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0 | Subcapital stress fractures of the hip complicating total knee replacement | Management of Hip Fractures in the Elderly | Subcapital stress fracture of the femoral neck may complicate total knee replacement particularly if a large deformity has been corrected in a poorly mobile patient. This complication must be suspected in a patient presenting with ipsilateral hip pain following a total knee replacement as prompt diagnosis and internal fixation prior to fracture displacement is more likely to allow preservation of the patient's own femoral head |
0 | Degenerative Changes in the Elbow Joint after Radial Head Excision for Fracture: Quantitative 3-Dimensional Analysis in Bone Density, Stress Distribution and Bone Morphology | Pediatric Supracondylar Humerus Fracture 2020 Review | HYPOTHESIS AND BACKGROUND: Some speculate that excision may lead to elbow arthritis and associated problems; however, evidence supporting these theories is limited. It is hypothesized that radial head excision causes bone density changes as a result of asymmetric stress distributions, consequently leading to osteophyte formation. In this study, we sought to quantitatively compare the 3-dimensional bone density and stress distributions between operative and non-operative elbows in patients that underwent radial head excision. Furthermore, we aimed to quantify the bone morphologic changes using the 3-dimensional models in the same cohort. METHODS: Six patients who had undergone radial head excision for radial head fractures were enrolled after retrospective identification. We created 3-dimensional bone models using computed tomography data obtained from the injured and uninjured elbows. Humerus and ulna models were divided into the anatomical regions and the bone density of each region was assessed and described by their percentage of high-density volume (%HDV). We also constructed finite element models and measured the stress values at each region. Furthermore, we compared the bone morphology by superimposing the operative elbows onto mirror-image of the non-operative elbows. RESULTS: The mean interval from radial head excision to examination was 8.4 ± 3.3 years. The %HDV of the operative side were higher than those of non-operative side at the anterolateral trochlea (77.5 ± 6.5% vs. 64.6 ± 4.0%; p = 0.028) and posterolateral trochlea (70.7 ± 7.8% vs. 63.1 ± 3.8%; p = 0.034) regions of the distal humerus. Reciprocal changes were observed in the proximal ulna, as %HDV was also higher in the lateral coronoid (52.6 ± 9.6% vs. 34.2 ± 6.6%; p = 0.007). The stress distributions paralleled bone density measurements. The operative elbows demonstrated an enlarged capitellum and a widened and deepened trochlea with osteophyte formation, compared with non-operative side. DISCUSSION AND CONCLUSION: In elbows treated with radial head excision, we identified asymmetric bone density and stress alterations at the lateral side of the ulnohumeral joint and bone morphologic changes across the joint. These data support the theory that radial head excision contributes to ulnohumeral arthritis over the long-term. LEVEL OF EVIDENCE: Level III; Case-Control Design; Prognosis Study. |
0 | Radical vulvectomy and bilateral inguinal-femoral lymphadenectomy through separate incisions-experience with 100 cases | MSTS 2018 - Femur Mets and MM | Over a 6-year period 100 patients with vulvar cancer were treated by radical vulvectomy and bilateral inguinal femoral lymphadenectomy performed through separate incisions. The average age of the patients was 68.8 years. Ninety patients had squamous carcinoma, six had melanoma and four had other vulvar malignancies. FIGO staging was stage 1-46, stage II-25, and stage III-23, and stage IVa-6. Twenty-seven patients were found to have spread of tumor to groin nodes, 21 unilateral and six bilateral. For patients with squamous carcinomas, groin nodes were positive in four of 45 (8.9%) with tumor diameter < 2 cm vs. 17 of 42 (40.5%) with tumors> 2 cm. In 60 patients with unilateral squamous tumors, no isolated contralateral node metastases were found, however two of 13 patients (15.4%) with positive ipsilateral nodes had positive contralateral nodes also. One patient with negative nodes developed bilateral recurrent tumor in the skin bridges and subsequently died. Overall 5-year survival corrected for death from intercurrent illness was 74.6%. Corrected survival by stage for squamous carcinomas was as follows: stage I-96.7%, stage II-85%, stage III-45.8% and stage IV-50%. |
0 | 3-Dimensional prebent plate fixation in corrective osteotomy of malunited upper extremity fractures using a real-sized plastic bone model prepared by preoperative computer simulation | Distal Radius Fractures | PURPOSE: To assess the clinical outcome and accuracy of prebent plate fixation in corrective osteotomy for malunited upper extremity fractures using a plastic bone model manufactured by preoperative computer simulation.
METHODS: Nine consecutive patients underwent computed tomography (CT)-based 3-dimensional corrective osteotomy for malunited upper extremity fractures. There were 4 cubitus varus deformities, 1 cubitus valgus deformity, and 4 forearm diaphyseal malunions. We constructed a computer model of the affected bones using the CT data and simulated the 3-dimensional deformity correction on a computer. A real-sized plastic model of the corrected bone was manufactured by rapid prototyping. We used a metal plate, prebent to fit the plastic bone model, in the actual surgery. Patients were evaluated after an average follow-up of 22 months (range, 14-36 mo). We retrospectively collected radiographic and clinical data at the most recent follow-up and compared them with preoperative data. We also performed CT after surgery and evaluated the error in corrective osteotomy as the difference between preoperative simulation and postoperative bone model.
RESULTS: The range of forearm rotation and grip strength in patients with forearm malunions improved after corrective osteotomies of the radius and ulna. Wrist pain, which 2 patients with forearm malunion had experienced before surgery, disappeared or decreased substantially after surgery. Radiographic examination indicated that preoperative angular deformities were nearly nonexistent after all corrective osteotomies. Three-dimensional errors in the corrective osteotomy using a prebent plate, as evaluated by CT data, were less than 3 mm and 2degree.
CONCLUSIONS: Prebent plate fixation in corrective osteotomy for malunited upper extremity fractures using a 3-dimensionally corrected, real-sized plastic bone model prepared by preoperative computer simulation is a precise and relatively easily performed technique that results in satisfactory clinical outcome.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV. |
0 | Early results of one-stage correction for hip instability in cerebral palsy | PJI DX Updated Search | Background: We evaluated the clinical and radiological results of one-stage correction for cerebral palsy patients. Methods: We reviewed clinical outcomes and radiologic indices of 32 dysplastic hips in 23 children with cerebral palsy (13 males, 10 females; mean age, 8.6 years). Ten hips had dislocation, while 22 had subluxation. Preoperative Gross Motor Function Classification System (GMFCS) scores of the patients were as follows; level V (13 patients), level IV (9), and level III (1 ). Acetabular deficiency was anterior in 5 hips, superolateral in 7, posterior in 11 and mixed in 9, according to 3 dimensional computed tomography. The combined surgery included open reduction of the femoral head, release of contracted muscles, femoral shortening varus derotation osteotomy and the modified Dega osteotomy. Hip range of motion, GMFCS level, acetabular index, center-edge angle and migration percentage were measured before and after surgery. The mean follow-up period was 28.1 months. Results: Hip abduction (median, 40ð), sitting comfort and GMFCS level were improved after surgery, and pain was decreased. There were two cases of femoral head avascular necrosis, but no infection, nonunion, resubluxation or redislocation. All radiologic indices showed improvement after surgery. Conclusions: A single event multilevel surgery including soft tissue, pelvic and femoral side correction is effective in treating spastic dislocation of the hip in cerebral palsy. Copyright é 2012 by The Korean Orthopaedic Association |
0 | Transsphenoidal pituitary surgery in the elderly is safe and effective | Upper Eyelid and Brow Surgery | OBJECT: With an increasingly ageing population, the number of elderly people diagnosed with pituitary tumours continues to rise. There is a concern that with increasing age and comorbidities, there is higher anaesthetic risk, as well as peri-operative morbidity and mortality from pituitary surgery. This study aimed to audit the benefits and complications of transsphenoidal surgery performed in a large pituitary centre in elderly patients. METHODS: Data on all elderly patients (age: >/= 70 years) undergoing transsphenoidal surgery at a large tertiary referral centre between November 2003 and August 2012 were collected retrospectively. RESULTS: A total of 104 operations were performed on 102 patients during 106 months. Median age was 75.2 years (range: 70-94) and 63 (61%) of the patients were male. Median follow-up was 15.2 months (range: 2.3-84.4). The majority presented with either peripheral visual field defects (26.4%) or pituitary hormone deficits (17.9%). A significant number (21.7%) of tumours were incidental radiological findings while investigating other diagnoses like stroke and dementia. 48.1% of operations were undertaken microscopically and the remaining 51.9% were endoscopic. Median hospital stay was 4 days (range: 3-18). Intra-operative complications included hypotension (1.9%) and blood loss requiring transfusion (2.9%). The 30-day complications included transient diabetes insipidus (9.6%), syndrome of inappropriate anti-diuretic hormone secretion (8.7%), delayed cerebrospinal fluid leak requiring lumbar drainage (0.9%) with no patient requiring formal repair. There were no peri-operative deaths. Long-term assessment suggested 79% had improved or stable endocrine function with 7% achieving biochemical cure and 91% showed improved or stable visual fields. CONCLUSIONS: Pituitary surgery in the elderly, whether microscopic or endoscopic, has low morbidity and mortality and is a safe and effective intervention for both symptom control and functional outcomes. |
0 | How Are We Measuring Patient Satisfaction After Anterior Cruciate Ligament Reconstruction? | OAK 3 - Non-arthroplasty tx of OAK | Background: Reconstruction of the anterior cruciate ligament (ACL) is one of the most common orthopaedic operations in the United States. The long-term impact of ACL reconstruction is controversial, however, as longer term data have failed to demonstrate that ACL reconstruction helps alter the natural history of early onset osteoarthritis that occurs after ACL injury. There is significant interest in evaluating the value of ACL reconstruction surgeries. Purpose: To examine the quality of patient satisfaction reporting after ACL reconstruction surgery. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the MEDLINE database was performed using the PubMed interface. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as well as the PRISMA checklist were employed. The initial search yielded 267 studies. The inclusion criteria were: English language, US patient population, clinical outcome study of ACL reconstruction surgery, and reporting of patient satisfaction included in the study. Study quality was assessed using the Newcastle-Ottawa scale. Results: A total of 22 studies met the inclusion criteria. These studies comprised a total of 1984 patients with a mean age of 31.9 years at the time of surgery and a mean follow-up period of 59.3 months. The majority of studies were evidence level 4 (n = 18; 81.8%), had a mean Newcastle-Ottawa scale score of 5.5, and were published before 2006 (n = 17; 77.3%); 5 studies (22.7%) failed to clearly describe their method for determining patient satisfaction. The most commonly used method for assessing satisfaction was a 0 to 10 satisfaction scale (n = 11; 50.0%). Among studies using a 0 to 10 scale, mean satisfaction ranged from 7.4 to 10.0. Patient-reported outcome and objective functional measures for ACL stability and knee function were positively correlated with patient satisfaction. Degenerative knee change was negatively correlated with satisfaction. Conclusion: The level of evidence for studies reporting patient satisfaction is low, and the methodologies for reporting patient satisfaction are variable. Additionally, within the past decade there has been a significant decline in the inclusion of this outcome measure within published ACL studies. As sports surgeons are increasingly called on to demonstrate the value of operative procedures, attention should be paid to understanding and reporting patient satisfaction. |
0 | Morbidity and Safety of Iliac Crest Reference Array Pins in Navigated Total Hip Arthroplasty: A Prospective Cohort Study | Hip Fx in the Elderly 2019 | BACKGROUND: Navigated total hip arthroplasty (THA) can employ intra-osseous pins through a separate incision to secure reference arrays to the iliac crest. This study is the first to investigate the consequences of pin use in THA in vivo.
METHODS: A prospective, consecutive series of 43 patients presenting for navigated THA were included. Two temporary 125 x 4 mm Schanz screws were inserted into the iliac crest for the attachment of a reference array. Telephone follow-up occurred at 6 and 12 weeks post-operatively. Patients were asked about pain, interference with daily activities, how often the wound was noticed, and duration of discomfort. Patient body mass index was recorded.
RESULTS: The follow-up rate was 100%. Pin site pain at any time post-operatively was reported by 24 patients (56%). This improved to 30%, 9%, and 2% at 3, 6, and 12 weeks, respectively. On average, pain lasted for 16 days total. The most common complaints after pain were clothing discomfort (23%), pain when wearing a belt (12%), or pain when mobilizing (9%). For the majority (98%) of patients, all symptoms had resolved by 12 weeks. There was no nerve injury, pin site fracture, infection, or screw breakage. Patients with body mass index greater than 30 kg/m<sup>2</sup> were up to 3 times more likely to experience pin site pain (P = .05), and had a longer duration of pain (P = .04).
CONCLUSION: Surgeons and patients should be aware that using navigational pins for array fixation carries low complication rates but often will cause pain and irritation that resolves in the short term. |
0 | Still's disease and recurrent complex regional pain syndrome type-i: The first description | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Complex regional pain syndrome (CRPS) is a chronic neuropathic pain disorder characterized by neuropathic pain associated with local edema and changes suggestive of autonomic involvement such as altered sweating, skin color, and skin temperature of the affected region. CRPS was described associated with several diseases, such as trauma, psychiatric conditions, and cancer. However, no case associated with Still's disease has been previously described. In this paper, the authors describe the first case of |
0 | No association of the single nucleotide polymorphism rs8044769 in the fat mass and obesity-associated gene with knee osteoarthritis risk and body mass index: A PPPULATION-BASEd STUDY IN China | OAK 3 - Non-arthroplasty tx of OAK | Objectives: previous genome-wide association studies (GWAS) have reported significant association of the single nucleotide polymorphism (snp) rs8044769 in the fat mass and obesity-associated gene (FTO) with osteoarthritis (OA) risk in European populations. However, these findings have not been confirmed in Chinese populations. Methods: We systematically genotyped rs8044769 and evaluated the association between the genetic variants and oA risk in a case-controlled study including 196 oA cases and 442 controls in a northern Chinese population. Genotyping was performed using the sequenom MassARRAY ipLeX platform. Results: We found that the variant T allele of rs8044769 showed no significant association of OA risk (p = 0.791), or association with body mass index (BMI) (pmeta = 0.786) in an additive genetic model. However, we detected a significant interaction between rs8044769 genotypes and BMI on oA risk (p = 0.037), as well as a borderline interaction between rs8044769 genotypes and age on oA risk (p = 0.062). Conclusions: our findings indicate that rs8044769 in the FTo gene may not modify individual susceptibility to OA or increased BMI in the Chinese population. Further studies are warranted to validate and extend our findings. |
0 | Changes in the structure and the symptoms of the osteoarthritic knee and prediction of future knee replacement over an 8-year follow-up period | Surgical Management of Osteoarthritis of the Knee CPG | Objective: In osteoarthritis clinical trials, the clinical relevance of a change in structure (e.g., joint space width, cartilage volume) or symptoms is not very well know. If they were predictive of a hard clinical outcome (i.e., joint replacement), they could be considered as clinically relevant. The objective of this study was to assess the association between changes in joint space width (i.e., structure) and in WOMAC score (i.e., symptoms) and the occurrence of future knee replacement. Material and Methods: 133 subjects with primary knee OA were followed prospectively for a mean of eight years. Joint space width was assessed using/with standard x-rays at baseline and each year during 3 years. Symptoms were assessed with the |
0 | Asymptomatic median mononeuropathy among men with chronic paraplegia | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | OBJECTIVES: To compare electrophysiologic abnormalities of the median nerve in asymptomatic paraplegic subjects and able-bodied controls and to examine the influence of personal factors on these parameters. DESIGN: Cross-sectional survey. SETTING: University hospital. PARTICIPANTS: Forty-seven men with paraplegia and 36 able-bodied controls underwent nerve conduction studies on both upper limbs. All were free of hand numbness in the past month, diabetic mellitus, or neuromusculoskeletal injuries to the upper limbs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Nerve conduction studies of the bilateral median and ulnar nerves. RESULTS: Although the 2 groups were of comparable age and had a similar body mass index (BMI), the subjects with paraplegia had a significantly higher proportion of asymptomatic median mononeuropathy than the controls (25.5% vs 5.6%, P=.02). The spinal cord injury (SCI) group had a prolonged median distal latency and a slowed digit-wrist sensory nerve conduction velocity. Multivariate general linear model analysis showed that prolonged motor and sensory latencies of the median nerve were associated with the SCI group and with greater BMI. CONCLUSIONS: The asymptomatic subjects with paraplegia had a significantly higher frequency of median mononeuropathy than the able-bodied controls. There was also an association between BMI and distal latency of the median nerve |
0 | Population-based Canadian hip fracture rates with international comparisons | Management of Hip Fractures in the Elderly | SUMMARY: We identified hospitalizations throughout Canada during 2000-2005 in which the most responsible diagnosis was a proximal femoral fracture. Use of the US fracture risk assessment tool (FRAX) would be inappropriate for Canada as it would overestimate fracture risk in Canadian women and older men. INTRODUCTION: It is recommended that the WHO fracture risk assessment tool should be calibrated to the target population. METHODS: We identified hospitalizations for women and men throughout Canada during the study period 2000-2005 in which the most responsible diagnosis was a proximal femoral fracture (147,982 hip fractures). Age-standardized hip fracture rates were compared between Canadian provinces, and national rates were compared with those reported for the USA and Germany. RESULTS: There were relatively small differences in hip fracture rates between provinces, and most did not differ appreciably from the Canadian average. Hip fracture rates for women in Canada in 2001 were substantially lower than in the USA (population-weighted rate ratio 0.70) and were also lower than in Germany for 2004 (population-weighted rate ratio 0.74). CONCLUSIONS: Overall hip fracture rates for Canadian women were found to be substantially lower than those for the USA and Germany. This study underscores the importance of assessing country-specific fracture patterns prior to adopting an existing FRAX tool |
0 | Histological evaluation of spontaneous osteonecrosis of the medial femoral condyle and short-term clinical results of osteochondral autografting: a case series | AMP (Acute Meniscal Pathology) | Although many surgical modalities for spontaneous osteonecrosis of the knee (SONK) of the medial femoral condyle have been reported, few reports have described these treatment options from the etiological point of view. Recently, osteochondral autografting has gained popularity for use in small cartilage injuries. The aims of this study were to characterize the SONK lesion histopathologically and to report on preliminary clinical results of autogenous osteochondral grafting for SONK. Six patients with SONK of the medial femoral condyle underwent osteochondral autografting. Average age was 54.2 years (range, 50-57 years). Using Koshino's classification, three patients' lesions were classified as stage III and three as stage IV. Classical histological investigation of the lesions was performed in all cases. All the patients achieved favorable pain relief after osteochondral autografts. The mean duration of follow-up was 27.7 months (range, 23-45 months). An increase in the average Lysholm score was found, ranging from 54.7 preoperatively to 92.3 postoperatively. Histological investigation of the lesions revealed articular bone plate fracture with enchondral ossification, reactive cartilage tissue formation, and proliferation of fibrous tissue. An area of osteonecrosis was observed in detached or fragmented osteochondral lesions. Osteochondral autografting was performed on six patients for the SONK and the short-term clinical results were favorable. Histological results give support to subchondral fracture as the etiological mechanism underlying SONK. |
1 | The relationship between catastrophizing and disability in amputees experiencing phantom pain | DoD PRF (Psychosocial RF) | Purpose: In recent years, researchers have noted that catastrophizing predicts both self-reported and objective measures of disability in a variety of chronic pain conditions. The present study sought to examine this in a working-age amputee population experiencing phantom pain. Method: Participants completed a postal questionnaire incorporating measures of pain, disability and coping. A response rate of 62% resulted in 315 completed data sets being incorporated into the study. Results: Utilizing the three subscales of the Sickness Impact Profile, catastrophizing uniquely predicted 11% of the variance in overall level of disability, 6% in physical disability and 13% in psychosocial disability after accounting for demographic, amputation and pain-related variables. Conclusion: The findings suggest that catastrophizing is a significant predictor of self-reported disability in an amputee population. This population have lifetime rehabilitation needs in that prostheses have to be remade on a regular basis. The service provided tends to focus on physical rehabilitation with the goal of providing amputees with limbs that most closely resemble the appearance and function of the intact limb. This study provides tentative support for development of an intervention that specifically targets catastrophizing. (PsycINFO Database Record (c) 2016 APA, all rights reserved) |
0 | Radioembolization with yttrium microspheres for neuroendocrine tumour liver metastases | MSTS 2018 - Femur Mets and MM | Background: 90Y microsphere radioembolization is performed by injecting the microspheres through a hepatic artery catheter placed percutaneously via the femoral or brachial artery. This study assessed the efficacy of 90Y microsphere therapy for patients with unresectable neuroendocrine tumour liver metastases (NETLMs). Potential prognostic factors were analysed for their impact on overall survival. Methods: A prospectively collected database for patients with NETLMs treated by 90Y microspheres in two centres from 2003 to 2008 was examined retrospectively. Serial radiographic evidence was collected during follow-up to assess response. Results: Fifty-eight patients were included, 51 of whom had évaluable disease at most recent follow-up. Six patients achieved a complete response, 14 a partial response, 14 had stable disease and 17 had disease progression. Overall survival rates at 1, 2 and 3 years were 86, 58 and 47 per cent respectively; median survival was 36 (range 1 -61) months. Extent of tumour involvement, radiographic response to treatment, extrahepatic disease and tumour grade were significant prognostic factors for overall survival. Conclusion: 90Y microsphere radioembolization achieved a radiographic response in a significant proportion of patients with NETLMs. Copyright © 2010 British Journal of Surgery Society Ltd. |
0 | The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Supracondylar Humeral Fracture Pearls and Pitfalls | Pediatric Supracondylar Humerus Fracture 2020 Review | Supracondylar humeral fractures are the most common type of pediatric elbow fracture. With proper treatment, these injuries usually heal well and the patients return to full function. However, a small percentage of these injuries may result in devastating complications and, thus, provoke anxiety in many surgeons treating them. This article provides tips for successful management of these injuries without complications and provides references for further study. |
0 | Monitoring the one year postoperative infection rate after primary total hip replacement | PJI DX Updated Search | PURPOSE: Infection of a total hip replacement is potentially a devastating complication. Statistical process control methods have been generating interest as a means of improving the quality of healthcare, and we report our experience with the implementation of such a method to monitor the one year infection rate after primary total hip replacement. METHOD: Infection was defined as the growth of the same organism in cultures of at least two aspirates or intra-operative specimens, or growth of one pathogen in a patient with local signs of infection such as erythema, abscess or draining sinus tract. The cumulative summation test (CUSUM test) was used to continuously monitor the one year postoperative infection rate. The target performance was 0.5% and the test was set to detect twice that rate. RESULTS: Over the three year study period, 2006 primary total hip replacements were performed. Infection developed within one year after surgery in eight (0.4%) hips. The CUSUM test generated no alarms during the study period, indicating that there was no evidence that the process was out of control. CONCLUSION: The one year infection rate after primary total hip replacement was in control. The CUSUM test is a useful method to continuously ensure that performance is maintained at an adequate level |
0 | Bone mineral alterations and Mg content in aging | Management of Hip Fractures in the Elderly | The authors propose to determine whether the quantity of bone mass reduction linked to aging is accompanied by qualitative modifications of the mineral structure. To this end, 18 samples of cancellous bone from the femoral heads of two groups of patients (Groups A & B), were examined. Group A was made up of 8 old osteopenic patients suffering from fracture of the femur neck (age 62-84). Group B consisted of 10 young non-osteopenic subjects (age 34-53). Through chemical analysis a statistically significant percentage increase in Mg++ was noted in Group A and, by X-Ray diffraction, significant presence of beta-TCP. Mineral structure alterations occur in the process of aging of the skeletal tissue |
0 | Intraoperative low-dose ketamine infusion reduces acute postoperative pain following total knee replacement surgery: A prospective, randomized double-blind placebo-controlled trial | Surgical Management of Osteoarthritis of the Knee CPG | Objective: To evaluate the effect of intraoperative low-dose ketamine with general anesthesia on postoperative pain after total knee replacement surgery. Study Design: A randomized, double-blind comparative study. Place and Duration of Study: Ankara Numune Training and Research Hospital, Turkey, from January and June 2011. Methodology: Sixty adults undergoing total knee arthroplasty were enrolled in this study. The patients were randomly allocated into two groups of equal size to receive either racemic ketamine infusion (6 (mu)g/kg/minute) or the same volume of saline. A visual analogue scale (VAS) was used to measure each patient's level of pain at 1, 3, 6, 12, and 24 hours after surgery. Time to first analgesic request, postoperative morphine consumption and the incidence of side effects were also recorded. Results: Low-dose ketamine infusion prolonged the time to first analgesic request. It also reduced postoperative cumulative morphine consumption at 1, 3, 6, 12, and 24 hours postsurgery (p < 0.001). Postoperative VAS scores were also significantly lower in the ketamine group than placebo, at all observation times. Incidences of side effects were similar in both study groups. Conclusion: Intraoperative continuous low-dose ketamine infusion reduced pain and postoperative analgesic consumption without affecting the incidence of side effects |
0 | Ulcerative and mutilating variant of carpal tunnel syndrome | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Cutaneous involvement in severe carpal tunnel syndrome is secondary to damage to sensory and autonomic fibers of the median nerve. We report the case of a 63 year old man who presented skin and bone lesions, confined to the sensory zones of both median nerves. The lesions consisted of dystrophic modifications of the fingernails, progressive sclerosis, skin thickening and ulcerations on the fingers, acro-osteolysis, and purulent inflammation with subsequent auto-amputation of the distal phalanx of the right index finger. Clinical, neurophysiological and surgical findings are reported. The recovery of the ulcerative lesions suggests the reversibility of autonomic disturbances after surgery |
1 | Meniscal allograft transplantation after meniscectomy: clinical effectiveness and cost-effectiveness | AMP (Acute Meniscal Pathology) | PURPOSE: To assess the clinical effectiveness and cost-effectiveness of meniscal allograft transplantation (MAT) after meniscal injury and subsequent meniscectomy.
METHODS: Systematic review of clinical effectiveness and cost-effectiveness analysis.
RESULTS: There is considerable evidence from observational studies, of improvement in symptoms after meniscal allograft transplantation, but we found only one small pilot trial with a randomised comparison with a control group that received non-surgical care. MAT has not yet been proven to be chondroprotective. Cost-effectiveness analysis is not possible due to a lack of data on the effectiveness of MAT compared to non-surgical care.
CONCLUSION: The benefits of MAT include symptomatic relief and restoration of at least some previous activities, which will be reflected in utility values and hence in quality-adjusted life years, and in the longer term, prevention or delay of osteoarthritis, and avoidance or postponement of some knee replacements, with resulting savings. It is likely to be cost-effective, but this cannot be proven on the basis of present evidence.
Level of evidence: Iv. |
0 | The course of health status and (health-related) quality of life following fracture of the lower extremity: a 6-month follow-up study | Hip Fx in the Elderly 2019 | Purpose: The aim of this prospective study was to describe the course of health status (HS), health-related quality of life, and quality of life (QOL) in patients with lower extremity fractures (LEF) up to 6 months post-fracture. Methods: Patients (n = 171; age range 18â??100 years) completed the World Health Organization Quality of Life assessment instrument-Bref (WHOQOL-Bref) and the Short Musculoskeletal Function Assessment questionnaire (SMFA) at time of diagnosis (i.e., pre-injury status), 1 week, and 6 months post-fracture. Linear mixed modeling was performed. Results: Interaction effects of time with treatment were detected for the WHOQOL-Bref facet Overall QOL and General health (p = .002) and Physical health (p = .003). Patients did not return to their pre-injury Physical health, Psychological health, and Environment 6 months post-fracture (p < .05). No effects were found for Social relationships. The SMFA subscale Lower extremity dysfunction showed main effects for time and treatment (p < .0001) with full recovery at 6 months (p = .998). An interaction effect of time with treatment was found for Daily life consequences (p < .0001) with nonoperatively treated patients showing full recovery (p = 1.00), whereas surgically treated patients did not (p = .002). Conclusions: Six months after LEF, patients still experienced impaired physical and psychological health on the WHOQOL-Bref compared to their pre-injury status. However, patients showed full recovery on SMFA Lower extremity dysfunction, indicating that the choice of the questionnaire influences the derived conclusions. LEF did not affect satisfaction with social relationships. |
0 | 18F-FDG PET/CT as an indicator of progression-free and overall survival in osteosarcoma | MSTS AUC - Based on ACR Lit Review | UNLABELLED: The aim of our study was to retrospectively evaluate whether maximum standardized uptake value (SUV(max)), total lesion glycolysis (TLG), or change therein using (18)F-FDG PET/CT performed before and after initial chemotherapy were indicators of patient outcome. METHODS: Thirty-one consecutive patients who underwent (18)F-FDG PET/CT before and after chemotherapy, followed by tumor resection, were retrospectively reviewed. Univariate Cox regression was used to analyze for relationships between covariates of interest (SUV(max) before and after chemotherapy, change in SUV(max), TLG before and after chemotherapy, change in TLG, and tumor necrosis) and progression-free and overall survival. Logistic regression was used to evaluate tumor necrosis. RESULTS: High SUV(max) before and after chemotherapy (P = 0.008 and P = 0.009, respectively) was associated with worse progression-free survival. The cut point for SUV(max) before chemotherapy was greater than 15 g/mL* (P = 0.015), and after chemotherapy it was greater than 5 g/mL* (P = 0.006), as measured at our institution and using lean body mass. Increase in TLG after chemotherapy was associated with worse progression-free survival (P = 0.016). High SUV(max) after chemotherapy was associated with poor overall survival (P = 0.035). The cut point was above the median of 3.3 g/mL* (P = 0.043). High TLG before chemotherapy was associated with poor overall survival (P = 0.021). Good overall and progression-free survival was associated with a tumor necrosis greater than 90% (P = 0.018 and 0.08, respectively). A tumor necrosis greater than 90% was most strongly associated with a decrease in SUV(max) (P = 0.015). CONCLUSION: (18)F-FDG PET/CT can be used as a prognostic indicator for progression-free survival, overall survival, and tumor necrosis in osteosarcoma |
1 | The value of arthroscopy of the knee in the management of sports injuries | AMP (Acute Meniscal Pathology) | A retrospective review of 31 sportsmen and 4 sportswomen who underwent arthroscopy of the knee is presented. The indications for and the results of arthroscopy are discussed. The recommendation that an arthroscopy be performed on all patients in whom it is proposed to do a meniscectomy is made. |
0 | Magnetic resonance imaging of the hip: Anatomy and pathology | AMP (Acute Meniscal Pathology) | The aim of this review is to outline the normal anatomy of the hip and to discuss common painful conditions of the hip that affect the general adult population. Hip pain is a common complaint with many different etiologies. In this review, hip pathologies are divided by location into osseous, intra-articular and extra-articular lesions. Magnetic resonance imaging (MRI) is the modality of choice for investigating painful hip conditions due to its multiplanar capability and high contrast resolution. This review focuses on the characteristic MRI features of common traumatic and pathologic conditions of the hip. |
0 | Clinical value of SPECT/CT for evaluation of patients with painful knees after total knee arthroplasty--a new dimension of diagnostics? | PJI DX Updated Search | BACKGROUND: The purpose of our study was to evaluate the clinical value of hybrid SPECT/CT for the assessment of patients with painful total knee arthroplasty (TKA). METHODS: Twenty-three painful knees in patients following primary TKA were assessed using Tc-99m-HDP-SPECT/CT. Rotational, sagittal and coronal position of the TKA was assessed on 3D-CT reconstructions. The level of the SPECT-tracer uptake (0-10) and its anatomical distribution was mapped using a validated localization scheme. Univariate analysis (Wilcoxon-Mann-Whitney, Spearmean's-rho test, p < 0.05) was performed to identify any correlations between component position, tracer uptake and diagnosis. RESULTS: SPECT/CT imaging changed the suspected diagnosis and the proposed treatment in 19/23 (83%) knees. Progression of patellofemoral OA (n = 11), loosening of the tibial (n = 3) and loosening of the femoral component (n = 2) were identified as the leading causes of pain after TKA.Patients with externally rotated tibial trays showed higher tracer uptake in the medial patellar facet (p = 0.049) and in the femur (p = 0.051). Patients with knee pain due to patellofemoral OA showed significantly higher tracer uptake in the patella than others (p < 0.001). CONCLUSIONS: SPECT/CT was very helpful in establishing the diagnosis and guiding subsequent management in patients with painful knees after TKA, particularly in patients with patellofemoral problems and malpositioned or loose TKA |
1 | Incidence and prediction of psychiatric morbidity after a motor vehicle accident in Japan: The Tachikawa Cohort of Motor Vehicle Accident Study | DoD PRF (Psychosocial RF) | OBJECTIVES: To assess both the incidence of new-onset psychiatric illness after involvement in a motor vehicle accident in Japan for comparison with Western data and the predictors of psychiatric morbidity and posttraumatic stress disorder (PTSD) evaluated immediately after the accident. DESIGN: Prospective cohort study of injured patients assessed immediately and 4-6 wks after involvement in a motor vehicle accident. SETTING: Intensive care unit in a teaching hospital in Tokyo, Japan. PATIENTS: Total of 100 consecutive patients with motor vehicle accident-related injuries (mean Injury Severity Score, 11.2; mean Glasgow Coma Scale, 14.5; age, 18-69 yrs) admitted to the intensive care unit. Patients with traumatic brain injury, suicidality, current psychiatric or neurologic illness, or cognitive impairment were excluded. MEASUREMENTS: An extensive clinical interview and evaluation of vital signs, sociodemographic variables, previous traumatic events, family history of psychopathology, Impact of Event Scale-Revised, Hospital Anxiety and Depression Scale, Clinician-Administered PTSD Scale, and Mini-International Neuropsychiatric Interview. RESULTS: A total of 31 patients showed some form of new-onset psychiatric illness at the 4- to 6-wk follow-up. The majority of illnesses consisted of depression (major depression, n = 16; minor depression, n = 7) and PTSD (full PTSD, n = 8; partial PTSD, n = 16). Other illnesses included alcohol dependence (n = 3), obsessive-compulsive disorder (n = 2), agoraphobia (n = 2), and social phobia (n = 1). Both psychiatric morbidity and PTSD were predicted by a sense of life threat (odds ratio, 4.2 and 6.2, respectively), elevated heart rate (odds ratio, 1.6 and 1.7), and higher Impact of Event Scale-Revised intrusion subscale score (odds ratio, 1.1 and 1.1). CONCLUSION: This study showed that psychopathology and PTSD after a motor vehicle accident in Japan is common and that the incidence is within the range of that in Western countries. A combination of a sense of life threat, heart rate, and Impact of Event Scale-Revised intrusion subscale allowed for significant prediction of psychiatric morbidity and PTSD. © 2008 Lippincott Williams & Wilkins, Inc. |
0 | Economic evaluation of methyl aminolaevulinate-based photodynamic therapy in the management of actinic keratosis and basal cell carcinoma | Reconstruction After Skin Cancer | OBJECTIVESTo evaluate the cost-effectiveness of a recent approach, methyl aminolaevulinate-based photodynamic therapy (MAL-PDT; Metvix; Galderma, Lausanne, Switzerland) in AK and BCC.METHODSA medical decision tree was developed for simulation of all possible outcomes associated with the medical decision to apply MAL-PDT or a comparator. The time horizon was 1 year for AK and 5 years for BCC. The comparators were cryotherapy in AK and excision surgery in BCC. Clinical data for the model were obtained from the literature. Data on medical management resulted from a Delphi panel performed among 12 Belgian dermatologists. Based on the model, the cost per full responder was calculated, whereby a responder was defined as a patient with all lesions clinically responding and showing an excellent cosmetic result.RESULTSMAL-PDT is a more expensive treatment compared with cryotherapy for AK. However, the cost per full responder is comparable with cryotherapy (euro363 and euro379, respectively). Incremental cost per extra full responder is euro401. Incremental cost per full responder is euro469 for nodular BCC and euro251 for superficial BCC, both compared with excision surgery.CONCLUSIONSThe results suggest that MAL-PDT is a cost-effective intervention in AK taking a 1-year time horizon, if society is willing to pay euro1.50 per day of response, and that MAL-PDT is better value for money than excision in BCC, taking a 5-year time horizon.BACKGROUNDVarious effective therapeutic options are currently available for the treatment of actinic keratosis (AK) and basal cell carcinoma (BCC), but none is perfect. Poor cosmesis resulting from surgical procedures and skin irritation induced by topical agents remain significant problems. |
0 | Custom total hip arthroplasty | HipFx Supplemental Cost Analysis | Custom total hip arthroplasty (THA) has been advocated as a primary operation to achieve optimal proximal fit and fill in THA. Because of the increased cost of the implant, it must be proved that survivorship of the custom component is improved compared with a well-cemented or cementless off- the-shelf femoral prosthesis. A series of 64 primary and revision femoral component custom titanium uncemented THAs were reviewed. In the primary custom group 90.9%, and in the revision group 80%, had good to excellent results using the Harris hip scoring system at a mean follow-up period of 6.5 years. The age range was 32 to 74 years (mean, 53 years). Thigh pain was present in 17% of the patients in this series. Significant osteolysis occurred in 4.7% of the cases. The average time to failure for the four primary custom THAs was 4.1 years, and for the four revision custom THAs, 2.4 years. Despite excellent proximal fit and fill, these short-term results have not resulted in improved success rates compared with a well-cemented or cementless off-the-shell femoral when performing THA |
0 | Osteochondral Autograft Transfer for Focal Cartilage Lesions of the Knee With Donor-Site Back-Fill Using Precut Osteochondral Allograft Plugs and Micronized Extracellular Cartilage Augmentation | Osteochondritis Dissecans 2020 Review | Osteochondral autograft transfer (OAT) allows for the treatment of focal chondral lesions of the femoral condyles. Patients undergoing OAT have been shown to have the greatest rate and quickest return to sport of any cartilage-restoration procedure. Disadvantages encountered with the OAT procedure include limited donor sources, small treatable lesion size, and donor-site morbidity. Here, we describe our preferred technique of open OAT with donor-site back-filling using precut fresh osteochondral allograft plugs and micronized extracellular cartilage augmentation. Advantages to this technique include single-stage transfer of living autologous osteochondral grafts allowing for early ambulation, predictable return to sport, enhanced long-term graft survival, and decreased donor-site morbidity secondary to fresh osteochondral allograft back-fill. |
0 | Preventing the development of chronic pain after orthopaedic surgery with preventive multimodal analgesic techniques | AAHKS (8) Anesthetic Infiltration | The prevalences of complex regional pain syndrome, phantom limb pain, chronic donor-site pain, and persistent pain following total joint arthroplasty are alarmingly high. Central nervous system plasticity that occurs in response to tissue injury may contribute to the development of persistent postoperative pain. Many researchers have focused on methods to prevent central neuroplastic changes from occurring through the utilization of preemptive or preventive multimodal analgesic techniques. Multimodal analgesia allows a reduction in the doses of individual drugs for postoperative pain and thus a lower prevalence of opioid-related adverse events. The rationale for this strategy is the achievement of sufficient analgesia due to the additive effects of, or the synergistic effects between, different analgesics. Effective multimodal analgesic techniques include the use of nonsteroidal anti-inflammatory drugs, local anesthetics, alpha-2 agonists, ketamine, alpha(2)-delta ligands, and opioids. [References: 175] |
0 | Minimally invasive surgery unicompartmental knee arthroplasty assisted by computer navigation system | Surgical Management of Osteoarthritis of the Knee CPG | Background: Computer navigation system in total hip replacement can strictly locate prosthetic position. Objective: To explore the feasibility and preliminary effect of minimally invasive surgery unicompartmental knee arthroplasty (MIS-UKA) assisted by computer navigation system. Methods: Between May 2009 and May 2010, 28 consecutive patients (28 knees) with unicompartmental knee osteoarthritis were treated with MIS-UKA assisted by computer navigation system. Results and Conclusion: All cases were followed up for average 18 months (12-24 months). The mean length of incision was 6.8 cm, the mean surgical time was 91.6 minutes, the mean blood loss during operation was 45.8 mL and the mean drainage was 38.5 mL. At the last follow up, all cases achieved significant relief of pain, improvement of HSS score and range of motion, and correction of varus deformity. None had complications of infection, fat embolism, deep vein thrombosis, malposition of prosthesis, dislocation and loosing. Computer navigation system-assisted MIS-UKA gives a better correction of alignment of the leg and orientation of the components. Computer navigation system can effectively improve the outcome of MIS-UKA |
0 | Cervical epidural anesthesia and surgical blood loss in radical mastectomy | AAHKS (8) Anesthetic Infiltration | To determine whether epidural anesthesia reduces intraoperative blood loss, intraoperative blood loss during radical mastectomy in three groups of patients was compared: cervical epidural plus 67% N2O and O2 (n=22);enflurane and 67% N2O and O2 (n=21); and deep enflurane and 67% N2O and O2 (n=15). Intra-operative blood loss was significantly reduced in the epidural anesthesia group (401 ± 167 ml; mean ± 1 SD) as compared with the normotensive-enflurane group (644 ± 234 ml) and the mild hypotensive-enflurane group (615 ± 218 ml) (p<0.05). The number of patients given blood transfusion during surgery were 1 of 22 patients in the epidural group, 6 of 21 patients in the nomotensive-enflurane group, and 2 of 15 patients in the mild hypotensive-enflurane group. The duration of surgery and anesthesia did not differ significantly among the three groups. However, the awakening time was significantly shorter in the epidural group compared with both enflurane groups (p<0.05). The beneficial effects op epidural anesthesia have been reported in total hip replacement and are thought to be due to a decrease in arterial blood pressure. The results of the current study indicate that the mild reduction of arterial blood pressure is unlikely to be responsible for the significant reduction of surgical blood loss associated with cervical epidural block. The application of cervical epidural anesthesia for radical mastectomy is a safe practice and could provide a reduction of surgical blood loss. |
0 | Injury patterns from major urban terrorist bombings in trains: the Madrid experience | DoD LSA (Limb Salvage vs Amputation) | BACKGROUND: Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI. METHODS: We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS. RESULTS: The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo's grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1-6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h. CONCLUSIONS: Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries. |
1 | Can we reduce morphine use in elderly, proximal femoral fracture patients using a fascia iliac block? | Hip Fx in the Elderly 2019 | Proximal femoral fractures are becoming increasingly common with an ageing population. Many patients have multiple comorbidities increasing their risk of opiate complications. 40 consecutive patients presenting with a proximal femoral fracture to a trauma centre in the UK were given either a Fascia Iliaca Block (FIB) with oral analgesia or just oral analgesia to control their pre-operative pain. Numeric pain scores and morphine consumption were used as outcome measures. Patients receiving a FIB had significant reduction in their pain scores compared to patients only receiving oral pain relief. There was also a significant reduction in both the actual oral morphine taken and the renal calculated level of morphine products in the group receiving the FIB. Patients undergoing a FIB required almost 50 mg less oral morphine pre-operatively. Nerve blocks should be used routinely to help pre-operative pain in proximal femoral fracture patients and to reduce the amount of morphine products prescribed. This prevents potential opiate complications in a highly susceptible cohort of patients often suffering with impaired renal function as a co-morbidity. |
0 | Comparison the effect of acupuncture in treatment of De Quervainâ??s disease with steroid injection | Distal Radius Fractures | INTERVENTION: Control group (injection): To inject the sheath around the abductor pollicis longus and extensor pollicis brevis tendons, the insulin needle is inserted 1 cm proximal to the radial styloid process at the angle of 45 degree from the skin and parallel to the direction of the tendons. If resistance is so high, the needle is slightly pulled back and then a mixture of 0.5 ml of (40 mg) methylprednisolone acetate and 0.5 ml of 2% lidocaine is injected. The injection is performed for one session. Intervention 1: Intervention group (Acupuncture): Sterile needles are inserted perpendicularly into LIâ?5 , LUâ?7, LUâ?9 and also ashi points (points with maximal tenderness) to the depth of 0.5 cun. These points are selected based on the meridians contributing to the affected area of wrist . Acupuncture treatment consists of 5 sessions of 30 minutes duration that is administered within 1 week. (1 cun: The breadth of the patient's thumb). Intervention 2: Control group (injection): To inject the sheath around the abductor pollicis longus and extensor pollicis brevis tendons, the insulin needle is inserted 1 cm proximal to the radial styloid process at the angle of 45 degree from the skin and parallel to the direction of the tendons. If resistance is so high, the needle is slightly pulled back and then a mixture of 0.5 ml of (40 mg) methylprednisolone acetate and 0.5 ml of 2% lidocaine is injected. The injection is performed for one session. Intervention group (Acupuncture): Sterile needles are inserted perpendicularly into LIâ?5 , LUâ?7, LUâ?9 and also ashi points (points with maximal tenderness) to the depth of 0.5 cun. These points are selected based on the meridians contributing to the affected area of wrist . Acupuncture treatment consists of 5 sessions of 30 minutes duration that is administered within 1 week. (1 cun: The breadth of the patient's thumb) Treatment â? Drugs Treatment â? Other CONDITION: De Quervain's tenosynovitis. ; Radial styloid tenosynovitis [de Quervain] Radial styloid tenosynovitis [de Quervain] PRIMARY OUTCOME: Function. Timepoint: Prior to the intervention, 2 weeks and 6 weeks after the end of intervention. Method of measurement: Quickâ? Disabilities of the Arm, Shoulder and Hand (Qâ?DASH) score. Pain. Timepoint: Prior to the intervention, 2 weeks and 6 weeks after the end of intervention. Method of measurement: Visual Analogue Scale (VAS) score. INCLUSION CRITERIA: INCLUSION CRITERIA: The patients with clinical diagnosis of De Quervain's tenosynovitis including pain and swelling around styloid process of radius and positive Finkelstein test who have symptoms more than 4 weeks. Exclusion criteria: The patients with acute symptom less than 4 weeks; history of direct trauma or fracture of wrist; previous history of local injection or surgery around styloid process of radius; uncontrolled concomitant disease such as diabetes mellitus or coagulopathy; abnormal findings in blood tests and radiography of wrist. |
0 | Changes in bone mineral density, lean body mass and fat content as measured by dual energy x-ray absorptiometry in patients with prostate cancer without apparent bone metastases given androgen deprivation therapy | Management of Hip Fractures in the Elderly | PURPOSE: We characterize the consequences of androgen deprivation therapy on body composition in elderly men. MATERIALS AND METHODS: Using a dual energy x-ray absorptiometry instrument, we determined the changes in bone mineral density, bone mineral content, fat body mass and lean body mass in 35 patients with prostate cancer without bone metastases who received luteinizing hormone releasing hormone analogue for 12 months. RESULTS: At baseline conditions 46% of cases were classified as osteopenic and 14% as osteoporotic at the lumbar spine and 40% were osteopenic and 4% osteoporotic at the hip. Androgen deprivation significantly decreased bone mineral density either at the lumbar spine (mean gm./cm.2 [SD] 1.00 [0.194], 0.986 [0.172] and 0.977 [0.182] at baseline, and 6 and 12 months, respectively, p <0.002) or the hip (0.929 [0.136], 0.926 [0.144] and 0.923 [0.138], p <0.03). A more than 2% decrease in bone mineral density was found at the lumbar spine in 19 men (54.3%) and at the hip in 15 (42.9%). Bone mineral content paralleled the bone mineral density pattern. Lean body mass decreased (mean gm. [SD] 50,287 [6,656], 49,296 [6,554] and 49,327 [6,345], p <0.003), whereas fat body mass consistently increased (18,115 [6,209], 20,724 [6,029] and 21,604 [5,923] p <0.001). CONCLUSIONS: Serial bone densitometry evaluation during androgen deprivation therapy may allow the detection of patients with prostate cancer at risk for osteoporotic fractures, that is those with osteopenia or osteoporosis at baseline and fast bone loss. The change in body composition may predispose patients to accidental falls, thus increasing the risk of bone fracture |
0 | Improving emergency medicine residents' approach to patients with alcohol problems: a controlled educational trial | DoD PRF (Psychosocial RF) | STUDY OBJECTIVE: We determine whether training using a structured skills-based intervention would improve emergency medicine residents' knowledge and practice in screening and intervening with patients presenting to the emergency department with alcohol problems.
METHODS: In a controlled trial conducted at 2 similar emergency medicine residency programs associated with urban, Level I trauma centers, a 4-hour didactic, video, and skills-based workshop was conducted. Main outcome measures included (1) scores on changes in self-reported knowledge, current practice, self-efficacy, role-responsibility, attitudes and beliefs, and provider readiness to change from baseline to 1 year after intervention and (2) change in practice as measured by record review before and after intervention.
RESULTS: The intervention group (n=17) had a significant increase in knowledge scores (P <.001) and practice with regard to percent of medical records with evidence of screening and intervention (17% before versus 58% after; 95% confidence interval [CI] 31 to 50; P <.001); no change was observed in the control group (n=19). These increases were significantly different between groups (95% CI 30 to 54; P <.001). There were no significant differences within or between groups for composite scores derived for current practice, self-efficacy, role responsibility, or readiness to change.
CONCLUSION: A brief, structured, educational intervention for residents contributed to significant improvement in knowledge and practice with regard to patients with alcohol problems. |
0 | INFECTIOUS ENDOCARDITIS IN PATIENTS AT PELTIER HOSPITAL IN DJIBOUTI | Dental Implant Infection | Bacterial endocarditis remains a serious tropical disease. Bacterial endocarditis is predisposed by the presence of a lesion on the intracardiac surface upon which blood borne pathogens adhere, damage the endothelium and colonize causing vegetation on the valves. Majority of patients have a history of either, indwelling catheters or devices, recent dental procedures and or infections, prosthetic heart valves, intravenous drug abuse and or immuno-suppression. Hemodialysis, chronic intravenous access and immuno-suppression have been identified as major risk factors. Transthoracic echocardiography and blood cultures obtained aseptically prior to empiri cal therapy forms the cornerstone of bacterial endocarditis diagnosis by applying the modified Duke's Criteria for infectious endocarditis diagnosis. Medical records of 350 inpatients with a median age of 58 years (± 2) years and admitted between June 2019 to August, 2021 were reviewed and 98 (28 %) satisfied the study inclusion criteria. 47 (48 %) of the participants had positive blood cultures. The major causative organisms of infectious endocarditis were Staphylococcus epidermidis (32 %), Staphylococcus aureus (28 %), Streptococcus viridans (21 %), Enterococcus faecalis (17 %) and Pseudomonas aeruginosa (2 %). All the cases with a possible infectious endocarditis diagnosis had an underlying cardiopathy. Methicillin resistance was observed with Staphylococcus epidermidis (14 %), and Staphylococcus aureus (29 %) isolates. Streptococcus viridans and Enterococcus faecalis isolates were penicillin resistant. Gentamicin, rifampicin, fosfomycin and vancomycin were the drugs of choice for managing infectious endocarditis and antimicrobial stewardship is necessary to safeguard their effectiveness in the future. |
0 | Rehabilitation after plate fixation of upper and lower extremity fractures | Distal Radius Fractures | Post-operative rehabilitation and weight-bearing protocols are important to fracture fixation outcomes, yet there is a dearth in the literature concerning universal treatment guidelines following plate fixation of extremity fractures. There are controversies regarding time to allow weight-bearing and range of motion for most fractures of the upper and lower extremity. This lack of a consensus has led to varying practice guidelines and differing anecdotal protocols between treating surgeons. This review attempts to establish consensus guidelines for the post-operative rehabilitation required for patients following plate fixation of common upper and lower extremity fractures. |
1 | Reduced blood loss after total knee arthroplasty with local injection of bupivacaine and epinephrine | AAHKS (8) Anesthetic Infiltration | Our goal was to determine by direct measurement of drain output whether intraoperative injection of bupivacaine with epinephrine significantly reduces postoperative blood loss in total knee arthroplasty (TKA). The study and control groups were primary TKAs performed by 1 surgeon using a single-cemented TKA design and a consistent postoperative protocol. The study group comprised 37 sequential TKAs injected intraoperatively with bupivacaine and epinephrine (one-third pericapsular, two-thirds peri-incisional). The control group included 71 sequential TKAs. The study group had 32% (95% confidence interval, 11%-48%), or 195 mL, less drain output (P = .006). There were no statistically significant differences in the transfusion rate or bleeding indices. Control and study groups were comparable regarding tourniquet times, intraoperative soft-tissue releases, preoperative anticoagulant use, and overall postoperative complications. Our study demonstrated a statistically significant decrease in TKA postoperative drain output with intraoperative injection of bupivacaine with epinephrine. |
0 | A potential complication of endoscopic carpal tunnel release | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Complications of carpal tunnel release have been well documented in the literature. Recently, a procedure for endoscopic release of the transverse carpal ligament has been described. This case report demonstrates a potential complication of endoscopic carpal tunnel release, in which the flexor digitorum superficialis tendon to the ring finger was nearly cut when the arthroscopic trocar passed beneath it. The procedure was converted to an open carpal tunnel release when the transverse fibers of the carpal ligament were not seen after several passes of the trocar. This complication was related to the inability to fully extend the wrist and metacarpophalangeal joints because of arthritic contractures. This case underscores the need for accurate identification of endoscopic anatomy prior to release of the carpal tunnel. The surgeon should not hesitate to convert to open technique if it becomes necessary |
1 | Magnetic resonance imaging assessment for unicompartmental knee replacement: a limited role | Surgical Management of Osteoarthritis of the Knee CPG | The purpose of this study was to see if MRI has a role in pre-operative assessment of patients for unicompartmental knee replacement. Until now, surgeons have been unable to predict whether a patient is suitable until the operation itself when the anterior cruciate ligament is inspected. We found that 33% of patients with anteromedial osteoarthritis had a degenerate anterior cruciate ligament according to magnetic resonance imaging, compared to only 13% on surgical inspection. We conclude that MRI is too sensitive to changes of the anterior cruciate ligament to be of much practical value |
0 | Eleven myths of dentoalveolar surgery | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | Through the years, dentists who perform dentoalveolar surgery have perpetuated many myths and other unproven beliefs from one generation to another. Sometimes, these beliefs originated in older textbooks, while others were given birth by mentors sharing anecdotal experiences with their students. Even today, many of these scientifically unsupported statements are perpetuated in surgical textbooks and in continuing education forums and are passed on to students in dental schools. In today's evolving environment of evidence-based medicine and dentistry, these anecdotal observations do not withstand scrutiny. The purpose of this article is to review the more common surgical myths and to test their validity against scientific evidence |
0 | Cranial and peripheral neuropathy in rheumatoid arthritis with special emphasis to II, V, VII, VIII and XI cranial nerves | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Background: Cranial neuropathy in rheumatoid arthritis (RA) is relatively rare compared to the frequently reported peripheral neuropathy. Methods: We investigated the occurrence of subclinical cranial and peripheral nerve involvement in 55 patients with RA. Results: Patients had a mean age of 43.1 years and a mean duration of illness of 6.4 years. All patients presented with electrophysiological findings suggestive of peripheral neuropathy. In addition, 69.1% of them had entrapment neuropathies, in which carpal tunnel syndrome was the most common (54.6%). Sensorimotor neuropathy at sites other than usual entrapment sites was diagnosed in 70.9%, while bilateral distal sensory neuropathy in lower limbs was identified in 29.1%. Among cranial nerves examined, optic and vestibulocochlear neuropathies were common (29.1% of eyes and 40% of ears examined). Spinal accessory neuropathy was reported in 21.8% of records. Neither facial nor trigeminal nerves were affected. Electrophysiological characteristics of neuropathies were indicative of axon loss. Significant association was identified between neuropathy and patients'ages (P < 0.01), duration of the illness (P < 0.001), presence of rheumatoid nodules (P < 0.001) and disease stages (P < 0.001). Conclusions: Our results indicate that cranial and non-compressive neuropathies are not uncommon in RA. This extends the pathologic disease spectrum. We do not confirm, but suggest the contribution of chronic immune-mediated vasculitis and/or neurotoxicity in RA neuropathies. Of clinical importance, subclinical neuropathy may never progress and/or be of clinical significance, which contradicts that of comparable diseases, such as systemic lupus erythematosus. Advances in genetics implicate a complex immune genetics which controls susceptibilities and adaptive molecular mechanisms as a culprit of phenotypical heterogenicity among related diseases. (copyright) 2006 Asia Pacific League of Associations for Rheumatology |
0 | Frontal lobe dysfunctions in schizophrenia--I. Eye movement impairments | Upper Eyelid and Brow Surgery | The phenomena of eye movement impairments in schizophrenia are interpreted in this paper, Part I of a two-paper series, in the context of neural mechanisms of attention and eye movement control. The predominant pattern of attention and eye movement impairment in schizophrenia--a disruption of smooth pursuit by saccadic intrusions--is consistent with a disinhibition of saccades. This disinhibition may be related to a dysfunction of frontal eye field mechanisms involved in feedback regulation of saccades and smooth pursuit during visual tracking. A second, less specific type of smooth pursuit impairment consists of saccadic substitution, and may be interpreted in terms of a dysfunction of temporo-parietal mechanisms of task-engagement. |
1 | Breast lesions in reduction mammaplasty specimens: a histopathological pattern in 534 patients | Reduction Mammoplasty for Female Breast Hypertrophy | BACKGROUND: The prevalence of breast lesions (benign, precancerous and cancer lesions) in reduction mammaplasty (RM) specimens has rarely been reported in Europe and never in the Swiss population.
METHODS: Personal and histopathological data from 534 female patients who underwent RM were reviewed.
RESULTS: Benign and/or malignant lesions were detected in 76.2% of all patients. Benign breast lesions associated with an increased risk of developing breast cancer represented 2.8% of all lesions. Breast cancer in situ was identified in 5 (0.9%) patients. Patient age and previous history of breast cancer were risk factors for incidental breast cancer.
CONCLUSION: The rate of incidental carcinoma in situ was higher for patients with breast cancer history. Probably due to preoperative breast cancer investigation, no occult invasive breast cancer was found in reduction mammary specimens. Therefore before RM, breast cancer evaluation should be considered for all patients, especially for those with breast cancer risk factors (e.g., patient age, personal history of breast cancer). |
0 | Randomised controlled study comparing general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty: study protocol | OAK 3 - Non-arthroplasty tx of OAK | INTRODUCTION: Total knee arthroplasty is a highly effective treatment for end-stage knee osteoarthritis, and it is usually performed under spinal or general anaesthesia with or without a surgical tourniquet. Some debate about the preferred mode of anaesthesia regarding patient outcomes remains. The aim of this study, which compares general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty, is to determine the optimal type of anaesthesia regimen and assess the effect of a tourniquet on the patient's recovery following total knee arthroplasty.
METHODS AND ANALYSIS: This study is a randomised, controlled, parallel-group, four-arm study comparing spinal and general anaesthesia with and without a tourniquet in 400 patients undergoing fast-track total knee arthroplasty, with a 12-month follow-up. The primary outcome is cumulative intravenous oxycodone consumption by patient-controlled analgesia during the first 24 postoperative hours. Secondary outcomes include postoperative nausea and vomiting, the length of hospital stay, the duration of the surgery, blood loss, demand for surgical unit resources, complications, readmissions, postoperative knee function, range of motion, health-related quality of life, prolonged pain and mortality.
ETHICS AND DISSEMINATION: This study's protocol is in accordance with the declaration of Helsinki. The results of this study will be disseminated in international peer-reviewed journals.
TRIAL REGISTRATION NUMBER: NCT03364088; Pre-results. |
0 | Microbiology and injury characteristics in severe open tibia fractures from combat | PJI DX Updated Search | BACKGROUND: Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluate the effect of injury characteristics and surveillance cultures on outcomes in combat-related severe open tibia fractures. METHODS: We conducted a retrospective study of all combat-related open Gustilo and Anderson (G/A) type III diaphyseal tibia fractures treated at our centers between March 2003 and September 2007. RESULTS: One hundred ninety-two Operation Iraqi Freedom/Operation Enduring Freedom military personnel with 213 type III open tibial shaft fractures were identified. Fifty-seven extremities (27%) developed a deep infection and 47 extremities (22%) ultimately underwent amputation at an average follow-up of 24 months. Orthopedic Trauma Association type C fractures took significantly longer to achieve osseous union (p = 0.02). G/A type III B and III C fractures were more likely to undergo an amputation and took longer to achieve fracture union. Deep infection and osteomyelitis were significantly associated with amputation, revision operation, and prolonged time to union. Surveillance cultures were positive in 64% of extremities and 93% of these cultures isolated gram-negative species. In contrast, infecting organisms were predominantly gram-positive. CONCLUSIONS: Type III open tibia fractures from combat unite in 80.3% of cases at an average of 9.2 months. We recorded a 27% deep infection rate and a 22% amputation rate. The G/A type is associated with development of deep infection, need for amputation, and time to union. Positive surveillance cultures are associated with development of deep infection, osteomyelitis, and ultimate need for amputation. Surveillance cultures were not predictive of the infecting organism if a deep infection subsequently develops |
0 | Magnetic resonance arthrography results that indicate surgical treatment for partial articular-sided supraspinatus tendon avulsion: a retrospective study in a tertiary center | Glenohumeral Joint OA | Background Specific findings on magnetic resonance arthrography (MRA) that indicate the need for surgery in patients with partial articular-sided supraspinatus tendon avulsion (PASTA) are not well understood. |
0 | Effects of 2-year therapy with ipriflavone in elderly women with established osteoporosis | Distal Radius Fractures | The effectiveness and safety of a longâ?term treatment with ipriflavone were investigated in 49 elderly osteoporotic women (age 65â?79) with at least one vertebral fracture and forearm bone mineral density (BMD) below 2 SD of ageâ?matched average. Women were randomly allocated to treatment with either oral ipriflavone (200 mg x 3/day) or placebo plus 1 g oral calcium supplementation per day for 2 years. Forty subjects completed one year, and 27 two years of treatment. Women treated with ipriflavone (n= 14) experienced a 4.1±1.9% increase in the distal radius BMD at year 1 (p<0.05 vs placebo), and a 7.1±3.0% increase (p<0.05 vs placebo) at year 2. No changes occurred in the control group (n=13): 0.6±1.4% at year 1, and 0.4±1.5% at year 2. BMD of the proximal femur, measured in a subgroup of patients, showed no changes in the ipriflavoneâ?treated patients, and a not significant tendency to decrease in the placebo group. The fracture rates for new vertebral fractures were significantly different for the study period between the ipriflavone and placebo groups (11 vs 22 per 100 patientâ?years; p<0.05). A significant (p<0.05) decrease of urinary hydroxyproline excretion in the ipriflavone group, and an increase in serum calcium (p<0.01) and phosphate (p<0.01) in the placebo group were observed. Adverse reactions (ARs), primarily gastrointestinal symptoms, occurred in 14 ipriflavoneâ?treated women and in 12 control subjects: 3 patients treated with ipriflavone and 2 receiving the placebo were withdrawn for ARs. Modest abnormalities of liver function test were detected, with no differences between the groups. In conclusion, longâ?term treatment with ipriflavone may represent a safe and useful modality to improve bone density and perhaps prevent vertebral fractures in elderly women with osteoporosis. |
0 | Quadriceps fat pad edema: significance on magnetic resonance images of the knee | AMP (Acute Meniscal Pathology) | OBJECTIVE: While clinically reading magnetic resonance (MR) images of the knees we have occasionally noted edema within the suprapatellar fat pad, with mass effect both on the suprapatellar joint recess posteriorly, and on the quadriceps tendon anteriorly. This MR appearance is analogous to Hoffa's disease described in the infrapatellar fat pad. We sought to evaluate the frequency and pattern of this finding and to provide clinical and histological correlation.
PATIENTS: The suprapatellar (quadriceps) fat pad was evaluated in 770 consecutive MR examinations (on 1.5 T and 0.3 T) in 736 patients (353 females and 383 males, age range 5-86 years, mean 44.3 years).
DESIGN: The MR images were retrospectively evaluated by two observers in consensus for the presence of quadriceps fat pad edema with mass effect. In 46 patients who had intravenous administration of gadolinium, the presence of enhancement was also evaluated. Clinical correlation was performed in abnormal cases; in one patient, 1-year follow-up MRI was evaluated and in one patient a percutaneous biopsy as well as 2-year clinical follow-up was performed.
RESULTS: Thirty-two (4.2%) knees in 29 patients showed quadriceps fat pad edema and mass effect. In five of these patients imaging of the contralateral knee was also performed and four of these showed symmetric edema. Another five cases had gadolinium-enhanced images with prominent enhancement. Most patients had clinical symptoms of meniscal tears (n=16, 55%) or anterior knee pain (n=8, 27.6%). The remainder had nonspecific pain (n=4, 13.8%) or suspected avascular necrosis (n=1, 3.4%). In the case with 1-year follow-up MRI, improvement was seen. Biopsy in another patient revealed vasculitis with obliteration of the small vessels. Resection of the fat pad in this patient led to complete resolution of the symptoms.
CONCLUSION: Suprapatellar fat pad edema may be analogous to Hoffa's disease, is rare, and may be a cause of anterior knee pain. However, this finding is not infrequent and its precise association with symptoms remains unclear. |
0 | Anabolic role of lysyl oxidase like-2 in cartilage of knee and temporomandibular joints with osteoarthritis | OAK 3 - Non-arthroplasty tx of OAK | BACKGROUND: Lysyl oxidase like-2 (LOXL2) is a copper-dependent amine oxidase. Our previous studies showed that LOXL2 is elevated during mouse fracture healing. The goal of this study was to evaluate the potential of LOXL2 to act as an anabolic agent in cartilage affected by osteoarthritis (OA).
METHODS: LOXL2 was visualized in tissues from human knee and hip joints and temporomandibular joints (TMJ) by immunofluorescence. The activity of LOXL2 in human articular and TMJ chondrocytes was assessed by cell-based assays, microarray analysis, and RT-qPCR, and LOXL2-mediated activation of NF-kappaB and extracellular signal-related kinase (ERK) signaling pathways was measured by western blotting. To examine LOXL2-induced effect in vivo, we implanted Matrigel-imbedded human chondrocytes into nude mice and exposed them to exogenous LOXL2 for 6 weeks. Finally, LOXL2-induced effects on collagen type 2 alpha1 (COL2A1) and phospho-SMAD2/3 were evaluated by immunofluorescence analysis.
RESULTS: LOXL2 staining was detected in damaged regions of human TMJ, hip and knee joints affected by OA. Stimulation with transforming growth factor (TGF)-beta1 upregulated LOXL2 expression, while pro-inflammatory cytokines IL-1beta and TNF-alpha downregulated LOXL2, in human chondrocytes. Viral transduction of LOXL2 in OA chondrocytes increased the mRNA levels of chondroitin sulfate proteoglycan (CSPG4), aggrecan (ACAN), sex determining region Y-box containing gene 9 (SOX9), and COL2A1 but reduced the levels of extracellular matrix (ECM)-degrading enzymes matrix metalloproteinase (MMP)1, MMP3, and MMP13. Further, forced expression of LOXL2 promoted chondrogenic lineage-specific gene expression, increased the expression of COL2A1 in the presence of TNF-alpha, and inhibited chondrocyte apoptosis. LOXL2 expression also inhibited IL-1beta-induced phospho-NF-kappaB/p65 and TGF-beta1-induced ERK1/2 phosphorylation. Matrigel constructs of human chondrocytes from the knee joint and TMJ implanted in nude mice showed anabolic responses after LOXL2 transduction, including increased expression of SOX9, ACAN, and COL2A1. Finally, immunofluorescence staining revealed co-localization of LOXL2 with SOX9 in the nuclei of cells in the implants, decreased phospho-SMAD2/3, and increased COL2A1 staining.
CONCLUSION: Our results suggest that although LOXL2 is upregulated in cartilage affected by OA, this may be a protective response that promotes anabolism while inhibiting specific catabolic responses in the pathophysiology of OA. |
0 | Mental health among clients of the Sydney Medically Supervised Injecting Centre (MSIC) | DoD PRF (Psychosocial RF) | The Sydney Medically Supervised Injecting Centre (MSIC) is a supervised injecting facility (SIF) where people who inject drugs (PWID) can do so legally, under health professional supervision. The majority of clients have low levels of education and employment, high rates of incarceration and unstable housing and poor social networks, and 70 % do not access local health services. These factors increase the risk of poor mental health, and it has been documented that PWID have elevated rates of mood, anxiety, personality and psychotic disorders; post-traumatic stress disorder (PTSD); and higher rates of trauma exposure, suicidality and self-harm. The current study is the first to investigate the mental health among clients of a SIF. Validated instruments to examine clients' mental health, social networks and trauma histories were administered to 50 frequently attending clients by a mental health nurse. The majority of respondents were unemployed, homeless and had a history of incarceration, and 82 % report they had been diagnosed with a mental health problem, but only 24 % report they were receiving treatment. Respondents had poor social networks, had poorer mental health symptoms compared to US inpatients and had experienced multiple traumatic events, and a high number of respondents had scores indicative of PTSD. These results highlight the need for mental health clinicians to be employed in SIFs and other drug consumption rooms (DCRs) to assist clients to address their mental health and psychosocial needs, particularly in light of the fact that these services are often the only places these PWID engage with in an ongoing way. |
1 | The 2012 ABJS Nicolas Andry Award: The Sequence of Prevention: A Systematic Approach to Prevent Anterior Cruciate Ligament Injury | Anterior Cruciate Ligament Injuries CPG | BACKGROUND: ACL injuries are common, often devastating injuries that lead to short-term disability and long-term sequelae, many of which lack effective treatment, such as osteoarthritis. Therefore, prevention of ACL injury is currently the only effective intervention for these life-altering sequelae, while much of the literature has a rehabilitative focus. QUESTIONS/PURPOSES: The primary long-term purpose of our multidisciplinary collaborative research team has been to develop ACL injury prevention programs by determining which factors related to ACL injury should be altered, followed by how and when they should be altered. METHODS: Our primary study objectives were to determine: (1) modifiable risk factors; (2) how these factors can best be modified; and (3) when is the best time to diminish these risk factors. Throughout the course of various studies, we determined the modifiable factors related to increased ACL injury risk. Our research team then focused on exploring numerous ways to augment these factors to maximize prevention efforts. We developed a sequence of prevention models that provide a framework to monitor progress toward the ultimate goal of preventing ACL injuries. RESULTS: The modifiable factors shown in our work include biomechanical and neuromuscular functionality. When targeted in physical training, we have determined that these factors can be enhanced to effectively aid in the prevention of ACL injuries. Preliminary data have shown that childhood and early adolescence may be valuable periods to implement such training. CONCLUSIONS: Current evidence has led to the evolution of clinical assessment tools for high-risk athletes and interventions for large populations and specific high-risk individuals. Targeted intervention implemented at the specified developmental stage of highest risk may be the final step toward the maximal reduction of ACL injury risk in young athletes |
0 | Adamantinoma of tibia: a study of 12 cases | MSTS 2018 - Femur Mets and MM | BACKGROUND: Adamantinoma is a rare tumor of long bones that can be mistaken for a carcinoma, and numerous other lesions such as myoepithelial tumor, malignant mixed tumor of bone, fibrous dysplasia/osteofibrous dysplasia, and vascular tumors.
METHODS: The histology and clinical features of 12 cases accrued from the surgical pathology files over a period of 23 years were analyzed.
RESULTS: Of the 12 cases, 4 were men and 8 women, with a mean age of 30 years. Radiologically the tumor presented as a lytic, eccentric, intracortical lesion in the tibia. The histology revealed epithelial islands with basaloid, spindle, and squamous features on a background of fibrotic stroma. Three patients came back with local recurrences, and one of them developed pulmonary metastasis.
DISCUSSION: In this article, an attempt is made to study the morphology, biology, and the differential diagnoses of adamantinoma of long bones. |
1 | Patient satisfaction needs as related to knee stability and objective findings after ACL reconstruction using the LARS artificial ligament | Anterior Cruciate Ligament Injuries CPG | The purposes of this study are to compare patient satisfaction with the objective measurement of knee stability and assess early complications following ACL reconstruction using a LARS artificial ligament. Forty-seven patients were reviewed 8-45 months after surgery. Assessment was made by the Knee and Osteoarthritis Outcome Score for patient satisfaction, a modified International Knee Documentation Committee form for clinical knee stability, and a Telos stress radiography for PA stability. Complications were assessed at interview and were double-checked with charts. The LARS artificial ligament may be a safe device to reconstruct an ACL tear. Documenting mechanical stability of the knee is inadequate when reporting follow-up studies and a questionnaire assessing patient satisfaction should be added to provide a better picture of the outcome and results |
0 | The Epidemiology of Benign Proliferative Processes of the Skeletal System in Children | Osteochondritis Dissecans 2020 Review | A suspicion of a proliferative bone lesion in a child seems to be a major diagnostic problem for clinicians. There are no diagnostic and treatment algorithms described in the literature and no reliable cohort epidemiological data. Our study was conducted among 289 paediatric patients (0-18 years old) with an initial diagnosis of a bone tumour or tumour-like lesion. The study comprised a retrospective epidemiological analysis, an assessment of the concordance of the initial diagnoses with the histopathological diagnoses and an analysis of the specific locations of the various bone lesions. The results obtained have made it possible to formulate the following conclusions. (1) The most common proliferative bone lesion in children is osteochondroma; also common are fibrous dysplasia, non-ossifying fibromas and bone cysts. (2) Verifying the initial diagnosis by means of biopsy is essential. (3) Osteochondromas are typically located in the metaphyses of long bones, fibrous dysplasia in the femur and skull, cyst-like lesions in the proximal humerus and non-osteochondral fibromas exclusively in the lower limbs. What could improve the quality of treatment for children with primary proliferative bone diseases is the establishment of centres of paediatric orthopaedic oncology skilled in early diagnosis and prompt management. |
0 | The older worker with osteoarthritis of the knee | Surgical Management of Osteoarthritis of the Knee CPG | BACKGROUND: Changing demographics mean that many patients with large joint arthritis will work beyond traditional retirement age. This review considers the impact of knee osteoarthritis (OA) on work participation and the relation between work and total knee replacement (TKR). SOURCES: Two systematic searches in Embase and Medline, supplemented by three systematic reviews. AREAS OF AGREEMENT: Probably, although evidence is limited, knee OA considerably impairs participation in work (labour force participation, work attendance and work productivity). AREAS OF UNCERTAINTY/RESEARCH NEED: Little is known about effective interventions (treatments, work changes and policies) to improve vocational participation in patients with knee OA; or how type of work affects long-term clinical outcomes (e.g. pain, function and the need for revision surgery) in patients with TKRs. The need for such research is pressing and opportune, as increasing numbers of patients with knee OA or TKR expect to work on |
0 | A personalized snack-based intervention for hip fracture patients: development, feasibility and acceptability | Management of Hip Fractures in the Elderly | INTRODUCTION: Undernutrition is common in older people admitted to hospital with hip fracture. Oral supplementation with sip feeds may be provided but compliance is a major problem. OBJECTIVE: To develop a personalized snack-based intervention for practical implementation in hip fracture patients and to assess feasibility, adherence, acceptability and cost. PARTICIPANTS AND METHODS: Twenty-three older hip fracture patients with a mean age (SD) 84.1 (6.3) were provided with three between-meal snacks daily for 4 weeks following surgery. Dietary counselling, assessment of acceptability and feasibility were undertaken and costs of intervention calculated. RESULTS: Sixteen of the 23 participants recruited completed the study. Mean estimated energy derived from the snacks provided 26% of daily energy requirements. Monitoring adherence proved problematic and stocktakes highlighted discrepancies. Although several participants reported that they did not usually eat between meals, overall the intervention was acceptable to participants. The cost of implementation was 21.29 UK pounds per participant per week. CONCLUSIONS: Although it proved feasible, practical difficulties were encountered with implementation and adherence due to timing. A more appropriate time to deliver such an intervention may be after the acute phase is over and patients are back home. The costs compared favourably with the alternative of providing sip feeds |
1 | Injecting autologous platelet rich plasma solely into the knee joint is not adequate in treating geriatric patients with moderate to severe knee osteoarthritis | PRP (Platelet-Rich Plasma) | Knee pain caused by osteoarthritis (OA) is commonly seen in geriatric patients. Patients with knee OA are often complicated with joint pain, soreness, and weakness. The injection of autologous platelet rich plasma (aPRP) has been proven to be effective in treating mild knee OA. The effect of injecting aPRP in treating moderate to severe degrees of knee OA remains controversial. This study aimed to evaluate the effectiveness of aPRP in treating patients with at least grade 2 on the Kellgren and Lawrence system for the classification of knee OA using a proteomic approach and clinical evaluation tool of Lequesne index. Musculoskeletal ultrasound was used for accurate needle placement into the knee joint, and to the perimeniscal soft tissue for the injection of aPRP. Three monthly aPRP injections were performed. Group 1 patients received intra-articular (IA) injection only, while group 2 received simultaneous IA and pes anserinus aPRP injections. After two monthly aPRP injections, both groups revealed significant drops in average SF total protein concentrations, and increases in the protein concentrations associated with chelation and anti-aging (eg/transthyretin, matrilin, and complement). However, it is group 2 that revealed significant decreases in the protein concentrations associated with inflammation (eg/immunoglobulin and apolipoprotein), and improved knee functional status. SF appeared to become less susceptible to degeneration after aPRP injections in group 2. As a result, at least 2 monthly injection of IA aPRP in conjunction with accurate injection of aPRP to the perimeniscal soft tissue structure such as the pes anserinus may be a viable option in treating patients with moderate to severe degrees of knee OA. |
0 | The use of inflammatory markers as a method for discharging patients post hip or knee arthroplasty | PJI DX Updated Search | Background: Complications after orthopaedic surgery have a substantial impact on resources, including the financial resources of the health-care system. Early detection of patients developing complications, thus excluding those patients without complications should have a major impact on patients' management. Methods: We evaluated the prognostic value of blood levels of inflammatory markers (interleukin-6, C-reactive protein, total white blood cell count) for complications after primary hip and knee arthroplasty in a routine setting, and their impact on patient management. First, the three inflammatory markers were evaluated in 68 consecutive patients treated at the Department of Orthopaedics. Laboratory markers were measured on days 2 and 4 after surgery. Second, patient management before and after adapting the routine order for laboratory parameters after arthroplasty were evaluated. Results: We could show that interleukin-6 and the C-reactive protein had an almost equal negative predictive value for the exclusion of postsurgical complications. Nevertheless, interleukin-6 returned below its reference levels almost 2 days earlier compared to the other markers. This made an earlier discharge of patients with presumable complications-less postsurgical process possible. Conclusions: So, the total number of patients treated as well as the financial reimbursement could be increased and concurrently occupancy days and averaged length of stay were reduced. é 2011 by Walter de Gruyter Berlin Boston |
1 | Analysis of IR thermal imager for mass blind fever screening | Coronavirus Disease 2019 (COVID-19) | BACKGROUND: Obtaining meaningful temperature for the human body requires identifying a body site that will provide reliable data across a large population. It is important to understand that skin temperature does not solely depend on body-core temperature and may be affected by other physiological and environmental factors. Currently, there is lack of empirical data in correlating facial surface temperature with body core temperature. Present IR systems in use at airports/immigration checkpoints have not been scientifically validated particularly in regards to the false-negative rate. As a result, they may create a false sense of security by underestimating the number of febrile (and possibly infected) individuals. This article evaluates the effectiveness of thermal scanner when it is being used for mass blind screening of potential fever subjects such as SARS or bird flu patients. METHODS: Bio-statistics with regression analysis and ROC is applied to analyse the data collected (502) from the SARS hospital in Singapore and conclusive results are drawn from them. The results are vital in determining two very important pieces of information: the best and yet practical region on the face to take readings and optimal pre-set threshold temperature for the thermal imager. RESULTS: (1) The thermal scanner can be used as a first line tool for the mass blind screening of hyperthermia, (2) the readings from the scanner suggest good correlation with the ear temperature readings, (3) an imager temperature threshold should be determined by the environmental factors, outdoor condition in particular, the physiological site offset and the performance characteristics of thermal imager to warrant the most accurate and reliable screening operation. CONCLUSIONS: The analysis suggested that the thermal imager used holds much promise for mass blind screening when the readings from a specific region have a good correlation with the ear temperature. From the regression analysis, the best reading is taken from the maximum temperature in the eye region, followed by the maximum temperature in the forehead region. With ROC analysis, a randomly selected individual from the fever group has a test value larger than that for a randomly selected individual from the normal group in 97.2% of the time. The test can distinguish between the normal and febrile groups and an optimum threshold temperature for the thermal imager can be found. The pre-set threshold cut-off temperature for the current thermal imager was found to be 36.3 degrees C with reference to the associated environmental condition. Any temperature readings that exceed this reading will trigger off the alarm and a thermometer will be used to verify the whether the person is having fever. |
0 | The basic science of the patella: structure, composition, and function | Surgical Management of Osteoarthritis of the Knee CPG | The patella is the largest sesamoid bone in the body. The patellofemoral joint provides an integral articulating component of the extensor mechanism of the knee joint. A detailed description of patella anatomy, embryology and development, neurovascular anatomy, biomechanical function, and imaging modalities is provided in this article. Common patellar pathologies such as patellar instability, trochlear dysplasia, patella alta and baja, and patellofemoral joint arthritis as well as patellofemoral arthroplasty as a treatment option are also discussed. An understanding of the normal anatomy and biomechanics of the patella is a necessary prerequisite for understanding the pathogenesis of disorders involving the knee |
0 | Acute occlusion of popliteal and/or tibial arteries: The value of percutaneous treatment | DOD - Acute Comp Syndrome CPG | Objectives: To describe early and mid-term results with a percutaneous therapeutic protocol including thromboaspiration, thrombolysis, and correction of the underlying lesion by PTA. Methods: Thirty-three consecutive selected patients with recent (<1 month) reversible acute ischaemia associated with popliteal and/or tibial occlusion were studied. The primary endpoints were technical success (defined as residual mural thrombus less than 20% of the lumen and the presence of at least one tibial artery on angiogram), patient survival and limb salvage at 1 and 12 months. Secondary endpoints included complications, primary, assisted primary and secondary patency determined by duplex scan at 1, 6 and 12 months. Results: Technical success was achieved in 27 patients (82%). Twenty patients were treated by thromboaspiration ± thrombolysis only, and seven required additional PTA (26%). In six patients (18%), percutaneous techniques failed, and embolectomy was performed in two, bypass in one and major amputations in three (9%). For the entire series, the survival rate was 100% at 1 month and 94% at 1 year. The limb salvage rate was 91% at 1 month and 1 year. The cumulative primary patency, assisted primary patency and secondary patency rates were 81%, 81% and 86% respectively at 1 month and 66%, 72% and 77%, respectively, at 12 months. Early complications occurred in 10 patients (30%): five groin haematomas (15%), four compartment syndromes (12%) and one haemoglobinuria (3%). Conclusion: Percutaneous techniques offer excellent early and mid-term results in selected patients presenting with acute ischaemia with popliteal and/or tibial arteries occlusion. |
0 | Clinical burden and incremental cost of fractures in postmenopausal women in the United Kingdom | HipFx Supplemental Cost Analysis | This cohort study of postmenopausal women in the United Kingdom aged (greater-than or equal to)50 years determined the incremental cost of health care and clinical outcomes in the 12. months following incident, selected fractures (non-vertebral non-hip [NVNHF], vertebral [VF] and multiple [MF]). Incremental costs and outcomes of the fracture cohorts were compared with those of cohorts comprised of women without fractures who were individually matched on age and comorbidity. Cohorts were identified from The Health Improvement Network database, a primary health care database, from 2001 to 2005. We estimated 1-year incremental costs (hospitalizations; general practice, accident/emergency, and referral visits; and prescription medications) associated with each fracture type. Descriptive analyses examined occurrence of subsequent fractures and death. No long-term health care costs or outcomes were assessed. Overall, 14,030 women had NVNHF, 1471 had VF, and 193 had MF. The risk of death was greater for women with fractures than for women in the non-fracture cohorts. Mean incremental cost for fractures compared with no fractures was (pounds)1152 for VF; (pounds)690 for NVNHF, and (pounds)2581 for MF. Of the total incremental cost, hospitalizations represented 54%-90% and medications represented 7%-29%. In all fracture cohorts, most of the total annual costs were concentrated in the 6. months after the date of fracture. Fractures among postmenopausal women represent an important burden to the health system due to the increase in health resource utilization and related costs. In this study, hospitalizations were the main driver of the overall incremental cost during the 12. months following the fracture. Mortality in women in the selected fracture cohorts was higher than in women in the non-fracture cohorts. (copyright) 2012 Elsevier Inc |
0 | Medial ulnar collateral ligament origin in children and adolescents: an MRI anatomic study | Pediatric Supracondylar Humerus Fracture 2020 Review | BACKGROUND: The medial ulnar collateral ligament (MUCL) is the primary stabilizer against valgus stress on the elbow. The anatomy of the 3 bundles of the MUCL has been well studied in adults, but our review of the English literature found no study evaluating the origin of the MUCL in a large group of asymptomatic, skeletally immature elbows as it relates to the medial epicondylar physis. METHODS: Magnetic resonance T1-coronal images of 44 skeletally immature elbows (ages 5 to 17 y) with no history of fracture were evaluated by 2 independent musculoskeletal radiologists, a board-certified orthopaedic surgeon with fellowship training in pediatric orthopaedics, and an orthopaedic surgery resident. The location of the origin of the anterior bundle of the MUCL (aMUCL) was identified and its distance from the medial epicondylar physis was measured. RESULTS: All 44 images showed that the aMUCL attached either on or medial to the medial epicondylar physis. The average distance from the origin of the aMUCL to the medial epicondylar physis was 3.1 mm. There was no statistically significant relationship between age and location of the aMUCL insertion relative to the physis (P=0.183). CONCLUSIONS: In the skeletally immature elbow, the aMUCL originates medial to the medial epicondylar physis. CLINICAL RELEVANCE: Although treatment of medial epicondylar humeral fractures remains controversial, understanding the relationship between the aMUCL and the medial epicondylar physis may be helpful in making decisions regarding fracture management. |
0 | Mesenchymal cells inhibit expansion but not cytotoxicity exerted by gamma-delta T cells | Reconstruction After Skin Cancer | BACKGROUND: Multipotent mesenchymal stromal cells (MSCs) exert a relevant immunosuppressive activity by inhibiting T- and B-lymphocytes, natural killer (NK) cells and dendritic cell expansion. Nevertheless, a possible activity on gamma/delta T cells has still not been evaluated. Gamma-delta T lymphocytes play an important role in the control of cancer and they have been shown to be implicated in graft-vs.-host disease. Thus, modulation of activation and proliferation of these cells could be relevant for therapeutic purposes. MATERIALS AND METHODS: Peripheral blood mononuclear cells from 21 healthy donors were used as source for gamma-delta T cells, expanded in presence of 10 IU mL(-1) interleukin-2 (IL-2) and 1 microM zoledronate. MSCs were recovered from patients undergoing routine total hip replacement surgery, and characterised by flow cytometry. Cytotoxicity on multiple myeloma and melanoma cell lines was assessed by measuring dilution of the carboxyfluorescein diacetate succinimydylester dye (CFSE). Gamma-delta T cells were then incubated with MSCs in contact cultures, and with addition of MSC-conditioned medium. RESULTS: In this article we confirmed that (1) in vitro expanded gamma-delta T cells play a significant anti-proliferative effect on multiple myeloma and melanoma cells and (2) multipotent mesenchymal stromal cells effectively suppress the ex vivo expansion of T cells carrying a specific T-cell receptor gene (TCR) rearrangement, Vgamma9/Vdelta2, induced by the combination of IL-2 and zoledronate, without interfering with their cytotoxic activity. DISCUSSION: These findings contribute to explain the activity of ex vivo expanded mesenchymal cells, suggesting that MSCs would interact with gamma-delta T lymphocytes. CONCLUSION: This effect could be relevant in separating graft-vs.-host from the graft-vs.-tumour effect, especially considering the possibility of modulating T-lymphocytes activity by the immunomodulating drugs now available. |
0 | Adalimumab and the heart: Cause of concern? | Surgical Management of Osteoarthritis of the Knee CPG | Background: Anti-TNF agents are widely used by rheumatologists in the treatment of rheumatoid arthritis, ankylosing spondylitis and psoriatic arthropathy. Dermatologists and gastroenterologists also use them in plaque psoriasis and crohn's disease respectively. Whilst such agents are gaining popularity, by modulating immune response patients become more susceptible to infection. Methods: A 25-year-old man with known plaque psoriasis and previous balloon dilation for aortic coarctation in childhood was reviewed in outpatients with polyarthropathy, lethargy, weight loss, pyrexia and drenching night sweats for six weeks. Clinical examination revealed mild pyrexia, bilateral painful knees with effusions, significant weight loss, splinter haemorrhages, Osler's nodes and an ejection systolic murmur which was not new. In view of the deterioration in his functional status and the uncertainty of the diagnosis he was admitted for further investigations. Results: Medication on admission included only fortnightly adalimumab. He denied excessive alcohol, smoking or recreational drugs. Blood tests revealed new normocytic anaemia (Hb 11.3 g/dL), leukocytosis (12.1x109/L) with neutrophilia, elevated ESR (113 mm/hr) and CRP (117 mg/L). Urine dipstick was positive for blood. The differential diagnosis at this stage included infective endocarditis (IE), lymphoma, TB and vasculitis. A vasculitis screen and three sets of blood cultures were collected. Knee aspiration suggested acute synovitis and CT chest, abdomen and pelvis was normal. He had an echocardiogram 3 months previously for assessment of left ventricular (LV) function as he was on adalimumab. Although LV function was normal, the report suggested moderate aortic stenosis probably subvalvular. As he already fulfilled 4 minor criteria of the revised classification for IE he was started on broad spectrum antibiotics - intravenous (iv) benzylpenicillin and gentamicin - whilst awaiting blood culture results and further assessment of the aortic valve. Blood cultures isolated a fully sensitive streptococcus viridans in all 6 bottles: an organism suggestive of endocarditis. Transoesophageal echocardiography suggested a vegetation on the aortic valve therefore the diagnosis of IE was now definite with 2 major and 4 minor criteria. He was therefore treated with iv benzylpenicillin monotherapy for 4 weeks, following which was referred to our regional cardiothoracic centre for aortic valve replacement. Conclusions: Anti-TNF agents are increasingly used and patient susceptibility to infection is recognised. This is the first report of IE in a patient receiving adalimumab. It is likely that the combination of a structurally abnormal valve and immunosuppression made him more susceptible to valvular infection. We would therefore recommend full cardiovascular examination in all patients prior to initiation of anti-TNF treatment and referral for echocardiography if any abnormalities are detected or if patients had previous cardiac history, to stratify the risk of IE |
0 | 2015 Beers Criteria and STOPP v2 for detecting potentially inappropriate medication in community-dwelling older people: prevalence, profile, and risk factors | OAK 3 - Non-arthroplasty tx of OAK | Purpose: To comparatively assess the prevalence rates of potentially inappropriate medications (PIMs) obtained by the former and latest versions of American Geriatrics Society Beers Criteria (AGS BC) and screening tool of older personâ??s potentially inappropriate prescriptions (STOPP), and analyze the factors of influence on PIM. Methods: Cross-sectional study including 582 community-dwelling older adults over the age of 65. Sociodemographic, clinical, functional, and comprehensive drug therapy data were collected. The primary endpoint was the percentage of patients receiving at least one PIM. Results: A total of 3626 prescriptions were analyzed. PIMs were detected in 35.4% and 47.9% of patients according to the STOPP v1 and the 2012 AGS BC, respectively. This percentage rose to 54% when 2015 AGS BC were used and reached 66.8% with STOPP v2. The kappa coefficient between STOPP v2 and its former version was lower than the one between the updated Beers Criteria and their former version (0.41 vs 0.85). The agreement was good (0.65) between both latest criteria. The number of medications, psychological disorders, and insomnia were predictors of PIM. A novel finding was that bone and joint disorders increased the odds for PIM by 78%. Conclusions: The 2015 AGS BC showed high sensitivity and good applicability to the European older patients. Both updated tools identified some pharmacological groups (benzodiazepines, PPIs, and opioids, among others) and certain health problems (insomnia, psychological disorders, and osteoarticular diseases) as factors of influence on PIM. Based on these findings, interventions aimed at promoting appropriate use of medications should be developed. |
0 | A pitfall in the insertion of a sliding screw | Management of Hip Fractures in the Elderly | This article describes the problem that can arise when an effort is made to insert a malaligned side plate during a sliding screw fixation |
0 | Total hip arthroplasty: Use and select complications in the US Medicare population | HipFx Supplemental Cost Analysis | Use and outcomes of primary total hip arthroplasty among US Medicare recipients more than 65 years of age were investigated by means of physician and hospital claims for a 5% random sample during 1986 through 1989. Cases involving hip fracture or evidence of existing orthopedic devices in the hip were omitted. Use rates were higher for women than for men and were substantially lower for Blacks than Whites. Major complications (death, further hip surgery, infection, pulmonary embolism) were uncommon. These data document the frequent use of total hip arthroplasty, and confirm the rarity of serious adverse outcomes. Further studies should investigate the lower use of total hip arthroplasty among Blacks |
0 | Clinicopathological Characteristics and Prognosis of Squamous Cell Carcinoma of the Breast: A Population-Based Analysis | MSTS 2022 - Metastatic Disease of the Humerus | BACKGROUND: To better understand the clinicopathological features and prognostic profiles of squamous cell carcinoma (SCC) of the breast.
METHODS: Information on breast cancer was obtained from the Surveillance, Epidemiology, and End Results database (2004-2016). Comparative analyses were carried out to investigate the heterogeneity in the clinicopathological characteristics and survival outcomes between SCC and invasive ductal carcinoma (IDC), while propensity score matching was conducted to analyze the variations among baseline characteristics. Prognostic factors for SCC of the breast were successively identified using Cox regression analysis.
RESULTS: A total of 382 SCC patients and 561477 IDC patients were identified in this study. Comparatively, the SCC cohort exhibited a higher proportion of male individuals, poor differentiation, an advanced TNM stage, an increasing percentage of triple-negative (TN) subtype, an increasing rate of organ involvement, and less access to therapeutics. The aggressive profile was consistent in the TN subgroup, with a significantly higher proportion in SCC than in IDC (25.7% vs 6.8%). Prognosis of SCC was profoundly poorer than that of IDC (mOS, 78.6 months and 121.6 months, P < .0001; mBCSS 91.9 months vs 135.6 months, P < .0001), of which the inferior tendency remained stable among disease stage and therapeutic options, while no difference was detected in the 2 subgroups with the TN subtype. The 2-year survival rate was 66.9% and the 5-year survival rate was 51.4%, with the risk factors being older age, bilateral disease, advanced TNM stage, bone and visceral involvement, surgical intervention, radiation treatment, and chemotherapy.
CONCLUSIONS: This study systematically analyzed the heterogeneous characteristics of SCC of the breast in comparison with IDC. Squamous cell breast cancer presented with increasing aggressive behavior and inferior prognosis. Prospective studies should focus on this subgroup and introduce individualized therapeutic protocols in clinical practice. |
0 | Knee joint biomechanics following arthroscopic partial meniscectomy | AMP (Acute Meniscal Pathology) | We investigated spatiotemporal data, joint kinematics, and joint kinetics during gait in a group of subjects who had recently undergone arthroscopic partial meniscectomy and compared the results to those of healthy controls. Gait analysis was performed on 105 pain-free meniscectomy patients and 47 controls, walking at a self-selected speed. The meniscectomy population was comparable to controls in spatiotemporal parameters and knee kinematics. However, they had reduced range of motion (ROM) and lower peak moments in the sagittal plane on the operated limb compared to the nonoperated limb. Compared to controls, the meniscectomy patients had significantly larger knee adduction moments over stance, even after accounting for their greater body weight. These differences likely increase articular loads on the medial compartment of the tibiofemoral joint and may contribute to the high risk of knee osteoarthritis following arthroscopic meniscal surgery. |
1 | Analysis of the characteristics of patients with open tibial fractures of Gustilo and Anderson type III | DoD LSA (Limb Salvage vs Amputation) | OBJECTIVE: To analyze the characteristics of patients with Gustilo-Anderson Type III open tibial fractures treated at a tertiary care hospital in Sao Paulo between January 2013 and August 2014. METHODS: This was a cross-sectional retrospective study. The following data were gathered from the electronic medical records: age; gender; diagnosis; trauma mechanism; comorbidities; associated fractures; Gustilo and Anderson, Tscherne and AO classifications; treatment (initial and definitive); presence of compartment syndrome; primary and secondary amputations; MESS (Mangled Extremity Severity Score) index; mortality rate; and infection rate. RESULTS: 116 patients were included: 81% with fracture type IIIA, 12% IIIB and 7% IIIC; 85% males; mean age 32.3 years; and 57% victims of motorcycle accidents. Tibial shaft fractures were significantly more prevalent (67%). Eight patients were subjected to amputation: one primary case and seven secondary cases. Types IIIC (75%) and IIIB (25%) predominated among the patients subjected to secondary amputation. The MESS index was greater than 7 in 88% of the amputees and in 5% of the limb salvage group. CONCLUSION: The profile of patients with open tibial fracture of Gustilo and Anderson Type III mainly involved young male individuals who were victims of motorcycle accidents. The tibial shaft was the segment most affected. Only 7% of the patients underwent amputation. Given the current controversy in the literature about amputation or salvage of severely injured lower limbs, it becomes necessary to carry out prospective studies to support clinical decisions. |
0 | Treatment of Painful, Irreparable Partial Meniscal Defects With a Polyurethane Scaffold: Midterm Clinical Outcomes and Survival Analysis | PJI DX Updated Search | BACKGROUND: A biodegradable polyurethane scaffold was designed to fulfill a challenging clinical need in the treatment of patients with painful, irreparable partial meniscal defects. HYPOTHESIS: The use of an acellular polyurethane scaffold for new tissue generation in irreparable, partial meniscal defects provides both midterm pain relief and improved functionality. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 44 patients with irreparable, partial meniscal defects (29 medial and 15 lateral) were implanted with a polyurethane scaffold in a prospective, single-arm proof-of-principle study with a minimum 5-year follow-up. Clinical outcomes were measured with the visual analog scale (VAS) for pain, International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline and at 2- and 5-year follow-up. Magnetic resonance imaging (MRI) was used to evaluate the meniscal implant and cartilage status of the index compartment. Kaplan-Meier time-to-treatment failure distributions were also performed. Removal of the scaffold, conversion to a meniscal transplant, or unicompartmental/total knee arthroplasty was used as endpoints. RESULTS: Seven patients were lost to follow-up (15.9%). The patients who participated in this study showed significant clinical improvement after surgery (mean [+/-SD] at baseline, 2 years, and 5 years: 56.2 +/- 21.6, 24.6 +/- 22.7, and 19.3 +/- 26.9, respectively [VAS]; 206.5 +/- 79.7, 329.8 +/- 108.9, and 333.6 +/- 112.2, respectively [total KOOS]). MRI of the scaffolds showed a smaller sized implant when compared with the native meniscus with an irregular surface at 2- and 5-year follow-up. A stable cartilage status of the index compartment at 5-year follow-up was demonstrated in 46.7% of patients compared with the baseline status. During the follow-up period, 62.2% of the implants survived. At final follow-up, 66.7% of the medial scaffolds were still functioning versus 53.8% of the lateral scaffolds. CONCLUSION: A polyurethane meniscal implant can improve knee joint function and significantly reduce pain in patients with segmental meniscus deficiency up to 5 years after implantation. A stable cartilage status of the index compartment at 5-year follow-up was demonstrated in 46.7% of patients, calling into question the chondroprotective ability of the implant. In addition, a relatively high failure rate was noticed. Long-term and randomized controlled studies are mandatory to confirm the initial results and the reliability of this procedure |
1 | Indications for performing carpal tunnel surgery: clinical quality measures | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | BACKGROUND: Rates of carpal tunnel surgery vary for unclear reasons. In this study, the authors developed measures determining when surgery is necessary (benefits exceed risks), inappropriate (risks outweigh benefits), or optional. METHODS: Measures were developed using a modified-Delphi panel. Clinical scenarios were defined incorporating symptom severity, symptom duration, clinical probability of carpal tunnel syndrome, electrodiagnostic testing, and nonoperative treatment response. A multidisciplinary panel of 11 carpal tunnel syndrome experts rated appropriateness of surgery for each scenario on a scale ranging from 1 to 9 scale (7 to 9, surgery is necessary; 1 to 3, surgery is inappropriate). RESULTS: Of 90 scenarios (36 for mild, 36 for moderate, and 18 for severe symptoms), panelists judged carpal tunnel surgery as necessary for 16, inappropriate for 37, and optional for 37 scenarios. For mild symptoms, surgery is generally necessary when clinical probability of carpal tunnel syndrome is high, there is a positive electrodiagnostic test, and there has been unsuccessful nonoperative treatment. For moderate symptoms, surgery is generally necessary with a positive electrodiagnostic test involving two or more of the following: high clinical probability, unsuccessful nonoperative treatment, and symptoms lasting longer than 12 months. Surgery is generally inappropriate for mild to moderate symptoms involving two or more of the following: low clinical probability, no electrodiagnostic confirmation, and nonoperative treatment not attempted. For severe symptoms, surgery is generally necessary with a positive electrodiagnostic test or unsuccessful nonoperative treatment. CONCLUSIONS: These are the first formal measures assessing appropriateness of carpal tunnel surgery. Applying these measures can identify underuse (failure to provide necessary care) and overuse (providing inappropriate care), giving insight into variations in receipt of this procedure |
0 | Outcomes of Distal Ulna Fractures Associated With Operatively Treated Distal Radius Fractures | Distal Radius Fractures | BACKGROUND: The purpose of this study was to report outcomes in patients with nonstyloid distal ulna fractures treated in conjunction with open reduction internal fixation (ORIF) of distal radius fractures.
METHODS: A retrospective review of all patients who had undergone ORIF of a distal radius fracture over a 5-year period at a single institution was performed. Radiographic review was performed to identify patients with a concomitant fracture of the distal ulna. Radiographs were examined to determine whether and how the distal ulna fracture was stabilized and to assess healing of the distal ulna. Range of motion (ROM) was determined by review of the patients' charts. All skeletally mature patients with distal ulna fractures (not including isolated styloid fractures) undergoing surgical fixation of the distal radius fracture were included. Patients were excluded if follow-up was inadequate. There were 172 fractures of the distal ulna meeting the inclusion criteria. Seven patients were excluded. There were 91 patients treated without ulna fixation (ulna-no) and 74 patients treated with ulna fixation (ulna-yes).
RESULTS: Seventy-two (97%) of the ulna-yes patients healed. All patients in the ulna-no group healed. The only significant difference in ROM was in pronation, although the magnitude of this difference was relatively small.
CONCLUSIONS: Fractures of the distal ulna have high rates of healing and result in equivalent motion regardless of whether the distal ulna is treated operatively. Routine surgical fixation of concomitant distal ulna fractures during distal radius ORIF does not appear to be necessary. |
0 | Tissue pressure threshold for peripheral nerve viability | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | To investigate the pressure threshold for peripheral nerve dysfunction in compression syndromes (carpal tunnel and compartment syndromes), carpal canal pressure was elevated to 40, 50, 60, and 70 mm Hg in normal volunteers. Motor and sensory latencies and amplitudes of the median nerve were evaluated before compression, after 30-240 minutes of compression, and during the postcompression recovery phase. Although some functional loss occurred at 40 mm Hg, motor and sensory responses were completely blocked at a threshold tissue fluid pressure of 50 mm Hg, measured by the wick catheter. In one subject in whom diastolic blood pressure was significantly higher than in other subjects, the threshold pressure was raised slightly. The Semmes-Weinstein monofilament test and the 256-cycle vibratory test were more sensitive than two-point discrimination tests for evaluating peripheral nerve function in this compression model. These results indicate that between 40 mm Hg and 50 mm Hg there exists a critical pressure threshold at which peripheral nerve is acutely jeopardized. Compartment decompression may not be indicated when interstitial pressures are below this level |
0 | Fracture history and bone loss in patients with MS | Management of Hip Fractures in the Elderly | Objectives: We have previously shown that MS patients have significantly reduced bone mass and a high prevalence of abnormal vitamin D status. The object of this study was to characterize the frequency of adulthood fractures in MS patients, prospectively determine rates of bone loss in MS, and determine whether vitamin D status is a predictor of bone loss. Methods: MS patients (36 women, 18 men) were compared with age- and gender-matched healthy controls (35 women, 14 men). Bone mass was performed by dual x-ray absorptiometry at baseline and at 12-month intervals over 2 years. Results: Fractures in the absence of major trauma had occurred in 2% of controls and 22% of MS patients (p < 0.002). Over the 2 years of prospective follow-up, both women and men with MS lost substantially more bone in the femoral neck than did controls (3% and 6% per year in pre- and postmenopausal women with MS versus 0.5% and 0.8% per year in controls; 7.3% per year in men with MS versus 1.6% per year in controls). Bone loss in the spine was also greater in women with MS than in controls (1.6 to 3.5% per year loss in MS patients versus no change in controls). Duration of steroid treatment beyond 5 months and ambulatory status were both predictors of bone loss. Bone loss in the spine occurred faster in MS patients with low (<20 ng/mL) 25-hydroxyvitamin D levels (1.9% per year, p < 0.04), whereas in those with normal 25- hydroxyvitamin D levels, bone loss was insignificant. At the femoral neck, bone loss was substantial in all patients, but was somewhat faster in the group with low levels of 25-hydroxyvitamin D (5.6% per year, p < 0.0001) compared with the group with high levels of 25-hydroxyvitamin D (4.3% per year, p = 0.03). Conclusions: MS patients have more frequent fractures and lose bone mass more rapidly than do their healthy age- and gender-matched peers, in part related to insufficient vitamin D. Vitamin D repletion in MS patients who are deficient might reduce, to some extent, the rate of bone loss and decrease osteoporosis-related fractures |
0 | Arthroscopic treatment of ulnar impaction syndrome | DoD - ACS - Interrater Reliability | Ulnar impaction syndrome occurs in the setting of a central traumatic or degenerative defect in the triangular fibrocartilage complex in patients with ulnar positive variance. Chondral and subchondral edema, mechanical impingement of the articular disc, and chondromalacia of the distal ulna, proximal lunate, and proximal triquetrum produce symptoms with activity that do not improve with rest. Decreasing ulnocarpal load-sharing across the wrist with recession of the distal ulna is necessary to relieve symptoms in the majority of patients. Arthroscopic treatment with triangular fibrocartilage complex debridement and arthroscopic ulnar wafer resection is an effective treatment for ulnar impaction syndrome. It affords a single-stage, minimally invasive approach, with similar efficacy and fewer complications than open wafer resection or ulnar shortening osteotomy. [References: 7] |
0 | Normal anatomy and biomechanics of the knee | AMP (Acute Meniscal Pathology) | Functionally, the knee comprises 2 articulations-the patellofemoral and tibiofemoral. Stability of the joint is governed by a combination of static ligaments, dynamic muscular forces, meniscocapsular aponeurosis, bony topography, and joint load. The surgeon is ill equipped to undertake surgical treatment of a dislocated knee without a sound footing in the anatomic complexities of this joint. We review the normal anatomy of the knee, emphasizing connective tissue structures and common injury patterns. |
1 | The Effect of Concomitant Biceps Tenodesis on Reoperation Rates After Rotator Cuff Repair: A Review of a Large Private-Payer Database From 2007 to 2014 | Trial Systematic Review Project | PURPOSE: To determine if reoperation rates are higher for patients who underwent isolated rotator cuff repair (RCR) than those who underwent RCR with concomitant biceps tenodesis using a large private-payer database.
METHODS: A national insurance database was queried for patients who underwent arthroscopic RCR between the years 2007 and 2014 (PearlDiver, Warsaw, IN). The Current Procedural Terminology (CPT) 29,827 (arthroscopy, shoulder, surgical; with RCR) identified RCR patients who were subdivided into 3 groups-group 1: RCR without biceps tenodesis; group 2: RCR with concomitant arthroscopic biceps tenodesis (CPT 29827 and 29,828); group 3: RCR with concomitant open biceps tenodesis (CPT 29827 and 23,430). Reoperation rates (revision RCR, subsequent biceps surgeries) and complications at 30 days, 90 days, 6 months, and 1 year were analyzed. Multivariate logistic regression was used to compare reoperations and complications between groups. Rotator cuff tear size, whether the biceps was ruptured and whether a biceps tenotomy was performed, was not available.
RESULTS: Group 1: 27,178 patients. Group 2: 4,810 patients. Group 3: 1,493 patients. More patients underwent concomitant arthroscopic than concomitant open tenodesis (P < .001). A total of 2,509 patients underwent a reoperation for RCR or biceps tenodesis within 1 year after RCR. When adjusted for age, sex, and comorbidities, no significant differences in reoperation rates at 30 days or 90 days among the 3 groups, but significantly more patients who had a tenodesis, required a reoperation compared with those who did not have a tenodesis at 6 months and 1 year (both P < .001). Urinary tract infections were more common in patients who did not have a tenodesis, whereas dislocation, nerve injury, and surgical site infection were more common in tenodesis patients.
CONCLUSIONS: Higher reoperation rates at 1 year were seen in patients who had concomitant biceps tenodesis.
LEVEL OF EVIDENCE: Level III, case-control database review study. |
0 | Study of the relation between body weight and functional limitations and pain in patients with knee osteoarthritis | OAK 3 - Non-arthroplasty tx of OAK | OBJECTIVE: To assess the influence of the body weight in functional capacity and pain of adult and elderly individuals with knee osteoarthritis.
METHODS: The sample consisted of 107 adult and elderly patients with knee osteoarthritis divided into two groups (adequate weight/adiposity and excessive weight/adiposity) according to body mass index and percent of body fat mass, assessed by electric bioimpedance. Subjects were evaluated for functional mobility (Timed Up and Go Test), pain, stiffness and function (Western Ontario and MacMaster Universities Osteoarthritis Index - WOMAC), pain intensity (Visual Analogue Scale - VAS) and pressure pain tolerance threshold (algometry in vastus medialis and vastus lateralis muscles). Data were analyzed with Statistical Package of the Social Sciences, version 22 for Windows. Comparisons between groups were made through Student's t test, with significance level set at 5%.
RESULTS: There was predominance of females in the sample (81.3%), and mean age was 61.8+/-10.1 years. When dividing the sample by both body mass index and adiposity, 89.7% of them had weight/adiposity excess, and 59.8% were obese. There was no difference between groups regarding age, pain intensity, pressure pain tolerance threshold, functional mobility, stiffness and function. However, pain (WOMAC) was higher (p=0.05) in the group of patients with weight or adiposity excess, and pain perception according to VAS was worse in the group of obese patients (p=0.05).
CONCLUSION: Excessive weight had negative impact in patients with osteoarthritis, increasing pain assessed by WOMAC or VAS, although no differences were observed in functionality and pressure pain tolerance. |
0 | Long term use of analgesics and risk of osteoarthritis progressions and knee replacement: Propensity score matched cohort analysis of data from the Osteoarthritis Initiative | OAK 3 - Non-arthroplasty tx of OAK | Objectives: To determine the association between the long-term use of analgesics and progression of osteoarthritis (OA) as evidenced by up to 3-years follow-up worsening of radiographic Kellgren-Lawrence (KL) grade and incidence of knee replacement (KR). Design: Using nearest neighbor matching of the propensity scores with caliper in the Osteoarthritis Initiative (OAI) cohort, 173 index (Analgesic +) and 173 referent (Analgesic -) subjects were included. Analgesic + and - subjects had analgesics in all and none of their visits, respectively. Analgesic + and - subjects were balanced in their demographics, baseline, first, second and third year body mass index (BMI), Western Ontario and McMaster (WOMAC) total score, Physical and Mental health summary scales (SF-12), Physical Activity Scale for the Elderly (PASE) and Charleston Comorbidity Scale. Analgesic + and - subjects were also matched for baseline radiographic KL grade. Interval increase in the KL grade and incidence of KR were defined as the outcome. Results: Included subjects had average 6.5 years of follow-up. By the third year, 44 subjects had an interval increase in the KL grade; 29 in Analgesic + and 15 among Analgesic - subjects (P = 0.024). By the eighth-year, 41 subjects had their first KR; 29 in Analgesic + and 12 among Analgesic - subjects (P = 0.005). Hazard Ratio (HR) of OA progression and KR for Analgesic + subjects was 1.91 (1.02-3.57) and 2.57 (1.31-5.04), respectively. Conclusions: Long-term use of analgesics may be associated with radiographic progression of knee OA and increased risk of future KR. |
0 | Predictors of visual outcome with transsphenoidal excision of pituitary adenomas having suprasellar extension: A prospective series of 100 cases and brief review of the literature | Upper Eyelid and Brow Surgery | OBJECTIVE: The aim was to assess the factors influencing the visual outcome following trans-sphenoidal excision of pituitary adenomas. MATERIALS AND METHODS: One hundred consecutive patients of pituitary adenomas with suprasellar extension (SSE) were operated by trans-sphenoidal approach from July 2003 to December 2006. There were 52 male and 48 female patients with a mean age of 42.47 years. The visual impairment score, which was used to evaluate the visual outcome was produced by adding the scores for visual acuity and visual field defects of each patient (from the tables of the German Ophthalmological Society). The mean diameter, the SSE and the parasellar extension of the lesion were noted in the magnetic resonance imaging study. The average follow-up was 43.5 months. RESULTS: The mean diameter of the tumor was 32.97 mm, and the mean SSE was 14.95 mm. The parasellar extension was present in 27 patients. The vision improved in 61 of the 71 patients (85.91%). The shorter the duration of visual symptoms and smaller the size of the lesion resulted in better visual outcome. The age and the preoperative visual impairment did not show any correlation with the visual outcome. CONCLUSIONS: Patients with visual symptoms of <1-year duration (P < 0.01) and adenomas of <36.5 mm diameter (P < 0.009) have better visual outcome. |
0 | Stem cells in breast epithelia | MSTS 2018 - Femur Mets and MM | The rodent and human nonpregnant mammary glands contain epithelial, intermediate and myoepithelial cells which have all been isolated as cell lines in vitro. Transforming growth factor-alpha (TGF alpha) and basic fibroblast growth factor (bFGF) are produced by myoepithelial cells and can stimulate the growth of intermediate stem cells in vitro. Epithelial and intermediate cells behave like stem cells in vitro, since they can differentiate into alveolar-like an myoepithelial cells. The myoepithelial differentiation pathway is associated with the early expression of a calcium-binding regulatory protein called p9Ka and the protease, Cathepsin D. Myoepithelial cells are also present in benign lesions but not in malignant mammary carcinomas of rats or humans, whose resultant cell lines fail to differentiate completely along the myoepithelial cell pathway. Loss of the myoepithelial cell in some invasive carcinomas may be compensated, at least in part, by changes in malignant cells. Over-expression of TGF alpha and/or erbB receptors may reduce the requirement for TGF alpha, whilst ectopic production of bFGF and its receptors and p9Ka/Cathespin D may assist in tumorigenesis and in metastasis, respectively. Thus compensation for, or retention of, molecules potentially involved in the differentiation of mammary cells may be a mechanism by which malignancy progresses in some human invasive carcinomas. [References: 79] |
1 | Value of power Doppler and gray-scale US in the diagnosis of carpal tunnel syndrome: contribution of cross-sectional area just before the tunnel inlet as compared with the cross-sectional area at the tunnel | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | OBJECTIVE: To determine the value of gray-scale and power Doppler ultrasonography in the evaluation of carpal tunnel syndrome (CTS). MATERIALS AND METHODS: Median nerves at the carpal tunnel were evaluated by using gray-scale and power Doppler ultrasonography and by using accepted and new criteria in 42 patients with CTS (62 wrists) confirmed by electromyogram and 33 control subjects. We evaluated the cross-sectional area of the nerve just proximal to the tunnel inlet (CSAa), and at mid level (CSAb). We then calculated the percentage area increase of CSAb, and area difference (CSAb-CSAa). We measured two dimensions of the nerve at the distal level to calculate the flattening ratio. The power Doppler ultrasonography was used to assess the number of vessels, which proceeded to give a score according to the vessel number, and lastly evaluated the statistical significance by comparing the means of patients with control subjects by the Student t test for independent samples. Sensitivities and specificities were determined for sonographic characteristics mentioned above. We obtained the receiver operating characteristic (ROC) curve to assess the optimal cut-off values for the diagnosis of CTS. RESULTS: A statistically significant difference was found between patients and the control group for mean CSAb, area difference, percentage area increase, and flattening ratio (p < 0.001, p < 0.001, p < 0.001, p < 0.05, respectively). From the ROC curve we obtained optimal cut-off values of 11 mm(2) for CSAb, 3.65 for area difference, 50% for the percentage of area increase, and 2.6 for the flattening ratio. The mean number of vessels obtained by power Doppler ultrasonography from the median nerve was 1.2. We could not detect vessels from healthy volunteers. Mean CSAbs related to vascularity intensity scores were as follows: score 0: 12.3 +/- 2.8 mm(2), score 1: 12.3 +/- 3.1 mm(2), score 2: 14.95 +/- 3.5 mm(2), score 3: 19.3 +/- 3.8 mm(2). The mean PI value in vessels of the median nerve was 4.1 +/- 1. CONCLUSION: Gray-scale and power Doppler ultrasonography are useful in the evaluation of CTS |
0 | Osteoarthritis year in review 2017: clinical | PRP (Platelet-Rich Plasma) | This review is based on a systematic review of the literature relevant to clinical topics in osteoarthritis (OA) performed for the time period February 22, 2016 to April 1, 2017. A PubMed search using the terms “osteoarthritis” and “treatment or epidemiology” returned over 800 papers, of which 57 are reviewed here, with inclusion primarily based on relevance to clinical OA. Epidemiologic studies in this time frame focused on the incidence and prevalence of OA, comorbidities and mortality in relation to OA (particularly obesity and cardiovascular disease), and multiple joint involvement. Papers on therapeutic approaches to OA considered: non-pharmacologic options, a number of topical, oral, and intra-articular therapies, as well as the cost-effectiveness of some OA treatments. There an enormous need to identify novel strategies to reduce the impact of this highly prevalent and debilitating condition. |
0 | Different risk magnitudes of femoral neck and intertrochanteric fractures in Thai women | Management of Hip Fractures in the Elderly | OBJECTIVE: To study the risk factors associated of femoral neck and intertrochanteric fractures in Thai women. MATERIAL AND METHOD: A case,control study was conducted in Bangkok and its vicinity between 1997 and 1998 to compare factors related to each type of hip fracture in Thai women. Cases, aged > or =51 years old, were diagnosed as intertrochanteric or femoral neck fracture and were matched with controls by age and sex. Multinomial logistic regression was performed for significant associated factors. RESULTS: Recent physical activity and steroid-containing traditional medicine were strongly associated with intertrochanteric fractures (adjusted odds ratio (OR) 0.17 (95% CI: 0.07, 0.42) and 6.50 (95% CI: 1.93, 21.82), respectively) when compared to femoral neck fractures. Cerebrovascular accident (CVA) was more related to femoral neck fractures when compared to intertrochanteric fractures (adjusted OR 8.63 (95% CI: 2.28, 32.66), and 4.79 (95% CI: 1.19, 19.29), respectively). CONCLUSION: Intertrochanteric fracture could be minimized more by encouraging physical activities and avoidance of steroid use while the reduction of femoral neck fracture should be achieved more by CVA prevention |
0 | Hyaluronic acid instillation following arthroscopic anterior cruciate ligament reconstruction: a double-blinded, randomised controlled study | OAK 3 - Non-arthroplasty tx of OAK | PURPOSE: To assess the effect of hyaluronic acid instillation after arthroscopic anterior cruciate ligament (ACL) reconstruction for improving pain, range of movement, and function of the knee.
METHODS: 28 men and 4 women underwent arthroscopic ACL reconstruction for isolated ACL rupture (partial or complete) and instability after recreational sports injury 2 to 120 months earlier. They were randomised to undergo arthroscopic ACL reconstruction followed by intra-articular viscoseal instillation (13 men and 3 women) or arthroscopic ACL reconstruction alone (15 men and 1 woman). The knee injury osteoarthritis outcome score (for pain, symptoms, activities of daily living, sport and recreation function, and quality of life), range of movement, knee circumference, and analgesic use were assessed on days -1, 1, and 2, and weeks 2, 6 and 12.
RESULTS: Patient demographics were similar at baseline. At postoperative days 1 and 2, all subscales of the knee injury osteoarthritis outcome score (except for quality of life) were significantly higher in the viscoseal group. At weeks 2, 6, and 12, improvement in both groups equalised. Knee swelling (change in knee circumference) was significantly less in the viscoseal group at days 1 and 2 (p=0.009 and p=0.038, respectively, Mann-Whitney U test). Only one patient in the viscoseal group had a limited range of movement. No patient developed any adverse reaction.
CONCLUSION: Intra-articular viscoseal instillation improved pain control and swelling 2 days after arthroscopic ACL reconstruction. |
0 | Osteoporosis and African American women | Management of Hip Fractures in the Elderly | The incidence of osteoporosis and related fractures in African American women is half that of Caucasian women. African American women who sustain osteoporosis-related fractures have increased disability and decreased survival. Given the exponential increase in hip fracture rate among African American women over the age of 70 years, the risk of osteoporosis among this population may be underestimated. This review focuses on racial differences in women's bone mineral density (BMD) and bone metabolism and on various explanations for these observed differences. Environmental risk factors for osteoporosis and related fractures among African American women and modalities for prevention and treatment of osteoporosis are discussed. African American women begin menopause with higher BMD and have lower rates of women's bone loss after menopause, which account for their decreased incidence of osteoporosis and related fractures. The risk factors for osteoporosis among African American women are similar to those found in Caucasian women. Lifestyle interventions, such as calcium and vitamin D supplementation, smoking cessation, and increased physical activity, should be encouraged to enhance peak bone mass and to decrease bone loss. These interventions and other treatment modalities, such as hormone replacement therapy, bisphosphonates, and selective estrogen receptor modulators, should be studied further in African American women |
0 | Computed tomography of the carpal tunnel: a radioanatomical study | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Cross-sectional anatomy of the carpal tunnel was evaluated by computed tomography (CT) on eight cadavers. Prior to CT, the wrists were marked and, subsequently, anatomical cross sections of the specimens were carefully made along the markers. The anatomical section planes closely correlated with the levels of the CT images. Photographs of one of the specimens were taken for comparative studies |
1 | Early failure and mortality following intramedullary fixation of peritrochanteric fractures | Management of Hip Fractures in the Elderly | Background: The treatment of subtrochanteric and unstable pertrochanteric fractures by operative methods is technically demanding and presents a surgical challenge to the orthopedic surgeon. Fixation failure rates of 5-33% have been reported. However, outstanding results (98% healing) have recently been reported in a large series of 90 fractures treated by one surgeon using an intramedullary Gamma nail. In our department, these fractures are treated by many different surgeons with different levels of surgical training. The aim of this study was therefore to assess our experience with intramedullary fixation of peritrochanteric fractures. Methods: Between January 1998 and December 1999, a total of 37 peritrochanteric fractures were treated with intramedullary fixations. There were 25 women and 12 men. The average age of the patients was 79 years. The 37 operations were performed by 18 different surgeons! (9 registrars and 9 senior registrars or consultants). Results: Two patients were lost to follow-up. The overall 6 months fixation failure rate was 8/37 = 22%. The fixation failure rate among survivors at 6 months was 8/20 = 40%. The 6 months mortality rate was 17/37 = 46%. Conclusions: It may be wise to refer patients requiring intramedullary peritrochanteric surgery to a specialist |
0 | Outcomes of knee replacement in patients with posttraumatic arthritis due to previous tibial plateau fracture | OAK 3 - Non-arthroplasty tx of OAK | Introduction: Tibial plateau fractures are routinely treated with open reduction internal fixation (ORIF); however, the long-term results of ORIF are unclear. The purpose of the current study is to evaluate outcomes in these patients, including: the rate of conversion of ORIF to total knee arthroplasty (TKA), the relationship between elevated inflammatory markers after the initial ORIF and subsequent infection in TKA, and the rationale behind performing the conversion to TKA in one step versus two steps. Methods: Using current procedural terminology (CPT) codes, we assembled a cohort of 891 patients (933 knees) who underwent ORIF for a tibial plateau fracture from 2007 to 2017 at the investigating institution. The patients were then reviewed for pertinent demographic information and for the outcomes of interest. Results: Of the 933 knees, a total of 20 knees (2.15%) required conversion from ORIF to TKA. Of the 20 knees that underwent conversion to TKA, three were performed as a two-stage conversion. Of the 20 knees that underwent TKA, seven experienced postoperative arthrofibrosis, four experienced postoperative infection, and four required revision. Conclusion: Our retrospective study suggests that the need for conversion to TKA is uncommon following ORIF of a tibial plateau fracture. Furthermore, the conversion to TKA can be performed as a one- or two-stage procedure, and based on our study, we suggest that there may be higher rates of infection with the single stage conversion. Level of evidence: Level III, Retrospective study. |
0 | Reduced delays in A&E for elderly patients with hip fractures | Management of Hip Fractures in the Elderly | Published guidelines recommend early transfer of patients with hip fractures to hospital wards and avoidance of unnecessary delays in A&E. We describe a protocol whereby the liaison of an orthopaedic trauma co-ordinator with A&E reduced A&E-to-ward transfer times by 43%. Following introduction of the new protocol, 39% of hip fracture patients were in a ward bed within 3 h of admission to A&E compared to 4% previously. The new protocol also reduces administrative workload for the on-call orthopaedic SHOs |
0 | Longitudinal construct validity of the Health Utilities Indices Mark 2 and Mark 3 in hip fracture | Hip Fx in the Elderly 2019 | PURPOSE: The objective of this study is to evaluate the longitudinal construct validity of the Health Utilities Index Mark 2 (HUI2) and Health Utilities Index Mark 3 (HUI3) using a convergent/divergent validity approach in patients recovering from hip fracture, with the Functional Independence Measure (FIM) as the comparator.
METHODS: A total of 278 patients with a primary diagnosis of hip fracture were interviewed 3-5 days after surgery and then at 1 and 6 months using the HUI2, HUI3 and the FIM and a Likert-type rating of hip pain. A priori hypotheses were formulated. Convergent and divergent correlations between HUI2, HUI3 and FIM change scores for the baseline to 1-month and baseline to 6-month intervals were examined.
RESULTS: Overall HUI2 detected continued gain in health-related quality of life between 1 and 6 months after fracture, as the change increased from 0.20 to 0.29 units. The correlation between change in the overall HUI2 score and total FIM score was moderate (r = 0.50) over the 6-month interval, but larger than the observed correlation over the 1-month interval (r = 0.36). The correlation between change in overall HUI3 score and total FIM over the 1-month interval was small (r = 0.32), and the correlation between change in overall HUI3 score and total FIM was moderate (r = 0.37) over the 6-month interval. All hypotheses for the divergent correlations were supported.
CONCLUSIONS: Weaker correlations were reported for change over 1 month as compared to change over the 6 months after fracture. Findings supported the longitudinal construct validity of the overall HUI2 and HUI3 for the assessment of recovery following hip fracture, particularly for change over the 6 months following fracture. |
0 | AUtologous fat graft in foot calcaneal postsurgical chronic ulcer | DoD SSI (Surgical Site Infections) | INTRODUCTION: Post-traumatic injury of talus's posterior area and ankle joint with consequent scar formation is often complicated by an unhealing trophic ulcer. Aim of this paper is to evaluate the autologous fat graft effectiveness in treating Achilles tendon area wounds.
MATERIAL AND METHODS: From October 2011 to March 2014 we treated with fat graft a total of 7 patients with post-surgical painful chronic ulcer of calcaneal area. Mean age was 38.6 years (range 22-64 years). One patient was a professional football player who was presenting a post-injury ulcer not respondant to advanced dressings.
RESULTS: Wound rehepitelization was observed in all cases treated within one month and fat grafting resolved pain related to the wound. All patient returned to their daily normal activities. In all cases treated we observed an increased softness of perilesional post-surgical scars. Our professional football player came back able to perform an usual training 5 days post-operation obtaining complete rehepitelization within 3 weeks.
DISCUSSION: Our surgical approach showed a therapeutic effect that relies on biological properties of adipose tissue; those properties are clear in both procedures of chronic ulcer's rehepitelization stimulation and perilesional tissue's enhancement obtaining pain control. The procedure is safe, with low rate of complication. |
1 | Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators | DoD SSI (Surgical Site Infections) | OBJECTIVE: To compare unreamed intramedullary nailing (IMN) with external fixation (EF) in patients with Type II, IIIA, and IIIB open fractures of the tibial shaft.
DESIGN: An inception cohort of consecutive patients with Type II, IIIA, and IIIB tibial fractures incurred between January 1988 and March 1993 were systematically allocated into one of two treatment groups. Patients were treated and followed with a prospectively designed protocol.
PATIENTS AND SETTING: All patients were skeletally mature and had incurred a fracture of the tibial diaphysis within twenty-four hours of presentation to the tertiary care hospital, a Level I Trauma Center. One hundred seventy-four fractures in 168 patients were stabilized with either IMN (104) or half-pin EF (70). There were 132 men and thirty-six women, with an average age of thirty-three years (range, 14 to 77 years).
INTERVENTION: Except for the selection of the fixation device, open fracture care was similar in the two treatment groups. All patients underwent emergent irrigation and debridement with concomitant skeletal stabilization. Cephalosporin antibiotics were administered perioperatively for twenty-four to forty-eight hours. No wounds were closed primarily. Delayed primary closure, skin grafting, and/or myoplasty were performed between three and ten days after injury.
MAIN OUTCOME MEASURES: The main outcome measures were final fracture alignment, presence of infection or inflammation, hardware failure, time to union, and the number of operative procedures.
RESULTS: The IMN group had significantly fewer incidences of malalignment than did the EF group [8 vs. 31 percent; p = 0.00005; confidence interval (CI) = 0.18, 0.76] and had significantly fewer subsequent procedures (mean of 1.7 vs. mean of 2.7 per fracture; p = 0.001; CI = 0.45, 1.59). IMN resulted in fewer infections/ inflammatory problems than did EF at the injury site (13 vs. 21 percent; p = 0.73; CI = -0.63, 0.45) and significantly fewer at surgical interfaces (i.e., pin sites, nail and interlocking screw insertion sites; 2 vs. 50 percent; p = 0.000; CI = 0.39, 0.60). No significant difference was found in the healing rates for the two implant groups. The more severe Gustilo injury types had longer healing times regardless of the type of fixation.
CONCLUSIONS: Results suggest that unreamed interlocking intramedullary nails are more efficacious than half-pin external fixators, in particular with regard to maintenance of limb alignment. However, the severity of soft tissue injury rather than the choice of implant appears to be the predominant factor influencing rapidity of bone healing and rate of injury site infection. |
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