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0 | Phalloplasty and penile implant surgery | Panniculectomy & Abdominoplasty CPG | Impotence is often accompanied by loss of phallic length. To enhance penile prosthesis surgery, it is possible to perform simple adjuvant procedures that will increase perceived or true length. This article presents an overview of these techniques, which may be categorized as involving removal or fixation of tissue above or below the shaft of the penis; division of the suspensory ligament; and augmentation of the corpora cavernosa through stretch or grafting. We believe that the use of these techniques will become increasingly commonplace as patient satisfaction is reported. © 2009 Current Medicine Group, LLC. |
0 | Hip fracture patients have generalized osteopenia with a preferential deficit in the femur | Management of Hip Fractures in the Elderly | Bone density was measured in 31 white women with hip fractures by single- and dual-photon absorptiometry at the radius, lumbar spine and proximal femur. The mean age was 71.4 years. Comparison with premenopausal normals revealed Z-scores as follows: radius, -1.75; spine, -1.45; femoral neck, -2.40; Ward's triangle, -2.41; and trochanter, -1.42. These values altered when calculated for the patient's age by the use of sex- and race-specific regressions against age in a healthy, non-fracture population. The age-corrected Z-scores were as follows: radius, -0.09; spine, -0.18; femoral neck, -0.79; Ward's triangle, -0.44; and trochanter, -0.80. Thus, although our patients had absolute osteopenia at all skeletal sites when compared with young normals, when compared with age-matched normals (relative osteopenia) the only site with a noticeable deficit was the femur. Interpretation of the extent of osteopenia by comparison with young normals may lead to different conclusions than when an age-matched population is used. Patients with hip fractures had a preferential deficit in density of the femur when compared with normal women of their age |
0 | Nomogram-based Prediction of Overall Survival in Patients with Metastatic Urothelial Carcinoma Receiving First-line Platinum-based Chemotherapy: Retrospective International Study of Invasive/Advanced Cancer of the Urothelium (RISC) | MSTS 2022 - Metastatic Disease of the Humerus | Background The available prognostic models for overall survival (OS) in patients with metastatic urothelial carcinoma (UC) have been derived from clinical trial populations of cisplatin-treated patients. Objective To develop a new model based on real-world patients. Design, setting, and participants Individual patient-level data from 29 centers were collected, including metastatic UC and first-line cisplatin- or carboplatin-based chemotherapy administered between January 2006 and January 2011. Intervention First-line, platinum-based, combination chemotherapy. Outcome measurements and statistical analysis The population was randomly split into a development and a validation cohort. Generalized boosted regression modelling was used to screen out irrelevant variables and address multivariable analyses. Two nomograms were built to estimate OS probability, the first based on baseline factors and platinum agent, the second incorporating objective response (OR). The performance of the above nomograms and that of other available models was assessed. We plotted decision curves to evaluate the clinical usefulness of the two nomograms. Results and limitations A total of 1020 patients were analyzed (development: 687, validation: 333). In a platinum-stratified Cox model, significant variables for OS were performance status (p < 0.001), white blood cell count (p = 0.013), body mass index (p = 0.003), ethnicity (p = 0.012), lung, liver, or bone metastases (p < 0.001), and prior perioperative chemotherapy (p = 0.012). The c-index was 0.660. The distribution of the nomogram scores was associated with OR (p < 0.001), and incorporating OR into the model further improved the c-index in the validation cohort (0.670). Conclusions We developed and validated two nomograms for OS to be used before and after completion of first-line chemotherapy for metastatic UC. Patient summary We proposed two models for estimating overall survival of patients with metastatic urothelial carcinoma receiving first-line, platinum-based chemotherapy. These nomograms have been developed on real-world patients who were treated outside of clinical trials and may be used irrespective of the chemotherapeutic platinum agent used. |
0 | A 12-week supervised exercise therapy program for young adults with a meniscal tear: Program development and feasibility study | OAK 3 - Non-arthroplasty tx of OAK | OBJECTIVE: To describe the development and feasibility of an exercise therapy program for treatment of young adults (18-40 years of age) with a meniscal tear.
METHODS: Researchers and experienced physical therapists developed a 12-week supervised neuromuscular and strengthening exercise therapy program based on clinical expertise and available evidence. Six patients (age range 22-39 years) considered eligible for meniscal surgery by an orthopedic surgeon underwent the program. Patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and evaluated the program during a semi-structured qualitative interview. Feedback from patients was included to finalize the exercise therapy program.
RESULTS: Median improvements (Range) in KOOS subscales were 15 (0-33) for Pain, 11 (-11 to 50) for Symptoms, 16 (3-37) for Function in daily living, 23 (10-45) for Function in sport and recreation, and 9 (-6 to 31) for Quality of life. The patients found the program relevant and effective with only a few short-lasting adverse events and important clinical improvements after four to ten weeks. Physical therapist supervision was considered important. No patients wanted surgery up to 6 month after the exercise therapy program.
CONCLUSION: A neuromuscular and strengthening exercise therapy program was feasible and showed important improvement in a small group of young adults with meniscal tears. |
1 | The glenoid in total shoulder arthroplasty: Current concepts | Glenohumeral Joint OA | Total shoulder arthroplasty is an accepted treatment for glenohumeral arthritis. In appropriately selected patients, total shoulder arthroplasty decreases pain and improves function. One of themost common causes for failure is glenoid loosening, which leads to postoperative pain, limitation of function, and the possibility of revision surgery. The current literature has devoted considerable attention to the attributes of the glenoid in total shoulder arthroplasty. This article reviews the current state of knowledge about the glenoid, examining specifically the options for younger patients, for revision surgery, for glenoid erosion, and for maximizing implant longevity. The literature was searched for studies within the last 2 years regarding the glenoid in total shoulder arthroplasty, and relevant articles were selected for review. As the incidence of total shoulder arthroplasty increases, accurate and durable management of the glenoid will help minimize complications and promote better clinical outcomes. Clearly, further research is warranted on the optimal indications for the various techniques and strategies for treating the glenoid. © 2013 Wolters Kluwer Health. |
0 | Gait deviations in individuals with inflammatory joint diseases and osteoarthritis and the usage of three-dimensional gait analysis | OAK 3 - Non-arthroplasty tx of OAK | This chapter describes three-dimensional gait analysis and common gait deviations in adults with rheumatoid arthritis (RA) and osteoarthritis (OA). Furthermore, we describe changes in gait deviations following surgical and non-surgical interventions. Gait analysis is used to define gait deviations and to evaluate varying surgical approaches, types of surgeries and non-pharmacologic interventions. Most studies examine gait in adults with knee OA. Limitations of existing studies include small samples, poor selection of controls, sample heterogenecity, lack of baseline gait assessments and inconsistency in measurement. Across studies, time and distance parameters are generally used to provide a global measure of gait deviations. Individuals with RA and OA in the lower extremities exhibit reduced walking speed/cadence and decreased motion and moments in relation to healthy subjects. Future research should include larger sample sizes, the use of proper controls, pre- and post-assessments and identify gait abnormalities early in the disease process to minimise long-term consequences. |
0 | Multiple Osteochondral Allograft Transplantation with Concomitant Tibial Tubercle Osteotomy for Multifocal Chondral Disease of the Knee | Osteochondritis Dissecans 2020 Review | Symptomatic patellofemoral chondral lesions are a challenging clinical entity, as these defects may result from persistent lateral patellar maltracking or repetitive microtrauma. Anteromedializing tibial tubercle osteotomy has been shown to be an effective strategy for primary and adjunctive treatment of focal or diffuse patellofemoral disease to improve the biomechanical loading environment. Similarly, osteochondral allograft transplantation has proven efficacy in physiologically young, high-demand patients with condylar or patellofemoral lesions, particularly without early arthritic progression. The authors present the surgical management of a young athlete with symptomatic tricompartmental focal chondral defects with fresh osteochondral allograft transplantation and anteromedializing tibial tubercle osteotomy. |
0 | Damage control surgery and open abdominal management: recent advances and our approach | DoD - ACS - Interrater Reliability | The concept of damage control and improved understanding of the pathophysiology of abdominal compartment syndrome (ACS) have been proven to be great advances in the management of both traumatic and nontraumatic surgical conditions. The practice of damage control surgery includes 3 components: 1) abbreviated resuscitative surgery for rapid control of hemorrhage and abdominal contamination by gastrointestinal contents, followed by temporary abdominal wall closure for planned reoperation and prevention of ACS; 2) restoration of physiologic function, including rewarming and correction of coagulopathy and hemodynamic stabilization in the intensive care unit; and 3) re-exploration for the definitive management of injuries and abdominal wall closure. Although this new approach can decrease the mortality rate of patients with severe physiological derangement, the establishment of clearly defined indications is necessary. For patients who require damage control surgery, interventional radiology should be integrated into the strategy for achieving hemostasis. Angiographic evaluation and embolization should be considered immediately after initial operation, especially for patients with combined intraperitoneal and retroperitoneal hemorrhage, severe hepatic injury, or ongoing hemorrhage after damage control surgery. In many patients who require conventional open abdominal management following damage control surgery or decompressive laparotomy for ACS, the granulating abdominal contents are covered with only a skin graft, which is associated with a risk of enterocutaneous fistula. These patients will ultimately require complex abdominal wall reconstruction at a later stage. We have performed early fascial closure using an anterior rectus abdominis sheath turnover flap method. This technique may reduce the need for skin grafting and subsequent reconstruction and can be considered as an alternative method for the early management of patients with open abdomen. [References: 45] |
0 | The practice of unicompartmental knee arthroplasty in the United Kingdom | Surgical Management of Osteoarthritis of the Knee CPG | PURPOSE: To survey the current practice of unicompartmental knee arthroplasty (UKA) in the United Kingdom. METHODS: Questionnaires were sent to all 341 local members of the British Association for Surgery of the Knee to inquire into their practice of UKA, including clinical indications, preoperative investigations, surgical approach, preferences in implant design, and the role of UKA in relation to high tibial osteotomy. RESULTS: 56% of respondents performed less than 16 UKAs per year, whereas 16.5% performed over 30 per year. 89.5% of the respondents used anteroposterior radiographs as their main investigation tool. Only 30% and 16.5% used posteroanterior 30 degrees flexion and varus/valgus stress radiographs, respectively, despite being better investigation tools. 57% considered arthroscopy, despite its invasive nature. The main contra-indications to UKA were anterior cruciate ligament deficiency with instability (95%), focal grade-III osteoarthritis in the contralateral compartment (87%), and osteoporosis with rheumatoid arthritis (80.5%), but only 59% of respondents considered an inability to passively correct a pre-existing varus or valgus deformity as a contra-indication. 51.5% of respondents preferred minimally invasive approach, 96% preferred cemented fixation, and over two thirds used the mobile bearing design. 72% of respondents expressed preference for total knee arthroplasty over UKA in localised lateral compartment osteoarthritis. CONCLUSION: Modern UKA has gained popularity in properly selected patients with localised medial compartment osteoarthritis, provided the knee is not anterior cruciate ligament deficient and any deformity is passively correctable |
0 | Acute forefoot and midfoot injuries | DOD - Acute Comp Syndrome CPG | Forefoot and midfoot injuries in the athlete are common. Injuries of the digits include subungual hematomas and fractures. Metatarsal fractures occur frequently in sports, and their treatments range greatly. Hyperflexion and extension injuries about the first metatarsophalangeal joint can be very debilitating. Midfoot sprains and fractures require a high index of suspicion for diagnosis. |
0 | Impact of Visceral Fat on Survival and Metastasis of Stage III Colorectal Cancer | MSTS 2022 - Metastatic Disease of the Humerus | Background/Aims: Previous studies have investigated the relationship between visceral obesity and the risk of colorectal tumors. Visceral obesity may affect the outcome of colorectal cancer (CRC), including survival and metastasis. We investigated the associations between visceral adipose tissue and oncologic outcomes in stage III CRC.
Methods: Four hundred seventy-two patients with stage III CRC were identified. Subcutaneous and visceral adipose tissue areas were measured volumetrically via computed tomography for each patient at different levels of the lumbar spine. After adjusting for age, sex, and other clinical factors, the effects of visceral adipose tissue area on mortality and recurrence were assessed using Cox proportional hazard regression.
Results: In univariate and multivariate analyses, a higher visceral adipose tissue to total adipose tissue (VT) ratio (hazard ratio [HR], 1.041; 95% CI, 1.008 to 1.075; p=0.015) and higher visceral adipose tissue to subcutaneous adipose tissue (VS) ratio (HR, 1.016; 95% CI, 1.005 to 1.028; p=0.006) were both associated with poor CRC-specific survival. Interestingly, in the evaluation of each site of recurrence, a higher VT ratio (HR, 1.069; 95% CI, 1.010 to 1.131; p=0.020) and higher VS ratio (HR, 1.024; 95% CI, 1.003 to 1.045; p=0.023) were both related to a higher risk of peritoneal seeding and tumor recurrence. The VT ratio at the L3-L4 level was significantly associated with a higher risk of peritoneal seeding and tumor recurrence (HR, 4.969; 95% CI, 1.303 to 18.949; p=0.019), while other levels showed no such relationship.
Conclusions: Visceral obesity is closely related to increased risks of CRC-specific mortality and peritoneal seeding metastasis in stage III CRC patients. |
0 | Acute hematogenous septic arthritis of the knee in adults | OAK 3 - Non-arthroplasty tx of OAK | Purpose of study: To evaluate the factors associated with acute hematogenous septic arthritis of the knee in adults and to assess the outcome after open knee arthrotomy. Methods: We performed a prospective evaluation of 26 adult patients with acute nongonococcal septic arthritis of the knee presenting within 7 days. All patients underwent open knee arthrotomy, and final evaluation by means of Knee society score of the affected knee was compared with the contra lateral normal knee. Results: The average duration of symptoms at the time of presentation was 3.9 days. Staphylococcus aureus was the commonest bacteria isolated in 17 (65.4 %) patients. The average duration of follow-up in our study was 18.5 months. In our study, Knee society score decreases as the age of the patient advances (P < 0.05) and also it was found to be low (P < 0.05) in the affected knee as compared to contra lateral normal knee. Conclusion: Our study shows that age of the patient at presentation is critical as it shows significant reduction in knee score. This explains that the septic arthritis may contribute to the progression of age-related degeneration of the knee joint. There appears to be no definite contributing factors or conditions associated with acute hematogenous septic arthritis of the knee in adults, although further study may be warranted regarding this matter. © 2012 Springer-Verlag. |
1 | Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: A prospective randomized study | DoD LSA (Limb Salvage vs Amputation) | Background: Dislocations and fracture-dislocations involving the tarsometatarsal joint are a relatively common injury. These injuries are associated with long-term disability from subsequent painful osteoarthritis and residual deformity. This study evaluated whether performing a primary arthrodesis (PA) resulted in improved functional outcome and fewer subsequent surgeries as compared to primary open reduction and internal fixation (PORIF). Materials and Methods: Forty patients with acute tarsometatarsal joint fractures or fracture dislocations were prospectively randomized to undergo either PORIF or PA. Clinical and radiographic examination, in addition to Short Form-36 (SF-36) and Short Musculoskeletal Function Assessment (SMFA) questionnaires, were evaluated at intervals of 3, 6, 12, and 24 months following surgery in 32 patients. A patient satisfaction phone survey was also performed. Results: The rate of planned and unplanned secondary surgeries, including hardware removal and salvage arthrodesis, between ORIF and PA groups, 78.6% vs. 16.7% was significantly different. No statistically significant differences were found with physical functioning for the PORIF or PA groups with regard to SF-36 or SMFA scores at any followup time interval. However, time from injury had a significant effect with impaired functioning at three months compared to all future intervals. No difference in satisfaction rates were found between PORIF and PA at an average of 53 months in a phone survey. Conclusion: PA of tarsometatarsal joint injuries resulted in a significant reduction in the rate of followup surgical procedures if hardware removal is routinely performed with no significant difference in SF-36 and SMFA outcome scores when compared to PORIF. Copyright © 2009 by the American Orthopaedic Foot & Ankle Society. |
1 | Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery | Upper Eyelid and Brow Surgery | PURPOSE: To examine patients' subjective perception of visual function and health-related quality of life as affected by blepharoptosis and the change in these perceptions after blepharoptosis surgery. METHODS: A 27-item questionnaire pertaining to vision-related activities and symptoms was used preoperatively to assess 50 consecutive patients (18 years old or older) with unilateral or bilateral acquired involutional blepharoptosis, and postoperatively six to eight weeks after blepharoptosis repair. RESULTS: Of the 24 items statistically analyzed, 16 items (67%) demonstrated significant improvement postoperatively (P < .05) among the unilateral cases and 18 items (75%) showed significant improvement postoperatively (P < .05) among the bilateral cases. The four activities that improved the most after surgery for both the unilateral and bilateral groups were the ability to perform fine manual work, hanging or reaching objects above eye level, watching television, and reading. CONCLUSIONS: Surgical repair of acquired involutional blepharoptosis resulted in significant improvement in several aspects of patients' subjective visual function and health-related quality of life. These issues are important in determining both the indications for and outcome of blepharoptosis surgery. |
0 | Heterotopic ossification of the elbow treated with surgical resection: risk factors, bony ankylosis, and complications | Pediatric Supracondylar Humerus Fracture 2020 Review | BACKGROUND: Heterotopic ossification is the most common extrinsic cause of elbow contracture and may lead to clinically important stiffness, and rarely, complete bony ankylosis. Surgery sometimes is performed to treat this problem, and published reports differ regarding the factors that are associated with success or failure after this operation and whether the procedure is effective for patients with elbow ankylosis. QUESTIONS/PURPOSES: We wished (1) to identify potential patient characteristics and modifiable risk factors that are associated with improvements in ROM after surgery for heterotopic ossification of the elbow; (2) to compare ROM gains between patients with complete ankylosis and partially restricted ROM; and (3) to characterize the complications of elbows treated by surgical release and excision of heterotopic ossification followed by a standardized rehabilitation program. METHODS: We reviewed the records of all patients treated operatively for heterotopic ossification of the elbow from September 1999 to February 2012 at one institution by one surgeon. General indications for the surgery were clinically symptomatic or debilitating heterotopic ossification of the elbow. Each patient received prophylaxis postoperatively consisting of indomethacin (or single-shot radiation for patients with sensitivity to antiinflammatory medications). All patients received a physical therapy regimen and used a continuous passive motion machine for 6 weeks. Patient demographics, mechanism of injury, time between injury and surgery, and medical history were reviewed for comparison. Followup was at a mean of 13 months (range, 3-106 months); no patients were lost to followup. Thirty-nine patients (46 elbows) with heterotopic ossification treated with excision were identified: 10 patients (16 elbows) had burns, 28 patients (29 elbows) had trauma, and one patient (one elbow) had a closed head injury. Eight of the 39 patients (12 of 46 elbows [26%]) had complete ankylosis at the time of surgery. RESULTS: Hypertension, obesity, and absence of intraoperative anterior ulnar nerve transposition were associated with an adverse effect on change from preoperative to final arc of motion. The group with ankylosis had greater preoperative to postoperative gain in arc compared with the group with partial restriction (96°, 95% CI, 84°-107° and 59°, 95% CI, 46°-72°, respectively). For the entire cohort there was an overall improvement in mean flexion-extension arc of motion from 35° to 103° at final followup (p < 0.001; 95% CI, 57°-80°), with a 17% rate of complications (three patients [three elbows] with heterotopic ossification, three patients [three elbows] with nerve palsies, one patient [one elbow] with deep wound infection, and one patient [one elbow] with an unstable elbow). CONCLUSIONS: Patients with partially and completely restricted ROM showed substantial improvement in postoperative ROM. Hypertension, obesity, and absence of intraoperative anterior ulnar nerve transposition were negative predictors of outcome in our series. Surgery combined with postoperative prophylaxis and a regimented rehabilitation program are feasible modalities to treat patients with heterotopic ossification of the elbow. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence. |
0 | Outcomes of distal humerus diaphyseal injuries fixed with a single-column anatomic plate | Distal Radius Fractures | PURPOSE: The locking compression extra-articular distal humerus plate (EADHP) is an anatomically shaped, angular stable single-column fixation system for distal third humerus fractures. The purpose of this retrospective study was to evaluate clinical and radiographic outcomes after open reduction and internal fixation of distal humerus fractures with this device.
METHODS: Twenty-one consecutive patients with distal humerus fractures were treated with the EADHP system between February 2006 and June 2012. Of these, 19 were clinically and radiographically evaluated after a mean follow-up of 10.4 months. Follow-up assessment included anteroposterior and lateral radiographs, assessment of range of motion (ROM), pain according to a visual analogue scale (VAS) and Disabilities of the Arm, Shoulder and Hand (DASH) score.
RESULTS: All fractures demonstrated satisfactory reduction and healing at an average of 7.3 months. One patient showed post-operative sensory ulnar neuropathy that recovered completely, and nine patients had a preoperative radial nerve palsy, which recovered spontaneously following exploration and plating. Mean post-operative ROM was as follows: flexion 126degree, extension -7degree, pronation 82degree and supination 83degree. The VAS score was zero points in eight patients, while the mean DASH score was 25.8 points.
CONCLUSIONS: For extra-articular distal humerus fractures, including high-energy injuries often seen in gunshot wounds or motor vehicle injuries, the anatomically shaped angular stable single-column plate provides satisfactory clinical and radiographic results and serves as a valuable tool in the treatment of these injuries. |
0 | Differences in mammalian target of rapamycin gene expression in the peripheral blood and articular cartilages of osteoarthritic patients and disease activity | OAK 3 - Non-arthroplasty tx of OAK | The gene expression of mTOR, autophagy-related ULK1, caspase 3, CDK-inhibitor p21, and TNF α was measured in the peripheral blood of osteoarthritic (OA) patients at different stages of the disease aiming to establish a gene expression profile that might indicate the activity of the disease and joint destruction. Whole blood of 65 OA outpatients, 27 end-stage OA patients, 27 healthy volunteers, and knee articular cartilages of 28 end-stage OA patients and 26 healthy subjects were examined. OA outpatients were subjected to clinical testing, ultrasonography, and radiographic and WOMAC scoring. Protein levels of p70-S6K, p21, and caspase 3 were quantified by ELISA. Gene expression was measured using real-time RT-PCR. Upregulation of mTOR gene expression was observed in PBMCs of 42 OA outpatients ("High mTOR expression subset") and in PBMCs and articular cartilages of all end-stage OA patients. A positive correlation between mTOR gene expression in PBMCs and cartilage was observed in the end-stage OA patients. 23 OA outpatients in the "Low mTOR expression subset" exhibited significantly lower mTOR gene expression in PBMCs compared to healthy controls. These "Low mTOR" subset subjects experienced significantly more pain upon walking, and standing and increased total joint stiffness versus "High mTOR" subset, while the latter more often exhibited synovitis. The protein concentrations of p70-S6K, p21, and caspase 3 in PBMCs were significantly lower in the "Low" subset versus "High" subset and end-stage subjects. Increases in the expression of mTOR in PBMCs of OA patients are related to disease activity, being associated with synovitis more than with pain. © 2013 Elena V. Tchetina et al. |
0 | Bone grafting in femoral neck fractures: results in 28 cases operated on with multiple pinning and cancellous bone grafting | Management of Hip Fractures in the Elderly | Twenty-eight patients with displaced femoral neck fractures were operated on with multiple pinning combined with cancellous bone grafting from the ipsilateral greater trochanter. The bone graft was introduced through a drilled channel in the femoral neck without exposing the fracture. At follow-up after 2 years, seven patients had died. Two patients had been reoperated with prosthetic replacement of the hip. Nineteen fractures were united and one had developed segmental collapse. In femoral neck fractures, complications from non-union and segmental collapse are still a major problem. Even if the impaired vascular supply to the femoral head is responsible for most of the complications, anatomic reduction and a stable fixation are conductive to fracture union. Comminution of the posterior wall of the femoral neck has a negative influence on the security of fixation due to a persisting posterior gap after reduction. In previous reports, bone grafting of the posterior defect in the femoral neck through an open approach has achieved good results. Only a few studies, however, describe a technique of introducing bone chips through a drilled channel in the femoral neck. The use of the ipsilateral greater trochanter as the sole donor site for bone grafting in femoral neck fractures has not been reported previously |
0 | Cardiac surgery in the time of the coronavirus | Coronavirus Disease 2019 (COVID-19) | The current Covid-19 pandemic is a significant global health threat. The outbreak has profoundly affected all healthcare professionals, including heart surgeons. To adapt to these exceptional circumstances, cardiac surgeons had to change their practice significantly. We herein discuss the challenges and broad implications of the Covid-19 pandemic from the perspective of the heart surgeons. |
0 | Double plating for the treatment of distal tibia and fibula fractures: case series of twenty five patients | DoD SSI (Surgical Site Infections) | BACKGROUND: The treatment of fractures of the distal third of the tibia and fibula usually involves two incisions, thus raising the risk of wound dehiscence, wound necrosis, infection, and the delayed union or non-union of distal tibial fractures. To decrease and prevent aforementioned serious complications, one-incision double-plating technique was advocated here.
AIM: The aim of this work was to evaluate the results and effects of the one-incision, double-plating technique in the fractures of distal third of the tibia-fibula and fibula.
PATIENTS AND METHODS: Twenty-five patients with fractures of the distal third of the tibia-fibula, were treated with one incision, double plating between June 2007 and January 2009. The reduction and fixation of the tibia and fibula were conducted in all patients using one incision. The type of fractures based on AO classification were A1 (n = 6), A2 (n = 4), B1 (n = 12) and C1 (n = 3). All patients were followed-up at least until the patient was fully weight-bearing and the soft tissues had healed (median, 15 months; range, 12-24).
RESULTS: Postoperative follow-up showed that 24 fractures healed within the range of the normal healing time. Only one patient with delayed union healed without surgical intervention by 7 months postoperatively. There were no cases of malunion or non-union. Importantly, at their last follow-up visit, the fracture was in excellent position and healed radiographically, and the patient could walk without pain and support.
CONCLUSIONS: One-incision double-plating is a safe and effective alternative for treatment of distal tibia and fibula fractures. |
0 | Assessment of knee function | Surgical Management of Osteoarthritis of the Knee CPG | In our department we are evaluating the problem of assessing function in patients with arthritic knees before and after operation. In the clinic we use very simple tests, which are easily reproducible. Nonetheless, they are objective and give a more accurate indication of the capacity of the knee, the object of our concern, than data gathered by conventional methods from patients' subjective descriptions. By measuring constant criteria, we get data from which valid comparisons and aggregations can be made and ultimately valid conclusions drawn. At the other extreme we use highly sophisticated techniques, which are not cheap and hence of limited availability, to obtain a much more complete picture of the changing patterns of activity which follow knee replacement operations. We hope in due course to be able to compare the results of both techniques and to use the more sophisticated as an instrument for validating, or otherwise, the less sophisticated, that is, for determining how reliable an index assessement by the simple method provides of the part knee function plays in total mobility |
0 | Operative treatment of distal radial fractures with locking plate system-a prospective study | Glenohumeral Joint OA | The aim of this study was to determine the results of operative treatment of distal radial fractures with a 2.4-mm locking plate system in a single tertiary teaching hospital. Seventy-five patients were recruited into the study between May 2004 and November 2006. There were 41 males and 34 females, with a mean age of 51. Seventy-five percent of patients had AO type C fractures. All patients were allowed free active mobilisation of the wrist joint immediately after surgery. They were followed up at two weeks, three months, six months, one year and two years. Assessments of pain, motion, grip strength, and standard radiographs were performed. The Gartland and Werley functional scores, the modified Green and O'Brien score, and the disabilities of the arm, shoulder and hand (DASH) scores were recorded. The radiographic results at the final follow-up showed a mean of 18degree of radial inclination, 5degree of volar tilt, 1.3-mm radial shortening, and no articular incongruity. Twenty-nine percent of patients showed grade 1 osteoarthritic changes and 6% had grade 2 changes in their final follow-up radiographs. An excellent or good result was obtained in 98% and 96% of patients according to the Gartland and Werley, and modified Green and O'Brien scores, respectively. The mean DASH score was 11.6, indicating a high level of patient satisfaction. Internal fixation of distal radial fractures with a 2.4-mm locking plate system provided a stable fixation with good clinical outcomes and patient satisfaction. |
0 | Coronal malalignment in the adult knee | AMP (Acute Meniscal Pathology) | Coronal plane deformity in the adult patient is a complex clinical problem. Once the hip, knee, and ankle joint centers lose collinerarity, the knee is exposed to abnormal loads across its tibiofemoral compartments, leading to early degenerative changes. Malalignment can coexist with arthrosis and ligamentous instability. High tibial osteotomy and distal femoral osteotomy have been useful tools to realign the adult knee. They can be performed along with ligament reconstruction and cartilage restoration procedures with high success rates. Despite novel techniques and fixation methods, principles of deformity correction should be followed to maximize clinical outcomes. |
0 | Volar morphology of the distal radius in axial planes: a quantitative analysis | Distal Radius Fractures | To investigate the cause of rupture of the flexor pollicis longus (FPL) after volar plate fixation of distal radius fractures, previous studies have examined the shape of the distal radius in the sagittal plane or in the lateral view. However, there are no reports on the anatomical shape of the volar surface concavity of the distal radius in the axial plane. We hypothesized that this concavity might contribute to the mismatch between the plate and the surface of the radius. To test this hypothesis, we constructed three-dimensional models of the radius and FPL based on computed tomography scans of 70 normal forearms. We analyzed axial cross-sectional views with 2 mm intervals. In all cases, the volar surface of the distal radius was concave in the axial plane. The concavity depth was maximum at 6 mm proximal to the palmar edge of the lunate fossa and progressively decreased toward the proximal radius. FPL was closest to the radius at 2 mm proximal to the palmar edge of the lunate fossa. The volar surface of the distal radius was externally rotated from proximal to distal. These results may help to develop new implants which fit better to the radius and decrease tendon irritation. |
0 | Comparison between preassembled and modular cups in primary cementless total hip arthroplasty: A two-year minimum follow-up study | DoD SSI (Surgical Site Infections) | We prospectively analyzed 83 patients who underwent ceramic-on-ceramic THA using preassembled (n = 22) or modular acetabular components (n = 61) between June 2010 and June 2012. There were no significant differences in mean postoperative radiographic outcomes, functional outcomes, or complications between the two groups. Both groups showed satisfactory performance at the 2. year follow up. Only the gender of the patients was significantly different between the two groups. Half of the women had smaller acetabular diameters accommodating a cup size of only 48-50-mm. Although a preassembled cup with a 36-mm ceramic liner is proven to be safe in the short term, future research should focus on evaluating the long-term risks. |
0 | Prevention of falls in the elderly--a review | HipFx Supplemental Cost Analysis | The proportion of elderly in the society increases and fall frequency increases with advancing age. Many falls result in fractures and also soft tissue injuries, longstanding pain, functional impairment, reduced quality of life, increased mortality, and excess in healthcare costs. Due to the magnitude of these negative effects, a variety of single- and multicomponent fall-preventive intervention programs has been initiated.This review identifies programs that, in randomized controlled trials (RCTs), have been shown with fall-reductive effects.The most effective strategies in community-dwelling elderly include regular physical training with program that includes several different training modalities. Modification of the overall or patient-specific risk factor profile in home hazard modification program has been proven to decrease fall risk in community-living elderly. The elderly in the community benefit also from wearing antislip shoe devices when walking in icy conditions, from adjustment of psychotropic medication, and from structured modification of multipharmacy. If vitamin D levels in blood are low, supplementation is beneficial as is the first eye cataract surgery and pacemaker implantation in patients with cardioinhibitory carotid sinus hypersensitivity. In addition to modification of specific risk factors, generalized and individualized multifactorial preventive programs, all including some sort of physical training, have been found to decrease the fall risk. In summary, there is now strong evidence in the literature that structured fall-preventive programs in the elderly, especially in high-risk groups, are beneficial in reducing both the number of fallers and the number of falls in community |
0 | Targeting the gut microbiome to treat the osteoarthritis of obesity | OAK 3 - Non-arthroplasty tx of OAK | Obesity is a risk factor for osteoarthritis (OA), the greatest cause of disability in the US. The impact of obesity on OA is driven by systemic inflammation, and increased systemic inflammation is now understood to be caused by gut microbiome dysbiosis. Oligofructose, a nondigestible prebiotic fiber, can restore a lean gut microbial community profile in the context of obesity, suggesting a potentially novel approach to treat the OA of obesity. Here, we report that - compared with the lean murine gut - obesity is associated with loss of beneficial Bifidobacteria, while key proinflammatory species gain in abundance. A downstream systemic inflammatory signature culminates with macrophage migration to the synovium and accelerated knee OA. Oligofructose supplementation restores the lean gut microbiome in obese mice, in part, by supporting key commensal microflora, particularly Bifidobacterium pseudolongum. This is associated with reduced inflammation in the colon, circulation, and knee and protection from OA. This observation of a gut microbiome-OA connection sets the stage for discovery of potentially new OA therapeutics involving strategic manipulation of specific microbial species inhabiting the intestinal space. |
0 | The Evolving Role of Pre-pectoral ADM-assisted Approach in Implant-based Immediate Breast Reconstruction Following Conservative Mastectomy: An Overview of the Literature and Description of Technique | Acellular Dermal Matrix | BACKGROUND/AIM: The recent development of acellular dermal matrix (ADM) devices has enhanced implant-based breast reconstruction surgery following conservative mastectomy for therapeutic and risk-reducing purposes leading to improved aesthetics. In the traditional sub-pectoral approach, coverage of the implant is provided by the pectoral muscles superiorly and the ADM inferiorly. The need to eliminate breast animation, reduce post-operative dysfunctional pain and the risk of capsular contracture, have stimulated surgeons to investigate the feasibility of placing the implant over the pectoralis major muscle with complete coverage with ADM thus inventing a novel pre-pectoral approach. MATERIALS AND METHODS: We reviewed the literature regarding this evolving technique of muscle sparing ADM-assisted implant-based immediate breast reconstruction. Also, we describe our technique, and present pictures of the post-operative result. RESULTS AND CONCLUSION: The early reported results of the pre-pectoral breast reconstruction approach are encouraging and confirmed the potential benefits of eliminating breast animation and reducing postoperative pain. However, most of these studies had a small sample size (<100 patients) and were retrospective in nature with a limited follow-up duration and lack of data regarding the objective aesthetic assessment and oncological outcome. Nevertheless, suitable patients undergoing conservative mastectomy and implant-based reconstruction should be offered this option while further evaluation is being performed. |
0 | Treatment of humeral shaft fractures with antegrade intramedullary locking nail | DoD SSI (Surgical Site Infections) | Antegrade interlocked humeral nailing for stabilization of humeral fractures was introduced many years ago, and studies on this method in the orthopedic literature have shown mixed results. The purpose of this investigation was to document the clinical outcome and complications associated with the use of an antegrade intramedullary nail (T2, Stryker) for the humeral fractures. Between 2005 and 2008, 52 fractures of the humeral shaft were treated operatively with this intramedullary nail in our department. Eight patients were polytraumatized, and four patients had an open fracture. The mean age of patients was 51.7 years. Forty-eight patients had an adequate duration of clinical follow-up (a mean of 18 months) for analysis. Complications were recorded, and the time to union was measured. Shoulder and elbow functions were assessed using the Constant Score and the Morrey Score, respectively. Forty-six fractures healed, with a mean time to clinical union of 10.3 weeks. Two patients developed pseudarthroses. There were four adverse events: two proximal screws backed out, one superficial infection at the insertion point, and one fracture at the distal end of the nail. Ninety-one percentage of patients had an excellent or good shoulder function. Five further operations were necessary: two for treatment of pseudarthroses, two for removal the backed out proximal screws, and one wound debridement for superficial infection. Antegrade humeral nailing is a valid therapeutic option for stabilization of humeral shaft fractures. By strictly adhering to the operation technique, the number and the severity of complications can be reduced. When good fracture alignment and stability are obtained, uneventful bone healing with good functional results is the rule. |
0 | Risk Factors Associated with Failure of Cephalomedullary Nail Fixation in the Treatment of Trochanteric Hip Fractures | Hip Fx in the Elderly 2019 | Background: Intramedullary (IM) nailing is widely performed in elderly patients with trochanteric fractures. Thus, it is important to identify causative factors associated with fixation failure. We investigated fixation failures after IM nailing in elderly patients with trochanteric fractures and compared the failure group with nonfailure group to identify risk factors of fixation failure.
Methods: A total of 396 patients aged 65 years or older underwent IM nailing for trochanteric fractures between January 2012 and August 2016 at our institution. Of those, 194 patients who were followed up for more than 12 months were enrolled in this study; 202 patients were excluded due to death during follow-up, bedridden status before injury, and loss to follow-up. All patients underwent plain radiography and preoperative computed tomography (CT).
Results: Fixation failure occurred in 11 patients (5.7%). Seven patients had stable fractures (AO/OTA); eight patients had basicervical fractures (confirmed by CT). Five patients had comminution in the greater trochanter (confirmed by CT). Regarding fracture reduction, eight patients showed discontinuity in the anterior cortex. The position of the lag screw on the lateral view was in the center in six patients and in a posterior area in the other five patients. On the basis of comparison with the 183 patients without fixation failure, risk factors of fixation failure were higher body mass index (BMI; p = 0.003), basicervical type of fracture (p = 0.037), posterior placement of the lag screw on the lateral view (p < 0.001), and inaccurate reduction of the anterior cortex (p = 0.011).
Conclusions: Among the risk factors of fixation failure after IM nailing in elderly patients with trochanteric fractures, discontinuity of the anterior cortex and posterior position of the lag screw are modifiable surgeon factors, whereas higher BMI and basicervical type of fracture are nonmodifiable patient factors. Therefore, care should be taken to avoid fixation failure in IM nailing for patients with a basicervical type of fracture or higher BMI or both. |
0 | Gluteal re-contouring with combination treatments: implants, liposuction, and fat transfer | Panniculectomy & Abdominoplasty CPG | Patients seeking augmentation or re-contouring of the gluteal region have three basic options: gluteal implants, liposuction, and augmentation with fat injections. In many cases, all three treatments are used together to achieve attractively shaped buttocks with proper proportions and good projection. The treatment or combination of approaches that is appropriate for each individual patient is discovered through consultation that focuses on understanding a patient's goals. To determine the treatment(s) required by a patient, his or her unique anatomy must be analyzed to identify gluteal areas that have excesses or deficiencies that can be successfully addressed in gluteal re-contouring. |
1 | Do preexisting abdominal scars threaten wound healing in abdominoplasty? | Panniculectomy & Abdominoplasty CPG | PURPOSE: Abdominal scars may impair healing after abdominoplasty. We aimed to determine whether right subcostal or upper midline scars led to increased wound healing problems. METHODS AND MATERIALS: Review of all patients who had abdominoplasty from March 1998 to February 2008 was performed. Variables studied included age, gender, body mass index (BMI), medical history, and postoperative complications. Statistical analysis was performed in Stata SE, version 10. RESULTS: Of 420 abdominoplasty procedures, 62.2% had open gastric bypass surgery (GBS) and 19% had laparoscopic GBS. Seven percent (n = 29) of the series had a right subcostal scar. Overall risk of any complication was 32.9%, with 18.3% risk of wound healing problem (18.3%) and seroma (14.9%). chi(2)analysis revealed a significant relationship between any abdominal scar and any complication (P = .001), and wound healing problem specifically (P = .009). The subcostal scar was significantly associated with wound healing problems (P = .003). The upper midline scar was not associated with wound healing or seroma complication. While multivariate analysis erased any significant relationship between abdominal scars and complications, elevated BMI presented a significant threat to wound healing. With every unit increase in BMI, a 5% increase in the risk of any complication and a 6% increased risk in wound healing was calculated (P = .001). There was no difference in complications between the open and laparoscopic GBS groups, indicating that the upper midline incision did not pose a threat to wound healing. CONCLUSIONS: Elevated BMI poses a greater threat to healing than does abdominal scar. Caution is recommended in undermining when the right subcostal scar exists. |
0 | Long-term results of uncemented total hip arthroplasty with the Taperloc femoral component in patients with Dorr type C proximal femoral morphology | PJI DX Updated Search | AIMS: To investigate the longevity of uncemented fixation of a femoral component in total hip arthroplasty (THA) in patients with Dorr type C proximal femoral morphology. PATIENTS AND METHODS: A total of 350 consecutive uncemented THA in 320 patients were performed between 1983 and 1987, by a single surgeon using the Taperloc femoral component. The 63 patients (68 hips) with Dorr type C proximal femoral morphology were the focus of this review. The mean age of the patients was 69 years (24 to 88) and mean follow-up was 16.6 years (ten to 29). Survival analysis included eight patients (eight hips) who died without undergoing revision surgery prior to obtaining ten years follow-up. All 55 surviving patients (60 hips) were available for clinical assessment and radiographic review. As a comparator group, the survival and implant fixation in the remaining 282 THAs (257 patients) with Dorr type A and B morphology were evaluated. The mean age of these patients was 52 years (20 to 82). RESULTS: In the Dorr C patient group the mean Harris hip score improved from 51 points (21 to 69 points) pre-operatively to 89 (74 to 100) at final follow-up. No femoral component was loose by radiological criteria and osteolysis was only identified around two stems (3.3%). There was one revision (1.6%) of a well-fixed femoral component for sepsis at 11 years. The survival of the Taperloc femoral component at 20 years with revision for any reason as the endpoint was 98% (95% confidence interval; 87 to 99). A total of ten (3.5%) of the Dorr A and B patient group of 282 THAs required revision surgery. Only one (0.4%) for aseptic loosening. A total of two hips (1%) were loose by radiographic criteria and osteolysis occurred around 12 hips (4%). CONCLUSION: This study demonstrates that excellent fixation can be achieved using the Taperloc stem in patients with Dorr type A and B, and Dorr type C bone. TAKE HOME MESSAGE: The Taperloc stem demonstrated equivalent results in Dorr type A and B and Dorr type C bone. Cite this article: Bone Joint J 2016;98-B:595-600 |
0 | Intimate Relationships Buffer Suicidality in National Guard Service Members: A Longitudinal Study | DoD PRF (Psychosocial RF) | OBJECTIVE: Members of the U.S. military are at a high suicide risk. While studies have examined predictors of suicide in the U.S. military, more studies are needed which examine protective factors for suicide. Informed by the interpersonal theory of suicide, this study examined the strength of the intimate relationship and its role as a buffer of suicidality in National Guard service members.
METHOD: A total of 712 National Guard residing in a Midwestern state, who had all recently returned home from a deployment, took part in this study and completed surveys at 6 and 12 months postdeployment. They were assessed on suicide risk, mental health (depression, post-traumatic stress disorder, anxiety), and relationship satisfaction.
RESULTS: Lower relationship satisfaction and more depressive symptoms at the 6-month assessment were significantly related to greater suicide risk at 12 months. Each interaction between couple satisfaction and three mental health variables (PTSD, depression, and anxiety) at the 6-month assessment was significantly associated with suicide risk at 12 months.
CONCLUSIONS: The strength of the intimate relationship serves as a buffer for suicide in National Guard service members who have PTSD, anxiety, or depression. Interventions that strengthen these intimate relationships could reduce suicide in service members. |
0 | Long-term aspirin use and the risk of total, high-grade, regionally advanced and lethal prostate cancer in a prospective cohort of health professionals, 1988-2006 | MSTS 2022 - Metastatic Disease of the Humerus | Experimental studies suggest a role for aspirin in the chemoprevention of prostate cancer and epidemiological evidence supports a modest inverse association between regular aspirin use and prostate cancer risk, especially for advanced disease. In a prospective cohort study of 51,529 health professionals aged 40-75 years at baseline, we evaluated long-term aspirin use and the incidence of total, high-grade (Gleason 8-10, n = 488), regionally advanced (T3b-T4 or N1, n = 228) and lethal prostate cancer (M1, bony metastases or prostate cancer death, n = 580) from 1988-2006. We used Cox proportional hazards regression to evaluate risk associated with frequency (days/week), quantity (tablets/week), recency and duration of aspirin use after multivariable adjustment for confounders and other predictors of prostate cancer risk. A total of 4,858 men were diagnosed with prostate cancer during the 18-year study period. Men taking = 2 adult-strength aspirin tablets a week had a 10% lower risk of prostate cancer (p-for-trend = 0.02). For regionally advanced cancer, we observed no significant associations with aspirin use. For high-grade and lethal disease, men taking = 6 adult-strength tablets/week experienced similar reductions in risk hazard ratio [HR = 0.72 (95% confidence intervals [CI]: 0.54, 0.96) and HR = 0.71 (95% CI: 0.50, 1.00)]. Analytical approaches to address bias from more frequent prostate-specific antigen screening among aspirin users did not yield different conclusions. We observed reductions in the risk of high-grade and lethal prostate cancer associated with higher doses of aspirin, but not with greater frequency or duration, in a large, prospective cohort of health professionals. Our data support earlier observations of modest inverse associations with advanced prostate cancer. Copyright © 2010 UICC. |
0 | Influence of knee flexion and atraumatic mobilisation of infrapatellar fat pad on incidence and severity of anterior knee pain after tibial nailing | AMP (Acute Meniscal Pathology) | We evaluated the incidence and aetiology of anterior knee pain (AKP) in a series of patients that underwent intramedullary nailing for stabilisation of tibial fractures. During the preparation of the entry site no excision of the infrapatellar fat was allowed and electrical haemostasis was kept at the lowest level. Medullary canal was reamed and the nails inserted in position of knee flexion over 100 degrees. All fractures were fixed using medial paratendinous approach. Functional outcome was measured using Lysholm knee score. The knee range of movement and return to previous level of activity were also documented and analysed. Mean follow up was 38.9 months (range 12-84 months). In total 60 patients with 62 tibial shaft fractures were analysed. The mean age at the time of final follow up was 49.4 years (range 20-87). In 22 (35.5%) a newly developed and persisting pain in the anterior region of the operated knee was reported. According to VAP scale, the pain was mild (VAS 1-3) in 12 cases (19.4%) and moderate (VAS 4-6) in 10 (16.1%). In 16 cases (73%) the pain was noticed 6-12 months after injury and subjectively related to return to full range of working and recreational activities. The mean Lysholm knee score in the group without AKP was 90.8. In the AKP group with mild pain it was 88.4 and in the group with moderate AKP it was 79.9. Complete return to previous professional and recreational activities occurred in 49/60 patients (81.7%). Content with the treatment regarding expectations in recovery dynamics and return to desired level of activity was present in 98.3% of patients; one patient was unsatisfied with the treatment. Our results indicate that respecting the physiological motion of Hoffa pad and menisci during knee flexion, accompanied with atraumatic mobilisation of retrotendinous fat, reduces incidence and severity of anterior knee pain following intramedullary fixation of tibial shaft fractures. |
0 | Popliteal blocks for foot and ankle surgery: success rate and contributing factors | Surgical Management of Osteoarthritis of the Knee CPG | The purpose of the present study was to evaluate the factors contributing to the success of popliteal nerve blocks performed by podiatric surgical residents in various stages of training. A retrospective review was conducted of 143 consecutively performed blocks during a 2-year period. A total of 29 blocks using a lateral approach and 114 blocks using a modified posterior approach were performed. The intrinsic and extrinsic variables contributing to block outcome were analyzed. A total of 109 successful blocks were performed, for an overall success rate of 76.2%. Significant differences (p < .002) were found between the success and failure groups with respect to the patients body mass index and age. No differences were observed between the success and failure groups with respect to the block approach or months of resident training. In conclusion, podiatric surgical residents in all stages of training can safely and effectively perform popliteal nerve blocks for peri- and postoperative analgesia. Surgeons should be aware of the potential influence of patients body mass index and age on the overall block success rates |
0 | Characterization of a consistent radiographic finding in chronic anterior cruciate ligament deficiency: the posteromedial osteophyte | Surgical Management of Osteoarthritis of the Knee CPG | Often found in patients undergoing total knee arthroplasty (TKA) is an osteophyte, at the posterior lateral corner of the medial tibial plateau, that prevents anterior translation. This osteophyte does not occur in the presence of an entirely normal anterior cruciate ligament (ACL) with normal vascularity. Although similar findings have been reported in animal studies, to our knowledge this has never been documented in humans. To determine the incidence of this finding in our patient population, anteroposterior and lateral x-rays of the affected knee of 90 patients undergoing TKA were reviewed. Forty-two percent (43/102 knees) had radiographic signs of this stabilizing osteophyte. This finding confirms previous animal research and may lead to a better understanding of how the knee adapts to improve stability in a chronic ACL-deficient state |
0 | The efficacy of ultrasound-guided pulsed radiofrequency of genicular nerves in the treatment of chronic knee pain due to severe degenerative disease or previous total knee arthroplasty | AAHKS (8) Anesthetic Infiltration | Background: Pulsed radiofrequency of genicular nerves in the management of osteoarthritis related chronic knee pain has recently become a promising treatment. Ultrasonography has replaced fluoroscopic guidance in pain medicine. The aim of this study was to investigate the effect of ultrasound-guided genicular pulsed radiofrequency on knee pain and function in patients who had severe knee osteoarthritis or who had previous knee arthroplasty. Material/Methods: The retrospective study included a total of 23 patients with chronic knee pain, of which 17 patients were included in Group I (non-operated), and 6 patients were included in Group II (post-arthroplasty). Treatment was based on ultrasound-guided pulsed radiofrequency of the superior medial, superior lateral, and inferior medial genicular nerves. The Visual Analog Scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) scores were assessed before treatment, and at 3 weeks and at 3 months following the procedure. Results: Pulsed radiofrequency of the genicular nerves significantly reduced perceived pain and disability in the majority of the patients. The proportion of the patients with improvement of 350% in pretreatment VAS scores at 3 weeks and 3 months following treatment were 14 out of 17 patients (82%) and 15 out of 17 patients (88%) in Group 1, and 4 out of 6 patients (67%), 4 out of 6 patients (67%) in Group 2, respectively. Conclusions: Our study results suggest that ultrasound-guided pulsed radiofrequency of genicular nerves is a safe and minimally invasive procedure that significantly alleviates pain and disability in patients with severe degenerative disease or with previous knee arthroplasty. |
0 | Revision following cemented and uncemented primary total hip replacement: a seven-year analysis from the New Zealand Joint Registry | Dental Implant Infection | We have reviewed the rate of revision of fully cemented, hybrid and uncemented primary total hip replacements (THRs) registered in the New Zealand Joint Registry between 1999 and December 2006 to determine whether there was any statistically significant difference in the early survival and reason for revision in these different types of fixation. The percentage rate of revision was calculated per 100 component years and compared with the reason for revision, the type of fixation and the age of the patients. Of the 42 665 primary THRs registered, 920 (2.16%) underwent revision requiring change of at least one component. Fully-cemented THRs had a lower rate of revision when considering all causes for failure (p < 0.001), but below the age of 65 years uncemented THRs had a lower rate (p < 0.01). The rate of revision of the acetabular component for aseptic loosening was less in the uncemented and hybrid groups compared with that in the fully cemented group (p < 0.001), and the rate of revision of cemented and uncemented femoral components was similar, except in patients over 75 years of age in whom revision of cemented femoral components was significantly less frequent (p < 0.02). Revision for infection was more common in patients aged below 65 years and in cemented and hybrid THRs compared with cementless THRs (p < 0.001). Dislocation was the most common cause of revision for all types of fixation and was more frequent in both uncemented acetabular groups (p < 0.001). The experience of the surgeon did not affect the findings. Although cemented THR had the lowest rate of revision for all causes in the short term (90 days), uncemented THR had the lowest rate of aseptic loosening in patients under 65 years of age and had rates comparable with international rates of aseptic loosening in those over 65 years. |
0 | [Comparison of various types of pharmacological prevention of lower extremities deep vein thrombosis in patients with proximal femoral fractures] | Management of Hip Fractures in the Elderly | Adminstration of coagulation-active substances is one of the options to prevent thromboemboembolic disease (TED), including deep vein thrombosis and systemic response to stress entailed by an injury or a surgical procedure. Lately, a synthetic analogue of the heparin molecule--of its functionally active part--pentasaccharide (PS), has been developed, among others. Potential effects of different pharmacopreventive therapies of the deep vein thrombosis was studied in a group of 146 subjects, who suffered proximal femoral fractures and were operated in the Ist Surgical Clinic, VFN Hospital, during 2001-2006. The patients were randomized into 4 different anticoagulant groups (UFH, LMWH, PS short-term and PS long-term). Thromboembolic symptoms, selected postoperative complications and laboratory findings of selected blood count parameters, coagulation, active phase proteins and adhesion molecules, were monitored. The results indicate existing increased risk of the deep vein thrombosis and a lower rate of the coagulation and fibrinolytic cascade activation, suggesting a higher rate of the hemostatic status stability in the pentasaccharide groups, especially in the groups receiving the long-term pentasaccharide medication (over a month). Therefore, potential pentasaccharide protective effect preventing development of the deep vein thrombosis may be expected |
0 | Comparison of urinary markers for bone resorption in multiple myeloma | MSTS 2018 - Femur Mets and MM | Multiple myeloma causes extensive bone remodeling. Classical biochemical markers such as urinary calcium have poor sensitivity for detecting multiple myeloma bone remodeling. New biochemicals have been developed including a carboxyterminal telopeptide of collagen I (CTX). We used an immunoenzymatic assay to determine urinary CTX in 60 patients with multiple myeloma. This marker was evaluated with regard to total pyridinolines, urinary calcium, radiological features, pain and response to treatment with bisphosphonates. In patients with bone involvement, CTX concentrations were significantly higher (+230%) than those of deoxypyridinoline (DPD) (+175%) and pyridinolines (PYD) (+130%). In all patients we have found a close correlation between CTX and DPD but not between CTX and PYD. Compared to radiological features, CTX was more sensitive (97%) and specific (96%) than DPD. After treatment by bisphosphonates, the fall in CTX concentrations was paralleled to urinary calcium and more marked than pyridinolines. Although our results need to be confirmed, CTX appears to be a potential marker to explore bone involvement in multiple myeloma. |
0 | Posterior urethral injuries and the Mitrofanoff principle in children | DoD SSI (Surgical Site Infections) | OBJECTIVE: To report our experience of children with trauma causing posterior urethral injury who at some stage underwent a Mitrofanoff intervention, as post-traumatic urethral injuries can demand long-term treatment which (regardless of the surgical intervention) requires a period of dilatation of the reconstructed urethra. PATIENTS AND METHODS: From 1992 to 2001, 14 patients with urethral injuries underwent a Mitrofanoff procedure. Thirteen had been run over by a motor vehicle and had severe hip injuries, and one had a direct non-penetrating perineal impact lesion (13 boys and one girl, aged 2-13 years at the time of the accident). In all cases the Mitrofanoff procedure involved interposing the appendix between the bladder and the umbilicus. Only one of the children (because of extremely high bladder filling pressures) also underwent an augmentation cystoplasty and closure of the bladder neck because there were bony fragments in the urethra. RESULTS: The Mitrofanoff technique was considered useful in most cases. All patients during a given period used the Mitrofanoff conduit to empty their bladder every 3 h; 10 of the 14 are currently voiding urethrally, with an adequate flow, and four are not, but emptying the bladder periodically via the appendicovesicostomy. The only girl in the group has a major hip deformity and is unlikely to undergo urethroplasty; two patients are expecting definitive treatment and the other, although having a patent urethra, has no urinary flow. He is currently 19 years old and has no erections. CONCLUSIONS: The treatment of posterior urethral injuries represents a challenge to surgical teams. Although primary suturing of the separated urethral ends is accepted as the best treatment, the construction of a temporary continent urinary diversion may be considered in the most severe cases. |
1 | PRP Injections for the Treatment of Knee Osteoarthritis: A Meta-Analysis of Randomized Controlled Trials | PRP (Platelet-Rich Plasma) | OBJECTIVE: To evaluate effectiveness, in terms of patient-reported outcome measures, of platelet-rich plasma (PRP) injections for knee osteoarthritis compared to placebo and other intraarticular treatments.
DESIGN: PubMed, Cochrane Library, Scopus, Embase, Web of Science, as well as the gray literature were searched on January 17, 2020. Randomized controlled trials (RCTs) comparing PRP injections with placebo or other injectable treatments, in any language, on humans, were included. Risk of bias was assessed following the Cochrane guidelines; quality of evidence was graded using the GRADE guidelines.
RESULTS: Thirty-four RCTs, including 1403 knees in PRP groups and 1426 in control groups, were selected. WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score favored PRP, with a statistically and clinically significant difference versus placebo at 12-month follow-up (P = 0.02) and versus HA (hyaluronic acid) at 6-month (P < 0.001) and 12-month (P < 0.001) follow-ups. A clinically significant difference favoring PRP versus steroids was documented for VAS (Visual Analogue Scale) pain (P < 0.001), KOOS (Knee Injury and Osteoarthritis Outcome Score) pain (P < 0.001), function in daily activities (P = 0.001), and quality of life (P < 0.001) at 6-month follow-up. However, superiority of PRP did not reach the minimal clinically important difference for all outcomes, and quality of evidence was low.
CONCLUSIONS: The effect of platelet concentrates goes beyond its mere placebo effect, and PRP injections provide better results than other injectable options. This benefit increases over time, being not significant at earlier follow-ups but becoming clinically significant after 6 to 12 months. However, although substantial, the improvement remains partial and supported by low level of evidence. This finding urges further research to confirm benefits and identify the best formulation and indications for PRP injections in knee OA. |
0 | Periodontal diseases as bacterial infection | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | The periodontal disease is conformed by a group of illnesses affecting the gums and dental support structures. They are caused by certain bacteria found in the bacterial plaque. These bacteria are essential to the onset of illness; however, there are predisposing factors in both the host and the microorganisms that will have an effect on the pathogenesis of the illness. Periodontopathogenic bacterial microbiota is needed, but by itself, it is not enough to cause the illness, requiring the presence of a susceptible host. These diseases have been classified as gingivitis, when limited to the gums, and periodontitis, when they spread to deeper tissues. Classification of periodontal disease has varied over the years. The one used in this work was approved at the International Workshop for a Classification of Periodontal Diseases and Conditions, held in 1999. This study is an overview of the different periodontal disease syndromes. Later, the systematic use of antibiotic treatment consisting of amoxicillin, amoxicillin-clavulanic acid, and metronidazole as first line coadjuvant treatment of these illnesses will be reviewed |
0 | The balance between extracellular cathepsins and cystatin C is of importance for ovarian cancer | MSTS 2018 - Femur Mets and MM | BACKGROUND: A major step in cancer formation involves the degradation of the extracellular matrix, mediated by multiple degradative actions of (lysosomal) proteases. Extracellular release of lysosomal proteases (cathepsins) and their inhibitors has been associated with the development and progression of several types of cancer. We investigated whether cathepsins in ovarian cyst fluid (oCF) were associated with disease outcome in patients with epithelial ovarian cancer (EOC).
MATERIALS AND METHODS: The levels of cathepsin B (CatB), H (CatH), L (CatL) and X (CatX) and their most abundant extracellular inhibitor cystatin C (CysC) were determined in oCF of 50 EOC patients by quantitative ELISAs. The cathepsin levels and ratios between cathepsins and CysC were related to clinicopathological parameters (Mann-Whitney U and Kruskal-Wallis tests) and survival (Cox Regression analysis).
RESULTS: Median (25th-75th percentile) levels of cathepsin B, H, L, X and CysC in oCF were 97 (42-203), 18 (12-32), 61 (37-108), 20 (13-47) and 657 (501-805) ng mL(-1) respectively. Ratio of CysC/CatB was significantly lower for patients with metastatic compared with localised EOC (P = 0.025). Ratios of CysC/CatH and CysC/CatX differed significantly between histological subtypes (P = 0.012 and P = 0.035 respectively) and were significantly higher for high-grade tumours compared with low-grade tumours (P = 0.031 and P = 0.039 respectively). Neither cathepsins nor their ratios were significant predictors of survival for EOC patients.
CONCLUSIONS: Ratios between CysC and cathepsins in oCF differed significantly between important clinicopathological subgroups. We believe that a complex cascade of proteolytic events, in which cathepsins play different roles, might be responsible for progression and metastasis in EOC. |
0 | Exposure of the surgeon to radiation during surgery | Distal Radius Fractures | Exposure to radiation over many years increases the incidence of cataracts and promotes the development of carcinoma of the thyroid gland. A prospective study of 24 operative procedures involving minimal invasive techniques and fluoroscopic guidance was undertaken in order to measure the radiation exposure to the primary surgeon. The study was conducted during 8 K-wire osteosyntheses in fractures of the distal radius, 8 closed interlocking intramedullary nailings in fractures of the femur and 8 internal fixator procedures, with or without posterior autogenic transpedicular bone grafting, in fractures of the lumbar spine. Radiation was monitored with the use of high sensitive thermoluminescent dosimeters. Fluoroscopy was necessary during the procedures, with exposure times ranging from 55 s to 12 min 35 s. The radiation dose received per procedure ranged from 0.6-259.3 microSv and was well within the dose limits set by German law. |
0 | Clinical outcomes of bacteremic pneumococcal pneumonia in the era of antibiotic resistance | Patrick’s pharmacoepidemiology project | Limited data are available about the impact of antimicrobial resistance on clinical outcomes in cases of pneumococcal pneumonia. This was studied in 146 persons hospitalized with invasive pneumonia due to Streptococcus pneumoniae (minimum inhibitory concentration of cefotaxime, ââ?°Â¥.25 Ã?¼g/mL) who were identified through population-based active surveillance for the period of November 1994 through April 1996. Compared with matched control subjects who had infection with more-susceptible S. pneumoniae, the proportion of subjects who died or who were admitted to an intensive care unit did not differ significantly. Multivariable analysis showed no significant contribution of antimicrobial resistance to mortality or the requirement for care in an intensive care unit. The ability to detect an effect of antimicrobial resistance on these important outcome measures may have been influenced by aggressive multidrug empirical therapy in this group of hospitalized patients. Factors other than resistance, such as severity of illness at presentation and advance directive status ("do not resuscitate" orders), appear to have a stronger influence on pneumococcal pneumonia outcomes |
0 | An evaluation of an educational intervention in psychology of injury for athletic training students | DoD PRF (Psychosocial RF) | Context: "Psychosocial Intervention and Referral" is 1 of the 12 content areas in athletic training education programs, but knowledge gained and skill usage after an educational intervention in this area have never been evaluated. Objective: To evaluate the effectiveness of an educational intervention in increasing psychology-of-injury knowledge and skill usage in athletic training students (ATSs). Design: Observational study. Setting: An accredited athletic training education program at a large Midwestern university. Patients or Other Participants: Participants included 26 ATSs divided into 2 groups: intervention group (4 men, 7 women; age = 21.4 ± 0.67 years, grade point average = 3.37) and control group (7 men, 8 women; age = 21.5 ± 3.8 years, grade point average = 3.27). Data Collection and Analysis: All participants completed the Applied Sport Psychology for Athletic Trainers educational intervention. Psychology-of-injury knowledge tests and skill usage surveys administered to all participants at the following intervals: baseline, intervention week 3, and intervention week 6. Retention tests were administered to intervention group participants at 7 and 14 weeks after intervention. Analysis techniques included mixed-model analysis of variance (ANOVA) and repeated-measures ANOVA. Results: The Applied Sport Psychology for Athletic Trainers educational intervention effectively increased psychology-of injury knowledge (29-point increase from baseline to intervention week 6; F2,23 = 29.358, Pp² = 0.719) and skill usage (50-point increase from baseline to intervention week 6; F2,23 = 5.999, P = .008, ηp² = 0.343) in undergraduate ATSs. These increases were maintained at the 7-week and 14-week retention testing (P < .001 for both). Conclusions: This first attempt at evaluating an educational intervention designed to improve ATSs' knowledge and skill usage revealed that the intervention was effective. Although both knowledge and skill usage scores decreased by the end of the retention period, the scores were still higher than baseline scores, indicating that the intervention was effective. (PsycINFO Database Record (c) 2016 APA, all rights reserved) |
0 | Dorsal instrumentation for idiopathic adolescent thoracic scoliosis: rod rotation versus translation | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | The radiographic and clinical outcomes and complications among two groups of adolescent patients treated for idiopathic thoracic scoliosis with dorsal instrumentation using a unified implantation system (Universal Spinal System) were compared retrospectively. A total of 69 patients were included in the study. In 30 patients an intraoperative correction of the scoliosis was performed by translation and segmental correction (translation group, Helsinki). In 39 patients the correction was achieved according to the Cotrel-Dubousset rod rotation maneuver (rod rotation group, Berlin). The goal of the present study is to investigate whether one of the operative procedures leads to a better correction of idiopathic adolescent thoracic scoliosis than the other. The mean follow-up interval was 30 months, with a minimum of 12 months. There were no significant preoperative differences in age (15+/-2 years in both groups), gender, or type of scoliosis (King types 2, 3, and 4). The preoperative radiographic measurements showed no significant differences between the two groups. In both patient groups, the thoracic primary curve, the lumbar secondary curve and the thoracic apical rotation were improved by the operation. Lumbar apical rotation and the sagittal profile were unchanged in both groups. The thoracic primary curve was corrected from 50 degrees +/-6 degrees to 24 degrees +/-7 degrees in the translation group and from 54 degrees +/-11 degrees to 220 degrees +/-11 degrees in the rod rotation group. The extent of the correction of the thoracic curve was significantly greater in the rod rotation group than in the translation group (59% vs. 52% correction). In contrast, the translation procedure seems to have a more beneficial effect on spinal balance than rod rotation. Neurological complications did not occur. In both patient groups an increase in the non-instrumented lumbar curve was noted, in two cases each. In three patients from the rod rotation group the instrumentation had to be removed due to a late infection with negative microbiological results |
0 | Human osteoarthritic (OA) and rheumatoid arthritis (RA) tissues express the novel histamine H4 receptor (H4R) | Surgical Management of Osteoarthritis of the Knee CPG | Purpose: To determine whether the H4 receptor is pharmacologically expressed in human OA and RA tissues, and the different cell types that express this receptor. Methods: Human synovial tissues from OA and RA tissues were collected with the consent from patients undergoing total knee replacement. These tissues were investigated using RT-PCR, immunohistochemistry and by competitive radiolabled antagonist binding assays. The expression of H4R RNA and protein were investigated using RT-PCR and immunohistochemical methods with human H4R antibodies. Synovial membranes were evaluated histologicaly following Hematoxyline Eosine staining. To determine the phenotype of the cells expressing H4R, mast cells were revealed using anti tryptase and c-kit antibodies. Dentritic cells, macrophage and endothelial cells were revealed using S100, CD68 and the Von Willebrand factor respectively. CD4 was used as a marker for mature helper T cells, and CD8 as a marker for mature Cytotoxic T cells. To ascertain whether the H4 receptor is pharmacologically expressed, human OA synoviocytes from 5 patients were evaluated in competitive radiolabled antagonist binding assays. The effect of Thioperamide on metalloproteinases was studied zymography. Results: The H4 receptor was detected at RNA and protein levels in both OA and RA synovial tissues, with a significantly greater number of cells staining positive in inflammatory RA tissues. In synovial membranes from patients with RA, H4 receptor was detected in mast and dentritic cells as well as in the macrophage-like type B synoviocytes infiltrating within the vascular wall, in the diffuse cellular infiltrate and in the superficial lining cell layer and in the pannus. When vessels from rheumatoid synovial membranes or OA showed features of vasculitis, a positive signal for H4 receptor was detected within the media and adventitia of the vascular wall but not in the internal tunic endothelial cells (intima, which stains positive for the von Willebrand factor). In newly dissociated and cultured human OA synoviocytes, specific [3H] radiolabeled antagonist binding was displaced by both Thioperamide and a selective H4 receptor antagonist indicating expression of pharmacologically active H4R in these diseased tissues. The zymographies revealed that MMP-9 activity is upregulated by IL-1b and this effect is greatly diminished by Thioperamide. Conclusions: This study shows the in situ localization of H4R in human OA and RA tissues in both infiltrating immune cells and synoviocytes associated with disease pathogenesis. We provide also first pharmacological evidence of H4R expression by radio-labeled binding. Hence, H4R may be an attractive target in the development of new approaches for therapeutic treatment of OA and RA and possibly other diseases where histamine plays a crucial event in mediating leukocyte trafficking and tissue degradation |
1 | A collaborative system to improve compartment syndrome recognition | DOD - Acute Comp Syndrome CPG | BACKGROUND AND OBJECTIVE: Acute compartment syndrome (ACS) is a rare but serious complication of extremity injury that can cause permanent damage or death. ACS development is variable and unpredictable, and delay in recognition or treatment of ACS can lead to significant morbidity. Our objective was to create a reliable system for recognition of patients at risk and monitoring for ACS that could withstand frequent provider turnover.
METHODS: Using the Model for Improvement, we identified key drivers and failure modes for 2 processes: resident and nurse practitioner proper order entry and bedside nurse proper documentation of monitoring. Interventions were tested in frequent plan-do-study-act cycles. Effective interventions were used in combination to test for sustainability.
RESULTS: Proper order entry increased from 23% at baseline to 90%. Proper documentation for patients with correct orders increased from 15% to 70%. Individual interventions, including pocket card distribution, electronic medical record order set, and direct discussion by team leaders, were associated with improvement among residents but were not sustained with team turnover. Incorporating all 4 individual interventions into the on-boarding process for residents produced consistent success. Nursing documentation improved with education and maintenance of proper order entry.
CONCLUSIONS: We built a reliable, sustainable system to recognize and monitor patients at risk for ACS. Interventions designed to minimally disrupt existing workflows were individually associated with improvement. We achieved sustainability through staff turnover when we incorporated the interventions into routine orientation for new staff. Hospitals can use existing orders and protocols to sustain surveillance for ACS and other acute conditions. |
0 | Mechanical and repeated antimicrobial therapy using a local drug delivery system in the treatment of peri-implantitis: a randomized clinical trial | Dental Implant Infection | BACKGROUND: Peri-implantitis is an inflammatory process caused by microorganisms affecting the tissues around an osseointegrated implant in function, resulting in a loss of supporting bone. Limited data exist regarding the treatment of peri-implantitis. The aim of this study was to assess the clinical and microbiologic outcome of repeated local administration of minocycline microspheres, 1 mg, in cases of peri-implantitis., METHODS: Thirty-two subjects with at least one implant with a probing depth > or =4 mm combined with bleeding and/or exudate on probing and the presence of putative pathogenic bacteria were included in the study. At baseline, subjects were randomly assigned to receive local minocycline microspheres (17 subjects and 57 implants) or chlorhexidine gel (15 subjects and 38 implants) following debridement. Treatments were performed on three occasions: baseline and days 30 and 90. Follow-up examinations were conducted at 10 days and at 1, 3, 6, 9, and 12 months., RESULTS: The use of minocycline resulted in significant improvements in probing depths compared to chlorhexidine at days 30, 90, and 180 (P = 0.5, P = 0.01, and P = 0.04, respectively). For the deepest sites of the minocycline-treated implants, the mean probing depth reduction was 0.6 mm at 12 months. Regarding bleeding on probing, significant differences between groups, based on all four sites at the implants, were found at days 30, 90, 180, 270, and 360. Both treatments resulted in a marked reduction in the indicator bacteria., CONCLUSIONS: The use of a repeated local antibiotic as an adjunct to the mechanical treatment of peri-implantitis lesions demonstrated improvements in probing depths that were significantly different from controls and were sustained for 6 months. The adjunctive use of minocycline microspheres is beneficial in the treatment of peri-implant lesions, but the treatment may have to be repeated. |
0 | Acute carpal tunnel syndrome as a complication of oral anticoagulant therapy | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Acute carpal tunnel syndrome is well recognized in patients with haemophilia and conservative management with factor replacement and temporary splinting is recommended. There have, however, been very few reported cases of acute carpal tunnel syndrome as a complication of oral anticoagulant therapy. We describe such a case in a patient on long-term warfarin anticoagulation, drawing attention to particular features of the history and clinical findings. In contrast to previous reports, we recommend prompt decompression under local anaesthesia and continuation of the anticoagulant therapy |
0 | Encounters with pseudoaneurysms in orthopaedic practice | DoD SSI (Surgical Site Infections) | Thirteen pseudoaneurysms are presented of which five were caused as a complication of pin/wire placement of external fixators (one conventional and four Ilizarov frames). The most common symptom was the presence of profuse persistent bleeding from either the wound or the pin/wire site. In nine patients the pseudoaneurysm was directly caused by a fracture or subsequent fracture stabilisation. Pre-operative evaluation included radiography, arteriography, Doppler and computed tomography (CT) angiography. Depending on the site and size of the pseudoaneurysm management consisted of either ligation, resection and end-to-end anastamosis/vein grafting, lateral suture, endoaneurysmorrhaphy or selective embolisation.A high index of suspicion needs to be maintained following penetrating injury in the vicinity of a major vessel, particularly in the presence of persisting symptoms. External fixators are widely used to treat complex orthopaedic problems. The procedure is technically demanding, requiring a sound knowledge of cross-sectional limb anatomy. Injudicious use may result in potentially life/limb threatening complication of pseudoaneurysm. |
1 | The clinical significance of anterior horn meniscal tears diagnosed on magnetic resonance images | AMP (Acute Meniscal Pathology) | We assessed the accuracy of magnetic resonance imaging in detecting clinically significant lesions of the anterior horn of the meniscus by reviewing 947 consecutive knee magnetic resonance imaging reports. Of these, 76 (8%) indicated a tear of the anterior horn of the medial or lateral meniscus. Thirty-one of these 76 patients underwent a subsequent arthroscopic examination, and their operative reports were reviewed. The 45 patients who were not examined arthroscopically were contacted and interviewed for clinical follow-up. Among the 31 patients who underwent arthroscopic examination, 8 anterior horn tears were noted in the predicted area (26% true-positive results), 23 patients had intact anterior horns (74% false-positive results), and 18 had normal intact menisci in all zones. Of the 45 patients who did not undergo arthroscopic surgery, 6 had isolated anterior horn tears reported on magnetic resonance imaging, and 5 of the 6 were asymptomatic at follow-up. The other 39 patients had multiple pathologic conditions noted on the magnetic resonance imaging report and continued to report knee pain at the follow-up interview. Increased signal intensity at the anterior horn of the meniscus seen on magnetic resonance imaging commonly does not represent a clinically significant lesion. We recommend correlation with the physical examination when interpreting this "positive" finding on knee magnetic resonance imaging examinations. |
0 | Platelet-Rich Plasma Increases Anti-inflammatory Markers in a Human Coculture Model for Osteoarthritis | OAK 3 - Non-arthroplasty tx of OAK | BACKGROUND: Platelet-rich plasma (PRP) has anti-inflammatory effects with potential applications in the treatment of osteoarthritis (OA).
PURPOSE: To use an in vitro coculture model of OA in human cartilage and synovium to investigate the anti-inflammatory effects of 2 different PRP preparations.
STUDY DESIGN: Controlled laboratory study.
METHODS: A coculture system was created using osteoarthritic cartilage and synovium from 9 patients undergoing total knee arthroplasty. Interleukin-1beta (IL-1beta) was added to each coculture to induce inflammation. Two PRP preparations were obtained-one yielding low white blood cell and platelet concentrations (PRPLP) and one yielding high platelet and white blood cell concentrations (PRPHP). Either PRPLP, PRPHP, or medium was added to the coculture wells. Control wells contained OA cartilage and synovium but neither IL-1beta nor PRP. Normal, non-OA cartilage was obtained to establish baseline gene expression levels. Quantitative polymerase chain reaction was used to measure changes in markers of inflammation in the tissues (a disintegrin and metalloproteinase with thrombospondin motifs-5 [ADAMTS-5], tissue inhibitor of metalloproteinases-1 [TIMP-1], vascular endothelial growth factor [VEGF], aggrecan, and type I collagen) at 0, 24, 48, and 72 hours.
RESULTS: Treatment with PRPLP or PRPHP significantly decreased expression of TIMP-1 and ADAMTS-5 in cartilage, increased aggrecan expression in cartilage, and decreased ADAMTS-5, VEGF, and TIMP-1 expression in synovium compared with control cocultures (P < .05). There was significantly less nitric oxide production in the PRPLP and PRPHP groups compared with controls (P < .05). There were significant differences in gene expression in the normal cartilage compared with all 4 groups of OA cartilage at all 4 time points. Treatment with either PRPLP or PRPHP returned some gene expression to the same levels in normal cartilage but not for all markers of inflammation.
CONCLUSION: This coculture model assessed 2 different PRP preparations and their anti-inflammatory effects over time on human OA cartilage and synovium. Both had a significant anti-inflammatory effect on gene expression; however, there was no difference in the anti-inflammatory effect between the 2 preparations.
CLINICAL RELEVANCE: Osteoarthritis is a leading cause of chronic disability, and less invasive treatment methods are needed. Study results suggest that PRP injections may be an effective alternative anti-inflammatory agent in the treatment of OA. |
1 | The use of bootstrap methods for analysing health-related quality of life outcomes (particularly the SF-36) | SR for PM on OA of All Extremities | Health-Related Quality of Life (HRQoL) measures are becoming increasingly used in clinical trials as primary outcome measures. Investigators are now asking statisticians for advice on how to analyse studies that have used HRQoL outcomes. HRQoL outcomes, like the SF-36, are usually measured on an ordinal scale. However, most investigators assume that there exists an underlying continuous latent variable that measures HRQoL, and that the actual measured outcomes (the ordered categories), reflect contiguous intervals along this continuum. The ordinal scaling of HRQoL measures means they tend to generate data that have discrete, bounded and skewed distributions. Thus, standard methods of analysis such as the t-test and linear regression that assume Normality and constant variance may not be appropriate. For this reason, conventional statistical advice would suggest that non-parametric methods be used to analyse HRQoL data. The bootstrap is one such computer intensive non-parametric method for analysing data. We used the bootstrap for hypothesis testing and the estimation of standard errors and confidence intervals for parameters, in four datasets (which illustrate the different aspects of study design). We then compared and contrasted the bootstrap with standard methods of analysing HRQoL outcomes. The standard methods included t-tests, linear regression, summary measures and General Linear Models. Overall, in the datasets we studied, using the SF-36 outcome, bootstrap methods produce results similar to conventional statistical methods. This is likely because the t-test and linear regression are robust to the violations of assumptions that HRQoL data are likely to cause (i.e. non-Normality). While particular to our datasets, these findings are likely to generalise to other HRQoL outcomes, which have discrete, bounded and skewed distributions. Future research with other HRQoL outcome measures, interventions and populations, is required to confirm this conclusion. (copyright) 2004 Walters and Campbell; licensee Biomed Central Ltd |
0 | Revision of ceramic fracture with ceramic-on-polyethylene in total hip arthroplasty: Medium-term results | PJI DX Updated Search | There is no consensus on the bearing of choice in revision for ceramic fracture after total hip arthroplasty (THA). The aim of this study was to evaluate the outcomes using ceramic-on-polyethylene (CoP) articulation in revision for ceramic breakage. Twelve patients who underwent revision hip surgery between 2002 and 2013 were followed-up. Appropriate surgical technique, including accurate synoviectomy, was used. The cup and the head were changed in four patients and only the liner and the head were replaced in the remaining eight patients. At the final follow-up there were no cases of re-revision due to tribological reasons, and only one case of polyethylene (PE) wear and osteolysis was scheduled for a new revision because of clear cup malposition. Complications were four cases of dislocation, one case of loosening and one case of infection. Revision of fractured ceramic is a challenging situation with a high risk of early complications. Using CoP liners with accurate synoviectomy and correction of misalignment can be considered a valuable bearing option at medium-term follow-up |
0 | Development of a knee scoring scale | AMP (Acute Meniscal Pathology) | Two knee scoring scales have been tested against post-osteotomy knees for degeneration arthritis and post-arthroplasty knees (McIntosh Operation) and were found to be acceptable for both conditions. Scoring Scale I was slightly better than Scale II. This scale should be tested on other types of knee reconstruction. Modifications in this scale may be needed in the future in an effort to produce as near perfect an objective knee function scoring method as is possible. |
0 | "The Skiver Screw": A useful fixation technique for iliac wing fractures | Hip Fx in the Elderly 2019 | Summary:The contour of the ilium is curved and the iliac fossa is thin, making adequate fixation for fractures involving the iliac wing challenging to achieve at times. The purpose of this article is to describe a previously unreported technique for enhancing fixation in iliac fractures using simple cortical screws. |
0 | A case report of rhabdomyolysis and pressure sores following hypotensive anaesthesia and prolonged surgery in the prone position | Surgical Management of Osteoarthritis of the Knee CPG | A 51 year old, 89 kg , fit and well man was unexpectedly admitted to our high dependency unit (HDU) following an elective lumbar decompression and fusion. Induction of anaesthesia was uneventful and anaesthesia was maintained using a combination of Isoflurane and Remifentanil. Invasive arterial pressure monitoring was instigated and mean arterial blood pressures were maintained at 30% below his baseline throughout the procedure. The patient was placed prone on a spinal (Jackson) table and careful attention to pressure points was documented. He received six litres of fluid intra-operatively; there was no record of urine output. He was normothermic throughout. Arterial blood gases were monitored at regular intervals. The duration of the procedure was unexpectedly long at nine hours due to surgical difficulties. On turning the patient supine, reddened non-blanching pressure areas on his chin, chest and thighs were noted. In the recovery room, the patient was agitated, confused, tachycardic, appeared hypovolaemic and had haematuria. In view of these features and duration of surgery, he was admitted to HDU. Creatinine kinase (CK) levels were markedly raised at 32 000 IU/L with a normal troponin and renal function. Myoglobinuria was noted and a diagnosis of rhabdomyolysis secondary to prolonged skeletal muscle hypoperfusion was made. The patient was treated with aggressive intravenous fluids, mannitol and urine alkalinisation. By day seven his CK was reduced to 1400 IU.l(-1) and normal renal function was preserved. The pressure sores were treated conservatively and were healed at six weeks post-surgery. Discussion Rhabdomyolysis as a complication of prone positioning of patients during surgery is rare, and previous case reports cite morbid obesity as a risk factor [1]. We present a case of rhabdomyolysis following prone positioning combined with a hypotensive anaesthetic technique in a non-obese patient. Post-operative rhabdomyolysis is more commonly noted following prolonged procedures that require dorsal lithotomy and knee chest positions, and is attributed to compression of the abdominal contents and the reduction in venous and arterial flow. [1]. We propose that the weight of the patient through a relatively small area of the upper chest and upper thighs, on the spinal table, created a high pressure and muscle necrosis, possibly compounded by a hypotensive technique. Measures have been undertaken in our hospital to ensure this does not re-occur, which include teaching sessions on the role and techniques of hypotensive anaesthesia. Thought is also given during long spinal procedures to stopping mid-way and turning the patient supine. Through highlighting this case we have made colleagues aware of the importance of checking a post-operative CK in patients with persistent red pressure areas, maintaining adequate hydration and avoidance of multiple nephrotoxic agents |
0 | Peroneus brevis rotation flap: Anatomic considerations and clinical experience | DoD LSA (Limb Salvage vs Amputation) | Background: Large soft tissue defects of the distal third of the leg are common occurrences at trauma centers. Massive defects often require vascularized free tissue transfer for coverage; however, smaller defects may frequently be closed by rotation of local tissue. The peroneus brevis muscle is ideally located to provide coverage of the exposed distal fibula. Methods: An anatomic dissection of the peroneus brevis muscle and its vascular pedicles was performed in 10 fresh cadaveric leg specimens. Patients who underwent this procedure at our institution were retrospectively reviewed. Results: Each dissected muscle had an average of 3.5 vascular pedicles (range, 2-6), which arose from the peroneal artery in all but two cases. The average distance of the distal pedicle from the tip of the lateral malleolus was 6.7 cm (range, 3.5-12.0 cm). The muscle belly ended an average of 6.0 mm proximal to the tip of the lateral malleolus. Half of the specimens had muscle bellies that extended to or past the tip of the lateral malleolus. This rotation flap has been successful in covering four wounds with exposed distal fibula in four patients. Conclusion: The anatomic characteristics of the peroneus brevis muscle are ideal for soft tissue coverage of the distal fibula. Ease of elevation and reliability have made this rotational flap the procedure of choice for small soft tissue defects over the distal fibula at our institution. |
1 | The unstable Colles' fracture | Distal Radius Fractures | One hundred and twenty-one displaced Colles' fractures were assessed radiographically until union. An acute loss of position occurred during the first week of splintage, necessitating re-manipulation in six fractures. In the remaining 115 fractures whose position had been retained after one week, chronic instability led to a mean increase of 8.22 degrees dorsal angulation, a mean loss of 5.61 degrees radial angle, and 3.26 mm radial shortening. The extent to which the chronic collapse of radial angle and length occurred was determined solely by the initial deformity and was not related to either intraarticular involvement or the presence of radiographically visible comminution. However, the absence of radiographically visible comminution of the dorsal radius did confer stability against mal-union in dorsal angulation. |
0 | Sciatic nerve block for lower limb surgery in elderly patients | Surgical Management of Osteoarthritis of the Knee CPG | Objectives: To evaluate the effectiveness of regional anaesthesia and haemodynamic stability of sciatic nerve block for lower limb surgery in elderly patients. Material And Methods: A prospective study of fifty patients was carried out at the department of anaesthesiology of Hayatabad Medical Complex, Peshawar and Pakistan Institute of Medical Sciences Islamabad from May 2003 to April 2004. Sciatic nerve block was performed using the posterior approach of Labat. After identification of sciatic nerve, 20 ml of 0.5% bupivacaine was injected through 22 G spinal needle. Effectiveness of sciatic nerve block was assessed by degree of sympathetic, sensory and motor blockade below knee. Patients were monitored haemodynamically at five minutes interval throughout the procedure. Results: Fifty patients, 20 male and 30 female, were included in the study. Their age ranged from 50 to 70 years. Mean of onset of sympathetic block was 5 minutes while onset of complete anaesthesia i.e sensory and motor blockade was 25 minutes on average. Anaesthesia was rated as excellent in 30 (60%) patient, good in 15 (30%) patients and fair in 5 (10%) patients. Postoperative analgesic effect of the block remained for 16 hours. All patients remained stable haemodynamically as indicated by blood pressure, heart rate and oxygen saturation. Conclusion: Sciatic nerve block provides good anaesthesia and haemodynamic stability during lower limb surgery and prolong analgesia during postoperative period. Hence it is a good alternative for general anaesthesia |
0 | Anatomy of the distal radioulnar joint | Distal Radius Fractures | The distal radioulnar joint (DRUJ) is of the utmost importance in treatment of fractures of the distal radius. To improve the treatment of these fractures, knowledge of the anatomy and biomechanics of the DRUJ is essential. Three major findings from anatomic specimen studies of the DRUJ are discussed. The radius of the curvature of the sigmoid notch is 4-7 mm larger than that of the ulnar head, and consequently pronation and supination are a combined rotation and sliding movement in the DRUJ. The ulnar head has an average inclination of 20 degrees relative to the long axis of the ulna. Being parallel to the ulnar head, the sigmoid notch of the radius should have the same inclination. In the DRUJ, stability supported by joint surface architecture is minimal, and the ligament is therefore of particular importance to the stability. [References: 4] |
0 | How are outcomes affected by performing a one-stage combined procedure simultaneously in bilateral developmental hip dysplasia? | Developmental Dysplasia of the Hip 2020 Review | PURPOSE: The aim of this study was to compare the outcomes of one-stage combined surgical treatment in children of unilateral and bilateral developmental hip dysplasia diagnosed after walking age. METHODS: We reviewed 24 patients who underwent one-stage combined surgery for DDH diagnosed after walking age. Group I consisted of 12 patients with bilateral disease who underwent bilateral operation at one operative setting. Group II consisted of 12 patients with unilateral disease. Pre-operatively the hips were classified according to Tönnis classification. Acetabular dysplasia was evaluated by measuring acetabular index (AI) angles pre-operatively. The acetabular improvements with time regarding AI was noted immediately postoperatively, every six months, and at the final follow-up examination. RESULTS: Mean follow up of the bilateral group I and group II were 54.8 months (range 20-84 months) and 52.6 months (24-80), respectively. There were no statistically significant differences between immediate postoperative and final follow up acetabular index improvement rates in both groups. Also there was no significant difference when both hips were compared in group I. The clinical final outcome of both groups and within group I was similar. CONCLUSIONS: Simultaneous combined surgery is a challenging but worthwhile procedure for late diagnosed patients with bilateral DDH. The short-mid term outcomes of the procedure are encouraging. |
0 | Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery | AMP (Acute Meniscal Pathology) | BACKGROUND: The Medical Outcomes General Health Survey (SF-36) is a widely used health status measure; however, limited evidence is available for its performance in orthopedic settings. The aim of this study was to examine the magnitude and meaningfulness of change and sensitivity of SF-36 subscales following orthopedic surgery.
METHODS: Longitudinal data on outcomes of total hip replacement (THR, n = 255), total knee replacement (TKR, n = 103), arthroscopic partial meniscectomy (APM, n = 74) and anterior cruciate ligament reconstruction (ACL, n = 62) were used to estimate the effect sizes (ES, magnitude of change) and minimal detectable change (sensitivity) at the group and individual level. To provide context for interpreting the magnitude of changes in SF-36 scores, we also compared patients' scores with age and sex-matched population norms. The studies were conducted in Sweden. Follow-up was five years in THR and TKR studies, two years in ACL, and three months in APM.
RESULTS: On average, large effect sizes (ES> or =0.80) were found after orthopedic surgery in SF-36 subscales measuring physical aspects (physical functioning, role physical, and bodily pain). Small (0.20-0.49) to moderate (0.50-0.79) effect sizes were found in subscales measuring mental and social aspects (role emotional, vitality, social functioning, and mental health). General health scores remained relatively unchanged during the follow-up. Despite improvements, post-surgery mean scores of patients were still below the age and sex matched population norms on physical subscales. Patients' scores on mental and social subscales approached population norms following the surgery. At the individual level, scores of a large proportion of patients were affected by floor or ceiling effects on several subscales and the sensitivity to individual change was very low.
CONCLUSION: Large to moderate meaningful changes in group scores were observed in all SF-36 subscales except General Health across the intervention groups. Therefore, in orthopedic settings, the SF-36 can be used to show changes for groups in physical, mental, and social dimensions and in comparison with population norms. However, SF-36 subscales have low sensitivity to individual change and so we caution against using SF-36 to monitor the health status of individual patients undergoing orthopedic surgery. |
0 | Young athletes return too early to knee-strenuous sport, without acceptable knee function after anterior cruciate ligament reconstruction | OAK 3 - Non-arthroplasty tx of OAK | PURPOSE: The purpose of this study was to evaluate the return to knee-strenuous sport rate, muscle function and subjective knee function among adolescent patients (15-20 years of age) and adult patients (21-30 years of age) 8 and 12 months, respectively, after anterior cruciate ligament (ACL) reconstruction. It was hypothesised that no differences in outcome would be found between age groups at 8 or 12 months after ACL reconstruction.
METHODS: Cross-sectional data from five tests of muscle function, from the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Tegner Activity Scale (Tegner), performed at 8 and 12 months after a primary ACL reconstruction, were extracted from a rehabilitation outcome register. A total of 270 (51% women) athletes, aged 15-30 years, who were all involved in knee-strenuous sport prior the injury, were included at 8 months after ACL reconstruction. At 12 months 203 (51% women) were included. The return to knee-strenuous-sport rates and the rate of achieving a limb symmetry index of >= 90% in all five tests of muscle function, defined as recovery of muscle function, and subjective knee function scores, as measured with the KOOS, were compared between age groups.
RESULTS: The adolescent patients had a higher (50%) return to knee-strenuous sport rate compared with the adult patients (38%) 8 months after ACL reconstruction (p = 0.04). At the 12-month follow-up, no difference was found between the age groups; 74 and 63%, respectively. At the 8-month follow-up, 29% of the patients, in both age groups, who had returned to sport had recovered their muscle function in all five tests of muscle function. At the 12-month follow-up, the corresponding results were 20% for the adolescents and 28% for the adult patients. No difference in mean KOOS scores was found between the age groups at 8 or at 12 months after ACL reconstruction.
CONCLUSION: The majority of young athletes make an early return to knee-strenuous sport after a primary ACL reconstruction, without recovering their muscle function. To set realistic expectations, clinicians are recommended to ensure that young athletes receive information about not to return before muscle function is recovered and that this may take longer time than 12 months.
Level of evidence: Ii. |
0 | Physical Activity in the Acute Ward Following Hip Fracture Surgery is Associated with Less Fear of Falling | Hip Fx in the Elderly 2019 | Early mobilization following hip fracture surgery reduces medical complications and mortality, but may increase the risk of falling. The aim was to objectively measure the physical activity (time spent upright) the first week after hip fracture surgery and relate it to functional performance and fear of falling at discharge. The 24-hr upright time was measured for a median of six days using a thigh-worn accelerometer in 37 patients (mean 80 years +/- 8.4) and increased from median 13 (IQR 6-31) min to 46 (11-107) min at day 7. More upright time at discharge was associated with less fear of falling (r = -.48, p = .01, n = 27), which also was associated with fast gait speed (r = -.50, p = .02, n = 23) and a faster Timed Up and Go test time (r = .54, p < .01, n = 22), indicating a need for further studies on motivation and limitations for more physical activity following hip fracture surgery. |
1 | Meniscectomy | AMP (Acute Meniscal Pathology) | To review the meniscus from a historical perspective especially on surgical management and general guidelines for arthroscopic meniscectomy procedures for various types of meniscal tears. We searched MEDLINE and PubMed for the years of 1980-2010 using the terms meniscus, meniscal repair, menisectomy, and arthroscopy. Orthopedic surgeons frequently encounter patients with pain or functional impairment of the knee joint and repair or resection of the injured meniscus is one of the most common orthopedic operative procedures. The object of meniscal surgery is to reduce pain, restore functional meniscus and prevent the development of degenerative osteoarthritis in the involved knee. Historically, total meniscectomy was a common procedure performed for meniscus tear symptoms. However, it has been reported that total meniscectomy has deleterious effects on the knee. In the past, the menisci were thought as a functionless remnant tissue. Currently, it is known that the meniscus is an important structure for knee joint function. Menisci provide several vital functions including mechanical support, localized pressure distribution, and lubrication to the knee joint. It is widely accepted that the function of the meniscus can be preserved through minimal excision. An arthroscopic partial meniscectomy preserving more of the meniscus is preferred over total meniscectomy. In recent decades, this shift toward arthroscopic partial meniscectomy has led to the development of new surgical techniques. |
0 | Hypocalcaemia in patients with metastatic bone disease treated with denosumab | MSTS 2018 - Femur Mets and MM | Abstract Background This analysis was performed to further characterise treatment-emergent hypocalcaemia in patients with bone metastases receiving denosumab. Methods Laboratory abnormalities and adverse events of hypocalcaemia in patients with metastatic bone disease were analysed using data from three identically designed phase 3 trials of subcutaneous denosumab 120 mg (n = 2841) versus intravenous zoledronic acid 4 mg (n = 2836). Results The overall incidence of laboratory events of hypocalcaemia grade �2 was higher with denosumab (12.4%) than with zoledronic acid (5.3%). Hypocalcaemia events were primarily grade 2 in severity and usually occurred within the first 6 months of treatment. Patients who reported taking calcium and/or vitamin D supplements had a lower incidence of hypocalcaemia. Prostate cancer or small-cell lung cancer, reduced creatinine clearance and higher baseline bone turnover markers of urinary N-telopeptide of type I collagen (uNTx; >50 versus �50 nmol/mmol) and bone-specific alkaline phosphatase (BSAP; >20.77 μg/L [median] versus �20.77 μg/L) values were important risk factors for developing hypocalcaemia. The risk associated with increased baseline BSAP levels was greater among patients who had >2 bone metastases at baseline versus those with >2 bone metastases at baseline. Conclusion Hypocalcaemia was more frequent with denosumab versus zoledronic acid, consistent with denosumab's greater antiresorptive effect. Low serum calcium levels and potential vitamin D deficiency should be corrected before initiating treatment with a potent osteoclast inhibitor, and corrected serum calcium levels should be monitored during treatment. Adequate calcium and vitamin D intake appears to substantially reduce the risk of hypocalcaemia. |
0 | Fracture of the femoral neck: optimal screw position and bone density determined by computer tomography | Management of Hip Fractures in the Elderly | The bone density of five proximal femurs from female cadavers was measured with computed tomography using a pixel size of 1.2 mm. A three dimensional reconstruction was performed along four well-defined axes. The region of maximal relative bone density correlated well with a previous report of the optimal position of a screw when treating a fracture of the femoral neck |
1 | A critical review of literature regarding the effectiveness of physical therapy management of hip fracture in elderly persons | Management of Hip Fractures in the Elderly | The purpose of this review is to analyze the research literature that has examined the effectiveness of physical therapy in the management of hip fractures in elderly persons. Using literature databases and keywords, we located relevant studies. Fifteen studies met the criteria and were then categorized according to Sackett's levels of evidence. Six studies were graded at level I, six at level II, and three at level V, with level I having the highest level of evidence. From the levels of evidence, one grade A, three grade B, and two grade C recommendations were developed, with grade A being the most significant recommendation. Clinical recommendations are offered about patients with dementia, therapeutic exercise, and when and for how long rehabilitation should continue. In addition, future research directions are provided |
1 | Psoas Compartment Block vs Periarticular Local Anesthetic Infiltration for Pain Management After Anterior Total Hip Arthroplasty: A Prospective, Randomized Study | AAHKS (8) Anesthetic Infiltration | BACKGROUND: The psoas compartment block (PCB) or periarticular soft-tissue local anesthetic injection are forms of regional anesthesia often used as one of the components in multimodal anesthesia applied during total hip arthroplasty (THA). The most efficacious form of regional anesthesia for THA has yet to be determined.
METHODS: In a single-surgeon, prospective, clinical trial, patients undergoing THA via direct anterior approach were randomized to receive an intraoperative periarticular local anesthetic infiltration (periarticular injection) or a PCB. Postoperative pain scores, narcotic consumption, and complications were recorded.
RESULTS: Forty-nine patients were randomized to the PCB and 50 were randomized to the periarticular injection. The resting pain score 3 hours postoperatively was statistically significantly lower in the periarticular injection group by 1.1 point (2.9 +/- 2.2 vs 4.0 +/- 2.2, P = .036). No difference was found in resting pain scores or ambulatory pain scores in the morning or evening of postoperative day 1, 2, or at the 3-week follow-up visit. There was no difference in in-hospital narcotic consumption between groups (P = 1.0). There were no major complications directly related to the block in either group. A total of 6 patients reported complaints of transient numbness, 5 in the PCB group (5/49, 10.2%), and one in the periarticular injection group (1/50, 2%, P = .087).
CONCLUSION: These results demonstrate similarity between the 2 methods. We prefer periarticular anesthetic infiltration over PCB due to improved immediate postoperative pain scores and avoidance of potential symptoms associated with nerve blockade. |
0 | Occult vascular injuries following gunshot wounds resulting in long bone fractures of the extremities | DoD SSI (Surgical Site Infections) | The routine use of arteriography following penetrating injuries to the extremities has declined in popularity in recent years. A careful physical examination coupled with Doppler-derived blood pressure has been shown to be sufficient to determine the presence of significant vascular injuries in most circumstances. Evaluating for occult vascular injuries in the presence of a complex wound involving the fracture of a long bone, however, seems to be an exception to this trend in management. This study was undertaken to ascertain the incidence of occult versus clinically apparent vascular injuries in patients suffering gun shot wounds (GSW) to the extremities that were associated with a long bone fracture. To address the value of invasive arteriographic evaluation, physical examination (pulse palpation, Doppler- derived limb blood pressure) was compared to arteriography in 75 consecutive patients following a GSW that resulted in fracture of the tibia/fibula (n = 28), femur (n = 19), humerus (n = 17), or radius/ulna (n = 11). Fourteen patients (19%) had an abnormal physical examination, with 13 (93%) of these also having an abnormal arteriogram. Of the 61 (81%) patients with a normal physical examination, an occult vascular injury was found on subsequent arteriography in 17 (28%). These occult injuries were classified as minor (intimal flap less than one-fourth the diameter of the vessel, segmental narrowing, noncritical branch vessel injury) or major (large intimal flap, occlusion, pseudoaneurysm, A-V fistula). The majority (83%) of occult injuries were minor and did not require operative intervention. Seventeen per cent of the occult injuries were classified as major, but required repair or ligation in only one (1.6% of all patients with normal vascular physical examination). There were no amputations or complications resulting from the nonoperated occult injuries after a mean follow up period of 5.4 months. We conclude that clinically occult arterial injuries-although present in nearly one-third of patients following GSW and fracture-typically demonstrate an uneventful, self-limited natural history. Although the sensitivity of physical examination alone is relatively modest (77%) in detecting occult vascular injuries, the benign natural course for the vast majority of these injuries and the infrequent need for surgical repair suggest that the routine use of arteriography is not justified even when the GSW is associated with a long bone fracture. |
0 | Interventional management of hypervascular osseous metastasis: role of embolotherapy before orthopedic tumor resection and bone stabilization | MSTS 2018 - Femur Mets and MM | OBJECTIVE: The purpose of this study was to evaluate, in relation to intraoperative estimated blood loss (EBL), the effectiveness of preoperative transcatheter arterial embolization of hypervascular osseous metastatic lesions before orthopedic resection and stabilization.
MATERIALS AND METHODS: Between June 1987 and November 2007, 22 patients underwent transcatheter arterial embolization of tumors of the long bone, hip, or vertebrae before resection and stabilization. Osseous metastatic lesions from renal cell carcinoma, malignant melanoma, leiomyosarcoma, and prostate cancer were embolized. All patients were treated with a coaxial catheter technique with polyvinyl alcohol (PVA) particles alone or a combination of PVA particles and coils. After embolization, each tumor was angiographically graded according to devascularization (grades 1-3) based on tumor blush after contrast injection into the main tumor-feeding arteries.
RESULTS: In patients with complete devascularization (grade 1), mean EBL was calculated to be 1,119 mL, whereas in patients with partial embolization (grades 2 and 3) EBL was 1,788 mL and 2,500 mL. With respect to intraoperative EBL, no significant difference between devascularization grades was found (p > 0.05). Moderate correlation (r = 0.51, p = 0.019) was observed between intraoperative EBL and tumor size before embolization. Only low correlation (r = 0.44, p = 0.046) was found between intraoperative EBL and operating time. Major complications included transient palsy of the sciatic nerve and gluteal abscess in one patient.
CONCLUSION: The results of this study support the concept that there is no statistically significant difference among amounts of intraoperative EBL with varying degrees of embolization. |
0 | Regional differences in hip bone mineral density levels in Norway: the NOREPOS study | Management of Hip Fractures in the Elderly | SUMMARY: Large regional differences in hip fracture rates within Norway have previously been shown. However, regional differences in hip bone mineral density (BMD) have not yet been assessed. In this study including 10,504 hip scans, there were significant regional differences in BMD. Further studies to address reasons for the regional differences in hip fracture risk are warranted. INTRODUCTION: Bone mineral density (BMD) at the hip is an important determinant of hip fracture. While regional differences in Norwegian hip fracture rates have previously been shown, no comparative studies of hip BMD have been conducted. METHODS: Total hip BMD was measured by DXA in two population-based studies across Norway during 1997-2002. Valid hip scans with in vivo calibration were obtained from 5127 subjects in Tromso (age 30-89 years) and 5377 subjects in Bergen (age 47-50 and 71-75 years). RESULTS: Women >or=60 years in Tromso had 0.052 g/cm(2) higher age-adjusted BMD than women in Bergen, whereas BMD among women <60 years was similar in Tromso and Bergen. Age-adjusted total hip BMD was 0.035 g/cm(2) lower in men >or=60 years in Bergen compared with Tromso, and the corresponding figure for men <60 years was 0.028 g/cm(2). While adjustment for body mass index explained some, but not all of the differences, smoking, physical activity, diabetes prevalence, self-perceived health, intake of alcohol and estrogen use did not. CONCLUSIONS: Regional differences in BMD at the hip were found in Norway. Reasons for this and potential impact on hip fracture rates should be explored in further studies |
1 | Evaluation of the American Society of Anesthesiologists physical status classification system in risk assessment for plastic and reconstructive surgery patients | Panniculectomy & Abdominoplasty CPG | Background: The American Society of Anesthesiologists Physical Status (ASA-PS) classification is a ranking system that quantifies patient health before anesthesia and surgery. Some surgical disciplines apply the ASA-PS to gauge a patients likelihood of developing postoperative complications. Objective: In this study, the authors analyze whether ASA-PS scores can successfully predict risk for postoperative complications in plastic and reconstructive operations. Methods: The authors retrospectively reviewed the charts of 1801 patient procedures and selected for inclusion 1794 complex plastic and reconstructive operations that took place at 1 of several academic medical institutions between January 2008 and January 2012. ASA-PS scores, patient comorbidities, and postoperative complications were analyzed. Percentile data were treated with tests for proportions. Nonpercentile data were analyzed through comparison of means (t test). Low-risk (ASA 1-2) and high-risk (ASA 3+) groups were compared with simple odds ratios. Results: For the 1430 women and 364 men in the patient cohort (average age, 49.5 years), the overall complication rate was 27.7%. When patients with complications were compared to those without, body mass index, operation time, recent major surgery, diabetes, hypertension, renal disease, cancer, and oral contraceptive use were statistically significant. After high-risk (n = 398) and low-risk (n = 1396) groups were identified, infection, delayed wound healing, deep vein thrombosis, and overall complications had significantly increased incidence in the high risk group. Notably, deep vein thrombosis displayed the highest odds ratio (4.17) and a complication rate increase from 0.93% to 3.77%. Conclusions: ASA-PS scores can be used either as substitutes for or as adjuncts to questionnaire-based risk assessment methods in plastic surgery. In addition to deducing significant findings for deep vein thrombosis incidence, ASA-PS scores hold important predictive associations for multiple non venous thromboembolism complications, providing a broader measurement for postoperative complication risks. © 2014 The American Society for Aesthetic Plastic Surgery, Inc. |
1 | Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremia | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | OBJECTIVE. To investigate the prevalence, duration, and etiology of bacteremia following dental extractions performed after a single administration of chlorhexidine mouthwash. DESIGN AND SETTING. A randomized, controlled trial performed in a university hospital. METHODS. A series of 106 patients with mental and behavioral disabilities who underwent dental extractions under general anesthesia were randomly assigned to a control group or chlorhexidine group. The exclusion criteria applied were use of antibiotics in the previous 3 months, use of oral antiseptics, any type of congenital or acquired immunodeficiency, and disease that predisposes the patient to infections or bleeding. The chlorhexidine group had 0.2% chlorhexidine mouthwash administered for 30 seconds before any dental manipulation. Blood samples were collected at baseline, 30 seconds, 15 minutes, and 1 hour after the dental extractions. Subculture and further identification of the isolated bacteria were performed by conventional microbiological techniques. RESULTS. The prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96% and 79%, respectively, at 30 seconds (P = .008), 64% and 30% at 15 minutes (P < .001), and 20% and 2% at 1 hour (P = .005). The most frequently identified bacteria were Streptococcus species in both the control and chlorhexidine groups (64% and 68%, respectively), particularly viridans group streptococci. CONCLUSION. We recommend the routine use of a 0.2% chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremia. (copyright) 2007 by The Society for Healthcare Epidemiology of America. All rights reserved |
0 | The Application of All-arthroscopic Technique to Deep Osteochondral Lesions in the Talus With Scaffold and Autograft Bone Taken From the Tibial Plafond | Osteochondritis Dissecans 2020 Review | Osteochondral lesions in the talus are frequently seen disorders that can cause chronic ankle pain. Surgical treatment is determined by the size and location of the lesion. The microfracture procedure and additional application of scaffold technique have gained popularity for the treatment of small osteochondral defects. However, these techniques may be insufficient and have poor outcomes in deep lesions. Therefore, several different invasive surgical techniques that require the malleolar osteotomy have been described. Problems associated with the invasive surgical intervention may be seen such as reduction loss in the osteotomy site, delayed union or nonunion, permanent pain, and/or swelling. We describe a new all-arthroscopic technique for the treatment of deep talus osteochondral lesions using an autologous bone graft taken from the tibial plafond region together with a chitosan-based noncellular scaffold. |
0 | Implementation of a Breast/Reconstruction Surgery Coordinator to Reduce Preoperative Delays for Patients Undergoing Mastectomy With Immediate Reconstruction | Reduction Mammoplasty for Female Breast Hypertrophy | PURPOSE: Mastectomy with immediate reconstruction (MIR) requires coordination between breast and reconstructive surgical teams, leading to increased preoperative delays that may adversely impact patient outcomes and satisfaction. Our cancer center established a target of 28 days from initial consultation with the breast surgeon to MIR. We sought to determine if a centralized breast/reconstructive surgical coordinator (BRC) could reduce care delays.
METHODS: A 60-day pilot to evaluate the impact of a BRC on timeliness of care was initiated at our cancer center. All reconstructive surgery candidates were referred to the BRC, who had access to surgical clinic and operating room schedules. The BRC worked with both surgical services to identify the earliest surgery dates and facilitated operative bookings. The median time to MIR and the proportion of MIR cases that met the time-to-treatment goal was determined. These results were compared with a baseline cohort of patients undergoing MIR during the same time period (January to March) in 2013 and 2014.
RESULTS: A total of 99 patients were referred to the BRC (62% cancer, 21% neoadjuvant, 17% prophylactic) during the pilot period. Focusing exclusively on patients with a cancer diagnosis, an 18.5% increase in the percentage of cases meeting the target (P = .04) and a 7-day reduction to MIR (P = .02) were observed.
CONCLUSION: A significant reduction in time to MIR was achieved through the implementation of the BRC. Further research is warranted to validate these findings and assess the impact the BRC has on operational efficiency and workflows. |
0 | Nanomedicines Reprogram Synovial Macrophages by Scavenging Nitric Oxide and Silencing CA9 in Progressive Osteoarthritis | AMP (Acute Meniscal Pathology) | Osteoarthritis (OA) is a progressive joint disease characterized by inflammation and cartilage destruction, and its progression is closely related to imbalances in the M1/M2 synovial macrophages. A two-pronged strategy for the regulation of intracellular/extracellular nitric oxide (NO) and hydrogen protons for reprogramming M1/M2 synovial macrophages is proposed. The combination of carbonic anhydrase IX (CA9) siRNA and NO scavenger in "two-in-one" nanocarriers (NAHA-CaP/siRNA nanoparticles) is developed for progressive OA therapy by scavenging NO and inhibiting CA9 expression in synovial macrophages. In vitro experiments demonstrate that these NPs can significantly scavenge intracellular NO similar to the levels as those in the normal group and downregulate the expression levels of CA9 mRNA (˜90%), thereby repolarizing the M1 macrophages into the M2 phenotype and increasing the expression levels of pro-chondrogenic TGF-ß1 mRNA (˜1.3-fold), and inhibiting chondrocyte apoptosis. Furthermore, in vivo experiments show that the NPs have great anti-inflammation, cartilage protection and repair effects, thereby effectively alleviating OA progression in both monoiodoacetic acid-induced early and late OA mouse models and a surgical destabilization of medial meniscus-induced OA rat model. Therefore, the siCA9 and NO scavenger "two-in-one" delivery system is a potential and efficient strategy for progressive OA treatment. |
0 | Primary sarcoma of the anterior cruciate ligament - A case report | PJI DX Updated Search | Clear cell sarcoma of tendons and aponeuroses (CCSTA) is a rare, aggressive soft tissue malignancy, which is found in intimate association with tendon, aponeurosis or fascia. It has not previously been reported in association with intraarticular ligaments. We report the first case of an intraarticular |
0 | Squamous cell carcinoma arising from chronic osteomyelitis | MSTS 2018 - Femur Mets and MM | OBJECTIVES: Our aim was to present the results from a retrospective study of 7 cases of squamous cell carcinoma arising from chronic osteomyelitis.
METHODS: We treated seven cases of chronic osteomyelitis related squamous cell carcinoma between 1993 and 2005. The patients had an average age of 54.5 (range: 38-71) years, with a male predominance (6 men, 1 woman). We analyzed the time up to cancerization, the localization and histopathological type of the carcinoma, and the type and result of the treatment.
RESULTS: The mean time between the occurrence of the skin lesions and the diagnosis of malignant degeneration was 24.5 (range: 9 to 40) years. The carcinoma resulted from tibia osteomyelitis in 4 cases, femur osteomyelitis in 2 cases and humerus osteomyelitis in one. The pathological examination showed five cases of a well differentiated squamous cell carcinoma with bone invasion, and two cases of invasive squamous cell carcinoma. The treatment consisted of amputation in all but one patient, who refused the amputation. The six amputee patients did not show local recurrence or metastatic dissemination over a period of five years.
CONCLUSION: Amputation appears to be an effective treatment method in squamous carcinoma secondary to chronic osteomyelitis. |
0 | The Amsterdam wrist rules: the multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma Background | Distal Radius Fractures | Although only 39 % of patients with wrist trauma have sustained a fracture, the majority of patients is routinely referred for radiography. The purpose of this study was to derive and externally validate a clinical decision rule that selects patients with acute wrist trauma in the Emergency Department (ED) for radiography. Method This multicenter prospective study consisted of three components: (1) derivation of a clinical prediction model for detecting wrist fractures in patients following wrist trauma; (2) external validation of this model; and (3) design of a clinical decision rule. The study was conducted in the EDs of five Dutch hospitals: one academic hospital (derivation cohort) and four regional hospitals (external validation cohort). We included all adult patients with acute wrist trauma. The main outcome was fracture of the wrist (distal radius, distal ulna or carpal bones) diagnosed on conventional Xrays. Results A total of 882 patients were analyzed; 487 in the derivation cohort and 395 in the validation cohort. We derived a clinical prediction model with eight variables: Age; sex, swelling of the wrist; swelling of the anatomical snuffbox, visible deformation; distal radius tender to palpation; pain on radial deviation and painful axial compression of the thumb. The Area Under the Curve at external validation of this model was 0.81 (95 % CI: 0.77 0.85). The sensitivity and specificity of the Amsterdam Wrist Rules (AWR) in the external validation cohort were 98 % (95 % CI: 9599 %) and 21 % (95 % CI: 15 %28). The negative predictive value was 90 % (95 % CI: 8199 %). Conclusion The Amsterdam Wrist Rules is a clinical prediction rule with a high sensitivity and negative predictive value for fractures of the wrist. Although external validation showed low specificity and 100 % sensitivity could not be achieved, the Amsterdam Wrist Rules can provide physicians in the Emergency Department with a useful screening tool to select patients with acute wrist trauma for radiography. The upcoming implementation study will further reveal the impact of the Amsterdam Wrist Rules on the anticipated reduction of Xrays requested, missed fractures, Emergency Department waiting times and health care costs. Conflict of interest: none declared. Financial support: none declared. ICMJE forms provided by the authors are available online along with the full text of this article. |
0 | The relative benefits of tamoxifen in older women with T1 early-stage breast cancer treated with breast-conserving surgery and radiation therapy | MSTS 2018 - Femur Mets and MM | Small, hormone receptor-positive breast carcinomas in older women are associated with low local recurrence rates. The relative benefits of adjuvant hormonal therapy remain unclear in elderly women with small, node-negative breast cancer after breast-conserving surgery and adjuvant radiation therapy. From our institutional data base, 224 patients >=65 years of age with T1N0M0 breast cancer treated with BCS+RT were identified. Of these, 102 patients (45.5%) received tamoxifen (TAM) and 122 patients (54.5%) did not (no-TAM). The median follow-up time was 62.6 months. The 10-year local relapse-free survival (LRFS) was 98% in both the TAM and no-TAM cohorts (p = 0.58); the 10-year DMFS was 83% TAM vs. 89% no-TAM (p = 0.91). There was no difference in 10-year contralateral breast relapse or overall survival (OS) between the two cohorts. In univariate and multivariate analysis, use of TAM was not associated with LRFS, distant metastases-free survival (DMFS), OS, or a reduction in contralateral breast cancers when compared with the no-TAM cohort. In this large cohort of T1N0 elderly breast cancer patients treated with CS+RT, the use of TAM did not appear to decrease ipsilateral breast relapse, contralateral breast relapse, distant metastasis, or OS. |
0 | Nutritionally deficient streptococci: electron microscopic study of 14 strains isolated in bacterial endocarditis | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | Fourteen strains of nutritionally deficient streptococci were isolated from patients with bacterial endocarditis and observed by light and electron microscopy. In brain-heart infusion broth supplemented wit Isovitalex, they could be distributed into three morphological groups in which numerous abnormalities involving septation or cell wall structure were showed. Group I (strains 7, 8, 13, 14) was characterized by coccobacilli resulting from failure of cross wall formation between two cocci. Cell wall structure was normal. Group II (strains 2, 4, 5, 11, 12) was characterized by long chains of elongated bacteria (rod-shaped bacteria) resulting from failure of cross wall formation and failure of separation of daughter cells after division; cell wall structure was normal. Group III (strains 1, 3, 6, 9, 10) was characterized by different abnormalities of cell wall thickness and structure. The cell wall was irregularly enlarged (strains 9, 10), thick and stratified (strain 1), or desquamating (strains 3, 6). These abnormalities of septation with or without abnormalities of cell wall appear to be much more important than those observed on normal streptococci during unbalanced growth in deprived media. They can be compared to the abnormalities shown in vivo by the bacteria of the dental plaque. The differences observed between the strains might be due to different metabolic deficiencies |
0 | Stage classifications, types of joint destruction, and bone scintigraphy in Charcot joint disease | Management of Hip Fractures in the Elderly | The histories of 36 Charcot joints (including four fractures) in 22 patients were investigated and a new stage classification system (Stage I-III) was introduced. Scintiscanning showed the uptake magnitude of radioactive substance in the Charcot lesions ranged from 6-22 times that of normal areas |
1 | An algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle | DoD SSI (Surgical Site Infections) | BACKGROUND: Wound breakdown after orthopaedic foot and ankle surgery may necessitate secondary soft tissue coverage. The foot and ankle region is challenging to reconstruct for orthopaedic and plastic surgeons owing to its complex bony anatomy and unique functional demands. Therefore, identifying strategies for plastic surgery of these wounds may help guide surgeons in defining the best treatment plan.
QUESTIONS/PURPOSES: We evaluated our current algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle with respect to whether (1) prophylactic or simultaneous soft tissue coverage affected wound-healing complications (secondary plastic surgery, orthopaedic hardware removal, malunion, further orthopaedic surgery, ultimate failure) and (2) postoperative referral for soft tissue management was associated with wound location, size, and orthopaedic procedure.
METHODS: We retrospectively reviewed 112 patients who underwent elective orthopaedic foot or ankle surgery and required concomitant plastic surgery at our institution. Study end points included secondary plastic surgery procedures, hardware removal for infection, foot or ankle malunion, further orthopaedic surgery, and wound-healing failure as defined by a chronic nonhealing wound or need for amputation. Minimum followup was 0.6 months (mean, 24.9 months; range, 0.6-197 months). Four patients were lost to complete followup. We developed an algorithm that centers on two critical points of care: preoperative evaluation by the orthopaedic surgeon and evaluation and treatment by the plastic surgeon after referral.
RESULTS: Compared with postoperative intervention, prophylactic or simultaneous soft tissue coverage did not lead to differences in frequency of secondary plastic surgery procedures (p = 0.55), hardware removal procedures (p = 0.13), malunions (p = 0.47), further orthopaedic surgery (p = 0.48), and ultimate failure (p = 0.27). Patients referred postoperatively for soft tissue management most frequently had dorsal ankle wounds (p < 0.001) of smaller size (p = 0.03), most commonly associated with total ankle arthroplasty (p = 0.004).
CONCLUSIONS: Using our algorithmic approach, prophylactic or simultaneous soft tissue coverage did not improve the study end points. In addition, unexpected postoperative wound breakdown necessitating a plastic surgery consultation most commonly occurred on the dorsal ankle after total ankle arthroplasty. Our algorithm facilitates early identification of skin instability and enables prompt soft tissue coverage before or concurrently with orthopaedic procedures. The effect of prophylactic or simultaneous soft tissue coverage on postoperative wound healing requires further investigation.
LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence. |
0 | Role of nonoperative treatment in managing degenerative tears of the medial meniscus posterior root | AMP (Acute Meniscal Pathology) | BACKGROUND: Tears of the medial meniscus posterior root can lead to progressive arthritis, and its management has no consensus. The aim of our study was to evaluate the effect of supervised exercise therapy on patients with medial meniscus posterior root tears.
MATERIALS AND METHODS: Between January 2005 and May 2007, 37 patients with this tear verified by magnetic resonance imaging (MRI) and osteoarthritis grade 1-2 by radiographic examination were treated by a short course of analgesics daily for up to 6 weeks and then as required during follow-up, as well as a 12-week supervised exercise program followed by a home exercise program. Final analysis was performed for 33 patients, average age 55.8 (range 50-62) years and average follow-up of 35 (range 26-49) months. Patients were followed up at 3, 6, and 12 months and yearly thereafter using the Lysholm Knee Scoring Scale, Tegner Activity Scale (TAS), and visual analog scale (VAS). The analysis was performed using one-way analysis of variance (ANOVA) and Pearson's correlation coefficient to determine the relationship between Lysholm score and body mass index (BMI).
RESULTS: Patients showed an improvement in Lysholm score, TAS, and VAS, which reached maximum in 6 months and later was accompanied by a decline. However, scores at the final follow-up were significantly better than the pretherapy scores. There was also a progression in arthritis as per Kellgren and Lawrence radiographic classification from median 1 preintervention to median 2 at the final follow-up. A correlation between BMI and Lysholm scores was seen (r = 0.47).
CONCLUSION: Supervised physical therapy with a short course of analgesics followed by a home-based program results in symptomatic and functional improvement over a short-term follow-up; however, osteoarthritis progression continues and is related to BMI. |
0 | Common hand injuries in the athlete | Diagnosis and Treatment of Carpal Tunnel Syndrome CPG | Common injuries to the hand and wrist of athletes have been discussed under the headings of ligament injuries, fractures, tendon injuries, and neurovascular injuries. Although the frequency and mechanisms of certain injuries may be different in the athlete than in the nonathlete, the principles of proper early diagnosis and adequate treatment are the same whether the patient is an athlete or not |
0 | What is the optimal treatment of atrophic scaphoid non-union? | Distal Radius Fractures | Aim: To evaluate the efficacy of the treatment method of autogenous iliac wing or radius bone graft and fixation with screw applied to cases of scaphoid non-union. Material and Method: A retrospective evaluation was made of 89 cases between 2000 and 2014. Postoperative measurements were taken of both wristsâ?? movement with a goniometer and muscle strength was assessed with a dynamometer. Fractures were evaluated radiologically according to the Herbert-Fisher System and the functional results according to the Herbert-Fisher Classification System and the Mayo Clinic Modified Wrist Scoring System. The data were input to the SPSS system and evaluated with the Shapiro-Wilk test. Results: Non-union were on the right side in 47 and the left side in 42 cases. The fracture was seen to be in the waist in 60 cases (67.5%), in the proximal third in 27 cases (30.3%) and in the distal third in two cases (2.2%). The mean follow-up period was 16.4 months (range, 5-72 months). Definitive findings of union were observed in 71 cases. The mean time to union was 14.9 weeks (range, 8-40 weeks). Discussion: The grafting procedure applied is an invasive technique but if it is considered that there are negative effects of open surgery on the feeding of the scaphoid bone, then in the treatment of scaphoid non-union which is atrophic non-union, ultimately autogenous bone grafting and screw fixation is a safe and successful method and because of the pain created by an iliac wing graft, radius distal bone graft can be considered more appropriate. |
1 | The incidence of bacteraemia associated with tracheal intubation | Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures | Expert committees on bacterial endocarditis prophylaxis have provided differing opinions on whether tracheal intubation is an 'at-risk' manipulation. We studied the incidence of bacteraemia after orotracheal and nasotracheal intubation. The study group comprised 110 patients who underwent surgery under general anaesthesia. Venous blood samples were collected from each patient at baseline and 30 s after intubation. Samples were processed with conventional microbiological techniques. Bacteraemia after tracheal intubation was detected in 13 patients (11.8%); six after orotracheal intubation and seven after nasotracheal intubation. Staphylococci and streptococci were the most commonly isolated bacterial species. Seven isolates (54%) were resistant to oxacillin. The incidence of bacteraemia was similar after orotracheal (12.0%) and nasotracheal intubation (11.7%). The recommendation for bacterial endocarditis prophylaxis with flucloxacillin when performing nasotracheal intubation, as put forward by the British Society for Antimicrobial Chemotherapy, needs further consideration |
0 | Hepatobiliary rickets | The Treatment of Pediatric Supracondylar Humerus Fractures AUC | Rickets secondary to hepatobiliary disease is a rare condition; however, the skeletal manifestations are similar to simple nutritional rickets. These skeletal changes include epiphyseal plate abnormalities, pseudofractures, bowing of long bones, scoliosis, and fractures. One-hundred and twelve charts and radiographs of patients with chronic hepatobiliary disease admitted to Children's Hospital of Michigan from 1968 to 1978 were reviewed. Nineteen, or 17%, of these patients showed roentgenographic evidence of rickets. Orthopedic management is primarily concerned with the treatment of fractures and prevention or correction of deformities in those children whose longevity justifies treatment |
0 | Critical care management of adults with community-acquired severe respiratory viral infection | Coronavirus Disease 2019 (COVID-19) | With the expanding use of molecular assays, viral pathogens are increasingly recognized among critically ill adult patients with community-acquired severe respiratory illness; studies have detected respiratory viral infections (RVIs) in 17-53% of such patients. In addition, novel pathogens including zoonotic coronaviruses like the agents causing Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS) and the 2019 novel coronavirus (2019 nCoV) are still being identified. Patients with severe RVIs requiring ICU care present typically with hypoxemic respiratory failure. Oseltamivir is the most widely used neuraminidase inhibitor for treatment of influenza; data suggest that early use is associated with reduced mortality in critically ill patients with influenza. At present, there are no antiviral therapies of proven efficacy for other severe RVIs. Several adjunctive pharmacologic interventions have been studied for their immunomodulatory effects, including macrolides, corticosteroids, cyclooxygenase-2 inhibitors, sirolimus, statins, anti-influenza immune plasma, and vitamin C, but none is recommended at present in severe RVIs. Evidence-based supportive care is the mainstay for management of severe respiratory viral infection. Non-invasive ventilation in patients with severe RVI causing acute hypoxemic respiratory failure and pneumonia is associated with a high likelihood of transition to invasive ventilation. Limited existing knowledge highlights the need for data regarding supportive care and adjunctive pharmacologic therapy that is specific for critically ill patients with severe RVI. There is a need for more pragmatic and efficient designs to test different therapeutics both individually and in combination. |
0 | Wnt Pathway in Bone Repair and Regeneration - What Do We Know So Far | TO: WNT2 Pathway Modulator | Wnt signaling plays a central regulatory role across a remarkably diverse range of functions during embryonic development, including those involved in the formation of bone and cartilage. Wnt signaling continues to play a critical role in adult osteogenic differentiation of mesenchymal stem cells. Disruptions in this highly-conserved and complex system leads to various pathological conditions, including impaired bone healing, autoimmune diseases and malignant degeneration. For reconstructive surgeons, critically sized skeletal defects represent a major challenge. These are frequently associated with significant morbidity in both the recipient and donor sites. The Wnt pathway is an attractive therapeutic target with the potential to directly modulate stem cells responsible for skeletal tissue regeneration and promote bone growth, suggesting that Wnt factors could be used to promote bone healing after trauma. This review summarizes our current understanding of the essential role of the Wnt pathway in bone regeneration and repair. |
1 | Effects of denosumab in patients with bone metastases with and without previous bisphosphonate exposure | MSTS 2018 - Femur Mets and MM | Bone metastases place patients at increased risk of skeletal-related events (SREs), including pathologic fractures, spinal cord compression, severe pain requiring radiotherapy or surgery, and hypercalcemia, because of increased osteoclast-mediated bone resorption. Denosumab, a fully human monoclonal antibody, decreases bone resorption by inhibiting RANKL, which mediates osteoclast activity. We compared the effects of denosumab in two phase 2 studies in patients with bone metastases naive to intravenous bisphosphonate therapy (IV BP; n=255) and those with elevated levels of the bone resorption marker urinary N-telopeptide (uNTX) despite ongoing IV BP treatment (n=111). Patients were randomized to receive IV BP every 4 weeks or subcutaneous denosumab every 4 weeks (30/120/180 mg) or every 12 weeks (60/180 mg). Patients treated with denosumab experienced a rapid and sustained reduction in bone turnover regardless of prior IV BP exposure. After 25 weeks, the median uNTX reduction was 75% (IV BP-naive) and 80% (prior IV BP) after denosumab treatment and 71% (IV BP-naive) and 56% (prior IV BP) in the IV BP arms. Denosumab patients with prior IV BP exposure had marked suppression of the osteoclast marker TRAP-5b (median reduction: denosumab 73%, IV BP 11%). SRE incidence was low across both studies. In patients previously treated with BPs, the rate of first on-study SRE was lower in the denosumab groups (8%) than the IV BP group (17%). Denosumab appeared to be well tolerated in both studies. Denosumab suppresses bone resorption markers independently of prior BP treatment, even in patients who appear to respond poorly to BPs. © 2010 American Society for Bone and Mineral Research. |
0 | Pathological fracture of the femur in Alagille Syndrome: A case report | Pediatric Diaphyseal Femur Fractures 2020 Review | Alagille Syndrome is a rare autosomal dominant genetic disorder, occur only 1:70,000 in population, and characterized by reduced interlobular bile ducts, and resultant nutritional deficiencies associated with the inability to absorb fat-soluble vitamins such as vitamin D. Patients are at risk for secondary osteoporosis, rickets/osteomalacia, and ultimately may result in fracture. The majority of patients suffer from chronic cholestasis, which can have a variety of adverse effects on bone metabolism. Hypothyroidism has been described in some Alagille Syndrome patients, and eventually delayed puberty can occur. Two until fourteen percents of patients of Alagille syndrome will suffer from fractures, in which it primarily occurs in the lower limb long bones in the absence of significant trauma. This study aimed to present a rare case of pathological fracture of femur in Alagille syndrome patient and its management in our hospital. Six-year-old male with pain on his right thigh came to our ER after fell down while putting on his pants. He had been diagnosed with biliary atresia at the age of 3 months and underwent surgical bile duct reconstruction. In addition, he also suffered from congenital hypothyroidism and consequently, stunted growth. The pathological fracture of the femur was treated conservatively with hemispica cast. At 2 months follow up, there is already radiographic evidence of fracture healing occurred by secondary intention and callus formation. By ensuring adequate calcium and vitamin D intake, monitoring for vitamin D deficiency, monitoring for fragility fractures, and avoiding trauma-related accidents, a proper conservative treatment using hemispica cast could still always be considered for managing such diaphyseal fractures in Alagille syndrome, especially in relatively low-resource countries such as Indonesia. |
1 | Breast reduction with use of the free nipple graft technique | Reduction Mammoplasty for Female Breast Hypertrophy | In properly selected patients, the results of free nipple graft breast reduction may be equal or superior to a pedicle technique. A free nipple graft is clearly indicated for gigantomastia, but it is also useful in severe macromastia, when a large, bulky pedicle may impede adequate reduction and optimal contour, and in patients with fatty breasts and inverted nipples. Disadvantages include the loss of ability to breast-feed, loss of nipple sensation, and possible hypopigmentation in the nipple-areola. The author discusses patient selection and describes execution of this technique. (Aesthetic Surg J 2001;21:261-271.). |
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