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Radiohumeral synostosis, femoral bowing, other skeletal anomalies and anal atresia, a variant example of Antley-Bixler syndrome?
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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We report a newborn with radiohumeral synostosis, femoral bowing, anal atresia, a prominent nose (pear shaped nose), slender ribs, long tapering fingers with distal camptodactyly, genital hypoplasia and a neonatal humeral fracture. Among the possible differential diagnoses a variant example of Antley-Bixler syndrome is considered to be the most likely final diagnosis
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Cyclic hydrostatic compress force regulates apoptosis of meniscus fibrochondrocytes via integrin alpha5beta1
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OAK 3 - Non-arthroplasty tx of OAK
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Meniscus is a semilunar fibrocartilaginous tissue, serving important roles in load buffering, stability, lubrication, proprioception, and nutrition of the knee joint. The degeneration and damage of meniscus has been proved to be a risk factor of knee osteoarthritis. Mechanical stimulus is a critical factor of the development, maintenance and repair of the meniscus fibrochondrocytes. However, the mechanism of the mechano-transduction process remains elusive. Here we reported that cyclic hydrostatic compress force (CHCF) treatment promotes proliferation and inhibits apoptosis of the isolated primary meniscus fibrochondrocytes (PMFs), via upregulating the expression level of integrin alpha5beta1. Consequently, increased phosphorylated-ERK1/2 and phosphorylated-PI3K, and decreased caspase-3 were detected. These effects of CHCF treatment can be abolished by integrin alpha5beta1 inhibitor or specific siRNA transfection. These data indicate that CHCF regulates apoptosis of PMFs via integrin alpha5beta1-FAK-PI3K/ERK pathway, which may be an important candidate approach during meniscus degeneration.
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Malunited Colles' fractures: correction with a biplanar closing wedge osteotomy
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Distal Radius Fractures
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A malunited Colles' fracture causes distortion of three anatomic features of the distal radius: length of the bone and the angles of its articular surface in both frontal and sagittal planes. The relative importance of each of these factors was studied in a series of 14 patients with malunited Colles' fractures and severe disabilities. Reversal of the normal palmar tilt of the distal radius in the sagittal plane was the most consistent and serious deformity of the bone, and in five patients it was associated with dorsal subluxation of the entire carpus. Correction of the malunion was achieved with a biplanar closing wedge osteotomy without a bone graft. Resection of the ulna head and decompression of the median nerve within the carpal tunnel were done to reduce the likelihood that additional surgery would be required in the future.
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Infected fractures of the distal tibial metaphysis and plafond: achievement of limb salvage with free muscle flaps, bone grafting, and ankle fusion
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DoD SSI (Surgical Site Infections)
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Infection after fractures of the tibial plafond is a challenging problem that may even result in amputation. The current study evaluates a limb salvage protocol and the associated long term functional outcome in 6 patients (mean age 46 years) who were treated for infection after a fracture of the distal tibial metaphysis and plafond. Our limb salvage protocol included 3 stages: 1) radical debridement and stabilization of the ankle with a bridging external fixator, 2) soft tissue coverage with free muscle flaps, and 3) ankle fusion using iliac crest bone graft for filling the existing defects measuring 4.2 cm on average. At a mean followup of 5.5 years (range, 2-10.5 years), limb-salvage and eradication of infection was accomplished in all extremities. Fusion of the ankle joint was achieved in all patients, with one patient requiring a supplemental bone grafting procedure for delayed healing of the fusion site. All patients are able to walk without assistive devices and five of six patients are pain free. Limb salvage with free muscle flaps, bone grafting, and ankle fusion is a viable option for the treatment of infected tibial metaphysis and plafond fractures.
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Sympathetic skin response in myelopathies
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Autonomic dysfunctions cause significant morbidity and mortality among patients with spinal cord disorders. Sympathetic skin response (SSR), a simple, noninvasive electrophysiological technique, may be useful for assessing sympathetic functions in patients with myelopathies. Our aim was to study SSR in patients with myelopathy and correlate it with clinical features, severity of the impairment, somatosensory evoked potentials, and outcome. Thirty patients (15 men, 15 women) 12 to 60 years old with myelopathies of different etiology were studied. Subjects with clinical, electrophysiologic, or radiologic evidence of lesions outside the spinal cord were excluded. Somatosensory evoked potentials (SSEP) were recorded from scalp with median nerve stimulation at the wrist and posterior tibial nerve below the medial malleolus. The SSR was recorded from palm and sole after stimulating the supraorbital nerve at forehead, median nerve at wrist, and posterior tibial nerve below medial malleolus. The SSR was considered abnormal when absent. The sites of the lesions in these patients were cervical (13), thoracic (16), and lumbar (1). The lesion was clinically complete in six patients. Good motor recovery was noted in 16 subjects. SSR was absent from sole in 25 and palm in 10 patients from all three sites of stimulation. In addition, three patients also had absent SSR from palm on posterior tibial nerve (PTN) stimulation. SSEP was absent from median (N(19) in three and posterior tibial (N(39)) in 20 patients. Among 10 patients with absent SSR from palm, only three had a good outcome. Presence of SSR from palm to PTN stimulation correlated with sparing of bladder sensations and good outcome. However, absent SSR from sole did not correlate with clinical features, bladder dysfunction, or outcome. Sympathetic skin response is frequently abnormal in patients with myelopathies. Spinal afferent and efferent tracts for SSR are different and may be affected individually. The afferent pathways are closely related to tracts conveying bladder sensation. Preserved palmar SSR on PTN stimulation may suggest good motor outcome. SSR may be a valuable adjunct in evaluating patients with myelopathies
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Is medullary carcinoma of the breast hormone dependent?
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MSTS 2018 - Femur Mets and MM
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From 1951 to 1981, 22 patients with metastatic medullary carcinoma of the breast were treated with hormonal therapies at Roswell Park Memorial Institute. Bilateral oophorectomy was performed in 6 premenopausal patients, and none had objective response, although one patient did have stable disease for 7 months. Three of these patients subsequently underwent bilateral adrenalectomy and none responded. Thirteen of 16 postmenopausal patients underwent bilateral adrenalectomy and only one had an objective response of 4 months. Eight of 22 patients received additive hormones, and one patient was treated with Tamoxifen. There was no objective response to these therapies. From this study, it appears that medullary carcinoma of the breast is less often responsive to endocrine therapy, and this finding correlates well with the recent data showing lower frequency of estrogen receptor-positive tumors in these patients.
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Endocrine aspects of bone metastases
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MSTS 2018 - Femur Mets and MM
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Skeletal lesions are a frequent complication of breast and prostate cancer and a hallmark of multiple myeloma. Endocrine and paracrine factors modulate various aspects of bone metastases, including tumour proliferation, skeletal susceptibility to tumour homing, the microenvironment needed to support tumour persistence, and the initiation of a vicious cycle between tumour and bone-resident cells that further promotes tumour growth. Endocrine changes, such as oestrogen or vitamin D deficiency, contribute to a fertile bone microenvironment that might promote bone metastases. Bone health could be impaired further by existing cancer treatments, especially sex hormone deprivation. In this Review, we discuss the effect of hormones and associated local factors on cross-talk between bone metabolism and tumour biology. We review the biology of osteolytic and osteosclerotic lesions, with a focus on endocrine aspects, and outline potential therapeutic targets. We also summarise endocrine aspects of the pathogenesis and clinical presentation of bone metastases and provide an update on existing and future treatments. © 2014 Elsevier Ltd.
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Risk of surgery for subacromial impingement syndrome in relation to neck-shoulder complaints and occupational biomechanical exposures: A longitudinal study
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DoD PRF (Psychosocial RF)
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Objectives The aim of this longitudinal study was to evaluate the risk of surgery for subacromial impingement syndrome (SIS) in relation to neck-shoulder complaints and occupational biomechanical shoulder exposures. Methods The study was based on the Musculoskeletal Research Database at the Danish Ramazzini Centre. We linked baseline questionnaire information from 1993-2004 on neck-shoulder complaints, job titles, psychosocial work factors, body mass index, and smoking with register information on first-time surgery for SIS from 1996-2008. Biomechanical exposure measures were obtained from a job exposure matrix based on expert judgment. We applied multivariable Cox regression. Results During 280 125 person-years of follow-up among 37 402 persons, 557 first-time operations for SIS occurred. Crude surgery rates increased from 1.1 to 2.5 per 1000 person-years with increasing shoulder load. Using no neck-shoulder complaints and low shoulder load at baseline as a reference, no neck-shoulder complaints and high shoulder load showed an adjusted hazard ratio (HRadj) of 2.55 [95% confidence interval (95% CI) 1.59-4.09], while neck-shoulder complaints in combination with high shoulder load showed an HRadj of 4.52 (95% CI 2.87-7.13). Subanalyses based on 18 856 persons showed an HRadj of 5.40 (95% CI 2.88-10.11) for complaints located specifically in the shoulder in combination with high shoulder load. Conclusions Based on these findings, persons with neck-shoulder and especially shoulder complaints in combination with high shoulder load seem an obvious target group for interventions aimed at reducing exposures to prevent surgery for SIS.
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Predicting pain and disability in patients with hand fractures: comparing pain anxiety, anxiety sensitivity and pain catastrophizing
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DoD PRF (Psychosocial RF)
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There is a range of anxiety-related constructs associated with pain and pain-related disability. Those most often examined are pain catastrophizing, pain anxiety and anxiety sensitivity. All three are conceptualized to be important in the development and maintenance of chronic pain, and are included within fear avoidance models. Surprisingly these constructs are not routinely examined together, and when they are, have been investigated in healthy individuals using experimental techniques or patients with chronic conditions. Although these constructs are also thought to be important in acute clinical pain, they tend not to been examined together in the same study. The focus of the current research was therefore to examine these three anxiety-related constructs in an acute pain setting, and examine their relative influence on both pain and pain-related functional disability. Participants were 82 patients with a hand fracture, recruited from a fracture clinic at a general hospital. They completed a battery of measures related to anxiety, pain and disability. Once controlling for injury-related variables, catastrophizing was found to predict current pain, pain- related anxiety predicted task-related pain, whereas anxiety sensitivity was (negatively) associated with disability. These findings are discussed in light of the relative role that these anxiety-related constructs have in pain and disability, as well as implications for future research.
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A novel surgical approach for treating distal radial extraarticular malunion: Oblique osteotomy with buttress plate stabilization
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Distal Radius Fractures
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PURPOSE: Distal radial extraarticular malunions are not uncommon. However, requirements of surgical correction depend on multiple conditions. Traditionally, surgical techniques include closing or opening wedge osteotomies. Each has unique advantages and disadvantages. An oblique osteotomy was developed to simplify the revision surgery.
METHODS: Forty-eight consecutive adult patients with 48 malunions were surgically treated. An oblique osteotomy of 45degree vertical to the radial longitudinal axis was performed from medio-distally to latero-proximally. Consequently, the osteotomized fragments were compressed with a bone clamp. The proximal part of the distal fragment was pushed backward to correct the dorsal tilt. A 7-hole buttress plate was inserted volarly and cancellous bone graft was packed. Postoperatively, a short-arm splint or brace without restriction of all five metacarpophalangeal joints was applied for 6 weeks.
RESULTS: Forty-one patients were followed for an average of 2.8 years (range, 1.1-5.8 years). All malunions healed within 6 weeks. The union rate was 100% and no complications occurred. Radiographically, ulnar variance, volar tilt of radial articulation, and radial inclination restored to acceptable criteria in all patients. Patients with Modified Mayo Wrist Score (MMWS) improved from 17% to 80% ( p < 0.001) and Disability of Arm, Shoulder and Hand (DASH) Score improved from 0% to 80% ( p < 0.001). The relationship between MMWS and DASH Score was highly correlated (correlation coefficient = -0.90).
CONCLUSION: The described approach may be an excellent alternative for treating distal radial extraarticular malunions. The technique is not difficult but the satisfactory rate is high.
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High-resolution cartilage imaging of the knee at 3 T: Basic evaluation of modern isotropic 3D MR-sequences
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AMP (Acute Meniscal Pathology)
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Purpose: To evaluate qualitative and quantitative image quality parameters of isotropic three-dimensional (3D) cartilage-imaging magnetic resonance (MR)-sequences at 3 T. Materials and methods: The knees of 10 healthy volunteers (mean age, 24.4 ± 5.6 years) were scanned at a 3 T MR scanner with water-excited 3D Fast-Low Angle Shot (FLASH), True Fast Imaging with Steady-state Precession (TrueFISP), Sampling Perfection with Application-optimized Contrast using different flip-angle Evolutions (SPACE) as well as conventional and two individually weighted Double-Echo Steady-State (DESS) sequences. The MR images were evaluated qualitatively and quantitatively (signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), SNR efficiency, CNR efficiency). Quantitative parameters were compared by means of a Tukey-test and sequences were ranked according to SNR/CNR, SNR/CNR efficiency and qualitative image grading. Results: The highest SNR was measured for SPACE (34.0 ± 5.6), the highest CNR/CNR efficiency (cartilage/fluid) for the individually weighted DESS (46.9 ± 18.0/2.18 ± 0.84). SPACE, individually weighted and conventional DESS were ranked best with respect to SNR/CNR and SNR/CNR efficiency. The DESS sequences also performed best in the qualitative evaluation. TrueFISP performed worse, FLASH worst. The individually weighted DESS sequences were generally better than the conventional DESS with the significant increase of cartilage-fluid contrast (46.9 ± 18.0/31.9 ± 11.4 versus 22.0 ± 7.3) as main advantage. Conclusion: Individually weighted DESS is the most promising candidate; all tested sequences performed better than FLASH. © 2010 Elsevier Ireland Ltd. All rights reserved.
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Reduction mammaplasty with the modified round block technique in Chinese patients and its anatomy study
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Although reduction mammaplasty is one of the most common procedures in plastic surgery, it is associated with some serious complications, especially in cases of severe hypertrophy or advanced ptosis, including necrosis of the nipple and areola, absence of normal sensation of the nipple-areolar complex, and loss of lactational function for future nursing. A thorough understanding of the breast anatomy is vital for successful reduction mammaplasty. This article describes the blood supply and innervation of the breasts, and introduces a modified round block technique for reduction mammaplasty based on this anatomy.
METHODS: Six adult female cadavers were used to assess the vasculature of the anterior thorax and the nerve distribution of the breasts according to vascular perfusion and autopsy. Based on this anatomical study, a modified round block technique was designed for reduction mammaplasty, which was performed in 40 Chinese patients with breast hypertrophy.
RESULTS: Wuringer's horizontal septum was observed in all six cadavers. In the superficial layer, the main sources of blood are the second and third intercostal perforating branches of the internal thoracic artery, which run along the medial ligaments, and the branches of the lateral thoracic artery, which run along the lateral ligaments. In the deep layer, the main sources of blood are the fourth and fifth intercostal artery perforators, which run along Wuringer's horizontal septum. Innervation of the nipple-areolar complex is achieved mainly by the lateral branches of the fourth intercostal nerve, which also run along Wuringer's horizontal septum toward the nipple-areolar complex. The 40 patients with breast hypertrophy underwent successful reduction mammaplasty using our modified round block technique, except for one case, which developed necrosis of the nipple-areolar complex.
CONCLUSIONS: Reduction mammaplasty using our modified round block technique can maximally preserve the blood supply to the remaining gland as well as the innervation to the nipple-areolar complex, while maintaining the advantages of the traditional technique, such as an invisible scar and good projection.
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Alendronate in early postmenopausal women: effects on bone mass during long-term treatment and after withdrawal. Alendronate Osteoporosis Prevention Study Group
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Management of Hip Fractures in the Elderly
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We studied the effect on bone mass of alendronate treatment for 5 yr and its withdrawal. Four hundred and forty-seven postmenopausal women with normal bone mass entered a 3-yr randomized trial followed by a 2-yr open label extension. Three hundred and eleven women completed the first 3 yr, and 263 consented to continue and completed the extension. We are reporting data from groups using the dose of alendronate currently approved for osteoporosis prevention (5 mg) or from the group in which alendronate treatment was withdrawn: 52 women received alendronate (5 mg) for 5 yr (group I), 56 received 3 yr of placebo followed by alendronate (5 mg) for 2 yr (group II), and 52 received alendronate (20 mg) for 2 yr followed by 3 yr off therapy (group III). In group I, alendronate (5 mg) increased bone mineral density (BMD) at the spine and trochanter by 2.5-3.2% (P < 0.001 vs. baseline) and stabilized total body and femoral neck BMD (change vs. baseline, P = NS) over 5 yr. By the end of 5 yr, BMD was comparable at the spine, hip, and total body in groups I and III. The 3-yr decrease in BMD after withdrawal of alendronate (20 mg) in group III was 1.8-5.7% (P < 0.01 vs. baseline) and similar to the 3-yr decrease in BMD in group II during the initial 3 yr. In conclusion, alendronate (5 mg) for 5 yr or alendronate (20 mg) for 2 yr followed by 3 yr off therapy prevented postmenopausal bone loss. After withdrawal of alendronate (20 mg), bone loss resumed at the normal early postmenopausal rate
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The post-traumatic meniscal extrusion, sign of meniscotibial ligament injury. A case series
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AMP (Acute Meniscal Pathology)
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BACKGROUND: Medial meniscal extrusion (ME) has been found to be associated to anterior cruciate ligament (ACL) injury. Post-traumatic extrusion is mainly attributed to meniscotibial ligament (MTL) tear. The aim of this retrospective study was to assess the incidence of MTL tear associated with meniscal extrusion, evaluate arthroscopic findings and the associated clinical findings.
HYPOTHESIS: The medial meniscal extrusion, when associated to ACL injury, is related to a tear of the MTL.
PATIENTS AND METHODS: Patients who underwent to primary or revision ACL reconstruction with associated medial meniscal rise and/or meniscotibial tear or insufficiency were retrospectively identified over a 5-year period (from 2015 to 2019). Twenty-four patients were included in this study with preoperative magnetic resonance imaging (MRI) carried out at our institution Each MRI was evaluated by the senior author for the presence of meniscal extrusion and also for the additional pathology of meniscotibial ligament. Patient medical records were reviewed to obtain demographic information, including age, gender, and arthrometric evaluation of anteroposterior laxity.
RESULTS: All included patients underwent arthroscopic ACL reconstruction using autograft tissue, (19 primary and in 5 revision ACL reconstruction). The mean age was 31.2 years (range: 15-57; SD: 12.3 years) at the time of surgery. ME was identified at MRI in all cases preoperatively and confirmed arthroscopically. No correlation was found between meniscal extrusion and anteroposterior translation (rho=-0.270; p=0.202). Neither between having more than 3mm of extrusion and gender (chi<sup>2</sup>=0.80; p=0.371), acute/chronic lesion (chi<sup>2</sup>=0.91; p=0.341) and primary/revision reconstructions (chi<sup>2</sup>=0.83; p=0.364). In the last three patients, arthroscopic treatment of meniscal extrusion was carried out through outside-in repair of medial meniscus at its capsular junction. Reduction of meniscal extrusion has been verified by MRI, performed at 3-month follow-up.
DISCUSSION: A high prevalence of ME was found at MRI in patients with ACL injury and MTL tear. Therefore, ME may be associated to acute or chronic ligamentous injury involving the MTL, and its tear can be considered as the main determinant of extrusion. Further research is needed to increase evidence concerning MTL incidence and surgical outcomes.
LEVEL OF EVIDENCE: IV, retrospective case series.
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Pathogenesis and treatment of glucocorticoid-induced osteoporosis
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HipFx Supplemental Cost Analysis
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Aging is associated with a marked decline in bone mineral density (BMD), an increased likelihood of falling and a much greater propensity for fracture. Several factors contribute to aging-related bone loss, including reduced bone formation, increased bone resorption, recent bodyweight loss, poor nutritional status and the coexistence of other, often rheumatological, conditions. Any of these factors can lead to an uncoupling of the bone remodelling unit. In addition, the frequent use of glucocorticoids to treat a vast array of conditions has contributed to an ever-expanding group of elderly individuals who are at extremely high risk for spine and hip fractures. Owing to the surprisingly high morbidity and mortality associated with these fractures in the elderly, an understanding of the pathogenesis and epidemiology of glucocorticoid-induced osteoporosis is paramount. The factors that contribute to bone loss in older individuals treated with glucocorticoids include reduced muscle mass, poor nutrition, hypogonadism, vitamin D deficiency and secondary hyperparathyroidism. Recent studies suggest that a prophylactic approach to this problem could have a huge impact on the medical, social and economic costs of osteoporosis
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DepoDur® (extended-release epidural morphine): a review of an old drug in a new vehicle
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AAHKS (8) Anesthetic Infiltration
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The use of epidural opioid can no longer be considered a novel postoperative analgesic, whether used as a one-time bolus or given via an epidural infusion with or without local anesthetic. In this role, epidural opioid is well accepted and efficacious. However, epidurals and other current strategies for treating acute postoperative pain are all limited by side effects and complications. Epidural infusions can provide excellent postoperative analgesia but can also lead to problems and complications related to catheter placement, such as the potential for epidural hematoma with anticoagulation, technical issues with the infusion pumps, and the time and labor necessary to place, adjust, and manage catheters and infusions. Extended-release epidural morphine (EREM, DepoDur®; Endo Pharmaceuticals, Chadds Ford, PA) has been studied and increasingly utilized as a method to improve postoperative analgesia of epidural dosing without the use of infusions. Via a delivery system using liposome encapsulation, EREM provides novel analgesic benefits but also contributes a new set of concerns to the field of pain management: unique onset and duration of opioid adverse effects. These issues have generated controversy in clinical anesthesia. In this review, we provide an overview of the published basic science, background research, and current clinical studies, as well as recent applications and experience with EREM. © 2007 Elsevier Inc. All rights reserved.
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Meniscal tear characteristics in young athletes with a stable knee: arthroscopic evaluation
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AMP (Acute Meniscal Pathology)
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BACKGROUND: There has been great interest in the literature regarding meniscal tears in unstable knees, but there is not as much information available on stable knees.
PURPOSE: To report the characteristics of isolated meniscal tears (type and location) in athletes with intact cruciate ligaments.
STUDY DESIGN: Case series; Level of evidence, 4.
METHODS: Arthroscopic surgery was performed on 314 (83.1%) knees in the acute phase ( < 6 weeks) of injury and on 64 (16.9%) knees more than 6 weeks after injury for a total of 364 athletes (378 knees). Cooper's classification was used to classify the meniscal tears according to the type and location.
RESULTS: Overall, 262 of 378 tears (69.3%) were located in the medial meniscus and 116 (30.7%) in the lateral meniscus. Vertical tears (77.5%) were significantly more frequent than were horizontal tears (22.5%; chi(2) test, P < .001). A total of 23.2% of tears involved the peripheral zones (zone 0 or 1), and tears that extended into the posterior horn accounted for 75.7%. Regarding the tear shape between male and female athletes, on both sides there were no statistically significant differences in the percentage of horizontal, bucket-handle, longitudinal, or radial tears.
CONCLUSION: The characteristics of isolated meniscal tears differ with regard to the sport, sex, and tear location and type from those seen in unstable knees. This knowledge is useful in knee injury management.
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Chinese external fixation treatment for fractures of the distal end of the radius
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Distal Radius Fractures
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One hundred forty-five patients with fractures of the distal end of the radius (age range, 13 to 76 years; means, 61 years) were treated conservatively with a Chinese system of external fixation. Most of the fractures were of the extension and extraarticular type. The fixation system consists of four splints used in conjunction with three pressure pads and three or four slings. The system was used after successful manipulative reduction, and the patients were instructed to move their joints as soon as possible. The results, especially in elderly patients, were highly encouraging. We believe that this Chinese system of external fixation serves as a kind of functional brace.
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Description of a minimally invasive technique with a modified instrument for the osteosynthesis of proximal femoral fractures using the standard DHS and case series
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Hip Fx in the Elderly 2019
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INTRODUCTION: the number of hip fractures is estimated to increase from 1.66 million in 1990 to 6.26 million by 2050. Internal fixation is the most common surgical treatment for intertrochanteric fractures.
OBJECTIVES: the objective of the present research is to describe a minimally invasive technique with a modified instrument for the treatment of stable proximal femoral trochanteric fractures using the standard DHS, classified as Tronzo types 1 and 2 (AO 31A1.2), and presenting a case series.
METHODS: a case was selected to present the technique. Patients operated by this technique undergo a clinical evaluation and preoperative preparation as routine. The criteria for inclusion in the study were the presence of stable fracture of the proximal femur verified by two hip specialist orthopedists, and operated by the minimally invasive technique with a modified instrument using a standard DHS. Exclusion criteria were cases of patients operated for unstable fractures, and the use of other surgical techniques. A case series of 98 patients was performed and discussed.
RESULTS: minimally invasive technique with a modified instrument using the standard DHS device can reduce bleeding, it decreases soft tissue injuries, surgical time, and hospital stay, as any other MIPO procedures. Ninety-eight patients underwent the operation (Tronzo types I and II), 59 female and 39 male, ages from 50 to 85 years old. Immediate post-operative complications were shortening of the lower limb, loss of fracture reduction, and death by clinical complications.
CONCLUSION: the present study describes a minimally invasive surgical technique using a modified instrument to perform proximal femoral osteosynthesis for stable trochanteric fractures, using the standard DHS.
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Comparative biology of chronic and aggressive periodontitis vs. peri-implantitis
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Dental Implant Infection
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This review was undertaken to address the similarities and dissimilarities between the two disease entities of periodontitis and peri-implantitis. The overall analysis of the literature on the etiology and pathogenesis of periodontitis and peri-implantitis provided an impression that these two diseases have more similarities than differences. First, the initiation of the two diseases is dependent on the presence of a biofilm containing pathogens. While the microbiota associated with periodontitis is rich in gram-negative bacteria, a similar composition has been identified in peri-implant diseases. However, increasing evidence suggests that S. aureus may be an important pathogen in the initiation of some cases of peri-implantitis. Further research into the role of this gram-positive facultative coccus, and other putative pathogens, in the development of peri-implantitis is indicated. While the initial host response to the bacterial challenge in peri-implant mucositis appears to be identical to that encountered in gingivitis, persistent biofilm accumulation may elicit a more pronounced inflammatory response in peri-implant mucosal tissues than in the dentogingival unit. This may be a result of structural differences (such as vascularity and fibroblast-to-collagen ratios). When periodontitis and peri-implantitis were produced experimentally by applying plaque-retaining ligatures, the progression of mucositis to peri-implantitis followed a very similar sequence of events as the development of gingivitis to periodontitis. However, some of the peri-implantitis lesions appeared to have periods of rapid progression, in which the infective lesion reached the alveolar bone marrow. It is therefore reasonable to assume that peri-implantitis in humans may also display periods of accelerated destruction that are more pronounced than that observed in cases of chronic periodontitis. From a clinical point of view the identified and confirmed risk factors for periodontitis may be considered as identical to those for peri-implantitis. In addition, patients susceptible to periodontitis appear to be more susceptible to peri-implantitis than patients without a history of periodontitis. As both periodontitis and peri-implantitis are opportunistic infections, their therapy must be antiinfective in nature. The same clinical principles apply to debridement of the lesions and the maintenance of an infection-free oral cavity. However, in daily practice, such principles may occasionally be difficult to apply in peri-implantitis treatment. Owing to implant surface characteristics and limited access to the microbial habitats, surgical access may be required more frequently, and at an earlier stage, in periimplantitis treatment than in periodontal therapy. In conclusion, it is evident that periodontitis and peri-implantitis are not fundamentally different from the perspectives of etiology, pathogenesis, risk assessment, diagnosis and therapy. Nevertheless, some difference in the host response to these two infections may explain the occasional rapid progression of peri-implantitis lesions. Consequently, a diagnosed peri-implantitis should be treated without delay.
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Options in Acellular Dermal Matrix-Device Assembly
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Acellular Dermal Matrix
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Prepectoral prosthetic breast reconstruction has become increasingly popular during the last several years. Original shortcomings and poor outcomes in the 1970s have been overcome with the use of the bioengineered breast concept-namely, use of improved form stable breast implants, autologous fat grafting, and acellular dermal matrices (ADMs). Careful use of these reconstructive tools combined with improved mastectomy skin flaps has lead to successful early outcomes. Prepectoral breast reconstruction mitigates the animation deformities and muscle tightness previously associated with dual-plane prosthetic breast reconstruction while at the same time producing reproducible and outstanding aesthetic outcomes. The use of ADM is a critical component to performing prepectoral breast reconstruction. There are many techniques utilized to inset the ADM. Various methods of direct in vivo inset have been performed. These techniques are employed following completion of the mastectomy and are performed with both 2-stage as well as single-stage direct-to-implant reconstruction. Various ex vivo techniques have also been used for prepectoral breast reconstruction. Various prefabricated constructs of ADM and implant/tissue expander can be created on the back table while the mastectomy is in progress, which decreases operative time and improves surgical efficiency. This article will describe briefly the history of prepectoral reconstruction as well as describing the various techniques used for creating the ADM-device interphase.
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Fractures in spina bifida from childhood to young adulthood
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Summary: This study assessed the prevalence and types of fractures in spina bifida and examined risk factors for fracture. Fracture prevalence was highest in childhood and reduced in adolescence and young adulthood. The importance of maintaining mobility is highlighted by the increased risk of fracture in those who are non-ambulatory. Introduction: The aims of this study are to study the prevalence and types of fractures according to age group in spina bifida and examine risk factors associated with fracture. Methods: This is a retrospective cohort study of 146 individuals with spina bifida aged 2 years or older who attended the paediatric or adult spina bifida multidisciplinary clinic at a single tertiary hospital. Results: Median age at which first fracture occurred was 7 years (interquartile range 4â??13 years). Fracture rates in children (ages 2â??10), adolescents (ages 11â??18) and adults (age > 18) were 10.9/1000 (95 % confidence interval 5.9â??18.3), 5.4/1000 (95 % CI 1.5â??13.8) and 2.9/1000 (95 % CI 0.6â??8.1) patient years respectively. Childhood fractures predominantly involved the distal femur and femoral shaft; these fractures were rarely seen in adulthood. Non-ambulatory status was associated with a 9.8 times higher risk of fracture compared with ambulatory patients (odds ratio 9.8, p = 0.016, 95 % CI 1.5â??63.0). Relative risk of re-fracture was 3.1 (95 % CI 1.4â??6.8). Urological intervention with intestinal segments was associated with renal calculi (p = 0.037) but neither was associated with fracture. Conclusions: The risk of fracture is lower in adults compared with children with spina bifida. The predominant childhood fracture affects the distal femur, and immobility is the most significant risk factor for fracture. Clinical factors contributing to fracture risk need to be elucidated to enable selection of patients who require investigation and treatment of osteoporosis.
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Does metaphyseal cement augmentation in fracture management influence the adjacent subchondral bone and joint cartilage?: An in vivo study in sheep stifle joints
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OAK 3 - Non-arthroplasty tx of OAK
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Augmentation of implants with polymethylmethacrylate (PMMA) bone cement in osteoporotic fractures is a promising approach to increase implant purchase. Side effects of PMMA for the metaphyseal bone, particularly for the adjacent subchondral bone plate and joint cartilage, have not yet been studied. The following experimental study investigates whether subchondral PMMA injection compromises the homeostasis of the subchondral bone and/or the joint cartilage.Ten mature sheep were used to simulate subchondral PMMA injection. Follow-ups of 2 (4 animals) and 4 (6 animals) months were chosen to investigate possible cartilage damage and subchondral plate alterations in the knee. Evaluation was completed by means of high-resolution peripheral quantitative computed tomography (HRpQCT) imaging, histopathological osteoarthritis scoring, and determination of glycosaminoglycan content in the joint cartilage. Results were compared with the untreated contralateral knee and statistically analyzed using nonparametric tests.Evaluation of the histological osteoarthritis score revealed no obvious cartilage damage for the treated knee; median histological score after 2 months 0 (range 4), after 4 months 1 (range 5). There was no significant difference when compared with the untreated control site after 2 and 4 months (P=0.23 and 0.76, respectively). HRpQCT imaging showed no damage to the metaphyseal trabeculae. Glycosaminoglycan measurements of the treated joint cartilage after 4 months revealed no significant difference compared with the untreated cartilage (P=0.24).The findings of this study support initial clinical observation that PMMA implant augmentation of metaphyseal fractures appears to be a safe procedure for fixation without harming the subchondral bone plate and adjacent joint cartilage.
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Postoperative Wound Breakdown Caused by Pyoderma Gangrenosum After Bilateral Simultaneous Total Knee Arthroplasty
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Surgical Management of Osteoarthritis of the Knee CPG
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Pyoderma gangrenosum is a noninfective necrosis of dermal tissues. Rarely, it occurs after surgery or trauma. However, lack of awareness and its striking similarity to a clinical picture of sepsis usually delay diagnosis and initiation of the correct management. We describe a unique case of its occurrence in both surgical wounds after bilateral total knee arthroplasty and discuss the differential diagnoses and management. (copyright) 2007 Elsevier Inc. All rights reserved
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Interrater reliability of the Berg Balance Scale when used by clinicians of various experience levels to assess people with lower limb amputations
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DoD LSA (Limb Salvage vs Amputation)
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BACKGROUND: People with lower limb amputations frequently have impaired balance ability. The Berg Balance Scale (BBS) has excellent psychometric properties for people with neurologic disorders and elderly people dwelling in the community. A Rasch analysis demonstrated the validity of the BBS for people with lower limb amputations of all ability strata, but rater reliability has not been tested. OBJECTIVE: The study objective was to determine the interrater reliability and intrarater reliability of BBS scores and the differences in scores assigned by testers with various levels of experience when assessing people with lower limb amputations. DESIGN: This reliability study of video-recorded single-session BBS assessments had a cross-sectional design. METHODS: From a larger study of people with lower limb amputations, 5 consecutively recruited participants using prostheses were video recorded during an in-person BBS assessment. Sixteen testers independently rated the video-recorded assessments. Testers were 3 physical therapists, 1 occupational therapist, 3 third-year and 4 second-year doctor of physical therapy (DPT) students, and 5 first-year DPT students without clinical training. Rater reliability was calculated using intraclass correlation coefficients (ICC [2,k]). Differences in scores assigned by testers with various levels of experience were determined by use of an analysis of variance with Tukey post hoc tests. RESULTS: The average age of the participants was 53.0 years (SD=15.7). Amputations had occurred at the ankle disarticulation, transtibial, and transfemoral levels because of vascular, trauma, and medical etiologies an average of 8.2 years earlier (SD=7.9). Berg Balance Scale scores spanned all ability strata. Interrater reliability (ICC [2,k]=.99) and intrarater reliability of scores determined in person and through video-recorded assessments by the same testers (ICC [2,k]=.99) were excellent. For participants with the lowest levels of ability, licensed professionals assigned lower scores than did DPT students without clinical training. LIMITATIONS: Intrarater reliability calculations were based on 2 testers. CONCLUSIONS: Berg Balance Scale scores assigned to people using prostheses by testers with various levels of clinical experience had excellent interrater reliability and intrarater reliability.
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Side-to-side asymmetries in landing mechanics from a drop vertical jump test are not related to asymmetries in knee joint laxity following anterior cruciate ligament reconstruction
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: Asymmetries in knee joint biomechanics and increased knee joint laxity in patients following anterior cruciate ligament reconstruction (ACLR) are considered risk factors for re-tear or early onset of osteoarthritis. Nevertheless, the relationship between these factors has not been established. The aim of the study was to compare knee mechanics during landing from a bilateral drop vertical jump in patients following ACLR and control participants and to study the relationship between side-to-side asymmetries in landing mechanics and knee joint laxity.
METHODS: Seventeen patients following ACLR were evaluated and compared to 28 healthy controls. Knee sagittal and frontal plane kinematics and kinetics were evaluated using three-dimensional motion capture (200 Hz) and two synchronized force platforms (1000 Hz). Static anterior and internal rotation knee laxities were measured for both groups and legs using dedicated arthrometers. Group and leg differences were investigated using a mixed model analysis of variance. The relationship between side-to-side differences in sagittal knee power/energy absorption and knee joint laxities was evaluated using univariate linear regression.
RESULTS: A significant group-by-leg interaction (p = 0.010) was found for knee sagittal plane energy absorption, with patients having 25% lower values in their involved compared to their non-involved leg (1.22 +/- 0.39 vs. 1.62 +/- 0.40 J kg<sup>-1</sup>). Furthermore, knee sagittal plane energy absorption was 18% lower at their involved leg compared to controls (p = 0.018). Concomitantly, patients demonstrated a 27% higher anterior laxity of the involved knee compared to the non-involved knee, with an average side-to-side difference of 1.2 mm (p < 0.001). Laxity of the involved knee was also 30% higher than that of controls (p < 0.001) (leg-by-group interaction: p = 0.002). No relationship was found between sagittal plane energy absorption and knee laxity.
CONCLUSIONS: Nine months following surgery, ACLR patients were shown to employ a knee unloading strategy of their involved leg during bilateral landing. However, this strategy was unrelated to their increased anterior knee laxity. Side-to-side asymmetries during simple bilateral landing tasks may put ACLR patients at increased risk of second ACL injury or early-onset osteoarthritis development. Detecting and correcting asymmetric landing strategies is highly relevant in the framework of personalized rehabilitation, which calls for complex biomechanical analyses to be applied in clinical routine.
Level of evidence: Iii.
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Elbow arthroplasty using a convertible implant
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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Total elbow arthroplasty remains the most definitive functional procedure for patients with end-stage painful arthritis of the elbow. Complication rates have historically been quite high, and early revision was not uncommon. A greater understanding of elbow anatomy and kinematics has led to advances in prosthetic design and surgical technique. The success of modern elbow arthroplasty for low-demand patients with rheumatoid arthritis has approached that of hip and knee arthroplasty. Mechanical failures have been noted to increase as a complication of both longevity and the use of elbow arthroplasty in a younger, higher-demand patient population. As the indications for total elbow arthroplasty widen to include more complex situations, it becomes more important to precisely recreate the flexion-extension axis of the elbow to optimally balance muscle forces and ligaments in an effort to improve implant durability. Advances in implant modularity and instrumentation can make determination and recreation of the flexion-extension axis more reliable and reproducible. An anatomic convertible implant allows the surgeon great versatility in choosing to perform hemiarthroplasty or unlinked or linked total elbow arthroplasty with assurance that later revision can be performed without the compulsory removal of well-fixed components. Conversion from an unlinked to a linked constraint, and visa versa, can be performed at any time. If late conversion is required, it can be performed in a minimally invasive fashion
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Comparative analysis of visual field and image distortion in 30 degrees and 70 degrees arthroscopes
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Upper Eyelid and Brow Surgery
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PURPOSE: There have been very few attempts to compare the visual fields and image distortion in arthroscopes. To better understand the images generated using existing arthroscopes, we performed image-mapping experiments to assess field of view and image distortion. The purpose of this study was to quantify and compare the visual fields obtained using 30 degrees and 70 degrees arthroscopes and assess image distortion in each arthroscope. METHODS: A complete arthroscopy system was used in this study. To perform this quantitative analysis, we created a customized measurement device that consisted of three parts: (1) distance marker, (2) chessboard pattern, and (3) angle marker. Three observers collectively assessed the appropriate position of the arthroscope during simulation. For each scope, ten simulations were performed at distances between 1 and 3 cm. Using the obtained arthroscope images, field of view and image distortion were measured and calculated. RESULTS: The field of view of the 70 degrees arthroscope was 5, 10, and 15 mm wider in diameter in comparison with the 30 degrees arthroscope at 1, 2, and 3 cm, respectively. Moreover, the 70 degrees arthroscope had less 0.66, 0.13, and 0.26 pixels of root-mean-square distance than the 30 degrees arthroscope at 1, 2, and 3 cm, respectively. The 70 degrees arthroscope also contained 0.78 pixels less at the maximal error than the average 30 degrees arthroscope. Therefore, the 70 degrees arthroscope demonstrated less distortion than the 30 degrees arthroscope. There was no significant difference between the two scopes with respect to median curvature measurement at 1-cm distance. CONCLUSION: The 70 degrees arthroscope demonstrates technical advantages over the 30 degrees arthroscope, including a wider field of view and a less image distortion at the periphery. A wide angle and less image distortion can help better orient the surgeon within the joint cavity when a panoramic picture is needed to repair rotator cuff tears, in case of hip arthroscopy, or while treating the lesions of posterior horn of medial meniscus.
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1 |
Total weight loss associated with increased physical activity after bariatric surgery may increase the need for total joint arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: Retrospectively, our institution noticed an increased number of patients undergoing total joint arthroplasty (TJA) after bariatric surgery. Considering that bariatric surgery is a proven modality to reduce osteoarthritic pain, we sought to identify a reason some patients may later require TJA. The objective of this study was to investigate the hypothesis that rapid or increased weight loss after bariatric surgery may be a risk factor for TJA.
METHODS: Weight loss parameters were retrospectively assessed in 15 bariatric surgery patients who subsequently received a primary TJA and compared with matched bariatric controls.
RESULTS: Patients who required a TJA lost 27.9% more of their body mass index (BMI) compared with controls (P = .049). Furthermore, patients who underwent TJA 25-48 months postbariatric surgery lost 78.2% more of their BMI compared with controls (P<.001). Total knee arthroplasty patients lost 43.9% more of their BMI compared with controls (P = .02), and the difference in BMI change for total hip arthroplasty patients was not significant versus controls.
CONCLUSION: These results contradict the tenant that weight loss is universally protective against arthritis and merit larger prospective investigations.
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Is the degree of osteophyte formation associated with the symptoms and functions in the patellofemoral joint in patients undergoing total knee arthroplasty?
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Surgical Management of Osteoarthritis of the Knee CPG
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Osteophyte formation and loss of articular cartilage are the main pathologic features of osteoarthritis in the patellofemoral joint. The goal of this study was to determine whether the degree of osteophyte formation was associated with the degree of cartilage loss and the patellofemoral symptoms and functions in osteoarthritic patients undergoing total knee arthroplasty (TKA). We evaluated 71 knees in 54 consecutive patients who underwent TKA under the diagnosis of osteoarthritis. The degree of patellofemoral osteophyte formation was assessed by proportional diameter and proportional rim involvement. The cartilage status was assessed by depth and size of the cartilage lesion. The patellofemoral symptoms and functions included anterior knee pain, abilities of chair-rising and stair-climbing and quadriceps muscle power. No significant association was found between the degrees of patellar or trochlear osteophyte formation with anterior knee pain or any of the patellofemoral functional parameters (P>0.05). The degree of osteophyte formation in the patella and the trochlea had a significant but weak correlation with the status of patellar cartilage and the status of the trochlear cartilage, respectively (correlation coefficient = 0.22-0.41 and P<0.05). This study indicates that physicians need to be cautious not to easily reach the conclusion that the patellofemoral symptoms and functional disabilities can be attributed to the presence of osteophyte in the patellofemoral joint in consulting patients with the patellofemoral radiographs or deciding on patellar resurfacing in TKA
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Optimising the use of bone-targeted agents in patients with metastatic cancers: A practical guide for medical oncologists
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MSTS 2018 - Femur Mets and MM
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Bone metastases can be associated with a significant worsening of patient morbidity and mortality. Bisphosphonates have been extensively researched and shown to delay the onset and reduce the incidence of complications from bone metastases. The most commonly used bisphosphonates are intravenous pamidronate, intravenous ibandronate, intravenous zoledronic acid and oral/intravenous clodronate. Several bone-targeted agents with innovative mechanisms of action are currently being developed. These include receptor activator of nuclear factor-kB ligand (RANKL) inhibitors, CCR1 inhibitors, Src inhibitors, DKK1-neutralising antibodies, activin antagonists and endothelin-1 inhibitors. In an era of individualised medicine, oncologists are being faced with an increasing number of questions when dealing with bone-targeted agents. These questions not only include the choice of which drug to use (i.e. bisphosphonates or RANKL inhibitor) but also the best treatment strategy to use. This review will provide medical oncologists with a practical guide to the use of bone-targeted agents. © Springer-Verlag 2011.
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Worsening of pain and function over 5 years in individuals with 'early' OA is related to structural damage: Data from the osteoarthritis initiative and CHECK (Cohort Hip & Cohort Knee) study
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OAK 3 - Non-arthroplasty tx of OAK
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Objective: To analyse the relation of joint damage on evolution of pain and physical functioning in two different cohorts of early phase of osteoarthritis (OA): Osteoarthritis Initiative (OAI) and Cohort Hip & Cohort Knee study (CHECK). Methods: Longitudinal data of 4-5 years follow-up (= medium term) of CHECK study and OAI were used. The Western Ontario and McMaster Universities of Osteoarthritis Index (WOMAC) was used to measure pain and physical functioning. For comparison with CHECK a subgroup of the OAI Incidence cohort was selected, Generalised estimating equations were used and all models were adjusted for gender, Body Mass Index, age, amount of working hours, racial background and hip pain at baseline. Finally, an interaction term was added to assess a possible differential effect of radiological progression on evolution of pain and function in the two cohorts. Results: At baseline, CHECK had less radiographic OA (K&L â?¤2) compared with the OAI Incidence subgroup, but at follow-up CHECK had more radiographic change (51% vs 15% â?¤1 K&L point increase; p<0.001). Over 4 years of follow-up, evolution of pain and physical functioning remained fairly stable in both cohorts, however, at different levels, OAI participants had less pain and less problems with physical functioning compared to CHECK participants. Both cohorts showed the same negative effect of rapid radiological change (K&L change of 2 points) on pain and physical function. Conclusions: In participants with 'early symptomatic OA' rapid radiological change (change of â?¤2 grades of K&L in 4 or 5 years) is related to worsening of pain and function
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Clinical trials in metastatic breast cancer to bone: past--present--future
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MSTS 2022 - Metastatic Disease of the Humerus
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The skeleton is the most common site of metastatic disease in breast cancer and the site of first distant relapse in almost one half of the cases. Bone metastases are the source of a considerable morbidity, including pain, long bone fractures in 10-20%, and hypercalcemia in 10-15% of the cases. The median survival after first relapse in bone is close to two years compared to three months after first relapse in liver. A review of endocrine and chemotherapy trials indicates that patients with metastatic bone disease have a lower response rate to antineoplastic therapy than patients with soft tissue or visceral metastases, but this probably reflects selection bias and the insensitivity of our current methods for evaluating bone response. Classical UICC criteria require radiological recalcification, implying not only tumor regression but also bone healing, which can take many months. Symptom evaluation, measurement of tumor markers and of biochemical parameters of bone turnover should be further investigated for early assessment of bone response. Pain relief could occur in more than half of the patients after radiotherapy, but uncertainty remains as to the relationship between radiotherapy dose or fractionation and the incidence duration of pain relief. Radioactive isotopes have been used successfully in patients with blastic bone metastases from prostate cancer, but controlled studies are lacking in breast cancer. The pathophysiology of metastatic bone destruction makes it logical to use osteoclast inhibitors. Bisphosphonates are potent inhibitors of bone resorption that have opened the way for a noncytotoxic medical treatment of bone metastases. Two large-scale studies in patients with breast cancer metastatic to the skeleton, one with clodronate and one with pamidronate, indicate that the prolonged administration of oral bisphosphonates, in addition to systemic antineoplastic therapy, can reduce the frequency of morbid skeletal events, including the incidence of hypercalcemic episodes and the need for radiotherapy, and probably the incidence of severe pain and of fractures. On the other hand, in patients with established tumor-induced osteolysis, intravenous pamidronate infusions can induce bone pain relief and an objective sclerosis of lytic lesions maybe in one-third and in one-fourth of the cases, respectively. These figures must, however, be taken with caution, and prospective placebo-controlled trials in large series of patients are needed. [References: 95]
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Impact of joint laxity and hypermobility on the musculoskeletal system
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Glenohumeral Joint OA
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Excessive joint laxity, or hypermobility, is a common finding of clinical importance in the management of musculoskeletal conditions. Hypermobility is common in young patients and in general is associated with an increased incidence of musculoskeletal injury. Hypermobility has been implicated in ankle sprains, anterior cruciate ligament injury, shoulder instability, and osteoarthritis of the hand. Patients with hypermobility and musculoskeletal injuries often seek care for diffuse musculoskeletal pain and injuries with no specific inciting event. Orthopaedic surgeons and other healthcare providers should be aware of the underlying relationship between hypermobility and musculoskeletal injury to avoid unnecessary diagnostic tests and inappropriate management. Prolonged therapy and general conditioning are typically required, with special emphasis on improving strength and proprioception to address symptoms and prevent future injury. Orthopaedic surgeons must recognize the implications of joint mobility syndromes in the management and rehabilitation of several musculoskeletal injuries and orthopaedic disorders.
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Impact of Systemic Therapy in Metastatic Renal-Cell Carcinoma Patients With Synchronous and Metachronous Brain Metastases
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MSTS 2022 - Metastatic Disease of the Humerus
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The prognosis of metastatic renal-cell carcinoma patients with brain metastases has significantly improved over the past 5 to 10 years. Through modern radiation techniques, the ability to achieve effective intracranial disease control has also improved. However, there remains a paucity of evidence characterizing the impact of systemic therapy in controlling extracranial disease in the setting of aggressive intracranial management.
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Diagnosis of congenital hip dysplasia in the newborn
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Developmental Dysplasia of the Hip CPG
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BACKGROUND AND PURPOSE: Screening of newborn infants for congenital hip dysplasia may be done by clinical examination, ultrasound, or radiography--or a combination of these. Studies that have used clinical examination followed by ultrasound imaging for infants with certain risk factors have shown excellent results, but they were performed by very experienced practitioners. We wanted to find out whether the results of such screening would be equally good with less optimal staffing. Thus, we evaluated the real-life performance of a screening program for detection of congenital hip dysplasia in newborn infants. SUBJECTS AND METHODS: We performed a retrospective chart review of all infants (n = 1,983) referred for evaluation for suspected congenital hip dysplasia from one single obstetric hospital, where 19,820 infants had been screened from 1992 through 2001. Infants were referred either because of a positive finding during the Ortolani and Barlow examinations or because of the presence of risk factors. RESULTS: The reasons for referral of the 1,983 infants (10% of those examined) were: positive clinical signs in 255 (1.3% of all examined) and risk factors in 1,547 (7.8%), and a combination of both in 114 (0.6%). 67 other infants (0.3%) who had passed the initial pediatric screening were later referred from the local health centers. Finally, 23 of the 1,983 infants were subsequently referred again by their health center for renewed orthopedic evaluation. Of the infants who were treated (298/1,983 = 15% of those referred), those with a pathological examination result were represented proportionately more than infants who were referred because of risk factors (0.8% as opposed to 0.5%). Delayed diagnoses occurred in 1.7/1,000 infants. INTERPRETATION: The performance of a screening protocol for congenital hip dysplasia in a real-life setting involving several physicians both on the pediatric and orthopedic side may not live up to expectations based on the use of such a protocol in an optimized setting. This type of analysis of screening data may serve to pinpoint weaknesses, and thus lead to adjustments that may enhance quality
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The threshold elicited motor response via an in situ femoral nerve catheter predicts analgesia following total knee replacement
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AAHKS (8) Anesthetic Infiltration
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Background: Continuous femoral nerve blocks are a part of the multimodal perioperative anesthetic regimen following total knee replacement. Elicitation of a quadriceps muscle contraction (QC) at placement is desirable. We prospectively evaluated the relationship between elicited motor response and threshold current with block success in situ femoral nerve catheters after total knee replacement. Methods: After Institutional Review Board approval and written informed consent, 100 adults aged �18 years, undergoing total knee replacement were studied. The threshold current for an elicited motor response (QC or sartorius muscle contraction [SC]) was recorded during needle insertion, after femoral nerve catheter advancement, and prior to local anesthetic administration on the first postoperative day. Patients were assessed for pinprick sensory anesthesia of the femoral nerve distribution by an observer unaware of the current threshold or evoked motor response at 5-minute intervals for 30 minutes. A successful block was considered a lack of pinprick sensation within 30 minutes. Results: Ninety patients completed the study. A QC was obtained at needle insertion in 89 and maintained following catheter advancement in 77 subjects. Prior to drug administration a QC was obtained in 66 patients, 13 demonstrated an SC, and 11 had no motor response. QC prior to drug administration had a sensitivity of 0.85 (95% confidence intervals [CI]: 0.75 to 0.92) and a specificity of 0.55 (95% CI: 0.37 to 0.72) for complete femoral nerve block. The specificity of a QC prior to drug administration was greater than at catheter placement (P = 0.006). Compared to the threshold current at catheter placement, 27 patients had a decrease, 60 had an increase, and 3 exhibited no change in the threshold current prior to drug administration (P<0.01). The median interquartile range (IQR) threshold current in patients that achieved a complete block was 0.56 (0.29 to 0.80) mA compared with 1.1 mA (0.41 to 2.75) mA for incomplete blocks (P<0.01). The area under the receiver operator characteristics curve for current threshold prior to local anesthetic administration (0.74) was greater than at catheter placement (0.45) (P<0.001). The intersection of sensitivity and specificity for the minimal threshold current prior to local anesthetic injection was 0.84 mA. Conclusion: The elicited motor response and current threshold from a stimulating femoral catheter measured prior to local anesthetic injection is an important determinant of the success of femoral nerve block following bolus administration. © 2010 Nader et al, publisher and licensee Dove Medical Press Ltd.
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Range of motion and function are not affected by increased post constraint in patients undergoing posterior stabilized total knee arthroplasty
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Constrained primary total knee arthroplasty (TKA) can provide stability in the face of incompetent collateral structures or irreconcilable flexion-extension imbalances. However, little is known about its effect on overall knee range of motion (ROM). This study determines whether TKA with increased constraint affects postoperative ROM. Methods: Patients undergoing primary TKA using either posterior stabilized (PS) or constrained condylar knee (CCK) inserts were match-paired based on body mass index, preoperative ROM, and direction and severity of the coronal deformity, yielding 68 pairs. ROM and Knee Society Score (KSS) were obtained preoperatively and at 6. weeks, 4. months, and 1. year. Results: When the 68 matched pairs were considered, all outcome variables related to ROM between the PS and CCK groups at each of the postoperative intervals were similar. Additionally, both the individual items and combined scores of the KSS were similar between groups at all time points. Conclusions: We demonstrate that the use of increased constraint does not affect ROM, relief of pain, or function after TKA. Level of evidence: Level III (retrospective case-controlled study, based on prospectively collected data). © 2013 Elsevier B.V.
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Comparison of complications associated with commercially available and custom-made articulating spacers in two-stage total hip arthroplasty revision
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Hip Fx in the Elderly 2019
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Background: Two-stage revision with interim placement of an articulating antibiotic-loaded spacer is the 'gold standard' for prosthetic hip joint infection treatment. However, commercially available and custom-made articulating spacer options exist. This study presents a comparison of these two spacer types in terms of interim complications (periprosthetic fracture, spacer dislocation, infection), post second-stage infection control, and a minimum 2-year functional and general health outcomes. Methods: Seventy-eight patients between January 1999 and August 2008 were treated with a two-stage revision, with placement of an articulating spacer during the interim period. Interim complication data, radiographic evaluation, and infection follow-up status were retrospectively reviewed. Additionally, modified Harris Hip Score and Short Form-12v2 scores were collected at a mean follow-up of 58.3 months (range, 24.3-135.3 months). Results: There were no statistically significant differences in interim complication rates between commercially available (n27) (prefabricated, n13; mold systems, n14) and noncommercial custom-made (n51) articulating spacer groups. However, there was a higher recurrence of infections after the second-stage procedure in the custom-made spacer group (21.6% compared with 0.0%) (P0.001). Similar functional and general health outcomes, as well as instances of prosthesis loosening, were found between spacer types at last office follow-up visit. Conclusions: These data suggest that custom-made articulating spacers, which allow flexibility in construction at often cheaper costs than commercially available options, offer similar performance in terms of mechanical complications. However, more emphasis may need to be placed on antibiotic choice and concentration to decrease the incidence of infection recurrence. © 2013 Wolters Kluwer Health.
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Getting patients back on their feet after a hip fracture
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PJI DX Updated Search
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Hip fracture is a potentially devastating condition for older people. Although the initial treatment is surgical repair of the fracture, a long-term multidisciplinary management approach involving the patient's GP is required to maximise recovery and ensure secondary prevention strategies are implemented
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Low risk of nonunion with lateral locked plating of distal femoral fractures-A retrospective study of 191 consecutive patients
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Hip Fx in the Elderly 2019
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INTRODUCTION: The reported rate of nonunion of distal femoral fractures varies in the literature. Several risk factors for nonunion following lateral locked plating (LLP) have been described. We aimed to study the rate of nonunion, and risk factors thereof, in a Swedish population where fragility fractures are common. A secondary aim was to study risk factors for reoperation for any cause.
PATIENTS AND METHODS: We retrospectively reviewed the hospital files and radiographs of all adult patients admitted to our institution with a distal femoral fracture, from 2004 through 2013. In cases treated with LLP, medical comorbidities, fracture characteristics and implant characteristics were analysed as potential risk factors for nonunion, defined as any surgical intervention to improve healing.
RESULTS: There were 8 cases (4%, 95%CI: 1.8-8.1%) of nonunion in 191 fractures treated with LLP. Patients with nonunion were younger: 62 vs. 81 years (p = 0.009) and more commonly had open fractures: 38% vs. 9% (p = 0.034). No patient 80 years or older had a surgical intervention for nonunion. Lower age was independently associated with reoperation for any cause, but not for nonunion.
DISCUSSION: The low rate of nonunion in this study is probably due to the fact that we present data from a complete cohort from a geographic catchment area. Referral centres with a high proportion of young patients with high-energy injuries, may be better suited for studies on risk factors for nonunion, due to higher statistical power. However, results from such institutions may not be generalizable to the more common low-energy fractures.
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1 |
Discharging pin sites following K-wire fixation of distal radial fractures: a case for pin removal?
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DoD SSI (Surgical Site Infections)
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The aim of this study was to find out whether discharging pin sites following Kirschner-wire fixation of distal radial fractures warrant early wire removal. In a prospective study of 50 patients with a closed distal radial fracture treated by manipulation and either percutaneous or mini-incision Kirschner-wiring, we identified 14 patients (28%) with discharging pin sites. All of the cases were observed within the first two weeks following surgery. Of the 14 cases, only 2 patients had a positive swab culture and were treated with systemic antibiotics. In all cases the Kirschner wires were left in situ until serial radiographs demonstrated satisfactory union. Three patients (8.6%) in the percutaneous group had superficial radial nerve irritation, which settled following wire removal. Deep soft tissue infection, pyoarthrosis, osteomyelitis, and extensor tendon rupture were not encountered. We conclude that pin site discharge, whether sterile or infected, is in general not an indication for early wire removal.
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Deformity after fracture of the lateral humeral condyle in children
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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We studied 28 displaced (Jacob types II and III) fractures of the lateral humeral condyle in 28 children. There were only two Milch type I fractures. Twenty-one fractures were treated by open reduction and internal fixation with K-wires, Palmer nails, or sutures. Seven patients were treated with a plaster cast, five following closed reduction, and the primary displaced position being accepted in two. Anatomic reduction was obtained in 18 patients. All but one fracture were united at review 2 years to 16 years later. The distal humerus was wider on the injured side in all patients. Six patients had a visible varus deformity, and three patients had a visible valgus deformity. The radiologic tilt of the joint surface and the depth of the trochlear groove were measured in patients more than 10 years old at review. All patients with a final varus tilt of the joint surface on the injured side were less than 9 years of age at injury, and all but one of the patients with Milch type II fractures had a deepening of the trochlear groove. Two patients developed avascular necrosis of the trochlea. One of these had a concomitant fracture of the medial humeral epicondyle, and the other suffered a lateral condylar fracture preceded by a supracondylar fracture. We conclude that a reduced growth potential at the trochlear groove is a regular complication of the Milch type II fracture, and that the Jacobs classification is the most useful in the assessment of the method of treatment
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Osteoporosis among estrogen-deficient women--United States, 1988-1994
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Management of Hip Fractures in the Elderly
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Each year in the United States, hip fractures result in approximately 300,000 hospital admissions and an estimated $9 billion in direct medical costs. Most of these fractures result from osteoporosis among women who experience accelerated bone loss after natural or surgically induced menopause. Measurement of bone mineral density (BMD) is the best tool available to assess osteoporotic fracture risk for women after menopause; a reduction of one standard deviation (SD) in femoral BMD is comparable to a 14-year increase in age on the risk for hip fracture. A technology that allows highly accurate and precise measurement of BMD is dual energy x-ray absorptiometry (DXA). CDC's Third National Health and Nutrition Examination Survey (NHANES III) was the first nationally representative survey that used DXA to estimate osteoporosis prevalence based on BMD in the U.S. population, providing baseline information for assessing national prevention and intervention needs for this disease. This report compares self-reported health information with BMD measurements from NHANES III conducted during 1988-1994; the findings indicate that most estrogen-deficient women in the United States who had femoral osteoporosis based on BMD were unaware of having this condition, reflecting the evolving nature of research and clinical practice regarding osteoporosis
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TULUA Lipoabdominoplasty: No Supraumbilical Elevation Combined With Transverse Infraumbilical Plication, Video Description and Experience With 164 Patients
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Panniculectomy & Abdominoplasty CPG
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BACKGROUND: TULUA is a fundamentally different lipoabdominoplasty technique intended to reduce the risk of vascular compromise, correct wall laxity through a unique plication, allow freedom in choosing umbilical position, reduce tension on closure, and keep the final scar low. OBJECTIVES: The objectives of this article were to describe the TULUA technique and its variations, delineate the indications and contraindications, show the expected results, and determine its safety profile. METHODS: A series of 164 patients is presented. The technique's basic tenets were (1) infraumbilical wide transverse plication; (2) no undermining above the umbilicus; (3) unrestricted liposuction, including the supraumbilical tissues; (4) umbilical amputation and neoumbilicoplasty in the ideal position with a skin graft; and (5) low transverse scar placement. Complications were recorded and tabulated. Results were evaluated utilizing Salles' and the author's graded scales. RESULTS: Scores averaged 9.4 out of 10 on the Salles' scale and 5.6 out of 6 on the author's scale, demonstrating adequate correction of the abdominal contour and the wall and skin laxity, with properly placed scars and umbilici, without compensatory epigastric bulging. Overall, 20% of the patients experienced a complication; 9.7% experienced delay in healing or graft take of the umbilicus, 0.6% developed skin necrosis, 0.6% experienced a wound dehiscence, 2.4% had an infection, and 4.9% developed a seroma. CONCLUSIONS: The TULUA lipoabdominoplasty technique was found to improve abdominal wall laxity and aesthetics similar to traditional abdominoplasty, based on the evaluated parameters. The complications associated with the procedure are within the range of other abdominoplasty techniques, and the technique potentially has a reasonable safety profile with less risk of vascular compromise.
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Local anesthetic wound infiltration for pain management after periacetabular osteotomy
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Developmental Dysplasia of the Hip 2020 Review
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Background and purposeâ?To our knowledge, there is no evidence to support the use of local infiltration analgesia (LIA) for postoperative pain relief after periacetabular osteotomy (PAO). We investigated the effect of wound infiltration with a longâ?acting local anesthetic (ropivacaine) for postoperative analgesia after PAO. Patients and methodsâ?We performed a randomized, doubleâ?blind, placeboâ?controlled trial (ClinicalTrials.gov: NCT00815503) in 53 patients undergoing PAO to evaluate the effect of local anesthetic infiltration on postoperative pain and on postoperative opioid consumption. All subjects received intraoperative infiltration followed by 5 postoperative injections in 10â?hour intervals through a multiâ?holed catheter placed at the surgical site. 26 patients received ropivacaine and 27 received saline. The intervention period was 2 days and the observational period was 4 days. All subjects received patientâ?controlled opioid analgesia without any restrictions on the total daily dose. Pain was assessed at specific postoperative time points and the daily opioid usage was registered. Resultsâ?Infiltration with 75 mL (150 mg) of ropivacaine did not reduce postoperative pain or opioid requirements during the first 4 days. Interpretationâ?The clinical importance of ropivacaine as single component in postoperative treatment of pain is questionable, and we are planning further studies to explore the potential of LIA in larger volumeâ?and also a multimodal regimenâ?to treat pain in this category of patients.
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Endoscopic approach to cubital tunnel syndrome
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The Treatment of Pediatric Supracondylar Humerus Fractures AUC
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The cubital tunnel syndrome is one of the most common entrapment neuropathy of the upper limb. The ulnar nerve can be compressed in the oteofibrous tunnel by the bone structures, the Osborne's ligament, the fascia of the ulnar flexor muscle of the carpus or of the aponeurosis of the deep flexor of the fingers. Pressure values in the cubital tunnel >50 mm Hg induce blocking of intraneural circulation with electrodiagnostic modifications, clinical signs and histological changes including demyelinazion of the nerve proximal to the cubital tunnel. Surgery becomes essential in case of failure of conservative and physical therapy. Various surgical techniques have been described in the literature for the treatment of the ulnar neuropathy at the elbow. In this paper the authors report a new endoscopic technique for the treatment of ulnar nerve entrapment at the elbow which requires respect of specific electrodiagnostic and clinical criteria of inclusion. The restored joint active motion following elbow arthroscopy in osteoarthritis can induce or get worse a ulnar nerve neuropathy; endoscopy neurolysis is essential to remove perineural adherences and reduces the nerve stress. Immediate well-being of the patient, lesser invasiveness and minimum vascular complications are clear advantages of the endoscopic approach, while the treatment of the pathologies proximal and distal to the Struther's arcade is a limit of the technique
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Prospective, Blinded, Randomized Controlled Trial of Stemless Versus Stemmed Humeral Components in Anatomic Total Shoulder Arthroplasty: results at Short-Term Follow-up
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Stemless humeral components for anatomic total shoulder arthroplasty (aTSA) have several reported potential benefits compared with stemmed implants. However, we are aware of no Level-I, randomized controlled trials (RCTs) that have compared stemless implants with stemmed implants in patients managed with aTSA. We sought to directly compare the short-term clinical and radiographic outcomes of stemless and stemmed implants to determine if the stemless implant is noninferior to the stemmed implant. METHODS: We performed a prospective, multicenter, single-blinded RCT comparing stemless and short-stemmed implants in patients managed with aTSA. Range-of-motion measurements and American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant scores were obtained at multiple time points. Device-related complications were recorded. Radiographic evaluation for evidence of loosening, fractures, dislocation, or other component complications was performed. Statistical analysis for noninferiority was performed at 2 years of follow-up for 3 primary end points: ASES score, absence of device-related complications, and radiographic signs of loosening. All other data were compared between cohorts at all time points as secondary measures. RESULTS: Two hundred and sixty-five shoulders (including 176 shoulders in male patients and 89 shoulders in female patients) were randomized and received the allocated treatment. The mean age of the patients (and standard deviation) was 62.6 ± 9.3 years, and 99% of the shoulders had a primary diagnosis of osteoarthritis. At 2 years, the mean ASES score was 92.5 ± 14.9 for the stemless cohort and 92.2 ± 13.5 for the stemmed cohort (p value for noninferiority test, <0.0001), the proportion of shoulders without device-related complications was 92% (107 of 116) for the stemless cohort and 93% (114 of 123) for the stemmed cohort (p value for noninferiority test, 0.0063), and no shoulder in either cohort had radiographic signs of loosening. Range-of-motion measurements and ASES, SANE, and Constant scores did not differ significantly between cohorts at any time point within the 2-year follow-up. CONCLUSIONS: At 2 years of follow-up, the safety and effectiveness of the stemless humeral implant were noninferior to those of the stemmed humeral implant in patients managed with aTSA for the treatment of osteoarthritis. These short-term results are promising given the potential benefits of stemless designs over traditional, stemmed humeral components. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Association of gastrocnemius tendon calcification with chondrocalcinosis of the knee
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: Chondrocalcinosis of the knee is a common radiological finding in the elderly. However, visualization of chondrocalcinosis may be difficult in patients with advanced cartilage loss. The purpose of this study was to determine sensitivity, specificity, and accuracy of gastrocnemius tendon calcification that might serve as a radiographic marker of chondrocalcinosis in patients with painful knees.
DESIGN AND PATIENTS: We prospectively evaluated 37 knee radiographs in 30 consecutive patients (29 men, 8 women; mean age 67 years, age range 37-90 years) with painful knees who had radiographic evidence of chondrocalcinosis. The frequency of fibrocartilage, hyaline cartilage, and gastrocnemius tendon calcification was determined. For a control group, we evaluated knee radiographs in 65 consecutive patients with knee pain (54 men, 11 women; mean age 59 years, age range 40-93 years) who had no radiological signs of chondrocalcinosis. The frequency of gastrocnemius tendon calcification in the control group was determined.
RESULTS: Gastrocnemius tendon calcification was 41% sensitive, 100% specific, and 78% accurate in predicting chondrocalcinosis. The gastrocnemius tendon was calcified on 15 of 37 (41%) radiographs in the experimental group and on 0 of 67 radiographs in the control group. In the chondrocalcinosis group, 23 (62%) had posterior hyaline cartilage calcification, 14 (38%) had anterior hyaline cartilage calcification, 31 (84%) had medial meniscus calcification, and 36 (97%) had lateral meniscus calcification.
CONCLUSIONS: Our results show that gastrocnemius tendon calcification is an accurate radiographic marker of chondrocalcinosis in patients with knee pain.
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Quality of Life in Relation to Pain Response to Radiation Therapy for Painful Bone Metastases
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MSTS 2022 - Metastatic Disease of the Humerus
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Purpose To study quality of life (QoL) in responders and nonresponders after radiation therapy for painful bone metastases; and to identify factors predictive for a pain response. Patients and Methods The prospectively collected data of 956 patients with breast, prostate, and lung cancer within the Dutch Bone Metastasis Study were used. These patients, irradiated for painful bone metastases, rated pain, QoL, and overall health at baseline and weekly afterward for 12 weeks. Using generalized estimating equations analysis, the course of QoL was studied, adjusted for primary tumor. To identify predictive variables, proportional hazard analyses were performed, taking into account death as a competing risk, and C-statistics were calculated for discriminative value. Results In total, 722 patients (76%) responded to radiation therapy. During follow-up, responders had a better QoL in all domains compared with nonresponders. Patients with breast or prostate cancer had a better QoL than patients with lung cancer. In multivariate analysis, baseline predictors for a pain response were breast or prostate cancer as primary tumor, younger age, good performance status, absence of visceral metastases, and using opioids. The discriminative ability of the model was low (C-statistic: 0.56). Conclusions Responding patients show a better QoL after radiation therapy for painful bone metastases than nonresponders. Our model did not have enough discriminative power to predict which patients are likely to respond to radiation therapy. Therefore, radiation therapy should be offered to all patients with painful bone metastases, aiming to decrease pain and improve QoL.
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Meniscal Ramp Lesion Repair by a Trans-septal Portal Technique
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AMP (Acute Meniscal Pathology)
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The identification of meniscal ramp lesions can be quite difficult or even impossible with conventional anterior arthroscopic viewing and working portals. Although even the use of transnotch viewing maneuvers into the posteromedial compartment increases the likelihood of diagnosis, it is the posteromedial and trans-septal portals that provide the best direct visualization of these many times "hidden lesions." In this surgical technique description, we describe a method to not only adequately visualize the ramp lesion, but also provide subtle variations to existing surgical techniques that can help limit injury to neurovascular structures as well as gain satisfactory vertical suture repair of this posteromedial meniscocapsular injury.
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Strength-based rehabilitation on clinical outcomes in patients post-partial meniscectomy: a systematic review and meta-analysis
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To determine the effect of strength-based rehabilitation programs on patients who underwent partial meniscectomy procedures.
DESIGN: Three databases MEDLINE, PubMed and EMBASE were searched from inception to May 9th, 2022. Data on functional outcomes such as quadriceps and hamstring strengths, as well as patient-reported outcomes such as Knee Osteoarthritis and Outcome Score (KOOS) and Visual-Analogue Scale (VAS) were recorded.
RESULTS: A total of nine studies comprising 417 patients were included in this review. There were no significant differences in quadriceps or hamstring strength measures between pre and post-intervention for both groups. KOOS scores significantly increased from pre and post-intervention in both control and exercise groups. VAS scores changed from 5.0 cm to 1.4 cm in the exercise arm and 3.1 cm to 1.9 cm in the control arm.
CONCLUSION: Strength-based exercise programs for patients post-partial meniscectomy did not result in significantly different improvements in quadriceps or hamstring strength compared to control programs. However, strength-based exercise programs resulted in significantly higher KOOS scores and a greater decrease in VAS scores. Further studies, specifically well-designed systematic randomized controlled trials are necessary in order to elucidate the specifics behind what type of exercises to use in addition to load progression and frequency of training.
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GEIS-21: a multicentric phase II study of intensive chemotherapy including gemcitabine and docetaxel for the treatment of Ewing sarcoma of children and adults: a report from the Spanish sarcoma group (GEIS)
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MSTS 2022 - Metastatic Disease of the Humerus
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BACKGROUND: First Spanish trial of Ewing sarcoma (ES) including adults and children with the aim to test the efficacy of Gemcitabine and Docetaxel (G/D) in newly diagnosed high-risk (HR) patients.
METHODS: This was a prospective, multicentric, non-randomised, open study for patients 40 years with newly diagnosed ES. HR patients (metastatic, axial-pelvic primaries or bone marrow micrometastasis) received 2 window cycles of G/D. Patients with an objective response (OR) to G/D received 12 monthly cycles of G/D after completion of mP6. The primary end point was the OR rate to the G/D window phase and the event-free survival (EFS) and overall survival (OS) for all patients. The study is registered at ClinicalTrials.gov (identifier: NCT00006734).
RESULTS: Forty-three patients were enroled, median age 17 years (range, 3-40). After a median follow-up of 43.4 months, the 5-year OS rate is 55.0% (95% CI, 41-74%) with an EFS of 50.0% (95% CI, 36-68%). The 5-year OS and EFS rates for standard risk (SR) patients was 76.0% (95% CI, 57-100%) and 71.0% (CI, 54-94%); for HR 36.0% (CI, 20-65%) and 29.0% (CI, 15-56%). Twelve of 17 (70.6%) high-risk (HR) patients showed an OR (7 PR and 5 SD) to G/D window therapy. The 5-year OS rate for patients 18 years of age was 74.0% (CI, 56-97%) and 31.0% for >18 years (95% CI, 15-66%), P<0.001. Grade 4 adverse events during mP6 occurred in 28/39 of patients (72%) and did not correlate with age. Multivariate survival analyses with <18 vs 18 and risk groups significant differences, P<0.00001. Using a Cox model for OS, both age and risk group were statistically significant (P=0.0011 and P=0.0065, respectively).
CONCLUSIONS: Age at diagnosis is an independent prognostic factor superior to the presence of metastases with 18 years as the strongest cut-off. The mP6 regimen provided survival curves that plateau at 3 years and G/D produced significant responses in HR-ES that is worth further exploring.
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Comparison of Intraoperative Soft Tissue Balance Between Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty Performed by a Newly Developed Medial Preserving Gap Technique
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OAK 3 - Non-arthroplasty tx of OAK
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Background: Medial stability of the knee is considered to be associated with good clinical results after total knee arthroplasty (TKA). This study aimed to compare intraoperative soft tissue balance between cruciate-retaining (CR) and posterior-stabilized (PS) TKA performed by a newly developed medial preserving gap technique, which aimed at preserving medial stability throughout the range of motion. Methods: Seventy CR-TKAs and 70 PS-TKAs were performed in patients with varus type osteoarthritis with the novel technique guided by tensor measurements. Final intraoperative soft tissue balance with femoral trial component in place and patellofemoral joint reduced, including the joint component gap and varus/valgus ligament balance (varus angle), with the knee at 0° (full extension), 10° (extension), 30° 45° 60° 90° (flexion), 120° and 135° (deep flexion), was measured with Offset Repo-Tensor under 40 lbs of joint distraction force. The medial compartment gap (MCG), lateral compartment gap, and medial joint looseness (MCG-polyethylene insert thickness) at each flexion angle were calculated from the measured joint component gap and varus ligament balance, and compared between CR-TKA and PS-TKA. Results: The MCGs from extension to deep flexion of the knee showed no significant differences between CR-TKA and PS-TKA. The lateral compartment gaps in PS-TKA from 30° to 60° of knee flexion was significantly larger than those in CR-TKA (P <.05). Medial joint looseness showed no significant differences between CR-TKA and PS-TKA which is consistent within 1 mm from extension to flexion of the knee. Conclusion: PS-TKA similarly achieved medial stability comparable to CR-TKA using the medial preserving gap technique.
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Anterior-stabilized TKA is inferior to posterior-stabilized TKA in terms of postoperative posterior stability and knee flexion in osteoarthritic knees: a prospective randomized controlled trial with bilateral TKA
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OAK 3 - Non-arthroplasty tx of OAK
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PURPOSE: To determine whether knee stability, range of motion (ROM) and clinical scores differ between anterior-stabilized (AS) and posterior-stabilized (PS) total knee arthroplasty (TKA). METHODS: This prospective randomized controlled trial included 34 patients with severe bilateral knee osteoarthritis who underwent bilateral TKA between June 2010 and July 2011 using AS and PS designs of a single-implant system. AS TKA with ultracongruent inserts was performed in one knee and PS TKA with a cam-post mechanism was performed in the other knee in each patient. Clinical and radiological data from a mean follow-up period of 5Â years, including ROM, clinical scores, peak knee torque determined by isokinetic test, knee joint laxity determined by Telos stress views, tourniquet time and subjects' preference were analyzed. RESULTS: The mean postoperative knee flexion angle did not differ between groups until 1Â year. Beginning 2Â years postoperatively, the knee flexion angle decreased slightly in the AS group and was smaller than that in the PS group (pâ??=â??0.004). The mean Knee Society knee score was higher in the PS group than in the AS group after 2Â years. The quadriceps strength did not differ between groups. The mean posterior laxity after TKA was 6-8Â mm greater in the AS group than in the PS group. No radiological loosening was observed in either group. More subjects preferred PS knees to AS knees. However, this difference was not significant. CONCLUSION: AS primary TKA was inferior to PS TKA in terms of posterior knee stability, postoperative knee flexion and clinical scores after 2Â years. LEVEL OF EVIDENCE: Therapeutic study, Level 1.
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Circular external fixation and cemented PMMA spacers for the treatment of complex tibial fractures and infected nonunions with segmental bone loss
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DoD LSA (Limb Salvage vs Amputation)
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Purpose: The purpose of this study was to compare the outcome of combined circular external fixation and cemented polymethylmethacrylate (PMMA) spacer application between a cohort of patients with grade 3 open fractures and infected tibial nonunions and concomitant segmental bone loss. Methods: The study was designed as a retrospective cohort study. All patients who were treated for complex tibial fractures or infected nonunions with segmental bone loss between 2009 and 2013 were included if they were aged between 16 years and 60 years, sustained acute traumatic grade 3 open tibial fractures, presented with infected nonunion, and were followed up for a minimum of 12 months. Patients with a history of ipsilateral tibial fractures, contralateral lower extremity fractures, polytrauma, chest, or abdominal trauma and patients with head injuries were excluded. Both groups were treated with aggressive debridement, circular external fixation, and antibiotic-impregnated PMMA spacer. Outcome measures were the time in the external fixator (EFT) and the external fixation index (EFI). Results: Twenty-four patients with a mean age of 32 ± 14.7 years were included. Twelve patients with a mean age of 32 + 14 years and a mean bone defect of 82 + 36 mm were treated for acute complex grade 3 open tibial fractures, and 12 patients with a mean age of 35.1 + 15.7 years and a mean bone defect of 50 + 26 mm were treated for infected nonunions. There was no significant difference (p = 0.44) between the groups for EFT (249 ± 99 daysâ??tibial fractures; 255 ± 142 daysâ??infected nonunion). There were significant between group differences (p = 0.027) for EFI (37.3 ± 9.1 cm/daysâ??tibial fractures; 56 ± 14.5 cm/daysâ??infected nonunion). Conclusion: The findings of this study suggest that patients were treated for infected nonunion with segmental bone loss using circular external fixation, distraction osteogenesis, and antibiotic-impregnated PMMA spacers, and the spacers may not offer any advantage over a conventional approach using the principles of osteogenesis only. In contrast, antibiotic-impregnated spacers for open tibial trauma were advantageous and reduced the EFI considerably.
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Ultrasound analyses of the calcaneus predict relative risk of the presence of at least one vertebral fracture and reflect different physical qualities of bone in different regions of the skeleton
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Management of Hip Fractures in the Elderly
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Broadband ultrasound attenuation (BUA) and speed of sound (SOS) were determined together with bone mineral density (BMD) of the lumbar spine and of the proximal right hip (QDR 2000, Hologic) in 1252 females (mean age 56 +/- 11). We then calculated the predictive power of BUA and SOS for at least one vertebral fracture and correlation-coefficients of BMD of the spine and hip as well as BUA and SOS in different age groups (SPSS PC + Vers. 2.2. for IBM PC software). The overall prevalence of at least one vertebral fracture was 10.14% (127 out of 1252 patients). The relative risk for the presence of at least one vertebral fracture was 2.7 for BMD spine below 0.7 g Calcium/cm2 (69 out of 249 patients), 1.8 for BMD hip below 0.7 g Calcium/cm2 (106 out of 589 patients), 1.9 for SOS calcaneus below 1500 m/s (99 out of 499 patients) and 1.7 for BUA calcaneus below 110 dB/MHz (103 out of 605 patients). The relative risk for the presence of at least one vertebral fracture increases significantly (p < 0.01). In the age group < 50 the coefficients of correlation were 0.4655 between BMD spine and BUA calcaneus, 0.5259 between BMD spine and SOS calcaneus, 0.4327 between BMD hip and BUA, 0.2760 between BMD hip and SOS. In the age group > 70 the coefficients of correlation were 0.3699 between BMD spine and BUA, 0.3481 between BMD spine and SOS, 0.5946 between BMD hip and BUA, 0.5138 between BMD hip and SOS, respectively. All coefficients of correlation were highly statistically significant (p < 0.001). We conclude that BUA and SOS predict relative risk of the presence of at least one vertebral fracture as well as BMD spine and BMD hip. With increasing age BUA and SOS appear to be an independent predictor, not being inevitably correlated to BMD but possibly reflecting different qualities of bone at different sites of the skeleton
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The wrist: field evaluation and treatment
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Distal Radius Fractures
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A poorly diagnosed and treated wrist injury could become a career-ending injury. Optimal treatment begins on the playing field, not the operative field. A careful, thorough field evaluation is mandatory to ensure prompt recognition of a potentially debilitating injury. Suspected fractures or ligamentous disruption require immediate referral to a physician for definitive early treatment. When the trainer and physician work as a team, early diagnosis, treatment, and rehabilitation of wrist injuries can be instituted to reach the goal of maintaining functional healthy wrists for future athletic endeavors. [References: 73]
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Effects of dexamethasone in preventing postoperative emetic symptoms after total knee replacement surgery: a prospective, randomized, double-blind, vehicle-controlled trial in adult Japanese patients.[Retraction in Clin Ther. 2018 Apr 30;:; PMID: 29724497]
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AAHKS (2) Corticosteroids
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BACKGROUND: Postoperative emetic symptoms (nausea, retching, and vomiting) are common following total joint replacement, with an incidence as high as 83% when no prophylactic antiemetic is provided. However, most antiemetics currently used in Japan, such as antihistamines (eg, hydroxyzine), butyrophenones (eg, droperidol), and dopamine receptor antagonists (eg, metoclopramide), have been associated with adverse effects (AEs), such as excessive sedation, hypotension, dry mouth, dysphoria, hallucinations, and extrapyramidal symptoms.
OBJECTIVE: The aim of this study was to assess the efficacy and tolerability of 3 doses of intravenous dexamethasone monotherapy versus vehicle in preventing emetic symptoms after total knee replacement performed under combined general and epidural anesthesia.
METHODS: This prospective, randomized, double-blind, vehicle-controlled trial was conducted at the Department of Anesthesiology, University of Tsukuba Institute of Clinical Medicine, Tsukuba, Japan. Adult Japanese patients scheduled to undergo total knee replacement were eligible. Patients were randomly assigned to 1 of 4 treatment groups: dexamethasone 4, 8, or 16 mg, or vehicle (control). Patients received combination anesthesia with sevoflurane and nitrous oxide in pure oxygen (general) and lidocaine (epidural). Study drugs were administered intravenously after the completion of surgery. An investigator blinded to treatment assignment monitored patients for emetic symptoms for 24 hours after the patient awoke. Patients rated their satisfaction with the study drug using a linear, 11-point scale (0 = complete satisfaction to 10 = complete dissatisfaction). Tolerability was assessed by the study investigator using spontaneous reporting and patient interview.
RESULTS: A total of 80 patients were enrolled (58 women, 22 men; mean [SD] age, 59 [10] years; mean [SD] height, 154 [7] cm; mean [SD] body weight, 55 [7] kg; 20 patients per treatment group). The demographic, clinical, and surgical data were comparable between the 4 treatment groups. The rates of emesis-free patients were 35% (7 patients), 70% (14), and 75% (15) with dexamethasone 4, 8, and 16 mg, respectively, compared with 30% (6) with vehicle (P = NS, 0.013, and 0.005, respectively). Median (range) patient satisfaction scores were significantly higher in the groups receiving dexamethasone 8 and 16 mg (both, 0.0 [0-9]) compared with controls (6.0 [0-10]) (P = 0.013 and 0.008, respectively). This effect was not found with the 4-mg dose. No clinically serious AEs attributed to the study drug were observed in any of the 4 treatment groups.
CONCLUSIONS: In this study of a small, select group of adult Japanese patients undergoing total knee replacement, the rates of emesis-free patients were higher with dexamethasone 8 and 16 mg compared with vehicle 24 hours after anesthesia induction. This effect was not found with the 4-mg dose. All treatments were well tolerated.
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Engineering lubrication in articular cartilage
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OAK 3 - Non-arthroplasty tx of OAK
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Despite continuous progress toward tissue engineering of functional articular cartilage, significant challenges still remain. Advances in morphogens, stem cells, and scaffolds have resulted in enhancement of the bulk mechanical properties of engineered constructs, but little attention has been paid to the surface mechanical properties. In the near future, engineered tissues will be able to withstand and support the physiological compressive and tensile forces in weight-bearing synovial joints such as the knee. However, there is an increasing realization that these tissue-engineered cartilage constructs will fail without the optimal frictional and wear properties present in native articular cartilage. These characteristics are critical to smooth, pain-free joint articulation and a long-lasting, durable cartilage surface. To achieve optimal tribological properties, engineered cartilage therapies will need to incorporate approaches and methods for functional lubrication. Steady progress in cartilage lubrication in native tissues has pushed the pendulum and warranted a shift in the articular cartilage tissue-engineering paradigm. Engineered tissues should be designed and developed to possess both tribological and mechanical properties mirroring natural cartilage. In this article, an overview of the biology and engineering of articular cartilage structure and cartilage lubrication will be presented. Salient progress in lubrication treatments such as tribosupplementation, pharmacological, and cell-based therapies will be covered. Finally, frictional assays such as the pin-on-disk tribometer will be addressed. Knowledge related to the elements of cartilage lubrication has progressed and, thus, an opportune moment is provided to leverage these advances at a critical step in the development of mechanically and tribologically robust, biomimetic tissue-engineered cartilage. This article is intended to serve as the first stepping stone toward future studies in functional tissue engineering of articular cartilage that begins to explore and incorporate methods of lubrication. © 2012, Mary Ann Liebert, Inc.
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Psychometric evaluation of the DMSS-4 in a cohort of elderly post-operative hip fracture patients with delirium
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Hip Fx in the Elderly 2019
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BACKGROUND: Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Rapid reliable identification of clinical subtypes can allow for more targeted research efforts.
METHODS: We explored the concordance in attribution of motor subtypes between the Delirium Motor Subtyping Scale 4 (DMSS-4) and the original Delirium Motor Subtyping Scale (DMSS) (assessed cross-sectionally) and subtypes defined longitudinally using the Delirium Symptom Interview (DSI).
RESULTS: We included 113 elderly patients developing DSM-IV delirium after hip-surgery [mean age 86.9 +/- 6.6 years; range 65-102; 68.1% females; 25 (22.1%) had no previous history of cognitive impairment]. Concordance for the first measurement was high for both the DMSS-4 and original DMSS (k = 0.82), and overall for the DMSS-4 and DSI (k = 0.84). The DMSS-4 also demonstrated high internal consistency (McDonald's omega = 0.90). The DSI more often allocated an assessment to "no subtype" compared to the DMSS-4 and DMSS-11, which showed higher inclusion rates for motor subtypes.
CONCLUSIONS: The DMSS-4 provides a rapid method of identifying motor-defined clinical subtypes of delirium and appears to be a reliable alternative to the more detailed and time-consuming original DMSS and DSI methods of subtype attribution. The DMSS-4, so far translated into three languages, can be readily applied to further studies of causation, treatment and outcome in delirium.
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Lung cancer screening results in the National Cancer Institute New York study
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Reconstruction After Skin Cancer
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METHODSThree major medical centers participated in the study, recruiting approximately 10,000 cigarette smoking men older than 45 years of age at each center: Memorial Sloan-Kettering Cancer Center (MSKCC) in New York, NY, Johns Hopkins Hospital in Baltimore, MD, and The Mayo Clinic in Rochester, MN. At MSKCC, the men were divided randomly into two groups: a dual screen group received four monthly sputum cytology examinations in addition to annual posteroanterior and lateral chest X-rays and an X-ray only group received annual chest X-rays but no sputum examinations. The men suspected of lung carcinoma because of radiologic or sputum cytology findings were referred immediately for evaluation, and those with operable lung carcinoma were recommended for surgery and treated with intent to cure.RESULTSThe men who entered into the study remained in the screening program for 5- 8 years, depending on their date of enrollment, and were followed for 2 years after screening. Follow-up was completed on more than 99%. There were 53 of the 10,040 men in the study who were found to have lung carcinoma on initial examination (prevalence): 23 were in the X-ray only group; of 30 found in the dual screen group, 9 (all with squamous cell carcinoma) were detected by cytology alone. During the entire study and the 2-year follow-up period, 354 of the 10,040 men developed lung carcinoma, equally divided between the dual screen and X-ray only groups. Nearly two-thirds (190 men) had lesions that were detected by screening, and over 50% (100 men) were in Stage I. Excluding oat cell carcinoma, during the screening period 175 of 250 carcinomas (70%) were detected by screening. In contrast, during the 2-year post-screening period, 61 lung carcinomas were diagnosed of which only 12 (20%) were Stage I. Chest X-ray was most effective in detecting peripheral adenocarcinomas of the lung, which were the most common cell type. Cytology was most effective in detecting early epidermoid carcinomas of major bronchi. The epidermoid carcinomas grew slowly, metastasized late, and after becoming visible by X-ray could be treated equally effectively as in the earlier occult stage. Forty percent of all the lung carcinomas were detected in Stage I, and at least two-thirds of the patients with Stage I lung carcinoma treated by complete resection did not die of their disease. Overall 5-year survival of all patients with lung carcinoma who had enrolled in the detection program was 35%, compared with 13% for the United States as a whole during this same time period.CONCLUSIONSSputum cytology and the chest X-ray complemented each other as lung carcinoma detection techniques. The chest X-ray best detected peripheral adenocarcinomas of the lung, which are the most common type of lung carcinoma. Sputum cytology detected epidermoid carcinomas arising in major bronchi, but these are slow growing tumors that can be resected and cured after becoming visible by chest X-ray. Thus, for subjects at risk of lung carcinoma who could be followed by annual chest X-rays, sputum cytology did not improve survival, but for high risk subjects who had only a single screening examination, sputum cytology increased the number of early lung carcinomas detected. The design of the current study did not permit evaluation of chest X-ray screening versus nonscreening for prevention of death from lung carcinoma. However, the large proportion of Stage I lung carcinomas and the high survival rate of patients in this study compared with Surveillance, Epidemiology, and End Results program data strongly suggested that screening for lung carcinoma in high risk populations is a valuable public health measure.BACKGROUNDAnecdotal reports of radiologically occult early stage lung carcinomas detected by sputum cytology suggested that screening by cytology might lead to earlier diagnosis, more effective surgical therapy, and lower death rates from lung carcinoma. Thus, a randomized study was undertaken to evaluate sputum cytology as a lung carcinoma screening technique supplementing the chest X-ray.
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0 |
Dependency after hip fracture in geriatric patients: a study of predictive factors
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Management of Hip Fractures in the Elderly
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Five hundred and sixteen community-dwelling, ambulatory, geriatric hip fracture patients who were independent prior to fracture were followed prospectively to determine which patients regained their prefracture independent living status at 3-, 6-, and 12-month follow-up. At 3-, 6-, and 12-month follow-up, 78, 77, and 76% of the patients, respectively, had regained their prefracture independent living status. Analysis was performed to determine which pre- and postinjury factors were predictive of a patient regaining prefracture independent living status at 3, 6, and 12 months after fracture. Patients who were younger than age 85, independent in activities of daily living prior to fracture, independent in ambulation at hospital discharge, and who had three or more medical comorbidities were more likely to regain their prefracture independent living status
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0 |
Risk of complication and revision total hip arthroplasty among medicare patients with different bearing surfaces
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Management of Hip Fractures in the Elderly
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Background: To address the long-term problems of bearing surface wear and osteolysis associated with conventional metal-polyethylene (M-PE) total hip arthroplasty (THA), metal-metal (M-M), and ceramic-ceramic (C-C) bearings have been introduced. These bearing surfaces are associated with unique risks and benefits and higher costs. However the relative risks of these three bearings in an older population is unknown. Questions/purposes: We compared the short-term risk of complication and revision THA among Medicare patients having a primary THA with metal-polyethylene (M-PE), metal-metal (M-M), and ceramic-ceramic (C-C) bearings. Methods: We used the 2005 to 2007 100% Medicare inpatient claim files to perform a matched cohort analysis in three separate cohorts of THA patients (M-PE, M-M, and C-C) who were matched by age, gender, and US census region. Multivariate Cox proportional-hazards models were constructed to compare complication and revision THA risk among cohorts, adjusting for medical comorbidities, race, socioeconomic status, and hospital factors. Results: After adjusting for patient and hospital factors, M-M bearings were associated with a higher risk of periprosthetic joint infection (hazard ratio, 3.03; confidence interval, 1.02-9.09) when compared with C-C bearings (0.59% versus 0.32%, respectively). There were no other differences among bearing cohorts in the adjusted risk of revision THA or any other complication. Conclusions: The risk of short-term complication (including dislocation) and revision THA were similar among appropriately matched Medicare THA patients regardless of bearing surface. Hard-on-hard THA bearings are of questionable value in Medicare patients, given the higher cost associated with their use and uncertain long-term benefits in older patients. Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence. (copyright) 2010 The Author(s)
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0 |
Role of physical exercise for improving posttraumatic nerve regeneration
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Diagnosis and Treatment of Carpal Tunnel Syndrome CPG
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Despite the great regenerative ability of the peripheral nervous system (PNS), traumatic peripheral nerve damage often causes severe chronic disability. Rehabilitation following PNS trauma usually employs therapeutic exercise in an attempt to reanimate the target organs and stimulate functional recovery. Over the past years, important neurobiological determinants of PNS regeneration and successful end-organ reinnervation were unveiled. Such knowledge provides cues for designing novel strategies for treating and rehabilitating traumatic PNS damage. Physical exercise, by means of treadmill or wheel running, is neuroprotective and neuroregenerative. Research conducted on rodents demonstrates that endurance exercise modulates several of the cellular and molecular responses to peripheral nerve injury and by doing so it stimulates nerve regeneration and functional recovery following experimental PNS injury. Treadmill running increases the number of regenerating neurons, the rate of axonal growth, and the extent of muscle reinnervation following peripheral nerve injury. Furthermore, treadmill running has the ability to increase the release of neurotrophins and growth factors in the spinal cord, the injured nerve, and reinnervating muscles. Treadmill running also seems to prevent the development of neuropathic pain and allodynia as a result of peripheral nerve damage. In addition, physical exercise, even if performed for a short period of time, exerts positive conditioning effects in neuroregeneration capacity, improving the acute response to peripheral nerve insults. Some of these effects can also be obtained with passive exercise or manual stimulation. In humans, however, evidence demonstrating a positive effect of exercise on nerve regeneration is at best poor. (copyright) 2013 Elsevier Inc
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0 |
Survivorship of Hemiarthroplasty With Concentric Glenoid Reaming for Glenohumeral Arthritis in Young, Active Patients With a Biconcave Glenoid
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Glenohumeral Joint OA
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INTRODUCTION: Hemiarthroplasty with concentric glenoid reaming (known as "ream and run") may be an option for treating glenohumeral arthritis in younger patients with a biconcave glenoid. The goal of this study was to evaluate early results of this technique.
METHODS: Two senior, fellowship-trained shoulder surgeons (G.R.W. and M.D.L.) performed a retrospective review of 23 patients (24 shoulders) with a biconcave glenoid and end-stage degenerative glenohumeral arthritis treated with hemiarthroplasty with concentric glenoid reaming. The mean patient age at the time of surgery was 50 years. We evaluated the Penn Shoulder Score (PSS), Single Assessment Numeric Evaluation (SANE) score, and Simple Shoulder Test (SST) score or the time to revision surgery.
RESULTS: Twenty-four humeral hemiarthroplasties with concentric glenoid reaming were performed in 23 patients. Twenty patients (21 shoulders) reached the end point of 2-year follow-up or revision surgery. Six shoulders (25%) required revision surgery at an average of 2.7 years (range, 0.7 to 7.2 years), and three were lost to follow-up. The remaining 14 patients (15 shoulders) were followed up for an average of 3.7 years (range, 2.3 to 4.9 years). At 2-year follow-up, these 15 shoulders did not require revision surgery and had an average SANE score, PSS, and SST score of 74.5%, 82.9, and 10.4, respectively. Increasing age correlated positively with the SANE score (r = 0.62; P = 0.015), PSS (r = 0.52; P = 0.047), and SST score (r = 0.63; P = 0.012). Early postoperative forward elevation correlated weakly with the PSS (r = 0.24; P = 0.395), and early postoperative external rotation correlated moderately with the PSS (r = 0.53; P = 0.044). Final external rotation correlated moderately with the PSS (r = 0.69; P = 0.005).
DISCUSSION: Modest results were achieved with a hemiarthroplasty and concentric glenoid reaming in young patients with end-stage glenohumeral arthritis and a biconcave glenoid. Younger age and stiffness were associated with worse outcomes. Given the high revision rate and the percentage of patients who had unsatisfactory results, this procedure should be performed only after careful patient selection. Patients who are willing and able to undergo aggressive physical therapy focused on achieving early range of motion are more likely to have a satisfactory outcome after humeral hemiarthroplasty with concentric glenoid reaming.
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0 |
Carotid sinus hypersensitivity is common in patients presenting with hip fracture and unexplained falls
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Management of Hip Fractures in the Elderly
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BACKGROUND: We tried to determine the prevalence of carotid sinus hypersensitivity (CSH) in patients with hip fractures with and without a clear history of an accidental fall. METHODS: We studied 51 patients hospitalized for a hip fracture and 51 matched controls from our outpatients department. All patients were subjected to a carotid sinus massage in the supine and upright position. Patients were categorized in accidental (Group A) and unexplained (Group B) fallers. RESULTS: Six of 33 (18.2%) patients in Group A and 12 of 18 (66.7%) patients in Group B (P < 0.001) had a positive response to the carotid sinus massage. Nine controls (17.6%) also demonstrated CSH. Patients in Group B were older (A: 75.5 +/- 8.5 years vs B: 80.1 +/- 5.9 years, P =0.029) and were more likely to have a history of unexplained falls or syncope in the past (A: 0% vs B: 66.7%, P < 0.0001) than individuals in group A. Vasodepressor/mixed forms accounted for the majority of CSH responses in Group B (75%). When compared with the control group, CSH was still more common in Group B (B: 66.7% vs control: 17.6%, P < 0.0001) but not in Group A (A: 18.2% vs control: 17.6%, P =1.000). CONCLUSIONS: The prevalence of CSH is increased in elderly patients with hip fractures, only in those who present with an unexplained fall and report a history of syncope or unexplained falls in the past. The vasodepressor/mixed forms account for the majority of CSH responses in the group of unexplained fallers
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0 |
Education-to-job mismatch and the risk of work injury
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DoD PRF (Psychosocial RF)
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Objectives: To examine the association between education-to-job mismatch and work injury. Methods: Cross-sectional data from the 2003 and 2005 Canadian Community Health Surveys (n = 63 462) were used to examine the relationship between having an educational level that is incongruent with occupational skills requirements and the risk of sustaining a work injury requiring medical attention or a work-related repetitive movement injury (RMI). The effect on injury of the interaction of overeducation with recent immigrant status was also examined. Models were stratified by sex and adjusted for possible confounders. Occupational physical demands were conceptualised as a potential mediating variable. Results: After adjustment for covariates, over-education was associated with work injury and RMI for both sexes. Adjustment for occupational demands attenuated the impact on work injury but did not eliminate the effect on RMI among men. The interaction of over-education and recent immigrant status resulted among men in a fourfold increase in the odds of work injury compared with non-recent immigrants who were not overeducated. After adjustment for occupational demands, over-educated recent immigrant men still had more than a twofold increase in the odds of injury. Conclusions: The risk of sustaining a work injury is higher among those whose education exceeds that of job requirements. These findings highlight the need to address barriers to suitable employment, particularly among recent immigrants. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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Feasibility study of contralateral risk-reducing mastectomy with breast reconstruction for breast cancer patients with BRCA mutations in Japan
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Reduction Mammoplasty for Female Breast Hypertrophy
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BACKGROUND: Contralateral risk-reducing mastectomy (CRRM) for breast cancer patients with BRCA mutations has been reported to not only reduce breast cancer incidence but also to improve survival. The National Comprehensive Cancer Network guidelines recommend providing CRRM to women with BRCA mutations who desire CRRM after risk-reduction counseling. However, in Japan, CRRM cannot be performed generally because it is not covered by health insurance. Thus, we conducted a feasibility study to confirm the safety of CRRM.
METHODS: CRRM with bilateral breast reconstructions were performed for breast cancer patients with BRCA mutations. The primary endpoint was early adverse events within 3 months, and secondary endpoints were late adverse events.
RESULTS: Between August 2014 and November 2016, ten patients were enrolled. The median age was 37.5 years, and five of the patients had the BRCA1 mutation while five had the BRCA2 mutation. Six patients received neoadjuvant chemotherapy. Eight patients selected silicone breast implants, and two patients selected transverse rectus abdominis myocutaneous flap reconstruction. Pathological findings showed no evidence of occult breast cancers in any of the patients. At a median of 25.5 months follow-up time, CRRM-related early adverse events were hematoma (subsequently removed by re-operation; grade 2, n = 1), wound infection (grade 2, n = 1), skin ulceration (grade 1, n = 2) and wound pain (grade 1, n = 1). Overall, there were no grade 3 or more severe adverse events.
CONCLUSION: Our results confirm that CRRM with reconstruction could be performed safely.
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1 |
Dynamic compared with static external fixation of unstable fractures of the distal part of the radius: a prospective, randomized multicenter study
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Distal Radius Fractures
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BACKGROUND: External fixation is an established method of treating certain types of distal radial fractures. We have designed a dynamic external fixator to treat these fractures. The purpose of the present study was to compare this device with current static bridging external fixators in terms of anatomical and functional results.
METHODS: We conducted a prospective randomized study to compare the radiographic and clinical results of dynamic external fixation with those of static external fixation for the treatment of seventy unstable distal radial fractures. Mobilization of the wrist was begun in the dynamic fixator group on the day after surgery. The external fixation frames were kept in place for a mean of six weeks. The patients were assessed clinically and radiographically at the time of removal of the fixator and at three, six, and twelve months.
RESULTS: Dynamic fixation resulted in a significantly better restoration of radial length at all follow-up visits in comparison with static fixation. There were no significant differences in radial tilt or radial inclination between the two groups. Wrist flexion, radial deviation, and pronation-supination were regained significantly faster in the dynamic fixator group. Wrist extension was significantly better in the dynamic fixator group in comparison with the static fixator group at all follow-up times. Self-evaluation with use of the Disabilities of the Arm, Shoulder and Hand score and a visual analog pain score demonstrated no significant differences between the two groups at the time of the latest follow-up. Superficial pin-track infections were significantly more common in the dynamic external fixator group than in the static fixator group.
CONCLUSIONS: Continuous dynamic traction with a dynamic external fixator compares favorably with the use of static external fixators for the treatment of unstable fractures of the distal part of the radius.
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0 |
Transglutaminase 2 induced by retinoic acid decrease human chondrocyte apoptosis induced by hydrogen peroxide
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Surgical Management of Osteoarthritis of the Knee CPG
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Purpose: Osteoarthritis is a disease characterized by destruction and failure of the extracellular matrix, which serves as the functional component of the articular cartilage. The production of extracellular matrix is solely dependent on the chondrocytes, which makes up the only cell type in the articular cartilage. Therefore, chondrocyte death and survival are essential for maintaining the articular cartilage. Transglutaminase 2 (TGase 2) is an enzyme catalyzing Ca(2+)-dependent protein cross-linking. TGase 2 has been shown to be induced and activated during apoptosis. We have previously shown that TGase 2 expression is increased in human chondrocytes undergoing apoptosis. Furthermore, inhibition of TGase 2 by monodansylcadaverine (MDC); a competitive substrate of TGase 2; and TGase 2 siRNA have increased chondrocyte apoptosis. These findings suggested a possible protective role of TGase 2 in chondrocyte apoptosis. Retinoic acid (RA) and its various synthetic analogs affect mammalian cell growth, differentiation, and apoptosis. RA consistently induces TGase 2 expression and activation, and it was recently shown that increased TGase 2 expression protected NIH3T3 cells from apoptosis. The purpose of this study was to demonstrate whether TGase 2 is induced in human chondrocytes with RA and explore the role of TGase 2 in human chondrocyte apoptosis. Methods: 1. Human chondrocytes culture and apoptosis assay. Human chondrocyte culture, apoptosis induction and analysis of TGase 2 expression was performed as previously described. Briefly, human chondrocytes were obtained from the articular cartilage of patients undergoing total knee arthroplasty and cultured in monolayer. Chondrocyte apoptosis was induced by treating with H(2)O(2) (1mM) for 24 hours. Apoptosis was assessed by two methods, biochemically by Annexin-V
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0 |
Age and surgical management determine quality of life after trochanteric fracture
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Management of Hip Fractures in the Elderly
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Purpose: The aim of the study was to determine factors influencing functional ability and quality of life six months after trochanteric fracture treated surgically. Patients and method: A multicentre cohort included 459 patients (356 females and 103 males, mean age 80 years) in Eastern France. Sixty-two percent of the fractures were stable and 38% were unstable. Determinants of functional ability assessed by the Merle d'Aubigne and Harris scores, of quality of life by the Duke Health profile, and of return to home at 6 months after surgery were considered using logistic regression analyses. Result: Older age was the most prominent factor predicting bad functional ability (p<.001) and quality of life (p<.05). The material for surgery predicted 6-month poor functional ability (p<.001), probably through the different strategies for care management involved. The quality of fracture reduction assessed on lateral radiographs, as well as post-operative complications were predictors of a better functional ability (p<.001) and less frequent return to home (p<.001). Conclusion: Age and surgical management procedure are determinants of outcome at 6 month after trochanteric fracture
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0 |
Primary total elbow replacement for fractures of the distal humerus
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Distal Radius Fractures
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OBJECTIVE: Achieving stability and pain-free function for osteoporotic intraarticular multifragmentary fractures of the distal humerus in elderly patients by primary total elbow replacement (TER).
INDICATIONS: Non-soft-tissue-attached fragments, poor-quality bone, where stable osteosynthesis is not attainable. Severely comminuted intraarticular closed type C fractures according to the AO classification with multiple small bone/cartilage fragments. In case of degenerative joint diseases and/or previous surgery in rheumatoid patients also type A and B fractures. High compliance, low demand, and old patient > 65 years.
CONTRAINDICATIONS: Type II or III Gustilo-Anderson open fractures (primary irrigation and debridement). Preexisting infection, open wounds. Younger, high-demand or noncompliant patient. Paralysis of the biceps muscle.
SURGICAL TECHNIQUE: Supine positioning of patient. Triceps-sparing dorsal approach. Elevation of medial aspect of the triceps from posterior aspect of the humerus and capsula, reflecting the triceps in continuity with the ulnar periosteum and the forearm fascia. If removal of distal part of the humerus, the triceps insertion can be left intact. Preparation of humerus: no reconstruction of multifractured condyles; excavate bone from medial and lateral supracondylar ridges with burr. Preparation of ulna: remove tip of olecranon. Cemented humeral and ulnar components. Bone graft interposition behind anterior flange of humeral component. Resection of radial head and coronoid process, if impingement after trial reduction. Triceps reattachment transosseous through olecranon.
POSTOPERATIVE MANAGEMENT: No formal physical-therapy sessions. Avoid single-event weight lifting of > 5 kg and repetitive lifting of > 1 kg. Discourage playing racquets sports.
RESULTS: 49 acute distal humeral fractures in 48 patients (average age: 67 years) were treated with TER. 43 fractures were followed at an average of 7 years. According to the AO classification, five fractures were type A, five type B, and 33 type C. The average flexion arc at follow-up was 24-131 degrees, the Mayo Elbow Performance Score averaged 93. Data of complications were obtained from records in all 49 patients. 32 of the 49 elbows had neither a complication nor any further surgery from the time of the index arthroplasty to the most recent follow-up evaluation. Ten additional operative procedures, including five revision arthroplasties, were required. The retrospective review supports recommendation for TER for the treatment of an acute distal humeral fracture, when strict inclusion criteria are observed.
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A phase 2 multicenter, randomized, placebo-controlled study to evaluate the clinical efficacy, safety, and tolerability of sublingual sufentanil nanotaba,(cents) in patients following elective unilateral knee replacement surgery
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Surgical Management of Osteoarthritis of the Knee CPG
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Introduction: Intravenous patient-controlled analgesia (IV PCA) with morphine is the standard of care in many hospitals for the management of acute post-operative pain. However, IV PCA is associated with several limitations, including, the risk of PCA pump programming errors, reduced patient mobility secondary to the requisite IV line, and increased risk of analgesic gaps due to infiltrated and dislodged IV catheters or pump malfunction. Furthermore, while morphine is the most commonly used analgesic in this treatment modality, it can produce many undesirable side effects due to accumulation of active metabolites, especially in elderly and renally impaired patients. The Sufentanil NanoTab PCA System is a novel patient-controlled sublingual analgesia (PCSA) product candidate with a pre-programmed patient lock-out feature that is designed for use in hospital settings to provide effective, titratable, patient-controlled analgesia and reduce the risk of programming errors. The Sufentanil NanoTab PCA System also avoids the IV-related limitations of IV PCA by being designed to provide convenient and safe patient self-administration of Sufentanil NanoTabs sublingually for oral transmucosal absorption. The active drug, sufentanil, is a high therapeutic index opioid approved for intravenous and epidural administration. Although the analgesic efficacy of sufentanil has been well established, its use has been limited due to its short IV plasma half-time. In the NanoTab oral transmucosal dosage form, sufentanil demonstrates a therapeutically appropriate pharmacokinetic profile for post-operative PCA usage and has the potential for improved patient tolerability over IV PCA morphine. The primary objective of this study was to evaluate the efficacy, safety and tolerability of Sublingual Sufentanil NanoTabs in patients following knee replacement surgery. Methods: A total of 101 patients following elective unilateral knee replacement were randomized to receive placebo, 5 mcg, 10 mcg or 15 mcg doses of Sufentanil NanoTabs for post-operative pain after stabilization of pain levels in the post-operative care unit. Study drug was nurse administered sublingually as needed to treat pain at the patient's request, with a minimum re-dosing interval of 20 minutes. Patients were allowed to drop out of the study at any time. The primary efficacy endpoint was Sum of the Pain Intensity Difference SPID-12 (a cumulative measure of the difference in pain intensity over the 12-hour study compared to baseline). Results: Only the patients receiving 15 mcg Sufentanil NanoTabs experienced a significant reduction in pain intensity compared to placebo for the primary endpoint SPID-12 using the three alternative imputation Methods (last-LOCF, p=0.018, baseline-BOCF, p=0.007, and worst-WOCF, p=0.015 observation carried forward). Furthermore, the only the 15 mcg dose met a key secondary endpoint, lower percentage of patient dropouts due to inadequate analgesia compared to placebo (p=0.006). No significant differences were observed among treatment groups for the overall incidence of adverse events with mild to moderate nausea and vomiting being the most common. There were no serious adverse events related to study drug. Conclusions: This Phase 2 study demonstrates analgesic efficacy, safety and tolerability of the Sublingual Sufentanil NanoTab in management of acute moderate-to-severe post-operative pain following knee replacement surgery. Future Phase 3 studies of the Sufentanil NanoTab PCA System will further delineate the safety and efficacy of this PCSA system
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0 |
Abnormal cortisol awakening response predicts worse cognitive function in patients with first-episode psychosis
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DoD PRF (Psychosocial RF)
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BACKGROUND: Cognitive impairment, particularly in memory and executive function, is a core feature of psychosis. Moreover, psychosis is characterized by a more prominent history of stress exposure, and by dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. In turn, stress exposure and abnormal levels of the main HPA axis hormone cortisol are associated with cognitive impairments in a variety of clinical and experimental samples; however, this association has never been examined in first-episode psychosis (FEP).
METHOD: In this study, 30 FEP patients and 26 controls completed assessment of the HPA axis (cortisol awakening response and cortisol levels during the day), perceived stress, recent life events, history of childhood trauma, and cognitive function. The neuropsychological battery comprised general cognitive function, verbal and non-verbal memory, executive function, perception, visuospatial abilities, processing speed, and general knowledge.
RESULTS: Patients performed significantly worse on all cognitive domains compared to controls. In patients only, a more blunted cortisol awakening response (that is, more abnormal) was associated with a more severe deficit in verbal memory and processing speed. In controls only, higher levels of perceived stress and more recent life events were associated with a worse performance in executive function and perception and visuospatial abilities.
CONCLUSIONS: These data support a role for the HPA axis, as measured by cortisol awakening response, in modulating cognitive function in patients with psychosis; however, this association does not seem to be related to the increased exposure to psychosocial stressors described in these patients.
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Physical activity in relation to knee cartilage T2 progression measured with 3tmri over a period of 4 years: Data from the osteoarthritis initiative
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AMP (Acute Meniscal Pathology)
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Objective: The purpose of this study was to analyze the longitudinal association between physical activity levels and early degenerative cartilage changes in the knee, measured using T2 relaxation times over a period of 4 years in individuals without clinical or radiographic evidence of OA. Design: Cartilage T2 was measured at baseline and after 2 and 4 years in 205 subjects aged 45-60 years from the Osteoarthritis Initiative (OAI) incidence and normal cohorts with no knee pain (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score of zero), and a Kellgren Lawrence (KL) score of <2 at baseline. Physical activity was scored using the Physical Activity Scale for the Elderly (PASE) questionnaire, which was obtained yearly over 4 years. The relationship between physical activity and T2 was studied using a mixed model linear regression, including random effects, and adjusted for age, sex, and body mass index (BMI). Results: T2 values for all PASE tertiles progressed over the 4-year period. T2 progression was increased in the highest tertile of physical activity compared to the mid-tertile at the medial tibia (MT) (P=0.041), patella (Pat) (P=0.019), and average T2 of all knee compartments combined (P=0.033). Subjects with the lowest 15% PASE scores showed significantly higher T2 progression compared to the mid-level physical activity group at the lateral femur (LF) (P=0.025), lateral tibia (LT) (P=0.043), medial femur (MF) (P=0.044), tibiofemoral compartment (P=0.017), patellofemoral compartment (P=0.016), lateral compartments (P=0.003), and average of all compartments (P=0.043). Conclusion: High and very low PASE scores were associated with greater progression of cartilage T2 measurements in asymptomatic, middle-aged individuals, suggesting accelerated cartilage matrix biochemical degeneration over time. © 2013 Osteoarthritis Research Society International.
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Low-energy femoral shaft fractures after long-term alendronate therapy: Report of seven cases
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Hip Fx in the Elderly 2019
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Background There is increasing evidence suggesting a high incidence of low-energy fractures of the diaphysis or the proximal femur in patients receiving bisphosphonates for a long time. Bisphosphonate-related femoral fractures occur after low-energy trauma and have a typical simple transverse or oblique radiographic pattern, with focal or generalized increased cortical thickness, cortical beaking, and medial spiking. Materials and methods This article presents six female patients who experienced seven transverse femoral diaphysis and subtrochanteric fractures with cortical thickening and beaking; all patients had alendronate treatment for 4-10 years (average, 9 years) before their fracture. Results The typical radiographic findings, long-term administration of alendronate, low-energy mechanism of fracture, and related literature support the fact that the fractures in the patients presented in this series should be related to alendronate treatment. Conclusion Until definite evidence is available, alendronate treatment in patients with osteoporosis is not now prohibited by the healthcare authorities, probably because its beneficial influence outweighs the adverse effects. However, this adverse effect deserves attention of medical practitioners; physicians should be alert on alendronateâ??s possible suppressive effect on bone turnover, which in turn may be responsible for the occurrence of femoral fractures.
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Early venous thromboembolism is a strong prognostic factor in patients with advanced pancreatic ductal adenocarcinoma
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MSTS 2022 - Metastatic Disease of the Humerus
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Background: There are still controversial data regarding the prognostic value of Venous ThromboEmbolism (VTE) in advanced Pancreatic Ductal AdenoCarcinoma (PDAC) and thromboprophylaxis is poorly prescribed despite international recommendations. Methods: Medical charts of patients consecutively treated for advanced PDAC from 2010 to 2019 were retrospectively reviewed. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan–Meier method. Prognostic Factors were identified using a multivariate Cox’s proportional hazard model. Early VTE was defined as VTE occurring within the three months following the PDAC diagnosis. Results: A total of 174 patients were included (median age: 67 years; males: 55.2%; performance status (PS) 0–1: 88.5%) with metastatic disease in 74.7%. At baseline, Khorana score was high (= 3) in the vast majority of cases (93.7%). The cumulative incidences of VTE were 12.4% (95% CI 7.3–17.2) at 3 months, 20.4% (95% CI 13.9–26.4) at 6 months and 28.1% (95% CI 20.0–35.3) at 12 months. Patients who experienced early VTE had shorter PFS (3.8 months vs. 7.1 months; HR = 2.02; 95% CI 1.21–3.37; p = 0.006) and shorter OS (8.0 months vs. 14.1 months; HR = 2.42; 95% CI 1.37–4.30; p = 0.002) compared to the others, independently of prognostic factors such as PS, liver metastases, carcinomatosis, and chemotherapy regimen. Conclusion: early VTE is a strong prognostic factor in advanced PDAC and occurs in about one in 10 patients.
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0 |
Single Shot Infraclavicular Brachial Plexus Block vs Local Infiltration After Wrist Arthroscopy Surgery
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Distal Radius Fractures
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If the patient is willing to participate and signs the consent, he/she will be randomized to one of the two treatment groups: 1. Single shot block 2. Local Infiltration In the institution investigators usually advocate for regional anesthesia and intravenous sedation for the repair of open fracture of the distal radius. Patients will be monitored during block performance with standard ASA monitors. All patients will receive 2 L of oxygen via a nasal cannula. Sedatives will be titrated to effect. Midazolam 1â?2 mg, and fentanyl 50â?100 mcg will be used for sedation. Block time out will be preformed according to standard operating procedure. All blocks will be done under ultrasound guidance. Sonosite S nerve machine will be used with a low frequency curvilinear (C5) US probe with 2â?5 MHZ frequency. Both single shot and local infiltration will be performed according to the SOP in the department. Ultrasound survey of the deltopectoral groove below the clavicle will take place. The axillary artery and the three cords (posterior, medial and lateral) of the brachial plexus will be identified in short axis view deeper to the pectoralis minor muscle. For single shot blocks: A 4 inch 21 gauge single shot (Bâ?Braun) needle will be introduced inâ?plane towards the posterior cord of the brachial plexus and 1â?2 mL of dextrose 5% (D5%) bolus will be used to verify correct placement of the needle in the vicinity of the posterior cord and adequate spread pattern to both lateral and medical cord. 20 ml of of Ropivicaine 0.5% will be injected through the needle with intermittent aspiration after each 5 ml bolus injection. For local infiltration: At the end of surgery, surgeon will inject 10 ml of Ropivacaine 0.5% into the arthroscopy portals and the wrist. Specifically, 1 ml to 2 ml of Ropivacaine 0.5% will be injected into each portal with the remainder of the volume injected into the joint space itself. Block success will be defined as a change in cutaneous sensation to touch with an alcohol pad in the posterior, medial and lateral cord distribution over the forearm and the hand within 30min after injection. Subjects with successful catheter placement per protocol and nerve block onset will be retained in the study. Subjects with a failed catheter insertion or misplaced catheter indicated by a lack of sensory changes will have their catheter replaced or will be single shot blocked and withdrawn from the study. Intraoperative sedation will consist of intermittent boluses of midazolam (1â?2 mg), fentanyl (50â?100 mcg) and propofol infusion, titrates to sedation and patient comfort (25â?50 mcg/kg/min). All patients will receive prophylaxis for postoperative nausea and vomiting (PONV) during surgery. The protocol for prophylaxis against PONV includes administration of 4 mg of dexamethasone after induction of anesthesia and 4 mg of ondansetron 20 minutes before recovery from anesthesia. Dexamethasone is withheld if the patient has poorly controlled diabetes mellitus (DM). Uncontrolled DM will be defined as random blood glucose above 250 mg/dl.
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Identification of fractures from computerized Medicare files
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Management of Hip Fractures in the Elderly
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Study of non-hip fractures, which are a serious public health problem for persons greater than or equal to 65 years of age, has been hindered by the absence of an economical method for case identification. We assessed the utility of computerized Medicare inpatient, emergency room, hospital outpatient department and physician claims for identifying fractures in an elderly Tennessee Medicaid population. We used these files for 1987 to identify 3086 possible fractures and reviewed medical records for a sample of 1440. Using this sample, we developed a definition of probable fractures that excluded claims unlikely to represent newly diagnosed fractures. For all fractures, this definition had a positive predictive value of 94%, which for individual fracture sites, ranged from 79% (tibia/fibula) to 98% (hip). Of fractures in the reviewed sample, 91% were identified as probable fractures; this upper bound for sensitivity varied between 75% (femoral shaft) and 100% (patella). These data suggest that computerized Medicare files can be used for rapid and economical fracture ascertainment among persons greater than or equal to 65 years of age. However, further work is needed to obtain better estimates of sensitivity
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New concept for total wrist replacement
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Surgical Management of Osteoarthritis of the Knee CPG
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Wrist prostheses have never achieved the sort of clinical outcomes found with those of hips and knees. We have developed a novel uncemented modular wrist prosthesis with screw fixation, metal-on-metal coupling, and ball-and-socket articulation. Eight patients admitted for wrist arthrodesis to treat primary or secondary osteoarthritis (not rheumatoid) were operated on. The prosthesis reduced the amount of bone removed and spared the distal radioulnar joint. After 7 to 9 years we found that the fixed centre of the ball-and-socket articulation provided good stability and mobility, and relief of pain and grip strength were satisfactory. We saw no luxations, metacarpal fractures or cut-outs, or mechanical failures of the implants. Two distal screws loosened (revised with new distal screws), and one early inflammation and one late infection occurred (revised to arthrodesis). We propose modifications to the implant with reduction in the diameter of the screws and the height of the threads, and rounding of the distal tip. The technique should include release of the third carpometacarpal joint, alignment of the capitate and the third metacarpal, and arthrodesis of the joint with bone chips
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Discoid menisci in children: MR features
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AMP (Acute Meniscal Pathology)
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OBJECTIVE: To define the MR appearance of discoid meniscus in children.
MATERIALS AND METHODS: In 22 children (15 girls and 7 boys; age range 5-17 years; median age 9 years) who were referred for evaluation of painful knees 27 discoid lateral menisci were identified. Meniscal shape and signal intensity and abnormalities of the surrounding structures were evaluated and compared with adult standards. Clinical (11 knees) or surgical (10 knees) follow-up was available on 16 patients (21 knees).
RESULTS: The menisci were classified as slab type (no. 20) or wedge type (no. 7). Transverse diameter at the midbody was 22.4 mm (range 10.5-36.7 mm) for discoid lateral menisci and 6 mm (range 5.1-28.3 mm) for medial menisci. Of 27 menisci, 23 had a central band of diffusely increased signal. Extension of intrameniscal signal to the joint space was noted in 16 of 23 menisci. Of 9 patients with intrameniscal signal who underwent surgery, only 7 had tears. Associated popliteal cysts occurred in 3 knees. No medial meniscal injury was observed.
CONCLUSION: The characteristic MRI appearance of symptomatic discoid meniscus in children is that of a diffusely thick meniscus with a slab configuration and diffusely increased intrameniscal signal that may or may not extend to the joint surface.
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Accuracy of CT arthrography in the assessment of tears of the rotator cuff
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Glenohumeral Joint OA
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CT arthrography and arthroscopy were used to assess tears of the rotator cuff in 259 shoulders. Tear size was determined in the frontal and sagittal planes according to the classification of the French Arthroscopy Society. CT arthrography had a sensitivity of 99% and a specificity of 100% for the diagnosis of tears of supraspinatus. For infraspinatus these figures were 97.44% and 99.52%, respectively and, for subscapularis, 64.71% and 98.17%. For lesions of the long head of the biceps, the sensitivity was 45.76% and the specificity was 99.57%. Our study showed an excellent correlation between CT arthrography and arthroscopy when assessing the extent of a rotator cuff tear. CT arthrography should, therefore, be an indispensable part of pre-operative assessment. It allows determination of whether a tear is reparable (retraction of the tendon and fatty degeneration of the corresponding muscle) and whether this is possible by arthroscopy (degree of tendon retraction and extension to subscapularis). ©2005 British Editorial Society of Bone and Joint Surgery.
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Total nasal reconstruction with alloplastic and autogenous grafts
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Acellular Dermal Matrix
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The basic principles of successful total nasal reconstruction include providing a sufficient amount of tissue coverage, creating an adequate structural framework, and fashioning a viable inner lining. Relative uniformity of opinion exists regarding sources for tissue coverage and nasal lining. A variety of options exists, however, regarding the type of material used for nasal framework. Alloplastic metals, such as vitallium or titanium mesh, combined with autogenous soft tissue coverage, are reliable alternatives for use in total nasal reconstruction.
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0 |
MR imaging in osteoarthritis: hardware, coils, and sequences
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AMP (Acute Meniscal Pathology)
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Whole-organ assessment of a joint with osteoarthritis (OA) requires tailored MR imaging hardware and imaging protocols to diagnose and monitor degenerative disease of the cartilage, menisci, bone marrow, ligaments, and tendons. Image quality benefits from increased field strength, and 3.0-T MR imaging is used increasingly for assessing joints with OA. Dedicated surface coils are required for best visualization of joints affected by OA, and the use of multichannel phased-array coils with parallel imaging improves image quality and/or shortens acquisition times. Sequences that best show morphologic abnormalities of the whole joint include intermediate-weighted fast-spin echo sequences. Also quantitative sequences have been developed to assess cartilage volume and thickness and to analyze cartilage biochemical composition.
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0 |
Prediction of Conservative Treatment Failure for Isolated Unilateral Mandibular Condylar Fractures Using Quantitative Measures: Suggestion of Indications for Intervention
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Pediatric Supracondylar Humerus Fracture 2020 Review
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BACKGROUND: Interest in the treatment of mandibular condyle fracture in cases of maxillofacial trauma has been a huge concern for decades because of a diversity of opinions on the topic and the relatively few studies conducted on individuals treated by physiotherapy or rehabilitation with or without intermaxillary fixation (IMF). METHODS: We measured fracture gaps between bone ends over an 8-year period from 2012 to 2019. The study cohort was composed of only conservatively treated patients. This retrospective study was conducted to identify factors that influence treatment failure by comparing a functional treatment (physiotherapy) group with an IMF group in terms of fracture gaps and other variables. In addition, an algorithm was devised to enable clinicians to determine promptly whether IMF is needed for mandibular condylar fractures. RESULTS: Significant correlations were observed between several parameters and malocclusion. Multiple regression analysis resulted in the following coefficients: 0.072 for fracture gap (P = 0.006) and 0.006 for age (P < 0.05) in functional treatment group. However, in the IMF group, correlations with malocclusion were 0.063 for fracture gap (P = 0.000) and 0.003 for age (P = 0.083). CONCLUSIONS: We proposed a diagnostic algorithm for isolated unilateral mandibular condyle fractures that provides guidance regarding surgical correction. If indications for surgical correction, as regards anatomical location, fracture level, fracture gap between bone ends, and patient cooperability, are not satisfied, clinicians should select IMF or functional treatment (rehabilitation). If the fracture gap is less than 6 mm and the patient is cooperative, functional rehabilitation would be more suitable than IMF.
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Postburn edge shoulder adduction contracture: anatomy and elimination with trapeze-flap plasty--a new approach
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DOD - Acute Comp Syndrome CPG
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Postburn scar shoulder adduction contracture is the most common among big joints' contractures. As the contracture impedes all upper limb function, surgical reconstruction is indicated as early as the contracture is formed. Many flaps and techniques have been suggested, yet the problem is not resolved completely. Three hundred forty-six edge scar shoulder adduction contractures were eliminated personally in 277 patients. Contracture anatomy was studied before and during surgery. Effectiveness of the existing and newly developed techniques was evaluated. Edge shoulder scar adduction contracture is caused by scars located on anterior and/or posterior shoulder joint surface and is characterized by the presence of the fold along the axillary fossa edge. Crest of the fold is the edge of scars. The fold's lateral sheet is scars (causes contracture); medial sheet and axillary fossa skin stay uninjured. Lateral scar sheets have surface deficit in length; the deficit spreads from the fold's crest to the shoulder joint rotation axis and has a trapezoid form. The conclusion was made that the adequate technique should consist of sheet surface deficit compensation with the flap of the same (trapezoid) shape. The medial fold sheet and axillary fossa served as an excellent donor site for the flap. Depending on contracture severity, several variants of the trapeze-flap plasty were developed: trapeze-flaps alone or in combination with skin grafts. In all cases, contractures were eliminated completely with trapeze-flap plasty without serious complications. No flap loss and contracture recurrence took place. The proposed techniques are based on the anatomy of the contracture. They are easy to plan and perform, allow complete restoration of the upper limb's function, and improve shoulder joint region appearance in general. The author believes that the trapeze-flap plasty procedure is a preferred technique for adult and pediatric patients with edge scar shoulder adduction contracture.
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The benefice of mobile partsâ?? exchange in the management of infected total joint arthroplasties with prosthesis retention (DAIR procedure)
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AAHKS (2) Corticosteroids
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Background: The management of prosthetic joint infections (PJI) with debridement and retention of the implant (DAIR) has its rules. Some authors claim that lacking the exchange of mobile prosthetic parts is doomed to failure, while others regard it as optional. Methods: Single-center retrospective cohort in PJIs treated with DAIR. Results: We included 112 PJIs (69 total hip arthroplasties, 9 medullary hip prostheses, 41 total knee arthroplasties, and 1 total shoulder arthroplasty) in 112 patients (median age 75 years, 52 females (46%), 31 (28%) immune-suppressed) and performed a DAIR procedure in all casesâ??48 (43%) with exchange of mobile parts and 64 without. After a median follow-up of 3.3 years, 94 patients (84%) remained in remission. In multivariate Cox regression analysis, remission was unrelated to PJI localization, pathogens, number of surgical lavages, duration of total antibiotic treatment or intravenous therapy, choice of antibiotic agents, immune-suppression, or age. In contrast, the exchange of mobile parts was protective (hazard ratio 1.9; 95% confidence interval 1.2â??2.9). Conclusions: In our retrospective single-center cohort, changing mobile parts of PJI during the DAIR approach almost doubled the probability for long-term remission.
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1 |
Factors affecting articular cartilage repair after open-wedge high tibial osteotomy
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OAK 3 - Non-arthroplasty tx of OAK
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BACKGROUND: To evaluate the factors that affect articular cartilage repair after open-wedge high tibial osteotomy (OWHTO) and the relationship between regeneration of articular cartilage repair and clinical outcomes.
METHODS: Among the cases of OWHTO that were performed from March 2005 to February 2012, the patients who followed up for >2years and received a second-look arthroscopy were retrospectively reviewed. For clinical evaluation, the Knee Society scores and Western Ontario and McMaster Universities Osteoarthritis Index score were measured. For radiologic evaluation, the Kellgren-Lawrence scale, mechanical femorotibial angle, and joint line obliquity were used. In the initial and second-look arthroscopy, the status of the articular cartilage of the medial compartment was evaluated.
RESULTS: A total of 62 knees (61 patients) were included in this study. Articular cartilage repair was observed in 18 knees (29.0%). In multiple logistic regression analysis, patients with Kellgren-Lawrence Grade 4 (OR 0.076; 95% CI 0.007-0.822; P=0.034), the existence of a bipolar lesion (OR 0.108; 95% CI 0.016-0.724; P=0.022), or joint line obliquity >5degree (OR 0.109; 95% CI 0.013-0.936; P=0.043) had significantly lower odds of articular cartilage repair compared to the corresponding counter group. In a comparison of clinical outcomes between a group that had articular cartilage repair and a group without repair, no significant difference was observed (P>0.05).
CONCLUSIONS: Severe arthrosis, existence of a bipolar lesion, and marked postoperative joint line obliquity had a negative impact on articular cartilage repair after OWHTO. However, articular cartilage repair showed unknown clinical significance.
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0 |
Outcomes in the management of Gartland III supracondylar fracture in a paediatric institution
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Pediatric Supracondylar Humerus Fracture 2020 Review
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Background Supracondylar fractures are the most common elbow fracture described in children. Different types of fixation, including cross- and side-pin fixations, have been described and compared. However, there is still controversy about which of the two techniques provides better stability and results. The iatrogenic injury of the ulnar nerve is a known complication of the medial pin compared to the side pins placement. Materials and methods An evaluation was made of a retrospective cohort of patients diagnosed with Gartland III supracondylar fractures. The aim was to compare post-operative neurological injuries in patients treated with cross pin vs. side pins. Results A total of 141 patients were included, of whom 61% were boys. Closed reduction was performed in 96.5% of the cases, and crossed nail fixation was used in 78.7% of them. The post-operative diagnosis classification changed from Gartland III to IV in 18.4% of the cases. Post-operative nerve injury was present in 12.8% of patients, with the ulnar nerve being the most affected (61.1%). There were no statistically significant differences between the groups with and without neurological injury. Discussion The incidence of iatrogenic ulnar nerve injuries after crossed pins fixation has been reported in the literature to be as high as 15%, which was similar to the one found in our study (12.8%). Elbow flexion â??necessary to maintain the fracture reduction, as well as elbow oedema are known factors for the injury of the ulnar nerve. The injury of the ulnar nerve should be avoided at all costs during the osteosynthesis with crossed pins. Therefore, the technique described by Dorgan is recommended, which uses a minimal medial incision and exploration of the ulnar nerve before the osteosynthesis with nails is performed. Evidence level III.
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0 |
Effect of addition of magnesium sulphate and fentanyl to ropivacaine continuous femoral nerve block in patients undergoing elective total knee replacement
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AAHKS (8) Anesthetic Infiltration
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This prospective double blinded study was designed to compare the effect of magnesium or fentanyl addition to ropivacaine in continuous femoral nerve block in patients undergoing elective total knee replacement under general anesthesia. Sixty patients undergoing elective TKR under general anesthesia, were randomly allocated into three equal groups, Group (R): given 30 mL Ropivacaine 0.2%. Group (R+F): given 30 mL Ropivacaine 0.2% and 4 μg mL -1 fentanyl. Group (R+M): given 30 mL Ropivacaine 0.2% and 50 mg mL-1 of magnesium sulphate, through femoral catheter. The following parameters were evaluated: (1) demographic data of the patients and duration of the surgery, (2) intraoperative and postoperative hemodynamics, (3) intraoperative fentanyl requirements, (4) the severity of postoperative pain for 24 h, (5) time to first request of analgesia and (6) amount of postoperative morphine consumed in 0-6, 6-12, 12-18, 18-24 and 0-24 h, postoperatively. There were no difference among the three groups as regards the demographic data, the duration of tire surgery, the pre and postoperative hemodynamics, the total intraoperative fentanyl consumption and the VAS during the 1 st postoperative hour. The postoperative pain showed significant lower values in groups (R+F) and (R+M) compared to group (R) when measured at 6, 12, 18 and 24 postoperative hours. The time for the first postoperative request for analgesia was statistically longer in tire (R+M) group and (R+F) group compared with group (R). The postoperative morphine consumption was statistically lower in groups (R+F) and (R+M) compared to group (R) but insignificant between groups (R+F) and (R+M). The admixture of magnesium sulphate or fentanyl to ropivacaine for continuous femoral nerve block provided a significant prolongation of postoperative analgesia than ropivacaine alone.
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0 |
Provider factors associated with intramedullary nail use for intertrochanteric hip fractures
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HipFx Supplemental Cost Analysis
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BACKGROUND: Intramedullary nails provide no clear outcomes benefit in the majority of patients with intertrochanteric hip fracture, yet their use in the United States continues to increase. Non-patient factors that are associated with intramedullary nail use among Medicare patients have not been examined. The goal of this study was to identify the surgeon and hospital characteristics that were associated with the use of intramedullary nails compared with plate-and-screw devices among elderly Medicare patients with intertrochanteric hip fractures. METHODS: Medicare beneficiaries who were sixty-five years of age or older and underwent inpatient surgery to treat an intertrochanteric femoral fracture with use of an intramedullary nail or a plate-and-screw device were identified from the United States Medicare files for 2000 to 2002. Surgeon and hospital characteristics from the Medicare provider enrollment files were merged with the claims. Generalized linear mixed models with fixed and random effects modeled the association between surgeon and hospital factors and intramedullary nail use (compared with plate and screws), controlling for patient age, sex, and race; subtrochanteric fracture; Charlson comorbidity score; nursing home residence; and Medicaid-administered assistance. The adjusted odds ratios of receiving an intramedullary nail by year, surgeon, and hospital factors are reported. RESULTS: There were 192,365 claims for surgery to treat an intertrochanteric hip fracture that met the inclusion criteria and matched with surgeon and hospital information. There were 15,091 surgeons who performed intertrochanteric hip fracture surgeries in Medicare patients in 3480 hospitals between March 1, 2000, and December 31, 2002. The surgeon factors associated with intramedullary nail use include younger surgeon age (less than forty-five years old), an osteopathy degree, and operating at more than one hospital. The hospital factors associated with intramedullary nail use include a higher volume of intertrochanteric hip fracture surgeries, teaching hospital status, and having resident assistance during surgery. Surgeon factors improved the model fit more than hospital factors. CONCLUSIONS: The use of intramedullary nails was strongly associated with early-career surgeons and surgeon training programs. Our findings suggest that orthopaedic faculty at teaching hospitals and younger surgeons may be selecting orthopaedic implants on the basis of factors other than clinical outcomes evidence. We expect that intramedullary nail use will continue to increase as long as new surgeons are preferentially trained in intramedullary nailing procedures and surgeon reimbursement remains insulated from the treating hospital's burden of their choices for higher cost devices under the Medicare payment system
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0 |
A Multicenter, Prospective, Randomized, Contralateral Study of Tissue Liquefaction Liposuction vs Suction-Assisted Liposuction
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Panniculectomy & Abdominoplasty CPG
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Background: Tissue liquefaction liposuction (TLL) deploys a novel energy source utilizing a stream of warmed, low-pressurized, and pulsed saline to extract fat tissue. Objectives: Compare TLL to suction-assisted liposuction (SAL) to determine which device is more efficient for surgeons and provides better recovery for patients. Methods: Thirty-one adult female patients were followed prospectively in a contralateral study design comparing differences in bruising, swelling, tenderness, and incision appearance ratings between TLL and SAL procedures. Surgical efficiency and appearance of the lipoaspirate were also compared. Results: All 31 patients successfully completed the study. For TLL and SAL procedures, the average volumes of infusion (1.242 vs 1.276 L) and aspirated supernatant fat (704 vs 649 mL) were statistically similar. TLL median fat extraction rate was faster than SAL (35.6 vs 25 mL/min; P < 0.0001), and stroke rate was reduced in TLL vs SAL procedures (48 vs 120 strokes/min; P < 0.0001), and both were statistically significant. The mean total scores for bruising, swelling, treatment site tenderness, and incision appearance were lower, indicating improved patient recovery on the TLL side. Conclusions: TLL and SAL techniques produced comparable volume of fat aspirate. TLL demonstrated a 42% faster fat extraction rate and a 68% reduction in arm movements needed to complete the procedure compared to SAL, both of these differences are statistically significant. The TLL side was noted to have reduced bruising and swelling and improved incision site appearance with less tenderness compared to the SAL side. Level of Evidence 2:
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0 |
Ewing's sarcoma
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MSTS 2022 - Metastatic Disease of the Humerus
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Ewing's sarcoma is a highly malignant tumor of uncertain origin. A strong relationship is suggested between Ewing's sarcoma and tumors of neural origin. The radiologic manifestation of Ewing's sarcoma are protean and lesions may be lytic, mixed lytic-sclerotic, or rarely, predominantly sclerotic. The lower extremity long bones are predominantly affected and most lesions are diaphyseal or metadiaphyseal. CT and particularly MR imaging are invaluable in further delineating the extent of disease not readily manifested on plain radiographs. Gallium scintigraphy and gadolinium-enhanced MR images are best for following the response to therapy. Ewing's sarcoma must be distinguished from other round cell tumors including lymphoma, neuroblastoma, and primitive neuroectodermal tumor of bone as well as from osteosarcoma. [References: 22]
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1 |
Hospital volume affects outcome after total knee arthroplasty
|
Surgical Management of Osteoarthritis of the Knee CPG
|
Background and purpose - The influence of hospital volume on the outcome of total knee joint replacement surgery is controversial. We evaluated nationwide data on the effect of hospital volume on length of stay, re-admission, revision, manipulation under anesthesia (MUA), and discharge disposition for total knee replacement (TKR) in Finland. Patients and methods - 59,696 TKRs for primary osteoarthritis performed between 1998 and 2010 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified into 4 groups according to the number of primary and revision knee arthroplasties performed on an annual basis throughout the study period: 1-99 (group 1), 100-249 (group 2), 250-449 (group 3), and >/= 450 (group 4). The association between hospital procedure volume and length of stay (LOS), length of uninterrupted institutional care (LUIC), re-admissions, revisions, MUA, and discharge disposition were analyzed. Results - The greater the volume of the hospital, the shorter was the average LOS and LUIC. Smaller hospital volume was not unambiguously associated with increased revision, re-admission, or MUA rates. The smaller the annual hospital volume, the more often patients were discharged home. Interpretation - LOS and LUIC ought to be shortened in lower-volume hospitals. There is potential for a reduction in length of stay in extended institutional care facilities
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0 |
Current studies of acupuncture in cancer-induced bone pain animal models
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MSTS 2018 - Femur Mets and MM
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Acupuncture is generally accepted as a safe and harmless treatment option for alleviating pain. To explore the pain mechanism, numerous animal models have been developed to simulate specific human pain conditions, including cancer-induced bone pain (CIBP). In this study, we analyzed the current research methodology of acupuncture for the treatment of CIBP. We electronically searched the PubMed database for animal studies published from 2000 onward using these search terms: (bone cancer OR cancer) AND (pain OR analgesia) AND (acupuncture OR pharmacopuncture OR bee venom). We selected articles that described cancer pain in animal models. We analyzed the methods used to induce cancer pain and the outcome measures used to assess the effects of acupuncture on CIBP in animal models. We reviewed articles that met our inclusion criteria. Injection of mammary cancer cells into the cavity of the tibia was the most frequently used method for inducing CIBP in the animal models. Among the eight selected studies, five studies demonstrated the effects of electroacupuncture on CIBP. The effects of acupuncture were assessed by measuring pain-related behavior. Future researches will be needed to ascertain the effectiveness of acupuncture for treating CIBP and to explore the specific mechanism of CIBP in animal models.
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0 |
Impact of reduction mammoplasty on the quality of life of obese patients suffering from symptomatic macromastia: A descriptive cohort study
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Reduction Mammoplasty for Female Breast Hypertrophy
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Background Although reduction mammoplasty (RM) is an effective and efficient treatment for symptomatic macromastia, overweight and obese patients who request this treatment are frequently rejected because of selection criteria based on the body mass index. Scientific evidence is inconclusive regarding the increased postoperative complications in obese patients undergoing RM, and there is a lack of adequately designed studies examining the impact of RM on the quality of life of this group of patients. Patients and methods A descriptive cohort study was performed on 37 consecutive obese patients (body mass index > 30 kg/m2) undergoing bilateral RM for symptomatic macromastia. Short Form SF-36 quality-of-life questionnaires were completed at interviews a week before surgery and 6 and 18 months after surgery. In addition, 37 women of matching ages, who were companions of patients hospitalized at our short-stay surgery unit, were used as a control group for comparison. Significant differences between repeated measurements on a single sample were assessed using the Wilcoxon signed-rank test. To evaluate these changes, we used effect size by computing Hedgesâ?? g corrected. Results The preoperative SF-36 physical component score was significantly lower than the control group's score (40 vs. 53, p < 0.001). There was no significant difference in the mental component score (45 vs. 49, p = 0.210). Postoperative SF-36 scores were increased with a normalizing effect, as 18 months after surgery only the body pain domain scored lower than the control group scores. Conclusions According to our results, obese women with symptomatic macromastia undergoing RM exhibited increased quality of life, and this improvement was maintained over time. Therapy: Level III Evidence.
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0 |
Inhaled corticosteroids and the risk of fractures in older adults: a systematic review and meta-analysis
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Management of Hip Fractures in the Elderly
|
BACKGROUND: Inhaled corticosteroids (ICS) are commonly prescribed medications for the management of asthma and chronic obstructive pulmonary disease. It is well established that long-term use of these drugs may lower bone mineral density. However, whether ICS increase the risk of fractures remains unknown. Recent studies that have attempted to explore this risk have had conflicting results. We sought to explore the risk of ICS and fractures among older adults by conducting a systematic review and meta-analysis of the literature. METHODS: We systematically searched several databases, including MEDLINE, EMBASE and the Cochrane Library, to identify pertinent studies. Those studies that potentially met our inclusion criteria were identified by two reviewers. Relative risks (RRs) were pooled using the random effects model. We also explored dose-response by stratifying the analysis on high and low doses of ICS. Heterogeneity was assessed using the Q statistic and publication bias was assessed using the funnel plot. RESULTS: Thirteen studies, including four randomized controlled trials, were included in the review. The pooled RRs for hip fractures and any fractures were 0.91 (95% CI 0.87, 0.96) and 1.02 (95% CI 0.96, 1.08), respectively. When we restricted the analysis to users of high-dose ICS, the pooled RRs for any fractures and hip fractures were 1.30 (95% CI 1.07, 1.58) and 1.32 (95% CI 0.90, 1.92), respectively. The funnel plot did not show evidence of publication bias. CONCLUSION: We found no association between the use of ICS and fractures in older adults. A slight increase in risk was seen in those using high-dose ICS. The significance of this association should be investigated further
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0 |
Rothia dentocariosa Endocarditis: Case report and review of infections caused by this organism
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Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
|
A 13-year-old girl with congenital ventricular septal defect developed infective endocarditis following dental treatment. Isolation of the pathogen revealed a non-acid-fast aerobic branching rod which was identified as Rothia dentocariosa. In spite of complications, the infection was treated successfully with penicillin and gentamicin. A member of the family Actinomycetaceae, R. dentocariosa is a common inhabitant of the mouth and throat and rarely causes infection. It has been reported to cause infective endocarditis in 13 patients, sepsis in 2 immunocompromised patients and abscess in 4 other patients. The clinical description, morphological, biochemical and serological characteristics and antibiotic sensitivity of R.dentocariosa in these patients are reviewed
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0 |
Burden of major musculoskeletal conditions
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Surgical Management of Osteoarthritis of the Knee CPG
|
Musculoskeletal conditions are a major burden on individuals, health systems, and social care systems, with indirect costs being predominant. This burden has been recognized by the United Nations and WHO, by endorsing the Bone and Joint Decade 2000-2010. This paper describes the burden of four major musculoskeletal conditions: osteoarthritis, rheumatoid arthritis, osteoporosis, and low back pain. Osteoarthritis, which is characterized by loss of joint cartilage that leads to pain and loss of function primarily in the knees and hips, affects 9.6% of men and 18% of women aged > 60 years. Increases in life expectancy and ageing populations are expected to make osteoarthritis the fourth leading cause of disability by the year 2020. Joint replacement surgery, where available, provides effective relief. Rheumatoid arthritis is an inflammatory condition that usually affects multiple joints. It affects 0.3-1.0% of the general population and is more prevalent among women and in developed countries. Persistent inflammation leads to joint destruction, but the disease can be controlled with drugs. The incidence may be on the decline, but the increase in the number of older people in some regions makes it difficult to estimate future prevalence. Osteoporosis, which is characterized by low bone mass and microarchitectural deterioration, is a major risk factor for fractures of the hip, vertebrae, and distal forearm. Hip fracture is the most detrimental fracture, being associated with 20% mortality and 50% permanent loss in function. Low back pain is the most prevalent of musculoskeletal conditions; it affects nearly everyone at some point in time and about 4-33% of the population at any given point. Cultural factors greatly influence the prevalence and prognosis of low back pain
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