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Hypercalcemia of malignancy: Treatment with intravenous dichloromethylene diphosphonate
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MSTS 2018 - Femur Mets and MM
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Twelve patients with hypercalcemia associated with various malignancies were treated with intravenous dichloromethylene diphosphonate (CI2MDP), a potent inhibitor of osteoclastic bone resorption, in doses of 2.5 mg/kg of body weight initially and 5.0 mg/kg thereafter for up to 7 days. Mean serum calcium concentration fell from 13.8 ± 0.6 mg/dL (SEM) before CI2MDP to 9.8 ± 0.7 mg/dL (SEM) (p < 0.001) after 7 days. Urine calcium excretion fell from 775 ± 95 mg/g creatinine (SEM) to 272 ± 70 mg/g creatinine (SEM) (p < 0.005), and urine hydroxyproline excretion fell from 144 ± 28 mg/g creatinine (SEM) to 78 ± 18 mg/g creatinine (SEM) (p < 0.05) after treatment with CI2MDP. The CI2MDP was well tolerated, and adverse effects were limited to asymptomatic hypocalcemia in two patients. The ability of CI2MDP to correct hypercalcemia and reduce urine calcium and hydroxyproline excretion in these patients is consistent with the hypothesis that increased bone resorption is primarily responsible for this complication of malignancy and suggests that CI2MDP may be highly useful in managing this condition.
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Does adding antibiotics to cement reduce the need for early revision in total knee arthroplasty?
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PJI DX Updated Search
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BACKGROUND: There is considerable debate about whether antibiotic-loaded bone cement should be used for fixation of TKAs. While antibiotics offer the theoretical benefit of lowering early revision due to infection, they may weaken the cement and thus increase the likelihood of aseptic loosening, perhaps resulting in a higher revision rate. QUESTIONS/PURPOSES: We (1) compared the frequency of early knee revision arthroplasty in patients treated with antibiotic-loaded or non-antibiotic-loaded cement for initial fixation, (2) determined effects of age, sex, comorbidities, and surgeons' antibiotic-loaded cement usage patterns on revision rate, and (3) compared causes of revision (aseptic or septic) between groups. METHODS: Our study sample was taken from the Canadian Joint Replacement Registry and Canada's Hospital Morbidity Database and included cemented TKAs performed between April 1, 2003, and March 31, 2008, including 20,016 TKAs inserted with non-antibiotic-loaded cement and 16,665 inserted with antibiotic-loaded cement. Chi-square test was used to compare the frequency of early revisions between groups. Cox regression modeling was used to determine whether revision rate would change by age, sex, comorbidities, or use of antibiotic-loaded cement. Similar Cox regression modeling was used to compare cause of revision between groups. RESULTS: Two-year revision rates were similar between the groups treated with non-antibiotic-loaded cement and antibiotic-loaded cement (1.40% versus 1.51%, p = 0.41). When controlling for age, sex, comorbidities, diabetes, and surgeons' antibiotic-loaded cement usage patterns, the revision risk likewise was similar between groups. Revision rates for infection were similar between groups; however, there were more revisions for aseptic loosening in the group treated with non-antibiotic-loaded cement (p = 0.02). CONCLUSIONS: The use of antibiotic-loaded cement in TKAs performed for osteoarthritis has no clinically significant effect on reducing revision within 2 years in patients who received perioperative antibiotics. Longer followup and confirmation of these findings with other national registries are warranted
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Risk Factors for Infection After Knee Arthroscopy: Analysis of 595,083 Cases From 3 United States Databases
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PJI DX Updated Search
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PURPOSE: To identify and quantify patient- and procedure-related risk factors for post-arthroscopic knee infections using a large dataset. METHODS: An administrative health care database including 8 years of records from 2 large commercial insurers and Medicare (a 5% random sample) was queried to identify all knee arthroscopies performed on patients aged at least 15 years using Current Procedural Terminology (CPT) codes. Each CPT code was designated as a high- or low-complexity procedure, with the former typically requiring accessory incisions or increased operative time. Deep infections were identified by a CPT code for incision and drainage within 90 days of surgery. Superficial infections were identified by International Classification of Diseases, Ninth Revision infection codes without any record of incision and drainage. Patients were compared based on age, sex, body mass index, tobacco use, presence of diabetes, and Charlson Comorbidity Index. RESULTS: A total of 526,537 patients underwent 595,083 arthroscopic knee procedures. Deep postoperative infections occurred at a rate of 0.22%. Superficial infections occurred at a rate of 0.29%. Tobacco use and morbid obesity were the largest risk factors for deep and superficial infections, respectively (P < .001; relative risk of 1.90 and 2.19, respectively). There were also higher infection rates among patients undergoing relatively high-complexity arthroscopies, men, obese patients, diabetic patients, and younger patients (in order of decreasing relative risk). Increased Charlson Comorbidity Index was associated with superficial and total infections (P < .001). CONCLUSIONS: Post-arthroscopic knee infections were more frequent among morbidly obese patients, tobacco users, patients undergoing relatively complex procedures, men, obese patients, diabetic patients, relatively young patients, and patients with increased comorbidity burdens in this study population. This knowledge may allow more informed preoperative counseling, aid surgeons in patient selection, and facilitate infection prevention by targeting individuals with higher inherent risk. LEVEL OF EVIDENCE: Level IV, cross-sectional study
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0 |
Does cruciate retention primary total knee arthroplasty affect proprioception, strength and clinical outcome?
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Surgical Management of Osteoarthritis of the Knee CPG
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PURPOSE: It remains unclear what the contribution of the PCL is in total knee arthroplasty (TKA). The goal of this study was to investigate the influence of the PCL in TKA in relationship to clinical outcome, strength and proprioception. METHODS: Two arthroplasty designs were compared: a posterior cruciate-substituting (PS) and a posterior cruciate-retaining (CR) TKA. A retrospective analysis was performed of 27 CR and 18 PS implants with a minimum of 1 year in vivo. Both groups were compared in terms of clinical outcome (range of motion, visual analogue scale for pain, Hospital for Special Surgery Knee Scoring system, Lysholm score and Knee Injury and Osteoarthritis Outcome Score), strength (Biodex System 3 Dynamometer(R)) and proprioception (balance and postural control using the Balance Master system(R)). Each design was also compared to the non-operated contralateral side in terms of strength and proprioception. RESULTS: There were no significant differences between both designs in terms of clinical outcome and strength. In terms of proprioception, only the rhythmic weight test at slow and moderate speed shifting from left to right was significant in favour of the CR design. None of the unilateral stance tests showed any significant difference between both designs. There was no difference in terms of strength and proprioception between the operated side and the non-operated side. CONCLUSION: Retaining the PCL in TKA does not result in an improved performance in terms of clinical outcome and proprioception and does not show any difference in muscle strength. LEVEL OF EVIDENCE: III
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1 |
Erratum to "Sonographic findings of the median nerve and prevalence of carpal tunnel syndrome in patients with Parkinson's disease" [Eur. J. Radiol. 67 (3) (2008) 546-550]
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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PURPOSE: Parkinson's disease (PD) is a chronic progressive disorder which is characterized by rest tremor, akinesia or bradykinesia and rigidity. Carpal tunnel syndrome (CTS) is caused by compression of median nerve and can occur as a result of repetitive trauma. The aim of this study was to estimate the prevalence of CTS in PD and evaluate the median nerve sonographically. MATERIALS AND METHODS: Fifty-three wrist of 29 patients with PD were included in the study according to Hoehn and Yahr (H&Y) clinical stage and divided into two groups. The first group consisted of 29 wrists of patients with mild PD (H&Y stage I-II). The second group consisted of 24 wrists of patients with severe PD (H&Y stage III-IV). Thirty-six wrists of 20 age-matched patients were used as control group. Both of the patients with PD and control group underwent sonography and electromyography (EMG). Axial sonograms of the median nerve were obtained at the level of distal radioulnar joint (level 1) and at the level of pisiform bone in the carpal tunnel (level 2). At each level, the cross-sectional area of the median nerve and flattening ratio were calculated. RESULTS: There was no significant difference for all parameters, except one parameter, between the patients with PD and control group, and also among mild and severe groups of PD and control group (p > 0.05). Interestingly, amplitude of median nerve in the second finger was significantly lower in PD patients than control group within normal limits (p=0.010). Of all wrists of PD patients, 13 (24.4%) have been diagnosed as CTS and 7 (19.4%) control wrists had CTS. Median nerve cross-sectional area of CTS patients were more than 10 mm2 in 6 (46%) wrists of PD patients but in only 1 (14%) control wrist at each level. Although it was not statistically significant, there was higher cross-sectional area at each level in patients with severe PD (level 1: 10.43+/-2.30 mm2, level 2: 10.35+/-3.19 mm2) than patients with mild PD (level 1: 9.93+/-2.61 mm2, level 2: 9.51+/-2.83 mm2) and control group (level 1: 9.69+/-3.19 mm2, level 2: 9.07+/-3.61 mm2). CONCLUSION: PD may pose a risk for the development of CTS due to the repetitive movement of tremor. Although sonography is not an ideal method of diagnosis for CTS, it may take our attention for indicating CTS in patients with PD especially in severe ones
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0 |
Tibial pilon fractures: which method of treatment?
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DoD SSI (Surgical Site Infections)
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A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Ruedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Ruedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne >= 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.
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0 |
Comparison of piroxicam and naproxen in osteoarthritis of the foot
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Management of Hip Fractures in the Elderly
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Osteoarthritis is the most common joint disease and the second highest ranking cause of disability in the US. Osteoarthritis commonly affects the hands, wrists, spine, knees, and feet. One of the mainstays of treatment for osteoarthritis is the use of nonsteroidal anti-inflammatory drugs. While there have been controlled comparison studies of the various nonsteroidal anti-inflammatory drugs, these have been limited to osteoarthritis of the hands, spine, and hip. This study was a randomized, double-blind, parallel study of 8 weeks' duration comparing piroxicam (Feldene, 20 mg daily) to naproxen (Naprosyn, 1,000 mg daily) in the treatment of osteoarthritis of the foot in 45 patients. Both groups experienced significant pain relief and improvement of mobility
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0 |
Low-Dose Ketamine Infusion for Emergency Department Patients with Severe Pain
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Hip Fx in the Elderly 2019
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Objective: Use of low-dose ketamine infusions in the emergency department (ED) has not previously been described, despite routine use in perioperative and other settings. Our hypothesis was that a low-dose ketamine bolus followed by continuous infusion would 1) provide clinically significant and sustained pain relief; 2) be well tolerated; and 3) be feasible in the ED. Methods: We prospectively administered 15 mg intravenous ketamine followed immediately by continuous ketamine infusion at 20mg/h for 1 hour. Optional morphine (4mg) was offered at 20, 40, and 60 minutes. Pain intensity, vitals signs, level of sedation, and adverse reactions were assessed for 120 minutes. Results: A total of 38 patients were included with a median initial numerical rating scale (NRS) pain score of 9. At 10 minutes, the median reduction in pain score was 4, with 7 patients reporting a score of 0. At 60 and 120 minutes, 25 and 26 patients, respectively, reported clinically significant pain reduction (decrease NRS score>3). Heart rate, blood pressure, respiratory rate, and oxygen saturation remained stable. Mild or moderate side effects including dizziness, fatigue, and headache were common. Patient satisfaction was high; 85% reported they would have this medication again for similar pain. Conclusion: A low-dose ketamine infusion protocol provided significant pain relief with mostly mild side effects and no severe adverse events.
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1 |
Factors Related to Postoperative Osteochondritis Dissecans of the Lateral Femoral Condyle After Meniscal Surgery in Juvenile Patients With a Discoid Lateral Meniscus
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AMP (Acute Meniscal Pathology)
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PURPOSE: The purpose was to assess the incidence of postoperative osteochondritis dissecans (OCD) and the related epidemiologic factors following meniscal surgery for juvenile discoid lateral meniscus (DLM).
METHODS: The study was a retrospective review of 103 knees in 89 patients with a mean age of 12.1 years who underwent arthroscopic meniscal surgery for DLM. Mean follow-up was 4.2 years. The surgical procedures were either saucerization, saucerization with repair or subtotal meniscectomy, depending on the type of DLM tear. Postoperative OCD lesions were identified radiographically. Age, sex, weight, Lysholm score, Tegner activity scale, exercise frequency, and surgical procedure were compared between the postoperative OCD diagnosis group and non-OCD control group.
RESULTS: Postoperative OCD was diagnosed in 8/103 (7.8%) knees following DLM surgery. The incidence of postoperative OCD was significantly greater for patients age less than 10 years old, and male sex, low weight, Lysholm score, Tegner activity scale preinjury and after returning to sports, and exercise frequency per week on univariate analyses. On multivariate analyses, postoperative OCD occurred more commonly with subtotal meniscectomy than with saucerization or saucerization with repair, and in patients less than 11 years of age. Receiver operating characteristic curve analysis revealed a cutoff value of age at surgery of 10 years.
CONCLUSIONS: Subtotal meniscectomy and patients younger than 10 years at the time of surgery are at greater risk for postoperative OCD. To decrease this risk, if possible, we recommend performing saucerization or saucerization with repair in patients undergoing surgery for DLM.
LEVEL OF EVIDENCE: Level III-retrospective comparative study.
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War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks
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DoD PRF (Psychosocial RF)
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This paper seeks to bridge the divisive split between advocates of trauma-focused and psychosocial approaches to understanding and addressing mental health needs in conflict and post-conflict settings by emphasizing the role that daily stressors play in mediating direct war exposure and mental health outcomes. The authors argue that trauma-focused advocates tend to overemphasize the impact of direct war exposure on mental health, and fail to consider the contribution of stressful social and material conditions (daily stressors). Drawing on the findings of recent studies that have examined the relationship of both war exposure and daily stressors to mental health status, a model is proposed in which daily stressors partially mediate the relationship of war exposure to mental health. Based on that model, and on the growing body of research that supports it, an integrative, sequenced approach to intervention is proposed in which daily stressors are first addressed, and specialized interventions are then provided for individuals whose distress does not abate with the repair of the social ecology.
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Efficacy and safety of monthly oral minodronate in patients with involutional osteoporosis
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Management of Hip Fractures in the Elderly
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Monthly minodronate at 30 or 50 mg had similar efficacy as 1 mg daily in terms of change in bone mineral density (BMD) and bone turnover markers with similar safety profiles. This new regimen provides patients with a new option for taking minodronate. INTRODUCTION: Minodronate at a daily oral dose of 1 mg has been proven to have antivertebral fracture efficacy. In the present study, the efficacy and safety of oral minodronate at monthly doses of either 30 mg or 50 mg were compared with a daily dose of 1 mg. METHODS: A total of 692 patients with involutional osteoporosis were randomized to receive minodronate at either 30 or 50 mg monthly or a daily dose of 1 mg. The primary endpoint was the percent change from baseline in lumbar spine (LS) BMD at 12 months. Total hip BMD, bone turnover markers, serum calcium (Ca), and parathyroid hormone (PTH) levels were also evaluated. RESULTS: Minodronate at monthly doses of 30 or 50 mg were noninferior to the 1 mg daily dose in terms of change in LS-BMD. Changes in total hip BMD were also comparable. Although a transient decrease in serum Ca and increase in PTH levels were observed in all three groups at slightly different magnitudes and time courses, changes in bone turnover markers were comparable among the different dosage groups with a similar time course. Safety profiles were also comparable. CONCLUSION: Minodronate at monthly doses of 30 or 50 mg has similar efficacy to the daily 1 mg dose in terms of BMD and bone turnover markers with similar tolerability
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Tibial shaft fractures - Management and treatment options. A review of the current literature
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DOD - Acute Comp Syndrome CPG
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Treatment of tibial shaft fractures is still discussed controversial. In the present study current literature was reviewed with the objective to demonstrate current recommendations concerning tibial shaft fractures. Tibial shaft fractures are often caused by high-energy trauma with severe concomitant soft-tissue injuries. Solid bone union without hypertrophy, fast mobilization and full range of motion without further soft-tissue damages are the aims of the therapy. Non-displaced tibial shaft fractures in patients with good compliance can be treated conservatively. Deep venous thrombosis, compartment syndrome, soft tissue injury and chronic regional pain syndrome are the major risks of conservative treatment and need to be required. Operative treatment can be performed with several different implants. Intramedullary nailing with a huge biomechanical stability seems to be the implant of choice. Only rare indications for plate osteosynthesis can be found. The use of external fixation has declined even though external fixation is still the implant of choice in first line treatment of multiple trauma according to the damage control principles. Open fractures with precarious blood supply and weak soft tissue covering are vulnerable to complications and remain a challenge for every treating surgeon. Reconstruction of axis, length and rotation is essential for a good outcome. The choice of technique depends on fracture localization, type of fracture, history of concomitant disorders and soft tissue damage. © Ä?eská spoleÄnost pro ortopedii a traumatologii 2006.
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Surgical Treatment for Infected Long Bone Defects after Limb-Threatening Trauma: Application of Locked Plate and Autogenous Cancellous Bone Graft
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DoD SSI (Surgical Site Infections)
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BACKGROUND: Treatment strategies for bone defects include free bone grafting, distraction osteogenesis, and vascularized bone grafting. Because bone defect morphology is often irregular, selecting treatment strategies may be difficult. With the Masquelet technique, a fracture site is bridged and fixed with a locking plate after treating deep infection with antibiotic-containing cement, and a free cancellous bone-graft is concomitantly placed into the defects. This procedure avoids excessive bone resection.
METHODS: We studied 6 patients who underwent surgical treatment for deep infection occurring after extremity trauma (2004 through 2009). Ages at surgery ranged from 29 to 59 years (largest age group: 30 s). Mean follow-up was 50.7 months (minimum/maximum: 36/72 months). One patient had complete amputation of the upper extremity, 3 open forearm fractures, 1 closed supracondylar femur fracture, and 1 open tibia fracture. In all patients, bone defects were filled with antibiotic-containing cement beads after infected site debridement. If bacterial culture of infected sites during curettage was positive, surgery was repeated to refill bone defects with antibiotic-containing cement beads. After confirmation of negative bacterial culture, osteosynthesis was performed, in which bone defects were bridged and fixed with locking plates. Concomitantly, crushed cancellous bone grafts harvested from the autogenous ilium was placed in the bone defects.
RESULTS: Time from bone grafting and plate fixation to bone union was at least 3 and at most 6 months, 4 months on average. Infection relapsed in one patient with methicillin-resistant Staphylococcus aureus, necessitating vascularized fibular grafting which achieved bone union. No patients showed implant loosening or breakage or infection relapse after the last surgery during follow-up.
CONCLUSION: The advantage of cancellous bone grafting include applicability to relatively large bone defects, simple surgical procedure, bone graft adjustability to bone defect morphology, rapid bone graft revascularization resulting in high resistance to infection, and excellent osteogenesis.
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Prospective randomized trial comparing alumina ceramic-on-ceramic with ceramic-on-conventional polyethylene bearings in total hip arthroplasty
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Management of Hip Fractures in the Elderly
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This prospective randomized study aims to compare the outcome between an alumina ceramic-on-ceramic (CC) articulation with a ceramic on ultra-high-molecular-weight polyethylene articulation (CP). Fifty-six hips in 55 patients with mean age 42.2 (range, 19-56) each received uncemented components, a 28-mm alumina head with randomization of acetabular liner. Mean St Michael's outcome score for each group with up to 10 years follow-up (median, 8 years; range, 1-10) was 22.8 and 22.9, respectively (P = .819). Wear was identified in all but 1 CP replacement, but only 12 of the 23 CC. Mean wear in the CP group was 0.11 mm/y and 0.02 mm/yr in the CC group (P < .001). Other than significantly greater wear in the polyethylene group, there was no significant difference in midterm outcome between the 2 groups
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The effect of intravenous iron on postoperative transfusion requirements in hip fracture patients: study protocol for a randomized controlled trial
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Hip Fx Time to Surgery
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BACKGROUND: Anaemia following hip fracture is common. Approximately 30 to 45% of patients have haemoglobin concentrations below population norms on admission, and around 10% are severely anaemic. Anaemia on admission, and in the postoperative period, is associated with poor outcomes with regard to mobility, postoperative mortality and readmission. There is currently no clear consensus on the optimal method of managing perioperative anaemia in this group of frail patients with frequent comorbidity. Liberal red cell transfusion in the postoperative period does not appear to improve outcome, whereas tranexamic acid appears to reduce transfusion rate at the expense of increased cardiovascular morbidity. There are encouraging results from one centre with the use of agents to stimulate red cell production, including intravenous iron and erythropoietin. UK practice differs significantly from these patients and these studies, and it is not clear whether these promising results will translate to the UK population. METHODS/DESIGN: This is a single-centre randomized controlled parallel group trial, in a British university hospital.Randomization is achieved using a website and computer-generated concealed tables. Participants are 80 patients 70 years or over with acute hip fracture undergoing operative repair. The intervention group receive three daily infusions of 200 mg iron sucrose, starting within 24 hours of admission. The control group receive standard hospital care at the discretion of the clinical team. Red cell transfusions for each group are given in accordance with standard clinical triggers. The primary outcome is an increase in mean reticulocyte count in the intervention group at day 7. Secondary outcome measures include haemoglobin concentrations, early and late transfusion rates, infectious and cardiovascular complications, mobility and 30-day mortality. DISCUSSION: This is a pilot study to demonstrate haematopoietic efficacy of intravenous iron in this setting. Hence, we have chosen to measure change in reticulocyte count rather than the more clinically relevant differences in haemoglobin concentration or transfusion rate. If our results are positive, the study will provide the necessary information for development of a full-scale trial of intravenous iron. TRIAL REGISTRATION: Current Controlled Trials ISRCTN76424792; UK Medicines and Healthcare products Regulatory Authority (EuDRACT: 2011-003233-34).
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Preoperative urine-specific gravity and the incidence of complications after hip fracture surgery: A prospective, observational study
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Hip Fx in the Elderly 2019
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BACKGROUND: Mild to moderately severe dehydration is common in the elderly, but its relationship to surgical outcome is unclear.
OBJECTIVES: To study the incidence of dehydration prior to hip fracture surgery and its relationship to postoperative complications.
DESIGN: Prospective observational study.
SETTING: Operation department and orthopaedic ward at a regional hospital.
PATIENTS: Forty-five patients [median (interquartile range) age 78 (75 to 86) years] undergoing acute hip fracture surgery.
INTERVENTIONS: A urine sample was taken on admission to the operating theatre. Complications were assessed 2 days postoperatively using a check-list.
MAIN OUTCOME MEASURES: Dehydration was considered to be present if the urinary specific gravity was 1.020 or higher, indicating renal water conservation. The number and type of postoperative complications were recorded.
RESULTS: Dehydration was present in one third of the patients. Sixty percent of these patients had at least one postoperative complication, whereas the corresponding proportion was 30% in the euhydrated patients (P < 0.01). Only one patient (3%) had more than one complication in the euhydrated group compared with six patients (40%) in the dehydrated group (P < 0.01). Euhydrated patients had a mean of 0.3 postoperative complications per surgery, whereas dehydrated patients scored 1.1 complications (P < 0.015). The higher incidence included confusion, arterial desaturation and cardiovascular events.
CONCLUSION: Dehydration before surgery nearly quadrupled the number of postoperative complications after hip fracture repair.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT 01294930.
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Total wrist arthroplasty. Experience with Swanson flexible silicone implants, 1982-1988
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Distal Radius Fractures
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In a study of the results of silicone rubber arthroplasty of the wrist 18 patients (19 operated wrists) were re-examined after a mean follow up of five years. Experience with the ulnar head implant was discouraging, and it was not used in the last eight wrists. This did not affect the outcome, patients having good supination and pronation without pain. The range of motion with the radiocarpal prostheses was 0-70 degrees, mean 39 degrees. Radiological results showed severe subsidence in all patients followed up for more than two years, and prosthetic fracture in five (26%), which was disappointing. Nevertheless the patients had a useful range of motion and all but two were relieved of pain. By the patients' own assessments 16 wrists were considered good, one fair, and two poor. Predictors of failure (prosthetic fracture) were poor alignment before operation, postoperative range of motion of more than 50 degrees, and rupture of the carpal extensor tendon. With these reservations we recommend the silicone spacer as the best solution for most patients with severe problems of the wrist as a result of rheumatoid arthritis.
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0 |
Balance Evaluation and Gait Analysis After Arthroscopic Partial Meniscectomy
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AMP (Acute Meniscal Pathology)
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Purpose: The purpose of this study is to investigate how walking and balance are affected at different time intervals after arthroscopic partial meniscectomy (APM).
Methods: Forty-five patients with APM and a healthy control group of 46 people were included in the study. Gait and bipedal balance analysis were performed to the patient group twice in 4 weeks and 12 weeks after surgery.
Results: In the gait analysis performed after 4 weeks, stance phase (SP), step time (ST), and total double support (TDS) were higher, and step length (SL), swing phase (SWP), cadence (C), and speed (V) in the patient group were lower. After 12 weeks, SP, TDS, and step width (SW) data were higher in the patient group and SWP was lower. In both measurements, the gait of the patient group is not symmetrical. In open-eye balance test, it was observed that the data of length of ellipse (LoE), area of ellipse (AoE), and path length of CoP (PL) were different after 4 weeks but these differences disappeared after 12 weeks. Width of ellipse (WoE), LoE, AoE, and PL data were different in the test performed with eyes closed after 4 weeks. In addition to the same data after 12 weeks, the medio-lateral direction (ML) was also higher than the patient group.
Conclusion: After 12 weeks, walking has not fully recovered. There was no difference in the balance analysis with eyes open, but the differences were still present in the eyes-closed analysis.
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Abdominoplasty-derived dermal-fat graft augmentation gluteoplasty
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Plastic surgeons are exploring novel techniques for augmentation gluteoplasty as the demand for this procedure increases annually in the United States. OBJECTIVES: The authors retrospectively reviewed a series of lower abdominal dermal-fat graft augmentation gluteoplasties to validate the procedure. METHODS: Nine consecutive patients underwent abdominoplasty or torsoplasty in which 2 oval dermal-fat grafts were excised, de-epithelialized, and then implanted into subfascial gluteal pockets for augmentation. All operations were independently conducted by 1 of 2 surgeons at facilities in Maryland and New Jersey. RESULTS: The mean age of the 9 female patients was 46 years. The mean dermal-graft size was 188 cm(2), and the mean graft weight was 288 g. One graft became infected and required excision 39 days after the procedure. There were no other complications. All surviving grafts provided a substantial increase in posterior projection and long-lasting gluteal volume. CONCLUSIONS: Dermal-fat graft augmentation gluteoplasty provides a voluminous, natural-feeling, and durable aesthetic result. The procedure should be considered a viable option for patients undergoing abdominoplasty or torsoplasty, especially as more experience is gained. LEVEL OF EVIDENCE: 4.
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Significant risk of arthrolysis after simultaneous anterior cruciate ligament reconstruction and treatment of dislocated bucket-handle meniscal tear
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AMP (Acute Meniscal Pathology)
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INTRODUCTION: Postoperative stiffness is a feared complication after anterior cruciate ligament (ACL) reconstruction. In case of associated dislocated bucket-handle meniscal tear (BHMT), reduction is urgent, with ligament reconstruction in the same surgical step.
HYPOTHESIS: Treatment of associated dislocated BHMT in ACL reconstruction incurs increased risk of arthrolysis for stiffness in flexion and/or extension.
MATERIAL AND METHODS: A retrospective exposure/non-exposure study included 208 patients undergoing ACL reconstruction between January 2009 and December 2018. Those showing dislocated medial or lateral BHMT at surgery (group A) were compared versus those free of meniscal lesions (group B). The main objective was to assess the risk of surgical revision for arthrolysis within 12 months. Group A included 69 patients: 40 male (58%), 29 female (42%); mean age, 29.0+/-11.2 years. Group B included 139 patients: 68 male (49%), 71 female (51%); mean age, 30.0+/-10.4 years. Patients were classified according to age of ACL tear, as acute (<6 weeks), subacute (6 weeks to 6 months), or chronic (>6 months).
RESULTS: Risk of revision surgery for arthrolysis was greater in Group A than in Group B, with 7 (10.1%) and 4 (2.9%) cases respectively (p=0.044), with 12-month arthrolysis-free survival of 89.7% (95% CI, 82.7-97.2) and 97.1% (95% CI, 94.3-99.9) respectively (p=0.023). Stiffness in flexion and extension was more frequent in Group A at 6 weeks and at 6 months (p>0.05). Risk of arthrolysis did not significantly differ according to accident-to-surgery time in the overall series (p=0.421) or specifically in Group A (p=0.887). The BHMT was sutured in 39 cases (56.5%), including 3 failures (7.7%) at 12 months' follow-up. Arthrolysis was required in 6 patients treated by meniscal suture (15.4%) and just 1 patient treated by meniscectomy (3.3%) (p=0.128).
CONCLUSION: The present study confirmed increased risk of surgical revision for arthrolysis after ACL reconstruction in case of dislocated BHMT treated in the same surgical step. Age of ACL tear and type of BHMT treatment (suture or meniscectomy) showed no impact on postoperative stiffness.
LEVEL OF EVIDENCE: IV, retrospective exposure/non-exposure cohort study.
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0 |
Sensory conduction study in chronic sensory ataxic neuropathy
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Sensory conduction was studied in six patients with chronic sensory ataxic neuropathy of an idiopathic type and associated with Sjogren's syndrome. Motor nerve conduction velocities were normal in most cases, but sensory nerve potentials could not be evoked in a routine peripheral nerve conduction study. Cortical and cervical somatosensory evoked potentials (SEPs) and evoked potentials from Erb's point were barely recorded by median nerve stimulation at the wrist. When the median nerve was stimulated at more proximal points, clear potentials were recorded from Erb's point, but cortical SEPs were still hardly elicited. Thus the sensory nerves are centrally and peripherally involved in this condition, and the involvement is more prominent in the distal portion in the peripheral nerve. These findings suggest that central-peripheral distal axonopathy is a process involved in this illness and that the dorsal root ganglia may be primarily involved, in accord with previous pathological studies
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Detection of antibiotic resistance genes in samples from acute and chronic endodontic infections and after treatment
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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OBJECTIVE: The purpose of this study was twofold: survey samples from acute and chronic endodontic infections for the presence of genes encoding resistance to beta-lactams, tetracycline and erythromycin, and evaluate the ability of treatment to eliminate these genes from root canals. DESIGN: DNA extracts from samples of abscess aspirates (n=25) and root canals of teeth with asymptomatic apical periodontitis (n=24) were used as template for direct detection of the genes blaTEM, cfxA, tetM, tetQ, tetW, and ermC using real-time polymerase chain reaction (PCR). Bacterial presence was determined using PCR with universal bacterial primers. Root canals of the asymptomatic cases were also sampled and evaluated after chemomechanical procedures using NiTi instruments with 2.5% NaOCl irrigation. RESULTS: All abscess and initial root canal samples were positive for bacteria. At least one of the target resistance genes was found in 36% of the abscess samples and 67% of the asymptomatic cases. The most prevalent genes in abscesses were blaTEM (24%) and ermC (24%), while tetM (42%) and tetW (29%) prevailed in asymptomatic cases. The blaTEM gene was significantly associated with acute cases (p=0.02). Conversely, tetM was significantly more prevalent in asymptomatic cases (p=0.008). Treatment eliminated resistance genes from most cases. CONCLUSIONS: Acute and chronic endodontic infections harboured resistance genes for 3 classes of widely used antibiotics. In most cases, treatment was effective in eliminating these genes, but there were a few cases in which they persisted. The implications of persistence are unknown. Direct detection of resistance genes in abscesses may be a potential method for rapid diagnosis and establishment of proactive antimicrobial therapy
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A Case of Primary Aortoenteric Fistula: Review of Therapeutic Challenges
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PJI DX Updated Search
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BACKGROUNDS: Primary aortoenteric fistula (PAEF) is a lethal cause of gastrointestinal bleeding. They mainly originate from eroding abdominal aortic aneurysms into the intestinal wall. Other known causes involve malignancies, infection, corpora aliena, or radiation therapy. Traditional treatment consists of resection of the fistula and extra-anatomic reconstruction. In situ repair and endovascular stenting have offered new therapeutic options in managing this complex entity. CASE REPORT: A 79-year-old woman presented with a PAEF. She was known with a 3.9-cm abdominal aortic aneurysm and polymyalgia rheumatica. The initial treatment consisted of endovascular stenting. Several months later, she presented with persistent inflammation of the aortic endoprosthesis. The prosthesis and inflammatory tissue were resected, and in situ reconstruction with autologous superficial femoral vein and omentoplasty was performed. Two years later, she remains well with no evidence for infection or bleeding. CONCLUSIONS: Polymyalgia rheumatica might induce an AEF as in this patient no other provoking factors were retained. The different therapeutic options all have their advantages and disadvantages. In line with this case, we suggest an individualized approach for AEFs. In case of precarious hemodynamical state or life expectancy, endovascular treatment is indicated. Afterward, the possibility and/or necessity of open repair should be discussed. For stable patients with respectable life expectancy in situ repair with autologuous vein or rifampicin-soaked prosthesis (adjusted to comorbidities) might be most appropriate. Extra-anatomic reconstruction still remains a valuable alternative in older patients and in the presence of any other local factors hampering in situ reconstruction
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Impact of the COVID-19 pandemic on orthopedic trauma workload in a London level 1 trauma center: the "golden month"
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Hip Fx in the Elderly 2019
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Background and purpose - The COVID-19 pandemic has been recognized as an unprecedented global health crisis. This is the first observational study to evaluate its impact on the orthopedic workload in a London level 1 trauma center (i.e., a major trauma center [MTC]) before (2019) and during (2020) the "golden month" post-COVID-19 lockdown.
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Evaluation of a powered ankle-foot prosthetic system during walking
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DoD LSA (Limb Salvage vs Amputation)
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OBJECTIVE: To determine whether a powered ankle-foot prosthesis improves gait mechanics, physical performance, and user satisfaction after traumatic transtibial amputation. DESIGN: Pre-post. SETTING: Gait analysis laboratory. PARTICIPANTS: Young individuals with traumatic transtibial amputation (n=11) and matched controls (n=11). INTERVENTIONS: Wearing an energy-storing and -returning (ESR) foot and a powered ankle-foot prosthesis. MAIN OUTCOME MEASURES: Gait mechanics, physical performance, and user satisfaction. RESULTS: The powered prosthesis ankle range of motion (ROM) was significantly larger ( approximately 30%) than that of the ESR limb. However, both devices demonstrated significantly less ankle ROM than the control and intact limbs. At preswing, the ESR limb generated approximately 40% less peak ankle power than control and intact limbs. In contrast, the powered prosthesis generated significantly greater peak ankle power than control (35%) and ESR ( approximately 125%) limbs, resulting in the powered limb absorbing twice the peak knee power observed in the control and intact limbs. The powered prosthesis limb peak hip power generation was approximately 45% greater at preswing than that of the intact limb. Walking velocity increased with the powered prosthesis compared with the ESR limb and was greater than that of the control group. However, physical performance measures were not significantly different between ESR and powered conditions. User satisfaction scores indicated a preference for the powered prosthesis over the ESR limb. CONCLUSIONS: Compensatory strategies during gait with the ESR and powered prosthetic devices were similar to those reported in the literature. However, the addition of ankle power and ROM by the powered prosthesis appeared to increase compensatory strategies at proximal joints.
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Chondroitins 4 and 6 sulfate in osteoarthritis of the knee: a randomized, controlled trial
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine whether chondroitin sulfate (CS) is effective in inhibiting cartilage loss in knee osteoarthritis (OA). METHODS: In this randomized, doubleâ?blind, placeboâ?controlled trial, 300 patients with knee OA were recruited from an outpatient clinic, from private practices, and through advertisements. Study patients were randomly assigned to receive either 800 mg CS or placebo once daily for 2 years. The primary outcome was joint space loss over 2 years as assessed by a posteroanterior radiograph of the knee in flexion; secondary outcomes included pain and function. RESULTS: Of 341 patients screened, 300 entered the study and were included in the intentâ?toâ?treat analysis. The 150 patients receiving placebo had progressive joint space narrowing, with a mean +/â? SD joint space loss of 0.14 +/â? 0.61 mm after 2 years (P = 0.001 compared with baseline). In contrast, there was no change in mean joint space width for the 150 patients receiving CS (0.00 +/â? 0.53 mm; P not significant compared with baseline). Similar results were found for minimum joint space narrowing. The differences in loss of joint space between the two groups were significant for mean joint space width (0.14 +/â? 0.57 mm; P = 0.04) and for minimum joint space width (0.12 +/â? 0.52 mm; P = 0.05). CS was well tolerated, with no significant differences in rates of adverse events between the two groups. CONCLUSION: While there was no significant symptomatic effect in this study, longâ?term treatment with CS may retard radiographic progression in patients with OA of the knee. However, the clinical relevance of the observed structural results has to be further evaluated, and further studies are needed to confirm the structural effects of CS.
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The use of radiofrequency energy for arthroscopic chondroplasty in the knee
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PJI DX Updated Search
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We present a review of the current literature surrounding the use of radiofrequency energy for arthroscopic chondroplasty in the knee. This review article summarizes basic science, clinical efficacy, and recent advances in the understanding of radiofrequency energy use for the treatment of chondral lesions. Laboratory evidence of increased mechanical stability and decreased release of inflammatory mediators associated with the use of radiofrequency energy chondroplasty is described with clinical evidence of decreased pain and increased functional scores when compared with mechanical chondroplasty. We re-examine concerns about the immediate side effects of radiofrequency energy use, including damage to local structures, in light of new potentially contradictory results, as well as the progression of techniques and probe design. However, although reported complications are few, because the quality of clinical evidence about safety and efficacy remains low, we suggest cautious and judicious use of this technology until future research has clearly defined the long-term clinical outcomes and risks. é 2011 Arthroscopy Association of North America
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Hip disease and hip arthroplasty
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PJI DX Updated Search
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There has been a significant increase in the prevalence of obesity in the United States over the last 20 years, with the highest percentage in Mississippi. The percentage of obese patients undergoing total hip arthroplasty (THA) appears to be increasing at an even faster rate. Orthopedic surgeons performing hip arthroplasty need to be aware of potential issues to minimize complications associated with this population. This article outlines preoperative and postoperative care and describes current techniques and tools used by surgeons in obese patients to facilitate soft tissue dissection, exposure, implant placement, and closure. é 2011
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Plastic surgeon compliance with national safety initiatives: clinical outcomes and "never events"
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: Venous thromboembolism and surgical-site infection have been identified as preventable complications that are addressed by the National Quality Forum and the Surgical Care Improvement Project. The authors examined compliance of faculty with venous thromboembolism and surgical-site infection prophylaxis and incidence of adverse outcomes in patients at risk. METHODS: The authors performed retrospective chart reviews on 243 patients who underwent abdominoplasty or panniculectomy from 2000 to 2007 and documented demographics and adverse outcomes. Analysis was completed using Pearson's chi-square and Fisher's exact test for categorical variables. Significance was set at p < 0.05. Obesity was defined as body mass index more than 30 and morbid obesity was defined as body mass index more than 40. RESULTS: Of 243 patients, 144 (59 percent) were obese. Seventeen patients (7 percent) suffered complications. All 243 patients received at least one form of venous thromboembolism prophylaxis. One patient had a deep venous thrombosis, and two had pulmonary embolism. These three patients were morbidly obese. Seventy-four percent of patients received appropriate antibiotics. Thirteen patients (5.3 percent) developed significant postoperative infection requiring hospitalization, 12 (92 percent) of whom received appropriate antibiotics. Eleven of these 13 patients (85 percent) were obese, and seven (54 percent) were morbidly obese. Obesity proved to be the only significant risk factor (p > 0.05). CONCLUSIONS: Despite very good compliance with safe practice initiatives, significant adverse outcomes occurred. Obesity was the only pervasive risk factor. This study highlights the potential need for compliance with quality measures and demonstrates that adverse outcomes may result despite adherence to best surgical practices.
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Perioperative anesthetic management of orthopedic injuries
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DOD - Acute Comp Syndrome CPG
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Management of orthopedic trauma is challenging. Although many patients have isolated trauma, such as hip fractures, others suffer multiple injuries requiring an evaluation of the patient's physiologic condition before administering an anesthetic. Anesthesiologists must consider all aspects of the patient's status when administering care and thus can significantly impact morbidity, mortality, and outcome in terms of quality of life and return to preinjury activity level.
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Knee donor site morbidity following harvest of medial femoral trochlea osteochondral flaps for carpal reconstruction
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OAK 3 - Non-arthroplasty tx of OAK
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Purpose This study examines donor site morbidity associated with the medial femoral trochlea (MFT) when used as a donor site for vascularized osteochondral flaps for reconstruction of challenging carpal defects such as proximal pole scaphoid nonunion and advanced Kienböck disease. Methods The retrospective study population included all patients who had undergone MFT flap harvest for scaphoid or lunate reconstruction. Chart review, patient questionnaires, and validated knee function assessment tools were used: International Knee Documentation Committee Subjective Knee Form scores ranged from 0 (maximal disability) to 100 (no disability). Western Ontario and McMaster Universities osteoarthritis index scores ranged from 0% (no disability) to 100% (maximal disability). Magnetic resonance imaging and radiographs were obtained on the donor knee on the majority of patients. Results Questionnaire response rate was 79% (45 of 57 patients). Average patient age was 35 ± 11 years (range, 19-70 years). Average postoperative follow-up was 27 ± 17 months (range, 9-108 months). The indication for MFT flap reconstruction was scaphoid nonunion in 30 patients and Kienböck disease in 15 patients. All 45 patients had a stable knee on examination. Magnetic resonance and radiographic imaging obtained on 35 patients exhibited no pathological changes. Average duration of postoperative pain was 56 ± 59 days (range, 0-360 days); average duration until patients reported the knee returning to normal was 90 ± 60 days (range, 14-360 days). Forty-three of 44 patients would have the same surgery again if needed; overall satisfaction with the surgery was rated as 5 ± 1 (range, 2-5) on a scale from 0 (no satisfaction) to 5 (maximal satisfaction). Average International Knee Documentation Committee score was 96 ± 9 (range, 56.3-100) and the average Western Ontario and McMaster Universities score was 6% ± 16% (range, 0%-68%). Conclusions Medial femoral trochlea osteochondral flap harvest results in minimal donor site morbidity in the majority of patients. Symptoms are time limited. Intermediate-term follow-up demonstrates excellent results in subjective outcome measures.
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Role of mesotherapy in musculoskeletal pain: Opinions from the Italian Society of Mesotherapy
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Mesotherapy is the injection of active substances into the surface layer of the skin. This method allows a slower spread, higher levels, and longer lasting effects of drugs in the tissues underlying the site of injection (skin, muscle, and joint) compared with those following intramuscular injection. This technique is useful when a local pharmacological effect is required and relatively high doses of drug in the systemic circulation are not. Mesotherapy should only be undertaken following a complete clinical workup and subsequent diagnosis. Encouraging results have been reported in randomized, controlled clinical trials and in observational studies involving patients with various forms of musculoskeletal pain. Recommendations by experts from the Italian Society of Mesotherapy for appropriate use of mesotherapy in musculoskeletal pain and an algorithm for treating localized painful conditions are provided. Copyright (copyright) 2012 Massimo Mammucari et al
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Hip fracture and urinary incontinence--use of indwelling catheter postsurgery
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Hip Fx in the Elderly 2019
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BACKGROUND: Norway has a higher incidence of hip fractures than any other country. For older individuals, a hip fracture may cause dramatic changes in health status like incontinence and daily activities. Patients with hip fractures are at high risk of urinary incontinence (UI) after surgical repair. A urinary indwelling catheter (UIC) is inserted preoperatively, but should be removed within 24 hours. Our aims were to identify indicators that might predict clinical challenges related to urinary incontinence 1 year after hip fractures.
METHODS: Inclusion criteria were patients with hip fracture age 65 years or older. They were admitted form their own home to two acute-care hospitals during 2004-2006. We used the Resident Assessment Instrument for Acute Care.
RESULTS: A total of 331 patients were included. Thirty-five (11%) had UIC 72 hours after surgery. These patients had more frequently experienced delirium, urinary tract infection, cognitive impairment and discouragement than their counterparts. After 12 months, patients with previous UI had lower functioning levels than those with no previous UI. They had moved four times more frequently to a nursing home and had over twice the mortality.
CONCLUSIONS: Patient with UI should be followed up with a multidisciplinary team after discharged from hospital.
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Cost effectiveness of a two-year home exercise program for the treatment of knee pain
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To assess the cost effectiveness of a 2â?year home exercise program for the treatment of knee pain. METHODS: A total of 759 adults aged > or = 45 years were randomized to receive exercise therapy, monthly telephone contact, exercise therapy and telephone contact, or no intervention. Efficacy was measured using selfâ?reported knee pain at 2 years. Costs to both the National Health Service and to the patient were included. RESULTS: Exercise therapy was associated with higher costs and better effectiveness. Direct costs for the interventions were pound 112 for the exercise program and pound 61 for the monthly telephone support. Participants allocated to receive exercise therapy were significantly more likely to incur higher medical costs than those in the noâ?exercise groups (mean difference pound 225; 95% confidence interval pound 218, pound 232; P < 0.001). CONCLUSION: Exercise therapy is associated with improvements in knee pain, but the cost of delivering the exercise program is unlikely to be offset by any reduction in medical resource use.
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A Randomized Controlled Trial Comparing "High-Flex" vs "Standard" Posterior Cruciate Substituting Polyethylene Tibial Inserts in Total Knee Arthroplasty
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PJI DX Updated Search
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The purpose of this study is to compare the range of motion and clinical outcomes of a standard posterior-stabilized (PS) vs the high-flex (HF) polyethylene tibial insert of a posterior cruciate substituting total knee arthroplasty system. One hundred patients were entered into a prospective, blinded, randomized clinical trial in which 50 patients received a Genesis II PS insert and 50 patients received a Genesis II HF insert (Smith & Nephew, Memphis, TN). At an average follow-up of 2.7 years (range, 2.3-3.1 years), there were no differences in any outcome measures (Western Ontario and McMaster Universities osteoarthritis index, Short-Form 12, Knee Society clinical rating scores, anterior knee pain). There were no differences (P = .811) in average knee flexion at 2 years (standard, 123ð ñ 7ð; HF, 124ð ñ 7ð). In summary, this prospective blinded randomized clinical trial demonstrated no differences between a PS and HF polyethylene design. Long-term evaluation will be required to comment on differences in polyethylene wear and implant longevity. é 2009
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Improvements in rehabilitation of the postmeniscectomized or meniscal-repaired patient
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AMP (Acute Meniscal Pathology)
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Recent advances in the surgical management of meniscal problems (arthroscopic meniscectomy or meniscal repair) have been associated with far less morbidity postoperatively. Aggressive rehabilitation programs using innovative devices have allowed the patients an early return to normal activities or competition. Even with the best surgical technique, rehabilitation of the hamstring and quadriceps musculature is necessary to provide the patient with an optimal surgical result. [References: 22]
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Minimal incisions vertical endoscopic lifting and fat grafting as a systematic approach to the rejuvenation of the periocular esthetic unit
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Upper Eyelid and Brow Surgery
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PURPOSE: The forehead/brow complex, the temporal region, the upper eyelid, the zygomatic area, the lower eyelid, and the cheek comprise the periocular esthetic unit. The combination of variable degrees of tissue descent and fat deflation of the component parts of the unit determine its appearance with age. The authors report the results of tissue repositioning through a minimal incisions vertical endoscopic lift and volume restoration used in combination to restore the natural youthful appearance of the periocular esthetic unit. METHODS: The authors retrospectively reviewed the charts of patients who underwent minimal incisions vertical endoscopic lift and fat grafting over a 12-year period in 3 different centers. Patients results were evaluated with standardized pre- and postoperative pictures graded by masked observers in a scale from poor, fair, satisfactory, to very satisfactory results. Patient satisfaction was self-graded in the same manner. RESULTS: The study consists of 400 patients, of whom 337 (85%) were women and 63 (14.8%) were men, with a mean age of 46 years (range 38-67) for women and mean age of 53 years (range 48-65) for men. Mean follow up was 16 months (range 6 months-8 years); in 180 patients follow up was 2 years or longer. Additional procedures included lower blepharoplasty in 205 patients (51%), neck lift in 102 patients (26%), upper blepharoplasty in 63 patients (15.7%), lateral canthoplasty in 9 patients (2.3%), and upper eyelid ptosis in 6 patients (1.5%). The results were graded as satisfactory or very satisfactory by 95% of patients and by 91% of observers. CONCLUSIONS: On the basis of the anatomical changes that occur in the periocular esthetic unit, tissue repositioning is indicated to address the descent of the superior complex and in minor part of the inferior complex, while volume restoration is indicated to address the volume depletion of the inferior and the lateral complexes and for refinements of the superior complex. The authors propose a systematic combination of lifting and filling to naturally restore the youthful appearance of the periocular esthetic unit. Conservative blepharoplasty can be associated in selected cases for result optimization.
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Long-term neurological complications associated with surgery and peripheral nerve blockade: outcomes after 1065 consecutive blocks
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Surgical Management of Osteoarthritis of the Knee CPG
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Peripheral nerve blockade is gaining popularity as an analgesic option for both upper or lower limb surgery. Published evidence supports the improved efficacy of regional techniques when compared to conventional opioid analgesia. The incidence of neurological deficit after surgery associated with peripheral nerve block is unclear. This paper reports on neurological outcomes occurring after 1065 consecutive peripheral nerve blocks over a one-year period from a single institution. All patients receiving peripheral nerve blocks for surgery were prospectively followed for up to 12 months to determine the incidence and probable cause of any persistent neurological deficit. Formal independent neurological review and testing was undertaken as indicated. Thirteen patients reported symptoms that warranted further investigation. A variety of probable causes were identified, with peripheral nerve block being implicated in two cases (one resolved at nine months and one remaining persistent). Overall incidence of block-related neuropathy was 0.22%. Persistent postoperative neuropathy is a rare but serious complication of surgery associated with peripheral nerve block. Formal follow-up of all such blocks is recommended to assess causality and allow for early intervention
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Granuloma after sling surgery: an attempt to answer the 'why' and 'what to do next'
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Upper Eyelid and Brow Surgery
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PURPOSE: To review cases of granuloma formation after sling surgery with a view to find out possible aetiological factors and propose a further plan of management MATERIALS AND METHODS: A retrospective analysis of 120 eyes of 108 patients who underwent frontalis sling surgery with silicone rod from Jan 2008 to Dec 2015 was conducted. All patients with severe ptosis and poor levator function who underwent frontalis sling surgery with silicone rod were included in the study irrespective of the cause of ptosis and method of passing the sling. A complete ophthalmic and ptosis examination was done. In all the cases, the prolene suture was tied over the sleeve to tighten it and it was buried along with the silicone rod in forehead pocket. All the cases with granuloma formation were first subjected to a microbiological examination including culture and sensitivity to antibiotics. All the patients were given a trial of antibiotics. RESULTS: We encountered 10 cases of granuloma in 120 eyes of 108 patients operated during this period. The duration between time of surgery and presentation varied from 2 weeks to 4 months. The microbiological examination revealed positive culture in 5 cases. None of the cases responded to the course of antibiotics given for 10 days. The histopathological examination done in 5 cases (2 of them culture positive and 3 of them culture negative) revealed granulomatous inflammation of non-specific type. The sling was explanted in all cases which resulted in prompt resolution of granuloma in 7-10 days. CONCLUSIONS: The granuloma is primarily due to exposure of the sling itself or the sleeve enveloping the sling or the suture tied around the sleeve thereby. They do not respond to antibiotics but respond very well to explantation. These patients can be taken up for re-sling surgery after a waiting period of 3 months.
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Silicon and silicone levels in patients with silicone implants
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Reduction Mammoplasty for Female Breast Hypertrophy
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Although a potential link between silicone gel breast implants and autoimmune connective tissue disease has been suggested, none has been proven. The potential role of silicone as an immune adjuvant remains very controversial. Currently available techniques do not easily allow precise measurements of silicone in tissues. However, all compounds containing silicon (which would include silicone) can be measured accurately. The present study was designed to measure silicon levels in the fibrous capsules of patients with silicone-gel breast implants, saline breast implants and silicone inflatable penile prostheses. Baseline control silicon levels were obtained from the breast tissue of patients undergoing breast reduction, who had no exposure to breast implants. All silicon measurements were carried out using atomic absorption spectrometry with a graphite furnace. The mean silicon levels in 16 breast tissue control samples from 8 patients undergoing breast reduction varied from 0.046 to 0.742 micrograms/g dry weight, with the median mean being 0.0927. The median silicon level in capsules from 6 patients with saline implants was 7.7 micrograms/g (range 36.6). The median silicon level in capsules from 5 patients with silicone inflatable penile prostheses was 19.5 micrograms/g (range 34.8). Although the levels of silicon in capsules of patients with saline breast prostheses and penile implants were higher than in control samples, they were much lower than those from the capsules of the 58 gel implants (median 9979 micrograms/g). Of the 58 silicone gel breast implants (from 20 patients with bilateral implant removal and 18 patients with unilateral removal) which had been inserted from 1974 to 1990, 28 were intact, 8 had pinhole leaks, and 22 were ruptured. Median capsule silicon levels and ranges for all 58 implants, for intact only, for leaking, and for ruptured were: 9979 (152,000), 10,477 (88,703), 6592 (65,396), and 9922 (152,387) micrograms/g respectively. There were no significant differences in silicon levels associated with implant status, duration in situ, or year of implantation. Capsule contracture was not associated with higher levels of capsule silicon. Capsule silicon levels were about 10(6) times higher than previously assayed blood silicon levels. This may be because silicone released from implants remains localized in capsular tissue, or because blood-borne silicone is quickly excreted. Using 29Si nuclear magnetic resonance spectroscopy, no detectable silicone was found in the blood of 7 control women and 7 women with silicone-gel implants (5 with known implant rupture).
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Periprosthetic femoral fractures associated with contralateral hip disease
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Management of Hip Fractures in the Elderly
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Femoral osteolysis associated with contralateral hip degenerative changes is a risk factor for ipsilateral periprosthetic femoral fracture. We report 5 comminuted proximal shaft fractures around loose femoral implants occurring in patients with both symptomatic femoral lysis and a painful hip on the other side. Our evolving strategy involves timely revision surgery once this pattern is recognized. Once fracture has occurred, emergent revision requires extensive medical evaluation, availability of long-stem revision implants, and appropriate instrumentation and allografts for fracture fixation. (copyright) 2005 Elsevier Inc. All rights reserved
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A population pharmacokinetic model for the complex systemic absorption of ropivacaine after femoral nerve block in patients undergoing knee surgery
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AAHKS (8) Anesthetic Infiltration
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Because of its slow systemic absorption and flip-flop kinetics, ropivacaine's pharmacokinetics after a peripheral nerve block has never been thoroughly characterized. The purpose of this study was to develop a population pharmacokinetic model for ropivacaine after loco-regional administration and to identify patient characteristics that may influence the drug's absorption and disposition. Frequent plasma samples were taken up to 93 h after a 100 mg dose given as femoral block for postoperative analgesia in 15 orthopedic patients. Ropivacaine plasma concentration-time data were analyzed using a nonlinear mixed effects modeling method. A one-compartment model with parallel inverse Gaussian and time-dependent inputs best described ropivacaine plasma concentration-time curves. Ropivacaine systemic absorption was characterized by a rapid phase (mean absorption time of 25 ± 4.8 min) followed by a much slower phase (half-life of 3.9 ± 0.65 h). Interindividual variability (IIV) for these parameters, 58 and 9 %, indicated that the initial absorption phase was more variable. The apparent volume of distribution (V/F = 77.2 ± 11.5 L, IIV = 26 %) was influenced by body weight (Î? 1.49 % per kg change) whereas the absorption rate constant (slower phase) of ropivacaine was affected by age (Î? 2.25 % per year change). No covariate effects were identified for the apparent clearance of the drug (CL/F =10.8 ± 1.0 L/h, 34 IIV = 34 %). These findings support our hypothesis that modeling a complex systemic absorption directly from plasma concentration-time curves exhibiting flip-flop kinetics is possible. Only the age-effect was considered as relevant for possible dosing adjustments. © 2012 Springer Science+Business Media New York.
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Complications of ambulatory major dermatological surgery in patients older than 85 years
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Reconstruction After Skin Cancer
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BACKGROUND: During the last decades, the progressive ageing of the population has resulted in a rising skin cancer incidence. Although previous studies detected no higher morbidity for dermatological surgery in senior patients, their exclusion from optimal surgical treatment remains as a common clinical practice. OBJECTIVE: The aim of this study was to determine the diseases treated with ambulatory major dermatological surgery, the surgical morbidity and the associated variables in >/= 85 year-old patients. PATIENTS/METHODS: This is an observational study on 247 successive patients older than 85 years of age who underwent dermatological surgery in a single Ambulatory Mayor Surgery unit. Studied variables were age, gender, tobacco-alcohol exposure, co-morbid medical conditions, blood-thinning medication, antibiotic prophylaxis, number of lesions, location, histopathological diagnosis, area of skin removed, surgical technique, type of flap, length of surgery, entrance order, suture thread, surgical complications and need of post-operative admission. RESULTS: The most common site was head and neck (82.7%). The most frequent tumour was basal cell carcinoma (45.1%), followed by squamous cell carcinoma (38.7%) and melanoma (8.3%). Direct closure was the most frequent procedure (55.6%). Of the total number of patients, 7.9% of patients suffered complications; necrosis followed by cellulitis were the most frequent. Length of surgical procedure, area of skin removed and reconstruction with skin-graft were significantly related to higher risk of post-operative complications. CONCLUSIONS: No intra or post-surgical mortality or life-threatening local complications were detected. Most post-surgical local complications appeared after wide excisions and complex reconstruction techniques that prolonged the length of the surgery.
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1 |
Avascular necrosis after treatment of DDH: the protective influence of the ossific nucleus
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Developmental Dysplasia of the Hip CPG
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We retrospectively reviewed the results of open or closed reduction for developmental dysplasia of the hip (DDH) in 49 children younger than 12 months old, who had 57 hip dislocations. Group A (18 hips) developed partial or complete avascular necrosis (AVN), and group B (39 hips) did not develop AVN. Thirty-eight hips were treated by closed reduction, and 17 had open reduction. One patient with bilateral hip dislocation initially had closed reductions followed by bilateral open reduction 3 months later. With the numbers available for study, there was no significant difference in the occurrence of AVN with respect to variables such as preliminary traction, closed versus open reduction, Pavlik harness use, and age at the time of operative intervention. However, the presence of the ossific nucleus before reduction, detected either by radiographs (p < 0.001) or ultrasonography (p = 0.033) was statistically significant in predicting AVN. Only one (4%) of 25 hips with an ossific nucleus developed AVN, whereas 17 (53%) of 32 hips without an ossific nucleus before reduction developed AVN. Our results suggest that the presence of the ossific nucleus before closed or open reduction for DDH may decrease the risk of AVN
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Analysis of muscle atrophy after hip fracture in the elderly
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Management of Hip Fractures in the Elderly
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OBJECTIVES: To examine the relationship between muscle atrophy, ambulatory ability, and fracture type, and to make a specific rehabilitation regimen for each fracture type. DESIGN: Observational study. SETTING: Public hospital. PARTICIPANTS: Consecutive patients (N=53) with hip fracture (mean age, 83.6y) who underwent operative treatment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The ambulatory ability score and the cross-sectional areas of lower-limb muscles as measured on computed tomography scans. RESULTS: Muscle atrophy was not related to fracture type. Although the mean ambulatory ability score decreased significantly from 4.5+/-0.3 points prior to injury to 3.0+/-0.6 points 1 month postadmission, the degree of muscle atrophy was not associated with the decrease in ambulatory ability. CONCLUSIONS: It seems likely that other factors are more important than muscle atrophy and fracture type in determining recovery after surgical repair of a fracture and that there is no need for rehabilitation regimens based on fracture types
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Effects of virtual reality training on gait biomechanics of individuals post-stroke
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Management of Hip Fractures in the Elderly
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OBJECTIVE: To evaluate gait biomechanics after training with a virtual reality (VR) system and to elucidate underlying mechanisms that contributed to the observed functional improvement in gait speed and distance.DESIGN: A single blind randomized control study.SETTING: Gait analysis laboratory in a rehabilitation hospital and the community.PARTICIPANTS: Fifteen men and three women with hemiparesis caused by stroke.INTERVENTIONS: Subjects trained on a six-degree of freedom force-feedback robot interfaced with a VR simulation. Subjects were randomized to either a VR group (n=9) or non-VR group (NVR, n=9). Training was performed three times a week for 4 weeks for approximately 1h each visit.MAIN OUTCOME MEASURES: Kinematic and kinetic gait parameters.RESULTS: Subjects in the VR group demonstrated a significantly larger increase in ankle power generation at push-off as a result of training (p=0.036). The VR group had greater change in ankle ROM post-training (19.5%) as compared to the NVR group (3.3%). Significant differences were found in knee ROM on the affected side during stance and swing, with greater change in the VR group. No significant changes were observed in kinematics or kinetics of the hip post-training.CONCLUSIONS: These findings are encouraging because they support the potential for recovery of force and power of the lower extremity for individuals with chronic hemiparesis. It is likely that the effects of training included improved motor control at the ankle, which enabled the cascade of changes that produced the functional improvements seen after training
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An experience of ischemic limb salvage associated with myositis ossificans of the left thigh
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Management of Hip Fractures in the Elderly
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A case of ischemic limb salvage associated with myositis ossificans of the left thigh in a 66-year-old man was reported. The patient had a medical history of cerebral palsy and a cervical spinal cord injury, and had an operative past history of hip arthroplasty for fracture of the left femoral neck 10 years before. He showed ischemic symptoms such as paleness, coldness, and loss of the left dorsal arterial pulsation in the left toe, and had a rapidly growing mass in the left thigh. Roentgenography and computed tomography showed a mass 10 cm by 10 cm by 8 cm in size with severe calcification in the left quariceps muscle. Occlusion of the left common femoral artery was found in the arteriogram. Surgery was carried out in order to establish an accurate diagnosis and to rescue the left lower limb. The arterial pulsation was recovered as the result of completely resecting the left quariceps muscle tumor. The pathohistological diagnosis was of myositis ossificans in the quariceps muscle of the thigh. Etidronate disodium was administered in order to prevent a recurrence postoperatively. The patient has been well for the 13 months since surgery
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LARS versus hamstring tendon autograft in anterior cruciate ligament reconstruction: a single-centre, single surgeon retrospective study with 8Â years of follow-up
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OAK 3 - Non-arthroplasty tx of OAK
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Purpose: The choice of graft type in the anterior cruciate ligament (ACL) reconstruction remains a subject of controversy. The aim of this study was to assess the outcomes in ACL reconstructions performed using a four-strand hamstring tendon graft (4SHG) or a LARS ligament comparing the effectiveness of the two grafts at a medium follow-up of 8Â years. Methods: This retrospective, single-centre, single surgeon study evaluated the clinical, functional and radiographic outcomes in 50 patients who underwent ACL reconstruction (25 4SHG and 25 LARS). Patients who underwent surgery after more than 6Â months from injury and showed radiographically visible degenerative changes at time of surgery were excluded from the study. Results: None of the patients underwent re-surgery in the same knee. The range of motion of the operated knee, compared to the contralateral, was good for both groups. The anterior drawer test resulted negative in 21 patients (84%) in the LARS group and eight patients (32%) in the 4SHG group (P = 0.039). The Lachman test was negative in 19 patients (76%) in the LARS group and in 11 patients (44%) in the 4SHG group (P = 0.045). Although other results of ACL reconstruction measured by Lysholm scores, IKDC evaluation, Tegner scores and radiographic images showed using a LARS graft tended to be superior to using a 4SHG, there were no statistically significant differences calculated. Conclusion: Our results suggest that 4Â years after ACL reconstruction using a LARS ligament or 4SHG dramatically improves the function outcome, while the patients in the LARS group displayed a higher knee stability than those in the 4SHG group.
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Natural history and clinical significance of MRI-detected bone marrow lesions at the knee: a prospective study in community dwelling older adults
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Surgical Management of Osteoarthritis of the Knee CPG
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INTRODUCTION: There are conflicting data on the natural history and clinical significance of bone marrow lesions (BMLs). The aims of this study were to describe the natural history of MRI-detected BMLs at the knee using a quantitative measure and examine the association of BMLs with pain, function and stiffness scores, and total knee replacement (TKR) surgery. METHODS: A total of 395 older males and females were randomly selected from the general population (mean age 63 years, range 52 to 79) and measured at baseline and approximately 2.7 years later. BMLs were determined using T2-weighted fat saturation MRI by measuring the maximum area of the lesion. Reproducibility was excellent (intraclass correlation coefficient (ICC): 0.97). Pain, function, and stiffness were assessed by Western Ontario and McMaster Universities Osteoarthritis (WOMAC) scores. X-ray was used to assess radiographic osteoarthritis (ROA) at baseline. RESULTS: At baseline, 43% (n = 168/395) had a BML. Of these 25% decreased in size and 24% increased. Of the remaining sample (n = 227), 7% developed a new BML. In a multivariable model, a change in BML size was associated with a change in pain and function scores (beta = 1.13 to 2.55 per 1 SD increase, all P < 0.05), only in those participants without ROA. Lastly, baseline BML severity predicted TKR surgery (odds ratio (OR) 2.10/unit, P = 0.019). CONCLUSIONS: In a population based sample, BMLs (assessed by measuring maximal area) were not static, with similar proportions both worsening and improving. A change in BML size was associated with changes in pain in those without established ROA. This finding suggests that fluctuating knee pain may be attributable to BMLs in those participants with early stage disease. Baseline BMLs also predicted TKR surgery. These findings suggest therapeutic interventions aimed at altering the natural history of BMLs should be considered
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1 |
Multimodal pain management for total hip arthroplasty
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AAHKS (2) Corticosteroids
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Multimodal pain management uses a variety of pharmacological agents administered at different perioperative times to target both peripheral and central nerve transduction and the various biochemical pathways, enzymes and receptors that signal painful stimuli and inflammation. This article reviews the role of patient-controlled analgesia, peripheral nerve blocks, local periarticular injections and extended-release epidural morphine injections that can be used in a multidisciplinary approach to analgesia. By decreasing narcotic consumption and improving pain control, multimodal pain management can reduce the numerous adverse effects associated with increased opioid use and improve mobility with physical therapy, both of which can have a direct effect on decreasing length of stay and reducing serious perioperative complications. © 2013 Elsevier Inc.
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Patent focus on cancer chemotherapeutics. III Angiogenesis agents: October 2000 - March 2001
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MSTS 2018 - Femur Mets and MM
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Angiogenesis refers to the formation of new blood vessels from existing blood vessels, a process that is believed to be a key requirement for tumour growth and metastasis. Angiogenesis inhibition represents a new approach to cancer chemotherapy and several agents and approaches are now entering late clinical development. This review summarises the key aspects of recent patent applications referring to cancer chemotherapy and cancer drug discovery that involve inhibition or reduction of angiogenesis. The review covers the main mechanism-based approaches such as MMPIs, inhibitors of the growth factor signalling pathways, integrin antagonists and urokinase inhibitors. Additional sections relating to vascular damaging agents, endogenous inhibitors and selected natural products are also included. The scope includes applications that published from October 2000 through March 2001.
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Effects of traditional and ultrasonic liposuction on adipose tissue: a biochemical approach
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Panniculectomy & Abdominoplasty CPG
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Little is known about the interaction of ultrasonic liposculpture with fat tissue. The surgical technique is well established and its clinical effects are satisfactory. However, the in vivo effects on adipose tissue remain to be determined. Previous studies have shown that ultrasound waves break fat cells. The purpose of this study was to ascertain whether ultrasound waves can cause the release of fatty acids from the molecular structure of triglycerides. A double-blind study was designed with samples obtained from traditional and ultrasonic liposuction of an equivalent area in the same patient. Samples were checked for triglycerides and for free fatty acids. Triglyceride values were always higher in the sample that had undergone ultrasonic procedure. No significant differences were observed between the free fatty acid chromatograms of the two kinds of samples analyzed. Data showed that no changes occurred in the triglyceride molecule when using ultrasound waves in the experimental conditions.
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Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: This is a continued examination of 10 years of prospectively collected Florida in-office adverse event data and new comparable data from mandatory Alabama in-office adverse event data reporting. OBJECTIVE: To determine which office surgical procedures have resulted in reported complications. METHODS: This study is a compilation of mandatory reporting of office surgical complications by Florida and Alabama physicians to a central agency. Reports resulting in death or a hospital transfer were further investigated over the telephone or on-line to determine the reporting physician's board certification status, hospital privilege status, and office accreditation status. RESULTS: In 10 years in Florida, there were 46 deaths and 263 procedure-related complications and hospital transfers; 56.5% (26/46) of deaths and 49.8% (131/263) of hospital transfers were associated with non-medically necessary (cosmetic) procedures. The majority of deaths (67%) and hospital transfers (74%) related to non-medically necessary (cosmetic) procedures were from procedures performed on patients under general anesthesia. Liposuction and liposuction with abdominoplasty or other cosmetic procedure resulted in 10 deaths and 34 hospital transfers. Thirty-eight percent of offices reporting adverse events were accredited by an independent accrediting agency, 93% of physicians were board certified, and 98% of physicians had hospital privileges. The most common specialty of physicians reporting adverse events was plastic surgery (45% of all reported complications). Dermatologists reported four total complications (no deaths) and accounted for 1.3% of all complications over the 10-year period. In 6 years in Alabama, there were three deaths and 49 procedure-related complications and hospital transfers; 42% (22/52) of hospital transfers and no deaths were associated with non-medically necessary (cosmetic) procedures. The majority of hospital transfers related to cosmetic procedures (86%) were from procedures performed on patients under general anesthesia. Liposuction accounted for no deaths and two hospital transfers. Seventy-one percent of offices reporting adverse events were accredited by an independent accrediting agency, and 100% of physicians were board-certified. Plastic surgery was the most common specialty represented in adverse event reporting (42.3% of all reported complications). Dermatologists reported one complication (no deaths) and accounted for 1.9% of all complications over the 6-year period. CONCLUSIONS: Continued analysis reveals that medically necessary office surgery does not represent an emergent hazard to patients. The data obtained from 10 and 6 years of adverse event reporting in Florida and Alabama, respectively, are comparable and consistent. Medically necessary surgical procedures performed in the office setting by dermatologists have an exceedingly low complication rate, and complications that arose were largely unexpected, isolated, and possibly unpreventable. Cosmetic procedures performed in offices by dermatologists under local and dilute local anesthesia yielded no reported complications. Complications from cosmetic procedures accounted for nearly half of all reported incidents in Florida and Alabama, and in both states, plastic surgeons were most represented in adverse event reports. Liposuction performed under general anesthesia requires further investigation because deaths from this procedure continue to occur despite the ability to use dilute local anesthesia for this procedure. Requiring physician board certification and physician hospital privileges does not seem to increase safety of patients undergoing surgical procedures in the office setting. Mandatory reporting of adverse events in the office setting should continue to be championed. Reporting of delayed deaths after hospital outpatient and ambulatory surgery center procedures should be implemented. All data should be made available for scientific analysis after protecting patient confidentiality.
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Management of metastatic disease of the appendicular skeleton
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MSTS 2018 - Femur Mets and MM
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Treatment advances have resulted in improved prognosis for patients with cancer metastatic to bone. The management of appendicular skeletal metastases requires a multi-disciplinary approach. The overall disease prognosis is important in determining the appropriate surgical treatment of metastases, with simple measures for those with the poorest prognosis and resection with reconstruction for those expected to survive more than 1 year. This article reviews management options available for patients with skeletal metastases affecting the appendicular skeleton and broaches the controversies of prophylactic fixation of impending fractures. © 2006 Elsevier Ltd. All rights reserved.
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Knee osteoarthritis after anterior cruciate ligament injury: a systematic review
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SR for PM on OA of All Extremities
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BACKGROUND: This is a systematic review of studies on the prevalence of osteoarthritis in the tibiofemoral joint more than 10 years after an anterior cruciate ligament injury, the radiologic classification methods used, and risk factors for development of knee osteoarthritis. METHODS: A systematic search was performed in PubMed, EMBASE, and AMED. Inclusion criteria were studies involving patients with anterior cruciate ligament injury, either isolated or combined with medial collateral ligament or meniscal injury and either surgically or nonsurgically treated, and a minimum 10-year follow-up with radiologic assessment. Methodological quality was evaluated using a modified version of the Coleman methodology score. RESULTS: Seven prospective and 24 retrospective studies were included. The mean modified Coleman methodology score was 52 of 90. Reported prevalence of knee osteoarthritis for subjects with isolated anterior cruciate ligament injury was between 0% and 13%. For subjects with anterior cruciate ligament and additional meniscal injury, the prevalence varied between 21% and 48%. Seven different radiologic classification systems were used in the studies. Only 3 studies reported reliability results for the radiologic assessments. The most frequently reported risk factor for development of knee osteoarthritis was meniscal injury. CONCLUSION: This systematic review suggests that the prevalence rates of knee osteoarthritis after anterior cruciate ligament reconstruction reported by previous reviews have been too high. The highest rated studies reported low prevalence of knee osteoarthritis for individuals with isolated anterior cruciate ligament injury (0%-13%) and a higher prevalence of knee osteoarthritis for subjects with combined injuries (21%-48%). Overall, the modified Coleman methodology score was low for the included studies. No universal methodological radiologic classification method exists, making comparisons of the studies and stating firm conclusions on the prevalence of knee osteoarthritis more than 10 years after anterior cruciate ligament injury difficult
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Traumatic injuries and persistent opioid use in the USA: findings from a nationally representative survey
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DoD PRF (Psychosocial RF)
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BACKGROUND: Although opioid abuse is a rising epidemic in the USA, there are no studies to date on the incidence of persistent opioid use following injuries. Therefore, the aims of this study are: (1) to examine the incidence of persistent opioid use among a nationally representative sample of injured and non-injured populations; (2) to evaluate whether an injury is an independent predictor of persistent opioid use.
METHOD: Data from the Medical Expenditure Panel Survey were pooled (years 2009-2012). Adults were followed for about 2 years, during which they were surveyed about injury status and opioid use every 4-5 months. To determine whether injuries are associated with persistent opioid use, weighted multiple logistic regressions were constructed.
RESULTS: While 2.3 million injured individuals received any opioid during the follow-up, 371 170 (15.6%) individuals became persistent opioid users (defined as opioid use across multiple time points). In a multiple logistic regression analysis adjusting for sociodemographic characteristics and self-reported health, those who sustained injuries were 1.4 times (95% CI 1.1 to 1.9) more likely to report persistent opioid use than those without injuries.
CONCLUSIONS: We found injuries to be significantly associated with persistent opioid use in a nationally representative sample. Further investment in injury prevention may facilitate reduction of persistent opioid use and, thus, improve population health and reduce health expenditures.
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Work and power of the knee flexor and extensor muscles in patients with osteoarthritis and after total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Introduction: The inflammatory manifestations of knee osteoarthritis (OA) lead to muscle inhibition and hypotrophy, resulting in a reduction in total muscle work and muscle power. Total knee arthroplasty (TKA) is the most adequate surgery for the treatment of advanced OA. However, its effects on muscle functional behavior have not been well understood. Objective: To compare the total work and power of the knee flexor and extensor muscles in patients with OA (20) and in patients post-TKA (12) at two angular velocities (60°/sec and 240°/sec). Methods: An isokinetic Biodex dynamomeer was used to assess muscle power and total work during isokinetic contractions. Two-way ANOVA for repeated measures was used to compare total muscle work and muscle power between the groups (SPSS software, version 13.0; significance level, P < 0.05). Results: There was no difference between the OA and TKA groups for the total work of both knee extensors and flexors at the two angular velocities (P � 0.05). In addition, no difference was observed in the muscle power of the knee extensors and flexors (P � 0.05). Conclusion: Total work and power were similar in the OA and TKA groups, suggesting that TKA did not improve functional capacity, which was similar in both groups. © 2012 Elsevier Editora Ltda. All rights reserved.
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Hemispheric asymmetry in visual recognition of words and motor response in schizophrenic and depressive patients
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Upper Eyelid and Brow Surgery
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Two-letter Hangul words were presented tachistoscopically as target words to either the right or left visual field of normal subjects, schizophrenics, and depressive patients. The subjects' task was to judge the similarity or difference between the target words and the words used for comparison. They were to signal as soon as possible by pressing a key with their hands. In normal subjects, the correct response rate was significantly higher in the left hemisphere; there was little difference in the speed of motor response between the two hemispheres, however. Compared with normal subjects, both patient groups showed generalized impairment. Schizophrenia was associated with impairment in the left hemisphere, depression was associated with impairment in the right hemisphere.
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Ultrasound appearance of the hip joint in newborns during the first week of life
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Developmental Dysplasia of the Hip CPG
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The frequency of different types of hip joints in newborns was determined on the basis of ultrasound screening examinations performed during the first week of life. A higher percentage (14.1%) of abnormal hip joints were seen in comparison with the groups examined in later weeks of life suggesting the possibility of natural improvement in a number of cases. The more frequent appearance of pathology in girls was confirmed. Further investigations on the natural history of hip joint development in the newborn and on the general principles of screening examinations are needed
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Functional status and severity of osteoarthritis in elderly is associated to the polymorphism of TNFA gene
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Osteoarthritis (OA) is a major musculoskeletal disease with high prevalence in the elderly. The study of genetic polymorphisms of inflammatory mediators involved in OA may contribute to the elucidation of the complex pathophysiology of this disease and identification of susceptibility individuals. AIM: This study aimed to evaluate the association between polymorphism at tumor necrosis factor alpha gene (SNP - 308â??G/A TNFA) with presence, severity and functional status of osteoarthritis in elderly. METHODS: This study was characterized as case-control and encompassed 257 physically independent elderly (Mean Age: 68.55â??±â??5.2; Minimum age: 60 and Maximum age: 82) were recruited. After this selection, the groups were divided in: 92 elderly individuals with osteoarthritis (case group) and 165 without the disease (control group). METHODS: The individuals were genotyped by the TaqMan real-time PCR system. The subjects were classified based on the degree of radiological impairment according to the criteria of Kellgren-Laurence and regarding functional impairment using the WOMAC and LEQUESNE questionnaires. RESULTS: TNFA gene polymorphic individuals (subjects harboring allele A) are more affected by OA (Ï?2â??=â??8.7, pâ??=â??0.003), once they have major radiological lesion both in hip (Fisher-Freeman-Halton Testâ??=â??3.9, pâ??=â??0.04) and knee (Fisher-Freeman-Halton Testâ??=â??4.0, pâ??=â??0.04) as well as worse functional status assessed by the Lequesne questionnaire (Mann-Whitney, pâ??=â??0.04). At the multivariate analysis, after adjustment for age, gender, body mass index, the presence of rare allele for TNFA (allele A) increases the susceptibility to OA development [OR: 1.87 (95% CI: 1.1-3.2)]. CONCLUSION: We conclude that the SNP -â??308â??G/A of TNFA gene may affect osteoarthritis susceptibility, severity and functional status of individuals with osteoarthritis.
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Segmental tibial fractures: An assessment of procedures in 27 cases
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DOD - Acute Comp Syndrome CPG
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Twenty-seven patients (two women) with segmental tibial fractures (19 open) were treated in our institution with a mean age of 38.9 years (range 22-67 years) and a mean Injury Severity Score of 11.5 (9-34). Sixteen fractures were stabilised initially with an interlocking nail, seven with an external fixator, one with a hybrid external fixator, two cases were plated and one was treated in plaster. The mean size of the segment was 11.5cm (range 4-20cm). Soft tissue coverage was required in 17 cases. There were three cases of compartment syndrome, six cases of superficial infection and four deep infection cases (two of which required amputation). In four cases, excision of the non-viable segment was necessary. Overall, 13 patients were subjected to a second operative procedure (OP) (four external fixators were replaced with the AO solid tibial nail, two Ilizarov bone transports following excision of the dead bone segment, 2 below knee amputations, 3 exchange reamed nailings, 1 LISS plate application for stability and 1 ring fixator for compression of a fracture). Five patients underwent third procedure (two Ilizarov for bone transport, two exchange nailing, and one bone grafting). The mean time to union of the proximal segment was 38.8 weeks (range 10-78 weeks) and 41.4 weeks (range 12-65 weeks) for the distal segment, respectively. The treatment of segmental tibial fractures poses many problems to the surgeon due to the precarious blood supply of the intermediate segment. The risk of non-union delayed union, infection and additional procedures is high as seen in this series of patients. © 2003 Elsevier Science Ltd. All rights reserved.
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Functional and radiographic outcomes of intertrochanteric hip fractures treated with calcar reduction, compression, and trochanteric entry nailing
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Management of Hip Fractures in the Elderly
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OBJECTIVES: Shortening after intertrochanteric hip fractures with sliding constructs is an increasingly recognized problem by the orthopaedic community. It often results in a limb length discrepancy causing maladaptation of the abductor lever arm. Functional limitations can also result from altered hip biomechanics and negatively influence patient outcomes. We hypothesized that with trochanteric entry nailing, calcar reduction, and intraoperative compression, a near-normal restoration of gait parameters and satisfactory outcomes can be achieved. DESIGN: Level 4, prospective descriptive study. SETTINGS: Level 1 trauma care center. PATIENTS/PARTICIPANTS: Fifty-eight patients with intertrochanteric hip fractures were managed operatively from 2007 to 2008. A strict exclusion criterion was used to analyze the data of interest for a final cohort of 30 patients. INTERVENTION: Stable fixation was achieved with trochanteric entry nail after calcar reduction and intraoperative compression of the fracture site. Patients were grouped into stable (n = 17) and unstable (n = 13) fracture types based on the OTA classification. OUTCOME/MEASUREMENTS: Postoperative collapse was measured as telescoping of the lag screw from lateral cortex and blade tip migration within the femoral head. Alteration in femoral head offset and abductor lever arm was measured at the last follow-up visit. Gait parameters were recorded and compared with contralateral side at 6-week, 3-, 6-, and 12-month follow-up visits. Functional outcomes were assessed through 36-item short form health survey (version 2) and Harris Hip Scores at 1 year. RESULTS: Fracture type (stable or unstable) significantly predicted telescoping (P = 0.007). Mean telescoping was 3.3 mm (SD = 2.41 mm) in the unstable group versus 1.2 mm (SD = 0.81 mm) in the stable group (P = 0.004). The stable group recovered 95% of the single limb stance versus 91% in the unstable group, at 1 year. (P = 0.02). Return of single limb stance improved from 76% to 95% between 6 weeks and 6 months. No improvement in gait was seen after 6 months (P > 0.05). The average scores on the physical and mental components of 36-item short form health survey and Harris Hip Scores were 44, 53, and 89, respectively. The radiographic union rate was 100%. There was 1 (3%) screw cutout that did not require a revision surgery in our series. There were no cases with implant failure, femur fracture, or any wound complications. CONCLUSIONS: Satisfactory functional outcomes with near-normal gait restoration can be achieved in cases of intertrochanteric hip fractures with an emphasis on calcar reduction and compression after fixation with trochanteric entry nail. LEVEL OF EVIDENCE: Therapeutic Level IV. See page 128 for a complete description of levels of evidence
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Medical conditions among Iraqi refugees in Jordan: data from the United Nations Refugee Assistance Information System
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Dental Implant Infection
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OBJECTIVE: To determine the range and burden of health services utilization among Iraqi refugees receiving health assistance in Jordan, a country of first asylum., METHODS: Medical conditions, diagnosed in accordance with the tenth revision of the International classification of diseases, were actively monitored from 1 January to 31 December 2010 using a pilot centralized database in Jordan called the Refugee Assistance Information System., FINDINGS: There were 27 166 medical visits by 7642 Iraqi refugees (mean age: 37.4 years; 49% male; 70% from Baghdad; 6% disabled; 3% with a history of torture). Chronic diseases were common, including essential hypertension (22% of refugees), visual disturbances (12%), joint disorders (11%) and type II diabetes mellitus (11%). The most common reasons for seeking acute care were upper respiratory tract infection (11%), supervision of normal pregnancy (4%) and urinary disorders (3%). The conditions requiring the highest number of visits per refugee were cerebrovascular disease (1.46 visits), senile cataract (1.46) and glaucoma (1.44). Sponsored care included 31 747 referrals or consultations to a specialty service, 18 432 drug dispensations, 2307 laboratory studies and 1090 X-rays. The specialties most commonly required were ophthalmology, dentistry, gynaecology and orthopaedic surgery., CONCLUSION: Iraqi refugees in countries of first asylum and resettlement require targeted health services, health education and sustainable prevention and control strategies for predominantly chronic diseases.
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Comparison of adductor canal block and femoral nerve block for postoperative pain in total knee arthroplasty:a systematic review and meta-analysis
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AAHKS (9/10) Regional Nerve Blocks
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A total knee arthroplasty (TKA) has always been associated with moderate-to-severe pain. A systematic review of randomized controlled trials (RCTs) and non-RCTs was performed to evaluate the efficacy and safety of pain control of adductor canal block (ACB) and femoral nerve block (FNB) after TKA. Relevant literatures about the ACB and FNB after TKA for reducing pain were searched from Medline (1996-January, 2015), Embase (1980-January, 2015), PubMed (1980-January, 2015), Web of Science (1980-January, 2015), and The Cochrane Central Register of Controlled Trials. High-quality RCTs and non-RCTs were picked to evaluate the visual analogue scale (VAS) and other outcome. This systematic review and meta-analysis were performed according to the PRISMA statement criteria. The software RevMan 5.30 was used for the meta-analysis. Eight literatures fitted into the inclusion criteria. There were no significant differences in VAS score with rest or mobilization at 4, 24, and 48 h between ACB group and FNB group. There were also no significant differences in the strength of quadriceps and adductor, the length of hospital stay, and complications of vomiting and nausea. Present meta-analysis indicated that ACB shows no superiority than FNB group. Both of them can reduce the pain score after TKA. As referred to which method to adopt, it is determined by the preference of the surgeons and anesthesiologists.
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The effect of complete radial lateral meniscus posterior root tear on the knee contact mechanics: a finite element analysis
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AMP (Acute Meniscal Pathology)
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BACKGROUND: In recent years, with technological advances in arthroscopy and magnetic resonance imaging and improved biomechanical studies of the meniscus, there has been some progress in the diagnosis and treatment of injuries to the roots of the meniscus. However, the biomechanical effect of posterior lateral meniscus root tears on the knee has not yet become clear. The purpose of this study was to determine the effect of a complete radial posterior lateral meniscus root tear on the knee contact mechanics and the function of the posterior meniscofemoral ligament on the knee with tear in the posterior root of lateral meniscus.
METHODS: A finite element model of the knee was developed to simulate different cases for intact knee, a complete radial posterior lateral meniscus root tear, a complete radial posterior lateral meniscus root tear with posterior meniscofemoral ligament deficiency, and total meniscectomy of the lateral meniscus. A compressive load of 1000 N was applied in all cases to calculate contact areas, contact pressure, and meniscal displacements.
RESULTS: The complete radial posterior lateral meniscus root tear decreased the contact area and increased the contact pressure on the lateral compartment under compressive load. We also found a decreased contact area and increased contact pressure in the medial compartment, but it was not obvious compared to the lateral compartment. The lateral meniscus was radially displaced by compressive load after a complete radial posterior lateral meniscus root tear, and the displacement took place mainly in the body and posterior horn of lateral meniscus. There were further decrease in contact area and increases in contact pressure and raidial displacement of the lateral meniscus in the case of the complete posterior lateral meniscus root tear in combination with posterior meniscofemoral ligament deficiency.
CONCLUSIONS: Complete radial posterior lateral meniscus root tear is not functionally equivalent to total meniscectomy. The posterior root torn lateral meniscus continues to provide some load transmission and distribution functions across the joint. The posterior meniscofemoral ligament prevents excessive radial displacement of the posterior root torn lateral meniscus and assists the torn lateral meniscus in transmitting a certain amount of stress in the lateral compartment.
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1 |
Scheduled analgesic regimen improves rehabilitation after hip fracture surgery hip
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Hip Fx in the Elderly 2019
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Background: Postoperative pain often is the limiting factor in the rehabilitation of patients after hip fracture surgery. Questions/purposes: We compared an approach using scheduled analgesic dosing with as-needed analgesic dosing in patients after hip fracture surgery, to compare these approaches in terms of (1) resting and dynamic pain intensity, (2) postoperative patient mobility, and (3) functional end points. Methods: We conducted a prospective cohort study of 400 patients who underwent surgical treatment of hip fractures at our hospital. The groups were formed sequentially, such that the first 200 patients formed the intervention group (treated with scheduled analgesic intake for the first 3 weeks after surgery), and the next 200 patients were the control group (treated using a protocol of analgesic administration on request). Resting and dynamic pain intensity, mobility, and functional performance were compared between the two analgesic protocols. Results: As expected, analgesic consumption was lower in the control group (tramadol doses, 27 versus 63; paracetamol doses, 29 versus 63). Despite the large difference in the amounts of analgesics consumed, resting and dynamic pain intensity showed improvement in each group and there was no difference between groups in terms of postoperative pain. However, there was a positive correlation between functional outcomes and analgesic consumption in the control group. The intervention group achieved higher functional performance on discharge (elderly mobility scale, 11 versus 8; functional independence measure, 88 versus 79). On discharge, fewer patients in the intervention group were wheelchair ambulators (3 versus 32), meaning more patients in the intervention group were able to walk. Conclusions: The study showed that a scheduled analgesic intake can improve the functional outcomes of patients with geriatric hip fractures after surgery. Level of Evidence: Level II, therapeutic study. See the guidelines for authors for a complete description of levels of evidence. © 2013 The Author(s).
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Obesity is no longer a risk factor for dislocation after total hip arthroplasty with a double-mobility cup
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Hip Fx in the Elderly 2019
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PURPOSE: Dislocation is one of the most feared complications after total hip arthroplasty (THA). This risk is greater in obese patients compared with the general population.
METHODS: We performed a retrospective cohort study in which the main objective was to compare the dislocation rate between obese patients (BMI > 30 kg/m2) (exposed group) and non-obese patients (BMI <= 30 kg/m2) (unexposed group) after primary THA with a double-mobility acetabular cup. The patients had a minimum follow-up of 24 months.
RESULTS: The 'obese' group consisted of 77 THA cases and the 'non-obese' group of 425 cases; the two groups were similar in terms of age, gender and ASA score. After a mean follow-up of 58.3 +/- 27 months (range 27-159), 43 patients had been lost to follow-up and 56 had died; the two groups had similar mean values. One patient in the 'obese' group had suffered a dislocation due to a fall 16 months after the THA. One patient in the 'non-obese' group had suffered a dislocation after a periprosthetic femur fracture with stem subsidence two months after the THA procedure. Both patients underwent surgical revision where the double-mobility cup was preserved; there were no further dislocation events as of the last follow-up. The dislocation rate in the two groups was similar (1.3 % versus 0.23%, p > 0.05). No cases of loosening were found. Revisions were secondary to deep or superficial infection (n = 22), periprosthetic femur fracture (n = 10) or haematoma (n = 3).
CONCLUSION: These findings imply that double-mobility cups are a reliable way of reducing the risk of dislocation in obese patients after primary THA.
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1 |
Screw fixation for supracondylar humerus fractures in children: a report of seventeen cases
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Pediatric Supracondylar Humerus Fracture 2020 Review
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PURPOSE: Supracondylar fractures in the pediatric population are common. For years, K-wires have been the preferred method of surgical fixation. However, fixation with K-wires alone may lead to multiple complications. This study reports the results of surgical care of supracondylar humerus fractures using screw fixation with K-wires or screw fixation alone. METHODS: This study retrospectively reviewed all patients with supracondylar humerus fractures treated with screw fixation between 2007 and 2013. Patients treated only with smooth wires, or having a displaced medial epicondyle, or presenting with lateral condyle fractures were excluded from the study. Flynn's criteria were used to determine the outcome. RESULTS: Seventeen patients who met inclusion criteria formed the study group. All patients were followed until union, resolution of complications, and return to preinjury activity level. Satisfactory outcome was reported in 70.6% of patients with less than 15° loss of either flexion or extension. Mean time to union was 6.5 weeks (range 3.3-12.1 weeks). Screw fixation alone had a shorter mean time to union (5.5 weeks) than compared screw fixation with K-wires group (6.9 weeks). Full range of motion following surgical invention was associated with Flynn's criteria (p valueâ??=â??0.044). CONCLUSION: Screw fixation for pediatric supracondylar fractures is a viable option to achieve healing and early motion in highly unstable fractures as well as fractures which require (1) increased stability, (2) maintenance of stability during wound checks in the immediate postoperative period and after discontinuation of the cast, or (3) if further exploration like associated vascular injury is warranted.
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0 |
Meniscal calcification, pathogenesis and implications
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AMP (Acute Meniscal Pathology)
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PURPOSE OF REVIEW: The purpose of this review is to discuss recent advances in the understanding of the nature of meniscal calcification and its relationships with meniscal degeneration and cartilage lesions in osteoarthritis.
RECENT FINDINGS: Calcium crystals are universally present in hyaline articular cartilage, as well as the meniscus of the knee of end-stage osteoarthritis patients. Osteoarthritis meniscal cells display a distinct gene-expression profile different from normal meniscal cells, have elevated expression of ankylosis progressive analog (ANKH) and ectonucleotide pyrophosphatase/phosphodiesterase1 (ENPP1) and produce more calcium minerals than normal meniscal cells in vitro. Meniscal calcification is positively associated with meniscal degeneration, which is an early event in the development of osteoarthritis and correlates with cartilage lesions and clinical osteoarthritis scores. Phosphocitrate is a potent calcification inhibitor of osteoarthritis meniscal cell-mediated calcium deposition. Its effect on preventing meniscal degeneration and the molecular mechanisms underlying its disease-modifying activity in osteoarthritis remains elusive.
SUMMARY: Recent findings support a pathogenic role of meniscal calcification in osteoarthritis. Meniscal calcification, similar to meniscal degeneration, is a predisposing factor for cartilage lesions. Meniscal calcification is a new target for the development of therapeutic disease-modifying drugs for osteoarthritis.
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Cost-Effectiveness of Different Forms of Intra-Articular Injections for the Treatment of Osteoarthritis of the Knee
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OAK 3 - Non-arthroplasty tx of OAK
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INTRODUCTION: Osteoarthritis (OA), as one of the leading causes of disability, decreases the quality of life for those suffering from the disease and creates a substantial financial burden. Intra-articular hyaluronic acid (HA) can provide relief from the symptoms of OA and multiple HA products are prescribed. The purpose of this study is to examine the single payer cost-effectiveness of various HA products in the treatment of knee OA.
METHODS: A single payer economic evaluation was conducted comparing Synvisc() (Sanofi, USA), Durolane() (Bioventus, USA), Hyalgan() (Fidia Pharma Inc., USA), SupartzTM (Bioventus, USA), and Euflexxa() (Ferring Pharmaceuticals Inc., USA). Utility scores for HA products were obtained by extracting Western Ontario and McMaster Universities Arthritis Index pain, stiffness and function from randomized controlled trials and converting them to health utilities index mark 3 scores. The cost of a treatment included the cost of the HA injection, cost of a knee injection procedure and cost of a doctor's visit for each required injection. Cost-utility in 2015 USD per quality-adjusted life years (QALY) saved was calculated for each HA product, and incremental cost-effectiveness ratios were calculated to compare the effectiveness of HA products to one another and to conventional care.
RESULTS: When compared to conventional care, all investigated HA products were cost-effective, assuming a willingness-to-pay threshold of $50,000/QALY gained. The HA product Euflexxa had the most favorable cost-utility ratio ($5785.52/QALY) when compared to all other HA brands.
CONCLUSION: The present study showed several HA products to be cost-effective in comparison to conventional care, with Euflexxa having the most favorable cost/QALY gained ratio compared to the other HA products.
FUNDING: Ferring Pharmaceutics Inc.
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Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic providers
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AMP (Acute Meniscal Pathology)
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STUDY DESIGN: Nonexperimental, retrospective design. OBJECTIVES: This study was designed to compare clinical diagnostic accuracy (CDA) between physical therapists (PTs), orthopaedic surgeons (OSs), and nonorthopaedic providers (NOPs) at Keller Army Community Hospital on patients with musculoskeletal injuries (MSI) referred for magnetic resonance imaging (MRI). BACKGROUND: US Army PTs are frequently the first credentialed providers privileged to examine and diagnose patients with musculoskeletal injuries. Physical therapists assigned at Keller Army Community Hospital have also been credentialed with privileges to order MRI studies for several years. METHODS AND MEASURES: To reduce provider bias, a retrospective analysis was performed on 560 patients referred for MRI over an 18-month period. An electronic review of each patient's radiological profile was performed to assess agreement between clinical diagnosis and MRI findings. Data analyses were performed through descriptive statistics and contingency tables. RESULTS: Analysis on agreement between clinical diagnosis and MRI findings produced a CDA of 74.5% (108/145) for PTs, 80.8% (139/172) for OSs, and 35.4% (86/243) for NOPs. There was a significant difference in CDA between PTs and NOPs (P<.001), and between OSs and NOPs (P<.001). There was no difference in CDA between PTs and OSs (P>.05). CONCLUSIONS: Clinical diagnostic accuracy by PTs and OSs on patients with musculoskeletal injuries was significantly greater than for NOPs, with no difference noted between PTs and OSs.
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Proof-of Concept Study of Topical 3%-Diclofenac-Nano-Emulsion Cream for Knee OA Pain
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OAK 3 - Non-arthroplasty tx of OAK
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This will be a multiâ?center, doubleâ?blind, placeboâ?controlled, multipleâ?dose, parallel treatment study. A total of 126 subjects will be randomized to receive either 3%â?Diclofenacâ?NE cream or a placebo cream respectively. Following screening and a washout period from previous treatments subjects will be enrolled and will selfâ?apply the study medication. During the study, subjects will apply 3%â?Diclofenacâ?NE or placebo cream three times daily for 28 days and complete a homeâ?diary. Subjects will visit the clinic at midâ?treatment for a follow up examination and again for a final examination at the end of treatment.
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Validation of the Chinese Western Ontario and McMaster Universities Osteoarthritis Index in Patients From Mainland China With Osteoarthritis of the Knee
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To establish the reliability, validity, and sensitivity to change of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) among Chinese subjects with osteoarthritis (OA) of the knee, living in mainland China.
METHODS: A multicenter, randomized, double-blind, placebo-controlled, parallel-group study was conducted for validation of the electronic personal digital assistant version of the WOMAC Numerical Rating Scale (NRS) 3.1 Index in China. A total of 287 subjects with OA of the knee were randomized to receive either meloxicam (15 mg) or placebo. Psychometric properties of the WOMAC were evaluated by estimating the reliability, validity, and sensitivity to change. Equivalence of the electronic version was also compared with the paper version.
RESULTS: Intraclass correlation coefficients for the WOMAC pain, stiffness, and physical function subscales were 0.81, 0.76, and 0.85, respectively, indicating good test-retest reliability. Similarly, internal consistency was strong (Cronbach's alpha for the 3 WOMAC subscales was 0.84, 0.86, and 0.96, respectively). Pearson's correlation coefficients for WOMAC pain and Short Form 36 health survey (SF-36) bodily pain, as well as WOMAC physical function and SF-36 physical functioning domains were >0.4, indicating convergent validity, whereas the coefficients for all 3 WOMAC domains with SF-36 mental health and mental health component scores were <0.4, indicating divergent validity. There was strong discriminant validity between healthy volunteers and OA patients. The effect sizes of change from baseline to week 12 in WOMAC subscale scores were large, demonstrating sensitivity to change. Equivalence between paper and electronic versions was very high.
CONCLUSION: The culturally and linguistically validated Chinese version of the WOMAC NRS 3.1 for mainland China is psychometrically robust in its validity, reliability, and sensitivity to change for patients with OA of the knee.
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Concepts of anaerobic infection in relation to prevention and management
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
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Concepts of anaerobic infection are reviewed in relation to the management of wounds that might be contaminated by facultative or anaerobic organisms or mixtures of these. Considerations of post-operative wound infections oblige us to consider the indications for per-operative antimicrobial prophylaxis and to bear in mind the role of anaerobes and the possibility of pathogenic synergy in these situations. Pathogenic associations of anaerobes with other organisms are further considered in relation to periodontal disease and anaerobic vaginosis. The various roles of anaerobes in enteropathogenic conditions are briefly considered. There is a continuing obligation on clinical bacteriologists and clinicians to work together towards the more effective prevention and management of infections that may or may not have a significant anaerobic component
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Carpal tunnel syndrome in children with mucopolysaccharidosis and related disorders
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Four cases of mucopolysaccharidosis or mucolipidosis and carpal tunnel syndrome in children are presented. Carpal tunnel release achieved clinical and electrical improvement in all cases
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No Decrease in Infection Rate with the Use of Local Vancomycin Powder After Partial Hip Replacement in Elderly Patients with Comorbidities
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DoD SSI (Surgical Site Infections)
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Introduction The goal of this study was to evaluate the effects of local intra-wound vancomycin powder (VP) administration to decrease surgical site infections (SSIs), particularly in elderly patients with comorbidities, after having undergone partial hip replacement in the treatment of intertrochanteric (ITF) or femoral neck fractures (FNF). Methods We retrospectively reviewed patients who underwent partial hip replacement in the treatment of ITF or FNF in one year. We divided the patients into two groups. The non vancomycin-treated group received standard systemic prophylaxis only (1 gr cefazolin IV), while the vancomycin-treated group received 1 gr of VP in the surgical wound just before surgical closure in addition to the systemic prophylaxis. We included patients of 64 years or older who also had one or more comorbidities. We compared the post-operative SSI rates between the non vancomycin-treated group and the vancomycin-treated group. Results A total of 93 patients were included in the study. We detected post-operative wound infection in six patients (6.4%). The rate of SSI was found to be 5.7% in the vancomycin-treated group and 6.9% in the non vancomycin-treated group respectively, which showed no statistically significant difference (p:0.498). The incidence of SSI was statistically higher in the patients who had a follow-up in the post-operative intensive care unit than the patients who had not any follow-up in the intensive care unit. Conclusion Local application of VP in the surgical wound was found to be ineffective in reducing the incidence of SSI after partial hip replacement in elderly patients with comorbidities.
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Efficacy of intra-articular injections of platelet-rich plasma as a symptom- and disease-modifying treatment for knee osteoarthritis - the RESTORE trial protocol
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PRP (Platelet-Rich Plasma)
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BACKGROUND: Knee osteoarthritis (OA) causes substantial pain, physical dysfunction and impaired quality of life. There is no cure for knee OA, and for some people, the disease may involve progressive symptomatic and structural deterioration over time. Platelet-rich plasma (PRP) is a therapeutic agent that aims to address underlying biological processes responsible for OA pathogenesis. As such, it has the potential to improve both symptoms and joint structure. The aim of this clinical trial is to determine whether a series of injections of PRP into the knee joint will lead to a significantly greater reduction in knee pain, and less loss of medial tibial cartilage volume over 12 months when compared to a series of placebo saline injections in people with knee OA.
METHODS: This will be a two-group, superiority, randomised, participant-, interventionist- and assessor-blinded, placebo-controlled trial. Two hundred and eighty-eight participants aged over 50 years with painful knee OA and mild to moderate structural change on x-ray (Kellgren and Lawrence grade 2 and 3) will be randomly allocated to receive either three PRP injections or three normal saline injections into the knee joint at weekly intervals. The primary outcomes will be 12-month change in average overall knee pain severity (numeric rating scale) and medial tibial cartilage volume (magnetic resonance imaging (MRI)). Secondary outcomes include additional measures of knee pain and other symptoms, function in daily living and sport and recreation, quality of life, participant-perceived global ratings of change, and other MRI structural outcomes including meniscal and cartilage morphology, synovitis, effusion, bone marrow lesions and cartilage defects. A range of additional measures will be recorded, and a separate health economic evaluation will be performed.
DISCUSSION: The findings from this study will help determine whether PRP improves both clinical and structural knee OA outcomes over 12 months when compared to a series of placebo saline injections.
TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN12617000853347 . Prospectively registered 9th of June 2017.
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Involvement of peripheral and spinal tumor necrosis factor α in spinal cord hyperexcitability during knee joint inflammation in rats
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OAK 3 - Non-arthroplasty tx of OAK
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Objective. Tumor necrosis factor α (TNFα) is produced not only in peripheral tissues, but also in the spinal cord. The purpose of this study was to address the potential of peripheral and spinal TNFα to induce and maintain spinal hyperexcitability, which is a hallmark of pain states in the joints during rheumatoid arthritis and osteoarthritis. Methods. In vivo recordings of the responses of spinal cord neurons to nociceptive knee input under normal conditions and in the presence of experimental knee joint inflammation were obtained in anesthetized rats. TNFα, etanercept, or antibodies to TNF receptors were applied to either the knee joint or the spinal cord surface. Results. Injection of TNFα into the knee joint cavity increased the responses of spinal cord neurons to mechanical joint stimulation, and injection of etanercept into the knee joint reduced the inflammationevoked spinal activity. These spinal effects closely mirrored the induction and reduction of peripheral sensitization. Responses to joint stimulation were also enhanced by spinal application of TNFα, and spinal application of either etanercept or anti-TNF receptor type I significantly attenuated the generation of inflammation-evoked spinal hyperexcitability, which is characterized by widespread pain sensitization beyond the inflamed joint. Spinally applied etanercept did not reduce established hyperexcitability in the acute kaolin/ carrageenan model. In antigen-induced arthritis, etanercept decreased spinal responses on day 1, but not on day 3. Conclusion. While peripheral TNFα increases spinal responses to joint stimulation, spinal TNFα supports the generation of the full pattern of spinal hyperexcitability. However, established spinal hyperexcitability may be maintained by downstream mechanisms that are independent of spinal TNFα. © 2014, American College of Rheumatology.
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Sports injuries in children
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Diagnosis and Treatment of Osteochondritis Dissecans AUC
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Introduction: Sports injuries in children affect both growing bone and soft tissues, and can result in damage of growth mechanisms with subsequent lifelong, growth disturbance. This clinical review unfolds the incidence and distribution, physiology, injury characteristics and the prevention modalities. Methods: A comprehensive in Medline literature search was performed, and the reference lists of sports injuries related journals and text books was consulted. Results: During growth, there are significant changes in the biomechanical properties of bone. In young athletes, as bone stiffness increases and resistance to impact diminishes, sudden overload may cause bones to bow or buckle. Fractures that are initially united with some deformity can completely remodel, and the bone may appear totally normal in later life. Discussion/conclusion: Most injuries caused in children's sports are minor and self-limiting, suggesting that children and youth sports are safe. The training programmes should take into account their physical and psychological immaturity, so that growing athletes can adjust to the changes in their bodies. (copyright) The Author 2008. Published by Oxford University Press. All rights reserved
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Further evidence for treatment of recalcitrant neuropathy of the upper limb with autologous vein wrapping
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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The treatment of entrapment neuropathy in the upper extremity with surgical decompression has generally provided good results. Recurrence of symptoms, however, is not uncommon, and its management is both challenging and difficult. Autologous vein graft wrapping is an alternative technique, and it is recommended for the treatment of recalcitrant upper limb nerve compression in which 2 or more previous surgical procedures have failed to resolve the problem. Each patient underwent both subjective and objective evaluation. To our knowledge, this is the largest reported single series of vein wrapping cases in the upper limb outside the United States and the first to report results using the well-validated patient evaluation measure
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Markers of bone resorption predict hip fracture in elderly women: The
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Management of Hip Fractures in the Elderly
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Increased bone turnover has been suggested as a potential risk factor for osteoporotic fractures. We investigated this hypothesis in a prospective cohort study performed on 7598 healthy women more than 75 years of age. One hundred and twenty-six women (mean years 82.5) who sustained a hip fracture during a mean 22-month follow-up were age-matched with three controls who did not fracture. Baseline samples were collected prior to fracture for the measurement of two markers of bone formation and three urinary markers of bone resorption: type I collagen crass-linked N- (NTX) or C-telopeptide (CTX) and free deoxypyridinoline (free D-Pyr). Elderly women had increased bone formation and resorption compared with healthy premenopausal women. Urinary excretion of CTX and free D-Pyr, but not other markers, was higher in patients with hip fracture than in age-matched controls (p = 0.02 and 0.005, respectively). CTX and free D-Pyr excretion above the upper limit of the premenopausal range was associated with an increased hip fracture risk with an odds ratio (95% confidence interval) of 2.2 (1.3-3.6) and 1.9 (1.1-3.2), respectively, while markers of formation were not. Increased bone resorption predicted hip fracture independently of bone mass, i.e., after adjustment for femoral neck bone mineral density (BMD) and independently of mobility status assessed by the gait speed. Women with both a femoral BMD value of 2.5 SD or more below the mean of young adults and either high CTX or high free D-Pyr levels were at greater risk of hip fracture, with an odds ratio of 4.8 and 4.1, respectively, than those with only low BMD or high bone resorption. Elderly women are characterized by increased bone turnover, and some markers of bone resorption predict the subsequent risk of hip fracture independently of hip BMD. Combining the measurement of BMD and bone resorption may be useful to improve the assessment of the risk of hip fracture in elderly women
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Psoriatic arthritis or could it be singleton-merten syndrome?
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Surgical Management of Osteoarthritis of the Knee CPG
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Aims To describe Singleton-Merten Syndrome as an unusual cause of arthritis associated with a psoriasiform rash. Methods Case report. Results We present this case of a girl who at 11 months suffered from discrete red scaly areas on the trunk, limbs and scalp. She was given a diagnosis of psoriasis which remained poorly controlled throughout childhood, despite phototherapy and methotrexate treatment. In infancy, slow gross motor development was noted and felt to be related to hypermobility. She also began complaining of morning stiffness and pain in her hands and knees. The ESR was slightly raised at 17 but all other investigations were negative including ANA, rheumatoid factor and HLA-B27. X-rays showed osteopenic bones but no joint erosion. A diagnosis of psoriatic arthritis was made and although wheelchair bound, she never had significant joint inflammation. Dental concerns also emerged with delayed eruption and very malformed teeth with short roots. She was of proportional short stature with height at the 3rd centile at 10 years. At 11 years a systolic murmur was first heard although she had no cardiac symptoms. An echocardiograph revealed a moderately stenosed valve which rapidly progressed with syncopal episodes 18 months later. At this point the ejection fraction was 21% and a computed tomography scan revealed calcification of the aortic arch to the transverse arch. She had an aortic root replacement with pulmonary autograft. Around this time, she had repeat X-rays which were felt to not be typical of psoriatic arthritis. Instead they showed acro-osteolysis with periarticular osteopaenia, and medullary widening. Subsequently given her other clinical features, Singleton-Merten Syndrome was diagnosed. Conclusions Singleton-Merten Syndrome is a rare autosomal dominant multisystem condition with less than 10 cases reported in the literature. It is thought to be due to abnormal calcium deposition although its genetic basis is not known. Manifestations include aortic valve calcification, osteoporosis with widened medullary cavities, muscle weakness, short stature, psoriasiform eruptions, glaucoma and dentin dysplasia. Rheumatologists commonly treat arthropathies and therefore although this is a rare cause we hope to highlight awareness of this syndrome
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Management of a pelvic mass following a worn uncemented total hip arthroplasty
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PJI DX Updated Search
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Intrapelvic granulomatous masses from polyethylene wear debris can easily be misdiagnosed if orthopaedic etiology is not considered. This article presents the case of a 50 year old woman with history of hip joint trauma and total hip arthroplasty (THA) revisions who presented to her gynecologist with a large intrapelvic cyst. Prolonged use of an indwelling drain and failure to recognize the orthopaedic origin of the mass resulted in articular infection that required an antibiotic spacer and subsequent THA revision. This patient did not have pain or evidence of medial wall defects, but did have a history of trauma, revision arthroplasty and acetabular allograft. In the presence of these findings, wear-induced polyethylene debris should be considered in the differential diagnosis of the pelvic mass. é 2012 Elsevier Inc
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Local infiltration analgesia for postoperative pain after hip arthroplasty: a systematic review and meta-analysis
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AAHKS (8) Anesthetic Infiltration
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UNLABELLED: Postoperative pain after hip arthroplasty (HA) is very common and severe. Currently, use of routine analgesic methods is often accompanied by adverse events (AEs). Local infiltration analgesia (LIA) for controlling pain has been a therapeutic option in many surgical procedures. However, its analgesic efficacy in HA and its safety remain unclear. Data from 9 randomized controlled trials, involving 760 participants, comparing the effect of LIA with that of placebo infiltration or no infiltration on patients undergoing HA were retrieved from an electronic database, and the pain scores, analgesic consumption, and AEs were analyzed. Effects were summarized using weighted mean differences, standardized mean differences, or odds ratio with fixed or random effect models. There was strong evidence of an association between LIA and reduced pain scores at 4 hours at rest (P < .00001) and with motion (P < .00001), 6 hours with motion (P = .02), and 24 hours at rest (P = .01), and decreased analgesic consumption during 0 to 24 hours (P = .001) after HA. These analgesic efficacies for LIA were not accompanied by any increased risk for AEs. However, the current meta-analysis did not reveal any associations between LIA and the reduced pain scores or analgesic consumption at other time points. The results suggest that LIA can be used for controlling pain after HA because of its efficacy in reducing pain scores and thus can reduce analgesic consumption on the first day without increased risk of AEs.
PERSPECTIVE: This is the first pooled database meta-analysis to assess the analgesic effects and safety of LIA in controlling pain after HA. The derived information offers direct evidence that LIA can be used for patients undergoing HA because of its ability to reduce pain scores and analgesic consumption without any additional AEs.
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Ultrasound-guided adductor canal block: a cadaveric study investigating the effect of a thigh tourniquet
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AAHKS (8) Anesthetic Infiltration
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Background: Placement of local anaesthetic within the adductor canal using ultrasonography is an alternative to femoral nerve blocks for postoperative pain relief after knee joint replacement surgery. However, the effect of an inflated thigh tourniquet on the distribution of local anaesthetic within the adductor canal is unknown. The aim of this cadaveric study was to compare the distribution of radioâ?opaque dye within the adductor canal in the presence or absence of an inflated thigh tourniquet. Methods: Bilateral ultrasoundâ?guided adductor canal blocks were performed on the thawed lower limbs of five fresh frozen human cadavers. The left and right lower cadaver limbs were randomised to receive or not receive a thigh tourniquet inflated to 300 mm Hg for 1 h. Xâ?rays with iohexol radioâ?opaque dye were obtained in four views, and fiducial markers inserted as reference points. Virtual editing technology was used to recreate outlines representing the distribution of the radioâ?opaque dye and superimpose these on anatomical images. Results: Radioâ?opaque dye was distributed on the medial aspect of the thighs with entire and well circumscribed margins. The majority of the radioâ?opaque dye was confined within the adductor canal. Superiorâ?inferior dye distribution was 315.2 mm [95% confidence intervals (CI) 288.7â?341.7] and 263.9 mm (95% CI 238.9â?288.9) in the presence and absence of an inflated thigh tourniquet, respectively (diff 95% CI â?80.46 to â?22.22, P=0.0081). Image analysis using the recreated radioâ?opaque outlines suggested that the most proximal point of the radioâ?opaque dye was 99.6 mm (95% CI 82.52â?116.7) or 116.6 mm (95% CI 61.77â?171.4) below the inguinal ligament in the presence and absence of an inflated thigh tourniquet, respectively (diff 95% CI â?38.51 to 72.43, P=0.456). Conclusions: Application and inflation of thigh tourniquets significantly increased the combined superiorâ?inferior dye distribution within the adductor canal of cadaveric limbs. There was insufficient evidence to suggest significant proximal spread of 25 ml of local anaesthetic to involve the motor branches of the femoral nerve. In some patients, the local anaesthetic may reach the popliteal fossa in close approximation to the sciatic nerve. Copyright © 2018 British Journal of Anaesthesia
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Nonoperative management of patients with carcinoma metastatic to bone
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MSTS 2018 - Femur Mets and MM
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The skeleton is the most common site of metastatic spread of cancer and a leading cause of morbidity and mortality from cancer. Treatment of bone metastases can lead to improvement in survival and quality of life. Because bone metastases usually are widespread by the time they become symptomatic, nonoperative management options play an integral role in their treatment. Potential treatment options for carcinoma metastatic to bone include bone-targeted agents, systemic anticancer therapy, conventional and stereotactic body radiation therapy, and ablative techniques.
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Most patients gain weight in the 2 years after total knee arthroplasty: comparison to a healthy control group
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Surgical Management of Osteoarthritis of the Knee CPG
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OBJECTIVE: While joint arthroplasty improves the functional ability of persons with severe knee osteoarthritis (OA), the long-term effects of surgical intervention on body mass have not been evaluated. The objective of this study was to determine if a reduction in body mass index (BMI) was present following unilateral total knee arthroplasty (TKA) compared to an age-matched healthy control group who did not have surgery. METHOD: One hundred and six adults with unilateral, end-stage knee OA and thirty-one persons without knee pain participated in the prospective longitudinal study. Subjects with OA underwent primary unilateral TKA and received post-operative out-patient physical therapy. Height, weight, quadriceps strength and self-perceived functional ability were measured at baseline and at a 2-year follow-up. RESULTS: There was a significant interaction effect between body mass over time and subject group (P=0.017). BMI showed a significant increase over 2 years for the surgical group (P<0.001), but not for the control group (P=0.842). Sixty-six percent of the persons in the surgical group gained weight over the 2 years with an average weight gain of 6.4 kg, or 14 pounds, 2 years after their initial physical therapy visit. Educational level, marital status, income level and activity level prior to surgery were not related to post-surgical weight gain. CONCLUSION: The majority of subjects gain weight after surgery and this cannot be attributed to the effects of aging. Weight gain after TKA should be treated as an independent concern and management of orthopedic impairments will not result in weight loss. Post-operative care should include access to nutrition or weight management professionals in addition to medical and physical therapy services
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The association between antagonist hamstring coactivation and episodes of knee joint shifting and buckling
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: Hamstring coactivation during quadriceps activation is necessary to counteract the quadriceps pull on the tibia, but coactivation can be elevated with symptomatic knee osteoarthritis (OA). To guide rehabilitation to attenuate risk for mobility limitations and falls, this study evaluated whether higher antagonistic open kinetic chain hamstring coactivation is associated with knee joint buckling (sudden loss of support) and shifting (a sensation that the knee might give way).
DESIGN: At baseline, median hamstring coactivation was assessed during maximal isokinetic knee extensor strength testing and at baseline and 24-month follow-up, knee buckling and shifting was self-reported. Associations between tertiles of co-activation and knee (1) buckling, (2) shifting and (3) either buckling or shifting were assessed using logistic regression, adjusted for age, sex, knee OA and pain.
RESULTS: 1826 participants (1089 women) were included. Mean +/- SD age was 61.7 +/- 7.7 years, BMI was 30.3 +/- 5.5 kg/m(2) and 38.2% of knees had OA. There were no consistent statistically significant associations between hamstring coactivation and ipsilateral prevalent or incident buckling or the combination of buckling and shifting. The odds ratios for incident shifting in the highest in comparison with the lowest tertile of coactivation had similar magnitudes in the combined and medial hamstrings, but only reached statistical significance for lateral hamstring coactivation, OR(95%CI) 1.53 (0.99, 2.36).
CONCLUSIONS: Hamstring coactivation during an open kinetic chain quadriceps exercise was not consistently associated with prevalent or incident self-reported knee buckling or shifting in older adults with or at risk for knee OA.
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Brief report: intraarticular sprifermin not only increases cartilage thickness, but also reduces cartilage loss: location-independent post hoc analysis using magnetic resonance imaging
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OAK 3 - Non-arthroplasty tx of OAK
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OBJECTIVE: To determine whether an anabolic drug (sprifermin) is capable of reducing cartilage loss wherever it occurs in a given knee, using a subject-specific, location-independent analysis of cartilage change in patients with knee osteoarthritis (OA).
METHODS: Study participants (n = 168; ages >=40 years, 69% women) had symptomatic femorotibial OA not confined to the medial compartment. Sprifermin (10, 30, or 100 mug) or placebo was injected intraarticularly 3 times over 3 weeks, both after randomization (baseline) and 3 months later. Coronal magnetic resonance images were acquired at baseline and 3, 6, and 12 months after treatment. The femorotibial cartilage of each subject was segmented, and changes in cartilage thickness were computed across 16 subregions. Location-independent post hoc analysis was used to compute summary scores of negative and positive changes in the subregions, summarized as the total cartilage thinning sum score (ThCTnS) and the total cartilage thickening sum score (ThCTkS), capturing change in either direction in each knee. Ordered values of the magnitude of subject-specific subregional changes in thickness were determined. The ThCTnS and ThCTkS in each sprifermin dose group at 12 months of followup were compared with the values in the matched placebo groups, using the Wilcoxon-Mann-Whitney test.
RESULTS: The mean +/- SD ThCTnS was -591 +/- 617 mum (median -360 mum, Q1/Q3 = -820/-200 mum) in patients treated with 100 mug sprifermin (n = 57), and -921 +/- 777 mum (median -745 mum, Q1/Q3 = -1,190/-380 mum) in patients given placebo (n = 18). The mean difference in the ThCTnS between the 100-mug sprifermin group and the placebo group was 331 mum (95% confidence interval [95% CI] 24, 685), a difference that was statistically significant (P = 0.03). The mean difference in the ThCTkS in the 100-mug sprifermin group compared with the placebo group was 237 mum (95% CI 34, 440), also a statistically significant difference (P = 0.028).
CONCLUSION: Sprifermin not only increases cartilage thickness, but also reduces cartilage loss. Subject-specific, location-independent analysis of both cartilage thinning and thickening represents a sensitive and informative approach for studying the effects of disease-modifying OA drugs.
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Epidemiological pro file of hospitalised injuries among electric bicycle riders admitted to a rural hospital in Suzhou: A cross-sectional study
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DoD PRF (Psychosocial RF)
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Police reports indicate an increasing burden of electric bike (E-bike) casualties in China; however, hospitalised injury data have not been reported. The aim of the present work was to describe hospitalised injury patterns for E-bikers involved in road crashes and explore injury risk disparities among them. For the period October 2010 to April 2011, this cross-sectional study retrospectively collected information for hospitalised E-bikers involved in road crashes from hospital records, in Suzhou China, using the International Classification of Diseases, 10th revision (ICD-10) injury diagnosis codes. Injury nature and body region were further categorised using ICD-10 codes. Multivariate logistic regression was used to assess the risk of specific injury types. We found that hospitalised E-biker injuries (n = 323) accounted for 57.2% of road traffic hospitalisations over the 6-month study period. The average age, length of stay and hospitalisation cost were 43.8 years, 10.0 days and ¥8229 (US$1286), respectively. Fractures and head injuries were common. The odds of traumatic brain injuries were significantly elevated for night-time E-bike crashes and incidents other than colliding with motor vehicles. These findings confirm E-bike injuries as an important population health problem and identify elevated injury odds in different E-biker groups. Future injury prevention initiatives should include encouraging helmet use among E-bikers. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Anaesthesiological problems in patients with rheumatoid arthritis undergoing orthopaedic surgeries
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AAHKS (8) Anesthetic Infiltration
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The article presents anaesthesiological problems in patients with rheumatoid arthritis (RA) scheduled for orthopaedic surgeries. Organ changes due to RA and related treatment were taken into account. The anaesthetic techniques used for patients with RA underwent orthopaedic procedures were presented. © Clinical Rheumatology 2008.
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The influence of age on outcome after operation for the carpal tunnel syndrome
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Decompression of the carpal tunnel is a common surgical procedure. Although the incidence of the carpal tunnel syndrome increases with age, there is no clear information available on the outcome of surgery in relation to age. We studied prospectively 87 consecutive patients who underwent decompression, using a validated self-administered questionnaire, and found that improvement in symptoms and function decreased with increasing age. This was most marked in patients over the age of sixty years
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Platelet-Rich Plasma, Bone Morphogenetic Protein, and Stem Cell Therapies
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PRP (Platelet-Rich Plasma)
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The frequency of use of "biologics," including platelet-rich plasma (PRP), bone morphogenetic protein (BMP), and stem cell therapies in the treatment of orthopaedic conditions has significantly increased over the past few decades. The use of PRP and stem cells has been proposed for a wide variety of conditions including knee and hip osteoarthritis (OA), tendon strains and tendinopathies, muscle strains, and acute and chronic soft-tissue injuries. It has also been proposed for use in the enhancement of healing during surgical treatments. BMP has seen use in promoting fracture union and spinal fusion and has been researched as an adjunct in other procedures as well. The current state of the literature in the use and support of these biologics is outlined here.
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Postoperative analgesia by intraarticular clonidine and neostigmine in patients undergoing knee arthroscopy
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AMP (Acute Meniscal Pathology)
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BACKGROUND AND OBJECTIVE: Clonidine and neostigmine have a central mechanism of analgesic action and are synergistic when given intrathecally. Both drugs also have a peripheral analgesic effect. The purpose of this study was to compare the analgesic effect of intraarticular clonidine and neostigmine, used separately and in combination, in patients undergoing knee arthroscopy.
METHODS: Eighty-four American Society of Anesthesiologists (ASA) I and II patients scheduled for meniscus repair under arthroscopy were allocated randomly in 6 groups to receive in a double-blind manner at the end of surgery 150 microg of intraarticular clonidine with subcutaneous saline, 500 microg of intraarticular neostigmine with subcutaneous saline, an intraarticular combination of 150 microg of clonidine and 500 microg of neostigmine with subcutaneous saline, 150 microg of intraarticular clonidine with 500 microg of subcutaneous neostigmine, 500 microg of intraarticular neostigmine with 150 microg of subcutaneous clonidine, or intraarticular and subcutaneous isotonic saline. Postoperative pain scores were measured on a visual analog scale (VAS) at rest and on mobilization. Paracetamol (1 g) was given as a rescue medication when pain score was greater than 40.
RESULTS: VAS scores at rest and on mobilization were lower in the first 5 groups compared with the intraarticular saline group (P <.05), but no significant difference was documented between the treated groups. The time to the first paracetamol administration was shorter in the saline group compared with the other groups, and the paracetamol demand was also higher in this group. Forty-five percent of the patients who had received clonidine had at least 1 episode of hypotension versus 4% of those who did not (P <.01). The incidence of bradycardia was 20% and 0%, respectively (P =.01). The incidence of nausea was not statistically different in patients who did and did not receive neostigmine (43% v. 36%, respectively).
CONCLUSION: Intraarticular administration of 150 microg of clonidine, 500 microg of neostigmine, or both produce postoperative analgesia, and the combination is not more effective.
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Bone graft substitutes for articular support and metaphyseal comminution: what are the options?
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DoD SSI (Surgical Site Infections)
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Subchondral and metaphyseal bone defects pose a great challenge for the Orthopaedic surgeon not only because the support for the articular surface has been lost but also because the mechanism for the nourishment of articular cartilage through the subchondral plate is distorted. A number of options are available to the surgeons, none of them perfect. Autografting has an appreciable high rate of harvest site morbidity, allograft is associated with infection transmission and host immunologic response. These realities have stimulated interest in supplying bone replacement materials (demineralised bone matrix, synthetic bone substitutes, bone morphogenic proteins). This paper presents the indications and applications of bone substitutes for metaphyseal defects and subchondral support in orthopaedic trauma.
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Balloon guided cement augmentation of lliosacral screws in the treatment of insufficiency fractures of the sacrum-description of a new method and preliminary results
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Hip Fx in the Elderly 2019
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PURPOSE OF THE STUDY Fragility fractures of the pelvic ring in the elderly population are a serious problem in orthopaedics. The treatment options range from conservative treatment to diverse operative options. We present a balloon guided new technique of implanting cement augmented screws aiming at improved implant anchorage and reduced cement leakage. MATERIAL AND METHODS We describe a newtechnique of balloon-guided cement augmented iliosacral screws. Afterthe balloon has been insufflated and contrast medium has been instillated for leakage detection, iliosacral screws can safely be placed with a relevant cement depot. RESULTS All patients (n = 8) treated in this way were allowed to weight bear on both legs and mobilisation was tolerated the next day after surgery. In the post-operative controls including X-ray and CT scan we noticed no cement leakage. Pain level as measured by the visual analog scale was significantly reduced to pre-surgery (mean 7.6 pre-operatively, mean 2.5 post-operatively). In addition pain medication could be reduced gradually soon after surgery. CONCLUSIONS The described procedure to address fragility fractures of the pelvic ring is a safe and easy to handle method. There are three advantages: First the osteoporotic S1 vertebral body can by stabilised by the amount of cement; second the cement leakage can be prevented by the balloon-compaction of the cancellous bone and the possibility to control the created cavity with contrast medium; third the bone-screw interface is much stronger compared to other procedures and is biomechanically superior against vertical shear stress. In contrast to sacroplasty, the cement application is guided by the previous use of a balloon.
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Effect of the shorter stays in emergency departments time target policy on key indicators of quality of care
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DoD SSI (Surgical Site Infections)
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Aim: To determine whether implementation of a national health target called Shorter Stays in Emergency Departments impacted on clinical markers of quality of care. Method: A retrospective pre- and post-intervention study from 2006 to 2012 examined quality of care metrics for five different indicators at different sites in relation to the implementation of the target using a general linear model for times to treatment. Explanatory variables included period (pre- or post-target), ethnicity, age, deprivation and severity of condition. Back transformed least square means were used to describe the outcomes. Results: The times to treatment for ST elevation myocardial infarction; 36.9 (28–49) vs 47.6 (36–63) minutes p=0.14, antibiotics for severe sepsis; 105.9 (73–153) vs 104.3 (70–155) minutes p=0.93, analgesia for moderate or severe pain; 48 (31–75) vs 46 (32–66) minutes p =0.77, theatre for fractured neck of femur; 35.4 (32.1–39.1) vs 32.4 (29.2–36.1) hours, and to theatre for appendicitis; 14.1 (12–17) vs 16.4 (14–20) hours were unchanged after implementation of the target. Treatment adequacy was also unchanged for these indicators. Conclusion: Introduction of the Shorter Stays in Emergency Departments target was not associated with any clinically important or statistically significant changes in the time to treatment and adequacy of care for five different clinical indicators of quality of care in Aotearoa New Zealand. For those indicators measured at one site only, it is unknown whether these results can be generalised to other sites.
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Combined orthogeriatric care in the management of hip fractures: a prospective study
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Management of Hip Fractures in the Elderly
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AIMS: To evaluate the efficacy of combined care between orthopaedic surgeons and geriatricians in the management of patients with fractured necks of femur. PATIENTS AND METHODS: A prospective study of the admissions to a district general hospital with hip fractures was carried out over a 5-year period. In the years 1992-1994, medical problems in this patient group were managed by a consultation-only service. At the end of 1994, a consultant geriatrician was appointed to manage these patients jointly with the orthopaedic surgeons, and the study was then carried through until the end of 1996. Information about the patients from admission to discharge or death was gathered prospectively using a proforma for the 3 years prior to orthogeriatric care, and the 2 years after. Main outcome measures were mortality, length of stay and discharge destination. These were compared for the two periods--pre- and post-orthogeriatric care. RESULTS: No significant differences were noted in mortality, length of stay or discharge destination. CONCLUSIONS: Combined orthogeriatric care according to our model did not have an impact on our chosen outcome measures
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Minimal-resection arthroplasty to treat meniscal tears with associated condyle lesions: finite element analysis
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AMP (Acute Meniscal Pathology)
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An early intervention prosthesis which minimizes the extent of resected healthy bone would be advantageous to patients for whom a total or unicompartmental replacement would sacrifice extensive healthy tissue. In this study the use of a device to treat osteoarthritis localized upon a single condyle of the femur with an associated irreparable meniscal tear is considered. The effects of implant alignment are considered from the standpoint of kinematics and potential for cartilage damage. The results suggest that alterations in implant position influence joint kinematics during stance. Anteroposterior (AP) adjustment of the medial prosthesis minimizes the capability of the knee to rotate internally, placing higher demands on the cruciate ligaments. AP adjustments of the lateral prosthesis induces greater posterior drawback, reducing internal-external rotation. Natural knee kinematics are best reproduced by the medial condyle rather than the lateral condyle. Stress exposure of the cartilage increased with the introduction of the femoral condyle prosthesis, which may progress eventually to osteoarthritis, although the results indicate that the medial condyle device is less likely to lead to cartilage damage than is lateral condyle replacement. This study demonstrates that a minimal-resection femoral condyle device may provide sufficient knee joint function to serve as an interim treatment prior to total or unicompartmental knee arthroplasty.
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Autoimmune aspects of cytokine and anticytokine therapies
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Cytokines and anticytokines are used increasingly in the treatment of immune, autoimmune, inflammatory, infectious, and malignant disorders. Commonly used treatments include the anti-tumor necrosis factor agents interferon (alpha), interferon (beta), interferon (gamma), and interleukin 2. Several autoimmune phenomena have been reported in patients treated with these substances. This review summarizes the published data on the autoimmune manifestations associated with cytokine and anticytokine therapies, as well as describes possible mechanisms of these phenomena. (copyright) 2003 by Excerpta Medica Inc
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