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The predictive value of five clinical signs in the evaluation of meniscal pathology
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AMP (Acute Meniscal Pathology)
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One hundred sixty-one consecutive patients with knee pain of at least 1 year's duration were studied on a prospective basis to determine the predictive value of five common clinical tests for the diagnosis of meniscal tears. Each patient had a preoperative examination that evaluated the presence or absence of joint line tenderness, pain on forced flexion, the presence of a positive McMurray test, positive Apley grind and distraction tests, and the presence of a block to extension. The results of these tests were then compared to arthroscopic findings. This study indicates that no one test is predictive for the diagnosis of a meniscal tear; a combination of tests should be used. The presence of anterior cruciate ligament pathology will render these tests less effective for diagnosis of meniscal pathology. Chondromalacia patella is negatively correlated with the presence of joint line tenderness and pain on forced flexion.
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Toxic oil syndrome: a syndrome with features overlapping those of various forms of scleroderma
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Thirty-two toxic oil syndrome (TOS) patients were selected because they presented with scleroderma-like changes and were observed during the first 36 months of evolution of the disease. Initially, these patients presented with a noncardiogenic pulmonary edema, eosinophilia, arthralgia/arthritis, peripheral edema, and myositis. Histologic investigations showed a widespread chronic interstitial infiltrate with lymphocytic vasculitis. They subsequently developed peripheral neuropathy, joint contractures, scleroderma-like changes, Raynaud phenomenon, pulmonary hypertension, sicca syndrome, and liver disease. Biopsy studies during this stage showed fibrosis and obliterating arteriopathy. Late features of TOS are musculoskeletal pain, cramps, livedo reticularis, carpal tunnel syndrome, and digital tuft changes. TOS is a new chemically induced scleroderma-like syndrome with features overlapping those of eosinophilic fasciitis, systemic sclerosis, and forms of localized scleroderma
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Dual Diagnosis and Total Hip Arthroplasty
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Hip Fx in the Elderly 2019
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The co-occurrence of a mental illness and a substance abuse disorder (SUD) is common and has been referred to as a "dual diagnosis" (DD). Although studies have independently investigated mental illness alone and SUD alone, few have examined the effects of these entities combined on complications. A search of the Medicare database from 2005 to 2012 identified 2000 DD patients who underwent total hip arthroplasty (THA). They were compared with 86,976 patients with mental illness only and 590,689 controls (no mental illness or SUD). Medical comorbidities and postoperative complications at 30-day, 90-day, and minimum 2-year time points were analyzed. There was a significant increase (P<.001) in 7 (53.8%) of 13 recorded postoperative medical complications, including acute renal failure (odds ratio [OR], 1.78), postoperative anemia (OR, 1.31), and blood transfusion (OR, 1.24), at the 90-day time point. In addition, there was a statistically significant increase overall in periprosthetic infection (periprosthetic joint infection OR, 4.30; P<.001), periprosthetic fracture (OR, 2.80; P<.001), dislocation (OR, 6.38; P<.001), and the need for THA revision (OR, 3.58; P<.001). When compared with patients with mental illness only, DD patients remained at significantly (P<.001) increased risk for 90-day and overall postoperative surgical complications, including dislocation, periprosthetic joint infection, and THA revision. Patients with a DD were at significant risk for perioperative complications compared with both control patients and patients with mental illness only. Studies investigating only psychiatric disease or only SUD may miss a vulnerable cohort. Further investigation is needed to exactly define to what extent DD amplifies complication rates. [Orthopedics. 2018; 41(3):e321-e327.].
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Revision anterior cruciate ligament reconstruction: timing of surgery and the incidence of meniscal tears and degenerative change
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AMP (Acute Meniscal Pathology)
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We reviewed 87 patients who underwent revision reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the interval between failure of the primary graft and revision reconstruction. Patients were divided into two groups: early revision surgery within six months of graft failure, and delayed revision. Degenerative change was scored using the French Society of Arthroscopy system. There was a significantly higher incidence of articular cartilage degeneration in the delayed group (Mann-Whitney U-test, 53.2% vs 24%, p < 0.01). No patient in the early group had advanced degenerative change, compared to 9.2% of patients in the delayed group. There was no significant difference (Mann-Whitney U-test, p = 0.3) in the incidence of meniscal tears between the two groups. We conclude that revision reconstruction should be carried out within six months of primary graft failure, in order to minimise the risk of degenerative change.
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Bones and salt: The renin-angiotensinaldosterone axis in bone
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Management of Hip Fractures in the Elderly
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Osteoporosis and hypertension are characterised by abnormalities in calcium metabolism, with emerging evidence of cellular and molecular mechanisms that underlie the comorbidity of both conditions. Increased urinary calcium has been associated with hypertension, which in some studies has also been associated with increases in PTH. Additionally high salt intake is associated with increased urinary calcium losses and reducing salt intake can reduce urinary calcium. Evidence from epidemiological studies suggest a link between hypertension and osteoporosis, e.g., higher blood pressure in elderly women was associated with increased bone loss at the femoral neck. Clinical studies indicate a benefit of angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARBs) in reducing fracture risk and improving bone metabolism. It appears that the renin angiotensin system (RAS) may be one of the several factors involved in bone metabolism. RAS plays an important role in regulating blood volume, total body sodium and systemic vascular resistance. As vasculature has an important role in bone remodelling, and alterations in RAS could alter the regulation of blood flow to bone, impacting on bone turnover. Additionally, angiotensin I and II (AI, AII) have been found to be potent stimulators of osteoclastic bone resorption. Experiments using transgenic hypertensive mice expressing both the human renin and human angiotensinogen genes indicate that activation of RAS induces high turnover osteoporosis with accelerated bone resorption. Furthermore their results suggest that A II indirectly promotes the differentiation and activation of osteoclasts responsible for bone resorption through the upregulation of the activator of receptor activator of nuclear factor kappa-B ligand (RANKL). Therefore, strategies such as reducing dietary salt intake and the use of specific antihypertensive agents, in addition to thiazide diuretics, such as ACE inhibitors and ARBs which reduce blood pressure and cardiovascular risk may provide additional benefits in reducing osteoporosis and fracture
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Effect of custom-made and prefabricated orthoses on grip strength in persons with carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background:Based on the literature, patients with carpal tunnel syndrome are suggested to wear a custom-made wrist orthosis immobilizing the wrist in a neutral position. Many prefabricated orthoses are available on the market, but the majority of those do not assure neutral wrist position.Objectives:We hypothesized that the use of orthosis affects grip strength in persons with carpal tunnel syndrome in a way that supports preference for custom-made orthoses with neutral wrist position over prefabricated orthoses.Study design:Experimental.Methods:Comparisons of grip strength for three types of grips (cylindrical, lateral, and pinch) were made across orthosis types (custom-made, prefabricated with wrist in 20 degrees of flexion, and none) on the affected side immediately after fitting, as well as between affected side without orthosis and nonaffected side.Results:Orthosis type did not significantly affect grip strength (p = 0.661). Cylindrical grip was by far the strongest, followed by lateral and pinch grips (p < 0.050). The grips of the affected side were weaker than those of the nonaffected side (p = 0.002).Conclusions:In persons with carpal tunnel syndrome, neither prefabricated orthoses with 20 degrees wrist extension nor custom-made wrist orthoses with neutral wrist position influenced grip strength of the affected hand. Compared to the nonaffected side, the grips of the affected side were weaker.Clinical relevanceThe findings from this study can be used to guide application of orthoses to patients with carpal tunnel syndrome
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Is it safe to combine abdominoplasty with other dermolipectomy procedures to correct skin excess after weight loss?
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Panniculectomy & Abdominoplasty CPG
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The development of sophisticated bariatric surgery techniques has led to an increasing number of patients demanding a complexity of body contouring procedures that can be achieved either with a step-by-step approach or by combining dermolipectomy in various regions. The aim of this study was to test the hypothesis that abdominoplasty-related morbidity and outcome may be worsened by combining abdominoplasty with other dermolipectomies and to determine whether any predictive risk factor could be identified. Seventy-three consecutive patients undergoing abdominoplasty with (n = 26) and without (n = 47) additional dermolipectomy on the upper arms, inner thighs, breasts, and buttocks were included in this study. Additional dermolipectomies did not increase abdominoplasty-related morbidity but revealed better long-term results (p = 0.10). Statistically significant risk factors were male sex, age (>41 years), overweight (BMI >30), prolonged operations (>3 hours), and extensive blood loss (1,000 mL). Most importantly, better outcome was obtained in patients whose weight reduction was greater (p = 0.04). The authors' results suggest that combined dermolipectomy procedures can be advocated in patients who have reached their intended level of weight reduction and if prolonged operative time and excessive blood loss are avoided.
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The societal burden of osteoporosis in Sweden
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HipFx Supplemental Cost Analysis
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In osteoporosis, the bone mass is decreased, thereby increasing the risk of fractures. Common osteoporotic fractures include those at the hip, the spine and the forearm. Fractures are a burden to society; in terms of costs, morbidity and mortality. The main objective of this study was to estimate the burden of osteoporosis in Sweden. The study used a prevalence-based bottom-up approach to estimate the total annual burden of osteoporosis in Sweden. The burden was assessed from a societal perspective including medical care costs, non-medical care costs, informal care and indirect costs. Moreover, the value of quality-adjusted life-years (QALYs) lost because of fractures was included in the total burden estimations. The total annual fracture cost was estimated at MSEK 5639, which is about 3.2% of the total health care costs in Sweden. Community care was the most important cost category accounting for 66% of the total annual cost followed by medical care costs (31%), informal care (2%) and indirect costs (1%). By combining the annual value of QALYs lost (MSEK 10354) and the annual fracture costs, the total annual societal burden of osteoporosis in Sweden was estimated at MSEK 15183. Assuming no changes in the age-differentiated fracture risk, the annual burden of osteoporosis was projected to increase to MSEK 26301 in the year 2050. The present study shows the societal burden of osteoporosis in Sweden to be higher than previously perceived. This burden is substantial and must be acknowledged as an important health problem. Osteoporosis-related fractures do not only lead to high medical care costs but also to high community care costs
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A genitourinary cancer-specific scoring system for the prediction of survival in patients with bone metastasis: A retrospective analysis of prostate cancer, renal cell carcinoma, and urothelial carcinoma
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MSTS 2022 - Metastatic Disease of the Humerus
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Aim: The aim of this study was to develop a risk scoring system specific to patients with bone metastasis of genitourinary cancer. Materials and Methods: This study included 180 patients with bone metastasis of three major types of genitourinary cancer: prostate cancer (n=111), renal cell carcinoma (n=43,), and urothelial carcinoma (n=26). Clinical factors at diagnosis of bone metastasis were evaluated to identify independent prognostic factors. Results: Multivariate analysis showed that type of primary cancer, poor performance status, the presence of visceral metastases, high Glasgow prognostic score and elevated neutrophil-to-lymphocyte ratio were independently predictive of poor prognosis. Patients were able to be classified by the prognostic risk score into four prognostic groups with low, intermediate, high, and very high risk. Conclusion: This risk scoring system could be useful for predicting survival of patients with bone metastasis of genitourinary cancer and in making decisions on appropriate treatments for them.
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Derotational osteotomy at the distal femur is effective to treat patients with patellar instability
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: Increased femoral antetorsion influences patellofemoral joint kinematics. The aim of this study was to retrospectively evaluate the clinical outcome after derotational osteotomies and combined procedures in patients with patellofemoral instability.
METHODS: All patients with derotational osteotomies and combined procedures in patients with patellofemoral instability and increased femoral antetorsion performed between 2007 and 2016 were retrospectively analyzed. Exclusion criteria were open growth plates, posttraumatic deformities, and a follow-up period less than 12 months. Simple radiography and magnetic resonance imaging to evaluate cartilage lesions, trochlear dysplasia, tubercle distance, and osseous malalignment as frontal axis and torsion were performed on every patient. Patients were evaluated pre- and postoperatively using the visual analog scale (VAS) for pain, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, the subjective IKDC evaluation form, the Lysholm score, and the Tegner activity score.
RESULTS: Out of 222 femoral osteotomies, a total of 42 patients (44 knees) met the inclusion criteria. Mean preoperative femoral antetorsion of 31degree (SD +/- 9degree) and mean valgus malalignment of 1degree (SD +/- 3degree) were observed. An intended derotation of 12degree (SD +/- 5degree) was set overall. The additional procedures included correction of valgus in 50% (n = 22), MPFL reconstruction in 64% (n = 28), patellofemoral arthroplasty in 18% (n = 8), trochleoplasty in 14% (n = 6), tibial tubercle transfer in 14% (n = 6). During the mean follow-up period of 44 months (SD +/- 27, range 12-88), a total of five patients were lost to follow-up, resulting in a follow-up rate of 89% (n = 39). A significant pain relief from VAS 4 (SD +/- 3) to VAS 2 (SD +/- 2) (p = 0.006) as well as improved scores, WOMAC: from 80 (SD +/- 14) to 88 (SD +/- 16) (p = 0.007), Lysholm: from 46 (SD +/- 21) to 71 (SD +/- 24) (p < 0.001), IKDC: from 54 (SD +/- 13) to 65 (SD +/- 17) (p < 0.001), were observed postoperatively. During the follow-up period, no patellar re-dislocation was observed.
CONCLUSION: Combined derotational osteotomy is a suitable treatment for patellar instability due to torsional malformity, as it leads to a significant reduction of pain, and a significant increase of knee function with good-to- excellent results in the short-term follow-up.
Level of evidence: Iv.
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Pain drawings predict outcome of surgical treatment for degenerative disc disease in the cervical spine
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Glenohumeral Joint OA
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INTRODUCTION: Pain drawings have been frequently used in the preoperative evaluation of spine patients. For lumbar conditions comprehensive research has established both the reliability and predictive value, but for the cervical spine most of this knowledge is lacking. The aims of this study were to validate pain drawings for the cervical spine, and to investigate the predictive value for treatment outcome of four different evaluation methods.
METHODS: We carried out a post hoc analysis of a randomized controlled trial, comparing cervical disc replacement to fusion for radiculopathy related to degenerative disc disease. A pain drawing together with Neck Disability Index (NDI) was completed preoperatively, after 2 and 5 years. The inter- and intraobserver reliability of four evaluation methods was tested using kappa statistics, and its predictive value investigated by correlation to change in NDI.
RESULTS: Included were 151 patients, mean age of 47 years, female/male: 78/73. The interobserver reliability was fair for the modified Ransford and Uden methods, good for the Gatchel method, and very good for the modified Ohnmeiss method. Markings in the shoulder and upper arm region on the pain drawing were positive predictors of outcome after 2 years of follow-up, and markings in the upper arm region remained a positive predictor of outcome even after 5 years of follow-up.
CONCLUSIONS: Pain drawings were a reliable tool to interpret patients' pain prior to cervical spine surgery and were also to some extent predictive for treatment outcome.
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Comparison of six calcaneal quantitative ultrasound devices: precision and hip fracture discrimination
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Management of Hip Fractures in the Elderly
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Quantitative ultrasound (QUS) is now accepted as a useful tool in the management of osteoporosis. There are a variety of QUS devices clinically available with a number of differences among them, including their coupling methods, parameter calculation algorithms and sites of measurement. This study evaluated the abilities of six calcaneal QUS devices to discriminate between normal and hip-fractured subjects compared with the established method of dual-energy X-ray absorptiometry (DXA). The short-term and mid-term precisions of these devices were also determined. Thirty-five women (mean age 74.5+/-7.9 years) who had sustained a hip fracture within the past 3 years, and 35 age-matched controls (75.8+/-5.6 years) were recruited. Ultrasound measurements were acquired using six ultrasound devices: three gel-coupled and three water-coupled devices. Bone mineral density was measured at the hip using DXA. Discrimination of fracture patients versus controls was assessed using logistic regression analysis (expressed as age- and BMI-adjusted odds ratios per standard deviation decrease with 95% confidence interval) and receiver operating characteristics (ROC) curve analysis. Measurement precision was standardized to the biological range (sCV). The sCV ranged from 3.14% to 5.5% for speed of sound (SOS) and from 2.45% to 6.01% for broadband ultrasound attenuation (BUA). The standardized medium-term precision ranged from 4.33% to 8.43% for SOS and from 2.77% to 6.91% for BUA. The pairwise Pearson correlation coefficients between different devices was highly significant (SOS, r = 0.79-0.93; BUA, r = 0.71-0.92). QUS variables correlated weakly, though significantly, with femoral BMD (SOS, r = 0.30-0.55; BUA, r = 0.35-0.61). The absolute BUA and SOS values varied among devices. The gel-coupled devices generally had a higher SOS than water-coupled devices. Bone mineral density (BMD) and BUA were weakly correlated with weight (r = 0.48-0.57 for BMD and r = 0.18-0.54 for BUA), whereas SOS was independent of weight. All the QUS devices gave similar, statistically significant hip fracture discrimination for both SOS and BUA measures. The odds ratios for SOS (2.1-2.8) and BUA (2.4-3.4) were comparable to those for femoral BMD (2.6-3.5), as were the area under the curve (SOS, 0.65-0.71; BUA, 0.62-0.71; BMD, 0.65-0.74) from ROC analysis. Within the limitation of the sample size all devices show similar diagnostic sensitivity
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Fatal pulmonary tumor embolism in a child with chondroblastic osteosarcoma
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MSTS 2018 - Femur Mets and MM
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Fatal embolic chondroblastic osteosarcoma to the lung is an extremely rare phenomenon. We report a case of a 15-year-old boy who developed bilateral pulmonary embolism shortly after resection of the right distal femur for chondroblastic osteosarcoma. The patient succumbed to right-sided heart failure 8 weeks later. An autopsy revealed extensive intravascular tumor emboli in the bilateral pulmonary arteries and their branches. No metastatic lesions were identified in the lungs. We review the clinical, radiologic, and pathologic findings of this patient and the literature. © 2008 Society for Pediatric Pathology.
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Moving towards a more inclusive patient and public involvement in health research paradigm: the incorporation of a trauma-informed intersectional analysis
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DoD PRF (Psychosocial RF)
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BACKGROUND: The concept of patient engagement in health research has received growing international recognition over recent years. Yet despite some critical advancements, we argue that the concept remains problematic as it negates the very real complexities and context of people's lives. Though patient engagement conceptually begins to disrupt the identity of "researcher," and complicate our assumptions and understandings around expertise and knowledge, it continues to essentialize the identity of "patient" as a homogenous group, denying the reality that individuals' economic, political, cultural, subjective and experiential lives intersect in intricate and multifarious ways.
DISCUSSION: Patient engagement approaches that do not consider the simultaneous interactions between different social categories (e.g. race, ethnicity, Indigeneity, gender, class, sexuality, geography, age, ability, immigration status, religion) that make up social identity, as well as the impact of systems and processes of oppression and domination (e.g. racism, colonialism, classism, sexism, ableism, homophobia) exclude the involvement of individuals who often carry the greatest burden of illness - the very voices traditionally less heard in health research. We contend that in order to be a more inclusive and meaningful approach that does not simply reiterate existing health inequities, it is important to reconceptualize patient engagement through a health equity and social justice lens by incorporating a trauma-informed intersectional analysis. This article provides key concepts to the incorporation of a trauma-informed intersectional analysis and important questions to consider when developing a patient engagement strategy in health research training, practice and evaluation. In redefining the identity of both "patient" and "researcher," spaces and opportunities to resist and renegotiate power within the intersubjective relations can be recognized and addressed, in turn helping to build trust, transparency and resiliency - integral to the advancement of the science of patient engagement in health research.
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Mandibular Condyle Reconstruction With Fibula Free-Tissue Transfer: The Role of the Masseter Muscle
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: Free fibula flap is an option for primary restoration after disarticulation mandibular resection, though literature on technique refinements is scarce. The authors hypothesized that inset of the masseter, the key mandibular elevator muscle, at the reconstructed mandible may optimize functional recovery. METHODS: All patients undergoing reconstruction of mandibulectomy-condylectomy defect (January 2009 to January 2014) by means of a fibular flap were prospectively studied. The neocondyle was formed by the distal portion of the fibula and placed directly into the glenoid fossa with preservation of the temporomandibular disc. The deep portion of the masseter was inset at the angle of the reconstructed mandible.Condylar position was postoperatively evaluated by panoramic radiographs. Patients self-evaluated speech, chewing, swallowing, and facial appearance. RESULTS: Two patients had immediate and 3 delayed reconstruction involving condyle ramus body, in the study period. During a mean follow-up of 32 months, 4 patients had satisfactory occlusion, 1 patient had an open-bite deformity, but was able to masticate solid food and maintain an oral diet. Although no significant condyle dislocation was recorded, 2 patients had slight ipsilateral deviation on mouth opening. Nevertheless, cosmesis was satisfactory and all patients maintained intelligible speech. Functional score was 13.6 +/- 1.14 and facial appearance score was 4 +/- 0.7. CONCLUSION: The free fibula transfers with direct seating of the fibula into the condylar fossa followed by masseter muscle reinsertion provides acceptable functional reconstruction of the mandibulectomy-condylectomy defect.
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The Ideal Implant for Mayo 2A Olecranon Fractures? An Economic Evaluation Ideal Implant Mayo 2A Olecranon Fracture (short form running title)
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DoD SSI (Surgical Site Infections)
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BACKGROUND AND OBJECTIVES: The ideal implant for stable, non-comminuted olecranon fractures is controversial. Tension Band Wiring (TBW) is associated with lower cost but higher implant removal rates. Plate fixation (PF) is purported to be biomechanically superior with lower failure and implant removal rates however associated with higher cost. The primary aim of this study is to look at the clinical outcomes for all Mayo 2A olecranon between PF and TBW. The secondary aim is to perform an economic evaluation between PF and TBW. METHODOLOGY: This is a retrospective study of all surgically treated Mayo 2A olecranon fractures in a tertiary hospital from 2005 to 2016. Demographic data, medical history, range of motion and complications were collected. All inpatient and outpatient costs in a 1-year period post-surgery including the index surgical procedure were collected via hospital administrative cost database (normalized to 2014). RESULTS: A total of 147 cases were identified (94 TBW, 53 PF). PF was associated with higher mean age (p-value <0.01), higher American Society of Anesthesiologists score (p-value <0.01), higher proportion of hypertensives (p-value 0.04). There was no difference in range of motion achieved at 1 year for both groups. In terms of complications, TBW was associated with more symptomatic hardware (21.6% compared to 13.7%, p-value 0.24) and implant failures (16.5% compared to none, p-value < 0.01) while the plate group had a higher wound complication (5.9% compared to none, p-value 0.02) and infection rate (9.8% compared to 3.1%, p-value 0.09). TBW had a higher removal of implant rate of 30.9% compared to 22.7% in PF (p-value 0.36). PF had a higher cost at all time points from the index surgery ($10,313.64 compared to $5,896.36, p-value <0.01), 1-year cost excluding index surgery ($5,069.61 compared to $3,850.46, p-value 0.46) and outpatient cost ($1,667.80 compared to $1,613.49, p-value 0.27). DISCUSSION AND CONCLUSION: Based on our study results, we have demonstrated that TBW is the ideal implant for Mayo 2A olecranon fractures from both a clinical and economic standpoint boasting equal clinical results, potentially similar implant removal rates to PF and a lower cost over a 1-year period. In choosing the ideal implant, the surgeon must take into account firstly, the local TBW and PF removal rate which can vary significantly due to the patient's profile and beliefs and secondly, the PF implant cost.
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Can injection CT scan assess the residual femoral head vascularity after acute neck fracture?
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Management of Hip Fractures in the Elderly
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INTRODUCTION: Femoral neck fracture jeopardizes the vital prognosis of the elderly subject and the functional prognosis of the young subject. The vascular consequence is important, with the risk of osteonecrosis of the femoral head. In young patients, predicting the risk of necrosis at the acute stage seems warranted so as to optimize the choice of therapy. CT with injection could be useful to study the residual bone vascularity after an acute fracture of the femoral neck. HYPOTHESIS: The CT scan with injection can diagnose ischemia of the femoral head after neck fracture by demonstrating hypoperfusion and thus estimating the risk for osteonecrosis. PATIENTS AND METHOD: A CT scan with injection was performed prospectively in 20 adult patients who had given informed consent after verification of the inclusion and exclusion criteria. Ten presented femoral neck fracture and 10 a pertrochanteric fracture, the latter making up the control group. The second control group was the healthy side of patients presenting a femoral neck fracture. The images were analyzed after delineating a region of interest as a volume at the center of the femoral head. The results were analyzed after modeling based on the physical principle of diffusion. RESULTS: No differences were found between the "healthy hip," "fractured hip," "femoral neck fracture," and "trochanteric region fracture" groups. The only statistically significant correlation was found between the "fractured hip" and "healthy hip" of the same patient independently of the type of fracture. DISCUSSION: The results do not confirm the working hypothesis. This study was mainly limited by the small number of patients included, but this did not substantially effect the study's conclusions. According to the results, it seems that this study provided a CT evaluation of bone mineral density. At the end of the study, it seems that CT with injection is not well adapted in assessing residual femoral head vascularity or estimating the risk of progression towards avascular necrosis. According to the literature, only dynamic MRI with injection seems to be effective in this assessment and estimation. LEVEL OF EVIDENCE: Level III prospective comparative diagnostic
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Treatment of distal humerus fractures
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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The elbow is a complex joint and is vital in positioning the hand in space. We believe that open reduction internal fixation offers the best chance for return to function following intra-articular fractures of the distal humerus. We advocate the following principles for the effective treatment of these injuries: identification and protection of the ulnar nerve followed by transposition, broad exposure of the fracture utilizing an olecranon osteotomy, anatomic restoration of the articular surface with preservation of all osteochondral fragments, rigid fixation of both columns using pre-contoured plates and screws, and the institution of early range of motion post-operatively
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Elmslie-Trillat procedure
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Surgical Management of Osteoarthritis of the Knee CPG
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Patella instability is a complex and frequently observed condition. Although most initial dislocations are successfully treated nonoperatively, some patients with recurrent instability require surgical intervention. Recurrent instability can be associated with structural abnormalities including a tibial tubercle trochlear groove distance greater than 20 mm, trochlear dysplasia, or patella alta. For patients with closed growth plates who have recurrent instability episodes and have failed a nonoperative course of therapy, patellar taping, and bracing, a distal realignment procedure should be considered. The Elmslie-Trillat procedure is a distal bony realignment with medial soft tissue tightening that offers a more rapid recovery than more extensive distal realignments with established excellent long-term results in nonarthritic patients. (copyright) 2009 by Lippincott Williams & Wilkins
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Hip arthroplasty for failed treatment of proximal femoral fractures
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PJI DX Updated Search
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Failed treatment of an intertrochanteric fracture typically leads to profound functional disability and pain. Salvage treatment with hip arthroplasty may be considered. The aim of this study was to evaluate the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture. Twenty-one patients were treated in our hospital with hip arthroplasty for failed treatment of intertrochanteric hip fracture. There were sixteen women and five men with a mean age of 75.8 years (range 61-85 years). Fourteen patients had failure of a previous nail fixation procedure, five had failure of a plate fixation, one of hip screws fixation and one of Ender nail fixation. In 19 out of 21 patients we performed a total hip arthroplasty-14 cases used modular implants with long-stems and five cases used a standard straight stem. In 2 of 21 cases we used a bipolar hemiarthroplasty. A statistically significant improvement was found comparing pre and postoperative conditions (p < 0.05). Our experience confirms that total hip arthroplasty is a satisfactory salvage procedure after failed treatment of an intertrochanteric fracture in elderly patients with few serious orthopaedic complications and acceptable clinical outcomes. é 2009 Springer-Verlag
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Controlling pain after total knee arthroplasty using a multimodal protocol with local periarticular injections
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: Measures for pain management after total knee arthroplasty (TKA) are important for early improvement in the quality of life after operation and early postoperative rehabilitation. We investigated the benefits and safety analgesic effect of locally injected drugs around the total knee prosthesis. METHODS: 60 patients undergoing TKA for osteoarthritis were divided randomly into three groups.Group A (20 knees; control group), this group did not receive multimodal drug cocktailtherapy; group B (21 knees), received intra-articular injection of a multimodal drug cocktail; and group C (19 knees), received localperiarticular injection of a multimodal drug cocktail. All analgesics administered in the first 24 h after surgery were recorded. The evaluation items included assessment of pain using a 100-point visual analogue scale (VAS) after the patients awoke on the day of the operation and on postoperative day 1, the dose of diclofenac sodium suppository, the number of days for acquiring assisted ambulation with a walking cane, and side effects. Assessment of flexion angles was conducted at postoperativeweek 1 and at theconclusion of the study. RESULTS: The VAS scores on the day of surgery and the amounts of diclofenac sodium used indicated good pain relief in groups B and C; the level of pain control was higher in group C than in group B. No cardiac or central nervous system toxicity was observed. CONCLUSIONS: Periarticular injection with multimodal drugs can significantly reduce the requirements for analgesia, with no apparent risks, following TKA
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Pediatric monteggia fractures: A multicenter examination of treatment strategy and early clinical and radiographic results
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DOD - Acute Comp Syndrome CPG
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BACKGROUND:: Monteggia fractures remain challenging pediatric injuries because of difficulties in diagnosis, propensity for instability, and complexity of late reconstruction. The objective of this investigation was to assess the efficacy of the following treatment strategy based upon ulnar fracture pattern: closed reduction (CR) for plastic/greenstick fractures, intramedullary (IM) pin fixation for transverse/short oblique fractures, and open reduction and internal fixation for long oblique/comminuted fractures. METHODS:: A total of 112 acute Monteggia fracture patients were retrospectively analyzed at two level 1 pediatric trauma centers from 2000 to 2011. Mean age was 6.9±2.9 years (range, 0.6 to 16.7 y); 54% were male. Mean clinical follow-up was 19.8 weeks. Fracture patterns were classified and patients were separated into 3 groups: treatment according to the strategy versus more rigorous versus less rigorous intervention. The Fisher exact test was used to compare the rates of failure between the groups. "Failure" was defined as failure to obtain and maintain an anatomic reduction of the radial head and/or loss of ulnar reduction during follow-up. RESULTS:: None of the 57 patients treated according to the strategy experienced failure, nor did any of the 23 patients treated more rigorously. In contrast, 6 of 32 patients (19%) who were treated less rigorously compared with the recommended strategy demonstrated recurrent radiocapitellar instability (n=3), loss of ulnar fracture reduction requiring revision surgery (n=2), or both events together (n=1) (P<0.001). Specifically, all treatment failures occurred in complete fractures treated nonoperatively - there were 6/18 failures (33% failure rate) of complete fractures treated nonoperatively compared with 0/52 failures of complete fractures treated operatively (P<0.001). Other complications were similarly distributed between the treatment groups and consisted of 1 ulnar nonunion, 2 compartment syndromes, and 3 transient nerve palsies/neuropraxias. Comminuted fractures required open reduction of the radiocapitellar joint more than other fracture types (P<0.001). CONCLUSIONS:: In this pediatric Monteggia series, recurrent instability only occurred in patients who were not treated according to the ulnar-based strategy. Complete ulnar fracture patterns are at risk of failure without initial operative treatment. LEVEL OF EVIDENCE:: Level III, therapeutic.
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Can the early reduction of tumour markers predict outcome in surgically treated sporadic medullary thyroid carcinoma?
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MSTS 2018 - Femur Mets and MM
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BACKGROUND AND AIMS: Patients with sporadic medullary thyroid carcinoma (MTC) have a variable clinical course. Our aim was to analyse the reduction of tumour markers after thyroidectomy with meticulous dissection and relate it to clinical outcome.
MATERIALS AND METHODS: Twenty consecutive patients with palpable sporadic MTC underwent thyroidectomy with central and uni- or bilateral modified radical neck dissection; three were subjected to mediastinal dissection. Basal (b-) and stimulated (s-) calcitonin (CT) and carcinoembryonic antigen (CEA)-levels were measured before and 6-8 weeks after primary surgery, and the reduction of these tumour markers was determined.
RESULTS: Median CT (b- and s-) were markedly reduced after surgery (98.5% and 99.1%, respectively), and CEA decreased 11 times. CT (b-) fell >99% in seven patients after surgery; in these and four additional patients, CT (s-) showed a similar reduction. During follow-up (median 52.5 months), two patients (stages IV B and C) died of MTC; they had <95% reduction of CT. Four patients (stage IV A) are alive with verified metastases. Eight patients (one stage III, seven stage IV A) are alive with hypercalcitoninemia. Five stages I-III patients and one stage IV A patient are disease-free.
CONCLUSIONS: Thyroidectomy and meticulous dissection caused a pronounced reduction of tumour markers. A postoperative reduction of CT (s-) >or=97% seems to be associated with less aggressive clinical course, while CEA had lower predictive value.
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Abdominal compliance: A bench-to-bedside review
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DOD - Acute Comp Syndrome CPG
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Abdominal compliance (AC) is an important determinant and predictor of available workspace during laparoscopic surgery. Furthermore, critically ill patients with a reduced AC are at an increased risk of developing intra-abdominal hypertension and abdominal compartment syndrome, both of which are associated with high morbidity and mortality. Despite this, AC is a concept that has been neglected in the past.AC is defined as a measure of the ease of abdominal expansion, expressed as a change in intra-abdominal volume (IAV) per change in intra-abdominal pressure (IAP):AC = DELTAIAV / DELTAIAPAC is a dynamic variable dependent on baseline IAV and IAP as well as abdominal reshaping and stretching capacity. Whereas AC itself can only rarely be measured, it always needs to be considered an important component of IAP. Patients with decreased AC are prone to fulminant development of abdominal compartment syndrome when concomitant risk factors for intra-abdominal hypertension are present.This review aims to clarify the pressure-volume relationship within the abdominal cavity. It highlights how different conditions and pathologies can affect AC and which management strategies could be applied to avoid serious consequences of decreased AC.We have pooled all available human data to calculate AC values in patients acutely and chronically exposed to intra-abdominal hypertension and demonstrated an exponential abdominal pressure-volume relationship. Most importantly, patients with high level of IAP have a reduced AC. In these patients, only small reduction in IAV can significantly increase AC and reduce IAPs.A greater knowledge on AC may help in selecting a better surgical approach and in reducing complications related to intra-abdominal hypertension.
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Current clinical and pathogenetic understanding of beta2-m amyloidosis in long-term haemodialysis patients
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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As the number of patients undergoing long-term haemodialysis continues to grow, beta2-microglubulin (beta2-m) amyloidosis is emerging as an increasingly common complication. The frequency of beta2-m amyloid-related osteoarthropathy in haemodialysis patients rises steadily with length of survival. We confirmed that the prevalence of carpal tunnel syndrome increases with years of dialysis. Up to 50% of patients had developed this complication after 20 years were affected and the percentage was even higher after 25 years. Although retention of beta2-m is a necessary requirement for onset of amyloidosis, it is probably not sufficient. Using an in vitro model of beta2-m-related amyloid fibril (fAbeta2-m) extension, we demonstrated that various amyloid-associated molecules, such as apolipoprotein (apo) E and proteoglycans, accelerate beta2-m amyloid fibril formation. General categories of therapeutic approaches for amyloidosis include prevention of onset or progression, symptomatic therapy (conservative treatment, orthopedic procedures, and physiotherapy), and renal transplantation. In association of haemodialysis, beta2-m has been removed by high-flux membranes or a beta2-m adsorption column. However, proof is lacking that amyloid deposits are decreased by long-term use of dialysis techniques to eliminate beta2-m. More effective treatment procedures are needed
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1 |
Safety and Utility of the Drainless Abdominoplasty in the Post-Bariatric Surgery Patient
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Panniculectomy & Abdominoplasty CPG
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INTRODUCTION: Surgical drains are used in abdominoplasty patients to combat wound closure disruption by hematoma or seroma formation. Several recent publications have described techniques that allow abdominoplasty to be performed safely without the need for surgical drains. This has not, however, been described in the case of the bariatric patient, who is often considered to be of higher postoperative complication risk. Here, we describe our experience of the drainless abdominoplasty in patients who have undergone massive weight loss (MWL) after a bariatric procedure. METHODS: A retrospective review was conducted of 172 patients who had undergone drainless abdominoplasty using the progressive tension suture technique from 2011 to 2014. Thirty-five patients who had undergone MWL after bariatric surgery were assigned to group A. One hundred thirty-seven patients who had not undergone MWL with no history of bariatric surgery were assigned to group B. Demographics, intraoperative outcomes, and postoperative outcomes were compared. RESULTS: Patients in group A were older (mean age, 48.7 vs 42.7 years; P = 0.003) and had a higher body mass index (26.6 vs 24.6 kg/m, P = 0.01), a significantly larger tissue resection (2379 vs 1228 g, P = 0.0001), and a higher estimated blood loss (100 vs 120 mL, P = 0.049). There was also a significant group-to-group difference in the American Society of Anesthesiologists Physical Status Classification distribution, with a higher percentage of MWL patients having higher scores. Despite these differences, group A did not have a statistically higher incidence of complications. There was no statistically significant difference in the rate of seroma formation (11% vs 2%, P = 0.055), wound infection (2.9% vs 4.4%, P = 0.68), wound dehiscence (8.6% vs 8.0%, P = 0.91), meralgia paresthetica (2.8% vs 1.5%, P = 0.51), or rate of reoperation (11.4% vs 13.9%, P = 0.7) between the 2 groups. CONCLUSION: Despite post-bariatric surgery patients being considered higher risk for postoperative complications, drainless abdominoplasty can be safely offered to this population by using a progressive tension suture technique.
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Dupuytren's disease in women: evaluation of long-term results after operation
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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A study of the long-term results after operation on 66 women (83 hands) with Dupuytren's disease showed that women are twice as likely as men to have a postoperative flare reaction. Why a flare reaction develops is uncertain. In this study, patients who had a carpal tunnel release at the time of operation for treatment of Dupuytren's disease or those who had an extensive fasciectomy, as opposed to removal of only the contracted tissue, were more apt to have a flare reaction. In addition, after operation, moderate or severe loss of finger flexion occurred in 35% of hands without a flare reaction and in 76% of those who had a flare reaction. This suggests that women having an operation for treatment of Dupuytren's disease are apt to have a worse result than men
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Immunosuppressive agents for treating IgA nephropathy
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Osteochondritis Dissecans 2020 Review
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- Background IgA nephropathy is the most common glomerulonephritis worldâ?wide. IgA nephropathy causes endâ?stage kidney disease (ESKD) in 15% to 20% of affected patients within 10 years and in 30% to 40% of patients within 20 years from the onset of disease. This is an update of a Cochrane review first published in 2003 and updated in 2015. Objectives To determine the benefits and harms of immunosuppression strategies for the treatment of IgA nephropathy. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 9 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria We included randomised controlled trials (RCTs) and quasiâ?RCTs of treatment for IgA nephropathy in adults and children and that compared immunosuppressive agents with placebo, no treatment, or other immunosuppressive or nonâ?immunosuppressive agents. Data collection and analysis Two authors independently assessed study risk of bias and extracted data. Estimates of treatment effect were summarised using random effects metaâ?analysis. Treatment effects were expressed as relative risk (RR) and 95% confidence intervals (95% CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Risks of bias were assessed using the Cochrane tool. Evidence certainty was evaluated using GRADE methodology. Main results Fiftyâ?eight studies involving 3933 randomised participants were included. Six studies involving children were eligible. Disease characteristics (kidney function and level of proteinuria) were heterogeneous across studies. Studies evaluating steroid therapy generally included patients with protein excretion of 1 g/day or more. Risk of bias within the included studies was generally high or unclear for many of the assessed methodological domains. In patients with IgA nephropathy and proteinuria > 1 g/day, steroid therapy given for generally two to four months with a tapering course probably prevents the progression to ESKD compared to placebo or standard care (8 studies; 741 participants: RR 0.39, 95% CI 0.23 to 0.65; moderate certainty evidence ). Steroid therapy may induce complete remission (4 studies, 305 participants: RR 1.76, 95% CI 1.03 to 3.01; low certainty evidence ), prevent doubling of serum creatinine (SCr) (7 studies, 404 participants: RR 0.43, 95% CI 0.29 to 0.65; low certainty evidence ), and may lower urinary protein excretion (10 studies, 705 participants: MD â?0.58 g/24 h, 95% CI â?0.84 to â?0.33; low certainty evidence ). Steroid therapy had uncertain effects on glomerular filtration rate (GFR), death, infection and malignancy. The risk of adverse events with steroid therapy was uncertain due to heterogeneity in the type of steroid treatment used and the rarity of events. Cytotoxic agents (azathioprine (AZA) or cyclophosphamide (CPA) alone or with concomitant steroid therapy had uncertain effects on ESKD (7 studies, 463 participants: RR 0.63, 95% CI 0.33 to 1.20; low certainty evidence ), complete remission (5 studies; 381 participants: RR 1.47, 95% CI 0.94 to 2.30; very low certainty evidence), GFR (any measure), and protein excretion. Doubling of serum creatinine was not reported. Mycophenolate mofetil (MMF) had uncertain effects on the progression to ESKD, complete remission, doubling of SCr, GFR, protein excretion, infection, and malignancy. Death was not reported. Calcineurin inhibitors compared with placebo or standard care had uncertain effects on complete remission, SCr, GFR, protein excretion, infection, and malignancy. ESKD and death were not reported. Mizoribine administered with reninâ?angiotensin system inhibitor treatment had uncertain effects on progression to ESKD, complete remission, GFR, protein excretion, infection, and malignancy. Death and SCr were not reported. Le lunomide followed by a tapering course with oral prednisone compared to prednisone had uncertain effects on the progression to ESKD, complete remission, doubling of SCr, GFR, protein excretion, and infection. Death and malignancy were not reported. Effects of other immunosuppressive regimens (including steroid plus nonâ?immunosuppressive agents or mTOR inhibitors) were inconclusive primarily due to insufficient data from the individual studies in low or very low certainty evidence. The effects of treatments on death, malignancy, reduction in GFR at least of 25% and adverse events were very uncertain. Subgroup analyses to determine the impact of specific patient characteristics such as ethnicity or disease severity on treatment effectiveness were not possible. Authors' conclusions In moderate certainty evidence, corticosteroid therapy probably prevents decline in GFR or doubling of SCr in adults and children with IgA nephropathy and proteinuria. Evidence for treatment effects of immunosuppressive agents on death, infection, and malignancy is generally sparse or lowâ?quality. Steroid therapy has uncertain adverse effects due to a paucity of studies. Available studies are few, small, have high risk of bias and generally do not systematically identify treatmentâ?related harms. Subgroup analyses to identify specific patient characteristics that might predict better response to therapy were not possible due to a lack of studies. There is no evidence that other immunosuppressive agents including CPA, AZA, or MMF improve clinical outcomes in IgA nephropathy. Plain language summary Immunosuppressive agents for treating IgA nephropathy What is the issue? â?¨ IgA nephropathy is a common kidney disease that often leads to decreased kidney function and may result ultimately in kidney failure for oneâ?third of affected people. The cause of IgA nephropathy is not known, although most people with the disease have abnormalities in their immune system. What did we do? â?¨ We searched for all the research trials that assessed the effect of immunosuppressive therapy in people with IgA nephropathy in September 2019. We measured the certainty we could have about the treatments using a system called "GRADE". What did we find? â?¨ We found 58 studies involving 3933 adults and children who were treated with immunosuppressive therapy. Patients in the studies were given either steroids or other forms of therapy to reduce the actions of their immune system. The treatment they got was decided by random chance. Steroid therapy taken for 2 to 4 months appeared to slow damage to the kidney and probably prevents patients from developing kidney failure. It is really uncertain whether steroids cause side effects such as serious infection. One study was stopped early because patients who received steroid therapy had more infections than those patients who were given placebo. Other medications like cyclophosphamide, azathioprine, and mycophenolate mofetil did not clearly protect kidney function in people with IgA nephropathy. Conclusions Steroid therapy may prevent kidney failure in IgA nephropathy but the risks of serious infections are uncertain with treatment.
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WITHDRAWN: Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures
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HipFx Supplemental Cost Analysis
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BACKGROUND: Hip fracture is a major cause of morbidity and mortality in older people and its impact, both on the individual and to society, is substantial. OBJECTIVES: To examine the effects of co-ordinated multidisciplinary inpatient rehabilitation, compared with usual (orthopaedic) care, for older patients with hip fracture. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2002), MEDLINE (1966 to December 2002), conference proceedings and reference lists of articles and books. We also contacted colleagues and trialists. SELECTION CRITERIA: Randomised and quasi-randomised trials of post-surgical care using specialised rehabilitation of mainly older patients (aged 65 years or over) with hip fracture. DATA COLLECTION AND ANALYSIS: Trial assignment to included, excluded and awaiting assessment categories, was by consensus. Two reviewers independently assessed trial quality and extracted data. Limited additional information was sought from most trialists. As well as pooling data from primary outcomes, supplementary analyses were performed to combine clinically relevant outcomes and investigate possible explanatory factors. MAIN RESULTS: In this minor update, new data for two already included trials have been incorporated, resulting in only slight changes to the pooled results.The nine included trials involved 1887 patients. The combined outcomes of death or requiring institutional care showed no significant difference between intervention and control groups (relative risk 0.93; 95% confidence interval 0.83 to 1.05). There was considerable heterogeneity in length of stay and cost data. Using death and deterioration in function as a further combined outcome variable yielded a relative risk of 0.91 (95% confidence interval 0.83 to 1.01). This should be interpreted with caution due to heterogeneity. No quality of life measures were reported and the two trials investigating carer burden showed no evidence of detrimental effect from the intervention. The review update did not result in any new data for these outcomes. AUTHORS' CONCLUSIONS: The available trials reviewed had different aims, interventions and outcomes. Combined outcome measures (e.g. death or institutional care) tended to be better for patients receiving co-ordinated inpatient rehabilitation, but the results were heterogeneous and not statistically significant.Future trials of post-surgical care involving inpatient rehabilitation, or other models such as 'early supported discharge' and 'hospital at home' schemes, should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than attempt to evaluate its components
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Hand splints in rehabilitation
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Hand splinting in rehabilitation has a long tradition and represents a well-established clinical treatment method. There are various therapeutic goals in hand splinting, from immobilization to functional improvement. Pathological conditions that frequently require splint treatment as a part of their rehabilitation management are rheumatoid arthritis (RA), osteoarthritis, tendinopathies, neurological diseases, and burn injuries. Moreover, splint treatment plays an important role in the aftercare of hand surgery. Scientific evidence is poor. There are a number of studies about RA demonstrating that working wrist splints do not have a detrimental effect on grip strength, but no beneficial effects can be statistically proven. The studies concerning splint treatment of carpal tunnel syndrome (CTS) report evidence for significant short-term relief from clinical symptoms. Following stroke there is insufficient evidence to support or refute the effectiveness of hand splinting. The lack of clinical evidence is in contrast to the widespread clinical use. It is our hope that this review article will encourage physicians and therapists to conduct randomized, controlled clinical trials to broaden the scope of available evidence of the efficacy of this treatment method. (copyright) 2004 by Begell House, Inc
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Determination of a safe INR for joint injections in patients taking warfarin
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: With an increase in life expectancy in 'developed' countries, the number of elderly patients receiving joint injections for arthritis is increasing. There are legitimate concerns about an increased risk of thromboembolism if anticoagulation is stopped or reversed for such an injection. Despite being a common dilemma, the literature on this issue is scarce.
METHODS: We undertook 2,084 joint injections of the knee and shoulder in 1,714 patients between August 2008 and December 2013. Within this cohort, we noted 41 patients who were taking warfarin and followed them immediately after joint injection in the clinic or radiology department, looking carefully for complications. Then, we sought clinical follow-up, correspondence, and imaging evidence for 4 weeks, looking for complications from these joint injections. We recorded International Normalised Ratio (INR) values before injection.
RESULTS: No complications were associated with the procedure after any joint injection. The radiologists who undertook ultrasound-guided injections to shoulders re-scanned the joints looking for haemarthroses: they found none. A similar outcome was noted clinically after injections in the outpatient setting.
CONCLUSION: With a mean INR of 2.77 (range, 1.7-5.5) and a maximum INR within this group of 5.5, joint injections to the shoulder and knee can be undertaken safely in primary or secondary care settings despite the patient taking warfarin.
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The preoperative machine learning algorithm for extremity metastatic disease can predict 90-day and 1-year survival: An external validation study
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: The prediction of survival is valuable to optimize treatment of metastatic long-bone disease. The Skeletal Oncology Research Group (SORG) machine-learning (ML) algorithm has been previously developed and internally validated. The purpose of this study was to determine if the SORG ML algorithm accurately predicts 90-day and 1-year survival in an external metastatic long-bone disease patient cohort.
METHODS: A retrospective review of 264 patients who underwent surgery for long-bone metastases between 2003 and 2019 was performed. Variables used in the stochastic gradient boosting SORG algorithm were age, sex, primary tumor type, visceral/brain metastases, systemic therapy, and 10 preoperative laboratory values. Model performance was calculated by discrimination, calibration, and overall performance.
RESULTS: The SORG ML algorithms retained good discriminative ability (area under the cure [AUC]: 0.83; 95% confidence interval [CI]: 0.76-0.88 for 90-day mortality and AUC: 0.84; 95% CI: 0.79-0.88 for 1-year mortality), calibration, overall performance, and decision curve analysis.
CONCLUSION: The previously developed ML algorithms demonstrated good performance in the current study, thereby providing external validation. The models were incorporated into an accessible application (https://sorg-apps.shinyapps.io/extremitymetssurvival/) that may be freely utilized by clinicians in helping predict survival for individual patients and assist in informative decision-making discussion before operative management of long bone metastatic lesions.
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Pauwel's osteotomy and osteosynthesis in patients with non-union of femoral neck fractures
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Management of Hip Fractures in the Elderly
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Objective:- To evaluate the results of Pauwel's ostetotomy and oseosynthesis in patients with non union of femoral neck fractures. Material and methods:- This Study was conducted in the Orthopaedic Unit, Nishtar Hospital, Multan during the period of 1989-1998. A total of 30 patients were included in the study. Results:- Thirty cases of neglected fracture neck of femur treated in Nishtar Hospital Multan from 1989-1998. Five patients were treated first with traction where greater trochanter migrated a way up to bring it down to the proper level. Then osteotomy was done. In 25 cases Pauwels' osteotomy was primarily done and fixed with 120-degree osteotomy plate. Conclusion:- This is a reliable method of dealing with non-union of the fracture neck of the femur in young adults
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Risk factors for infection in total knee artrhoplasty, including previously unreported intraoperative fracture and deep venous thrombosis
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Surgical Management of Osteoarthritis of the Knee CPG
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PURPOSE: To carry out a statistical analysis on the significant risk factors for deep late infection (prosthetic joint infection, PJI) in patients with a knee arthroplasty (TKA). METHODS: A retrospective observational case-control study was conducted on a case series of 32 consecutive knee infections, using an analysis of all the risk factors reported in the literature. A control series of 100 randomly selected patients operated in the same Department of a University General Hospital during the same period of time, with no sign of deep infection in their knee arthroplasty during follow-up. Statistical comparisons were made using Pearson for qualitative and ANOVA for quantitative variables. RESULTS: The significant (p>0.05) factors found in the series were: Preoperative previous knee surgery, glucocorticoids, immunosuppressants, inflammatory arthritis. INTRAOPERATIVE: prolonged surgical time, inadequate antibiotic prophylaxis, intraoperative fractures. Postoperative secretion of the wound longer than 10 days, deep palpable haematoma, need for a new surgery, and deep venous thrombosis in lower limbs. Distant infections cutaneous, generalized sepsis, urinary tract, pneumonia, abdominal. CONCLUSIONS: This is the first report of intraoperative fractures and deep venous thrombosis as significantly more frequent factors in infected TKAs. Other previously described risk factors for TKA PJI are also confirmed
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The effect of leukocyte interleukin injection (Multikine) treatment on the peritumoral and intratumoral subpopulation of mononuclear cells and on tumor epithelia: a possible new approach to augmenting sensitivity to radiation therapy and chemotherapy in oral cancer--a multicenter phase I/II clinical Trial
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Reconstruction After Skin Cancer
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OBJECTIVES/HYPOTHESIS: The main objective of this study was to investigate the effect of the administration of a novel immunoadjuvant, leukocyte interleukin injection, as part of an immuno-augmenting treatment regimen on the peritumoral and intratumoral subpopulations of the tumor infiltrating mononuclear cells and on the epithelial and stromal components, when administered to patients with advanced primary oral squamous cell carcinoma classified as T2-3N0-2M0, as compared with disease-matched control patients (not treated with leukocyte interleukin injection). STUDY DESIGN: Multicenter Phase I/II clinical trial. Fifty-four patients from four clinical centers were included in the dose-escalating study (27 in each group [leukocyte interleukin injection-treated and control groups]). Cumulative leukocyte inter-leukin injection doses were 2400, 4800, and 8000 IU (as interleukin-2 equivalent). METHODS: Paraffin-embedded tumor samples obtained at surgical resection of the residual tumor (between days 21 and 28 after treatment initiation) were used. Histological analysis, necrosis evaluation, and American Joint Committee on Cancer grading were performed from H&E-stained sections. Immunohistochemical analysis was performed on three different tumor regions (surface, zone 1; center, zone 2; and tumor-stroma interface, zone 3). Trichrome staining was used to evaluate connective tissue, and morphometric measurements were made using ImagePro analysis software. Cell cycling was determined by the use of Ki-67 marker. RESULTS: Leukocyte interleukin injection treatment induced a shift from stromal infiltrating T cells toward intraepithelial T cells and posted a significant (P <.05) increase in intraepithelial CD3-positive T cells independent of the leukocyte interleukin injection dose, whereas the increase in CD25 (interleukin-2 receptor alpha [IL-2Ralpha])-positive lymphoid cells was significant only at the lowest leukocyte interleukin injection dose (P <.05). Furthermore, both low- and medium-dose leukocyte interleukin injection treatment induced a significant (P <.05) increase in the number of cycling tumor cells, as compared with control values. CONCLUSION: The results could be highly beneficial for patients with oral squamous cell carcinoma. First, leukocyte interleukin injection treatment induces T-cell migration into cancer nests and, second, noncycling cancer cells may enter cell cycling on administration of leukocyte interleukin injection. This latter effect may modulate the susceptibility of cancer cells to radiation therapy and chemotherapy. The findings may indicate a need to re-evaluate the way in which follow-up treatment (with radiation therapy and chemotherapy) of patients with head and neck cancer is currently approached.
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What Is the Important Point Related to Follow-Up Sonographic Evaluation for the Developmental Dysplasia of the Hip?
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Developmental Dysplasia of the Hip 2020 Review
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Developmental dysplasia of the hip (DDH) is an important cause of childhood disability. Subluxation or dislocation can be diagnosed through pediatric physical examination; nevertheless, the ultrasonographic examination is necessary in diagnosing certain borderline cases. It has been evaluated routine sonographic examination of 2,444 hips of 1,222 babies to determine differences in both, developmental dysplasia and types of hips, and evaluatedtheir developmentonthe 3-monthfollow-up. Evaluatingthe pathologic "α" angles under 59, there was no statistically significant differences between girls and boys in both right (55.57 ± 3.73) (56.20 ± 4.01), (p = 0.480), and left (55.79 ± 3.96) (57.00 ± 3.84), (p = 0.160) hips on the 45th day of life. Routine sonographic examinations on the 45th day of life revealed that 51 of (66.2%) 77 type 2a right hips were girls and 26 (33.8%) were boys. The number of the right hips that develop into type 1 was 38 (74.5%) for girls and 26 (100%) for boys on the 90th day of life (p = 0.005). A total of 87 type 2a left hips included 64 girls (73.6%) and 23 boys (26.4%). In the 90th day control, 49 right hip of girls (76.6%) and 21 right hip of boys (91.3%) developed into type 1 (p = 0.126). In the assessment of both left and right hips, girls showed a significantly higher frequency in latency and boys showed significantly higher development in the control sonography. A total of 31 girls (2.5%) and 11 boys (0.9%) accounted for a total of 42 (3.4%) cases who showed bilateral type 2a hips in 1,222infants.Onthe 90thday control,26 girls (83.9%) andall11 boys (100%)developed into type 1 (p = 0.156). The study emphasizes the importance of the sonographic examination on the 90th day of life. Results of the investigation include the data of sonographic screening of DDH on the 45th day, and also stress the importance of the 90th-day control sonography after a close follow-up with physical examination between 45th and 90th days of life.
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Rearthroplasty after conventional total hip prosthesis and double-cup prosthesis. A comparative study
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Management of Hip Fractures in the Elderly
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Revision of 19 Muller total hip prostheses and 9 ICLH double-cup prostheses is compared. In the Muller group the mean operation time was 186 min, the amount of blood transfused 3526 ml, and the hospital stay 34.9 days. The corresponding figures for the ICLH group were 94 min, 1389 ml, and 25.7 days. Revision of the conventional hip prostheses involved technical difficulties and complications such as femoral fractures and postoperative dislocations, which were not seen in the ICLH group, in which the revision was as easy to perform as the primary operation. The clinical result 6 months after revision was significantly better in the ICLH group. Thus, the double-cup prosthesis provides another possibility for revision. However, a relatively high incidence of early loosening indicates that it should not be used in older patients in whom one would expect a follow-up shorter than the lifetime of a conventional hip prosthesis
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Radiologic discrepancies in diagnosis of fractures in a Dutch teaching emergency department: a retrospective analysis
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Hip Fx in the Elderly 2019
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BACKGROUND: Missed fractures in the emergency department (ED) are common and may lead to patient morbidity.
AIM: To determine the rate and nature of radiographic discrepancies between ED treating physicians, radiologists and trauma/orthopaedic surgeons and the clinical consequences of delayed diagnosis. A secondary outcome measurement is the timeframe in which most fractures were missed.
METHODS: A single-centre retrospective analysis of all missed fractures in a general teaching hospital from 2012 to 2017 was performed. Data regarding missed fractures were provided by the hospital's complication list and related database. Additional data were retrieved from the electronic medical records as required for the study.
RESULTS: A total of 25,957 fractures were treated at our ED. Initially, 289 fractures were missed by ED treating physicians (1.1%). The most frequently missed fractures were the elbow (28.6%) and wrist (20.8%) in children, the foot (17.2%) in adults and the pelvis and hip (37.3%) in elderly patients. Patients required surgery in 9.3% of missed fractures, received immobilization by a cast or brace in 45.7%, had no treatment alterations during the first week in 38.1%. Follow-up data were lacking for 6.9% of cases. 49% of all missed fractures took place between 4 PM and 9 PM. There is a discrepancy in percentages of correctly diagnosed fractures and missed fractures between 5 PM and 3 AM.
CONCLUSION: Adequate training of ED treating physicians in radiographic interpretation is essential in order to increase diagnostic accuracy. A daily multidisciplinary radiology meeting is very effective in detecting missed fractures.
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Intraarticular findings after gunshot wounds through the knee
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DoD SSI (Surgical Site Infections)
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OBJECTIVES: To compare the radiographic findings in patients with a low-velocity gunshot wound through the knee with the intraarticular pathology as documented by arthroscopy, and to evaluate arthroscopic management of these injuries.
STUDY DESIGN: Retrospective review of a protocol.
MATERIALS AND METHODS: Thirty-three patients with low-velocity gunshot wounds through the knee, no significant soft tissue injury, and no fracture requiring repair were studied. Radiographs were evaluated for bullet fragments, loose bodies, and debris. All patients were treated with arthroscopic evaluation and management of intraarticular pathology. The arthroscopic findings were compared with the radiographic findings.
RESULTS: Five chondral injuries and fourteen meniscal injuries not suspected on the basis of plain films were found during arthroscopic evaluation. Seven patients had no radiographic evidence of debris, loose bodies, or bullet or bone fragments in the joint. Five of these seven (71%) had debris and meniscal damage. Debridement of all loose bodies was possible using arthroscopy and occasional miniarthrotomy. No patient in the series had an infection.
CONCLUSIONS: Patients who sustain a low-velocity gunshot through the knee have soft tissue injuries not visible on plain radiographs in most cases, and therefore operative treatment is warranted. Arthroscopic management of these injuries appears to be a safe and effective method of treatment.
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Handling of COVID-19 in the emergency department : Field report of the emergency ward of the University Hospital Münster
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Coronavirus Disease 2019 (COVID-19)
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With the COVID-19 pandemic, emergency rooms are faced with major challenges because they act as the interface between outpatient and inpatient care. The dynamics of the pandemic forced emergency care at the University Hospital Münster to extensively adjust their processes, which had to be carried out in the shortest time possible. This included the establishment of an outpatient coronavirus test center and a medical student-operated telephone hotline. Inside the hospital, new isolation capacities in the emergency room and a dedicated COVID-19 ward were set up. The patient flow was reorganized using flow diagrams for both the outpatient and inpatient areas. The general and special emergency management was optimized for the efficient treatment of COVID-19-positive patients and the staff were trained in the use of protective equipment. This report of our experience is intended to support other emergency departments in their preparation for the COVID-19 pandemic.
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Recent Advances in Multimodal Analgesia
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AAHKS (8) Anesthetic Infiltration
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Greater understanding of the pathophysiology and mechanism of acute pain has led to advances in pharmacologic therapy. Understanding the principles of multimodal therapy along with surgical-specific protocols leads to improved outcome in patients. However, further large-scale randomized trials need to be performed to further establish and demonstrate the long-term benefit of multimodal therapy for patients undergoing surgery. © 2012 Elsevier Inc..
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Reasons for failure of primary total hip arthroplasty performed through a direct anterior approach
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Hip Fx in the Elderly 2019
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The direct anterior approach (DAA) for total hip arthroplasty (THA) is a technique popular among some arthroplasty surgeons. There is currently a paucity of data regarding reasons for failure of THA using the DAA. The authors conducted a retrospective review of prospectively collected data on 56 patients who underwent revision THA at their institution after failing primary THA that was performed through a DAA either at their institution (n=8) or elsewhere (n=48) from January 1, 2010, to June 1, 2017. Patients were grouped by modes of failure and compared using patient characteristics, surgical factors, and radiographic outcomes. Total hip arthroplasties performed through the DAA failed due to infection in 21 (38%) patients, aseptic/mechanical loosening in 14 (25%) patients, intraoperative fracture in 6 (11%) patients, postoperative fracture in 6 (11%) patients, tendinitis or pain of unknown etiology in 3 (5%) patients, metallosis in 3 (5%) patients, instability/dislocation in 2 (4%) patients, and leg length discrepancy in 1 (2%) patient. Patients who underwent revision due to unrecognized intraoperative fracture had a lower body mass index (BMI) and weight than patients who had failure due to postoperative fracture, aseptic loosening, or infection. The 4 most common modes of failure included infection, aseptic loosening, unrecognized intraoperative fracture, and postoperative fracture. Together, these made up 84% of failed DAA THAs. Patients with a lower BMI are more likely to have failure due to intraoperative fractures. Patients with a higher BMI are more likely to have failure due to postoperative fracture, aseptic loosening, or infection.
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Infectious Complications Leading to Explantation in Implant-Based Breast Reconstruction With AlloDerm
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Acellular Dermal Matrix
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OBJECTIVE: The role for acellular dermal matrix in implant-based breast reconstruction-providing coverage of the inferolateral border of the underlying prosthesis and allowing control over the inframammary fold-has become increasingly popular. Although AlloDerm (LifeCell, Branchburg, NJ) is free of cellular components responsible for the antigenic response, its processing does not guarantee sterility. In this study, we examine the infectious complications in tissue expander/implant-based reconstruction with AlloDerm. METHODS: A retrospective cohort analysis was completed on 321 implant-based breast reconstructions over a 10-year period (1998-2008) at an academic institution. Of these cases, 75 reconstructions used AlloDerm and 246 reconstructions did not. The incidence of infections that required readmission for intravenous (IV) antibiotics and explantation was determined. Prosthetic explants due to hematoma or patient dissatisfaction were excluded from analysis. RESULTS: There were no differences in rates of readmission for IV antibiotics (2.8% vs 5.3%; P = .291). The rate of explantation due to infected fluid collections and extrusion was higher in the AlloDerm group (8.0%, n = 6) than that in the control group (1.6%, n = 4). This result was statistically significant (P = .013). CONCLUSION: In this study, the rates of IV antibiotic administration for the treatment of cellulitis in implant-based breast reconstructions did not differ because of the presence of AlloDerm; however, the rate of explantation was statistically higher in reconstructions using AlloDerm. This technique has great potential in breast reconstruction, especially for single-staged implant-based reconstruction, but careful counseling of patients with regard to the higher risk of explantation is necessary.
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Differential knee joint loading patterns during gait for individuals with tibiofemoral and patellofemoral articular cartilage defects in the knee
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine compartment-specific loading patterns during gait, quantified as joint reaction forces (JRF), of individuals with knee articular cartilage defects (ACD) compared to healthy controls (HC).
METHODS: Individuals with ACDs and HC participated. Individuals with ACDs were divided into groups according to ACD location: PF (only a patellofemoral ACD), TF (only a tibiofemoral ACD), and MIX (both PF and TF ACDs). Participants underwent three-dimensional gait analysis at self-selected speed. TF joint reaction force (TF-JRF) was calculated using inverse dynamics. PF joint reaction force (PF-JRF) was derived from estimated quadriceps force (F<sub>QUAD</sub>) and knee flexion angle. Primary variables of interest were the PF- and TF-JRF peaks (body weight [xBW]). Related secondary variables (gait speed, quadriceps strength, knee function, activity level) were evaluated as covariates.
RESULTS: First peak PF-JRF and TF-JRF were similar in the TF and MIX groups (0.75-1.0 xBW, P = 0.6-0.9). Both peaks were also similar in the PF and HC groups (1.1-1.3 xBW, P = 0.7-0.8), and higher than the TF and MIX groups (P = 0.004-0.02). For the second peak PF-JRF, only the HC group was higher than the TF group (P = 0.02). The PF group walked at a similar speed as the HC group; both groups walked faster than the TF and MIX groups (P < 0.001). With gait speed and quadriceps strength as covariates, no differences were observed in JRF peaks.
CONCLUSIONS: The results suggest the presence of a TF ACD (TF and MIX groups), but not a PF ACD (PF group), may affect joint loading patterns during walking. Walking slower may be a protective gait modification to reduce load.
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Moleculight i: xÎ?äó in Wound Healing
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DoD LSA (Limb Salvage vs Amputation)
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Diabetic foot disease is a global health problem. Diabetes affects over 450million people worldwide, expected to rise to 1 in 10 people by 2040. 60Î?Ã?Ã?70% will lose sensation in their feet and up to 25% will develop a diabetic foot ulcer (DFU Î?Ã?Ã? a wound on the foot). More than half of DFUs become infected requiring hospitalisation and 20% of infections result in amputations contributing to 80% of nonÎ?Ã?Ã?traumatic amputations performed in the developed world. DFUs cost the NHS â?¬Ãº1billion in financial year 2014Î?Ã?Ã?15. A diabetic foot ulcer is a form of chronic wound. Chronic wounds are wounds that fail to progress through the normal phases of wound healing in an orderly and timely manner and become hard to heal. Almost all chronic wounds are known to have bacteria within and this is termed colonisation. Wounds can progress from being colonised to becoming infected. The concentration of bacteria can predict delayed healing or infection. This study aims to use a novel hand held device, Moleculight i:XÎ?äó, in a pilot study to investigate the clinical effectiveness and decision making associated with its use in the assessment of DFUs. Moleculight i:XÎ?äó is a hand held device that emits violet blue light. By controlling distance from the wound and ambient light, Moleculight i:XÎ?äó identifies bacteria above a preÎ?Ã?Ã?determined concentration by identifying natural fluorescence in the bacteria cell wall. Patients attending a specialist DFU clinic will be screened and if eligible and consenting will be recruited. Patients will be randomised into two groupsâ?â?? those who receive treatments as usual (TAU) alone (in line with NICE guidelines) and those that receive TAU plus Moleculight i:XÎ?äó imaging. The main objective is to describe the proportion per group with healed DFUs at 12week follow up in these two comparable groups of 30 patients each.
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Diagnostic Validity of Combining History Elements and Physical Examination Tests for Traumatic and Degenerative Symptomatic Meniscal Tears
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: The current approach to the clinical diagnosis of traumatic and degenerative symptomatic meniscal tears (SMTs) proposes combining history elements and physical examination tests without systematic prescription of imaging investigations, yet the evidence to support this diagnostic approach is scarce.
OBJECTIVE: To assess the validity of diagnostic clusters combining history elements and physical examination tests to diagnose or exclude traumatic and degenerative SMT compared with other knee disorders.
DESIGN: Prospective diagnostic accuracy study.
SETTINGS: Patients were recruited from 2 orthopedic clinics, 2 family medicine clinics, and from a university community.
PATIENTS: A total of 279 consecutive patients who underwent consultation for a new knee complaint.
METHODS: Each patient was assessed independently by 2 evaluators. History elements and standardized physical examination tests performed by a physiotherapist were compared with the reference standard: an expert physicians' composite diagnosis including a clinical examination and confirmatory magnetic resonance imaging. Participating expert physicians were orthopedic surgeons (n = 3) or sport medicine physicians (n = 2). Penalized logistic regression (least absolute shrinkage and selection operator) was used to identify history elements and physical examination tests associated with the diagnosis of SMT and recursive partitioning was used to develop diagnostic clusters.
MAIN OUTCOME MEASURES: Diagnostic accuracy measures were calculated including sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CIs).
RESULTS: Eighty patients had a diagnosis of SMT (28.7%), including 35 traumatic tears and 45 degenerative tears. The combination a history of trauma during a pivot, medial knee pain location, and a positive medial joint line tenderness test was able to diagnose (LR+ = 8.9; 95% CI 6.1-13.1) or exclude (LR- = 0.10; 95% CI 0.03-0.28) a traumatic SMT. Combining a history of progressive onset of pain, medial knee pain location, pain while pivoting, absence of valgus or varus knee misalignment, or full passive knee flexion was able to moderately diagnose (LR+ = 6.4; 95% CI 4.0-10.4) or exclude (LR- = 0.10; 95% CI 0.03-0.31) a degenerative SMT. Internal validation estimates were slightly lower for all clusters but demonstrated positive LR superior to 5 and negative LR inferior to 0.2 indicating moderate shift in posttest probability.
CONCLUSION: Diagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of SMT. These results represent the initial derivation of the clusters and external validation is mandatory.
Level of evidence: I.
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Associations of clinical and biomarker variables withcartilage damage in painful pre-radiographic knee osteoarthritis. results from a population-based study
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OAK Recommendation 9 Articles
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Objectives: To evaluate the association of clinical and biomarker variables with cartilage damage in subjects with knee pain and no radiographic OA Methods: Subjects with knee pain, age 40-79, stratified by age decade and gender, were recruited in a cross-sectional population-based study. Subjects were evaluated clinically, with MRI, x-ray and biomarkers. MRI of cartilage (MRC) was scored 0-4 on six knee joint surfaces. Cartilage damagewas defined as MRC -2 at any joint site. X-rays were read using Kellgren-Lawrence (KL) 0-4 grading. Urine biomarkers included Ctelopeptide of type II collagen (uCTX-II) (Nordic Bioscience), type II and type I and II collagen cleavage neoepitopes (uC2C, uC1,2C) (Ibex), Ntelopeptide of type I collagen (uNTX-I) (Ostex). Serum biomarkers included sC1,2C, sC2C, c-propeptide of type II procollagen (sCPII), 846 epitope (sCS846) (Ibex), cartilage oligomeric matrix protein (sCOMP) (AnaMar) and hyaluronic acid (sHA) (Corgenix). Ratios of type II collagen degradation with synthesis markers were also evaluated. Biomarker data were log transformed. Clinical variables included pain duration, pain frequency, WOMAC pain severity, age, gender, BMI, smoking, knee examinations, history of meniscectomy and knee injury. Only subjects with normal x-rays (KL<2) were included in this analysis. Univariate logistic regression analysiswas performed initially. Variables with p<0.25 in univariate analysis were entered into a forward stepwise multivariable logistic regression analysis. All analyses utilized stratum sampling weights. Results: Of 255 subjects, 152 (59.6%) had KL grade <2 and were included in the analysis. Of these, 78.1% had cartilage damage. Mean age was 53.7 years, mean BMI 25.9, 53% were female, 15.9% had history of severe injury requiring a walking aid, 1% had meniscectomy. Results for the multivariable logistic regression analysis are shown in Table 1. The risk of cartilage damage was significantly increased in those with an increase in uC2C/sCPII ratio. Other biomarkers were not significant. Age was also associated with cartilage damage with a significantly increased risk in the 60+ age group (OR 5.93; 95% CI 1.74, 20.20) and a trend towards significance in the 50-59 year old age group (OR 2.50; 95% CI 0.96, 6.55). The presence of lateral tibiofemoral tenderness on knee examination was associated with a significantly reduced risk of cartilage damage on MRI (OR 0.39; 95% CI 0.16, 0.98). Conclusions: In this population-based study of symptomatic subjects with no radiographic OA, the ratio of uC2C/sCPII and older age were associated with an increased risk of cartilage damage, while lateral tibiofemoral tenderness was associated with a reduced risk of cartilage damage. Lateral tenderness likely relates to periarticular pain syndromes and hence may be helpful in ruling out the presence of cartilage damage in those with knee pain. These findings may be useful for future studies aimed at identifying cohorts with early knee OA for epidemiologic research or clinical trials
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Pudendal nerve neuralgia after hip arthroscopy: Retrospective study and literature review
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Hip Fx in the Elderly 2019
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Introduction: Pudendal nerve neurapraxia is a classic complication after traction on the fracture table. Diagnosis, however, is difficult and often overlooked, especially after arthroscopy in traction on fracture table; incidence is therefore not known exactly. Hypothesis: The study hypothesis was that incidence of pudendal nerve neuropathy exceeds 1% after hip arthroscopy. Materials and methods: Results for 150 patients (79 female, 71 male) undergoing hip arthroscopy between 2000 and 2010 were analyzed retrospectively. The principal assessment criterion was onset of pudendal neuralgia. Secondary criteria were risk factors (history, surgery time, type of anesthesia), associated complications, onset to diagnosis interval and pattern of evolution. Results: At a mean 93 months' follow-up, there were 3 cases (2 women, 1 man) (2%) of pure sensory pudendal neuralgia; 2 concerned labral lesion resection and 1 osteochondromatosis. Surgery time ranged from 60 to 120. min, under general anesthesia with curarization. Time to diagnosis was 3 weeks. No complementary examinations were performed. Spontaneous resolution occurred at 3 weeks to 6 months. No significant risk factors emerged. Conclusion: The present study found 2% incidence of pudendal neuralgia, with no risk factors emerging from analysis. Prevention involves limiting traction force and duration by using a large pelvic support (diameter > 8-10. cm). Patient information and postoperative screening should be systematic. Level of evidence: Level IV. Retrospective study. © 2013 Elsevier Masson SAS.
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Determinants of bone loss from the femoral neck in women of different ages
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Management of Hip Fractures in the Elderly
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An age-stratified sample of 304 women from Rochester, Minnesota, aged 30-94 years (median 60 years) at baseline underwent measurement of femoral neck bone mineral density (BMD) over a follow-up period extending to 16 years. The average rate of change in femoral neck BMD was -1.0% per year (range -10.0% to +13.4%) and did not vary significantly with age. Because there was no marked increase in the rate of loss around the time of menopause, nor convincing evidence of there being a subset of fast losers, there was fairly good tracking of individual values over time; the correlation of baseline with femoral neck BMD values 16 years later was 0.83. Although a large number of potential determinants was assessed, the only consistent predictor of femoral neck bone loss in women of different ages was baseline femoral neck BMD (r = -0.15; p = 0.023). Otherwise, different sets of risk factors were identified for premenopausal women, women within 20 years of menopause, and women 20 years or more postmenopausal, but the predictive power of these different multivariate models was modest. Nonetheless, these data indicate that femoral neck BMD is quite predictable for extended periods of time. This is reassuring with respect to the use of statistical models that incorporate such data to estimate future fracture risk
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Treatment of aneurysmal bone cysts of the pelvis and sacrum
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MSTS 2018 - Femur Mets and MM
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Background: Aneurysmal bone cysts are benign, non-neoplastic, highly vascular bone lesions. The purpose of this study was to describe the prevalence, the clinical presentation, and the recurrence rate of aneurysmal bone cysts of the pelvis and sacrum and to examine the diagnostic and therapeutic options and prognosis for patients with this condition. Methods: Forty consecutive patients with an aneurysmal bone cyst of the pelvis and/or sacrum were treated from 1921 to 1996. Their medical records and radiographic and imaging studies were reviewed, and histological sections from the cysts were examined. Seventeen lesions were iliosacral, sixteen were acetabular, and seven were ischiopubic. Seven involved the hip joint, and two involved the sacroiliac joint. All twelve sacral lesions extended to more than one sacral segment and were associated with neurological signs and symptoms. Destructive acetabular lesions were associated with pathological fracture in five patients and with medial migration of the femoral head, hip subluxation, and hip dislocation in one patient each. The mean duration of follow-up was thirteen years (range, three to fifty-three years). Results: Thirty-five patients who were initially treated for a primary lesion had surgical treatment (twenty-one had excision-curettage and fourteen had intralesional excision); two patients also had adjuvant radiation therapy. Of the thirty-five patients, five (14%) had a local recurrence noted less than eighteen months after the operation. Of five patients initially treated for a recurrent lesion, one had a local recurrence. At the latest follow-up examination, all forty patients were disease-free and twenty-eight (70%) were asymptomatic. There were two deep infections. Conclusion: Aneurysmal bone cysts of the pelvis and sacrum are usually aggressive lesions associated with substantial bone destruction, pathological fractures, and local recurrence. Current management recommendations include preoperative selective arterial embolization, excision-curettage, and bone-grafting.
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An Overview of Cardenolides in Digitalis - More Than a Cardiotonic Compound
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Reduction Mammoplasty for Female Breast Hypertrophy
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The genus Digitalis L. containing species, commonly known as the "foxglove", is the main source of cardenolides, which have various pharmacological properties effective against certain pathological conditions including myocardial infarction, arterial hypertension, cardiac dysfunction, angina, and hypertrophy. Togehter with a prime effect of controlling the heart rhythm, many workers demonstrated that lanatoside C and some other cardiac glycosides are effective in several cancer treatments such as prostate and breast cancers. Due to digoxigenin derivatives of cardenolides, which are mainly used for medicinal purposes, such as digoxigenin, D. lanata as a main source is of great interest for commercial scale production of cardenolides in Europe. Phytochemical studies on cardenolides, naturally occurring plant secondary metabolites, have mainly focused on the species of the genus Digitalis L., as the members of this family have a high level and diverse content of cardenolides. During the last few decades, plant tissue culture techniques have been optimised for many plant species including Digitalis, however, the production capacity of cardenolides somehow failed to reach a commercially desired extent. In this review paper, the genus Digitalis is evaluated in terms of its main botanical and physiological features, traditional uses, molecular genetics and metabolomics, cellular mechanism of action, medicinal uses, clinical pharmacology, drug interactions, therapy in the management of cardiovascular disorders, potential utility of therapy in extracardiac conditions, and toxicity.
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Meniscal pathology in children and adolescents
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AMP (Acute Meniscal Pathology)
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The menisci play a key role in knee biomechanics and long-term cartilage protection. Preserving the meniscus is thus a major functional consideration in children and adolescents. In normal menisci, lesions are traumatic in origin. They are often vertical, in the posterior segment, associated with anterior cruciate ligament tear. In abnormal menisci, lesions are much more specific to children, occurring atraumatically, mainly in discoid menisci. Clinical signs of traumatic meniscal lesion are minimal, and associated ligament involvement should be systematically screened for. In contrast, clinical findings are rich and specific in discoid malformative pathology, sometimes showing the typical "clunk" sign highly suggestive of a detachment. The complementary examination of choice is MRI. In children more than in adults, lesions need screening for in apparently normal menisci. This particularly concerns ramp lesions of the medial meniscus. It is important also to be aware of false signs, and notably linear hypersignal of vascular origin in the posterior segment of the medial meniscus. MRI is essential in determining type of tear and guiding surgery in discoid meniscal pathology. Indications for meniscal repair in children are maximal, even in lesions extending into the white zone, and the risk of failure needs to be assumed. All meniscal suture techniques - all-inside, in-out and out-in - need to be acquired. Meniscectomy, even partial, should be exceptional. Treatment of symptomatic discoid meniscus usually involves minimal central meniscoplasty and suture of the discovered lesion. Results of meniscal repair in children are generally very satisfactory, whatever the type or site of lesion. Vertical suture is to be preferred; suture failure is often only partial. In all, optimal treatment of meniscal pathology in children and adolescents requires perfect knowledge of pediatric specificities and above all mastery of repair techniques to restore meniscal tissue as fully as possible so as to conserve future knee function.
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Surgical interventions for treating tarsometatarsal (Lisfranc) fracture dislocations
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SR for PM on OA of All Extremities
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This is the protocol for a review and there is no abstract. The objectives are as follows:To assess the effects (benefits and harms) of different surgical interventions for treating tarsometatarsal (Lisfranc) fracture dislocations
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Mid-term survival of total knee arthroplasty in patients with posttraumatic osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE OF THE STUDY There is limited evidence on survival and complication rates in patients after total knee arthroplasty for posttraumatic osteoarthritis. The failure mechanisms leading to revision remain an issue of constant debate. The purpose of this study was to analyze the mid-term survival of primary total knee arthroplasties as well as to evaluate complications and failure mechanisms in patients with posttraumatic knee osteoarthritis. MATERIAL AND METHODS This retrospective study included 79 patients with an average age of 59 years at the time of primary total knee arthroplasty. A functional and radiographic assessment was obtained during outpatient clinical follow-up at 3 and 12 months postoperatively and yearly intervals after that. Survival rates were calculated using Kaplan-Meier analyses. The mean postoperative follow-up was 69 months. RESULTS At 69 month the revision-free survival rate was 88.6%. In nine cases (11.4%) a revision procedure was performed. The leading cause of revision was a periprosthetic infection (n = 6, 66.6%). An age of fewer than 55 years at the time of total knee arthroplasty had a significant influence on implant survival (p = 0.018) with superior survival in favor of the older patient population. At most recent follow-up, a mean Knee Society Score of 82 points and an average Function Score of 77 points were observed. CONCLUSIONS Periprosthetic joint infection is the primary failure mechanism leading to a revision in patients with total knee arthroplasty for posttraumatic osteoarthritis. Apart from the increased infection rate, total knee arthroplasties in patients with posttraumatic osteoarthritis revealed results that were comparable to patients with primary osteoarthritis.
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Current diagnosis of infective endocarditis
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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An analysis was made of 91 cases of infective endocarditis (IE) with regard to causative organisms and their sensitivities to various antibiotics, the clinical features of the disease, the laboratory test results and other items were important in establishing a diagnosis of IE. The number of cases of IE has shown a tendency to increase in recent years, particularly in the number of elderly patients, and the ratio of total cases consisting of prosthetic valve endocarditis (PVE) has shown a sharp increase. The most common causative organism is still Streptococcus viridans, but there has been an increase in the incidence of IE due to benzyl-penicillin-resistant strains of Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus faecalis and other fastidious organisms. The percentage of underlying diseases represented by combined valvular diseases has been increasing, while the primary known cause of the infection of IE was dental treatments. A positive value for CRP, an accelerated value for ESR, leukocytosis, anemia, a decrease in serum Fe, a positive value for RA-T, were all parameters which showed a high correlation with IE, and these should be useful in establishing the diagnosis of IE. The use of cardioechography to detect cardiac vegetation is important in relation to establishing the diagnosis and prognosis of IE, and the evaluation of the therapeutic results
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Age-related changes in the attentional control of visual cortex: a selective problem in the left visual hemifield
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Upper Eyelid and Brow Surgery
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To what extent does our visual-spatial attention change with age? In this regard, it has been previously reported that relative to young controls, seniors show delays in attention-related sensory facilitation. Given this finding, our study was designed to examine two key questions regarding age-related changes in the effect of spatial attention on sensory-evoked responses in visual cortex--are there visual field differences in the age-related impairments in sensory processing, and do these impairments co-occur with changes in the executive control signals associated with visual spatial orienting? Therefore, our study examined both attentional control and attentional facilitation in seniors (aged 66-74 years) and young adults (aged 18-25 years) using a canonical spatial orienting task. Participants responded to attended and unattended peripheral targets while we recorded event-related potentials (ERPs) to both targets and attention-directing spatial cues. We found that not only were sensory-evoked responses delayed in seniors specifically for unattended events in the left visual field as measured via latency shifts in the lateral occipital P1 elicited by visual targets, but seniors also showed amplitude reductions in the anterior directing attentional negativity (ADAN) component elicited by cues directing attention to the left visual field. At the same time, seniors also had significantly higher error rates for targets presented in the left vs. right visual field. Taken together, our data thus converge on the conclusion that age-related changes in visual spatial attention involve both sensory-level and executive attentional control processes, and that these effects appear to be strongly associated with the left visual field.
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Clinics in diagnostic imaging (82). Lesser trochanter metastasis
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Management of Hip Fractures in the Elderly
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A 73-year-old woman who had previous mastectomy for breast carcinoma presented with persistent pain over the left hip area for two to three months. Pelvic radiograph showed an expanded osteolytic lesion involving the lesser trochanter of the left femur, with adjacent ill-defined destructive changes. She subsequently developed a displaced pathological fracture through the lesser trochanteric metastasis. The clinical features and pathophysiology of bone metastases are discussed. The role of imaging, with additional illustrative examples, is emphasised
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Olecranon osteotomy fixation using a novel device: the olecranon sled
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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A posterior approach to the elbow utilizing an olecranon osteotomy has been shown to provide excellent visualization of the distal humerus articular surface. However, many bony stabilization and fixation methods for the olecranon osteotomy are usually prominent, frequently symptomatic, and often require a second operation for removal. This paper evaluates the use of an innovative device, the olecranon sled, in fixation of olecranon osteotomies for exposure of intra-articular distal humerus fractures and provides follow-up results. A retrospective review of all patients with intra-articular distal humerus fracture treated through an olecranon osteotomy approach and fixed with an olecranon sled, between September 2008 and December 2011 was conducted. Charts and radiographs were reviewed to determine olecranon union or nonunion, presence of symptomatic hardware, and need for secondary surgery to remove symptomatic olecranon fixation. Fourteen patients were included in the study. Average clinical follow-up was 33.5 weeks (range, 6 to 118 wk). There were no olecranon nonunions. One patient underwent additional surgery for symptomatic hardware removal (7.1%). Two additional procedures were performed; 1 for revision open reduction and internal fixation of distal humerus fracture nonunion (7.1%) and 1 for release of elbow contracture (7.1%). Although follow-up is limited, the use of this device has been associated with excellent rates of olecranon union with a low rate of symptomatic hardware requiring removal
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A technique for reduction mammoplasty
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Reduction Mammoplasty for Female Breast Hypertrophy
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The author presents a technique for reduction mammoplasty in which the amount of skin removed is limited to a small area in the middle part of the breast. The glandular tissue is resected laterally and medially at the caudal part of the circumference of the breast, along with a midline wedge. With this technique and with the retraction of the skin and the sutures that pull this skin to the midline, the final result is a very short horizontal scar.
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Partial lipectomy, but not PVN lesions, increases food hoarding by Siberian hamsters
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Panniculectomy & Abdominoplasty CPG
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We tested the inverse relationship between body fat and food hoarding in Siberian hamsters by decreasing or increasing body fat through partial surgical lipectomy (LIPX) or by making obesity-inducing lesions of the paraventricular nucleus of the hypothalamus (PVNx), respectively. We asked three questions. 1) Is food hoarding increased after body fat loss due to LIPX? 2) Is food hoarding decreased after PVNx? 3) Does PVNx affect the hoarding response to LIPX? Hamsters housed in a simulated burrow system increased food hoarding after LIPX followed by a decrease to pre-LIPX levels as body fat was partially compensated through an increase in the mass of their unoperated fat pads. PVNx hamsters had increased body mass and food intake but did not have decreased food hoarding, nor was food hoarding increased by LIPX in PVNx hamsters. The partial body fat compensation by LIPX + PVNx hamsters suggests that the damaged PVN did not cause a general failure to sense energy deficits but did affect the ability to integrate internal and external energy stores.
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A randomised, placebo controlled, comparative trial of the gastrointestinal safety and efficacy of AZD3582 versus naproxen in osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To evaluate the gastrointestinal safety and efficacy of the COX inhibiting nitric oxide donator AZD3582 in patients with hip or knee osteoarthritis. METHODS: 970 patients were randomised (7:7:2) to AZD3582 750 mg twice daily, naproxen 500 mg twice daily, or placebo twice daily in a double blind study. The primary end point was the six week incidence of endoscopic gastroduodenal ulcers (diameter > or =3 mm). Overall damage measured on the Lanza scale was a secondary end point. Safety and tolerability assessments included endoscopic upper gastrointestinal erosions and the gastrointestinal symptom rating scale (GSRS). Efficacy was primarily assessed by WOMAC. RESULTS: The incidence of ulcers with AZD3582 was 9.7% and with naproxen 13.7% (p = 0.07, NS), v 0% on placebo. The incidence of Lanza scores >2 was higher with naproxen (43.7%) than with AZD3582 (32.2%) (p<0.001). Compared with baseline, significantly fewer ulcers and erosions developed in stomach and stomach/duodenum combined, and fewer erosions developed in stomach, duodenum, and both combined on AZD3582 than on naproxen. GSRS reflux and abdominal pain subscale scores were lower for AZD3582 than for naproxen but there was no difference for indigestion, constipation, and diarrhoea. AZD3582 was as effective as naproxen at improving WOMAC scores. Both agents were well tolerated, with no significant effects on blood pressure. CONCLUSIONS: At doses with similar efficacy in relieving osteoarthritis symptoms, the primary end point of six week endoscopic gastroduodenal ulcer incidence was not significantly different between AZD3582 and naproxen. Most secondary endoscopic gastrointestinal end points favoured AZD3582.
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Catheter-Directed Intraarterial Thrombolysis as Part of a Multidisciplinary Management Protocol of Frostbite Injury
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DoD LSA (Limb Salvage vs Amputation)
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PURPOSE: To evaluate intraarterial catheter-directed thrombolysis for prediction and prevention of delayed surgical amputation as part of multidisciplinary management of frostbite injury. MATERIALS AND METHODS: A retrospective review was performed of 13 patients (11 men, 2 women; median age, 33.4 y; range, 8-62 y) at risk of tissue loss secondary to frostbite injury and treated with catheter-directed tissue plasminogen activator (t-PA) thrombolysis. Amputation data were assessed on follow-up (mean, 23 mo; range, 9-83 mo). Angiographic findings were classified into complete, partial, and no angiographic response and assessed for association with follow-up amputation rates. Correlation between amputation outcome and duration of cold exposure (mean, 23 h; range, 5-96 h), time between exposure and rewarming therapy (mean, 25.5 h; range, 7-95 h), and time between exposure and t-PA thrombolysis (mean, 32 h; range, 12-96 h) was assessed. Complications were recorded. RESULTS: Of 127 digits at risk on baseline angiography that were treated with catheter-directed thrombolysis, complete recovery was seen in 106 (83.4%). Total mean t-PA dose per extremity was 27.5 mg (range, 12-48 mg) over a mean period of 34 hours (range, 12-72 h). Patients with complete angiographic response (8 patients; 79.5% of digits) did not require amputations; 4 of 5 patients (80%) with partial angiographic response (20.5% of digits) underwent amputation (P = .007). There was no significant correlation between amputation rates and duration of cold exposure (P = .9), time to rewarming therapy (P = .88), and time to thrombolysis (P = .56). Femoral access site bleeding in 2 patients was managed conservatively. One patient underwent surgical exploration for brachial artery hematoma. CONCLUSIONS: Intraarterial catheter-directed thrombolysis should be included in initial management of frostbite injury, as it may prevent delayed amputations. The degree of angiographic response to thrombolysis can potentially predict amputation outcomes.
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0 |
Effects of toe-in and toe-in with wider step width on level walking knee biomechanics in varus, valgus, and neutral knee alignments
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Increased peak external knee adduction moments exist for individuals with knee osteoarthritis and varus knee alignments, compared to healthy and neutrally aligned counterparts. Walking with increased toe-in or increased step width have been individually utilized to successfully reduce 1st and 2nd peak knee adduction moments, respectfully, but have not previously been combined or tested among all alignment groups. The purpose of this study was to compare toe-in only and toe-in with wider step width gait modifications in individuals with neutral, valgus, and varus alignments.
METHODS: Thirty-eight healthy participants with confirmed varus, neutral, or valgus frontal-plane knee alignment through anteroposterior radiographs, performed level walking in normal, toe-in, and toe-in with wider step width gaits. A 3x3 (groupxintervention) mixed model repeated measures ANOVA compared alignment groups and gait interventions (p<0.05).
RESULTS: The 1st peak knee adduction moment was reduced in both toe-in and toe-in with wider step width compared to normal gait. The 2nd peak adduction moment was increased in toe-in compared to normal and toe-in with wider step width. The adduction impulse was also reduced in toe-in and toe-in with wider step width compared to normal gait. Peak knee flexion and external rotation moments were increased in toe-in and toe-in with wider step width compared to normal gait.
CONCLUSION: Although the toe-in with wider step width gait seems to be a viable option to reduce peak adduction moments for varus alignments, sagittal, and transverse knee loadings should be monitored when implementing this gait modification strategy.
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1 |
Magnetic stimulation F-responses
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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We used the 9 cm Cadwell magnetic coil, stimulating at the wrist, to obtain simultaneous median and ulnar nerve F-responses. Surface recording was performed from conventional thenar and hypothenar sites. It is known that with this type of coil it is difficult to accomplish selective supramaximal stimulation of the median or ulnar nerve individually. We found it possible, however, to record a compound muscle action potential of supramaximal or near supramaximal amplitude, as well as F-responses, in both thenar and hypothenar muscles simultaneously. We assessed this technique for F-response latency determination in controls and patients with carpal tunnel syndrome. In controls, there was no significant difference in the F-minimal latency or the F-minimum-maximum range obtained by the two methods. In patients with carpal tunnel syndrome, with median F-responses very delayed or absent on conventional testing, magnetically elicited thenar F-responses were of shorter latency, similar to F's recorded in the hypothenar muscles, suggesting they were recorded from ulnar innervated thenar muscles. Although magnetic stimulation allows simultaneous determination of median and ulnar F-latencies, sparing patients several painful stimuli, and shortening the electrophysiologic examination, magnetic stimulation in patients with carpal tunnel syndrome may elicit thenar recorded F-responses that are not of median origin. Use of this technique is limited by the lack of focality of the stimulus, which has been the major limiting factor in its use on peripheral nerves
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0 |
Maximal Levator Muscle Resection for Primary Congenital Blepharoptosis with Poor Levator Function
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Upper Eyelid and Brow Surgery
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PURPOSE: To evaluate the clinical outcomes of maximal levator muscle resection surgery in patients with poor levator function. METHODS: This prospective study included 29 eyelids of 23 patients who underwent maximal levator resection surgery. Pre- and postoperatively, all patients' routine ophthalmic examination including evaluation of upper eyelid skin crease positions; levator muscle function (LF), rima palpebrarum (RP), and margin-reflex distance (MRD) measurements were recorded. Outcome was considered successful when the difference between the two upper eyelids was </=1 mm; if the difference between the two eyelid margins was more than 1 mm and less than 2 mm, it was considered to be satisfactory. More than 2 mm difference was considered to be poor. RESULTS: Mean patient age was 11.3 +/- 8.6 years (3 months to 24 years). Mean follow-up time was 22.8 +/- 6.9 months (10 to 36 months). Preoperatively mean RP, MRD, and LF measurements were 5.5 +/- 1.7 mm, -0.14 +/- 1.6 mm, 2.5 +/- 1.4 mm (0-4 mm), respectively. Preoperatively, eight (27,6%) patients had skin crease. Abnormal head posture was detected in eight (34.8%) of the patients. Postoperatively, RP, MRD, and LF values increased significantly (p < 0.05). Mean RP, MRD, and LF measurements were 8.3 +/- 1.5 mm, 2.6 +/- 1.2 mm, 5.1 +/- 2.1 mm, respectively. Fourteen subjects (60.9%) had successful results, two subjects (8.7%) had satisfactory results, and seven subjects (30.4%) had poor results. Abnormal head postures of all patients were resolved. CONCLUSIONS: Maximal levator resection may be a good alternative method to frontalis suspension in congenital blepharoptosis patients with poor levator function.
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0 |
Methods of operative treatment of proximal femur fractures in elderly patients with osteoporosis
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Management of Hip Fractures in the Elderly
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Introduction. Progressive osteoporosis as a cause of bone fractures is a serious clinical and social problem.<br /> Material and methods. We studied 465 elderly patients treated surgically for fractures of the proximal femur. 3rd and 4th-degree fractures of the femoral neck according to the Garden scale were operated by Austin-Moore hemiarthroplasty or total hip replacement. In unstable peritrochanteric fractures, intramedullary Gamma nail osteosynthesis was applied in 69 patients, which allows for early mobilization and full weight-bearing. This method minimizes possible complications and mortality. <br /> Results. There were no fatal complications during post-surgery hospitalization. Two patients over 80 years of age suffered decubitus ulcers. Re-osteosynthesis was not required after intramedullary Gamma nail osteosynthesis. In long-term follow-up we observed two failures after union of femoral neck fracture in younger patients
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0 |
Surgical Management of Medial Discoid Meniscus in Pediatric and Adolescent Patients
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Medial discoid meniscus (MDM) is an exceedingly rare anatomic abnormality that presents similarly to other meniscal pathologies. Symptomatic MDM is typically managed arthroscopically with mixed short-term and long-term outcomes, although the existing knowledge about MDM is limited. The purpose of this study was to describe the presentation and surgical treatment of MDM in pediatric and adolescent patients.
METHODS: Medical records of 12 knees with MDM in 8 pediatric and adolescent patients treated between 1991 and 2016 were reviewed retrospectively for patient characteristics, clinical manifestations, radiographic findings, operative techniques, and surgical outcomes.
RESULTS: Of the 446 knees diagnosed arthroscopically with discoid menisci, lateral discoid meniscus was noted in 434 knees (97.3%) and MDM was present in 12 knees (2.7%). The MDM series included 8 patients of mean age 13.8 years (range: 7.8 to 19.8), of which 5 were males (63%), and 4 (50%) had bilateral involvement. Of the 11 knees with available clinical records, all cases presented symptomatically (pain, mechanical symptoms); 10 (91%) had concurrent physical exam findings. On intraoperative examination, discoid morphologies were described as complete in 4/8 knees (50%) or incomplete in 4/8 (50%), with associated instability in 6/12 (50%). Meniscal tears were reported in 9 cases (75%)-primarily, horizontal cleavage tears. Saucerization was performed in 11 knees (92%), with medial meniscal repair in 7 (58%), when indicated. Retear of the medial meniscus occurred in 4/11 knees (36%) at a mean of 25.8 months postoperation; 2 knees required revisions. One knee developed arthrofibrosis and underwent arthroscopic lysis of adhesions.
CONCLUSIONS: MDM is a rare diagnosis, representing 3% of all discoid menisci, with a nonspecific clinical manifestation. Operative management of symptomatic MDM typically involves saucerization and meniscal repair, when indicated, for concurrent tears. Symptom resolution is common short-term, but long-term outcomes include recurrent meniscal tears. Subsequent observational studies are important to evaluate long-term outcomes, such as arthritic changes, with the advancement of arthroscopic techniques for meniscal preservation.
LEVEL OF EVIDENCE: Level IV-retrospective case series.
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0 |
Repeated Time-to-event Analysis of Consecutive Analgesic Events in Postoperative Pain
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Hip Fx Time to Surgery
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BACKGROUND: Reduction in consumption of opioid rescue medication is often used as an endpoint when investigating analgesic efficacy of drugs by adjunct treatment, but appropriate methods are needed to analyze analgesic consumption in time. Repeated time-to-event (RTTE) modeling is proposed as a way to describe analgesic consumption by analyzing the timing of consecutive analgesic events. METHODS: Retrospective data were obtained from 63 patients receiving standard analgesic treatment including morphine on request after surgery following hip fracture. Times of analgesic events up to 96 h after surgery were extracted from hospital medical records. Parametric RTTE analysis was performed with exponential, Weibull, or Gompertz distribution of analgesic events using NONMEM, version 7.2 (ICON Development Solutions, USA). The potential influences of night versus day, sex, and age were investigated on the probability. RESULTS: A Gompertz distribution RTTE model described the data well. The probability of having one or more analgesic events within 24 h was 80% for the first event, 55% for the second event, 31% for the third event, and 18% for fourth or more events for a typical woman of age 80 yr. The probability of analgesic events decreased in time, was reduced to 50% after 3.3 days after surgery, and was significantly lower (32%) during night compared with day. CONCLUSIONS: RTTE modeling described analgesic consumption data well and could account for time-dependent changes in probability of analgesic events. Thus, RTTE modeling of analgesic events is proposed as a valuable tool when investigating new approaches to pain management such as opioid-sparing analgesia.
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0 |
A study of the effects of a physiotherapy treatment technique known as Mulligan technique in people suffering from knee pain over a prolonged period, i.e, more than 3 months
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OAK 3 - Non-arthroplasty tx of OAK
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INTERVENTION: Intervention1: Mulligan Techniques: Mulligan technique involves "glides"or forces delivered by a physiotherapist, causing accessory joint movements, while the subject performs active movement. Control Intervention1: Sham technique/ Placebo: Hand placement mimicking the treatment technique without actually delivering the gliding force CONDITION: Knee Osteoarthritis PRIMARY OUTCOME: Numerical Pain Rating Scaleâ?â?â?â?â?â?Timepoint: Immediate pre and post intervention SECONDARY OUTCOME: Timed Up and Go testâ?â?â?â?â?â?Timepoint: Immediate pre and post intervention INCLUSION CRITERIA: 1. Radiologically diagnosed degenerative tibiofemoral osteoarthritis with bilateral involvement, grades 1 to 3 according to the Kellgren and Lawrence classification 2.Duration of the condition: >3 months
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1 |
Psychological factors predicting outcome after traumatic injury: The role of resilience
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DoD PRF (Psychosocial RF)
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Background Increasingly, studies have examined the psychological impact on individuals who survive a traumatic physical injury. The primary aim of this study was to determine the stability of resilience and its association with depressive symptoms Methods: This study included 110 adults admitted to a Level I trauma center. Resilience and depression were measured at baseline and 12 months. Injury-related variables included Glasgow Coma Scale, Injury Severity Score, etiology of injury, and type of injury Results: Analysis revealed that resilience remained stable over 12 months regardless of injury severity, etiology, or type. Negative correlations were found between baseline resilience and 12-month depression (P <.01), as well as Glasgow Coma Scale and depression (P =.001) Conclusions: Injured individuals with low resilience are more likely to be depressed at 12 months. Assessing resilience at the time of injury may be useful in identifying those at risk for depression 1 year later.
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1 |
Surgical wound infection occurrence in clean operations; risk stratification for interhospital comparisons
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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A five year prospective study of surgical wound infection complicating eight clean elective operations was carried out in 9,108 community hospital patients by detailed stratification of risk. Remote infection, diabetes mellitus and/or operations lasting beyond 4 hours characterized high risk patients with disparate surgical wound infection rates of 1.7 percent to 7.9 percent for individual operations. Absence of these three factors defined a low risk population with statistically similar rates of 0.8 percent to 2.8 percent for the different operations, with an over-all rate of 1.5 percent. Low and high risk definitions derived from observations in eight hospitals in 1975-1977 were predictive in 12 hospitals in 1978-1979. Both classes of patients with surgical wound infection had prolonged postoperative hospitalization. Staphylococcus aureus was recovered from 50 percent of the surgical wound infections in low risk patients with hernia repair, hip fracture repair, hip prosthesis, laminectomy and mastectomy operations and from 5 percent with cesarean section, femoropopliteal bypass and hip replacement procedures (P less than 0.001). In nine high risk patients, bacteria recovered from remote infections were also present in surgical wound infections. Comparison of the occurrence of surgical wound infections in clean operations in different hospitals may be made more meaningful by stratification or risk factors and analysis of expected infecting bacteria
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0 |
Long-term results in children with massive bone osteoarticular allografts of the knee for high-grade osteosarcoma
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PJI DX Updated Search
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BACKGROUND: Reconstruction of distal femur or proximal tibia in growing patients is a challenge for the high rate of complications and limb length discrepancy at the end of growth. The purpose of this study was to evaluate the long-term outcome of children affected by high-grade osteosarcoma of the knee region, reconstructed by osteoarticular bone allograft of distal femur, and proximal tibia. METHODS: We retrospectively reviewed 25 patients treated for high-grade osteosarcoma, 13 in the distal femur and 12 in the proximal tibia. The mean follow-up was 124 months. Clinical and radiologic evaluation was carried out in the 20 long-term survivors with a minimum follow-up of 7 years from surgery. The rates of survival of the implants were estimated with use of the Kaplan-Meier method. Functional and radiographic evaluation was done according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up in all the patients that still had the allograft. RESULTS: Five patients died during the first 2 years of follow-up for disease-related causes. Of the remaining 20 osteoarticular allografts (10 of the distal femur and 10 of the proximal tibia), 12 failed: 4 in the distal femur and 8 in the proximal tibia. All the failures were related to a graft fracture, but in 4 patients with subchondral collapse the graft was maintained and converted into an allograft prosthetic composite. No deep infection of the primary reconstruction was observed. The overall rate of allograft survival was 70% at 5 years and 58% at 10 years in the distal femur, and 45% at 5 years and 20% at 10 years in the proximal tibia. At final follow-up, 8 patients still walked on the primary implant, 6 in the distal femur, and 2 in the proximal tibia. The functional outcome of these patients was evaluated as good in 5 patients (3 with distal femoral and 2 with proximal tibial allograft), and poor in 3. CONCLUSIONS: Although mechanical complications significantly affect the outcome, osteoarticular allografts may represent a viable option for reconstruction in children older than 8 with high-grade sarcomas about the knee. LEVEL OF EVIDENCE: Level IV
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Complications in lumbar fusion surgery for chronic low back pain: Comparison of three surgical techniques used in a prospective randomized study. A report from the Swedish Lumbar Spine Study Group
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DoD PRF (Psychosocial RF)
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The reported complication rates after various surgical techniques used to create a lumbar fusion vary within wide ranges. In a previous paper, the Swedish Lumbar Spine Study Group have reported on the clinical outcome of lumbar spine fusion for chronic low back pain in a comparably homogeneous patient population where there were no significant differences between baseline sociodemographic, clinical and paraclinical characteristics. In this report we compared the complication rates of the surgical procedures used in that study and analyzed the association between complications and baseline variables, and between outcome results and complications. A multicenter randomized study was conducted where 211 patients aged 25-65 were treated with lumbar fusion according to three different surgical techniques: noninstrumented posterolateral fusion (PLF, n=71), instrumented posterolateral fusion (VSP, n=68), and in the third procedure we added an interbody fusion with solid autogenous bone grafts ("360", n=72). We categorized complications as: early/late, major/minor. The association between complications and sociodemographic characteristics (age, gender, comorbidity, previous surgery, smoking), and technical variables (surgical technique, levels fused, hospital category) was analyzed. The association between outcome variables (patient global assessment, pain, disability, depressive symptoms) and complications was analyzed. A literature review was conducted. There was no mortality. There was no significant difference in clinical outcome between the surgical groups after 2 years, although the power to detect such a difference was low. The total complication rate after 2 years in the PLF group was 12%, compared with 22% in the VSP group, and 40% in the "360" group (P=0.0003). After exclusion of complications, there was still no difference in outcome between the groups. The odds ratio (confidence intervals) of having a complication was 5.3 (2.2-12.7) when "360" was used compared with PLF, and 2.4 (1.1-5.3) for "360" compared with VSP. There was no association between clinical outcome and complications on a group level. The reintervention rate was 6% in the PLF group, 22% in the VSP, and 17% in the "360" group (P=0.020). The odds ratio (confidence intervals) of having a reintervention was 4.0 (1.3-11.9) when instrumentation was used compared with non-instrumented fusion. In this prospective randomized study comparing three lumbar fusion techniques in a comparably homogeneous patient population, complications increased significantly with increasing technicality of the surgical procedure. Even though we did not find a significant association between clinical outcome and complications after 2 years, the increased morbidity inflicted on an individual patient was not negligible. In this light, and as no fusion technique produced superior clinical outcome irrespective of whether complications were included or excluded in the analyses, the patient and the treating physician should carefully discuss the possible advantages and drawbacks of the different surgical options before making a decision. In order to make valid comparisons of both complication and reintervention rates after lumbar fusion, there is a need for a consensus in the spinal society regarding the definition of these entities.
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Localized chronic suppurative bone infection as a sequel of peri-implantitis in a hydroxyapatite-coated dental implant
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Plaque-induced lesions can produce peri-implant bone loss with ultimate implant loss. Although the peri-implant tissues seem to be more resistant than the periodontal ones to plaque and calculus, they can produce a more extensive spread of the infection to the deeper tissues around implants. The case of a 45-year-old female patient is presented in which, over a three year period, there was a progressive loss of peri-implant bone and the formation of a periapical radiolucency with an external fistula. The implant was removed and examined with the cutting-grinding system. Microscopy examination showed that most of the hydroxyapatite (HA) was still adherent to the metal. There was a detachment in the area of the HA-titanium interface. The implant surface was almost completely covered by bacteria. Bacteria were also present in the bone medullary spaces surrounding the implant. The infection of the periodontal tissues had progressed into the alveolar bone, thus producing a localized bone infection. The cause of the implant failure is probably related to a defective connection of the abutment or to overloading of the implant due to the presence of interlocks in the prosthetic restoration
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0 |
Celecoxib 200 mg q.d. is efficacious in the management of osteoarthritis of the knee or hip regardless of the time of dosing
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVES: The primary objective was to demonstrate equivalence between a.m. and p.m. dosing of celecoxib 200 mg q.d. An equivalence assessment of q.d. vs b.i.d. dosing was a secondary objective. METHODS: In this randomized, doubleâ?blind study, patients with symptomatic osteoarthritis of the knee or hip were randomized to receive celecoxib 200 mg q.d. a.m., celecoxib 200 mg q.d. p.m. or celecoxib 100 mg b.i.d. The primary outcome variable, measured at week 12 on a 0â? to 10â?point integrated scale, was patient satisfaction assessment (pain relief, walking/bending, and willingness to continue medication). Equivalence was declared if the 95% confidence interval (CI) of the difference (a.m. q.d. vs p.m. q.d., b.i.d. vs q.d.) fell within the interval of â?2 to +2. RESULTS: A total of 697 patients were enrolled in this trial. For the a.m. vs p.m. comparison, the 95% CIs were within the prespecified equivalence criteria for all three measures of patient satisfaction: pain relief, mean â?0.2, 95% CI â?0.53 to 0.68; ability to walk and bend, mean â?0.2, 95% CI â?0.54 to 0.64; willingness to continue medication, mean â?0.7, 95% CI â?0.98 to 0.49. The 95% CIs for the q.d. vs b.i.d. comparison were also within the â?2 to +2 interval. CONCLUSION: Regardless of the time of day at which celecoxib 200 mg q.d. is administered, patients are equally satisfied with the pain relief, ability to walk and bend, and willingness to continue medication.
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0 |
The Effect of Preoperative Physical Status on Pain Management in Total Knee Arthroplasty Patients Receiving Adductor Canal Blockade
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AAHKS (9/10) Regional Nerve Blocks
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INTRODUCTION: Managing postoperative pain can be challenging for arthroplasty surgeons. While pain control modalities, such as adductor canal blockade (ACB), have been proven effective, the multifactorial nature of pain perception may serve as an obstacle for optimizing pain control. This study assesses the effect of patient pre-operative physical status on patient perception of pain. Specifically, we compared 1) lengths of hospital stay (LOS), 2) pain levels, and 3) opioid consumption in patients receiving total knee arthroplasty (TKA) who presented with an American Society of Anesthesiologists physical status score (ASA) of 2 and 3.
MATERIALS AND METHODS: A single hospital, single surgeon database was reviewed for patients who had TKA between January 2015 and April 2016. Only patients with an ASA class of 2 or 3 who received ACB were analyzed. This yielded 106 patients with a mean age of 63 years, comprised of 36 men and 70 women. Patients were stratified into those with an ASA class of 2 (n= 58) and those with an ASA class of 3 (n= 48). Electronic medical records were reviewed to obtain demographic and endpoint data. Pain was quantified using Visual Analog Scale (VAS). Continuous variables were compared using the student' s t-test and analysis of variance, while categorical variables were compared using chi-square analysis.
RESULTS: There was no significant difference found between the two groups in LOS (2.25 days vs. 2.19 days; p=0.805), VAS scores (4.95 vs. 5.75; p=0.306), and opioid consumption on day 0 (17.77 morphine eq vs. 23.49 morphine eq; p=0.233) and day 3 (9.11 morphine eq vs. 19.87 morphine eq; p=0.100). However, patients with an ASA score of 2 had a significantly lower opioid consumption on day 1 (32.20 morphine eq vs. 52.70 morphine eq; p=0.049), day 2 (19.21 morphine eq vs. 40.71 morphine eq; p=0.018), and overall (78.30 morphine eq vs. 135.77 morphine eq; p=0.024).
CONCLUSION: Despite the effectiveness of ACB in controlling pain, patient pre-operative status may affect perception of pain. This study demonstrates that patients with a higher ASA physical status classification consumed more opioid medication postoperatively, despite having similar pain scores and lengths of stay to those with a lower classification. Future studies should assess all ASA classifications and stratify for preoperative opioid consumption and tolerance as a possible confounder.
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0 |
Musculoskeletal ultrasonography in patients with rheumatoid arthritis
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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In the current paradigm for management of patients with rheumatoid arthritis (RA), obtaining clinical remission of symptoms remains the most important aim, but achieving radiographic remission is another key goal of treatment. Several parameters detectable by musculoskeletal ultrasonography can predict the development of severe RA, as well as monitor patients' responses to treatment; thus, musculoskeletal ultrasonography is widely used for evaluating patients with RA, both in clinical trials and in clinical practice. This Review describes the applications of musculoskeletal ultrasonography in patients with RA, focusing on the identification of ultrasonographic features that predict the development of erosions. Such predictive markers include high vascularity of synovitis, persistent synovitis, tenosynovitis of the extensor carpi ulnaris tendon, and erosive changes in the distal ulna. This article also describes ultrasonographic scores that could feasibly be integrated into daily rheumatology practice for the evaluation of patients with RA. (copyright) 2013 Macmillan Publishers Limited. All rights reserved
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0 |
Simple bone cysts: Better with age?
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Methods: Twenty four subjects with SBC who participated in a prior randomized clinical trial but had not healed at trial conclusion were evaluated for cyst healing. The following clinical and radiographic data were evaluated: age, sex, pain (Visual Analogue Scale), functional health (Short Form 36), subsequent fracture, involved bone, cyst area (cm3), distance from physis (cm), endosteal thickening (yes/no), scalloping (no new scalloping/ new scalloping), opacity/radiolucency (as is), loculation (yes/ no), trabeculation (yes/no), tubulation (yes/no), transition zone (sharp/wide), geographic borders (geographic nonpermeative/ nongeographic permeative), radiodense rim (>50%/no rim), and growth plate status (open/closed). Cyst healing was graded as: 1-cyst clearly visible; 2-cyst visible but multilocular and opaque; 3-sclerosis around or within a partially visible cyst; or 4-complete healing with obliteration of cyst. Healing was defined as grade 4. Purpose: The purpose of this study was to evaluate whether simple bone cysts (SBC) resolve with age. Results: Of 24 subjects, 15 (63%) were male, 18 (75%) cysts were located in the humerus, and 4 (25%) in the femur. Patients were followed for 7.0±1.0 years following initial treatment with a mean age at follow-up of 17.2±3.2 years and 14 (87%) of growth plates were closed. Pain was minimal (0.6/10), function was high (91/100), and none of the patients had experienced subsequent fractures. Although distance from physeal scar had increased (P<0.0001), cyst area reduction (P<0.1) and overall cyst healing (P<0.2) had not changed. Of the 24 subjects, none were graded as healed at time of follow-up. Of the remaining radiographic variables, only decreased loculation (P<0.02) and increased endosteal thickening (P<0.04) showed significant changes. Conclusion: Despite the assumption that most SBC will resolve with skeletal maturity, this study indicates that none of the cysts were graded as completely healed although 87% of growth plates were closed. Significance: Growth plate closure may not signify healing of SBC and although symptoms and fractures are rare, further studies are needed to follow patients with SBC through early adulthood.
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1 |
Clinical results of arthroscopic meniscal repair using biodegradable screws
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AMP (Acute Meniscal Pathology)
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This study was performed to assess the clinical results of meniscus refixation using biodegradable Clearfix meniscal screws. Between July 1999 and June 2001 this technique was performed on 65 patients, of whom 60 (27 women, 33 men; 92%) were followed up by clinical examination after an average of 18 months (range 8-34). The average age of the patients at the time of surgery was 30 years (15-58). Two patients had already undergone a partial meniscectomy at the time of follow up; three patients had had a recurrence of typical clinical signs of a meniscal tear. The other 55 patients rated the overall clinical result as "excellent" (n=21), "good" (n=31) or "satisfactory" (n=3). The average Lysholm score [20] at the time of examination was 93 (49-100) points. The Tegner-Lysholm activity grade [29] preinjury was 5.6 (3-9), compared to a grade of 5.1 (3-9) at the follow-up examination. As a result of our study, biodegradable screws can be recommended as fixation devices with a high rate of good and excellent clinical results.
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0 |
Analysis of Low-Field Magnetic Resonance Imaging Scanners for Evaluation of Knee Pathology Based on Arthroscopy
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Osteochondritis Dissecans 2020 Review
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BACKGROUND: In recent years, few studies have evaluated low-field magnetic resonance imaging (MRI) diagnoses compared with intraoperative findings of the knee. PURPOSE: To determine the accuracy and sensitivity of low-field MRI scanners in diagnosing pathology of the menisci, cruciate ligaments, and osteochondral surfaces. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: MRI examinations without intra-articular contrast were performed on 379 patients for knee pathologies over a 4-year period. The MRI examinations were done using a 0.2-tesla scanner utilizing a dedicated knee coil and read by 1 of 3 board-certified, musculoskeletal fellowship-trained radiologists. Within a mean time of 50 days after MRI, all patients underwent knee arthroscopy performed by 1 of 2 sports fellowship-trained orthopaedic surgeons. Operative notes from the knee arthroscopies were then reviewed by a single independent observer, and the intraoperative findings were compared with the MRI reports. RESULTS: For medial meniscus tears, the sensitivity, specificity, positive predictive value, and negative predictive value were 83%, 81%, 89%, and 71%, respectively. For lateral meniscus tears, the values were 51%, 93%, 84%, and 73%, respectively. For anterior cruciate ligament (ACL) tears, the values were 85%, 94%, 69%, and 97%, respectively. For osteochondral lesions, the values were 8%, 99%, 29%, and 94%, respectively. For posterior cruciate ligament (PCL) tears, the specificity and negative predictive value were 99% and 100%, respectively. CONCLUSION: Low-field MRI was an accurate tool for evaluation of medial meniscus and ACL tears. However, within the study population, it is not as effective in diagnosing lateral meniscus tears and showed a poor ability to detect osteochondral lesions. More information is needed to properly assess its ability to diagnose PCL tears.
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0 |
Evidence that popliteal fat provides damping during locomotion in the cat
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Panniculectomy & Abdominoplasty CPG
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Current models and concepts of motor control represent the limb as a neuro-musculoskeletal system and rarely include other potentially important supporting tissues such as fascia and adipose tissue. It is possible that a normal complement of adipose tissue could contribute to the viscoelastic properties of supporting limbs and enhance stability during locomotion. The purpose of this study was to determine if the popliteal fat pad plays a role in locomotion in the cat. It is hypothesized that the fat pad limits flexion and reduces angular acceleration of the included hip, knee and ankle joints in the sagittal plane throughout the step cycle. 3D kinematics from 3 spontaneously locomoting decerebrate cats both before and after lipectomy were recorded during treadmill walking. Four time points throughout the step cycle were chosen for angular acceleration analysis: mid-stance, paw off, mid-swing and peak deceleration at the end of the re-extension of the knee. Significant increases in maximum angular acceleration for the hip, knee and ankle joints at these time points were observed. No significant increase in range of motion was found across all 3 included angles after lipectomy. Therefore, the hypothesis that the popliteal fat pad acts to decrease the angular acceleration is supported by these findings. The data indicate that the popliteal fat pad contributes to the damping component of the viscoelastic properties of the limb. These results may be applied to models of the hindlimb and knowledge of the effects of obesity on movement.
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Prevalence of persistent pain in the U.S. Adult population: new data from the 2010 national health interview survey
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Published adult prevalence estimates of chronic pain in the United States vary significantly. A more consistent pain measure is needed to assess unmet need for pain management in the general population. In this study, secondary analyses of the 2010 Quality of Life Supplement of the National Health Interview Survey are used to calculate the point prevalence of "persistent pain," which we defined as constant or frequent pain persisting for at least 3 months. Rates of persistent pain are also calculated by risk group, chronic condition, and disability status. Findings show that about 19.0% of adults in the United States report persistent pain. Rates of persistent pain are higher among women, adults aged 60 to 69, adults who rate their health as fair or poor, adults who are overweight or obese, and those who were hospitalized 1 or more times in the preceding year. Most adults who report conditions such as arthritis, carpal tunnel syndrome, or back or joint pain do not describe their pain as "persistent." Of the estimated 39.4 million adults who report persistent pain, 67.2% say their pain is "constantly present," and 50.5% say their pain is sometimes "unbearable and excruciating." PERSPECTIVE: Persistent pain, defined as self-reported pain "every day" or "most days" in the preceding 3 months, is a useful way to characterize health-related quality of life in the general population, and policy makers should consider including this core measure in ongoing health surveys like the National Health Interview Survey and the Medical Expenditure Panel Survey, the authors conclude
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The safety of liposuction: Results of a national survey
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND. Liposuction procedures are increasing in frequency and may be performed in hospitals, ambulatory surgery centers, or physician offices. Deaths associated with liposuction and previous surveys of liposuction safety have raised concern about the safety of office-based surgery. OBJECTIVE. To determine the safety of office-based, tumescent liposuction among dermatologic surgeons. METHODS. A survey mailed out to dermatologic surgeons in August 2001 requested retrospective information regarding the number of patients undergoing liposuction, the setting in which the procedures were performed, and the complications that occurred during the 7-year period from 1994 to 2000. A detailed complication record was requested for each serious adverse event or death reported. Surveys were mailed to 517 worldwide members of the American Society for Dermatologic Surgery (ASDS) listed as performing liposuction; 505 had adequate contact information. The main outcome mesure was the rate of serious adverse events (SAEs) or deaths per 1000 liposuction procedures for each service setting and for each level of conscious sedation. RESULTS. The overall response rate was 89% (450/505), and of these, 78% (349/450) perform liposuction. A total of 267 dermatologic surgeons completed the survey; 261 provided data on 66,570 liposuction procedures. No deaths were reported. The overall serious adverse event rate was 0.68 per 1000 cases. The SAE rates were higher for hospitals and ambulatory surgery centers than for nonaccredited office settings. SAE rates were also higher for tumescent liposuction combined with intravenous or intramuscular sedation than combined with oral or no sedation. CONCLUSION. Office-based tumescent liposuction performed by dermatologic surgeons is safe, with a lower complication rate than hospital-based procedures. Future legislation should recognize the proven safety of this procedure as performed by dermatologic surgeons in their offices.
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0 |
Treatment of myeloma in patients not eligible for transplantation
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MSTS 2018 - Femur Mets and MM
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Multiple myeloma (MM) remains an incurable disease for most patients, with a median survival of 4 to 5 years. High-dose chemotherapy followed by transplantation has resulted in improvement in response rates and survival compared with conventional therapy, but relapse is nearly universal and not all patients are candidates for this option of aggressive treatment. Standard therapeutic strategies for newly diagnosed patients not eligible for transplantation include pulsed high-dose dexamethasone, melphalan with prednisone, and vincristine in combination with doxorubicin and dexamethasone, as well as other combinations of alkylating agents. Emerging therapies under clinical investigation for first-line therapy include thalidomide, the thalidomide analog lenalidomide, and the proteasome inhibitor bortezomib alone and in combination with other agents, particularly dexamethasone. At an interim analysis, thalidomide combined with melphalan and prednisone was shown to induce a complete or near complete remission (CR) rate of 28% and overall (complete + partial) response rate of 77% in elderly patients generally not eligible for transplantation. These results are comparable to those obtained with high-dose therapy and may obviate transplantation in these patients. Induction therapy with bortezomib-based combinations induces complete and near complete remissions in a similar proportion of patients. These regimens include bortezomib and dexamethasone alone and in combination with doxorubicin, thalidomide, or melphalan. Use of thalidomide or bortezomib does not preclude stem cell harvest. Survival benefits need to be firmly established before these novel regimens emerge as the new standard of care for newly diagnosed disease. However, front-line treatment with combinations involving these agents is a promising strategy that may improve the standard of care for patients both eligible and ineligible for stem cell transplantation. Copyright © 2005 by Current Science Inc.
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Comparison of frailty metrics and the Charlson Comorbidity Index for predicting adverse outcomes in patients undergoing surgery for spine metastases
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MSTS 2022 - Metastatic Disease of the Humerus
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OBJECTIVE: Frailty-the state defined by decreased physiological reserve and increased vulnerability to physiological stress-is exceedingly common in oncology patients. Given the palliative nature of spine metastasis surgery, it is imperative that patients be healthy enough to tolerate the physical insult of surgery. In the present study, the authors compared the association of two frailty metrics and the widely used Charlson Comorbidity Index (CCI) with postoperative morbidity in spine metastasis patients. METHODS: A retrospective cohort of patients who underwent operations for spinal metastases at a comprehensive cancer center were identified. Data on patient demographic characteristics, disease state, medical comorbidities, operative details, and postoperative outcomes were collected. Frailty was measured with the modified 5-item frailty index (mFI-5) and metastatic spinal tumor frailty index (MSTFI). Outcomes of interest were length of stay (LOS) greater than the 75th percentile of the cohort, nonroutine discharge, and the occurrence of = 1 postoperative complication. RESULTS: In total, 322 patients were included (mean age 59.5 ± 12 years; 56.9% of patients were male). The mean ± SD LOS was 11.2 ± 9.9 days, 44.5% of patients had nonroutine discharge, and 24.0% experienced = 1 postoperative complication. On multivariable analysis, increased frailty on mFI-5 and MSTFI was independently predictive of all three outcomes: prolonged LOS (OR 1.67 per point, 95% CI 1.06-2.63, p = 0.03; and OR 1.63 per point, 95% CI 1.29-2.05, p < 0.01, respectively), nonroutine discharge (OR 2.65 per point, 95% CI 1.74-4.04, p < 0.01; and OR 1.69 per point, 95% CI 1.36-2.11, p < 0.01), and = 1 complication (OR 1.95 per point, 95% CI 1.23-3.09, p = 0.01; and OR 1.41 per point, 95% CI 1.12-1.77, p < 0.01). CCI was found to be independently predictive of only the occurrence of = 1 postoperative complication (OR 1.45 per point, 95% CI 1.22-1.72, p < 0.01). CONCLUSIONS: Frailty measured with either mFI-5 or MSTFI scores was a more robust independent predictor of adverse postoperative outcomes than the more widely used CCI. Both mFI-5 and MSTFI were significantly associated with prolonged LOS, higher complication rates, and nonroutine discharge. Further investigation in a prospective multicenter cohort is merited.
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High morbidity and mortality after lower extremity injuries in Malawi: A prospective cohort study of 905 patients
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Developmental Dysplasia of the Hip 2020 Review
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Introduction A lower extremity injury can be a devastating event in low-income countries due to limited access to surgical care. Its incidence, treatment patterns, and outcomes, however, have not been well-described. Methods We prospectively enrolled all patients admitted with lower extremity trauma to a tertiary hospital in Lilongwe, Malawi between October 2010 and September 2011. Patients with a lower extremity injury but primarily admitted for unrelated reasons were excluded. The outcomes were deaths, complications, and length of hospital stay. Results Of the 905 patients eligible for analysis, 696 (77%) were males. Most patients had femur fractures (46%), and most were treated non-operatively (70%). Overall mortality rate was 3.9%. For adult patients with femur fractures, mortality was higher in patients treated with traction (9.0%) than for those treated with surgery (1.3%). The total complication rate was 15%, with adjusted odds of developing a complication higher in patients with concurrent head injury (ORÂ =Â 2.8; 95% CI: 1.3â??6.0), and patients who had an operative treatment (ORÂ =Â 2; 95% CI: 1.2â??1.9). The median length of stay was 16 days (IQR: 6â??27) and was greatest among patients with femur fractures. Conclusion Lower extremity injuries resulted in substantial mortality and morbidity in this low-income country. Mortality was particularly high among patients with femur fractures who did not have surgery. Modern orthopedic trauma surgery is greatly needed in low-income countries.
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1 |
The Suprapubic Dermoadipose Flap for Aesthetic Reshaping of the Postpregnancy Abdomen
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Panniculectomy & Abdominoplasty CPG
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Background: Postpregnancy full-length diastasis of the recti abdominis muscles is a common condition occasionally associated with atrophy of the subcutaneous fat located at the midline above and below the umbilicus. Objectives: The authors report a preliminary clinical experience with the suprapubic flap to prevent the late postoperative contour deformities of the postpregnancy abdomen. Methods: Between January 2005 and January 2015, all female patients undergoing abdominoplasty with the suprapubic flap were included in the present study. Electronic clinical records were reviewed to analyze the patients' ages, body mass index (BMI) scores, pregnancies, risk factors, and operative times, followed by a telephone-based survey to measure patient satisfaction. Results: Twenty-two patients were included. Their ages ranged from 19 to 36 years (mean, 27 years) and their BMI ranged from 17.5 to 22.5 kg/m2 (mean, 20.5 kg/m2). Postoperative follow up ranged from 12 months to 10 years (mean, 89 months). All patients had experienced at least one pregnancy and many of them multiple or twin pregnancies. Umbilical hernias were present in 18 patients. There were 5 unusual cases: one hematoma, one seroma, and three cases of hypertrophic scarring. Thirteen additional minutes were required, on average, to associate the flap. All patients were satisfied or very satisfied with the results. Conclusions: The suprapubic dermoadipose flap is an effective option to prevent the midline depression that would otherwise remain on the hypogastric region of postpregnant slim women with midline fat tissue atrophy. Level of Evidence 4:
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A technical note on the reduction of distal radius fractures with angular stable plates
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Distal Radius Fractures
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Plating of distal radius fractures is a common procedure. Especially in busy practices the procedure is mostly performed by a single surgeon. By the use of a distance holder screw in the most proximal hole of the shaft of an angular stable distale radius plate a Lever arm can be created that allows indirect reduction of a dorsal ly displaced distal radius fracture. The method described here may facilitate the Operation in that the articular block can be securely fixed while the plate is stable centered on the shaft of the radius. Especially for single surgeon operations this may save time. In contrast the costs of an extra angular stable screw must be accepted.
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Sequential scintimetry after femoral neck fracture. Methodologic aspects and prediction of healing complications
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Management of Hip Fractures in the Elderly
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Forty-five patients with recent cervical hip fractures were included in a prospective, clinical, radiographic and sequential scintimetric study. Striking changes in radionuclide uptake over the entire hip region on the fracture side were found during the first 5 postoperative months. Fractures that healed without complications showed the highest relative femoral head uptake at 1 week and a peak value at 6 weeks, followed by a gradual decline at the subsequent examinations. Fractures with complications (redisplacement, nonunion, or late segmental collapse) showed a lower initial uptake and a more gradual increase and only a slight tendency towards increased uptake after 3 months. The accuracy in predicting nonunion with scintimetric examination alone is high both at 1 and at 6 weeks, and the accuracy is almost equally high with combined scintimetric, radiographic, and clinical assessment 3-5 months postoperatively
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Is the delay to surgery for isolated hip fracture predictive of outcome in efficient systems?
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Hip Fx Time to Surgery
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BACKGROUND: Adverse outcomes for patients with isolated hip fracture have been documented when preoperative delay is longer than 48 hours. An efficient system will have the capacity to repair all hip fractures within 48 hours. We hypothesized that in an efficient system, there would be a medical justification for a delay greater than 48 hours. The purpose of this study was to identify the causes and outcome of delay for hip surgery in an efficient system. METHODS: All patients with isolated hip fracture admitted to a regional trauma center from April 1993 to March 2003 were reviewed. Demographics, presence of comorbidity, preoperative delay, complications, and mortality were collected. Univariate and multivariate analysis were carried out. RESULTS: The cohort included 977 patients. Overall mortality was 12.2%. Surgery was performed within 24 hours in 53% of cases and within 48 hours in 87% of cases. The presence of comorbidity partly explained longer (>48 hours) surgical delays. Multivariate analysis revealed that age greater than 65, male sex, and the presence of pulmonary and cardiac comorbid conditions or an active cancer but not surgical delay were associated with mortality and complications. However, surgical delay was associated with longer postsurgical hospital stay, independently of the presence of comorbidity or increasing age. CONCLUSIONS: Preoperative delay does not entail adverse outcomes when the surgery is delayed to allow for treatment of comorbid medical conditions. Preoperative delay is associated with a longer hospital stay. The presence of comorbidity only partly explains preoperative delay and adverse outcomes. A prospective study coding for the severity of comorbid conditions and the justification of the preoperative delay will be required to fully elucidate the link between delay and outcome.
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An integrated AMLAB-based system for acquisition, processing and analysis of evoked EMG and mechanical responses of upper limb muscles
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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An integrated multi-channel AMLAB-based data acquisition, processing and analysis system has been developed to simultaneously display, quantify and correlate electromyographic (EMG) activity, resistive torque, range of motion, and pain responses evoked by passive elbow extension in humans. The system was designed around the AMLAB analog modules and software objects called ICAMs. Each channel consisted of a time and frequency domain block, a torque and angle measurement block, an experiment number counter block and a data storage and retrieval block. The captured data in each channel was used to display and quantify: raw EMG, rectified EMG, smoothed rectified EMG, root-mean-squared EMG, fast Fourier transformed (FFT) EMG, and normalized power spectrum density (NPSD) of EMG. Torque and angle signals representing elbow extension measured by a KIN-COM dynamometer during neural tension testing, as well as signals from an electronic pain threshold marker were interfaced to AMLAB and presented in one integrated display. Although this system has been designed to specifically study the patterns and nature of evoked motor responses during clinical investigation of carpal tunnel syndrome (CTS) patients, it could equally well be modified to allow acquisition, processing and analysis of EMG signals in other studies and applications. In this paper, we present for the first time the steps involved in the design, implementation and testing of an integrated AMLAB-based system to study and analyse the mechanically evoked electromyographic, torque and ROM signals and correlate various levels of pain to these signals. We also present samples of resistive torque ROM, and raw and processed EMG recordings during passive elbow extension
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Infection Rate of Intramedullary Nailing in Closed Fractures of the Femoral Diaphysis After Temporizing External Fixation in an Austere Environment
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Pediatric Diaphyseal Femur Fractures 2020 Review
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OBJECTIVES: To determine the infection rate of intramedullary (IM) nailing of closed diaphyseal femur fractures after temporary stabilization with external fixation in an austere combat environment. DESIGN: Retrospective case series. SETTING: Iraq and Afghanistan Theater and Military Medical Treatment Centers in the United States and Landstuhl, Germany. PATIENTS: Military personnel who underwent temporizing external fixation of a closed diaphyseal femur fracture (OTA 32) with later conversion to an IM nail between 2003 and 2012. INTERVENTION: Patients were identified from the Joint Theater Trauma Registry and Department of Defense electronic medical record, and a retrospective review was performed. MAIN OUTCOME MEASUREMENTS: Variables measured included age, gender, mechanism of injury, Injury Severity Score, associated injuries (to include thoracic and abdominal injuries), base deficit, history of massive transfusion, date of injury, date and place of external and IM fixations, time to conversion procedure, report of superficial or deep infection, report of fracture union, and date of last follow-up. RESULTS: One hundred twenty-two patients, mean age 25 (18-43) years, sustained 125 closed femoral diaphyseal fractures from May 2003 to July 2012. External fixation was performed at a mean of 0.2 days (median of the day of injury) and a range of 0-3 days. Mean time to IM nail conversion procedure was 6.9 (1-20) days. Infection rate was 2.5%, with a P of 0.188. Average follow-up was 41.4 (12-119) months. CONCLUSIONS: Acceptable low infection rates can be achieved after IM nailing of closed diaphyseal femur fractures treated with initial external fixation in an austere combat environment. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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1 |
Streamlining an existing hip fracture patient pathway in an acute tertiary adult Irish hospital to improve patient experience and outcomes
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Hip Fx in the Elderly 2019
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OBJECTIVE: To improve access for hip fracture patients to surgery within 48 h of presentation to the Emergency Department, and to increase the number of patients receiving pre-operative orthogeriatric review, through streamlining an existing hip fracture patient pathway.
DESIGN: A pre-post design involving a multi-disciplinary team use of the Define, Measure, Analyse, Improve and Control framework integral to Lean Six Sigma (LSS) methodology, to assess and adapt the existing hip fracture pathway from presentation to Emergency Department to the initiation of surgery.
SETTING: A 600-bed teaching hospital in Ireland.
PARTICIPANTS: Nursing, medical, administrative and physiotherapy staff working across Emergency Medicine, Orthogeriatrics and Orthopaedic Specialities and Project management.
INTERVENTIONS: LSS methodology was used to redesign an existing pathway, improving patient access to ortho-geriatrician assessment, pain relief and surgery in line with the Irish Hip Fracture Data Base Key performance indicators.
MAIN OUTCOME MEASURES: Access to pain relief, access to surgery and volume of patients receiving ortho-geriatric assessment.
RESULTS: The percentage of patients undergoing surgery within 48 h of presentation to Emergency Department increased from 55% to 79% at 3 months, and to 85% at 6 months. Improvements were also achieved in the secondary performance metrics relevant to quality of patient care. All care pathway changes were cost neutral.
CONCLUSIONS: Hip fracture surgery within 48 h of presentation to hospital is a recognized standard of hip fracture care associated with decreased length of stay and decreased mortality. With respect to this performance metric, this intervention has contributed to improved patient outcomes.
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Mapping phantom movement representations in the motor cortex of amputees
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
|
Limb amputation results in plasticity of connections between the brain and muscles, with the cortical motor representation of the missing limb seemingly shrinking, to the presumed benefit of remaining body parts that have cortical representations adjacent to the now-missing limb. Surprisingly, the corresponding perceptual representation does not suffer a similar fate but instead persists as a phantom limb endowed with sensory and motor qualities. How can cortical reorganization after amputation be reconciled with the maintenance of a motor representation of the phantom limb in the brain? In an attempt to answer this question we explored the relationship between the cortical representation of the remaining arm muscles and that of phantom movements. Using transcranial magnetic stimulation (TMS) we systematically mapped phantom movement perceptions while simultaneously recording stump muscle activity in three above-elbow amputees. TMS elicited sensations of movement in the phantom hand when applied over the presumed hand area of the motor cortex. In one subject the amplitude of the perceived movement was positively correlated with the intensity of stimulation. Interestingly, phantom limb movements that the patient could not produce voluntarily were easily triggered by TMS, suggesting that the inability to voluntarily move the phantom is not equivalent to a loss of the corresponding movement representation. We suggest that hand movement representations survive in the reorganized motor area of amputees even when these cannot be directly accessed. The activation of these representations is probably necessary for the experience of phantom movement. (copyright) The Author (2006). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved
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1 |
Lipoabdominoplasty with Anatomical Definition
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: In the past two decades, lipoabdominoplasty has increased in popularity worldwide, presenting low rates of complications and morbidity when the proper surgical steps are followed. The authors present an update of the lipoabdominoplasty technique with the addition of an abdominal definition and standardized steps for its safe execution, an initial personal experience with the procedure that improves the aesthetic results. METHODS: Anatomical limits are described for preoperative markings for selective liposuction with abdominal definition. Specific areas of the abdomen are presented to differentiate the areas for an intense or moderate liposuction and the areas for superficial and deep liposuction for anatomical definition. The principles of traditional lipoabdominoplasty are also described and maintained. The initial experiences with 128 patients undergoing the technique are included. RESULTS: One hundred twenty-eight patients were operated on by the senior author (O.S.) from 2016 to 2019 using the described technique. One patient presented with a seroma (0.8 percent), and two had a small skin epitheliolysis (1.5 percent). No other major complications were observed. It is the senior author's opinion that the obtained aesthetic results from the lipoabdominoplasty with definition are superior to those of the traditional technique, as it enhances the natural contour of the abdomen. CONCLUSIONS: Lipoabdominoplasty with anatomical definition has improved the aesthetic results of traditional lipoabdominoplasty without compromising the safety of that technique. More natural results along the abdominal contour that avoid a completely flat abdomen have been observed by most patients. This approach is safe and reproducible, with low complication rates, and it effectively enhances body contour.
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0 |
Nerve entrapment syndromes in musicians
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Nerve entrapment syndromes are common in instrumental musicians. Carpal tunnel syndrome, ulnar neuropathy at the elbow, and thoracic outlet syndrome appear to be the most common. While electrodiagnostic studies may confirm the diagnosis of nerve entrapment, they may be falsely normal in musicians. Non-operative treatment with instrument and technique modification may help. Involvement with the musician's teacher to implement appropriate treatment is recommended. Outcomes for both non-operative and operative treatment for various nerve entrapment syndromes have yielded mostly good to excellent results, similar to the general population
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Improved prediction of knee osteoarthritis progression by genetic polymorphisms: the Arthrotest Study
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: The aim of this study was to develop a genetic prognostic tool to predict radiographic progression towards severe disease in primary knee OA (KOA) patients. METHODS: This investigation was a cross-sectional, retrospective, multicentric association study in 595 Spanish KOA patients. Caucasian patients aged >/=40 years at the time of diagnosis of primary KOA of Kellgren-Lawrence grade 2 or 3 were included. Patients who progressed to Kellgren-Lawrence score 4 or who were referred for total knee replacement within 8 years after diagnosis were classified as progressors to severe disease. Clinical variables of the initial stages of the disease (gender, BMI, age at diagnosis, OA in the contralateral knee, and OA in other joints) were registered as potential predictors. Single nucleotide polymorphisms and clinical variables with an association of P < 0.05 were included in the multivariate analysis using forward logistic regression. RESULTS: A total of 23 single nucleotide polymorphisms and the time of primary KOA diagnosis were significantly associated with KOA severe progression in the exploratory cohort (n = 220; P < 0.05). The predictive accuracy of the clinical variables was limited: area under the curve (AUC) = 0.66. When genetic variables were added to the clinical model (full model), the prediction of KOA progression was significantly improved (AUC = 0.82). Combining only genetic variables (rs2073508, rs10845493, rs2206593, rs10519263, rs874692, rs7342880, rs780094 and rs12009), a predictive model with good accuracy was also obtained (AUC = 0.78). The predictive ability for KOA progression of the full model was confirmed on the replication cohort (two-sample Z-test; n = 62; P = 0.190). CONCLUSION: An accurate prognostic tool to predict primary KOA progression has been developed based on genetic and clinical information from OA patients
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Validity and reliability of a shoe-embedded sensor module for measuring foot progression angle during over-ground walking
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OAK 3 - Non-arthroplasty tx of OAK
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Wearable systems are becoming increasingly popular for gait assessment outside of laboratory settings. A single shoe-embedded sensor module can measure the foot progression angle (FPA)during walking. The FPA has important clinical utility, particularly in populations with knee osteoarthritis, as it is a target for biomechanical treatments. However, the validity and the day-to-day reliability of FPA measurement using wearable systems during over-ground walking has yet to be established. Two gait analysis sessions on 20 healthy adults were conducted. During both sessions, participants performed natural over-ground walking in a motion capture laboratory and on a 100 m linear section of outdoor athletics track. FPA was measured in the laboratory via marker trajectory data, while the sensor module measured FPA during the outdoor track walking. Validity was examined by comparing the laboratory- and sensor-measured average FPA. Day-to-day reliability was examined by comparing the sensor-measured FPA between the first and second gait analysis sessions. Average absolute error between motion capture and sensor measured FPA were 1.7° and 2.1° at session 1 and 2, respectively. A Bland and Altman plot indicated no systematic bias, with 95% limit of agreement widths of 4.2° â?? 5.1°. Intraclass correlation coefficient (ICC2k)analysis resulted in good to excellent validity (ICC = 0.89 â?? 0.91)and reliability (ICC = 0.95). Overall, the shoe-embedded sensor module is a valid and reliable method of measuring FPA during over-ground walking without the need for laboratory equipment.
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0 |
Estimated prevalence and patterns of presumed osteoporosis among older Americans based on Medicare data
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HipFx Supplemental Cost Analysis
|
Introduction: Estimates of osteoporosis (OP) prevalence based on bone mineral density testing and fracture occurrence may be imprecise for small demographic groups. Medicare data are a useful supplemental source of information on OP. Methods: We studied people ages (greater-than or equal to)65 years covered by Medicare 2005. Cases of presumed OP were beneficiaries with physician services or inpatient claims for OP or for an associated fracture (hip, distal forearm, spine) in 1999-2005. Results: Among 911,327 beneficiaries with 6 or 7 years of Medicare coverage, the overall prevalence of OP and associated fractures was 29.7%. Prevalence was four times higher for women than men, increased with age, and was two times higher for whites, Hispanic Americans, and Asian Americans than African Americans. Among people with OP-associated fracture claims, the proportion with an OP diagnosis was 49.7% overall (women, 57.1%; men, 21.9%) and was lower for men than women and for African Americans than other ethnic groups. Conclusions: The low proportion of beneficiaries who had an OP-associated fracture and also had an OP diagnosis, particularly among men and African American women, suggests suboptimal recognition and management of OP. Study limitations included lack of validation of our definition of OP and potential misclassification of race/ethnicity. (copyright) 2009 International Osteoporosis Foundation and National Osteoporosis Foundation
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0 |
Results of treatment of subtrochanteric femoral fractures with the AO/ASIF Long Trochanteric Fixation Nail (LTFN)
|
Hip Fx in the Elderly 2019
|
PURPOSE OF THE STUDY: This retrospective study reports on the clinical results of a group of 23 patients with subtrochanteric femoral fractures using the Long Trochanteric Fixation Nail (LTFN). MATERIAL: Between January 2005 and January 2008, 23 patients (20 women, 3 men; average age: 64.8 years old) with subtrochanteric femoral fractures were treated surgically. According to the AO/ASIF Classification, the most frequent fracture type was an 32-A1. They were also classified regarding the Seinsheimer Classification, in which the commonest type was the IIB. Of the 23 fractures, 14 of them had been the result of an unexpected fall, 2 were the result of a high-energy trauma and 7 consisted of pathologic fractures. METHODS: All the patients were treated using the LTFN device and they all received clinical and radiological follow-ups at least until their fractures were consolidated. The average surgery time, average decrease in haemoglobin in the first 24 hours post-surgery, average need for red blood cell transfusion, postoperative mortality at a 6th month follow-up, time to autonomous deambulation, most frequent destination at the time of discharge, average time for consolidation of the fracture and average follow-up time were reported. Intraoperative and postoperative complications were also recorded. RESULTS: The average surgery time from cut to stitch was 97.45 minutes with the decrease in haemoglobin averaging 26.45 g/L and, on average, the need for red blood cell transfusion was 1.12 concentrates. In the first postoperative week, 57.1% of the total number patients were capable of deambulation. The time to hospital discharge was 12.9 days. After an average follow-up of 13.9 months, total weightbearing was achieved in the 64.7% of the patients. The average consolidation time was 21.6 weeks and none of the patients developed pseudoarthrosis. Technical failures were seen in 4.3% of the cases: 1 patient suffered a migration of the distal locking screw. There were no cases of deep infection, cut-out, bending/breaking of the implant, malrotation or fracture of the femoral shaft at the tip of the implant. DISCUSSION: From a mechanical point of view the use of a long intramedullary nail in combination with a blade or a screw seems to be the most appropriate treatment for subtrochanteric fractures of the femur. Despite the improvement of implants and surgical techniques, failures due to complications are still considerable. The low distal shaft diameter of the LTFN, in combination with an extremely precise positioning of the blade in the middle of the femoral head, can prevent mechanical complications. Open reduction and cerclage cabling may be required so as to obtain a correct alignment of the fracture. CONCLUSSION: We conclude that the LTFN is a safe and reliable intramedullary device for the treatment of subtrochanteric fractures of the femur. Deambulation within the first postoperative surgery is possible when positioned properly. Its implantation requires more surgical time than the standard nails.
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