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IMPACT-Restart: the influence of COVID-19 on postoperative mortality and risk factors associated with SARS-CoV-2 infection after orthopaedic and trauma surgery

Hip Fx in the Elderly 2019

AIMS: The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period. METHODS: A multicentre retrospective study was conducted of all patients presenting to nine centres over a 50-day period during the COVID-19 pandemic (1 March 2020 to 19 April 2020) with a minimum of 50 days follow-up. Patient demographics, American Society of Anesthesiologists (ASA) grade, priority (urgent or elective), procedure type, COVID-19 status, and postoperative mortality were recorded. RESULTS: During the study period, 1,659 procedures were performed in 1,569 patients. There were 68 (4.3%) patients who were diagnosed with COVID-19. There were 85 (5.4%) deaths postoperatively. Patients who had COVID-19 had a significantly lower survival rate when compared with those without a proven SARS-CoV-2 infection (67.6% vs 95.8%, p < 0.001). When adjusting for confounding variables (older age (p < 0.001), female sex (p = 0.004), hip fracture (p = 0.003), and increasing ASA grade (p < 0.001)) a diagnosis of COVID-19 was associated with an increased mortality risk (hazard ratio 1.89, 95% confidence interval (CI) 1.14 to 3.12; p = 0.014). A total of 62 patients developed COVID-19 postoperatively, of which two were in the elective and 60 were in the urgent group. Patients aged > 77 years (odds ratio (OR) 3.16; p = 0.001), with increasing ASA grade (OR 2.74; p < 0.001), sustaining a hip (OR 4.56; p = 0.008) or periprosthetic fracture (OR 14.70; p < 0.001) were more likely to develop COVID-19 postoperatively. CONCLUSION: Perioperative COVID-19 nearly doubled the background postoperative mortality risk following surgery. Patients at risk of developing COVID-19 postoperatively (patients > 77 years, increasing morbidity, sustaining a hip or periprosthetic fracture) may benefit from perioperative shielding. Cite this article: Bone Joint J 2020;102-B(12):1774-1781.

The Modular Universal Tumour And Revision System (MUTARS(R)) in endoprosthetic revision surgery

Management of Hip Fractures in the Elderly

The aim of this study was to present the clinical and functional results of revision surgery after failed hip endoprostheses using the Modular Universal Tumour And Revision System (MUTARS(R)). Functional results of the hip endoprostheses were recorded by applying the Harris hip score. The extent of the presurgical radiological bone defect was measured according to the classification system of the German orthopaedic association (DGOOC). Indications for revision surgery on 45 patients (21 female, 24 male) were aseptic loosening (19 patients), infection (16 patients), or periprosthetic fracture (Vancouver classification B2, B3 and C, in nine patients). Revision surgery was performed after 8.6 years on average (min. 0.6; max. 14.25 years). Large defects of the proximal femur (80% medial or lateral diaphysis; 20% meta-diaphysis according to DGOOC classification) were adequately reconstructed. The average follow-up was 38.6 months. Complications occurred in eight patients: one luxation, two aseptic loosenings, and five reinfections were diagnosed. The Harris hip score (presurgical 30; postsurgical 78) showed significant improvement after revision surgery. Regarding the extent of the patients' bone defects, good functional results were achieved. The comparatively low number of luxations and loosenings is due to the high modularity of the prosthesis with arbitrary antetorsion in the hip joint. However, high reinfection rates in mega-implants still constitute a problem and should be the subject of further studies

Return to work after lower limb amputation

DoD LSA (Limb Salvage vs Amputation)

PURPOSE: To review the literature on return to work after lower limb amputation. METHOD: A comprehensive review of literature on return to work after lower limb amputation was carried out, searching MEDLINE and PubMED. RESULTS: Most authors found return-to-work rate to be about 66%. Between 22 and 67% of the subjects retained the same occupation, while the remainder had to change occupation. Post-amputation jobs were generally more complex with a requirement for a higher level of general educational development and were physically less demanding. The return to work depends on: general factors, such as age, gender and educational level; factors related to impairments and disabilities due to amputation (amputation level, multiple amputations, comorbidity, reason for amputation, persistent stump problems, the time from the injury to obtaining a permanent prosthesis, wearing comfort of the prosthesis, walking distance and restrictions in mobility); and factors related to work and policies (salary, higher job involvement, good support from the implementing body and the employer and social support network). CONCLUSIONS: Subjects have problems returning to work after lower limb amputation. Many have to change their work and/or work only part-time. Vocational rehabilitation and counselling should become a part of rehabilitation programme for all subjects who are of working age after lower limb amputation. Better cooperation between professionals, such as rehabilitation team members, implementing bodies, company doctors and the employers, is necessary.

Accelerating the aesthetic benefit of wound healing by triterpene

Reconstruction After Skin Cancer

Intention of the study (EudraCT No 2009-017418-56) is a proof of aesthetic benefit of triterpene treatment in superficial wounds. In an open, prospective, controlled, randomized, blindly evaluated multicentre phase II clinical trial a triterpene ointment (OG-S10) is compared intra individually with a state-of-the-art moist wound healing dressing (Mepilex(®)) in split thickness skin graft donor sites. The graft wound areas at the upper leg were divided into two equal halves, one proximal and one distal site. Decided by randomization the one site was treated with triterpene and the other in comparison with moist dressing. Triterpene treatment went on for 14 days as covering the wound at every change of wound dressing with the ointment (100 mg/cm(2)). The comparative treatment went on as covering the site by this dressing alone. The outcome of these different treatments was evaluated by two blindly observing distant experts on the basis of photographs of the wound healing progress. Photographs were taken day 14, 3 month and 1 year after treatment. The only criterion for evaluation of the two sites was similarity of the wound area to the surrounding skin in terms of colour and texture: which of the two sites, the proximal or the distal, was aesthetically superior in normal skin appearance after 14 days at the end of treatment, after 3 month of follow up and 1 year after treatment? The descriptive comparison is demonstrating quite a remarkable advantage of the ointment versus the moist wound dressing in promoting wound healing: even having in mind the small number of 24 patients within the protocol, the superiority of aesthetic benefit by triterpene treatment after 14 days (22 out of 24 patients), after 3 month (15 out of 19 patients) and after 1 year (8 out of 10 patients) is obvious.

Retinal nerve fiber layer assessment by scanning laser polarimetry and standardized photography

Upper Eyelid and Brow Surgery

PURPOSE: To determine whether, in a clinical setting, scanning laser polarimetry and retinal nerve fiber layer photography provide equivalent information on the retinal nerve fiber layer. METHODS: We prospectively studied 60 patients with glaucoma or ocular hypertension and 24 healthy subjects. With scanning laser polarimetry, an estimate of the cross section of the retinal nerve fiber layer was obtained. By using a photographic reference set, we quantified photographs of the retinal nerve fiber layer. Visual fields were used to relate the results of both methods to functional damage. RESULTS: The scanning laser polarimetry measurements yielded reproducible cross-section values (coefficient of variation, 6.6%). Comparison of cross-section values and photograph scores gave Pearson correlation coefficients smaller than r = .4 (P < .01), improving to a maximum of r = .53 after compensation for offset. When cross-section values were compared to the mean deviation of the visual field, the Spearman correlation coefficients varied from an r of -.34 to -.53 (P < .01). Correction for offset resulted in an r of -.54 to -.65. When photograph scores and mean deviation of the visual field were compared, the Spearman correlation coefficients varied from an r of -.65 to -.71 (P < .01). CONCLUSIONS: Because r was maximal at .53, the information on the retinal nerve fiber layer obtained with scanning laser polarimetry and photography seems not equivalent. This result could not have been because of lack of reproducibility. Although the results suggested possible offset in scanning laser polarimetry, other methodologic differences must be considered to explain the differences between the two techniques.

Low power Ga-Al-As laser treatment of painful osteoarthritis of the knee. A double-blind placebo-controlled study

OAK 3 - Non-arthroplasty tx of OAK

The aim of this double�blind study was to evaluate the effect of low power Ga�Al�As laser treatment on chronic pain related to osteoarthritis of the knee with periarticular tender points. Twenty�nine out�patients with uni� or bilateral osteoarthritis of the knee were included and randomly assigned to treatment with either laser or placebo laser. Fourteen patients received active laser treatment and all patients included completed the study. The effect variables were daily levels of pain, analgesic requirements, palpation tenderness and isokinetic quadriceps strength. Each patient participated in the study for 9 weeks and registered daily level of pain and consumption of analgesics. In weeks 4, 5 and 6 the patients received a total of nine treatments, each of 15 min and administered to periarticular tender points. The dose per treatment was 22.5 joule. No significant differences in any of the effect variables were found between the two groups before, during or after treatment. With regard to the patients' overall assessment there was a clearly demonstrable positive effect of treatment in both groups. This is likely to be due to a placebo effect.

Psychological wellbeing among carers of people with spinal cord injury: a preliminary investigation from South India

DoD PRF (Psychosocial RF)

STUDY DESIGN: A cross-sectional study that assessed people with spinal cord injury (SCI) and their carers who attended the 3-day health care program. OBJECTIVES: The study examined the nature and prevalence of the factors associated with psychological morbidity among carers of people with SCI. SETTING: A community reintegrated population of persons with SCI and their carers attended the 3-day program in the Department of Physical Medicine and Rehabilitation, Christian Medical College Hospitals, Vellore, South India. METHODS: Thirty-eight people with SCI and their carers participated in this cross-sectional study. RESULTS: Thirty (78.9%) carers of people with SCI were psychologically distressed. While carers were distressed, they were not significantly depressed. Educational level of carers and suicidal behavior of people with SCI were significantly associated with psychological distress. CONCLUSION: The findings of this study suggest that health care workers should have a high index of suspicion of psychological morbidity, in carers of people with SCI. Identification of risk factors may lead to useful target interventions.

Evolution of the vertical scar in Lejour's mastoplasty technique

Reduction Mammoplasty for Female Breast Hypertrophy

This paper presents a series of 54 consecutive cases of vertical mastoplasty carried out over the period February 1994 to April 1995. In 30 cases breast reduction was performed, in 19 pure mastopexy, and in the remaining 5, a mastopexy-breast augmentation with a silicon gel prosthesis was carried out. The parameters used for analyzing the persistence of vertical scarring were: inframammary cutaneous folds, wrinkling of the skin, and puckering at 1, 3, and 6 months during the postoperative period. An attempt has been made to establish how the vertical scar has evolved over this period. The study done by age groups as well as the study of the breast's cutaneoglandular characteristics provides data as to with which morphotype and worst results were obtained.

Acute Iatrogenic Limb Ischaemia, a Report of 2 Late Presentation Cases

DoD LSA (Limb Salvage vs Amputation)

INTRODUCTION: With increasing use of percutaneous vascular procedures, access complications that present to a vascular surgeon increase. The most limb-threatening condition is acute limb ischaemia. Acute limb ischaemia is the most common vascular surgical emergency. In spite of recent advances in vascular surgery, it continues to carry a poor prognosis, if not early diagnosed and managed. METHODS: This is a case-report of 2 patients referenced to a vascular surgery emergency department of a tertiary hospital with late acute limb ischaemia. RESULTS: Patient 1: Male, 42 years, alcoholic, autonomous, presented with pain with elbow active movements in a secondary hospital. Excluded acute orthopaedic injury, doctor recorded signs of acute limb ischaemia and referenced patient to a tertiary hospital, where vascular surgeon diagnosed an acute advanced upper limb ischaemia. Bed-side Eco-Doppler showed an echogenic linear material on a thrombosed umeral artery, surgically confirmed to be a guidewire (Fig.1. Surgical extraction of intra-umeral guidewire). Reviewing patient history, this guidewire should have been missed over 6 months, by the time the patient was hospitalized on an ICU for alcoholic coma. Patient underwent umeral, radial and ulnar thromboembolectomy and had a no-reflow status. However, poor persistent global status, with limited mobilization, pressure forces and prolonged vasotropic support, promoted progression of a cyanotic leg plaque to a necrotic evolving leg ulcer with septic response, despite persistent good perfusion of the foot (Fig.2. Necrotic evolving leg ulcer). Unfortunately, the two reported patients underwent urgent major limb amputation, patient 1 above the elbow, and patient 2 above the knee. CONCLUSION: Acute limb ischaemia continues to carry a poor limb and life prognosis if not early diagnosed. We should be alert for the increasingly prevalence of iatrogenic acute limb ischaemia, and regularly evaluate perfusion status of limbs after any percutaneous procedure.

Level of participation in physical therapy or an internet-based exercise training program: associations with outcomes for patients with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: To examine whether number of physical therapy (PT) visits or amount of use of an internet-based exercise training (IBET) program is associated with differential improvement in outcomes for participants with knee osteoarthritis (OA). METHODS: A secondary analysis was performed using data from participants in 2 arms of a randomized control trial for individuals with symptomatic knee OA: PT (N = 135) or IBET (N = 124). We examined associations of number of PT visits attended (up to 8) or number of days the IBET website was accessed during the initial 4-month study period with changes in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total, pain and function subscales, as well as a 2-min Step Test, at 4-month and 12-month follow-up. RESULTS: Participants with more PT visits experienced greater improvement in WOMAC total score (estimate per additional visit = - 1.18, CI 95% = - 1.91, 0.46, p < 0.001) and function subscore (estimate = - 0.80, CI 95% = - 1.33, - 0.28, p < 0.001) across follow-up periods. For WOMAC pain subscale, the association with number of PT visits varied significantly between 4- and 12-month follow-up, with a stronger relationship at 4-months. There was a non-significant trend for more PT visits to be associated with greater improvement in 2-min Step Test. More frequent use of the IBET website was not associated with greater improvement for any outcome, at either time point. CONCLUSION: Increased number of PT visits was associated with improved outcomes, and some of this benefit persisted 8 months after PT ended. This provides guidance for PT clinical practice and policies. TRIAL REGISTRATION: NCT02312713 , posted 9/25/2015.

Favourable mid-term results of the VerSys CT polished cemented femoral stem for total hip arthroplasty

Management of Hip Fractures in the Elderly

We evaluated the mid-term clinical and radiographical performance of a cohort of patients who underwent primary total hip replacement with a modern, forged cobalt-chrome, polished cemented femoral stem with proximal and distal centralisation. Sixty-seven patients with 73 hybrid total hip replacements were followed up clinically and radiographically for an average of 6.1 years (4-8.5). No patient was lost. No hips required revision, and all stems are radiographically well-fixed. Four hips developed localised osteolysis: one at the site of a proximal periprosthetic fracture, another at the level of a lateral femoral window of a previous core decompression, the third at the mid third of the femoral component, and the fourth on the greater trochanter, associated with accelerated polyethylene wear. This modern polished stem yielded excellent, predictable clinical and radiographic results at an intermediate follow-up

Discovery of Selenocysteine as a Potential Nanomedicine Promotes Cartilage Regeneration With Enhanced Immune Response by Text Mining and Biomedical Databases

AMP (Acute Meniscal Pathology)

BACKGROUND: Unlike bone tissue, little progress has been made regarding cartilage regeneration, and many challenges remain. Furthermore, the key roles of cartilage lesion caused by traumas, focal lesion, or articular overstress remain unclear. Traumatic injuries to the meniscus as well as its degeneration are important risk factors for long-term joint dysfunction, degenerative joint lesions, and knee osteoarthritis (OA) a chronic joint disease characterized by degeneration of articular cartilage and hyperosteogeny. Nearly 50% of the individuals with meniscus injuries develop OA over time. Due to the limited inherent self-repair capacity of cartilage lesion, the Biomaterial drug-nanomedicine is considered to be a promising alternative. Therefore, it is important to elucidate the gene potential regeneration mechanisms and discover novel precise medication, which are identified through this study to investigate their function and role in pathogenesis. METHODS: We downloaded the mRNA microarray statistics GSE117999, involving paired cartilage lesion tissue samples from 12 OA patients and 12 patients from a control group. First, we analyzed these statistics to recognize the differentially expressed genes (DEGs). We then exposed the gene ontology (GO) annotation and the Kyoto Encyclopaedia of Genes and Genomes (KEGG) pathway enrichment analyses for these DEGs. Protein-protein interaction (PPI) networks were then constructed, from which we attained eight significant genes after a functional interaction analysis. Finally, we identified a potential nanomedicine attained from this assay set, using a wide range of inhibitor information archived in the Search Tool for the Retrieval of Interacting Genes (STRING) database. RESULTS: Sixty-six DEGs were identified with our standards for meaning (adjusted P-value < 0.01 log2 - FC >=1.2). Furthermore, we identified eight hub genes and one potential nanomedicine - Selenocysteine based on these integrative data. CONCLUSION: We identified eight hub genes that could work as prospective biomarkers for the diagnostic and biomaterial drug treatment of cartilage lesion, involving the novel genes CAMP, DEFA3, TOLLIP, HLA-DQA2, SLC38A6, SLC3A1, FAM20A, and ANO8. Meanwhile, these genes were mainly associated with immune response, immune mediator induction, and cell chemotaxis. Significant support is provided for obtaining a series of novel gene targets, and we identify potential mechanisms for cartilage regeneration and final nanomedicine immunotherapy in regenerative medicine.

Post-traumatic stress disorder, social anxiety disorder, and depression in survivors of the Kosovo War: experiential avoidance as a contributor to distress and quality of life

DoD PRF (Psychosocial RF)

Few studies have been conducted on psychological disorders other than post-traumatic stress disorder (PTSD) in war survivors. The aim of this study was to examine PTSD, social anxiety disorder (SAD), and major depressive disorder (MDD) and their associations with distress and quality of life in 174 Albanian civilian survivors of the Kosovo War. This included testing of conceptual models suggesting that experiential avoidance might influence associations between anxiety and mood disorders with psychological functioning. Each of the three psychiatric disorders was associated with greater experiential avoidance and psychological distress, and lower quality of life. Being a refugee was associated with a higher likelihood of having SAD and MDD. We found evidence for experiential avoidance as a partial mediator of the respective effects of SAD and PTSD on quality of life; experiential avoidance did not mediate the effects of disorders on global distress. We also found support for a moderation model showing that only war survivors without SAD and low experiential avoidance reported elevated quality of life; people with either SAD or excessive reliance on experiential avoidance reported compromised, low quality of life. This is the third independent study, each using a different methodology, to find empirical support for this moderation model [Kashdan, T. B., & Breen, W. E. (2008). Social anxiety and positive emotions: a prospective examination of a self-regulatory model with tendencies to suppress or express emotions as a moderating variable. Behavior Therapy, 39, 1-12; Kashdan, T. B., & Steger, M. F. (2006). Expanding the topography of social anxiety: an experience sampling assessment of positive emotions and events, and emotion suppression. Psychological Science, 17, 120-128]. Overall, we provided initial evidence for the importance of addressing PTSD, SAD, MDD, and experiential avoidance in primarily civilian war survivors.

Predictive Value of Nutritional Markers for Wound Healing Complications in Bariatric Patients Undergoing Panniculectomy

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Hypoproteinemia and nutritional deficiencies are common after bariatric surgery, and although massive weight loss (MWL) patients experience increased wound complication rates, the association has not been causatively determined. OBJECTIVES: This study investigated preoperative nutritional parameters and wound complications in MWL patients (postbariatric and diet-controlled) undergoing panniculectomy at 2 academic institutions. METHODS: One hundred sixty-one consecutive patients undergoing elective panniculectomy after bariatric surgery or diet-controlled weight loss were identified. Patient demographics and nutritional indices (serum protein, albumin, and micronutrient levels) were analyzed. Complications including wound separation, infection, and operative debridements were compared. Post hoc comparisons tested for correlation between complications and nutritional markers. RESULTS: Postbariatric patients lost an average of 151 lb and presented at an average of 32 months after gastric bypass. Diet-controlled weight loss patients lost an average of 124 lb. Despite MWL, albumin levels were higher in the bariatric group (3.8 vs 3.4 g/dL, P < 0.05). Conversely, bariatric patients experienced increased wound complications (27% vs 14%; P < 0.05). Factors which were found to correlate to increased risk of wound dehiscence and infection were elevated body mass index at time of panniculectomy and amount of tissue removed. Multivariate analysis did not show serum albumin or percent weight loss to independently predict complications. CONCLUSIONS: Bariatric patients presenting for elective operations are at risk for protein and micronutrient deficiency. Despite aggressive replacement and normalization of nutritional markers, bariatric patients experience increased wound complications when compared to nonbariatric patients and traditional measures of nutritional evaluation for surgery may be insufficient in bariatric patients.

Evaluation of platelet function using PFA-100 R in patients treated with Acetylsalicylic acid and qualified for Trauma and Orthopedic surgery procedures

Hip Fx in the Elderly 2019

The phenomenon of high on-acetylsalicylic acid (ASA) treatment platelet (PLT) reactivity - HATPR - and its clinical implications have not been fully understood. Little data is available on assessing PLT activity based on the severity of intra- and postoperative bleeding in a population of orthopedic patients with normal closure time (CT) measured by a PLT function analyzer PFA-100 R, despite being given long-term ASA therapy. The aim is to assess PLT function using PFA-100 R in patients with ASA therapy and qualified for trauma and orthopedic surgery procedures. The retrospective analysis covered 384 patients whose PLT reactivity was assessed using PFA-100 R. Out of those, 198 had been taking ASA with a 75 mg dose until hospital admission. In addition, a group of 70 patients with a proximal femoral fracture surgically treated using the dynamic hip screw (DHS) was selected, in whom severity of bleeding was assessed by HIP ASA (+). The reference group comprised 52 patients (without ASA therapy) who were operated on due to the same indications. Normal CT was found in 37% of ASA-receiving patients. Patients with normal CT, despite ASA therapy, exhibited significantly more intense bleeding after DHS surgery. A similar number of patients required red blood cells (RBCs) transfusion in HIP ASA (+) and HIP ASA (-). Increased risk of complications in HIP ASA (+) group was not found. CONCLUSIONS: Normal PLT function assessed using PFA-100 R is a common phenomenon in patients with long-term ASA treatment and who are qualified for trauma and orthopedic surgery procedures. In many cases, it seems that inadequate response to ASA is only a laboratory phenomenon.

The use of dual-mobility bearings in patients at high risk of dislocation

Developmental Dysplasia of the Hip 2020 Review

AIMS: Instability continues to be a troublesome complication after total hip arthroplasty (THA). Patient-related risk factors associated with a higher dislocation risk include the preoperative diagnosis, an age of 75 years or older, high body mass index (BMI), a history of alcohol abuse, and neurodegenerative diseases. The goal of this study was to assess the dislocation rate, radiographic outcomes, and complications of patients stratified as high-risk for dislocation who received a dual mobility (DM) bearing in a primary THA at a minimum follow-up of two years. MATERIALS AND METHODS: We performed a retrospective review of a consecutive series of DM THA performed between 2010 and 2014 at our institution (Hospital for Special Surgery, New York, New York) by a single, high-volume orthopaedic surgeon employing a single prosthesis design (Anatomic Dual Mobility (ADM) Stryker, Mahwah, New Jersey). Patient medical records and radiographs were reviewed to confirm the type of implant used, to identify any preoperative risk factors for dislocation, and any complications. Radiographic analysis was performed to assess for signs of osteolysis or remodelling of the acetabulum. RESULTS: There were 151 patients who met the classification of high-risk according to the inclusion criteria and received DM THA during the study period. Mean age was 82 years old (73 to 95) and 114 patients (77.5%) were female. Mean follow-up was 3.6 years (1.9 to 6.1), with five patients lost to follow-up and one patient who died (for a reason unrelated to the index procedure). One patient (0.66%) sustained an intraprosthetic dislocation; there were no other dislocations. CONCLUSION: At mid-term follow-up, the use of a DM bearing for primary THA in patients at high risk of dislocation provided a stable reconstruction option with excellent radiographic results. Longer follow-up is needed to confirm the durability of these reconstructions.

Clinical study of a C31G containing mouthrinse: effect on salivary microorganisms

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

In vitro studies have demonstrated the antiplaque properties of C31G, a potent broad spectrum antimicrobial agent consisting of an equimolar mixture of alkyl dimethyl glycine and alkyl dimethyl amine oxide, buffered with citric acid. In this initial clinical study, C31G at concentrations of 0.05%, 0.1%, 0.2% and 0.5%. Listerine, and placebo were tested in a complete crossover design. Twelve subjects were evaluated, with a minimum of 2 days between treatments. Parameters monitored were salivary bacterial counts and saliva glycolysis. The 0.5% and 0.2% C31G mouthrinses significantly reduced total bacterial counts in saliva samples obtained up to and including three hours after rinsing, compared with counts obtained prerinsing or after placebo rinsing. Both 0.5%, and 0.2% C31G significantly inhibited glycolysis of salivary bacteria for up to 6 hours postrinsing, compared with pH values obtained prerinsing. 0.1% and 0.05% C31G exhibited little or no effect in either assay. Listerine showed a significant reduction in bacterial counts for up to 1 hour postrinsing, compared with prerinse counts, but the effect was less sustained. Listerine showed no significant inhibition of glycolysis at any time point. No tooth staining or altered taste sensation was noted with either product

Lateral Condyle Fractures in Children

Pediatric Supracondylar Humerus Fracture 2020 Review

Lateral condyle fractures are the second most common fracture sustained in the pediatric elbow. Several classification systems are used to describe these fractures. The more recently described classifications help guide management, which is based on the degree of displacement and stability of the fracture. The goal of management is to obtain reduction of the articular surface and fracture union using closed or open reduction and fixation with Kirschner wires or screws. Motion should improve after the surgery. Complications, such as osteonecrosis and nonunion, are rare, but the treating surgeon should watch for these conditions.

Dilemma of high rate of conversion from knee arthroscopy to total knee arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

We tried to reduce our rate of conversion from index knee arthroscopy to total knee arthroplasty (TKA) for degenerative pathology (primarily meniscal) in the setting of coexisting arthritis in patients 50 years or older. We hypothesized that, by using a 2-surgeon independent evaluation method, we could reduce the rate to less than 10% by 3-year follow-up. Forty-two consecutive patients were initially evaluated by the knee replacement surgeon to determine if they were TKA candidates. They were then independently evaluated by another surgeon regarding the need for TKA and the possibility of arthroscopic debridement. The data showed a tendency: The under-10% target rate was nearly reached in patients younger than 65 years (12%; 2/17) but not in patients older than 65 years (36%; 9/25). The overall rate of conversion to TKA was 26%. The 2 main groups (arthroscopy only, arthroscopy-plus-TKA) did not differ in all measured characteristics. Failure of our method to achieve better outcomes demonstrates that conventional criteria are poor in predicting which patients with meniscal pathology, which is believed to be relatively more symptomatic than coexisting arthritis, should avoid arthroscopy and go straight to TKA.

Grafts and flaps

DoD SSI (Surgical Site Infections)

'Grafts' and 'flaps' are the terms used to describe pieces of tissue that are transferred from one part of the body to another during reconstructive procedures. A graft is a piece of tissue that is detached from its site (and, most importantly, blood supply) of origin, and transferred to a different site, where it relies on the local blood supply to survive. Skin is the most commonly grafted tissue, but a graft may be of any tissue (e.g. fascia, fat, tendon, nerve, vessel, bone, composite tissue). The recipient bed must consist of healthy, well-vascularized tissue. Grafts cannot survive on poorly vascularized, densely scarred or irradiated tissue, tendon denuded of paratenon, bone denuded of periosteum, or infected tissue. The process of a graft acquiring a blood supply from its new recipient bed is termed 'take'. A flap is a piece of tissue that has an integral blood supply. Flaps can be classified according to their site, geometry, composition or blood supply. Flaps can be used to cover poor recipient beds, joint contractures, to cover open fractures or joints, and to import blood supply in infected or irradiated wounds. Flaps can also be used to reconstruct specific structures, such as the thumb (toe transfer), breast (latissimus dorsi or free abdominal flap), mandible (fibular flap) and pharynx (jejunal flap). If there are several reconstructive options, the composition of the defect morbidity of the, donor site, patient preference and the surgeon's experience should be considered when choosing which flap to use. © 2006 Elsevier Ltd. All rights reserved.

Cementless distal fixation modular stem without reconstruction of femoral calcar for unstable intertrochanteric fracture in patients aged 75 years or more

Hip Fx in the Elderly 2019

INTRODUCTION: Hemiarthroplasty (HA) using standard-length femoral stem with reconstruction of femoral calcar or using calcar replacing prosthesis for unstable intertrochanteric fractures in elderly patients is a viable option. However, both of the techniques increase the complexity of procedure, operative trauma and complication. This study evaluated the clinico-radiological results of the MP-Link cementless distal fixation modular prosthesis without reconstruction of femoral calcar for unstable intertrochanteric fracture in patients aged 75 years or more. HYPOTHESIS: Bipolar HA using the MP-Link cementless distal fixation modular prosthesis for unstable intertrochanteric fractures in patients aged 75 years or more, do not need to reconstruct the femoral calcar. MATERIALS AND METHODS: Forty-two patients (42 hips) underwent bipolar HA using the MP-Link cementless distal fixation modular prosthesis for unstable intertrochanteric fractures from January 2008 to January 2012. Five (11.9%) patients were lost to follow-up. The 37 remaining patients (37 hips) were available for evaluation. The mean age was 83.9+/-5.2 years. Their clinico-radiological data were prospectively gathered. RESULTS: All of 37 patients, 4 patients (10.8%) died within 1 year postoperatively. At the final follow-up, 31 (83.8%) out of 37 patients were regained preoperative ambulatory status; the mean Harris hip score (HHS) of the 15 patients who died during the follow-up period of 7-59 months, was 84.5+/-2.4 points; the 22 healthy patients were followed for 68.6+/-14.7 months, with mean HHS of 84.6+/-2.8 points. Radiologically, none of stems had evidence of loosening; 16 stems had subsidence of 2-3mm without clinical significance; the bone in-growth fixation was achieved in 24 patients and stable fibrous fixation in 13 patients. DISCUSSION: Bipolar HA using the MP-Link cementless distal fixation modular prosthesis for unstable intertrochanteric fractures in patients aged 75 years or more, without reconstruction of the femoral calcar, may achieve a satisfactory clinico-radiological outcome, and could regain preoperative ambulatory status in most patients (83.3%). LEVEL OF EVIDENCE: IV, Retrospective study.

Histological observations on biopsies harvested following sinus floor elevation using a bioactive glass material of narrow size range

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

We evaluated the bone augmenting capacity of bioactive glass particles, size range 300-355 microns (BG-particles), in human sinus floor elevations using histomorphometrical methods. A total of 10 patients underwent bilateral grafting, using a 1:1 mixture of autogenous bone particles (from iliac crest) and BG-particles at one side (experimental side), and bone particles only at the other side (control side, split mouth design). A total of 72 bone biopsies were taken at the time of fixture installation; that is, 3 patients at 4 months, 3 at 5 months and 3 at 6 months after grafting and 1 patient at 16 months (when she presented again). In each case 6 biopsies were taken, 3 left and 3 right. Histomorphometry showed that in grafts at control sides, trabecular bone was present after 4 months, comprising almost 41% of the tissue volume. This bone contained viable osteocytes and was of mature lamellar type and showed a mature histological appearance. Bone volume continued to increase slightly, to 42% at 5 months, 44% at 6 months and 45% at 16 months. The graft volume at experimental sides consisted at 4 months for 28% of woven and some lamellar bone, and increased to 35% at 5 months and 38% at 6 months, when mainly lamellar bone was found. At 16 months a lamellar bone volume of 45% was found. The BG-particles transformed and became excavated with time, starting at 4 months, and their centers gradually filled with bone tissue. All BG-particles had disappeared by resorption at 16 months after grafting and had been replaced by bone tissue. Parameters of bone turnover (% osteoid surface, % resorption surface, mineral apposition rate as measured by tetracycline labeling) indicated that bone remodeling was very active at both sides, during more than 6 months, despite the mature histological appearance of the bone tissue. From these histological observations, we conclude that a 1:1 mixture of autogenous bone/BG-particles seems a promising alternative to autogenous bone only, when low amounts of bone tissue are available for sinus augmentation

Lymphoedema and lipoedema of the extremities

Panniculectomy & Abdominoplasty CPG

Lymphoedema is a clinical manifestation of an impaired lymphatic drainage with accumulation of lymphatic fluid. Lipoedema is characterized by bilateral enlargement of the legs and / or arms due to abnormal deposition of fatty tissue, which accumulates fluid. Conservative treatment including compressions garments and lymphatic drainage is suitable to prevent ongoing clinical deterioration although both diseases cannot be cured. The ability to properly diagnose lymphoedema and lipoedema is crucial to prevent the significant morbidity and loss of quality of life that is associated with this condition. It is imperative that patients with lymphoedema are referred to specially trained healthcare professionals to ensure optimal treatment. Continuous therapy with strict compliance of the patients is essential, and premature interruption is the most frequent mistake. Lipoedema is a different entity but patients are still fighting for acceptance. The mutual relation of lipoedema and obesity and the poor knowledge of the underlying mechanisms limit the acceptance of lipoedema as a relevant disease. © 2008 by Verlag Hans Huber, Hogrefe AG.

Implications of bone metastases and the benefits of bone-targeted therapy

MSTS 2018 - Femur Mets and MM

Several cancers, including those originating in the breast, prostate, and lung, exhibit a propensity to metastasize to bone, resulting in debilitating skeletal complications. These sequelae, such as intractable pain, pathologic fractures, spinal compression, and hypercalcemia, greatly erode the patients' quality of life. Bisphosphonates, a class of antiresorptive drugs, are now the mainstay of the treatment of skeletal-related events in myeloma bone disease and many solid cancers with bone metastases. Current evidence indicates that newer-generation nitrogen-containing bisphosphonates, particularly zoledronic acid, are potent inhibitors of bone resorption. In addition, increased understanding of the pathogenesis of bone metastasis has resulted in the development of several bone-targeted therapies including a monoclonal antibody targeting the receptor activator of nuclear factor (NF)-kappaB ligand (RANKL). In this review, clinical evidence regarding the efficacy and safety of currently available bone-targeted therapies including bisphosphonates and anti-RANKL monoclonal antibody in the treatment of bone metastasis due to breast cancer, prostate cancer, lung cancer, and multiple myeloma bone disease will be summarized.

The development and validation of a quality of life-measurement tool for patients with meniscal pathology: the Western Ontario Meniscal Evaluation Tool (WOMET)

AMP (Acute Meniscal Pathology)

OBJECTIVE: To develop and validate a disease-specific, health-related quality of life (HRQOL) index for patients with meniscal pathology. Our hypothesis was that the Western Ontario Meniscal Evaluation Tool (WOMET) would provide adequate reliability, validity, and responsiveness in measuring HRQOL in patients with meniscal tears or who have undergone meniscal repair or resection. STUDY DESIGN: Validation of a measurement tool. SETTING: A tertiary, university-affiliated, sport medicine clinic. PARTICIPANTS: A methodological protocol based on that of Guyatt et al was used to develop the Western Ontario Meniscal Evaluation Tool (WOMET). Patients with meniscal symptomology and in whom magnetic resonance imaging had suggested meniscal pathology were selected from referrals to a sport medicine clinic. Using this cohort, the development of the WOMET proceeded through item generation, reduction, and instrument pretesting. A second cohort of postarthroscopy patients with confirmed meniscal pathology was used to assess the reliability of the WOMET and validate the instrument. RESULTS: The final instrument has 16 items representing the domains of physical symptoms (nine items), sports/recreation/work/lifestyle (four items), and emotions (three items). It demonstrated adequate content and construct validity when compared with other measures. Test-retest reliability was assessed and was found to be high, with an intraclass correlation coefficient of 0.833. The new instrument was also found to be more responsive than other knee measurement tools when assessed in the same cohort. CONCLUSIONS AND CLINICAL RELEVANCE: The WOMET is a disease-specific tool designed to evaluate HRQOL in patients with meniscal pathology. It is therefore put forth as a validated measurement tool to be used in clinical trials evaluating treatments for meniscal pathology. It could also be used as a prospective outcome measure in research or in clinical practice.

Conservative management of symptomatic knee osteoarthritis: A flawed strategy?

AAHKS (4) Acetaminophen

Conservative management of medial compartment knee osteoarthritis (OA) is a misleading term used to describe the application of medical, orthotic, and/or rehabilitative therapies exclusive of surgical interventions. The implication of this nomenclature is that these therapies offer satisfactory symptom relief, alter disease progression, and have limited side effects. Unfortunately, conservative therapeutic options possesses few, if any, characteristics of an ideal treatment, namely one that significantly alleviates pain, improves knee function, and reduces medial compartmental loading without adverse side effects. As uncompensated mechanical loading is a primary culprit in the development and progression of knee OA, we propose that the therapeutic perspective of conservative treatment should shift from pharmacological treatments, which have no influence on joint loading, minimal potential to alter joint function, substantial associated risks, and significant financial costs, towards minimally invasive load absorbing therapeutic interventions. A safe and effective minimally invasive medical device specifically engineered for symptomatic relief of medial knee OA by limiting joint contact forces has the potential to reduce the clinical and economic knee OA burden. This review characterizes the current standard of care recommendations for conservative management of medial compartment knee OA with respect to treatment efficacy, risk profile, and economic burden. © D.C. Crawford et al.

The Role of Bariatric Surgery in the Obese Total Joint Arthroplasty Patient

OAK 3 - Non-arthroplasty tx of OAK

Although bariatric surgery is a proven means of weight loss and treatment of obesity-related comorbidities in morbidly obese patients, it is not yet clear how it affects outcomes after total joint arthroplasty in this high-risk patient population. This article explores the effects of obesity and bariatric surgery on osteoarthritis and total joint arthroplasty, and also discusses the financial and ethical implications of use of bariatric surgery for risk reduction before total joint arthroplasty.

Denosumab: RANKL inhibition in the management of bone loss

MSTS 2018 - Femur Mets and MM

Receptor activator of nuclear factor-kB (RANK), its ligand (RANKL) and its decoy receptor osteoprotegerin (OPG) together play a key role in osteoclastogenesis. Alterations in the RANKL/ OPG ratio are central in the pathogenesis of bone loss, from osteoporosis in all its forms to malignancy-induced bone loss. This fact has led to the search for drugs capable of targeted RANKL inhibition in the management of skeletal disorders associated with bone loss. Promising preclinical data using OPG have paved the way for the development of the new agent denosumab, a high-affinity, high-specificity, fully human monoclonal antibody to RANKL, shown to be able to induce a dose-dependent, rapid, profound and sustained inhibition of bone resorption lasting for months after a single subcutaneous injection in healthy postmenopausal women, men and patients with multiple myeloma or metastatic breast cancer. Data from a phase II study in postmenopausal women with low bone mineral density (BMD) demonstrate that the sustained inhibition of bone resorption induced by three or six monthly subcutaneously administered denosumab was associated with significant increases in BMD for up to two years of treatment. Antifracture efficacy and long-term skeletal and extraskeletal safety of denosumab are being addressed in ongoing phase III trials. The potential of denosumab to prevent bone loss has also been demonstrated in malignancy-induced bone loss. Ongoing studies in rheumatoid arthritis are also promising.

Childhood and adolescent sports-related overuse injuries

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

Youth sports participation carries an inherent risk of injury, including overuse injuries. Little leaguer's shoulder, a stress fracture of the proximal humerus that presents as lateral shoulder pain, usually is self-limited. Little leaguer's elbow is a medial stress injury; treatment consists of complete rest from throwing for four to six weeks followed by rehabilitation and a gradual throwing program. Spondylolysis is a stress fracture of the pars interarticularis. Diagnostic modalities include plain film radiography, bone scan, computed tomography, single photon emission computed tomography, and magnetic resonance imaging. Treatment usually is conservative. Spondylolisthesis is the forward or anterior displacement of one vertebral body over another and may be related to a history of spondylolysis. Diagnosis is made with plain film radiography and graded according to the amount of displacement. Osgood-Schlatter disease presents as anterior knee pain localized to the tibial tubercle. Diagnosis is made clinically, and most patients respond to conservative measures. Calcaneal apophysitis (or Sever's disease) is a common cause of heel pain in young athletes, presenting as pain in the posterior aspect of the calcaneus. Copyright (copyright) 2006 American Academy of Family Physicians

Increased serum erythropoietin concentration after allogeneic compared with autologous blood transfusion

Management of Hip Fractures in the Elderly

Serum erythropoietin (sEPO) level is known to increase as hemoglobin (Hb) concentration decreases during and after preoperative autologous blood donation (PAD). The endogenous erythropoietin (EPO) production after allogeneic blood transfusion has not to our knowledge, been studied. The aim of the present study was to determine whether there is, after surgery, any change in sEPO concentration after allogeneic blood transfusion, and whether there is any difference in EPO response after autologous or allogeneic blood transfusion. Thirty-one patients approaching total hip-joint replacement surgery, were randomized to receive either allogeneic red blood cells (n = 15) or predeposited autologous whole blood transfusion (n = 16). The relationship between Hb, sEPO, and reticulocytes in the recipients were repeatedly analyzed before, during and after surgery. The Hb followed an expected pattern, with a decreased concentration after PAD in the autologous group, then in both groups after surgery. The sEPO concentration was significantly higher in the allogeneic than in the autologous group on day one and day 4-5 postoperatively. The reticulocyte level, on the contrary, was higher in the autologous patients before, one hour after, and one day after surgery. The study showed a greater increase in sEPO concentration after allogeneic blood transfusion than after autologous blood transfusion. There may be an inverse relationship between sEPO and the reticulocyte level

A novel approach to thoracic wall reconstruction based on a muscle perforator

Acellular Dermal Matrix

When reconstructing the thoracic wall, non-adaptation of the suture line is a critical concern, especially when artificial implants are used. Therefore, a reliable and safe flap is required. Based on an anatomical study of cadavers, we decided to dissect the pectoralis major musculo-cutaneous flap into two parts, on the surface and beneath the muscle fascia, while preserving the muscle perforators. We designated the skin portion as the V-Y advancement flap or rotation V-Y advancement flap and the muscle flap as the transposition flap. Both flaps had different suture lines. We applied this method to two patients requiring reconstruction of anterior thoracic defects with artificial implants. One patient did not have adverse effects, and the flaps took well. The shape of the breast did not change significantly. However, the other patient was a heavy smoker. Although the V-Y advancement flap took well, the cutaneous triangular tip made at the time of tumour resection became necrotic. However, the underlying pectoralis major muscles successfully covered the implants and did not show any signs of infection. In conclusion, reconstruction of the anterior thoracic wall to change the suture line with a V-Y advancement flap, based on the muscle perforator and pectoralis major muscle flap, is a useful and reliable method, especially when an artificial implant is used.

Revision cartilage cell transplantation for failed autologous chondrocyte transplantation in chronic osteochondral defects of the knee

Diagnosis and Treatment of Osteochondritis Dissecans AUC

The management of failed autologous chondrocyte implantation (ACI) and matrix-assisted autologous chondrocyte implantation (MACI) for the treatment of symptomatic osteochondral defects in the knee represents a major challenge. Patients are young, active and usually unsuitable for prosthetic replacement. This study reports the results in patients who underwent revision cartilage transplantation of their original ACI/MACI graft for clinical or graft-related failure. We assessed 22 patients (12 men and 10 women) with a mean age of 37.4 years (18 to 48) at a mean of 5.4 years (1.3 to 10.9). The mean period between primary and revision grafting was 46.1 months (7 to 89). The mean defect size was 446.6 mm(2) (150 to 875) and they were located on 11 medial and two lateral femoral condyles, eight patellae and one trochlea. The mean modified Cincinnati knee score improved from 40.5 (16 to 77) pre-operatively to 64.9 (8 to 94) at their most recent review (p < 0.001). The visual analogue pain score improved from 6.1 (3 to 9) to 4.7 (0 to 10) (p = 0.042). A total of 14 patients (63%) reported an 'excellent' (n = 6) or 'good' (n = 8) clinical outcome, 5 'fair' and one 'poor' outcome. Two patients underwent patellofemoral joint replacement. This study demonstrates that revision cartilage transplantation after primary ACI and MACI can yield acceptable functional results and continue to preserve the joint

Trochanteric bone grafts in foot and ankle surgery

Management of Hip Fractures in the Elderly

Eighty-five patients who underwent trochanteric bone graft harvest in association with foot and ankle surgery were studied retrospectively by patient questionnaire. The average follow-up was 49 months (range, 14-101 months). Ninety-five percent of the patients expressed satisfaction with the procedure, in that they would choose to accept the trochanteric bone graft again if required to make the choice. However, 31% of the patients acknowledged some degree of hip discomfort and 4% reported some daily pain. Nineteen of 85 patients (22%) were treated for trochanteric pain. Most patients responded to strengthening/stretching and heat/ice. Four patients (5%) had failed or delayed union of the arthrodesis in which trochanteric bone graft was utilized. The greater trochanter may be considered as an alternative for major bone graft when the iliac bone is not available and when weightbearing is restricted for at least 6 weeks after surgery. As with the use of iliac bone graft, patients should be alerted to the possibility of postoperative discomfort. Surgical details should be followed to minimize the risk of peritrochanteric fracture

Osteoporosis: A neglected but treatable disease

Management of Hip Fractures in the Elderly

Osteoporosis is a disease that is commonly seen in residents of long-term care facilities. The personal and economic consequences associated with osteoporosis are similar to common conditions such as COPD, stroke, or MI, yet osteoporosis awareness in all age groups remains low. Spine and hip fractures are associated with an increased morbidity and mortality, and nursing home residents who sustain a fracture are far more likely to be hospitalized in the next year compared to patients who have not had fractures. Both the United States Preventive Services Task Force and the National Osteoporosis Foundation recommend bone mineral density testing for all women over age 65. All nursing home residents should be considered for nonpharmacologic therapies such as calcium, Vitamin D, and conditioning exercises. Those patients found to have osteoporosis by bone mineral testing or because of a history of a low-trauma fracture should also receive pharmacologic therapy

Treatment of Popliteal (Baker) Cysts With Ultrasound-Guided Aspiration, Fenestration, and Injection: Long-term Follow-up

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: The purpose of this study was to determine the efficacy of ultrasound-guided aspiration, fenestration, and injection as a treatment in patients with symptomatic popliteal cysts. HYPOTHESIS: Ultrasound-guided aspiration, fenestration, and injection (UGAFI) is an effective and safe treatment option for symptomatic popliteal cysts. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: Patients who received a UGAFI of popliteal cysts from 2008 to 2011 were identified. Preaspiration (PA) and follow-up Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, cyst recurrence, complications, cyst complexity, and size were obtained and compared for statistical significance. UGAFI involved aspiration of fluid through a spinal needle, fenestration of the cyst walls and septations, and injection of 1 mL (40 mg) triamcinolone (Kenalog) and 2 mL 0.5% bupivacaine (Sensorcaine) into the decompressed remnant. RESULTS: The mean PA WOMAC score (48.55) improved significantly at final follow-up (FFU) to 17.15 (P < 0.0001) for 47 patients. Within the WOMAC subcategories, there was also a significant difference in pain (PA, 10.68; FFU, 3.94; P < 0.0001), stiffness (PA, 4.51; FFU, 1.77; P < 0.0001), and physical function (PA, 31.34; FFU, 12.17; P < 0.0001). There were 6 reaspirations for recurrence (12.7%), and 1 patient underwent unicompartmental knee arthroplasty. There were no infections or other complications. CONCLUSION: Significant clinical improvement in patients with symptomatic popliteal cysts can be achieved via UGAFI as the sole treatment. CLINICAL RELEVANCE: UGAFI is a safe and effective option as the sole treatment modality for symptomatic popliteal cysts.

Role of bone-anabolic agents in the treatment of breast cancer bone metastases

MSTS 2018 - Femur Mets and MM

Skeletal metastases are an incurable complication afflicting the majority of patients who die from advanced breast cancer. They are most often osteolytic, characterized by net bone destruction and suppressed new bone formation. Life expectancy from first diagnosis of breast cancer bone metastases is several years, during which time skeletal-related events - including pain, fracture, hypercalcemia, and spinal cord compression - significantly degrade quality of life. The bone marrow niche can also confer hormonal and chemo-resistance. Most treatments for skeletal metastases target bone-destroying osteoclasts and are palliative. Recent results from the Breast cancer trials of Oral Everolimus-2 trial suggest that agents such as the mammalian target of rapamycin inhibitor everolimus may have efficacy against breast cancer bone metastases in part via stimulating osteoblasts as well as by inhibiting tumor growth. Selective estrogen receptor modulators similarly inhibit growth of estrogen receptor-positive breast cancers while having positive effects on the skeleton. This review discusses the future role of bone-anabolic agents for the specific treatment of osteolytic breast cancer metastases. Agents with both anti-tumor and bone-anabolic actions have been tested in the setting of multiple myeloma, a hematological malignancy that causes severe osteolytic bone loss and suppression of osteoblastic new bone formation. Stimulation of osteoblast activity inhibits multiple myeloma growth - a strategy that might decrease breast cancer burden in osteolytic bone metastases. Proteasome inhibitors (bortezomib and carfilzomib) inhibit the growth of myeloma directly and are anabolic for bone. Drugs with limited anti-tumor activity but which are anabolic for bone include intermittent parathyroid hormone and antibodies that neutralize the WNT inhibitors DKK1 and sclerostin, as well as the activin A blocker sotatercept and the osteoporosis drug strontium ranelate. Transforming growth factor-beta inhibitors have little tumor antiproliferative activity but block breast cancer production of osteolytic factors and are also anabolic for bone. Some of these treatments are already in clinical trials. This review provides an overview of agents with bone-anabolic properties, which may have utility in the treatment of breast cancer metastatic to the skeleton.

Angiogenesis and nerve growth factor at the osteochondral junction in rheumatoid arthritis and osteoarthritis

Surgical Management of Osteoarthritis of the Knee CPG

Objectives. The osteochondral junction can be a source of pain in both RA and OA. Growth of blood vessels and nerves from the subchondral bone into articular cartilage may mediate the association between joint pathology and symptoms. We have investigated associations between angiogenesis, inflammation and neurovascular growth factor expression at the osteochondral junction in human arthritis. Methods. Osteochondral junctions from medial tibial plateaux of patients undergoing arthroplasty for RA (n = 10) or OA (n = 11), or from non-arthritic post-mortem controls (n = 11) were characterized by immunohistochemistry for CD34 and smooth muscle alpha-actin (blood vessels), CD68 (macrophages), CD3 (lymphocytes), proliferating cell nuclear antigen, vascular endothelial, platelet-derived and nerve growth factor (NGF). Results. Osteochondral angiogenesis was demonstrated as increased endothelial cell proliferation and vascular density in non-calcified articular cartilage, both in RA and OA. Osteochondral angiogenesis was associated with subchondral bone marrow replacement by fibrovascular tissue expressing VEGF, and with increased NGF expression within vascular channels. RA was characterized by greater lymphocyte infiltration and PDGF expression than OA, whereas chondrocyte expression of VEGF was a particular feature of OA. NGF was observed in vascular channels that contained calcitonin gene-related peptide-immunoreactive sensory nerve fibres. Conclusions. Osteochondral angiogenesis in RA and OA is associated with growth factor expression by cells within subchondral spaces, vascular channels and by chondrocytes. NGF expression and sensory nerve growth may link osteochondral angiogenesis to pain in arthritis

An observational audit of pain scores post-orthopaedic surgery at a level two state hospital in Cape town

Surgical Management of Osteoarthritis of the Knee CPG

Objectives: The aim was to determine whether postoperative pain is satisfactorily controlled in patients undergoing orthopaedic surgery at a level two state hospital in Cape Town. Design: Two observational audits were performed 12 months apart as part of a full audit cycle. Setting and subjects: In view of perceived poor postoperative pain control, an audit was performed of acute postoperative pain scores, anaesthesia techniques, and patient satisfaction with pain control. Orthopaedic patients undergoing surgical procedures at a level two state hospital in Cape Town were enrolled in the two audits. Patient groups included both patients admitted to the hospital and day-cases. Outcome measures: Patients admitted to hospital following major surgery, rated their perceived pain over 48 hours, using a visual analogue scale (VAS). Day-case patients scored their pain in hospital, and were then contacted telephonically after 24 hours, and if required, after 48 hours. A VAS score (greater-than or equal to) 4 was regarded as unacceptable. The interventions employed after the first audit were: pain rounds, staff education and training, increased postoperative epidural time, patient-controlled analgesia pumps and indwelling femoral catheters following total knee replacement. Results: Data were analysed from 71 patients in each audit. Mean VAS scores were unacceptable 12 and 24 hours after major surgery (range 4 - 5.1 in audit 1). Following the introduction of the aforementioned interventions, the mean pain scores were < 4 at every time point measurement, and significantly lower than in audit 1 at most assessment times (p < 0.05). Patient satisfaction with pain control improved from 32.4% in audit 1 to 54.9% in audit 2. Conclusion: Acute postoperative pain is an important clinical problem in orthopaedic surgery. Following the demonstration of unacceptable postoperative pain scores in the first audit, specific interventions were shown to significantly improve pain control in the follow-up audit. (copyright)

A specific protocol of autologous bone marrow concentrate and platelet products versus exercise therapy for symptomatic knee osteoarthritis: a randomized controlled trial with 2 year follow-up

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Cell-based therapies have shown promise for the treatment of knee osteoarthritis (OA). The current study compared exercise therapy to autologous bone marrow concentrate (BMC) and platelet products for knee OA treatment. METHODS: Patients with symptomatic knee OA (N = 48) were randomized into either an exercise therapy control group or treatment group with injection of autologous BMC and platelet products. Patients in the control group could crossover to BMC treatment after 3 months. Clinical outcomes were documented at baseline and at 6-weeks, 3, 6, 12 and 24 months, including the Knee Society Score (KSS), Pain Visual Analogue Scale, Short Form-12 Scales (SF-12), and Lower Extremity Activity Scale (LEAS). RESULTS: All patients in the exercise group crossed over to receive BMC treatment after 3 months (N = 22 crossover). At 3 months, KSS-knee, SF-12 Physical, and LEAS improved significantly in the crossover group compared to exercise, similar to significant improvements on KSS-knee and LEAS for the treatment group (N = 26) compared to exercise group at 3 months. After BMC treatment, patients' clinical outcome scores (except SF-12 Mental Health), were significantly improved through the 2-year follow-up compared to baseline. No serious adverse events were reported. CONCLUSION: The use of image-guided percutaneous BMC with platelet products yielded better results than exercise therapy as an effective alternative therapy for patients with symptomatic moderate to moderate-severe osteoarthritis of the knee. Trial registration NCT02034032. https://clinicaltrials.gov/ct2/show/NCT02034032 . Registered 13 January 2014.

Allograft compared with autograft infection rates in primary anterior cruciate ligament reconstruction

Anterior Cruciate Ligament Injuries CPG

BACKGROUND: Injuries to the anterior cruciate ligament are the most common surgically treated knee ligament injury. There is no consensus regarding the optimal graft choice between allograft and autograft tissue. Postoperative septic arthritis is an uncommon complication after anterior cruciate ligament reconstruction. The purpose of this study was to compare infection rates between procedures with use of allograft and autograft tissue in primary anterior cruciate ligament reconstruction. METHODS: A combined prospective and retrospective multicenter cohort study was performed over a three-year period. Graft selection was determined by the individual surgeon. Inclusion and exclusion criteria were equivalent for the two groups (allograft and autograft tissue). Data collected included demographic characteristics, clinical information, and graft details. Patients were followed for a minimum of 5.5 months postoperatively. Our primary outcome was intra-articular infection following anterior cruciate ligament reconstruction. RESULTS: Of the 1298 patients who had anterior cruciate ligament reconstruction during the study period, 861 met the criteria for inclusion and formed the final study group. Two hundred and twenty-one patients (25.6%) received an autograft, and 640 (74.3%) received an allograft. There were no cases of septic arthritis in either group. The 95% confidence interval was 0% to 0.57% for the allograft group and 0% to 1.66% for the autograft group. The rate of superficial infections in the entire study group was 2.32%. We did not identify a significant difference in the rate of superficial infections between autograft and allograft reconstruction in our study group. CONCLUSIONS: While the theoretical risk of disease transmission inherent with allograft tissue cannot be eliminated, we found no increased clinical risk of infection with the use of allograft tissue compared with autologous tissue for primary anterior cruciate ligament reconstruction

Snowboarder's wrist: its severity compared with Alpine skiing

Distal Radius Fractures

BACKGROUND: Although the upper extremity, especially the wrist, has been reported to be the most commonly injured site in snowboarding, the severity of these injuries is still unknown. The purpose of this study is to compare the severity of wrist injuries in snowboarding with those in alpine skiing for insight into the treatment of snowboarder's wrist. MATERIALS AND METHODS: The cases of 11,598 patients injured while snowboarding and skiing who presented to the Zao clinic during the past 7 seasons were reviewed and compared. Demographics were studied, focusing on fractures around the wrist joint. Roentgenographically precise assessment of the distal radial fracture was performed according to AO classification. RESULTS: Snowboarders were more likely to injure the wrist than were skiers (18.7% vs. 2.5%, p<0.01). In these wrist injuries, distal radial fractures occurred at a rate of 0.28 per 1000 snowboarders and 0.008 per 1000 skiers. Comminuted and articular fractures classified as AO type A3, B and C, which required surgical treatment, were 49.4% of distal radial fractures in snowboarders and 23.8% in skiers. CONCLUSION: Wrist injury sustained while snowboarding is characterized as a severe and complex injury. Thus, we call attention to its severity in the treatment of snowboarder's wrist.

Management of unstable pertrochanteric fractures with proximal femoral locking compression plates and affect of neck-shaft angle on functional outcomes

Hip Fx in the Elderly 2019

BACKGROUND: Management of unstable pertrochanteric fractures remains a challenge with various implant choices. Intramedullary devices are usually preferred for the management of the unstable fractures. When nailing is unsuitable for the configuration of the fracture extra medullary procedures are preferred. PFLCP is a contact limited implant that allows multiple angularly stable fixations with preserving more bone stock after implantation as an extramedullary implant. There are only a few reports in the literature about the osteosynthesis of unstable trochanteric fractures with proximal femoral locking compression plates and their results are conflicting. In the present study we aimed to evaluate the functional and radiological outcomes of proksimal femoral locking compression plates in open reduction and internal fixation of AO/OTA 31A2-2 and 3 fractures. METHODS: Patients older than 18 years of age with a minimum follow-up time of 1 year matching the inclusion criteria retrospectively evaluated. Patients' demographics, Singh index, intra and post-operative data, mobilization and union time gathered from the patients' files. Baumgaertner modified criteria of fracture reduction was used to assess the post-operative reduction quality. Early and last follow-up radiographs were used to evaluate malunion and change in neck- shaft angle. Final clinical outcome was assessed using the Harris Hip scoring system. RESULTS: 18 male and 13 female patients with the mean age of 74 (46-88) met the inclusion criteria. Reduction quality according to Baumgaertner modified criteria was good in 25 patients and acceptable in 6. Mean union time was 21.53 +/- 4.18 weeks. There was neither non-union nor malunion. The mean neck-shaft angle change was -3.1degree +/- 2.16degree. The mean HHS was 77.90 +/- 4.84 and there was no significance in HHS according to reduction quality and change in neck-shaft angle (p = 0.385, p = 0.0059). HHS was negatively correlated with age, mobilization time and, longer union time (p < 0.05). There was no correlation between Singh index and reduction quality (p = 0.865). Singh index was only correlated with the patient's age (p = 0.000, rho = -0.595). There were 2 infections and, 2 backing of the proximal screws. CONCLUSION: Even though PFLCP is not the first choice in management of unstable pertrochanteric fractures, it must be kept in mind as an alternative to the other conventional plates and intramedullary implants with the properties of an increased stability by multiaxial screw locking and the results are satisfactory when appropriate settlement achieved.

Experimental and computational simulation of total hip arthroplasty dislocation

Management of Hip Fractures in the Elderly

Other than fatal pulmonary embolism and deep infection, dislocation following total hip replacement remains probably the most vexing complication to patient and surgeon. Subluxation and dislocation are complex, poorly understood phenomena. Many important questions in this area unfortunately do not lend themselves well to clinical or registry study. Appropriate realistic laboratory models have been lacking. This article synthesizes new work undertaken independently by two groups of biomechanical investigators using very different, but complimentary, methodologies to study the mechanisms of dislocation, and especially the influence of specific design and surgical variables

Laser Treatment on Acupuncture Points Improves Pain and Wrist Functionality in Patients Undergoing Rehabilitation Therapy after Wrist Bone Fracture. A Randomized, Controlled, Blinded Study

Distal Radius Fractures

The objective of this study was to determine whether application of laser beam on acupuncture points has a positive effect on the rehabilitation of patients with a diagnosis of distal radius fracture (1.5 inches proximal to distal articular surface of the radius) when applied with active conventional physical therapy exercises. Patients with a distal radius fracture treated with closed reduction, percutaneous pinning, and a short cast for six weeks was included and were assigned to one of two study groups. The control group was given simulated laser acupuncture with the laser off, while the experimental group received laser beam on acupuncture points. A low power infrared 980 nm, 50 mW laser (Diller & Diller Laser Performance) electric energy, was used; each acupuncture point was irradiated for 30 seconds at 8,000 Hz at each therapy session. In both groups, treatment was applied to the following points: Ipsilateral- Yanggu (S15), Yangchi (SJ4), Waiguan (SJ15), Yangxi (LI5), Daling (PC7); Bilateral- Hegu (L14); Contralateral- Shenmail (VL62), Kulun (V60), Taixi (KID3). All of the patients underwent a total of 10 sessions, at a frequency of three times per week. They were evaluated using the VAS, the Patient-Rated Wrist Evaluation (PRWE), and wrist mobility ranges at the beginning of treatment, at the end of the fifth session, at the 10th session, and a week after the 10th session. The patients treated with laser beam exposure on acupuncture points showed 44% reduction in pain and 33% of improvement in the functional status of the wrist compared with the control group. Application of laser beam on acupuncture points combined with active rehabilitation exercises show benefits in the rehabilitation of patients with a distal radius fracture managed with percutaneous pinning and a short cast.

Early neuromuscular electrical stimulation to optimize quadriceps muscle function following total knee arthroplasty: A case report

Surgical Management of Osteoarthritis of the Knee CPG

Fisheye STUDY DESIGN: Case report. Fisheye BACKGROUND: Following total knee arthroplasty (TKA), restoration of normal quadriceps muscle function is rare. One month after surgery, quadriceps torque (force) is only 40% of preoperative values and quadriceps activation is only 82% of preoperative levels, despite initiating postoperative rehabilitation the day after surgery. Early application of neuromuscular electrical stimulation (NMES) offers a possible approach to minimize loss of quadriceps torque more effectively than traditional rehabilitation exercises alone. Fisheye CASE

Location-specific hip joint space width for progression of hip osteoarthritis - Data from the Osteoarthritis Initiative

OAK 3 - Non-arthroplasty tx of OAK

Objective: To establish the performance of a location-specific computer-assisted quantitative measure of hip joint space width (JSW), by measuring responsiveness in those with hip osteoarthritis (OA) and pain and those without. Secondary purposes included investigating the most responsive location and comparison to minimum joint space width (mJSW). Methods: Design: nested case-control.Data: from the Osteoarthritis Initiative (OAI), a longitudinal cohort study of knee OA. All participants had standardized standing anterior-posterior (AP) pelvis radiographs at baseline and 48 months.Case definition (1): subjects with a total hip replacement (THR) after the 48 month visit (. n=27) were selected and matched (1:1) on sex and age to subjects without a THR.Case definition (2): subjects with a THR at any point after baseline (. n=79) were selected and the contralateral (CL) hip was designated the case hip, and subjects were matched (1:1) as above.Pain: the CL hip group were examined for the presence/absence of pain.Measurements of superior hip JSW were made at three fixed locations relative to a landmark-based line, facilitated by software.The standardized response mean (SRM) was used to examine sensitivity to change from baseline to 48 months. Paired t-tests were used to compare cases and controls. Results: Significant differences were observed between cases and controls and those with and without pain. The location-specific measure outperformed mJSW in all analyses, with SRM ranging from 0.53 (contralateral hip) to 1.06 (THR hip). The superior-medial location was most responsive. Conclusion: A new computer-assisted location-specific measure of hip JSW may provide a superior method to mJSW for radiographic OA progression. The superior-medial location was the most responsive.

Salvage Options in the Cerebral Palsy Hip: A Systematic Review

PJI DX Updated Search

Background: No preferred procedure exists for the chronically painful, unreconstructable subluxated or dislocated hip in cerebral palsy. The purpose of this study was to compare pain relief and complication rates of salvage procedures in cerebral palsy for ambulatory and nonambulatory populations. Methods: We searched Medline, Embase, and Cochrane databases using the search terms "cerebral palsy" and "hip dislocation." Inclusion and exclusion criteria were established to maintain data quality for analysis. A systematic review yielded 28 studies. Relevant information for postoperative pain and complications were extracted from each study and described. Our initial search identified 721 articles. Two hundred twenty duplications were excluded. Five hundred one were screened by title and abstract. One hundred articles underwent further full text and reference evaluation, yielding 25 studies. An additional 3 studies were then identified from the list of 25, yielding a total of 28 studies, which met our inclusion criteria. Results: Among nonambulators, femoral head resection (FHR), valgus osteotomy (VO), and total hip arthroplasty (THA) were found to relieve pain better than arthrodesis [odds ratio (OR) 7.3, 95% confidence interval (CI), 2.2-24.8; OR 5.9, 95% CI, 1.6-22.8; OR 11.7, 95% CI, 1.1-297.5, respectively]. Arthrodesis had a significantly higher complication rate than FHR, VO, THA, and shoulder prosthetic interposition. No significant differences in complication rate were found between FHR and VO. Pain relief rates among nonambulators for FHR, VO, THA, shoulder prosthetic interposition, and arthrodesis were 90.4%, 88.4%, 93.8%, 90.9%, and 56.3%, respectively. Complication rates among nonambulators were 24.0%, 33.3%, 35.3%, 28.6%, and 106.3%, respectively. Comparison of pain relief and complication rates among ambulatory cerebral palsy patients in all procedures except THA was not possible because the populations could not be separated from nonambulators in numbers sufficient to perform statistical analysis. Data were available for 32 confirmed cases of THA in ambulators and was associated with a 93.3% pain relief rate and a 38.2% complication rate. Conclusions: Among nonambulators, the available literature suggests that FHR, VO, and THA may be superior at relieving pain than arthrodesis. FHR had the lowest absolute percentage of complications; however, no significant differences in complication rate or pain relief were found in nonambulators undergoing FHR or VO. Most of the complications for VO were implant related, and potentially amenable to hardware removal versus complications in FHR, which were related to the procedure itself such as proximal migration and heterotopic bone formation. THA in nonambulators was associated with complications such as dislocation and revision. Arthrodesis in nonambulators was associated with >100% complication rate and inferior pain relief compared with other procedures. Ambulatory patients had excellent pain relief with THA; however, the complication rate is higher than can be expected with non-neurological populations. Insufficient data exist to support use of other salvage procedures in ambulators. These conclusions should be interpreted with caution as all studies involved level IV evidence. Level of Evidence: IV (systematic review of level IV studies)

The impact of bisphosphonate therapy on survival of lung cancer patients with bone metastasis

MSTS 2018 - Femur Mets and MM

Introduction: Bone metastases occur in 20% to 40% of patients with lung cancer. Recent studies (most in vitro) demonstrate an anti-proliferative effect of third-generation biphosphonates (BPs) on lung tumours which may, indirectly, have an impact on the survival. Objectives: This was a study of the effects of treatment with BPs on the course and survival of lung cancer patients with bone metastases. Patients and methods: For the study 108 male patients with lung cancer (stage IV) were recruited consecutively. Of these, 55/108 patients with positive bone scan experienced bone pain and received Nitrogen BPs (NBPs), specifically zoledronic acid (ZOL), 4 mg i.v. every 21 days (Group A). The other 53 patients received no NBPs, of which 30/53 had a positive bone scan (Group B) and 23/53 a negative bone scan (Group C). All patients were treated with combination chemotherapy consisting of Docitaxel 100 mg/m2 and Carboplatin AUC = 6. Results: Group A had a statistically significant longer mean survival and time to progression than Groups B and C (p<0.001). A statistically significant positive correlation was found between the number of cycles of therapy with NBPs and total patient survival (p<0.01, Pearson Correlation) and time to progression (p<0.01). Regarding the pain effect in relation to baseline, no significant difference was observed between the two groups of patients (with and without NBPs) with positive bone scan (p>0.05). Conclusion: The addition of NBPs to the treatment regime appears to increase overall survival in lung cancer patients with bone metastases. Further studies are needed to support the potential usefulness of NBPs as an independent therapeutic agent against lung cancer.

Femorotibial offset. A morphologic feature of the natural and arthritic knee

Surgical Management of Osteoarthritis of the Knee CPG

Eccentric wear identified in retrieval studies of failed total knee arthroplasties may reflect unrecognized intrinsic morphologic characteristics of the knee. This study identifies a previously unreported morphologic offset between the center of the tibia and femur using computed tomography scans in 38 preoperative arthritic knees and 38 controls. There is a statistically significant offset between femur and tibia centers in patients and control subjects. There is no significant difference between patients and control subjects in either AP or mediolateral translation of centers. The clinical relevance of this observation is that it may prompt strategies to address morphologic offset, thereby reducing eccentric wear in total knee arthroplasty

Infection following operative treatment of ankle fractures

DoD SSI (Surgical Site Infections)

UNLABELLED: Information on the microbiology of infections after operative ankle fractures, on the details of a treatment protocol used when the ankle joint is preserved, and on the outcome of this protocol will be helpful for the physicians managing patients with this complex problem. We therefore determined the most common pathogen of these infections, the infection recurrence rate, and the amputation rate. We retrospectively reviewed 26 patients of a mean age of 43 years with infections following operative treatment of ankle fractures. Twenty-one of 26 patients (81%) were compromised hosts according to the Cierny-Mader classification. Patients presenting up to 10 weeks postoperatively were treated by debridement and either hardware retention (if implants were judged stable) or hardware removal (if implants were loose). All patients presenting more than 10 weeks postoperatively underwent debridement and hardware removal, with the exception of one patient who underwent below knee amputation. Staphylococcus aureus was identified in 17 patients (65%) and was oxacillin-resistant in six (23%). The infection recurred in five of 18 patients who were followed up for 8 months on average. Three recurrent infections were controlled with repeat debridement. The remaining two patients underwent below-knee amputation, resulting in amputations in 3 of 18 patients. Infection after operative treatment of ankle fractures is a limb-threatening complication, especially in patients with comorbidities, such as diabetes mellitus. Treatment is challenging with high infection recurrence and amputation rates. LEVEL OF EVIDENCE: Level IV, therapeutic study case series.

Usability of the AAOS Appropriate Use Criteria (AUC) for the surgical management of knee osteoarthritis in clinical practice

OAK 3 - Non-arthroplasty tx of OAK

PURPOSE: The Appropriate Use Criteria (AUC) for the surgical treatment of knee osteoarthritis were developed by the American Academy of Orthopedic Surgeons (AAOS) to guide surgeons in selecting the most evidence-based surgical option. This study aimed to assess the usability of the AUC by comparing the actual surgical treatment provided at our institution with that recommended by the AUC. METHODS: A retrospective review of the medical charts and radiographs of all patients who underwent surgery for knee osteoarthritis (OA) at our hospital was performed between January and December 2017. Data including each patient's age, gender, pain level, mechanical symptoms, range of motion (ROM) and instability, radiographic pattern and severity, limb alignment, and type of surgical interventions received were collected. The collected data were input into the AUC application to determine the rate of appropriateness of the treatments. Afterwards, the agreement between the actual treatment provided and the AUC recommendation was assessed. RESULTS: A consecutive series of 100 patients were included. The mean age was 63.1 years, with the majority of the patients aged (73%) between 50 and 69 years. Most of the patients were females (74%), and 61% had left knee OA. The most frequent type of patient was a middle-aged patient with function-limiting pain at short distances, no mechanical symptoms or functional instability with full ROM, severe knee multicompartmental radiographic features, and varus or valgus malalignment. Out of the 100 patients, total knee arthroplasty (TKA) was performed in 85 patients, unicompartmental knee arthroplasty (UKA) was performed in 11 patients, and high tibial osteotomy (HTO) was performed in four patients. According to the AUC, 90 (90%) cases were treated with an appropriate surgical treatment, whereas 10 (10%) cases were treated with a maybe appropriate treatment. The actual surgical treatment performed at our hospital was in agreement with the AUC recommendation in 100% of the TKA cases, 90.9% of the UKA cases, and 100% of the HTO cases. Thus, the agreement rate with the AUC was 99% in all surgical cases. CONCLUSION: This study demonstrated that the AUC for the surgical treatment of knee OA can be applied easily in a clinical setting. Most of the treatments provided at our institution were appropriate and in agreement with the AUC recommendations. Additionally, the AUC had a web-based application that was easy to use and simple for identifying treatment recommendations. LEVEL OF EVIDENCE: Retrospective study, level IV.

Outcome of anterior cruciate ligament reconstruction using quadriceps tendon autograft

Anterior Cruciate Ligament Injuries CPG

PURPOSE: The purpose of this study was to determine the outcome of anterior cruciate ligament (ACL) reconstruction using a quadriceps tendon autograft. TYPE OF STUDY: A case series of patients who had received arthroscopic ACL reconstructions using quadriceps tendon autograft was retrospectively evaluated. METHODS: Sixty-seven ACL reconstructions were evaluated at a mean of 41 months (range, 27 to 49 months). Clinical assessment was made using a modified Lysholm score, documentation of International Knee Documentation Committee (IKDC), the anterior knee pain questionnaire of Shelbourne and Trumper, and by KT-2000 arthrometric analysis. Isokinetic strength testing and radiographic assessments were also performed. RESULTS: Arthrometric analysis showed that 63 knees (94%) were graded A or B with a median laxity of 2 mm postoperatively. The Lysholm score improved postoperatively from 71 to 90 ( P < or = .05). Extension peak torque of the quadriceps muscle recovered to 82% and 89% of that of the contralateral knee at 180 degrees/second at 1 year and 2 years after surgery, respectively. The patellar position in terms of congruence angle and Insall-Salvati ratio did not show any significant change. Only 4 patients complained of moderate pain on kneeling and 1 patient complained of harvest-site tenderness. CONCLUSIONS: ACL reconstruction using a quadriceps tendon autograft showed satisfactory results with reduced donor-site morbidities. The quadriceps tendon can be a reliable source of graft, and is comparable to bone-patellar tendon-bone or hamstring tendon in ACL reconstruction. LEVEL OF EVIDENCE: Level IV, Case Series (no, or historical, control group)

Surgical Staples: A Superior Alternative to Sutures for Skin Closure After Neck Dissectionâ??A Single-Blinded Prospective Randomized Clinical Study

Reconstruction After Skin Cancer

Purpose To evaluate the efficacy of staples in skin closure after neck dissection in patients with oral squamous cell carcinoma. The authors hypothesized that the use of staples would result in better wound closure compared with the use of nonabsorbable monofilament sutures. Materials and Methods A prospective single-blinded randomized clinical trial was performed to compare various parameters, including time for wound closure, inflammatory changes, pain, cost efficacy, complications, and esthetic outcome of skin closure with surgical staples versus nonabsorbable monofilament sutures and to determine their statistical relevance using Ï?2 and Mann-Whitney U tests. Result In a study of 124 patients, the mean skin closure time was 29.2 ± 4 minutes with sutures (n = 61) and 5.3 ± 1.29 minutes with staples (n = 63), which was significant (P =.01). Mean pain scores during removal using the visual analog scale were 5.08 ± 1.29 and 3.15 ± 0.89 with sutures and staples, respectively. Postoperative complications, such as gapping and stitch abscess with purulent discharge, were noted. Conclusion Staples provided better esthetics with fewer complications, faster closure, minimal pain at removal, and faster healing compared with sutures. The slowest closure time in the staples group was 4 times faster than the fastest closure time in the sutures group. However, staples cost 5 times more than sutures.

Mid-term outcomes of mobile-bearing lateral unicompartmental knee arthroplasty

OAK 3 - Non-arthroplasty tx of OAK

Background: This research was undertaken to evaluate Oxford Domed Lateral unicompartmental knee replacement (UKR) survival and clinical and radiological outcomes. The study also considered the influence of body mass index (BMI) on results and proposed contralateral healthy knee anatomic femorotibial angle (AFTA) as a predictor of postoperative knee alignment. Methods: A retrospective evaluation of 41 primary Oxford Domed Lateral UKR performed in 41 patients in the same institution was undertaken on a patient group comprising of 10 men and 31 women with a mean age of 63 years (range: 38â??81 years). A minimum follow-up of two years was required. Results: The total revision rate was one out of 41 patients (2.4%), with a mean follow-up of 49 months (range: 25â??84 months). One patient presented with a traumatic medial dislocation of the bearing after 15 months (resulting in an overall dislocation rate of 2.4%). The visual analogue scale (VAS) and the Oxford knee score (OKS) demonstrated significant postoperative improvement (P < 0.001). Survival at five years, with revision for any reason as the endpoint, was 97.5%. No significant correlation was observed between BMI and postoperative flexion angle, radiologically measured parameters, or pre- and postoperative VAS and OKS. Significant correlation was found (r = 0.77, P < 0.001) between postoperative and contralateral healthy knee anatomic femorotibial angles. Conclusions: The Oxford Domed Lateral UKR presents a low dislocation rate and excellent mid-term clinical and functional results. Contralateral healthy knee AFTA appears to be a predictor of postoperative knee alignment.

The protective effect of meniscus allograft transplantation on articular cartilage: A systematic review of animal studies

OAK 3 - Non-arthroplasty tx of OAK

Despite widespread reporting on clinical results, the effect of meniscus allograft transplantation on the development of osteoarthritis is still unclear. The aim of this study was to systematically review all studies on the effect of meniscus allograft transplantation on articular cartilage in animals. Pubmed and Embase were searched for original articles concerning the effect of meniscus allograft transplantation on articular cartilage compared with both its positive (meniscectomy) and negative (either sham or non-operated) control in healthy animals. Outcome measures related to assessment of damage to articular cartilage were divided in five principal outcome categories. Standardized mean differences (SMD) were calculated and pooled to obtain an overall SMD and 95% confidence interval. 17 articles were identified, representing 14 original animal cohorts with an average timing of data collection of 24 weeks [range 4 weeks; 30 months]. Compared to a negative control, meniscus allograft transplantation caused gross macroscopic (1.45 [0.95; 1.95]), histological (3.43 [2.25; 4.61]) damage to articular cartilage, and osteoarthritic changes on radiographs (3.12 [1.42; 4.82]). Moreover, results on histomorphometrics and cartilage biomechanics are supportive of this detrimental effect on cartilage. On the other hand, meniscus allograft transplantation caused significantly less gross macroscopic (-1.19 [-1.84; -0.54]) and histological (-1.70 [-2.67; -0.74]) damage to articular cartilage when compared to meniscectomy. However, there was no difference in osteoarthritic changes on plain radiographs (0.04 [-0.48; 0.57]), and results on histomorphometrics and biomechanics did neither show a difference in effect between meniscus allograft transplantation and meniscectomy. In conclusion, although meniscus allograft transplantation does not protect articular cartilage from damage, it reduces the extent of it when compared with meniscectomy.

The incidence and characteristics of accelerated knee osteoarthritis among women: The Chingford cohort

OAK 3 - Non-arthroplasty tx of OAK

Background: Prior research on accelerated knee osteoarthritis (AKOA) was primarily confined to the Osteoarthritis Initiative, which was enriched with people with risk factors for knee osteoarthritis (KOA). It is unclear how often AKOA develops in a community-based cohort and whether we can replicate prior findings from the Osteoarthritis Initiative in another cohort. Hence, we determined the incidence and characteristics of AKOA among women in the Chingford Study, which is a prospective community-based cohort. Methods: The Chingford Study had 1003 women with quinquennial knee radiographs over 15 years. We divided the 15-year observation period into three consecutive 5-year phases. Within each 5-year phase, we selected 3 groups of participants among women who started a phase without KOA (Kellgren-Lawrence [KL] < 2): 1) incident AKOA developed KL grade â?¥ 3, 2) typical KOA increased radiographic scoring (excluding AKOA), and 3) no KOA had the same KL grade over time. Study staff recorded each participant's age, body mass index (BMI), and blood pressure at baseline, 5-year, and 10-year study visits. We used multinomial logistic regression models to test the association between groups (outcome) and age, BMI, and blood pressure at the start of each phase. The cumulative incidences and odds ratios (OR) from each phase were pooled using a fixed-effect meta-analysis model. Results: The person-based cumulative incidence of AKOA was 3.9% over 5 years (pooled estimate across the three 5-year phases). Among incident cases of KOA, AKOA represented ~ 15% of women with incident KOA. Women with AKOA were older than those with typical (OR = 1.56, 95%CI = 1.16-2.11) or no KOA (OR = 1.84, 95%CI = 1.40-2.43). Women with AKOA had a greater BMI than those without KOA (OR = 1.52, 95%CI = 1.17-1.97). We observed no association between group and blood pressure. Conclusions: In a community-based cohort, > 1 in 7 women with incident KOA had AKOA. Like the Osteoarthritis Initiative, people with AKOA were more likely to have greater age and BMI.

Arthroscopic resection of the shelf (mediopatellar plica) in the knee under local anesthesia in outpatient clinic

Surgical Management of Osteoarthritis of the Knee CPG

Forty-two knees with symptomatic mediopatellar plicae (shelves) were managed using the operative method under local anesthesia. Of these, thirty-one knees had isolated mediopatellar plicae, and eleven had other associated intra-articular pathologic condition, such as meniscal tear, lateral patellar tracking, osteochondritis dissecans, and minor osteoarthritic changes. The clinical results were excellent or good in thirty-seven (88%) patients, fair in five patients after an average follow-up of twenty-five months. No case showed deterioration after surgery. Because there are no definitive criteria for the indication of shelf resection, arthroscopic resection of the shelf under local anesthesia is recommended if there is any possibility of it being the cause of knee pain

Association between rehabilitation timing and major complications of total knee arthroplatsy

PJI DX Updated Search

OBJECTIVE: To investigate the association between rehabilitation timing and the occurrence of post-total knee arthroplasty complications and related medical service utilization. METHODS: Data from Taiwan's National Health Insurance Research Database from 2003-2006 were used to perform a retrospective study on patients who received their initial total knee arthroplasty during 2004-2005 (a total of 21,143 subjects). All subjects were divided into 1 of 3 groups based on the timing of their rehabilitation after total knee arthroplasty, namely, the within 2 weeks group, the after 2 weeks group or the no-rehabilitation group. RESULTS: We found that patients in the no-rehabilitation group and the after 2 weeks group had higher incidences of prosthetic infection (odds ratio (OR) =1.29, p=0.0409; OR=1.66, p=0.0012) and deep venous thrombosis (OR=1.51, p=0.0099; OR=2.07; p=0.0007) than in the within-2-weeks group. In addition, compared with the within-2-weeks group, the after 2 weeks group had higher total medical expenses (exponentiated regression coefficient: Exp. (beta) =1.07, p=0.0211), and the no-rehabilitation group had lower total medical expenses (Exp. (beta) =0.01, p<0.0001). CONCLUSION: The results of this study indicated that, because the incidence rates of complications and medical service utilization among total knee arthroplasty patients in the within 2 weeks group were lower than in the after 2 weeks group, the timing of rehabilitation may be 1 factor affecting post-TKA complications and promoting high levels of medical service utilization. These findings could be useful for clinicians and health policymakers attempting to improve total knee arthroplasty services

Myoclonus, palmomental reflex and cognitive functions in Parkinson's disease

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Idiopathic Parkinson's disease (IPD), is a chronic, progressive neurological disease which is presented with motor and non motor symptoms. One of these symptoms, is myoclonus, the pathophysiology of which remains controversial. Myoclonus in IPD is often considered to be related to Levo-DOPA treatment. Moreover, myoclonic movements which are not related to treatment, are described. To evaluate the occurrence of myoclonus and its relationship with the cortical involvement in idiopathic Parkinson's disease, we studied. 31 patients who had no evidence of dementia. Clinical assessment was performed with the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn and Yahr staging (HY), and the Mini-Mental State Examination (MMSE). Clinical assessment showed a range of mild-to-moderate disease severity. All patients underwent polygraphic electromyographic (EMG) recording and attempted elicitation of long-latency EMG responses. We also studied palmomental reflex (PMR) by electrophysiological assessment. Multichannel surface EMG recording during muscle activation showed myoclonic discharges in 17 patients. There was no sinificant difference of age, gender, disease duration, severity of disease, and cognitive function in patients with and without myoclonus. Electrophysiological studies showed significantly lower rate of resting tremor in patients with myoclonus. C reflex amplitude was significantly higher and PMR obtained with median nerve stimulation at the wrist, had a higher incidence in this group. We think that these findings may reflect a very mild cortical involvement in PH with myoclonus and that electrophysiological examination of PMR may be a useful method giving additional information and easy to apply

Cross-sectional and longitudinal associations between serum inflammatory cytokines and knee bone marrow lesions in patients with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: To describe cross-sectional and longitudinal associations between serum levels of interleukin (IL) - 6, IL-17A, IL-17F, IL-23 and knee bone marrow lesions (BMLs) in patients with knee osteoarthritis (OA). DESIGN: Patients (n = 192) with symptomatic knee OA (mean 63 years, range 50-79, female 53%) were assessed at baseline and after 24 months. At each time point, serum IL-6, IL-17A, IL-17F and IL-23 were measured using Bio-Plex Multiplex Immunoassays with Luminex xMAP technology. Knee BMLs were scored using the modified whole organ MRI score (WORMS) from T2 weighted fat-suppressed fast spin echo magnetic resonance imaging (MRI). Multivariable linear regression and log binominal regression were used to determine the associations between cytokines and BMLs. RESULTS: Baseline IL-6 (quarters) were significantly associated with total knee BMLs (P < 0.01 for the trend) as well as associated with an increase in BML score (P = 0.05 for the trend), after adjustment for confounders. Baseline IL-17F and IL-23 (highest quarters vs others) was associated with an increase in BML score in females (P = 0.04 for IL-17F; P = 0.01 for IL-23), but not in males, in multivariable analyses. In contrast, IL-17A was not significantly associated with BMLs in either females or males. CONCLUSION: IL-6 is associated with increased knee BMLs in both females and males with OA. Serum IL-17F and IL-23 predicted increased knee BML scores in females only, suggesting that inflammation is involved in BML pathogenesis in knee OA, especially in women. TRAIL REGISTRATION: ClinicalTrials.gov identifier: NCT01176344; Australian New Zealand Clinical Trials Registry: ACTRN12610000495022.

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AAHKS (9/10) Regional Nerve Blocks

BACKGROUND: Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected. OBJECTIVE: To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR. METHODS: We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement. RESULTS: Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7-23% of patients after THR and 10-34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test. CONCLUSIONS: The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention. STUDY REGISTRATION: Current Controlled Trials ISRCTN52305381. FUNDING: This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Bio-resorbable versus metal implants in wrist fractures: a randomised trial

Distal Radius Fractures

BACKGROUND: Distal radius fractures are often surgically treated if insufficient reduction has been achieved or after conservative treatment has failed. Treatment using metal implants often demands a secondary operation to remove the implant. A bio-resorbable implant (in this study the Reunite osteosynthesis plate by Biomet Inc) should obviate the need for a secondary operation with equal functional results. MATERIALS AND METHODS: Thirty-two patients with a distal radius fracture were assigned to treatment with either a bio-resorbable implant (N = 19) or a metal implant (N = 13). Both groups received the same postoperative care and were followed for 52 weeks in the outpatient clinic. The hypothesis of this study was a decrease in re-operation rate in the experimental group with equal functional results. RESULTS: Five out of 19 patients treated with the Reunite plate were re-operated and four out of 13 treated with metal implants needed a secondary operation. In both implants, equal functional results in Range of Motion and DASH scores were found. CONCLUSION: There were no significant differences between the experimental and control group with respect to re-operations, DASH scores and Range of Motion. Because of the higher initial costs and equal results, the use of bio-resorbable implants must be considered carefully.

Differences in trabecular bone texture between knees with and without radiographic osteoarthritis detected by fractal methods

AMP (Acute Meniscal Pathology)

OBJECTIVE: To develop an accurate method for quantifying differences in the trabecular structure in the tibial bone between subjects with and without knee osteoarthritis (OA). METHODS: Standard knee radiographs were taken from 26 subjects (seven women) with meniscectomy and radiographic OA Kellgren & Lawrence grade 2 or worse in the medial compartment. Each case knee was individually matched by sex, age, body mass index and medial or lateral compartment with a control knee. A newly developed augmented Hurst orientation transform (HOT) method was used to calculate texture parameters for regions selected in X-ray images of non-OA and OA tibial bones. This method produces a mean value of fractal dimensions (FD MEAN), FDs in the vertical (FDV) and horizontal (FDH) directions and along a direction of the roughest part of the tibial bone (FDSta), fractal signatures and a texture aspect ratio (Str). The ratio determines a degree of the bone texture anisotropy. Reproducibility was calculated using an intraclass correlation coefficient (ICC). Comparisons between cases and controls were made with paired t tests. The performance of the HOT method was evaluated against a benchmark fractal signature analysis (FSA) method. RESULTS: Compared with controls, trabecular bone in OA knees showed significantly lower FD MEAN, FDV, FDH and FDSta and higher Str at trabecular image sizes 0.2-1.1mm (P<0.05, HOT). The reproducibility of all parameters was very good (ICC>0.8). In the medial compartment, fractal signatures calculated for OA horizontal and vertical trabeculae were significantly lower at sizes 0.3-0.55 mm (P<0.05, HOT) and 0.3-0.65 mm (P<0.001, FSA). In the lateral compartment, FDs calculated for OA trabeculae were lower than controls (horizontal: 0.3-0.55 mm (P<0.05, HOT) and 0.3-0.65 mm (P<0.001, FSA); vertical: 0.3-0.4mm (P<0.05, HOT) and 0.3-0.35 mm (P<0.001, FSA). CONCLUSION: The augmented HOT method produces fractal signatures that are comparable to those obtained from the benchmark FSA method. The HOT method provides a more detailed description of OA changes in bone anisotropy than the FSA method. This includes a degree of bone anisotropy measured using data from all possible directions and a texture roughness calculated for the roughest part of the bone. It appears that the augmented HOT method is well suited to quantify OA changes in the tibial bone structure.

A large-scale replication study for the association of rs17039192 in HIF-2alpha with knee osteoarthritis

SR for PM on OA of All Extremities

Osteoarthritis (OA) is a common disease with a genetic component for its etiology. Recently, a genetic association of a single nucleotide polymorphism (SNP), rs17039192 in HIF-2alpha with knee OA has been reported in a Japanese population; however, controversy exits for its replication and a role of HIF-2alpha in OA. This study aimed to evaluate the association of the SNP by a large-scale replication study. A total of 8,457 subjects (3,129 OA cases and 5,328 controls) from seven independent cohorts from six countries (Japan, China, Taiwan, Korea, Greece, and Australia) were recruited and genotyped. The association of rs17039192 with knee OA was evaluated by meta-analyses. The association of the HIF-2alpha SNP was not replicated in any of the populations. Contrary to the previous report, the odds ratios (ORs) of the risk allele frequency were all less than 1. A combined analysis for the seven populations also showed no replication of the association (OR = 0.91, 95% confidence interval = 0.81-1.03). Our large-scale meta-analysis showed that the association of rs17039192 in HIF-2alpha with knee OA is negative. The significance of HIF-2alpha in human OA (idiopathic OA as a common disease) should be further evaluated carefully

Efficacy of antibiotics in low-velocity gunshot fractures

DoD SSI (Surgical Site Infections)

We have investigated the efficacy of intravenous antibiotic therapy as a prophylactic measure to prevent infection following low-velocity gunshot fractures. Ninety-six consecutive patients were randomized prospectively to either an antibiotic group (Group I) or a nonantibiotic group (Group II) and were followed in a special gunshot wound clinic. Only patients with fractures that could be treated by closed techniques and did not require internal fixation were included. Sixty-seven patients (73 fractures) were followed radiographically. At follow-up, 36 fractures in Group 1 and 37 fractures in Group II comprised the study group. A total of two infections, one in each group, was documented. No significant infection prophylaxis was demonstrated by the use of intravenous antibiotics in these injuries.

Defining hip pain trajectories in early symptomatic hip osteoarthritis - 5 year results from a nationwide prospective cohort study (CHECK)

OAK 3 - Non-arthroplasty tx of OAK

Objective: To define distinct hip pain trajectories in individuals with early symptomatic hip osteoarthritis (OA) and to determine risk factors for these pain trajectories. Method: Data were obtained from the nationwide prospective Cohort Hip and Cohort Knee (CHECK) study. Participants with hip pain or stiffness and a completed 5-year follow-up were included. Baseline demographic, anamnestic, physical examination characteristics were assessed. Outcome was annually assessed by the Numeric Rating Scale (NRS) for pain. Pain trajectories were retrieved by latent class growth analysis (LCGA). Multinomial logistic regression was used to calculate risk ratios. Results: 545 participants were included. Four distinct pain trajectories were uncovered by LCGA. We found significant differences in baseline characteristics, including body mass index (BMI); symptom severity; pain coping strategies and in criteria for clinical hip OA (American College of Rheumatology (ACR)). Lower education, higher activity limitation scores, frequent use of pain transformation as coping strategy and painful internal hip rotation were more often associated with trajectories characterized by more severe pain. No association was found for baseline radiographic features. Conclusion: We defined four distinct pain trajectories over 5 years follow-up in individuals with early symptomatic hip OA, suggesting there are differences in symptomatic progression of hip OA. Baseline radiographic severity was not associated with the pain trajectories. Future research should be aimed at measuring symptomatic progression of hip OA with even more frequent symptom assessment.

Equal effectiveness of electrical and volitional strength training for quadriceps femoris muscles after anterior cruciate ligament surgery

Anterior Cruciate Ligament Injuries CPG

Neuromuscular electrical stimulation and voluntary muscle contraction are two exercise modes widely used in rehabilitation to strengthen skeletal muscle. Since there is no debate as to which mode is most effective, we compared electrical stimulation with voluntary contraction performed at matched intensities following reconstructive surgery of the anterior cruciate ligament. Forty men and women, aged 15-44, were randomly assigned to either an electrical stimulation or a voluntary contraction group. None of the subjects had a previous history of neuromuscular injury. The subjects received treatment for 30 minutes a day, 5 days a week, for 4 weeks. Knee extension torque was monitored during treatment to try to match the absolute muscular tensions (quantified as "activity") achieved during therapy. To match the activity of the subjects in the electrical stimulation group, who were treated at the highest stimulation intensity they could tolerate, the subjects in the voluntary contraction group were paced at progressively increasing intensities corresponding to 15, 25, 35, and 45% of the injured limb's maximum voluntary torque during weeks 1, 2, 3, and 4, respectively. We found no significant difference between the groups in terms of maximum voluntary knee extension torque throughout the study period. In addition, 1 year after surgery, there was still no significant difference between groups with regard to knee extension torque (p > 0.4). These data suggest that neuromuscular electrical stimulation and voluntary muscle contraction treatments, when performed at the same intensity, are equally effective in strengthening skeletal muscle that has been weakened by surgical repair of the anterior cruciate ligament

Expression of the growth factor pleiotrophin and its receptor protein tyrosine phosphatase beta/zeta (RPTP(beta)/(zeta)) in patients with osteoarthritis

Surgical Management of Osteoarthritis of the Knee CPG

Purpose: Pleiotrophin (PTN) is a heparin-binding growth factor expressed in the cartilage in foetal and young age, but its exact role remains unclear as yet. The purpose of this paper is to study the expression of PTN and its receptor protein tyrosine phosphatase beta/zeta (RPTP(beta)/(zeta)) in the cartilage and the subchondral bone of patients with osteoarthritis. Methods: We studied the cartilage and the subchondral bone from 29 patients who had undergone total knee and hip arthroplasty for osteoarthritis, by using Western blot and immunohistochemistry analyses. As controls, we used eight patients operated for fractures of femoral head, who did not present radiological or macroscopical osteoarthritic changes Results: PTN and

Acute Injury of the Articular Cartilage and Subchondral Bone: A Common but Unrecognized Lesion in the Immature Knee

AMP (Acute Meniscal Pathology)

OBJECTIVE. We studied the prevalence of injuries of the articular cartilage and subchondral bone after acute trauma in skeletally immature knees using high-resolution MRI. MATERIALS AND METHODS. We reviewed knee MRIs of 126 young children and adolescents suspected to have internal knee derangement, including 82 with open physes and a control group of 44 who were skeletally mature. High-resolution proton density and T2-weighted pulse sequences were used in all patients. The prevalence of common injuries in the two groups was compared using chi-square analysis. Levels of interobserver agreement for evaluation of chondral lesions in the skeletally immature group were determined using the kappa statistic. RESULTS. In the skeletally immature group, chondral lesions were the most prevalent injuries (prevalence = 0.34, p = 0.009) followed by meniscal and anterior cruciate ligament injuries (prevalence = 0.23 and 0.24, respectively). No significant difference in the prevalence of chondral injury before and after physeal closure was seen (p = 0.45). There was no significant difference in the prevalence of anterior cruciate ligament injuries between the two groups, but meniscal injuries were more prevalent in the skeletally mature patients (prevalence = 0.41, p = 0.037). Interobserver agreement for chondral injuries in the group with open physes was good (weighted ? = 0.45-0.51). CONCLUSION. The most common injuries occurring as a result of acute trauma to the immature knee were chondral. In patients with open physes, chondral injuries were significantly more prevalent than anterior cruciate ligament and meniscal injuries.

Neurological complications in children with supracondylar fractures of the humerus

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

OBJECTIVE: To study the incidence of primary and secondary nerve injury in supracondylar fractures of the humerus, and to find out which factors may be responsible for iatrogenic nerve injuries. DESIGN: Retrospective study. SETTING: University Hospital, The Netherlands. SUBJECTS: 32 children admitted with type II or type III supracondylar fracture of the humerus. MAIN OUTCOME MEASURES: Incidence of primary and secondary nerve injury and their relation to type of fracture and treatment. RESULTS: 3 patients developed primary nerve injuries (9%). 4 further children developed nerve injury during treatment. All these children had several closed reductions attempted before definitive treatment was given (either pinning with a Kirschner wire or overhead traction). CONCLUSION: Several attempts at closed reduction may cause iatrogenic nerve injury in unstable supracondylar fractures of the humerus

Relationship between periodontal diseases and preterm birth: recent epidemiological and biological data

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

For ten years, the incidence of preterm birth does not decrease in developed countries despite the promotion of public health programs. Many risk factors have been identified including ethnicity, age, tobacco, and infection. However, almost 50% of preterm birth causes remain unknown. The periodontal diseases are highly prevalent inflammatory and infectious diseases of tooth supporting tissues leading to an oral disability. They influence negatively general health worsening cardiovascular diseases and diabetes. Periodontal diseases have been also suspected to increase the rate of preterm birth, but data remain contradictory. The objective of this review is to present the principal results of epidemiological, biological, and interventional studies on the link between periodontal diseases and preterm birth. The conclusions of this work underline the importance for the physician/obstetrician to identify women at risk for preterm birth and to address these patients to dentist for periodontal examination and treatment in order to limit adverse pregnancy outcomes

Laboratory and clinical characteristics of Staphylococcus lugdunensis prosthetic joint infections

PJI DX Updated Search

Staphylococcus lugdunensis is a coagulase-negative staphylococcus that has several similarities to Staphylococcus aureus. S. lugdunensis is increasingly being recognized as a cause of prosthetic joint infection (PJI). The goal of the present retrospective cohort study was to determine the laboratory and clinical characteristics of S. lugdunensis PJIs seen at the Mayo Clinic in Rochester, MN, between 1 January 1998 and 31 December 2007. Kaplan-Meier survival methods and Wilcoxon sum-rank analysis were used to determine the cumulative incidence of treatment success and assess subset comparisons. There were 28 episodes of S. lugdunensis PJIs in 22 patients; half of those patients were females. Twenty-five episodes (89%) involved the prosthetic knee, while 3 (11%) involved the hip. Nine patients (32%) had an underlying urogenital abnormality. Among the 28 isolates in this study tested by agar dilution, 24 of 28 (86%) were oxacillin susceptible. Twenty of the 21 tested isolates (95%) lacked mecA, and 6 (27%) of the 22 isolates tested produced beta-lactamase. The median durations of parenteral beta-lactam therapy and vancomycin therapy were 38 days (range, 23 to 42 days) and 39 days (range, 12 to 60 days), respectively. The cumulative incidences of freedom from treatment failure (standard deviations) at 2 years were 92% (+/-7%) and 76% (+/-12%) for episodes treated with a parenteral beta-lactam and vancomycin, respectively (P=0.015). S. lugdunensis is increasingly being recognized as a cause of PJIs. The majority of the isolates lacked mecA. Episodes treated with a parenteral beta-lactam antibiotic appear to have a more favorable outcome than those treated with parenteral vancomycin

ERK1/2-mediated activation of DRP1 regulates mitochondrial dynamics and apoptosis in chondrocytes

AMP (Acute Meniscal Pathology)

OBJECTIVE: To determine the Dynamin-related protein 1 (DRP1) regulation of mitochondrial fission in chondrocytes under pathological conditions, an area which is underexplored in osteoarthritis pathogenesis. DESIGN: DRP1 protein expression was determined by immunohistochemistry (IHC) or immunofluorescence (IF) staining of cartilage sections. IL-1beta-induced DRP1 mRNA expression in chondrocytes was quantified by qPCR and protein expression by immunoblotting. Mitochondrial fragmentation in chondrocytes was visualized by MitoTracker staining or IF staining of mitochondrial marker proteins or by transient expression of mitoDsRed. Mitochondrial reactive oxygen species (ROS) levels were determined by MitoSOX staining. Apoptosis was determined by lactate dehydrogenase (LDH) release assay, Caspase 3/7 activity assay, propidium iodide (PI), and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining and IF staining of cleaved caspase 3. Cytochrome c release was determined by confocal microscopy. Surgical destabilization of the medial meniscus (DMM) was used to induce osteoarthritis (OA) in mice. RESULTS: Expression of DRP1 and mitochondrial damage was high in human OA cartilage and in the joints of mice subjected to DMM surgery which also showed increased chondrocytes apoptosis. IL-1beta-induced mitochondrial network fragmentation and chondrocyte apoptosis via modulation of DRP1 expression and activity and induce apoptosis via Bax-mediated release of Cytochrome c. Pharmacological inhibition of DRP1 activity by Mdivi-1 blocked IL-1beta-induced mitochondrial damage and apoptosis in chondrocytes. Additionally, IL-1beta-induced activation of extracellular signal-regulated kinase 1/2 (ERK1/2) is crucial for DRP1 activation and induction of mitochondrial network fragmentation in chondrocytes as these were blocked by inhibiting ERK1/2 activation. CONCLUSIONS: These findings demonstrate that ERK1/2 is a critical player in DRP1-mediated induction of mitochondrial fission and apoptosis in IL-1beta-stimulated chondrocytes.

The risk of renal impairment in hormone-refractory prostate cancer patients with bone metastases treated with zoledronic acid

MSTS 2018 - Femur Mets and MM

BACKGROUND: Bisphosphonates have been used to treat bone metastases in hormone-refractory prostate cancer (HRPC), but certain agents have been associated with renal toxicity. For this observational study, the authors assessed the risk of renal impairment in patients with HRPC who received zoledronic acid from December 1999 to April 2005. METHODS: A comprehensive medical records review was performed in a major tertiary oncology center (n = 122 patients). The primary outcome of renal impairment was defined as an increase >or=0.5 mg/dL or >or=1.0 mg/dL over baseline creatinine value if the baseline value was <1.4 mg/dL or >or=1.4 mg/dL, respectively. A risk factor analysis was conducted using the Andersen-Gill extension to the Cox proportional hazards model. RESULTS: Renal impairment was observed in 23.8% of patients. The risk of renal impairment increased with an extended duration of zoledronic acid therapy (<6 months, 11.1%; >or=24 months, 26.3%) and previous pamidronate treatment (45.5% vs 19.0% for patients with no prior pamidronate). A significantly greater risk of renal impairment was associated with increasing age at zoledronic acid initiation, prior pamidronate use, and a history of renal disease, hypertension, or smoking (P <or= 0.05). CONCLUSIONS: In an outpatient clinic setting, the risk of renal impairment among patients with HRPC who received zoledronic acid was greater than the risk reported previously in clinical trials.

Selenomethionine inhibits IL-1(beta) induced Nitric Oxide Synthase (iNOS) and cyclooxygenase 2 (COX2) in primary human chondrocytes

Surgical Management of Osteoarthritis of the Knee CPG

Purpose: Inflammatory cytokine Interleukin-1 (IL-1 (beta)) stimulates reactive oxygen species (ROS), which mediates downstream cell signaling, modulating catabolic and inflammatory gene expression such as inducible nitric oxide synthase (iNOS) and cyclooxygenase 2 (COX2). The nutritional and antioxidant factor selenium (Se), has long been considered to play an important role in Osteoarthritis (OA). The ability of Se to neutralize reactive oxygen and nitrogen species is one potential chondroprotective mechanism against OA progression. In this study, we test if Se can neutralize inflammatory and catabolic effects of IL-1(beta) and examine the common signaling pathways involved. Methods: Primary chondrocytes and treatment. Primary human chondrocytes were isolated by enzymatic digestion as previously described from nonlesional cartilage of patients undergoing total knee replacement surgery. Chondrocytes were pretreated with and without 0.5 (mu)M SelenoMethionine (SeMet) for 24 hrs and then followed by 50 pg/ml or 100 pg/ml 1L-1(beta) treatment for up to 24 hrs. RNA isolation and Real Time RT-PCR. Total RNA was extracted and reverse transcribed into cDNA for Real Time RT-PCR analysis. The ABI Prism 7000 sequence detection system and relative quantification software (Applied Biosystems, Foster City, CA) were used for real-time analyses. Analysis of relative mRNA expression levels of iNOS and COX2 were normalized to 18S gene expression. Values are the mean (SEM) percentage as a percentage of IL-1(beta) induced iNOS and COX2 mRNA levels for three independent experiments, conducted in triplicate. The relative mRNA level in cells treated with IL-1(beta) alone was set at 100%. Immunoblotting and Phosphorylation Assay. Whole cell lysates from chondrocytes for each tested condition were separated by electrophoresis on reducing gradient gels, and transferred to nitrocellulose for immunoblotting. Membranes were blocked with 5% BSA in TBS/0.1% Tween 20 (TBS-T). Polyclonal primary antibodies against Phospho-p44/42 MAPK 3(Erk1/2), Phospho-p38 MAPK (Thr180/Tyr182), Phospho-SAPK/JNK (Thr183/Tyr185), Phospho-IKK(alpha)/(beta) (Ser 176/180) Phospho- NF-kB p65 (Ser 536) were obtained from Cell Signaling Technology (Danvers, MA) and used at 1:1000 dilution. A monoclonal antibody against tubulin (Sigma) was used as a normalization control at 1:10,000 dilution. Anti-rabbit and anti-mouse IgG-HRP (Jackson ImmunoResearch, West Grove, PA) secondary antibodies were diluted 1:50,000. The results shown are representative of two independent experiments, conducted in duplicate. Results: Pretreatment of chondrocytes with SeMet significantly inhibited the IL-1(beta) induced iNOS gene expression (by ~30%) and COX2 gene expression (by ~40%), Figure 1. Furthermore, SeMet (Graph presented)selectively inhibited IL-1(beta) activated p38 MAPK and NF-kB activity, but not JNK, ERK and IKK(alpha)/(beta) activity (Figure 2, Western blot). Conclusions: Taken together, our data show that Se can partially reverse IL-1(beta) induced iNOS and COX2 gene expression, and shows evidence of altering IL-1(beta) activated cell signaling. These results suggest that one mechanism by which Se may exert a chondroprotective effect is through regulation of cell signaling pathways induced by pro-inflammatory cytokines

The changing landscape of the medical management of skeletal metastases in nonsmall cell lung cancer

MSTS 2018 - Femur Mets and MM

PURPOSE OF REVIEW: Skeletal metastases are a frequent site of involvement for patients with metastatic nonsmall cell lung cancer. Skeletal metastases may result in skeletal-related events. These complications typically result in significant morbidity for patients and substantially increase the economic costs associated with the treatment of patients with skeletal metastases. The management of skeletal metastases in patients with nonsmall cell lung cancer is evolving as improved treatments and monitoring become available. RECENT FINDINGS: In recent years, bisphosphonates such as zoledronic acid have shown efficacy in preventing and delaying skeletal-related events in patients with a variety of solid tumors, including nonsmall cell lung cancer. Biochemical markers of bone turnover such as bone-specific alkaline phosphatase and N-terminal telopeptide of collagen type I have shown some utility in predicting which patients are at greatest risk of developing skeletal-related events. These biochemical markers may play a role in directing treatment of skeletal metastases with either bisphosphonates or newer targeted therapies such as denosumab. SUMMARY: The management of skeletal metastases from nonsmall cell lung cancer is evolving as biochemical markers may be used to guide the treatment of these patients. Newer targeted therapies are also in development and may be used in the treatment of patients with skeletal metastases. © 2008 Lippincott Williams & Wilkins, Inc.

Effect of estrogen replacement therapy on patella cartilage in healthy women

Surgical Management of Osteoarthritis of the Knee CPG

OBJECTIVES: Patellofemoral osteoarthritis (OA) is a significant cause of morbidity. Epidemiological data suggests that the use of oestrogen replacement therapy (ERT) may protect against tibiofemoral knee OA. However, the effect on patellofemoral OA is unknown. The aim of this study was to test the hypothesis that long term ERT (greater than 5 years) is associated with increased patella cartilage in post menopausal women. METHODS: We studied 81 women (42 current users (> 5 yrs) of oestrogen replacement therapy and 39 never users). Articular cartilage volumes were determined by post-processing images acquired in the sagittal plane using a T1-weighted fat suppressed magnetic resonance sequence on an independent workstation. RESULTS: There was no difference in the amount of patella cartilage in women on ERT compared to women on no ERT. After adjusting for patella bone size, years since menopause, body mass index, age of menopause and smoking, ERT users had 2.07 +/- 0.76 ml of patella cartilage compared to 1.93 +/- 0.89 ml in non-users (P = 0.24 for difference). CONCLUSIONS: This study suggests that use of ERT for more than 5 years does not have a significant effect on patella cartilage, in contrast to the previously described effect on tibial cartilage. The reasons for this are unknown, but may indicate that there are differences in the mechanisms for development of knee OA at these sites

Cost-utility of reduction mammaplasty assessed for the Brazilian public health system

Reduction Mammoplasty for Female Breast Hypertrophy

BACKGROUND: Economic evaluation is important for making decisions about resource allocation. Few cost-utility or cost-effectiveness studies on breast hypertrophy have been reported in the medical literature. OBJECTIVES: The authors sought to determine the cost-utility of reduction mammaplasty in the Brazilian national health care system. METHODS: This randomized controlled study was conducted in a university-affiliated hospital. Sixty patients with breast hypertrophy were enrolled prospectively and were assigned randomly to either the control group (n = 30 patients who received follow-up for 6 months) or the treatment group (n = 30 patients who underwent reduction mammaplasty). Direct costs were recorded, and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) was administered to both groups at the beginning of the study (preoperatively for the treatment group) and 3 and 6 months postoperatively. Utility was determined with Instrument 6D of the Brazilian version of the Short-Form Health Survey (SF-6D), from the SF-36 data. RESULTS: At the 6-month follow-up, the treatment group showed an improvement in utility, with an average direct cost of approximately 104. CONCLUSIONS: Reduction mammaplasty performed in the Brazilian national health care system provides a cost-utility ratio equivalent to approximately 142 per 1 quality-adjusted life year.

Knowledge, attitudes and status of oral health in children at risk for infective endocarditis

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

AIM: The purpose of this study was to assess the oral health status of 104 children (2-17 years of age) at risk for infective endocarditis attending the Paediatric Cardiology Service of the Martagao Gesteira Institute of Child Care and Paediatrics, Rio de Janeiro, Brazil, and their guardians' attitudes towards and knowledge about endocarditis risks. METHODS: A structured interview was carried out with guardians and an oral examination was performed on each child to determine scores for the plaque index (PI), gingival index (GI) and dmft/DMFT index. RESULTS: The percentage of guardians who understood the meaning of 'heart infection' was 9.6%, who knew the possibility of heart disease caused by dental procedures was 60.6%, who understood the requirement for antibiotic cover before dental treatment was 72.1%, and who understood the importance of good oral health to prevent infective endocarditis was 41.3%. As regards oral health behaviours, 46.1% of children brushed their teeth three times or more a day, 28.8% had never visited a dentist before, and only 24.3% attended the dentist for prevention. There was visible plaque in 98% and gingival bleeding in 99% of children in this study. The caries experience for primary dentition (dmft) was 2.62%, and 3.97 for permanent dentition (DMFT). CONCLUSIONS: Based on these results, we can conclude that the guardians' knowledge and attitudes about oral health were not good. This group at risk has poor oral health, which may give rise to a frequent bacteraemia under physiological conditions

Connective Tissue and Age-Related Diseases

AMP (Acute Meniscal Pathology)

We begin this chapter by describing normal characteristics of several pertinent connective tissue components, and some of the basic changes they undergo with ageing. These alterations are not necessarily tied to any specific disease or disorders, but rather an essential part of the normal ageing process. The general features of age-induced changes, such as skin wrinkles, in selected organs with high content of connective or soft tissues are discussed in the next part of the chapter. This is followed by a section dealing with age-related changes in specific diseases that fall into at least two categories. The first category encompasses common diseases with high prevalence among mostly ageing populations where both genetic and environmental factors play roles. They include but may not be limited to atherosclerosis and coronary heart disease, type II diabetes, osteopenia and osteoporosis, osteoarthritis, tendon dysfunction and injury, age-related disorders of spine and joints. Disorders where genetics plays the primary role in pathogenesis and progression include certain types of progeria, such as Werner syndrome and Hutchinson-Gilford progeria belong to the second category discussed in this chapter. These disorders are characterized by accelerated signs and symptoms of ageing. Other hereditary diseases or syndromes that arise from mutations of genes encoding for components of connective tissue and are less common than diseases included in the first group will be discussed briefly as well, though they may not be directly associated with ageing, but their connective tissue undergoes some changes compatible with ageing. Marfan and Ehlers-Danlos syndromes are primary examples of such disorders. We will probe the role of specific components of connective tissue and extracellular matrix if not in each of the diseases, then at least in the main representatives of these disorders.

Intramedullary nails for long bone metastases: why do they fail?

MSTS 2022 - Metastatic Disease of the Humerus

Metastatic disease to long bones is common and often requires stabilization to treat or prevent fracture. Intramedullary fixation is used in many metaphyseal and diaphyseal lesions. The goal of this study was to investigate the causes of and risk factors for reconstructive failure in intramedullary fixation of metastatic disease. We performed a retrospective review of 112 consecutive reconstructions for metastatic disease treated with an isolated intramedullary nail. There were 81 reconstructions in the femur, 25 in the humerus, and 6 in the tibia. All included patients were followed until death or reconstructive failure. All surviving patients had a minimum 2-year follow-up.Ten failures required construct revision. Median time to revision was 17.9 months (range, 3-93 months). The causes of failure included surgeon error, tumor progression, nonunion, and hardware failure. Patients with short survival times (P<.001) or a diagnosis of lung cancer (P=.029) were unlikely to fail. Revision was required in 6 solitary lesions (P=.012), 3 cases of lymphoma (P=.002), 3 cases of progressive renal cell carcinoma (P=.040), and 2 radiation-associated fractures (P=.007). Intramedullary stabilization is a successful operation for appropriate lesions. Failures may be minimized with proper implant selection and surgical technique, resection or curettage of renal cell carcinoma, avoidance of radiation-associated fractures, and overestimating patient survival.

External ultrasound-assisted lipoplasty from our own experience

Panniculectomy & Abdominoplasty CPG

External ultrasound-assisted liposuction (XUAL) is a new technique that requires traditional aspirative liposuction after the application of high frequency ultrasonic fields delivered through the skin into a wetted tissue. Initial data suggest that it has some advantages over the traditional procedure, especially regarding the achievement of less traumatic surgery with superior clinical outcome. This preliminary report describes a comparative study between conventional liposuction and the external ultrasound-assisted technique as the modality of treatment for fat deposits in 65 bilateral anatomical areas. The results showed considerable superiority of the ultrasound-assisted series. We found less resistance to the canulla with more rapid removal of fat and the aspirated tissue showed less blood content with intact viable fat cells. Patients report less pain and discomfort on the ultrasound-treated sides and we found less swelling and bruising, with superior skin shrinkage. Clinical recovery was also enhanced by the external ultrasound and no complications were reported with the technique.

Treatment of gonarthroses and coxarthroses. Experience with a new dosage form of piroxicam

OAK 3 - Non-arthroplasty tx of OAK

Piroxicam tablets of 20 mg were tried in a four�week multicentre study in 1823 patients suffering from gonarthroses and coxarthroses. During the trial period one half of the patients received the medication in suspended form, the other half took the tablets undissolved. Both modes of ingestion revealed no significant differences as regards efficacy and tolerance. The treatment with piroxicam entailed a distinct improvement of all parameters investigated so that, in 81.8% of all cases, the trialists rated the therapeutic success as 'excellent' or 'good'. Side�effects were noted in 20.3% of the patients, with gestational irritations rating highest at 17.8%, as common with all inhibitors of prostaglandin synthesis. Treatment was discontinued in 6.1% of the patients. Copyright © 2011 Elsevier B. V., Amsterdam. All Rights Reserved.

Cartilage Injury in the Knee: Assessment and Treatment Options

AMP (Acute Meniscal Pathology)

Cartilage injuries in the knee are common and can occur in isolation or in combination with limb malalignment, meniscus, ligament, and bone deficiencies. Each of these problems must be addressed to achieve a successful outcome for any cartilage restoration procedure. If nonsurgical management fails, surgical treatment is largely based on the size and location of the cartilage defect. Preservation of the patient's native cartilage is preferred if an osteochondral fragment can be salvaged. Chondroplasty and osteochondral autograft transfer are typically used to treat small (<2 cm) cartilage defects. Microfracture has not been shown to be superior to chondroplasty alone and has potential adverse effects, including cyst and intralesional osteophyte formation. Osteochondral allograft transfer and matrix-induced autologous chondrocyte implantation are often used for larger cartilage defects. Particulated juvenile allograft cartilage is another treatment option for cartilage lesions that has good to excellent short-term results but long-term outcomes are lacking.

Rheumatoid arthritis in tight disease control is no longer risk of bone mineral density loss

Hip Fx in the Elderly 2019

Objectives: Rheumatoid arthritis (RA) is an independent risk factor of osteoporosis. However, if disease activity is successfully controlled using the treat-to-target (T2T) strategy, the risk of bone mineral density (BMD) loss can be diminished. We evaluated if RA is a risk factor even when the T2T is applied in clinical cases. Methods: From September 2017 to August 2019, 741 patients were examined using dual-energy X-ray absorptiometry; of these, 279 were diagnosed with RA who attained clinical remission within 6 months (RA-rem) and 53 could not attain clinical remission (RA-nonrem), while 409 were not diagnosed with RA (non-RA). The following characteristics between RA-rem and non-RA were matched using the propensity score matching (PSM) technique: age, sex, past bone fragility fracture experience, osteoporosis drug intervention ratio, glucocorticoid administration ratio, mean dose, Barthel Index score, body mass index, serum-creatinine-to-cystatin C ratio, and the number of comorbidities. The BMDs and changes of the lumbar spine, femoral neck, total hip, and greater trochanter were statistically compared between the RA-rem and the non-RA after PSM, and between RA-nonrem and RA-rem after PSM using the Mann-Whitney U test. Results: In total, 107 patients of RA-rem and 108 of non-RA were recruited. BMDs and changes of every part demonstrated no significant differences between the 2 groups. BMDs in every part of RA-rem after PSM were significantly greater than those in every part of RA-nonrem, while no significant difference in change during follow-up. Conclusions: If disease activity is controlled in clinical remission, RA will not contribute to BMD reduction.

The third molar as a cause of deep space infections

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

An 81-month review of patients with deep space infections attributed to third molars requiring hospital admission is presented. Thirty-one patients were identified, with males predominating 2:1 and mandibular third molars as an etiology predominating 15:1. All patients were aged 23 years or older. Most patients identified (24) had one or more medical problems or other risk factors, the most frequent of which was smoking (18). All patients developing postoperative infections (9) had complete or partial bone impactions and a preoperative diagnosis of pericoronitis

Dynamic hip screw fixation versus multiple screw fixation for intracapsular hip fracture

PJI DX Updated Search

PURPOSE: To compare dynamic hip screw (DHS) fixation with multiple screw fixation for intracapsular hip fractures in terms of complications and conversion to hemiarthroplasty or total hip arthroplasty (THA). METHODS: Records of 52 884 patients aged >/=50 years who underwent internal fixation using a dynamic hip screw (n=18 014, 34.1%) or multiple screws (n=34 870, 65.9%) for intracapsular femoral neck fracture from September 2007 to September 2013 were extracted from the hospital admission database that covers all admissions to the National Health Service hospitals in England using the ICD-10 and OPCS-4 codes. Gender, age, and Charlson comorbidity score of each patient were recorded, as were complications at specific time intervals and revision to hemiarthroplasty or THA at one and 4 years. RESULTS: Compared with DHS fixation, multiple screw fixation resulted in shorter hospital stay (15 vs. 13 days, p<0.001) and lower rates of 30-day myocardial infarction (2% vs. 1.5%, p=0.022), 30-day lower respiratory tract infection (12.4% vs. 10.6%, p=0.001), 90-day mortality (10.4% vs. 8.6%, p=0.001), and avascular necrosis (0.1% vs. 0.06%, p=0.032), but a higher rate of conversion to hemiarthroplasty or THA at one or 4 years (all p<0.001). CONCLUSION: Multiple screw fixation for intracapsular hip fracture was associated with a higher conversion rate to hemiarthroplasty or THA at one and 4 years, compared with DHS fixation

The current position of precuffed expanded polytetrafluoroethylene bypass grafts in peripheral vascular surgery

DOD - Acute Comp Syndrome CPG

Objective Long-term results of precuffed expanded polytetrafluoroethylene (ePTFE) grafts used for peripheral bypass surgery are lacking. The aim of this study was to obtain the long-term outcomes of precuffed ePTFE grafts compared with autologous saphenous vein (ASV) grafts used in patients with peripheral arterial disease (PAD). Methods A single-institution retrospective study of precuffed ePTFE and ASV graft performances in patients with PAD was undertaken between January 2004 and December 2012. Five-year primary patency, secondary patency, and limb salvage rates were determined by Kaplan-Meier analyses. Results A total of 467 bypass grafts were included in this study (169 precuffed ePTFE grafts and 298 ASV grafts). Secondary patency rates of ePTFE vs ASV at 1 and 5 years, respectively, were as follows: for 134 supragenicular femoropopliteal bypasses, 60% and 27% vs 89% and 85% (P <.05); for 190 infragenicular femoropopliteal bypasses, 40% and 25% vs 86% and 79% (P <.05); and for 84 femorocrural bypasses, 30% and 14% vs 50% and 50% (P <.05). Five-year limb salvage rates of ePTFE vs ASV for supragenicular femoropopliteal bypasses were 82% vs 94% (P =.16); for infragenicular femoropopliteal bypasses, 41% vs 92% (P <.05); and for femorocrural bypasses, 43% vs 64% (P =.06). Conclusions ASV bypasses are still the first-choice conduit in peripheral bypass surgery performed in patients with PAD. Precuffed ePTFE bypasses are acceptable alternatives in the absence of adequate autologous vein.

The potential influence of regionalization strategies on delivery of care for elective total joint arthroplasty

Surgical Management of Osteoarthritis of the Knee CPG

Regionalization of total joint arthroplasty (TJA) to high volume hospitals (HVHs) may affect access to care and complication risk. Using administrative data, 2,560,314 patients who underwent primary total hip or knee arthroplasty from 1991 to 2006 were categorized by whether an HVH (>200 annual TJAs) was available locally. Associations among patient characteristics, hospital utilization, and in-hospital complications were estimated using regression modeling. The complication risk was higher (Odds Ratio 1.18 [95% CI: 1.16, 1.20]) if patients went to a local low volume hospital. Black and Medicaid patients were more likely to utilize the local low volume hospital than a local HVH. Utilizing a local HVH is associated with lower complication risks. However, patients from vulnerable groups were less likely to utilize these patterns

Assessment of treatment of Osteochondrosis dissecans (OCD) of shoulder joint in dogs - The results of two years of experience

Glenohumeral Joint OA

Osteochondrosis is a common and clinically important joint disorder that occurs in human and many species of animals such as pigs, horses and dogs. The aim of this article is to present the results of conservative and surgical treatment of Osteochondrosis dissecans (OCD) and to compare the recovery time in relation to race, age and extent of cartilage damage. The study was performed on 36 dogs of both sexes, aged from 4 to 24 months, weighing 12-70 kg, of different breeds (predisposed and non-specific for this disease). All patients underwent clinical, orthopedic and radiological examination through which the location of OCD changes in the shoulder joint and the degree of this problem were established. Based on the examinations the patients were qualified for particular treatment procedures. Control tests were performed after 14, 30 and 60 days, which allowed for a precise evaluation of the progress of therapy. Achieved results indicate that dogs age and the lesions extent in the shoulder joint have an impact on the outcome of treatment. Studies showed that the best therapeutic effects were obtained in dogs aged 6-10 months, which underwent surgery. The study proved that the early diagnosis of OCD strongly influence the recovery rate and may inhibit the development of degenerative changes in the joint (DJD).

Poor reproducibility of the MRI measurement of distal femoral torsion

AMP (Acute Meniscal Pathology)

Recent publications on patient-specific instrumentation for total knee arthroplasty have reported considerable variability in the axial positioning of the cutting guides for the femoral component. These personalized cutting guides are manufactured based on bone shape data, generated from magnetic resonance imaging (MRI) or computed tomography (CT). The goal of this study was to compare the reproducibility and accuracy of distal femoral torsion (DFT) values measured using these two imaging modalities. We hypothesized that MRI does not reproducibly and consistently measure DFT and is not as accurate as CT scan. METHODS: Anonymized radiology records from 54 patients that included MRI and CT scans of the knee were read in random order by two observers, on two separate occasions. These records were from patients being considered for a meniscal or osteochondral graft and who had their knee explored, but who had not undergone femoral or tibial surgery and were free of osteoarthritis. The DFT was estimated using the posterior condylar angle (PCA), using both its anatomical and surgical definitions. The intra- and inter-observer reproducibility of the MRI and the differences relative to CT scan measurements were analysed. RESULTS: The average intra-observer difference for the MRI evaluation of the anatomical PCA was 0.8+/-1.2degree; it was 0.4+/-0.9degree for the surgical PCA. More than 1degree difference from the average was found in 8 cases (14%) using the anatomical PCA measurement and 4 cases (7.4%) when using the surgical PCA (P=0.4). The intraclass correlation coefficients (ICCs) were 0.67 (95% CI: 0.33-0.85) and 0.74 (95% CI: 0.47-0.89) for the anatomical and surgical PCA, respectively. The average inter-observer difference for the MRI evaluation of the anatomical PCA was 1.6+/-1.4degree; it was 1.5+/-1.0degree for the surgical PCA. More than 1degree difference from the average was found in 27 cases (50%) using the anatomical PCA measurement and 22 cases (40%) when using the surgical PCA (P=0.4). The ICCs were 0.31 (95% CI: 0.14-0.65) and 0.48 (95% CI: 0.06-0.75) for the anatomical and surgical PCA, respectively. The average differences between the CT and MRI measurements were 1.4+/-1.1degree (0.2-5degree) and 1.1+/-0.8degree (0-3.6degree) for the anatomical and surgical PCA, respectively. Greater than 1degree difference between CT and MRI was found in 29 records (54%) for the anatomical PCA and in 18 records (33%) for the surgical PCA (P=0.03). CONCLUSION: DFT measurement on MRI is more reproducible and consistent when using the surgical PCA. MRI measurements differed by more than 1degree relative to CT measurements in more than one-third of cases. CASE CONTROL STUDY: Level III.

Distal Tibial Tuberosity Focal Dome Osteotomy Combined With Intra-Articular Condylar Osteotomy (Focal Dome Condylar Osteotomy) for Medial Osteoarthritis of the Knee Joint

AMP (Acute Meniscal Pathology)

High tibial osteotomy for medial-compartment knee osteoarthritis (OA) is an established biological knee reconstruction surgical procedure. In open- and closed-wedge high tibial osteotomy, the angulation correction axes are away from the center of rotation and angulation. This results in translation deformity, which alters the orientation of the adjacent joint and the length of the limb. In the present study, we combined the distal tibial tuberosity focal dome osteotomy centered on the center of rotation and angulation with the longitudinal condylar osteotomy (focal dome condylar osteotomy) for knee OA. The advantages of this procedure are as follows: physiological orientation of adjacent joint is achieved; limb length is maintained; joint stabilization in the coronal plane is achieved; patella infra is prevented; sufficient bone contact between the medial and posterior cortex is achieved; early weight-bearing walking is possible; and fibular osteotomy is not required. This study describes the details of the surgical procedure, including our compass cutter for accurate dome osteotomy and the postoperative rehabilitation program for patients with knee OA and moderate-to-severe varus deformity.

Fracture risk and adjuvant hormonal therapy among a population-based cohort of older female breast cancer patients

Management of Hip Fractures in the Elderly

The risk of hip and other fractures was examined among a population-based group of older women with breast cancer. Women using aromatase inhibitors (AIs) were found to be over three times more likely to have a hip fracture over approximately 3 years' follow-up. Other fracture risk factors were also identified. INTRODUCTION: Aromatase inhibitors have been shown in randomized trials to increase total fracture risk compared with tamoxifen, but the fracture risks in the trials were relatively low, and no difference in hip fracture has been demonstrated. METHODS: A population-based cohort of 2003 breast cancer survivors >/=65 were followed prospectively for a median of 36 months. Patient survey information regarding adjuvant breast cancer therapies, prescription osteoporosis treatments, and other factors potentially associated with fracture was supplemented with cancer registry information. Hip and total nonvertebral fractures were determined using a validated Medicare algorithm, and the association of these fractures with adjuvant hormonal therapies was examined using Cox models. RESULTS: The cohort of 2,748 women with a mean age of 72.8 (SD 5.4) included 28.2% who took an aromatase inhibitor and 27.8% tamoxifen. There were 41 hip fractures (1.5%) and 218 nonvertebral fractures (7.9%) among the cohort. Subjects using AIs (adjusted hazard ratio 3.24 (1.05, 9.98)) and subjects not using hormone therapy (3.32 (1.14, 9.65)) were more likely than users of tamoxifen to have a hip fracture. Bisphosphonate use was more common among AI users but did not explain these results. Users of AIs were more likely to have nonvertebral fractures, but this result did not reach statistical significance (adjusted hazard 1.34 (0.92, 1.94)). CONCLUSIONS: Hip and other fractures were common in an older population-based cohort of breast cancer survivors, and aromatase inhibitor use was associated with an increase in the short-term risk of hip fractures not detected in randomized controlled trials

Association of obesity and systemic factors with bone marrow lesions at the knee: a systematic review

OAK 3 - Non-arthroplasty tx of OAK

OBJECTIVE: The objective of this study was to systematically review the literature to determine whether obesity and systemic factors, including age, gender, heritability, dietary factors, smoking, serum and urine biomarkers of cartilage or bone metabolism, bone-related factors, and medication, are associated with knee bone marrow lesions (BMLs) identified on magnetic resonance imaging in asymptomatic pre-osteoarthritis and osteoarthritis populations. METHODS: Electronic searches of MEDLINE and EMBASE were performed from January 1, 1996 to September 30, 2012 using the following keywords: bone marrow lesion(s), bone marrow (o)edema, osteoarthritis, and knee. Studies examining obesity and non-biomechanical factors in relation to the presence, incidence, or change in BMLs were included. Two independent reviewers extracted data and assessed methodological quality of selected studies. Due to the heterogeneity of the studies, we performed a best evidence synthesis. RESULTS: Among 30 studies, 17 were considered high quality. The study populations were heterogeneous in terms of symptoms and radiographic knee osteoarthritis. There was strong evidence for an association between serum lipids and BMLs and no association between age and BMLs. There was moderate evidence for a relationship between obesity and BMLs. There was limited evidence for gender, smoking, C-telopeptide of type I collagen, anti-bone-resorptive treatments, licofelone, and chondroitin sulfate. There was a paucity of evidence for heritability and conflicting evidence for dietary fatty acids. CONCLUSION: There is strong evidence for serum lipids and moderate evidence for obesity as risk factors for knee BMLs. Given the role of BMLs in the pathogenesis of knee osteoarthritis, identification of modifiable risk factors of BMLs and therapeutic interventions targeting BMLs has the potential to reduce the burden of knee osteoarthritis.

The IPSO study: ibuprofen, paracetamol study in osteoarthritis. A randomised comparative clinical study comparing the efficacy and safety of ibuprofen and paracetamol analgesic treatment of osteoarthritis of the knee or hip

Management of Hip Fractures in the Elderly

OBJECTIVE: To compare the analgesic efficacy of single and multiple doses of ibuprofen with that of paracetamol in patients with knee or hip osteoarthritis (IPSO study).METHOD: 222 patients were randomised in a double blind, multicentre study-156 (70%) had a painful knee joint and 66 (30%) a painful hip joint. The main efficacy criterion was pain intensity assessment after a single dose (ibuprofen 400 mg, paracetamol 1000 mg). Functional disability assessment and patient global assessment were carried out over 14 days.RESULTS: The sum of the pain intensity difference over 6 hours after the first administration was significantly higher (p = 0.046) in the ibuprofen group than in the paracetamol group. Over 14 days pain intensity decreased from the first day and was significantly lower in the ibuprofen group than in the paracetamol group (p<0.05). The functional disability of the patient was assessed using the WOMAC; the ibuprofen group improved significantly over 2 weeks compared with the paracetamol group for each of the subscales: stiffness (p<0.002), pain (p<0.001), physical function (p<0.002). The drugs were equally safe.CONCLUSION: The IPSO study shows that for the treatment of osteoarthritic pain, ibuprofen 400 mg at a single and multiple dose (1200 mg/day) for 14 days is more effective than paracetamol, either as a single dose of 1000 mg or a multiple dose (3000 mg/day). Because ibuprofen and paracetamol have similar tolerability, this study indicates that the efficacy/tolerability ratio of ibuprofen is better than that of paracetamol in this indication over 14 days

A retrospective study of the risk factors for ridge expansion with self-tapping osteotomes in dental implant surgery

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

PURPOSE: To analyze the risk factors associated with the survival of self-threading implants placed with the ridge expansion technique using self-tapping osteotomes after at least 24 months. MATERIALS AND METHODS: This retrospective study followed patients for at least 2 years in whom implants had been inserted by means of the ridge expansion technique. The patient was taken as the unit of analysis, and the loss of any implant as a result of mobility at any time during the follow-up period was considered as a failure. A number of patient variables were recorded: sociodemographic (age/sex), anatomical (bone quantity/quality, expansion zone), infection history (prior antibiotic therapy for active infection), prosthodontic (type of provisional prosthesis and type of definitive rehabilitation), and surgical (number of surgical stages, the use of biomaterials or atraumatic maxillary sinus elevation). Risk factors were expressed as values of relative risk (RR) and the odds ratio. RESULTS: Seventy-four patients (157 implants) were followed over a mean period of 38.8 +/- 7.7 months. Most patients (91.9%) did not lose any implants, and failures occurred mainly after implant loading (5.4%). Sociodemographic factors (sex and age) were not associated with a significant risk of implant failure. However, the existence of previous local infection (RR = 34.0), the use of an immediate fixed provisional prosthesis (RR = 15.0), and type D3 bone (RR = 5.1) were seen to be the main risk factors involved in this technique for the period assessed. CONCLUSIONS: The risk of failure when implants are placed using self-tapping osteotomes was highest in patients who had active local infection; immediate provisionalization and less dense bone were also associated with additional risk of failure

Osteochondral defects in the ankle: Why painful?

Osteochondritis Dissecans 2020 Review

Osteochondral defects of the ankle can either heal and remain asymptomatic or progress to deep ankle pain on weight bearing and formation of subchondral bone cysts. The development of a symptomatic OD depends on various factors, including the damage and insufficient repair of the subchondral bone plate. The ankle joint has a high congruency. During loading, compressed cartilage forces its water into the microfractured subchondral bone, leading to a localized high increased flow and pressure of fluid in the subchondral bone. This will result in local osteolysis and can explain the slow development of a subchondral cyst. The pain does not arise from the cartilage lesion, but is most probably caused by repetitive high fluid pressure during walking, which results in stimulation of the highly innervated subchondral bone underneath the cartilage defect. Understanding the natural history of osteochondral defects could lead to the development of strategies for preventing progressive joint damage. © The Author(s) 2010.

Factors predicting incidence of post-operative delirium in older people following hip fracture surgery: a systematic review and meta-analysis

Hip Fx in the Elderly 2019

OBJECTIVE: Delirium is one of the most common complications following hip fracture surgery in older people. This study identified pre- and peri-operative factors associated with the development of post-operative delirium following hip fracture surgery. METHODS: Published and unpublished literature were searched to identify all evidence reporting variables on patient characteristics, on-admission, intra-operative and post-operative management assessing incident delirium in older people following hip fracture surgery. Pooled odds ratio (OR) and mean difference of those who experienced delirium compared to those who did not were calculated for each variable. Evidence was assessed using the Downs and Black appraisal tool and interpreted using the GRADE approach. RESULTS: A total of 6704 people (2090 people with post-operative delirium) from 32 studies were analysed. There was moderate evidence of nearly a two-times greater probability of post-operative delirium for those aged 80 years and over (OR: 1.77; 95% CI: 1.09, 2.87), whether patients lived in a care institution pre-admission (OR: 2.65; 95% CI: 1.79, 3.92), and a six-times greater probability of developing post-operative delirium with a pre-admission diagnosis of dementia (OR: 6.07, 95% CI: 4.84, 7.62). There was no association with intra-operative variables and probability of delirium. CONCLUSION: Clinicians treating people with a hip fracture should be vigilant towards post-operative delirium if their patients are older, have pre-existing cognitive impairment and poorer overall general health. This is also the case for those who experience post-operative complications such as pneumonia or a urinary tract infection. Copyright © 2017 John Wiley & Sons, Ltd.

Sheet fitting palsy

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

A 73-year-old woman developed an acute thrombosis of a persistent median artery following a Sisyphean struggle with a poorly fitted bedsheet. Ultrasound was able to diagnose the problem in a case where precise localization by electrodiagnostic testing was difficult

International society of geriatric oncology (SIOG) clinical practice recommendations for the use of bisphosphonates in elderly patients

MSTS 2018 - Femur Mets and MM

A society of geriatric oncology (SIOG) task force reviewed information from the literature (in PubMed) on bisphosphonates in elderly patients with bone metastases until December 2005. Additional pertinent data were obtained from the manufacturers. Bisphosphonates are recommended in the elderly with bone metastases to prevent skeletal-related events. Intravenous formulations are preferred for the treatment of hypercalcaemia. It has been recognised that zoledronic acid, ibandronate and pamidronate can effectively contribute in relieving metastatic bone pain. Creatinine clearance should be monitored in every patient, and a less renally toxic agent should be used where evidence of similar efficacy is available. The assessment and optimisation of hydration status is recommended. Due to the risk from osteonecrosis of the jaw, routine oral examination and treatment of dental problems by a dental team is recommended before bisphosphonates. Physicians should choose the most appropriate bisphosphonate. Safety precautions are particularly important in elderly patients. Further research is needed in this population. © 2006 Elsevier Ltd. All rights reserved.