholds in workers exposed to vibration
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The vibration perception thresholds (VPT) at six frequencies from 16 to 500 Hz were examined in 77 workers exposed to hand-arm vibration and in 77 controls using a limits procedure. A dose-response relationship between VPTs and exposure to vibration was found, and the age-adjusted VPTs at each frequency were higher in workers exposed to vibration than in controls. Carpal tunnel syndrome (at 250 Hz) and consumption of alcohol (at 125 Hz) significantly increased the VPT, but vibration-induced white finger was not correlated with VPT. Indices for low (16 and 32 Hz) and high (63-500 Hz) VPT frequencies were calculated to evaluate the entire vibrogram, which consisted of several frequencies with two numbers. The results showed that hand-arm vibration disturbs first the high frequencies, and that the disturbance spreads thereafter to the low frequencies. The characteristics of the VPT test regarding vibration exposure and the association between VPT and nerve symptoms in the hand support the view that VPT is a useful measure for vibration-induced sensory nerve damage
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0 |
The effect of tibio-talar arthrodesis on foot kinematics and ground reaction force progression during walking
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OAK 3 - Non-arthroplasty tx of OAK
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Degenerative osteoarthritis in the subtalar and midâ?tarsal joints occurring after tibioâ?talar arthrodesis is thought to be a consequence of abnormal foot dynamics. We hypothesized that the forward tilt of the tibia during stance induces early heelâ?off and alteration of the progression of ground reaction force (GRF) after ankle arthrodesis. Threeâ?dimensional gait analysis was performed on nine patients who had an ankle arthrodesis fused in a neutral position and on ten control subjects. Patients walking barefoot were compared to controls. The GRF progression was shifted forward during midâ?stance, heelâ?off occurred earlier and was associated with less anterior tilt of the tibia and a more posterior position of the GRF with reference to the metatarsal heads. The GRF progression, heelâ?off and tibial tilt were not significantly different between patients and controls when walking in shoes but the GRF was still more posterior at heelâ?off. Increasing the walking speed worsened the anomalies of foot dynamics. These alterations of foot dynamics are thought to be associated with pathogenic stresses applied to the midâ?foot.
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1 |
Opioid-free analgesia by continuous psoas compartment block after total hip arthroplasty. A randomized study
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AAHKS (9/10) Regional Nerve Blocks
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BACKGROUND AND OBJECTIVE: Adequate analgesia is needed after total hip arthroplasty to control pain at rest and during rehabilitation. Our aim was to compare, in a randomized study, the efficacy of two analgesia regimens in control of postoperative pain after total hip arthroplasty: opioid-free continuous psoas compartment block vs. an opioid/non-steroidal anti-inflammatory drugs continuous intravenous infusion.
METHODS: In all, 73 patients (ASA I-III), aged 61-82 yr, undergoing total hip arthroplasty were prospectively enrolled in a single-blind randomized trial. Patients were allocated either to the study group (Group A, n = 37) or to the control group (Group B, n = 36). Patients in Group A underwent preoperative placement of a catheter in the psoas compartment and, 30 min before the end of surgery, the catheter was primed with a loading dose of 0.75% ropivacaine (0.4 mL kg(-1)) followed by a continuous infusion of 10 mL h(-1) ropivacaine 0.2% for 48 h. Patients in Group B received, from 1 h before the end of surgery, a continuous intravenous infusion of 0.1% morphine and 0.12% ketorolac at 2 mL h(-1) for 48 h. Both groups received spinal anaesthesia for surgery. Pain scores at rest and after mobilization, amount of rescue analgesia, nausea/vomiting and haemodynamic parameters were recorded.
RESULTS: In Group A, median pain scores were very low during the whole study duration both at rest and during physiotherapy in comparison to Group B. Less rescue analgesia was needed and less nausea and vomiting was observed in Group A.
CONCLUSIONS: Opioid-free continuous psoas compartment block seems to be an appropriate and reliable technique in providing effective postoperative analgesia at rest and during physiotherapy after total hip arthroplasty when compared to intravenous morphine/ketorolac infusion.
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0 |
Aromatase expression in osteoarthritic and osteoporotic bone
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Management of Hip Fractures in the Elderly
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OBJECTIVE: Estrogen deprivation is a central mechanism in the development of osteoporosis with aging. Results from recent studies also suggest the involvement of estrogens in the pathophysiology of osteoarthritis (OA). Aromatization of androgenic precursors in peripheral tissue is the main source of estrogens in postmenopausal women and in men. However, the importance of aromatase expression in bone is a subject of controversy. This study was undertaken to determine aromatase expression in bone samples from patients with hip fracture and patients with OA. METHODS: We studied 104 patients with hip fracture (n = 60) or primary hip OA (n = 44). Aromatase expression was determined in trabecular bone samples from the femoral neck and in osteoblast cultures grown by the primary explant technique (n = 62), using real-time reverse transcriptase-polymerase chain reaction. RESULTS: Aromatase RNA was detected in bone samples at levels similar to those found in adipose tissue. Transcript levels were significantly lower in bone tissue samples obtained from patients with OA than in those obtained from patients with fracture (P = 0.00001). Likewise, primary cultures of osteoblast cells from OA patients revealed lower aromatase expression than those of cells from fracture patients (P = 0.012). Results were independent of age or sex differences. CONCLUSION: Our findings indicate that the aromatase gene is expressed in bone tissue in high amounts, similar to those found in adipose tissue, but transcript levels are lower in tissue samples and osteoblast cultures from patients with OA than in those from patients with hip fracture. Since estrogens may help to prevent local cartilage degradation, it can be speculated that such a reduced expression of aromatase could facilitate the development of OA
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Lupus erythematosus: considerations for dentistry
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Lupus erythematosus, or LE, is a connective tissue disease that affects a number of organ systems. Patients with this condition can experience several other serious conditions--bleeding, infection, endocarditis, adrenal insufficiency and mucocutaneous disease--that can affect the provision of dental care. The authors describe considerations for managing dental treatment of patients with LE
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Excision arthroplasty with delayed wound closure for the infected total hip replacement
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Methods of management of infections in total hip replacement vary from the use of antibiotics with reimplantation to a complete removal of the prosthetic unit. This is a series of 10 consecutive patients having documented sepsis following total hip replacement characterized by gram-negative organisms which was managed with the method of excision (Girdlestone) arthroplasty with delayed wound closure. Parenteral antibiotics were used while the wound remained open. Once wound healing had been accomplished, the patients were placed on appropriate oral antibiotics and continued on same for approximately 6 months. The duration of follow-up was 3-5 years. All patients have continued to remain free of clinical sepsis. One patient has chronic pain. All patients are fully ambulatory and are fully satisfied with their functional capacities. Recognizing a serious infection following total hip replacement, especially characterized by the presence of gram-negative organisms, requires drastic treatment methods. Excision arthroplasty with delayed wound closure is a reasonable alternative, especially in view of the functional results obtained
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Detection of osteomyelitis using (18)FDG and positron emission tomography
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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A positron emission tomography (PET) scan with 2-[fluorine-18]fluoro-2-deoxy-D-glucose ((18)FDG) was performed on a patient with clinical and laboratory signs of infection after a removed hip prosthesis but with indistinct signs on the bone scan and radiographs. The PET scan confirmed the clinical and laboratory signs and revealed an unidentified focus of infection in the distal area of the right femur
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A comparison of early and late reconstruction of malunited fractures of the distal end of the radius
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DoD SSI (Surgical Site Infections)
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We retrospectively evaluated the results for ten patients in whom a malaligned fracture of the distal end of the radius had been treated with early reconstruction (an average of eight weeks [range, six to fourteen weeks] after the injury) consisting of an osteotomy through the site of the fracture, autogenous cancellous iliac-crest bone-grafting, and internal fixation. The results for these patients were compared with those for ten patients in whom functional limitation after complete healing of a fracture of the distal end of the radius in a malreduced position had been treated with late reconstruction (an average of forty weeks [range, thirty to forty-eight weeks] after the injury) consisting of an osteotomy, corticocancellous bone-grafting, and internal fixation. The average duration of follow-up was forty-eight months (range, twenty to 120 months) after the early reconstructions and thirty-four months (range, twenty-four to forty-eight months) after the late reconstructions. After the early reconstructions, flexion of the wrist averaged 45 degrees; extension of the wrist, 52 degrees; pronation of the forearm, 79 degrees; and supination of the forearm,77 degrees, compared with 42, 45, 77, and 68 degrees, respectively, after the late reconstructions. Grip strength averaged forty-two kilograms after the early reconstructions, compared with twenty-five kilograms after the late ones. One patient from each cohort had mild pain in the radiocarpal joint. According to the scale of Fernandez, there were seven excellent and three good results after the early reconstructions, and one excellent, seven good, and two fair results after the late reconstructions. Complications included a rupture of the extensor pollicis longus tendon twelve weeks after one of the early reconstructions, persistent pain at the donor site of the iliac-crest bone graft after a late reconstruction, and a delayed union that necessitated a second procedure after another late reconstruction. We believe that the results of early and late reconstruction of malunited fractures of the distal end of the radius are comparable. For patients who have radiographic characteristics that are predictive of persistent functional limitation, early reconstruction is technically easier and reduces the over-all period of disability.
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Shoulder function after surgical treatment of displaced fractures of the humeral shaft: a randomized trial comparing antegrade intramedullary nailing with minimally invasive plate osteosynthesis
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Minimally invasive plate osteosynthesis for humeral shaft fractures has been described recently, but there are no randomized studies comparing the clinical results for shoulder function between this technique and locking intramedullary nailing. METHODS: A prospective randomized study was performed. Fortyâ?one humeral shaft fractures (40 patients) were randomized to be treated with a minimally invasive plate (n = 21) or a locking intramedullary nail (n = 19). Clinical and radiographic outcome assessments were conducted at 1 year postoperatively. Shoulder function was the primary outcome, as measured by the University of California, Los Angeles Shoulder Scale. Elbow function was measured by the Brobergâ?Morrey score, and fracture consolidation and complications were the main secondary outcomes. RESULTS: At 1 year postoperatively, no significant difference was found with regard to shoulder function according to the University of California, Los Angeles scale between the minimally invasive plate and locking intramedullary nail (31.4 points vs 31.2 points, P = .98). There was also no difference in elbow function (94.8 points vs 94.1 points, P = .96). Complications were similar between the groups, without significant differences regarding infection (P > .99), symptomatic shoulder stiffness (P = .488), and neurapraxia of the lateral cutaneous nerve of the forearm (P = .475). Fracture union was achieved in all but 1 patient (2.4%) in the intramedullary nail group within 1 year after the surgical procedure. CONCLUSION: There is no significant difference in shoulder function between antegrade intramedullary nailing and minimally invasive plate osteosynthesis for the treatment of displaced humeral shaft fractures, despite the limited power of our study.
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Fully Awake Breast Reduction
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Reduction Mammoplasty for Female Breast Hypertrophy
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The authors present 25 cases and an in-depth 4-minute video of fully awake aesthetic breast reduction, which was made possible by thoracic epidural anesthesia. There are obvious and important advantages to this technique. Not only does this allow for intraoperative patient cooperation (i.e., patient self-positioning and opinion for comparison of breasts), meaning a shorter and more efficient intraoperative time, there also is a reduction in postoperative pain, complications, recovery, and discharge times. The authors have also enjoyed great success and no complications with this technique in over 150 awake abdominoplasty/total body lift patients. The authors feel that the elimination of the need for general anesthesia by thoracic epidural sensorial-only anesthesia is a highly effective and efficient technique, with very few disadvantages/complications, providing advantages to both patients and surgeons.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Location of the ankle center for total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: The purpose of this study was to investigate the ankle center position as determined from the malleoli for total knee arthroplasty (TKA).
METHODS: We retrospectively analyzed computed tomography data from 102 patients with osteoarthritic knees. The tibial anteroposterior (AP) axis and transmalleolar axis (TMA) were used as rotational reference axes of the knee and ankle joint, respectively. With these axes, we regarded the offset distance from the intermalleolar midpoint as the position of the ankle center and investigated any angular osteotomy errors on the proximal tibia when the ankle center was assumed to the intermalleolar midpoint.
RESULTS: The mean offset distances relative to the tibial AP axis were 1.8+/-0.9mm medial and 4.2+/-1.2mm anterior, and the distances relative to the TMA were 3.0+/-0.9 and 3.6+/-1.1mm in the coronal and sagittal planes, respectively. Mean angular osteotomy errors were 0.3+/-0.2degree in the coronal plane and 0.8+/-0.2degree in the sagittal plane.
CONCLUSIONS: The ankle center was located around the intermalleolar midpoint. The position of the ankle center observed along the knee reference axis further approached the intermalleolar midpoint than when observed along the ankle reference axis in the coronal plane, but not in the sagittal plane. And the coronal angular osteotomy error was smaller than the sagittal error. Therefore, the intermalleolar midpoint in the coronal plane is a reliable landmark for the ankle center during TKA. However, surgeons should be cognizant of this sagittal angular error.
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Injury specific trauma registry: Outcomes of a prospective cohort with proximal femur fractures
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Hip Fx in the Elderly 2019
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Background: The elderly population is prone to hip fractures, and treating such patients to achieve good outcomes can be challenging. Collection of outcomes data can support clinicians to modify their treatment protocols and improve outcomes over time. The aim of this study is to compare different surgical procedures in patients with neck of femur and intertrochanteric fractures in terms of clinical, functional and radiological outcomes using injury-specific outcome scores.
Methods: The study data was derived from the existing single-center, prospective orthopaedic trauma registry initiated from July 2015. Functional, clinical and radiological outcomes were assessed using Modified Harris Hip Score and The Radiographic Union Score for Hip. Mean radiological outcome scores was compared by Mann-Whitney U test and deaths by Chi-square and Odds ratio.
Results: Of the total 138 patients, 53 (38%) were neck of femur and 85 (62%) Intertrochanteric fractures with fall as leading cause of injury. At 12 months follow-up, modified Harris Hip Score showed 67% excellent-good results in both dynamic hip screw (N=6) and total hip replacement (N=3) followed by 50% in intramedullary nail (N=2). Hemiarthroplasty has fair-poor outcomes with significantly higher deaths as compared to other procedure groups (p=0.016). Radiological outcomes showed non-significant trend towards better outcomes in dynamic hip screw as compared to intramedullary nail (p=0.08).
Conclusion: Our 12 months follow-up data suggest that dynamic hip screw and total hip replacement have better clinical, functional outcomes followed by intramedullary nail. Hemiarthroplasty has fair-poor clinical and functional outcomes with significantly higher deaths as compared to other procedure groups.
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Comparative outcomes of combined corticosteroid with low volume compared to high volume of local anesthetic in subacromial injection for impingement syndrome: systematic review and meta-analysis of RCTs
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Trial Systematic Review Project
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Subacromial impingement syndrome (SIS) is one of the most frequent pathologies of the shoulder, which may cause serious restriction of daily activities and lifestyle changes. Corticosteroid injection (CI) into the subacromial space is a palliative treatment option. Currently, there have been no studies that compare between the different volumes of CI injection. We have conducted a systematic review and meta-analysis to answer our specific study questions: Are high volume (< 5 ml) better than low volume (= 5 ml) of CI injection with respect to pain reduction? This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Relevant studies were identified from Medline and Scopus from inception to May 11, 2017 that reported American shoulder and elbow surgeons (ASES) function score, pain visual analog score (VAS), and postoperative complications of either group. Fifteen studies were included for the analysis of high volume (more than or equal 5 ml), and 5 studies were included for analysis of low volume (less than 5 ml). Overall, there were 1101 patients (732 in the high-volume group and 369 in the low-volume group). A pooling of mean VAS and ASES function score was (N = 557) 2.02 (95% CI 1.52, 2.53), (N = 190) 82.59 (95% CI 76.92, 88.27) in high-volume group and (N = 179) 2.60 (95% CI 1.94, 3.26), (N = 95) 84.65 (95% CI 81.64, 86.82) in low-volume group, respectively. The unstandardized mean difference of ASES and VAS of high volume was - 0.58 (95% confidence interval (CI): - 1.38, 0.22) and - 2.06 (95% CI - 8.35, 4.23) scores lower than low-volume CI in SIS patients, but without statistical significance. A total of 11 studies in the high-volume group and 4 studies in the low-volume group reported adverse effects. The total complication rate per patient was 6.2% (2.3, 10.1%) in the high-volume group and 11.7% (0.3, 12%) in the low-volume group (p = 0.091). No significant differences were noted for complications. In subacromial impingement syndrome, the corticosteroid injection had acceptable pain and functional outcomes. Higher volume had a lower ASES, VAS, and risk of having complication when compared to lower volume. However, there are no statistically significant differences between groups. Larger, randomized noninferiority or equivalent trial studies are needed to confirm these findings as the current literature is still insufficient. Level of evidence I.
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Perioperative chronic use of statins and the risk of muscle complaints in patients undergoing knee and hip endoprosthesis surgery
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AAHKS (4) Acetaminophen
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Study Objective: To assess whether regular statin therapy enhances muscular and hepatic deterioration and muscle complaints in patients undergoing elective arthroplasty. Design: Prospective, case-controlled, observational study. Setting: Tertiary-level university teaching hospital in Eastern Finland. Patients: 48 ASA physical status I, II, and III patients, aged 51 to 84 years, 24 of whom were scheduled for hip arthroplasty (12 pts with and 12 without statin therapy) and 24 patients who were to undergo knee arthroplasty (12 pts with and 12 without statin therapy). Interventions: Before and after surgery, all patients were interviewed for muscular and hepatic symptoms and signs. Main Measurements: S-creatine kinase, S-alanine aminotransferase, P-creatinine, S-lactate dehydrogenase, P-potassium, S-myoglobin, and U-myoglobin were measured at baseline and at 6, 24, and 72 hours after surgery. Main Results: S-creatine kinase and S-myoglobin increased in all study groups at 6 hours after surgery and remained elevated for 72 hours, with no differences noted in patients treated with or without statins. There was no increase in the amount of muscular or hepatic complaints after surgery. Conclusion: Long-term statin therapy does not appear to increase the risk of muscular adverse effects in patients receiving major endoprosthesis surgery. © 2010 Elsevier Inc. All rights reserved.
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Rates, trends, and severity of depression after burn injuries
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DoD PRF (Psychosocial RF)
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It is commonly assumed that patients hospitalized for burn treatment will experience some level of depression. However, little is known about the trends in severity of depression over time. The purpose of this study was to determine the rates and severity of depression over a 2-year period. The Beck Depression Inventory was administered at 1 month (N = 151), 1 year (N = 130), and 2 years (N = 125) after discharge. At 1 month, 54% of patients showed symptoms of moderate to severe depression, and at 2 years, 43% of the patients responding still reported moderate to severe depression. The average correlation between scores over time was high. Women had higher depression scores than men at each time period. An interaction between gender and having a head or neck injury was also observed at 1 month and 1 year after discharge. Results suggest that routine outpatient screening for depression is warranted.
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Effects of Aquatic Training and Bicycling Training on Leg Function and Range of Motion in Amateur Athletes with Meniscal Allograft Transplantation during Intermediate-Stage Rehabilitation
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AMP (Acute Meniscal Pathology)
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Meniscal allograft transplantation (MAT) is a treatment modality for restoring knee function in patients with irreversible meniscal injury. Strengthening programs to promote functional recovery are treated with caution during the intermediate rehabilitation phase following MAT. This study analyzed the effects of aquatic training (AQT) and bicycling training (BCT) during the intermediate stage of rehabilitation in amateur athletes that underwent MAT. Participants (n = 60) were divided into AQT (n = 30) and BCT (n = 30) groups. Both groups performed training three times per week from 6 to 24 weeks following surgery. International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) score, knee joint range of motion (ROM), isokinetic knee strength, and Y-balance test (YBT) performance were evaluated. All measured variables for the AQT and BCT groups improved significantly after training compared with pre-training values. The IKDC score and YBT were significantly higher for AQT than for BCT. The knee flexion ROM and isokinetic muscle strength were significantly improved in the BCT group compared to those in the AQT group. The AQT group exhibited greater improvement in dynamic balance, whereas BCT provided greater improvement in isokinetic muscle strength. AQT and BCT were effective in reducing discomfort and improving knee symptoms and functions during intermediate-stage rehabilitation following MAT in amateur athletes.
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Blister formation with negative pressure dressings after total knee arthroplasty
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PJI DX Updated Search
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Background Negative pressure wound dressings have revolutionized the treatment of open wounds by stimulating the formation of granulation tissue and hastening wound closure. We hypothesized that negative pressure therapy in the immediate postoperative period after total knee arthroplasty (TKA) in high-risk patients would also hasten the time to a dry wound. Methods This prospective, randomized trial compared the number of days to a dry wound after TKA with application of a negative pressure dressing compared with sterile gauze dressing in 51 patients undergoing 60 TKA surgeries (9 bilateral). Patients undergoing primary TKA who were obese (BMIZ30) and received enoxaparin were randomized to receive either a negative pressure dressing or sterile gauze for 48 hours postoperatively. The days to a dry wound, total weight of drainage, number of gauze dressings used, duration of hospital stay and infection rate were recorded. Results Twenty-four knees received negative pressure therapy and 36 knees had sterile gauze placed. There was no significant difference in the primary endpoint of days to a dry wound (4.3 days with negative pressure and 4.1 days with sterile gauze). There were two postoperative infections, one in each arm of the study. The study was stopped prematurely when 15 of 24 knees (63%) treated with the negative pressure wound dressing developed skin blisters. Conclusions Negative pressure wound therapy did not appear to hasten wound closure and was associated with blisters. There does not appear to be a benefit to the routine use of negative pressure wound dressings in the immediate postoperative TKA period. é 2011 Wolters Kluwer Health | Lippincott Williams &Wilkins
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Pharmacoeconomic analysis of osteoporosis treatment with risedronate
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HipFx Supplemental Cost Analysis
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Hip fracture is an important and costly problem. Therapy with the bisphosphonate risedronate effectively prevents hip and other fractures among women with established osteoporosis. Risedronate is a first-choice therapy option in the German Guidelines of the Dachverband Osteologie for Osteoporosis according to evidence-based medicine criteria for the treatment of postmenopausal osteoporosis, osteoporosis of the elderly (women aged > 75 years) and glucocorticoid-induced osteoporosis. There are few published economic evaluations of bisphosphonates in Germany. Therefore, an assessment of the cost-effectiveness of risedronate utilizing a state transition Markov model of established postmenopausal osteoporosis based on randomized clinical trial data was developed. Uncertainty underlying model parameters and outcomes was dealt with using traditional sensitivity analysis and stochastic sensitivity analysis to produce quasi-95% Cls. We focused on patients aged 70 years, since this population most closely matches the randomized controlled trial and is typical of osteoporosis patients in Germany. The baseline model was a cohort of 1,000 70-year-old women, who received risedronate for 3 years and were followed up for an overall observation period of 10 years, modelling transitions through estimated health states and evaluating outcomes. Over the 3-year treatment period and 10-year observation period, risedronate dominated the current average basic treatment in Germany. In the risedronate group 33 hip fractures were averted and 32 quality-adjusted life years (QALYs) were gained (discounted values). Risedronate treatment saves costs for German social insurance: the present net value of the associated costs from the perspective of German social insurance is [symbol: see text]10.66 million if risedronate treatment is used versus [symbol: see text]11 million if basic treatment is used. Thus, net savings of [symbol: see text]340,000 for the treatment group per 1,000 treated women were calculated. Furthermore, risedronate treatment is cost effective from the perspective of the statutory health insurance with costs per averted hip fracture in the analyzed population of [symbol: see text]33,856 and cost per QALY gained of [symbol: see text]35,690. Both results demonstrate cost-effectiveness and are far below the accepted threshold level of [symbol: see text]50,000. Based on this analysis, risedronate is a cost-effective treatment for postmenopausal osteoporosis within the German health care system, offering benefits for osteoporotic patients and for budget decision-makers
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Mud-Bath Therapy in Addition to Usual Care in Bilateral Knee Osteoarthritis: An Economic Evaluation Alongside a Randomized Controlled Trial
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AAHKS (4) Acetaminophen
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Objective: To perform a cost-effectiveness analysis of mud-bath therapy (MBT) in addition to usual treatment compared to usual treatment alone in patients with bilateral knee osteoarthritis (OA). Methods: An economic evaluation alongside a randomized controlled trial was conducted. Patients were randomly assigned to receive either a 2-week cycle of MBT in addition to their usual treatment or to continue routine care alone. The EuroQol 5-domain questionnaire was administered at baseline, 2 weeks, and at 3, 6, 9, and 12 months. Direct health care resource consumption data up until 12 months were derived from a daily diary given to patients and returned at prescheduled followup visits. Results: A total of 103 patients were included (n = 53 for MBT patients; n = 50 for controls). Overall, patients in the MBT group accrued mean ± SD 0.835 ± 0.10 quality-adjusted life years (QALYs) compared to 0.753 ± 0.11 in the control group (P < 0.001). Average direct costs per patient (�303 versus �975; P < 0.001) were higher in the control group, primarily because of hospitalization for total knee replacement and use of intraarticular hyaluronic acid. Bootstrapping replications of costs and QALY sample distributions consistently indicated that the MBT therapy combined with standard therapy represents a dominant strategy as compared with standard therapy alone. The probability of MBT being cost-effective at standard cost-effectiveness thresholds (e.g., �20,000/QALY) is 100%. Conclusion: The results of this cost-effectiveness analysis support the use of MBT as midterm complementary therapy in the management of knee OA.
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