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Self-management of injection-related wounds among injecting drug users
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DoD PRF (Psychosocial RF)
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Injection-related wounds are an important complication of injection drug use. This study describes behaviors related to self-management of injection-related wounds and identifies factors associated with behaviors that may increase the potential for harm. We conducted interviews with 101 injecting drug users in Washington, DC. A total of 82 (81.2%) injecting drug users reported ever having an injection-related wound, and of these 93.9% reported self-management of their wounds. The most commonly reported behaviors were cleaning and applying ointment to wounds; however, several participants engaged in behaviors determined to be more potentially harmful, including acquiring antibiotics without prescriptions and manipulating their wounds. In multivariate analysis, injecting drug users who had ever injected amphetamines were more likely to engage in potentially harmful self-management behaviors (adjusted odds ratio = 4.38; 95% confidence interval = 1.15â??16.64). Self-management of injection-related wounds is common and certain behaviors may increase the potential for harm. Further research is needed to best focus efforts to improve wound care for injecting drug users. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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1 |
Unicompartmental versus total knee arthroplasty database analysis: is there a winner?
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Surgical Management of Osteoarthritis of the Knee CPG
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BACKGROUND: TKA and unicompartmental knee arthroplasty (UKA) are both utilized to treat unicompartmental knee arthrosis. While some surgeons assume UKA provides better function than TKA, this assumption is based on greater final outcome scores rather than on change in scores and many patients with UKA have higher preoperative scores. QUESTIONS/PURPOSES: We therefore asked whether TKA would demonstrate (1) better change in clinical outcome scores from preoperative to postoperative states and (2) better survivorship than UKA. METHODS: We evaluated 4087 patients with 5606 TKAs and 179 patients with 279 UKAs performed between 1978 and 2009. Patients with TKA were older and heavier than patients with UKA (mean age, 68 versus 66 years; mean BMI, 32 versus 29). We compared preoperative, latest postoperative, and change in Knee Society Clinical Rating System (KSCRS), SF-12, and WOMAC scores. Minimum followup was 2 years (UKA: mean, 7 years; range, 2.0-23 years; TKA: mean, 6.5 years; range, 2.0-33 years). Preoperative outcome measure scores (WOMAC, SF-12, KSCRS) were higher in the UKA group. RESULTS: Patients with UKA had higher postoperative KSCRS and SF-12 mental scores. Changes in score for all WOMAC domains were similar between groups. Total KSCRS changes in score were similar between groups, although patients with TKA had higher knee scores (49 versus 43) but lower function scores than UKA (21 versus 26). Cumulative revision rate was higher for UKA than for TKA (13% versus 7%). Kaplan-Meier survivorship at 5 and 10 years was 95% and 90%, respectively, for UKA and 98% and 95%, respectively, for TKA. CONCLUSIONS: While patients with UKA had higher pre- and postoperative scores than patients with TKA, the changes in scores were similar in both groups and survival appeared higher in patients with TKA
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Eliminating cardiac contamination from myoelectric control signals developed by targeted muscle reinnervation
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DoD LSA (Limb Salvage vs Amputation)
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The electrocardiogram (ECG) artifact is a major noise contaminating the myoelectric control signals when using shoulder disarticulation prosthesis. This is an even more significant problem with targeted muscle reinnervation to develop additional myoelectric sites for improved prosthesis control in a bilateral amputee at shoulder disarticulation level. This study aims at removal of ECG artifacts from the myoelectric prosthesis control signals produced from targeted muscle reinnervation. Three ECG artifact removal methods based on template subtracting, wavelet thresholding and adaptive filtering were investigated, respectively. Surface EMG signals were recorded from the reinnervated pectoralis muscles of the amputee. As a key parameter for clinical myoelectric prosthesis control, the amplitude measurement of the signal was used as a performance indicator to evaluate the proposed methods. The feasibility of the different methods for clinical application was also investigated with consideration of the clinical speed requirements and memory limitations of commercial prosthesis controllers.
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0 |
Effect of eccentric exercise on patients with chronic exertional compartment syndrome
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DOD - Acute Comp Syndrome CPG
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There are a number of similarities between chronic exertional compartment syndrome (CECS) and the effects of high force eccentric contractions in healthy controls. We hypothesised that CECS patients would be particularly susceptible to pain, fatigue and swelling after eccentric exercise. Ten CECS patients [aged 30.3 (8.0) years, mean (SD)], 7 males) and 14 healthy controls [aged 32.3 (9.0) years, 7 males] performed 40 maximal eccentric contractions of the anterior tibial muscles at an angular velocity of 90(o) s(-1). Maximal voluntary isometric contractions (MVC), force generated by electrical stimulation at 10 Hz and 50 Hz and muscle thickness (measured by real-time ultrasound scanning) were measured before exercise and for 10 min afterwards. Ratings of pain and tenderness were made before exercise, then 24 h and 48 h later. The two groups were comparable for initial isometric strength and muscle size. MVC force immediately after exercise fell to 90 (2.5)% [mean (SEM)] in patients and 86.5 (2.4)% in controls (P<0.0005 for both groups) and had not recovered after 10 min. Preferential loss of force at the low stimulation frequency occurred in both groups to a similar extent (20%, P<0.0005) and continued to decline over 10 min of recovery. There was no significant change in muscle thickness in either group. Only mild pain and tenderness were reported by the controls. The patients showed great individual variation but their mean pain scores were significantly higher during dorsiflexion and palpation (P<0.05) 24 h after exercise. After 48 h the patients reported more pain during dorsiflexion (P=0.005), plantarflexion (P<0.05) and palpation (P<0.05). These results suggest that some, but not all, CECS patients may be more susceptible to the pain associated with eccentric contractions that is thought to be the cause of damage and inflammation of connective tissue.
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Which Extrinsic and Intrinsic Factors are Associated with Non-Contact Injuries in Adult Cricket Fast Bowlers?
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: The high prevalence of injury amongst cricket fast bowlers exposes a great need for research into the risk factors associated with injury. Both extrinsic (environment-related) and intrinsic (person-related) risk factors are likely to be implicated within the high prevalence of non-contact injury amongst fast bowlers in cricket. Identifying and defining the relative importance of these risk factors is necessary in order to optimize injury prevention efforts.
OBJECTIVE: The objective of this review was to assess and summarize the scientific literature related to the extrinsic and intrinsic factors associated with non-contact injury inherent to adult cricket fast bowlers.
METHOD: A systematic review was performed in compliance with the PRISMA guidelines. This review considered both experimental and epidemiological study designs. Studies that included male cricket fast bowlers aged 18 years or above, from all levels of play, evaluating the association between extrinsic/intrinsic factors and injury in fast bowlers were considered for inclusion. The three-step search strategy aimed at finding both published and unpublished studies from all languages. The searched databases included MEDLINE via PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Controlled Trials Register in the Cochrane Library, Physiotherapy Evidence Database (PEDro), ProQuest 5000 International, ProQuest Health and Medical Complete, EBSCO MegaFile Premier, Science Direct, SPORTDiscus with Full Text and SCOPUS (prior to 28 April 2015). Initial keywords used were 'cricket', 'pace', 'fast', 'bowler', and 'injury'. Papers which fitted the inclusion criteria were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).
RESULTS: A total of 16 studies were determined to be suitable for inclusion in this systematic review. The mean critical appraisal score of the papers included in this study was 6.88 (SD 1.15) out of a maximum of 9. The following factors were found to be associated with injury: bowling shoulder internal rotation strength deficit, compromised dynamic balance and lumbar proprioception (joint position sense), the appearance of lumbar posterior element bone stress, degeneration of the lumbar disc on magnetic resonance imaging (MRI), and previous injury. Conflicting results were found for the association of quadratus lumborum (QL) muscle asymmetry with injury. Technique-related factors associated with injury included shoulder-pelvis flexion-extension angle, shoulder counter-rotation, knee angle, and the proportion of side-flexion during bowling. Bowling workload was the only extrinsic factor associated with injury in adult cricket fast bowlers. A high bowling workload (particularly if it represented a sudden upgrade from a lower workload) increased the subsequent risk to sustaining an injury 1, 3 or 4 weeks later.
CONCLUSION: Identifying the factors associated with injury is a crucial step which should precede the development of, and research into, the effectiveness of injury prevention programs. Once identified, risk factors may be included in pre-participation screening tools and injury prevention programs, and may also be incorporated in future research projects. Overall, the current review highlights the clear lack of research on factors associated with non-contact injury, specifically in adult cricket fast bowlers.
SYSTEMATIC REVIEW REGISTRATION NUMBER: Johanna Briggs Institute Database of Systematic Reviews and Implementation Reports 1387 (Olivier et al., JBI Database Syst Rev Implement Rep 13(1):3-13. doi: 10.11124/jbisrir-2015-1387 , 2015).
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1 |
Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents
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Osteochondritis Dissecans 2020 Review
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To determine the diagnostic performances of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents we compared them with arthroscopic findings in a consecutive series of pediatric patients (< or = 16 years old). Stratification effects by patient age and magnetic resonance imaging center were examined. There were 139 lesions diagnosed clinically, 128 diagnosed by magnetic resonance imaging, and 135 diagnosed arthroscopically. There was no significant difference between clinical examination and magnetic resonance imaging with respect to agreement with arthroscopic findings (clinical examination, 70.3%; magnetic resonance imaging, 73.7%), overall sensitivity (clinical examination, 71.2%; magnetic resonance imaging, 72.0%), and overall specificity (clinical examination, 91.5%; magnetic resonance imaging, 93.5%). Stratified analysis by diagnosis revealed significant differences only for sensitivity of lateral discoid meniscus (clinical examination, 88.9%; magnetic resonance imaging, 38.9%) and specificity of medial meniscal tears (clinical examination, 80.7%; magnetic resonance imaging, 92.0%). For magnetic resonance imaging, children younger than 12 years old had significantly lower overall sensitivity (61.7% versus 78.2%) and lower specificity (90.2% versus 95.5%) compared with children 12 to 16 years old. There was no significant effect of magnetic resonance imaging center. In conclusion, selective magnetic resonance imaging does not provide enhanced diagnostic utility over clinical examination, particularly in children, and should be used judiciously in cases where the clinical diagnosis is uncertain and magnetic resonance imaging input will alter the treatment plan.
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Magnetic resonance imaging T1 and T2 mapping provide complementary information on the bone mineral density regarding cancellous bone strength in the femoral head of postmenopausal women with osteoarthritis
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Hip Fx in the Elderly 2019
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Background: Since bone mass is not the only determinant of bone strength, there has been increasing interest in incorporating the bone quality into fracture risk assessments. We aimed to examine whether the magnetic resonance imaging (MRI) T1 or T2 mapping value could provide information that is complementary to bone mineral density for more accurate prediction of cancellous bone strength. Methods: Four postmenopausal women with hip osteoarthritis underwent 3.0-T MRI to acquire the T1 and T2 values of the cancellous bone of the femoral head before total hip arthroplasty. After the surgery, the excised femoral head was portioned into multiple cubic cancellous bone specimens with side of 5 mm, and the specimens were then subjected to microcomputed tomography followed by biomechanical testing. Findings: The T1 value positively correlated with the yield stress (Ï?y) and collapsed stress (Ï?c). The T2 value did not correlate with the yield stress, but it correlated with the collapsed stress and strength reduction ratio (Ï?c/Ï?y), which reflects the progressive re-fracture risk. Partial correlation coefficient analyses, after adjusting for the bone mineral density, showed a statistically significant correlation between T1 value and yield stress. The use of multiple coefficients of determination by least squares analysis emphasizes the superiority of combining the bone mineral density and the MRI mapping values in predicting the cancellous bone strength compared with the bone mineral density-based prediction alone. Interpretation: The MRI T1 and T2 values predict cancellous bone strength including the change in bone quality.
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Eradication of infection, survival, and radiological results of uncemented revision stems in infected total hip arthroplasties
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PJI DX Updated Search
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Background and purpose - The use of uncemented revision stems is an established option in 2-stage procedures in patients with periprosthetic joint infection (PJI) after total hip arthroplasty (THA). However, in 1-stage procedures, they are still rarely used. There are still no detailed data on radiological outcome after uncemented 1-stage revisions. We assessed (1) the clinical outcome, including reoperation due to persistent infection and any other reoperation, and (2) the radiological outcome after 1- and 2-stage revision, using an uncemented stem. Patients and methods - Between January 1993 and December 2012, an uncemented revision stem was used in 81 THAs revised for PJI. Patients were treated with 1- or 2-stage procedures according to a well-defined algorithm (1-stage: n = 28; 2-stage: n = 53). All hips had a clinical and radiological follow-up. Outcome parameters were eradication of infection, re-revision of the stem, and radiological changes. Survival was calculated using Kaplan-Meier analysis. Radiographs were analyzed for bone restoration and signs of loosening. The mean clinical follow-up time was 7 (2-15) years. Results - The 7-year infection-free survival was 96% (95% CI: 92-100), 100% for 1-stage revision and 94% for 2-stage revision (95% CI: 87-100) (p = 0.2). The 7-year survival for aseptic loosening of the stem was 97% (95% CI: 93-100), 97% for 1-stage revision (95% CI: 90-100) and 97% for 2-stage revision (95% CI: 92-100) (p = 0.3). No further infection or aseptic loosening occurred later than 7 years postoperatively. The radiographic results were similar for 1- and 2-stage procedures. Interpretation - Surgical management of PJI with stratification to 1- or 2-stage exchange according to a well-defined algorithm combined with antibiotic treatment allows the safe use of uncemented revision stems. Eradication of infection can be achieved in most cases, and medium- and long-term results appear to be comparable to those for revisions for aseptic loosening
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Incidence and risk factors of bisphosphonate-related osteonecrosis of the jaw in multiple myeloma patients having undergone autologous stem cell transplantation
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MSTS 2018 - Femur Mets and MM
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BACKGROUND: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a severe complication of bisphosphonate therapy. Due to their long survival and subsequently high cumulative doses of bisphosphonates, multiple myeloma patients have the highest risk of developing BRONJ of all patients treated with bisphosphonates. The purpose of the present study was to evaluate the incidence and risk factors for BRONJ in multiple myeloma patients after high-dose chemotherapy and autologous stem cell transplantation (ASCT).
PATIENTS AND METHODS: We retrospectively analyzed the data of 120 multiple myeloma patients after high-dose chemotherapy and ASCT treated with bisphosphonates and assessed the incidence and risk factors of BRONJ.
RESULTS: Of the 120 patients, 23 (19%) developed BRONJ. 6 patients suffered several BRONJ events, resulting in a total incidence of 23%. The risk for BRONJ was significantly higher for patients with rheumatism and recent dental manipulations. Furthermore, the number of previous bisphosphonate rotations, the duration of bisphosphonate therapy, and the type and cumulative dose of bisphosphonate used were associated with the incidence of BRONJ.
CONCLUSION: Our study is the first to determine the risk of BRONJ in a homogeneous group of multiple myeloma patients treated with high-dose chemotherapy and ASCT.
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Predictive value of inflammatory markers for irrigation and debridement of acute TKA infection
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PJI DX Updated Search
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The roles of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are well established in the diagnosis of total joint infection. However, it is not entirely clear what value preoperative CRP and ESR have in predicting outcomes following irrigation and debridement with insert exchange for acute hematogenous total knee arthroplasty infection. The total joint registry at the authors' institution was reviewed to identify all patients who underwent irrigation and debridement with insert exchange for a diagnosis of acute hematogenous infection of a primary total knee arthroplasty. Patient medical records were then reviewed for preoperative white blood cell count and CRP and ESR levels; interval from symptom onset to surgery; infecting organism; and any additional surgery for infection. Average patient age was 72 years (range, 51-91 years). Forty-four patients were men and 26 were women. Mean follow-up was 54 months (range, 12-176 months). Seventy-two procedures (69 patients) met the inclusion criteria. Of these, 20 (28%) additional procedures for infection were performed and were classified as treatment failures. Average CRP was 173.7 mg/L in the successful group and 159.0 mg/L in the failed group (P=.31). Mean ESR at the time of irrigation and debridement with insert exchange was 61.3 mm/hr in both groups (P=.49). Although CRP and ESR are well established in the diagnosis of infection, no role currently exists for them in predicting the outcomes of irrigation and debridement with insert exchange for the treatment of acute hematogenous total knee arthroplasty infection
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1 |
Preoperative intermittent manual traction in congenital dislocation of the hip
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Developmental Dysplasia of the Hip CPG
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To avoid prolonged hospitalization and the complications of skin and skeletal traction, we have devised a method of intermittent preoperative manual traction in the treatment of congenital dislocation of the hip. Of 60 hips that were followed for more than 1 year, 88.3% had Class I or Class II results according to Severin's criteria. No hip in this series was complicated by avascular necrosis of the proximal femoral epiphysis
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0 |
Preoperative acute normovolaemic hemodilution (ANH) in combination with hypotensive epidural anaesthesia (HEA) during knee arthroplasty surgery. No effect on transfusion rate. A randomized controlled trial [ISRCTN87597684]
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AAHKS (4) Acetaminophen
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Background: Hypotensive epidural anaesthesia (HEA) combines a high epidural anaesthesia, performing a sympathetic blockade, with low-dose iv-infusion of epinephrine to stabilize circulation in the conscious patient. Mean artery blood pressure is reduced to 45-50 mmHg and hereby a reduced blood loss. In this study we have combined HEA with preoperative acute normovolaemic hemodilution (ANH) in attempt to further reduce the blood loss and need for blood transfusion in total knee arthroplasty surgery (TKR). Methods: Twenty-eight patients scheduled for TKR are randomised to ANH or no hemodilution (non-ANH). Both groups are anaesthetized with HEA. ANH is established with predonation of 20 % of the total blood volume, and replacement with equal volume of HAES 6 %. Blood re-transfusion is completed within 6 h. Results: A mean of 877 ml blood was predonated (19.7 % of the total blood volume). Blood loss was, except from the intraoperative loss, significantly higher in ANH group. The total loss was 1306 mL(ANH) vs. 1026 mL (non-ANH), p < 0.05. Except from the first hour postoperatively, hematocrit was identical in between groups postoperatively. The amount of blood transfusion was identical 386 ml (ANH) vs. 343 ml (non-ANH) (ns). 50 % went through surgery without receiving blood (ANH) vs. 58 % (non-ANH). No renal, neurological or cardiopulmonary complications were registered. Conclusions: These data suggest no benefits in combining HEA and ANH in TKR surgery. Probably because of the reduced viscosity of the blood after ANH, there is an increased postoperative blood loss. The need for homologous blood transfusion was identical. © 2002 Juelsgaard et al;licensee BioMed Central Ltd.
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Metastatic disease of the skeleton
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MSTS 2018 - Femur Mets and MM
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Metastatic cancer is among the most frequent causes of skeletal pain associated with a destructive bone lesion or pathologic fracture in adults. Patients with a known primary carcinoma should undergo systematic evaluation and monitoring to determine the extent of skeletal disease and risk of pathologic fracture. Patients without a known primary carcinoma who have symptoms consistent with metastatic disease of the skeleton present a diagnostic dilemma. Plain radiographs may not reveal a metastatic lesion until extensive marrow replacement has occurred. Bone scans are more sensitive than radiographs and provide a survey of the entire skeleton. However, increased uptake on a bone scan is not specific and some neoplasms are poorly detected by scintigraphy. Computed tomography can identify bone destruction or neoplastic bone formation that is not easily demonstrated by plain radiographs and can help the clinician assess the risk of pathologic fracture. Magnetic resonance imaging may be helpful in detecting and defining the extent and precise location of marrow lesions and soft tissue extension of neoplasms.
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0 |
Retained cartilage in the distal radial physis of foals
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Distal Radius Fractures
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Examination of growth plate defects in the distal radial physis of 13 foals three to 70 days of age revealed lesions in the lateral and medial aspects of the distal radial physis; the lateral defects were more numerous and obvious. Lesions consisted of widening of the zone of hypertrophying cells of the metaphyseal growth plate (retained cartilage), retained cartilage with discontinuity of cartilage and primary spongiosa, and microfracture of the primary spongiosa. In some foals, the cartilage retention was thought to be due to primary spongiosa microfracture, although fracture subsequent to cartilage abnormality was not excluded.
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0 |
The long telegraph nail for humeral shaft fractures - How to avoid non-union
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Introduction: The long Telegraph Nail was developed for use in humeral shaft fractures. Proximal locking is ensured by two or three screws, locked in the nail. Distal anteroposterior locking can be either static or dynamic. Materials and Methods: The study initially included 148 patients who were operated between September 1998 and February 2005. There were 86 women with an average age of 68 years and 62 men with an average age of 53 years. After excluding patients with pathological fractures and those who were lost to follow-up, we were able to analyse 104 patients to determine the rate of nonunion. Patients were divided into three groups: no distal locking, static distal locking, and dynamic distal locking. The Constant score was measured in 56 patients to determine shoulder function after the procedure. The average follow-up time was three years. Results: There were no cases of post-operative radial nerve palsy or infection. The overall non-union rate was 7.7%. Without distal locking, the non-union rate was 12.5%; with static distal locking, the rate was 12.5% also. There were no cases of non-union in patients treated with dynamic distal locking. The average weighted Constant score was 105%. There were no functional clinical consequences, especially in the rotator cuff. Conclusion: The long Telegraph(registered trademark) nail is used for anterograde nailing of the humeral shaft with a simplified dynamic or static distal locking system. In this series, use of the dynamic distal locking system resulted in a lower non-union rate. When implanted correctly, the system does not appear to affect shoulder function
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0 |
pH and metal concentration of synovial fluid of osteoarthritic joints and joints with metal replacements
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Due to degradation and metal dissolution during articulation of metal joint replacements the chemical periprosthetic environment may change. The aim was to establish whether metal replacements cause the local changes in pH and elevated metal concentrations. Methods: pH was measured on samples from 167 patients: native hip and knee osteoarthritic joints, joints with hip and knee replacements revised for aseptic or septic reasons. pH of synovial fluid and periprosthetic tissue was measured perioperatively using a microelectrode and pH indicator papers for removed metal components. Metal concentrations were measured in 21 samples using inductively coupled plasma mass spectrometry. Results: The mean pH value of synovial fluid at native osteoarthritic joints (n = 101) was 7.78 ± 0.38. The mean pH value of synovial fluid at revision aseptic operation (n = 58) was 7.60 ± 0.31, with statistically significant difference (p = 0.002) compared to native osteoarthritic joints. The mean pH value of synovial fluid at revision septic operation (n = 8) was 7.55 ± 0.25, with statistically significant difference (p = 0.038) compared to native osteoarthritic joints. Measurements in tissue and at stems were not reliable. In the majority of samples taken at revision increased levels of cobalt and chromium were measured. Conclusion: A small but statistically significant difference was observed in the pH of synovial fluid between natural joints with degenerative diseases and joints treated with metal replacements. Based on the increased metal levels we expected the value of pH to be lower, but the influence of metal ions is counteracted by the buffering capacity of human body. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 2507â??2515, 2017.
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Screening for nasal carriage of Staphylococcus aureus among patients scheduled to undergo orthopedic surgery: Incidence of surgical site infection by nasal carriage
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OAK 3 - Non-arthroplasty tx of OAK
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Background Staphylococcus aureus (S. aureus), including MRSA, is considered to be the leading cause of surgical site infection (SSI) after orthopedic surgery. We screened for nasal carriers of S. aureus among patients who were scheduled to undergo orthopedic surgery at our hospital to reveal the effect of nasal S. aureus carriage on SSI. Our study design clearly has the intent of finding S. aureus nasal carriage and eradicating MRSA when found, and this strategy is to verify whether it's effective for preventing orthopedic surgical infections. Methods Subjects were 4148 patients who underwent preoperative screening for nasal carrier and subsequently underwent orthopedic surgery during a 7-year period between April 2007 and March 2014. The incidence of SSI among patients who were operated in our department was investigated, and the rates were compared between patients with and without nasal carriage to reveal the effect of preoperative nasal carriage on SSI. Results In total, 1036 patients were nasal carriers of S. aureus (carriage rate, 25.0%), whereas 140 patients carried MRSA (carriage rate, 3.4%). SSI developed in 24 patients [incidence, 0.58% (24/4148)] consisting of 12 non-carriers [0.39% (12/3112)] and 12 carriers [1.16% (12/1036)] with a significant difference in the incidence between the groups. Among 24 cases of SSI, more than half (13 cases) were caused by bacterial species other than S. aureus or those that could not be detected by the tests used. Only 7 patients out of 24 SSI patients, S. aureus was the bacterium detected in preoperative nasal cultures and the causal bacterium for SSI (concordance rate of 29.2%). Conclusions It was difficult to reduce the incidence rate of SSI in eradication group to the same level as nasal culture negative group. However, nasal carriage of S. aureus or MRSA may be a risk factor for SSI in orthopedic surgery.
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Operative Treatment In Non-Emergency Sports Injuries: A Sports Medicine Clinic Experience
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AMP (Acute Meniscal Pathology)
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PURPOSE: To elucidate referrals from sports medicine clinic (SMC) to orthopaedics, consensus rates among physicians and surgeons on surgical need in these patients, and reasoning of the patients who refused to have surgery despite the recommendations by both groups in non-emergency sports injury patients.
METHODS: We conducted a retrospective cohort analysis by using the administrative and referral records of a sports medicine clinic for the 15 months between October 2017 and January 2019. Gender, age, diagnosis and type of sport were compared between two groups (patients referred to orthopaedics vs patients treated in SMC). Agreement between orthopaedics and SMC on surgical need in those patients who were referred to orthopaedics was evaluated. We additionally screened the hospital archive for surgery reports of patients recommended surgery, and, if a patient did not have a surgery record, we investigated the reasons by telephone interview and categorized these reasons.
RESULTS: Surgical evaluation needed for 4.7% (n=155) of the patients. Patients referred to orthopaedics were younger (median: 22.0 years), mostly male (n=119, 76.8%) and involved in contact sports (n=108, 69.7%) (p<0.001 for all) compared to patients treated conservatively. Majority of the consultations were made owing to certain diagnoses such as cruciate/collateral ligament sprain (n=70, 45.2%), meniscal tear (n=21, 13.5%), and cartilage injuries (n=15, 9.7%). Most of the patients diagnosed with Achilles tendon rupture (n=2, 100%) and patellar instability (n=13, 81.3%) were referred to surgery. Orthopaedics agreed with the sports medicine physicians' opinions in most cases (n=110, 71.0%). Thirty-four patients (30.9%) recommended surgery by the surgeon postponed/refused the treatment for various reasons or had surgery in another hospital.
CONCLUSION: Most non-emergency sports injuries can be treated conservatively. Young and male patients participating in contact sports are more likely to need surgical treatment. Non-surgeon musculoskeletal health care providers may consider referring patients to orthopaedics considering the data demonstrated in this study. Nevertheless, patient's motivation to undergo an operation should be considered before referring to orthopaedics.
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Can We Quantify Functional Improvement Following Total Knee Arthroplasty in the Clinical Setting?
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OAK 3 - Non-arthroplasty tx of OAK
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The purpose of this study was to determine if improvements in knee function after arthroplasty could be practicably measured in the clinical setting using available, validated technology. The tools we assessed included a timed test of common activities, a platform posturography analysis, and a portable gait laboratory device to quantify body segment motion. We measured the function of 25 total knee arthroplasty patients before surgery and at 1, 4, 12, and 24 months after surgery. Assessment of sit-to-stand, walking, stair climbing, lunging, Knee Society Scores, and Oxford Survey Scores were collected at each interval. Patients showed significant improvement in step length, gait speed, symmetry of weight distribution, symmetry of lunging, and speed of stair climbing. Changes in function with long-term follow-up can be precisely measured, making this technology promising for clinical or research applications.
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0 |
Effect of prophylaxis for deep venous thrombosis in traumatic spinal cord injury
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MSTS 2022 - Metastatic Disease of the Humerus
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Inclusion criteria: Exclusion criteria: 1. Incomplete spinal cord injury patient 2. Spinal cord injury without neurological deficit 3. Pathological fractures of the spine 4. Congenital deformity of the spine 5. Localised infection in extremities 6. Derranged PT/INR Values DEEP VENOUS THROMBOSIS IN TRAUMATIC SPINAL CORD INJURY Intervention(n=50): Subcutaneous low molecular weight heparin (enoxaparin 40 mg/day) given for 2 months Physiotherapy of all joints Massage Control(n=50): Physiotherapy of all joints Massage Patients clinical assessment for DVT using WELL SCORE along with d dimer assay every, 2 weeks after getting into either study or control group. USG doppler to rule out DVT (considered the gold standard in the study).
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The effects of ACL deficiency on the meniscus and articular cartilage
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OAK 3 - Non-arthroplasty tx of OAK
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Objectives: Through altered tibiofemoral kinematics, isolated tears of the anterior cruciate ligament (ACL) likely affect the meniscus and its ability to distribute joint forces. Changes in meniscal movement and deformation may result in altered cartilage contact location and volume, possibly leading to osteoarthritis. Little is known regarding the effects of acute ACL injury on meniscal translation and deformation as well as cartilage contact location and deformation. Using a newly developed, minimally invasive methodology, we investigated meniscal behavior and cartilage contact during dynamic knee flexion in ACL-intact and ACLdeficient states. We hypothesized that after ACL-transection, both the menisci and cartilage will show greater deformation and the menisci will translate more posteriorly. Methods: Five human cadaveric knees were tested with six 1.0 mm steel beads injected in both the medial and lateral meniscus and three into the femur and tibia. 3D bone models were created using CT scans and articular cartilage was mapped on MRIs to create rigid cartilage models. Dynamic stereo x-ray (DSX) images were obtained during dynamic knee flexion from 10-40 degrees with a 50 lb load before and after ACL transection (Figure 1). Meniscal deformation and movement were measured by change in arc length along the implanted bead locations and translation of the center of the created ellipse (Figure 1). Cartilage models were co-registered with DSX data to evaluate cartilage deformation, measured by depth of penetration and location of contact. ACL intact and ACL transected states were compared. Results: After ACL transection, the total arc length of the lateral meniscus decreased 2.7 mm in the mid portion and posterior horn while the change in arc length of the medial meniscus was minimal. The medial and lateral meniscus translated 0.9 mm (sd= 1.0 mm) and 1.6 mm (sd= 0.7 mm) more posteriorly. The cartilage penetration change was minimal in the medial and increased by 0.3 mm in the lateral compartment. Cartilage contact location moved posteriorly 1.7 mm and 2.7 mm in the medial and lateral meniscus, respectively (Figure 1). Conclusion: Following ACL-transection, both menisci and cartilage contact location translate more posteriorly, lateral compartment more than medial. Cartilage deformation increased in the lateral compartment as well. Circumferential meniscal deformation decreased in the lateral compartment along the mid portion and posterior horn. The authors hypothesize this may be due to meniscal complexity that is not completely understood. The posterior horn may be subjected to compressive forces or altered knee kinematics that have yet to be correlated. This model illustrates that dynamic evaluation of changes in the meniscus and cartilage is feasible and that ACL injury may lead to altered wear patterns. Further testing with higher knee flexion angles, higher loads, and other injury patterns will be performed.
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The Tibial Tubercle-Trochlear Groove Distance/Trochlear Dysplasia Index Quotient Is the Most Accurate Indicator for Determining Patellofemoral Instability Risk
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AMP (Acute Meniscal Pathology)
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PURPOSE: The primary aim of our study was to evaluate diagnostic accuracy of the tibial tubercle-trochlear groove (TT-TG) distance relative to associated quotients produced from trochlear width (TT-TG distance/TW) and trochlear dysplasia index (TT-TG distance/TDI) for detecting patellofemoral instability. Secondary aims included identifying thresholds for risk and comparing differences between cases and controls.
METHODS: Consecutive sampling of electronic medical records produced 48 (21 males, 27 females) patellofemoral instability cases (19 +/- 7 years old) and 79 (61 males, 18 females) controls (23 +/- 4 years old) who had a history of isolated meniscal lesion, as evaluated by magnetic resonance imaging. Standardized methods were employed with measurements executed in a blinded and randomized manner. A receiver operating characteristic curve assessed accuracy by area under the curve (AUC). The index of union (IU) was employed to identify a threshold for risk. Two-sample t-tests examined group differences. P < .05 denoted statistical significance.
RESULTS: The AUC values were .69 (.60, .79) for TT-TG distance, .81 (.73, .88) for TT-TG distance/TW, and .85 (.78, .91) for TT-TG distance/TDI. Thresholds were 14.7 mm for TT-TG distance, .36 for TT-TG distance/TW, and 1.88 for TT-TG distance/TDI. Cases demonstrated statistically significant (P < .001) greater values for each measure compared with controls: TT-TG distance (15.8 +/- 4.2 mm vs 12.9 +/- 3.6 mm, [1.4, 4.3]); TT-TG distance/TW (.51 +/- .24 vs .31 +/- .09, [.13, .27]); TT-TG distance/TDI (3.07 +/- 1.55 vs 1.7 +/- .7, [.9, 1.84]).
CONCLUSION: The TT-TG distance, TT-TG distance/TW, and TT-TG distance/TDI measures were 69%, 81%, and 85%, respectively, accurate for determining patellofemoral instability risk. Thresholds for risk were 14.7 mm for TT-TG distance, .36 for TT-TG distance/TW, and 1.88 for TT-TG distance/TDI. The thresholds reported in this study may help in advancing clinical decision-making.
LEVEL OF EVIDENCE: Level III, diagnostic retrospective comparative observatory trial.
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0 |
Acute respiratory distress syndrome secondary to radiotherapy for breast cancer: A case report
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Coronavirus Disease 2019 (COVID-19)
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Objective: Unusual or unexpected effect of treatment Background: Radiotherapy is often used as an adjuvant therapy in breast cancer following surgical resection of the primary malignant tumor. It has multiple respiratory side effects, but acute respiratory distress syndrome (ARDS) is a rare complication. We describe here the case of a woman with breast cancer who developed ARDS 1 week after her final radiotherapy session. Case Report: A 69-year-old female with breast cancer presented 1 week after her final session of radiotherapy. She had developed a sudden onset of hypotension unresponsive to fluids, oxygen desaturation unresponsive to high flow oxygen, and new bilateral infiltrates had appeared on chest x-ray (CXR) predominant in the left upper lobe, which was interestingly the main area affected by the radiotherapy beams. A diagnosis of atypical ARDS secondary to radiotherapy was established. She was intubated and a low tidal volume/high positive end-expira-tory pressure (PEEP) strategy was utilized to manage her condition. After 48 hours, the infiltrates diminished remarkably, and she was extubated the following day. On discharge, she had a completely normal CXR; a com-puted tomography (CT) chest performed 1 month later showed complete resolution of the alveolar opacities. Conclusions: ARDS remains an extremely rare complication of thoracic radiotherapy. However, physicians must be wary of its development in order to diagnose it quickly and treat accordingly.
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1 |
Mid-Term Clinical and Radiological Outcomes of Lateral Meniscal Allograft Transplantation with Suture-Only Fixation Plus Capsulodesis
|
AMP (Acute Meniscal Pathology)
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BACKGROUND: Meniscal allograft transplantation (MAT) is an effective reconstructive procedure for treating symptomatic post-meniscectomy syndrome. It consists of replacing the lost meniscal tissue aiming to improve the clinical outcomes and prevent a progressive deterioration of the joint. The aim of this study was to evaluate meniscal graft survivorship and report on the radiographic (in terms of graft extrusion, joint space width and alignment) and the functional results through a mid-term follow-up of lateral MAT performed with a soft tissue fixation technique after capsulodesis.
METHODS: 23 patients who underwent lateral MAT as a single procedure were included. The KOOS, Lysholm, Tegner, VAS scales were used for patient assessment. Magnetic resonance imaging and a complete radiographic protocol were conducted to determine the degree of meniscal extrusion and the changes in the degree of osteoarthritis and coronal alignment. Assessments were performed after two and seven years of follow-up.
RESULTS: A significant improvement in all the scores, relative to preoperative values, was found after seven years of follow-up. This improvement remained consistent throughout the first and second follow-up periods. A mean absolute extrusion of 2.2 mm +/- 1.6 and an extrusion percentage of 28.0% +/- 11.43 were found, with no significant differences throughout the follow-up periods. There was no statistically significant difference in terms of the frontal mechanical axis and joint space narrowing between the preoperative value and at the first and second follow-up periods. A survival rate of 85.7% was found after seven years of follow-up.
CONCLUSIONS: Capsulodesis results in a low degree of meniscal extrusion in isolated lateral MAT fixed with a suture only technique, which is maintained after seven years of follow-up, with a high graft survival index (>85%) and satisfactory results on the functional scales.
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0 |
Current insights in intra-abdominal hypertension and abdominal compartment syndrome
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DoD - ACS - Interrater Reliability
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A compartment syndrome exists when increased pressure in a closed anatomic space threatens the viability of the tissue within the compartment. When this occurs in the abdominal cavity it threatens not only the function of the intra-abdominal organs, but it can have a devastating effect on distant organs as well. Recent animal and human data suggest that the adverse effects of elevated intra-abdominal pressure (IAP) can occur at lower levels than previously thought and even before the development of clinically overt abdominal compartment syndrome (ACS). The ACS is not a disease but truly a syndrome, a spectrum of symptoms and signs that can and mostly does have multiple causes. It is only recently that this condition received a heightened awareness. This article reflects the current state of knowledge on intra-abdominal pressure regarding etiology, epidemiology, diagnosis, IAP measurement, organ dysfunction, prevention and treatment. [References: 108]
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0 |
Recurrent carpal tunnel syndrome--analysis of the impact of patient personality in altering functional outcome following a vascularised hypothenar fat pad flap surgery
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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We retrospectively analysed 25 patients (27 hands) who had both clinical and electrophysiological confirmation of true recurrent carpal tunnel syndrome from January 2004 to December 2009. In all the patients, after releasing the nerve a vascularised fat pad flap was mobilised from the hypothenar region and sutured to the lateral cut end of flexor retinaculum. The patient characteristics, co-morbidities, duration of symptom, interval between first release and revision surgery and intra-operative findings were assessed against post-operative relief of pain, recovery of sensory and motor dysfunction. The average age of the patients was 58 years (43-81) and the dominant hand was involved in 22 patients. Intra-operatively the nerve was compressed by scar tissue connecting the previously divided ends of the retinaculum in 18 and nine had scar tissue and fibrosis around the nerve. Following surgery 16 patients had complete recovery (asymptomatic at the first follow-up), eight had delayed recovery (partial recovery of symptoms at final follow-up) and three had a poorer outcome (persistence of preoperative symptoms at the final follow-up). The patients with delayed recovery/poorer outcome had a) Early recurrence; b) Diabetes mellitus; c) Obesity; d) Cervical spine problems; e) Involvement of non-dominant hand; and f) Intraoperative scar tissue and fibrosis. The hypothenar fat pad transposition flap provides a reliable source of vascularised local tissue that can be used in patients with recurrent carpal tunnel syndrome. The factors that were associated with poorer/delayed recovery were involvement of non-dominant hand, recurrence within a year from the previous surgery, intra-operatively scar tissue in the carpal tunnel and associated co-morbidities, like obesity diabetes mellitus and cervical spine problems
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0 |
Does Timing of Primary Total Hip Arthroplasty Prior to or After Lumbar Spine Fusion Have an Effect on Dislocation and Revision Rates?
|
Developmental Dysplasia of the Hip 2020 Review
|
BACKGROUND: Patients undergoing primary total hip arthroplasty (THA) following lumbar spine fusion have an increased incidence of dislocation compared to those without prior lumbar fusion. The purpose of this study is to determine if timing of THA prior to or after lumbar fusion would have an effect on dislocation and revision incidence in patients with both hip and lumbar spine pathology. METHODS: One hundred percent Medicare inpatient claims data from 2005 to 2015 were used to compare dislocation and revision risks in patients with primary THA with pre-existing lumbar spine fusion vs THA with subsequent lumbar spine fusion within 1, 2, and 5 years after the index THA. A total of 42,300 patients met inclusion criteria, 28,668 patients of which underwent THA with pre-existing lumbar spinal fusion (LSF) and 13,632 patients who had prior THA and subsequent LSF. Patients who had THA first followed by LSF were further stratified based on the interval between index THA and subsequent LSF (1, 2, and 5 years), making 4 total groups for comparison. Multivariate cox regression analysis was performed adjusting for age, socioeconomic status, race, census region, gender, Charlson score, pre-existing conditions, discharge status, length of stay, and hospital characteristics. RESULTS: Patients with prior LSF undergoing THA had a 106% increased risk of dislocation compared to those with LSF done 5 years after THA (P < .001). Risk of revision THA was greater in the pre-existing LSF group by 43%, 41%, and 49% at 1, 2, and 5 years post THA compared to the groups with THA done first with subsequent LSF. Dislocation was the most common etiology for revision THA in all groups, but significantly higher in the prior LSF group (26.6%). CONCLUSION: Results of this study demonstrate that sequence of surgical intervention for concomitant lumbar and hip pathology requiring LSF and THA respectively significantly impacts the fate of the THA performed. Patients with prior LSF undergoing THA are at significantly higher risk of dislocation and subsequent revision compared to those with THA first followed by delayed LSF. LEVEL OF EVIDENCE: 3.
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0 |
"Reverse" hip spacer for massive distal femur defects in peri-prosthetic knee infections
|
PJI DX Updated Search
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BACKGROUND: Bone loss in the distal femur is a common problem in knee revision surgeries. The problem is exacerbated in the context of an active infection. In extreme cases this bone loss could compromise the feasibility of a two-stage exchange protocol using dynamic spacers due to the inherent instability of this type of spacers. Use of a hip prefabricated spacer in a "reverse" way forming a ball-and- socket joint is a therapeutic option in cases of massive bone defect and infection. MATERIAL AND METHODS: A retrospective review was performed of our institutional database to identify all cases of massive distal femoral defect in which this technique was used from January 2010 to December 2013. A record was made of the epidemiological data, characteristics of the infection (clinical and microbiological), and adverse event during the spacer stage. The main end-point was the infection eradication rate (minimum: 18 months of follow-up). The complications associated with the technique were also assessed. Finally, each patient completed a visual analogue pain scale, and a satisfaction questionnaire (SAPS). RESULTS: This technique was successfully used in six cases so far, controlling the infection in all cases. Mean femoral defect was 117cm (range: 32-191cm). Mean time with spacer was 7.6 months, with no major complications. All but one patient reached second stage reconstruction with a mega-prosthesis, and mean time since second stage was 34.7 months. All patients stated high levels of satisfaction with the technique employed, as well as and low pain scores (mean visual analogue pain scale: 1; range: 0-4). CONCLUSION: A reproducible and safe technique is described. Patients report a high level of satisfaction with the procedure, and there were no cases of recurrence of the infection after a minimum follow-up of 18 months
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0 |
Pediatric acl repair: the effects of lower extremity nerve blocks on same day surgery discharge
|
Surgical Management of Osteoarthritis of the Knee CPG
|
Background and aims: Anterior cruciate ligament(ACL) repair is a notoriously painful procedure. Adult studies demonstrate the benefit of lower extremity nerve blocks in providing high quality postoperative analgesia which can facilitate same day surgery(SDS) discharge. We performed an observational study involving pediatric patients who underwent an ACL repair on an ambulatory basis that either did or did not receive lower extremity nerve blocks and compared their opioid consumption and need for unscheduled hospital admission(UHA). Methods: We retrospectively reviewed the charts of 123 sequential patients undergoing SDS ACL repair at the Children's Hospital of Pittsburgh from January 2009 through April 2012. Patients were divided into three groups: the control group(CG) received no nerve blocks(n=39); group-1(GP-1) received single shot femoral and sciatic nerve blocks(n=58); and group-2(GP-2) received femoral perineural catheters with disposable elastomeric pumps and single shot sciatic blocks(n=26). We analyzed the incidence of UHA (chisquared) and opioid consumption (Mg/kg in morphine equivalents)[mg/ kgMSE]in the PACU1 and PACU2(scheffe). Results: (Table Presented) Conclusions: The use of lower extremity nerve blocks following ACL repair in pediatric patients facilitates reliable SDS discharge, and a significant reduction in opioid consumption. Data trends towards increased SDS discharge with the use of continuous catheters
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0 |
Expressing effects of osteoporosis interventions in terms of postponing of fractures
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Management of Hip Fractures in the Elderly
|
OBJECTIVE: To estimate the effect from an osteoporosis intervention in terms of postponement of hip fractures. DESIGN: A Markov model using Nordic data on mortality and hip fracture incidence. PATIENTS: Women aged 50 years and older with increased risk of hip fracture. INTERVENTION: A hypothetical intervention that reduces the risk of hip fracture by 50%. MAIN OUTCOME MEASURES: Postponement of hip fractures--that is increase in expected fracture-free survival from osteoporosis interventions. RESULTS: A 1-year treatment would on average postpone hip fracture by 12 days if therapy were started at the age of 50 years and 23, 55, 90 or 74 days if the treatment were started at the ages of 60, 70, 80 or 90 years, respectively. For 10 years of treatment, the benefit was 146, 260, 369, 373 and 167 days, respectively. The younger the patient, the lower the risk of fracture and, consequently, the greater the benefit for those few who actually could benefit. CONCLUSIONS: The benefit in terms of average postponement of hip fractures from osteoporosis intervention was, other things being equal, greatest in women aged 70-90 years. Fracture postponement may represent an alternative to risk reductions in expressing the effect of osteoporosis interventions
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1 |
The Correlation between Preoperative and Postoperative Hypoalbuminaemia and the Development of Acute Kidney Injury with Respect to the KDIGO Criteria in the Hip Fracture Surgery in Elderly Patients
|
Hip Fx in the Elderly 2019
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Objective: The aim of the present study was to determine the correlation between preoperative and postoperative hypoalbuminaemia and acute kidney injury (AKI) in the hip fracture surgery in elderly patients.
Methods: A total of 160 patients aged >=65 years were scanned retrospectively. They were grouped into four as the preoperative albumin level of <3.8, preoperative albumin level of >3.8, postoperative day 2 albumin level of <2.9 and postoperative day 2 albumin level of >2.9. In the beginning and 7 days, age, gender, white blood cell, haemoglobin, haematocrit, glucose, blood urea nitrogen, serum creatinine, albumin values, fever, anaesthesia method, presence of blood transfusion, surgical period, hospitalisation durations and expenses in the postoperative period were recorded for all the patients.
Results: In the study, 92 women and 68 men were scanned. AKI was observed in 28 (17.5%) patients, and 16 (57.1%) patients were determined in stage 1. AKI development in Group 1 and Group 3 was significantly high (p<0.05). Advanced age, multiple drug usage, postoperative glucose level and blood product transfusion during the operation were significantly associated with AKI (p<0.05). The hospitalisation period and cost were high in patients with AKI (p<0.05).
Conclusion: It was determined that hypoalbuminaemia was associated with AKI development, and preoperative or postoperative hypoalbuminaemia affected AKI development at similar rates. Advanced age, multiple drug usage, postoperative glucose level and blood product transfusion during the operation were associated with AKI.
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0 |
Imaging Appearances of Musculoskeletal Developmental Variants in the Pediatric Population
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Osteochondritis Dissecans 2020 Review
|
Variations in musculoskeletal development in children are commonly encountered. These variants often have a confusing appearance on imaging and may simulate pathologic conditions. However, in many instances, these normal variants have certain features that allow for confident determination of the benign nature of these entities. An awareness of the characteristic imaging features is therefore important for radiologists. In this review, we focus on 4 specific categories of variants in the development: (1) variations in the normal ossification of skeletal structures, (2) the appearance of tendinous and ligamentous insertions in the developing skeleton, (3) overlapping lines that can be confused with fractures or other pathologic conditions, and (4) variant orientation of normal bones. We review the etiology and imaging appearance of these entities and also describe methods of differentiating these benign entities from pathologic lesions. Although in certain cases, correlation with clinical parameters is needed to confidently diagnose the lesion as benign, in many cases, an appreciation of the characteristic imaging features alone would suffice and prevent a potentially costly workup.
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0 |
Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To determine whether zolpidem is a safer alternative to benzodiazepines. DESIGN: Retrospective cohort study. SETTING: Community based. PARTICIPANTS: Health maintenance organization members with an initial prescription for zolpidem (n = 43,343), alprazolam (n = 103,790), lorazepam (n = 150,858), or diazepam (n = 93,618). MEASUREMENTS: Zolpidem and benzodiazepine prescriptions were identified from pharmacy databases. Rates of nonvertebral fractures and hip fractures requiring hospitalization were compared before and after an initial prescription for each treatment, adjusting for confounders using doubly robust estimation. RESULTS: In patients aged 65 and older, the rates of nonvertebral fractures and dislocations were similar in the pre- treatment intervals. The rate ratios (RRs) for the 90-day posttreatment interval relative to the pretreatment interval were 2.55 (95% confidence interval (CI) = 1.78-3.65; P < .001) for zolpidem, 1.14 (95% CI = 0.80-1.64; P = .42) for alprazolam, 1.53 (95% CI = 1.23-1.91; P < .001) for lorazepam, and 1.97 (95% CI = 1.22-3.18; P = .01) for diazepam. The ratio of RRs (RRR)-the RR in the posttreatment period adjusted for the corresponding RR in the pretreatment period-were 2.23 (95% CI = 1.36-3.66; P = .006) for zolpidem relative to alprazolam, 1.68 (95% CI = 1.12-2.53; P = .02) for zolpidem relative to lorazepam, and 1.29 (95% CI = 0.72-2.30; P = .32) for zolpidem relative to diazepam. The RRs decreased with time from the initial prescription (trend P < .001), as would be expected if the association is causal. CONCLUSION: In older adults, the risk of injury with zolpidem exceeded that with alprazolam and lorazepam and was similar to that with diazepam. If the associations are causal, then the high incidence of these fractures implies that these treatment induce a substantial number of fractures and consequential costs. Further study of the association is imperative
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0 |
Musculoskeletal changes following non-invasive knee injury using a novel mouse model of post-traumatic osteoarthritis
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OAK 3 - Non-arthroplasty tx of OAK
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Objective: Post-traumatic osteoarthritis (PTOA) is a common consequence of traumatic joint injury, with 50% of anterior cruciate ligament (ACL) rupture patients developing PTOA within 10-20. years. Currently accepted mouse models of PTOA initiate symptoms using various methods, none of which faithfully mimic clinically-relevant injury conditions. In this study we characterize a novel non-invasive mouse model of PTOA that injures the ACL with a single load of tibial compression overload. We utilize this model to determine the time course of articular cartilage and subchondral bone changes following knee injury. Design: Mice were euthanized 1, 3, 7, 14, 28, or 56. days after non-invasive knee injury. Knees were scanned using micro-computed tomography (μCT) in order to quantify subchondral trabecular bone, subchondral bone plate, and non-native bone formation (heterotopic ossification). Development of osteoarthritis (OA) was graded using the osteoarthritis research society international (OARSI) scale on histological sections of injured and uninjured knees. Results: Following injury we observed a rapid loss of trabecular bone in injured knees compared to uninjured knees by 7. days post-injury, followed by a partial recovery of trabecular bone to a new steady state by 28. days post-injury. We also observed considerable non-native bone formation by 56. days post-injury. Grading of histological sections revealed deterioration of articular cartilage by 56. days post-injury, consistent with development of mild OA. Conclusions: This study establishes a novel mouse model of PTOA, and describes the time course of musculoskeletal changes following knee injury, helping to establish the window of opportunity for preventative treatment. © 2012 Osteoarthritis Research Society International.
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0 |
Ibandronate for the treatment of hypercalcemia or nephrocalcinosis in patients with multiple myeloma and acute renal failure: Case reports
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MSTS 2018 - Femur Mets and MM
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Multiple myeloma disrupts calcium homeostasis by a variety of mechanisms, including bone destruction and resorption. This causes hypercalcemia. When left untreated, hypercalcemia leads to nephrocalcinosis, impairment of kidney function, and eventually renal failure. Some degree of renal dysfunction is common in myeloma patients. Here, we report case studies showing the efficacy and renal safety of the single-nitrogen bisphosphonate, ibandronate, for the treatment of hypercalcemia and/or nephrocalcinosis in multiple myeloma patients hospitalized with acute renal failure. Patients (n = 7) received either one or two intravenous infusions of ibandronate (2-6 mg). Ibandronate was well tolerated in all patients and returned elevated blood calcium levels to normal. Renal function improved for all patients and normalized in 3/7 patients. We conclude that ibandronate is involved in rapidly improving or restoring acute renal function and calcium levels to within the normal range in this patient population. To clarify the exact value of ibandronate, further investigation is warranted in randomized prospective trials. Copyright © 2006 S. Karger AG.
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0 |
Osteoporosis as a risk factor for distal radial fractures: a case-control study
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Distal Radius Fractures
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BACKGROUND: Distal radial fractures occur earlier in life than hip and spinal fractures and may be the first sign of osteoporosis. The aims of this case-control study were to compare the prevalence of osteopenia and osteoporosis between female and male patients with low-energy distal radial fractures and matched controls and to investigate whether observed differences in bone mineral density between patients and controls could be explained by potential confounders.
METHODS: Six hundred and sixty-four female and eighty-five male patients who sustained a distal radial fracture, and 554 female and fifty-four male controls, were included in the study. All distal radial fractures were radiographically confirmed. Bone mineral density was assessed with use of dual x-ray absorptiometry at the femoral neck, total hip (femoral neck, trochanter, and intertrochanteric area), and lumbar spine (L2-L4). A self-administered questionnaire provided information on health and lifestyle factors.
RESULTS: The prevalence of osteoporosis was 34% in female patients and 10% in female controls. The corresponding values were 17% in male patients and 13% in male controls. In the age group of fifty to fifty-nine years, 18% of female patients and 5% of female controls had osteoporosis. In the age group of sixty to sixty-nine years, the corresponding values were 25% and 7%, respectively. In adjusted conditional logistic regression analyses, osteopenia and osteoporosis were significantly associated with distal radial fractures in women. Osteoporosis was significantly associated with distal radial fractures in men.
CONCLUSIONS: The prevalence of osteoporosis in patients with distal radial fractures is high compared with that in control subjects, and osteoporosis is a risk factor for distal radial fractures in both women and men. Thus, patients of both sexes with an age of fifty years or older who have a distal radial fracture should be evaluated with bone densitometry for the possible treatment of osteoporosis.
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0 |
1alpha,25-Dihydroxyvitamin D3 regulates the expression of Id1 and Id2 genes and the angiogenic phenotype of human colon carcinoma cells
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MSTS 2018 - Femur Mets and MM
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1alpha,25-Dihydroxyvitamin D3 (1alpha,25(OH)2D3) has antitumor activity in addition to its classical action on calcium metabolism and bone tissue biology. It is thought to regulate the expression of multiple target genes and thus modulate processes critical for tumor growth and metastases. Here we show that 1alpha,25(OH)2D3 differentially regulates the expression of Id1 and Id2 genes, members of a family of transcriptional regulators of cell proliferation and differentiation. 1alpha,25(OH)2D3 induced epithelial differentiation in SW480-ADH human colon carcinoma cell line by promoting expression of the proteins implicated in adherent junction formation, including E-cadherin, and by inhibiting beta-catenin transcriptional activity. 1alpha,25(OH)2D3 activated the human Id1 gene promoter and rapidly induced Id1 RNA and protein. Ectopic overexpression of Id1 was not sufficient to induce E-cadherin, which was critical for the morphological changes induced by 1alpha,25(OH)2D3 in SW480-ADH cells. Conversely, Id2 transcription rate, RNA and protein levels were decreased by 1alpha,25(OH)2D3. Id2 downregulation by 1alpha,25(OH)2D3 mediated the antiproliferative effect of 1alpha,25(OH)2D3 on SW480-ADH cells. In addition, we showed that 1alpha,25(OH)2D3 changed the levels of the inducer of angiogenesis, vascular endothelial growth factor and the potent antiangiogenic factor thrombospondin-1, leading to a balanced change in the angiogenic potential of SW480-ADH human colon carcinoma cells.
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0 |
High tibial osteotomy in the treatment of adult osteochondritis dissecans
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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This study reports one surgeon's experience using valgus high tibial osteotomy in the treatment of osteochondritis dissecans of the medial femoral condyle in adult patients. Seven knees in six patients with osteochondritis dissecans were reviewed as the basis of the study. Five patients (five knees) were men, and one patient (two knees) was a woman. The average age at surgery was 32 years. Patients reported medial knee pain, recurrent effusions, and disability. An average of three procedures per knee had been performed previously. Four knees had achieved union of the osteochondral fragments but with overlying articular cartilage degeneration observed at arthroscopy. Three knees had failed attempts at fixation with eventual excision of the fragmented osteochondral lesions. None of the knees showed diffuse medial compartment gonarthrosis by radiographic or arthroscopic examinations. Involved knees had relative varus malalignment with an average femoral and tibial angle of 0 degree compared with the uninvolved knees average of 5 degrees valgus. Preoperative technetium scintigraphy showed isolated uptake in the medial femoral condyle of all involved knees. Preoperative Lysholm scores averaged 39 points. Patients were observed for an average of 30 months after surgery. The average Lysholm score at latest followup was 89 points. Femoral and tibial angles averaged 9 degrees valgus. On subjective questioning, all patients reported marked improvement, satisfaction with the surgery, and said they had no need for additional operative intervention
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0 |
Efficacy and safety of three different approaches for ultrasound guided femoral nerve block for patients undergoing total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
|
Introduction: Total knee arthroplasty (TKA) causes considerable postoperative pain. It can prolong hospitalization, impair rehabilitation and early mobilization, and may worsen functional outcome. Effective postoperative pain control following TKA lowers the risk of postoperative complications, such as thromboembolic disease and nosocomial infection. Patient-controlled IV analgesia with opioids is associated with side effects (nausea, vomiting, pruritis, ileus, urinary retention, sedation and respiratory arrest), which could delay the initiation of physical therapy. Femoral nerve blocks (FNB) have been shown to significantly improve postoperative analgesia and have less side effects as compared with opioid therapy. Objective: The purpose of this prospective, single blinded, randomized study was to determine efficacy and safety of three different approaches for ultrasound guided FNB: single-shot femoral nerve block (SFNB), continuous femoral nerve block (CFNB) with non-stimulating catheter, and CFNB with stimulating catheters. Material and Methods: We enrolled 53 patients (ages 18-90 years) undergoing TKA in this pilot study. All patients were randomly assigned to one of three groups (SFNB, CFNB with non-stimulating catheter, and CFNB with stimulating catheter). We excluded patients who had redo surgery on the ipsilateral knee, radicular pain in the same leg, BMI (greater-than or equal to)45, allergy to local anesthetics, opioid habituation, neuropathy of any etiology in the surgical extremity or any contraindications to regional block. All blocks were performed under ultrasound guidance combined with neural stimulation. All patients were evaluated in the PACU at arrival (time 0), 30 minutes and 1 hour after arrival in the PACU, and then at 12, 24 and 48 hours after the surgery. All patients were assessed for ability to move the knee, numeric pain scores, amount of supplemental pain medications and overall satisfaction of the patient with pain control. Results: There was no statistically significant difference between these three groups with respect to age, gender, height, weight, total block time, total surgery time or needle depth (p>0.05). (Table presented) From our preliminary results, patients from CFNB with non-stimulating catheters had better pain relief at rest (at 24 and 48 hours) and during the movement (30 minutes, 1 hour, 12 hours) as compared with SFNB and CFNB with stimulating catheters. There was no statistically significant difference in amount of PCA opioid consumption during the 48 hours after surgery. (Figure presented) Conclusion: Single-shot femoral nerve block (SFNB) and continuous femoral nerve block (CFNB) comprise the two main peripheral blocks used in contemporary practice for TKA. Stimulating catheters are sometimes used in
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0 |
The validity of duruoz hand index (DHI) in geriatric population
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Background The Duruoz Hand Index (DHI) [1] has 18 items of daily activities questions. It was developed to assess the functional disability of rheumatoid hand and cross validated for some other arthropaties of the hand (osteoarthritis, systemic sclerosis, carpal tunnel syndrome, stroke, flexor tendon rupture etc.). Objectives To assess the usefulness of the DHI to evaluate functional disability of hands in geriatri population. Methods Subjects aged more than 65 were recruited into the study. The local or systemic diseases which may affect directly the hand function were exclusion criteria. Demographic and functional characteristics of subjects were evaluated. The functional assessment was performed with DHI, Hand Functional Index (HFI), Health Assessment Questionnaire (HAQ), Purdue Pegboard (fingertip dexterity and hands coordination) and grip strength (JAMAR) and 3 kinds of pinch (tip, lateral, chuck) strengths (JAMAR). The DHI was correlated (Spearman's correlation coefficient) with the other functional parameters to assess the convergent validity and with non-functional parameters to assess the divergent validity. p<0.05 was significant. Results Fifty patients (33 female) with mean age 72.6 (range: 65-90) were recruited. The average score of DHI was 16.32 (SD: 17.57) and 26.0% of patients had zero score (without disability). The DHI had not any significant relation with demographic data such as age, hand dominancy, alcohol consumption, smoking and DHI has poor or fair correlation with fatigue level and Pittsburg Sleep Quality Index (divergent validity). The DHI has significant and good correlation with Health Assessment Questionnaire (HAQ), Hand Functional Index, Purdue Pegboard scores, grip strength and 3 types of pinch strengths (convergent validity). The strongest relation of DHI is with HAQ (rho: 0.782; p<0.0001). Conclusions The DHI is practical scale and it is useful to assess the functional disability of hands accurately in geriatric population
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0 |
New therapeutic approaches to treat medullary thyroid carcinoma
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MSTS 2018 - Femur Mets and MM
|
Medullary thyroid carcinoma (MTC) accounts for up to 8% of all thyroid cancers. Although primary surgery is curative in the vast majority of patients treated at an early stage, disease can persist or recur with deleterious effects on quality of life. Local and distant metastases can occur and are the major causes of mortality. Reoperation, embolization, and perhaps radiotherapy can improve the outcome for some patients who are not cured by primary surgery, but there is a need for novel treatments. No comprehensive clinical trial data are available on conventional cytotoxic agents for the treatment of MTC. Patients with distant metastases, in particular, might benefit from several novel compounds directed against angiogenesis and molecular targets in tumor cells, such as products of the proto-oncogene RET and mutants of it, and other signaling components. Well-conducted clinical trials are needed to assess and optimize these treatment strategies, and this article outlines how such trials should be conducted. Although RET mutations are common in hereditary MTC and can occur in some cases of sporadic MTC, knowledge of other molecular defects associated with the development of MTC should reveal new targets for therapy. ©2008 Nature Publishing Group.
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0 |
The efficacy of a counter-rotational powered toothbrush in the maintenance of endosseous dental implants
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Dental Implant Infection
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BACKGROUND: Although most patients with implants have lost their natural teeth because of poor oral hygiene, limited data exist to guide practitioners in their recommendations of home-care regimens for their patients' endosseous dental implants and maintenance of peri-implant soft-tissue health. The authors conducted a study to compare the home-care effectiveness of a counter-rotational powered tooth-brush with that of conventional home-care regimens. METHODS: Before starting the six-year study, the authors trained 85 clinical investigators at 32 dental research centers across the United States in gathering periodontal data. Data for 2,966 implants were entered into a centralized database. Outcomes were derived from 24-month observations of a subset of the implants studied. RESULTS: Repeated-measures analysis of the toothbrushing methods used on 2,966 implants showed that the counter-rotational powered toothbrush removed plaque significantly better than manual methods (P < .0001 Wald statistic) from all implant surfaces and at all recall intervals up to 24 months. Similar results were demonstrated for the gingival index. CONCLUSIONS: The counter-rotational powered brush appears to be well-suited for home-care regimens aimed at maintaining optimal peri-implant soft-tissue health in patients with dental implants. CLINICAL IMPLICATIONS: The importance of maintaining the health of the peri-implant tissues is well-recognized by the dental profession. The counter-rotational powered toothbrush is an effective tool in meeting the oral hygiene challenges associated with implant prosthesis maintenance.
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The relationship between retinal vessel calibre and knee cartilage and BMLs
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Whether the increase in vascular disease prevalence and mortality in OA populations is a result of co-occurrence of cardiovascular disease and OA, which are both common in the older population, is due to OA treatments or to the common association with reduced physical activity and/or obesity is unclear. One way to explore this non-invasively is to examine the cross-sectional relationship between changes in retinal microvasculature, which have been shown to be markers of generalized vascular pathology, and knee structural changes in an asymptomatic community-based population. Methods. A community sample of 289 (61% women) aged 50-79 years with no knee symptoms underwent magnetic resonance imaging (MRI) of their dominant knee in 2003. Cartilage volume and bone marrow lesions (BMLs) were determined. All subjects also had retinal photographs taken from which retinal arteriolar and venular diameters were determined and summarized as the central retinal arteriolar equivalent (CRAE) and the central retinal venular equivalent (CRVE). Results: Retinal venular diameter was significantly wider in subjects with a BML compared with subjects without a BML (mean (SD) 214.2 (2.8) μm versus 207.5 (1.1) μm respectively independent of age, gender and BMI. A trend for decreased medial tibial cartilage with increasing CRAE was also observed (regression coefficient -2.70 μl, 95%CI-5.74, 0.5, p=0.08). Conclusion: These findings suggest that vascular pathology, indicative of inflammatory processes, is associated with early structural knee changes. The role of micro-vascular changes in the pathogenesis of OA warrants further investigation. © 2012 Davies-Tuck et al.; licensee BioMed Central Ltd.
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Age Is Not a Contraindication for Cartilage Surgery: A Critical Analysis of Standardized Outcomes at Long-term Follow-up
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Age is commonly accepted as a negative prognostic factor in cartilage surgery, and cutoff values of 30 to 40 years have been previously suggested as treatment indication. However, the lower outcome scores documented in older patients do not take in consideration the decreasing requirements of an aging joint.
PURPOSE: To analyze the real effect of age in terms of recovery with respect to the functional level expected for different age categories of patients treated for cartilage lesions.
STUDY DESIGN: Cohort study; Level of evidence, 3.
METHODS: Patients with International Cartilage Repair Society (ICRS) grade 3-4 defects, involving femoral condyles or trochlea without osteoarthritis, were treated with arthroscopic matrix-assisted autologous chondrocyte transplantation; 157 patients were evaluated with IKDC subjective and Tegner scores before surgery and then after 2 and 10 years. Results were first evaluated by dividing patients into 2 age groups according to the generally approved cutoff value of 40 years. The analysis was then repeated after the scores of each patient were standardized according to the score achievable per the normative data in healthy patients for the corresponding sex and age category.
RESULTS: A significant improvement in all scores was observed. IKDC subjective score improved from 38.9 +/- 14.5 to 74.7 +/- 21.8 at 10 years. When a cutoff value of 40 years was used, older patients reached a significantly worse IKDC subjective value at 10 years (65.8 +/- 24.3 vs 77.2 +/- 20.4, P = .007). However, different findings were obtained after the scores were standardized. Although optimal results were still found in younger patients (<30 years), patients older than 40 years also appeared to benefit from the treatment, and no significant differences were noted compared with the younger population.
CONCLUSION: The benefit of cartilage treatments in patients with increasing age but without any sign of osteoarthritis was higher than previously reported in literature. In fact, when the decreasing functional level expected by an aging population was considered, standardized results showed an overall benefit after cartilage treatment in patients older than 40 years that was not significantly different from the outcome achieved in younger patients. Thus, age is not a strict contraindication as previously suggested, and future studies should consider standardization of data to prove the real age limit of cartilage treatments.
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Day-case or short-stay admission for arthroscopic knee surgery: a randomised controlled trial
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AMP (Acute Meniscal Pathology)
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The Royal Colleges, The Audit Commission, and politicians have encouraged day-case care for patients undergoing arthroscopic knee surgery. However, there remains both public and professional concern regarding the acceptability and safety of this form of management, although there are clear economic benefits. In a prospective randomised controlled trial, 50 patients underwent arthroscopic surgery as a day-case and 50 patients were admitted overnight. Outcome was assessed by postal questionnaire 4 weeks after discharge. A linear visual analogue scale was used to measure pain levels. The response rate was 93%. The diagnoses and types of arthroscopic surgery were similar in both groups. In total, 94% of day-cases and 91% of patients admitted overnight expressed overall satisfaction. Pain after discharge was similar in both groups. Day-case management was preferred by 90% of day-case patients and by 64% of those admitted overnight. Of patients in the day-case group, 12% had to be admitted overnight because of recovery problems, but 7% of patients randomised to overnight stay discharged themselves. One patient admitted overnight required readmission because of a wound haematoma. Patients who had received day-case management returned to work significantly faster than those who had been admitted. Modern anaesthetic techniques with special attention to anti-emesis and pain control have reduced postoperative morbidity to acceptable levels. Provided that patients are properly selected and well informed, day-case care is preferable for the majority of patients undergoing arthroscopic surgery of the knee.
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The uncemented, titanium-coated RM cup: Survival and analyses of failures
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Management of Hip Fractures in the Elderly
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This study evaluates the incidence of revision of the monoblock, uncemented, titanium-coated RM (Robert Mathys) cup (Mathys Medical, Bettlach, Switzerland) in primary total hip arthroplasty, Between 1991 and 1995 a total of 630 RM cups were implanted in 462 patients. A Kaplan-Meier survival analysis was performed with failure defined as acetabular revision for any reason. The mean follow-up was 8.2 years. A total of 34 acetabular revisions (5%) were carried out: 15 for recurrent dislocation due to cup malposition, nine for wear caused by impingement of a loose femoral component, five for aseptic loosening, only one cup was revised for articular polyethylene wear, and four for other causes. The cumulative survival rate of the RM cup is 91% at 10.7 years, with a worst case scenario of 87%. The cumulative survival rate for aseptic loosening was calculated: 99% at 10.7 years. The titanium-coated RM cup shows an impressive survival rate with revision for aseptic loosening as endpoint. Correct cup positioning is the key to success and requires experience and meticulous surgical technique. (copyright) Wichtig Editore, 2005
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Wear rate of highly cross-linked polyethylene in total hip arthroplasty. A randomized controlled trial
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Management of Hip Fractures in the Elderly
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BACKGROUND: Highly cross-linked polyethylene was introduced for clinical use in total hip arthroplasty with the expectation that it would exhibit less wear when compared with conventional polyethylene. The purpose of this study was to report the clinical and radiographic results, after a minimum of five years of follow-up, of a randomized, blinded, controlled trial comparing a conventional polyethylene with a first-generation highly cross-linked polyethylene.METHODS: One hundred patients were enrolled in a prospective, randomized controlled study comparing highly cross-linked and conventional polyethylene acetabular liners in total hip arthroplasty. Fifty patients were in each group. At the time of follow-up, clinical outcomes were assessed and steady-state femoral head penetration rates (after bedding-in) for each patient were calculated with use of a validated radiographic technique. In addition, a statistical comparison of polyethylene wear between groups was performed with use of generalized estimating equations.RESULTS: At a mean of 6.8 years postoperatively, there were no differences between the two polyethylene groups with regard to the Harris hip score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), or Short Form-12 (SF-12) score. The mean femoral head penetration rate in the first through fifth years was found to be significantly lower in the group treated with the highly cross-linked polyethylene (0.003 mm/yr [95% confidence interval, +/-0.027]) than it was in the group treated with conventional polyethylene (0.051 mm/yr [95% confidence interval, +/-0.022]) (p=0.006). Men treated with a conventional polyethylene liner had a significantly higher (p<or=0.012) femoral head penetration rate (0.081 mm/yr [95% confidence interval, +/-0.065]) than both men and women with a highly cross-linked liner (-0.013 mm/yr [95% confidence interval, +/-0.074] and 0.009 mm/yr [95% confidence interval, +/-0.028], respectively). The general estimating equations demonstrated that the group with a highly cross-linked polyethylene liner had a significantly lower femoral head penetration rate than the group with a conventional polyethylene liner (p=0.025), and a significantly higher femoral head penetration rate was demonstrated in men with a conventional polyethylene liner when compared with both men and women with a highly cross-linked liner (p=0.003).CONCLUSIONS: At a minimum of five years postoperatively, the steady-state femoral head penetration rate associated with this first-generation highly cross-linked polyethylene liner was significantly lower than that associated with a conventional polyethylene liner. Long-term follow-up is required to demonstrate the clinical benefit of this new material
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Total elbow arthroplasty: Outcomes driving the evolution of implant design
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Pediatric Supracondylar Humerus Fracture 2020 Review
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»Since the 1940s, innovations in total elbow arthroplasty (TEA) implant design have been made based on reported outcomes. However, complications still exist and current designs remain imperfect.»Currently, linked (semiconstrained) implants can be used for any indication for TEA; however, aseptic loosening at the bone-cement interface remains a concern.»Unlinked (unconstrained) prostheses have been used primarily in patients with rheumatoid arthritis and in situations where the soft-tissue envelope is intact; however, dislocation and/or instability can occur.»Convertible prostheses may provide a solution when the stability of the elbow can be determined intraoperatively, and a semiconstrained implant can be used if the soft-tissue envelope is not intact. Recent long-term results are promising.»There are 3 questions that we sought to answer in this review: (1) How did the failures of early implants change the evolution of TEA designs? (2) How did the evolution of implant design change the indications for TEA? (3) How do the results after TEA differ depending on the indications?
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Ethnic and racial factors influencing well-being, perceived pain, and physical function after primary total joint arthroplasty
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Management of Hip Fractures in the Elderly
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Background: Studies suggest, even when controlling for disease severity, socioeconomic status, education, and access to care, racial and ethnic minorities receive lower-quality health care and have worse perceived pain and function before and after total joint arthroplasty. Question/purposes: We evaluated the influence of race and ethnicity on well-being, pain, and function after total joint arthroplasty and determined whether race, ethnicity, sex, and joint involvement influenced perceived function and pain after total joint arthroplasty. Patients and Methods: We retrospectively reviewed the records of 1749 patients receiving total joint arthroplasty (739 hips and 1010 knees). Sixty-eight percent were women, with a mean age of 65 years at followup. We assessed patients preoperatively and at a minimum of 2 years (mean, 5.1 years; range, 2-16 years) on perceived well-being, function, and pain, as well as clinical assessment tools. Also, we assessed the behavior of dependent measures between groups over time. Results: Preoperatively, in both TKA and THA candidates, African American patients presented with worse scores. Postoperatively, all patients had substantial improvement, yet African Americans who had TKA or THA continued to have worse scores on some measures. In both TKA and THA, women had worse scores. Conclusions: Racial and ethnic minorities undergoing hip and knee arthroplasty appear to have worse patient-perceived outcomes (well-being, pain, and function) when compared to whites. This discrepancy is most pronounced for African Americans. Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. (copyright) 2011 The Association of Bone and Joint Surgeons(registered trademark)
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Arterial anatomy of the nipple-areola complex
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Reduction Mammoplasty for Female Breast Hypertrophy
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The blood supply of the nipple-areola complex was investigated radiographically in five fresh cadavers that had been systemically injected with lead oxide. The blood supply of the breast is derived from the external mammary, internal mammary, intercostal, and thoracoacromial arteries. We found that branches of the external and internal mammary arteries provided the dominant blood supply to the nipple-areola complex. These branches provide small vessels that traverse the subcutaneous tissue to the nipple- areola complex. Branches are given off to the areolar skin. These ascended, arborizing in the upper and middle thirds of the nipple.
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Treatment patterns and survival after 18F-fluorodeoxyglucose positron emission tomography/computed tomography-guided local consolidation therapy for oligometastatic non-small cell lung cancer: a two-center propensity score-matched analysis
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MSTS 2022 - Metastatic Disease of the Humerus
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Purpose: In this retrospective study, we evaluated the treatment patterns and survival after positron emission tomography-computed tomography (PET/CT)-guided local consolidation therapy (LCT) for oligometastatic non-small cell lung cancer (NSCLC). Methods: We reviewed the medical records of Chinese patients with oligometastatic stage IV non-small cell lung cancer (= 5 metastases) who had undergone PET/CT and were eligible for systemic therapy at two centers between May 2005 and August 2019. Propensity score matching (1:1) was used to reduce selection bias and imbalanced distribution of confounding factors. Results: We identified 84 eligible patients and used propensity scores to create well-matched groups of 35 patients who did or did not undergo LCT. Among all patients, the 1-year overall survival (OS) rate was 47.6% and the 2-year OS rate was 22.6%. Relative to the group that did not receive LCT, the LCT group had a significantly higher OS rate (13 months vs. 7 months, p = 0.002). The two groups had similar incidences and classifications of LCT-related side effects. In multivariable analysis, LCT was found to be strongly associated with a favorable OS (hazard ratio: 0.508, 95% confidence interval: 0.311–0.828, p = 0.001). Conclusion: We concluded that LCT was significantly associated with improved clinical outcomes among the Chinese patients with oligometastatic NSCLC who were eligible for systemic treatment and could undergo PET/CT evaluation.
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Displaced supracondylar fractures of the humerus in children
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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From 1972 to 1981, 60 children with severely displaced supracondylar fractures were treated with closed reduction and vertical osseous traction with a screw in the olecranon. None of the patients had complications (infection or neurovascular damage) due to the treatment, but eight patients had loss of reduction and required second reduction. The average hospitalization time was 2.6 weeks, and all fractures had united within four weeks. A follow-up study of 56 patients was performed an average of 78 months after the injury. All patients had an excellent (75%) or good (25%) end result. Vertical osseous traction is easy to apply and carries few risks of complications. The method is recommended, provided longer hospitalization time is acceptable or permissible
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Zoledronic acid plus methylprednisolone versus zoledronic acid or placebo in symptomatic knee osteoarthritis: a randomized controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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Background: The aim of this study was to compare the efficacy and safety of zoledronic acid (ZA) plus intravenous methylprednisolone (VOLT01) to ZA, and placebo for knee osteoarthritis. Methods: A single-center, double-blind, randomized controlled trial (RCT) was carried out. Adults (aged ⩾50 years) with knee osteoarthritis, significant knee pain [⩾40 mm on a 100 mm visual analog scale (VAS)], and magnetic resonance imaging-detected bone marrow lesion (BML) were randomized to receive a one-off administration of VOLT01, ZA, or placebo. The primary hypothesis was that VOLT01 was superior to ZA in having a lower incidence of acute phase responses (APRs) over 3 days. Secondary hypotheses were that VOLT01 was noninferior to ZA, and both treatments were superior to placebo in decreasing BML size over 6 months and in improving knee pain [Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and VAS] and function (WOMAC) over 3 and 6 months. Results: A total of 117 patients (62.2 ± 8.1 years, 63 women) were enrolled. The incidence of APRs was similar in the VOLT01 (90%) and ZA (87%) groups (p = 0.74). VOLT01 was superior to ZA in improving knee pain and function after 6 months and noninferior to ZA in reducing BML size. However, BML size change was small in all groups and there were no between-group differences. Compared with placebo, VOLT01 but not ZA improved knee function and showed a trend toward improving knee pain after 6 months. Conclusions: Administering intravenous methylprednisolone with ZA did not reduce APRs or change knee BML size over 6 months, but in contrast to ZA or placebo, it may have a beneficial effect on symptoms in knee osteoarthritis. Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12613000039785.
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Hyaluronic acid and chondroitin sulfate content of osteoarthritic human knee cartilage: Site-specific correlation with weight-bearing force based on femorotibial angle measurement
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AMP (Acute Meniscal Pathology)
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This study analyzed glycosaminoglycan (GAG) content in specific compartments of the knee joint to determine the impact of malalignment and helped refine indications for osteotomy. To assess malalignment, the radiological femorotibial angle (FTA) was measured and knee joints were also graded for OA severity with the Kellgren/Lawrence (K/L) classification. Cartilage samples were obtained from 36 knees of 32 OA patients undergoing total knee replacement surgery. Explants were harvested from the medial femoral condyle (MFC), lateral femoral condyle (LFC), patellar groove (PG), and lateral posterior femoral condyle (LPC). Concentrations of hyaluronic acid (HA) and ehondroitin sulfate (CS) were measured by high-performance liquid chromatography (HPLC). With OA severity, the average FTA significantly increased. HA and CS content in MFC was negatively correlated with radiographic FTA. In LFC, HA ratio, which is HA content in lateral condyle divided by medial condyle and chondroitin 6 sulfate, increased until about 190° FTA. Importantly, at >190° these contents were significantly decreased. HA and CS content of the femoral condyle shows topographic differences that are related to OA grade and weight-bearing force based on FTA. The clinical relevance is that osteotomy may not be indicated for patients with severe varus (>190°) © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
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Infective endocarditis and dentistry: outcome-based research
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Antibiotic prophylaxis for prevention of infective endocarditis has long been recommended for patients receiving dental care. Two studies of patients with endocarditis found limited risk associated with dental treatment. It is imperative that guidelines for therapy be based on outcome studies and on evidence of safety, efficacy and cost effectiveness
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Rheumatoid shoulder assessed by ultrasonography: Prevalence of abnormalities and associated factors
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DoD PRF (Psychosocial RF)
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Introduction: The shoulder involvement in rheumatoid arthritis (RA) is common. It can be subclinical and compromise the function of the upper limb. Musculoskeletal ultrasonography can detect subclinical abnormalities in rheumatoid shoulder. Our aim was to assess the prevalence of ultrasound abnormalities in rheumatoid shoulder, and investigate their association with different parameters. Methods: Cross-sectional study including 37 patients with RA, meeting the ACR/EULAR 2010 classification criteria, who were enrolled during a month. A questionnaire with sociodemographic, clinical and laboratory data was filled in for all patients. Ultrasound evaluation was performed by a single experienced operator. For each patient, both of shoulders were evaluated. Results: Mean age was 50 years with female predominance. Median disease duration of RA was 7.5 years. All patients had a seropositive form of RA. Mean clinical DAS28 was 5.1. Mean HAQ was 1.2. Thirty-one (83.8%) patients had involvement of the shoulder: unilateral in 9(24.3%) cases and bilateral in 22(59.5%) cases. Synovitis was found in 16(43.2%) patients with Doppler in 4 (10.8%) cases. Sub-acromial bursitis was noted in 14 (37.8%) cases and the effusion in 20 (54.1%). Synovitis was noted especially in elderly individuals (p: 0.01). The Doppler was visualized in elderly patients (p: 0.01), with a shorter disease duration (p: 0.02) and with a high SDAI (p: 0.006). US inflammatory findings in anterior recess of glenohumeral joint were linked to a higher synovial index (p: 0.03) and a higher level of rheumatoid factor (p: 0.01). Conclusion: 59.5% of our RA patients had bilateral involvement of the shoulder which was related to the disease activity. Ultrasound should be a systematic tool to look for the involvement of this joint in RA patients.
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Tight calorie control in geriatric patients following hip fracture decreases complications: a randomized, controlled study
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Hip Fx in the Elderly 2019
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BACKGROUND & AIMS: Optimizing nutritional intake has been recommended for geriatric patients undergoing hip-fracture surgery. Whether nutritional support guided by repeated measurements of resting energy requirements (REE) improves outcomes in these patients is not known.
METHODS: A randomized, controlled, unblinded, prospective, cohort study comparing provision of energy with a goal determined by repeated REE measurements using indirect calorimetry, with no intervention. Oral nutritional supplements were started 24 h after surgery and the amount adjusted to make up the difference between energy received from hospital food and measured energy expenditure.
RESULTS: 50 Geriatric patients were included in the study. Patients in the intervention group (n = 22) received significantly higher daily energy intake than the control group (n = 28) (1121.3 +/- 299.0 vs. 777.1 +/- 301.2 kcal, p = 0.001). This was associated with a significantly less negative cumulative energy balance (-1229.9 +/- 1763 vs. -4975.5 +/- 4368 kcal, p = 0.001). A significant negative correlation was found between the cumulative energy balance and total complication rate (r = -0.417, p = 0.003) as well as for length of hospital stay (r = -0.282, p = 0.049).
CONCLUSION: We have demonstrated that nutritional support actively supervised by a dietician and guided by repeated measurements of REE was achievable and improved outcomes in geriatric patients following surgery for hip fractures. Clinicaltrials.gov Identifier: NCT017354435.
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Ultrasound quantification of acetabular rounding in hip dysplasia: reliability and correlation to treatment decisions in a retrospective study
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Developmental Dysplasia of the Hip 2020 Review
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Currently, acetabular rounding is only subjectively assessed on ultrasound for developmental dysplasia of the hip. We tested whether acetabular rounding can be quantified reliably and can distinguish between hips requiring and not requiring treatment. Consecutive infants (n = 90) suspected of having dysplasia of the hip, seen at a pediatric orthopedic clinic, were separated into four diagnostic categories (normal, borderline but resolved, treated by brace, treated surgically). Acetabular rounding was assessed by semi-quantitative grade (0 = nil, 1 = mild, 2 = moderate, 3 = severe) by three observers and by direct measurement of acetabular radius of curvature (AROC) by two observers. Inter-observer reliability of rounding grade was poor (κ = 0.30-0.37). AROC had an inter-observer intra-class correlation coefficient of 0.84 and coefficient of variation of 29%-34%. Mean AROC was significantly higher for hips requiring treatment than for those not requiring treatment (3.3 mm vs. 1.6 mm, p = 0.007). AROC reliably quantifies an observation currently being made subjectively by radiologists and surgeons, and may be useful as a supplementary ultrasound index of dysplasia of the hip in future prospective studies.
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Patient-perceived outcome after displaced distal radius fractures. A comparison between radiological parameters, objective physical variables, and the DASH score
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Distal Radius Fractures
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Outcome after distal radius fractures has traditionally been measured by radiological parameters and objective physical variables. To what extent these measurements reflect outcome as perceived by the patient has been questioned. We evaluated the association between radiological position, objective physical result (grip strength and range of movement), and the patient-perceived outcome, measured with the Disabilities of the Arm, Shoulder, and Hand outcome (DASH) score, in 78 patients with a healed unilateral distal radius fracture treated with either closed reduction and plaster splint or external fixation. Fifty-seven females and 21 males (median age 59 yr; range, 22-95) were retrospectively assessed after a mean of 22 months and the mean DASH score was 13 points. Linear correlations between final radiological and objective physical measurements and DASH score were weak or insignificant. However, radial shortening > or = 2mm, dorsal angulation >15 degrees, and radial angulation >10 degrees were each significantly associated with a poorer DASH score. Reduced grip strength, extension, and ulnar deviation correlated with a poorer DASH score. In conclusion, we found that better final radiological and objective physical results were associated with a better patient-perceived outcome, as measured by the DASH score, in this patient group.
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A modified two-incision minimally invasive total hip arthroplasty: Technique and short-term results
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Management of Hip Fractures in the Elderly
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Between 2003 and 2005, a total of 425 consecutive cases with a modified two-incision minimally invasive total hip arthroplasty (THA) were performed at our hospital. We analysed 225 cases with greater than 12 months follow-up clinically and radiographically. The mean operative time was 70 minutes. Patients could walk on crutches at 1.5 days and discontinued crutch use at an average of 3 weeks. Patients were able to walk upstairs without support at 4 weeks. Radiographic analysis showed the mean lateral opening angle and anteversion of the acetabular components were 43.0(degrees) and 17.3(degrees), and 97% of the femoral stems were in neutral alignment. There was no radiographic evidence of component migration or subsidence at the most recent follow-up. Therefore, from these early results, a modified two-incision THA was found to be an excellent surgical modality, which allows early rehabilitation and does not increase complications when compared to other MIS two-incision THA technique. (copyright) Wichtig Editore, 2006
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Effect of single vision soft contact lenses on peripheral refraction
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Upper Eyelid and Brow Surgery
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PURPOSE: To investigate changes in peripheral refraction with under-, full, and over-correction of central refraction with commercially available single vision soft contact lenses (SCLs) in young myopic adults. METHODS: Thirty-four myopic adult subjects were fitted with Proclear Sphere SCLs to under-correct (+0.75 DS), fully correct, and over-correct (-0.75 DS) their manifest central refractive error. Central and peripheral refraction were measured with no lens wear and subsequently with different levels of SCL central refractive error correction. RESULTS: The uncorrected refractive error was myopic at all locations along the horizontal meridian. Peripheral refraction was relatively hyperopic compared to center at 30 and 35 degrees in the temporal visual field (VF) in low myopes and at 30 and 35 degrees in the temporal VF and 10, 30, and 35 degrees in the nasal VF in moderate myopes. All levels of SCL correction caused a hyperopic shift in refraction at all locations in the horizontal VF. The smallest hyperopic shift was demonstrated with under-correction followed by full correction and then by over-correction of central refractive error. An increase in relative peripheral hyperopia was measured with full correction SCLs compared with no correction in both low and moderate myopes. However, no difference in relative peripheral refraction profiles were found between under-, full, and over-correction. CONCLUSIONS: Under-, full, and over-correction of central refractive error with single vision SCLs caused a hyperopic shift in both central and peripheral refraction at all positions in the horizontal meridian. All levels of SCL correction caused the peripheral retina, which initially experienced absolute myopic defocus at baseline with no correction, to experience absolute hyperopic defocus. This peripheral hyperopia may be a possible cause of myopia progression reported with different types and levels of myopia correction.
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Knee stability in posterior cruciate ligament retaining total knee arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Anteroposterior knee laxity was evaluated in 14 patients (19 knees) who had posterior cruciate ligament retaining total knee arthroplasty using the Miller Galante I prosthesis. The followup ranged from 87 to 118 months (average, 105.9 months), and the measurements were done using the KT-2000 arthrometer. The mean anteroposterior displacement with the knees with Miller Galante I prostheses was 10.1 mm at 30 degrees flexion and 8.1 mm at 75 degrees flexion. In the 15 knees with Miller Galante I prostheses with flexion greater than 90 degrees, seven had less stability at 75 degrees than at 30 degrees flexion. These knees were considered to have a nonfunctional posterior cruciate ligament, and they had a worse Knee Society score (81.1) than did the other eight knees with Miller Galante I prostheses (89.9). There were four knees in which the flexion was less than 90 degrees. In this study, approximately half of the knees with posterior cruciate ligament retaining total knee arthroplasty did not have good anteroposterior stability in flexion an average of 9 years after surgery
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Probability of fractures predicted by FRAX(registered trademark) and observed incidence in the Spanish ECOSAP Study cohort
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Management of Hip Fractures in the Elderly
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Purpose: To assess the ability of the Spanish version of the WHO fracture risk assessment tool (FRAX(registered trademark)) to predict the observed incident fractures in the ECOSAP Study cohort. Methods: 5201 women, aged 65 or older, were enrolled in a three-year, prospective study by a non-randomized sampling of consecutive cases in 58 primary care centers in Spain. Participants completed an osteoporosis and fracture risk questionnaire and attended follow-up visits every 6. months. All radiologically or surgically confirmed low-trauma, non-spinal fractures were collected. The individual 10-year absolute risks of hip and major osteoporotic fractures were calculated with the FRAX(registered trademark) algorithms for Spain without the inclusion of the bone mineral density (BMD) measurements. Calibration was evaluated by comparing the three-year estimated (E) fractures predicted with FRAX(registered trademark) with the number of observed (O) fractures, and their discriminative ability for the probability of new fractures with the area under the receiving operating characteristic (ROC) curves. Results: Fifty (0.96%) women sustained an incident hip fracture, and 201 (3.81%) women presented with major osteoporotic fractures (hip, forearm or humerus). The E/O ratios for hip and major osteoporotic fractures were 1.10 and 0.66 respectively. Clinical vertebral fractures were not collected; therefore, the E/O ratio for major fractures should be expected to be lower. The difference between E and O cases reached statistical significance ((chi)(2), p<0.001). Areas under the ROC curves were 0.640 and 0.615 for hip and major osteoporotic fractures respectively. Conclusions: The Spanish FRAX(registered trademark) underestimates the risk for major osteoporotic fractures. The estimated risk for hip fractures was similar to the observed fractures; however the algorithm had only modest discriminative ability. These results should be interpreted in the context of the relatively low number of observed fractures, especially at the hip. (copyright) 2011 Elsevier Inc
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There is inadequate evidence to determine the effectiveness of nonpharmacological and nonsurgical interventions for hand osteoarthritis: an overview of high-quality systematic reviews
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SR for PM on OA of All Extremities
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BACKGROUND: Patients with hand osteoarthritis are commonly treated by health care professionals (allied to medicine). Practice should be informed by updated evidence from systematic reviews of randomized controlled trials. PURPOSE: The purpose of this overview is to summarize the evidence from systematic reviews of the effectiveness of nonpharmacological and nonsurgical interventions for patients with hand osteoarthritis. DATA SOURCES AND STUDY SELECTION: Systematic reviews published between January 2000 and October 2008 were identified by a comprehensive literature search. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently selected reviews for inclusion, assessed their methodological quality, and extracted and synthesized data according to predefined criteria. Four systematic reviews finally were included. Based on single randomized controlled trials, there is some evidence of the effect of pain relief from topical capsaicin compared with placebo and for favorable functional outcomes for exercise and education compared with osteoarthritis information alone. LIMITATIONS: In overviews, results are dependent on available systematic reviews. They are important tools to guide choice of interventions and locate areas where more research is needed, but they might not be useful for deciding specifically how interventions should be carried out. CONCLUSIONS: There currently is insufficient high-quality evidence regarding nonpharmacological and nonsurgical interventions for hand osteoarthritis. Considering the limited research evidence and the prevalence and impact of the disease, there is an urgent need for more trials of nonpharmacological and nonsurgical interventions for hand osteoarthritis
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Novel cartilage-specific splice variants of fibronectin
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: To determine the nature of alternatively spliced isoforms of fibronectin expressed in healthy bovine articular cartilage and cartilage derived from human osteoporotic and osteoarthritic joints. DESIGN: Our study focused on a single alternatively spliced region of the fibronectin gene, the variable region. Bovine cartilage samples were obtained within 12h of slaughter and human cartilage samples were obtained within 8h of the time of joint replacement surgery. RNA was extracted and alternatively spliced isoforms of fibronectin were amplified using RT-PCR. RESULTS: Two novel alternatively spliced forms of fibronectin designated (V+I-10)(-) and (V+III-15)(-) were identified in bovine articular cartilage. Fibronectin is composed of multiple repeats of three types of homologous units and these two novel isoforms specifically splice out single individual repeating units. Expression of all these isoforms was dependent upon the presence of an extracellular matrix. In the human samples the expression profiles obtained with osteoporotic hip and osteoarthritic knee cartilage was not uniform. The (V+C)(-) isoform was present in all samples and the (V+I-10)(-) isoform was distributed between both osteoporotic and osteoarthritic cartilage. However, the (V+III-15)(-) isoform was shown to be associated with osteoarthritic cartilage with statistical significance (P< 0.015 ). In addition a third novel splice variant was identified and designated as III-15X. Translation of the III-15X isoform results in a truncated form of fibronectin lacking a significant portion of the C-terminus. Further RT-PCR analysis of several other tissue types suggests that these variants are cartilage specific. CONCLUSION: Our results demonstrate the existence of three new cartilage specific isoforms of fibronectin and indicate that expression of one or more may be associated with osteoarthritis. Published by Elsevier Science Ltd. All rights reserved
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North American male reference population for speed of sound in bone at multiple skeletal sites
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Management of Hip Fractures in the Elderly
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Alternatives to dual-energy X-ray absorptiometry (DXA) have been sought to increase access to low-cost osteoporosis risk assessment. Early quantitative ultrasound (QUS) systems measured speed of sound (SOS) and broadband ultrasound attenuation (BUA) at the calcaneus, and these were demonstrated to be good predictors of hip fracture risk. Recent studies have demonstrated the usefulness of other peripheral sites to assess bone status. The Sunlight Omnisense (Sunlight Medical, Rehovot, Israel) is a portable, inexpensive QUS device capable of multiple-site SOS measurement. To provide a robust male reference database, 588 healthy Caucasian males aged 20-90 yr were recruited from 6 centers across North America. SOS measurements were taken at the distal 1/3 radius, proximal third phalanx, midshaft tibia, and fifth metatarsal. A female reference database has previously been collected at North American sites. The results indicate that SOS in males exhibits an age-related decline beginning in the fifth decade at the radius, phalanx, and metatarsal, whereas the tibial SOS remains nearly constant until the ninth decade. Although females reach a higher-peak SOS than males at most sites, SOS is higher in males at all sites after the sixth decade, as a result of a more gradual decline in SOS. Longitudinal monitoring of healthy men should be performed to confirm these cross-sectional results
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Ventral hernia repair with simultaneous panniculectomy
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Panniculectomy & Abdominoplasty CPG
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The repair of a ventral hernia in an obese patient presents an interesting clinical challenge. We retrospectively reviewed the charts of 55 patients who, over a 12-year period from 1983 to 1995, concomitantly underwent both ventral herniorrhaphy and panniculectomy or abdominoplasty. In six of 55 patients, the hernia was recurrent. Forty-six patients had primary abdominal wall hernias or diastasis recti. Nineteen of 55 patients had weight greater than 200 lbs. This last subset of patients had a significantly higher incidence of complications, such as seroma, cellulitis, and persistent wound drainage. In our 55 patients, we experienced only two hernia recurrences (3.6%) during an average patient follow-up of 53 weeks. From this experience, we believe that simultaneous ventral hernia repair and panniculectomy is a safe and efficacious approach to these two problems so commonly found in the obese patient. Patients with a preoperative weight greater than 200 lbs can be expected to have a greater risk of wound complications. In all cases, the wounds eventually healed with no long-term sequelae.
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MRSA-infected external iliac artery pseudoaneurysm treated with endovascular stenting
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Surgical Management of Osteoarthritis of the Knee CPG
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A 48-year-old woman with severe juvenile-onset rheumatoid arthritis presented with a bleeding cutaneous sinus distal to her right total hip replacement scar. Methicillin resistant Staphylococcus aureus (MRSA) was isolated on culture. She had previously undergone bilateral total hip and knee replacements at aged 23 and six years later had the right knee prosthesis removed for infection, with subsequent osteomyelitis of the femoral shaft and right total hip prosthesis disruption. Peripheral arteriography was performed in view of persistent bleeding from the sinus, which revealed a 6 cm false aneurysm filling from and compressing the right external iliac artery (EIA). A PTFE-covered, balloon expandable JOSTENT was deployed in the right EIA, successfully excluding the false aneurysm and preventing further bleeding from the sinus. No graft infection was reported at 12 months. This case illustrates the potential use of endovascular stent-grafting in the treatment of an infected pseudoaneurysm
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Two-Stage Revision Anterior Cruciate Ligament Reconstruction
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PJI DX Updated Search
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The number of primary anterior cruciate ligament (ACL) tears is rapidly increasing. In patients who wish to return to their preoperative level of function, specifically as it pertains to participation in sports, the gold standard of treatment following an ACL tear remains an anterior cruciate ligament (ACL) reconstruction. Despite a majority of good/excellent results following primary ACL reconstruction, there is a growing subset of patients with persistent or recurrent functional instability who require revision ACL reconstruction. Preoperative planning for revision ACL reconstruction requires a careful understanding of the root cause of ACL failure, including possible technical causes of primary ACL failure and the presence of combined knee pathology that was not addressed at the index ACL reconstruction. The decision to perform 2-stage revision ACL reconstruction is multifactorial and is reached by technical considerations that may make a 1-stage revision less optimal, including tunnel widening, arthrofibrosis, active infection, and others. Concomitant knee pathology such as meniscal deficiency, malalignment (including an increase in posterior tibial slope), chondral lesions, and other ligamentous laxity may also require a staged approach to treatment. This evidence-based review covers the indications for 2-stage revision ACL reconstruction, surgical techniques, evidence for and technique of bone grafting prior ACL tunnels, and outcomes of 2-stage revision stratified by initial cause of ACL reconstruction failure. With proper preoperative planning and an understanding of the cause of failure following the primary ACL reconstruction, revision ACL reconstruction can offer excellent outcomes in the motivated patient. [Orthopedics. 2016; 39(3):e456-e464.]
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Long-term results of bipolar hemiarthroplasty for osteoarthritis of the hip and idiopathic osteonecrosis of the femoral head
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Management of Hip Fractures in the Elderly
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BACKGROUND: Satisfactory results have been reported from long-term studies on bipolar hemiarthroplasty for femoral neck fracture. However, long-term results of this procedure for osteoarthritis of the hip (OA) and idiopathic necrosis of the femoral head (ION) have given rise to pessimism. These poor results have often reported migration of the bipolar head, but few had described the direction of this migration. The purpose of the present study was to conduct a long-term follow-up analysis of bipolar hemiarthroplasty for OA and ION, including the direction of migration. METHODS: We retrospectively reviewed a consecutive series of 64 patients (76 hips) who underwent primary bipolar hemiarthroplasty for symptomatic OA and ION with a cementless femoral component between 1976 and 1995. Of these 64 patients, 35 patients (40 hips) were available for clinical and radiographic review at a minimum follow-up duration of 10 years. RESULTS: The Japanese Orthopaedic Association score significantly improved and pain relief was high following surgery; however, preservation of acetabular bone stock could not be achieved because of migration. The survival rate declined 10 years after surgery. Superomedial migration was found to be a risk factor for revision, and one factor affecting superomedial migration was the postoperative center edge angle. CONCLUSIONS: The long-term results of bipolar hemiarthroplasty for OA and ION are not favorable. If a sufficient centripetal position is obtained with reaming, the bipolar head tends to migrate superomedially, subsequently requiring revision
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Diagnosis and treatment of Parkes Weber syndrome: a review of 10 consecutive patients
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PJI DX Updated Search
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BACKGROUND: We sought to retrospectively analyze the clinical presentation, diagnosis, treatment, and outcomes of patients with Parkes Weber syndrome (PWS) who were treated at a single institution. METHODS: A retrospective review was conducted of medical records of all patients with PWS treated at La Paz Children's Hospital between 1994 and 2010. RESULTS: Ten patients (median age, 14.8 years [range, 2-52 years]) were identified, including 7 women and 3 men. Six patients presented with lower limb hypertrophy and capillary malformation at birth, and both the right and left lower extremities were equally involved. Severe tricuspid insufficiency was observed in 1 patient. The median dysmetria between both lower extremities was 2.19 cm. Four patients are being treated successfully with compression garment therapy. Three patients underwent resection of multiple arteriovenous nidus. Three patients had palliative embolizations. One patient required above the knee amputation secondary to ischemia and chronic severe pain. CONCLUSIONS: The early recognition of PWS is required to establish the most appropriate treatment and prevent short-term morbidity and unnecessary invasive diagnostic tests. Treatment should be individualized according to the age and clinical features of each patient. Although initial conservative management is recommended, surgery continues to play an important role in order to improve the quality of life in these patients
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Characteristics of refractory sweating areas following minimally invasive surgery for axillary hyperhidrosis
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Panniculectomy & Abdominoplasty CPG
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Background: Several surgical strategies have evolved for the treatment of focal axillary hyperhidrosis (FAH). However, nonresponders are found in every procedure. Until now no characterization of the recurrent sweating areas has been reported. The aim of this study was to characterize the axillary sweat area by using the iodine starch test in nonresponders prior to surgery. Methods: Prior to minimally invasive surgery, 24 (15 females, 9 males) nonresponders underwent a repetitive iodine starch test to define the area of recurrent sweating. Size and distribution of the hyperhidrotic area were documented. Results: Eighteen patients had undergone previous liposuction and six liposuction curettage. The size of recurrent sweating area was 10.2 cm 2 (range = 5.5-24.5 cm2). We were able to identify three different patterns of recurrent sweating: crescent (33%), circular (41%), and insertion-spot type (26%). Conclusion: Patterns of recurrent sweating areas may partially indicate insufficient planning and implementation of surgery, resulting in nonresponders. We suggest that exact preoperative identification of the hyperhidrotic area be mandatory. © 2008 Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery.
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Operating room efficiency and timing during coronavirus disease 2019 outbreak in a referral orthopaedic hospital in Northern Italy
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Coronavirus Disease 2019 (COVID-19)
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PURPOSE: The SARS-CoV-2 outbreak affected health care systems at different levels with important consequences on health, economy, and social structures. This paper aims to analyse the impact on surgical block utilisation and efficiency in an orthopaedics reference centre in Northern Italy. METHODS: The timeframe chosen for the current analysis was April 2020, to be compared with the corresponding period in 2019. Number and type of procedures, first case delay, occupancy rate, and turnover time were used as indicators to benchmark the activities. RESULTS: The overall number of surgical procedures decreased by 57%, from 537 in 2019 to 230 in the same timeframe in 2020. Orthopaedic procedures predominated in 2019, with 434 cases (80.8%), while in 2020, trauma was the leading activity, with 200 cases (86.9%). Orthopaedic surgery had a relative decrement of 93% while trauma has relatively increased by 94%. Mean first case delay in orthopaedic room (OR) was two hours and 36 minutes (SD 01:40:21) in 2020 compared with only 19 minutes (SD 00:02:15) in 2019. OR occupancy rate was 59% in 2020 compared with 89% in 2019. Turnover time raised from 21 minutes in 2019 to 53 min in 2020. CONCLUSIONS: These data clearly show the deep impact of COVID-19 pandemic on OR facilities. Efficiency indicators fell dramatically in April 2020 compared with the corresponding period in 2019. This scenario will deeply affect both the waiting lists and the economic burden of the hospital. Regaining efficiency and maintaining the quality and safety of the process while restoring elective orthopaedic surgery are among the main challenges that surgeons will face in the next time.
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Study of Relationship between Bone Mineral Density in Ipsilateral Proximal Femur and Severity of Osteoarthritis of Knee
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AMP (Acute Meniscal Pathology)
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Introduction: Osteoarthritis (OA) of the knee is the most common rheumatic disease that is characterized by degradation of articular cartilage, subchondral bone alteration, meniscal degeneration, synovial inflammatory response, and overgrowth of bone and cartilage. In severe OA, the reduced mobility caused by pain can increase bone loss and reduction of bone mineral density leading to osteoporosis.
Objective: To examine the possible relationship between severity of osteoarthritis (OA) and bone mineral density (BMD) by evaluating the bone mineral density in ipsilateral proximal femur and radiographic grading of knee OA in the Indian population.
Methods: In this cross-sectional observational study, 100 subjects diagnosed with OA knee using ACR criteria were enrolled. Severity of OA knee was assessed using Kellgren-Lawrence scale (1 to 4) on weight-bearing radiographs. The BMD, T-score, and Z-score of the ipsilateral proximal femur was measured by dual-energy X-ray absorptiometry. Pearson's correlation coefficient was used to test the association of severity of OA knee with BMD.
Results: Among 100 subjects, there were 51 females and 49 males with mean age 59.94 +/- 6.67. Maximum patients were with K-L grade 2 (42%) followed by grade 3 (30%) and grade 4 (22%). There was statistically significant (p < 0.0001) association between BMD and severity of OA knee. BMD decreased as the K-L grade of OA knee increased from 1 to 4. Similar statistically significant association was observed in T-score and Z-score.
Conclusion: The study concluded that BMD of ipsilateral proximal femur decreases with severity of OA knee. These data support the fact that the two conditions may be related to each other and primary care physicians must look for these two conditions in coexistence. Primary prevention of either of the two conditions should be advised, if the other condition coexists in the same patient.
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Long-term follow-up of radial shortening osteotomy for Kienbock disease
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Distal Radius Fractures
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BACKGROUND: Three previous studies have investigated the long-term outcome of radial osteotomy in the treatment of Kienbock disease. However, none used patient-based assessment. The purpose of this study was to investigate the long-term clinical and radiographic outcomes of this osteotomy, including the subjective evaluation of the patient with use of the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire.
METHODS: A DASH questionnaire was sent to nineteen patients with Kienbock disease who had undergone a radial shortening osteotomy, and thirteen replied. The mean age at the time of surgery was thirty-nine years. On the basis of the Lichtman classification, six patients had stage-II, four had stage-IIIA, and three had stage-IIIB disease. Prior to surgery, ulnar variance was positive in six patients, neutral in four, and negative in three. The mean duration of follow-up was twenty-one years. Clinical evaluation, including calculation of the modified Mayo wrist score, and radiographic evaluation were also performed on twelve of the thirteen patients.
RESULTS: The mean DASH score was 8 points (range, 0 to 23 points), and patient satisfaction was high. Compared with the findings in the contralateral wrist, the mean range of motion was 81% in flexion and 82% in extension and mean grip strength was 88%. The mean modified Mayo wrist score was 83 points, and the clinical results were excellent in six patients, good in five, and moderate in one. The DASH scores tended to be worse in patients with Lichtman stage-IIIB disease. Follow-up radiographs revealed that the Lichtman stage had progressed in six of the twelve patients.
CONCLUSIONS: Although most patients had mild wrist pain, patient satisfaction and the clinical results were satisfactory following a radial shortening osteotomy. This procedure is a reliable long-term treatment for Lichtman stage-II and IIIA disease and may be a reasonable option for patients with stage-IIIB disease.
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Outcomes after Open Reduction and Plate Fixation of Distal Humerus Fractures
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Distal humerus fractures (DHFs) have been a serious challenge since the beginning of surgery. The outcome of surgical treatment of a DHF should not only be assessed with clinical ratings. It is also important to take into account the patient's subjective evaluation of limb function. MATERIAL AND METHODS: The study involved 26 patients after surgical treatment of DHF. The Quick DASH (QDASH) scale was used to assess the subjective results of surgical treatment of DHF, and the objective Mayo Elbow Performance Score (MEPS) was used to assess the clinical outcome. Relationships between the subjective and objective scores were tested with Pearson's correlation coefficient. RESULTS: 85% of the patients had excellent or good QDASH scores, and 65% of patients had excellent or good MEPS scores. The Pearson correlation coefficient between the subjective and objective assessments was -0.91, indicating total dependence. CONCLUSIONS: Open reduction and internal fixation using two perpendicular plates allows for achieving good stability of fixation, early rehabilitation and quick return to the desired level of activity, which contributes to a high percentage of good objective and subjective results of treatment. Subjective assessment of upper limb function after DHF surgery fully correlates with objective assessment.
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What are the costs of queuing for hip fracture surgery in Canada?
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Management of Hip Fractures in the Elderly
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This paper investigates the effect of wait time for hip fracture surgery in Canada on post-surgery length of stay in hospital and inpatient mortality. After controlling for observed and unobserved patient and hospital characteristics, pre-surgery delay has little effect on either of the two outcome variables. Patients from higher income postal-codes experience only slightly shorter delays, and income has no substantial effect on post-surgery outcomes. For hip fracture patients surgery delay may lead to greater pre-surgery inpatient costs and more patient discomfort, but we find no evidence of a detrimental impact on post-surgery outcomes
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Effect of Abdominal Lipectomy on Lipid Profile, Glucose Handling and Blood Pressure in Patients with Truncal Obesity
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Previous studies have found that people with apple (android)-shaped body fat distribution are at risk of developing cardiovascular disease, impaired glucose tolerance and hypertension. METHODS: To investigate the effects of lipectomy, we measured lipid and lipoprotein levels, indices associated with glucose tolerance and blood-pressure. The tests were performed pre-operatively and 3 and 12 months post-operatively in 34 subjects (obese lipectomy patients with android-shaped body fat distribution) and 23 controls (obese breast reduction patients). RESULTS: In subjects, total cholesterol, LDL and blood pressure were significantly lower at 3 months follow-up, but returned to pre-operative levels at 12 months follow-up. Plasma insulin decreased significantly at 3 months follow-up, and continued to decrease at 12 months follow-up. Triglycerides, HDL, fasting blood sugar, glycosylated hemoglobin and C-peptide did not change at 3 and 12 months follow-up. There were no changes in controls. CONCLUSIONS: Lipectomy in patients with truncal obesity may reduce plasma insulin levels, but had no lasting effect on plasma lipids.
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Wound healing after laser treatment of oral and oropharyngeal cancer
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Reconstruction After Skin Cancer
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The wound healing after laser surgery is delayed in contrast to conventional scalpel surgery. There are some animal studies, which investigated the effects of laser surgery upon wound healing, whereas clinical investigations on wound healing of human mucous membrane after laser surgery is missing. A histological study on the laryngeal mucosa of 11 patients after laser incisions who underwent emergent laser debulking surgery for acute airway obstruction and a clinical study of 24 patients with oral or oropharynx cancer who were treated by laser surgery were performed to investigate the course of wound healing. The histological findings showed that the beginning of wound healing was delayed after laser surgery. The duration of wound healing after laser surgical tumour resection revealed a clear dependence on the size of the initial defect. The average duration of wound healing after CO(2) laser surgery (32.8 +/- 9.2 days) was significantly shorter than after Nd:YAG laser surgery (40.4 +/- 9.2). Due to the more pronounced zone of necrosis at the base of the wound ground this effect is more evident using the Nd:YAG laser. However, the different course of wound healing with both laser systems does not seem to have a negative influence on functional results.
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Chronic osteomyelitis of the pelvis
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Reconstruction After Skin Cancer
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The aim of this study was to examine the aetiology and response to treatment of a series of patients with pelvic osteomyelitis. Criteria for selection were multiple positive intra-operative cultures and/or a positive radiological diagnosis. Twenty patients met these criteria (age range: 21-78 years, mean = 46). Data was recorded on host status using the Cierny-Mader classification, neurological status, causative organisms; sensitivities were recorded and the treatment and its outcome. Pelvic osteomyelitis was frequently caused by unusual organisms; a high incidence (45%) of neurologically compromised patients was noted. There were important differences in infective organisms, treatment and outcome in the paraplegic and non-paraplegic population. A high mortality and a high incidence of squamous cell carcinoma was observed. Pelvic osteomyelitis should be managed differently to long bone osteomyelitis as far as the antibiotic therapy is concerned, with a greater need for broad spectrum antibiotics in pelvic osteomyelitis. The response to surgical resection was similar to long bone osteomyelitis with a high chance of success with marginal resection in type A hosts and with wide resection in type B hosts.
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The outcome of the treatment of diaphyseal primary bone sarcoma by resection, irradiation and re-implantation of the host bone: extracorporeal irradiation as an option for reconstruction in diaphyseal bone sarcomas
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MSTS 2022 - Metastatic Disease of the Humerus
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We analysed the outcome of patients with primary non-metastatic diaphyseal sarcomas who had en bloc resection with preservation of the adjoining joints and reconstruction with re-implantation of sterilised tumour bone after extracorporeal radiation (50 Gy). Between March 2005 and September 2009, 32 patients (16 Ewing's sarcoma and 16 osteogenic sarcoma) with a mean age of 15 years (2 to 35) underwent this procedure. The femur was the most common site in 17 patients, followed by the tibia in 11, humerus in three and ulna in one. The mean resected length of bone was 19 cm (10 to 26). A total of 31 patients were available at a mean follow-up of 34 months (12 to 74). The mean time to union for all osteotomy sites was 7.3 months (3 to 28): metaphyseal osteotomy sites united quicker than diaphyseal osteotomy sites (5.8 months (3 to 10) versus 9.5 months (4 to 28)). There were three local recurrences, all in soft-tissue away from irradiated graft. At the time of final follow-up, 19 patients were free of disease, one was alive with disease and 11 had died of disease. The mean Musculoskeletal Tumor Society Score for 29 patients evaluated at the last follow-up was 26 (9 to 30). Extracorporeal irradiation is an oncologically safe and inexpensive technique for limb salvage in diaphyseal sarcomas and has good functional results.
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Imaging of cartilage repair procedures
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Osteochondritis Dissecans 2020 Review
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The rationale for cartilage repair is to prevent precocious osteoarthritis in untreated focal cartilage injuries in the young and middle-aged population. The gamut of surgical techniques, normal postoperative radiological appearances, and possible complications have been described. An objective method of recording the quality of repair tissue is with the magnetic resonance observation of cartilage repair tissue (MOCART) score. This scoring system evaluates nine parameters that include the extent of defect filling, border zone integration, signal intensity, quality of structure and surface, subchondral bone, subchondral lamina, and records presence or absence of synovitis and adhesions. The five common techniques of cartilage repair currently offered include bone marrow stimulation (microfracture or drilling), mosaicplasty, synthetic resorbable scaffold grafts, osteochondral allograft transplants, and autologous chondrocyte implantation (ACI). Complications of cartilage repair procedures that may be demonstrated on magnetic resonance imaging (MRI) include plug loosening, graft protuberance, graft depression, and collapse in mosaicplasty, graft hypertrophy in ACI, and immune response leading to graft rejection, which is more common with synthetic grafts and cadaveric allografts.
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Osteochondritis Dissecans Lesions of the Pediatric and Adolescent Knee
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Osteochondritis Dissecans 2020 Review
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Osteochondritis dissecans of the knee in pediatric and adolescent patients remains an incompletely understood entity, with multiple theories proposed for its underlying cause and variable treatment modalities. In addition to the importance of history and examination, treatment is primarily guided by lesion stability, which can be determined by MRI and arthroscopic findings. Other important factors that can influence healing include patient skeletal maturity, lesion location, and the size of the lesion. The purpose of this article is to review the most current epidemiology, classification, and pathoanatomy of the disease and discuss the different treatment options.
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A New Suturing Method for Optimal Wound Healing: Technique and Experience
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Wound closure utilizing barbed sutures has been associated with healing problems, such as thread extrusion, infection, and the increase of an inflammatory response around the scar. OBJECTIVES: In our study, the senior author described a novel technique of skin incision and wound closure based on de-epithelization and bi-layer tension-free closure that minimizes complications. METHODS: In this retrospective study, the authors reviewed the evolution of wound healing for the novel technique developed by the senior author by analyzing clinical reports of 817 patients who underwent surgery for abdominoplasty or breast reduction utilizing power-assisted liposuction mammaplasty with the new incision and closure technique. In addition, three separate plastic surgeons reviewed the wound characteristics and overall appearance by analyzing photographs that were taken over the course of 12 months to document the healing process. RESULTS: The overall complication rate was 14.1%, with 0.4% hematoma, 1.25% infection, 0.8% seroma, 1.5% necrosis, 3.75% erythema, 3.3% delayed wound healing, and 3.1% suture extrusion. The authors reported the rate of step-off border (9%), contour irregularities (6.5%), margin separation (1.25%), edge inversion (3.2%), excessive distortion (0.9%), and bad overall appearance (6.4%) of the cases. CONCLUSIONS: This new technique in wound incision and closure based on de-epithelization and bilayer tension-free closure reduces the complications associated with barbed sutures.
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Peripheral visual perception during exercise: why we cannot see
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Upper Eyelid and Brow Surgery
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Peripheral visual perception may be relevant to performance in sports. Peripheral visual perception seems to be impaired during strenuous exercise. The hypothesis proposed is that a decrease in cerebral oxygenation is associated with impairment in peripheral visual perception during strenuous exercise. Recent behavioral and physiological data are presented to support the hypothesis.
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The Synovial Flap in Recurrent and Failed Carpal Tunnel Surgery
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Recurrent carpal tunnel syndrome is defined by a return of numbness after a symptom-free period after surgical decompression. The most common reason for recurrent symptoms is thought to be the formation of a constrictive scar. In this event, it seems reasonable to lay a barrier about the nerve after rerelease to try to prevent recurrent scar formation. We believe this approach is also reasonable during revision surgery for iatrogenic nerve injury. In this article, we describe the indications and technique and clinical experience using a synovial flap used to cover the median nerve after revision decompression at the wrist. (copyright) 2007 Elsevier Inc. All rights reserved
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Cancer-treatment-induced bone loss, part 2
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AAHKS (2) Corticosteroids
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Purpose. The pathophysiology, frequency, sequelae, diagnosis, and treatment of cancer-treatment-induced bone loss (CTIBL) are discussed. Summary. CTIBL is a long-term complication associated with cancer therapies that can directly or indirectly affect bone metabolism. Although CTIBL can occur in any patient receiving a cancer therapy known to cause bone loss, CTIBL is most common in patients with breast or prostate cancer who receive chemotherapy, hormone therapy, or surgical castration, as these can cause hypogonadism and induce bone loss. CTIBL causes bone fragility and an increased susceptibility to fractures; therefore, prevention, early diagnosis, and treatment of CTIBL are essential to decrease the risk of fracture. Bone loss occurs more rapidly and tends to be more severe in patients with CTIBL compared with those with normal age-related bone loss. Fractures of the hip, vertebra, and wrist are the fractures most commonly associated with bone loss. CTIBL is diagnosed by measuring bone mass using bone densitometry. Treatment of CTIBL consists of changing diet and lifestyle such as optimizing calcium and vitamin D intake, exercising, modifying behaviors known to increase the risk of CTIBL and pharmacologic therapy with hormone replacement therapy (HRT), selective estrogen-receptor modifiers (SERMs), calcitonin, or a biphosphonate. Conclusion. Early identification and treatment of CTIBL are essential to prevent fractures. Patients should be instructed to optimize calcium and vitamin D intake, exercise regularly, and modify lifestyle behaviors known to cause bone loss. Patients with CTIBL should be treated with an oral or i.v. bisphosphonate; SERMs or HRT may be an option in some patients if contraindications do not exist. Copyright © 2006, American Society of Health-System Pharmacists, Inc. All rights reserved.
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Open Distal Radius Fractures: Timing and Strategies for Surgical Management
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DoD SSI (Surgical Site Infections)
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Open distal radius fractures are rare injuries with few studies to guide treatment. Degree of soft tissue injury and contamination may be a primary consideration to dictate timing and operative intervention. Antibiotics should be started as early as possible and include a first-generation cephalosporin. Surgical fixation remains a matter of surgeon preference: although studies support the use of definitive internal fixation, many surgeons address contaminated injuries with external fixation. Although postoperative outcomes are similar to closed injuries for low-grade open distal radius fractures, high-grade injuries with more complex fracture patterns carry a high risk of complications, poor outcomes, and repeat surgical procedures.
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0 |
Emerging concepts of the cell biology of the meniscus
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AMP (Acute Meniscal Pathology)
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Three distinct populations of cells are now recognized in the knee joint meniscus: (a) round or oval-shaped fibrochondrocytes; (b) fibroblast-like cells; (c) superficial zone cells. Injury to the meniscus causes apoptosis in specific sites and an upregulation of gene expression for type I, II, III, and VI collagen and other matrix molecules. Cells in the superficial zone respond to injury by increased expression of alpha smooth muscle actin and migration into the wound site. Together, these studies reveal that the meniscus is tailored to accommodate tensile and compressive stresses in different regions of the tissue. The meniscus mounts a vigorous repair response to injury by initial recruitment of a specific cell population to the wound site and an increase in gene expression for matrix proteins. © 2002 Lippincott Williams & Wilkins, Inc.
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An advice and exercise program has some benefits over natural recovery after distal radius fracture: a randomised trial
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Distal Radius Fractures
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QUESTION: Does an advice and exercise program improve outcome for adults following distal radius fracture?
DESIGN: Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.
PARTICIPANTS: Fifty-six patients whose fracture had been managed with pins and/or cast.
INTERVENTION: The experimental group received a physiotherapist-directed program of advice and exercises. The control group did not receive any physiotherapy intervention.
OUTCOME MEASURES: The primary outcome was wrist extension (measured with a goniometer). Secondary outcomes were the other wrist ranges of motion (measured with a goniometer), grip strength (measured with a dynamometer), pain, and activity limitations (measured with questionnaires). These outcomes were measured initially, then three and six weeks later. Participants also rated their satisfaction with physiotherapy intervention at Week 6.
RESULTS: No difference was found between groups for the primary outcome of wrist extension (mean difference 6 deg, 95% CI -3 to 14), nor for the secondary outcomes of other range of motion data and grip strength. The difference between groups for pain was -16 points out of 100 (95% CI -27 to -5) at Week 3, and -14 points (95% CI -25 to -3) points at Week 6, and for activity was -13 points out of 100 (95% CI -24 to -2) at Week 3; in favour of the experimental group. The experimental group was also more satisfied with the amount of physiotherapy intervention.
CONCLUSION: An advice and exercise program provided some additional benefits over no intervention for adults following distal radius fracture.
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Distal radius bone mineral density estimation using the filling factor of trabecular bone in the x-ray image
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Distal Radius Fractures
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Osteoporosis is characterized by an abnormal loss of bone mineral content, which leads to a tendency to non-traumatic bone fractures or to structural deformations of bone. Thus, bone density measurement has been considered as a most reliable method to assess bone fracture risk due to osteoporosis. In past decades, X-ray images have been studied in connection with the bone mineral density estimation. However, the estimated bone mineral density from the X-ray image can undergo a relatively large accuracy or precision error. The most relevant origin of the accuracy or precision error may be unstable X-ray image acquisition condition. Thus, we focus our attentions on finding a bone mineral density estimation method that is relatively insensitive to the X-ray image acquisition condition. In this paper, we develop a simple technique for distal radius bone mineral density estimation using the trabecular bone filling factor in the X-ray image and apply the technique to the wrist X-ray images of 20 women. Estimated bone mineral density shows a high linear correlation with a dual-energy X-ray absorptiometry (r=0.87).
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Temporal profile of care following mild traumatic brain injury: predictors of hospital admission, follow-up referral and six-month outcome
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DoD PRF (Psychosocial RF)
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Objective: To investigate the clinical management and medical follow-up of patients with mild traumatic brain injury (mTBI) presenting to emergency departments (EDs). Methods: Overall, 168 adult patients with mTBI from the prospective, multicentre Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) Pilot study with Glasgow Coma Scale (GCS) 13â??15, no polytrauma and alive at six months were included. Predictors for hospital admission, three-month follow-up referral and six-month functional disability (Glasgow Outcome Scale-Extended (GOSE) â?¤ 6) were analysed using multivariable regression. Results: Overall, 48% were admitted to hospital, 22% received three-month referral and 27% reported six-month functional disability. Intracranial pathology on ED head computed tomography (multivariable odds ratio (OR) = 81.08, 95% confidence interval (CI) [10.28â??639.36]) and amnesia (>30-minutes: OR = 5.27 [1.75â??15.87]; unknown duration: OR = 4.43 [1.26â??15.62]) predicted hospital admission. Older age (per-year OR = 1.03 [1.01â??1.05]) predicted three-month referral, while part-time/unemployment predicted lack of referral (OR = 0.17 [0.06â??0.50]). GCS < 15 (OR = 2.46 [1.05â??5.78]) and prior history of seizures (OR = 3.62 [1.21â??10.89]) predicted six-month functional disability, while increased education (per-year OR = 0.86 [0.76â??0.97]) was protective. Conclusions: Clinical factors modulate triage to admission, while demographic/socioeconomic elements modulate follow-up care acquisition; six-month functional disability associates with both clinical and demographic/socioeconomic variables. Improving triage to acute and outpatient care requires further investigation to optimize resource allocation and outcome after mTBI. ClinicalTrials.gov registration: NCT01565551.
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Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To estimate the prevalence of bone and soft tissue abnormalities in asymptomatic knees using peripheral magnetic resonance imaging (pMRI) and to examine the relationship between these abnormalities and Kellgren-Lawrence (K-L) graded X-rays.
METHOD: Volunteers (20-68 years) with no history of knee pain, injury or bone or joint disease were recruited. Individuals underwent a single MRI scan and radiograph of their non-dominant knee. pMR images were acquired in sagittal plane using a 3-D gradient-echo protocol. Two radiologists graded the presence and severity of cartilage degeneration, osteophytosis, meniscal and ligamentous abnormalities, bone marrow edema and subchondral cysts. X-rays were acquired using a fixed-flexion technique and graded using the K-L scale.
RESULTS: Forty-four individuals, mean age (SD) 41.1 (14.2) years, participated. K-L grading of X-rays revealed 29 individuals were grade 0, 12 were grade 1 and 3 were grade 2. Five individuals showed evidence of cartilage lesions, the femoral trochlea, medial femur and patella being those regions most commonly affected. Twelve individuals (27.3%) showed evidence of osteophytosis, nine of whom did not show evidence on X-ray. Forty-three individuals showed evidence of at least one meniscal abnormality while 27 individuals (61.4%) had abnormalities in at least three of the four regions of the knee.
CONCLUSION: Our results suggest that osteophytes may be more prevalent in this population than radiographic data suggests due to the limitations of two-dimensional imaging. Meniscal degeneration or tears, a risk factor for knee osteoarthritis, are highly prevalent in asymptomatic individuals with the medial anterior and posterior horns being the most commonly affected regions.
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The use of a perioperative supra-physiological dose of glucocorticoid is not supported by evidence â?? A systematic review
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AAHKS (2) Corticosteroids
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Introduction: A supra-physiological dose of glucocorticoid (SDS) is administered routinely in the perioperative management of patients on long-term regular glucocorticoid therapy. The dose of glucocorticoid used in these regimens varies. The current treatment is based on two 60-year-old case reports. No data exist to document the required dose of glucocorticoid to prevent perioperative hypotension or the category of patients needing this dose. Having in mind that high doses of glucocorticoids have several potential side effects, this practice ought to be re-evaluated in the light of available evidence. Methods: We searched MEDLINE, Embase and the Cochrane Library for data about perioperative stress dose. The search was conducted by the two authors and repeated by a research librarian to ensure inclusion of all related studies. All original articles and reviews relating to the perioperative use of SDS in chronic glucocorticoid-treated patients were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were applied. Results: A total of 21 studies met the inclusion criteria of which five were prospective studies, five retrospective studies, three randomised controlled trials and eight reviews (three systematic reviews, one Cochrane review, three treatment guidelines, and one meta-analysis). No data supported routine use of SDS. Patients who continued their normal glucocorticoid treatment throughout the perioperative period had no need for SDS. Conclusion: No evidence supports the preoperative use of SDS in patients receiving chronic glucocorticoid therapy.
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0 |
Lipid metabolism of monosodium glutamate obese rats after partial removal of adipose tissue
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Panniculectomy & Abdominoplasty CPG
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We analyzed the effects of partial fat pad removal on retroperitoneal and epididymal fat depots and carcass metabolism of control (C) and MSG-obese (M) rats. Three-month-old C and M male Wistar rats were submitted to either partial surgical excision of epididymal and retroperitoneal fat tissue (lipectomy, L) or sham surgery (S) and studied after 7 or 30 days. Retroperitoneal and epididymal tissue re-growth after lipectomy was not observed, as indicated by the low pads weight of the L groups. The lipolysis rate was stimulated in LC7 and LM7, probably due to surgical stress and low insulin levels. In LM7, but not in LC7, in vivo lipogenesis rate increased in retroperitoneal and epididymal fat tissue, as did the diet-derived lipid accumulation in epididymal fat tissue. Although these local increases were no longer present in LM30, this group showed a large increase in the percentage of small area adipocytes in both pads as well as increased carcass lipogenesis rate. The present data showed that the partial removal of fat depots affected the metabolism of control and MSG-obese rats differently. In the obese animals only, it stimulated both local and carcass lipogenesis rate as well as adipocyte differentiation, i.e. responses likely to favor excised tissue re-growth and/or compensatory growth of non-excised depots.
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0 |
Hyperbaric oxygen in trauma and surgical emergencies
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DOD - Acute Comp Syndrome CPG
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Hyperbaric oxygen therapy (HBO), that is the administration of 100% oxygen delivered under pressure, has a beneficial effect in several surgical conditions. Its use has been assessed and audited and its pharmacological effects demonstrated. It is appropriate for use in several acute surgical conditions as evidence-based therapy. These are: Gas Gangrene Crush Injuries, Compartment Syndromes & Acute Traumatic Ischaemias Enhancement of Healing in Selected Problem Wounds Exceptional Blood loss Anaemia Necrotising Soft Tissue Infections Compromised Skin Grafts & Flaps Thermal Burns HBO therapy suffers from previous inappropriate use, lack of knowledge, and scarce hyperbaric facilities. Hyperbaric therapy, when properly supervised by a physician trained in its use, working closely with a surgeon, and ethically used for appropriate indications, can be a useful adjunct to surgical practice. Military surgeons may be in a situation in which they can utilize HBO in acute surgical conditions and trauma. They are urged to identify HBO facilities, both fixed and portable, and to establish communication with hyperbaric therapy colleagues. [References: 48]
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0 |
Comparison of two different locking plates for two-, three- and four-part proximal humeral fractures - Results of an international multicentre study
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DoD SSI (Surgical Site Infections)
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Purpose: The aim of this study was to compare the functional outcome, quality of restoration, and complication rate after open reduction and internal fixation (ORIF) of displaced or unstable 2-, 3- and 4-part humeral fractures using two different locking plates. Methods: The data used in this analysis was prospectively collected in two large multicentre studies in 15 European Level 1 trauma centres. A total of 318 patients with proximal humeral fractures were treated with ORIF using either the locking proximal humerus plate (LPHP) or proximal humeral internal locking system (PHILOS). Outcome measurements included Constant and Neer scores, evaluation of local pain at the fracture site and complications, and radiographic assessment at one year. Results: At one year, the mean Constant scores (relative to the contralateral shoulder) improved significantly for both groups and were above 80% for 2-, 3-, and 4-part fractures. A significantly shorter surgical time, less pain at the fracture site, and better functional outcome was achieved by PHILOS-treated patients with 2-part fractures throughout the one-year follow-up month and with 3-part fractures at three months (p<0.05). There was no difference between the treatment outcomes for 4-part fractures, and no difference in the complication rates (p>0.05). Conclusions: PHILOS and LPHP can be considered as useful implants for ORIF of displaced and unstable proximal humeral fractures. There was a slight advantage of the PHILOS system with regard to operative time and functional outcome, especially for the treatment of 2- and 3-part fractures. © Springer-Verlag 2011.
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What Risks are Associated with Primary THA in Recipients of Hematopoietic Stem Cell Transplantation?
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Hip Fx in the Elderly 2019
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INTRODUCTION: As patients who receive hematopoietic stem cell transplantation are at increased risk of avascular necrosis (AVN) and subsequent degenerative arthritis, THA may be considered in some of these patients, particularly as overall patient survival improves for patients undergoing stem-cell transplants. Patients receiving hematopoietic stem cell transplantation theoretically are at increased risk of experiencing complications, infection, and poorer implant survivorship owing to the high prevalence of comorbid conditions, immunosuppressive therapy regimens including corticosteroids, and often low circulating hematopoietic cell lines; however, there is a paucity of studies elucidating these risks.
QUESTIONS/PURPOSES: We asked: (1) What is the overall mortality of patients with hematopoietic stem cell transplantation who have undergone THA? (2) What is the complication rate for these patients? (3) What are the revision and reoperation rates and implant survivorship for these patients?
PATIENTS AND METHODS: Between 1999 and 2013, we performed 42 THAs in 36 patients who underwent stem-cell transplants. Other than those who died, all were available for followup at a minimum of 2 years; of the patients whose procedures were done more than 10 years ago and who are not known to have died, two (5%) had not been seen in the last 5 years and so are considered lost to followup. All patients underwent thorough evaluation by the transplant team before arthroplasty; general contraindications included active medical comorbidities or evidence of unstable end-organ damage, active rejection, and critically low circulating hematopoietic cell lines. Underlying primary diseases leading to hematopoietic stem cell transplantation included lymphoma (14/42; 33%), plasma cell disorders (10/42; 24%), leukemia (9/42; 21%), and amyloidosis (3/42; 7%). Complications, reoperations, revisions, and implant and patient survivorship, were recorded from chart review and data from the institutional total joint registry. Mean followup was 5 years (range, 2-15 years).
RESULTS: Patient survivorship free of mortality was 91% (95% CI, 81%-100%) and 82% (95% CI, 68%-96%) at 2 and 5 years, respectively. Complications occurred in four of 42 THAs (10%); these complications included an intraoperative fracture and a venous thromboembolism. Revisions occurred in two of 42 (5%) THAs; there were no reoperations. Implant survivorship free of component revision for any reason or implant removal accounting for death as a competing risk was 93% (95% CI, 83%-100%) at 5 years.
CONCLUSION: With appropriate medical evaluation and comanagement by transplant specialists, carefully selected patients with hematopoietic stem cell transplants may undergo elective primary THA, although complications do occur in this relatively fragile patient population. Although implant survivorship was modest at 93% at 5 years, there was not a high risk of revision for infection. Improved outcomes for these patients may be expected as their medical management advances and additional comparative studies may clarify other important patient factors.
LEVEL OF EVIDENCE: Level IV, therapeutic study.
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0 |
Synergistic toxicity of gentamicin- and nanosilver-doped polymethylmethacrylate bone cement on primary human osteoclasts
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PJI DX Updated Search
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Bacterial colonization of implant surfaces is a feared complication in surgery and orthopedics. Due to the increasing number of periprosthetic infections caused by multidrug-resistant microorganisms, new antibacterial coatings for biomaterials must be developed. The excellent antibacterial properties of silver nanoparticles (AgNPs) against multidrug-resistant bacteria, for example, have been repeatedly described. For this reason, we tested a nanosilver-doped polymethylmethacrylate (PMMA) bone cement and a nanosilver-coated titanium alloy regarding their influence on osteoclastogenesis of primary human peripheral blood mononuclear cells. Both implant variants did not inhibit osteoclast differentiation. Excellent cell attachment and unaltered podosomal structures were confirmed. Additionally, no induction of oxidative or endoplasmic reticulum stress could be observed. However, PMMA loaded with gentamicin and nanosilver inhibited preosteoclast fusion and further osteoclastogenesis. The material also led to decreased clathrin-dependent endocytosis as well as decreased levels of endoplasmic reticulum stress. Therefore, biomaterial functionalization with AgNPs did not disturb osteoclastogenesis, while addition of gentamicin reduced the cytocompatibility of nanosilver-doped materials towards human osteoclasts
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0 |
Infections of electrophysiologic cardiac devices
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Infections related to electrophysiologic cardiac device placement are increasing dramatically and are associated with adverse outcomes. With the US population aging and living longer, cardiac devices are utilized in an older population with significant comorbidities, making the threat from infectious complications significant. Electrophysiologic cardiac devices typically include an implanted pulse generator and an intravascular lead. Infection may occur at any component of the device, resulting in varied presentations. Bacteremia in cardiac device recipients may reflect primary generator pocket infection, or alternate sources of bacteremia may result in secondary hematogenous lead infection. This review focuses on the pathology, diagnosis, management and prevention of electrophysiologic cardiac device infections
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