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Is the clinical outcome after cartilage treatment affected by subchondral bone edema?
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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PURPOSE: Subchondral bone edema is a common finding after cartilage treatment, but its interpretation is still debated. The aim of this study is to analyse the presence of edema after matrix-assisted autologous chondrocyte transplantation (MACT) for knee cartilage lesions at different follow-up times and its correlation with the clinical outcome. METHODS: Two hundred and forty-eight magnetic resonance imagings (MRIs) of patients treated with a hyaluronic acid-based MACT for lesions of the knee articular surface were considered. The MRIs belonged to 116 patients (mean age at surgery 28.6 +/- 10.3 years, average defect size 2.4 +/- 1.0 cm2), 57 affected by degenerative cartilage lesions, 27 traumatic and 32 were osteochondritis dissecans (OCD). MRI follow-up was performed from 6 to 108 months after treatment. Other than its presence or absence, the subchondral bone edema was evaluated using a 3-level grading considering extension and hyperintensity, and with the WORMS score edema classification. The IKDC subjective score was collected at the time of every MRI. RESULTS: An analysis of the entire MRI group showed that edema is not constantly present through the follow-up, but presents a particular and well-defined trend. Edema was present within the first 2 years and was then markedly reduced or disappeared at 2 and 3 years (p = 0.044). Afterwards the level of edema increased again (p < 0.0005) and remained steadily present at medium/long-term follow-up. Patellar lesions presented significantly lower edema (p = 0.012), whereas OCD lesions presented more edema at all follow-up (p = 0.002) and a different trend, with an increasing level of edema over time. No correlation was found between edema and clinical outcome. CONCLUSIONS: Edema after MACT is present during the first phases of cartilage maturation up to 2 years of follow-up, and then tends to disappear. However, after a few years, it tends to reappear. Less edema was found in the patella, whereas more edema was found in the OCD, where subchondral bone is primarily involved. Interestingly, the presence of edema was not correlated with a poorer clinical outcome. Whether this might be a prognostic factor at longer follow-up remains to be determined, but our results give some indication on what to expect on both MRI edema and clinical outcome after MACT. LEVEL OF EVIDENCE: Case series, Level IV
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Anatomic Hip Center Decreases Aseptic Loosening Rates After Total Hip Arthroplasty with Cement in Patients with Crowe Type-II Dysplasia: A Concise Follow-up Report at a Mean of Thirty-six Years
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Developmental Dysplasia of the Hip 2020 Review
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We previously reported the two to twenty-two-year results of 145 total hip arthroplasties (THAs) with cement performed from 1969 to 1980 in 117 patients with Crowe type-II dysplasia. The purpose of the present study was to update the long-term effects of a nonanatomic hip center on component loosening and aseptic revision in this cohort. Forty-nine patients (sixty hips) were alive at a mean of thirty-six years. The overall cumulative incidence of aseptic revision at thirty-five years was 32% for acetabular cups and 21% for femoral stems. Acetabular loosening was less likely with a hip center placed within the true acetabular region (TAR), <15 mm superior to the approximate femoral head center (AFHC), <35 mm superior to the interteardrop line (ITL), or within zone 1. Femoral loosening and revision were less likely with the hip center placed <35 mm superior to the ITL and within zone 1. An anatomic hip center was associated with significantly lower loosening and aseptic revision rates for both acetabular and femoral components. The current study supports the placement of acetabular components in an anatomic position to promote long-term durability after THA with cement. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Rapid, progressive neuropathic arthropathy of the hip in a patient co-infected with human immunodeficiency virus, hepatitis C virus and tertiary syphilis: Case report
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PJI DX Updated Search
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Background: Syphilis is a chronic infection that is classified into three stages. In its tertiary stage, syphilis spreads to the brain, heart and other organs; the lesions may involve the skin, mucous membranes and bones. Neuropathic arthropathy associated with tertiary syphilis has rarely been described in Europe and its association with HIV-HCV co-infection has not been reported so far.This article reports the case of a man with tertiary syphilis presenting with rapidly evolving neuropathic arthropathy of the hip and extensive bone destruction.Case presentation: On initial presentation, the patient complained of progressively worsening left-sided coxalgia without localized or generalized inflammation. The patient reported to have no history of previous infections, trauma or cancer. Plain x-ray films of the left coxofemoral joint showed marked degeneration with necrosis of the proximal epiphysis of femur and morphological alterations of the acetabulum without protrusion. Primary coxarthrosis was diagnosed and hip arthroplasty was offered, but the patient declined treatment. Three months later, the patient presented a marked deterioration of his general condition. He disclosed that he was seropositive for HCV and HIV, as confirmed by serology. Syphilis serology testing was also positive. A Girdlestone's procedure was performed and samples were collected for routine cultures for bacteria and acid fast bacilli, all resulting negative.Although histological findings were inconclusive, confirmed positive serology for syphilis associated with progressive arthropathy was strongly suggestive of tertiary syphilis, probably exacerbated by HIV-HCV co-infection. The patient partially recovered the ability to walk.Conclusions: Due to the resurgence of syphilis, this disease should be considered as a possible cause of neuropathic arthropathy when other infectious causes have been ruled out, particularly in patients with HIV and/or HCV co-infection. é 2011 Drago et al; licensee BioMed Central Ltd
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Five-year results of metal-on-metal resurfacing arthroplasty in Asian patients
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Management of Hip Fractures in the Elderly
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Clinical results of 50 metal-on-metal resurfacing arthroplasties in 45 Japanese patients were evaluated to a minimum follow-up of 5 years. The predominant diagnosis was developmental dysplasia or dislocation of the hip (70%). One patient died of an unrelated cause and another was lost to follow-up. Two hips received revision surgery, including 1 femoral neck fracture and 1 septic loosening. In the remaining 46 hips, 1 hip showed femoral component loosening. Clinical scores of the 46 hips were satisfactory at the final follow-up. The survival rate at 5 years was 96% when failure was attributed to revision for any reason. Metal-on-metal resurfacing arthroplasty in Japanese patients, who have a different distribution of hip diseases from European and American patients, showed similarly promising early clinical results
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0 |
Cathepsin B and L activities in gastric cancer tissue: correlation with histological findings
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MSTS 2018 - Femur Mets and MM
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Cathepsin B and L activities in cancerous and noncancerous mucosal tissues from 29 patients with gastric cancer were determined with a small amount of tissue homogenate. Both enzyme activities were significantly higher in cancerous tissues than in noncancerous tissues. The cathepsin B activity was higher with decreasing differentiation of the cancerous tissues, and also with increasing depth of invasion and metastasis to regional lymph nodes. Significantly high cathepsin B activity was observed in specimens of poorly differentiated adenocarcinomas, as well as in specimens from patients with extensive metastasis to n2 or n3 lymph nodes. These results suggest that high cathepsin B activity is characteristic of gastric cancer which invades and metastasizes. Therefore, in cases of marked elevation of cathepsin B activity in cancerous tissues, relatively extensive resection may be necessary to obtain a cure.
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Dysbaric osteonecrosis and its radiographic classification in China
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MSTS 2018 - Femur Mets and MM
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Dysbaric osteonecrosis was found in 259 cases among 2260 examined hyperbaric workers from several occupations. No positive cases were found in the divers in shipyards and diving experiments. Naval divers showed the lowest incidence (2.1%) and fishery divers the highest (19.8%). Distribution of long bone lesions was 46.0% in upper humerus, 37.7% in upper femur, 8.3% in lower femur, and 8.0% in upper tibia. We classify long bone lesions into three radiographic stages, the first two on the basis of size of the bone lesions as projected on the radiographs, and the third stage on the basis of extension of the lesion toward articular destruction. The three-stage classification system correlates with the clinical symptoms, and the working capacity of the individual patients tends to correlate with the severity of dysbaric osteonecrosis and can be understood by the general public.
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'Nonagenarians' with a hip fracture: is a different orthogeriatric treatment strategy necessary?
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Hip Fx in the Elderly 2019
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Nonagenarians differ from patients aged 70-79 and 80-89 years in baseline characteristics, complication and mortality rates. Differences increased gradually with age. The results of this study can be used, in combination with the Almelo Hip Fracture Score, to deliver efficiently targeted orthogeriatric treatment to the right patient group.
PURPOSE: In previous literature, elderly with a hip fracture are frequently defined as >= 70 years. However, given the ageing population and the rapidly increasing number of 'nonagenarians' (aged >= 90 years), the question rises whether this definition is still actual. The aim of this study is to determine whether nonagenarians show differences compared to patients aged 70-79 years and patients aged 80-89 years in terms of patient characteristics, complications and mortality rate.
METHODS: From April 2008 until December 2016, hip fracture patients aged >= 70 years treated according to our orthogeriatric treatment model were included. Patients were divided into three different groups based on age at admission: 70-79 years, 80-89 years and >= 90 years. Patient characteristics, risk of early mortality, complications and outcomes were analysed. Risk factors for 30-day mortality in nonagenarians were determined.
RESULTS: A total of 1587 patients were included: 465 patients aged 70-80 years, 867 patients aged 80-90 years and 255 patients aged >= 90 years. Nonagenarians were more often female and had a lower haemoglobin level at admission. Prefracture, they were more often living in a nursing home, were more dependent in activities of daily living and mobility and had a higher risk of early mortality calculated with the Almelo Hip Fracture Score (AHFS). Post-operative, nonagenarians suffer significantly more often from delirium and anaemia. The 30-day mortality and 1-year mortality were significantly higher. Differences increased gradually with age.
CONCLUSION: Nonagenarians differ from patients aged 70-79 and 80-89 years in baseline characteristics, complication and mortality rates. Differences increased gradually with age. The results of this study can be used, in combination with the Almelo Hip Fracture Score, to deliver efficiently targeted orthogeriatric treatment to the right patient group.
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Pathogenesis and treatment of renal failure in multiple myeloma
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MSTS 2018 - Femur Mets and MM
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Renal failure is a frequent complication in patients with multiple myeloma (MM) that causes significant morbidity. In the majority of cases, renal impairment is caused by the accumulation and precipitation of light chains, which form casts in the distal tubules, resulting in renal obstruction. In addition, myeloma light chains are also directly toxic on proximal renal tubules, further adding to renal dysfunction. Adequate hydration, correction of hypercalcemia and hyperuricemia and antimyeloma therapy should be initiated promptly. Recovery of renal function has been reported in a significant proportion of patients treated with conventional chemotherapy, especially when high-dose dexamethasone is also used. Severe renal impairment and large amount of proteinuria are associated with a lower probability of renal recovery. Novel agents, such as thalidomide, bortezomib and lenalidomide, have significant activity in pretreated and untreated MM patients. Although there is limited experience with thalidomide and lenalidomide in patients with renal failure, data suggest that bortezomib may be beneficial in this population. Clinical studies that have included newly diagnosed and refractory patients indicate that bortezomib-based regimens may result in rapid reversal of renal failure in up to 50% of patients and that full doses of bortezomib can be administered without additional toxicity.
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Proteolysis in human breast cancer
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: The process of proteolysis is important at several stages of the metastatic cascade. A balance between the expression of the genes encoding endogenous proteinases and inhibitors exists and when the production of proteinases exceeds that of inhibitors proteolysis occurs.
AIMS: To determine whether differences in the profile and activity of proteinases and inhibitors exist within breast tumour tissue (n = 51), surrounding background breast tissue (n = 43), normal breast tissue from breast reduction mammoplasty operations (n = 10), and cells of the breast cancer cell line, MCF-7.
METHODS: Proteinase (matrix metalloproteinase 1 (MMP-1), MMP-2, MMP-3, MMP-9, urokinase-type plasminogen activator (uPA), and tissue-type PA (tPA)) and inhibitor (tissue inhibitor of metalloproteinases; TIMP-1 and TIMP-2) expression and proteinase activity were compared using substrate zymography, western blotting, immunohistochemistry, and quenched fluorescent substrate hydrolysis.
RESULTS: The presence of all proteinases and inhibitors was greater in breast tumour tissue when compared with all other types of breast tissue (p < 0.05). The activity of total MMPs as determined by quenched fluorescent substrate hydrolysis was also greater in breast tumours (p < 0.05).
CONCLUSIONS: There is increased proteolysis in human breast tumours when compared with other breast tissues.
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Average cost of VA rehabilitation, mental health, and long-term hospital stays
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DoD PRF (Psychosocial RF)
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This article describes the development of a database for the cost of inpatient rehabilitation, mental health, and long-term care stays in the Department of Veterans Affairs from fiscal year 1998 forward. Using "bedsection," which is analogous to a hospital ward, the authors categorize inpatient services into nine categories: rehabilitation, blind rehabilitation, spinal cord injury, psychiatry, substance abuse, intermediate medicine, domiciliary, psychosocial residential rehabilitation, and nursing home. For each of the nine categories, they estimated a national and a local (i.e., medical center) average per diem cost. The nursing home average per diem costs were adjusted for case mix using patient assessment information. Encounter-level costs were then calculated by multiplying the average per diem cost by the number of days of stay in the fiscal year. The national cost estimates are more reliable than the local cost estimates.
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Lateral epicondylitis (tennis elbow): Nonoperative, open, or arthroscopic treatment?
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Lateral epicondylitis (tennis elbow) is a common cause of lateral elbow pain. It is characterized as a degenerative tendinosis, predominantly within the origin of the extensor carpi radialis. Recent controlled trials have proved the benefit of nonoperative modalities (including activity modification, physical therapy, bracing, and injection) in initial treatment. Recalcitrant cases can be treated effectively in a majority of cases by surgical treatment, of which open debridement is the gold standard. The newer technique of arthroscopic debridement has shown favorable early clinical results. (copyright) 2003 Lippincott Williams & Wilkins
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How many clinic visits does it take to treat distal radial fractures?
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Distal Radius Fractures
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The purpose of this study was to evaluate the changes in alignment during the course of treatment for extra-articular distal radius fracture and the relationship of initial and intermediate radiographs, with the final radiograph taken at fracture union. A cohort of 96 consecutive patients who were conservatively managed for extra-articular distal radius fracture in an 18-month period was undertaken. The radiographs analysed were taken at prereduction, postreduction, a week later and at fracture union. The radiological parameters analysed were radial tilt, radial length, radial inclination, dorsal comminution and ulnar styloid fracture. There was a significant change in radiographic alignment between initial and immediate postreduction radiographs, and between postreduction 1 week later radiographs (p < 0.05), but the number of patients in the 1 week later and fracture union groups remained similar (p > 0.05). All patients with poor radiological outcome had ulnar styloid fractures. This was also associated with dorsal comminution in 86% of patients. Patients with satisfactory radiological outcome had ulnar styloid fracture and comminution in 34% and 43% of patients respectively. The final radiological outcome was not found to be influenced by initial unsatisfactory alignment of radial tilt, radial length and radial inclination individually or in combination. We suggest that two clinic visits after initial reduction of the fracture should be sufficient to manage such injuries; the first visit 1 week after manipulation to detect unacceptable displacement and if found satisfactory, the last visit at fracture union for final review, advice and referral to physiotherapy.
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Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds
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Management of Hip Fractures in the Elderly
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The objectives of the present study were to estimate 10 year probabilities of osteoporotic fractures in men and women according to age and bone mineral density (BMD) at the femoral neck. Risks were computed from the incidence of a first hip, distal forearm, proximal humerus and symptomatic vertebral fracture from patient records in Malmo, Sweden and future mortality rates for each year of age from Poisson models using the Swedish patient register and statistical year book. Fracture probability was computed using the Swedish population and cut-off values for T-scores based on the NHANES III female population. We assumed that the risk of fracture increased with decreasing BMD as assessed by meta-analysis in independent studies. The 10-year probability of any fracture was determined from the proportion of individuals fracture-free from the age of 45 years. With the exception of forearm fractures in men, 10 year probabilities increased with age and T-score. In the case of hip and spine fractures, fracture probabilities for any age with low BMD were similar between men and women. The effect of age on risk independently of BMD suggests that intervention thresholds should not be at a fixed T-score but vary according to absolute probabilities. Intervention thresholds based on hip BMD T-scores are similar between sexes
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Two-directional arthrographic assessment for treating bilateral development dislocation of the hips in children after walking age
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Developmental Dysplasia of the Hip 2020 Review
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We reviewed the treatment outcome in 14 hips of 7 patients who were diagnosed as having bilateral developmental dislocation of the hip (DDH) after walking age and could be followed up until they were at least 14 years of age. Based on the results of two-directional arthrography of the hip, closed reduction was performed in 2 hips, and open reduction was performed without osteotomy in 12 hips. The final radiographic evaluations were made according to the Kalamchi and MacEwen classification and Severin classification. The mean age at the initial visit was 1 year and 9 months (range, 1 year and 5 months to 3 years). The outcome was satisfactory for one hip in Group â? and 2 hips in Group â?¡ according to the Kalamchi and MacEwen classification, and in 83% of the Severin Class â? and â?¡ hips. Arthrography was useful for identifying asymmetry, demonstrating the usefulness of a treatment strategy based on arthrography of the hip.
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Safety of recombinant deoxyribonucleic acid-derived growth hormone: The National Cooperative Growth Study experience
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The National Cooperative Growth Study has monitored the safety of recombinant human GH (rhGH) since 1985. Data have been collected from more than 19,000 children representing over 47,000 patient-years of rhGH treatment. Children receiving GH for renal disease were more likely to develop problems such as intracranial hypertension than those with GH deficiency (P < 0.01). Children with idiopathic short stature were less likely to develop slipped capital femoral epiphysis than those with GH deficiency or Turner's syndrome (P < 0.01). There was no evidence of an increased recurrence of leukemia or central nervous system tumors. There were 3 new cases of leukemia in children without known risk factors for developing leukemia and 5 cases in children with known risk factors. Growth deceleration associated with high affinity, high capacity antibodies to GH was found in only 2 of 5039 subjects tested (0.04%). Major adverse events in association with rhGH treatment have been rare, and preexisting medical conditions such as renal insufficiency may affect their frequency
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The influence of continuous versus interval walking exercise on knee joint loading and pain in patients with knee osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To evaluate whether knee contact force and knee pain are different between continuous and interval walking exercise in patients with knee osteoarthritis (OA).
METHODS: Twenty seven patients with unilateral symptomatic knee OA completed two separate walking exercise sessions on a treadmill at 1.3m/s on two different days: 1) a continuous 45min walking exercise session, and 2) three 15min bouts of walking exercise separated by 1h rest periods for a total of 45min of exercise in an interval format. Estimated knee contact forces using the OpenSim software and knee pain were evaluated at baseline (1st minute of walking) and after every 15min between the continuous and interval walking conditions.
RESULTS: A significant increase from baseline was observed in peak knee contact force during the weight-acceptance phase of gait after 30 and 45min of walking, irrespective of the walking exercise condition. Additionally, whereas continuous walking resulted in an increase in knee pain, interval walking did not lead to increased knee pain.
CONCLUSION: Walking exercise durations of 30min or greater may lead to undesirable knee joint loading in patients with knee OA, while performing the same volume of exercise in multiple bouts as opposed to one continuous bout may be beneficial for limiting knee pain.
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Acute coronary syndromes with significant troponin increase in patients with hip fracture prior to surgical repair: differential diagnosis and clinical implications
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Hip Fx in the Elderly 2019
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Myocardial infarction after hip fracture but before surgical repair is associated with a 30-day mortality as high as 30 % at 1 month. In Florence, since 2011, hip fractures are referred to a multidisciplinary hip fracture team including internal medicine specialists, anesthesiologists, and orthopaedic surgeons. The aim of the present investigation was to evaluate the clinical characteristics of patients with hip fracture who had at hospital admission a significant increase of troponin (>10 times reference levels), the diagnostic and therapeutic strategies adopted, and overall 1-year survival. Protocol at admission included careful clinical evaluation (including bedside echocardiography) in order to stratify surgical risk and schedule surgery and anaesthesiology strategy. 21/1025 patients had preoperative significant troponin increase. In sixteen patients, a diagnosis of NSTEMI was made, five presented with ST elevation. In five patients with NSTEMI considered at very high surgical risk (ASA >= 3, severe cognitive and functional impairment), surgery was not performed. None survived at 1 year. Hip surgery was performed in the other 11. Four underwent coronary revascularization after hip surgery. In this group, 1-year survival was 80 %. Four of five ST elevation patients fulfilled criteria for stress cardiomyopathy confirmed by angiography. Hip surgery was performed, and the patients are alive at 1-year follow-up. Close to 2 % of patients with hip fracture are found to have a significant troponin increase before surgery. Three out of four have an NSTEMI diagnosis. In patients undergoing hip surgery, survival at 1 year is close to 80 %. In patients with ST elevation at admission, stress cardiomyopathy should be considered in the differential diagnosis. This clinical condition is associated with a favourable prognosis after hip surgery.
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Arthritis patterns in familial Mediterranean fever patients and association with M694V mutation
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Surgical Management of Osteoarthritis of the Knee CPG
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Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterized by recurrent attacks of febrile peritonitis, pleuritis and synovitis. Arthritis is a common and important feature of FMF. The clinical spectrum of arthritis in 71 FMF patients was retrospectively investigated. Mutations in the familial Mediterranean (MEFV) gene were screened. Unlike the previous reports on arthritis of FMF, most of the FMF patients (59%) in this study had symmetric two-joint arthritis whereas monoarticular, oligoarticular and polyarticular arthritis was presented in 20, 8 and 10% of the patients, respectively. Knees were affected in 45 (63%) patients, ankles in 30 (42%), elbows in 11 (15%), wrists in 12 (17%), hips in 12 (17%), small joints of the hands 7 (10%), small joints of the feet 2 (3%) and sacroiliac in 1 (1%). Destruction of the hip was observed in 2 (3%) patients and required hip replacement. Amyloidosis developed in 2 (3%) of our patients. Mutations in the MEFV gene were identified in 50 (71%) patients and the most dominant mutation detected was M694V (64%). Since FMF can be diagnosed by a simple DNA mutation analysis, all arthritis patients of certain origins (Arabs, Turks, Armenians and Jews) should be tested for FMF in order to prevent the complications (amyloidosis and protracted arthritis) by introducing colchicine which is the treatment of choice for FMF
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Comparison of osteoporosis and calcium intake between Japan and the United States
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Management of Hip Fractures in the Elderly
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The number of osteoporotic females in Japan with vertebral bone mineral density measured by dual energy x-ray absorptiometry, defined as less than -3 SD of the peak bone mass, is approximately 10,000,000, corresponding to 8% of the whole population of Japan. While this value approximately corresponds to the prevalence of low bone mineral density in the United States, the incidence of hip fracture appears to be much less in Japan than in the United States, 50,000 per 125,000,000 per year compared with 250,000 for a population twice as large. This seems to be paradoxical because of the lower bone mineral density and lower calcium intake in Japan, with 400-500 mg/day mainly as soybean products, small fish with bones, and vegetables. The difference in hip fracture incidence, however, may not actually be as wide as it seems when the larger number of bedridden elderly subjects in Japan is taken into consideration. In these bedridden subjects with severe immobilization osteoporosis, hip fracture is only prevented by the fact that they are not ambulatory. Life-style difference may also offer an explanation. Sitting on a tatami mattress on completely flexed knees with frequent standing up, along with other household work, in a narrow home space may ensure a marked development of hip musculature and also provide skill in balancing oneself to prevent fails. The difference in fracture incidence should be analyzed from various angles to obtain a firm ground for the future prevention of hip fracture due to osteoporosis. Although osteoporosis universally affects all races and nationalities, conspicuous differences may be encountered in the severity of its manifestations and complications.(ABSTRACT TRUNCATED AT 250 WORDS)
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The importance of lymph node ratio for patients with mandibular infiltration of oral squamous cell carcinoma
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MSTS 2022 - Metastatic Disease of the Humerus
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Purpose: Lymph node ratio (LNR) essentially improves assessment of prognosis and therapeutic decision making for patients with oral squamous cell carcinoma, as it considers both the number of positive lymph nodes and the number of dissected lymph nodes. Mandibular infiltration by oral squamous cell carcinoma is a vital clinicopathological feature, significantly worsens prognosis. However, to the best of our knowledge, data on the influence of LNR on prognosis for patients with OSCC and mandibular infiltration are not available. Materials and methods: A retrospective chart review of 89 patients with treatment-naive oral squamous cell carcinoma and histopathologically proven mandibular infiltration (pT4a) was performed. Exclusion criteria were primarily curative intended surgery (radical tumor resection, neck dissection and segmental mandibulectomy) with negative resection margins. Exclusion criteria were neoadjuvant chemoradiotherapy, erosive infiltration of the mandible, T4b classification, perioperative death, unresectable disease, synchronous malignancy, follow-up <3 months, and inadequate information to correctly determine clinicopathological characteristics. Results: We observed a significant correlation on univariate analysis between locoregional recurrence and pathologic N classification (p = 0.004), perineural invasion (p = 0.005) and lymph node ratio (p < 0.001). On multivariate analysis, lymph node ratio (p = 0.028) was shown to be an independent indicator for locoregional recurrence. Conclusion: LNR predicted locoregional recurrence better than the conventional nodal staging system and therefore might serve as a more precise risk stratification tool. LNR >7% led to a 11.419-fold higher risk for locoregional recurrence of patients with mandibular infiltration due to OSCC.
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Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support?
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Glenohumeral Joint OA
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PURPOSE: The aim of this study was to retrospectively analyze a large group of CT and MRI examinations for appropriateness using evidence-based guidelines.
METHODS: The authors reviewed medical records from 459 elective outpatient CT and MR examinations from primary care physicians. Evidence-based appropriateness criteria from a radiology benefit management company were used to determine if the examination would have met criteria for approval. Submitted clinical history at the time of interpretation and clinic notes and laboratory results preceding the date of the imaging study were examined to simulate a real-time consultation with the referring provider. The radiology reports and subsequent clinic visits were analyzed for outcomes.
RESULTS: Of the 459 examinations reviewed, 284 (62%) were CT and 175 (38%) were MRI. Three hundred forty-one (74%) were considered appropriate, and 118 (26%) were not considered appropriate. Examples of inappropriate examinations included brain CT for chronic headache, lumbar spine MR for acute back pain, knee or shoulder MRI in patients with osteoarthritis, and CT for hematuria during a urinary tract infection. Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only thirteen percent [corrected] of inappropriate studies had positive results and affected management.
CONCLUSION: A high percentage of examinations not meeting appropriateness criteria and subsequently yielding negative results suggests a need for tools to help primary care physicians improve the quality of their imaging decision requests. In the current environment, which stresses cost containment and comparative effectiveness, traditional radiology benefit management tools are being challenged by clinical decision support, with an emphasis on provider education coupled with electronic order entry systems.
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Posterior ankle and subtalar arthroscopy: indications, technique, and results
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Osteochondritis Dissecans 2020 Review
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Over the decades, arthroscopy has grown in popularity for the treatment of many foot and ankle pathologies. While anterior ankle arthroscopy is a widely accepted technique, posterior ankle/subtalar arthroscopy is still a relatively new procedure. The goal of this review is to outline the indications, surgical techniques, and results of posterior ankle/subtalar arthroscopy. The main indications include: 1) osteochondral lesions (of subtalar and posterior ankle joint); 2) posterior soft tissue or bony impingement; 3) os trigonum syndrome; 4) posterior loose bodies; 5) flexor hallucis longus (FHL) tenosynovitis; 6) posterior synovitis; 7) subtalar (or ankle) joint arthritis; 8) posterior tibial, talar, or calcaneal fractures (for arthroscopic reduction and internal fixation). Although posterior ankle/subtalar arthroscopy has shown to be safe and effective in the treatment of many of the above mentioned conditions, thorough knowledge of the anatomy, correct indications, and a precise surgical technique are essential to produce good outcomes.
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Comparing the methods of measuring compartment pressures in acute compartment syndrome
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DOD - Acute Comp Syndrome CPG
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The objectives of this study were to compare the reliability and accuracy of published methods of measuring intramuscular compartment pressures. A muscle compartment model was constructed. Pressure was standardized using a water column exerting pressure on a muscle slab. The following three methods of intracompartmental pressure were used to measure the pressure within the muscle slab of the model: (1) Stryker, (2) manometric IV pump, and (3) Whitesides method. The Stryker and IV pump methods were similarly accurate compared with the "standard pressure." The Whitesides method was not reliable in measuring a reproducible pressure. The IV pump method is comparable to the Stryker instrument in terms of accuracy and ease of use. If a Stryker instrument is unavailable, the IV pump method can serve as a suitable and satisfactory alternative.
Copyright 2003, Elsevier Science (USA). All rights reserved.)
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The management of fractures of the elbow joint in athletes
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Objective: A thorough review of the literature regarding fracture management of injuries to the elbow was reviewed, with emphasis placed on the care of the athlete. Data sources: The MEDLINE electronic database was searched from its inception to August 2004 with the following terms: elbow joint, athletic injuries, radius fractures, ulna fractures, Monteggia fractures, dislocations, and humerus fractures. Study section: Review articles, book chapters, original research, and case reports were used to construct this review. Data extraction: Results from the literature search were reviewed by the authors and selected to pertain to the treatment of the athlete. Studies with treatment and prognostic information were preferentially outlined and reviewed. Data synthesis: Proximal radius, coronoid, olecranon, Monteggia, and distal humerus fractures, as well as elbow dislocations, were thoroughly reviewed with regard to diagnosis, treatment, and prognosis. Conclusions: Most fractures about the elbow have a good prognosis for return to sport. Many can be treated conservatively with protected but early range of motion. More complex elbow fractures and dislocations require precise diagnosis and surgical treatment for optimal outcome, and the prognosis for return to sport is more guarded in these circumstances
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Prophylactic antibiotic therapy is associated with an increased prevalence of Aspergillus colonization in adult cystic fibrosis patients
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Aspergillus colonization is a common phenomenon in adult cystic fibrosis (CF) patients. The clinical significance of Aspergillus for the pathogenesis of CF lung disease remains unclear and factors predisposing to such colonization are still completely unknown. We investigated the prevalence of Aspergillus colonization in 104 adult CF patients who attended our outpatient clinic in 1997. With respect to demographic and clinical data, and antibiotic therapy received, we further examined which factors were associated with Aspergillus colonization in these patients. Repeated investigations of CF sputum samples revealed Aspergillus species in 43/104 (41.3%; 95% confidence interval 30.2-52.5%) of the patients. We found no significant relationship between Aspergillus colonization and age (P > 0.4), gender (P = 0.4), colonization with pseudomonas species (P > 0.6), lower lung function values (P > 0.9), or worse chest radiography (P > 0.1). Surprisingly, the prevalence of Aspergillus colonization was higher in CF patients receiving prophylactic antibiotic therapy (oral antibiotics: P = 0.05; inhalative antibiotics: P = 0.035; both antibiotics: P = 0.048). Prophylactic antibiotics are widely used to eradicate or decrease chronic bronchopulmonary infection in CF. Our results indicate that long-term antibiotic therapy may predispose CF patients to Aspergillus colonization
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Geometry of proximal femur in the prediction of femoral neck fracture in the elderly female Thai population
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Management of Hip Fractures in the Elderly
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A retrospective study of two groups of 157 patients with one-sided hip fracture and 157 aged matched control group was performed in Siriraj hospital. Geometric measurement of femoral neck was performed as hip axis length (HAL), femoral neck length (FNL), femoral neck width (FNW), femoral head diameter (FHD), acetabular bone width (ABW), and femoral neck-shaft angle (NSA). All geographic parameters are higher in length/width or degree in the femoral neck fracture group than in the normal control group. Among these parameters, ABW has the strongest association with femoral neck fracture (p 0.000, odds ratio = 2.85), followed by FNW (p 0.001, odds ratio = 2.51). According to the low sensitivity and specificity, and ROC curve, using this parameter as a screening tool for femoral neck fracture is still questionable. Further prospective study with a standard position, interval changing of femoral geometry, or combined with bone density or femoral architecture is suggested
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0 |
Essential Amino Acid Supplementation Mitigates Muscle Atrophy After Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Substantial muscle atrophy occurs after total knee arthroplasty (TKA), resulting in decreased strength and impaired mobility. We sought to determine whether perioperative supplementation with essential amino acids (EAA) would attenuate muscle atrophy following TKA and whether the supplements were safe for ingestion in an older surgical population.
Methods: We performed a double-blind, placebo-controlled, randomized trial of 39 adults (age range, 53 to 76 years) undergoing primary unilateral TKA who ingested 20 g of EAA (n = 19) or placebo (n = 20) twice daily for 7 days preoperatively and for 6 weeks postoperatively. At baseline and 6 weeks postoperatively, magnetic resonance imaging (MRI) scans were obtained to measure quadriceps and hamstrings muscle volume. Secondary outcomes included functional mobility and strength. Data on physical activity, diet, and patient-reported outcomes (Veterans RAND 12-Item Health Survey and Knee injury and Osteoarthritis Outcome Score) were collected. Safety was determined through blood tests evaluating blood urea nitrogen, creatinine, creatinine clearance, homocysteine, and renal and liver function. Laboratory values at baseline, on the day of surgery, and at 2 days, 2 weeks, and 6 weeks postoperatively were compared between treatment groups. Analysis of covariance models, with baseline values as covariates, were used to evaluate outcomes between treatment groups. P values were adjusted for multiple tests.
Results: Compared with baseline, the EAA group had significantly less decrease in mean quadriceps muscle volume compared with the placebo group in the involved leg (-8.5% +/- 2.5% compared with -13.4% +/- 1.9%; p = 0.033) and the contralateral leg (-1.5% +/- 1.6% compared with -7.2% +/- 1.4%; p = 0.014). The hamstrings also demonstrated a greater muscle-volume-sparing effect for the EAA group than for the placebo group in the involved leg (-7.4% +/- 2.0% compared with -12.2% +/- 1.4%; p = 0.036) and contralateral leg (-2.1% +/- 1.3% compared with -7.5% +/- 1.5%; p = 0.005). There were no differences between the groups in terms of functional measures or strength. Blood chemistry values varied significantly between assessments periods but did not statistically differ between groups.
Conclusions: The results of the present study suggest that EAA supplementation is safe and reduces the loss of muscle volume in older adults recovering from TKA.
Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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0 |
Surgery for posttraumatic wrist deformity. Radial osteotomy and/or ulnar shortening in 16 Colles' fractures
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Distal Radius Fractures
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16 patients with pain and impaired function after malunited fracture of the distal radius were treated with opening wedge lengthening osteotomy of the radius with bone grafting (12 cases), shortening osteotomy of the ulna (3 cases), or a combination of these methods (1 case), with or without reattachment of the triangular fibrocartilage complex. 4 patients had to be reoperated because of redislocation, resorption of the graft, fracture of the plate, or persistent non-union. At re-examination after a median of 4 years, all patients but 2 were improved by the procedure.
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0 |
Role of the A-beta fibre damage in paroxysmal pain
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Patients suffering from neuropathic pain often complain of sensory deficits and different types of pain combined in various ways. Neuropathic pain may be ongoing, such as burning pain, or paroxysmal, such as electrical-shock-like sensations, or provoked by various stimuli, e.g. gentle brushing or cold water. Although specific types of pain may predominate in some etiologic categories, none of them are etiologic specific. Hence patients suffering from an identical disease may present with heterogeneous sensory signs and symptoms. Recent studies in patients with neuropathic pain demonstrate that paroxysmal pain is related to abnormalities in neurophysiological tests that assess large-myelinated fibres (Abeta-fibres) function. More specifically, paroxysmal pain correlates with the delay of the Abeta-fibre-mediated blink reflex in patients with postherpetic neuralgia, and with reduction of the median nerve sensory conduction velocity in patients with carpal tunnel syndrome. These data suggest that paroxysmal pain reflects demyelination of non-nociceptive, large-myelinated fibres and indicate that, regardless of the disease, paroxysmal pain may be invariably related to Abeta-fibre damage. Consistently with animal studies describing spontaneous ectopic discharges recorded in Abeta-fibre axons after nerve injuries, paroxysmal pain may be related to high-frequency bursts generated in demyelinated Abeta-fibres. Whether these highfrequency bursts in demyelinated Abeta-fibres are sufficient to provoke pain per se or do so only after ephaptic transmission to the neighbouring C fibres, or through the involvement of wide dynamic range neurons is an open matter. Neurophysiological studies showing that paroxysmal pain reflects Abeta-fibre damage suggest that a specific type of pain may arise through the same pathophysiological mechanism, regardless of aetiology. This calls for a change in the way we classify and treat patients with neuropathic pain in clinical practice. Instead of grouping patients by aetiology, they should be probably grouped according to the various qualities of pain. This approach might minimize pathophysiological heterogeneity within the groups under study and increase the power to detect a positive treatment result
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0 |
Long-term followup of total hip arthroplasty in patients with cerebral palsy
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PJI DX Updated Search
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Background Patients with cerebral palsy (CP) are at risk for hip arthrosis secondary to the loss of joint congruity. Questions/purposes We asked whether THA relieved pain, improved function, and provided durable improvements. Methods We retrospectively identified 56 patients (59 hips) with CP who had THAs for painful hips. Chart review determined the preoperative, postoperative, and current functional levels. All patients or caregivers completed a questionnaire, including a modified Gross Motor Function Classification System mobility scale and qualitative reports of pain and satisfaction. Pain levels were measured on a visual analog scale at three times: preoperative, postoperative, and current. The average age of the patients at the time of surgery was 30.6 years. Minimum followup was 2 years (average, 9.7 years; range, 2-28 years). Results Pain relief was obtained in all patients. All patients returned to preoperative function (59) and 52 patients returned to prepain functional status (88%). Seven patients underwent acetabular component revisions, and two patients had a femoral stem component revision. The 2-year implant survival was 95%, and 10-year survivorship was 85%. Conclusions THA can provide durable relief and improved function in patients with CP with severe coxarthrosis. Level of Evidence Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. é The Association of Bone and Joint Surgeonsî 2009
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0 |
Nerve conduction velocity in human limbs with late sequelae after local cold injury
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Cold-induced neuropathy may play a dominant role in the long-term sequelae with cold sensitivity after local cold injuries (LCIs). Somatosensory functions were assessed and nerve conduction velocity (NCV) and motor distal delay (MDD) were measured in the limbs of 31 Norwegian former soldiers with persistent cold Iitolerance 3-4 years after the primary LCI. NCV measurements were performed in 24 lower and 16 upper extremities. NCV was related to degree of overall subjective complaints quantified by means of a visual analogue scare (VAS). Motor (MNCV) and sensory conduction velocity (SNCV) in the lower extremities and SNCV in the hands were significantly decreased compared with controls. MDD was pathologically increased in the feet. NCV of the forearms ranged from normal to significant reduction. The more pronounced effect on the lower extremities may be caused by deeper cooling of the calves compared with forearms for several reasons. No significant associations were found between VAS and NCV except for the right median nerve. NCV measurements may provide objective findings in cold-injured patients and in those with few or no conspicuous clinical signs
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Optimal management of physeal elbow injuries in the skeletally immature athlete remains undefined: A systematic review
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Importance Physeal elbow injury remains common for the youth athlete. In this patient population, the most effective treatment strategy for these injuries is not established. Objective This systematic review aimed to synthesise current literature regarding treatment and outcomes of physeal elbow injuries in the skeletally immature athlete. Evidence review A systematic literature review was completed using two databases (PubMed and ScienceDirect). Search terms included â � paediatric elbow injury', â � adolescent elbow injury', â � elbow physeal injury', â � avulsion fracture medial epicondyle' and â � little league elbow'. Inclusion criteria were: English language, Level of Evidence I-IV, physeal elbow injury as a direct consequence of athletic activity, involvement of a distinct treatment modality and/or outcome, publication after 1989 and skeletal immaturity demonstrated through radiographic measurements. Findings Twelve studies consisting of treatment of avulsion fractures of the medial epicondyle, medial epicondyle fragmentation, olecranon stress fractures and olecranon apophysitis met criteria and were included in this study. The most common injury was avulsion fracture of the medial epicondyle. Of these patients, 68.5% underwent operative fixation with average return to play at 3.3 months and 31.5% underwent non-operative treatment with an average return to play of 8.4 months. For medial epicondylar fragmentation, 90.2% of patients were treated non-operatively with average return to play at 3.8 months. Operative intervention was performed on 85.7% of patients with olecranon epiphysial stress fractures and average return to play was at 7 months. Operative intervention was performed on 87.5% of patients with persistence of the olecranon physis with average return to play of 4 months. All cases of olecranon apophysitis were treated non-operatively and return to play was not documented. Conclusions and relevance This systematic review demonstrates the heterogeneity of the treatment options for physeal injury in the adolescent athlete. This analysis supports that operative management may expedite return to play for avulsion fracture of the medial epicondyle, though medial epicondylar stress fractures can be successfully managed non-operatively. Limited data suggest surgical intervention of olecranon epiphysial stress fractures and persistence of the olecranon physis may allow athletes faster return to play. Level of evidence IV.
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0 |
Randomized trial of Codetron for pain control in osteoarthritis of the hip/knee
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OAK 3 - Non-arthroplasty tx of OAK
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Patients suffering from pain due to osteoarthritis of the hip and knee participated in a doubleâ?blind placebo controlled trial using daily Codetron home care units for 6 weeks over the tibial, saphenous, popliteal and sciatic nerves, and tender points. Seventyâ?four percent of patients in the real Codetron (Group A) and 28% of the patients in sham Codetron (Group B) improved their pain level more than 25% as measured by visual analogue scale. The difference in pain improvement in the two groups was statistically significant (p less than 0.02 using Fisher's exact probability ratio). Other functional parameters proved to be insensitive to change in this study. This is highly suggestive of beneficial effect of nonhabituating Codetron as a complementary modality in the therapy of chronic pain conditions such as osteoarthritis.
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0 |
GUEPAR hinge knee prosthesis
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OAK 3 - Non-arthroplasty tx of OAK
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Early and late results of the GUEPAR hinge knee prosthesis were evaluated on a series of 184operations performed before January 1st, 1974. There were 3 immediate deaths and 26 before 5. years. Nineteen prostheses were removed. One hundred and twenty-six knees had degenerative osteoarthritis, 52rheumatoid arthritis. Twenty-two had been operated on before. Patellar displacement, present in 27% of the cases, was the most frequent cause of complaint: pain or instability, proportional to the severity of displacement, made re-operation necessary in 10% of the patients. Addition of a patellar prosthesis was the most successful treatment as far as pain is concerned: it is probably advisable as a primary procedure. Deep infections occurred in 8.3% of the cases, infrequently after 2. years. Healing was obtained in all cases either by revision or by removal and arthrodesis: but functional results were poor except when fusion was achieved, in half of the cases of arthrodesis. Loosening occurred in 16% of the cases, mainly as a consequence of inadequate technique. It was frequently tolerated: re-operation was necessary in 6% of the total. Late functional results were evaluated in 99cases with a follow-up of 5 to 8. years. Apart from loosening, the results did not deteriorate. Sixty percent were evaluated as excellent or good, 29% fair, and 11% poor. In consideration of these results, the choice of this prosthesis should be limited to special cases. To prevent complications, the use of a patellar prosthesis, of reinforced models and of cementing under pressure is advisable. © 2013.
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Smoking status as a predictor of hip fracture risk in postmenopausal women of northwest Texas
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Management of Hip Fractures in the Elderly
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INTRODUCTION: The purpose of this study was to determine the effect of cigarette smoking on the risk of hip fracture for postmenopausal women living in rural and urban areas of Northwest Texas. METHODS: Using an unmatched case-control design, we compared postmenopausal women who had recently experienced osteoporotic hip fracture with women who had not. Both study groups completed a questionnaire on demographic, clinical, and behavioral risk factors for osteoporotic hip fracture. We categorized smoking status as never smoked, former smoker, and current smoker. Covariates included age, weight, age at menopause, physical activity, estrogen replacement, calcium supplementation, and rurality. We used univariate and multivariate logistic regressions to test the associations between hip fracture and the independent variables of interest. RESULTS: We found an increased risk of hip fracture for former smokers (adjusted odds ratio [OR], 2.27; 95% confidence interval [CI], 1.22-4.21) and current smokers (adjusted OR, 3.72; 95% CI, 1.59-8.70). Residence in a rural county (population <100,000) also was associated with increased risk (adjusted OR, 2.71; 95% CI, 1.48-4.95). CONCLUSION: Former and current smoking increased the risk of hip fracture in this population of postmenopausal women
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0 |
SAS weekly rounds: avascular necrosis
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AAHKS (2) Corticosteroids
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Osteonecrosis of the femoral head is a condition that affects upwards of 10,000 individuals in the USA each year. The peak incidence is in the fourth decade of life, and overall, there is a male preponderance. The condition accounts for up to 12% of total hip arthroplasties performed in developed countries. The etiology can be traumatic or non-traumatic, with 90% of atraumatic cases attributed to corticosteroid therapy or excess alcohol consumption. Osteonecrosis of the femoral head reflects the final common pathway of a range of insults to the blood supply and ultimately results in femoral head collapse, acetabular involvement, and secondary osteoarthritis. Currently, conservative treatment options, which aim to correct pathophysiologic features allowing revascularization and new bone formation, appear to be able to delay but not halt the progression of this condition. As a consequence of femoral head osteonecrosis, many individuals undergo surgical treatments including: core decompression, osteotomy, non-vascularized bone matrix grafting, free vascularized fibular grafts, limited femoral resurfacing, total hip resurfacing, and total hip arthroplasty.
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Traumatic retroperitoneal hematoma illustrated on Tc-99m methylene diphosphonate bone scintigraphy in a patient presenting with a fall
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Management of Hip Fractures in the Elderly
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Retroperitoneal haematoma is rarely described in the context of bone scintigraphy, as it is usually an incidental discovery on bone scan carried out for another purpose. We report a case of a right retroperitoneal haematoma detected on Tc-99m-methylene diphosphonate bone scintigraphy taken in an elderly patient presenting with a mechanical fall and a right acetabular fracture
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0 |
Association of prostate-specific antigen levels and patterns of benign and malignant uptake detected. on bone scintigraphy in patients with newly diagnosed prostate carcinoma
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MSTS 2018 - Femur Mets and MM
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The bone scan patterns of benign and malignant uptake in 432 patients with newly diagnosed prostate carcinoma were reviewed in relation to prostate-specific antigen (PSA) levels determined within 4 months of scintigraphy. Scan results were categorized in terms of likelihood of metastatic disease and anatomical locations of benign and malignant lesions were tabulated. At least one suspect focus was identified in 138 scans (32%), and metastatic bone disease was present in 38 (9%). Metastatic disease prevalence increased from 1% for PSA <20 ng x ml(-1) to 58% for PSA>100 ng x ml(-1). Among patients with PSA>20 ng x ml(-1) (n = 157), 70 (45%) had at least one bone scan finding of concern for metastases and 35 (22%) proved to have metastatic disease. Almost all scans with metastases had either limited disease (< or = 5 suspicious lesions; n = 16; 42%) or extensive metastases (> 20 abnormalities; n = 19; 50%). The majority of patients with limited skeletal metastases had PSA < 100 ng x ml(-1) (11/16; 69%), while almost all patients with extensive skeletal involvement had PSA >100 ng x ml(-1) (17/19; 89%). Among those with limited metastatic disease, most (13/16; 81%) had at least one lesion in the pelvis or sacrum; the next most common sites were in the thoracic and lumbar spine (six each; 38%). In scans with a low to moderate suspicion for bone metastases, the only anatomical site with a significantly higher prevalence of malignant than benign lesions was the pelvis.
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Power-assisted liposuction (PAL) of multiple symmetric lipomatosis (MSL)--a longitudinal study
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Multiple symmetric lipomatosis (MSL) is a rare condition leading to grotesque disfigurement. Complete removal is almost impossible and recurrences inevitable. The objective of this study was to evaluate powered-assisted liposuction (PAL) for the treatment of MSL. METHODS: Magnetic resonance imaging (MRI) was performed before and after surgery for quality assessment. To exclude malignancy incisional biopsies were taken before surgery. Outcome measures included aspiration volumes, duration of surgery, early morbidity, recurrence rates, and overall patient satisfaction. RESULTS: Seven male patients aged between 43 and 70 years were identified. The mean liposuction volume equaled 2948+/-1566 mL, the mean surgery time 74+/-28 minutes. One hematoma was observed, whereas 1 recurrence rate was noticed after a mean follow-up of 14 months. Malignancy was excluded by histology in 5 patients. Preoperative MRI confirmed the diagnosis with no signs for malignancy and showed an efficient removal of the lesions. After a mean follow-up of 18 months, a high patient satisfaction was achieved. CONCLUSION: PAL can serve as an efficient method for the treatment of MSL. It has a significant effect on tightening of the skin, leading to a high patient satisfaction.
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0 |
Industry Update: The latest developments in therapeutic delivery
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MSTS 2018 - Femur Mets and MM
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The present industry update covers the period 16 November to 15 December 2010, with information sourced from company press releases, regulatory agencies and patent search engines. A number of significant mergers took place with Novartis and Alcon set to form the largest eye company division in the industry. Roche announced the planned loss of 4800 positions to reduce operating costs, and focus on efficiency, productivity and strengthening their pipeline. US FDA approval of a Phase I/II study of embryonic stem cells for the treatment of macular degeneration represents an exciting proposition, with enormous potential benefits if this and any following studies are successful. The recently reported results of the pre-exposure prophylaxis study with Truvada ® represents a major breakthrough in achieving significant reductions in the acquisition of the HIV virus by men and transgender women having sex with men. The potential development of an effective vaccine against ricin toxin is another exciting, if unsettling, development. Interesting journal articles this month include a description of the potentially low-cost development of nasally delivered vaccines derived from modified Bacillus subtilis, as well as the use of radiofrequency-mediated hyperthermic destruction of cancerous cells targeted with immunomodified gold nanoparticles. © 2011 Future Science Ltd.
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A case of spontaneous hemoarthrosis after a total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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A 63-year-old woman with osteoarthritis had undergone right total knee arthroplasty. Nineteen months later, the patient presented with a recurrent hemoarthrosis. Open arthrotomy revealed hypertrophic synovium with small clots in the suprapatellar pouch, but entrapment of synovial tissues could not be observed. Histological examination of the extirpated specimen showed fibrous hypertrophy of synovium. The patient has no symptoms 51 months after surgery
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Systemic lupus erythematosus is not a risk factor for poor outcomes after total hip and total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Objectives: Historically, arthroplasty in systemic lupus erythematosus (SLE) patients has been less successful than for patients with osteoarthritis (OA). It is not known if SLE remains an independent risk factor for poor arthroplasty outcomes or if other factors, such as avascular necrosis (AVN), continue to play a role. Methods: A case-control study using data from a single-institution arthroplasty registry compared SLE total hip arthroplasty (THA) and total knee arthroplasty (TKA) with OA controls matched by age, gender and presence of AVN. Baseline, two-year administrative and self-report data, and diagnosis leading to arthroplasty were evaluated. Results: A total of 54 primary SLE THA and 45 primary SLE TKA were identified from May 2007 through June 2011. AVN was present in 32% of SLE THA and no TKA. SLE THA had worse preoperative WOMAC pain (42.5 vs. 52.7; =0.01) and function (38.8 vs. 48.0; =0.05) compared with OA. However, at two years there was no difference in WOMAC pain (91.1 vs. 92.1; =0.77) or WOMAC function (86.4 vs. 90.8; =0.28). SLE TKA were similar to OA in both preoperative pain (42.6 vs. 48.4; =0.14) and function (42.1 vs. 46.8; =0.30) and two-year pain (85.7 vs. 88.6; =0.50) and function (83.7 vs. 85.1; =0.23). Compared to OA, SLE THA and TKA patients had more renal failure (14% vs. 1%; =0.007) and hypertension (52% vs. 29%; =0.009). In a multivariate linear regression, SLE was not predictive of either poor pain or poor function. Conclusions: While SLE patients have more comorbidities than OA, and SLE THA have worse preoperative pain and function compared with OA controls, SLE was not an independent risk factor for poor short-term pain or function after either hip or knee arthroplasty.
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Arthroscopic management of osteoarthritis of the knee
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Surgical Management of Osteoarthritis of the Knee CPG
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Recent advances in instrumentation and a growing understanding of the pathophysiology of osteoarthritis have led to increased use of arthroscopy for the management of degenerative arthritis of the knee. Techniques include lavage and debridement, abrasion arthroplasty, subchondral penetration procedures (drilling and microfracture), and laser/thermal chondroplasty. In most patients, short-term symptomatic relief can be expected with arthroscopic lavage and debridement. Greater symptomatic relief and more persistent pain relief can be achieved in patients who have acute onset of pain, mechanical disturbances from cartilage or meniscal fragments, normal lower extremity alignment, and minimal radiographic evidence of degenerative disease. Arthroscopic chondroplasty techniques provide unpredictable results. Concerns include the durability of the fibrocartilage repair tissue in subchondral penetration procedures and thermal damage to subchondral bone and adjacent normal articular cartilage in laser/thermal chondroplasty. Although recent prospective, randomized, double-blinded studies have demonstrated that outcomes after arthroscopic lavage or debridement were no better than placebo procedure for knee osteoarthritis, controversy still exists. With proper selection, patients with early degenerative arthritis and mechanical symptoms of locking or catching can benefit from arthroscopic surgery
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1 |
Nongenitourinary infections caused by Mycoplasma hominis in adults
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Eleven new cases of Mycoplasma hominis infection occurring outside the genitourinary tract in adults not in the puerperium were evaluated in relation to the 25 cases previously reported. Cases of bacteremia (n = 14) were commonly associated with trauma or manipulation of the genitourinary tract and were often self-limited. Wound infections (n = 14) followed surgery by 4-14 days in most cases and may have arisen from contamination from the genitourinary or respiratory tract. Joint infections (n = 5) appeared to have resulted from bacteremic seeding in some cases and affected prosthetic joints in particular. Least frequent were central nervous system infections (one case of meningitis and two of brain abscess) and respiratory tract infections (three cases of empyema). The large majority of patients had fever, and infected fluid collections were commonly purulent. The response to therapy was difficult to assess in many cases, but responses to tetracycline, clindamycin, and drainage alone were observed. Identification of M. hominis requires clinical suspicion and alertness on the part of the bacteriology laboratory
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Fused micro-computed tomography (μCT) and histological images of bone specimens
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MSTS 2018 - Femur Mets and MM
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Objectives: To describe a stepwise process to obtain fused images from micro-computed tomography (μCT) and histological images of bone specimens. Material and methods: Four surgically resected human femoral heads from four patients who had total hip replacement were imaged at a spatial resolution of 12-microns by using μCT. Histological sections of four focal bone lesions including bone cyst in osteoarthritis (n = 2) and subchondral bone plate fracture in osteonecrosis (n = 2) were prepared and digitized. μCT images were reformatted and adjusted to match the histological images using a landmark-based visual co-registration. Fused μCT and histological images were displayed in a cine-loop video mode with a gradual transition from one image to the other. Results: μCT images of the four focal bone lesions could be successfully fused with the corresponding histological images with a near perfect match of the bone trabeculae. Conclusion: We present a stepwise process to obtain fused images from histological and reformatted μCT images of human femoral heads.
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Initiation of tumor necrosis factor alpha (TNF>) antagonists and risk of fractures in patients with selected rheumatic and autoimmune diseases
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Management of Hip Fractures in the Elderly
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Background/Purpose: Inflammation mediates bone resorption, in part through TNF+. In experimental models TNF+ antagonists reduce inflammation-mediated bone resorption; however, the effect of this class of drugs on fracture risk in patients is unknown. We tested the hypothesis that initiation of TNF+ antagonists reduced the risk of fractures compared to nonbiologic comparators in patients with RA. Methods: Using four large administrative databases we assembled a retrospective cohort of patients with RA from 1998 to 2005 enrolled in Tennessee's Medicaid Program (TennCare), Kaiser Permanente Northern California (KPNC), Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE), and multi-State Medicaid programs (MAX) and identified patients who initiated either a TNF+ antagonist (n=20,814) or a non biologic disease modifying anti-rheumatic drug (DMARD): hydroxychloroquine (HCQ), sulfazalasine (SSZ) and/or leflunomide (LEF) (n=8,964). We used baseline covariate data to calculate propensity scores (PS) to match treatment groups, and Cox regression to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs). We compared the risk of the first fracture (hip, radius/ulna, humerus, or pelvic); first hip fracture; and first clinical vertebral fracture between PS-matched cohorts of new users of TNF+ antagonists and non biologic
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Functional outcome of extra-articular distal humerus fracture fixation using a single locking plate: A retrospective study
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Pediatric Supracondylar Humerus Fracture 2020 Review
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PURPOSE: The optimal method for fixation of extra-articular distal humerus factures poses a management dilemma. Although various plate configurations have been proposed, anatomic shaped extra-articular distal humerus locking plates have emerged as a viable solution for these complex injuries. We assessed clinico-radiologic outcome in our retrospective case series of extra-articular distal humerus fractures managed with these plates. METHODS: Forty-five patients of extra-articular distal humerus fractures, who were operated at our level 1 trauma centre between January, 2012 and December, 2016, were identified. After exclusion, 36 patients were available for the final assessment. All patients were operated with the triceps-reflecting modified posterior approach. Regular clinico-radiologic follow-up was done evaluating elbow functionality, fracture union, secondary displacement, non-union, implant failure and any complications; Mayo Elbow Performance score (MEPS) was used for the final functional assessment. RESULTS: Twenty-four (66.7%) male and 12 (33.3%) female patients constituted the study group, who had an average follow-up of 15 months. Preoperatively three patients and post-operatively one patient had radial nerve palsy; all had neurapraxia and recovered completely. Overall, 34 (94.4%) patients were adjudged to have complete radiological union within 3 months; 2 (5.5%) patients developed non-union. Mean flexion achieved was 122.9° ± 23°, and mean extension was -4.03° ± 6.5°; 1 patient with head injury developed flexion deformity of 45°. Average MEPS at the final follow-up was 90.8° ± 9.9°. CONCLUSION: Stable reconstruction and early initiation of physiotherapy are utilitarian to envision optimal outcome; the use of precontoured extra-articular distal humerus locking plates has yielded satisfactory results with minimal complications in our hands.
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1 |
Internal fixation versus nontreatment of hip fractures in senile patients
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Management of Hip Fractures in the Elderly
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Institutionalized senile patients with hip fractures have a high mortality regardless of whether treatment consists of internal stabilization or is non-operative. In an effort to select the best therapeutic approach in this type of patient, 150 patients were examined in 3 comparable groups. In the first group of 50 patients treatment consisted of surgical stabilization of the fracture. In the second group of 45 patients treatment was non-operative; mortality in these 2 groups was over 50% at the end of 16 weeks. In an effort to improve this degree of risk we transferred 53 patients from the psychiatric hospital to a general hospital for prompt internal stabilization of the hip fractures. There was a striking decrease in mortality to 28% in the third group. We have concluded that under optimal conditions, prompt surgical stabilization of hip fractures in elderly senile individuals offers them the best opportunity of surviving the injury and is preferable to nontreatment
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Re-fracture and correlated risk factors in patients with osteoporotic vertebral fractures
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Re-fracture risk is higher following osteoporotic fracture. However, there is no accurately reported rate of re-fracture incidence in southwest China. The purpose of this study was to describe the osteoporotic vertebral fracture (OVF) survival for re-fracture state and analyze the risk of re-fracture. This historical cohort study was conducted in four hospitals in southwest China. Patients aged â?¥ 50Â years (n = 586) with OVF who were supposed to receive anti-osteoporosis drugs after the fracture were included (2012â??2017). Telephone follow-up and referring case files were used to estimate the survival for re-fracture and identify the determinants of re-fracture. A total of 555 patients completed the follow-up investigation. Overall, 285 patients experienced a re-fracture, and the longest follow-up investigation time was 72Â months. The survival rates for re-fracture at 12Â months, 24Â months, 36Â months, and 48Â months were 82.0%, 71.5%, 61.7%, and 34.0%, respectively. The factors correlated with re-fracture hazard were advanced age [hazard ratio (HR) = 1.996], being female (HR = 1.342), smoking (HR = 1.435), history of hypertension (HR = 1.219) and diabetes (HR = 3.271), and persistence of taking anti-osteoporosis drugs after fracture [0â??3Â months, 4â??6Â months, 7â??12Â months, and more than 12Â months (HR = 0.703)]. OVF patients with advanced age, who were female, smoked, had fracture with hypertension or diabetes, and who complied poorly with anti-osteoporosis drug treatment presented higher prevalence of re-fracture and low anti-osteoporosis adherence in southwest China. The management of anti-osteoporosis after fracture is necessary in this area.
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Ipsilateral distal radius and scaphoid fractures
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Distal Radius Fractures
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Simultaneous fractures of the distal radius and scaphoid are uncommon. Previous reports have outlined a variety of treatment methods for this condition. We describe the results in eight patients with simultaneous fractures of the distal radius and scaphoid, who were treated at National Taiwan University Hospital from 1987 to 1998. Treatments for the distal radius fractures included pin-in-cast in one patient, casting in one, external fixation in one, external fixation after pinning in three, and open reduction with internal fixation in two. All scaphoid fractures occurred at the scaphoid waist, and were treated with long-arm thumb spica in three patients, Herbert screw fixation in two, and percutaneous pinning in three. All of the fractures united, and none of the patients developed scaphoid avascular necrosis. One patient suffered from superficial radial nerve injury during external fixation. The functional results of the wrist were good in five patients and fair in three. To prevent the possible over-distraction of the scaphoid fracture, fixation of the scaphoid should be performed if a distraction force is to be applied during the treatment of the distal radius fracture. If no distraction force is to be applied, a thumb spica may provide adequate fixation for the scaphoid fracture.
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Complications in Distal Radius Fracture
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Distal Radius Fractures
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BACKGROUND. Distal radius fractures (FRD) are up to 17% of all diagnosed fractures and are the most commonly treated fractures in adult orthopedic patients. The management could be either conservative or surgical, depending on AO bone fracture classification. The principles of good treatment involves an anatomical reduction with a proper immobilization that keep the reduction. OBJECTIVE. Determine if percutaneous pinning for six weeks versus three has major complications in distal radius fractures.
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Introducing a Clinical Practice Guideline Using Early CT in the Diagnosis of Scaphoid and Other Fractures
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Distal Radius Fractures
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OBJECTIVE: We developed and implemented clinical practice guideline (CPG) using computerized tomography (CT) as the initial imaging method in the emergency department management of scaphoid fractures. We hypothesized that this CPG would decrease unnecessary immobilization and lead to earlier return to work.
METHODS: This observational study evaluated implementation of our CPG, which incorporated early wrist CT in patients with "clinical scaphoid fracture": a mechanism of injury consistent with scaphoid fracture, anatomical snuff box tenderness, and normal initial plain x-rays. Outcome measures were the final diagnosis as determined by orthopaedic review of the clinical and imaging data. Patient outcomes included time to return to work and patient satisfaction as determined by telephone interview at ten days.
RESULTS: Eighty patients completed the study protocol in a regional emergency department. In this patient population CT detected 28 fractures in 25 patients, including six scaphoid fractures, five triquetral fractures, four radius fractures, and 13 other related fractures. Fifty-three patients had normal CT. Eight of these patients had significant ongoing pain at follow up and had an MRI, with only two bone bruises identified. The patients with normal CTs avoided prolonged immobilization (mean time in plaster 2.7 days) and had no or minimal time off work (mean 1.6 days). Patient satisfaction was an average 4.2/5.
CONCLUSION: This CPG resulted in rapid and accurate management of patients with suspected occult scaphoid injury, minimized unnecessary immobilization and was acceptable to patients.
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Increased prevalence of self-reported fractures in Asian Indians with diabetes: Results from the ICMR-INDIAB population based cross-sectional study
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Hip Fx in the Elderly 2019
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Background: Diabetes mellitus (DM), has been associated with increased fracture risk. However, there are no data pertaining to the prevalence of fractures for patients with DM in India. The aim of this study was to determine the prevalence of fractures in Asian Indians with and without diabetes. Methods: The study used the data of Indian Council of Medical Researchâ??India Diabetes (ICMRâ??INDIAB) study, a community- based cross sectional survey conceived with the aim of obtaining the prevalence rates of diabetes in India as a whole. A community-based sample of 57,117 individuals aged â?¥20 years was obtained. Diabetes was diagnosed by oral glucose tolerance test using capillary blood (except in self-reported diabetes). Fractures were self-reported. Results: Fracture data were available in 54,093 subjects. Out of these, 1416 (2.6%) had fractures. Overall prevalence of diabetes and prediabetes was 7.1% and 10.5% respectively. Prevalence of fractures was significantly higher in diabetes group (4%) compared with non-diabetes group (2.5%). In multivariate logistic regression analysis, diabetes was associated with an increased risk (1) of any fracture (OR=1.28, 95% CI: 1.07â??1.5) and (2) of low trauma fracture (hip and spine combined) (OR = 1.8, 95% CI:1.1â??2.8). After gender stratification, diabetes was a risk factor for fracture only in women. Age (>40 years) in women, high waist circumference (>90 cm) in men, alcohol consumption and urban residence in both men and women were other significant contributors to fracture risk. Conclusion: Increased prevalence of self-reported fractures was seen in individuals with diabetes in this population-based study from India.
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Repeat falls and the recovery of social participation in the year post-hip fracture
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Management of Hip Fractures in the Elderly
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BACKGROUND: although the majority of hip fractures are the result of a fall, whether repeated falls in the year post-fracture adversely influence recovery of social participation is not known. DESIGN: analysis of data from a longitudinal cohort study. SUBJECTS: community-dwelling women aged > or = 65 years, admitted to one of two hospitals in Baltimore with a new, non-pathological fracture of the proximal femur between 1992 and 1995. METHODS: information on falls was collected from a falls diary. At the baseline, 6- and 12-month evaluations, subjects were asked about the number of times in the 2 weeks prior to the evaluation they had participated in 10 categories of social activities. We examined the association of repeated falls with social participation using generalized estimating equations. The effect of physical and psychological functions was examined by including measures of lower extremity functional performance and depressive symptoms into the model. RESULTS: the analyses included 196 women, mean age = 80.2 years. Eighty-one subjects fell. The subjects with >1 fall between evaluations participated in a mean (95% CI) of 3.5 (0.12, 6.9) and 4.3 (0.9, 7.7) fewer social activities at 6 and 12 months post-fracture, respectively, compared to those who did not fall (P = 0.0003). These results were attenuated by adjustment for depressive symptoms, but not by lower extremity functional performance. CONCLUSIONS: in the year post-fracture, repeated falls in women were associated with decreased social participation independent of lower extremity function. Depressive symptoms in repeated fallers may partly explain this association
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Median nerve deformation in differential finger motions: ultrasonographic comparison of carpal tunnel syndrome patients and healthy controls
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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We investigated the median nerve deformation in the carpal tunnel in patients with carpal tunnel syndrome and controls during thumb, index finger, middle finger, and a four finger motion, using ultrasound. Both wrists of 29 asymptomatic volunteers and 29 patients with idiopathic carpal tunnel syndrome were evaluated by ultrasound. Cross-sectional images during motion from full extension to flexion were recorded. Median nerve cross-sectional area, perimeter, aspect ratio of the minimal enclosing rectangle, and circularity in extension and flexion positions were calculated. Additionally, a deformation index was calculated. We also calculated the intra-rater reliability. In both controls and patients, the median nerve cross-sectional area became significantly smaller from extension to flexion in all finger motions (p < 0.05). In flexion and extension, regardless of the specific finger motion, the median nerve deformation, circularity and the change in perimeter were all significantly greater in CTS patients than in controls (p < 0.05). We found excellent intra-rater reliability for all measurements (ICC > 0.84). With this study we have shown that it is possible to assess the deformation of the median nerve in carpal tunnel syndrome with ultrasonography and that there is more deformation of the median nerve in carpal tunnel syndrome patients during active finger motion. These parameters might be useful in the evaluation of kinematics within the carpal tunnel, and in furthering our understanding of the biomechanics of carpal tunnel syndrome in the future
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Relationship between bone marrow lesions, cartilage loss and pain in knee osteoarthritis: results from a randomised controlled clinical trial using MRI
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To assess in a multicentre randomised doubleâ?blind phase III clinical trial evaluating the effect of licofelone in comparison with naproxen on knee osteoarthritis (OA) the presence of, and change in, bone marrow lesions (BML) over time, their relationship to cartilage volume loss, meniscal extrusion and pain. METHODS: Patients with knee OA were selected from the dataset of a recently published randomised controlled trial. MRI was performed at baseline, 6, 12 and 24 months to assess BML score (modified Wholeâ?Organ MRI Score) and cartilage volume changes over time. Pain levels were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire. RESULTS: One hundred and sixtyâ?one patients completed the study according to protocol. The global knee and all subregions showed increased BML scores over time (p <0.001, 24 months) except for the medial tibial plateau in the licofelone group. In multivariate regression analysis, licofelone treatment predicted reduction in BML score in the medial tibial plateau (β= â?0.280, p = 0.026). BML scores at baseline correlated with cartilage volume over time; however, correlation was limited to 12 months. No positive correlation was found between BML and WOMAC scores. CONCLUSIONS: BML scores were found to increase over time, probably owing to accumulation of chronic structural changes. Correlation between BML and cartilage volume was strong at baseline but not over time, probably due to the study drug. Licofelone reduced the BML score in the medial tibial plateau. In contrast to previous reports, no positive relationship was found between BML score (baseline or change over time) and pain, probably an effect of the selected population.
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Fundamentals of sonographic diagnosis of infant hip dysplasia
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Developmental Dysplasia of the Hip CPG
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Since 1978 we have examined 3,500 infant hips by ultrasonography. We classified these hips into four basic categories: (a) normal, according to age; (b) delayed ossification (dysplasia); (c) partial dislocation (subluxation); and (d) dislocation (total luxation). Ultrasound provides no exposure to radiation and can differentiate soft tissue much better than radiography. It clearly offers a new tool for infant screening with the potential for widespread application
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Screw versus helical proximal femoral nail in the treatment of unstable trochanteric fractures in the elderly
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DoD SSI (Surgical Site Infections)
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Purpose: Comparison of clinical, radiological and functional outcomes of screw proximal femoral nail (PFN) and helical PFN in management of unstable trochanteric fractures. Methods: This prospective randomised comparative study included 60 patients with closed unstable intertrochanteric fractures (AO classification-A2.2–A2.3 & A3.1–A3.3). Patients were randomised to 2 treatment groups using simple random sampling method utilizing computer based randomisation. Screw PFN and helical PFN were used for internal fixation with 30 patients in each group. Results: Both groups were similar in respect of age, gender, fracture classification, quality of fracture reduction, duration of hospitalization, post-operative complications, residual/late deformity as well as functional assessment. However, mean duration of surgery was significantly lower (23.1%) in helical PFN group as compared to screw PFN group (43.32 ± 8.20 min vs. 35.20 ± 6.03 min, p < 0.001). Furthermore, mean blood loss was not significant in either of the study groups but it was significantly lesser (30.1%) in helical PFN group as compared to screw PFN group (77.80 ± 17.39 ml vs. 59.80 ± 14.96 ml, p < 0.001). Also, mean number of images taken was significantly lower (58.7%) in helical PFN group as compared to screw PFN group (29.52 ± 4.85 no vs. 18.60 ± 3.12 no, t = 9.47; p < 0.001). Conclusion: Both screw PFN and helical PFN are equally effective implants in internal fixation of unstable trochanteric fractures with no statistically significant difference (p > 0.05) in any of the outcome measures. However, helical PFN group fared marginally better in terms of operative time, blood loss and imaging required.
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Reconstructing proximal humeral fractures using the bicipital groove as a landmark
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Controversy persists in the literature regarding the use of the bicipital groove as an anatomic landmark to restore humeral head retroversion when treating complex proximal humeral fractures with arthroplasty. We quantified the three-dimensional geometry of the bicipital groove in 49 dried humeri relative to the intramedullary axis, quantified the reliability of using the bicipital groove as an anatomic landmark, and compared this reliability with that of the conventional technique that uses a fixed, average angle relative to the epicondylar axis to establish humeral head retroversion. The data show the anterior offset of the bicipital groove is nearly constant from proximal (7.3 mm +/- 2.8 mm) to distal (7.2 mm +/- 1.5 mm) relative to the intramedullary axis. Given the consistency, the distal bicipital groove (at the level of the surgical neck) is a reasonable landmark to establish humeral head retroversion after complex proximal humeral fractures having reliability (angular error of 7.9 degrees +/- 5.8 degrees) as good as or better than the conventional fixed-angle technique
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Medicare Reimbursement Attributable to Periprosthetic Joint Infection Following Primary Hip and Knee Arthroplasty
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PJI DX Updated Search
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This study estimated Medicare reimbursement attributable to periprosthetic joint infection (PJI) across the continuum of covered services four years following hip or knee arthroplasty. Using 2001-2008 Medicare claims data, total and annual attributable reimbursements were assessed using generalized linear regression, adjusting for potential confounders. Within one year following arthroplasty, 109 (1.04%) of 10,418 beneficiaries were diagnosed with PJI. Cumulative Medicare reimbursement in the PJI arm was 2.2-fold (1.9-2.6, P<.0001) or $53,470 ($39,575-$68,221) higher than that of the non-PJI arm. The largest difference in reimbursement occurred the first year (3.2-fold); differences persisted the second (2.3-fold) and third (1.9-fold) follow up years. PJI following hip or knee arthroplasty appears costly to Medicare, with cost traversing several years and health care service areas
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A randomised controlled trial to compare patient satisfaction with two different types of local anaesthesia in ptosis surgery
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Upper Eyelid and Brow Surgery
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BACKGROUND: Ptosis surgery is performed under local anaesthetic to allow intra-operative assessment of lid positioning. Most commonly the anaesthetic is administered as a subcutaneous infiltration at the surgical site. Ptosis surgery using a regional nerve block has also been described, with reported advantages for minimising levator paralysis and disruption of the surgical landmarks. This study was designed to compare patient satisfaction with the two techniques of local anaesthetic administration. METHODS: 32 patients undergoing ptosis surgery were enrolled into a randomised controlled trial to receive local anaesthetic either by subcutaneous infiltration or by regional nerve block. Patient satisfaction was measured postoperatively with a self-administered vertical response column questionnaire, the Iowa Satisfaction with Anaesthesia Scale (ISAS). RESULTS: Of the 32 patients who were recruited 3 patients were excluded from analysis due to incomplete questionnaires or deviation from the trial protocol. Patient groups were well matched in terms of age, sex, time on waiting list, anaesthetic risk score, and operating grade of surgeon. Comparison of ISAS scores with the Mann Whitney test demonstrated an equal level of patient satisfaction with the two techniques. CONCLUSION: This randomised controlled trial found regional nerve blocks to be associated with equal levels of patient satisfaction as the more standard technique of diffuse infiltration of local anaesthetic along the upper eyelid. This result supports the use of regional nerve blocks as a valid alternative for anaesthesia in ptosis surgery.
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A midvastus muscle-splitting approach for total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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This study presents a modification of the medial parapatellar surgical approach for total knee arthroplasty. This approach separates the vastus medialis muscle in the direction of its fibers beginning at the superior pole of the patella. One hundred eighteen consecutive total knee arthroplasty cases, performed by a single surgeon, were randomized prospectively to receive a medial parapatellar or midvastus muscle-splitting surgical approach. The frequency of lateral retinacular releases was recorded, patellar tilt and translation were measured, and quadriceps strength was tested. The midvastus muscle-splitting approach provided excellent exposure to all knees. Patellar stability and quadriceps strength were equivalent for the two approaches. It is concluded that the midvastus muscle-splitting approach is an efficacious alternative to the medial parapatellar approach for primary total knee arthroplasties
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Acute flank pain due to renal infarction: Limitations of unenhanced CT
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PJI DX Updated Search
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A fifty-two-year-old woman developed severe right flank pain; she had an initial non-contrast CT, which was inconclusive. Subsequently, contrast enhanced CT showed subtotal infarction of the right kidney and occlusion of the right main renal artery. The current trend is using unenhanced helical CT for the diagnosis of acute flank pain; therefore, the diagnosis of acute renovascular occlusion is delayed. Although unenhanced helical CT can show other abdominal conditions such as appendicitis, diverticulitis, adnexal disease and aortic rupture, it cannot show acute renal artery occlusion. Contrast-enhanced CT was done to arrive at the final diagnosis, as the laboratory results were not conclusive and the patient had continuous flank pain for 48 hours
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Disparities in joint replacement utilization: A quality of care issue
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Surgical Management of Osteoarthritis of the Knee CPG
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Although total joint replacement is an effective treatment option for end-stage lower extremity osteoarthritis, racial disparities in joint replacement utilization have been well documented. These disparities may be due in part to patient-level factors such as willingness to consider joint replacement and worse expectations of joint replacement outcomes. In addition, African-Americans may have worse outcomes after total joint replacement and are more likely to have surgery performed by surgeons with lower volumes or in hospitals with lower volumes. All of these issues may be considered concerns with the quality of care delivered to African-Americans with osteoarthritis. (copyright) Copyright Clinical and Experimental Rheumatology 2007
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Social complexity beliefs predict posttraumatic growth in survivors of a natural disaster
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DoD PRF (Psychosocial RF)
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OBJECTIVE: Most studies on posttraumatic growth (PTG) have focused on personal characteristics, interpersonal resources, and the immediate environment. There has been less attention on dynamic internal processes related to the development of PTG and on how these processes are affected by the broader culture. Calhoun and Tedeschi's (2006) model suggests a role of distal culture in PTG development, but empirical investigations on that point are limited. The present study investigated the role of social complexity-the generalized belief about changing social environments and inconsistency of human behavior-as a predictor of PTG. Social complexity was hypothesized to be associated with problem-solving approaches that are likely to give rise to cognitive processes that promote PTG.
METHOD: A sample of 446 survivors of Typhoon Haiyan, 1 of the strongest typhoons ever recorded at the time, answered self-report measures of social complexity, cognitive processing of trauma, and PTG.
RESULTS: Structural equation modeling indicated a good fit between the data and the hypothesized model; belief in social complexity predicted stronger PTG, mediated by cognitive processing.
CONCLUSION: The results provide evidence for how disaster survivors' beliefs about the changing nature of social environments and their corresponding behavior changes are predictors of PTG and suggest a psychological mechanism for how distal culture can influence PTG. Thus, assessing social complexity beliefs during early the phases of a postdisaster psychosocial intervention may provide useful information on who is likely to experience PTG. Trauma workers might consider culture-specific social themes related to social complexity in disaster-affected communities. (PsycINFO Database Record
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Patients' experiences following local-regional recurrence of thyroid cancer: a qualitative study
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DoD PRF (Psychosocial RF)
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BACKGROUND AND OBJECTIVE: The psychosocial impact of local-regional thyroid cancer recurrence is not known. The aim of this study was to explore thyroid cancer patients' experiences relating to diagnosis and treatment of local-regional disease recurrence.
METHODS: We conducted 15 semi-structured interviews with survivors of differentiated thyroid cancer who underwent neck reoperation for recurrent disease. Participants were recruited from the clinical practices of thyroid surgeons and endocrinologists at University Health Network and Mount Sinai Hospitals in Toronto, Ontario. Participant interviews were audio-recorded, transcribed verbatim, and analyzed using qualitative methods. Saturation of themes was achieved.
RESULTS: Local-regional recurrence of thyroid cancer was associated with significant psychological distress. Confidence in healthcare providers as well as psychosocial support from family or social relations, were helpful in coping with disease recurrence. After recovery from treatment, post-traumatic growth was reported. However, questions and worry about the risk for future recurrence lingered at follow-up.
CONCLUSIONS: Local-regional recurrence of thyroid cancer has a significant psychosocial impact on patients, and support needs are heightened throughout the experience. Healthcare providers should strive to ensure that medical information and psychosocial needs of such patients are met, throughout the treatment experience, as well as at follow-up.
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Neonatal septicemia isolates and resistance patterns in a tertiary care hospital of North India
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Patrick’s pharmacoepidemiology project
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Background: Septicemia continues to be a major cause of neonatal mortality and morbidity worldwide. Methodology: To know the rate of neonatal septicemia in our tertiary care centre, a retrospective analysis of 2,247 blood samples was done over a period of four years and three months (July 2003 to October 2007). Results: During that period, a total of 296 (13.17%) blood samples were found to be positive for bacterial isolates. Gram-negative septicemia (80.40%) was identified in more cases than Gram-positive septicemia (20.60%) with Klebsiella species 84 (28.3%) being the most common isolate. Maximum resistance among Gram-negative organisms was seen in amoxycillin/ampicillin and third-generation cephalosporins. Amikacin, cefoperazone/sulbactam and imipenem were found to be good alternative drugs. Among Gram-positive organisms, all strains were sensitive to Vancomycin. Conclusion: Continued surveillance for various pathogens and their susceptibility profile should be done to effectively and timely treat the patients of neonatal septicaemia. Copyright �© 2010 Kaistha et al
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Viscosupplementation for Osteoarthritis of the Knee: A Key Opinion Leader Panel Discussion
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OAK 3 - Non-arthroplasty tx of OAK
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With a sharp rise in the prevalence of osteoarthritis of the knee (OAK) in a younger population, new management strategies are needed to preserve mobility, improve patients' quality of life, and reduce the effects of potential disease-related comorbidities. Viscosupplementation with the use of hyaluronic acid (HA) injection is a treatment option for OAK that can provide lubrication and elastic shock absorption, leading to potential pain relief, improved function, and reduced stiffness. A key opinion leader (KOL) panel discussion was held December 3, 2016, with the objective of sharing opinions, ideas, information, and trends regarding OAK and the potential treatment and management offered by viscosupplementation. The panel concluded that viscosupplementation with HA injections presents a viable, cost-effective, and safe alternative for the treatment of OAK.
DISCLOSURES: This panel discussion and report was facilitated by Magellan Rx Manage-ment and funded by Sanofi. Bert and Ruane report fees from Sanofi outside of this project. Sgaglione reports royalty payments from Zimmer Biomet and Wolters Kluwer. Dasa has received fees from Bioventus and Myoscience. All the authors received an honorarium for work on this project. Lopes is employed by Magellan Rx Management.
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Relations among sociodemographic, neurologic, clinical, and neuropsychologic variables, and vocational status following mild traumatic brain injury: A follow-up study
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DoD PRF (Psychosocial RF)
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OBJECTIVES: To explore the long-term relations among sociodemographic, neurologic, clinical, and neuropsychologic variables, and vocational status in persons with mild traumatic brain injury (MTBI), and to identify the symptoms that determine whether or not these individuals return to work. DESIGN: Longitudinal quasi-experimental between-groups design. PARTICIPANTS: Eighty-five MTBI subjects aged between 16 and 65 years. SETTING: The emergency ward of the Trois-Rivieres Regional Hospital Centre in Quebec, Canada. MAIN OUTCOME MEASURES: Age, gender, Glasgow Coma Scale score, duration of posttraumatic amnesia, duration of retrograde amnesia, total of symptoms at emergency, time elapsed since the trauma, Paced Auditory Serial Addition Task, Stroop Color Word Test, California Verbal Learning Test, and the number of symptoms at follow-up (12 to 36 months posttrauma). RESULTS: Only the total number of symptoms reported at follow-up was related to vocational status. The majority of individuals had returned to work 1 year or more post-MTBI. Individuals who had not returned to work reported the greatest number of symptoms, which could be linked to their affective status. Six affective symptoms, 5 cognitive symptoms, 6 physical symptoms, and 8 symptoms relating to social and daily life activities differentiated the participants who had returned to work from those who had not. CONCLUSIONS: Patient characteristics, injury severity indicators, and cognitive functions were not associated with vocational status. To better understand post-MTBI vocational status, it is important to focus on subjective complaints that arise following the injury. © 2006 Lippincott Williams & Wilkins, Inc.
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Psychological resources, positive illusions, and health
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DoD PRF (Psychosocial RF)
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Psychological beliefs such as optimism, personal control, and a sense of meaning are known to be protective of mental health. Are they protective of physical health as well? The authors present a program of research that has tested the implications of cognitive adaptation theory and research on positive illusions for the relation of positive beliefs to disease progression among men infected with HIV. The investigations have revealed that even unrealistically optimistic beliefs about the future may be health protective. The ability to find meaning in the experience is also associated with a less rapid course of illness. Taken together, the research suggests that psychological beliefs such as meaning, control, and optimism act as resources, which may not only preserve mental health in the context of traumatic or life-threatening events but be protective of physical health as well.
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Intrathecal ropivacaine for ambulatory surgery
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: The rationale of this study was to evaluate intrathecal ropivacaine for ambulatory surgery. METHODS: One hundred fifty patients with American Society of Anesthesiologists physical status 1 scheduled for knee arthroscopy were studied. Patients were randomly assigned to receive 4 ml of one of five isobaric intrathecal solutions: Patients in group 1 (n = 30) received 8 mg of bupivacaine; patients in group 2 (n = 30) received 8 mg ropivacaine; patients in group 3 (n = 30) received 10 mg ropivacaine; patients in group 4 (n = 30) received 12 mg ropivacaine; and patients in group 5 (n = 30) received 14 mg ropivacaine. The level and duration of sensory anesthesia were recorded along with the intensity and duration of motor block. Patients were interviewed to identify transient neurologic symptoms. RESULTS: Intrathecal ropivacaine 10 mg produced shorter sensory anesthesia and motor blockade than bupivacaine 8mg (152 +/- 44 min and 135 +/- 41 min vs. 181 +/- 44 min and 169 +/- 52 min, mean +/- SD; P < 0.05). However, the quality of intraoperative analgesia was significantly lower in the 10-mg ropivacaine group (P < 0.05). Ropivacaine 12 mg produced sensory and motor block almost comparable to bupivacaine 8 mg. Ropivacaine 14 mg produced sensory and motor block comparable to ropivacaine 12 mg but significantly increased the time to void. No sign of transient radicular irritation were noted. CONCLUSION: Intrathecal ropivacaine 12 mg is approximately equivalent to bupivacaine 8 mg. At this dose, ropivacaine offers no significant advantage compared with bupivacaine
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Effects of pH on the silk fibroin coating of CoCrMo alloy
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PJI DX Updated Search
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Bacteria related infections are still cited as a major problem for the implant materials resulting in failure of device especially knee and hip replacement. Two main approaches are focused for inhibiting the bacterial adhesion to the surface. These involve bactericidal substances and anti-adhesive coatings. Silk fibroin is one of the promising materials due to its good drug loading capacity and efficiency. In this study, the effects of pH on the silk fibroin coating of CoCrMo alloy, prepared by means of layer by layer, was investigated thoroughly using scanning electron microscope (SEM), Atomic Force Microscope (AFM) Attenuated Total Reflectance Fourier Transform Infrared (ATR-FTIR) Spectroscopy. A medical grade CoCrMo was coated with variable number of silk fibroin up to 14 layers at pH 3.0, 3.5, and 5.5 at room temperature. As a result, only silk fibroin films prepared at pH 3.0 and 3.5 were found to convey the general characteristics of the mixture of silk I and II, while the samples prepared at pH 5.5 exhibited the lack of some specific amide structures which influence the general characteristics of silk I and II. Moreover, regardless of pH, the surface roughness was determined to increase with the increasing number of layers. However, as the pH increases the surface roughness decreases at 6, 10 and 14 layers
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The effects of arthroscopic partial lateral meniscectomy in an otherwise normal knee: a retrospective review of functional, clinical, and radiographic results
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AMP (Acute Meniscal Pathology)
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A retrospective review of patients who underwent arthroscopic partial lateral meniscectomy for lateral meniscus tears in otherwise normal knees was conducted to review the long-term functional, clinical, and radiographic results. Twenty-six patients (27 knees) were evaluated by questionnaire; 20 patients (21 knees) also underwent physical examination and radiographic analysis. Minimum follow-up was 5 years and mean follow-up was 8 years. Patient data were obtained from detailed questionnaires, knee examinations, and radiographs. Excellent or good results decreased from 92% at the time of maximal improvement to 62% at the most recent follow-up: 85% of patients were initially able to return to their preinjury activity level; however, only 48% were able to maintain this level of activity at the most recent follow-up. Seventy-two percent of patients had either one or no Fairbank changes and there was no statistical difference when comparing radiographic criteria in the operated and nonoperated knee. Early results for partial lateral meniscectomy can be quite good; however, significant deterioration of functional results and decreased activity level can occur. Radiographic changes did not correlate with subjective symptoms and functional outcome in our patient population. Our findings suggest that the functional outcome for patients undergoing partial lateral meniscectomy may deteriorate with time and it may be helpful to counsel patients concerning long-term expectations.
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Ulcerative keratitis caused by beta-hemolytic Streptococcus equi in 11 horses
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Reconstruction After Skin Cancer
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Purpose To describe 11 clinical cases of ulcerative keratitis in horses associated with beta-hemolytic Streptococcus equi in Florida, USA. METHODS: Retrospective clinical study (1996-99). RESULTS: Beta-hemolytic Streptococcus equi was cultured from 11 horses with deep ulcers, descemetoceles or iris prolapse (n = 8), a suture abscess found with a penetrating keratoplasty for a stromal abscess (n = 1), and ulceration that developed following keratectomy/irradiation for corneal squamous cell carcinoma (n = 2). Beta-hemolytic Streptococcus equi subspecies zooepidemicus was found in 10 eyes and subspecies equi in one. Marked signs of uveitis including miosis and hypopyon were present in 8/11 (72.7%) eyes. Keratomalacia was severe in all eyes. The mean diameter of the ulcers associated with beta-hemolytic Streptococcus was 10.2 +/- 6.1 mm. Eight of the eyes required conjunctival flap surgery (four grafts dehisced) and one eye corneal transplantation. Two eyes were treated with medication only. Isolate sensitivity to antibiotics included ampicillin (6/11), bacitracin (11/11), cephalothin (11/11), chloramphenicol (11/11), gentamicin (5/11), polymyxin B (2/11), and tobramycin (1/11). All isolates were resistant to neomycin. The average healing time was 44.7 +/- 26.7 days. The visual outcome was positive in 8/11 eyes, and the globe retained in 9/11 eyes. CONCLUSIONS: Although Gram-positive bacteria predominate in the normal conjunctival microflora of horses throughout the world, Gram-negative bacteria and fungi are more often isolated from equine ulcers. Beta-hemolytic Streptococcus spp. are associated with a very aggressive ulcerative keratitis with the capability to digest conjunctival graft tissue. Clinical signs are pronounced. Aggressive surgical and intensive medical therapy with topical antibiotics and protease inhibitors is indicated.
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Long-term results of cementless femoral reconstruction following intertrochanteric osteotomy
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Dental Implant Infection
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PURPOSE: The objective of this retrospective cohort study was to assess the long-term outcome of cementless femoral reconstruction in patients with previous intertrochanteric osteotomy (ITO)., METHODS: We evaluated the clinical and radiographic results of a consecutive series of 45 patients (48 hips, mean age 50 years) who had undergone conversion hip replacement following ITO with a cementless, grit-blasted, double-tapered femoral component. Clinical outcome was determined using the Harris hip score. Stem survival for different end points was assessed using Kaplan-Meier survivorship analysis., RESULTS: At a mean follow-up of 20 (range, 16-24) years, 11 patients (12 hips) had died, and no patient was lost to follow-up. Six patients (six hips) underwent femoral revision, two for infection, three for aseptic loosening and one for periprosthetic fracture. Mean Harris hip score at final follow-up was 78 points (range, 23-100 points). Stem survival for all revisions was 89% (95%CI, 75-95) at 20 years, and survival for aseptic loosening was 93% (95%CI, 80-98)., CONCLUSIONS: The long-term results with this type of cementless femoral component in patients with previous intertrochanteric osteotomy are encouraging and compare well to those achieved in patients with normal femoral anatomy.
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Effects of neoadjuvant radiochemotherapy on pathological staging and prognosis for locally advanced esophageal squamous cell carcinoma
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Reconstruction After Skin Cancer
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The role of neoadjuvant therapy in the treatment of locally advanced esophageal carcinoma still remains controversial. The aim of this study was to evaluate the effects of neoadjuvant radiochemotherapy on pathological staging and prognosis in the patients with locally advanced esophageal squamous cell carcinoma. Between January 1991 and December 2000, 473 patients with advanced esophageal carcinoma diagnosed by endoscopic biopsy underwent surgical resection in our center. With informed consent, they were randomized into four groups: neoadjuvant chemotherapy, neoadjuvant radiotherapy, neoadjuvant radiochemotherapy, and surgery alone (control group). The preoperative computed tomography staging criteria were the following: Stage I, the tumor limited to the esophageal lumen or the thickness of the esophageal wall varied between 3-5 mm; Stage II, the thickness exceeds 5 mm but no invasion to the mediastinum or distant metastasis; Stage III, the tumor invades adjacent mediastinal structure; and Stage IV, there is distant metastasis. The tumor resection rate, pathological stage, treatment-related complication, and survival among groups were compared. The radical resection rate for the patients in radiotherapy and radiochemotherapy groups was increased in comparison with the control group (P < 0.05). Their pathological stage after esophagectomy was regressed significantly than that of the control group (50.85%, 55.08% vs. 0%, P < 0.05). The adjuvant chemotherapy group did show significant improvement on resection rate and pathological staging compared with the control group. The treatment-related complication in the three neoadjuvant groups had no significant difference from that of the control group (P > 0.05). The 3-year survival rate of radiotherapy and radiochemotherapy groups were significantly higher than that of the control group (69.49%, 73.73% vs. 53.38%, P < 0.05). The 5-year survival rate of radiochemotherapy group was higher than that of the radiotherapy group although did not show a statistical difference (P > 0.05). Rational application of neoadjuvant radiochemotherapy seems to provide a modest benefit in radical resection and survival in patients with locally advanced esophageal carcinoma.
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Perioperative dexketoprofen or lornoxicam administration for pain management after major orthopaedic surgery - A randomized, controlled study
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Surgical Management of Osteoarthritis of the Knee CPG
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Background and aims: Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for multimodal postoperative pain management. We evaluated postoperative pain relief and opioid sparing effects of dexketoprofen and lornoxicam after major orthopaedic surgery. Methods: After ethical committee approval and informed consent 120 patients undergoing elective hip or knee replacement under general anaesthesia were randomised to receive 50 mg dexketoprofen (GD), 8 mg lornoxicam (GL) or placebo intravenously (GP) at the beginning of skin closure and at 12(th) h postoperatively. Postoperatively, PCA was started (0.01 mg/kg bolus dose, lockout 10 min without continuous infusion). Pain assessments was made using VAS at rest or during movement on postoperative 1, 2, 4, 6, 8, 12 and 24(th) hours. Results: The three groups were similar in terms of age, gender, ASA class; number of patients underwent hip or knee surgery, weight, and height and operation duration. Patients in GD and GL demonstrated significantly reduced pain scores at rest and active motion compared to GP with lower scores in the dexketoprofen group. Patients in GD and GL used significantly less morphine in the postoperative period compared to GP. The total morphine consumption of patients in GD was significantly lower than GL. Regarding sedation there were no differences between the groups. Conclusions: Intravenous application of two doses of 50 mg dexketoprofen and two doses of 8 mg lornoxicam improved analgesia and decreased morphine consumption following major orthopaedic surgery. Also dexketoprofen was superior to lornoxicam in terms of pain relief and decreased morphine consumption
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0 |
Traumatic osteochondral injury of the femoral head treated by mosaicplasty: a report of two cases
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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The increased risk of symptomatic progression towards osteoarthritis after chondral damage has led to the development of multiple treatment options for cartilage repair. These procedures have evolved from arthroscopic lavage and debridement, to marrow stimulation techniques, and more recently, to osteochondral autograft and allograft transplants, and autogenous chondrocyte implantation. The success of mosaicplasty procedures in the knee has led to its application to other surfaces, including the talus, tibial plateau, patella, and humeral capitellum. In this report, we present two cases of a chondral defect to the femoral head after a traumatic hip dislocation, treated with an osteochondral autograft (OATS) from the ipsilateral knee, and the inferior femoral head, respectively, combined with a surgical dislocation of the hip. At greater than 1 year and greater than 5 years of follow-up, MRI studies have demonstrated good autograft incorporation with maintenance of articular surface conformity, and both patients clinically continue to have no pain and full active range of motion of their respective hips. In our opinion, treatment of osteochondral defects in the femoral head surface using a surgical dislocation combined with an OATS procedure is a promising approach, as full exposure of the femoral head can be obtained while preserving its vasculature, thus enabling adequate restoration of the articular cartilage surface
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0 |
Cosmetic considerations and nonlaser cosmetic procedures in ethnic skin
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Panniculectomy & Abdominoplasty CPG
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The face of the aesthetic patient is changing to be more representative of the ethnic diversity of the United States population. It is imperative that the cosmetic dermatologic surgeon not only understand the concerns of the ethnic aesthetic patient but have an awareness of the unique needs of those with darker skin.
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0 |
General principles
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DOD - Acute Comp Syndrome CPG
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This article outlines basic bone structure and physiology, reviews the fundamental concepts of bone injury, briefly correlates bone edema patterns with mechanism of injury, and finally reviews magnetic resonance imaging during fracture healing. Copyright © 2006 by Thieme Medical Publishers, Inc.
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Meniscal regeneration in the long-term after total meniscectomy?
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AMP (Acute Meniscal Pathology)
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A cohort of 39 patients (28 male, 11 female) that had undergone total meniscectomy as adolescents (mean age 16 years) underwent FISP 3D Magnetic Resonance Imaging at a mean follow up of 30 years. The presence of meniscal tissue was assessed by two independent observers blinded to the operation details. The volume of any meniscal tissue present was calculated. A posterior horn remnant was seen in 57% of medial and 45% of lateral meniscectomy cases. The mean volume of an operated medial meniscal remnant was 0.29 mL compared with a mean volume of 1.15 mL for an intact medial meniscus. The mean volume of an operated lateral meniscal remnant was 0.30 mL compared with 1.07 mL for an intact lateral meniscus. We have shown that the incidence of incomplete excision of the posterior horn is more common after total medial meniscectomy, and that at a mean follow up of 30 years there is no convincing in vivo MRI evidence of long-term meniscal regeneration.
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Change in the use of hormone replacement therapy and the incidence of fracture in Oslo
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Management of Hip Fractures in the Elderly
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Fracture incidence in Oslo decreased from the 1970s to the 1990s in younger postmenopausal women, but not in older women or in men. Concurrently, hormone replacement therapy increased considerably. Using data from the Oslo Health Study, we estimated that roughly half the decline might be attributed hormone replacement therapy. INTRODUCTION: Between the late 1970s and the late 1990s, the incidence of hip fracture and distal forearm fracture decreased in younger postmenopausal women in Oslo, but not in elderly women or in men. The purpose of this report is to evaluate whether the decreased incidence was coherent with trends in use of hormone replacement therapy (HRT). METHODS: Data on estrogens were collected from official drug statistics, data on fractures from published studies and data on bone mineral density (BMD) from the Oslo Health Study. RESULTS: The sale of all estrogens increased 22 times from 1979 to 1999, and the sub-category estradiol combined with progestin increased 35 times. In the corresponding period the incidence of distal forearm fracture in women aged 50-64 years decreased by 33% and hip fracture by 39%. Based on differences in BMD between users and non-users of HRT, we estimated that up to half of this decline might be due to HRT. CONCLUSIONS: The reduction in fracture incidence in postmenopausal women in Oslo occurred in a period with a substantial increase in the use of HRT. Future surveillance will reveal whether the last years' decline in use of HRT will be translated into increasing fracture rates
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0 |
The middle radioulnar joint and triarticular forearm complex
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Distal Radius Fractures
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The forearm is composed of the radial and ulnar shafts, which are linked by the interosseous membrane and intercalated between the elbow and wrist. The radius and ulna are connected by three joints, the proximal, middle, and distal radioulnar joints. The forearm ensures pronation/supination and longitudinal load transfer. The biomechanical and clinical relevance of the proximal and distal radioulnar joints is well established. In contrast, the middle radioulnar joint was considered relatively unimportant until studies published in the last decade showed that it fulfils crucial biomechanical functions and is of considerable clinical significance. We believe the conventional concept in which the forearm is viewed as part of either the elbow or the wrist is outdated and that a more relevant concept describes the forearm as a triarticular complex that functions as a full-fledged entity. In this concept, the three forearm radioulnar joints (proximal, middle, distal) work together to provide stability, mobility and load transfer. Here, we will argue for the relevance of the triarticular complex concept based on published data about forearm biomechanics and pathological conditions.
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0 |
Surgical approaches to the posteromedial and posterolateral aspects of the knee
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AMP (Acute Meniscal Pathology)
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Surgical approaches to the posterior aspect of the knee are not commonly needed, and their use has become even rarer with the increasing sophistication of arthroscopic technology. As a result, physicians in orthopaedic surgical training are not often exposed to the practical use of surgical dissection around the posterior corners of the knee. For certain procedures, however, greater clinical utility and decreased surgical morbidity render focused posterior exposure the preferred alternative to the classic popliteal dissection with its wide exposure of the popliteal anatomy. Surgical indications include ligament repair or reconstruction around the posteromedial or posterolateral aspect of the knee, inside-out meniscal repair, posterior cruciate ligament tibial inlay reconstruction, and Baker's cyst excision. To minimize complications, these focused approaches require adeptness with the complex anatomy of the posterior, posteromedial, and posterolateral aspects. [References: 36]
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Serum hyaluronic acid concentration predicts the progression of joint space narrowing in normal knees and established knee osteoarthritis - a five-year prospective cohort study
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: Serum hyaluronic acid (sHA) is a serum biomarker for knee osteoarthritis (OA). Although sHA concentration is elevated in patients with knee OA, the relationship between serum concentration and disease progression remains unclear. We examined the relationship between sHA concentration and radiographic progression of knee OA in a cohort of individuals followed for 5 years.
METHODS: We prospectively enrolled 444 individuals and measured their sHA concentrations at baseline. Anterior-posterior weight bearing knee radiographs were obtained at baseline and the 5-year endpoint. Osteoarthritic knee changes were classified according to Kellgren-Lawrence (KL) grade, and joint space narrowing (JSN) was measured using a Knee Osteoarthritis Computer-Aided Diagnosis (KOACAD) system. Correlations between sHA concentration, progression in KL grade, and JSN were assessed using regression models, taking into account potentially confounding factors.
RESULTS: OA progressed from KL grades 0 or 1 in 129 of the 323 knees, and from KL grades 2 or 3 in 61 of the 119 knees. Higher sHA concentrations were correlated with KL grade progression (p = 0.004). The mean JSN, as assessed by KOACAD over 5 years, was 0.23 +/- 0.55 mm, and sHA concentration was positively correlated with progression of JSN in KL grades 0 or 1 (p = 0.021) and KL grades 2 or 3 (p = 0.008) knees.
CONCLUSION: Serum HA concentration was positively correlated with progression of KL grade. sHA was also positively correlated with progression of JSN in knees with and without OA, suggesting that sHA concentration may be a useful predictor of knee OA progression.
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0 |
Psychiatric disorders following first breast cancer recurrence: prevalence, associated factors and relationship to quality of life
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DoD PRF (Psychosocial RF)
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OBJECTIVE: The purpose of this study was to investigate the prevalence of and factors associated with psychiatric disorders and the impact on quality of life (QOL) in patients with first breast cancer recurrence.
METHODS: We analyzed the baseline data on 50 consecutively enrolled recurrent breast cancer patients, participating in a feasibility study of multifaceted psychosocial intervention. Psychiatric disorders, including major depressive disorder (MDD), dysthymic disorder, panic disorder, post-traumatic stress disorder (PTSD), generalized anxiety disorder and adjustment disorders (AD), were evaluated according to the Structured Clinical Interview for the DSM-III-R and IV. The patients' demographic data, biomedical factors, social support, mental adjustment to cancer, personality traits and QOL were also evaluated.
RESULTS: Eleven (22%) met the DSM-III-R and IV criteria for MDD, PTSD or AD (MDD, 2%; PTSD, 2%; AD, 20%). Univariate analysis indicated that current doxorubicin/cyclophosphamide, presence of a confidant, past history of MDD, helplessness/hopelessness and neuroticism were significantly associated with psychiatric disorders. On multivariate logistic regression analysis, past history of MDD and helplessness/hopelessness were significant associated factors. Psychiatric disorders were significantly associated with lower functional scales ('emotional functioning', 'body image' and 'future perspective') and higher symptom scales ('appetite loss', 'diarrhea', 'fatigue' and 'nausea-vomiting') in QOL.
CONCLUSIONS: The result suggests that asking about history of depression and appropriate intervention, including psycho-education, are needed for patients with first breast cancer recurrence in order to detect and manage psychological distress. Although further studies are needed to clarify causal links between psychiatric disorders and QOL, patients' psychiatric disorders were associated with QOL.
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0 |
A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures
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Management of Hip Fractures in the Elderly
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The aim of this study was to evaluate the effect of a geriatric-anesthesiologic intervention program for the prevention and treatment of acute confusional states (ACS) in elderly patients treated for femoral neck fractures. The intervention program was based on the results of previous prospective studies in similar patient populations. The outcome of the intervention, comprising 103 patients, was compared with that of an earlier study comprising 111 patients. The intervention program consisted of pre- and post-operative geriatric assessments, oxygen therapy, early surgery, prevention and treatment of peri-operative blood pressure falls and treatment of post-operative complications. The incidence of ACS was lower, 47.6%, in the intervention study compared with 61.3% (P less than 0.05) in the control study. Furthermore, the ACS that occurred in the intervention study was less severe and of shorter duration than that in the control study. The incidence of post-operative decubital ulcers, severe falls, and urinary retention was also lower. The mean duration of orthopedic ward stay was 17.4 days in the control study and 11.6 days in the intervention study (P less than 0.001). It can be concluded that the intervention program reduced the incidence, severity, and duration of ACS which resulted in a shortened orthopedic ward stay
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0 |
Effects of intra-articular SHINBARO treatment on monosodium iodoacetate-induced osteoarthritis in rats
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: SHINBARO is a refined herbal formulation used to treat inflamed lesions and bone diseases. This study aimed to investigate the anti-osteoarthritic activities of intra-articular administration of SHINBARO and determine its underlying molecular mechanism in a monosodium iodoacetate (MIA)-induced osteoarthritis rat model.
METHODS: Male Sprague-Dawley rats received a single intra-articular injection of MIA into the infrapatellar ligament of the right knee. Subsequently, the rats were treated with normal saline, SHINBARO, and diclofenac once daily for 21 days. Rats treated with normal saline, but not MIA, comprised the control group. Histological changes in the femur of the MIA-induced osteoarthritis rat model were observed by micro-computed tomography scanning and staining with hematoxylin and eosin, and safranin-O fast green. Serum levels of PGE2 and anti-type II collagen antibodies in the MIA-induced osteoarthritis rat model were measured using commercial kits. Protein levels of inflammatory enzymes (iNOS, COX-2), pro-inflammatory cytokines (TNF-alpha, IL-1beta), and inflammatory mediators (NF-kappaB, IkappaB) in cartilaginous tissues were determined by western blot analysis.
RESULTS: Intra-articular administration of SHINBARO (IAS) at 20 mg/kg remarkably restrained the decrease in bone volume/total volume, being 28 % (P = 0.0001) higher than that in the vehicle-treated MIA group. IAS (2, 10, and 20 mg/kg) treatment significantly recovered the mean number of objects values with increased percentage changes of 13.5 % (P = 0.147), 27.5 % (P = 0.028), and 44.5 % (P = 0.031), respectively, compared with the vehicle-treated MIA group. The serum level of PGE2 in the IAS group at 20 mg/kg was markedly inhibited by 60.6 % (P = 0.0007) compared with the vehicle-treated MIA group, and the anti-collagen type II antibody level in the IAS group was reduced in a dose-dependent manner. IAS (20 mg/kg) effectively suppressed the induction of inflammation-mediated enzymes (iNOS and COX-2) and pro-inflammatory cytokines (TNF-alpha and IL-1beta). IAS treatment also downregulated the NF-kappaB level and increased the IkappaB-alpha level in the MIA- induced osteoarthritis rat model.
CONCLUSION: SHINBARO inhibited PGE2 and anti-type II collagen antibody production and modulated the balance of inflammatory enzymes, mediators, and cytokines in the MIA-induced osteoarthritis rat model.
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0 |
Extended applications of the reamer-irrigator-aspirator (RIA) system
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MSTS 2018 - Femur Mets and MM
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While the RIA system was initially designed for reaming and clearing the femoral canal contents in preparation for femoral nailing, it has since been used in various other applications in the field of orthopaedic surgery. The RIA is an ideal device for accessing large quantities of autogenous bone graft, to be used in the treatment of nonunions, segmental bone loss, or arthrodesis. The RIA has also been used for treatment of intramedullary infections and osteomyelitis, as well as intramedullary nailing of long bones with metastatic lesions, as it allows for clearing the canal of infectious/tumour burden, and lowers the risk of dissemination into the soft tissues and systemic circulation. There is also some limited evidence that the RIA may be used for clearing the femoral/tibial canal of cement debris. Despite multiple applications, the use of RIA has a risk of eccentric reaming and iatrogenic fractures. RIA is also a costly procedure, and its routine use may not be advantageous in the setting of limited health care resources.
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0 |
Epinephrine and clonidine do not improve intrathecal sufentanil analgesia after total hip replacement
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AAHKS (8) Anesthetic Infiltration
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BACKGROUND: We compared analgesia after intrathecal sufentanil alone, sufentanil with epinephrine 200 microg and sufentanil with clonidine 30 microg in patients after total hip replacement, the endpoints being onset and duration of action.
METHODS: We performed a randomized double-blind study of 45 patients for elective total hip arthroplasty using continuous spinal anaesthesia. As soon as a pain score higher than 3 on a 10 cm visual analogue scale was reported, sufentanil 7.5 microg alone, sufentanil 7.5 microg + epinephrine 200 microg or sufentanil 7.5 microg + clonidine 30 micro g in 2 ml normal saline was given intrathecally. Pain scores, rescue analgesia (diclofenac and morphine) and adverse effects (respiratory depression, postoperative nausea and vomiting, itching) were observed for 24 h after surgery.
RESULTS: Time to a pain score of <3 [6 (SD 1) vs 6 (1) vs 5 (1) min], time to the lowest pain score [7 (2) vs 8 (2) vs 8 (2) min] and time to the first dose of systemic analgesic for a pain score >3 [281 (36) vs 288 (23) vs 305 (30) min] were similar in all three groups. Adverse effects and analgesic requirements during the first 24 h were also similar.
CONCLUSION: After total hip replacement, all three analgesic regimens gave good analgesia with comparable onset and duration of action, and minor adverse effects.
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0 |
Carpal tunnel syndrome caused by Mycobacterium szulgai
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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We describe 2 cases of infection due to Mycobacterium szulgai revealed by a carpal tunnel syndrome (CTS) that was the only clinical manifestation. Both patients regularly cleaned their fish tank with bare hands. The diagnosis was made by isolation of M. szulgai from synovium. The cause of the CTS was a synovitis. Previous synovectomies were ineffective. Improvement was observed with antibiotic treatment. The only way to diagnose this unusual infection is to perform histology of synovium and to isolate the mycobacteria from synovium culture
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0 |
Noninvasive radio frequency for skin tightening and body contouring
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Panniculectomy & Abdominoplasty CPG
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The medical use of radio frequency (RF) is based on an oscillating electrical current forcing collisions between charged molecules and ions, which are then transformed into heat. RF heating occurs irrespective of chromophore or skin type and is not dependent on selective photothermolysis. RF can be delivered using monopolar, bipolar, and unipolar devices, and each method has theoretical limits of depth penetration. A variant of bipolar delivery is fractional RF delivery. In monopolar configurations, RF will penetrate deeply and return via a grounding electrode. Multiple devices are available and are detailed later in the text. RF thermal stimulation is believed to result in a microinflammatory process that promotes new collagen. By manipulating skin cooling, RF can also be used for heating and reduction of fat. Currently, the most common uses of RF-based devices are to noninvasively manage and treat skin tightening of lax skin (including sagging jowls, abdomen, thighs, and arms), as well as wrinkle reduction, cellulite improvement, and body contouring.
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0 |
Bovine viral diarrhea virus cyclically impairs long bone trabecular modeling in experimental persistently infected fetuses
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MSTS 2018 - Femur Mets and MM
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Persistent infection (PI) with bovine viral diarrhea virus (BVDV) has been associated with osteopetrosis and other long bone lesions, most commonly characterized as transverse zones of unmodeled metaphyseal trabeculae in fetuses and calves. This study was undertaken to characterize the morphogenesis of fetal long bone lesions. Forty-six BVDV-naïve pregnant Hereford heifers of approximately 18 months of age were inoculated with noncytopathic BVDV type 2 containing media or media alone on day 75 of gestation to produce PI and control fetuses, respectively, which were collected via cesarean section on days 82, 89, 97, 192, and 245 of gestation. Radiographic and histomorphometric abnormalities were first detected on day 192, at which age PI fetal long bone metaphyses contained focal densities (4 of 7 fetuses) and multiple alternating transverse radiodense bands (3 of 7 fetuses). Day 245 fetuses were similarly affected. Histomorphometric analysis of proximal tibial metaphyses from day 192 fetuses revealed transverse zones with increased calcified cartilage core (Cg.V/BV, %) and trabecular bone (BV/TV, %) volumes in regions corresponding to radiodense bands (P < .05). Numbers of tartrate resistant acid phosphatase positive osteoclasts (N.Oc/BS, #/mm(2)) and bone perimeter occupied (Oc.S/BS, %) were both decreased (P < .05). Mineralizing surface (MS/BS, %), a measure of tissue level bone formation activity, was reduced in PI fetuses (P < .05). It is concluded that PI with BVDV induces cyclic abnormal trabecular modeling, which is secondary to reduced numbers of osteoclasts. The factors responsible for these temporal changes are unknown but may be related to the time required for osteoclast differentiation from precursor cells.
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0 |
Longstanding nonunions of scaphoid fractures with bone loss: successful reconstruction with vascularized bone grafts
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Distal Radius Fractures
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Vascularized bone graft from the dorsum of distal radius was used to treat 22 nonunions of scaphoid fractures, with a mean delay of 4 years from the initial injury. Four of the eight patients with associated scapho-styloid arthritis also underwent a closing wedge osteotomy of the distal radius. Follow-up time ranged from 14 to 74 months. Union was accomplished in 6 to 12 weeks and wrist range of motion and grip strength improved postoperatively in all patients. Complete absence of pain was noted in 16 patients and the other six, all of whom had arthritic wrist changes or carpal collapse, only experienced pain with strenuous activities. The simple graft dissection, the avoidance of anastomoses and the lack of donor site morbidity are additional advantages to this surgical technique, which is successful even in cases with an avascular proximal pole.
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0 |
Insall-Burstein posterior-stabilized knee prosthesis in rheumatoid arthritis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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The authors reviewed 65 Insall-Burstein (Zimmer, Warsaw, IN) total condylar posterior-stabilized knee prostheses in 50 patients with rheumatoid arthritis with a follow-up period of at least 5 years (range, 5-13 years). Forty-two knees in 31 patients were evaluated using the Knee Society knee and functional rating scores. Radiographic assessment was performed using standing long radiographs (hip to ankle). Radiolucent lines were studied using fluoroscopic-centered views. Excellent or good clinical results were obtained in 95% of the cases, and the average knee score improved from 22.5 to 90 points. No cases of radiologic loosening were observed. Incomplete radiolucent lines around the tibial component were detected in only 17% and were nonprogressive. Two patients developed hematogenous late deep infection, which required removal of the prosthesis in both, followed, at a second stage, by arthrodesis in one and prosthesis reimplantation in the other. Three knees (7%) had a painful impingement of the patella. Two of these were successfully reoperated with arthroscopic debridement of the peripatellar synovial tissues. Survivorship analysis, based on endpoints such as prosthesis removal for any cause or radiologic loosening (complete radiolucent line thicker than 1 mm, tilt, or subsidence of the component), showed a cumulative success rate of 96.2% at 13 years
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0 |
Effect of acute reamed versus unreamed intramedullary nailing on compartment pressure when treating closed tibial shaft fractures: a randomized prospective study
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DOD - Acute Comp Syndrome CPG
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OBJECTIVE: To compare anterior and deep posterior compartment pressures during reamed and unreamed intramedullary nailing of displaced, closed tibial shaft fractures.
DESIGN: Randomized prospective study.
SETTING: University Hospital/Level I trauma center.
PATIENTS: Forty-eight adults with forty-nine fractures treated with intramedullary nailing within three days of injury.
INTERVENTION: After intraoperative placement of compartment pressure monitors, the tibia fractures were treated by either unreamed intramedullary nailing or reamed intramedullary nailing. A fracture table and skeletal traction were not used in any of these procedures.
MAIN OUTCOME MEASUREMENTS: Compartment pressures and deltaP ([diastolic blood pressure] - [compartment pressure]) were measured immediately preoperatively, intraoperatively, and for twenty-four hours postoperatively.
RESULTS: Compartment syndrome did not occur in any patient. Peak average pressures were obtained during reaming in the reamed group (30.0 millimeters of mercury anterior compartment, 34.7 millimeters of mercury deep posterior compartment) and during nail insertion in the unreamed group (33.9 millimeters of mercury anterior compartment, 35.2 millimeters of mercury deep posterior compartment). The average pressures quickly returned to less than thirty millimeters of mercury and remained there for the duration of the study. The deep posterior compartment pressures were lower in the reamed group than in the unreamed group at ten, twelve, fourteen, sixteen, eighteen, twenty, twenty-two, and twenty-four hours postoperatively (p < 0.05 at each of these times. A statistically significant difference between anterior compartment pressures could not be shown with the numbers available. The deltaP values were greater than thirty millimeters of mercury at all times after nail insertion in both the reamed and unreamed groups.
CONCLUSION: These data support acute (within three days of injury) reamed intramedullary nailing of closed, displaced tibial shaft fractures without the use of a fracture table.
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0 |
A review of oscillating field stimulation to treat human spinal cord injury
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PJI DX Updated Search
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OBJECTIVE: To report the results of use of a human oscillating field stimulator (OFS) in a phase 1 trial of 14 human patients with complete motor and sensory spinal cord injury. METHODS: Entry criteria were complete spinal cord injury between C5 and T10 in patients 18-65 years old with no transection on magnetic resonance imaging. All patients received the National Acute Spinal Cord Injury Study III methylprednisolone protocol. Cord compression or instability was treated before entry. All patient injuries remained complete (based on American Spinal Cord Injury scoring) with no somatosensory evoked potentials (SSEPs) below the injury after surgery or for 48 hours. All patients were implanted with the OFS within 18 days. Patients were checked every 2 weeks after implantation. The OFS was explanted at 15 weeks. Independent neurologic examinations (American Spinal Cord Injury score, visual analog scale for pain, and SSEPs) were done at 6 weeks, 6 months, and 1 year. Statistical analyses were done by Wilcoxon rank sum test and analysis of variance (ANOVA). RESULTS: There were no complications at insertion, and one wound infection occurred after explant for a 3.5% infection rate. One patient was lost to follow-up after 6 months. All 14 patients had a mean visual analog scale score of 8 at implant and 2 at 6 months, and 13 remained a mean score of 2 at 1 year. Mean improvement in light touch score at 1 year was 25.9 points (ANOVA, P < 0.001; Wilcoxon, P = 0.02). Mean improvement in pinprick score at 1 year was 15.2 points (ANOVA, P < 0.001; Wilcoxon, P = 0.02). Mean improvement in motor score was 6.9 (ANOVA, P < 0.01; Wilcoxon, P = 0.02). Of eight patients with cervical cord injuries, six had improvement in arm SSEPs, and one recovered a tibial SSEP. Of six patients with thoracic injuries, one recovered an abnormal lower SSEP. CONCLUSIONS: Treatment of human spinal cord injury with an OFS is safe, reliable, and easy. Compared with National Acute Spinal Cord Injury Study III compliant paralyzed patients, our results suggest efficacy
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1 |
Glenohumeral osteoarthritis in active patients: diagnostic tips and complete management options
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Glenohumeral Joint OA
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In the normal glenohumeral joint, the humeral head and the glenoid articulate via smooth and congruent articular surfaces. In the osteoarthritic shoulder, however, both the articular surface anatomy and orientation may be severely distorted and the soft tissues grossly contracted, leading to pain and loss of function. While replacement arthroplasty is the treatment of choice in the elderly, therapeutic options for young active patients include conservative treatment, arthroplasty, and corrective osteotomy and are directed, whenever possible, toward joint preservation.
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0 |
Integrated algorithm for reconstruction of complex forms of Poland syndrome: 20-year outcomes
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Panniculectomy & Abdominoplasty CPG
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SummaryBackground The extent of breast and chest-wall deformity varies widely in Poland syndrome, and a variety of techniques are required to correct them. The aim of this study is to analyse our experience and long-term follow-up, and to propose an algorithmic approach to this complex deformity. Patients and methods Retrospective case-note review from a prospectively maintained database was carried out on 37 patients. All patients treated between 1993 and 2013 were reviewed, and long-term outcome was assessed by an objective photographic documentation. The patients were invited to a photographic documentation, and the correlation between the subjective judgement and objective results in the late course was analysed. Based on our experience, we propose an algorithmic approach to this complex skeletal and soft-tissue deformity. Results Medical photographs were obtained from 32 patients (22 females and 10 males). The age range was 11-44 years. Significant reduction in asymmetry was possible in all patients. The mean follow-up time was 8.5 years (range, 2.2-20). The complex developmental defect involved the skin, subcutaneous tissue, breast, muscle, ribs and other skeletal abnormalities. The following treatments were applied alone or in combination: lipomodelling, liposuction, tissue expansion and implants, custom-made prosthesis, islanded pedicled latissimus dorsi muscle flaps, pedicled and free muscle-sparing transverse rectus abdominis flaps, prosthetic chest-wall reconstruction and various combinations including multistage procedures. Surgery on the contralateral breast in female and male patients was necessary in 22 patients (20 female and two male). Assessment of the late result by four non-professionals (two females and two males) and one male plastic surgeon showed that the objective aesthetic results of the authors' reconstructions according to the proposed algorithm were sufficient. Conclusions Poland syndrome is a complex developmental deformity in which several tissues are involved. It is crucial to have an armamentarium of techniques to tackle a variety of defects to meet patients' expectations, and to improve their quality of life. The clinical outcome of the currently presented algorithm proved beneficial in the decision process for the treatment of these congenital deformities.
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0 |
Prevention of excessive postoperative sliding of the short femoral nail in femoral trochanteric fractures
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Hip Fx in the Elderly 2019
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INTRODUCTION: Lag screw cut-out is one of the major postoperative complications on femoral trochanteric fractures. However, precise analyses of excessive sliding and lag screw cut-out were limited. The purpose of this study was to investigate the factors that induce this unfavorable event.
METHODS: From April 2010 to April 2013, 226 patients were operated in our institute using a short femoral nail. Among them, 177 patients (29 males and 148 females) with a mean age of 84 years (60-97 years), who were followed up >3 months, were included in this study. The postoperative sliding distance, fracture type (AO/OTA classification), tip-apex distance (TAD), reduction pattern in the postoperative X-ray (antero-posterior and lateral views), bone quality (canal flare and cortical indices), walking ability at the time of pre-injury and final follow-up, and complications were investigated retrospectively.
RESULTS: The mean sliding distance was 3.7 mm, and one cut-out case (0.6 %) was observed. The sliding distance of the AO/OTA 31-A2 fractures was significantly longer than that of the A1 fractures (p < 0.0001). Regarding the reduction pattern, the sliding distance of the intramedullary type was longer than that of the extramedullary and anatomical types in the lateral view (p < 0.01, p < 0.001, respectively). Further, even in the medial and anatomical types, where the reduction patterns are recommended in the antero-posterior view, the sliding distance of the intramedullary type was significantly longer than that of the anatomical type in the lateral view. There was no correlation of bone quality with the sliding distance.
CONCLUSIONS: Because the sliding distance increased in the intramedullary type in the lateral view of unstable fractures, an accurate reduction in the lateral view at surgery is important, particularly in unstable fractures.
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