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Stereoscopic spot filming in arthrography
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AMP (Acute Meniscal Pathology)
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Stereoscopic spot filming has proven efficacious on selective occasions where overlying structures have hindered the diagnosis of meniscal tears. Arthrograms performed for the localization of loose bodies or bony or chondral defects benefit from stereoscopy so frequently that we use the technique as routine for these cases. By dint of its simplicity and economy, stereoscopic spot filming deserves a place in the diagnostic armamentarium of the experienced arthrographer.
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Lifetime fracture risk: an approach to hip fracture risk assessment based on bone mineral density and age
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Management of Hip Fractures in the Elderly
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Hip fractures occur late in life following a substantial reduction in skeletal mass. If risk for such fractures could be predicted early, efforts to prevent excessive bone loss would be more successful and could be directed at the individuals most likely to be affected. With this objective in mind, we devised an approach to estimating the lifetime risk of a proximal femur fracture based on age and on current femoral bone mineral density, using population-based data from ongoing studies of osteoporosis and fractures among Rochester, Minnesota, women. Our calculations indicate that, at any given age, the lifetime risk of a proximal femur fracture rises as current bone density diminishes. At any given level of femoral bone density, lifetime risk rises with younger age and increasing life expectancy. While these trends seem robust, estimates of risk vary substantially with the assumptions that underlie the model. Consequently, these assumptions must be validated before our findings can be applied clinically to predict risk for individual patients
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Elbow interposition arthroplasty in children and adolescents: Long-term follow-up
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Distal Radius Fractures
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A long-term follow-up was made of 12 elbows operated upon between 1971 and 1986, with more than 20 years' follow-up, in nine males and three females, age at the time of surgery between 10 and 19 years . Eight right and four left elbows were involved, and there were three aetiological causes. Seven cases were sequelae of elbow fractures, of which five were supracondylar and two were of the olecranon. There were four cases of juvenile rheumatoid arthritis and one was post-osteomyelitis. The surgical technique involved a modification made by Vainio of MacAusland's technique (wider resection of the osseous ends and total covering of the bloody surfaces) [5, 9]. After extirpating the tissue blocking the joint, we proceeded to remodel the distal humerus in a wide V shape, the proximal end of the ulnar and, if necessary, the radial head. The proximal end of the ulna was sectioned transversely. All surgery was carried out sub-periosteally. Then, an interposition material was placed in one piece and sutured over the distal humerus and cut ends of the ulna and radius. The articular ends were brought together, and the capsule was closed using equidistant stitching, as is the skin. A small compression bandage was applied, and the arm was immobilised with a collar and cuff sling, with the forearm flexed to slightly less than a right angle. In ten cases, the interposition material was fascia lata grafts; in one case, skin graft and in one case, Gelfoam graft. Early rehabilitation began when post-operative pain allowed. Follow-up ranged from 25 to 32 years. Pre-surgical movement ranged between 90° and 120° of flexion and 30° and 90° of extension. Post-operative range varied between 90° and 150° of flexion. The five cases of full pre-operative ankylosis achieved between 90° and 150° of flexion and between 0° and 70° of extension. The total range of motion at the latest follow-up varied from 35° to 150°. Patients who were able to perform flexion of 120° or more were considered to be excellent, those between 90° and 119° were graded good, from 60° to 89° fair and those 59° or less poor. The ability to attain a hand to mouth position requires a mobility of 120°. We obtained excellent results in two patients, good results in three, fair results in four and poor results in three. The fascia lata was used in 83% of cases, obtaining excellent to good results in five patients (41%). Elbow interposition arthroplasty has its indications in children and adolescents where arthrodesis or total joint replacement cannot be performed. © 2007 Springer-Verlag.
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The relationship between physical and mental health variables in individuals with spinal cord injury from Latin America
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DoD PRF (Psychosocial RF)
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BACKGROUND: Previous research has examined the health-related quality of life (HRQOL) and mental health of persons with spinal cord injury (SCI), but the majority of the research has taken place in the United States, Western Europe, and other developed countries. Limited research has been conducted with persons with SCI in Latin America.
OBJECTIVE: To examine the relationship between HRQOL and mental health in persons with SCI from Neiva, Colombia.
DESIGN: Cross-sectional.
SETTING: Participants were recruited from the Foundation for the Integral Development of People with Disabilities, a nonprofit community organization for persons with disabilities.
PARTICIPANTS: Forty persons with SCI from Neiva, Colombia.
METHODS: Caregivers completed the Spanish versions of questionnaires.
MAIN OUTCOME MEASURES: Participants completed self-report measures of HRQOL (SF-36 Health Questionnaire) and mental health (Satisfaction with Life Scale, Patient Health Questionnaire-9, and State Trait Anxiety Inventory).
RESULTS: The hypothesis that higher HRQOL would be related to better mental health found robust support, as the canonical correlation between these 2 sets of variables uncovered that 50.4% of the variance was shared, such that persons with lower HRQOL had reduced mental health. Within this canonical correlation, anxiety, fatigue, and general health loaded most highly, suggesting that persons with SCI who experienced lower energy and reduced general health tended to have high anxiety. Additionally, 9 out of the 18 bivariate correlations between these 2 variable sets were statistically significant.
CONCLUSIONS: In Latin America, SCI rehabilitation services are extremely sparse and rarely include interventions that target postinjury mental health. The current study suggests that mental health issues in patients with reduced HRQOL warrant attention in SCI rehabilitation services, especially in this region.
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Diagnosis and referral of rheumatoid arthritis by primary care physician: Results of a pilot study on the city of Pisa, Italy
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The aims of the present study were to evaluate, in the city of Pisa: (1) the prevalence of rheumatoid arthritis; (2) the reliability of the prevalence estimated by primary care physicians, using the rheumatologist's diagnosis as the "gold standard" and (3) the economic impact of the disease. The Tuscany registry of primary care physicians constituted the framework from which a sample of subjects was selected. The rheumatoid arthritis (RA) subjects >18 years followed by each primary care physician constituted the population studied. Each general practitioner (GP) was asked to fill out a questionnaire regarding their patients affected by RA and to send it to the tertiary rheumatologic centre, where the diagnosis was confirmed/discarded, the clinical and epidemiological data were collected in a standardized form and a number of data for the estimation of costs were gathered. The estimated prevalence of RA was 5.1 per thousand (CI, 4.4-5.7). The reliability of general practitioners in the diagnosis of rheumatoid arthritis was on the whole 69%. However, when an analysis of every physician was carried out, a high degree of heterogeneity in the prevalence of RA per physician was found. Overall, the mean annual cost per patient with RA was estimated at about 5,878 euros ((euro); median, 6,434 (euro); inter quartile range, 669-7,052 (euro)), with a high variability mainly dependent on the degree of patient disability. More than 90% of the overall annual cost per patient was due to the medical and non-medical direct components of costs. The prevalence of RA in Tuscany seems highly comparable with similar prevalence studies in Italy. The annual cost per patient with RA was highly variable and strictly dependent on the level of disability. More than 90% of the overall cost was due to the direct burden of costs. (copyright) 2009 Clinical Rheumatology
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The Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis
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Surgical Management of Osteoarthritis of the Knee CPG
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The Knee injury and Osteoarthritis Outcome Score (KOOS) was developed as an extension of the WOMAC Osteoarthritis Index with the purpose of evaluating short-term and long-term symptoms and function in subjects with knee injury and osteoarthritis. The KOOS holds five separately scored subscales: Pain, other Symptoms, Function in daily living (ADL), Function in Sport and Recreation (Sport/Rec), and knee-related Quality of Life (QOL). The KOOS has been validated for several orthopaedic interventions such as anterior cruciate ligament reconstruction, meniscectomy and total knee replacement. In addition the instrument has been used to evaluate physical therapy, nutritional supplementation and glucosamine supplementation. The effect size is generally largest for the subscale QOL followed by the subscale Pain. The KOOS is a valid, reliable and responsive self-administered instrument that can be used for short-term and long-term follow-up of several types of knee injury including osteoarthritis. The measure is relatively new and further use of the instrument will add knowledge and suggest areas that need to be further explored and improved
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Fixation of acetabular fractures. A novel method of pre-operative omega plate contouring
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose Of The Study The aim of the study was to describe a novel Omega plate and the procedure for obtaining an accurate pelvic inlet view, the mode of pre-operative plate contouring, the surgical procedure used and the evaluation of results in the first 15 patients treated using this method. Material And Methods In the period 2009-2011, a total of 232 patients underwent osteosynthesis for pelvic fractures. Out of them, 52 were treated by the modified Stoppa approach and 12 with the original Omega plate. Between July 2010 and January 2014, a novel 3.5-mm Omega plate was used in 12 men and 3 women. The average duration of follow-up was 8.5 months in 11 patients; four were shortly after surgery. The multi-functional Omega plate is described in detail. An exact pelvic inlet projection, named the "computer tomography-defined (CTD) view", was based on pre-operative CT examination. It facilitates pre-operative contouring of the plate according to a mirror image of the uninjured half of the pelvis. The surgical procedure enables us to apply the contoured plate to the correct position; the plate completes reduction, restores normal pelvic anatomy and makes operative time shorter. The radiographic evaluation of post-operative results was done using the Matta classification and functional outcome was assessed by the Harris Hip Score.Results Surgery using the isolated Stoppa approach was carried out in 11 patients and a procedure combining the Stoppa approach with another method was used in four patients. All operations were successfully completed, during two of them the external iliac vein was injured and treated by vascular suturing. No other vascular or nerve injury occurred. One deep wound infection successfully healed was recorded. The post-operative radiographic results were excellent or satisfactory in 12 and poor in three patients. At follow-ups of 6 to 12 months, no failure of fracture reduction or osteosynthesis was recorded in 11 patients. Neither avascular necrosis of the femoral head nor heterotopic ossification was found. One patient showed signs of post-injury arthritis at 6 months after surgery. The functional result assessed by the Harris Hip Score was excellent in seven patients, good in two (one of them with gonarthrosis), satisfactory in one patient with contralateral total hip replacement and ipsilateral gonarthrosis, and poor in one patient with hemiparesis after a stroke.Discussion Shape and size variability in CTD pelvic inlet views do not allow us to create a unified anatomically correct implant. Contouring during the operative procedure may not be accurate enough and significantly prolongs the time of surgery. Therefore, a custom-made plate for each patient seems to be an optimal method. It has been demonstrated on a group of 50 patients that CTD images of the right and left halves of the pelvis are identical in 68% and very similar (variation in length up to 5 mm and in curvature up to 3 mm) in 18%. At present plate contouring according to a mirror image of the acetabulum, which will be obtained by III printing, is prepared. Conclusions Pre-operative contouring of an Omega plate based on a post-injury CT scan of the uninjured half of the pelvis is over 80% accurate or almost accurate. The multi-functional 3.5-mm pelvic plate Omega allows us to stabilise complicated fractures of the superior ramus of the pubic bone, anterior acetabular column or quadrilateral plate as well as fractures above the linea arcuata or uncomplicated fractures of the posterior column. The stabilisation of all fragments of the anterior column and quadrilateral plate is very firm and the Omega plate is resistant to fragment redisplacement. Also, it is its advantage that it can remain in situ if total hip arthroplasty is required later
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Ultrasound screening for developmental dysplasia of the hip and its socioeconomic impact: Experience of tertiary care health level
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Developmental Dysplasia of the Hip 2020 Review
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Objective: The purpose of this study was to investigate the usefulness of screening ultrasound to detect developmental dysplasia of the hip in infants with risk factors and to assess its socioeconomic impact. Patients and methods: This is a retrospective study. In the duration of 30. months, all infants born at Hospitals in our region were examined clinically for hip dislocation. All those with clinically dislocated hips were excluded and referred for follow up to a pediatric orthopedic surgeon. After referral to our tertiary care center, a 6. week hip ultrasound scan was performed for those infants with stable hips on examination, having risk factors for dysplastic hips including positive family history, breech presentation and inconclusive clinical findings.We used an ultrasound technique that combines the two known methods (Graf's technique and Harcke's method). Results: 3540 Hip ultrasound scans were performed, of those scanned 12 (0.33%) were found to have dislocated hips and 98 (2.8%) to have different grades of dysplastic hips. Among these twelve patients; six of them had a first degree relative with congenital dislocation of hips, three had breech presentation at birth and three had inconclusive clinical findings. Those with dysplastic hips were followed up by serial ultrasound examinations but did not require active intervention. Conclusion: Screening ultrasound is a useful tool for detection of hip dislocation and dysplasia especially among the population of infants at increased risk of developmental dysplasia of the hip. Limitation of screening ultrasound programs for those at risk only reduces the financial burden with better outcome in choosing candidates for further workup especially surgical intervention. © 2014.
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Cartilage Repair With Autologous Bone Marrow Mesenchymal Stem Cell Transplantation: Review of Preclinical and Clinical Studies
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Osteochondritis Dissecans 2020 Review
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Clinical trials of various procedures, including bone marrow stimulation, mosaicplasty, and autologous chondrocyte implantation, have been explored to treat articular cartilage defects. However, all of them have some demerits. We focused on autologous culture-expanded bone marrow mesenchymal stem cells (BMSC), which can proliferate without losing their capacity for differentiation. First, we transplanted BMSC into the defective articular cartilage of rabbit and succeeded in regenerating osteochondral tissue. We then applied this transplantation in humans. Our previous reports showed that treatment with BMSC relieves the clinical symptoms of chondral defects in the knee and elbow joint. We investigated the efficacy of BMSC for osteoarthritic knee treated with high tibial osteotomy, by comparing 12 BMSC-transplanted patients with 12 cell-free patients. At 16-month follow-up, although the difference in clinical improvement between both groups was not significant, the arthroscopic and histological grading score was better in the cell-transplanted group. At the over 10-year follow-up, Hospital for Special Surgery knee scores improved to 76 and 73 in the BMSC-transplanted and cell-free groups, respectively, which were better than preoperative scores. Additionally, neither tumors nor infections were observed in all patients, and in the clinical study, we have never observed hypertrophy of repaired tissue, thereby guaranteeing the clinical safety of this therapy. Although we have never observed calcification above the tidemark in rabbit model and human histologically, the repair cartilage was not completely hyaline cartilage. To elucidate the optimum conditions for cell therapy, other stem cells, culture conditions, growth factors, and gene transfection methods should be explored.
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Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears
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Optimizing the Management of Full-Thickness Rotator Cuff Tears
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BACKGROUND: Treatment of irreparable rotator cuff tears remains controversial. Latissimus dorsi transfer to the greater tuberosity has been proposed for the treatment of irreparable tears associated with severe functional impairment and chronic, disabling pain. METHODS: Sixty-seven patients with sixty-nine irreparable, full-thickness tears of at least two complete tendons were managed with latissimus dorsi transfer and were reviewed clinically and radiographically after an average of fifty-three months. The study group included fifty-two men and fifteen women, with an average age of sixty-one years. Thirteen patients also had deficient subscapularis function preoperatively. Outcome measures included the Constant and Murley score and the Subjective Shoulder Value. Osteoarthritis and acromiohumeral distance were measured on standardized radiographs. RESULTS: The mean Subjective Shoulder Value increased from 28% preoperatively to 66% at the time of follow-up (p < 0.0001). The mean age and gender-matched Constant and Murley score improved from 55% to 73% (p < 0.0001). The pain score improved from 6 to 12 points (of a possible 15 points) (p < 0.0001). Flexion increased from 104 degrees to 123 degrees , abduction increased from 101 degrees to 119 degrees , and external rotation increased from 22 degrees to 29 degrees (p < 0.05). Abduction strength increased from 0.9 to 1.8 kg (p < 0.0001). There was a slight but significant increase in osteoarthritic changes (from stage 0.8 to stage 1.3; p = 0.0002). In shoulders with a negative preoperative lift-off test, significant improvements were observed in terms of both function and pain, and strength doubled from 1.0 to 2.0 kg (p = 0.0001), but osteoarthritic changes progressed from stage 0.7 to stage 1.1 (p = 0.0006). In shoulders with poor subscapularis function, no improvement in these parameters was observed. CONCLUSIONS: Latissimus dorsi transfer durably and substantially improves chronically painful, dysfunctional shoulders with irreparable rotator cuff tears, especially if the subscapularis is intact. If subscapularis function is deficient, the procedure is of questionable benefit and probably should not be used
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A Randomized, Multicenter, Phase III Trial to Evaluate the Efficacy and Safety of Polmacoxib Compared with Celecoxib and Placebo for Patients with Osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Background: The aim of this study was to evaluate the safety and analgesic efficacy of polmacoxib 2 mg versus placebo in a superiority comparison or versus celecoxib 200 mg in a noninferiority comparison in patients with osteoarthritis (OA).
Methods: This study was a 6-week, phase III, randomized, double-blind, and parallel-group trial followed by an 18-week, single arm, open-label extension. Of the 441 patients with knee or hip OA screened, 362 were randomized; 324 completed 6 weeks of treatment and 220 completed the extension. Patients were randomized to receive oral polmacoxib 2 mg (n = 146), celecoxib 200 mg (n = 145), or placebo (n = 71) once daily for 6 weeks. During the extension, all participants received open-label polmacoxib 2 mg. The primary endpoint was the change in Western Ontario and McMaster Universities (WOMAC)-pain subscale score from baseline to week 6. Secondary endpoints included WOMAC-OA Index, OA subscales (pain, stiffness, and physical function) and Physician's and Subject's Global Assessments at weeks 3 and 6. Other outcome measures included adverse events (AEs), laboratory tests, vital signs, electrocardiograms, and physical examinations.
Results: After 6 weeks, the polmacoxib-placebo treatment difference was -2.5 (95% confidence interval [CI], -4.4 to -0.6; p = 0.011) and the polmacoxib-celecoxib treatment difference was 0.6 (CI, -0.9 to 2.2; p = 0.425). According to Physician's Global Assessments, more subjects were "much improved" at week 3 with polmacoxib than with celecoxib or placebo. Gastrointestinal and general disorder AEs occurred with a greater frequency with polmacoxib or celecoxib than with placebo.
Conclusions: Polmacoxib 2 mg was relatively well tolerated and demonstrated efficacy superior to placebo and noninferior to celecoxib after 6 weeks of treatment in patients with OA. The results obtained during the 18-week trial extension with polmacoxib 2 mg were consistent with those observed during the 6-week treatment period, indicating that polmacoxib can be considered safe for long-term use based on this relatively small scale of study in a Korean population. More importantly, the results of this study showed that polmacoxib has the potential to be used as a pain relief drug with reduced gastrointestinal side effects compared to traditional nonsteroidal anti-inflammatory drugs for OA.
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The effect of storage time on adipose-derived stem cell recovery from human lipoaspirates
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Panniculectomy & Abdominoplasty CPG
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Multipotent adipose-derived stromal/stem cells (ASCs) can be isolated with high yield from human subcutaneous lipoaspirates. This study reports our experience isolating, expanding, differentiating and immunophenotypically characterizing ASCs over a period of 4 days after having surgically obtained the lipoaspirate samples. The ultimate goal is to understand how to optimize the consistent isolation of ASCs from lipoaspirates. The length of time between adipose tissue harvest and processing will need to be systematically evaluated with respect to cell yield, viability, and function since some distance is likely to exist between the plastic surgeon's office where lipoaspiration is performed and the current Good Manufacturing Practices (cGMP) laboratory where the ASCs are isolated. The objective of this study was to determine the effect of time delays on the yield and function of ASCs after collagenase digestion. We were able to isolate ASCs from lipoaspirates up to 72 h after the surgical procedure. The ASCs isolated on sequential days after the original tissue harvest proliferated, differentiated and maintained cell surface markers. We found that the initial 24-hour period is optimal for isolating ASCs with respect to cell yield and that there was no significant difference between ASC cell proliferation and differentiation ability within this period of time. In contrast, each of these parameters declined significantly for tissues maintained at room temperature for 48 or 72 h prior to isolation. These findings should be considered in the future development of standard operating procedures for cGMP processing of clinical-grade human ASCs.
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A phase II study of docetaxel and carboplatin with concurrent radiation therapy for locally advanced head and neck cancer
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Objective: In this study we evaluate the clinical response and safety profile of a regimen of docetaxel. +. carboplatin concurrent with radiotherapy (RT) in locally advanced squamous cell carcinoma of head and neck (HNSCC). Methods: Between January 2006 and December 2008, we enrolled 38 patients (stage IVA: 29 patients; stage III: 9 patients). Fourteen had oral cavity cancer (tongue 10, buccal mucosa 2, alveolar ridge 1, floor of mouth 1), 10 had oropharyngeal cancer (base of tongue 5, tonsil 5), 13 had laryngeal cancer, and 1 had maxillary sinus cancer. Patients received concurrent docetaxel 15mg/m(2) 1-h infusion plus carboplatin AUC of 2, 30-min infusion on days 1, 8, 15, 22, 29, and 36. RT began on day 1 of concurrent chemotherapy with 2cGy/fraction, 5 fractions/week (total dose: 66-70cGy). Tumor was assessed by CT scan 3 months post-completion of concurrent chemoradiotherapy. Results: Thirty-five patients were evaluated (2 refused to receive all treatments, 1 had serious adverse event [rash, wheezing] from docetaxel first dose). The primary study endpoint of clinical response was achieved in 26 (74.3%) patients, 6 (17.1%) had stable disease, and 3 (8.6%) had disease progression. The 2-year disease-free survival was 62.9% (CI: 45.85-79.95%). The 2-year overall survival was 64.1% (CI: 43.52-84.68%). The most common Grade 3 toxicities were mucositis, xerostomia and dysphagia (13.9% each) and dermatitis (11%). No Grade 4 toxicities were observed. Conclusion: In conclusion, this study with a limited number of patients, docetaxel. +. carboplatin concurrent with RT appears to show acceptable activity and is generally well tolerated in patients with locally advanced HNSCC. (copyright) 2010 Elsevier Ireland Ltd
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Optimizing Treatment Strategies in Myeloma Cast Nephropathy: Rationale for a Randomized Prospective Trial
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MSTS 2018 - Femur Mets and MM
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Renal failure is a frequent complication of multiple myeloma (MM) that strongly affects patient survival. Although a variety of renal diseases may be observed in MM, myeloma cast nephropathy (MCN), a tubulo-interstitial disorder related to precipitation of a monoclonal light chain (LC) within tubular distal lumens, is the main cause of severe and persistent renal failure. To date, the respective frequency and initial evolution of renal disorders associated with monoclonal LC in MM remain poorly defined. Treatment of MCN relies on urgent symptomatic measures and rapid introduction of chemotherapy to reduce the production of monoclonal LC. The introduction of novel chemotherapy regimens based on the association of bortezomib with dexamethasone is likely to have improved the prognosis of MM patients with renal failure. In addition, the combination of novel agents with efficient removal of circulating LC through high cut-off hemodialysis membrane may further increase renal response rate. However, the impact on patient and renal outcomes of these potential therapeutic advances has not been evaluated in prospective studies. The randomized trials EuLITE in the UK and Germany and MYRE in France should help to answer these issues. MYRE is a randomized controlled phase III trial (NCT01208818) that aims to better define the epidemiology and typology of inaugural renal failure in MM and to optimize therapy of MCN patients with and without dialysis-dependent renal failure. © 2012 National Kidney Foundation, Inc.
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Heart failure is a clinically and densitometrically independent risk factor for osteoporotic fractures: Population-based cohort study of 45,509 subjects
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Objective: The aim of the study was to determine whether heart failure is associated with an increased risk of major osteoporotic fractures that is independent of bone mineral density (BMD). Methods:Weconducted a population-based cohort study in Manitoba, Canada, by linking a clinical registry of all adults 50 yr ofageandolderwhounderwentinitialBMDtestingfrom1998- 2009 with administrative databases. We collected osteoporosis risk factors, comorbidities, medications, and BMD results. Validated algorithms identified recent-onset heart failure before the BMD test and new fractures after. The main outcome was time to major osteoporotic fractures (i.e. clinical vertebrae, distal forearm, humerus, and hip), and multivariable proportional hazards models were used for analyses. Results: The cohort consisted of 45,509 adults; 1,841 (4%) had recent-onset heart failure. Subjects with heart failure were significantly (P<0.001) older (74 vs. 66 yr) and had more previous fractures (21 vs. 13%) and lower total hip BMD [T-score, -1.3 (SD 1.3) vs. -0.9 (SD 1.2)] than those without. There were 2703 incident fractures over the 5-yr observation. Overall,10%of heart failure subjects had incident major fractures compared with 5% of those without [unadjusted hazard ratio (HR), 2.45; 95% confidence interval (CI), 2.11-2.85]. Adjustment for osteoporosis risk factors, comorbidities, and medications attenuated but did not eliminate this association (HR, 1.33; 95% CI, 1.11-1.60), nor did further adjustment for total hip BMD (HR, 1.28; 95% CI, 1.06-1.53). Conclusions: Heart failure is associated with a 30% increase in major fractures that is independent of traditional risk factors and BMD, and it also identifies a high-risk population that may benefit from increased screening and treatment for osteoporosis. Copyright © 2012 by The Endocrine Society.
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Iliac intramedullary stabilization for Type IIIA fragility fractures of the pelvis
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Hip Fx in the Elderly 2019
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There have been few reports on fixation of Rommens classification Type IIIA fragility fractures of the pelvis (FFPs). Here, we present our less invasive surgical technique, called iliac intramedullary stabilization (ILIS), for the internal fixation of Type IIIA FFPs. The technique involves a closed reduction, termed the femur internal rotation reduction method (FIRM), whereby the fracture fragments are repositioned using lateral rotators by internally rotating the femur while the patient is in the prone position. Two iliac screws are inserted on the ilium bilaterally via the supra-acetabular bone canal during FIRM and connected with two transverse rods and two cross connectors. We refer to this internal fixation procedure as ILIS. We retrospectively recruited patients with Type IIIA fractures, treated using this procedure, at our institute between October 2017 and October 2019. We evaluated operative and post-operative outcomes. We enrolled 10 patients (9 women and 1 man; mean age, 85.2 years) who were followed up for over 6 months. All patients suffered FFPs after falling from a standing position. The mean operative time was 145.1 (range, 94-217) minutes, and the mean blood loss was 258.5 (range, 100-684) ml. All patients were allowed full weight bearing from post-operative day 1. All patients achieved bone union and regained their pre-injury walking ability at 6 months after surgery without evident secondary displacement. In conclusion, our ILIS technique allows less invasive internal fixation of Type IIIA FFPs with adequate stability for full weight bearing from post-operative day 1.
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Surgical Treatment Strategy for Distal Humerus Intra-articular Fractures
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Treating distal humerus fractures, especially those involving intra-articular lesions, is complex and often technically demanding. Although there still exist many controversial issues, the goal of treatment is to establish anatomical stable fixation by restoring the two columns and the articular surface. Universally, a posterior midline incision is applied, and the approach varies according to the further management of the triceps or olecranon. Evidence supports dual plate fixation as the optimal fixation method, and debates regarding appropriate plating configuration are still ongoing. As multiple clinical studies comparing results of parallel and perpendicular plate fixation have shown no actual difference, it is important to place the plates according to the fracture configuration.
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Selective computed tomography-guided perisciatic injection as a diagnostic tool in multiple hereditary exostoses
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Multiple osteochondromas, also known as multiple hereditary exostoses, is an autosomal-dominant disease. Multiple osteochondromas are characterized by the development of cartilage-capped bony tumors, known as osteochondromas. Osteochondromas can cause limb deformities, limb-length discrepancies, angular deformations, bursitis, and impingement of adjacent tendons or neurovascular structures. They have also been reported as a cause of sciatic pain. Sometimes, more than 1 location of neural compression exists, thereby presenting a difficult diagnostic challenge for treating physicians. This article describes a patient with multiple hereditary exostoses and accompanying severe sciatic pain who was referred for a revision decompressive spine surgery. The patient's functional impairment was such that he was unable to sit for a few minutes. A selective computed tomography-guided perisciatic nerve injection was performed to differentiate between lateral spinal stenosis and peripheral nerve compression or impingement by an existing large pelvic osteochondroma. The patient reported substantial relief and regained the ability to sit pain free immediately postoperatively. Excision of a proximal femur osteochondroma was performed based on the results of a selective perisciatic nerve injection, resulting in successful resolution of his sciatic pain and functional impairment. The current case is an example of the diagnostic challenge in treating patients with multiple anatomic lesions that can cause symptoms and demonstrate how selective computed tomography-guided perisciatic nerve injection can aid clinicians in obtaining an accurate diagnosis and choosing the most appropriate surgical management
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The carpal tunnel syndrome: About a Tunisian hospital series
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background: Carpal tunnel syndrome (CTS) is the most frequent ductal syndrome. Few epidemiological studies in Tunisia exist. Aim: To describe clinical, biological and electromyographic data of Tunisian patients with CTS Methods: A retrospective study including 80 patients with CTS, during the period going from 2009 to 2010. Results: A female predominance was observed with an average age of 52 years. Acroparesthesia was the main complaint, followed by night awakenings and muscular weakness. Physical examination showed a positive Tinel (91.2%) and Phalen (82.5%) tests, a decrease of tactile sensitivity (26.2%) and a thenar amyotrophy (10%). The Electromyography was abnormal in 85% cases. The most revealing lesions were demyelinating, sensitivo-motor predominance (66%) abnormalities. on Biology, hyperglycemia (12.5%), hyperuricemia (8.7%) and renal failure (7.5%) were the most observed. Medical treatment was drawn on analgesics and anti-inflammatory for 90% of our patients. Local steroid injections were indicated for 35% of patients, leading to a clinical improvement in 90% of cases. Surgery was made in only 13.8% patients. Conclusion: Tunisian patients with CTS were female patients, housewifes with obesity or overweight. No other differences were observed in comparison with the literature
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Development of prognosis in palliative care study (PiPS) predictor models to improve prognostication in advanced cancer: Prospective cohort study
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MSTS 2022 - Metastatic Disease of the Humerus
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Objective: To develop a novel prognostic indicator for use in patients with advanced cancer that is significantly better than clinicians' estimates of survival. Design: Prospective multicentre observational cohort study. Setting: 18 palliative care services in the UK (including hospices, hospital support teams, and community teams). Participants: 1018 patients with locally advanced or metastatic cancer, no longer being treated for cancer, and recently referred to palliative care services. Main outcome measures: Performance of a composite model to predict whether patients were likely to survive for "days" (0-13 days), "weeks"(14-55 days), or "months+" (>55 days), compared with actual survival and clinicians' predictions. Results: On multivariate analysis, 11 core variables (pulse rate, general health status, mental test score, performance status, presence of anorexia, presence of any site of metastatic disease, presence of liver metastases, C reactive protein, white blood count, platelet count, and urea) independently predicted both two week and two month survival. Four variables had prognostic significance only for two week survival (dyspnoea, dysphagia, bone metastases, and alanine transaminase), and eight variables had prognostic significance only for two month survival (primary breast cancer, male genital cancer, tiredness, loss of weight, lymphocyte count, neutrophil count, alkaline phosphatase, and albumin). Separate prognostic models were created for patients without (PiPS-A) or with (PiPS-B) blood results. The area under the curve for all models varied between 0.79 and 0.86. Absolute agreement between actual survival and PiPS predictions was 57.3% (after correction for over-optimism). The median survival across the PiPS-A categories was 5, 33, and 92 days and survival across PiPS-B categories was 7, 32, and 100.5 days. All models performed as well as, or better than, clinicians' estimates of survival. Conclusions: In patients with advanced cancer no longer being treated, a combination of clinical and laboratory variables can reliably predict two week and two month survival.
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Blunt traumatic diaphragmatic rupture Single-center experience with 38 patients
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DoD SSI (Surgical Site Infections)
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Blunt traumatic diaphragmatic rupture (BTDR) is uncommon, but is associated with high rates of morbidity and mortality. The purpose of this study was to present our experience with management of this injury. Medical records of 38 patients with BTDR who were treated in our hospital from January 2001 to June 2016 were analyzed retrospectively. The sex, age, cause of injury, location of rupture, mode of diagnosis, time to diagnosis, the presence of herniation and bowel perforation, the presence of preoperative shock and intubation, Injury Severity Score (ISS), associated injuries, comorbidity, the operative procedure, morbidity and mortality, and the predictive factors affecting the outcome of BTDR were evaluated. There were 32 men (84.2%) and 6 women (15.8%) with a mean age of 51.2 years (range 18–84 years). The diagnosis could be preoperatively established in 28 patients (73.7%) with a plain chest X-ray or computed tomography scan. Rupture of diaphragm was left-sided in 31 patients (81.6%), right-sided in 6 (15.8%), and bilateral in 1 (2.6%). Sixteen patients had preoperative shock (systolic blood pressure <90 mm Hg, heart rate >120/min). Initial operative approaches were laparotomy in 22 patients (57.9%) and thoracotomy in 16 (42.1%). Eleven required additional exploration. The rate of additional exploration was higher in patients who initially underwent thoracotomy than laparotomy (56.2% vs 9.1%, P = .003). Patients who underwent additional exploration had a significantly longer operation time (330 minutes vs 237.5 minutes, P = .012), and a significantly higher morbidity rate (72.7% vs 22.2%, P =.008). Overall mortality was observed in 6 patients (15.8%). The mortality was associated with right-sided TDR (P = .042) and preoperative shock (P = .003). Neither ISS nor delay in diagnosis posed a statistically significant risk to the outcome of patients. Intra-abdominal organ injuries are more common than intrathoracic injuries in patients with BTDR, indicating that laparotomy should be the initial approach in these patients. Preoperative shock and right-sided TDR are predictive of mortality after BTDR.
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The association between immunodeficiency and the development of autoimmune disease
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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There is a paradoxical relationship between immunodeficiency diseases and autoimmunity. While not all individuals with immunodeficiency develop autoimmunity, nor are all individuals with autoimmunity immunodeficient, defects within certain components of the immune system carry a high risk for the development of autoimmune disease. Inherited deficiencies of the complement system have a high incidence of systemic lupus erythematosus (SLE), glomerulonephritis, and vasculitis. Carrier mothers of children with chronic granulomatous disease, an X-linked defect of phagocytosis, often develop discoid lupus. Several antibody deficiencies are associated with autoimmune disease. Autoimmune cytopenias are commonly observed in individuals with selective IgA deficiency and common variable immune deficiency. Polyarticular arthritis can be seen in children with X-linked agammaglobulinemia. Combined cellular and antibody deficiencies, such as Wiskott-Aldrich syndrome, carry an increased risk for juvenile rheumatoid arthritis and autoimmune hemolytic anemia. Several hypothetical mechanisms have been proposed to explain the associations between autoimmunity and immunodeficiency. Immunologic defects may result in a failure to exclude microbial antigens, resulting in chronic immunologic activation and autoimmune symptoms. There may be shared genetic factors, such as common HLA alleles, which predispose an individual to both autoimmunity and immunodeficiency. Defects within one component of the immune system may alter the way a pathogen induces an immune response and lead to an inflammatory response directed at self-antigens. An understanding of the immunologic defects that contribute to the development of autoimmunity will provide an insight into the pathogenesis of the autoimmune process
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Oral rivaroxaban for the prevention of symptomatic venous thromboembolism after elective hip and knee replacement
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Management of Hip Fractures in the Elderly
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A once-daily dose of rivaroxaban 10 mg, an oral, direct Factor Xa inhibitor, was compared with enoxaparin 40 mg subcutaneously once daily for prevention of venous thromboembolism in three studies of patients undergoing elective hip and knee replacement (RECORD programme). A pooled analysis of data from these studies (n = 9581) showed that rivaroxaban was more effective than enoxaparin in reducing the incidence of the composite of symptomatic venous thromboembolism and all-cause mortality at two weeks (0.4% vs 0.8%, respectively, odds ratio 0.44; 95% confidence interval 0.23 to 0.79; p = 0.005), and at the end of the planned medication period (0.5% vs 1.3%, respectively; odds ratio 0.38; 95% confidence interval 0.22 to 0.62; p < 0.001). The rate of major bleeding was similar at two weeks (0.2% for both) and at the end of the planned medication period (0.3% vs 0.2%). Rivaroxaban started six to eight hours after surgery was more effective than enoxaparin started the previous evening in preventing symptomatic venous thromboembolism and all-cause mortality, without increasing major bleeding
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MR appearance of autologous chondrocyte implantation in the knee: correlation with the knee features and clinical outcome
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To relate the magnetic resonance imaging (MRI) appearance of autologous chondrocyte implantation (ACI) in the knee in the 1st postoperative year with other knee features on MRI and with clinical outcome.
DESIGN AND METHODS: Forty-nine examinations were performed in 49 patients at 1 year after ACI in the knee. Forty-one preoperative magnetic resonance (MR) examinations were also available. The grafts were assessed for smoothness, thickness in comparison with that of adjacent cartilage, signal intensity, integration to underlying bone and adjacent cartilage, and congruity of subchondral bone. Presence of overgrowth and bone marrow appearance beneath the graft were also assessed. Presence of osteophyte formation, further cartilage defects, appearance of the cruciate ligaments and the menisci were also recorded. An overall graft score was constructed, using the graft appearances. This was correlated with the knee features and the Lysholm score, a clinical self-assessment score. The data were analysed by a Kruskal-Wallis H test followed by a Mann-Whitney U test with Bonferroni correction as post-hoc test.
RESULTS: Of 49 grafts, 32 (65%) demonstrated complete defect filling 1 year postoperatively. General overgrowth was seen in eight grafts (16%), and partial overgrowth in 13 grafts (26%). Bone marrow change underneath the graft was seen; oedema was seen in 23 grafts (47%), cysts in six grafts (12%) and sclerosis in two grafts (4%). Mean graft score was 8.7 (of maximal 12) (95% CI 8.0-9.5). Knees without osteophyte formation or additional other cartilage defects (other than the graft site) had a significantly higher graft score than knees with multiple osteophytes (P=0.0057) or multiple further cartilage defects (P=0.014). At 1 year follow-up improvement in the clinical scores was not significantly different for any subgroup. Knees with a graft score of 8 points or greater had a better improvement of the clinical score than those of 7 points or fewer.
CONCLUSIONS: At 1 year follow-up after ACI, higher graft scores are associated with an overall better preserved knee joint. ACI improves the clinical outcome, but there is no statistically significant correlation of graft score and clinical outcome.
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Hybrid high tibial osteotomy is superior to medial opening high tibial osteotomy for the treatment of varus knee with patellofemoral osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: To evaluate patellofemoral congruity after opening wedge high tibial osteotomy (OWHTO) and hybrid HTO.
METHODS: Twenty-four knees with hybrid HTO and 24 with OWHTO were evaluated in this study. The Caton-Deschamps and modified Miura-Kawamura indices were used to evaluate pre- and post-operative patellar heights for both types of surgery. Tibial tuberosity-trochlear groove (TT-TG) distance, patellar tilt, and medial and lateral joint space at the patellofemoral joint were compared. Anterior knee pain was assessed using the Kujala anterior knee pain scale.
RESULTS: There was no significant difference between the correction angles of the hybrid HTO and OWHTO. Pre- and post-operative values for the Caton-Deschamps and modified Miura-Kawamura indices in patients who underwent hybrid HTO changed from 0.90 to 0.94 and from 0.95 to 1.03, respectively, with no significant differences noted. Following OWHTO, these values decreased significantly from 0.91 to 0.73 and from 1.06 to 0.84, respectively (p < 0.01). The post-operative patellar height after OWHTO was significantly lower than that after hybrid HTO (p < 0.01). After hybrid HTO, the TT-TG distance decreased significantly from 11.4 to 7.4 (p < 0.01), but it did not change significantly after OWHTO. Although pre- and post-operative patellar tilt were not altered significantly in either group, the medial joint space of the patellofemoral joint was significantly increased post-operatively following hybrid HTO (p = 0.035). The pre-operative Kujala scores were significantly lower in the hybrid HTO group, but post-operative scores improved in both groups.
CONCLUSIONS: Hybrid HTO provides a better post-operative patellofemoral joint than does OWHTO with regard to patellar position and reduction of the TT-TG distance, as well as improved clinical outcomes. Hybrid HTO, rather than OWHTO, is the preferred technique for the treatment of varus knees combined with patellofemoral osteoarthritis.
LEVEL OF EVIDENCE: Retrospective comparative study, Level III.
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Effects of potent anticholinergics, sedatives and antipsychotics on postoperative mortality in elderly patients with hip fracture: a retrospective, population-based study
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Management of Hip Fractures in the Elderly
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BACKGROUND: Concomitant use of several medications for somatic and mental disorders is common in elderly people and increases the risk of falls, with hip fracture being the most serious consequence. OBJECTIVE: The objective of this study was to describe relationships between use of sedatives, antipsychotics or potent anticholinergics and postoperative mortality in patients with hip fractures. METHODS: A retrospective analysis was conducted on population-based data collected during a 2-year period from 1999 to 2000 on 461 hip fracture surgery patients aged > or = 65 years in Finland. Information on co-morbidities and intake of sedatives, antipsychotics and potent anticholinergics was obtained from the original patient records. Information on deaths was obtained from the official death statistics in Finland. RESULTS: In men, use of potent anticholinergics was associated with excess age-adjusted mortality at 30 days, 3 months, 6 months and 3 years, but not in women at any timepoint. CONCLUSION: Use of potent anticholinergic drugs emerged as an independent predictor of excess mortality in men at 3 months and 3 years. Presence of cardiovascular disease and chronic lung disease were independent risk factors for excess mortality at 6 months and 3 years in men. In addition, chronic lung disease independently predicted excess mortality at 30 days. Use of potent anticholinergics should be evaluated critically after hip fracture surgery, especially in men with cardiovascular or chronic lung diseases
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A multi-scale finite element model for investigation of chondrocyte mechanics in normal and medial meniscectomy human knee joint during walking
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OAK 3 - Non-arthroplasty tx of OAK
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Mechanical signals experienced by chondrocytes (articular cartilage cells) modulate cell synthesis and cartilage health. Multi-scale modeling can be used to study how forces are transferred from joint surfaces through tissues to chondrocytes. Therefore, estimation of chondrocyte behavior during certain physical activities, such as walking, could provide information about how cells respond to normal and abnormal loading in joints. In this study, a 3D multi-scale model was developed for evaluating chondrocyte and surrounding peri- and extracellular matrix responses during gait loading within healthy and medial meniscectomy knee joints. The knee joint geometry was based on MRI, whereas the input used for gait loading was obtained from the literature. Femoral and tibial cartilages were modeled as fibril-reinforced poroviscoelastic materials, whereas menisci were considered as transversely isotropic. Fluid pressures in the chondrocyte and cartilage tissue increased up to 2MPa (an increase of 30%) in the meniscectomy joint compared to the normal, healthy joint. The elevated level of fluid pressure was observed during the entire stance phase of gait. A medial meniscectomy caused substantially larger (up to 60%) changes in maximum principal strains in the chondrocyte compared to those in the peri- or extracellular matrices. Chondrocyte volume or morphology did not change substantially due to a medial meniscectomy. Current findings suggest that during walking chondrocyte deformations are not substantially altered due to a medial meniscectomy, while abnormal joint loading exposes chondrocytes to elevated levels of fluid pressure and maximum principal strains (compared to strains in the peri- or extracellular matrices). These might contribute to cell viability and the onset of osteoarthritis.
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Orthogeriatric co-management of hip fractures in elderly patients: The experience of the Orthopaedic Unit of ASMN Hospital in Reggio Emilia
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Management of Hip Fractures in the Elderly
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Introduction Hip fractures are a major health care problem. Most of the elderly patients with such a fracture have one or more co-morbid conditions that affect the outcome and must be managed. Epidemiological studies showed a high incidence of medical complications during hospital stays and also frequent re-admission for medical disease. Moreover, a high percentage of surviving subjects loses their abilities in daily living. A multidimensional approach mainly based on the co-management of patients between orthopaedists and geriatricians has been developed with the aim of reducing complications, length of stay, readmission rate, mortality and in general leading to lower levels of care and better function of patient at discharge. Multidimensional intervention has been shown to be successful also in postacute and rehabilitation phase improving functional recovery of patients and reducing the risk of institutionalization. Materials and methods A co-managed Ortho-Geriatric Service for all patients aged 75 years admitted with a hip fracture was implemented in ASMN in Reggio Emilia in 2007. The service was set up within the Orthopaedic Unit but the model includes separate responsibilities between orthopaedists and geriatricians and a number of standardized protocols based on evidence-based procedure allowing high-level standard of care. After early rehabilitation the patients may be discharged directly to home or to rehabilitation facilities. Data were collected at admission during hospital stay and after 3, 6 and 12 months from the fracture by telephone interviews. Results More than 250 patients per year were admitted with fragility hip fracture to Ortho-Geriatric Services. The co-management led to a significant reduction in surgical delays and a quicker mobilization of patients. The number of patients operated within 48 h rose from 10% to nearly 50% and more than 80% of patients, without weight bearing restriction, were out of bed 1 day after surgery. A significant reduction of acute length of stay was also observed. Both acute and 1-year mortality showed a clear reduction trend. Comorbidity and prefracture functional status were patient's characteristics significantly related to long-term outcome while, among interventional factors, surgical delay showed a negative relationship with mortality and the access to Rehabilitation Service affects functional abilities. Conclusions Despite significant positive results, it is necessary to bear in mind that the co-care models represent a difficult task to be achieved and have to face with cultural, economics and administrative limits. However, the Ortho-Geriatric approach represents an important way to improve administrative and clinical results in elderly patients with hip fracture
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The geometry of the tibial plateau and its influence on the biomechanics of the tibiofemoral joint
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Surgical Management of Osteoarthritis of the Knee CPG
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Background: The geometry of the tibial plateau is complex and asymmetric. Previous research has characterized subject-to-subject differences in the tibial plateau geometry in the sagittal plane on the basis of a single parameter, the posterior slope. We hypothesized that (1) there are large subject-to-subject variations in terms of slopes, the depth of concavity of the medial plateau, and the extent of convexity of the lateral plateau; (2) medial tibial slope and lateral tibial slope are different within subjects; (3) there are sex-based differences in the slopes as well as concavities and convexities of the tibial plateau; and (4) age is not associated with any of the measured parameters. Methods: The medial, lateral, and coronal slopes and the depth of the osseous portion of the tibial plateau were measured with use of sagittal and coronal magnetic resonance images that were made for thirty-three female and twenty-two male subjects, and differences between the sexes with respect to these four parameters were assessed. Within-subject differences between the medial and lateral tibial slopes also were assessed. Correlation tests were performed to examine the existence of a linear relationship between various slopes as well as between slopes and subject age. Results: The range of subject-to-subject variations in the tibial slopes was substantive for males and females. However, the mean medial and lateral tibial slopes in female subjects were greater than those in male subjects (p < 0.05). In contrast, the mean coronal tibial slope in female subjects was less than that in male subjects (p < 0.05). The correlation between medial and lateral tibial slopes was poor. The within-subject difference between medial and lateral tibial slopes was significant (p < 0.05). No difference in medial tibial plateau depth was found between the sexes. The subchondral bone on the lateral part of the tibia, within the articulation region, wasmostly flat. Age was not associated with the observed results. Conclusions: The geometry of the osseous portion of the tibial plateau is more robustly explained by three slopes and the depth of the medial tibial condyle. Clinical Relevance: The sex and subject-to-subject-based differences in the tibial plateau geometry found in the present study could be important to consider during the assessment of the risk of knee injury, the susceptibility to osteoarthritis, and the success of unicompartmental and total knee arthroplasty. Copyright (copyright) 2008 by The Journal of Bone and Joint Surgery, Incorporated
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Safety report from the desirudin postmarketing registry-Europe in patients undergoing major orthopedic surgery (desire)
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction : Introduction: Deep venous thrombosis (DVT) is an important complication in patients undergoing major orthopedic surgery (MOS). The American College of Chest Physicians recommends perioperative DVT prophylaxis for all patients undergoing major surgical or invasive procedures. Perioperative anticoagulant (AC) administration should be optimally managed to balance the risk of thromboembolic and bleeding episodes. There are scant alternatives to heparin-based anticoagulation for surgical patients. Desirudin is the first thrombin inhibitor administered subcutaneously and approved by the FDA for DVT prophylaxis in total hip replacement (THR) surgeries in the US. Desirudin is an AC with a short-term and reversible effect (2-3 hr. half-life) and may provide an option for better management, monitoring and less risk of bleeding in patients requiring anticoagulation for treatment or prophylaxis after MOS. Methods : This was a multi-center, prospective, single-arm, registry in patients undergoing MOS in Europe. All patients received desirudin 15 mg subcutaneous (SC) BID and were followed and evaluated for DVT, PE, bleeding and death throughout hospitalization. Challenging Case Report (only complete if your submission falls into the nullChallenging Case Reportnull category. If you select the nullChallenging Case Reportnull category on the next step, this section must be completed.): N/A Results : After IRB approval and informed consent, 603 patients were enrolled in the registry, 581 patients were included in the data analysis, 303 (52.15%) underwent THR, 196 (33.73%) total knee replacement, 39 (6.72%) hip fracture repair, 43 (7.4%) other (e.g. spinal and trauma). Mean age was 67.9 (plus or minus) 5 yr. (range 11-100 yr.). Two-thirds of patients had 3 or more risk factors for DVT not including orthopedic surgery. Thirty-five percent had a prior DVT episode, 13% post-thrombotic syndrome, 9.8% prior PE, 10% history of cancer, 30% obese (BMI > 30), 17% smokers, 17% DM and 33% CHF. Patients received desirudin for a mean of 11 (plus or minus) 6.6 days and 28.3% of patients received desirudin for greater than 12 days (max 57 days). The timing of desirudin administration varied and was given prior to surgery in 50.3% and after surgery in 48.8% of patients. There were 11 (1.8%) confirmed venous thrombotic events, 8 (1.38%) DVT's and 3 (0.52%) PE's including one fatal case after an emergent spinal surgery due to trauma. Desirudin was discontinued in 5 (0.86%) patients due to bleeding. Discussion : Patients undergoing MOS are at high risk for major VTE and require a reliable and effective AC therapy with fewer risks. Prophylaxis with desirudin in this patient registry resulted in few VTE events and fewer patients requiring discontinuation of therapy due to bleeding. The results from this registry suggest that desirudin has low risk for bleeding, PE and VTE and can be administered safely for prophylaxis in this patient population
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Noninvasive measurement of compartment syndrome
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DOD - Acute Comp Syndrome CPG
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This study compared the effectiveness of a commercially available invasive intracompartmental pressure measuring device with an investigational noninvasive hardness measuring device in 75 patients undergoing examination for possible compartment syndrome. Legs, forearms, thighs, and arms were tested. Pressure values and hardness ratios were compared to one another as continuous variables and to the clinical diagnosis of compartment syndrome as discrete variables. The compartment with the highest pressure reading within a limb diagnosed with compartment syndrome was compared to limbs without compartment syndrome. Due to the low specificity of the noninvasive measurement of hardness compared to the invasive pressure measurement (0.82 versus 0.96), this study does not support the use of the hardness monitor in the diagnosis of compartment syndrome.
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The outcome of partial arthroplasty for treatment of type 1 intertrochanteric fractures in Iraqi elderly patients
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Hip Fx in the Elderly 2019
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Background: When a fracture affects the proximal end of the femur at an extracapsular location and between the greater and the lesser trochanter, a dense trabecular type of bone, the fracture is known as intertrochanteric fracture. Indeed, there are two principal risk factors for fractures affecting the proximal end of femur. These are the age related reduction in bone mineral density and falls. Arthroplasty is indicated in cases with severe comminuted fractures, osteoporotic bones that are not easily fixed by internal fixation and in case of degenerative arthritis. Aim of the study: The aim of the current study was to assess the outcome of arthroplasty in 40 Iraqi patients with intertrochanteric fracture treated by arthroplasty. Patients and methods: The current study was conducted in Al-Diwaniyah teaching hospital, Al-Diwniyah province, Iraq. The study included 40 patients who were operated up on during the last 5 years. The first case is dated back to January the 3rd 2015 and the last case is dated back to September the 15th 2019. Variables included in the current study included age, gender, main clinical manifestations, history of chronic medical illness, preparation time, operative time, time of postoperative walking, intra-operative complications and post-operative complications. Results: The time needed to prepare patients to operation was ranging from 1 to 2 days with a mean of 1.30 ±0.46 days. Operative time was ranging from 60 to 90 minutes with a mean of 74.13 ±9.67 minutes. All patients were able to walk during a maximum period of first day post-operatively after successful operation. Only single patient died and he was known to be hypertensive, diabetic and having ischemic heart disease and the cause of death was acute myocardial infarction with ventricular fibrillation. Surgical wound abscess was seen in one patient who was known to be diabetic mellitus. Dislocation happened in a single patient and was managed successfully. Conclusion: for elderly patients with intertrochanteric fracture, partial hemiarthroplasty offers rapid mobilization with minimal rate of complications and may be preferred for internal fixation because of the high failure rate and higher rate of complications in association with internal fixation.
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Therapist's practice patterns for subsequent fall/osteoporotic fracture prevention for patients with a distal radius fracture
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Distal Radius Fractures
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STUDY DESIGN: Cross-sectional survey.
INTRODUCTION: Multifactorial risk factor screening and treatment is needed for subsequent falls/osteoporotic fractures prevention (SFOFP), given the elevated risk among patients with distal radius fracture (DRF).
PURPOSE OF THE STUDY: The primary objective was to describe hand therapists' knowledge and clinical practice patterns for assessment, treatment, referral, and education with respect to SFOFP for patients with DRF older than 45 years. Secondary objective was to explore therapist's preferences in content and delivery of knowledge translation tools that would support implementation of SFOFP.
METHODS: A cross-sectional multinational (Canada, the United States, and India) survey was conducted among 272 therapists from August to October 2014. Completed surveys were analyzed descriptively.
RESULTS: Surveys were completed by 157 therapists. Most respondents were from the United States (59%), certified hand therapists (54%), and females (87%). Although 65%-90% believed that they had knowledge about SFOFP assessment, treatment, and referral options, 55% did not include it in their routine practice for patients with DRF. Most assessed medication history (82%) and never used a Fracture Risk Assessment Tool (90%) or lower extremity muscle strength testing (54%) to identify those at risk of secondary fractures. With respect to treatment, approximately 33% always used upper extremity muscle strengthening exercises. Most reported rarely (sometimes to never) using balance (79%), lower extremity muscle strengthening (85%), bone strengthening (54%), or community-based physical activity (72%) programs. Similarly, when surveyed about patient education, therapists rarely (sometimes to never) advised patients about web-based resources (94%), regular vision testing (92%), diet for good bone health (87%), bone density evaluation (86%), footwear correction (73%), and hazard identification (67%). Most hand therapists were interested to receive more information on SFOFP for patients with DRF. Nearly one-half preferred to have Web sites for patients, and two-fifth were in favor of pamphlets for patients.
CONCLUSION: Current practice patterns reveal care gaps and limited implementation with respect to SFOFP for patients with DRF. Future research should focus on web-based educational/knowledge translation strategies to promote implementation of multifactorial fall risk screening and hand therapist's engagement in SFOFP for patients with DRF.
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Occupational Therapists Whose Primary Area of Practice Is Hand TherapySelf-Reported Cumulative Trauma Disorders
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Hand therapists perform hand-intensive work and engage in tasks that require movements and postures cited in the literature to be risk factors for the development of cumulative trauma disorders. This study was conducted to determine the incidence, prevalence, and types of work-related cumulative trauma disorders of the hand, wrist, and elbow experienced by occupational therapists whose primary area of practice is hand therapy. A survey was sent to a national random sample of 289 occupational therapists, 227 of whom responded. A total of 328 upper-extremity injuries/syndromes were reported by 165 (79 %) of the respondents; 62 % of those injuries occurred as a result of cumulative work trauma. This study identified hand therapy as another occupation where cumulative trauma disorders are common. It is crucial that hand therapists become cognizant of their occupational risks and limitations so that such painful and disabling conditions can be prevented
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Results of total shoulder arthroplasty in patients aged 55 years or younger versus those older than 55 years: an analysis of 1135 patients with over 2 years of follow-up
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Glenohumeral Joint OA
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BACKGROUND: The results of anatomic total shoulder arthroplasty (TSA) in younger patients have not been clearly elucidated. The purpose of this study was to compare early outcomes after TSA in patients aged 55 years or younger versus patients older than 55 years.
METHODS: A total of 1135 patients who were treated with TSA for glenohumeral arthritis and had a mean follow-up period of over 4 years were retrospectively reviewed. Etiologies included osteoarthritis (n = 1044), osteonecrosis (n = 35), inflammatory arthritis (n = 34), and post-traumatic arthritis (n = 22). Validated outcome measures, range of motion, and patient satisfaction were recorded. Preoperative and postoperative metrics were compared, and a multivariate analysis was performed to isolate age from sex, body mass index, previous surgery, and diagnosis as independent factors.
RESULTS: Female patients, patients with a history of surgery, and patients with a diagnosis of osteonecrosis were more likely to undergo TSA when aged 55 years or younger. Both age groups showed similar preoperative range of motion and showed no differences in recorded outcome scores. Postoperatively, patients older than 55 years had slightly greater active abduction (P = .004) and internal rotation (P = .030). A higher percentage of patients older than 55 years rated their outcome as better or much better compared with those aged 55 years or younger (P = .003).
CONCLUSIONS: Female sex, a history of surgery, and a diagnosis of osteonecrosis were associated with undergoing TSA when aged 55 years or younger. Despite similar preoperative function and minor differences in postoperative range of motion and outcome scores, patients aged 55 years or younger reported lower overall satisfaction with their TSA.
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Simultaneous hip and upper limb fracture in the elderly: incidence, features and management considerations
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Distal Radius Fractures
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We performed a retrospective analysis of all patients admitted to a single unit over 4 years with fractured neck of femur. Of the 760 patients admitted over this period of time 36 (4.7%) were found to also have a fracture of the upper limb. The associated upper limb fractures were distal radius (n=28), olecranon (n=2) and neck of humerus (n=5) and fifth metacarpal (n=1), with the same ratio of intracapsular to extracapsular fractures as the whole group. The female to male ratio in the isolated hip fracture group was 2.4:1 and for the combined fractures group was 8:1 (difference P=0.014). The mean patient age was 77.3 years for isolated hip fractures and 83.9 for the combined group (P=0.037). The mean total length of stay in hospital for isolated hip fracture was 15.6 days and for combined fractures was 20.4 days (P=0.010). We have demonstrated that combined upper limb and neck of femur fractures occur in a population that is older and predominantly female. They are associated with a significant increase in hospital stay and increased difficulties in mobilisation as a consequence of the combined fractures. It is therefore important to recognise this specific subgroup of patients presenting with hip fractures in order to ensure that they receive adequate treatment and rehabilitation and that the use of valuable health care resources are optimised.
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Adding triamcinolone to viscosupplementation: One year outcome of randomized trial
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OAK Recommendation 9 Articles
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Purpose: This is an extended follow up of a randomised controlled trial to evaluate if the addition of triamcinolone to viscosupplementation could alter one-year pain and function of viscosupplementation alone. Methods: We prospectively enrolled 104 patients with knee osteoarthritis and randomized them to receive either a single intraarticular injection (6 mL) of hylan GF-20 (Group viscosupplementation [Group VS]), or a single intraarticular injection of hylan GF-20 (6 mL) and 1 mL (20 mg) of triamcinolone hexacetonide (Group VS+T). VAS,WOMACTM, and Lequesne questionnaires were completed at baseline, at weeks 1, 4, 12, 24 and at one year. Results: At week 1 the WOMAC and VAS scores were lower in Group VS+T, compared with Group VS. There was no difference regarding the adverse effects. At weeks 4, 12, 24 and one year there were no differences within the groups. At one year only Group VS+T still showed a difference from baseline for VAS. Conclusions: The addition of triamcinolone hexacetonide improves first-week symptom and functional scores of viscosupplementation and does not alter its adverse effects. There might be benefits for the one year pain results
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Clinical and radiological results of non-cement impaction bone-graft method of total hip arthroplasty for rheumatoid arthritis
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Management of Hip Fractures in the Elderly
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We performed total hip arthroplasty using the non-cement impaction auto-bone-grafting method with the resected femoral head for acetabular protrusion that is not combined with the destruction of acetabular rim or dysplasia of the hip joint. Ten patients (eight women and two men) with rheumatoid arthritis who showed acetabular protrusion underwent total hip arthroplasty using this method. All patients were able to walk with full weight within 5 days after surgery. The short-term results of our cases were very good. The postoperative periods of the radiographic-bone incorporation of the grafting bone were 2 months after surgery in four joints, 3 months after surgery in four joints, and 4 months after surgery in three joints. There were no cases that showed any migration or radiolucency around the acetabular component at the time of follow-up. Our operative technique is simple and easy, and it is a useful method for the treatment of protrusion in patients with rheumatoid arthritis. (copyright) Japan College of Rheumatology 2007
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Topical verapamil as a scar modulator
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Skin injuries and the consequent loss of tissue integrity triggers a sequence of cellular and biochemical events that lead to a healed wound. Any failure during this rather sophisticated process may result in pathological scarring. METHODS: To evaluate the efficacy of topical verapamil as a modulator of the healing process, a group of five observers (plastic surgeon, dermatologist, physiotherapist, biologist, and layman) analyzed pictures of 120 patients 3 months after abdominoplasty (60 patients) and mammoplasty (60 patients). Half of each group of patients used the topical verapamil scar modulator. Pictures were rated using the Stony Brook Scale. RESULTS: According to the classification established by us, the scars in patients who used topical verapamil scar modulator showed better results than those who did not (p < 0.05). Patients treated with verapamil presented good-quality scarring (80 % of mammoplasty scars and 75.2 % abdominoplasty scars), while patients who did not use healing modulators showed 48 and 51.2 % satisfaction for mammoplasty and abdominoplasty scars, respectively. No adverse reactions were observed or reported after the use of topical verapamil. CONCLUSIONS: This is the first clinical trial that reports the use of topical verapamil as a modulator in the healing process in the postoperative period. Based on clinical results and on the high level of reliability and statistical significance, we concluded that verapamil at a concentration of 50 µM is an excellent choice as a scar modulator; its use avoids the development of keloids and hypertrophic scars after plastic surgery.
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0 |
Beneficial effects of hypertonic mannitol in acute ischemia--reperfusion injuries in humans
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DoD LSA (Limb Salvage vs Amputation)
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Acute ischemia-reperfusion of extremities is characterized by edema, compartment syndrome and neuromuscular dysfunction. Intravenous hypertonic mannitol has been shown to be of benefit in several experimental models. The authors' 5-year experience with the use of hypertonic mannitol and the treatment of acute ischemia reperfusion injuries in humans has been reviewed. Some of 186 patients with acute arterial occlusion following thromboembolism (149) and trauma (37) were treated. Hypertonic mannitol (25 g intravenous bolus followed by 5-10 g intravenous/h) was given perioperatively. Length of preoperative ischemia varied from 1 to 24h. Some of 57.5% of patients had preoperative neuromuscular dysfunction. Following revascularization, limb salvage was obtained in 97.7% of surviving patients and neuromuscular dysfunction improved in 89%. Overall, 15% required fasciotomy. The mortality rate was 3.2%. These data suggest that hypertonic mannitol may have some protective effect in acute ischemia-reperfusion injuries of human extremities. It may decrease the need for fasciotomy and minimize neuromuscular dysfunction.
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0 |
Influence of conversion on the perioperative and oncologic outcomes of laparoscopic resection for rectal cancer compared with primarily open resection
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DOD - Acute Comp Syndrome CPG
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Background: This study aimed to evaluate the influence of conversion on perioperative and short- and long-term oncologic outcomes in laparoscopic resection for rectal cancer and to compare these with those for an open control group. Methods: The data of 276 consecutive patients who underwent surgery for rectal cancer between 2006 and 2010 at a single institution were prospectively collected. Of the 276 patients, 114 underwent primarily open surgery, and 162 underwent laparoscopic surgery (on an intention-to-treat basis). Of the 162 laparoscopic patients, 38 (23.5 %) underwent conversion to open surgery. The three groups of patients were compared: the conversion surgery group, the open surgery group, and the completed laparoscopy surgery group. Results: The converted patients had more wound infections (18.4 vs 4.8 %, p = 0.009), but the wound infection rate in the primarily open group also was significantly higher than in the laparoscopic resection group (p = 0.007). No further differences in perioperative morbidity, including anastomotic leakage, were found. The perioperative 30-day mortality rate was comparable between all the groups (0.6 vs 2.6 vs 2.6 %, nonsignificant difference). The oncologic parameters such as number of harvested lymph nodes and rate of R0 resection were equal in all the groups. The completed laparoscopy group had a shorter hospital stay [12 vs 16 days in the primarily open group (p = 0.02) vs 15 days in the converted group (p = 0.03)]. The rates for survival, local recurrence (4.5 vs 3 vs 3 %), and metachronous metastasis (10.1 vs 9.3 vs 9 %) did not differ significantly between the three groups after a period of 3 years. Conclusion: Conversion to open surgery in laparoscopic rectal resection has no negative effect on perioperative or long-term oncologic outcome. © 2013 Springer Science+Business Media New York.
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0 |
Total hip arthroplasty using a combined anterior and posterior approach via a lateral incision in patients with ankylosed hips
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PJI DX Updated Search
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BACKGROUND: For most patients with severely ankylosed hips, traditional surgical approaches do not provide sufficient exposure during THAs. We report our experience with a combined anterior and posterior approach using a lateral incision for total hip arthroplasty (THA) in patients with severe, spontaneous bony hip ankylosis. METHODS: Between January 2004 and December 2008, patients with severe, spontaneous bony hip ankylosis underwent THA via a combined anterior and posterior approach using a lateral incision. RESULTS: We included 47 patients (76 hips) with a mean age of 53 (range 22-72) years in our study. All surgeries were successful, and no significant postoperative complications occurred. The mean operative duration was 1.5 (range 1.3-1.7) hours, and mean blood loss was 490 (range 450-580) mL. The mean duration of follow-up was 5.5 (range 2-11) years. Harris hip score improved from 53 to 88 points postoperatively, and the outcome was good to excellent in 88.37% of cases. Heterotopic ossification occurred in 6 hips, and infection, which resolved with antibiotics, occurred in 1 patient. CONCLUSION: This combined anterior and posterior approach to THA using a lateral incision in patients with severe, spontaneous ankylosis provides very good exposure, protects the abduction unit and results in good to excellent postoperative recovery
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1 |
Pullout strength of cement-augmented and wide-suture transosseous fixation in the greater tuberosity
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Trial Systematic Review Project
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BACKGROUND: Obtaining strong fixation in low-density bone is increasingly critical in surgical repair of rotator cuff tears because of the aging population. To evaluate two new methods of improving pullout strength of transosseous rotator cuff repair in low-density bone, we analyzed the effects of 1) using 2-mm suture tape instead of no. 2 suture and 2) augmenting the lateral tunnel with cement.
METHODS: Eleven pairs of osteopenic or osteoporotic cadaveric humeri were identified by dual-energy x-ray absorptiometry. One bone tunnel and one suture were placed in the heads of 22 specimens. Five randomly selected pairs were repaired with no. 2 suture; the other six pairs were repaired with 2-mm suture tape. One side of each pair received lateral tunnel cement augmentation. Specimens were tested to suture pullout. Data were fitted to multivariate models that accounted for bone mineral density and other specimen characteristics.
FINDINGS: Two specimens were excluded because of knot-slipping during testing. Use of suture tape versus no. 2 suture conferred a 75-N increase (95% CI: 37, 113) in pullout strength (P<0.001). Cement augmentation conferred a 42-N improvement (95% CI: 10, 75; P=0.011). Other significant predictors of pullout strength were age, sex, and bone mineral density.
INTERPRETATION: We show two methods of improving the fixation strength of transosseous rotator cuff repairs in low-density bone: using 2-mm suture tape instead of no. 2 suture and augmenting the lateral tunnel with cement. These methods may improve the feasibility of transosseous repairs in an aging patient population.
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0 |
Results of treatment of infection in both knees after bilateral total knee arthroplasty
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Background: The purpose of this study was to review the results and complications of treatment of simultaneous infection of both knees after bilateral total knee arthroplasty. Methods: Between 1976 and 1999, twenty-one patients with a mean age of seventy-one years were treated for simultaneous infection of both knees after bilateral total knee arthroplasty. Two patients died within two years, and one patient was lost to follow-up after one year. The remaining eighteen patients were followed for a mean of five years. At the time of presentation, all twenty-one patients had had symptoms for less than three weeks. Eleven patients (twenty-two knees) were treated with attempts at prosthetic salvage with surgical debridement and administration of suppressive antibiotics. Resection arthroplasty was performed as the initial treatment in ten patients (twenty knees). Results: Of the ten patients treated with initial resection, seven patients (fourteen knees) underwent subsequent reimplantation. All fourteen knees were functioning well at the time of the latest follow-up, and none had been revised at a mean of two years after reimplantation. Of the eleven patients (twenty-two knees) who had been initially treated with prosthetic salvage, nine patients (eighteen knees) had a recurrence of the infection that required a reoperation (bilateral resection arthroplasty in seven patients, bilateral above-the-knee amputation in one patient, and repeat debridement of both knees in one patient). Two of the seven patients who had resection underwent reimplantation six weeks postoperatively, and the other five patients (ten knees) did not have reimplantation because of low functional demands and prohibitive medical comorbidity. Conclusion: We believe that treatment of simultaneous infection of both knees after bilateral total knee arthroplasty should consist of bilateral resection arthroplasty and delayed reimplantation after a period of intravenous administration of organism-specific antibiotics. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence
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0 |
Rehabilitation costs: implications for prospective payment
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To obtain information relevant to development of prospective payment for Medicare rehabilitation facilities (RFs) and skilled nursing facilities (SNFs): compares service utilization, length of stay (LOS), case mix, and resource consumption for Medicare patients receiving postacute institutional rehabilitation care. DATA SOURCES/STUDY SETTING: Longitudinal patient-level and related facility-level data on Medicare hip fracture (n = 513) and stroke (n = 483) patients admitted in 1991-1994 to a sample of 27 RFs and 65 SNFs in urban areas in 17 states. STUDY DESIGN: For each condition, two-group RF-SNF comparisons were made. Regression analysis was used to adjust RF-SNF differences in resource consumption per stay for patient condition (case mix) and other factors, since random assignment was not possible. DATA COLLECTION/EXTRACTION METHODS: Providers at each facility were trained to collect patient case-mix and service utilization information. Secondary data also were obtained. PRINCIPAL FINDINGS: RF patients had shorter LOS, fewer total nursing hours (but more skilled nursing hours), and more ancillary hours than SNF patients. After adjustment, ancillary resource consumption per stay remained substantially higher for RF than SNF patients, particularly for stroke. The adjusted nursing resource consumption differences were smaller than the ancillary differences and not statistically significant for hip fracture. Supplemental outcome findings suggested minimal differences for hip fracture patients but better outcomes for RF than SNF stroke patients. CONCLUSIONS: Much can be gained from an integrated approach to developing prospective payment for RFs and SNFs. In that context, consideration of condition-specific per-stay payment methods applicable to both settings appears warranted
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0 |
Vitamin E for intermittent claudication
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SR for PM on OA of All Extremities
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Background: It is thought that vitamin E may improve tolerance to intermittent claudication (i.e. pain caused by ischaemia in the muscles of the leg during exercise), thereby relieving the pain, through a variety of mechanisms.Objectives: The objective of this review was to determine the effects of vitamin E on people with intermittent claudication.Search methods: The authors searched the Cochrane Peripheral Vascular Diseases Group trials register, reference lists of relevant articles and a library specialising in literature on vitamins (most recent search performed in November 2000).Selection criteria: Controlled trials comparing vitamin E with placebo, or other interventions, in patients with intermittent claudication.Data collection and analysis: Both authors extracted data and assessed study quality independently.Main results: Five eligible studies were found with a total of 265, predominantly male, participants. The average age was 57 years. The follow-up varied from 12 weeks to 18 months. The trials were small and generally of poor quality. The people studied were reasonably homogeneous but five different doses of vitamin E were used and four different physical outcomes were measured. No trials were identified that compared vitamin E with treatments other than placebo.All trials showed positive effects on one of their main outcomes. No serious adverse effects of vitamin E were reported. Two trials that lasted approximately eight months and used similar doses reported patients' subjective evaluation of the treatment. The relative risk for the combined results of these two trials using a random effects model was 0.57 with a 95% confidence interval of 0.28 to 1.15.Authors' conclusions: While vitamin E - which is inexpensive and has had no serious side effects reported with its use - may have beneficial effects, there is insufficient evidence to determine whether it is an effective treatment for intermittent claudication
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0 |
Does Dexamethasone Reduce Hospital Readiness for Discharge, Pain, Nausea, and Early Patient Satisfaction in Hip and Knee Arthroplasty? A Randomized, Controlled Trial
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: Reduction in postoperative pain, nausea, and vomiting in patients undergoing total joint arthroplasty may facilitate earlier discharge from hospital and reduce healthcare costs. This study was performed to primarily assess whether perioperative dexamethasone reduced hospital length of stay and to assess the effect on pain, nausea and vomiting, and patient satisfaction.
METHODS: One hundred sixty-four patients undergoing total hip arthroplasty or total knee arthroplasty were randomized to receive either 8 mg intravenous dexamethasone (n = 86) or placebo (n = 78) at induction and at 24 hours postsurgery. The primary outcome was length of stay and secondary outcomes were pain and nausea visual analog scale scores, analgesic and antiemetic usage, blood glucose level, and patient satisfaction.
RESULTS: Participants in the study group achieved earlier readiness for discharge. There was a 20% reduction in pain scores and morphine usage was 27% lower in the study group. Nausea scores were similar in the 2 groups but there was lower antiemetic usage in the study group. Satisfaction scores at 6 weeks postsurgery in the dexamethasone group were significantly higher than the placebo group. There was no difference in complication rates between the 2 groups.
CONCLUSION: The administration of intravenous dexamethasone could lead to earlier readiness for discharge especially in patients undergoing elective total hip arthroplasty, primarily by a reduction in postoperative pain scores and/or morphine requirements.
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0 |
Analysis of knee functional flexion axis in navigated TKA: Identification and repeatability before and after implant positioning
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OAK 3 - Non-arthroplasty tx of OAK
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Purpose: Providing correct rotational alignment of femoral component in total knee arthroplasty (TKA) is mandatory to achieve correct kinematics, good ligament balance and patellar tracking. The purpose of this study was to evaluate potential clinical applications of functional flexion axis (FFA) by analysing the differences between pre- and post-implant placement. This evaluation was supported by the analysis of repeatability, assessing the robustness of the proposed method. Methods: Anatomical acquisitions and passive kinematics were acquired on 87 patients undergoing TKA using a commercial navigation system. Knee FFA was estimated, before and after implant positioning, from three flexion-extension movements between 0 and 120°. The angle between FFA and transepicondylar axis was analysed in frontal and axial planes. Repeatability coefficient and intraclass correlation coefficient (ICC) were used to analyse the reliability and the agreement in identifying the axis. Results: The analysed angle presented differences between pre- and post-operative conditions only in the frontal plane (from -8.3 ± 5.5° to -2.8 ± 5.3°) (p < 0.0001). There was good intraobserver reliability and agreement. Repeatability coefficient ranged between 4.4° (3.7-4.9°) and 3.4° (2.9-3.8°), the ICC between 0.87 (0.83-0.91) and 0.93 (0.90-0.95) and the standard deviation ranged between 1.3 and 1.0°. Conclusions: The present study demonstrated that TKA affected the estimation of FFA only in the frontal plane. This method reported good repeatability, demonstrating its usefulness for clinical purposes particularly to evaluate rotational positioning of the femoral component in the axial plane. Level of evidence: Case series, Level IV. © 2013 Springer-Verlag Berlin Heidelberg.
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1 |
Cementless versus cemented glenoid components in conventional total shoulder joint arthroplasty: analysis from the Australian Orthopaedic Association National Joint Replacement Registry
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Glenohumeral Joint OA
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BACKGROUND: Glenoid loosening is a common mode of failure after total shoulder arthroplasty (TSA). Newer cementless glenoid components have been introduced to promote biological fixation with the aim to decrease glenoid loosening. Limited data are available comparing revision rates between cemented and cementless glenoid fixation in TSA. The study aim was to compare the revision rates of cemented and cementless design glenoid components used in conventional TSA performed for the diagnosis of osteoarthritis. The secondary aim was to compare various subclasses of glenoid components.
METHODS: Data were obtained between April 16, 2004, and December 31, 2016, from the Australian Orthopaedic Association National Joint Replacement Registry. Within the study period, 10,805 primary conventional TSAs were identified. The analysis was undertaken for the diagnosis of osteoarthritis, which represented 95.8% of all conventional TSA procedures.
RESULTS: At 5 years, in patients with primary TSA procedures, those with cemented glenoids had a lower revision rate than those with cementless glenoids: 3.7% versus 17.9% (hazard ratio for entire period, 4.77). The most common revision diagnosis for primary conventional TSA with cementless glenoid fixation was rotator cuff insufficiency (4.4% for cementless vs 0.4% for cemented), instability and/or dislocation (3.8% for cementless vs 0.8% for cemented), and loosening and/or lysis (1.1% for cementless vs 1.1% for cemented).
CONCLUSIONS: Cementless glenoid components in conventional TSA had a significantly higher revision rate than cemented glenoid components. The loosening rates between cemented and cementless glenoid components were similar. Glenoid design and fixation are important considerations when selecting a prosthesis for TSA.
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0 |
Obesity in patients and nurses increases the nurse's risk of injury lifting patients
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DoD PRF (Psychosocial RF)
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As the number of Americans who are overweight and obese grows, the risk of lifting injuries to both patients and nurses increases. Occupational back and other musculoskeletal injuries are preventable; however, many changes in the workplace must occur in order to assure prevention and safe lifting. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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0 |
Distal radius fractures
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Distal Radius Fractures
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Distal radius fractures are a common injury, particularly in the elderly population. Severity of these fractures is directly related to the bone mineral density of the patient, and clinical results are dependent on this parameter as well. In terms of treatment, several options exist. Nonoperative management consists of closed treatment with casting. Operative treatment options include intrafocal pinning, nonbridging and bridging external fixation, arthroscopic-assisted external fixation, and various methods of open reduction internal fixation. When operative intervention is indicated, considerations include the characteristics of the fracture and the experience of the surgeon with the treatment modalities. [References: 86]
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0 |
Knee dislocation. Complications of nonoperative and operative management
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DoD LSA (Limb Salvage vs Amputation)
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Because of the nature and extreme severity of the injury, complications will continue to be a common denominator in traumatic knee dislocations. The major complications that cause significant morbidity, including amputation and death, are now relatively infrequent. Prompt recognition and treatment of these complications are of utmost importance to assure functional viability of the extremity. These complications must continue to be addressed preoperatively and postoperatively. Minor complications will persist after significant knee surgery. New complications will evolve as newer techniques, instrumentation, and procedures are introduced. Ligament reconstructive surgery is relatively new and technically demanding. The surgeon must continue to use meticulous technique and attention to detail. Orthopedic surgeons must continue to closely evaluate the procedures they perform, making sure they are as technically correct as possible. Each surgeon must observe and determine what technique will be of true benefit to the patient. Most complications that do occur can be corrected or at least improved if they are handled early and with a true understanding of the problem.
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1 |
Utilization of agents to prevent skeletal-related events among patients with multiple myeloma: analysis of real-world data
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MSTS 2018 - Femur Mets and MM
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PURPOSE: This study examined real-world utilization patterns of bone-targeted agents (BTA) in patients with multiple myeloma (MM).
METHODS: In this retrospective cohort study, adults with an MM diagnosis recorded in 2012-2014 were identified from electronic health records in the Oncology Services Comprehensive Electronic Records (OSCER) database. Patients received zoledronic acid (ZA) or pamidronate (PA) on/after first MM diagnosis recorded in the study period, had no BTA use in prior 6 months, and were followed through earliest of May 31, 2015 or last clinic visit. Patients with any solid tumor diagnosis were excluded. Time to BTA initiation, compliance (>= 12 administrations in a year), switching, and non-persistence (switch or >= 90-day gap in therapy) were described by agent and follow-up period.
RESULTS: Among 9,617 patients with MM, 3,735 (38.8%) received a BTA. Most patients (90.9%) received ZA, with first BTA use generally seen within 3 months of first observed MM diagnosis (ZA 76.1%, PA 75.1%). A minority of ZA (27.4%) and PA (23.0%) patients were compliant in Year 1, with lower compliance in Year 2 (19.8% and 15.6%, respectively). The median time to non-persistence was 16.2 (95% confidence interval [CI] 15.4-17.4) months for ZA and 13.8 (95% CI 11.5-15.4) months for PA. Persistence was 86% at 6 months and 34% at 24 months for ZA, and 77% and 30% for PA, respectively.
CONCLUSIONS: These results highlight the possibility of suboptimal prevention of skeletal-related events due to non-compliant dosing and non-persistence after patients initiate BTA therapy.
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0 |
Improving time to surgery for hip fracture patients. Impact of the introduction of an emergency theatre
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Hip Fx in the Elderly 2019
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Hip fractures are a major cause of morbidity and mortality1. Surgery performed on the day of or after admission is associated with improved outcome2,3. An audit cycle was performed examining time to surgery for hip fracture patients. Our initial audit identified lack of theatre space as one factor delaying surgery. A dedicated daytime emergency theatre was subsequently opened and a re-audit was performed to assess its impact on time to surgery. Following the opening of the theatre, the proportion of patients with a delay to hip fracture surgery greater than 36 hours was reduced from 49% to 26% with lack of theatre space accounting for 23% (3 of 13) of delayed cases versus 28.6% (9 of 32) previously. 44% of hip fracture surgeries were performed in the emergency theatre during daytime hours, whilst in-hospital mortality rose from 4.6% to 6%. We conclude that access to an emergency theatre during daytime hours reduced inappropriate delays to hip fracture surgery.
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0 |
The Effect of Adductor Canal Block on Knee Extensor Muscle Strength 6 Weeks After Total Knee Arthroplasty: A Randomized, Controlled Trial
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Total knee arthroplasty (TKA) reduces knee extensor muscle strength (KES) in the operated limb for several months after the surgery. Immediately after TKA, compared to either inguinal femoral nerve block or placebo, adductor canal block (ACB) better preserves KES. Whether this short-term increase in KES is maintained several weeks after surgery remains unknown. We hypothesized that 48 hours of continuous ACB immediately after TKA would improve KES 6 weeks after TKA, compared to placebo.
METHODS: Patients scheduled for primary unilateral TKA were randomized to receive either a continuous ACB (group ACB) or a sham block (group SHAM) for 48 hours after surgery. Primary outcome was the difference in maximal KES 6 weeks postoperatively, measured with a dynamometer during maximum voluntary isometric contraction. Secondary outcomes included postoperative day 1 (POD1) and day 2 (POD2) KES, pain scores at rest and peak effort, and opioid consumption; variation at 6 weeks of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of hospital stay.
RESULTS: Sixty-three subjects were randomized and 58 completed the study. Patients in group ACB had less pain at rest during POD1 and during peak effort on POD1 and POD2, consumed less opioids on POD1 and POD2, and had higher median KES on POD1. There was no significant difference between groups for median KES on POD2, variation of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of stay. There was no difference between groups in median KES 6 weeks after surgery (52 Nm [31-89 Nm] for group ACB vs 47 Nm [30-78 Nm] for group SHAM, P= .147).
CONCLUSIONS: Continuous ACB provides better analgesia and KES for 24-48 hours after surgery, but does not affect KES 6 weeks after TKA. Further research could evaluate whether standardized and optimized rehabilitation over the long term would allow early KES improvements with ACB to be maintained over a period of weeks or months.
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0 |
A bone metastasis model with osteolytic and osteoblastic properties of human lung cancer ACC-LC-319/bone2 in natural killer cell-depleted severe combined immunodeficient mice
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MSTS 2018 - Femur Mets and MM
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Lung cancer is commonly associated with multiple-organ metastasis, and bone is a frequent metastatic site for lung cancer. Lung cancer frequently develops osteolytic, and less frequently osteoblastic, metastasis to bone. Osteolytic metastasis models of lung cancer have been reported, but no osteoblastic metastasis model is available for lung cancer. In the present study, we established a reproducible model of human lung cancer with both osteolytic and osteoblastic changes in natural killer cell-depleted severe combined immunodeficient mice. Intravenous inoculation of ACC-LC-319/bone2 cells resulted in the development of metastatic colonies in the lung, liver, and bone of the mice. As assessed sequentially by X-ray photographs, osteolytic bone lesions were observed by day 28, and then osteoblastic lesions were detected by day 35. Histological examination revealed the presence of bony spurs, a hallmark of osteoblastic bone metastasis, where osteoclasts were hardly observed. Treatment with an anti-human vascular endothelial growth factor antibody, bevacizumab, as well as zoledronate, inhibited the number of experimental bone metastases, including osteoblastic changes produced by ACC-LC-319/bone2 cells. These results indicate that our bone metastasis model by ACC-LC319/bone2 might be useful to understand the molecular pathogenesis of osteolytic and osteoblastic metastasis, and to identify molecular targets to control bone metastasis of lung cancer.
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0 |
Metastatic lesions of the proximal femur
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MSTS 2018 - Femur Mets and MM
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Skeletal metastases are common in the adult population. The proximal femur is a frequently affected bone in the appendicular skeleton. The orthopaedic surgeon may be the first to find a pathologic lesion of the proximal femur and appropriate diagnosis and nonoperative management is essential prior to surgical treatment. Bisphosphonates and radiation therapy are used in conjunction with surgical management to minimize pain and prevent further destruction. Surgical management may consist of internal fixation, with or without polymethylmethacrylate, or endoprosthesic replacement. The goal of treatment is to relieve pain and allow for function while minimizing systemic complications.
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0 |
Teicoplanin versus cefamandole in the prevention of infection in total hip replacement
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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In a prospective, controlled, single-blind study the efficacy of teicoplanin versus cefamandole in preventing infections in total hip replacement was investigated in 496 consecutive patients. A single intravenous dose of teicoplanin (400 mg) was as effective as two intravenous doses of cefamandole (2 g before and 1 g after surgery). No major complications were observed in either group. Infective wound complications were observed only in the cefamandole group. These infections, although not dangerous for the patients, required supplementary antibiotic treatment in all cases. Teicoplanin is a reasonable choice as a prophylactic agent in orthopaedic surgery when a high risk of infection due to staphylococci is present
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0 |
Caregiver Supervision and Child-Injury Risk: I. Issues in Defining and Measuring Supervision; II. Findings and Directions for Future Research
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DoD PRF (Psychosocial RF)
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Objective: To discuss the role of caregiver supervision in child-injury risk, with attention given to definitional and methodological issues and outlining important questions to be addressed in future research. Methods: Analysis, synthesis, and critique of existing literature. Results: Comparisons across studies are difficult because of insufficient specificity regarding what constitutes supervision. Hence, a multi-dimensional definition of supervision is developed based on the literature. Numerous issues arise when attempting to measure supervision and these are extensively discussed, along with reporting on the recent development of two questionnaire measures of supervision (Beliefs About Supervision Questionnaire and Parent Supervision Attributes Profile Questionnaire) that have shown good validity and hold promise for addressing the problem of measuring caregiver supervision in reliable and valid ways. A review of the findings on relations between supervision and child-injury risk reveals that many substantive questions remain unanswered. A number of recommendations for future research are given and a conceptual model is presented that focuses attention on the need for research that examines how factors interact to influence child-injury risk. This model has relevance not only for research but also for prevention and serves to emphasize the complementary nature of environment-oriented and person-oriented approaches to child-injury prevention. Conclusion: Direct evidence linking supervision to child-injury risk is scarce and many important questions remain unanswered. Based on the conceptual model presented, in future research it is important to examine how supervision interacts with other key factors to influence children's risk of injury. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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1 |
Marriage abdominoplasty expands the mini-abdominoplasty concept
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Panniculectomy & Abdominoplasty CPG
|
The marriage of aggressive superwet liposculpture of the abdomen and adjacent anatomic regions with a modification of well-established open surgical techniques to address skin excess and perform muscle plication was used to treat 29 patients presenting for aesthetic abdominal contouring over the past 3 1/2 years. The charts of 57 patients who had aesthetic contouring procedures on the abdomen performed from December of 1994 to July of 1998 were retrospectively reviewed. Fifteen patients underwent suction lipectomy alone, 13 patients were treated with conventional abdominoplasty, and 29 underwent "marriage abdominoplasty." The 29 patients who underwent marriage abdominoplasty presented with deformities marked by excess lower abdominal skin and adipose tissue, with or without muscle laxity (Psillakis types II, III, and IV). Seventeen procedures were performed under local anesthesia with deep conscious sedation on an outpatient surgical basis. In 12 patients, the operation accompanied a hysterectomy, urologic procedure, or additional aesthetic surgical procedure(s) and was done under general anesthesia. Suction aspirates ranged between 540 and 2600 cc (mean, 1160 cc) and were accompanied by lower abdominal skin excision in every case, which was performed predominantly through short and medium-length incisions (mean, 15 cm). Rectus abdominis muscle plication was performed where necessary, using vertical plication of the infraumbilical rectus muscles in 27 patients (93 percent) and full-length plication in two patients (7 percent). All patients demonstrated significantly improved contours and have seemed to manifest less pain when compared with patients treated by full traditional abdominoplasty. Postoperative complications have included upper abdominal skin waviness (2), annoying paresthesias and discomfort persisting for 6 months (1), seroma (1), and marginal skin necrosis with an open wound (1). The latter problem occurred in the only patient who was treated with a revision procedure. Thus, the complication rate was 17 percent (5 of 29 patients). The marriage of aggressive superwet liposculpture of the entire abdomen with standard open surgical techniques used to treat skin excesses and allow abdominal muscle plication where necessary offers the advantage of reduced surgery when compared with full abdominoplasty, while consistently achieving significant contour improvement. This concept is applicable to the majority of patients presenting for the treatment of abdominal deformities and has markedly expanded the application of the mini-abdominoplasty concept.
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0 |
Bone scan in systemic amyloidosis
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MSTS 2018 - Femur Mets and MM
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Thirty patients diagnosed as having systemic amyloidosis (six with primary amyloidosis and 24 with secondary amyloidosis) were given bone scans with 99Tc(m)-methylene diphosphonate in order to evaluate the skeletal and extra-osseus uptake and their clinical-scintigraphic correlation. Extra-osseous uptake appeared in nine instances, more frequently in primary (5/6) than in secondary (2/24) amyloidosis. Fourteen patients had clinical and echocardiographic suspicion of cardiac amyloidosis but only one showed cardiac uptake. Six patients had probable hepatic involvement but in only two cases was hepatic uptake seen. The extra-osseus uptake suggests the presence of amyloid deposits in the organs and soft tissues which take up the bone tracer. The absence of any uptake does not rule out amyloid infiltration.
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0 |
(iv) Treatment options for articular cartilage damage in the knee
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Osteochondritis Dissecans 2020 Review
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Chondral damage within the knee of young patients remains a challenge to orthopaedic surgeons, with the chance of resulting mechanical symptoms limiting activity and the risk of progression to osteoarthritis. There are a number of different treatment options which utilize one of two principles for filling chondral defects: either bone marrow stimulation leading to fibrocartilaginous repair or transplantation of mature hyaline cartilage into the defect. In this article we review the current treatment options for symptomatic chondral damage within the knee, discussing the basic science, techniques involved and the evidence supporting each method.
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0 |
Osteosarcoma: A Comparison of Jaw versus Nonjaw Localizations and Review of the Literature
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MSTS 2022 - Metastatic Disease of the Humerus
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Purpose . It is assumed that osteosarcomas of the jaws mainly occur at older ages, whereas the most prominent sites, that is, the long bones, are more affected at ages <20. Jaw-localized tumors are less malignant and have lower metastatic spread rates. Patients and Methods. This study analyses the nationwide data of the Dutch Cancer Registry on osteosarcoma during the period from 1991 to 2010. Age-corrected incidence rates were calculated. Results . In 949, 38 patients had tumors in the maxilla and in 58 in the mandible. Median age for maxilla, mandible, and other localizations was 45.5, 49, and 23 years, respectively. Age-corrected incidence for osteosarcomas increased after a steep decline for the age cohorts from 20 to 60 years to nearly the same level as the younger patients. The incidence for maxillary lesions showed a steady increase from 0.46 to 1.60 per million over all age ranges; the highest incidence for mandibular lesions was found in the age cohort from 60 to 79 years. In respect to histology, no shifts for age were found, except for Paget's disease-related osteosarcoma. In older patients, chemotherapy was omitted more often. Overall survival was similar for all age groups, except for extragnatic tumor patients in the age range of 60-79 years. Conclusions . Osteosarcomas have comparable incidences below the age of 20 as compared with ages >60 years. Poorer outcome in older people is likely due to refraining from chemotherapy.
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Histological changes in congenital and acquired blepharoptosis
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Upper Eyelid and Brow Surgery
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Histological specimens of eyelids from patients with congenital genuine ptosis and acquired involutional ptosis are compared. In congenital ptosis there is evidence of true muscular dystrophy of the levator muscle as demonstrated by: loss of cross striations, random decrease in muscle fibre diameter, sarcolemmal retraction, nuclei alignment, and fibrous and fatty tissue displacement of the striated fibres. In involutional ptosis disinsertion of the levator aponeurosis from its normal insertion on the inferior-anterior surface of the tarsus is demonstrated. Correlation between clinical presentation and surgical correction is explained in light of these findings.
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Effects of lead, zinc and copper absorption on peripheral nerve conduction in metal workers
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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To examine the antagonistic effects of lead, zinc and copper on the nervous system in man, we measured maximal motor and sensory conduction velocities (MCV and SCV, respectively) in the distal radial and median nerves in 20 gun metal founders with asymptomatically increased absorption of these metals [blood lead concentrations ranged from 16 to 64 (mu)g/dl (mean 42)]; and analyzed metal effects on nerve conduction by multiple regression analysis. The MCVs in the radial and median nerves and the SCV in the forearm segment of the median nerve were significantly slowed; indicators of lead absorption (urinary delta-aminolevulinic acid and coproporphyrin) were inversely correlated with the SCV in the radial nerve. The SCVs in the radial nerve and in the hand segment of the median nerve, which were not significantly slowed, were positively related to indicators of copper absorption (plasma or erythrocyte copper). The SCV in the radial nerve was also positively related to the indicator of zinc absorption (plasma zinc); similarly, the MCVs in the radial and median nerves were positively related to the indicators of zinc absorption (erythrocyte or urinary zinc). These findings suggest that copper and zinc antagonize the subclinical effects of lead on peripheral nerve conduction velocities; the conduction velocity in the distal radial nerve is sensitive not only to asymptomatic lead absorption but also to zinc and copper absorption
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Presence of pannus-like tissue on osteoarthritic cartilage and its histological character
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: To investigate and characterize pannus-like tissue which is often present on osteoarthritic articular cartilage. DESIGN: Cartilage specimens from 15 knee and five hip joints of patients with osteoarthritis (OA) undergoing arthroplasty were stained for HE and Safranin-O. They were also immunostained by antitype I collagen, type II collagen, CD68, IL-1beta and MMP3 antibodies. RESULTS: Ninety percent of joints have pannus-like tissue on the articular surface, preferentially in a marginal area. The articular cartilage was divided into three regions according to the location: the marginal zone, the intermediate zone and the paraeburnated zone. Pannuslike tissue in OA knee joint occurred 45.9%, 27.5% and 11.1% of the surface of each region respectively. Histologically, pannus-like tissue could be classified into the vascular type and the fibrous type. Extracellular matrix of both types of tissues were negative for Safranin-O and type II collagen, but positive for type I collagen. IL-1beta and MMP3 expressing cells are predominant in pannus-like tissue, whereas CD68 positive cells were infiltrated in only a few samples. Vascular type tissue kept continuity with bone marrow suggesting mesenchymal origin. CONCLUSION: Pannus-like tissue exists in advanced OA cartilage, preferentially in the marginal zone. It expressed IL-1beta and MMP3, which strongly suggests that it contributes to cartilage degradation
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[The effects of two different continuous passive motion protocols on knee range of motion after total knee arthroplasty: a prospective analysis]
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVES: We prospectively evaluated the effects of continuous passive motion (CPM) started after two different time intervals following total knee arthroplasty (TKA) on short- and long-term results, in comparison with standard physical therapy. METHODS: Eighty-six patients were randomized to three groups following TKA for primary osteoarthritis. The control group (n=28) received only conventional physical therapy. Group I and II, each consisting of 29 patients, were treated with conventional physical therapy combined with CPM that was started on the first and third postoperative days, respectively, and continued until discharge with three one-hour sessions daily. Preoperative and postoperative measurements of the knee range of motion were recorded. Clinical and functional results were assessed using the Knee Society rating system. The patients were followed-up for at least two years (range 26 to 52 months). RESULTS: The duration of CPM was 22 hours in group I, and 19 hours in group II (p>0.05). Knee flexion values measured in the CPM groups on day 3 and at discharge showed significant differences with those of the control group, but no significant differences were found between the groups after the first postoperative month in this respect (p>0.05). The mean duration to reach 100 degrees of passive knee flexion (p=0.03) and the mean length of hospital stay (p=0.04) in the CPM groups were shorter by three and two days compared to the control group, respectively. Clinical and functional knee scores showed significant improvements in all the groups postoperatively (p<0.001), but there were no significant differences between the groups with respect to pre-and postoperative knee scores (p>0.05). CONCLUSION: Even though CPM protocols applied following TKA may shorten the length of hospital stay, CPM applications do not offer additional short- and long-term benefits over standard physical therapy with respect to knee flexion and clinical and functional results
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Double-blind clinical evaluation of intra-articular glucosamine in outpatients with gonarthrosis
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OAK 3 - Non-arthroplasty tx of OAK
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Fiftyâ?four outpatients with gonarthrosis participated in a doubleâ?blind clinical test with the aim of evaluating the efficacy and tolerance of intraâ?articular glucosamine in comparison with a 0.9% NaCl placebo. Each patient had one intraâ?articular injection per week for five consecutive weeks. Pain, active and passive mobility of the joint, swelling, and generalized and local intolerance symptoms were recorded before beginning the treatment, and four weeks after the last injection. Glucosamine reduced pain to a significantly greater extent than did placebo, and resulted in significantly more painâ?free patients. The angle of joint flexion substantially increased after glucosamine treatment. Active mobility increased with both treatments, with a more favorable trend after glucosamine administration. Knee swelling did not decrease significantly after glucosamine, whereas it worsened (although not significantly) after placebo. There were no local or general intolerance symptoms during and after treatment. Glucosamine administration was able to accelerate the recovery of arthrosic patients, with no resulting side effects, and to partially restore articular function. In addition, the clinical recovery did not fade after treatment ended, but lasted for the following month, at least. These features are a definite improvement over antirheumatic drugs, the major drawbacks of which are action of short duration and side effects. Glucosamine therapy therefore deserves a selected place in the management of osteoarthrosis. Copyright © 2011 Elsevier B. V., Amsterdam. All Rights Reserved.
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Endoscopic carpal tunnel release. A current perspective
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Carpal tunnel syndrome is defined as a clinical condition related to dysfunction of the median nerve specifically related to the carpal tunnel. This article reviews anatomy, current surgical treatment options, technique, indications and contraindications, efficacy, complications, and the author's own perspective on the subject
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Familial association of femoral trochlear dysplasia with recurrent bilateral patellar dislocation
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Surgical Management of Osteoarthritis of the Knee CPG
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Femoral trochlear dysplasia is an anatomic deformity that predisposes patients to patellar instability, including patellar subluxation and dislocation, and can lead to severe patellofemoral joint degeneration if left untreated. Femoral trochlear dysplasia leading to recurrent bilateral patellar dislocation has rarely been reported as having a familial association. Orthopedic surgeons who encounter patients presenting with chronic patellar instability with no underlying disease or syndrome should be aware of the presence of femoral trochlear dysplasia leading to recurrent bilateral patellar dislocation. Although femoral trochlear dysplasia remains uncommon, the presence of bilateral recurrent patellar dislocation in multiple members of the same family is highly suggestive of genetic inheritance. This article describes 3 patients from 1 family who presented with femoral trochlear dysplasia leading to recurrent bilateral patellar dislocation. To our knowledge, this is the second article to describe a familial form of femoral trochlear dysplasia associated with recurrent bilateral patellar dislocation and is the first article in English. A lower threshold for screening and early intervention for symptomatic family members may be indicated to prevent the long-term effects of chronic patellar subluxation, dislocation, and patellofemoral arthritis
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Treatment with lorecivivint, a novel, intra-articular CLK/DYRK1A inhibitor that modulates the WNT pathway, led to improved responder outcomes in subjects with knee osteoarthritis: a post HOC analysis of a phase 2b trial
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TO: WNT2 Pathway Modulator
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Purpose: Lorecivivint (LOR, SM04690), a small-molecule, intra-articular (IA) CLK/DYRK1A inhibitor that modulates the Wnt pathway, demonstrated beneficial effects on patient-reported outcomes (PROs) in early phase knee osteoarthritis (OA) studies. PROs assessed as discrete group threshold responses may represent therapeutic benefits of a drug in a more clinically meaningful manner than PROs assessed as changes in mean threshold responses. A post hoc analysis of a Phase 2b trial of LOR measured the proportions of LOR-treated subjects (0.07 mg dose) and placebo-treated subjects who achieved 30%, 50%, or 70% threshold responses in PROs relative to baseline at Week 12. Methods: Subjects in this 24-week Phase 2b trial had ACR-defined knee OA, Kellgren-Lawrence (KL) grades 2-3, and Pain NRS scores between �4 and �8 in the target knee and <4 in the contralateral knee. A single 2mL IA injection of 0.03 mg, 0.07 mg, 0.15 mg, or 0.23 mg LOR or vehicle placebo (PBO) was given in the target knee at baseline. The proportions of subjects meeting 30%, 50%, or 70% threshold responses at Week 12, relative to baseline PROs, in the weekly average of daily Pain Numeric Rating Scale (NRS) [0-10], Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain [0-100], WOMAC Function [0-100], and Patient Global Assessment (PtGA) [0-100] were determined. The odds ratios (OR; 95% CI) of subjects achieving each threshold response level with LOR compared to PBO were calculated using non-responder imputation. Results: In total, 635 subjects (91.4%) completed the trial (mean age 59.0 [±8.5] years, BMI 29.0 [±4.0] kg/m2, female 58.4%, KL grade 3 57.3%); 115 subjects were treated with 0.07 mg LOR and 116 subjects with PBO. Treatment with 0.07 mg LOR versus PBO significantly (P<0.05) increased the odds of demonstrating a 30% threshold response in Pain NRS (LOR, n=74; PBO, n=49; OR 2.47 [1.45, 4.19]) and WOMAC Function (LOR, n=70; PBO, n=53; OR 1.85 [1.10, 3.12]) at Week 12. Treatment also significantly increased the odds of demonstrating a 50% threshold response in WOMAC Pain (LOR, n=58; PBO, n=42; OR 1.79 [1.06, 3.03]) and PtGA (LOR, n=40; PBO, n=22; OR 2.28 [1.25, 4.16]). All subjects treated with LOR exhibited increased numerical odds ratios of achieving improved threshold responses in all PROs relative to PBO at Week 12. Conclusions: In the Phase 2b post hoc analysis, IA LOR for the potential treatment of knee OA demonstrated improved threshold responses across PRO measures of pain, function, and patient global assessment relative to PBO. Phase 3 studies are ongoing. Figure: Responder outcomes from a Phase 2b trial of LOR: Pain NRS, WOMAC Pain, WOMAC Function, and Patient Global Assessment at Week 12. [Formula presented]
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Subungual melanoma
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DoD LSA (Limb Salvage vs Amputation)
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Twenty (1.5%) of 1 350 patients with malignant melanoma treated during a 17-year period had their primary lesion in the nail bed. The thumb (5 patients) and big toe (7) were the most commonly involved digits. Mean delay before diagnosis was 1.4 years. Thirteen patients were black and 7 white. Eight patients (40%) were initially misdiagnosed as having traumatic, infective or benign lesions. Four patients presented with recurrent local disease after inappropriate nail excision or inadequate nail biopsy, while 2 patients had regional nodal spread and 2 had systemic metastases. Mean Breslow depth was 5.7 mm. The histogenetic subtypes were acral lentiginous melanoma (12 patients) and nodular melanoma (4 patients); 4 lesions were unclassifiable. All patients underwent amputation of the involved digit and 12 required node dissection (therapeutic in 11, prophylactic in 1). Five patients (25%) are alive (mean 52 months, range 29-99 months); 4 are disease-free and 1 has brain metastases. Overall median survival was 32 months with a 26% 5-year survival rate. Delayed diagnosis and advanced disease at presentation contributed to the poor prognosis in nail bed melanoma.
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Mortality following surgery for fractures of the neck of femur
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Management of Hip Fractures in the Elderly
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The mortality following surgery for hip fractures during 1982 is reviewed. 91 procedures were performed on 89 patients. The mortality rate at 4 weeks following general anaesthesia was 2.7%. This is much lower than previously reported. Possible reasons for the variation in mortality between this series and others, are discussed
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Principles of Breast Re-Reduction: A Reappraisal
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: This article examines outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction.
METHODS: A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Patient demographics, surgical technique, and outcomes were analyzed.
RESULTS: Ninety patients underwent breast re-reduction surgery. The average interval between primary and secondary surgery was 14 years (range, 0 to 42 years). The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 percent)]. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 percent)]. The nipple-areola complex was repositioned in 60 percent of patients (n = 54). The mean volume of tissue resected was 250 g (range, 22 to 758 g) from the right breast and 244 g (range, 15 to 705 g) from the left breast. Liposuction was also used adjunctively in all cases (average, 455 cc; range, 50 to 1750 cc). Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 percent).
CONCLUSIONS: Breast re-reduction can be performed safely and predictably, even when the previous technique is not known. Four key principles were developed: (1) the nipple-areola complex can be elevated by deepithelialization rather than recreating or developing a new pedicle; (2) breast tissue is removed where it is in excess, usually inferiorly and laterally; (3) the resection is complemented with liposuction to elevate the bottomed-out inframammary fold; and (4) skin should not be excised horizontally below the inframammary fold.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Improved tissue repair in articular cartilage defects in vivo by rAAV-mediated overexpression of human fibroblast growth factor 2
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Therapeutic gene transfer into articular cartilage is a potential means to stimulate reparative activities in tissue lesions. We previously demonstrated that direct application of recombinant adeno-associated virus (rAAV) vectors to articular chondrocytes in their native matrix in situ as well as sites of tissue damage allowed for efficient and sustained reporter gene expression. Here we test the hypothesis that rAAV-mediated overexpression of fibroblast growth factor 2 (FGF-2), one candidate for enhancing the repair of cartilage lesions, would lead to the production of a biologically active factor that would facilitate the healing of articular cartilage defects. In vitro, FGF-2 production from an rAAV-delivered transgene was sufficient to stimulate chondrocyte proliferation over a prolonged period of time. In vivo, application of the therapeutic vector significantly improved the overall repair, filling, architecture, and cell morphology of osteochondral defects in rabbit knee joints. Differences in matrix synthesis were also observed, although not to the point of statistical significance. This process may further benefit from cosupplementation with other factors. These results provide a basis for rAAV application to sites of articular cartilage damage to deliver agents that promote tissue repair
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Anatomy and biomechanics of the sternoclavicular joint
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Glenohumeral Joint OA
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Disorders of the sternoclavicular (SC) joint are becoming increasingly recognized as significant contributors to shoulder dysfunction in many patients, especially after a traumatic injury. Despite the increased interest, a thorough understanding of the anatomy and biomechanics of the SC joint is required for safe and efficient surgical treatment. The purpose of this article is to review the current state of anatomical and biomechanical knowledge surrounding the SC joint and to discuss their implications on surgical intervention.
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Evolving diagnostic criteria for multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Multiple myeloma (MM) is a plasma cell malignancy historically defined by the presence of end-organ damage, specifically, hypercalcemia, renal failure, anemia, and bone lesions (CRAB features) that can be attributed to the neoplastic process. In 2014, the International Myeloma Working Group (IMWG) updated the diagnostic criteria for MM to add specific biomarkers that can be used to make the diagnosis of the disease in patients who did not have CRAB features. In addition, the update allows modern imaging methods including computed tomography (CT) and positron emission tomography-CT to diagnose MM bone disease. These changes enable early diagnosis, and allow the initiation of effective therapy to prevent the development of end-organ damage in patients who are at the highest risk. This article reviews these and several other clarifications and revisions that were made to the diagnostic criteria for MM and related disorders. The updated disease definition for MM also automatically resulted in a revision to the diagnostic criteria for the asymptomatic phase of the disease termed smoldering MM (SMM). Thus the current diagnosis and risk-stratification of SMM is also reviewed in this article. Using specific prognostic factors, it is possible to identify a subset of patients with SMM who have a risk of progression to MM of 25% per year (high-risk SMM). An approach to the management of patients with low- and high-risk SMM is discussed.
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Popliteal artery injury in orthopedic knee surgery
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DoD LSA (Limb Salvage vs Amputation)
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Objectives: Iatrogenic popliteal artery trauma associated with knee orthopedic surgery are extremely rare, but present high morbidity. The effect of concomitant orthopedic and vascular lesions in relation to limb loss in patients with lower extremity vascular lesions and their predictive factors is analyzed. Material and methods: A retrospective study of popliteal artery trauma associated with orthopedic knee surgery was designed in a single center. For this, the medical records were reviewed between October-1979 to October-2016. The mechanism of production, mode of repair and related complications were analyzed as main variables. Results: During this period, 74 popliteal artery injuries were treated, of which 10 were associated with orthopedic surgery (13.5%). During those 36 years, 7,400 orthopedic interventions were performed (10 / 7,400, 0.1%). The injuries were secondary to 4 total knee prosthesis, 2 femur re-fractures, 2 tibia rod, 1 de-epifisiodesis and 1 osteosarcoma. The clinic was acute ischemia in 5 cases, hemorrhage in 2 and false aneurysm in 3. The median age was 43 years, with 3 in pediatric age. Were made 6 arteriographies and 2 angio-CT was required, since Doppler signal lacked diagnostic capacity. The repair was immediate (0-12 h) in 3 patients, in 1 between 12-24 hours and over 24 hours in 6 occasions. All were medially treated, the majority of which were the saphenous vein (3), prosthetic interposition (2), simple suture (2) and plasticity with patch (1). There were 3 compartmental syndromes that required fasciotomies. On two occasions an amputation was necessary, both in late repair. The functional capacity was manifestly altered in 4 patients: 2 for major amputation and 2 for external popliteal sciatic nerve injury. Conclusions: Late repairs and with prosthetic material were associated with an increased risk of limb loss. An image test is always required, since the Doppler signal is not very specific. The success of repair is clearly associated with early diagnosis and repair. The association of nerve and venous injuries is accompanied by greater disability and complications.
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Influence of degenerative changes of cervical spine on dysfunctions of the motor system in middle-aged women
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Glenohumeral Joint OA
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The aim of this study was to assess the impact of the degenerative changes of the cervical spine on mobility of the entire spine and shoulder joints, and on muscle mass of the shoulder girdle. Examinations covered a group of 60 women, aged 45-55 years, working in an office for at least 8 hours a day. Significant degenerative changes of the cervical spine and neurological complications of the shoulder girdle and the upper limb concomitant of them were discovered on the basis of X-ray pictures. Assessment of the functional state of the women with the degenerative changes of the cervical spine was conducted on the basis of measurements of its mobility and measurement of mobility and muscle mass of the shoulder girdles. Limitations of all the examined types of motion were found in all women with degenerative changes of the cervical spine. Greater limitations, in reference to physiological norms, were observed on the painful side of the body. The results of mobility tests of the shoulder joints indicated limitations of all the examined types of motion in both joints. The result of circumferential measurements also showed that the muscle mass was greater on the side, on which the pain had not occurred. However, the observed differences were not statistically significant.
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Effect of intraoperative blood loss on the serum level of cefazolin in patients managed with total hip arthroplasty. A prospective, controlled study
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Management of Hip Fractures in the Elderly
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The effect of intraoperative blood loss on serum levels of cefazolin in patients being managed with total hip arthroplasty was studied. Eighteen patients, thirteen men and five women, with a mean age of sixty-five years (range, forty to eighty-five years) were enrolled in the study. Fifteen had a primary total hip arthroplasty and three, a revision. Each patient served as his or her own control. Baseline clearance of cefazolin was determined at a minimum of forty-eight hours before the operation. Each patient received one gram of cefazolin intravenously. Serial serum concentrations were determined from specimens drawn at zero, five, ten, twenty, thirty, sixty, 120, 240, and 300 minutes after administration. Fifteen minutes before the skin incision was made, each patient again received one gram of cefazolin intravenously. Serum samples were collected at the same time-intervals, and the serum levels of cefazolin were determined with use of capillary electrophoresis. Data regarding intraoperative blood loss as well as replacement of fluid and blood were recorded. The administration of the antibiotic, retrieval of the serum samples, and estimation of the blood loss were performed by the same person in the same manner for all patients. The preoperative and intraoperative creatinine clearances (mean and standard deviation), estimated with use of the formula of Cockcroft and Gault, were 62.06 +/- 21.28 and 74.02 +/- 24.75 milliliters per minute, respectively. The amount of intraoperative blood loss averaged 1137 +/- 436 milliliters (range, 675 to 2437 milliliters). The preoperative and intraoperative cefazolin clearances averaged 0.49 +/- 0.21 and 0.52 +/- 0.30 milliliter per minute per kilogram, respectively. During joint replacement, the commonly accepted interval between doses of cefazolin is four hours. In the present study, the serum level of cefazolin at four hours was forty-five micrograms per milliliter. This corresponds to an osseous concentration that well exceeds the minimum inhibitory concentration for Staphylococcus aureus, which is 0.5 microgram per milliliter. This study suggests that, with blood losses of less [corrected] than 2000 milliliters, it is not necessary to administer cefazolin at intraoperative intervals of less than four hours in order to maintain a concentration of antibiotics that is higher than the minimum inhibitory concentration for the most common infecting organisms
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What Is the Implant Survivorship and Functional Outcome After Total Humeral Replacement in Patients with Primary Bone Tumors?
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: Total humeral replacement is an option to reconstruct massive bone defects after resection of locally advanced bone tumors of the humerus. However, implant survivorship, potential risk factors for implant revision surgery, and functional results of total humeral replacement are poorly elucidated because of the rarity of the procedure.
QUESTIONS/PURPOSES: We asked: (1) What is the revision-free implant and overall limb survivorship after total humerus replacement? (2) What factors are associated with implant revision surgery? (3) What is the functional outcome of the procedure as determined by the Musculoskeletal Tumor Society (MSTS) score and the American Shoulder and Elbow Surgeons (ASES) score?
METHODS: Between August 1999 and December 2018, 666 patients underwent megaprosthetic reconstruction after resection of a primary malignant or locally aggressive/rarely metastasizing tumor of the long bones at our department. In all, 23% (154) of these patients had a primary tumor located in the humerus. During the study, we performed total humeral replacement in all patients with a locally advanced sarcoma, in patients with pathological fractures, in patients with skip metastases, or in patients with previous intralesional contaminating surgery, who would have no sufficient bone stock for a stable implant fixation for a single joint megaprosthetic replacement of the proximal or distal humerus. We performed no biological reconstructions or reconstructions with allograft-prosthetic composites. As a result, 5% (33 of 666) of patients underwent total humerus replacement. Six percent (2 of 33) of patients were excluded because they received a custom-made, three-dimensionally (3-D) printed hemiprosthesis, leaving 5% (31) of the initial 666 patients for inclusion in our retrospective analysis. Of these, 6% (2 of 31) had surgery more than 5 years ago, but they had not been seen in the last 5 years. Median (interquartile range) age at the time of surgery was 15 years (14 to 25 years), and indications for total humeral replacement were primary malignant bone tumors (n = 30) and a recurring, rarely metastasizing bone tumor (n = 1). All megaprosthetic reconstructions were performed with a single modular system. The implanted prostheses were silver-coated beginning in 2006, and beginning in 2010, a reverse proximal humerus component was used when appropriate. We analyzed endoprosthetic complications descriptively and assessed the functional outcome of all surviving patients who did not undergo secondary amputation using the 1993 MSTS score and the ASES score. The median (IQR) follow-up in all survivors was 75 months (50 to 122 months), with a minimum follow-up period of 25 months. We evaluated the following factors for possible association with implant revision surgery: age, BMI, reconstruction length, duration of surgery, extraarticular resection, pathological fracture, previous intralesional surgery, (neo-)adjuvant radio- and chemotherapy, and metastatic disease.
RESULTS: The revision-free implant survivorship at 1 year was 77% (95% confidence interval 58% to 89%) and 74% (95% CI 55% to 86%) at 5 years. The overall limb survivorship was 93% (95% CI 75% to 98%) after 1 and after 5 years. We found revision-free survivorship to be lower in patients with extraarticular shoulder resection compared with intraarticular resections (50% [95% CI 21% to 74%] versus 89% [95% CI 64% to 97%]) after 5 years (subhazard ratios for extraarticular resections 4.4 [95% CI 1.2 to 16.5]; p = 0.03). With the number of patients available for our analysis, we could not detect a difference in revision-free survivorship at 5 years between patients who underwent postoperative radiotherapy (40% [95% CI 5% to 75%]) and patients who did not (81% [95% CI 60% to 92%]; p = 0.09). The median (IQR) MSTS score in 9 of 13 surviving patients after a median follow-up of 75 months (51 to 148 months) was 87% (67% to 92%), and the median ASES score was 83 (63 to 89) of 100 points, with higher scores representing better function.
CONCLUSION: Total humeral replacement after resection of locally advanced bone tumors appears to be associated with a good functional outcome in patients who do not die of their tumors, which in our study was approximately one- third of those who were treated with a resection and total humerus prosthesis. However, the probability of early prosthetic revision surgery is high, especially in patients undergoing extraarticular resections, who should be counseled accordingly. Still, our results suggest that if the prosthesis survives the first year, further risk for revision appears to be low. Future studies should reexamine the effect of postoperative radiotherapy on implant survival in a larger cohort and evaluate whether the use of soft tissue coverage with plastic reconstructive surgery might decrease the risk of early revisions, especially in patients undergoing extraarticular resections.
LEVEL OF EVIDENCE: Level III, therapeutic study.
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Distal medial tibial locking plate for fixation of extraarticular distal humeral fractures; an alternative choice for fixation
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Pediatric Supracondylar Humerus Fracture 2020 Review
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OBJECTIVE: The aim of this study was to describe an alternative fixation method for distal humeral extra-articular fractures through posterior approach using distal tibia anatomic locking plate; and to evaluate the patient's functional outcome and union condition. METHODS: Eighteen patients (11 men and 7 women; average age of 37.0 ± 17.3 years (range: 18-73 years)) with a distal humeral extra-articular fracture who were treated with distal tibial medial locking plate were included into the study. The mean follow up time was 36.2 ± 16.7 (12-57) months. Functional results were evaluated with perception of pain, range of joint motion, grasp and pinch strengths. RESULTS: Union was achieved in 17 of 18 patients. Only one patient had non-union due to infection and underwent debridement. The mean time for union was 7.8 ± 5.9 months (2-20). Patient perception of pain was X = 1.88 ± 2.50 and X = 4.55 ± 2.68, respectively, at rest and activity. The active ranges of joint motion were adequate for functional use. General functional state of affected extremity (DASH-T) was perfect (X = 27.14 ± 25.66), the performance of elbow joint was good (X = 84.44 ± 11.57). There were no differences in the comparison of grasp and pinch grip of patients with uninvolved extremity (p > 0.05). CONCLUSIONS: In distal humeral extra-articular fractures, use of distal medial tibia plate has advantages such as providing high rates for union, low rates for complication, and early return to work with early rehabilitation, therefore it may be considered a fixation choice that can be used for distal humeral extra-articular fractures. LEVEL OF EVIDENCE: Level IV, therapeutic study.
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Delamination of tantalum porous coating from a TKA due to regional dissemination of debris
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PJI DX Updated Search
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Metallic debris from metal-on-metal bearings is a recognized mode of failure that may lead to implant loosening and periprosthetic soft tissue reactions. The sequelae of metallosis have been most commonly reported with respect to total hip arthroplasty. The authors report a rare case of metallosis following a hybrid metal-on-polyethylene total knee arthroplasty that used a porous tantalum tibial knee component. A total knee arthroplasty patient who presented with knee pain but normal radiographs was found to have delamination of her tibial component that resulted in marked periprosthetic soft tissue metallosis
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The effects of liposuction removal of subcutaneous abdominal fat on lipid metabolism are independent of insulin sensitivity in normal-overweight individuals
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Abdominal fat (both visceral and subcutaneous) accumulation is associated with an increased risk of developing insulin resistance. The latter stands as the basis upon which diabetes, hypertension, and atherogenic dyslipidemia tend to build up. Hence, abdominal liposuction (AL) could theoretically hold metabolic benefits. We undertook the present study to assess the effects of AL on carbohydrate and lipid metabolism. METHODS: This is a prospective study including 20 healthy volunteers (M2/F18) aged 39.6 +/- 7.7 years old (24-52), body mass index (BMI) = 25.3 +/- 4.7 kg/m(2) (19.8-36) who underwent AL. Before and 4 months after AL, we measured glucose and insulin concentrations, HOMA index [glucose (mM) x IRI (microUI/l)/22.5], free fatty acids (FFA), glycerol, total cholesterol and triglycerides, high-density lipoprotein (HDL)-cholesterol (HDL-c), low-density lipoprotein (LDL)-cholesterol (LDL-c), very low-density lipoprotein (VLDL)-cholesterol (VLDL-c) and apolipoproteins (apo) B, AI and AII, adiponectin (Adp), and ultra-sensitive C-reactive protein (CRP). RESULTS: Lipo-aspirate averaged 5.494 +/- 5.297 cc (600-19.000). Weight, BMI, and waist circumference decreased significantly 4 months after surgery by 4.6, 4.6 and 5.9%, respectively. There were significant decrements in FFA (-35%, p < 0.0001), glycerol (-63%, p < 0.0005), VLDL-c (-15.2%; p < 0.001), and triglycerides (-21.3%, p < 0.002), an increase in HDL-c (+10%, p < 0.03), Apo AI (+10.1%, p < 0.02), and Apo AII (+11.8%, p < 0.001). Total cholesterol, LDL-c, ApoB, and the LDL-c/ApoB ratio raised by +15% (p < 0.0005), +27.3% (p < 0.000), +15.1% (p < 0.008) and +2.76% (p < 0.008), respectively. Glucose, insulin, the HOMA index, Adp, and CRP were not significantly altered after AL. CONCLUSION: AL in healthy normal weight or slightly overweight subjects improves the major lipoprotein components of obesity-associated dyslipidemia. This improvement occurs independent of insulin sensitivity.
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Electroacupuncture serum inhibits TNF-alpha-mediated chondrocyte inflammation via the Ras-Raf-MEK1/2-ERK1/2 signaling pathway
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OAK 3 - Non-arthroplasty tx of OAK
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The Ras-Raf-mitogen-activated protein kinase kinase (MEK)1/2-extracellular signal-regulated kinase (ERK)1/2 signaling pathway contributes to the release of chondral matrix-degrading enzymes and accelerates the degradation of articular cartilage. Electroacupuncture (EA) treatment has been widely used for the treatment of osteoarthritis (OA); however, the mechanism underlying the effects of EA on OA remains unclear. Therefore, the present study evaluated the anti-inflammatory effects and potential underlying mechanisms of EA serum (EAS) on tumor necrosis factor (TNF)-alpha-mediated chondrocyte inflammation. A total of 30 Sprague Dawley rats were randomly divided into three groups: The blank group; experimental group I, which received 15 min of EA treatment; and experimental group II, which received 30 min of EA treatment. Subsequently, serum samples were obtained. Chondrocytes were isolated from the knee cartilage of Sprague Dawley rats, and were identified using collagen type II immunohistochemistry. TNF-alpha-treated chondrocytes were used as a cell model, and subsequently the cells were treated with EAS from each group for various durations. The results demonstrated that EAS treatment significantly promoted the viability and inhibited the apoptosis of TNF-alpha-treated chondrocytes. In addition, interleukin (IL)-1beta concentration was significantly increased in the model group compared with in the control group, whereas EAS significantly reduced IL-1beta concentration in TNF-alpha-treated chondrocytes. Furthermore, the protein expression levels of Ras, Raf and MEK1/2 were reduced in the EAS groups compared with in the model group. EAS also significantly inhibited the phosphorylation of ERK1/2, and the expression of downstream regulators matrix metalloproteinase (MMP)-3 and MMP-13. In conclusion, these results indicated that EAS may inhibit TNF-alpha-mediated chondrocyte inflammation via the Ras-Raf-MEK1/2-ERK1/2 signaling pathway in vitro, thus suggesting that EAS may be considered a potential therapeutic strategy for the treatment of OA.
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A Review of National Insurance Coverage of Post-bariatric Upper Body Lift
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Panniculectomy & Abdominoplasty CPG
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INTRODUCTION: Recent years have seen an increased utilisation of upper body lift following massive weight loss. Although it is typically considered cosmetic, the recurrent skin conditions and decline in quality of life may warrant medical necessity. We evaluated current insurance coverage and characterised policy criteria for upper body lift in the post-bariatric population. METHODS: We defined upper body lift as a combination of mastopexy and upper back excision (UBE) and conducted a cross-sectional analysis of US insurance policies. Insurance companies were selected based on their enrolment data and market share. A web-based search and telephone interviews were conducted to identify the policy. Criteria were abstracted from the publicly available policies that offered coverage. RESULTS: Of the 56 insurance companies assessed, 5% would consider coverage of both procedures. Although fewer companies held established policies for UBE than mastopexy in the post-bariatric population (79% vs 96%, p = 0.0081), there were significantly more policies that offered pre-approval for UBE than for mastopexy (30% vs 5%, p = 0.0017). Three medical necessity criteria were common to both procedures: evidence of functional impairment, secondary skin conditions, and medical photographs. CONCLUSION: Policy criteria for coverage of mastopexy or UBE differ greatly between companies. Further evaluation of medical necessity criteria for post-bariatric mastopexy and UBE with the establishment of a standardised guideline is needed. We propose a comprehensive list of reporting recommendations to help optimise authorisation of upper body lift in the post-bariatric population, and we urge plastic surgeons to challenge current definition of "cosmetic" by insurance companies. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Extended replacement of the thoracic aorta
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PJI DX Updated Search
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OBJECTIVES: We present our experience of total aortic arch replacement. METHODS: Twenty-nine patients (21 males and 8 females; mean age 63.3 +/- 13.3 years) with extended thoracic aortic aneurysms underwent graft replacement. The pathology of the diseased aorta was non-dissecting aneurysm in 11 patients, including one aortitis and aortic dissection in 18 patients (acute type A: one, chronic type A: 11, chronic type B: six). Five patients had Marfan syndrome. In their previous operation, two patients had undergone the Bentall procedure, three had endovascular stenting, one had aortic root replacement with valve sparing and 12 had hemi-arch replacement for acute type A dissection. Approaches to the aneurysm were as follows: posterolateral thoracotomy with rib-cross incision in 16, posterolateral thoracotomy extended to the retroperitoneal abdominal aorta in seven, mid-sternotomy and left pleurotomy in three, anterolateral thoracotomy with partial lower sternotomy in two and clam-shell incision in one patient. Extension of aortic replacement was performed from the aortic root to the descending aorta in 4, from the ascending aorta to the descending aorta in 17 and from the ascending to the abdominal aorta in eight patients. Arterial inflow for cardiopulmonary bypass consisted of the femoral artery in 15 patients, ascending aorta and femoral artery in seven, descending or abdominal aorta in five and ascending aorta in two. Venous drainage site was the femoral vein in 10, pulmonary artery in eight, right atrium in five, femoral artery with right atrium/pulmonary artery in four and pulmonary artery with right atrium in two patients. RESULTS: The operative mortality, 30-day mortality and hospital mortality was one (cardiac arrest due to aneurysm rupture), one (rupture of infected aneurysm) and one (brain contusion), respectively. Late mortality occurred in three patients due to pneumonia, ruptured residual aneurysm and intracranial bleeding. Actuarial survival at 5 years after the operations was 80.6 +/- 9.0%. Freedom from the subsequent aortic events was 96.0 +/- 3.9% at 5 years. CONCLUSIONS: Our treatment method for extensive thoracic aneurysms achieved satisfactory results using specific strategies and appropriate organ protection according to the aneurysm extension in the selected patients
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1 |
Clinical characteristics of invasive Haemophilus aphrophilus infections
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Haemophilus aphrophilus, an oral fastidious Gram-negative commensal with low pathogenicity, is a member of the HACEK group (H. aphrophilus, H. paraphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella spp.), and a rare cause of human infections. We reviewed the characteristics of 8 cases of H. aphrophilus infections diagnosed in our hospital from 1990-2003, and an additional 20 cases identified from the MEDLINE database, from 1990 to 2003. Their mean age was 47.4 years (range, 7-73 years), and 21 cases (75%) were male. The major manifestation was bone and joint infections (9 cases, 32%), including osteomyelitis, discitis, epidural abscess, spondylodiscitis, septic arthritis and prevertebral infection. Seven cases (25%) presented with infective endocarditis, involving native valves, and one underwent valvular replacement. Of note, 3 cases (10%) had ophthalmic infections (endophthalmitis in 2 cases and canaliculitis in 1), and 2 of them had previous ophthalmic procedures. Other manifestations included bacteremia, meningitis, brain abscess, cervical lymphadenitis, facial cellulitis, empyema, and purulent pericarditis and tamponade. All patients except 1 survived. Recent dental procedure was recalled by 11 cases (39%), and may be a predisposing factor for invasive H. aphrophilus infection. Appropriate antimicrobial therapy, such as a beta-lactam/beta-lactamase inhibitor, ceftriaxone or cefotaxime or a fluoroquinolone, can lead to a favorable clinical outcome
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1 |
Cutaneous surgery in patients receiving warfarin therapy
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Reconstruction After Skin Cancer
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BACKGROUND: Anticoagulant treatment with warfarin is an essential therapy in patients with prosthetic heart valves and atrial fibrillation to prevent thromboembolisms. The question whether to stop warfarin treatment in patients undergoing cutaneous surgery is debatable. OBJECTIVE: To evaluate the outcome of surgery in patients that were treated with warfarin and underwent excisional and Mohs surgeries. METHODS: Warfarin therapy was continued in all patients that underwent excisional and Mohs surgery in our practice from November 1999 to November 2000. Perioperative complications such as bleeding and cosmetic outcome are evaluated. RESULTS: A total of 560 patients underwent Mohs surgery and 530 patients underwent excisional surgery. Sixteen patients (1.5%) were treated with coumadin with international normalized ratio (INR) values within the therapeutic values. Seventy-seven patients that underwent surgery on the same days as the warfarin-treated patients served as the control group. Intraoperative bleeding was easily controlled and postoperative bleeding was not recorded in any of the patients. All wounds healed without any complication, including full-thickness grafts. CONCLUSION: Coumadin treatment should be continued in patients undergoing cutaneous surgery. This will decrease the risk of thromboembolic events.
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Silent soft tissue pathology is common with a modern metal-on-metal hip arthroplasty
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PJI DX Updated Search
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BACKGROUND AND PURPOSE: Adverse reactions to metal debris have been reported to be a cause of pain in metal-on-metal hip arthroplasty. We assessed the incidence of both symptomatic and asymptomatic adverse reactions in a consecutive series of patients with a modern large-head metal-on-metal hip arthroplasty. METHODS: We studied the early clinical results and results of routine metal artifact-reduction MRI screening in a series of 79 large-head metal-on-metal hip arthroplasties (ASR; DePuy, Leeds, UK) in 68 patients. 75 hips were MRI scanned at mean 31 (12-52) months after surgery. RESULTS: 27 of 75 hips had MRI-detected metal debris-related abnormalities, of which 5 were mild, 18 moderate, and 4 severe. 8 of these hips have been revised, 6 of which were revised for an adverse reaction to metal debris, diagnosed preoperatively with MRI and confirmed histologically. The mean Oxford hip score (OHS) for the whole cohort was 21. It was mean 23 for patients with no MRI-based evidence of adverse reactions and 19 for those with adverse reactions detected by MRI. 6 of 12 patients with a best possible OHS of 12 had MRI-based evidence of an adverse reaction. INTERPRETATION: We have found a high early revision rate with a modern, large-head metal-on-metal hip arthroplasty. MRI-detected adverse rections to metal debris was common and often clinically "silent". We recommend that patients with this implant should be closely followed up and undergo routine metal artifact-reduction MRI screening
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0 |
Fracture risk in people with primary biliary cirrhosis: a population-based cohort study
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Management of Hip Fractures in the Elderly
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BACKGROUND & AIMS: Controversy exists as to whether people with primary biliary cirrhosis (PBC) have an increased risk of developing osteoporosis and the extent to which this may translate into an increased risk of fracture. We have performed a cohort study using the General Practice Research Database to quantify the excess fracture risk in people with PBC. METHODS: We identified 930 people with PBC and 9202 age- and sex-matched control subjects. We used Cox regression to estimate the hazard ratios for any fracture, hip fracture, and ulna/radius fracture in the PBC cohort compared with the general population. RESULTS: There were approximately 2-fold relative increases in the risk of any fracture, hip fracture, and ulna/radius fracture for the PBC cohort compared with the general population (hazard ratio [HR], 2.03; 95% confidence interval [CI]: 1.70-2.44; HR 2.14 (95% CI: 1.40-3.28), and HR, 1.96; 95% CI: 1.42-2.71, respectively). The absolute excess in fracture rates were for any fracture, 12.5 per 1000 person-years (95% CI: 8.1-16.9); for hip fracture, 1.9 per 1000 person-years (95% CI: 0.3-3.5); and for ulna/radius fracture, 3.4 per 1000 person-years (95% CI: 1.2-5.7). In those people with more severe disease, the relative risks of fracture were similar (any fracture HR, 2.24; hip fracture HR, 1.25; ulna/radius fracture HR, 1.28). CONCLUSIONS: There are modest increases in both the absolute and relative fracture risks in people with PBC compared with the general population, with the excess risks similar in those with more severe disease
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0 |
Distal radius microstructure and finite element bone strain are related to site-specific mechanical loading and areal bone mineral density in premenopausal women
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Distal Radius Fractures
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While weight-bearing and resistive exercise modestly increases aBMD, the precise relationship between physical activity and bone microstructure, and strain in humans is not known. Previously, we established a voluntary upper-extremity loading model that assigns a person's target force based on their subject-specific, continuum FE-estimated radius bone strain. Here, our purpose was to quantify the inter-individual variability in radius microstructure and FE-estimated strain explained by site-specific mechanical loading history, and to determine whether variability in strain is captured by aBMD, a clinically relevant measure of bone density and fracture risk. Seventy-two women aged 21-40 were included in this cross-sectional analysis. High resolution peripheral quantitative computed tomography (HRpQCT) was used to measure macro- and micro-structure in the distal radius. Mean energy equivalent strain in the distal radius was calculated from continuum finite element models generated from clinical resolution CT images of the forearm. Areal BMD was used in a nonlinear regression model to predict FE strain. Hierarchical linear regression models were used to assess the predictive capability of intrinsic (age, height) and modifiable (body mass, grip strength, physical activity) predictors. Fifty-one percent of the variability in FE bone strain was explained by its relationship with aBMD, with higher density predicting lower strains. Age and height explained up to 31.6% of the variance in microstructural parameters. Body mass explained 9.1% and 10.0% of the variance in aBMD and bone strain, respectively, with higher body mass indicative of greater density. Overall, results suggest that meaningful differences in bone structure and strain can be predicted by subject characteristics.
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0 |
Mechanical stimulation toward tissue engineering of the knee meniscus
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AMP (Acute Meniscal Pathology)
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Current clinical practices do not adequately regenerate the meniscus of the knee secondary to a tear. Complete or partial meniscus removal leads to degenerative changes within the joint. Tissue engineering of the meniscus promises a potent solution. Before embarking on tissue engineering of the meniscus, it is crucial to have a thorough comprehension of the biomechanical role that this tissue fulfills and how the structure of meniscus is uniquely suited to that purpose. To better understand this, we have examined the meniscus, as well as associated tissues, within the body. For the first time, the knee meniscus is rigorously compared to ligament, tendon, and cartilage, and inferences are drawn on how mechanical stimulation may be used to channel growth in the meniscus. We have examined in detail the loading conditions that these tissues experience in vivo and how each is uniquely adapted to its loading environment. These tissues are capable of achieving some degree of remodeling because of mechanical stimuli. By understanding the mechanisms that can stimulate and promote regeneration in related tissues, we hope to harness that knowledge to achieve the goal of meniscal regeneration. [References: 108]
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Osteolysis of the greater trochanter following reattachment of hip abductors using polyester suture in total hip arthroplasty
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Management of Hip Fractures in the Elderly
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We report a specific pattern of osteolysis around bone tunnels on the lateral cortex of the greater trochanter following abductor reattachment using a polyester suture. Radiographs of 395 patients who underwent cemented THA during a four year period between 1999 and 2003 were reviewed. 27 patients had abductor reattachment using number 5 EthibondTM suture through bone tunnels. These patients displayed a predominantly osteolytic pattern of bone reaction around the greater trochanter bone tunnels. All patients were subsequently reviewed in clinic at 4-7 years following surgery. Three patterns of response were observed around the bone tunnels. Recognition of this unique osteolysis pattern may be important in the investigation of complications following cemented THA. (copyright) Wichtig Editore, 2009
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Retrograde versus antegrade nailing of femoral shaft fractures
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To compare union rates and complications of retrograde intramedullary nailing of femoral shaft fractures with those of antegrade intramedullary nailing. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Two hundred eighty-three consecutive adult patients with 293 fractures of the femoral shaft who underwent stabilization with antegrade or retrograde inserted femoral nails were studied. There were 140 retrograde nails and 153 antegrade nails. Twelve fractures in twelve patients were excluded (three in patients who died early in the postoperative period, three in patients because of early amputation, four in patients who were paraplegic, and two in patients who fractured through abnormal bone owing to metastatic carcinoma), leaving 134 fractures treated with retrograde nails and 147 treated with antegrade nails. One hundred four femurs treated with retrograde nails (Group R) and ninety-four femurs treated with antegrade nails (Group A) had sufficient follow-up and served as the two study groups. The average clinical follow-up was twenty-three months (range 6 to 66 months) for Group R and twenty-three months (range 5 to 64 months) for Group A. Both groups were comparable with regard to age, gender, number of open fractures, degree of comminution, mode of interlocking (i.e., static or dynamic), and nail diameter (P > 0.05)
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1 |
Early or delayed surgical treatment in compound limb fractures due to high velocity missile injuries: a 5-year retrospective study from Medical City in Baghdad
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Compound limb fractures due to high-velocity missiles are complex and usually associated with multiple other injuries. These can occur in both military and civilian settings. High-velocity missiles are presently used by terrorists worldwide. Early surgical debridement and skeletal fixation are the gold standards in managing these injuries, but data supporting these recommendations are lacking.
AIM OF THE STUDY: Our aim was to determine the relationship between time (the time of injury to the time of surgical treatment) and the rate of deep infection in patients treated in Medical City, Baghdad, Iraq due to terrorist activity from 2004-2008.
DESIGN: This is a retrospective review of a series of open limb fractures.
PATIENTS AND METHOD: A total of 102 civilian patients with 114 limb fractures due to high-velocity missile injuries were selected for this study from Medical City records. Patients were followed in the outpatient department in Medical City Teaching Complex both clinically and radiologically.
RESULTS: Surgical treatment was accomplished in less than six hours from time of injury in group A (55 fractures, 48.4%) and more than six hours in group B (59 fractures, 51.7%). The infection rate for group A was 30.9% and group B was 23.7%.
CONCLUSION: A very high infection rate was noted for these injuries, and there was no increase in the rate of deep infection in patients treated more than six hours after the injury.
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The Avon Patellofemoral Joint Replacement: Mid-Term Prospective Results from an Independent Centre
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Approximately 10% of patients with osteoarthritis (OA) of the knee have unicompartmental OA confined to the patellofemoral joint (PFJ). The main surgical options are total knee replacement (TKR) and PFJ replacement (PFJR). PFJR has a number of advantages over TKR, including being less invasive, preserving the unaffected parts of the knee, allowing faster recovery and better range of motion and function. We report our prospective mid-term results of the Avon PFJR for established isolated PFJ arthritis in 61 consecutive procedures.
METHODS: Sixty-one Avon PFJRs were performed in 57 patients. The outcome measures were the new Oxford knee score (OKS), Hungerford and Kenna score (HKS), and Crosby Insall knee scores. Only patients with severe isolated PFJ OA were included. The diagnosis was based on a combination of clinical, radiological and, where available, arthroscopic findings.
RESULTS: Mean follow-up was 5.09 years (range, 12 to 124 years). There were 2 revisions in the first 5 years. The median HKS score was 80 (interquartile range, 70 to 95) and the mean OKS was 31.8 (+/- standard deviation, 8.7) at 5 years. These were significantly better (p < 0.001) than the preoperative scores.
CONCLUSIONS: The Avon prosthesis gives good functional outcomes in the medium term and survives well. Our data support other studies in the literature and is the largest independent prospective study to date.
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0 |
Frequency and impact of active clinical issues and new impairments on hospital discharge in patients with hip fracture
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Management of Hip Fractures in the Elderly
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BACKGROUND: Hip fracture is associated with significant mortality and disability. Patients who are discharged from the hospital with active clinical problems may have worse outcomes than those patients without active clinical problems. OBJECTIVE: To assess the frequency and impact of clinical problems at discharge on clinical and functional hip fracture outcomes. METHODS: Detailed clinical data were collected from 559 patients in a prospective, multicenter observational cohort study. Active clinical issues (ACIs) on discharge included the following: temperature of 38.3 degrees C or higher, heart rate of more than 100/min or less than 60/min, systolic blood pressure higher than 180 mm Hg or lower than 90 mm Hg, diastolic blood pressure higher than 110 mm Hg or lower than 60 mm Hg, respiratory rate of more than 24/min, oxygen saturation of less than 90%, altered mental status, no oral intake, shortness of breath, chest pain, arrhythmias, or wound infection. New impairments (NIs) included bowel and bladder incontinence, inability to get out of bed, and decubitus ulcer. Outcomes were deaths, readmissions, and functional mobility 60 days after discharge. RESULTS: Overall, 94 patients (16.8%) had 1 or more ACIs, and 229 (41.0%) had 1 or more NIs on discharge. Both ACIs and NIs on discharge were associated with increased risk-adjusted rates of death (odds ratio, 1.8; 95% confidence interval, 1.2-2.8) or readmission (odds ratio, 1.7; 95% confidence interval, 1.2-2.3). The NIs on discharge were also associated with worse functional mobility (P<.004). These relationships persisted in multivariate analyses that controlled for a previously validated, hip fracture-specific risk adjustment measure. CONCLUSIONS: Clinicians should consider information about ACIs and NIs when deciding readiness for discharge and planning post-acute care
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Intraobserver and interobserver reliability of the assessment of the patellar articular cartilage in osteoarthritic patients undergoing total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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This study was performed to investigate intraobserver and interobserver reliability of the intraoperative assessment of patellar cartilage status and the decision on patellar resurfacing based on the cartilage assessment in osteoarthritic patients undergoing total knee arthroplasty. Photographs of patellar cartilage were taken in 80 knees of 53 patients undergoing total knee arthroplasty. Three investigators assessed the depth and size of the cartilage lesion and made a decision on patellar resurfacing, using the photographs twice. Intraobserver and interobserver reliabilities were calculated with the kappa coefficient. Cartilage assessment had substantial intraobserver (kappa = 0.77 for depth and 0.71 for size) and moderate interobserver (kappa = 0.54 for depth and 0.45 for size) reliabilities. Decision on patellar resurfacing had almost perfect intraobserver and substantial interobserver reliabilities (kappa = 0.88 and 0.68, respectively). We found that intraoperative assessment of the patellar articular cartilage and the decision for patellar resurfacing are reliable
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Physiological characterization of neuropathy in Fabry's disease
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Fabry's disease is commonly associated with a painful, debilitating neuropathy. Characterization of the physiological abnormalities is an important step in evaluating response to specific therapies. Twenty-two patients with Fabry's disease, and with relatively preserved renal function, underwent conventional and near-nerve conduction studies, electromyography, sympathetic skin responses, and quantitative sensory testing (QST). Nerve conduction studies were mostly normal except for an increased frequency of median nerve entrapment at the wrist in 6 (27%) patients. Sympathetic skin responses were preserved in 19 of 20 (95%) of the patients. The QST showed increased or immeasurable cold and warm detection thresholds in patients, significantly different from controls (n = 28) in the hand (P < 0.001, P = 0.04, respectively) and foot (P < 0.001 for both). Cold thresholds were more often abnormal than were warm thresholds. Vibration thresholds were normal in the feet and, in some patients, elevated in the hand only, probably due to frequent median nerve entrapment at the wrist. Our findings suggest that the neuropathy of Fabry's disease is characterized by an increased prevalence of median nerve entrapment at the wrist and by thermal afferent fiber dysfunction in a length-dependent fashion, with greater impairment of cold than warm sensation. (copyright) 2002 Wiley Periodicals, Inc
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